Texas Environmental Research Consortium
The following are forms to be completed as part of the proposal package. The forms included are:

Application Form: HARC Form 52

Instructions for Application Form: HARC Form 52 Instructions

Key Contacts Form: HARC Form 53

Additional Key Contacts: HARC Form 54

Itemized budget: HARC Form 55 (found in a separate file as it is an excel spreadsheet)

Abstract: HARC Form 56

Current and Pending Projects: HARC Form 57

Certification Regarding Lobbying, Suspension and Debarment, Single Audit: HARC
Form 58

List of Authorized Personnel: HARC Form 59

Certification regarding use of Certified Labs

TERC Conflict of Interest Policy and Certification
Revised: 04/08

Texas Environmental Research Consortium
Application Form – HARC Form 52
Complete all of the following information including signature.
Please insert the project number and title for the proposal being submitted:
________ (project number: title)
1. Applicant Information
Legal Name of Organization: Organizational Unit:
Address (street, city, state, zip code):
Employer Identification Number (EIN):
Principal Investigator
Telephone Number:
E-mail address:
Administrative Contact:
Telephone Number:
E-mail address:
2. Type of Applicant (enter appropriate letter): a. University
___ c. National Laboratory b. Profit Organization d. Non-profit Organization
3. Type of Application: ___ New
4. Total Funding Requested:
____ Continuation
$__________________ e. Other (specify):
____________________________
____ Revision ____ RFQ
5. Proposed Project Schedule: ____________ Start Date ___________End Date
6. Is this proposal being submitted to another funding source?
____Yes _____ No If yes, list organization:___________________________
7.
To the best of my knowledge and belief, all data in this application are true and correct. The document has been duly authorized by the governing body of the applicant and the applicant will comply with Federal certifications regarding Debarment, Suspension and other Responsibility Matters from covered transactions by any Federal department or agency. The applicant also certifies to the best of his/her knowledge or belief that it is in compliance with the Federal Lobbying Certification for Contracts, Grants, Loans and Cooperative Agreements and that any subsequent subcontracts made from this award, should this contract be awarded, are subject to these same assurances.
Typed Name of
Authorized Representative Title Telephone number
Signature of Authorized Representative Date Signed
__________________________________ ______________
HARC use only
Date and Time Received: __________________ Received By: ________________________________
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Texas Environmental Research Consortium
Instructions for HARC Form 52
Top section: If proposal is in response to an RFP, list the project code and title that corresponds to your proposal.
Section l. Applicant information
Provide the legal name of the institution or organization that is submitting this proposal
Provide the complete mailing address for this institution/organization
Provide the Employer Identification Number (EIN) provided by the IRS
Provide the name of the organizational unit or department under which this proposal is being developed
Provide the name, telephone number and e-mail address of the Principal Investigator (P.I.) for this proposal
Provide the name, telephone number and e-mail address of the person identified as the project Administrative
Contact
Section 2. Type of Applicant
Specify the type of institution or organization submitting this proposal.
If other than those listed please specify the type of institution or organization
Section 3.
Type of Application: Specify if this is a new application, a continuation of previous research conducted, or a revision of an application previously made to HARC.
Section 4.
Total of Funding Requested: Provide the total amount of funding being requested in this proposal.
Section 5 . Proposed Project Schedule:
Note the expected start date for initiation of this project.
Note the expected date for completion of this project. This should reflect the date on which you expect to be able to submit completed work to HARC.
Section 6. Is this project being submitted to another funding source?
If you or your sponsoring organization has already submitted or plan to submit this project in expectation of receiving funding from another organization please acknowledge by marking yes or no. If yes, please list the funding organization.
Section 7. Authorization and Assurances
Read carefully the information contained in Section 7 prior to signing as the Authorized Representative:

That all the information contained in the proposal as submitted is true and correct to the best of your knowledge.
 That your signature equates with your governing body’s agreement to participate.

