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I> dAana Housing and Community Deve opment Autho rnty <br />CDBG Payroll Authorization Form - Recipient <br />Recipient: City of South Bend <br />,Opard Number: I)R2OR-01.8-003 <br />Please list all employees and their respective rate of pay that will be utilized on this award. Tf a rate of pay changes, a new <br />Payroll Authorization Form must be submitted. This form must be signed by the chief executive officer of the recipient and <br />certified by a Notary Public. <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />9, <br />10. <br />Seal: <br />Em to ee Name <br />Primary Authorized Signature <br />Signature <br />.Typed Name and Title <br />Date <br />Notary Public <br />Subscribed and sworn before the this <br />of 20— <br />Notary Public <br />Typed Name <br />day <br />My Commission <br />Expires <br />Comity of <br />Residence <br />Hourly Rate o <br />Pav <br />$ <br />$ <br />Hourly Fine <br />Bene t or <br />1'ercenta�e <br />