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2. Organization Name*
4. Address Line 1*
6. Address Line 2
8. City*
9. State*
10. Zip Code*
12. Applicant Name*
14. Phone Number*
15. Email Address*
17. Website Address
19. Describe the organization’s purpose and/or mission and the people served. *
21. Briefly describe the program or the event for which you are requesting funds. *
23. Briefly describe how Revenue Sharing funding would be utilized. (Please list items and activities to be funded with any Revenue Sharing funds allotted. Funding cannot be used for core budget needs or program or event staffing such as security, instructors, cleanup crews, etc.)*
25. Has this organization received Revenue Sharing Funds in the past?*

    1. Yes
    2. No
27. Specify year(s), event and amount received:
29. Are you a non-profit organization?*

    1. Yes
    2. No
31. Please enter your Tax Identification Number*
33. Please attach your most recent W9 form*
34. Please attach your most recent 590 form*
36. Please attach additional documents
37. Please attach additional documents
39. Additional documents may be emailed to [email protected].
41. I swear under penalty of perjury that the information supplied herein is true and correct*

    1. I agree.
43. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
45. Electronic Signature*
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field