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Aloha Independent Living Hawaii - Agency Name _ <br />Independent Living Services - 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, Hawai'i Revised Statutes. <br />ff awarded a grant from the County of Hawaii, I (we) understand and will <br />comply with the requirement to submit a year -end report to the County <br />Council within 60 days 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 your program's or <br />agency's future funding requests. <br />i <br />V( <br />Si nature of Board Presi nt/Chair <br />MWO' <br />of Executive Director <br />,3t 1 <br />Date <br />1 31 tt <br />Date <br />UNSIGNED PROPOSALS WILL NOT BE ACCEPTEDI <br />NONPROFIT GRANT APPLICATION <br />FISCAL YEAR 2011 -12 <br />Page 6 <br />