Block Number: 1) Enter the name and address of recipient organization. If additional space is required, attach a separate sheet to accompany the form. 2) Enter the three digit community/nonprofit number that your organization has been assigned by Office of Community Development. 3) Enter the recipient organization’s telephone number, fax number, and e-mail address (if available). 4) Select your preferred method of receiving your funds. If Electronic Funds Transfer is selected, please remember to submit the Agreement for Direct Deposit of State Warrants.” If “Authorization by check, just mark your selection. 5) The bottom portion of the DS3 card is so the Office of Community Development will know where to mail a copy of the for Payment and Status of Funds Report” (DS5) after it has been “Request processed and paid. 6) Please have both sections of this card dated and signed by the same party who signed the Signature Card” (DS2 [number 4]). “Authorized Retain a copy of the completed and signed DS3 for your files. Mail completed and signed original DS3 to: Ohio Development Services Agency Attn: Fiscal Grant Management Office of Community Development PO Box 1001 Columbus OH Phone: (614) 466-2285
Block Number: 1) Enter the name and address of recipient organization. If additional space is required, attach a separate sheet to accompany the form. 2) Enter the three digit community/nonprofit number that your organization has been assigned by Office of Community Development. 3) Enter the recipient organization’s telephone number, fax number, and e-mail address (if available). 4) Select your preferred method of receiving your funds. If Electronic Funds Transfer is selected, please remember to submit the “Authorization Agreement for Direct Deposit of State Warrants.” If by check, just mark your selection. 5) The bottom portion of the DS3 card is so the Office of Community Development will know where to mail a copy of the “Request for Payment and Status of Funds Report” (DS5) after it has been processed and paid. 6) Please have both sections of this card dated and signed by the same party who signed the “Authorized Signature Card” (DS2 [number 4]). Retain a copy of the completed and signed DS3 for your files. Mail completed and signed original DS3 to: Ohio Development Services Agency Attn: Fiscal Grant Management Office of Community Development PO Box 1001 Columbus OH Phone: (614) 466-2285
DS3GDI_Oct2012.docx