Draft initial-grant-guidance-bil

FY 2022 STATE INITIAL GRANT GUIDANCE
I.

INTRODUCTION
President Biden signed the Bipartisan Infrastructure Law (BIL; Public Law 117-58) on
November 15, 2021, making a once-in-a-generation investment in the Nation’s
infrastructure and economic competitiveness. This landmark investment will rebuild
America’s critical infrastructure, tackle the climate crisis, address legacy polluted sites,
advance environmental justice, and drive the creation of good-paying union jobs. By
addressing long overdue infrastructure and environmental improvements and
strengthening our resilience to the changing climate, this investment in our communities
across the country will grow the economy sustainably and equitably for decades to come.
Section 40601 of the BIL creates an orphaned well site plugging, remediation, and
reclamation program within the Department of the Interior (DOI) to address orphaned
wells and well sites on Federal lands. 1 Subsection (d) creates a grant program for Tribes,
and subsection (c) creates three types of grants for states:
1. Initial grants (Section 40601(c)(3))
2. Formula grants (Section 40601(c)(4))
3. Performance grants (Section 40601(c)(5))
This document:
1. sets forth the application process for states and provides requirements for carrying
out activities under the Initial grants authorized by Sec. 40601(c)(3) of the BIL;
and
2. describes what the Department of the Interior considers to be the best practices for
establishing, conducting, and reporting on the activities of a program to plug,
remediate, and reclaim orphaned wells on state and private lands.
The document indicates what information is required in applications for an Initial grant
and for expenditure of the grant funding. It also includes a number strongly
recommended best practices that can help maximize the benefits and transparency of
activities carried out with Initial grant funding. Many of these best practices may form
the basis for future requirements in the subsequent orphaned well grants, so states
expecting to apply for subsequent rounds of grants are encouraged to ensure their
programs apply these best practices as early as possible in order to promote consistent
standards for well plugging and reclamation activities, and that benefits from the program
can be properly tracked.

Section 40601 amends Section 349 of the Energy Policy Act of 2005, but for simplicity all references to the
amended Section 349 will be written as components of Section 40601 of the BIL in this document.
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II.

DEFINITIONS
“Administrative costs" identified in Sec. 40601(c)(2)(B)(i), limited to not more than 10
percent of the funds received, 2 are those costs that cannot be directly attributed to well
plugging and site reclamation projects, but instead to general grants management or
program administration. Administrative costs can be expended for personnel or nonpersonnel costs, and can be direct or indirect, but should represent the costs to the State
for managing the overall grant-funded work rather than preparation for and execution of
individual projects.
“Communities of color” are those communities with a higher than national average
percent of individuals in a block group who list their racial status as a race other than
white alone and/or list their ethnicity as Hispanic or Latino. That is, all people other than
non-Hispanic white-alone individuals. The word "alone" in this case indicates that the
person is of a single race, not multiracial. A block group is an area defined by the Census
Bureau that usually has in the range of 600-3,000 people living in it. 3
“Date of receipt of funds” - as identified in Sec. 40601(c)(3)(A)(i)(II)(cc) this is the date
on which the awarded grant is available for obligation in the receiving State’s financial
system of record. For purposes of this guidance, the date of receipt shall refer to the date
when a recipient organization initiates its first drawdown of funds from the Automated
Standard Application for Payment (ASAP).
“Federal land” is defined in Sec. 40601(a)(1) as land administered by a land management
agency within the Department of Agriculture or the Department of the Interior.
“Federal wells” – Orphaned wells and well sites on Federal land are considered “Federal
wells” and are eligible for funding under the Sec. 40601(b) Federal Program. Orphaned
wells–and well sites associated with such wells–that were drilled subject to a federal
permit to drill may be considered Federal wells eligible for funding under the Sec.
40601(b) Federal Program, regardless of surface ownership. As the funding under the
Federal Program is not expected to be sufficient to remediate all eligible Federal wells, a
State may use grant funds received under Sec. 40601 to plug and remediate Federal wells
located on State or private land and may include those wells in its inventory of
documented orphaned wells on State or private land. Any plugging and reclamation
activities on such split-estate orphaned wells would be subject to the Federal
government’s on-shore plugging and reclamation standards.

Except as provided by Section 40601(c)(2)(B)(ii), which allows larger amounts to be used for administrative costs
under the small-scale Initial grants described further in Section IV of this document.
3
This definition is adopted from USEPA’s EJSCREEN definitions at: https://www.epa.gov/ejscreen/overviewdemographic-indicators-ejscreen#demoindex
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“Low-income communities” are those communities that in the last 12 months had a
median household income less than twice the poverty level. 4
“Orphaned Well” - The term “orphaned well” with respect to Federal or Tribal land,
means a well that is not used for an authorized purpose, such as production, injection, or
monitoring, and for which no operator can be located, or the operator of which is unable
to plug the well and to remediate and reclaim the well site. With respect to State or
private land, the term also:
(1) has the meaning given the term by the applicable State; or
(2) if that State uses different terminology, has the meaning given another term
used by the State to describe a well eligible for plugging, remediation, and
reclamation by the State.
“Tribal and indigenous communities” are communities whose members make up a
Federally recognized Indian Tribe, a State-recognized Indian Tribe, an Alaska Native
community or organization, a Native Hawaiian organization, or any other community of
indigenous people located in a State, including indigenous persons residing in urban
communities.
“Unobligated amounts” - For purposes of determining the deadline for expenditure under
Sec. 40601(c)(3)(C), “unobligated amounts” covers any funding that is not subject to a
definite commitment that creates a legal liability of the State for an immediate or future
payment for goods or services ordered or received, including by contract or sub-contract
award. 5
III.

PERMISSIBLE USES OF INTIAL GRANT FUNDS
A. As provided under Section 40601(c)(2), a State may use funding from Initial grants
to:
• plug, remediate, and reclaim orphaned wells located on State-owned or
privately-owned land;
• identify and characterize undocumented orphaned wells on State and private
land;
• rank orphaned wells based on factors including public health and safety,
potential environmental harm, and other land use priorities;
• make information regarding the use of funds received available on a public
website;
• measure and track emissions of methane and other gases associated with
orphaned wells;

This definition is similar to USEPA’s EJSCREEN definition at https://www.epa.gov/ejscreen/ejscreen-mapdescriptions#category-demographics
5
See Government Accountability Office definitions at: https://www.gao.gov/assets/gao-05-734sp.pdf
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•
•

•
•

•

measure and track contamination of groundwater or surface water associated
with orphaned wells;
remediate soil and restore native species habitat that has been degraded due to
the presence of orphaned wells and associated pipelines, facilities, and
infrastructure;
remediate land adjacent to orphaned wells and decommission or remove
associated pipelines, facilities, and infrastructure;
identify and address any disproportionate burden of adverse human health or
environmental effects of orphaned wells on disadvantaged communities,
including communities of color, low-income communities, and Tribal and
indigenous communities; and
administer the program of work identified in its grant agreement.

B. Initial grants are available for such activities where the surface is owned by the State
or by a private party, including, potentially, individually owned Indian properties that
are held in trust by the Secretary of the Interior but deemed by the State to be
‘orphaned wells’ on ‘private land,’ for purposes of compliance with this section only.
Funds may not be used for activities where the surface is owned by the United States
or by an Indian Tribe.
C. Section 40601(c)(3)(A) allows States to request an Initial grant of up to $25 million
under clause (i)–referred to as large-scale Initial grants–or up to $5 million under
clause (ii)–referred to as small-scale Initial grants. States may receive one Initial grant
under 40601(c)(3): either a small-scale grant or a large-scale project grant, but not
both.
D. Section 40601(c)(A)(i)(II)(cc) provides that a State that applies for a large-scale
Initial grant must include a certification that the State will use not less than 90% of its
requested funding to issue new contracts, amend existing contracts, or issue grants for
plugging, remediation, and reclamation work by not later than 90 days after the date
of the receipt of the funds.
E. Section 40601(c)(3)(C) - Expenditure and Reimbursement: A State that receives
funds under the Initial grant authority shall reimburse the Secretary in an amount
equal to the amount of funds that remain unobligated on the date that is one year after
the date of receipt of the funds. In other words, all funds must be obligated within a
year of date of receiving the funds otherwise unobligated funds shall be reimbursed to
the Secretary.

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IV.

INSTRUCTIONS FOR INITIAL GRANT APPLICATIONS
A. Deadline
i.

Small-Scale Grants (up to $5 million): States may apply for an Initial grant of
up to $5 million within a time frame sufficient to ensure that periods of
performance and final obligations are complete prior to September 30, 2030.

ii.

Large-Scale Grants (up to $25 million): The deadline for submitting
applications for Initial grants of up to $25.0 million is May 13, 2022, 11:59
pm EDT.

Applications must be emailed to orphanedwells@ios.doi.gov. An email
acknowledging receipt will be provided by DOI to the sending State within one
business day of receipt.
B. Required Elements
To be complete, the application should include sufficient details as described
below to provide assurances regarding the ability of the state to properly carry out
and oversee the activities to be funded.
i.

Federal Forms: The following Federal forms, all available at Grants.gov,
must be submitted for an Initial grant request for funding (the application) to
be complete:
(a) SF-424v4 Application for Federal Assistance
(b) SF-424A Budget Information for Non-Construction Programs
An SF-424A is a standard form that provides an estimate of the
work’s major cost centers (e.g., State employee labor, training,
equipment, contracting and other operational costs), where the sum
total of the budget justification equals the overall Initial grant
request.
(c) SF-LLL Disclosure of Lobbying Activities
(d) OMB Form 4040-0010 Key Contacts Form

ii.

Detailed Budget Proposal/Justification: This detailed information supports
and identifies the estimated costs provided in the SF-424A and should
include an itemized budget breakdown with unit costs for the period of the
Initial grant funding and the basis for estimating the costs of personnel
salaries, fringe benefits, project staff travel, materials and supplies,
equipment, and consultants and contracts. This document should also include
narrative descriptions of the items included in the project budget.
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iii.

Project Abstract Summary (OMB Form Number 4040-0019): A project
abstract of not more than one page will include the project purpose, activities
to be performed, expected deliverables or outcomes, intended beneficiaries,
and subrecipient activities (if known).

C. Recommended Elements
The following list includes the features the Department of the Interior has
determined are important components of successful orphaned well program.
Although not required in relation to Initial grant funding, many are expected to be
required for subsequent grants, and States are encouraged to incorporate these
features into projects funded with Initial grants.
For those parts that are applicable, the State should include the following
information as a narrative attachment to the required elements listed above:
(a) The State’s process for determining that a well has been orphaned,
including what efforts will be made to redeem financial assurances or
otherwise recoup remediation costs from any parties responsible under
State law;
(b) A description of the State’s plugging standards, including the witnessing
requirements (qualifications of witness, documentation);
(c) Details of the State’s prioritization process for evaluating and ranking
orphan wells and associated surface reclamation, including criteria,
weighting, and how such prioritization will address resource and financial
risk, public health and safety, potential environmental harm (including
methane emissions where applicable), and other land use priorities;
(d) If no prioritization process currently exists, the State should describe its
plans to develop and implement a prioritization process;
(e) Details of how the State will identify and address any disproportionate
burden of adverse human health or environmental effects of orphaned
wells on disadvantaged communities, including communities of color,
low-income communities, and Tribal and indigenous communities;
(f) The methodology to be used by the State to measure and track methane
and other gases associated with orphaned wells, including how the State
will confirm the effectiveness of plugging activities in reducing or
eliminating such emissions;
(g) The methodology to be used by the State to measure and track
contamination of groundwater and surface water associated with
orphaned wells, including how the State will confirm the effectiveness of
plugging activities in reducing or eliminating such contamination;

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(h) The methodology to be used to decommission or remove associated
pipelines, facilities, and infrastructure and to remediate soil and restore
habitat that has been degraded due to the presence of orphaned wells and
associated infrastructure;
(i) Methods the State will use to solicit recommendations from local officials
and the public regarding the prioritization of well plugging and site
remediation activities, and any other processes the State will use to solicit
feedback on the program from local officials and the public;
(j) Latitude/Longitude and all other data elements and associated units of
measure as indicated in the Orphaned Well Data Reporting Template that
accompanies this guidance;
(k) How the State will use funding to locate currently undocumented
orphaned wells;
(l) Plans the State has to engage third-parties in partnerships around well
plugging and site remediation, or any existing similar partnerships the
State currently belongs to;
(m) Training programs, registered apprenticeships, and local and economic
hire agreements for workers the State intends to conduct or fund in well
plugging or site remediation;
(n) Plans the State has to support opportunities for all workers, including
workers underrepresented in well plugging or site remediation, to be
trained and placed in good-paying jobs directly related to the project;
(o) Plans the state has to incorporate equity for underserved communities
into their planning, including supporting the expansion of high-quality,
good paying jobs through workforce development programs and
incorporating workforce strategy into project development;
(p) Procedures the State will use to coordinate with Federal or Tribal
agencies to determine whether efficiencies may exist by combining field
survey, plugging, or surface remediation work across private, State,
Federal, and Tribal land;
(q) The State’s authorities to enter private property, or a State’s procedures to
obtain landowner consent to enter private property, in the event that any
wells to be plugged will be accessed from privately owned surface;
(r) A work schedule covering the period of performance of the Initial grant;
and
(s) If applicable, a federally approved Indirect Cost Rate Agreement or
statement regarding State’s intention to negotiate or utilize the de
minimis rate.

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D. Restrictions on funding use (90% must be for contracts & grants)
States may not use more than 10 percent of the funds received as authorized under
Sec. 40601(3)(c)(3)(A)(i) for administrative costs associated with activities listed
in Section III. This limitation does not apply to an Initial grant of up to $5.0
million received as authorized under Sec. 40601(3)(c)(3)(A)(ii). However, States
receiving the smaller Initial grants must nonetheless comply with 2 CFR §
200.414, which requires States to adhere to federally-approved indirect cost rate
agreements.
E. Certifications

V.

i.

Small-Scale Grants: For small-scale grant applications up to $5 million, a
certification (see attached format) must be submitted to the Department that:
(a) The State has a plugging, remediation, and reclamation program in
effect for orphaned wells; or
(b) The State has the capacity to initiate such a program; or
(c) The funds provided under this paragraph will be used to carry out
any administrative action necessary to develop an application for a
formula grant or performance grant.

ii.

Large-Scale Grants: For large-scale grant applications up to $25 million, a
certification (see attached format) must be submitted to the Department that:
(a) The State is a Member State or Associate Member State of the
Interstate Oil and Gas Compact Commission;
(b) There are 1 or more documented orphaned wells located in the
State; and
(c) The State will use not less than 90 percent of the funding requested
to issue new contracts, amend existing contracts, or issue grants for
plugging of orphan wells, and reclamation of associated surface
conditions by not later than 90 days after the date of receipt of the
funds.

RECOMMENDED STANDARDS FOR MEASUREMENT, PLUGGING, AND
REMEDIATION
A. Pre and Post-Plugging Measurement or Estimation of Air and Water Pollution
i.

As a best practice, States are encouraged to conduct an inspection of each
orphaned well site being considered under this grant to measure or estimate
current contamination of surface water and groundwater and to measure or
estimate current emissions of methane, hydrogen sulfide, and other gas emissions.
States are also expected to conduct post-plugging inspections and measurements
to verify the lack of gaseous emissions or water contamination from plugged
wells and the achievement of vegetation performance standards appropriate to the
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site’s future land uses. Such post-plugging inspection and measurement will be
documented to create a verifiable record of activities performed under the grant.
ii.

States are encouraged to follow a third-party methodology for measurement and
verification, such as the American Carbon Registry’s methodology (once
finalized). 6 States should report in their Project Narrative the methodology or
methodologies they will use or require their contractors to use.

iii.

Pre- and post-plugging measurements or estimates, by well, of water
contamination, gaseous emissions (particularly methane), and acres restored
should be included in the Final Performance Report described in Section VII.C.
below.

B. Well Plugging and Site Remediation Standards
i.

VI.

States with established and documented well plugging standards and regulations
will require their contractors to meet those requirements. For a State that does not
have established well plugging standards, it is strongly recommended that the
work reflect, at a minimum: the plugging standards in the Bureau of Land
Management’s Onshore Oil and Gas Order No. 2 Section III.G for plugging wells
(https://www.blm.gov/sites/blm.gov/files/energy_onshoreorder2.pdf); or, for
offshore wells, the provisions of 30 CFR Part 250.

ii.

States will adhere to any well plug witnessing and documentation requirements
pursuant to State law.

iii.

For States with established well abandonment standards (inclusive of those
actions necessary to complete surface reclamation and revegetation), all well
closures shall meet those requirements. If a State does not have well abandonment
standards, then for a well site to be considered plugged and fully abandoned, such
that it can be reported as a completed unit, the work must reflect, at a minimum,
the Bureau of Land Management’s Reclamation and Abandonment Standards. For
additional details, see: https://www.blm.gov/sites/blm.gov/files/Chapter%206%20%20Reclamation%20and%20Abandonment.pdf

FEDERAL AND TRIBAL COORDINATION
Efficiency and cost-effectiveness in well plugging and site remediation will be
maximized by ensuring proper coordination in these activities between States, Tribes, and
the Federal government. As early as practical–preferably before State grant applications

https://americancarbonregistry.org/carbon-accounting/standards-methodologies/plugging-abandoned-orphaned-oiland-gas-wells
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are submitted–States should contact the relevant offices of Tribal or Federal land
management agencies to ensure the maximum level of coordination between States,
Federal land management agencies, and Tribes. States may reach out to the IOGCC or the
DOI/OEPC for a list of appropriate contacts.
When undertaking work on Federal land under a cost-sharing, Good Neighbor, or other
arrangement with the Federal government, States must collect the data required to be
reported under the BIL for wells plugged and sites remediated on Federal land. Early
coordination with Federal agencies is encouraged to ensure that States are collecting the
proper data in a format that can most easily be transferred to the Federal government.
States are also encouraged to consult with Federal agencies and Tribal representatives to
ensure appropriate and efficient collaboration on compliance issues (e.g., cultural
resources, endangered species, sacred sites) and to minimize disruption of operations and
land management activities, such as planning field activities to avoid special events that
might be impacted by the work.
VII.

REPORTING REQUIREMENTS
A. Quarterly Reports: Consistent with 2 C.F.R. § 200.328, States must submit
quarterly financial and performance reports to the DOI within 30 days of the close
of each Federal fiscal quarter. Financial reporting will use SF-425 or other forms
if specified by the Office of Management and Budget.
B. Personal Property report: States will be required to submit an annual Tangible
Personal Property Report (SF-428) if grant funds are used to purchase equipment.
C. Final Financial and Performance Reports: Consistent with 2 C.F.R. § 200.329,
States must submit a final financial and performance reports to the DOI within
120 days of period of performance end date. Financial reporting will use SF-425
or other forms if specified by the Office of Management and Budget.
D. 15-month report: States receiving either type of Initial grant must submit a report,
no later than 15 months after the date on which the State receives the funds,
describing the means by which the State used the funds in accordance with its
certification. If the 15-month report includes all of the detail that would have been
provided in the Final Financial and Performance Report described in VII.C, a
separate Final Financial and Performance Report need not be submitted..
E. Data Collection and Reporting
1. In order to simplify and standardize reporting and tracking requirements
and ensure that the Federal resources utilized are well-spent and achieving

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the statutory objectives, States are encouraged to track the following data
for all actions taken using orphaned well grant funding. Such data
elements will help inform, and be incorporated into, the processes being
developed for the forthcoming Formula grants and Performance grants
listed in Section I above. As appropriate, data tracking may be
accomplished through existing systems such as the Groundwater
Protection Council’s Risk-Based Data Management Solutions (RBDMS):
(a) Well location information (e.g., latitude/longitude);
(b) Well type (e.g. orphaned production or disposal well);
(c) Bureau of Labor Statistics NAICS codes for each of the employees
working on each well site, along with the hours each employee
spent on each site;
(d) The population living within a half mile radius of each well being
plugged;
(e) Pre-plugging methane emissions (if available);
(f) Post-plugging methane emissions;
(g) Surface water contamination identified;
(h) Surface water contamination remediated;
(i) Groundwater contamination identified;
(j) Groundwater contamination remediated;
(k) Acreage impacted by well and infrastructure (site footprint);
(l) Revegetation performance standard monitoring start date;
(m) Revegetation performance standard attainment date (project
complete);
(n) Actual total cost per well of plugging and surface reclamation; and
(o) If the project is located in a low-income, disadvantaged, and/or
minority community.
2. This list highlights important parameters that DOI will report to Congress
annually and is a subset of the larger data set to be reported by the States
as part of the quarterly performance reports (VII.A.) and 15-month report
(V.A.iii.) and detailed in the Orphaned Well Data Reporting Template
accompanying this guidance. States that intend to apply for a Formula
grant (as per forthcoming Formula grant guidance) should note that
information regarding the activities under such grants are required to be
posted on a public website, and States are strongly encouraged to develop
such a website to provide information to the public about the activities
undertaken using Initial grant funding as well. Developing a website is an
allowable use of Initial grant funds and ensuring that Initial grant activities
are tracked in the same manner as Formula grant activities will allow for a
better determination of the successes of the funding, help meet goals of
transparency and accountability, and make it easier for the State to meet
future reporting requirements.
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F. After providing the grantee an opportunity to redact personally identifiable or
proprietary information, the Department of the Interior will post successful grant
applications on a publicly available web site.
G. The Department of the Interior will publish a summary of performance
accomplishments on a publicly available web site, following submission by the
States of the report required in Section VII.C of this guidance.
VIII.

