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GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

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Page 1: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM
Page 2: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No.

GPA Involved

Day of Week Date Notified Time

Total No.Vehicles

Total No.Injured

GPA Division InvolvedYes No

Arrived Time

Road ofOccurrence

At IntersectionWith

Not at IntersectionBut Approx.

Nearest Road/LandmarkOf

BerthNo.

Row/LaneNo.

Slot No.

LOCATI

ON

Ft.AtNear

Other Location

Weather Surface Condition Light ConditionType Accident

Vehicle

Address (St./Rd. - Apt. No. - P.O. Box)

City State Zip

Drivers License No. State Class

Sex Race

Employer Home Phone

S.S.N. D.O.B.

Vehicle

Address (St./Rd. - Apt. No. - P.O. Box)

City State Zip

ClassStateDrivers License No.

Sex Race

Employer Home Phone

D.O.B.S.S.N.

Work Phone Work Phone

Driver Driver

Address

City State Zip

Vehicle Leased To

Year Make

V.I.N. Color

Lic. Plate No. State

Vehicle

Model

Year

Trailer/Chassis Lic. Plate No. State Year

Trailer/Container No. Length

Chassis No. Length

Insurance Co. Policy No.

Direction of Travel Speed Limit

Vehicle

Address

City State

Vehicle Leased To

Year Make Model

ColorV.I.N.

Lic. Plate No. State

StateTrailer/Chassis Lic. Plate No.

Trailer/Container No. Length

LengthChassis No.

Insurance Co. Policy No.

Speed LimitDirection of Travel

Zip

Year

Year

Owner Owner

Trailer Type Vehicle Type Trailer TypeVehicle Type

Company VehicleIdentification No. Identification No.

Company Vehicle

Vehicle Maneuver

Damage

Vehicle Removed By

Vehicle Maneuver

Vehicle Removed By

DamagePoint of Initial Contact Point of Initial Contact

201501030012 Saturday 1/3/2015 8:30:00 AM

CONTAINER OPERATIONSþ ¨ 2 1

CHATHAM DRIVE

100 West TOMOCHICHI RD¨þ

ANGLE DRY DAYLIGHT

CHANEY TERRY

2181 FOX STREET

SAVANNAH GA 31402

054077444 GA C

M BLACK

GPA 912-695-7056

054-07-7444 10/5/1972

1REVERE GEORGE WILLIAM

2492 QUACCO ROAD

POOLER GA 31322

052348446 GA CM

M BLACK

GEORGIA PORTS AUTHORITY330-942-3773

269-82-7600 2/11/1984

(912)964-3811

2

TICO TERMINAL SERVICES

75 BRAMPTON RD.

GARDEN CITY GA 31408

2013 TICO

1T9NS4ASODR825019 WHITE

JO13057

Jockey Truck

0

0

GEORGIA PORTS AUTHORITY

West 20

1REVERE JUANITA COSPER

2492 QUACCO RD

POOLER GA 31402

1999 FORD

1FAFP4041XF174298 RED

AWG9306 GA

MUSTANG

2015

0

0

COUNTRY G10A5286460

East 20

2

JOCKEY TRK- TRAILER

Turning Left

SLIGHT

PARICK GILMORE GPA ASSISTANT MANAGER

2 RIGHT SIDE

PASSENGER CAR

Straight

EXTENSIVE

SAPPS TOWING

4 LEFT SIDE

8:34:00 AM

CHATHAM ICTF YARD

Page 3: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Object Struck

Damage Other Than Vehicle

Injuries

Witnesses

Narrative

Investigated By Agency/Dept.Other Agency

Officer C.R.N.

PhotographsTaken

By

Investigating Officer Watch

Report Checked By

Report Date

Date Checked

YesNo

YesNo

Report Checked By Date Checked

Injured Taken To Taken By EMS Noti. Time EMS Arr. Time Hosp. Arr. Time

Notifications

1/4/2015

JOCKEY TRUCK VS. POV

þ¨ 123 OFFICER Jeffrey McCombes201501030012

þ¨ 123 OFFICER Jeffrey McCombes

123 OFFICER Jeffrey McCombes 0545-1815 1/3/2015

1/5/201548 Lieutenant Mario F Stefanski

Name Address Phone No.912-921-084211927 IDLEWOOD DR SAVANNAH GA 31419DAMEWOOD WILLIAM

Name Company/Dept Time Responded To SceneGEORGIA PORTS AUTHORITY POLICE 8:30:00 AM þ ¨ NoYesRYAN , JAMESGPA OPERATION ASSISTANT MANAGER8:30:00 AM þ ¨ NoYesGILMORE , PATRICKGPA SAFETY MANAGER 8:55:00 AM þ ¨ NoYesPAGE , PATRICKGPA RISK MANAGEMENT 8:55:00 AM ¨ þ NoYesJANDOVITZ , BETTY JGPA RISK MANAGEMENT 11:00:00 AM ¨ þ NoYesSTAGNITTO , SUSAN

VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELING EAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2 PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE AN IMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUE TO THE IMPROPER LEFT TURN.

