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Instructions for BLR 09110 -Page 2 of 2 <br /> Name of Clerk Insert the name of the LPA clerk. <br /> LPA Type Insert the type of clerk based on the LPA type. Types to choose from are: County, City, <br /> Town or Village. <br /> Name of LPA Insert the name of the LPA. <br /> Governing Body Type Insert the type of administrative body. choose Board for County; Council for a City or Town; <br /> President and Board of Trustees for a Village or Town <br /> Name of LPA Insert the name of the LPA, <br /> Date Insert the date of the meeting. <br /> Day Insert the day Clerk is signing the document. <br /> Month, Year Insert the month and year of the Clerk's signature. <br /> Seal The Clerk shall seal the document here, if required. If a seal is required, electronic signatures <br /> should not be used. <br /> Clerk Signature Clerk shall sign here. <br /> Approved The Department of Transportation shall sign and date here once approved. <br /> A minimum of three(3)certified signed originals must be submitted to the Regional Engineer's District office OR email PDF <br /> completed form with electronic signatures to your local District LRS office. <br /> Following IDOT's approval, distribution will be as follows: <br /> Local Public Agency Clerk <br /> Engineer(Municipal, Consultant or County) <br /> District <br /> Printed 11/20/25 BLR 09110(Rev.01/18/23) <br />