Group Seeking Funds:

Project/Program Title:

Incorporated?:

Federal Tax Identification Number:

Print Name:

Street Address:

City, State, Zip:

Business Phone:

Cell Phone:

E-mail address:

*All notifications will be made via email communication.

If funding is awarded, make check payable to:

Brief description of your project/program and expected benefits to the community:

Is this project new or ongoing?:
NewOngoing

Which of these statutorily-required criteria will your project/program address? [Check all that apply]:
Crime PreventionNeighborhood SafetyDrug Abuse Education or Prevention

What neighborhood(s) or area(s) within the boundaries of Orange County will be impacted by your project or program?:

What age groups will participate in your project or program?:

Amount of funds requested:

Are there other sources of funding for your program or project?:
YesNo

Please list other sources of funding: