Backup Documents 01/08-09/2013 Item #16E 6ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original
documents are to be forwarded to the Board Office only after the Board has taken action on the item.)
ROUTING SLIP
Complete routing lines #I through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
exce tion of the Chairman's signature, draw aline throu routing lines #1 through #4, complete the checklist, an d forward to Sue Filson line #5 .
Route to Addressee(s)
Office
Initials
Date
List in routing order
appropriate.
Initial
Applicable)
Agenda Date Item was
OMB
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01/08/13
1. Joshua Thomas, Grants Support
signed by the Chairman, with the exception of most letters, must be reviewed and signed
Specialist
Grant Application
Number of Original
1
2. Jennifer B. White, ACA
County Attorney
Documents Attached
3.County Attorney's Office
County Attorney
Chairman and Clerk to the Board and possibly State Officials.
4. BCC Office
Board of County Commissioners
t
�tl
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. Minutes and Records
Clerk of Court's Office
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document or the final negotiated contract date whichever is applicable.
4.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
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PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pending BCC approval. 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, including Sue Filson, need to contact staff for additional or missing
information. All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the
item.
Name of Primary Staff
Joshua Tho as
Phone Number
252 -8989
Contact
appropriate.
Initial
Applicable)
Agenda Date Item was
01/08/13
Agenda Item Number
16 E -6
Approved by the BCC
signed by the Chairman, with the exception of most letters, must be reviewed and signed
Type of Document
Grant Application
Number of Original
1
Attached
resolutions, etc. signed by the County Attorney's Office and signature pages from
Documents Attached
INSTRUCTIONS & CHECKLIST
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Rev ed 2.24.
Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is
Yes
N/A (Not
appropriate.
Initial
Applicable)
1.
Original document has been signed/initialed for legal sufficiency. (All documents to be
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signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office of the County Attorney. This includes signature pages from ordinances,
resolutions, etc. signed by the County Attorney's Office and signature pages from
contracts, agreements, etc. that have been fully executed by all parties except the BCC
Chairman and Clerk to the Board and possibly State Officials.
2.
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
3.
The Chairman's signature line date has been entered as the date of BCC approval of the
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document or the final negotiated contract date whichever is applicable.
4.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
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signature and initials are required.
5.
In most cases (some contracts are an exception), the original document and this routing slip
N/A
should be provided to Sue Filson in the BCC office within 24 hours of BCC approval.
��
Some documents are time sensitive and require forwarding to Tall assee within a certain
time frame or the BCC's actions are nullified. Be aware of your d adlines!
6.
The document was approved by the BCC on 01/08/13 (enter date) and all
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changes made during the meeting have been incorporated in the attached document.
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The County Attorney's Office has reviewed the changes, if applicable.
"�
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Rev ed 2.24.
MEMORANDUM
Date: January 15, 2013
To: Joshua Thomas, Support Specialist
Grants Management Department
From: Teresa Cannon, Deputy Clerk
Minutes and Records
Re: Volunteer Fire Assistance Grant Application
Attached is an original copy of the document referenced above, (Item #16E6)
approved by the Board of County Commissioners on January 8, 2013.
If you have any questions, please contact me at 252 -8411.
Thank you.
Attachment (1)
16E6
i001
ADAM H. PUTNAM
COMMISIONER
Florida Department of Agriculture and Consumer Services 16E6
Florida Forest Service
VOLUNTEER FIRE ASSISTANCE GRANT APPLICATION
LOCATED IN AN
YES ❑ NO Q9 IF YES, NAME OF TOWN:
POPULATION OF TOWN:
PROTECTED AREA: EST. POPULATION:! "3,200 SIZE: (SQ. MILES)f�
II i
WHAT IS THE FIRE DEPARTMENT ISO RATING? r4 - -- _
IS FIRE DEPARTMENT NIMS COMPLIANT? YES ® NO ❑
CURRENT COOPERATIVE AGREEMENT WITH FFS? YES ® NO ❑
DISTANCE OF CLOSEST MUTUAL AID FIRE DEPARTMENT: ml.
NAME OF FIRE DEPARTMENT: 1—Marco Island _
NUMBER OF FIREFIGHTERS: PAID: i 13 VOLUNTEERS: r 4 HAS APPLICANT RECEIVED GRANT FUNDS FROM ANY SOURCE IN
_ THE PAST 12 MONTHS? YES 0_ NO ❑
NO. OF INCIDENTS PAST YEAR: WILDLAND FIRE: F 8 __ OTHER.' 380 IF YES, WHERE? Florida Forest Service
NO. OF FIREFIGHTERS CERTIFIED AS:
WILDLAND FIREFIGHTER / 12 WILDLAND FIREFIGHTER ll 0 - AMOUNT: $ r 4,900.00
LIST TOTAL FUNDS RECEIVED FROM OTHER TAXING AUTHORITIES
SUCH AS CITY, COUNTY, TAXING DISTRICTS (Past 12 Months)
AMOUNT: $ F 0 _ -- -v
LIST OF FIREFIGHTING VEHICLES:
TYPE
MAKE/YR.MODEL
PUMP CAPACITY (GPM)
WATER CAPACITY (GAL.)
