HomeMy WebLinkAbout2012 Summer Food Service ProgramContract Renewal Agreement Certification Form 2012-2013
The Contract Renewal Agreement Certification Form must be completed and signed by the school food
authority's (SFA's) authorized representative. A copy of this form must be submitted by the SFA along with
copies of all applicable, required contract renewal documents listed in Section C below.
A. School Food Authority Information
Agreement Number (RCDT Code) 05016510P00
Schoc! Food Authority City of Evanston
Contractor Name Open Kitchens, Inc.
B. General Contract Information
Contract Type: F FSMC V Vended F FSMC—Vended ' Other
Programs: ❑ Lunch ❑ Breakfast ❑ Special Milk ❑ Afterschool Snack
6 Summer Meals ❑ Child and Adult Care Food Program
List all non -material contract revisions/amendments on additional paper, if applicable.
C. Required Documentation
Submit copies of the following documents.
• Contract Renewal Agreement Certification Form 2012-2013, signed by the SFA's authorized
representative;
• Contract Renewal Agreement, signed by both parties;
• Food -Based Meal Pattern Contract Amendment, signed by both parties;
• Certification forms, as applicable, signed annually by the contractor
o If the annual contract is $25,000 or more —Signed copy of the Certification Regarding
Debarment, Suspension, Ineligibility and Voluntary Exclusion —Lower Tier Covered
Transactions,
o If the annual contract is over $100,000—Signed copy of the Certificate Regarding Lobbying —
Contracts, Grants, Loans, and Cooperative Agreements,
o If the annual contract is over $100,000 and any funds other than Federal appropriated funds
have been used for lobbying —Signed copy of the Disclosure of Lobbying Activities;
• Written financial analysis, provided by the contractor, justifying all rate/fee increases/decreases;
• 21-day cycle menus (current and new) and an item -by -item food cost comparison for all menu items, as
required on Attachment 1 of the contract renewal reminder letter;
• Packaging fee cost analysis (pre -packaged vended meals only); and
• Any other amendments for allowable contract changes accompanied by written justification for the
amendment.
D. Contract Renewal Information
The written financial analysis, 21-day cycle menus, and item -by item food cost comparison to substantiate all
rate and/or fee adjustments were provided to the SFA by the contractor prior to the execution of the Contract
Renewal Agreement and the Food -Based Meal Pattern Contract Amendment. ❑ Yes ❑ No
Page 1 of 2
Renewal Terms —Meal Rates/Fees (refer to the contract for renewal terms; check the appropriate box):
V CPI —Food Away From Home (Dec) 2.9%
o CPI —All (Dec) 3.0%
❑ CPI —Food (Dec) 4.7%
❑ Other (specify)
Current Menu Planning Approach(es):
❑ Enhanced Food -Based
d Traditional Food -Based
❑ Nutrient -Based (NuMenus)
E. Certification Statement
Under the provisions of the United States Department of Agriculture, Food and Nutrition Service, I certify as a
sponsor in the Child Nutrition Programs all information contained in the executed Contract Renewal Agreement
and accompanying contract renewal documents is true and accurate.
I understand the nonprofit school food service program account cannot be used to pay for unallowable contract
costs. As authorized representative for the school food authority noted above, I will ensure operation of the
nonprofit school food service program, including use of nonprofit school food service program account funds, is
in compliance with the rules and regulations of the Illinois State Board of Education and the United States
Department of Agriculture regarding Child Nutrition Programs.
I understand revisions cannot be made to the executed Invitation for Bid and Contract without first submitting
proposed revisions to the Illinois State Board of Education for review and receiving written notification the
proposed revisions are allowable within the regulatory guidelines. Furthermore, I understand additional
documents and/or agreements, including those developed by the contractor, cannot become part of the
executed contract.
I understand all contract information provided to the Illinois State Board of Education is being given in
connection with the receipt of federal funds and deliberate misrepresentation may subject me to prosecution
under applicable state and federal criminal statutes. Further, I understand such misrepresentation could result
in the loss of federal and state funding received by the school food authority for School -Based Child Nutrition
Programs.
