Agenda 05/28/2019 Item #16D 6 (MOU w/Agriculatural & Labor Program, Inc.)05/28/2019
EXECUTIVE SUMMARY
Recommendation to approve a Memorandum of Understanding between Collier County, as the
provider of the Home Energy Assistance Program, and Agricultural and Labor Program, Inc., as
the provider of Low-Income Home Energy Assistance Program, to coordinate referrals and prevent
duplication of benefits.
OBJECTIVE: To provide home energy assistance aid to elders in the event of a home energy heating or
cooling emergency.
CONSIDERATIONS: The Community and Human Services (CHS) Division’s Services for Seniors
Program (CCSS) has been providing support to Collier County’s frail and elderly citizens for over thirty
(30) years through the grant programs. The County, as the Lead Agency, is responsible to respond to
seniors needs and manage the spending authority for Emergency Home Energy Assistance Program
(EHEAP) and partners with Agricultural and Labor Program, Inc (ALPI), who is the Low -Income Home
Energy Assistance Program (LIHEAP) provider for Collier County. EHEAP aids with home energy
emergencies to qualified, low-income households with at least one (1) person sixty (60) years of age or
older. The LIHEAP helps low income families with energy costs.
The EHEAP grant was accepted by the Board of County Commissioners (Board) on November 13, 2018,
Agenda Item #16D6, and the first amendment was executed by the Board on April 9, 2019, Agenda Item
#16D4. The grantor agency, Area Agency on Aging of Southwest Florida (AAASWFL) is requesting
CCSS, as the EHEAP lead agency, execute a Memorandum of Understanding (MOU) with the ALPI. On
occasion it may be necessary to refer persons to ALPI, the LIHEAP provider. This MOU with ALPI
allows for the necessary referrals between the participating agencies and coordination of services to
prevent duplication of benefits to participants.
FISCAL IMPACT: Funding from the AAASWFL is available in Human Services Grant Fund (707),
Project 33597. There is no Fiscal impact associated with this action.
GROWTH MANAGEMENT: There is no Growth Management impact from this recommendation.
LEGAL CONSIDERATIONS: This Item is approved for form and legality and requires a majority vote
for Board action. - JAB
RECOMMENDATIONS: To approve a Memorandum of Understanding between Collier County, as
the provider of the Home Energy Assistance Program, and Agricultural and Labor Program, Inc., as the
provider of Low-Income Home Energy Assistance Program, to coordinate referrals and prevent
duplication of benefits.
Prepared By: Wendy Klopf, Grant Coordinator, Community and Human Services Division
ATTACHMENT(S)
1. AAA-EHEAP MOU ALPI (PDF)
2. (Linked) EHEAP203.18 Executed Agreement Collier (PDF)
3. EHEAP 203.18.001 Executed (PDF)
16.D.6
Packet Pg. 938
05/28/2019
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.D.6
Doc ID: 8666
Item Summary: Recommendation to approve a Memorandum of Understanding between Collier
County, as the provider of the Home Energy Assistance Program, and Agricultural and Labor Program,
Inc., as the provider of Low-Income Home Energy Assistance Program, to coordinate referrals and
prevent duplication of benefits.
Meeting Date: 05/28/2019
Prepared by:
Title: Operations Coordinator – Community & Human Services
Name: Wendy Klopf
04/16/2019 4:58 PM
Submitted by:
Title: Manager - Federal/State Grants Operation – Community & Human Services
Name: Kristi Sonntag
04/16/2019 4:58 PM
Approved By:
Review:
Community & Human Services Blanca Aquino Luque Additional Reviewer Completed 04/17/2019 8:48 AM
Community & Human Services Maggie Lopez Additional Reviewer Completed 04/23/2019 9:25 AM
Community & Human Services Kristi Sonntag CHS Review Completed 05/01/2019 9:28 AM
Community & Human Services Akiko Woods Additional Reviewer Completed 05/01/2019 10:01 AM
Public Services Department Kimberley Grant Level 1 Reviewer Completed 05/03/2019 8:58 AM
Public Services Department Todd Henry Level 1 Division Reviewer Completed 05/03/2019 10:15 AM
Grants Erica Robinson Level 2 Grants Review Completed 05/03/2019 11:25 AM
County Attorney's Office Jennifer Belpedio Level 2 Attorney of Record Review Completed 05/06/2019 8:19 AM
Public Services Department Steve Carnell Level 2 Division Administrator Review Completed 05/14/2019 11:30 AM
County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Completed 05/15/2019 1:15 PM
Office of Management and Budget Valerie Fleming Level 3 OMB Gatekeeper Review Completed 05/15/2019 4:58 PM
Budget and Management Office Ed Finn Additional Reviewer Completed 05/17/2019 12:58 PM
Grants Therese Stanley Additional Reviewer Completed 05/20/2019 9:05 AM
County Manager's Office Heather Yilmaz Level 4 County Manager Review Completed 05/20/2019 1:13 PM
Board of County Commissioners MaryJo Brock Meeting Pending 05/28/2019 9:00 AM
16.D.6
Packet Pg. 939
16.D.6.aPacket Pg. 940Attachment: AAA-EHEAP MOU ALPI (8666 : LIHEAP-MOU with ALPI)
16.D.6.aPacket Pg. 941Attachment: AAA-EHEAP MOU ALPI (8666 : LIHEAP-MOU with ALPI)
Revised August 2007
Attestation Statement
Agreement/Contract Number EHEAP 203.18
Amendment Number NA
I, Board of County Commissioners, Andy Solis , 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 and
Collier County Board of Commissioners
(Recipient/Contractor name)
The only exception to this
electronic data processing
Signature of
Revised August 2007
nt would changes in page formatting, due to the differences in
which h no ffect on the agreement/contract content.
representative
Date
Approved as to form and legally
CLERK ('
nAsst ant County t n'ney
LTihAY /W.16
October 2018 — September 2019
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS CONTRACT is entered into between the Area Agency on Aging for Southwest Florida, Inc.
(Agency) and Collier County Board of County Commissioners (Contractor), collectively referred to as the
"Parties." The term Contractor for this purpose may designate a Vendor, Subgrantee or Subrecipient.
WITNESSETH THAT:
WHEREAS, the Agency has determined that it is in need of certain services as described herein; and
WHEREAS, the Contractor has demonstrated that it has the requisite expertise and ability to faithfully
perform such services as an independent Contractor of the Agency.
NOW THEREFORE, in consideration of the services to be performed and payments to be made, together
with the mutual covenants and conditions hereinafter set forth, the Parties agree as follows:
1. Purpose of Contract:
The purpose of this Contract is to provide services in accordance with the terms and conditions
specified in this contract including all attachments, forms and exhibits, which constitute the contract
document.
2 Incorporation of Documents within the Contract:
The contract will incorporate attachments, proposal(s), state plan(s), grant agreements, relevant
Department handbooks, manuals or desk books, as an integral part of the contract, except to the
extent that the contract explicitly provides to the contrary. In the event of conflict in language
among any of the documents referenced above, the specific provisions and requirements of the
contract document(s) shall prevail over inconsistent provisions in the proposal(s) or other general
materials not specific to this contract document and identified attachments.
3. Term of Contract:
This contract shall begin at twelve (12:00) AM., Eastern Standard Time October 1, 2018 or on the
date the contract has been signed by the last party required to sign it, whichever is later. It shall end
at eleven fifty-nine (11:59) P.M., Eastern Standard Time September 30, 2019.
4. Contract Amount:
The Agency agrees to pay for contracted services according to the terms and conditions of this
contract in an amount not to exceed $55,757.00 subject to the availability of funds. Any costs or
services paid for under any other contract or from any other source are not eligible for payment
under this contract.
5. Renewals:
By mutual agreement of the Parties, in accordance with Section 287.058(1)(g), Florida Statutes
(F.S.), the Agency may renew the contract for a period not to exceed three years, or the term of the
original contract, whichever is longer. The renewal price, or method for determining a renewal
1
LriLAY 6u.S.1 ZS
October 2018 — September 2019
price, is set forth in the bid, proposal, or reply. No other costs for the renewal may be charged. Any
renewal is subject to the same terms and conditions as the original contract and contingent upon
satisfactory performance evaluations by the Agency and the availability of funds.
6. Compliance with Federal Law:
6.1 If this contract contains federal funds this section shall apply.
6.1.1 The Contractor shall comply with the provisions of 45 Code of Federal Regulations (CFR)
75 and/or 45 CFR Part 92, 2 CFR Part 200 and other applicable regulations.
6.12 If this contract contains federal funds and is over $100,000.00, the Contractor shall comply
with all applicable standards, orders, or regulations issued under Section 306 of the Clean
Air Act as amended (42 United States Code (U.S.C.) 7401, et seq.), Section 508 of the
Federal Water Pollution Control Act as amended (33 U.S.C. 1251, et seq.), Executive Order
11738, as amended, and where applicable Environmental Protection Agency regulations 2
CFR Part 1500. The Contractor shall report any violations of the above to the Agency.
6.1.3 Neither the Contractor nor any agent acting for the Contractor, may not use any federal funds
received in connection with this contract to influence legislation or appropriations pending
before Congress or any state legislature. The Contractor must complete all disclosure forms
as required, specifically the Certification and Assurances Attachment, which must be
completed and returned to the Contract Manager prior to the execution of this contract.
6.1.4 In accordance with Appendix II to 2 CFR Part 200, the Contractor shall comply with
Executive Order 11246, Equal Employment Opportunity, as amended by Executive Order
11375 and others, and as supplemented in Department of Labor regulations 41 CFR Part 60
and in Department of Health and Human Services regulations 45 CFR Part 92, if applicable.
6.1.5 A contract award with an amount expected to equal or exceed $25,000.00 and certain other
contract awards will not be made to parties listed on the government -wide Excluded Parties
List System, in accordance with the OMB guidelines at 2 CFR Part 180 that implement
Executive Orders 12549 and 12689, "Debarment and Suspension." The Excluded Parties
List System contains the names of parties debarred, suspended, or otherwise excluded by
agencies, as well as parties declared ineligible under statutory or regulatory authority other
than Executive Order 12549. The Contractor shall comply with these provisions before
doing business or entering into subcontracts receiving federal funds pursuant to this contract.
The Contractor shall complete and sign the Certifications and Assurances Attachment prior
to the execution of this contract.
62 The Contractor shall not employ an unauthorized alien. The Agency will consider the employment
of unauthorized aliens a violation of the Immigration and Nationality Act (8 U.S.C. 1324a) and the
Immigration Reform and Control Act of 1986 (8 U.S.C. 1101). Such violation will be cause for
unilateral cancellation of this contract by the Agency.
63 If the Contractor is a non-profit provider and is subject to Internal Revenue Service (IRS) tax
exempt organization reporting requirements (filing a Form 990 or Form 990-N) and has its tax-
exempt status revolted for failing to comply with the filing requirements of the Pension Protection
Act of 2006 or for any other reason, the Contractor must notify the Agency in writing within
thirty (30) days of receiving the IRS notice of revocation.
FA
r5
w�.i�
r.rrnHr 2os.1 x
October 2018 — September 2019
6.4 The Contractor shall comply with Title 2 CFR Part 175 regarding Trafficking in Persons.
65 Unless exempt under 2 CPR Part 170.110(b), the Contractor shall comply with the reporting
requirements of the Transparency Act as expressed in 2 CFR Part 170.
6.6 To comply with Presidential Executive Order 12989, as amended, and State of Florida Executive
Order Number 11-116, Contractor agrees to utilize the U.S. Department of Homeland Security's
E -verify system to verify the employment of all new employees hired by Contractor during the
contract term. Contractor shall include in related subcontracts a requirement that Subcontractors
performing work or providing services pursuant to the state contract utilize the E -verify system to
verify employment of all new employees hired by the Subcontractor during the contract term.
Contractors meeting the terms and conditions of the E -Verify System are deemed to be in
compliance with this provision.
7. Compliance with State Law:
7.1 This contract is executed and entered into in the State of Florida, and shall be construed,
performed, and enforced in all respects in accordance with Florida law, including Florida
provisions for conflict of laws.
7.2 If this contract contains state financial assistance funds, the Contractor shall comply with Section
215.97, F.S., and Section 215.971, F.S., and expenditures must be in compliance with laws, rules,
and regulations, including, but not limited to, the Reference Guide for State Expenditures.
7.3 The Contractor shall comply with the requirements of Section 287.058, F.S. as amended.
7.3.1 The Contractor shall perform all tasks contained in ATTACHMENT I.
7.32 The Contractor shall provide units of deliverables, including reports, findings, and drafts, as
specified in ATTACHMENT I to be received and accepted by the contract manager prior to
payment.
7.3.3 The Contractor shall comply with the criteria and final date by which such criteria must be
met for completion of this contract as specified in ATTACHMENT I, Section III. Method of
Payment.
7.3.4 The Contractor shall submit bills for fees or other compensation for services or expenses in
sufficient detail for a proper pre -audit and post -audit.
7.3.5 If itemized payment for travel expenses is permitted in this contract, the Contractor shall
submit bills for any travel expenses in accordance with Section 112.061, F.S., or at such
lower rates as may be provided in this contract.
7.3.6 The Contractor shall allow public access to all documents, papers, letters, or other public
records as defined in Section 119.011(12), F.S., made or received by the Contractor in
conjunction with this contract except for those records which are made confidential or
exempt by law. The Contractor's refusal to comply with this provision will constitute an
immediate breach of contract for which the Agency may unilaterally terminate this contract.
7.4 If clients are to be transported under this contract, the Contractor shall comply with the provisions
of Chapter 427, F.S., and Rule Chapter 41-2, Florida Administrative Code (F.A.C).
7.5 Subcontractors who are on the Discriminatory Vendor List may not transact business with any
public entity, in accordance with the provisions of Section.287.134, F.S.
3
tSriY.A V 6U3.1 S
October 2018 — September 2019
7.6 The Contractor shall comply with the provisions of Section 11.062, F.S., and Section 216.347,
F.S., which prohibit the expenditure of contract funds for the put -pose of lobbying the legislature,
judicial branch or a state agency.
7.7 The Agency may, at its option, terminate the Contract if the Contractor is found to have submitted
a false certification as provided under Section 287.135(5), F.S., has been placed on the
Scrutinized Companies with Activities in the Iran Petroleum Energy Section List, the Scrutinized
Companies with Activities in Sudan List, or the Scrutinized Companies that Boycott Israel list, or
if the contractor had been engaged in business operations in Cuba or Syria or is engaged in a
boycott of Israel.
8. Background Screening:
The Contractor shall ensure that the requirements of Section 430.0402 and Chapter 435, F.S., as
amended, are met regarding background screening for all persons who meet the definition of a
direct set -vice provider and who are not exempt from the Agency's level 2 background screening
pursuant to Sections 430.0402(2)-(3), F.S. The Contractor must also comply with any applicable
rules promulgated by the Agency and the Department for Health Care Administration regarding
implementation of Section 430.0402 and Chapter 435, F.S. To demonstrate compliance with this
provision, Contractor shall submit the Background Screening Affidavit of Compliance (Screening
Form) to the Agency upon thirty (30) days of execution of this contract. Should the Agency have a
completed Screening Form on file for the Contractor, a new Screening Form will be required every
twelve (12) months.
8.1 Further information concerning the procedures for background screening may be found at
http://elderaffai s.state.fl.us/doea/backgroiundscreening.php.
9. Grievance Procedures:
The Contractor shall develop, implement, and ensure that its Subcontractors have established
grievance procedures to process and resolve client dissatisfaction with, or denial of, service(s) and
address complaints regarding the termination, suspension, or reduction of services, as required for
receipt of funds. These procedures, at a minimum, will provide for notice of the grievance
procedure and an opportunity for review of the Subcontractor's determination(s).
10. Public Records and Retention:
10.1 By execution of this contract, Contractor agrees to all provisions of Chapter 119, F.S., and any
other applicable law, and shall:
10.1.1 Keep and maintain public records required by the Agency to perform the contracted set -vices.
10.12 Upon request from the Agency's custodian of public records, provide the Agency a copy of
the requested records or allow the records to be inspected or copied within a reasonable time
at a cost that does not exceed the cost provided in Chapter 119, F.S., or as otherwise
provided by law.
10.1.3 Ensure that public records that are exempt or confidential and exempt from public records
disclosure requirements are not disclosed except as authorized by law for the duration of the
contract term and following completion of the contract if the Contractor does not transfer the
records to the Agency.
4
LUP All 21W.16
October 2018 — September 2019
10.1.4 Upon completion of the contract, the Contractor will either transfer, at no cost to the
Agency, all public records in possession of the Contractor to the Agency or will keep and
maintain public records required by the Agency. If the Contractor transfers all public records
to the Agency upon completion of the contract, Contractor shall destroy any duplicate public
records that are exempt or confidential and exempt from public records disclosure
requirements. If the Contractor keeps and maintains public records upon completion of the
contract, the Contractor shall meet all applicable requirements for retaining public records.
All records stored electronically must be provided to the Agency in a format that is
compatible with the information technology systems of the Agency.
10.2The Agency may unilaterally cancel this contract, notwithstanding any other provisions of this
contract, for refusal by the Contractor to comply with Section 10 of this contract by not allowing
public access to all documents, papers, letters, or other material made or received by the Contractor
in conjunction with this contract, unless the records arc exempt or confidential and exempt from
Section 24(a) of Article I of the State Constitution and Section 119.07(1), F.S.
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF
CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE
PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN
OF PUBLIC RECORDS AT:
Public Records Coordinator
Area Agency on Aging for Southwest Florida, Inc.
15201 N Cleveland Ave., Suite 1100
North Fort Myers, FL 33903
239-652-6900 or 866-413-5337
11. Audits, Inspections, Investigations:
11.1 The Contractor shall establish and maintain books, records and documents (including electronic
storage media) sufficient to reflect all assets, obligations, unobligated balances, income, interest
and expenditures of funds provided by the Agency under this contract. Contractor shall
adequately safeguard all such assets and assure that they are used solely for the purposes
authorized under this contract. Whenever appropriate, financial information should be related to
performance and unit cost data.
11.2 The Contractor shall retain and maintain all client records, financial records, supporting
documents, statistical records, and any other documents (including electronic storage media)
pertinent to this contract for a period of six (6) years after completion of the contract, or longer
when required by law. In the event an audit is required by this contract, records shall be retained
for a minimum period of six (6) years after the audit report is issued or until resolution of any
audit findings or litigation based on the terms of this contract, at no additional cost to the
Agency.
11.3 Upon demand, at no additional cost to the Agency, the Contractor shall facilitate the duplication
and transfer of any records or documents during the required retention period.
11.4 The Contractor shall assure that the records described in this section will be subject at all
reasonable times to inspection, review, copying, or audit by federal, state, or other personnel duly
authorized by the Agency.
E
111HILAY /1U.5.16
October 2018 — September 2019
11.5 At all reasonable times for as long as records are maintained persons duly authorized by the
Agency and federal auditors, pursuant to 45 CFR Part 75, will be allowed full access to and the
right to examine any of the Contractor's contracts and related records and documents pertinent
to this specific contract, regardless of the form in which kept.
11.5.1 The Contractor shall provide a Financial and Compliance Audit Attachment to the Agency as
specified in this contract and ensure that all related third -party transactions are disclosed to
the auditor.
11.5.2 Contractor agrees to comply with the Inspector General in any investigation, audit,
inspection, review, or hearing performed pursuant to Section 20.055, Florida Statutes.
Contractor further agrees that it shall include in related subcontracts a requirement that
subcontractors performing work or providing services pursuant to this contract agree to
cooperate with the Inspector General in any investigation, audit, inspection, review, or
hearing pursuant to Section 20.055(5), F.S. By execution of this contract, the Contractor
understands and will comply with this subsection.
12. Nondiscrimination -Civil Rights Compliance:
12.1 The Contractor shall execute Assurances as stated in the Assurances -Non -Construction Programs
Attachment that it will not discriminate against any person in the provision of services or benefits
under this contract or in employment because of age, race, religion, color, disability, national
origin, marital status, or sex in compliance with state and federal law and regulations. The
Contractor further assures that all Contractors, Subcontractors, Sub -grantees, or others with whom
it arranges to provide services or benefits in connection with any of its programs and activities are
not discriminating against clients or employees because of age, race, religion, color, disability,
national origin, marital status, or sex.
12.2 During the term of this contract, the Contractor shall complete and retain on file a timely,
complete, and accurate Civil Rights Compliance Checklist, attached to this contract.
12.3 The Contractor shall establish procedures pursuant to federal law to handle complaints of
discrimination involving services or benefits through this contract. These procedures will include
notifying clients, employees, and participants of the right to file a complaint with the appropriate
federal or state entity.
12.4 If this contract contains federal funds, these assurances are a condition of continued receipt of or
benefit from federal financial assistance, and are binding upon the Contractor, its successors,
transferees, and assignees for the period during which such assistance is provided. The Contractor
further assures that all Subcontractors, Vendors, or others with whom it arranges to provide
services or benefits to participants or employees in comzection with any of its programs and
activities are not discriminating against those participants or employees in violation of the above
statutes, regulations, guidelines, and standards. In the event of failure to.comply, the Contractor
understands that the Agency may, at its discretion, seek a court order requiring compliance with
the terms of this assurance or seek other appropriate judicial or administrative relief, including,
but not limited to, termination of the contract and denial of further assistance.
13. Monitoring by the Agency:
The Contractor shall permit persons duly authorized by the Agency to inspect and copy any records,
papers, documents, facilities, goods, and services of the Contractor which are relevant to this
6
rlrit'Ar LU.S.1 d
October 2018 — September 2019
contract, and to interview any clients, employees, and Subcontractor employees of the Contractor to
assure the Agency of the satisfactory performance of the terms and conditions of this contract.
Following such review, the Agency will provide a written report of its findings to the Contractor
and, where appropriate, the Contractor shall develop a Corrective Action Plan (CAP). The
Contractor hereby agrees to correct all deficiencies identified in the CAP in a timely manner as
determined by the Contract Manager.
14. Provision of Services:
The Contractor shall provide services in the manner described in ATTACHMENT I.
15. Indemnification:
The Contractor shall indemnify, save, defend, and hold harmless the Agency and its agents and
employees from any and all claims, demands, actions, and causes of action of whatever nature or
character arising out of, or by reason of the execution of this agreement or performance of the
services provided for herein. It is understood and agreed that the Contractor is not required to
indemnify the Agency for claims, demands, actions, or causes of action arising solely out of the
negligence of the Agency.
6d Except to the extent permitted by Section 768.28, F.S., or other Florida law, this Section 16 is
not applicable to contracts executed between the Agency and state agencies or subdivisions
defined in Section 768.28(2), F.S.
Ira Insurance and Bonding:
161 The Contractor shall provide continuous adequate liability insurance coverage during the
existence of this contract and any renewal(s) and extension(s) of it. By execution of this contract,
unless it is a state agency or subdivision as defined by Section 768.28(2), F.S., the Contractor
accepts full responsibility for identifying and determining the type(s) and extent of liability
insurance coverage necessary to provide reasonable financial protections for the Contractor and
the clients to be served under this contract. The limits of coverage under each policy maintained
by the Contractor do not limit the Contractor's liability and obligations under this contract. The
Contractor shall ensure that the Agency has the most current written verification of insurance
coverage throughout the term of this contract. Such coverage may be provided by a self-
insurance program established and operating under the laws of the State of Florida. The Agency
reserves the right to require additional insurance as specified in this contract.
162 Throughout the term of this contract, the Contractor shall maintain an insurance bond from a
responsible commercial insurance company covering all officers, directors, employees, and
agents of the Contractor authorized to handle funds received or disbursed under all agreements
and/or contracts incorporating this contract by reference in an amount commensurate with the
funds handled, the degree of risk as determined by the insurance company, and consistent with
good business practices.
IZ Confidentiality of Information:
The Contractor shall not use or disclose any information concerning a recipient of services under
this contract for any purpose prohibited by state or federal law or regulations except with the
written consent of a person legally authorized to give that consent or when authorized by law.
btitAY /W.l2S
October 2018 — September 2019
18 Health Insurance Portability and Accountability Act:
Where applicable, the Contractor shall comply with the Health Insurance Portability and
Accountability Act (42 USC 1320d.), as well as all regulations promulgated thereunder (45 CFR
Parts 160, 162, and 164).
19. Incident Reporting:
191 The Contractor shall notify the Agency immediately but no later than forty-eight (48) hours from
the Contractor's awareness or discovery of conditions that may materially affect the Contractor's
or Subcontractor's ability to perform the services required to be performed under this contract.
Such notice shall be made orally to the Agency's Contract Manager (by telephone) with an email
to immediately follow.
192 The Contractor- shall immediately report knowledge or reasonable suspicion of abuse, neglect, or
exploitation of a child, aged person, or disabled adult to the Florida Abuse Hotline on the
statewide toll-free telephone number (1-800-96ABUSE). As required by Chapters 39 and 415,
F.S., this provision is binding upon the Contractor, Subcontractors, and their employees.
20. New Contract(s) Reporting:
The Contractor shall notify the Agency within ten (10) days of entering into a new contract with
any of the remaining four (4) state human service agencies. The notification shall include the
following information: (1) contracting state agency and the applicable office or program issuing the
contract; (2) contract name and number; (3) contract start and end dates; (4) contract amount; (5)
contract description and commodity or service; (6) Contract Manager name and contact
information. In complying with this provision, and pursuant to Section 287.0575, F.S., as amended,
the Contractor shall complete the Contractor's State Contracts List attached to this contract.
