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Bidding and Letting Notices

Posted on: January 11, 2023

RFP - Pavement Condition Index Update 2023

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CITY OF PEORIA NOTICE OF REQUEST FOR PROPOSALS:

PAVEMENT CONDITION INDEX UPDATE 2023

PEORIA, ILLINOIS

PRESUBMITTAL MEETING 11:00AM TUESDAY, JANUARY 24, 2023

STATEMENTS DUE: 11:00 AM TUESDAY, JANUARY 31, 2023

The City of Peoria is requesting Proposals from qualified firms to assist the City in collecting, processing, and updating the Pavement Condition Index (PCI) for City streets. The goal of this project is to inventory the street, rate the pavement condition, and update the City’s GIS-based data management system used in the planning and prioritization of maintenance and repairs. The City of Peoria’s Engineering Division will accept sealed proposals submitted to the Office of the City Engineer, 3505 N Dries Lane, Peoria, Illinois, until 11:00 AM Tuesday, January 31, 2023 for establishing a contract with a qualified firm.

Time is of the essence and any Statement of Interest and Qualifications received after the announced time and date for submittal, whether by mail or otherwise, will be rejected. Firms are responsible for ensuring that the Engineering Administrative Assistant receives their Statements before the deadline indicated. Statements received after the announced time and date of receipt, by mail or otherwise, will be returned unopened. Firms should submit three (3) hard copies and one (1) electronic copy (via USB or similar) of a Statement of Interest and Qualifications.

PAVEMENT CONDITION INDEX UPDATE

1.0 INTRODUCTION

The City plans to award a contract for these services to the best-qualified firm. Each firm will be considered and ranked by a Selection Committee based upon the criteria listed herein. The City will then enter into negotiations with the top-ranked firm. The negotiations will be to establish a detailed scope of services and total cost for services. Should the top-ranked firm and the City of Peoria not be able to reach an agreement, the City will terminate negotiations with that firm and open negotiations with the second ranked firm.

This process does not obligate the City to award a contract, or pay any cost incurred in the preparation of the firms responding to this request. The City reserves the right to accept or reject any or all statements received as a result of this request. All information submitted in response to this request will become the property of the City.

Please be aware that it is the City's policy to not compensate for any time or expenses incurred during the selection and negotiation processes.

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2.0 PROJECT DESCRIPTION

2.1 PROJECT NEED, PURPOSE AND OBJECTIVE

The project consists of collecting and processing condition data on streets to update the City’s street condition database including a pavement condition index for each street.

The City will use the PCI information and report to prioritize, budget, and schedule future street construction projects. The pavement condition database was originally created in 2014 and used PAVER 6.5.7. Subsequent assessments were conducted in 2017 and 2020. The City will provide, and interested firms shall match, the sectioning and sampling limits from the 2014, 2017 and 2020 assessments. The City currently has two street networks: arterials and non-arterials, which are separately funded and has five Council Districts.

2.2 PROJECT COMPONENTS

2.2.1 GENERAL SCOPE OF SERVICES

The scope of services sought by the City of Peoria shall include the provision of all required labor, materials, equipment, and expertise related to the collection, processing, and creation of the pavement condition inventory.

The following should be included in the submittal:

1. Collect, process, and create a user-friendly GIS database and layers within project schedule and budget.

2. Description of how the data collection, processing and database creation will be implemented and a project schedule including major milestones.

3. Description of the database.

4. The following will be required of the selected firm:

a. Participate in meetings

b. Provide high quality videos of each street

c. Provide Pavement Condition Index ratings for predefined street segments

The following data collection will be required as part of the base project:

A. Streets

a. Pavement Condition Index ratings

b. Surface Type

c. Lane Miles

d. Examples of representative condition ratings

The following data collection may be added based on bid alternates:

A. Signs

B. Pavement markings

a. Lines

b. Symbols

C. Sidewalks

D. LiDAR data

2.2.2 MEETINGS, PRESENTATIONS, AND REPORTS

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An initial kick off meeting, various project meetings, and a final report will be required.

2.2.3 DELIVERABLE PRODUCTS

The selected firm shall provide all deliverable products to the City Engineer for approval and dissemination. Hard copies and electronic copies of the deliverables will be required. Electronic format for all submittals shall be compatible with the current City software.

Deliverables include:

1. High resolution images/videos of each street, including the pavement and ROW

2. GIS layers for the assets collected (ESRI format) matching the City’s existing road segments

3. GIS database for the assets collected (ESRI format)

4. Pavement Condition Index Ratings

5. Pavement Condition Index Ratings Reports

6. Report describing data processing approach

2.2.4 PROVISIONS BY THE CITY OF PEORIA

The City of Peoria will provide the following information to the selected firm:

1. Aerial photography and topography in an electronic format.

2. ROW information available through the City of Peoria records including recent acquisitions.

3. Current GIS information including existing road segments.

4. Existing PCI ratings

5. Designation of a person from the engineering staff to act as the City’s project manager with respect to the two-way flow of information and for the purposes of having direct access to staff’s knowledge base. Such person shall have the authority to transmit instructions, receive information, and interpret and define existing City policy and decisions with respect to materials, equipment, and systems pertinent to the consultant services. However, the concurrence and authorization to begin any and all phases of this project shall reside with the City Engineer.

2.3 LOCATION OF PROJECT

Data will be collected on streets in the right of way in the City limits (approximately 975 lane miles). Alleys and marked state routes, highways, and interstates are not included in the base project. The marked state routes, highways, and interstates are Route 6, Route 8, Route 29, Route 40, Route 116, US 150, and Interstate 74. If there is budget available, alleys and marked routes may be added to the project. Further, bid alternates are requested to inventory signs, pavement markings, sidewalks and LiDAR data along the streets inventoried.

2.4 PROJECT SCHEDULE

Selection will be made according to the following table:

RFP advertised ................................................................................................ January 11, 2023 and January 12, 2023

Pre-submittal meeting at Public Works at 11:00 AM ........................................................... January 24, 2023

Due date for Statement of Interest and Qualifications at 11:00 AM .................................... January 31, 2023

Selection Committee ranks submittals .................................................................. January 31, 2023 to February 6, 2023

Committee informs highest ranked firm and begins negotiations ......................................... February 6, 2023

Contract submitted to Council Agenda process .................................................................... February 14, 2023

City Council Meeting at which Contract is Recommended for Approval ............................ February 28, 2023

Notice to Proceed Sent to Approved Firm ............................................................................ March 1, 2023

Project completed .................................................................................................................. July 1, 2023

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2.5 VOLUNTARY PRE-SUBMITTAL MEETING

A questions and answers session will be held at a pre-submittal meeting on Tuesday January 24, 2023 at 11:00 AM, in the Peoria Public Works Conference Room at 3505 N Dries Lane, Peoria.

2.6 PROJECT DURATION

It is anticipated that, after a firm is selected, the data collection and processing will take 3 months. Specific timelines will be mutually agreed upon between the selected firm and the City.

2.7 EXPECTED PROBLEMS

The City staff does not expect any problems with the project.

2.8 INVOICING AND PAYMENTS

The firm shall submit invoices at the end of each calendar month; such statements shall be inclusive of a detailed breakdown of all charges incurred. The detail shall indicate the personnel name, title, rate of pay, hours charged, and task worked. All direct costs shall be itemized. Multipliers will be clearly indicated and applied to total man-hours summated for the period. Invoices shall be based upon actual hours of performance.

Invoices shall be accompanied by progress reports. The invoices will not be considered complete without a progress report and will be deemed unpayable. The progress report will be inclusive of rates of completion for all tasks scoped and for rates of completion for all deliverable products.

If funds that IDOT oversees are to be used to fund engineering then the firms given such Work Orders shall follow IDOT policies and procedures regarding acceptable compensation methods and invoicing practices and use the appropriate BLRS forms including but not limited to BLR form 05513, 05514, 05530, 05620, & 05621. If state revolving loan funds or other funds, use the forms as directed by the funding agency.

3.0 PUBLIC NOTICE

The notice of Public Advertisement for Various Engineering Services will appear in the local Peoria Journal Star newspaper and/or posted to the City of Peoria’s Webpage (www.peoriagov.org), and posted to the City of Peoria’s e-alerts notification system on both Wednesday, January 11, 2023 & Thursday, January 12, 2023. The advertisement will allow 21 calendar days’ notice until all proposals are due on Tuesday January 31, 2023.

4.0 CONFLICT OF INTEREST

Submit a disclosure statement with the response. The disclosure statement shall be the IDOT BDE DISC 2 TEMPLATE modified for the City of Peoria. (SEE ATTACHED)

5.0 SUSPENSION AND DEBARMENT

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The City uses the SAM Exclusions, IDOT’s CPO’s website and the three other state CPO’s websites to verify suspensions and debarments. Submittals will be returned without being evaluated for vendors that are suspended or disbarred.

6.0 SUBMITTAL OF QUALIFICATIONS

Firms are to submit a written Statement of Interest and Qualification which presents the firm’s qualifications and understanding of the work to be performed. Selection criteria will include, but not limited to, qualifications, comparable recent experience, local presence, knowledge of local requirements, policies and procedures, capacity to perform work in the allotted time, construction planning, construction scheduling, overall approach to the project, and continuation of previous projects. Firms interested in submitting should have recent specific experience with this type of design, construction, and/or other services.

The submission should include:

1. A cover letter that includes:

1. Name, address, e-mail address and phone number of a contact person responsible for and knowledgeable of the Submittal.

2. Written response addressing each of the evaluation criteria listed in Section 7.0

3. Form BDE DISC Template modified for the City of Peoria attached to this solicitation.

4. Current EEO Number or copy of completed Employer Report Form CC-1. (See section 9.0 EEO for more information)

Firms will need to address each of the criteria set forth in section 7.0 carefully and thoroughly, as all submittals will be ranked on a point value system. The evaluation will be based upon a head-to-head comparison with the other firms submitting.

An individual authorized by the engineering firm to bind the offer MUST sign any submittal. All submittals without a signature will be deemed non-responsive and will not be acceptable. The City of Peoria reserves the right to reject any or all submittals.

All provisions of this Request for Qualifications shall also follow IDOT Bureau of Local Roads and Streets (BLRS) policies and procedures where applicable.

6.1 SUBMITTAL FORMAT

The submittal should be as concise as possible. Additional, promotional information should be avoided. The name of the firm and the location of the office that will have responsibility for the contract is required. Five (3) hard copies and one (1) electronic copy (via USB or similar) of the submittal will be required.

7.0 EVALUATION FACTORS

A. Technical Approach (25%)

1. Approach to planning, organizing and management of the project(s) including:

a. Tracking of schedules and budgets

b. Data collection

c. Data processing approach – preferably using technology, computer visioning and/or machine learning for data processing.

d. Database and video quality

e. Database user friendliness

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f. The estimated size of the data including the GIS layer, videos and database

2. Shall demonstrate its intent to meet the City’s goal of reducing project costs by incorporating technology by showing ability to be innovative and self-sufficient in completing tasks

3. Understanding of the scope of services listed in section 2.2.1

4. Communication Plan

B. Firm Experience and Qualifications (25%)

1. Name, size and brief description of the firm and office overseeing the project, including the same information for any proposed sub-consultants.

2. Qualification and experience of the firm and subconsultants (if any)

3. If subconsultants are anticipated, describe the role proposed for each firm or subconsultant involved and the approximate percentage of work assigned

4. Quality of the equipment and technology

5. Firm’s experience providing services to municipalities

6. Name and contact information of three applicable references from previous clients on similar work for the firm and subconsultant (if any)

7. Description of specialized expertise needed for the implementation of tasks outlined in Section 2.2.1 of this document

8. A summary of any specialized experience, qualifications or unique capabilities applicable to the tasks outlined in section 2.2.1 of this document

C. Project Cost (20%)

1. Base bid for approximately 975 lane miles of roadway PCI condition database & supporting data.

2. Alternate Bid #1: Sign inventory for all surveyed roads

3. Alternate Bid #2: Pavement marking inventories for all surveyed roads

4. Alternate Bid #3: Sidewalks

5. Alternate Bid #4: LiDAR data

6. Typical billing rate schedule for assigned personnel, including rate schedules for any proposed subconsultants.

D. Staff Capabilities (20%)

1. Qualifications and experience of the key team member(s)

2. Qualifications and experience of team members

3. Resumes of key personnel anticipated being assigned to the project(s)

4. An organizational chart showing the proposed role of staff on the projects and firm affiliation (if more than one firm is involved)

