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Backup Documents 02/23/2010 Item #16B7 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP l' 6 TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 8 7 THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document Original dl)cuments should be hand delivered 10 th.: Board Oflice rhe completed muting slip and original documents are to be forwarded to the Board Oftlce only aftrr the Board has taken action on the llel11 ) ROUTING SLIP Complete rouling lines #1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the excePtion of the Chairman's si~nature, draw a line through routing lines # 1 through #4, complete the checklist, and forward to Sue Filson (line #5). Route to Addressee(s) Office Initials Date (List in routine: order) 1. Scott R. Teach County Attorney SRT 2/22/1 0 2. 3. 4. 5. Ian Mitchell, BCC Office Board of County Commissioners jL,,,- 3ft 110 Supervisor 6. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION (The primary contact is the holder of the original document pending Bee approval. Normally the primary contact is the person who created/prepared the executive summary. Primary contact information is needed in the event one of the addressees above, including Sue Filson, need to contact staff for additional or missing infonnation. All original documents needing the Bee Chairman's signature are to be delivered to the BCC office only after the Bec has acted to approve the item.) Name of Primary Staff Sheila Convery Phone Number XS260 Contact Agenda Date Item was 23 February 2010 Agenda Item Number 16-B-7 Approved bv the BCC Type of Document Resolution (I); Agreement (4) Number of Original 5 Attached :1.. 0 ItvL{O Documents Attached I. INSTRUCTIONS & CHECKLIST Initial the Ves column or mark "N/A" in the Not Applicable column, whichever is a ro riate. Original document has been signed/initialed for legal sufficiency. (All documents to be signed by the Chairman, with the exception of most letters, must be reviewed and signed by the Office of the County Attorney. This includes signature pages from ordinances, resolutions, etc. signed by the County Attorney's Office and signature pages from contracts, agreements, etc, that have been fully executed by all parties except the BCC Chairman and Clerk to the Board and ossibl State Officials.) All handwritten strike-through and revisions have been initialed by the County Attorney's Office and all other arties exce t the BCC Chairman and the Clerk to the Board The Chairman's signature line date has been entered as the date ofBCC approval of the document or the final ne otiated contract date whichever is a licable. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's si nature and initials are re uired. In most cases (some contracts are an exception), the original document and this routing slip should be provided to Ian M ithchell in the BCC oflice within 24 hours of BCC approval. Some documents are time sensitive and require torwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of our deadlines! The document was approved hy the BCC on 2/23/10 (enter date) and all changes made during the meeting have heen incorporated in the attached document. The Count Attorne 's Office has reviewed the chan es, if a Iicable. Ves (Initial) SAC NI A (Not A licable) 2, N/A 3. SAC 4. SAC 5, SAC 6. J: Forms/ County Fonns/ Bee Formsl Original Documents Routing Slip WWS Original 9.03.04. Revised 1.26.05, Revised 2.24.05, Revised 9.18.09 16 B 7 '1 MEMORANDUM Date: March 1,2010 To: Sheila Convery Trans/Traffic Operations From: Teresa Polaski, Deputy Clerk Minutes & Records Department Re: Resolution 2010-40 and Agreement: Joint Agreement between FOOT and Collier County Enclosed for your records, please find 4 certified resolutions and 4 original agreements of the document as referenced above, (Agenda Item #1687) adopted by the Collier County Board of County Commissioners on Tuesday, February 23, 2010. The original Resolution is being retained in Minutes and Records for public record. If you have any questions, please call me at 252-8411. Thank you. Enclosure 1687 RESOLUTION NO. 2010- 40 A Resolution by the Board of County Commissioners of Collier County, Florida, authorizing a Joint Project Agreement between the Florida Department of Transportation (FOOT) and Collier County for the purpose of replacing or repainting traffic signal mast arm components previously installed by the FOOT with reimbursement to the County for its expenses. WHEREAS, as part of the Federally funded and State administered Collier County Advanced Traffic Management System Phase I installation the FOOT accomplished through a State project the reconstruction of five traffic signal installations maintained by Collier County utilizing steel mast ann signal support structures; and WHEREAS, the steel mast ann signal support structures provided by the State's contractor proved to be defective, causing their protective coatings to peel and allow rust to damage several components at each of the mentioned five intersections; and WHEREAS, the FOOT has secured replacement components for the defective and damaged components and wishes to engage in a Joint Project Agreement with Collier County to both secure the replacement of the defective components with the FOOT furnished new components and to repaint the non-replaced components to match the newly replaced components at FOOT expense; and WHEREAS, the FDOT has programmed up to $79,384.00 to reimburse Collier County for work to be accomplished under this Joint Project Agreement, which matches the County's total estimates for the work required to effect these replacements and repainting; and WHEREAS, it is in the interest of Collier County for such replacements and repainting to be accomplish to assure the continued structural integrity of the traffic signal mast ann support structures and the aesthetics of the intersection equipment. 1 1687 NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA, that: 1. The Board hereby approves the provisions and stipulations of the attached Joint Project Agreement for FOOT Project FM# 428318-1-52-01; and 2. The Board authorizes its Chairman to execute the Amendment to the Agreement. This Resolution adopted after motion, second, and majority vote favoring same this 23rd day of February, 2010. ,,' '.:':} 'j;~'l;-\~~"',,/, ATTES1>,,~.:-."";;;.:.' C; ~~k - DeDllt\i .clerk Attftll~:.~ .~~ C~ t,..... , 'f."'~ Gel,. ':..!H:;,."C" BOARD OF COUNTY COMMISSIONERS COLLIER COUNTY, FLORIDA BY: ~~W.~ ~ Fred W-'-C~yle, Chairmand Approved as to form and legal sufficiency: By:~iI-;? LL Scott R. Teach Deputy County Attorney Item # .lla81- Agenda 2.-1 't.? I. to Date Date Rae' 2 1687 FM #428318-1-58-01 JOINT PROJECT AGREEMENT BETWEEN THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION AND COLLIER COUNTY This is an Agreement by and between the STATE OF FLORIDA DEPARTMENT OF TRANSPORTA nON, (hereinafter, "DEPARTMENT") and COLLIER COUNTY, FLORIDA, (hereinafter, "COUNTTY ") for the DEPARTMENT to provide funds to refurbish color coating on existing signal poles and mast arms at various locations, and one mast arm replacement. WITNESSETH I. WHEREAS, the DEPARTMENT plans in its work program to fund in FY 09/10 to provide funds to refurbish color coating on existing signal poles and mast arms at various locations, and mast arm replacement located in SE corner of Airport-Pulling Road at Davis Boulevard intersection 235, pole 2, ann 2, FM# 428318-1-52-01 (hereinafter, "PROJECT"); and 2. WHEREAS, said PROJECT is on the State Highway System, is not revenue producing and is contained in the tentative Five Year Transportation Plan in FY 09/10; and 3. WHEREAS, the COUNTY is willing to undertake the PROJECT and the DEPARTMENT is willing to reimburse the COUNTY for costs directly related to completion of the PROJECT as described herein; and vd 4. WHEREAS, the COUNTY by Resolution No. 10-40 dated the23 day of h-bt"... ~ ' 2009, a copy of which is attached hereto and made a part hereof, has authorize the Chairman of the Board of County Commissioners or designee to enter into this Agreement. NOW THEREFORE, in consideration of the mutual benefits to be derived from joint participation in this Agreement, the parties agree as follows: 1. SERVICES AND PERFORMANCE I) The COUNTY agrees to undertake the PROJECT and the DEPARTMENT agrees to reimburse the COUNTY for said services, as stated in Section II below, provided they are performed in accordance with the DEPARTMENT's specifications and the terms and conditions of this Agreement. 2) The COUNTY shall complete the PROJECT within _6_ months from the execution of this Agreement. 3) The PROJECT consists of refurbishing color coating on existing signal poles and mast arms at various locations, and mast arm replacement located in SE corner of Airport- Pulling Road at Davis Boulevard intersection 235, pole 2, ann 2. 