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Okaloosa County BOCC — May 20, 2014 — State of Florida Department of Revenue Standard Contract CST46 — reading text
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have been paid er will be paid to any person for influencing or atlempting fo influence an officer or employee of
any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant,
loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with ifs
instructions.
(3) The undersigned shall require that the language of this certification be included in the award docurnents for all subawards at all tiers (including subcontracts,
subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shail certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transactions was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by 31 U.S.C. ~1352. Any person who fails fo file the required certification shail be subject to a civil penalty
of not less than $10,600 and not more than $100,000 for each such failure.
By: , Chairman Date:
Template: Revived 2/5/2014 19
Contract Number CST46
Exhibit 1, Excel INVOICE form
. INVGQICE
County Sheriff's Office INVOICE
Sheriff Service of Process (SOP) Contract #_
Address
Contact Person:
Phone #:
E-mail:
Date of Inveice: MM/DDIVYYY
Invoice Month/Year:
Sheriff invoice #: (if any)
Bill To: Florida Depariment of Revenue/Child Support Program
Contract Management Invoice Section
Email invoice to: sheriff invoices@dor.state.fl.us
Comments
pete DESCRIPTION. _| Unit Rate | Subtotal | Reimbursement Rate | AMOUNT
C) Service Of Process $20.00 $0.00 66% - $0.00
0 Service Of Process Credits $20.00) $0.00 66% $0.00
og Wits (Warrants for Arrest} $70.00 $0.00 66% $0.00
0 Writs (Warrants for Arrest) Credits $70.00) $0.00 66% $0.00
invoice Total: = $0.60
| certify the information above is frue and correct
(electronic signature typed below is acceptable)
Signature: Signature Date:
To: FDOR Operational Accounting:
The above charges have been reviewed and are approved for payment.
Amount approved:
Date Approved:
FDOR-Child Support Program Approval Certification Signature:
Tenplate Revived 23/2014 20
Contract Number CST46
Exhibit 2 Substantiating Report to invoice (Excel form)
Total # of Service of
‘Process
Sheriff Service of Process & Writs
Substantiating Report To Invoice
Total # of Writs
| Contract Number:
Grand Total of Services
Month and Year of Invoice
Florida Department of ~..\Defendant-Information: °
Revenue : Person being served (Required
Date Received or Completed (Required)
[mmidd/yyyy] Z
Plaintiff Information (Optional)
Template Revised 2/3/2014 21