Fillable Project Certification Form printable pdf download

Project Certification Form

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Project Certification Form

Grantee: ____________________Project Number: _________________

Grantee contact for audit purposes

Name: __________________________________________________________

Address: ______________________________________________________

Phone: (___) ____________

Email: ____________________

Project description – list facilities developed and/or property acquired (use

additional pages, as required):

List other funds on project (sources and amounts) (use additional pages, as

required):

Interest earned on advance grant funds: $ __________________

Has a notice of completion been filed?

Yes ______ No _______

If no, please explain:

Certification:

I hereby certify that all grant funds were expended on the above named Project and that

the Project is complete and we have made final payment for all work done.

I have read California Penal Code § 118 and understand that every person who testifies,

declares, deposes, or certifies under penalty of perjury and willfully states as true any

material matter which he or she knows to be false, is guilty of perjury, which is a felony

punishable by imprisonment in state prison for two, three, or four years.

Furthermore, I have read California Penal Code § 72 and understand that every person

who, with the intent to defraud, presents for allowance or for payment to any state board

or officer, or to any county, city, or district board or officer, authorized to allow or pay the

same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty

of a felony-misdemeanor punishable either by imprisonment in county jail for a period of

not more than one year, by a fine not exceeding one thousand dollars, or both, or by

imprisonment in state prison, by a fine a fine not exceeding ten thousand dollars, or

both.

I represent and warrant that I have full authority to execute this Project Certification of

project completion on behalf of the Grantee. I declare under penalty of perjury that the

foregoing project certification of project completion for the above-mentioned Grant is true

and correct.

______________________________

Grantee’s Authorized Representative

(Printed or Typed name)

______________________________

_________________

Grantee’s Authorized Representative (Signature)

Date

Revised 5/1/06

Project Certification Form

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