Laserfiche WebLink
Grassroots Arls P~ograrn 4 <br /> - -~' ',' · ;~$ubgrantee Application Form <br /> <br /> a. Applicant Fiscal Agent I! your counly's Grassroots Arts Program Local Distributing Agent awards <br /> subgrants only lo federally lax. exempl non.profll corporations'end your <br /> organization does not have that status, please provide Ihe following information <br /> · about y~ur Fiscal Agent. This is the Payee to which checks will be issued. <br /> Name of Organization . <br /> Comect Person's Name <br /> Contac1 Person's Title <br />,. Mailing Address <br /> <br /> Oily County <br /> State Zip Code, ~ : <br /> Area Code, Telephone ( ] Day <br />· ( I Evening <br /> <br /> Name end Posilion of Aulhorizlng Official <br /> This is Ihe person who is legally able Io obligate the fiscal agent. <br /> <br /> IRS lax determination letter on file with LDA attached <br /> <br /> g. Certification We understand-lhat failure IO respond to any of the above items may seriously <br /> hinder Ihe consideration of Ihls application. We certify that we .are committed <br /> . to Ihe complelion of the proposed project in compliance with legal requiyements <br /> and granting procedures. We cerlify that the information contained in this <br /> application, including all allachments and suppurling malerials, is true and <br /> correct to the besl of our knowledge. <br /> <br /> .Signature of Authorizing Official Date <br /> Signature of Project Director Dale <br /> <br /> Signature of Fiscal Agent Authorizing Official Date <br /> <br /> 10; Checklist Please make sure the application is complele by following this checkgs[. <br /> which corresponds to the numbered items in Ihe form. Incomplete applications <br /> will not be reviewed. <br /> <br /> ._Z 1. Applic.ant Organizalion information complete <br /> _Z 2. Operallng Income section complete and fiscal information altached in <br /> duplicate <br /> Z__ Income and expense statement for previous year <br /> Z_ Operating budget for current year <br /> Z.. Planned operallng budgel for next year <br /> ~ 3. Tolel Amount Requested <br /> _X. 4. InternaIOperations narralive complete <br /> ._Z 5. Community Involvement nalratlve complete <br /> -~ 6. Program Description complete <br /> ..X 7. Financial Information complete and addilion correcl <br /> H/A 8. Applicant Fiscal Agent complete (if applicable) <br /> ...Zg. Certification signatures provided <br /> <br /> The applicant should retain e copy oflhe application for its flies. <br /> <br /> <br />