2. 

4. CIVIC APPROPRIATION REQUEST FOR FUNDING

6. Contact Information

8. Agency/Organization:
9. Application Date:
11. Project Title:
13. Total Project Cost:
14. Town Funds Requested:
16. Contact Person Name:
17. Phone Number:
19. Fax:
20. Email:
22. Mailing Address:
24. Project Address (If Different)

26. Agency Information

28. Agency Purpose/Mission:
30. List Agency Officers And/Or Directors:
32. Year Incorporated As A 501c(3):
33. Taxpayer ID Number (TIN):
35. Main Source(s) Of Funding:

37. Project Description

39. (Attach Additional Sheets If Necessary):
41. File Upload

    Please upload all necessary files here. Thank you!

43. Additional Information

    (Please Attach)

    1. Proof of Agency 501c(3) status, or other.
    2. Agency's budget, prior three (3) years.
    3. Prior Middletown Civic Appropriations Requests: List year, amount requested, amount received and purpose of request.

45. Applications and supporting information must be delivered to the Finance Office, 350 East Main Road, or emailed to mtanguay@middletownri.com. Any questions regarding the application process should be directed to Marc W. Tanguay, Finance Director, Middletown Town Hall, 350 East Main Road, Middletown, RI 02842 -- Phone: (401) 846-4478 Fax: (401) 849-6267.

47. Authorized Signature:
48. Date:
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field