Local Fund Committee
Confidential Information: All information provided will remain confidential; and will only be used for recommendations of the __________________ Advisory Council on behalf of the individual.
(PLEASE TYPE OR PRINT)
- APPLICANT’S NAME DATE: , 20
- 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|
- How much is requested? (Individual maximum grant is $250.00.)
Up to $ .(maximum needed) OR exactly $ .
- 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