16 Sergeant James M Ryan

SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60 8:40:00 AM 8:54:00 AM

Page 4: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Diagram

GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No. Day of Week Date Notified Time Arrived Time201501030012 Saturday 1/3/2015 8:30:00 AM 8:34:00 AM

Page 5: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Accident Number

201501030012Agency NCIC

GA0250800Accident Date

01/03/2015Georgia Ports Authority - Accident Report Continuation

I SPOKE TO THE DRIVER OF VEHICLE #2, MR. GEORGE REVERE, AND HE STATED, THE DRIVER OF VEHICLE #1 DROVE INTO HIS DRIVER'S SIDE DOOR AS HE WAS DRIVING STRAIGHT ON CHATHAM DRIVE. HE ADVISED VEHICLE #1 NEVER SLOWED DOWN OR STOPPED, "HE JUST TURNED RIGHT INTO ME". HE STATED HE BANGED HIS HEAD ON THE DRIVER'S SIDE WINDOW AND HE COMPLAINED OF LOWERED BACK PAIN AND DIZZINESS. I NOTIFIED GPAPD DISPATCH OF THE INJURIES, AND THEY CONTACTED SOUTHSIDE FIRE EMS TO COME TO THE SCENE. I NOTICED THE POINT OF IMPACT ON HIS DRIVER'S SIDE DOOR AS WELL AS DAMAGE TO THE FRONT LEFT FENDER, WHEEL WELL, TIRE, RIM, FRONT BUMPER, LEFT FRONT HEADLIGHTS, BROKEN DRIVER'S SIDE WINDOW, BROKEN FRONT WINDSHIELD, AND DAMAGED HOOD. THERE WAS DEBRIS AND VEHICLE FLUIDS LAYING ON THE GROUND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN ON CHATHAM DRIVE. DRIVER #1, MR. TERRY CHANEY, STATED HE WAS DRIVING WEST ON CHATHAM DRIVE ABOUT TO TURN LEFT INTO THE CUSTOMS PORTAL AREA. HE STATED HE NEVER SAW MR. REVERE'S MUSTANG. HE INITIALLY STATED TO ME ON SCENE, "I DIDN'T EVEN LOOK OVER THERE. I JUST TURNED". HE STATED HE THEN FELT THE COLLISION BETWEEN BOTH VEHICLES. MR. CHANEY ADVISED HE WAS NOT INJURED ON SCENE AND REFUSED EMS. I ISSUED MR. CHANEY A GEORGIA PORTS AUTHORITY SAFETY VIOLATION NOTICE FOR IMPROPER LEFT TURN (CAD0378), BUT HE REFUSED TO SIGN IT ON SCENE. HE THEN CHANGED HIS TESTIMONY STATING, "HE (VEHICLE#2) DROVE INTO MY TRUCK". I NOTICED SLIGHT FRONT LEFT BUMPER DAMAGE TO HIS JOCKEY TRUCK (13057). I THEN SPOKE TO THE WITNESS, MR. WILLIAM DAMEWOOD, AND HE STATED HE WAS IN HIS JOCKEY TRUCK BEHIND MR. CHANEY AT THE TIME OF THE COLLISION. HE ADVISED MR REVERE CAME TO A COMPLETE STOP AT THE STOP SIGN AND DROVE FORWARD. AS MR. REVERE WAS DRIVING FORWARD, MR. CHANEY TURNED LEFT INTO HIM CAUSING THE ACCIDENT. HE STATED MR. CHANEY NEVER SLOWED DOWN OR STOPPED BEFORE THE LEFT TURN. ALL THREE PARTIES PROVIDED WRITTEN STATEMENTS ON SCENE, AND POSSESSED VALID TWIC AND GPA CREDENTIALS. I INVENTORIED MR. REVERE'S FORD MUSTANG AND THEN HAD GPAPD DISPATCH CALL FOR A HEAD OUT TOWING SERVICE TO REMOVE HIS VEHICLE. BOTH PARTIES DRIVER'S LICENSES WERE VALID AND THEIR VEHICLES HAD ACTIVE INSURANCE COVERAGE. SAPPS TOWING ARRIVED ON SCENE AND REMOVED THE CAR AND CLEANED THE DEBRIS AND VEHICLE FLUIDS FROM THE ROADWAY.

CLEARED EXCEPTIONAL

ADDITIONAL REMARKS

Report By: OFFICER Jeffrey McCombes Page of

Page 6: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM
Page 7: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Injured Taken To By:

EMS Notified Time

Report By:

Witness(es): Name

EMS Arrival Time Hospital Arrival Time Photos Taken: Yes No By:

Department Report Date Checked By: Date Checked

DOT MICROFILM NUMBER (DO NOT WRITE IN THIS SPACE)

Address City State Zip Code Telephone No.

Accident Number Agency NCIC No. GEORGIA UNIFORMMOTOR VEHICLE ACCIDENT REPORT

County Date Rec. By DPS

Date Day of Week Time Off. Arrived Total Number Of: InsideCity Of:Vehicles Injuries Fatalities

Road ofOccurrence

At ItsIntersection

With

Corrected Report?Yes

Suppl. To Original?Yes

o o o o o o oSun M T W Th F S

Not At ItsIntersection But

oo

oo

oo

MilesFeet

o1

12

34

Interstate 2 o o oLowest St. Rt. Co. Road 4 City St.3

NorthSouth

EastWest

And Continuing in theDirection Checked AboveThe Next Reference Point is

Of:

1 2 3 4o o o oInterstate Lowest St. Rt. Co. Road City St.

1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line

1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line

Hit and Run?Yes

COMMERCIAL VEHICLES ONLYCarrier NameVehicle #

No. of Axles

Vehicle Config.

Address

C.D.L.?Vehicle Placarded? 1

If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:

Ran Off Road

State Zip

G.V.W.R. Fed. Reportable Cargo Body Type1 o 2 oYes No

I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate

oo

1 o Yes 2 o No C.D.L. Suspended?Hazardous Materials?

Released?

