"Certification Statement Regarding Business Integrity and Publicly Funded Program Compliance - Adult Care Food Program" - Florida

This "Certification Statement Regarding Business Integrity and Publicly Funded Program Compliance - Adult Care Food Program" is a part of the paperwork released by the Florida Department of Elder Affairs specifically for Florida residents.

The latest fillable version of the document was released on July 1, 2017 and can be downloaded through the link below or found through the department's forms library.

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Download "Certification Statement Regarding Business Integrity and Publicly Funded Program Compliance - Adult Care Food Program" - Florida

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ADULT CARE FOOD PROGRAM
CERTIFICATION STATEMENT REGARDING
BUSINESS INTEGRITY AND PUBLICLY FUNDED PROGRAM COMPLIANCE
Name of Institution:
Contract Number:
All Adult Care Food Program (ACFP) Institutions must provide a declaration of eligibility to participate in the
ACFP, based on the criteria that the institution has not been disqualified, nor have any of the principals of the
institution or sponsored facilities been disqualified, from any publicly funded program because of a violation
of that program’s requirements. “Publicly funded program” means any program or grant funded by federal,
state, or local government.
The ACFP Institutions are required to report the name of all publicly funded program(s) that the institution and
the principals of the ACFP Institution and each sponsored facility have participated in within the past seven
years. “Principal” means any individual who holds a management position within, or is an officer of, an ACFP
Institution or sponsored facility. Principals include all members of the ACFP Institutions and/or the sponsored
facility’s board of directors.
List the publicly funded programs participated in within the past 7 years by: 1) the ACFP institution and 2)
the principals of the ACFP institution and sponsored facilities:
1.
5.
2.
6.
3.
7.
4.
8.
To add more publicly funded programs, list on a separate page.
I certify that the ACFP Institutions and principals of the ACFP Institutions and sponsored facilities have not
been disqualified from any publicly funded program because of a violation of that program’s requirements
within the past seven years. In addition, I certify that neither the ACFP Institution nor the principals of the
ACFP Institution or sponsored facility have been convicted within the past seven years of any activity that
indicated a lack of business integrity. A business-related offense includes fraud, antitrust violations,
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements,
receiving stolen property, making false claims, obstruction of justice, or any other activity indicating a lack of
business integrity.
Signature of the Chairman of the Board, President, Owner Date or Delegated
Authority
Note: Any organization or individual that provides false information on this form will be subject to
applicable civil or criminal penalties and will be placed on the National Disqualified List.
Rev. 7/2017
ADULT CARE FOOD PROGRAM
CERTIFICATION STATEMENT REGARDING
BUSINESS INTEGRITY AND PUBLICLY FUNDED PROGRAM COMPLIANCE
Name of Institution:
Contract Number:
All Adult Care Food Program (ACFP) Institutions must provide a declaration of eligibility to participate in the
ACFP, based on the criteria that the institution has not been disqualified, nor have any of the principals of the
institution or sponsored facilities been disqualified, from any publicly funded program because of a violation
of that program’s requirements. “Publicly funded program” means any program or grant funded by federal,
state, or local government.
The ACFP Institutions are required to report the name of all publicly funded program(s) that the institution and
the principals of the ACFP Institution and each sponsored facility have participated in within the past seven
years. “Principal” means any individual who holds a management position within, or is an officer of, an ACFP
Institution or sponsored facility. Principals include all members of the ACFP Institutions and/or the sponsored
facility’s board of directors.
List the publicly funded programs participated in within the past 7 years by: 1) the ACFP institution and 2)
the principals of the ACFP institution and sponsored facilities:
1.
5.
2.
6.
3.
7.
4.
8.
To add more publicly funded programs, list on a separate page.
I certify that the ACFP Institutions and principals of the ACFP Institutions and sponsored facilities have not
been disqualified from any publicly funded program because of a violation of that program’s requirements
within the past seven years. In addition, I certify that neither the ACFP Institution nor the principals of the
ACFP Institution or sponsored facility have been convicted within the past seven years of any activity that
indicated a lack of business integrity. A business-related offense includes fraud, antitrust violations,
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements,
receiving stolen property, making false claims, obstruction of justice, or any other activity indicating a lack of
business integrity.
Signature of the Chairman of the Board, President, Owner Date or Delegated
Authority
Note: Any organization or individual that provides false information on this form will be subject to
applicable civil or criminal penalties and will be placed on the National Disqualified List.
Rev. 7/2017
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