HomeMy WebLinkAbout2012-195A Department of Economic Opportunity — Small Cities Community Development Block Grant Program
ATTACHMENT L - Signature Authorization Form ao 1 a • RSA 10i1r201 1
Subm/tan orl final Signature Authorization Form with each copyof the contract. 1 O 3 1
Recipient: Contract Number: NONE Funding Source: g W-
Indian River County 12DB-OH - 10-40-01 -N01 ® Small Cities CDBG
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Mailing Address (Street or P.O . Box): 1801 27th Street Local Government DUNS
City, State, and Zip Code: . Vero Beach , FL 32960 079208989
Project Contact Person : Telephone Number. E-mail Address:
Michael C. Hotchkiss (772) 226-1821 Ext: mhotchkiss@ircgov. com
Financial Contact Person : Telephone Number. E-mail Address:
Edward Halsey (772) 226-1205 Ext: ehalsey@clerk. indian-river.org
Other Local Government Contact: Telephone Number. E-mail Address:
W. Erik Olson (772) 226-1834 Ext: eolson@ircgov.com
Requests for Funds ( RFFs) require (check one): ® one signature ❑ two signatures of individuals authorized
below. RFFs must be submitted via the Department's website at hftp://ecdbg . doe, myflorida.com/ (or by an
alternative means specified by the Department).
Name Typed : Michael C. Hotchkiss Date: !U • - f � + We
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® Check here if above person is authorized E-mail Address:
to submit RFFs.
Name Typed : Art Pfeffer Date: l * 0700) • I
Signature
® Check here if above person is authorizedE-mail Address:
to submit RFFs. ck ? ser 4w ar @ i rc clove to ou...
Name Typed : Gordon Sparks Date: 'L
Si nate
® Check here if above person is authorizedE-mail Address: JS ��aV� KPS C l �'C 90y . C a vn
to submit RFFs.
Name Typed . Date:
Signature
❑ Check here if above person is authorized .••`°""NpH N "
p E-mail Address: ��1aNbip,
to submit RFFs. r ' ' ' •
1 certify, as the recipient's Chief Elected Official, that the above signatures are of the indiv' , fi rized
to sign Requests for Funds and to submit RFF's electronically.
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Typed Name: Gary C . Wheeler Date: 111 !511 �'
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® Check here if your local government utilizes Electronic Funds Transfer (EFT) from the State off' • Igmoose It
® Check here if your local government will be working on a reimbursement basis. °`°0-... E
❑ If this signature authority form pertains to a housing grant, check here if your local government will use an
escrow account for housing activities.
Moose
CDBG payments to local governments using EFT are 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 Program at 850/922- 1878 or 487-3644 if you have questions. You can check the status of
your deposit at the Comptroller's website: http://fIair. dbf. state.fl . us/.
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.
Name of Financial Institution: Wells Farge Bank, N .A. Account Number: 2000044270289
Address: 1001 20th Place Telephone Number: (772) 5694500
Moose
City, State and Zip Code: Vero Beach , FL 32960