Note: Complete this form for each proposed project. Please refer to the Proposal Submission Instructions for clarification for any of the following questions. Section I. Grantee Information and Cover Sheet Please the box that describes your organization Community Based CBO, non-501(c)(3) Regional Center (RC) Organization (CBO), EIN or 501(c)(3) No EIN a. Name of organization/Group b. Date c. Primary contact (Name) d. Mailing address e. Primary e-mail address f. Primary phone number g. Secondary contact email address h. Secondary contact phone number i. Brief description of the organization/group (organization type, group mission, etc.). Section II. Proposal Summary a. Project title b. Total amount requested $ c. Projected number of individuals impacted d. Duration of project (months) months Start date: / / End date: / / e. RC(s) in the project catchment area(s) Target zip code(s) for Los Angeles County*: Yes** No f. Did your organization receive **If yes, provide the grant number and answer questions and “f1” “f2.” funding for a project in FY If no, skip to question “g.” 2017/18? Grant # (CBOs only): f1. What is the current status of your project? f2. How is this proposal different from your current project? g. Will you be working with one or Yes*** No more CBO(s)?
Note: Complete this form for each proposed project. Please refer to the Proposal Submission Instructions for clarification for any of the following questions. Section I. Grantee Information and Cover Sheet Please the box that describes your organization Regional Center (RC) Community Based Organization (CBO), 501(c)(3) CBO, non-501(c)(3) EIN or No EIN a. Name of organization/Group b. Date c. Primary contact (Name) d. Mailing address e. Primary e-mail address f. Primary phone number g. Secondary contact email address h. Secondary contact phone number i. Brief description of the organization/group (organization type, group mission, etc.). Section II. Proposal Summary a. Project title b. Total amount requested $ c. Projected number of individuals impacted d. Duration of project (months) months Start date: / / End date: / / e. RC(s) in the project catchment area(s) Target zip code(s) for Los Angeles County*: f. Did your organization receive funding for a project in FY 2017/18? Yes** No **If yes, provide the grant number and answer questions “f1” and “f2.” If no, skip to question “g.” Grant # (CBOs only): f1. What is the current status of your project? f2. How is this proposal different from your current project? g. Will you be working with one or more CBO(s)? Yes*** No
DDSDisparityFundsProgramAttachmentA2.docx