SS Org. Eval. Form

For 4Culture Use Only

Contract No. Program Name

CP – Preservation Sustained Support

Date Received Program Coordinator

ORGANIZATION EVALUATION FORM – Preservation Sustained Support Please complete the following form. This information allows us to evaluate the effectiveness of our programs, and the impact of 4Culture funding for preservation operations. This evaluation should be completed and submitted with the invoice within three weeks of the end of December. No final payment can be made until this form is received.

Organizational Information Organization Name: Address: Evaluation Completed By:

Phone:

Specifically, how did funding from 4Culture impact your program? (Suggested 4-8 lines. Examples might include information on ways in which the award allowed you to leverage support from additional sources; expand your capacity; better serve your core constituency; promote preservation, etc.)

Please describe demographics of those served by your programs (If applicable, also note and describe new audiences reached)

Organization Evaluation Form Page 2 of 2

Credits: please describe how “4Culture King County Lodging Tax” logos were used and/or credits made (on newsletters, other publications, web sites, exhibits, marketing or program materials.)

Attachments  Sample Marketing or Program Materials that include 4Culture King

County Lodging Tax logo (minimum of 3 examples)

 Final 2014 Budget (for both income and expenses, and including in-kind contributions)  5-8 Digital Photographs documenting your Programs including a

permission statement & photo credit information

(Must be submitted on CD or DVD, should be between 2 – 5MB, or maximum 300 dpi. We will not accept images sent by email. For more information, review the Photo Documentation Guidelines sheet included with your contract packet,or visit the “Manage Your Award” section on the program’s webpage.)

 Public Benefit Description: on a separate sheet of paper, please describe

your principal public benefits activities and services provided during the year, as outlined in the Contract Scope of Services (See Exhibit A at the end of the contract. Please provide specific information about programs and services.)

Quote (optional) Please provide a quoted “testimonial” from a participant in your programs (yourself, a visitor, constituent, community member, elected official, etc.) demonstrating the impact of your program.

Signature: Date:

Phone:

Organization Evaluation Form Page 2 of 2 Signature of this form implies consent for 4Culture to use any of the text or photographs submitted in organizational materials to include, but not limited to: website, official reports, educational documents, press releases and promotional materials, and annual report.