21. Banlauptcy Notification:
During the term of this contract, the Contractor shall immediately notify the Area Agency on Aging
for Southwest Florida, Inc. if the Contractor, its assignees, Subcontractors, or affiliates file a claim
for bankruptcy. Within ten (10) days after notification, the Contractor must also provide the
following information to the Area Agency on Aging for Southwest Florida, Inc.: (1) the date of
filing of the bankruptcy petition; (2) the case number; (3) the court name and the division in which
the petition was filed (e.g., Northern District of Florida, Tallahassee Division); and (4) the name,
address, and telephone number of the bankruptcy attorney.
22. Sponsorship and Publicity:
221 As required by Section 286.25, F.S., if the Contractor is a non-governmental organization which
sponsors a program financed wholly or in part by state funds, including any funds obtained
through this contract, it shall, in publicizing, advertising, or describing the sponsorship of the
program, state: "Sponsored by (Contractors name) and the State of Florida, Department of Elder
Affairs and/or the Area Agency on Aging for Southwest Florida, Inc.." If the sponsorship
reference is in written material, the words "State of Florida, Department of Elder Affairs and/or
the Area Agency on Aging for Southwest Florida, Inc." shall appear in at least the same size
letters or type as the name of the organization.
272 The Contractor shall not use the words "State of Florida, Department of Elder Affairs and the
Area Agency on Aging for Southwest Florida, Inc." to indicate sponsorship of a program
otherwise financed, unless specific authorization has been obtained by the Agency prior to use.
8
h1-rhA1` LUS.1 ZS
October 2018 — September 2019
23. Assignments:
23.1 The Contractor shall not assign the rights and responsibilities under this contract without the
prior written approval of the Agency, which shall not be unreasonably withheld. Any sublicense,
assignment, or transfer otherwise occurring without prior written approval of the Agency will
constitute a material breach of the contract.
232 The State of Florida is, at all times, entitled to assign or transfer, in whole or part, its rights,
duties, or obligations under this contract to another governmental agency in the State of Florida
upon giving prior written notice to the Contractor. In the event the State of Florida approves
transfer of the Contractor's obligations, the Contractor remains responsible for all work
performed and all expenses incurred in connection with this contract.
233 This contract shall remain binding upon the successors in interest of either the Contractor or the
Agency.
24 Subcontracts:
241 The Contractor is responsible for all work performed and for all commodities produced pursuant
to this contract, whether actually furnished by the Contractor or its Subcontractors. Any
subcontracts shall be evidenced by a written document and subject to any conditions of approval
the Agency deems necessary. The Contractor further agrees that the Agency will not be liable to
the Subcontractor in any way or for any reason. The Contractor, at its expense, shall defend the
Agency against any such claims.
212 The Contractor shall promptly pay any Subcontractors upon receipt of payment from the Agency
or other state agency. Failure to make payments to any Subcontractor in accordance with Section
287.0585, F.S., unless otherwise stated in the contract between the Contractor and
Subcontractor, will result in a penalty as provided by statute.
25. Independent Capacity of Contractor:
It is the intent and understanding of the Parties that the Contractor and any of its Subcontractors are
independent Contractors and are not employees of the Agency, and that they shall not hold
themselves out as employees or agents of the Agency without specific authorization from the
Agency. It is the further intent and understanding of the Parties that the Agency does not control
the employment practices of the Contractor and will not be liable for any wage and hour,
employment discrimination, or other labor and employment claims against the Contractor or its
Subcontractors. All deductions for social security, withholding taxes, income taxes, contributions
to unemployment compensation funds, and all necessary insurance for the Contractor are the sole
responsibility of the Contractor.
2CG Payment:
Payments shall be made to the Contractor for all completed and approved deliverables (units of
service) as defined in ATTACI3MENT I. The Contract Manager will have final approval of the
Contractor's invoice submitted for payment and will approve the invoice for payment only if the
Contractor has met all terms and conditions of the contract, unless the bid specifications, purchase
order, or this contract specify otherwise. The approved invoice will be submitted to the Agency's
finance section for budgetary approval and processing. Disputes arising over invoicing and
payments will be resolved in accordance with the provisions of Section 215.422, F.S. A Vendor
t'.riCAr LU.5. 16
October 2018 — September 2019
Ombudsman has been established within the Florida Department of Financial Services and may be
contacted at 800-342-2762.
27. Return of Funds:
The Contractor shall return to the Agency any overpayments due to unearned funds or funds
disallowed, and any interest attributable to such funds pursuant to the terms and conditions of this
contract, that were disbursed to the Contractor by the Agency. In the event that the Contractor or its
independent auditor discovers that an overpayment has been made, the Contractor shall repay said
overpayment immediately without prior notification from the Agency. In the event that the Agency
first discovers an overpayment has been made, the Contract Manager will notify the Contractor in
writing of such findings. Should repayment not be made forthwith, the Contractor shall be charged
at the lawful rate of interest on the outstanding balance pursuant to Section 55.03, F.S., after
Agency notification or Contractor discovery.
28. Data Integrity and Safeguarding Information:
The Contractor shall ensure an appropriate level of data security for the information the Contractor
is collecting or using in the performance of this contract. An appropriate level of security includes
approving and tracking all Contractor employees that request system or information access and
ensuring that user access has been removed from all terminated employees. The Contractor, among
other requirements, must anticipate and prepare for the loss of information processing capabilities.
All data and software shall be routinely backed up to ensure recovery from losses or outages of the
computer system. The security over the backed -up data is to be as stringent as the protection
required of the primary systems. The Contractor shall ensure all Subcontractors maintain written
procedures for computer system backup and recovery. The Contractor shall complete and sign the
Certification Regarding Data Integrity Compliance for Agreements, Grants, Loans, and
Cooperative Agreements prior to the execution of this contract.
29. Computer Use and Social Media Policy:
The Florida Department of Elder Affairs has implemented a Social Media Policy, in addition to its
Computer Use Policy, which applies to all employees, contracted employees, consultants, OPS and
volunteers, including all personnel affiliated with third parties, such as, but not limited to,
contractors and subcontractors. Any entity that uses the Department's computer resource systems
must comply with the Department's policy regarding social media. Social Media includes, but is not
limited to blogs, podcasts, discussion forums, Wikis, RSS feeds, video sharing, social networks like
MySpace, Facebook and Twitter, as well as content sharing networks such as Flickr and YouTube.
This policy is available on the Department's website at:
http://elderaffairs.state.fl.us/doeai'fnancial.php.
30 Conflict of Interest:
The Contractor shall establish safeguards to prohibit employees, board members, management, and
Subcontractors from using their positions for a purpose that constitutes or presents the appearance
of personal or organizational conflict of interest or personal gain. No employee, officer, or agent of
the Contractor or Subcontractor shall participate in the selection, or in the award of a contract
supported by state or federal funds if a conflict of interest, real or apparent, would be involved.
Such a conflict would arise when: (a) the employee, officer or agent; (b) any member of his/her
immediate family; (c) his or her partner; or (d) an organization which employs, or is about to
employ, any of the above individuals, has a financial or other interest in the firm being selected for
10
tMl tnAr 6U 5.1 iS
October 2018 — September 2019
award. The Contractor or Subcontractor's officers, employees, or agents will neither solicit nor
accept gratuities, favors, or anything of monetary value from Contractors, potential Contractors, or
parties to Subcontracts. The Contractors board members and management must disclose to the
Agency any relationship which may be', or may be perceived to be, a conflict of interest within
thirty (30) calendar days of an individual's original appointment, or, placement in that position, or if
the individual is serving as an incumbent, within thirty (30) calendar days of the commencement of
this contract. The Contractor's employees and Subcontractors must make the same disclosures
described above to the Contractor's board of directors. Compliance with this provision will be
monitored.
31. Public Entity Crime:
Pursuant to Section 287.133, F.S., a person or affiliate who has been placed on the Convicted
Vendor List following a conviction for a public entity crime may not submit a bid, proposal, or
reply on a contract to provide any goods or services to a public entity; may not submit a bid,
proposal, or reply on a contract with a public entity for the construction or repair of a public
building or public work; may not submit bids, proposals, or replies on leases of real property to a
public entity; may not be awarded or perform work as a Contractor, Supplier, Subcontractor, or
Consultant under a contract with any public entity; and may not transact business with any public
entity in excess of the threshold amount provided in Section 287.017, F.S., for CATEGORY TWO
for a period of thirty six (36) months following the date of being placed on the Convicted Vendor
List.
33. Purchasing:
33.1 The Contractor may purchase articles which are the subject of, or are required to carry out, this
contract from Prison Rehabilitative Industries and Diversified Enterprises, Inc., (PRIDE)
identified under Chapter 946, F.S., in the same manner and under the procedures set forth in
Sections 946.515(2) and (4), F.S. For purposes of this contract, the Contractor shall be deemed to
be substituted for the Agency insofar as dealings with PRIDE. This clause is not applicable to
Subcontractors unless otherwise required by law. An abbreviated list of products/services
available from PRIDE may be obtained by contacting PRIDE (800-643-8459).
332 The Contractor may procure any recycled products or materials which are the subject of, or, are
required to carry out, this contract in accordance with the provisions of Section 403.7065, F.S.
33.3 The Contractor may purchase articles that are the subject of, or required to carry out, this
contract from a nonprofit agency for the Blind or for the Severely Handicapped that is qualified
pursuant to Chapter 413, F.S., in the same manner and under the same procedures set forth in
Sections 413.036(1) and (2), F.S. For purposes of this contract, the Contractor shall be deemed to
be substituted for the Agency insofar as dealings with such qualified nonprofit agency are
concerned. Additional information about the designated nonprofit agency and the products it
offers is available at http://xvww.respectofflorida.org. This clause is not applicable to
Subcontractors unless otherwise required by law.
34. Patents, Copyrights, Royalties:
If this contract is awarded state funding and if any discovery, invention, or copyrightable material
is developed, produced, or ownership was purchased in the course of or as a result of work or
services performed under this contract, the Contractor shall refer the discovery, invention, or
copyrightable material to the Agency to be referred to the Department of State. Any and all patent
11
F�4�.
hmd AYzuj.Lt5
October 2018 — September 2019
rights or copyrights accruing under this contract are hereby reserved to the State of Florida in
accordance with Chapter 286, F.S. Pursuant to Section 287.0571(5)(k), F.S., the only exceptions to
this provision shall be those that are clearly expressed and reasonably valued in this contract.
34.1 If the primary purpose of this contract is the creation of intellectual property, the State of Florida
shall retain an unencumbered right to use such property, notwithstanding any agreement made
pursuant to this Section 34.
34.2 If this contract is awarded solely federal funding, the terms and conditions are governed by 2 CFR
200.315 or 45 CFR 75.322, as applicable.
34.3 Notwithstanding the foregoing provisions, if the Contractor or one of its Subcontractors is a
university and a member of the State University System of Florida, then Section 1004.23, F.S.,
shall apply, but the Agency shall retain a perpetual, fully -paid, nonexclusive license for its use
and the use of its Contractors, Subcontractors, or Assignees of any resulting patented,
copyrighted, or trademarked work products.
35. Emergency Preparedness and Continuity of Operations:
35.1 If the tasks to be performed pursuant to this contract include the physical care and control of
clients, or the administration and coordination of services necessary for client health, safety, or
welfare, the Contractor shall, within thirty (30) calendar days of the execution of this contract,
submit to the Agency's Contract Manager verification of an Emergency Preparedness Plan. In
the event of an emergency, the Contractor shall notify the Agency of emergency provisions.
352 In the event a situation results in a cessation of services by a Subcontractor, the Contractor shall
retain responsibility for performance under this contract and must follow procedures to ensure
continuity of operations without interruption.
36. Equipment:
36.1 Equipment means: (a) tangible personal property (including information technology systems)
having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds
the lesser of the capitalization level established by the organization for the financial statement
purposes, or $5,000.00 [for federal funds — 2 CFR 200.33 and 45 CFR 75.2, as applicable], or
(b); nonexpendable, tangible personal property of a non -consumable nature with an acquisition
cost of $1,000.00 or more per unit, and expected useful life of at least one (1) year; and hardback
bound books not circulated to students or the general public, with a value or cost of $250.00 or
more [for state funds].
362 Contractors and Subcontractors who are Institutions of Higher Education, Hospitals, and Other
Non -Profit Organizations shall have written property management standards in compliance with
2 CFR Part 200 Administrative Requirements (formerly OMB Circular A-110) that include: (a) a
property list with all the elements identified in the circular; (b) a procedure for conducting a
physical inventory of equipment at least once every two (2) years; (c) a control system to insure
adequate safeguards to prevent loss, damage, or theft of the equipment; and (d) maintenance
procedures to keep the equipment in good condition. The property records must be maintained on
file and shall be provided to the Agency upon request. The Contractor shall promptly investigate,
fully document, and notify the Agency's Contract Manager of any loss, damage, or theft of
equipment. The Contractor shall provide the results of the investigation to the Agency's Contract
Manager.
12
r✓ru✓yr Zu s. r e
October 2018 — September 2019
36.3 The Contractor's property management standards for equipment (including replacement
equipment), whether acquired in whole or part with federal funds and federally -owned equipment
shall, at a minimum, meet the following requirements and shall include accurately maintained
equipment records with the following information:
36.3.1 Property records must be maintained that include a description of the equipment;
36.3.2 Manufacturer's serial number, model number, federal stock number, national stock
number, or other identification number;
36.3.3 Source of funding for the equipment, including the federal award number identification
number;
36.3.4 Whether title vests in the Contractor or the federal government;
36.3.5 Acquisition date (or date received, if the equipment was furnished by the federal
government) and cost;
36.3.6 Information from which one can calculate the percentage of federal participation in the
cost of the equipment (not applicable to equipment furnished by the federal government);
36.3.7 Location use, and condition of the equipment and the date the information was reported;
36.3.8 Unit acquisition cost; and
36.3.9 Ultimate disposition data, including date of disposal and sales price or the method used to
determine current fair market value where a Contractor compensates the federal awarding
agency for its share.
36.3.10 A physical inventory must be taken, and the results reconciled with the property records
at least once every two (2) years.
36.3.11 A control system must be developed to ensure adequate safeguards to prevent loss,
damage, or theft of the property. Any loss, damage, or theft must be investigated.
36.3.12 Adequate maintenance procedures must be developed to keep the property in good
condition.
36.3.13 If the Contractor is authorized or required to sell the equipment, proper sales procedures
must be established to ensure the highest possible return.
36.4 Equipment purchased with federal funds with an acquisition cost over $5,000.00 and equipment
purchased with state funds with an acquisition cost over $1,000.00 is part of the cost of carrying
out the activities and functions of the grant awards, and title (ownership) will vest in the
Contractor [for federal funds see 2 CFR 200.313(a) and 45 CFR 75.320(a), as applicable], subject
to the conditions of 2 CFR Part 200 and/or 45 CFR part 75. Equipment purchased under these
thresholds is considered supplies and is not subject to property standards. Equipment purchased
with funds identified in the budget attachments to agreements covered by this contract or
identified in the sub -agreements with Subcontractors (not included in a cost methodology), is
subject to the conditions of Chapter 273, F.S., rule 60A-1.001 7, F.A.C., and 2 CFR Part 200
and/or 45 CFR Part 75.
365 The Contractor shall not dispose of any equipment or materials provided by the Agency, or
purchased with funds provided through this contract without first obtaining the approval of the
13
nrn Vkv /u s. r a
October 2018 — September 2019
Agency's Contract Manager. When disposing of property or equipment the Contractor must
submit a written request for disposition instructions to the Agency's Contract Manager. The
request should include a brief description of the property, purchase price, funding source, and
percentage of state or federal participation, acquisition date, and condition of the property. The
request should also indicate the Contractor's proposed disposition of the property (i.e., transfer or
donation to another agency that administers federal programs, offer of the items for sale, destroy
the items, etc.).
36.6 The Agency's Contract Manager will issue disposition instructions. If disposition instructions are
not received within one hundred twenty (120) days of the written request for disposition, the
Contractor is authorized to proceed as directed in 2 CFR §200.313 or 45 CFR § 75.320, as
applicable
36.7 Real property means land (including land improvements), buildings, structures and appurtenances
thereto, but excludes movable machinery and equipment. Real property may not be purchased
with state or federal funds through agreements covered under this contract without the prior
approval of the Agency. Real property purchases from Older Americans Act funds are subject to
the provisions of Title 42, Chapter 35, Subchapter III, Part A., Section 3030b United States Code
(USC). Real property purchases from state funds can only be made through fixed capital outlay
grants and aids appropriations and therefore are subject to the provisions of Section 216.348, F.S.
36.8 Any permanent storage devices (e.g.: hard drives, removable storage media) must be reformatted
and tested prior to disposal to ensure no confidential information remains.
36.9 The Contractor must adhere to the Agency's procedures and standards when purchasing
Information Technology Resources (ITR) as part of any agreement(s) incorporating this contract
by reference. An ITR worksheet is required for any computer related item costing $1,000.00 or
more, including data processing hardware, software, services, supplies, maintenance, training,
personnel, and facilities. The completed ITR worksheet shall be maintained in the LAN
administrator's file and must be provided to the Agency upon request. The Contractor has the
responsibility to require any Subcontractors to comply with the Agency's ITR procedures.
37. PUR 1000 Form:
The PUR 1000 Form is hereby incorporated by reference and available at:
http:Hwww.myflorida.com/at)t)s/vbs/adoc/F7740 PUR 1000.pdf
In the event of any conflict between the PUR 1000 Form and any terms or conditions of this
contract, the terms or conditions of this contract shall take precedence over the PURI000 Form.
However, if the conflicting terms or conditions in the PURI 000 Form are required by any section of
the Florida Statutes, the terms or conditions contained in the PUR1000 Form shall take precedence.
38. Use of State Funds to Purchase or Improve Real Property:
Any state funds provided for the purchase of or improvements to real property are contingent upon
the Contractor or political subdivision granting to the state a security interest in the property at least
to the amount of state funds provided for at least five (5) years from the date of purchase or the
completion of the improvements or as further required by law.
14
ti-rCAll /W.l2S
October 2018 — September 2019
39. Dispute Resolution:
Any dispute concerning performance of the contract shall be decided by the Agency's Contract
Manager, who shall reduce the decision to writing and serve a copy on the Contractor.
40. Financial Consequences:
If the Contractor fails to meet the minimum level of service or performance identified in this
contract, the Agency will impose financial consequences as stated in ATTACHMENT 1.
41. No Waiver of Sovereign Immunity:
Nothing contained in this contract is intended to serve as a waiver of sovereign immunity by any
entity to which sovereign immunity may be applicable.
42. Venue:
If any dispute arises out of this contract, the venue of such legal recourse shall be Lee County,
Florida.
43. Entire Contact:
This contract contains all the terms and conditions agreed upon by the Parties. No oral agreements
or representations shall be valid or binding upon the Agency or the Contractor unless expressly
contained herein or by a written amendment to this contract signed by both Parties.
44. Force Majeure:
The Parties will not be liable for any delays or failures in performance due to circumstances beyond
their control, provided the party experiencing the force majeure condition provides immediate
written notification to the other party and takes all reasonable efforts to cure the condition.
45. Severability Clause:
The Parties agree that if a court of competent jurisdiction deems any term or condition herein void
or unenforceable, the other provisions are severable to that void provision and shall remain in full
force and effect.
46. Condition Precedent to Contract Appropriations:
The Parties agree that the Agency's performance and obligation to pay under this contract is
contingent upon an annual appropriation by the Legislature.
47. Addition/Deletion:
The Parties agree that the Agency reserves the right to add or to delete any of the services required
under this contract when deemed to be in the State of Florida's best interest and reduced to a written
amendment signed by both Parties. The Parties shall negotiate compensation for any additional
services added.
48. Waiver:
The delay or failure by the Agency to exercise or enforce any of its rights under this contract will
not constitute or be deemed a waiver of the Agency's right thereafter to enforce those rights, nor will
any single or partial exercise of any such right preclude any other or further exercise thereof or the
exercise of any other right.
15 ry
#G .cit
LHL^ AY 6U.5. 16
October 2018 — September 2019
49. Compliance:
The Contractor shall abide by all applicable current federal statutes, laws, rules, and regulations as
well as applicable current state statutes, laws, rules and regulations. The Parties agree that failure of
the Contractor to abide by these laws shall be deemed an event of default of the Contractor and
subject the contract to immediate unilateral cancellation of the contract at the discretion of the
Agency.
50. Final Invoice:
The Contractor shall submit the final invoice for payment to the Agency no later than thirty (30)
days after the contract ending date unless otherwise specified in ATTACHMENT I. If the
Contractor fails to do so, all right to payment is forfeited and the Agency may not honor any
requests submitted after the aforesaid time period. Any payment due under the terms of this contract
may be withheld until all required documentation and reports due from the Contractor and necessary
adjustments thereto have been approved by the Agency.
51. Renegotiations of Modifications:
Modifications of the provisions of this contract shall be valid only when they have been reduced to
writing and duly signed by both parties.
52. Suspension of Work:
The Agency may in its sole discretion, suspend any or all activities under the contract or purchase
order, at any time, when in the best interests of the State to do so. The Agency shall provide the
Contractor written notice outlining the particulars of suspension. Examples of the reason for suspension
include, but are not limited to, budgetary constraints, declaration of emergency, or other such
circumstances. After receiving a suspension notice, the Contractor shall comply with the notice and
shall not accept any purchase orders. Within ninety (90) days, or any longer period agreed to by the
Contractor, the Agency shall either (1) issue a notice authorizing resumption of work, at which time
activity shall resume, or (2) terminate the contract or purchase order. Suspension of work shall not
entitle the Contractor to any additional compensation.
53. Termination:
53.1 Termination for Convenience. The Agency, by written notice to the Contractor, may terminate this
contract in whole or in part when the Agency determines in its sole discretion that it is in the
State's interest to do so. The Contractor shall not famish any product after it receives the notice of
termination, except as necessary to complete the continued portion of this contract, if any. The
Contractor shall not be entitled to recover any cancellation charges or lost profits.
532 Termination for Cause. The Agency may terminate this contract if the Contractor fails to: (1)
deliver the product within the time specified in the contract or any extension, (2) maintain
adequate progress, thus endangering performance of the contract, (3) honor any terms of the
contract, or (4) abide by any statutory, regulatory, or licensing requirement. Rule 60A-1.006(3),
F.A.C., governs the procedure and consequences of default. The Contractor shall continue work
on any work not terminated. Except for defaults of Subcontractors at any tier, the Contractor shall
not be liable for any excess costs if the failure to perform the contract arises from events
completely beyond the control, and without the fault or negligence, of the Contractor. If the
failure to perform is caused by the default of a Subcontractor at any tier, and if the cause of the
default is completely beyond the control of both the Contractor and the Subcontractor, and
16
r.a
ttrt,Al' LU -5. 16
October 2018 — September 2019
without the fault or negligence of either, the Contractor shall not be liable for any excess costs for
failure to perform, unless the subcontracted products were obtainable from other sources in
sufficient time for the Contractor to meet the required delivery schedule. If, after termination, it is
determined that the Contractor was not in default, or that the default was excusable, the rights and
obligations of the Parties shall be the same as if the termination had been issued for the
convenience of the Agency. The rights and remedies of the Agency in this clause are in addition
to any other rights and remedies provided by law or under the contract.
533 Upon termination of this contract, the Contractor and Subcontractors shall, at no cost to the
Agency, transfer all public records in their possession to the Agency and destroy any duplicate
public records that are exempt, or confidential and exempt, from public records disclosure
requirements. All records stored electronically shall be provided to the Agency in a format that is
compatible with the information technology systems of the Agency.
54. Electronic Records and Signature:
54.1 The Agency authorizes, but does not require, the Contactor to create and retain electronic records
and to use electronic signatures to conduct transactions necessary to cavy out the terms of this
contract. A Contractor that creates and retains electronic records and uses electronic signatures to
conduct transactions shall comply with the requirements contained in the Uniform Electronic
Transaction Act, Section 668.50, F.S. All electronic records must be fully auditable; are subject to
Florida's Public Records Law, Chapter 119, F.S.; must comply with contract Section 29, Data
Integrity and Safeguarding Information; must maintain all confidentiality, as applicable; and must
be retained and maintained by the Contractor to the same extent as non -electronic records are
retained and maintained as required by this contract.
The Agency's authorization pursuant to this section does not authorize electronic transactions
between the Contractor and the Agency. The Contractor is authorized to conduct electronic
transactions with the Agency only upon further written consent by the Agency.
54.2 Upon request by the Agency, the Contractor shall provide the Agency with non -electronic
(paper) copies of records. Non -electronic (paper) copies provided to the Agency of any
document that was originally in electronic form with an electronic signature must identify the
person and the person's capacity who electronically signed the document on any non -electronic
copy of the document.
55. Contract Manager:
The Agency may substitute any Agency employee to serve as the Contract Manager. An email
submitted by the Agency to the Contractor, shall constitute sufficient notice of such change.
