HomeMy WebLinkAboutYardberry/ENG/21,500/Kirk Property Demolition Yardberry Landscape Excavating Company
Engineering 2012
Appropriation 211 4462865; P.O. #26530
Contract Not To Exceed $21,500.00
AGREEMENT FOR PURCHASE OF GOODS AND SERVICES bo
THIS AGREEMENT FOR PURCHASE OF GOODS AND SERVICES "Agreement is
hereby entered into by and between the City of Carmel, Indiana, acting by and through its Board
of Public Works and Safety "City and Yardberry Landscape Excavating Company, an entity
duly authorized to do business in the State of Indiana "Vendor").
TERMS AND CONDITIONS
1. ACKNOWLEDGMENT, ACCEPTANCE:
Vendor acknowledges that it has read and understands this Agreement, and agrees that its execution of
same constitutes its acceptance of all of the Agreement's terms and conditions.
2. PERFORMANCE:
City agrees to purchase the goods and /or services (the "Goods and Services from Vendor using City
budget appropriation number 211 4462865 funds. Vendor agrees to provide the Goods and Services and to
otherwise perform the requirements of this Agreement by applying at all times the highest technical and
industry standards.
3. PRICE AND PAYMENT TERMS:
3.1 Vendor estimates that the total price for the Goods and Services to be provided to City hereunder
shall be no more than Twenty One Thousand Five Hundred Dollars ($21,500.00) (the "Estimate
Vendor shall submit an invoice to City no more than once every thirty (30) days detailing the Goods
and Services provided to City within such time period. City shall pay Vendor for such Goods and
Services within sixty (60) days after the date of City's receipt of Vendor's invoice detailing same, so
long as and to the extent such Goods and Services are not disputed, are in conformance with the
specifications set forth in Exhibit A, are submitted on an invoice that contains the information
contained on attached Exhibit B, and Vendor has otherwise performed and satisfied all the terms
and conditions of this Agreement.
3.2 Vendor agrees not to provide any Goods and Services to City that would cause the total cost of the
Goods and Services provided by Vendor to City hereunder to exceed the Estimate, unless City has
previously agreed, in writing, to pay an amount in excess thereof.
4. WARRANTY:
Vendor expressly warrants that the Goods and Services covered by this Agreement will conform to
those certain specifications, descriptions and /or quotations regarding same as were provided to
Vendor by City and /or by Vendor to and accepted by City pursuant to or as part of that certain City of
Carmel EngineeringDepartment Bid Proposal Package for "Project #12 -04" received by the City of
Carmel Board of Public Works and Safety on or about April 12, 2012, all of which documents are
incorporated herein by reference, and that the Goods and Services will be delivered in a timely, good
and workmanlike manner and free from defect. Vendor acknowledges that it knows of City's intended
use and expressly warrants that the Goods and Services provided to City pursuant to this Agreement
have been selected by Vendor based upon City's stated use and are fit and sufficient for their
\\Issrappsl \Usa Data Admm\LAW\ hareJ\Prot Svc. Goods Svc, \Engmcvmg\2012 \\'ARDBERRY LANDSCAPE EXCAVATING Good. Sete,,,.doc:5 /1/2012 8 .26 AMI
Yardberry Landscape Excavating Company
Engineering 2012
Appropriation 211- 4462865; P.O. #26530
Contract Not To Exceed $21,500.00
particular purpose.
5. TIME AND PERFORMANCE:
This Agreement shall become effective as of the last date on which a party hereto executes same "Effective
Date and both parties shall thereafter perform their obligations hereunder in a timely manner. Time is of the
essence of this Agreement.
6. DISCLOSURE AND WARNINGS:
If requested by City, Vendor shall promptly furnish to City, in such form and detail as City may direct, a list of
all chemicals, materials, substances and items used in or during the provision of the Goods and Services
provided hereunder, including the quantity, quality and concentration thereof and any other information
relating thereto. At the time of the delivery of the Goods and Services provided hereunder, Vendor agrees to
furnish to City sufficient written warning and notice (including appropriate labels on containers and packing)
of any hazardous material utilized in or that is a part of the Goods and Services.
7. LIENS:
Vendor shall not cause or permit the filing of any lien on any of City's property. In the event any such lien is
filed and Vendor fails to remove such lien within ten (10) days after the filing thereof, by payment or bonding,
City shall have the right to pay such lien or obtain such bond, all at Vendor's sole cost and expense.
8. DEFAULT:
In the event Vendor: (a) repudiates, breaches or defaults under any of the terms or conditions of this
Agreement, including Vendor's warranties; (b) fails to provide the Goods and Services as specified herein;
(c) fails to make progress so as to endanger timely and proper provision of the Goods and Services and does
not correct such failure or breach within five (5) business days (or such shorter period of time as is
commercially reasonable under the circumstances) after receipt of notice from City specifying such failure or
breach; or (d) becomes insolvent, is placed into receivership, makes a general assignment for the benefit of
creditors or dissolves, each such event constituting an event of default hereunder, City shall have the right to
(1) terminate all or any parts of this Agreement, without liability to Vendor; and (2) exercise all other rights
and remedies available to City at law and /or in equity.
9. INSURANCE AND INDEMNIFICATION:
Vendor shall procure and maintain in full force and effect during the term of this Agreement, with an insurer
licensed to do business in the State of Indiana, such insurance as is necessary for the protection of City and
Vendor from all claims for damages under any workers' compensation, occupational disease and /or
unemployment compensation act; for bodily injuries including, but not limited to, personal injury, sickness,
disease or death of or to any of Vendor's agents, officers, employees, contractors and subcontractors; and,
for any injury to or destruction of property, including, but not limited to, any loss of use resulting therefrom.
The coverage amounts shall be no less than those amounts set forth in attached Exhibit C. Vendor shall
cause its insurers to name City as an additional insured on all such insurance policies, shall promptly provide
City, upon request, with copies of all such policies, and shall provide that such insurance policies shall not be
canceled without thirty (30) days prior notice to City. Vendor shall indemnify and hold harmless City from and
against any and all liabilities, claims, demands or expenses (including, but not limited to, reasonable attorney
fees) for injury, death and /or damages to any person or property arising from or in connection with Vendor's
provision of Goods and Services pursuant to or under this Agreement or Vendor's use of City property.
\U,svrappsl \User Data Adtom \LAW\sharodtProl .Svc. Goods Svcs\Enguiivung\2012\} ARDBERR} LANDSCAPE EX6,' VATING Goods Smuts .doc:S /1/21112 R. 26 AM)
Yardberry Landscape Excavating Company
Engineering 2012
Appropriation 211- 4462865; P.O. #26530
Contract Not To Exceed $21,500.00
Vendor further agrees to indemnify, defend and hold harmless City and its officers, officials, agents and
employees from all claims and suits of whatever type, including, but not limited to, all court costs, attorney
fees, and other expenses, caused by any act or omission of Vendor and /or of any of Vendor's agents,
officers, employees, contractors or subcontractors in the performance of this Agreement. These
indemnification obligations shall survive the termination of this Agreement.
10. GOVERNMENT COMPLIANCE:
Vendor agrees to comply with all federal, state and local laws, executive orders, rules, regulations and codes
which may be applicable to Vendor's performance of its obligations under this Agreement, and all relevant
provisions thereof are incorporated herein by this reference. Vendor agrees to indemnify and hold harmless
City from any loss, damage and /or liability resulting from any such violation of such laws, orders, rules,
regulations and codes. This indemnification obligation shall survive the termination of this Agreement.
11. NONDISCRIMINATION:
Vendor represents and warrants that it and all of its officers, employees, agents, contractors and
subcontractors shall comply with all laws of the United States, the State of Indiana and City prohibiting
discrimination against any employee, applicant for employment or other person in the provision of any Goods
and Services provided by this Agreement with respect to their hire, tenure, terms, conditions and privileges of
employment and any other matter related to their employment or subcontracting, because of race, religion,
color, sex, handicap, national origin, ancestry, age, disabled veteran status and /or Vietnam era veteran
status.
12. E- VERIFY
Pursuant to I.C. 22 -5 -1.7 et seq., Company shall enroll in and verify the work eligibility status of all of its
newly -hired employees using the E- Verify program, if it has not already done so as of the date of this
Agreement. Company is further required to execute the attached Affidavit, herein referred to as Exhibit D,
which is an Affidavit affirming that: (i) Company is enrolled and is participating in the E- verify program, and
(ii) Company does not knowingly employ any unauthorized aliens. This Addendum incorporates by reference,
and in its entirety, attached Exhibit D. In support of the Affidavit, Company shall provide the City with
documentation that it has enrolled and is participating in the E- Verify program. This Agreement shall not take
effect until said Affidavit is signed by Company and delivered to the City's authorized representative.
Should Company subcontract for the performance of any work under this Addendum, the Company
shall require any subcontractor(s) to certify by affidavit that: (i) the subcontractor does not knowingly employ
or contract with any unauthorized aliens, and (ii) the subcontractor has enrolled and is participating in the E-
verify program. Company shall maintain a copy of such certification for the duration of the term of any
subcontract. Company shall also deliver a copy of the certification to the City within seven (7) days of the
effective date of the subcontract.
If Company, or any subcontractor of Company, knowingly employs or contracts with any
unauthorized aliens, or retains an employee or contract with a person that the Company or subcontractor
subsequently learns is an unauthorized alien, Company shall terminate the employment of or contract with
the unauthorized alien within thirty (30) days "Cure Period Should the Company or any subcontractor of
Company fail to cure within the Cure Period, the City has the right to terminate this Agreement without
consequence.
The E- Verify requirements of this Agreement will not apply, should the E- Verify program cease to exist.
\VSSVrappsl \U.a Data Admm\LAW\ sham] \Prot Svcs Good. Svc.\Engmcvumg\2012 \}'ARDBERR} LANDSCAPE EX VATING Goo&. Smut.. doc 5 /1/2012 K 26 Ahf]
Yardberry Landscape Excavating Company
Engineering 2012
Appropriation 211 4462865; P.O. #26530
Contract Not To Exceed $21,500.00
13. NO IMPLIED WAIVER:
The failure of either party to require performance by the other of any provision of this Agreement shall not
affect the right of such party to require such performance at any time thereafter, nor shall the waiver by any
party of a breach of any provision of this Agreement constitute a waiver of any succeeding breach of the
same or any other provision hereof.
14. NON- ASSIGNMENT:
Vendor shall not assign or pledge this Agreement, whether as collateral for a loan or otherwise, and shall not
delegate its obligations under this Agreement without City's prior written consent.
15. RELATIONSHIP OF PARTIES:
The relationship of the parties hereto shall be as provided for in this Agreement, and neither Vendor nor any
of its officers, employees, contractors, subcontractors and agents are employees of City. The contract price
set forth herein shall be the full and maximum compensation and monies required of City to be paid to
Vendor under or pursuant to this Agreement.
16. GOVERNING LAW; LAWSUITS:
This Agreement is to be construed in accordance with and governed by the laws of the State of Indiana,
except for its conflict of laws provisions. The parties agree that, in the event a lawsuit is filed hereunder, they
waive their right to a jury trial, agree to file any such lawsuit in an appropriate court in Hamilton County,
Indiana only, and agree that such court is the appropriate venue for and has jurisdiction over same.
17. SEVERABILITY:
If any term of this Agreement is invalid or unenforceable under any statute, regulation, ordinance, executive
order or other rule of law, such term shall be deemed reformed or deleted, but only to the extent necessary to
comply with same, and the remaining provisions of this Agreement shall remain in full force and effect.
18. NOTICE:
Any notice provided for in this Agreement will be sufficient if it is in writing and is delivered by postage
prepaid U.S. certified mail, return receipt requested, to the party to be notified at the address specified
herein:
If to City: City of Carmel AND Douglas C. Haney, City Attorney
One Civic Square Department of Law
Carmel, Indiana 46032 One Civic Square
ATTENTION: Mike McBride Carmel, Indiana 46032
If to Vendor: Yardberry Landscaping Excavating Company
9940 S 1000 W
Anderson, IN 46017
Telephone: 765- 378 -5783
E -Mail:
ATTENTION: Tim Yardberry
Notwithstanding the above, notice of termination under paragraph 19 hereinbelow shall be effective if given
orally, as long as written notice is then provided as set forth hereinabove within five (5) business days from
the date of such oral notice.
\Uss.rapps l \User Data Admm\LA W\shar ,I ProiSvc Gods Svcs \Eng..Yrmg\21I12 \'ARDBERRY LANDSCAPE EXTVATING Goods Sirvittsdoc:5 /1/2012 8 26 AM]
Yardberry Landscape Excavating Company
Engineering 2012
Appropriation 211- 4462865; P.O. #26530
Contract Not To Exceed $21,500.00
19. TERMINATION:
19.1 Notwithstanding anything to the contrary contained in this Agreement, City may, upon notice to
Vendor, immediately terminate this Agreement for cause, in the event of a default hereunder by
Vendor and /or if sufficient funds are not appropriated or encumbered to pay for the Goods and
Services to be provided hereunder. In the event of such termination, Vendor shall be entitled to
receive only payment for the undisputed invoice amount representing conforming Goods and
Services delivered as of the date of termination, except that such payment amount shall not exceed
the Estimate amount in effect at the time of termination, unless the parties have previously agreed in
writing to a greater amount.
19.2 City may terminate this Agreement at any time upon thirty (30) days prior notice to Vendor. In the
event of such termination, Vendor shall be entitled to receive only payment for the undisputed
invoice amount of conforming Goods and Services delivered as of the date of termination, except
that such payment amount shall not exceed the Estimate amount in effect at the time of termination,
unless the parties have previously agreed in writing to a greater amount.
20. REPRESENTATIONS AND WARRANTIES
The parties represent and warrant that they are authorized to enter into this Agreement and that the persons
executing this Agreement have the authority to bind the party which they represent.
21. ADDITIONAL GOODS AND SERVICES
Vendor understands and agrees that City may, from time to time, request Vendor to provide additional goods
and services to City. When City desires additional goods and services from Vendor, the City shall notify
Vendor of such additional goods and services desired, as well as the time frame in which same are to be
provided. Only after City has approved Vendor's time and cost estimate for the provision of such additional
goods and services, has encumbered sufficient monies to pay for same, and has authorized Vendor, in
writing, to provide such additional goods and services, shall such goods and services be provided by Vendor
to City. A copy of the City's authorization documents for the purchase of additional goods and services shall
be numbered and attached hereto in the order in which they are approved by City.
22. TERM
Unless otherwise terminated in accordance with the termination provisions set forth in Paragraph 19
hereinabove, this Agreement shall be in effect from the Effective Date through December 31, 2012 and shall,
on the first day of each January thereafter, automatically renew for a period of one (1) calendar year, unless
otherwise agreed by the parties hereto.
23. HEADINGS
All heading and sections of this Agreement are inserted for convenience only and do not form a part of this
Agreement nor limit, expand or otherwise alter the meaning of any provision hereof.
24. BINDING EFFECT
The parties, and their respective officers, officials, agents, partners, successors, assigns and legal
representatives, are bound to the other with respect to all of the covenants, terms, warranties and obligations
set forth in Agreement.
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Yardberry Landscape Excavating Company
Engineering 2012
Appropriation i 211- 4462865; P.O. #26530
Contract Not To Exceed $21,500.00
25. NO THIRD PARTY BENEFICIARIES
This Agreement gives no rights or benefits to anyone other than City and Vendor.
26, ADVICE OF COUNSEL:
The parties warrant that they have read this Agreement and understand it, have had the opportunity to obtain
legal advice and assistance of counsel throughout the negotiation of this Agreement, and enter into same
freely, voluntarily, and without any duress, undue influence or coercion.
27. ENTIRE AGREEMENT:
This Agreement, together with any exhibits attached hereto or referenced herein, constitutes the entire
agreement between Vendor and City with respect to the subject matter hereof, and supersedes all prior oral
or written representations and agreements regarding same. Notwithstanding any other term or condition set
forth herein, but subject to paragraph 16 hereof, to the extent any term or condition contained in any exhibit
attached to this Agreement or in any document referenced herein conflicts with any term or condition
contained in this Agreement, the term or condition contained in this Agreement shall govern and prevail.
This Agreement may only be modified by written amendment executed by both parties hereto, or their
successors in interest.
IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA Yardberry Landscaping Excavating Company
by and through its Board of Public
Works and Safety
0
By:
By
/James Brainard Pr: i+ii g 00" icer Authorized:'Sibnature
gat::
if Printed Aame
ary °nn Burke, Vent,'
Da z Qu^�✓
i Title
el Lori Wa gin, Member FID/TIN: 3� /8 /7s
Dat cif I f
Last Four of SSN if Sole Proprietor:
ATTEST:
Date: S
Diana Cordray, IAFClerk- Treasurer
Date:
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BID PROPOSAL SUMMARY PAGE
Complete the following information and place as the cover page
to your bid packet. Insert all documents into an envelope with
project name and your company name clearly marked on the
outside. Seal the envelope.
