Salina
Regional
Health
Foundation
Grant Application
Community Health Investment Program (CHIP)
Applicant: Date:
Project Title:
Revenue:
CHIP Grant Request ___ $
$
$
$
$
Total $
Expenses:
$
$
$
$
$
$
$
$
$
$
Total $
How will the CHIP dollars specifically be used?
Is applicant a 501 (c) 3 Nonprofit Organization? Yes
No . If yes, please complete:
Total Annual Operating Budget of the Applying Organization $
Tax Identification Number
I certify that the organization is current on all IRS filings, including form 990 tax returns and all quarterly payroll
returns:
Signature Print Name Here Title
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