2017 Social Service Funding Application

Application and supporting materials are due by 5:00 PM on Monday, March 6, 2017.

Please use this computer generated form.
Completed application should be submitted online.
Form may also be printed for your records before you submit the application.

SECTION A
Agency Information






SECTION B
Main contact person for this application and program. Please list information for the person to be contacted regarding this application.









SECTION C
2015 Funding Request


Children
People with Developmental Disabilities
People with Physical Disabilities
People with Mental Health Issues
People with Substance Abuse Issues
Seniors
Low Income
Other (please list below)




SECTION D
Please be sure that your application includes copies of the documents listed below.

Failure to include these documents may result in denial of this application.

You may attach the documents below or send them to either HHS@desplaines.org  or fax to 847.827.2292.



Click on input field above to upload your file.


Click on input field above to upload your file.


Click on input field above to upload your file.


Click on input field above to upload your file.
Completed application
Proof of non-profit status (i.e., letter of tax-exempt status from the Illinois Department of Revenue)
Budget for project/program (if unable to include in application)
W-9 Form
Most recent annual report

Certification of Information

I certify that the information provided is true to the best of my knowledge. I am also aware that this information is subject to review and verification and I may have to provide documents to support this application. I am also aware that any misstatements or false facts could result in denial of the application.


*indicates required fields.