REMAINDER OF THEPAGE INTENTIONALLY LEFT BLANK
17 {''4
btit•Ar LU -S.16
October 2018 — September 2019
56. Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
57. All Terms and Conditions Included:
This contract and its ATTACHMENTS I -XXIV including any exhibits referenced in said attachments,
together with any documents incorporated by reference, contain all the terms and conditions agreed
upon by the Parties. There are no provisions, terms, conditions, or obligations other than those
contained herein, and this contract shall supersede all previous communications, representations or
agreements, either written or verbal between the Parties.
By signing this contract, the Parties agree that they have read and agree to the entire contract.
IN WITNESS, THEREOF, the Parties hereto have caused this contract to be executed by their
undersigned officials as ly authorized.
CONTRACTOR: C LIER O AREA AGENCY ON AGING FOR
BOARD OF CO Y CO S NERS SOUTHWESTiyFLORIDA, INC.
SIGNED BY: SIGNED BY: / +`t�--
NAME: ANDY SOLIS
The Contractor name, as shown on page 1 of
Collier County Board of County Commissioners
a.
this contract, and mailing address of the
%Collier County Community and Human Services
TITLE:
official payee to whom the payment shall be
3339 E Tamiami Trail, Suite 211
Naples, FL 34112
made is:
DATE:
The name of the contact person and street
Director
b.
address where financial and administrative
Collier County Board of County Commissioners
records are maintained is:
%Collier County Community and Human Services
3339 E Tamiami Trail, Suite 211
DUNS: 0769977790
ti
1
Naples, FL 34112
Approved as to form and legality
The name, address, and telephone number of
Director
c.
the representative of the Contractoro
Collier County Board of County Commissioners
�.:
responsible for administration of the program
�oCollier County Community and Human Services
3339 E Tamiami Trail, Suite 211
under this contract is:
Naples, FL 34112
�\
(239)252-2273
The section and location within the Agency
Area Agency on Aging for Southwest Florida, Inc.
d.
where Requests for Payment and Receipt and
15201 North Cleveland Avenue, Suite 1100
Expenditure forms are to be mailed is:
North Fort Myers, FL 33903
The name, address, and telephone number
Becky MacKenzie, Director of Program & Planning
e.
of the Contract Manager for this contract
Area Agency on Aging for Southwest Florida, Inc.
is:
15201 North Cleveland Avenue, Suite 1100
North Fort Myers, FL 33903
239-652-6900
Upon change of representatives (names, addresses, and telephone numbers) by either party, notice shall be
provided in writing to the other party.
57. All Terms and Conditions Included:
This contract and its ATTACHMENTS I -XXIV including any exhibits referenced in said attachments,
together with any documents incorporated by reference, contain all the terms and conditions agreed
upon by the Parties. There are no provisions, terms, conditions, or obligations other than those
contained herein, and this contract shall supersede all previous communications, representations or
agreements, either written or verbal between the Parties.
By signing this contract, the Parties agree that they have read and agree to the entire contract.
IN WITNESS, THEREOF, the Parties hereto have caused this contract to be executed by their
undersigned officials as ly authorized.
CONTRACTOR: C LIER O AREA AGENCY ON AGING FOR
BOARD OF CO Y CO S NERS SOUTHWESTiyFLORIDA, INC.
SIGNED BY: SIGNED BY: / +`t�--
NAME: ANDY SOLIS
NAME:
MARIANNE G LORIN
TITLE:
TITLE:
RESIDENT/CEO
CHAIRMAN
DATE:
DATE:Ey7sC
`
Federal Tax ID: 59-6000558
Fiscal Year Ending Date: 09130
DUNS: 0769977790
ti
1
Approved as to form and legality
ATTEST,.
CRY 9L K KI
LE1tK
18
^`
�.:
Assistant County A rnuy
t =+ s to hairman
winnalure on1V.
S
�\
October 2018 — September 2019
INDEX OF ATTACHMENTS
nHhAY LU.5.16
ATTACHMENT
STATEMENT OF WORK........................................................................................................................
2C
ATTACHMENT II
FINANCIAL AND COMPLIANCE AUDIT............................................................................................45
ATTACHMENT III
CERTIFICATIONS AND ASSURANCES..............................................................................................51
ATTACHMENT IV
ASSURANCES -NON -CONSTRUCTION PROGRAMS......................................................................56
ATTACHMENT V
FLORIDA DEPARTMENT OF ELDER AFFAIRS CIVIL RIGHTS COMPLIANCE CHECKLIST....
58
*ATTACHMENT VII
BACKGROUND SCREENING................................................................................................................62
*ATTACHMENT IX
BUDGETSUMMARY..............................................................................................................................63
ATTACHMENT X
EHEAP ADMINISTRATIVE AND OUTREACH EXPENSE BUDGET DETAIL................................64
ATTACHMENT XI
RECEIPTS AND EXPENDITURE REPORT...........................................................................................65
ATTACHMENT XII
REQUESTFOR PAYMENT.....................................................................................................................66
ATTACHMENT XIII
INVOICE REPORT SCHEDULE.............................................................................................................67
ATTACHMENT XIV
POVERTY INCOME GUIDELINES........................................................................................................68
ATTACHMENT XV
LIHEAPPAYMENT MATRIX................................................................................................................69
ATTACHMENT XVI
SOURCESOF INCOME...........................................................................................................................70
ATTACHMENT XVII
OUTREACHPLAN SURVEY..................................................................................................................71
ATTACHMENT XVIII
EHEAP APPLICATION AND ELIGIBILITY WORKSHEET................................................................81
ATTACHMENT XIX
EHEAP APPLICATION AND ELIGIBILITY INSTRUCTIONS...........................................................83
ATTACHMENT XX
EHEAP CLIENT FILE CONTENT CHECKLIST...................................................................................86
ATTACHMENT XXI
EHEAP COST REIMBURSEMENT SUMMARY...................................................................................87
ATTACHMENT XXII
COST ALLOCATION PLAN...................................................................................................................88
*ATTACHMENT XXIV
SERVICE RATE REPORT.......................................................................................................................91
*Attachments V1, VIII & XX1II have been intentionally omitted
19
�s
October 2018 — September 2019
ATTACHMENT
STATEMENT Or WORK
Lti-AY LUJ. 16
i. SERVICES TO BE PROVIDED
A. DEFINITION OF TERMS
1. 18 hours - The timeframe within which all applications for crisis assistance shall be acted upon
with an eligible action to mediate the crisis within eighteen (18) hours of the application date
stamp, and documenting in the client file the eligible action taken.
2. Caseworker - Person who is responsible for determining program eligibility by completing the
Emergency Home Energy Assistance for the Elderly Program (EHEAP) Eligibility Worksheet
and awarding crisis benefits.
3. Caseworker Signature Date - The date that the client's completed application is processed,
eligibility determined, and the crisis resolved. This date shall not be changed. Signatures must be
in ink. Rubber-stamped signatures will not be accepted.
4. Client Application Date -The date that the client's completed application is completed (whether
by self or with assistance) and signed by the elder. This date shall not be changed. Signatures
must be in ink. Rubber-stamped signatures will not be accepted. This date shall not be changed.
If an elder cannot write their signature on the application, or any other required document, and
must sign with an "X", two witnesses are required.
5. Crisis - A home cooling or heating crisis exists when an elder has no access to, or is in
immediate danger of losing access to, needed home energy.
6. Crisis Assistance - Assistance provided to an elder who has no access to, or is in danger of
losing access to, needed home energy.
7. Date of Resolution - The date that a documented commitment to pay was made to the utility
vendor to resolve the energy crisis. This date is used as the EHEAP Client Enrollment date in
the Department's Client Information and Registration Tracking System (CIRTS). This date shall
not be changed.
a. The amount of time elapsed between the Date Stamp and the Date of Resolution shall
determine whether or not the eighteen (18) hour rule was met.
b. Vendors must be paid within forty-five (45) days of the date of resolution.
8. Date Stamp - The date the application and all required documentation is presented in acceptable
form to intake staff. An inked stamp must be used, and the date shall not be changed. The 18 -
hour rule for crisis resolution begins when the application is date stamped.
9. Disability- A disabling condition that causes an elder to be determined eligible to receive
Supplement Security Income (SSI) or Social Security Disability Income (SSDI) from the Social
Security Administration.
20
r
4;�k
hi-RIAY LU3.16
October 2018 — September 2019
10. Elder - An individual aged sixty (60) years or older.
11. Eligible Action - An action taken by the caseworker to mediate an elder's energy crisis. Eligible
actions include:
a. Approval of an elder's application;
b. Denial of an elder's application pending further information;
c. Denial of an elder's application because the elder is deemed ineligible;
d. Contact with a utility vendor to halt utility disconnection or interruption in services; or
e. Written referral to and providing the elder with assistance contacting, another agency if
EHEAP funding is not available or the elder is ineligible.
12 Energy Subsidy - Utility costs paid directly or indirectly to the elder who lives in government -
subsidized housing.
13. Household - Any individual or group of individuals who are living together as one economic
unit for whom residential energy is customarily purchased in common or who make
undesignated payments for energy in the form of rent.
14 Household Member - Persons in a household who share a common kitchen or bath and purchase
residential energy in common.
15. Intake Worker - Person who accepts the EHEAP application and required documentation and
may have the responsibility to determine eligibility or award crisis benefits.
16. Minimum Level of Service - Service to a minimum of one household per month.
17. Crisis Assistance Benefit - Payment of a heating/cooling energy bill; the purchase of
heating/cooling device; and/or the repair of a heating/cooling device.
18 Priority for Assistance - Households with the highest home energy needs and lowest household
income, which will be determined by taking into account both the energy burden and the unique
situation of such households with members of vulnerable populations, including very young
children, individuals with disabilities, and frail elder individuals.
19. Provider - The entity that has entered into a contract, subcontract, or Memorandum of
Understanding (MOU) to provide services under EHEAP. For the purposes of this contract, the
terms "Provider" and "Contractor" may be used interchangeably.
20. Reasonable Promptness - Within fifteen (15) working days of receiving the client's completed
application.
21. Request for Payment - Submission of actual monthly expenditures for reimbursement.
22. Service Unit - One individual (elder) served.
23. Social Security Number - The number on an elder's Social Security card or the number provided
by an award or determination letter from an entity, such as a government agency, that has
already verified the social security number.
24. Supervisory/Peer Review Date - The date that a supervisor or peer reviewed the application and
documentation, and signed the application indicating vendor payment can be made. The intent of
21
S
1"HbAY 6US.10
October 2018 — September 2019
the supervisor/peer review is to avoid errors in eligibility determination and payment amounts
and to alleviate the possibility of fraud. This date shall not be changed. Signatures must be in
ink. Rubber-stamped signatures will not be accepted.
25. Verification Date - The date the caseworker verified previous Low -Income Horne Energy
Assistance Program (LIHEAP) crisis benefits with the LIHEAP provider or the minimum
amount necessary to resolve the crisis with the utility company. This date shall not be changed.
B. GENERAL DESCRIPTION
1. General Statement
The Emergency Home Energy Assistance for the Elderly Program (EHEAP) serves the mission
of the Agency by providing home energy assistance aid to elders in the event of a home energy
heating or cooling emergency. EHEAP is designed to assist low-income households with at least
one member aged sixty (60) or older experiencing a heating or cooling emergency. Eligible
households may receive one crisis assistance benefit up to a maximum of $600.00 in the cooling
season and one crisis assistance benefit up to a maximum of $600.00 in the beating season.
These funds are intended to be used to make payments to utility companies and/or fuel suppliers;
purchase blankets, portable heaters, fans, and air conditioners; repair or replace existing heating
or cooling equipment; pay deposits, late fees, or disconnect and reconnection fees; provide
temporary emergency shelter; or resolve other heating and cooling emergencies.
2. Authority
The relevant federal and state authorities governing EHEAP are:
a. Low Income Home Energy Assistance Act of 1981;
b. 42 United States Code (U.S.C.) § 8621 et seq.;
c. Title XXVI of Public Law 97-35, as amended;
d. 45 Code of Federal Regulations (CFR) Part 96, Subpart H;
e. Section 409.508, Florida Statutes (F.S);
f. Chapter 73C-26, Florida Administrative Code (F.A.C.);
g. State of Florida LIHEAP Policies and Procedures Manual; and
It. LIHEAP State Plan.
3. Scope of Service
The Contractor is responsible for the programmatic, fiscal, and operational management of
EHEAP. Eligible elders may receive one crisis assistance benefit per heating or cooling season,
not to exceed $600.00 each. If eligible, elders may receive one summer crisis assistance benefit
during the period from April 1 to September 30, and one winter crisis assistance benefit during
the period of October 1 to March 31, each year. An elder's eligibility for crisis benefits is not
related to EHEAP contract periods.
Weather-Related/Supply Shortage funds can be provided in addition to crisis benefits when
authorized by the Florida Department of Economic Opportunity (DEO). In the event of a
weather-related event or supply shortage, the President of the United States, Governor of the
22
t,
15rit3Ar 6VJ.16
October 2018 — September 2019
State of Florida, or Executive Director of DEO may declare a weather- related crisis and release
additional funds to assist affected households. When benefits are distributed for a weather-
related/supply shortage emergency, the Contractor shall comply with directives provided by the
DOEA as to the allowable expenditures of these funds.
a. The services provided under this contract shall be in a manner consistent with and described
in ATTACHMENT I, SECTION 11: MANNER OF SERVICE PROVISION. Contractor, in
collaboration with its EHEAP program partners, shall ensure the following service tasks are
completed:
(1) Consumer Outreach;
(2) Program Partners and Stakeholders Coordination;
(3) Elder's Benefit Eligibility Determination; and
(4) Benefit Disbursement.
4. Major Program Goals
EHEAP is designed to provide crisis assistance to eligible low-income households with at least
one individual aged sixty (60) or older experiencing a heating or cooling emergency. The
program allows for payments to utility companies and/or fuel suppliers; for the purchase of
blankets, portable heaters, fans, and/or air conditioners; for the repair or replacement of existing
heating or cooling equipment; for the payment of deposits, late fees, disconnect and
reconnection fees; for the provision of temporary emergency shelter; or to resolve other heating
and cooling emergencies. The program also provides eligible elders with weather-related/supply
shortage emergency benefits when authorized by DEO.
a. Crisis Assistance
A home cooling or heating crisis exists when an elder has no access or is in danger of losing
access to, needed home energy because one or more of the following conditions is present:
(1) The elder's home cooling or heating energy source has been cut off,
(2) The elder has been notified that the elder's home cooling or heating energy source for will
soon be cut off,
(3) The elder has an energy bill or notice for which the due date has lapsed;
(4) The elder has received a notice indicating the household's energy bill is delinquent or past
due;
(5) The elder is unable to get delivery of heating fuel, is out of heating fuel, or is in danger
of being out of heating fuel; or
(6) The elder has other problems with lack of cooling or heating in the home, such as
needing to pay a deposit, needing a repair or purchase of heating or cooling equipment,
or needing interim emergency measures to avoid further crisis.
23 mow.
Llir"Ar LU -5. 16
October 2018 — September 2019
b. Allowable Categories for Crisis Assistance are:
(1) Electric;
(2) Gas;
(3) Propane;
(4) Wood/coal;
(5) Refillable fuels; and
(6) Pre -pay home energy usage.
(i) The elder is within seven days of using the remaining balance of the pre -purchased
energy source, the elder's power is currently disconnected/shut off, or the elder needs
a deposit.
(a) The LIHEAP Payment Matrix (ATTACHMENT XV) shall be used to determine the
benefit amount.
C. CLIENTS TO BE SERVED
1. General Description
EHEAP provides for direct client services to elders in low-income households experiencing a
home energy heating or cooling emergency. A household receiving EHEAP services may not
have an income above one hundred fifty percent (150%) of the poverty level, as published by the
United States Department of Health and Human Services.
2. Client Eligibility
To be eligible for services under this contract, and to receive assistance, an elder must:
a. Be aged sixty (60) or older;
b. Reside in the EHEAP service area (Planning and Service Area) at the time the home energy
costs were incurred;
c. Complete and return an EHEAP application with all required information and verification to
Contractor, while funds remain available;
d. Provide a fuel bill or other documentation evidencing an energy emergency and an
obligation to pay for home energy costs for the home in which they live;
e. Possess a total gross household income of not more than one hundred fifty percent (150%) of
the Office of Management and Budget (OMB) federal poverty level for the size of the
household, in accordance with Section I.C.3.d of this contract;
f. Be experiencing one or more verifiable home cooling or heating crises.
g. Not be a resident of a group living facility or a home where the cost of residency is at least
partially paid (or subsidized) through a foster care or residential program administered by the
state;
h. Not be a student living in a dormitory; and
i. Legally reside in the State of Florida.
24
hHhAF LU.5.16
October 2018 — September 2019
3. Client Determination
Contractor shall begin taking applications for EHEAP services upon execution of this contract
and continue taking applications until the contract expires or funds are exhausted. Contractor
will not accept applications when funds are exhausted for a particular time period. Contractor
shall:
a. Provide assistance to elders in completing Agency provided applications for assistance and
determining eligibility;
b. Ensure that no one is excluded from program participation on the grounds of race, color,
national origin, sex, or age, and ensure that such persons shall not be subjected to
discrimination under any activity funded in whole or in part with these funds;
c. Treat homeowners and those who rent equitably under this contract;
d. Calculate the income eligibility of the elder by using the past thirty (30) days earnings for all
occupants of the household annualized or the elder's current economic situation and
reference the current Sources of Income (ATTACHMENT XVI) to determine what is
considered allowable income. Contractor shall proceed as follows;
(1) Total household income cannot exceed one hundred fifty percent (150%) of the current
federal Poverty Income Guidelines (ATTACHMENT XIV); and
(2) Obtain a self -declaration from household members aged eighteen (18) years or older
claiming zero income. Self -declarations must be completed and signed by the household
member who is claiming zero income.
e. Determine if all or part of the elder's utility costs are paid directly (utility reimbursement) or
indirectly (utility allowance) by the government if the elder lives in govermnent-subsidized
housing. Contractor shall proceed as follows:
(1) If total home heating or cooling costs are included in the rent and the elder has no
obligation to pay any portion of the costs, then the elder is not eligible for assistance;
and
(2) If there is a Florida Section 8 (Housing Choice Voucher Program) or a Public Housing
Authority (PHA) Program energy subsidy available to the elder during the period
covered by the utility bill, then the elder is only eligible for partial assistance. The
energy subsidy for the period covered by the utility bill must be subtracted from the
allowable EHEAP benefit calculated for the household.
f. Use program qualification approvals or notifications to document household size and income
of elders receiving Supplemental Nutrition Assistance Program (SNAP) or SSI. Elders shall
meet program income eligibility guidelines and possess a total gross household income of
not more than 150% of the OMB federal poverty level for the size of the household. The
benefit level to be provided to elders receiving SNAP or SSI shall be the same as that
provided to other qualified elders;
g. Obtain a signed statement of maintenance from the elder explaining how basic living
expenses, (i.e., food, shelter and transportation are being provided) if the total household
25
L^ HLAr LU.i. 125
October 2018 — September 2019
income is less than fifty percent (50%) of the current federal poverty guidelines and no one
in the household is receiving SNAP;
h. Ensure elders receive no more than one approved crisis assistance benefit during the cooling
season, April 1 - September 30, and one approved crisis assistance benefit during the
heating season, October 1 - March 31;
(1) Crisis assistance benefit may consist of payment of more than one energy obligation, per
heating and cooling season, for a household to resolve a single crisis, thus allowing for:
(i) The purchase or repair of fans, blankets, air conditioners, and/or portable heaters in
addition to heating/cooling bill assistance, that combined does not exceed the
maximum crisis benefit of $600; and
(ii) Crisis situations which may involve a heater or air conditioner that is powered by
both gas and electricity, in which case both energy obligations are eligible for a crisis
benefit payment that combined does not exceed the maximum crisis benefit of $600.
(2) Water, sewer, and garbage charges may not be paid unless included on a utility bill and
required as part of the energy portion of the bill to maintain service to the household, not
to exceed the maximum limit of $600;
(3) Repair or replacement of a heating/cooling unit is allowable within the maximum limit
of $600, provided any required installation or repair work is completed by a licensed
contractor;
(4) Deposits to connect or restore energy are allowable, not to exceed the maximum limit of
$600;
(5) Late fees, disconnect fees, and reconnect fees are allowable, not to exceed the maximum
limit of $600;
(6) Charges from a previous account held by the elder that is now closed are allowable, not
to exceed the maximum limit of $600;
(7) Payment to landlord when utility costs are included in the elder's rent is allowable, not to
exceed the maximum limit of $600; and
(8) Payment for temporary emergency shelter is allowable, if due to energy related crisis, not
to exceed the maximum limit of $600.
i. In no case shall the Contractor be required to incur costs in excess of the full contract
amount to provide services to the clients.
II. MANNER OF SERVICE PROVISION
A. SERVICE TASKS
In order to achieve the goals of EHEAP, Contractor shall ensure the following tasks are performed:
1. Ensure that all eligible elders meet the requirements of Section I.C.2 of this contract;
2 Ensure that all energy assistance payments made to home energy vendors comply with the
requirements of Section II.A14.d of this agreement;
w
LtnbAr LUS. 125
October 2018 — September 2019
3. Implement appropriate program management and operational controls to ensure all applications
for crisis assistance are acted upon with an eligible action to mediate the crisis within eighteen
(18) hours of the application date stamp, and document in the client file that the crisis was
resolved within eighteen (18) hours.
4. Provide all elders approved for EHEAP funding with a written Notice of Approval and Appeal
within fifteen (15) working days of crisis resolution. The written Notice of Approval and Appeal
shall include:
a. Type and amount of assistance;
b. Name of the home energy vendor to be paid on elder's behalf,
c. The next date when the elder will be eligible to apply for further assistance; and
d. Contractor's appeal process.
5. Provide all elders whose EHEAP applications were denied with a written Notice of Denial and
Appeal within fifteen (15) working days of receiving the elder's application. The written Notice
of Denial and Appeal shall contain:
a. Name of the elder;
b. Date of application;
c. Type of benefit sought;
d. Reason(s) for denial;
e. Statement on Contractor's benefit limits, if applicable;
f Contractor's appeal process;
g. Explanation of circumstances under which the elder may reapply;
h. Information or documentation needed for the elder to reapply;
i. The name, address, and phone number applicable to the appeal process; and
j. Number of days the elder has to file the appeal.
6. Maintain consumer appeal procedures that provide an opportunity for a fair administrative
hearing to elders whose applications for assistance are denied or whose applications are not
acted upon with reasonable promptness;
7. Provide an opportunity for elders to file a written appeal or complaint with Contractor's Program
Supervisor within ten (10) working days of receipt of the written Notice of Denial and Appeal.
a. Upon receipt of a validly filed appeal or complaint, Contractor must respond in writing
within ten (10) working days;
b. Elders may appeal Contractor's first response by filing its objections to the response with
Contractor's Director, Executive Director, or Board Chair, as applicable, within five (5)
working days of receipt of the first response; and
c. Upon receipt of a validly filed objection to the first response, Contractor must respond in
writing within ten (10) working days, and the response must clearly state the final outcome
of the appeal, that the decision is final, and if applicable, the circumstances under which the
elder may reapply for services.
27
t "
MtSAY Zvi. 18
October 2018 — September 2019
8. Post appeal provisions in a prominent place and in plain view at all locations where EHEAP are
received;
9. Ensure all ineligible applicants and applicants denied crisis assistance, when EHEAP funds are
not available or are insufficient to meet their emergency home energy needs, are referred to and
assisted in securing help through other community resources;
10 Ensure no consumer fees are charged to, nor donations accepted from, an elder as a prerequisite
for receiving EHEAP benefits. Post in a conspicuous place at all locations where EHEAP
applications are received the following notice: "No money, cash, or checks will be requested or
received from customers in the EHEAP office. If an employee asks for money, report this to the
agency executive director or Agency head."
11 Compare LIHEAP records and EHEAP records for households with elderly members to avoid
duplicate crisis assistance payment during the same eligibility period and maintain
documentation sufficient to ensure compliance with this requirement;
12 Maintain a written policy and implement procedures to protect and secure elder applicants'
information and social security numbers in order to protect their identities from theft or fraud.
This policy shall address the handling of both paper and electronic records and files. Contractor
shall, in collecting elders' social security numbers, use the Notice Regarding Collection of
Social Security Numbers, which is incorporated into this contract by reference, (Notice of
Instruction#071113 -1 -1-S WCBS,
http://elderafi'airs.state.fl.us/doeal/notices/July13/LIHEAP%20Noticc%20re%20Social%20Secur
ity%20Numbers%20Final.pdtl. The Notice Regarding Collection of Social Security Numbers
shall be signed by the elder and retained in the client file;
13 Consumer Outreach
Ensure that households in all counties within the service area wishing to benefit from the
program have the opportunity to do so. Contractor shall undertake consumer outreach initiatives
in all counties within the service area designed to inform potentially eligible households about
EHEAP. Outreach efforts must focus on elderly households with disabled individuals, young
children, and where the highest percentage of the household income is required to pay for their
home energy. Specific outreach initiatives shall include, but are not limited to:
a. Informing all service area local agencies, non -profits, and similar organizations that are in
regular contact with the low-income population about the EHEAP program, especially those
serving seniors;
b. Encouraging EHEAP program participation through local television and radio programs,
and placing announcements of the EHEAP program in media community calendars;
c. Developing and implementing a written procedure for making home visits to households
with homebound elderly persons in order to assist with the completion of the program
application when other assistance is not available;
d. Making visits to provide information, and/or malting presentations about EHEAP in
response to requests by local congregational centers serving elderly or disabled persons;
e. Providing information concerning the local weatherization program to all persons who
request it (including organizations that provide outreach activities); and
f. Completing the EHEAP Outreach Plan Survey (ATTACHMENT XVII) to demonstrate to the
Agency that outreach efforts to inform potentially eligible households about EHEAP shall be
LHL"AV 6US.1i5
October 2018 — September 2019
made to target households in all counties. The EHEAP Outreach Plan Survey is required to
be submitted by Contractor to the Contract manager within thirty (30) days of the contract
execution date.
14 Program Partners and Stakeholder Coordination
Contractor shall coordinate services with other program partners and stakeholders to prevent the
duplication of services, facilitate referrals, and improve the efficiency of services for consumers.
Coordination activities shall include, but not be limited to:
a. Communicating with the DEO LIHEAP contractors in their respective service areas to
prevent the duplication of benefits to elders. Additionally, Contractor shall review LIHEAP
and EHEAP records for households with elderly members to ensure duplicate crisis
assistance payments are not received during the same heating or cooling season;
b. Developing a new, or continuing an existing, MOU with the Weatherization Assistance
Program (WAP) in the service area. The MOU shall detail cooperative efforts and describe
the actions that will be taken by both parties to ensure coordination and referrals. The MOU
shall be reviewed and renewed at least every five years. Contractor, in coordination with the
local WAP agency, shall develop a system by which elders who have received more than
three EHEAP and LIHEAP benefits in the last eighteen (18) months and who are
homeowners are referred to a WAP provider. Contractor shall maintain copies of all MOUs;
c. Establishing a new, or continuing an existing, MOU with service area LIHEAP contractors.
Each MOU shall ensure coordination of services, avoid duplication of assistance, and
increase the quality of services provided to elders. The MOU shall direct LIHEAP providers
to refer elders aged sixty (60) or older to EHEAP providers for energy assistance. The MOU
shall be reviewed and renewed at least every five (5) years. Contractor shall maintain copies
of all MOUS. MOUS with local LIHEAP agencies shall be updated if the contracting parties
change. The MOUS must be applicable to Contractor's current EHEAP program
requirements and guidelines;
d. Developing agreements with home energy vendors that benefit elders. Contractor shall
maintain copies of all vendor agreements. All agreements between Contractor and home
energy vendors shall contain the following conditions:
(1) The beginning and ending date of the Vendor Agreement;
(2) The Contractor's representative(s) authorized to resolve a crisis situation and make a
payment commitment on behalf of an elder;
(3) The home energy vendor's representative(s) authorized to resolve a crisis;
(4) A description of how energy payments will be made directly to the home energy vendor
on behalf of the EHEAP eligible customer;
(5) Assurance from the home energy vendor that no household receiving EHEAP assistance
will be treated adversely because of such assistance under applicable provisions of state
law or public regulatory requirements;
(6) Assurance that the home energy vendor will not discriminate, either in the cost of goods
supplied or the services provided, against the eligible household on whose behalf
payments are made;
29
Y
111H11AY /,uj.1 x
October 2018 — September 2019
(7) A statement that only energy-related elements of a utility bill are to be paid. No water
and sewage charges may be paid except if required by the energy vendor to resolve the
crisis and no other resources to pay that portion of the bill can be secured by the elder or
Contractor;
(8) A statement that Contractor may not pay for charges that result from illegal activities
such as a worthless check or meter tampering, and that the home energy vendor is aware
that those charges are the responsibility of the elder;
(9) Assurance fiom the home energy vendor that when the benefit amount to the elder does
not pay for the complete charges owed by an elder, the elder is responsible for the
remaining amount owed;
(10)Details on how the home energy vendor will assist Contractor in verifying the elder's
account information and, in the case of crisis assistance, make timely commitments to
resolve the crisis. A process should be in place to verify the current amount owed and the
minimum amount necessary to resolve the crisis situation;
(11)Contractor's commitment to make payment to the home energy vendor within forty-five
(45) days of the date of crisis resolution;
(12)Assurance from the home energy vendor that when EHEAP payments made to the
vendor cannot be applied to the elder's account, the funds will be returned to Contractor
or, with Contractor's approval, applied to another eligible customer's account;
(13)Assurance that the Contractor shall collect a signed Authorization for Release of General
and/or Confidential Information for EHEAP Data from each eligible elder and ensure the
signed releases are available for inspection by the home energy vendor;
(14)Assurance that home energy vendors is aware that as long as signed Authorization for
Release of General and/or Confidential Information for EHEAP Data are collected and
available, the home energy vendor will provide the requested customer data to DEC;
(15)The agreement will be reviewed by both parties at least every five (5) years;
(16) The agreement must be signed by a representative of both Contractor and the vendor who
has authority to bind the entity and enter into such commitments; and
(17) The home energy vendor, with the exception of municipal providers, must be in "active"
status with the State of Florida: (http://sunbiz.org/search.html) and the vendor's name
must be checked on Excluded Parties List System (EPLS) (https://www.epls. ov). The
business name on the vendor agreement must match the legal business name on the State
of Florida website.
15. Comply with the Federal Financial Accountability and Transparency Act (FFATA) by securing
a Dun and Bradstreet Numbering System (DUNS) number (www.dnb.com) and maintaining an
active and current profile in the System for Award Management (SAM) (www.sam.gov); and
16 Based on local need for EHEAP services and other non-EHEAP energy assistance resources in
the service area, Contractor may limit crisis benefits to less than those stated in Section LC.31.
Policy changes concerning the amount of crisis benefits available to elders requires Agency
approval and require notification of the change be sent to current and potential elders.
30
LULAY ZW .1 x
October 2018 — September 2019
B. STAFFING REQUIREMENTS
1. Use of Subcontractors
If an entity other than the Contractor provides any service required under this contract, the
Contractor shall ensure the following requirements are met:
a. Eligible entities that provide outreach, perform intake, make eligibility determinations, or
process benefit payments must be one of the following:
(1) A Local City Government;
(2) A Local County Government;
(3) A Community -Based Organization;
(4) A Faith -Based Organization; or
(s) A State Community Services Agency.
b. Entities providing any administrative function under this contract shall provide to Contractor
a list of all individuals performing administrative functions for the EHEAP. The list must
include Subcontractor's employees, agents and representatives serving EHEAP
administratively. For each individual on the list, Subcontractor must also provide the
individual's EHEAP administrative duties and function(s). Additionally, Subcontractor must
provide total salary and benefit amounts for each individual on the list, specifying all funding
sources from which that person is paid and the corresponding amounts of that pay charged to
each funding source.
c. For the term of this contract, each month Subcontractor shall provide to Contractor the
following information:
(1) The total number of individuals served with crisis assistance for the reporting month;
(2) The total number of individuals ineligible or denied assistance during the reporting month;
(3) The total number of individuals served by referral to other community resources for
energy assistance during the reporting month; and
(4) The total amount of funding expended for crisis assistance per county for the reporting
month.
d. Entities providing any service required under this contract must comply with the FFATA.
This includes securing a DUNS number (www.dnb.com) and maintaining an active and
current profile in the System for Award Management (SAM) (www.sam.gov).
e. Entities must maintain current written agreements in the following formats with service
providers:
(1) A MOU shall be executed by both parties if a service provider performs any service
required under this contract and is paid for providing specific services without a direct
pass-through of federal funds. The MOU shall clearly state program expectations and the
role and responsibilities of each entity.
(2) Contractor shall submit a copy of all MOUS to the Agency's Contract Manager within
thirty (30) days of the contract execution date; and
(3) An EHEAP subcontract shall be executed by both parties if a service provider performs
any service required under this contract and is awarded a direct pass-through of federal
31
hHhAY 6U.5.16
October 2018 — September 2019
funds to operate the program and provide program services. Contractor shall submit a
copy of all subcontracts to the Agency's Contract Manager within thirty (30) days of the
contract execution date.
f. Eligible entities must provide the service provider commensurate compensation for the
delivery of administrative and outreach activities and for the delivery of crisis benefits.
Commensurate compensation of administration and outreach activities shall include cost -
reimbursement of actual expenses or a negotiated rate for specific activities.
g. If any of the work required under this contract is subcontracted, Contractor shall include in
the subcontract that the subcontractor is bound by the terms of this contract, is bound by all
applicable state and federal laws and regulations, and shall hold the Agency and Contractor
harmless against all claims of any nature arising out of the subcontractor's performance of
work under this contract to the extent allowed and required by law.
h. Subcontractor shall not be permitted to perform services related to this contract without an
executed subcontract and an approved Provider Cost Analysis or MOU verifying that
subcontractor's staff is paid from non-federal resources or is compensated for such activities
by EHEAP. In accordance with Sections 25-26 of the Standard Contract, the Agency shall
not be responsible or liable for any obligations or claims resulting from any subcontract.
i. Contactor shall document the subcontractor's progress in performing its work under this
contract in the quarterly report:.
j. For each subcontractor, Contractor shall provide a written statement to the Agency regarding
whether that subcontractor is a minority vendor, as defined in Section 288.703, F.S.
IL If this contract involves the use of a subcontractor or third party, then Contractor shall not
delay the implementation of its agreement with the subcontractor. If any circumstances
occur that may result in a delay of the initiation of the subcontract or in the performance of
the subcontractor for a period of sixty (60) days or more, Contractor shall notify the
Agency's Contract Manager and the Agency's Chief Financial Officer in writing of such
delay.
C. SERVICE DELIVERY
1. Service Delivery Location
Contractor shall ensure that the services provided under this contract are available to residents
within each county in the Service Area by in-person service, telephone, and/or other electronic
means.
2. Service Times
Contractor shall provide the services listed in this contract during normal business hours.
Normal business hours are defined as Monday through Friday, 8:00 a.m. to 5:00 p.m. local time,
excluding holidays, and force majeure.
3. Contractor shall publish its service delivery location, toll-free telephone number, and normal
business hours in available forms of media (i.e. newspapers, radio, television, website
publications, etc.).
32
t riHhA11 Lui.16
October 2018 — September 2019
D. DELIVERABLES
1. Deliverables
a. Certification that Contractor must operate during its regular business hours, as identified in
Section ILC.2 of this contract.
b. Contractor shall provide the minimum level of service per month in each county served, as
defined in Section I.A.16.
2. Source Documentation
The deliverables shall be reported monthly on Contractor's monthly financial status reports.
Successful completion of the deliverables shall be determined by the Agency's receipt of
Contractor's Receipts and Expenditure Report (ATTACHMENT XI) and Request for Payment
(ATTACHMENT XII) containing the number of individuals served with crisis assistance;
number of individuals ineligible or denied assistance; number of applicants served by referral to
other community resources for energy assistance; a summary of funds expended per county for
the reporting month using the EHEAP Cost Reimbursement Summary form (ATTACHMENT
XXI); and the certification required in Section ILD. 1.
3. Records and Documentation
Contractor will maintain a separate record (paper and CIRTS) for each EHEAP applicant that
includes the following as applicable:
a. The EHEAP Application and Eligibility Worksheet, (ATTACHMENT XVIII), completed
and signed by Contractor and the elder. The application must be approved by a supervisor or
peer prior to payment remittance. Contractor is responsible for using the most recent
application, eligibility worksheet, and EHEAP Application and Eligibility Worksheet
Instructions (ATTACHMENT XIX), issued by the Agency.
(1) If Contractor approves an application, one elderly member of the household must be
registered in CIRTS using the EHEAP Application and Eligibility Worksheet
(ATTACHMENT XVIII); or
(2) If Contractor denies an application, the elder must be registered in CIRTS using the
EHEAP Application and Eligibility Worksheet (ATTACHMENT XVIII).
b. The elder's name, address, sex, and age;
c. Names, ages and current identification documentation (no more than one year expired) of all
household members;
d. Social Security numbers and documentation of those numbers for all household members or
the citation to the applicable exemption;
e. Signed notice regarding the collection of Social Security numbers (Notice of Instruction
#071113-1-I-SWCBS,
http://elderaffairs .state.11.us/doea/notices/July13/LIHEAP%20Notice%20re%20Social %20
Security%20Numbers%20Final.pdf)•
f. Income amount and method of verification for all household members.,
g. Income documentation to support eligibility that is representative of the elder's current
economic situation;
33
ttaSAY 21W.16
October 2018 — September 2019
h. Statement of self -declaration of income, if applicable;
i. A signed statement of how basic living expenses (i.e., food, shelter, and transportation) are
being provided if the total household income is less than fifty percent (50%) of the current
Federal Poverty Guidelines and no one in the household is receiving SNAP assistance;
j. Documentation of the elder's obligation(s) to pay an energy bill for the residence in which
they live. Use of the most current utility bill(s) which provides the vendor's name and address,
account holder's name and physical address, account number, and amount(s) due is required.
If an elder's utility bill, cutoff notice, or door -hanger notice or similar documentation does not
include all of this information, Contractor must document the verified missing information by
writing the information on the utility bill and on the EHEAP Application and Eligibility
Worksheet;
k. Signed Authorization for Release of General and/or Confidential Information for LIHEAP/
EHEAP Federal Reporting or a statement on the application which states that the elder
refused to sign the waiver;
I. Copies of approval or denial letters, including those related to the initial application and all
appeals, which are provided to the elder;
in. If preference is given due to a disability, documentation of such disability that includes
disability income or a physician's statement;
n. Documentation of referrals to LIHEAP and WAP;
o. Notation if EHEAP prevented a disconnection or restored an energy disruption;
p. Documentation of coordination with LIHEAP providers to avoid duplication of crisis
services for households with elderly residents;
q. Proof of payment made to vendors;
r. Documentation of calculation of benefits for elders living in subsidized housing; and
s. Completed EHEAP Client File Content Checklist, (ATTACHMENT XX).
E. PERFORMANCE SPECIFICATIONS
1. Reports
Contractor is responsible for responding in a timely fashion to additional routine and/or special
requests for information and reports required by the Agency. Contractor must establish due dates
for any subcontractor's report that permits Contractor to meet the Agency's reporting
requirements.
a. Contractor shall report monthly on Contractor's Request for Payment, (ATTACHMENT
XII), as delineated in Section II.E.1.i. of this contract.
b. Administrative and Outreach Expense Budget Detail
Contractor shall submit to the Agency's EHEAP Contract Manager the EHEAP
Administrative and Outreach Expense Budget Detail (ATTACHMENT X). The
Administrative and Outreach Expense Budget Detail shall clearly delineate planned
expenditures for funds retained by the Contractor and funds subcontracted. The
Administrative and Outreach Expense Budget Detail shall include all Contractor positions,
by title, to be paid with these funds and shall detail the estimated number of hours, the
hourly wage, and the estimated salary to be paid by EHEAP. Funding sources, estimated
hours, and hourly wage shall be identified for the balance of salary where EHEAP funds are
34
�mht
t HtlAI- LUS.16
October 2018 — September 2019
used to pay less than one hundred percent (100%) of the salary. Percentages must be
supported by the submitted cost allocation plan.
c. For the term of this contract, each month Contractor shall provide to the Agency, by the 91h
of each month for the preceding month, the following:
(1) The total number of individuals served with crisis assistance for the reporting month;
(2) The total number of individuals ineligible or denied assistance during the reporting month;
(3) The total number of individuals served by referral to other community resources for
energy assistance during the report month; and
(4) The total amount of funding expended for crisis assistance per county for the reporting
month.
d. Cost Allocation Plan
The Contractor shall submit to the agency's EHEAP Contract Manager the EHEAP Cost
Allocation Plan (ATTACHMENT XXII). The Cost Allocation Plan shall provide budgeting
methodology, allocation distribution, and the data source(s) used.
e. Provider Cost Analysis
State of Florida Chief Financial Officer Memorandum No. 02 (released October 3, 2012),
requires Contractor to provide assistance to the Agency's Contract Manager in completing the
DOEA Cost Analysis for Non -Competitively Procured Contracts in Excess of Category II -
Addendum to the EHEAP Cost Allocation Plan (ATTACHMENT XXII).
(1) The Contractor shall submit a completed Cost Analysis which shall reflect Administrative,
Outreach, and Crisis Service allocations as delineated on the Budget Summary
(ATTACHMENT IX) and must be sufficient to explain the expenditures' allowability,
allocability, and reasonableness. The Cost Analysis shall be submitted and approved by
the Agency prior to execution of this contract. All subsequent amendments that affect the
budget shall also be submitted and approved by the Agency prior to any change.
f. EHEAP Summary Report—Monthly and Quarterly Report
Contractor shall ensure timely and accurate CIRTS data entry of EHEAP activity and submit
to the Agency's EHEAP Contract Manager or designee the service report entitled "EHEAP
Summary" from CIRTS. The report shall reflect the use of EHEAP in each county in the PSA
and shall be inclusive of all approved elders applying for crisis energy assistance during the
reporting month. The report shall be submitted with each monthly billing, due on the 9th of
each month.
Contractor shall ensure timely and accurate CIRTS data entry of EHEAP activity and submit
to the Agency's EHEAP Contract Manager or designee the service report entitled "EHEAP
Summary" from CIRTS. The report shall reflect the use of EHEAP in each county in the PSA
and shall be inclusive of all elders applying for crisis energy assistance during the reporting
month or period. The report shall be submitted based on the following schedule:
REPORT
REPORTING PERIOD
SEASON
DATE DUE TO DEPARTMENT
1
10/01/18-12/31/18
Heating Season
January 09, 2019
2
01/01/19-03/31/19
Heating Season
April 09, 2019
3
04/01/19-06/30/19
Cooling Season
July 09, 2019
4
07/01/19 — 09/30/19
Cooling Season
October 09, 2019
35
nut.Ar 6U.5.1 iS
October 2018 — September 2019
11.5.2.1.1.1 The EHEAP Summary Report parameters for the program year shall be:
11.5.2.1.1.2 PSA;
11.5.2.1.1.3 All Providers;
11.5.2.11.4 Your Location;
11.5.2.1.1.5 EHEAP;
11.5.2.1.1.6 All Cities;
11.5.2.1.1.7 Poverty Line $12,140;
11.5.2.1.1.8 Each Additional Household Members $4,320; and
11.5.2.1.1.9 Current Reporting Period.
g. Outreach Plan Survey
Contractor shall submit to the EHEAP Contract Manager the EHEAP Outreach Plan
Survey (Attachment XVII). The purpose of the Outreach Plan Survey is to delineate all
activities and efforts for the program year. The EHEAP Outreach Plan Survey is due
within thirty (30) days of the contract execution date.
h. Within three months of execution of this contract, Contractor shall provide the Agency
a list of all individuals performing any administrative functions for the EHEAP. The list
must include Contractor's employees, agents, and representatives, as well as all
employees, agents, or representatives of subcontractor(s) or sub-subcontractor(s)
serving EHEAP administratively. For each individual on the list, Contractor must also
provide the individual's EHEAP administrative duties and function(s). Additionally,
Subrecipient must provide total salary and benefit amounts for each individual on the
list, specifying all funding sources from which that person is paid and the corresponding
amounts of that pay charged to each funding source.
i. For the term of this contract, each month Contractor shall provide to the Agency, by the
9th of each month for the preceding month, the following information:
• The total number of individuals served with crisis assistance for the reporting
month;
• The total number of individuals ineligible or denied assistance during the
reporting month;
• The total number of individuals served by referral to other community resources
for energy assistance during the reporting month; and
• The total amount of funding expended for crisis assistance per county for the
reporting month.
j. Program Effectiveness Reports
Contractor agrees to provide to the Agency any additional service reports requested by the
Agency concerning the effectiveness of the program and shall include any statistics and
information that the Agency may require. The reporting period shall begin with the effective
date of this contract in a format and according to a schedule provided by the Agency for each
report.
IR
uw�,t
LH LAY LU.S.I zS
October 2018 — September 2019
2 Monitoring and Evaluation Methodology
Contractor shall monitor its performance under this contract, as well as that of its subcontractors,
subrecipients and consultants who are paid from funds provided under this contract, to ensure
that the scope of work is accomplished within the specified time periods and budgets set and that
other performance goals stated in this contract are achieved. Such review shall be made for each
function or activity set forth in this contract and reported in the quarterly report.
a. Contractor shall review completed EHEAP applications in accordance with the EHEAP
Client File Content Checklist, (ATTACHMENT XX).
b. The Agency shall, at its own discretion, conduct investigations concerning any aspect of
Contractor's performance of this contract.
c. The Agency shall conduct a full onsite review of Contractor at least once during each three-
year period. Contractor shall allow the Agency to cavy out monitoring, evaluation, and
technical assistance, and shall ensure the cooperation of its employees, and of any
subcontractors with whom Contractor contracts to carry out program activities.
d. The Agency shall conduct desk review activities throughout the year to monitor contractual
program requirements.
e. The Agency shall conduct EIIEAP intake site visits.
f In conjunction with onsite monitoring visits and desk review activities, the Agency shall
review a sample of completed EHEAP client files in accordance with the EHEAP Client File
Content Checklist, (ATTACHMENT XX).
g. The Agency shall conduct follow-up reviews including prompt return visits to Contractors
that fail to meet the goals, standards, and requirements established by the state and federal
funding agency.
F. CONTRACTOR RESPONSIBILITES
1. Make vendor payments directly to fuel and/or home energy providers on behalf of eligible elders.
2. Determine the correct amount of each crisis benefit based on the minimum necessary amount
needed to resolve the crisis, but not more than the item limits or total limit set by the Agency.
The maximum crisis benefit for this contract period is $600.00 per household per season.
3. Encourage households to seek assistance prior to incurring non -energy penalties such as
disconnect/reconnect fees, additional deposits, interest or late payments.
4. Provide EHEAP crisis services to households with elders in every city within the service area.
a. Contractor shall ensure that each city within their service area receives a minimum level of
crisis services monthly, as delineated in Section I,16.;
b. EHEAP funded staff shall make themselves available in all underserved counties as needed,
to ensure that the minimum level of service is met; and
c. Contractor shall provide oversight to ensure that the minimum level of service is provided
monthly in each city in their Contractor's service area.
5. Make crisis benefit payments to vendors on behalf of approved elders within forty-five (45) days
of the date of crisis resolution.
6. Make payments on behalf of those elders with the highest home energy needs and the lowest
household income, which will be determined by taking into account both the energy burden and
37
rtarHr Zus. i x
October 2018 — September 2019
the unique situation of households that result from having members of a vulnerable population,
including very young children, the disabled and frail elders.
7. Refund to the Agency, with non-federal funds, all funds incorrectly paid on behalf of elders that
cannot be collected from the elder.
8. Develop adequate procedures to ensure EHEAP funds are appropriately budgeted and expended
to permit payment of energy assistance benefits in both the heating and cooling seasons, ensure
that this is a twelve- month program, and ensure that funding is available to and expended in, all
cities within their service area. Procedures should include referral to other community agencies
when funds budgeted for a particular time period are exhausted and elders are subsequently
denied.
9. Develop monitoring and oversight procedures to ensure that administrative costs that exceed the
contracted EHEAP administrative award to Contractor or Subcontractor are paid from non-
federal sources.
10. Develop adequate procedures to address the use of EHEAP funds for elders who are on oxygen
support or a "Lifeline Program" and must have power.
11. Develop a written policy regarding the use of funds for repairing or replacing heating or cooling
equipment. The procedures must address the conditions under which an elder is eligible for such
funds and what constitutes an emergency related to lack of heating or cooling.
12. Ensure providers and appropriate staff participate in training opportunities scheduled by the
Agency to cover EHEAP policies and procedures.
la Ensure the provision of training for all providers and staff members assigned responsibilities
within the program.
14 Maintain an EHEAP Policies and Procedures Manual to serve as a local resource for program
administration, training, and reference. The EHEAP Policies and Procedures Manual shall be
distributed to all subcontractors that provide any service under EHEAP. The EHEAP Policies
and Procedures Manual shall be reviewed during, and in accordance with, the Agency's EHEAP
contract monitoring schedule, and shall include the following:
a. The State of Florida LIHEAP Policies and Procedures Manual;
b. An MOU or Subcontract with EHEAP providers;
c. An MOU with all service area LIHEAP providers;
d. An MOU with all service area WAP providers;
e. Contractor's cost allocation methodology;
f Written policies and procedures to ensure that all energy assistance payments made to home
energy vendors comply with the requirements of the Vendor Agreement;
g. Adequate procedures to ensure that EHEAP funds are appropriately budgeted and expended
to sufficiently allow for energy assistance benefits in both the heating and cooling seasons,
ensure that this is a twelve- month program, and to ensure that funding is available to, and
expended in, all counties within Contractor's service area;
h. Policies regarding the detection and prevention of fraud and abuse of program funds;
i. Policies that address serving family members and employees;
W.
