The New Mexico Breastfeeding Task Force
Grant Application Cover Sheet


Name of Local Task Force: _______________________________________________

Project Title: __________________________________________________________

Address: _____________________________________________________________

Contact Name: _________________________________________________________

Address:  _____________________________________________________________

Phone/Fax: __________________________    ________________________________

E-mail: _______________________________________________________________

Please provide a brief synopsis of your project. A few sentences are sufficient.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Total Grant Amount Requested: _____________________________________________

Check Should Be Made Out To: _____________________________________________




____________________________    ____________      ___________________________
Signature of Grant Coordinator               Date                       Print or Type Name


____________________________     ____________     ___________________________
Signature of Local Task Force Chair     Date                       Print or Type Name




__________
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Grant Application Budget Form

                     Description of Proposed             Itemized Expense         Actual Expense due
                                 Expense                                                                    November 15, 2012

          1.     ______________________      _________________         ______________

          2.     ______________________      _________________         ______________

          3.     ______________________      _________________         ______________    

          4.     ______________________      _________________          _____________

          5.     ______________________      _________________        ______________

          6.     ______________________      _________________      _______________

          7.     ______________________      _________________       _______________

          8.     ______________________      _________________        ______________

          9.     ______________________      _________________       _______________

        10.     ______________________      _________________       _______________

        11.     _____________________        _________________       _______________
     
                                    Total Expenses       _________________       _______________ 


Money should only be used for expenses specified in the grant unless approved by the NM Breastfeeding Task Force Grant Committee. 
Extensions for completion of the grant may also be requested from the Grant Committee.

Final accounting must  be submitted by November 15, 2012 for actual grant expenditures incurred up to September 30, 2012.


__________________________________ ___________    ________________
Print or Type Name                                                                         Date


__________________________________
Signed by grant coordinator or other fiscal agent 




                                           

Submit applications to:                                                             Grant Committee Contact:
Sharon Giles-Pullen                                                                 Jacie Coryell
WIC Nutrition Bureau                                                               8801 Lagrima de Oro NE
2040 South Pacheco                                                               Albuquerque, NM 87111
Santa Fe, NM 87505                                                               
jacie@swcp.com   505-293-5215         
sharon.giles-pullen@state.nm.us