WITAN PROJECT SUMMARY FORM

2008 – 2009

Information requested must be on this form

with 12 copies on 2-sided, 3-hole punch paper.

Financial statement and budget must be attached.

Please do not include any additional materials at this time.

Agency Name:_____________________________________________________________________

Address:__________________________________________________________________________

Contact Person:____________________________________________________________________

Phone:____________________________________________________________________________

E-mail:____________________________________ Website: _______________________________

Non-Profit Tax I.D.#:________________________________________________________________

Amount Requested:___________________________________Date:__________________________

Itemize Project Request:

Explanation of Project:

Project Timetable:

Services Provided By Your Agency:

Communities or Counties Served By Your Agency:

Page 2                         WITAN PROJECT SUMMARY FORM

Number of clients served by your agency:_______________________________________________

Number of people who would be DIRECTLY affected by this project:_______________________

Amount and source of present funding: $_______________________________________________

Does your agency have an “Auxiliary”?  Yes__________              No__________

If “Yes”, what is its function?

Do you have any community-wide fundraising event(s)?     Yes__________         No__________

If “Yes”, describe the event(s), including how much each event nets in income to your agency.

Number of Staff:_____________________  Number of Volunteers:__________________________

Annual Income:  $________________________Annual Expenses:  $_________________________

Administrative Costs:  $___________________Fundraising Costs:  $________________________

How do you plan to promote WITAN’S support of your agency/project?

Newsletter__________Web Site_________ Agency Press Release_________ Brochure__________

Other (Explain):

Please make 12 copies of this application on 2-sided, 3-hole punch paper along with current Financial Statement and Budget.

Please do not send any additional materials at this time.

Please send to:	Please Note:
WITAN	WITAN will not fund the following:
Attention: Mary Ann Freedman	1) For-Profit Organizations
P.O. Box 5448	2) Salaries for an Agency’s Executive Director
Akron, Ohio 44334-0048	3) Any political parties, candidates or
	organizations supporting politically charged issues.