3135-0112 Our Town Partner Information Form

NEA Application

Our Town Partner Information
(For Our Town Applications only)

OMB No. 3135-0112
Expires 11/30/2013

Read the
instructions for
this form before
you start.

To be completed only by the one primary partner and included in the application package.
Lead Applicant for Partnership
(official IRS name):
Primary Partner’s IRS name:
Popular name (if different):
Mr.

Primary Partner’s
Authorizing
Official
Email
Address:

Ms.

First:

Last:

Address:
City/State/Zip Code (9-digit number):
Primary 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 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.