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CDBG Grant <br />SIGNATORY FORM AND CERTIFICATION <br />Ne.tpient Name _ Orate County , -- <br />Address P -O• Box 8181 <br />Hillsborough, N.C. 27278 <br />Signatures of Individuals authorised to sign Requisition for CDBG Rinds forms. (Two signatures m>qulnd on each requisklon.) <br />(Snatun <br />(Signature) <br />Signature <br />Kenneth Chavious <br />yped Name <br />Albert K'ttrell <br />(Typed Name) <br />sped Nam. <br />Rod visser <br />(Signature (Typed Name <br />CERTIFICATION <br />1. (14 1 certify that an signatures above woof ON Individuals outhorlsad to sign RequlYtion for CDBG Funds form for the above mrAplrtt. <br />Cartltying OfflcW <br />2. () The governing board has pasted a radution authorising the persons above to sign Requisition for CDOG Funds forms for-dw above <br />reciplent. A copy of tln resoknion is attached. <br />1 certify that the signatures above are thou of tin IndMduals authorised by rnoludon of the governing board of the Ieclpient to sign <br />Requisition for CDBG Furls forms. <br />CDBG #101 19186) Certifying Official <br />INSTRUCTIONS FOR COMPLETING SIGNATORY FORM AND CERTIFICATION <br />I. Indicate name and address of the recipient. <br />2. Two authorized signature* shall be required on all Requisition for CDBG Funds farms. The Division of Community <br />Assistance will check the signatures on each requisition form to see that they match the audwdz@4 signature* on the <br />Signatory Form and Certification. Only the signatures of persons shown on the Signatory Forms and Cerdfication will be <br />accepted. <br />3. To allow for flexibility in nuking requisition request:, It is rocammended that four audorized sigl:tures appear on the <br />Semtory Form and Cettletcation. Local governments may choose one of two options in completing the Certification. If <br />the local government chooses to use the first option, the chief elected official or the chief finance officer must sign the <br />form as the certifying official. In signing as the certifying official, the chief elected official or chief finum officer certifies <br />that: 1) the signatures are authentic and 2) that the persons designated as sl/utories are authorised to sign requisitions <br />for payment. If the chief elected official or she chief finance officer is the certifying official, slat person may not also be <br />an authorized signature. <br />If the community wishes to have both the chief elected official and the chief finance officer sign requisitions for payment, <br />the community should select the second option for certification. In this case, the gowning board must pas: a resolution <br />authorizing sufficient persons to act as signatories. In addition, an individual who Is not desiptated as a signatory must <br />certify the authenticity of the authorized signatures. Anyone who knows all of the persons authorized to sign requisitions <br />may sign as- the certifying official. Another local government staff person or member of the governing body is <br />recommended. <br />4. If the recipient wishes to change the persons authorized to sign the requisition for CDBG funds form a new Signatory <br />Form and Certification must be submitted to On Division of Community Assistance. <br />S. No erasures or corrections may appear on the Signatory Form and C rtifecagkm. <br />