Backup Documents 01/22/2019 Item #16D 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP U
L ryry
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 5
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.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Susan Golden Community and Human 1/18/2019
Services
2. Jennifer Belpedio County Attorney Office
3. BCC Office Board of County w1,--stA
Commissioners \- & z/ `\`'t—q\
4. Minutes and Records Clerk of Court's Office
tolitii
S'Yr
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above,may need to contact staff for additional or missing information.
Name of Primary Staff Susanolden/,C�-IS, P,hon Number 252-2336
Contact/ Department c-pN f\ t\ O tile,— O tk ,
Agenda Date Item was 1/22/201 Agenda Number 16.D.5
Approved by the BCC
Type of Document HUD Substantial Amendment—2 Number of Original 4—Housing Authority
Attached amendments to existing agreements Documents Attached
w/Housing Authority&City of Naples
PO number or account
number if document is
to be recorded
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. Does the document require the chairman's original signature? 511.441„f 0K Stamp OK
2. Does the document need to be sent to another agency for additional signatures? If yes, NA
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be SG
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 NA
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 SG
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 SG
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding 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 1/22/2019 and all changes made during the
meeting have been incorporated in the attached document. The County Attorney's /`j
Office has reviewed the changes,if applicable. ,.
9. Initials of attorney verifying that the attached document is the version approved by the .�
BCC,all changes directed by the BCC have been made,and the document is ready for t - sus._ 1
Chairman's signature.
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
1 6 D 5
MEMORANDUM
Date: January 24, 2019
To: Susan Golden, Community & Human Services
From: Teresa Cannon, Sr. Deputy Clerk
Minutes & Records Department
Re: HUD Substantial Amendment to an Existing Agreement
w/HousingAuthority
Enclosed please find three (3) originals of the document referenced above (Agenda
Item #16D5), approved by the Board of County Commissioners on Tuesday, January
22, 2019.
The Minutes & Records Department has retained an original as part of the Board's
Official Records.
If you have any questions, please contact me at 239-252-8411.
Thank you.
Enclosure
Enclosures
1605
FAIN# M-17-UC-12-0217
M-16-UC-12-0217,
M-15-UC-12-0217,
M-14-UC-12-0217&
M-13-UC-12-2017
Federal Award Date EST 10/2017
Federal Award HUD
Agency
CFDA Name Home Investment
Partnership (HOME)
CFDA/CSFA# 14239
Total Amount of $513,949
Federal Funds $628,780
Awarded
Subrecipient Name Collier County
Housing Authority
DUNS# 040977514
FEIN# 59-1490555
R&D No
Indirect Cost Rate No
Period of 10/1/17 -3/31/20
Performance 6/30/22
Fiscal Year End 9/30
Monitor End Date 6/20- 9/22
FIRST AMENDMENT TO AGREEMENT BETWEEN COLLIER COUNTY
AND
COLLIER COUNTY HOUSING AUTHORITY
THIS AMENDMENT is made and entered into this OW day of�Cl`I''1 r14 , 2019, by and between
Collier County, a political subdivision of the State of Florida, ("COUNTY" or"Gra\tee") having its principal
address as 3339 E.Tamiami Trail,Naples FL 34112,and "COLLIER COUNTY HOUSING AUTHORITY"
a quasi-governmental agency established by Florida Statute 421 existing under the laws of the State of Florida,
having its principal office at 1800 Farm Workers Way,Immokalee,FL 34142.
RECITALS
WHEREAS,on September 26,2017 the COUNTY entered into an Agreement using HOME Investment
Partnerships (HOME) Program funds for the Tenant Based Rental Assistance Program to provide low and
moderate income households with rent,security deposits and utility deposits for a period of up to two(2)years.
WHEREAS, the Parties desire to amend the Agreement to clarify project detail language and amend
Exhibit D.
