COM 0768.000 1996-1998 - Laserfiche WebLink

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e FOR OFFICE USE ONLY DEPT LOG # EXEMPTION GRANTED BY DIRECTOR OF FINANCE DATE DECEMBER 30. 1997 STATE OF HAWAII PURCHASE OF SERVICE APPLICATION TITLE PAGE State Agency Issuing RFP: Dept. of Human Services. Office of Youth Services Response to RFP # RFP Title: (Communities That Care) Proposal 2. APPLICANT INFORMATION 3. APPLICANT MEETS 1 YEAR REQUIREMENT LEGAL NAME: IN SERVICE ACTIVITY INDICATED Hawaii County Parks & Recreation X YES NO (for Ka'u Learning Center, umbrella for the Kau Council) IF NO, REQUEST FOR EXEMPTION IS AT- DBA: TACHED I STREET ADDRESS: YES NO none 4. FEDERAL TAX ID A 99-0289332 MAILING ADDRESS: P. O. Box 446 5. STATE TAX ID 30097500 Na'alehu, HI 96772 6. DESCRIPTIVE TITLE OF APPLICANT'S 7. TYPE= OF APPLICANT PROJECT: X NON PROFIT ORGANIZATION FOR PROFIT ORGANIZATION "KOKUA KA'U" STATE AGENCY _.j ___COUNTY AGENCY 8. TARGET GROUP: 9. GEOGRAPHIC AREA TO BE SERVED (CIT- Ka u Youth: IES, COUNTIES, ISLANDS, STATEWIDE, ETC.): Late Elementary & High School Ka'u District of Hawaii County 10. FUNDING REQUEST 11. PERSON TO BE CONTACTED ON MATTERS FY 97-98: $40,000. INVOLVING THIS APPLICATION NAME: Ed Yokoyama FY 99-99: $55,000. TITLE: County P&R Puna-Kau Supervisor PHONE NUMBER: (808) 961-8740 FY 99-00: $35,000. NAME: Charlene Hart TOTAL REQUEST: TITLE: Kau Council Liaison $120,000. PHONE NUMBER: (808) 928-8142 12. 1 CERTIFY THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. TYPED NAME OF AUTHORIZED REPRESENTATIVE: George Yoshida TITLE: Director, Hawaii County Parks & Recreation PHONE NUMBER: (808) 961-8311 AUTHORIZED SIGNATURE: DATE SIGNED: January 20, 1998 B&F Form FOS POST 101 (11117/94) 1