(Name) County Long-Term Recovery Committee (LTRC)
(Name) County Long-Term Recovery Committee (LTRC)(Date)List all representatives currently serving on your County LTRC and attach this form to the LTRC Request for Funding. Please print or type name, address, phone number and e-mail address:Agency/ OrganizationNameElectedOfficial:Yesor NoAddressPhone NumberE-Mail AddressDepartment of Human ResourcesCitizen Corps CouncilCounty Emergency Management AgencyDepartment of Public HealthCounty Cooperative ExtensionNonProfit/Community Organization with 501 (c) 3 Tax StatusSalvation ArmyRed CrossChamber of CommerceFaith-Based OrganizationBanking/FinancialMental Health ExpertFiscal AgentPlease list all others on a separate sheet of paper. ................
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