American Speech-Language-Hearing Association

Information For:

ASHA Personnel Issues Year-End Grant Report

Grant Summary

Instructions

Each Year-End Grant Report requires two forms:

  1. Grant Summary Form
  2. Expense Form [XLS]

Please complete each field. You may put N/A if not applicable. The deadline for submission of the Grant Summary and Expense Form is December 3, 2012. See the ASHA Personnel Issues Grants FAQs for details.

Note: You must complete the Grant Summary Form in one sitting. Therefore, please allow sufficient time as you cannot save your information. You can cut text from other applications (e.g., Word) and paste into this form. Please limit your report to one page.

* indicates required field.

Contact Information

Project Title:*

President's First Name:*

President's Last Name:*

State Association:*

Mailing Address:*

City:*

State:*

Zip Code:*

Phone Number:*

E-mail:*

Project Manager:*

Project Manager's First Name:

Project Manager's Last Name:

Mailing Address:

City:

State:

Zip Code:

Phone Number:

E-mail:

Year-End Report*

You may cut and paste text from Word or a similar application.

President's Signature

The insertion of my name below is proof that I am the president of this association and can attest to the validity of the information contained in this Personnel Grant Summary Report.

President's Signature:*

State Association:*

State Association's EIN Number (The Employer Identification Number is also known as a Federal Tax Identification Number, and is used to identify a business entity.):*

IRS Non-profit Designation (e.g., 501(c)(3)):*

Today's Date (MM/DD/YYYY):*

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