• After completing this page, print it. This is the last page of the application form.

C. Match Requirements Section

Is your total cash match at least 100% of the grant request?   Yes   No

Will you be using federal monies to carry out this project?  Yes   No
D. Income

Earned Income: Include revenue from the sale of admissions, tickets, and memberships.
  $
  $

Contributions: Include cash contributions from businesses, corporations, foundations, and other private sources.
  $
  $

Other Revenue: Include revenue from sources other than those listed above.
  $
  $

Total Cash Income: $

E. Statement of Assurances
The applicant hereby agrees and acknowledges:
a) that, if funds are awarded, they will conduct their operations in accordance with title VI and VII of the Civil Rights Act of 1964, as amended, and the Rehabilitation Act of 1973, as amended, which bar discrimination against any employee, applicant for employment or any person participating in any sponsored program on the basis of race, creed, color, national origin, religion, sex, age, or physical or mental disability, and require compensation for employment at no less than minimum wage requirements, and provide safe and sanitary working conditions;
b) they will expend funds received as a result of this application solely on the described project;
c) that, if the proposed project impacts a property listed on or having qualities making it eligible for listing on the National Register of Historic Places, the applicant will consult with the Historic Preservation Office, State Historical Society of Iowa, and will act in accordance with the Secretary of Interior's Standards for Archeology & Historic Preservation;
d) that the facts, figures, and representations made in this application, including all attachments, are true and correct to the best of their knowledge;
e) that the filing of this application has been authorized by the governing board of the applicant;
f) that failure to comply with the Historic Site Preservation Grant program administrative rules will disqualify the application.

Signature of person with legal authority to obligate the Applicant
:

Date:

Typed name and title of the above person:

Date:

Signature of Project Manager/Contact Person:

Date:


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