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Backup Documents 01/11/2011 Item #16D 9ORTOIAC OMPANY ALL ORIGINAL DOCUMENTT SENT TOLIP 16 D 9 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 #1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the _ _ _. . . . . _ _ , _..1 ------ I am .w.....,.1. H I ­..,elntn tl,r rhrrklict and forward to Ian Mitchell (line #5). exception or me cnMMM s sl nalwc, uiaw o..... u.. �� ,.....,. Route to Addressee(s) ..... .. ............. .... - ......_ , Office Initials Date (List in routing order) Grants Coordinator (Initial) Applicable) I. January 11, 2011 Agenda Item Number 16 D -09 2. signed by the Chairman, with the exception of most letters, must be reviewed and signed 3. Certifications Number of Original 2 4. Jennifer White, Assistant County County Attorney LJ if 12- It b Attorney contracts, agreements, etc. that have been fully executed by all parties except the BCC 5. Ian Mitchell, Executive Manager Board of County Commissioners I I Iq (y 0 6. Minutes and Records Clerk of Court's Office n/a 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 Ian Mitchell, need to contact staff for additional or missing information. All original documents needing the BCC Chairman's signature are to be delivered to the ACC office only after the BCC has acted to approve the umu.) Name of Primary Staff Nick Green, HHVS Phone Number 252 -2376 Contact Grants Coordinator (Initial) Applicable) Agenda Date Item was January 11, 2011 Agenda Item Number 16 D -09 Approved b y the BCC signed by the Chairman, with the exception of most letters, must be reviewed and signed Type of Document Certifications Number of Original 2 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 FInitial riate. (Initial) Applicable) 1. Original document has been signed/initialed for legal sufficiency. (All documents to be NG 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 NG document or the final ne otiated contract date whichever is applicable. 4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's NG signature and initials are required. 5. In most cases (some contracts are an exception), the original document and this routing slip NG 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 01/11/11 and all changes made during NG the meeting have been incorporated in the attached document. 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 16D 9 MEMORANDUM Date: January 14, 2011 To: Nick Green, Grants Coordinator Human & Human Services From: Martha Vergara, Deputy Clerk Minutes & Records Department Re: DCF Grant Certificates — Grant Contract #HFZ1D Attached is one original and one copy as referenced above (Item #16139) approved by the Board of County Commissioners on January 11, 2011. The other original can be found in the Minutes and Record's Department, being kept as part of the Board's Official Records. If you have any questions please call me at 252 -7240. Thank you. Attachment (2) SCR Provider Required Information/Documents 16D 60A- 1.006, F.A.C., Vendors and Contractors The integrity, reliability and qualifications of a bidder or offeror, with regard to the capability in all respects to perform fully the contract requirements, shall be determined by the agency prior to the award of the contract. M Legal (Corporate) Name of Collier County Board of County Commissioners Provider Agency and fictitious name, if conducting business under a different name b. Address including City, County, 3299 Tamiami Trail East State and Zip Code Naples, Florida 34112 c. Mailing address of the official 3299 Tamiami Trail East payee to whom payment shall be 7t" Floor made as indicated on the Naples, FL 34112 MyFloridaMarketPlace registration d. Name and title of Authorized Official Signer Delegation of Authority required, to include sample signature, if not President, Chariman, or CEO Fred W. Coyle, Chairman, Collier County Board of County Commissioners ❑ Attached e. Contact person Marcy Krumbine, Director, Housing, Human and Veteran Services ✓ Name and title; 3339 Tamiami Trail East, Suite 211 ✓ street address (where financial and MarcvKrumbinena.colliergov.net administrative records are Phone: 239 - 252 -8442 maintained) Fax: 239 - 252 -2638 ✓ electronic address ( e:mail); ✓ telephone number, and ✓ fax number f. Representative for the administration of the program ✓ Name and title: • street address, • electronic address (e:mail); • telephone number, and • fax numbers g. Type of SCR 082610 Nick Green, Grants Coordinator, Housing 3339 Tamiami Trail East, Suite 211 NickGreen(a)colliergov.net Phone: 239 - 252 -2376 Fax: 239 - 252 -6668 Other (Descri I I Nonprofit (Attach IRS and Veteran Services c 3 or other support h. Board of Directors • Listing of board members, to include address, phone number and e:mail address, and their term expiration. • Copies of By -Laws • Copies of prior year meeting minutes. ❑ Attached 16D 9 http //www.colliergov.net/Index.aspx?paqe=30 List of BCC and related information http•// www .collierclerk.com /RecordsSearch Board Minutes ❑ Attached ❑ Attached i. Copies of applicable NA — Not a facility facility licenses ❑ Attached j. Copies of all applicable NA — Not a facility facility accreditations ❑ Attached ® Attached a. Proof of registration with Internal Revenue Services (IRS) ❑ Attached ✓ Federal Employer Identification FEIN -59- 6000558 Number (FEIN) 09/30 ✓ Provider's Fiscal Year End Date (Month and Day only) b. Proof of registration with Department of Revenue (DOR) ❑ Attached ® Not applicable Per 12/15/10 instruction from IRS (if taxable activities) phone line representative, government agencies are exempt as reference in IRS Publication 557 ✓ Most recent 990 c. Proof of registration with Department of Financial Services ® Attached ❑ Not applicable (DFS) Note: Vendors must file a W -9 with DFS. d. Proof of registration with the Florida Department of State ❑ Attached NA — Government Agency Division of Corporations 2 SCR Provider Required Information /Documents 16D 9 e. Proof of registration on MyFloridaMarketPlace ® Attached Rule 60A- 1.030, F.A.C. requires http://dms.myflorida.com/business operations /state purchasing /mvflorida marketplace /mfmp_ vendors / vendor_ toolkit /mfmp_vendor_registration vendors doing business with the state of Florida to register with MFMP. f. Proof of registration as a Minority Vendor or Disabled Veteran, when ❑ Attached ® Not applicable applicable. k ` a. Department of Business and Professional Regulations (DBPR) ❑ Attached ® Not applicable Certain businesses must be Government Agency licensed by DBPR. b. Department of Agriculture and ❑ Attached ® Not applicable Consumer Services (DOACS) Government Agency Certain services are regulated by DOACS. Proof of registration as a charitable ❑ Attached ® Not applicable organization. c. Department of Health (DOH) ❑ Attached ® Not applicable Determines whether health care Government Agency practitioners meet minimum licesure requirements. d. Copy of required applicable insurance coverage: ✓ Liability ❑ Attached • Automobile ❑ Attached ❑ Not applicable • Workers Compensation ❑ Attached ✓ Employee Dishonesty ❑ Attached ✓ Additional bonds or letters of ❑ Attached ❑ Not applicable credit, when required Written documentation of both the ® Attached determination and existence of such insurance is required. y�,.... Y ' L �S9 ruf tai( n T. SCR 082610 3 16D g a. Geographic Area Served (Counties) Collier Count b. Service description to include, but Youth Haven not be limited to: ❑ Attached Shelter for Abused Women and Children • types of service to be provided St. Matthew's House • service delivery location BCC (HHVS) • times of service Refer to grant application HFZ1 D • staff qualifications • unit cost. c. Copy of the provider's policies and NA — will not be providing direct services procedures relating to the reporting of ❑ Attached suspicion or knowledge of abuse /neglect or abandonment according to Florida Statutes d. Applicable ACHA-Program Medicaid ❑ Attached NA— Government Agency e. usr or Z:)uocoi when applicable f. Program Operatic supporting narrative g. Agency Operating Budget supporting narrative h. Match plan /sources, when applicable a. and ✓ Checklist ✓ Deaf or Hard of Hearing compliance attestation b. Documentation to support financial viability , such as ✓ most recent audit, ✓ balance statements ❑ Attached: Youth Haven, St. ❑ Not applicable Matthew's House, Shelter for Abused Women and Children Attached I See grant owDocument.aspx ?documentid =28191 Attached I N Not ® Attached ® Attached — on file with DCF ❑ Attached ❑ Attached heBoard /InternalAudit c. To qualify as Preferred Provider, the new agency must submit an affidavit ❑ Attached ® Not applicable attesting to the following: ✓ Agrees to offer the state of Florida the most advantageous price offered to any of its customers ✓ Has a principal place of e i SCR Provider Required Information/Documents 16D 9 ✓ Commits contractually to maximize the use of Florida residents, products and other Florida -based businesses d. Other documents determined required by contract manager, such as Cost Analysis /Method of Rate Setting, ❑ Attached ( ® Not applicable Medicaid rates, etc. e. In accordance with Section Contract #, starting and ending 287.0575(2), F.S., providers must notify dates, total amount, brief the Dept. of any contracts with the description of the purpose and following agencies: services provided, and name and contact info. of the agency's contract manager. ✓ Department of Children and ❑ Attached — Grant HFZD1 ❑ Not applicable Families (DCF); ✓ Agency for Persons with Disabilities ❑ Attached ® Not applicable (APD ✓ Department of Health (DOH); ❑ Attached ® Not applicable ✓ Department of Elderly Affairs ❑ Attached ® Not applicable (DEA), and ✓ Department of Veterans (DOV) ❑ Attached ® Not applicable f. Copies of prior year monitoring http://www.collierclerk.com/l)df/2009CAFR.I)df The Single Audit Section begins on page 177 of reports issued by any agency, including DCF. 389. The organization certifies that the facts and information contained in this application and any attached documents are true and correct. Collier County Board of County Commissioners Name of Organization Signature of Authorized Official Date Chairman, Collier County Board of County Commissioners Title Please return the completed form and required documentation to: Department of Children and Families 2295 Victoria Avenue, Fort Myers, Florida 33901 Attn. Robert Farr, Contract, rdahagement Unit ATTEST: U T E. 8R C , C*k SCR 082610 By. it tW* to t Approved aa's to form & legai SuN(olencp afs\' I7N�1At �., ss�� nt cunty At ornev° T�rvry ��2 9. w�A \ s DCF USAGE ONLY List 16D 9 http / /dms mvflorida com /business operations /state purchasim, /vendor information /conv icted suspended discriminatory complaints vendor lists /suspended vendor list Convicted Vendor List I " Checked http://dms.mvflorida.com/business operations /state purchasing /vendor information /conv icted suspended discriminatory complaints vendor lists /convicted vendor list Purchase Agreement or other legal documentation of the transfer of ❑ Attached previous provider's assets and liabilities to the new provider Contract Assignment ✓ DCF Approval of contract ❑ Attached assignment ✓ Contract Assignment ❑ Attached