FEDERAL GRANT #: GRANTEE/UGLG NAME: B ___ DC 55 0001 – – – – DEHCR GRANT AGREEMENT #: B ___ DF 55 0001 – – – – B ___ DI 55 0001 – – – – B ___ DN 55 0001 – – – – E ___ DC 55 0001 – – – – M ___ SG 55 0001 – – – – MBE/WBE REPORT For DEHCR Use ONLY PREPARER CERTIFICATION I hereby certify that, to the best of my knowledge and belief, the contents in this report are true and correct. Full Name of Preparer’s Report Preparer: Signature: Job Title & Preparer’s Date Signed: Company/Employer: Preparer’s Preparer’s ( ) _____ _______ ext. ____ – Telephone Email Address: Number: For Grantees / UGLGs: Signature of the Chief Elected Official Typed Name of the Chief Elected Official Title Date Signed
FEDERAL GRANT #: GRANTEE/UGLG NAME: B – ___ – DC – 55 – 0001 DEHCR GRANT AGREEMENT #: B – ___ – DF – 55 – 0001 B – ___ – DI – 55 – 0001 B – ___ – DN – 55 – 0001 MBE/WBE REPORT E – ___ – DC – 55 – 0001 M – ___ – SG – 55 – 0001 For DEHCR Use ONLY PREPARER CERTIFICATION I hereby certify that, to the best of my knowledge and belief, the contents in this report are true and correct. Full Name of Report Preparer: Preparer’s Signature: Preparer’s Job Title & Company/Employer: Date Signed: Preparer’s Telephone Number: ( ) _____ – _______ ext. ____ Preparer’s Email Address: For Grantees / UGLGs: Signature of the Chief Elected Official Typed Name of the Chief Elected Official Title Date Signed