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Cultural Council of Indian River County Summer Cultural Camp Children's Services Advisory Committee - Indian River County NOT FOR PROFIT AGENCY CERTIFICATION The County of Indian River requires , as a matter of policy , that any Consultant or firm receiving a contract or award resulting from the Request for Qualifications issued by the County of Indian River, Florida , shall make certification as below. Receipt of such certification , under oath , shall be a prerequisite to the award of contract and payment thereof. I (we) hereby certify that if the contract is awarded to me , our firm , partnership , or corporation , that no members of the elected governing body of Indian River County , nor any professional management, administrative official or employee of the County , nor members of his or her immediate family, including spouse , parents , or children , nor any person representing or purporting to represent any member or members of the elected governing body or other official , has solicited , has received or has been promised , directly or indirectly, any financial benefit , including but not limited to a fee , commission , finder's fee , political contribution , goods or services in return for favorable review of any Proposal submitted in response to the Request for Qualifications or in return for execution of a contract for performance or provision of services for which Proposals are herein sought. The undersigned certifies that he/she is a principal or officer of the firm applying for consideration and is authorized to make the above acknowledgments and certifications for and on behalf of the applicant . The undersigned certifies that the Applicant has n6t .heen convicted of a public entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida Statutes. Failure to sign this form will result in disqualification. Handwritten Signature of Authorized Principal (s) : DATE : l93 v NAME : Sheila B . Tucker TITLE : Chairman of the Board of Directors NAME OF FIRM/PARTNERSHIP/CORPORATION : Cultural Council of Indian River County FOR AND ON BEHALF OF THE APPLICANT : Sworn to and subscribed to me , a Notary Public, this day of 01W , 2003 . BY: 6fzt �1(� ra �( � LL- (SEAL) (TYPE NAME & TITLE) r VAN MEt E r-r'A55169 DFBRA G. V A�Cg169 CEXpIRES UL 1S, 3 /TAM boom AOVVMO