Agreement signed by the three parties (old and new providers and the Department) Program Administrator Signature Date Contract Administrator Signature Date 11 SCR Provider Required Information /Documents 16D 7 Contract Director Signature Date Program Director Signature Date Legal Counsel Signature Date SCR 082610 Attachment IV 16D Contract No. HFZ1D CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION CONTRACTS /SUBCONTRACTS This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, signed February 18, 1986. The guidelines were published in the May 29, 1987 Federal Register (52 Fed. Reg., pages 20360 - 20369). INSTRUCTIONS 1. Each provider whose contract/subcontract equals or exceeds $25,000 in federal moneys must sign this certification prior to execution of each contract/subcontract, Additionally, providers who audit federal programs must also sign, regardless of the contract amount. The Department of Children and Families cannot contract with these types of providers if they are debarred or suspended by the federal government. 2. This certification is a material representation of fact upon which reliance is placed when this contract /subcontract is entered into. If it is later determined that the signer knowingly rendered an erroneous certification, the Federal Government may pursue available remedies, including suspension and /or debarment. 3. The provider shall provide immediate written notice to the contract manager at any time the provider learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms "debarred ", "suspended ", "ineligible ", "person ", "principal ", and "voluntarily excluded ", as used in this certification, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the department's contract manager for assistance in obtaining a copy of those regulations. 5. The provider agrees by submitting this certification that, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this contract/subcontract unless authorized by the Federal Government. 6. The provider further agrees by submitting this certification that it will require each subcontractor of this contract/subcontract, whose payment will equal or exceed $25,000 in federal moneys, to submit a signed copy of this certification. 7. The Department of Children and Families may rely upon a certification of a provider that it is not debarred, suspended, ineligible, or voluntarily excluded from contracting /subcontracting unless it knows that the certification is erroneous. 8. This signed certification must be kept in the contract manager's contract file. Subcontractor's certification must be kept at the provider's business location. CERTIFICATION (1) The prospective provider certifies, by signing this certification, that neither he nor his principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this contract/subcontract by any federal department or agency. (2) Where the prospective provider is unable to certify to any of the statements in this certification, such prospective provider shall attach an explanation to this certification. Fr P O/ // / ate Ctiatrnnan ' rveme (type or print) i me ' CF 1126, PDF 09/2003 - ATTEST.; Approv" an to TOrm a iayni ou et ocu slstant Cnunty Attcrtle4 9 CIXISIn�n�6 f.�mllles State of Florida Department of Children and Families VERIFICATION OF PROVIDER SUBCONTRACTING STATUS 16D 9 Charlie Crist Governor Robert A. Butterworth Secretary Nicholas B. Cox SunCoasl Region Director In accordance with the provisions of Section I.H of the Grant Agreement terms and Conditions ❑ This contract allows the provider to contract for the provision of all services under this contract. ❑ This contract does not allow the provider to subcontract for the provision of any services under this contract. ® This grant allows the provider to subcontract for the provision of the following services under this grant: As applied for in the Challenge Grant solicitation # LPZ01 and approved by award PROVIDER SELECT ONE OF THE FOLLOWING: o work is current y pe ormedby ssu- contract— orse services which are under contract or there is currently no intent to subcontract for contracted services being negotiated with the department. Subcontractors are currently performing services which are under contract or there is an X_- intent to subcontract for contracted services being negotiated with the department. ® Please provide a list of those services: As applied for relating to solicitation # LPZ01 The provider understands that if the Department allows subcontracting and the provider chooses to subcontract any of the contracted services, the provider shall submit a written request to subcontract for the provision of services to the Contract Manager for Department approval. -"r � I Signature of provider personnel allthorizeki Date to legally bind the provider _— Exception (please specify services) _ ❑ Disapprove services to be subcontracted. P.O. Box 60085, Fort Myers, Florida 33906 -0085 ATTEST: Mission: Protect the Vulnerable, Promote Strong and Economically Self- Sufficient Families, and Advance Personal and Family and Resiliency DWIGHT E.- SROCK, Cler g e to form h, legal Sufficienc, 9y: – �i t0 fill _. l l6D 9 Attachment CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (Including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly, This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. `r F i} Signature - Date HFZ1D Name of Authorized individual —i Application or Contract Number oIe� Cot�h� V Boa�(o� �ot,,¢� Co M;s5i0nerS Name e of Organization n / �_ l atnt `LI CF 1123, PDF 03/96 = ,VMR.T E �•aE >a� ea iEyy aau 7.i YOwi -: ,X legal SUfflCten CI® I ...` Page — SiVJ NI �� a Wit iT