DCHD PROPOSAL ACTIVITY/PARTNER SUPPLEMENT
If your project will be carried out in more than one physical location, complete an Activity Supplement for each activity and location. Each Partner
or Consultant that will be providing direct services as a part of this project and is projected to receive $5,000 or more in funding must complete a
Partner Supplement. Job Descriptions must be attached for all DCHD funded staff. If the project is funded, all contractual requirements and
obligations of the fiscal manager will be passed on to the Partners.
PROJECT SUMMARY: Briefly describe your role in the provision of services for this project
I certify that I am authorized to sign legal documents on behalf of this organization.
I certify that the information contained in this funding application is true and correct.
Signature Print Name Date
EXECUTIVE DIRECTOR/CEO NAME:
CONTACT PERSON (NAME/TITLE):
# OF OVERALL CLIENTS SERVED:
# OF DCHD CLIENTS SERVED:
# OF OVERALL UNITS PROVIDED:
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