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State Fiscal Yeaz 2011 Community Transportation Programs <br />Federal and State Assistance Certifications and Assurance <br />20 <br />STATE FISCAL YEAR 2011 • <br />FEDERAL/STATE CERTIFICATIONS AND ASSURANCES SIGNATURE PAGE <br />(Required of all Applicants) <br />AFFIRMATION OF APPLICANT <br />Legal Name of Applicant: <br />Name .and Relationship of Authorized Representative: <br />BY SIGNING BELOW, on behalf of the Applicant, I declare that the Applicant has duly authorized me to make <br />these certifications and assurances and bind the Applicant's compliance. Thus, the Applicant agrees to comply with <br />all Federal statutes and regulations, and follow applicable Federal directives, and comply with the certifications and <br />assurances as indicated on the foregoing page applicable to each application it makes to the Federal Transit <br />Administration (FTA) and for State assistance in State Fiscal Year 2011. <br />The State of North Carolina and FTA intend that the certifications and assurances the Applicant selects on the <br />preceding certifications and assurances category selection page, as representative of the certifications and assurances <br />in this document, should apply, as provided, to each project for which the Applicant seeks now, or may later, seek <br />State or FTA assistance during State Fiscal Year 2011. <br />The Applicant affirms the truthfulness and accuracy of the certifications and assurances it has made in the <br />statements submitted herein with this document and any other submission made to the State and FTA, and <br />acknowledges that the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. 3801 et seq., and implementing <br />U.S. DOT regulations, "Program Fraud Civil Remedies," 49 CFR part 31 apply to any certification, assurance or <br />submission made to the State and FTA. The criminal provisions of 18 U.S.C. 1001 apply to any certification, • <br />assurance, or submission made in connection with a Federal public transportation program authorized in 49 U.S.C. <br />chapter 53 or any other statute. <br />In signing this document, I declare under penalties of perjury that the foregoing certifications and assurances, and <br />any other statements made by me on behalf of the Applicant are true and correct. <br />Signature of Authorized Official <br />Name/Title of Authorized Official <br />Date Signed <br /> <br />16 <br />