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l.ikIL TO: <br />Earl Billings <br />Department of Veteran <br />Ccmmuni tv Affairs <br />2571 Executive Center <br />Tallahassee, Fl. <br />32301 <br />GrRANiT APP.- -'r A -1.10N <br />and <br />Circle East <br />SERVICw_ Oc 19 i� <br />Page 1 of 7 <br />* Submit an Grig_4nal Cop <br />* PLEASE T'rp� <br />QUEST:0:iS <br />1. Local Govern -menta? Unit Apolying for Grant:: <br />Board of County Commissioners of <br />Name: Indian River Countv, Florida- Telephcre : 005) 562-8000 <br />name oi: town, city or county ) <br />Address: 1840 25th Street, Suite N158 z;0: 32960 <br />County: Indian River County <br />2. Delegate Agency (s) : Mental Health Association <br />(applicable only for private non profit corporation ue ega,teS) <br />3. Person with over-all responsibility of grant: 0U_ Dopa; t.:,ent will <br />contact this person should questions arise <br />Nama: Jane M. Baldwin, Director Telenhone : e05) 562-5713 <br />Address: 1020 21st Street P.O. Box 427 Vero Beach, Florida 32960 <br />Signature: <br />4. Name and address of person authorized to receive funds. If this ap- <br />plication is funded, checks gill be :wiled to this person. All ch�ci <br />will --be wade payable to the local 5overament. <br />Name: Jeff Barton, Finance Director <br />Indian Iver ounty <br />Address: 1840 25th Street. - - <br />Vero Beach, Florida zip: 32.960 <br />NOTE: THIS APPLICATION MUST E.E POSTMARKED NO LATER THAN <br />FEBRUARY 11 1982 -I'd"OFDFR TO 3E CONSIDERED. <br />$ <br />ecoK 48 PA,,r7,82 <br />