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Everett Forward Grant Program | Subrecipient Agreement | Page 17 <br />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 /> <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 /> <br /> <br /> <br /> <br /> <br />_____________________________ ______________________________ <br />Printed Name Signature <br /> <br /> <br />_____________________________ ______________________________ <br />Title Date <br /> <br /> <br /> <br />Ken Salem <br />Director of Strategic Initiatives <br />Ken Salem <br />12/20/2023