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Grant Application

Date: __________________
Organization: _____________________________________________________________________
Address: _________________________________________________________________________
Contact Person: ___________________________________________________________________
Phone: _________________________ Email: ____________________________________________
Person in charge of project: __________________________ Phone/email: ____________________

Project: __________________________________________________________________________
Purpose/Objectives of the Grant: _____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Summary of the Project: _____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Description of the benefits to be achieved and the population to be served: __________________
__________________________________________________________________________________
__________________________________________________________________________________
Amount requested and rationale: ______________________________________________________
__________________________________________________________________________________
Estimated cost of the project, if different from request: ___________________________________
Other funding sources contacted: _____________________________________________________
Brief summary of current organizational budget, including all funding sources: _________________
__________________________________________________________________________________
Date for first funding: _____________ Do you wish to receive funding in installments? Yes/No
Schedule of Implementation: _________________________________________________________

Attach, if available and applicable: An organizational mission statement, any supporting statements, the names of directors, a financial report, project descriptions, or other documentation.

Mail completed application to:
The Madison Foundation, Inc. Distribution Committee, P.O. Box 446, Madison, CT 06443

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