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HomeMy WebLinkAboutExhibits USA/Mid-America Arts Alliance; 2008-10-07;2018 Baltimore Avenue Kansas City, Missouri 64108 816/421-1388 EXHIBITSUSA AGREEMENT Bookings - 44010 PLEASE READ THOROUGHLY Fiscal Year 2010 arts alliance THIS AGREEMENT, dated September 16, 2008, by and between Mid-America Arts Alliance, through its national division, ExhibitsUSA (hereinafter referred to as "ExhibitsUSA"), and William D. Cannon Art Gallery 1775 Dove Lane Carlsbad, CA 92009-4048 (hereinafter referred to as "Exhibitor"), WHEREAS, ExhibitsUSA wishes to make Teapots: Object to Subject available to selected exhibitors, and WHEREAS Exhibitor wishes to share Teapots: Object to Subject with its community, NOW, THEREFORE, in consideration of the mutual promises in this agreement, the parties above agree as follows: ~^ 1. EXHIBITION, DATES a. Exhibitor agrees to host the exhibition Teapots: Object to Subject (hereinafter referred to as "Exhibition"), coordinated, subsidized, and available from ExhibitsUSA for the period beginning November 10,2009 and ending January 28, 2010 and to accept and display the Exhibition under the condition stated herein. b. The Exhibitor shall not alter the incoming shipping date, opening display date, ending display date or outgoing shipping date without written permission from ExhibitsUSA. 2. PROGRAM COST, EXHIBITION FEE, MANNER OF PAYMENT a. Exhibitor shall pay an Exhibition Fee of $6,150.00 U.S. dollars. b. The full Program Cost to ExhibitsUSA of the Exhibitor's display of the Exhibition is $9,460.00 c. The portion of this fee not paid by the exhibitor is $3,310.00. The portion of this fee not paid by the exhibitor is supported by grants to ExhibitsUSA from: The National Endowment for the Arts and other public and private contributions to ExhibitsUSA and Mid-America Arts Alliance. ExhibitsUSA's requirements for reporting to these funders are outlined in paragraph 4. Requirements for crediting these funders are outlined in paragraph 5. d. A 25% deposit of $1,537.50 must be received with this signed Agreement. The balance of the Exhibition Fee is due in full on November 10, 2009. Checks should be made payable to ExhibitsUSA. Two invoices are attached to the ExhibitsUSA Agreement for your convenience. e. If ExhibitsUSA is not able to provide the Exhibition as described in this Agreement, the deposit will be returned in full to Exhibitor. 2018 Baltimore • Kansas City, Missouri 64108 • (816)421-1388 • FAX (816) 421-3918 • www.maaa.org IN PARTNERSHIP WITH: ARKANSAS ARTS COUNCIL, KANSAS ARTS COMMISSION, MISSOURI ARTS COUNCIL, NEBRASKA ARTS COUNCIL, OKLAHOMA ARTS COUNCIL, TEXAS COMMISSION ON THE ARTS, AND THE NATIONAL ENDOWMENT FOR THE ARTS M-AAA,'.'• '.''.), „•"• >;"".-f,. Regional Touring-,' '* : • "''-'• •' * • Program EXHmiTSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGE 2 f . If Exhibitor cannot fulfill the terms of the Agreement, the deposit will be forfeited and retained by ExhibitsUSA. Exhibitor may also be subject to cancellation provisions as provided in paragraph (10) of this Agreement. 3. SHIPPING a. Incoming Shipping of Exhibition 1. Exhibitor will receive the Exhibition via van line from the previous exhibition site. Exhibitor will be responsible for providing personnel to assist with the unloading of the Exhibition. Exhibitor will not be responsible for incoming shipping costs and should contact ExhibitsUSA before accepting collect shipments. 2. ExhibitsUSA will make a good faith effort to facilitate the arrival of the Exhibition no later than 4 business days in advance of November 10, 2009 . ExhibitsUSA shall not be held responsible for delays outside of its control. 3. If the Exhibition has not been received within four days prior to November 10, 2009, Exhibitor must contact ExhibitsUSA IMMEDIATELY. 4. In order to ensure that the Exhibition will be delivered to the proper location, Exhibitor must indicate below the shipping address to be used for transport. If this information is not provided, the Exhibition cannot be shipped. INCOMING SHIPPING INFORMATION: (OIUL/fiM D. &3A/MOM ffer Name of Exhibitor Contact Person Telephone Number Address Address City State Zip LOADING DOCK? YES^Noitcircle one) IF YES, LOCATION: EXHIBITSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGES b. Outgoing Shipping of Exhibition Van Line - Fixed Rate 1. . Exhibitor will coordinate with ExhibitsUSA registrar and representative of the designated van line carrier to transport the exhibit to the next exhibit site. Exhibitor is responsible for payment of its pro-rated share of outgoing transportation charges. The amount of the pro-rated transportation charges will be determined upon completion of the booking of the exhibition tour and will be communicated to the Exhibitor in writing at the earliest possible date. Payment is due to ExhibitsUS A upon the opening of the exhibit. 