Form BLR 05212 Jurisdictional Transfer Agreement (Local Public Agency to Local Public Agency) - Illinois

Form BLR05212 is a Illinois Department of Transportation form also known as the "Jurisdictional Transfer Agreement (local Public Agency To Local Public Agency)". The latest edition of the form was released in October 25, 2018 and is available for digital filing.

Download an up-to-date Form BLR05212 in PDF-format down below or look it up on the Illinois Department of Transportation Forms website.

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Jurisdictional Transfer Agreement
(Local Public Agency to Local Public Agency)
CONVEYOR
RECIPIENT
Local Public Agency No. 1
County
Local Public Agency No. 2
County
In accordance with authority granted in Section 4-409 of the Illinois Highway Code, this agreement is made and entered into between the
above Local Public Agency No. 1 hereinafter referred to as "Conveyor" and the above Local Public Agency No. 2, hereinafter referred to as
"Recipient", to transfer the jurisdiction of the designated location from the Conveyor to the Recipient.
Location Description
Road Name
Route(s)
Length
Key Route(s) Information
Termini
This transfer
does not
does include NBIS Structure No(s).
Include for Municipalities Only
WHEREAS, the authority to make changes to the Municipal Street System is granted to the Municipality of Section 7-101 of the Illinois
Highway Code.NOW THEREFORE IT IS AGREED that the corporate authority of said municipality will pass an ordinance providing for the
transfer of the above location and shall attach hereto and make a part thereof a copy of a location map as Addendum No. 1 and an original
of the ordinance as Addendum No. 2 and
Include for Counties Only
WHEREAS, the authority to make changes to the County Highway System is granted to the County by Section 5-105 of the Illinois
Highway Code.NOW THEREFORE IT IS AGREED that the County Board of said County will pass a resolution providing for the transfer of
the above location and shall attach hereto and make a part thereof a copy a location map as Addendum No. 1 and an original of the
resolution as Addendum No. 2, and
Include for Township/Road Districts Only
WHEREAS, the authority to make changes to the Township/Road District System is granted to the Highway Commissioner under Section
6-201.3 of the Illinois Highway Code. The Conveyor Agrees to prepare a map of the above location and attach a copy of such location map
hereto. IT IS MUTUALLY AGREED, that this jurisdictional transfer will become effective (check one):
Upon IDOT approval
calendar days after
other
Attachments
Additional information and/or stipulations, if any, are hereby attached and identified below as being a part of this agreement.
Location Map (Addendum No.1)
Ordinance/Resolution (Addendum No. 2)
IT IS FURTHER AGREED, that the provisions of this agreement shall be binding upon and insure to the benefit of the parties hereto, their
successor and assigns.
Signatures
APPROVED BY CONVEYOR
APPROVED BY RECIPIENT
APPROVED
STATE OF ILLINOIS
Name of Local Public Agency Official
Name of Local Public Agency Official
DEPARTMENT OF TRANSPORTATION
Title
Title
Director
Local Public Agency Official
Date
Local Public Agency Official
Date
Office of Program Development
Date
Printed 06/05/19
BLR 05212 (Rev. 10/25/18)
Page 1 of 1
Jurisdictional Transfer Agreement
(Local Public Agency to Local Public Agency)
CONVEYOR
RECIPIENT
Local Public Agency No. 1
County
Local Public Agency No. 2
County
In accordance with authority granted in Section 4-409 of the Illinois Highway Code, this agreement is made and entered into between the
above Local Public Agency No. 1 hereinafter referred to as "Conveyor" and the above Local Public Agency No. 2, hereinafter referred to as
"Recipient", to transfer the jurisdiction of the designated location from the Conveyor to the Recipient.
Location Description
Road Name
Route(s)
Length
Key Route(s) Information
Termini
This transfer
does not
does include NBIS Structure No(s).
Include for Municipalities Only
WHEREAS, the authority to make changes to the Municipal Street System is granted to the Municipality of Section 7-101 of the Illinois
Highway Code.NOW THEREFORE IT IS AGREED that the corporate authority of said municipality will pass an ordinance providing for the
transfer of the above location and shall attach hereto and make a part thereof a copy of a location map as Addendum No. 1 and an original
of the ordinance as Addendum No. 2 and
Include for Counties Only
WHEREAS, the authority to make changes to the County Highway System is granted to the County by Section 5-105 of the Illinois
Highway Code.NOW THEREFORE IT IS AGREED that the County Board of said County will pass a resolution providing for the transfer of
the above location and shall attach hereto and make a part thereof a copy a location map as Addendum No. 1 and an original of the
resolution as Addendum No. 2, and
Include for Township/Road Districts Only
WHEREAS, the authority to make changes to the Township/Road District System is granted to the Highway Commissioner under Section
6-201.3 of the Illinois Highway Code. The Conveyor Agrees to prepare a map of the above location and attach a copy of such location map
hereto. IT IS MUTUALLY AGREED, that this jurisdictional transfer will become effective (check one):
Upon IDOT approval
calendar days after
other
Attachments
Additional information and/or stipulations, if any, are hereby attached and identified below as being a part of this agreement.
Location Map (Addendum No.1)
Ordinance/Resolution (Addendum No. 2)
IT IS FURTHER AGREED, that the provisions of this agreement shall be binding upon and insure to the benefit of the parties hereto, their
successor and assigns.
Signatures
APPROVED BY CONVEYOR
APPROVED BY RECIPIENT
APPROVED
STATE OF ILLINOIS
Name of Local Public Agency Official
Name of Local Public Agency Official
DEPARTMENT OF TRANSPORTATION
Title
Title
Director
Local Public Agency Official
Date
Local Public Agency Official
Date
Office of Program Development
Date
Printed 06/05/19
BLR 05212 (Rev. 10/25/18)
Page 1 of 1
BLR 05212
This form shall be used when a Local Public Agency (LPA) and another Local Public Agency desire a jurisdictional transfer of a roadway.
For more information see Chapter 5 of the Bureau of Local Roads and Street Manual (BLRS Manual). For signature requirements, refer to
Chapter 2, Section 3.05(b) of the BLRS Manual.
Conveyor
Local Public Agency No. 1
Insert the name of LPA who is the conveyor for the jurisdictional transfer
County
Insert the name of the county in which the LPA is located.
Recipient
Local Public Agency No. 2
Insert the name of LPA who is the recipient for the jurisdictional transfer
County
Insert the name of the county in which the LPA is located.
Location Description
Local Name
Insert the local(common) name of the roadway involved in the transfer.
Route
Insert the route number of the roadway involved in the transfer.
Length
Insert the length of the transfer in miles to the nearest hundredth.
Key Route Information
Insert the key route(s) information of the roadway involved in the transfer. This information will need to be
obtained from the Department of Transportation. It will be a 14 digit code.
Termini
Insert the beginning and ending termini of the transfer. When describing the limits of the jurisdictional transfer
the wording of the termini description should be consistent between the agreement itself and any ordinances,
or resolutions that may be included with the agreement. If not enough room insert page.
Structure Transfer
Check the appropriate box as to the status of the transfer of any structures located within termini of the
roadway transfer. List structures on the line provided. If no structure exists then insert N/A on the line. Any
structure not specifically excluded is considered part of the jurisdictional transfer. The number must
be the NBIS number. If there is not enough room to list all NBIS structures, then attach list of structures on a
separate piece of paper as an addendum.
Effective Jurisdictional
Transfer Date
Check the appropriate box as to when the jurisdictional transfer will become effective. For a number of
calendar days transfer insert the number of calendar days and the date after. For other check the box and
insert when effective, example upon final acceptance.
Attachments
List any additional information and/or stipulations that are part of this agreement.
Signatures
Local Public Agency
(Conveyor)
The LPA shall insert their name, title then sign and date.
Local Public Agency
(Recipient)
The LPA shall insert their name, title then sign and date.
State of Illinois
Upon approval the Department of Transportation shall sign and date here.
Attachments:
Attach as required a location map of the jurisdictional transfer as Addendum No.1, and if required a
resolution or ordinance as Addendum No. 2, along with any other required attachments. All attachments
must be legible and in black and white.
A minimum of three (3) signed originals must be submitted to the Regional Engineer's District office.
Following the IDOT's Approval, distribution will be as follows:
Local Public Agency Clerk (one for each LPA)
District File (Electronically after execution)
Bureau of Local Roads and Streets Central Office
Bureau of Operations District Office (Electronically after execution)
District Roadway Inventory (Electronically after execution)
Printed 06/05/19
BLR 05212 (Rev. 10/25/18)

Download Form BLR 05212 Jurisdictional Transfer Agreement (Local Public Agency to Local Public Agency) - Illinois

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