Backup Documents 04/24/2012 Item #16F 2ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16F2
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
exception of the Chairman's signature, draw a line through routing lines #I through #4, complete the checklist, and forward to Sue Filson (line #5).
Route to Addressee(s)
(List in routing order)
Office
Initials
Date
1 Joshua Thomas
Grant Compliance Office
(Initial)__
Applicable)
—Z
2. Colleen Greene, Assistant County
Attorney
County Attorney's Office
16F2
Approved by the BCC
3.
Type of Document
4.
Number of Original
1
Attached
5. Ian Mitchell, Executive Manager
Board of County Commissioners
e�
6. Minutes and Records
Clerk of Court's Office
PRIMARY CONTACT INFORMATION
-)Z
(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 Thomas -Grant Support Specialist
Phone Number
239 - 252 -8989
Contact
appropriat e.
(Initial)__
Applicable)
Agenda Date Item was
April 24, 2012
Agenda Item Number
16F2
Approved by the BCC
signed by the Chairman, with the exception of most letters, must be reviewed and signed
Type of Document
Grant Application /Certifications
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 W WS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is
Yes
N/A (Not
appropriat e.
(Initial)__
Applicable)
1.
Original document has been signed /initialed for legal sufficiency. (All documents to be
Yes
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
N/A
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
Yes
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
Yes
signature and initials are required.
5.
In most cases (some contracts are an exception), the original document and this routing slip
Yes
should be provided to Ian Mitchell in the BCC office within 24 hours of BCC approval.
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!
6.
The document was approved by the BCC on (enter date) and all
Yes
changes made during the meeting have been inc rporated in the attached document.
r6
The County Attorney's Office has reviewed the changes, if applicable.
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip W WS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
16F2
MEMORANDUM
DATE: April 30, 2012
TO: Josh Thomas, Grants Support Specialist
Administrative Services Department
FROM: Teresa Polaski, Deputy Clerk
Minutes and Records
RE: Volunteer Fire Assistance Grant Application and Certificate
Attached is one (1) original of the document, referenced above (Agenda Item
#16F2), approved by the Board of County Commissioners on Tuesday, April 24,
2012.
If you should have any questions, please contact me at 252 -8411.
Thank you.
Attachment (1)
Florida Department of Agriculture and Consumer Services
16F2
'- Florida Forest Service
ADAM H. PUTNAM VOLUNTEER FIRE ASSISTANCE GRANT APPLICATION
COMMISIONER
LEGAL NAME Collier County Board of Commissioners
FORM OF ORGANIZATION: (Municipal, Fire District, Non - Profit, County)
Isles of Capri Fire Rescue District
ADDRESS
175 Capri Blvd.
CITY Naples
IF COUNTY, LIST VFD'S BENEFITING FROM GRANT:
STATE FL
ZIP 34113
COUNTY Collier
COUNTY #
EMPLOYER IDENTIFICATION NUMBER (EIN)
5 9 6 f 0 F 0 1 0 1 5 5 8
r%Ae'C 44AOA ow N/n/) A Ilk
' -
IS FIRE DEPARTMENT LOCATED IN AN INCORPORATED TOWN?
(� _
YES ❑ NO (X IF YES, NAME OF TOWN:
WHAT IS THE FIRE DEPARTMENT ISO RATING? r 4
I
-
,,
IS FIRE DEPARTMENT NIMS COMPLIANT? YES X NO [I
POPULATION OF TOWN: I_
CURRENT COOPERATIVE AGREEMENT WITH FFS? YES NO ❑
PROTECTED AREA: EST POPULATION 3 SIZE. (SQ, MILES)(` g
ff 1
DISTANCE OF CLOSEST MUTUAL AID FIRE DEPARTMENT: r3 fTli
NAME OF FIRE DEPARTMENT: I Marco Island
NUMBER OF FIREFIGHTERS: PAID 1 3 VOLUNTEERS I-2
HAS APPLICANT RECEIVED GRANT FUNDS FROM ANY SOURCE IN
THE PAST 12 MONTHS? YES ❑ NO [X
_
NO, OF INCIDENTS PAST YEAR, WILDLAND FIRE: F25 OTHER 1 O19
F_
I
IF YES, WHERE?