UiPIAr Zvi. 16
October 2018 — September 2019
j. Policies and procedures to secure applicant Social Security Numbers, in order to protect
applicants' identities;
k. Procedures for computer system backup and recovery;
1. Procedures for referral or access assistance to the "Lifeline Program";
in. A policy outlining the criteria to determine if a household has a "home energy crisis" and the
information and/or documentation required to verify the crisis;
n. Policies and procedures for determining the eligibility of elders applying for EHEAP;
o. Policies which encourage households to seek assistance prior to incurring non -energy
penalties such as disconnect/reconnect fees, additional deposits, interest, or late payments;
p. Procedures referring elderly homeowners who have received more than three energy benefits
(EHEAP or LIHEAP) in the last eighteen (18) months to the WAP provider;
q. A policy concerning the use of funds for the purchase or repair of heating or cooling
equipment;
r. Policies and procedures which detail allowable timeframes for elders to submit required
documentation, if missing at the time of application;
s. A resource guide, or the utilization of the Information and Referral database (ReferNET), to
access other energy assistance resources available at the local level to provide referrals to
elders when EHEAP Funding is not available or they do not qualify; or contacting the Area
Agency's Elder Help Line for resources.
t. Consumer appeal procedures that provide an opportunity for a fair administrative hearing at
the provider level to elders whose applications for assistance are denied, or whose
applications are not acted upon with reasonable promptness; and
u. Policies and procedures for conducting home visits to home -bound elders for completion of
the program application or eligibility determination when other assistance is not available.
15 Notwithstanding that tasks for which the Contractor is held accountable involve coordination
with other entities in performing this contract, the failure of other entities does not alleviate the
Contractor from any accountability for tasks or services that the Contractor is obligated to
perform pursuant to this contract.
G. AGENCY RESPONSIBILITIES
1. The Agency may provide technical support and assistance to the Contractor within the resources
of the Agency to assist the Contractor in meeting the requirements of this contract. The support
and assistance, or lack thereof, shall not relieve the Contractor from full performance of contract
requirements.
2 The Agency will provide to Contractor the State of Florida LIHEAP Policies and Procedures
Manual. The State of Florida LIHEAP Policies and Procedures Manual will provide information
and procedures needed to administer EHEAP in Florida.
(1) This contract excludes all provisions of the State of Florida LIHEAP Policies and
Procedures Manual in reference to LIHEAP Regular Home Energy Annual Benefits.
(2) To the extent any conflict arises between this contract and any incorporated reference
contained herein, this contract shall have precedence.
39
bt lJ'Al' /W. l iS
October 2018 — September 2019
Ill. METHOD OF PAYMENT
A. PAYMENT METHOD USED
The Method of Payment for this contract is a combination of cost reimbursement and advance
payments, subject to the availability of funds and Contractor performance. The Agency will pay the
Contractor upon satisfactory completion of the Tasks/Deliverables, as specified in Section II,
Manner of Service Provision, and in accordance with other terms and conditions of this contract.
1. Cost Reimbursement
The Contractor agrees to distribute funds as detailed in the Budget Summary (ATTACHMENT
IX), attached to this contract. Any change in allocation of categorical or total amounts of funds
identified on the Budget Summary form require a contract amendment. Payment may be
authorized only for allowable expenditures, which are in accordance with the limits specified in
ATTACHMENT IX. All Cost Reimbursement Requests for Payment must include the actual
Receipts and Expenditure Reports beginning with the first month of this contract.
a. Budget Summary
Contractor agrees to implement the distribution of funds as detailed in the Budget Summary
(ATTACHMENT IX). An amendment is required to change category allocations or the total
amount of this contract.
(1) Administrative Expense
Administrative expenses include costs for general administration and coordination of the
program, including direct and indirect costs. This includes the salaries, fringe benefits
(i.e. insurance, retirement, etc.), rent, utilities, travel, etc. associated with financial and
administrative management of the program. The use of other federal funds to supplement
the administrative operations of EHEAP, above and beyond the budgeted amount, is
prohibited. Administrative costs that exceed the contracted EHEAP administrative award
to Contractor or subcontractor must be paid from non-federal sources. Contractors must
have adequate procedures for monitoring and oversight to ensure compliance.
(2) Outreach Expense
Outreach expenses are those costs incurred in delivering EHEAP services that are not
purely administrative in nature. This may include staff and subcontractor expenses such
as salaries, fringe benefits (i.e. insurance, retirement, etc), rent, utilities, travel, etc. for
those employees performing outreach and intake, and any subcontractor expenses.
Outreach expense shall not include senior management expense, unless outreach and
intake involving direct contact with elders occurs. Documentation to support this
exception shall be maintained by Contractor and available upon request.
b. Weather/Related Supply Shortage
Weather Related/Supply Shortage funds are a set-aside for emergency assistance. These
funds must be held in this budget line item category until December 15`x' of the program year,
for use in response to a possible disaster. These funds shall only be used during state or
federal emergencies declared officially by the President of the United States, the Governor of
the State of Florida, or the Executive Director of DEO. In the event of an emergency being
40
t_HLAY 6US.1 iS
October 2018 — September 2019
officially declared, if Contractor or the Agency finds that the budgeted amount of Weather
Related/Supply Shortage emergency assistance funds is not sufficient to meet the emergency,
Contractor may, with the Agency's written authorization, draw on other contract categories
up to fifty percent (50%) of the total contract budget. When funds are distributed for a
weather-related/supply shortage emergency, the Agency will provide binding directives as to
the allowable expenditures of the funds. After December I5, if no emergency has been
declared, the Agency will release the funds and Contractor shall allocate these funds to the
crisis category of the program.
c. Indirect Cost Rate
Per 2 C.F.R.§ 200.331(a)(4), Subrecipients of federal awards are required to have an
approved, federally recognized indirect cost rate, negotiated between the Subrecipient and
the Federal Government. If no such rate exists, then the Subrecipient shall have either a rate
negotiated with DOEA (in compliance with 2 C.F.R. Part 200), or a de minimal indirect cost
rate as defined in 2 C.F.R. § 200.414(f). Subrecipient shall maintain its current Indirect Cost
Rate Proposal and make the proposal available upon request. If Subrecipient chooses to use
the de minimal rate, Subrecipient shall make sure it is entitled to use that rate and include a
statement to that effect. Subrecipient is not obligated to establish an indirect cost rate if
Subrecipient does not charge an indirect cost rate.
2 Advance Payments
Contractor may request up to two (2) months of advances at the start of the contract period to
cover program administration, outreach, and service costs. The payment of an advance will be
contingent upon the sufficiency and amount of funds released to the Agency by the State of
Florida ("budget release"). The Contractor's requests for advance require the written approval of
the Agency Contract Manager. The Contractor shall provide the DOEA Contract Manager
documentation justifying the need for an advance and describing how the funds will be
distributed. If sufficient budget is available, and the Agency's Contract Manager, in his or her
sole discretion, has determined that three is a justified need for an advance, the Agency will
issue approved advance payments after October 1, 2018.
a. Any advance payment the Contractor requests for subcontractors must be distributed within
seven days of receipt of payment from the Agency. The Contractor shall submit to the
Agency documentation to support full distribution of advance funds with report number 5,
due to the Agency on January 9, 2019, in accordance with the Invoice Report Schedule,
(ATTACHMENT XIII), to this contract.
b. All advance funds requested for the Contractor must be fully expended no later than
December 15, 2018. Any amount of advance payments not fully recouped on the Request for
Payment starting with Receipts and Expenditure Report number 5, in accordance with the
Invoice Report Schedule, (ATTACHMENT XIII), attached to this contract.
c. All advance payments made to the Contractor shall be reimbursed to the Agency as follows:
one -tenth of the advance payment received shall be reported as an advance recoupment on
each Request for Payment, starting with Receipts and Expenditure Report number 5, in
accordance with the Invoice Report Schedule, (ATTACHMENT XIII), attached to this
contract.
d. Interest earned on advances must be identified separately by source of funds, state or federal.
Contractor shall maintain advances of federal funds in FDIC interest bearing accounts,
unless an exception is made in accordance with 45 CFR Part 75. Interest earned in excess of
41
LAP -Ar 6U.5. 16
October 2018 — September 2019
$250 per year on Federal cash balances shall be returned to the Agency at the end of each
quarter of the contract period.
B. All payment requests shall be based on actual monthly expenditures beginning with the first month
of this contract. The schedule for submission of advance requests and requests for payment is in
ATTACHMENT XIII to this contract.
C. The final request for payment is due to the Agency no later than October 15, 2018.
D. METIIOD OF INVOICE PAYMENT
Payment shall be made upon Contractor's presentation of an invoice subsequent to the acceptance
and approval by the Agency of the deliverables on the invoice. The form and substance of each
invoice submitted by Contractor shall be as follows:
1. Have Remittance Address that corresponds exactly to the "Remit To" address provided to My
Florida Marketplace (MFMP) during registration;
2 Request payment for services as established in the Service Rate Report (Attachment: XXIV), of
this contract;
3. Contractor shall consolidate all Requests for Payment from subcontractors and Receipts and
Expenditure Reports that support requests for payment and shall submit them to the Agency
using Receipts and Expenditure Report (ATTACHMENT XI), Request for Payment
(ATTACHMENT XII), and Cost Reimbursement Summary (ATTACHMENT XXI);
4. Contractor shall include requiring supporting documentation as delineated in Section III. F. with
the cost reimbursement portion of the invoice.
E. PAYMENT WITHHOLDIDNG
Any payment due by the Agency under the terms of this contract may be withheld pending the
receipt and approval by the Department of all financial and programmatic reports due from the
Contractor and any adjustments thereto, including any disallowance not resolved.
F. SUPPORTING DOCUMENTATION REQUIREMENTS
For the reporting month, Contractor shall include the following with Request for Payment:
1. The number of individuals served, that include:
a. The number of individuals served with crisis assistance during the reporting month;
b. The number of individuals ineligible or denied assistance during the reporting month;
c. The number of individuals referred to other community resources for energy assistance
during the reporting month;
2 Certification that Contractor operated during its normal business hours during the reporting
month; and
3. The total amount of funding expended for crisis assistance per county for the reporting period;
G. FINANCIAL CONSEQUENCES
Failure to meet the deliverables described in this contract may result in a financial consequence and
may result in the redistribution of funding. Contractor shall ensure the provision of services and the
successful completion of deliverables as set forth in this contract.
1. The Agency shall not reimburse any expenditures associated with Deliverables not accepted by
42
LLL^AY 2U.5. 12S
October 2018 — September 2019
the Agency as successfully completed; however, this does not preclude Contractor from
receiving payment for such expenditures upon successful completion of the deliverable.
2 If Contractor fails to be open and available for services according to its regular business hours as
identified in Section ILC.2 of this contract, excluding weekends or state and federal holidays,
Contractor shall pay to the Agency financial consequences for such failure, unless the Agency
waives such failure in writing based upon its determination that the failure was due to factors
beyond the control of Contractor.
3. Contractor's failure to operate according to its regular business hours shall result in an
assessment of a financial consequence in the amount of $10.00 per day.
4 Any amounts due from financial consequences shall be paid by Contractor out of non-federal
funds.
H. REMEDIES -NONCONFORMING SERVICES
Contractor shall ensure that all participants served under this contract are eligible for the program
and that all monthly and/or quarterly performance reports and financial records are maintained for
each reporting period and submitted as stipulated in this contract.
1. Any nonconforming program service, performance report, or financial record not meeting the
aforementioned requirements is not eligible for reimbursement under this program. Contractor
shall solely bear the costs associated with enrolling, training, reporting and/or managing the
program. Contractor shall give immediate notice to the Agency of any significant and/or
systemic infraction that compromises Contractor's ability to provide participant services, to
achieve programmatic performance, or to provide sound financial management of the program.
CONSEQUENCES FOR NON-COMPLIANCE
Contractor shall ensure one hundred percent (100%) of the deliverables identified in this contract
are performed pursuant to contract requirements, and as described in Section ILD, are identified as
major deliverables in this contract.
1. If at any time the Contractor is notified by the Agency's Contract Manager that it has failed to
correctly, completely, or adequately perform these major deliverables, the Contractor will have
ten (10) days to submit a Corrective Action Plan (CAP) to the Contract Manager that
addresses the deficiencies and states how the deficiencies will be remedied within a time
period approved by the Contract Manager. The Agency shall assess a Financial Consequence
for Non -Compliance on the Contractor for each deficiency identified in the CAP which is not
corrected pursuant to the CAP. The Agency will also assess a Financial Consequence for
failure to timely submit a CAP. If Contractor fails to timely submit a CAP, the Agency shall
deduct 1% of the monthly value of the administrative funds in the contract for each day the CAP
is overdue, beginning the 11th day after notification by the Contract Manager of the deficiency.
The deduction will be made from the payment for the invoice of the following month.
2 In the event that Contractor fails to correct an identified deficiency within the approved time
period specified in the CAP, the Agency shall deduct, from the payment for the invoice of the
following month, 1% of the monthly value of the administrative funds in the contract for each
day the deficiency is not corrected. The Agency may also deduct, from the payment for the
invoice of the following month, 1% of the monthly value of the administrative funds in the
contract for each day the Contractor fails to timely submit a CAP.
43
,4„
L• HhAY 6U.5.125
October 2018 — September 2019
IV. SPECIAL PROVISIONS
A. The following is incorporated by reference:
1. State of Florida LIHEAP Policies and Procedures Manual,
B. Modifications
The Agency shall not be obligated to reimburse Contractor for expenditures in excess of the funded
amount of this contract unless and until the Agency officially approves such expenditures by
executing a written modification to the original contract, signed by both parties.
1. Contractor must use an Agency approved budget modification process.
2 For the purpose of transferring funds, the following are considered budget categories: (1)
Administrative, (2) Outreach, and (3) Crisis Assistance.
END OF ATTACHMENT
October 2018 — September 2019
FINANCIAL AND COMPLIANCE AUDIT
t5Hl:AV 6U.5.1 rf
ATTACHMENT H
The administration of resources awarded by the Agency to the Contractor may be subject to audits and/or monitoring by
the Area Agency on Aging for Southwest Florida as described in this section.
MONITORING
In addition to reviews of audits conducted in accordance with 2 CFR Part 200 (formerly OMB Circular A-133 as revised),
and Section 215.97, F.S., (see "AUDITS" below), monitoring procedures may include, but not be limited to, on-site visits
by the Agency and/or Department staff, limited scope audits as defined by OMB Circular A-133, as revised, and/or other
procedures. By entering into this agreement, the Contractor agrees to comply and cooperate with any monitoring
procedures/processes deemed appropriate by the Agency and/or Department. In the event the Agency and/or
Department determines that a limited scope audit of the Contractor is appropriate, the Contractor agrees to
comply with any additional instructions provided by the Agency and/or Department to the Contactor regarding such
audit. The Contractor further agrees to comply and cooperate with any inspections, reviews, investigations, or audits
deemed necessary by the Agency's Director of Program and Planning.
AUDITS
PART I: FEDERALLY FUNDED
This part is applicable if the Contractor is a State or local government or a non-profit organization as defined in 2 CFR
Part 200, Subpart A.
In the event that the Contractor expends $750,000.00 or more in federal awards during its fiscal year, the Contractor must
have a single or program -specific audit conducted in accordance with the provisions of 2 CFR Part 200. EXHIBIT 2 to
this agreement indicates federal resources awarded through the Agency by this agreement. In determining the federal awards
expended in its fiscal year, the Contractor shall consider all sources of Federal awards, including federal resources
received from the Agency. The determination of amounts of Federal awards expended should be in accordance with 2
CFR Part. An audit of the Contractor conducted by the Auditor General in accordance with the provisions of 2 CFR Part
200 will meet the requirements of this part.
In connection with the audit requirements addressed in Part I, paragraph 1, the Contractor shall fulfill the requirements
relative to auditee responsibilities as provided in 2 CFR §200.508.
If the Contractor expends less than $750,000.00 in federal awards in its fiscal year, an audit conducted in accordance with
the provisions of 2 CFR Part 200 is not required. In the event that the Contractor expends less than $750,000.00 in federal
awards in its fiscal year and elects to have an audit conducted in accordance with the provisions of 2 CFR Part 200 the
cost of the audit must be paid from non-federal resources (i.e., the cost of such audit must be paid from Contractor
resources obtained from other than federal entities.)
An audit conducted in accordance with this part shall cover the entire organization for the organization's fiscal year.
Compliance findings related to agreements with the Agency shall be based on the agreement's requirements, including any
rules, regulations, or statutes referenced in the agreement. The financial statements shall disclose whether or not the
matching requirement was met for each applicable agreement. All questioned costs and liabilities due to the Agency
shall be fully disclosed in the audit report with reference to the Area Agency on Aging for Southwest Florida, Inc.
agreement involved. If not otherwise disclosed as required by 2 CPR §200.510 the schedule of expenditures of federal
awards shall identify expenditures by agreement number for each agreement with the Agency in effect during the audit
period. Financial reporting packages required under this part must be submitted within the earlier of 30 days after receipt
of the audit report or 9 months after the end of the Contractor's fiscal year end.
45
t.Ht',Ail LUS. 12S
October 2018 — September 2019
PART H: STATE FUNDED
This part is applicable if the Contractor is a non -state entity as defined by Section 215.97(2), F.S.
In the event that the Contractor expends a total amount of state financial assistance equal to or in excess of $750,000.00
in any fiscal year of such Contractor, the Contractor must have a State single or project -specific audit for such fiscal
year in accordance with Section 215.97, F.S.; applicable rules of the Department of Financial Services; and Chapters
10.550 (local governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General.
EXHIBIT 2 to this agreement indicates state financial assistance awarded through the Agency by this agreement. In
determining the state financial assistance expended in its fiscal year, the Contractor shall consider all sources of state
financial assistance, including state financial assistance received from the Agency, other state agencies, and other
nonstate entities. State financial assistance does not include Federal direct or pass-through awards and resources
received by a nonstate entity for Federal program matching requirements.
In connection with the audit requirements addressed in Part II, paragraph 1, the Contractor shall ensure that the audit
complies with the requirements of Section 215.97(8), F.S. This includes submission of a financial reporting package as
defined by Section 215.97(2), F.S., and Chapter 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit
organizations), Rules of the Auditor General.
If the Contractor expends less than $750,000.00 in state financial assistance in its fiscal year, an audit conducted in
accordance with the provisions of Section 215.97, F.S., is not required. In the event that the Contractor expends less than
$750,000.00 in state financial assistance in its fiscal year and elects to have an audit conducted in accordance with the
provisions of Section 215.97, F.S., the cost of the audit must be paid from the nonstate entity's resources (i.e., the cost of
such an audit must be paid from the Contractor resources obtained from other than State entities).
An audit conducted in accordance with this part shall cover the entire organization for the organization's fiscal year.
Compliance findings related to agreements with the Agency shall be based on the agreement's requirements, including any
applicable rules, regulations, or statutes. The financial statements shall disclose whether or not the matching
requirement was met for each applicable agreement. All questioned costs and liabilities due to the Agency shall be fully
disclosed in the audit report with reference to the Agency agreement involved. If not otherwise disclosed as required by
Rule 691-5.003, F.A.C., the schedule of expenditures of state financial assistance shall identify expenditures by
agreement number for each agreement with the Agency in effect during the audit period. Financial reporting packages
required under this part must be submitted within 45 days after delivery of the audit report, but no later than 12 months after
the Conn -actor's fiscal year end for local governmental entities. Non-profit or for-profit organizations are required to
be submitted within 45 days after delivery of the audit report, but no later than 9 months after the Contractor's fiscal year
end. Notwithstanding the applicability of this portion, the Agency retains all right and obligation to monitor and oversee
the performance of this agreement as outlined throughout this document and pursuant to law.
PART III: REPORT SUBMISSION
Copies of reporting packages for audits conducted in accordance with 2 CFR Part 200 and required by PART I of this
contract's Financial and Compliance Audit Attachment shall be submitted, when required by 2 CFR §200.512 by or on
behalf of the Contractor directly to each of the following:
The Area Agency on Aging for Southwest Florida, Ine.at the following address:
Area Agency on Aging for Southwest Florida, Inc.
Attn: Tammy Rhoades, CFO
15201 N Cleveland Ave., Suite 1100
North Fort Myers, FL 33903
For fiscal year 2013 and earlier to the Federal Audit Clearinghouse designated in 2 CFR §200.36 at the following address:
Federal Audit Clearinghouse Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
46
L"hAr LU.S.1 b
October 2018 — September 2019
For fiscal year 2014 and later, pursuant to 2 CFR §200.512, the reporting package and the data collection form must be
submitted electronically to the Federal Audit Clearinghouse.
Pursuant to 2 CFR §200.512, all other Federal agencies, pass-through entities and others interested in a reporting package
and data collection form must obtain it by accessing the Federal Audit Clearinghouse.
The Contractor shall submit a copy of any management letter issued by the auditor, to the Area Agency on Aging for
Southwest Florida, hic.at the following address:
Area Agency on Aging for Southwest Florida, Inc.
Attn: Tammy Rhoades, CFO
15201 N Cleveland Ave., Suite 1100
North Fort Myers, FL 33903
Additionally, copies of financial reporting packages required by PART 11 of this contract's Financial and Compliance
Audit Attachment shall be submitted by or on behalf of the Contractor directly to each of the following:
The Area Agency on Aging for Southwest Florida, Inc.at the following address:
Area Agency on Aging for Southwest Florida, Inc.
Attn: Tammy Rhoades, CFO
15201 N Cleveland Ave., Suite 1100
North Fort Myers, FL 33903
The Auditor General's Office at the following address:
State of Florida Auditor General
Claude Pepper Building, Room 574
111 West Madison Street
Tallahassee, Florida 32399-1450
Any reports, management letter, or other information required to be submitted to the Agency pursuant to this agreement
shall be submitted timely in accordance with 2 CFR Part 200, Florida Statutes, and Chapters 10.550 (local governmental
entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General, as applicable.
Contractors, when submitting financial reporting packages to the Agency for audits done in accordance with 2 CFR Part
200 or Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor
General, should indicate the date that the reporting package was delivered to the Contractor in correspondence
accompanying the reporting package.
PART IV: RECORD RETENTION
The Contractor shall retain sufficient records demonstrating its compliance with the terms of this agreement for a period
of six (6) years fi•om the date the audit report is issued, and shall allow the Agency or its designee, the CFO or Auditor
General Access to such records upon request. The Contractor shall ensure that audit working papers are made available to
the Agency or its designee, CFO, or Auditor General upon request for a period of six (6) years from the date the audit report
is issued, unless extended in writing by the Agency.
47 5
LHLAr Zo J. r a
October 2018 — September 2019
EXIIBIT 1
PART I: AUDIT RELATIONSHIP DETERMINATION
Contractors who receive state or federal resources may or may not be subject to the audit requirements of 2 CFR Part 200
and/or Section 215.97, F.S. Contractors who are determined to be recipients or sub -recipients of federal awards and/or
state financial assistance may be subject to the audit requirements if the audit threshold requirements set forth in Part I
and/or Part II of Exhibit 1 are met. Contractors who have been determined to be vendors are not subject to the audit
requirements of 2 CFR §200.38, and/or Section 215.97, F.S. Regardless of whether the audit requirements are met,
Contractors who have been determined to be recipients or sub -recipients of Federal awards and/or state financial
assistance must comply with applicable programmatic and fiscal compliance requirements.
In accordance with 2 CFR Part 200 and/or Rule 69I-5.006, FAC, Contractor has been determined to be:
Vendor not subject to 2 CFR §200.38 and/or Section 215.97, F.S.
X Recipient/sub-recipient subject to 2 CFR §200.86 and §200.93 and/or Section 215.97, F.S.
Exempt organization not subject to 2 CFR Part 200 and/or Section 215.97, F.S. For Federal awards, for-profit
organizations are exempt; for state financial assistance projects, public universities, community colleges, district
school boards, branches of state (Florida) government, and charter schools are exempt. Exempt organizations must
comply with all compliance requirements set forth within the contract or award document.
NOTE: If a Contractor is determined to be a recipient/sub-recipient of federal and or state financial assistance and has
been approved by the Agency to subcontract, they must comply with Section 215.97(7), F.S., and Rule 69I-5006,
F.A.C.[state financial assistance] and 2 CFR §200.330[federal awards].
PART H: FISCAL COMPLIANCE REQUIREMENTS
FEDERAL AWARDS OR STATE MATCHING FUNDS ON FEDERAL AWARDS. Contractors who receive
Federal awards, state maintenance of effort funds, or state matching funds on Federal awards and who are determined to
be a sub- recipient must comply with the following fiscal laws, rules and regulations:
STATES, LOCAL GOVERNMENTS AND INDIAN TRIBES MUST FOLLOW:
2 CFR §200.416 - §200.417 — Special Considerations for States, Local Governments and Indian Tribes*
2 CFR §200.201 —Administrative Requirements**
2 CFR §200 Subpart F — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
NON-PROFIT ORGANIZATIONS MUST FOLLOW:
2 CFR §200.400 - §200.411 — Cost Principles*
2 CFR §200.100—Administrative Requirements
2 CPR §200 Subpart F — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
EDUCATIONAL INSTITUTIONS (EVEN IF A PART OF A STATE OR LOCAL GOVERNMENT)
MUST FOLLOW:
2 CFR §200.418 — §200.419 — Special Considerations for Institutions of Higher Education*
2 CFR §200.100—Administrative Requirements
2 CFR §200 Subpart F — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
49 w.
