Okaloosa County BOCC — July 15, 2014 — Gary S - 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: Gary J. Last Name: Stanford Title: Finance Officer Phone: (850) 689-5000 ext 3411 Fax: (850) 689-5882 Email Address: gstanford@clerkofcourts.cc Person Address 1: Person Address 2: City: State: ZIP + 4: Please complete the Person Address only if it is different from the Organization Address. Authorized Official Name: Charles K. Windes, Jr. Title: Chairman Authorized Official Signature: Note: Request should be signed by authorized organization business/signing official. Version 6/2013