Statement from Applicant Organization's
Chief Executive Officer &/or Chief Volunteer Officer

We do hereby certify that the information provided in this grant application is accurate and complete to the best of our ability and knowledge. We affirm that since the issuance of the tax determination letter, our organization's tax-exempt status has not been changed or revoked by the IRS.

We further acknowledge that if awarded a grant from the Vernon D. and Florence E. Roosa Family Foundation, we will provide certification to the Roosa Family Foundation that the funds have been used for the purposes for which the grant was awarded. We will make this certification within the time specified in the grant agreement.