Okaloosa County BOCC — July 15, 2014 — Rick O - GrantSolutions Grantee User Account Request Form

Grantee User Account Request Form Request Type: New Account Account Change Account Closure Partner Agency: Department of Health and Human Services Department of State Department of Agriculture Social Security Department of Transportation Denali Commission Other Treasury - RESTORE Act Role Authority: Authorizing Official Financial Officer Program Director/Principal Investigator Financial Officer Support Support Staff Organization Name: Okaloosa County Address 1: 1804 Lewis Turner Blvd, Ste 206 Address 2: City: Fort Walton Beach State: FL ZIP + 4: 32547-1285 Grant Number(s): This should be a grant number of any grant awarded to your organization that is or has been in GrantSolutions. This will be used to help confirm organization information. First Name: Ricky Last Name: Owen Title: RESTORE Act Coordinator Phone: (850) 651-7515 Fax: Email Address: rowen@co.okaloosa.fl.us Person Address 1: 1804 Lewis Turner Blvd, Ste 400 Person Address 2: City: Fort Walton Beach State: FL ZIP + 4: 32547-1285 Please complete the Person Address only if it is different from the Organization Address. Authorized Official Name: Charles K. Winders, Jr. Title: Chairman Authorized Official Signature: Note: Request should be signed by authorized organization business/signing official. Version 6/2013