Shepaug Friends of Music
Providing music opportunities for the youth of the Shepaug Valley Region.

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FINANCIAL ASSISTANCE REQUEST FORM

ORGANIZATION: _______________________________________________________

ORGANIZATION ADDRESS: _____________________________________________

CITY: ________________________________ STATE: ________ ZIP: ____________

CONTACT NAME: _____________________________ TITLE: __________________

TELEPHONE: (___) __________ FAX: (___) __________ CELL: (___) __________

EMAIL: ________________________ ORGANIZATION TAX ID: _______________

APPLICATION DATE: ____/____/_____ EVENT DATE: ____/____/____

AMOUNT OF REQUEST: $_________________

DESCRIBE PROGRAM AND USE OF FUNDS REQUESTED: _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

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PLEASE ATTACH:

1) A LETTER FROM QUALIFIED CONTACT PERSON REQUESTING THE ASSISTANCE - STATING THE NEED, THE BENEFICIARIES AND THE BENEFITS TO THE COMMUNITY. 
2) AN ITEMIZED BUDGET FOR THE PROGRAM IN NEED OF FUNDING
3) LIST OTHER SOURCES OF FUNDING FOR THIS PROJECT

Mail request to:
Shepaug Friends of Music
PO Box 83
Roxbury, CT 06783

www.shepaugmusic.org

For internal use only:

Date rec’d: ___/___/___