1 o 2Yes o No1

1Yes 2 No

Yes 2 Noo o

o o

Down Hill Runaway Cargo Loss or Shift Separation of Units

Carrier NameVehicle #Address

No. of Axles

Vehicle Config.

C.D.L?Vehicle Placarded?1

If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:

Ran Off Road Down Hill Runaway

o Yes 2 o No

Cargo Loss or Shift Separation ofUnits

State Zip

G.V.W.R.o o1 Yes 2 No

Fed. Reportable Cargo Body Type

I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate

oo

o o o o

o oo o

o o1 Yes 2 No 1 Yes 2 No

Yes No 1 Yes 2 No1 Yes 2 No

C.D.L. Suspended?Hazardous Materials?

Released?2

Driver #

Ped o

Last Name First Middle Driver #

Ped

Last Name First Middle

Address Address

State Zip DOB State Zip DOB

oo Male State oo Male

o

Female Female

City

Driver's License No.

PostedSpeed

Year

VIN

Tag #

Trailer Tag #

Sameoas Driver

Address

City

Removed By

AlcoholTestDriverConditionVehicleCondition

Most Harmful EventTraffic Control

Insurance Co. Policy No.

Class State

City

Driver's License No.

PostedSpeed

Make Model Telephone No.

Vehicle Color

State County Year

State County Year

Owner's Last Name First Middle

State Zip

o oRequest List

Type Results DrugTest

Type Results

Directionof TravelVehicleManeuver

VisionObscuredPedestrianManeuver

Contributing Factors

Vehicle Class Vehicle TypeDevice Inoperative? o oYes No

Insurance Co. Policy No.

Year Make Model Telephone No.

VIN

Tag #

Trailer Tag #

Address

o Sameas Driver

City

Removed By

AlcoholTestDriverConditionVehicleCondition

Most Harmful EventTraffic Control

Vehicle Color

State County

State County

First

Year

Year

MiddleOwner's Last Name

State

o

Zip

oRequest List

Directionof TravelVehicleManeuver

Vehicle ClassDevice Inoperative?

Contributing Factors

Vehicle Type

Type Results DrugTest

Type Results

o oYes No

VisionObscuredPedestrianManeuver

Class

DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447

SAVANNAH GA 31402 10/05/1972

054077444 C GA

o

20 GEORGIA PORTS AUTHORITY

2013 TICO Jockey Truck 912-695-7056

1T9NS4ASODR825019 WHITE

JO13057

o

75 BRAMPTON RD.

GARDEN CITY GA 31408

PARICK GILMORE GPA ASSISTANT MANAGER

2 0

2181 FOX STREET

2 0

1 4 1 13

1 1 011 1 77

o o

þo

1 CHANEY TERRY

TICO TERMINAL SERVICES

POOLER GA 31322 02/11/1984

052348446 CM GA

o

20 COUNTRY G10A5286460

1999 FORD MUSTANG 330-942-3773

1FAFP4041XF174298 RED

AWG9306 GA CHATHAM 2015

o

2492 QUACCO RD

POOLER GA 31402

SAPPS TOWING

2 0

2492 QUACCO ROAD

2 0

1 3 1 1

1 5 011 1 17

o þ

þo

2 REVERE GEORGE WILLIAM

REVERE JUANITA COSPER

201501030012 GA0250800 CHATHAM

GARDEN CITY0128:348:30þoooooo

01/03/2015

o þ

CHATHAM DRIVEo o o o o o

100 oþ

oo

TOMOCHICHI RDo þ o o o

oo o o o

912-921-084211927 IDLEWOOD DR SAVANNAH, GA 31419DAMEWOOD WILLIAM

SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60

8:40 8:54

GEORGIA PORTS AUTHORITY POLICE DEPARTMENT

OFFICER Jeffrey McCombes

OFFICER Jeffrey McCombes Lieutenant Mario F Stefanski 01/05/2015

0

0 0 o o 0

0oo

o o o oo o o oo o

00

0

0 0 o o 0

0oo

o o o oo o o oo o

00

01/03/2015

¨

¨

¨

þ ¨

Page 8: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

REMARKS

CITATIONS - VEHICLE # CITATIONS - VEHICLE #

First HarmfulEvent

VEH. # VEH. #

Number of Occupants

Point Of Initial Contact

Damage To Vehicles

SKID DISTANCEBEFORE IMPACT

AFTER Width Of Road

Damage OtherThan Vehicle:

Owner:

Occupants Driver #

Driver #

Or Pedestrian #

Or Pedestrian #

AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAG

Last Name First Address City State Zip

VEH FOR SAFETY AIRTAKEN

VEH.

VEH.

VEH.

VEH.

Traffic-WayFlow

Weather Surface Cond. Light Cond. Manner OfCollision

Location atArea of Impact

RoadComp.

Road Def. Road Character

PAGE OF

X X X X XXXX XXXX XXXX XXXX XXXXX XXXX

Construction/Maintenance Zone

0

Accident No. 201501030012

DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447

1 2

11 2 0 1 1 1 1 2 1 11

122

2144

01

01

02

02

1 0 2 1 3 2 02 4 1 1 3 2 2

2 4

VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELINGEAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE ANIMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUETO THE IMPROPER LEFT TURN.

Page 9: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No.

GPA Involved

Day of Week Date Notified Time

Total No.Vehicles

Total No.Injured

GPA Division InvolvedYes No

Arrived Time

Road ofOccurrence

At IntersectionWith

Not at IntersectionBut Approx.

Nearest Road/LandmarkOf

BerthNo.

Row/LaneNo.

Slot No.

