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Page 2 <br />CDBG Request Form <br />City of Ramsey <br />Name of Organization <br /> <br />FAMILY LIFE MENTAL <br /> <br />HEALTH CENTER <br /> <br /> Does your organization serve Iow to moderate income families or individuals? If you answer no, <br /> your organization is not eligible to receive CDBG funds. <br /> <br /> x Yes No <br /> <br />What percentage of persons served are Iow/moderate income individuals? <br /> <br /> .% <br /> <br />What percentage of low/moderate income persons served are Ramsey residents? <br /> <br /> .% <br /> <br />Will these funds be used for an expansion of an existing program? <br /> <br /> .Yes x .No <br />Will these funds be used for the creation of a new program? <br /> Yes x No <br /> <br />PLEASE PROVIDE THE FOLLOWING INFORMATION WFI"H YOUR APPLICATION: <br /> <br /> 1997 organization budget <br /> <br />· I~ ~,.,,,, ~,.-~ Proposed budget for CDBG funds <br /> <br />r :~ ;..,',,,..~, ~ ~ Schedule for expenditure of CDBG funds <br /> <br /> Name of individual(s) authorized to receive CDBG reimbursement checks <br /> <br /> A copy of the organization's articles of incorporation <br /> <br />I <br />I <br /> <br />I <br />I <br />I <br /> <br /> I <br /> I <br /> I <br /> I <br /> <br />I <br />I <br />I <br />I; <br />I <br />I <br />I <br /> <br /> <br />