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: |
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:
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 15 minutes 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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Milligan, Stephen |
File Modified | 0000-00-00 |
File Created | 2024-07-24 |