Hermanowski Family Foundation Initial Request Form

---

Organization Name: The Connection Center
Legal Name (if Different):
Also Known As: The Rec
Mailing Address: 1315 15th St SE, De Motte, IN 46310
City: De
State:
Postal Code:
Main Phone:
Main Fax:
Organization Website:
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: