Agenda - 05-03-2007-4f - Laserfiche WebLink

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~7 U.S. Department of Homeland Security O.M.B. No. 3067-0206 SUMMARY SHEET FOR ASSURANCES AND CERTIFICATIONS Expires February 28, 2007 FOR CA FOR (Name of Applicant) FY This summary sheet includes Assurances and Certifications that must be read, signed, and submitted as a part of the Application for Federal Assistance. An applicant must check each item that they are certifying to: Part I ^X FEMA Form 20-16A, Assurances-Nonconstruction Programs Part II ~ FEMA Form 20-16B, Assurances-Construction Programs Part III ~X FEMA Form 20-16C, Certifications Regarding Lobbying; Debarment, Suspension, and Other Responsibility Matters; and Drug-Free Workplace Requirements Part IV ^X SF LLL, Disclosure of Lobbying Activities (If applicable) As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the identified attached assurances and certifications. Typed Name of Authorized Representative Title Signature of Authorized Representative Date Signed NOTE: By signing the certification regarding debarment, suspension, and other responsibility matters for primary covered transaction, the applicant agrees that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by FEMA entering into this transaction. The applicant further agrees by submitting this application that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction," provided by the FEMA Regional Office entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. (Refer to 44 CFR Part 17.) Paperwork Burden Disclosure Notice "Public reporting burden for this form is estimated to average 1.7 hours per response. Burden means the time, effort and financial resources expended by persons to generate, maintain, retain, disclose, or to provide information to us. You may send comments regarding the burden estimate or any aspect of the form, including suggestions for reducing the burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0206). You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Please do not send your completed form to the above address. Form 20-16, FEB 01