Non-profit Community Grant to assist with the Treatment and Prevention of Bed Bugs

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1 Non-profit Community Grant to assist with the Treatment and Prevention of Bed Bugs The purpose of this grant is to provide community based non-profit organizations with funding for bed bug treatment/management, prevention and education. Eligible organizations may receive grants under this program for up to a maximum of $ Public institutions such as schools, prisons and hospitals, as well as private businesses, are not eligible for funding. Please complete all sections in full. Incomplete applications will result in processing delays. SECTION 1 ORGANIZATION INFORMATION Organization name: Organization mailing address: Organization physical address (if different from above): Name / title of contact person: Phone: Fax: Website: Full Mailing Address (If Different from Above): Does your organization qualify as a non-profit organization as defined by the Canada Revenue Agency*? Yes or No * A non-profit organization is an association, club, or society that is operated exclusively for social welfare, civic improvement, pleasure, recreation, or any other purpose except profit. It is not a charity. No part of the organization s income can be payable to or available for the personal benefit of any proprietor, member, or shareholder, unless the recipient is a club, society, or association whose primary purpose and function is to promote amateur athletics in Canada. From Does your organization qualify as a licensed child care facility? Yes or No Identify and briefly describe the programs and/or services that your organization provides: Identify and briefly describe the target population* served by your organization: * Target population means the subgroups of the population that your organization serves, such as the elderly, youth, persons with disabilities, families etc. Has your organization had an infestation of bed bugs in the past? Yes or No If yes, how did you treat the problem? Does your organization currently have an infestation of bed bugs? Yes or No 1

2 SECTION 2 FUNDING REQUEST How much funding is your non-profit organization applying for with this application (up to $2,000.00)? Has your non-profit organization previously received funding for bed bug treatment, education or prevention products or services? Yes or No Was this funding from municipal, provincial, federal programs and/or another organization? Yes or No If yes, please name those programs and/or organizations and the year funding was received. How does your organization plan to use this grant? 1. Prevention (ex: mattress covers, washer and dryers, etc.) 2. Treatment (ex: cost sharing extermination fees) 3. Education (ex: pamphlets, presentations, other printed materials, etc.) 2

3 SECTION 3 DETAILED BUDGETS PREVENTION If your organization will be using this grant, in whole or in part for prevention of a bed bug infestation, or to prevent the re-occurrence of a bed bug infestation, please provide details in the chart below about the type and number of preventative items planned for purchase and cost per unit. For prices of items purchased through the Manitoba Bed Bug Prevention Materials Program, please call MB-BUGS ( ) or us at bedbugs@gov.mb.ca On a separate page of paper, please describe in detail your complete prevention plan and how the products or services mentioned in the chart below will help you to prevent a bed bug infestation or to prevent the re-occurrence of a bed bug infestation. TYPE OF PREVENTATIVE ITEMS NUMBER COST PER ITEM SUB-TOTAL Ex: Twin Bed Bug Proof Mattress Covers 15 $ $ Ex: Full/Double Bed Bug Proof Mattress Covers 5 $ $ TOTAL PREVENTION BUDGET must be received before a grant cheque will be issued. REQUIRED: Attach the complete prevention plan to your application when you submit it for approval. (For helpful information on bed bug prevention visit our website at 3

4 SECTION 3 DETAILED BUDGETS CONT D TREATMENT (hiring a certified pest management professional) If your organization will be using this grant, in whole or in part for treatment of a bed bug infestation, please provide details in the chart below about the type of treatment planned (or completed). TYPE OF EXTERMINATION SERVICE ROOMS ROOM SUB-TOTAL Ex: Chemical Treatment 10 $ $ Ex: Heat Treatment 1 $ $ TOTAL TREATMENT BUDGET Required: An official quote from a professional exterminator must be attached to this application, in support of any costs itemized above. Many companies will provide you with a free estimate of costs. must be received before a grant cheque will be issued. For helpful information about preparing your unit(s) for treatment, visit our website at EDUCATION If your organization will be using this grant, in whole or in part for education about bed bug infestations, treatment or prevention, please provide details in the chart below about the type of education materials requested. To find out about available education print materials, please either call MB-BUGS ( ) or us at bedbugs@gov.mb.ca If you organization has a plan to educate staff and others about bed bugs and ways to prevent infestations, please provide complete details about your plan on a separate piece of paper and attach it to your application. EDUCATION NUMBER COST PER ITEM SUB-TOTAL e.g., Print materials to hand out to participants 20 $ 1.00 $ TOTAL EDUCATION BUDGET must be received before a grant cheque will be issued. 4

5 SECTION 3 DETAILED BUDGETS CONT D COMBINED TOTAL BUDGET: PREVENTION $. TREATMENT $. EDUCATION $. TOTAL GRANT REQUESTED (not to exceed $ ) $. SECTION 4 PAYMENT OF FUNDING Please indicate the name of the organization the cheque should be made payable to if your application is approved. Please make cheque payable to (please print): Cheques must be made payable to an organization, not to an individual. Copies of receipts and/or proof of payment for all expenses must be received prior to a cheque being issued. SECTION 5 DECLARATION By signing below, I state that all information included within this grant application is, to the best of my knowledge accurate. Applicant s name (please print) Applicant s title (please print) Applicant s signature Date SECTION 6 SUBMITTING YOUR APPLICATION Please return your completed application (and all required attachments) by mail, fax or to: Manitoba Health, Seniors and Active Living Bed Bug Grant Program Carlton Street Winnipeg, MB. R3B 3M bedbugs@gov.mb.ca If you have any questions or require further information please call MB-BUGS ( ), us at bedbugs@gov.mb.ca or visit our website at 5