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NOTICE <br /> Do not submit this certification to the DEPARTMENT with your signed contract. <br /> • The certification applies ONLY to governmental agencies,local units of government and non-profit agencies expending <br /> Federal funds for this project.It does not apply to for-profit public or private entities. <br /> • If 2 CFR Part 200,Subpart F,Section 200.501,Audit Requirements applies to your organization,submit the certification <br /> or a copy of your single audit to the DEPARTMENT at the end of your fiscal year for any fiscal year in which you <br /> expended any Federal funds related to this contract <br /> Single Audit Not Required Certification <br /> 1 certify that expended less than$750,000 in Federal awards in our fiscal year <br /> and was not required to have a single audit conducted. <br /> Si nature — Date <br /> Title <br /> Subrecipient Contact Information <br /> Subreci lent <br /> Contact Person Tie <br /> Address Cl .- State Zi Code <br /> Phone Fax Fiscal Year End E-mail <br /> _ 117 I <br /> Printed 04/2121 Page 16 of 16 BoBS 2804(Rev.04106120) <br />