E. Other (10%)

1. Ability to staff projects locally to enhance quality and efficiency (Prime and sub consultant)

2. Commitment to EEO goals

3. Quality of the proposal

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8.0 SELECTION PROCEDURE

Each criterion in the evaluation will be ranked on a scale of 1 to 10, where 10 equals the highest ranking of submittals received. A rank of 10 for any criterion indicates the most qualified firm for that criterion. Each numerical ranking will be multiplied by the weighted value below. A total point value for each submittal will be determined by the composite evaluation of the Selection Committee. The firm with the highest overall point total will be ranked first.

Criteria

Weight

Rank

Total

Technical Approach

25

10

250

Firm Experience and Qualifications

25

10

250

Project Cost

20

10

200

Staff Capabilities

20

10

200

Other

10

10

100

Total Maximum Points

1,000

NOTE: Total Maximum Points Possible assumes that a team receives a best rank of 10 on all criteria.

The Selection Committee will determine the best qualified firm by consensus based on the scored Statement of Interest and Qualifications. The City reserves the right to interview, if deemed necessary by the selection committee. The same criteria above will be used to evaluate the interviews. The City reserves the right to waive technicalities and to reject any or all Statements of Interest and Qualifications.

The City Engineer or designee shall institute negotiations with the best-qualified firms per committee consensus. The firms shall negotiate fee structure, multipliers, staffing, direct and indirect costs in a competitive manner at the negotiation of the contract. Fee structure, multiplier, direct and indirect costs for projects utilizing funds that IDOT oversees will follow IDOT’s policies and procedures.

9.0 EEO

To be awarded a contract, all Suppliers, Vendors, and Contactors to the City of Peoria must be registered in the City of Peoria’s Contract Compliance Program and have a current EEO Certification number. This program is unrelated to any State and Federal program.

The number is secured by completing and submitting, under notary seal, an Employer report form CC-1 (with required sexual harassment policy attached) to the City’s Equal Opportunity Office. Please note that the Certificate of Compliance is valid for one year and must be annually renewed. The form may be requested on-line from the City’s website (www.peoriagov.org). Click on Government, Equal Opportunity, Forms and downloads, then select “Employer Report CC-1”. The forms can also be obtained by writing, e-mailing, or calling:

City of Peoria Equal Opportunity Office

419 Fulton Street

Peoria, IL 61602

(309) 494-8530

eeo@peoriagov.org

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In accordance with Chapter 17 of the Peoria Municipal Code, a fifty-dollar ($50.00) processing fee will be charged with each original submission of the Employer Report Form CC-1 that results in an approved certificate as well as the Annual Renewal Application. The only exception to payment of the processing fee is neighborhood associations.

Although all vendors are encouraged to obtain Equal Employment Opportunity Certification, vendors do not need an Equal Opportunity Certification to respond to this Request for Proposal. The EEO Certification Number is only required prior to the award of the contract.

9.1 SUBCONSULTANT UTILIZATION

The City of Peoria is committed to promoting equal opportunity and has established the following subconsultant utilization goals for City funded projects: Ten percent (10%) MBE and Five percent (5%) WBE. The selected team will have an obligation to make a good faith effort to advance the City’s commitment to increase diversity among the firms working on City projects.

