Copyright (C) 2015 Preservation Howard County

PRESERVATION HOWARD COUNTY

Preservation Howard County

Grant Application Form

 

 

1.Name of Organization __________________________________________

 

2. Contact Name__                                           ______________________________

 

3. Title_________                     _______

 

4. Address of Organization_________________________________________

 

5. Phone ___________________e-mail_____________________________

 

6. web site (if applicable) _____________________________________

 

7. Is this organization tax exempt? [501(c)(3)] _______if yes, taxpayer ID_______

 

8. Project Name _________________________________________________

 

9.  Project Location

 

10.  Property Owner name if different from organization

 

11.  Describe the historical significance of the site

 

 

 

 

 

12.  Briefly describe your organization and its mission

 

 

 

 

 

13. Amount of money requested___________________

 

14. Provide a detailed description of the project and how the funds will be used.  Include size and scope of

        project.

 

 

 

 

 

15. When will the project begin?                                     When will it be completed?

 

16. What other sources of funds do you have, or expect to have?  Please indicate whether other sources are planned or committed?

 

 

 

 

 

17.  How will you measure the success of the project?

 

 

 

18.  How will this project help your organization accomplish its mission?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Budget Information

 

Expenses:

 

Please list total expected costs of the project

 

 

Personnel

 

 Administrative $_______

 Services                 _______

 Other                      _______

 Materials (please list)

   ________                                                                                                                 _

 

   _________

 

   _________                                                                                                              

 

Other

   __________

 

Total Cost                    $________

 

Income:

Please list how you expect to fund this project

 

 

Grant request from Preservation Howard County      $ _______  _

Cash on hand                                                                          _________

Individual donations -amount planned                            _________

Corporate donations - amount requested                        _________

Corporate donation – amount received                            _________

Other grants – amount requested                                      _________

Other grants – amount received                                         _________

Other (fundraising projects or sale of goods                    _________

 

Total Income (must match total expenses)                  $  ________

 

Please list any in-kind, or non-cash donations for this project (such as services and/or materials)

 

 

I certify that all of the information in this application is true and correct.

 

_________________________________    Date____________

Signature of applicant

 

Print name of signer ______________________title ______________________

 

Non-Discrimination Statement

Title IV of the Civil Rights Act of 1964 provides that:

‘No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program of activity receiving federal financial assistance’ (section 601).

 

We have read the above statement and fully comply with its provisions.

 

Authorized signature___________________________________

 

Organization________________________________________

 

Date_______________________

 

Please print out and mail to:  Preservation Howard County, P.O. Box 406, Simpsonville, MD  21150