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14 <br /> ❑ Signed "Authorization to Release Information" for each persons who has more than 19.9% <br /> ownership interest in the organization <br /> ❑ Completed W-9 Form <br /> ❑ Certificate of Liability Insurance <br /> Agency Experience <br /> Please provide a brief description of your organization's past achievements in carrying out similar <br /> projects and evidence of successful record of meeting proposed budgets and timetables. <br /> For all projects for which you have received County funding within the last 5 years, please provide the <br /> information below. If you have not received County funding within the last 5 years, please complete for <br /> comparable projects. Copy and paste the chart below as needed for additional projects. <br /> Project Name <br /> Total Project Cost <br /> Amount and Source of County Funding <br /> Date of Funding Award Approval <br /> Date of Project Completion <br /> Project completed on schedule? ❑ Yes ❑ No <br /> Project completed within budget? ❑ Yes ❑ No <br /> If no, how much over/under budget? <br /> Other Comments: <br />