Engine
E -One 2005 Typhoon
1500
780
Engine
E -One 2005 Typhoon
1500
780
Brush
Ford F250 Pick -Up
120
200
TOTAL
ESTIMATED GRANT FUNDING REQUEST:
Title Chairwoman,
LIST OF EQUIPMENT
OR SUPPLIES TO PURCHASE WITH GRANT FUNDS:
FEDERAL
$ 1,260.00
NUMBER
DESCRIPTION
AMOUNT
APPLICANT
$ 1,260.00
36
5 gallon pails of Class A Foam
2,520.00
COUNTY
$
TOTAL
$ 2,520.00
(Federal not more than 50% of total. Applicant at least 50% of
total in matching funds.)
We understand that this is a 50 percent maximum cost -share program (Cooperative Forestry Assistance Act of 1978, PL 95 -313), and that funds on
deposit up to 50 percent of the actual purchase price of the items approved will be committed to our project. TO THE BEST OF MY KNOWLEDGE AND
BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE GOVERNING BODY OF THE APPLICANT HAS DULY AUTHORIZED
THIS DOCUMENT.
Type Name of Authorized Representative
Title Chairwoman,
Telephone Number: ( 239 ) 394 -8770
Georgia A. Hiller
Board -pf County Commissioners
FAX: ( 239) 394 -5862
Signature of th , 6iz .14 R presentative ,.
Dfi a Signed and 6,pbmitted
Email:
vr+vv- � I �RpY RG V. ;Iuu A I 1 t.71: `.
DW I E pR CK, Clerk
—Frnvvww we w rvrtn a legal SUMCMMY
Form AD -1047 (ii92)
U. S DEPARTMENT OFACRICULTURE
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
16E6
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,
7 CFR Part 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part IV of the
January 30, 1989, Federal Re,2ister(pages 4722 - 4733). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the proposed covered transaction.
(Before completing certification, read instructions on reverse.)
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) have not within a three -year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under a
public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen
property;
(c) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State or Local) with commission of any of the offenses enumerated in paragraph (1)(b) of this
certification; and
(d) have not within a three -year period preceding this application /proposal had one or more public
transactions (Federal, State or Local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
NAME
Collier County Board of County Commissioners
NAME AND TITLE OF AUTHORIZED
Georgia A. Hiller, Chairwoman
SIGNATURE
t
ZZ"tE BRO Clerk
!►'litre 7i::R
PR/AWARD NUMBER OR PROJECT NAME
Isles of Capri Fire Rescue District
I DATE
Ot-a,�-13
APiMV*d es to form & legal Sufgcjoey
Asa ant County Attorney
Form AD-1 047 (i/92) (REVERSE)
INSTRUCTIONS FOR CERTIFICATION
16E6
I . By signing and submitting this form, the prospective primary participant is providing the certification set out
on the reverse side in accordance with these instructions.
2. The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective participant shall submit an explanation of why it
cannot provide the certification set out on this form. The certification or explanation will be considered in
connection with the department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such
person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency determined to enter into this transaction. If it is later determined that the prospective
primary participant knowingly rendered an erroneous certification, in addition to other remedies available to
the Federal Government, the department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the department or agency to
whom this proposal is submitted if at any time the prospective primary participant learns that its certification
was erroneous when submitted or has become erroneous by reason of changed circumstances.
5. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as
used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which this proposal is
being submitted for assistance in obtaining a copy of those regulations.
6. The prospective primary participant agrees by submitting this form that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person
who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency entering into this transaction.
7. The prospective primary participant further agrees by submitting this form that it will include this clause
titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier
Covered Transactions," provided by the department or agency entering into this covered transaction, without
modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may, but is not required to,
check the Nonprocurement List.
9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order
to render in good faith the certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a prudent person in the ordinary
course of business dealings.
10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency may terminate this transaction for cause or
default.
2
16E6
ASSURANCES —NON- CONSTRUCTION PROGRAMS OMB Approval No. 0348 -0040
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency.
Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be
notified.
As the duly authorized representative of the applicant I certify that the applicant:
1. Has the legal authority to apply for Federal assistance, and the
institutional, managerial and financial capability (including funds
sufficient to pay the non - Federal share of project costs) to ensure
proper planning, management and completion of the project
described in this application.
2. Will give the awarding agency, the Comptroller General of the
United States, and if appropriate, the State, through any authorized
representative, access to and the right to examine all records, books,
papers, or documents related to the award; and will establish a proper
accounting system in accordance with generally accepted accounting
standards or agency directives.
