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Cities Combating Hunger through Afterschool and Summer Meal <br /> Programs (CHAMPS) <br /> Grant Disbursement Form <br /> I CITY AGENCY CONTACT INFORMATION <br /> Lead Contact Name Dave Jaffe, Recreation Coordinator <br /> Email Address djaffe@cityofredlands org <br /> Phone (909) 798 7572 X 4220 <br /> II FISCAL AGENT INFORMATION- <br /> Fiscal Agent Name Danielle Garcia, Director of Management Services/Finance <br /> Fiscal Agent Contact 35 Cajon Street <br /> Information PO Box 3005 (mailing) <br /> (Address and Redlands, CA 92373 <br /> Telephone) 909 798-7542 <br /> Federal Tax IR # 95-6000766 <br /> III W-9FORM* InadditiontoprovidingtheFederalTaxlD#above,please submitacopyof yourcity's <br /> W-9 form <br /> 1V. MAKE CHECK PAYABLE TOinclude m ill <br /> ( a ng addressifdifferentfromabove) <br /> Please list any additional information we may need to properly disburse your grant funds(e g <br /> splittinggrant amount into separate disbursements,etc ) <br /> Please email these documents to Dawn Schluckebier at schluckebler@nlc ore <br />