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. e <br /> NOT FOR PROFIT AGENCY CERTIFICATION <br /> The County of Indian River requires , as a matter of policy , that any Consultant or <br /> firm receiving a contract or award resulting from the Request for Qualifications <br /> issued by the County of Indian River, Florida , shall make certification as below . <br /> Receipt of such certification , under oath , shall be a prerequisite to the award of <br /> contract and payment thereof. <br /> I (we ) hereby certify that if the contract is awarded to me , our firm , partnership , or <br /> corporation , that no members of the elected governing body of Indian River <br /> County , nor any professional management , administrative official or employee of <br /> the County, nor members of his or her immediate family, including spouse , <br /> parents , or children , nor any person representing or purporting to represent any <br /> member or members of the elected governing body or other official , has solicited , <br /> 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 , <br /> goods or services in return for favorable review of any Proposal submitted in <br /> response to the Request for Qualifications or in return for execution of a contract <br /> for performance or provision of services for which Proposals are herein sought . <br /> The undersigned certifies that he/she is a principal or officer of the firm applying <br /> for consideration and is authorized to make the above acknowledgments and <br /> certifications for and on behalf of the applicant . <br /> The undersigned certifies that the Applicant has not been convicted of a public <br /> entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida <br /> Statutes . <br /> Failure to si n this form will result in discivalificatiod ' <br /> Handwritten Signature of Authorized Principal (s ) : DATE : J <br /> NAME : Andrew Jefferson <br /> TITLE : President <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : St. Peter's Human Services , Inc . <br /> FOR AND ON BEHALF OF THE APPLICANT: <br /> Sworn to and sulpscribed to <br /> ! Notalry licthis <br /> y 0 gY <br /> RUTH L JEFFERSON f <br /> a r MY COMMIS$ION I DD 19M CXo lV <br /> 0 F IFiES: May 6, 2007 TYPE NAME & TITLE <br /> Notary Pitgc <br /> Commissioners <br /> 1840 25t' Street <br /> Vero Beach , FL 32960 <br /> X <br />