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<br />APPENDICES, Page | 63 <br /> <br />Grantees are required to update this list and submit it to the BSCC any time a new third- <br />party subcontract with an NGO is executed after the initial assurance date. Grantees shall <br />retain (on-site) applicable source documentation for each subcontracted party that verifies <br />compliance with the requirements listed in the Prop 64 PH&S Grant RFP. These records <br />will be subject to the records and retention language found in the standard BSCC Grant <br />Agreement. <br /> <br />Unless prior approval is obtained, the BSCC prohibits disbursement or reimbursement to <br />any NGO that does not meet the requirements listed above and for which the BSCC does <br />not have a signed Criteria and Assurance form on file. <br />A signature below is an assurance that all requirements listed above have been <br />met. <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 /> <br />7.C. - Page 71 of 101 <br />130