The recipient entity's physical address:
          

The recipient entity's mailing address (if different):
          

Type of Entity (for instance, a nonprofit corporation): 

If the entity is a corporation, list the names of the incorporators:
          

The last four digits of the entity's taxpayer ID number: 

What is the dollar amount of the request? 

What type of request is this? 

Is this entity in good standing with the Secretary of State? 

Provide the name of each member of the recipient entity's governing board and officers:
          

Provide a summary of the project or program:
          

What is the budget relative to the project for which funding is requested?:
          Salaries. . . . . . . . . . . . .
          Professional Services. . .
          Contracts . . . . . . . . . . .
          Acquisitions . . . . . . . . .
          Major Repairs . . . . . . .
          Operating Services. . . .
          Other Charges. . . . . . .

Does your organization have any outstanding audit issues or findings? 

If 'Yes' is your organization working with the appropriate governmental agencies to resolve those issues or findings?
          

What is the entity's public purpose, sought to be achieved through the use of state monies?
          

What are the goals and objectives for achieving such purpose?
          

What is the proposed length of time estimated by the entity to accomplish the purpose?
          

If any elected or appointed state official or an immediate family member of such an official is an officer, director, trustee, or employee of the recipient entity who receives compensation or holds any ownership interest therein:
     (a) If an elected or appointed state official, the name and address of the official and the office held by such person:
                
    
     (b) If an immediate family member of an elected or appointed state official, the name and address of such person; the name, address, and office of the official to whom the person is related; and the nature of the relationship:
                

     (c) The percentage of the official's or immediate family member's ownership interest in the recipient entity, if any:
                

     (d) The position, if any, held by the official or immediate family member in the recipient entity:
                 

If the recipient entity has a contract with any elected or appointed state official or an immediate family member of such an official or with the state or any political subdivision of the state:
(a) If the contract is with an elected or appointed state official, provide the name and address of the official and the office held by such person: 
               

(b) If the contract is with an immediate family member of an elected or appointed state official:
          Provide the name and address of such person:
              

          Provide the name, address, and office of the official to whom the person is related:
               

          What is the nature of the relationship? 

(c) If the contract is with the state or a political subdivision of the state, provide the name and address of the state entity or political subdivision of the state:
                

(d) The nature of the contract, including a description of the goods or services provided or to be provided pursuant to the contract:
               


Contact Information
name:   
                                       address: 
                                       phone: 
                                       fax: 
                                       e-mail:  
                                       relationship to entity:   


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