3. Will establish safeguards to prohibit employees from using
their positions for a purpose that constitutes or presents the
appearance of personal or organizational conflict of interest, or
personal gain.
4. Will initiate and complete the work within the applicable time
frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970
(42 U.S.C. §§ 4728 -4763) relating to prescribed standards for merit
systems for programs funded under one of the nineteen statutes or
regulations specified in Appendix A of OPM's Standards for a Merit
System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to: (a)Title VI
of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title
IX of the Education Amendments of 1972, as amended (20 U.S.C. §§
1681 -1683, and 1685 - 1686), which prohibits discrimination on the
basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. § 794), which prohibits discrimination on the
basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. §§ 6101 - 6107), which prohibits discrimination
on the basis of age;
(e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-
255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616),
as amended, relating to nondiscrimination on the basis of alcohol
abuse or alcoholism; (g) §§ 523 and 527 of the Public Health Service
Act of 1912 (42 U.S.C. 290 -dd -3 and 290 ee -3), as amended, relating
to confidentiality of alcohol and drug abuse patient records; (h) Title
VIII of the Civil Rights Act of 1968 (42 U.S.C. § 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing
of housing; (1) any other nondiscrimination provisions in the specific
statute(s) under which application for Federal assistance is being
made; and 0) the requirements of any other nondiscrimination
statute(s) which may apply to the application.
7. Will comply, or has already complied, with the requirements of
Titles 11 and III of the Uniform Relocation Assistance and Real
Property Acquisition Policies Act of 1970 (P.L. 961 -646) which
provide for fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or federally assisted
programs. These requirements apply to all interests in real property
acquired for project purposes regardless of Federal participation in
purchases.
8. Will comply with the provisions of the Health Act (5 U.S.C. §§
1501 -1508 and 7324 -7328) which limit the political activities of
employees whose principal employment activities are funded in
whole or in part with Federal funds.
9. Will comply, as applicable, with the provisions of the Davis -
Bacon Act (40 U.S.C. §§ 276a to 276a -7), the Copeland Act (40
U.S.C. § 276c and 18 U.S.C. §§ 874), and the Contract Work Hours
and Safety Standards Act (40 U.S.C. §§ 327 -333), regarding labor
standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase
requirements of Section 102 (a) of the Flood Disaster Protection Act
of 1973 (P.L. 93 -234) which requires recipients in a special flood
hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable
construction and acquisition of $10,000 or more.
11. Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of environmental
quality control measures under the National Environmental Policy
Act of 1969 (P.L. 91 -190) and Executive Order (EO) 11514; (b)
notification of violating facilities pursuant to EO 11738; (c)
protection of wetlands pursuant to EO 11990; (d) evaluation of flood
hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management program
developed under the Coastal Zone Management Act of 1972 (16
U.S.C. §§ 1451 et seq.); (f) conformity of Federal actions to State
(Clear Air) Implementation Plans under Section 176(c) of the Clear
Air Act of 1955, as amended (42 U.S.C. § 7401 et seq.); (g)
protection of underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended, (P.L. 93 -523); and (h)
protection of endangered species under the Endangered Species Act
of 1973, as amended, (P.L. 93 -205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16
U.S.C. §§ 1271 et seq.) related to protecting components or potential
components of the national wild and scenic rivers system.
V, 8-5 (02/05)
Authorized for Local Reproduction
Standard Form 424B (9- 03)Prescribed by OMB Circular A -102
13. Will assist the awarding agency in assuring compliance with
Section 106 of the National Historic Preservation Act of 1966, as
amended (16 U.S.C. 470), EO 11593 (identification and protection of
historic properties), and the Archeological and Historic Preservation
Act of 1974 (16 U.S.C. 469a -1 et seq.).
14. Will comply with P.L. 93 -348 regarding the protection of
human subjects involved in research, development, and related
activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966
(P.L. 89 -544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the
care, handling, and treatment of warm blooded animals held for
i
16E6
research, teaching, or other activities supported by this award of
assistance.
16. Will comply with the Lead -Based Paint Poisoning Prevention
Act (42 U.S.C. §§ 4801 et seq.) which prohibits the use of lead based
paint in construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit Act of 1984.
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations and policies governing
this program.
SIGNAT RE F T ORIZED CERTIFYING OFFICIAL
TITLE
Chairwoman, Board of County Commissioners
APPLIdAW CAGANIZATION
DATE
Collier County Board of County Commissioners
SUBMI -U D
Cs -13 V -I�
ATTEST; - ,
D X T E. 9ROCK, Clerk
''h
V, B-6 (02/05)
Authorized for Local Reproduction)
Standard Form 424B (9 -03
Prescribed by OMB Circular A -102
Appmed as to form & legal Sulftl RCy
A881 ant County Attorney