Application Certification

OMB Control Number: 1505-0274

Expiration Date: 3/31/2022

CORONAVIRUS CAPITAL PROJECTS FUND

U.S. DEPARTMENT OF THE TREASURY

Certification of Application

I, the undersigned, as an Authorized Representative of the Applicant referenced below, hereby submit an application (“Application”) on behalf of the Applicant for funds allocated to the Applicant under the Coronavirus Capital Projects Fund, established by Section 604 of the Social Security Act, as added by Section 9901 of the American Rescue Plan Act of 2021. In connection with this Application, I, the undersigned Authorized Representative of the Applicant, hereby:

1. Certify that all of the information provided in this Application is true, complete, and correct after reasonable inquiry of people, systems, and other information available to the Applicant; and

2. Affirm that I am an Authorized Representative of the Applicant with the authority to make the above certification, enter into agreements to bind the Applicant, including the agreements below, and submit this Application.

On behalf of the Applicant, I, the Authorized Representative, agree that:

1. The Applicant has and shall retain documentation and records to support the information provided in this Application; and

2. The Applicant shall make such supporting documents and records available upon request by the U.S. Department of the Treasury or any authorized oversight body.

Applicant Name: ___[AUTOMATICALLY POPULATED]____________

Application Number: ___ [AUTOMATICALLY POPULATED] ____

Authorized Representative Name: ___[AUTOMATICALLY POPULATED ]____ _____

Authorized Representative Title: __ AUTOMATICALLY POPULATED __

Date: ________________

WARNING: Anyone who knowingly submits a false claim or makes a false statement may be subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties (18 U.S.C. §§ 287, 1001; 31 U.S.C. §§ 3729, 3802). Treasury may refer any allegations of fraud, waste, or abuse in connection with Coronavirus Capital Projects Fund to the Treasury Inspector General.