S Grant - Community and Schools Phase III Tobacco Use Prevention and Cessation Initiative Grant Acceptance

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Part IV-Additional Materials For applications to be considered complete, the following items are mandatory and required by the NC Administrative Code, with the exception of item #5. These additional materials must be sent by mail or delivery service in one package, postmarked by March 29, 2005. ® 1. Completed and signed "Agreement and Certification" form (available on the HWTFC website, www.hwtfc.or~). ® 2. Letters of Agreement (consent) from all partnering organization (agencies other than the fiscal agentllead applicant organization that will be receiving funds from this grant as subcontractors to the lead applicant organization). ® 3. At least three (3) Letters of Support from collaborating individuals or organizations (other than partnering organizations submitting letters of agreement). ® 4. A list of three (3) references whom the Commission may contact regarding the lead applicant organization's ability to achieve results through grant funding. ® 5. Evidence of paid and earned media that resulted from previous teen tobacco use prevention and cessation activities if available. ® 6. Copy of letter of determination of nonprofit status from IRS or proof of lead applicant organization's status as a state agency, local government or other political subdivision of the state. ® 7. Budget of the lead applicant organization, clearly demonstrating the source for all in- kind contributions included in the project budget and reflecting expected income from other sources which have been applied for or have been received that will be used as matching funds for the project. ® 8. Most recent audit of the lead applicant organization. ® 9. List of lead applicant organization's teen tobacco use prevention and cessation programs funded by grants or awards in the last five years, including the grant.awazd amounts and the names of granting entities. ^ 10. Nonprofit organizations must submit the following information for the lead applicant organization: • mission statement and organizational goals • boazd of directors • organizational history • current programs, activities and accomplishments • list of contributors to the organization with the amounts given for the current yeaz as reported on the Lead Applicant Organization's IRS Form 990. Applicants may submit either the IRS Form 990 or another document with this same information such as an Annual Report. (This information will be used to determine potential conflicts of interest and will be kept CONFIDENTIAL. This information will be shazed only with HWTFC Commissioners and select HWTFC staff. ) 22