Scholarship Grant Report Form

Colleges and Universities who received a scholarship grant to be disbursed to a student or students from a La Crosse Area Community Foundation scholarship fund must complete this form after the scholarship has been disbursed.

Questions? Call Megan at (608) 782-3223 ext. 26 or email megan@laxcommfoundation.com.

Organization Name:(Required)

Scholarship Fund Name:(Required)

Grant Amount:(Required)

Grant Date:(Required)

Grant Number:

Contact Person:(Required)

Contact Email:(Required)

Name of scholarship recipient(s), including amount awarded, declared major and school email address for each student:(Required)

Date scholarship funds were disbursed to student account(s):(Required)

Were all of the grant funds disbursed?(Required)

Yes

I certify that the selection of the recipient was done in an open, fair and equitable process; that no member of any recipient's immediate family participated in the selection process; and that the criteria for the scholarship, as determined by the donor, was fully met.(Required)

Yes

Signature:(Required)