Custodial Statement Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Additional Emergency Contacts (also able to pick up child):
Mission Statement a. Employees are the most valuable resource in the City’s effective and efficient delivery of services to the public. The parties have a commitment to prevent drug or alcohol impairment in the workplace and to xxxxxx and maintain a drug and alcohol free work environment. The parties also have a mutual interest in preventing accidents and injuries on the job and, by doing so, protecting the health and safety of employees, co-workers, and the public.
Loan Application Buyer agrees, within a reasonable time, to make a good faith loan application with a credible financial institution;
CERTIFICATION STATEMENT Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be terminated and payment may be withheld if this certification is inaccurate. The contractor understands that it is the contractor’s responsibility to verify whether a child support obligor who is more than 30 days delinquent is the sole proprietor, partner, shareholder or owner with an ownership interest of at least 25%.
CMI/RAI MDS Report Recognizing the mutual objective of quality resident care, the Employer agrees to meet through the Union Management Committee with the Union as soon as practicable after the receipt of the annual CMI/RAI MDS report. The Employer agrees to provide the Union with staffing levels, and staffing mix information; the impact of related payroll costs on staffing levels and a written notice of the CMI/RAI MDS report for the facility. The purpose of this meeting is to discuss the impact of the CMI/RAI MDS report on the staffing levels in the Home, quality resident care, and provide the Union with an opportunity to make representation in that regard. The parties shall meet as necessary to discuss other changes or workload issues. The parties may invite additional participants to attend the meeting to support constructive review and discussion.
LITIGATION STATEMENT CHECK ONE [ ] The undersigned bidder has had no litigation and/or judgments entered against it by any local, state or federal entity and has had no litigation and/or judgments entered against such entities during the past ten (10) years. [ ] The undersigned bidder, BY ATTACHMENT TO THIS FORM, submits a summary and disposition of individual cases of litigation and/or judgments entered by or against any local, state or federal entity, by any state or federal court, during the past ten (10) years. COMPANY NAME AUTHORIZED SIGNATURE NAME (PRINT OR TYPE) TITLE Failure to check the appropriate blocks above may result in disqualification of your bid. Likewise, failure to provide documentation of a possible conflict of interest, or a summary of past litigation and/or judgments, may result in disqualification of your bid. E VERIFICATION CERTIFICATION Contract No.Y20-1058-MV I hereby certify that I will utilize the U.S. Department of Homeland Security’s E-Verify system in accordance with the terms governing the use of the system to confirm the employment eligibility of the individuals classified below. In accordance with s. 837.06, Florida Statutes, I understand and acknowledge that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duties shall be guilty of a misdemeanor in the second degree, punishable as provided in s. 775.082 or s. 775.083, Florida statutes. All persons, including subcontractors and their workforce, who will perform work under Contract No.Y20-1058-MV, Heavy Equipment Parts and Labor, within the state of Florida. NAME OF CONTRACTOR: ADDRESS OF CONTRACTOR: AUTHORIZED SIGNATURE: TITLE: DATE: RELATIONSHIP DISCLOSURE FORM FOR USE WITH PROCUREMENT ITEMS, EXCEPT THOSE WHERE THE COUNTY IS THE PRINCIPAL OR PRIMARY BIDDER For procurement items that will come before the Board of County Commissioners for final approval, this form shall be completed by the Bidder and shall be submitted to the Procurement Division by the Bidder. In the event any information provided on this form should change, the Bidder must file an amended form on or before the date the item is considered by the appropriate board or body. Part I INFORMATION ON BIDDER: Legal Name of Bidder: Business Address (Street/P.O. Box, City and Zip Code): Business Phone: ( ) Facsimile: ( ) INFORMATION ON XXXXXX’S AUTHORIZED AGENT, IF APPLICABLE: (Agent Authorization Form also required to be attached) Name of Bidder’s Authorized Agent: Business Address (Street/P.O. Box, City and Zip Code): Business Phone: ( ) Facsimile: ( ) Part II IS THE BIDDER A RELATIVE OF THE MAYOR OR ANY MEMBER OF THE BCC? YES NO IS THE MAYOR OR ANY MEMBER OF THE BCC THE BIDDER’S EMPLOYEE? YES NO IS THE BIDDER OR ANY PERSON WITH A DIRECT BENEFICIAL INTEREST IN THE OUTCOME OF THIS MATTER A BUSINESS ASSOCIATE OF THE MAYOR OR ANY MEMBER OF THE BCC? YES NO If you responded “YES” to any of the above questions, please state with whom and explain the relationship. (Use additional sheets of paper if necessary) Part III
LEAD WARNING STATEMENT Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, lessors must disclose the presence of lead-based paint and/or lead-based paint hazards in the dwelling. Student must also receive a federally approved pamphlet on lead poisoning prevention. That pamphlet is available at xxxx://xxx0.xxx.xxx/lead/protect-your-family-lead-your-home-1
DOCUMENTS COMPRISING THE BID 13.1 The bid to be prepared by the bidder shall comprise:
Pro Forma Statement The Receiver, as soon as practicable after Bank Closing, in accordance with the best information then available, shall provide to the Assuming Institution a pro forma statement reflecting any adjustments of such liabilities and assets as may be necessary. Such pro forma statement shall take into account, to the extent possible, (i) liabilities and assets of a nature similar to those contemplated by Section 2.1 or Section 3.1, respectively, which at Bank Closing were carried in the Failed Bank's suspense accounts, (ii) accruals as of Bank Closing for all income related to the assets and business of the Failed Bank acquired by the Assuming Institution hereunder, whether or not such accruals were reflected on the Accounting Records of the Failed Bank in the normal course of its operations, and (iii) adjustments to determine the Book Value of any investment in an Acquired Subsidiary and related accounts on the "bank only" (unconsolidated) balance sheet of the Failed Bank based on the equity method of accounting, whether or not the Failed Bank used the equity method of accounting for investments in subsidiaries, except that the resulting amount cannot be less than the Acquired Subsidiary's recorded equity as of Bank Closing as reflected on the Accounting Records of the Acquired Subsidiary. Any Loan purchased by the Assuming Institution pursuant to Section 3.1 which the Failed Bank charged off during the period beginning the day after the Bid Valuation Date to the date of Bank Closing shall be deemed not to be charged off for the purposes of the pro forma statement, and the purchase price shall be determined pursuant to Section 3.2.
Per-‐Registrar Transactions Report This report shall be compiled in a comma separated-‐value formatted file as specified in RFC 4180. The file shall be named “gTLD-‐transactions-‐yyyymm.csv”, where “gTLD” is the gTLD name; in case of an IDN-‐TLD, the A-‐label shall be used; “yyyymm” is the year and month being reported. The file shall contain the following fields per registrar: Field # Field name Description 01 registrar-‐name Registrar’s full corporate name as registered with IANA 02 iana-‐id For cases where the registry operator acts as registrar (i.e., without the use of an ICANN accredited registrar) 9999 should be used, otherwise the sponsoring Registrar IANA id should be used as specified in xxxx://xxx.xxxx.xxx/assignments/registrar-‐ids 03 total-‐domains total domain names under sponsorship in any EPP status but pendingCreate that have not been purged 04 total-‐nameservers total name servers (either host objects or name server hosts as domain name attributes) associated with domain names registered for the TLD in any EPP status but pendingCreate that have not been purged 05 net-‐adds-‐1-‐yr number of domains successfully registered (i.e., not in EPP pendingCreate status) with an initial term of one (1) year (and not deleted within the add grace period). A transaction must be reported in the month the add grace period ends.
