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Page 2 <br />CDBG Request Form <br />City of Ramsey <br />Name of Organization <br /> <br />Alexandra House, Inc. <br /> <br />Does your organization serve low to moderate income families or individuals? If you answer no, <br />your organization is not eligible to receive CDBG funds. <br /> <br /> xx Yes No <br /> <br />What percentage of persons served are low/moderate income individuals? <br /> <br /> 90 % <br /> <br />What percentage of low/moderate income persons served are Ramsey residents? <br /> <br /> 10 % <br /> <br />Will these funds be used for an expansion of an existing program? <br /> <br /> Yes xx No <br />Will these funds be used for the creation of a new program? <br /> Yes xx No <br /> <br />PLEASE PROVIDE THE FOLLOWING INFORMATION WITH YOUR APPLICATION: <br /> xx 1997 organization budget <br /> xx Proposed budget for CDBG funds <br /> <br /> XX Schedule for expenditure of CDBG funds 1997 Per Diem budget <br /> xx Name of individual(s) authorized to receive CDBG reimbursement checks <br /> xx A copy of the organization's articles of incorporation <br /> <br /> <br />