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Backup Documents 06/23/2015 Item #16D 6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 160 THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNAT 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 Initials Date 1. Peggy Hager Community & Human Services Division (CHSD) 6//�/� 2. County Attorney Office County Attorney Office 2.3 1� 3. BCC Office Board of County -114 Commissioners \n4/5/ 0-43\6 4. Minutes and Records Clerk of Court's Office ��nn ttI 1 111V (e/245 l5 3'ssfnl 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 Rosa Munoz,CHS Phone Number 252-5713 Contact/ Department Agenda Date Item was June 23,2015 Agenda Item Number 16D6 Approved by the BCC Type of Document Amendment#2 to DLC Agreement- Number of Original 3 Attached Community Access Administrative Services Documents Attached Program PO number or account • number if document is AltLi 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. (Initial) Applicable) 1. Does the document require the chairman' riginal signature? S1A1V () RM 2. Does the document need to be sent to another agency for additional signatures? If yes, N/A 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 RM signed by the Chairman, with the exception of most letters, must be reviewed and signed by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A Office and all other parties except the BCC Chairman and the Clerk to the Board 5. The Chairman's signature line date has been entered as the date of BCC approval of the RM document or the final negotiated contract date whichever is applicable. 6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's RM signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip RM 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 06/23/15 and all changes made RM during 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 th Chairman's signature. ,1 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 MEMORANDUM 1 6 D Date: June 24, 2015 To: Rosa Munoz, Grant Coordinator Housing, Human & Veteran Services From: Martha Vergara, Deputy Clerk Minutes & Records Department Re: Amendment #2 to Agreement between Collier County and David Lawrence Mental Health Center, Inc. Grant #B-14-UC-12-0016 Agmt #CD14-07PS Attached are two (2) original amendment to the agreement referenced above, (Item #16D6) approved by the Board of County Commissioners on Tuesday, June 23, 2015. An original has been kept by the Minutes and Records Department for the Official Records of the Board. If you have any questions, please feel free to contact me at 252-7240. Thank you. Attachment 160 6 Grant# - B-14-UC-12-0016 CFDA/CSFA# - 14.218 Subrecipient—David Lawrence Mental Health Center, Inc. Agreement#CD14-07PS FAIN: NO DUNS # - 096580782 IDIS#486 FEID FEIN# - 59-2206025 Fiscal Year End: 06/30 Monitor End: 09/2015 SECOND AMENDMENT TO AGREEMENT BETWEEN COLLIER COUNTY AND DAVID LAWRENCE MENTAL HEALTH CENTER, INC. k. THIS AGREEMENT is made and entered into this Q3r day of 2015, by and between David Lawrence Mental Health Center, Inc., a private not- or-profit corporation existing under the laws of the State of Florida, herein referred to as SUBRECIPIENT and Collier County, Florida, herein to be refered to as "COUNTY," collectively stated as the "Parties." WHEREAS, the County entered into an agreement with Community Development Boock Grant Program (CDBG) funds to be used for Community Access Administrative Services Program Project (hereinafter referred to as the "Agreement"); and WHEREAS, in accordance with HUD regulations and the Collier County Consolidated Plan concerning the preparation of various Action Plans, the County advertised a substantial amendment on May 19, 2015 with a 30-day Citizen comment period from May 19, 2015 to June 19, 2015; and WHEREAS, the Parties desire to amend the Agreement to decrease CDBG funding, beneficiaries, and to revise language in agreement; and NOW, THEREFORE, in consideration of foregoing Recitals, and other good and valuable consideration, the receipt and sufficiency of which is hereby mutually acknowledged, the Parties agree to amend the Agreement as follows: Words Sal-through are deleted; Words Underlined are added *All references to Housing, Human and Veteran Services (HHVS) throughout agreement shall now read Community and Human Services Division (CHSD). *All references to Department throughout the agreement shall now read Division. DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 1 of 16 S 1 k 4.: PART I SCOPE OF WORK The Subrecipient shall, in a satisfactory and proper manner and consistent with any standards required as a condition of providing CDBG assistance, as determined by Collier County Housing, Human and Veteran Services (HHVS) Community and Human Services Division (CHSD), to perform the tasks necessary to conduct the program as follows: SCOPE OF SERVICES 1.1 SPECIAL GRANT CONDITIONS A. Within thirty (30) calendar days of the execution of this agreement, the Subrecipient must deliver to HHVS CHSD for approval a detailed project schedule for the completion of the project. B. The following resolutions and policies must be adopted by the Subrecipient's governing body within thirty (30) days of conveyance: 17 1. Affirmative Fair Housing Policy IX 2. Affirmative Action/Equal Opportunity Policy • 3. Conflict of Interest Policy I 4. Equal Opportunity Policy • 5. Procurement Policy 17 6. Residential Anti-displacement and Relocation Policy • 7. Sexual Harassment Policy Fl 8. Procedures for meeting the requirements set forth in Section 3 of the Housing and Urban Development Act of 1968, as amended (12 U.S.C. 794 1 u) • 9. Procedures for meeting the requirements set forth in Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794) • 10. Fraud Policy 1.2 PROJECT DETAILS A. Project Description/Budget Public Services Federal Funds Project Component One: Salaries $64,590$50,590 Funding costs will include but not limited to the following expenses: Fund 2 Full Time (FT) Benefits Managers, partial salary for Quality DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 2 of 16 6 Improvement and Program Support Director. 1 6 0 Project Component Two:Supplies $22,500 Funding costs will include but not limited to the following expenses: purchase and set up of computer kiosks at various David Lawrence Center locations. Project Component Three:Posta,'e/Freijiht/Shippini' $2,712 Funding costs will include but not limited to the following expenses: All costs associated with postage, freight and shipping. Total: $89,802 $75,802 The Subrecipient will accomplish the following project tasks: Project Tasks 1. Maintain and provide to the County resident income certification or presumed eligibility documentation (Exhibit E) or documentation of Census Track meetings, as requested 1. Subrecipient will pay all closing costs related to the conveyance of the properties. 2. Maintain and provide to the County resident income certification or presumed eligibility documentation (Exhibit E) 3. Provide quarterly reports on progress, national objectives, and procurement thresholds (Exhibit C) 4. Required attendance by a representative from Executive Management at quarterly partnership meetings, as requested 5. Provide monthly construction and rehabilitation progress reports until completion of ❑ construction and rehabilitation. 6. Identify Lead Project Manager. [1 7. Provide Site Design and Specifications. 8. Comply with Davis Bacon Labor Standards. 9. Provide Certified Payroll weekly throughout construction and rehabilitation. �( 10. Provide interior and exterior rehabilitation, as approved by the County. ❑ DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 3 of 16 160 . 11. Comply with Uniform Relocation Act(URA)if necessary. 12 Ensure applicable number of units are 504/ADA accessible. Q 13. Ensure the applicable affordability period for the project is met. B. National Objective The CDBG program funds awarded to Collier County must benefit low-moderate income persons (LMI). As such the Subrecipient shall be responsible for ensuring that all activities and beneficiaries meet the definition of: Low Mod Clientele (LMC) or . . . f 1LMA-Low/Mod Area Benefit VLMC-Low/Mod Clientele Benefit-PB f lLMH-Low/Mod Housing Benefit f lLMJ- Low/Mod Job Creation/Retention C. Project Outcome The Subrecipient will provide Community Access Administrative Services and purchase and set up of computer kiosks to serve a minimum of three hundred (300) one hundred (100) persons. D. Payment Deliverables The Following Table Details the Payment Deliverables PAYMENT DELIVERABLES Payment Deliverable Payment—Supporting Submission Schedule Documents Project Component One:Salaries Submission of supporting monthly Funding costs will include but not documents must be provided as limited to the following expenses: Fund back up as evidenced by i.e. time 2 Full Time (FT) Benefits Managers, sheets, payroll registers, banking partial salary for Quality Improvement documents, and any additional and Program Support Director. documents as needed—Exhibit B Final 10%($6,159.00) ($5,059) released upon documentation of a minimum of 300 100 persons served Final 10% ($7,580.20) $5,059.00 of retainage held will be released upon document that at least 51% of persons served, are low to moderate income households, in order to meet a CDBG National Objective (LMI/LMC). Failure on behalf of the subrecipient in achieving the DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 4 of 16 + 7 160 6 national objective under this agreement will require repayment of the CDBG investment under this agreement and the acquisition agreement. 1.4 AGREEMENT AMOUNT The COUNTY agrees to make available EIGHTY NINE SEVENTY FIVE THOUSAND EIGHT HUNDRED TWO DOLLARS AND NO CENTS ($89,75,802.00) for the use by the SUBRECIPIENT during the Term of the Agreement (hereinafter, the aforestated amount including, without limitation, any additional amounts included thereto as a result of a subsequent amendment(s) to the Agreement, shall be referred to as the "Funds"). Modifications to the "Budget and Scope" may only be made if approved in advance. Budgeted fund shifts between line items and project components shall not be more than 10% and does not signify a change in scope. Fund shifts that exceed 10% of a line item and a project component shall only be made with board approval. All improvements specified in Section I. Scope of Work shall be performed by SUBRECIPIENT employees, or shall be put out to competitive bidding under a procedure acceptable to the COUNTY and Federal requirements. The SUBRECIPIENT shall enter into contract for improvements with the lowest, responsive and qualified bidder. Contract administration shall be handled by the SUBRECIPIENT and monitored by HHVS CHSD, which shall have access to all records and documents related to the project. The County shall reimburse the SUBRECIPIENT for the performance of this Agreement upon completion or partial completion of the work tasks as accepted and approved by HHVS CHSD. SUBRECIPIENT may not request disbursement of CDBG funds until funds are needed for eligible costs, and all disbursements requests must be limited to the amount needed at the time of the request. Invoices for work performed are required every month. SUBRECIPIENT may expend funds only for allowable costs resulting from obligations incurred during the term of this agreement. If no work has been performed during that month, or if the SUBRECIPIENT is not yet prepared to send the required backup, a $0 invoice will be required. Explanations will be required if two consecutive months of$0 invoices are submitted. Payments shall be made to the SUBRECIPIENT when requested as work progresses but, not more frequently than once per month. Reimbursement will not occur if Subrecipient fails to perform the minimum level of service required by this agreement. Final invoices are due no later than 90 days after the end of the agreement. Work performed during the term of the program but not invoiced within 90 days after the end of the agreement may not be processed without written authorization from the Grant Coordinator will not be reimbursed. The County Manager or designee may extend the term of this Agreement for a period of up to 180 days after the end of the agreement. The extension must be authorized in writing by formal letter prior to the expiration of the agreement. The extension must be authorized in writing by formal letter to the Subrecipient. No payment will be made until approved by HHVS CHSD for grant compliance and adherence to any and all applicable local, state or Federal requirements. Payment will be made upon receipt of a properly DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 5 of 16 160 6 completed invoice and in compliance with §218.70, Florida Statutes, otherwise known as the "Local Government Prompt Payment Act." Signature page to follow Remainder of the page left intentionally blank DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 6 of 16 0 1606 IN WITNESS WHEREOF, the SUBRECIPIENT and the County, have each, respectively, by an authorized person or agent, hereunder set their hands and seals on the date first written above. ATTEST: BOARD OF COUNTY COMMISSIONERS OF DWIGHT E. . :OCK, CLE' COLLINTY, FLORIDA �`, � ;_6, ►L-; By: / •st as to Chairman'sD-1 M u S TIM NANCE,CHAIRMAN signature only. DAVID LAWRENCE MENTAL HEALTH CENTER, d X ' Date1\ C n o 1�j INC.,d/b/a FAVID AWRENCE CENTER (SEAL) By: ri. Sco Burgess, ChiE xecutive Officer Approved as to form and legality: Jennifer A. Belpedio Assistant County Attorney DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 7 of 16 PART V EXHIBITS1 6 6 EXHIBIT "C" REPORTING SCHEDULE The SUBRECIPIENT shall submit quarterly reports to Grantee based on the following schedule. Activity Reporting Period Repeft-Due-Date October-1-4 December 314 January 10th January 314 March 314 April 10th April 14 June 30th July 10t July4-4 September 30th October 1.0t • _ .1/ COMMUNITY ACCESS ADMINISTRATIVE SERVICES PROGRAM Date Submitted: Activity Reporting Period: Contact Person: Telephone: Email: GENERAL 1. Activity Status or Milestones describe any significant actions taken or outcomes achieved during this reporting period. ,gin „a? DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 8 of 16 160 6 ACTIVITY STATUS Complete the following information by entering the appropriate numbers for this reporting period in the tables below. Do not duplicate information from previous reporting periods. &c This Deporting Pecs d No. Active Projects No. Projects Complete .---- . ..- No. Properties-field TOTAL HOUSEHOLD INFORMATION Complete these tables for those properties sold during this reporting period. Household-Data ' No. Extremely Low Income Households(0 30%AMI) No. Very Low Income Households(31 50% AMI) No. Low Income Households(51 80% AMI) No. Moderate Income Households(81 120% AMI) TOTAL • . _ . . . _ _1111. _ Raee Total No. Hispanic White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander American Indian/Alaska Native and White Black/African American and White American Indian/Alaskan Native and Black/African American Other Multi Racial TOTAL DLC CDBG CD14-07PS Community Access Administrative Services Program Od Amendment#2 Page 9 of 16 EXHIBIT "H C" 1 6 136 QUARTERLY PERFORMANCE REPORT DATA GENERAL Grantee is required to submit to HUD, through the Integrated Disbursement and Information System ("IDIS") Performance Reports. The County reports information on a quarterly basis. To facilitate in the preparation of such reports, Subrecipient shall submit the information contained herein within ten (10) days of the end of each calendar quarter. QUARTERLY PROGRESS REPORT Sub-recipients: Please fill in the following shaded areas of the report � a Agency Name: David Lawrence Center Y4 .- Date: , .;..,., Project Title: Community Access Administrative Services Program Alternate Program Contact: Shane Bos lfe,Director �,. Contact: Rob vviikineen Telephone Number: 23g-354-1402 0 12/31/14 03/31/16 G06/30/4-5 `, ;$9/39/1-5 Activity Reporting Period Report Due Date October 1st—December 31st January 10th January 31st—March 31st April 10th April 1st—June 30th July 10th July 1st—September 30th October 10th Please take note: Each quarterly report needs to include cumulative data beginning from the start of the agreement date. Please list the outcome goal(s)from your approved application&sub-recipient agreement and indicate your progress in meeting 1. those goals since the beginning of the agreement. A.Outcome Goals: list the outcome goal(s)from your approved application&sub recipient agreement Outcome 1: Provide community access services, including healtl'Care enrollmentl'l nd provide educational materials on insurance options to persons accessin kiosk sites. _.. 11 r , Outcome 2: Purchase and install free-standing computer benefits kiosks at DLC sites. Outcome 3: Employ ersonnel to assist person utilizing kiosks. ; Outcome 4: Serve 300100 individuals DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 10 of 16 1606 qutcome 5: B.Goal Progress: Indicate the progress to date in meeting each outcome goal. Outcome 1: Outcome 2: Outcome 3 etc: ys6•:. _ _ c..eti. .LTi Is this project still in compliance with the original project schedule?If more than 2 months behind schedule,must submit a new 2. timeline for approval. Yes `, No If no,explain: M 3v. 3. Since effective date of agreement,of the persons assisted,how many.... a. ...now have new access(continuing)to this service or benefit? b. ...now has improved access to this service or benefit? 1 _ :.nom c. ...now receive a service or benefit that is no longer substandard? TOTAL: 0 4. What funding sources are applied for this period I program year? $ $ 1.111 Section 108 Loan Guarantee - HOPWA $ Other Consolidated Plan Funds - it CDBG $ Other Federal Funds - ,;!',14101,17', ESG , State/Local Funds - HOME Total $ Entitlement $ Total Other Funds - Funds - DLC CDBG CD14-07PS Community Access Administrative Services Program 1 1 Amendment#2 Page 1 1age of 16 li' 160 6 5. What is the total number of UNDUPLICATED clients served this quarter,if applicable? a. Total No.of adult females served: 0 d Total Noof females served under 18: 0 b. Total No.of adult males served: 0 Total No.of males served under 18: 0 TOTAL: 0 TOTAL: 0 c. Total No. of families served: a ;-'Total No.of female head of household: 0 6. What is the total number of UNDUPLICATED clients served since October,if applicable? a. Total number of adult females served Total number of females servedunder 18: 0 b. Total number of adult males served: 0', Total number of males served under 18: 0 TOTAL: 0 TOTAL: 0 c. Total No.of families served: Sr,Total No.of female head of household: 0 Complete EITHER question#7 OR#8.Complete question#7 if your program only serves clients in one or more of the listed HUD Presumed Benefit categories. Complete question#8 if any client in your program does not fall into a Presumed Benefit category. DO NOT COMPLETE BOTH QUESTION 7 AND 8. 7. PRESUMED BENEFICIARY DATA: 8. OTHER BENEFICIARY DATA:INCOME RANGE Indicate the total number of UNDUPLICATED Indicate the total number of UNDUPLICATED persons persons served since October 1 who fall into served since October 1 who fall into each income each presumed benefit category (the total category(the total should equal the total in question#6): should equal the total in question#6): Report as: Report as: O Abused Children 0 Extremely low Income(0-30%) O Homeless Person 0 Low Income(31-50%) O Battered Spouses 0 Moderate Income(51-80%) 0 Persons w/HIV/AIDS 0 ',Above Moderate Income(>80%) 0 Elderly Persons Veterans Chronically/Mentally ill It 7 v, Physically Disabled Adults O Other-Youth TOTAL: 0 TOTAL: 0 9. Racial 8,Ethnic Data: (if applicable)', Please indicate how many UNDUPLICATED clients served since October fall into each race category. In addition to each race category, please indicate how many persons in each race category consider themselves Hispanic (Total Race column should equal the total cell). RACE ETHNICITY White of whom, how many are Hispanic? Black/African American 0 , 0 of whom, how many are Hispanic? Asian „.; 0 ;of whom, how many are Hispanic? American Indian/Alaska Native Ci',71.1‘f,4,',;:;:linii, 0 of whom, how many are Hispanic? Native Hawaiian/Other Pacific Islander a , 0 ';of whom, how many are Hispanic? American Indian/Alaskan Native&White 0' 0 of whom, how many are Hispanic? Black/African American&White 0 Ii. of whom, how many are Hispanic? Am. Indian/Alaska Native&Black/African Am. 0' ® of whom, how many are Hispanic? Other Multi-racial 0' } of whom, how many are Hispanic? Other 0 0 of whom, how many are Hispanic? TOTAL: 0 0 TOTAL HISPANIC Name: Signature: Your typed name here represents your electronic Title: signature DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 12 of 16 �A EXHIBIT "E D" ,�.'�� fs INCOME CERTIFICATION INSTRUCTIONS Complete form, and retain appropriate supporting documentation, to document providing CDBG assistance to an eligible beneficiary. Please file in your organization's records and have on hand for future monitoring visits. Effective Date: A. Household Information Member Names—All Household Members Relationship Age 1 2 3 4 5 6 7 8 B. Assets: All Household Members, Including Minors Member Asset Description Cash Value Income from Assets 1 2 3 4 5 6 7 8 Total Cash Value of Assets B(a) —, Total Income from Assets B(b) If line B(a) is greater than $5,000, multiply that amount by the rate specified by HUD (applicable rate 2.0%)and enter results in B(c), otherwise leave blank. B(c) DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 13 of 16 CA 6 0 6 C. Anticipated Annual Income: Includes Unearned Income and Support Paid on 1 Behalf of Minors Member Wages/ Benefits/ Public Other Salaries Pensions Assistance Income (include tips, commissions, Asset bonuses,and Income overtime) 1 (Enter the 2 greater of box B(b)or 3 box B(c), 4 above, in 5 box C(e) 6 below) 7 8 Totals (a) (b) (c) (d) (e) Enter total of items C(a)through C(e). This amount is the Annual Anticipated Household Income. D. Recipient Statement: The information on this form is to be used to determine maximum income for eligibility. I/we have provided, for each person set forth in Item A, acceptable verification of current and anticipated annual income. I/we certify that the statements are true and complete to the best of my/our knowledge and belief and are given under penalty of perjury. WARNING: Florida Statutes 817 provides that willful false statements or misrepresentations concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S. 775.082 and 775.083. Signature of Head of Household Date Signature of Spouse or Co-Head of Household Date Adult Household Member (if applicable) Date DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 14 of 16 CAO 160 6 Adult Household Member (if applicable) Date E. CDBG Grantee Statement: Based on the representations herein, the family or individual(s) named in Item A of this Income Certification is/are eligible under the provisions of the CDBG Program. The family or individual(s) constitute(s) a: Very-Low Income (VLI) Household means and individual or family whose annual income does not exceed 30 percent of the area median income as determined by the U.S. Department of Housing and Urban Development with adjustments for household size. (Maximum Income Limit $ ). Low-Income (LI) Household means and individual or family whose annual income does not exceed 50 percent of the area median income as determined by the U.S. Department of Housing and Urban Development with adjustments for household size. (Maximum Income Limit $ ). Moderate-Income (MOD) Household means and individual or family whose annual income does not exceed 80 percent of the area median income as determined by the U.S. Department of Housing and Urban Development with adjustments for household size. (Maximum Income Limit $ ). Based upon the (year) income limits for the Naples-Marco Island Metropolitan Statistical Area(MSA) of Collier County, Florida. Signature of the CDBG Administrator or His/Her Designated Representative: Signature Date Printed Name Title F. Household Data Number of Persons By Race/Ethnicity By Age Native American Asian Black Hawaiian or White Oth 0— 26— 41 — 62+ Indian Other Pac. er 25 40 61 Islander Hispanic Non- Hispanic DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 15 of 16 CA9 160 6 NOTE: Information concerning the rate or ethnicity of the occupants is being gathered for statistical use only. No beneficiary is required to give such information he or she desires to do so, and refusal to give such information will not affect any right he or she has to the CDBG program. EXHIBIT "F E" ANNUAL AUDIT MONITORING REPORT OMB Circular A-133 Audits of States, Local Governments, and Non-Profit Organizations requires the Collier County Housing, Human and Veterans Services Department to monitor our sub recipients of federal awards and determine whether they have met the audit requirements of the circular and whether they are in compliance with federal laws and regulations. Accordingly, we are requiring that you check one of the following, provide all appropriate documentation regarding your organization's compliance with the audit requirements, sign and date this form; Subrecipient Name Fiscal'Year Period Total State Financial Assistance Expended during most recently completed Fiscal Year Total Federal Financial Assistance Expended during most $ recently completed Fiscal Year Check Appropriate Boxes We have exceeded the $500,000 federal/state expenditure threshold for our fiscal year ending ❑ as indicated above and have completed our Circular A-133 audit. A copy of the audit report and management letter is attached. We exceeded the $500,000 federal/state expenditure threshold for our fiscal year ending as Elindicated above and expect to complete our Circular A-133 audit by . Within 30 days of completion of the A-133 audit, we will provide a copy of the audit report and management letter. ❑ We are not subject to the requirements of OMB Circular A-133 because we: ❑ Did not exceed the $500,000 federal/state expenditure threshold for the fiscal year indicated above ❑ Are exempt for other reasons — explain An audited financial statement is attached and if applicable, the independent auditor's management letter. (If findings were noted, please enclose a copy of the responses and corrective action plan.) Certification Statement I hereby certify that the above information is true and accurate. Signature Date Print Name and Title This form may be used to monitor Florida Single Audit Act (Statute 215.97) requirements. DLC CDBG CD14-07PS Community Access Administrative Services Program Amendment#2 Page 16 of 16