STATE JUSTICE INSTITUTE
APPLICATION SUMMARY
1. APPLICANT
a. Organization Name_________________________________________
b. Street/P.O. Box ____________________________________________
c. City _____________________________________________________
d. State ___________
e. Zip Code ___________________________
f. Phone Number ____________________________________________
g. Name & Phone Number of Contact Person
_________________________________________________________
h. Title ____________________________________________________
i. E-Mail Address ____________________________________________
2. TYPE OF APPLICANT (Check appropriate box)
□ National organization operating in
conjunction with State court
□ National State court support
organization
□ College or university
□ Other non-profit organization or
agency
□ Individual
□ Corporation or partnership
□ Other unit of government
□ Other ______________________
______________________
3. PROPOSED START DATE __________________________________
4. PROJECT DURATION (months) ______________________________
5. APPLICANT FINANCIAL CONTACT
a. Organization Name_________________________________________
b. Street/P.O. Box ____________________________________________
c. City _____________________________________________________
d. State ___________
e. Zip Code ___________________________
f. Phone Number ____________________________________________
g. Name & Phone Number of Contact Person
_________________________________________________________
h. Title ____________________________________________________
i. E-Mail Address ___________________________________________
j. Organization EIN ________________________________________
6. a. AMOUNT REQUESTED FROM SJI $_______________________
b. AMOUNT OF MATCH
Cash Match $_________________
In-kind Match $_________________
c. TOTAL MATCH $____________________
d. OTHER CASH $____________________
e. TOTAL PROJECT COST $____________________
7. TITLE OF PROPOSED PROJECT
8. PROJECT SUMMARY
9. CERTIFICATION
On behalf of the applicant, I hereby certify that to the best of my knowledge the information in this application is true and complete. I have read
the attached assurances (Form D) and understand that if this application is approved for funding, the award will be subject to those assurances. I
certify that the applicant will comply with the assurances if the application is approved, and that I am lawfully authorized to make these
representations on the behalf of the applicant.
_______________________________________________ ________________________________ _______________________________
SIGNATURE OF RESPONSIBLE OFFICIAL TITLE DATE
(For applications from State and local courts, Form B - Certificate of State Approval, must be attached)
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orm A 5/2020
