Backup Documents 06/14-15/2011 Item #16D8
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 D
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 8
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
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
exce tion of the Chairman's si nature, draw a line throu h routin lines #1 throu #4, com lete the checklist, and forward to Ian Mitchell line #5 .
Office Initials Date
1. Ashlee Franco, Accounting HHVS
Supervisor
2. Jennifer White
3. Ian Mitchell, Executive Manager
4- 130 4 rd M : rl\)tt. Re.c r- cl.
~
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 needs 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 Ashlee Franco 1 Housing, Human and Phone Number 252-2689
Contact Veteran Services Please call or e-mail
for nick UD
Agenda Date Item was June 14,2011 Agenda Item Number 16 D 8
Approved by the BCC .2
Type of Document Amendment to contract agreement Number of 3 sets ~ signatures
Attached an original signature from the Documents Attached total)
Chairman needed on each copy
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is Yes N/A (Not
appropriate. (Initial) Applicable)
1. Original document has been signed! initialed for legal sufficiency. (All documents to be AF
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 AF
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 ofBCC approval of the AF
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 AF
signature and initials are required.
5. In most cases (some contracts are an exception), the original document and this routing slip AF
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 BCe's actions are nullified. Be aware of your deadlines!
6. The document was approved by the BCC on 6/14/2011 (enter date) and all changes AF N/A
made during the meeting have been incorporated in the attached document. The
County Attorney's Office has reviewed the chanl!es, if applicable.
I: Forms! County Forms! BCC Forms! Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP16 0 8
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
ROUTING SLIP
Complete routing lines # I through #4 as appropriate for additional signatures, dates, and/or information needed, Ifthe document is already complete with the
exception of the Chairman's signature, draw a line through routing lines #1 through #4, complete the checklist, and forward to Ian Mitchell (line #5),
Route to Addressee(s) Office Initials Date
(List in routing order)
1, Ashlee Franco, Accounting HHVS (L~ 7/29/11
Supervisor
2. Clerk of Courts Minutes and Records Dept., 4tn Fl.
3.
4,
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 needs 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 Ashlee Franco / Housing, Human and Phone Number 252-2689
Contact Veteran Services Please call or e-mail
for Dick UD
Agenda Date Item was June 14,2011 Agenda Item Number 16D 8 (Item#2108)
Approved by the BCC
Type of Document Contract Agreement Number of Signature Already
Attached an original signature from the Documents Attached on Contracts
Chairman already obtained
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is Yes N/A (Not
appropriate, (Initial) Applicable)
1. Original document has been signed! initialed for legal sufficiency, (All documents to be AF
signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office ofthe County Attomey. This includes signature pages from ordinances,
resolutions, etc, signed by the County Attomey'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 AF 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 ofBCC approval of the AF Signature
document or the final negotiated contract date whichever is applicable. already on docs
4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's AF Signature
signature and initials are required. already on docs
5. In most cases (some contracts are an exception), the original document and this routing slip AF Signature
should be provided to Ian Mitchell in the BCC office within 24 hours of BCC approval. already on
Some documents are time sensitive and require forwarding to Tallahassee within a certain docs
time frame or the BCC's actions are nullified. Be aware of your deadlines!
6. The document was approved by the BCC on 6/14/2011 (enter date) and all changes AF N/A
made during 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 WWS Original 9,03,04, Revised 1.26.05, Revised 2.24.05
I6.n 8
MEMORANDUM
Date:
June 29, 2011
To:
Ashley Franco
Housing, Human and Veteran Services
From:
Teresa Polaski, Deputy Clerk
Minutes & Records Department
Re:
Amendment to Agreement No. HCE-203.10
Attached for your records is three (3) originals of the document referenced above
(Item #16D8 ) approved by the Collier County Board of County Commissioners
June 14,2011.
Please forward on for additional signatures and return a fully executed original
back to the Minutes & Records Department to be kept in the Board's Official
Records.
If you have any questions, please feel free to contact me at 252-8411.
Thank you,
160
8 cl
AMENDMENT 003
Contract No. HCE 203.10
Amendment Page 1
This AMENDMENT, entered into by the Area Agency on Aging for Southwest Florida, Inc.,
hereinafter referred to as the "Agency" and Collier County Board of Commissioners,
hereinafter referred to as the "recipient," amends contract renewal HCE 203.10.
The purpose of this amendment is to (1) extend this contract for 90 days or until a new contract
is executed, whichever comes first, and (2) to revise Attachment VIII, Budget Summary. The
2011-2012 allocation is shown below.
Program Title Funding Source CFDA/CSFA# 2011-2012
Fund Amounts
Home Care for the Elderly General Revenue 65001 $89,277.00
The amendment shall be effective on July 1, 2011. All provisions in the agreement and any
attachments thereto in conflict with this amendment shall be and are hereby changed to conform
with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at
the level specified in the agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed
by their officials there unto duly authorized.
CONTRACTOR: Collier County Board of
Commissioners
AGENCY: Area Agency on Aging for
Southwest Florida, Inc.
Signe Signed 4~~~,fl--7~
By By
Name: Fred Coyle Name: Leigh ~~wak
Title: Chairman Title: Board President
Date: lD ~\ " Date: ,\d~ 6JdlClI
,
Federal ill Number: 59-6000558
Fiscal Year End: 9/30
; L
Approved as to t
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AMENDMENT 003
Contract No. HCE 203.10
HOME CARE FOR THE ELDERLY PROGRAM
BUDGET SUMMARY
Collier County Board of Commissioners
1. HCE Subsidies
2. HCE Case Management
3. Total
160
Amendment Page 2
ATTACHMENT VIII
$ 82,704.00
$ 6,573.00
$ 89,277.00
8-
160
8.
