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APPENDIX V"
Certification of Local Government Approval
For Nonprofit Organizations
l, (\ ON R. Paundec. Chaitmanuly authorized to act on behalf of the:
(Name andTitle) '
Oaloo SL ( pense, R iC ‘ C. hereby approve the submission of the following
(Name of City or Court} Government)
Emergency Solutions Grant Application proposed by O epoctunt aN i Luc i
rq
Name of\Agency
which will serve persons living in /) ValonSa
. (MamecohGity-er County)
This certification solely warrants that the jurisdiction has agreed to allow the nonprofit organization to seek
the grant to be able to serve citizens in need who reside in this jurisdiction. This certification places no
responsibility or liability upon the local government jurisdiction related to the nonprofit’s performance of
srant-funded activities in our jurisdiction.
By: Don g. Pomunds Chaiicrars
(Name) (Title)
(Signature)
{Date}
This form MUST BE signed, dated and returned with the grant application in order for
the application to be considered for funding.
Ae i ee ee ter te ererrennn at me ee et ee
2013 Emergency Solutions Grant Application LPZ10 46 | Page