$ Other (Specify)___________________________________ $ A Expenditure total A Revenue - list all revenue excluding NA4LVC Assistant Funds $ Fees or Charges $ Membership $ Fund Raising $ Municipal Contribution $ In Kind (Specify) ___________________________________ $ Other Municipal Government Sources $ Other (Specify)___________________________________ $ B Revenue total B Total Requested from Naturally Active for Life Victoria County (A-B): $__________________ The applicant certifies that the above statement and supporting documentation have been inspected & verified and appropriate conditions and intent of the approved project have been fulfilled. Documents inspected/verified by: Signature ___________________________________ Name _______________________________ Position ___________________________________ Date _______________________________ Evaluation / Final Report Please provide an Evaluation & Final Report for your initiative one month following the completion of your program, event, etc. to be eligible to receive further funding in the future (Including cancelled cheque (s), account summary, receipts, etc. showing proof of expenditures approved for your initiative): Physical Activity Healthy Eating Assistance Fund Final Report Organization:
Other (Specify)___________________________________ $ A Expenditure total A $ Revenue - list all revenue excluding NA4LVC Assistant Funds Fees or Charges $ Membership $ Fund Raising $ Municipal Contribution $ In Kind (Specify) ___________________________________ $ Other Municipal Government Sources $ Other (Specify)___________________________________ $ B Revenue total B $ Total Requested from Naturally Active for Life Victoria County (A-B): $__________________ The applicant certifies that the above statement and supporting documentation have been inspected & verified and appropriate conditions and intent of the approved project have been fulfilled. Documents inspected/verified by: Signature ___________________________________ Name _______________________________ Position ___________________________________ Date _______________________________ Evaluation / Final Report Please provide an Evaluation & Final Report for your initiative one month following the completion of your program, event, etc. to be eligible to receive further funding in the future (Including cancelled cheque (s), account summary, receipts, etc. showing proof of expenditures approved for your initiative): Physical Activity Healthy Eating Assistance Fund Final Report Organization: