UniversityofIllinoisContractforProfessionalandArtisticServicesUnder$5,000

InstructionstoDepartment
TheContractforProfessionalandArtisticServicesformisforservicesthattotal$4,999.99orlessforthelifeofthecontract/project
andmustbefullysignedbeforeservicescommence.
x Readandcompletethestatementsonthispage(AthroughJ,completetwo(2)originalsofthecontractandobtainthesignaturesof
Contractorandthedepartmentonbothoriginals.Bysigningthecontract,thedepartmentcertifiestothestatementsonthispage.
x Contractorandthedepartmenteachretainone(1)originalofthefullysignedcontract.
x Whenservicesarecomplete,attachaphotocopyofthefullysignedcontractandthispagetoaninvoicevoucherandforwardtothe
OBFS,UniversityPayables.ThisContractisnotappropriatewheretheagreementiswiththirdpartiesforservicesandproductsthat
access University computing resources and/or manipulate, access or store student records, student data, personally identifiable
information, credit card data, confidential data, or high risk data of the University. Additional terms and scrutiny are required to
ensurecompliancewithFERPAandthepresenceofadequatesecuritytoprotectsuchinformation.ContactPurchasingforfurther
instructions.
x ChangestothisformrequireLegalCounselreview
DepartmentStatements:
A. Unobligatedfundsareavailabletopaytheamountofthecontract.
B. TheseservicesareessentialandcouldnotbesatisfactorilyperformedbyUniversityofIllinoisemployees.
C. ServicescannotbesatisfactorilysecuredthroughtheUniversityemploymentprocess.
D. Individuals who perform services for any University department are presumed to be employees of the University unless the
relationship satisfies IRS standards for Independent Contractor. (See Business and Financial Policies and Procedures (BFPP)
Manual,Section17.2.)Note:IftheserviceswillbeprovidedbyanindividualwhoisnotaU.S.Citizen,whethertheserviceswillbe
performedinsideoroutsidetheU.S.,seeBFPPManual,Section18.2.
Foracontractwithanindividual,thefollowingquestionsmustbeanswered.
Yes
No
WilltheindividualprovideessentiallythesameserviceasprovidedbyaUniversityemployee?
HastheindividualpreviouslybeenpaidasaUniversityemployeetoperformoraccomplishtheservice?
WilltheUniversityhavealegalrighttocontrolhowtheindividualwillperformoraccomplishtheservice?
WilltheindividualsuperviseordirectUniversityemployeesaspartoftheserviceprovided?
Is it currently expected that the University will hire this individual as an employee immediately following the
terminationofthecontractualserviceprovided?
IftheanswertoanyoftheabovequestionsinthissectionDisyes,mostlikelytherelationshipofIndependentContractorcannotbe
establishedorapprovedtheindividualwillbetreatedasanemployeefortaxpurposesandtaxeswillbewithheld.
Ifallquestionsareansweredno,mostlikelytheindividualisanIndependentContractor.Taxeswillnotbewithheldfrompayments.
IftheIRSdeterminesthattheIndependentContractorstatusisincorrectandthatthisindividualshouldbeclassifiedasanemployee,
the department is responsible for payment of any penalties or back taxes. Additional detailed information used to determine
employee/IndependentContractorstatuscanbefoundinSection17.2,ClassificationofIndependentContractorsVersusEmployees.
Formoreinformationoncontractingwithanindividual,contacttheOBFS,PurchasingDivision(UIC,UISandUIUC).
E.Contractoristhemostqualifiedperson/firmavailablegiventheconstraintsoftimeandcost.
F. FeetobepaidisappropriateconsideringthequalificationsofContractor,normalfee,andthenatureoftheservicesrequired.
G.Noapparentconflictofinterestexistsinregardtothiscontract.(SeeBFPPManual,Section17.1.)
H.AfterreviewingSection17.1,ConsultantsandOtherContractorsforProfessionalandArtisticServices(lessthan$5,000),
DepartmenthasclassifiedthisContractoras:
lowrisk
mediumriskor
highrisk.
Accordingly,Departmenthascheckedtheappropriatesection(13.Insurance)ofthisContracttoreflectminimumlimitsofinsurance
inaccordancewithpolicy.
I. IffeepaymentsaretobemadefromrestrictedfundsprovidedbytheU.S.Governmentand/ortheStateofIllinois,tothebestofmy
knowledge:
1. EitherContractorssalaryisnotcurrentlypaid100%fromfundsprovidedbytheU.S.Government/StateofIllinoisorapprovalto
payContractorsfeehasbeenobtainedfromtheFederalsponsor/StateofIllinois(Attachcopyofapproval.)or,
2. ThefeetobepaidContractordoesnotexceedthemaximumallowableratepaidtoaGS18(daily,weekly,monthly,orannually,
asappropriate),oradvancedwrittenapprovalhasbeenobtainedfromthesponsor.(Attachcopyofapproval.)
Rev.September24,2010

