Grant Request Form

The organization or person named in this form will act as the responsible fiscal agent for any funds which might be received and will comply with applicable tax laws, regulations, and The Tolland Fund's policies. In addition, we understand that The Tolland Fund requires periodic program and financial expenditures reports from grant recipients and may request the opportunity to visit our programs before awarding a grant or after a grant has been made for purposes of grant evaluation.

		Organization or Individual
Name:
Address:
City:
State:		-- Select --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:
Email:
Contact:
Title:
Project Summary:
		-------------- The following is required for 501(c)(3) organizations only --------------
Project Budget: Amount Request: Tax ID: Admin Cost Ratio: