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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 receiving a <br /> contract or award resulting from the Request for Qualifications issued by the County of Indian <br /> River, Florida, shall make certification as below. Receipt of such certification , under oath , shall <br /> be a prerequisite to the award of contract and payment thereof. <br /> I (we) hereby certify that if the contract is awarded to me, our firm , partnership, or corporation , <br /> that no members of the elected governing body of Indian River County, nor any professional <br /> management, administrative official or employee of the County, nor members of his or her <br /> immediate family, including spouse, parents, or children , nor any person representing or <br /> purporting to represent any member or members of the elected governing body or other official , <br /> has solicited , 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 , goods or services <br /> in return for favorable review of any Proposal submitted in response to the Request for <br /> Qualifications or in return for execution of a contract for performance or provision of services for <br /> which Proposals are herein sought. <br /> The undersigned certifies that he/she is a principal or officer of the firm applying for consideration <br /> and is authorized to make the above acknowledgments and certifications for and on behalf of the <br /> applicant. <br /> The undersigned certifies that the Applicant has not been convicted of a public entity crime within <br /> the past 36 months, as set forth in Section 287 . 133, Florida Statutes . <br /> Failure to sign this form will result in disqualification Q <br /> Handwritten Signature of Aut zed Principal(s): ATE: .r" �'J — 3 <br /> NAME: Mercy Ross <br /> TITLE: Owner/Operator <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : <br /> Ross Small World Child Care Center <br /> Sworn to and subscribed to FOR AND ON BEHALF OF THE APPLICANT: <br /> me , a Notary Public, this <br /> 28 day of MAY , 2003 . <br /> BY: Mercy Ross <br /> OWNER/ OPERATOR <br /> (SEAL) (TYPE NAME & TITLE) <br /> Georgie M. Williams <br /> commission IN DD102418 <br /> Expires March 21 , 2006 <br /> OF � `� Bonded Thru <br /> Atlantic Bonding Co., Inc. <br /> X <br />