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Cultural Council of Indian River County; After School Arts Program Children' s Services Advisory Committee 2004 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. (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 ser%✓ices 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 not been convicted of a public entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida Statutes . Failure to sicjn this form will result in disqualification., Handwritten Signature of Authorized Principal 's) : DATE: NAME : Sheila Tucker E n OIL ko�4 TITLE: Chairman of the Board of Directors NAME OF FOR AND ON BEHALF OF THE APPLICANT: FIRM/PARTNERSHIP/CORP ORATION : , Cultural Council of Indian River County Sworn to and subscribed to me , a Notary Public, this i / day of , 2004 . Y: q�zj a r% a e0oe. tod .Z ( fes. p � (,d6►onDO�y � (TYPE NAOE & TITLE) 20pj 5144 �. 1. tc < 1 Y Lam , r, ss 6.4,i,'vNS 1 m : 14 s�, It 7L It iL r