Funding Request Form

Fiscal Year 09 (July 1, 2008 to June 30, 2009)

Instructions: Please fill out this form completely and click "submit."

If you have questions about whether this is the proper place to submit your request, please feel free to contact Justine Almada in the Office of Council Member Garodnick by calling 212-788-7393, or by emailing jxalmada@gmail.com. All requests must be submitted online by Friday, March 28.

* Required field.

Your Organization

Legal Name of Organization*

Your organization's Federal Identification (FEIN) Number*

Is your organization a 501(c) Corporation?*

Yes
No

Organization Contact Information (No P.O. Boxes)*

Building #*

Street*

Suite (if applicable)

City*

State*

Zip Code*

Contact First Name*

Contact Last Name*

Contact Prefix

Contact Title

Contact Phone #, with extension (if applicable)*

Contact Fax #

Contact E-Mail*

Fiscal Conduit Information (FC)

What organization serves as your Fiscal Conduit?

What is its Federal Identification (FEIN) Number?

Fiscal Conduit Contact Information

Building #

Street

Suite (if applicable)

City

State

Zip Code

FC Contact First Name

FC Contact Last Name

FC Contact Prefix

FC Contact Title

FC Contact Phone #, with extension (if applicable)

FC Contact Fax #

FC Contact E-Mail

About Your Organization

Mission Statement*

Annual Budget*

In which council district is your organization located?*

Does your organization serve residents of other districts?*

Yes
No

IF YES, which districts?

About Your Funding Request(s):

Note, there is a difference between a request for capital and expense funds.

Expense funds are an organization's operational funds for programmatic activities.

Capital funds are for hardware, such as computers and other equipment, and must be a request of more than $35,000.

Expense funds request:*

Total expense project cost (if applicable)

Purpose of expense funding requested*

Capital funds request

Total capital project cost

Purpose of capital funding requested

Did your organization receive funding from the City of New York last year?*

Yes
No

IF YES: How much? (Please specify expense and capital amounts.)

IF YES: How were those funds used?