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STATE AGENCY REQUEST FOR FUNDING FROM INDIAN RIVER COUNTY <br />FISCAL YEAR 2018/20/9 <br />A. Program Cover Page <br />Agency: <br />Contact Person: <br />Title: <br />Address: <br />Website Address: <br />Program Title: <br />do-7U:4�i Auo'� Telephone <br />HAM Fax: <br />r o3) bbl- 3220 <br />( gl� 3 4C9 7 9 227 <br />11 m. lde�.,F(e,<A rd m Fldr,�% _ eo„? <br />I certify that information contained in this application accurately reflects the activities of this agency and <br />that the expenditures or portions thereof for which County funds are being requested are not reimbursed <br />by any o - er sour <br />Sfgnature Print name and title <br />Brief description of the Program for which funding is requested: 125, 2 -7, I q ; H LI 8 ° 7 pz <br />Julnnlaly r%UPV1L <br />Amount requested from Indian River County for 2018/2019: $ 3 Z _ 10 <br />Total Proposed Program budget for 2018/2019: $ j 3 , S 2 / . 3u <br />Percent of total Program budget: % <br />Current Funding (2017/2018) $ `) 2 f , Ro <br />Dollar increase / (decrease) in request: $ <br />Percent increase / decrease in request: % <br />If request increased 5% or more, briefly explain why: <br />The Organization's Board of Directors has approved this application on (date): <br />Name of President/Chair of the Board <br />Name of Exec. Director/CEO <br />Signature <br />Signature <br />123 <br />If <br />MAR 2 ) 1018 <br />