HomeMy WebLinkAboutGRNT - Multi-Jurisdictional Trfc Sgnl C & S CITY OF PALM DESERT
PUBLIC WORKS DEPARTMENT
STAFF REPORT
REQUEST: Authorize the Director of Public Works to Apply for a Matching
Grant for a Multi-jurisdictional Traffic Signal Coordination and
Synchronization Project on Major Corridors, and to Act as Lead
Agent on the Project
SUBMITTED BY: Mark Greenwood, P.E., Director of Public Works
DATE: March 12, 2009
ATTACHMENT: MSRC Local Government Match Program Announcement and
Application Materials
Vicinity Map
Recommendation:
By Minute Motion:
1.) Authorize the Director of Public Works to apply for an MSRC Clean
Transportation Funding grant for a multi-jurisdictional traffic signal
coordination and synchronization project;
2.) Authorize the Director of Public Works to seek partnership participation
from adjacent cities and to serve as lead agent on the project; and
3.) Obligate an amount not to exceed $50,000 from Traffic Signal Fund
234, to be reimbursed by grant funds at a rate of 50%, resulting in a
total expenditure of$25,000.
Background and Discussion:
The Mobile Source Air Pollution Reduction Review Committee (MSRC) recently
announced funding available under its Local Government Match Program. Under this
program, eligible cities and counties may apply for matching grant funds under six
project categories. A new category, added this year, is the "Multi-Jurisdictional Traffic
Signal Coordination & Synchronization" category.
Staff believes this program offers a good opportunity to leverage the City's traffic signal
funds. With Council approval, staff will seek to partner with the cities of La Quinta,
Indian Wells, and Rancho Mirage, and to lead a project that will result in traffic signal
coordination and synchronization along three major corridors:
Staff Report
MSRC Grant
Page 2 of 2
March 12, 2009
• Monterey Avenue between Highway 111 and the I-10 Interchange
• Washington Street befinreen Highway 111 and the I-10 Interchange
• Highway 111 from Jefferson Street to as far as Frank Sinatra
The grant application filing period begins on March 24. Staff attended a workshop on
March 4, where it was learned that funds will be awarded on a first-come, first-served
basis and that qualifying applications received on the first day of filing will be funded at
some level.
Fiscal Impact: This is a matching fund grant; therefore, the City must obligate
certain funds to be reimbursed at 50%. It is recommended that Council set a not-to-
exceed amount of$50,000, resulting in a maximum net expenditure of $25,000.
Therefore, staff recommends that City Council, by Minute Motion, authorize the Director
of Public Works to apply for an MSRC Clean Transportation Funding grant for a multi-
jurisdictional traffic signal coordination and synchronization project; authorize the
Director of Public Works to seek partnership participation from adjacent cities and to
serve as lead agent on the project; and obligate an amount not to exceed $50,000 from
Traffic Signal Fund 234, to be reimbursed by grant funds at a rate of 50%.
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Prepared By: Departm nt ead:
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ark Diercks, P.E. Mark Gre nwood, P. .
Transportation Engineer Director of Public Works
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Announcing the MSRC's Clean Transportation Funding
Local Government Match Program
FY 2008/2009
A Funding Opportunity for Cities & Counties in the
South Coast Air Quality Management District
Program Announcement & Application
PA2009-07
February 6, 2009
C�ean Transp�arta�a�
Funding from the MSRC
��n��..�n�„<�a:,����,�,z�,���„�,,-,�>„�E�;A�, �,��Et��
DATE: February 6, 2009
TO: Local Government Official
FROM: Ron Roberts, Chair, MS RC
SUBJECT: MSRC Local Government Match Program Announcement
The Mobile Source Air Pollution Reduction Review Committee (MSRC) is pleased to announce
a new round of Clean Transportation FundingT"" available exclusively to cities and counties
within the South Coast Air Quality Management District (AQMD). The Local Government Match
Program offers to co-fund Alternative Fuel Infrastructure and Heavy-Duty Vehicle projects
implemented by cities and counties that utilize their Motor Vehicle Registration Fee Subvention
Funds, commonly referred to as AB 2766 Subvention Funds. The MSRC, using its
Discretionary Funds, will contribute match funding towards qualifying projects. All cities and
counties within the jurisdiction of the AQMD who receive AB 2766 Subvention Funds are eligible
to participate in this Program.
Eligible project categories for this year's Local Government Match Program have been
expanded significantly to better support cities' and counties' air quality improvement needs. Six
project categories are eligible to receive MSRC matching funds under the FY 2008-'09 Program.
Three categories are continued from last year's highly successful program:
■ New, Expanded, or Upgraded Alternative-Fuel Infrastructure
■ Purchase of Heavy-Duty Alternative Fuel Vehicles
■ Remote Fleet Vehicle Diagnostics
New Match Program categories for FY 2008-'09 include:
■ Off-Road Vehicle Diesel Engine Re-Powers and Verified Diesel Emission Control
System Retrofit Devices
■ Emergency Response Vehicle Diesel Engine Re-powers and Verified Diesel Emission
Control System Retrofit Devices
■ Multi-Jurisdictional Traffic Signal Coordination & Synchronization
Please refer to the Program Announcement for more details on all eligible Match Program
project categories.
As in past years, local governments can also earn an MSRC match contribution on locally
generated public funds in addition to AB 2766 Subvention Funds. This would apply to cities or
counties which have fully obligated or appropriated their Subvention Fund balances, but still
have unmet requirements for qualifying projects. The requirements and conditions relative to
MSRC Clean Transportation FundingT""
FY'08/'09 Local Govemment Match Program
this Program feature are discussed in detail in subsequent Sections of this Program
Announcement.
MSRC staff is available to assist applicants during the preparation of their Local Government
Match Program applications. Please refer to Section I of the Program Announcement for a
listing of MSRC Staff points of contact.
Should you have any immediate questions regarding this Program Announcement, please
contact Ray Gorski, MSRC Technical Advisor, at (909) 396-2479, or Ms. Cynthia Ravenstein,
MSRC Contracts Administrator, at (909) 396-3269. The Announcement and Application
documents can also be accessed via the Internet by visiting MSRC's Clean Transportation
FundingT"^ website at www.cleantransportationfundinq.orq .
On behalf of the MSRC Clean Transportation Funding Program, we look forward to working with
you to develop air qu ality improvement projects for your community.
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MSRC Clean Transportation Fundingr""
FY'08/'09 Local Government Match Program
TABLE OF CONTENTS
Page
Section I: Program Introduction........................................................................ 1
I.A. Program Schedule....................................................................................... 2
I.B. Applicant Workshop 2
I.C. Participation Guidelines, Requirements, and Conditions...................................... 2
I.D. Application Submittal Instructions......... ....................................... 5
I.E. Application Preparation Overview....................................................................... 7
I.F. If You Need Help... ............................................................................................... 8
Section II: Alternative Fuel Infrastructure Projects.............................................. 9
II.A. Alternative Fuel Infrastructure Application Forms........................................... 12
Section III: Purchase of Alternative Fuel Heavy-Duty Vehicles............................... 18
III.A. Vehicle Purchase Application Forms........................................................... 19
Section IV: Emergency Response Vehicle Re-Powers 8� Retrofits........................ 23
IV.A. Emergency Response Vehicle Application Forms.......................................... 27
Section V: Off-Road Equipment Re-Powers & Retrofits ...................................... 32
V.A. Off-Road Equipment Application Forms.................................................... 35
Section VI: Multi-Jurisdictional Traffic Signal Coordination 8�Synchronization....... 40
VI.A. Traffic Signal Coordination Application Forms ............................................. 43
Section VII: Remote Fleet Vehicle Diagnostics................................................... 49
VII.A. Fleet Vehicle Diagnostics Application Forms ............................................. 51
Section VIII: Application Checklist............................................................................... 55
Section IX: Sample Contract............................................................................. 56
Section X: W-9 &Insurance
Forms............................................................................................................. 66
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MSRC Clean Transportation FundingT""
FY'08/'09 Local Government Match Program
SECTION I: PROGRAM INTRODUCTION
The Mobile Source Air Pollution Reduction Review Committee (MSRC) is pleased to announce a
Clean Transportation FundingT"^ opportunity available exclusively to cities and counties within the
South Coast Air District. The Local Government Match Program (Match Program) offers to co-fund
clean air projects implemented by cities and counties utilizing their AB 2766 Subvention Funds. The
MSRC, using its Discretionary Funds, will contribute a "funding match" towards a qualifying project.
The MSRC has allocated $3.0 million in Clean Transportation FundingT"' forthe Match Program.
The primary goal of the Match Program is to assist local governments in meeting their obligations
under the South Coast AQMD Fleet Rules. The Program encourages development of new, publicly
accessible alternative-fuel refueling infrastructure, and offers funding assistance to local jurisdictions
when purchasing low-emission, clean fuel heavy-duty vehicl es.
All cities and counties within the jurisdiction of the South Coast AQMD who receive AB 2766
Subvention Funds are eligible to participate in this Match Program. Applications will be accepted
beginning on March 24, 2009 and continuing through May 29, 2009. At this time, the MSRC does not
envision any extensions to the term of the Match Program application acceptance period.
The Match Program is not a competition in the traditional sense. Funding will be distributed on a first-
come, first-served basis to applicants that satisfy specified project requirements. However, as funding
is limited, the availability of match funds cannot be guaranteed.
MSRC contributions under the Matc h Program are as follows:
■ A "dollar for dolla�" match against AB 2766 Subvention Funds and/or other local public funds
applied towards qualifying alternative-fuel refueling infrastructure (Section II);
■ A dollar for dollar match against AB 2766 Subvention Funds and/or other local public funds for
qualifying heavy-duty vehic les(Section III);
■ A dollar for dollar match against AB 2766 Subvention Funds and/or other local public funds for
municipal fleets that re-power or retrofit emergency response vehicl es(Section IV);
■ A dollar for dollar match against AB 2766 Subvention Funds and/or other local public funds for
municipal fleets that re-power or retrofit off-road diesel equipm ent(Section V);
■ A 50% match against AB 2766 Subvention Funds and/or other local public funds for
jurisdictions that partner with neighboring cities, counties, or Caltrans to implement multi-
jurisdictional traffic signal coordination and synchronization projects; i.e., an MSRC
contribution of $0.50 for each Subvention Fund and/or local fund dollar applied towards the
qualifying synchronization project(Section VI);
■ A dollar for dollar match against AB 2766 Subvention Funds and/or other local public funds for
municipal fleets that equip their light and medium-duty vehicles with qualifying remote vehicle
diagnostics and smog check devices. (Section VII).
A thorough discussion of the Local Government Match Program categories, participation
requirements, and project guidelines is included in Section I.C., "Participation Guidelines,
Requirements, & Conditions", below.
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MSRC Clean Transportation FundingT"'
FY'08/'09 Local Government Match Program
I.A. PROGRAM SCHEDULE
The MSRC Local Government Match Program will be conducted in accordance with the timeline
illustrated in Table I.A-1, below. As shown, project applications will be accepted beginning on March
24, 2009. Applications will be accepted through May 29, 2009. Applications may be submitted at any
time during this period. Funds will be awarded on a first-come, first-served basis for eligible
projects that conform to Match Program requirements during the application acceptance
period or until such time as all available proqram funds have been expended.
Table I.A-1 Key Program Dates
Subvention Fund Match Program Event Date
Program Announcement&Application Release February 6, 2009
Applicant Workshop March 4, 2009
Earliest Date for Application Submission March 24, 2009
Last Date that Applications Will Be Accepted No later than 5:00 pm on
May 29, 2009
I.B. APPLICANT WORKSHOP
An Applicant Workshop for the Local Government Match Program will be held on March 4, 2009.
Please note that attendance at the applicant workshop is voluntarv. The purpose of the
workshop is to provide new or updated solicitation information, provide clarification regarding this
Program Announcement & Application package, and answer general questions regarding application
preparation. In addition, the applicant workshop will provide a forum to address individual application
preparation issues and provide one-on-one guidance to potential bidders. The location and time for
the applicant workshop is as follows:
Date: March 4, 2009
Time: 10:30 a.m. — 11:30 a.m.
Location: South Coast AQMD Headquarters
Conference Room CC6
Address: 21865 Copley Drive
Diamond Bar, Cal ifornia 91765
In addition, MSRC staff members are available to answer questions and provide technical guidance
as appropriate during the application acceptance period. Please refer to Section I.F. of this document
for a list of MSRC Staff contacts.
I.C. PARTICIPATION GUIDELINES, REQUIREMENTS, 8� CONDITIONS
The MSRC's Local Government Match Program has been designed to make the application and
participation requirements uncomplicated for the cities and counties within the South Coast Air
District. However, to ensure that the Match Program conforms to all applicable AQMD regulations
and MSRC policies, the following requirements and conditions have been established and apply to all
applicants:
1. Earliest Date for an MSRC-Funded Project to Commence — The release date of this Program
Announcement, February 6, 2009, is the earliest date work on a project can commence and be
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MSRC Clean Transportation FundingT'"
FY'08/'09 Local Government Match Program
potentiallv eligible for MSRC Local Government Match Funding. Any expenditures made in
anticipation of an award of MSRC Local Government Match Funding and prior to execution of a
contract are solely at the proposer's risk. If no Local Government Match Fund contract is
executed, neither the MSRC nor South Coast AQMD are liable for payment of any funds
expended in anticipation of a contract. Please note that in the event a contract is executed,
reimbursement for any costs incurred by the proposer in anticipation of the contract is at the
discretion of the M SRC and South Coast AQMD.
