Sample Participant Award Application form

Local Fund Committee

CONFIDENTIAL

REQUEST

SAMPLE

FDC Application Form – 9-28-16

 

www.ccjcfoundation.org

 

 

Mailing Address:

Confidential Information:   All information provided will remain confidential; and will only be used for recommendations of the __________________ Advisory Council on behalf of the individual.

 APPLICANT INFORMATION

(PLEASE TYPE OR PRINT)

  1. APPLICANT’S NAME           DATE:                    , 20     

                     

  1. This request for Local Fund Committee funds is for a participant of the:
  Adult Drug Court  Family Dependency Drug Court  Veterans Treatment Court
 Juvenile Drug Court  Mental Health Court  _____________ Court

 

  1. How much is requested? (Individual maximum grant is $250.00.)

Up to $                         .(maximum needed) OR exactly $                         .

 

  1. How will the money be used (please detail the problem and how it will be solved if these monies are awarded to you.) Please add another page if necessary.

  Complete form: FDC Application Form – 9-28-16