All proposals submitted in response to this Request shall be ...

All proposals submitted in response to this Requestshall be irrevocable for a period ofOne Hundred Twenty (120) days after the Proposaldue date and may not be withdrawn by the Vendorduring this period. After such time has elapsed, theVendor may withdraw the proposal if it has not beenselected prior to the request to withdraw. Suchwithdrawal shall be requested in writing.The City reserves the right to waive technicalities or to accept or reject any proposal orcombination of proposals based upon the City’s determination of its best interest.2Form A-1 10/09

ALL questions pertaining to this Request (RFP or RFQ) must be submitted in writing atleast five (5) business days prior to the deadline for submission to:Teri LegnerInterim UC2B Consortium CoordinatorCity of Champaign102 N. Neil St.Champaign, IL 61820Facsimile: (217) 403-8725Email:teri.legner@ci.champaign.il.usVendors are prohibited from contacting any other staff of the City of Champaignregarding this Request except as specifically set forth herein. Failure to comply with thisprovision may result in rejection of any or all proposals.1.3 General InstructionsA. All proposals should follow the format described in this Section and in “Contentand Format” Section of this Request. Vendor shall provide informationrequested by this Request in a direct and concise manner. Responses shall referdirectly to section numbers in this Request and meet or exceed the requirementsas described.B. The requirements stated herein are mandatory unless stated otherwise. Itshould be understood that failure to respond to a specific requirement may bethe basis for eliminating a Vendor from consideration during comparativeevaluation of proposals.C. The City of Champaign reserves the right to accept or reject any or all proposals,or portions thereof.D. When a package proposal is made for a package price, the package price shall betaken to include all items referenced in the package.E. The Vendor may submit multiple proposals involving various methods of meetingproposal objectives. However, each submitted proposal shall be complete inevery respect and marked as Proposal No. 1, No. 2, etc. on the cover page.F. Subsequent to receipt of proposals, the City or its authorized representative mayrequire the Vendor to make oral presentations or to respond to telephone callsor clarify its Proposal.4Form A-1 10/09

G. Section and subsection numbering should be in a consistent format using thenumbers indicated in the “Content and Format” section of the Request andbeginning each section on a new page.1.4 Content and FormatAn original plus the required number of copies of the proposal shall be submitted along with allthe required documentation. The original and copies of the proposal shall be packagedseparately and securely bound and sealed. Each shall show the name and address of theVendor submitting the proposal on the front cover.Proposals should include the following in the order listed. Each section should be labeled.a. Cover LetterRespondents shall provide a cover letter or letter of transmittal that briefly summarizesthe company's interest and relevant qualifications for the project. This letter shall notexceed two (2) pages, and shall be signed by an agent of the responding firm who isauthorized to negotiate the details of the proposed services.b. Vendor Information and Executive SummaryThe Executive Summary is limited to five (5) pages and should include a writtensummary of the proposal for review and, at a minimum, the following information:1. Company Name2. Company Size3. Company Location4. Company Website5. Financial Stabilitya. Include in such description, where applicable, i. the credit rating ofyour firm’s parent entity, or ii. related subsidiaries that would provideservices under this RFPb. If the Vendor is publicly traded, please attach the Vendor’s most recent10-K. If the Vendor is privately owned, please enclose an auditedConsolidated Balance Sheet, Consolidated Profit and Loss Statement anda Dunn and Bradstreet Comprehensive ReportIMPORTANT: Financial information shall be assumed to be Confidential and will not beshared in an open forum or made available to the public.6. Time in business / Year established5Form A-1 10/09

1.8 Customer Service(4) The previous and existing compliance by the Vendor with laws andordinances relating to the contract;(5) The quality, availability and adaptability of the supplies, machinery, plantor other equipment or contractual services to the particular use required;(6) The sufficiency of the financial resources and financial ability of theVendor to enter into and perform the contract or service;(7) Whether the Vendor is entitled to Local Preference pursuant to Section12.5-34 of the Champaign Municipal Code, 1985 as amended;(8) Completion and approval of the EEO/AA paperwork.The City expects the Vendor to deliver a high level of customer service regarding themaintenance, repair, delivery, and installation of any equipment and the provision of anyservice to the City, its employees and its customers.1.9 Rights to Submitted MaterialsAll proposals, responses, inquiries, or correspondence relating to or in reference to thisRequest, and all reports, charts, displays, and other documentation submitted by the Vendorshall become the property of the City when received and shall not be returned to the Vendor.The City reserves the right to use the material or any ideas submitted in this proposal inresponse to the Request whether amended or not. Selection or rejection of any proposal doesnot affect this right.1.10 Proprietary InformationAny restrictions on the use of information contained within a proposal shall be clearly stated assuch within the proposal. The City will only be able to comply with a request for confidentialityto the extent allowed by law.1.11 Affirmative ActionIf this contract will be over $17,500, the Vendor shall comply with the Equal Opportunity inPurchasing Ordinance of the City of Champaign (Section 12.5-65 of the Champaign MunicipalCode, 1985, as amended). Pursuant to the Ordinance, the Vendor must have on file aCertificate of Approval or an Affirmative Action Form plus an approved Affirmative Action Planbefore a Vendor can be selected. Inquiries concerning this requirement may be directed to theCommunity Relations Office, 102 N. Neil Street, Champaign, IL 61820 or by telephone at (217)403-8830.8Form A-1 10/09

1.12 Acceptance of Proposal ContentThe contents of the proposal or parts thereof selected by the City will be incorporated into thefinal Contract Documents to the extent they comply with this Request.1.13 Cost of the Vendor to Respond to RequestThe City is not responsible for any cost incurred by a Vendor in the process of responding to thisRequest or for any pre-contract costs incurred by any Vendor participating in the selectionprocess.1.14 Public AdvertisingThe Vendor is specifically denied the right to use the name of the City of Champaign or Urbana-Champaign Big Broadband (UC2B) for public advertising or reference in any form or mediumwithout the express written permission of the City of Champaign.1.15 TerminationThe City reserves the right to terminate the selection process at any time, to reject any or allproposals and to award the contract in the best interest of the City of Champaign.9Form A-1 10/09

II.Scheduled Maintenance Services and Adds, Moves and Changes for FTTP ElectronicEquipment and Associated HardwareVendor may be required to update software or firmware for ONT’s, Gateway Routers andWireless Access Points on a non-priority, scheduled maintenance basis. Software and/orfirmware updates will be installed on a scheduled service visit as updates are released. Vendormay need to respond to non-service effecting alarm notices on a non-priority, scheduledmaintenance basis. All devices will receive security patches and firmware upgrades that will beinstalled on a scheduled service visit as they are released.III.Local Phone Number for DispatchVendor will be required to provide local phone number for UC2B’s call center to dispatch repairand maintenance services.IV.Hours of Operations and Call VolumesThe Vendor shall be available to receive calls for trouble resolution, repair and maintenanceservices between the hours of 7:00 a.m. and 7:00 p.m. Monday through Friday. It is not yetknown what the peak volume period will be or how many calls are anticipated. The initial grantis for approximately 2500 residential and business customers and approximately 200 anchorinstitutions to be served. It is anticipated that this will be the total number of customers in theprogram for the first year of the contract with the Vendor. After the initial year, it is not yetknown whether or not the UC2B network will be extended to serve a larger footprint of theUrbana-Champaign area or whether additional businesses and commercial customers will beserved.V. Close out of Trouble TicketThe Vendor will be responsible for closing out any trouble tickets with the UC2B call center.VI.Replacement of EquipmentIf the ADTRAN, Gateway Routers or Wireless Access Point equipment needs to be replaced, theVendor will have a supply of replacement equipment from UC2B that will be replenished overtime as needed.VII.Material and Product ProtectionThe Vendor shall be responsible for protecting finished work, equipment, supplies, andmaterials from loss, injury, and/or damages from any cause whatsoever until final acceptanceor close-out of the trouble ticket or maintenance ticket by the appropriate UC2Brepresentative. Vendor shall be responsible for the proper care of any UC2B furnished11Form A-1 10/09

materials, supplies, and equipment while it is in their custody. Vendor shall issue writtenreceipts for all such property and account to UC2B for any damage to, or loss of, such propertywhile in their custody or control.VIII.Access to FacilitiesVendor shall coordinate activities with the appropriate building owner, manager or tenant togain the required access. Vendors shall provide a (2) hour arrival window for customer’s repairor maintenance. Vendor shall also provide sufficient resources to coordinate all necessaryaccess.IX.SafetyVendor shall adhere to all applicable federal, state, and local safety regulations and alloperations shall be conducted in a safe manner to protect both the public and the employees ofthe Vendor.X. Questions and ResponsesProvide in these Sections discussions on your technical qualifications and experience with repairand maintenance projects as related to the requirements above. Also, provide answers to thefollowing questions.A. Previous management responsibilities related to the repair and maintenance of FTTPelectronic equipment and associated hardware of a full scale FTTP or similar project.Provide information regarding your company’s current and past contracts, providingexperience in terms of similar size, scope, complexity and duration of projects.B. Please describe your company’s approach to repair and maintenance services,describing in detail your trouble and maintenance ticket process, assignment oftechnicians, and trouble resolution process. How will your company interface withUC2B’s Call Center? Describe your approach in working with UC2B.C. Describe the plan and personnel to perform repair and maintenance services andproject oversight of the work. Designate the key contact for UC2B to contact for anyproblem resolution. Describe the plan to deal with escalated issues and the approach tosolving issues. How many individuals within your company are available and certified forrepair and maintenance services? Because of the nature of the work, it is required thatall Vendors’ personnel working on the project will be required to have a criminalbackground check and a pre-employment drug screen.D. Provide your safety record with OSHA incident rates and their approach to safetytraining. Describe your company’s testing plan, quality control plan, checking of12Form A-1 10/09

