Orange County Specific Project Expenditure Report Form Page 3
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ORIGINAL SIGNATURE AND NOTARIZATION REQUIRED
I hereby certify that information provided in this specific project expenditure report is true and correct based on
my knowledge and belief. I acknowledge and agree to comply with the requirement of section 2-354, of the Orange
County code, to amend this specific project expenditure report for any additional expenditure(s) incurred relating to
this project prior to the scheduled Board of County Commissioner meeting. I further acknowledge and agree that
failure to comply with these requirements to file the specific expenditure report and all associated amendments may
result in the delay of approval by the Board of County Commissioners for my project or item, any associated costs
for which I shall be held responsible. In accordance with s. 837.06, Florida Statutes, I understand and acknowledge
that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the
performance of his or her official duty shall be guilty of a misdemeanor in the second degree, punishable as
provided in s. 775.082 or s. 775.083, Florida Statutes.
Date:___________
____________________________________________
Signature of ⌂ Principal or ⌂ Principal’s Authorized Agent
(check appropriate box)
PRINT NAME AND TITLE: ___________________
STATE OF FLORIDA
:
COUNTY OF____________ :
I certify that the foregoing instrument was acknowledged before me this _____ day of ____________, 20___ by
________________________. He/she is personally known to me or has produced _________________________ as
identification and did/did not take an oath.
Witness my hand and official seal in the county and state stated above on the _____ day of _____________,
in the year __________.
______________________________________
Signature of Notary Public
(Notary Seal)
Notary Public for the State of Florida
My Commission Expires: ____________________
Staff signature and date of receipt of form _____________________________________________
Staff reviews as to form and does not attest to the accuracy or veracity of the information provided herein.
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