Authorized Agent Signature. By signing this Agreement, the undersigned represents and warrants that he or she has received and read a copy of this Agreement, inclusive of attachments and exhibits, and that he or she is either (a) the Participant or, (b) if the Participant is an organization, an individual acting on the Participant’s behalf who is authorized to sign and enter into this Agreement.
Authorized Agent Signature. Please have an authorized agent sign the report certification in the space provided. This must be completed in order for the report to be accepted by OHA. OREGON HEALTH AUTHORITY Public Health Division Agreement Expenditure Report Agency: Agreement #: Budget Period: to Reporting Period: to - % of Budget Period Elapsed If Applicable to Agreement: - - $ $ To-Date In-Kind To-Date Match Expenditures Expenditures Budget Report Period Expenditures To-Date Total Expenditures % Spent To-Date Salaries & Wages $ - $ - $ - - Position # 1 (list title) $ Position # 2 (list title) $ Position # 3 (list title) $ Position # 4 (list title) $ Position # 5 (list title) $ - $ - $ - - - $ - $ - - - $ - $ - - - $ - $ - - - $ - $ - - - - - $ - $ $ Fringe Benefits $ - $ - - - - $ - $ $ Travel $ - $ - In State Travel $ Out of State Travel $ - $ - $ - - - $ - $ - - - - - $ - $ $ Equipment $ - $ - - - - $ - $ $ Supplies $ - $ - - - - $ - $ $ Sub Agreements* $ - $ - *A 'Sub Agreement Detail Report' must be completed and attached if budget includes sub agreements - - - $ - $ $ Other $ - $ - Other # 1 (please list) $ Other # 2 (please list) $ Other # 3 (please list) $ Other # 4 (please list) $ - $ - $ - - - $ - $ - - - $ - $ - - - $ - $ - - - - - $ - $ $ Total Direct Charges $ - $ - - - - $ - $ $ Indirect $ - $ - Indirect Rate - - - - - - $ - $ $ Totals $ - $ - I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the federal award. I am aware that any false, fictitious or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (2 CFR 200.415) Authorized Agent Signature Date Report Prepared By Phone OREGON HEALTH AUTHORITY Public Health Division Sub Agreement Detail Report (Attachment to Public Health Division Agreement Expenditure Report) Agency: Agreement #: Budget Period: to Reporting Period: to Sub Agreement #1 Agency % of Budget Period Elapsed - If Applicable to Agreement: Budget Report Period Expenditures To-Date Total Expenditures % Spent To-Date To-Date In-Kind Expenditures To-Date Match Expenditures Salaries & Wages $ - $ - $ - - $ - $ - Fringe Benefits $ - $ - $ - - $ - $ - Travel $ - $ - $ - - $ - $ - Equipment $ - $ - $ - - $ - $ - Supplies $ - $ - $ - - $ - $ - Sub Agreements $ - $...
