Note: This Organization Summary is also available for download in Microsoft Word format; you can download it and fill it in on your own computer.

Does 100% of your Board contribute to your oganization?

Yes

No

PURPOSE OF GRANT:

	General Operating (support for the organization as a whole)
	Special Program or Project (specific activity of the organization consistent with its mission)
	Capital Expenditure (funds spent for additions or improvements to plant or equipment)
	Endowment
	Technical Assistance
	Other

BRIEF BRIEF DESCRIPTION OF REQUEST:

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AMOUNT OF REQUEST:_______________________

FISCAL YEAR END: ___________________________