Small Grant Application

Small Grant Application

Parent’s Name (Mother or Father): 

Phone Number: 

Email: 

Social Security Number: 

Adopted Child(ren) and Special Needs: 

[List each with name, DOB, Date of Adoption, Place of Adoption, Special Needs if any]

Annual Household Income (based on latest income tax filing): 

Home Address: 

Summary of the financial needs specific to this grant application:

Last application granted (Amount/Date):

Fund release method (PayPal, Zelle, Check or other):

Disclaimer & Signature

I certify that all information provided is true and complete to the best of my knowledge. I hereby grant Village of the Stars the right to use my stories, including photos and other media, for promotional purposes in support of its stated mission.

[Signature]

[Printed Name]

Date (mm/dd/yyyy): 

Filing Ref #: mmddyyFL (FL is the initial of first & last name)