L11 LA LUS.16
October 2018 — September 2019
*Some Federal programs may be exempted from compliance with the Cost Principles Circulars as noted in 2 CFR
§200.400(5) (c).
**For funding passed through U.S. Health and Human Services, 45 CFR 75; for finding passed through U.S.
Department of Education, 34 CFR 80.
STATE FINANCIAL ASSISTANCE. Contractors who receive state financial assistance and who are determined to be
a recipiem/sub-recipient must comply with the following fiscal laws, rules and regulations:
Section 215.97, F.S. Chapter 69I-5, F.A.C.
State Projects Compliance Supplement Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
49
LHI AY 6US.18
October 2018 — September 2019
EXIIH3IT 2
FUNDING SUMMARY
Note: Title 2 CFR, as revised, and Section 215.97(5), F.S. require that the information about Federal Programs
and State Projects included in Exhibit 1 be provided to the recipient. Information contained herein is a
prediction of funding sources and related amounts based on the contract budget.
FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS
CONTRACT CONSIST OF THE FOLLOWING:
GRANT AWARD (FAIN#): 17EA-OF-13-00-16-003 FEDERAL AWARD DATE: April 1, 2018
DUNS NUMBER: 076997790
PROGRAM TITLE FUNDING SOURCE
CFDA
AMOUNT
Emergency Home Energy Assistance United States Department of
for the Elderly Program Health and Human Services
93.568
$ 55,757.00
EHEAP Collier
93.568
$ 55,757.00
TOTAL FEDERAL AWARD
$ 55,757.00
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED
PURSUANT TO THIS CONTRACT ARE AS FOLLOWS:
FEDERAL. FUNDS:
2 CFR Part 200 — Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal
Awards. OMB Circular A-133 —Audits of States, Local Governments, and Non -Profit Organizations
2. STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS CONTRACT
CONSIST OF THE FOLLOWING:
MATCHING RESOURCES FOR FEDERAL PROGRAMS
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL STATE AWARD
QTATFFTNAN("RAT AQQTQTAVf-EQUT1jECTT"Q!-c 21507 FQ
PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT
TOTAL AWARD
COMPLIANCE RE'QUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT
TO THIS CONTRACT ARE AS FOLLOWS:
STATE FINANCIAL ASSISTANCE
Section 215.97, F.S., Chapter 69I-5, F.A.C, State Projects Compliance Supplement Reference
Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
50`,
L'HL^Al' LU -5.16
October 2018 — September 2019
ATTACHMENT III
CERTIFICATIONS AND ASSURANCES
DOEA will not award this Contract unless Contractor completes this CERTIFICATIONS AND ASSURANCES. In
performance of this contract, Contractor provides the following certifications and assurances:
• Debarment and Suspension Certification (29 CFR Part 95 and 45 CFR Part 75)
• Certification Regarding Lobbying (29 CFR Part 93 and 45 CFR Part 93)
• Nondiscrimination & Equal Opportunity Assurance (29 CFR Part 37 and 45 CFR Part 80)
• Certification Regarding Public Entity Crimes. Section 287.133. F.S.
• Association of Community Organizations for Reform Now (ACORN) Funding Restrictions Assurance (Pub.
L. 111-117)
• Scrutinized Companies Lists and No Boycott of Israel Certification. Section 287.135.F.S.
• Certification Regarding Data Integrity Compliance for Contracts. Grants. Loans and Cooperative
Agreements
• Verification of EmIlloyment Status Certification
• Records and Documentation
• Certification Regarding Inspection of Public Records
CERTIFICATIONREGARDING DEBARMENT, SUSPENSION,AND OTHER RESPONSIBILITY
MATTERS — PRIMARY COVERED TRANSACTION.
The undersigned Contractor certifies, to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
covered transactions by a Federal department or agency;
2. Have not within a three-year period preceding this Contract been convicted 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,
making false statements, or receiving stolen property;
3. Are not presently indicted or otherwise criminally or civilly charged by a government entity (Federal, State or local)
with commission of any of the offenses enumerated in paragraph A.2. of this certification; and/or
4. Have not within a three-year period preceding this application/proposal had one or more public transactions
(Federal, State, or local) terminated for cause of default.
The undersigned shall require that language of this certification be included in the documents for all subcontracts at all
tiers (including subcontracts, sub -grants and contracts under grants, loans and cooperative agreements) and that all sub
recipients and contractors shall provide this certification accordingly.
A. CERTIFICATION REGARDING LOBBYING — CERTIFICATION FOR CONTRACTS, GRANTS,
LOANS, AND COOPERATIVE AGREEMENTS
The undersigned Contractor certifies, to the best of its knowledge and belief, that:
No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
51 ... .
I'HbAr /U.5. 16
October 2018 — September 2019
influencing or attempting to influence 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.
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 employee of a Member of Congress in connection with a Federal contract, grant, loan, or cooperative
agreement, the undersigned shall also complete and submit Standard Form — LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
The undersigned shall require that language of this certification be included in the documents for all subcontracts at all
tiers (including subcontracts, sub -grants and contracts under grants, loans and cooperative agreements) and that all sub -
recipients and contractors shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this Contract was made or
entered into. Submission of this certification is a prerequisite for malting or entering into this Contract imposed by 31
U.S.C. 1352. 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.
B. NON-DISCRE IINATION & EQUAL OPPORTUNITY ASSURANCE (29 CFR PART 37 AND 45 CFR PART
80).—
As
0).—
As a condition of the Contract, Contractor assures that it will comply fully with the nondiscrimination and equal
opportunity provisions of the following laws:
1. Section 188 of the Workforce Investment Act of 1998 (WIA), (Pub. L. 105-220), which prohibits discrimination
against all individuals in the United States on the basis of race, color, religion, sex, national origin, age, disability,
political affiliation, or belief, and against beneficiaries on the basis of either citizenship/status as a lawfully admitted
immigrant authorized to work in the United States or participation in any WIA Title I -financially assisted program
or activity.
2. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as amended, and all requirements imposed by or pursuant
to the Regulation of the Department of Health and Human Services (45 CFR Part 80), to the end that, in accordance
with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or
national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to
discrimination under any program or activity for which the Applicant receives Federal financial assistance from the
Department and/or Agency.
3. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112) as amended, and all requirements imposed by or
pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 84), to the end that, in
accordance with Section 504 of that Act, and the Regulation, no otherwise qualified handicapped individual in
the United States shall, solely by reason of his handicap, be excluded from participation in, be denied
the benefits of, or be subjected to discrimination under any
program or activity for which the Applicant receives Federal financial assistance from the Agency.
4. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended, and all requirements imposed by or pursuant
to the Regulation of the Agency of Health and Human Services (45 CFR Part 91), to the end that, in accordance
with the Act and the Regulation, no person in the United States shall, on the basis of age, be denied the benefits of,
be excluded from participation in, or be subjected to discrimination under any program or activity for which the
Applicant receives Federal financial assistance from the Agency.
5. Title IX of the Education Amendments of 1972 (Pub. L. 92-318), as amended, and all requirements imposed by or
pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 86), to the end that, in
accordance with Title DC and the Regulation, no person in the United States shall, on the basis of sex, be excluded
from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any education
program or activity for which the Applicant receives Federal financial assistance from the Agency.
6. The American with Disabilities Act of 1990 (Pub. L. 101-336), which prohibits discrimination in all employment
practices, including job application procedures, hiring, firing, advancement, compensation, training, and other
52 �,
btibAr LU.5. 16
October 2018 — September 2019
terms, conditions, and privileges of employment. It applies to recruitment, advertising, tenure, layoff, leave, fringe
benefits, and all other employment-related activities.
Contractor also assures that it will comply with 29 CFR Part 37 and all other regulations implementing the laws listed
above. This assurance applies to Contractor's operation of the WIA Title I — financially assisted program or activity,
and to all contracts, Contractor makes to carry out the WIA Title I — financially assisted program or activity.
Contractor understands that the Agency and/or DOEA and the United States have the right to seek judicial enforcement
of the assurance. The undersigned shall require that language of this assurance be included in the documents for all
subcontracts at all tiers (including subcontracts, sub -grants and contracts under grants, loans and cooperative
agreements) and that all sub recipients and contractors shall provide this assurance accordingly.
C. CERTIFICATION REGARDING PUBLIC ENTITY CRIMES, SECTION 287.133, F.S.
Contactor hereby certifies that neither it, nor any person or affiliate of Contractor, has been convicted of a Public Entity
Crime as defined in Section 287.133, F.S., nor placed on the Convicted Vendor List.
Contractor understands and agrees that it is required to inform Area Agency and DOEA immediately upon any change
of circumstances regarding this status.
D. ASSOCIATION OF C O M M U N I T Y ORGANIZATIONS FOR REFORM NOW (ACORN) FUNDING
RESTRICTIONS ASSURANCE (Pub. L. 111-117).
As a condition of the Contract, Contractor assures that it will comply fully with the federal funding restrictions
pertaining to ACORN and its subsidiaries per the Consolidated Appropriations Act, 2010, Division E, Section 511 (Pub.
L. 111-117). The Continuing Appropriations Act, 2011, Sections 101 and 103 (Pub. L. 111-242), provides that
appropriations made under Pub. L. 111-117 are available under the conditions provided by Pub. L. 111-117.
The undersigned shall require that language of this assurance be included in the documents for all subcontracts at all
tiers (including subcontracts, sub -grants and contracts under grants, loans and cooperative agreements) and that all sub
recipients and contractors shall provide this assurance accordingly.
E. SCRUTINIZED COMPANIES LISTS AND NO BOYCOTT OF ISRAEL CERTIFICATION,
SECTION 287.135, F.S.
In accordance with section 287.135, F.S., Contractor hereby certifies that it is not listed on the Scrutinized
Companies that Boycott Israel List and that it is not participating in a boycott of Israel.
If this Contract is in the amount of $1 million or more, in accordance with the requirements of section 287.135,
F.S., Contractor hereby certifies that it is not listed on either the Scrutinized Companies with Activities in Sudan
List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List and that it is not
engaged in business operations in Cuba or Syria.
Contractor understands that pursuant to section 287.135, F.S., the submission of a false certification may result
in the Agency terminating this contact and the submission of a false certification may subject Contractor to civil
penalties and attorney fees and costs, including any costs for investigations that led to the finding of false
certification.
If Contractor is unable to certify any of the statements in this certification, Contractor shall attach an
explanation to this Contract.
F. CERTIFICATION REGARDING DATA INTEGRITY COMPLIANCE FOR CONTRACTS,
AGREEMENTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS
The Contractor and any Subcontractors of services under this contract have financial management systems
capable of providing certain information, including: (1) accurate, current, and complete disclosure of the financial
53
L"t1LA11 LUS.1 iS
October 2018 September 2019
results of each grant -funded project or program in accordance with the prescribed reporting requirements; (2) the
source and application of funds for all contract supported activities; and (3) the comparison of outlays with
budgeted amounts for each award. The inability to process information in accordance with these requirements
could result in a return of grant funds that have not been accounted for properly.
2. Management Information Systems used by the Contractor, Subcontractors, or any outside entity on which the
Contractor is dependent for data that is to be reported, transmitted or calculated, have been assessed and verified
to be capable of processing data accurately, including year -date dependent data. For those systems identified to be
non-compliant, Contractors will take immediate action to assure data integrity.
3. If this contract includes the provision of hardware, software, firmware, microcode or imbedded chip technology,
the undersigned warrants that these products are capable of processing year -date dependent data accurately. All
versions of these products offered by the Contractor (represented by the undersigned) and purchased by the state
will be verified for accuracy and integrity of data prior to transfer.
4. In the event of any decrease in functionality related to time and date related codes and internal subroutines that
impede the hardware or software programs from operating properly, the Contractor agrees to immediately make
required corrections to restore hardware and software programs to the same level of functionality as warranted
herein, at no charge to the state, and without interruption to the ongoing business of the state, time being of the
essence.
5. The Contractor and any Subcontractors of services under this contract warrant that their policies and procedures
include a disaster plan to provide for service delivery to continue in case of an emergency including emergencies
arising from data integrity compliance issues.
G. VERIFICATION OF EMPLOYMENT STATUS CERTIFICATION
As a condition of contacting with the Area Agency on Aging for Southwest Florida, Inc., Contractor certifies the use
of the U.S. Department of Homeland Security's E -verify system to verify the employment eligibility of all new
employees hired by Contractor during the contract term to perform employment duties pursuant to this contract and
that any subcontracts include an express requirement that Subcontractors performing work or providing services
pursuant to this Contract utilize the E -verify system to verify the employment eligibility of all new employees hired
by the Subcontractor during the entire contract term.
The Contactor shall require that the language of this certification be included in all sub -agreements, sub -grants, and
other agreements/contracts and that all Subcontractors shall certify compliance accordingly.
This certification is a material representation of fact upon which reliance was placed when this contract was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by
Circulars A-102 and 2 CFR Part 200 and 215 (formerly OMB Circular A-110).
H. RECORDS AND DOCUMENTATION
The Contractor agrees to make available to Agency staff and/or any party designated by the Agency any and all
contract related records and documentation. The Contractor shall ensure the collection and maintenance of all
program related information and documentation on any such system designated by the Agency. Maintenance
includes valid exports and backups of all data and systems according to Agency standards.
I. CERTIFICATION REGARDING INSPECTION OF PUBLIC RECORDS
In addition to the requirements of Sections 10.1 and 10.2 of the Standard Contact, and 119.0701(3) and (4) F.S., and
any other applicable law, if a civil action is commenced as contemplated by Section 119.0701(4), F.S., and the
Agency is named in the civil action, Contactor agrees to indemnify and hold harmless the Agency for any
costs incurred by the Agency, and any attorneys' fees assessed or awarded against the Agency from a Public
Records Request made pursuant to Chapter 119, F.S., concerning this contract or services performed thereunder.
a. Notwithstanding Section 119.0701, F.S., or other Florida law, this section is not applicable to contracts executed
between the Department and state agencies or sub divisions defined in Section 768.28(2), F.S.
54 i ,
t6ririAr ZU.S.1iS
October 2018 — September 2019
2. Section 119.01(3), F.S., states if public funds are expended by an agency in payment of dues or membership
contributions for any person, corporation, foundation, trust, association, group, or other organization, all the
financial, business, and membership records of such an entity which pertain to the public agency (Area Agency
on Aging for Southwest Florida, Inc.) are public records. Section 119.07, F.S, states that every person who has
custody of such a public record shall permit the record to be inspected and copied by any person desiring to do so,
under reasonable circumstances.
Additionally, I certify this organization does not provide for institutional memberships.
Contractor's signature below attests that records pertaining to the dues or membership application by the Agency are
available for inspection as stated above.
By execution of this contract, Contractor must include these provisions (A -J) in all related subcontract agreements (if
applicable).
By signing below, Con • or certifies the representations outlined in parts A through J above are hue and correct.
3319 Tamiami Trail E 4211
(ANDY SOLIS, CHAS MAN) (Street Address)
Collier County Board of County Commissioners 1 i j( jjr
(Contractor) (Date)
ATTRCT<
r,;'sigtiawv 00 Y.
ss
Naples, FL 34112
(City, State, ZIP code)
Approved as to form and legality
q 4b
Assistant County At �i rncY
C�n"1' ra..
�ar
-j)
ririhAY LU3. 12S
October 2018 – September 2019
ATTACHMENT IV
ASSURANCES—NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average forty-five (45) minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing
the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction Project (0348-0043),
Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
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.
1. 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 cost) 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 frame 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 19 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 statues 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 VRI 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; (i) 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.
Z Will comply, or has already complied, with the requirements of Titles H and III of the uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) 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.
56
LtLLAY /W.16
October 2018 - September 2019
8 Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C. §1501-1508 and 7324-7328), which limit
the political activities of employees whose principal employment activities are fimded 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 sub -agreements.
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 is $10,000.00 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. §1721 et seq.) related to protecting components
or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of
1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related
activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C.§2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities
supported by this award of assistance.
16. Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C. §4801 et seq.), which prohibits the use of
lead- based paint in construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and 2 CFR Part 200.
I& Will comply with all applicable requirements of all other federal laws, executive rders, regulations and policies
governing this program. O
SIGNATURE OF AUTHORIZED CERTIFYING CHAIRMAN
OFFICIAL
ANDY SOLIS -
APPLICANT ORGANIZATION—�ESUBMITTED
Collier County Board of County Commissroli�J,s,, I
ATTEST 7 Approved as to form and legality
CRY ALK. KIN (La CLERK;'
II'ITI�'fr' Ass �tant County A r rey \O\ a\
cimin}nrn nttlu
L"HL"AY Zvi. 16
October 2018 — September 2019 ATTACHMENT V
FLORIDA DEPARTMENT OF ELDER AFFAIRS CIVIL RIGHTS COMPLIANCE CHECKLIST
Program/FacilityName
County
AAA/Contractor
Address
Completed By
City, State, Zip Code
Date
Telephone
PART I: READ THE ATTACHED INSTRUCTIONS FOR ILLUSTRATIVE INFORMATION WHICH WILL HELP YOU COMPLETE THIS FORM.
1. Briefly describe the geographic area served by the program/facility and the type of service provided:
,For questions 2-5 please indicate the fell
2. Population of area served
3. Staff currently employed
'(4. Clients currently enrolled/registered
S. Advisory/Governing Board if applicable
Total # % % % %
)wing: White Black Hispanic Other
%
Female
% %
Disabled Over 40
Source of data:
Pffectiverlate-
N/A
❑
YES
❑
Effective date:
8. Are eligibility requirements for services applied to clients and applicants without regard to race, color, national
origin, sex, age, religion or disability?
PART IL USE A SEPARATE SHEET OF PAPER FOR ANY EXPLANATIONS REQUIRING MORE SPACE. IF N/A or NO EXPLAIN.
6. Is an Assurance of Compliance on file with DOEA? N/A YES
❑ ❑
NO
❑
7. Compare the staff composition to the population. Is staff representative of the population?
N/A
❑
YES
❑
NO
❑
8. Are eligibility requirements for services applied to clients and applicants without regard to race, color, national
origin, sex, age, religion or disability?
N/A
❑
YES
❑
NO
❑
9. Are all benefits, services and facilities available to applicants and participants in an equally effective manner
regardless of race, sex, color, age, national origin, religion or disability?
N/A
❑
YES
❑
NO
❑
10. For in-patient services, are room assignments made without regard to race, color, national origin or disability?
N/A
YES
NO
❑
❑
❑
11. Is the program/facility, accessible to non-English speaking clients? N/A YES NO
❑ ❑ ❑
12 Are emplo eea, applicants and participants informed of thein protection against discrimination? If YES, how? N/A YES NO
Verbal f Written❑ Postern El El n
RM
LMhAY LU -5. 16
October 2018 — September 2019
13. Give the number and current status of any discrimination complaints regarding services or employment filed
against the program/facility.
N/A
NUMBER
❑
❑
*Notice of Corrective Action Sent
PART IV: FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONTRACTS OF $50,000.00 OR MORE.
Telephone Response Due
20. Do you have a written affirmative action plan? If NO, explain. YES
14. Is the program/facility physically accessible to mobility, hearing, and sight -impaired individuals?
N/A
YES NO
❑
❑
❑ ❑
PART III: THE FOLLOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 15 OR MORE EMPLOYEES. IF NO
EXPLAIN.
15. Has as a self-evaluation been conducted to identify any barriers to serving disabled individuals, and to snake any YES NO
necessary modifications? ❑ ❑
16. Is there an established grievance procedure that incorporates due process in the resolution of complaints?
YES
NO
❑
❑
17. Has a person been designated to coordinate Section 504 compliance activities?
YES
NO
❑
❑
18. Do recruitment and notification materials advise applicants, employees and participants of nondiscrimination on
the basis of disability?
YES
❑
NO
❑
19. Are auxiliary aids available to assure accessibility of services to hearing and sight -impaired individuals? YES
NO
Reviewed by
❑
❑
*Notice of Corrective Action Sent
PART IV: FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONTRACTS OF $50,000.00 OR MORE.
Telephone Response Due
20. Do you have a written affirmative action plan? If NO, explain. YES
NO
❑
❑
59
''x
It �
Reviewed by
In Compliance: YES ❑ NO* ❑
Program Office
*Notice of Corrective Action Sent
Date
Telephone Response Due
On -Site ❑ Desk Review ❑
Response Received
59
''x
ht_ii: A1' 6uS.16
October 2018 — September 2019
ATTACHMENT V
INSTRUCTIONS FOR THE CIVIL RIGI3TS COMPLIANCE CHECKLIST
1. Describe the geographic service area such as a district, county, city or other locality. If the program/facility selves
a specific target population such as adolescents, describe the target population. Also, define the type of service
provided.
2. Enter the percent of the population served by race and sex. The population served includes persons in the
geographical area for which services are provided such as a city, county or other regional area. Population statistics
can be obtained from local chambers of commerce, libraries, or any publication from the 1980 Census containing
Florida population statistics. Include the source of your population statistics. ("Other" races include Asian/Pacific
Islanders and American Indian/Alaskan Natives.)
3. Enter the total number of firll-time staff and their percent by race, sex and disability. Include the effective date of
your summary.
4. Enter the total number of clients who are enrolled, registered or currently served by the program or facility, and list
their percent by race, sex and disability. Include the date that enrollment was counted.
5. Enter the total number of advisory board members and their percent by race, sex, and disability. If there is no
advisory or governing board, leave this section blank.
6. Each recipient of federal financial assistance must have on file an assurance that the program will be conducted in
compliance with all nondiscriminatory provisions as required in 45 CFR 80. This is usually a standard part of the
contract language for DOEA Recipients and their Sub -grantees, 45 CFR 80.4 (a).
7. Is the race, sex, and national origin of the staff reflective of the general population? For example, if 10% of the
population is Hispanic, is there a comparable percentage of Hispanic staff?
8. Where there is a significant variation between the race, sex or ethnic composition of the clients and their availability
in the population, the program/facility has the responsibility to determine the reasons for such variation and take
whatever action may be necessary to correct any discrimination. Some legitimate disparities may exist when
programs are sanctioned to serve target populations such as elderly or disabled persons, 45 CFR 80.3 (b) (6).
9. Do eligibility requirements unlawfully exclude persons in protected groups from the provision of services or
employment? Evidence of such may be indicated in staff and client representation (Questions 3 and 4) and also
through on-site record analysis of persons who applied but were denied services or employment, 45 CFR 80.3 (a)
and 45 CFR 80.1 (b) (2).
10. Participants or clients must be provided services such as medical, nursing and dental care, laboratory services,
physical and recreational therapies, counseling and social services without regard to race, sex, color, national origin,
religion, age or disability. Courtesy titles, appointment scheduling and accuracy of record keeping must be applied
uniformly and without regard to race, sex, color, national origin, religion, age or disability. Entrances, waiting
rooms, reception areas, restrooms and other facilities must also be equally available to all clients, 45 CFR 80.3 (b).
11. For in-patient services, residents must be assigned to rooms, wards, etc., without regard to race, color, national
origin or disability. Also, residents must not be asked whether they are willing to share accommodations with
persons of a different race, color, national origin, or disability, 45 CFR 80.3 (a).
12. The program/facility and all services must be accessible to participants and applicants, including those persons who
may not speak English. In geographic areas where a significant population of non-English speaking people live,
program accessibility may include the employment of bilingual staff. In other areas, it is sufficient to have a policy
or plan for service, such as a current list of names and telephone numbers of bilingual individuals who will assist
60
LHLAII zVS. 125
October 2018 — September 2019
in the provision of services, 45 CFR 80.3 (a).
13. Programs/facilities must make information regarding the nondiscriminatory provisions of Title VI available to their
participants, beneficiaries or any other interested parties. This should include information on their right to file a
complaint of discrimination with either the Area Agency on Aging for Southwest Florida, Inc. and/or
the Florida Agency of Elder Affairs or the U.S. Agency of HHS. The information may be supplied verbally or in
writing to every individual or may be supplied through the use of an equal opportunity policy poster displayed in
a public area of the facility, 45 CFR 80.6 (d).
14. Report number of discrimination complaints filed against the program/facility. Indicate the basis, e.g., race, color,
creed, sex, age, national origin, disability, retaliation; the issues involved, e.g., services or employment, placement,
termination, etc. Indicate the civil rights law or policy alleged to have been violated along with the name and
address of the local, state or federal agency with whom the complaint has been filed. Indicate the current status,
e.g., settled, no reasonable cause found, failure to conciliate, failure to cooperate, under review, etc.
15. The program/facility must be physically accessible to disabled individuals. Physical accessibility includes
designated parking areas, curb cuts or level approaches, ramps and adequate widths to entrances. The lobby, public
telephone, restroom facilities, water fountains, information and admissions offices should be accessible. Door
widths and traffic areas of administrative offices, cafeterias, restrooms, recreation areas, counters and serving lines
should be observed for accessibility. Elevators should be observed for door width, and Braille or raised numbers.
Switches and controls for light, heat, ventilation, fire alarms, and other essentials should be installed at an
appropriate height for mobility impaired individuals.
16. Section 504 of the Rehabilitation Act of 1973 requires that a recipient of federal financial assistance conduct a self-
evaluation to identify any accessibility barriers. Self-evaluation is a four -step process:
• With the assistance of a disabled individual/organization, evaluate current practices and policies which do not
comply with Section 504.
