Supplement No 1 to Agreement - INDOT - Olive Street Reconstruction

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Version 6-8-2017 Non -Collusion The undersigned attests, subject to the penalties for perjury, that he/she is the LPA, or that he/she is the properly authorized representative, agent, member or officer of the LPA, that he/she has not, nor has any other member, employee, representative, agent or officer of the LPA, directly or indirectly, to the best of his/her knowledge, entered into or offered to enter into any combination, collusion or agreement to receive or pay, and that fie/she has not received or paid, any sum of money or other consideration for the execution of this Contract other than that which appears upon the face of this Contract, Furthermore, if the undersigned has knowledge that a state officer, employee, or special state appointee, as those terms are defined in IC §4-2-6-1, has a financial interest in the Conti -act, the Party attests to compliance with the disclosure requirements in IC §4-2-6-10.5. In Witness Whereof, LPA and the State of Indiana have, through duly authorized representatives, entered into this Contract, The PARTIES having read and understand the forgoing terms of this Contract do by their respective signatures dated below hereby agree to the terms thereof. LPA: City of South Bend STATE OF INDIANA Department of Transportation 'J-Recommcnded for approval by: Print or type name and title Robert D. Cates, Director Signature and date Contract Administration Division Print or e name and title Signafiare'and date Print or type name and title J"/ /,,/ " 17"4 SighatMe :nd(,dit LPA DUNS # Date: Executed by: (FOR) Brandye Hendrickson, Commissioner Date: Department of Administration Jessica. Robertson, Commissioner Date: Attest State Budget Agency Auditor or Clerk Treasurer I This instrument prepared by: Ellen Hite November 14,2017 Brian E. Bailey, Director LOM Approved as to, Form and Legality: Gregory F. Zoeller, Attorney General of Indiana Date: R) Page 4 of 4