HomeMy WebLinkAbout2004-197 SENT
United States Department of the Interior G
FISH AND WILDLIFE SERVICE
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'A 1875 Century Boulevard
Atlanta, Georgia 30345
In Reply Refer to :
FWS/R4/CRF/RF July 2004
FY 2003
REFUGE REVENUE SHARING PAYMENT FORM
(October 1, 2002 - September 30, 2003)
(PART 1 ) :
COUNTY COMPLIANCE CERTIFICATION
(With Section VI of the Civil Rights Act of 1964
Pertaining to Refuge Revenue Sharing Payments)
The undersigned assures that COUNTY/PARISH will administer payments
under the Refuge Revenue Sharing Act ( 16 U . S . C . 715s) in accordance with Section VI of the Civil Rights Act of 1964 (78
Stat. 252 ; 42 U . S . C . 2000d) and in compliance with the regulations issued pursuant thereto, which are contained in 43 CFR
Part 17 (forfurther information, search the Internet for Code of Federal Regulations 43 CFR Part 17 Nondiscrimination in
Federally Assisted Programs of the Department of the Interior).
COUNTY/PARISH REPRESENTATIVE TITLE DATE
(PART 2) :
RECEIPT FOR CHECK
This annual payment is made in accordance with the Refuge Revenue Sharing Act
(amended in 1978 by Public Law 95-469)
COUNTY/PARISH of Indian River County STATE of FI ori d ;;
The check represents the GREATER of: three-fourths of 1 percent (0 .75 percent) of the fair market (appraised) value of fee
land acquired, or 25 percent of net receipts, or 75 cents per acre for fee lands located within the National Wildlife Refuge
System in the same County/Parish.
RECEIVED BY :
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COUNTY/PARISH REPRIESENTATIVE TITLE DA �E
3151 52478493 $ 77 , s34 on
CHECK NO. CHECK AMOUNT
(Please return this signed form to Charlotte Underwood (404/679- 7216) in the self-addressed envelope attached. )
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yATLANTA GA 30345
VOID AFTER ONE YEAR
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