paperwork activity and reporting process, and other related project managementmethods.E. List and describe any subcontractors and define the role of the subcontractor inperforming the work and the plan to manage any subcontractors. Define the percentageof work to be assigned to the subcontractors.F. If your company was to provide materials management and inventory control,describe in detail how you would perform this? Describe the methods to track andreport materials and handling procedures. Address inventory operations, storage areaneeds, and chain of custody.G. Describe any special scheduling work or customer notification work to be performedby UC2B in assisting the Vendor in completing the Work.H. Indicate if there are any limitations on the hours of the week available to perform theWork and any related costs impacts based on a five (5) day schedule.I. Identify any discrepancies in the description of the work not included in the RFP andyour approach to address those issues by going above and beyond the duty inperforming the work. State any skills of the trade developed by your firm that setshigher standards in performing the work.J. Ensure at least one employee with each crew is fluent in English. The employees mustbe trained to be respectful of personal property and set a high customer servicestandard by adhering to orders and instruction of the homeowner. Please describe yourpolicies in working with homeowners or customers.K. The selected Vendor will provide services related to the UC2B project and Consortiumworking on an “as needed” basis, working under the general supervision and reportingto the Interim Consortium Coordinator of the City of Champaign on behalf of UC2B.Additionally, the selected Vendor will work closely with the City Attorney, the PolicyBoard, and other officials. Please provide a communication plan as to how you will keepall informed and involved in your work.L. Female and minority firms are strongly encouraged to submit proposals. The goodfaith efforts of all proposers, as evidenced by their Equal Opportunity in Purchasingsubmittal and their proposal, will be closely reviewed to ensure that they have exercisedand continue to exercise efforts to employ and utilize minority employees in theirbusiness and on this undertaking. All proposals shall include a statement of recentefforts to include minority and female employees in their business and efforts inpromoting inclusion in the profession generally.13Form A-1 10/09

XI.Cost ProposalThis section shall adequately describe all of the costs for each section of repair andmaintenance functions from the time of contract execution through June 30, 2013.UC2B is looking for competitive responses that understand the early stage nature and potentialimitations of the initial project. The UC2B initial deployment will include installation of 200anchor institutions and businesses and 2,500 residences. Additional sites may be added but arenot guaranteed as part of the initial response and subject to change according to the policiesand growth assumptions that will be determined by the UC2B Policy Committee. UC2B islooking for creative pricing options that align with the execution and subscriber take rate forservices. Creative approaches will be given additional consideration. Respondents to the RFPshould provide a description of their costs, billing and payment requirements for delivery ofservices.At a minimum the proposal should include the following pricing detail and options available toUC2B:1) Cost for Repair and Trouble Resolution (Priority Basis)a. Cost per truck roll and FTTP electronic equipment repair servicesi. Price should include options for retainer, per subscriber monthly/annualservice rates and one-time dispatch or hourly feeii. Alternative retainer modeliii. Incremental service costs associated with replacement of an ONT,Gateway Router or Wireless Access Point.2) Cost for Scheduled Maintenance, Adds, Moves and Changes (Non-Priority Basis)a. Cost per truck roll and FTTP electronic equipment maintenance, adds, moves,and changes servicesi. Price should include options for retainer, per subscriber monthly/annualservice rates and one-time dispatch or hourly feeii. Alternative retainer modeliii. Incremental service costs associated with replacement of an ONT,Gateway Router or Wireless Access Point.Additionally, the following questions shall be addressed:What are the payment terms, including whether there is a prompt payment discount and/orlate payment penalty?Are there specific price targets, and if so, what are they? How will the amount of services usedbe measured and what will the charges be? What will the charges be if the services consumed14Form A-1 10/09

are higher or lower than what is contracted for?Exceptions to the RFP: Proposers may find instances where they must take exception withcertain requirements or specifications of the RFP. All exceptions shall be clearly identified in thissection, and written explanations shall include the scope of the exceptions, the ramifications ofthe exceptions for UC2B, and a description of the advantage to be gained or disadvantages tobe incurred by UC2B as a result of these exceptions.Attachment A.1: Specifications Regarding InstallationThe following information provides the Specifications regarding how the equipment wasoriginally installed. Picture of the installation are also included in this Request underAttachment A.2.Inside Work PackagesEach subscribing entity has received a single fiber drop and has an indoor ONT installed in itspremise.I. “Inside” work for Anchor and IRU Sites:114 Anchor and IRU sites have received UC2B electronics and one single-strand fiber patchcable from the Outside Plant (OSP) fiber termination panel to a pre-determined location for thefiber service box, which has been located near the desired ONT and Gateway location.15Form A-1 10/09

