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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 /> receives 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 result in disqualification. <br /> Handwritten Signature of Authorized Principal (s) : DATE : D <br /> NAME : Sd b zt c 7W <br /> TITLE : Executive Director <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : Redlands Christian Migrant <br /> Association Inc, <br /> FOR AND ON BEHALF OF THE APPLICANT : <br /> Sworn to and subscribed to Q <br /> me , a Notary Public, this a., <br /> J_day of QW , 2009 . BY : <br /> (SEAL) (TYPE NAME & ITLE) <br /> NOMRY'PUBLIC • STATE OF FLORIDA <br /> Mary A. Alfaro <br /> pommission # DD617405 <br /> xpires: NOV 26, 2010 <br /> BONDED TjmU AT1.MIC BONDING Co., INC. <br /> I <br />