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Heritage Fund Application Form

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Applicant Information

Applicant Legal Name

First

Middle

Last

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

the Name Budget:

Applicant Support Information

Status Number

Government Issued identification with Photo

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Type of Document with Current address

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Project Information

Applying as

An Individual
Group or Department (ALL names must be provided)

Title of the Project

Project Background

Summary of the project including but not limited to rationale, history or philosophy, and benefits of the project

Budget:

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Please provide a detailed budget for your project, including specific line-items and costs. A minimum of two (2) quotes for purchase/fees for services are required within a submission and must be noted in the budget with hard copies of quotes

Sample Budget

Activity	Item	Budget




Total
Total Project Cost:	Personal Contributions:	Amount of funding Requested:
Approached other funding source(s): □ YES □ NO Receiving funding support from additional source(s) in the amount of: $________________ SOURCE: ________________________________ Personal Equity Contribution: AMOUNT: $_______________________

Third Party Payment to:

Support Documentation

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List, briefly explain and attach copies. Support documentation must include but is not limited to: any correspondence relations to the project, quotes/invoices, and information relative to the project. Use of any Naicatchewenin First Nation Facilities/property require written approval which must be included in the project.

Name

First

Middle

Last

Date

Signature

Clear Signature