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Facility Address: <br />Email Address: <br />Accountant /CPA: <br />Firm (if applicable): <br />Address: <br />City, ST, Zip <br />Address: <br />Address: <br />City, ST, Zip <br />Fax No.: ( ) — <br />Phone No.: <br />Mailing Address: Address: <br />Address: <br />City, ST, Zip <br />YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT <br />Amount of Request for County Nonprofit Grant Program Funds: <br />1. Prior Year Award of County Nonprofit Grant Program Funds: <br />FY 09 -10 FY 10 -11 FY 11 -12 <br />2. Agency Mission Statement: <br />EXHIBIT A <br />NONPROFIT GRANT APPLICATION <br />FY 2013 -2014 <br />Page 1 of 7 <br />