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California Health & Human Services Agency California Department of Social Services <br />CCD 34 (2/23) Page 9 of 32 <br /> <br /> <br />Section IX – Certifications and Fiscal Information <br />Fiscal Information Required for All Applicants <br />1. Self-Certification for Franchise Tax Board and Department of Tax and Fee <br />Administration <br />By checking this checkbox, the applicant certifies that they are not a delinquent tax payor <br />on the list located on the Franchise Tax Board web page. <br />By checking this checkbox, the applicant certifies that they are not a delinquent tax payor <br />on the list located on the Department of Tax and Fee Administration web page. <br />By checking this checkbox, the applicant certifies that they are not on the list of <br />sanctioned entities located on the Office of Foreign Assets Control web page. <br />2. Registration in the System for Award Management* <br />Please enter your agency’s Unique Entity Identifier Number: KZE9G2M4GRX9 <br />*SAM registration is required for any entity to bid on and get paid for federal contracts or to <br />receive federal funds (Federal Acquisition Regulations (FAR) Part 52.204-7). To find your <br />agency’s Unique Entity Identifier Number, visit the System for Award Management web page. <br />3. Board of Directors Approval <br />Does the applying agency have a Board of Directors? <br />No <br />Sole proprietorship <br />Other; Please explain <br /> <br /> <br /> <br />Yes <br />If the applying agency has a Board of Directors, the applicant must self-certify that it <br />has received Board of Directors approval to receive CCTR Expansion Funding. <br />Yes, the Board of Directors has approved the applicant’s receipt of CCTR Expansion <br />funding should an award be extended. <br />No, the Board of Directors has not approved the applicant’s receipt of CCTR Expansion <br />funding should an award be extended. <br />Please note: Public agencies without Board approval are not eligible for CCTR <br />Expansion funding. <br />N/A, Please provide reason; i.e. the Board did not have a scheduled meeting during the <br />application process <br /> <br /> <br /> <br />If N/A, please provide the date that Board approval is expected. <br />Date