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I hereby verify that all the information submitted on the Grant Application and Financial Form is true to the best of my knowledge and belief and that there has been no material omission.  I hereby agree to notify the Foundation in writing of any changes in facts or circumstances concerning my application or this financial statement.




____________________________                                                                                               
Date                                                                                                                                                




_________________________________
 Signature of Applicant (Print Name After Signature)



Please mail or email a scan of this document to:
American Indonesian Cultural and Education Foundation
521 5th Avenue, Suite 1700
New York, NY 10175

Email: info@aicef.org