HomeMy WebLinkAboutDivision of Energy, Housing and Community Resources Certification FormDivision of Energy, Housing and Community Resources
Signature Certification Form
Signature Certification Form Revised: July 17, 2019
UNIT OF GENERAL LOCAL GOVERNMENT’S (UGLG’S) NAME: Oshkosh, City of
DEHCR GRANT AGREEMENT #: CV 21-30
SIGNATURE CERTIFICATION FORM
The Authorized Signatories cannot include the Chief Elected Official (CEO).
Community Development
Director
3/29/22
Signature of Authorized Person Title Date
Typed Name of Authorized Person: Kelly Nieforth
This signature replaces the previously authorized signature of: H. Allen Davis III, Community
Development Director 5/25/21
Grants Coordinator 3/29/22
Signature of Authorized Person Title Date
Typed Name of Authorized Person: Emily Tardiff
This signature replaces the previously authorized signature of: Steven Wiley, Associate Planner,
5/25/2021
City Clerk 3/29/22
Signature of Authorized Person Title Date
Typed Name of Authorized Person: Jessi Balcom
This signature replaces the previously authorized signature of:
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I HEREBY CERTIFY THAT THE ABOVE SIGNATORIES ARE AUTHORIZED TO SIGN THE REQUEST FOR
PAYMENT OF COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS.
City Manager 3/29/22
Signature of Chief Elected Official Title Date
Typed Name of Chief Elected Official: Mark A. Rohloff
Emily Tardiff
DocuSign Envelope ID: 97199140-D6CA-4FA9-8A27-007238B97994
Division of Energy, Housing and Community Resources
Signature Certification Form
Signature Certification Form Revised: July 17, 2019
SIGNATURE CERTIFICATION FORM (INSTRUCTIONS)
The Unit of General Local Government’s (UGLG’s) Chief Elected Official (CEO) must authorize
at least two (2) individuals to serve as signatories for requesting payment of CDBG funds.
Except for the CEO, any local official or employee may be authorized to request CDBG funds.
Authorized Signatories do not have to be the same individuals that sign community checks.
The CEO cannot authorize him/herself to be a signatory. The CEO is disqualified from
being authorized to request funds, as the CEO is responsible for certifying the Authorized
Signatories. The CEO must only sign the Signature Certification form after the Authorized
Signatories have signed and dated the form.
Only the three individuals authorized on the Signature Certification form may sign the Request
for Disbursement of Community Development Block Grant Funds form. Each CDBG payment
request requires two (2) signatures, at least one of which must be a representative of the
community (Clerk, Treasurer, Public Works Director, Board Member, etc.). Contracted Grant
Administrators and their support staff may be authorized to serve as signatories, but only one
(1) of the two required signatures on a CDBG payment request may come from a representative
of a contracted firm.
Fill-in the “Unit of General Local Government’s (UGLG’s) Name” and the “Grant Agreement
Number” fields found in the upper right corner of the Signature Certification form.
Fill-in the “[Job] Title” and the “Typed Name” fields pertaining to the person being authorized to
serve as a signatory for CDBG payment requests. If the Authorized Signatory is replacing a
previously authorized individual, the name of the replaced signatory must be provided. [For
example: Betty Williamson, the newly elected Clerk, is replacing former Clerk Abbey Svenson
on Attachment 8-C1: Signature Certification (SAMPLE).] The CEO may authorize up to three
(3) signatories, at least one of which must be a representative of the local community (Clerk,
Treasurer, Public Works Director, Board Member, etc.). Common combinations of Authorized
Signatories include (but are not limited to):
Example #1:
OR
Example #2:
OR
Example #3:
1. Contracted Grant
Administrator
2. Local Clerk
3. Local Board
Member
1. Contracted Grant
Administrator*
2. Contracted Grant
Admin’s Assistant*
3. Local Clerk
1. Local Clerk
2. Local Board
Member #1
3. Local Board
Member #2
*When two (2) representatives of a contracted firm are listed as Authorized Signatories, only one (1) may provide a signature
on a CDBG payment request. The second required signature would need to come from the representative of the local
community (i.e. the ‘Local Clerk’ in Example #2 above).
IMPORTANT REMINDER!
The UGLG’s CEO cannot authorize him/herself to be a
signatory. The CEO is disqualified from being authorized to
request CDBG funds, as the CEO is responsible for certifying
the Authorized Signatories.
DocuSign Envelope ID: 97199140-D6CA-4FA9-8A27-007238B97994
Division of Energy, Housing and Community Resources
Signature Certification Form
Signature Certification Form Revised: July 17, 2019
Each Authorized Signatory must provide his/her signature along with the date when they signed
the Signature Certification form.
The Signature Certification form is not valid until fully signed and dated by the Authorized
Signatories and the CEO. The CEO’s signature and date signed must be added to the form
after the Authorized Signatories sign and date the form.
Should the Authorized Signatories’ name or authorization status to continue signing the Request
for Disbursement of Community Development Block Grant Funds forms change, a new form
must be completed and submitted to DEHCR. If the UGLG has any questions, contact
DEHCR’s Bureau of Community Development.
When this Signature Certification form has been completed, retain a copy of the signed form for
the local CDBG project files.
Submit the completed form to DEHCR. DEHCR prefers electronic submittal(s) but paper copies
are acceptable (one copy). There is no need to utilize postage-paid mail if the signed document
is submitted via email, however, a copy of the completed form must also be kept in the UGLG’s
local project files.
Email: Your assigned DEHCR CDBG Project Representative or DOACDBG@wisconsin.gov
Mail: [Insert Your Assigned DEHCR Project Representative’s Name Here]
Wisconsin Department of Administration
Division of Energy, Housing and Community Resources
Bureau of Community Development, 9th Floor
P.O. Box 7970
Madison, WI 53707-7970
DocuSign Envelope ID: 97199140-D6CA-4FA9-8A27-007238B97994