FY 23-24 Letter of Intent Application - Grossmont Healthcare District

2023-2024 Letter of Intent Application

The following section contains instructions for submitting a Letter of Intent to apply. Organizations that haven’t previously received grant funds from the District are requested to complete this form, regardless of the amount of funds being requested. Submission of a full or simplified grant application is not required.

"*" indicates required fields

Contact Info

Legal Name of Organization*

Organization Website

Organization Point of Contact*

First Last

Contact Email Address*

Letter

Please attach a one page typed PDF letter that briefly describes: 1) your organization and its mission 2) the amount of funds being requested 3) the title of the project for which funds are being requested including a) the population it would benefit, b) how it supports the District’s priority health needs/mission, and c) the anticipated number of East County residents that would benefit.

Upload file:*

Accepted file types: pdf, Max. file size: 50 MB.

IRS Determination Letter or Other Verification of Nonprofit Status

Upload file:*

Accepted file types: pdf, Max. file size: 50 MB.

Balance Sheet or Income Statement

Please include the most recent document.

Upload file*

Accepted file types: pdf, Max. file size: 50 MB.

Project Budget

Please include a one page line item anticipated project budget for the funds being requested.

Upload file*

Accepted file types: pdf, Max. file size: 50 MB.

Grant Application Signature

Signature*

I (we) certify that all information included in this application is complete and accurate.

Digital Signature*

First Last Title

By checking the “Signature” box above and including your full name and title, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.