Request for Financial Assistance

THE NAVAJO NATION INDIAN WELLS CHAPTER REQUEST FOR FINANCIAL ASSISTANCE Student Enrichment Program DATE:______

Name ______Indian Wells Chapter Registered Voter? Yes/No Physical Address: ______Mailing Address: ______Census Number: ______Social Security Number: ______Contact Person: ______Telephone Number: ______

I am requesting financial assistance for Student Enrichment Program Name of Program/Enrichment Sponsor: ______Describe the specific nature of Program: ______**Please Attach Flyer, Program, or Agenda verifying the event If financial assistance is approved, how will the fund be used? ______Have you applied for other public or tribal financial assistance? Yes No If, NO, explain:______Name of Entity/Agency ______Address: ______Amount Funds Received: ______Contact Person: ______Telephone Number: ______

Signature: ______Date: ______

CHAPTER ADMINISTRATION ACTION

DATE/TIME RECEIVED: ______BY: ______FUNDS BUDGETED? YES – Unrestricted No – Restricted Fiscal Year: ______No FUNDS AVAILABLE: YES – BALANCE: ______NO – CHAPTER APPROVED? Yes No AMS: ______DATE: ______…………………………………………………………………………………………………………… ………………………………………………  APPROVED – AMOUNT: ______CHECK NO. ______ACCOUNT/SUB-ACCT NO: ______Check received by: (Print Name) ______Date: ______(Signature) ______ DISAPPROVED – Reason: ______

______…………………………………………………………………………………………………………… ………………………………………………. COORDINATOR/MANAGER: ______DATE: ______

CHAPTER OFFICIAL CONCURRENCE: ______DATE: ______

Amendment 10/18/2016