EXHIBIT A. CORONAVIRUS STATE FISCAL RECOVERY FUND ACCEPTANCE CERTIFICATION
AR ADC 006.09.4 Exh. AArkansas Administrative CodeEffective: May 5, 2022
Effective: May 5, 2022
Ark. Admin. Code 006.09.4 Exh. A
EXHIBIT A. CORONAVIRUS STATE FISCAL RECOVERY FUND ACCEPTANCE CERTIFICATION
I, _____________________________________________, certify that I am the Chief Executive Officer, or equivalent officer, (Chief Executive) of ________________________________________ located in ______________________________, Arkansas (Subrecipient) and, on behalf of the Subrecipient, I hereby certify, represent, warrant and agree that:
1. I have the authority to bind the Subrecipient by this certification and to make each Coronavirus State Fiscal Recovery Fund (“SFRF”) Request seeking direct payment and/or reimbursement whether now or hereafter requested from the COVID-19 Testing Program created by the State of Arkansas and managed by the Arkansas Department of Finance and Administration (“Department”); and
a. All payment and reimbursement requests only qualify if: (i) such request is for funds to cover the cost of COVID-19 testing for an employee who is subject to an employer-required or employer-mandated COVID-19 vaccination or immunization, whose health benefit plan does not cover the cost of COVID-19 testing, and who wishes to continue employment by claiming an exemption under one of the options of the specific exemption process provided for by Ark. Code Ann. § 11-5-118 (Act 1115 of the 2021 Regular Session, 93rd General Assembly); and (ii) such cost having been incurred during the period that begins January 14, 2022 and ends on July 31, 2023; and
5. Failure of any SFRF Request or any use of SFRF Funds to meet any COVID-19 Testing Program qualifications and requirements, or if there is any misrepresentation made by the Subrecipient related to this certification, shall require, upon any request of the Department, that the Subrecipient repay to the State of Arkansas the related COVID-19 Testing Program funds.
I certify under the penalties of perjury that I have read the above certification and my statements contained herein are true and correct to the best of my knowledge.
[Print Participant Name here]
By: __________________________________________________
Signature: _____________________________________________
Title: __________________________________________________
Date: __________________________________________________
STATE OF ARKANSAS | ) | |
) | SS: | |
COUNTY OF __________ | ) |
Before me, a Notary Public in and for said County and State, personally appeared ______________________________, known to me to be the Chief Executive Officer or equivalent officer of ___________________________________, and I acknowledge the execution of the foregoing.
Witness my hand and Notarial Seal this ___ day of __________, 202__.
________________________________________ | |
My Commission Expires: | Notary Public Residing in ____________________ |
County, Arkansas | |
________________________________________ | |
____________________ | (Printed Signature) |
BEFORE SUBRECIPIENT RECEIVES ANY SFRF FUNDS, THIS FULLY EXECUTED AND NOTARIZED CORONAVIRUS STATE FISCAL RECOVERY FUND ACCEPTANCE CERTIFICATION MUST BE E-MAILED AND SENT VIA U.S. MAIL TO THE FOLLOWING ADDRESSES:
Email Address: [email protected]
U.S. Mail: Arkansas Department of Finance and Administration
P.O. Box 3278
Little Rock, AR 72203-3278
Credits
Adopted emergency effective Jan. 14, 2022. Amended May 5, 2022.
Current with amendments received through January 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 006.09.4 Exh. A, AR ADC 006.09.4 Exh. A
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