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"\Ir- <br />EXHIBIT 12-E Local Assistance Procedures Manual <br />Attachment A PS&E Checklist Instructions <br />a. Profit and loss sharing. <br />b. Capital contributions, including equipment. <br />c. Other applicable ownership interests. <br />9. Control of and participation in this contract. Identify by <br />time, race, sex, and "firm" those individuals (and their titles) <br />who are responsible for day-to-day management andpolicy <br />decision making, including, but not limited to, those with <br />prime responsibility for: <br />a. Financial decisions <br />b. Management decisions, such as: <br />1. Estimating <br />2. Marketing and sales <br />3. Hiring and firing of management personnel <br />4. Purchasing of major items or supplies <br />c. Supervision of field operations <br />Note.—If, after filing this Schedule B and before the comple- <br />tion of the joint venture's work on the contract covered by this <br />regulation, there is any significant change in the information <br />submitted, the joint venture must inform the grantee, either di- <br />rectly or through the prime contractor if the joint venture is a <br />subcontractor. <br />Affidavit <br />"The undersigned swear that the foregoing statements are cor- <br />rect and include all material information necessary to identify <br />and explain the terms and operation of ourjoint venture and the <br />intended participation by each joint venturer in the undertaking. <br />Further, the undersigned covenant and agree to provide to <br />grantee current, complete and accurate information regarding <br />actual joint venture work and the payment therefor and any pro- <br />posed changes in any of the joint venture arrangements and to <br />permit the audit and examination of the books, records and files <br />of the joint venture, or those of each joint venturer relevant to <br />the joint venture, by authorized representatives of the grantee or <br />the Federal funding agency. Any material misrepresentation <br />will be grounds for terminating any contract which may be <br />awarded and for initiating action under Federal or State laws <br />concerning false statements." <br />Revised 3-95 <br />08-07-95 <br />FR -2 <br />...................................................... <br />Name of Finn Name of Pimm <br />................................................................ <br />...................... <br />Signature Signature <br />.......................................................................I.,........ <br />Name Name <br />....:.............. .... .............. I ......... .............................I ...... <br />. <br />Title Title <br />................................................ ................ I .......... ....... <br />Date Date <br />Date <br />State of <br />County of <br />On this _ day of 19 _, before me <br />appeared (Name) to me personally <br />known, who, being duly sworn, did execute the foregoing affi- <br />davit, mid did state that he or she was properly authorized by <br />(Name of firm) to execute the <br />affidavit and did so as his or her free act and deed. <br />Notary Public <br />Commission expires <br />[Seal] <br />Date <br />State of <br />County of <br />On this _ day of , 19 _, before me <br />appeared (Name) to Inc personally known, <br />who, being duly sworn, did execute the foregoing affidavit, and <br />did state that he or she was properly authorized by (Name of <br />firm) to execute the affidavit <br />and did so as his or her free act and deed. <br />Notary Public <br />Commission expires <br />[Seal] <br />Page 12-10 <br />June 29,2012 <br />OB 12-04 <br />