HomeMy WebLinkAboutPSA - Consultant for Pathways Workforce Program - Angeles Gonzalez1316 COUNTY-C[Tv BUILDING 1
;T PHONE 574/ 235-9251
227 W. JEFFERSON BOULEVARD � m��aF
;,�, FAX 574/ 235-9171
,-
Sol JTH BEND_ INDIANA 46601-1 930
�{
1866
CITY OF SOUTH BEND JAMES MUELLER, MAYOR
BOARD OF PUBLIC WORKS
January 28, 2020
Angeles Gonzalez
4211-313 Irish Hills Dr.
South Bend, IN 46614
RE: Professional Services Agreement
Dear Mr. Gonzalez:
The Board of Public Works, at its meeting held on January 28, 2020, approved the above
referenced agreement as a consultant for Pathways Workforce Program in the amount of
$69,000.
Enclosed please find a copy of the agreement for your records.
If you have any further questions regarding this matter, please call this office at (574)
235-9251.
Sincerely,
Linda M. Martin, Clerk
Enclosure
GARY A. GILOT ELIZABETH A. MARADIK THERESE J. DORAU JORDAN V. GATHERS JOSEPH R. MOLNAR
AGREEMENT FOR WORKFORCE PROGRAM MANAGEMENT SERVICES
THIS AGREEMENT FOR WORKFORCE PROGRAM MANAGEMENT
SERVICES (this "Agreement") is made effective as of January 1, 2020 (the "Effective
Date"), by and between the City of South Bend, Indiana, a municipal corporation organized
and operating under the laws of the State of Indiana, acting by and through its Board of
Public Works (the "City"), and Angeles Gonzalez, an Indiana resident (the "Provider").
RECITALS
WHEREAS, the City desires to promote opportunities for local employers to recruit
potential employees and has established or assisted in certain workforce development
programs; and
WHEREAS, to facilitate and enhance the City's efforts in growing local
employment opportunities, including through certain workforce development programs,
the City desires to engage program coordinators responsible for recruitment of candidates
and serving as a single point of contact for community partners engaged in workforce
development efforts; and
WHEREAS, the Provider is duly qualified to provide the workforce program
services set forth in attached Exhibit A (the "Services"); and
WHEREAS, the City believes that the actions contemplated by this Agreement are
in the best interests of the health, safety, and welfare of the City and its residents.
NOW THEREFORE, for and in consideration of the mutual covenants and
promises contained herein, the City and the Provider hereby agree as follows:
1. Contract mount and Term.
The Provider will provide the Services in
accordance with the terms of Exhibit A during the period commencing on January 1, 2020
of this Agreement and ending on December 31, 2020 (the "Services Term"). In accordance
with the terms and conditions of this Agreement, the City will expend an amount not to
exceed Sixty -Nine Thousand Dollars ($69,000.00) (the "Contract Amount") for the
Provider's performance of the Services during the Services Term.
2. Travel Allonan °e: ° Other Ex enses. The City shall reimburse the Provider
for travel expenses pre -approved by the Contract Administrator ("Allowable Travel
Expenses") in an aggregate amount not to exceed Two Thousand Dollars ($2,000.00)
during the Services Term (the "Travel Allowance"). The Allowable Travel Expenses shall
be incurred in accordance with the guidelines set forth on Exhibit B. With the exception
of the Allowable Travel Expenses payable from the Travel Allowance, the Provider will
not seek from the City, and the City will not pay to the Provider, any amount in excess of
the Contract Amount as compensation for the Provider's performance of the Services or for
any other costs or expenses related to the Services. All other costs or expenses related to
the Provider's performance of the Services will be paid by the Provider and will not be
reimbursed by the City.
3. Coi r erf 07ta qji j2o, 5erryi es. The Provider will submit monthly reports at
the times and in the manner prescribed by the Contract Administrator (as defined below),
which requirements are subject to change in the Contract Administrator's sole discretion.
As compensation for the Provider's satisfactory performance of the Services, the City will
pay the Contract Amount in equal monthly installments (each a "Contract Installment").
The City will not be required to pay any Contract Installment if the City is not satisfied
with the Provider's performance under this Agreement or any default or breach of this
Agreement by the Provider exists, as the City may determine in its sole discretion. The
sum of all Contract Installments will not exceed the Contract Amount.
4. 1 erniination rah" j reeinent. Effective immediately upon delivery of a
written termination notice to the Provider, the City may terminate this Agreement, in whole
or in part, for any reason, if the City determines that such termination is in the best interest
of the City. If the City Controller makes a written determination that funds are not
appropriated or are otherwise unavailable to support the continuation of this Agreement, it
shall be cancelled. A determination by the City Controller that funds are not appropriated
or are otherwise unavailable to support the continuation of performance shall be final and
conclusive. The City will not be required to pay any Contract Installment or be otherwise
liable for any cost associated with the Provider's performance of any Services after the
effective date of termination.
S. "atf 1'rr a uctL � i� The Provider will submit her work product to
the City in accordance with the terms of the Scope of Work. Any and all work product
submitted by the Provider to the City as part of the Provider's performance of the Services
will become the exclusive property of the City, and the City will have the right to use and
reproduce copies of the Provider's work product as the City determines in its sole discretion
without compensation to the Provider except the compensation expressly provided for in
this Agreement.
6. Re niedier,; ', r Breach ). Cc rra.cl. Failure to complete the Services in
accordance with this Agreement may be considered a material breach, and shall entitle the
City to impose sanctions against the Provider including, but not limited to, suspension of
all payments, and/or suspension of the Provider's involvement in the workforce program
management on behalf of the City. The Provider shall repay any portion of the Contract
Amount expended for matters not within the scope of the Services.
7 f acraten anc e oJ" &Tear s .rlcc es s� to Records. The Provider shall keep a
written record, in a form acceptable to the City, related to the use and expenditure of the
Contract Amount. Within thirty (30) days of the expiration or termination of this
Agreement, the Provider shall provide the City with a final accounting of the use and
disposition of the Contract Amount by the Provider. Unless otherwise authorized by the
City or required by law, such records shall be maintained by the Provider for a period of
four (4) years of the date of this Agreement. The Provider understands and agrees to
2
comply with the legal requirements of I.C. 5-14-3-1 et seq. (commonly known as Indiana's
Access to Public Records Act), if applicable, with respect to all documentation related to
the Contract Amount.
8. Audit Reeluir•ements. The Provider agrees to make all information available
to the Indiana State Board of Accounts, the City's Internal Auditor (as defined below), and
the Contract Administrator (as defined in Section 12 below) as requested to comply with
any review related to the receipt and use of the Contract Amount and the Provider's
performance of the Services. If requested by the City or the Contract Administrator, the
Provider shall provide the City a progress report on the Services. If requested by the City
or the City's Internal Auditor, the Provider shall arrange for a financial and compliance
audit of the Contract Amount to be conducted by an independent public or certified public
accountant (or as applicable, the Indiana State Board of Accounts) and in accordance with
applicable Indiana State Board of Accounts standards. The City's Internal Auditor shall
mean the City Controller or Acting City Controller appointed pursuant to I.C. 36-4-9-6 (the
"City Controller") or any person appointed or retained by the City Controller or the City
for the purpose of auditing this Agreement or other agreements of the City.
9. ("On i l's O ' Int r e t. The Provider hereby certifies and agrees that no
member, officer, or employee of the City, or its designees or agents, and no member of the
governing body of the City of South Bend or the Provider (and no one with whom there is
a family or business tie) who exercises any functions or responsibilities with respect to the
receipt and use of City funds 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 this Agreement or the Services.
10. Relationship. The Provider shall at all times be an independent contractor
for the performance of the Services rather than an employee of the City, and no act or
omission to act by the Provider shall in any way bind or obligate the City. This Agreement
is strictly for the benefit of the parties and not for any third -party or person. This
Agreement was negotiated by the parties at arm's length and each of the parties hereto has
reviewed the Agreement after the opportunity to consult with independent legal counsel.
Neither party shall maintain that the language in the Agreement shall be construed against
any signatory hereto. The City and the Provider hereby renounce the existence of any form
of agency relationship, joint venture, or partnership between the Provider and the City and
agree that nothing contained herein or in any document executed in connection herewith
shall be construed as creating any such relationship between the City and the Provider.
11. Irrc emni al,ion. The Provider hereby agrees to defend, indemnify, and
hold harmless the City, its officials, 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 of this Agreement.
12. N61imv. Any notice required or permitted to be delivered hereunder shall
be deemed to be delivered, whether or not actually received, when deposited in the United
3
States Postal Service, postage prepaid, registered or certified mail, return receipt requested,
addressed to the City or the Provider, as the case may be, at the address set forth below.
Provider: City:
Angeles Gonzalez Daniel Buckenmeyer (the "Contract Administrator")
4211-313 Irish Hills Dr. Department of Community Investment
South Bend, IN 46614 City of South Bend
227 W. Jefferson Boulevard, Suite 1400 S.
South Bend, IN 46601
13. f� arya OpL)� a'1 ?. The Provider shall comply with federal, state, and local
law in her hiring and employment practices and policies for any activity covered by this
Agreement.
14. En crrr�l �rrr�rz rra��rr . � li crlrlc� 1 aaw . 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. This Agreement may be amended only by separate
writing, approved by authorized representatives of both the Provider and the City. This
Agreement will be construed and interpreted according to the laws of the State of Indiana.
15. rlssi err ient. The Provider shall not assign or subcontract the whole or any
part of this Agreement or her obligations hereunder without the prior written consent of the
Board of Public Works of the City.
16. dual P orlynit � on _D scr�i�arhiati n � �:'crr�r�,�Cr`� nce. The Provider shall
-_._.__mm ...
comply with all applicable laws and regulations in her hiring and employment practices
and policies for any activity covered by this Agreement. The Provider shall comply with
all state, federal, and municipal laws, regulations, and standards applicable to her activities
pursuant to this Agreement including, but not limited to, the requirements imposed by Ind.
Code 22-9-1-10 (non-discrimination), the provisions of Ind. Code 5-22-16.5
(disqualification for dealings with the government of Iran), and the provisions of Ind. Code
22-5-1.7 (requiring E-Verify for new employees and prohibiting employment of
unauthorized aliens). Each of the foregoing provisions is incorporated herein as if set forth
in full, and the Provider certifies that she is in compliance with each such provision and
shall remain in compliance through the term of this Agreement.
17. Nori-(:"olhvvion. The undersigned attests, subject to the penalties of perjury,
that she is the Provider and that she has not entered into or offered to enter into any
combination, collusion, or agreement to receive or pay, and that she has not received or
paid, any sum of money or other consideration for the execution of this Agreement other
than that which appears upon the face hereof. The Provider agrees that she will execute
and submit to the City and any other appropriate bodies, an affidavit in the form attached
hereto as Exhibit C.
11
18. 1 r u e e l oi, leice. The Provider hereby agrees to make a good faith
effort to provide and maintain a drug -free workplace. The Provider will give written notice
to the City within ten (10) days after receiving actual notice that the Provider or an
employee of the Provider within the State of Indiana has been convicted of a criminal drug
violation occurring in the workplace.
IN WITNESS WHEREOF, the Parties hereto have caused this Agreement to be
effective as of the Effective Date stated above.
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
Date: January 28, 2020
Gary A. Gih t, President
Therese I orau l ember
V
Gathers "m' Iernber
�—Member
.... �r.
Elizabeth M'araA Me tuber
o!�� la Molnar,r �.�.� .m...... �.
�p Member
ATTEST
�...
inda M. Martin
ANGELES GONZALEZ,
an Indiana resident
Date: ,....� ..�.. ........ 2020
n,� �onza ez
5
EXHIBIT A
CITY OF SOUTH BEND
DEPARTMENT OF COMMUNITY INVESTMENT
PATHWAYS WORKFORCE DEVELOPMENT PROGRAM
SCOPE OF WORK
2020 PROGRAM YEAR
The City of South Bend Department of Community Investment, working on behalf of the Mayor, has
created this Scope of Work for the Pathways Program consultants to achieve key deliverables that will
contribute to successful program outcomes in 2020:
Program Purpose:
The purpose of the program is to create a program to increase the efficiency of the labor market
by bridging the current disconnect between employers with unfulfilled jobs — and that segment
of the City's population that is un/under employed or not participating in the labor force
whatsoever.
Program Goal for 2020:
0 Increase outputs*
*defined as South Bend residents who successfully matriculate and graduate from a Pathways
training program to find long-term placement in a higher -paying and more satisfying career.
General Consultant Expectations:
Serve as primary liaison between The City of South Bend's Department of Community
Investment, Work One, and the community as a resource for the Pathways program.
Resident Recruitment:
• Interface directly with South Bend residents to make them aware of the Pathways program
and its potential benefits for them.
Evaluate individual residents and their potential for program success to assure meaningful
and appropriate use of resources.
m Coordinate on -site intake for the Pathways program at Work One. Assure that all South
Bend residents who visit the facility are made aware of the program and opportunity.
• Coordinate participation and presentations during weekly ETC (Educational Training
Connection) intake programs on -site at Work One.
• Speak before organizations and groups to promote information about the program.
EXHIBIT B
Travel Guidelines
(Adapted from the City of South Bend Travel Policy, effective April 1, 2019)
Transportation. Provider may be required to travel via air transportation or ground
transportation, including rail transport, personal vehicle, or other means.
Air Transportation. Provider will travel via Coach / Economy Class for Domestic
travel within the Continental United States, including Alaska, Hawaii, Canada,
Caribbean, and Mexico. Overseas travel will be handled on a case -by -case basis. Provider
will first explore the option of using South Bend International Airport (SBN). If the cost
of a flight through SBN is within $300 of a flight out of Chicago (O'Hare or Midway),
the employee is encouraged to use SBN. Within these guidelines, Provider should
schedule air travel to secure the most affordable and efficient means of air transportation,
taking into account layover time, weekend travel, additional hotel and other expense,
airfare savings, etc.
Ground Transportation. Ground transportation is the desired means of
transportation for in -state and near -state destinations.
P r onalw Vehicle. A personal vehicle may be used for business travel and
will be reimbursed at the mileage rate as defined by the Internal Revenue Service.
Provider must maintain liability and property damage coverage on Provider's vehicle at
the statutory requirements in the state of registration.
ACCIDENTS. Provider must promptly report all accidents while
traveling under this Services Agreement to the appropriate state and local
authorities and to the Contract Administrator. In the case of an accident and subsequent
claim, the coverage provided by the employee's personal insurance will apply. The
City assumes no responsibility for damage to the employee's vehicle or for liability
claims for any injury incurred.
MECHANICAL FAILURE. Expenses for mechanical malfunction of a
personal vehicle used for travel pursuant to this Services Agreement are
considered the Provider's responsibility and are not reimbursable.
TRAFFIC CITATIONS. Traffic violations incurred by Provider while
using a personal vehicle are also not reimbursable.
Rail or Bus Transport. Provider may use rail or bus transport when cost
and time factors are favorable for Provider's travel needs.
Lodging. Provider is expected to patronize reasonably priced hotels/motels which
provide comfortable living quarters in the proximity of the work location visited to
minimize the cost of ground transportation during travel. Provider is not required to share
room accommodations. When attending conferences or seminars, the Provider shall use
Employer Engagement:
Engage consistently with DCI staff to identify opportunities for partnership with South Bend
employers. There are two general categories that employer -based opportunities may
present themselves within:
o Placement Opportunities:
■ If an employer with an immediate need for trained employees from existing
Pathways programs is identified, engage and seek opportunities to place
program graduates.
o Customized Training Opportunities:
■ If an employer with a more specialized and/or larger need for employees is
identified, engage DCI Staff to accompany consultant in meeting with the
employer to identify specific needs and evaluate opportunities to provide
on -demand and/or customized training.
Community Engagement:
• Identify key community partner organizations, associations, service providers and
community stakeholders to introduce and request their promotion of the Pathways program
to their own constituencies.
• Coordinate with community partner organizations (as defined above) to represent and
promote the program at meetings, workshops and conferences.
• Visit key stakeholders on a periodic and consistent basis to achieve the above, include visits
and outcomes in weekly reports to DCI staff.
Program Reporting:
• Daily: Maintain the DCI online reporting tool to track daily Pathways recruitment activities.
• Weekly: Submit weekly reports to DCI Staff highlighting activities and successes in resident
recruitment, employer engagement and community engagement.
• Monthly: Submit monthly invoices in a timely fashion.
Coordinate with DCI Staff and WorkOne to handle referral management, training, placement,
and tracking
« Work One will act as a case manager for individuals in the program; handling drug testing,
Work keys testing, setting up curriculums, and assisting in placement upon program
completion.
Manage candidate follow-up to track interviewing, hiring, and placement outcomes
• All candidates will need to have progress tracked from program entry to job placement, with
information recorded on training, interviewing, and placements
• Candidates will need to provide surveys upon completion of the program that can be used
for evaluation in future endeavors
The consultant will submit invoices monthly for payment and demonstrate completion of all
requirements from recruitment to reporting.
0 Invoices will have a 30 day turn -around time, consistent with City policy
EXHIBIT C
Contractor's Affidavit
[See attached.]
best efforts to reside in the host hotel, or in a hotel recommended by the attending
conference, as long as such rates are considered reasonable by the Contract
Administrator.
Meals and Incidental Expenses. The actual amount spent must be reasonable in relation
to the locale visited. Meals are reimbursable if the Provider is away from home overnight.
Meals while traveling off site for a day, without overnight accommodation, are normally
not reimbursable. However, if the travel time exceeds ten (10) hours, the Provider may be
reimbursed for one meal. Incidental expense includes such items as fees and tips given to
porters, baggage carriers, bellhops, and transportation expense between places of lodging
and business site visited and places where meals are taken.
Miscellaneous Expense. All necessary business calls and messages while travelling are
reimbursable. Personal telephone calls to family members from the hotel of residence are
reimbursable. Expense incurred for internet connectivity to access work e-mail when
traveling is reimbursable. Laundry and valet service are reimbursable if the Provider is
traveling on business for more than three (3) consecutive days. All miscellaneous
expense incurred must be deemed to be of reasonable amount for the length of the travel
period. Miscellaneous expense deemed to be excessive by the Contract Administrator
will not be reimbursed to the Provider.
Non -Reimbursable Items. Certain expenses are not considered travel -related and are not
reimbursable. The following is not all inclusive, but is intended to serve as a guide:
1. credit card fees;
2. personal entertainment expense (e.g. in -room or theater movies, athletic events,
newspapers, books, etc.);
3. expense for spouse or family travel;
4. fines or penalties for parking and traffic violations;
5. loss or damage to personal vehicle or property while on personal business;
6. in-flight beverages, meals, and headset rental;
7. travel / trip life insurance charges;
8. items that normally require a purchase order;
9. personal medical expenses, personal toiletries, and grooming;
10. alcoholic beverages.
Reimbursement. The Provider is required to submit receipts and an itemized list of
expenses to the Contract Administrator for payment of reimbursable expense items
exceeding $5.00. Failure to submit original receipts may result in a delay in processing
the expense report and may result in the denial of reimbursement of the expense item
incurred. An itemized hotel bill is required to support lodging, meals, and other expense
incurred during the hotel stay. Itemized receipts are required to support expenses for
meals and miscellaneous expense. Credit card statements are not acceptable as a receipt
for travel expense incurred. Generic receipts are not acceptable for justification of any
expense item submitted for reimbursement.
When lIle prospective Contractor is unable to certify to any of the statentents belolp, it shall altach an explanation to this Affidavit.
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
(Must be completed for all quotes and bids. Please type or print)
STATE OF )
SS:
COUNTY )
The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury that
1. Contractor has not, nor has any other member, representative, or agent of the firm,
company, corporation or partnership represented by him, entered into any combination, collusion
or agreement with any person relative to the price to be bid by anyone at such letting nor to
prevent any person from bidding nor to induce anyone to refrain from bidding, and that this bid
is made without reference to any other bid and without any agreement, understanding or
combination with any other person in reference to such bidding. Contractor further says that no
person or persons, firms, or corporation has, have or will receive directly or indirectly, any
rebate, fee, gift, commission or thing of value on account of such sale; and
2. Contractor certifies by submission of this proposal that neither contractor nor any of its
principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any Federal department or agency;
and
3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
investment activities in Iran.
a. For purposes of this Certification, "Iran" means the government of Iran and any agency or
instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16,5-5, as amended from
tune -to -time,
b. As provided by hid. Code § 5-22-16.5-8, as amended from tune -to -time, a Contractor is
engaged in investment activities in Iran if either:
i. Contractor, its successor or its affiliate, provides goods or services of twenty million
dollars ($20,000,000) or more in value in the energy sector of Iran; or
ii. Contractor, its successor or its affiliate, is a financial institution that extends twenty
million dollars ($20,000,000) or more in credit to another person for forty-five (45)
days or more, if that person will (i) use the creditto provides goods and services in
Non -Collusion Non-DebamientAllidavit Non Iran Komi
the energy sector in Iran; and (ii) at the time the financial institution extends credit, is
a person identified on list published by the Indiana Department of Administration.
4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain
any employee or contract with a person that the Contractor subsequently learns is an
unauthorized alien. Contractor agrees that he/she/it shall enroll in and verify the work eligibility
status of all of Contractor's newly hired employees through the E-Verify Program as defined by
LC. 22-5-1.7-3. Contractor's documentation of enrollment and participation in the E-Verify
Program is included and attached as part of this bid/quote; and
5. Contractor shall require his/her/its subcontractors performing work under this public
contract to certify that the subcontractors do not knowingly employ or contract with an
unauthorized alien, nor retain any employee or contract with a person that the subcontractor
subsequently learns is an unauthorized alien, and that the subcontractor has enrolled in and is
participating in the E-Verify Program, The Contractor agrees to maintain thus certification
throughout the term of the contract with the City of South Bend, and understands that the City
may terminate the contract for default if the Contractor fails to cure a breach of this provision no
later than thirty (30) days after being notified by the City.
6. Persons, partnerships, corporations, associations, or joint venturers awarded a contract by
the City of South Bend through its agencies, boards, or commissions shall not discriminate
against any employee or applicant for employment in the performance of a City contract with
respect to hire, tenure, terms, conditions, or privileges of employment, or any matter directly or
indirectly related to employment because of race, sex, religion, color, national origin, ancestry,
age, gender expression, gender identity, sexual orientation or disability that does not affect that
person's ability to perform the work.
In awarding contracts for the purchase of work, labor, services, supplies, equipment, materials,
or any combination of the foregoing including, but not limited to, public works contracts
awarded under public bidding laws or other contracts in which public bids are not required by
law, the City, its agencies, boards, or commissions may consider the Contractor's good faith
efforts to obtain participation by those Contractors certified by the State of Indiana as a Minority
Business ("MBE") or as a Women's Business Enterprise ("WBE") as a factor in determining
the lowest, responsible, responsive bidder.