Company: }4,61)eleizy CAS
Project Name: Residential Structure and Site Demolition for the former
Kirk Parcel at 106 Street and the future Illinois Street
connection in Carmel, Indiana.
Date Submitted: y. /gt- z�
Bid Amount:
T NO
rcle j `v (quoter) is claiming "Local Preference"
one
on this project.
CITY OF CARIVIEL
BID PROPOSAL SHEET
Residential Structure and Site Demolition for the former Kirk Parcel at 106
Street and the future Illinois Street connection in Carmel, Indiana.
Item I 1
Item Quantity Unit Unit Cost Total Cost
1 DEMOLITION AND REMOVAL 1 LS $T2 ad
2 STRUCTURAL BACKFILL 1 LS 35" 3 jb O
Total Quote $021-5" 0 2 1.5o d
5 Exhibit f}
State Form 52414
Prescribed by State Board of Accounts Form No. 96 (Revised 2005)
CONTRACTOR'S BID FOR PUBLIC WORK FORM 96
PART I
(To be completed for all bids. Please type or print)
Date: April 18, 2012
1. Governmental Unit (Owner): City of Carmel
2. County Hamilton
3. Bidder (Firm): Yardberry Landscape Excavating Company
Address: 9940 S 1000 W
City /State: Anderson, IN
4. Telephone Number: 765 378 5783
5. Agent of Bidder (if applicable): Tim Yarberry
Pursuant to notices given, the undersigned offers to furnish labor and /or material necessary to complete
the public works project of City of Carmel 1
(Governmental Unit) in accordance with plans and specifications prepared by (�f"K l�oz�'
and dated 5 -n for the sum of
f? 7 5.°
The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in the
notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance with the
notice. Any addendums attached will be specifically referenced at the applicable page.
If additional units of material included in the contract are needed, the cost of units must be the same as
that shown in the original contract if accepted by the governmental unit. If the bid is to be awarded on a unit
basis, the itemization of the units shall be shown on a separate attachment.
The contractor and his subcontractors, if any, shall not discriminate against or intimidate any employee,
or applicant for employment, to be employed in the performance of this contract, with respect to any matter
directly or indirectly related to employment because of race, religion, color, sex, national origin or ancestry.
Breach of this covenant may be regarded as a material breach of the contract.
CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS
(If applicable)
I, the undersigned bidder or agent as a contractor on a public works project, understand my statutory
obligation to use steel products made in the United States (I.C. 5- 16 -8 -2). I hereby certify that I and all
subcontractors employed by me for this project will use U.S. steel products on this project if awarded. I
understand that violations hereunder may result in forfeiture of contractual payments.
ACCEPTANCE
The above bid is accepted this 18th day of April 2012 subject to the
following conditions:
Contracting Authority Members:
Tim Yarberry
PART 11
(For projects of $100,000 or more IC 36- 1 -12 -4)
Governmental Unit: City of Carmel
Bidder (Firm) Yardberry Landscape Excavating Company
Date: 04/18/12
These statements to be submitted under oath by each bidder with and as a part of his bid.
Attach additional pages for each section as needed.
SECTION I EXPERIENCE QUESTIONNAIRE
1. What public works projects has your organization completed for the period of one (1) year prior to the
date of the current bid?
