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GROUP 3 EQUIPMENT <br /> <br /> Equipment (Itemized) Agency Funds State Funds Total Cost <br /> 1 - Snowraob±le su±t 250.00 250.00 <br /> 1 - Snowmobile saddle bag 107.00 107.00 <br /> 1 - pr. glove liners 14.00 14.00 <br /> 2 - Fleece dickies 32.00 32.00 <br /> Sub-Total 250. O0 153. O0 403. O0 <br /> <br />Group 4 Total Grant Costs <br /> <br /> Agency Funds State Funds* Total Cost <br />Grant 1200.00 I000.00 2200.00 <br /> Total <br /> Costs <br /> <br />*Must equal the amount listed in Amount of Payment on Agreement, (Form SG-006). <br /> <br />The figures on this report will need to be backed up by documentation available at your office. You do not need <br />to send this information at this time, however it should be readily available for audit purposes. <br /> <br />Remember <br />Please print or type. <br />Use plain bond paper if additional space is needed. <br />Attach the additional pages to this form. <br />Return this form with the Agreement Forms SG-006 <br />Keep one copy for your agency files. <br /> <br />"This is to certify that the State Funds requested will be used only for the purposes set forth in Laws of <br />Minnesota 1997, Chapter 216, Sec. 5, Subd. 8 and the information contained in this form is correct to the best of <br />my knowledge." <br /> <br />Signature of Agency Administrator <br /> <br />Date <br /> <br />I <br /> <br /> <br />