LOCATI

ON

Ft.AtNear

Other Location

Weather Surface Condition Light ConditionType Accident

Vehicle

Address (St./Rd. - Apt. No. - P.O. Box)

City State Zip

Drivers License No. State Class

Sex Race

Employer Home Phone

S.S.N. D.O.B.

Vehicle

Address (St./Rd. - Apt. No. - P.O. Box)

City State Zip

ClassStateDrivers License No.

Sex Race

Employer Home Phone

D.O.B.S.S.N.

Work Phone Work Phone

Driver Driver

Address

City State Zip

Vehicle Leased To

Year Make

V.I.N. Color

Lic. Plate No. State

Vehicle

Model

Year

Trailer/Chassis Lic. Plate No. State Year

Trailer/Container No. Length

Chassis No. Length

Insurance Co. Policy No.

Direction of Travel Speed Limit

Vehicle

Address

City State

Vehicle Leased To

Year Make Model

ColorV.I.N.

Lic. Plate No. State

StateTrailer/Chassis Lic. Plate No.

Trailer/Container No. Length

LengthChassis No.

Insurance Co. Policy No.

Speed LimitDirection of Travel

Zip

Year

Year

Owner Owner

Trailer Type Vehicle Type Trailer TypeVehicle Type

Company VehicleIdentification No. Identification No.

Company Vehicle

Vehicle Maneuver

Damage

Vehicle Removed By

Vehicle Maneuver

Vehicle Removed By

DamagePoint of Initial Contact Point of Initial Contact

201501030012 Saturday 1/3/2015 8:30:00 AM

CONTAINER OPERATIONSþ ¨ 2 1

CHATHAM DRIVE

100 West TOMOCHICHI RD¨þ

ANGLE DRY DAYLIGHT

CHANEY TERRY

2181 FOX STREET

SAVANNAH GA 31402

054077444 GA C

M BLACK

GPA 912-695-7056

054-07-7444 10/5/1972

1REVERE GEORGE WILLIAM

2492 QUACCO ROAD

POOLER GA 31322

052348446 GA CM

M BLACK

GEORGIA PORTS AUTHORITY330-942-3773

269-82-7600 2/11/1984

(912)964-3811

2

TICO TERMINAL SERVICES

75 BRAMPTON RD.

GARDEN CITY GA 31408

2013 TICO

1T9NS4ASODR825019 WHITE

JO13057

Jockey Truck

0

0

GEORGIA PORTS AUTHORITY

West 20

1REVERE JUANITA COSPER

2492 QUACCO RD

POOLER GA 31402

1999 FORD

1FAFP4041XF174298 RED

AWG9306 GA

MUSTANG

2015

0

0

COUNTRY G10A5286460

East 20

2

JOCKEY TRK- TRAILER

Turning Left

SLIGHT

PARICK GILMORE GPA ASSISTANT MANAGER

2 RIGHT SIDE

PASSENGER CAR

Straight

EXTENSIVE

SAPPS TOWING

4 LEFT SIDE

8:34:00 AM

CHATHAM ICTF YARD

Page 10: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Object Struck

Damage Other Than Vehicle

Injuries

Witnesses

Narrative

Investigated By Agency/Dept.Other Agency

Officer C.R.N.

PhotographsTaken

By

Investigating Officer Watch

Report Checked By

Report Date

Date Checked

YesNo

YesNo

Report Checked By Date Checked

Injured Taken To Taken By EMS Noti. Time EMS Arr. Time Hosp. Arr. Time

Notifications

1/4/2015

JOCKEY TRUCK VS. POV

þ¨ 123 OFFICER Jeffrey McCombes201501030012

þ¨ 123 OFFICER Jeffrey McCombes

123 OFFICER Jeffrey McCombes 0545-1815 1/3/2015

1/5/201548 Lieutenant Mario F Stefanski

Name Address Phone No.912-921-084211927 IDLEWOOD DR SAVANNAH GA 31419DAMEWOOD WILLIAM

Name Company/Dept Time Responded To SceneGEORGIA PORTS AUTHORITY POLICE 8:30:00 AM þ ¨ NoYesRYAN , JAMESGPA OPERATION ASSISTANT MANAGER8:30:00 AM þ ¨ NoYesGILMORE , PATRICKGPA SAFETY MANAGER 8:55:00 AM þ ¨ NoYesPAGE , PATRICKGPA RISK MANAGEMENT 8:55:00 AM ¨ þ NoYesJANDOVITZ , BETTY JGPA RISK MANAGEMENT 11:00:00 AM ¨ þ NoYesSTAGNITTO , SUSAN

VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELING EAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2 PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE AN IMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUE TO THE IMPROPER LEFT TURN.

16 Sergeant James M Ryan

SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60 8:40:00 AM 8:54:00 AM

Page 11: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Diagram

GEORGIA PORTS AUTHORITY - PORT POLICE DEPARTMENT- ACCIDENT REPORTCase No. Day of Week Date Notified Time Arrived Time201501030012 Saturday 1/3/2015 8:30:00 AM 8:34:00 AM

Page 12: GEORGIA PORTS AUTHORITY - PORT POLICE …gpa.gaports.com/purchasing/webbids.nsf... · Georgia Ports Authority - Accident Report ... Accident Number Agency NCIC No. GEORGIA UNIFORM

Accident Number

201501030012Agency NCIC

GA0250800Accident Date

01/03/2015Georgia Ports Authority - Accident Report Continuation

I SPOKE TO THE DRIVER OF VEHICLE #2, MR. GEORGE REVERE, AND HE STATED, THE DRIVER OF VEHICLE #1 DROVE INTO HIS DRIVER'S SIDE DOOR AS HE WAS DRIVING STRAIGHT ON CHATHAM DRIVE. HE ADVISED VEHICLE #1 NEVER SLOWED DOWN OR STOPPED, "HE JUST TURNED RIGHT INTO ME". HE STATED HE BANGED HIS HEAD ON THE DRIVER'S SIDE WINDOW AND HE COMPLAINED OF LOWERED BACK PAIN AND DIZZINESS. I NOTIFIED GPAPD DISPATCH OF THE INJURIES, AND THEY CONTACTED SOUTHSIDE FIRE EMS TO COME TO THE SCENE. I NOTICED THE POINT OF IMPACT ON HIS DRIVER'S SIDE DOOR AS WELL AS DAMAGE TO THE FRONT LEFT FENDER, WHEEL WELL, TIRE, RIM, FRONT BUMPER, LEFT FRONT HEADLIGHTS, BROKEN DRIVER'S SIDE WINDOW, BROKEN FRONT WINDSHIELD, AND DAMAGED HOOD. THERE WAS DEBRIS AND VEHICLE FLUIDS LAYING ON THE GROUND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN ON CHATHAM DRIVE. DRIVER #1, MR. TERRY CHANEY, STATED HE WAS DRIVING WEST ON CHATHAM DRIVE ABOUT TO TURN LEFT INTO THE CUSTOMS PORTAL AREA. HE STATED HE NEVER SAW MR. REVERE'S MUSTANG. HE INITIALLY STATED TO ME ON SCENE, "I DIDN'T EVEN LOOK OVER THERE. I JUST TURNED". HE STATED HE THEN FELT THE COLLISION BETWEEN BOTH VEHICLES. MR. CHANEY ADVISED HE WAS NOT INJURED ON SCENE AND REFUSED EMS. I ISSUED MR. CHANEY A GEORGIA PORTS AUTHORITY SAFETY VIOLATION NOTICE FOR IMPROPER LEFT TURN (CAD0378), BUT HE REFUSED TO SIGN IT ON SCENE. HE THEN CHANGED HIS TESTIMONY STATING, "HE (VEHICLE#2) DROVE INTO MY TRUCK". I NOTICED SLIGHT FRONT LEFT BUMPER DAMAGE TO HIS JOCKEY TRUCK (13057). I THEN SPOKE TO THE WITNESS, MR. WILLIAM DAMEWOOD, AND HE STATED HE WAS IN HIS JOCKEY TRUCK BEHIND MR. CHANEY AT THE TIME OF THE COLLISION. HE ADVISED MR REVERE CAME TO A COMPLETE STOP AT THE STOP SIGN AND DROVE FORWARD. AS MR. REVERE WAS DRIVING FORWARD, MR. CHANEY TURNED LEFT INTO HIM CAUSING THE ACCIDENT. HE STATED MR. CHANEY NEVER SLOWED DOWN OR STOPPED BEFORE THE LEFT TURN. ALL THREE PARTIES PROVIDED WRITTEN STATEMENTS ON SCENE, AND POSSESSED VALID TWIC AND GPA CREDENTIALS. I INVENTORIED MR. REVERE'S FORD MUSTANG AND THEN HAD GPAPD DISPATCH CALL FOR A HEAD OUT TOWING SERVICE TO REMOVE HIS VEHICLE. BOTH PARTIES DRIVER'S LICENSES WERE VALID AND THEIR VEHICLES HAD ACTIVE INSURANCE COVERAGE. SAPPS TOWING ARRIVED ON SCENE AND REMOVED THE CAR AND CLEANED THE DEBRIS AND VEHICLE FLUIDS FROM THE ROADWAY.

CLEARED EXCEPTIONAL

ADDITIONAL REMARKS

Report By: OFFICER Jeffrey McCombes Page of

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Injured Taken To By:

EMS Notified Time

Report By:

Witness(es): Name

EMS Arrival Time Hospital Arrival Time Photos Taken: Yes No By:

Department Report Date Checked By: Date Checked

DOT MICROFILM NUMBER (DO NOT WRITE IN THIS SPACE)

Address City State Zip Code Telephone No.

Accident Number Agency NCIC No. GEORGIA UNIFORMMOTOR VEHICLE ACCIDENT REPORT

County Date Rec. By DPS

Date Day of Week Time Off. Arrived Total Number Of: InsideCity Of:Vehicles Injuries Fatalities

Road ofOccurrence

At ItsIntersection

With

Corrected Report?Yes

Suppl. To Original?Yes

o o o o o o oSun M T W Th F S

Not At ItsIntersection But

oo

oo

oo

MilesFeet

o1

12

34

Interstate 2 o o oLowest St. Rt. Co. Road 4 City St.3

NorthSouth

EastWest

And Continuing in theDirection Checked AboveThe Next Reference Point is

Of:

1 2 3 4o o o oInterstate Lowest St. Rt. Co. Road City St.

1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line

1 2 3 4 5o o o o oInterstate Lowest St. Rt. Co. Road City St. Co. Line

Hit and Run?Yes

COMMERCIAL VEHICLES ONLYCarrier NameVehicle #

No. of Axles

Vehicle Config.

Address

C.D.L.?Vehicle Placarded? 1

If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:

Ran Off Road

State Zip

G.V.W.R. Fed. Reportable Cargo Body Type1 o 2 oYes No

I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate

oo

1 o Yes 2 o No C.D.L. Suspended?Hazardous Materials?

Released?

1 o 2Yes o No1

1Yes 2 No

Yes 2 Noo o

o o

Down Hill Runaway Cargo Loss or Shift Separation of Units

Carrier NameVehicle #Address

No. of Axles

Vehicle Config.

