CRGP Grant Report

For Agencies

Today's Date *

Agency Name *

Phone *

Email *

Federal Employer Identification Number (FEIN) *

Agency Contact (Your Name) *

Job Title *

Address

Street Address *

City *

State *

Postal code *

Caregiver Respite Grant Program Applicant / Family Caregiver's Name *

Care receiver/client's name *

Dates of Respite *

How many hours of respite care were provided? *

Hourly or Daily Rate *

Total Amount *

Before RCAW can send awarded grant funds to Agencies, Facilities, and Organizations, you must send a copy of the W9 to [email protected]. *

I Understand

Fraud Discalimer: RCAW funds the majority of its programs with state and federal funds. We are responsible for ensuring funds are used for their intended purpose and in a manner to conduct the goals and objectives identified in the grant. RCAW reserves the right to deny a grant application if it suspects or detects fraudulent information contained on a grant application RCAW also reserves the right to report suspected fraud to the appropriate officials, and applicants will be banned from applying for grants in the future. They may be subject to repayment of said grant funds to RCAW. All parties involved in grant fraud can potentially be charged with government grant fraud. Using state and federal grant dollars for unjust enrichment, personal gain, or other than their intended use is a form of theft, subject to criminal prosecution. I have read and understand the Grant Program Detailed Fraud Disclaimer. The link is provided here: https://respitecarewi.org/wp-content/uploads/2023/05/Grant-Program-Detailed-Fraud-Disclaimer.pdf *

Yes, I have read and understand the Grant Program Detailed Fraud Disclaimer.

By electronically signing below, I attest there was provided respite care for the total dollar amount listed above. Furthermore, by signing below, I agree to hold harmless and indemnify RCAW and its representatives for any damages or liabilities it incurs from this agreement. *

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