Last Name Title Telephone Number Fax Number Email address Signature of Authorized Representative Date Signed Implementing Agency Financial Officer (Chief Financial Officer, Comptroller, Treasurer, or similar position.) First Name Last Name Title Telephone Number Fax Number Email address Signature of Authorized Representative Date Signed Program Agency Authorized Official First Name Last Name Title Telephone Number Fax Number Email address Signature of Authorized Representative Date Signed ** ICJIA specific modification to GATA form
Last Name Title Telephone Number Fax Number Email address Signature of Authorized Representative Date Signed Implementing Agency Financial Officer (Chief Financial Officer, Comptroller, Treasurer, or similar position.) First Name Last Name Title Telephone Number Fax Number Email address Signature of Authorized Representative Date Signed Program Agency Authorized Official First Name Last Name Title Telephone Number Fax Number Email address Signature of Authorized Representative Date Signed ** ICJIA specific modification to GATA form
ICJIA-Uniform-Application-for-Grant-Assistance-ARI-FY19.docx