2. Fixed-rate shipping includes the cost of inside delivery and pick up within 50 feet of the delivery truck to and from one location. Exhibitor will be liable for any additional charges incurred as a result of special services such as multiple delivery sites or pick up locations, uncrating by shipping company, packing by shipping company, et cetera. 3. ExhibitsUS A will specify the institution and address to which the exhibit is to be shipped, as well as the date by which the exhibit must arrive at the next exhibit site. 4. Exhibitor will retain bill of lading receipts for a period of three weeks from the date of shipment. 5. Exhibitor will be liable for any costs resulting from exhibitor's delay or failure to transport the exhibit in accordance with the provisions of this attachment. c. Exhibitor will be responsible for reasonable supervision and care of the Exhibition, crates, packing material and everything contained therein, from its incoming shipping until its outgoing shipping according to the timeline. 4. PROJECT EVALUATION REPORT By accepting the Exhibitions and grant specified in paragraph 2(c) EXHIBITOR IS OBLIGATED TO THE SATISFACTORY COMPLETION AND SUBMISSION OF THE EXHIBITSUSA EVALUATION REPORT. Exhibitor should be collecting information for this report as the program develops. ExhibitsUS A is required to provide evaluation reports to the funders in paragraph 2(c). Submission of any final report to a state arts agency does not satisfy this requirement. The Final Evaluation is due to ExhibitsUSA NOT LATER THAN February 27, 2010. 5. CREDIT REQUIREMENTS The program you are presenting is being made available to your community by ExhibitsUSA, which is supported by public agencies and private contributors. Our ability to raise funds for such programs is directly related to the credit acknowledgments you provide. You are required to give proper credit to ExhibitsUSA and its funding sources in all promotional and educational materials. This section provides you with the detailed credit language and how it is required to be used. In the event ExhibitsUSA secures a sponsor for a particular program that affects your Exhibition, you may receive amended credit requirements, a. CREDIT PANELS: When provided by ExhibitsUSA, all framed credit panels must be prominently displayed at or near the entrance to the Exhibition at all times. EXHIBITSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGE 4 b. For ADVERTISEMENTS, ANNOUNCEMENTS, WEBSITES, BROCHURES, INVITATIONS TO OPENINGS and other printed materials and electronic materials the following is required: A Program of ExhibitsUSA, a national division of Mid-America Arts Alliance and The National Endowment for the Arts -OR- A Program of (ExhibitsUSA logo) and The National Endowment for the Arts Type size should be consistent with the majority of the type in your materials and never smaller than eight (8) point type. c. For NEWS RELEASES: ExhibitsUSA will provide credit language for news releases in the publicity kit that will arrive in advance of the Exhibition. Exhibitor's failure to meet the above credit requirements will jeopardize its participation in future ExhibitsUSA programs. 6. INSURANCE, CONDITION REPORTS, DAMAGES a. ExhibitsUSA will provide insurance coverage at its own cost for the complete contents of the Exhibition during transit, unpacking, installation, display, storage, dismantling, and repacking. Upon request, ExhibitsUSA will provide Exhibitor a bona fide certificate of insurance coverage, the contents of which shall remain confidential with Exhibitor and shall not be made public. b. Exhibitor will prepare and file a Condition Report with ExhibitsUSA at both the beginning and conclusion of the Exhibition on forms provided by ExhibitsUSA. The Condition Report book will arrive in the crates with the Exhibition. c. Exhibitor will also complete a checklist receipt, which will arrive in advance of the Exhibition, confirming safe arrival of all objects, and will return it to ExhibitsUSA within five (5) business days of the Exhibition arrival. d. Exhibitor will report any and all damages or losses to the Exhibition while in Exhibitor's custody immediately by telephone to ExhibitsUSA. Within 24 hours of discovery of damage or loss, Exhibitor will send a full written statement with photographs to ExhibitsUSA detailing the extent, time, place and circumstances of the damage or loss. All damaged materials must be left as discovered unless the Exhibitor is instructed by ExhibitsUSA to proceed otherwise or unless emergency measures are necessary to prevent further damage. 