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Grassroots Arts Program 4 ' <br /> Subgrantee Application Form <br /> <br /> 8, Applicant Fiscal Agent If your county's Grass~oots Aris Program Local Dislribuling Agenl awards <br /> subgranls only Io federally tax. exempt non-profil corporations and your <br /> organizalion does not have Ibat stales, please provide the following information <br /> about your Fiscal Agent,'Tbis is the Payee lo which checks will be issued. <br /> Name el Organization ____ __ <br /> · Contact Perso~fs Name _ <br /> <br /> Mailing Address <br /> <br /> City Counly <br /> Stale Zip Code <br /> Area Code, Telephone ( ! Day <br /> ( ) Evening <br /> <br /> Name and Position of Adlhorizing Official <br /> This is the person who is legally able to obligala the fiscal agent. <br /> <br /> IRS lax determination letter on file with LDA__.__ afleched <br /> <br />9. Cerlification .,- We understand that failure to respond to any of tile above items may seriously <br /> hinder the consideralion of this application, We cattily that we are committed <br /> to the completion of tile proposed project in compliance with legal requirements <br /> <br /> applicatlon, including all atlachments and supporting materials, is true and <br /> correc~ Io the best of our knowledge. <br /> <br /> .SigniOule el Au~,rizing O~icial' <br /> Sig'nalure of Project Dimclor / Date <br /> <br /> Signature of Fiscal Agent Authorizing Official Dale <br /> <br /> 10. Checklist Please ma~e sore the application is complete by following this checklist, <br /> which cosresponds Io the numbered items in Ihe form. Incomptelo apptlcotions <br /> will not be reviewed. <br /> ~X 1. Applicant Orgenizelion informalion complete <br /> __X_ 2. Operaling Income section complete and fiscal information attached in <br /> duplicate <br /> <br /> --~ 3. Total Amounl Requested <br /> <br /> _~X 6. Program Description complele <br /> _~ 7, Financial Information complele and addition cormcl <br /> [q~t.. 8. Applicant Fiscal Agent complete (if applicable) <br /> ~ 9. Certiticalion slgnelures provided <br /> <br /> The applicanl should retain a copy of lbo application for its files. <br /> <br /> <br />