K-5 - Title VI Non-Discrimination Agreement - Appoint Title VI Coordinator - North Park Road Improvements 2 3

Form 131024 (07-12) Title VI Non-Discrimination Agreement Iowa Department of Transportation and CITY of TIFFIN, IOWA Agency Information Name and title of adminstrative head: Name: Tim Kasparek Title: Mayor, City of Tiffin, Iowa Address: 300 Railroad Street City: Tiffin State: IA ZIP Code: 52340 County: JOHNSON COUNTY Phone/FAX: 319-359-0820/na Email: [email protected] Name and title of designated Title VI coordinator: Name: Doug Boldt Title: Title VI Coordinator/City Administrator Address: 300 Railroad Street City: Tiffin State: IA ZIP Code: 52340 County: JOHNSON COUNTY Phone/FAX: 319-545-2572 ext 2/na Email: [email protected] *If the Title VI coordinator changes, please contact the Iowa DOT Title VI specialist. Title VI Program I. Organization and staffing Pursuant to 23 C.F.R. § 200, CITY of TIFFIN, IOWA has appointed a Title VI coordinator identified above, who is responsible for implementing and monitoring the local public agency's (LPA’s) Title VI program per this agreement, and is the representative for issues and actions pertaining to this agreement. The LPA will provide the Iowa Department of Transportation with a copy of the LPA’s organizational chart that illustrates the level and placement of the Title VI coordinator. The LPA will notify the Iowa DOT in writing of any changes to the LPA’s organization chart, Title VI coordinator or Title VI coordinator contact information. II. Assurances required Pursuant to 49 C.F.R. § 21.7, every application for federal financial assistance or continuing federal financial assistance must provide a statement of assurance and give reasonable guarantee that the program is (or, in the case of a new program, will be) conducted in compliance with all requirements imposed by or pursuant to 49 C.F.R. § 21 (Nondiscrimination in Federally Assisted Programs of the Department of Transportation – Effectuation of Title VI of the Civil Rights Act of 1964). Fully executed standard DOT Assurances (including Appendices A, B and C) are attached to this agreement. Page 1 of 7