Backup Documents 12/10-11/2013 Item #16D10ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1601
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.
h'Y..a .., huti.ti'a
a
Complete routing lines # I 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 routinglines
# 1 through #2, complete the checklist, and forward to the L; Attorney umce.
Route to Addressees (List in routing order)
Office
Initials
Date
1. Lori Fisher
HHVS
5�F
is -)0-1 3
2. Jennifer Belpedio
County Attorney Office
Approved by the BCC
I.Z112,) 1
3. BCC Office
Board of County
Commissioners
Type of Document
Z \3
4. Minutes and Records
Clerk of Court's Office
Attached
Original document has been signed/initialed for legal sufficiency. (All documents to be
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
,AA.—.. .., —A t� —t—t staff fnr additinnal or missino infnrmatinn
aLLLLI\rJJYYJ A
Name of Primary Staff
..wv vw.. .... ��
Lori Fisher
Phone Number
239-252-2995
Contact / Department
appropriate.
Initial)
Applicable)
Agenda Date Item was
December 10 2013
Agenda Item Number
16D 10
Approved by the BCC
Does the document need to be sent to another agency for additional signatures? If yes,
Type of Document
Grant Modification DREF Grant #
Number of Original
2 dt i
Attached
Original document has been signed/initialed for legal sufficiency. (All documents to be
Documents Attached
PO number or account
Needs Grantor Signature (DEO)
number if document is
, lv
JU/
to be recorded
All handwritten strike -through and revisions have been initialed by the County Attorney's
INSTRUCTIONS & CHECKLIST
jbe,w„ti,1J� 101 ;t 0 13
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)
Applicable)
1.
Does the document require the chairman's original signature?
2.
Does the document need to be sent to another agency for additional signatures? If yes,
provide the Contact Information(Name; Agency; Address; Phone)hed 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
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.
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.
_ Qy
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 on and all changes made
during the meeting have been incorporated in the attached ocument. The County
Attorney's Office has reviewed the changes, if a licable.
9.
Initials of attorney verifying that the attached document is the Ikersion approved by the
BCC, all changes directed by the BCC have been made, and a document is ready for the
Chairman's signature.
jbe,w„ti,1J� 101 ;t 0 13
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
16D10 1
MEMORANDUM
Date: December 16, 2013
To: Lori Fisher, Grants Support Specialist
Housing, Human & Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Certified Signature Forms for DRI K Grant #IODB-D4-09-21-01-
K09
Attached is an certified copy of the document referenced above, (Item #16D10)
approved by the Board of County Commissioners on December 10, 2013.
The second original will be held on file in the Minutes and Records Department for
the Board's Official Record.
If you have any questions, please contact me at 252-8411.
Thank you.
Attachment
16010
Memorandum
To: Clerk's Minutes & Records
From: Lori Fisher
Date: December 10, 2013
Subject: Signature Authority forms approval
BCC meeting 12/10/2013 item #16D10
Re: Collier County and DEO for DRI K Grant #10DB-D4.09.21.01-K09
�. Y
Two uthoriV for Signature forms each with the Chairwoman's original signature
One °r� needs to be sent to Monique Kabitzke at DEO. One original is for your
records. I would like a certified copy back please for our records.
*Note* There are four forms for signature one form for each grant A, Z DRI K &
DREF and two copies a total of 8 pages for signature.
Please contact me if you have any questions at 252-2995.
Thanks You
>
Lori Fisher
Grants Support Specialist
Housing, Human and Veteran Services
Department of Housing, Human and Veteran Services
Collier County
16010
EXECUTIVE SUMMARY
Recommendation to approve Four (4) signature authority forms for submittal to the Florida
Department of Economic Opportunity.
OBJECTIVE: Identify Collier County staff members and the chief elected official involved with
administering Disaster Recovery grants funded through the Florida Department of Economic
Opportunity (DEO).
