Application Date:
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COJ PSG Program:
Agency Legal Name:
Also Known As:
Program Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Website:
Contact Person Email Address:
Executive Director First Name:
Executive Director Last Name:
2019 -2020 PSG Requested Amount (don't go over 24% & $150,000): 2020 -2021 PSG Requested Amount (don't go over 24% & $150,000): 2021 -2022 PSG Requested Amount (don't go over 24% & $150,000): 2022 -2023 PSG Requested Amount (don't go over 24% & $150,000): (Whole Numbers Only)
Tax ID (FEIN):
 
(Please enter only the 9 digits without any '-'s)
2016 Organizational Annual Revenues: 2017 Organizational Annual Revenues: 2018 Organizational Annual Revenues:
 
(Data Source: IRS Tax Return)2019 Organizational Annual Revenues:
2017 Organizational Annual Revenues: 2018 Organizational Annual Revenues: 2019 Organizational Annual Revenues: 2020 Organizational Annual Revenues: (Data Source: IRS Tax Return)
2018 Organizational Annual Revenues: 2019 Organizational Annual Revenues: 2020 Organizational Annual Revenues: 2021 Organizational Annual Revenues: (Data Source: IRS Tax Return)
   
CERTIFICATION: I , hereby certify that the information and representations contained in the Fiscal Year 2020 Public Service Grant application is true and correct., hereby certify that the information and representations contained in the Fiscal Year 2021 Public Service Grant application is true and correct., hereby certify that the information and representations contained in the Fiscal Year 2022 Public Service Grant application is true and correct., hereby certify that the information and representations contained in the Fiscal Year 2023 Public Service Grant application is true and correct.
Applicant Title: Date:
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