to both report information and request instructions from an agency related to real property under the same award
9. Comments. Provide any special notes or comments regarding the real property being reported or the report itself in
this block. Comments should relate to issues not addressed elsewhere in other sections of the report. Attach additional
sheets if necessary. If a negative report (no change in real property status) is being submitted for all parcels of real
property, enter the term “Negative” in this block. If there have been changes with some but not all parcels of real
property, identify the parcels with negative status in this block (as follows: “Negative status for the following Properties
:”) and provide the related attachment(s) for each parcel with changes to report.
10. Certification. By signing this report (block 11b.) the recipient is certifying that to the best of their knowledge and
belief the information contained in this report is true, correct and accurate and constitutes a material representation of
fact upon which the Federal government may rely. Note that a false statement of fact in this report may constitute a
violation of Federal law and may be grounds for possible punishment as provided in 18 U.S.C. 1001.
11a. Typed or Printed Name and Title of Authorized Certifying Official.
Enter the full name and title of the
authorized certifying official.
11b. Signature of Authorized Certifying Official. The authorized certifying official must sign here certifying to the facts
presented in the report. A copy of the governing body’s authorization for the certifying official to sign official documents
on behalf of their organization as an official representative must be on file in the recipient’s office. (See item 10. above.)
11c. Telephone. Enter the telephone number (including area code and extension) of the individual listed in section
11d. Email address. Enter the email address of the individual listed in section 11a.
11e. Date report submitted. Enter the date the report is submitted to the Federal agency using the following format
12. Agency use only. This section is reserved for Federal agency use only.