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w <br />• <br />4• <br />GRANT APPLICATION Page 6 of 7 <br />Local Governmental Unit Applying: Ai <br />, <br />Town, County, or City) <br />13. CONTRACTUAL INFORMATION - Complete one for each Delegate Agency <br />General <br />Name of Delegate Agency: LZ1111 z <br />;.1 �t r• ' 1, <br />Address, zo- hr i.cr• � '�- <br />Contact Person: <br />Telephone: ( 300 <br />Tax F;rempt Number _ _ 2._� <br />71t none, attach a copy of the certif-icatee o <br />incorporation) <br />DELEGATE AGENCY BUDGET FOR THIS PPOGIV,-M <br />ADMINISTRATIVE EXPE:SFS <br />1. <br />Salaries - - - - <br />2. Rr_ntt;l __-----------------.--- <br />3. Travel - ____------ ----------------- <br />4. Sup]_i.c�----------------- - - - - -- <br />5. other fq). rif'y vn ntiach&,iTt-- - ------- - - - - -- <br />— <br />6. TOTAF.. (l.a.;u:sl through -5j ___ <br />__---- _----- - - - - -- - <br />PROGRAl EXPENSES <br />7. Salaries <br />S. -Space ---------`--------------- <br />9.Tr<ivcl ---------------------------- <br />10. F'c uimnnt - - - - - - - - -- - - - - - - - - - - - - - - --• - 7 sem. �, <br />11. Other . Z-- -h- on attach merit)) _ (J; -1"f )iI�1G_ _ _ r?•ytiy�ILp <br />12. TOTAL (lines <br />_7-tt----th_l-------------------� <br />13. TOTAL, EXPENSES (line --6-Sand-1 i ne 12 ) - - - - - - - - - - - yy, <br />14. *TOTAL SALARY_AND _AD:•1INI STRATIVF? I::{PF:2:SES_(lines 6 and 7)- - - <br />*TOTAI, GRANTEE AUC) DELEGATES) ADMINISTWNTIVE AND SALARY F.XPEl7SES <br />COMBINED MUST NOT EXCEED 15% OF TOTAL BUDGET. <br />THE.DELEGATE AGENCY 11PRPRY APPnOVES THIS APPLICATION AND WILL COMPLY <br />WITH ALL RULES, REGULATIONS AND CONTRACTS RELATING THERETO: <br />ROVED BY: Director <br />(Title) <br />TTESTED BY: <br />Title <br />(Signature) <br />Signature <br />