NOW, THEREFORE, in consideration of foregoing Recitals, and other good and valuable
consideration,the receipt and sufficiency of which is hereby mutually acknowledged,the Parties agree to amend
the Agreement as follows:
1
Collier County Housing Authority HM 17-13 IDIS#570
Tenant Based Rental Assistance , -‘-
16D5
Words StruckThrough are deleted;Words Underlined are added
1.1.C. Agreement Amount
Tenant Based Rental Assistance Federal Funds Match
Project Component 1:TBRA Rent,Security Deposits $462,555 $115,639
and Utility Deposits 141,476(to be
$565,903 provided by
Collier County)
Project Component 2:Project Delivery $51,394 $12,81815,719
(to be provided
$62,877 by Collier
County
Grand Total $513,919 $128,48.7
$628,780 $157,195
1.2.C. Project Outcome
The HOME Tenant Based Rental Assistance project will serve approximately 34 households with
Rent Payments,electric utility and/or security deposits
1. 50%of eligible applicants receive eligible housing within three(3)months of approval from
date of income certification,based on availability of funds,and housing.
2. 10% of program participants who have participated in the program for 13 months or longer
maintain or gain employment,as evidenced by pay stubs or tax returns.
3. 5% of program participants who have participated in the program for 13 months or longer
will have a decrease in rental subsidy.
1.3 PERIOD OF PERFORMANCE
Services of the SUBRECIPIENT shall start on the October 1, 2017 and shall end on "ter
2920 June 30, 2022. The term of this Agreement and the provisions herein may be extended by
amendment to cover any additional time period during which the SUBRECIPIENT remains in
control of HOME funds or other HOME assets, including program income.
1.4 AGREEMENT AMOUNT
The COUNTY agrees to make available - •A. _ -'•'! ' :! -"' _ _ - e
-2..2? • ! e ' t• ' ! • e H ! SIX HUNDRED
TWENTY EIGHT THOUSAND SEVEN HUNDRED EIGHTY DOLLARS AND NO CENTS
($628,780) for use by the SUBRECIPIENT, during the Term of the Agreement(hereinafter, shall
be referred to as the"Funds").
2
Collier County Housing Authority HM 17-13 IDIS#570
Tenant Based Rental Assistance
‘c7 )
1605
Exhibit D is amended as follows:
EXHIBIT"D"
INCOME CERTIFICATION
INSTRUCTIONS
Retain completed form, including appropriate supporting documentation, to be validated by CHS at the interim
and close out monitoring.
Effective Date:
A. Household Information
Member Names—All Household Members Relationship Age
1 1 1 ! 1
2 1
3 ! I
4 ! 1 1 1
5 1
6 I 1 1
7
8 1 l 1 I 1
B. Assets: All Household Members,Including Minors
Income
Member Asset Description Cash Value from Assets
1 ! I
2 II
3 II
4 11
5 11
6 ' 1
7 ' 1
8
Il
Total Cash Value of Assets B(a) I
Total Income from Assets B(b) 1
3
Collier County Housing Authority HM 17-13 IDIS#570
Tenant Based Rental Assistance
1605
If line B(a) is greater than $5,000,multiply that amount by the rate specified
by HUD(applicable rate .06%)and enter results in B(c),otherwise leave
blank. B(c)
C. Anticipated Annual Income:Includes Unearned Income and Support Paid on Behalf of Minors
Member Wages/ Benefits/ Public Other
Salaries Pensions Assistance Income
(include tips, Asset
commissions,
bonuses,and Income
overtime)
1 [ I I (Enter the
2 greater of
I I I I I box B(b) or
3
box B(c),
4 I 1 I I I above, in
5 I I I I I I box C(e)
6 I I I below)
7
8 II 11 I I
Totals (a) (b) (c) (d) (e)
Il Ii
Enter total of items C(a)through C(e). I
This amount is the Annual Anticipated Household Income.
D. Recipient Statement: The information on this form is to be used to determine maximum income for
eligibility. I/we have provided,for each person set forth in Item A,acceptable verification of current and
anticipated annual income. I/we certify that the statements are true and complete to the best of my/our
knowledge and belief and are given under penalty of perjury.
WARNING:Florida Statutes 817 provides that willful false statements or misrepresentations concerning income
and assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by
fines and imprisonment provided under S. 775.082 and 775.083.
