Application For Support Form

Name of Lead Organization:

Email Address:

Are you using a fiscal agent? If so, please name them and attach a letter of support from them.

Name and contact information of person to call for more information or questions about this application:

Description of Project:

What is the target population and/or geographic boundaries for the project?

How is the Project related to the West Indy Quality of Life Plan?

Expected Results/Impact for the neighborhood:

Who are your partner organizations and/or resident partners?

How will this build relationships and/or partnerships among organizations & businesses?

Timeline for Project:

Budget:

Funding Request:

Total Cost of Project:

Other Funding Sources (please note whether committed or yet to come):

Plans to Sustain the Project and Keep People Engaged Beyond the Grant:

Please agree to the following statement by typing your name and date in the boxes below:

I agree to provide a brief report including pictures describing results that were achieved within 60 days of project completion.

Lead Organization (type full name):

Date (enter today's date):

Partner(s) (type full name(s)):

Date (enter today's date):

Please email, mail, or fax a copy of your 501c3 to the following:
Email: Beth@westindydev.org
Fax: 317-638-9514
Mailing Address:
Beth Gibson – WICF
1211 S Hiatt Street,
Indianapolis, IN 46221

WICF


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