Grant Application

Phone Numbers*

Number	Type (mobile, fax, etc.)

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(if other than above)
Request Data
Project Title*
Total Budget for this Project*
Request Amount*
Estimated Start Date*
Date Format: MM slash DD slash YYYY

Communities Served*

List the communities / counties served by this project

Program Reach*
Total number of people to be served during grant period
Youths with Disabilities Reach*
Total number of people under age 21 with documented physical or mental disabilities to be served by this project.
Type of Request*
- Capital
- Technical assistance
- Operating
- Endowment
- Program / Project Start-up
- Other
Type of Request (Other)*
Please specify
Project Description
Summary description of overall project to be funded under this grant*
Brief description of goals and objectives for this project*
Timetable for implementation and duration of project*
Provide a brief summary of the organization's mission and/or history.*
Provide a brief description of current programs/projects and activities other than the proposed.*
Required Financial Attachments
Project request budget*
Accepted file types: pdf, doc, docx, xls, xlsx.
For your entire project
IRS Letter of Determination*
Accepted file types: pdf, doc, docx.
501(c)(3) organization
Other Required Information

Board Members*

Name	Organization

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Organization Information