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DocuSign Envelope ID:DDA1623E-FEA2-4FED-A473-17044A283D43 <br /> PROJECT INCOME Explanation Cash Income Amount <br /> A. Admissions <br /> B. Contracted� � <br /> Revenue <br /> C. Other Revenue � <br /> Corporate Support: � <br /> O. Private Support Foundation Support: � <br /> Other private support: � <br /> Federal: � <br /> E. Government Support State/Regional: � <br /> Local(not including this request): � <br /> F. Applicant Cash <br /> G. Grant Amount Requested $�n��e��/�� 2400 <br /> H. Total Cash Income <br /> (must equal Total Cash <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 /snOtDeCe88@ry. <br /> [] Application Forrn, including signature <br /> [] Narrative <br /> O Detailed Budget(if necessary) <br /> [] Resumes of key artists involved in grant funded program(s) <br /> [] Sample prognorno, prasa, or other materials from this or similar past programs <br /> O Letters of support from community partners (if applicable) <br /> O 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. DVO, or high resolution photographs (8 images per artist MAX), clearly labeled with <br /> dimensions and media and indicate top of image <br /> o Dance or theater artist: CD or DVD, or link to high-quality online video (3-5 minutes) <br /> o Music and spoken word: CD . MP3 or link to high-quality online video(3-5 minutes) <br /> o 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 project in compliance with legal requirements and granting <br /> procedures. I certify that the information contained in this app|ication, including attachments and supporting materials, is <br /> true and correct. <br /> APPLICANT <br /> Printed or typed name: Renzo Ortega <br /> Signature: 1� �1 <br /> Q11�/Dahe: 5/27/2O17 <br /> 20l7Grossmolsp/oQrom Grant Application Packet 5 <br />