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i' · Grassroots Arts Program 4 <br />~ Subgrantee Application Form <br /> <br /> 8. Applicant Fiscal Agent I[ your county's Gtass~oots Arts P~ogram Local Dislribuling Agent awards <br /> subgrams only to federally tax. exempt non-profit corporations and your <br /> organization does not have Ihat status, please provide the following information <br /> about your Fiscal Agent. This is the Payee to which checks will be issued. <br /> Name el Organization <br /> · Contact Person's Name <br /> Contact Person's Title _ <br /> Mailing Address <br /> <br /> City County ~ <br /> Stat~ Zip Code <br /> Area Code, Telephone ( ) Day <br /> I ) Evening <br /> <br /> Name and Position of Authorizing Official <br /> This is the person who is legally able to obligate the fiscal agent. <br /> <br /> IRS lax delermination letter on file with LDA attached <br /> <br /> 9. Certification ~ We undersland that failure'to respond to any of the above items may seriously <br /> hinder the consideration of this applicalion. We certify that we are committed <br /> Io the completion of the proposed project in compliance wilh legal requirements <br /> and granting procedures. We cerdly that the information contained in thls <br /> application, including all atlachments and supporting materials, is true and <br /> correct to the best of our knowledge. <br /> <br /> Signalum el Fiscal Agent Authorizing Ollicial Dale <br /> ~ 1. Appticanl Organi;,alion informatioh complete <br /> <br /> N/A__ 8. At:,plicanl Fiscal Agent complete (il applicablel <br /> <br /> <br />