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North Caro[ina Water/Wastewater Common ~Application Form <br />For use by ARC, CWMTF, DENR, DOC, and Rural Center applicants. <br />CERT[FICATION BY CHtEF ELECTED OFFICtAUAU1NORIZED REPi2ESENTATNE <br />The attached sfatements and exhibits are hereby made part af fhis agplicaiion and the undersigned representative of the <br />applicant certifies that the inforrnation in this appfication and the attached statements and exhibifs is true, correct, and <br />complete to the best of his/her knowledge and betief. He/She fur#her certifies that: ~ <br />1 as Aufhorizeci Representative, he/she has been authorized to file this application 6y formal action of the goveming <br />body~ <br />2 that the goveming body agrees that if a grar-t and/or loan is awarded, the applicant will provide proper and #imely <br />submitfal of all documentation requested by the Grantor Agency; <br />3 that the gaverning body agrees to provide for proper mainfenance and operatian of the approved project after its <br />completion; <br />4 that the appticant has substantially complied with or will comply with alt federal, state and local laws, ru(es and <br />regula6ons and ordinances as applicable ta this project; and <br />5 that the applicant will adopt and place into efFect on ar befiore the completion of the project a schedule of fees and <br />charges which will provide for the adeqtaate and proper operafion, maintenance, adminisiration and repayment of <br />all principle and interest an foans of the project. <br />6. that the appflcant has fotlowed proper accounting and fiscal reporFing procedures, as evidenced by the appficanf's <br />most recent audit report, and that the applicant is in substantial compliance with provision of the general fisca! . <br />control laws of the Stafe. <br />7. that the (Town or County), North Carollna is organized and chartered under the laws of IVarth Carolina. AI! officfals <br />and empfoyees are aware of, and in futl compliance with iVCGS 14234, °Director of public trust contracting for his <br />own benefit, partiapa6on in business transaction involving public funds; exemptions °(For units of tocal <br />gavemments only.) <br />Frank~~ifton , County Manager ~ 2/29/2012 <br />'FYPED NAME TYPED TITLE DATE <br />Pfease note: ORiGtNA! signatures a€e required for each agency application. <br />Page 5 of 5 <br />Version 09/10 <br />