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MUHAMMAD SUBUH FOUNDATION www.msubuhfoundation.org

SUBUD HOUSE PROJECT APPLICATION FORM 2012-13 INSTRUCTIONS 1. Please fill in this form by computer or by hand, making sure you write clearly in English. If the space is insufficient or if you have additional information, please write this on a separate sheet of paper. After completing, print and sign, then scan all pages for emailing. 2. If you are unable to complete and forward all the items at the time you submit your application, you can supplement this information later, but remember missing information can slow up the processing of your application. 3. Send the application to the Administrator of the Muhammad Subuh Foundation at the following address, and copies to your National Committee and Zonal Representative: Lillian Shulman 8408 SE 33rd Ave Portland, OR 97222, USA Email: lillianshulman@netscape.net

A. WE ARE SENDING COPIES OF THIS APPLICATION TO: Name of National Committee Officer:       Name of Zonal Representative:      

email address:       email address:      

B. APPLICANT Name of Applicant (national organization or local group):

     

Name of person submitting application and with whom the Foundation should correspond:

     

Address for correspondence:

           

Telephone:

     

E-mail:

     

Fax:

     

C. LOAN OR GRANT We hereby apply for a grant/loan (or both) from the Muhammad Subuh Foundation for our Subud House project as follows: Grant (US dollars):

     

Loan (US dollars):

     

Total (US dollars:

     

D. CATEGORY (tick which ever is applicable) Muhammad Subuh Foundation Subud House Grant/Loan Application Fill-in form v3-2011

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National Subud House

Local Subud House

E. PROJECT OUTLINE (please tick the applicable boxes) We plan to purchase a plot of land and build a Subud house on it We already have the land and plan to build a Subud house on it We plan to purchase a space/floor in an existing building We plan to purchase an existing house for developing a Subud house Other (please specify, if it is for renovations, or additions, for an enterprise, etc):      

F. INFORMATION ABOUT YOUR GROUP/COUNTRY 1. Total membership in your country:

Men:      

Women:      

2. Total membership of the local group:

Men:      

Women:      

3. Any other planned use of the Subud House, apart from latihan?       4. Importance/priority/benefit of this project for your group/country?       5. Names of any International Helpers, WSC members or MSF Foundation Trustees who visited the land/project, if any:      

G. DOCUMENTS REQUIRED 1. An English translation of the resolutions taken at the national/group levels relating to the project is: Enclosed

To follow

2. Details of the organization that will own the property after the project is completed: Name:       Address:       Dates of Fiscal Year:       3. Provide details on the legal status of the above organization under the laws of your country:       4. A copy of the founding (articles) documents of the Subud organization in your country is: Enclosed

To follow

5. IMPORTANT: Is Subud legally registered in your country?

YES

NO

Can the organization own property?

YES

NO

If the answer is No, please provide reason & possible solution:      

H. DETAILS OF LAND/BUILDING 1. Provide complete address of Subud house:             2. Provide telephone number at Subud House, if available:       3. (a) Are public transportation facilities available to the property location? (b) Is parking available at the property location?

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YES

NO

YES

NO

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4. Is it easily accessible by most members of your group? 5. What is the size of:

YES

land:       building:       floor space:      

NO

sq meters

feet

6. Expected purchase price and/or building cost (in US dollars):       7. Expected legal costs to transfer property into the Subud organization’s name (in US dollars):       8. Property liens: A full and complete title search was conducted and it revealed no liens nor encumbrances (Please enclose a copy thereof as evidence or explain how the title search was made) The title search is still to be completed, explanation on results to follow 9. Building permit:

Enclosed

To follow

This area does not require any building permit from the government to build a Subud House It is not customary to obtain building permits in this area (Please explain why not):      

I. HOUSE DESIGN 1. Total floor space

No. of sq meters:      

No. of stories/floors:      

2. Room plan (please submit a plan of the land and a simple drawing of the building plan on A-4 or letter size paper) 3. Construction schedule (Timeline for various stages):      

