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End of the Year Itemized Summary Form

  1. Shelby County Board of Commissioners

    END OF YEAR ITEMIZED SUMMARY FORM

  2. EXECUTIVE DIRECTOR

  3. GENERAL CONTACT FOR FOR FINANCIAL DOCUMENTS

  4. DESCRIPTION OF GRANT REQUEST

  5. SUMMARY OF ORGANIZATION

  6. Itemized Account of Funds Received

  7. Attachments:

  8. Please upload the following:

  9. 1. Certified copy of itemized budget detailing how received grant funds were used

    This document should be certified by the CFO of your organization or the preparer of the financial documents.

  10. ACKNOWLEDGEMENT:

    Please read the following and if you agree to the provisions sign below.

  11. The information provided has been submitted in good faith and as completely as our records and recollections permit.

  12. I understand that failure to provide the requested information could hinder my ability to receive government funding in the future.

  13. I understand that the information provided in this application shall be open to inspection upon filing with the office of the Shelby County Board of Commissioners.

  14. Leave This Blank:

  15. This field is not part of the form submission.