Agenda 05/11/2010 Item #16D 3
Agenda Item No. 1603
May 11, 2010
Page 1 of 10
EXECUTIVE SUMMARY
Recommendation to approve and authorize the Chairman to sign an
agreement between Collier County Parks and Recreation and the Early
Learning Coalition of Southwest Florida for a Voluntary Pre-Kindergarten
Education Program with anticipated reimbursements of $108,400 and to
authorize the County Manager and/or his designee to sign in subsequent
years.
Obiective: To provide high-quality, low-cost childcare.
Considerations: For many years the Parks and Recreation Department has provided a
preschool program for four and five year oJds, As a licensed child care facility, our
facilities qualify to participate in the State of Florida for the Voluntary Pre-Kindergarten
Education Program (VPK).
A constitutional amendment passed by Florida's voters in Nov. 2002 required a voluntary
pre-kindergarten (VPK) program for all four-year-old children by fall 2005. House Bill 1-
A was signed into law by Govemor Bush on January 2, 2005, creating a program
designed to prepare four-year-olds for kindergarten and build the foundation for their
educational success.
The program allows a parent to enroll his or her eligible child (four years old by
September 1 and residing in Florida) in a VPK program. The VPK program is FREE for
eligible children; regardless of family incomc.
The local early learning coalitions in the state are responsible for administering the
program for the counties in their service area. Community Coordinated Care for Children,
Inc (4C) works with the Early Leaming Coalition of Southwest Florida as its contractor
in coordinating the State of Florida reimburs"ment of $2,71 0 per child.
The attached agreement applies to the 2010 -- 201 I VPK program year. A new agreement
must be signed for each subsequent program year to remain eligible to deliver the VPK
program.
Five sites will be participating in this program; Immokalee Community Park, East Naples
Community Park, Max Hasse Community Park and Golden Gate Community Center.
Fiscal Impact: $108,400 in anticipated reimbursements is being budgeted in FYI I (40
children x $2,710 per child) and will be dispersed to the corresponding cost center. Total
expenses of$41 ,387 are budgeted in FYII.
Leaal Consideration: This item has been reviewed ,md approved by the County
Attomey's Office and is legally sufficient for Board action.-CMG
Agenda Item No. 1603
May 11 , 2010
Page 2 of 10
Growth Manaaement Impact: No Growth Management Impact is associated with
this action.
Recommendation: Recommendation to approve and authorize the Chairman to sign
an agreement between Collier County Parks and Recreation and the Early Learning
Coalition of Southwest Florida for a Voluntary Pre-Kindergarten Education Program with
anticipated reimbursements of $1 08,400 and to authorize the County Manager and/or his
designee to sign in subsequent years.
Prepared Bv: Shari Ferguson, Regional Manager, Parks and Recreation Department
Item Number:
Item Summary:
Meeting Date:
Agenda Item No. 16D3
May 11, 2010
Page 3 of 10
COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
1603
Recommendation to approve and authorize the Chainnan to sign an agreement between
Collier County Parks and Recreation and the Early Learning Coalition of Southwest Florida
for a Voluntary Pre-Kindergarten Education Program with anticipated reimbursements of
$108,400 and to authorize the County Manager and/or his designee to sign in subsequent
years.
5/11/20109:00:00 AM
Date
Approved By
Kathy Carpenter
Public Services
Executive Secretary
Public Services Admin.
4/2312010 1 :24 PM
Date
Approved By
Barry Williams
Public Services Division
Director - Parks & Recreation
Parks & Recreation
4/23/20102:32 PM
Date
Approved By
Marla Ramsey
Public Services Division
Administrator ~ Public Services
Public Services Division
4/28120109:50 AM
Date
Approved By
Colleen Greene
County Attorney
Assistant County Attorney
County Attorney
5/3/20109:19 AM
Date
Approved By
OMS Coordinator
County Manager's Office
Office of Management & Budget
513/201010:53 AM
Date
Approved By
Jeff Klatzkow
County Attorney
5/3/2010 11 :08 AM
Date
Approved By
Sherry Pryor
Office of Management &
Budget
Management! Budget Analyst, Senior
Office of Management & Budget
513/2010 12:48 PM
Date
Approved By
Mark Isackson
Office of Management &
Budget
Management/Budget Analyst, Senior
Office of Management & Budget
513120102:58 PM
iil\
Agenda Item No. 16D3
May 11, 2010
""'
STATE OF FLORIDA
VOLUNTARY PREKINDERGARTEN
EDUCATION PROGRAM
STATEWIDE PROVIDER AGREEMENT
I. PARTIES
1. THIS AGREEMENT is made and entered into this day of , 20~, by and
between the Early Learning Coalition of Southwest Florida , with its principal
offices located at 5256 Summerlin Commons Way, Fort Myers, FL (hereinafter referred to as "COALITION')
and with its principal offICes located
at (hereinafter referred to as "PROVIDER").
