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This form must accompany all requests for grant payment.

Grant Distribution will only be awarded up to the amount of the grant allocation and only with applicable receipts. Please use a separate form for RCCF and YAC awards and designate RCCF or YAC on the form.

GRANTEE: _____________________________________________________________

FISCAL AGENT (if applicable):_____________________________________________

ADDRESS:  _____________________________________________________________

(Fiscal Agent’s or, if not applicable, Grantee’s Address)

YEAR APPROVED: _____________

PROGRAM/PROJECT TITLE: _____________________________________________

A grant payment is hereby requested for the above program/project to be used for the approved purpose, as follows:

Grant funds in full:                 $ ____________________

Signature of Authorized Representative

________________________________________________________________________

Print or Type Name and Title

Dated: ___________________

Please mail or deliver to:
Roscommon County Community Foundation
701 Lake Street
PO Box 824
Roscommon, MI  48653
Or e-mail to:  rococofo@yahoo.com

If you have any questions, please call the Foundation office at (989) 275-3112.