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HomeMy WebLinkAboutContract - NIWB - Pathways ProgramBOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date September 1, 2016 Name Sarah Heintzelman Department Comm Inv BPW Date September 13th, 2016 Phone Extension 5842 Required Prior to Submittal to Board Legal ® Attorney Name Michael Schmidt Controller review is required for all Contracts $5,000.00 or more Controller ❑ and greater than one year in length per the City Purchasing Policy Purchasing ❑ Check the Appropriate Item Type — Required for Ai/ Submissions ❑ Agreement ® Contract ❑ Proposal ❑ Addendum ❑ Bid Opening ❑ Quote Opening ❑ Chg Order No. Ease./Encroach. Other: Company or Vendor New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Terms of Contract Purpose/Description ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet ❑ Quote Award ❑ C/O & PCA No. ❑ PCA ❑ Traffic Control ❑ Resolution ❑ Claim Required Information Northern Indiana Workforce Board (NIWB) L_J Yes U If Yes, Approved by Purchasing ® No ❑ MBE Completed E-Verify Form Attached ❑ Yes ❑ WBE ❑ No Pathways Program 408-1001-460-31.06 $100, 000 Training programs to train necessary skills to under skilled workers to meet labor needs in the community. For Change Orders Only Amount of " Increase ❑ Decrease Previous Amount $ Current Percent of Change: % New Amount $ Total Percent of Change: % Dispersal After Approval Copy ® Sarah Heintzelman, Community Investment ® Judy Love, Community Investment ® Jacob Alexander, Community Investment AGREEMENT FOR SERVICES BY AND BETWEEN THE CITY OF SOUTH BEND, ACTING BY AND THROUGH ITS BOARD OF PUBLIC WORKS, AND NORTHERN INDIANA WORKFORCE BOARD, INC. THIS AGREEMENT is made effective the 13ih day of September, 2016, by and between the City of South Bend, Indiana, Acting By and Through its Board of Public Works, having its offices at 1300 County -City Building, 227 West Jefferson, South Bend, Indiana, 46601 ("BPW") and NORTHERN INDIANA WORKFORCE BOARD, INC., ("NIWB" or "Provider"), having its principal place of business at South Bend, Indiana. WITNESSETH: WHEREAS, the BPW is a contracting body of the City of South Bend and exists and operates under the provisions of I.C. 36-4-9-5, as amended from time to time; and WHEREAS, pursuant to I.C. 36-4-4-2(a); 36-4-5-3; 36-1-3-2 and 36-1-3-3, the BPW has the power and duty to assist the Executive in the efficient government of the City; and WHEREAS, the BPW has contracted for programs intended to assist the City in community and economic development through efforts promoting workforce solutions for people, business and communities; and WHEREAS, NIWB works to develop, implement, foster and encourage collaborative and economic development through efforts promoting workforce solutions for people, business and communities; and WHEREAS, NIWB is a not -for -profit domestic corporation created to promote community development within the City of South Bend, Indiana, and has knowledge, experience and expertise to deliver Workforce Development Programs; and WHEREAS, the BPW has determined that due to NIWB's knowledge, experience and expertise, it is in the best interests of the City through BPW to retain NIWB's services to assist the City in accomplishing Programs to administer training programs with multiple community partners in the City of South Bend and the City of Mishawaka; and WHEREAS, NIWB is willing to assist the City in its efforts by providing the requested services which are more specifically described below and are subject to the terms and conditions of this Agreement; and WHEREAS, the City, by and through its City Common Council, has appropriated funds as required by I.C. 5-22-17-3 and authorized the expenditure of these funds for the purposes set forth in this Agreement; and WHEREAS, this Agreement hereby supersedes and replaces any and all writings or pre- existing Agreements between NIWB and the City of South Bend, Indiana and any such pre- existing agreement between NIWB and the City of South Bend, Indiana shall be considered void. NOW THEREFORE, in consideration of the mutual promises and obligations in this Agreement, the parties now agree as follows: SECTION 1. Definitions. For purposes of this Agreement, the following terms have the meanings referred to in this Section: BPW: The term "BPW" shall mean the Board of Public Works of the City of South Bend. City Controller: The term "City Controller" shall mean the City Controller or Acting City Controller appointed pursuant to Indiana Code § 36- 4-9-6. City's Internal Auditor: The term "City's Internal Auditor" shall mean the City Controller or any person appointed or retained by the City Controller or the Commission for the purpose of auditing the Provider for this Agreement or other agreements of the City. Competitive Bidding Requirements: Indiana Code § 36-1-12 with respect to contracts for construction, reconstruction, alteration, repair or renovation of a structure or improvement, and Indiana Code § 5-22 and Common Council Resolution 2690-98 to other transactions. Contract Administrator: The term "Contract Administrator" shall refer to the Assistant Executive Director of the Department of Community Investment, City of South Bend. Effective Date: The term "Effective Date" shall have the meaning ascribed to such term in the opening paragraph of this Agreement. Expiration Date: The term "Expiration Date" shall mean December 31, 2016 Requested Services: The term "Requested Services" shall mean the services described at EXHIBIT "A" as well as other related expertise and assistance to the City by Provider. Taxes: All governmental assessments, franchise fees, excises, license and permit fees, levies, charges and taxes, of every kind and nature whatsoever, which at any time during the Term may be assessed, levied, or imposed on, or become due and payable out of or in respect of, (i) activities conducted on behalf of the City. NIWB: The term ` NIWB" shall mean Northern Indiana Workforce Board, Inc., organized under the laws of the State of Indiana and having its offices branded as WorkOne in South Bend, Indiana. For purposes of this Agreement, "Provider" shall herein mean "NIWB". SECTION 2. Retention and Acceptance of Provider, Schedule of Services. A. The BPW hereby retains the Provider to provide the City the Requested Services that are more specifically described at EXHIBIT "A" attached hereto and incorporated herein. The Provider hereby accepts the appointment to provide the Requested Services and agrees to provide the Requested Services under the terms and conditions set forth in this Agreement. B. Upon receipt of a notice to proceed from the Contract Administrator, the Provider shall commence the Requested Services in accordance with the terms and conditions of this Agreement and the schedule established for Project ("Project Schedule") or as otherwise mutually agreed by the parties in writing. The Project Schedule is more particularly described at EXHIBIT "B" attached hereto and incorporated herein. The Provider hereby certifies that it has sufficient experience, expertise and financial aptitude to complete the Requested Services in the manner and within the timeframe set forth in the Project Schedule. C. Should the Provider fail to complete the Requested Services in accordance with the terms and conditions of this Agreement including, but not limited to, in accordance with the Project Schedule, the Contract Administrator may withhold payment due Provider. Further, if the damages are imposed against Provider, any monies due and payable to the City thereby, may be retained out of any monies earned by the Provider under the terms of this Agreement. An extension of time may be granted in the event of extenuating circumstances by the Provider applying for and receiving written permission for an extension of time from the BPW. SECTION 3. Parties' Responsibilities. A. Information and Communications. The BPW shall provide all reports, and other data requested by the Provider necessary for the Provider to accomplish the Requested Services. The BPW and the Provider agree that the BPW shall be permitted to obtain at no additional cost and to retain any and all documents prepared or caused to be prepared by the Provider in connection with the services to be provided by the Provider and the Provider agrees to provide 3 the City with said documents upon request by City. Said documents may be used by the City or others with respect to the City's undertakings with respect to the Project. B. Reports and Budd. The Provider agrees to provide the Contract Administrator and the Internal Auditor a report regarding the performance of the Requested Services and that status of the Project in relation thereto, at least every fifteen (15) days following the Effective Date of this Agreement or upon the written request of the Contract Administrator or the Internal Auditor. The report must describe the Provider's progress in completing the Requested. C. Project Budget. In exchange for the consideration set forth herein, the Provider hereby agrees to develop and abide by the Project budget which shall not exceed One Hundred Thousand and 00/100 Dollars ($100,000.00) ("Project Budget"). D. Final Resort. The Provider shall provide to the BPW a final report within thirty (30) days of the Termination Date of this Agreement summarizing the successes or failures of this engagement and the Provider's delivery of the Requested Services in addition to a final accounting of all revenues and expenditures as described above. E. Records. The Provider agrees to keep and maintain, not less than two (2) years after the termination of this Agreement, at its business office, separate and independent records, reasonably satisfactory to the Internal Auditor and in compliance with Indiana law, consistent with generally accepted accounting principles. F. Point of Contact. The BPW hereby designates the Assistant Executive Director of Community Investment (the "Contract Administrator") as the Provider's point of contact with the BPW for purposes of this Agreement. The Contract Administrator shall be responsible for the provision of information to the Provider under this Agreement. G. Auditing Requirements. The Provider agrees to make all information available to the Internal Auditor or any other entity as required by Indiana law. The Provider understands and acknowledges that the City's Internal Auditor may perform, at any reasonable time and for a period extending to two (2) years after the termination of this Agreement, a review of understanding and completed contracts for compliance with contract provisions and hereby agrees to provide the City's Internal Auditor prompt access to all information and documents (whether electronic or otherwise) requested by the City's Internal Auditor for the purposes of completing such audit, which such access must be provided at least during normal business hours. Further, the Provider shall permit the City's Internal Auditor to audit, examine and make excerpts of transcripts from such records and to make all contracts, invoices, materials, payrolls, records of personnel, conditions of employment and other data relating to all matters covered by this Agreement. At regular intervals during the term of this Agreement, the BPW may conduct reviews of the content and progress of the Requested Services. H. Form 990. The Provider agrees to file its annual Form 990 required under the Internal Revenue Code and its accompanying regulations promptly with the Internal Revenue Service and to submit a copy of said Form 990 (and all amendments thereto) to the City's M Internal Auditor within five (5) days of their filing. I. Revision of Requested Services If, as a result of such review hereunder, it is the opinion of the BPW that revisions of the scope of the Requested Services are necessary or the methods employed by the Provider are inappropriate, the City may require such revisions to the scope or methods by notifying the Provider in writing. J. Additional Auditing Requirements for Not -For -Profit Organizations The Provider understands that not -for -profit entities receiving City of South Bend funds equal to or greater than $100,000.00 are required to supply an independent audit. Audited financial reports must be provided to the City's Internal Auditor on an annual basis, including any A-133 Audits. If the not -for -profit entity is required to submit an E-1 form to the Indiana State Board of Accounts, the entity shall also forward a copy of the E-1 to the City's Internal Auditor. The City may also make an examination of the Provider's fidelity bonding and fiscal and accounting procedures to determine whether these procedures meet the requirements of this Agreement. K. Competitive Bidding Requirements To the extent funds provided to NIWB are used for construction, reconstruction, alteration, repair or renovation of a structure or improvement, Competitive Bidding Requirements shall be followed. SECTION 4. Compensation. A. Fees. As compensation for services performed pursuant to this agreement, the BPW agrees to pay the Provider a fee in the amount of One Hundred Thousand and 00/100 Dollars ($100,000.00) for services rendered (the "Contract Amount"). The Provider agrees to cap administrative and program development costs at 10% of the Contract Amount. B. Invoices. The Provider shall submit an invoice for progress payments to the BPW for services performed under this Agreement, which invoice shall identify the project, the task, a description of the services completed and the time for each billing. Invoices shall be submitted for services rendered. In the event of termination of this Agreement as provided in SECTION 6, all non -disputed sums owing and due the Provider for services rendered shall be paid within thirty (30) days of receipt of any invoice. SECTION 5. Term. The Term of this Agreement shall commence on September 13`h' 2016, and shall terminate on the earlier of December 31, 2016, or the Termination Date, as described at SECTION 6, below. This Agreement shall be renewable on such terms and for such period as the Parties shall agree in writing. Notwithstanding the foregoing, this Agreement is subject to annual appropriations of sums sufficient to support such renewal term in accordance with Indiana Code § 5-22-17-3. W SECTION 6. Termination and Default. A. Termination. This Agreement shall expire on the earlier of. (i) the Expiration Date without notice to either party; (ii) within twenty (20) days of an offending party's receipt of a Default Notice (as defined below) if such default or failure continues and remains uncured as discussed in Section 6(B) below through no fault of the party initiating the termination (the "Termination Date"). Upon termination of this Agreement for any reason, all data, electronic files, documents, procedures, reports, estimates, summaries other work papers, financial statements and any other supporting documents, whether completed or in process, accumulated by the Provider or prepared or provided by BPW or the Provider relating to this Agreement or the Requested Services shall be and remain the property of City and be delivered to the City in a usable form within sixty (60) days of the Termination Date of this Agreement. The City shall retain or be granted by the Provider without restriction all title, ownership, or intellectual property rights, including copyright, patent, trademark, and trade secret rights, in any data gathered or generated by the Provider in performance of the Requested Services under this Agreement. B. De ault. Any failure by either party to perform any term or provision of this Agreement, which failure continues uncured for a period of Twenty (20) Days following written notice of such failure from the other party (the "Default Notice"), unless such period is extended by written mutual consent, shall constitute a default under this Agreement. Any Default Notice given pursuant to the preceding sentence shall specify the nature of the alleged failure and, where appropriate, the manner in which said failure satisfactorily may be cured. If the nature of the alleged failure is such that it cannot reasonably be cured within such 20-Day period, then the commencement of the cure within such time period, and the diligent prosecution to completion of the cure thereafter, shall be deemed to be a cure within such 20-Day period. Upon the occurrence of a default under this Agreement, the non -defaulting party may institute legal proceedings to enforce the terms of this Agreement or, in the event of a material default, terminate this Agreement. If the default is cured, then no default shall exist and the noticing party shall take no further action. C. Misrepresentations. Notwithstanding any other provision of this Agreement to the contrary, if a party intentionally, knowingly or recklessly makes a written representation materially related to the provision of the Requested Services or the obligations of said party under this Agreement, the other party may terminate the agreement immediately upon delivery of a Default Note. D. Proiect Close -Out. In the event that the Provider expends funds or perform services that are less than the Contract Amount or if the Project is canceled, expired or terminated for any reasons, the Contract Amount not incurred or claimed by the Provider shall be no longer available under this Agreement after all compensation earned and reimbursable expenses incurred as of the date the Provider received written notification of the cancellation or termination Project have been paid. 10 SECTION 7. Confidentiality, Conflict of Interest, and Disclosure. A. Confidential Information. The Provider acknowledges that information which the BPW regards as confidential or proprietary in nature ("Information"), may come to the knowledge of the Provider during the Provider's performance of services. The Provider shall treat the Information as strictly confidential and agrees that the Provider will not, at any time or in any manner, either directly or indirectly, (i) use, or allowed to be used, any Information for the Provider's own benefit or the benefit of any director, official, employee or agent or any third party, or (ii) divulge, disclose or communicate in any manner any Information to any third party without the written consent of the BPW. The Provider shall be responsible for maintaining the confidentially of any Information in its possession, including taking appropriate measures to secure said Information against such uses and dissemination and to inform any person to which it allows to access such information of its confidentiality. The Provider shall be responsible for any actions taken by those individuals or organizations who or which receive or obtain such Information from the Provider. A violation of this SECTION 7 shall be deemed to be a material breach of this Agreement. B. Covenant Survive Agreement. The confidentiality provisions of this Agreement remain in full force and effect after, and survive the termination of this Agreement. C. Conflict of Interest. The Provider hereby certifies and agrees that no member, officer, or employee of the City, or its designees or agents, no member of the governing body of the Commission or the City of South Bend or the Provider (and no one with whom they have family or business ties) who exercises any functions or responsibilities with respect to the Project during his or her tenure or for one year thereafter, shall have any financial benefit, direct or indirect, in any contract or subcontract, or the proceeds thereof, for work to be performed in connection with the Project. The Provider further agrees that it will incorporate into every written contract the following provision: "INTEREST OF CONTRACTOR AND EMPLOYEES: The Contractor covenants that no person who presently exercises any functions or responsibilities in connection with the Community Development Program, and no one with whom they have family or business ties, has any personal financial benefit, direct or indirect in this Contract." D. Uniform Conflict of Interest Disclosure Statement The Provider acknowledges that he or she (or it and its directors, officer, employees and agents), may potentially be deemed to be a "public servant" as defined by Indiana Code § 35-41-1-24. The Provider hereby represents and certifies that it may enter into this agreement under Indiana Code § 35-44-1 and, to the extent applicable, has executed and filed with the City and the appropriate bodies a Uniform Conflict of Interest Disclosure Statement, the form of which is attached hereto and incorporated herein as Exhibit C. The Provider has executed and filed with the City a Contractor's Non -Collusion and Non -Debarment Affidavit, Certification Regarding Investment with Iran, Employment Eligibility Verification, Non -Discrimination Commitment and Certification of Use of United States Steel Products or Foundry Products. 7 SECTION 8. Relationship. A. Independent Contractor. The Provider shall at all times be an independent contractor rather than an employee of the City, and no act, action or omission to act by the Provider shall in any way bind or obligate the City, except as specifically provided under the terms of this Agreement. It is understood and agreed by the parties that the Provider will not be entitled to any benefits enjoyed by the City or the staff of the City in the normal course of their employment. B. Tax Obligations. The Provider is solely responsible for compliance with federal, state and local laws and regulations relating to taxes and social security payments that may be required to be made in connection with the compensation provided under this Agreement. The City, however, may file informational returns with the United States Internal Revenue Service or similar state agency regarding payment made to the Provider in accordance with this Agreement under conditions imposed by federal, state or local laws applicable to such payment. The City shall provide IRS Form 1099 if applicable. SECTION 9. Indemnification. The Provider hereby agrees to defend, indemnify, and hold harmless the City, its officials, directors, employees, and agents from any and all claims of any nature which arise from the performance by the Provider under this Agreement and from all costs and attorney fees in connection therewith, excepting for claims arising out of the negligence of the City, its officials, directors, employees, and agents. The obligations of the Provider under this Section shall survive the termination or expiration of this Agreement. SECTION 10. Equal Opportunity. The Provider shall comply with federal, state and local law in its hiring and employment practices and policies for any activity covered by this Agreement. SECTION 11. Entire Agreement. This Agreement sets forth the entire agreement and understanding between the Parties as to the subject matter hereof, and merges and supersedes all prior discussions, agreements, and understanding of any and every nature between them. SECTION 12. Law Governing. This Agreement shall be construed and interpreted according to the laws of the State of Indiana. SECTION 13. Assignment. The Provider's obligations under this Agreement may not be assigned or transferred to any other person or entity without the prior written consent of the City. SECTION 14. Amendment. This Agreement may be amended only by separate writing, approved by both the Provider and the City. SECTION 15. Notices. All notices or other communications which are required or permitted under the terms of this Agreement shall be sufficient if delivered personally, by registered or certified mail, return receipt requested, or by generally recognized, prepaid, overnight air courier services, to the address and individual set forth below. All such notices to either party shall be deemed to have been provided when delivered, if delivered personally, three (3) days after mailed, if sent by registered or certified mail, or the next business day, if sent by generally recognized, prepaid, overnight air courier services. City: Assistant Executive Director Department of Community Investment City of South Bend 1400 County City Building South Bend, Indiana 46601 Telephone: (574) 235-5822 bpawlows@southbendin.gov With a Copy to: Corporation Counsel's Office 227 West Jefferson Blvd. 1200 County -City Building South Bend, Indiana 46601 Telephone: (574) 235-9241 Facsimile: (574) 235-7670 Provider Northern Indiana Workforce Board, Inc. Greg Vollmer — President/CEO 0 851 S. Marietta St. South Bend, IN 46601 Phone: 317.828.2751 Fax: 574.239.2672 Email: gvollmer@gotoworkone.com With a Copy to: Northern Indiana Workforce Board, Inc. Jeff Balogh — CFO 600 E. Carmel Drive, Suite 147 Carmel, IN 46032 Phone: 574.855.6148 Fax: 317.819.8329 Email: jbalogh@gotoworkone.com SECTION 16. Counterparts. This Agreement may be executed in counterparts, all of which shall be deemed originals. SECTION 17. Corporate Authority. The undersigned persons executing and delivering this Agreement on behalf of the Provider represent and certify that they are the duly authorized officers of the Provider with authority to execute this Agreement; that the Provider has the full legal right, power and authority to enter into this Agreement and to grant the rights and perform the obligations of the Provider herein; that no third party consent or approval is required to grant such rights or perform such obligations hereunder; that this Agreement has been duly executed and delivered by the Provider and constitutes