HomeMy WebLinkAbout171-21 RESOLUTION113 West Mountain Street
Fayetteville, AR 72701
(479) 575-8323
Resolution: 171-21
File Number: 2021-0458
CORONA VIRUS STATE FISCAL RECOVERY FUND AGREEMENT:
A RESOLUTION TO AUTHORIZE CHIEF FINANCE OFFICER PAUL BECKER TO SIGN A
CORONA VIRUS STATE FISCAL RECOVERY FUND AGREEMENT WHICH WILL ALLOW
THE CITY OF FAYETTEVILLE TO REQUEST FEDERAL FUNDS PURSUANT TO
RECOVERY FUND LEGISLATION
WHEREAS, the American Rescue Plan Act passed by Congress has allocated direct funding to
municipalities with populations over 50,000; and
WHEREAS, to access to that funding, municipalities must register on-line, name an authorized
representative whose identity is verified and have that representative sign the funding agreement; and
WHEREAS, the Mayor has assigned Paul Becker, Chief Financial Officer of the City of Fayetteville,
to register as the authorized signer; and
WHEREAS, CFO Paul Becker's identity has been verified by the Treasury Department; and
WHEREAS, the City Council needs to authorize CFO Paul Becker to sign the Corona Virus State
Fiscal Recovery Fund Agreement so the City can receive its the allocation which is expected to be
approximately $17.9 million.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
FAYETTEVILLE, ARKANSAS:
Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes Paul Becker,
Chief Financial Officer, to sign a Corona Virus State Fiscal Recovery Fund Award Terms and
Page 1 Printed on 0/10121
Resolution: 171-21
File Number: 2021-0458
Conditions Agreement, a copy of which is attached to this Resolution, as the City of Fayetteville's
Authorized Representative.
PASSED and APPROVED on 6/15/2021
Attest:
�•�G�
Kara Paxton, City Clerk TreagB t
.,,G /N i o`,,
Page 2 Printed on 6116121
City of Fayetteville, Arkansas 113 West Mountain Street
Fayetteville, AR 72701
(479)575-8323
Text File
File Number: 2021-0458
Agenda Date: 6/15/2021 Version: 1 Status: Passed
In Control: City Council Meetinq File Type: Resolution
Agenda Number: 1.
CORONA VIRUS STATE FISCAL RECOVERY FUND AGREEMENT:
A RESOLUTION TO AUTHORIZE CHIEF FINANCE OFFICER PAUL BECKER TO SIGN A
CORONA VIRUS STATE FISCAL RECOVERY FUND AGREEMENT WHICH WILL ALLOW THE
CITY OF FAYETTEVILLE TO REQUEST FEDERAL FUNDS PURSUANT TO RECOVERY FUND
LEGISLATION
WHEREAS, the American Rescue Plan Act passed by Congress has allocated direct funding to municipalities
with populations over 50,000; and
WHEREAS, to access to that funding, municipalities must register on-line, name an authorized representative
whose identity is verified and have that representative sign the funding agreement; and
WHEREAS, the Mayor has assigned Paul Becker, Chief Financial Officer of the City of Fayetteville, to
register as the authorized signer; and
WHEREAS, CFO Paul Becker's identity has been verified by the Treasury Department; and
WHEREAS, the City Council needs to authorize CFO Paul Becker to sign the Corona Virus State Fiscal
Recovery Fund Agreement so the City can receive its the allocation which is expected to be approximately
$17.9 million.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
FAYETTEVILLE, ARKANSAS:
Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes Paul Becker, Chief
Financial Officer, to sign a Corona Virus State Fiscal Recovery Fund Award Terms and Conditions
Agreement, a copy of which is attached to this Resolution, as the City of Fayetteville's Authorized
Representative.
