Ascension Michigan Community Benefit and Investment Program Request Form
Thank you for considering a partnership with Ascension Michigan hospitals; we are committed to building, supporting, and enriching the communities we are proud and privileged to serve. Through partnerships with other non-profit organizations, along with public entities and others, we are able to expand the Mission, Vision and Values of Ascension across our Michigan service areas.

Click here to learn more about the Ascension Michigan Community Benefit and Investment Program, including funding criteria, funding terms, submission deadlines, and how to submit a request.

Funding requests received April 1, 2024 through June 30, 2024 will be considered for the Fall Funding term, and notification of request outcome will be communicated on or before August 31, 2024.

NOTE: The following hospitals are not currently accepting funding requests at this time: Ascension St. Mary's Hospital, Ascension St. Joseph Hospital, and Ascension Standish Hospital.

Should you have any questions about the program, please contact the Ascension Michigan Community Benefit and Investment Team at micbie@ascension.org.
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REQUESTING ORGANIZATION INFORMATION
Organization Name *
Organization's Mission
 *
About the Organization
 *
In order to provide context for your request, we ask that you provide a brief description of the organization as a whole and the support and/or services the organization provides.
Response limited to 1,000 characters including spaces
Organization Address *
Please include physical address, city, and zip code.
Organization Affiliation
 *
Please indicate if your organization is affiliated with a national or state entity.
Organization Service Area *
Please indicate which county(s) the organization serves. Check up to three (3) that apply.
Required
Organization Type
 *
Is your organization listed in the Ascension Neighborhood Resource directory?
 *
Is Ascension currently a dues paying member of the organization?
*
Please describe if, and how, Ascension is actively engaged with the organization.
 *
This may include participation on a board, committee, and/or sponsorship of other events or programs.
Response limited to 1,000 characters including spaces.
Contact Name *
Contact Email *
Contact Phone *
Please enter digits only (e.g. 555-123-4567 should be entered as 5551234567)
ACTIVITY INFORMATION
Name of Activity *
Activity Type
 *
Note: Ascension Michigan is not currently awarding funding requests for golf outings and community walk/run/ride events. Click here to learn more about activities that would be excluded from consideration.

Please indicate which best describes the activity.
Activity Timeline *

Note: Activities occurring before August 31, 2024 will be ineligible for consideration per the current funding term timeline. Click here to learn more about the funding terms.

If the activity takes place on a specific date, please indicate the date of the activity.

If the activity is a program that takes place over a period of time, please indicate the start date of when funds are expected to be used.

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Activity Description
 *
Please describe the activity. Your response should provide a "big picture" overview of the activity.  
Response limited to 1,000 characters including spaces.
Please indicate if the activity addresses any of the following community needs *
Select up to three (3) needs.
Required
Please explain the anticipated impact of the activity
 *
 As relevant to the activity, include the number of individuals, counties, grades, ages, etc., served.  
Response limited to 1,000 characters including spaces.
Please indicate which priority population(s) will be served by the activity
 *
This includes age group, gender, race/ethnicity, uninsured, medically complex, etc. Also identify any high-risk or vulnerable populations targeted by this activity.
Response limited to 1,000 characters including spaces.
Please indicate if other organizations will be participating and describe their involvement 
*
Response limited to 1,000 characters including spaces.
FUNDING INFORMATION
Amount Requested *
Ascension Michigan will not consider requests exceeding $25,000.
Please enter digits only (e.g. $1,000 should be entered as 1000).
Previous Funding  *
Please indicate if the organization has received funding from Ascension during the current Fiscal Year (July 1, 2023 - June 30, 2024).
Which Ascension hospital are you requesting funds from?
 *
NOTE: The following hospitals are not currently accepting funding requests at this time: Ascension St. Mary's Hospital, Ascension St. Joseph Hospital, and Ascension Standish Hospital.
Please indicate how funds will be used
 *
Please provide answer for each question.
Yes
No
To secure a venue, staff, supplies, or other goods/services for the activity
To market, advertise, and/or promote the activity
To support operational costs of the organization, i.e. rent, salaries, office supplies
To contribute to a capital campaign
To provide direct services to individuals within the priority population as described above
If Yes to the above question: “To provide direct services to individuals within the priority population as described above”, please indicate what percentage of the request funds will be restricted to provide direct services to individuals within the priority population
Please enter digits only (e.g. 25% should be entered as 25).
MARKETING INFORMATION
If funding was awarded, please indicate the following
*
Please provide answer for each question.
Yes
No
Would Ascension receive tickets to the activity?
Would Ascension be publicly recognized as a funding partner?
Would Ascension become a member of the organization?
If Yes to the above question: “Would Ascension receive tickets to the activity?”, please indicate the fair market value of the ticket package that Ascension will receive
Please enter digits only (e.g. $250 should be entered as 250).
If Yes to the above question: “Would Ascension be  recognized as a sponsoring partner?”, please describe how Ascension will be recognized, including list of all places where Ascension’s name and/or logo will be used

Examples may include recognized on the organization’s social media platforms, media/news releases, program brochure/flier, email, annual report, electronic signage, etc.

Response limited to 1,000 characters including spaces.

Please clarify the marketing items (e.g. logo, ad) associated with the approved funding level, including the fair market value of marketing space that Ascension would receive
 *

Response limited to 1,000 characters including spaces.

Please indicate the start date of when Ascension’s marketing items (e.g. logo, ad) will be used?
 *
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Please indicate the end date of when Ascension’s marketing items (e.g. logo, ad) will be used?
 *
MM
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Prior to clicking the "Submit" button below, please email a copy of the organization's W-9 Form to micbie@ascension.org.
The W-9 Form is required by Ascension's payment processing system to verify the Taxpayer Identification Number (TIN) of organizations receiving funds from Ascension. It is requested as part of the Ascension Michigan's CBI Program submission process to ensure all necessary documentation is available should the funding request be approved. 

More information about the W-9 Form, including a blank version of the form, can be found here: https://www.irs.gov/forms-pubs/about-form-w-9.
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