Backup Documents 09/09/2014 Item #16D18 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SEN Try
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR
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. Jennifer A. Belpedio, ACA County Attorney Office 4-
2. BCC Office Board of County
'Commissioners T�
3. Minutes and Records Clerk of Court's Office 770(\ a 1(21(4 (2:FO\
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 Phone Number cal) Tea- f'c-k'`
Contact/ Department Lisa Oien 252-6141
Agenda Date Item was Agenda Item Number t •.D �g
Approved by the BCC 9/9/2014 16D
Type of Document Number of Original 4 forms 6. o
Attached Four Annual eCDBG Access Authorization Documents Attached >/ � ..s"- N/
Forms
Original signature needed �Jfvr11 EeI; c+cgef
PO number or account S
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?
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 o,\4=eN
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
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 awa • . our deadlines!
8. The document was approved by the BCC o pan• all changes made during [}, •
the meeting have been incorporated in the a : • •• : • ument. The County 0.j►'
Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the 4 N/A is
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
1 6018
MEMORANDUM
Date: September 17, 2014
To: Lisa Oien, Grant Coordinator
Housing, Human & Veteran Services
From: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Annual eCDBG Authorization Forms to Access DRI Contract(s)
DRI 10DB-D4-09-21-01-K09; DRI 08DB-D3-09-21-01-A03;
DRI 07DB-3V-09-21-01-Z01 & DREF 12DB-P5-09-21-01-K39
with the Florida Department of Economic Opportunity
Attached is a certified copy of each of the access authorization forms referenced above,
(Item #16D18) approved by the Board of County Commissioners on September 9, 2014.
The Minutes and Record's Department has held the original forms for the Board's
Official Record.
If you have any questions, please feel free to call me at 252-8406.
Thank you.
Attachment
1 6018
DEDepartment of Economic Opportunity
Annual eCDBG Access Authorization Form 6/4/2014
Use the tab key to move between form fields when completing the form electronically.
Funding Source:
Recipient Name: Contract Number:
❑ Small Cities CDBG
Collier County DREF 12DB P5 09 21 01 K39 DRI ❑NSP
Mailing Address (Street or P.O. Box): 3339 Tamiami Trail East,Suite 211
City,State,and Zip Code: Naples,Fl 34112
Recipient's DUNS#: 076997790 Recipient's FEID#: 59-6000558
Note: A maximum of two employees of the Recipient can be authorized to access eCDBG for this contract. The
individuals listed below have been designated to access eCDBG on behalf of the Recipient listed above for the purpose of
submitting Requests for Funds (RFFs) and required reports. The eCDBG website address is—
http://www.deoecdbg.com. If you need to update the names of the individuals who are authorized to access eCDBG for
this contract,submit a copy of the eCDBG Access Authorization Update Form to the Department. CDBG Operations
Unit Phone Number: (850) 717-8406.
Primary User's Name/Title:
Date: B/I,1 i" I ' it
1-1 Edmond Kushi,Accountant
44 atwm-
Phone Number: 239-252-4220 E-mail Address:edmondkushi @colliergov.net
Secondary User's Name/Title:
Date: 43 A( i
Lisa Oien,Grants Coordinator t'
Signature
Phone Number: 239-252-6141 E-mail Address:lisaoien @colliergov.net
As the Chief Elected Official of the Recipient,I certify that the above individuals are authorized to submit RFF's and
reports through eCDBG on behalf of the Recipient.
Name: Tom Henning
Title: Chairman,Board of Collier County Date: QI �y
Commissioners Signature `r
Additional Payment Information for Processing Requests for Fun If
® Check here if the Recipient utilizes Electronic Funds Transfer(EFT)from the State of Florida.
® Check here if the Recipient will be working on a reimbursement basis.
❑ If this signature authority form pertains to a housing rehabilitation grant,check here if your local government will
use an escrow account for housing activities.
CDBG payments to local governments using EFT are 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. 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.
