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-11- <br />CTF-I-B <br />CHILDREN'S TRUST FUND <br />0-4 Program Name: "School's out Days" I <br />Counties to be Served by this Program: Ramsey County students attending <br />School District #621 elementary schools including Pinewood Sunnvside. St. tnhn's <br />Potentially Potentially <br />Number of Clients to be Served: 600 Children 600 ,adults <br />*1/3 of the school age children enrolled in the three schools named above. <br />This is a x primhry secondary prevention program. <br />THE FOLLOWING DOCUMENTS ARE TO BE INCLUDED IN THE APPENDIX OF THE APPLICATION: <br />1. Evidence of Non -Profit Status. 501 (c)(3): <br />Yes, x Not Applicable <br />2. Evidence of Workers' Compensation Insurance: <br />Fu <br />_ x Yes. No x <br />3. Evidence of certified compliance from the Commissioner of Human T' <br />Rights regarding Affirmative Action policies (M Stat. 363.073), s <br />or a corporation policy: <br />Yes, —x No <br />As of this date, the City has not been required to submit such policies. �'• <br />4. Assurances and Agreements (CTF form V-A, B, C), signed: <br />x Yes, - No �M <br />i <br />5. Current Organizational Chart, indicating the proximity of this <br />program to other programs in your agency: �` <br />x _ Yes, No <br />6. Evidence of Federal Identification Number: { <br />x Yes, No Fed. ID # 41-6008912 <br />7. Eevidence of MN Tax Identification Number: <br />x Yes, No MN Tax ID #9034948 <br />