HomeMy WebLinkAboutExhibit 15The Children's Trust
Grant Application Forms
Certifications Page
Official Certifications
Has the Agency been sanctioned for non-compliance with any contract, government law or regulation
related to the operational program proposed with this application within the past three years, or has your
agency had any violations under the public entity crimes statute? (click one box)
❑ YES -include copy in Supporting Documents section, in order indicated in Table of Contents
❑ NO
Please describe in a separate attachment any litigation or regulatory action filed against the Agency in
the last three years related to the operational program proposed with this application, including case
name, court name, and current
of Contents. If nlude one has cbeennt(s) filedin acknowledge Supporting
this by checking below ' in
order indicated in the Table
❑ NOT APPLICABLE
I do hereby certify that all facts, figures, and representations made in the application(s) are true and
correct. Furthermore, all applicable statutes, terms, conditions, regulations and procedures for program
'compliance and fiscal control, including but not limited to, those contained in the Bid Solicitation and
Core Contract, will be implemented to ensure proper accountability of contracts. 1 certify that the funds
requested in this application(s) will not supplant funds that would otherwise be used for the purposes sett
forth in this project(s) and are a true estimate of the amount needed to operate the proposed program(s).
The filing of this application(s) has been authorized by the contracting entity and I have been duly
authorized to act as the representative of the agency in connection with this application(s). 1 also agree
jto follow all terms, conditions, and applicable federal and state statutes. Further, I understand that it is
the responsibility of the agency head to obtain from its governing body the authorization for the
ce
of award.
f this application.nsa�hatesuch contract authorization
may bemust
escnded forfailure todays
pro de such
of I further understand
documentation.
This bid process is subject to a ��to°ne of Silence" and the state the best of my knowledge, submissionof interest
this laws
proposal2 51 in
et.seg. F.S.), I further state t
compliance with the state and county conflict of interest laws.
Lastly, I hereby attest that all work contained within this proposal is the unique and original product of
the agency I represent, and has not been plagiarized or duplicated in any way from another agency's
work product.
Print Authorized Official's Name:
Authorized Official's Title:
Date of Signature:
Authorized Official's Signature in BLUE INK: