Attestation Statement Sample Clauses

Attestation Statement. A Responsible Company Official must sign the Attestation Statement (Attachment B) indicating understanding of the Privacy Act restrictions relating to the use of this service. The signed and dated Statement must be submitted to SSA with this User Agreement. If the Responsible Company Official signing the original Attestation Statement leaves the company or no longer has authority to make legally binding commitments on behalf of the company, a new Responsible Company Official must submit a new signed Attestation Statement prior to the submission of any new SSN verification requests.
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Attestation Statement. I verify that the information provided above is true and correct to the best of my knowledge and belief. Printed Name of Parent/Guardian Signature Address City State Zip Code Phone Number Email Date OMB Control No. 1810-0021 (Exp. 04/30/2023) For Parent/Guardians:
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Attestation Statement. Notwithstanding the foregoing, no Performance Assurance Formatted: Indent: Hanging: 36
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Attestation Statement. Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy of the information supplied. The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals and make such information available to the individual in accordance with the requirements of the Privacy Act. PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021. The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 000 Xxxxxxxx Xxxxxx, X.X., XXX/Xxxx 0X000, Xxxxxxxxxx, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020. 0000 X 000xx Xx Tukwila WA 98168 (000) 000-0000 Xxxxxxx.xxxxxx.xxx STUDENT HISTORY INFORMATION (complete for grades 6-12) Student’s Name: Birth Date: / / Month Day Year Washington State law (RCW 28A.225.330) permits a school district to request that you briefly indicate in writing whether the above-named student has any past, current, or pending disciplinary action or any history of violent behavior. This same statute also requires school districts to request school records of such actions or behaviors. This information will be used to plan for the appropriate placement and program for the student and to ensure the safety of others. The existence of disciplinary actions or violent behaviors will not, by themselves, bar the enrollment of the student. The Tukwila School District Board of Directors has also determined that the absence of records known to exist implies an immediate and continuing danger to the student or others, or an immediate and continui...
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Attestation Statement. Notwithstanding the foregoing, no Performance Assurance requirement will be required for the Customer’s TSR if the Customer has an NT Transmission Service Agreement, the Customer’s Eligible TSR is for transmission of a new Network Resource, and the Customer submits a statement attesting to the resource and generation conditions specified in section 29.2(viii) of the OATT.
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Attestation Statement. As an anticipated enrollee in North Carolina Central University’s School of Business, I have read, understand and accept all terms and conditions outlined within this program agreement. I also understand that the institution reserves the right to cancel or modify this program at any time. If the student is a minor (below the age of 18), a parent or legal guardian must also sign this agreement. Print Name Date
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Related to Attestation Statement

  • LITIGATION STATEMENT CHECK ONE [ ] The undersigned bidder has had no litigation and/or judgments entered against it by any local, state or federal entity and has had no litigation and/or judgments entered against such entities during the past ten (10) years. [ ] The undersigned bidder, BY ATTACHMENT TO THIS FORM, submits a summary and disposition of individual cases of litigation and/or judgments entered by or against any local, state or federal entity, by any state or federal court, during the past ten (10) years. COMPANY NAME AUTHORIZED SIGNATURE NAME (PRINT OR TYPE) TITLE Failure to check the appropriate blocks above may result in disqualification of your bid. Likewise, failure to provide documentation of a possible conflict of interest, or a summary of past litigation and/or judgments, may result in disqualification of your bid. E VERIFICATION CERTIFICATION Contract No.Y20-1058-MV I hereby certify that I will utilize the U.S. Department of Homeland Security’s E-Verify system in accordance with the terms governing the use of the system to confirm the employment eligibility of the individuals classified below. In accordance with s. 837.06, Florida Statutes, I understand and acknowledge that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duties shall be guilty of a misdemeanor in the second degree, punishable as provided in s. 775.082 or s. 775.083, Florida statutes. All persons, including subcontractors and their workforce, who will perform work under Contract No.Y20-1058-MV, Heavy Equipment Parts and Labor, within the state of Florida. NAME OF CONTRACTOR: ADDRESS OF CONTRACTOR: AUTHORIZED SIGNATURE: TITLE: DATE: RELATIONSHIP DISCLOSURE FORM FOR USE WITH PROCUREMENT ITEMS, EXCEPT THOSE WHERE THE COUNTY IS THE PRINCIPAL OR PRIMARY BIDDER For procurement items that will come before the Board of County Commissioners for final approval, this form shall be completed by the Bidder and shall be submitted to the Procurement Division by the Bidder. In the event any information provided on this form should change, the Bidder must file an amended form on or before the date the item is considered by the appropriate board or body. Part I INFORMATION ON BIDDER: Legal Name of Bidder: Business Address (Street/P.O. Box, City and Zip Code): Business Phone: ( ) Facsimile: ( ) INFORMATION ON XXXXXX’S AUTHORIZED AGENT, IF APPLICABLE: (Agent Authorization Form also required to be attached) Name of Bidder’s Authorized Agent: Business Address (Street/P.O. Box, City and Zip Code): Business Phone: ( ) Facsimile: ( ) Part II IS THE BIDDER A RELATIVE OF THE MAYOR OR ANY MEMBER OF THE BCC? YES NO IS THE MAYOR OR ANY MEMBER OF THE BCC THE BIDDER’S EMPLOYEE? YES NO IS THE BIDDER OR ANY PERSON WITH A DIRECT BENEFICIAL INTEREST IN THE OUTCOME OF THIS MATTER A BUSINESS ASSOCIATE OF THE MAYOR OR ANY MEMBER OF THE BCC? YES NO If you responded “YES” to any of the above questions, please state with whom and explain the relationship. (Use additional sheets of paper if necessary) Part III

  • Antitrust Certification Statements (Tex Government Code § 2155.005) By submission of this bid or proposal, the Bidder certifies that: I affirm under penalty of perjury of the laws of the State of Texas that: (1) I am duly authorized to execute this contract on my own behalf or on behalf of the company, corporation, firm, partnership or individual (Company) listed below; (2) In connection with this bid, neither I nor any representative of the Company has violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus. & Comm. Code Chapter 15; (3) In connection with this bid, neither I nor any representative of the Company has violated any federal antitrust law; (4) Neither I nor any representative of the Company has directly or indirectly communicated any of the contents of this bid to a competitor of the Company or any other company, corporation, firm, partnership or individual engaged in the same line of business as the Company.

  • Problem/ Solution Statement Problem California’s forest health crisis is an emergency of unprecedented scope and scale, with disastrous implications for the state’s environment, economy, energy systems, and human life. Unlike essentially all other technologies and solutions proposed to respond to the crisis, gasification has the potential to process forest waste in a way that extracts value and sequesters a large portion of its carbon. Before the recipient’s development of the pre- commercial Powertainer technology, no one had developed gasification technology that could economically respond to the problem. As a result, there have not yet been any large-scale deployments of distributed, commercial-scale gasification technology. The acceleration of tree mortality and persistent drought conditions make finding solutions to this problem more critical with each passing day.

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