Grant Application

Organization Information
Application Organization*
Full Legal Name
Doing Business As
Previous Name
If Changed
Tax Exempt ID #
(attach IRS determination letter if available)
Executive Director*
Contact Information
Name*
Prefix First Middle Last
Title*
Email*
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*
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
Captcha

Save and Continue Later

Number	Type (mobile, fax, etc.)

Name	Organization

Organization Information

Contact Information

Request Data

Project Description

Required Financial Attachments

Other Required Information

Thank you to our meeting sponsors