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If yes, please list the provider and payment amount. <br />STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS IRO CERTIFY THAT THIS IS A TRUE AND CORRECT <br />COP THE ORI NAL Ol FIIE F <br />FICE. <br />R L R, <br />BY D.C. <br />DATE `"l-Ia-55 <br />rIVV1ue vidmu t-unainq 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 />No <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 />Yes. Indian River County has obtained releases from certain hospitals, cimmitting thagt those <br />hospitals release any claims they have against the County for any challenge to the local special <br />assessment that is the sours of this IGT. <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 John A. Titkanich, Jr. certify that the statements and information contained <br />in this submittal are true, accurate, and complete. <br />Signature of Officer or Administrator <br />County Administrator <br />Title <br />/2, Z®ZS <br />Date <br />