Request to Apply for a Grant
Date: |
Department: |
Name: |
Contact Info: |
Grant Due Date: |
Grant Name and Funding Agency: |
Grant Summary: |
Request Received by Auditor on by |
Copied to Commissioners on via |
Copied to Council on via |
Copied to County Attorney on via |
Authorized to Proceed on by |
with Grant Application on by |
Authorized to Proceed on by with |
Grant Application on by |
DESCRIPTION | Paid by Grant | Paid by County | N/A |
DESCRIPTION | Paid by Grant | Paid by County | N/A |
Salary | |||
INPRS | |||
Social Security (wage x 6.20%) | |||
Medicare (wage x 1.45%) | |||
Who will cover unemployment expense? | |||
Who will cover worker’s compensation insurance? | |||
Employer’s Share of Insurance Coverage | |||
Dental | |||
Vision | |||
Supplemental Pay | |||
Insurance Expense over Excess Loss | |||
What tools will the Grant require? | |||
Training Expense? | |||
Personal Computer, Software, Internet and Email | |||
Vehicle/Fuel | |||
Does the Grant require matching funds? | |||
What is the Grant start date? | |||
When does the Grant expire? | |||
Can a Grant administration fee be charged? | |||
Grant Summary
Local Project Name -----------------------------------------------------------
Award Number -----------------------------------------------------------
Award Name -----------------------------------------------------------
Award Method Advanced/Reimbursement/Other*(see note)
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Fund Name/Number -----------------------------------------------------------
Initiating Office/Department -----------------------------------------------------------
Contact Person Name -----------------------------------------------------------
Contact Person Phone -----------------------------------------------------------
Contact Person E-Mail -----------------------------------------------------------
Pass-Through Agency -----------------------------------------------------------
Contact Person Name -----------------------------------------------------------
Contact Person Phone -----------------------------------------------------------
Contact Person E-Mail -----------------------------------------------------------
Federal Grant? Yes/No
Federal Agency -----------------------------------------------------------
Federal Program/Project Title -----------------------------------------------------------
CFDA Number -----------------------------------------------------------
Passed to Sub-recipients Yes/No
Notes: -----------------------------------------------------------
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*noncash, loan, income