MONTGOMERY COUNTY HISTORIC PRESERVATION GRANT FUND

APPLICATION
FOR FISCAL YEAR 2009

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Group or Organization Name: _________________________________________________

Address___________________________________________________________________

__________________________________________________________________________

Name of Contact Person: _____________________________________________________

Contact Person Phone No.:(Home) __________________ (Office)

(cell) (e-mail)

Contact Person Address: ______________________________________________________

__________________________________________________________________________

THE FOLLOWING INFORMATION MUST BE SUBMITTED BEFORE YOUR GRANT

REQUEST CAN BE CONSIDERED. APPLICATION IS DUE SEPTEMBER 30, 2008:

1. On a separate sheet of paper, briefly describe your organization, its objectives, and
membership. Attach a copy of the organization's charter or founding document, and a
copy of your tax exempt certificate.

2. On a separate sheet of paper, provide the following information:

a. Describe briefly and/or name your project.

b. What is/are the purpose(s) of your project?

c. Who will see/benefit from your project i.e. your target audience, if any?

d. What exactly will be produced or achieved?

e. Describe and/or list the materials and resources you will use.

f. How will the project contribute to historic preservation?

g Who are the primary persons involved? This should include project manager,
consultants, resource experts, etc. Describe briefly their qualifications or attach
resumes. NOTE: Indicate the primary person responsible for the project if
different from the contact person listed above.

h. Amount of money requested:_____________________

Application - Page 2

3. On a separate sheet of paper, describe how you will carry out the project.

a. Project starting date__________(no earlier than 1/1/09)

b. Project ending date___________(no later than 12/31/09)

c. What are the three to five most important milestones in your project and the
expected month of their completion?

4. Include any essential support materials which help explain your project (e.g. photograph of
building if appropriate, brochure, survey, resumes, etc.)

5. BUDGET: The following outline is to guide you in submitting your budget. See Guidelines,
p. 2, Item 4 for explanation of in-kind matching contributions for volunteer hours. Please note:
TOTAL INCOME must equal or exceed TOTAL EXPENSES.

INCOME EXPENSES

A. Matching Contributions Personnel

-Cash _________ -Consultants _______

-In-kind _________ -Other _______

-TOTAL _________ -TOTAL _______

Materials ________
Printing/Copying ________
B. HPC Grant Request _________ Photos/Video ________
Postage ________
C. Total of A. & B. _________ Insurance ________
Other (Identify) ________
________
________

TOTAL EXPENSES____________

6. BUDGET EXPLANATION Discuss briefly where your organizations matching funds will
come from and what kind of services will be performed as part of the in-kind match of volunteer
hours.

7. Describe other projects undertaken by and completed by your organization, including sources
of funds.

NOTE: PLEASE CAREFULLY READ THE INSURANCE REQUIREMENTS AS FOUND

IN THE ATTACHED GENERAL CONDITIONS. IF YOU HAVE QUESTIONS, CONTACT
YOUR INSURANCE AGENT OR CALL THE HPC OFFICE FOR MORE INFORMATION.

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Application - Page 3

8.
I hereby authorize the submission of this request for funds and understand that, should my
organization receive funding, it will be obligated to provide display materials and/or volunteer
time as part of at least one educational event sponsored by the Historic Preservation Commission
in 2009 or 2010.

_____________________________________________________________________
Signature of President of Date
Organization

I hereby certify that ___________________________ is the President of

(Name)
_____________________________and is duly elected, and that the information contained in
this
(Organization)
application and its addenda is true and correct to the best of my knowledge.

____________________________________________________________
Signature of Secretary of Date
Organization

Return completed form and attachments to Susan Soderberg, Historic Preservation

Section, Maryland-National Capital Park and Planning Commission, 8787 Georgia
Avenue, Silver Spring, Maryland, 20910. For information, call Susan Soderberg or Scott
Whipple at (301) 563-3400. Application is due September 30, 2008
July, 2008