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• Contract #68-2004 <br />Personalized Patient Home Assistance, Inc. <br />II. The site(s) for the performance of work done in connection with the specific agreement aze <br />listed below: <br />(Street address) <br />(City, county, state, zip code) <br />Contractor will inform the County of any additional sites for performance of work under this <br />agreement. <br />False certification or violation of the certification shall be grounds for suspension of payment, <br />suspension or termination of grants, or government-wide Federal suspension or debarment <br />(Section 4 CFR Part 85, Section 85.615 and 86.620). <br />G <br />Signature Title <br />~~ per, !1-ohs <br />Agency/Or zation Date <br />(Certification signature should be same as Contract signature.) <br />• <br />Federal Certification -Drug-Free Workplace (06/04) Page 2 of 2 <br />