NO. OF FIREFIGHTERS CERTIFIED AS:
WILDLAND FIREFIGHTER 1 WILDLAND FIREFIGHTER 11 15
0 f
AMOUNT: $
LIST TOTAL FUNDS RECEIVED FROM OTHER TAXING AUTHORITIES
SUCH AS CITY, COUNTY, TAXING DISTRICTS (Past 12 Months)
AMOUNT:$
LIST OF FIREFIGHTING VEHICLES:
TYPE
MAKENR.MODEL
PUMP CAPACITY (GPM)
WATER CAPACITY (GAL)
Engine
E -One 2005 Typhoon
1500
780
Engine
E -One 2005 T hoon
1500
780
ESTIMATED GRANT FUNDING REQUEST.
LIST OF EQUIPMENT
OR SUPPLIES TO PURCHASE WITH GRANT FUNDS:
FEDERAL
$ 4900.00
NUMBER
DESCRIPTION
AMOUNT
APPLICANT
$ 4900.00
1
Skid Unit to be installed on F -25
9 800.0
COUNTY
$
TOTAL
$ 9800.00
(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
Telephone Number: ( 239) 394 -8770
Fred W. Coyle
Chairman
FAX ( 239) 7' `
394 - 5862..
Sig 7o�;Z zed Repres alive
pto
Date Sind an ubm ted
ad as to tgorm Vegaisufficl racy
Email: ^,
r%Ae'C 44AOA ow N/n/) A Ilk
' -
vI1v J_11 -90-9 RC V. 121 VU +, � - -- ¢.]WI I V tAJ*N duff( 1_ -
Colleen dreene,
Assistant County Attorney
Fornt AD -1047 q,,Y2)
U. S. DEPARTMENTOFAGRICULTURE
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
16Fp
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, [,ederal Register( pages 4722-4733). Copies of the regulations may he 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, snaking 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 ( I )(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 det'ault.
(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.
vAn iP
Collier County Board of County
Commissioners
NAHL AND TI TLF 0F,1 C Tff
Fred W. Coyle
Chairman
1H) ,Y1 TRESh.% TA
PR - 1t{S iRD: \'tJ,ktRFRORPROJECT, \'A:11E
Isles of Capri Fire Rescue District
SIGNATURE DATF
proved as to form & legal sufficiency
�— Colleen Greene,
Assistant County Attorney
ATTEST
DWI T E ROCK +Cleik ,
+ktttt>Kt of to N l�rrrt f
dal Awe tart 's --
16F2
OMB Approval No. 0348 -0040
ASSURANCES — NON - CONSTRUCTION PROGRAMS
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 1 certify that the applicant:
I. 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
1'ramc 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
Vlll 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 If 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, B -5 (02/05)
Authorized for Local Reproduction
Standard Form 424B (9- 03)Prescribed by OMB Circular A -102
16F2
research, teaching, or other activities supported by this award of
13. Will assist the awarding agency in assuring compliance with assistance.
Section 106 of the National historic Preservation Act of 1966. as
amended(16 U.S.C. 470). EO 11593 (identification and protection of 16. Will comply with the Lead-Based Paint Poisoning Prevention
historic properties), and the Archeological and Historic Preservation Act(42 U.S.C. §§4801 et seq.)which prohibits the use of lead based
Act of 1974(16 U.S.C.469a-1 et seq.). paint in construction or rehabilitation of residence structures.
14. Will comply with P.L. 93-348 regarding the protection of 17. Will cause to be performed the required financial and
human subjects involved in research. development, and related compliance audits in accordance with the Single Audit Act of 1984.
activities supported by this award of assistance.
18. Will comply with all applicable requirements of all other
15. Will comply with the Laboraton Animal Welfare Act of 1966 Federal laws, executive orders. regulations and policies governing
(P.I.. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the this program.
care,handling,and treatment of warm blooded animals held for
SIGNAT R OF AUTHORIZED CERTIF ING OFFICIAL TITLE
w.
Chairman, Board of County Commissioners
APPLICANT ORGANIZATION DATE
Collier County Board of County Commissioners SUBMITTED l�/_) //
U
ved as to lc.rm&legal sufficiency
Assistant County Attorney ?
lit 13-6(02/05)
*' Auffitjr ed fof.LoC ft6production)
•
+ 010 rm 424B (9-03
rz Prescri ,diy OMB Circular A-I 02