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Do not recreate or revise this document; revisions and recreations will not be accepted. Copying this form is acceptable; see(2)below. Failure to complete and return the necessary documents per instructions will result in your county not receiving an Incentive Payment for Calendar Year 2021. Documents include the original Signing Resolution, Year-End Certification(s), and a copy of documentation of the appointment(s)of the County Highway Superintendent(s);they must be received at the NDOT by December 31,2021. Year-End Certification of County Highway Superintendent For Determining Incentive Payment January 1,2021 to December 31, 2021 *(1)(a)Certification of the county of HALL that: COUNT .BOARD --__ _ was '�'re ,S-.3= _ _ coags ol..c.e se _ ,.,;:ab,a the appointed County Highway Superintendent from OCTOBER 7 , 2021 to ._D- EM$FR 3] ,2021, (b)the above listed person is not D or is a Licensed County Highway Superintendent, License Number S- - Class , s ,: _ a.-.:.a - .,'in:,6 irce,:ses: :4 (c)the above listed person is not ❑or is a Licensed Engineer in Nebraska, License Number E- , (d)the superintending services of the above listed person were provided by: !.Checi< ci6e boy! ® Employment ❑ Contract ❑ Contract(interlocal agreement)between this with this (consultant) County and the following listed County(ies) County with this and/or Municipality(ies) County (e)the above listed individual assisted in the following: Reference Neb. Rev. Stat. §39-2502 1. Developing and annually updating a long-range plan based on needs and coordinated with adjacent local governmental units, 2. Developing an annual program for design,construction,and maintenance, 3. Developing an annual budget based on programmed projects and activities, 4. Submitting such plans,programs, and budgets to the local governing body for approval;and 5. Implementing the capital improvements and maintenance .- ' i ie •rovided in the approved plans, programs, and budgets. Signature of County '.ard Chairperson *(2) If your county had a licensed superintendent for a portion of the calendar year; had two or more successive licensed superintendents;and/or did not have an appointed Highway superintendent for any portion(s)of the year, complete a separate Year- End Certification form for EACH appointed county highway superintendent AND for any period without an appointed county highway superintendent. For any period of time your county did not have an appointed highway superintendent, write "County Board" as the name of the"Superintendent." Copy this form as needed to account for these separate periods. (3) The payment amount will be computed based on (a) your most recent Federal Census, rural population; (b)the number of full calendar months served by the appointed superintendent who is licensed or exempted from licensure under the Superintendents Act; (c) class of license, A or B; (d)whether your Superintendent is employed, or under contract(consultant or interlocal agreement with another county and/or incorporated municipality); and(e)if the appointed County Highway Superintendent assisted with the required duties in (1)(e)above. Reference Neb. Rev. Stat. §§39-2302 and 39-2501 through 39-2505. (4) Failure to return the Year-End Certification(s),Signing Resolution,and a copy of documentation of the appointment(s)of the superintendent(s)per the instructions will result in your county not receiving an Incentive Payment. >-,E Return the completed original resolution and certification(s), and a �F SHL s�'•r``'v 47�`�.,- s p-A copy of the documentation of appointment(s) by December 312021 to: f ' f,i `L+ - >. a Highway Local Liaison Coordinator t:::.4,11....* . ` Boards-Liaison Services Section ' Local Assistance Division • ~alb•,� ' Nebraska Department of Transportation PO Box 94759 Lincoln NE 68509-4759 Page 2 of 3