Individual Grant Application

Please fill in all blanks before submitting.

Name of Individual Applying for Grant

Mailing Address

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

Phone Number of Individual Applying for Grant

Name of Person Making Application

Address

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

Phone Number of Person Making Application

Title

Name of Minister, Doctor or Community Leader Reference

Address

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

Phone Number of of Minister, Doctor or Community Leader Reference

Purpose of your Grant Request

Source

Amount $

Source

Amount $

Grant Request $

Project Total $

Note: It is our procedure to pay grants to a certified third party such as Hardin County Ministerial Association. Grants are normally a one-time event. Upon award of grant, Name of Grantee and appropriate description may be released to media or other public use for foundation.

Upload Supporting Documents

Drop files here or

Max. file size: 50 MB.

e.g., proof of incident, bill needing coverage, or medical appointment

Signature

All Financial or Medical Information provided will only be used for evaluation of grants and not provided to third parties without permission

Date