Attachment 11_Disclosure of All Prior DFC Funding.docx

Attachment 11. Disclosure of All Prior DFC Funding

Applicants must indicate the status of the grant award recipient/legal applicant coalition or non-coalition entity by completing both the checklist and the table below. At the bottom sign and date the form. Do not include information about STOP ACT or DFC Mentoring grants on this form. Applicants should indicate their state with respect to DFC funds by checking the appropriate box below.

Coalition:

☐ Coalition has had no prior DFC funding ☐ Coalition applicant formerly funded through DFC

Legal applicant/grant recipient:

☐ Legal applicant/grant recipient for a coalition that has had no prior DFC funding ☐ Legal applicant/grant recipient for a coalition(s) funded through DFC for [ # ] years

List in the table below all of the DFC funding ever received. Add as many rows as needed to include all required information.

Disclosure of All Prior DFC Funding

By signing below, I attest that [organizational applicant name] is applying for Year [enter year number] of DFC funding. I also attest that the information provided in the above table is true and correct.

NOTE: All forms must be dated between January 2020 and the deadline for submission of this application. All forms require signatures and dates or they will be screened out and not move forward to merit review. Handwritten and/or electronic signatures are acceptable.

Official Coalition Representative’s Name Official Coalition Representative’s Signature

Official Coalition Representative’s Title Official Coalition Representative’s Organization/Agency

Date

Grant Award Recipient/Legal Applicant’s Name Grant Award Recipient/Legal Applicant’s Signature

Grant Award Recipient/Legal Applicant’s Title Grant Award Recipient/Legal Applicant’s Organization/Agency

Date

See Section H. Other Information of the NOFO for instructions to upload this attachment.