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Upon review of the Duplication of Benefits Reporting Form,the City may request additional information related to <br /> the funding sources listed above. Please maintain documentation for each of the sources of funds acquired during <br /> the period of performance for this agreement. <br /> I hereby certify that I have read the above certification, and that the information and my statements provided <br /> herein by me are true and correct to the best of my knowledge, and by my signature on this document, <br /> acknowledge my understanding that any intentional or negligent misrepresentation or falsification of any of the <br /> information in this document could subject me to punishment under federal and/or civil liability and/or in criminal <br /> penalties, including but not limited to fine or imprisonment or both under Title 18,United States Code,Sec. 1001, <br /> et seq.and punishment under federal law. <br /> i <br /> 1 <br /> John Olson '' <br /> Printed Name .ture <br /> Executive Director March 16, 2022 <br /> Title Date <br /> LIEVE R E T T Everett Forward Grant Program ( Subrecipient Agreement Page 17 <br /> WASHINGTON <br />