J. BUDGET AND FINANCES (in US$) 1. Total cost:       2. Total Funds collected so far:       (a) Funds collected from other Subud organizations (please list):             (b) Pledges from members so far (please list):       3 (a) Other expected income (e.g. renting out premises, enterprise, etc.):       (b) Fund raising activities:       4. Expected maintenance costs (utilities, taxes, upkeep, repairs, etc.) – monthly:      

K. BANK INFORMATION Account name:       Account number:       Bank name:       Bank address:       Swift code no:       Other routing code (specify):      

ABA No:      

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DOCUMENTS REQUIRED: A certificate or letter from your bank showing that at least two signatures are necessary for withdrawing money from the account into which funds will be placed for the project. This document is required by MSF before any money transfers will be made. Legal and Subud names and positions of account signatories: 1.       2.       3.      

L. CURRENCY EXCHANGE RESTRICTIONS This information is very important and should be accurate, so please provide a written opinion from a lawyer, your banker, or a letter from the government concerning any currency exchange restrictions about the movement of funds to/from overseas. If the document is not in English, translation by an authorized translator is required before it is sent to the Muhammad Subuh Foundation. Enclosed

To follow

M. LOAN (if you apply for a Muhammad Subuh Foundation loan) 1. Taking out a loan for this project is/has been allowed by: The constitution of our organization A decision of the governing body A decision by our National Committee on:       /       /      

(date DD/MM/YYYY)

Other (please specify):       2. State length of period desired to pay back the loan: (please provide your repayment plan and schedule)

     

years

3. How much can you pay per month/quarter/year on the Loan Amount?       US$/month

      US$/quarter

      US$/year

4. How soon after the funds are given will the first payment start?       months 5. Interest payment: We will be capable of paying interest up to       % yearly, if required We will be unable to pay any interest (if you tick this space, please explain, why it is not possible for the group to pay any interest on the loan amount) Reason:       6. Have you obtained loans from local banks, or elsewhere (from members)? If so, what were the results?      

7. LOAN GUARANTEES - If a loan is requested The following members have offered to personally guarantee to repay any loan provided by the Muhammad Subuh Foundation to the group / organization: Name:       Amount (US$)       Name:       Amount (US$)       Name:       Amount (US$)       Name:       Amount (US$)       Name:       Amount (US$)       Name:       Amount (US$)       Total (US$)       We hereby guarantee that the loan will be repaid in full to the Muhammad Subuh Foundation. We hereby agree that no sale or extra mortgages of the property will be undertaken without the

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written agreement of the Muhammad Subuh Foundation.

We declare that the information in this application is true (all group helpers and committee members should sign). Attach a separate sheet if necessary. Signed by: ______________________________ (Signature) Name:      

Dated:      

Signed by: ______________________________ (Signature) Name:      

Dated:      

Signed by: ______________________________ (Signature) Name:      

Dated:      

Signed by: ______________________________ (Signature) Name:      

Dated:      

Tick one:

Tick one:

Tick one:

Tick one:

helper

committee

helper

committee

helper

committee

helper

committee

N. REPORTING You will be requested to send a Letter of Agreement (model included below) and a yearly report (model included below) including photos to the Muhammad Subuh Foundation’s Administrator – with copies to your National Committee and Zone Representative. MSF will send you the Agreement Letter to sign if funding is awarded and the Yearly Report Form to be filled in and returned to us in a timely manner after the end of the fiscal year in which the funding is awarded. The yearly report should be signed by all helpers and committee members in your group. Agreed by: (Person submitting application and with whom the Foundation should correspond) Name:       Subud function/title:      

Signature:________________________________

Date:      

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MODEL LETTER OF AGREEMENT - __________________________________ Dear

