Application (Page 11 of 12)
Rev. May 2017
CERTIFICATION AND AFFIRMATION
I certify that I am an authorized representative of the Applicant and as such am authorized to make the statement of
affirmation contained herein.
I certify that the Applicant does NOT knowingly employ any person who is an unauthorized alien and that the
applicant has complied with federal law (8 U.S.C. § 1324a) requiring the examination of an appropriate document
or documents to verify that each individual is not an unauthorized alien.
I certify that the Applicant is enrolled and will participate in a federal work authorization program as defined in
Section 285.525(6), RSMo, with respect to employees working in connection with the activities that qualify the
Applicant for the Missouri Small Business Loan Program. I certify that the Applicant will maintain and, upon
request, provide the Department of Economic Development documentation demonstrating the Applicant’s
participation in a federal work authorization program with respect to employees working in connection with the
activities that qualify the Applicant for this Program.
I understand that, pursuant to section 285.530.5, RSMo, a general contractor or subcontractor of any tier shall not
be liable under sections 285.525 to 285.550 when such general contractor or subcontractor contracts with its direct
subcontractor who violates section 285.530.1, if the contract binding the contractor and subcontractor affirmatively
states that the direct subcontractor is not knowingly in violation of section 285.530.1 and shall not henceforth be in
such violation and the contractor or subcontractor receives a sworn affidavit under the penalty of perjury attesting to
the fact that the direct subcontractor’s employees are lawfully present in the United States.
I understand that if the Applicant is found to have employed an unauthorized alien, the Applicant may be subject to
penalties pursuant to sections 135.815, 285.025, and 285.535, RSMo.
I hereby agree to allow representatives of the Department of Economic Development access to the property and
applicable records as may be necessary for the administration of the Missouri Small Business Loan Program.
I certify under penalties of perjury that the above statements and information contained in the application and
attachments are complete, true, and correct to the best of my knowledge and belief.
I attest the information submitted by the company to DED regarding the project is consistent with documents
provided to lenders, other governmental entities or investors who may provide funding for the project and that DED
is authorized to verify such information from any source.
For a privately held company, I agree to disclose any person who owns an ownership interest or who is employed in
a management capacity by the company who has committed a felony, is presently under indictment, or is on parole
I attest there are no pending or threatened liens, judgments, or material litigation which is likely to affect the viability
of the company as an ongoing concern.
I certify the company does not have any delinquent non-protested federal, state or local taxes
I certify that neither the operations of the company nor the requested funding would violate any existing agreement.
I certify that the company has not filed (nor is about to file) for bankruptcy.
I certify the company has not failed to fulfill any obligations under any other state or federal program.
I certify the signatory is the authorized representative of the applicant and is authorized to make the statement of
affirmation contained therein.
Copy of the executed Memorandum of Understanding between the Applicant and the United States
Citizenship and Immigration Services (USCIS).