4) The COUNTY agrees to undertake the PROJECT, with its own forces or through a contractor, in accordance with DEPARTMENT's standards, specifications, permit requirements, and all applicable federal, state and local statutes, rules and regulations. 1687 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE20F9 5) All tracings, plans, specifications, maps and/or reports prepared or obtained under this Agreement shall be considered works made for hire and shall become the property of the DEPARTMENT without restriction or limitation on their use. The DEPARTMENT will have the right to visit the PROJECT site for inspection of the work and the drawings at any time. 6) The COUNTY shall allow public access to all documents, papers, letters or other material subject to the provisions of Chapter 119, Florida Statutes, and made or received by the COUNTY in conjunction with this Agreement. Failure by the COUNTY to grant such public access shall be grounds for immediate unilateral cancellation of this Agreement by the DEPARTMENT. 7) All notices under this Agreement and invoices from the COUNTY to the DEPARTMENT shall be directed to the following addresses: TO DEPARTMENT: TO COUNTY: Florida Department of Transportation Keith Slater, Project Manager 801 North Broadway Bartow, FL 33830 County Traffic Operations Engineer Collier County 2885 South Horseshoe Drive Naples, Florida 34104 II. PAYMENT TERMS I) The DEPARTMENT agrees to a maximum participation in the PROJECT in the amount of SEVENTY NINE THOUSAND THREE HUNDRED EIGHTY-FOUR DOLLARS ($79,384.00). 2) The DEPARTMENT agrees to reimburse the COUNTY for the herein described services at the compensation amount as detailed in this Agreement. The COUNTY agrees to complete the PROJECT for the amount set forth in this Agreement. 3) The DEPARTMENT agrees to make reimbursement payments to the COUNTY in accordance with Fla. Stat. ~339.12; the DEPARTMENT'S obligation to pay shall be subject to legislative approval and appropriation. In the event the COUNTY proceeds with the PROJECT with its own forces, the COUNTY will only be reimbursed for direct costs (this excludes general and administrative overhead). 4) The COUNTY agrees to the following time frames: (I) upon receipt, the DEPARTMENT has five (5) working days to inspect and approve the goods and services, unless the Agreement specifies otherwise; (2) the DEPARTMENT has 20 days to deliver a request for payment (voucher) to the Department of Banking and Finance; (3) the 20 days are measured from the latter of the date the invoice is received or the goods or services are received, inspected and approved. 5) If a payment is not available within 40 days, a separate interest penalty at the rate established pursuant to Fla. Stat. ~55.03( I), per day will be due and payable, in addition to the invoice amount, to the Vendor. Intcrest penalties of less than one (I) dollar will not be enforced unlcss the COUNTY requests payment. Invoices which have to be returned to the COUNTY because of the COUNTY'S preparation errors will result in a delay in the payment. The invoice payment requirements do not start until a properly completed 1687 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE30F9 invoice is provided to the DEPARTMENT. 6) A Vendor Ombudsman has been established within the Department of Banking and Finance. The duties of this individual include acting as an advocate for the COUNTY if it experiences problems in obtaining timely payment(s) from a state agency. The Vendor Ombudsman may be contacted at (850) 413-5516 or by calling the Department of Financial Services Hotline. 1-877-693-5236. 7) Invoices or requests for payment from the COUNTY shall be submitted quarterly in detai I sufficient for a proper pre-audit and post-audit thereof and in sufficient detail for the DEPARTMENT to confirm the extent of work completed and compliance of such work with the terms of this Agreement. 8) Bills or invoices for travel expenses, if applicable, specifically authorized in this Agreement shall be submitted and paid in accordance with Fla. Stat. S 112.061. 9) Records of costs incurred under terms of this Agreement shall be maintained and made available upon request to the DEPARTMENT at all times during the period of this Agreement and for three years after final payment is made. Copies of these documents and records shall be furnished to the DEPARTMENT upon request. Records of costs incurred include any consultant's or contractor's general accounting records and the project records, together with supporting documents and records, of any consultant or contractor and all sub-consultants or sub-contractors performing work on the PROJECT, and all other records of the PROJECT considered necessary by the DEPARTMENT for a proper audit of costs. 