10.0 EMPLOYEE/EMPLOYMENT RESTRICTIONS- THE CONSULTANT:

THE CONSULTANT, (hereinafter referred to as “SERVICE PROVIDER”) agrees, as a condition of accepting this contract with the City of Peoria, that, for a period of one (1) year following completion of this contract, it shall be prohibited from hiring, directly or indirectly, any City employee or official who was involved, directly or indirectly in: (1) the selection and/or recommendation to select the SERVICE PROVIDER for performance of this contract; (2) coordinating the efforts of the SERVICE PROVIDER in the consummation or completion of this contract; or (3) monitoring or determining the performance of the SERVICE PROVIDER. The SERVICE PROVIDER further acknowledges and agrees that, upon the City’s determination that a violation of this provision has occurred, the penalty imposed, at the sole discretion of the City, may include one or more of the following: (1) cancellation of any other contract(s) between the City of Peoria and the SERVICE PROVIDER; (2) disqualification of the SERVICE PROVIDER from bidding or being awarded future contracts with the City of Peoria for a period of two [2] years; and/or (3) payment of liquidated damages to the City of Peoria in the amount of TWENTY FIVE THOUSAND DOLLARS ($25,000.00). This section shall not apply to any City Employee involved in the 2018-2019 reduction in force, furlough or early retirement incentive offered by the city within 2018-2019. This section shall not apply to any City Employee involved in the 2020-2021 reduction in force, furlough or early retirement incentive offered by the city within 2020-2021. For more information see Ordinance Section 2-342 Procurement: revolving door prohibition.

11.0 OMMISSION OF SCOPE

Please indicate if you believe a major item(s) is(are) missing from scope of services outlined in this RFP.

12.0 QUESTIONS

All information regarding the project is contained within the contents of this request. Questions or comments regarding the request or the process related to the request should be submitted via email to the City Engineer, Andrea Klopfenstein, at aklopfenstein@peoriagov.org.

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 1 of 7

PTB #:

Consultant Name

Legal Address

City, State, Zip

Telephone Number Email Address

The telephone number and email address supplied above must be a contact readily available if the City of Peoria Illinois

Department of Transportation (IDOT) has questions.

The disclosures hereinafter made by the firm are each a material representation of fact upon which reliance is placed should

the City of Peoria IDOT enter into the contract with the firm. The firm further certifies that the City Department has received

the disclosure forms for each Statement of Interest.

Section 50-35 of the Illinois Procurement Code provides that all offers of more than $50,000 and all subconsultant

agreements with an annual value of more than $50,000 shall be accompanied by disclosure of the financial interests of the

firm. This disclosed information for the successful firm will be maintained and subject to release by request pursuant to the

Freedom of Information Act, filed with the Procurement Policy Board, and shall be incorporated as a material term of the

contract. Furthermore, pursuant to Section 5-5, the Procurement Policy Board may review a proposal, bid, or contract and

issue a recommendation to void a contract or reject a proposal or bid based on any violation of the Procurement Code or

the existence of a conflict of interest as provided in subsections (b) and (d) of Section 50-35.

Prime Consultant’s Responsibility

The City of Peoria IDOT Chief Procurement Officer (CPO) may void the offer or contract if it is later determined that the

prime or subconsultant rendered a false or erroneous disclosure. A prime consultant or subconsultant may be suspended

or debarred for violations of the Procurement Code. If a false certification is made by the subconsultant, then the prime

consultant’s submitted offer and the executed contract may not be declared void, unless the prime consultant refuses to

terminate the subconsultant upon the State’s request after a finding that the subconsultant’s certification was false.

Instructions

The following packet includes three sections that must be completed and returned with the Statement of Interest, or the firm

may be considered nonresponsive and the Statement of Interest will not be accepted:

1. Qualifying Questions for Form A,

2. Form A: Financial Information & Potential Conflicts of Interest Disclosure, and

3. Form B: Other Contracts & Procurement-Related Information Disclosure.

Form A and Form B must be signed and dated by a person that is authorized to execute contracts for your organization.

Photocopied or stamped signatures are not acceptable. The person signing can be, but does not have to be, the person for

which the form is being completed. The firm is responsible for the accuracy of any information provided.

Checking the NOT APPLICABLE STATEMENT on Form A does not allow the firm to ignore Form B. Form B must be

completed, checked, and dated.

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 2 of 7

Form A: Financial Information & Potential Conflicts of Interest Disclosure

Form A pertains to the individuals meeting the ownership or distributive share requirements as stated below.

The financial interests to be disclosed shall include:

• Any ownership or distributive income share that is in excess of 5% or an amount greater than 60% of the annual salary

of the Governor, of the offering entity or its parent entity, whichever is less, the current annual salary of the Governor

is $177,412.00.

• If the firm is owned by an Employee Stock Ownership Plan (ESOP) please check the appropriate box on Form A and

provide the % of ownership.

