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<br />FLORIDA DEPARTMENT OF JUVENILE JUSTICE <br />COMBINATION GRANT APPLICATION <br /> <br /> <br />PROGRAM INFORMATION: <br /> <br />Grant program name: <br />Amount of grant funds requested: $ (FY 1999/2000) $ (FY 2000/2001) <br />Program located in Juvenile Justice District # <br />Florida county (grant program location): <br />Grant Category (check only one): 0 Community Juvenile Justice Partnership 0 General Revenue <br />o Combination 0 Other (List) <br />GRANT PROVIDER INFORMATION: <br /> <br />~ . <br />Grant ProviderILead Agency name: <br />Grant ProviderlLead Agency status: 0 Governmental 0 Private not-for-profit 0 Private for profit <br />Federal Identification Number: <br />Authorized Agency Official's name: <br />Mailing address: <br />City: <br />Telephone number: ( <br />Name of fiscal officer: <br /> <br />) <br /> <br />Ext. <br /> <br />, Florida Zip Code <br />Fax number: ( <br /> <br />Telephone number: ( <br /> <br />) <br />) <br /> <br />Ext. <br /> <br />Name of fiscal agency if not Lead Agency: <br />Grant Program Director's name: <br />Mailing address: <br />City: <br /> <br />Telephone number: ( <br /> <br />) <br /> <br />Ext. <br /> <br />, Florida Zip Code <br />Fax number: ( <br /> <br />) <br /> <br />CERTIFICATION: <br />I do hereby certify that all facts, figures, and representations made in the application are true and cor- <br />rect. Furthermore, all applicable statutes, regulations, and procedures for program compliance and <br />fiscal control will be implemented to ensure proper accountability of grant funds. I certify that the funds <br />requested in this application will not supplant funds that would otherwise be used for the purpose set <br />forth in this project. The Grant Applicant has authorized the filing of this application and I have been <br />duly authorized to act as the representative of the Applicant in connection with this application. <br /> <br />Authorized Official's Signature <br /> <br />. Date <br /> <br />Authorized Official's Name (typed) <br /> <br />Ext. <br /> <br />Name of Agency or Entity <br /> <br />Telephone Number <br /> <br />3/CG <br />