7. SECURITY REQUIREMENTS The Exhibition referenced in the Agreement requires security precautions for its proper care, protection and maintenance. Exhibitor will provide the following minimum security requirements: Moderate A EXHE3ITSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGES (furniture and installation technique emphasis) For exhibitions which do not require distinct environmental control, but which have multiple display modes (floor, wall, pedestal, ceiling), and require display furniture and trained installation staff. These exhibitions are inherently vulnerable, due to artistic media. a. No food or drink in gallery or around artworks at any time b. Fire protection according to local ordinance c. Minimum 3 trained staff for incoming shipping, installation, de-installation, and outgoing shipping d. Limited-access gallery e. Exhibition locked after hours; alarms or night guards may also be required f. Total temperature control (gallery temperature maintained at constant 68-72°) g. No relative humidity extremes (+/-10% fluctuation in a 24-hour period) h. No sunlight; light sources (including windows with shades/blinds) must have ultraviolet filters i. Exhibitor must have or be able to produce display furniture including: Locked cases for small objects Vitrines on pedestals Objects on the floor or on very large pedestals must have ropes or other barriers to keep public at least 40 inches from the objects at all times j. Staff trained specifically for secure supervision of the exhibition must remain in the display area at all times while open to the public 8. RESPONSIBILITY, LIABILITY a. Exhibitor is responsible for damages and costs of repairs to the Exhibition, crates, packing material and everything contained therein when such damages are the result of: 1. Exhibitor noncompliance of stipulated security precautions as outlined in section 7; or 2. The negligence of personnel selected by Exhibitor to assist in handling the Exhibition; or 3. Exhibitor's negligence in any respect to provide for and insure the safety and protection of the Exhibition. 4. Exhibitor does not adhere to damage reporting and other procedures identified in paragraph 6 hereof. b. Exhibitor shall bear the full and complete burden of any and all liability to persons or property, other than the Exhibition and its crates, arising out of or incurred in connection with the program and shall absolve and hold harmless ExhibitsUSA from any and all such liability. 9. PHOTOGRAPHS Photographs of the work contained in the Exhibition, or its unpacking, installation, dismantling, or EXHIBITSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGE 6 repacking are prohibited unless specifically and solely for Exhibitor's reasonable publicity and promotional purposes for this showing of the Exhibition or for ExhibitsUS A. 10. CANCELLATION Exhibitor may cancel its intention to display the Exhibition only upon written notice from Exhibitor, received and acknowledged by ExhibitsUSA, which shall be accompanied by a cancellation fee payable to Mid-America Arts Alliance in the amount of the full Exhibition Fee plus any costs for storing the Exhibition during the cancelled display period. Any deposit received by ExhibitsUSA shall be credited toward the cancellation fee. If, in the event of Exhibitor's cancellation, ExhibitsUSA is able to book the Exhibition with another exhibitor at the full fee, one-half of the Exhibition Fee will be returned to Exhibitor. 11. NON-PROFIT STATUS Exhibitor affirms that it is legally incorporated with not-for-profit status as designated by the Internal Revenue Service, or is a unit of state, local or tribal government. Exhibitor agrees to notify ExhibitsUSA immediately of any alteration of this status which may occur prior to the conclusion of the Exhibition. 12. ASSURANCE OF COMPLIANCE All ExhibitsUSA programs are made possible by support to Mid-America Arts Alliance from state and federal sources. As a result, exhibitors are required to comply with state and federal regulations as follows: a. Exhibitor agrees to comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), and where applicable, Title IX of the Education Amendments Act of 1972 (20 U.S.C. 1681 et seq). Title VI, Section 504, and the Age Discrimination Act prohibit discrimination on the basis of race, color, national origin, handicap or age in any program or activity receiving ExhibitsUSA assistance. Title IX prohibits discrimination on the basis of sex in any education program receiving ExhibitsUSA assistance. b. Exhibitor's financial records and supporting documents (pertaining