(A) Not later than sixty days after the pole replacement fund created in section 191.27 of the Revised Code receives funds for the purpose of providing program reimbursements under the Ohio broadband pole replacement and undergrounding program, the department of development shall develop and publish an application form for the program and post the form on the department web site.

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(B) An application shall include the following information:

(1) The number, cost, and locations of pole replacements, mid-span pole installations, and undergrounding for which reimbursement is requested;

(2) Documentation sufficient to establish that the pole replacements, mid-span pole installations, and undergrounding described in the application have been completed;

(3) Documentation sufficient to establish how the costs for which reimbursement is requested comport with the reimbursement requirements under the program;

(4) The reimbursement amount requested under the program;

(5) Documentation of any broadband grant funding awarded or received for the area described in the application;

(6) Accounting information that is sufficient to demonstrate that costs for which a program reimbursement is requested are eligible for a program reimbursement pursuant to division (C) of section 191.21 of the Revised Code, if the applicant has received any grant funding described in division (B)(5) of this section;

(7) A notarized statement, from an officer or agent of the applicant, that the contents of the application are true and accurate and that the applicant accepts the requirements of the program as a condition of receiving a program reimbursement;

(8) Any information necessary to demonstrate the applicant’s compliance, and agreement to comply, with any conditions associated with the reimbursement awarded to the applicant;

(9) Any other information the department considers necessary for final review and for the award and payment of program reimbursements.

(C) If any federal funds are used for any awards under the program, the application form shall identify and describe any additional federal conditions required in connection with the use of the federal funds.