First Responder COVID-19 Stipend Worksheet Submission

Organization's Information:
Organization's Name*
Organization's Mailing Address*
Street Address Address Line 2 City State ZIP Code
Authorizing Official's Information
Is the person submitting this form also the authorizing official?*
Aurthorizing Official's Name*
First Last
Authorizing Official's Title*
Authorizing Official's Phone*
Authorizing Official's Email*
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Submitter's Information
Your Name*
First Last
Your Title*
Your Phone*
Your Email*
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Hazard Pay Worksheet(s)
Upload Hazard Pay Worksheet(s) *
Must be uploaded as an .xlsx or .xls
Drop files here or

Max. file size: 1 GB.
Certification and Submission
1. Record Retention: Between the Effective Date and the date three (3) years after the Completion Date, at any time during the Awardee’s normal business hours, and as often as the State shall demand, the Awardee shall make this form available to the State. The Awardee shall permit the State to audit, examine, and reproduce such records, and to make audits of all contracts, invoices, materials, payrolls, records of personnel, and other information relating to all matters covered by this Agreement. (Awardee as stated in this paragraph means municipality or county.)

2. The Awardee is required to retain, at a minimum, payroll records for all first responders that received a hazard payment, and weekly certification of availability for on call firefighters and volunteer firefighters not compensated through standard payroll procedures. This award is also subject to Audit requirements.

3. Close out: At the end of the award period, the Awardee shall submit a final accounting of funds expended and funds remaining, if any. Any remaining funds are required to be returned to the State of New Hampshire in a manner to be prescribed and provided prior to close out.

Certification:
I do hereby certify that all information provided in or attached to this document is complete, accurate, and up-to-date as of the date specified below I further certify that there are no willful misrepresentations of information provided. I understand that it is my responsibility to immediately notify GOFERR in regards to any changes, corrections, or updates to the information provided. Municipalities or counties using the designated signing authority option must attach evidence demonstrating the authority to sign.
*
I agree to the above
Statement of Acknowledgement*
By writing my full name below (as an electronic signature), selecting today's date and clicking the submit button, I am attesting that the information provided in this form and the attachments are true and accurate to the best of my ability. I also acknowledge that failure to provide accurate and/or misleading information may be grounds for disqualification. Lastly, I understand that everything submitted is subject to audit and review.
Certification Date*
MM slash DD slash YYYY

First Responder COVID-19 Stipend Worksheet Submission

Organization's Information:

Authorizing Official's Information

Submitter's Information

Hazard Pay Worksheet(s)

Certification and Submission