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Orginization or Group Name*

Legal Entity (If different than applicant)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact Person*

Primary Contact Phone*

Primary Contact Email*

Amount of Funding Request*

Value of Matching Funds/Goods/Services*

Cash*

Goods/Services (In-kind)*

Total Budget For This Project (In-Kind + Cash + Funding Request)

Communities/Entities Served By This Program/Project

Sinature (S)/Date*

1. Briefly (two to four sentences) describe your intended project along with a short outline of how the requested funds will be used.

2. describe the overall project/program to be funded under this request, providing detail as well as any supporting research or documentation of the effectiveness of the intended project.

3. Provide the maintenance plan for the project, including specific information on who is responsible for completing work.

4. Provide a timetable for the project/program. Please include specific steps/activities, responsible person/group for carrying out the activities, and anticipated dates the steps will be completed.

5. Please describe community involvement in the project/program, if applicable, for both the planning and implementation phases.

6. Please indicate any other organizations, agencies or entities with whom you have worked to analyze the problem/issue to be addressed, and identify the proposed solution. (Feel free to include support data from those agencies.)

7. What are the measurable short-term and long-term outcomes of this project/program?

8. Please list other funders this proposal has been or will be submitted to. For each, indicate the amount requested, the status of the request (i.e. submitted, pending, funded, or declined), and if funded, specify amount.

9. Please indicate the overall project/program budget and funding allocations.

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Blue Line Foundation Funding Request