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GROUP 3 EQUIP~NT <br /> <br />Equipment (Itemized) Agency Funds State Funds Total Cost <br />Sub-Total <br /> <br />Grou 4 Total Grant Costs <br /> <br /> Agency Funds State Funds* Total Cost <br />Grant Total Costs -~ ~,-~ ~ ~ ~' oo~ -- <br /> <br />*Must equal the amount listed in Amount of Paymem on Agreement, (Form SG-006). <br /> <br />The figures on this report will need to be backed up by documentation available at your office. You do not n <br />to send this information at this time, however it should be readily available for audit purposes. <br /> <br />Remember <br />Please print or type. <br />Use plain bond paper if additional space is needed. <br />Attach the additional pages to this form. <br />Return this form with the Agreement Form, SG-006 <br />Keep one copy for your agency files. <br /> <br />"This is to certify that the State Funds requested will be used only for the purposes set forth in Laws of <br />Minnesota 1997, Chapter 216, Sec. 5, Subd. 8 and the information comained in this form is correct to the best of <br />my knowledge." <br /> <br />Signatur~ of ~mini~nm~ <br /> <br />Dat~ <br /> <br /> <br />