Form Program Informatio Program Informatio Program Information Sheet

IMLS PROGRAM INFORMATION SHEET

PLEASE NOTE: Information contained within this form may be made publicly available.

1. Applicant Information

a. Legal Name as it appears in SAM.gov : (5a from SF424S):

b. Organizational D-U-N-S® Number (5f from SF-424S):

c. Expiration date of your SAM.gov registration

d. Organizational Unit Name (if different from Legal Name):

e. Organizational Unit Address (if different from Legal Name address)

Street 1

Street 2

City

County

State

Zip+4/Postal Code

-

f. Organizational Unit Type (check one):

Academic Library

Library Association

School Library or School District applying on behalf of a School Library or Libraries

Aquarium

Library Consortium

Arboretum/Botanical Garden

Museum Library

Art Museum

Museum Services Organization/Association

Science/Technology Museum

Children’s/Youth Museum

Special Library

Community College

Native American Tribe/Alaska Native/Native Hawaiian Organization

Specialized Museum**

Digital Library

Four-year College

Natural History/Anthropology Museum

State Library

General Museum*

State Museum Agency

Graduate School of Library and Information Science

Nature Center

State Museum Library

Planetarium

Zoo

Historic House/Site

Public Library

Institution of higher education other than listed above

Historically Black College or University (HBCU)

Research Library/Archives

History Museum

Other

* A museum with collections representing two or more disciplines equally (e.g., art and history)

** A museum with collections limited to one narrowly defined discipline (e.g., textiles, maritime, ethnic group)

IMLS PROGRAM INFORMATION SHEET

2. Organizational Financial Information
a. Please complete the following table for the Organizational Unit for the three most recently completed fiscal years.
Fiscal Year		Total Revenue*		Total Expenses**		Surplus or Deficit
* For nonprofit tax filers, Total Revenue can be found on Line 12 of the IRS Form 990.
** For nonprofit tax filers, Total Expenses can be found on Line 18 of the IRS Form 990.
b. If you had a budget surplus or deficit greater than 10% of your annual operating budget for two or more of the three fiscal years listed above, please explain the circumstances of this surplus or deficit in the box below.
c. Were there any material weaknesses identified in your prior year’s audit report?
Yes	No		Not applicable
A material weakness is a deficiency, or combination of deficiencies, in internal control, such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented, or detected and corrected on a timely basis.
If yes, please explain.
d. Has your organization had an A-133 audit in the past three years?
Yes	No

IMLS PROGRAM INFORMATION SHEET

Refer to the Notice of Funding Opportunity for descriptions of these options and instructions for how to make selections.

3. Grant Program
a. Laura Bush 21st Century Librarian Program	d. Museums for America
1. Select one:	1. Select one:
Planning Grant	Learning Experiences
National Forum Grant	Community Anchors
Project Grant	Collections Stewardship
Research Grant
2. Select one:	2. Select one:
Pre-professional	$5,000–$25,000 with no cost share permitted.
Masters-level and Doctoral-level Programs	$25,001–$500,000 with cost share required.
Early Career Development
Continuing Education	e. National Leadership Grants for Museums
3. Select one:	1. Select one:
	Advancing Digital Assets and Capacity Com Collections Stewardship
Community Anchors	Collections Care and Access
National Digital Platform	Diversity and Inclusion
Curating Collections	Professional Development
	2. Select one: Non-research grant, $50,000–$1,000,000 with cost share required.
b. National Leadership Grants for Libraries
1. Select one:	Research grant, $50,000–$1,000,000 with no cost share required.
Sparks Grant
Planning Grant	Rapid prototyping grant, $5,000–$50,000 with no cost share required.
National Forum Grant
Project Grant
Research Grant	f. Museum Grants for African American History and Culture
2. Select one:
Community Anchors
National Digital Platform	1. Select one:
Curating Collections	$5,000–$25,000 with no cost share permitted.
	$25,001–$150,000 with cost share required.
c. Native American/Native Hawaiian Library Services
	g. Museums Empowered (an MFA Special Initiative)
1. Select one:
Native American Basic Grant	Select one:
Native American Enhancement Grant	Digital Technology
Native Hawaiian Library Services	Diversity and Inclusion
	Evaluation
	Organizational Management
	Select one:
	$5,000 - $25,000 with no cost share permitted
	$25,001 - $250,000 with cost share required
	h. Native American/Native Hawaiian Museum Services

4. Performance Goals
Select one of the following three IMLS agency-level goals: (a) Learning, (b) Community, or (c) Content and Collections. Then select at least one of the performance goals listed beneath it:
a. Learning
Train and develop museum and library professionals
Support communities of practice
Develop and provide inclusive and accessible learning opportunities
b. Community
Strengthen museums and libraries as essential partners in addressing the needs of their communities
c. Content and Collections
Broaden access and expand use of the Nation’s content and collections
Improve management of the Nation’s content and collections
Improve preservation, conservation, and care of the Nation’s content and collections
If you select a performance goal listed beneath Learning or Community for your project, click here to review the specific performance measure statement choices and the information you will be required to collect for each.
5. Funding Request
a. IMLS funds requested:			b. Cost share amount:

IMLS PROGRAM INFORMATION SHEET

6. Population Served

Please select the target population(s) served by the proposed project:

General Population

Museum and/or Library Professionals

Early Childhood/Preschool (0-5 years)

Native Americans/Alaska Natives/Native Hawaiians

Middle Childhood/Primary School (6-12 years)

People with Mental or Physical Challenges/Disabilities

Adolescents/High School (13-19 years)

People Who Are Low Income/Economically Disadvantaged

Adults

Rural Populations

Aging, Elderly, Senior Citizens (65+ years)

Scholars/Researchers

Ethnic or Racial Minority Populations other than Native Americans/Native Hawaiians

Unemployed

Urban Populations

Families/Intergenerational

Other

Immigrants/Refugees

Military Families

If other, please specify:

7. Museum Profile (Museum Applicants Only)

a. Is your institution organized on a permanent basis for essentially educational or aesthetic purposes, and is it either a private not-for-profit organization that has tax-exempt status under the Internal Revenue Code or a unit of state or local government.

Yes

No

b. Does your institution own or use tangible objects, either animate or inanimate?

Yes

No

c. Does your institution care for these objects?

Yes

No

d. Does your institution exhibit these objects to the general public at least 120 days a year through facilities your institution owns or operates?

Yes

No

e. Your institution’s attendance for the 12-month period prior to the application

f. Year your institution was first open and exhibiting to the public:

g. Total number of days your institution was open to the public for the 12-month period prior to application:

h. Does your institution employ at least one professional staff member, or the full-time equivalent, whether paid or unpaid, who is primarily engaged in the acquisition, care, or exhibition to the public of tangible objects owned or used by your institution?

Yes

No

i. Number of full-time paid institution staff:

j. Number of full-time unpaid institution staff:

k. Number of part-time paid institution staff:

l. Number of part-time unpaid institution staff:

IMLS PROGRAM INFORMATION SHEET

8. Project Elements (Museums for America and National Leadership Grants for Museums Applicants Only)
Your response to this question will help us match your application to reviewers with appropriate experience. Make your choice under the project category that you selected in Question 3 (Grant Program).
LEARNING EXPERIENCES
If you are applying in the Learning Experiences Project Category, select the primary element that is core to your proposed project from the list below (check only one):
Adult Programs			Interpretation
Digital Media			K-12 Programs, With Schools
Early Learning			K-12 Programs, Out of School
Exhibitions			Professional Development/Training
Family Programs			Public Programs
COMMUNITY ANCHORS
If you are applying in the Community Anchors Project Category, select the primary element that is core to your proposed project from the list below (check only one):
Audience Research and Evaluation			Community Outreach
Civic Engagement			Digital Media
Community-Driven Exhibitions and Programs			Professional Development/Training
Community-Focused Planning Activities
COLLECTIONS STEWARDSHIP
If you are applying in the Collections Stewardship Project Category, select the primary element that is core to your proposed project from the list below (check only one):
Access and Use		Collections Management		Conservation
Database Management		Cataloguing, Inventorying, Registration		Conservation Environmental Improvement/Rehousing
Digitization		Collections Information Management		Conservation Survey
Software Applications				Conservation Treatment
Website Development		Collections Planning		Professional Development/Training
Please identify the material type(s) that will be affected by your project:
Animals, living				Photographic Materials
Animals, preserved				Plants, living
Architecture				Plants, preserved
Books and Paper				Sculpture
Electronic Media				Textiles
Objects				Wooden Artifacts
Paintings

0	OMB Number 3137-0071, Expiration date: 7/31/2018 IMLS-CLR-F-0028