CONSIDERATION: The Board of County Commissioners received four federally -funded Disaster
Recovery grants from the Florida Department of Economic Opportunity (DEO).
The Disaster Recovery grants are administered through Collier County's Department of Housing,
Human and Veteran Services (HHVS). Several hurricane hardening projects were established for
funding under these agreements. The projects are at various stages of development with most being
complete at this time. The older grants remain open with the grantor agency for reporting and
reprogramming purposes.
Due to staff changes it is necessary to update the information for specific staff members and the chief
elected official for administering the grants. The DEO provides a specific Signature Authority Form for
the grantee to use when identifying or updating the administrative staff. A form for each grant is being
submitted at this time to update the HHV S staff currently administering the grants, the designate
individuals authorized to sign REQUEST For FUNDS (RFF) and the current Chief Elected Official.
The information and Board approval information for each grant is listed below.
Disaster Recovery Grant #
BCC approval date
Agenda item #
07DB-3 V-09-21-01-ZO 1
5/22/2007 __101,
08DB-D3-09-21-01-A03
5/13/2008
16D17
101313-134-09-21-01-K09
2/23/2010
16D 10
12DB-P5-09-21-01-K39
7/26/2011
16D1
Approval of this item will serve as an update to Collier County's previously submitted Signature
Authority Forms with the DEO.
FISCAL IMPACT: These forms have no impact on the approved budgets for these grants and related
projects. No general funds are associated with these projects.
GROWTH MANAGEMENT IMPACT: There are no growth management impacts associated with
this program.
LEGAL CONSIDERATION: This item is approved as to form and legality and requires majority vote
for approval - JAB
STAFF RECOMMENDATION: Recommendation to approve and authorize the Chairman to sign
Signature Authority Forms for Disaster Recovery Grant agreements, between the Florida Department of
Economic Opportunity and Collier County to maintain efficiency and timely operations in the HHVS
Department.
PREPARED BY: Lori Fisher, Grants Support Specialist, Housing, Human and Veteran Services
16D10
Department of Economic Opportunity — Small Cities Development Block Grant Program
ATTACHMENT L - SIGNATURE AUTHORITY FORM
Submit an original Signature Authority Form with each contract.
............................................................... _........_---- ..........................................................................................................................................
Recipient ! Contract # Funding Source
Board of Collier County Commissioners ! 12DB-P5-09-21-01-K39 [ ]Small Cities CDBG
.........._....................................-............._................................................ ...................... ._..._._._.......,.._..........................................................................................................._.........................._...._............_.._._.......................---,
Mailing Address (Street or Post Office Box) [ X] Disaster Recovery
3339 Tamiami Trail East, Suite 211 [ ]Neighborhood Stabilization
...... ...... _...................................................---......................................._..._.................._............................_........................................................._............._...._............................._..__............-------...._..._............................................._._.._..,...............--.._...........-... -......................... ................... __..... _...........
City, State and Zip Code Local Government DUNS #
Naples, FL 34112 076997790
...........
Project Contact Person
Telephone #
E-mail Address
Lisa Oien, Grants Coordinator
239-252-6141
lisaoien@colliergov.net
Collier County Housing, Human
i n ture
�7 3....._..._......
DRv..s
X ] Check here if above person is authorized to submit RFFs
and Veteran Services
_.._................. _._..._.... _...............................
----..... _......... ......... _............................. ....................................... _............... -----.................................. _............................. _....................... _._..................... .............. ..
.............................................................................................. _.._............... _...................................
Financial Contact Person
,.....................
Telephone #
E-mail Address
Bendisa Marku, Supervisor
239-252-2689
bendisamarku@colliergov.net
Accountant, Collier County
Date Signature
..:.:_....^.._�_3............................... ._.....%._L�.�..
[ ]Check here if above person is authorized to submit RFFs
Housing, Human and Veteran
j
Services_...................__
--..._...................._......................................................................_..........._......................._...........
. . ._..........._...................................................._........................_....._............ - ..._......._..._
......_....._......................................................_.._..._...__....................................................................._............_.._._.._....
Other Local Government Contact
Telephone #
E-mail Address
Kristi Sonntag, Grants Manager
239-252-2486
kristisonntag@colliergov.net
Collier County Housing, Human
andVeteran Services
............................ ................................................................................................................................... _................................................
Requests for Funds (RFFs) require
......... ...........................................................................................................................
(check one); [ ] one signature [ X ] two signatures by individuals authorized below.
RFFs must be submitted via the Department's website
at http://ecdbg.dca.state.fl.us/ (or by an alternative means specified by
the Department).
Typ11 ed Na11 me
Bendisa__Marku... Supervisor Accountant
1 Date 1 Si n
/1 ......................_9 .
[ X ] Check here if above person is authorized to submit RFFs
E- ail Address
bendisamarku@colliergov.net
_...... __..__.............._........._............
........... ................ ..._......._................................................................................__...._........._.........................__..._._......................._.................._._.:
Typed Name
TBD, Housing, Human and Veteran Services Accountant_.;
i n ture
�7 3....._..._......
DRv..s
X ] Check here if above person is authorized to submit RFFs
Eil ddress
i
.......... ..... _......................... ...................... _................................................................................. ._.._... _.._...................................... _.................................
Typed Name
............................................. _...................... _........................ __..... _............ _
Date Signature
Lisa Oien, Grants Coordinator......_........................................._... _..................... _._................................
..
._.........._.....".:.....................-.........._.....................................................
[ ]Check here if above person is authorized to submit RFFs
E-mail Address
lisaoien@colliergov.net
.............................
......................................................................... .._......................................................................
Typed Name
LoriFisher,.._Grants..SupPort Specialist........................................................................................%_
Date Signature
..:.:_....^.._�_3............................... ._.....%._L�.�..
[ ]Check here if above person is authorized to submit RFFs
E-mail Address
Lori.fisher@colliergov.net r;
I certify, as the recipient's Chief Elected Official, that the above signatures are the
Funds and to submit RFFs electronically. _
_................................................... _......................_........................
................... _... _ _...
Typed Name Date Si natui
Georgia A. Hiller, Esq, Chairwoman 2 loi L3
Board.._of..Collier County._Commissioners..................................._........................_.................................................................................................r i M...
[ X ] Check here if your local government utilizes Electronic Funds Transfer (EF -f 4c
[ X ] Check here if your local government will be working on a reimbursement basis.
the State of Florida.
to sign Requests for
........................................ .............. .... ................... ...................... .................... ............................. ........................ ................... ... ..................... ............................ -......................................................................
CDBG payments to /oca/governments using EFTare automatically deposited in the local government's general account. If the
account is interest bearing, the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: httpl/flair.dbf.state.fl.us/. Local governments not receiving EFT, and not working on a reimbursement basis, must
establish a non-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
sinatures on the account must b.e_bonded..........................................................._..................... ............. ................................. _........ ................... _................... ---........................................... .._... _....................... ......... _.................... __................................................
Name of Financial Institution Account Number
FifthThird Ban . _......................................................._.. ......... ... ........................................................t. ........ .
Street Address or Post Office Box Telephone Number F
999 Vanderbilt Beach Road
1239-591-6397 .' , t`4•_ ::.:; ....................__........
................................................
....................................................................-......................._...................................................................................................................:..............................................................._.. _.
City, State and Zip Code
Approved as to form and legality `
........................................................................ �i` AEtse April
DWt T E•
..,.
Asst nt Coonty A ey 9y.
of Economic Department Opportunity — Small Cities Development Block Grant Program 16DIi,
p PPo tY
ATTACHMENT L - SIGNATURE AUTHORITY FORM
Submit an o�igina/Signature Authoity Form with each contract:
.................................... ............ ,........................................................................... __................................................................