That the governing body is assuring compliance with Federal Certification regarding Debarment, Suspension and other Responsibility Matters from covered transaction by any Federal Department or Agency.

That the applicant certifies to the best of his/her knowledge that the agency is in compliance with the Federal
Lobbing Certification for Contract, Grants, Loans and Cooperative Agreements, and that any subsequent subcontract made from this award, should this contract be awarded, is subject to the same assurances.
Please provide the name, title, and telephone number of the duly Authorized Representative typed in the space provided.
The Authorized Representative shall sign and date the application.
This original signed hard copy shall be submitted to HARC.
Revised: 04/08

Texas Environmental Research Consortium
Key Contacts Form – HARC 53
 Authorized Representative : Original awards and amendments will be sent to this individual for review and acceptance, unless otherwise indicated.
Name:
Title:
Complete Address:
Phone Number:
Fax Number:
E-mail Address:

Payee : Individual authorized to accept payments
Name:
Title:
Complete Address:
Phone Number:
Fax Number:
E-mail Address:
 Administrative Contact : Individual to contact concerning contracting and administrative matters:
Name:
Title:
Phone Number: Fax Number:
E-mail Address:
Financial Contact : Individual to contact concerning financial questions relative to invoices submitted:

Name:
Title:
Phone Number: Fax Number:
E-mail Address:
Name:
Title:
Phone Number:
E-mail Address:

Principal Investigator: Individual responsible for the technical completion of the proposed work.
Fax Number:
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Texas Environmental Research Consortium
Additional Key Contacts (use as many sheets as needed) – HARC Form 54
 Major Co-Investigator: Individual responsible for the completion of major portions of the proposed work.



Name:
Title:
Phone Number:
E-mail Address:
Fax Number:
Major Co-Investigator: Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
E-mail Address:
Fax Number:
Major Co-Investigator : Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
E-mail Address:
Fax Number:
Major Co-Investigator : Individual responsible for the completion of major portions of the proposed work.
Name:
Title:
Phone Number:
E-mail Address:
Fax Number:
 Other : Individual responsible for _______________________________ (describe).
Name:
Title:
Phone Number:
E-mail Address:
Fax Number:
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Texas Environmental Research Consortium
Budget Form and Justification Instructions
Allowable costs are those costs deemed allowable in the Texas Uniform Grant Management
Standards (UGMS) (1 Texas Administrative Code §5.141- 5.167), the TCEQ Allowable
Expenditures Guidelines and all applicable state rules and law.
Describe the basis for calculating the personnel, costs, travel, equipment, supplies, contractual support, and other costs identified in the itemized budget and explain the basis for their calculation. The budget justification must not exceed two consecutively numbered (bottom center), 8.5x11-inch pages with 1-inch margins.
A. Personnel: List name and position, the percent of time budgeted to this project, and the rate or rates used to calculate personnel cost. Rates may include fringe benefits or burdened hourly rates.
B. Travel: Travel costs, including per diem, will be reimbursed only in the amount of actual costs, up to the maximum allowed by law for Texas state employees' travel at the time the cost is incurred. Reimbursement for costs will not exceed actual costs and in no case will they exceed the market price in the local area where the Contract Activity is performed. Travel by volunteers will not be reimbursed.
Specify travel and purpose (i.e., fieldwork, attendance at meetings, etc.) for the proposed work.
Provide basis for cost estimates (i.e., number of travelers, airfare, per diem, miles traveled, mileage allowance, hotel rates, etc.).
C. Equipment: List, describe, and justify any equipment required. Equipment is defined as any item costing $5,000 or more with a useful lifespan of more than one year. Allowable items will be limited to research equipment necessary and not available to conduct this project.
D. Supplies: List and justify all supply items and provide the cost basis for the amount requested.
E. Subcontracts: Describe the need and basis for subcontractors listed. Provide the cost basis for budgeted amount.
F. Other Costs: List and justify other direct cost items and describe the cost basis for budgeted amount.
G. Indirect Cost Rate: There is a 15% cap on indirect costs and only those institutions with a negotiated IDC rate may request this. Proof of a federally negotiated IDC rate must be provided at the time of contracting.
Revised: 04/08

Texas Environmental Research Consortium
Abstract – HARC Form 56 – One Page Limit
Project Code:
Investigators:
Institution/Organization:
Project Period:
Title:
Total Budget:
Revised: 04/08

Texas Environmental Research Consortium
Current and Pending Projects – HARC Form 57
List other projects on which the Principal Investigator and other key personnel are currently working or projects that are anticipated within the time frame of the proposed project.
Name and Dates of Project Funding Source
Position on Project
(PI, Co-PI, Collaborator, Consultant) and % time committed
Revised: 04/08

Texas Environmental Research Consortium
HARC Form 58
CERTIFICATION REGARDING LOBBYING
Houston Advanced Research Center
Certification for Contracts and Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) None of these Federal or State of Texas appropriated funds have been paid or will be paid to employ, as a regular full-time or part-time or contract employee, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) None of these State of Texas appropriated funds have been or will be used to pay, on behalf of the agency or an officer or employee of the agency, membership dues to an organization that pays part or all of the salary of a person who is required by the Texas Ethics Commission under Chapter 305 to register as a lobbyist.
(3) None of these State of Texas funds have been or will be used to pay a person or entity required to register with the Texas Ethics Commission under Chapter 305; or any partner, employee, employer, relative, contractor, consultant, or related entity of a person or entity that is required to register with the
Texas Ethics Commission under Chapter 305; or a person or entity that has been or will be hired to represent associations or other entities for the purpose of affecting the outcome of legislation, agency rules, ordinances, or other governmental policies.
(3) Violation of this certification subjects the undersigned to reduction of amounts appropriated for administration in an amount not to exceed $100,000 for each violation and/or become ineligible to receive additional State of Texas funds.
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure, if such funding is Federal.
____________________________________________
Name and Title of Authorized Representative
____________________________________________
Signature of Authorized Representative
Date____________
Revised: 04/08

Texas Environmental Research Consortium
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal or
State department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
(3) All lower tier participants shall be required to sign this form.
Name of Applicant ___________________________________________________________
Name of Program ___________________________________________________________
____________________________________________
Name and Title of Authorized Representative
_____________________________________________ ______________
Signature of Authorized Representative Date
Revised: 04/08

Texas Environmental Research Consortium
The applicant is not a local government or non-profit and therefore is not required to submit an annual single audit. The applicant understands and agrees, however, that the TCEQ may contract for or conduct an audit of a grant recipient’s grant-funded program.
The applicant is a local government or non-profit and currently expends combined state funds of less than $500,000 per year and, therefore, is not required to submit an annual single audit. The applicant understands and agrees, however, that the TCEQ may contract for or conduct an audit of a grant recipient’s grant-funded programs.
The applicant is a local government or non-profit and currently expends state funding of
$500,000 or more per year and, therefore, is required to submit an annual single audit to the
Grant Manager by an independent auditor made in accordance with UGMS. The applicant understands and agrees that, in addition to the single audit requirements, that the TCEQ may also contract for or conduct an audit of a grant recipient’s grant-funded program.
__________________________________________
Signature of Authorized Representative
______________
Date
Revised: 04/08

Texas Environmental Research Consortium
Please list all personnel that will be working on this project.
Project Number:
P.I. Name:
Organization :
It is anticipated the personnel to be paid on the above project include:
Personnel Hourly Rate (Salary only)
Revised: 04/08

Texas Environmental Research Consortium
HARC Form 60
CERTIFICATION REGARDING USE OF CERTIFIED LABS
Houston Advanced Research Center
Certification for Contracts and Agreements
If any laboratory produces data under this Contract and the preparation of such data commences on or after July 1, 2008, the laboratory must be accredited by TCEQ according to Title 30 Texas
Administrative Code (TAC) Chapter 25 (relating to Environmental Testing Laboratory Accreditation and Certification) Subchapters A and B as amended, for the matrices, methods, and parameters of analysis, unless TCEQ agrees in writing to allow one of the regulatory exceptions specified in 30 TAC
25.6.
The undersigned certifies, to the best of his or her knowledge and belief, that (please check only one):
(1) Applicable data may be produced under this contract and the laboratory has been accredited by TCEQ according to Title 30 Texas Administrative Code (TAC) Chapter
25 (relating to Environmental Testing Laboratory Accreditation and Certification)
Subchapters A and B as amended, for the matrices, methods, and parameters of analysis.
(2) Applicable data may be produced under this contract and TCEQ has agreed in writing to allow one of the regulatory exceptions specified in 30 TAC 25.6 for the laboratory.
Copy of waiver is provided.
(3) Applicable data may be produced under this contract through the procurement of services from a third-party laboratory that has been accredited by TCEQ according to
Title 30 Texas Administrative Code (TAC) Chapter 25 (relating to Environmental
Testing Laboratory Accreditation and Certification) Subchapters A and B as amended, for the matrices, methods, and parameters of analysis.
Name of certified laboratory: _____________________________________________
(4) Applicable data may be produced under this contract and the HARC project manager and TCEQ liaison agree that the laboratory techniques to be employed in this project are not subject to the certification requirements. Copy of documentation is provided.
(5) There will be no applicable data produced under this contract.
Date____________ ____________________________________________
Signature of Authorized Representative
____________________________________________
Name and Title of Authorized Representative
Name of Organization and Subcontract number
Revised: 04/08

Texas Environmental Research Consortium
Texas Environmental Research Consortium
Conflict of Interest Policy
Section 1. Purpose
The Texas Environmental Research Consortium (TERC) is a 501(c)(3) nonprofit organization that is dedicated to improving air quality throughout the State of Texas by improving policymakers’ and scientists’ understanding of ozone and other pollutants to assure the development of scientifically valid and cost effective air quality policies. It is also TERC’s mission to facilitate the development, commercialization and certification of new technologies to maximize emission reductions.
It is the policy of TERC to adhere rigorously to the highest moral and ethical standards.
Its mission and responsibilities are to be administered in a professional manner that assure maximum consideration relative to ethical, moral and legal conduct of its affairs.
Section 2. Definitions
A.
Conflicts of Interest. A Conflict of Interest exists when a real or perceived private interest of a Director, Officer, Contractor, Consultant, Committee Member or other employee is in conflict with the interests of TERC, as when such individual receives improper personal benefit as a result of his or her position with TERC or when the individual has other duties, loyalties, responsibilities or obligations that are, or may be viewed as being, inconsistent with those of TERC.
B.
Interested Person. Any Board Member, Officer, Member of a Committee,
Contractor or Consultant with Board-held or delegated powers who has a direct or indirect financial interest in a TERC matter.
C.
Financial Interest. A person has a financial interest if the person has, directly or indirectly, through business, investment or family: an ownership or investment interest in any entity with which TERC has a transaction or arrangement or which stands to benefit from TERCsponsored projects; or a compensation arrangement with TERC or with any entity or individual with which TERC has a transaction or arrangement or which stands to benefit from TERC-sponsored projects; or
3. a potential ownership or investment interest in, or compensation arrangement with, any entity or individual with which TERC is negotiating a transaction or arrangement or which stands to benefit from
TERC-sponsored projects.
The payment or receipt of items such as political contributions, dues payments, legal and consulting fees and the like shall not constitute receipt of an improper personal benefit unless such items directly relate to TERC business or projects.
D.
Family. Family includes spouse, parent, children, siblings, grandparents, grandchildren, sons and daughters-in-law, and brothers and sisters-in-law.
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Texas Environmental Research Consortium
Section 3. Conflict of Interest Policy. The activities of TERC’s Directors, Officers,
Employees, Committee Members, Contractors and Consultants are expected to fully comply with all applicable laws, rules and regulations. Additionally, Directors, Officers, Employees,
Committee Members, Contractors and Consultants of TERC may not personally benefit from his or her relationship or employment with TERC except through compensation received directly from TERC. Conflicts of Interest are prohibited as a matter of TERC policy. Each Director,
Officer, Employee, Committee Member, Contractor or Consultant is to manage his or her personal and professional affairs in such a way as to avoid conflicts of interest and to avoid creating the appearance of a conflict of interest. TERC’s research and technology decisions must be based solely on the best interests of TERC, without regard to personal, family, business or other extraneous considerations. Relationships and arrangements which may be the basis of a conflict of interest are:
A. Direct or indirect financial interest in a company which maintains a business contracting or subcontracting relationship with TERC, without advance written disclosure to and approval by the Chairman of the Board of Directors and/or
TERC’s Executive Director.
Receipt of salary, fees or any other direct or indirect remuneration for services from a company which maintains a business, contracting or subcontracting relationship with TERC or which stands to benefit from TERC-sponsored projects;
Employment, whether public or private, in an organization which may impact the operations of TERC in a regulatory, business, contracting or subcontracting manner, without advance written disclosure to and approval by the Chairman of the Board of Directors of TERC and/or TERC’s Executive Director.
Receipt of any gifts, favors, or preferential treatment that might reasonably tend to affect the discharge of official duties of an officer, member of the Board of Directors, contractor, subcontractor or Committee Member of TERC.
Securing privileges or exemptions for oneself or another because of one’s service as an officer, member of the Board of Directors, contract, subcontractor or Committee
Member of TERC.
Disclosure or use of confidential information for personal gain. Confidential information includes, but is not limited to, financial, personnel, intellectual and technology information regarding contractors, subcontractors, applicants and all organizations that maintain a direct or indirect relationship with TERC.
Use of TERC’s personnel, materials, assets, or other resources for direct or indirect personal benefit.
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Texas Environmental Research Consortium
Section 4. Procedures.
A.
Duty to Disclose By Director or Committee Member.
1.
A Director or Committee Member shall have the affirmative duty to disclose any possible conflict of interest at the time it arises as well as in the annual conflict of interest statement that must be completed.
2.
In connection with any actual or possible conflicts of interest, a Director or Committee Member must disclose the existence of his or her financial interests and all material facts relating thereto to the Board of Directors and Members of Committees with Board-delegated powers considering the proposed transaction or arrangement.
B.
Determining Whether a Conflict of Interest Exists. After disclosure of the financial interest and all material facts relating thereto, and after any discussion thereof, the interested person shall leave the Board or committee meeting while the financial interest is discussed and voted upon. The remaining Board or committee members shall decide if a conflict of interest exists.
