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'.� ! t�t,��" Minnesota llepartment ot riealth lirant Agreement <br /> �CIh1A14[AloiXfAI1NI <br /> .�ccountin Tnformation: (Shaded areas to be com leted by Financial Management) <br /> I Fiscal Xear: 1 1 Total Amount of Agreement: $2,978 <br /> I <br /> Accounting Distribution: For the period of February 10, 201 1 to August 3], 201 1 Fiscal Year: 11 <br /> Fund Or # A r. Re t. Cat. Amount <br /> s �;'� „r.� � �:!3t:r7:�t. ��� �i>s; �3� ;��tt�:�' 1 � ;'rt�c; ��':;'rr. i t';.U�:i <br /> 300 8402 482 482V $2,978 <br /> I I CFDA:(federal dollars only): 93.236 <br /> Accounting Distribution: For the period of to Fiscal Year: <br /> Fund Or # A r. Re t. Cat. Amount <br /> �i �4;'�' ;1! ! i f:li� !7.`I.. !'( `:?: lit F<.iitl: t. tti!'I;�C: S?'A"l�ii; l l:\iJS� <br /> CPDA:(federal dollars only): <br /> Accounting Distribution: For the period of to Fiscal Year: <br /> Fund Or # A r. Re t. Cat. Amount <br /> �'�.; 1, . I(:��! i�.;i_.:<< '��'�: I;,' 1'C!f:!'s 1(�"1'i\'C.� �:� �.t�j,. �! �i��i <br /> CFDA:(federal dollars only): <br /> , Vendor# (�32oqobl <br /> (� Object Commodity Amount <br /> Purchase Ord mber/Signature/Date Code Code <br /> E cum ance Data 2�2'� � 2(� �2�j"(7 � � <br /> (Indivirla�al signing ce .' that funcls have been encumbered as r by Minn. Stat. ��'16A15 anc� 16C.05J <br /> NOTICE TO GRANTEE: You are required by Minn. Stat.§ 270C.65, Subd: 3, to provide your socia] security number or federal employer tax identification <br /> numUer and Minnesota tax identification number if you do business with the State of' Minnesota. This infoimation may be used in the enforcement of' federal and state <br /> tax laws. Supplying these immbers could result in action to require you to file state tax retums and pay delinquent state tax liabilities. This G•ant A�reement will not be <br /> approved unless these numhers are � v�o •ded. T'hese numbers will be available to federal and state tax authorities and state personnel involved in approving the Grant <br /> Agreement and the paymei�t of state obligations. <br /> Grantee Name and Address: <br /> City of Centerville PWSID; 10200036 <br /> I � Mayor Thomas Wilharber <br /> 1880 Main Street <br /> � Centerville, MN 55038 <br /> Social Security or Federal Employer {.D. No. 41-1267014 Minnesota Tax 1.D. No. (if applicable) <br /> TH IS PAGE OF THE GRANT AGREEMENT CONTAINS PRIVATE INFORMATION. EXCEPT AS DEFINED ABOVE, THIS PACE SHOLILD NOT BE <br /> REPR011UCED OR DISTRIBUTEA EXTERNALLY V17THOl�T EXPRESS WRITTEN PERMISSION OF THE GRANTEE. <br /> II !f Joc� circulnte this grant agree+nent inter•nnll}', only offices !hn! reyuire necess (o ihe rnx idenlification numberAND nl! individunlsloffices signing this grnnt <br /> ngreemenr shor�ld hnve nccess to thrs pnge. <br /> HL-01S50-14 (Ol/10) <br /> � 30 <br /> I <br />