OCFS 5001 – County of Saratoga, New York

Aging OCFS-5001

Program Title

Program Year

County

FUNDING INFORMATION

Please Describe Other Category

FUND AMOUNTS

TOTAL PROGRAM AMOUNT:

OCFS FUNDS ALLOCATED:

OCFS FUNDS REQUESTED:

PERIOD OF ACTUAL PROGRAM OPERATION

FROM:

TO:

AGENCY INFORMATION

THIS AGENCY IS:

Private, Not-for-Profit

Public

Religious Corporations

FEDERAL ID #:

CHARITIES REG.#:

AGENCY WEBSITE:

IMPLEMENTING AGENCY:

MAILING ADDRESS:

ADDRESS LINE 2:

CITY:

STATE:

ZIP CODE:

CONTACT PERSON FOR AGENCY

LAST NAME:

FIRST NAME:

TITLE:

PHONE NUMBER:

EXTENSION:

FAX NUMBER:

EMAIL:

EXECUTIVE DIRECTOR FOR AGENCY

LAST NAME:

FIRST NAME:

TITLE:

PHONE NUMBER:

EXTENSION:

FAX NUMBER:

EMAIL:

EXECUTIVE DIRECTORY/BOARD CHAIRPERSON SIGNATURE

Disclaimer: This form will be submitted to the Saratoga County Department of Aging & Youth Services. Please note that submission of these forms to the County Department of Aging and Youth Services does NOT guarantee funding will be allocated to your program.

Changes have been submitted on the electronic OCFS-5001, Individual Program Application-Program Information; OCFS-5002, Agency Program Profile; and/or OCFS-5003, Individual Program Application - Program Summary-Program Components.