New Mexico Special Appropriation Grant Agreement 2026 Packet2

Extracted text

DATE: May 14, 2026
TO: Governing Body
Finance Committee
Public Works and Utilities Committee
FROM: Jesse Roach, Interim Public Utilities Department Director
SUBJECT: New Mexico Special Appropriation Grant Agreement
______________________________________________________________________________
The New Mexico Office of the State Engineer has generously offered up to two million
dollars ($2,000,000) in legislative appropriations to the City of Santa Fe to reimburse fiscal
year 2026 costs associated with critical maintenance and improvements at Nichols Dam.
The actual amount will be determined by qualifying expenses through June 30, 2026 that
will not be reimbursed through any other funding mechanism. The City of Santa Fe’s Public
Utilities Department expects to be able to take advantage of nearly $1,300,000 of this
generous offer and recommends approval of the attached NEW MEXICO SPECIAL
APPROPRIATION GRANT AGREEMENT for Santa Fe Critical Dam Maintenance and
Improvement Project ZJ5134.

1
NEW MEXICO SPECIAL APPROPRIATION GRANT AGREEMENT
Santa Fe Critical Dam Maintenance and Improvement Project ZJ5134
This Special Appropriation Grant Agreement (“Agreement”) is made and entered into by
and between the State of New Mexico, Office of the State Engineer (“Grantor” or “OSE”)
and the City of Santa Fe (“Grantee”) (individually “Party” and collectively “Parties”). This
Agreement shall be effective as of the date the OSE executes it (“Effective Date”).
WITNESSETH
WHEREAS, pursuant to Subsection 102 of Section 5 of Chapter 210 of Laws
2023 the Legislature appropriated ten million dollars ($10,000,000) to OSE for critical
dam maintenance and improvement projects, Subsequently, Subsection 134 of
Section 5 of Chapter 160 of Laws 2025 provided that the OSE was permitted to use
up to six million dollars ($6,000,000) of that appropriation to the OSE for other
identified purposes. In the event that some of the identified purposes may not be
able to utilize their maximum allocations, the OSE desires to enter into an agreement
with the Grantee to grant up to two million dollars ($2,000,000) of remaining funds
available to the Grantee from the appropriation for additional critical dam
maintenance and improvement projects in Santa Fe, with the final amount to be
established at OSE’s sole discretion, (“Project”); and
NOW, THEREFORE, the Parties mutually agree as follows:
ARTICLE I - SCOPE OF WORK
A. Grantee agrees that it will implement, in all respects, the activities outlined in its
Program Description, attached hereto as Exhibit “A,” and incorporated herein by
reference.
B. Grantee agrees to make no change to the Program Description as defined herein
without first submitting a written request to the OSE and obtaining the OSE’s written
approval of the proposed change.
ARTICLE II - LENGTH OF GRANT AGREEMENT
A. The term of this Agreement shall become effective July 1, 2025, and will terminate on
June 30, 2026.
B. The General Appropriation Act of 2025, Section 5 states: “Unless otherwise indicated,
the appropriation may be expended in fiscal years 2025 and 2026”. Per section 5, any
unexpended funds remaining at the end of fiscal year 2026 shall revert to the
appropriate fund.
ARTICLE III - REPORTS
A. Evaluation:
a. Grantee agrees to systematically collect, analyze, and use data to evaluate
programs, initiatives, and policies by examining both the process and

