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D. Certification <br />I certify that Election Assistance to Individuals with Disabilities (EAID) Grant <br />funds will be used only for the polling places listed on the attached worksheet(s) <br />and only to purchase: <br />• Physical accessibility improvements to polling places in Minnesota and, or, <br />• Improvements to assist individuals with disabilities to vote privately and <br />independently. <br />Name of Jurisdiction: <br />Printed Name of Applicant: <br />Title of Applicant: <br />Signature: Date: <br />All questions must be completely answered. An unanswered question could result <br />in the disqualification of the application. <br />All information must be submitted in writing as part of this application. If a <br />question is not applicable, please indicate. The EAID Grant Program Improvement <br />Worksheet (Attachment A) must be included with this application. <br />Forward completed applications via email to elections.dept@ state.mn.us, <br />Attention: Todd Pierce. <br />If necessary, fax or mail completed application and all accompanying worksheets <br />and documents to: <br />MN Secretary of State <br />Attention: Todd Pierce <br />180 State Office Building <br />100 Rev. Dr. Martin Luther King Jr. Blvd. <br />St. Paul, MN 55155 -1299 <br />Fax: 651- 296 -9073 <br />All submissions must be received by 4:00 p.m. on Wednesday, September 12, <br />2007. <br />All work must be completed no later than August 1, 2008. <br />4 <br />