2. Funding Availability - The amount of FY 2008-'09 MSRC Clean Transportation FundingT"^
allocated for the Match Program is $3.OM. Funding is available on a first-come, first-served basis
to applicants proposing qualifying projects. For the purpose of this Match Program, all qualified
project applications received on or before 5:00 p.m. on the first day of the Application Acceptance
Period, March 24, 2009, will be deemed received at the same time. In the event the Match
Program is oversubscribed following receipt of first-day applications, MSRC funds will be
distributed on a pro rata share basis to qualified project applications. Please note that the
Geographic Funding Minimums discussed in paragraph 5, below, will take precedence in the
event funding must be pro-rated. Qualifying applications received after 5:00 p.m. on March 24,
2009 will be funded in the order of receipt. Please note that as MSRC funding is limited, the
availability of match funding cannot be guaranteed.
3. MSRC Match Funding Percentages — The MSRC will match AB 2766 Subvention Funds and
Local Funds in accordance with the following guidelines:
■ Alternative Fuel Infrastructure: The MSRC will match AB 2766 Subvention Funds and/or other
Local Funds on a "dollar for dolla�" basis'. The maximum MSRC match amount per project for
permanent installations shall not exceed $400,000 under this category; the maximum MSRC
match amount for mobile or temporary hydrogen refueling infrastructure shall not exceed
$150,000 under this category;
■ Heavv-Dutv Vehicle Purchases: The MSRC will match AB 2766 Subvention Funds and/or
other Local Funds dollar for dollar in an amount not to exceed $25,000 per qualifying heavy-
duty vehicle. This is discussed further in Section III;
■ Emergency Response Vehicle Re-Powers & Retrofits: The MSRC will match AB 2766
Subvention Funds and/or other Local Funds dollar for dollar for emergency response vehicle
re-powers, not to exceed an MSRC contribution of $50,000 per emergency response vehicle
re-power. In addition, the MSRC will match AB 2766 Subvention Funds and/or other Local
Funds dollar for dollar for emergency response vehicle retrofits with verified Level 3 diesel
emission control devices, not to exceed an MSRC contribution of $20,000 per emergency
response vehicle retrofit. The funding target for Emergency Response Vehicle projects under
this Program Announcement is $750,000. This is discussed further in Section IV;
■ Off-Road Equipment Re-Powers & Retrofits: The MSRC will match AB 2766 Subvention
Funds and/or other Local Funds dollar for dollar for off-road vehicle re-powers, not to exceed
an MSRC contribution of $50,000 per off-road vehicle re-power. In addition, the MSRC will
match AB 2766 Subvention Funds and/or other Local Funds dollar for dollar for off-road
vehicle retrofits with verified Level 3 diesel emission control devices, not to exceed an MSRC
contribution of$20,000 per off-road vehicl e retrofit. This is discussed further in Section V;
■ Multi-Jurisdictional Traffic Siqnal Coordination & Svnchronization: The MSRC will provide a
matching contribution not to exceed $0.50 for each dollar of A B 2766 S ubvention F unds and/or
other Local funds committed by the local government. This is discussed further in Section VI.
' i.e., the MSRC will not pay more than 50% of project costs.
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MSRC Clean Transportation Fundingr"'
FY'08/'09 Local Government Match Program
The maximum MSRC match amount per project shall not exceed $150,000; the total m aximum
funding allocation for this category shall not exceed $500,000;
■ Fleet Manaqement & Remote Vehicle Diaqnostics: The MSRC will match AB 2766 Subvention
Funds and/or other Local Funds dollar for dollar. The maximum MSRC match amount per
project shall not exceed $50,000 under this category. The total allocated funding for Remote
Vehicle Diagnostics under this Program Announcement is $250,000. This is discussed further
in Section VII.
4. Definition of Local Funds— For the purpose of the Match Program, "Local Funds" are defined as
revenues or other public money that is generated at the local jurisdictional level, including but not
limited to Measure A, Measure C, other local sales tax, and local fees and assessments. Local
Funds do not include State or Federal funding allocations and grants, South Coast AQMD funding
grants, or other revenues that are not locally generated.
5. Geographical Funding Minimum - The MSRC has established a Geographical Funding
Minimum for each county within the AQMD. The geographical funding minimum amount has been
set at $375,000 per county. This funding set-aside guarantees a minimum level of funding for
each county to implement clean fuel projects. At the end of the application submittal period, May
29, 2009, if any county has funds remaining in its geographical minimum, these funds will be
made available to qualifying projects from any other county in order of receipt.
6. Eligibility Requirements — Only cities and counties within the South Coast Air District that
receive AB 2766 Subvention Funds are eligible to submit an application underthe Match Program.
In addition, the contracting entity for the project must be the city or county who submitted the
application. Participation by other agencies or private businesses is allowed, but would be
handled through separate subcontracts or agreements with the funded applicant. Please be
aware that the applying city or county is solely responsible for the performance of any Contract
under the Match Program.
7. Project Teaming - Teaming by cities and/or counties, and the pooling of AB 2766 Subvention
Funds, is encouraged. Please note that a lead team member must be designated for the purpose
of application submittal and contracting. If desired, multiple cities and/or counties may form a
Joint Powers Authority (JPA)for the purpose of application submittal and contracting. Please note
that all members of the JPA must meet the eligibility requirements of the preceding paragraphs. A
letter designating the lead agency and authorizing such agency to act on behalf of their interests
must be submitted from each participating city and/or county as an element of the project
application.
8. MSRC Match Funds Paid on a Reimbursement Basis Only — MSRC Clean Transportation
Funding�" match funds will be distributed on a Reimbursement Basis only upon completion of the
approved project and subm ission of all required reports and invoices.
9. Use of Future AB 2766 Subvention Fund Allocations — In addition to their existing Subvention
Fund balances, cities and counties may also apply their anticipated AB 2766 Subvention Funds
from the fiscal year commencing July 1, 2009 and ending June 30, 2010 to projects proposed
under the MSRC Match Program. However, any existing subvention fund balance must be
fully encumbered or allocated prior to proposing the use of future funds.
10. Project Completion Deadlines — All projects must be 100% completed within 24 months of
contract execution.
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MSRC Clean Transportation FundingT""
FY'08/'09 Local Government Match Program
11. Reporting Requirements — The reporting requirements established for the Match Program are
intended to ensure adequate monitoring of the use of publi c funds, while avoiding the im position of
excessive reporting burdens on the funding recipients. Individual reporting requirements will be a
function of the type of project proposed. Refer to Sections II, III, IV, V, VI and VII of this
document. for a description of reporting requirements .
12. Promotion Requirements: Funding recipients under the Local Government Match Program are
required to perform public outreach to promote their MSRC co-funded project. Acceptable
outreach may include, but is not limited to, notices included in city/county mailings, newspaper
notices, flyers, information items at council meetings and com munity events, etc.
13. Audit Requirements — In accordance with state law, all projects funded with MSRC Discretionary
Funds are subject to audit. The provisions of the audit are discussed in the Sample Contact,
included as Section IX of this document. It is highly recommended that applicants employ
standard governm ent accounting practices w hen admi nistering their M SRC co-funded project.
14. Additional Conditions on MSRC Match Funding
• Projects funded under the MSRC Match Program are not eligible to apply for additional
MSRC funds under any other MSRC Work Program solicitation;
• Projects awarded MSRC funding under a previous Work Program are not eligible to
receive additional M SRC Discretionary Funds under this P rogram;
• MSRC matching funds over and above the original contract amount will NOT be
available for any reason, including project cost overruns. Applicants must use
additional subvention funds or sources other than MSRC Discretionary Funds to cover
foreseen or unforeseen project cost increases. (The 5% cont�act value increase
typically allowable in MSRC Discretionary Fund contracts will not be available under
the Local Government Match Program);
• MSRC match funds are not intended to fund existing staff salaries. Project
management costs necessary to implement new alternative fuel infrastructure projects
are allowable; however, the MSRC reserves the right to reduce or delete project
management costs that appear excessive.
I.D. APPLICATION SUBMITTAL INSTRUCTIONS
A Project Application must be completed and submitted to participate in the Local Government Match
Program. The necessary forms for each category are included in Sections II, III, IV, V, VI and VII of
this document. Applications must be submitted in accordance with the instructions outlined below and
all requested information must be supplied.
1. Application Elements -All applications must contain the following:
a) Cover letter - Transmittal of the application must be accompanied by a cover letter affirming
that the lead city or county has approved the proposed project. The letter must be siqned by
the person(s)authorized to contractually bind the proposinq entitv.
For joint applications (from more than one city and/or county) the applicant must include a
statement confirming authorization to act on behalf of the other co-applicants. The applicant
must include a letter of support, including contact name and telephone/fax number, from all
proposing entities of a joint application.
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MSRC Clean Transportation FundingT""
FY'08/'09 Local Govemment Match Program
b) EXHIBITS A-D - Applications must include the following completed EXHIBITS, including all
required attachm ents and supporting docum entation as requested:
■ EXHIBIT A: Applicant Information
■ EXHIBIT B: Project Description/Statement of Work
■ EXHIBIT C: Project Budget
■ EXHIBIT D: Project Implementation Schedule
c) Certifications: All applicants must submit the following located in Section X, as an element of
their Application:
• Internal Revenue Service Form W-9 — Request for Taxpayer ldentification Number and
Certification. If you are selected for an award, you cannot be established as a vendor
without this information.
■ Certificate of Insurance or Letter of Self Insurance. If the applicant is unable to provide the
certificate of insurance as an element of the application, a statement by the applicant
affirming that the certificate will be provided within 45 days of notification of a funding
award will be sufficient. Please note that all MSRC Discretionary Fund contracts require a
Certificate of Insurance or Letter of Self Insurance;
2. Application Submittal Instructions - All applicants must submit one (1) original application and
three (3) copies (total of four) in a sealed envelope, marked in the upper left-hand corner with the
name and address of the applicant and the words "PA2009-07, Local Government Match
Program". The original application should be submitted unbound on white, 8 '/2" x 11" paper.
When possible, any charts, illustrations, pictures, etc. should be affixed to standard size paper to
facilitate reproduction. The earliest date for application submittal is March 24, 2009. All
applications received prior to 5:00 p.m. on March 24, 2009 will be deemed received at the same
time. Please note that Match Program applications must be received no later than 5:00 p.m. on
May 29, 2009 to be considered for funding. All applications should be directed to:
Procurement Unit
South Coast Air Quality Management District
21865 Copley Drive
Diamond Bar, CA 91765
Please note that faxed or e-mailed applications will not be accepted.
3. Addenda — The Mobile Source Air Pollution Reduction Review Committee may modify the
Program Announcement and/or issue supplementary information or guidelines relating to the
Program Announcement during the application preparation period of February 6, 2009 to May 29,
2009. Please note that Program Announcement amendments will be posted on the MSRC
website at www.cleantransportationfundinq.orp .
4. Application Modifications - Once submitted, applications cannot be altered without the prior
written consent of the M obile Source Air Pollution Reduction Review Committee.
5. Application Screening - Applications received in response to the Local Government Match
Program Announcement will be screened to insure they comply with all program requirements and
policies of the MSRC and South Coast AQMD. The screening criteria are as follow s:
■ Proposed project must be sponsored by an eligible AB 2766 Subvention Fund recipient;
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MSRC Clean Transportation FundingT""
FY'O8/'09 Local Government Match Program
■ Applications are required to contain all requested information delineated in Section I.E. of this
document.
6. Application Evaluation and App�oval Process - Applications will be evaluated as received to
ensure compliance with Match Program requirements. Applications that do not comply with the
stipulated requirements will be returned to the project applicant for revision and resubmission.
Only applications received that comply with all minimum submission requirements will be deemed
acceptable. Any returned applications will lose their original submittal date and, if resubmitted, will
be issued a new date upon receipt by the MSRC for purposes of disbursing funds on a first-come,
first-serve basis.
Applications deemed compliant by MSRC staff will be forwarded to the MSRC Technical Advisory
Committee (MSRC-TAC) for review and concurrence with staff's recommendation. Following
MSRC-TAC approval, a funding recommendation will be forwarded to the MSRC for approval. For
all applications recommended for approval by the MSRC-TAC, the applicant will be requested to
complete a Campaign Contributions Disclosure Form, which will be provided by MSRC staff at the
appropriate time.
Applications recommended for funding by the MSRC will be forwarded to the South Coast AQMD
Governing Board for final approval. Please note that the MSRC reserves the right to not fund any
projects in this Program, to modify award amounts, or reallocate part of all funding under this
Program to another MSRC Clean Transportation FundingTM category.
Upon receipt of Governing Board approval, the MSRC Staff will prepare a contract for execution
by the applicant. The time period from AQMD Governing Board approval to contract execution is
anticipated to be approxim ately ninety (90) days.
I.E. APPLICATION PREPARATION OVERVIEW
In an effort to reduce the paperwork burden on applicants, a template-based application format has
been adopted by MSRC for Local Governm ent Match Program applications.
Forms are included specific to each of the following sections of this Program Announcement. The
forms are designed to be self-explanatory and should prove straightforward to complete. However,
should questions arise during the application preparation, please contact the appropriate MSRC staff
representative as shown in Section I.F.
The forms included in the following Exhibits should be completed by the applicant and submitted in
accordance with the instructions provided in Section I.D.2, "Application Submittal Instructions", above.
The exhibits are briefly sum marized as follows:
■ Exhibit A, "Applicant Information", requests general information from the applicant. This
information is to be provided in the desi gnated spaces on the tem plate;
■ Exhibit B, "Project Description/Statement of Work, requests that the appli cant provide a Project
Description/Statement of Work delineating: a) project goals and objectives; b) statement of
work; and c) project end products. Please note that only the requested input data is required;
applicants are not required to perform emissions reductions calculations as an element of their
Match Program application;
■ Exhibit C, "Project BudgeY', requests a cost breakdown of the proposed project including: a)
total project cost; b) AB 2766 funds from current fund balance allocated to the proposed
project; c) AB 2766 Subvention Funds allocated from the FY 2008-'09 appropriation; d) Local
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MSRC Clean Transportation FundingT""
FY`08/'09 Local Government Match Program
Funds allocated to the proposed project; e) MSRC match funds requested (per the maximum
allowable contributions as discussed in Section I.C., above; and f) additional funding
contributions to the project other than MSRC Discretionary Funds, AB 2766 Subvention
Funds, orqualifying Local Funds;
■ Exhibit D, "Project Implementation Schedule", requests the submittal of a schedule depicting
key project milestones, task completion dates, etc. Please note that all projects must be
completed no later than 24 m onths from the date of contract exec ution.
If awarded MSRC match funds, Exhibits A-D will become integral elements of the contract between
the applicant and the M SRC.
I.F. IF YOU NEED HELP
This Program Announcement and Application can be obtained by accessing the MSRC web site at
www.cleantransportationfundinq.orq . MSRC staff members are available to answer questions during
the application acceptance period. In order to help expedite assistance, please direct your inqui ries to
the applicable staff person, as fol lows:
■ For General, Administrative, or Contractual Questions, please contact:
Cynthia Ravenstein, MSRC Contracts Administrator
Phone: 909-396-3269
FAX: 909-396-3682
E-mail: cvnthiaCa�cleantransportationfundi ng.orq
■ For Technical Assistance, please contact:
Ray Gorski, MSRC Technical Advisor
Phone: 909-396-2479
FAX: 909-396-3682
E-mail: ravCa�cleantransportationfundinq.orq
■ For Contractual Assistan ce, please contact:
Dean Hughbanks, AQMD Procurement Manager
Phone: 909-396-2808
E-mail: dhuqhbanks(a�aqmd.qov
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SECTION VI: MULTI-JURISDICTIONAL TRAFFIC SIGNAL COORDINATION &
SYNCHRONIZATION
Introduction: Everyone knows iYs easier to drive on an arterial roadway when you can move with the
flow of traffic through a series of intersections where the light turns green just ahead of you. That is
the benefit from traffic signal synchronization - a coordinated set of timing plans for a group of signals
on an arterial that creates a smooth traffic flow. The goal is to allow cars and buses to move through
the arterial with the fewest stops at intersections, while at the same time minimizing delay for the side
streets.
There is, however, an additional benefit to traffic signal synchronization above and beyond driver
convenience. Automobiles typically emit higher levels of pollutants during deceleration and
acceleration. Thus, "stop and go" driving conditions contribute significantly to air pollution in
congested urban areas. By synchronizing traffic signals along an arterial, the number of"red lights" a
vehicle encounters is reduced, resulting in lower engine emissions. When multiplied by the number of
vehicles that traverse an arterial corridor during periods of peak traffic volume, even a small reduction
in an individual engine's emissions can yield significant benefits. In addition, synchronization also
results in an overall increase in average vehicle speed, and is a recognized strategy to mitigate
roadway congestion.
Traffic signals are typically synchronized along arterial streets to facilitate smooth cross-town
commuting. However, the synchronization of signals is generally performed within the borders of
individual jurisdictions. For motorists traveling along an arterial street, crossing a municipal boundary
generally means an unnecessary stop as they pass from one signal system to the next.
This Local Government Match Program category is intended to encourage collaboration between
adjacent cities and counties to precisely coordinate and synchronize traffic signal systems across the
shared boundaries. While the category is broad in terms of scope and project eligibility, the MSRC
has adopted the following project implementation parameters in an effort to maximize program
effectiveness.
Traffic Signal Project Requirements 8� Conditions: The following requirements apply to
applications seeking funding for the implementation of multi-jurisdictional traffic signal coordination
and synchronization projects:
• Multiple Participants Requirement - The intent of this category is to incentivize local
governments to partner with neighboring jurisdictions and pool resources to implement multi-
jurisdictional traffic flow improvement projects. As such, the MSRC requires that an
application be submitted on behalf of two or more eligible participants.
• Definition of "Eligible Participant" - Eligible participants include cities and counties within
the South Coast AQMD who receive AB 2766 Subvention Funds. For the purpose of this
Program Category, the California Department of Transportation (Caltrans) is also deemed an
Eligible Participant.
■ Other Participants - The MSRC recognizes that cities and counties may choose to retain the
services of professional traffic engineering firms when implementing traffic flow improvement
projects. The use of commercial traffic management consultants is allowable under this
Program; however, these professional firms are not considered eligible participants as defined
above. Applicants intending to use consultants to assist in project implementation must still
meet the requirements relative to minimum eligible participants.
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■ Joint Application Requirements 8� Options - Teaming by cities and/or counties and the
pooling of AB 2766 Subvention Funds is required under this project category. A lead team
member must be designated for the purpose of application submittal and contracting. If
desired, multiple cities and/or counties may form a Joint Powers Authority (JPA) for the
purpose of application submittal and contracting. Please note that all members of the JPA
must meet the eligibility requirements of this Local Match Program category. A letter
designating the lead agency and authorizing said agency to act on behalf of their interests
must be submitted by each eligible participant as an element of the project appl ication.
■ Minimum Amount of Subvention Funds/Local Funds Applied to Project - Each eligible
participant must commit a minimum AB 2766 Subvention Fund and/or qualifying Local Fund
contribution to the proposed traffic signal project. For the purpose of this Category, the
minimum contribution from each eligible participant is 5°/a of the total project cost. For projects
that partner with Caltrans, it is not required that Caltrans make a minimum contribution
towards project im plementation.
■ Lead Agency Restriction - Although Caltrans is deemed an eligible participant under this
category, Caltrans cannot serve in the capacity of project Lead Agency and cannot be the
contract signatory.
Eligible Traffic Signal Coordination � Synchronization Projects: The following traffic signal
coordination and synchronizati on project types are eligible to receive MSRC match funding:
■ Level 1 Projects - Update 8� Coordination of Signal Timing Plans Between Adjacent
Jurisdictions Using Existing Systems — This project type involves the synchronization of
traffic signals across a jurisdictional boundary as a result of mutual updating and coordinating
each jurisdiction's signal timing plans.
• Level 2 Projects - Purchase $ Installation of Compatible Signal Coordination Hardware
and Software — Projects in this category include the purchase of new, compatible
hardware/software to allow interconnection of signals between adjacent jurisdictions. This
also includes replacement of existing UTCS systems with modern, closed loop systems
designs utilizing hardwire, fiber optic, radio control, or m icrowave interconnects.
■ Level 3 Projects - Traffic Management Center Software � Communications Upgrades —
This project type includes hardware and/or software upgrades to the existing traffic control
facility to allow compatibility with adjacent jurisdictions. This category is limited to system
upgrades only, and is not intended for new facility construction or modifications other than
those necessary to coordinate and synchroniz e traffic signals between adjacent jurisdictions.
Signal Synchronization System Testing 8� Implementation: For Level 2 and 3 projects, an initial
system testing and implementation phase of six (6) months is allowable for reimbursement using
MSRC matching funds. System testing and implementation beyond this initial six month period shall
be the sole responsibility of the jurisdiction. System maintenance of any type is not an allowable use
of MSRC match funds.
Reporting Requirements: The following minimum level of reporting is required of funding recipients
under this category:
■ Contractor shall provide quarterly Progress Reports that summarize the project results to date
including, but not limited to: the status of traffic signal coordination and synchronization tasks,
achievement of milestones, preliminary findings and recommendations for completion of
contract; and any project delays or problems encountered and recommended solutions.
Progress Reports that do not comply will be returned to the Contractor as inadequate;;
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FY'08/'09 Local Government Match Program
■ A concise Final Report submitted at the end of the project, documenting completion of all
contract tasks, as well as project results. This report should include traffic flow improvement
measurements, including reduction in average peak hour vehicle delay at coordinated
intersections, increase in average peak hour vehic le speed along the arterial, etc.
Maximum MSRC Match Funding: The MSRC will co-fund traffic signal coordination &
synchronization projects at a match level of $0.50 against each dollar of AB 2766 Subvention Funds
and/or local funds applied to the project. The maximum MSRC match per project is $150,000. MSRC
Discretionary funds will be disbursed on a reim bursement basis.
Eligible Project Costs: Project costs that are eligi ble for MS RC matching funds include the fol lowing:
■ Direct labor costs associated with system design, timing plan development, hardware and
software installation, underground facility construction, including hardwire or fiber installation,
systems engineering and integration, system testing and verification, and project
management. Project management costs eligible for reimbursement with MSRC match funds
shall be capped at 10% of the total project cost;
• Purchase of capital equipment, hardware, and software directly related to the traffic signal
coordination and synchronization project, including but not limited to signal controllers, loop
detectors, and interconnect equipment;
■ Traffic control facility hardware and software upgrades that allow compatibility between
jurisdictions.
Ineligible Project Costs: Project costs that are ineligible and cannot be matched or reimbursed
include the following:
■ Purchase of real property, including right-of-way;
■ Construction of new traffic s ignals;
■ Traffic Management Center facility modifications, upgrades, and/or construction costs beyond
those directly related to eligible equipment and software installation;
■ Traffic signal timing plan adjustment beyond the project term;
• Administrative costs deemed excessive by the M SRC.
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FY'O8/'09 Local Government Match Program
VI.A. APPLICATION FORMS
EXHIBIT A
APPLICANT INFORMATION
Multi-Jurisdictional Traffic Signal Coordination & Synchronization
(Return this page as part of your Match Program application)
C. Please provide the following applicant information in the space provided.
Applicant Name:
Address:
Contact Person: Title:
Telephone Number: Fax #:
E-Mail Address:
A. Please provide the follow ing information:
1. Please provide the names of all other project participants:
a)
b)
c)
d)
YES NO
2. Is Caltrans participating in your project? O O
3. Have you attached a letterfrom each participant designating a lead O O
agency authorizi ng that agency to act on behalf of the other participants?
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FY'O8/'09 Local Government Match Program
EXHIBIT B
PROJECT DESCRIPTION/STATEMENT OF WORK
Multi-Jurisdictional Traffic Signal Coordination & Synchronization
(Return this page as part of your Match Program application only if you are applying for
Traffic Signal match funding)
A. STATEMENT OF WORK: Please provide a Statement of Work for the proposed multi-jurisdictional traffic
signal coordination and synchronization project. Include all Project Tasks as they relate to the design and
implementation of traffic signal improvements. Each Task should be described with sufficient detail to
adequately convey the work to be performed.
B. PROJECT ORGANIZATIONAL STRUCTURE: Please describe the proposed Project Organizational
Structure, including: a) description of the agency implementing the project, b) roles and responsibilities of
each additional participating jurisdiction, including Caltrans; c) use of subcontractors, if any; d) key project
staff, including Project Manager, and e)project reporting structure.
C. Please attach an 8 '/" x 11" map showing the location(s) of the arterials and signalized intersections to be
synchronized under the proposed project.
D. Project Readiness - Please describe the time frame for project implementation and any anticipated barriers
to project completion. Address other funds used to match or support the project. If project requires on-
going funding, include a discussion on what funding will be used for continuing operation.
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FY'08/'09 Local Government Match Program
EXHIBIT C
PROJECT BUDGET
Multi-Jurisdictional Traffic Signal Coordination & Synchronization
(Return this page as part of your Match Program application only if you are applying for
Traffic Signal match funding)
A. Please provide your Current Unallocated Subvention Fund Balance: $
B. Please provide the following Project Cost by Category Information:
PROJECT COSTS BY FUNDING CATEGORY AMOUNT
1. AB 2766 SUBVENTION FUNDS APPLIED TO TRAFFIC SIGNAL
PROJECT FROM EXISTING UNALLOCATED BALANCE: $
2. AB 2766 SUBVENTION FUNDS APPLIED TO TRAFFIC SIGNAL
PROJECT FROM FUTURE YEAR ALLOCATION (FY 2009/2010): $
3. LOCAL FUNDS APPLIED TO TRAFFIC SIGNAL PROJECT
(e.g., MEASURE A, MEASURE C): $
4. TOTAL AB 2766 SUBVENTION FUNDS AND LOCAL FUNDS APPLIED
TO TRAFFIC SIGNAL PROJECT(SUM OF LINES 1, 2, and 3): $
5. AMOUNT OF MSRC MATCH FUNDING REQUESTED(MAXIMUM
AMOUNT IS 50% OF THE LINE 4 AMOUNT): $
6. ADDITIONAL PROJECT CO-FUNDING FROM OTHER SOURCES: $
7. TOTAL PROJECT COST: $
C. Please list all funding sources other than AB 2766 Subvention Funds, Local Funds,or MSRC Match
Funds:
NON-AB 2766/LOCAL FUNDING SOURCES AMOUNT
a) $
b) $
c) $
TOTAL"OTHER" PROJECT CO-FUNDING: $
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FY'O8/'09 Local Govemment Match Program
EXHIBIT C
PROJECT BUDGET- Continued
Multi-Jurisdictional Traffic Signal Coordination & Synchronization
(Return this page as part of your Match Program application only if you are applying for
Traffic Signal match funding)
D. As applicable, please list all Traffic Signal Synchronization costs by Cost Element. Please provide
as much detail as practicable when specifying project costs. For example, please provide labor
categories, hourly rates, number of hours,etc.when defining labor costs.
CAPITAL EQUIPMENT COSTS(HARDWARE/SOFTWARE COMPONENTS, ETC.):
1. $
2. $
3. �
4. $
5. �
TOTAL CAPITAL EQUIPMENT COSTS: $
DIRECT LABOR COSTS:
1. LABOR HOURS x $/HOUR= $
2. LABOR HOURS x $/HOUR= $
3. LABOR HOURS x $/HOUR= $
4. LABOR HOURS x $/HOUR= $
TOTAL DIRECT LABOR COSTS: $
OTHER DIRECT COSTS, INCLUDING SUBCONTRACTORS:
1. $
2. $
3. $
4. �
TOTAL OTHER DIRECT COSTS: $
ADMINISTRATIVE COSTS: $
TOTAL PROJECT COST: $
PLEASE NOTE THAT THE TOTAL PROJECT COST REFLECTED IN SUBSECTIONS B AND D, ABOVE,
SHOULD BE CONSISTENT.
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FY'08/'09 Local Government Match Program
EXHIBIT D
PROJECT IMPLEMENTATION SCHEDULE
Multi-Jurisdictional Traffic Signal Coordination & Synchronization
(Return this page as part of your Match Program application)
Please provide, either in the space outlined below or separate attached sheet, a Milestone Schedule for your
proposed multi-jurisdiction traffic signal coordination project. The schedule should include anticipated start and
completion dates for each task, activity, or milestone identified in Exhibit B, "Project Description/Statement of
Work". If you are using Federal funds and/or working through Caltrans, please be sure that fulfil/ment of related
requirements (e.g. ITS minor project waiver, TIP amendment and ADA issues) has been addressed in your
timeline.
The format requirements for the Project Implementation Schedule are flexible. A template is provided below:
PROJECT MILESTONE START DATE COMPLETION
Example: Task 1 — Update of existing signal Authority to Proceed(ATP)+ ATP+ 3 months
timing plans... one month
__ _. _ .
__ __ __ __ ___ - - --_ __ .__ _
_ __ _ __ __ _ __ _ _ _ _ __ _ _ _
__ _ _ _ __ _ . _ _..
__ __ _ _ ____ _ ______ _---- __ _
__ __ _ _ _ __ __ _._ __ . __ _ _ __
__ _ _ __ __ _ __ _ __ _
_ __ _ _ _ . _ __ _ _.. _
_ . _ _ _ __ . . _.
If a separate milestone schedule is attached, please label the attachment "Exhibit D: Project Milestone
Schedule"and include in your application package.
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FY`08/'09 Local Government Match Program
EXHIBIT E
PROJECT IMPLEMENTATION DATA
Multi-Jurisdictional Traffic Signal Coordination & Synchronization
(Return this page as part of your Match Program application only if you are applying for
Traffic Signal match funding)
A. Please provide the following input data as applicable to the proposed Multi jurisdictional Traffic Signal
Coordination and Synchronization Project:
Input Data
Length of Roadway or Arterial Segment Undergoing Signal Synchronization miles
Number of Traffic Signals to be Coordinated/Synchronized signals
Average Daily Peak Traffic Volumes Along Project Segment vehicles
_ _ __
Before Project Peak Period Level of Service(LOS) LOS
After Project Peak Period Level of Service(LOS) LOS
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SECTION VIII: APPLICATION CHECKLIST
DID YOU REMEMBER TO...
❑ Attach a Cover Letter siqned by an individual authorized to contractually bind the
submitting entity?
❑ Complete and attach Exhibit A, "Applicant Information"?
❑ Complete and attach Exhibit B, "Project Description/Statement of Work"?
❑ Attach an 8'/2" x 11" Site Map/Plan to Exhibit B, if applicable?
❑ Complete and attach Exhibit C, "Project Budget"?
❑ Attach Exhibit D, "Project Implementation Schedule", to your application? A re all
requested Project Milestones identified on your schedule?
❑ Commit to provide a Certificate of Insurance within 45 days of notification of award.
❑ Attach W-9(Section VII)?
❑ Prepare one original applic ation plus three(3)copies, for a total of four. Did you verify the
correct mailing address?
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SECTION IX: SAMPLE CONTRACT
South Coast C�ean�'rans ortadon
P
�• • Air Quality Management District Fundirtg trom �h. MSRC
LOCAL GOVERNMENT MATCH PROGRAM CONTRACT
1. PARTIES - The parties to this Contract are the South Coast Air Quality Management District (hereinafter
referred to as "AQMD") whose address is 21865 Copley Drive, Diamond Bar, California 91765-4178, and ***
(hereinafter referred to as"CONTRACTOR")whose address is***.
2. RECITALS
A. AQMD is the local agency with primary responsibility for regulating stationary source air pollution in the
South Coast Air Basin in the State of California (State). AQMD is authorized under State Health &
Safety Code Section 44225 (Assembly Bill (AB) 2766) to levy a fee on motor vehicles for the purpose of
reducing air pollution from such vehicles and to implement the California Clean Air Act.
B. Untler AB 2766 the AQMD'S Governing Board has authorized the imposition of the statutorily set motor
vehicle fee. By taking such action the State's Department of Motor Vehicles (DMV) is required to collect
such fee and remit it periodically to AQMD.
C. AB 2766 further mandates that thirty (30) percent of such vehicle registration fees be placed by AQMD
into a separate account for the sole purpose of implementing and monitoring programs to reduce air
pollution from motor vehicles.
D. AB 2766 creates a regional Mobile Source Air Pollution Reduction Review Committee (MSRC) to
tlevelop a work program to fund projects from the separate account. Pursuant to approval of the work
program by AQMD'S Governing Board, AQMD Board authorized a contract with CONTRACTOR for
services described in Attachment 1 - Statement of Work, expressly incorporatetl herein by this reference
and made a part hereof of this Contract.
E. CONTRACTOR has met the requirements for receipt of AB 2766 Discretionary Funds as set forth in
CONTRACTOR's Local Government Match Program Application dated***.
3. DMV FEES-CONTRACTOR acknowledges that AQMD cannot guarantee the amount of fees to be collected
under AB 2766 will be sufficient to fund this Contract. CONTRACTOR further acknowledges that AQMD'S
receipt of funds is contingent on the timely remittance by State's DMV. AQMD assumes no responsibility for
the collection and remittance of motor vehicle registration fees by DMV to AQMD in a timely manner.
4. AUDIT - Additionally, CONTRACTOR shall, at least once every two years, or within two years of the
termination of the Contract if the term is less than two years, be subject to an audit by AQMD or its
authorized representative to determine if the revenues received by CONTRACTOR were spent for the
reduction of pollution from Motor Vehicles pursuant to the Clean Air Act of 1988. AQMD shall coordinate
such audit through CONTRACTOR'S autlit staff. If an amount is found to be inappropriately expended,
AQMD may withhold revenue from CONTRACTOR in the amount equal to the amount which was
inappropriately expended. Such withholding shall not be construed as AQMD'S sole remedy and shall not
relieve CONTRACTOR of its obligation to perform under the terms of this Contract.
5. REPORTING - CONTRACTOR shall submit reports to AQMD as outlined in Attachment 1 - Statement of
Work. AQMD reserves the right to review, comment, and request changes to any report produced as a result
of this Contract.
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6. TERM - The term of this Contract is from the date of execution by both parties to ***, unless terminated
earlier as provided for in Clause 7 below entitled Termination, extended by amendment of this Contract in
writing, or unless all work is completed and a final report is submitted and approved by AQMD prior to the
termination date. No work shall commence prior to the Contract start date, except at CONTRACTOR'S cost
and risk, and no charges are authorized until this Contract is fully executed. Upon written request and with
adequate justification from CONTRACTOR, the MSRC Contracts Administrator may extend the Contract up
to an additional six months at no additional cost. Term extensions greater than six months must be reviewetl
and approved by the MSRC.
7. TERMINATION - In the event any party fails to comply with any term or contlition of this Contract, or fails to
provide the services in the manner agreed upon by the parties, including, but not limited to, the requirements
of Attachment 1 - Statement of Work, this shall constitute a material breach of the Contract. The
nonbreaching party shall have the sole and exclusive option either to notify the breaching party that it must
cure this breach within fifteen (15) days or provide written notification of its intention to terminate this
Contract with thirty (30) day's written notice. Notification shall be provided in the manner set forth in Clause
17 below, entitled - Notices. Termination shall not be the exclusive remedy of the nonbreaching party. The
nonbreaching party reserves the right to seek any and all remedies provided by law. AQMD will reimburse
CONTRACTOR for actual costs incurred (not to exceed the total Contract value), including all noncancellable
commitments incurred in performance of this Contract through the effective date of termination for any
reason other than breach.
8. EARLY TERMINATION—This Contract may be terminated early due to any of the following circumstances:
A. The vehicles or equipment become inoperable through mechanical failure of components or systems
directly related to the alternative fuel technology being utilized, and such failure is not caused by
CONTRACTOR'S negligence, misuse, or malfeasance.
B. The fueling station becomes inoperable, and is either not technically able to be repaired, or is too costly
to repair, and such failure is not caused by CONTRACTOR's negligence, misuse, or malfeasance.
9. REFUELING STATION OPERATIONAL AVAILABILITY — [USE FOR PROJECTS WITH
INFRASTRUCTURE] CONTRACTOR is obligated to comply with the alternative-fuel refueling infrastructure
Operational Availability requirements set forth as follows:
A. CONTRACTOR commits to ensuring fast-fill refueling stations remain operational and accessible to
public andlor fleets for a period of no less than five (5) years from the date the station begins dispensing
fuel in either its initial or expanded capacity. Should CONTRACTOR desire to deviate from this
obligation, for reasons other than those stated in Clause 8.6, above, CONTRACTOR shail reimburse
AQMD for a prorated share of the funds provided for fueling facilities as indicated in the table below:
5 year Operational Availability Obligation Percentage of MSRC Funds to be
Termination Occurs Reimbursed
Within Year 1 100°/a
Between Years 1-2 80%
Between Years 2-3 60%
Between Years 3-4 40%
Between Years 4-5 20%
After Year 5 0%
B. CONTRACTOR commits to ensuring time-fill, single dispenser, apparatus-type stations remain
operational for a period of no less than three (3) years from the date the station begins dispensing fuel in
either its initial or expantletl capacity. Should CONTRACTOR desire to tleviate from this obligation, for
56
MSRC Clean Transportation FundingT"'
FY'08/'09 Local Government Match Program
reasons other than those stated in Clause 8.B, above, CONTRACTOR shall reimburse AQMD for a
prorated share of the funds provided for fueling facilities as indicated in the table below:
3 year Operational Availability Obligation Percentage of MSRC Funds to be
Termination Occurs Reimbursed
Within Year 1 100%
Between Years 1-2 66%
Between Years 2-3 33%
After Year 3 0%
C. The appropriate reimbursable amount shall be paid to AQMD within sixty (60) days from the date the
station ceases operation. CONTRACTOR shall not be responsible for any reimbursement to AQMD if the
obligation is terminated as a result from one or more reasons set forth in Clause 8.B.
10. INSURANCE-
A. CONTRACTOR shall furnish evidence to AQMD of workers' compensation insurance for each of its
employees, in accordance with either California or other states' applicable statutory requirements prior to
commencement of any work on this Contract.
