Delta Dental Indiana - Delta Dental - Community Relations Grant

Name of the Organization:

Contact Person:

Title:

Street Address:

City:

State:

Zip Code:

Phone:

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Email Address:

Employer Identification Number:

Program Title:

Total cost of program:

Amount Requested:

Are you seeking other sponsors:

YesNo

If so, please list:

Is your organization providing any of the funding for this program:

YesNo

If yes, how much:

Does this program benefit:

Children:

YesNo

Seniors:

YesNo

Low Income Individuals:

YesNo

Minorities:

YesNo

At-risk Individuals:

YesNo

Arts:

YesNo

Recreation:

YesNo

Education:

YesNo

Community Development:

YesNo

Other:

YesNo

Is this an ongoing program:

YesNo

If yes, please indicate period of time this program will cover:

Date funds needed:

Please enter the security code:

Community Benefit Contribution Request

Does this program benefit:

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