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- AC.000NTWS i,;, CERTIFICATION <br />1NSTRUCTIOUS: <br />Page . 3 of 10 <br />I. Complete Section I OR'Section II (Requirement for ALL Applicants) <br />2. Attach a -copy of an Audit Report completed for your organization by an <br />independent.Accounting firm. This report must have been completed <br />not more than twelve (12) months prior to the date of application. (Requirement <br />or Community Action Agencies, Limited Purpose Agencies, and mig-rant/seasonal <br />farmworker organizations ONLY.) <br />i <br />SECTIONII - STATEMENT OF PUBLIC FINANCIAL OFFICER (To be completed only if <br />Applicant 'is a public agency local government; or when the accounting <br />system of a private non-profit agency will be maintained -by a public <br />agency.) <br />I am the Chief Financial Officer of Indian River Count <br />Type Name of Local Government <br />and, in 'this capacity, 1 will be responsible for providing financial services <br />adequate to insure the establishment and maintenance of an accounting ,ystem for <br />Indian River i s a public Count which <br />Name o Applicant <br />(or non-profit) agency or local government charged with carrying out a program(s) <br />under the Community Services Block Grant.in -It-dian River C t <br />Name of Community <br />The accounting system will have internal controls adequate to safeguard the assets <br />of such agendW es), check the accuracy and reliability of accounting data, promote - <br />operating efficiency, and .encourage compliance with prescribed management policies <br />° of the agency0es) . <br />.Indian River County <br />(Type Name of Local Government) <br />Jeff Barton �3 <br />Type Name of Chief Financial Off* er) Date <br />--- - <br />1305-567-8000 <br />(S (Signat f Chi nancial Officer) Te I ephone <br />71:4.s'��'rr....'+.m'5:»h*,33•'tdG.r'�:1_1�Y�1 <br />SECTION If - STATEMENT OF CERTIFIES? PUBLIC ACCOUNTANT (To be completed only if <br />Applicant is a private non -pro ' agency; or a public agency whose <br />accounting system will not be maintained by a public agency.) <br />I am a certified or duly licensed public accountant.and have been engaged to <br />examine and report on the financial accounts of the <br />which is a private nog -profit organ - <br />(Name of Applicant <br />ization (or public agency) carrying out a program(s) under the Community Services <br />Block Grant in 'I have reviewed <br />Name of Community <br />the accounting system that this agency has established and, in my opinion, it <br />includes internal controls adecuate to safeguard the assets of the agency, check <br />the accuracy and reliability of accounting data, promote operating efficiency, and <br />encourage compliance with prescribed• management policies of the agency. <br />(Type Name of Firm) <br />(Type Name of Accountant <br />0 <br />Date <br />(Signature of Accountant) Tei o e): ` <br />FEB. 16 193 s x rAt , <br />