Amount Requested |
Please enter the Dollar Amount Requested: |
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Organization Information |
Tax identification number issued by the IRS: |
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Legal name of organization (as listed on IRS): |
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* Organization is also known as: |
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Contact Person Name: |
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* Title: |
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E-Mail Address: |
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Phone: |
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* Fax: |
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Address: |
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City: |
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Zip Code: |
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* Website Address: |
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Brief description of organization's history, mission statement, including the year your organization was established:
(one paragraph) |
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List and brief description of organizational programs and services offered:
(no more than one paragraph per program or service) |
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List and brief description of recent organizational accomplishments:
(one paragraph) |
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Organization's fiscal year (e.g. January 1-December 31): |
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Annual operating budget (for the current year, the amount of the total annual organizational budget): |
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Program Request |
Project start and end dates (period your funding request covers): |
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One sentence program title: |
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Description of request, including its principal objectives and expected outcomes: |
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Problems and issues your program or organization address: |
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Qualifications of your organization and its principal personnel to implement the stated objectives and achieve the intended outcomes: |
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Degree to which your proposal builds on existing services in the community rather than duplicating them: |
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Funding received to date for your program as well as sources from which funding is being sought: |
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Plans for sharing knowledge about the program/organization with other in your field: |
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General explanation of how the requested funds will be used:
(e.g. personnel, supplies) |
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Number and description of the targeted population to benefit from your program:
(e.g. 30 low-income Hispanic children, ages 12-15) |
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Geographic area(s):
(state, county, city, neighborhood to benefit from the request) |
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Amount of the total project budget: |
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* Describe the gender, ethnicity, and population served if over 50% of clients served by your program/organization belong to a defined group: |
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Do you have collaborative partners? |
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