Common use of Claims Certification and Program Integrity Clause in Contracts

Claims Certification and Program Integrity. Anytime Contractor submits a claim to the County for reimbursement for services provided under Exhibit A of this Agreement, Contractor shall certify by signature that the claim is true and accurate by stating the claim is submitted under the penalty of perjury under the laws of the State of California. The claim must include the following language and signature line at the bottom of the form(s) and/or cover letter used to report the claim: “Under the penalty of perjury under the laws of the State of California, I hereby certify that this claim for services complies with all terms and conditions referenced in the Agreement with San Mateo County. Executed at California, on , 20 Signed Title Agency ” The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b) a. Employs fewer than 15 persons. b. Employs 15 or more persons and, pursuant to section 84.7 (a) of the regulation (45 C.F.R.

Claims Certification and Program Integrity. Anytime Contractor submits a claim to the County for reimbursement for services provided under Exhibit Schedule A of this Agreement, Contractor shall certify by signature that the claim is true and accurate by stating the claim is submitted under the penalty of perjury under the laws of the State of California. The claim must include the following language and signature line at the bottom of the form(s) and/or cover letter used to report the claim: “Under the penalty of perjury under the laws of the State of California, I hereby certify that this claim for services complies with all terms and conditions referenced in the Agreement with San Mateo County. Executed at California, on , 20 Signed Title Agency ” The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b) a. Employs fewer than 15 persons. b. Employs 15 or more persons and, pursuant to section 84.7 (a) of the regulation (45 C.F.R.

Claims Certification and Program Integrity. Anytime Contractor submits a claim to the County for reimbursement for services provided under Exhibit A of this Agreement, Contractor shall certify by signature that the claim is true and accurate by stating the claim is submitted under the penalty of perjury under the laws of the State of California. The claim must include the following language and signature line at the bottom of the form(s) and/or cover letter used to report the claim: “Under the penalty of perjury under the laws of the State of California, I hereby certify that this the claim for services complies with all terms and conditions referenced in the Agreement with San Mateo County. Executed at California, on , 20 2004 Signed Agency Title Agency ” (Required only from Contractors who provide services directly to the Public on The undersigned (hereinafter called the "“Contractor(s)"”) hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of and for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b) ) a. Employs (/) employs fewer than 15 persons. . b. Employs ( ) employs 15 or more persons and, pursuant to section Section 84.7 (a) of the regulation (45 C.F.R.C.F.R. 84.7 (a)), has designated the following person(s) to coordinate its efforts to comply with the DHHS regulation. Name of 504 Person - Type or Print TGMC Residential Care Facilities, Inc. dba Golden Manor 443 ▇’▇▇▇▇▇▇ Street Name of Contractor(s) - Type or Print ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇ ▇▇ ▇▇▇ ▇▇▇▇▇ ▇▇▇▇ ▇▇ ▇▇▇▇▇ City State Zip Code I certify that the above information is complete and correct to the best of my knowledge. ~ 2.~€,2~0O4 ~c.Qrthi~ ~TWz ~dfl~Tc~t Date Signature and Title of Authorized Official *Exception: DHHS regulations state that: “If a recipient with fewer than 15 employees finds that, after consultation with a handicapped person seeking its services, there is no method of complying with (the facility accessibilty regulations).. .other than making a significant alteration in its existing facilities, the recipient may, as an alternative, refer the handicapped person to other providers of those services that are accessible.” Name of Contractor: TGMC Residential Care Facilitiesjpc dba Golden Manor Contact Person: ▇▇▇▇ ▇▇▇▇▇ Address: 443 O’▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇ Phone Number: ▇▇▇-▇▇▇-▇▇▇▇ Fax Number: Does the Contractor have any employees? ~ Yes — No Does the Contractor provide benefits to spouses of employees? j~No U Yes, the Contractor complies by offering equal benefits, as defined by Chapter 2.93, to / its employees with spouses and its employees with domestic partners.