Reso 2021-173 Accept Grant Funds for Redevelopment of Memorial Park 1105 Bancroft

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PROJECT COMPLETION Certification Form GRANTEE: PROJECT Number: GRANTEE contact for audit purposes Name: Address: Phone: ( ) Email: PROJECT COMPLETION — list the features and support amenities (use additional pages, if needed): List other funds (sources and amounts) used on Project (use additional pages, if needed): Interest earned on advanced Grant funds: $ Interest spent on ELIGIBLE COSTS: $ Did the GRANTEE file a "Notice of Completion" with the County Recorder? Yes _ No 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 not exceeding ten thousand dollars, or both. I represent and warrant that I have full authority to execute this Project Completion Certification on behalf of the GRANTEE. I declare under penalty of perjury that the foregoing certification of Project Completion for the above -mentioned Grant is true and correct. GRANTEE'S AUTHORIZED REPRESENTATIVE Title (Printed or Typed name) GRANTEE'S AUTHORIZED REPRESENTATIVE (Signature) Date is