Endless Mountains Heritage Region, Inc.
Pennsylvania Heritage Areas Program
NOTICE OF INTENT FORM
Part I. Applicant Information:
Contact Name:____________________________________ Title:_____________________________
Organization:_______________________________________________________________________
Type of Organization: (Circle One) 501(c)(3) or Municipality
Address:___________________________________________________________________________
Phone:_______________________________ Email:_______________________________________
List of active Project Partners: (include name, organization, & phone number)
Part II. Budget Information
Grant Amount Requested = $___________________________
Required Cash Match = $___________________________
[implementation is 50% grant/50% cash match]
[special purpose study is 75% grant/25% cash match]
Administrative Fee to EMHR, Inc. [6% of grant amount] $___________________________
Projected Total Project Cash Cost plus admin fee = $___________________________
Potential List of Matching Funds:
Name Amount
Private
or Public In-hand or Pledged or Pending
Part III. Project Details
Project Title:________________________________________________________________________
Circle One: Implementation Project or Special Purpose Study (SPS)
Expected Start Date:___________________ Expected Completion Date:______________________
Project Description Summary: (Please reference "Grant Application Priority Areas" as attached)
EMHR Use ONLY Date Received:_______________________ Initials:____________
Acknowledgement & Feedback Sent:____________________________________