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<br />38 <br /> <br /> PROJECT COMPLETION Certification Form <br /> <br />GRANTEE: ______________________________________ PROJECT Number: _________________ <br /> <br />GRANTEE contact for audit purposes <br /> <br />Name: __________________________________________________________________________ <br /> <br />Address: ________________________________________________________________________ <br /> <br />Phone: (_____) __________________ Email: _______________________________________ <br /> <br />PROJECT COMPLETION – list the features and support amenities (use additional pages, if needed): <br /> <br /> <br />List other funds (sources and amounts) used on Project (use additional pages, if needed): <br /> <br /> <br />Interest earned on advanced Grant funds: $ ________________ <br />Interest spent on ELIGIBLE COSTS: $ ________________ <br /> <br />Did the GRANTEE file a “Notice of Completion” with the County Recorder? Yes __ No __ <br /> <br />Certification: <br />I hereby certify that all Grant funds were expended on the above named Project and that the Project is <br />complete and we have made final payment for all work done. <br />I have read California Penal Code §118 and understand that every person who testifies, declares, deposes, <br />or certifies under penalty of perjury and willfully states as true any material matter which he or she knows to <br />be false, is guilty of perjury, which is a felony punishable by imprisonment in state prison for two, three, or four <br />years. <br />Furthermore, I have read California Penal Code §72 and understand that every person who, with the intent to <br />defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or District <br />board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, <br />voucher, or writing, is guilty of a felony-misdemeanor punishable either by imprisonment in county jail for a <br />period of not more than one year, by a fine not exceeding one thousand dollars, or both, or by imprisonment <br />in state prison, by a fine not exceeding ten thousand dollars, or both. <br />I represent and warrant that I have full authority to execute this Project Completion Certification on behalf of <br />the GRANTEE. I declare under penalty of perjury that the foregoing certification of Project Completion for the <br />above-mentioned Grant is true and correct. <br /> <br />__________________________________________ ______________________________ <br />GRANTEE’S AUTHORIZED REPRESENTATIVE Title <br />(Printed or Typed name) <br /> <br />__________________________________________ ______________________________ <br />GRANTEE’S AUTHORIZED REPRESENTATIVE (Signature) Date <br /> <br /> <br />202