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Letter of Intent Form

Questions about the 2025 grants process: chuber@donatelifewisconsin.org.

Begin the form below — all components are required.

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Organization
Organization Legal Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Website*
EIN*
Project Staff Contact
Name
First Last
Title*
Email Address*
Phone Number*
Fiscal Staff Contact
Name*
First Last
Email*
Phone*
Project Need
This mini-grant funding opportunity celebrating the online donor registry’s 15th anniversary is specifically intended to increase the number of individuals who register to become organ, eye and tissue donors. Best use of funds must be solely dedicated to projects that encourage new enrollees in the Wisconsin Donor Registry. This funding opportunity excludes support for events such as parades and fundraising activities. We want innovative interactive projects that target one or more of the intended audiences detailed below.

Wisconsin Department of Health Services (DHS) data from the first half of 2024 indicates the following observations:
- Age Demographics indicate less than 55% enrollment in the 20-24 year old and 64+ year old age categories.
- Race/Ethnicity Demographics indicate less than 30% enrollment in people identifying as African American or Asian.
- Sex Demographics indicate only 53.4% men register as organ donors compared to 60.1% of women.
Any or all of the DLW educational materials below may be duplicated and used at/for Mini-Grant-funded projects.

Materials branded solely by an OPO or other recovery or transplant organization(s) should not be used at MIni-Grant funded events, activities or programs.
- Facts About Living Donation
- Facts About Organ, Tissue, and Eye Donation
- What Can Be Donated
- DHS Registry Fact Sheet
Project Information
Project Name*
Target Audience (see Project Need section)*
Project Overview
Required information:
- Description of project
- Internal/external partners to accomplish project
- How many individuals does your organization intend to reach through the project?
- How will your organization measure success? (e.g. number of people who visited booth/participated in event, # of educational materials distributed, # of people who joined registry during event, other?)
Project Overview*
Funding Request
Total Amount Requested*
Project funding requests may not exceed $5,000. Funds are awarded (reimbursed to the organization) at the conclusion of a project based on project budget and applicable expense documentation.
Please enter a number from 0 to 5000.
Project Budget
Instructions for budget development:
- Budgeted expenses must reflect work plan activities(e.g. budget must not include event planning expenses if intent of project is educational material development).
- Budget item detail must provide justification in form of math formula to explain how line item’s final cost was determined. Examples:
- DLW does not provide reimbursement for sales tax.
Total Amount: Materials/Supplies*
Materials/Supplies*
List specific expense items, along with calculation of how total cost was determined.
Total Amount: Equipment/Technology*
Equipment/Technolgy*
List specific expense items, along with calculation of how total cost was determined.
Total Amount: Marketing/Printing*
Marketing/Printing*
List specific expense items, along with calculation of how total cost was determined.
Total Amount: Professional Fees/Services*
Professional Fees/Services*
List specific expense items, along with calculation of how total cost was determined.
Total Amount: Meetings/Events*
Meetings/Events*
List specific expense items, along with calculation of how total cost was determined.
Total Amount: Postage/Shipping
Postage/Shipping*
List specific expense items, along with calculation of how total cost was determined.
Total Amount: Other Items*
Other*
List specific expense items, along with calculation of how total cost was determined.
Attestation
All boxes must be checked before the form can be submitted. The undersigned certifies that:
*
- The individual providing supervision of the Project Staff Contact has given approval to submit this project/Letter of Intent.
*
- The individual or department responsible for financial reporting/financial oversight of grant projects is aware of this project submission.
*
- The project can be completed by December 31, 2025. Note: No extensions will be granted.
*
- The applicant organization has the ability to begin the project on or shortly after project approval.
*
- The applicant organization will use DLW materials, when available for volunteer training or public exhibits.
*
- The organization agrees to recognize DLW support on any public-facing materials, displays, presentations and trainings.
*
- The applicant organization is exempt from taxation under section 501(a) of the Internal Revenue Code.
*
- The applicant organization’s Federal tax exemption determination has not been revoked and the present operation of the organization and its current sources of support are consistent with the organization’s continuing tax-exempt classification as set forth in such Determination Letter.
Certification*
I certify that the Attestation Statements above are accurate and true.
Name of Individual*
Job Title*
Email*
Date*
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Name
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Grants

Letter of Intent Form

Organization

Project Staff Contact

Fiscal Staff Contact

Project Need

Project Information

Project Overview

Funding Request

Project Budget

Attestation