* 1. Name of Organization:

* 2. Organization Contact Information:

* 3. Fiduciary Contact Information (If applicable):
* Please note: A fiduciary is an external entity who is acting on your behalf in legal and/
or financial matters. The fiduciary is not an organization's internal finance director or
accounting representative.

* 5. Anticipated funding request for 2016-2017 (For planning purposed only. The amount in final proposal can be different, though please keep in mind, applicants will only be allowed to apply for a maximum total dollar amount of $36,492.00).

* 6. If applicable, please list the amount of parent trust funds received since 2011 to conduct parent leadership training, the models and number of cycles and the amount of parent trust funds returned (if any).

For example:
In 2013-2014 we received $7,177.00 for 1 cycle of PEP, no funds were returned.
In 2012-2013 we received $18,443.00 for 1 cycle PSEE, returned $552.00.

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