THUS DONE AND SIGNED at Baton Rouge, Louisiana, on Click here to enter day of month, year. STATE AGENCY SIGNATURES _________________________________________ Assistant Superintendent Louisiana Department of Education _________________________________________ State Superintendent of Education Louisiana Department of Education WITNESSES’ SIGNATURES LEA SIGNATURES ______________________________________ Print Name of LEA Superintendent _____________________________________ ______________________________________ Print Name of LEA Test Coordinator ______________________________________ n/a ______________________________________ Name of LEA Finance/Budget Coordinator
THUS DONE AND SIGNED in the presence of the undersigned Notary Public and competent witnesses at , Louisiana, on this day of , 20 . WITNESSES: DIVISION OF ADMINISTRATION XXXXX X. XXXXX, LCDBG DIRECTOR NOTARY PUBLIC My Commission expires: WITNESSES: MANUFACTURING, INC. PRESIDENT NOTARY PUBLIC My Commission expires: WITNESSES: CITY OF MAYOR NOTARY PUBLIC My Commission expires: Please note: Attachment A is the contract between the State and the local governing bodies with Exhibits, A-F. Attachment B is the Employee Survey Form Attachment C is the Employee Characteristics Record Attachment D is the Quarterly Status of Sources and Uses LCDBG ECONOMIC DEVELOPMENT PROGRAM Attachment B COMMUNITY: COMPANY: PROGRAM YEAR: CURRENT DATE: / / Employee: LAST NAME FIRST NAME Employee: SSN (last four digits only) DATE HIRED / / Employee: JOB TITLE OR POSITION HUD Income Limits for FY PARISH The Employee’s FAMILY INCOME is: Please circle the number that corresponds to the income category and number of persons in your family. The income is determined by computing the total income of all family members for the last three months and then multiplying that number by four. 1 Person 2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons Above - more than Moderate less than Low – less than Extremely Low less than ⎦ ⎦ ⎦ ⎦ ⎦ Employee: Racial Category: African American or Black White Alaskan Native or American Indian Asian African American or Black and White Alaskan Native or American Indian and White Alaskan Native or American Indian and Black Asian and White Native Hawaiian or Other Pacific Islander ϒ Other Multi Racial ϒ ϒ ϒ ϒ Please mark this box if the employee is of thefollowing ethnicity: ϒ Hispanic or Latino Employee: Check if applicable: ⎦ Unemployed at time of hire Note: 18 U.S.C. Sec 1001 provides that “whoever knowingly and willfully makes any materially false, fictitious, or fraudulent statement or representation;…shall be fined under this title or imprisoned not more than five years or both. Signature Attachment C Employee Characteristics Record Date of Report NAME RACE/ETHNICITY INCOME Code NAME Al/AN H Asian H Blk / AA H NH/O Xx X Xxxxx H AI/AN and White H Asian and White H Blk/AA and White H AI/AN and Black H Other Multi Racial H Une mplo yed Extra Low Low Mod Above H-Number of people in column to the left with Hispanic/Latino Ethnicity Al/AN-American Indian/Alaskan Native B/AA-Black/African American NH/OPI-Native Hawaiian/Other Pacific Islander Attachment D QUARTERLY STATU...
THUS DONE AND SIGNED in Baton Rouge, Louisiana this day of January, 2024, before the undersigned Notary Public and witnesses after due reading of the whole. WITNESSES: Xxxx Xxxxxxxx Superintendent NOTARY PUBLIC THUS DONE AND SIGNED in Baton Rouge, Louisiana this day of January, 2024, before the undersigned Notary Public and witnesses after due reading of the whole. WITNESSES: EAST BATON ROUGE PARISH SCHOOL BOARD BY: Xxxxx Xxxxxx-Xxxxx President
THUS DONE AND SIGNED by and on behalf of CustomerFullName at Windhoek on this day of (Customer Signatory) (As Witness 1) (As Witness 2) THUS DONE AND SIGNED: by and on behalf of SALT at Windhoek on this day of (SALT Signatory) (As Witness 1) (As Witness 2)
THUS DONE AND SIGNED in Lafayette, Louisiana by the Parties hereto after due reading of the whole. WITNESSES: TECHNICAL INDUSTRIES, INC. Printed Name BY: GXXXXX X. XXXXX Printed Name SHENGLI OILFIELD HIGHLAND PETROLEUM EQUIPMENT (USA) Printed Name BY: ZXXXXXX XXXX Printed Name SHENGLI OILFIELD HIGHLAND PETROLEUM EQUIPMENT CO., LTD. Printed Name BY: YXXX XXXXXXXX Printed Name