AA), A"_4�
Authori d'Re--resentative Si nature
Mail, fax, or email to:
Approved as to form:
W. Grant Farrar
Corporation Counsel
C�Ty h%Afdir, 6 -14-�z-
Title Date
Ms. Denise LeFever
Nutrition Programs
Illinois State Board of Education
100 North First Street W270
Springfield, IL 62777-0001
Fax: 217-524-6124
Email: dlefever@isbe.net
Please submit documents only once. For example, do not fax and mail. Only one copy of each set of
documents is necessary.
Page 2 of 2
ILLINOIS STATE BOARD OF EDUCATION
100 North First Street
Springfield, IL62777-0001
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION
LOWER TIER COVERED TRANSACTIONS
This certification is required by the regulations implementing Executive Orders 12549 and 12689, Debarment and Suspension. 2 CFR
417 Subpart C Responsibilities of Participants Regarding Transactions. The regulations were published in the May 25, 2010 Federal
Registor (pages 29183-29189). Copies of the regulations may be obtained by contacting the Illinois State Board of Education
BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS BELOW.
CERTIFICATION
The prospective lower tier participant certifies, by submission of this Certification, that:
(1) Neither it nor 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;
(2) It will provide immediate written notice to whom this Certification is submitted if at any time the prospective lower tier participant
learns its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
(3) It shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended dedarod inehgaaa,
or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency wan wn.rr,
this transaction originated,
(4) It will include the clause titled Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Fxclusion—Lower Tier
Covered Transactions, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered
transactions;
(5) The certifications herein are a material representation of fact upon which reliance was placed when this transaction was entered
into; and
(6) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prnspectavo
participant shall attach an explanation to this Certification
e 1 rit, iV#w 6 -M J
Organization Name
PR/Award Number or Project Name
/ kI.Ly 73a 7i5OC/piJl G`v
Vj
Name ofAuf rued Representative Title
Original natur Authorized Representative Date
Instructions for Certification
1. By signing and submitting this Certification, the prospective lower tier participant is providing the certifications set out herein
2. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other
remedies available to the Federal government, the department or agency with which this transaction originated may pursue ail
available remedies, including suspension and/or debarment.
3. Except for transactions authorized under paragraph 3 above, if a participant in a covered transaction knowingly enters into a
lower tier covered transaction with a p>�on who is suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the Federal government, the department or agency with which this
transaction originated may pursue all available remedies, including suspension and/or debarment.
4, The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary
covered transaction, principal, proposal, and voluntarily excluded, as used herein, have the meanings set out in the Definitions
and Coverage sections of the rules implementing Executive Order 12549 and Executive Order 12689 You may contact the oerson
,o which this Certification is submitted for assistance in obtaining a copy of those regulations.
5. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered a ansactron
that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows the certification
is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each
participant may, but is not required to, check the "GSA Excluded Parties List System' at http.//epis.arnet gov/.
6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good
faith the certification required herein. The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings
ISBE 85-34 (3/12)
ILLINOIS STATE BOARD OF EDUCATION
100 North First Street
Springfield, IL 62777-0001
CERTIFICATE REGARDING LOBBYING
The undersigned certifies, to the best of his or her knowledge and belief, that.
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing
or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Cong�s�
or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee
of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement the undersigned
shall complete and submit ISBE 85-37, "Disclosure of Lobbying Activities," in accordance with its instructions
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards
at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all
subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into
Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U S
Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
Organization Name
PR/Award Number or Project Name
Name of Authorized Representative Title
ID , X 64�
Original Stature ofAuthorized Representative Date
Approved as to form:
W, Grant Farrar
Corporation Counsel
ISSE 85-36 (3112)
Date of Original Contract
Ye r of R newal ircle)
12� 3 4
Contract Renewal Agreement for
Food Management Services
Nonprofit Food Service Program
This document contains the rates and fees for the furnishing of food service anagement for nonprofit food
service programs for the period beginning ivy 1 , 2012, and ending S 3/ , 2013. The terms and
conditions of the original contract are applicable to the contract renewal. Upon acceptance, this document
shall constitute the contract renewal between the Food Service Management Company (FSMC) and the
School Food Authority.
The FSMC shall not plead misunderstanding or deception because of the character, location, or other
conditions pertaining to the contract.
PER MEAL PRICES MUST BE QUOTED AS IF NO USDA
COMMODITIES WILL BE RECEIVED
1. Reimbursable Breakfasts
2. Reimbursable Breakfasts -Meal Rate Fee
3. Reimbursable Lunches`
4. Reimbursable Lunches -Meal Rate Fee
5. Management Fee per School Meal
(Breakfasts and Lunches)
6. A la Carte Equivalents Fee*
7. A la Carte Management Fee
8. After -School Snacks
9. Special Milk
10. Other (specify)
2011-2012
Rate
1.
2.XXXXXXX
1,02, 319 7
4.XXXXXXX
5.
2012-2013
Rate**
1.
2.
3.
4.
5.
Percentage
Increase***
1.
2.XXXXXXX
3. 2.7
4.XXXXXXX
5.
6.
6.
6.
7.
7.
7.
8.
8.
8.
9.
9.
9.
10.
10.
10.
*Rates must be the same.
**Rates must not be rounded up. Do not exceed four decimal places.
***Perce'e increase /must not exceed the allowable increase established in the original contract.
F( od Service Management Company
Stre Address
//.rIK,
City State ip Code
By submission of this proposed renewal agreement, the FSMC certifies that, in the event they receive a
renewal award under his
citation, the FSMC shall operate in accordance with all applicable current
progra regulations. hi Bement shall not exceed one year.
/ Authorized Signature Title Date
Acceptance of Contract Renewal Aareement
chool Fo d !thor*tyAuthorize Siture
��v`tiS l c-> P70
Agreement Number
d /T y !/ h)4-/, C /2_
Title Date
This form may not be revised without permission from the Illinois State Board of Education Nutrition Programs Division.
Updated 1/18112
3/22/12
City of Evanston
it
Open Kitchens, Inc.
THIS AMENDMENT to an Invitation for Bid and Contract, is entered into by and between
City of Evanston ("SFA") and Open Kitchens, Inc. ("Contractor") (collectively, the "Parties"
and each, a "Party").
WITNESSETH:
WHEREAS, the SFA and Contractor entered into a certain Invitation for Bid and Contract
dated June 1, 2012, (the Invitation for Bid and Contract, as amended by any renewals prior
to the effective date of this Amendment, are hereinafter referred to as the "Contract"),
whereby the Contractor manages and operates the SFA's food service program in [City],
Illinois;
WHEREAS, the Parties are required to amend the aforesaid Contract in order to comply
with the federal regulatory requirements regarding the Food -Based Meal Pattern
requirements and nutrition standards outlined in the Code of Federal Regulations, 7 C.F.R.
Parts 210 and 220; and
WHEREAS, both Parties wish to amend the Contract,
NOW, THEREFORE, in consideration of the promises herein contained and for other good
and valuable consideration, the Parties hereto agree the following language shall be
incorporated into the applicable sections of the Contract and shall supersede all related
existing terms.
FOOD SERVICE MANAGEMENT COMPANY/VENDOR RESPONSIBILITIES
Beginning with the 2012-2013 Contract Term and for all remaining Contract Terms,
if applicable, the Contractor shall ensure all reimbursable meals meet the Food -
Based Meal Pattern and nutrition standards as required by the USDA per
Attachment 1. Reimbursable meals must adhere to all calorie ranges and meet the
nutrition standards for the National School Lunch, School Breakfast, and/or summer
meals programs, as applicable.
FOOD SPECIFICATIONS
As required by the USDA Nutrition Standards in the National School Lunch and
School Breakfast Programs, Implementation Timeline for Final Rule —Jan 2012
and/or other subsequent guidance issued by the USDA:
Page 1 of 5
3/22112
o All breads, bread alternates, and grains must adhere to the whole grain -rich
requirements, as outlined.
o All food items must adhere to the sodium target levels in Contract Terms
subsequent to the 2012-2013 Contract Term, if applicable.
o Nutrition label or manufacturer specifications must indicate zero grams of
trans fat per serving for all foods, as outlined.
o Fluid milk must be low -fat (1 percent milk fat or less, unflavored only) or fat -
free (unflavored or flavored). Two choices must be offered daily as required
by the SFA.
TERMS AND TERMINATION
® Beginning with the 2012-2013 Contract Term, a flat meal rate fee shall be
implemented in the amount of $2.3869 per reimbursable lunch. The meal rate fee
has been justified by a detailed written financial analysis and item -by -item food cost
comparison of a current 21-day cycle menu as compared to a 21-day cycle menu
based on the new Food -Based Meal Pattern requirements, provided to the SFA by
the Contractor. In Contract Terms subsequent to the 2012-2013 Contract Term, if
applicable, the meal rate fee shall remain constant and shall not be subject to any of
the meal rate and fee adjustment terms contained in the Contract.
Implementation of the meal rate fee is conditional upon the Contractor providing
reimbursable meals that meet the Food -Based Meal Pattern and nutrition standards
as required by the USDA. In the event the reimbursable meals do not meet the
Food -Based Meal Pattern and nutrition standards, as determined by the Illinois State
Board of Education, the USDA, or any other governmental or government -appointed
entity with monitoring authority, the Contractor shall reimburse the SFA in the
amount equal to the sum of all meal rate fees paid to the Contractor from the date of
implementation of the meal rate fee through the date of such determination. The
meal rate fee may be subsequently reinstated at the discretion of the SFA at such
time as the reimbursable meals are determined to be in compliance with the Food -
Based Meal Pattern and nutrition standards. The meal rate fee shall not be
retroactive at any time.
This Amendment is effective on June 1, 2012 and all terms contained herein shall be
binding for the Term of the Contract, including all subsequent renewals, if applicable, unless
amended. Except as otherwise specifically set forth in this Amendment, all other terms and
provisions of the Contract shall remain the same and continue in full force and effect. The
Parties agree that upon the effective date of this Amendment, it shall become a binding and
integral part of the Contract.
Each Party represents and warrants to the other Party that this Amendment has been duly
authorized, executed and delivered by and on behalf of each such Party, and constitutes
the legal, valid and binding agreement of said Party.
Page 2 of 5
3/22/12
Each Party represents and warrants to the other Party that this Amendment has been duly
authorized, executed and delivered by and on behalf of each such Party, and constitutes
the legal, valid and binding agreement of said Party.
IN WITNESS WHEREOF, the Parties have entered into this Amendment as of the day and
year set forth below.
[SCHOOL FOOD AUTHORITY NAME]
ApProved as to forma
� By:
W Grant Farrar Date
Corporation Counsel Name (printed):
Title: (,( t-Y % %) ( 6E'C-
[CONTRACC/TOR NAME]
By: o-1.41, / F mzV-
Name (printed): / / ��C /u/ f jp u✓ 2
Title: n o
Page 3 of 5
Date
Attachment i
Nutrition Standards in the National School Lunch and School Breakfast Programs —Jan. 2012
Breakfast Meal Pattern
Lunch Meal
Pattern
Grades K-5•
I Grades 6-8° 1
Grades 9.128
Grades K-5 Grades 6-8
Grades 9-12
Meal Pattern
Amount of Food' Per Week (Minimum
Per Dau)
i
Fruits (cups)"'
5(1)
5(1)0
1 5(1)`
2'/2('/2)
2'h('h)
5(1) 1
Vegetables (cup sy'°
0
0
0
3% ('/n)
3'/4 ('/�)
5 (1)
Dark green
1 0
0
0
/z
%:
Red/Orange t
0
0
0
'/4
%
194
tieans/Peas'
0
0
0
/z
%,
1/2(Legumes)
Starch
0
0
0
%a
!4
' -
ty`
Other s
0
0
0
/
1/2
Additional Veg to
0
0
0
1
1
1
Reach Total"
Grains (oz eq)'
7-10(1)'
8-10(1)'
9-10(1))
8-9(1)
8-100)
10-12(2)
Alternates
O k
O k
O it
8-10(l)
9-10(l)
10-12 (2)
oz etq)Meat
Fluid milk (cups)'
5(1)
5(1)
1 5(I)
5(1) 1
5(1)
5(1) 1
Other Specifications: Daily Amount Based on the Average for a 5-Day Week
Min -max calories 350-500 400-550 450-600 550-650 600-700 750-850
(kcsj)m.n.o I
Saturated fat < 10 < 10 < 10 < 10 < 10 < 10
(% of total calories)
Sodium (mg)", P < 430 < 470 < 500 < 640 < 710 _ 740
Trans fat"'° Nutrition label or manufacturer specifications most indicate zero grams of trans fat per serving.
• 'In the SBP, the above age -grade groups are required beginning .July I, 2013 (SY 2013-14) In SY 2012-2013 only, schooh men contitu c
to use the meat pattern for grades K-12 (see § 220.23).
• 'Food items included in each food group and subgroup and amount equivalents. Minimum creditable serving is 'i cup.
• `One quarter -cup of dried fruit counts as '/z cup of fruit; 1 cup of leafy greens counts as '/s cup of vegetables. No more than halt ol'the
fruit or vegetable offerings may be in the form of juice. Al l juice must be 100% ful l-strength.
• 'For breakfast, vegetables may be substituted for fruits, but the first two cups per week of any such substitution must be from the
dark green, red/orange, beans and peas (legumes) or "Other vegetables" s u b g r o u p s as defined in §210 10(c)(2)( i ❑).
• 'The fruit quantity requirement for the SBP (5 cups/week and a minimum of I cup/day) is effective Inly I. 2014 (SY 2014-2015)
• 'Larger amounts of these vegetables may be served.
• eThis category consists of"Other vegetables" as defined in §210. 10(c)(2)(iii)(G) For the purposes of the NSLP. "Other �cgcwhk; �eyuuemmn
may be met with any additional amounts from the dark green, red/orange, and beans/peas (legumes) vegetable suharoaps as defined in
§210.10(c)(2)(iii).
• "Any vegetable subgroup may be offered to meet the total weekly vegetable requirement.
• 'At least half of the grains offered must be whole grain -rich in the NSLP beginning July I, 2012 (SY 2012-2013), and ill the SBP beginning
July 1, 2013 (SY 2013-2014). All grains must be whole grain -rich in both the NSLP and the SBP beginning Iuk 1. 2014 ( SY 2014-1,1
• Jln the SBP, the grain ranges must be offered beginning July 1, 2013 (SY 2013-2014)
• 'There is no separate meat/meat alternate component in the SBP. Beginning July I. 2013 (SY 2013-2014). schoo6 nml\
substitute 1 oz, eq. of meat/mcat alternate for 1 oz. eq. of grains after the minimum lady grams requimnem is met
• 'Fluid milk must be low -fat (I percent milk fat or less, unflavored) or fat -free (unflavored or flavored)
•"The average daily amount of calories for a 5-day school week must be within the range (at least the minimum and no more than tha
maximum values).
• "Discretionary sources of calories (solid fats and added sugars) may be added to the meal pattern if within the specifications for calories.
saturated fat, trans fat, and sodium. Foods of minimal nutritional value and fluid milk with fat content greater than I pet cem milk hit arc
not allowed.
• 'In the SBP, calories and trans fat specifications take effect beginning July 1, 2013 (SY 2013-2014).
• PFinal sodium specifications are to be reached by SY 2022-2023 or .July 1, 2022 Intermediate sodium gpeci ficalions are Qsulhl hed f l
2014-2015 and 2017-2018. See required intermediate specifications in § 210.100)(3) for lunches and § 220 8(00) 'or hreak hni
Food and Nutrition Service, United States Department of Agriculture
Page 4 of 5
Attachment 1
Implementation Timeline for Final Rule —Jan. 2012
Implementation (School Year) for NSLP (L) and SBP (B)
New Requirements
12014/15 12022/23
2012/13
2013114 2015116 2016/17 2017/18 '
Fruits Component
' e Offer fruit daily
L
• Fruit quantity increase to 5 cups/week
B
(minimum I cup/day)
i
Vegetables Component
• Offer vegetables subgroups weekly
L
Grains Component
• Half of grains must be whole grain -rich
L
B
• All grains must be whole -grain rich
L, B
• Offer weekly grains ranges
L
B
Meats/Meat Alternates Component
j
(• Offer weekly meats/meat alternates ranges
L
(daily min.)
Milk Component
• Offer only fat -free (unflavored or flavored)
L B
and low -fat (unflavored) milk
Dietary Specifications (to be met on average over a week)
• Calorie ranges
L
B
• Saturated fat limit (no change)
L, B
i
• Sodium Targets
o Target 1
L. B .
o Target
I IS
o Final target
I_I;
' Zero grams of trans fat per portion
L
B
Menu Planning
l
• A single FBMP approach
L
B
Age -Grade Groups
• Establish age/grade groups: K-S, 6-8, 9-12
I.
B ( j
Offer vs. Serve
• Reimbursable meals must contain a fruit or
I
( B
vegetable (1/2 cup minimum)
Monitoring
• 3-year adm. review cycle
L, B J
• Conduct weighted nutrient analysis on I
L
B
I week of menus I I
Food and Nutrition Service, United States Department of Agriculture
Page 5 of 5
ILLINOIS STATE BOARD OF EDUCATION
100 North First Street
Springfield, IL 62777-0001 I
DISCLOSURE OF LOBBYING ACTIVITIES 11
Directions: Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352. (See reverse forpublic burden sc sure.)
1. TYPE OF FEDERALACTION
❑ a. Contract ❑ b. Grant ❑ c. Cooperative agreement ❑ d. Loan ❑ e. Loan guarantee ❑ f. Loan insurance
2. STATUS OF FEDERALACTION
❑ a. Bid/offer/application ❑ b. Initial award ❑ c. Post -award
3. REPORTTYPE
❑ a. Initial filing ❑ In Material change ❑ For material change only: Year Quarter Date of last report
4. NAME AND ADDRESS OF REPORTING ENTITY
❑ Prime ❑ Subawardee, Tier , if known Congressional District, if known
5. IF REPORTING ENTITY IN NO.4 IS SUBAWARDEE, ENTER NAME AND ADDRESS OF PRIME
Congressional District, if known
6. FEDERAL DEPARTMENT/AGENCY
7. FEDERAL PROGRAM NAME/DESCRIPTION
CFDA Number, if applicable
8. FEDERALACTION NUMBER, if known 9. AWARD AMOUNT, if known
10a. NAME AND ADDRESS OF LOBBYING ENTITY b. INDIVIDUALS PERFORMING SERVICES
(If individual, last name, first name, MI) (Including address if different from No. 10a) (last name, first name, MI)
(Attach Continuation Sheei(s) ISBE 85.37A, ifgecessary)
11. AMOUNT OF PAYMENT (check all that apply)
❑ Actual ❑ Planned
12. FORM OF PAYMENT (check all that apply)
❑ a. Cash ❑ b. in -kind; specify: nature
13. TYPE OF PAYMENT (check all that apply)
❑ a. Retainer ❑ b. One-time fee
❑ d. Contingent fee
❑ e. Deferred
value
❑ c. Commission
❑ f. Other, specify
14. Brief description of services performed or to be performed and date(s) of service, including officer(s), employee(s), or members) contacted, for
payment indicated in item 11.
15. ❑ YES ❑ NO CONTINUATION SHEET(S), ISBE 85-37A ATTACHED
16. 1 ORIGINAL SIGNATURE
Information requested through this form is authorized by title 31
U.S.C. Section 1352. This disclosure of lobbying activities is a material PRINT NAME OR TYPE
representation of fact upon which reliance was placed by the tier above
when this transaction was made or entered into. This disclosure is required
pursuant to 31 U.S.C. 1352. This information will be reported to the Congress TITLE
semi-annually and will be available for public inspection. Any person who
fails to file the required disclosure shall be subject to a civil penalty of n,.. TELEPHONE NUMBER DATE
less than $10,000 and not more than $100,000 for each such failure.
SEE 85-37 (3/12)
Bid -Rigging 'Certi#icaton
authorized agent of / %,all
do hereby certify that neither
(Agent)
%
(Contractor)
U (Contractor)
a duly
nor any individual presently affiliated with ? /0 i c _� .•
(Contractor) '
, has been barred from bidding on a public contract as a
result of a violation of either Section 33E-3 (bid -rigging) or Section 33E-4 (bid rotating)
of the Illinois Criminal Code, contained in Chapter 38 of the Illinois Revised Statutes.
X Z6`L�.�
d
Contractor