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Home My WebLink AboutRes 16-12 WA Approval of ESC 11 contract Business and Student Support Services WESTLAKE ACADEMY RESOLUTION NO. 16-12 A RESOLUTION OF THE BOARD OF TRUSTEES OF WESTLAKE ACADEMY AUTHORIZING THE SUPERINTENDENT TO ENTER INTO A CONTRACT WITH THE EDUCATION SERVICE CENTER REGION 11 FOR VARIOUS BUSINESS AND STUDENT SUPPORT SERVICES FOR THE OPERATION OF WESTLAKE ACADEMY. WHEREAS, the Westlake Academy has utilized the business and student services of the Education Service Center Region 11, which is responsible for providing training for faculty and staff, providing compliance training for public education rules and regulations, performing the payroll functions in full compliance with the Texas Education Agency (TEA) Financial Accountability System Resource Guide, as well as offering software and information technology training and hosting services to Westlake Academy; and, WHEREAS, additional personnel costs for the Academy would have a greater impact to the Academy's operating budget than utilizing these contracted services offered by the Education Service Center Region 11, and the quality of these services has been exceptional; and WHEREAS, the Board of Trustees finds that the passage of this Resolution is in the best interest of the citizens of Westlake as well as the students, their parents, and faculty of Westlake Academy. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF TRUSTEES OF THE WESTLAKE ACADEMY, TEXAS: SECTION 1: The above findings are hereby found to be true and correct and are incorporated herein in its entirety. SECTION 2: The Board of Trustees of the Westlake Academy hereby approves the contract with the Education Service Center Region 11 functions at Westlake Academy attached hereto as Exhibit "A"; and further authorizes the Superintendent to execute this agreement. SECTION 3: If any portion of this Resolution shall, for any reason, be declared invalid by any court of competent jurisdiction, such invalidity shall not affect the remaining provisions hereof and the Board hereby determines that it would have adopted this Resolution without the invalid provision. WA Resolution 16-12 Page I of 2 SECTION 4: That this resolution shall become effective from and after its date of passage. PASSED AND APPROVED BY THE BOARD OF TRUSTEES OF WESTLAKE ACADEMY, A CHARTER SCHOOL OF THE STATE OF TEXAS, ON THE loth DAY OF AUGUST 2016. Laura Wheat, President ATTEST: . t Kelly dwar ` , Board Secretary Thomas E. Brymer, S p intendent APPROV T OR L Stanfon Lo Bubert, School Attorney WA Resolution 16-12 Page 2 of 2 EDUCATION SERVICE CENTER III G I Westlake Academy Contract Summary for Business Services .27 Enrollment Period:09/01/2016-08/31/2017 Last Year Enrollment:831 Answer Price If you wish to sign up for Business Services,please indicate the service for Payroll Support which you wish to contract in the box on the right, Services Only Fee(see Business Service Contract Price List in the"Business Center $20,394.00 Handbook") Do you wish to sign up for the Requisition Module?if yes,please enter the amount of users in the box on the right. A Requisition Module fee of$580+$20 per user will be applied. Bank Reconciliation:Enter the number of bank accounts that will be reconciled by ESC Region 11's Business Center in the box on the right. $200 per month for the first bank account,$50 per month for each additional account. Contract Adjustment Business Manager Service F (Call for quote Brandilyn DePalma (817)740-7610) By clicking the box on the right,1,as an authorized representative of the a above mentioned District/Charter,agree to the terms of the attached "Business Center Handbook"stating DistrictlCharter Responsibility and ESC Region 11 Business Center Responsibility and Business Center Price List. Total: S20,394.00 Contract Contact. Marlem Rutledge mrutledge@Westlake-tx.org(817)490-5737 Res WA 16-12 36 11as7 Print Date: 7/8f2016 Page 1 of 2 Additional tees will be charged for public schools having more than five campuses or more than one payroll frequency :2�-- d&ow Superintendent jr Approved srg ee 1 o Date Executive Director TV Education Service Jnter Region 11 Da'a _.. Note- 1 Use the Printer Icon located to the nght of the contract name an the Contract Home page to print a copy of this contract. Click on Review/Submit Contracts on the contract home page t_SSC Region 41: Return a signed and dated copy to the district. Res WA 16-12 36 crn+r t 1097 Pnnt Date 7/812016 Pepe 2 of 2 EDUCATION SERVICE CENTER GI Westlake Academy Contract Summary for Comprehensive Services Basic Contract .4 Enrollment Period: 09/01/2016-08/31/2017 Last Year Enrollment:831 Answer Price Do you wish to sign up for the Comprehensive Services Basic Contract?If __.._Public(Charter) yes,please select your district's classification from the box on the right. Total S- Contract Contact: Marlene Rutledge,mrutiedger„'7a Westlake-tx.org,(817)490-5737 Res WA 16-12 32 ciao: ioi64 Print Date: 718 16 Page 1 of 1 EDUCATION SERVICE CENTER Westlake Academy Contract Summary for Management Information Systems Software & Support Service (TxEIS Student and Business) .a Enrollment Period-09/01/2016-08/31/2017 Last Year Enrollments 831 Answer Price TxEIS STUDENT If you wish to sign up for the TxEIS Student Software Contract,please enter 1.00 the number of regular instructional campuses using this software in the box on the right. TxEIS Student Annual License Fee $4,825.00 Please indicate the number of alternative campuses in your district using 0.00 this software in the box on the right. TxEIS Student Software License Fee(Alternative Campuses) Is this your FIRST year to contract with ESC Region i 1 for your student system software?If yes,please select the option(s)you wish to purchase in the,boxes below: First-Year District Installation Fee FirsVYear Campus Training Fee First-Year Conversion of Deb from Prior Vendor Fee Do you wish to add the txGr System ?If yes,enter the 37.00 $1,036,00 ntunber of distric txGrade users(Number of TEACHERS)in the box on the right Do you wish to add the txAttendance System Option?if yes,enter the 1,00 $4660,00 nunhber of campuses using txAttendanre in the box on the right. Do you with to add the TxEIS Health Application System?if yes,please 1,00 $43$,00 enter the number of campus"using this system in the box on the right. Re WA 16-12 91 cm Moss Print Date: TIM016 Page,1 of a TxEIS BUSINESS If you wish to sign up for the TxEIS Business Software Contract,please 0 check the box on the right. TxEIS Business System Annual License Fee $5,900.00 Please indicate the number of employees in your district in the box on the 103.00 $515.00 right. Is this your FIRST year to contract with ESC Region 11 for your Business software?If yes,please select the option(s)you wish to purchase in the boxes below: First-Year Installation and Training Fee First-Year Conversion of Data from Prior Vendor If you wish to sign up for the Requisition/Purchase Order System,please 26.00 indicate the number of users in the box on the right. Requisition/Purchase Order Annual License Fee $600•00 Requisition/Purchase Order User Fee $520.00 Total., $14,281.00 Contract ConUct. Finance contact:Marlene Rutledge mrutIedge@wesffake-tx,org(817)490-5737;Student contact-Ange Surngarner abumgarner@westlakeacademy.org(817)4W5765 *Atirwall liceftng fee prowdes soltwore maintenance,support,and all regularly scheduled training sessions,workdays,and ow In"fings. Res WA 16-12 81 ciD#. tim Print Date: 7/aQ2016 Page 2 of 2 EDUCATION SERVICE CENTER RIGI n Westlake Academy Contract Summary for Technology Resources Education Consortium (TREC) .42 Enrollment Period: 09/0112016-08/31/2017 Last Year Enrollment:831 Answer Price The following fees reflect your district's quoted TREC services.if you have any questions or would like to make changes,please contact Debby Roiling (817)740-7540 or dreilingscl l.not. TREC Library Management Service 1,450.00 $1,450.00 TREC Resource Management Services 0.00 TREC Data Services 0.00 Enter ESC Region 11 quoted adjustment(if any) 0.00 Please update your district's library contacts by clicking on the following link:I(BRARY CONTACTS Total: $1,450.00 Contract Contact: Dr.Mechelle Bryson(Executive Principal),mbryson@westlakeacademy.org,(817)490-5761;Amy Hess (Librarian),ahes estlakeacademy.org,(817)490-5757 Res WA 16-12 4s cot iio9a Print Date: 702016 Page 1 of 1 EDUCATION SERVICE CENTER 1UG1 Westlake Academy Contract Summary for TSDS PEIMS Support ,7 Enrollment Period.09/01/2016-08/31/2017 Last Year Enrollment:831 Answer Price Please