Grant for Organizations

Please fill out all information carefully below -

Today's Date

Name of Organization

Address and City of Organization

Website if Applicable

First Name of Contact Person

Last Name of Contact Person

Title of Contact Person

Best Phone # to be reached by

Please provide a brief description of your organization and how it fits into HRF's Mission

Amount Requested for Project

Please explain exactly what these funds will be used for

Provide anticipated impact of program, service or project on the population to be served. If this is an existing program or service, include proven success from previous years:

What is the expected/projected # of people who will be supported through this program, service, or project?

Which PA counties will be served?

Do you serve and support individuals outside the state the of PA?

Can you provide a brief regional breakdown? (If not applicable, please answer N/A)

Please list other sources of funding for your program, service, or project (if any):

IN ADDITION:

*Please include a proposed total budget for the project including income and expenses. Please attach any document to help understand the reason for your request, including proposals, letter of support for the project, etc.

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