United Way of Adams County, Decatur, Indiana » Online Economic Relief Initiative Grant Application

Online Economic Relief Initiative (ERI) Grant Application

Fields marked with a * are required.

Organization or Agency Name: *

Organization's Email *

Organization's Phone *

Organization's EIN # *

Your First Name *

Your Last Name *

Title (How are you associated with the company)*

Your Phone *

Phone Type: *

CellLand Line

Accept Texts: *

YesNo

Amount of Grant Request *

Statement Of Needs

What are your emergency needs due to the coronavirus (COVID-19) pandemic? Please be specific. *

How has the COVID restrictions affected your organization? *

When did the concern begin? Have you maintained office hours since mid-March? *

Statement of Spending

What results do you expect to achieve if awarded an emergency relief grant? *

What expenses do you anticipate following the lift of COVID restrictions? Example: thermometers, sanitation gear, face masks for staff / clients, etc. *

What more do you wish to share with the COVID Committee?

Read & Initial

I agree to account for and return any amount of the unused / unaccounted for allocation.

By checking this, I understand that I have given the Adams County Community Foundation / United Way of Adams County permission to share my application with other committees so that I may beeligiblefor assistance beyond this selection committee.

e-Sign | Person Submitting Application:*