Received: ____________
Considered: ____________
TOTAL: ____________
Project # : ____________

Your Name
Your Agency
Your Address
Your Phone Number

PROJECT TITLE:_________________________________________________________________________

SPONSORING ORGANIZATION ( If you receive a grant, this is the name of the agency we would make a
check payable to): ________________________________________________________________________________________

*FEIN#_______________________________________ Amount Requested: __________________________

Contact Person: _________________________________ Phone Number: _____________________________

Address: ________________________________________________________________________________

Project Date(s) and Location(s) of Activities:




PROJECT DESCRIPTION: (attach summary no longer than two typed pages)
1)What your group wants to accomplish.
2)The need you are trying to meet.
3)What you plan to do. Be specific. List the times, places and people who will be participating.

EVALUATION PLAN: Write a paragraph or two on how you will determine whether or not your project was a success. We especially like hearing from youth on this topic.

BUDGET: Attach itemized budget. Be sure to include items such as supplies, travel, publicity, consultation, etc., and any in-kind or additional funding you hope to receive for this project. Awards are limited to a maximum of $________ per application. The Mini-Grants Advisory Committee reserves the right to reduce the amount of a requested award based on review of the application.

*FEIN#: Awards can only be made to organizations who have a non-profit federal tax-exempt status 501(c)3. The federal identification number assigned to the non-profit is the *FEIN#.