Certifications and Signature. Certifications: Modifications to any certifications are not valid or binding, unless otherwise agreed by ADB. By (Name of Borrower or Recipient): Fill in the name as it appears in the Grant Agreement. Date Signed: Enter the date WA is signed by authorized representative(s), not the date it was prepared. Authorized Representative(s): Pass this application to authorized representative(s), who is (are) designated in the Evidence of Authority to Sign Withdrawal Applications form submitted to ADB. Verify that the list of authorized representative(s) has not been changed. Type of Disbursement (Indicate an 'X' in the appropriate box): (select one box) Liquidation of Advance STATEMENT OF EXPENDITURES (SOE) SHEET FOR APDRF GRANT ADB Grant No. Application No. Sheet No. For the period: to Type of Form (Indicate an 'X' in the appropriate box [select one box]): SOE Sheet Oct 2017 - Item No. Contract/PO Record No. for EA's Description of Goods & Services Name & Address of Supplier Date of Payment (Due) Total Amount of xxxx paid/payable ADB's Disbursement Percentage ADB's Share of Expendituresa For Advance Fund Only Remarks Exchange Rate b Amount for Liquidation b Attachment 2 to Schedule 2 * EA = Executing Agency, PO = Purchase Order TOTAL TOTAL Notes:
Certifications and Signature. THIS CONTRACT MUST BE SIGNED IN INK BY AN AUTHORIZED REPRESENTATIVE OF Contractor. The undersigned certifies under penalty of perjury both individually and on behalf of Contractor is a duly authorized representative of Contractor, has been authorized by Contractor to make all representations, attestations, and certifications contained in this Contract and to execute this Contract on behalf of Contractor. XXXXXX COUNTY SIGNATURE BOARD OF COMMISSIONERS: Chair Date Commissioner Date Commissioner Date Authorized Signature: Department Director or designee Date Authorized Signature: Chief Administrative Officer Date Reviewed by Signature: Xxxxxx County Legal Counsel Date Reviewed by Signature: Xxxxxx County Contracts & Procurement Date [CONTRACTOR] SIGNATURE Authorized Signature: Date Title: EXHIBIT A STATEMENT OF WORK 1. STATEMENT OF SERVICES. Contractor shall perform Services as described below.
Certifications and Signature. I, the person identified in Part 1, or if applicable the authorised representative of the person identified in Part 1, understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder’s relationship with Pershing setting out how Pershing may use and share the information supplied to Pershing. [I/the Account Holder’s representative]* acknowledge(s) that the information contained in this form and information regarding [my/the Account Holder’s]* account(s) may be reported to the tax authorities of the country in which this account(s) is/are maintained and exchanged with the tax authorities of another country or countries in which the Account Holder may be tax resident where those countries have entered into Agreements to exchange financial account information. [I/the Account Holder’s representative] undertake(s) to notify the recipient of any change in circumstances that causes any certification on this form to become incorrect and to provide a suitably updated form within 30 days of such change.
Certifications and Signature. THIS CONTRACT MUST BE SIGNED IN INK BY AN AUTHORIZED REPRESENTATIVE OF Contractor. The undersigned certifies under penalty of perjury both individually and on behalf of Contractor is a duly authorized representative of Contractor, has been authorized by Contractor to make all representations, attestations, and certifications contained in this Contract and to execute this Contract on behalf of Contractor. XXXXXX COUNTY SIGNATURE BOARD OF COMMISSIONERS: Chair Date Commissioner Date Commissioner Date Authorized Signature: 6.10.2021 Department Director or designee Date Authorized Signature: Chief Administrative Officer Date Reviewed by Signature: Xxxxxx County Legal Counsel Date Reviewed by Signature: Xxxxxx County Contracts & Procurement Date CENTER FOR HOPE AND SAFETY SIGNATURE Authorized Signature: Date Title: EXHIBIT A STATEMENT OF WORK
Certifications and Signature. Please refer to the Standard Certifications and Covenants for EXIM Applications posted on EXIM’s website as document EIB 18-CN. THE STANDARD CERTIFICATIONS AND COVENANTS FOR EXIM APPLICATIONS ARE INCORPORATED INTO THIS BENEFICIARY CERTIFICATE AND AGREEMENT AS IF FULLY SET FORTH HEREIN. When signing this Beneficiary Certificate and Agreement in the space provided below, the undersigned authorized officer signing on our behalf certifies and represents that he or she is fully authorized to sign on our behalf, and that HE OR SHE HAS READ the Standard Certifications and Covenants for EXIM Applications AND IS CERTIFYING AND COVENANTING, as appropriate, to all of the certifications, acknowledgments and covenants set forth in that document. (Signature of Authorized Officer of Beneficiary) Name: Title: Tel. #: Email: NOTICES
Certifications and Signature. Submissions by Prospective TAs shall include the following signed statement with their respective responses: The undersigned, as an authorized official of the Prospective TA, does hereby certify under penalty of perjury that: • The information contained within this Proposal, and all documents submitted with this Proposal, are true, accurate and complete; • The Prospective TA is a not-for-profit entity, tax-exempt under 501(c)(3) of the Internal Revenue Code, with an active New York State Charities registration number, or an approved exemption, and in good standing; • The Prospective TA is in compliance with all local, state and federal law; and • The Prospective TA understands that false statements made herein are punishable as a Class A Misdemeanor pursuant to NY Penal Law Section 210.45. Signature of Authorized Certifying Name/Title Official Date Sworn to before me this day of , 20 ; Notary Public APPENDIX 1 CHAMPLAIN XXXXXX POWER EXPRESS, INC. PROPOSED CERTIFICATE CONDITIONS Certificate Condition 165 165. The Certificate Holders shall establish the Xxxxxx River and Lake Champlain Habitat Enhancement, Restoration, and Research/Habitat Improvement Project Trust (“the Trust”) solely for the purposes of protecting, restoring, and improving aquatic habitats and fisheries resources in the Xxxxxx River Estuary, the Harlem and East Rivers, Lake Champlain, and their tributaries, in order to minimize, mitigate, study, and/or compensate for the short-term adverse aquatic impacts and potential long-term aquatic impacts and risks to these water bodies from Facility construction and operation and for the administration of the Trust to the extent expressly authorized in these Certificate Condition.
