Backup Documents 10/08/2013 Item #16K 1ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16KI
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.
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 Addressees (List in routing order)
Office
Initials
Date
1.
Attorney
Initial
2.
October 8, 2013
Agenda Item Number
16 -K -1
3. Kevin L. Noell, ACA
County Attorney Office
N/A
4. BCC Office
Board of County
Commissioners
G� h
3
5. Minutes and Records
Clerk of Court's Office
Documents Attached
j a1ll
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
Kevin L. Noell, ACA, Office of the County
Phone Number
252 -8400
Contact / De artment
Attorney
Initial
Agenda Date Item was
October 8, 2013
Agenda Item Number
16 -K -1
Approved by the BCC
Does the document need to be sent to another agency for additional signatures? If yes,
N/A
Type of Document
Settlement Agreement and Mutual Release
Number of Original
3
Attached
Original document has been signed/initialed for legal sufficiency. (All documents to be
Documents Attached
PO number or account
signed by the Chairman, with the exception of most letters, must be reviewed and signed
number if document is
`
to be recorded
Sct� `c�cx��a k a.�►\
N/A
STRUCTIONS & CHECKLIST
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
Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is
Yes
N/A (Not
appropriate.
Initial
1.
Does the document require the chairman's original signature?
KLN
_Applicable)
2.
Does the document need to be sent to another agency for additional signatures? If yes,
N/A
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
KLN
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
N/A
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
KLN
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
KLN
signature and initials are required.
7.
In most cases (some contracts are an exception), the original document and this routing slip
N/A
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 t Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of our deadlines!
8.
The document was approved by the BCC on 10/08/131 and all changes made
KLN
during the meeting have been incorporated in the attached document. The County
Attorney's Office has reviewed the changes, if applicable.
9.
Initials of attorney verifying that the attached document is the version approved by
N
BCC, all changes directed by the BCC have been made, and the document is ready r n
f
Chairman's signature.
"I,/
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
16K1
MEMORANDUM
Date: October 14, 2013
To: Kevin Noell, Assistant County Attorney
County Attorney's Office
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Settlement Agreement & Mutual Release w /Elayne Jackson
Attached are two (2) originals as referenced above, (Agenda Item #16K1) approved by the
Board of County Commissioners on Tuesday, October 8, 2013.
An original has been kept by the Minutes and Record's Department as part of the
Board's Official Records.
If you have any questions, please contact me at 252 -8411.
Thank you.
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Omm OF TfiE COUPTY ATTOitNEY
INTEROFFICE MEMORANDUM
TO: Minutes & Records / Recording
FROM: Marian R. Colli, Advanced Certified Paralegal�Aa'
DATE: October 9, 2013
RE: Redacting Exempt Information Prior to Recording
Pursuant to your request to our office, this memorandum is to request that you redact the
following information from the attached Settlement Agreements, relating to the Elayne Jackson
lawsuit:
1. On the first page of Exhibit 1, the handwritten birth date and both Medicare claim
numbers, all of which can identify Ms. Jackson. (It will need to be redacted on all three original
documents.)
2. Any other statutory exemptions you would normally redact.
Thank you.
Attachments
cc: Kevin Noell, Assistant County Attorney
12- 1316- CA/679
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SETTLEMENT AGREEMENT AND MUTUAL RELEASE
THIS SETTLEMENT AGREEMENT AND MUTUAL RELEASE
(hereinafter referred to as the "Agreement and Release ") is entered into and made on
this W day of CQ t C�1 r- , 2013 by and between ELAYNE JACKSON
(hereinafter referred to as "Plaintiff') and Board of County Commissioners for Collier
County (hereinafter referred to as the "County ")
WITNESSETH:
WHEREAS, Plaintiff filed a lawsuit against the County in the Circuit Court for
the Twentieth Judicial Circuit in and for Collier County, Florida, styled Elayne Jackson v.
Collier County, Florida, Case No. 12- 1316 -CA (hereinafter referred to as the "Lawsuit ");
and
WHEREAS, Plaintiff and the County, without either party admitting any liability
or fault, desire to settle the Lawsuit and any and all disputes that arise from, relate or
refer in any way, whether directly or indirectly, known or unknown, to the incidents
described or allegations made in the Complaint filed in the Lawsuit; and,
WHEREAS, Plaintiff and the County desire to reduce their settlement to a
writing so that it shall be binding upon her as well as her respective owners, principals,
elected officials, officers, employees, ex- employees, agents, attorneys, representatives,
insurers, spouses, successors, assigns, heirs and affiliates.
WHEREAS, Plaintiff and Plaintiff's attorney agree and covenant to fully comply
with all applicable Medicare laws, liens, and Set - Asides, specifically including Section
42 USC § 1395y.
Page 1 of 5
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NOW, THEREFORE, in consideration of the mutual covenants, promises and
consideration set forth in this Agreement and Release, and with the intent to be legally
bound, Plaintiff and the County agree as follows:
1. Plaintiff and the County adopt and incorporate the foregoing recitals,
sometimes referred to as "Whereas Clauses ", by reference into this Agreement and
Release.
2. In consideration of the resolution of all disputes or claims arising from or
referring or relating in any way, whether directly or indirectly, to the Lawsuit, and for and
in consideration of the sum of Seventy -Five Thousand Dollars and 00/100 ($75,000.00)
and other valuable consideration, the receipt and adequacy of which is hereby
acknowledged by Plaintiff, Plaintiff agrees to dismiss the Lawsuit with prejudice.
Settlement proceeds shall be paid within twenty (20) days from the date the Agreement
is approved by the Board of County Commissioners.
3. In consideration of the resolution of the Lawsuit, and for other good and
valuable consideration, the receipt and adequacy of which is hereby acknowledged,
Plaintiff, on behalf of herself, her attorneys, agents, representatives, insurers, heirs,
successors and assigns, hereby expressly releases and forever discharges the County,
as well as its elected officials, officers, employees, ex- employees, agents, attorneys,
representatives, successors, assigns, insurers and affiliates from any and all claims,
demands, causes of actions, damages, costs, attorney's fees, expenses and obligations
of any kind or nature whatsoever that they have asserted or could have asserted in the
Lawsuit or that arise from or relate or refer in any way, whether directly or indirectly, to
Page 2 of 5
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the Lawsuit or any incident, event or allegation referred to or made in the Complaint in
the Lawsuit.
4. Notwithstanding anything that may be to the contrary in Paragraph 3 of
this Agreement and Release, Plaintiff and the County agree that either of them (as well
as any other persons or entities intended to be bound) shall, in the event of any breach,
retain the right to enforce the terms and conditions of this Agreement and Release.
5. Plaintiff and Plaintiffs attorney agree and covenant to fully comply with all
applicable Medicare laws, liens, and Set - Asides, specifically including Section 42 USC
§ 1395y.
6. Plaintiff and the County acknowledge and agree that this Agreement and
Release is intended to and shall be binding upon their respective owners, principals,
officials, officers, employees, ex- employees, agents, attorneys, representatives,
insurers, successors, assigns, spouses, heirs, and affiliates.
7. Plaintiff and the County recognize and acknowledge that this Agreement
and Release memorializes and states a settlement of disputed claims and nothing in
this Agreement and Release shall be construed to be an admission of any kind, whether
of fault, liability, or of a particular policy or procedure, on the part of either Plaintiff or the
County.
8. Plaintiff and the County acknowledge and agree that this Agreement and
Release is the product of mutual negotiation and no doubtful or ambiguous language or
provision in this Agreement and Release is to be construed against any party based
upon a claim that the party drafted the ambiguous provision or language or that the
party was intended to be benefited by the ambiguous provision or language.
Page 3 of 5
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9. This Agreement and Release may be amended only by a written
instrument specifically referring to this Agreement and Release and executed with the
same formalities as this Agreement and Release.
10. In the event of an alleged breach of this Agreement and Release, Plaintiff
and the County agree that all underlying causes of action or claims of Plaintiff have
been extinguished by this Agreement and Release and that the sole remedy for breach
of this Agreement and Release shall be for specific performance of its terms and
conditions or any damages arising from the breach. In this regard, Plaintiff and the
County further agree that the sole venue for any such action shall be in the Twentieth
Judicial Circuit in and for Collier County, Florida in Naples, Florida.
11. This Agreement and Release shall be governed by the laws of the State of
Florida.
12. Plaintiff and Plaintiff's attorney shall be solely responsible for any
Medicare lien, other liens, or Medicare Set - Asides.
13. The document titled "Addendum to Settlement Agreement and Mutual
Release" attached as Exhibit "1" is incorporated into this Agreement by reference.
[Signature page to follow.]
Page 4 of 5
(FAX)239 598 9002
P.007/011
16K1
IN WITNESS WHEREOF, Plaintiff, and the County have signed and sealed
this Agreement and Release as set forth below.
Date:
ATT -C-S ; BOAR O C UNTY CO MISSIONER
t G'H1 E �RE�K; Clerk OF C LLI R OU TY, LORIDA S
,�, r� y—•.� By:
St' uty Clerk
014tur pp
Approved as to form and By.
legality:
By:
Kevin L. Noell
Assistant County Attorney
STATE OF fkedg ,jy W
COUNTY OF Rr")'dewre
-Ueorgia A. Hiller, Esq.
Chairwoman
Theodore -el n, Esq.
Attorney for Maintiff
THIS SETTLEMENT AGREEMENT AND RELEASE BETWEEN PLAINTIFF AND
COLLIER COUNTY, FLORIDA WAS SWORN TO and subscribed by ELAYNE
J CKSON before me on this ZD ; day of e
_ , 2013.
Signature of Nota Personally Known
ry Public
or
Produced Identification y/
Commissioned Name of Notary Public T
(Please print, type or stamp) yPe of Identification Produced
My Commission expires:
`DAVID J. O'BRIEN
" NOTARYPU13LIC
STATE OF RHODE ISLAF,ED #751473
LMY COMMISSION EXPiR`S 3014
12- 1316- ca/663
Page 5 of 5
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ADDENDUM TO
SETTLEMENT AGREEMENT AND MUTUAL RELEASE
Representations With Regard to Medicare's Interests
Releasor hereby warrants and represents that I presently am not, nor have ever been enrolled in
Medicare Part A or Part B. Further, I have no claim for Social Security Disability benefits nor am I
appealing or re- filing for Social Security Disability benefits.
OR
Releasor is a male emale hose date of birth is t I I and has a Medicare claim number
of 036oSa3'MA presently am enrolled in Medicare Part A or Part B or previously was
C01 Ifs�� �o1413-10 4ot0cisGL
enrolled from to p R tS" t . Releasor warrants and represents there has been full
disclosure of his /her Medicare status to Releasee.
Medicare's Interests
In reaching agreement on the terms of this Release, the parties acknowledge Releasor's possible
entitlement to Social Security disability benefits pursuant to 42 U.S.C. § 423, and receipt of Medicare
or Medicaid benefits under 42 U.S.0 § 1395y, as well as the entitlement of the Centers for Medicare
and Medicaid Services ( "CMS ") to subrogation and intervention, pursuant to 42 U.S.C. § 1395y(b) (2)
to recover any overpayment made by CMS. The parties to this Release agree that this Release is not
intended to shift to CMS the responsibility for payment of medical expenses for the treatment of
injury related conditions. The parties agree that this settlement is intended to provide Releasor a
lump sum and /or future periodic payment which will foreclose Releasee's responsibility for future
payment of all injury related medical expenses.
Non - reimbursable Expenses (where there is an MSA or other future medical expense consideration)
The parties to this Release understand that many common medical expenses are not payable or
reimbursable under the Medicare program. These medical expenses, not covered by Medicare but
necessary in the ongoing treatment of the Releasor's injury, and without an nrlm;scion of liability on
EXHIBIT
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the part of the Releasee, have been taken into consideration in the calculation and settlement of
Releasor's future medical expenses. Funds for these non - Medicare covered medical expenses have
been included in the lump sum settlement amount and shall not be paid from any Medicare
allocation amount.
Benefit Eligibility
Releasor acknowledges that any decision regarding entitlement to Social Security benefits or
Medicare or Medicaid benefits, including the amount and duration of payments and offset
reimbursement for prior payments is exclusively within the jurisdiction of the Social Security
Administration, the United States Government, and the U.S. Federal Courts, and is determined by
Federal law and regulations. As such, the United States Government is not bound by any of the
terms of this Release.
Future Benefits
Releasor has been apprised of his /her right to seek assistance from legal counsel of his /her choosing
or directly from the Social Security Administration or other government agencies regarding the
impact this Release may have on Releasor's current or future entitlement to Social Security or other
governmental benefits. Releasor acknowledges that acceptance of these settlement funds may
affect Releasor's rights to other governmental benefits, insurance benefits, disability benefits, or
pension benefits. Notwithstanding this possibility, Releasor desires to enter into this Release
agreement to settle his /her injury claim according to the terms set forth in this Release.
Medicare Recovery Action
Releasor agrees to hold harmless, indemnify and defend Releasee from any cause of action,
including, but not limited to, an action by CMS to recover or recoup Medicare benefits or loss of
Medicare benefits, if CMS determines that the money set -aside has been spent inappropriately or
2
380652.1
uy,cwcui3 12:03 Zelman & Hanlon (FAX)239 598 9002 P.0101011
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for any recovery sought by Medicare, including past, present, and future and /or conditional
payments. Releasor agrees not to use designated Medicare allocation funds to pay claims for
conditional payments that may have been made by Medicare.
Complete Understanding
Releasor hereby declares that the terms of this Release have been completely read and are fully
understood and voluntarily accepted for the purpose of making a full and final settlement of any
and all claims, disputed or otherwise, on account of injuries and /or damages related to the Claims
set forth herein, and for the express purpose of precluding forever any further additional claims
against the Release arising out of the aforesaid incident, accident or occurrence.
As to the releaser only:
STATE OF
COUNTY OF
THIS ADDENDUM TO SETTLEMENT AGREEMENT AND MUTUAL RELEASE BETWEEN PLAINTIFF AND COLLIER
COUNTY, FLORIDA WAS SWORN TO and subscribed by Elayne Jackson, before me on this day
of 2013.
Q2�e-o�r-
Personally Known
Signature of Notary Public
or
� �� l�✓�r�
Produced Identification
TZ 6'6;e-,ebe
Commissioned Name of Notary
Public Type of Identification Produced
(Please print, type or stamp)
My Commission expires:
bAVID J. O'EiRIEN
NOTARY PUBLIC
STATE OF RHODE ISLAND #751473
]GAMY COMMISSION EXPIRES 318/14 -
380652.1
As to the Releasee only:
BOARD OF COUNTY COMMISSIONERS
OF COLLIER COUNTY, FLORIDA
-71
Date
GEORGIA -A. HILLER, ESQ., Chairwoman
ATTEST: ,
DWIGHT 3l3RflCk,'�W*
MW is to CWegr* K F
si na
Approved as to form and
legality:
Kevin L. Noell
Assistant County Att rney
4
380652.1
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