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704 --455 -1206 Town of Harrlsburg <br />05:31:04 10-06-2011 6121 <br />Atlac3iaWt R <br />Cabarrus County Parks Department <br />PA Box 707, Concord, NC 28026 -0707 <br />MATCHING INCENTIVE GRANT APPLICANT <br />INFORMATION FORM <br />1. APPLICANT INFORMATION <br />ORGANIZATION NAME <br />NON - PROFIT <br />Ho� rr+gbxm- � <br />YES NO <br />ADDRESS {parr �s Llr(s <br />PHONE NUMBER <br />FAX NUMBER <br />OTHER NUMBER <br />17.0. 0x�$� J J <br />( ) 2 - a 6 -5719 <br />_ <br />(704)4sq -s623 <br />PROJECT COORD6NATOTSNAME j12n'+CL L OW C(.r <br />! <br />EMAIL ADDRESS <br />ADDRESS <br />5503 f e�rove <br />PHONE NUMBER <br />FAX NUMBER <br />OTHER NUMBER <br />4xre.S� zBcr)5 <br />� - rl 4 3 <br />70 2 -0893 <br />70� j-f 55 5 gg'55 <br />SCHOOL PRINCIPA ' NAME (IF PROJECT LOCATED ON SCHOOL PROPERTY) <br />4 'L <br />EMAIL ADDRESS <br />h <br />r.,Z <br />ADDRESS <br />PHONE NUMBER <br />FAX NUMBER <br />OTHER NUMBER <br />h 10. <br />ill <br />K <br />✓ Lt - , <br />2. PROJECT INFORMATION <br />DESCRIPTIVE TITLE OF PROJECT <br />4asy 'L 5bw Fa- Co, cess, s-l-nd aid Annau C( rl -000--17 <br />PROJECT SITE <br />loo -rci sb! r Fa k <br />STREETADDRESS <br />CITY <br />STATE <br />ZIPCODE <br />5,7 5 RCAF kway <br />f - q,r <br />2807 S <br />AREAS AFFECTED BY PROJECT �] <br />(SCHOOLS, NJNICIPALITIES, ETC,) i 1�'�F �J IJI LrO} <br />NEW PROJECT <br />START DATE Fa t 2 <br />CO- 60- r rI/t5 <br />Of 4-GOING PROJECT <br />COMPLETION DATE <br />WILL A FEE BE CHARGED FOR USE <br />ON -G03NG MAINTENANCE FOR PROJECT WILL BE PROVIDED BY: <br />OF FACILITYIPROJECT? <br />Yuv46 <br />YES 1� NO <br />ESTIMATED FUNDING: <br />TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION IS TRUE AND CORRECT. THE <br />DOCUMENT HAS BEEN AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL <br />APPLICANT $ 45 Ooo <br />COIW' I. YwfrH THE ATTACHED ASSURANCES IF THE GRANT ISAWARDED. <br />TYPED NAME OF PROJECT COORDINATOR <br />l3en ,+cL, L„owa_,� � i <br />COUNTY $ <br />37, DO D , <br />IN-KIND $ <br />TOTAL $ OZ 0C)o <br />SIGNATURE OF PROJECT COORDINATOR <br />10 <br />Attachment number 6 <br />F -7 Page 159 <br />