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NOT FOR PROFIT AGENCY CERTIFICATION <br /> The County of Indian River requires , as a matter of policy, that any Consultant or <br /> firm receiving a contract or award resulting from the Request for Qualifications <br /> issued by the County of Indian River, Florida , shall make certification as below. <br /> Receipt of such certification , under oath , shall be a prerequisite to the award of <br /> contract and payment thereof. <br /> I (we ) hereby certify that if the contract is awarded to me , our firm , partnership , or <br /> corporation , that no members of the elected governing body of Indian River <br /> County, nor any professional management, administrative official or employee of <br /> the County, nor members of his or her immediate family, including spouse , <br /> parents , or children , nor any person representing or- purporting to represent any <br /> member or members of the elected governing body or other official , has solicited , <br /> has received or has been promised , directly or indirectly, any financial benefit, <br /> including but not limited to a fee , commission , finder's fee , political contribution , <br /> goods or services in return for favorable review of any Proposal submitted in <br /> response to the Request for Qualifications or in return for execution of a contract <br /> for performance or provision of services for which Proposals are herein sought. <br /> The undersigned certifies that he/she is a principal or officer of the firm applying <br /> for consideration and is authorized to make the above acknowledgments and <br /> certifications for and on behalf of the applicant . <br /> The undersigned certifies that the Applicant has not been convicted of a public <br /> entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida <br /> Statutes . <br /> Failure to sign this form will result in disqualification <br /> Handwrltt Ignature of Authorized Principal(s) : DATE : � C3 ;Z <br /> NAME <br /> TITLE oard President <br /> NAM' OF FIRM/PARTNERSHIP/CORPORATION : <br /> Indian River County Healthy Start Coalition Inc <br /> Sworn to and subscribed to FOR AND ON BEHALF OF THE APPLICANT: <br /> me a Notary Public, this <br /> �y of , 2004 . BY: <br /> RENOtDD083460 <br /> a MY cokimlSSIa� RES: Fe(SEAL) (TYPE NAME & TIT NOTAFW fi N=y Sw <br /> Indian River Board of County Commissioners <br /> 1840 25th Street <br /> Vero Beach , FL 32960 <br /> X <br />