AGENCY NAME:

PROJECT /ACTIVITY NAME:

CONTACT PERSON:

ADDRESS:

PHONE NUMBER:

AMOUNT REQUESTED:

When does the fiscal year for the program being funded begin?

Has your organization received funding from the City previously ?

If so, what was the source and amount of funding received ?

Description/Justification (Using 300 words or fewer, describe the program for which funding is being

requested, the importance of the program and why City funding is needed.)

This request should be supported (maximum of three pages) with the following information:

1.  Description of funding support received from all other sources such as the United Way, Douglas County,

USD 497, state/federal grants and private funding.

2. Total budget for the agency, number of personnel, and how the funding would be used (e.g., personnel,

equipment, material, etc.).

3. Does the agency anticipate the need to request funding beyond 2004?

Additional information may be provided within the three (3) page limit.  Submit 12 copies of this form and

supporting material by April 14, 2003 to: Debbie Van Saun, Asst. City Manager, Fourth Floor, City Hall,

6 E. 6th Street, P.O. Box 708 Lawrence, KS 66044. Please do not submit the material in a binder.