Name of Financial Institution: Fifth Third Bank Account Number: 113-8577
Address: 999 Vanderbilt Beach goad Telephone Number (239) 591-6397
Attest:as tQ Chairman's
City,State and Zip Code: N ,at , 3410s Approved as to form and legality 4
ATT7ST: '3\N
DWIGHT E. BROPK, CIOrk •L � psis County Att 5, ¢
1 6018
DEDepartment of Economic Opportunity
Annual eCDBG Access Authorization Form 6/4/2014
Use the tab key to move between form fields when completing the form electronically.
Funding Source:
Recipient Name: Contract Number:
❑ Small Cities CDBG
Collier County DRI 07DB 3V 09 21 01 Z01
®DRI ❑NSP
Mailing Address (Street or P.O. Box): 3339 Tamiami Trail East,Suite 211
City,State,and Zip Code: Naples,Fl 34112
Recipient's DUNS#: 076997790 Recipient's FEID#: 59-6000558
Note: A maximum of two employees of the Recipient can be authorized to access eCDBG for this contract. The
individuals listed below have been designated to access eCDBG on behalf of the Recipient listed above for the purpose of
submitting Requests for Funds (RFFs) and required reports. The eCDBG website address is—
http://www.deoecdbg.com. If you need to update the names of the individuals who are authorized to access eCDBG for
this contract,submit a copy of the eCDBG Access Authorization Update Form to the Department. CDBG Operations
Unit Phone Number: (850) 717-8406.
Primary User's Name/Title: S 'y
Date:
Edmond Kushi,Accountant ate
Phone Number: 239-252-4220 E-mail Address:edmondkushi @colliergov.net
Secondary User's Name/Title: t
Date: o/3 /'-( �j . C
Lisa Oien,Grants Coordinator Signature
Phone Number: 239-252-6141 E-mail Address:lisaoien @colliergov.net
As the Chief Elected Official of the Recipient,I certify that the above individuals are autho 'zed to submit RFF's and
reports through eCDBG on behalf of the Recipient.
Name: Tom Henning
Title: Chairman,Board of Collier County Date: q l g l •
Commissioners .lgnak
Additional Payment Information for Processing Requests for Funds
® Check here if the Recipient utilizes Electronic Funds Transfer(EFT)from the State of Florida.
® Check here if the Recipient will be working on a reimbursement basis.
❑ If this signature authority form pertains to a housing rehabilitation grant,check here if your local government will
use an escrow account for housing activities.
CDBG payments to local governments using EFT are 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. 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.
Name of Financial Institution: Fifth Third Bank Account Number: 113-8577
Address: 999 Vanderbilt Beach Road %: Telephone Number (239) 591-6397
City,State and Zip Code: Naples,Florida 3410S7 Attest as t0 Chairman s_ Approved as to form and legality
•
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C3w1 HT E. g° •.OK, t;
,C A stan�oun oney
'V
' , Department of Economic Opportunity 1 6 D 18
DES
• Annual eCDBG Access Authorization Form 6/4/2014
Use the tab key to move between form fields when completing the form electronically.
Recipient Name: Contract Number: Funding Source:
❑ Small Cities CDBG
Collier County DRI 08DB-D3 09 21 01 A03
®DRI ❑NSP
Mailing Address (Street or P.O. Box): 3339 Tamiami Trail East,Suite 211
City,State,and Zip Code: Naples,Fl 34112
Recipient's DUNS#: 076997790 Recipient's FEID#: 59-6000558
Note: A maximum of two employees of the Recipient can be authorized to access eCDBG for this contract. The
individuals listed below have been designated to access eCDBG on behalf of the Recipient listed above for the purpose of
submitting Requests for Funds (RFFs) and required reports. The eCDBG website address is—
http://www.deoecdbg.com. If you need to update the names of the individuals who are authorized to access eCDBG for
this contract,submit a copy of the eCDBG Access Authorization Update Form to the Department. CDBG Operations
Unit Phone Number: (850) 717-8406.
