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Process for review on: b. Program is subject to E.O. 12372 but has not been selected by State for review.

c. Program is not covered by E.O. 12372. *15. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

YES

NO If Yes, explain:

16. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001) **I Agree

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions. 17c. Telephone (area code, number and extension) 17a. Typed or Printed Name and Title of Authorized Certifying Official Lauren Holmes1 17d. Email Address lhartley@lhc.la.gov 17b. Signature of Authorized Certifying Official

17e. Date Report Submitted (Month, Day, Year) 09/25/2025

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