Opioid Settlement Grant Application

Opioid Settlement Grant Application
Application Details

Application Due Date: December 2, 2024 at 4:00PM

Anticipated Notice of Award: January 2, 2025

Anticipated Funding Period: 1 Year
Section One: Organizational Information
Organization Name:*
Federal Tax ID #:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Organization:*

Non-profit and/or 501(c)(3)For ProfitGovernmental
Purpose of Organization:*
Annual Operating Budget (must attach documentation):*

Cancelof
Year Established:*
Number of Employees:*
Number of Volunteers:*
Is the Organization Licensed or Accredited by the State of of Tennessee?*

NoYes (must attach documentation below)
Cancelof
Project Contact Name:*
Contact Title:*
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com

Section Two: Funding Information
Total Funding Request:*
What percentage of the total project cost will the request funds cover?*
What percentage of funds requested will be used to serve residents of Lawrence County?*
Funding currently being received from Lawrence County*
Budget Narrative*
Please provide a detailed justification for each line item in the budget, explaining how these expenses support the project's objectives and goals. We recommend filling out the Budget first and then filling out this section.
Sustainability*
Please provide information about how this project will be sustained after the funding period. Include details such as other grants or funding sources that the organization has or plans to obtain.
Budget for Opioid Settlement Funding
The TN OAC's Remediation List must be used to determine which strategies are addressed.
Organization Name:*
Expense or Activity:*
Description:*
Strategy Addressed:*
Cost:*
Quantity: *
Total Cost:*
Project Total:*

Project Work Plan
The TN OAC's Remediation List must be used to determine which strategies are addressed.
Organization:*
Total Funds Requested:*
Overall Goals(s) of Project:*
Objectives: What is the measurable objective you are seeking to achieve?*
Activities: What activities will be completed that help achieve the corresponding objective?*
Remediation Strategy: Please use the TN OAC's table (linked above)*
Outcomes: What measurable results are you seeking to achieve by completing the corresponding activities?*
Measure of Success: How will success of objectives & outcomes be assessed? What data points will be measured?*
Timeframe: When will this part of the project begin and end?*
Accountability: Who is responsible for each project?*
Funds Requested: What are the requested grant funds for this part of the project?*
Should be Empty: