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SUbgrantee 'ApPJ~cat;°n Form <br /> <br />9. Applicant Flail Aiient ti your ~un~y'a Gressroots ~s Pr~ra~ L~sl Ol~;~;~ Agem swor~ <br /> su~ronts 0nly ia fedorol~ lax-exempt fion-~rofit ear.reliant o~ ~ur <br /> <br /> information o~ ~ur Fiscal Agent. This is the Po~e to ~ich ~ecks ~ll ~ <br /> issue. <br /> <br /> Conta~ Perso~'s Name <br /> Como~ Parson's Title <br /> Mailing A~;ess <br /> <br /> Ci~ Coun~ <br /> State Zip C~o <br /> Area C~e, Telephone( ) Day <br /> Area C~e. Home Telephone ( ) Evening <br /> Name an~ Poshlon gl Authorizing O~c~M <br /> ~s is ~e person who is legally 8b{e qo obligate 1he (i~l agent. <br /> <br />...... · SJgn~u/e of Auth~Jng Official /~ D~ <br /> ~]gflature of Pmj~c~Direu~r /~a;e <br /> <br /> Signature of Fiscal Agent Authorizing Official Date <br /> <br /> 10. Checklist please ma~e sure the appiicotion is complete b~ following this ~her.~ilst, which <br /> corresponds to the numbered items in the form. Incomplete applications will <br /> nol be reviewed. <br /> X I. Applicant Organization information complelo <br /> ~ 2. OperefinglncomesectloncompJeleandfiscallnformatlonatlached <br /> in duplicate <br /> )[ Income and expense statemem for previous year <br /> X Operating budget for current year <br /> X Planned operating budget for hex1 year <br /> X 3. TotalAmount Requested <br /> X 4. Internal Operations narrative complete <br /> X .5. Communityinvolvement narrative complete <br /> · X 6. Program DescrTption comptele <br /> X7 <br /> ~7~8: Financial Information complete and addition correct <br /> Applicant Fiscal Agent complete (if appticableJ <br /> X 9, Certification signatures provided <br /> <br /> The applicant should retain a copy of the application for ils filea. <br /> <br /> I(a) <br /> <br /> <br />