B. CONTRACTOR shall furnish evidence to AQMD of general liability insurance with a limit of at least
$1,000,000 per occurrence, and $2,000,000 in a general aggregate prior to commencement of any work
on this Contract. AQMD shall be named as an additional insured on any such liability policy, and thirty
(30) days written notice prior to cancellation of any such insurance shall be given by CONTRACTOR to
AQMD.
C. CONTRACTOR shall furnish evidence to AQMD of automobile liability insurance with limits of at least
$100,000 per person and $300,000 per accident for bodily injuries, and $50,000 in property damage, or
$1,000,000 combined single limit for bodily injury or property damage, prior to commencement of any
work on this Contract. AQMD shall be named as an additional insured on any such liability policy, and
thirty (30) days written notice prior to cancellation of any such insurance shall be given by
CONTRACTOR to AQMD.
D. If CONTRACTOR fails to maintain the required insurance coverage set forth above, AQMD reserves the
right either to purchase such additional insurance and to deduct the cost thereof from any payments
owed to CONTRACTOR or terminate this Contract for breach.
E. All insurance certificates should be mailed to: AQMD Risk Management, 21865 Copley Drive, Diamond
Bar, CA 91765-4178. The AQMD Contract Number must be included on the face of the certificate.
F. CONTRACTOR must provide updates on the insurance coverage throughout the term of the Contract to
ensure that there is no break in coverage during the period of contract performance. Failure to provide
evidence of current coverage shall be grounds for termination for breach of Contract.
(i) (Use above clause or Self Insurance clause below)-Remove before
printing
Selflnsurance Clause:
INSURANCE - CONTRACTOR represents that it is permissibly self-insured and will maintain such self-insurance
in accordance with applicable provisions of California law throughout the term of this Contract. CONTRACTOR
shall provide evidence of sufficient coverage during the term of this Contract and any extensions thereof that meet
or exceed the minimum requirements set forth by the South Coast AQMD below. CONTRACTOR shall furnish
certificate of self-insurance to: South Coast Air Quality Management District, Attn: Risk Management O�ce. The
AQMD Contract Number shall be included on the face of the certificate. If CONTRACTOR fails to maintain
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MSRC Clean Transportation FundingT""
FY'08/'09 Local Government Match Program
the required insurance coverage, AQMD reserves the right to terminate the Contract or purchase such additional
insurance and bili CONTRACTOR or deduct the cost thereof from any payments owed to CONTRACTOR.
Minimum insurance coverages are as follows:
A. Worker's compensation insurance in accordance with either California or other state's applicable statutory
requirements.
B. General Liability insurance with a limit of at least$1,000,000 per occurrence, and $2,000,000 in general
aggregate.
C. Automobile Liability insurance with limits of at least$100,000 per person and $300,000 per accident for
bodily injuries and$50,000 in property damage, or$1,000,000 combined single limit for bodily injury or
property damage.
11. INDEMNIFICATION — CONTRACTOR agrees to hold harmless, defend, and indemnify, AQMD, its officers,
empioyees, agents, representatives, and successors-in-interest against any and all loss, damage, cost, or
expenses which AQMD, its officers, employees, agents, representatives, and successors-in-interest may
incur or be required to pay by reason of any injury or property damage caused or incurred by
CONTRACTOR, its employees, subcontractors, or agents in the performance of this Contract.
12. PAYMENT
A. AQMD shall pay CONTRACTOR a Firm Fixed Price of*** Dollars ($***) upon completion of the project
on a reimbursement basis. Any funds not expended upon early contract termination or contract
completion shall revert to the AB 2766 Discretionary Fund. Payment of charges shall be made by
AQMD to CONTRACTOR within thirty (30) days after approval by AQMD of an itemized invoice
prepared and furnished by CONTRACTOR.
B. An invoice submitted to AQMD for payment must be prepared in duplicate, on company letterhead, and
list AQMD'S contract number, periotl covered by invoice, and CONTRACTOR'S social security number
or Employer ldentification Number and submittetl to:
South Coast Air Quality Management District
21865 Copley Drive
Diamond Bar, CA 91765-4178
Attn: Cynthia Ravenstein, MSRC Contract Administrator
C. No funds shall be paid out to CONTRACTOR pursuant to this Contract, until the project described in
Attachments 1 and 2 is completed and proof of completion is provided to AQMD. If the project
described in Attachments 1 and 2 is not completed and satisfactory proof of completion is not provided
to AQMD, no monies shall be due and payable to CONTRACTOR. Proof of completion shall include a
Final Report detailing the project goals and accomplishments.
D. Additional AB 2766 Discretionary Match Funds will not be available to fund project cost overruns. Any
project cost overruns must be funded from other than AB 2766 Discretionary Funds.
E. The Firm Fixed Price amount of this Contract shall not exceed the total AB 2766 Funds applied to the
project described in Attachments 1, 2, and 3 of this Contract.
F. If, at the completion of the Project described in Attachment 1, the vehicie expenditures and/or
infrastructure expenditures are less than the Total Cost amount(s)contained in Attachment 2, the actual
amount of AB 2766 Discretionary Funds reimbursed to CONTRACTOR shall be adjusted on a prorated
basis as described in Attachment 2.
G. CONTRACTOR must submit final invoice no later than ninety(90) days after the termination date of this
Contract or invoice may not be paid.
13. MOBILE SOURCE EMISSION REDUCTION CREDITS(MSERCs)
A. The MSRC has adopted a policy that no MSERCs resulting from AB 2766 Discretionary Funds may be
generated andlor sold.
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FY'O8/'09 Local Government Match Program
B. CONTRACTOR has the opportunity to generate MSERCs as a by-product of the project if a portion of the
air quality benefits attributable to the project resulted from other funding sources. These MSERCs, which
are issued by AQMD, are based upon the quantified vehicle miles traveled (VMT) by project vehicles or
other activity data as appropriate. Therefore, a portion of prospective MSERCs, generated as a result of
AB 2766 Funds, must be retired. The portion of prospective credits funded by the AB 2766 program, and
which are subject to retirement, shall be referred to as"AB 2766-MSERCs."
C. The determination of AB 2766-MSERC's is to be prorated basetl upon the AB 2766 program's
contribution to the cost associated with the air quality benefits. In the case where AB 2766 Discretionary
Funds are used to pay for the full differential cost of a new alternative fuel vehicle or for the retrofitting or
repowering of an existing vehicle, all MSERCs attributable to AB 2766 Discretionary Funds must be
retired. The determination of AB 2766-MSERCs for infrastructure and other ancillary items is to be
prorated based upon the AB 2766 program's contribution to the associated air quality benefits.
Determination of the project's overall cost will be on a case-by-case basis at the time an MSERC
application is submitted. AQMD staff, at the time an MSERC application is submitted, will calculate total
MSERCs and retire the AB 2766-MSERCs. CONTRACTOR would then receive the balance of the
MSERCs not associated with AB 2766 funding.
14. DISPLAY OF MSRC LOGO - [USE FOR VEHICLE PROJECTS AND INFRASTRUCTURE PROJECTS]
CONTRACTOR agrees to permanently display one MSRC decal in a prominent location on each vehicle
purchased pursuant to this Contract. CONTRACTOR also agrees to permanently display one MSRC decal in
a prominent location on each fueling or charging station constructed or upgraded pursuant to this Contract.
Decals will be provided by MSRC upon notification that subject fueling station equipment and/or vehicles are
placed into service. Decals are approximately twelve (12) inches in height and eighteen (18) inches in width
(Note: a smaller decal may be provided if CONTRACTOR demonstrates that application of the standard
decal is not feasible). CONTRACTOR shall maintain decal for life of vehicle or equipment subject to this
Contract. Should any decal become damaged, faded, or otherwise unreadable, CONTRACTOR shall request
replacement decal from MSRC and apply new decal in the same or other prominent location. MSRC shall not
be responsible for damage to paint or other vehicle surfaces arising from application or removal of decals. In
addition, all promotional materials related to the project, including, but not limited to, press kits, brochures
and signs shall include the MSRC logo. Press releases shall acknowledge MSRC financial support for the
project.
15. ACCRUAL OF MILEAGE WITHIN SOUTH COAST AIR QUALITY DISTRICT — [USE FOR VEHICLE
PROJECTS ONLY] CONTRACTOR is obligated to comply with the geographical restriction requirements as
follows:
A. Each of the vehicles funded under this Contract must accrue at least 85% of its annual mileage or engine
hours of operation within the geographical boundaries of the South Coast Air Quality Management District
for a period of no less than five (5) years from the date the vehicle enters service (new vehicles) or
returns to service (repowered vehicles). Should CONTRACTOR deviate from or fail to comply with this
obligation, for reasons other than those stated in Clause 8.A., CONTRACTOR shall reimburse AQMD for
a prorated share of the funds provided for the vehicle as indicated in the table below:
5 year Operations Obligation Percentage of MSRC Funds
Termination Occurs to be Reimbursed
Within Year 1 100%
Between Years 1-2 80%
Between Years 2-3 60%
Between Years 3-4 40%
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Between Years 4-5 20%
After Year 5 0%
B. The appropriate reimbursable amount shall be paid to AQMD within sixty (60) days from the date the
vehicle ceases to operate in accordance with the geographical restriction. CONTRACTOR shall not be
responsible for any reimbursement to AQMD if the obligation is terminated as a result from one or more
reasons set forth in Clause 8.A.
C. Should CONTRACTOR sell, lease, transfer, assign or otherwise divest itself of the vehicles during the five
year period referred to in clause 15A, notice shall be provided to AQMD no less than 30 days preceding
the sale, lease, transfer, or assignment is effectuated. The agreement effectuating the sale, lease,
transfer or assignment shali state that the AQMD is an intended third-party beneficiary of the agreement
and shall include the following requirement: the obligation to accrue mileage within the South Coast Air
Quality Management District shall be a continuing obligation of the subsequent purchaser, lessee,
transferee, successor in interest, heir or assign and shall remain in full force antl effect until the expiration
of the five year operation period. This obligation shall be passed down to any subsequent purchaser,
lessee or transferee during this five year term and AQMD shall be an intended third-party beneficiary of
any subsequent agreement. Upon receiving notice of any subsequent sale, lease, transfer, assignment or
other divestiture, AQMD may elect to either require the reimbursement specified in Clause 15A and 15B,
or require the subsequent purchaser, lessee, transferee or assignee to comply with the continuing
obligation to operate the vehicle for a period of no less than five (5) years from the tlate the vehicle
entered service (new vehicles) or re-service (re-poweretl vehicles). Notice of AQMD's election of
remedies shall be provided to CONTRACTOR and any subsequent purchaser, lessee, transferee or
assignee in a timely fashion.
16. NOTICES -Any notices from either party to the other shall be given in writing to the attention of the persons
listed below or to other such addresses or addressees as may hereafter be designated in writing for notices
by either party to the other. A notice shall be deemed received when delivered or three days after deposit in
the U.S. Mail, postage prepaid, whichever is earlier.
AQMD: South Coast Air Quality Management District
21865 Copley Drive
Diamond Bar, CA 91765-4178
Attn: Cynthia Ravenstein, MSRC Contract Administrator
CONTRACTOR: ***
***
***
Attn: ***
17. EMPLOYEES OF CONTRACTOR
A. CONTRACTOR warrants that it will employ no subcontractor without written approval from AQMD.
CONTRACTOR shall be responsible for the cost of regular pay to its employees, as well as cost of
vacation, vacation replacements, sick leave, severance pay and pay for legal holidays.
B. CONTRACTOR shall also pay all federal and state payroil taxes for its employees and shall maintain
workers'compensation and liability insurance for each of its employees.
C. CONTRACTOR, its o�cers, empioyees, agents, or representatives shall in no sense be considered
employees or agents of AQMD, nor shall CONTRACTOR, its officers, employees, agents, or
representatives be entitled to or eligible to participate in any benefits, privileges, or plans, given or
extended by AQMD to its employees.
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D. CONTRACTOR warrants that it has no interest and shall not acquire any interest, direct or indirect,
which would conflict in any manner or degree with the performance of services required to be performed
under this Contract. CONTRACTOR further represents that in performance of this Contract, no person
having any such interest shall be employed by CONTRACTOR or any subcontractor.
18. NON-DISCRIMINATION - In the performance of this Contract, CONTRACTOR shall not discriminate in
recruiting, hiring, promotion, demotion, or termination practices on the basis of race, religious creed, color,
national origin, ancestry, sex, age, or physical handicap and shall comply with the provisions of the California
Fair Employment & Housing Act (Government Code Section 12900, et seq.), the Federal Civil Rights Act of
1964 (P.L. 88-352) and all amendments thereto, Executive Order No. 11246 (30 Federal Register 12319),
and all administrative rules and regulations issued pursuant to said Acts and Order. CONTRACTOR shall
likewise require each subcontractor to comply with this clause and shall include in each such subcontract
language similar to this clause.
19. ASSIGNMENT- The rights granted hereby may not be assigned, sold, licensed, or otherwise transferred by
either party without the prior written consent of the other, and any attempt by either party to do so shall be
void upon inception.
