Certification Form Page 2
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4Section D—Declaration Stating that Recipient Subawards a Single Award Over $500,000
If a recipient agency, subawards a single award of $500,000 or more then the granting agency should provide a list; including, name, address
and DUNS # of each such sub-recipient.
Sub-Recipient Agency Name/Address
Sub-Recipient DUNS Number
If additional space in necessary, please duplicate this page.
OMB Control No. 1121-0340 Expiration Date: 12/31/2015
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