109.00.6 ATTACHMENT B. CRIMINAL BACKGROUND DISCLOSURE FORM - ECONOMIC DEVELOPMENT
AR ADC 109.00.6 ATTACHMENT BArkansas Administrative Code
Ark. Admin. Code 109.00.6 ATTACHMENT B
109.00.6 ATTACHMENT B. CRIMINAL BACKGROUND DISCLOSURE FORM - ECONOMIC DEVELOPMENT
In connection with the Application submitted to the Arkansas Development Finance Authority by __________(Name of Borrower) requesting participation in__________(Name of Program), I, __________(Principal)1, on behalf of __________(Borrower), being duly sworn, hereby certify that I, or any principal [FN2] of __________(Borrower):
have/has not been convicted by any state or federal jurisdiction of any felony:Or
have/has been convicted by a state or federal jurisdiction of a felony and the following details are provided:Jurisdiction | Date | Offense | Punishment | Details |
|---|---|---|---|---|
I, __________(Name), in my capacity as __________(Title/Position with Borrower), further certify that I have the authority and knowledge to make the representations contained herein and agree to the terms of ADFA's Criminal Background Check Policy.
Date: | |
(Signature) | |
(Printed/Typed Name) | |
(Title/Position with Borrower) |
STATE OF ______________________________ | ) |
) | |
COUNTY OF ______________________________ | ) |
Before me, __________, a Notary Public of the state and county stated above, personally appeared __________, with whom I have personal knowledge, and who, acknowledged that _he executed the foregoing instrument for the purpose stated therein.
Witness my hand and seal this __________ day of __________, 20__________.
My Commission Expires: | |
Notary Public |
Principal for purposes of this Attachment B shall include: if the borrower is a partnership, association, limited liability company, or corporation, any person who has at least a ten percent (10%) ownership interest in any ownership entity of such partnership, limited liability company or corporation.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 109.00.6 ATTACHMENT B, AR ADC 109.00.6 ATTACHMENT B
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