_______________:

It is my pleasure to inform you that the Board of Trustees of the Muhammad Subuh Foundation (Grantor) has approved a grant as follows: GRANT AMOUNT: ___________ TO: __________________________ in support of the following charitable purpose: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Grant payment will be made according to the bank account given in your application. The grant funds will be used as described in your grant proposal: _______________ ___________________________________________________________________ These grant funds are to be expended over the period _____ through ___________ In order to abide by U.S. laws under which the Muhammad Subuh Foundation is registered, the following terms and conditions apply to your organization's use of the Foundation's grant: 1. Purpose Under United States law, Foundation grant funds, and income earned on those funds, may be spent only for charitable, religious, scientific, literary or educational purposes. This grant is made only for the purposes stated in this letter, and it is agreed that these grant funds will be used only for such purposes substantially in accordance with the budget submitted with your grant proposal. It is also understood that no substantial changes will be made from the approved budget without the Foundation's prior approval in writing. 2. Separate Fund All Foundation grant funds received by your organization must be maintained in a separate fund dedicated to the charitable purposes described in this letter. Such a separate fund may be either 1) a physically separate bank account restricted to the described charitable purposes, or 2) a separate bookkeeping account (limited to the described charitable purposes) maintained as part of your financial records. The Foundation encourages, whenever feasible, the deposit of grant funds in an interest bearing account. 3. Reporting A written report signed by an appropriate officer of your organization must be furnished to the Foundation to the attention of: within three (3) months after the close of each fiscal year in which your organization receives or spends any portion of Foundation grant funds (including income, if any, from such funds) until the grant funds are spent in full or the grant is otherwise terminated. According to our records, your organization's fiscal year ends: ________ The report for each fiscal year is due no later than: ____________

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In addition, within three (3) months following the fiscal year end in which your organization completes its use of the grant funds, a final written report is to be furnished to the Foundation with respect to all expenditures under the grant (including salaries, travel, and supplies). Interim annual reporting will be required, in writing, until all grant funds are expended. Each written report, including the final written report, must contain two parts: a narrative account and a financial account of what was accomplished by the expenditure of the grant funds during the period covered by the report. A. Narrative Account: The narrative account should provide a detailed description of what was accomplished by the grant, including a description of the progress made toward achieving the goals of the grant and an assurance that the activities under the grant have been conducted in conformity with the terms of the grant. B. Financial Account: The financial account should provide a financial statement reporting, in U.S. dollars, all expenditures of Foundation grant funds and any income earned on those funds. The financial statement should include only Foundation funds received and expended under this grant during the period covered by the report. It is assumed that the financial statement will be prepared from books and records maintained on a fund accounting (cash) basis. Only expenditures made in support of the grant purposes should be charged against the grant, and records should be maintained of such expenditures adequate to enable the use of such funds to be checked readily. If written reports are not submitted to the Foundation on a timely basis, United States law requires that the Foundation withhold further payments, if any, to your organization and to any affiliate organization under this grant or under any other Foundation grant and prohibits the Foundation from awarding any new grants to your organization or any affiliate organization. 4. Record Maintenance and Inspection Your organization must maintain records of receipts and expenditures and make your books and records available to the Foundation for inspection at reasonable times. The Foundation may monitor and conduct an evaluation of operations under this grant, which may include a visit by Foundation personnel to observe your organization's program, discuss the program with your organization's personnel and review financial and other records and materials connected with the activities financed by this grant. 5. Record Retention [for private foundation grantees only] If you are classified by the Internal Revenue Service as a private foundation, United States law requires that such accounting records, as well as copies of the reports submitted to the Foundation, be kept by your organization for at least four years after completion of the use of the grant funds. 6. Prohibited Activities So that the Foundation may comply with the tax laws of the United States, it is understood that Foundation grant funds will not be used for any of the following purposes: A. To carry on propaganda, or otherwise to attempt to influence any legislation (within the meaning of Section 4945(d)(1) of the United States Internal Revenue Code); B. To influence the outcome of any specific public election or to carry on, directly or indirectly, any voter registration drive (within the meaning of Section 4945(d)(2) of the United States Internal Revenue Code ["IRC"]); C. To make grants to individuals for travel, study or other similar purposes by such individuals (such as scholarships, fellowships or grants for research), unless such grants satisfy the requirements of Section 4945(g) of the IRC;