Recipient Contract # Funding Source
Board of Collier County Commissioners 08DB-D3-09-21-01-A03 [ ]Small Cities CDBG
...... ......... .............. ................................................. _........................................................._...................................._._......................._.._......................................._.................................................................... _............ .........................................................
Mailing Address (Street or Post Office Box) [ x] Disaster Recovery
3339 Tamiami Trail East Suite 211 [ ]Neighborhood Stabilization
..........................................................................
.............................................................................................................................................................................................................._.............................................................................................................................._..._............................................................................................................
City, State and Zip Code Local Government DUNS #
Naples, FL 34112 076997790
Project Contact Person
; Telephone #
Lisa Oien, Grants Coordinator
239-252-6141
Collier County Housing, Human
and Veteran Services
;................................. ...._........................
..... .................... ................................................................. ..............................................................
Financial Contact Person
Telephone #
Bendisa Marku, Supervisor
239-252-2689
Accountant, Collier County
Housing, Human and Veteran
E- ails
E-mail Address
lisaoien@colliergov.net
E-mail Address
bendisamarku@colliergov.net
........... ................. .... ......._._...........
....___----_
Other Local Government Contact Telephone # I E-mail Address
Kristi Sonntag, Grants Manager 239-252-2486 kristisonntag@colliergov.net
Collier County Housing, Human
and Veteran Services i
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Requests for Funds (RFFs) require (check one); [ ] one signature [ X ] two signatures by individuals authorized below.
RFFs must be submitted via the Department's website at http://ecdbg.dca.state.fl.us/ (or by an alternative means specified by
the Department).
Typed Name
Bendisa....Marku, Supervisor Accountant...................................................................................._1�,
i Date
.�......s.....3......._.....................
Signa
......................................................
�....
X Check here if above person is authorized to submit RFFs
[ ] P
j E -(hail Rddress
_...... _.... _..........
I...._bendisamarku @colliergov. net...................._............................_........._.............
.. ................. _.............. _...... .... ....... _.__......................................................................... _............. ._.................. __I......._.
Typed Name
j Dat
Si natur �
Edmond Kushi�...._Accountant......................................................................................................_..._......._.
................................
�...._.......
.......�i ...�%S4res
[ X ] Check here if above person is authorized to submit RFFs
E- ails
TYped...Name......................................................................................................................................................................................:....Date
..........................................................................................................................................
I/-S-i�_.........._......_..---......_.........._.._
:............... _..............
Signature
Lisa Oien Grants Coordinator._...................._....._.._.................................
,_._.............................._.................................._,...........................................................
_ ........................
[ ]Check here if above person is authorized to submit RFFs
E-mail Address
lisaoien@collierqov.net
.....................................................................................................................................................................
Typed Name
Date
;
1 Signature—
, �..
Lori..._Fisher,.._Grants._Support Specialist......................._..__................................_......_...............1..(?__..
.....-._��..............._............._..................................................._......................................_..................
[ ]Check here if above person is authorized to submit RFFs
E-mail Address
.................... _.._.............................................. _._........... ..... _.._... _.......... ........................................................ _... _............................ _........... _._.... ,................ _....................... _....... _-.._.... _............... _...... _...............
I certify, as the recipient's Chief Elected Official, that the above signatures are o e individual authorized to sign Requests for
Fundsand to submit RFFs electronically...........................................................................................................................................................................................................................................................................................................................................................
Typed Name
Date gna re
Georgia A. Hiller, Esq, Chairwoman ; ' Z 11 Q 15
1
Boardof Collier CountyCommissioners / J..............................1......................................................................................................................................................................
................... ...............................................................................................................................................................:.............................................................................................
[ X ] Check here if your local government utilizes Electronic Funds Transfer ( e State of Florida.
[ X ] Check here if your local government will be working on a reimbursement sis.
.................................................................................................................................................................................................................................................................................................................................................................
CDBG payments to local governments using EFTare automatically deposited in the local governments general account. If the
account is interest bearing, the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http•//flair.dbf.state.fl.us/. Local governments not receiving EFT, and not working on a reimbursement basis, must
establish a non-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
sinatures on the account must be bonded._.........................._......_..........................._..._..............,..............................................................................................................................._..............................._........._........._..__=....:,.............................................
9 ............................
Name of Financial Institution Account Number
Fifth Third Bank 113-8577 _.._._ry.:.._.,. _..._:..................:................._................
............................................................
........_............................._........................._.._._............................_.._......................._.._........._..._....._..............._....................,..._...._.._...._.................._........_...
Street Address or Post Office Box Telephone Number'";;
999 Vanderbilt Beach Road 239-591-6397
s : ......:.......... ............. ;..:................
.::..._f ..................
.........
City, State and Zip Code APPtoved as to forth and legaiit�..................... ATTEST:
Naples, Florida 34108 -.................. .._...._........... _._.__.................................. _....................... ....... ........................................... _.........................
+tflrrru4
Assiataat Coun ttomey
_ a..... ^nlu
201
16010
Department of Economic Opportunity — Small Cities Development Block Grant Program
ATTACHMENT L - SIGNATURE AUTHORITY FORM
Submit an origins/Signature Authonly Form with each contract.
_ ..... _..---..............................-- ......................._.. ._............ ......... ............... _..... _........ _.........................
.
Recipient Contract # Funding Source
Board of Collier County Commissioners 10D6 -D4 -09-21-01-K09 [ ] Small Cities CDBG
..._...................................................................................................................................................................................................................................................................................................................................................... [
Mailing Address (Street or Post Office Box) X ] Disaster Recovery
3339 Tamiami Trail East, Suite 211 [ ]Neighborhood Stabilization
...............................................--................................_..... _...................................................................__._..........._..._._...._......__..__......._................._.._..__..._..............................................................----.................................._._._..................i..... ............ _._................ _......... ---........................ .... _._......................
.
City, State and Zip Code Local Government DUNS #
Naples, FL 34112 076997790
Project Contact Person
Telephone #
1 E-mail Address
Lisa Oien, Grants Coordinator
239-252-6141
lisaoien@colliergov.net
Collier County Housing, Human
and Veteran Services
......... ............ ..... ....................................................................................................................
......... ............................................. _.._.........................................................._...................................................................................
..... ..............................................................................................................................................
Financial Contact Person
.........................
Telephone #
E-mail Address
Bendisa Marku, Supervisor
i 239-252-2689
bendisamarku@colliergov.net
Accountant, Collier County
Housing, Human and Veteran
Services....................
_. .... _........................................................................
................ .................... ........................................................ _...........................................................!........._...._.............................
Other Local Government Contact
........................................ ................. ................
Telephone #
....................................._;......................................................................................................_.
E-mail Address
Kristi Sonntag, Grants Manager
239-252-2486
kristisonntag@colliergov.net
Collier County Housing, Human
andVeteran Services
.._...................................._._................_.._.....__......................._.._...._....._........................................................:........................................................_........_.._._.........................._...._.............._......__................_...._..............._................................
........................................._.........................._............................................
Requests for Funds (RFFs) require
......
(check one); [ ] one signature
[ X ] two signatures by individuals authorized below.
RFFs must be submitted via the Department's
website at http://ecdbg
dca state fl us/ (or by an alternative means specified by
the Department).
Typed Name aWrX,
Bendisa„ Marku,.._Supervisor Accountant...................................................................................1.........
[ X ] Check here if above person is authorized to submit RFFs E-maiddress
.net
Typed Name L)i
Edmond Kushi, Accountant .............................%/..
....................................................... ............. ._
(X ]Check here if above person is authorized to submit RFFs E-
.. ..................................... _..... __........................... _....................
