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I <br /> <br /> DIVISION OF YOUTH SERVICES - CBA <br /> pROGRAH AGREEHEN? <br /> <br />S~nsorin~ hgency ~n%~ ~ S~ County <br />Contac~ Person (name & address) Pro,ram <br /> <br /> P. O. ~x ~ Funding Period <br /> ~ord, ~ 2~26~3~ PhoneT04/7~-6191 thru <br /> <br /> USA Assiqned I.D. <br />Referril Sources ~810~, ~d <br />a~ci~, F~y ~t ~ors, p~5, New Program <br />s~ts, s~l ~rs~el. Continuation <br /> <br /> Client Captcity 10 per S~O~ Antlciptted average length of stay 137 <br /> <br /> (d~ys) . Estimdted n~er of youth to bt served during funding period <br /> 310 <br /> <br /> Ui:e received in regional office <br /> Date received in centr41 office <br /> Ddte of fHA Approval <br /> <br /> Please submit 4 copies with original signatures. <br /> <br />elf the funds being requested will be used for more than one program component <br />please provide this information for each compOnent on a separate sheet. <br /> <br />DYS (Rev. 1-87) <br /> <br /> <br />