Form 4921 - Economic Vitality Incentive Program Grant Application (Fy 2012 - Round 2) Page 6

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Michigan Department of Treasury

Application Due Date:

4921 (Rev. 07-12), Page 6

July 27, 2012

Economic Vitality Incentive Program Grant Application (FY 2012 - Round 2)

Issued under authority of Public Act 107 of 2012 and Public Act 236 of 2012.

PART 1: PRIMARY INFORMATION

1. Primary Local Unit Name

2. Primary Local Unit Code

3. Primary Local Unit FEIN

4. Primary Local Unit County

5. Mailing Address

6. City

7. State

8. ZIP Code

PART 2: PROJECT OVERVIEW

9. Project Title

10. Project Type

Merger

Inter-Local Agreement

Cooperative Effort

11. Estimated Start Date

12. Estimated Completion Date

13. Estimated Total Project Cost

14. Grant Amount Requested

15. Local Units Participating in Project (include county and local unit code)

16. Are the local unit(s) involved willing to devote appropriate resources and time to this project?

Yes

17. Is there potential for expansion of the project to include additional local units at a later date?

Yes

PART 3: PROJECT CONTACT INFORMATION

Note: The project contact individual should be a vital part of the grant project and will be Treasury’s contact.

18. Contact Name

19. Contact Title

20. Contact Telephone Number

21. Contact Fax Number

22. Contact E-mail Address

23. Contact Local Unit Name

PART 4: CERTIFICATION

24. I certify that all statements in this application, including all requested supplemental information, are true, complete and accurate to the best of

my knowledge. If awarded, I agree to allow the Department of Treasury and the State Auditor General’s Office (and/or any of their duly authorized

representatives) access, for the purposes of inspection, audit, and examination, to any books, documents, papers, and records of the grantee which

are related to this project. I agree to allow the Department of Treasury to conduct periodic program reviews of the project. The purpose of these

reviews will be to determine adherence to stated project goals and to review progress of the project in meeting its objectives. I agree to submit

quarterly and final narrative and financial status reports to the Department of Treasury. I understand that failure to submit any required reports

may result in the termination of the grant. I understand that this grant may be terminated if the Department of Treasury concludes that I am not in

compliance with the conditions and provisions of this grant, or have falsified any information. By way of signature, I agree with all conditions of this

grant program.

Primary Local Unit Chief Administrative Officer Signature (as defined in MCL141.422b)

Date

Printed Name of Primary Local Unit Chief Administrative Officer

Title