Cover Sheet for General Support Requests

Cover Sheet for Requests to the Moriah Fund

About the Organization

Organization name / Telephone / Fax
Postal Address
Name and title of contact person / Contact person’s telephone, extension, and email
Organization’s Tax ID Number / Website / Name & title of chief executive officer
Name and title of official authorized to sign grant agreements / Signature

Organizational Budget

Total Revenues / Total Expenses
Previous year (actual) / $ / $
Current year / $ / $
Subsequent year / $ / $

About the Request

Type of support requested:

___ General support ___ Project support ___ Donor Advised

Amount requested / Time period for which grant is requested

Dates of fiscal year

Summary of request (no more than two paragraphs)

Please complete the following section ONLY if your organization is requesting project, rather than general, support.

Total Project Budget

Total Revenues / Total Expenses
Previous year (actual) / $ / $
Current year / $ / $
Subsequent year / $ / $