Standard Form 424 - Application For Federal Domestic Assistance - Short Organizational Page 3

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APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

9. * 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 218, Section 1001)

** I Agree

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

AUTHORIZED REPRESENTATIVE

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Email:

* Telephone Number:

Fax Number:

* Signature of Authorized Representative:

* Date Signed: