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Attachment K Department of Community Affairs Neighborhood Stabilization Program Florida Small Cities Community Development Block Grant (CDBG ) Program Cot .....Recipient ........... ... .. .._..... ................ .._......_...__.. ......__.._ _ _Submit an oS�GN��CURE AUHoOtYRITY FormFORM Submitcontract ZQQ9 oval Government nm __3�.....2..� _._..........__...... ent DUNS Number Indian River County 10DB-4X40-40-01 - 1`13 079208989 Mailing Address (Street or Post Office Box) -....--.._._.....-_.__.._._.._......_....._..__.__... ! 180127th Street _.. ....._.._ ........__.._......._._......_._.................. ............_.............................._.... .. j City, State and Zip Code Vero- Beach , Florida 32960-3388 ... .... ..... . _ ... - _ - _ . .. _ . . --- - - - - . . . ........................b..................................... ........... ._.. ......._-.................................................. . ...... . ..... ...... . . . ._. ...� Project Contact Person Telephone # j 772) 226 1254 ............... ......__..._._. . _ .... .............................................. ............_............._......._._.-- --._.. .................._.._...... ......__ .__._.....__...i Robert M . Keating, Community Development Director E-mail Address ...... . ......................_...... ..._bkeatinaircgov com ......... ............... .. .........._............_.. .. . .........._......_._..._ .__..........-..................._...._...._._.__. Financial Contact Person Telephone # 772 226- 1205 _. ....... ..........__........._..._....................__...._...... ................. .................. ._............._....... ......................._............................_........................ __. Diane Bernardo - Finance Director E-mail Address id_bernardo@clerk. indian-r_ive_ r. or Requests for Funds ( RFFs) from the Florida Small Cities CDBG Program require (check one): [ ] one signature [ ] two 1 signatures of individuals authorized below. No more than two individuals can be authorized to use Florida PAPERS. CDBG contracts require that at least one ( 1) RFFs must be submitted each quarter and should reflect all expenditures incurred Burin4that reporting period - --..... .... - _ ___._ _-- _ .-.--. . __._. __. _. .............. Typed Name Da Si atur Robert M . Keatin Community Dev Director �, � .-_-__..... ._........ ._..._ __ . --- .7.9 . .. o _.�... __ [ X ] Check here if the above person will be the E-mai Ad ess designated FloridaPAPERS user. bkeat1111.11.11.. ing@ircgov.com _ Typed Name Date I Signature ...... .. _.. __............. _ . . . .. . .. .. _. .... .. ...._ .... .. ... . ._ 1. . ._ .. . . .. ... .... . . . .. ... . .... ... .. .. _.. . ... _ . _ .. [ J Check here if the above person will be the E- mail Address i designated FloridaPAPERS user. . ._. ._ . ... ...... ........__ . . _ . -_. .. .. .. ...... .._.......__..... ............ . .. ....... _...... ...... _. _....- .. ............. _... . .. . .. .... ........ . . . __ ...... Typed Name Date I Signature j l i [ ] Check here if the above person will be the E-mail Address designated FloridaPAPERS user. _ _ -- - - - - - - — __ _ _ _.... ... ._... _ _ .. . _ .._......... .. .... __ . _. _._. -......__ _.._ ..._. .... ._.. _.. . -- ......_ ._...... - I certify, as the recipient's Chief Elected Official, that the above signatures are of the individuals authorized to sign Requests for Funds and to submit RFF's electronically to the Small Cities Community Development Block Grant Program using FloridaPAPERS . ....... .........._._......._.... .......................... ... .. ... __....._..__........._._..........................._--..._ ...._...._._..__.. ...._.._. .... ...._..__......../. ......._ ... ......_........... _._..............._...... . ...__._ .. _ .................. ....; Typed Name I Date vi�; Ik Wesl.ey._S . Davis, BCC..Chairman.............-- --- ._._.._ fAU.gust._...1.$-,.........20 ._.... .... .... ......_....._......................._D.. ...._.._..... ... .. ...... _... _. . ...... . .. ...[X] Check here if your local government utilizes Electronic Funds Transfer ( EFT) Sc a of Florida . j j [X] Check here if your local government will be working on a reimbursement basis. [ ] If this signature authority form pertains to a housing grant, check here if your local government will use an escrow account for housing. activities_ __ ........... .............. _._ _ __. .....__............__.___....__...._..._.._....__- _._.._.._....__.._.._._...._......_..... ..__...__._ CDBG payments to local governments using EFrare automatically deposited in the local government's general account. If the account is interest bearing, the CDBG funds must be transferred to a non- interest bearing account. Please call the CDBG i Program at 850/922- 1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's website : http : //flair. dbf. state .fl . us/ . ...... ...... . ..._ ...............__.. ._..........._.........._....._.......__...._....._...._._............................. ...._ _. . _ . _ -- ....... ... ....._..............._.............._..__.._.__......... ....__....._.._................_..........__ ................ . ... .- ._.........__ ......... Local . . governmen is not receivin g EFT, and not working on a reimbursement basis, must establish a non - interest bearing account. Provide account information for the financial institution ( insured by FDIC) below . All signatures on the account must be bonded . Name of Financial Institution 1 Account Number RBC Bank 053100850-7680027195 ...._.. ._................_._................---...... ...........__._ .................__._.. ... -............_......._...... ........................ ...---- ---- . .._.._ _._..._._......._.._......._. ._........_................_..._... .. __........-- ---..........._...._ - - -._...-............_......... ................................._.. Street Address or Post Office Boxf T Number elephone Nu be ;.. .. 1417 Centura �FplwaHighway. ._....__.............. --...._... __....__...................................................... ......._ _.(......(252) 454-3557._or..@ 0) 226- 5985............ -- City, State and Zip Code _ - Rocky Mount, NC 27802