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for` Service Providers <br />Rf Yes <br />❑ No <br />4. Copy of facility license and proof of appropriate certification or registration <br />RCi Yes <br />with certifying board. <br />❑ No <br />5. Monthly or Weekly Calendar detailing Services Provided <br />RAJ Yes <br />❑ No <br />6. Local CJPP Advisory Board Members and Terms <br />9i Yes <br />❑ No <br />7. Budget Line Item Justification Form <br />F6 Yes <br />❑ No <br />8. Budget Summary Form <br />kI Yes <br />❑ No <br />9. Project Income Report (if applicable) ❑ Yes <br />Rai No 11N/A <br />10. Information regarding all funding sources beyond CJPP funds (Grants, County WI Yes <br />Funds, etc.) ❑ No <br />NOTE: Please number your attachments and submit in the order indicated above. <br />Return_to Form_ Selection._ Page <br />