3135-0112 Consortium Partner Information Form

NEA Application

Consortium Partner Information
(For official Consortium Applications only)

OMB No. 3135-0112
Expires 11/30/2010

Read the
instructions for
this form before
you start.

To be completed only by the one primary consortium partner and included in the application package. Do not complete
this form if you are applying for a Challenge America Fast-Track Review Grant.
Lead Applicant for Consortium
(official IRS name):
Primary Consortium Partner’s IRS name:
Popular name (if different):
Mr.

Primary
Consortium
Partner’s
Authorizing
Official
Email
Address:

Ms.

First:

Last:

Address:
City/State/Zip Code (9-digit number):
Consortium Partner’s
Taxpayer ID Number (9-digit number):
Web Address:
Contact:

--

http://
Mr.

Ms.

First:

Last:

Title:
E-mail:
Telephone:

(

)

ext.

Fax:

(

)

Organization’s Total Operating Expenses for the most recently completed fiscal
year (unaudited figures are acceptable):
$
Mission/purpose of your organization:

Briefly describe your organization’s involvement in planning and executing the consortium project including
programming, management, finances, and any responsibilities for matching the Arts Endowment’s grant. Be
specific; do not provide a general statement of support for the project. Use this space only.