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ea <br />• <br />DBE CERTIFICATION FORM <br />STATE OF <br />COUNTY OF <br />1 HEREBY DECLARE AND AFFIRM THAT I AM THE <br />(Tide - Owner, President, <br />and duty adbmiz d repranotative of <br />Co -Venturer, etc.) <br />wbose, address is <br />(Name of Firm) <br />• I hereby dedare and affirm that I am a _._ tKrnorky (or) Female <br />(specify which) Business Eote rprise (NME or WBE) as defined by the contract doarman coW <br />below, sod that I wM provide on request infamstm to docame d tris fact <br />Thus firm is inter eyed in quotingNdding on the following categories of work being procured for the <br />Indian River County Council on Aging <br />Project No. <br />This firm has current DBE/hMElWBE cat&action from the fotlowutg agencies: <br />I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT <br />THE CONTENTS OF THE FOREGOING DOC WW ARE 'TRUE AND CORRECT, AND <br />THAT I AM AUTHORIZED ON BEHALF OF THE FMM TO DdA= THIS AFFIDAVIT. <br />(Dift) (Anne) <br />STATE OF COUNff OF <br />bn this dry of 19 be & s ■R <br />the Ac" signed omcror, pasoostly appm ed <br />. renown to me to be the person dasmgmd in the ftisob* <br />amelevit sod arlmowleAied tht t5e fsbel M.;. -A—1 :�,.:,. Sams= .oat iur ere <br />purposes therm coma6d <br />In witne w dmw( I berraanto set my hand and oSidal seat. <br />(SEAL) <br />My Commin±oa Evira <br />• Collative called DBEs <br />DBE FORM 2 <br />ATTACHMENT C <br />- 24 - <br />