Backup Documents 04/08/2014 Item #16D 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIT L D
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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 he 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 Attomey Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Lisa Oien HHVS c,• /,�� 607/
� Y
2. Jennifer Belpedio County Attorney Office 2 > tot`-4
3. BCC Office Board of County b
Commissioners \1 / j `�\\ovA
4. Minutes and Records Clerk of Court's Office
R� L( (ro([t{ 2 31lpm
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 Lisa Oien , yri Phone Number 239-252-6141
Contact/ Department Please call for pick up
Agenda Date Item was 4/8/2014 Agenda Item Number 16D3
Approved by the BCC
Type of Document Signature Authority forms Number of Original 2
Attached NEEDS CHAIRMANS ORIGINAL Documents Attached
SIGNATURE
PO number or account
number 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. (Initial) Applicable)
1. Does the document require the chairman's original signature? G>,
2. Does the document need to be sent to another agency for additional signatures? If yes,
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
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 �
5. The Chairman's signature line date has been entered as the date of BCC approval of the 4_
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
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip
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 April 8,2014 and all changes made
during the meeting have been incorporated in the attached document. The Count r i i
t si s
Attorney's Office has reviewed the changes,if applicable. i f'-
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 hoe +
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
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160 3
MEMORANDUM
Date: April 11, 2014
To: Lisa Oien, Grants Coordinator
Housing, Human &Veteran Services
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: Signature Authority Forms (8)
Grant #07-DB-3V-09-21-01-Z01
Attached are (3) three original of the CBDG agreement pages referenced above,
(Item #16D3) approved by the Board of County Commissioners on Tuesday, April 8,
2014.
A copy of the original agreement signature page will be held in the Minutes and
Records Department as part of the Board's Official Records.
Thank you.
1603
Department of Economic Opportunity—Small Cities Development Block Grant Program
ATTACHMENT L-SIGNATURE AUTHORITY FORM
Submit an original Signature Authority Form with each contract.
Recipient ! Contract# Funding Source
•
Board of Collier County Commissioners 07DB-3V 09-21-01-Z01 ; [ ]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 1 076997790
Project Contact Person 1 Telephone # E-mail Address
Lisa Oien, Grants Coordinator 1 239-252-6141 1 lisaoien @colliergov.net
Collier County Housing, Human
and Veteran Services
Financial Contact Person Telephone # 1 E-mail Address
Bendisa Marku, Supervisor 239-252-2689 bendisamarku @colliergov.net
Accountant, Collier County
Housing, Human and Veteran
' Services
Other Local Government Contact I Telephone # 1 E-mail Address
Kristi Sonntag, Grants Manager ! 239-252-2486 1 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
I the Department).
Typed Name Da a 7 *Za*,"
B endisa Marku, Supervisor Accountant J /a? // ��C�.
[X] Check here if above person is authorized to submit RFFs ; -mai Address
bendisamarku@colliergov.net
•
Typed Name I Date 1 Signature ?
Edmond Kushi, Accountant 3//2//9 c.�� tiu1'
[X] Check here if above person is authorized to submit RFFs 1 E-mail Address
edmondkushi@colliergov.net
Typed Name Date Signature
1 Lisa Oien, Grants Coordinator 3/ii LV. L � ri (-7 .
[ ]Check here if above person is authorized to submit RFFs 1 E-mail A dress
lisaoien @colliergov.net
Typed Name i Date . Signature
[ ]Check here if above person is authorized to submit RFFs i E-mail Address
I certify, as the recipient's Chief Elected Official,that the above signatures are of the individuals aut orized to sign Requests for
Funds and to submit RFF's electronically.
Typed Name Date Signature /
Tom Henning, Chairman
Board of Collier County Commissioners 1 171/4 / y —
[ X ] Check here if your local government utilizes Electronic Funds Transfer(EFT)from the State of Flori.:.
j [ 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 k .,,. ,r
. Name of Financial Institution ; Account Number
Fifth Third Bank '{ - 113-8577
Street Address or Post Office Box ^ .. : ,_. , Telephone Number
999 Vanderbilt Beach Road !: 239-591-6397
,. ;,� d legality a:. t.City, State and Zip Code
Naples, Florida 34108 � ~r S f Revised April 2011
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