10) The DEPARTMENT, during any fiscal year, shall not expend money, incur any liability, or enter into any contract which, by its terms, involves the expenditure of money in excess of the amounts budgeted as available for expenditure during such fiscal year. Any contract, verbal or written, made in violation of this subsection is null and void, and no money may be paid on such contract. The DEPARTMENT shall require a statement from the Comptroller of the DEPARTMENT that funds are available prior to entering into any such contract or other binding commitment of funds. Nothing herein contained shall prevent the making of contracts for periods exceeding one year, but any contract so made shall be executory only for the value of the services to be rendered or agreed to be paid for in succeeding fiscal years. Accordingly, the State of Florida's performance and obligation to pay under this Contract is contingent upon an annual appropriation by the Legislature. II) No funds received pursuant to this Agreement may be expended for lobbying the Legislature or a state agency. III. GENERAL PROVISIONS I) This document incorporates and includes all prior negotiations, correspondence, conversations, agreements, or understandings applicable to the matters contained herein, and the parties agree that there are no commitments, agreements or understandings concerning the subject matter of this Agreement that are not contained in this document. Accordingly, it is agreed that no deviation from the terms hereof shall be predicated upon any prior representation or agreements whether oral or written. It is further agreed that no 1687 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE40F9 modification, amendment or alteration in the terms or conditions contained herein shall be effective unless contained in a written document executed with the same formality and of equal dignity herewith. 2) Unless otherwise specifically stated herein, this Agreement shall be governed by and construed in accordance with the laws of the State of Florida. 3) Except as otherwise provided herein, this Agreement shall continue in effect and be binding on the parties until the PROJECT is completed, final costs are known and legislatively appropriated reimbursements, if approved, are made by the DEPARTMENT. 4) If any part of this Agreement shall be determined to be invalid or unenforceable by a court of competent jurisdiction or by any other legally constituted body having the jurisdiction to make such determination, the remainder of this Agreement shall remain in full force and effect provided that the part of this Agreement thus invalidated or declared unenforceable is not material to the intended operation of this Agreement. 5) The COUNTY shall not sublet, assign or transfer any work under this Agreement without the prior written consent of the DEPARTMENT. 6) A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Fla. Stat. ~287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. 7) An entity or affiliate who has been placed on the discriminatory vendor list may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity. IV. TERMINATION I) The DEPARTMENT reserves the right to seek termination or cancellation of this Agreement in the event the COUNTY shall be placed in either voluntary or involuntary bankruptcy. The DEPARTMENT further reserves the right to terminate or cancel this Agreement in the event an assignment be made for the benefit of creditors. 2) If the DEPARTMENT determines that the performance of the COUNTY is not satisfactory. the DEPARTMENT shall have the option of (i) immediately terminating the Agreement, or (ii) notifying the COUNTY of the deficiency with a requirement that the deficiency be corrected within a specified time, otherwise the Agreement will be terminated at the end of such time, or (iii) take whatever action is deemed appropriate by 1687'1 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE50F9 the DEPARTMENT. 3) If the DEPARTMENT requires termination of the Agreement for reasons other than unsatisfactory performance of the COUNTY, the DEPARTMENT shall notify the COUNTY of such termination, with instructions as to the effective date of termination or specify the stage of work at which the Agreement is to be terminated. 4) If the Agreement is terminated before performance is completed, the COUNTY shall be paid only for that work satisfactorily performed for which costs can be substantiated. Such payment, however, may not exceed an amount which is the same percentage of the contract pricc as the amount of work satisfactorily completed is a percentage of the total work called for by this Agreement. All work in progress will become the property of the DEPARTMENT and will be turned over promptly by the COUNTY. V. INDEMNITY 1) When either party receives notice of claim for damages that may have been caused by the other party in the performance of services required under this Agreement, that party will immediately forward the claim to the other party. Each party will evaluate the claim, and rcport its findings to each other within fourteen (14) working days and jointly discuss options in defending the claim. A party's failure to promptly notify the other of a claim will not act as a waiver of any right herein. 2) The COUNTY agrees to include the following indemnification provision in all contracts with contractors/sub-contractors and consultants/sub-consultants who perform work in connection with this Agreement: "The contractor shall indemnify, defend, save and hold hannless the DEPARTMENT and all of its officers, agents or employees from all suits, actions, claims, demands, liability of any nature whatsoever arising out of, because of, or due to any negligent act or occurrence of omission or commission of the contractor, its officers, agents or employees. Neither the contractor, nor any of its officers, agents or employees will be liable under this section for damages arising out of injury or damage to persons or property directly caused or resulting from the sole negligence of the DEPARTMENT or any of its officers, agents or employees." 3) Nothing in this Agreement shall be construed as a waiver of the defense of sovereign immunity or any limit of liability pursuant thereto by either the DEPARTMENT or the COUNTY 4) The DEPARTMENT shall not be obligated or liable hereunder to any party other than the COUNTY. 1687 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE60F9 VI. AUDITS I) Audits:The administration of resources awarded by the DEPARTMENT to the COUNTY may be subject to audits and/or monitoring by the Department, as described in this section. 2) MONITORING A. By entering into this agreement, the COUNTY agrees to comply and cooperate fully with any monitoring procedures/processes deemed appropriate by the DEPARTMENT. In the event the DEPARTMENT determines that a limited scope audit of the recipient is appropriate, the COUNTY agrees to comply with any additional instructions provided by the DEPARTMENT staff to the COUNTY regarding such audit. The COUNTY further agrees to comply and cooperate with any inspections, reviews, investigations, or audits deemed necessary by the Chief Financial Officer (CFO) or Auditor General. 3) PART I: STATE FUNDED A. The COUNTY as a recipients of state funds pursuant to Fla. Stat. g2 I 5.97(2)(m), i.e., a non-state entity as defined by Fla. Stat. g215.97(2)(m), is to have audits done annually using the following criteria: B. Fla. Stat. g215.97 (2) (a): Each nonstate entity that expends a total amount of state financial assistance equal to or in excess of $500,000 in any fiscal year of such nonstate entity shall be required to have a state single audit, or a project-specific audit, for such fiscal year in accordance with the requirements of this section and applicable rules of the Executive Office of the Governor and the CFO; and Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General. In determining the state financial assistance expended in its fiscal year, the recipient shall consider all sources of state financial assistance, including state financial assistance received from the Department, other state agencies, and other non-state entities. State financial assistance does not include Federal direct or pass-through awards and resources received by a non-state entity for Federal program matching requirements. C. In connection with the audit requirements addressed in A above, the COUNTY shall ensure that the audit complies with the requirements of Fla. Stat. g215.97(7). This includes submission of a financial reporting packagc as defined by Fla. Stat. g215.97(2)(d), and Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General. D. If the COUNTY expends less than $500,000 in state financial assistance in its fiscal year, an audit conducted in accordance with the provisions of Fla. Stat. g215.97 is not required. In the event that the recipient expends less than $500,000 in state financial assistance in its fiscal year and elects to have an audit conducted in accordance with the provisions of Fla. Stat. 9215.97, the cost of the audit must be paid from the non-state entity's resources (i.e., the cost of such an audit must be paid from the recipient's resources obtained from other than State entities). 1687 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE 7 OF 9 E. State awards are to be identified using the Catalog of State Financial Assistance (CSF A) title and number, award number and year, and name of the state agency awarding it. 4) PART II: OTHER AUDIT REQUIREMENTS A. The COUNTY shall follow up and take corrective action on audit findings. Preparation of a summary schedule of prior year audit findings, including corrective action and current status of the audit findings is required. Current year audit findings require corrective action and status of findings. B. Records related to unresolved audit findings, appeals, or litigation shall be retained until the action is completed or the dispute is resolved. Access to project records and audit work papers shall be given to the DEPARTMENT, the Comptroller, and the Auditor General. This section does not limit the authority of the DEPARTMENT to conduct or arrange for the conduct of additional audits or evaluations of state financial assistance or limit the authority of any other state official. 5) PART III: REPORT SUBMISSION A. Any reports, management letter, or other information required to be submitted to the DEPARTMENT pursuant to this Agreement shall be submitted timely in accordance, Florida Statutes, and Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General, as applicable. B. Recipients, when submitting financial reporting packages to the DEPARTMENT for audits done in accordance with Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General, should indicate the date that the reporting package was delivered to the recipient in correspondence accompanying the reporting package. C. The documents listed below in (i) and (ii) shall be submitted to the DEPARTMENT: Florida Department of Transportation Attn: Karen A. Miracola, District JP A/LF A Coordinator PO Box 1030 Fort Myers, FL 33902-1030 (i) Copies of financial reporting packages required herein by Florida Statutes. (ii) Copies of reports or the management letter required herein by Florida Statutes. D. The documents listed above in (i) and (ii) shall be submitted to the Auditor General's Office: Auditor General's Office Room 401, Pepper Building III West Madison Street Tallahassee, Florida 32399-1450 1687 FM #428318-1-58-01 JP A: COLLIER COUNTY PAGE80F9 6) PART IV: RECORD RETENTION A. The COUNTY shall retain sufficient records demonstrating its compliance with the terms of this Agreement for a period of at least five years from the date the audit report is issued, and shall allow the DEPARTMENT, or its designee, the state CFO or Auditor General access to such records upon request. The COUNTY shall ensure that the independent audit working papers are made available to the DEPARTMENT, or its designee, the state CFO, or Auditor General upon request for a period of at least five years from the date the audit report is issued, unless extended in writing by the DEPARTMENT. Rest of this page intentionally left blank. 1687 FM #428318-1-58-01 JPA: COLLIER COUNTY PAGE90F9 IN WITNESS WHEREOF, COLLIER COUNTY has caused this Agreement to be executed in its behalf through its Board of County Commissioners through its Chairperson or designee, and the DEPARTMENT has caused this Agreement to be executed in its behalf through its District Secretary for District One, FLORIDA DEPARTMENT OF TRANSPORTATION as indicated below. This Agreement shall become effective on: Date to be entered by the DEPARTMENT COLLIER COUNTY, FLORIDA ~~~~~( CL_~ftK~t~_t~ La (SEAL) DATE " At us,t. It'~\lG GM 11'tIIIII .. 'jl~fl<ltih' '~'l'~ J', .. ~.' _,' ,1 . . .' ..', ~\.. \'.: ~". ,It t! t.v fir' \:Jt~ ; i CHAIRMAN OR DESIGNEE ~%~Ie, Cl1aiflllaA 2/23.'10 DATE COLLIER COUNTY: LEGAL REVIEW: BY: ~II- /? L~ d-J~3~b , DATE STATE OF FLORIDA DEPARTMENT OF TRANSPORT A nON ATTEST BY: EXECUTIVE SECRETARY (SEAL) DISTRICT SECRETARY OR DESIGNEE DISTRICT ONE PRINT NAME DATE PRINT NAME DATE FLA. DEPT. OF TRANS, LEGAL REVIEW: BY: DATE