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By signing this agreement, you represent that your organization is (please check the correct box): <br />D Qualified as an organization described in Section 501(c)(3) of the Code, and that you do not know of <br />any proposal by or reason for the IRS to revoke or change that status; <br />D A duly established agency of the United States government, or of the government of a state or a <br />political subdivision of a state such as a county, city, or special district; or <br />D A Tribal government. <br />By signing this agreement, you agree to provide a two-to three -page grant report within two months of the <br />grant completion date listed above. Grant reports should include responses to the following: <br />• Please discuss the progress you made toward the goals/objectives outlined in your attached <br />proposal. <br />• What major challenges or issues did you encounter along the way? <br />• What were the most significant things you learned? <br />• Please provide a breakdown of all expenses that were covered by this grant. <br />• If you have disseminated results or findings from this project, please provide links to any reports (or <br />include them as an attachment). <br />In carrying out work supported by this grant, you agree that you will not unlawfully discriminate in your <br />employment practices, volunteer opportunities, or the delivery of programs or services on the basis of race, <br />ethnicity, national origin, ancestry, religion, gender, gender identity/expression, age, medical condition, <br />disability, veteran status, marital status, sexual orientation, or any other characteristic protected by <br />applicable federal, state, or local law. <br />Please note that the Foundation is not seeking any recognition or publicity for this grant. If it helpful to your <br />organization to publicize the award, you are welcome to mention that support was provided by The <br />Momentum Fund at Group Health Foundation. <br />Terms of agreement accepted by: <br />For gran~ recipient~r ization <br />Signature -~--"'----""'-'------"=--oi!,,---------- <br />Printed name -,;-,6 l-A m.b <br />Title /n-/CY/Y11 Mm lnisfrtd-o-r- <br />Date g'--IJ;-1 f? <br />For the Foundation <br />Signature <br />Printed name <br />Title <br />Date <br />Cory Sbarbaro <br />Acting President & CEO