HomeMy WebLinkAboutLocalFundingInitiativeRequestForm1.
Senate Sponsor:
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2.Date of Request:Click here to enter a date.
3.
Project/Program Description:Click here to enter text.4.
Amount of Request:Amount Requested for OperationsAmount Requested for
Fixed Capital OutlayTotal Amount of
Requested State FundsClick here to enter text.Click here to enter text.Click here to enter text.5.Total Project Cost (if greater than Total Requested State Funds):Click
here to enter text.6.Type, Amount and Percent of Match:
Type
Amount
Percent
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7.
Was the project previously funded by the State?Fiscal Year(s)AmountClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click
here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.8.Is future-year funding likely to be requested?Click here to enter text.9.
Program Performance (if needed, include additional documentation):
a.
How will requested funds be spent? Include supporting documentation.
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b.Identify expected program results and the expected benefit associated from the requested funds.
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Who will benefit from receipt of State funds?Click here to enter text.d.What specific measures will be used to document performance data for the project, if it receives funds?Click
here to enter text.
10.Requestor Contact information:
a.Name and Title:Click here to enter text.
b.
Organization:Click here to enter text.
c.
E-mail Address:Click here to enter text.
d.
Phone Number:Click here to enter text.11
Recipient Contact Information:a.Organization:Click here to enter text.b.Municipality and County:Click here to enter text.c.Organization type (check all that
apply):☐For-profit Corporation
☐Not-for-profit Corporation
☐
501c3 entity☐
Other (please specify)Click here to enter text.d.
Contact Name and Title:Click here to enter text.e.
E-mail Address:Click here to enter text.f.Phone Number:Click here to enter text.