R2011-68 AUTHORIZING AN AGREEMENT WITH TELE SCAN, INC.

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f Exhibit G B. No department director or any employee or any officer of the City of Decatur has any financial interest,directly or indirectly, in the award of this contract except as listed on a separate attached sheet to this affidavit. C. That the Professional Service Provider is not barred from bidding on any contract as a result of violation of 720 ILCS 5/33E-3 and 5/33E-4(Bid Rigging or Bid Rotating). SECTION III. DRUG FREE WORKPLACE AND DELINQUENT ILLINOIS TAXES STATEMENT The undersigned states under oath that the Professional Service Provider is in full compliance with the Illinois Drug Free Workplace Act,30 ILCS 580/1,et. seq. The undersigned also states under oath and certifies that the Professional Service Provider is not delinquent in payment of any tax administered by the Illinois Department of Revenue except that the taxes for which liability for the taxes or the amount of the taxes are being contested in accordance with the procedures established by the appropriate Revenue Act; or that the Professional Service Provider has entered into an agreement(s)with the Illinois Department of Revenue for the payment of all taxes due and is in compliance with the agreement. (65 ILCS 5/11-42.1-1) SECTION IV. FAMILIARITY WITH LAWS STATEMENT The undersigned,being duly sworn,hereby states that the Professional Service Provider and its employees are familiar with and will comply with all Federal, State and local laws applicable to the project, which may include,but is not limited to,the Prevailing Wage Act and the Davis-Bacon Act. PR SI SERVICE PROVIDER i ature Printed Name Title SUBSCRIBED and SWORN to before me this,�k day of ,20 1 ( . Cut, Notary Public ++++++++++++++++++++++ + "OFFICIAL SEAL" + + MARY BETH EWING + + NOTARY PUBLIC,STATE OF ILLINOIS + + MY COMMISSION EXPIRES 11-03-2011 + G-3