• Modify policies and practices that do not meet Section 504 requirements.
• Take remedial steps to eliminate any discrimination that has been identified.
• Maintain self-evaluation on file. (This checklist may be used to satisfy this requirement if these four steps have
been followed.), 45 CFR 84.6.
17. Programs or facilities that employ 15 or more persons must adopt grievance procedures that incorporate appropriate
due process standards and provide for the prompt and equitable resolution of complaints alleging any action
prohibited by Section 504.45 CFR 84.7 (b).
18. Programs or facilities that employ 15 or more persons must designate at least one person to coordinate efforts to
comply with Section 504.45 CFR 84.7 (a).
19. Continuing steps must be taken to notify employees and the public of the program/facility's policy of
nondiscrimination on the basis of disability. This includes recruitment material, notices for hearings, newspaper
ads, and other appropriate written communication, 45 CFR 84.8 (a).
20. Programs/facilities that employ 15 or more persons must provide appropriate auxiliary aids to persons with impaired
sensory, manual or speaking skills where necessary. Auxiliary aids may include, but are not limited to, interpreters
for hearing impaired individuals, taped or Braille materials, or any alternative resources that can be used to provide
equally effective services, 45 CPR 84.52 (d).
21. Programs/facilities with 50 or more employees and $50,000.00 in federal contracts must develop, implement and
maintain a written affirmative action compliance program in accordance with Executive Order 11246, 41 CFR 60
and Title VI of the Civil Rights Act of 1964, as amended.
61
bfil-Ar ZU.S.I zS
October 2018 — September 2019
ATTACHMENT VII
BACKGROUND SCREENING
DEPARTAIENT OF
BACKGROUND SCREENING
ELDER
AFFAIRS Affidavit of Compliance - Employer
STATE OF FLORIDA
AUTHORITY: This form is required annually of all employers to comply with the attestation
requirements set forth in section 435.05(3), Florida Statutes.
➢ The term "employer" means any person or entity required by law to conduct background screening,
including but not limited to, Area Agencies on Aging, Aging Resource Centers, Aging and Disability
Resource Centers, Lead Agencies, Long -Term Care Ombudsman Program, Serving Health Insurance Needs
of Elders Program, Service Providers, Diversion Providers, and any other person or entity which hires
employees or has volunteers in service who meet the definition of a direct service provider. See §§
435.02, 430.0402, Fla. Stat.
➢ A direct service provider is "a person 18 years of age or older who, pursuant to a program to provide
services to the elderly, has direct, face-to-face contact with a client while providing services to the client
and has access to the client's living area, funds, personal property, or personal Identification information
as defined in s. 817.568. The term includes coordinators, managers, and supervisors of residential
facilities; and volunteers." § 430.0402(1)(6), Fla. Stat.
ATTESTATION:
As the duly a uthorized representative of
Employer Name
located at
Street Address City State ZIP code
I, do hereby affirm under penaIty of perjury
Nome of Representative
that the above named employer Is in compliance with the provisions of Chapter 435 and section
430.0402, Florida Statutes, regardinglevel2 background screening.
Signature of Representative Date
STATE OF FLORIDA, COUNTY OF
Sworn to (or affirmed) and subscribed before me this _ day of
to me or produced
20� by
(Name of Representative) who is personally known
PdnLType, or Stamp Commissioned Name of Notary Public Notary Public
DOEA Form 235, Affidavit of Compliance- Employer, Effective April 2012
Form available at: Wto Veldffafflmsta betfl. use I r i
62
as proof of Identification.
Section 435.05SL F.S.
October 2018 — September 2019
.hi1—
ANNUAL BUDGET SUMMARY AND DETAIL
LHLAY ZW.1 Z5
EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
for
Collier County Board of County Commissioners
Collier
EHEAP ADMINISTRATION BUDGET $ 4,545.00
EHEAP OUTREACH BUDGET $ 8,555.00
EHEAP CRISIS ASSISTANCE $ 42,657.00
TOTAL $ 55,757.00
Projected minimum number of individuals to be served
Energy Assistance* 215
*Eligible households may be provided with one benefit per season up to six hundred dollars per benefit. The
minimum number of consumers may reflect duplicated consumers if a consumer receives a benefit in both
seasons.
63
October 2018 — September 2019
ATTACHMENT X
t:HtsAF 6V.5. t 8
EHEAP ADMINISTRATIVE AND OUTRFACH EXPENSE BUDGET LIETML
PSA CONTRACT #
Emergency glome Energy Assistance Program
Adtnit wadnn Subtotal 5
Outreach Subtotal S
Total $
UALCAY /U.5. 16
October 2018 — September 2019
ATTACHML, NT X1
RECEIPTS AND EXPENDITURE; REPORT
EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
PROVIDER NAME, AOURES5 PIHONEN AND FEf M
Program Fundingg 8ouroe' �'i
THIS R[PQRT PERIOD
FROM
TO
EHEAP
CONTRACT
1Cmergency Home Energy
PERIODr
AsststaAed for the Ektedy Program)
CONTRACTS
REPORT#
PSAk
CERTWICATION' I Wiy to the best of try 9mowlettfle and Belief
that this ierwri is ownplele and ata outlays herein are for purpones set Perth
In the Contract.
Prepared by Qdo,_
Approvedby
Date.
PART A 8UDGETED INCOMFJRECEIPT$
1. Approved
2 Actual Retelpt
3. Tolol Recidpls
4. Parcentot
Budget
For hits Report
Year to Dade
Approved Budget
1, Agteernenl Apnouna
S0 DD
$0.00
3006
%
2 Interest on Agreement Funds
50100
50.00
$0.00
%
3. TOTAL AGREEMENT AMOUNT
501g0
S0.0D
$0,00
%
PART 6: EXPENDITURES
1. Approved
2 E#ewouriis
3. Ezpetddures
4 Percent of
oudget
For Thas Report
Year to Dole
Approved Sudgel
I . adtrinAration
$0.00
5090
5000
%
2 pulmoth
#0 00
50.00
50 gD
%
3 Crisis Sews
10 DD
50.00
50,00
%
4 Weather Related Somalis
10.00
50.00
1000
%
S.WeuaherRelstedAdmn'astrallon
$000
$0.00
#0.00
%
S. TOTAL CXPENDtTURES
50,00
S0.0D
$0.00
%
00EA FORM 105p revised 1 108
65
October 2018 - September 2019
ATTACHMT, NT XII
REQUEST rOR PAYMENT
REQUEST FOR PAYMENT
EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
I riHhAY ZuJ.16
CONTRACTOR NAME, ADDRESS, PHONEa and F1209
TYPE OF REPORT:
Contract
Comreei P+Hod
Advance Ragdem _-. _-_
Regmtt Period
Reps" M
RAIrn4oreamtm Ro""t
Inv6le+a__._-._____
PSA_ _
GEATIFICATIOW IltafebyWIlly that INS regU491 to the best of mp NAwsiadpa to be complelo and""atEnd conforms with the terms of the ahm,6 wmrsct,
Prepared by/ 0e1+'N,..�.. -- ApprovedbM�e .,....__._._-, O#lel
PARTA: SUDGETSUMMARY
ADMINISTRATION
OUTREACH
CRe51S
WRATHER
ADMIRISTRATfO
WVAIM
TOTAL
SERVICES
SERVICES
SERVICE$
RELATED
RFAATPA
30.00
50.00
30.00
SO=
50.00
1200
1. Approved Contract Am000l
B. Previous Funds Reeelvd for
$0,00
sees
$200
34.00
30.00
10.00
Contract Pef1att
S. Conlratt Memo Ulna l nheV4iAa 2)
1§,00
$000
SOHO
Meo
$0.00
SOHO
h. Previous lRtnd3 Requested and Not
1400
30.00
5090
10.00
$0.00
3090
Rewlvad fat C"Irbet PadOd
S. Coohaer Balance VMO O mhu&aro e)
30)0
$0,00
00,00
$0,00
WAS
10.00
PART S: CONTRACT FUNDS REOUESi
_....
1, AAIIclpaled Cash Needs
30.00
0000
#090
0.00
10.00
1090
Itat .2od tdonlh, Attach Justification)
2. NEI EapandOuree, FOt Madth
34.00
1090
SO90
$0.00
s0.00
30.00
I00EA Form I OSP, Part S, tine S)
1, TOTAL
WAO
salhe
30.00
50.00
10.00
SAW
PART Cr NET FUNDSREDUESTEO
I. Laai Advance Appllad
septi
MAO
30.116
so,Go
Mal,
56.00
2, TOTAL FUNDS RED{y1.3TED
$0.00
$0.00
10,00
39,00
§0.00
50.00
iPMt R. LPe 1 piing* Purl C, L ree 1)
PMT O: SERVICE INFORMATION
Mundell 00Indllid11940 Nerved Wits COME aslittart" swing IM tort month:
Nium sr of 4ndh4&alsInalgmle ordenFd asststanae du ring IM raparl sonlh;
INIMbet of ipol'niddsls s sd by relerial t0 Other C6ire1Wally lee0dfatF lar eirelify aflistimm during rhe ration month:
CaNNlcrdlon lutannrd; Conftsdat lute6y cedldss that It has been Open Ned Operating dining It%normal alertness Kerins for she Mpartinp month, as
eendad Mrlw S [semm of WOA NaCUOn, Of HIS EHFAP Caolfa94
1==
0 M
w.laN dtn97
66
"A _'
October 2018 — September 2019
ATTACHMENT XIII
INVOICE REPORT SCHEDULE
hl-ihAF LVJ.16
Report Number
Based Upon
Date Due to the Department
1
October Advance*
Upon receipt of executed contract.
2
November Advance*
Upon receipt of executed contract.
3
October Invoice
November 09, 2018
4
November Invoice
December 09, 2018
5
December Invoice
January 09, 2019
6
January Invoice
February 09, 2019
7
February Invoice
March 09, 2019
8
March Invoice
April 09, 2019
9
April Invoice
May 09, 2019
10
May Invoice
June 09, 2019
11
June Invoice
July 09, 2019
12
July Invoice
August 09, 2019
13
August Invoice
September 09, 2019
14
September Invoice
October 09, 2019
15
Final Request for Payment
October 15, 2019
* Advance based on projected cash need.
Note # 1: Report #1 for Advance Basis Agreements cannot be submitted to the Agency prior to
October 1 or until the agreement with the Agency has been executed and a copy sent to the
Agency. Actual submission of the vouchers to the Agency is dependent on the accuracy of
the Receipts and Expenditure Report.
Note #2: Report numbers 5 through 11 shall reflect an adjustment of one-tenth of the total advance
amount, on each of the reports, repaying advances issued the first two months of the agree -
Note # 3: Submission of expenditure reports may or may not generate a payment request. If final
expenditure report reflects funds due back to the Agency, payment is to accompany the
report.
Note 44: ALL Expenditure Reports are due by 12:00 p.m. on the 9th of each month. IF the 9th falls
on a Saturday, then the report will be due by the 8th by 12:00 p.m. AND IF the 9th falls
on a Sunday, the report will be due by the 10th by 12:00 p.m. Actual submission of the
vouchers to Dept. of Elder Affairs is dependent on the accuracy of the expenditure report
which is verified and paid by CIRTS data only.
67
t,'tlCHr 6U.5.1 S
October 2018 — September 2019
ATTACHME, NT XIV
Li El'
FLORIDA DEPARTMENT of
ECONOMIC OPPORTUNITY
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) POVERTY
INCOME GUIDELINES*
EFFECTIVE OCTOBER 1, 2018
PEOPLE IN THE HOUSEHOLD
150%
1
$18,210
2
$24,690
3
$31,170
4
$37,650
5
$44,130
6
$50,610
7
$57,090
8
$63,570
For each additional person in the household
with more than 8 people, add:
$ 6,480
*These figures are based on the 2017 U.S. Department of Health and Human Services (HHS) poverty
guidelines published in the Fedeml Register• on January 13, 2018.
nt'
M
October 2018 - September 2019
ATTACHMENT XV
LIHEAP PAYMENT MATRIX
LHLAY /W. 16
LOW-INCOME IIOMT ENERGY AS$TSTANCE PICOGRAM PAYMENT MATRIX - FI 2418[2419
HHS
POVERTY LEVELS
BY HOUSEHOLD SIZE AND INCOME
HOUSEHOLD
INCOME IN DOLLARS PER YEAR
NUMBER OF
50% of
Over 50% of Poverty
At least 75% but no
Over 100% but no more
Over 125%
but no
PEOPLE IN
Poverty or
but Less
than 75%
more than 100%
125%
Poverty
more than 150%
Less
Povertythan
Poverty
HOUSEHOLD
At or Below
Annual Income at Least but No Greater Than
1
$6,070
$6,071
$9,105
$9,106
$12,140
$12,141
$15,175
$15,176
$18,210
2
$8;230
$8,231
$12,345
$12,346
j $16,460
$16,461
$20,575
$20,576
$24,690
3
$10,390
$10,391
$15,585
$15,586
$20,780
$20,781 (
$25,975
$25,976
$31,170
4
$12,550
$12,551
$18,825
$18,826
$25,100
$25,101+
$31,375
$31,376
$37,650
5
$14,710
$14,711
$22,065
$22,066
$29,420
$29,421
$36,775
$36,776
$44,130
6
$16,870
$16,871
$25,305
$25,306
$33,740
$33,741:
$42,175
$42,176
$50,610
7
$19,030
$19,031
$28,545
$28,546
$38,060
$38,061
$47,575
$47,576
$57,090
8
$21,190
$21,191
$31,785
$31,786
i $42,380 ;
$42,381
$52,975
$52,976
$63,570
9
$23,350
$23,351
$35,025
$35,026
$46,700
$46,701
$58,375
$58,376
$70,050
10
$25,510
$25,511
$38,265
$38,266
$51,020 ,
$51,021;
$63,775
$63,776
$76,530 '
11
$27,670
$27,671
$41,505
$41,506
$55,340
$55,341
$69,175
$69,176
$83,010
12
$29,830
$29,831
$44,745 j
$44,746
$59,660
$59,661;
$74,575
$74,576
$89,490
13
$31,990
$31,991
$47,985
$47,986
$63,980
$63,981
$79,975
$79,976
$95,970
14
$34,150
$34,151
$51,225:
$51,226
$68,300 ++?
$68,301',
$85,375
$85,376
$102,450
15
$36,310
$36,311
$54,465
$54,466
$72,620
$72,621
$90,775
$90,776
$108,930
16
$38,470
$38,471
$57,705
$57,706
$76,940
$76,941
$96,175
$96,176
$115,410
17
$40,630
$40,631
$60,945
$60,946
$81,260
$81,261
$101,575
$101,576
$121,890
18
$42,790
$42,791
$64,185
$64,186
$85,580
$85,581
$106,975
$106,976
$128,370
19
$44,950
$44,951
$67,425
$67,426
$89,900
$89,901
$112,375
$112,376
$134,850
20
$47,110
$47,111
$70,665
$70,666
$94,220
$94,221
$117,775
$117,776
$141,330
These figures ate based upon the 2018 U.S. Department olHealth and
Human Sendces (HHS) Pm erty Guidelines pubh'shed in the Fedora!
Register an january 13, 2018.
R
octo
J✓I115Ar /W.16
ATTACB ENT XVI
LOW INCOME HOME ENERGYASSISTANCE PROGRAM (LIHEAP)
FY 2018/2019 SOURCES OF INCOME
EFFECTIVE OCTOBER 1, 2018
INCLUDED FXCLL-DED
SOURCES OF INCOME SOURCFS OF INCOME
(Includes total annual cash receipts before taxes from all sourced
1. Money wages and salaries before any deductions
2. Net receipts from non -faint employment (receipts fiama
Person's oum unincorporated business, professional
enterpase, or partnership, after deductions for business
expenses)
3. Net receipts from firm self-employment (receipts fronts
farm which one operates as an owner, tenter, or
sharecroppef, after deductions for farm operating
expenses)
4. REGULAR PAYMENTS FROM:
Social Security
Railroad retirement
Unemployment compensation
Strike benefits from union funds
XYocket's compensation
Veteran's payments
Public Assistance or Temporary Assistance for Needy Families
(TANF), Supplemental Security Income, and non -federally funded
General Assistance of General Relief money payments.
5. Payments to foster children age 18 or older received throughthe
Independent Living Program
1. CAPITAL GAINS
Any Assets demur down as u7dtdrawals from a bank, or the
sale of property, a house, or a cat.
2. Tax Refunds
3. Gifts
4. Loans
5. Lump -sum inheritances
6. One-time insurance payments
7. Poster Cue Payments*
S. Compensation for injury
9. Combat zone pay to the oailitarc
10. Adoption Subsidies
11. Reverse Mortgage PatInente
12. NON-CASH BENEFITS
(a) Employef-paid of union paid portion ofhealth
insurance of other employee benefits
Tiaiving stipends
Alimony
Child Support 13.
Social Security Benefit Gamishes for Non -Payment of
School Loans. (The total amount of the Social Security Retirement
benefit including the garnished deduction must he used when
calculating the applicant's iaaome.)
10. \Lditaty family allotment of other regular sepportfrom
a family member of someone not living in the
household
11. Pdvatepensions
12. Government employee pensions{mcludingmilitart
retirement pay)
13. Reguhu insurance or annuity payments
14. Educational Assistance:
Grants, Fellowships, Assistantships, College or
University Scholatships — Only count as income those funds
specifically allotted for living expenses
15.
Dividends
16.
Interest
17.
Net rental income
18.
Net toyalties
19.
Periodic receipts from estates or trusts
20.
Net gambling or lottery winnings
70
(b) Food of housing received in lien of wages
[cl The value of food and fuel pxoduced and
consumed on farms.
(d) Tlteimputedvalueofrentfromowmer-occupied
non-firm or farm housimg.
(e) Federal non-cssh benefit programs such as Medicare,
Medicaid, Food Stamps, school lunches, and housing
assistance.
Supplemental Security Income (SSI) benefits cannot be
gannisbed for any reason unless a recipient received an
overpayment of benefits.
The total amount of the SSI benefit minus the garnished
deduction for recoupment must be used when calculating
the applicant's income.
*Persons whose cost of residence is paid through a foster
tate or residential program administered by the state
cannot be counted as household members.
btiCAY LUS.I iS
October 2018 — September 2019
ATTACHMENT XVII
OUTREACH PLAN SURVEY
PSA Click here to enter text.
COUNTY(IES) Click here to enter text.
AGENCY'S EHEAP COORDINATOR Click here to enter text.
PHONE W/EXT. Click here to enter text.
EMAIL Click here to enter text.
1. ELDERLY OUTREACH
Describe the efforts to increase the number and percentage of elderly households served.
Click here to enter text.
2. INTEGRATION OF OTHER LOCAL AGENCIES IN OUTREACH
Describe what local coordination efforts support outreach activities. Identify agencies, utilities, charities, and
others incorporated in these efforts and the activities included,
Click here to enter text,
3. ADVERTISING, PROMOTIONAL, MEDIA, AND OTHER PRINT OUTREACH EFFORTS
a. Brochures— please select all of the options you currently use in your program from the list below:
❑ Use a locally developed brochure (send an electronic copy with your survey)
❑ Other, please describe Click here to enter text.
How will the brochures be distributed/used (check all that apply):
❑ Display at County courthouse/office building
❑ Provide to Senior Citizen Centers in county
❑ Provide to meal sites in county
❑ Provide to "Meals on Wheels" for distribution
❑ Provide to local utility companies and heating fuel providers
❑ To cooperating local agencies (such as Salvation Army)
❑ Grocery stores or similar businesses
❑ Provide to churches
❑ Provide to hospitals
❑ Provide to day care facilities
❑ Provide to local libraries
❑ Laundromats
❑ Provide to banks
❑ Provide to clinics
71
October 2
L^ t-iLAY /U -J. I ZS
❑ Provide to Head Start Programs
❑ Other: Click here to enter text.
b. POSTERS
Please select all of the options you currently use in your program from the list below:
❑ Use locally developed poster (send a copy with your survey)
❑ Don't use posters
How does your agency distribute or use program posters (check all that apply):
❑ Display at County courthouse/office building
❑ Provide to Senior Citizen Centers in county
❑ Provide to meal sites in county
❑ Provide to grocery stores
❑ Provide to laundromats
❑ Provide to churches
❑ Provide to hospitals
❑ Provide to day care facilities
❑ Provide to local libraries
❑ Provide to other businesses
❑ Provide to clinics
❑ Provide to Head Start Programs
❑ Provide to banks
❑ Other: Click here to enter text.
c. PAID ADVERTISING
Does your agency use paid advertising to promote the program?
❑ Yes
❑ No (if you answered No — go to Section D)
Total Budget for advertising (per fiscal year) $ Click here to enter text.
Does you agency advertise in NEWSPAPERS? ❑ Yes ❑ No
Name of Paper
Click here to enter text.
City/Location
Click here to enter text.
Name of Paper
Click here to enter text,
City/Location
Click here to enter text.
Name of Paper
Click here to enter text.
City/Location
Click here to enter text.
Frequency or # of times ads are placed per cooling season: Click here to enter text.
Frequency or # of times ads are placed per heating season: Click here to enter text.
When do you advertise (check all that apply)?
72
:J
October 2018
btibAY LU -5.16
❑ April
❑
October
❑ May
❑
November
❑ June
❑
December
❑ July
❑
January
❑ August
❑
February
❑ September
❑
March
Do you use the same ad for all newspaper advertising? ❑ Yes ❑ No
If not, how many different ads do you place? Click here to enter text.
In which language(s) are your ads place? (check all that apply)
❑ English
❑ Spanish
❑ Other (please list) Click here to enter text.
Does your agency advertise in SHOPPERS? ❑ Yes ❑ No
Name of Shopper Click here to enter text. City/Location Click hereto enter text.
Name of Shopper Click hereto enter text. City/Location Click hereto enter text.
Frequency or # of times ads are placed per cooling season: Click hereto enter text.
Frequency or # of times ads are placed per heating season: Click here to enter text.
When do you advertise (check all that apply)
❑ April ❑ October
❑ May ❑ November
❑ June ❑ December
❑ July ❑ January
❑ August ❑ February
❑ September ❑ March
Do you use the same ad for all shopper advertising? ❑ Yes ❑ No
If not, how many different ads do you place? Click here to enter text.
In which language(s) are your ads place? (check all that apply)
❑ English
❑ Spanish
❑ Other (please list) Click hereto enter text.
Does your agency advertise on RADIO? ❑ Yes ❑ No
Station Call Letters Click here to enter text. City/Location Click here to enter text.
Station Call Letters Click here to enter text. City/Location Click here to enter text.
73
UILAr LU.5.1 ZS
October 2018 - Frequency or # of times ads are placed per cooling season: Click here to enter text.
Frequency or # of times ads are placed per heating season: Click here to enter text.
When do you advertise (check all that apply)
❑ April ❑ October
❑ May ❑ November
❑ June ❑ December
❑ July ❑ January
❑ August ❑ February
❑ September ❑ March
Do you use the same ad for all radio advertising? ❑ Yes ❑ No
If not, how many different ads do you place? Click here to enter text.
In which language(s) are your ads place? (check all that apply)
❑ English
❑ Spanish
❑ Other (please list) Click here to enter text.
Does your agency advertise on TELEVISION? ❑ Yes ❑ No
Station Call Letters Click here to enter text. City/Location Click here to enter text.
Cable Operator Click hereto enter text. City/Location Click here to enter text.
Frequency or # of times ads are placed per cooling season: Click here to enter text.
Frequency or # of times ads are placed per heating season: Click hereto enter text.
When do you advertise (check all that apply)
❑
April
❑
October
❑
May
❑
November
❑
June
❑
December
❑
July
❑
January
❑
August
❑
February
❑
September
❑
March
Do you use the same ad for all television advertising? ❑ Yes ❑ No
If not, how many different ads do you place? Click hereto enter text.
In which language(s) are your ads place? (check all that apply)
❑ English
❑ Spanish
❑ Other (please list) Click hereto enter text.
OTHER PAID AVERTISING (Please Describe): Click hereto enter text.
74
L" riLAY 60.5.16
October 2d. FREE MEDIA PROMOTION/COVERAGE
Please check all the appropriate selections related to how your agency utilizes free media
promotion/coverage:
❑ Issue Press Releases to local/area media
Are press releases sent out more than one time per year? ❑ Yes ❑ No
If yes, how often? Click hereto enter text.
Do you use the same press release each time? ❑ Yes ❑ No ❑ N/A
❑ Prepare announcements for public access television (cable)
❑ Prepare public service announcements (PSAs)
❑ Arrange for on air radio or television interviews
❑ Post information on a County or Agency website
❑ Post information or link to other local websites
❑ Our agency does not take part in any Free Media Promotion
Are any of these materials translated? ❑ Yes ❑ No
❑ Spanish ❑ Other non-English languages
Web activities:
❑ Post information on a County or Agency website
❑ Post information or link to other local websites
e. DIRECT PROMOTIONAL ACTIVITIES
Please select all of the appropriate selections related to how your agency completes Direct Promotional
Activities:
❑ Direct mail — Anticipated size of mailing(s) Click here to enter text. (number of pieces sent)
❑ Telephone promotion (not application taking)
❑ Displays/at stores, malls, etc.
