HomeMy WebLinkAboutDS Local Agency Technical Assistance Grant ApplicationNotarized Affidavit
My name is Cristine Alilovich I am Assistant City Manager [Title] of
City of San Rafael [Name of Organization to receive grant].
My personal knowledge of the facts stated herein has been derived from my employment with
City of San Rafael [Name of Organization to receive grant].
I swear or affirm that I have personal knowledge of the facts stated in this Application for a Local Agency
Technical Assistance Grant under the provisions of Decision (D.) 22-02-026, as authorized by the
Legislature and the California Public Utilities Commission, I am competent to testify to them, and I have
the authority to make this Application on behalf of and to bind the Organization.
I further swear or affirm that City of San Rafael [Name of Organization to receive grant]
agrees to comply with all federal and state statutes, rules, and regulations, including the California
Advanced Services Funds program rules the Commission establishes, covering broadband services and
state contractual rules and regulations, if granted a Local Agency Technical Assistance grant.
I further swear or affirm that City of San Rafael [Name of Organization to receive grant] agrees to comply
with the terms, conditions and requirements of the grant and thus submits to the jurisdiction of the
Commission with regard to the disbursement and administration of the grant if granted a Local Agency
Technical Assistance grant.
I swear or affirm that I agree to comply with Rules 1.11 and 2.2 of the California Public Utilities
Commission's Rules of Practice and Procedure.
I swear or affirm, under penalty of perjury, and under Rule 1.1 of the California Public Utilities
Commission's Rules of Practice and Procedure, that, to the best of my knowledge, all of the statements
and representations made in this Application are true and correct.
If City of San Rafael [Grantee Name] violates the terms and conditions of this award or other
program and project compliance requirements, it shall be subject to Public Utilities Code Sections 2108
and 2111. The Commission may impose the maximum penalties allowed under Public Utilities Code
sections 2108 and 2111 for failure to meet the program and project compliance requirements, as
determined by the Commission.
Signature and title /I 5I's
Crisiine Ahlovich, Assistani 01V Manager
Type or print name and title
SUBSCRIBED AND SWORN before me on the OTday of 20 d2oZ.
Notary Public In and For the State ofIV
My Commission expires ��64
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BRENNA KATHLEEN NURMI
zti Notary Public . California
` " a Marin County
Commission # 2297544
""'"" My Comm. Expires Jul 18, 2023
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of Marin
On AW M4 Awl � �Abefore me, Brenna Kathleen Nurmi, Notary Public
a 01(insert name and title of the officer)
personally appeared (_l IP h A- k lC.X
who proved to me on the basis of satisfactory evidence to be the person whose Warne{ aye
sutc,ribed to the within instrument and acknawfedged to me that l Ity executede same in
i th rauthorized capacitysigY�ature(gon the instrument the
pe( or the entity upon beha3f of wh:ch the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
BRENNA KATHLEEN NURMI
Notary Public - California
Marin County a
Commiss'i'on a 2297544
My Comm. Expires Jul 18, 2023
(Seal)