• If the firm is a publicly traded entity subject to Federal 10K reporting, in which case it may submit its 10K disclosure in

place of the prescribed disclosure.

• If the firm is a privately held entity that is exempt from Federal 10K reporting, but has more than 100 shareholders, it

may submit the information that Federal 10K companies are required to report and list the names of any person or entity

holding any ownership share that is in excess of 5%.

‒ If this is true for your firm, check “Other” box on Form A and designate the firm is a 10K and supply the 10K

documents as additional attachments within the disclosure.

• The names, addresses, and dollar or proportionate share of ownership of each person making the disclosure, their

instrument of ownership or beneficial relationship, and notice of any potential conflict of interest resulting from the current

ownership or beneficial interest of each person making the disclosure having any of the relationships identified in Section

50-35 and on the disclosure form.

A button is supplied on Form A called “Add another Form A”, which once clicked will copy Form A. Click the button as many

times as you need to identify individuals who meet the above criteria.

If your firm has over 50 pages of Form A’s, please provide a summary of the disclosures at the end of Form B as an

attachment.

Additionally, if your firm has an abundance of individuals with the same Form A information, you can fill out one (1) Form A

and provide an attached listing of those individuals to save time.

Form B: Other Contracts & Procurement-Related Information Disclosure

The firm shall identify, by checking “Yes” or “No” on Form B any other current or pending contracts, proposals, leases, or

other ongoing procurement relationships the offering entity has with the City of Peoria IDOT and any other unit of state

government and shall clearly identify the unit and the contract, proposal, lease, or other relationships.

If “Yes” is checked, the firm must identify each such relationship by listing the State of Illinois agency name and other

descriptive information such as project number, title, contract, etc.

If “No” is checked, the firm only needs to check the box, sign and date at the bottom of Form B.

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 3 of 7

Qualifying Questions for Form A

The following six questions must be answered in order to determine how Form A is to be completed.

Answer all six questions before going on to Form A.

Ownership Certification

The following clarifies the ownership structure of your firm for IDOT’s review.

Yes No

1. Is your firm a Subsidiary and owned by a Parent entity(ies)?

If your answer is “Yes”, please disclose the Parent entity(ies) on Form A.

2. Will the individuals that will be submitted on Form A equal 100% ownership?

If your answer is “No”, please verify by answering the following question.

a) Is any of the remaining ownership held by individuals receiving or holding less than 5% of the

offering entity’s or parent entity’s total distributive income, or less than 60% of the annual salary

of the Governor? (If you feel the answer is No, please add an explanation.)

Identifying Financial Information & Potential Conflicts of Interest

Yes No

3. Does anyone in your organization have a direct or beneficial ownership share of greater than

5% of the offering entity or parent entity?

4. Does anyone in your organization have a direct or beneficial ownership share of less than

5%, but which has a value greater than 60% of the annual salary of the Governor?

5. Does anyone in your organization receive more than 60% of the annual salary of the Governor

of the offering entity’s or parent entity’s distributive income? (Note: Distributive income is, for

these purposes, any type of distribution of profits. An annual salary is not distributive income.)

6. Does anyone in your organization receive greater than 5% of the offering entity’s or parent

entity’s total distributive income, but which is less than 60% of the annual salary of the

Governor?

If the answer to questions 2 – 6 are “Yes”, the completion of Form A is required, and the APPLICABLE STATEMENT

must be signed and dated.

If the answer to questions 2 - 6 are “No”, then the NOT APPLICABLE STATEMENT of Form A must be signed and

dated.

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 4 of 7

Form A: Financial Information & Potential Conflicts of Interest Disclosure

Disclosure of the information contained in this form is required by Section 50-35 of the Illinois Procurement Code (30 ILCS

500). Firms desiring to enter into a contract with the City of Peoria State of Illinois must disclose the financial information

and potential conflict of interest information as specified in this Disclosure Form.

Disclosure of Financial Information

The individual named below has an interest in the FIRM (or its Parent) in terms of ownership or distributive income share

that is in excess of 5%, or an interest which has a value of more than 60% of the annual salary of the Governor.

