HomeMy WebLinkAboutFire & Rescue Grant App.SF 1199A Page 1 of 1
SECTION 1 (TO BE COMPLETED BY PAYEE)
Standard Form 1199A
A ORGANIZATION NAME
Ashland Fire & Rescue
ADDRESS (street, route, P.O. Box, APO/FPO)
455 Siskiyou Blvd
CiTY STATE ZIPCODE
Ashland Oregon 97520 -2135
B NAME OF PERSON(S) ENTITLED TO PAYMENT
Robert Cockell
C CLAIM OR PAYROLL ID
NUMBER Suffix
Prefix 93-6002117
PAYEE/JOINT PAYEE CERTIFICATION
I certify that I am entitled to the payment identified above.
In signing this form, authorize my payment to be sent to
the financial institution named below to be deposited to the
designated account.
DATE
D TYPE OF DEPOSITOR ACCOUNT
Checking
E DEPOSITOR ACCOUNT NUMBER
1536O2541069
F TYPE OF PAYMENT
Other, Grant Award
EMVV-2003-FP-03307
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY
OMB No 151-0007
(if applicable)
TYPE AMOUNT
JOINT ACCOUNT HOLDERS' CERTIFICATION (optional)
I certify that I have read and understood the instructions, including the SPECIAL
NOTICE TO JOINT ACCOUNT HOLDERS.
SIGNATURE DATE
/ /
SIGNATURE DATE SIGNATURE
DATE
/ /
SECTION 2
GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS
Federal Emergency Management Agency Attn: Assistance to Firefighters Grant Program
Grants Management Branch, Room 350, 500 C Street S.W., Washington, D. C. 20472
NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
CHECK DIGIT
DEPOSITOR ACCOUNT TITLE
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial
institution, I certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts
240, 209, and 210.
https://portal.fema.gov/firegrant/jsp/fire/awards/sf_1199a_p.jsp 3/22/2004