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If yes, please list the provider and payment amount. <br />o:,.j.._ AI <br />ST -.TE Of ILORIDA <br />INDIAN R WER COUNTY <br />THIS IS TO CERTIFY THAT THIS ISA TRUE AND CORRECT <br />COPY OF THE ORIGINAL ON FU IN THIS OFFICE. <br />RYAN L BUTA, CLERK <br />BY / I .c. <br />DATE !6 / O� <br />I IVvlUe INGIIIC runain Source Amount <br />$ - <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 />7. Were funds utilized for the IGT specifically appropriated by the organization's board? <br />If yes, provide the board minutes and date of the appropriation. <br />I John A. Titkanich certify that the statements and information contained <br />in this submittal are true, accurate, and complete. <br />4�1e <br />4natureOficer or Admini for <br />_ County Administrator <br />Title <br />Date <br />Attest: Ryan L. Butler, Clerk of <br />Circuit Court and Comptroller <br />By: <br />De u Clerk <br />