Application: Agency Name:___________________________________________________
Address:______________________________________________________
City:_________________________________________________________
State:______________Zip:_________________
Telephone:______________________________
TITLE OF GRANT:_______________________________________________
BRIEF EXPLANATION OF PURPOSE OF GRANT:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
INTERNAL REVENUE SERVICE TAX EXEMPTION STATUS:
Date of 501(c)3 status:_________________
Date of 509(a) status:__________________
AGENCY DIRECTOR:
Name:______________________________________________________
Address:____________________________________________________
City:_______________________________________________________
State:________________________ Zip:_____________
Grant Amount Requested:
$__________________ Total Project Cost: $_________________
Percentage of Board of Trustees / Directors providing financial support: ______________
SUMMARY OF BUDGET RELATING TO GRANT
REQUEST:
IDENTIFY OTHER SOURCES OF FUNDING,
EITHER CURRENT OR APPLIED FOR:
PROPOSED PROJECT PERIOD:
Begins:________________ Ends:_____________________
STATEMENT Of THE PROJECT:
Provide a summary of
the project to include specific purpose of the grant request, administration,
program objectives, anticipated results, and method of evaluation.
CERTIFICATION:
I hereby certify the
above information is true and correct.
Signatures:
______________________________________________
date:________
Board President
______________________________________________
date:________
Agency Director