C.D.L?Vehicle Placarded?1

If YES, Name or 4 Digit Number from Diamond or Box:1 Digit Number from Bottom of Diamond:

Ran Off Road Down Hill Runaway

o Yes 2 o No

Cargo Loss or Shift Separation ofUnits

State Zip

G.V.W.R.o o1 Yes 2 No

Fed. Reportable Cargo Body Type

I.C.C.M.C. # U.S. D.O.T. # InterstateIntrastate

oo

o o o o

o oo o

o o1 Yes 2 No 1 Yes 2 No

Yes No 1 Yes 2 No1 Yes 2 No

C.D.L. Suspended?Hazardous Materials?

Released?2

Driver #

Ped o

Last Name First Middle Driver #

Ped

Last Name First Middle

Address Address

State Zip DOB State Zip DOB

oo Male State oo Male

o

Female Female

City

Driver's License No.

PostedSpeed

Year

VIN

Tag #

Trailer Tag #

Sameoas Driver

Address

City

Removed By

AlcoholTestDriverConditionVehicleCondition

Most Harmful EventTraffic Control

Insurance Co. Policy No.

Class State

City

Driver's License No.

PostedSpeed

Make Model Telephone No.

Vehicle Color

State County Year

State County Year

Owner's Last Name First Middle

State Zip

o oRequest List

Type Results DrugTest

Type Results

Directionof TravelVehicleManeuver

VisionObscuredPedestrianManeuver

Contributing Factors

Vehicle Class Vehicle TypeDevice Inoperative? o oYes No

Insurance Co. Policy No.

Year Make Model Telephone No.

VIN

Tag #

Trailer Tag #

Address

o Sameas Driver

City

Removed By

AlcoholTestDriverConditionVehicleCondition

Most Harmful EventTraffic Control

Vehicle Color

State County

State County

First

Year

Year

MiddleOwner's Last Name

State

o

Zip

oRequest List

Directionof TravelVehicleManeuver

Vehicle ClassDevice Inoperative?

Contributing Factors

Vehicle Type

Type Results DrugTest

Type Results

o oYes No

VisionObscuredPedestrianManeuver

Class

DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447

SAVANNAH GA 31402 10/05/1972

054077444 C GA

o

20 GEORGIA PORTS AUTHORITY

2013 TICO Jockey Truck 912-695-7056

1T9NS4ASODR825019 WHITE

JO13057

o

75 BRAMPTON RD.

GARDEN CITY GA 31408

PARICK GILMORE GPA ASSISTANT MANAGER

2 0

2181 FOX STREET

2 0

1 4 1 13

1 1 011 1 77

o o

þo

1 CHANEY TERRY

TICO TERMINAL SERVICES

POOLER GA 31322 02/11/1984

052348446 CM GA

o

20 COUNTRY G10A5286460

1999 FORD MUSTANG 330-942-3773

1FAFP4041XF174298 RED

AWG9306 GA CHATHAM 2015

o

2492 QUACCO RD

POOLER GA 31402

SAPPS TOWING

2 0

2492 QUACCO ROAD

2 0

1 3 1 1

1 5 011 1 17

o þ

þo

2 REVERE GEORGE WILLIAM

REVERE JUANITA COSPER

201501030012 GA0250800 CHATHAM

GARDEN CITY0128:348:30þoooooo

01/03/2015

o þ

CHATHAM DRIVEo o o o o o

100 oþ

oo

TOMOCHICHI RDo þ o o o

oo o o o

912-921-084211927 IDLEWOOD DR SAVANNAH, GA 31419DAMEWOOD WILLIAM

SAINT JOSEPHS HOSPITAL SOUTHSIDE FIRE EMS 25-M-60

8:40 8:54

GEORGIA PORTS AUTHORITY POLICE DEPARTMENT

OFFICER Jeffrey McCombes

OFFICER Jeffrey McCombes Lieutenant Mario F Stefanski 01/05/2015

0

0 0 o o 0

0oo

o o o oo o o oo o

00

0

0 0 o o 0

0oo

o o o oo o o oo o

00

01/03/2015

¨

¨

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REMARKS

CITATIONS - VEHICLE # CITATIONS - VEHICLE #

First HarmfulEvent

VEH. # VEH. #

Number of Occupants

Point Of Initial Contact

Damage To Vehicles

SKID DISTANCEBEFORE IMPACT

AFTER Width Of Road

Damage OtherThan Vehicle:

Owner:

Occupants Driver #

Driver #

Or Pedestrian #

Or Pedestrian #

AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAG

Last Name First Address City State Zip

VEH FOR SAFETY AIRTAKEN

VEH.

VEH.

VEH.

VEH.

Traffic-WayFlow

Weather Surface Cond. Light Cond. Manner OfCollision

Location atArea of Impact

RoadComp.

Road Def. Road Character

PAGE OF

X X X X XXXX XXXX XXXX XXXX XXXXX XXXX

Construction/Maintenance Zone

0

Accident No. 201501030012

DOT-523 (12/03) MAIL TO: GEORGIA DEPARTMENT OF TRANSPORTATION, CRASH REPORTING UNIT P.O. BOX 80447, CONYERS, GA. 30013-8447

1 2

11 2 0 1 1 1 1 2 1 11

122

2144

01

01

02

02

1 0 2 1 3 2 02 4 1 1 3 2 2

2 4

VEHICLE #1 WAS TRAVELING WEST ON CHATHAM DRIVE IN THE CHATHAM ICTF YARD, AND VEHICLE #2 WAS TRAVELINGEAST ON CHATHAM DRIVE AND STOPPED AT THE STOP SIGN AT THE ENTRANCE TO THE CHATHAM ICTF YARD. VEHICLE #2PROCEEDED EAST ON CHATHAM DRIVE AND APPROXIMATELY 60 FEET EAST OF THE STOP SIGN VEHICLE #1 MADE ANIMPROPER LEFT TURN CAUSING A COLLISION BETWEEN BOTH VEHICLES. VEHICLE #1 IS AT FAULT FOR THE COLLISION DUETO THE IMPROPER LEFT TURN.

