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Attachment K Department of Community Affairs Neighborhood Stabilization Program � Florida Small Cities Community Development Block Grant (CDBG ) Program "P4 G SIGNATURE AUTHORITY FORM ZQ09 AUG 2 �e Pry 3 ' P _4444__._.... -....__ _ _ Submit-an , original Signature Authority Form with each contract _ —_ — _ _ 2 Reci ient Contract # Local Government DUNS Number Indian River County 10DB-4X- 10-40-01 - F13 079208989 ._. _....0._..d_..__—_...__........ ....... ..........._...._. ._...__..........._.-................,,..., ...._........_........._.._ _ ..__.,. _......._..._.._.. _ __.__.................._._.........._ ^..._..- -- -_-....__...._._..- i Mailing Address (Street or Post Office Box) 1801 27th Street _.._._. _ _ _..____.____ _...._........._._.__.__ . . .._._-----.._._.....-.---.--_._ .. ._.____._........._.._.... __._.._....._............._ .. City, State and Zip Code i _Vero Beach, Florida 32960-3388 _ —.__.._.-_ _..__._____.-.__._.._..---44_44..---.-...... Project Contact Person I Telephone # (772) _226- 1254 Robert M . Keating , Community Development Director E-mail Address _..............._. ..............__._._......_....___...._.__ __.._....._............._.._._.... ......___------_..._) 9 � i I bkeating (dircgov. com . ._....._ ........................................---......_. .__.............................._.4444..............__..... ---- ._.. __...........4.44....4..... _.._._... _44.44 _.._ ... ...__._....__......_........._...._._.._.._..........---...-.------......__..............._..._._.._ _._. Financial Contact Person Telephone # 772 226- 1205 Diane Bernardo - Finance Director t E-mail Address dbernardo@clerk. indian-river. org _444.4_.-....__.._� ..... ..___... - ..... _._._..._................................. _4____4_4_ _._._..._. � _._. __...___..___.._._ Requests for Funds ( RFFs) from the Florida Small Cities CDBG Program require (check one): [ ] one signature [ ] two I signatures of individuals authorized below. No more than two individuals can be authorized to use Florida PAPERS. CDBG i contracts require that at least one ( 1) RFFs must be submitted each quarter and should reflect all expenditures incurred during that reporting _period . _ _...__ i Typed Name Da Si atur Robert..M ...._Keatin9do... Community Dev Director_..............-- - .- - ----. _. _... ��_Q.....� ....._......._.. ... -� E r..._ ... _ 7—do..__ [ X ) Check here if the above person will be the E-mail Address designated FloridaPAPERS user. _ - - _ bkeating@ircgov. com . — 44 .44 ..._...._ .. .. . .........----..._..._..__._._........._� __._..._.. ... _. ........._._.. _ Typed Name j Date Signature ._..................._. __._....._................_............._................ .......................................................-.............odd,......__..._.............. ......._. —..—. — __ _ __.-i...._ ...._.4........_..I......_.__...- .._.._....--..............................I.__.._._...._... [ ] Check here if the above person will be the E- mail Address designated.._FloridaPAPERS user. ........ -.---..._..........-___....._i.._._...................._-...._-......................-.___-._................__.____.___........4.._....4...... .......-._ __4....._____ 44....4.-.....4. Typed Name Date Signature [ .... j...44.. .._. __. .. . _.... . .. _. .__�.____. .. . . . ..... _ _ _ ,.._..... .......... .. ..... _ . _.._......................_.._ --_....... _ .- .........._- __44.44-. _ . _._....... Check here if the above person will be the E-mail Address _._._._-.. . _ . . _. _44 .44_. ....._...____.____. _. .__desi.9nated04 .4...4 aPAPERS user. _._ ..._..._...___.__._-_.. _.._._.._.__...._... - _ _____....._-___.___.__.-__.___-... _ _....._........_....._.... _._._I I certify, as the recipient's Chief Elected Official, that the above signatures are of the individuals authorized to sign Requests for Funds and to submit RFF's electronically to the Small Cities Community Development Block Grant Program using Florida PAPERS . I` __-_........._..._....._...._..__......_-_4444 _ --- _ ._._....._.. WesleS . Davis , BCC Chairman -.._..._......_................._ ._,...._ _ do"- — _ ......._..._.........._._............._4._._.4...._.......... _ ...._...._........._................_..._..__..-. Typed Name Date e / Ey ..............do _____44__4.4—_..IAu u s t_.1..8_,......... 0.0.. __4444_.._ . _ -._.. .._... __:_ .__. _.__ _..._-...__........._._. _444_ - 4 [ X] Check here if your local government utilizes Electronic Funds Transfer ( EFT) from the St e of Florida . [X] Check here if your local government will be working on a reimbursement basis. [ ] If this signature authority form pertains to a housing grant, check here if your local government will use an escrow account ; for housing activities , - ............__.----.....-_............4....__...__.___._._�_.___ __ .._ ____..._ _..................._..._.__..__...__........._. ___ _ ..._.....__-__ .._._.___.._.__.__._.. CDBG payments toloca/ governments using EFTare automatically deposited in the local government's general account. If the account is interest bearing, the CDBG funds must be transferred to a non- interest bearing account. Please call the CDBG I Program at 850/922 - 1878 or 487 -3644 if you have questions . You can check the status of your deposit at the Comptroller's I website : http : //flair. dbf, state ,fl , us/ . - 4444..—_...._.. — ..........._.........__..........._._.__..._..._....._—..___.....__................................. -.__.._.._..._ __..............._.._,-.....—......__._......- __...0.._..._.....— - - - 44_4_......._4 Local governments not receiving EFT, and not working on a reimbursement basis, must establish a non- interest bearing account. Provide account information for the financial institution ( insured by FDIC) below. All signatures on the account must be bonded . ......................_.........__..._.._....................---..._--- ___....__...._............._...._ __--_.____.___ _...__._.._....-........................_... ___.__ __444_4__.._—._............._ . _ _._...................._...._....._-___.._......._...._...----4444 I Name of Financial Institution Account Number RBC Bank _.................. ...... —.__............_..... _ ................_— _.-.__._............_._._ _.._...__. __. __ 053100850-7680027195 I..-_ ___ _.__. ..._........._ — -- —..__. _......__...._......._— _ __ .......... — ........._..__........_...._..� Street Address or Post Office Box Telephone Number 1417 Centura _Highway._._.._..._........._._-.._.. .. ..................._..............._..................._._..._I..-(252) 454-3557 or (800) 226-5985 ....._....;...._............_.......... . . _. ......__..._..__....---._.�.__._....._........_..._......._...........--- City, State and Zip Code I Rocky„Mount, NC 27802 _ -