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an <br /> '1 �/j�j��� �(��J� NA�/Q1 thb s r Ayuti i4Y VMI!y�y e r ; <br /> 4t,. �{` 'a a 4t ' 4 1 4 + y� •% ��t l . 4e . '., Q� .�}•}� y PI 3 " <br /> ' U , h4 n�. 4��_,�`�p/,,•Z�TJ }'�f�' :'.' r t ' . . t •_ y , + 1► ftwP o 11L11 m ! <br /> 111r1V1 V1� .� OF a _ _ _ <br /> •'. GRANT: 3 18.700 00 � >. ` r r • : ti <br /> 4 DEPARTTAMIT RECEIVIIM (iRANL. $ <br /> ', CONTACT PERSON: �,,;� t► r��u..,� � , � � " ` ' <br /> dd <br /> x PHONE N <br /> 1 • st, How long is the grant foi't_1 year3*4tya� n a4'... Stagy Date•_ ORIGINAL <br /> ,4 11 . 62. . , . I the groat squire you to tend this function af1w Me srw Is <br /> over?� <br /> 30 Does the grant require a match? <br /> y Cud1 <br /> If yea, does the groat an the match to be In Kind sel vices? ' <br /> 4. Percentage of match _ N/A ' -- <br /> Oyu <br /> S• Grant match amount <br /> required $`N/A <br /> 69 When are the matching Inds comma from (i.e. In Kind Serviced <br /> Reserve for Contingency)? <br /> 7. �no, F. ,F.Btu.5corer ca 'W or start up coats? • <br /> (Atta ; y Yo�)will bo wooded in capital oosb or stmt up costs Y� No <br /> yc; addingan"Y��iSpP�l pod�ti uti ' S <br /> u Yom. P (if ad naoaai apecoMIS no!ong 0 �t ltmda? Yea No <br /> p cede attach a schedule.) <br /> �• �Ption Position Position <br /> 011 . 11 Position Position Position <br /> Regula' Solaria <br /> 011 . 13 Other Salaried dt Wages (PT) <br /> 012. 11 Social Security . <br /> 012. 12 Rotiranunt-Contriwtions <br /> 012. 13 hwuraace•Life dt Health <br /> 012. 14 Worker's Compensation <br /> 012. 17 S/Sm Medicam Matching <br /> TOTAL <br /> 90 What L the total cost of each position including benefits, capital start-up, auto <br /> Salary and Benefits expense, travel and operating? <br /> Operating Costa Capital <br /> Total Costs <br /> 10, Whet V the atlmeted cod of the gnat to the county ovw five years? s <br /> tch C acd <br /> First Year $ $ 6 TOW <br /> Second Year S S <br /> s $ s <br /> Third Year $ $ <br /> $ s s <br /> Fourth Year $ $ S <br /> s <br /> Fifth Year s s S <br /> S <br /> Signature of Preparers Date: ' <br /> 376 <br />