Mission Funding Information Form




Organization Name:

Program/Project Title:

Organization Address:

City:	State	Zip Code:



Contact Person:

Telephone Number: - -

E-Mail:

Do you have a contact at Derry Church? If so, please share their name:


Please select the budget year the organization opperates on: Calendar/Annual Fiscal

Does this organization have 501 (3)(C) Status? Yes No

Address to which donations/correspondence should be sent: (if different than the address of the organization) Donation Address:

City:	State:	Zip Code:



Form Submitted By:



Project Title:



1. State the mission or purpose of your organization.(If your organization has adopted a statement of mission, please share it with us)

2. Describe the community in which your organization ministers.

3. List specific programs/projects by which your organization currently attempts to respond to its community’s need. In what ways are people being helped through direct assistance, self-development, and public policy advocacy?

4. Identify aspects of your program/project that would be enabled by this Mission funding (check all that apply): Supplies Personel Other

5. What is the overall cost of this program/project? What amount are you requesting from Derry Presbyterian Church?

(If available, please mail or email a copy of your organizations budget)