2
outcomes to determine their effectiveness. Grantee agrees to review and
update the existing evaluation plan regularly throughout the fiscal year.
b. Grantee agrees that data entered into a database or otherwise provided to the
OSE, is complete, accurate, and allows the OSE’s designated evaluation
contractor to develop and implement an evaluation system and/or to provide
relevant reports derived from the available data.
c. To adequately evaluate the progress of the Project statewide, Grantee shall
provide, within thirty (30) days, upon request of the OSE’s evaluator(s),
information and access to program records and records of contractors working
for Grantee.
B. Progress Reports:
a. To adequately evaluate the progress of this Agreement, Grantee shall provide
periodic quarterly progress reports to the OSE (“Progress Reports”). The
Progress Reports shall contain a narrative and/or bulleted highlights of
successes and challenges, aa detailed budget breakdown of project
milestones and expenditures to date, which includes expenditure back-up
documentation, a certification all expenditures comply with the requirements
of this Agreement, and anticipated project milestones and expenditures during
the next quarter, in the form required by the OSE, attached hereto as Exhibit
“B,” and incorporated herein by reference (“Quarterly Progress Report”), and
such other information following the objectives of Grantee’s evaluation as may
be of assistance to the OSE in its evaluation. The first quarterly Progress
Report is due on the thirtieth (30th) day following the end of the quarter, directly
after the Effective Date.
b. Grantee represents and warrants that Quarterly Progress Reports submitted
to the OSE will not contain any “personally identifiable information” or
“individually identifiable health information” in accordance with HIPAA.
C. Final Report:
a. Grantee shall submit one copy of the final report for the Project to the OSE.
The Final Report shall include the information called for in Article III,
Paragraphs B (1) and B (2) for the fourth quarter. This requirement shall survive
the termination of this Agreement.
b. The Final Report and final reimbursement shall include sufficient detail to
evaluate the effectiveness of each program component and shall be submitted
no later than July 10th following expiration of the Term of this Agreement.
D. Annual Report:
a. Grantee shall submit one copy of the annual report for the Project to the OSE.
The Annual Report shall include the relevant data from the Project, including
highlights for the period, budget to actual expenditures to date, and other
information requested by the OSE in the format provided by the OSE. This
requirement shall survive the termination of this Agreement.

3
b. The Annual Report shall be submitted no later than the date determined by the
OSE.
ARTICLE IV - CONSIDERATION AND METHOD OF PAYMENT
A. In consideration of Grantee’s satisfactory completion of all work and services required
to be performed under the terms of this Agreement, and in compliance with all other
Agreement requirements herein stated, the OSE shall pay Grantee a sum not to
exceed two million dollars ($2,000,000). The funds are to be expended in
accordance with the proposed budget attached hereto as Exhibits “C,” incorporated
herein by reference. The Parties agree that the Grantee’s expenditure of these monies
shall not deviate from the line items or amounts of the budget without the prior written
approval of the OSE.
B. It is understood and agreed that if any portion of the funds set forth in Article IV,
Paragraph (A), are not expended at the completion of this Agreement for the
purpose(s) designated in this Agreement, shall revert to the OSE for disposition.
C. All Grantee payment requests shall be subject to Grantor review and acceptance.
Payments will be made on a reimbursement of actual cost basis for cost incurred by
Grantee during the grant period unless the Grantor determines, with the express
permission of the State Controller, that advance payment to Grantee is justified.
Grantee must submit all payment requests to Grantor no later than July 15, 2026.
Payment requests shall be sent to the Program Manager and include, at minimum, the
following documentation:
a. A completed Request for Payment Form, attached hereto as Exhibit “D.”
b. A copy of the paid invoice or receipt from vendor (or due and payable invoice
from vendor in the case of advance payment).
c. A copy of the canceled check for the payment made to vendor (in the case of
advance payment Grantee shall send a copy of the cancelled check for the
payment made to the vendor to Grantor within five days of the vendor’s deposit
of the check to document appropriate use of the funds advanced).
D. Payment shall be made only for those services specified in this Agreement and not
funded by any other public entity funding source. The Grantee shall not bill the OSE
for the same service or services that have been billed to another funding agency
or source.
ARTICLE V - MODIFICATION AND TERMINATION
A. The OSE, upon written notice to Grantee, shall have the unilateral right to immediately
terminate this Agreement if, in the judgment of the OSE, the provisions of this
Agreement are violated or the activities described in the Program Description do not