DOI STANDARD AWARD TERMS AND CONDITIONS

A. DOI Standard Award Terms and Conditions will be included in all Initial grants, at the
time of award. These standard terms and conditions can be found at:
https://www.doi.gov/sites/doi.gov/files/uploads/doi-standard-award-terms-andconditions-effective-december-2-2019-revised-june-19-2020.pdf
B. Award recipients will be expected to comply with Executive Order 14005, Ensuring the
Future Is Made in All of America by All of America’s Workers, which requires awardees
and sub-awardees of Federal financial assistance awards to maximize the use of goods,
products, materials, and services from sources that will help American businesses
compete in strategic industries and help America's workers thrive.
C. The Federal awarding agency may make site visits as warranted to ensure appropriate
fiscal accountability and oversight. States shall provide Federal awarding agency access
to relevant documentation in state possession and facilitate, to the extent necessary and
appropriate, Federal awarding agency access to project sites.
D. For project work that involves construction, alteration, or repair, award recipients, and
any sub-awardees, will be expected to comply with the Davis-Bacon Act, which requires
that not less than locally prevailing wages and fringe benefits be paid to employees.
E. States are encouraged to consider prioritizing projects, and/or the benefits that flow from
those projects, in disadvantaged communities.
F. The DOI Freedom of Information Act Office provides guidelines to requestors of grant
applications around what information may be redacted from applications. This
information includes patent rights, confidential financial information, personally
identifiable information (PII), and detailed budget, consultant, and business assets
information. 2 CFR § 200.338 places limitations on public access to award-related
documents.

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G. As required by Section 70914 of the Bipartisan Infrastructure Law on or after May 14,
2022, none of the funds under a federal award that are part of Federal financial assistance
for infrastructure may be obligated for a project unless all of the iron, steel, manufactured
products, and construction materials used in the project are produced in the United States,
unless subject to an approved waiver. The requirements of this section must be included
in all subawards, including all contracts and purchase orders for work or products.

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State Certification
Orphaned Well Site Plugging, Remediation, And Restoration
Small-Scale Initial Capacity Grant
Consistent with Section 40601(c)(3)(A)(ii)(III) of the Infrastructure Investment and Jobs Act
(aka Bipartisan Infrastructure Law), the State or Commonwealth of
____________________________ certifies that it:
has in effect a plugging, remediation, and reclamation program for
orphaned wells;
o

OR
o

has the capacity to initiate such a program;

OR
that the funds will be used to carry out any administrative actions
necessary to develop an application for a formula grant or a performance grant
under Section 40601(c)(4) or Section 40601(c)(5), respectively.
o

__________________________________ _________________________________
Certifying Official Name
Title

__________________________________ _________________________________
Certifying Official Signature
Date

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State Certification
Orphaned Well Site Plugging, Remediation, And Restoration
Large-Scale Initial Project Grant
Consistent with Section 40601(c)(3)(A)(i)(II)(aa) of the Infrastructure Investment and Jobs Act
(aka Bipartisan Infrastructure Law), the State or Commonwealth of
________________________________ certifies that it is a Member State or Associate Member
State of the Interstate Oil and Gas Compact Commission.
The State or Commonwealth also certifies that it has one (1) or more documented orphaned wells
located within our State or Commonwealth.
And the State or Commonwealth certifies that it will use no less than 90 percent of the funds
requested under this grant to issue new contracts, amend existing contracts, or issue grants for
plugging, remediation and reclamation work on orphaned wells within our State or
Commonwealth by not later than 90 days after the date of receipt of the funds.

________________________________
Certifying Official Name

_________________________________
Title

__________________________________
Certifying Official Signature

________________
Date

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