Signature of Head of Household Date
Signature of Spouse or Co-Head of Household Date
4
Collier County Housing Authority HM 17-13 IDIS#570
Tenant Based Rental Assistance
1605
Adult Household Member(if applicable) Date
Adult Household Member(if applicable) Date
E. HOME Grantee Statement: Based on the representations herein,the family or individual(s)named in
Item A of this Income Certification is/are eligible under the provisions of the HOME. The family or
individual(s)constitute(s)a:
1 Extremely-Low Income (ELI)30%Household means and individual or family whose annual
income does not exceed 30 percent of the area median income as determined by the U.S.
Department of Housing and Urban Development with adjustments for household size.
(Maximum Income Limit$ I I ).
Very Low-Income(VLI)50%Household means and individual or family whose annual income
does not exceed 50 percent of the area median income as determined by the U.S.Department of
Housing and Urban Development with adjustments for household size.
(Maximum Income Limit$ ( h.
1 1 60% Threshold _Household means and individual or family whose annual
income does not exceed 59 60 percent of the area median income as determined by the U.S.
Department of Housing and Urban Development with adjustments for household size.
(Maximum Income Limit$ I ).
1 Low Income(LI) 80%Household means and individual or family whose annual income does
not exceed 80 percent of the area median income as determined by the U.S. Department of
Housing and Urban Development with adjustments for household size.
(Maximum Income Limit$1 I ).
Based upon the I 1 (year) income limits for the Naples-Marco Island Metropolitan Statistical Area
(MSA)of Collier County, Florida.
Signature of the HOME TBRA Administrator or His/Her Designated Representative:
Signature Date
5
Collier County Housing Authority HM 17-13 IDIS#570
Tenant Based Rental Assistance
1605
Printed Name Title
F. Household Data
Number of Persons
By Race/Ethnicity By Age
Native
American Hawaiian or Oth 0— 26— 41 —
Asian Black White 62+
Indian Other Pac. er 25 40 61
Islander
Hispanic I I I I I III II II
Non- I I I 1 I I I I I i 11 I I I II I
Hispanic
NOTE: Information concerning the rate or ethnicity of the occupants is being gathered for statistical use only.
No occupant is required to give such information he or she desires to do so, and refusal to give such information
will not affect any right he or she has an occupant.
This section intentionally left blank.
6
Collier County Housing Authority HM 17-13 IDIS 14570
Tenant Based Rental Assistance ( v�
1605
IN WITNESS WHEREOF, the SUBRECIPIENT and the County, have each, respectively, by an
authorized person or agent,hereunder set their hands and seals on the date first written above.
A1TEST; BOAR�j ♦ ��OUN OVIMISSIONERS OF
Ciysta i. Kinzel, CI qRK ' �� Y,FI,O'
'
• C
By: 4111111111F-
IuitDeputy
Clerk / W. L. McDaniel,Jr.,
,SIgf;wtu; cif Chairman
Date: jaaliq
Collier County I Iousing Authority
Dated: t 09
(SEAL) A .At����.
By: di'+ _ '
Oscar Hentschel, Executive Director
Date: '/ nog
J g
Approved as to form and legality:
J 51"nifer A. Belpo \4
Assistant County ttorney , \
Date: I / as I k 9
Item# `6/-75
Agerda 1)2_2)
t Ley
Date t `7
Date t 11)41
Reed
1�
. putt'Clerk
7
Collier County Housing Authority HM 17-13 IDIS#570
Tenant Based Rental Assistance
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 b D 5
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.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Lisa Oien Community and Human
Services //77 l9
2. Jennifer Belpedio County Attorney Office l���`J t I 31 19
3. BCC Office Board of County .�
Commissioners / .\�A k��
4. Minutes and Records Clerk of Court's Office 1
I9- M 313°1
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above,may need to contact staff for additional or missing information.
Name of Primary Staff Lisa Oien/CHS Phone Number 252-6141
Contact/ Department
Agenda Date Item was 1/22/2019 Part of a HUD Substantial ✓ Agenda Item Number 16.D.5
Approved by the BCC amendment item
Type of Document Amendment to subrecipient agreement with Number of Original
Attached City of Naples in Triplicate Documents Attached 3
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever• Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? _5441,,,,,, a- _ NA
2. Does the document need to be sent to another agency for addi onal signatures? If yes, NA
provide the Contact Information(Name;Agency;Address;Ph eon an attached she .
3. Original document has been signed/initialed for legal sufficiency. cu111entsfo be LO
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 NA
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 LO
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 LO
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding 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 01/22/2019 and all changes made during theN/A is not
meeting have been incorporated in the attached document. The County Attorney's 4. \1 an option for
Office has reviewed the changes,if applicable. .� this line.
9. Initials of attorney verifying that the attached document is the version approved by the i' /A is not
BCC,all changes directed by the BCC have been made,and the document is ready for th- •; ` option for
Chairman's signature. this line.
ON,
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 ��,5�
1605
MEMORANDUM
Date: January 24, 2019
To: Lisa Oien, Grants Coordinator
Community & Human Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Amendment to Subrecipient Agreement w/City of Naples
Attached are three (3) originals of each document referenced above,
(Item #16D5) approved by the Board of County Commissioners on
Tuesday, January 22, 2019.
An original has been kept by the Minutes and Record's Department for the
Board's Official Record.
If you have any questions, please feel free to contact me at 252-8411.
Thank you
Attachment
1605
FAIN# B-18-UC-12-0016
Federal Award Date Est. 10/2018
Federal Award Agency HUD
CFDA Name Community Development
Block Grant
CFDA/CSFA# 14.218
Total Amount of Federal Funds $100,000
Awarded
Subrecipient Name City of Naples
DUNS# 084130293
FEIN 59-6000382
R&D No
G;ti ,G`ITC�OORLIG�=_TOR Indirect Cost Rate No
RECEOVED Period of Performance 10/01/2018-4/30/2020
1 2018 Fiscal Year End 9/30
DEC
Monitor End: 12/2025
COLLIER COUNTY CHS GRANTS
BY:
FIRST AMENDMENT TO AGREEMENT BETWEEN COLLIER COUNTY
AND
CITY OF NAPLES
ANTHONY PARK EXERCISE STATIONS
This Amendment is entered into this - y of \C�� �,.X\ 019, by and between Collier County, a
political subdivision of the State of Florida, ("COUNTY"or"Grange") having its principal address at 3339
E Tamiami Trail, Naples FL 34112, and "City of Naples", ("Subrecipient"), having its principal office at 735
8th Street South, Naples, Florida 34102-1401.
RECITALS
WHEREAS, on September 11, 2018, the COUNTY entered into an Agreement for awarding
Community Development Block Grant Program funds to be used for the Anthony Park Exercise Stations
(hereinafter referred to as the"Agreement");and
WHEREAS,the parties desire to clarify the project details.
NOW, THEREFORE, in consideration of foregoing Recitals, and other good and valuable
consideration,the receipt and sufficiency of which is hereby mutually acknowledged,the Parties agree to
amend the Agreement as follows:
City of Naples Anthony Park Exercise Stations First Amendment CD18-02 IDIS#580 1
16D5
{
Words Struck Through are deleted;Words Underlined are added
PART I
SCOPE OF WORK
* *
CHS,as an administrator of the CDBG program,will make available CDBG funds up to the gross amount
of$100,000 to the City of Naples for the purchase and installation of outdoor fitness equipment stations
at Anthony Park.
1.2 PROJECT DETAILS
A. Project Description/Project Budget
Description Federal Amount
Project Component 1:The purchase and installation of outdoor fitness equipment $100,000
stations at Anthony Park.
Total Federal Funds: $100,000
D. Payment Deliverables
Payment Deliverable Payment Supporting Documentation Submission Schedule
Project Component 1: Submission of supporting documents Submission of
The installation including must be provided as backup as monthly invoices.
acquisition/purchase of outdoor evidenced by, banking documents,
fitness equipment stations at completed AIA G702-1992 form,or
Anthony Park equivalent document per contractor's
Schedule of Values and any additional
documents as needed.
* * *
Exhibit"C"is amended as follows:
City of Naples Anthony Park Exercise Stations First Amendment CD18-02 IDIS#580 2
1 6 D5
EXHIBIT C
QUARTERLY PERFORMANCE REPORT DATA
GENERAL-Grantee is required to submit to HUD, through the Integrated Disbursement and Information System
("IDIS")Performance Reports. The County reports information on a quarterly basis.To facilitate in the preparation
of such reports, Subrecipient shall submit the information contained herein within ten (10) days of the end of each
calendar quarter.
Agency Name: City of Naples
Date:
Project Title: Anthony Park Restroom Project
Program Contact:Felix Gomez
Telephone Number: 239 237-7101
IDIS# 580
Activity Keportmg Yerloa 1CepOrt Due vete
October 1st-December 31st January 10th
January 1st-March 31st April 10th
April 1st-June 30th July 10th
July 1st-September 30th October 10th
*REPORT FOR QUARTER ENDING:(check one that applies to the corresponding grant period):
12/31/18 03/31/19 0 06/30/19 ❑ 09/30/19
Please take note: The CDBG/HOME/ESG Program year begins October 12018-September 30,2019. Each quarterly report needs
to include cumulative data beginning from the start of the program year October 1,2018.
1 Please list the outcome goal(s)from your approved application &subrecipient agreement and indicate
your progress in meeting those goals since October 1, 2017.
A. Outcome Goals: list the outcome goal(s)from your approved application&subrecipient agreement.
Outcome 1: The purchase and installation of outdoor fitness equipment stations at Anthony Park.
Outcome 2:Document that at least 51%of persons served,are low to moderate Income,In order to meet a CDBG LMI/LMA
National Objective
Outcome 3:
B. Goal Progress:Indicate the progress to date in meeting each outcome goal.
Outcome 1:
Outcome 2:
Outcome 3:
City of Naples Anthony Park Exercise Stations First Amendment CD18-02 IDIS#580 3
1605
2.Is the project still in compliance? Y or N
If no explain:
3.Since October 1,2018-of the persons assisted,how many.... Answer ONLY for Public Facilities&Infrastructure
Activities *03 Matrix Codes
a. ..,now have new access(continuing)to this service or benefit? 0
b. ...now have improved access to this service or benefit? 0
c. ...now receive a service or benefit that is no longer substandard?0
Total 0
q What funding sources did the subrecipient apply for this period?
Section 108 Loan Guarantee $ CDBG $
Other Consolidated Plan Funds $ - HOME $ -
Other Federal Funds ESG _
State/Local Funds HOP WA .L -
Total Entitlement
$ - Funds
5.What is the total number of UNDUPLICATED Persons(LMC)or Households(LMH)served this QUARTER,If applicable?
Answer question 5a or 5b not both.
For LMC activities:people,race/ethnicity and income data is reported by persons.
For LMH activities:Households,race/ethnicity and income level data are reported by households,regardless the
number of persons in the household.
0 Total No.of persons served under 18:(LMC) 0
a. Total No.PersonslAdults
servcd:(LMC)
QTR TOTAL#of Persons: 0 QTR TOTAL#Persons: 0
b. Total No.of Households served: 0 Total No.of female head of household:(LMH) 0
OTR TOTAL#of 0 OTR FHH 0
What is the total number of UNDUPLICATED clients served since
6. October,if applicable? Answer question 6a or 6b not both
a. Total No.Persons/Adults served:(LMC) 0 Total No.of persons$erved under 18: 0
(LMC' I 1
YTD TOTAL; 0 YTD TTL: 0
City of Naples Anthony Park Exercise Stations First Amendment CD28-02!D/S#580 4
161) 5
b. Total No.of Households served:(LMH) 0 Total No.of female head of 0
household:(LMH)
YTD TOTAL: 0 YTD TOTAL: 0
Complete EITHER question 7 or question 8 not both 1 I !
Complete question#7a and 7b If your program only serves clients In one or more of the listed HUD Presumed Benefit categories.
