OPIOID SETTLEMENT

GRANT APPLICATION

Business Name ____________________________________________

Amount Requested _________________________

SECTION 1: ORGANIZATION INFORMATION

Organization Name:

Mailing Address:

Website (if applicable):

Primary Contact Name:

Title:

Phone Number:

Email Address:

Federal Tax ID (EIN):

Is your organization a registered 501(c)(3)?	☐ Yes	☐ No

Year Founded:

SECTION 2: PROGRAM OVERVIEW

Project Title:

Amount of Funding Requested:

Total Program Budget:

Please provide a brief summary of the proposed program or project (3–5 sentences):

SECTION 3: PROGRAM DETAILS

Is this a: ☐ New Program

☐ Expansion of an Existing Program

☐ Pilot or One-Time Initiative

Describe your program or initiative. Include specific services or activities to be funded.

What Schedule A Core Strategy or Schedule B Approved Use does your initiative address?

(See Exhibit A)

Target population to be served (e.g., demographics, number of individuals, geographic focus):

Location(s) of service delivery:

SECTION 4: IMPACT, SUSTAINABILITY & EVALUATION

Evaluation Plan:

How will you measure “success”?

What data will you collect, and how?

Sustainability Plan:

If funding is not renewed, how will you continue the program?

Are there other sources of funding or community partnerships supporting this work?

Describe your organization’s capacity to successfully implement this program (staffing, experience, partnerships, etc.):

SECTION 5: BUDGET

Total Amount Requested from City:

Please attach a program budget including:

Personnel costs

Supplies/materials

Facilities/space

Other direct costs

Administrative/overhead (if applicable)

SECTION 6: ADDITIONAL MATERIALS (Attach as Applicable)

Proof of 501(c)(3) status

Annual budget

Most recent financial statement.

SIGNATURE

I certify that the information contained in this application is accurate and complete to the best of my knowledge.

Name:

Title:

Signature:

Date:

Applications may be dropped off at the Moundsville City Building at 800 Sixth Street, Moundsville, WV 26041 or emailed to rhealy@cityofmoundsville.com