Form 135 - A - Application For Subsequently Claiming Tax Benefits Page 3
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3APPLICANT CERTIFICATION
1. The information submitted by the Applicant to the Department of Economic Development (DED) in connection with
the application is true and correct and such information is consistent with documents provided to lenders, other
government programs, or investors who may provide funding for the Project;
2. To my knowledge, there is no person who is actively engaged in the management of the Applicant who has been
convicted of a felony, is currently under indictment for a felony, or is currently on parole or probation;
3. There are no pending or threatened liens, judgments, or material litigation against the Applicant or any person who is
engaged in the management of the Applicant that would have a material impact on the viability of the Applicant;
4. The Applicant is not delinquent with respect to any federal, state or local taxes or fees;
5. The Applicant has obtained or is capable of obtaining all necessary federal, state and local permits and licenses;
6. Neither the operations of the Applicant nor the receipt of tax credits would violate any existing agreements;
7. I certify that the Applicant does NOT knowingly employ any person who is an unauthorized alien and that the
applicant has complied with federal law (8 U.S.C. § 1324a) requiring the examination of an appropriate document or
documents to verify that each individual is not an unauthorized alien.
8. I certify that the Applicant is enrolled and will participate in a federal work authorization program as defined in Section
285.525(6), RSMo, with respect to employees working in connection with the activities that qualify Applicant for this
program. I certify that the Applicant will maintain and, upon request, provide the Department of Economic
Development documentation demonstrating Applicant’s participation in a federal work authorization program with
respect to employees working in connection with the activities that qualify applicant for this program.
9. I certify that the Applicant shall include in any contract it enters with a subcontractor in connection with the activities
that qualify applicant for this program, an affirmative statement from the subcontractor that such subcontractor is not
knowingly in violation of Section 285.530.1, RSMo, and shall not be in violation during the length of the contract. In
addition the Applicant will receive a sworn affidavit from the subcontractor under the penalty of perjury, attesting that
the subcontractor’s employees are lawfully present in the United States. I certify that the Applicant will maintain and
provide the Department of Economic Development access to documentation demonstrating compliance with this
requirement.
10. I understand that if the Applicant is found to have employed an unauthorized alien, Applicant may subject to penalties
pursuant to Sections 135.815, 285.025, and 285.535, RSMo.
11. I attest that I have read and understand the Business Facility Credit or Enterprise Zone Program guidelines,
specifically as it relates to the Tax Credit Accountability Act of 2004 (SB 1099).
12. I hereby agree to inform DED if, at any time prior to Project completion, there is any change to any of the
certifications made herein.
13. I hereby agree to allow DED, Department of Revenue, or either of their designated representatives, access to the
property and applicable records as may be necessary for the administration of this program.
14. I certify under penalties of perjury that the above statements, information contained in the application and
attachments are complete, true, and correct to the best of my knowledge and belief.
I certify that I am an authorized representative of the Applicant and as such am authorized to make the statement of
affirmation contained herein. I also realize that failure to disclose material information regarding the viability of the
Applicant, Management, or other facts related to the Project may result in criminal prosecution to the extent of Missouri law.
Typed or Printed Name
Title
Signature
Date
Notary Public Embosser Or Black
State
County
Ink Rubber Stamp Seal
USE RUBBER STAMP IN
Subscribed and Sworn Before Me, This
CLEAR AREA BELOW.
Day of
Year
Notary Public Signature
Notary Public Name
Commission Expires
(Typed Or Printed)
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.
Submission of this certification is a prerequisite for making or entering into this transaction.
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