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CERTIFICATION STATEMENT
I certify that the information I am providing is true and accurate to the best of my knowledge. I
authorize Clarke County to make inquiries as necessary to verify the accuracy of the statements made
by me. I understand that false statements will result in forfeiture of benefits. I understand this
application, even if favorably received, does not constitute a commitment on the part of Clarke County
to extend grants. I understand that by submitting this application, Clarke County is under no obligation
to approve and/or extend an assistance grant. I agree to indemnify and hold harmless Clarke County,
its officers, directors, employees, agents and volunteers from any and all claims, loss or other liability
arising from or related to the services that Clarke County provides before, during, and after the grant
review process (including reasonable attorney fees). I agree to be bound by the grant agreement, if my
application is accepted. I agree to provide documentation, if needed, of all uses of grant funding.
Notice: Clarke County is dedicated to maintaining the confidentiality of all private client information
including proprietary business data, business plans, and tax ID numbers. As an organization receiving
financial support from state and federal agencies, we may be required to document and share client
information with public and non-profit agencies as a condition of program funding.
Clarke County will make available to the public, through FOIA, the names of any non-profits receiving
these public funds.
NOTE: The IRS does consider monies through this grant program taxable income. Therefore, the
appropriate tax forms will be issued.
By checking this box, I certify that I am not using this grant money for the same expenses and
same time periods as EIDL, PPP, or other grant awards.
Signature of Executive Director or Board Chair
Print Name of Executive Director or Board Chair
CHECKLIST OF REQUIRED DOCUMENTS INCLUDED
____ A completed and signed application form
____ A copy of your IRS 501 status
____ A copy of your most recent federal tax return
____ A copy of your driver’s license or other form of ID
____ Copies of bills for which you are seeking reimbursement. For rent, include a copy of your lease
____ A W9 for tax purposes; see last page of this document.
Questions? Please contact Tiffany Kemp at tkemp@clarkecounty.gov or 540-955-5100
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