PLEASE REVIEW CAREFULLY BEFORE SUBMITTING
This form is a request for a contribution from the HCSC, funding is not guaranteed.
Applications should be emailed to firstname.lastname@example.org or submitted online using THIS FORM.
NO hard copies will be accepted by hand or mail. Provide clear, specific information. Failure to complete this form correctly may result in rejection.
Verify that your organization can receive funds BEFORE submitting. Checks will not be made out to individual requestors but to their organizations. The check will be made payable to the organization listed on this form.
Receipts must be submitted within 45 days after the event. Failure to submit receipts to email@example.com may result in denial of future applications.
If funds are awarded and not used in their entirety, they must be returned to the address below. Returned funds must be accompanied by a copy of this approving document along with an explanation of why funds were returned.
Unit 29420 Box GD
APO AE 09173