Organization
Name
_______________________________________________________________
Address ________________________________________________________________
City____________________________________________________________________
State___________________________________Zip______________________________
IRS Determination____________________Type_________________________________
Contact
Contact Name____________________________________________________________
Title____________________________________________________________________
Phone___________________________________________________________________
Email____________________________________________________________________
Other
Info________________________________________________________________
Amount
Requested__________________________________________________________
Purpose of Grant___________________________________________________________
Date Needed______________________________________________________________
Project Summary
In a half page, summarize why your organization is requesting this grant, what outcomes you hope to achieve,
and how you will spend the funds if the grant is made.
