Backup Documents 10/10/2017 Item #16D 6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 6
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. Dawn Whelan Community and Human ,J1' 08/28/17
Services
2. County Attorney Office County Attorney Office
3. BCC Office Board of County
Commissioners / � ) xcXV—1
4. Minutes and Records Clerk of Court's Office
10P0/11- `fir Ism
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 Dawn Whelan, Grant Coordinator, Phone Number 239-252-4230
Contact/ Department Community and Human Services
Agenda Date Item was acpteittivrt6 Agenda Item Number 16D
Approved by the BCC oc3 x lb 2-0V1_
Type of Document Certification , Number of Original 2
Attached Documents Attached
PO number or account
number if document is N/A
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(ORIGINAL DW
2. Does the document need to be sent to another agency for additional signatures? If yes, DW
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 DW
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 DW
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 DW
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 DW
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip DW
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 onnd all changes made during the
meeting have been incorporated in the attache document. The County Attorney's •t
Office has reviewed the changes,if applicable.
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 t
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
Instructions
1 6 06
1) There are 2 original Certifications
Call: Dawn Whelan, Grant Coordinator
Public Services Department
239-252-4230
•
1: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
1606
MEMORANDUM
Date: October 11, 2017
To: Dawn Whelan, Grants Coordinator
Community & Human Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Vendor Certification regarding Scrutinized Companies Lists
Attached are the one (1) original of the document referenced above, (Item #16D6)
approved by the Board of County Commissioners on Tuesday, October 10, 2017.
An original document has been held in the Minutes & Records Department as part of
the Board's Official
Records.
If you have questions, please feel free to call me at 252-8411.
Thank you
Attachment
1606
VENDOR CERTIFICATION REGARDING
SCRUTINZED COMPANIES LISTS
Respondent Vendor Name: Collier County Board of County Commissioners
Vendor FEIN: 59-6000558
Vendor's Authorized Representative Name and Title: Penny Taylor, Chairman
Address: 3299 Tamiami Trail, East, Suite 202
City: Naples State: Florida Zip: 34112
Phone Number: 239-252-8383
Email Address: PennyTaylor(a colliergov.net
Section 287.135, Florida Statutes, prohibits agencies from contracting with companies, for
goods or services over $1,000,000, that are on either the Scrutinized Companies with Activities
in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector
List. Both lists are created pursuant to section 215.473, Florida Statutes.
As the person authorized to sign on behalf of Respondent, I hereby certify that the company
identified above in the section entitled "Respondent Vendor Name" is not listed on either the
Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities
in the Iran Petroleum Energy Sector List. I understand that pursuant to section 287.135, Florida
Statutes, the submission of a false certification may subject company to civil penalties,
attorney's fees, and/or costs.
Certified By: Penny Taylor, Chairman
Print Name Print Title
who is authorized to sign on .- alf of the above referenced company.
Authorized Signature: 1
t
Approved as to form and legality t1 X138 .-TOROC
VSAssistant County An mey
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SI JRd1tk01lyy
Effective July 2015
(CF-1110-1516) r