Organizational Grant Form

Reason for request (Be specific as to dollar request, program that is to be funded, program budget, people/community to be served)

Have funds been requested/received from other groups or organizations for this particular need?

Is funding needed by a specific time? Explain:

Has your organization received a grant from the NHDSA in the past?

Please provide the history and mission of your organization, how funds were spent in the past years if you received a grant from us, and include your annual budget or report:

Please be aware that the NHDSA may request a copy of your annual budget or report before approving this request.