Backup Documents 04/09/2013 Item #16D 6 ,
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 6
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. Steve Smith HHVS y4 q 9- i3
2. Jennifer White Office within HHVS
3. County Attorney Office County Attorney Office
4. BCC Office Board of County Gl�
Commissioners /S1 'N\\Z\VD
5. Minutes and Records Clerk of Court's Office eP(r 1-1112 ((I 3 Pn
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 Steve Smith, \.-Nsz\I �>v�v�.1.._ Phone Number 252-7787
Contact/ Department �e\-env, Se,f'•f PP1egs_e Se,J Copy
Agenda Date Item was 4/9/2013 Agenda Item Number 16D6 J
Approved by the BCC
Type of Document Assurances Number of Original one
Attached Documents Attached
PO number or account
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? 4/6
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
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 d/R
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. /Yw
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 /WA
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on I- -(enter date)and all changes made //��
during the meeting have been incorporated in the attached document. The County St'4'
Attorney's 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 the (311v
Chairman's 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
1606
MEMORANDUM
Date: April 15, 2013
To: Steve Smith, RSVP Coordinator
Housing, Human & Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Assurances
Attached for your records is a copy of the document as referenced above (Item
#16D6) approved by the Board of County Commissioners on April 9, 2013.
The Minutes and Records Department will maintain the original in the Board's
Official Records.
If you have any questions, please contact me at 252-8411.
Thank you.
Attachment
1 6 0 6 _ .
ASSURANCES
As the duly authorized representative of the applicant,I certify,to the best of my knowledge and belief,that the applicant:
1. Has the legal authority to apply for federal assistance,and the institutional, 8. Will comply with the provisions of the Hatch Act(5 U.S.C.1501-1508 and
managerial,and financial capability(including funds sufficient to pay the 7324-7328)which limit the political activities of employees whose principal
non-federal share of project costs)to ensure proper planning,management, employment activities are funded in whole or in part with Federal funds.
and completion of the project described in this application. 9. Will comply,as applicable,with the provisions of the Davis-Bacon Act(40
2. Will give the awarding agency,the Comptroller General of the United U.S.0 276a and 276a-77),the Copeland Act(40 U.S.0 276c and 18 U.S.C.
States,and if appropriate,the state,through any authorized representative, 874),and the Contract Work Hours and Safety Standards Act(40 U.S.C.
access to and the right to examine all records,books,papers,or documents 327-333),regarding labor standards for Federally assisted construction sub-
related to the award;and will establish a proper accounting system in agreements.
accordance with generally accepted accounting standards or agency 10. Will comply,if applicable,with flood insurance purchase requirements of
directives. Section IO2(a)of the Flood Disaster Protection Act of 1973(P.L.93-234)
3. Will establish safeguards to prohibit employees from using their position which requires the recipients in a special flood hazard area to participate in
for a purpose that constitutes or presents the appearance of personal or the program and to purchase flood insurance if the total cost of insurable
organizational conflict of interest,or personal gain. construction and acquisition is 510,000 or more.
4. Will initiate and complete the work within the applicable time frame after 11. Will comply with environmental standards which may be prescribed
receipt of approval of the awarding agency. pursuant to the following:(a)institution of environmental quality control
5. Will comply with the Intergovernmental Personnel Act of 1970(42 U.S.C. measures under the National Environmental Policy Act of 1969(P.L.91-
4728-4763)relating to prescribed standards for merit systems for programs 190)and Executive Order(EO)11514;(b)notification of violating facilities
funded under one of the nineteen statutes or regulations specified in pursuant to EO 11738;(c)protection of wetlands pursuant to EO 11990;(d)
Appendix A of OPM's Standards for a Merit System of Personnel evaluation of flood hazards in floodplains in accordance with EO 11988;(e)
Administration(5 CFR 900,Subpart F). assurance of project consistency with the approved state management
program developed under the Coastal Zone Management Act of 1972(16
6. Will comply with all federal statutes relating to nondiscrimination. U.S.0 1451 et seq.);(f)conformity of federal actions to State(Clean Air)
These include but are not limited to:Title VI of the Civil Rights Act of hnplementation Plans under Section 176(c)of the Clean Air Act of 1955,as
1964(P.L.88-352)which prohibits discrimination on the basis of amended(42 U.S.C.7401 et seq.);(g)protection of underground sources of
race,color,or national origin;(b)Title IX of the Education drinking water under the Safe Drinking Water Act of 1974,as amended
Amendments of 1972,as amended(20 U.S.C.1681-1683,and (P.L.93-523);and(h)protection of endangered species under the
1685-1686).which prohibits discrimination on the basis of sex;(c) Endangered Species Act of 1973,as amended(P.L.93-205).
Section 504 of the Rehabilitation Act of 1973,as amended(29
U.S.C.794),which prohibits discrimination on the basis of disability 12. Will comply with the Wild and Scenic Rivers Act of 1968(16 U.S.0 1271
(d)The Age Discrimination Act of 1975,as amended(42 U.S.C. et seq.)related to protecting components or potential components of the
6101-6107),which prohibits discrimination on the basis of age;(e) national wild and scenic rivers system.
The Drug Abuse Office and Treatment Act of 1972(P.L.92-255),as 13. Will assist the awarding agency in assuring compliance with Section 106 of
amended,relating to nondiscrimination on the basis of drug abuse; the National Historic Preservation Act of 1966,as amended(16 U.S.C.
(f)The Comprehensive Alcohol Abuse and Alcoholism Prevention, 470),EO 11593(identification and protection of historic properties),and
Treatment and Rehabilitation Act of 1970(P.L.91-616),as the Archaeological and Historic Preservation Act of 1974(16U.S.C.469a-I
amended,relating to nondiscrimination on the basis of alcohol abuse et seq.).
or alcoholism;(g)sections 523 and 527 of the Public Health Service 14. Will comply with P.L.93-348 regarding the protection of human subjects
Act of 1912(42 U.S.C.290dd-3 and 290ee-3),as amended,relating involved in research,development,and related activities supported by this
to confidentiality of alcohol and drug abuse patient records;(h)Title award of assistance.
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 15. Will comply with the Laboratory Animal Welfare Act of 1966(P.L.89-544,
of housing;(i)any other nondiscrimination provisions in the National as amended,7 U.S.C.2131 et seq.)pertaining to the care,handling,and
and Community Service Act of 1990,as amended;and(j)the treatment of warm blooded animals held for research,teaching,or other
requirements of any other nondiscrimination statute(s)which may activities supported by this award of assistance.
apply to the application. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act(42
7. Will comply,or has already complied,with the requirements of Titles II and U.S.C.§§4801 et seq.)which prohibits the use of lead based paint in
III of the Uniform Relocation Assistance and Real Property Acquisition construction or rehabilitation of residence structures.
Policies Act of 1970(P.L.91-646)which provide for fair and equitable 17. Will cause to be performed the required financial and compliance audits in
treatment of persons displaced or whose property is acquired as a result of accordance with the Single Audit Act of 1984,as amended,and OMB
federal or federally assisted programs.These requirements apply to all Circular A-133,Audits of States,Local Governments,and Non-Profit
interests in real property acquired for project purposes regardless of federal Organizations.
participation in purchases. 18. Will comply with all applicable requirements of all other Federal laws,
executive orders,regulations,application guidelines,and policies governing
this program.
SIGNA : • '• H•; ZED CERTIFYING OFFICIAL "9-/3 TITLE
GSA \ CZ�o�M,41tJ
APPLI �;!' • •TION DATE SUBMITTED
C. e r Co a n y Qoca_roL o-'CZ)J r‘-t-/
ComrniSStd.ev_rs
as to form & legal Sufficiency
ATTEST!"` 4
DWI e T E. BROCI 1,Clerk 21
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