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QRA%NT NAME: �lDAyeaL RM1�1<qq `/ 1GRANT H AMOUNT OF GRANT: DEPARTMENT RECEIVI g� CONTACT PERSON: ��TI-�--1Arn►it�1b TELEPHONE:I,, Jw 1. How long is the grant for? ts'Q Starting Date: 2. Does the grant require you to fund this functign afteril�e,br yt 1s�oyet?v �� _Yes No 3. Does the grant require a match? Yes No If yes, does the grant allow the match to be In -Kind services? Yes No 4. Percentage of match to grant _c5O + y % 5. Grant match amount required! a • M-'), (-)n 6. Where are the matching funds coming from Q.c. In -Kind Services; Reservc for Contingency)? t Noun s av►r +��v �� P�otyns 7. Does the grant cover capital costs or start-up costs? Yes No If no, how much do you think will be needed in capital costs or start-up costs: $ (71a- C_MT\)C (Attach a detail listing of costs) 8. Are you adding any additional positions utilizing the grant funds? Yes No If yes, please list. (If additional space is needed, please attach a schedule.) Acct. Description Position Position Position Position Position 011.12 Regular Salaries 011.13 Other Salaries & Wages (PT) 012.11 Social Security 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? N/A Salary and Benefits Operating Costs Capital Total Costs 10. What is the estimated cost of the grant to the county over five years? Dylkf1f P bx) a C___� V Signature of Preparer: -1� ��Date: �� rDU Grant Amount Other Match Costs Not Covered Match Total First Year $ $ $ d $ Second Year $ $ $ Third Year $ $ $ $ Fourth Year $ $ $ $ Fifth Year $ $ $ $ C___� V Signature of Preparer: -1� ��Date: �� rDU