II. TERM OF AGREEMENT
2. This Agreement applies to the 20~-20~ VPK program year, including the 20~-20~ school year and summer
2022- programs. This Agreement shall begin on , or on the date on which the Agreement is signed by
the last party required to sign the Agreement, whichever occurs last, and expires upon completion of all of the PROVIDER's
VPK programs (ie., school-year program, summer program, or both programs) or August 31, 2022-, whichever occurs first.
The COALITION is not obligated to pay for costs Incurred by the PROVIDER before the Agreement's beginning date or after
its ending date.
3. The PROVIDER must complete and sign a new Agreement each subsequent program year to remain eligible to deliver the
VPK program.
III. PROVIDER ELIGIBILITY
4. The PROVIDER certifies that it has registered with the COALITION by completing and submitting to the COALITION or the
COALITION's contractor the Statewide Provider Registration Application (Form AWI-VPK 10) and Class Registration
Application (Form AWI-VPK 11). If any information submitted in any of these applications changes, the PROVIDER agrees to
notify In writing the COALITION or the COALITION's contractor immediately of the change.
5. This Agreement shall bind the successors, assigns, and legal representatives of the PROVIDER and of any legal entity that
succeeds to the obligations of the State of Florida. If the ownership or corporate structure of the PROVIDER changes, the
current PROVIDER shall notify the COALITION within 10 calendar days before the change. In addition, whenever a signatory
to the executed Agreement changes, a new Agreement must be executed.
6. The COALITION has reviewed the applications submitted by the PROVIDER and, based on the information submitted, has
determined that the PROVIDER is eligible to deliver the VPK program d~ring the program year specified in Paragraph 2.
7. Although the COALITION has determined that the PROVIDER is eligible to deliver the VPK program, the PROVIDER
understands that the COALITION has an ongoing duty to verify the PROVIDER's compliance with the Florida Statutes, state
rules, and procedures of the COALITION and the Agency for Wor1<force Innovation.
Page 1 of 9
Form
AWI-VPK 20
(02114/2007)
Statewide Provider Agreement
Agency for Workforce Innovation - Office of Early Learning
Agenda Ilem No. 16D3
May 11, 2010
Page 5 of 10
VOluntary Prekindergarten Education Program
15. The PROVIDER agrees that each of Us VPK classes in a school-year (540 instructional hours) program under
section 1002.55, Florida Statutes, or section 1002.63, Florida Statutes, if applicable, shall have for each class at least one of
the following instructors:
a. A prekindergarten instructor who:
I. Holds a child development associate (CDA) credential issued by the National Credentialing Program of the
Council for Professional Recognition or a credential approved by the Florida Department of Children and
Family Services under section 1002.55(3)(c)1.b., Florida Statutes, as being equivalent to the national CDA
credential; and
Ii. Has completed a training course approved by the Fiorida Department of Education under section 1002.59,
Florida Statutes, in emergent literacy (if completed on or after October 1, 2005) or has completed training
approved by the Florida Department of Children and Family Services under section 402,305(2)(d)5., Florida
Statutes, section 402.316(6), Florida Statutes, or section 402,3131 (5), Florida Statutes, in early literacy and
language development (if completed before October 1, 2005); or
b. A prekindergarten instructor who holds one of the educational credentials (i.e., associate's or higher degree) listed in
section 1002.55(4), Florida Statutes, or an educational credential approved by the Florida Department of Education
under section 1002.55(4)(e), Florida Statutes, as being equivalent to or greaterlhan those educational credentials.
In addition, the PROVIDER agrees that, for each VPK class composed of 11 or more children (see Paragraph 9a),
the PROVIDER shall have a second adu~ prekindergarten instructor who meels the requirements provided in
Paragraph 14 but who is not required to have the credentials or training required in this paragraph.
16. The PROVIDER agrees that each of its VPK classes in the summer (300 instructional hours) program under section 1002.61,
Florida Statutes, if applicable, shall have for each class at least one prekindergarten instructor who:
a. Is a certified teacher, or
b. Holds one of the educational credentials (i,e., bachelo(s or higher degree) listed in section 1002,55(4)(a) or (b),
Florida Statutes.
17. The PROVIDER acknowledges that each private provider is required to have a prekindergarten director who has a director
credential. The PROVIDER understands thatlhe direcliJr must have one of the following director credentials:
a. A child care facility director credential approved by the Florida Department of Children and Family Services under
section 402.305(2)(1), Florida Statutes; and
b. A VPK director endorsement approved by the Florida Department of Education under section 1002.57, Florida
Statutes (if the child care facility director credential is issued after December 31, 2006),
V. PROGRAM PERFORMANCE AND PROBATION
18. The PROVIDER understands that, in accordance with section 1002.69(5), Florida Statutes, the Florida Department of
Education shall annually calculate each provide(s kindergarten readiness rate, expressed as the percentage of VPK children
who are assessed as ready for kindergarten. The kindergarten readiness rate shall be based exclusively on. the results of the
statewide kindergarten screening for children completing the VPK program.
19. The PROVIDER understands that, in accordance wUh section 1002.67(3)(c)1., Florida Statutes, if the PROVIDER's
kindergarten readiness rate falls below the minimum rate adopted by the State Board of Education as' satisfactory, the
PROVIDER is required to submit for approval, and implement, an improvement plan.
20. The PROVIDER understands that, in accordance wUh section 1002.67(3)(c)2., Florida Statutes, if the PROVIDER's
kindergarten readiness ra1e falls below the minimum satisfactory rate for 2 consecutive years, the PROVIDER shall be placecl
on probation and be required to take certain corrective actions for the VPK program, including, but not limited to, the use of a
curriculum approved by the Florida Department of Education.
AWI-VPK 20 (02114/2007)
Statewide Provider Agreement
Page 30f9
Agency for Workforce Innovation - Office of Earlv LeaminQ
Agenda Item No. 16D3
May 11, 2010
Page 6 of 10
Voluntary Prekinderaarten Education Program
VI. CHILD ELIGIBILITY AND ENROLLMENT
21. The PROVIDER understands that the COALITION or the COALITION's contractor shall determine the eligibility of children for
enrollment in the VPK Program and shall issue to each eligible child a Certificate of Eligibility (Form AWI-VPK 02 or
substantially similar form). The PROVIDER agrees that iI shall not admit a child in the VPK program unless the child has been
determined eligible for the program by the COALITION or the COALITION's contractor.
22. The PROVIDER understands that each child's parent or guardian is responsible for finding an eligible private provider or
public school to admit the child in the VPK program and that the COALITION shall not assign children to providers or schools.
23. The PROVIDER agrees that, upon deciding to admit a child in the VPK program, the PROVIDER shall notify the COALITION
or the COALITION's contractor of the enrollment in accordance with procedures of the COALITION and the Agency for
Workforce Innovation. The PROVIDER understands that iI shall not be paid for a child who is not enrolled with the
COALITION.
24. The PROVIDER understands that iI may deliver the VPK program for children who reside in a Florida county other than the
Florida county where the PROVIDER is located,
25. The PROVIDER agrees to follow the Agency for WorKforce Innovation's procedures for delayed enrollments (i.e., enrolling a
child in the VPK program after part of the program instruction has been delivered for other children in the child's VPK class').
VII, CHILD ATTENDANCE AND DISCIPLINE
26. The PROVIDER agrees that, in accordance with section 1002.71(6)(a), Florida Statutes, the PROVIDER shall provide a copy
of its attendance policy in writing to the parent or guardian of each child upon enrollment of the child in the VPK program.
27. The PROVIDER agrees that, if it removes (e.g., dismisses) a child from the VPK program, the PROVIDER shall, in
accordance with the COALITION's procedures, submil to the COALITION or the COALITION's contractor documentation
specifying reasons for removing the child from the program. The PROVIDER understands that, until the PROVIDER submits
to the COALITION or the COALITION's contractor documentation specifying reasons for removing the child, the COALITION
may withhold payment of funds for all children that the PROVIDER serves in the VPK program.
28. The PROVIDER agrees to document, in accordance with procedures of the COALITION and the Agency for Workforce
Innovation, the daily attendance of each child enrolled with the PROVIDER in the VPK program.
29. The PROVIDER understands that, in accordance with section 1002.71(6)(b)2., Florida Statutes, the parent or guardian of
each child in the VPK program must verify, each month, the child's attendance on the prior month's certified child attendance,
The PROVIDER agrees, in accordance wilh procedures of the COALITION and the Agency for Workforce Innovation, to
collect from each child's parent or guardian Form AWI-VPK 03S or Form AWI-VPK '03L (Student Attendance and Parental
Choice Certificate) signed by the parent or guardian. The PROVIDER agrees to keep each original signed form for at least 2
years in accordance with section 1002.71(6)(b)3., Florida Statutes.
VIII. NONDISCRIMINA nON
30. The PROVIDER understands that, in accordance with section 1002.53(6)(c), Florida Statutes, the PROVIDER may not
discriminate against a parent or child, including the refusal to admit a child for enrollment in the VPK program, on the ground
of race, color, or national origin.
, AWl policies and procedures may be viewed at: http.//www.floridajobs.org/earlylearning/IMP!.htm!.
AWI-VPK 20 (0211412007)
Statewide Provider Agreement
Page4of9
AQency for Workforce Innovation - Office of Earlv Learning
Agenda Item No. 16D3
May 11, 2010
Page 7 of 10
Voluntary Prekindergarten Education Proaram
31. The PROVIDER understands that, in accordance with section 1 002.71 (8)(a), Florida Statutes, the PROVIDER may not require
payment of a fee or charge for services provided for a child in the VPK program during instructional hours reported for funding.
32, The PROVIDER understands that, in accordance with section 1002.71(8)(b), Florida Statutes, the PROViDER may not require
a child to enroll for, or require the payment of any fee or charge for, supplemental services (e.g., "extended-day,"
"extended-year: 'wrap-around," or "full-day" services) as a condition of admitting the child in the VPK program.
IX. COMPENSATION I FUNDING
33, The PROVIDER understands that, in accordance with section 1002.71(5)(b), Florida Statutes, the PROVIDER shail receive a
prepayment each month based on the PROVIDER's child enrollment in the VPK program. The PROVIDER understands that
prepayments shall be reconciled and adjusted based on actual chiid attendance in the program in accordance with the Agency
for Workforce Innovation's unifonn attendance policy' The PROVIDER further understands that, if the PROVIDER and the
COALITION mutually agree in writing, instead of receiving prepayments, the PROVIDER shall receive a payment each month
based on reimbursement for actual child attendance in the program.
34. The PROVIDER shall return to the COALITION any overpayment due to unearned funds or as result of error or funds
disallowed under this Agreement. If the PROVIDER discovers an overpayment the PROVIDER shall repay the overpayment
y,;thin the timefrarne specified by the COALITION without prior notification from the COALITION. If the COALITION discovers
an overpayment, the COALITION shall notify the PROVIDER of the overpayment by mail. If repayment is not made by the
date specified by the COALITION, the COALITION is entitled to withhold funds from the next month's prepayment or payment.
35. The PROVIDER agrees that, if the end-of-year reconciliation results in a deficiency, the COALITION may withhold funds from
any payments, including school readiness, owed to the PROVIDER to cover the deficiency. If the PROVIDER ceases to
deliver the VPK program, the PROVIDER agrees to return the deficient funds. If the PROVIDER fails to retum the deficient
funds, the PROViDER is subject to collection efforts
36. The PROVIDER understands that, in accordance with section 1002.71, Florida Statutes, payments for a child shall not exceed
funding for one full-time equivalent (FTE) child. The PROVIDER further understands that, in accordance with
section 1002.71(3)(b), Florida Statutes, an HE child is calculated annually by multiplying the base child allocation provided in
the General Appropriations Act by the county's district cost differential provided in section 1011.62(2), Florida Statutes.
37. The PROVIDER agrees to follow all payment procedures adopted by the COALITION and the Agency for WorUorce
Innovation.
38, If the PROVIDER is a Head Star! Agency, the PROVIDER understands that, in accordance with federal law, the PROVIDER's
Head Star! programs must be "in addition to, and not in substttution for, comparable services previously provided without
Federal assistance" (Title 42, United States Code, section 9835(c)}.
