Backup Documents 06/24/2014 Item #16D18 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP A
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 6 D 1 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 Attomey Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Lisa Carr HHVS It 6/18/2014
2. Jennifer B. Belpedio, ACA Office located in HHVS �'ZS�`�
County Attorney Office Department
3. BCC Office Board of County
�Commissioners f t�,( c-)1Z--tikkl\
Office
Minutes and Records Clerk of Court's Of ce `-]' [al-1H_ `r
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 misting information.
Name of Primary Staff Lisa Carr l (2SkV� Phone Number 252-2339
Contact/ Department
Agenda Date Item was 6/24/2014 Agenda Item Number 16.D.18
Approved by the BCC
Type of Document Amendments w/Attestation Statements- Number of Original 3 originals c
Attached Area Agency on Aging for Southwest Documents Attached
Florida,Inc. `Z`+-tckv r-, s
PO number or account CszPrv�vh�'cy
number if document is ` C�v-42—..)
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 Y/
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.,✓✓✓
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 V
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's LNC
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 LNC if
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 ✓
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip LNC
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 6/24/2014 Lenter 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 LNC
BCC,all changes directed by the BCC have been made,and the document is ready for he
Chairman's signature. �!C�
1:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2. ,.. ; •, • ed 11/30/12
16D1
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
161) jg . .
MEMORANDUM
Date: June 27, 2014
To: Lisa Carr, Grants Coordinator
Housing, Human & Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Amendments and Attestation Statement with the Area Agency on
Aging for SWFL, Inc. for the Alzheimer's Disease Initiative
Program (ADI 203.12.009), Community Care for the Elderly
Program (CCE 203.12.010)
Attached for further processing are three (3) original copies of the each amendment
document referenced above, (Item #16D18) approved by the Board of County
Commissioners June 24, 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 252-8411.
Thank you
Attachments (3)
Amendment 09 ADI 203.12.009
4
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC1 6 p 18
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
This AMENDMENT, entered into between the Area Agency on Aging for Southwest Florida, Inc. ("Agency") and
Collier County Board of County Commissioners, ("Recipient"), amends agreement ADI 203.12.
The purpose of this amendment is to increase allocations by $4,800.00 affecting Year Two, 2013-2014, revise
ATTACHMENT III—EXHIBIT I and revise ATTACHMENT VIII Budget Summary.
This amendment shall be effective on May 27, 2014. 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.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF,the parties hereto have caused this 3 page amendment to be executed by their officials there
unto duly authorized.
Collier County Board of County Area Agency on Aging for Southwest
Contractor: Com ssioners Florida, Inc..
/ SIGNED
SIGNED B : Gam- BY:
NAME: Tom Henning / NAME: Ronald Lucchino, PhD
TITLE: Chairman TITLE: Board President
DATE: June 24, 2014 ///)[DATE: 7/ f
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
Approved as to form and legality
As37stant C
�A onn orney c) b!
Attest as to.Chairman's -5- o��
signatu`re only. cn
1
C��O�
Amendment 09 ADI 20314n 1 8
ATTACHMENT III
EXHIBIT— 1
1. FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS
AGREEMENT CONSIST OF THE FOLLOWING:
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL FEDERAL AWARD
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT
TO THIS AGREEMENT ARE AS FOLLOWS:
2. STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS AGREEMENT
CONSIST OF THE FOLLOWING:
MATCHING RESOURCES FOR FEDERAL PROGRAMS
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL STATE AWARD
STATE FINANCIAL ASSISTANCE SUBJECT TO Sec.215.97,F.S.
PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT
Alzheimer's Disease Initiative General Revenue/TSTF-2013-2014 65004 $141,387.00
TOTAL AWARD $141,387.00
COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO
THIS AGREEMENT ARE AS FOLLOWS:
•
2
Amendment 09 ADI 203.114 0 1 8
ATTACHMENT VIII
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
BUDGET SUMMARY
for
Collier County Board of County Commissioners
2013-2014
1. Respite $138,657.00
2. Case Management and Case Aide Allocation 2,730.00
3. Total $141,387.00
3
160 1 ,
•
Attestation Statement
Agreement/Contract Number: ADI 203.12
Amendment Number 009
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
1 l ; I. • 1 11111' '11 '. . .
(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.
•
\ /
t 6/24/2014
Signature o Recipient/ ontractor s resentative Date
l
Approved as to form and legality
_ Al�-� 0. -4.—m_
a nt County tirney
Attest as to Chairman's ��
Amendment 010 CCE 203.12.010
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
COMMUNITY CARE FOR THE ELDERLY PROGRAM 16 IJ 18
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. ("Agency") and
Collier County Board of County Commissioners, ("Recipient"),amends agreement CCE 203.12.
The purpose of this amendment is to transfer $16,688.00 from Case Management and Case Aide to Spending Authority
and increase Spending Authority $45,500.00, affecting Year Two, 2013-2014 for Collier County, and revise
ATTACHMENT III EXHIBIT—I and ATTACHMENT VIII,Budget Summary.
This amendment shall be effective on May 27, 2014. 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 3 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.
/ '
SIGNED : ,�� Jig& SIGNED BY: .�
I i
NAME: Tom Henning NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: June 24, 2014
DATE: (/?f At.
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
Approved as to form and legality
i. aar'" '` Assistant County At ey A
Ct. \,9
Attest as to Chairman's
signature only.
1
Amendment 010 16 018 CCE 203.12.010
ATTACHMENT III
EXHIBIT— 1
1. FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS
AGREEMENT CONSIST OF THE FOLLOWING:
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL FEDERAL AWARD
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT
TO THIS AGREEMENT ARE AS FOLLOWS:
2. STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS AGREEMENT
CONSIST OF THE FOLLOWING:
MATCHING RESOURCES FOR FEDERAL PROGRAMS
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL STATE AWARD
STATE FINANCIAL ASSISTANCE SUBJECT TO Sec.215.97,F.S.
PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT
Community Care for the Elderly Program General Revenue-Collier-2013-2014 65010 $ 774,181.00
TOTAL AWARD $ 774,181.00
COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO
THIS AGREEMENT ARE AS FOLLOWS:
Approved as to form and legality
Assistan County Atto
Attest as to Chairman's Lc�'
signature only.
2
Amendment 010 16 D 18 CCE 203.12.010
•
ATTACHMENT VIII
COMMUNITY CARE FOR THE ELDERLY PROGRAM
BUDGET SUMMARY
for
Collier County Board of Commissioners
Collier County
2013-2014
1. CCE Spending Authority $691,869.00
2. Case Management and 82,312.00
Case Aide
Total $774,181.00
3
16018
Attestation Statement
Agreement/Contract Number: CCE 203.12
Amendment Number 0010
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.
J\-./ li 6/24/2014
Signature of ient/ ontracto re s resentative Date
Approved as to form and legality
Attest as to Chairman's Assistant County ey
signature only.