HomeMy WebLinkAboutSignature pages_NETC_REF 13 ApplicationRenewable Energy Fund Round 13 ALASKA
Grant Application — Standard Form ENERGY
A&**,& AUTHORITY
Community/Grantee Name: Nushagak Electric & Telephone Cooperative
Regular Election is held: Annually, last election April j Date: 9/28/2020
2020
Authorized Grant Signer(s):
Printed Name
Title
Term
Signature
Robert Himschoot CEO/GM��
I authorize the above person(s) to sign Grant Documents:
(Must be authorized by the hiahest ranking oraanizationlcommunitvlmunicival official)
Printed Name
Title
Term
Sign ture
Pete Andrew
2020-2022
President, Board of
2��'
Directors
Grantee Contact Information:
Mailing Address:
Phone Number:
Fax Number:
Email Address:
Federal Tax ID #:
Box 350
Dillingham, AK. 995765
907-842-5251
907-842-2799
rhimschoot@nushagak.coop
92-0177246
Please submit an updated form whenever there is a change to the above information.
SECTION 14 — ADDITIONAL DOCUMENTATION AND CERTIFICATION
SUBMIT THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION:
AEA 21010 Page 50 of 51 9/28/2020
Renewable Energy Fund Round 13 ALAS KA
Grant Application — Standard Form ENERGY pp Y � N G
' AUTHORITY
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 I Robert Himschoot
Signature
r -
v'
0,
Title CEO/GM
I
Date 9/28/2020
AEA 21010 Page 51 of 51 9/28/2020