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d <br />GRANT APPLICATION Page 1 of 7 <br />(Type and Complete All Items) <br />Application for State Assistance Through the <br />COMMUNITY SERVICES TRUST FUND <br />REPLY TO: SUBMIT FOUR (4) COPIES <br />DEPARTMENT OF COMMUNITY AFFAIRS (ONE MUST BE ORIGINAL) <br />DIVISION OF COMMUNITY SERVICES <br />2571 EXECUTIVE CENTER CIRCLE, EAST <br />rALLAHASSEE, FLORIDA 32301 <br />1. <br />Local Governmental Unit Applying for Grant: <br />Name: <br />(name o/f+ t w1n, city or county) <br />Address: <br />County: <br />2.• Delegate Agency(s): <br />Telephone: (%s-1 $-(., - %o-? S! <br />zip= <br />3. Person with over-all responsibility of grant: (Our Department will <br />contact this person should questions arise) <br />Name: rr2 �'nr%1n n-1 <br />Telephone: Mal <br />Address: <br />Signature <br />4. Due to legislative requirements, all services must be certified by <br />the Department of Health and Rehabilitative Services (HRS) District <br />Administrator as not -being duplicative. In order to accomplish this <br />.requirement, all applicants must contact the District Administrator <br />prior to development of program proposals. <br />HRS person contacted: "' <br />(District Administrator) <br />Telephone: M51 613 6 4&3_ Date: 309 15774? <br />Contacted by i I Telephone <br />S. Following the completion of the grant application, formal approval of <br />the program proposal must be given by the HRS District Administrator. <br />Applications will not be accepted unless the following statement is <br />completed by the HRS District Administrator: <br />I g2 the �District HRS Administrator <br />-for District, hereby certify one of the following statements. <br />of fact: <br />The particular services to be offered in the <br />signs ure) listed programs are not duplicative of HRS programs. <br />Although similar services may be available from <br />HRS, we cannot provide these particular services <br />to these clients without the use of this money. <br />' g :i <br />