Form Application Form 4 Application Form 4 Partnership Statement

Partnership Statement

Complete one of these forms for each formal partner.
Legal name of applicant organization (5a from Face Sheet):
1. Legal name of partner organization:
2. Partner DUNS number:
3. Mailing address

Street1:

Street2:

City:

State: Zip+4:

4. Partner Web address: http://
5. Partner project contact name:
Title:
Telephone number:

E-mail:

6. Governing control of partner (choose one):
‰‰State Government
‰‰County Government
‰‰City or Township Government
‰‰Special District Government
‰‰Regional Organization
‰‰U.S. Territory or Possession
‰‰Independent School District
‰‰Public/State-Controlled Institution of Higher Education
‰‰Indian/Native American Tribal Government (Federally
Recognized)
‰‰Indian/Native American Tribal Government (Other than
Federally Recognized)
‰‰Indian/Native American Tribally Designated Organization
‰‰Public/Indian Housing Authority

‰‰Nonprofit with 501(c)3 IRS Status (Other than Institution
of Higher Education)
‰‰Nonprofit without 501(c)3 IRS Status (Other than
Institution of Higher Education)
‰‰Private Institution of Higher Education
‰‰Individual
‰‰For-Profit Organization (Other than Small Business)
‰‰Small Business
‰‰Hispanic-serving Institution
‰‰Historically Black Colleges and Universities (HBCUs)
‰‰Tribally Controlled Colleges and Universities (TCCUs)
‰‰Alaska Native and Native Hawaiian Serving Institutions
‰‰Nondomestic (non-U.S.) Entity
‰‰Other (specify)

7. What is the partner organization’s mission? [500 characters]

8. Describe the partner organization’s service area (audience served, including size, demographic characteristics,
and geographic area). [500 characters]

9. List the partner’s key roles and responsibilities in the project. [1000 characters]

Please note:
A. Submission of this application by the authorized representative of the applicant organization reflects the partner
organization’s agreement with the following statements:
• We will carry out the activities described above and in the application narrative.
• We will use any federal funds we receive from the applicant organization in accordance with applicable federal laws and
regulations as set forth in the program guidelines and the terms and conditions of the grant award.
• We assure that our facilities and programs comply with the applicable federal requirements and laws as set forth in the
program guidelines.
B. Prior to submission of the application, the applicant will ensure that the partner organization has provided to the applicant
a signed original of this Partnership Statement for the applicant’s records. Such original will be made available to IMLS, if
requested by IMLS.

OMB Number: 3137-0071, Expiration Date: 08/31/2013