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EXHIBIT A I <br />�GEI V FO <br />INDIAN RIVER COUNTY <br />DORI SLOSBERG DRIVER EDUCATION SAFETY ACT FEg 19 101 <br />GRANT PROGRAM REQUEST FOR FUNDING <br />SECTION A. APPLICANT INFORMATION eGDGET <br />Identify the agency or organization and official who is authorized to execute any grant related documents: <br />1. Applicant Name: School District Indian River County <br />2. Address: 6500 57th Street, Vero Beach, FL 32967 <br />3. Telephone Number: 772-564-3209 Fax: <br />4. Authorized Official: Anne Bieber <br />5. Fiscal Officer: Bruce Green <br />6. Program Director: Anne Bieber <br />7. Federal Identification Number: 596000673 <br />8. Status: Public School <br />SECTION B. PROGRAM INFORMATION <br />1. Program Name: School District Indian River County Driver Education <br />2. Program Type: Curriculum <br />3. Total program budget: $49,000.00 <br />4. Amount of grant funds requested: $49,000.00 <br />5. List other and/or potential funding sources for the program and any matching requirements for <br />such funds: <br />Funding Source: Amount: <br />_.�......__A�..._�...�.�....�..._.,,�_.�.�.__.._. _. _�..._��. $0.00 <br />6. Estimated number of students to be served: 110 <br />7. Cost per participant: $445.45 <br />SECTION C. CERTIFICATION <br />I Agree - By checking the "I Agree" box and entering your name below, I do hereby certify that all facts, <br />figures and representation made in this application are true and correct. Furthermore, all applicable <br />statutes, regulations and procedures for program compliance and fiscal control shall be implemented to <br />insure proper accountability of any grant funds awarded. I further certify that the funds requested in this <br />application shall not supplant funds that would otherwise be used for the purpose set forth in this <br />application. The filing of this application has been authorized by the Grant Applicant and I have been duly <br />authorized to act as the representative of the Grant Applicant in connection with this application. <br />EXHIBITA <br />