4
progress satisfactorily. In this regard, the OSE may demand a refund of all or part of
the funds dispersed to Grantee.
B. The Parties may modify any terms and conditions of this Agreement by mutual
agreement confirmed in writing with the same formalities for execution as this
Agreement.
C. Early Termination for Convenience: Except as provided in Article X and subparagraph
A above, either Party may terminate this Agreement by providing the other Party with
a minimum of thirty (30) days’ advance written notice of the termination.
D. Liability in the Event of Early Termination: In the event of early termination of this
Agreement by either party, the OSE’s sole liability shall be to reimburse Grantee in
accordance with this Grant Agreement for qualifying expenditures that were:
a. Incurred pursuant to a legally binding agreement entered into by Grantee
before Grantee’s receipt of the OSE’s notice of early termination or the
issuance by the Grantee of a notice of early termination;
b. Incurred on or before the termination date in the notice of early termination;
c. For permissible purposes under this Agreement’s Program Description and
procured and executed in accordance with applicable law; and
d. The subject of a Request for Payment Form properly and timely submitted in
accordance with Article IV of this Agreement.
ARTICLE VI – REPRESENTATIONS AND WARRANTIES
Grantee hereby represents and warrants that it will comply with all State laws, regulations,
policies, guidelines, and requirements with respect to the acceptance and use of State
funds. Also, Grantee certifies that:
A. It has the legal authority to receive and expend the funds as described in the Program
Description.
B. It shall meet all requirements of the General Appropriation Act of 2025, the
Regulations, and all other New Mexico State laws and regulations as they pertain to
all activity conducted under this Agreement and provide the OSE with verification
thereof.
C. It shall finance all costs of the Project, including all Project overruns.
D. Every facility, program, or other provider with which it contracts to perform the activities
that are subject to this Agreement shall, at all times, comply with all applicable State
and federal laws and regulations and any licensure requirements governing treatment
facilities, programs, or providers. All Contracts shall contain the following provisions:

5
a. “The Contractor agrees to comply, at all times, with all applicable State and
federal laws and regulations and any licensure requirements governing its
program and facility.”
b. The Grantee agrees it shall be solely liable for the failure of any of its providers
to meet and comply with all applicable State and federal laws and licensure
requirements governing the treatment provider or the program.
E. It shall comply with the State Procurement Code, Sections 13-1-28 through 13-1-199,
NMSA 1978.
F. All professional services, activities, or programs will be implemented through a
professional service contract. Grantee will submit all Project-related contracts and
agreements to the OSE for review and approval prior to execution. Amendments to
existing contracts will be submitted to the OSE for review and approval prior to
execution.
a. Without limiting the foregoing, Grantee shall be required to complete a request-
for-proposal (RFP) for contracts over sixty thousand dollars ($60,000);
provided, however, that if Grantee’s governing body’s guidelines have more
stringent requirements, the Grantee’s governing body’s guidelines must be
followed.
b. Sole Source contracts can be utilized if written justification is provided,
confirming that the organization is the only one in the area that can provide
services uniquely and substantially related to the intended purpose of the
contract. Grantee shall submit written documentation describing the reason(s)
for sole source contracting to the OSE prior to entering into the contract.
Grantee shall adhere to all applicable provisions and requirements outlined in
the State Procurement Code.
G. It will adhere to all OSE financial and accounting requirements, including the State’s
Model Accounting Practices, as amended from time to time.
H. It will comply with all applicable conditions and requirements prescribed by the OSE
regarding the receipt of Project funds.
I. It shall not at any time utilize or convert any equipment or property acquired or
developed pursuant to this Agreement for any use other than those specified in the
scope of work as defined in the Agreement without the prior approval of the OSE.
J. No member, officer, employee, or family member(s) of the Grantee, or its designees
or agents, no member of the governing body of the locality in which the program is
situated, and no other public official of such locality or localities who exercises any
functions or responsibilities with respect to the program during his/her tenure or for
one year thereafter, shall have any interest, direct or indirect, in any contract, or the
process thereof, for work to be performed in connection with the program assisted
under the grant, and the Grantee shall incorporate, in all such contracts, a provision
prohibiting such interest pursuant to the purposes of this certification.

