Form NMMLS Form 1 NMMLS Form 1 NMMLS

NATIONAL MEDALS PRA CLEARANCE 2017-07-03
2018 Nomination Form
National Medal for Museum and Library Service
(To be filled out by the nominated organization.)
A. Cover Sheet
1.

Legal Name of your Organization: 1 _________________________________________________________________
Organizational Unit (if different from Legal Name): ____________________________________________________

2.

Organization Address
Street 1: ____________________________

Street 2: ______________________________________

City: _______________________________

County: _______________________________________

State: ______________________________

Zip+4/Postal Code: ______________________________

3.

Telephone Number: ___________________

4.

Fax Number: ___________________________________

5.

Web Address: http://_____________________________________________________________________________

6.

Name of Organization’s Director/CEO: _______________________________________________________________
Title: __________________________________________________________________________________________
E-mail: ______________________________

7.

Telephone Number: ______________________________

Your Name (the person completing this form): _________________________________________________________
Title: ___________________________________________________________________________________________
E-mail: ______________________________

8.

1

Type of Organization (check one):

□ Academic Library
□ Aquarium
□ Arboretum/Botanical Garden
□ Art Museum
□ Children’s/Youth Museum
□ Digital Library
□ General Museum 2
□ Historic House/Site
□ History Museum
□ Library Association
□ Library Consortium
□ Museum Library

Telephone Number: _______________________________

□ Natural History/Anthropology Museum
□ Nature Center
□ Planetarium
□ Public Library
□ Research Library/Archives
□ School Library, or School District applying on
behalf of a School Library or Libraries
□ Science/Technology Museum
□ Special Library
□ Specialized Museum 3
□ Zoo
□ Other, please specify: ______________________________

If your organization is not an eligible entity on its own, then enter the name and address of the eligible entity under “Legal
Name.” For example, if a library that is part of a parent organization such as a university is applying, it would enter the
university under “Legal Name” and the library under “Organizational Unit.”
2
A museum with collections representing two or more disciplines (e.g., art and history)
3
A museum with collections limited to one narrowly defined discipline (e.g., textiles, stamps, maritime, ethnic group)

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A. Cover Sheet (continued)
9.

Governing Control (check one):

□ State Government
□ County Government
□ City or Township Government
□ Special District Government
□ Regional Organization
□ U.S. Territory or Possession
□ Independent School District
□ Public/State-Controlled Institution of
Higher Education
□ Indian/Native American Tribal
Government (Federally Recognized)
□ Indian/Native American Tribal
Government (Other than Federally
Recognized)
□ Public/Indian Housing Authority

□ Nonprofit with 501(c)3 IRS Status (Other than Institution
of Higher Education)
□ Nonprofit without 501(c)3 IRS Status (Other than Institution
of Higher Education)
□ Private Institution of Higher Education
□ Individual
□ For-Profit Organization (Other than Small Business)
□ Small Business
□ Hispanic Serving Institution
□ Historically Black Colleges and Universities (HBCUs)
□ Tribally Controlled Colleges and Universities (TCCUs)
□ Alaska Native and Native Hawaiian Serving Institutions
□ Nondomestic (non-U.S.) Entity
□ Other, please specify: ______________________________

10. Nominated Organization’s D-U-N-S® Number: 4 ________________________________________________
11. Nominated Organization’s Employer/Taxpayer Number (EIN/TIN): ________________________________
12. Congressional District of Nominated Organization: 5 ____________________________________________
13. Organization’s Annual Operating Budget: ____________________________________________________
14.
A.

Fiscal Year

B.

List Total Revenue/
Support Income 6

C.

List Total Expense/
Outlays 7

Most recently
completed FY ___
(insert)
Second most
recently
completed FY ___
(insert)

Difference between
B. Total Revenue and
C. Total Expenses

15. If your organization had a deficit greater than 10% of your annual operating budget for any of the fiscal years listed
above, please explain the circumstances of this deficit. [Text box]
16. Has your organization had an A-133 audit in the past three years? Yes; No
17. If no, has your organization had a financial statement audit in the past three years? Yes; No

4

Verify that your organization has a D-U-N-S® Number or take steps to obtain one. Your organization can receive a D-U-N-S®
Number at no cost by calling the dedicated toll-free D-U-N-S® Number request line at 1-866-705-5711 or by visiting
www.dnb.com/us.
5
Congressional Districts can be found by entering the zip code of the institution at www.house.gov/representatives/find.
6
For nonprofit tax filers Total Revenue can be found on line 12 of the IRS Form 990.
7
For nonprofit tax filers Total Expenses can be found on line 18 of the IRS Form 990.

