Acceptance of Award Terms without certification

OMB Approved No. 1505-0271

Expiration Date: November 30, 2021

U.S. Department of the Treasury
coronavirus state and Local Fiscal recovery funds

Recipient name and address: [Recipient to provide]

DUNS Number: [Recipient to provide] Taxpayer Identification Number: [Recipient to provide] Assistance Listing Number: 21.019

Sections 602(b)(2) and 603(b) of the Social Security Act (the Act) as added by section 9901 of the American Rescue Plan Act, Pub. L. No. 117-2 (March 11, 2021) authorizes the Department of the Treasury (Treasury) to make payments to certain recipients from the Coronavirus State Fiscal Recovery Fund and the Coronavirus Local Fiscal Recovery Fund.

Recipients hereby agrees, as a condition to receiving such payment from Treasury, agrees to the terms attached hereto.

Recipient:

__________________________________________________

Authorized Representative:

Title:

Date signed:

U.S. Department of the Treasury:

__________________________________________________

Authorized Representative:

Title:

Date:

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