6
a. No funds have been paid or will be paid, by or on behalf of the Grantee, to any
person for influencing or attempting to influence an officer or employee of the
State, any agency, or body in connection with the awarding of any Third Party
Obligation.
i. Grantee will require certifying language prohibiting lobbying to be
included in the award documents for all subawards, including
subcontracts, loans, and cooperative agreements.
K. It will comply with all applicable federal requirements and regulations.
The representations and warranties made by Grantee shall survive the Early
Termination or expiration of this Agreement.
ARTICLE VII - RETENTION OF RECORDS
A. Accountability: Grantee shall be strictly accountable for receipts and disbursements
relating to this Agreement. Grantee shall follow generally accepted accounting
principles, the State’s model accounting principles, § 6-6-2 NMSA 1978, and, if
feasible, maintain a separate bank account or fund with a separate organizational code
to ensure separate budgeting and accounting of the funds.
B. Record Retention: For six (6) years following the Program’s completion (“Record
Retention Period”), Grantee shall maintain all Project-related records, including, but
not limited to, all financial records, requests for proposals, invitations to bid, selection
and award criteria, contracts and subcontracts, advertisements, minutes of pertinent
meetings, as well as records sufficient to fully account for the amount and disposition
of funds from all sources budgeted for the Program, the purpose for which such funds
were used, and such other records as the OSE may prescribe.
a. All Program records must adhere to the New Mexico State Records Center and
Archives Rule for Functional Retention and Disposition Schedule, 1.21.2
NMAC.
C. Grantee shall make all Project records available to the OSE, the OSE’s Independent
Public Accountant, and the New Mexico State Auditor upon request. With respect to
the funds that are the subject of this Agreement, if the State Auditor or the OSE finds
any funds were improperly expended, Grantee shall be required to reimburse the State
all amounts found to be improperly expended plus interest in accordance with Article
IX below.
ARTICLE VIII - REPRESENTATIVES
A. Grantee hereby designates the person listed below as the official Grantee
Representative responsible for overall supervision of the approved Project:
a. Name: Jesse Roach
b. Title: Interim Public Utilities Department Director
c. Address: 801 W. San Mateo, Santa Fe, NM, 87505
d. Phone: (505) 955-4309

7
e. Email: jdroach@santafenm.gov
B. The OSE designates the person listed below as its Project Manager, responsible for
the overall administration of this Agreement, including compliance and monitoring of
Grantee:
a. Name: Sushil Chaudhary
b. Title: Senior Manager Executive Engineer
c. Address: 5550 San Antonio Drive, NE
d. Phone: (505) 383-4134
e. Email: sushil.chaudhary@ose.nm.gov
ARTICLE IX – IMPROPERLY REIMBURSED FUNDS
If the OSE determines part or all of the funds reimbursed under this Agreement were
improperly requested by Grantee, including but not limited to reimbursements based upon
fraud, mismanagement, misrepresentation, misuse, or violation of law by the Grantee,
after ten (10) days’ notice to Grantee and the opportunity to return such funds to the OSE,
the OSE may offset any funds due to Grantee from the State, until the improperly
reimbursed funds are fully repaid.
ARTICLE X – SCOPE OF AGREEMENT
This Agreement constitutes the entire and exclusive agreement between the Parties
concerning the subject matter hereof. The Agreement supersedes all prior or
contemporaneous agreements, understandings, discussions, communications, and
representations, written or verbal.
ARTICLE XII – LIABILITY
Neither Party shall be responsible for liability incurred as a result of the other Party’s acts
or omissions in connection with this Agreement. Any liability incurred in connection with
this Agreement is subject to immunities and limitations of the New Mexico Tort Claims Act.
ARTICLE XIII – APPROPRIATIONS
The terms and conditions of this Agreement are contingent upon the New Mexico
Legislature making sufficient appropriations and authorization for the performance of this
Agreement. If the Legislature fails to make sufficient appropriations and authorizations,
the OSE may immediately terminate this Agreement, in whole or in part, regardless of any
existing legally binding third-party contracts entered into by or between the Grantee and
a third party, by providing the Grantee with written notice of such early termination.
Grantee shall accept the OSE’s decision as to whether sufficient appropriations are
available, which shall be final and non-appealable. Grantee shall include a substantively
identical clause in all contracts between the Grantee and third parties that are (i) funded
in whole or part by funds made available under this Agreement and (ii) entered into
between the effective date of this Agreement and the Termination Date or early
termination date.