J. Contractorisaminority,femaleordisabledownedbusinessasdefinedintheBusinessEnterpriseforMinority,FemaleandPersons
withDisabilitiesAct(MAFBE30ILCS575etseq.,asamended).
Yes
No
ConsiderationwasgiventopotentialContractorsmeetingthecriteriaoftheMAFBEAct.
Yes
No
Ifno,explainwhyaMAFBEfirmwasnotconsidered.

____________________________________________________________________________________________________
____________________________________________________________________________

Rev.September24,2010

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1. This contract is between the Board of Trustees of the University of Illinois on behalf of Office of
Social Science Research, (hereinafter called University), and Leila SayedTaha with principal
addressat2224W23rdPlc,Chicago,IL60608,(hereinaftercalledContractor).
2. Nameofcurrentemployer(ifapplicable):_______________________________________________
3. Services:ContractoragreestofurnishtotheUniversitythefollowingservices.
TranslatinginterviewsfromArabictoEnglish
Serviceswillbeprovidedfortheperiodbeginning07/18/2015andending07/21/2015.
4. Compensation:Contractorshallreceiveascompensationforallworkandservicestobeperformed
herein,afeeof$20per hour/ day,oraflatfeeof$______________.Thisfeeistoincludeall
secretarial,clerical,andsimilarincidentalservices.Estimatedtravelexpensesarenottoexceed$0.
Totalcompensation(feeandtravel)isnottoexceed$340
5. SubjectWorkProduct:Inconsiderationforthepaymentdescribed,Contractoragreestoassignall
rights, title, and interest in all deliverable Subject Work Product (including all notes, designs,
drawings, memoranda, reports, computer programs/input and output, and other technical data) first
produced under this contract, including copyright, to the University. Contractor understands the
UniversityshallhaveexclusiverighttousetheSubjectWorkProductforanypurpose,includingbut
not limited to use, reproduction, distribution, sale, licensing, and sublicensing of the Subject Work
Product, and the development of derivative works based in whole or in part on the Subject Work
Product,withoutfurthercompensationtoContractor.Forworkproductnotfirstproducedunderthis
contract, Contractor certifies that it has acquired the necessary rights/licenses for the University to
copyandusesaidworkproduct,atitsdiscretion,withoutcompensationbytheUniversity.
6. Inventions and Discoveries: All inventions or discoveries first conceived or reduced to practice
underthiscontractshallbelongtotheUniversity.Contractoragreestodisclosepromptlyandfullyto
theUniversityeachinventionordiscoveryconceivedorreducedtopracticeunderthiscontract.The
University shall have the sole right to determine the disposition of Universityowned inventions.
Contractoragreestoexecuteanassignmentandrelateddocumentsnecessarytofurtherthepatenting
anddevelopmentoftheinventionandtocooperatewiththeUniversityinsuchactivities.
7. GoverningLaws:ThisContractisgovernedandinterpretedunderthelawsofIllinois,excludingits
conflictoflawsprovisions.
8. Independent Contractor: Contractor shall have sole control over the manner and means of
providing the work and services performed under this contract. Contractors relationship to the
University under this contract shall be that of independent contractor. Contractor will not be
consideredanagentoremployeeoftheUniversityforanypurpose.
9. Right to Reclassify: If Contractor is an individual, the University reserves the right to reclassify
ContractorsstatustothatofemployeeinaccordancewithInternalRevenueServiceguidelines.Such
reclassificationmayrequirethewithholdingoftaxes.
10. CertificationsMadebyContractor:Willfullyfalsifyingcertificationsoraffirmationsmaysubject
Contractortocriminalpenaltiesincludingfinesand/orimprisonment.
TypeofImmigration/NaturalizationVisa(ifapplicable):____________
StateofIllinoisEmployee:IfContractorisanemployeeoftheStateofIllinois,Contractorcertifies
ithaspermissionfromitsemployertoperformthisservice.
Bribery:Contractorcertifiesthat:
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A. IthasnotbeenconvictedofbriberyorattemptingtobribeanofficeroftheStateofIllinois,nor
hasContractormadeanyadmissionofguiltofsuchconductthatisamatterofpublicrecord(720
IllinoisCompiledStatutes5/33E).
B. No Federal appropriated funds have been paid or will be paid by Contractor to any person for
influencing or attempting to influence a Member of Congress, an officer or employee of any
agency,Congress,oranemployeeofaMemberofCongressinconnectionwiththeawardingofa
Federalcontract,grant,loan,theenteringintoofanycooperativeagreement,andtheextension,
continuation, renewal, amendment, or modification of any contract, grant, loan, or cooperative
agreement.
C. IfnonFederalfundshavebeenpaidorwillbepaidbyContractortoanypersonforinfluencingor
attemptingtoinfluenceaMemberofCongress,anofficeroremployeeofanyagency,Congress,
or an employee of a Member of Congress in connection with the awarding of this Federal
contract,grant,loan,orcooperativeagreement,Contractorshallcheckhere andcompleteand
submit Federal Standard Form, Disclosure Form to Report Lobbying, in accordance with its
instructions.
Contractor shall require that the language of this bribery certification be included in the award
documentsforallsubawardsatalltiersandthatallsubrecipientsshallcertifyaccordingly.
Loan Default: If Contractor is an individual, Contractor certifies pursuant to 5 Illinois Compiled
Statutes385thatitisnotindefaultforaperiodofsix(6)monthsormoreinanamountof$600or
more on the repayment of any educational loan guaranteed by the Illinois State Scholarship
CommissionmadebyanIllinoisinstitutionofhighereducationoranyotherloanmadefrompublic
fundsforthepurposeoffinancinghighereducation.
Barred from Contracting: Contractor certifies that it has not been barred from contracting as a
resultofaconvictionforbidriggingorbidrotatingunder720IllinoisCompiledStatutes5/33Eora
similarlawofanotherstate.
ExclusionsPartyListCertification:Contractorcertifiesthatneitheritnoranyofitsemployeesor
subcontractorswhomayprovideservicespursuanttothisContractiscurrentlysubjectofan
investigationorproceedingtoexcludeitasaproviderunderMedicareorMedicaidorunderanyother
federalorstatehealthcareprogramorunderanythirdpartyinsuranceprogram,norisitcurrently
excludedordebarredfromsubmittingclaimstoMedicareorMedicaidortoanyotherfederalorstate
healthcareprogramortoanythirdpartyinsurer.Contractorrepresentsandwarrantsithaschecked
theU.S.GeneralServiceAdministrations(GSA)ExcludedPartyListingSystem(EPLS),whichlists
partiesexcludedfromfederalprocurementandnonprocurementprograms.TheEPLSwebsite
includesGSA/EPLS,theU.S.DepartmentofHealthandHumanServices(HHS)OfficeofInspector
Generals(OIG)ListofExcludedIndividuals/Entities(LEIE),andtheU.S.DepartmentofTreasurys
(Treasury)SpeciallyDesignatedNationals(SDN)list.Contractoralsorepresentsandwarrantsithas
checkedtheIllinoisDepartmentofPublicAid(IDPA)OIGProviderSanctionslistofindividualsand
entitiesexcludedfromstateprocurementwithrespecttoContractor'semployeesandagents.Seethe
followingwebsites:http://www.usgovxml.com/dataservice.aspx?ds=EPLSand
http://www.state.il.us/agency/oig/search.asp.Universitywillterminatecontractwithoutpenaltyto
UniversityifContractorbecomesexcludedduringlifeofthisContract.
DelinquentPaymentsCertification:Contractororbiddercertifiesthatit,oranyaffiliate,isnot
barredfrombeingawardedacontractunder30ILCS500.Section5011prohibitsapersonfrom
enteringintoacontractwithaStateagencyifitknowsorshouldknowthatit,oranyaffiliate,is
delinquentinthepaymentofanydebttotheStateasdefinedbytheDebtCollectionBoard.Section
5012prohibitsapersonfromenteringintoacontractwithaStateagencyifit,oranyaffiliate,has
failedtocollectandremitIllinoisUseTaxonallsalesoftangiblepersonalpropertyintotheStateof
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IllinoisinaccordancewiththeprovisionsoftheIllinoisUseTaxAct.Contractorfurther
acknowledgesthatthecontractingStateagencymaydeclarethecontractvoidifthiscertificationis
falseorifContractor,oranyaffiliate,isdeterminedtobedelinquentinthepaymentofanydebttothe
Stateduringthetermofthecontract.
LaborCertification:Contractorcertifiesinaccordancewith30ILCS583/10thatnoforeignmade
equipment,materials,orsuppliesfurnishedtotheStateunderthecontracthavebeenproducedin
wholeorinpartbyforcedlabor,convictlabor,orindenturedlaborunderpenalsanction.
ChildLaborCertification:ContractorcertifiesinaccordancewithPublicAct940264thatno
foreignmadeequipment,materials,orsuppliesfurnishedtotheStateunderthecontracthavebeen
producedinwholeorinpartbythelaborofanychildundertheageof12.
FelonyCertification:Contractorcertifiesinaccordancewith30ILCS500/5010.5thatnoofficer,
director,partnerorothermanagerialagentofthecontractingbusinesshasbeenconvictedofafelony
undertheSarbanesOxleyActof2002oraClass3orClass2felonyundertheIllinoisSecuritiesLaw
of1953foraperiodoffiveyearspriortothedateofthebidorcontract.Contractoracknowledges
thatthecontractingagencyshalldeclarethecontractvoidifthiscertificationiffalse.
EnvironmentalCertification:Contractorcertifiesinaccordancewith30ILCS500/5014thatithas
not been found by a court or the Pollution Control Board to have committed a willful or knowing
violationofCivilPenaltiesoftheEnvironmentalProtectionActforaperiodoffiveyearspriortothe
date of the bid or contract. Contractor acknowledges that the contracting agency shall declare the
contractvoidifthiscertificationisfalse.

LeadPaintCertification:Pursuantto30ILCS500/5014.5,ifcontractoristheownerof
residentialrentalpropertyinIllinois,contractorcertifiesthatithasnotcommittedawillfulor
knowingviolationoftheIllinoisLeadPoisoningPreventionActthathasnotbeenmitigated.
FederalCertifications:Contractorcertifiesthatit:
A. Isnotpresentlydebarred,suspended,proposedfordebarment,declaredineligible,orvoluntarily
excludedfromcoveredtransactionsbyanyfederaldepartmentoragency
B. Hasnot,withinathree(3)yearperiodprecedingthiscontract,beenconvictedoforhadacivil
judgementrenderedagainstitforcommissionoffraudoracriminaloffenseinconnectionwith
obtaining, attempting to obtain, or performing a public (Federal, State, or Local) transaction or
contractunderapublictransaction,violationofFederalorStateAntitrustStatutesorcommission
of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statementsorreceivingstolenproperty
C. Isnotpresentlyindictedorcriminallyorcivillychargedbyagovernmententity(Federal,State,
orLocal)withcommissionofanyoftheoffensesenumeratedinpart(B)ofthiscertificationand
D. Has not, within a three (3) year period preceding this contract, had one (1) or more public
transactions(Federal,State,orLocal)terminatedforcauseordefault.
DepartmentofDefense(DOD)Employee:IfContractorisaformerDODemployeewho:
A. LeftserviceonorafterApril16,1987andthiscontractisenteredintowithintwo(2)yearsofthe
dateContractorleftservice,and
B. Servedinacivilianpositionforwhichtherateofpaywasequaltoorgreaterthantheminimum
payrateforGradeGS13oftheGeneralScheduleorintheArmedForcesinapaygradeof04or
higher,then
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ContractormustfileaDODForm1787withtheOfficeofGrantsandContracts.
11. StateBoardofElectionsRegistration(P.A.95971
Byacceptanceofthiscontractorpurchaseorder:
The contractor certifies that they are not required to register as a business entity with the State
BoardofElectionspursuanttotheProcurementCode(30ILCS500/20160).Further,thecontractor
acknowledgesthatallcontractsbetweenStateagenciesandabusinessentitythatdonotcomplywith
thisSectionshallbevoidableunderSection5060oftheProcurementCode(30ILCS500/5060).
(or)
The contractor certifies that they have registered as a business entity with the State Board of
ElectionsandacknowledgesacontinuingdutytoupdatetheregistrationpursuanttotheProcurement
Code(30ILCS500/20160).Further,thecontractoracknowledgesthatallcontractsbetweenState
agenciesandabusinessentitythatdonotcomplywiththisSectionshallbevoidableunderSection
5060oftheProcurementCode(30ILCS500/5060).
12. Indemnification: Contractor shall indemnify and hold harmless the University and Universitys
agents, servants, and employees against all loss, damage, and expense which it may sustain or for
whichitwillbecomeliableonaccountofinjurytoordeathofpersons,oronaccountofdamagetoor
destructionofpropertyresultingfromtheperformanceofworkunderthiscontractbyContractoror
its Subcontractors, or due to or arising in any manner from the wrongful act or negligence of
ContractororitsSubcontractorsofanyemployeeofanyofthem.
13. Insurance: Contractor shall cause a Certificate of Insurance to be issued showing the following
requiredcoverageinnolessthantheminimumcoveragelimitslistedbelowinEITHERlowrisk,
mediumrisk,ORhighriskcategory.Theinsurancecompaniesprovidingcoveragemusthavea
B+:VIorbetterratinginthecurrenteditionofBestsKeyRatingGuide.Contractormustagreeto
maintain such insurance for the duration of the project or the term for which services will be
rendered.
Insurance requirements are shown by category and the applicable category corresponds with the
Universitysassessmentofrisk.TheUniversitysdecisiontoissueawaiverofevidenceofinsurance
doesnotrelievetheContractorofitsobligationsunderSection12,Indemnification.
Note to vendor applicable insurance requirements are those directly below the box that is
checkedtoindicatelow,mediumorhighrisk:
LowRisk: Limitsimmediatelybelowapplyifthisboxischecked.
WAIVEDsoleproprietor
A. WorkersCompensationincluding
(noemployees)NOTE:Ifcompanyisinthe
OccupationalDiseasesCoverageA&B
construction business, trucking business
operating at a construction site, or other
hazardous occupation, 820 ILCS 185 of the
IllinoisCombinedStatutesrequiresthateven
soleproprietorsMUSTobtaininsurance.

B. CommercialGeneralLiability(occurrence
coverage,andincludingcontractualliability)

WAIVED

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C. AutoLiability
CheckifContractorwillnotdrivevehicleson Inanyevent,minimumlimitspursuantto
IllinoisStateLaw.
University.

MediumRisk: Limitsimmediatelybelowapplyifthisboxischecked.
A. WorkersCompensationincluding
OccupationalDiseases
CoverageA
IllinoisStatutoryLimits
CoverageB
$100,000E.L.eachdisease
$500,000E.L.eachemployee
Check if sole proprietor and Workers $100,000E.L.policylimit
Compensation (Coverage A&B) are not
applicable.
NOTE: If company is in the construction business,
trucking business operating at a construction site, or
other hazardous occupation, 820 ILCS 185 of the
Illinois Combined Statutes requires that even sole
proprietorsMUSTobtaininsurance.

B. CommercialGeneralLiability(occurrence
coverage,andincludingcontractualliability)
EachOccurrence
GeneralAggregate
ProductsCompletedOperationsAggregate
Personal&AdvertisingInjury
FireDamageLegalLiability

$500,000
$500,000
$500,000
$500,000
$10,000

WAIVED
C. AutoLiability(eitherpersonalor
commercial,asapplicable)
CombinedSingleLimiteachaccident,OR
BodilyInjury
PropertyDamage

$500,000
$500,000
$500,000

CheckifContractorwillnotdrivevehicleson Inanyevent,minimumlimitspursuantto
Universitypremises.
IllinoisStateLaw.

HighRisk: Limitsimmediatelybelowapplyifthisboxischecked.
A. WorkersCompensationincluding
OccupationalDiseases
Rev.September24,2010
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CoverageA
CoverageB

IllinoisStatutoryLimits
$500,000E.L.eachdisease
$500,000E.L.eachemployee
Check if sole proprietor and Workers $500,000E.L.policylimit
Compensation (Coverage A&B) are not
applicable.
NOTE: If company is in the construction business,
trucking business operating at a construction site, or
other hazardous occupation, 820 ILCS 185 of the
Illinois Combined Statutes requires that even sole
proprietorsMUSTobtaininsurance.