Completion
Contract Amount Class of Work Date Name and Address of Owner
$59,493.00 Demolition 03/12 INDOT
$39,586.00 Demolition 03/12 INDOT
$27,325.00 Drainage 12/11 City of Carmel
$273,205.00 Debris Removal 11/11 INDOT
2. What public works projects are now in process of construction by your organization?
Expected
Contract Amount Class of Work Completion Name and Address of Owner
Date
$519,338.50 Pipe Lining 05/11 INDOT
l
�S
3. Have you ever failed to complete any work awarded to you? No If so, where and why?
4. List references from private firms for which you have performed work.
Dan Swails, Indy Parks Recreation, 317 491 -2883
Tim Farley, H Stewart Kline Associates, 765 742 -0295
Max Abrell, DCRWD, 765 284 -6370
Bob Wiwi, Richmond Sanitary District, 765- 983 -7477
SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE
1. Explain your plan or layout for performing proposed work. (Examples could include a narrative of when
you could begin work, complete the project, number of workers, etc. and any other information which ygu
believe would enable the governmental unit to consider your bid.) ec,m,40/ J/,
2. Please list the names and addresses of all subcontractors (i.e. persons or firms outside your own firm
who have performed part of the work) that you have used on public works projects during the past five (5)
A ars,p1Qpg with a brief de cription of the work done by each subcontractor. C pg,'• UJ t-
3. If you intend to sublet any portion of the work, state the name and address of each subcontractor,
equipment to be used by the subcontractor, and whether you will require a bond. However, if you are
unable to currently provide a listing, please understand a listing must be provided prior to contract
approval. Until the completion of the proposed project, you are under a continuing obligation to
immediately notify the governmental unit in the event that you subsequently determine that you will use a
subcontractor on the proposed project. N b
4. What equipment do you have available to use for the proposed project? Any equipment to be used by
subcontractors may also be r quired to be listed by the governmental unit. ,„2oc /Co^ ,Ga
5. Have you entered into contracts or received offers for all materials which substantiate the prices used in
preparing your proposal? If not, please explain the rationale used which would corroborate the prices
listed.,,
SECTION III CONTRACTOR'S FINANCIAL STATEMENT
Attachment of bidder's financial statement is mandatory. Any bid submitted without said financial
statement as required by statute shall thereby be rendered invalid. The financial statement provided hereunder to
the governing body awarding the contract must be specific enough in detail so that said governing body can make
a proper determination of the bidder's capability for completing the project if awarded.
`f� S
SECTION IV CONTRACTOR'S NON COLLUSION AFFIDAVIT
The undersigned bidder or agent, being duly sworn on oath, says that he 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 include 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.
He 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.
SECTION V OATH AND AFFIRMATION
I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS AND INFORMATION
CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT.
Dated at Anderson, IN this 18th day of April 2012
Yardberry Landscape Excavating Company
(Name of Organization)
By
Owner
(Title of Person Signing)
ACKNOWLEDGEMENT
STATE OF Indiana
M adison ss
COUNTY OF
Before me, a Notary Public, personally appeared the above -named Tim Yarberry and
swore that the statements contained in the foregoing document are true and correct.
Subscribed and sworn to before me this 18th day of April 2012
Notary Public
My Commission Expires: 01/23/2017
County of Residence: Madison
f� INDIANA RETAIL TAX EXEMPT PAGE
C ®Jl II Car) t j' )�s
y CERTIFICATE NO. 003120155 002 0
PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 2 C LC)
35- 60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES, A
CARMEL, INDIANA 46032 -2584 VOUCHER, DELIVERY MEMO, PACKING SLIP
SHIPPING LABELS AND ANY CORRESPONDENC
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997
IRCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
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VENDOR WO t000 SHIP TO \J�C�� 1lS1VlSL-V(VLQ
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:ONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
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PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
PAYMENT
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE PO.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
SHIP REPAID.
C.O.D. SHIPMENTS CANNOT BE ACCEPTED.
PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY
SHIPPING LABELS.
THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
f(lf_I IM
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EXHIBIT D
AFFIDAVIT
being first duly sworn, deposes and says that
he /she is familiar with and has personal knowledge of the facts herein and, if called as a witness in this
matter, could testify as follows:
1. I am over eighteen (18) years of age and am competent to testify to the facts contained
herein.
2. Ivm now and at all times relevant hereinAave been employed by
/AaD 2��� (the "Employer
in the position of CCuiL,E,L.._
3. I am familiar with the employment policies, practices, and procedures of the Employer and
have the authority to act on behalf of the Employer.
4. The Employer is enrolled and participates in the federal E -Verify program. Documentation
of this enrollment and participation is attached and incorporated herein.
5. The Employer does not knowingly employ any unauthorized aliens,
6. To the best of my information and belief, the Employer does not currently employ any
unauthorized aliens.
7. FURTHER AFFIANT SAYETH NOT.
EXECUTED on the day of r" 20 i
Printed: lirri
I certify under the penalties for perjury under the laws of the United States of America and the State of
Indiana that the foregoing factual statements and representations are true and correct.
Printed: