Dss Form 3359 - Application For Participation Page 6
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9Certification
I certify that the information on this application, including all attachments, is true to the best of my knowledge; that this
organization nor any of its principals have been disqualified from any other publicly funded programs for violation of the
program’s requirements in the past seven years; that this organization nor any of its principals have been convicted of any
activity that occurred during the past seven years that indicated a lack of business integrity. A lack of business integrity
includes fraud, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen
property, making false claims, obstruction of justice, or any other activity indicating a lack of business integrity as defined
by the State agency. In addition, I will accept final administrative and financial responsibility for total operations at the
emergency shelters approved to participate in the Emergency Shelters Food Program, and understand that reimbursement
will be claimed for meals served to eligible participants; and that department officials may, for cause, verify information; and
that deliberate misrepresentation may subject me to prosecution under applicable state and criminal statutes. I understand
that the ESP will be available to all eligible participants regardless of race, color, national origin, sex, age, or disability; and
that this information is being given in connection with the receipt of federal funds, and that a deliberate misrepresentation
may subject me to prosecution under applicable state and federal criminal statutes. I further understand that institutions
and individuals providing false certifications will be placed on the National Disqualification List and will be subject to any
other applicable civil criminal penalties.
Name of Emergency Shelter Facility Representative
Name of Sponsor Representative
(Type or print)
(Type
or print)
Date
Signature of Center Representative
Date
Signature of Sponsor Representative
DSS Form 3359 (MAR 15)
PAGE 6
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