City of Fayetteville, Arkansas Page 1 Printed on 611612021
City Council Meeting Walk On
Paul Becker
Submitted By
City of Fayetteville Staff Review Form
2021-0458
Legistar File ID
6/15/2021
City Council Meeting Date - Agenda Item Only
N/A for Non -Agenda Item
6/10/2021 CHIEF FINANCIAL OFFICER (110)
Submitted Date Division / Department
Action Recommendation:
Staff recommends approving Paul Becker (Chief Financial Officer) to sign the attached Coronavirus State Fiscal
Recovery Fund Award Terms and Conditions agreement as the City of Fayetteville Authorized Representative
Account Number
Project Number
Budgeted Item? No
Does item have a cost? No
Budget Adjustment Attached? No
Budget Impact:
Fund
Project Title
Current Budget $ -
Funds Obligated $ -
Current Balance
Item Cost $ -
Budget Adjustment $ -
Remaining Budget
V20210527
Purchase Order Number: Previous Ordinance or Resolution #
Change Order Number: Approval Date:
Original Contract Number:
Comments: Accounts will be determined once an expenditure plan is approved by City Council.
CITY OF
FAYETTEVILLE
ARKANSAS
MEETING OF JUNE 15, 2021
TO: Mayor and City Council
THRU: Mayor Lioneld Jordan
FROM: Paul Becker, Chief Financial Officer
DATE: June 10, 2021
CITY COUNCIL MEMO
SUBJECT: Staff recommends approving Paul Becker (Chief Financial Officer) to sign the
attached Coronavirus State Fiscal Recovery Fund Award Terms and Conditions
agreement as the City of Fayetteville Authorized Representative
RECOMMENDATION:
To approve Paul Becker, CFO to sign the attached Coronavirus State Fiscal Recovery Fund
agreement which will allow the City to request federal funds pursuant to recovery fund
legislation from the Department of the Treasury. The allocation to the City is expected to be
approximately $17.9 million.
BACKGROUND / DISCUSSION:
The American Rescue Plan Act passed by Congress has allocated direct funding to
municipalities with populations over 50,000. However, access to that funding requires
municipalities to register on-line, name an authorized representative whose identity is verified
and have that representative sign the funding agreement.
The Mayor assigned Paul Becker, Chief Financial Officer of the City of Fayetteville, to register
as the authorized signer. Mr. Becker's identity has been verified by the Treasury Department,
and the City may now apply for the transfer of authorized funds to the City. To accomplish this,
the authorized signer (CFO of the City of Fayetteville) must sign the funding agreement which
indicates the condition that must be meet in the expenditure of the funds. A copy of that
agreement is attached. Once the funds are received the Mayor will bring a recommended
expenditure plan to the City Council. The Council may then approve or amend that
recommendation of eligible expenditures prior to any spending. The funds must be appropriated
by the City Council before any expenditure can be made. The administrative staff is currently
identifying eligible uses of these funds; no plan has yet been developed for your consideration.
BUDGET/STAFF IMPACT:
If approved the request for allocated funding will be submitted to the Treasury Department and
the money will be sent to the City to be held in escrow until a funding plan is appropriated by the
Council.
ATTACHMENTS:
Coronavirus State Fiscal Recovery Fund Award Terms and Conditions
Mailing Address:
113 W. Mountain Street www.fayetteville-ar.gov
Fayetteville, AR 72701
OMB Approved No. 1505-0271
Expiration Date: 11/30/2021
U.S. DEPARTMENT OF THE TREASURY
CORONAVIRUS STATE FISCAL RECOVERY FUND
Recipient name and address: DUNS Number:-
City of Fayetteville Taxpayer Identification Number:
113 West Mountain Street Assistance Listing Number and Title:
Fayetteville, Arkansas 72701
Sections 602(b)(2) and 603(b) of the Social Security Act (the Act) as added by section 9901 of the American Rescue Plan Act,
Pub. L. No. 117-2 (March 11, 2021) authorizes the Department of the Treasury (Treasury) to make payments to certain recipients
from the Coronavirus State Fiscal Recovery Fund and the Coronavirus Local Fiscal Recovery Fund.
Recipients hereby agrees, as a condition to receiving such payment from Treasury, agrees to the terms attached hereto.
Recipient:
-p-1 a , ZJ"
Authorized Representative Signature (above)
Authorized Representative Name: p Ire
Authorized Representative Title: CFO 6. t%Y r-r-% F_ Q LL e A
Date Signed: -tee , t t- 1 p- I
U.S. Department of the Treasury:
Authorized Representative Signature (above)
Authorized Representative Name:
Authorized Representative Title:
Date Signed:
PAPERWORK REDUCTION ACT NOTICE
The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of
information is 15 minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed
to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the
form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
control number assigned by OMB.
U.S. DEPARTMENT OF THE TREASURY
CORONAVIRUS STATE FISCAL RECOVERY FUND
AWARD TERMS AND CONDITIONS
1. Use of Funds.
a. Recipient understands and agrees that the funds disbursed under this award may only be used in compliance with sections
602(c) and 603(c) of the Social Security Act (the Act) and Treasury's regulations implementing that section and guidance.
b. Recipient will determine prior to engaging in any project using this assistance that it has the institutional, managerial, and
financial capability to ensure proper planning, management, and completion of such project.
2. Period of Performance. The period of performance for this award begins on the date hereof and ends on December 31, 2026. As
set forth in Treasury's implementing regulations, Recipient may use award funds to cover eligible costs incurred during the period
that begins on March 3, 2021 and ends on December 31, 2024.
3. Renorting. Recipient agrees to comply with any reporting obligations established by Treasury, as it relates to this award.
4. Maintenance of and Access to Records
a. Recipient shall maintain records and financial documents sufficierit to evidence compliance with sections 602(c) and
603(c), Treasury's regulations implementing those sections, and guidance regarding the eligible uses of funds.
b. The Treasury Office of Inspector General and the Government Accountability Office, or their authorized representatives,
shall have the right of access to records (electronic and otherwise) of Recipient in order to conduct audits or other
investigations.
c. Records shall be maintained by Reci_ient for a Deriod of five (5) years after all funds have been expended or returned to
Treasury, whichever is later.
5. Pre -award Costs. Pre -award costs, as defined in 2 C.F.R. § 200.458, may not be paid with funding from this award.
6 Administrative Costs. Recipient may use funds provided under this award to cover both direct and indirect costs.
7. Cost Sharing Cost sharing or matching fonds are not required to be provided by Recipient.
8. Conflicts of Interest. Recipient understands and agrees it must maintain a conflict of interest policy consistent with 2 C.F.R. §
200.318(c) and that such conflict of interest policy is applicable to each activity funded under this award. Recipient and
subrecipients must disclose in writing to Treasury or the pass -through entity, as appropriate, any potential conflict of interest
affecting the awarded funds in accordance with 2 C.F.R. § 200.112.
9 Compliance with Applicable Law and Regulations.
a. Recipient agrees to comply with the requirements of sections 602 and 603 of the Act, regulations adopted by Treasury
pursuant to sections 602(f) and 603(f) of the Act, and guidance issued by Treasury regarding the foregoing. Recipient also
agrees to comply with all other applicable federal statutes, regulations, and executive orders, and Recipient shall provide for
such compliance by other parties in any agreements it enters into with other parties relating to this award.
b. Federal regulations applicable to this award include, without limitation, the following:
i. rTnif* r Administrative Requirements5 Cost Principles; and Audit Requirements for Federal Awards. 2 C.F.R. Part
_11110200, other than such provisions as Treasury may determine are inapplicable to this Award and subject to such
exceptions as may be otherwise provided by Treasury. Subpart F — Audit Requirements of the Uniform Guidance,
implementing the Single Audit Act, shall apply to this award.
ii. Universal Identifier and System for Award Management (SAM), 2 C.F.R. Part 25, pursuant to which the award term
set forth in Appendix A to 2 C.F.R. Part 25 is hereby incorporated by reference.
iii. Reporting Subaward and Executive Compensation Information, 2 C.F.R. Part 170, pursuant to which the award term
set forth in Appendix A to 2 C.F.R. Part 170 is hereby incorporated by reference.
iv. OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement), 2 C.F.R. Part
180, including the requirement to include a term or condition in all lower tier covered transactions (contracts and
subcontracts described in 2 C.F.R. Part 180, subpart B) that the award is subject to 2 C.F.R. Part 180 and Treasury's
implementing regulation at 31 C.F.R. Part 19.
v. Recipient Integrity and Performance Matters, pursuant to which the award term set forth in 2 C.F.R. Part 200,
Appendix XII to Part 200 is hereby incorporated by reference.
