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Project NameAgency Name
I understand that criminal background checks and checks of public sex offender and child abuse websites/registries
are required every five years and upon learning of information that reasonably may suggest unsuitability, and
individuals will not be found suitable to interact with participating minors in the course of activities under the VOCA
award if an individual:
a.) withholds consent to a criminal history search required by this certified assurance;
b.) knowingly makes (or made) a false statement that affects, or is intended to affect, any search required by this condition;
c.) is listed as a registered sex offender on the Dru Sjodin National Sex Offender Public Website; or
d.) to my knowledge, has been convicted whether as a felony or misdemeanor under federal, state, tribal, or local law for
any of the following crimes or any substantially equivalent criminal offence, regardless of specific words by which it
may be identified in law:
1.) sexual or physical abuse, neglect, or endangerment of an individual under 18 at the time of offense;
2.) rape/sexual assault, including conspiracy to commit rape/sexual assault;
3.) sexual exploitation, such as through child pornography or sex trafficking;
4.) kidnapping;
5.) voyeurism; or
6.) is determined by a federal, state, tribal, or local government agency not to be suitable.
I, (Executive Director or Authorized Official) certify that all the above-stated
checks have been performed on the above-named individual(s) and the above-named individual(s), associated with the
VOCA-funded project are designated as suitable to interact with participating minors within the VOCA-funded project pursuant
to the conditions found at https://www.ojp.gov/funding/explore/interact-minors
and that the agency has complied with all the
requirements more fully detailed in the aforementioned link.
Date signedPrint name of person signing
Signature of Executive Director or Authorized Official
Certification
