HomeMy WebLinkAbout6. D (1) Contract with Project Impact`- ,I I \1
AGREEMENT FOR SERVICES
BY AND BETWEEN THE CITY OF SOUTH BEND, DEPARTMENT
OF REDEVELOPMENT, ACTING BY AND THROUGH THE
SOUTH BEND REDEVELOMENT COMMISSION
AND PROJECT IMPACT - SOUTH BEND, INC.
THIS AGREEMENT is made effective the 1 st day of January, 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 (the "Commission ") and
PROJECT IMPACT - SOUTH BEND, INC., a not - for - profit domestic corporation
organized under the laws of the State of Indiana ( "Project Impact" or the "Provider "), and
having its principal place of business at 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 I.C. 36 -7 -14, commonly known as the "Redevelopment of Cities and
Towns Act of 1953 ", as amended from time to time (the "Act'); and
WHEREAS, pursuant to the Act, specifically, I.C. 36- 7- 14- 39(b)(2)(K) and I.C.
36- 7- 14- 39(g), the Commission has the power and duty to allocate funds for job training
expenses; and
WHEREAS, under the authority of I.C. 36 -7 -14, the Commission has declared
the Airport Economic Development Area ( "AEDA ") to be an area in need of economic
development within the meaning of the Act and has adopted the Airport Area Economic
Development Plan ( "Development Plan") in order to facilitate economic development of
the Area; and
WHEREAS, part of the AEDA is located in an Enterprise Zone ( "UEZ ") created
under I.C. 5- 28 -15. A map of the AEDA and UEZ is attached hereto and made a part
hereof as Exhibit "A "; and
WHEREAS, the Commission desires to undertake certain actions and promote
certain activities within the AEDA and UEZ that are necessary to carry out the
Development Plan for the AEDA and facilitate development of the AEDA by providing
funds for job training pursuant to I.C. 36 -7 -14 (the "Project "); and
WHEREAS, Project Impact is a not - for - profit domestic corporation created to
promote job training within the AEDA and UEZ and has knowledge, experience and
expertise in job training; and
WHEREAS, the Commission has determined that due to Project Impact's
knowledge, experience and expertise, it is in the best interests of the Commission to
retain Project Impact's services to assist the Commission in accomplishing the Project;
and
WHEREAS, Project Impact is willing to assist the Commission in its efforts by
providing the Job Training Services which are more specifically described below and in
Exhibit "A" and are subject to the terms and conditions of this Agreement; and
WHEREAS, the Commission has appropriated funds for the Project in the
amount of Six Hundred Twenty -three Thousand Eighty -six Dollars ($623,086), for the
Project.
NOW, THEREFORE, it is agreed between the parties as follows:
SECTION 1. Definitions. For purposes of this Agreement, the following
terms have the meanings referred to in this Section:
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
Commission.
Commission: The term "Commission" shall mean the South Bend
Redevelopment Commission, the governing body of the
City of South Bend, Department of Redevelopment.
Contract
Administrator: The term "Contract Administrator" shall mean Don Inks,
Director of Economic Development for the Community and
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Economic Development Department.
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,
2009.
Job Training
Services: The term "Job Training Services" shall mean the services
described in Exhibit "B" as well as other related expertise
and assistance rendered to the Commission by the Provider.
Project Impact: The term "Project Impact" shall mean Project Impact -
South Bend, Inc., a not - for -profit corporation organized
under the laws of the State of Indiana and having its offices
in South Bend, Indiana.
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 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 Job Training Services that are more specifically described in Exhibit "B"
attached hereto and incorporated herein. The Provider hereby accepts the appointment to
provide the Job Training Services to the Commission and agrees to provide the Job
Training Services under the terms and conditions set forth in this Agreement. All
services provided by the Provider pursuant to this Agreement shall comply with the
requirements in I.C. 36- 7- 14- 39(b)(2)(K) and I.C. 36- 7- 14- 39(g).
B. Upon receipt of a notice to proceed from the Contract Administrator, the
Provider shall commence the Job Training Services in accordance with the terms and
conditions of this Agreement including, but not limited to, the procedures prescribed by
Indiana Code § 36 -7 -14, et seq., or as mutually agreed by the parties in writing. The
Provider hereby certifies that it has sufficient experience, expertise and financial aptitude
to complete the Job Training Services in the manner set forth in Exhibit "B ".
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C. Should the Provider fail to complete the Job Training Services in
accordance with the terms and conditions of this Agreement, the Contract Administrator
may withhold payments due the Provider. Further, if any damages are imposed against
the Provider, any monies due and payable to the Commission 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
Commission.
SECTION 3. Parties' Responsibilities.
A. Information and Communications. The Commission shall provide all data
requested by the Provider necessary for the Provider to accomplish the Job Training
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 the Commission. Said documents may be used by the Commission or
others with respect to the Commission's undertakings with respect to the Project.
B. Reports and Bud ets. The Provider agrees to provide the Contract
Administrator and the Internal Auditor with a report regarding the performance of the Job
Training Services and the 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 Job Training Services. The report shall specify the relation of
each service rendered by the Provider to the requirements of I.C. 36- 7- 14- 39(b)(2)(K)
and I.C. 36- 7- 14- 39(g).
C. Project Budget. In exchange for the consideration set forth herein, the
Provider hereby agrees to abide by the Project Budget as set forth in Exhibit "C" to this
Agreement in delivering the Job Training Services (the "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 Job Training
Services in addition to a final accounting of all revenues and expenditures as described
above.
E. Records. The Provider agrees to keep and maintain, for a period of 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.
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F. Point of Contact. The Commission hereby designates Don Inks (the
"Contract Administrator ") as the Provider's 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 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 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 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 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 term of this Agreement, the
Commission may conduct reviews of the content and progress of the Job Training
Services.
K 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 Internal Auditor within five (5) days of their filing.
L Revision of Job Training Services. If, as a result of any review hereunder,
it is the opinion of the Commission that revisions to the scope of the Job Training
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.
J. Additional Auditing Requirements for Not -For -Pro it Organizations. The
Provider understands that not - for -profit entities receiving City of South Bend funds,
including funds received from the Commission, 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
Provider is required to submit an E -1 form to the Indiana State Board of Accounts, the
Provider shall also forward a copy of the E -1 to the City's Internal Auditor. The
Commission 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.
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K. Competitive Bidding Requirements. To the extent funds provided to
Project Impact 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 for Services. As compensation for services performed pursuant to
this Agreement, the Commission agrees to pay the Provider a fee of Six Hundred
Twenty -three Thousand Eighty -six Dollars ($623,086) for services rendered(the
"Contract Amount ").
B. Invoices. Commission shall pay Provider one -sixth (1/6) of the Contract
amount to Provider upon approval of the Contract. Beginning with the fifth (5th) day of
each month thereafter, one - twelfth (1/12) of the Contract amount shall be disbursed to
Provider until the entire Contract amount is disbursed to Provider. However, the
Provider shall submit an invoice for the payments outlined above to the Commission
detailing the services performed under this Agreement, and shall include at a minimum,
the identification of the Project task and description of the services completed consistent
with Section 3(B) of the Agreement. Commission, in its sole discretion, shall evaluate
whether or not the services performed by Provider justify the progress payments made
pursuant to Section 4(B) of this Agreement. Upon receipt and review of the final report
pursuant to Section 3(D) of the Agreement, and in the event the Commission determines
services provided do not justify amounts paid to Provider, Commission shall withhold
payment, and any excess amounts previously paid to Provider shall be returned to
Commission. In the event of termination of this Agreement as provided in Section 6,
Provider will not be entitled to any amounts remaining to be paid, and will return to
Commission any amounts previously paid for which services have not been provided
pursuant to terms of this Agreement.
SECTION 5. Term.
The Term of this Agreement shall commence on the Effective 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 terms and for such
period as the Parties shall agree in writing. Notwithstanding the foregoing, this
Agreement is subject to annual appropriations of the Commission..
SECTION 6. Termination and Default.
A. Termination. This Agreement shall expire on the earlier of: (i) the
Expiration Date without notice to either party; or (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 ").
Gel
Upon termination of this Agreement for any reason, copies of 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 the Commission or the Provider relating to this
Agreement or the Job Training Services shall be and remain the property of the
Commission and be delivered to the Commission upon request in a usable form 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 Job Training Services under
this Agreement.
B. Default. 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 misrepresentation materially related to the provision of the Job Training 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 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 have been paid.
E. Continuation of Funding 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
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continuation of performance shall be final and conclusive.
SECTION 7. Confidentiality, Conflict of Interest, and Disclosure.
A. Confidential Information. The Provider acknowledges that information
which the Commission regards as confidential or proprietary in nature (the
"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 from the Provider. A
violation of this SECTION 7 shall be deemed to be a material breach of this Agreement.
B. Covenants 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 Commission, 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, 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 each of its directors, officers, 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, will execute and file with the
Commission and any other appropriate bodies a Uniform Conflict of Interest Disclosure
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Statement, the form of which is attached hereto and incorporated herein as Exhibit "D ".
SECTION 8. Relationship.
A. Independent Contractor. The Provider, and each of its directors, officers,
employees and agents, 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
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 Commission or the staff of the Commission
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 Commission, however, may file informational returns with the United
States Internal Revenue Service or similar state agency regarding payments 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
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 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 be construed and interpreted according to the laws of the
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State of Indiana and any suit based upon the rights and obligations contained in this
Agreement shall be filed in the courts of St. Joseph County, 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
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 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.
Commission: Don Inks
Director of Economic Development
12th Floor, County -City Building
South Bend, Indiana 46601
With a Copy to: City Attorney
14th Floor, County-City Building
South Bend, Indiana 46601
Provider Project Impact - South Bend, Inc.
55501 Moss Road
South Bend, Indiana 46628
With a Copy to:
SECTION 16. Counterparts.
This Agreement may be executed in counterparts, all of which shall be deemed
originals.
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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 Commission represent and certify that they are the duly authorized officers of the
Commission 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.
SECTION 18. Miscellaneous.
[RESERVED].
(remainder ofpage intentionally left blank)
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IN WITNESS WHEREOF, the Parties hereto have caused this Agreement to be
executed as of the day and year first above written.
PROJECT IMPACT - SOUTH BEND, CITY OF SOUTH BEND,
INC. DEPARTMENT OF REDEVELOPMENT
Printed Name aml 7'a e rime ame and Title
Gi bney \proj ectlmpact \sery i cesAG R3. doc
010709
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South Bend Redevelopment Commission
ATTEST:
Signature
rinte ame an it e
South Bend Redevelopment Commission
EXHIBIT A
AEDA/UEZ MAP
EXHIBIT `B"
Job Training Services
The PowerPoint presentation is not sufficient to define
the scope of services for this agreement.
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EXHIBIT "C"
Project Budget
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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 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):
1 (We) being the
(Title of Off cer or Name of Governing Body)
and having the power to appoint
(Name of Governmental 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 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
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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 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.
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EXHIBIT "D"
(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 unemancipated 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:
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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):