In no event shall persons or entities seeking the award of a City contract be required to award a
subcontract to an MBE/WBE; however, it may not unlawftilly discriminate against said
WBE/MBE. A finding of a discriminatory practice by the City's MBE/WBE Utilization Board
shall prohibit that person or entity from being awarded a City contract for a period of one (1)
year from the date of such determination, and such determination may also be grounds for
terminating the contact for which the discriminatory practice or noncompliance pertains,
7. The undersigned contractor agrees that the following nondiscrimination commitment
shall be made a part of any contract which it may henceforth enter into with the City of South
Bend, Indiana or any of its agencies, boards or commissions.
Non-CollusiunNon-DebannenlAlFidavit Non Iran Fonn
Contractor agrees not to discriminate against or intimidate any employee or applicant for
employment in the performance of this contract with privileges of employment, or any matter
directly or indirectly related to employment, because of race, religion, color, sex, gender
expression, gender identity, sexual orientation, handicap, national origin or ancestry. Breach of
this provision may be regarded as material breach of contract.
I, the undersigned bidder or agent as contractor on a public works project, understand my
statutory obligations to the use of steel products or foundry products made in the United States
(I.C. 5-16-8-1). I hereby certify that I and all subcontractors employed by me for this project will
use steel products or foundry products on this project if awarded. I understand that violations
hereunder may result in forfeiture of contractual payments.
I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid for
public works are true and correct. .
Dated this aJ W �1� of�, 20 ZC,
Signature of Contractor/Bidder or Its Agent
Printed Name and Title
Subscribed and sworn to before me this day of ,, 20_
My Commission Expires
Notary Public
County of Residence
Non -Collusion Non -Debarment Affidavit Non ]ran Fonn
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
Date 01/15/2020
Name Daniel Bu+ckenme er Department DCI
BPW Date 01/2I/2020 Phone Extension 5823
�% +v IIIIIII�IIWTP�WNIfYf'W��88iY�iiifllN�YNIWIpWi�I1hH/MEyY9i"' ,,,,, VIVIVIVIVIVIVIVIVIVINOIOfvNVix»++»»^
......._......�,�,�........u......,,�,,,.,.,w ,� „ _�._...
......----
.,� �..-. ............ ,_.... ......�,....w ����....m .�,�..
Required Prior to Submittal to Board
BPW Attorney E:1 Attorney Name
Dept. Attorney X Attorney Name Sandra Kenn el
............. .......
Purchasing
Check the
0 Professional Services Agreement
EJ Open Market Contract
Bid Opening
Quote Opening
Proposal Opening
E] Chg. Order, No.
Other:
Company or Vendor Name
New Vendor
MBE/WBE Contractor
Project Name
Project Number
Funding Source
Account No.
Amount
Terms of Contract
Purpose/Description
i4 Item l" rpe
x Contract
❑ Amendment/Addendum
El Bid Award
Quote Award
C/O & PCA No.
Traffic Control
Information
Gonzalez
All Submissions
Proposal
LJ Special Purchase, QPA
Req. to Advertise
E] Reject Bids/Quotes
PCA
Resolution
Ease./Encroach
Yeses If Yes, Approved by Purchasing
❑ Title Sheet
No
❑ WBE Completed E-Verify Form Attached No
Patwa s
'... Program
EDIT
404-1001-460-3 mm........,
9.30
$69,000
Consultant for Pathways Workforce Program
......._ or Ch!V a er Oily
Amount of ❑ Increase $
❑ Decrease$
............... w___..........
Previous Amount $
Increase .��................ . %_.._..���...����..
_.
Current Percent of Change: Decrease %) ITmm ..._ ......ww
New Amount $
Increase %
Total Percent of Change: Decrease %)
Time Extension Amount:
New Completion Date: