Copyright (C) 2015 Preservation Howard County
Preservation Howard County
Grant Application Form
1.Name of Organization __________________________________________
2. Name of Person applying for grant ________________________________
4. Address of Organization_________________________________________
5. Phone ___________________e-mail_____________________________
6. web site address (if available) _____________________________________
7. Is this organization tax exempt? [501(c)(3)] ________
if yes, taxpayer ID___________
8. Project location _________________________________________________
9. Amount of money requested___________________
10. Please briefly describe your organization and its mission:
11. Please provide a detailed description of your project and what the requested funds will be used for.
Include location, size and scope.
12. When will the project begin? _________________
When will it be completed? _________________
13. What other sources of funds do you have, or expect to have?
14. How will this project help your organization accomplish its mission?
Please list total expected costs of the project
Materials (please list)
Total Cost $________
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.
Signature of applicant
Print name of signer ______________________title ______________________
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.
Please print out and mail to: Preservation Howard County, P.O. Box 406, Simpsonville, MD 21150