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Backup Documents 05/24/2016 Item #16A24 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP A I TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office SRT 5-24-16 4. BCC Office Board of County DF Commissioners , 7 5. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION 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,may need to contact staff for additional or missing information. Name of Primary Staff Dan Hall Contact Information 239-252-6077 Contact/ Department Agenda Date Item was May 24,2016 ,/ Agenda Item Number 16A24 Approved by the BCC Type of Document "Public Officer Conflict of Interest Certification" Number of Original Attached related to recently approved Agreement No. 15- Documents Attached 6456 for Construction Engineering and Inspection(CEI)for Local Agency Program (LAP)funded projects.Growth Management Grant Fund 711/Commissioner Fiala PO number or account n/a number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature SRT 2. Does the document need to be sent to another agency for additional signatures? If yes, SRT provide the Contact Information(Name;Agency; Address; Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be SRT signed by the Chairman, with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's SRT Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the SRT document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's SRT signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip SRT should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved by the BCC on May 24,2016 and all changes made SRT during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. 9. Initials of attorney verifying that the attached document is the version approved by the BCC, all changes directed by the BCC have been made,and the document is ready for the Chairman's signature. T1s I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised .' I • t vised 11/30/12 4! 4 MEMORANDUM Date: May 25, 2016 To: Daniel Hall, Senior Project Manager Transportation Engineering & Construction Management From: Teresa Cannon, Deputy Clerk Minutes and Records Department Re: Public Officer Conflict of Interest Certifications — Commissioner Fiala Attached for your records is a copy of each certification as referenced above, (Item #16A24) adopted by the Board of County Commissioners on Tuesday May 24, 2016. The Minutes and Record's Department has held the originals for the Board's Official Record. If you have any questions, please feel free to contact me at 252-8411. Thank you. Attachment 1 it ile 44 PUBLIC OFFICER CONFLICT OF INTEREST CERTIFICATION ' Collier County is a Florida Department of Transportation(FDOT)Local Agency Program(LAP)certified agency. The funding source for LAP projects is the Federal Highway Authority(FHWA);whereby grant dollars are passed through the FDOT via a LAP agreement. I certify that I have no present conflict of interest on the following project(s): Financial Project Numbers: 429899-1 New Market Road Sidewalk 433176-1 Pine Ridge Turn Lane 433177-1 Golden Gate Intersection 434990-1 GG Various Sidewalks 1 435030-1 Sunshine Blvd. Sidewalks 435116-1 GG Collector Sidewalk 435117-1 North Naples Sidewalks 435118-1 Vanderbilt Bike Lane/Sidewalk 435119-1 49th Terrace Sidewalks The projects listed above will have LAP funded construction engineering inspection services provided by AIM Engineering& Surveying,Inc. I further certify that I will recuse myself from any capacity of decision making, approval, disapproval or recommendation of any consultant/contractor/vendor for selection on any contract if I have a conflict of interest or potential conflict of interest. As set forth in Sections 112.313 and 334.193, Florida Statutes, public officers of an agency may not have any interest, fmancial or otherwise direct or indirect; engage in any business transaction or professional activity; or accept any obligation of any kind which is in conflict with the proper conduct of their duties in the public interest. By signing below, I attest that public officers should avoid any conduct that might undermine the public trust, whether or not that conduct is unethical or lends itself to the appearance of ethical impropriety; and that public officers in the State of Florida are expected to safeguard their ability to make objective, fair and impartial decisions, in part, by not accepting any benefit under circumstances that could be inferred by a reasonable observer that the benefit was provided to influence a pending or future decision,or to reward a past decision. I realize that a violation of the above mentioned statutes is punishable in accordance with Section 112.317 or Section 334.193,Florida Statutes,and could result in disciplinary action. ATTEST: BOARD OF COUNTY COMMISSIONERS DWIGHT E.BROCK,CLERK COLLIER COUNTY,FLORIDA _ j-eiNse._ 6 , -0.-Ai/0.4a, kt- By: ,L ' gtt.�to Crla�bDe u�Clerk DONN FIALA, CHAIR Sia "lr.e of Dated: DA c, Q14, )1CQ Ap oved to f'�' ;� legality: 1 Scott R. each Deputy County Attorney [16-MBG-00259/1240262/1] IS 5(1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 241 6 A THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office SRT 5-24-16 4. BCC Office Board of County T Commissioners \r-N\141 5. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION 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,may need to contact staff for additional or missing information. Name of Primary Staff Dan Hall Contact Information 239-252-6077 Contact/ Department Agenda Date Item was May 24,2016 e./ Agenda Item Number 16A24 �� Approved by the BCC Type of Document "Public Officer Conflict of Interest Certification" Number of Original --Five— Attached iv'e—Attached related to recently approved Agreement No. 15- Documents Attached (OG 6456 for Construction Engineering and Inspection(CEI)for Local Agenc. ro .m (LAP)funded projects.Grog a'nagem.nt Grant Fund 711/Commission-r enning PO number or account n/a number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature SRT 2. Does the document need to be sent to another agency for additional signatures? If yes, SRT provide the Contact Information(Name; Agency;Address;Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be SRT signed by the Chairman,with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's SRT Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the SRT document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's SRT signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip SRT should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved by the BCC on May 24,2016 and all changes made SRT during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. 9. Initials of attorney verifying that the attached document is the version approved by the 5� " BCC,all changes directed by the BCC have been made,and the document is ready for the Chairman's signature. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revis-• 2.24.65;Re ised 11/30/12 t : 6fp -4 MEMORANDUM Date: May 25, 2016 To: Daniel Hall, Senior Project Manager Transportation Engineering & Construction Management From: Teresa Cannon, Deputy Clerk Minutes and Records Department Re: Public Officer Conflict of Interest Certifications — Commissioner Henning Attached for your records is a copy of each certification as referenced above, (Item #16A24) adopted by the Board of County Commissioners on Tuesday May 24, 2016. The Minutes and Record's Department has held the originals for the Board's Official Record. If you have any questions, please feel free to contact me at 252-8411. Thank you. Attachment I * PI I'''3 p 31 PUBLIC OFFICER CONFLICT OF INTEREST CERTIFICATION b L...,, Collier Collier County is a Florida Department of Transportation(FDOT)Local Agency Program(LAP)certified agency. The funding source for LAP projects is the Federal Highway Authority(FHWA);whereby grant dollars are passed through the FDOT via a LAP agreement. I certify that I have no present conflict of interest on the following project(s): Financial Project Numbers: 429899-1 New Market Road Sidewalk 433176-1 Pine Ridge Turn Lane 433177-1 Golden Gate Intersection 434990-1 GG Various Sidewalks 435030-1 Sunshine Blvd. Sidewalks 435116-1 GG Collector Sidewalk 435117-1 North Naples Sidewalks 435118-1 Vanderbilt Bike Lane/Sidewalk 435119-1 49th Terrace Sidewalks The projects listed above will have LAP funded construction engineering inspection services provided by AIM Engineering& Surveying,Inc. I further certify that I will recuse myself from any capacity of decision making, approval, disapproval or recommendation of any consultant/contractor/vendor for selection on any contract if I have a conflict of interest or potential conflict of interest. As set forth in Sections 112.313 and 334.193, Florida Statutes, public officers of an agency may not have any interest, financial or otherwise direct or indirect; engage in any business transaction or professional activity; or accept any obligation of any kind which is in conflict with the proper conduct of their duties in the public interest. By signing below, I attest that public officers should avoid any conduct that might undermine the public trust, whether or not that conduct is unethical or lends itself to the appearance of ethical impropriety; and that public officers in the State of Florida are expected to safeguard their ability to make objective, fair and impartial decisions, in part, by not accepting any benefit under circumstances that could be inferred by a reasonable observer that the benefit was provided to influence a pending or future decision,or to reward a past decision. I realize that a violation of the above mentioned statutes is punishable in accordance with Section 112.317 or Section 334.193,Florida Statutes,and could result in disciplinary action. ATTEST: BOARD OF COUNTY COMMISSIONERS DWIGHT E.BROCK,CLERK COLLIER COUNTY,FLORIDA / : , , , 0--CLK"IA- -____ 4 , �" 9.1KOvi A. st as tv C1 ma deputy Clerk TOM I 013c—_ _\_,,‘ N1NG, COMMISSIONER I1�t 11Y only. Dated: MO.,`... c / )o ItP i Ap ro ed as to fo • . d 1;_ality: \ ,/ L Sc-CRT ch Deputy County Attorney [16-MBG-00259/1240262/1] ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE " � °`° Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office SRT 5-24-16 4. BCC Office Board of County Commissioners ytS'/ 5)2A 5. Minutes and Records Clerk of Court's Office y c) )PRIMARY CONTACT INFORMATION I 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,may need to contact staff for additional o missing information. Name of Primary Staff Dan Hall Contact Information 239-252-6077 Contact/ Department Agenda Date Item was May 24,2016 Agenda Item Number 16A24 �' Approved by the BCC t Type of Document "Public Officer Conflict of Interest Certification" Number of Original +i've c3 Attached related to recently approved Agreement No. 15- Documents Attached 6456 for Construction Engineering and Inspection(CEI)for Local Agency Program (LAP)funded projects.Growtlagvtariag7ent Grant Fund 711/Commissio er Taylor PO number or account n/a _.__ number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature SRT 2. Does the document need to be sent to another agency for additional signatures? If yes, SRT provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be SRT signed by the Chairman,with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's SRT Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the SRT document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's SRT signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip SRT should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved bythe BCC on May 24,2016 and all changes made SRT PP ' during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes, if applicable. 9. Initials of attorneyverifying that the attached document is the version approved bye • fy� g pp BCC,all changes directed by the BCC have been made, and the document is readylefor the s; Chairman's signature. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,mcvised 2.24.05.Rased 11/30/12 .y ip dddLLL...j 2 MEMORANDUM Date: May 25, 2016 To: Daniel Hall, Senior Project Manager Transportation Engineering & Construction Management From: Teresa Cannon, Deputy Clerk Minutes and Records Department Re: Public Officer Conflict of Interest Certifications — Commissioner Taylor Attached for your records is a copy of each certification as referenced above, (Item #16A24) adopted by the Board of County Commissioners on Tuesday May 24, 2016. The Minutes and Record's Department has held the originals for the Board's Official Record. If you have any questions, please feel free to contact me at 252-8411. Thank you. Attachment 1fA2 U 11 PUBLIC OFFICER CONFLICT OF INTEREST CERTIFICATION . Collier County is a Florida Department of Transportation(FDOT)Local Agency Program(LAP)certified agency. The funding source for LAP projects is the Federal Highway Authority(FHWA); whereby grant dollars are passed through the FDOT via a LAP agreement. I certify that I have no present conflict of interest on the following project(s): Financial Project Numbers: 429899-1 New Market Road Sidewalk 433176-1 Pine Ridge Turn Lane 433177-1 Golden Gate Intersection 434990-1 GG Various Sidewalks 435030-1 Sunshine Blvd. Sidewalks 435116-1 GG Collector Sidewalk 435117-1 North Naples Sidewalks 435118-1 Vanderbilt Bike Lane/Sidewalk 435119-1 49th Terrace Sidewalks The projects listed above will have LAP funded construction engineering inspection services provided by AIM Engineering& Surveying,Inc. I further certify that I will recuse myself from any capacity of decision making, approval, disapproval or recommendation of any consultant/contractor/vendor for selection on any contract if I have a conflict of interest or potential conflict of interest. As set forth in Sections 112.313 and 334.193, Florida Statutes, public officers of an agency may not have any interest, fmancial or otherwise direct or indirect; engage in any business transaction or professional activity; or accept any obligation of any kind which is in conflict with the proper conduct of their duties in the public interest. By signing below, I attest that public officers should avoid any conduct that might undermine the public trust, whether or not that conduct is unethical or lends itself to the appearance of ethical impropriety; and that public officers in the State of Florida are expected to safeguard their ability to make objective, fair and impartial decisions, in part, by not accepting any benefit under circumstances that could be inferred by a reasonable observer that the benefit was provided to influence a pending or future decision,or to reward a past decision. I realize that a violation of the above mentioned statutes is punishable in accordance with Section 112.317 or Section 334.193,Florida Statutes, and could result in disciplinary action. ATTEST: BOARD OF COUNTY COMMISSIONERS DWIGHT E.BROCK,CLERK COLL R COUNTY,FLORIDA ce......_ By: Deputy Clerk PENNY TA OR,CO SSIONER :test as to Chairman s signature only. Dated: \---\a 2A�'�\�, Ap, ov-d as to fo.• . d -gality: am lir R.T-ach Deputy County Attorney [16-MBG-00259/1240262/1) 2__A /v' ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office SRT 5-24-16 4. BCC Office Board of County G\ Commissioners \ /\ $\z4\�, 5. Minutes and Records Clerk of Court's Office )954,1110 31Z� f""` PRIMARY CONTACT INFORMATION 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,may need to contact staff for additional or missing information. Name of Primary Staff Dan Hall -1-e6A5r.L%t•5• Contact Information 239-252-6077 Contact/ Department l Agenda Date Item was May 24,2016 Agenda Item Number 16A24V Approved by the BCC Type of Document "Public Officer Conflict of Interest Certification" Number of Original —Five Attached related to recently approved Agreement No. 15- Documents Attached 6456 for Construction Engineering and Inspection(CEI)for Local Agenc ogram (LAP)funded projects.Growt✓' :_,ment Grant Fund 711/Commissio '-r Hiller PO number or account n/a number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature SRT 2. Does the document need to be sent to another agency for additional signatures? If yes, SRT provide the Contact Information(Name;Agency;Address; Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be SRT signed by the Chairman, with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's SRT Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the SRT document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's SRT signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip SRT should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved by the BCC on May 24,2016 and all changes made SRT during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes, if applicable. 9. Initials of attorney verifying that the attached document is the version approved by t BCC,all changes directed by the BCC have been made, and the document is ready f the Chairman's signature. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revise 4.01Reu-i§ed 11/30/12 MEMORANDUM Date: May 25, 2016 To: Daniel Hall, Senior Project Manager Transportation Engineering & Construction Management From: Teresa Cannon, Deputy Clerk Minutes and Records Department Re: Public Officer Conflict of Interest Certifications — Commissioner Hiller Attached for your records is a copy of each certification as referenced above, (Item #16A24) adopted by the Board of County Commissioners on Tuesday May 24, 2016. The Minutes and Record's Department has held the originals for the Board's Official Record. If you have any questions, please feel free to contact me at 252-8411. Thank you. Attachment PUBLIC OFFICER CONFLICT OF INTEREST CERTIFICATION 1 6 A 2 4 Collier County is a Florida Department of Transportation(FDOT)Local Agency Program(LAP)certified agency. The funding source for LAP projects is the Federal Highway Authority(FHWA); whereby grant dollars are passed through the FDOT via a LAP agreement. I certify that I have no present conflict of interest on the following project(s): Financial Project Numbers: 429899-1 New Market Road Sidewalk 433176-1 Pine Ridge Turn Lane 433177-1 Golden Gate Intersection 434990-1 GG Various Sidewalks 435030-1 Sunshine Blvd. Sidewalks 435116-1 GG Collector Sidewalk 435117-1 North Naples Sidewalks 435118-1 Vanderbilt Bike Lane/Sidewalk 435119-1 49th Terrace Sidewalks The projects listed above will have LAP funded construction engineering inspection services provided by AIM Engineering& Surveying,Inc. I further certify that I will recuse myself from any capacity of decision making, approval, disapproval or recommendation of any consultant/contractor/vendor for selection on any contract if I have a conflict of interest or potential conflict of interest. As set forth in Sections 112.313 and 334.193, Florida Statutes, public officers of an agency may not have any interest, financial or otherwise direct or indirect; engage in any business transaction or professional activity; or accept any obligation of any kind which is in conflict with the proper conduct of their duties in the public interest. By signing below, I attest that public officers should avoid any conduct that might undermine the public trust, whether or not that conduct is unethical or lends itself to the appearance of ethical impropriety; and that public officers in the State of Florida are expected to safeguard their ability to make objective, fair and impartial decisions, in part, by not accepting any benefit under circumstances that could be inferred by a reasonable observer that the benefit was provided to influence a pending or future decision,or to reward a past decision. I realize that a violation of the above mentioned statutes is punishable in accordance with Section 112.317 or Section 334.193,Florida Statutes,and could result in disciplinary action. ATTEST: BOARD OF COUNTY OMMISSIONERS DWIGHT E.BROCK,CLERK COLLIER,COUNTY,F ORIDA _ bjevAD.LeirBy: `,Attest as to cfr4imialiNputy Clerk GEORdIA HILL R,COMMISSIONER signature only. Dated: o.. _ A prove. to.'o. d legality: \ I / 41111 Scott R.Teach Deputy County Attorney [16-M8G-00259/1240262/1] OVD ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO A THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURf 6 2 4 Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later than Monday preceding the Board meeting. **NEW** ROUTING SLIP Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office SRT 5-24-16 4. BCC Office Board of County Commissioners \-'s�/ S\-ZAVio 5. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION 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,may need to contact staff for additional or missing information. Name of Primary Staff Dan Hall Contact Information 239-252- 077 Contact/ Department Agenda Date Item was May 24,2016 I Agenda Item Number 16A24l Approved by the BCC Type of Document "Public Officer Conflict of Interest Certification" Number of Original e Oe......) Attached related to recently approved Agreement No. 15- Documents Attached 6456 for Construction Engineering and Inspection(CEI)for Local A ncy ogram (LAP)funded projects.Gro ManaAment Grant Fund 711/Commission ante i PO number or account n/a number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initial) Applicable) 1. Does the document require the chairman's original signature SRT 2. Does the document need to be sent to another agency for additional signatures? If yes, SRT provide the Contact Information(Name; Agency;Address;Phone)on an attached sheet. 3. Original document has been signed/initialed for legal sufficiency. (All documents to be SRT signed by the Chairman, with the exception of most letters,must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's SRT Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the SRT document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's SRT signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip SRT should be provided to the County Attorney Office at the time the item is input into SIRE. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 8. The document was approved by the BCC on May 24,2016 and all changes made SRT °� ���°� during the meeting have been incorporated in the attached document. The County . . Attorney's Office has reviewed the changes,if applicable. 9. Initials of attorney verifying that the attached document is the version approved by theF , , BCC,all changes directed bythe BCC have been made,and the document is readyf the y Chairman's signature. I, _A-• � I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,tvised 2.24.05;Rev.- d 11/30/12 I JP so4 k jf t :,,' w 4 MEMORANDUM Date: May 25, 2016 To: Daniel Hall, Senior Project Manager Transportation Engineering & Construction Management From: Teresa Cannon, Deputy Clerk Minutes and Records Department Re: Public Officer Conflict of Interest Certifications — Commissioner Nance Attached for your records is a copy of each certification as referenced above, (Item #16A24) adopted by the Board of County Commissioners on Tuesday May 24, 2016. The Minutes and Record's Department has held the originals for the Board's Official Record. If you have any questions, please feel free to contact me at 252-8411. Thank you. Attachment PUBLIC OFFICER CONFLICT OF INTEREST CERTIFICATION Collier County is a Florida Department of Transportation(FDOT)Local Agency Program(LAP)certified agency. The funding source for LAP projects is the Federal Highway Authority(FHWA);whereby grant dollars are passed through the FDOT via a LAP agreement. I certify that I have no present conflict of interest on the following project(s): Financial Project Numbers: 429899-1 New Market Road Sidewalk 433176-1 Pine Ridge Turn Lane 433177-1 Golden Gate Intersection 434990-1 GG Various Sidewalks 435030-1 Sunshine Blvd. Sidewalks 435116-1 GG Collector Sidewalk 435117-1 North Naples Sidewalks 435118-1 Vanderbilt Bike Lane/Sidewalk 435119-1 49th Terrace Sidewalks The projects listed above will have LAP funded construction engineering inspection services provided by AIM Engineering& Surveying, Inc. I further certify that I will recuse myself from any capacity of decision making, approval, disapproval or recommendation of any consultant/contractor/vendor for selection on any contract if I have a conflict of interest or potential conflict of interest. As set forth in Sections 112.313 and 334.193, Florida Statutes, public officers of an agency may not have any interest, financial or otherwise direct or indirect; engage in any business transaction or professional activity; or accept any obligation of any kind which is in conflict with the proper conduct of their duties in the public interest. By signing below, I attest that public officers should avoid any conduct that might undermine the public trust, whether or not that conduct is unethical or lends itself to the appearance of ethical impropriety; and that public officers in the State of Florida are expected to safeguard their ability to make objective, fair and impartial decisions, in part, by not accepting any benefit under circumstances that could be inferred by a reasonable observer that the benefit was provided to influence a pending or future decision,or to reward a past decision. I realize that a violation of the above mentioned statutes is punishable in accordance with Section 112.317 or Section 334.193,Florida Statutes,and could result in disciplinary action. ATTEST: BOARD OF COUNTY COMMISSIONERS DWIGHT E. BROCK,CLERK COLLIER CO ,FL A By: Ce t 33 t0 Chairn1an!£Deputy Clerk TIM NANCE,VICE CHAIRMAN signature only, Dated:\--\<,,-...\7-1-\ ,2\ Ap ro ed as to fo ,,_,an legally: i . e.ch t Deputy County Attorney [16-MBG-00259/1240262/1[ 5144