HomeMy WebLinkAbout6.C.(5) Agreement for Services with Hathaway 2~~~s~
AGREEMENT FOR SERVICES
BY AND BETWEEN THE CITY OF SOUTH BEND, DEPARTMENT
OF REDEVELOPMENT, ACTING BY AND THROUGH THE
SOUTH BEND REDEVELOMENT COMMISSION
AND HATHAWAY 2, INC.
THIS AGREEMENT is made effective the day of October, 2009, by
and between the City of South Bend, Department of Redevelopment, Acting By and
Through the South Bend Redevelopment Commission, having its offices at 1200 County-
City Building, 227 West Jefferson, South Bend, Indiana 46601 ("Commission'") and
Hathaway 2, Inc., a domestic corporation organized under the laws of the State of Indiana
("Hathaway'' or "Provider"), and having its principal place of business in South Bend,
Indiana.
WITNESSETH:
WHEREAS, the Commission is the governing body of the City of South Bend
Department of Redevelopment ("Department ') and exists and operates under the
provisions of LC. 36-7-14, commonly known as the "Redevelopment of Cities and
Towns Act of l 953". as amended from time to time ("Act"): and
WHEREAS, pursuant to the Act, the Commission has the power and duty to
investigate, study, and survey areas «~ithin the corporate boundaries of the City of South
Bend ('City-') that the Commission has determined to be in need of redevelopment within
the meaning of the Act and to redevelop said areas in a manner that will promote land use
in order to serve the best interests of the City and its inhabitants; and
WHEREAS, under the authority of LC. 36-7-14, the Commission has adopted
and declared the Airport Economic Development Area ("Area'-) to be an area in need of
redevelopment within the meaning of the Act and has acquired property, demolished
buildings, and otherwise prepared land for development now known as Ignition Park
located in the Area; and
WHEREAS, the Commission desires to undertake certain actions and promote
certain activities within the Area that are necessary to carry out and facilitate
development of the Area ("Project'-); and
WHEREAS, Hathaway, and in particular, Geraldine A. Hafllaway, its President,
has knowledge, experience and expertise in developing strategies and development plans;
and
WHEREAS, the Commission has determined that due to Hathaway's knowledge,
experience and expertise, it is in the best interests of the Commission to retain
Hathaway"s services to assist the Commission in accomplishing the Project; and;
WHEREAS, Hathaway is willing to assist the Commission 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 Commission has appropriated funds for the Project, including
funds for the Requested Services, as required by Indiana Code ~ 5-22-17-3.
SECTION 1. Definitions. For purposes of this Agreement, the following
terns have the meanings refen•ed to in this Section:
City Coiztrolle~•: The term "City Controller" shall mean the City Controller
or Acting City Controller appointed pursuant to Indiana
Code ~ 36-4-9-6.
Cit~~'s L~te~•»al
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.
Commission: The term "Commission" shall mean the South Bend
Redevelopment Commission, the governing body of the
City of South Bend Department of Redevelopment
Competitive Biddi~tg
Requi~•ei~ier~ts: Indiana Code j 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 with regard to
other transactions.
Contract
Ad»>inist-•atnr: The term "Contract Administrator" shall mean Don Inks.
Director of Economic Development for the Community and
Economic Development Department.
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Effective Date: The term "Effective Date"' shall have the meaning ascribed
to such tens in the opening paragraph of this Agreement.
Expi-•atio-- Date: The term "Expiration Date'' shall mean October 31, 2010.
Hat/zaway: The term "Hathaway" shall mean Hathaway 2, hoc., a
domestic corporation organized under the laws of the State
of Indiana and having its offices in South Bend, Indiana.
Requested Services: The term "Requested Services'" shall mean the services
described at EXHIBIT "A ".
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 Commission.
SECTION 2. Retention and Acceptance of Provider, Schedule of
Services.
A. The Commission hereby retains the Provider to provide to the
Commission 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 Seiti~ices to the Commission and agrees to provide
the Requested Services under the teams 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 Agn•eement including, but not limited to, the procedures prescribed by
Indiana Code ~ 36-7-14, et seq. and the schedule established for the Project ("Project
Schedule'') or as other~~-ise mutually a~~reed 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 teens and conditions of this Agreement including, but not limited to, in
accordance with the Project Schedule, the Contract Administrator may withhold
payments due Provider. Further, if any 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 teens of this Agreement. An extension of time may be granted in
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the event of extenuating circumstances by the Provider applying for and receiving written
permission for an extension of time from the Commmission.
SECTION 3. Parties' Responsibilities.
A. I_nfoi-mation ~n~d CO/911922T71ZCLltZOYIS. The Commission shall provide all
maps, reports, and other data requested by the Provider necessary for the Provider to
accomplish the Requested Services. The Commission and the Provider agree that the
Commission 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 the
Commission with said documents upon request by Commission. Said documents may be
used by the City or others with respect to the Commission's undertakings with respect to
the Project.
B. Reports and Budgets. 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 thirty
(30) 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 Services.
C. Project Budd. In exchange for the consideration set forth herein, the
Provider hereby agrees to develop and abide by the Project budget to be set forth as
APPENDIX "A" to this Agreement in delivering the Requested Services ('Project
Budget").
D. Final Report. The Provider shall provide to the Commission 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 Conruct. The Commission hereby designates Don Inks (the
"Contract Administrator") as the Providers point of contact with the Commission for
purposes of this Agreement. The Contract Administrator shall be responsible for the
provision of information to the Provider under this Agreement.
G. Auditing Reytriren~ents. The Provider agrees to make all information
available to the lnternal Auditor or any other entity as required by Indiana law. The
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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 outstanding 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 elech-onie 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 audits of 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 tern of this Agreement, the
Commission may conduct reviews of the content and progress of the Requested Services.
K Revision of Requested Se~~l~iccs. If, as a result of any review hereunder, it
is the opinion of the Commission that revisions of the scope of the Requested Services
are necessary or the methods employed by the Provider are inappropriate, the
Commission may require such revisions to the scope or methods by notifying the
Provider in writing.
L Provider Attthorit~~ to Hine Subcontructo~-s. Provider shall have the
authority to contract with a subcontractor or subcontractors in order to perform the
Requested Services pursuant to this Agreement. However, any agreement with
subcontractors shall be consistent with the terms and conditions of this Agreement, and
shall be paid by Provider out of the budget and funds described in this Agreement. To
the extent any fees of a subcontractor exceed the compensation described in Section 4,
such compensation shall be at the expense of Provider.
SECTION 4. Compensation.
A. Fees for Se~•vice.c. As compensation for services performed pursuant to
this agreement, the Commission agrees to pay the Provider a not to exceed fee of One
Hundred Twenty Thousand Dollars (~ 120,000) to be earned at a rate not to exceed One
Hundred Twenty-five Dollars (S 125.00) per hour for services rendered, and in addition,
Commission shall provide office space at Innovation Park located adjacent to the
University of Notre Dame on Edison Boulevard at a rate not to exceed Seven Hundred
Fifty Dollars ($750.00) per month.
B. IJwoices. The Provider shall submit an invoice for progress payments to
the Commission for services performed under this Agreement, which invoice shall
identify the Project, the task, and a description of the services completed. Invoices shall
be submitted within five (5) days of the preceding month for which services were
rendered. For example, the invoice seeking payment for services rendered in January,
2010 shall be submitted no later than February 5, 2010. In no event shall invoices exceed
the sum of Ten Thousand Dollars ($10,000.00) per month. h1 the event of termination of
this Agreement as provided in SECTION 6, all non-disputed sums owing and due the
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Provider for services rendered shall be paid within fifteen (15) days of receipt of any
invoice.
SECTION 5. Term.
The Term of this Agreement shall commence on the Commencement Date, and
shall terminate on the earlier of the Expiration Date or Termination Date, as described at
SECTION 6, below. This Agreement shall be renewable on such teams and for such
period as the Parties shall agree in writing. Notwithstanding the foregoing, this
Agreement is subject to annual appropriations of the Commission in accordance with
Indiana Code § 5-22-17-3.
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, copies all data, electronic
files, documents, procedures, reports, estimates, summaries other work papers, and any
other supporting documents, whether completed or in process, accumulated by the
Provider or prepared or provided by Commission or the Provider relating to this
Agreement or the Requested Services shall be and remain the property of Commission
and be delivered to the Commission upon request in a usable foam within sixty (60) days
of the Termination Date of this Agreement. The Commission 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 utrlt. 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 terns of this Agreement or. in the event of a material default,
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terminate this Agreement. If the default is cured, then no default shall exist and the
noticing party shall take no further action.
C. Misrepresentutions. 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 Notice.
D. Project 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 incur-ed or claimed by
the Provider shall be no longer available under this Agreement after all compensation
earned and reimbursable expenses incur-ed as of the date the Provider received written
notification of the cancellation or termination Project have been paid.
E. Reversion of Assets. At the conclusion, cancellation, assignment or
termination of this Agreement, all work product in whatever form, written, electronic, or
otherwise, shall be delivered to the Commmission, and the Parties hereby agree the
Commission and not Provider or any of Provider"s subcontractors or agents. has any
ownership interest in the work performed as part of this A~n•eement.
SECTION 7. Confidentiality, Conflict of Interest, and Disclosure.
A Confidential Infor~nution. The Provider acknowledges that information
which the Commission 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 Commission. 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 fi-om the Provider. A violation of this SECTION 7
shall be deemed to be a material breach of this Agreement.
B. Co~~enu~zt Sun~i~'e Agreement. The confidentiality provisions of this
Agreement remain in full force and effect after, and survive the termination of this
Agreement.
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C. Conflict of Intel°est. The Provider hereby certifies and agrees that no
member, officer, or employee of the Connnission, or its designees or agents, (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
Conh•actor 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 tics- has ally personal financial benefit, direct or indirect in
this Contract.
D. Uniform Conflict of Interest Disclosure State~r~ent. The Provider
acknowledges that 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
354-1 and, to the extent applicable, will execute and file with the Commission and any
other appropriate bodies a Uniform Conflict of Interest Disclosure Statement, the form of
which is attached hereto and incorporated herein as Exhibit C.
SECTION 8. Relationship.
A. Indc~pc~ndent Contractor. The Provider shall at all times be an independent
contractor rather than an employee of the Commission, and no act, action or omission to
act by the Provider shall in any way bind or obligate the Commission, except as
specifically provided under the terns of this Agreement. It is understood and agreed by
the parties that the Provider will not be entitled to any benefits enjoyed by the
Commission or the staff of the Connnission in the normal course of their emplo}nnent.
B. Tax Obli~atious. 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 Commission, 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 Commission shall provide IRS Form 1099 if
applicable.
SECTION 9. Indemnification.
The Provider hereby agrees to defend, indemnify, and hold harmless the
Commission, its officials, directors, employees, and agents from any and all claims of
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any nature which arise fi-om the performance by the Provider under this Agreement and
from all costs and attoi7ley fees in connection therewith, excepting for claims arising out
of the negligence of the Commission, 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 he 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
hansfen-ed to any other person or entity without the prior written consent of the
Commission.
SECTION 14. Amendment.
This Agreement may be amended only by separate writing, approved by both the
Provider and the Commission.
SECTION 15. Notices.
All notices or other communications which are required or pel7nitted 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.
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Commission: Don Inks
12th Floor, County-City Building
South Bend, Indiana 46601
With a Coj?y to: City Attorney
14th Floor, County-City Building
South Bend, Indiana 46601
Provider Hathaway 2, lnc.
c/o Geraldine A. Hathaway, President
601 Park Avenue
South Bend, Indiana 46616
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 rant such rights or perfoi-~n 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.
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SECTION 18. Miscellaneous.
[RESERVED].
(re~nuinde~• of pugc> intentionally left hlunh)
IN WITNESS WHEREOF, the Parties hereto have caused this Agreement to be
executed as of the day and year first above written.
HATHAWAY 2, INC.
CITY OF SOUTH BEND,
DEPARTMENT OF REDEVELOPMENT
s;,~m,~~„~~~
Geraldine A. Hathaway, President
Primed A~umi• and ~r~lr
sr~~«,~~„~~
Printed NrrnTe an lit e
South Bend Redevelopment Commission
ATTEST:
S'i,mnure
Printed .1'nnre not Tir e
South Bend Redevelopment Commission
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FXI-IIRIT 4
Requested Services
Strategic
Devise a sh-ategic vision and development plan for Ignition Park to achieve identified
strategic goals, including economic development objectives, from 2010 through 2020.
Tactical
Be the "face'" and primary contact for Ignition Park inquiries ti•om interested parties,
corporations, the press.
2. Seek near tei7n financial self-sustainability on an operating basis by taking the lead to
identify and pursue funding opportunities for Ignition Park, separately and collectively
with its certified tech park "sister" park-Innovation Park, through federal, state, regional,
local, and foundation grants and loans.
3. Establish Advisory Group consisting of City, University and local business to identify
key areas ofresearch-application opportunity for Ignition Park, Innovation Park.
4. Identify City role in the future management of Ignition Park if any.
5. Review next steps for environmental and design contracts.
6. Identify and pursue early recruitment opportunities.
7. Visit/Study comparable tech parks.
8. Identify appropriate tenant mix.
9. Prepare 5 year general operating and development budget.
10. Dete~nline property tax structure for Ignition Park.
11. Prepare and continuously update feasibility and timetable development brief for City,
University and local business.
12. Establish and maintain contact with the following in order to enhance a sense of
cooperation and remain aware of changes which help identify early recruitment
opportunities for tech business to assure a South Bend solution if Ignition Park is not
appropriate.
Project Future and Chamber of Commerce
South Bend Division of Public Development
University of Notre Dame and other University Consortium Members
Business Consortium Members as appropriate
Local Business
Real Estate Community
Blue Waters Group and other consultants that might impact the image of Ignition Park
Developers, Architects, Engineers and other consultants as deemed appropriate
Visits to Business Consortium members and other potential occupants of Ignition Park
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EXHIBIT "B"
Project Schedule
The Strategic and Tactical Services shall be delivered periodically between November 1,
2009 and October 31, 2010.
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APPENDIX "A" TO E~'HIBIT "B"
Project Budget
Total Fees and Expenses: $120,000
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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 LC. 31-3-4-1) of a public
servant who is unemaneipated 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 LC. 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 Subn>itting Statement:
2. Title or Position With Governmental Entity:
a. Governmental Entih':
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
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 conk-actors 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):
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 detei7ninable, state the
approximate dollar value of such profit or benefit.):
(Attach extra ~uges if additioi~ul 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 aatate-supported college or
university):
I (We) being the
(Title of Officer or Nume of Go~~erning Body)
and having the power to appoint
(Nunn of Go~~ernme~~tul Entity)
of
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 Oftice
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 Conh•act or Purchase
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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 peijw•y, the truth and
completeness of the statements made above, and that I am the above named public servant.
Signed:
Date:
(Signature of Public Servant)
Within I S 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.
Gibney\hathaway\servicesAGRdoc
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