Initial Proposal Summary
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Please note that dollar fields should contain NUMBERS ONLY, no commas, no dollar signs.
Name of Agency*:
Address*:
Contact Person & Title*:
Telephone*:
Fax Number:
E-mail address*:
501(c) (3)*
No
Yes
Agency Purpose & Mission*:
How many Clients did your agency serve last year*?
Total Current Year (Local) Agency Budget*:
$
Date on which fiscal year begins*:
Date incorporated*:
Do you have audited financial statements*?
No
Yes
If not, please explain:
Annual Salaries of Top Three Staff Members*:
Title
$
Length of Service
Title
$
Length of Service
Title
$
Length of Service
List principle sources of support for your agency such as United Way, Children's Services Council, local foundations, government grants, special events, individual contributions, etc.*:
Purpose of this Grant*:
Please include:
What the funds will be used for
The objectives of the project and the expected results
Total Project Budget* $
$
Amount Requested*
$
List funding sources for THIS project*:
Applied for:
$
$
$
Committed:
$
$
$
Received:
$
$
$
Anticipated Project Start Date*:
