Backup Documents 05/13/2014 Item #16D 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 0 5
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 Carr HHVS It 5/13/2014
2. Jennifer B. Belpedio, ACA Office located in HHVS
County Attorney Office Department °l 5/151)4.
3. BCC Office Board of County
Commissioners v /s/ � �6V4-
4. Minutes and Records Clerk of Court's Office q6(/ /`
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 Can Phone Number 252-2339
Contact/ Department -
Agenda Date Item . . 13/2014 Agenda Item Numb 16.D.5
Approved by the :.
Type of Document 1Amendment w/Attestation Statement Number of Original 3 originals
Attached Documents Attached
PO number or account
number if document is ` N./7N.
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 ✓
2. Does the document need to be sent to another agency for additional signatures? If yes, LNC V _ `
provide the Contact Information(Name;Agency; Address;Phone)on an attached sheet. �'�c�
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 MC' ,ri{
Office and all other parties except the BCC Chairman and the Clerk to the Board I"J
5. The Chairman's signature line date has been entered as the date of BCC approval of the LNC
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
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 tenter 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 CL,...4A
BCC,all changes directed by the BCC have been made,and the document is ready for e '
Chairman's signature.
vwirr
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
1605
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
1605
MEMORANDUM
Date: May 16, 2014
To: Lisa Carr, Grants Coordinator
Housing, Human & Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Agreement NSIP 203.14.001Amendment #1
and Attestation Statement with the Area Agency on Aging
for SWFL, Inc. d/b/a Senior Choices of Southwest Florida
for the Nutrition Services Incentive Program
Attached for further processing are three (3) original copies of the amendment
document referenced above, (Item #16D5) 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)
16 [15
Amendment 001 NSIP 203.14.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
NUTRITION SERVICES INCENTIVE PROGRAM
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, ("Recipient"), amends agreement
NS1P 203.14.
The purpose of this amendment is to amend Paragraph 2.4.3., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.3 of the Attachment I, is hereby amended to read:
2.4.3. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports, which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
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 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COWER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS 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: `_; 1 / !`_f
DATE:
Federal Tax ID. 59-6000588
Fiscal Year Ending Date: 09/30 Approved as to form and legality
-
+
D'Y°->lf' IT E'. SRO , Clerk
' Assistant County Atto
n . � ► �.tlir�iw 1
1605
Attestation Statement
Agreement/Contract Number: NSIP 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.
I 1•
� cJ/ / IJ/ l`
Si ature of Recipient/Contractor
ortirr esentative Date
�,. _ .7.; Approved Approved as to form and legality
O T titAi E. 13R0ry , Clark 'St.CL..\
__
Assistant County A ey
V
Atitst as to Chairman's
signature only.
1605
Amendment 001 NSIP 203.14.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC. ? ,
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
NUTRITION SERVICES INCENTIVE PROGRAM
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, ("Recipient"), amends agreement
NSIP 203.14.
The purpose of this amendment is to amend Paragraph 2.4.3., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.3 of the Attachment I, is hereby amended to read:
2.4.3. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports,which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
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 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY CO 'SSIONERS FLORIDA,INC.DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: /4 �I _ . SIGNED BY: 41'2- r `dam
NAME: Tom Hennin g NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: 5// s// 1 ��.
DATE: 4'4//
Federal Tax ID: 59=000588
Fiscal Year Ending-Date: 09/30
Approved as to form and legality
ATTEST:
Dw T E. BRO , Clerk
AssrUnt County Ah�'yey4``k1 11 s , 4
Gdv
16fl5
Attestation Statement
Agreement/Contract Number: NSIP 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.
/ . ,
ignature of Recipient/C i ntracto,-. esentative Date
Approved as to form and legality
&Li/L$.4511_
A e , ,..___orrt..7wraft÷,__, _ k_____ Assis nt County A o ey
signature en
Ty. -.
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