Hermanowski Family Foundation Initial Request Form

---

Organization Name: Mercy12 Recovery Community Project inc
Legal Name (if Different): Markie Person
Also Known As:
Mailing Address: 1026 Wisconsin Ave
City: Racinee
State: Wi
Postal Code: 53403
Main Phone:
Main Fax:
Organization Website: Www.Mercy12.org
Employer ID Number:
Organization Tax Status:

Proposal Information

---

Today’s Date:
Requested Amount:

Project Title:
Project Description:

Total Project Budget:

Other Funding
Sources For The Project (Committed & Potential):

Project Duration:
Geographical Area Served:
Age Group To Be Served:

Contact Information

---

Contact Prefix (Mr,Mrs etc.):
Contact First Name:
Contact Last Name:
Contact Title:
Contact Phone:
Contact Email: