Xxxxxxx, P E./Project Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:
Xxxxx, Esq Sher & Xxxxxxxxx LLP; 0000 X Xxxxxx, XX.; Xxxxx 000; Xxxxxxxxxx, XX 00000.
Xxxxxxxx, P E., P.S./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:
Xxxxxx, Xx Xxxxxxx X.
Xxxxxx Xxxx The right-of-way, the roadway and all improvements constructed thereon connecting the airport to a public highway.
Xxxxxxx Xxxx CareFirst BlueChoice’s Service Area is a clearly defined geographic area in which CareFirst BlueChoice has arranged for the provision of health care services to be generally available and readily accessible to Members. CareFirst BlueChoice will provide the Member with a specific description of the Service Area at the time of enrollment. The Service Area is as follows: the District of Columbia; the state of Maryland; in the Commonwealth of Virginia, the cities of Alexandria and Fairfax, Arlington County, the town of Vienna and the areas of Fairfax and Xxxxxx Xxxxxxxx Counties in Virginia lying east of Route 123. SAMPLE If a Member temporarily lives out of the Service Area (for example, if a Dependent goes to college in another state), the Member may be able to take advantage of the CareFirst BlueChoice Away From Home Program. This Program may allow a Member who resides out of the Service Area for an extended period of time to utilize the benefits of an affiliated Blue Cross and Blue Shield HMO. This Program is not coordination of benefits. A Member who takes advantage of the Away From Home Program will be subject to the rules, regulations and plan benefits of the affiliated Blue Cross and Blue Shield HMO. If the Member makes a permanent move, he/she does not have to wait until the Annual Open Enrollment Period to change plans. Please call 000-000-0000 or visit xxx.xxxx.xxx for more information on the Away from Home Program. CareFirst BlueChoice, Inc. 000 Xxxxx Xxxxxx, XX Xxxxxxxxxx, XX 00000 000-000-0000 An independent licensee of the Blue Cross and Blue Shield Association ATTACHMENT A BENEFIT DETERMINATIONS AND APPEALS AMENDMENT This attachment contains certain terms that have a specific meaning as used herein. These terms are capitalized and defined in Section A below, and/or in the Individual Enrollment Agreement to which this document is attached. These procedures replace all prior procedures issued by CareFirst BlueChoice, which afford CareFirst BlueChoice Members recourse pertaining to denials and reductions of claims for benefits by CareFirst BlueChoice. These procedures only apply to claims for benefits. Notification required by these procedures will only be sent when a Member requests a benefit or files a claim in accordance with CareFirst BlueChoice procedures. An authorized representative may act on behalf of the Member in pursuing a benefit claim or appeal of an Adverse Benefit Determination. CareFirst BlueChoice may require reasonable proof to determine whether an individual has been properly authorized to act on behalf of a Member. In the case of a claim involving Urgent/Emergent Care, a Health Care Provider with knowledge of a Member's medical condition is permitted to act as the authorized representative. SAMPLE
Xxxxx Xxxxxx Purchase Order and Sales Contact Email Please enter a valid email address that will definitely reach the Purchase Order and Sales Contact. 2 xxxxx@xxxxxxxxxxxx.xxx Purchase Order and Sales Contact Phone Numbers only, no symbols or spaces (Ex. 8668398477). The system will auto-populate your entry with commas once submitted which is appropriate and expected (Ex. 8,668,398,477). 2 3 6178200967 Company Website Company Website (Format - xxx.xxxxxxx.xxx) 4 None Entity D/B/A's and Assumed Names You must confirm that you are responding to this solicitation under your legal entity name. Go now to your Supplier Profile in this eBid System and confirm that your profile reflects your "Legal Name" as it is listed on your W9. In this question, please identify all of your entity's assumed names and D/B/A's. Please note that you will be identified publicly by the Legal Name under which you respond to this solicitation unless you organize otherwise with TIPS after award. Spectrum Resource Roofing, LLC Primary Address Primary Address 2 0000 Xxxxxx Xxxxx Primary Address City Primary Address City 7 Euless Primary Address State Primary Address State (2 Digit Abbreviation) 2 8 TX Primary Address Zip Primary Address Zip 9 76040 Search Words Identifying Vendor Please list all search words and phrases to be included in the TIPS database related to your entity. Do not list words which are not associated with the bid category/scope (See bid title for general scope). This will help users find you through the TIPS website search function. You may include product names, manufacturers, specialized services, and other words associated with the scope of this solicitation. roofing, shingles, roof repairs, metal roof, roofing contractor, built-up roofing, modified bitumen roofing, single ply roofing, TPO, PVC, EPDM, metal soffit, metal wall panels, GAF, Xxxxx Xxxxxxxx, Pac-Clad, roof maintenance Certification of Vendor Residency (Required by the State of Texas) Does Vendor's parent company or majority owner:
