Alcohol and Other Drugs

Accepting March 1 - April 15, 2016

Today's Date*

Name of Organization*

Organization's Mailing Address*

Contact Person for Project*

Phone*

-

Cell Phone

-

Contact's Email Address*

The Organziation is*

a registered 501(c)(3)

a department of a municipal, county or state government

a hospital, school (public or private), or department/program thereof

Tell us about your organziation and its purpose*

Project Name*

Is this a new or existing program?*

Grant Amount Requested (dollar amount only)*

Counties Impacted by Project*

Cities Impacted by Project*

Estimate the number of people that will be impacted by this project*

Project Start Date*

Project End Date*

If a partial grant is received, will this project be completed within the dates listed above?*

Project Overview/Purpose of Grant*

Total Cost of Project (dollar amount only)*

List Project Expenses*

List Project Income Sources*

List grants your organization has received in 2015 & 2016 from all sources*

Attachment Requirements: Most recent IRS Form 990 (pgs 1&2) If not applicable attach IRS Letter of Determination*