Agreement Number: RMC3
Exhibit S
Project Certification Form
GRANTEE NAME:
AGREEMENT NUMBER:
GRANTEE CONTACT FOR AUDIT PURPOSES
NAME
ADDRESS:
PHONE:
PROJECT DESCRIPTION – List facilities developed and/or property acquired
LIST OTHER FUNDS ON PROJECT (SOURCES AND AMOUNTS):
INTEREST EARNED ON ADVANCE GRANT AMOUNT: $
HAS A NOTICE OF COMPLETION BEEN FILED? YES NO
IF NO, PLEASE EXPLAIN:
CERTIFICATION:
I hereby certify that all grant funds were expended on the above named Project(s) within the
Performance Period of the Contract and/or the Amendments (___ through ___) and that the
Project(s) is/are complete and we have made final payment for all work done.
________________________________________ ___________________
Grantee Project Representative, Title Date
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5/2/2005