Minnesota Common Report Form

Minnesota Common Report Form
COVER SHEET
(You may reproduce this form on your computer)

Date of Report: _________________

Report Submitted to: _________________________

ORGANIZATION INFORMATION

Name of organization:
Legal name, if different:
Address:
City, State, Zip:
Employer Identification Number (EIN):
Phone:	Fax:	Web site:

Contact person regarding this application:
Title:	Phone:	E-mail:

GRANT INFORMATION

Grant ID, if applicable:
Amount and support type:	Date grant issued:
2-3 sentence description of grant:

Check one: