15 CAR pt. 61, Appendix B
CRIMINAL BACKGROUND DISCLOSURE FORM – ECONOMIC DEVELOPMENT
In connection with the Application submitted to the Arkansas Development Finance Authority by
___ requesting participation in ___, I, (Name of Borrower) ___, on behalf of ___, being (Principal)¹
(Borrower) duly sworn, hereby certify that I, or any principal² of ______: (Borrower)
☐ have/has not been convicted by any state or federal jurisdiction of any felony: Or
☐ have/has been convicted by a state or federal jurisdiction of a felony and the following details are provided:
| Jurisdiction | Date | Offense | Punishment | Details |
|---|---|---|---|---|
I, ___, in my capacity as ___, (Name) (Title/Position with Borrower) further certify that I have the authority and knowledge to make the representations contained herein and agree to the terms of ADFA's Criminal Background Check Policy.
Date: ______
(Signature)
(Printed/Typed Name)
(Title/Position with Borrower)
²Principal for purposes of this Attachment B shall include: if the borrower is a partnership, association, limited liability company, or corporation, any person who has at least a ten percent (10%) ownership interest in any ownership entity of such partnership, limited liability company or corporation.
CRIMINAL BACKGROUND DISCLOSURE FORM – ECONOMIC DEVELOPMENT (continued)
STATE OF ______ )
COUNTY OF ______ )
Before me, ___, a Notary Public of the state and county stated above, personally appeared ___, with whom I have personal knowledge, and who, acknowledged that _he executed the foregoing instrument for the purpose stated therein.
Witness my hand and seal this _ day of _, 20.
My Commission Expires:
Notary Public