Office of Congresswoman Yvette D. Clarke
Fiscal Year 2010 Appropriations Form

Due Date: Fully complete and return no later than February 13, 2009.
Must be submitted electronically to daniel.hattis@mail.house.gov

1. Date submitted:

2. Name of submitting organization:

3. Address of organization submitting request (please include website):

4. Contact information for point-of-contact at organization submitting request 
(name, address, phone number, email):

5. If the intended recipient of federal funding is different from the requesting 
organization, please provide contact information about the recipient:

Name of organization:
Point of contact:
Address:
Phone number:
Email:

6. Have you met with Congresswoman Clarke or a member of her staff about this 
request?  If so, please list the date of the meeting.

7. Mission or Core Value Statement of the Recipient (if you are other than a 
municipality):

8. Project name:

9. Amount of your request:

10. Please list the appropriations bill, program, and/or account from which you are 
requesting funds:

11. List any other House or Senate Members who may also make this request:

12. If your organization is submitting multiple requests, please state your 
organization's priority number for this project (a separate form must be completed 
for each request):


13. Project Description (please limit to 1 page): 

*	What is the anticipated benefit and/or impact of the project?   What 
communities will benefit from this project?  What is the national significance 
of the project?  What measurable outcomes will result from this project?

14. Has your project been authorized by law?  If yes, please cite the statutory 
authorization.

15. Is this a new project?  If not, please list all previous federal funding that this 
project has received.  For transportation projects, also list any High Priority Project 
(HPP) funds that the project has received.  If the project has received a federal 
appropriation in the past, please note this and provide a breakdown for each fiscal 
year.

16. Is this project included in the President's budget?  If so, for how much and 
under what account?

17. List all anticipated sources of funding (local, state, private, etc) and the amount 
you expect to receive from each source (most federal grant programs require match 
funding).

18. List the amount you have raised to date, the sources of these funds, and the 
amount of work you have completed.

19. Have you applied for any federal discretionary grants for this project?  If yes, 
for which programs have you applied?

20. Please attach a separate chart summarizing your project's complete budget.  
Within the budget, specifically note the expected breakdown for the federal funds 
that you are requesting (maximum one page).