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'~ ..... ~ubgrantee Al~pli~:atlo~ Form - <br /> <br />! IL Applicant Fiscal Agent , If your i:ounly's Grasstoots Ads Program Local <br /> subgrants only Io federally tax-exempl non-profilDistributlngcorporationsAgentend your <br /> organization does nol have that status, please provide the follow~ng informal|on <br />~~ about your FJacal Agenl. This is the Payee to wi}ich checks will be issued, <br /> Name of Organization. <br />.~ Conlacl Persons Name. <br /> Contacl Person'~ Tille i <br /> Mailing Address. ' <br /> <br /> Cily County.. <br /> Stale Zip Cpde <br />~ Area Code, Telephone (~ 1. Day <br /> I-- I Evening <br /> Name and Position of Authorizing Official <br /> This is the person who is legally able to obligate Ihe fiscal agent., <br /> <br /> fRS lax determination letter__ on file with LDA. attached <br /> <br /> 9. Certification W~ understand.that failure lO respond Io any of 1he above items may seriously <br /> hinder the conslde~afion of this application. We cerl{fy Ihal we pre commitled <br /> to the completion of the proposed projecl in compliance with legal requirements <br /> and granting procedures. We cerlily that the information contained in this <br /> applicallon, including all atlachmenls and suppoding materials, is true and <br /> correct Io Ihe best of our knowledge. <br /> <br /> .Signature ol'Authorizlng Official .- Date <br /> Signature of P~oject Director Date <br /> <br /> Signature ol Fiscal Agent Authorizing Olficial Date <br /> <br /> 10. Checklist Please make sure the application is complete by following this checklisl. <br /> which cor[esponds to the numbered items in the Iorm. Incomplete applications <br /> will not be reviewed. <br /> ~ 1. Appl?canl Organization information complete <br /> .~X 2. Opetat'ing Income section complete and fiscal information etlached in <br /> duplicate <br /> ~ Income and expense statemenl for previous year <br /> ~L. Operating budget for current year <br /> ~L. Planned oper'afing budget for next year <br /> X 3. Total Amounl Requested <br /> ~C 4. InternaIOpe[ations narrative complete <br /> 3( 5. Community Involvement narrative complete <br /> 3(6. P[og~am Description complete <br /> ..,[ 7. Financial Information complete and addition correct <br /> N/~L._ 8. Applicant Fiscal Agent complete (if applicable] <br /> 3(9. Certification signatures p~ovided <br /> <br /> The applicant should retain a copy of the application for its files. <br /> <br /> <br />