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STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THI4iSERTIFV THAT THIS IS RUEAND ORRECTCOOR ON FBS HIS OFFRv BUT CBy�r//'DAT/ - �Y <br />If yes, please list the provider and payment amount. <br />Provider Name Funding 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 certify that the statements and information contained <br />in this submittal are true, accurate, and complete. <br />gnature 6f Officer or Administrator <br />County Administrator <br />Title <br />9 <br />Date <br />