03-325 Resolution No. 03-325
RESOLUTION
AUTHORIZING EXECUTION OF A HIGHWAY SAFETY PROJECT AGREEMENT WITH
THE ILLINOIS DEPARTMENT OF TRANSPORTATION
(Occupant Protection Enforcement Zone Program)
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN,
ILLINOIS, that David M. Dorgan, City Manager, be and is hereby
authorized and directed to execute a Highway Safety Project
Agreement on behalf of the City of Elgin with the Illinois
Department of Transportation for the Occupant Protection
Enforcement Zone Program, a copy of which is attached hereto and
made a part hereof by reference .
s/ Ed Schock
Ed Schock, Mayor
Presented: November 19, 2003
Adopted: November 19, 2003
Vote : Yeas : 6 Nays : 0
Attest :
s/ Dolonna Mecum
Dolonna Mecum, City Clerk
, 4. ,
V. Illinois Department Highway Safety
of Transportation Project Agreement
Division of Traffic Safety
3215 Executive Park Drive/P.O. Box 19245
Springfield, Illinois 62794-9245
1. Applicant Elgin Police Department For Office Use Only
Agency: Project Number: OP4-1720-156
Address: 151 Douglas Avenue Project Occupant Protection Enforcement Zone
Elgin, IL 60128 Title: Program
Yof
PSP/Task: 19/06 Fund
Fundinin
g 1
TIN/FEIN: 36-6005862 PSP Title: Section 405 Funds
2. Governmental Elgin Police Department 3. Starting Date: November 20, 2003
Unit: 4. Expiration Date: September 30, 2004
Address: 151 Douglas Avneue 5A-E. Project Description (attached)
Elgin, IL 60120
TIN/FEIN: 36-6005862
5F. Project Description Summary:
This project provides funds for the agency to hireback officers during Click It or Ticket mobilization period. During this
period certified officers working overtime will conduct enforcement zones daily in support of Illinois occupant protection
laws.
Proposed
5G. Project Budget Federal Local Total
Personal Services $7,194 $0 $7,194
Fringe Benefits 0 0 0
Social Security 0 0 0
Travel 0 0 0
Contractual Services 0 0 0
Printing 0 0 0
Commodities 0 0 0
Equipment 0 0 0
Oper/Auto/Equipment 0 0 0
Totals $7,194 $0 $7,194
6. A Acceptance-It is understood and agreed by the undersigned that this project is subject to the attached agreement conditions.
B "Obligation of the state shall cease immediately,without penalty or further payment being required if,in any fiscal year,the Illinois General Assembly or federal funding source fails to appropriate
or otherwise make available funds for this contract."
7A. Project Director: 7B. Authorizing Official:
Name: Thomas Olson Name: DAVID DO R G A N
Title: Sergeant Title: - G I T Y. MANAGER
Address: 151 Douglas Avenue, Elgin, IL 60128 Address: • 150 DOUGLAS ELGIN IL - 601 Lt:
Phone: 847-289-26 11 Fax: 289-2950 Phone: 847 1 5591 . Fax:84 7 931 50 1 u
Signature: S �✓ihe) Y-0--- Signature: AO
Date: 1- is-o3 Date: / Z a 3
7C. Division of Traffic Safety Approval and Authorization to Expend Funds:
Tom DiLello, Director,Division of Traffic Safety
Name Title Signature Date
TS 1980(Rev. 9/95)
- TIllinois Department Highway Safety Project
of Transportation Single Audit Act Certification
Division of Traffic Safety
3215 Executive Park Drive/P.O. Box 19245
Springfield, Illinois 62794-9245
The Illinois Department of Transportation's Division of Traffic Safety (DTS) is the agency responsible for administering Illinois'
federal highway safety funds. The Single Audit Act of 1984 (P.L. 98-502) and the Amendments of 1996 (P.L. 104-156)
requires state and local governments that receive $300,000 or more in federal financial assistance a year to have an audit
made in accordance with the Office of Management and Budget (OMB) Circular A-133. One copy of the completed audit
report must be provided to the Division of Traffic Safety and one copy sent to:
Bureau of Census
Data Preparation Division
1201 East 10th Street
Jefferson, Indiana 47132
Attn: Single Audit Clearinghouse
Audit reports must be submitted to the Division of Traffic Safety within "30 days after completion of the audit, but no later than
one year after the end of the audit period."
Federal funds are provided for this project by the U.S. Department of Transportation. The program is listed in the Catalog of
Federal Domestic Assistance (CFDA) as State &Community Highway Safety 20.600.
In order for the Division of Traffic Safety to fulfill its responsibility, this form must be completed, signed and returned to verify
your agency's intent to comply with the Single Audit Act requirements.
