5680-82 Authorize City Reps to acquire fed surplus property

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1 Ohio State Department of Education STATE Of OHIO i ~ -State=Rgeneyfior-Proper-t-q-Utilization ---t - 4221 Westward Avenue APPLICATION FOR ELIGIBILITY Columbus, Ohio 43228 Legal name of organization City of Lakewood Telephone 12161 521-7580 Address 12650 Detroit Avenue City Lakewood County Cuyahoga Zip 44107 1 Application is being made as a (Please check one) (a) ? Pubiic agency or (b) ? PrNatP, nonprofit and tax exempt educational or public health organization, Please provide evidence that the organization is a public agency or enclose a copy of the letter orcertificate from the United State Internal Revenue Service evidencing tax-exemption under Section 501 of the Internal Revenue Code of 1954 2 Check type of agency or organization and attach a supplement to this application describing the program operations and activities For private, nonprofit organizations, •the following additional information is required (a) For educational institutions, include a description of the curriculum, the number of days in the school year, and the number and qualifications of the faculty or staff; (bl If a public health institution or organization, include a description of the health services offered, qualifications of staff and, if applicable, the number of beds, number of resident physicians, and number of registered nurses on the staff PUBLIC AGENCIES NONPROFIT INSTITUTION OR ORGANIZATION: ? State ? Public Health ? Education ? Health Center ~I CitY ? Public Safety ? School for Mentally Retarded ? Museum ? County ? Port/Transit Authority ? School for Physical Handicapped ? Clinic ? Township ? Otlier (Specify) ? Educational Radio or Television ? Nursing Home ? Conservation ? Geriatric Center ? Child Care Center ? Economic Development ? Library ? Research Institution ? Education ? Medical Institution ? Training Center ? Parks & Recreation ? Hospital ? Other Funding % Endowments Grants % Donations Tuition/Fees % Other Check if the applicant program is ? approved; ? accredited; ? or licensed Enclose evidence of such approval, accreditation, or licensing ? Check here if the applicant lacks evidence of formal approval, accreditation, or licensing, and refer to the enclosed instructions (Incorporation papers do not satisfy these instructions) Are the applicant's services available to the public at large? bias If only a specified group of people is served, please indicate who comprises this group Checklist of attachments submitted with this application Evidence that applicant's program is a public agency or exempt from paying taxes under Section 501 of the IRS Code of 7954 ? Description of proyram operations and activities ? Evidence of approval, accreditation, or licensing or information submitted in lieu thereof ? SASP Form No 202, "Resolution,"'properly signed, designating representatives authorized to bind the applicant to the terms and conditions governing the transfer of federal surplus personal property ? SASP Form No 203, nondiscrimination compliance assurance ? Statement concerning applicant's needs, resources, and ability to utilize the property ? Other statements or documentation required, as specified in the instructions, for certain categories of applicants Date 4-14-82 Signed Title Director of Finance FOR STATE AGENCY USE Application approved Application drsappraved- Comments or additional information Date' Signed OSP 201 Director