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SFY 2005 Community Transportation Program <br />State NCDOT Certifications and Assurances <br />STATE FISCAL YEAR 2004-2005 CERTIFICATIONS AND ASSURANCES <br />SIGNATURE PAGE <br />(Required of all Applicants for State/FTA assistance) <br />AFFIRMATION OF APPLICANT <br />Legal Name of Applicant: County of Orange. <br />Name of Authorized Representative: <br />Relationship of Authorized Representative: <br />BY SIGNING BELOW, on behalf of the Applicant, I declare that the Applicant has duly <br />authorized me to make these certifications and assurances and bind the Applicant's compliance. <br />Thus, the Applicant agrees to comply with all Federal statutes, regulations, executive orders, and <br />Federal requirements applicable to each application it makes to North Carolina Department of <br />Transportation (NCDOT) in State Fiscal Year 2004. <br />NCDOT intends that the certifications and assurances the Applicant selects on the other side of <br />this document, as representative of the certifications and assurances in Appendix A, should <br />apply, as required, to each project for which the Applicant seeks now, or may later, seek NCDOT <br />assistance during State Fiscal Year 2004. <br />The Applicant affirms the truthfulness and accuracy of the certifications and assurances it has <br />made in the statements submitted herein with this document and any other submission made to <br />FNCDOT, and acknowledges that the provisions of the Program Fraud Civil Remedies Act of <br />1986, 31 U.S.C. 3801 et seq., as implemented by U.S. DOT regulations, "Program Fraud Civil <br />Remedies," 49 CFR part 31 apply to any certification, assurance or submission made to NCDOT. <br />The criminal fraud provisions of 18 U.S.C. 1001 apply to any certification, assurance, or <br />submission made in connection with the Urbanized Area Formula Program, 49 U.S.C. 5307, and <br />may apply to any other certification, assurance, or submission made in connection with any other <br />program administered by NCDOT. <br />In signing this document, I declare under penalties of perjury that the foregoing certifications and <br />assurances, a other statements made by me on half of the Applicant are true and correct. <br />Signature <br />Date ~ ~/~_ <br />Name [~Q.r~^ <br />Authorized Renrese tive <br />19 <br />