Application Cover Sheet (Attachment A)

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* 1. Organization Information

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* 2. Project Contact Information

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* 3. Tier Level (pick one)

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* 4. Type of Project

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* 5. Projected Project Completion Month

Certification Statement
As an authorized representative of the organization making application for this grant, I hereby certify that matching funds in the amount identified above are available for the exclusive use of this proposed project. I further certify that the cash funds designated for this purpose are not derived from state grant funds.

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* 6. Initials

 Certification Statement
As an authorized representative of the organization making application for this grant, I hereby certify that matching funds in the amount identified in the budget will be contributed to support the above named project upon the award of the grant. I further certify that the materials and equipment identified in the in-kind contributions budget were not purchased with state funds and have not been used to provide match for other grants or contracts.

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* 7. Initials

Certification Statement
As an authorized representative of the organization making application for this grant, I hereby certify that, if awarded, all CIG funds will be expended by the end of State Fiscal Year, June 30, 2020.

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* 8. Person Authorized to submit the application for the organization

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