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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION Form 725-000-02 <br />PUBLIC TRANSPORTATION STRATEGIC <br />DEVELOPMENT <br />GRANT AGREEMENT EXHIBITS OGco8124 <br />EXHIBIT I <br />CERTIFICATION OF DISBURSEMENT OF PAYMENT TO VEHICLE ANDIOR EQUIPMENT VENDOR <br />DATE: <br />Agreement No (PTGA): <br />FM#: 407182-4-84-01 <br />PART I: Agency Acknowledgement Section <br />Indian River County BOCC, as the "Agency" for the above referenced agreement, hereby certifies that 100% of the <br />total payment <br />for has been submitted to , on <br />Agency's failure to certify or a falsification may impact future awards and may subject the person and/or entity making <br />the false statement to any and all civil and criminal penalties available pursuant to applicable Federal and State Law. <br />Agency Authorized Official Name: <br />Agency Signature: <br />PART II: Vendor Acknowledgement Section <br />_, having interest in the above referenced agreement has received 100% of its payment(s) for all equipment furnished <br />under this agreement on _from Indian River County BOCC . <br />Vendor Authorized Official Name: <br />Vendor Signature: <br />Exhibit t — Certification of Disbursement of Payment to Vehicle and/or Equipment Vendor will be initiated by FDOT through <br />Docusign at the time payment from FDOT has been made to the Agency. The DocuSign will be routed to the Agency and the <br />Vendor. Each patty will acknowledge the certification where applicable and must be completed within 20 business days from <br />Agency's receipt of payment from FDOT <br />Page 28 of 28 <br />