Primary User's Name/Title:
Date: SP 31 I '
Edmond Kushi,Accountant
ature
Phone Number: 239-252-4220 E-mail Address:edmondkushi @colliergov.net
Secondary User's Name/Title: Date: 6113 i c(
Lisa Oien,Grants Coordinator S azure :16-7
Phone Number: 239-252-6141 E-mail Address:lisaoien @colliergov.net
As the Chief Elected Official of the Recipient,I certify that the above individuals are authorized to submit RFF's and
reports through eCDBG on behalf of the Recipient.
Name: Tom Henning
Title: Chairman,Board of Collier County Date: y q I ref Ark_ �
Commissioners Signature
Additional Payment Information for Processing Requests for Fun
Check here if the Recipient utilizes Electronic Funds Transfer(EFT)from the State of Florida.
® Check here if the Recipient will be working on a reimbursement basis.
❑ If this signature authority form pertains to a housing rehabilitation grant,check here if your local government will
use an escrow account for housing activities.
CDBG payments to local governments using EFT are 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. 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.
Name of Financial Institution: Fifth Third Bank Account Number: 113-8577
Address: 999 Vanderbilt Beach Road ' ", Telephone Number (239) 591-6397
City,State and Zip Code: Naplesp 1 1 aj an'S Approved as to form and legality
ATTECT: g p
DWI HT E. BRv t t Piy' \\4*'
Assis me '
ai•
DE " Department of Economic Opportunity 1 60 18
Annual eCDBG Access Authorization Form 6/4/2014
Use the tab key to move between form fields when completing the form electronically.
Funding Source:
Recipient Name: Contract Number:
❑ Small Cities CDBG
Collier County DRI 10DB-D4-09-21-01-K09
DRI ❑ NSP
Mailing Address (Street or P.O. Box): 3339 Tamiami Trail East,Suite 211
City,State,and Zip Code: Naples,Fl 34112
Recipient's DUNS#: 076997790 Recipient's FEID#:59-6000558
Note: A maximum of two employees of the Recipient can be authorized to access eCDBG for this contract. The
individuals listed below have been designated to access eCDBG on behalf of the Recipient listed above for the purpose of
submitting Requests for Funds (RFFs) and required reports. The eCDBG website address is—
http://www.deoecdbg.com. If you need to update the names of the individuals who are authorized to access eCDBG for
this contract,submit a copy of the eCDBG Access Authorization Update Form to the Department. CDBG Operations
Unit Phone Number: (850) 717-8406.
Primary User's Name/Title: p
Date: D 131)4
Edmond Kushi,Accountant
re
Phone Number: 239-252-4220 E-mail Address:edmondkushi @colliergov.net
Secondary User's Name/Title:
Date: 3/0//4-/ AGLZ' (LI \
Lisa Oien,Grants Coordinator
Signature
Phone Number: 239-252-6141 E-mail Address:lisaoien @colliergov.net
As the Chief Elected Official of the Recipient,I certify that the above individuals are authorized to submit RFF's and
reports through eCDBG on behalf of the Recipient.
Name: Tom Henning
Title: Chairman,Board of Collier County Date: G J C/ly J
Commissioners C Signature
Additional Payment Information for Processing Requests for Funds
® Check here if the Recipient utilizes Electronic Funds Transfer(EFT)from the State of Florida.
® Check here if the Recipient will be working on a reimbursement basis.
❑ If this signature authority form pertains to a housing rehabilitation grant,check here if your local government will
use an escrow account for housing activities.
CDBG payments to local governments using EFT are 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. You can check
the status of your deposit at the Comptroller's website:http://ifilair.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.
Name of Financial Institution: Fifth Third Bank Account Number: 113-8577
•
;r•
Address: 999 Vanderbyttepach Rio �I{'� Telephone Number: (239) 591-6397
aS�`��nC�at g 4mial 5-
City,State and Zip Code: Napl s,Nbrida 34108 Approved as to form and legality
DWIG6 . E. i3RQCK, CIa1k L Assistant Coun orney
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