Certification Statement
Corporate
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Certification Statement

OWNER/OFFICER/ADMINISTRATOR CERTIFICATION STATEMENT – Providers must ensure that all balance sheets and income statements submitted include the following statements and signature. If the certifications provided do not appear directly on the financial statements they accompany, they must specifically reference the financial statements they certify by title and period below.

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THE BALANCE SHEET OR INCOME STATEMENT SHALL BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW.

I HEREBY CERTIFY THAT I HAVE EXAMINED THE BALANCE SHEET AND INCOME STATEMENT PREPARED BY _________________________________________ AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT, AND COMPLETE STATEMENT FROM THE BOOKS AND RECORDS OF THE PROVIDER AND NO OTHER MATERIAL CHANGE HAS OCCURRED.

FINANCIAL STATEMENT TITLE

PERIOD

  
  
  
  
  
  

_________________________________________________________________________________________________________
Signature of Owner/ Officer/ Administrator of Provider/Debtor

_________________________________________________________________________________________________________
Title

_________________________________________________________________________________________________________
Date


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