Name of Recipient Organization

Name of Contact Person

Phone of Contact Person

Email of Contact Person

Address of Contact Person
Street:

City: State: Zip:

Name of Program Funded by Grant

Total Amount Granted

Please provide a narrative report of how monies were utilized for the program and how progress was monitored. (Include population segments served, number of individuals that benefited, goals achieved, success rates, plans for maintaining financial viability if this program is on-going, etc.)

Please provide a financial accounting of how the grant monies were expended.

In the event that all granted funds were not expended, please explain how and when the balance of the grant will be used.

If the grant was used for a project other than its original purpose, please provide details why, including an explanation of the actual program that the grant funded.

I certify that the information provided is a complete and accurate accounting of the Community Benefit Fund grant received.

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Phone

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