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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 firm <br /> receiving a contract or award resulting from the Request for Qualifications issued by the <br /> County of Indian River, Florida, shall make certification as below. Receipt of such <br /> certification, under oath, shall be a prerequisite to the award of contract and payment <br /> 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 County, nor <br /> any professional management, administrative official or employee of the County, nor <br /> members of his or her immediate family, including spouse, parents, or children, nor any <br /> person representing or purporting to represent any member or members of the elected <br /> governing body or other official, has solicited , has received or has been promised , <br /> directly or indirectly, any financial benefit, including but not limited to a fee, commission, <br /> finder's fee, political contribution , goods or services in return for favorable review of any <br /> Proposal submitted in response to the Request for Qualifications or in return for <br /> execution of a contract for performance or provision of services for which Proposals are <br /> herein sought. <br /> The undersigned certifies that he/she is a principal or officer of the firm applying for <br /> consideration and is authorized to make the above acknowledgments and certifications <br /> for and on behalf of the applicant. <br /> The undersigned certifies that the Applicant has not been convicted of a public entity <br /> crime within the past 36 months, as set forth in Section 287. 133, Florida Statutes . <br /> Failure to sign this form will resuk in draaualirrcation. <br /> Handwritten Signaty� of Authorized Principal(s): DATE: <br /> NAME: ' k i✓ >( 1�I <br /> i <br /> TITLE: _ <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION: <br /> J <br /> FOR AND ON BEHALF OF THE APPLICANT: <br /> Sworn to and subscribed to <br /> e, Notary u lic, this i7 <br /> ay of 006. BY: <br /> �. (S ) (TYPE NAME & TITLE) <br /> ,. ,°•,yam.. RUMLJEFFEABON <br /> MY COAMAISSION i OD 1990f 0 <br /> IXP IS <br /> 1 8, 2007 <br /> m�aa miu�Welt UrEwwnrs <br />