39. If the PROVIDER receives federal funds under Title 20, United States Code, sections 6311-6322 (Title I), the PROVIDER
understands that, in accordance with federal law, the PROVIDER may "use [those Title I] Federal funds to supplement, [but]
not [to] supplant non-Federal funds' (Title 20, United States Code, section 6314(a)(3)(B)}.
X. NOTIFICATION
40. The PROVIDER agrees that it shall follow the notification requirements adopted by the COALITION for completing the class
transfer of a child.
" A WI policies and procedures may be viewed at: http://www.noridajobs.org/earlylearningIIMPl.hlml.
AWI-VPK 20 (02/14/2007)
Statewide Provider Agreement
Page5of9
Agency for Workforce Innovation - OffICe of Ear1y Learning
Agenda Item No. 1603
May 11, 2010
Page 8 of 10
Voluntary PrekinderQarten Education Program
41. The PROVIDER agrees that ~ shall follow the notification requirements adopted by the COALITION for submitting written
documentation given to the PROVIDER describing a child's absences for 'good cause.'
42 The PROVIDER agrees that it shall follow the requirements adopted by the COALITION for notifying the COALITION of all
changes in VPK class schedules.
43, The PROVIDER agrees that it shall follow the requirements adopted by the COALITION for notifying the COALITION of all
changes in prekindergarten instructors and prekindergarten directors.
44. The PROVIDER agrees that ~ shall follow the notification requirements adopted by the COALITION for submitting written
documentation demonstrating the temporary closure of the PROVIDER's VPK s~e which is beyond the PROVIDER's control.
45. The PROVIDER understands that failure to follow the COALITION's notification requirements is noncompliance with this
Agreement and may resutt in corrective action under Paragraph 52.
46. Each of the COALITION's notification requirements described in Paragraphs 40-45 is listed in Attachment _ and is part
of this Agreement.
XI. MAINTENANCE OF RECORDS I CONFIDENTIALITY
47. The PROVIDER agrees that it shall keep all VPK records of a child (except as allowed in Paragraph 29) for at least 3 years
after the child's last day of attendance, and recorns of a prekindergarten instructor or prekindergarten director for at least
3 years after the employee's last day of employment (except as required by the Agency for Workforce Innovation's
procedures') or, to the extent required, in accornance with the retention schedules and disposal process adopted under
section 119.021(2), Florida Statutes, whichever is greater.
48. The PROVIDER understands that, in accordance w~h section 1002.72, Florida Statutes, recorns of children enrolled in the
VPK program are confidential. The PROVIDER shall keep all VPK records confidentiai and disclose the recorns only in
accornance with law. The PROVIDER shall follow the Florida Public Recorns Act (chapter 119, Florida Statutes) and other
applicable laws regardin9 disclosure of any confidential information received by the State of Florida, the Agency for Workforce
Innovation, or the COALITION.
49. The PROVIDER understands that a parent of a VPK child has the right to inspect and review the individual records of his or
her child and obtain a copy of the records.
XII. COMPLIANCE VERIFICATION
50. The PROVIDER shall permit the COALITION, the COALITION's contractor, or the Agency for Workforce Innovation, at any
reasonable time, to enter the PROVIDER's VPK program site to verify the PROVIDER's compliance with this Agreement and
with the requirements of the VPK program as set forth in the Florida Statutes, state rules, and procedures of the COALITION
and the Agency for Workforce Innovation. This paragraph does not authorize the COALITION to enforce licensing
requirements under sections 402.301-402.319, Florida Statutes, or impose any requirement beyond this Agreement and the
requirements of the VPK program as set forth in the Florida Statutes, state rules, and procedures. .
51. The PROVIDER shall allow the COALITION, the COALITION's contractor, or the Agency for Workforce Innovation, to inspect
and copy the recorns maintained by the PROVIDER concerning the VPK program, prekindergarten instructors,
prekindergarten directors, and VPK children.
52. The COALITION may require the PROVIDER to submit corrective action plans for noncompliance under this Agreement.
. AWl policies and procedures may be viewed at: htrp:l/www.floridajobs.orglearfyleaminglIMPI.html.