Certifications and Signature. THIS CONTRACT MUST BE SIGNED IN INK BY AN AUTHORIZED REPRESENTATIVE OF Contractor. The undersigned certifies under penalty of perjury both individually and on behalf of Contractor is a duly authorized representative of Contractor, has been authorized by Contractor to make all representations, attestations, and certifications contained in this Contract and to execute this Contract on behalf of Contractor. XXXXXX COUNTY SIGNATURE BOARD OF COMMISSIONERS: Chair Date Commissioner Date Commissioner Date Authorized Signature: 6.10.2021 Department Director or designee Date Authorized Signature: Chief Administrative Officer Date Reviewed by Signature: Xxxxxx County Legal Counsel Date Reviewed by Signature: Xxxxxx County Contracts & Procurement Date MID-WILLAMETTE VALLEY COMMUNITY ACTION AGENCY SIGNATURE Authorized Signature: Date Title: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT BUSINESS ASSOCIATE CONTRACT PROVISIONS INTRODUCTION This Addendum to the contract between County, a political subdivision of the State of Oregon, hereinafter called the County, and Mid-Willamette Valley Community Action Agency hereinafter called Contractor is required by the Health Insurance Portability and Accountability Act of 1996, (HIPAA), as amended.
Certifications and Signature. THIS CONTRACT MUST BE SIGNED IN INK BY AN AUTHORIZED REPRESENTATIVE OF Contractor. The undersigned certifies under penalty of perjury both individually and on behalf of Contractor is a duly authorized representative of Contractor, has been authorized by Contractor to make all representations, attestations, and certifications contained in this Contract and to execute this Contract on behalf of Contractor. XXXXXX COUNTY SIGNATURE BOARD OF COMMISSIONERS: Chair Date Commissioner Date Commissioner Date Authorized Signature: 6.8.2021 Department Director or designee Date Authorized Signature: Chief Administrative Officer Date Reviewed by Signature: Xxxxxx County Legal Counsel Date Reviewed by Signature: Xxxxxx County Contracts & Procurement Date BRIDGEWAY RECOVERY SERVICES SIGNATURE Authorized Signature: Date Title: community safety, reduce criminal activity, and to assist those with alcohol/drug problems to enter and maintain an alcohol and drug free lifestyle. Contractor shall: • In collaboration with the Community Corrections Division of the Sheriff’s Office, ensure a minimum of 200-300 hours of cognitive based services towards the target population. All services will be directed at enhancing corrections client motivation, addressing addiction and criminogenic risk factors, and providing the behavioral skills to lead a clean and sober lifestyle • Provide a continuum of services which assesses and addresses corrections client motivation, criminogenic risks, and addiction needs • Address criminogenic needs including responsivity factors through all phases of treatment. • Provide Urinalysis testing for compliance with abstinence goals • Provide up to two (2) FTE Certified Alcohol & Drug Counselor and up to a half (0.5) FTE Alcohol & Drug Mentor for the target population • Utilize evidence based practices as outlined by the Correctional Program Checklist (CPC) • Contractor shall cooperate with the Correctional Program Checklist (CPC) and show continued improvement in program, specifically working toward/maintaining high adherence in the treatment characteristics domain • Include relapse prevention services and aftercare services • It is understood that Contractor will determine treatment level, duration, and intensity based on generally accepted practices and assessment information obtained during intake • Ensure all clients have been referred to or are enrolled in Oregon Health Plan • Xxxx for service not reimbursed under Oregon Health Plan • Demonstrate an under...
Certifications and Signature. THIS PRICE AGREEMENT MUST BE SIGNED IN INK BY AN AUTHORIZED REPRESENTATIVE OF Contractor. The undersigned certifies under penalty of perjury both individually and on behalf of Contractor is a duly authorized representative of Contractor, has been authorized by Contractor to make all representations, attestations, and certifications contained in this Price Agreement and to execute this Price Agreement on behalf of Contractor. MARION COUNTY SIGNATURES BOARD OF COMMISSIONERS: Chair Date Commissioner Date Date 6/2/2023 Commissioner Authorized Signature: Department Director or designee Date Authorized Signature: Chief Administrative Officer Date Marion County Legal Counsel 6/2/2023 Date 6/1/2023 Reviewed by Signature: Reviewed by Signature: Marion County Contracts & Procurement Date XXXXXX HOLDINGS INC. DBA XXXXXX ASPHALT SIGNATURE: Authorized Signature: Title: Date: Exhibits Exhibit 1: Cost Proposal Submission Form Exhibit 2: Request for Proposals #PW1299-23: Section 5. Scope of Work, Subsections 1.0 Delivery Location, Schedule, Price Agreement/Pricing, and Applicable Specifications through 4.0 Prevailing Wage Rates. Exhibit 1 Cost Proposal Submission Form DocuSign Envelope ID: 4E987556-2CB5-49BB-AF7A-2D9DD20E9A09 DocuSign Envelope ID: 4E987556-2CB5-49BB-AF7A-2D9DD20E9A09 Freight & Transportation Prices: Freight Table EXHIBIT 2 Request for Proposals #PW1299-23 Section 5. Scope of Work: 1.0 Delivery Location, Schedule, Price Agreement/Pricing, and Applicable Specifications through Section 4. - Prevailing Wage Rates.