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ADDITIONAL REMARKS

Accident Number Agency NCIC Accident Date Georgia Uniform Motor Vehicle Report Continuation

Report By:Page of

OCCUPANTS

Injured Taken To: By:

Witness - NamePhone

Address

Last Name First Address City State Zip AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAGVEH FOR SAFETY AIRTAKEN

OFFICER Jeffrey McCombes

Attach to DOT-523Attach to DOT-523 DOT-523C (12/03)

201501030012 GA0250800 01/03/2015

3 4

I SPOKE TO THE DRIVER OF VEHICLE #2, MR. GEORGE REVERE, AND HE STATED, THEDRIVER OF VEHICLE #1 DROVE INTO HIS DRIVER'S SIDE DOOR AS HE WAS DRIVING STRAIGHTON CHATHAM DRIVE. HE ADVISED VEHICLE #1 NEVER SLOWED DOWN OR STOPPED, "HE JUSTTURNED RIGHT INTO ME". HE STATED HE BANGED HIS HEAD ON THE DRIVER'S SIDE WINDOWAND HE COMPLAINED OF LOWERED BACK PAIN AND DIZZINESS. I NOTIFIED GPAPD DISPATCHOF THE INJURIES, AND THEY CONTACTED SOUTHSIDE FIRE EMS TO COME TO THE SCENE. INOTICED THE POINT OF IMPACT ON HIS DRIVER'S SIDE DOOR AS WELL AS DAMAGE TO THEFRONT LEFT FENDER, WHEEL WELL, TIRE, RIM, FRONT BUMPER, LEFT FRONT HEADLIGHTS,BROKEN DRIVER'S SIDE WINDOW, BROKEN FRONT WINDSHIELD, AND DAMAGED HOOD. THEREWAS DEBRIS AND VEHICLE FLUIDS LAYING ON THE GROUND APPROXIMATELY 60 FEET EASTOF THE STOP SIGN ON CHATHAM DRIVE. DRIVER #1, MR. TERRY CHANEY, STATED HE WAS DRIVING WEST ON CHATHAM DRIVEABOUT TO TURN LEFT INTO THE CUSTOMS PORTAL AREA. HE STATED HE NEVER SAW MR.REVERE'S MUSTANG. HE INITIALLY STATED TO ME ON SCENE, "I DIDN'T EVEN LOOK OVERTHERE. I JUST TURNED". HE STATED HE THEN FELT THE COLLISION BETWEEN BOTHVEHICLES. MR. CHANEY ADVISED HE WAS NOT INJURED ON SCENE AND REFUSED EMS. IISSUED MR. CHANEY A GEORGIA PORTS AUTHORITY SAFETY VIOLATION NOTICE FORIMPROPER LEFT TURN (CAD0378), BUT HE REFUSED TO SIGN IT ON SCENE. HE THEN CHANGEDHIS TESTIMONY STATING, "HE (VEHICLE#2) DROVE INTO MY TRUCK". I NOTICED SLIGHT FRONTLEFT BUMPER DAMAGE TO HIS JOCKEY TRUCK (13057). I THEN SPOKE TO THE WITNESS, MR. WILLIAM DAMEWOOD, AND HE STATED HE WAS INHIS JOCKEY TRUCK BEHIND MR. CHANEY AT THE TIME OF THE COLLISION. HE ADVISED MRREVERE CAME TO A COMPLETE STOP AT THE STOP SIGN AND DROVE FORWARD. AS MR.REVERE WAS DRIVING FORWARD, MR. CHANEY TURNED LEFT INTO HIM CAUSING THEACCIDENT. HE STATED MR. CHANEY NEVER SLOWED DOWN OR STOPPED BEFORE THE LEFTTURN.

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Report By: Page ofOFFICER Jeffrey McCombesAttach to DOT-523 DOT-523C (12/03)

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ADDITIONAL REMARKS

Accident Number Agency NCIC Accident Date Georgia Uniform Motor Vehicle Report Continuation

Report By:Page of

OCCUPANTS

Injured Taken To: By:

Witness - NamePhone

Address

Last Name First Address City State Zip AGE SEX NO. POS. INJURY TREAT. EJECT EQUIP. EXTRIC. BAGVEH FOR SAFETY AIRTAKEN

OFFICER Jeffrey McCombes

Attach to DOT-523Attach to DOT-523 DOT-523C (12/03)

ALL THREE PARTIES PROVIDED WRITTEN STATEMENTS ON SCENE, AND POSSESSEDVALID TWIC AND GPA CREDENTIALS. I INVENTORIED MR. REVERE'S FORD MUSTANG AND THENHAD GPAPD DISPATCH CALL FOR A HEAD OUT TOWING SERVICE TO REMOVE HIS VEHICLE.BOTH PARTIES DRIVER'S LICENSES WERE VALID AND THEIR VEHICLES HAD ACTIVEINSURANCE COVERAGE. SAPPS TOWING ARRIVED ON SCENE AND REMOVED THE CAR ANDCLEANED THE DEBRIS AND VEHICLE FLUIDS FROM THE ROADWAY.

CLEARED EXCEPTIONAL

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Report By: Page ofOFFICER Jeffrey McCombes 4 4

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GPA MDADT Software Page 1 EMW-2013-PU-00097 15-BM-10175598 01/08/15

Federal Grant Requirements Maritime Domain Awareness Data Tracking

EMW-2013-PU-00097 15-BM-10175598 1. The Georgia Ports Authority (GPA) is updating its current Port Police incident tracking software

Maritime Domain Awareness Data Tracking which is funded by a Federal FEMA Port Security Grant.

2. In accordance with standards set by this Grant, grant recipients and vendors of this project

must comply with all applicable federal standards and regulations:

A. Access to Records (44 CFR Part 13.36(i)(10))

Access by the grantee, the subgrantee, the Federal grantor agency, the Comptroller General of the United States, or any of their duly authorized representatives to any books, documents, papers, and records of the contractor which are directly pertinent to that specific contract for the purpose of making audit, examination, excerpts, and transcriptions.

B. Awarding Agency Reporting Requirements (44 CFR Part 13.36(i)(7))

1. Successful Vendor shall submit semi-annual performance reports to the Georgia Ports Authority Project Manager for the periods ending June 30 and December 31 by the tenth day of the following month.

2. The final performance report will be due 15 days after the earliest of project end date or grant project end date.

3. Performance reports will contain brief information on the following:

a. A comparison of actual accomplishments to the objectives established for the period.

b. The reasons for slippage if established objectives were not met.

c. Additional pertinent information including, when appropriate, analysis and explanation of any anomalies to the period objectives.

C. Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)

Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures and certifications are forwarded from tier to tier up to the recipient. (See attached Certification)

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GPA MDADT Software Page 2 EMW-2013-PU-00097 15-BM-10175598 01/08/15

D. Clean Air Act and the Federal Water Pollution Control Act (44 CFR Part 13.36(i)(12)) Compliance with all applicable standards, orders, or requirements issued under section 306 of the Clean Air Act (42 U.S.C. 1857(h), section 508 of the Clean Water Act (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency regulations (40 CFR part 15).

E. Copyrights (44 CFR Part 13.36 (i)(9) 1. The Federal awarding agency reserves a royalty-free, nonexclusive, and irrevocable

license to reproduce, publish or otherwise use, and to authorize others to use, for Federal Government purposes.

2. The copyright in any work developed under a grant, subgrant, or contract under a grant or subgrant; and

3. Any rights of copyright to which a grantee, subgrantee or a contractor purchases ownership with grant support.

F. Debarment and Suspension (44 CFR Part 13.35)

Guarantees and subgrantees must not make any award or permit any award (subgrant or contract) at any tier to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549, “Debarment and Suspension.” (Attached Certification must also be obtained from all lower tiers).

G. Energy Policy and Conservation Act (44 CFR Part 13.36(i)(13))

Mandatory standards and policies relating to energy efficiency which are contained in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (Pub. L. 94-163, 89 Stat. 871).

H. Records Retention Requirements (44 CFR Part 13.36(i)(11)) Retention of all required records for three years after grantees or subgrantees make final payments and all other pending matters are closed.

I. Rights to Inventions Made Under a Contract or Agreement (44 CFR Part 13.36(i)(8)) Notice of awarding agency requirements and regulations pertaining to patent rights with respect to any discovery or invention which arises or is developed in the course of or under such contract.

J. Termination (44 CFR Part 13.36(i)(2)), 44 CFR Part 13.43, and 44 CFR Part 13.44 GPA may terminate this contract in whole or in part at any time for convenience, or because of the vendor failure or default to fulfill its contract obligations, by written notice to the vendor.

K. Trafficking in Persons (2 CFR Part 175)

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GPA MDADT Software Page 3 EMW-2013-PU-00097 15-BM-10175598 01/08/15

REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF THE OFFERORS

Certification Regarding Lobbying This certification is required for an award of a contract utilizing Federal grant or subrecipient

funding exceeding $100,000. The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form – LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

(3) The undersigned shall require that the language of this certification, be included in the

award documents for all subawards at all tiers (including subcontracts, subgrants, and contacts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Offeror Name: __________________________________________________________________ Signature: _____________________________________________________________________ Printed Name: __________________________________________________________________ Title: __________________________________________________ Date: __________________

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GPA MDADT Software Page 4 EMW-2013-PU-00097 15-BM-10175598 01/08/15

REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF THE

OFFERORS

Certification Regarding Debarment, Suspension, Proposed Debarment, and Other Responsibility Matters-Primary Covered Transactions

1. The prospective primary participant certifies to the best of its knowledge and belief, that it and

its principals: a. Are not presently debarred, suspended, proposed for debarment, declared ineligible,

or voluntarily excluded from covered transactions by any Federal department or agency;

b. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

c. Are not presently indicted for or otherwise criminally or civilly charged by a

governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

d. Have not within a three-year period preceding this application/proposal had one or

more public transactions (Federal, State or local) terminated for cause or default. 2. Where the prospective primary participant is unable to certify to any of the statements in this

certification, such prospective participant shall attach an explanation to this proposal. 3. The undersigned shall require that the language of this certification, be included in the award

documents for all subawards at all tiers (including subcontracts, subgrants, and contacts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

Offeror Name: _________________________________________________________________ DUNS#: _______________________________________________________________________ Signature: _____________________________________________________________________ Printed Name: __________________________________________________________________ Title: __________________________________________________ Date: __________________