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GRANT NAME: 6 4_7A i7D ( hralli f GRANT # /14/14,Nt1.0L4,V\iL6 W AMOUNT OF GRANT: I 61 (Q i S Uill 2-21 `f Q ; DEPARTMENT RECEIVING GRANT: ' CONTACT PERSON: ! t ,11-1/ , -'2' TELEPHONE: ,4'{— L ('/ 0 1. How long is the grant for? ar2. Does the grant require you to fund this function after the grant is over? 3. Does the grant require a match? If yes, does the grant allow the match to be In -Kind services? 4. Percentage of match to grant 5. Grant match amount required Starting Date: Yes No Yes No Yes No 6. Where are the matching funds coming from (i.e. In -Kind Services; Reserve for Contingency)? 7 Does the grant cover capital costs or start-up costs? If no, how much do you think will be needed in capital costs or start-up costs: $ (Attach a detail listing of costs) 8. Are you adding any additional positions utilizing the grant funds? If yes, please list. (If additional space is needed, please attach a schedule.) Yes No Yes No Acct. Description Position Position Position Position Position 011.12 Regular Salaries $ Second Year $ $ $ 011.13 Other Salaries & Wages (PT) $ $ $ $ Fourth Year 012.11 Social Security $ $ Fifth Year $ $ „ 012.12 Retirement — Contributions 012.13 Insurance — Life & Health 012.14 Worker's Compensation 012.17 S/Sec. Medicare Matching TOTAL 9. What is the total cost of each position including benefits, capital, start-up, auto expense, travel and operating? Salary and Benefits Operating Costs Capital Total Costs 10. What is the estimated cost of the grant to the county over five years? Signature of Preparer: Date:(ft—i /L3 283 Grant Amount Other Match Costs Not Covered Match Total First Year $ $ $ $ Second Year $ $ $ $ Third Year $ $ $ $ Fourth Year $ $ $ $ Fifth Year $ $ „ $ $ Signature of Preparer: Date:(ft—i /L3 283