directly to the Exhibition) and all other records related to this ExhibitsUSA program shall be retained for a period of three years from the date of the Final Evaluation Report, or until a federal audit has been completed and any questions arising from it have been resolved, whichever is the lesser period. Exhibitor shall grant to ExhibitsUSA access to any pertinent books, documents, or other records kept by the Exhibitor to make audits or examinations as necessary. c. Exhibitor agrees to have its financial records examined by an independent auditor not less frequently than once every two years, consistent with requirements stated in federal Office of Management and Budget (OMB) Circular A-102, Attachment P, or Circular A-133, as applicable. d. Exhibitor shall not use federal or state funds provided by ExhibitsUSA or Mid-America Arts Alliance (if any) for purposes of lobbying to affect legislation of federal or state governments pursuant to United States Code, Section 1913. EXHffilTSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGE? e. Exhibitor's Final Evaluation Report shall be prepared in compliance with cost principles as established in OMB Circular A-122 ("Cost Principles for Non-profit Organizations", Circular A- 21 ("Cost Principles for Educational Institutions") or Circular A-87 ("Cost Principles for State and Local Governments"), as applicable. f. Exhibitor shall comply with the Drug-Free Workplace Act of 1988. g. Exhibitor certifies that its organization and principals are not suspended or debarred by any federal agency. h. Exhibitor shall comply with 29 CFR Part 505 of the Department of Labor, which provides that (1) all professional performers and related or supporting professional personnel employed on projects or productions which are financed in whole or in part with ExhibitsUSA funds will be paid not less than the minimum compensation for persons employed in similar activities, and (2) no part of any project or production which is financed in whole or in part with ExhibitsUSA funds will be performed or engaged in under working conditions which are unsanitary or hazardous or dangerous to the health and safety of the employees engaged in such project or production. i. Exhibitor certifies that its organization has on file a Section 504 Self-Evaluation. If Exhibitor has not previously conducted this self-evaluation or wishes to update the results of previously conducted evaluations, it may contact the NEA's Office of Civil Rights, free of charge, for a copy of a Program Evaluation Workbook. Copies of the above referenced federal guidelines can be obtained from the Office of Management and Budget or local libraries. 13. FUNDING DEFAULT, 'FORCE MAJEURE' a. In the event that any or all of the grants (as referenced in paragraph 2(a) above) or Exhibition fees to support the full cost of the Exhibition are not forthcoming to ExhibitsUSA, neither ExhibitsUSA nor Mid-America Arts Alliance nor Exhibitor shall be held liable and Mid-America Arts Alliance may amend or terminate this Agreement. b. Neither party will be held liable for any delay, adjournment or failure to perform the services and or comply with the understandings provided in this Agreement, in the event of war; riot; rebellion; electricity blackout; fire; flood; strike; lockout; labor difficulty; trade union action of any kind; action of the elements; accident; delay in transportation; laws, rules or regulations of any government authority having jurisdiction; or any other matter, events or conditions beyond the reasonable control of either of the parties, provided that the above list is not limitative and that it will not be necessary to establish whether any of these events or conditions affected only the parties to the present contract or whether they also affected third parties. The above events or conditions are hereafter referred to as Events of Force Majeure. This contract can be revoked totally or partially only if reasons of Force Majeure are present. c. If part or all of the Exhibition tour is canceled as a result of an Event of Force Majeure, then both parties will agree to hold the other completely harmless. 14. GOVERNING LAW EXHIBITSUSA AGREEMENT: Teapots: Object to Subject BOOKING 44010 PAGES The construction and interpretation of this Agreement shall at all times and in all respects be governed by the laws of the State of Missouri. 