HomeMy WebLinkAbout2011-239 Housing - Lu Lu (Jimmy Shwe) for Translator services/-~ ~~~
ORANGE COUNTY
COUNTYWIDE TRANSLATOR
CONTRACT $15,000 OR LESS
NORTH CAROLINA
THIS AGREEMENT, made and entered into this 1st day of July, 2011, ("Effective Date")
by and between Orange County, North Carolina, a body politic and corporate organized under the
laws of the State of North Carolina, (the "County"), and Lu Lu (Jimmy Shwe) (the "Provider");
WITNESSETH:
For the purpose and subject to the following terms and conditions hereinafter set forth, the
County hereby contracts for the services of the Provider, and the Provider .agrees to provide the
following Translation services (hereinafter referred to as "Services") to the County in accordance
with the terms of this Agreement, time being of the essence.
1. Contract. This Contract consists of this document and additional documents checked
below:
a. For Health Department:
i. ®Business Associates Agreement
b. For Department of Social Services:
i. ^ The General Terms and Conditions (Attachment A);
ii. ®_ The Scope of Work, description of services, and rate (Attachment B);
iii. ®Federal Certification Regarding Drug-Free Workplace (Attachment C);
iv. ®Conflict of Interest (Attachment D);
v. ®No Overdue Taxes (Attachment E);
vi. ^ Outcomes and Reporting (Attachment N)
These documents constitute the entire agreement between the Parties and supersede all prior oral
or written statements or agreements.
2. Provider's Responsibilities:
a. The Provider shall be qualified to translate between English and Karen with the
County staff.
b. Professional Conduct. The Provider shall adhere to the standards of professional
conduct of a translator while conducting the services to include the following:
i. The Provider will translate the information as clearly as possible without
changing the meaning and the intent of the document.
ii. The Provider will translate the information to the best of his/her ability.
c. Client Confidentiality.
Revised June 2011 1
i. The Provider acknowledges that she/he may have access to information that
is confidential and provided by state and federal laws and agrees to comply
with all privacy policies, regulations, and laws as well as the Health
Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-
191).
ii. The Provider agrees to protect confidential information (e.g., client name,
appointment type, telephone number, health information) that he/she may
receive in doing business with County. The Provider should ensure proper,
safe storage and protection of client information during use, and
shredding/deletion of such information when it is no longer necessary for
business purposes.
iii. Breaches of client confidentiality will result in automatic termination of this
Agreement.
d. Scope of Services.
i. Procedures and Guidelines when the Provider Accepts a Translation
Assignment:
1. When asked to translate from English into the second language, the
Provider will review the original English version and request any
clarification from County staff prior to translation.
2. As needed, the Provider will discuss with County staff
recommendations to improve the utility and cultural appropriateness
of material for the target audience prior to translation. Upon
consultation with Provider, County staff may choose to modify the
English version before resubmitting for a direct translation.
Document consultation may be charged as part of the translation
service, but must be agreed upon in advance.
3. All translations should match the original version in terms of content
and format.
4. The Provider will submit an electronic version of the translation.
Documents must be formatted using an MS Word software program
and/or submitted as a PDF so that County staff can open and read the
document.
3. County's Responsibilities. County will compensate Provider as provided in subsection 4
for translation services at the rate prescribed.
4. Payment for Services: The County agrees to pay at the rates specified for Services
satisfactorily performed in accord with this Agreement. The amount to be paid by the
County shall not exceed $1,000 ($35/hour for Translation services). Payment shall be
made within thirty (30) days of an invoice properly submitted to County. Should
Revised June 2011 2
Provider fail to perform its duties under the terms of this Agreement, County may,
without fault or penalty, withhold any payment associated with the work to be performed
until such time as said work is completed. The procedures for payment of services
rendered shall be as follows:
a. The Provider. The Provider will complete and submit either the County Invoice for
Payment of Translation Services form to County staff at the time the service is
rendered. County staff will verify the information, sign and forward the form for
payment of services.