select the following TSDS services for which your district will use. TSDS PEIMS Support-Please select the options(s)that aoalies to your district: PEIMS Support(all districts and charter schools) ® $2,250.00 PEIMS TSDS First Year Training(also select this checkbox if this is your district's first year to submit TSDS PEIMS) TSQS studentGPS Dashboard Support: studentCPS Dashboards-Annual Maintenance Training and Support ® $1,000.00 (Optional) studentGPS Dashboards-New Training and Support(Optional) IM 92M 99112999116 support• ECOS(Support for Fall Kindergarten Submission and Spring Pre-K ® $250,00 Submission) Totals S3,500.08 Contract Contacts Finance contact:Marlene Rutledge mrutiedge@Westlake-tx.org(817)490-5737;Student contact:Ange Stitrigarner,abumgarr r astlakea my.org,(817)490-5765 Res WA 16-12 ios =#. 1sogs Print Date: 71812016 Page 1 of 1 EDUCATION SERVICE CENTER 1UG1OIL I Westlake Academy Contract Summary for TxEIS Service Fees (Co-op Fee, Hosting Fee, Extracts) ,.,s Enrollment Period: 09/01/2016-08/31/2017 Gast Year Enrollment:831 Answer T Price Please indicate in the box on the right whether your district is self-hosting ESC Region Xi the TxEIS Business and/or Student software or if it is being hosted by ESC Hosted Region XI. If your district is self-hosted,please indicate the number of CPU in the box on the right. Please select the number of users that will use the TxEIS software.(Do not 1 -30 users include teachers that use Gradebook) TxEIS Co-op License Fee $257.14 TxEIS Hosting Fee $3,000,00 ESC Region 11 provides extracts from TxEIS that populate third-party 1-50 $500.00 software products with data.if your district uses third-party extracts,please select the number of extracts pulled per month that you require from the menu on right. Adjustment Total; $3,757.14 Contract Contact, Maderle Rutledge mrutiedge@west€ake-tx.org(817)490-5737 Res WA 16-12 iies4 Print Date, 702016 Page 1 of 1 EDUCATION SERVICE CENTER Master Interlocal R*1 JL G 11 Agreement This Master Interlocal Agreement("Agreement")is made by and between Education Service Center Region 11("ESC Region 11")and("Local Government'),(collectively referred to as the"Parties"or individually as the"Patty")acting herein by and through their respectively authorized officers or employees. PREMISES WHEREAS,Chapter 791 of the Texas Goverment Code authorizes local governments to contract with each other to provide governmental functions and services;and WHEREAS,The Parties wish to enter into this Agreement to provide local governments with greater efficiency and economy in purchasing products and services;and WHEREAS, the governing bodies of the Parties, individually and together, do hereby adopt and find the foregoing promises as findings of said governing bodies;and NOW THEREFORE,premises considered,and in consideration of and conditioned upon the mutual covenants and agreements,herein,the Parties hereto mutually agree as follows: AGREEMENT 1. Term: This Agreement is effective from the date of the last signature and shall automatically renew annually unless either patty gives sixty(60)days prior written notice of non-renewal. 2. Purpose:This Agreement shall: (1)Allow the Local Government to purchase products or services by purchase order, contract, agreement, or other appropriate legal method from ESC Region 11; and(2)Allow the Local Government to join ESC Region 11-sponsored purchasing cooperatives in order to purchase products or services from vendors which have been properly awarded contracts through statutorily authorized methods. 3. Relationship: The relationship between the Parties is that of Independent Contractor. Neither Party has the authority to bind the other in any manner. The Local Government may be required to enter into subsequent contractual arrangements with ESC Region 11 for specific products or services. 4. Agreement and Interpretation:The Parties covenant and agree that any litigation relating to this agreement,the terms,and conditions of the agreement will be interpreted according to the laws of the State of Texas and venue shall be exclusively in Tarrant County,Texas. 5. Each party paying for the performance of governmental functions or services must make those payments from current revenues available to the paying party. Local Government ESC Region 11 { 1451 S.Cherry Lane White Settlement,Texas 76103 Name of Local Government Attn:Dianna Casper Address of Local Government �1 1 Contact Name -Phone Number ESC Region 11 Executive Director Signature�` Email,Address Date Board President Signature Approval Date County/District#(if applicable) Print Date: 8/11/2016 DUOM N SERVICE CENTER N11,r Westlake Academy Contract Summary Report Last Year Enrollment:831 Contract Lock Date EnrollStart EnrollEnd Total Business Services 07/07/2016 09/01/2016 09/12/2017 $20,394.00 Comprehensive Services Basic Contract 07/07/2016 09/01/2016 09/12/2017 Management Information Systems 07/07/2016 09/01/2016 09/12/2017 $14,281.00 Software&Support Service(TxEIS Student and Business) Technology Resources Education 07/07/2016 09/01/2016 09/12/2017 $1,450.00 Consortium(TREC) TSDS PEIMS Support 07/07/2016 09/01/2016 09/12/2017 $3,500.00 TxEIS Service Fees(Co-op Fee, Hosting 07/07/2016 09/01/2016 09/12/2017 $3,757.14 Fee, Extracts) $43,382.14 Each party paying for the performance of governmental functions or services must make those payments from current revenues available to the paying party. Signature of Board President or Designee Date Approved by Board of Trustees - � ! ) 1 Signature of Superinten ent r Designee Date hCA t".1 -C a"l 4 to� Rt'"�,i.�'�V"i Designated District Contact E-mail ofDi rict Contact Please fax or e-mail to: For additional information,contact: Education Service Center Region I I Dr.Clyde W.Steelman,Jr. Atten:Dr.Clyde W.Steelman,Jr. (817)740-3630 1451 S.Cherry Lane clvde di esc I Lnet White Settlement,Texas 76108 Fax (817)740-7675 clvdes;iescI ].net ESC Region 11 Executive Director Signature Print Date: 8/11/2016 EDUCATION SERVICE m CENTER Master Interlocal I C1,11, IFUG Nil Agreement NOTE: Due to changes in the provisions of the Texas Government Code regarding interlocal cooperation contracts, all districts purchasing service contracts from ESC Region 11 must sign and subinit an updated Master Interlocal Agreement. Print Date: 8/11/2016 EDUCATION SERV[CF CENTER RIG 1 ( � 11 Westlake Academy Contract Summary for Business Services .27 Enrollment Period: 09/01/2016 - 08/31/2017 Last Year Enrollment: 831 Answer Price If you wish to sign up for Business Services, please indicate the service for Payroll Support which you wish to contract in the box on the right. Services Only Fee(see Business Service Contract Price List in the"Business Center $20,394.00 Handbook") Do you wish to sign up for the Requisition Module?If yes, please enter the amount of users in the box on the right. *A Requisition Module fee of$580+ $20 per user will be applied. Bank Reconciliation: Enter the number of bank accounts that will be reconciled by ESC Region 11's Business Center in the box on the right. $200 per month for the first bank account,$50 per month for each additional account. Contract Adjustment Business Manager Service Fees(Call for quote Brandilyn DePalma (817)740-7610) By clicking the box on the right, I,as an authorized representative of the Z above mentioned District/Charter,agree to the terms of the attached "Business Center Handbook"stating District/Charter Responsibility and ESC Region 11 Business Center Responsibility and Business Center Price List. Total: $20,394.00 Contract Contact: Marlene Rutledge mrutledge@Westlake-tx.org(817)490-5737 Res WA 16-12 36 CID#: 11097 Print Date: 7/8/2016 Page 1 of 2 EDUCATION SERVIC6--- CENTER RI GIN 11 Westlake Academy Contract Summary for Comprehensive Services Basic Contract v4 Enrollment Period: 09/01/2016 - 08/31/2017 Last Year Enrollment: 831 Answer Price Do you wish to sign up for the Comprehensive Services Basic Contract?If Public(Charter) yes,please select your district's classification from the box on the right. Total: Contract Contact: Marlene Rutledge, mrutledge@westlake-tx.org, (817)490-5737 Res WA 16-12 32 CID#: 10164 Print Date: 7/8/2016 Page 1 of 1 EDUCATION SERVICE CENTER 14 Westlake Academy Contract Summary for Management Information Systems Software & Support Service (TxEIS Student and Business) .6 Enrollment Period: 09/01/2016 -08/31/2017 Last Year Enrollment: 831 Answer Price TxEIS STUDENT If you wish to sign up for the TxEIS Student Software Contract,please enter 1.00 the number of regular instructional campuses using this software in