Name of Executive Director *

First Name

Last Name

Primary Contact Name *

Name of primary contact responsible for grant request

First Name

Last Name

Primary Contact Phone *

(###)

###

####

What is the effective date of your IRS exemption? *

MM

DD

YYYY

Your request for funding does not include an amount exceeding 20% of the total grant request for non-program funding. *

For example, proposals to fund advertising and marketing of the organization, consultant fees, non-program salaries, and temporary employee salaries may not exceed 20% of the grant request amount.

I confirm that our request is in compliance with the statement above.

If you receive a grant from OHSH in March of 2025, will you be able to spend the funds within 12 months of receipt? *

Yes

No

Amount Requested *

One Hundred Shares Houston grants either one $100,000 grant to one organization or two $50,000 grants to two organizations. Please indicate the amount of your grant request:

$100,000

$50,000

Is this a new program or an expansion of an existing program? *

New program

Expansion of existing program