For the 11 multi-strand drop cable sites with multiple Anchor or IRU entities in the samebuilding, UC2B has run a separate single strand patch cable from the OSP fiber terminationpanel to the pre-determined location for the fiber service box in each entity’s space.For sites that received UC2B electronics, once the fiber service box was installed, the Installerused a 3-meter SC-to-SC single-strand fiber patch cable to connect the Optical NetworkTerminal (ONT) to the fiber service box.A. UC2B supplied up to two (2) ten-foot Cat 5e Ethernet patch cables for connectingthe Customer’s wired devices. At the Customer’s request, (on the installationagreement) a single 25-foot Cat 5e patch cable was substituted for one of thetwo 10-foot patch cables. The “Inside” contractor did not install any permanentcopper Ethernet cabling as part of its contract.B. The installation information provided to the installer by UC2B specified whichfiber strand should be connected to the ONT at each multi-strand fiber dropcable location. Prior to the installer visiting the customer site, UC2B configuredand provisioned the correct VLANs on the customer’s fiber strands and providedany necessary fiber patching in the neighborhood cabinets or the UIUC nodes.C. UC2B provided the Anchor Institution installers with an ONT, a Gateway, a fiberservice box, a 3-meter fiber patch cable, a fiber patch cable to connect the OSPfiber termination panel to the fiber service box (if necessary) and two Category5e Ethernet cables for each customer. The installer supplied any other hardwarenecessary for the installation. The installer maintained a small inventory ofmaterials supplied by UC2B such as fiber optic and copper cables in variouslengths, as well as fiber service boxes.D. The installer installed the ONT and ran a series of UC2B–provided tests toconfirm that it worked correctly with the core Active Ethernet equipment.E. The installer configured the Gateway for both wired and wireless connections.Each customer has one SSID for its private Wi-Fi use, and potentially a UC2BnetSSID for a second “community” Wi-Fi SSID. Specific configuration informationwas given to the Installer.F. After verification of connectivity through the Gateway with the Installer’scomputer equipment, and all manufacturer and UC2B diagnostic tests had beensatisfied, Installer then connected and configured up to two of the customer’swired devices and two wireless devices to use the Gateway.G. The Installer was capable of configuring the following wired devices andconfigured up to two wired devices at each location:16Form A-1 10/09

i. Windows-based and Macintosh-based computersii. X-Box, Play-Station and Wii game consolesiii. Blu-Ray players with wired network capabilitiesiv. Television sets or TV set-top boxes (such as Apple TV’s, Roku or Boxesboxes) with wired network capabilities.H. The configuration of Linux-based computers, “smart” household appliances,medical devices and energy management devices with network connectivitycapabilities was the responsibility of the customer, not the Installer or UC2B.UC2B provided general on-line and printed instructions to guide customers inconfiguring various non-supported devices.I. The Installer then assisted in the configuration of up to a total of two wirelessdevices including:a. Smartphonesb. Game consolesc. Portable computers, tabletsd. TVs or TV set-top boxes with Wi-Fi capabilities.J. UC2B made available both on-line and printed general instructions forconnecting various wireless devices, to the UC2B wireless equipment.K. Before Installer left the customer site, Installer confirmed that all of the devicesthat Installer configured were accessing the network properly and had thecustomer sign a UC2B form that lists those various devices and verifies thatfunctionality.II. “Inside” FTTP Work:A. Once the fiber drop cable was installed to the exterior of the building, thelocation of the building penetration depended on the structure itself and thewishes of the customer and property owner. In some instances it wasappropriate to core drill a basement or crawlspace wall below grade. In otherinstances it was appropriate to core drill a basement or crawlspace wall abovegrade. Structures built on a concrete slab most likely required drilling a hole inthe wall of the structure slightly above the slab or ground elevation dependingon building style.B. Whenever the building penetration was above grade, a ¾” PVC conduit was usedto protect the cable where it was exposed above grade and to turn the fibercable 90 degrees into the building. Under no circumstancesdid the locate wire orany metallic sheathing enter the building. The Installer provided all exteriorrated PVC Conduit.17Form A-1 10/09

