SAMPLE Inquiry Form (NOT LIVE; FOR ILLUSTRATION Only)

Introduction

Thank you for your interest in SeaChange. PLEASE NOTE THAT THIS VERSION IS ONLY TO SHOW YOU THE QUESTIONS. THE ACTUAL FORM TO APPLY FOR A LOAN OF GRANT IS HERE. Please feel free to reach out to us at any time at info@seachangecap.org if you'd like to discuss your situation directly before completing the form. Please note: for inquiries related to higher education please use our higher education form instead.

Contact Information

Last Name

First Name

Email

Phone Number

Use format ###-###-####

Title

Organization

Website

Nature of Inquiry

What are you interested in?

Please select... A grant (to support a merger or sustainable collaboration) A loan (New York and Philadelphia only) A consulting project (e.g. financial analysis, restructuring support, etc) Learning more about SeaChange or its funds. Other

Please elaborate on the situation and how you think SeaChange might be able to help

How did you learn about SeaChange?

Please select... Referral Media Panel/Presentation Internet Search Other

Please explain

Organization Information

Organization Information

Contact Information

Last Name

First Name

Email

Title

Phone Number

Use format ###-###-####

Is the primary contact also the Executive Director / CEO?

Please select... Yes No

Executive Director

Last Name

First Name

Phone

Email

Title

Organization

Street Address

Town/City

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Zipcode

Legal Status: 

Please select... 501(c)3 / Nonprofit 501(c)4 B-Corp Fiscally sponsored program of a 501(c)3 Private Foundation

EIN

Use format ##-#######

Please briefly describe the organization's mission and core programs/services.

Financial Information (Organization One)

How would you describe the organization's financial health?

Please select... Strong Stable Weak Crisis

In the most recent fiscal year, did the organization show a surplus, a deficit, or breakeven?

Please select... Surplus Breakeven Deficit

In the current fiscal year, do you expect a surplus, a deficit, or breakeven?

Please select... Surplus Breakeven Deficit

Do you receive, or have you received in the last three years, support from?

The Altman FoundationThe Booth Ferris FoundationThe Clark FoundationThe Heckscher FoundationThe JM Kaplan FundThe New York Community TrustThe Thompson Family FoundationThe Lily Auchincloss FoundationThe Mertz Gimore FoundationNone of the Above

Please attach the following documents where available

Tax Exemption Certificate (mandatory)Audited Financial StatementsMost Recent Unaudited FinancialsCurrent Year Budget/ProjectionsProject Budget (if applicable)Other Documents (up to three) that you would like us to reviewPlease note that while this materials are not mandatory at this point they will be required to move to the next phase of the process.

If you are attaching other files please describe them:

Attach files here

Contact and Organization Information (Organization Two)

Contact Information

Last Name

First Name

Email

Title

Phone Number

Use format ###-###-####

Is the primary contact also the Executive Director / CEO?

Please select... Yes No

Executive Director

Last Name

First Name

Phone

Email

Title

Organization Information

Organization

Website

Street Address

Town/City

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Zipcode

Legal Status: 

Please select... 501(c)3 / Nonprofit 501(c)4 B-Corp Fiscally sponsored program of a 501(c)3 Private Foundation

EIN

Use format ##-#######

Please briefly describe the organization's mission and core programs/services.

Financial Information (Organization Two)

How would you describe the organization's financial health?

Please select... Strong Stable Weak Crisis

In the most recent fiscal year, did the organization show a surplus, a deficit, or breakeven?

Please select... Surplus Breakeven Deficit

In the current fiscal year, do you expect a surplus, a deficit, or breakeven?

Please select... Surplus Breakeven Deficit

Do you receive, or have you received in the last three years, support from?

