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2. Name of Person Applying*
4. Name of Business or Organization *
6. Funds Requested*
7. Funding Tier Requested*

   1. Tier 1: $2500 maximum
   2. Tier 2: $9,999 maximum
   3. Tier 3: $10,000- $49,999
   4. Tier 4: Special project above $50,000

   Select the funding tier for which you are applying

9. Letter of intent*

   Did you submit a letter of intent and receive approval to proceed from the LADPC board? (only applicable to tiers 2-4)

   1. No- applying for tier 1 funding
   2. Yes- letter of intent was approved
11. Applicant Type*

    Please check one

    1. Non Profit
    2. Tribe
    3. Private Business

    1. School
    2. Other
13. If Other is selected, please describe:
15. Phone Number*
16. Email Address*
18. Address*
20. City*
21. State*
22. Zip Code*
24. Federal Tax ID Number*
26. Provide a description of the project.*
28. Workplan narrative*

    Please provide an overview of your proposed workplan. A detailed workplan should be uploaded with other supporting documentation. 

30. Describe the project schedule/timeline.*
32. Budget Narrative*

    Please provide a detailed budget narrative with justifications for each line item (ex. personnel, materials, contracts etc.)

34. Sustainability

    Tiers 3 and 4 only: Please describe how this project will be sustained over time

36. Identify how this project would be modified if only partial funding is received.*
38. Supporting Documents*

    All documents must be uploaded into ONE PDF file. Required documents include:

    - Agency W9

    - Line Item Budget

    - Detailed Work Plan (include timeframe for each activity)

    - Letter(s) of support (Optional)

40. Goals and Objectives*

    Please include each of the project's goals and objectives. Must be S.M.A.R.T. (specific, measurable, achievable, relevant, and time-bound) goals

42. Eligibility*

    Describe how this project meets LADPC requirements (establish, operate, and maintain alcohol and drug abuse prevention, early intervention, or treatment services) as established under ORS 430.355

44. Equity and Diversity*

    Describe how this project demonstrates health equity and cultural/linguistically appropriate services

46. Target population *

    Specify if this project serves a minority population and the estimated total number of people served.

48. Permitting*
    -- Select One --Yes, permit has been obtainedYes, permit has not yet been obtainedNo, this project does not require any permits

    Does this project require any permits? (event in a park, temporary food etc)

50. Describe the applicant's experience in administering grants and/or delivering similar types of projects.*
52. Certifications and Representations

    The information in this application, including all attachments and certifications, are, to the best of the knowledge of the undersigned, complete, current and accurate. The application presents fairly the conditions of the eligibility of the undersigned. Proceeds of the award are intended to solely support the operations and reopening expenses of the applicant business.

    Should the Federal Government determine that a misrepresentation exists creating a default, the award may be forfeited and subject to repayment. Failure to repay or cure a default will result in any and all collection actions permissible by law, including through third party collection services or the Oregon Department of Revenue. The applicant agrees to allow the State to pursue such collection actions.

54. Insurance Requirements

    Depending on the funding level and nature of the project, insurance may be required.

    Insurance Acord 25-S with County required minimums (General Liability; Each Occurrence $2,000,000; Aggregate $4,000,000), Klamath County as additional insured, additional insured endorsement, proof of workers comp and auto coverage (if needed). If no employees or autos will be used for grant fulfillment, a document on letterhead stating no employees or autos will be used for grant fulfilment must be submitted (include it in the Supporting Documents section below). Proof of insurance will be required after the applicant has been awarded funding.

56. Acknowledgement *

    Submission of application does not guarantee funding. If funded, you will be required to report on progress and completion of the project. You will also be required to submit all financial backup documents demonstrating how funds are spent. By checking the box below you acknowledge your understanding.

    1. Acknowledged
58. Electronic Signature Agreement*

    I certify to the best of my knowledge that all information, contained in this application, including all attachments and certifications, is valid and accurate. I further certify that, to the best of my knowledge:

    1.  The application has been reviewed and approved by the authorized owner(s), managers with appropriately delegated authority, and/or in accordance with the organization’s articles of incorporation, articles of organization or bylaws, and

    2.  Signature authority is verified.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
60. Electronic Signature
62. Date and Time*
    Date and Time

    Date and Time
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field