Division of Community Health and Prevention

APPLICATION AND PLAN FOR HUMAN SERVICES
PROGRAM COVER PAGE


  1. APPLICANT ORGANIZATION

    NAME:

    ADDRESS:

    CITY:

    ZIP:

    PHONE:

    EMAIL ADDRESS FOR AUTHORIZED PROGRAM REPRESENTATIVE:

    FEIN NUMBER (Please attach Form W-9, when applicable):

    DUNS NUMBER:

    CAGE NUMBER:

  2. DATE OF SUBMISSION (Month) (Day) (Year)
  3. PROJECT PERIOD: From (Month) (Day) (Year) to  (Month) (Day) (Year)
  4. TYPE OF ORGANIZATION
    • Governmental entity
    • Not-for-profit corporation (Please attach documentation from the Secretary of State's Office regarding the status of your agency)
    • Tax-exempt organization (IRC 501(a) only) (Please attach documentation of current status)
  5. LEGISLATIVE DISTRICT (Include Congressional, State Senate District and State Representative District for each Sub-Grant 's service area)
    • Sub-Grant Type Service Area Congressional District State Senate District State Representative District
      example
      example
  6. ZIP CODE (Include zip code + 4 for your proposed service area(s) for each Sub-Grant)
    • Sub-Grant Type

      Service Area

      Zip Code + 4

  7. PROJECTED NUMBER OF PARTICIPANTS:
  8. IMPORTANT NOTICE
    • This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined in the Illinois State Finance Act, found at 30 ILCS 105/1 et seq. Failure to provide the information requested on this form may prevent your application from being processed.
  9. APPLICANT CERTIFICATION

    To the best of my knowledge, the data and statements in this application are true and correct. The applicant agrees to comply with all state/federal statutes and rules/regulations applicable to the program.

AUTHORIZED OFFICIAL

(Typed Name)

(Title)

(Signature)