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If yes, please list the provider and payment amount. <br />, iArL Of FLORIDA <br />iN01AN RCOUNTY <br />THIS 18 O RTIFY THAT THI818 &TRUE AND CORRECT <br />COPAEAE E ORIGION FI N 8 <br />8 I . RK <br />JEFFR NAL R <br />BY .C. <br />DATE l G <br />Provider Name Funding Source Amount <br />d. Does any portion of the provider donation constitute as a "bona fide donation" pursuant to 42 CFR <br />§ 433.54? 42 CFR § 433.54 requires donations will not be returned to the individual provider, the <br />provider class, or related entity under a hold harmless provision. <br />e. Is there an agreement between the IGT provider and the health care entity? If so, please specify <br />whether the agreement is written and provide the details. <br />No <br />7. Were funds utilized for the IGT specifically appropriated by the organization's board? <br />No <br />If yes, provide the board minutes and date of the appropriation. <br />I Joseph E. Flescher certify that the statements and information contained <br />in this submittal are true, accurate, and complete. •,'....h.Mlss <br />gnatt re of Office or Administrator <br />Joseph E. Flescher, Chairman =?o .• oQ�i <br />Title •.9,y�/, .1 .�� •> <br />,•,�ER COU@�� <br />September 21, 2021 <' <br />Date <br />Attest: Jeffrey R. Smith, Clerk of <br />Circuit Court and Comptroller <br />Deputy Clerk <br />APPR-OkIED AS 'fin FORM <br />ANLL) L.&t::AL SUFFICIENCY <br />