the box on the right. TxEIS Student Annual License Fee $4,825.00 Please indicate the number of alternative campuses in your district using 0.00 this software in the box on the right. TxEIS Student Software License Fee(Alternative Campuses) Is this your FIRST year to contract with ESC Region 11 for your student system software?If yes, please select the option(s)you wish to purchase in the boxes below: First-Year District Installation Fee First-Year Campus Training Fee First-Year Conversion of Data from Prior Vendor Fee Do you wish to add the txGradebook System Option?If yes,enter the 37.00 $1,036.00 number of districtwide txGradebook users (Number of TEACHERS)in the box on the right. Do you wish to add the txAttendance System Option?If yes,enter the 1.00 $460.00 number of campuses using txAttendance in the box on the right. Do you wish to add the TxEIS Health Application System?If yes, please 1.00 $425.00 enter the number of campuses using this system in the box on the right. R1 WA 16-12 91 CID#, 11095 Print Date: 7/8/2016 Page 1 of 2 TxEIS BUSINESS If you wish to sign up for the TxEIS Business Software Contract, please check the box on the right. TxEIS Business System Annual License Fee $5,900.00 Please indicate the number of employees in your district in the box on the 103.00 $515.00 right. Is this your FIRST year to contract with ESC Region 11 for your Business software?If yes, please select the option(s)you wish to purchase in the boxes below: First-Year Installation and Training Fee First-Year Conversion of Data from Prior Vendor If you wish to sign up for the Requisition/Purchase Order System,please 26.00 indicate the number of users in the box on the right. Requisition/Purchase Order Annual License Fee $600.00 Requisition/Purchase Order User Fee $520.00 Total: $14,281.00 Contract Contact: Finance contact: Marlene Rutledge mrutledge@westlake-tx.org (817)490-5737; Student contact: Ange Bumgarner abumgarner@westlakeacademy.org (817)490-5765 "Annual licensing fee provides software maintenance, support, and all regularly scheduled training sessions,workdays, and user meetings. Res WA 16-12 91 CID#: 11095 Print Date: 7/8/2016 Page 2 of 2 EDUCATION SERVICE CENTER RIG I N11 Westlake Academy Contract Summary for Technology Resources Education Consortium (TREC) r42 Enrollment Period: 09/01/2016 - 08/31/2017 Last Year Enrollment: 831 Answer Price The following fees reflect your district's quoted TREC services. If you have any questions or would like to make changes, please contact Debby Reiling (817)740-7540 or dreiling@esc11.net. TREC Library Management Service 1,450.00 $1.450.00 TREC Resource Management Services 0.00 TREC Data Services 0.00 Enter ESC Region 11 quoted adjustment(if any) 0.00 Please update your district's library contacts by clicking on the following link: LIBRARY CONTACTS Total: $1,450.00 Contract Contact: Dr. Mechelle Bryson(Executive Principal), mbryson@westlakeacademy.org, (817)490-5761, Amy Hess (Librarian), ahess@westlakeacademy.org, (817)490-5757 Res WA 16-12 48 CID#: 11098 Print Date: 7/8/2016 Page 1 of 1 EDUCATION SERVIC CENTER IUGii- 1 N 11 Westlake Academy Contract Summary for TSDS PEIMS Support r7 Enrollment Period: 09/01/2016 - 08/31/2017 Last Year Enrollment: 831 Answer Price Please select the following TSDS services for which your district will use. TSDS PEIMS Support-Please select the options(s)that applies to your district: PEIMS Support(all districts and charter schools) $2,250.00 PEIMS TSDS First Year Training(also select this checkbox if this is your district's first year to submit TSDS PEIMS) TSDS studentGPS Dashboard Support: studentGPS Dashboards -Annual Maintenance Training and Support 2 $1,000.00 (Optional) studentGPS Dashboards -New Training and Support(Optional) TSDS Core Collections Support: ECDS(Support for Fall Kindergarten Submission and Spring Pre-K 2 $250.00 Submission) Total: $3,500.00 Contract Contact: Finance contact: Marlene Rutledge mrutledge@Westlake-tx.org(817)490-5737; Student contact:Ange Bumgarner, abumgarner@westlakeacademy.org, (817)490-5765 Res WA 16-12 106 CID# 11096 Print Date: 7/8/2016 Page 1 of 1 EDUCATION SERVIC CENTER 111GIiN Westlake Academy Contract Summary Report Last Year Enrollment:831 Contra Contrac Lock Date Enrollstart EnrollEnd Total Business Services 