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DocuSign Envelope ID:70E97245-CBDE-4A68-90A8-9FB875F7C092 <br /> A. Admissions $0 <br /> B. Contracted <br /> $O <br /> Revenue <br /> C. Other Revenue $0 <br /> Corporate Support: $0 <br /> D. Private Support Foundation Support: $0 <br /> Other private support: $0 <br /> Federal: $0 <br /> E. Government Support State/Regional: $0 <br /> Local(not including this request): $0 <br /> F. Applicant Cash $0 <br /> G. Grant Amount Requested $300800 <br /> (in this application) <br /> H. Total Cash Income <br /> (must equal Total Cash $3000.00 <br /> Expenses, Item G above) <br /> PART 3: APPLICATION CHECKLIST <br /> - ' ' _- - -'-� ��� <br /> APPLICATION CHECKLIST <br /> Please compile in this order. Do not staple, bind, or put into individual folders or sleeves. Provide one copy, <br /> one sided, 8.5 x 11 white paper. A digital copy of the application is not necessary. <br /> [] Application Fonn, including signature <br /> O Narrative <br /> O Detailed Budget(if necessary) <br /> O Resumes of key artists involved in grant funded program(s) <br /> O Sample programs, pnaaa, or other materials from this or similar past programs <br /> O Letters of support from community partners (if applicable) <br /> U Work samples by artist(s), labeled with artists' name, title of work, date of work, produced in the last three years: <br /> o Visual artists: CD, DVD, or high resolution photographs (8 images per artist MAX), clearly labeled with <br /> dimensions and media and indicate top of image <br /> o <br /> Dance or theater artist: CD or DVD, or link to high-quality online video (3-5 minutes) <br /> o <br /> Music and spoken word: CD , MP3 or link to high-quality online video (3-5 minutes) <br /> o <br /> Literary arts: Manuscript(10-15 pages) submitted as .pdf file or hard copy <br /> PART 4: CERTIFICATION <br /> I understand that failure to respond to any of the above items may adversely affect the consideration of this application. I <br /> certify that I am committed to the completion of the proposed p ject in compliance with legal requirements and granting <br /> procedures. I certify that the information contained in this app|ioatiun, including attachments and supporting mateha|o, is <br /> true and correct. <br /> Printed or typed name: Dawn Hummer <br /> Signature: <br /> Date: May 22, 2017 <br /> 2017 Grassroots Program Grant Apptcation Packet 5 <br />