Copyright (C) 2015 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
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?
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