20. NON-EFFECT OF WAIVER—CONTRACTOR'S or AQMD'S failure to insist upon the performance of any or
all of the terms, covenants, or conditions of this Contract, or failure to exercise any rights or remedies
hereunder, shall not be construed as a waiver or relinquishment of the future performance of any such terms,
covenants, or conditions, or of the future exercise of such rights or remedies, unless otherwise provided for
herein.
21. ATTORNEYS' FEES - In the event any action (including arbitration) is filed in connection with the
enforcement or interpretation of this Contract, each party in said action shall pay its own attorneys' fees and
costs.
22. FORCE MAJEURE - Neither AQMD nor CONTRACTOR shall be liable or deemed to be in default for any
delay or failure in performance under this Contract or interruption of services resulting, directly or indirectly,
from acts of God, civil or military authority, acts of public enemy, war, strikes, labor disputes, shortages of
suitable parts, materials, labor or transportation, or any similar cause beyond the reasonable control of
AQMD or CONTRACTOR.
23. SEVERABILITY - In the event that any one or more of the provisions contained in this Contract shall for any
reason be held to be unenforceabie in any respect by a court of competent jurisdiction, such holding shall not
affect any other provisions of this Contract, and the Contract shall then be construed as if such
unenforceable provisions are not a part hereof.
24. HEADINGS - Headings on the clauses of this Contract are for convenience and reference only, and the
words contained therein shall in no way be held to explain, modify, amplify, or aid in the interpretation,
construction, or meaning of the provisions of this Contract.
25. DUPLICATE EXECUTION - This Contract is executed in duplicate. Each signed copy shall have the force
and effect of an original.
26, GOVERNING LAW-This Contract shail be construetl antl interpreted and the legal relations created thereby
shall be determined in accordance with the laws of the State of California. Venue for resolution of any
dispute shail be Los Angeles County, California.
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27. PRECONTRACT COSTS - Any costs incurred by CONTRACTOR prior to CONTRACTOR receipt of a fully
executed Contract shall be incurred solely at the risk of the CONTRACTOR. In the event that a formal
Contract is not executed, neither the MSRC nor the AQMD shall be liable for any amounts expended in
anticipation of a formal Contract. If a formal Contract does result, precontract cost expenditures authorized
by the Contract will be reimbursed in accordance with the cost schedule and payment provision of the
Contract.
28. PREVAILING WAGES — [USE FOR PROJECTS WITH INFRASTRUCTURE] CONTRACTOR is alerted to
the prevailing wage requirements of California Labor Code section 1770 et seq. Copies of the prevailing rate
of per diem wages are on file at the AQMD's headquarters, of which shall be made available to any
interested party on request. Notwithstanding the preceding sentence, CONTRACTOR shall be responsible
for determining the applicability of the provisions of California Labor Code and complying with the same,
including, without limitation, obtaining from the Director of the Department of Industrial Relations the general
prevailing rate of per diem wages and the general prevailing rate for holiday and overtime work, making the
same available to any interested party upon request, paying any applicable prevailing rates, posting copies
thereof at the job site and flowing all applicable prevailing wage rate requirements to its subcontractors.
CONTRACTOR shall indemnify, defend and hold harmless the South Coast Air Quality Management District
against any and all claims, demands, damages, defense costs or liabilities based on failure to adhere to the
above referenced statutes.
29. CHANGE TERMS - Changes to any part of this Contract must be requested in writing by CONTRACTOR,
submitted to AQMD and approved by MSRC in accordance with MSRC policies and procedures.
CONTRACTOR must make such request a minimum of 90 days prior to desired effective date of change. All
modifications to this Contract shail be in writing antl signed by both parties.
30. ENTIRE CONTRACT - This Contract represents the entire agreement between the parties hereto related to
CONTRACTOR providing services to AQMD antl there are no understandings, representations, or warranties
of any kind except as expressly set forth herein. No waiver, alteration, or modification of any of the
provisions herein shall be binding on any party unless in writing and signed by the party against whom
enforcement of such waiver, alteration, or modification is sought. The Statement of Work-Attachment 1, The
Payment Schedu�e-Attachment 2, and Supporting Documentation-Attachment 3, are incorporated by
reference herein and made a part hereof.
31. AUTHORITY-The signator hereto represents and warrants that he or she is authorized and empowered and
has the legal capacity to execute this Contract and to legally bind CONTRACTOR both in an operational and
financial capacity and that the requirements and obligations under this Contract are legally enforceable and
binding on CONTRACTOR.
[The Remainder of this Page is Intentionally Left Blank]
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MSRC Clean Transportation FundingT""
FY'08/'09 local Government Match Program
IN WITNESS WHEREOF, the parties to this Contract have caused this Contract to be tluly executed on their
behalf by their authorizetl representatives.
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT *'*
By:
By:
Dr.William A.Burke,Chairman,Governing Board Name:
Title:
Date: Date:
ATTEST:
Saundra McDaniel,Clerk of the Board
By:
APPROVED AS TO FORM:
Kurt R.Wiese,District Counsel
By:
//MSRC09LocalGovtMatch
Updated 1/7/09
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SECTION X: W-9 & INSURANCE FORMS
Fv�n, �'� R�+�r�est fr�r �`�a�pa��r ���ror�,���r�¢
r.u��..�����, Identif6catian Numb�r arrd C�rtifi���tian p���ae�. oa �ms
cxf�mrv„crc cf uwTrcabury 3en�$d1 the IFt�.
lrkcmal Ra�wua S�atica
�.� I4nma�s�aw.n nn y�ur income 4vc r�um)
m
�
� 6�ir�n�s ner�if dilf�eM from ebwa
�
m
�a Irdivid�l+ Exampt fram baakup
y� Che�k approFwiete box: ❑ Snle propri�or ❑ �rperation ❑ Parkrr.�°�ltiip ❑C0.har► --------- ❑withhokiirg
Q�' A�kF.at,a urnber,gtreet,arxl ar suite nx q
,�� G'� �� } esFi�er'r�neme arr�atldre�s(opti�ne�
0. v
� Git}�.eteta.are�ZIP c�sie
� Li�t arx ourx nunb+,r��aj hnre�optaneP�
�
Taxpayer ldenttficatlon Number(TINp
Entee your TIN in the eppropriate bc�x Tha TIM pmvidad muu9tt match tl-�e neme c�ia�pi Lii7e 1 to arroid �4�����Y��b�'
bsckup withhakiing.F+�r indi�iduale,thig i�y�aur eacrel eecuriCy number(3SI+1�.Hac�+r�v�r,for�i�id�-rt
alien,sale proprietc+r,ar di�regardad entity,eee�the Pert I inetn�ctione on pe�e 3. For<nhei°e�rtitiee,ft ie
your�,mplrn�r identificetion numbEr iE IRI�.IF you da not haue a numher,e�N�c��aa gax e�TthJ orr pa�e 3. �r
A�Aate.Jf U�e ecc�au,�%is ira move t!�w�e nan�,a€�tlae rhat ae�c,�a/c+�gee+ei�e,�zn�sa c�r!evhose t�urraLa.w Empioy�r identi5cation nurnber
to�(c+r.
CeMitication
Und.-r�neltic�.s of p3rjury,I certiCy�that:
1. lhe number etrcwn en this form ia my correct texpeyer ideirtificetim numbar�or I sm�vaiting for e number to be ieeuad to me},end
^c. I em r�ot aubject ta 6ackup r+tithh4lding becauaa:{ql I em eyu�mpt trom 6erkup withholdin�,or{b°�I heve nat been natifi5d by the Intemal
R�nanue Servi�(IRS�that 1 em eubject to F�eckup withhdding e�e resuR of a failure tn reQ�art ell inter�-�et oe di+ridenda,or��c'i the IFLS►�
nrn'rfied me that I am no br�er,subject to backup withhalding,end �
3. I am a U.S.pereon lincl�idinc�a lJ.B.reaidern alienj.
Gertificetion in�tructi�ria.You muet crcee cwt ikrrn F abwe if you have been ratifieci by the IRS that yau ere caimentfy aubject t��backup
withhaldiny�tracauee you have failed tr,report all irntereat�nd diwidende on your tax r�tum.F'or real eeteb3 traneediona, item 2 doee r�ot apply.
For mertgaga irrtarEet paid,acquiei[ian c�r al�ndcximent caf egcured propertY,canr„�letim nF debt,rontributione to en irxlividual retirement
arren�yment(IF�{{Y,and generally,�ymants other than inte�reet end dividencls,you ar�nert rcquieecl to eign the�'artificstien,but ynu muet
pravide your comact TIN.('�,a tt�i�7structions on p�e a.i
Si9n siqnature ot
H81'F3 17.5.persan► O�te R
Purpose 4f F�arm
A person wmo is require�i to fila an ii�fanna[ican r�tum�n�th the *An}�e�tate 4other than a fQrsign e�tate)�sr trUst.�ee
IRS,mu�t crbtain ysaur corree.t tz�ac��ayer iden#ification number Ragulatians sectirns 341.7701-8{ap end 7(a)far ss�clitivnal
(TIN)to repr�rt,for exampl�,inc�me{>3i��to yau,real e�tat� irrformation.
transactivns,rnrartgage ints�r���t yau p�i�J,r�r..c�ui�ition or F�ir��� �erson.If yvu r�re a ftaraign person,cla not usa
abandonment of secur�cl prnperty,c9ncell�iion of clsbt,or Form W-9. Instead,use the�ppropri�te Fs�rrn N`-��s�
contribution�y�u rnacl�tt��n IRf�. Publication 515,1hithhalding af Tax r�n Nonresi��ent Alien�
U.S. pers�n,l.lse Farm W-9 anly if uuu;:u���IJ.:�. wersc�n an�Fareign Entitiesj.
(including a resider�t ali�anj, �t7�SIY7�,*p:IR}�DUt't4Q1iHG'�TIN t4 tI1B fi�vnre�sadent alasa►who beGQrnes a resicfemt alien.
per�n requ+�iny it t,1h�rv��u��t:�r;�an+.l,whei�ap�licat�le,#a: G�nerally,c�nly a nonre�ident alisn indiv�idual m�y usc3 tf�a
1.Gartity that th�i TIN yau�i�+�i+✓in�1 is corrr3u-�k(or you ar� term�crf a t�tr�t}+ ha r�duce or slirnin�te U.;�.trax nn
w��iting for a nurnt�er to!�+iv�.ur��}, cert�in typ�caf income. Haweuer, mo�si tax tre�tic�contain�
2.Certify tha#y�7u�r�nr�t�4d>jac�tc�Ixic:ku{a+n�ithhc�lcling, P�ision knrnnm as a "saviny clause." Exc.�ti�7nE s�>erific�:l
�� in the savin�claus� rnay parmit an e�c�smEairon frorn �;roc#�
3. Glairn exem�tian fi�arn I�^kup+��ithlwlclii7�if yr>w ar+�a ��ntinue far c�rtain t}�pes of incorn�ev�n s�ft+�r th�ir�r,i�ic�nt
U.B.exem t a heis atharvrise bemme a U.S. resid�nt ali+�n#�r t�s �sur�>oa�.
P P Y�.
Mr�#e.!f a reyuastsv��'vs.s y�n,r a farr�>�att���D'�an FUr�ta 41'-9 to If yau ar�a a U.,9.resident�Iien uvh�i$relsrir7��n an
r+�c�ast vour TJ�I,yrw rnust usw��t�e rs+�u�fa�r�s foiya�iiit is excaption cont�tined in the$asing cl�use af a t�tr��#y tn
subctanbally�irndar tr�tlric�=urrat!F'b`-S. claim�n axemption irom U.3.tax on�;�rtain ty�,�,a��inrornc�,
�rou must attach a s#aterne�nt tQ Farm 4�'-J thai s����.ifie�#17�
Far ferjer�l t�:pur��o��yn�u ciir�a�i7sicia�r�J a{s��son if you fallawing frve items:
��: 1.The tr�aty c�ourhry.Gen�arally,thi�rnw�t I��i17�samr�
•An indnfidwal a•h�i��uitr�n��r r�ir��ant af th�l�li7i#� treaty under wtrich yote clainiad�t�mpti�n fir�m tnx����
���� n�nresident alien.
+►A partnershi{�.c�si�x�ratia�n,r�c�rn�a�rry.nr�Q€r:r:intuan 2.The treraty article addressi��th�irte=3me.
creat+�d or or�w3ni�r�in th�IJni�.l�tw�t�s�}r wn�.�ir thd I�w+s 64 � -me article numb�r(sar Incatic�n}in th�tayr,tr���iat
caf the Uni#ecl Si:�t�,r�r
ccantains the saving�cl�.aUe and its v�cc:�Rsti�na..
Cwe�1.hks. 1C+z'31:X Ft��m�-'4 if�i.f-�rt5?
