2010 Appropriations Request Form for Congressman Jos� E. 
Serrano (deadline is February 10, 2009)

Please note:  Congressman Serrano only funds organizations that are based in the 
16th Congressional District of New York.  If an applicant organization is based 
outside of the 16th Congressional District, a project will be eligible for funding only 
if the funding is targeted to an activity or program that demonstrably benefits the 
residents of the 16th Congressional District.

Contact Information

Name:

Organization Name:

Address:  (Street)
Address:  (City/State/Zip)

Phone Number:

Web Address:

Is applicant a 50l(c)3 non-profit organization?

Name of Primary Contact Person for Request including phone, cell, fax, and e-mail 
address:

Request Information:

Actual Recipient Name:

Project Name:

Purpose of Project: 

Brief Description of Project Request:

Brief Description of How the Funding will be Spent and a Justification 

Project Request Amount:

Brief Project Budget Breakout for the Requested amount only:  (e.g. salaries for 
new hires, equipment, construction, training etc.)  Please Note:  Appropriated 
dollars cannot be designated for the salaries of CEOs and other senior executives 
but can be included for the hiring of new personnel to implement or expand a 
program.

Total Cost of Project:  (Note:  if the amount requested is different from the total 
cost, please explain if this will be a multi-year request or if other sources are 
available to reach the total project cost.)

Agency from which funds are being requested (if known): (for example, Small 
Business Administration)

Previous Funding History:   (Please list all previous earmarks that the organization 
has received, including fiscal year for the earmark, what it was for, and the name of 
the federal agency that provided the earmark (for example, in FY 2002 an earmark 
was received from the Environmental Protection Agency for ...) 

Please note if the funding will be matched, and if yes, please identify the source of 
the match.

Please note if request is coming from a Lobbying Firm and if so, please indicate the 
name of the firm and contact person.

Please attach a list of Board Members for the Organization.

* After completing this form, please save it as a Word document, and send it via e-
mail to NY16Request@mail.house.gov