Attestation of Connected Communities Implementation Grant Milestone 4 Completion The undersigned, , hereby certifies (Name and Title) that I am a duly authorized representative of (Organization Name) and that all details listed in the Use Case Volume Table, submitted as part of the deliverables for Milestone 4, are accurate and have been sustained over a 3-month period. In addition, the transactions, substantiated by the transaction log provided by the HIE vendor, are complete, true and correct. Note, providing false or misleading information or failure to provide all required information will be considered grounds for disqualification and require the repayment of any grant funds previously paid. By signing I attest to the accuracy of all information submitted in response to this grant and verify that the information submitted is in fact complete, accurate and true. Signed and sworn under the penalties of perjury Dated at: (location) This day of , 201_. By: (Signature) Name: (Printed or Typed) Title/Position:
Attestation of Connected Communities Implementation Grant Milestone 4 Completion The undersigned, , hereby certifies (Name and Title) that I am a duly authorized representative of (Organization Name) and that all details listed in the Use Case Volume Table, submitted as part of the deliverables for Milestone 4, are accurate and have been sustained over a 3-month period. In addition, the transactions, substantiated by the transaction log provided by the HIE vendor, are complete, true and correct. Note, providing false or misleading information or failure to provide all required information will be considered grounds for disqualification and require the repayment of any grant funds previously paid. By signing I attest to the accuracy of all information submitted in response to this grant and verify that the information submitted is in fact complete, accurate and true. Signed and sworn under the penalties of perjury Dated at: (location) This day of , 201_. By: (Signature) Name: (Printed or Typed) Title/Position:
CC%20Milestone%204%20Attestation_08.31.17.docx