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Page 5 of 12 <br />1/21 <br />Non-Collusion, Acceptance <br />The undersigned attests, subject to the penalties for perjury, that the undersigned is the Grantee, or that <br />the undersigned is the properly authorized representative, agent, member or officer of the <br />Grantee. Further, to the undersigned’s knowledge, neither the undersigned nor any other member, <br />employee, representative, agent or officer of the Grantee, directly or indirectly, has entered into or been <br />offered any sum of money or other consideration for the execution of this Grant Agreement other than <br />that which appears upon the face hereof. Furthermore, if the undersigned has knowledge that a state <br />officer, employee, or special state appointee, as those terms are defined in IC § 4 -2-6-1, has a <br />financial interest in the Grant, the Grantee attests to compliance with the disclosure requirements <br />in IC § 4-2-6-10.5. <br />In Witness Whereof, the Grantee and IDEM have, through their duly authorized representatives, entered <br />into this Funding Agreement. The parties, having read and understood the foregoing terms of this <br />Funding Agreement, do by their respective signatures dated below agree to the terms thereof. <br />[Grantee] [IDEM] <br />By: _________________________________ By: _______________________________ <br />_____________________________________ ___________________________________ <br />Name and Title, Printed Name and Title, Printed <br />Date: _____________________________ Date: ___________________________ <br />THE REST OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK.