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GRANT APPLICATION Page 6 of 7 <br />. <br />Local Governmental Unit Applying: <br />At - <br />n, County, or City) <br />13. CONTRACTUAL INFORMATION - Complete one for each Delegate Agency <br />General <br />Name of Delegate Agency: <br />Address: 3 „ Tom/, <br />Contact Person: <br />Telephone: (3051 - <br />Tax <br />3057Tax Exempt Number q 7%q <br />-if none, attach a copy of the certificate of <br />incorporation) <br />DELEGATE AGENCY BUDGET FOR THIS PROGRAM <br />'r <br />}ADMINISTRATIVE EXPENSES <br />1. Salaries ' <br />2. Rental ----------------------=----- <br />3. Travel --------------------------- <br />4. Supplies ------•*.----L--------- --- ----- <br />5. Other (s-gecify on a-at <br />(lent) - - - - - '�' - "" - - - - <br />6. TOTAL ines-1 throu2h_5j _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _� <br />PROGRAM EXPENSES <br />7. Salaries ; <br />S. Rentaaai Sp -ace <br />a - - -- - - - - - - - - - - - - - - - - - - - - <br />9. Yrvel- ------------------------- <br />10. Equipment--------------------------1-�iot+.�°ii <br />11. Other (specify on attachment) —P�= ZA11w-G =Xp e�S - - - '_ a <br />12. TOTAL (lines -7 through -11)_ _ _ - - - - , - - - _ - - - _. r y <br />13. TOTAL EXPENSES -(line 6 and line 12) - - - - - - - - - - - - -- yy,� <br />-------- -n------- <br />14. *TOTAL SALARY—AND—ADMINISTRATIVE EXPENSES (lines 6 and 7) <br />*TOTAL GRANTEE AND DELEGATE(S) ADMINISTRATIVE AND SALARY EXPENSES <br />COMBINED MUST NOT EXCEED 15% OF TOTAL'.BUDGET. <br />THE DELEGATE AGENCY HEREBY APPROVES THIS APPLICATION AND WILL COMPLY <br />WITH ALL RULES, REGULATIONS AND CONTRACTS RELATING THERETO: <br />. i <br />APPROVED BY: Director <br />(Title) (Signature) <br />ATTESTED BY: <br />Title Signature <br />!o/F <br />SMG; <br />SEP U- 6 1978 <br />