Legal Name of Organization

________________________________________________________________________
Address

________________________________________________________________________
City/State/Zip

________________________________________________________________________
Authorized Contact Person

________________________________________________________________________
Title 					Phone

________________________________________________________________________
Purpose of Organization



________________________________________________________________________
Year Founded				Total Current Operating Budget

________________________________________________________________________
Primary Source of Funds

________________________________________________________________________
Tax Exempt Under IRS 501(c)(3)?

________________________________________________________________________
If not, is application pending?			Federal Tax ID#

________________________________________________________________________
Proposed Use of Contribution

________________________________________________________________________
Amount Requested    		Total Project Cost    		Numbers Served by Project

________________________________________________________________________
Geographic Area Served

________________________________________________________________________
Project Time Period

________________________________________________________________________
Source of Other Funds to Support Project


________________________________________________________________________
Signature of Contact Person			Date

________________________________________________________________________