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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. <br /> Handwritten Signature of Authorized Prin ipal (s ) : DAT -28-03 <br /> NAME : Henry Burson Jr . ' <br /> TITLE : Chairman of the Board <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : <br /> Prosect H . O . P . E . , Inc . <br /> FOR AND ON BEHALF OF THE APPLICANT : <br /> Sworn to and subscribed to <br /> me , a Notary Public , this <br /> 1. day of rA& Ui 2003 . BY : �- --- <br /> (SEAL ) (TYPE NAME & TITLE ) <br /> „W, DEMa. <br /> Put*C • ftft of floAdo <br /> � sonn # DD194076 <br /> ' o, n� Notary Assn. <br /> X <br /> 1 <br />