EO 20-44
Contract Agreement Attestation
Your organization has been identified to receiving Specific State and/or Federal Appropriation funds as
“Direct Appropriation (Earmark)” or as “Non-competitively Bid” (statutory established entity, etc.) to manage
state resources on behalf of the Florida Department of Health (FDOH) to local communities. This document
requests your immediate attention and attestation to the following information and must be returned to the
Department within the assigned due date to satisfy the requirements under the Governor’s Executive Order
Number 20-44, published February 20, 2020.
Legal Name of Your Organization:
IRS Issued Tax Id/DUNS Number:
Type of Your Organization:
(Non-Profit, For-Profit, Educational Institution, Local Municipality, Other)
Service Location for Your Organization: (city)__________________ (county)____________________
Does your organization have a President/Director/Chief Executive (Yes/No)?
If Yes, please complete the following. If No, please explain: __________________________________
First/M/Last Name/Suffix:
Title:
Contact:
Does your organization have a Chief Financial Officer or Equivalent (Yes/No)?
If Yes, please complete the following. If No, please explain: __________________________________
First/M/Last Name/Suffix:
Title:
Contact:
If your organization is a “Not-For-Profit” under the Internal Revenue Codes, what is the highest Salary
Compensation package of your highest paid employee? $____________________
Did your organization prepare an IRS Form 990 in the previous FY (Yes/No)?
What is the dollar amount of your organization's capital (assets & revenues) that is from grant
funding? (use previous FY data): State $___________ Federal $__________ other $_________
What is the dollar amount of your total assets? (e.g. cash, fixed assets, accounts receivable, etc.):
$_____________________
Attestation Statement: As an “Authorized Representative” of the Respondent, I duly attest to the
best of my knowledge that all information provided in this questionnaire are accurate and true as
presented. I also understand that pursuant to section 287.135, Florida Statutes, the submission of a
false certification may be subject to civil penalties, attorney’s fees, and/or costs.
Authorized name (Please Print)
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signature
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