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APPENDIX V
Certification of Local Government Approval
For Nonprofit Organizations
, Dies teats s (has Poe. duly authorized to act on behalf of the
(Name and Title)
Oka lads Co VUYTY 2 CC, hereby approve the submission of the following
(Name of Ci#er County Government)
Emergency Solutions Grant Application proposed by Olea loese. Coviws uacty Deve loom ent Corporativmy
Name of Agency .
which will serve persons living in O ka lo POA.
(Name-eF€ity-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
grant-funded activities in our jurisdiction.
By: Ch riewan
(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.
2013 Emergency Solutions Grant Application 46| Page