Legal Name of Organization

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Legal name of organization

Street address of organization

CityStateZip code

Telephone numberFax number

Executive Director / CEOTitleEmail

Geographic area served: ______

Number of persons served annually: ______

Number of employees: ______full-time; ______part-time; ______volunteers

Specific purpose for which funds are requested: (Grant awards are only eligible for infrastructure projects, which include construction, renovation, equipment, furniture, or technology-related projects, including training).

Amount requested: (Maximum grant award is $50,000) ______

1.)Describe the principal purposes and services of your organization.

2.)Describe your proposed project, including its viability and purpose.

3.)Describe your target population.

4.)Detail the budget for the proposed project.

5.)Outline the need for the proposed project.

6.)How will the proposed project benefit the persons served by the health center?

7.)Indicate any ways in which your project may be innovative.

8.)Will a grant from MassDevelopment help to leverage funds from any other source?

9.)Will your project be sustainable after the grant is expended?

10.)Has your organization received grant funding from this program in prior years? If so, for which years, what projects, and how much was received?

Please attach a copy of your IRS 501(c)3 tax status letter.

Contact person for this program, if different from Executive Director / CEOEmail

Signature of Executive Director / CEODate

Please be aware that grants from MassDevelopment are subject to our Contractor Policy as described in Section 6 of the form Grant Agreement provided to you. Grantees will be required to provide the name of any general contractor or construction manager (if one is engaged) to

MassDevelopment at least 10 days prior to the closing of the Grant.

Please return 3 copies of the completed and signed application, including answers to questions and IRS letter, byDecember 18, 2015, to:

Massachusetts Development Finance Agency

Attention: Tonya Ingram, Program Administrator

99 High Street, 11th Floor

Boston, MA 02110

Applications must be received no later than 5:00 p.m. in the Boston office of MassDevelopment.

For questions regarding the process or program, please send an email toTonya Ingram, MassDevelopmentProgram Administrator, at .

MassDevelopment anticipates completing the review process and making grants in early 2016.