8
ARTICLE XIV – REQUIRED TERMINATION CLAUSE
Grantee shall include the following or a substantially similar termination clause in all
contracts that are (i) funded in whole or part by funds made available under this Agreement
and (ii) entered into after the effective date of this Agreement:
A. “This contract is funded in whole or in part by funds made available under a State of
New Mexico (State) grant agreement. If the State terminates the grant agreement, the
[insert Grantee name] may terminate this contract by providing the contractor written
notice of such termination in accordance with the notice provisions in this contract. In
the event of termination pursuant to this paragraph, the [insert Grantee name] only
liability shall be to pay the contractor for acceptable goods and/or services delivered
and accepted prior to the termination date”.
ARTICLE XV: GENERAL PROVISIONS
A. Assignment: Grantee’s rights and obligations under this Agreement are personal
and may not be transferred or assigned without the prior written consent of the
OSE. Any attempt at assignment or transfer without such consent shall be void.
Any assignment or transfer of Grantee’s rights and obligations approved by the
OSE shall be subject to the provisions of this Agreement.
B. Binding Effect: Except as otherwise provided, all provisions of this Agreement,
including the benefits and burdens, shall extend to and be binding upon the Parties’
respective successors and assigns.
C. Authority: Each Party represents and warrants to the other that the execution and
delivery of this Agreement and the performance of such Party’s obligations have
been duly authorized.
D. Captions and References: The captions and headings in this Agreement are for
the convenience of reference only and shall not be used to interpret, define, or limit
its provisions. All references in this Agreement to sections (whether spelled out or
using the § symbol), subsections, exhibits, or other attachments are references to
sections, subsections, exhibits, or other attachments contained herein or
incorporated as a part hereof, unless otherwise noted.
E. Counterparts: This Agreement may be executed in multiple, identical, original
counterparts, each of which shall be deemed to be an original, but all of which,
taken together, shall constitute the same agreement.
F. Digital Signatures: If any signatory signs this agreement using a digital signature
in accordance with the State Policies regarding the use of digital signatures, then
any agreement or consent to use digital signatures within the electronic system
through which that signatory signed shall be incorporated into this Agreement by
reference.
G. Modification: Except as otherwise provided in this Agreement, any modification to
this Agreement shall only be effective if agreed to in a formal amendment, properly
executed, and approved in accordance with applicable New Mexico law and State
fiscal policies and rules. Modifications permitted under this Agreement, other than
Agreement amendments, shall conform to the policies issued by the State.

9
H. Statutes, Regulations, Fiscal Rules, and Other Authority: Any reference in this
Agreement to a statute, regulation, policy, or other authority shall be interpreted to
refer to such authority then current, as may have been changed or amended after
the Effective Date of this Agreement.
I. External Terms and Conditions: Notwithstanding anything to the contrary herein,
the State shall not be subject to any provision included in any terms, conditions, or
agreements appearing on the Grantee’s or a subcontractor’s website or any
provision incorporated into any click-through or online agreements related to the
Work unless that provision is specifically referenced in this Agreement.
J. Severability: The invalidity or unenforceability of any provision of this Agreement
shall not affect the validity or enforceability of any other provision of this
Agreement, which shall remain in full force and effect, provided that the Parties
can continue to perform their obligations under this Agreement in accordance with
its intent.
K. Survival of Certain Agreement Terms: Any provision of this Agreement that
imposes an obligation on a Party after the termination or expiration of this
Agreement shall survive the termination or expiration of this Agreement and shall
be enforceable by the other Party.
L. Third Party Beneficiaries: Except for the Parties’ respective successors and
assigns described in this Agreement, it does not and is not intended to confer any
rights or remedies upon any person or entity other than the Parties. Enforcement
of this Agreement and all rights and obligations hereunder are reserved solely to
the Parties. Any services or benefits that third parties receive as a result of this
Agreement are incidental to this Agreement and do not create any rights for such
third parties.
M. Waiver: A Party’s failure or delay in exercising any right, power, or privilege under
this Agreement, whether explicit or by lack of enforcement, shall not operate as a
waiver, nor shall any single or partial exercise of any right, power, or privilege
preclude any other or further exercise of such right, power, or privilege.
N. Standard and Manner of Performance: Grantee shall perform its obligations under
this Agreement in accordance with the highest standards of care, skill, and
diligence in Grantee’s industry, trade, or profession.
O. Licenses, Permits, and Other Authorizations: Grantee shall secure, prior to the
Effective Date, and maintain at all times during the term of this Agreement, at its
sole expense, all licenses, certifications, permits, and other authorizations required
to perform its obligations under this Agreement and shall ensure that all
employees, agents, and subcontractors secure and maintain at all times during the
term of their employment, agency or subcontractor, all licenses, certifications,
permits and other authorizations required to perform their obligations in relation to
this Agreement.
P. Venue and Choice of Law: This Agreement shall be governed by and construed in
accordance with the laws of the State of New Mexico, without regard to any conflict
of law provisions. Any legal suit, action, or proceeding arising out of or related to
this Agreement shall be instituted exclusively in the district courts located in Santa
Fe, New Mexico. The Parties hereby irrevocably submit to the exclusive jurisdiction
and venue of such courts in any such suit, action, or proceeding. The Parties waive
any objection to the laying of the venue of any such suit, action, or proceeding in

