Application for Grant County Opioid Settlement Funds.pdf

1 Application for Grant County Opioid Settlement Funds Applicant’s Agency: Click or tap here to enter text. Contact Person: Click or tap here to enter text. Phone: Click or tap here to enter text. Address: Click or tap here to enter text. Email: Click or tap here to enter text. Organization Information Organization’s Background Information, including any mission statement and purpose (Character Limit: 750): Click or tap here to enter text. Type of Organization: ☐ Non-Profit ☐ County Agency ☐ County Department ☐ School District ☐ City/Village/Township ☐ State/Federal Agency ☐ Other: Click or tap here to enter text. Project Information Project or Request Title: Click or tap here to enter text. Brief Summary of your Request (Character Limit: 250): Click or tap here to enter text. Amount Requested: Click or tap here to enter text. Total Project Budget (if applicable): Click or tap here to enter text. When are Funds Needed: Click or tap here to enter text. Project Start Date: Click or tap here to enter text. Project End Date: Click or tap here to enter text. Who will directly benefit from this project? Click or tap here to enter text. 2 Project Narrative Identify the Problem or Need to be Addressed (Character Limit: 2,500): Click or tap here to enter text. Identify the Project Goals and/or Desired Outcomes (Character Limit: 2,500): Click or tap here to enter text. Is this a new or ongoing project? Explain. (Character Limit: 750): Click or tap here to enter text. Identify other Principal Sources of Support (Character Limit: 750): (Describe the financial plan for current and future support of the proposed project. What is the rationale for the amount requested? If other funding is necessary to complete the project budget, where will it come from? How will you sustain this project into the future?) Click or tap here to enter text. How does this project meet the Goals of the Grant County Opioid Abatement Efforts? Check all that apply. ☐ Prevention Efforts ☐ Treatment and Recovery Efforts ☐ Address Provider Shortage ☐ Connecting People to Resources and Expanding Resources * * * * * * * * * * * * * ☐ I confirm that this Project impacts citizens of Grant County. ☐ I certify that I am authorized by my organization to apply for and implement this grant. ☐ I confirm that I have explored or applied for State Opioid Settlement Grant Funds. For all 501(c)3 organizations, please attach Form 990. Click or tap here to enter text. Click or tap here to enter text. Signature Date