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40. Estimated Funding
(Include all that apply)
Amount Requested from the State Applicant
Contribution (e.g. in kind, matching)
Local Contribution
Other Source of Contribution
Program Income
Total Amount
Applicant Certification
By signing this application, I certify (1) to the statements contained in the list of certifications* and (2)
that the statements herein are true, complete, and accurate to the best of my knowledge. I also provide the
required assurances* and agree to comply with any resulting terms if I accept an award. I am aware that
any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or administrative
penalties. (U.S. Code, Title 18, Section 1001)
(*) The list of certification and assurances, or an Internet site where you may obtain this list is contained
in the Notice of Funding Opportunity. If a NOFO was not required for the award, the state agency
will specify required assurances and certifications as an addendum to the application.
Authorized Representat
ive (Chief Elected Official)
41. First Name
42. Last Name
43. Suffix
44. Title
45. Telephone Number
46. E-mail Address
47.
Signature of Authorized Representative
48.
Date Signed
I Agree
____________________________________________________________
_______________________________________
