GRANTEE INFORMATION. A. FAFCC Member: <<ClinicName>> B. 501(c)(3) Fiscal Agent in Charge of Grant Funds: <<LegalName>>
C. Federal Tax ID #: <<TaxID>>
GRANTEE INFORMATION. Company/Grantee Name: Xxxxx Xxxxxx / Xxxxx Xxxxxx Company/Grantee Address: Xxxxx Xxxxxx / 0000 Xxxxx Xxxxxx Xx., Xxxxxxxxxx, XX 00000- Company/Grantee Phone Number: (000) 000-0000 Date:
GRANTEE INFORMATION. Grant Recipient TDA Grant Project No. Enter percent of budget from page 1 YFG- YFG portion percentage % Matching portion percentage % $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
GRANTEE INFORMATION. My address is: Account Information: Bank or Broker’s Name: ______________________________________ Name of My Account: ________________________________________ My Account Number: ________________________________________ Routing Information: _________________________________________ Contact Name at bank or brokerage and contact information: __________ My Social Security Number is:
GRANTEE INFORMATION. My address is: My Social Security Number is:
GRANTEE INFORMATION. Provide the Grantee’s name, mailing address, telephone number, fax number and email address. (6 & 7) Indicate the year of the grant and check the appropriate box to indicate whether the grant is awarded under the Rail Transportation Assistance Program (RTAP) or the Rail Freight Assistance Program (RFAP).This information should match the information provided in the grant application.
