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Funding Request

Please fill in the Funding Request form below:

The funding requests period has closed for the 2015-16 funding year. Check back soon for the opening of the 2016-17 funding requests period.


Sponsored Programs Funding Request Form

Target Population

Please indicate the PBC residents your organization serves:

Services

Please indicate the type of services that will be provided under this funding request along with the number of visits and clients served in the prior year:

Please indicate the type of services that will be provided under this funding request along with the number of visits and clients served in the prior year:

Number of Services Provided in 2014

Estimate of Additional Services that will be provided with Funding Requested

Funding Requests

Purpose of Funding
Is this a one-time funding need?* - required

Are there any other funding sources contributing to this project?

(Please list sources and amount of investment)

Has the Health Care District provided Funding to your Organization in Prior Years?* - required

If yes, please indicate by the amount of funding and how the funding was used:

CEO / Executive Director Signature:

Correspondence via Email: “Under Florida law, email addresses and all of the information contained in the emails are public records. If you do not want your email address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.”

 

Mandatory field(s) marked with *

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