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<br /> <br />Salaries <br />Fringe Benefll:s <br />FICA <br />Health Insurance <br />Worker's Compensation <br />Unemployment <br />Total ACquisition Costs <br />Subtotal <br /> <br /> <br />Rent <br />Equipment <br />Insurance: <br />Phone/Fax: <br />Postage: <br />Printing: <br />SupplieslMaterials: <br />Travel and Expenses: <br />Contract Services; <br />Other. (attach details) <br />Total <br /> <br /> <br />I certify that the information contained in this application is true and correct and that it contains no misrepresentations, falsifications, <br />intentio~al omissions, or concealment of material facts. I further certify that no contracts have been awarded, funds committed or <br />construction begun on the proposed project, and that none will be prior to issuance of a Release of Funds by th~ program <br />administrator. <br /> <br />Signature of Authorized Official <br /> <br />Mary Capra <br />Name of Authorized Official <br /> <br />Mayor <br />nle <br /> <br />January 12,2005 <br />Date <br /> <br />Page 4 <br />