vi. Govemmentwide Requirements for Drug -Free Workplace, 31 C.F.R. Part 20.
vii. New Restrictions on Lobbying, 31 C.F.R. Part 21.
viii. Uniform Relocation Assistance and Real Property Acquisitions Act of 1970 (42 U.S.C. §§ 4601-4655) and
implementing regulations.
ix. Generally applicable federal environmental laws and regulations.
c. Statutes and regulations prohibiting discrimination applicable to this award, include, without limitation, the following:
i. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d et seq.) and Treasury's implementing regulations at 31
C.F.R. Part 22, which prohibit discrimination on the basis of race, color, or national origin under programs or
activities receiving federal financial assistance;
ii. The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§ 3601 et seq.), which prohibits
discrimination in housing on the basis of race, color, religion, national origin, sex, familial status, or disability;
iii. Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794), which prohibits discrimination on the
basis of disability under any program or activity receiving federal financial assistance;
iv. The Age Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101 et seq.), and Treasury's implementing
regulations at 31 C.F.R. Part 23, which prohibit discrimination on the basis of age in programs or activities
receiving federal financial assistance; and
v. Title II of the Americans with Disabilities Act of 1990, as amended (42 U.S.C. §§ 12101 et seq.), which prohibits
discrimination on the basis of disability under programs, activities, and services provided or made available by state
and local governments or instrumentalities or agencies thereto.
10. Remedial Actions. In the event of Recipient's noncompliance with sections 602 and 603 of the Act, other applicable laws,
Treasury's implementing regulations, guidance, or any reporting or other program requirements, Treasury may impose additional
conditions on the receipt of a subsequent tranche of future award funds, if any, or take other available remedies as set forth in 2
C.F.R. § 200.339. In the case of a violation of sections 602(c) or 603(c) of the Act regarding the use of funds, previous payments
shall be subject to recoupment as provided in sections 602(e) and 603(e) of the Act.
11. Hatch Act. Recipient agrees to comply, as applicable, with requirements of the Hatch Act (5 U.S.C. §§ 1501-1508 and
7324-7328), which limit certain political activities of State or local government employees whose principal employment is in
connection with an activity financed in whole or in part by this federal assistance.
12. False Statements. Recipient understands that making false statements or claims in connection with this award is a violation of
federal law and may result in criminal, civil, or administrative sanctions, including fines, imprisonment, civil damages and
penalties, debarment from participating in federal awards or contracts, and/or any other remedy available by law.
13. Publications. Any publications produced with funds from this award must display the following language: "This project [is
being] [was] supported, in whole or in part, by federal award number [enter project FAIN] awarded to City of Fayetteville by the
U.S. Department of the Treasury."
14. Debts Owed the Federal Government.
a. Any funds paid to Recipient (1) in excess of the amount to which Recipient is finally determined to be authorized to retain
under the terms of this award; (2) that are determined by the Treasury Office of Inspector General to have been misused; or
(3) that are determined by Treasury to be subject to a repayment obligation pursuant to sections 602(e) and 603(e) of the
Act and have not been repaid by Recipient shall constitute a debt to the federal government.
b. Any debts determined to be owed the federal government must be paid promptly by Recipient. A debt is delinquent if it has
not been paid by the date specified in Treasury's initial written demand for payment, unless other satisfactory arrangements
have been made or if the Recipient knowingly or improperly retains funds that are a debt as defined in paragraph 14(a).
Treasury will take any actions available to it to collect such a debt.
15. Disclaimer.
a. The United States expressly disclaims any and all responsibility or liability to Recipient or third persons for the actions of
Recipient or third persons resulting in death, bodily injury, property damages, or any other losses resulting in any way from
the performance of this award or any other losses resulting in any way from the performance of this award or any contract,
or subcontract under this award.
b. fhe acceptance of this award by Recipient does not in any way establish an agency relationship between the Uniied States
and Recipient.