a valid and binding obligation of the Provider, enforceable in accordance with its terms, except as such enforceability may be limited by bankruptcy, insolvency, reorganization or similar Laws affecting creditors' rights generally or by general equitable principles. The undersigned persons executing and delivering this Agreement on behalf of the City represent and certify that they are the duly authorized officers of the Provider with authority to execute this Agreement, that they have been fully empowered, by proper resolution or action of the Commission to execute and deliver this Agreement and that all necessary action has been taken and done by the Commission to enter into this Agreement.. (remainder ofpage intentionally left blank) 10 IN WITNESS WHEREOF, the Parties hereto have caused this Agreement to be executed as of the day and year first above written. NORTHERN INDIANA WORKFORCE BOARD, INC. ignatur ( Y;q a K / 0/%Pr aw fit//W/X Fnnted Fame and CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS Gary Gilot, President James Mueller, Member Elizabeth A. Maradi�k, M ember Therese Dorau, Member David Relos, Member ATTEST: 11 dA Martin, Clerk EXHIBIT "A" Requested Services • NIWB will assist the Coordinator with the recruitment of participants • NIWB will handle all the bills associated with the provision of direct training • NIWB and the Coordinator will coordinate monitoring participant's progress • NIWB will enroll/train a minimum number of qualified South Bend residents for job training program • NIWB will ensure all enrollees /trainees will have a valid Driver's License or State issued Identification Card reflecting an address within the city limits • NIWB will provide reports indicating the number of applicants enrolled • NIWB will provide reports on the number of successful training completions • NIWB will provide reports on the number of applicants in On -the -Job Training (OJT) • NIWB will provide reports on the number of transitioned from OJT to full time - employment • NIWB will provide reports on the number of employers engaged in the training program • NIWB will provide reports on the number of employers hiring • NIWB will place a strong emphasis on assisting enrollees /trainees with creating professional/up- to -date resumes formatted to fit the needs of potential employers • NIWB will track and report all training participants' weekly wages before the start of the program and after job placement • NIWB will track and report all participants that are going from unemployed to employed • NIWB will track and report the number of participants that are increasing their skills from current employment to a better job prospect • NIWB will assist and work with the program coordinator to engage Community Leaders and Organizations to promote in the accountability and provision of services available and accessible to those most in need. 12 Activity/Methods Evaluation Goals Timeframe Accomplishments Measures WorkOne will Number of 40 Ongoing assist the participants Coordinator with the recruitment of participants. WorkOne will Paid Ongoing handle all bills Invoices/bills associated with the provision of direct training. WorkOne and the Number of Monthly Ongoing Coordinator will meetings/ coordinate database monitoring maintenance participant's progress. WorkOne will Number of 40 Ongoing enroll/train a South Bend minimum number residents in job of qualified South training Bend residents for session job training program. WorkOne will Number of 40 Ongoing ensure all applicants with enrollees/trainees valid driver's have a valid license or Driver's License identification or State issued cards Identification Card reflecting an address within the city limits WorkOne will Reports Ongoing provide reports indicating indicating number number of of applicants applicants enrolled. enrolled quarterly 13 WorkOne will Reports Ongoing provide reports on indicating the number of number of successful training successful completions. training completion WorkOne will Reports Ongoing provide reports on indicating the the number of number of applicants in On- applicants the -Job Training participating (OJT). in OJT WorkOne will Reports Ongoing prove reports on indicating the number of number of transitioned from OJT's OJT to full time- transitioned to employment. full-time employment WorkOne will Reports Ongoing provide reports on indicating the the number of number of employers engaged engaged in training employers program. WorkOne will Reports Ongoing provide reports on indicating the number of number of employers hiring. employers hiring 14 EXHIBIT `B Vetting and Training Schedule NIWB (through its' WorkOne office) will commence the training program on September 15t 2016 and will complete the training program on December 31, 2016. Program Process Week One (week one starts upon receiving confirmation of negative drug test results): Day One: Day Two: Day Three: Day Four: Enrollment in WorkOne Services WorkKeys Testing — Appropriate level for track must be obtained Barrier Assessment TORQ Assessment Evaluation of individual's desire to obtain employment Work History evaluation Resume and interview development Begin employer match — when OJTs are incorporated with program track o Each individual and employer is matched by the WorkOne Business Service Team. Every OJT is customized for the company and will be designed to accurately meet individuals and employer needs. Week Three and Beyond Subsequent weeks will follow appropriate track curriculums, which will be designed and administered by selected program providers. All training programs shall be designed to meet the needs of business in high growth/high demand industries. 