Office of Senator Kirsten Gillibrand
Fiscal Year 2010 Non-Defense Appropriations Request Form
(Please email to: Appropriations@Gillibrand.Senate.Gov by February 20th)

Section I (Organization Information)

*	Date Submitted:       	City:       	County:       

*	Name of Submitting Institution:       

*	Address:       

*	Phone:       

*	Website:      

Section II (Project)

*	Project Title:       

*	Project Description (2-3 specific sentence description of how the federal funding is 
intended to be spent):       

*	Amount of funding requested for FY2010:       

*	Total Project Cost:	     	

*	Priority (if submitting more than one request):        of    

*	Why does this project warrant federal funds? (2-3 specific sentence description):       

*	Authorizing Federal Legislation (if applicable):       

*	President's Budget (if applicable):       

Is your organization for-profit or is it a not-for-profit?  0  Yes	0  No		0  N/A

If seeking funding for a transportation project, is your project on the State Transportation Improvement 
Plan?  0  Yes	0  No		0  N/A

If seeking funding for a water or sewer project, is the system currently under consent decree?
0  Yes	0  No		0  N/A

*	What is the estimated start date for your project?:       

*	Please list the counties that will benefit from your project:       

*	Please list the current number of employees at the organization:       

*	Please list the approximate number of jobs this funding would create:       	

Section III (Sources of Funding)

Appropriation Bill:	Pick ONE  			

Account Title:       

House Member:       				

House Staffer(s):       

*	Please list ALL anticipated and received sources of funding for this specific project, 
and the amount you expect to receive or have already received from each source 
including the year. (e.g. State, Local, Private):       

*	If required, will matching funds be made available?
(Many projects have a cost-sharing requirement, which can range between 20-45%.  
Example of a project with a 45% match requirement - a $1 million project would receive 
a maximum of $550,000 from the Federal government and the remaining $450,000 
would have to be paid for through a non-federal source)
What percentage of the total request will be matched?     %

*	What other projects has your organization requested during this appropriations cycle?  
     

Section IV (Past Funding)

If you have previously received federal earmarked funding for this specific project, please list the 
amount of funding this specific project has received over the last four fiscal years.

FY09 Appropriation (requested and funded):       
Member of Congress:       
Source of Funding:       

FY08 Appropriation (requested and funded):       
Member of Congress:       
Source of Funding:       

FY07 Appropriation (requested and funded):       
Member of Congress:       
Source of Funding:       

FY06 Appropriation (requested and funded):       
Member of Congress:       
Source of Funding:       

*	Other Sources of Federal Funding, Year, and Amount (federal grants, contracts or 
other):       

*	Has your organization ever received federal funding in the form of an earmark?:  
Pick ONE

*	*If yes, please name the project and the fiscal year it was included:       

Section V (Contact Information)

Staff Contact Information at the Institution:
Name:       
Address:       
Email:      					
Phone:	      			Cell:       		Weekend:       
Other (24 Hour Number):       

Highest Level Person at the Institution (who the Senator may contact directly):
Name and Title:       
Address:       
Email:       
Phone:       			Cell:        		Weekend:       
Other (24 Hour Number):       

Institutions Representative (not required):
Name and Title:       
Address:       
Email:       
Phone:       			Cell:        		Weekend:       
Other (24 Hour Number):       







Section VI (One Pager)

Please provide a one-page summary that describes your proposed project and explains how the project 
meets the criteria of the bill and program title that you have selected and how the project benefits the 
region in the State of New York.       

Section VII (Budget)

Please provide a detailed budget of the project.

Section VIII (Letter of Support)

Please attach ONE letter of support from an agency/local government official/organization that supports 
your request for funding.  Only the first letter received will be accepted, any additional letters will be 
discarded.  

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