Backup Documents 05/13/2014 Item #16D 4 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 4
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 Initials Date
1. Lisa Can HHVS It 5/13/2014
2. Jennifer B. Belpedio, ACA Office located in HHVS ( 5 115114-
County Attorney Office Department
3. BCC Office Board of County 4.1 b `
Commissioners ` �/ S`1. t 4
4. Minutes and Records Clerk of Court's Office - 4(b(tcf
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 Carr Phone Number 252-2339
Contact/ Department
Agenda Date Item w.. 5/13/20 Agenda Item Numbe 16.D.4
Approved by the BCC
Type of Document 1Amendment w/Attestation Statement Number of Original 3 originals
Attached Documents Attached
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? LNC J
2. Does the document need to be sent to another agency for additional signatures? If yes, LNC V S
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 LNC
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's L-I'FE
Office and all other parties except the BCC Chairman and the Clerk to the Board A
5. The Chairman's signature line date has been entered as the date of BCC approval of the LNC 1/
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 LNC V
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip LNC V
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 5/13/2014 (enter date)and all changes LNC
made 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 r
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
16134
INSTRUCTIONS & CHECKLIST #2
Please send the original Chairman signed documents to additional agency for signature:
Kathy Gronberg, Fiscal Specialist III
Senior Choices of Southwest Florida, Inc.
15201 N Cleveland Ave Ste 1100
North Fort Myers, FL 33903
239-652-6900 Ext. 251
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
1604
MEMORANDUM
Date: May 16, 2014
To: Lisa Can, Grants Coordinator
Housing, Human & Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Agreement OAA 203.14.001 Amendment #1 (ADI 203.12.006)
and Attestation Statement with the Area Agency on Aging
for SWFL, Inc. d/b/a Senior Choices of Southwest Florida
for the Older Americans Act Program Title III
Attached for further processing are three (3) original copies of the amendment
document referenced above, (Item #16D4) approved by the Board of County
Commissioners May 13, 2014.
After the representative for Senior Choices has signed the documents, please return
one of the original copies to the Minutes & Records Department for the Board's
Official Record.
If you have any questions please call me at 252-8406.
Thank you
Attachments (3)
16134
Amendment 01 OAA 203.14.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC. dba
Senior Choices of Southwest Florida
OLDER AMERICANS ACT PROGRAM TITLE III
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc., dba Senior
Choices of Southwest Florida (Agency) and Collier County Board of County Commissioners (Contractor) and
amends contract OAA 203.14.
The purpose of this amendment is to (1) amend language in Paragraph 3.2.2 of ATTACHMENT I, and (2) update
ATTACHMENT VIII.
Line denotes completion of above summary
ATTACHMENT I:
(1) Paragraph 3.2.2 of ATTACHMENT I is hereby amended to read:
3.2.2 All advance payments made to the Contractor shall be returned to the Agency as follows: one-
tenth of the advance payment received shall be reported as an advance recoupment on each request
for payment, starting with report number five, in accordance with the Invoice Schedule,
ATTACHMENT VIII to this contract.
ATTACHMENT VIII:
(2) ATTACHMENT VIII is hereby replaced with the revised ATTACHMENT VIII and attached hereto.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with this
amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed by their officials there unto
duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY OMMIS'/ NERS FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY " SIGNED BY:
NAME: Tom Henning , NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT-
DATE: C/j 3/j`I Approved as to form and legality �� °t vr',
DATE:
at19
Asa�atant Conn tt orney �\y 1 'DWIGHT E. BROCK, Clerk
Amendment 01 16134
OAA 203.14.001
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
ATTACHMENT VIII
ADVANCE BASIS CONTRACT
Report Number Based On Submit to State
On This Date
1 January Advance* January 1
2 February Advance* January 1
3 January Expenditure Report February 9 *See Note#4*
4 February Expenditure Report March 9
5 March Expenditure Report April 9
6 April Expenditure Report May 9
7 May Expenditure Report June 9
8 June Expenditure Report July 9
9 July Expenditure Report August 9
10 August Expenditure Report September 9
11 September Expenditure Report October 9
12 October Expenditure Report November 9
13 November Expenditure Report December 9
14 December Expenditure Report January 9
15 Final Expenditure and Request for Payment February 15
16 Closeout Report March 1
Legend: * Advance based on projected cash need.
Note# 1: Report#1 for Advance Basis Agreements cannot be submitted to the Agency prior to January 1 or until
the agreement with the Agency has been executed.
Note # 2: Report numbers 5 through 14 shall reflect an adjustment of one-tenth of the total advance amount, on
each of the reports, repaying advances issued the first two months of the agreement. The adjustment shall
be recorded in Part C, 1 of the report (ATTACHMENT IX).
