Certifications and Assurances for Eligible Tribal Govern

OMB Approved No.

Expiration Date:

U.S. DEPARTMENT OF THE TREASURY

CERTIFICATIONS AND ASSURANCES
FOR ELIGIBLE TRIBAL GOVERNMENTS

LOCAL ASSISTANCE AND TRIBAL CONSISTENCY FUND

Recipient name and address: [Recipient to provide]

UEI Number: [Recipient to provide] Taxpayer Identification Number: [Recipient to provide] Assistance Listing Number:

I am an authorized representative of the recipient, and I certify that:

1. I have the authority on behalf of the recipient to request direct payment from the Department of the Treasury (“Treasury”) pursuant to section 605 of the Social Security Act (“the Act”) (42 U.S.C. 805), as added by section 9901 of the American Rescue Plan Act.

2. I understand that Treasury will rely on these certifications and assurances as material in making a direct payment to the recipient.

3. I understand that making false statements or claims in connection with this payment is a violation of federal law and may result in criminal, civil, or administrative sanctions, including fines, imprisonment, civil damages and penalties, debarment from participating in federal awards or contracts, or any other remedy available by law.
   
   
   

In connection with the receipt of a payment from section 605 of the Act (the “funds”), I hereby provide the following assurances on behalf of the recipient:

1. Pursuant to section 605(c) of the Act, the recipient will use the funds for governmental purposes other than lobbying activities.

2. The recipient will use the funds in accordance with all other applicable federal law and will comply with implementing guidance provided by Treasury and with reporting requirements and remedial procedures established by Treasury regarding the use of funds.

3. The recipient acknowledges that the funds constitute federal financial assistance and are subject to federal law applicable to federal financial assistance, including but not limited to the applicable provisions of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, 2 C.F.R. Part 200 as detailed in implementing guidance provided by Treasury.

4. The recipient will expend and account for the funds in accordance with the laws, policies, and procedures applicable to the recipient’s expenditure and accounting for its own funds.

5. The recipient will maintain records and financial documents sufficient to evidence compliance with section 605, these assurances, and implementing guidance issued by Treasury for a period of five (5) years after all funds have been expended or returned to Treasury, whichever is later.

6. The recipient acknowledges that the Treasury Office of Inspector General and the Government Accountability Office or their authorized representatives will have the right of access to records of the recipient in order to conduct audits or other investigations.
   
   
   

Signature: ____________________________

Name of Authorized Representative: ____________________________

Title of Authorized Representative: ____________________________

Date Signed: ____________________________

PAPERWORK REDUCTION ACT NOTICE

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