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21 B -24 <br />assistance ac:ivrt , >f applicable, <br />State intergovernmentai review process. Se'ect the <br />appropriate box. If °a.' ;s selected, enter the date the <br />f. Name and contact information of person to tie contacted on <br />matters involving this appplication. Snier bme name (First and last name <br />app:"oa ion was subrrilted to t*e Mate <br />required,,, meat n.* afffiattcn (if aff€l €a:ed Etta an organization otter <br />20, <br />is the ,applicant Delinquent opt any Federal Wit? <br />than t aF giant organizaticrij, telep'^one member (required), fax <br />rur"t er, and era address ;Requrr `'sF of the perm to co nzact, on <br />(Required ) Select t -^7e appropriate box. This questir a= 6$e=_ to <br />€tatters related to .his 3",li.ation,. <br />the applaw,11 organzaticr., riot the persc^ who signs as the <br />authorized representative. ,ategrires of debt include <br />del- nouent audit disaIowances, loans and taxes. <br />I yes, include an ex .da*ation on the o:,ntirr�ation street. <br />+. <br />Type of , can?. (Required <br />21, <br />Autborized Representative, ,Requ.red) Tc de signed and <br />Select °a p :c three app i.ant typeis I in accordance wit'^ agency <br />d� ed by e authodzed representative of the applicant <br />r 3tructicn3. <br />organzation. E-nter the narne. 'First and iast name requ red;± <br />Bile (Required;, telephone number R uireclj- fax number,. <br />A. State Government <br />NA, l onprcf"i with M 3C.3 IRS <br />B. County i= avwrnrr nt <br />Status i iher tdan Institute <br />and err, all aadress (Re z.airedj of the person auhorzea' to sign <br />04 or Township= Gmemment <br />of 4i2her Educatic <br />for the applicant. <br />D Spes4 District dovernment <br />N, Nonpraft without 5C? w'3 IRS <br />A ccpy of the governs bcd- s au -hori atop .^tar you to sbgn <br />- =regional Organ-ization <br />Status 101her than insbt: to' <br />this appheabon as ,he official representative trust be on f; e in <br />F 7ertorx or Pcssession <br />of "ipher Education) <br />the pu rr's o'fface +Certain Federa, ages €es may reel re <br />L. ndepenx,e. t Sc col District <br />0. Private €ns.itAon of H.Vher <br />that this autnonzation be submitted as part of the app- fiat o. _ <br />I =�.,,v :,,St3re Lc :ntroilec <br />Educat "cr <br />rs:rt tc of nigher Educate <br />F iror:nc =Za <br />=ndiam'Native American Tfta <br />Q, For -Profit + ganizato <br />i3cve€mment sFederaliiy <br />(Otnerthan Smarr 3•.�siness <br />Recevgnz <br />. Small Business <br />.t ndian,`flajvc American 76ba" <br />S,. Kspa :i;c -serve :nstitutic -,n <br />Gcvtrnment (Other than <br />T. H'-storioaliy Slack Cc= ,eeges <br />Federally Recognszed) <br />and Un versities (HE CUs, <br />K. ndiariMa ve American <br />�j. Trbaliy C•ontro4k Colleges <br />Tribally Oes:gr€aGed <br />and Ur versif4s (7CGJs) <br />Orga.ntrion <br />V. Alaska Native and Niat=ve <br />L. Pg t - d'Inwart r- ausing <br />Hawaiian Serving Institutions <br />Authority <br />W . toad mestic (non -JS), <br />Entity <br />, Ct!er ;specifyj <br />21 B -24 <br />