AGENCY:

Qtrly    Monthly    Other
(if Other, specify)

DATE:

RE Grant (award date):

NAME & TITLE OF PERSON REPORTING:

TELEPHONE NUMBER: ( ) -

PROGRAM: On a separate sheet of paper, please write a few paragraphs describing progress on your project since the last report or since the grant was awarded. If outcome objectives originally part of the project have been modified in any way, this information should be included. We are interested in any problems you've encountered.

APPROXIMATE # OF PERSONS TO BE SERVED BY PROJECT:


# PRESENTLY SERVED:

STAFFING PLANNED FOR PROJECT:


PRESENT STAFFING:

FINANCES:
TOTAL BUDGETED INCOME FOR PROJECT FROM ALL SOURCES:

TOTAL ACTUAL INCOME PLEDGED OR PAID FROM ALL SOURCES TO DATE:
(Include any information about requests for funding which have been postponed, denied or have had no response.)

TOTAL BUDGETED PROJECT EXPENSES:

ACTUAL EXPENSES INCURRED TO DATE ON THE ENTIRE PROJECT:

WILL BUDGET REQUIRE REVISION? IF SO, PLEASE TELL HOW THIS IS BEING ADDRESSED

PLEASE ATTACH A COPY OF THE PROJECT BUDGET, SHOWING ANY REVISIONS FROM BUDGET SUBMITTED WITH PROPOSAL.

SCHEDULE: PLANNED TIMELINE FOR PROJECT:
FROM:
TO:

IS PROJECT PRESENTLY ON SCHEDULE? (IF NOT, INDICATE REASONS)

ADDITIONAL INFORMATION: Please include copies of any publicity which may have occurred regarding this project, including promotional mailings.

REQUEST FOR PAYMENT (if applicable per conditions of contract)
Complete and return a "Request for Payment" form available from this web site. Select the appropriate form from the Klee Foundation Forms page.online at: http://kleefoundation.org/guidelines/forms/