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Department of Economic Opportunity - Small Cities Community Development Block Grant Program ATTACHMENT L - Signature Authorization Form 10/ 1 /2011 Submit an original Signature Authorization Form with each copy of the contract. Use the tab key to move between form fields when completing the form electronically. Recipient : Contract Number : Funding Source .- Indian ource :Indian River County 12DB- OH - 10 -40-01 - N01 ® Small Cities CDBG ❑ Disaster ❑ NSP Mailing Address ( Street or P . O . Box ) : 1801 27"' St . Local Government DUNS # : City , State , and Zip Code : Vero Beach , FL 32960 079208989 Project Contact Person : Telephone Number : E - mail Address : Michael C . Hotchkiss ( 772 ) 226- 1821 Ext : mhotchkiss@ircgov . com Financial Contact Person : Telephone Number: E - mail Address : Edward Halsey ( 772 ) 226- 1205 Ext : ehalsey@clerk . indian - river . org Other Local Government Contact : Telephone Number: E-mail Address : W . Erik Olson ( 772 ) 226 - 1834 Ext : eolson@ircgov . com Requests for Funds ( RFFs ) require (check one) : ® one signature ❑ two signatures of individuals authorized below . RFFs must be submitted via the Department ' s website at httr) : //ecdbq . doe . myflorida . com/ ( or by an alternative means specified by the Department) Signatures must be hand dated . 1 04 Name Typed : Michael C . Hotchkiss Date : � - /2 - / 2 Signature ® Check here if above person is authorized ov . com E- mail Address : mhotchkiss@ircgov . com to submit RFFs . @ 9 Name Typed : Erik Olson Dated \ �- - ---- Si natur ® Check here if above person is authorized ov . com E-mail Address : eolson@ircgov . com to submit RFFs . @ 9 Name Typed : Date : Si nature ❑ Check here if above person is authorized E -mail Address : to submit RFFs . Name Typed : Date : Signature n. ❑ Check here if above person is authorized E - mail Address : . • • • • • NFRS•ti to submit RFFs . 0 :.•• I certify , as the recipient' s Chief Elected Official , that the above signatures are of the indi uth d Is •�s to sign Requests for Funds and to submit RFF ' s electronically . • 4: ta � _ Typed Name : Gary C . Wheeler Date : /" /A / 2, ease Signature ® •• Check here if your local government utilizes Electronic Funds Transfer FT) from the State o • • .tom � K 7 +..,t! RIVER ® 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 EFT are 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 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 governments not receiving 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 : Wells Fargo Bank , N . A . Account Number: 2000044270289 Address : 1001 20th Place Telephone Number : ( 772 ) 569 - 5500 City , State and Zip Code : Vero Beach , FL 32960