FOR TO FEDERAL SURPLUS PROPERTY (41 CFR 101-44.207) Michigan Department of Technology, Management and Budget DTMB-0292 Revised 4/10/2018 Instructions on Page 3. SECTION 1. & OF Update New Federal Tax ID # Name of Organization Telephone # Mailing Address (PO Box #, Street, City & State) Fax # Street Address/Location (if different than mailing address) Organization Web Address ZIP Code+4 Organization Email Address County SECTION 2. Public Agency including Public Schools (if you checked public agency, complete Section 3 then skip to Section 8) Nonprofit, tax exempt Organization SECTION 3. PURPOSE OR OF College or University Care Center Training Center Hospital State Secondary School School for Physically Disabled Radio/TV Station Health Center County Elementary School School for Mentally Disabled Library Clinic City Pre-School Museum Sheltered Workshop Other School District Programs for Older Provider of Assistance to Training Program Specify Township Individuals Homeless/Impoverished SBA 8(a) Village Veterans Service Educational Activities Medical Institution SECTION 4. OR A OF Provide a Written Description SECTION 5. OF Contributions Other (specify) SECTION 6. Has the organization been determined to be tax exempt under Section 501 of the Internal Revenue Code of 1986? (Copy Required) Yes No 7. OR Has the organization been approved, accredited or licensed? By what Authority? (Copy Required) Yes No 8. Authorized Official Signature Printed Name Date 9. USE ONLY The applicant has been determined as: Conditionally eligible A nonprofit education (specify) Eligible public agency A nonprofit health Ineligible
(41 CFR 101-44.207) Michigan Department of Technology, Management and Budget DTMB-0292 Revised 4/10/2018 Instructions on Page 3. 1. & New Update Name of Organization Mailing Address (PO Box #, Street, City & State) Street Address/Location (if different than mailing address) ZIP Code+4 County Federal Tax ID # Telephone # Fax # Organization Web Address Organization Email Address 2. Public Agency including Public Schools (if you checked public agency, complete Section 3 then skip to Section 8) Nonprofit, tax exempt Organization 3. State County City School District Township Village College or University Secondary School Elementary School Pre-School Programs for Older Individuals Veterans Care Center School for Physically Disabled School for Mentally Disabled Museum Provider of Assistance to Homeless/Impoverished Service Educational Activities Training Center Radio/TV Station Library Sheltered Workshop Training Program SBA 8(a) Medical Institution Hospital Health Center Clinic Other Specify 4. Provide a Written Description 5. Contributions Other (specify) 6. Has the organization been determined to be tax exempt under Section 501 of the Internal Revenue Code of 1986? (Copy Required) Yes No 7. Has the organization been approved, accredited or licensed? (Copy Required) Yes No By what Authority? 8. Authorized Official Signature Printed Name Date 9. ONLY The applicant has been determined as: Eligible Ineligible Conditionally eligible A public agency A nonprofit education A nonprofit health (specify) OR SECTION SECTION SECTION SECTION SECTION SECTION FEDERAL TO OF OR OR PROPERTY USE OF PURPOSE FOR OF OF SURPLUS
DTMB-0292_Application_for_Eligibility_to_Receive_Federal_Surplus_Property_2018-02-26_620023_7.docx