GS $Mart® - AlphaPlan, Certification Form
Please note that this CertificationFormisthe acceptance certificate with respect to the Assets described in the Contract identified below. Once all other documents required by the Contract aresigned andapproved, this CertificationForm directsthe Lenderto paythe Supplier forsuchAssets on behalfoftheState. The payment to theSupplierwillbe no earlierthat theDateof Acceptance identified beloworthe scheduled date of payment in theContract on thePaymentSchedule.
Thefollowingwillbe prepared bytheLender on the Lender’s letterhead forthe Statetoexecute:
DATE:
AGENCYNAME:
CONTACTNAMEANDPHONENUMBER:
ADDRESS:
CITY,STATE,ZIP:
RE: ContractNo...... between ...... (StateAgency) and
...... (Supplier),with...... (Lender) as the State'sdesignated
Lender.
Dear....(CONTACTNAME)...... :
All paymentsand notices in connectionwith the Contract are to besent to the Lender designated in the Contract at the following address:
...... Lender......
...... Remit to Address ......
...... City, State,Zip......
The terms of the Contractspecify that the Supplier shall continueto perform all of itsperformance obligations and duties under the Contract and neither the Lendernor any Paying Agent shallbe responsible to perform any such obligations of the Supplier.
The Lender agrees that the State shall haveno continuingdisclosure obligation under S.E.C. Rule
15c2-12, andtherefore agrees to comply with the requirements forexemption fromthe Rule set forth in Section 15c2-12(d)(1)(i).
Pursuant to the Contract, the State hereby certifies(1) that the Assets describedin the Contract have been delivered to the State, have been inspected, have beenfound to be inconformance with the Contract and in good working order andare therefore fully and finally accepted by the State for all purposes of the Contract, and; (2) the Date ofAcceptance for suchassets is...... ,2......
The State is either self-insured [ ] (check if applicable), or insured under policy #
...... with ...... (Insurance companyname) with coverage as prescribedin the Contract.
The State further certifies, and the undersigned herebyrepresents, that the Assets described in the Contractare essentialto the State's obligation toperform the following functions and that the need is not temporary or expected to diminish in theforeseeable future. Specifically such Assets
Revised October 2016
were selected by the State to be used for the following purposes as indicated below or on the
attached page(s):
Lender:
Signature:______
By Name:______
Title:______
Date:______
Acknowledged by
State Department
Signature:______
By Name:______
Title:______
Date:______
Acknowledged by
State of California, Department of General Services
Signature:______
By Name:______
Title:______
Date:______
Revised October 2016