Host Agency Agreement Form - Department Of Labor - Senior Community Service Employment Program (Scsep) Page 2

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This Agreement may be amended by written mutual agreement.
This Agreement is in effect from _______________to ________________.
________________________________________________________________________
Signed-Host Agency
Host Agency: ____________________________________________________________
Name and Signature: ______________________________________________________
Title: ___________________________________________________________________
Date: ___________________________________________________________________
Signed Sponsor Project
Project Sponsor :
Department of Labor
Senior Community Service Employment Program
Name and Signature:
Dorothy Gutierrez________________________________
Title:
SCSEP Administrator
Date:
________________________________________________
Definition of Host Agency Status:
XXX ___
This host agency is a government agency.
__________
This host agency is a certified non-profit agency under Section 501(c )(3) of
the U.S. Internal Revenue Code.
_______ 501(c )(3) documentation is attached.
_______ 501(c )(3) documentation is on file with the sponsor.

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