5. Term. The term of this Agreement shall be from July 1, 20_ to June 30, 20
6. Errors and Omissions. Provider represents and agrees that Provider is qualified to
perform and fully capable of performing and providing the services required or
necessary under this Agreement in a fully competent, professional and timely manner to
the satisfaction of the County. Provider shall be responsible for all errors or omissions,
in the performance of the Agreement. Provider shall correct any and all errors,
omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the
County.
7. Additional Terms and Condition. The. County may have additional terms and conditions
that shall be provided as an attachment(s) and is (are) hereby incorporated by reference.
8. Precedence Among Contract Documents: In the event of a conflict between or among
the terms of the Contract Documents, the terms in the Contract Document with the
highest relative precedence shall prevail. The order of precedence shall be the order of
documents as listed in Paragraph 1, above, with this contract document having the
highest precedence then the first listed document and the last-listed document having the
lowest precedence. If there are multiple Contract Amendments, the most recent
amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
9. Non-waiver: Failure by County at any time to require the performance by Provider of
any of the provisions hereof shall in no way waive or affect the County's right hereunder
to enforce the same, nor shall any waiver by the .County of any breach be held to be a
waiver of any succeeding breach or a waiver of this Non-Waiver Clause.
10. Independent Contractor: The Provider shall operate as an independent Provider, and the
County shall not be responsible for any of the Provider's acts or omissions. The
Provider shall not be treated as an employee with respect to the Services performed
hereunder for federal or state tax, unemployment or workers' compensation purposes.
The Provider understands that neither federal, nor state, nor shall payroll tax of any kind
be withheld or paid by the County on behalf of the Provider or the employees of the
Provider.
11. Insurance: The Provider shall obtain, at its sole expense, all insurance needed to
adequately insure itself during the performance of these services.
Revised June 2011 3
12. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County
from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including
reasonable attorney's fees) arising from bodily injury, including death, to any person or
persons or damage to or destruction of any property caused in whole or in part by any
negligent or intentional act or omission on the part of the Provider.
13. Termination: This Agreement may be terminated at any time by mutual written
agreement of the parties or by the County upon written notice to the Provider.
14. Entire Agreement: The parties have read this Agreement and agree to be bound by all of
its terms, and further agree that it constitutes the complete and exclusive statement of the
Agreement between the parties unless and until modified in writing and signed by the
parties. Modifications may be evidenced by telefacsimile signature.
15. Governin Lg aw: Both parties agree that this Agreement shall be governed by the laws of
the State of North Carolina. Should either party initiate litigation to settle any dispute
involving the terms of this Agreement such litigation shall be initiated in the General
Court of Justice of North Carolina seated in Orange County, North Carolina.
16. Non Appro riation: Provider acknowledges that County is a governmental entity, and
the validity of this Agreement is based upon the availability of public funding under the
authority of its statutory mandate. In the event that public funds are unavailable and not
appropriated for the performance of County's obligations under this Agreement, then
this Agreement shall automatically expire without penalty to County immediately upon
written notice to Provider of the unavailability and non-appropriation of public funds.
IN WITNESS WHEREOF, Orange County and the Provider have signed this Agreement,
effective as of the day first written above.
[SIGNATURE PAGE TO FOLLOW]
Revised June 2011 4
ORANGE COUNTY
By' ~ ^ Z~ .- ~~
County ana r
200 S. Cameron S .
P.O. Box 8181
Hillsborough, NC 27278
PROVIDER: Lu Lu (Jimmy Shwe)
By. 4-
Title: `~ 1,;,,, ''
This instrument has been approved as to technical content.
a L. Fik s, H sing, Housing and
Community Development Department Director
This instrument has been pre-audited in the manner required by the Local Government Budget and
Fiscal Control Act.
~~w ~~ ~
Clarence G. Grier, Finance Director
Th' i stru n has been approved as to form and legal sufficiency.
A ette oore, S aff Attorney
Revised June 2011 5
BUSINESS ASSOCIATE AGREEMENT
This Agreement is made effective the 1St of July, 2011, by and between Orange County on
behalf of the Orange County Health Department, hereinafter referred to as "Covered Entity", and Lu Lu
(Jimmy Shwe), hereinafter referred to as "Business Associate," (individually, a "Party" and collectively,
the "Parties").
WITNESSETH:
WHEREAS, Sections 261 through 264 of the federal Health Insurance Portability and
Accountability Act of 1996, Public Law 104-191, known as "the Administrative Simplification provisions,"
direct the Department of Health and Human Services to develop standards to protect the security,
confidentiality and integrity of health information; and
WHEREAS, pursuant to the Administrative Simplification provisions, the Secretary of Health and
Human Services has issued regulations modifying 45 CFR Parts 160 and 164 (the "HIPAA Security and
Privacy Rule"); and
WHEREAS, the Parties wish to enter into or have entered into an arrangement whereby
Business Associate will provide certain services to Covered Entity, and, pursuant to such arrangement,
Business Associate may be considered a "business associate" of Covered Entity as defined in the
HIPAA Security and Privacy Rule (the agreement evidencing such arrangement is entitled Countywide
Translator Contract $15,000 or Less ,dated July 1, 2011, and is hereby referred to as the
"Arrangement Agreement"); and
WHEREAS, Business Associate may have access to Protected Health Information (as defined
below) in fulfilling its responsibilities under such arrangement;
THEREFORE, in consideration of the Parties' continuing obligations under the Arrangement
Agreement, the Parties agree to the provisions of this Agreement in order to address the requirements
of the HIPAA Security and Privacy Rule and to protect the interests of both Parties.
DEFINITIONS
Except as otherwise defined herein, terms used in this Agreement shall have the same meaning
as those terms set forth in the HIPAA Security and Privacy Rule.
II. CONFIDENTIALITY REQUIREMENTS
(a) Business Associate shall:
(i) use or disclose any protected health information solely as permitted or
required by this Agreement, the Arrangement Agreement (if consistent
with this Agreement and the HIPAA Security and Privacy Rule), or as
required by law. .
(ii) ensure that its agents, including a subcontractor, to whom it provides
protected health information received from or created by Business
Associate on behalf of Covered Entity, agrees to the same restrictions
and conditions that apply to Business Associate with respect to such
2
information. In addition, Business Associate agrees. to take reasonable
steps to ensure that its employees' actions or omissions do not cause
Business Associate to breach the terms of this Agreement;
(iii) implement appropriate safeguards to prevent use or disclosure of
protected health information other than as permitted or required by this
Agreement;
(iv) permit the Secretary of Health and Human Services to audit Business
Associate's records and practices related to use and disclosure of
protected health information to ensure Covered Entity's compliance with
the terms of the HIPAA Security and Privacy Rule;
(v) report to Covered Entity any use or disclosure of protected health
information which is not in compliance with the terms of this Agreement of
which it becomes aware;
(vi) report to Covered Entity any Security Incident of which it becomes
aware. For purposes of this Agreement, "Security Incident" means the
attempted orsuccessful-unauthorized access, use disclosure,
modification, or destruction of information or interference with system
operations in an information system; and
(vii) mitigate, to the extent practicable, any harmful effect that is known to
Business Associate of a use or disclosure of protected health information
by Business Associate in violation of the requirements of this Agreement.
(b) Notwithstanding the prohibitions set forth in this Agreement or the Arrangement
Agreement, Business Associate may use and disclose protected health information as
follows:
(i) if necessary, for the proper management and administration of Business
Associate or to carry out the legal responsibilities of Business Associate,
provided that as to any such disclosure, the following requirements are
met:
(A) the disclosure is required by law; or
(B) Business Associate obtains reasonable assurances from the
person to whom the information is disclosed that it will be held
confidentially and used or further disclosed only as required by
law or for the purpose for which it was disclosed to the person,
and the person notifies Business Associate of any instances of
which it is aware in which the confidentiality of the information has
been breached;
(ii) for data aggregation services, if such services are to be provided by
Business Associate for the health care operations of Covered Entity
pursuant to any agreements between the Parties evidencing their
business relationship.
