Community Wide

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

a religious organization

Tell us about your organziation and its purpose*

Project Name*

Is this a new or existing program?*

Grant Amount Requested*

Counties served by this project*

Cities served by this project*

Estimate the number of people that will be served*

Project Start Date*

Project End Date*

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

How will this project impact our communities & fulfill the mission of your organization?*

Total Cost of Project*

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*

Contact Us

1110 10th Avenue

Suite L-1

Menominee, Michigan, 49858

906-864-3599

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