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. ELIGIBILITY APPLICATION <br /> OFFICE OF MANAGEMENT AND BUDGET <br /> STATE SURPLUS PROPERTY <br /> SFN 17726(10-2011) <br /> Please read instructions. Incomplete applications will be returned. <br /> I. Name of Organization <br /> Cass County Sheriffs Office-Cass County North Dakota <br /> Mailing Address(P.O.Box Number and Street) City State ZIP Code <br /> Box 488 211 9th St. South Fargo North Dakota 58103 <br /> Street Address/Location Organization E-mail <br /> 211 9th St. South harmonm @casscountynd.gov <br /> County Telephone Number Fax Number <br /> Cass 701-241-5800 701-241-5805 <br /> II. Applicant Status How did you hear about North Dakota State Agency for Surplus Property? <br /> © Public Agency including Public Schools ❑ Co-worker ❑ Conference <br /> © Received an E-mail ❑ News Story/News Article <br /> ❑ Friend ❑ Other <br /> ❑ Nonprofit,Tax-exempt Organization <br /> 0 Advertisement <br /> III. Type or Purpose <br /> ❑State ❑ College or University ❑ Child Care Center ❑Training Center ❑ Medical Institution <br /> © County ❑ Secondary School ❑ School for Physically Impaired ❑ Radio/TV Station ❑ Hospital/Clinic <br /> ❑City 0 Elementary School ❑ School for Mentally Challenged ❑ Library 0 Health Center <br /> ❑Township ❑ Preschool ❑ Museum ❑ Sheltered Workshop Training Program <br /> ❑School District ❑ Program for Older Individuals ❑Ambulance ❑ Provider Assistance to Homeless Individuals <br /> ❑ Fire District ❑ DoD Service Educational Activity ❑ Disabled&Indigent ❑ Provider Assistance to Underprivileged Individuals <br /> IV. PROVIDE NARRATIVE DESCRIPTION OF PROGRAM OR SERVICES OFFERED, INCLUDING A DESCRIPTION OF <br /> FACILITIES OPERATED AND A LISTING OF THE TYPES OF PROPERTY NEEDED. (Use separate sheet of paper.) <br /> V. Sources of Funding(Provide documentation) <br /> ❑ Tax Supported ❑ Contributions 0 Grant © Other(specify) Cass County Government <br /> VI. If applying as a non-profit,tax-exempt organization,has the organization been determined to be tax exempt under Section 501 of the Internal Revenue <br /> Code of 1986?(Copy of letter from IRS must accompany application.) ©Yes ❑No <br /> VII. Has the organization been approved, If"yes",by what authority? <br /> accredited,or licensed? ❑Yes 13 No <br /> VIII. Signature of Administrative Official Date <br /> FOR STATE AGENCY USE ONLY <br /> This applicant has been determined Status <br /> ❑Eligible 0 Ineligible ❑ Public Agency ❑ Nonprofit Education ❑ Nonprofit Health <br /> Date Signature of Director <br />