HomeMy WebLinkAboutSect12_Signature Page_NETCRenewable Energy Fund Round 14 ALASKA
Grant Application — Standard Form ENERGY
AUTHORITY
SECTION 13 — AUTHORIZED SIGNERS FORM
Community/Grantee Name: Nushagak Electric & Telephone Cooperative
Regular Election is held: Annually, last election was in Date: 12/16/2021
March of 2021
Authorized Grant Signer(s):
Printed Name
Title
Term
Signature
Robert Himschoot
CEO/GM
j
Will Chaney
Electric Operations
Manage ctinCEO
f
I authorize the above person(s) to sign Grant Documents:
(Must be authorized by the highest ranking ❑r anization/communi /munici al official)
P
Printed Name
Title
Term
5'g alRe
ete Andrew
President, Board of
Directors
2020-2022
Grantee Contact Information:
Mailing Address:
Box 350
Dillingham, AK. 995765
Phone Number:
Fax Number:
907-842-5251
907-842-2799
Email Address:
rhimschoot@nushagak.coop
wch aney@ nusha ak.coo
Federal Tax ID #:
92-0177246
Please submit an updated form whenever there is a change to the above information.
AEA 23001 Page 50 of 52 11/16/2021
Renewable Energy Fund Round 14 ALASKA
Grant Application — Standard Form ENERGY
A&&'. AUTHORITY
8*CTJ-ON 14 WAV CE RTIkC—ATM—
SUNUMMLOMODMMOM WITH YOUR APPLICATION:
A. Contact information and resumes of Applicant's Project Manager, Project Accountant(s),
key staff, partners, consultants, and suppliers per application form Section 3.1, 3.4 and
3.6.
Applicants are asked to provide resumes submitted with applications in separate electronic
documents if the individuals do not want their resumes posted to the project web site.
B. Letters or resolutions demonstrating local support per application form Section 9.
C. For projects involving heat: Most recent invoice demonstrating the cost of heating fuel
for the building(s) impacted by the project.
D. Governing Body Resolution or other formal action taken by the applicant's governing
body or management per RFA Section 1.4 that:
• Commits the organization to provide the matching resources for project at the match
amounts indicated in the application.
• Authorizes the individual who signs the application has the authority to commit the
organization to the obligations under the grant.
• Provides as point of contact to represent the applicant for purposes of this
application.
• Certifies the applicant is in compliance with applicable federal, state, and local, laws
including existing credit and federal tax obligations.
E. An electronic version of the entire application on CD or other electronic media, per RFA
Section 1.7.
F. CERTIFICATION
The undersigned certifies that this application for a renewable energy grant is truthful
and correct, and that the applicant is in compliance with, and will continue to comply
with, all federal and state laws including existing credit and federal tax obligations and
that they can indeed commit the entity to these obligations.
Print Name Robert Himschoot
Signature
Title CEO/GM
Date I12/16/2021
AEA 23001 Page 51 of 52 11/16/2021