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City of San Leandro <br />Community Assistance Funding <br />GRANT COVER PAGE <br />ORGANIZATION: <br />FEDERAL TAX ID#: <br />ADDRESS: <br />CITY/STATE/ZIP: <br />PHONE: <br />FAX: <br />E-MAIL: <br />CONTACT NAME & TITLE: <br />IF APPLICABLE, FISCAL SPONSOR: <br />FEDERAL TAX ID#: <br />ADDRESS: <br />CITYlSTATE2IP: <br />PHONE: <br />FAX: <br />E-MAIL: <br />CONTACT NAME & TITLE: <br />Program Description (Program for which you are requesting funding) <br />PROGRAM TITLE: <br />CONTINUUM OF NEED (Describe where on the "Continuum of Need" your program fits): <br />PROGRAM DESCRIPTION (Describe proposed program in 25 words or less): <br />Amount Requested <br />AMOUNT REQUESTED FOR EACH FISCAL YEAR: 2008-2009 $ 2009-2010 $ <br />(Amount must be the same for each year) <br />Checklists 8~ Signatures -Verify, by checking each box that the following have been completed and are attached. <br />See Basic requirements in Instructions for number of copies needed. <br />Required Attachments: <br />_ IRS 501(C)3 LETTER <br />_ MOST RECENT AUDITOR FINANCIAL STATEMENTS <br />_ BOARD ROSTER (include all info. requested-see Sec II-D) <br />_ ORGANIZATION'S FY 2005-2006 BUDGET <br />_ COPY OF THE NONDISCRIMINATION POLICIES <br />EVIDENCE OF COMMITTED PROGRAM FUNDING <br />REFERENCE ARTICLE SUPPORTING NEED FOR PROGRAM IN SAN LEANDRO (include a maximum of two references) <br />____ ORGANIZATION CHART <br />(Note: Certificates of General Liability and Workers Compensation will be required for funded agencies.) <br />APPROVED BY: <br />SIGNATURE/EXECUTIVE DIRECTOR <br />PRINT NAME/EXECUTIVE DIRECTOR <br />APPROVED BY <br />DATE SIGNATURE/BOARD PRESIDENT <br />PRINT NAME/BOARD PRESIDENT <br />DATE <br />The City of San Leandro is an equal opportunity provider and will make reasonable accommodations to <br />applicants with special needs and/or disabilities in this request for proposals. <br />to <br />