State of California – The Natural Resources Agency
DEPARTMENT OF PARKS AND RECREATION
Per Capita Project Application Form
PROJECT NAME REQUESTED GRANT AMOUNT
$
PROJECT SITE NAME and PHYSICAL ADDRESS
where PROJECT is located including zip code
(substitute latitude and longitude where no street
address is available)
MATCH AMOUNT (if project is not serving
a severely disadvantaged community)
$
LAND TENURE ( all that apply)
Owned in fee simple by GRANTEE
Available (or will be available) under
a ( ) year lease or easement
NEAREST CROSS STREET
Project Type (Check one) Acquisition Development
COUNTY OF PROJECT LOCATION
GRANTEE NAME AND MAILING ADDRESS
AUTHORIZED REPRESENTATIVE AS SHOWN IN RESOLUTION
Name (typed or printed) and Title Email address Phone
GRANT CONTACT-For administration of grant (if different from AUTHORIZED REPRESENTATIVE) Name (typed or printed) and Title Email address Phone
GRANT SCOPE: I represent and warrant that this APPLICATION PACKET describes the intended use of the requested GRANT to complete the items listed in the attached Development PROJECT Scope/Cost Estimate Form or acquisition documentation. I declare under penalty of perjury, under the laws of the State of California, that the information contained in this APPLICATION PACKET, including required attachments, is accurate.
Signature of AUTHORIZED REPRESENTATIVE as shown in Resolution Date Print Name:
Title: