Dedicated Grant Application

Part 1

Indicate Requested Action(Required)

Create Account

Deposit Funds

Withdraw Funds

If selected Deposit/Withdraw, Amount:

Note: A 2% fee for each withdrawal total will be retained by the Foundation.

Part 2

Project Title(Required)

Name of applying Club, Sub-District, or State Project making a request(Required)

Applicant's Federal EIN Number(Required)

Note: All applications MUST have this number to be considered.

Responsible Contact Person(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

District(Required)

Part 3

Briefly describe the project for which you are requesting a grant(Required)

Is the project for which you have solicited the dedicated grant a Civic or Public Project, which will not result in a personal benefit or compensation to a member of the organization making this application?(Required)

Yes

The applicant, in making this application, also agrees to accept responsibility for the conduct of the project or the part of the project being assisted through the Indiana Lions Foundation, Inc. The applicant also agrees to make a six (6) month report and a final report, complete with pictures if possible, within one (1) year of receipt of the Grant on the expenditure of funds.

Source of funds received by the foundation for the dedicated grant:

Donor's Name(Required)

First Last

Amount(Required)

Donor's Name

First Last

Amount

Donor's Name

First Last

Amount

Signature of Authorized Grantee Officer(Required)

Date(Required)

Printed Name, Title(Required)

CAPTCHA

Dedicated Grant Application

Part 1

Part 2

Part 3

Source of funds received by the foundation for the dedicated grant:

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