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Subgrantee App~c.tion Form <br /> <br />8, APl~k~nt FI~:~I Ag~t If ,/~ur county's Gral~rcots ~ ~ram L~al Distributing Agent a~rds <br /> lu~rBnti on~ to f~rll~ t~-Bxempt non-pr~it ~rali~ a~ ~ur <br /> ~ln~t~ ~l not have thBt ~atus, pleB~e prairie ~a follo~ <br /> inf~mstlon a~ut ~ur F~I Agent. Th;s is the Pay~ to wh~h <br /> ;~u~. <br /> <br /> N~me ~ Organi~ti0n <br /> ~nle~ Per~n'; N~me <br /> Conta~ <br /> Msiling A~re~ <br /> <br /> C~ Coun~ <br /> St~ta Zip <br /> ~ea C~e, Telephone ( ) Day <br /> ~ea C~, Hom~ Telephone { ) Evening <br /> N~me ~ Poshion of Au~horb~ng O~cial <br /> ~is ~s ~he ~rson who ~s ~lly able m obligate ~he fiscal agenL <br /> <br /> IRS tm& dete~mination le~ar on file w{th ~A ~ aueched <br /> <br />9. Ce~on We understand that failure to res~nd to Iny of the a~e items may seriously <br /> hi.er the ~ideralion of this application. We ceni~ that we are commi~ed <br /> to the completion of the pro~s~ proje~ in complia~e with Iqal <br /> r~uiremonts and granting pr~ure;. We ce~i~ thai the information <br /> ~ntain~ in Ibis a~licalion, includino all a~achments and suppling <br /> msterla~s, is t~ua ~nd ~r;~ to the ~st of our knowl~e. <br /> <br /> Signature ol Fiscal Agent Aulhorizin9 Official Date <br /> <br /> 10. Chad[lilt Please make sure the application is complete by following this checklist, which <br /> co.ascends to the numbered items in the fnrm. Incomplete applications will <br /> not ba reviewed. <br /> X 1. Applicant Organization information complete <br /> X 7.. OperotinglncomesecUoncompleteandfiscalinfo~mationanached <br /> in duplicate <br /> N/.A. income and expense statement for previous year <br /> N/A Operating budget fei current year <br /> ](. Planned operating budget for nest year <br /> X 3. TotalAmoont Requested <br /> _.,Y~4. fntarnel Operations narrative complete <br /> -.~..5. Communilylnvolvement narrative complete <br /> X 6. Program Description complete <br /> X ?. Finsnciatlnlormetioncompteteandeddit;oncorrec~ <br /> H/~8. A4~plicant Fiscal Agent complete (il applicable) <br /> :X 9, Cenlfication sigrmtures provided <br /> The applicant shouid retain · copy o! *.he application (of its tiles. <br /> <br /> <br />