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____ The Applicant’s business has been and remains in compliance with all relevant laws, orders, and
regulations during the period of the COVID-19 disaster emergency under the Pennsylvania Governor’s
proclamation dated March 6, 2020, and any and all subsequent renewals. The foregoing includes, but is
not limited to, orders by the Governor, Secretary of Health, or other commonwealth officials
empowered to act during the emergency. Any noncompliant business will be ineligible for funding under
this program and may be required to return all, or a portion, of the funds awarded.
____ I understand that I am ineligible to receive funding under this COVID-19 Relief Statewide Small
Business Assistance Program if I, or any owner of 20 percent or more of the equity of the applicant, is
presently incarcerated or, for any felony, presently subject to an indictment, criminal information,
arraignment, or other means by which formal criminal charges are brought in any jurisdiction; or has
been convicted of, pleaded guilty or nolo contendere to, or commenced any form of parole or probation
(including probation before judgment) for, a felony involving fraud, bribery, embezzlement, or a false
statement in a loan application or an application for federal financial assistance within the last five years
or any other felony within the last year.
____ By executing this Business Certification, I hereby authorize the Pennsylvania CDFI Network and
its authorized representative (Lendistry) under the COVID-19 Relief Pennsylvania Statewide Small
Business Assistance Program to request access to, and review of, the Applicant’s Pennsylvania state tax
returns and tax return information. I hereby warrant that I am an authorized representative of the
Applicant and have full authority to waive confidentiality under Pennsylvania law and authorize release
of this information. I authorize the Pennsylvania Department of Revenue (the Department) to release
confidential information in the possession of the Department, including but not limited to methods such
as phone discussions, mail, facsimile, e-mail or other electronic means, and release the Department
from liability for said disclosure.
____ As Applicant, I further certify that the information provided in the grant application submitted
for this program and the information provided in all supporting documents and forms is true and
accurate in all material respects. I understand that knowingly making a false statement to obtain a grant
from the State of Pennsylvania is punishable under state and federal law, including under 18 USC 1001
and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 USC
645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if
submitted to a federally insured institution, under 18 USC 1014 by imprisonment of not more than thirty
years and/or a fine of not more than $1,000,000.
____ As Applicant, I acknowledge that the Pennsylvania CDFI Network will confirm the eligible grant
amount using tax documents I have submitted. I affirm that these tax documents are identical to those
submitted to the Internal Revenue Service. I also understand, acknowledge, and agree that the
Pennsylvania CDFI Network and its authorized representatives can share the tax Information with state
and federal authorized representatives for the purpose of compliance with federal and state grant
requirements and reviews.
Signature of Business Owner Date
___________________________ _________________________
