Grant Report Form

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71 Baltimore Street, Cumberland, Maryland 21502
301-876-9172
GRANT REPORTING FORM
Name of Organization reporting: _______________________________________________________________________________________________________
(Should be the same as on IRS Form 990)
Dates covered by this Grant: from: ________________________________ to: ___________________________________
Contact Person: ____________________________________________________________________________________________________________________________
Project/Program Name: __________________________________________________________________________________________________________________
Amount of Grant received: _______________________________________________________________________________________________________________
Purpose of Grant: __________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Number of individuals served: __________________________________________________________________________________________________________
State the progress made in achieving your measurable outcomes. _______________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Have there been any changes to your organization’s IRS 501(c)(3) not-for-profit status since you were awarded this
grant? If yes, please explain: _____________________________________________________________________________________________________________
Testimonials: Please tell us how this grant has impacted your organization or project.
To be used in marketing materials.
I hereby certify that the above and attached statements are true and accurate.
_________
Signature of Authorized Individual
Date

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