Agency Report Form

Agency name (required):

Today's date (required):

Grant number (required):

Your name (required):

Your title (required):

Your email (required):

Amount awarded (required):

Amount spent to date (required):

Amount remaining (required):

If there is an amount remaining, will it be spent? (required) (check one)
Yes No N/A 

If you answered no, please explain:

Project completion date (required):

What is the grant accomplishing? (required):

Projected number of children with special needs to be helped in this grant application (required):



Actual number of children helped (required):



If you have questions, please contact Debbie Billingsley, Grants Manager
at (502) 582-7522.