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Standard Grant Template Version 1.2 <br /> Grant Agreement Number <br /> I N N E s o I]e Minnesota Department of Health and The City of New Brighton <br /> MPH <br /> NIEAITMENTor MALIN Encumbrance Worksheet <br /> (Attach to all contracts, grants, and amendments) <br /> Vendor Name: Vendor Number: <br /> City of New Brighton 0000197701 <br /> Address: Federal Employer I.D. or Social Security#: <br /> 803 Old Highway 8 NW 41 6005406 <br /> City, State,Zip: Minnesota Tax I.D. No. (if applicable): <br /> New Brighton <br /> Starting Fiscal Year: 12 Total Amount of Agreement: $1,520.00 <br /> Start Date: 06/01/12 End Date: 08/31/12 <br /> Accounting Information <br /> Fiscal Year 1 <br /> Fund Dept ID Appr ID Project ID Activity ID Amount <br /> 3000 H123 8400 H12888B H12-888-0482W 8402 $ 1,520.00 <br /> H123 • <br /> $ <br /> H123 • <br /> $ <br /> CFDA#(if Federal $) <br /> Fiscal Year 2 <br /> Fund Dept ID Appr ID Project ID Activity ID Amount <br /> H123 $ <br /> H123 $ <br /> H123 $ <br /> CFDA#(if Federal $) <br /> Fiscal Year 3 <br /> Fund Dept ID Appr ID Project ID Activity ID Amount <br /> H123 $ <br /> H123 • <br /> $ <br /> H123 $ <br /> CFDA# (if Federal $) <br /> Financial Management Only <br /> Authorized Signature for x � Date Ds/24/2012 <br /> Encumbrance <br /> Contract Number I 46665 `= Onginl Code w 643 , <br /> Purchase Order Number;; 3000007254 Source Type. REIMB <br /> Category,Code • 84'101501 Account ID 441352 .: <br /> NOTE: This page of the Agreement Contract contains confidential information and should not be reproduced or distributed externally without written <br /> permission from the Vendor. Internal circulation of this page should only be to individuals/offices signing this Agreement Contract and those that require <br /> access to the tax identification number. <br /> Page 1 of 12 <br />