Global Health Corps

Partner Financial Assessment FY2019-2020

Thank you for your interest in becoming a Global Health Corps partner. If you would like any additional information about us at this time, you can visit our Be A Placement Organization page.

Please submit this form by 28 September 2018. Note that this form MUST be submitted by this date in order for your organization to be considered for partnership for the 2019-2020 fellowship year.

We highly recommend that a Finance staff member from your organization fill out this form.

Please make sure to press the "Submit" at the end of the form when you are finished!

Questions? Feel free to contact us at partners@ghcorps.org.

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Organization Name: *

Your Name: *

Email Address: *

Phone Number: *

Is the budget you are submitting at a multi-national organizational level or country/department level? *

Multi-national organizational level

Country/department level

Does your organization have audited financials? *

Yes

Please upload your organization's most recently audited financials. *

Please provide an action plan that would sustain the fellowship should your funding be reduced. Be as detailed as possible. * 🛈

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Revenue and Expenses

In the following sections, you will be entering information about your organization's revenue and expenses for the prior, current and next fiscal year.

Please enter the dates for the years below.

Prior Fiscal Year End
(DD-MM-YYYY) * +

Current Fiscal Year End
(DD-MM-YYYY) * +

Next Fiscal Year End
(DD-MM-YYYY) * +

Secured Revenue (USD)
For each row below, please provide the dollar amount of secured funding per fiscal year. Please round all amounts to the nearest whole number and mark any non-applicable fields with '0'.
NOTE: Do not list Global Health Corps as a source of funding. * 🛈

	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
1. Corporation	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
2. Foundation	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
3. Government	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
4. Individuals	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
5. In-Kind	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
6. Earned	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
7. Headquarters	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
8. Other	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year

What dollar amount of the total revenue is unrestricted for the fellowship? This means that funding for the fellows can be drawn from this source for the fiscal year that corresponds closely to the fellowship period, June 2019-August 2020. *

The total funding support you have listed in the sections above should closely reflect the operating income. If there is a significant variance, please explain in this section. If there is no significant variance, please indicate with 'N/A.' *

Expenses
Please provide your total operating expenses per fiscal year below.
*

	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
Personnel-Related Expenses	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
Other than Personnel-Related Expenses	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year
Total Annual Operating Expenses	Prior Fiscal Year	Current Fiscal Year	Next Fiscal Year

Current Fiscal Year Assets *

	Please round each amount to the nearest whole number.
Current Assets	Please round each amount to the nearest whole number.
Cash and Cash Equivalents	Please round each amount to the nearest whole number.
Account Receivables	Please round each amount to the nearest whole number.
Long Term Assets	Please round each amount to the nearest whole number.
Other Assets	Please round each amount to the nearest whole number.
Total Assets	Please round each amount to the nearest whole number.

Current Fiscal Year Liabilities and Net Assets *

	Please round each amount to the nearest whole number.
Current Liabilities	Please round each amount to the nearest whole number.
Long Term Liabilities	Please round each amount to the nearest whole number.
Other Liabilities	Please round each amount to the nearest whole number.
Unrestricted Net Assets	Please round each amount to the nearest whole number.
Temporarily Restricted Net Assets	Please round each amount to the nearest whole number.
Total Liabilities and Net Assets	Please round each amount to the nearest whole number.

I attest to the accuracy and validity of the information provided on this form. *

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