Hermanowski Family Foundation Initial Request Form

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Organization Name: Urban Survival Club
Legal Name (if Different):
Also Known As:
Mailing Address: PO Box 12072
City: Omaha
State: NE
Postal Code: 68112
Main Phone: 4029152398
Main Fax:
Organization Website: www.uscomaha.org
Employer ID Number:
Organization Tax Status: 501c3

Proposal Information

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Today’s Date: 3
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

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