10
the district courts of Santa Fe, New Mexico, and irrevocably waive and agree not
to plead or claim in any such court that any such suit, action, or proceeding brought
in any such court has been brought in an inconvenient forum.
[SIGNATURE PAGE AND EXHIBITS FOLLOW]

11
IN WITNESS WHEREOF, the parties have duly executed this Agreement as of the
OSE's date of execution.
APPROVED BY GRANTOR:
OSE Agency Head: By:_____________________
Title:____________________ Date:______
OSE Budget: By:_____________________
Title:____________________ Date:______
Chief Financial Officer: By:_____________________
Title:____________________ Date:______
AS TO LEGAL FORM AND SUFFICIENCY
OSE Counsel, By:_____________________
Title:____________________ Date:______

12
APPROVED BY GRANTEE:
Grantee: By:_____________________ Michael J. Garcia
Title: Mayor, City of Santa Fe Date:__________
Attest: By:_____________________ Geralyn F. Cardenas
Title: City Clerk, City of Santa Fe Date:__________
Grantee: By:_____________________ Andrea Phillips
Title: Finance Director, City of Santa Fe Date:__________
AS TO LEGAL FORM AND SUFFICIENCY
Grantee: By:_____________________ Marcos D. Martinez
Legal Counsel Title: City Attorney, City of Santa Fe Date:____________

13
EXHIBIT A
Project Description
The purpose of the Project is to grant up to two million dollars ($2,000,000) to the
Grantee to fund the reimbursement of costs associated with critical dam maintenance
and improvement projects for the City of Santa Fe. The final amount of the grant funding
provided by the Grantor to the Grantee will be established at the sole discretion of
Grantor, but will in no instance exceed the maximum amount. Grantee shall propose
allowable uses that will be subject to the review and acceptance/approval of the Grantor.

14
EXHIBIT B
Quarterly Progress Report
(TBD)

15
EXHIBIT C
Proposed Budget
(To be provided by Grantee)

16
EXHIBIT D
Request for Payment Form
STATE OF NEW MEXICO
GRANT APPROPRIATION
Request for Payment Form
I. Grantee Information (Must match your DFA Substitute W-9 Form) II. Payment Computation
A. Grantee: City of Santa Fe
B. Address:
(Complete Mailing, including Suite, if applicable)
A. Payment Request No. ______________________
B. Grant Amount: __________________________
C. AIPP Amount (If Applicable) : _________________
D. Funds Requested to Date: _________________
E. Amount Requested this Payment: ____________
F. Reversion Amount (if applicable ):
City, State, Zip
C. Contact Name/Phone #:
D. Grant No: ZJ5134 Santa Fe Dam Projects
G. Grant Balance: $ 0.00
Final Request for Payment (if applicable )H.
E. Project Title:
F. Grant Expiration Date:
III. Fiscal Year : 2026 (July 1, 2025-June 30, 2026)
(The State of NM Fiscal Year is July 1, 20XX through June 30, 20XX of the following year)
IV. Certifications
I hereby certify that all conditions and requirements for Payments outlined in the Agreement have been met, including but not limited to:
a. Submission and approval of a Project Budget as per Article IV, Section A of the Agreement.
b. Compliance with the Project Budget and expenditure of funds in accordance with the State Procurement Code and the State’s
Model Accounting Practices.
c. Submission of supporting documentation as required by the Agreement.
d. Maintenance of all necessary records and documentation as stipulated in the Agreement.
I attest that the information provided is correct; expenditures are properly documented and valid or actual receipts, and that the activity
fully complies with Article IX, Sec. 14 of the New Mexico Constitution, known as the “anti-donation” clause.
I hereby certify that all representations and warranties made in the Agreement remain true, accurate, and complete as of the date of
this request, and will continue to be so throughout the term of the Agreement. I acknowledge that these representations and warranties
are a material inducement for the Department to approve this pay request.
Grantee Fiscal Officer or Fiscal Agent (if applicable ) Grantee Representative
Printed Name Printed Name
Date: Date:
(State Agency Use Only)
Vendor Code: Fund No.: PO # Loc No.:
I certify that the State Agency financial and vendor file information agree with the above submitted information.
ASD Officer Date Division Grant Manager Date