❑ Displays/booths at events (check all that apply):
❑ Home Show
❑ Job Fair
❑ Meal Sites
❑ Health Fairs
❑ Other (please list): Click here to enter text.
Who will you target with your direct promotional activities (check all that apply)?
❑ Aging/Seniors/Elderly
❑ Disabled
❑ High Energy Users
❑ Families with children
❑ Last year's applicants
❑ Homebound
❑ Last year's home visit applicants
75
btill All LUS.I ZS
O ❑ Churches
❑ Head Start
❑ Specific Vendors
❑ Subsidized -housing residents
❑ Other (List)
f, HOME VISITS
Does your agency perform home visits? ❑ Yes ❑ No (if no, skip to Section 6, Special Outreach
Efforts)
Number of home visits conducted last year Click here to enter text.
Number of home visits expected this year Click here to enter text.
Do early applications reduce the number of home visits? ❑ Yes ❑ No
Check the criteria used to determine when home visits will be done (check all that apply):
❑ Age
❑ Disability
❑ Transportation difficulties (no car, can't drive, etc,)
❑ Applicant's work schedule
❑ Small children in household
❑ Language barrier/availability of translator
❑ Other (please list): Click here to enter text.
4. SPECIAL OUTREACH EFFORTS
Please check each of the Target/Special Needs populations you are carrying out special efforts to reach from the
list below:
❑ The working poor (check all activities that apply):
❑ Evening office hours
❑ Saturday morning office hours
❑ Saturday afternoon office hours
❑ Promote at churches
❑ Special phone/mail application efforts
❑ After hours home visits
❑ Promote at specific employers
❑ Other (please list):
❑ Households with young children:
❑ Provide materials to day care facilities
❑ Take applications at day care facilities
❑ Promote at churches
❑ Handouts to school children
❑ Materials for Pediatricians and clinics
❑ Other (please list):
76
1-lrrit;AY 2u S.1 ZS
❑ Non-English speaking population, etc.:
❑ Promote through Hispanic groups
❑ Provide brochures/posters in other languages to hospitals and clinics
❑ Promote through religious organizations
❑ Identify local interpreters to use
❑ Have signage at office in multiple languages
❑ Use pre-recorded messages in different languages
❑ Set application site at gatherings and events where minority groups congregate and interpreters
are available
S. INTAKE SITES AND TIMES
Please select the statement that best fits your application process:
❑ Take applications primarily through appointments
❑ Take applications by appointment and work in walk-ins
❑ Take applications by appointment and have day(s) for doing walk-ins
❑ Take applications primarily through walk-ins and reserve appointments for special needs or problem
cases.
❑ Take applications from walk-ins only
a. Identify the intake sites to be used daily (Monday through Friday)
Name of Site
Area/County(s) Served
Hours
Also LIHEAP provider?
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
❑No
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
El No
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
❑No
Click here to enter text.
Click here to enter text.
Click here to enter text.
Dyes
❑No
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
El No
Click here to enter text.
Click here to enter text.
Click here to enter text,
Dyes
EJ No
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
El No
Click here to enter text.
Click here to enter text.
Click here to enter text.
Dyes
El No
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
ONo
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
❑No
Click here to enter text.
Click here to enter text.
Click here to enter text.
El Yes
El No
Click here to enter text.
Click here to enter text.
Click here to enter text.
Dyes
❑No
Click here to enter text.
Click here to enter text.
Click here to enter text.
❑Yes
1:1 No
Click here to enter text.
Click here to enter text.
Click here to enter text.
OYes
El No
Click here to enter text.
Click here to enter text.
Click here to enter text.
Dyes
El No
b. Identify the Intake sites to be used regularly, as in once a week, twice a month, etc.
Name of Site
Area/County(s) Served
Day(s) of
Frequency
Hours
Also LIHEAP
Week
(time/??)
provider?
Click here to enter text.
Click here to enter text,
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text.
text.
77
I riHLAV /W.1 iS
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
provider?
Click here to enter text.
Click here to enter text.
text.
text.
Click here to
❑Yes ❑No
Click here to enter text.
Click here to enter text,
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
Click here to enter text.
Click here to enter text.
text.
text.
Click here to
❑Yes ❑No
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text,
Click here to enter text.
Click here to enter text.
text,
text.
Click here to
❑Yes ❑No
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
Click here to enter text.
Click here to enter text.
text,
text.
Click here to
❑Yes ❑No
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
Click here to enter text.
Click here to enter text.
text.
text.
Click here to
❑Yes ❑No
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text.
text.
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
Dyes ❑No
to enter
to enter
enter text.
text.
text.
c. Identify other sites to be used.
Name of Site
Area/County(s) Served
Day(s) of
Frequency
Hours
Also LIHEAP
Week
(time/??)
provider?
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text.
text.
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text.
text.
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text.
text.
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text,
text,
text.
Click here to enter text.
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text,
text,
d. Planned extended or flexible application times.
Area/County(s) Served
Day(s) of
Frequency
Hours
Also LIHEAP
Week
(time/??)
provider?
Evening Hours
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
text,
text.
b"t.Ar LU -5. 16
Evening Hours
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
❑
Thanksgiving
to enter
to enter
enter text.
Christmas Eve
❑
Christmas Day
text.
text.
here to
here to
Saturday Hours
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
enter
enter
to enter
to enter
enter text.
text.
text.
text.
text.
text.
Chief Financial Officer
Other
Click here to enter text.
Click here
Click here
Click here to
❑Yes ❑No
to enter
to enter
enter text.
hereto
here to
text.
text.
enter
enter
e. Days Offices are Closed
Check all holidays the agency is closed:
❑
Columbus Day
❑
Veterans Day
❑
Thanksgiving
❑
Friday after Thanksgiving
❑
Christmas Eve
❑
Christmas Day
❑
New Year's Eve
❑ New Years Day
❑ Martin Luther King, Jr.'s Birthday
❑ President's Day
❑ Good Friday
❑ Memorial Day
❑ Independence Day
❑ Labor Day
❑ Other (Please List)
❑ Click here to enter text.
❑ Click here to enter text.
❑ Click here to enter text.
6. SENIOR STAFF WORK SCHEDULES
Please provide the regular weekly office hours for the following:
Title
Name
Mon
Tue
Wed
Thurs
Fri
Executive Director
Click here to enter text.
Click
Click
Click
Click
Click
here to
here to
here to
here to
here to
enter
enter
enter
enter
enter
text.
text.
text.
text.
text.
Chief Financial Officer
Click here to enter text.
Click
Click
Click
Click
Click
here to
here to
here to
hereto
here to
enter
enter
enter
enter
enter
text.
text,
text.
text.
text.
EHEAP Program
Click here to enter text.
Click
Click
Click
Click
Click
Coordinator
here to
here to
here to
here to
here to
79
rrnryr /W.ix
............ ....... ................
enter
enter
enter
enter
I
enter
text.
text,
text.
text,
text.
7. OUTREACH ASSESSMENT/EVALUATION
Do you survey your applicants to assess the effectiveness of outreach efforts? ❑ Yes ❑ No
Surveys are targeted at
❑ Elderly
❑ Handicapped/disabled
❑ Households with young children
❑ Non-English speaking households
Surveys are not targeted ❑ Yes ❑ No
Do you track numbers of applicants at each outreach site? ❑ Yes ❑ No
Each time the site is used? ❑ For all visits combined? ❑
Do you compare types of outreach sites? ❑ Yes ❑ No
What is the most effective type of outreach site? (For example: senior center, library, town hall, fire
station, housing facility, etc.) Click here to enter text.
Do you track the number of home visits? ❑ Yes ❑ No
Do you track the reason for doing each home visit? ❑ Yes ❑ No
What other way do you assess the effectiveness and success of your outreach efforts? Click hereto enter text.
.e
hilhAP Zvi.l ZS
October 2018 — September 2019 ATTACHMENT XVIII
EHEAP APPLICATION AND ELIGIBILITY WORKSHEET
Emergency Home Energy Assistance for the Elderly Program- Application
Name:(First, M Last
Date of birth: Age: SSN:
Service address: Date Stamp
City: Florida County: ZIP Code: Intake worker's name:
Sex: ❑Male ❑Female Number of people in the household: Phone:
Marital Status: 0 Married 0 Partnered 0 Single 0 Separated 0 Divorced 0 Widowed Phone:
Race: 0 White 0 Black/African American 0 Asian O Native Hawaiian/Pacific Islander 0 American Indian/Alaska Native 0 Other
Ethnicity: 0 Hispanic/Latino 0 Other I Primary Language: 0 English O Spanish 0 Other
Does client have limited ability reading, writing, speaking, or understanding the English language? 0 Yes 0 No
Is the client a veteran? 0 Yes 0 No Was client referred to the local Veteran's Affairs office? 0 Yes 0 No 0 N/A
Applicant's income type(s): Applicant's monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
rMOMMM Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Is there a child 5 years of age or younger in the household? 0 Yes 0 No
Is there an individual with a disability in the household? 0 Yes 0 No
Is the applicant a U.S. citizen or an alien lawfully admitted for permanent residence? 0 Yes 0 No
Is the applicant a homeowner? 0 Yes 0 No
Does applicant live in government subsidized housing, such as Section 87 0 Yes 0 No
If yes, provide the complex name:
If yes, does the household receive an energy subsidy? 0 Yes 0 No
Does applicant live in a student dormitory, adult family care home, or any kind of group living facility? 0 Yes 0 No
ftv name:
Have you or any member of your household received energy assistance in the current season? 0 Yes 0 No
If yes, provide the name of Agency:
What is the primary source of home heating? (select one) 0 Electricity 0 Natural Gas 0 Propane 0 Wood/Coal 0 Refillable Fuels
Does household use supplemental heating source? 0 Electricity 0 Wood/Coal 0 N/A
Air conditioning unit type? 0 Central A/C 0 Window/Wall A/C 0 Fans 0 Other— specify (including evaporative cooler)
❑ Home cooling or heating energy source has been disconnected.
The information provided on this application, is to the best of my
knowledge, true and complete. I understand that priority in providing
assistance will be given to those households with the lowest income and
greatest need, i.e. those households in which the elderly, disabled, medically
needy, or children reside. I authorize the agency to make benefit payments
directly to my energy supplier. I am aware that after I have provided all the
information requested to determine my eligibility, if I am applying for crisis
assistance, Lou agency has 18 hours to act upon my application with an
eligible action. I am also aware that if I am not approved or denied within
the time allowed, or not approved for the correct amount, I have a right to
annral the di ,,inn !r£��„ cSon ,with an «x" r,u� witneccec a,P rPnnirrd t
Client
Bate:
0 Received notification that cooling or heating energy source is
anim, in he. diqrnrmct,d
Cl Cooling or heating energy source bill is delinquent or past due.
0 Cooling or heating energy source bill or notice's due date has
❑ Unable to get delivery of heating fuel, is out of heating fuel, or in
0 My home's energy equipment is inoperable,
0 I need a deposit.
0 Other
DOEA Form 114-1010112018
81
tbl-LP Ar 6UJ.16
Sectioome Elialibilitv3atermination
Annualize all household income.
Staple calculator tape here showing Poverty Guidelines effective 10/01/2018.
income calculations or write calculations Select the annual income limit by household size:
1. Add all gross monthly earned and
unearned income from the past 30
in this space. 150% of Poverty 50% of Poverty
01 .......... $18,210 $ 6,070
2. Add Medicare Premium ($134.00),
if
❑ 2..........$24,690 $ 8,230
❑ 3..........$31,170 $10,390
❑ 4,,,.,.,,,.$37,650 $12,550
3. Add Medicare Part D, if applicable.
4. To annualize, multiply the monthly
total by 12 months.
❑ 5..........$44,130 $14,710
Annual Household Income
❑ 6..........$50,610 $16,870
If the total annual household income is less than 50% of the current Federal Poverty Guidelines for household size (using chart above),
and no one in the household is receiving SNAP assistance, the applicant must provide a signed statement of how basic living expenses
Section Seven: rr.
Energy Vendor #1
Other Vendor #1
Contact made with LIHEAP provider to verify
previous crisis assistance.
Account Number:
Account/Voucher
Date:
Contact Person:
Number:
Date of contact:
Minimum Amount Due:
Amount Due:
Has the apolicant received LIHEAP crisis
Verification and Commitment
❑ Blanket ❑ Repair Existing Heating
If the minimum amount due is more than
❑ Portable Fan or Cooling Equipment
the past due amount, did the energy
Contact Person:
f�r❑ Emergency Shelter
vendor verify that this amount is required?
❑ Yes ❑ No ❑ N/A
Enemy Vendor#2
Other Vendor#2
Account Number:
AccounWoucher
Date:
If the minimum amount due to resolve the
Number:
crisis is more than the maximum allowed
($600), explain how the balance of the
Minimum Amount Due:
Amount Due:
amount due will be paid if approved for
EHEAP Crisis assistance.
Verification and Commitment
❑ Blanket ❑ Repair Existing Heating
❑ Portable Fan or Cooling Equipment
Contact Person:
❑ Emergency Shelter
(1) Total Energy Vendors $
(4) Total Other Vendors $ Is the name on the fuel bill that of the
(2) Energy Subsidy $
Total EHEAP Benefit applicants? ❑ Yes ❑ No
(3) Deduct (2) from (1) $
Add (3) and (4) $ If no, provide name on bill:
If the applicant is a homeowner, has he/she received more than three LIHEAP or EHEAP benefits in the last 18 months?
If the answer to the previous question is "yes", was the applicant referred to WAP? ❑ Yes ❑ No ❑ N/A
If the answer to the last question is "no", explain:
Section Nine: Resolution of Crisis
Resolution of the Heating/Cooling Energy
Crisis occurred within 18 hours, by the following eligible action: (Select all that apply)
❑ Approval of application
❑ EHEAP benefit prevented disconnection
❑ Commitment made to vendor
❑ EHEAP benefit restored energy already disconnected
❑ Denial of Application, pending additional information ❑ Yes client signed waiver
❑ Denial of Application, ineligible
❑ No client refused to sign waiver
❑ Written referral and assistance to access other communitv resources
Case Worker Sianature
I have determined the eligibility of the applicant.
Anoroval
I am not the The application eligibility • ed .
-documentation• determination
to I have
prior reviewed
friend,applicant, nor am I a - employee . - appropriate making payment.
Case Worker's Name: Supervisor/Peer's Name:
Case Worker's Signature:
Supervisor/Peer's Signature:
Date:
Dale:
Agency Name:
Agency Name:
hnhAY Zvi. 18
October 2018 — September 2019 ATTACHMENT XIX
EHEAP APPLICATION AND ELIGIBILITY INSTRUCTIONS
Department of Elder Affairs
Emergency Home Energy Assistance for the Elderly Program (EHEAP)
EHEAP Application Instructions
Section One: Annlicant (Age 60 and older) Information
Complete Section One in its entirety.
Special notes:
✓ The Date Stamp is the official application date;
✓ The Intake Worker (with name and phone number recorded) is the person who accepts the
application and required documentation;
✓ The applicant's income type(s) and monthly income amount is recorded in this section,and
✓ If any field is determined to be not applicable, complete the field by enteringN/A.
Section Two: Additional Household Members Information
Complete Section Two by listing additional household members and providing the information requested. Special notes:
✓ At a minimum, the name(s), age(s), and Social Security number(s) of each additional household member
is required;
✓ You will be attaching a calculator tape of the household's income calculations in the section
provided on the EHEAP Eligibility Worksheet; and
✓ If any field is determined to be trot applicable, complete the field by enteringN/A.
Section Three: Household Characteristics
Complete Section Three by answering each "Yes" or "No" question and providing additional information if applicable.
Special note:
✓ If airy field is determined to be not applicable, complete the field by enteringN/A.
Section Four: Heating and Cooling Information
Complete Section Four by answering each question. Special
note:
✓ Ifany field is determined to be not applicable, complete the field by enteringN/A.
Section Five: Energy Crisis Explanation
Section Five is completed by choosing the best possible explanation for the applicant's crisis and obtaining their signature
and date of signature.
Special note:
✓ If any field is determined to be not applicable, complete the field by enteringN/A.
Client Attestation and Signature
The applicant should read the attestation statement. If the applicant is unable to read the attestation statement, the intake
worker should read it to them before they sign and date the application.
At this point, the intake worker should have the applicant sign the waiver authorizing the release of general and/or
confidential information for LIHEAP/EHEAP federal reporting. CIRTS will require you to verify that either the
waiver has been signed or that the client has refused to sign.
October 2018 — September 2019
EHEAP Eligibilily Worksheet Instructions
hHt,Ar' 2U.5.16
Section Six: Broome Eligibility Determination
Complete Section Six by stapling the calculator tape in the space provided, entering the annual income, and checking
the appropriate number of individuals in the household to determine the household annual income limit.
Special notes:
✓ Adjacent to the annual income limit by household size is the fifty percent (50%) of poverty
amount by household size. If the annual household income is below the amount for the household
size, AND the household does not receive SNAP, the applicant must provide a written statement
of how basic living expenses are provided for the household.
✓ If any field is detervizined to be not applicable, complete the field by entei�iiigN/A.
Section Seven: Vendor. Benefit. and Verification Information
Complete Section Seven by completing in its entirety. Special notes:
✓ The minimum amount due is the amount provided to you during the verification process with the home
energy vendor.
✓ For those applicants receiving an energy subsidy, the minimum amount due will be reduced by the
energy subsidy amount listed on the applicant's public housing lease to determine the total EHEAP
benefit. The energy subsidy is deducted from home energy vendor payments only.
✓ It is allowable to make several crisis benefit payments for a household to resolve a single crisis. This may
include the purchase of blankets, portable fans, space heaters, and/or repair of existing heating/cooling
equipment, in addition to energy bill assistance, that combined does not exceed the maximum crisis
benefit of $600.
✓ Crisis situations that involve a heater or air conditioner that is powered by both gas and electricity are
eligible for a crisis benefit payment to both home energy vendors, that combined does not exceed the
maximum crisis benefit of $600.
✓ Allowable utility categories for heating/cooling bill assistance include the following:
a. Electricity;
b. Natural Gas;
e. Propane;
d. Wood/Coal; and
e. Refillable fuels;
✓ Crisis benefits may also be used for the following:
a. Pre -pay energy;
b. Purchase of blankets, portable fans, space heaters, and window air conditioners;
c. Repair of an existing heating/cooling unit;
d. Deposits to connect or restore energy;
e. Late fees and disconnect and reconnect fees;
f. Charges from a previous account held by the elder that is now closed;
g. Payment to landlord when utility costs are included in the elder's rent; and
h. Temporary emergency shelter, if due to energy related crisis.
✓ Water, sewer, and garbage MAY NOT be paid UNLESS included on the utility bill AND
REQUIRED by the home energy vendor to maintain service.
✓ Charges incurred due to illegal activities, such as a worthless check or meter tampering, MAY NOT be
paid with EHEAP funds.
✓ If any field is determined to be not applicable, complete the field by enteringN/A.
84
LHLAY LU}.125
October 2018 — September 2019
Section Fight: Weatherization Assistance Program (WAP) Referral
Complete Section Eight in its entirety.
Special notes:
✓ When determining the number of LII3EAP or EHEAP crisis benefits the applicant has had, you will
include the current application in the count, provided the application is approved. Refer back to Section
Seven, to the information obtained from the LIHEAP provider.
✓ If airy field is detei•iiiirred to be not applicable, complete the,fie7d by eiateringN/A.
Section Nine: Resolution of Crisis
Complete Section Nine by selecting all that applies to this applicant and application for services. Special
notes:
✓ The left-hand selections indicate that the application has been acted upon within the 18 -hour
requirement.
✓ If the selection is made to deny the application pending additional information from the client, the 18 -
hours has been met and does not repeat itself when the client returns with the pending information.
You have already met the requirement.
✓ If any field is determined to be riot applicable, complete ihe,fteld by enter•iiagN/A.
To complete this section, the individual who completes the EHEAP Eligibility Worksheet, determines income eligibility,
and provides the commitment to the utility vendor must sign and complete the requested information.
Special note:
✓ If you are the applicant, or a friend, relative, or employee of the applicant, you cannot determine the
eligibility or award EHEAP benefits. This application must be processed by someone who is not the
applicant or a friend, relative, or employee of the applicant.
AUuroval Signator
To complete this section, the signer is attesting that he/she has reviewed the application for completeness, determined
that all required documentation is included, and verified that the annual household income calculation and EHEAP
benefit awarded are correct.
hLir,Hr /U.s.Ia
October 2018 — September 2019 ATTACHMENT XX
EHEAP CLIENT FILE CONTENT CHECKLIST
ELDER'S NAME
PSA#
AGENCY
APPROVAL
DENIAL
NAME OF WORKER
APPLICATION: DATE
CRISIS RESOLUTION DATE ;
CHECK DATE
PROGRAM REQUIREMENTS MONITORED
Yes
No
N/A
COMMENTS
L Individual client file for the elder includes consumer's name, address, sex, and age.
2. Household contains a member 60 or older.
3. The household is in the Florida county covered by the contract.
4. All household members are listed and their name, age, DOB, and income(s) are included.
5. Client file contains documentation of Social Security numbers for all household members, or citation
to the applicable exemption.
6. Client file contains signed notice regarding collection of social security number(s).
7. The client file contains official income documents for all household members.
8. If income is self -declared, is there a self -declaration form signed by each individual household member
(18 years of age or older) lacking income verification or claiming zero income?
9. The household's total gross income is calculated correctly and is at or below 150% of the OMB Federal
Poverty Level for the household size.
10. Statement of how basic living expenses (i.e., food, shelter and transportation) are being provided if total
household income is less than 50% of the current Federal Poverty Guidelines and no one in the household
is receiving SNAP assistance.
11. Checked that elder does not live in student dormitory, adult family care home, or any kind of group
living facility.
12. Verified and documented household has not received LIHEAP Crisis Assistance during the same heating
or cooling season.
13. Documentation of Weatherization Assistance Program (WAP) referral, if applicable.
14. Copies of fuel bills, or other supporting documentation as proof of energy crisis, for the residence in
which they reside.
15. Signed copy of Authorization for Release of General and/or Confidential Information.
16. Only energy related elements of a utility bill are paid unless required to resolve the crisis.
17. Only the minimum necessary to resolve the crisis is paid. If a different amount is required by the utility
company, provide additional information on the Eligibility Worksheet.
18. Crisis energy benefit was reduced by energy subsidy, if applicable.
19. Energy crisis resolved within 18 hours by an eligible action.
20. Written notice of approval or denial for services that includes appeal procedures is issued within 15
working days of eligibility determination.
21. Appropriate benefit provided, at or below $600.00.
22. All required sections of the application are signed and dated by the elder, staff, and supervisory/peer
PRIOR to payment.
23. Proof of payment to vendor.
24. Place completed DOEA Form 211 (10/01/18) in client file.
Mo
October 2018 — September 2019
ATTACHMENT XXI
I2,111SAY 2,V.5. 115
EHEAP COST REIMBURSEMENT SUMMARY
Contract #
Report Period:
Budget
Category
Description
Numer of units
Amount
v
TOTAL ADMINISTRATION
$0.00
rO
_..
_ _.. ._., .....
..__. __._..
.._._ ..._... __.
TOTAL OUTREACH
$0.00
0
N
TOTAL CRISIS ASSISTANCE
:/
I
lw
8
y
m
e
F
m
E
E
n
gw
ry
�
PAY
i
c y
�
$
n
s�
p 00
e
Vi
� 6
e$
c
�S
u
g§
e
6
$
o
�
n
o
5 �
r
fia
8
@
S
$
L S
sE
a8
°
os
$�
_„
E b
nagc
c o
EE
2
i �+
N
uaPNoid
lP
)�fl^
.•
a
UOR949IuIwPtl
$
m
8
nn
nn
nn
nn
October 2018 — September 2019
ATTACHMENT XXIV
SERVICE RATE REPORT
hithAY 6u.5. t iS
PROGRAM: EMERGENCY HOME ENERGY ASSISTANCE FOR THE ELDERLY PRORAM (EHEAP)
Federally Funded
From 10/01/2018 to 09/30/2019
Category
METHOD OF
HIGH
SERVICE
PAYMENT
REIMBURSEMENT
UNIT TYPE
RATE
Administration
ADMINISTRATIVE
Cost
Cost Reimbursement
EPISODES
COSTS*
Reimbursement
Outreach
OUTREACH COSTS*
Cost
Cost Reimbursement
EPISODES
Reimbursement
Crisis
CRISIS ENERGY
Cost
Assistance
ASSISTANCE BENEFITS*
Reimbursement
Cost Reimbursement
EPISODES
*As stipulated in contract, these services are provided on a cost reimbursement basis.
N
16.D.6.cPacket Pg. 942Attachment: EHEAP 203.18.001 Executed (8666 : LIHEAP-MOU with ALPI)
16.D.6.cPacket Pg. 943Attachment: EHEAP 203.18.001 Executed (8666 : LIHEAP-MOU with ALPI)
16.D.6.cPacket Pg. 944Attachment: EHEAP 203.18.001 Executed (8666 : LIHEAP-MOU with ALPI)
16.D.6.cPacket Pg. 945Attachment: EHEAP 203.18.001 Executed (8666 : LIHEAP-MOU with ALPI)