......____----_-____
Typed Name Date - , Signature ~
Lisa Oien Grants Coordinator J..r_-.'......_'..................._...............................__.._.._...........:k.:�._._ .... _.......`-._...................................................................
....
..................................... ....._..._._.......................................................................................................................................................
[ ] Check here if above person is authorized to submit RFFs E-mail Address
......................................................................................... .
j...._I isaoien @col I iergov.net...................................._.._...................
Typed Name 1 Date Signature ��
i ...........................................................
YP - 1. '
Lori Fisher Grants Support Specialist
............................,..........._..._............... _._. )_" 3 c
[ ]Check here if above person is authorized to submit RFFs E-mail Address
..............................................................
Lri. f Sher@col l iergov. net
..................................
I certify, as the recipient's Chief Elected Official, that the above signatures are of th individuals au horized to sign Requests for
Funds and to submit RFFs electronically._._...................._...........--.
_......................._..._...... ............_........__ ..._......,- --.....................................................
Typed Name
Date ign tur
Georgia A. Hiller, Esq, Chairwoman
Board of Collier County Commissioners (Z l0 13 ..... ...._._.._................---....................................................
...... ................................ .................................................... ........................... _.........._...._..........................................................
f ..................................................... _.................._...........................................................................
[ X ] Check here if your local government utilizes Electronic Funds Transfer (EFT) ro a tate of Florida.
[ X ] Check here if your local government will be working on a reimbursement basi .
...... .... _.................... .................. .................................................................................................................... ........... ................................... _............................... _.._.................................................................................
CDBG payments to local governments using EfTare automatically deposited in the local government's general account. If the
account is interest bearing, the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http://flair.dbf.state.fl.us/. Local governments not receiving EFT, and not working on a reimbursement basis, must
establish a non-interest bearing account. Provide account information for the financial institution (insurgd,,by,F�DIC) below. All
,; -...
sinatures on the account must..be..bonded.............................................................................................,............................................................................................................................................................._.......:........_..._._..........................
Name of Financial Institution Account Number.
Fifth Third Bank 113-8577 � '� .._......._:............._.................. .._..._...~....._........._............
_..............._...._..................__..._....._...................._...................................................................................................,.........................................__......._................................_.__._...........3.._..... _
Street Address or Post Office Box Telephone Number
999 Vanderbilt Beach Road
239-591-6397"
......................:...:....s........... . ................................................
City, State and Zip Code Approved ATTEST:
Naoles. Florida 34108 pp edas_to_fQIIIL.3i�..lESx.:A.!.A.L.L ............................_ e�.�s�rsa�T- -w
B
Assistant County A ncy
Department of Economic Opportunity - Small Cities Development Block Grant Program 16010
ATTACHMENT L - SIGNATURE AUTHORITY FORM
Submit an ori ina/ Si nature Authori Form with each contract:_
9.................................... k'..._.................................._......._..................................................._...........................-...................................................................................
Recipient Contract # Funding Source
Board of Collier County Commissioners 07DB-3V-09-21-01-Z01 [ ]Small Cities CDBG
..................................................................._..........................__.._._....._.................................
[ X] Disaster Recovery
Mailing Address (Street or Post Office Box)
3339 Tamiami Trail East Suite 211 [ ]Neighborhood Stabilization
..........._...........................................................................................................................
i.....City,...State...and...Zip Code:............................................................................................ _ . Local Government DUNS #
Naples, FL 34112 076997790
........ __....................................... ..... ...... ....................................................................................... ,...._.............................. _..__.................................................................................................................. ...................... ---._........ _.............. _......... _._._...................................... _._.................... _............. _-------................_......_..........
Project Contact Person Telephone # E-mail Address
Lisa Oien, Grants Coordinator 239-252-6141 lisaoien@colliergov.net
Collier County Housing, Human
and Veteran Services _. .... _...... _ .......................... _.___
... .............. ............ ..._......._...... __._................. ........................... _... __....... _.... _............. ......._... _..... ;...... _................... _.................... _.............................. _.............. _......................... ........---...__.....__........_......_._................................................------....._..............._.........._...._..............
