Application Form - Alternative Fuel Vehicle (Afv) Conversion Grants Draft - Ohio Environmental Protection Agency - 2017 Page 3
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12Section 2. Applicant Certification Statement
Instructions: Please have the Authorizing Agent (the person authorized to sign contracts
on behalf of the applicant organization) read the Statement of Certification below, check
every applicable box, and sign the certification statement in Table 2-1, row a. After
the Authorizing Agent has signed, scan and save the entire application document with
all attachments as a single PDF file, to be submitted via email to derg@epa.ohio.gov. If
the project is selected for funding, this statement will become a legally binding exhibit in
the grant agreement.
Certification Questions
1. Does the applicant and/or company have any outstanding financial liabilities with
state or local governments in Ohio? Does the applicant and/or company owe: a.)
Any delinquent taxes to the State of Ohio (the “State”), a state agency or a political
subdivision of the State such as a city or county? b.) Any monies to the State or a
state agency for the administration or enforcement of the environmental laws of
the State? c.) Any other monies to the State, a state agency or a political
subdivision of the State that are past due? d.) Is the company the subject of any
existing tax lien; e.) Is the company subject to any unresolved finding for recovery
issued by the Ohio Auditor of State?
☐ Yes
☐ No
2. Has the applicant, related companies, or any officers: a.) been convicted of a
felony b.) Been convicted of or enjoined from any violation of state or federal
securities law? c.) been a party to any consent order or entry with respect to an
alleged state or federal securities law violation? d.) been a defendant in a civil or
criminal action?
☐ Yes
☐ No
If you have answered yes to any of the above, please provide a detailed explanation
including, but not limited to, the location, amounts, and case identification
numbers (if applicable) on a separate sheet.
Certification Statement
I certify that to the best of my knowledge the information contained in this application
and in the supplemental material is correct and complete. I certify that the funding
requested satisfies the eligibility requirements for this Program as represented in the
Request for Proposals and related materials. I certify that I understand that the funding
under this Program is subject to restrictions and other conditions listed in the Program
Request for Proposals, including (inter alia):
☐
The applicant will use the funding under this Program for the specific purposes
defined in the Program Request for Proposals.
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