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American Cancer Society -Agency Name <br />Quality of Life Programs for East Hawaii Cancer Patients - <br />Program Name <br />I (we) have read and understood all of the eligibility requirements; grant <br />conditions; award procedures; and records, reporting and fiscal accountability <br />requirements as mandated in Article 25, Sections 2-135 - 2-142.2, Hawaii <br />County Code, relating to Appropriation of Funds to Nonprofit Organizations. <br />I (we) hereby certify that information supplied herein including all supporting <br />documents is correct and that I (we) have the authority and ability to fully <br />administer the program(s) pursuant to law. <br />I (we) understand that information supplied herein shall be made public <br />according to Chapter 92F, Hawaii Revised Statutes. <br />If awarded a grant from the County of Hawaii, 1 (we) understand and will <br />comply with the requirement to submit ayear-end report to the Legislative <br />auditor within 60 davs after June 30 of the fiscal year. The report shall <br />include an explanation of the public benefits derived from the awarding of <br />the grant, a complete accounting of all expenditures supported by County <br />of Hawaii grant funds, and a listing of other funding sources and amounts <br />obtained during the award period. Failure to submit a timely, complete, and <br />accurate. year-end report will impact the evaluation of vour program's or <br />agency's future funding requests. <br />~~ay~oa <br />Date <br />~/a~loq <br />Date <br />UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! <br />NONPROFIT GRANT APPLICATION <br />FISCAL YEAR 2009-10 <br />Page 8 <br />Signature of Executive Director <br />