Applicant Agency Elgin Police Department Project Number OP4-1720-156
Project Title Occupant Protection Fnforcement 7one Program Project Period 11/70/03- 9/30/04
Total Cost $7,194 Federal $7,194 Local $0
To Be Completed by Applicant Agency:
Period Audit to Cover: to
Date Audit to Commence: Audit Conducted by:
Telephone:
Certification:
We certify the above information to be correct and that we will comply with the Single Audit Act as detailed in OMB circular
A-133. /�
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Signature of Authorizingficial Printed Name Telephone 014)
Date
P
�(1\ a-��->r� SiSIHOM-t�S IC��S�J 8L '��T1_ tot ‘1-I$ ;�.
i ature of P oject Direct or Printed Name Telephone Date
Rt
c Bf4++G -§'41 - 931-S42tt 11/2443
Signature of Fiscal Officer Printed Name Telephone Date
TS'2225(Rev.8/98)
Illinois Department Title VI Compliance Certification
of Transportation
Division of Traffic Safety
3215 Executive Park Drive/P.O.Box 19245
Springfield, Illinois 62794-9245
Public Law 88-352 -July 2, 1964 Title VI-Nondiscrimination in Federally Assisted Programs
Section 601 - No persons in the United States shall, on the grounds of race, color or national origin, be excluded from
participating in, be denied the benefits of or be subjected to discrimination under any program or activity receiving federal
financial assistance.
A. Program/Project Occupant Protection Enforcement Zone Program
B. Project Service Area Elgin Police Department
C. Estimated Program/Project Commencement November 20, 2003
Estimated Program/Project Completion September 30, 2004
Please complete D, E and F:
D. Will contras ors, subcontractors, suppliers or vendors be utilized in the project?
❑ Yes No
E. Total number of persons to be utilized for the project by race and sex: (Include those individuals who are identified
within the Personal Services line item-federal and local.)
Race Male Female
Caucasian 9
African American
Hispanic 'L
Asian American
American Indian
Total , I f
F. I certify that administration of this program/project will be in accordance with Title VI of the Civil Rights Act of 1964.
Applicant Agency Elgin Police Department
Project Director . Sgt . Thomas Olson
Telephone Number 847-289-2661
Signature Sit O(\\ 00..k,---- Date
V TS 2223(Rev. 9/95)
. • .. .
•
Illinois Department Local Projects
of Transportation Highway Safety Project
Division of Traffic Safety Agreement Certifications
3215 Executive Park Drive/P.O. Box 19245
Springfield, Illinois 62794-9245
Bribery
The undersigned agency certifies that it has not been convicted of bribery or attempting to bribe an officer or employee of
the State of Illinois, nor has the contractor made an admission of guilt of such conduct which is a matter of record, nor has
an official, agent or employee of the vendor been so convicted nor made such admission of bribery. Further, the contractor
is not in violation of Section 10.1 of the Illinois Purchasing Act, nor barred from bidding under Section 33E-3 or 33E-4 of the
Criminal Code of 1961.
Educational Loan Default
The undersigned agency certifies that it is not in default on an education loan as provided in the Educational Loan Default
Act(5 ILCS, 385/0.01 et. seq.).
Document Retention
The undersigned agency certifies that it will comply with the provision requiring that every contract for goods or services
entered into shall provide that the contractor (and subcontractor) maintain certain records and documentation relating to the
grand and/or contract for a minimum of three years after contract completion and final claim (49CFR, Part 18, Sect. 18.42).
Federal Taxpayer Identification Number
For individuals and sole proprietors; list social security number. For other entities, list employer identification number.
Federal Employer Identification Number(FEINS) must not be used for sole proprietorships.
Under penalties of perjury, the undersigned certifies that 36-6005862
is its correct Federal Taxpayer Identification Number. The undersigned is doing business as (please check one):
❑ Individual ❑ Real Estate Agent ❑ Sole Proprietorship _
Government Entity ❑ Partnership ❑ Tax Exempt Organization (IRC-501(a) only)
❑ Medical and Health Care ❑ Not-for-profit Corp. ❑ Corporation
❑ Services Provided Corp. ❑ Trust or Estate
If you fail to furnish your correct taxpayer identification number to this agency, you are subject to an IRS penalty of 550 for •
each such failure unless such failure is due to reasonable cause and not to willful neglect. Willfully falsifying certifica-
tions or affirmations may subject you to criminal penalties, fines and/or imprisonment.
Conflict of Interest
The undersigned agency agrees to comply with the provisions of the Illinois Purchasing Act prohibiting conflict of interest
(30 ILCS, 505/11.1-11.5). All the terms, conditions and provisions of those sections apply to this contract and are made a
part of this contract the same as though they were incorporated and included herein.
TS 2224 (Rev 12/01)
Drug-Free Workplace
A
Drug Free Workplace Act-Certification for Drug Free Workplace:
1. As required by the Drug Free Workplace Act(30 ILCS, 580/1 et. seq.), no grantee or contractor with 25 or more
employees shall receive a grant or be considered for the purpose of being awarded a contract for the procurement of
any property or services from the State, unless the grantee or contractor has certified to the State that the grantee or
contractor will provide a drug-free workplace.
2. Submission of this certification is a prerequisite for making or entering into this transaction imposed by the Drug Free
Workplace Act. False certification or violation of the certification may result in sanctions including, but not limited to,
suspension of contract or grant payments, termination of the contract or grant and debarment of contracting or grant
opportunities with the State for at least one (1)year but not more than five (5)years.
Certification: By signing this Agreement Certifications form, the undersigned affirms that he or she is authorized to execute
this certification and that he or she has read and complied with each of the above certifications, that the required responses
are true and correct and that the signature below constitutes an endorsement and execution of each certification and
assurance as though each certification was individually signed.
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Appli nt Agency Aut ori d Si ature
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