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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
SUBRECIPIENT CERTIFICATION OF PHYSICAL INVENTORY
Subrecipient Name: Contact Person:
Address: Phone Number:
I hereby certify that all property/equipment previously purchased with or transferred from the
Comprehensive Employment and Training Act (CETA) or the Job Training Partnership Act
(JTPA) program to the Workforce Investment Act (WIA) programs or purchased under any
Colorado Department of Labor and Employment (CDLE) federally funded grant or transferred
with the CDLE’s approval is included in the attached listing for the above-noted subrecipient.
The attached listing has been verified by a physical inventory. Changes/revisions are:
Noted Not Applicable
I certify that this property is being used for purposes that it was originally purchased for and
will be repaired or replaced by my insurance if damaged, lost, or stolen.
I certify that all property/equipment previously purchased with or transferred from the CETA
or the JTPA programs to WIA program or purchased under a CDLE federally funded grant or
transferred with the CDLE’s approval with a fair market value (FMV), established by our
existing local procedures, of $5,000 or more, has been identified.
I further certify that the proceeds of all property/equipment previously purchased with or
transferred from the CETA or JTPA program to the WIA program, with a FMV of $5,000 or
more, will be returned to CDLE, in order to return the proceeds to the U.S. Department of
Subrecipient Director's Signature Date
OYMENT
ENTORY
ansferred from the
ng Partnership Act
chased under any
grant or transferred
oted subrecipient.
visions are:
purchased for and
ed from the CETA
ally funded grant or
established by our
purchased with or
FMV of $5,000 or
Department of
COLORADO DEPARTMENT OF LABOR AND EMPLOY
CONTRACT CLOSEOUT TAX CERTIFICATION
In the performance of Contract/Grant Agreement Number
Expenditure Authorizations (EAs) awarded under said Contract/Grant Agreement, identified
as VAX/FCS123 number(s) : ,
, , ,
, , ,
, , ,
, , ,
I certify that I have complied with requirements of the law and the Colorado Department of Labor and Em
Grant Recipient Name:
Grant Recipient Address:
Grant Recipient Employer:
Employer's Identification Number:
This certification has been executed this day of
By
Authorized Signature
Title
OF LABOR AND EMPLOYMENT
UT TAX CERTIFICATION
, including the
ement, identified
, ,
, ,
, ,
, ,
, ,
o Department of Labor and Employment, regarding the obtaining of
, 2005.
Authorized Signature
GRANT RECIPIENT'S ASSIGNMENT OF REFUNDS, REBATES, AND CREDITS
Grant Recipient's Name: Contract/Grant Agreement
Street Address: No:
City and State:
Pursuant to the terms of Contract/Grant Agreement Number , including the
Expenditure Authorizations (EAs) awarded under said Contract/Grant Agreement, identified as
VAX/FCS123 number(s) : , , ,
, , , , ,
, , , , ,
, , , , ,
, , , , ,
, , , , ,
and in consideration of the reimbursement of costs and payment of fee, as provided in the said Contract/Grant Agreement and any
assignment thereunder, the Grant Recipient's Name and Address (hereinafter called the Grant Recipient) does hereby:
1. Assign, transfer, set over and release to the Colorado Department of Labor and Employment (hereinafter called
CDLE), all right, title and interest to all refunds, rebates credits or other amounts (including any interest thereon)
arising out of the performance of the said contract/grant agreement, together with all the rights of action accrued
on which may hereafter accrue thereunder.
2. Agree to take whatever action may be necessary to effect prompt collection of as such refunds, rebates, credits
or other amounts (including any interest thereon due or which may become due, and to forward promptly to
CDLE.
3. Agree to cooperate fully with CDLE as to any claim or suit in connection with such refunds, rebates, credits or
other amounts due (including an interest thereon): execute any protest, pleading, application, power of attorney
or other papers in connection therewith; and to permit CDLE to represent it at an hearing, trial or other
proceeding arising out of such claim or suit.
This assignment has been executed this day of , 2006.
By
Authorized Signature
Title
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
SCHEDULE OF UNCLAIMED CHECKS
Grant Recipient Name:
Contract/Grant Agreement Number:
Release Date:
VAX/FSC123 Check Check Payee's Last Known
Number Number Payee Amount Address
Total Amount Unclaimed
This schedule has been executed this day of , 2006.
By
Authorized Signature
Title
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
GRANT RECIPIENT'S RELEASE
Grant Recipient's Name:
Address:
Pursuant to the terms of Contract/Grant Agreement Number , including the Expenditure
Authorizations (EAs) awarded under said Contract/Grant Agreement, as VAX/FCS123 number(s):
, , , , , ,
, , , , , ,
, , , , , ,
, , , , , ,
and in consideration of the sum of Total amount paid of and payable of
($ of Unclaimed Checks Total) under the said Contract to
(Contractor's Name and Address)
hereafter called the Grant Recipient or to its assignees, if any, the Grant Recipient, upon payment of the said sum by the COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT, hereinafter called CDLE, does remise,
release, and discharge CDLE, its officers, agents, and employees, of and from all liabilities, obligations, claims, and demands whatsoever under or arising from said Contract/Grant Agreement except:
1.
Specified claims in stated amounts or in estimated amounts where the amounts are not susceptible of exact statement by the Grant Recipient, as follows( if none, so state):
VAX/ Invoice Expected
FCS123 Date Invoice Line Cost Payment
Number (If Known) Vendor or P.O. # Item Category Amount Amount
2.
Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Grant Recipient to third parties arising out of the performance of the said contract, which are not known to the Grant
Recipient on the date of the execution of this release and of which the Grant Recipient gives notice in writing to the CDLE within the period specified in the said Contract/Grant Agreement.
3.
Claims after closeout, for costs which results from the liability to pay Unemployment Insurance costs under a reimbursement system or to settle Worker's Compensation claims.
This release has been executed this day of , 2005.
By
Authorized Signature
Title
nditure
,
,
,
,
,
and payable of
tor's Name and Address)
led CDLE, does remise,
Expected
Payment
Amount
not known to the Grant
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Attachment I
Page 6 of 6
PHYSICAL INVENTORY LIST
Grant Recipient Name:
Contract/Grant Agreement Number:
Release Date:
VAX/FSC123 Purchase Property Program Funding SERIAL # Property Property
Number Date Description of Property Costs Sources if applicable Location Condition
Total Amount
I certify to the best of my knowledge and belief the above reported information is accurate and complete
for the period reported.
This Physical Inventory List has been executed this 2006
day of ___________________, 2005
By
Authorized Signature
Title
Revised: 6/05 57e2047e-912f-46f5-850c-ba83645237b7.xls
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