MSRC Clean Transportation FundingT""
FY'08/'09 Local Government Match Program
Few�r7\M`-@¢I�?v.1-'XASj p�i '�
4. TI�y t�;ir��nc1 �rnc�unt of inccrme that qualrfi�for thr� Misws� r.ef TIM�.If th�s raquest€+r diselQs�s or us�rs TINs in
€�x�m��tiai�fre�in tak:. �ricdaticai c�f f€�cl�+r�l Ic�w,thr�requ�t�r m�yr t+�subject to cio�il
�.��fficient facts ttr justity thg�temptian frcm tax uncl�r ��1£I CI'1191117�iI�lfY'ie�ItIBS.
ti7a t�rrr�a vf thc_+tr,�aty article. �i�lE.*GI�IG �i'�5,�1"UCt1Ofl�
Ex�arpt�-,Article 20 eyf the U.�.-�hina inccrme�tax tre�ty
�Ilaws an c�xefl7�tion fresm tax for schralarship ineorne
r�ac�i��+tl b}��Chines��tudent ternperrarily prasent in th�+ ��'rry�'
Ui�it€�cf 3fa.tas. Under U.S. I�ra+,this stud�rnt a�ll beacamr�� If�Kru arc��u7 in�li�riclu�l,ycru rnust g�rerally erner thc� nctmc_s
rKsici��t�tliei�fcsr tax purpcasas if his c�r her st�y in the Unitecl shcrs�r�em;ycnir sc�ci�il s€Mcurity card. How�er,if you have
Stat�s €txc��ls 5 c�len�iar years.Wov�reuer.paragraph�crf cl��nqeci your last n�rn+a, fa��inst�rrca, due to rnarriage
the fiisf F�i�crt�col tcr ihe U.S.-China treaty�dttt8d April 30, w�ith��h infurniin�#tI�N�oeial S€�urity Administr�hian of the
y��34���Ilcrws tl�re�Sravi�iona of Article 2d to continue to apply i��rn�+cMrv�g�,ai�tpr your first n�rn�,tha last narne shawn ran
€�r�si�after the Ghine�+student becornas u reBid�nt alien crf �rour soci�l�«�cuiity c�rcl,a�nd yr�.�r nevr last narne.
the Ui7itad S`��tes.A�hinsse atudsnt wh4 qual'rfies fvr this If tl��+�oc�ui�f is ii�jcaint narrres, list first,and then circle,
e.aycce�fian(und�r p�rragrAph 2 Qf the firat prateacdl��rrd is th�?n�ur�a crf thea�arst�n ar�ntity�a�hose number yau entered
relying on this euceeptiran to clairn an�cemption from tax qn in Part I crf t17�f�+rrri.
hi�c�r hur sch4larship e,r f�lle�,uship inccame v�uld ttttach to �,,�I�? ��r�ap�i�tur.Ent�r yr�ur individual name as shorv,m on
Form 1N-9 a�tatament that inelud�s the infc�rm�tian �our sv�iz�l sHcui°ity��ard on ths"Nttme"line.You mgy enter
cies�iibed aLime tcs suppart th�t�acernRtinn. y��ur h3usinr�s,tra�l�s,or"daing busine3ss as(LBA)"name t�n
If yr��� �re a nonresident alien or a foreign entity not subject thr�"Bu�ine�+ ritirn€+""lincs.
tv t�ackup wfithhcalding, give ths requ�ter the apprapri�te
�orn���tQd Form 4Y-8. Li��ni�ecf Nia��ility�ea�ru�aa�ny{LL�). If vtiu�rre tt sins�le-m€+mber
lLc:�includin4a�fcir�ign LLC��th a darnestic owner)that is
Wd"Nrxt is hackup wik�holding2 Perse�ns making esrtain disregardecl�s�n errtity separate froen its cawner undee
p�ymerrt�to you must und�c�tain cc�nditians withhold cxnd Trea�.iry ragulatians section 3f71.77�D1-3, enter the awners
a7�}r to thrg IRS 289'�af such p�yments(after December�1, n�ni€�r�n ihe"N�rne"line. Enter the LLC's narne on#he
2Q02j. This is c,�lled"'backup writhholding." Pa}�rnents that "Busin�ss i�;�i7i�"lii�a.Cheek the apprcrpriate bo�c for yQur
may be subject to b�ckup withhalding include intt�rast, filinf�statu�(sole presprietar,cQrporation,etc.),then ch�ck
divide�nds, broker�tnd barter�z�ccchan�teans�ctions, rents, thr�r�ox f�r"`t?tYr�r"and enter"LLC"in the spac6 prouided.
ro7�altlea,nvnemplcxyee pay, a�nd certain p�ymerrts frorn {yth€r ea�t�Cies.Enter kaur bu�iness narne as shcn�m on
fishing baat operators. Real estate tr�nsaction�ere nat required Fecier�l�ix dcrcuments an the "Name"line.This
subjeact to backup v►�ithholding. ntrrne aha�dd match tha nams shcxv,�n t�n the charter or other
'You vrill not be subj€�t to backup withholding an payrner7ts legal dacument ereating the errtity.Yau may errter arry
you rgoeive if you gi+u�the reques#er your correct TIN,malce busii�ess,trad�+,ar [iBA n�rne on th�"Business nr�rne"line.
the proper caert'rficstions,and repart all yaur t�:able interest N�te.Yr�u are requested ta check ths apprnpriate box for
and dividends on your tax retum. your status findit4dual,��ale prrprietor,c4r�armtian, atc.j.
P'ayernerets you r�ceiv�+wi!!be s�bpect#o backup
�������� �� Exempt Frarn Backup Withholdin�
1. Yau dc,ncat fumish your TIP,I to the requeslrar,car If you 3rc3 exempt, gnter yaur n�rne as dca�crihecl �tx�re ancl
2. You do ntat�certify ycaur T1N vahen raquirx�d ts�the Part check the r�ppropriate t7ox ft>r yraur status,then check thfl
II instruetiona pn page 4 for detAils},r�r "'F�sempt frQm backup writhholding"bax irr the line foll�veiny
th�busin�ss narne,sign and date the forrn.
�. The IR�tells the requ�ter thai+�ru iurnisheci an G�nerall indiuiducils inclu�din sol� ��are nr�t
incorrect TIN,or exernpt from backup withhalding.C4rpor�ti n�s arr�ax�rrrpt
4. The IR3 t�lls y�iu that y�au aia subj��t fio t�ackup fmm backupwilFrholding for c�rtain�+aymen#�,such as
withholding bacause you clicl not repe�rt�II your intaeest end irrter�t and diuidsnris.
dividend�on your tax return(h�r rewc�rt�ble intere�t�nd {�4te,If you are e�rnpt frorn ba�kup wi�ih�lcliiul,�3�i
dividends only'j,ar should still carri late this form to �rroit�
R f��ciula s�rrr�n�?�us
5. You�io not cc�rtify to th�rer.�uest�r thdt ynu arr�nr,t baclwp v��ithholding.
subj�ct to backup withh�lc�in��.ind�x�4�ou��for rr�{x�itable Exean�t }�aye�es.Ba�kup v��thhvlding i�ns3i r•�R�uir�vn any
interast und divid€�nd aac;runt�i�pen�c.i�fi�r 19b,3 onlyl, payrnents made tcs the f411vwing par����:
Csrt�in payaes and {7aymenis ar���mpt fr�m backu� 1.An organization exernpt from tcrx uncl�r uerti��n 501��,1.
vrithholding.S�e�a the instrwcti�ns I�Icrn �ncl th��ar�te any IRA,vr a custrsdial ac�unt uncWar€ec�tion�}�73(la}(Tj if th�
Instructic�ns fc�r the Ra�uastar��f Fx3nn�,'-�. �ccvunt satisfit�s th�requir�rn�nts r�f a�c#it�n 4l71��}(2�,
2.Ttre Uniteci State�or arr�+of its�gr�n�;i�ss a7r
Penalties instrurnent�liti�,
Fa�l�e to fvrr�is�Tlhl,If you iail itr� �.irni�h+,�a�ir carrr�ct TIN 3.A stmt�.the L�istrict c�f C�lurnbia,a pe��ession Uf th�s
tc�a requestrar,yuu€�re sul5j�rt t�� �Analty ai$50 fsar+�h United States, c�r�ny�f their pc�lftieal�uh�sliyisi�>i��r
such failure�nlr�s ynur fiailui�i•�elus�t��ir�u�>nalale c�uss� instrurnantaliti�s,
and nat to v�iliful r�eglect. 4.Aforeign governm�nt rr any of ii� �snlitiz:al uLll>CII+fI�G7ftE',
t:t'J`.l)j]�I�a�#y�Di����SQ JI�C3i'IMbl�'IdAf1 H5T1�:�1.Y�St�5PG3 tsa �Q�f1CI�BE3, C7P 111St1'FJITtsI'1t3�1t193.CJI'
wit�ho4drrrg.If you rn�ok�a f,al�+�s#e�i+�m�r�t�n+ith n� 6.An intematianal organizatican r�r �ir,��af it�n±��?nci�s car
rea�onable ka€�sis thai ra���.d�in i7x�la�r_:ku��wvi#hh��l�iin�,yt�u instrurn€�ntalities.
are subjeC# ta+�$5U0��alty: C�ther•i�Yaes that may bc?�x�m�t frs>m laa.icl€�.i�a
Crdrnina�aenalty for f�l�ifyir�inf�>rir��fiicar�.V�illfully vwithhcalding inrlude:
falsifying cartificadions.�sr ai�iri7iptia�nw�m�y 44ibj�r.t yo4i ta �,q�rpc,ratian.
criminal �aanaki�is inclucliny�fina��an�:4��>r im�ria�rnri�n#.
65
MSRC Clean Transportation Fundingr""
FY'08/'09 Local Government Match Program
Fi.rm @5t-P�4ev,+:1-247G6j p�, �
�.�ro�-����� ���cr�i��„��4f i��e, I��rt I. T�a�a€�a��er ld�ntific�tican
s�. ��1��31Nr in�c�curitie6 crr c€�mmaditie�reyuir€�cl tc�r�digt�cr ���.���. �T���
in fh�Ui7it�+d 3t�t€��,the Di�triet of C�lumbia,car a
�rer�r�ssiar7 of the Unitc�d State�, Ents�r�y�r.�um��?d'in,b1����apa•c���ria�e bnx. Ify�c�u nre�r�id�nt
�. �h.itur�as cemmis�i�n merehaflt register��with thre �lir�7�a��l��ezu cl�ncrt I��tve an�f ar•e not sligibla ta g�t ran �N,
�aimi�c�ciit�/Futur€�Tracling Cornmissi�rn, �our Tlh�is ycn.m IRS in�fividu�rl tal�ayer id�rrtifi�atitrn numt�r
�ITlhd�. Ei�t€!r it ii�tl�e�c�cial sc.�urity nurnber t�ox..If yau da
iC3. p�ret�l c�state investmerrt trust, nerf i�auc��an ITIN,swEt Hc,w#r�c,rat a F�d+f t3elow°.
11. ,�i7 a�ntity registered�rt all tim�during the�ix y�aar If��u t�rr���crle�:Er�ari�tcsr anci yc�u hav�+v�r EIN,yau may
w�clr��thg h�rar�stmrrrt Cornpany AGt of 1940�, €�i'�tw•9ifh�•yrtrur:;:�ihJ etr EIN.Hesu���u�+r,the IR�prefers that
1�. �k�arnman tru�t fund�pgrated by a b,ank un�7er S��u usr��crur��;hl.
saction 5�14{a). If y�u�rrr��sii�gl�-c�ui�ur LLG'th�t is rJisr�gardxl as an
13. R�fii��nci�al institutian, �ntif�se�:�ir�t�+frw-n it�crw�i�r�e(sr�e L�rxx�ted laatai�ity camparay
t�L�,`)cn1�.���a�p,errtsr yc�ur�SN (err EIN,if you httve ane1. If
1�. Cc rnicidlernan knovnr�in the inr�estmc�r�t cornrnunity€,�a fh+�LLt:is�ec�r�g�n�dc�i�,�aartn€arshi�a,etc.,�ter the ar�tity's
i�on7ir�r�r�csr custo�i3n,ar EIN.
1�. ps trust e�ernpt frarn ttix und�r secti+an 664 c�r ry,,y�,�,yc�u th�+cM��irt ai� ��ag�A far further clarificatior��f
clescrihed irr section 49�7. n<v7i�+�ncl TIN cznnl`aii��ti4rrs.