III. AVAILABILITY OF PROTECTED HEALTH INFORMATION
Business Associate shall:
(a) at the request of Covered Entity, provide access to protected health information in a
designated record set to Covered Entity or, as directed by Covered Entity, to an
individual, in a time and manner sufficient to permit Covered Entity to comply with the
requirements of 45 CFR 164.524.
3
(b) at the request of Covered Entity or an individual, make any amendment(s) to protected
health information in a designated record set that are directed by or agreed to by
Covered Entity, in a time and manner sufficient to permit Covered Entity to comply with
the requirements of 45 CFR 164.526.
(c) document disclosures of protected health information and information related to such
disclosures in a manner sufficient to permit Covered Entity to respond to a request by an
individual for an accounting of disclosures of protected health information in accordance
with 45 CFR 164.528 and provide such documentation to Covered Entity or an individual
as directed by Covered Entity.
IV. TERMINATION
(a) Term: This Agreement terminates when the Arrangement Agreement terminates or as
provided in Paragraph IV.b. below (termination for cause).
(b) Termination for cause: Upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity shall either:
(i) provide an opportunity for Business Associate to cure the breach or end
the violation or, if Business Associate does not cure the breach or end the
violation within the time specified by Covered Entity, terminate this
Agreement and the Arrangement Agreement; or
(ii) immediately terminate this Agreement and the Arrangement Agreement if
Business Associate has breached a material term of this Agreement and
cure is not possible.
(c) Return or destruction of protected health information: At termination of this Agreement,
the Arrangement Agreement (or any similar documentation of the business relationship
of the Parties), or upon request of Covered Entity, whichever occurs first, Business
Associate shall:
(i) if feasible, return or destroy all protected health information received from
or created or received by Business Associate on behalf of Covered Entity
that Business Associate still maintains in any form. Business Associate
shall only destroy protected health information with the written approval of
Covered Entity. After return or destruction, Business Associate shall
retain no copies of such information.
(ii) if return or destruction is not feasible, Business Associate will provide
Covered Entity with documentation explaining the reason that it is not
feasible. If the protected health information is not returned or destroyed,
Business Associate will extend the protections of this Agreement to the
information and limit further uses and disclosures to those purposes that
make the return or destruction of the information not feasible.
(d) Survival: The obligations of Business Associate under this Agreement shall survive the
expiration, termination, or cancellation of this Agreement, the Arrangement Agreement
and/or the business relationship of the parties, and shall continue to bind Business
Associate, its agents, employees, contractors, successors, and assigns as set forth
herein.
V. MISCELLANEOUS
4
(a) All protected health information that is created or received by Covered Entity and
disclosed or made available in any form, including paper record, oral communication,
audio recording, and electronic display by Covered Entity or its operating units to
Business Associate or is created or received by Business Associate on Covered Entity's
behalf shall be subject to this Agreement.
(b) A reference in this Agreement to a section in the HIPAA Security and Privacy Rule
means the section as in effect or as amended.
(c) In the event of an inconsistency between the provisions of this Agreement (including
definitions) and mandatory provisions of the HIPAA Security and Privacy Rule, as
amended, the HIPAA Security and Privacy Rule shall control. Where provisions of this
Agreement are different than those mandated in the HIPAA Security and Privacy Rule,
but are nonetheless permitted by the HIPAA Security and Privacy Rule, the provisions of
this Agreement shall control.
(d) Except as expressly stated herein or the HIPAA Security and Privacy Rule, the parties to
this Agreement do not intend to create any rights in any third parties.
(e) This Agreement may be amended or modified only in a writing signed by the Parties. No
Party may assign its respective rights and obligations under this Agreement without the
prior written consent of the other Party. None of the provisions of this Agreement are
intended to create, nor will they be deemed to create any relationship between the
Parties other than that of independent parties contracting with each other solely for the
purposes of effecting the provisions of this Agreement and any other agreements
between the Parties evidencing their business relationship.
(f) This Agreement will be governed by the laws of the State of North Carolina.
(g) No change, waiver or discharge of any liability or obligation hereunder on any one or
more occasions shall be deemed a waiver of performance of any continuing or other
obligation, or shall prohibit enforcement of any obligation, on any other occasion.
(h) The parties agree that, in the event that any documentation of the arrangement pursuant
to which Business Associate provides services to Covered Entity contains provisions
relating to the use or disclosure of protected health information that are more restrictive
than the provisions of this Agreement, the provisions of the more restrictive
documentation will control.
(i) In the event that any provision of this Agreement is held by a court of competent
jurisdiction to be invalid or unenforceable, the remainder of the provisions of this
Agreement will remain in full force and effect.
(j) The headings in this Agreement are for convenience of reference only and shall not
define or limit any of the terms or provisions hereof.
5
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year
written above.
COVERED ENTITY: BUSINESS ASSOCIATE:
Title:
By: ~~
Title:
6
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN
Contract # FY 2011 - 2012
A. CONTRACTOR INFORMATION
1. Contractor Agency Name:.Lu Lu
2. If different from Contract Administrator Information in General Contract:
Address
Telephone Number:
Fax Number: Email:
3. Name of Program (s): Translation Services
4. Status: ( )Public ( )Private, Not for Profit (X) Private, For Profit
5. Contractor's Financial Reporting Year July 1, 2011 through _ June 30, 2012
B. Explanation of Services to be provided and to whom (include SIS Service Code):
The Contractor will provide lan~ua~e translation services to the County
C. Rate per unit of Service (define the unit):
1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart)
2. Negotiated County Rate.
$35.00/hour
D. Number of units to be provided:
E. Details of Billing process and Time Frames; The County will reimburse the Contractor
for services described in this contract up to the budgetary limits of the contract allotment
The County will reimburse the Contractor at a rate of $35.00/hour for approved services
provided and travel at the county rate. For reimbursement, the Contractor must submit the
Orange Countv Department of Social Services Invoice for Payment of Translation
Services form to the County staff at the time services are rendered County staff will
verify the information, sign the form, and forward the form to the designated County
Administrator. The County will reimburse the Contractor monthlyupon receipt of a
complete and correctly filed report.
Contract-Scope of Work (06/04) Page lof 2
F. Area to be served/Delivery site(s): Orange Count
1
-2
(Signatu a of Co my Authorized Person) (Signature of Contractor)
(Date Submitted) (Date Submitted)
Contract-Scope of Work (06/04) Page 2of 2
ATTACHMENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
Orange County Department of Social Services
I. By execution of this Agreement the Contractor certifies that it will provide adrug-free
workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
B. Establishing adrug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
C. Making it a requirement that each employee be engaged in the performance of the
agreement be given a copy of the statement required by paragraph (A);
D. Notifying the employee in the statement required by paragraph (A) that, as a condition of
employment under the agreement, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring
in the workplace no later than five days after such conviction;
E. Notifying the County within ten days after receiving notice under subparagraph (D)(2)
from an employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions, within 30 days of receiving notice under
subparagraph (D)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain adrug-free workplace through implementation
of paragraphs (A), (B), (C), (D), (E), and (F).
Federal Certification -Drug-Free Workplace (06/04) Page 1 of 2
II. The site(s) for the performance of work done in connection with the specific agreement are
listed below:
1.
(Street address)
2
(City, county, state, zip code)
(Street address)
(City, county, state, zip code)
Contractor will inform the County of any additional sites for performance of work under this
agreement.
False certification or violation of the certification shall be grounds for suspension of payment,
suspension or termination of grants, or government-wide Federal suspension or debarment
(Section 4 CFR Part 85, Section 85.615 and 86.620).
Signature
Agency/Organization
Title
Date
(Certification signature should be same as Contract signature.)
Federal Certification -Drug-Free Workplace (06/04) Page 2 of 2
ATTACHMENT D
CONFLICT OF INTEREST POLICY
Orange County Department of Social Services
Conflict of Interest Defined:
A conflict of interest is defined as an actual or perceived interest by a (Contractor/staff
memberBoard member) in an action that results in, or has the appearance of resulting in,
personal, organizational, or professional gain. A conflict of interest occurs when an
employee/Contractor/Board member has a direct or fiduciary interest in another
relationship. A conflict of interest could include:
- Ownership with a member of the Board of Directors/Trustees or an employee
where one or the other has supervisory authority over the other or with a client
who receives services.
- Employment of or by a member of the Board of Directors/Trustees or an
employee where one or the other has supervisory authority over the other or
with a client who receives services.
- Contractual relationship with a member of the Board of Directors/Trustees or
an employee where one or the other has supervisory authority over the other or
with a client who receives services.
- Creditor or debtor to a member of the Board of Directors/Trustees or an
employee where one or the other has supervisory authority over the other or
with a client who receives services.
- Consultative or consumer relationship with a member of the Board of
Directors/Trustees or an employee where one or the other has supervisory
authority over the other or with a client who receives services.
The definition of conflict of interest includes any bias or the appearance of bias in a
decision-making process that would reflect a dual role played by a member of the
organization or group. An example, for instance, might involve a person who is an
employee and a Board member, or a person who is an employee and who hires
family members as consultants.
Employee/ContractorBoard Member Responsibilities:
It is in the interest of the organization, individual staff, and Board members to strengthen
trust and confidence in each other, to expedite resolution of problems, to mitigate the
effect and to minimize organizational and individual stress that can be caused by a
conflict of interest.
Employees are to avoid any conflict of interest, even the appearance of a conflict of
interest. This organization serves the community as a whole rather than only serving a
special interest group. The appearance of a conflict of interest can cause embarrassment
to the organization and jeopardize the credibility of the organization. Any conflict of
interest, potential conflict of interest, or the appearance of a conflict of interest is to be
reported to your supervisor immediately. Employees are to maintain independence and
objectivity with clients, the community, and organization. Employees are called to
Conflict of Interest Policy (06/04) Page 1 of 2
maintain a sense of fairness, civility, ethics and personal integrity even though law,
regulation, or custom does not require them.
Acceptance of Gifts:
Employees, members of employee's immediate family, and members of the Board are
prohibited from accepting gifts, money or gratuities from the following:
a. Persons receiving benefits or services from the organization;
b. Any person or organization performing or seeking to perform services under
contract with the organization; and
c. Persons who are otherwise in a position to benefit from the actions of any
employee of the organization.
Employees may, with the prior written approval of their supervisor, receive honoraria for
lectures and other such activities while on personal days, compensatory time, annual
leave, or leave without pay. If the employee is acting in any official capacity, honoraria
received by an employee in connection with activities relating to employment with the
organization are to be paid to the organization.
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
I, L i.~ ~ u ,certify that I have read the forgoing
information, understand it, and that no conflict of interest exists in the execution of this
contract.
Signature
Sworn to and subscribed before me on the o`2 ~ ~ day of ;,~,„, , 2011.
My Commission Expires: l U ~o ~ ~a vt 5
Page 2 of 2
June 27, 2011
Lu Lu
1105 W. Hwy 54 Bypass, Apt L6
Chapel Hill, NC 27516-2845
To: Orange County Department of Social Services
Certification:
I certify that I do not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at
the federal, State, or local level. I further understand that any person who makes a false
statement in violation of N.C.G.S. 143-6.2(b2) is guilty of a criminal offense punishable
as provided by N.C.G.S. 143-34(b).
Sworn Statement:
I, being duly sworn, say that I am Lu Lu; and that the foregoing certification is true,
accurate and complete to the best of my knowledge and was made and subscribed by me.
I also acknowledge and understand that any misuse of State funds will be reported to the
appropriate authorities for further action.
Sig~ture
Sworn to and subscribed before me on the a7~ day of ~ cam- , 2011.
L
otary Signature and Se 1)
My Commission Expires: '(J ~ U ~ ~ a o~5
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