Financial Contact Person Telephone # E-mail Address
Bendisa Marku, Supervisor 239-252-2689 j bendisamarku@colliergov.net
Accountant, Collier County
Housing, Human and Veteran
Servicesi
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Other Local Government Contact Telephone # ; E-mail Address
Kristi Sonntag, Grants Manager 239-252-2486 kristisonntag@colliergov.net
Collier County Housing, Human
and Veteran Services
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Requests for Funds (RFFs) require (check one); [ ] one signature [ X ] two signatures by individuals authorized below.
RFFs must be submitted via the Department's website at http://ecdbg.dca.state.fl.us/ (or by an alternative means specified by
the Department).
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Typed Name 1 Date` Si e l
Bendisa Marku Supervisor Accountant cl 7�..................i.............G:....................................................
,. p......... ll�.............,�..........��
[ X ] Check here if above person is authorized to submit RFFs-mai rAddress
.............. _......... ...... ......... _....... _...................................................... _...... .---.... _......... __._.�.._...... _.....................................bendisamarku@colliergov.net............_.........._._.._._.__....._.........__.......__..........................._............ ___.... _.........
......... - -
Typed Name 1 Date, Si a re
Edmond Kushi Accountant R' /� �rc-
..
l S ..........
[ X ] Check here if above person is authorized to submit RFFs E- ail Address '-
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Typed Name Date Signature
�— r` .......1 �'—
Lisa Oien Grants Coordinator
[ ] Check here if above person is authorized to submit RFFs E-mail Address
lisaoien@colliergov.net _..
..............................................................................._...................................................................................._._...................._.__.._._._._..........................;..__.._......_..................................................__.._..._......._... T .__._.._........_....
Typed Name D to Signature
Lori Fisher Grants Su ort S ecialist i '
.......................................... .
[ ]Check here if above person is authorized to submit RFFs E-mail Address
Lori.fisher@collierqov.net _
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I certify, as the recipients Chief Elected Official, that the above signatures are of the individuals authorized to sign Requests for
Fundsand to submit RFFs electronically...............................................................................................................................................:.
Y.�......................................................................................................................_......... ...............................
Typed Name Date Si at
Georgia A. Hiller, Esq, Chairwoman Z
.County .. ............ ... .........................._..............................................................__......._................................1..........._...............
......................
[ X ] Check here if your local government utilizes Electronic Funds Transfer (E om the tate of Florida.
[ X ] Check here if your local government will be working on a reimbursement basis.
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CDBG payments to local governments using EFTare automatically deposited in the local governments general account. If the
account is interest bearing, the CDBG funds must be transferred to a non-interest bearing account. Please call the CDBG
Program at 850/922-1878 or 487-3644 if you have questions. You can check the status of your deposit at the Comptroller's
website: http://flair.dbf.state.fl.us/. Local governments not receiving EFT, and not working on a reimbursement basis, must
establish anon-interest bearing account. Provide account information for the financial institution (insured by FDIC) below. All
sinatures on the account must be bonded.__,.....:_..:..:._............_.
..... g................................................................................................... ........................ ........ .._._.............................................................................................__......................_........................_.................................._.... -_.._....._.............._._....................
Name of Financial Institution ;Account Number
Fifth Third Bank .......................113-8577 4 ';;� ........................................................................
......................................................................................................................................................................................................................Zt
.... p
Street Address or Post Office Box ! Tele hone Number. , ti
999 Vanderbilt Beach Road 239- ... .......... _ ..._........_..._,. �__....................._._. ... �:....
City, State and Zip Code Approved as to form and legality ATTEST t-
Naples, Florida 34108
p.............................................................................................................................................................................................................................................................................1IA/i ....-.....$
i'�i�9i.......................R d April 2011
Ass nt County rn '
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