New Jersey Department of Health

APPLICATION FOR MINI-GRANT FUNDS

($36,000 or Less)

(TYPE OR PRINT ALL DATA)	FOR STATE USE ONLY
Spending Plan No.

___________________________

Funding Authorization No.(s)

___________________________

___________________________

___________________________
1.	Name of Applicant

2.	Street Address

City

County

State

Zip Code

3.	Name and Title of Fiscal Contact

Telephone No.

Street Address

County

City

State

Zip Code

Email Address

4.	Name of Attorney for Agency

Telephone No.

5.	Name and Title of Principal Contact

Telephone No.

Email Address

6.	Employer ID No.

7.	Certificate of Need Project (if applicable)

PENDING NOT REQUIRED
8.	Proposed Grant Title

9. Location of Proposed Project (include county)

10.	Site Locations

Number

ATTACH ADDITIONAL SHEETS
11.	a.	Will any member of the Board of Directors/Trustees receive any direct or indirect personal or monetary gain from the funding of this grant?	YES	NO

b.	Does any member of the Board of Directors/Trustees serve on any board, council commission, committee or Task Force which has regulatory or advising influence on the funding program?	YES	NO
MEMBER
BOARD, COUNCIL, ETC.
11. c. Type of payment plan preferred

Cost-Reimbursement Advance Payment	11d. Location where payments should be sent

12. Type of Agency (check one)	13. Does the Agency Meet the following Licensure Requirements?

YES	NO	PENDING	N/A

FOR FACILITY

FOR SERVICES

FOR PERSONNEL
PRIVATE NON-PROFIT	GOVERNMENT	HOSPITAL
PRIVATE PROFIT	OTHER (Specify)
14. Agency Fiscal Year End

15. Agency Accounting System:
Cash Basis	Other (Specify)
Accrual Basis
16. Type of Request	16a. Budget Period Mo./Day/Yr.

From:	Through:

b.	Project Period Mo./Day/Yr.

From:	Through:
NEW	RENEWAL OF GRANT NO.:
MULTI YEAR GRANT	MODIFICATION TO GRANT NO.:
YEAR:	1	2	3
17. Is political subdivision covered by NJ Civil Service Merit System?

YES	NO	18. Affirmative Action Plan

YES	NO	19. If grant is awarded, will funds be used to replace other funds which would be available in absence of award?

YES	NO
COST OF PROJECT
20a. Total Funds Needed

b.	Funds Requested from State

c.	Funds From Other Sources

21a. Name of NJDOH Representative Regarding Application

21b. Program (Granting Agency)

22.	CERTIFICATION – The applicant certifies that to the best of his/her knowledge and belief all data supplied in this application and attachments are true and correct, the document has been duly authorized by the governing body of the applicant and further understands and agrees that any grant received as a result of this application shall be subject to the grant conditions, and other policies, regulations and rules issued by the New Jersey Department of Health which include provisions described in grant application instructions.
NAME AND TITLE OF APPLICANT (Print)

SIGNATURE OF APPLICANT	DATE OF APPLICATION

ASSESSMENT OF NEED(S) - List the need(s) that illustrate the reason for the project:

OBJECTIVE(S) OF PROJECT - List what will be done to alleviate “Needs” described above:

COST OF PROJECT - Indicate costs related to project:

New Jersey State Department of Health

APPLICATION FOR MINI-GRANT FUNDS

($36,000 OR LESS)

(Attach additional sheets if necessary.)

FS-77

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

FS-77, Application for Mini Grant Funds

grants, fs-77, fs, financial services, mini-grant funds, 36,000 or less

EWhite

2004-04-13

NJDOH