Attestation Statement
Agreement/Contract Number HCE 203.10
Amendment Number
I, Fred Coyle , attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida, Inc. and
Collier County Board of Commissioners.
(Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement/contract content.
l\
Fred W. Coyle, Chairman
Signature of Recipient/Contractor
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AAA Contract Manager to initial and date indicating signatures/initials appropriate on all documents; ready
for AAA designee signature
initial date
Revised November 2010
160
8 -~t
\.:
AMENDMENT 003
Contract No. AD! 203.10
Amendment Page 1
This AMENDMENT, entered into by the Area Agency on Aging for Southwest Florida, Inc.,
hereinafter referred to as the "Agency" and Collier County Board of Commissioners,
hereinafter referred to as the "recipient," amends contract renewal ADI 203.10.
The purpose of this amendment is to (1) extend this contract for 90 days or until a new contract
is executed, whichever comes first, and (2) to revise Attachment VIII, Budget Summary. The
2011-2012 allocation is shown below.
Program Title Funding Source CFDA/CSFA# 2011-2012
Fund Amounts
Alzheimer's Disease Initiative- General Revenue 65004 $95,490,00
Respite Services
The amendment shall be effective on July 1, 2011. All provisions in the agreement and any
attachments thereto in conflict with this amendment shall be and are hereby changed to conform
with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at
the level specified in the agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed
by their officials there unto duly authorized,
CONTRACTOR: Collier County Board of
Commissioners
AGENCY: Area Agency on Aging for
Southwest Florida, Inc.
Signe
By
Signed
By
4k{,~.. ~~~~
. Leigh ~wak
Name:
Fred Co le
Name:
Title:
Chairman
Title:
Board President
Date: 19 ltiJ ' ,
Federal ill Number: 59-6000558
Fiscal Year End: 9/30
Date: J l/,-,t __ g dO { \
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Approved as to form .ij, legal Sufficiency
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AMENDMENT 003
Contract No. ADI 203.10
160
Amendment Page 2
ATTACHMENT VIII
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
1, Respite
2. Case Management
3. Total
BUDGET SUMMARY
Collier County Board of Commissioners
$ 95,290.00
$ 200.00
$ 95,490.00
8 ~~
160
,8.
Attestation Statement
Agreement/Contract Number ADI203.1O
Amendment Number
I, Fred Coyle , attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida, Inc. and
Collier County Board of Commissioners.
(Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement/contract content.
Fred W. Coyle, Chairman
Signature of Recipient/Contractor re
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ApprOVed a8 to form 8< lega.l Sufflclent:V
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AAA Contract Manager to initial and date indicating signatures/initials appropriate on all documents; ready
for AAA designee signature
initial date
Revised November 2010
AMENDMENT 001
160
8 c
Contract No. CCE 203.10
Amendment Page 1
This AMENDMENT, entered into by the Area Agency on Aging for Southwest Florida, Inc.,
hereinafter referred to as the "Agency" and Collier County Board of Commissioners,
hereinafter referred to as the "recipient," amends contract renewal CCE 203.10.
The purpose ofthis amendment is to (1) extend this contract for 90 days or until a new contract
is executed, whichever comes first, and (2) to revise Attachment VIII, Budget Summary. The
2011-2012 allocation is shown below.
Program Title Funding Source CFDA/CSFA# 2011-2012
Fund Amounts
Community Care for the Elderly General Revenue 65010 $653,779,00
The amendment shall be effective on July 1, 2011. All provisions in the agreement and any
attachments thereto in conflict with this amendment shall be and are hereby changed to conform
with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at
the level specified in the agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed
by their officials there unto duly authorized.
CONTRACTOR: Collier County Board of
Commissioners
Signed
By
Name: Fred Coyle
Title: Chairman
Date: U u:u I ,
Federal ill Number: 59-6000558
Fiscal Year End: 9/30
,,"
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AGENCY: Area Agency on Aging for
Southwest Florida, Inc.
Signed ~i1 '
By / 'J'~r~'
Name: Leigh Alma Nowak
Title: Board President
Date: JU)(j8, ?iJ( I
App!'ov~d as to torm /~ legt'tl Sufflclent-v
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AMENDMENT 001
Contract No. CCE 203.10
16D
Amendment Page 2
ATTACHMENT VIII
COMMUNITY CARE FOR THE ELDERLY PROGRAM
1. Lead Agency
2. Case Management
3. CCE Services
4. Total
BUDGET SUMMARY
Collier County Board of Commissioners
$ 98,067.00
$114,000.00
$441,712,00
$653,779.00
81
160
8 1
Attestation Statement
Agreement/Contract Number CCE 203.10
Amendment Number
I, Fred Coyle , attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida, Inc. and
Collier County Board of Commissioners,
(Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement/contract content.
tJ
Date
I ,
Fred W. Coyle, Chairman
Signature of Recipient/Contractor re
A.pP;~V~Ci as tn form .'5. ieg~i Sufflcien{:',
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AAA Contract Manager to initial and date indicating signatures/initials appropriate on all documents; ready
for AAA designee signature
initial date
Revised November 2010