FOR INDIVIDUAL

Name:

Address:

Stock with % or $ value of ownership/distributable income share:

Employee Stock Ownership Plan (ESOP):

Other (explain):

Disclosure of Potential Conflicts of Interest

Firm must check “Yes” or “No” to indicate which, if any, of the following potential conflict of interest relationships apply. If

the answer to any question is “Yes”, please describe and attach additional pages if needed.

Yes No

1. City of Peoria State employment, currently or in the previous three years, including

contractual employment of services?

If your answer is “Yes”, please answer each of the following questions, and provide description

in the space(s) below to those you answer yes to.

a) Are you currently an officer or employee of the City of Peoria either the Capital Development

Board or the Illinois State Toll Highway Authority?

b) Are you currently appointed to or employed by the City of Peoria any agency of the State of

Illinois? If you are currently appointed to or employed by the City of Peoria any agency of the

State of Illinois, and your annual salary exceeds 60% of the annual salary of the Governor,

provide the name of the state agency for which you are employed and your annual salary:

c) If you are currently appointed to or employed by the City of Peoria any agency of the State of

Illinois, and your annual salary exceeds 60% of the annual salary of the Governor, are you entitled

to receive (i) more than 7 ½% of the total distributable income of your firm, partnership,

association or corporation, or (ii) an amount in excess of the salary of the Governor?

d) If you are currently appointed to or employed by the City of Peoria any agency of the State of

Illinois, and your annual salary exceeds 60% of the annual salary of the Governor, are you and

your spouse or minor children entitled to receive (i) more than 15% in the aggregate of the total

distributable income of your firm, partnership, association or corporation, or (ii) an amount in

excess of two times the salary of the Governor?

2. City of Peoria State employment of spouse, father, mother, son, or daughter, including

contractual employment services in the previous two years?

If your answer is yes, please answer each of the following questions, and provide

description in the space(s) below to those you answer yes to.

Yes No

Add another Form A

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 5 of 7

a) Is your spouse or any minor children currently an officer or employee of the City of Peoria Capital

Development Board or the Illinois State Toll Highway Authority?

b) Is your spouse or any minor children currently appointed to or employed by the City of Peoria any

agency of the State of Illinois? If your spouse or minor children is/are currently appointed to or

employed by the City of Peoria any agency of the State of Illinois, and his/her annual salary

exceeds 60% of the annual salary of the Governor, provide the name of your spouse and/or minor

children, the name of the state agency for which he/she is employed and his/her annual salary.

c) If your spouse or any minor children is/are currently appointed to or employed by the City of

Peoria any agency of the State of Illinois, and his/her annual salary exceeds 60% of the annual

salary of the Governor, are you entitled to receive (i) more than 7 ½% of the total distributable

income of your firm, partnership, association or corporation, or (ii) an amount in excess of 100%

of the annual salary of the Governor?

d) If your spouse or any minor children are currently appointed to or employed by the City of Peoria

any agency of the State of Illinois, and his/her annual salary exceeds 60% of the annual salary of

the Governor, are you and your spouse or minor children entitled to receive (i) more than 15% in

the aggregate of the total distributable income of your firm, partnership, association or

corporation, or (ii) an amount in excess of two times the salary of the Governor?

3. Elective status: the holding of elective office of the State of Illinois, the government of the

United States, any unit of local government authorized by the Constitution of the State of

Illinois or the statutes of the State of Illinois currently or in the previous three years?

4. Relationship to anyone holding elective office currently or in the previous two years: spouse,

father, mother, son or daughter?

5. Appointive office: the holding of any appointive government office of the State of Illinois, the

United States of America, or any unit of local government authorized by the Constitution of

the State of Illinois or the statutes of the State of Illinois, which office entitles the holder to

compensation in excess of the expenses incurred in the discharge of that office currently or

in the previous three years?

6. Relationship to anyone holding appointive office currently or in the previous two years:

spouse, father, mother, son or daughter?

7. Employment, currently or in the previous three years, as or by any registered lobbyist of the

state government?

8. Relationship to anyone who is or was a registered lobbyist in the previous two years: spouse,

father, mother, son, or daughter?

9. Compensated employment, currently or in the previous three years, by any registered election

or re-election committee registered with the Secretary of State or any county clerk of the State

of Illinois, or any political action committee registered with either the Secretary of State or the

Federal Board of Elections?

Yes No

10. Relationship to anyone; spouse, father, mother, son, or daughter; who was a compensated

employee in the last two years by any registered election or re-election committee registered

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 6 of 7

with the Secretary of State or any county clerk of the State of Illinois, or any political action

committee registered with either the Secretary of State or the Federal Board of Elections?

11. Communication Disclosure. Disclose the name and address of each lobbyist and other

agent of the firm or offeror who is not identified in Form A, who has communicated, is

communicating, or may communicate, with any state officer or employee concerning the

statement of interest, bid or offer. This disclosure is a continuing obligation and must be

promptly supplemented for accuracy throughout the process and throughout the term of the

contract. If your firm uses (lobbyist firm), lobbyists that were either hired to work on

this specific SOI, bid or offer OR to assist your firm with this PTB, then answer Yes and

indicate specifics, else please mark No.

If yes, supply name and address of person(s) and firm name below and:

a) Disclose all lobbyist costs, fees, compensation, reimbursements, or other remunerations paid, or

to be paid related to this PTB Item.

b) Agree Consultant will not bill to the State any lobbyist costs, fees, compensation,

reimbursements, or other remunerations.

12. Suspension or Debarment Disclosure. For each of the persons identified under Form A,

disclose whether any of the following has occurred within the previous 10 years: suspension

or debarment from contracting with any governmental entity; professional licensure discipline;

bankruptcies; adverse civil judgments and administrative findings; and criminal felony

convictions. This disclosure is a continuing obligation and must be promptly supplemented for

accuracy throughout the procurement process and term of the contract, if the bid or offer is

successful. If yes, supply information below:

Name of person(s):

Nature and date of

disclosure:

If the answers to questions 2 – 6 are “Yes” under “Qualifying Questions for Form A”, check the box, sign and date below under “Applicable Statement”:

Applicable Statement

This Disclosure Form A is submitted on behalf of the INDIVIDUAL named on previous page. Under penalty of

perjury, I certify the contents of this disclosure to be true and accurate to the best of my knowledge.

Completed by:

Signature of Individual or Authorized Officer Date

If the answers to questions 2 - 6 are all “No”, under “Qualifying Questions for Form A”, check the box, sign and date below under “Not Applicable

Statement”:

Not Applicable Statement

Under penalty of perjury, I have determined that no individuals associated with this organization meet the criteria

that would require the completion of this Form A.

This Disclosure Form A is submitted on behalf of the FIRM listed on the first page.

Completed by:

Signature of Individual or Authorized Officer Date

The firm has a continuing obligation to supplement these disclosures under Sec. 50-35 of the Procurement Code.

Form B: Other Contracts & Procurement-Related Information Disclosure

Disclosure of the information contained in this form is required by Section 50-35 of the Illinois Procurement Code (30 ILCS

500). This information shall become part of the publicly available contract file. This Form B must be completed for

Consultant’s Disclosure Statement

RETURN WITH STATEMENT OF INTEREST

Printed 6/9/2022 Page 7 of 7

Statements of Interest in excess of $50,000, and for all open-ended contracts. This Form B must also be completed for

subconsultant agreements with an annual value of more than $50,000 from subconsultants identified in Section 20-120 in

the Illinois Procurement Code and for all open-ended subconsultant agreements.

Disclosure of Other Contracts and Procurement-Related Information

Answer the following question.

Yes No

1. Does the firm have any pending contracts (including leases), statements of interest, bids,

proposals, or other ongoing procurement relationship with the City of Peoria IDOT or any

other State of Illinois agency?

If your answer is “No”, the firm only needs to complete the signature box and date on the

bottom of this page.

If your answer is “Yes”, identify each such relationship by showing the agency name,

PTB/PSB if applicable, Project name and the role of your firm as either a Prime or Sub (attach

additional pages as necessary).

AGENCY PTB/PSB PROJECT NAME ROLE (PRIME/

SUB FIRM)

Add A Row

This Disclosure Form B is submitted on behalf of the INDIVIDUAL named on previous pages. Under penalty of

perjury, I certify the contents of this disclosure to be true and accurate to the best of my knowledge.

Completed by:

Signature of Individual or Authorized Representative Date

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