*1.Request for Opioid Settlement Funds proposal form:(Required.)

Organization/ Agency

Name, title/role

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

2.Amount requesting

3.Project Title

4.Brief Summary of your Project

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

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

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

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

9.Please upload any files here.

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