16. Protections for Whistleblowers.
a. In accordance with 41 U.S.C. § 4712, Recipient may not discharge, demote, or otherwise discriminate against an employee
in reprisal for disclosing to any of the list of persons or entities provided below, information that the employee reasonably
believes is evidence of gross mismanagement of a federal contract or grant, a gross waste of federal funds, an abuse of
authority relating..to a federal contract or grant,_a substantial and Specific danger to .public health_or_safety, .or a violation of
law, rule, or regulation related to a federal contract (including the competition for or negotiation of a contract) or grant.
b. The list of persons and entities referenced in the paragraph above includes the following:
i. A member of Congress or a representative of a committee of Congress;
ii. An Inspector General;
iii. The Government Accountability Office;
iv. A Treasury employee responsible for contract or grant oversight or management;
v. An authorized official of the Department of Justice or other law enforcement agency;
vi. A court or grand jury; or
vii. A management official or other employee of Recipient, contractor, or subcontractor who has the responsibility to
investigate, discover, or address misconduct.
c. Recipient shall inform its employees in writing of the rights and remedies provided under this section, in the predominant
native language of the workforce.
17. Increasing Seat Belt Use in the United States. Pursuant to Executive Order 13043, 62 FR 19217 (Apr. 18, 1997), Recipient
should encourage its contractors to adopt and enforce on-the-job seat belt policies and programs for their employees when
operating company -owned, rented or personally owned vehicles.
18. Reducing Text Messaging While Driving. Pursuant to Executive Order 13513, 74 FR 51225 (Oct. 6, 2009), Recipient should
encourage its employees, subrecipients, and contractors to adopt and enforce policies that ban text messaging while driving, and
Recipient should establish workplace safety policies to decrease accidents caused by distracted drivers.
OMB Approved No. 1505-0271
Expiration Date: 11/30/2021
ASSURANCE OF COMPLIANCE WITH CIVIL RIGHTS REQUIREMENTS
ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE
CIVIL RIGHTS ACT OF 1964
As a condition of receipt of federal financial assistance from the Department of the Treasury, the City of Fayetteville (hereinafter
referred to as "the Recipient") provides the assurances stated herein. The federal financial assistance may include federal grants,
loans and contracts to provide assistance to the recipient's beneficiaries, the use or rent of Federal land or property at below market
value, Federal training, a loan of Federal personnel, subsidies, and other arrangements with the intention of providing assistance.
Federal financial assistance does not encompass contracts of guarantee or insurance, regulated programs, licenses, procurement
contracts by the Federal government at market value, or programs that provide direct benefits. This assurance applies to all federal
financial assistance from or funds made available through the Department of the Treasury, including any assistance that the
Recipient may request in the future.
The Civil Rights Restoration Act of 1987 provides that the provisions of this assurance apply to all of the recipient's programs,
services and activities, so long as any portion of the recipient's program(s) is federally assisted in the manner proscribed above.
1. Recipient ensures its current and future compliance with Title VI of the Civil Rights Act of 1964, as amended, which
prohibits exclusion from participation, denial of the benefits of, or subjection to discrimination under programs and
activities receiving federal funds, of any person in the United States on the ground of race, color, or national origin (42
U.S.C. § 2000d et seq.), as implemented by the Department of the Treasury Title VI regulations at 31 CFR Part 22 and
other pertinent executive orders such as Executive Order 13166; directives; circulars; policies; memoranda and/or guidance
documents.
2. Recipient acknowledges that Executive Order 13166, "Improving Access to Services for Persons with Limited English
Proficiency," seeks to improve access to federally assisted programs and activities for individuals who, because of national
origin, have Limited English proficiency (LEP). Recipient understands that denying a person access to its programs,
services, and activities because of LEP is a form of national origin discrimination prohibited under Title VI of the Civil
Rights Act of 1964 and the Department of the Treasury's implementing regulations. Accordingly, Recipient shall initiate
reasonable steps, or comply with the Department of the Treasury's directives, to ensure that LEP persons have meaningful
access to its programs, services, and activities. Recipient understands and agrees that meaningful access may entail
providing language assistance services, including oral interpretation and written translation where necessary, to ensure
effective communication in the Recipient's programs, services, and activities.
3. Recipient agrees to consider the need for language services for LEP persons during development of applicable budgets and
when conducting programs, services and activities. As a resource, the Department of the Treasury has published its LEP
guidance at 70 FR 6067. For more information on LEP, please visit hitp://www.lep.gov.
