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DESIGNATION OF AUTHORITY <br />CORONVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT (CARES ACT) <br />CORONA RELIEF FUND CRF PROGRAM <br />Municipality: <br />Box 1: Authorized Agent <br />Box 2: Primary Agent <br />Agent's Name <br />Agent's Name <br />Signatur :. <br />Signature <br />!R 6< l <br />Organization/Official ositi Sj % <br />grganizati n/.Official Position <br />Ma m Ad'4 ..d <br />d�c /4 - xv-p, 1�� <br />Maili g Address <br />r -7 <br />C) C) u <br />City, State, i <br />�► �► l e A�n' �- 3 l� a <br />City, State, Zip <br />�� s ' � -3 3 icWC� <br />D jytime e phone <br />..) S - 2/ <br />DaytimeTelepho <br />mail Addr ss <br />E-mail Address <br />Box 3: Alternate Agent <br />Box 4: Authorized Agent to Request Funds/Reimbursements <br />Agent's Names pA D-n s <br />Official's Name Z`H k� a <br />!J, {vLA <br />Signature <br />Signature <br />�. <br />Organization /Off ial Position <br />ene n^ 6 <br />rga <br />t iy Psi io ty, <br />'' 1 <br />{ JJ11 <br />Mailing Addr <br />170 co <br />ling Acj i s <br />V evil I w-, env <br />City, State, Zip 3 <br />�, State, Zile z j � `! <br />Ch L <br />Daytime Telephone <br />2 -- SW 7) <br />Daytime�T ephone : <br />,,_ =-?2­-- 160,5 <br />E-mail Address <br />jyA�jC4,;,) <br />E-mail Address <br />orn �AI . C, <br />Box 5: Authorized Agent to Request Funds/Reimbursements <br />Box 6: Authorized Agent to Request Funds/Reimbursements <br />Agent's Name <br />Agent's Name L �'•I l /� n <br />Signature <br />Signature <br />roan' ati / fficial Pos n P� <br />S �J/ <br />g nizati q /cQ,ffi�cial Pos_ do {��j ry P.� <br />IdJ�"`i1�����1f(Avr bi <br />M' ddresdr <br />Mailin ,r4d656-2 6 631j�AS Me VISE <br />1 ➢ W ins � E <br />C , State, L ZfS <br />City,State, Zip DIU `y � -�^L 33� � <br />D ime ephone <br />Daytime el�epp- m <br />�3" <br />E- ail ddres /� <br />l� r <br />E-mailA�dre+ss y� i �`�' <br />�s- Q �O �J f— �4eI <br />The above Primary and Alterna Agents are hereby authorized to execute and sign the Interlocal and other pertinent documents related to the CARES <br />Act CRF Program. The persons designated in boxes 4 through 6 are authorized to excecute requests for reimbursement, certification, or other required <br />documents on behalf of the Municipality. <br />Municipality Authorized Agent Signature <br />/d1-1120 <br />Date <br />Page 2 of 2 <br />