Non-Profit Funding Request Form

December 30, 2024

Please complete the form below if you are interested in submitting a budget request to the Office of Assemblymember Khaleel M. Anderson. Once completed, your request will automatically be forwarded to our legislative team for review. Please note a completed form DOES NOT mean your organization is receiving a grant or grant nomination, this is just to log your inquiry/request. If my office has any follow-up questions, a member of the staff will reach out to you. Also, if you would like to request a meeting with Assemblymember Anderson or a member of his staff, please fill out the ‘Meet with Me’ form under ‘Community Corner' section of the website.

1. Name

Title

First Name

Middle Initial

Last Name

Suffix

2. Legal Name of the Entity

3. Legal Address of the Entity

Apt Number

City

State

Zip

4. Phone Number of the Entity

5. Tax Identification Number

6. Is your organization pre-qualified in New York State Grants Gateway?

(If no please do so before submitting this application or it will not be considered Visit https://grantsmanagement.ny.gov/get-prequalified)

Yes

7. What type of funding are you interested in applying for?

Capital funding:
Construction improvement, rehabilitation or reconstruction of facilities owned by eligible entities, acquisition by eligible entities of equipment and other capital assets, including vehicles, in support of health, safety, technology, or innovation.

Operational funding: Programmatic cost, Employee wages, Rent, Utilities, Marketing costs , Supplies,Raw materials

Amount Requesting

8. Purpose of the Request

9. Project Director Name

Title

First Name

Middle Initial

Last Name

Suffix

10. Project Director Phone Number

11. Project Director Email

Confirm Email:

12. Has your organization attended a Grant Information Session with the Office of State Assembly Member Khaleel M. Anderson? This is a requirement to proceed with this application. If no, please email Baow@nyassembly.gov to RSVP for the next Info Session in Winter/Spring 2025

Yes

User Name