Grant Request Form

Date:

Organization:

Are you a 501(c)(3) organization, as determined by the IRS? No Yes

(If yes, please attach a copy of your IRS Letter of Determination)

Contact Name, Title:

Address:

Phone:

E-Mail:

Name of Project/Event/Program:

This funding request fits in this/these area(s):

Youth	Poverty Prevention/Intervention	Community Betterment

Health Care	Human Services	Other:

Amount of Request: $

If awarded, check should be made out to:

What is the purpose of the project/event/program?

If funded, how will the grant dollars be used?

Who will benefit from this project?

Does this project have financial or in-kind support from other source(s)? If so, who has partnered to provide additional support?

Is there additional information that is helpful for the Board to know, when making this decision?

Signature of Contact	Date

Signature(s) of Club Member Supporting This Application	Date

For Rotary Club Use Only:	Special Fund Dollars Available:	Decision of Board:	Fully fund request	Award the organization $	The Board has declined to fund this request	Date of Board’s decision:	Club President’s Signature	Date IF FUNDED:	Date check was sent:	Check number:	Club Treasurer’s Signature	Date