Backup Documents 02/10/2015 Item #16D5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 6 0
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initi is Date
1. Peggy Hager CHS (5216 f/S
2. Jennifer A. Belpedio, ACA County Attorney Office S 15
3. BCC Office Board of County ` r�j
Commissioners v,\I z k a\kms'
4. Minutes and Records Clerk of Court's Office
2.046 ZPr
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff 1 Phone Number Please call for pick up
Contact/ Department Lisa Oien 252-6141
Agenda Date Item was / Agenda Item Number
Approved by the BCC 2/10/2015 ✓ _= 1-
Type of Document Four Signature Authority forms-4 originals Number of Original 16 grant modifications
Attached each for DRI A,Z,K and DREF-Frar Documents Attached
(o'riginignatures needed)
PO number or account's-
number
ccountsnumber if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. i ,,) Ap, licable)
1. Does the document require the chairman's original signature? , /1'I+4 1 `.
2. Does the document need to be sent to another agency for additional signatures? If yes, I /
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman,with the exception of most letters,must be reviewed and signed o
by the Office of the County Attorney. .
4. All handwritten strike-through and revisions have been initialed by the County Attorney's
Office and all other parties except the BCC Chairman and the Clerk to the Board V Y
5. The Chairman's signature line date has been entered as the date of BCC approval of the r/
document or the final negotiated contract date whichever is applicable. /(9-.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's
signature and initials are required. ��
7. In most cases(some contracts are an exception),the original document and this routing slip t/
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain ,}&_
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 2 1'0 and all changes made during (� , zs no
cue. „�/
the meeting have been incorporated in the attached document. The County
Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made, and the document is ready for the
Chairman's signature. �....
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
1 6 0 5
MEMORANDUM
Date: February 16, 2015
To: Lisa Oien, Grants Coordinator
Housing, Human & Veteran Services
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: DEO — Small Cities Development Block Grant Program
Attachment L — Signature Authority Forms
Disaster Recovery Initiative for the following contracts:
Contract #07DB-3V-09-21-01-Z01
Contract #08DB-D3-09-21-01-A03
Contract #10DB-D4-09-21-01-K09
Contract #12DB-P5-09-21-01-K39
Attached is four (4) original documents of each contract referenced above, (Item
#16D5) approved by the Board of County Commissioners on Tuesday, February 10,
2015.
Forward a fully executed original to the Minutes and Record's Department to be
kept as part of the Board's Official Record.
If you have any questions please call me at 252-7240.
Thank you.
Attachment
160 5
Department of Economic Opportunity—Small Cities Development Block Grant Program
ATTACHMENT L-SIGNATURE AUTHORITY FORM
Submit an ori inai Signature AuthorityForm with each contract.
Recipient 1Contract# I Funding Source
Board of Collier County Commissioners I 07DB-3V-09-21-01-Z01 I [ ] Small Cities CDBG •
•
Mailing Address(Street or Post Office Box) [X] Disaster Recovery •
3339 Tamiami Trail East Suite 211 [ ] Neighborhood Stabilization
City, State and Zip Code 1 Local Government DUNS #
Naples, FL 34112 1 076997790
Project Contact Person I Telephone # E-mail Address
Lisa Oien, Grants Coordinator 239-252-6141 lisaoien@colliergov.net
1 Collier County Housing, Human
1 and Veteran Services
Financial Contact Person Telephone # E-mail Address
Bendisa Marku,Supervisor 239-252-2689 bendisamarku@colliergov.net
1 Accountant, Collier County •
Housing, Human and Veteran •
•
I Services ,••
I Other Local Government Contact Telephone # E-mail Address •
Kristi Sonntag, Grants Manager 239-252-2486 kristisonntag@colliergov.net
1 Collier County Housing, Human 1 i
1 and Veteran Services i
1 Requests for Funds(RFFs) require (check one); [ ]one signature[X]two signatures by individuals authorized below.
1 RFFs must be submitted via the Department's website at http://ecdbg.dca.state.fl.us/(or by an alternative means specified by
1 the Department).
•
Typed Name ? Da I Si. �j re
'/I
BendisaMarkinSupervisor Accountant ...................................................................... .... �?......_...__._._.._.... ...,0r....:�1 ......._.. .........._ . .... -' ..__.....__.............__......._.__._
I [X]Check here if above person is authorized to submit RFFs E-mail Address
1 bendisamarku@colliergov.net
Typed Name Date Signature i -
Edmond Kushi, Accountant if gfrr i. "lel
[X]Check here if above person is authorized to submit RFFs E-mail Address
edmondkushi@cpllielgpv.net ., •
Typed Name Date 1 Signature
Lisa Oien Grants Coordinator i 9,f`- i e`c- 1� -- •
[ ]Check here if above person is authorized to submit RFFs i E-mail Address Y
lisaoien@collier ov.net i
Typed Name l Date I Signature
•
I
[ ]Check here if above person is authorized to submit RFFs 1 E-mail Address
I certify, as the recipient's Chief Elected Official,that the above signatures are of the individuals authorized to sign Requests for
1 Funds and to submit RFF's electronicall .
Typed Name 1 Date j Signature-- /��
Ta f Co...er ,Chairman i .2/0 /706,5 1 �/2/
Board of Collier County Commissioners / i
I [X]Check here if your local government utilizes Electronic Funds Transfer(EFT)from the State of Florida.
I [X]Check here if your local government will be working on a reimbursement basis.
CDBG payments to local governments using EFTare automatically deposited in the local government's general account. If the
account is interest bearing,the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG •
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http://flair.dbf.state.fl.us/. Local governments not receiving EFT, and not working on a reimbursement basis,must
1 establish a non-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
signatures on the account must be bonded.
Name of Financial Institution. i Account Number
Fifth Third Bank 113-8577
Street Address or Post,Office Box Telephone Number
999 Vanderbilt Beach:Road 239-591-6397
City, State and Zip Code
Naples, Florida341Q
Approved as to form and legality
Revised Apr' 2011
W Writ
' I,, ' est as Chairman's Assistant Co Attorney .=.2% ,
, . '.
-5 - nra only. �
160 5
Department of Economic Opportunity—Small Cities Development Block Grant Program
ATTACHMENT L-SIGNATURE AUTHORITY FORM
Submit an original Si nature Authority Form with each contract.
Recipient Contract# iFunding Source
Board of Collier CountyCommissioners 08DB-D3-09-21-01-A03 [ ]Small Cities CDBG
......................_.......... ...........
I Mailing Address(Street or Post Office Box) .. [X] Disaster Recovery
3339 Tamiami Trail East, Suite 211 ' [ ]Neighborhood Stabilization
City,State and Zip Code Local Government DUNS #
Naples, FL 34112 076997790
Project Contact Person ; Telephone # E-mail Address
Lisa Oien, Grants Coordinator 239-252-6141 lisaoien@colliergov.net
Collier County Housing, Human
and Veteran Services
Financial Contact Person Telephone # ; E-mail Address
Bendisa Marku,Supervisor 239-252-2689 bendisamarku@colliergov.net
Accountant,Collier County
Housing, Human and Veteran
Services
Other Local Government Contact Telephone # j E-mail Address
Kristi Sonntag, Grants Manager I 239-252-2486 kristisonntag@colliergov.net
Collier County Housing, Human •
and Veteran Services
Requests for Funds(RFFs) require (check one); [ ]one signature[X]two signatures by individuals authorized below.
RFFs must be submitted via the Department's website at http://ecdbg.dca.state.fl.us/(or by an alternative means specified by
the Department).
i
Typed Name Dat Si re
YP /7,
9
0% , "Zi..4.,
Bendisa Markus,._Supervisor Accountant .................._............._............................._....._?... .......�'�....._ .. .
[X]Check here if above person is authorized to submit RFFs aidress
bendisamarku@collier ov.net
Typed Name Dat , Signature
Edmond...Kushi„.....Accountant _._. I 9 L ......................_l._ Mae.._....._..............__...._..:.... . . ._-._..._...._._................._.................................._..........
[X]Check here if above person is authorized to submit RFFs E-mail Address
; edmondkushi@collier ov.net
Typed NameDate i Signaturenature
Lisa Oienrants Coordinator
9 /s
G
[ ]Check here if above person is authorized to submit RFFs E-mail Address
lisaoien@colliergov.net
Typed Name Date 1 Signature
I
[ ]Check here if above person is authorized to submit RFFs E-mail Address
•
•
I certify, as the recipient's Chief Elected Official,that the above signatures are of the individuals authorized to sign Requests for
Funds and to submit RFPs electronicall .
Typed Name I Date j Signatures/-</
-77,-)7 AnNc-z= , Chairman
ZA)/Zoos I
Board of Collier County Commissioners '
7 (71-ee
[X]Check here if your local government utilizes Electronic Funds Transfer(EFT)from the State of Florida.