07/0712016 0910112016 09/12/2017 $20.394 00 Comprehensive Services Basic Contract 0710712016 09r0112016 09/12/2017 _ Management Information Systems 0710712016 0910112016 09/12/2017 $14,281 00 Software&Support Service(TxEIS Student and Business) Techno'ogy Resources Education 07/0712016 0910112016 09/12/2017 $1.450.00 Consortium(TREC) TSDS PENS Support 07107r2016 0910112016 09/12/2017 $3.500 00 TxEIS Service Fees(Co-op Fee, Hosting 0710712016 09r0112016 09/12/2017 $3 757 14 Fee,Extracts) $43,382.14 leach party paying ror the performance orgovcrumental functions or services must make those pmments from current revenues available to the paying party. 54 i LP Signature of Board President or Designee Lute Approved b} Board ul'�Frustces 10 Ito Signature of Superinten •m r Designee Dale N1r-ZrI(' C-IC.L.+If.1 C A0, Designated District Contact Ij E-mail of Dt. rict Contact Please fox or e-mail to: For additional information,contact: Education Sera ice Center Region I I Dr.Cl)de W.Steelman.Jr. Auen:Dr.CKde W.Steelman.Jr. (817)740-3630 1451 S.Chem Lane Lk LIL.',d cwc l Lnct While Settlement.Texas 76108 Fax (817)740-7675 hwjw�� cl%desraeseI I.net ESC Rc ion 1 I Executive DirectoY Signature Print Date W1112016 EDUCATION SERVICE CENTER Master Interlocal Agreement NOTE: Due to changes in the provisions of the Texas Government Code regarding interlocal cooperation contracts, all districts purchasing service contracts from ESC Region 11 must sign and submit an updated Master Interlocal Agreement. Print Date: 7/7/2016 EDUCATIOS! SERVICE CENTER Master Interlocal RE G•I N Agreement This Master lrtterlocol Agreement('Agreerncrin is made by and between Eiduration Service Center Region 11 C'ESC Region 11")and O'Local Government"),(collectively referred to as the"Parties"or individually as the"Party")acttng herein by and through their resprctively authorized offiiccrs or enhploym PREMISES WHEREAS,Chapter 791 of the Texas Government Code authorizes local govarmhents to contract with each otter to provide governmental functions and services,and VVH EREAS,The Parties wish to enter ihno this Agreement to provide local governments with greater elliciency and economy in purchasing products and services;and WHEREAS, the governing bodies of tie Panics, individually and together, do lhcreby adopt and find tie foregoing promises as findings of said governing bodies;and NOW THEREFURF„premises considered,and in consideration of and conditioned upon die mutual covenants and agrKmcnls,herein,the Parties hereto mutually agree as follows: AGREEMENT 1. Tenn: This Agreement is effective from We date of the last signaUac and shall aulornatically renew annually unless either party gives sixty(60)days prior wvitien notice of non-renewal. 2. hnrposr:This Agreement shall (1)Allow the Local Government to purchase products or services by purchase order,coutrrct agreement, or other appropriate legal rndhod from ESC Region 11. and(2)Allow the E-acal Government to join ESC Region 11-sponsored purchasing cooperatives in order to purchase products or seti ices from vandars which have been properly awarded contacts through statutorily atthonzcd methods. 5, Relrtanshlp:The relationship between the Parties is that of independent Contractor. Neither Party has the authority to bind the other in any manner The Local Government may be required to enter into subsequent contractual arrangements with ESC Region I 1 for specific products or soviees- 4. Agrenutut and Interpretatow The Parties covenant anti agree that arty litigation relating to this agreement.the tennns,and conditions of the agreement will be interpreted according to the laws of tic State of Texas and venue shall be exclusively in Tarrant County.Teas. 5. Each party paying for the performance of govennental fmnctions or services must make those payments from current revenues available tc the paying party Local Government ESC Region It 1451 S Cherry Lane �lv G White Settlement Texas 76108 Name of Local Govennhc i Atin.Dianna C�sper Z oo 71 T��h r-ut,< P Address of Local Government 01-1 Mw lenf-') V-�aE, ��fl•� � Contact Name IlMone Number . ESC R I I ExtTltl a Director Sims r �c,�cq � �� `� — EmaiEAddress II n Ito tfp Date - --- Hoard President Signature Approval Date 22a--clIQ - County7Distnct 0(if applicable) Print Date 811112016