23-24 Dental Facility Expansion Grant

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* 1. FAFCC Member Clinic Name

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* 2. Fiscal Agent

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* 3. Federal Tax ID

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* 4. Project Liaison Name

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* 5. Project Liaison E-mail

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* 6. Project Liaison Phone Number

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* 7. By typing my name below, I certify that I understand that all funds be expended by June 30, 2024, and the organization must be in receipt of all purchases by that date. If any funds are unspent or equipment is not acquired by June 30, 2024, the organization forfeits all rights to the funds and/or equipment.

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* 8. Total amount of request

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* 9. Please provide a budget justification on how you arrived at the requested amount.

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* 10. How will these funds increase the number of dental patients served?

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* 11. What new or additional dental services will be provided with this funding?

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* 12. How will these funds improve the overall quality of care for patients?

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* 13. Please provide the estimated percentage of growth in the number of dental patients along with a detailed justification on how you arrived at that number.

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* 14. Please upload the organization's 501c3 designation letter.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 15. Please upload the organization's audit, review, 990, or a note of explanation if your organization does not have any of the documents mentioned.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 16. Please upload the required budget form. This MUST be the form that has been provided by FAFCC. No other formats will be accepted.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 17. Please upload any documents related to budget justification.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.