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D. To make any grant to any other organization (other than to public charities or exempt operating foundations) which does not comply with the requirements of Section 4945(d)(4) of the United States Internal Revenue Code; or E. To undertake any activity for any purpose other than the charitable purposes specified in Section 170(c)(2)(B) of the United States Internal Revenue Code. If you have further questions regarding activities that are not permitted, please contact the Foundation. 7. Return of Unused Funds Any grant funds, and any income earned on those funds, that are not spent or committed for the purposes of the grant, must be returned to the Foundation. 8. Compliance The Foundation reserves the right, in its sole discretion, to discontinue funding if it is not satisfied with the progress of the grant or the content of any written report. 9. Donor Recognition The Foundation requests that its support be publicized in your organization’s annual reports, website, newsletters, brochures, and any other materials as appropriate. If this letter correctly describes your understanding of the terms of this grant, please indicate your organization's agreement to such terms by having the enclosed copy of this letter signed by an appropriate officer of your organization and returned to the Foundation to the attention of : _________________________ In signing this letter, such officer represents to the Foundation that he/she has the authority to sign this letter on the organization's behalf. Payment of any grant funds will commence following receipt by the Foundation of a signed copy of this letter. On behalf of the Foundation, may we extend every good wish for the success of your work. Sincerely, __________________ ACCEPTED AND AGREED this

day of

, 20

ORGANIZATION LEGAL NAME: ________________________ By:

Printed Legal Name: _____________________

(Signature)

Title: ___________________________ To facilitate receipt of grant funds, complete the following: Payment will be made payable to: ____

________________________________________________

Check here and complete if payment should be mailed (provide address): _________________________________ _________________________________ _________________________________

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_____________________________

____

Check here if payment should be wired and attach separate sheet with complete wire instructions (used only with non-U.S. accounts)

This page may be printed, signed, scanned (or digitally photographed - please make sure everything is still legible), and re-attached to your acceptance form for emailing as a Word doc or PDF. Please return this form to the MSF Administrator via email: lillianshulman@netscape.net or via post to: Lillian Shulman 8408 SE 33rd Ave Portland, OR 97222, USA

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MODEL Subud House Yearly Report for the year: ____ The Muhammad Subuh Foundation - similar to all donor organizations - is responsible for the proper use of the funds it allocates to various projects. For this reason, and also to keep our records and website up-to-date, we need recipients to send us a brief yearly update on the progress of their Subud house project. The information we require is as follows:

Name of group:

Country:

1. Contact person: Postal address:

Telephone:

Fax:

Email address: 2. Number of members regularly using the house: 3. Who is the owner of your Subud house?

(Tick one)

Men

Women

Your national Subud organization Your group Other

4. Condition of house (regular maintenance/repairs needed/etc.). Please describe:

5. Have taxes, electricity, insurance been paid up-to-date?

Yes

No

6. Do you still have a mortgage or loan on the house? If yes, please give details:

7. Present use of premises For latihans,

(tick all uses applicable):

(number of)

For group meetings

times each week

(number of)

times every year

Rented to individuals or other organizations. Please describe:

Other uses. Please describe:

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8. Future plans (Do you plan, for example, to make an enterprise or a Susila Dharma project in the house?):

Date of report: This yearly report should be signed by a majority of helpers and committee members in your group, and a copy forwarded to your National Committee and Zone Representative. This page may be printed, signed, scanned (or digitally photographed - please make sure everything is still legible), and re-attached to your report form for emailing as a Word doc or PDF.

We declare that the above information is true (a majority of group helpers and committee members should sign). Attach a separate sheet if necessary. Signed by: Name: (Signature)

Dated: Signed by: Name:

Tick one:

helper

committee

Tick one:

helper

committee

Tick one:

helper

committee

Tick one:

helper

committee

Tick one:

helper

committee

(Signature)

Dated: Signed by: Name: (Signature)

Dated: Signed by: Name:

(Signature)

Dated: Signed by: Name: (Signature)

Dated:

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Please include several recent photos of your Subud house and send this form, together with photos, via email to Lillian Shulman, MSF Administrator: lillianshulman@netscape.net If email is not possible, you may send a signed hard copy and photos to: Lillian Shulman 8408 SE 33rd Ave Portland, OR 97222 USA (Please allow adequate time for international post.)

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MSF_Grant-Loan_House_Application_Fill-in_form_2012-13