Funding Request Form

From nhepiscopal.org

Re-Imagining
Funding Request Form
By Re-Imagining Advisory Team
May 2, 2005, 15:25

Request for Diocesan Mission and Vision Support

Date: __________________

Person Requesting Funding: __________________________________

Parish: ____________________

Address:

_________________________________

E-Mail: _______________________________

Tel. #: _________________________________

Total Amount Requested $____________

Date Needed ___________________________

The request is for

___Direct Payment

___Reimbursement [Attach all Receipts]

Send Payment/Make out Check to:

___________________________________________

Address:

___________________________________________

Name of Contact Person
(if different from Payee): __________________________

Telephone: _________________

Description of Request:

____________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

_______________________________________________________________

Expected Impact on local community, parish and greater community:

____________________________________________________________________________________

To which area of ministry does this best apply?

___Outreach ___Evangelism ___Youth and Young Adult

Signature _____________________________________

If necessary use the back of the form for additional information.

Send to:

Re-Imagining Advisory Team

Attn: Margaret Porter

63 Green Street

Concord, New Hampshire 03301

Phone: 603 244 1914

Fax: 603 225 7884

www.nhepiscopal.org