Government Certifications

OMB Approved No. 1505-0264

Expiration Date: 10/31/2020

CERTIFICATION

I, [Insert name of signatory], am the chief executive of [insert name of local government entity], and I certify that:

1. I have the authority on behalf of [insert name of local government entity] to request direct payment from the Department of the Treasury (“Treasury”) pursuant to section 601(b) of the Social Security Act, as added by section 5001 of the Coronavirus Aid, Relief, and Economic Security Act, Pub. L. No. 116-136, div. A, Title V (Mar. 27, 2020).

2. I understand that Treasury will rely on this certification as a material representation in making a direct payment to [name of local government entity].

3. [Insert name of local government entity]’s proposed uses of the funds provided as direct payment under section 601(b) of the Social Security Act will be used only to cover those costs that—

1. are necessary expenditures incurred due to the public health emergency with respect to the Coronavirus Disease 2019 (COVID–19);

2. were not accounted for in the budget most recently approved as of March 27, 2020, for [insert name of local government entity]; and

3. were incurred during the period that begins on March 1, 2020, and ends on December 30, 2020.

By: _________________________________

Signature:____________________________

Title:________________________________

Date:________________________________

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is two hour per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.