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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 <br /> firm receiving a contract or award resulting from the Request for Qualifications <br /> issued by the County of Indian River, Florida , shall make certification as below. <br /> Receipt of such certification , under oath , shall be a prerequisite to the award of <br /> contract and payment 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 <br /> County, nor any professional management, administrative official - oremployee of <br /> the County, nor members of his or her immediate family, including spouse, <br /> parents , or children , nor any person representing or purporting to represent any <br /> member or members of the elected governing body or other official , has solicited , <br /> 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 , <br /> goods or services in return for favorable review of any Proposal submitted in <br /> response to the Request for Qualifications or in return for execution of a contract <br /> for performance or provision of services for which Proposals are herein sought. <br /> The undersigned certifies that he/she is a principal or officer of the firm applying <br /> for consideration and is authorized to make the above acknowledgments and <br /> certifications for and on behalf of the applicant. <br /> The undersigned certifies that the Applicant has not been convicted of a public <br /> entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida <br /> Statutes . <br /> Failure to si n this form will result in discivalfficaffon. <br /> Handwritten Signature of Authofriiz-ed. Principal(s): DATE: 51 sloq <br /> NAME: Cx ✓1 � <br /> TITLE: ^cbe .Ls <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : , <br /> "ren <br /> FOR DON BEHALF OF THE APPLICANT: <br /> Sworn to and subscribed to <br /> me, a NotaryP lic, this <br /> qday of 2004. - Br. <br /> Jan S . Huffert , CEO <br /> (SEAL) (TYPE NAME & TITLE) <br /> Indian River Board of County Commissioners <br /> 1840 25t!' Street + <br /> t f. V/ero Beach ; FL 32960 j �� A°'�� TRA s,:AvcrR j <br /> x . <br /> q <br /> COMMmSION +I� DD 02571 y n <br /> M8 .fir 'A r a r <br /> . {'� ♦ � k 4 f�� i'� � a yrW >,,,t� ; `vv.� ? Y13+vOTARV' . FL N01ery Service d {.. <br /> AA LFA"74f <br /> � `6 Y t3� <br /> s ' +ss t '�. " - <br /> �i','.`'�wF� � may; �;� 'p�`' 71�� , . •"�,: ` .a. '. . r r' ' <br /> M1 <br /> w. <br /> �� <br />