Request for Appropriations/Grant Form
Non-Profit Organization: ____________________________ Date: _____
Requester Name: ____________________________________________
City: __________________________ State: ________ Zip: _________
Phone: ________________________ Email: ______________________
Project Name: ______________________________________________
Dollar Amount
Requested: $ _______________ EIN#_______________
Reason for funds: ____________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________________
Print Name of Person(s) Benefiting: _________________________________
Non-Profit Organization Authorized Signature:
Print Name: _______________________________________________________
Title: ____________________________________________________________
Signature of Printed Name: ___________________________________________
Earthly Angels Autism Fund Authorized Signature:
Printed Name: _____________________________________________________
Signature of Printed Name: ___________________________________________
Email to: rdeliseo@verizon.net or mail to: EAAF, 32 Huckleberry Lane, Duryea, PA 18642