A\M-VPK 20 (02/14/2007)
Statewide Provider Agreement
Page 6 of 9
AQency for Workforce Innovation - Office of Early Learning
Agenda Item No. 1603
May11,2010
Page 9 of 10
Voluntary Prekindergarten Education Program
53. The PROVIDER's noncompliance with any term in this Agreement may result in the COALITION wrthhoiding funds.
54. The COALITION shall notify the PROVIDER in writing of any financial penalties. The COALITION may deduct the amount of
the penalty from invoices submitled by the PROVIDER.
XIII. TERMINATION
55. The PROVIDER and the COALITION may agree to terminate this Agreement by mutual agreement. Notice of termination
must be given, and alternative arrangements for uninterrupted services shall be made for children enrolled with the
PROVIDER in the VPK program, at least 30 calendar days before the termination date.
56. If the PROVIDER withdraws as a provider from the VPK program, the PROVIDER must give notice to the COALITION or the
COALITION's contractor, and altemative arrangements for uninterrupted services shall be made for children enrolled with the
PROVIDER in the VPK program, at least 30 calendar days before the termination date.
57. If the PROVIDER fails to comply with all terms and conditions of this Agreement and with all requirements of the VPK program
as set forth in the Florida Statutes, state rules, and procedures of the COALITION and the Agency for Workforce Innovation"
the COALITION shall notify the PROVIDER in writing and give the PROVIDER a period to comply, which period must be at
least 10 days and shall be specified by the COALITION. If the PROVIDER does not comply within the period given. the
COALITION may terminate this Agreement.
58. If funds required to finance this Agreement become unavailable, the COALITION may terminate this Agreement with prior
writlen notice of at least 24 hours before termination. This notice of termination due to lack of funds must be delivered in
person with proof of delivery or by ceriified mail with return receipt requested The COALITION is the final authority as to the
availability of funds. The COALITION shall not reallocate funds earmarj(ed for this Agreement to another program, thereby
causing the "lack of funds." In the event of termination of this Agreement, the PROVIDER shall be paid for the instructional
hours completed through the termination date.
59. Any obligation for payment under this Agreement is contingent upon an annual appropriation by the Legislature. If the funds
upon which this Agreement depends are wrthdrawn or redirected, the Agreement is terminated and the COALITION has no
further liability to the PROVIDER beyond payment for the instructional hours completed through the termination date.
XIV. DISPUTE RESOLUTION
60. The PROVIDER agrees to submit any disputes or disagreements concerning this Agreement in writing to the COALITION or
the COALITION's contractor. The COALITION agrees to respond to the dispute or disagreement within 10 business days after
receiving the dispute or disagreement. If the PROVIDER is dissatisfied with the response, the COALITION agrees to allow the
PROVIDER to bring the dispute or disagreement before a quorum of the membership of the COALITION or a standing
commitlee of the coalition composed exclusively of voting members for a final decision.
. AWl pOlicies and procedures may be viewed at: http.//wwwfloridajobs.org/earlyleaming/IMPI.hlml.
AW.VPK 20 (02/14/2007)
Statewide ProVIder Agreement
Page 7 019
Agency for Workforce Innovation - Office of Ea~y Learning
Agenda Item No. 16D3
May 11, 2010
Page 10 of 10
VOluntary Prekinderg8~en Education Progrem
XVIII. EXECUTION OF AGREEMENT
The PROVIDER has caused this Agreement to be executed as of the date set forth in Paragraph
Colleen Greene,
Assl81ant County Attorney
Signature of Director / Operator / Principal
or Authorized Representative
Title
Print Name
Date
ATTEST:
DWIGHT E. BROCK, Clerk
By:
o
."
...
-
o
z
)>
r-
STATE OF FLORIDA
COUNTY OF
THE FOREGOING was acknowledged before me this
20~ by
day of
, who is personally known to me/presented
as identification, and who did not take an oath.
WITNESS my hand and official seal in the County and State set forth above.
NOTARY PUBLIC
The COALITION has caused this Agreement to be executed as of the date set forth in Paragraph 1.
Melanie Holaway
Print Name
Signature of Coalition Executive Director
or Authorized Representative
Director of Provider Services
Title
Date
o
."
...
-
o
z
)>
r-
STATE OF FLORIDA
COUNTY OF
THE FOREGOING was acknowledged before me this
20_. by
day of
, who is personally known to me/presented
as identification, and who did not take an oath.
WITNESS my hand and official seal in the County and State set forth above.
NOTARY PUBLIC
AWI.VPK 20 (0211412007)
Statewide Provider Agreement
Page 9 of 9