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F P `. <br /> j , <br /> NOT FOR PROFIT AGENCY CERTIFICATION <br /> The County of Indian River requires , as a matter of policy, that any Consultant or firm receiving a <br /> contract or award resulting from the Request for Qualifications issued by the County of Indian <br /> River, Florida , shall make certification as below. Receipt of such certification , under oath , shall <br /> be a prerequisite to the award of contract and payment thereof. <br /> 17, <br /> I (we ) hereby certify that if the contract is awarded to me, our firm , partnership , or corporation , <br /> that no members of the elected governing body of Indian River County, nor any professional <br /> management, administrative official or employee of the County, nor members of his or her <br /> immediate family, including spouse, parents , or children , nor any person representing or <br /> purporting to represent any member or members of the elected governing body or other official , <br /> has solicited , has received or has been promised , directly or indirectly, any financial benefit, <br /> including but not limited to a fee , commission , finder's fee, political contribution , goods or services <br /> in return for favorable review of any Proposal submitted in response to the Request for <br /> Qualifications or in return for execution of a contract for performance or provision of services for <br /> F <br /> which Proposals are herein sought. <br /> The undersigned certifies that he/she is a principal or officer of the firm applying for consideration <br /> and is authorized to make the above acknowledgments and certifications for and on behalf of the <br /> applicant, <br /> The undersigned certifies that the Applicant has not been convicted of a public entity crime within <br /> the past 36 months , as set forth in Section 287 . 133 , Florida Statutes . <br /> Failure to sign this form will result in disqualification, <br /> Handwritten Signature of Authorized Principal (s ) : DAT Z �_ <br /> NAME : Andrew Jefferson <br /> TITLE : President <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : <br /> St . Peter ' s Human Services , Inc . <br /> FOR ON BEHALF THE APPLICANT: <br /> Sworn to and su scribed to <br /> r _Notary Pu lic, this j <br /> -t <br /> day of 2003 . <br /> kot <br /> 1 J� <br /> (SEAL) (TYPE NAME & TITLE ) <br /> n. Y •.y , RUTFI !_ JEFFERSON <br /> MY C:OMMISSION # DD 199000 <br /> -z EXPIRES: May 6, 2007 <br /> ;1j,�° Bonded ''hru Notary Pt"Ic Undwwrbfs <br /> X <br />