Note #3: Submission of expenditure reports may or may not generate a payment request. If final expenditure
report reflects funds due back to the Agency, payment is to accompany the report.
Note #4: ALL Expenditure Reports are due by 12:00 p.m. on the 9th of each month. IF the 9th falls on a Saturday,
then the report will be due by the 8th by 12:00 p.m. AND IF the 9th falls on a Sunday, the report will be
due by the 10`h by 12:00 p.m. Actual submission of the vouchers to Dept. of Elder Affairs is dependent
on the accuracy of the expenditure report which is verified and paid by CIRTS data only.
2
16134
Attestation Statement
Agreement/Contract Number: OAA 203.14
Amendment Number 001
1, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
11 5J13 JIL{
ignature of Recipient/Contractor epresentative Date
,- -u ; .. Approved as to form and legality
D E. BROCK, Clerk(:),61A-AA)a-C_CUtrak_
Assistant County Atte�+ney
nest as to hairrman s
signature only.
,,,>,
M II' 17
s Amendment 01 OAA 203.14.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC. dba 1 6 0 4
Senior Choices of Southwest Florida
OLDER AMERICANS ACT PROGRAM TITLE III
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc., dba Senior
Choices of Southwest Florida(Agency) and Collier County Board of County Commissioners (Contractor) and
amends contract OAA 203.14.
The purpose of this amendment is to (1) amend language in Paragraph 3.2.2 of ATTACHMENT I, and (2) update
ATTACHMENT VIII.
Line denotes completion of above summary
ATTACHMENT I:
(1) Paragraph 3.2.2 of ATTACHMENT I is hereby amended to read:
3.2.2 All advance payments made to the Contractor shall be returned to the Agency as follows: one-
tenth of the advance payment received shall be reported as an advance recoupment on each request
for payment, starting with report number five, in accordance with the Invoice Schedule,
ATTACHMENT VIII to this contract.
ATTACHMENT VIII:
(2) ATTACHMENT VIII is hereby replaced with the revised ATTACHMENT VIII and attached hereto.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with this
amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed by their officials there unto
duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COM SSIONERS FLORIDA,INC.DBA SENIOR CHOICES OF
/ SOUTHWEST FLORIDA
SIGNED B • ii I . SIGNED BY: `W9 - Ake `
NAME: Tom Henning NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT-
DATE: Approved as to form and legality
DATE: r d`f
ATTEST:
Assistant County Att 5
, 3 v rr �1
1
}
1604 4
Amendment 01 OAA 203.14.001
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
ATTACHMENT VIII
ADVANCE BASIS CONTRACT
Report Number Based On Submit to State
On This Date
1 January Advance* January 1
2 February Advance* January 1
3 January Expenditure Report February 9 *See Note#4*
4 February Expenditure Report March 9
5 March Expenditure Report April 9
6 April Expenditure Report May 9
7 May Expenditure Report June 9
8 June Expenditure Report July 9
9 July Expenditure Report August 9
10 August Expenditure Report September 9
I 1 September Expenditure Report October 9
12 October Expenditure Report November 9
13 November Expenditure Report December 9
14 December Expenditure Report January 9
15 Final Expenditure and Request for Payment February 15"
16 Closeout Report March 1
Legend: * Advance based on projected cash need.
Note# 1: Report#1 for Advance Basis Agreements cannot be submitted to the Agency prior to January 1 or until
the agreement with the Agency has been executed.
Note# 2: Report numbers 5 through 14 shall reflect an adjustment of one-tenth of the total advance amount,on
each of the reports, repaying advances issued the first two months of the agreement. The adjustment shall
be recorded in Part C, 1 of the report(ATTACHMENT IX).
•
Note#3: Submission of expenditure reports may or may not generate a payment request. If final expenditure
report reflects funds due back to the Agency, payment is to accompany the report.
Note#4: ALL Expenditure Reports are due by 12:00 p.m. on the 9th of each month. IF the 9th falls on a Saturday,
then the report will be due by the 8th by 12:00 p.m. AND IF the 9th falls on a Sunday,the report will be
due by the 10th by 12:00 p.m. Actual submission of the vouchers to Dept. of Elder Affairs is dependent
on the accuracy of the expenditure report which is verified and paid by CIRTS data only.
2 G�'
6D4
Attestation Statement
Agreement/Contract Number: OAA 203.14
Amendment Number 001
I, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
•
3 1 LI
Signature of Recipient/Contract r representative Da e
w? r tea:
Approved as to form and legality
. „ . Assistant County • Y
.` i quest as to Ghairma
;J a �g ture O1''1
tff,� t