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. � '• � " <br /> CONDITIONS/CERTIFICATIONS <br /> FINANCIAL ASSISTANCE AGREEMENTS <br /> ILLINOIS ENVIRONMENTAL PROTECTION AGENCY <br /> 1. Taxpayer lderatification Number and Legai Status Disclosure Certification <br /> Under penalties of perjury, I certify that the name, taxpayer identification number, and <br /> legal status listed below are correct. <br /> Organization: �i r r a� /..'�. �-c:ea.r v� /�.c i�v o i.s` <br /> , <br /> Taxpayer ldentification Number: <br /> Federal Employer ldentification Number(FEIN): F 999�f - e(o9 9 - oS <br /> (Enter fhe name of the entity as used to apply for the entity's FEIN and the FE/N.) <br /> Legal Status (please check if you are an incorporated City, Village or Town in the State <br /> of Illinois): <br /> �_ Govemmental Entity <br /> Definition: <br /> The term "Recipient" as used herein refers to the individual or entity ldentified as the <br /> applicant in the Municipal Brownfields Redevelopment Grant Application Package <br /> submitted to the Illinois EPA for funding consideration. The term "Recipient" as used <br /> herein also refers to an individual or entity that has entered into a Financial Assistance <br /> Agreement with the Illinois EPA. I <br /> 2. Capability , <br /> The Recipient certi�es that it: I <br /> (i) Has authority/involvement to accomplish the planned scope of work in the ' <br /> Financial Assistance Agreement(Agreement) project area. <br /> (ii) Is capable of accomplishing the planned scope of work in a timely manner to meet <br /> scheduled deadlines during the Agreement period. <br /> (iii) Can obtain financial resources (eligible match), and has the necessary legal, <br /> This Agency is authorized to require this information under 415 ILCS 5✓4(k). Disclosure of this infamatior►is required. Failure to do so <br /> may prevent this form from being processed and could resutt in your application being denied. This form has been approved by the Fonns <br /> Management Center. <br /> ConditionslCerdfications <br /> IL 532-2818 March 2005 <br /> LPC 627 8/05 <br />