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• ATTACHMENT D <br />FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION <br />1875 ORANGE AVE E <br />TALLAHASSEE, FL 32311-6160 <br />(850) 488-6551 <br />Attachment #: Executive Order 20-44 Attestation Form <br />This form must be returned annually to FWC by April 1 to satisfy the requirements under the Governor's <br />Executive Order Number 20-44, published February 20, 2020. Your attestation is needed for the following <br />information <br />Legal Name of Organization <br />IRS Issued Tax Id/DUNS Number: <br />unTt4 of J rn t) L Oar% 1�i Ver - �B pav d <br />59 to D 0 0 Cel 4 <br />C o mmiss cr erS <br />Type of Organization —Non -Profit —For -Profit _Educational Institution _Local Municipality VOtheerr OAS V l+ <br />V <br />Service Location for Organization:e-p b Ze-0-o I (city), l n C Q -1'i VIAl Ve i (county) <br />1) Does the organization currently receive 50% or more of its budget annually from the State of Florida or <br />from a combination of State and Federal funds? _Yes <br />2) All compensation must be reported and shall indicate what percent of compensation comes directly from <br />the State or Federal allocations to the Contractor. IF THE ANSWER TO #1 IS YES, please submit the <br />following information to the Contract Manager: <br />a) A copy of the IRS Form 990. <br />b) Documentation showing total compensation—to include salary, bonuses, cashed -in leave, cash <br />equivalents, severance pay, retirement benefits, deferred compensation, real -property gifts, and any <br />other payout—for all members of the Contractor's executive leadership team for the past tax year. <br />c) Total compensation amount: $ <br />d) Total number of members: <br />3) The Contractor shall provide this information on an annual basis to the Contract Manager, along with <br />the requirement to inform the Contract Manager of any changes in total executive compensation <br />between the annual reports. <br />Attestation Statement: As an "Authorized Representative" of the Respondent, I duly attest to the best of <br />my knowledge that all information provided in this questionnaire is accurate and true as presented. I also <br />understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may <br />be subject to civil penalties, attorney's fees, and/or costs. <br />Contractor/Authorized Representative Signature <br />Chi e( -bepa-hi Coryy7�roller <br />Title <br />A/ <br />Printed Name <br />