C. The removable outdoor protective sheath was removed from the UC2B provideddrop cable where it entered the building.D. The single-strand indoor-outdoor fiber drop cable was terminated into a smallfiber service box, which was mounted to a baseboard in the building at a locationpredetermined by the customer during the canvass by UC2B personnel. The fiberservice box was supplied by UC2B.If the predetermined location was not suitable, the Installer’s staff worked withthe customer to determine a suitable location for the fiber service box. All FTTPsites received UC2B electronics, and once the fiber service box was installed, theInstaller used a UC2B-supplied 3-meter SC-to-SC single strand fiber patch cableto connect the Optical Network Terminal (ONT) to the fiber service box.E. UC2B supplied up to two (2) ten-foot Cat 5e Ethernet patch cables for theCustomer’s wired devices. At the Customer’s request, (on the installationagreement) a single 25-foot Cat 5e patch cable may have been substituted forone of the two 10-foot patch cables. The installation contractor did not installany permanent copper Ethernet cabling as part of tits UC2B contract.F. UC2B provided an ONT, a Gateway, a 3-meter jumper cable, the fiber service boxand Two (2) Cat 5e Ethernet cables for each customer. The Installer supplied anyother hardware necessary for the installation. The Installer maintained a smallinventory of UC2B supplied materials including cables in various lengths as wellas fiber service boxes.G. The Installer installed the ONT and ran a series of UC2B–provided tests on theInstaller’s computer to confirm that the ONT was communicating correctly withthe core Active Ethernet equipment in the Neighborhood Cabinet. Prior to theInstaller arriving to install the fiber drop cable, UC2B personnel patched throughthe MST port for that customer to the Active Ethernet chassis in theNeighborhood Cabinet and provisioned the right VLAN(s) for that customer onthat MST port.H. The Installer configured the Gateway for both wired and wireless connections.Each customer has one SSID for their private Wi-Fi use, and potentially aUC2Bnet SSID for a second “community” Wi-Fi SSID. Specific configurationinformation was given to the Installer.I. After confirming connectivity through the customer’s UC2B network Gateway,and all diagnostic tests had been satisfied, Installer then connected andconfigured up to two of the customer’s wired devices to the Gateway. Wireddevices eligible for Installer-provided configuration include:18Form A-1 10/09

i. Windows-based and Macintosh-based computers;ii. X-Box, Play-Station and Wii game consoles;iii. Blu-Ray players with wired network capabilities;iv. Television sets or TV set-top boxes (such as Apple TV’s, Roku or Boxesboxes) with wired network capabilities.The configuration of Linux-based computers, “smart” household appliances,medical devices and energy management devices with network connectivitycapabilities was the responsibility of the customer, not the Installer or UC2B.UC2B provided general on-line and printed instructions to guide customers inconfiguring various non-supported devices.J. Once the customer’s two wired devices had been configured, Installer thenassisted in the configuration of up to a total of two wireless devices including:i. smartphones,ii. game consoles,iii. portable computers, tabletsiv. TVs or TV set-top boxes with Wi-Fi capabilities.UC2B made available both on-line and printed general instructions forconnecting various wireless devices, to the UC2B wireless equipment.K. Before Installer left the customer site, Installer confirmed that all of the devicesthat Installer configured are accessing the network properly and had thecustomer sign a UC2B form that lists those various devices and verifies thatfunctionality.L. The Installer did not install any non-UC2B equipment or install non-UC2B cablesin UC2B conduit or into buildings on the behalf of others at the same time asinstalling cables or equipment for UC2B.M. The Installer supplied all materials for the installations except the single-strandADC pre-terminated drop cables, dual strand and multi-strand fiber drop cables,OSP fiber termination panels, fiber service boxes, 3-meter fiber jumper cables,fiber patch cables to connect the OSP fiber termination panel and the fiberservice box (where needed), Category 5e Ethernet cables, Optical NetworkTerminals (ONTs), Gateways and Wireless Access Points.N. The UC2B supplied ONTs and Gateways are two separate devices that connect toeach other via a short Cat 5e Ethernet patch cable provided by UC2B. Ifadditional Wireless Access Points are installed by UC2B, they will be a third19Form A-1 10/09

device and will also connect to the ONT via a short Cat 5e Ethernet patch cablesupplied by UC2B.20Form A-1 10/09

Network design for atypical FTTP locationserved with a single strandDesktopComputerTVHome10 GbpsConnectionto CoreNode 9UC2BTA-5000SwitchTypicalBackboneRing - 216Fiber StrandsNode 8UC2BTA-5000SwitchFiber PatchPanelsTA-5000NeighborhoodCabinetiPadSmartPhoneLaptopONT6-12 Fiber Strands inMST Feeder CableWi-FiServiceBoxIPTV Set-Top BoxGateway1 FiberStrandat 1Gbps1 Fiber Strandat 1 GbpsMulti-ServiceTerminal (MST)1 Fiber Strandat 1 Gbps1 Fiber Strandat 1GbpsSchoolBusiness6/20/12

Network design for atypical Anchor Institutionwith a multi-strand cableDesktopComputerTVMedical10 GbpsConnectionto CoreNode 9UC2BTA-5000SwitchiPadSmartPhoneWi-FiIPTV Set-Top BoxGatewaySchoolTypicalBackboneRing - 216Fiber StrandsNode 8UC2BTA-5000SwitchSpliceCaseLaptopONTOSP FiberTermination36-144 StrandLateral Fiber CableServiceBoxSingle Strand CableMulti-StrandFiber Drop CableMulti-StrandFiber CableMulti-StrandFiber CableMulti-StrandFiber CableBusinessSplice Case6/20/12

DISCLOSURE AFFIDAVIT(NOTE: This Affidavit must be completely filled out and signed by any party doing business with the City. This Affidavitassists the City in making determinations relative to conflict of interest and other laws.)(Fill in state and county in which affidavit is being signed)STATE OF )COUNTY OF )) ss.I, the undersigned, being duly sworn, do state as follows:SECTION 1. BUSINESS STATUS STATEMENTA. (hereafter "Contractor” or “Vendor") is a Corporation:Contractor’s Federal Tax Identification Number, or in the case of an individual or soleproprietorship, Social Security Number:(If a Corporation, complete B; If a Partnership or LLC, complete C; If an Individual, complete D)B. CORPORATIONThe State of Incorporation is .Registered Agent of Corporation in Illinois:NameAddressCity, State, ZipTelephoneBusiness Information (If Different from RegisteredAgent):Company Address, Principal OfficeCity, State, ZipTelephoneWebsiteFacsimileThe corporate officers are as follows (list and identify all corporate officers - attach additionalsheets if necessary):President:Vice President:Secretary:D-5 01/09

C. PARTNERSHIP OR L.L.C.The business address is:Telephone:Fax:Website or Email Address:The partners or members are as follows: (Attach additional sheets if necessary)(Name, Home Address and Telephone)(Name, Home Address and Telephone)(Name, Home Address and Telephone)D. INDIVIDUAL PROPRIETORSHIPThe business address isTelephone:Fax:My home address isTelephone:Fax:Email or website:SECTION 2. NON-COLLUSION STATEMENTA. This proposal, bid or contract is made without any connection or common interestin the profits with any other person other than the Vendor except as listed on aseparate attached sheet to this affidavit.Check One:Others Interested in ContractNoneD-5 01/09

B. No department director or any employee or any officer of the City of Champaignhas any financial interest, directly or indirectly, in the award of this contractexcept as listed on a separate attached sheet to this affidavit.C. That the Contractor/Vendor is not barred from bidding on any contract, if bidding processwas used) as a result of violation of 720 ILCS 5/33E-3 and 5/33E-4 (Bid Rigging or BidRotating).SECTION 3. DRUG FREE WORKPLACE AND DELINQUENT ILLINOIS TAXESSTATEMENTThe undersigned states under oath that the Contractor/Vendor is in full compliance with theIllinois Drug Free Workplace Act, 30 ILCS 580/1. The undersigned also states under oath andcertifies that Contractor/Vendor is not delinquent in payment of any tax administered by theIllinois Department of Revenue except that the taxes for which liability for the taxes or the amountof the taxes are being contested, in accordance with the procedures established by theappropriate Revenue Act; or that the Vendor has entered into an agreement(s) with the IllinoisDepartment of Revenue for the payment of all taxes due and is in compliance with theagreement.SECTION 4. FAMILIARITY WITH LAWS STATEMENTThe undersigned, being duly sworn, hereby states that the Contractor/Vendor and its employeesare familiar with and will comply with all Federal, State and local laws applicable to the project,which may include, but is not limited to, the Prevailing Wage Act and the Davis-Bacon Act.CONTRACTOR/VENDOR_______________________________SignaturePrinted Name:Title:SUBSCRIBED and SWORN to before me this ____ day of _______________, 20___.________________________________Notary PublicMy Commission Expires: _______________________D-5 01/09

Community Relations Office102 North Neil StreetChampaign, Illinois 61820(217) 403-8830 or (217) 403-8835 (fax)Requested by:Approved by:Office Use OnlyDate:Date:Vendor Number: Code: Entered: CROFINCertificate Number:AFFIRMATIVE ACTION REPORT FORMCertificate Expiration Date:Failure to properly complete and sign this form prior to the execution of a contract with the City, or within 7 daysafter a request to submit this report, will result in it being returned unprocessed thereby resulting in adelay or denial of eligibility to bid or do business with the City of Champaign.Section I. Identification1. Company Name and Address:d/b/a:Chief Executive Officer:Address:City/State/Zip:Telephone: ( ) - Fax: ( ) -FEI Number:E-mail Address:Check one of the following:Social Security Number:Corporation Partnership Individual Proprietorship Limited Liability Corp.2. Name and Address of the Company’s Principal Office (answer only if not the same as above):Name:Address:3. Major activity of your company (product or service):City/State/Zip:4. Nature of Business:Contract:Bid:

Register as a new vendor for future projects.Other:SECTION II. Policies and PracticesDescription of Equal Employment Opportunity (EEO) Policies and Practices YES NOA. Is it the Company’s policy to recruit, hire, train, upgrade, promote and discipline persons withoutregard to race, color, sex, religion, national origin, age, mental and/or physical disability?B. Has someone been assigned to develop procedures, which will assure that the EEO policy isimplemented and enforced by managerial, administrative, and supervisory personnel? If so,please indicate the name and title of the official charged with this responsibility.Name: Title:Telephone:E-mail:Fax:C. Has the company developed a written Affirmative Action Plan? Note: a copy of the AffirmativeAction Plan must be submitted with this form in order to be considered eligible to dobusiness with the City of Champaign. If you would like technical assistance in developing a plan,please contact the Community Relations Office at (217) 403-8830.D. Has the company developed a written policy statement prohibiting Sexual Harassment? Note:Please attach a copy of the policy statement.E. If advertising is used, does it specify that all qualified applicants will be considered foremployment without regard to race, color, sex, religion, national origin, mental and/or physicaldisability, or age?F. Has the contractor notified all of its sub-contractors of their obligations to comply with the EqualOpportunity requirements either in writing, by inclusion in subcontracts or purchase orders?G. Is your company a minority/women owned business? (Defined as at least 51% owned byindividuals who are of the female gender and/or who have origins in one or more of the followinggroups: African American, Hispanic, Asian American, and Native American.)H. If you answered “YES” to G, please check all classifications that apply: African AmericanAsian American Hispanic Native American FemaleI. If you answered “YES” to G, would you like to be added to our Minority E-mail Group and/orMinority Directory? Please include your e-mail address:J. Is the company a state certified minority/women owned business? If yes, please attach a copy ofstate certification.

K. Is your company certified with IDOT as a DBE firm? (Defined as a small business firm that isowned and controlled by socially and economically disadvantaged individuals.)L. Does the company have collective bargaining agreements with labor organizations?M. Have the labor organizations been notified of the company’s responsibility to comply with theEqual Employment Opportunity requirements in all contracts with the City of Champaign?SECTION III. Employment Informationa. Please complete the company work force analysis on the bottom of this page. Use the number of employees asof the most recently payroll period. Be sure to complete all applicable columns.b. Job Classifications (see descriptions, next page)c. Identify the geographical area(s) from which the company may reasonably recruit employees(Use city, county, Standard Metropolitan Statistical Area, or distance in miles from company location, etc.)d. If minorities and females are currently under-represented in your work force, please attach a copy of anexplanation of your plan to recruit and hire qualified minorities and females.Job CategoriesOverall TotalsWhite (Not ofHispanic Origin)Black or African-American (Not ofHispanic Origin)Hispanic orLatinoAsian orPacificIslanderAmericanIndian orAlaskan NativeM F M F M F M F M F M F(A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L) (M)Officials & MgrsProfessionalsTechniciansSales WorkersOffice & ClericalCraft Workers(Skilled)Operatives(Semi-Skilled)Laborers(Unskilled)Service Workers

TOTALM = MALE, Column B is sum of Rows D, F, H, J and L. F = FEMALE, Column C is sum of Rows E, G, I, K and M.Date of above Data:SECTION IV. CertificationThe company certifies that it has answered all of the foregoing questions truthfully to the best of itsknowledge and belief and agrees that it/he/she will comply and abide by the City’s Affirmative ActionOrdinance (Section 12.5-65) and Human Rights Guarantee provision (Section 12.5-64).Signature: Typed Name & Title Telephone Number Date

DEFINITIONS OF TERMINOLOGY LISTED IN THE WORKFORCE PROFILE TABLE(See previous Page)DESCRIPTION OF RACE/ETHNIC CATEGORIESRace/ethnic designations as used by the Department do not denote scientific definitions of anthropological origins. For the purposes of this report, an employee may be included in thegroup to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be counted in more than one race/ethnic group. Therace/ethnic categories for this report are:White (Not of Hispanic origin). All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.Black of African-American (Not of Hispanic origin). All persons having origins in any of the Black racial groups of Africa.Hispanic or Latino. All persons of Mexican, Puerto Rican, Cuban, Central of South American, or other Spanish culture or origin, regardless of race.Asian or Pacific Islander. All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, forexample, China, India, Japan, Korea, the Philippine Islands and Samoa.American Indian or Alaskan Native. All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation orcommunity recognition.DESCRIPTION OF JOB CATEGORIESEach employee should be counted in only one job category. Select the category containing the jobs most similar to that performed by the employee. The jobs listed in each category areintended to provide an example, not a complete list, of all job titles falling into that category.Officials and Managers. Occupations requiring administrative and managerial personnel who set broad policies, exercise overall responsibility for execution of these policies, and directindividual departments or special phases of firm’s operations. Includes: officials, executives, middle management, plant managers, department managers, and superintendents, salariedsupervisors who are members of management, purchasing agents and buyers, railroad conductors and yard masters, ship captains, mates and other officers farm operators andmanagers, and kindred workers.Professionals. Occupations requiring either college graduation or experience of such kind and amount as to provide a comparable background. Includes: accountants and auditors,airplane pilots and navigators, architects, artists, chemists, designers, dietitians, editors, engineers, layers, librarians, mathematicians, natural scientist, registered professional nurses,personnel and labor relations specialist, physical scientist, physicians, social scientist, teachers, surveyors and kindred workers.Technicians. Occupations requiring a combination of basic scientific knowledge and manual skill which can be obtained through 2 years of post high school education, such as is offered inmany technical institutes and union colleges, or through equivalent on-the-job training. Include: computer programmers, drafters, engineering aides, junior engineers, mathematical aides,licensed, practical or vocational nurses, photographers, radio operators, scientific assistants, technical illustrators, technicians (medical, dental, electronic, physical science), and kindredworkers.Sales. Occupations engaging wholly or primarily in direct selling. Includes: advertising agents and sates workers, insurance agents and brokers, real estate agents, and brokers, stock andbond sales workers, demonstrators, sales workers and sales clerks, grocery clerks, and cashiers/checkers, and kindred workers.Office and Clerical. Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly non manual though some manual work not directly involved withaltering or transporting the products is included. Includes: bookkeepers, collectors (bills and accounts), messengers and office helpers, office machine operators (including computer),shipping and receiving clerks, stenographers, typists and secretaries, telegraph and telephone operators, legal assistants, and kindred workers.Craft Workers (Skilled). Manual workers of relatively high skill level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerableindependent judgment and usually receive an extensive period of training. Includes: the building trades, hourly paid supervisors and lead operators who are not members of occupations,compositors and typesetters, electricians, engravers, painters (construction and maintenance), motion picture projectionists, pattern and model makers, stationary hand painters, coaters,bakers, decorating occupations, and kindred workers.Operatives (Semi-Skilled). Workers who operate machine or processing equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeksand require only limited training. Includes: apprentices (auto service and stitchers, dryers, furnace workers, heaters, laundry and dry cleaning operatives, milliners, mine operatives andlaborers, motor operators, oilers and greasers (except auto), painters (manufactured articles), photographic process workers, truck and tractor drivers, knitting, looping, taping andweaving machine operators, welders and flame cutters, electrical and electronic equipment assemblers, butchers and meat cutters, inspectors, testers and graders, hand packers andpackagers, and kindred workers.Laborers (Unskilled). Workers in manual occupations which generally require no special training who perform elementary duties that may be learned in a few days and require theapplication of little or no independent judgment. Includes: garage laborers, car washers and greasers, groundskeepers and gardeners, farm workers, stevedores, wood choppers, laborersperforming lifting, digging, mixing, loading and pulling operation and kindred workers.Service Workers. Workers in both protective and nonprotective service occupations. Includes: Attendants (hospital and other institutions, professional and personal service, includingnurses aides, and orderlies), barbers, char workers and cleaners, cooks, counter and fountain workers, elevator operators, firefighters and fire protection, guards, doorkeepers, stewards,

janitors, police officers and detectives, porters, waiters and waitresses, amusement and recreation facilities attendants, guides, ushers, public transportation attendants, and kindredworkers.J:\CMO\CRO\A-Affirmative Action\FORMS-LOGS\AA FORMS\Affirmative Action Report Form REVISED 2011.03.15.docx

DUAL REPRESENTATION AFFIDAVIT(Note: Every professional must completely fill out and sign this affidavit or must receive a determination that theaffidavit is not required in connection with this contract.STATE OF )) SS.COUNTY OF )[Fill in State and County in which affidavit is being signed.]The undersigned professional, being duly sworn, states and as certifies that it will read, review,agree to, and abide by the following City of Champaign Dual Representation Policy. The Policymay be obtained from the City of Champaign Legal Department.I. DISCLOSUREWhere dual representation exists or is proposed, the professional shall provide fullinformation in writing to the City and the other party with respect to the representation of theother party at the earliest possible time that the issue is known to the professional.Detailed disclosure of the nature and extent of the services to be rendered and areaswhere services overlap with that of the City should be provided by written correspondenceby the professional.II. CONSENTWhere dual representation exists or is proposed, the professional hereby agrees that theCity shall have the option of 1) providing consent in writing; or 2) withdrawing from anycontractual commitment with the professional; or 3) requesting the professional to notprovide the services to the other party.PROFESSIONALSignature______________________________Printed Name:Title:Subscribed and sworn to before me this ____ day of _______________, 20___.My Commission Expires: ________________________________________________________Notary PublicForm D-9 01/05