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18. Were there any material weaknesses identified in your organization’s 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.)

19. If yes, please explain. [Text box]
20. Number of full-time paid organization staff: _________

Number of part-time paid organization staff: __________

Number of full-time unpaid organization staff

Number of part-time unpaid organization staff

(including volunteers): ___________________________

(including volunteers): ____________________________

21. Total number of days the organization was open to the public for the past 12-month period prior to application: ____
22. Name of Nominating Individual: _____________________________________________________________________
Title: _________________________________________

Relationship to Organization: _______________________

E-mail: _______________________________________

Telephone Number: _______________________________

In addition to the Cover Sheet (Section A), your submission must include the following parts (Sections BD below). Do not include additional cover letters, binders, folders, or attachments.
B. Executive Summary and Mission Statement (not to exceed one single-spaced page; no less than 12point type)
• Summarize why you believe this organization deserves to win the National Medal for Museum
and Library Service.
• Provide this organization’s mission statement or statement of purpose as well as a brief
institutional history.
C. Narrative 8 (not to exceed four single-spaced pages; no less than 12-point type)
The National Medals are designed to recognize outstanding libraries and museums that have
made significant contributions in service to improve the wellbeing of their communities. This
year, we are particularly interested in museum and library programs that build community
cohesion and serve as a catalyst for positive community change, including services for veterans
and military families, at-risk children and families, the un- and under-employed, and youth
confronting barriers to STEM-related employment. Address questions 1-4 thoroughly and
succinctly. The jurors considering the pool of potential medal recipients will focus carefully on
your answers to these questions.

8

For organizations applying in the Digital Library category, please address:
•
services to your community including services to other organizations and services to end users;
•
access to resources;
•
sustainability and preservation plans for the digital library;
•
accessibility for people with disabilities (e.g., compliance with the Americans with Disabilities Act).

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1. Describe the community 9 and the particular community needs addressed.
• Quantify and describe the population groups/communities your organization is reaching
through its programs, services, and/or partnerships.
• What particular community needs do you address?
• How did you identify these particular needs and work with the community to craft
solutions?
• How are these needs incorporated into your strategic plan?
2. Describe the programming your organization has developed for these particular community
needs. (See section C.1.)
• Please include a brief description of your full portfolio of services, even if you focus on a
particular area of service.
• How do you involve your community in the development of your programs?
• How have these partnerships increased your ability to reach out to the targeted
population groups and communities you serve?
• Describe how you serve community members with special needs. Please address
accessibility for people with disabilities.
3. Describe what impact your organization’s programs and services have had on the identified
community needs.
• Do you conduct a formal evaluation of your programs? If so, what have you learned
about meeting the needs of your audiences?
• If you do not have a formal evaluation of programs, how do you measure success?
• How have you used this information to plan future programs and services?
4. Describe your organization’s financial situation.
• List your organization’s three primary sources of revenue. Do you have a sustainable
funding model that will enable growth?
• Describe any private or non-profit groups that support your mission and activities and
the extent of their support.
D. Letters of Support (required - three maximum, submitted with the Nomination Form)
• These letters should come from community members who have direct knowledge of the
organization’s community service. We recommend that the letters come from different
segments of the broader community served by the institution and from individuals who
have either witnessed or experienced first-hand a particular program or service.
• Nomination letters from members of Congress are welcome and will not count against the
three-letter maximum.
• Address letters to the Director of the Institute of Museum and Library Services and include
them with this Nomination Form.

9

Academic and research libraries may interpret “community” as your campus community and/or local community.

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Website – https://www.imls.gov/grants/available/national-medal-museum-and-library-service
Deadline: October 02, 2017
Download FY 2018 Nomination Form (Fill-in PDF, 520KB)
Visit the National Medals page in our National Initiatives section to learn more about the annual
celebration of the National Medal recipients.
Program Overview:
The National Medals are designed to recognize outstanding libraries and museums that have made
significant contributions in service to improve the wellbeing of their communities. This year, we are
particularly interested in museum and library programs that build community cohesion and serve as a
catalyst for positive community change, including services for veterans and military families, at-risk
children and families, the un- and under-employed, and youth confronting barriers to STEM-related
employment.
Selected institutions demonstrate extraordinary approaches to serving their constituents; they exceed
expected levels of community outreach. These organizations have established themselves as community
anchor institutions. Recipient institutions are honored at an awards ceremony that is held in
Washington, DC.
Nominations should describe the:
• population served and community needs;
• institution’s programs, services, and partnerships;
• impact and evaluation of programs; and
• financial sustainability.
How are the recipients of the National Medal selected?
The Director of the Institute of Museum and Library Services, with the advice of the Museum and Library
Services Board, selects the recipients of the National Medals. In addition to the Medal, IMLS may grant
a monetary award.
When are the recipients of the National Medal announced?
The recipients of the National Medals are usually announced in the spring on the IMLS website and
through a press release.
Who is eligible for a National Medal?
For museums:
•

Aquariums, Arboretums/Botanical Gardens, Art Museums, Children’s/Youth Museums, General
Museums, Historic Houses/Sites, History Museums, Natural History/Anthropology Museums,

NATIONAL MEDALS PRA CLEARANCE 2017-07-03

•

•

Nature Centers, Planetariums, Science/Technology Museums, Specialized Museums, and Zoos
may be nominated for the National Medal for Museum Service if they: are either a unit of State
or local government or a private nonprofit organization that has tax-exempt status under the
Internal Revenue Code;
are located in one of the 50 States of the United States of America, the District of Columbia, the
Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the
Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the
Federated States of Micronesia, or the Republic of Palau; and
qualify as a museum that, using a professional staff, is organized on a permanent basis for
essentially educational or aesthetic purposes; owns or uses tangible objects, either animate or
inanimate; cares for these objects; and exhibits these objects to the general public on a regular
basis through facilities that it owns or operates.

A public or private nonprofit agency which is responsible for the operation of a museum may apply on
behalf of the museum.
Previous library of museum medal recipients may reapply after ten years.
For libraries:
•

•

Academic and Research Libraries/Archives, Digital Libraries, Library Associations, Library
Consortia, Public Libraries, Research Libraries/Archives that make information available to the
public and that are not an integral part of an institution of higher learning, Public School
Libraries, Tribal Libraries, and Private or Special Libraries that are considered libraries as
determined by the State in which they are located, may be nominated for the National Medal
for Library Service. They should also be: either a unit of State or local government or be a
private nonprofit organization that has tax-exempt status under the Internal Revenue Code; and
located in one of the 50 States of the United States of America, the District of Columbia, the
Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, the
Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the
Federated States of Micronesia, or the Republic of Palau.

Who may nominate a library or museum for the National Medal?
Anyone, including the institution’s employees, board members, members of its community, and elected
officials, may nominate a museum or library for this honor.
What steps should nominators take?
• If an institution self-nominates, it simply needs to submit the nomination materials to IMLS by
the deadline.
• If someone outside of the institution wants to make a nomination, they should notify the
museum or library directly and ask them to complete and submit the nomination form in
advance of the deadline.
What information is necessary in order for an institution to be considered for the National Medal and
who is responsible for providing it?

NATIONAL MEDALS PRA CLEARANCE 2017-07-03
Your institution, not the individual who nominates it, must complete the Nomination Form and include
the following four parts:
1. Cover Sheet
2. Executive Summary & Mission Statement
3. Narrative (four questions)
4. Letters of Support
Do not include additional cover letters, binders, folders or attachments. For detailed information on
answering parts B-D, refer to the Nomination Form.
What is the deadline for submitting the Nomination Form?
The Nomination Form and letters of support should be sent by October 2, 2017, to this email address:
[email protected]
Alternatively, nominations may be mailed and postmarked by October 2, 2017, to this address:
The National Medal for Museum and Library Service
Office of the Director
Institute of Museum and Library Services
955 L’Enfant Plaza North, SW, Suite 4000
Washington, DC 20024-2135
For more information about the National Medal for Museum and Library Service contact
[email protected] or call (202)653-4757