PRESUMED BENEFICIARY DATA ONLY:
7. PRESUMED BENEFICIARY DATA ONLY:(LMC)YTD
(LMC)Quarter
Indicate the total number of UNDUPLICATED Indicate the total number of UNDUPLICATED persons served
persons served this quarter who fall into each since October 1 who fall into each presumed benefit category
presumed benefit category(the total should equal (the total should equal the rotal in question#6 a or 6
the total in question#6 a or 6 b): 6):
a. Presumed Benefit Activities Only:(LMC)QTR b. Presumed Benefit Activities Only:(LMC)YTD
0 Abused Children ELI 0 Abused Children ELI
0 Homeless Person ELI 0 Homeless Person ELI
O Migrant Farm workers LI 0 Migrant Farm workers LI
O Battered Spouses LI 0 Battered Spouses I LI
O Persons w/HN/AIDS LI 0 Persons w/HIV/AIDS LI
O Elderly Persons LI or MOD 0 Elderly Persons LI or MOD
O illiterate Adults LI 0 Illiterate Adults LI
O Severely Disabled Adults LI 0 Severely Disabled Adults LI
0 QUARTER TOTAL 0 YTO TOTAL
Complete question#Ba and 8b If any client in your program does not fall Into a Presumed Benefit category.
OTHER BENEFICIARY DATA:INCOME RANGE
a. OTHER BENEFICIARY DATA:INCOME RANGE
Indicate the total number of UNDUPLICATED persons
Indicate the total number of UNDUPLICATED served since October I (YTD)who frill into each income
persons served this Quarter(OTRI who fall into each category(the total should equal the total in question#6):
income category(the total should equal the total in
• question#6):
Ell Extremely low Income(0-30%) 0 ELI Extremely low Income(0-30%) 0
LI Low Income(31-50%) 0 Ll Low Income(31-50%) 0
MOD Moderate Income(51-80%) 0 MOD Moderate Income(51-80%) 0
NON-LOW Above Moderate Income(>80%) 0 NON-LOW Above Moderate Income(>80%) 0
QTR TOTAL: 0 YTDOTAL: 0
• 9. Racial&Ethnic Data: (if applicable)
Please indicate how many UNDUPLICATED Please indicate how many UNDUPLICATED clients
clients served this Quarter(QTR)fall served since October(YTD)fall into each race
into each race category.In addition to each nice category.In addition to each race category,please
category,please indicate how many persons in indicate how many persons in each race category
each race category consider themselves consider themselves Hispanic(Total Race column
Hispanic(Total Race column should equal the
total cell). should equal the total cell).
City of Naples Anthony Park Exercise Stations First Amendment CD18-02IDIS#580 5
1605
ETHNICITY/ ETHNICITY •
a. RACE HISPANIC b. RACE /HISPANIC '
i I
White 0 0 White 0 0
Black African 0 0 Black/African 0 0
Asian 0 9 Asian 0 0
American Indian/Alaska 0 0 American Indian/Alaska 0 0
Native Hawaiian/Other Pacific 0 0 Native Hawaiian/Other Pacific 0 9
American Indian/Alaskan Native& 0 0 American Indian/Alaskan Native& 0 0
Black/African American& 0 0 Black/African American& 0 0
Indian/Alaska Native&Black/African 0 0 indianJAlaska Native&Black/African 0 0
Other Multi- 0 0 Other Multi- 0 0
0 0 I TOTAL: 0 0
Name: Signature:
Title: Your typed name here represents your electronic
ienature
* * *
SIGNATURE PAGE TO FOLLOW
* * *
II
hf
II
City of Naples Anthony Park Exercise Stations First Amendment C018-02 IDIS#580 6 f!
9 1
1 6 D 5
IN WITNESS WHEREOF, the SUBRECIPIENT and the County, have each, respectively, by an
authorized person or agent, hereunder set their hands and seals on the date first written above.
ATTEST: BOARD F ' TY CO SIONE:S OF COLLIER
Crystal K. Kinzel,Clerk of Courts UT , • ' N
•
/ W. L. McDaniel,Jr.,
,Deputy Clerk , Chairman
ASt a5 to Chairman's Date: •' 2 /7C'/9
s! "attire only.
City of Na.
By: 4110(
n
rlonorable Bill . ett, Mayor
Date: 12Gli?O! $
Ap roved as to form and legality:
A
Jenna erA. Belpedio �c6 Approved as to form and legality
Assistant County Attorn QBY ( ttrtC7
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Robert D. Pratt,City A
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City of Naples Anthony Park Exercise Stations First Amendment CD18-02 IDIS#580 7