Signature and Acknowledgement. Insured has signed this agreement and received a copy of it. If Insured is a corporation, the person signing is an officer of that corporation authorized to sign this agreement. If the Insured is not a corporation, all Insureds listed in any policy have signed. LIABILITY. Insured understands and agrees that FIRST has no liability to Insured or any person or entity upon the exercise of FIRST's right of cancellation, except in the event of willful or intentional misconduct by FIRST. AGENT OR BROKER REPRESENTATIONS AND WARRANTIES SIGNATURES GENUINE. To the best of our knowledge, the Insured's signature is genuine. AUTHORIZATION/RECOGNITION. The Insured has authorized this transaction. Both the Insured and the Agent/Xxxxxx recognize the security interest granted herein, pursuant to which the Insured assigns to FIRST all unearned premium, dividends and certain loss payments. Upon cancellation of any of the policies listed in the Schedule of Policies, the Agent/Xxxxxx agrees to immediately pay FIRST all unearned commissions and all unearned premiums, dividends and loss payments received. If such funds are not remitted to FIRST within 10 days of receipt by the Agent/Xxxxxx, the Agent/Xxxxxx agrees to pay FIRST interest on such funds at the maximum rate allowed by applicable law. POLICIES EFFECTIVE/PREMIUMS CORRECT. The policies listed in the Schedule of Policies are in full force and effect, and the premiums are correct as listed. INSURED HAS THIS DOCUMENT. The Insured has been given a copy of this agreement. NO INSOLVENCY. To the best of our knowledge, neither the Insured nor the insurance companies are insolvent or involved in a bankruptcy or similar proceeding as debtor, except as clearly indicated on page 1 of this agreement. FOR THE SCHEDULED POLICIES, AGENT OR BROKER WARRANTS THAT: DEPOSIT/PROVISIONAL PREMIUMS. Any Audit or Reporting Form policies or policies subject to retrospective rating included in this agreement are noted below in section (a). The deposit or provisional premiums for these policies are not less than the anticipated premiums to be earned for the full term of the policies.
Signature and Acknowledgement. Insured has signed and received a copy of this Agreement. If the insured is not an individual, the undersigned is authorized to sign this Agreement on behalf of the insured. All the insureds listed in any Policy have signed. Insured acknowledges and understands that insurance premium financing law does not require a insured to enter into a premium financing agreement as a condition of the purchase of any insurance policy.
Signature and Acknowledgement. BY SIGNING THIS AGREEMENT, YOU HEREBY ACKNOWLEDGE THAT THE YOU HAVE READ, UNDERSTOOD, AND AGREE TO ALL OF THE TERMS SET FORTH HEREIN. THE STATE OF UTAH SANTAQUIN CITY Name: Name: Xxxxxx X. Xxxxx Title: Title: Mayor, Santaquin City Date: Date: Governor’s Office of Economic Opportunity Name: Attest: Title: Name: Xxxxxx X. Xxxxxx Date: Title: Recorder, Santaquin City Governor’s Office of Economic Opportunity Date: Name: Title: Date: Governor’s Office of Economic Opportunity Date: Division of Finance State of Utah Contract Number: 230630570 Vendor #: 73535G Commodity Code: 99999 ATTACHMENT A: STANDARD TERMS AND CONDITIONS FOR GRANTS BETWEEN GOVERNMENT ENTITIES
Signature and Acknowledgement. To signify your agreement with all of the above paragraphs, please sign below. SIGNATURE: DATE: Submission Options
Signature and Acknowledgement. Your signature below indicates that you have read (or been read) this client consent form, have received answers to your questions, and you freely consent to have your information, and that of your minor children (if any), entered into the HMIS database. You also consent to share your information with other participating organizations as described in this consent form. ☐ I consent to sharing my photograph. (Check here) Client Name: DOB: Last 4 digits of SS_ Signature Date _ ☐ Head of Household (Check here) Minor Children (if any): Client Name: DOB: Last 4 digits of SS Living with you? (Y/N) Client Name: DOB: Last 4 digits of SS Living with you? (Y/N) Client Name: DOB: Last 4 digits of SS Living with you? (Y/N) Print Name of Organization Staff Print Name of Organization Page of 3 Modified 03/19/18 Signature of Organization Staff Date Modified 03/19/18 COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC SOCIAL SERVICES Family Solutions Center (FSC) Two-Way Gram SECTION A (To be completed by the referring FSC Staff) To (HCM or BWS-LOD Staff): Date: From (FSC Agency Name): FSC Staff Name: FSC Staff Telephone Number: FSC Staff Fax Number: SECTION B (To be completed by the referring FSC Staff) Adult Participant Name (Please Print): SSN (Last four digits only): Birthdate: Telephone Number: Other Adult Name: SSN (Last four digits only): Birthdate: Telephone Number: Families Immediate Housing Need: □ Emergency Shelter □ Move-In Assistance □ Eviction Prevention □ Rental Subsidy Assistance SECTION C (To be completed by the HCM or BWS-LOD) Date Two-Way Gram Received: Date returned to FSC: The participant has the following Homeless Programs and Services potentially available: Temporary Homeless Assistance Emergency Assistance to Prevent Eviction Permanent Homeless Assistance Rental Assistance Moving Assistance Temporary Homeless Assistance Program (THAP)+14 □ □ 4-Month
Signature and Acknowledgement. Acknowledge we have signed this PA and have received an executed copy of it. If the Insured/Borrower is a corporation, limited liability company, partnership or other entity, we warrant we are authorized to sign this PA on its behalf, acting alone, and to bind such entity. If there is more than one Insured/Borrower listed on any Policies, we warrant we are, acting alone, authorized to sign for and to bind all Insureds/Borrowers.
Signature and Acknowledgement. BY SIGNING THIS AGREEMENT, YOU HEREBY ACKNOWLEDGE THAT THE YOU HAVE READ, UNDERSTOOD, AND AGREE TO ALL OF THE TERMS SET FORTH HEREIN. THE STATE OF UTAH EAGLE MOUNTAIN CITY Name: Name: Title: Title: \t1\ Date: Date: \d1\ Governor’s Office of Economic Opportunity Name: Title: Date: Governor’s Office of Economic Opportunity Name: Title: \t4\ Date: \d4\ Governor’s Office of Economic Opportunity Date: Division of Finance State of Utah Contract Number: 230630578 Vendor #: 38936AE Commodity Code: 99999 ATTACHMENT A: STANDARD TERMS AND CONDITIONS FOR GRANTS BETWEEN GOVERNMENT ENTITIES
Signature and Acknowledgement. I hereby agree to the terms and conditions set forth in this rollover form and acknowledge having established a self-directed account through execution of an account application. I understand the rules and conditions applicable to a (check one) Rollover Direct Rollover. I qualify for the rollover or direct rollover of assets listed in the asset liquidation above and authorize such transactions. If this is a rollover or direct rollover, I have been advised to see a tax advisor due to the important tax consequences of rolling assets into an self-direct account. If this is a rollover or direct rollover, I assume full responsibility for this rollover or direct rollover transaction and will not hold the Plan Administrator, Custodian, or Issuer of either the distributing or receiving plan liable for any adverse consequences that may result. I understand that no one at Advanta IRA or any of its licensees has authority to agree to anything different than my foregoing understandings of Advanta IRA policy. If this is a rollover or direct rollover, I irrevocably designate this contribution of assets with a value of $ as a rollover contribution. By signing this form, I certify that I am completing this rollover within: A. Sixty calendar days following the day I received the assets, I have not performed a rollover of these assets from an IRA within the last 12 months and the rollover DOES NOT contain my required minimum distribution (RMD). B. If I am a non-spouse beneficiary, this is a direct roll over from an employer plan and the rollover contribution DOES NOT contain my required minimum distribution (RMD). Your Signature: Date: Rev. 12/21 Advanta IRA | 00000 Xxxxxxx Xx., Ste 2, Largo, FL 33773 | P: 800.425.0653 | F: 866.385.6045 | XxxXxxxxxxx@XxxxxxxXXX.xxx Interested Party Designation (IPD) 1 General Information
