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<br />. <br /> <br />. <br /> <br />. <br /> <br />Appendix B - Application Cover Sheet <br /> <br />Organization Information: <br /> <br />City of Arde"-!ii,l!s <br />Name of Organization <br /> <br /> <br />12'15 WestHi9~...a'i96 <br />Address <br />(651) 631-5120 <br />Phone <br /> <br />"rden Hills MN55.1.1.,?,.., <br />City, State, Zip <br />.. ___J621JJi34-51}7 <br />Fax <br /> <br />Legal Name, if different <br />41-6008992 <br />Employer Identification # (EIN) <br /> <br />_ _ _ _________~.ci.arden-~mSi~~_~~_u_s __~ <br />Website <br /> <br />Michelle Wolfe <br /> <br /><::!_!Y_A_~_~_~~_!,~Y~!9T <br />Name of executive director Title <br />or president <br />Kar~J'I_~~r:ton ._____ _ __S-pmmuni!YJ?~_~l?ir~g~_ __J~212J~}_1:=~1~_ karen.~~!'!_f::J!I@Ci~~~~-hills.mn.lJ!!__ __,____ <br />Name of contact person Title Phone Email <br />regarding this application <br /> <br />(651 ).~.31,:.,5..1.,.?.7 ",rnic.helle.woife@ci.arden.::hil!s.crrt,~clJ.~__,_ <br />Phone Email <br /> <br />_Mu~~~~~~~~Jq_IJJ____._____ _ ~~J~fJL'1:,_9J!i:~~(LT~~surer J~~J_L~!4.=.~II~ __~_~_I"1:_l.Iz_a~sic.ic.tiq_1.I_l~_~1_~!_r;l~!!.-::hjI15.mn.us___ <br />Name of finance contact Title Phone Email <br /> <br />Is your organization an IRS 501 (c)(3). 501 (c)(4), or 501 (c)(6) not-for-profit' <br />if yes, state which IRS 501 designation <br /> <br />DYes 0 No <br /> <br />applies <br /> <br />to <br /> <br />your <br /> <br />organization <br /> <br />If no, is your organization a public agency/unit of government? 0 Yes 0 No <br /> <br />If no, check with Blue Cross for details on using fiscal agents. and list name and address of fiscal <br />age nt: <br /> <br />Name <br /> <br />Fiscal agent's EIN Number <br /> <br />Address <br /> <br />City, State, Zip <br /> <br />Name of contact person regarding this application <br /> <br />Title <br /> <br />Phone Email <br /> <br />Proposal Information <br /> <br />Please give a 2-3 sentence summary of request: <br />Request for assistance in updating the City's camp plan to incorporate active community planning principles. <br /> <br />Population served: 10,000 <br />Project dates (if applicable): . Jul'C2.()06:July 2007 <br /> <br />Geographic area served: of Arden Hills <br />Fiscal year end December 31 <br /> <br />Budget <br /> <br />Dollar amount requested: <br /> <br />Total annual organizational <br />budget <br />Time period of above amount: <br /> <br />$47,437.60 <br /> <br />$8,180,661 <br /> <br />Cash match (if any): <br /> <br />$26,250.00 <br />---------.--..--.-- <br /> <br />',\Melro-in'tu~\ardellh;lls\Planning\COnmlunilY Devcl"pmenllGrantslBCBS Gralll "'499 App<:ndix B Fr"m.doc <br />