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Grassroots Arts Program <br /> Sub§rantee Application Form <br /> <br /> 8. Applicant Fiscal Agent If your county's Gras~ools Arts Program Local Oistribuling Agent awards <br /> subgrants only to ledelally tax. exempt non.profit corporations and your <br /> organization does not have Ihat stalus, please provide the following informallOn <br /> about yodr Fiscal Agent. This is the Payee to which checks will be issued. <br /> Name of Organization' <br /> · Conlact Person's Name <br /> Contact Person's Title <br /> Mailing Address <br /> <br /> City County <br /> Slale Zip Code <br /> Area Code, Telephone ( ] Day <br /> ( ) _ Evening <br /> <br /> Name and Position of Aulhozlzing O~,ficial <br /> This is 1he person who is legally able Io obligate tim fiscal agent. <br /> <br /> IRS tax determination letter on file With LDA attached <br /> <br />9. Certlflcat~on ~' We understand that failure to respond Io any of Ihe above ifeals may seriously <br /> hinder the consideration of this application. We curtify thal we are committed <br /> <br /> Siona~,~Jre o! A~-~,mrizing Official D~te <br /> Si~alure of Project Director <br /> <br /> ],I/~A B. Applicant Fiscal Agent complete (if applicable) <br /> <br /> <br />