Somerset County Opioid Funds request

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* 1. Request for Opioid Settlement Funds proposal form:

Organization/ Agency

Name, title/role

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

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* 2. Amount requesting

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* 3. Project Title

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* 4. Brief Summary of your Project

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* 5. What Remediation Use / Core Strategy / Approved use from Exhibit E does your purposed project relate to and how.

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* 6. If the requested amount is unable to be provided, could you accept a lower amount to complete your project?

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* 7. How will you sustain this project after the funding is over?

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* 8. Please provide a Budget for the project you are requesting funding for.

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* 9. Please upload any files here.

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