15 EXHIBIT "C" (2/93) Form 236 Uniform Conflict of Interest Disclosure Statement Indiana Code 35-44-1-3 A public servant who knowingly or intentionally has a pecuniary interest in or derives a profit from a contract or purchase connected with an action by the governmental entity served by the public servant commits conflict of interest, a Class D Felony. A public servant has a pecuniary interest in a contract or purchase if the contract or purchase will result or is intended to result in an ascertainable increase in the income or net worth of the public servant or a dependent of the public servant who is under the direct or indirect administrative control of the public servant; or receives a contract or purchase order that is reviewed, approved, or directly or indirectly administered by the public servant. "Dependent" means any of the following: the spouse of a public servant; a child, stepchild, or adoptee (as defined in I.C. 31-3-4-1) of a public servant who is not emancipated and less than eighteen (18) years of age; and any individual more than one-half (1/2) of whose support is provided during a year by the public servant. The foregoing consists only of excerpts from I.C. 35-44-1-3. Care should be taken to review I.C. 35-44-1-3 in its entirety. 1. Name and Address of Public Servant Submitting Statement: 2. Title or Position With Governmental Entity: 3. a. Governmental Entity: b. County: 4. This statement is submitted (check one): a. as a "single transaction" disclosure statement, as to my financial interest in a specific contract or purchase connected with the governmental entity which I serve, proposed to be made by the governmental entity with or from a particular contractor or vendor; or b. as an "annual" disclosure statement, as to my financial interest connected with any contracts or purchases of the governmental entity which I serve, which are made on an ongoing basis with or from particular contractors or vendors. 5. Name(s) of Contractor(s) or Vendor(s): 6. Description(s) of Contract(s) or Purchase(s) (Describe the kind of contract involved, and the effective date and term of the contract or purchase if reasonably determinable. Dates required if 4(a) is selected above. If "dependent" is involved, provide dependent's name and relationship): M 7. Description of My Financial Interest (Describe in what manner the public servant or "dependent' expects to derive a profit or financial benefit from, or otherwise has a pecuniary interest in, the above contract(s) or purchase(s); if reasonably determinable, state the approximate dollar value of such profit or benefit.): (Attach extra pages if additional space is needed) 8. Approval of Appointing Officer or Body (To be completed if the public servant was appointed by an elected public servant or the board of trustees of a state -supported college or university): I (We) being the of (Title of Officer or Name of Governing Body) and having the power to appoint (Name of Governmental Entity) the above named public servant to the public position to which he or she holds, hereby approve the participation to the appointed disclosing public servant in the above described contract(s) or purchase(s) in which said public servant has a conflict of interest as defined in Indiana Code 35-44-1-3; however, this approval does not waive any objection to any conflict prohibited by statute, rule, or regulation and is not to be construed as a consent to any illegal act. Elected Official Office 9. Effective Dates (Conflict of interest statements must be submitted to the governmental entity prior to final action on the contract or purchase.): Date Submitted Date of Action on Contract or Purchase 10. Affirmation of Public Servant: This disclosure was submitted to the governmental entity and accepted by the governmental entity in a public meeting to the governmental entity prior to final action on the contract or purchase. I affirm, under penalty of perjury, the truth and completeness of the statements made above, and that I am the above named public servant. Signed: (Signature of Public Servant) Date: Within 15 days after final action on the contract or purchase, copies of this statement must be filed with the State Board of Accounts, Indiana Government Center South, 302 West Washington Street, Room E418, Indianapolis, Indiana, 46204-2765 and the Clerk of the Circuit Court of the county in which the governmental entity executed the contract or purchase. A copy of this disclosure will be forwarded to the Indiana State Ethics Commission. 17 lu