Todays Date: ____________

ACCESS! Grand Rapids: Agency Update

August 2014-June 2015
Agency Name: ___________________________________________________________________
Mailing Address:__________________________________________________________________
City, State, Zip:___________________________________________________________________
Website:
Staff Contact at Agency
(Person who will handle ticket requests)

Phone

E-mail

ext.

_______

Fax

*All update are sent via EMAIL. Please ensure that we have a current address and that your system is set up to
receive messages from us.

Contact Persons Position at Agency____________________________

*In order to ensure the most up-to-date information, please bookmark our website and facebook pages:
www.artistscreatingtogether.org & www.facebook.com/accessgrhotline

PLEASE PRINT OR TYPE CLEARLY. All information must be completed and returned for
continued service. Please fill out completely - our funders require this information.
Primary County

_____ Other Counties Served

_______

Areas of Service Check all that apply:

Number of People and Age Groups Served:

____
____
____
____
____
____
____
____

_______ Total number of people served yearly

_____% Adults ages 26+
_____% Adults between 19 and 26
_____% Youth between 7 and 18
_____% Youth between birth and 6
_____ % Male
_____ % Female

Mental Health
Cognitive Disabilities
Substance Abuse/Recovery
Developmental Disability
Mobility Impairment
Blindness/Visual Impairment
Deafness/Hearing Impairment
Other: ______________________

Which is the primary area of service?

What was your total actual expenses for your

last completed fiscal year? ________________
What is your total budget for your current
fiscal year?_____________________________

Page 1

Is your Agency a Non-Profit? _____Yes _____No

*If no, please contact the Program Director BEFORE completing this form.
Please add these additional staff e-mail addresses who would like to receive the ACCESS! Grand Rapids
Monthly Update. Only the official Agency Contact may make ticket requests.
Name:

___

Name:

Title: __________________
___ Title: ___________________

Email:

_______

Email:

_______

Agency Description briefly state the general purpose and goals of your agency what you do, not your mission
statement.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Demographic info Our funders require this information from us.

Of the total number of people served each year, what percent are:
_____ % Caucasian
_____ % African American
_____ % Hispanic
_____ % Asian American
_____ % Pacific American
_____ % Native American
_____ % Children with disabilities
_____ % Adults with disabilities

Agency Certification
We certify that the information included in this agency update is true and complete to the best of our
knowledge.
Agency Director

Staff Contact at Agency - handling requests

Signature ___________________________

Signature _____________________________

Name ______________________________

Name ________________________________

(Please print)

(Please print)

Date signed _________________________

Date signed ___________________________

Telephone _________________ Ext______

Telephone ___________________ Ext______

Page 2

ACCESS! Grand Rapids: Agency Invoice for August 2014-June 2015

For services through June 30, 2015

Agency Name: ________________________________________________

Please return a copy of this invoice with your payment & agency sign-up form.
A copy of this invoice ensures that your account is credited accurately.

Your Agency Budget for FY15 (must be 3rd party verifiable):

Amount Due:

$___________________________

$_____________________________________
(Use sliding scale below to determine fee)

If your Agency Budget Is

Your 2013/2014 Fee Is

Up to$50,000
$50,001.................$100,000
$100,001.$250,000
$250,001...............$500,000
$500,001$1,000,000
$1,000,001.$1,500,000
$1,500,001............$2,000,000
$2,000,001.$3,000,000
$3,000,001............$4,000,000
$4,000,001.......... and above

$50.00
$75.00
$170.00
$175.00
$280.00
$300.00
$446.00
$557.00
$667.00
$686.00

Make check payable to: Artists Creating Together

If paying by credit card, circle:
Name on Card

VISA

MasterCard

Signature

____

(Please print)

Card Number

Expiration Date_____________Zip Code _____________

Three or Four Digit Security Code:____________________(Located on the back of a Visa or Mastercard)

Submit completed form and Agency Invoice to ACT at:

Mail: 1140 Monroe Ave NW, Suite 4101; Grand Rapids, MI 49503
E-mail: program@artistscreatingtogether.org
Fax: #616-885-5867
If you have any questions, please contact ACT Program Director, Katie Brower at
#616-885-5866 or program@artistscreatingtogether.org
ACCESS! Grand Rapids Sign-up form and Agency Invoice are adapted from VSA Georgias 2013-2014 Agency Update form and
Invoice for their Community Events program.