B. CommercialGeneralLiability(occurrence
coverage,andincludingcontractualliability)
EachOccurrence
GeneralAggregate
ProductsCompletedOperationsAggregate
Personal&AdvertisingInjury
FireDamageLegalLiability

$1,000,000
$2,000,000
$2,000,000
$1,000,000
$100,000

C. AutoLiability(eitherpersonalor
commercial,asapplicable)
CombinedSingleLimiteachaccident,OR
BodilyInjury
PropertyDamage

$1,000,000
$1,000,000
$1,000,000

Ifappropriate,additionalinsurancerequirementsforthiscontractarecheckedbelow:
D. Professional Liability Specialty $1,000,000perclaim
ErrorsandOmissions
$3,000,000intheaggregate
E. Professional Liability Medical $1,000,000perclaim
Malpractice
$3,000,000intheaggregate
F.

EmployeeDishonesty

G.

Other

$150,000eachoccurrence

Umbrellaliabilityinsurancemaybeusedtomeetthegeneralliabilitycoveragelimitrequirements.
SubcontractorsmustcomplywiththesameinsurancecoveragerequirementsasContractor.
SubcontractorsshallsubmittherequiredCertificateofInsurancethroughtheprimaryContractor.

Rev.September24,2010
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ChangestothisformrequireLegalCounselreview.

With respect to the required Commercial General Liability (CGL) insurance shown under High
Risk, The Board of Trustees of the University of Illinois shall be added to the Contractors CGL
policy as an additional insured. In order to meet this requirement, the following wording should
appearonanyCertificateofInsuranceprovided:"TheBoardofTrusteesoftheUniversityofIllinois
isanadditionalinsuredforanyliabilityincurredbytheUniversityarisingfromtheactivitiesofthe
Contractorand/orSubcontractorperformingworkonbehalfoftheContractor."
WhenanyprofessionalservicesareperformedinconnectionwiththisContract,ProfessionalLiability
for Contract and its employees and agents shall be required and maintained for the duration of the
contract. A claimsmade policy that is replaced or not renewed must have an extended reporting
period of not less than two (2) years. When policies are renewed or replaced any retroactive date
mustcoincidewith,orprecedecommencementofservicesbytheContractororSubcontractorunder
thisContract.
Professional Liability insurance shall include coverage for errors, omissions, and negligent acts
related to the rendering of said professional services with limits not less than $1,000,000 per claim
and$3,000,000intheaggregate,asshownabove.
ContractorshallfurnishanyoriginalCertificate(s)ofInsuranceevidencingtherequiredcoverageto
beinforceonthedateofthisContract,andanyrenewalCertificate(s)ofInsurance,ifcoveragehas
anexpirationorrenewaldateoccurringduringthetermofthisContracttotheUniversityofIllinois
PurchasingDivision.
Universitys receipt of any insurance certificate shall not be deemed acceptance that insurance
requirementsintheContracthavebeensatisfied.FailureofUniversitytoobtaincertificatesorother
insurance evidence from the Contractor shall not be deemed a waiver by University. Failure to
complywithinsurancerequirementsmayberegardedasabreachofcontractterms.
14. Entire Agreement: This contract, attachments, and incorporated references shall constitute the
entireagreementbetweenthepartieswithrespecttothesubjectmatterhereinandsupersedesallprior
communications and writings with respect to the content of said contract. In case of any conflict
betweenthiscontractandanyattachmentsorincorporatedreferences,thetermsofthiscontractshall
prevail.Nomodification,renewal,extension,orwaiverofthiscontractorofanyoftheprovisionsof
thiscontract,shallbebindinguponeitherContractorortheUniversityunlessreducedtowritingand
dulyexecutedasprovidedforinthecontract.
15. Signature:Bysigningthiscontract,Contractorsignifiesagreementwithandacceptanceofallthe
terms, conditions and specifications in this contract. The person signing below represents and
warrantsthathe/shehasauthoritytobindhis/hercompany.

BoardofTrusteesoftheUniversityof
Illinois

Contractor

By:WalterK.Knorr,Comptroller

Date

Signature

UnitHeadforWalterK.Knorr

Date

PrintName

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Date

AbovesignatureoftheUnitHeadalsocertifiesto
thedepartmentstatements.

Rev.September24,2010
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10