[X]Check here if your local government will be working on a reimbursement basis.
CDBG payments to local governments using EFTare automatically deposited in the local government's general account. If the
account is interest bearing,the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http://flair.dbf.state.fl.us/. Local governments not receiving EFT,and not working on a reimbursement basis, must
establish a non-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
si natures on the account must be bonded.
Name of Financial InstitutionAccount Number
Fifth Third Bank "�-- ..... 1 113-8577
Street Address or Post Offiee'Btix I Telephone Number
999 Vanderbilt Beach Road' 239-591-6397
City, State and Zip Code
! Naples F Ida,. 108 Approved as to form and legality
DWIGHT a - Revised April 2011
sOtstItt
est as to Chairman's ' Q ��
v
B:- 0 I.itatur• only Assistant County R. ,rney ,z , � p`�`
160 5
Department of Economic Opportunity—Small Cities Development Block Grant Program
ATTACHMENT L-SIGNATURE AUTHORITY FORM
Submit an original Signature Authority Form with each contract.
1 Recipient I Contract# 1 Funding Source
Board of Collier County Commissioners ; .10DB-D4-09-21-01-K09 __ j [ ]Small Cities CDBG
Mailing Address(Street or Post Office Box) [X]Disaster Recovery
' 3339 Tamiami Trail East Suite 211 [ ]Neighborhood Stabilization
City, State and Zip Code Local Government DUNS#
Naples, FL 34112 076997790
Project Contact Person —I Telephone # . E-mail Address
Lisa Oien,Grants Coordinator 239-252-6141 lisaoien@colliergov.net
Collier County Housing, Human
andVeteran Services _-_._._...._.....____.------..._........................................_-._.._.....__...__...._..._.__.___.......-._....___i._.._.______.—.—_— __...___..._...........___..___...._._-..._......__............_�
Financial Contact Person Telephone # E-mail Address
Bendisa Marku,Supervisor j 239-252-2689 bendisamarku@colliergov.net
Accountant, Collier County
Housing, Human and Veteran
Services _ ---.____._._._._._..._._..........._......_._.—_—._._._._.........._..._ :.---------...—__..........._..—.__.__._._._..__..._..___._____.___.._
Other Local Government Contact Telephone #
E-mail Address
Kristi Sonntag, Grants Manager 239-252-2486 kristisonntag@colliergov.net
Collier County Housing, Human
andVeteran Services _ ..... ..I..-....,..-_.__..........._....._.._..-- _.....-...._.—_........................_..._.___..........._._._._._........_...._.............__....._._____—.............._.__......._..._.._—_.______'
Requests for Funds(RFFs) require (check one); [ ]one signature[X]two signatures by individuals authorized below.
RFFs must be submitted via the Department's website at htto://ecdbg.dca.state.fl.us/(or by an alternative means specified by
the Department).
Typed Name I Datp, ( Sig e
Bendisa Marku,Supervisor Accountant _._........._ 1_,/ ... ..�....1,1 _,���C ���� ........... _.._ —.__..._.
[X]Check here if above person is authorized to submit RFFs ( E-mail Address
! bendisamarku@colliergov.net_
Typed Name I DatR r Signa
Edmond Kushi.,. Accountant gf/, —_.,,,,.--,_,. (�Q�,
[X]Check here if above person is authorized to submit RFFs E- ai Address
-_! edmondkushi@collie_r_gpv.net
Typed Name Date ,- 1 Signature -
Lisa Oien, Grants Coordinator --- ..._..__..._....__.__—._.___....__— ..._..../Y/ !--_—......._..._...._....__-.-.._ _
[ ]Check here if above person is authorized to submit RFFs E-mail Address
lisaoien@colliergov.net
Typed Name Date [ Signature
[ ]Check here if above person is authorized to submit RFFs E-mail Address
I certify, as the recipient's Chief Elected Official,that the above signatures are of the individuals authorized to sign Requests for
Funds and to submit RFPs electronically__
Typed Nae j Date � Signatur _
-77m 4/ C , Chairman /gid/r®/-
Board of Collier County Commissioners
i [X Check here if your local government utilizes Electronic Funds Transfer(EFT)from the State of Florida.
[X]Check here if your local government will be working on a reimbursement basis.
CDBG payments to local governments using EFTare automatically deposited in the local government's general account. If the
account is interest bearing,the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http://flair.dbf.state.fl.us/. Local governments not receiving EFT,and not working on a reimbursement basis,must
establish a non-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
signatures on the account must be bonded,
Name of Financial Institution r Account Number
Fifth Third Bank j-113-8577
Street Address or Post Office Box I Telephone Number
999 Vanderbilt Beach Roadj°-... 1 239-591_6397
k City, State and Zip Code Approved as to form and legality i
INaples. For ,08 . . ...... _............_...._... .-..__—................._... --.__... —......... —--._..__._...-._..._._.._--....._ —..-.............. _-.1
.._..__._._. Revised Apri,11
DWIGHT E. BROCKC, ; Attest as to Chairman's %C�
.,VAssistant County ey �'" cA(
v; �)14nature only.
160 5
Department of Economic Opportunity-Small Cities Development Block Grant Program
ATTACHMENT L-SIGNATURE AUTHORITY FORM
Submit an ori inal Signature Authon Form with each contract. -.
':. Recipient 1 Contract# Funding Source
Board of Collier County Commissioners ' 12DB-P5-09-21-01-K39 [ ]Small Cities CDBG
I Mailing Address(Street or Post Office Box) X] Disaster Recovery
3339 Tamiami Trail East, Suite 211 [ 'Neighborhood Stabilization
City, State and Zip Code Local Government DUNS #
Naples, FL 34112 076997790
•
•
Project Contact Person 1 Telephone # E-mail Address
1 Lisa Oien, Grants Coordinator 1 239-252-6141 lisaoien@colliergov.net
Collier County Housing, Human
1and Veteran Services 1
I Financial Contact Person i Telephone # E-mail Address
Bendisa Marku,Supervisor 1 239-252-2689 bendisamarku@colliergov.net
Accountant,Collier County
Housing, Human and Veteran
Services 1
1 Other Local Government Contact 1 Telephone # E-mail Address
Kristi Sonntag, Grants Manager 1 239-252-2486 1 kristisonntag@colliergov.net
1Collier County Housing, Human
and Veteran Services •
Requests for Funds(RFFs) require (check one); [ ]one signature [X]two signatures by individuals authorized below.
RFFs must be submitted via the Department's website at http://ecdbg.dca.state.fl.us/(or by an alternative means specified by
the Department).
Typed Name Dat ! Signa / .,,,Liwit,_
1 Bendisa Mark. Su ervisor Accountant
1 [X]Check here if above person is authorized to submit RFFs mail Address
• bendisamarku@colliergov.net
1 Typed Name
__ ......_ ...._ ......._ ....... . ............_ _......._......._D..-a
,....,...............................Signatur-
......_ r_ ... . .........._.
,
EdmondKushi�....Account nt � � r 50
I [X]Check here if above person is authorized to submit RFFs E-ma
Address 4 —
•
edmondkushi@collier ov.net
r
1 Typed Name Date
_ Si nature
YP
9
in rnCoordinator - c== _Lisa 0 e Gats -/S
[ ]Check here if above person is authorized to submit RFFs E-mail Address
lisaoien@colliergov.net....................................-...._...__..................._.-..............................._......._..-.__..-..--....._....................-........................_............
Typed Name Date 1 Signature
[ ]Check here if above person is authorized to submit RFFs E-mail Address
I certify, as the recipient's Chief Elected Official,that the above signatures are of the individuals authorized to sign Requests for
1 Funds and to submit RFF's electronically.
1 Typed Name 1 DateSignature -------
/,ni IV ii-A10-- -- , Chairman 7,o/fa/I- /
l
—e.
Board of Collier County Commissioners
[X]Check here if your local government utilizes Electronic Funds Transfer(EFT)from the State of Florida.
[X]Check here if your local government will be working on a reimbursement basis.
1 CDBG payments to local governments using EFTare automatically deposited in the local government's general account. If the
account is interest bearing,the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
1 Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http://flair.dbf.state.fl.us/. Local governments not receiving EFT, and not working on a reimbursement basis, must
establish a non-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
1 si natures on the account must be bonded. ..
Name of Financial Institution I Account Number
Fifth Third Bank ,' . 1 113-8577
1 Street Address or Post Office Box e 1. ''tlr;�•• ? : Telephone Number
999 Vanderbilt Beach-Road `....`.... 1._.239-591-6397 . _.._.........__......_...._.._... ._-.._..__..............
Na les, Fe and Zip Code Approved as to form and a!
_tX...............................
Revised April 2011
DWIGHT E. BROCK, —� c�\\� CAS'
B Attest as to Chairman's 0
Assistant county A
BY _ si9ilature only. � y � `\