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<br />APPENDICES, Page | 61 <br /> <br />REQUIRED ATTACHMENT: Applicants will be prompted to upload this document to the <br />BSCC Submittable Application Portal. This is a sample. <br />Download a fillable form from the Prop 64 Grant homepage. <br /> <br />It is the policy of the BSCC to protect grant funds from unreasonable risks of fraudulent, <br />criminal, or other improper use. As such, the Board will not enter into contracts or provide <br />reimbursement to applicants that have been: <br /> <br />1. debarred by any federal, state, or local government entities during the period of <br />debarment; or <br />2. convicted of fraud, theft, or embezzlement of federal, state, or local government grant <br />funds for a period of three years following conviction. <br /> <br />Furthermore, the BSCC requires grant recipients to provide an assurance that there has been <br />no applicable debarment, disqualification, suspension, or removal from a federal, state or <br />local grant program on the part of the grantee at the time of application and that the gra ntee <br />will immediately notify the BSCC should such debarment or conviction occur during the term <br />of the Grant contract. <br /> <br />The BSCC also requires that all grant recipients include, as a condition of award to a <br />subgrantee or subcontractor, a requirement that the subgrantee or subcontractor will provide <br />the same assurances to the grant recipient. If a grant recipient wishes to consider a <br />subgrantee or subcontractor that has been debarred or convicted, the grant recipient must <br />submit a written request for exception to the BSCC along with supporting documentation. <br /> <br />By signing below, applicant affirms that: <br />• I/We are not currently debarred by any federal, state, or local entity from applying for <br />or receiving federal, state, or local grant funds. <br />• I/We have not been convicted of any crime involving theft, fraud, or embezzlement of <br />federal, state, or local grant funds within the last three years. We will notify the BSCC <br />should such debarment or conviction occur during the term of the grant contract. <br />• I/We will hold subgrantees and subcontractors to these same requirements. <br /> <br />A grantee may make a request in writing to the Executive Director of the BSCC for an <br />exception to the debarment policy. Any determination made by the executive director shall <br />be made in writing. <br /> <br />AUTHORIZED SIGNATURE <br />(This document must be signed by the person who is authorized to sign the Grant Agreement.) <br />NAME OF AUTHORIZED OFFICER TITLE TELEPHONE NUMBER <br /> <br />STREET ADDRESS CITY STATE ZIP CODE <br /> <br />EMAIL ADDRESS <br /> <br />AUTHORIZED OFFICER SIGNATURE (Blue Ink Only or E-signature) DATE <br /> <br />APPENDIX E <br />Certification of Compliance with BSCC Policies <br />Regarding Debarment, Fraud, Theft, and Embezzlement <br />7.C. - Page 69 of 101 <br />128