Organization:___________________________________________________________________________

Address: ______________________________________________________________________________

City/State/Zip: __________________________________________________________________________

Contact Person:________________________________________________________________________

Daytime Phone:_________________________________Mobile:__________________________________

Email Address: _________________________________________________________________________

Title of Project:__________________________________________________________________________

BTF Priority Addressed: ____ Housing ____ Lasting Equipment ____Education ____Recreation

Grant will support the needs of (check all applicable):

____ only Adults with developmental disabilities

____ both Adults and Children with developmental disabilities

____ only Children with developmental disabilities

____ Other, specify:_______________________________________________________________________

______________________________________________________________________________________

Amount Requested:_____________________________

Name of Organization's Authorizing Agent:_____________________________________________________

Signature of Authorizing Agent:______________________________________________________________

Date:________________________________________