Local Government’s Contact Person for the Grant: Local Government Manager: Name: Mr./Ms. Name: Mr./Ms. Title: Title: Organization: Address: Address: City/State/Zip: City/State/Zip: Telephone: Telephone: E-mail: E-mail: Chief Elected Official: Site Control: Name: Mr./Ms. Owned by local government Title: Leased by applicant for 25 years or more Address: Easement City/State/Zip: Populations this project is intended to serve: Costs rounded to nearest dollar: Primarily children with disabilities CNCB requested: $______________.00 Primarily veterans with disabilities Local government’s matching $ ______________.00 Children with disabilities and veterans with disabilities Please use the and Justification for this Project” “Description to explain how the project will serve the intended groups. Total cost of project $ ______________.00 Recreation Resources Service (RRS) regional consultant: Project Name: local governing board must approve this certification.) Approval by local governing board: (The I hereby certify the information contained in the attached application is true and correct and the required matching funds will be available during the project period. A local government must match the grant with at least one dollar ($1.00) of local funds for every four dollars ($4.00) in grant funds. Date Adopted: _______________________ Chief Elected Official: ______________________________ _______________________________________ (Signature) or Type Name and Title)
Local Government’s Contact Person for the Grant: Name: Mr./Ms. Title: Organization: Address: City/State/Zip: Telephone: E-mail: Local Government Manager: Name: Mr./Ms. Title: Address: City/State/Zip: Telephone: E-mail: Chief Elected Official: Name: Mr./Ms. Title: Address: City/State/Zip: Site Control: Owned by local government Leased by applicant for 25 years or more Easement Populations this project is intended to serve: Primarily children with disabilities Primarily veterans with disabilities Children with disabilities and veterans with disabilities Please use the “Description and Justification for this Project” to explain how the project will serve the intended groups. Costs rounded to nearest dollar: CNCB requested: $______________.00 Local government’s matching $ ______________.00 Total cost of project $ ______________.00 Recreation Resources Service (RRS) regional consultant: Project Name: Approval by local governing board: (The local governing board must approve this certification.) I hereby certify the information contained in the attached application is true and correct and the required matching funds will be available during the project period. A local government must match the grant with at least one dollar ($1.00) of local funds for every four dollars ($4.00) in grant funds. Date Adopted: _______________________ Chief Elected Official: ______________________________ _______________________________________ (Signature) or Type Name and Title)