Grant Application - New North Metro Community Services

Date *

Name of Person Completing Application *

Your Email Address: *

Your Relationship to Person(s) you are requesting assistance for: *

Eligible Individual (1) Information

Name *

Address *

State *

County of Residence *

Date of Birth *

City *

Zip Code *

Disability / Medical Conditions

Eligible Individual (2) Information

If applying for more than 1 person in the same household.

Name

Address

State

County of Residence

Date of Birth

City

Zip Code

Disability / Medical Conditions

Contact Information

Primary Contact Name *

Primary Contact Phone *

Primary Contact Email *

Additional Contact Name

Additional Contact Phone

Payee Information

Payee #1 Name *

Account #

Address *

City, State, Zip *

How should we submit funds *

Mail check directly to payee

Forward check to someone else

If we need to forward a check, who should it go to?

Payee #2 Name

Account #

Address

City, State, Zip

How should we submit funds

Mail check directly to payee

Forward check to someone else

If we need to forward a check, who should it go to?

Grant Agreement: I am submitting this grant request on behalf of a person or people who have identified Intellectual and Developmental Disabilities. I understand that if I am not able to use approved funding for the need identified above, I am responsible for returning unused funds to North Metro Community Services.

I agree to the Grant Agreement *

Yes

Thank you for your request. It has been sent.

There was an error trying to send your request. Please try again later.

Grants