Individual Grant Application

Name of Individual Applying for Grant

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number of Individual Applying for Grant

Name of Person Making Application

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number of Person Making Application

Title

Name of Minister, Doctor or Community Leader Reference

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number of of Minister, Doctor or Community Leader Reference

Attach Purpose of Grant: on Back, single-spaced, typed or printed.

Drop files here or

Max. file size: 20 MB.

1. Event or Condition with Pictures 2. Time critical 3. Benefits to individual 4. Long Term Benefit 5. Personal Financial Statement must be completed and attached with grant application 6. Other Financial help

Source

Amount $

Source

Amount $

Grant Request $

Project Total $

Note: It is our procedure to pay grants to a certified third party such as Hardin County Ministerial Association. Grants are normally a one-time event. Upon award of grant, Name of Grantee and appropriate description may be released to media or other public use for foundation.

Other attachments to include:

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Max. file size: 20 MB.

Copy of last year’s tax return and Personal Finance Statement if applicable Other pertinent information you think would be hopeful to the Benevolent Committee Release to approach government agencies, medical institutions or credit bureaus for verification of grant request

Signature

All Financial or Medical Information provided will only be used for evaluation of grants and not provided to third parties without permission

Date