Statement of Agreement, Authorization & Certification

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Rev. 01/22
VNA Foundation, Inc.

1180 Spring Centre S Boulevard, Suite 304
Altamonte Springs, Florida 32714


Agency Name:________________________________________________________



Telephone: ____________________________________________________________

Proposal Request:______________________________________________________

Designated Spokesperson:  ______________________________________________

Alternate Spokesperson:_________________________________________________

Statement of Agreement:
We agree to furnish a report on expenses related to products and services funded by the grant.  We accept the terms and conditions set out in Exhibit A of the VNA Foundation, Inc. Grants Policies and Procedures Statement, attached hereto.

Our signatures acknowledge that the information contained in this funding proposal may be shared with other funders.  In addition, this certifies that this request is consistent with our organization’s Mission/Articles of Incorporation and Bylaws and has been approved by a majority of the Board of Directors on (date):


Statement of Certification:
We certify that the 501(c)(3) status for  __________________________________   has not been revoked or modified since creation of the attachment.

_____________________________________                      ________________________________________

Typed Name of Agency Administrator                                 Typed Name of Board Officer

____________________________________                         ________________________________________

Signature                                                                                            Signature

____________________________________                          ________________________________________

Date:                                                                                                     Date:

Rev. 03/03

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