Name of Organization ____________________________________ Date_______

Taxpayer/Employer ID Number _______________________________

Project Title _______________________________________________

Brief Description of Project

Contact Person_______________________________________________

Total Project Cost ____________________________________________

SPOOM Grant Awarded Date and Amount _______________________

Project Expenses

Materials_______________________________________________

Labor _________________________________________________

Professional Fees or Services ( if applicable)___________________

Total Expenditures________________________________________

Source of Matching Funds

Contributions _______________________________________

Materials- If donated, estimated value ____________________

In-kind Services- Document hours and hourly rate____________

Equipment Use- If donated ______________________________

Total Source of Matching Funds ______________________________

Please mail this with the documented receipts to the SPOOM Treasurer.