Agency Application For Funding

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"*" indicates required fields

Step 1 of 11

Legal Name of Requesting Agency:*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Website*

Board Chair*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Agency Director*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Total Amount of Funds Requested from CCBDD:*

Funding Period (Start)*

Funding Period (End)*

General purpose for which funds are requested:*

Establish a new program or service

Expand an existing program or service

Maintain an existing program or service

Other

Present annual budget of requesting agency:*

Cash reserves on hand:*

Amount necessary to maintain six (6) month reserve:*

*Based on total expenses from most recent fiscal year including capital expenses but not depreciation. Attach separate page if necessary.

History and background of requesting agency is required of all agencies not previously funded. Attach narrative description of agency's mission, past and present programs, individuals served, statistical/anecdotal evidence of success, etc., if not already submitted for prior funding.

Upload

Accepted file types: doc, docx, rtf, txt, Max. file size: 256 MB.

Previously funded within the last five calendar years?*

Yes

List grants previously funded and date by CCBDD:*

Describe the need or problem to be addressed by proposed project, and the anticipated goals and outcomes. Include applicable statistics and examples. Attach separate page if necessary.*

Information regarding individuals to be served:

1) Number of persons with developmental disabilities from Cape Girardeau County presently served in existing program (if applicable)

2) Number of additional persons with developmental disabilities from Cape Girardeau County to be served in new or expanded program

3) Prospective ages of persons with developmental disabilities from Cape Girardeau County to be served by this existing/new/expanded program

0-4

5-15

16-20

21-55

56-Older

Please list all anticipated sources of funding for this project and the amounts requested from each source.*

Add additional fields as needed.

Source of funding

Amount of funding requested

Prospective or committed?

Total projected funding*

I affirm that I have reviewed this report and to the best of my knowledge, the information furnished is true, correct and complete. My signature below authorizes this application for funding through the Cape Girardeau County Senate Bill 40 Board.

Signature of Board Chair*

Signature of Agency Director*

Date

This field is for validation purposes and should be left unchanged.

Agency Application For Funding

Serving Cape County Since 1975

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