Letter of Intent

Legal name of organization:
Address of organization:
City:
State:
Zip:
Email:
Phone:
Fax:

Chief Executive Officer (CEO)/Executive Director:

Name:
Title:

Contact Person for this Application, if different from CEO/Executive Director.

Name:
Phone:

Amount Requested:

$

Period Time in which funds will be spent:

From:
To:
Organization's total budget:	$
Project budget (if applicable):	$
Organization's Fiscal Year:	to
Main Geographic Area Served:
Area of Interest into which your request falls:	Arts & Culture Community & Economic Development Education Environment Social Welfare
Type of project funds are requested for:	(operating support/new program or project/capital)
Number of Persons served annually:	(indicate duplicated or unduplicated)

Is your organization classified as a charitable organization under Section 501(c)(3)?
yes no

Is your organization classified as an organization to which contributions may be deducted under Section 170(c)(1) of the Internal Revenue Code?
yes no

Specific Purpose for which Grant Funds are Requested:

Anticipated Outcome of Project:

Brief Statement of your Organization's History, Purpose and Services: