FY2011 Congressionally Directed Funding Request Form

Congressman Sanford D. Bishop, Jr. FY2011 Congressionally Directed Funding Request Form

1. Organization Name

2. Organization Address

3. Phone number/Fax/email

4. Primary Contact Person (including phone number and email address)

a. Washington, D.C. contact person (if applicable)

5. Organizational Structure: For Profit____ Non – Profit____ Government____ Educational Institution____ Other (please specify)____

a. If you represent a local government or Agency, please provide contact information (i.e., name, address, phone number) for the Mayor or Chief Administrative Officer. b. If your organization is a non-profit, please submit a copy of your state issued 501(c)3 certification. Lack of such certification may eliminate your project from consideration. 6. Provide a brief description of the activity or project for which funding is requested. 7. Which Appropriations Subcommittee should this request be submitted to (i.e., Transporation/HUD, Homeland Security, Agriculture)? 8. Program or project request? 9. If this program request, is report or bill language required? If so, please provide draft bill or report language for consideration. 10.Project Budget:

a. What is the total project cost? b. What is the amount you are requesting from the Subcommittee for FY 2011? c. Include a breakdown of the requested funding? For example, salary $40,000; computers $3,000, etc.) d. Are other funding sources contributing to this project or activity? What amount does each of these funding sources contribute? e. Has your organization received Congressionally Directed funding in previous years? If yes, please provide a detailed breakdown of all funds ever received through this process (i.e., amount, year, account, project purpose, etc). 11. Has your organization ever received any Federal grants/funding? If so, please provide the details regarding this funding (i.e., amount, date(s), Agency). 12. What are your Organization’s primary activities? 13. What is the national significance of the project, and what specific federal responsibility does the funding of this project or activity further? For example, what measurable improvements in social status, health status, educational achievement, or similar outcomes will result from this project? 14. What is the local significance of the project, particularly to the 2nd Congressional District of Georgia and is there any local or state funding ` support of this project or activity? 15. Is this a programmatic request? If so, what is its relationship/relevance to the State of Georgia and/or to the second Congressional District of Georgia? What is the hopeful measurable outcome of the expenditure of Federal funds for this request?

16. Do you or your organization have any financial, business or other relationship with Congressman Bishop, members of his family or any member of his congressional or campaign staff? If so, please provide an explanation and the details of this relationship. PLEASE NOTE: House Appropriations Subcommittees may require that additional or separate request forms be submitted for projects under their purview. This includes including the Defense, Labor, Health and Human Services & Education, Transportation and Interior Subcommittees. Under some circumstances, funds approved for projects under the Congressionally Directed funding process may be ultimately opened to a competitive bidding process. Please contact Congressman Bishop’s staff for further information.