Requirement Certifications. Under penalties or perjury, the undersigned certifies that the name, taxpayer information number and legal status listed below are correct. Name: Xxxxxxx Xxxxxxxxx Parents Alliance Employment Project 0000 Xxxxx Xxxxx, Xxxxx 000, Xxxxx, XX 00000 000-000-0000 xxxxxxxxxx@xxxxxxx-xxxxxxxx.xxx Taxpayer Identification Number: 00-0000000 Legal Status (check one): Individual Government entity Owner of sole proprietorship Partnership Tax-exempt hospital of extended care facility Nonresident alien individual Estate of legal trust Foreign Corporation Corporation providing or billing medical partnership estate or trust and/or health care services Other – not-for-profit _X _ Corporation NOT providing or billing organization: medical and/or health care services _ Community College or Other Educational Institution The Service Provider acknowledges that the individual signing below is authorized to execute this Agreement and that each signature constitutes the acceptance of this Agreement. Service Provider: By: Date Xxxxxxx Xxxxxxxxx, Executive Director Parents Alliance Employment Project 0000 Xxxxx Xxxxx, Xxxxx 000, Xxxxx, XX 00000 000-000-0000 xxxxxxxxxx@xxxxxxx-xxxxxxxx.xxx McHenry County Board By: Xxxxxxx Xxxxxxx, Chairman Date McHenry County Workforce Network Board By: Xxxxx X. Xxxxxx, Chairman Date PART I GRANTEE’S APPROVED BUDGET PROGRAM: WIOA (Workforce Innovation and Opportunity Act) – Youth Program NAME OF Service Provider/Subrecipient: Parents Alliance Employment Project APPLICATION GRANT NUMBER: Grant 22-681002 PROJECT DURATION: BEGIN DATE: 1 July 2023 END DATE: 30 June 2024 SUMMARY OF PROJECT – BY BUDGET/COST CATEGORY Cost Category Description Funding Request Personnel $96,945.11 Fringe $15,087.26 Travel $1,572.00 Other/Payroll Processing and Professional Development $2,660.54 Total $116,264.91 PART II SPECIAL GRANT CONDITIONS