C.
Addressing a Conflict of Interest. When the Board or a Board committee is considering a transaction, arrangement or project that could result in a conflict of interest for a particular member, the following steps must be taken:
1.
The Member with a potential conflict shall leave the meeting during the discussion and vote relating to the transaction, arrangement or project that would result in a conflict of interest; and
2.
The members present shall determine, by majority vote, whether the transaction, arrangement or project is in TERC’s best interest and for its own benefit, and whether it is fair and reasonable to TERC.
D.
Violations of the Conflicts of Interest Policy.
1.
If the Board or Committee has reasonable cause to believe that a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose.
2.
If, after hearing the response of the member and making such further investigation as may be warranted in the circumstances, and the Board or
Committee determines that the member has, in fact, failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action.
Section 5.
Duty to Disclose by TERC’s Executive Director and Consultant(s). TERC’s
Executive Director and Consultant(s) are strictly prohibited from engaging in any activity that constitutes a real or perceived conflict of interest. Real or perceived conflicts of interest shall be brought to the immediate attention of the Chairman of the Board of Directors. The Executive
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Texas Environmental Research Consortium
Director and Consultant(s) shall fully resolve any real or perceived conflicts of interest as prescribed by the Chairman of the Board of Directors and in the best interests of TERC.
Section 6. Duty to Disclose by the Houston Advanced Research Center. The Houston
Advanced Research Center (HARC) serves as TERC’s Research and Technology Manager.
Accordingly, HARC is integrally involved in administering TERC’s air quality research and technology programs. TERC compensates HARC for the services it provides. HARC, its employees, contractors and consultants are strictly prohibited from engaging in any activities that would constitute a real or perceived conflict of interest. HARC shall have the duty to disclose any potential real or perceived conflict of interest involving itself, its employees, contractors and consultants in writing to TERC’s Executive Director and Board Chairman. HARC shall assure prompt resolution of any real or perceived conflict of interest as prescribed by the Executive
Director and Board Chairman. HARC and its employees, contractors and consultants also shall complete TERC’s Conflict of Interest Certification form annually.
Section 7. Failure to Resolve Conflicts of Interest. The failure of TERC’s Executive
Director, Consultant and HARC to resolve conflicts of interest as described above may result in immediate termination of these persons’ or entities’ employment or contractual relationships with TERC.
Section 8. Bribery. Directors, Officers, Employees, Consultants And Contractors are strictly forbidden from offering, promising or giving money, gifts, loans, rewards, favors or anything of value to anyone, including governmental officials, employees, agents or other intermediary(ies)
(either inside or outside the United States) which is prohibited by law. Those paying a bribe may subject TERC and themselves to civil and criminal penalties. Accordingly, no improper payments will be tolerated.
Section 9. Records of Proceedings. The minutes of the Board and all committees with
Board-delegated powers shall contain:
A.
Names of Persons with Financial Interest. The names of the persons who disclosed or otherwise were found to have a financial interest in connection with an actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present, and the
Board’s or committee’s decision as to whether a conflict of interest in fact existed.
B.
Names of Persons Present. The names of the persons who were present for discussions and votes relating to the transaction, arrangement or project, the content of the discussion, including any alternatives to the proposed transaction, arrangement or project, and a record of any votes taken in connection therewith.
Section 10. Annual Certification. In addition to disclosing and acting on conflicts of interest as they arise, TERC’s Board Members, Officers, Employees, Consultants and Contractors shall complete a Certification Statement at the end of each year acknowledging receipt of a copy of
TERC’s Conflict of Interest Policy and certifying compliance with this policy.
Attachment: TERC’s Conflict of Interest Certification Form.
Revised: 04/08
AUSTIN: 980000.30000: 327627v2

Texas Environmental Research Consortium
Texas Environmental Research Consortium
Conflict of Interest Policy Certification Statement
I hereby acknowledge receipt of a copy of the Conflict of Interest Policy of the Texas
Environmental Research Consortium (“TERC”), which applies to my professional and personal dealings with TERC. By executing this Certification Statement, I acknowledge that I have read and understand TERC’s Conflict of Interest Policy and agree to be bound by all provisions therein. I further acknowledge that I am now and all relevant times have been in compliance with its provisions.
Signature Date
Print Name
Revised: 04/08

Texas Environmental Research Consortium
Texas Environmental Research Consortium
Conflict of Interest Policy Certification Statement
I hereby acknowledge receipt of the Conflict of Interest Policy of the Texas
Environmental Research Consortium (“TERC”), which applies to the professional and personal dealings of employees within our organization who are working on projects funded by TERC through the Houston Advanced Research Center (HARC).
By executing this Certification Statement, I acknowledge that I have forwarded this policy and received certification statements from those employees involved with a
TERC project. The executed Certification Statements will be on file in our grants office for auditing purposes.
I further acknowledge that our organization is now and all relevant times have been in compliance with its provisions.
Signature Date
Print Name
_____________________________________
Organizational Name
Revised: 04/08