HomeMy WebLinkAboutAgreement_General_08/11/2016 (5) ��ouESr4 TEQUESTA POLICE DEPARTMENT ,
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' ;°o cti ' MEMORANDUM �
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To: Mr. Michael Couzzo, Village Manager
From: Christopher L. Elg, Chief of Police
Date: July 26, 2016
Subject: Check Replacement Request
This form is being sent to us in order to have a replacement check issued for
reimbursement of Mantee patrol overfime. The original check was never
received by the Village and was presumably lost in the mail. PBC needs this form
signed in order to stop payment on the lost check and send a replacement.
The indemification portion of the form is detailed in section five of the form and
basically states that the Village will hold PBC harmless based on the initiation of
this check replacement request.
Action Requested: Authorize the Village Manager to sign the form requesting
the replacement check be issued by PBC.
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SNA20NIt.BOCK
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�'.��"��G•. APPLICATION FOR CHECK REPLACEMENT
AIUD INDEMNITY AGREEMENT
(Please print all information)
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DATE: ----------------
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(First� (Middlel (Last) �
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1. That the address of the above is � S 7 �����-'S�`' �� � ��� �`��� J � `��
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(5treet, Apt. , City, Stare, Zip codel
2. That check number 7A� sz�_, dated2/11116, drawn by the Palm Beach County Board oi County
Commissioners on Welis Fargo Bank in the amount of S 7dQ� �,�, issued payable to the order of
Vil aqe pf aa uecta and the undersigned makes application for a duplicate
check to replace said check which has been lost or destroyed.
3. That the check (was! (was notl endorsed. If endorsed, state exactlythe manner of all endorsements appearing
thereon:
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4. That the undersigned has not received the proceeds from said check, and the whereabouts of said check is
unknown.
5, In consideration of County's reliance upon the foregoing representations and certifications and in further
consideration of County's compliance with the foregoing request, the undersigned hereby agrees to indemnify
and hold County harmless from and against any and all ciaims, demand, losses, damages, actions, including
expenses, costs, and reasonahle attorney's fees which County at any time may sustain or incur by reason of
County's reliance upon the foregoing representations and warranties and compliance with the foregoing
request of the undersigned.
The undersigned understands that the undersigned will be liable to the Coun[y for payment of a sum of money
equal to the original check, including without limitation expenses, costs, ancl reasonable attorney fees, if any
assertions in this document are untrue, The undersigned hereby agrees to deliver the original County's check to
County for cancellation if the same shall ever be found.
NOTE: AREPLACEMENTCHECKWILLNOTBEISSUEDUNTILTHISFORMISPROPERLY
EXECUTED AND FILED WITH THE CLERt<, AND THE CLERI< HAS RECEIVED
CONFIRMATtON fROM THE BANK THAT TH CHECK HAS NOT BEEN NEGOTIATED.
APPLICANT SIGNATURE: (Payee or if a ____ DATE: __ L`°� �� �� ��/
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STATE OF _����� �� __ 7-S � / y
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COUNTY OF __� fn�_ �3e G'C�
The fo oipg instrument was acknowledged before me this ____a �_ day of __�J "!' �___, __________,
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(Name of person acknowled ingi f Affix Notary Seal or Stamp:
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(Signature of Notary lic)
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�����jy p� DEBRA ANN TELFRIN
Check One: Personally i<nown _� or Produced Itlentification _____ ; o �" e�;s,
a„ . o Notary Public - State ot Florida
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Type o f Iden ti fication Pro duce d: _____________________________ �'' � Commission # EE 842843
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ADDENDUM
Public Records: In accordance with Sec. 119.0701, Florida Statutes, the Contractor
rnust keep and maintain this Agreement and any other records associated therewith and that are
associated with the performance of the work described in the Scope of Services. Upon request,
the Contractor must provide the public with access to such records in accordance with access and
cost requirements of Chapter 119, Florida Statutes. Further, the Contractor shall ensure that any
exempt or confidential records associated with this Agreement or associated with the
performance of the work described in the Scope of Services are not disclosed except as
authorized by law. Finally, the Contractor shall retain the records described in this paragraph
throughout the performance of the work described in the Scope of Services, and at the conclusion
of said work, transfer to the Village, at no cost to the Village, all such records in the possession
of the Contractor and destroy any duplicates thereo£ Records that are stored electronically must
be transferred to the Village in a format that is compatible with the Village's information
technology systems.