Healthier Community Grant Application

NAME OF ORGANIZATION

TYPE OF ORGANIZATION: (please check one of the following)
Not-for-profit with 501c status under IRS Code (please include a copy of your determination letter from the IRS)Government Agency or DepartmentPublic Education InstitutionOther (please state type)

CONTACT PERSON:

TELEPHONE NUMBER:

E-MAIL:

MAILING ADDRESS:

City

STATE:

ZIP CODE:

COMMUNITY (IES) directly served by this grant (list all):

Project Purpose- Grant funds will be used to:

This project is needed because:

Have other sources of funding been sought?
YesNo

If so what sources:

Persons who will directly benefit from this project include:

How many people will benefit:AdultsChildren/ Youth

Is this a new project?
YesNo

If NOT new how long has it existed?

Amount of request from Foundation:

Total Budget needed for project:

The amounts and sources of other committed funds:

Additional information for this grant can be submitted but shall not exceed one page in length.

Signature Applicants Representative

Title of person

Date signed

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