2015-231 - Laserfiche WebLink

Home Browse Search

Attachment K— eCDBG Access Authorization Form Submit an original eCDBG Access Authorization Form with each copy of the contract. Use the tab key to move between form fields when completing the form electronically. Recipient Name: Contract Number. Funding Source: 71 Indian River County 16DB-OK-10-40-01-N05 Small Cities CDBG Mailing Address(Street or P.O Box): 1801 27,1'Street i City,State,and Zip Code: Vero Beach,FL 32960 Recipient's DUNS#• 079208989 Recipient's FEID#. 596000674 Note: A maximum of two employees of the Recipient can be authorized to access eCDBG for this contract. The individuals listed below have been designated to access eCDBG on behalf of the Recipient listed.above for the purpose of submitting Requests for Funds(RFFs)and required reports. The eCDBG website address is—http://www.deoecdbg.com. If you need to update the names of the individuals who are authorized to access eCDBG for this contract,submit a copy of SC-55, U eCDBGAccess Authorization Update Form,to DEO. CDBG Program Phon Number: 850)717-8405 ro Primary User's Name: .,^ Date: k +' Arluna Weragoda Signa JQ Title: Capital Projects Manager E-mail Address:aweragoda ov.como Secondary User's Name: Date: �t i ( .•�'�OA1MlSS•'••. Q) �I Vincent Burke .J .+,• Si azure , V: Cjl Title: Utilities Director E-mail Address:vburke@ircgov.com0 I M®r _H As the Chief Elected Official of the Recipient,I certify that the above individuals are authorizer tb sub 's U] and reports through eCDBG on behalf of the Recipient. to Name: Bob Solan 119cerrber 1, 2 15 R�;fR000Nj,�.E' N >` o ate: /C XML \ J U) la Title: Chairman BOCC ��^ W t` Signature Additional Payment Information for Processing Requests for Funds ® Check here if the Recipient utilizes Electronic Funds Transfer(EFT) from the State of Florida. ❑ Check here if the Recipient will be working on a reimbursement basis. I ❑ If this signature authority form pertains to a housing rehabilitation grant,check here if your local government will use an escrow account for housing activities. CDBG payments to localgovernments 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. You can check the status j of your deposit at the Comptroller's website: http://flair.dbf.state.fl.us/ L.ocalgovernments 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: Account Number: Address: Telephone Number: City,State and Zip Code: Rev. 09/03/2015 39