Social Service Relief Treasury Form

Please fill out the COVID-19 form

Step 1

Step 2

Step 3

Background / Eligibility

Does all requested funds will be used for the sole purpose of serving individuals within the service area of Health & Wellness Foundation:

Organization Information

Organization Name:

Organization Address:

Address Line1

Address Line2

Land Mark

City

State

Country

Zip Code

Website:

EIN Number:

Executive Director /CEO Name:

First Name

Last Name

Executive Director / CEO Email:

Board Chair:

First Name

Last Name

Is the Executive Director / CEO the Primary Contact for this Grant Application:

Primary Contact Name:

First Name

Last Name

Primary Contact No:

Primary Contact Email id:

Primary Contact Role:

What population is being served? What has been the impact of COVID-19 on this population? How has your organization responded to serve them:

How much funding is being requested:

Describe briefly how the funding will be used. What is the expected timeframe for use of funds:

Please provide copy of Annual Operating Budget or Most Recent Audit:

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