15. BINDING EFFECT This Agreement sets forth the full and complete understanding between ExhibitsUSA and Exhibitor and shall be binding upon ExhibitsUSA and Exhibitor, as well as their respective successors and assigns. Any questions or clarifications required by Exhibitor regarding this Agreement must be directed to ExhibitsUSA prior to the execution of this document by Exhibitor. This Agreement may be altered only in writing, signed by both parties, except as provided herein. IN WITNESS WHEREOF, the parties hereto have executed this Agreement September 16, 2008. EXHIBITSUSA, a national division Will&m D. ] of Mid-America Arts Alliance (M-AAA) Bv Name: Dee A. Harris Title: Director; Visual Arts and Humanities Date September 16, 2008 B Date By. Print Name Title OP E.Xfl/B/T/OM3 Date The following information is required for reporting to federal and state agencies. Please confirm accuracy. U.S. Congressional District No: 50 State House District No: County Name: San Diego State Senate District No: ExhibitsUSA Final Evaluation Form Checklist/Instructions Please feel free to record all or any part of your responses on separate sheets if that is more convenient for you. Please do not feel compelled to conduct elaborate research to complete the form. Your brief descriptions, observations, and recollections are what we need. > "Exhibition Attendance Only" • This entry refers only to the exhibition itself. • If you do not keep visitor counts, or do not distinguish children (age 18 and under) from adults in attendance, please enter estimates. In that event, it would be best if you indicate that the numbers are estimates. > "Other Activities" • This is an especially important part of the report, but one that historically has been particularly prone to confusion. • Please fill in by type description each activity you held in conjunction with the exhibition. If possible, we would like to have adult and child attendance figures here too, separate from those for the exhibition itself. Again, if you do not have attendance records, estimates will be fine. • If you have a number of groups participate in a given activity, please give us that number as well. • If you repeat an activity several times (e.g. a workshop), please count each repetition as a separate activity. • For "total number of other activities," please simply enter that total. This is not an attendance figure, but a count of the activities themselves. > "Number of artists or humanities scholars ... other activities" • Here we ask you to note the number of artists or humanities scholars who were involved in your local supplementation of the exhibition, and in any other way associated with the show, such as in ancillary activities. • The number you indicate here should not include any artists on our exhibition checklist. > "Project Description" questions • Please use this section to note anything you would like us to know about your organization's experience with this exhibition. > Newspaper advertisements, articles, reviews, other public relations materials, etc. • Here, we would like to see anything you care to include that your organization produced, or that appeared in the mass media related to your hosting of the exhibition. • If possible, please include 2 copies of any invitation cards, pamphlets, or other publicity material that you produced in numbers. <» If you have any photographs of people viewing the exhibition, please favor us with copies. These are extremely helpful to us in more than one way. Financial Information Section Expenses: Record here a total of actual expenses incurred for the exhibit. Include a pro-rated share of staff time and administrative costs, as appropriate. Please also figure in the exhibit fee paid to Mid- America Arts Alliance. Cash Allocation and Income: Record all actual allocated funds and income received or due to be received for the exhibit. This number should include grants; funds from sponors; operating budget allocations; etc. Gift shop sales, program participation fees, and similar income related to the exhibit should then be added into the allocated funds. The total for this section should be equal to or greater than your total cash expenses. In-Kind: In-Kind Contributions. This line is for the value of items or services identified with the project which are provided to your organization by outside parties at no cost to your organization. Volunteer services can be shown in one of three ways: Donated professional services (e.g. a lawyer donating legal advice) should be valued at his or her professional rate. Services that are similar to those performed by a paid staff member(s) from your organization should be valued at the same rate as the paid staff. All other services should be valued at the current federal minimum wage (even though we know they're worth more!) *> Please sign and date the report. <» Return original to: Raina Heinrich, Exhibitor Relations Assistant ExhibitsUSA 2018 Baltimore Ave. Kansas City, MO 64108 «J* Make one copy for your records. * FOR