Laserfiche WebLink
Grassroots Art Program <br /> Subgrantee Application Form <br /> <br />Applicant Fiacal Agent if your county's Grassfools Aris Program Local Distributing Agent awards <br /> subgranls only 1o federaU¥ t~x-exempt non-profit corporations arid your <br /> orgar~izalion does not h~ve t~et status, please provide 1he following <br /> info,marion e~ut your Fiscal Agenl. This is the Payee to which checks will be <br /> issued. <br /> <br /> Name of Organization <br /> <br /> t,(ailing Address <br /> <br /> Ci~ Counly <br /> State Zip Code <br /> Area Code, Telephone ( ). Day <br /> Area Code, Home Telephone ( ) Evening <br /> Name and Position of AuthoHzlng Official <br /> This is the person who ;s legally able lo obligate the fiscal agenl. <br /> <br /> IRS tax determination letter on file with LDA auached <br /> <br />Ce~iflcation We understand that failure 1o res~nd lo any of the above items may seriously <br /> to the completion of ~he proposed project in compliance ~th legal <br /> <br /> comalned in ~his application, including all a[tachmems and supporting <br /> m~letiBIs, is t~ue and cot~ect to 1he best of our knowledge. <br /> <br /> Signalu~e of Project Dilecmr Dam <br /> <br /> S~9nalu~e of Fiscal Agent Authorizing Official D~le <br /> <br /> Pleas~ make sure the application is comple:e by following this checkl~sl, which <br /> <br /> in dupl;cale <br /> Income and expense statemenl for previous year <br /> year <br /> x Planned operating budget for ne~ year <br /> x 3. TotalAmount Requested <br /> <br /> x 6. Pr~ram Description complete <br /> x 7. Financiallnformalloncompleleanda~tiencor~ecl <br /> ~/a B. Apptlcant FiscalAgent complete (if appt;cabte) <br /> x 9. Cenlf;cation signalures p~ded <br /> The applicant should tetain a copy of the appl~catlon for hs files. <br /> <br /> <br />