4. Recipient acknowledges and agrees that compliance with this assurance constitutes a condition of continued receipt of
federal financial assistance and is binding upon Recipient and Recipient's successors, transferees and assignees for the
period in which such assistance is provided.
5. Recipient acknowledges and agrees that it must require any sub -grantees, contractors, subcontractors, successors,
transferees, and assignees to comply with assurances 1-4 above, and agrees to incorporate the following language in every
contract or agreement subject to Title VI and its regulations between the Recipient and the Recipient's sub -grantees,
contractors, subcontractors, successors, transferees, and assignees:
The sub -grantee, contractor, subcontractor, successor, transferee, and assignee shall comply with Title VI of the
Civil Rights Act of 1964, which prohibits recipients of federal financial assistance from excluding from a program
or activity, denying benefits of, or otherwise discriminating against a person on the basis of race, color, or
national origin (42 U.S.C. § 2000d et seq.), as implemented by the Department of the Treasury's Title VI
regulations, 31 CFR Part 22, which are herein incorporated by reference and made apart of this contract (or
agreement). Title VI also includes protection to persons with "Limited English Proficiency " in any program or
activity receiving federal financial assistance, 42 U.S.C. § 2000d et seq., as implemented by the Department of the
Treasury's Title VI regulations, 31 CFR Part 22, and herein incorporated by reference and made apart of this
contract or agreement.
6. Recipient understands and agrees that if any real property or structure is provided or improved with the aid of federal
financial assistance by the Department of the Treasury, this assurance obligates the Recipient, or in the case of a subsequent
transfer, the transferee, for the period during which the real property or structure is used for a purpose for which the federal
financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any
personal property is provided, this assurance obligates the Recipient for the period during which it retains ownership or
possession of the property;
7. Recipient shall cooperate in any enforcement or compliance review activities by the Department of the Treasury of the
aforementioned obligations. Enforcement may include investigation, arbitration, mediation, litigation, and monitoring of
any settlement agreements that may result from these actions. That is, the Recipient shall comply with information requests,
on -site compliance reviews, and reporting requirements.
S. Recipient shall maintain a complaint log and inform the Department of the Treasury of any complaints of discrimination on
the grounds of race, color, or national origin, and limited English proficiency covered by Title VI of the Civil Rights Act of
1964 and iniplernenting regulations and provide, upon request, a list of all such reviews or proceedings based on the
complaint, pending or completed, including outcome. Recipient also must inform the Department of the Treasury if
Recipient has received no complaints under Title VI..
9. Recipient must provide documentation of an administrative agency's or court's findings of non-compliance of Title V1 and
efforts to address the non-compliance, including any voluntary compliance or other agreements between the Recipient and
the administrative agency that made the finding. If the Recipient settles a case or matter alleging such discrimination, the
Recipient must provide documentation of the settlement. If Recipient has not been the subject of any court or administrative
agency finding of discrimination, please so state.
10. If the Recipient makes sub -awards to other agencies or other entities, the Recipient is responsible for ensuring that
sub -recipients also comply with Title VI and other applicable authorities covered in this document State agencies that make
sub -awards roust have in place standard grant assurances and review procedures to demonstrate that that they are effectively
monitoring the civil rights compliance of sub -recipients.
The United States of America has the right to seek judicial enforcement of the terms of this assurances document
and nothing in this document alters or limits the federal enforcement measures that the United States may take in order to
address violations of this document or applicable federal law.
Under penalty of perjur , the unders-geed official(s) cerhfirc that hr/che nas reaC ar_u ttn�erSt (t tic r)hll�al.)nnC aS
herein described, that any information submitted in conjunction with this assurance document is accurate and complete, and
that the Recipient is in compliance with the aforementioned nondiscrimination requirements.
c ►I Y o a F A -t F -ci E v t Lt.L 7, �
Recipient Date
1V Q.S, a -
Signature of Authorized Official:
PAPERWORK REDUCTION ACT NOTICE
The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of
information is 15 minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed
to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the
form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
control number assigned by OMB.