TMg chart k�elcrv«r shcnrrs types of payrn€nts tt�at rnay ba M�vv ta y�t a TMI�.If}r�u rira nat I�awe a TIN, apply for c+ne
er�c�rrtipt(ram t�ackup v�rithholding.The chart applifis ta th� i17�n7�td'12t�+1y.Ti�a�7�tl��foP�an aSN,get Farm °,.,..S-�,
par.�m��t reci�ients listed above, 1 through 16. &��lis:�ti�ri�fe�r a�vci�l S�scurity C:ard,frorn your local Social
M�'o�,�paymr,ant�e tae... 1fMEN tl�payn�,t�exampt ��urifiy A�fi�7inistrafii�ai��fice crr get this form online�t
�� wavw.s:,e�ls�+r�urily.g�asr�cantane�ss-5.pdf.Ycau ma�alsr�g�t this
ftrrm by�allii�s� 1-�Qt1-772-1213.Use Form W-7,,4pplication
Irrteree�t e�d diuidend paymeMa All ew�xmpt recapients erar�ept fcu•IR�Inclrt+iciva�l T�xp��er ldentification Number,to appl�t
for 9 fcrr�n IT1N,c�r Farm SS-4,,4pplication fe,r Employ�er
I�sntifi��tion Nurnber,to�pply for an EIN.Ycau can apply fc�r
6�roker�sneectiona E�ssmpt recipiente 7 through 13. �41'i EII`J 4�lline 17y�eifiCes5ing the IR9 web6ltEs�t
Atgo,�pgr�n ne�ister�d under www.irs.g�v,+,(�usanes,s�s,�and clicking on Ernployer ID
the Irr�eatmeM,ad�,�iec�e,4c[�f Nurnl��ars uncipr R€+lated Tcapies. '�fau can get Forrns W-7 and
19.�w no re�ulery�ac�a ae a ;i.3-�frun�tl��I RS Gry visiting svww_ir�..�try rar t�y call ing
brokae 1-�8CJC1-TAY�-Ft:}RM�1-8C�1-$29-3�76ti.
Berter ew:77errge trgneectia-e Estampt rscipienta 1 tMr,ugh� If y�ru �r€��iskad ta compl�te Farrn V1`-9 t]ut d4 not h�3ve a
snd patror�age dividende TIhJ,writs �'yawlied F�r"in the space for the TIN, sign and
dat�thQ forrn;�nc!give it ta the requester. For interest and
Paym�eme ov�r$B0o requirctJ GanerelM'.��P��'��P��� diuidend pa.yrnents, and certain payrnents made v�ith respect
to be repartad euid diract � th�ough i' to re�dily tr�.dabl�a instrurn�ants, generr�lly y�ou will hawre 60
selee over$5,oao� days to get a TIhJ arrd grve it to the requeQtsr befoi�e you are
subjr,ct to backup v��thholding Qn paymerrts.The 60-d�3r rul�
'See Form ioea-MIBG,f�Aree911anetwe Inaxiu�and it�ir�tructions. dve�not itpply tci ohh�r ty� of p3ymerrts.You vt�III be
'Ha�,ea�r,tha tu�krr�iry peryrn�,rrt�made tu�asip4ration firrl+.�ing aroas �ubject to t�+ckup v�+ithhQlding on all such {��yrnents until 1rou
proceet�e paid t+�en attornay ur�aecti�n BqiS�P�,even if che�ttame�v�e P�+�da your TIM1I to the r�quester.
oarporaiior�snd reportabl�an FsJrm 109�9-MI9G are na[erasmpt fram NoSe.W"riting"A�aplied Ft�r"rneans that you h3u�alra�r�y
Geclapwithholding:rnedicel and heelth ciere pay�n�trta,auorneyo'f�;end �pp�ied for a TIN vr that y4u irrtend ta apply for one span.
Pa}'rnerte fcr earvic�a peid try a Fsderal exccu6re�ency.
Ca�t�ar�:.4 di�rsgarrieci�rnesti�c entity tl�i,at f�a.s a fr�reign
c,wner rnust use�tae a�r�}oriate�m 41r 8.
66
MSRC Clean Transportation FundingT""
FY`08/'09 Local Government Match Program
F„rm�"1-s�q�ev.�-2t�a5j Peye 4
P'�rt II. �ertificatit�n �h�rt Cd�rn°�� �nd I�umb�r Ti� Giwe the
T4 tx3f�'.I�IS�'I tff fM9 Wlt�lhO�f�lfl��Bflt tfi£4t'fOLI�I'B 3 1�.�.. fTi��l,�P�Q!�"
r��ratrn,trr r�sid€ant�lien,si�n Form W-9.Yflu may be
rc�yuest�rci t�si�n by tMp�arithhc�iding a�e�nt ev�n if itr�rr-�s 1,4, �mr ca�is t at�ccau�ae.� �i;�s��r,a�and ssN o�.
�I'1tI ��t9ICIW 111C�IG�t9 C?IFIAI'WIS�S. 1.hy€livi�lu�l The indiwiduel
Fc�r a jedi7t a.cccrunt,anly the par.�on whase TIN is sh�rn ii� �.Ta��r�<sr,n�r�i�Yd�iclu�la UQi�,t The e�uql o�,vnar af thA ecrouM
F'ar�f I shauld$ign�ta�h�n requirsdj. F�empt r�acipients,s�e Ac,c�w-rt� ar,if�ombined fun�ie,tnA firsrt
gX�7�t'dt Ff2:MT7 82ICkUE7 4'V1t.hhf�dll)g On p8g€5 2. indi,tidual c�n tha ect.ount'
�si�y7�atwre r�s�rem�s��t�.C4mpleta the cartification as 3.t;usrt+:xlian ae�,exirrt raf a�mii7�r Th:+min�ar'
Il�dlCa�tecl ii�1 thrC�ugh 6 ta9low+. +ll„'rf<r�,n C;iit to Mina��AcKj
4.t�.Th�us+ual ie+wc�c�rle Tha graMrar-truat��
1.li�ter�esf,d��idc�c�, artd 6ar4er exettar�ge account$ $e�vinfle t�uat{g�antar ia
�:s�ae��c�hefafe 19�&�4�d b�v6cer aeccrunis c�e�sideeed �,t�sr uvart:�'�
ae�iwe duirim�198�.l�ou rnust give yvur correct TIN, but yau �,�e,e�au�d t�1�ac��um The adual o.timee'
cicr not haiv�e tv sign th�a certifiea�ian. tha��n+at g k+qal c�r uelid
2.Inf�srest;c��uis�e�rbd,braker.and barter earcha€�ge t�vac uncler.�rte lerwr
a�cc�um#s ope��roed after 1983 and broker accaunts 5.s,:al��,�p„�str:��I�i����r The aa•ner'
cm�f3uc���ed�active��ing 1983.Ysau must sign th� s�in4�ka-�nvvner LLC
certifica�tiorr or backup withholdin�v��ill apply. If yrau are �ar cieix q�pe�ai eccnu�n; �ive nar„e end aN�t
suFaject ta backup+n�ithholding and yvu are mer�ely providing
yerur corr�ct TIN ta the requester,y�au rnust cresss aut item 2 B.:�,�e pro�rri�tryi�hip�r The a�unar'
ii�th€s cartific,�tion taefore signing the form. sinql�cn���,cr L.L�.
3.Reab estat�transaciior�s.You must sign the �. A'KAIICI U'14�,2@t8I?,{?Y L9�ffI EPRICy+•
cc�rtihcatiorr.Y'ou rnay cross out item 2 of the cJertification. ��„givn t�v�t
4.{Ath�r paiyKrr�ents.You must givra yaur correct TIN, faut 8.Ce,rp��x�te or LLG elsctinQ The ccrporgticn
ycau do not have tcr sign the Gartificatian unless yeau hawe coip�iate atatus csn Farm
been netifled that}rou hmve previously given an incarrect TIN. +3a3�
"�"}th�er pa.yrnants° include payrnent�rnade in the cours�of
the r�equester's trade ar business far rents,roynities,gcrads 9.�aciauon,cluta,i�ligioue, The crgena.etiui
(oU��r than bills for merch�ndise�,medieal and health care cherit;�bl�,eduastionel.or
scsrvioe�(ncluding payments to corpor�tions),Eaaym�nis ta� �hw°tex-�npt�qeu,izaci�r,
nan�ernplayee for services,paymerifs ta certain fi$hing bo�t �4.Pertnei�hiFi�rmuki-mc�nber The�rtn��mhip
cre»�rnernbers and fishermen,arrd gross proce�d�paid to LLC
attarn�ya(including payment�to a�rpor�tions).
5.Morigaga interest p�d 6y you,aCt�utS�ficTn c9�' 11.A b�k�•ar rEgiertered The broker a naminee
abandanmer�t o#seca�rec9 p�cr;ae�ty,eanc�+fEa#i�n af delst, ��n5in�
c{ual�ed tui#�on prn�am�aym�nts(u[a�er se�c#o�a 529�. 12.Arx«,rrt��rch the C�apertmam The public eMiry
IR,�t,Caverda�M��,AfC�I@f MS�A O[MSA Ct�►1�f�butions or af fiipiicukure in the neme af
c�giributiona,and perasic�a c��tri6utio�ra.Ynu muat give s public arrtity�auch ee a
yvur ccarrect TIN, but you dsa not h€�ve to sign tha ercate�r Ic3cel g�vemm�m,
cgrtlfic�ition. scl-�ol��iatrict,4r prieona tltiat
r�caivee agricukueal progrem
P�YmeMs
�Liat fir�t and cn la tha nen�of the p�reon whcs�nurober ycu iumieh.ff
cxyly nna F,era�n an a jnirt eco�nt hee en SSM,that�»raan'u n�mbrsr rnuet
he fum�ihed.
'Circk�tlrye mi�a nama and iurrieh the mincr'a.S�.�N.
P
Y�u mi.rat�ow q+�ur ndiuidud nerrtic+andy�u rna-ry alen eMer y�twr businea�
vr"C}B.A'name an the aearnd iwrr»line.Yau rney waa either yrwr S5N�+r
EIN(rf�u haua ona).IF yau are a sala prapri�dar,IR5�ncoar�y�cu u>
us�puur SSN.
'Liat firt�t arrd c►ele tl-�nenra o(ths 4sge1 tn�[.eeteite,ar p�nnion tn.�t.(D�
�t iumsh tFw TIFJ of thn peracnel repreeernsi6wr�ar ir�t+�e utiler�a the lapnl
�rrtity ir,��df s�r.�t daei�nerted in tFy ecmurrt titla.�
Mate.If no name is circled a�hen mare th�n ane narnc�i�
listed,the number»�ill be consider�ed tr�he#hat bf th�6r�t
narne liated.
Privacy�1ct Motic�
Section 6it79 0�the lntemal R�e�n�ie Ca�e requiras you ts�prrnride your cprcect Tlhl to per�ons who must fil�inf�xmatinn i�t�irns
with the IR�to re{aort inters�t,cliau.i�ncl�,�n�i rert�in otl�er incom�paid h7�,�au, mortigag�irrter�st y^s�u�ai��,th�ar.q.uisitiun ur
abandonme�nt of sscurecl prr�p�rly,r.z�ncell�ion of d�t�t,or contributinns ycau rnade�o an IRA,or Archer t+11�a3r H:3Ja.Th�IRS
uses the nwmbers 1ar identifir�tinn�u��3cr�an�l to hel{�verifiy ths ac�curacy of yaur t�c retum.The IR�m�}�als�Cxrz�vi�l+� Uiie
infarmation to the D�{�aitmeni af Jusii�irx rivil ans:l crirninal litigation,t�nd tca cities, states,and thg Qi�krict c�f C•a�luml�i�t�r,an}+
out their ta�I�v^s.We rnay trlsa�li�:ln��thi�infi�nnstion io c3ther cauntrieg under a ta�c 7ssty,ta farJerul ancl w�.i#��u.��snci��to
er�force federal non#ax crirninal I�rva,�r trj 1'�:Iai�l Immf enir�reernent and ir�telligenee agencies h�cornt�at#r�rx�iiUrn.
Yau must proaids y�ur TIN�vheth»r ur nt>t�u�i�e r�quit�cl to file a tmt retum.Payers must generally wvithhealcl 2�4o u�f�:�rxahfr�
intsrgst,dividsncl,ari�J�gitain r3thr�r��ayrnrant�t��n��yr�vaha does nat giwe a TIN to a pa}ree. ��ariain�»rnaliCie� n�.�+,,al��a{y�71y.
67
MSRC Clean Transportation FundingT""
FY'O8/'09 Local Government Match Program
CERTIFICATE OF INSURANCE/
LETTER OF SELF INSURANCE
All MSRC contractors are required to provide a Certificate of Insurance naming the South Coast Air Quality
Management District as an additional insured within forty-five (45) days of receipt of notification of a funding
award.
It has been the experience of the MSRC that many cities and counties within the South Coast Air District are
self-insured. If your city or county is self-insured, please provide a letter to that effect with your application
package. A sample self-insurance letter is included below. This sample is intended only to be representative of
an acceptable letter. Your city's format and content may be different. Please refer to the requirements of the
Sample Contract.
(date)
MSRC Contracts Administrator
South Coast Air Quality Management District
21865 Copley Drive
Diamond Bar, California 91765
Subject: Statement of Self-Insurance
Dear MSRC Contracts Administrator:
This is to certify that self-administers and insures, defends, settles and pays third party claims for
bodily injury, personnel injury, death, and/or property damage. Protection under this program is warranted to
meet or exceed $1 million, combined Single Limit, per occurrence, and $2 million in general aggregate.
Additionally, is permissively self-insured for Worker's Compensation under the laws of the
State of California.
agrees to provide the South Coast Air Quality Management District with thirty (30) days prior
written notice of any changes in this program.
If you need any further information regarding this risk-retention program, please contact the Risk Management
Staff at(000)000-0000.
Sincerely,
Risk Manager
If you have questions regarding insurance, please contact the MSRC Contracts Administrator.
68
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