Common use of Signature and Certification Clause in Contracts

Signature and Certification. REQUIRED The adult household member who fills out the application must sign below. If Part 4 is completed, the adult signing the form must also list the last four digits of his/her Social Security Number (SSN) or check the box if no SSN. See Privacy Act Statement on the back of this page. If you have listed a case number in Part 2 or are applying on behalf of a ▇▇▇▇▇▇ child, or have checked the box that your child(ren) will not qualify for Free/Reduced- Price meals, the last four digits of the SSN is not needed. “I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that CACFP officials may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.” Signature of Adult Today’s Date X Print Name of Adult Signing Social Security Number (SSN) (last four digits) XXX-XX- Check if no SSN OSPI CNS (Rev. 1/19) Page 1 of 2 White Native Hawaiian or Pacific Islander Multi-Racial Black or African American Asian Not Hispanic or Latino We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for receiving meals during care.

Signature and Certification. REQUIRED The adult household member who fills out the application must sign below. If Part 4 is completed, the adult signing the form must also list the last four digits of his/her Social Security Number (SSN) or check the box if no SSN. See Privacy Act Statement on the back of this page. If you have listed a case number in Part 2 or are applying on behalf of a ▇▇▇▇▇▇ child, or have checked the box that your child(ren) will not qualify for Free/Reduced- Price meals, the last four digits of the SSN is not needed. “I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that CACFP officials may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.” Signature of Adult Today’s Date X Print Name of Adult Signing Social Security Number (SSN) (last four digits) XXX-XX- Check if no SSN OSPI CNS (Rev. 1/195/18) Page 1 of 2 White Native Hawaiian or Pacific Islander Multi-Racial Black or African American Asian Not Hispanic or Latino We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for receiving meals during care.