ORGANIZATIONS IN MID-AMERICA ARTS ALLIANCE MEMBER STATES (AR, KS, MO, ME, OK, XX) Make one copy and send it to your state arts agency. Randy Smith Elain Fisher Arkansas Arts Council Nebraska Arts Council 1500 Tower Building 1004 Farnam St. 323 Center Street Plaza Level Little Rock, AR 72201 Omaha, NE 68102 Chris Howell Suzanne Tate Kansas Arts Commission Oklahoma Arts Council 700 SW Jackson, Suite 1004 PO Box 52001-2001 Topeka, KS 66603-3761 Oklahoma City, OK 73152 Michael Donovan Cassandra Scholte Jensen Missouri Arts Council Texas Commission on the Arts 815 Olive St., Ste. 16 PO Box 13406 St. Louis, MO 63101 Austin, TX 78711 Final Evaluation Report Booking Number:. Institution: Address: City:_ DUNS Number:. Contact Person: Telephone: Project Title: Project Date: State:_Zipi IXflHMRusa 2018 Baltimore Avenue Kansas City, MO 64108 phone 800.473.EUSA(3872) 816.421.1388 Fax 816.421.3918 Program/Exhibition Information Exhibition Attendance only OTHER Activities and Number of Time Offered Total OTHER Activity Attendance Attendance Attendance Adults Children Attendance Attendance Adults Children Total Number of OTHER Activities: Number of ARTISTS who are NOT REPRESENTED IN THE EXHIBITION participating in OTHER Activities PROJECT DESCRIPTION: (On a separate page, please answer the following questions) 1. What were the strengths of the exhibition? Please explain. 2. What were the weaknesses of the exhibition? Please explain. 3. How did the support materials (labels, text panels, books, videotapes, programming guide, etc.) meet your needs and your visitors' needs? 4. Would you repeat this type of exhibition in the future? If not, why not? Please explain. 5. Please relate to us any stories, insights or observations about your exhibition hosting and its significance for your institution or community. 6. If you provided public programming with your exhibition hosting, how did you develop your programming? Did you use the ExhibitsUSA support materials to plan your programming? Did your public programming bring in new audiences to your institution? 7. How did attendance for this traveling exhibit compare with your usual traveling exhibit attendance? (i.e. Same attendance; lower attendance; higher attendance; etc.) 8. In what ways could we improve our service to you? BE SURE TO INCLUDE any photographs or slides you have taken of the exhibition installation or people viewing the exhibition; INCLUDE copies of newspaper advertisements or articles, press releases, exhibition reviews, educational materials produced for the exhibition, etc... Exhibitor's Personnel involved in project: Number full-time: Number part-time: ______ Number volunteers: ______ EXHIBITION FINANCIAL SUMMARY: ACTUAL TOTAL CASH EXPENSES FOR EXHIBIT (including fees, shipping, security, facilities, etc.) Fees Shipping Security Educational Programming Reception Lecture/Speaker's fees Other: Total: ACTUAL TOTAL EXHIBITOR CASH ALLOCATION AND INCOME FOR EXHIBIT (including grants, operating budget funds, sponsorships, gift shop sales, etc.) Operating Budget Funds (for traveling exhibit rental fees, shipping, security, etc.) Grants Donations Gift Shop Sales Educational Programming Fees Other: Total: ACTUAL TOTAL IN-KIND CONTRIBUTIONS FOR EXHIBIT (include the total amount of all non-cash services contributed in the implementation of the exhibition, such as volunteer hours, donations for receptions, etc.) YOUR Organization: AN IN-DEPTH VIEW 1. What is your institution's annual operating budget? 2. How many PAID full time and part time staff does your organization have at this time? How many UNPAID full time and part time staff does your organization currently have? How many volunteers? Paid full time Unpaid full time Volunteers 3. What is your organization's mission? How do traveling exhibits support your mission? 4. Has your organization rented traveling exhibitions before? If so, how often? How has this exhibition compared with exhibits you have had in the past, either from ExhibitsUSA or another traveling exhibition service? 5. According to our records the predominant racial characteristics of you and your organization is "" (check the list below). If incorrect, please circle the correct information. A [Asian/Pacific Islander] B [Black, not Hispanic] H [Hispanic] W [White, not Hispanic] N [American Indian/Alaskan Native G [General (1/2 staff, board, or membership not one race)] The following information is required for reporting to the National Endowment for the Arts. State House State Senate U.S. Congressional District No.: District No.: District No.: County Name:_ Submitted by Authorizing Official: Signature Name (type or print) Title Date M-AAA USE ONLY PublishedFee TotalFee Grant