The Altman FoundationThe Booth Ferris FoundationThe Clark FoundationThe Heckscher FoundationThe JM Kaplan FundThe New York Community TrustThe Thompson Family FoundationThe Lily Auchincloss FoundationThe Mertz Gimore FoundationNone of the Above

Please attach the following documents where available

Tax Exemption Certificate (mandatory)Audited Financial StatementsMost Recent Unaudited FinancialsCurrent Year Budget/ProjectionsProject Budget (if applicable)Other Documents (up to three) that you would like us to reviewPlease note that while this materials are not mandatory at this point they will be required to move to the next phase of the process.

If you are attaching other files please describe them:

Attach files here

Loan Application: Loan Information

What type of loan are you seeking?

Please select... Working Capital Real Estate Finance Refinancing Bridge Finance Expansion/Growth Other

Please briefly describe how you will use the proceeds of the loan?

What is the total amount of the loan that you are seeking?

How long do you expect to need the funds?

Please select... < 1 Year 1-3 Years 3-5 Years More than 5 years

How will you repay the loan?

Please select... Refinancing by other lenders at project completion City or State Funding Operating Surplus Earned Income Sale of an asset Philanthropy Other/Unsure

Please explain what conversations you have had with traditional lenders (e.g. banks or CDFIs). Why is the loan not easily financed by these lenders?

What will the funds allow you to do in terms of program impact and how will this be measured?

Is the board aware that you are seeking a loan?

Please select... Yes No

Board Member

Merger and Sustainable Collaboration Application: Process Status

Please very briefly explain the potential collaboration and the current status of the process

What is the status of the collaboration?

Please select... Exploration/Discussion Planning Implementation Completed

How do the organizations know each other

Overlapping Board MembersCommon FundersJoint Programmatic WorkStaff ConnectionsOther

If this survey is not being filled out by one of the contacts please briefly explain who you are and what role you are playing in the proposed collaboration

What best describes the type of collaboration you are proposing?

Please select... Merger Program Back Office Other

How long ago did discussions begin?

Please select... Less than one month 1-3 months 3-6 months 6-12 months 12-24 months Don't know

Who first initiated discussions

Please select... Executive Director/President/CEO Board Member(s) Funder(s) Community Leaders/ Organizations Other

Is this the first time the organizations have been in discussions?

Please select... Yes No

If a Memorandum of Understanding (MOU), Term Sheet, or similar document has been signed b the organizations, please attach it:

What are the principal benefits of the proposed collaboration?

What are the principal risks associated with the proposed collaboration?

Have you estimated the one-time costs associated with exploring or completing the collaboration?

Please select... Yes No It's in process

Please attach a spreadsheet with a a breakdown of the estimated costs and note any which have already been paid.

Merger and Sustainable Collaboration Application: Process (continued)

In addition to a possible grant from from SeaChange or its affiliated funds, how do you expect that the costs will be covered?

Funding from one or more of the organizationsNew Support from Existing FundersSupport from New Funders

Have other funders been approached for support

Please select... Yes No - But we intend to No - We do not intend to

If yes, please provide a list of potential and committed funders and their actual/expected levels of support

Has a consultant/mediator/facilitator been engaged in the process?

Please select... Yes Not Yet We do not intended to use a consultant

Please explain who retained (or expect to retrain) and the process by which they were selected

If you have signed (or expect to sign) an engagement letter, please attach it

Consulting Inquiry

What best describes your consulting need?

Please select... Financial Analysis/Modeling Restructuring Support Risk Management Fund Structuring and Design Transaction Support Other

Please describe the situation that you face and how you believe SeaChange may be able to help.

Please rest assured that all information collected by SeaChange will be treated confidentially.

Please attached any files that you think would be helpful for us in understanding your situation?

Thanks for your interest

We take confidentiality very seriously. However, in order to move forward with a grant or loan we will need to seek approval from certain of our funding partners. Do we have your permission to share your information with our funders at this time?

Please select... Yes No

We strive to be respectful of the scare time of our potential nonprofit partners. How long did this form take you to complete?

Please select... Less than one hour Two - Three Hours More than three hours

Do you have any comments on what would make it more helpful?