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i • of GRANT APPLICATION Page 1 of 7 (Type and Complete All Items) Application for State Assistance Through the COMMUNITY SERVICES TRUST FUND PLY TO: SUBMIT FOUR (4) COPIES PARTMENT OF COMMUNITY AFFAIRS (ONE MUST BE ORIGINAL) VISION OF COMMUNITY SERVICES 71 EXECUTIVE CENTER CIRCLE, EAST LLA)iASSEE, FLORIDA 32301 Local Governmental Unit Applying for Grant: Name: jkMAy&pk D1rx 191 * 1�Telephone name of t wn, city or county) Address: County: . Delegate Agency(s): I 9 Y Person with over-all responsibility of grant: (Our Department will contact this person should questions. Name:: (�iG�r1C 'c r[lf Telephone: (i%5g Address: Signature: s / girl Jdi%tD�r7`� _ s Due to legislative requirements, .all services must be certified by the Department of Health and Pehabilitativ,: Services (HRS) District Administrator as not bein3 duplicative. In order to accomplish this requirement, all applicants must contact the District Administrator prior to development of program proposals. HRS person contact(d: ,CX,-,A$ (District Administrator) Telephone: cys-) (S' I / /•�'3 _ Date: 157 7 Contacted by:_ '. /):f Telephone (JZ., �.JrC' �_ Following the completion of the grant application, formal approval of the program propr_)s,al must be given by the 11R5 District Administrator. Applications will not. be accepted unless, the, following statement is completed by the: HRS District Administrator: A�IZI the/District HRS Administrator for District f�( , hereby certify one of the following statements of fact: 11L -1_.. The particular services to be offered in the signature) listed programs are not duplicative of HRS programs, Although similar services may be available from HRS, we cannot provide these particular services to these clients without the use of this money.