Backup Documents 11/10/2009 Item #16D 4
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 0 ).
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE 'f.
Print on pink paper. Attach to original document. Original documents should he hand delivered to the lJoard Office. The completed routing slip and original
document<; arc to be forwarded to the Board Oftice only after the Board has taken lldion on the item.)
ROUTING SLIP
Complete routing lines # I through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
exceotion of the Chainnan's SI2Dature, draw a line throuet routine. lines # I throueh #4, comolete the checklist, and torward to Ian Mitchell.
Route to Addressee(s) Office Initials Date
(List in routine. order)
I.
2.
3.
4.
5.1an Mitchell, Supervisor Bee Office Board of County Commissioners v'~-- llll') lo'}
6. Minutes and Records- Clerk of Court's Office
PRIMARY CONT ACT INFORMATION
(The primary contact is the holder oftbe original document pending Bee approval. Normally the primary contact is the person who created/prepared the executive
summary. Primary contact information is needed in the event one of the addressees above, including Sue Filson, need to contact staff for additional or missing
information. All original documents needing the Bec Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the
item.)
Name of Primary Staff Wendy Klopf, Operations Coordinator Phone Number 252-2901
Contact
Agenda Date Item was November 10, 2009 Agenda Item Number 16D4
Approved bv the BCC
Type of Document Certifications-Challenge Grant-Return Number of Original I
Attached Original Certifications to be sent to DCF Documents Attached
1.
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
a ro riate.
Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman, with the exception of most letters. must be reviewed and signed
by the Office of the County Attorney. This includes signature pages from ordinances,
resolutions, etc. signed by the County Attorney's Office and signature pages from
contracts, agreements, etc. that have been fully executed by all parties except the BCC
Chairman and Clerk to the Board and ossibl State Officials.)
All handwritten strike-through and revisions have been initialed by the County Attorney's
Office and all other arties exce t the BCC Chairman and the Clerk to the Board
The Chairman's signature line date ha, been entered as the date ofBCC approval of the
document or the final ne otiated contract date whichever is a licable.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si nature and initials are re uired.
In most cases (some contracts are an exception), the original document and this routing slip
should be provided to Sue Filson in the BCC office within 24 hours of BCC approval.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCe's actions are nullified. Be aware of our deadlines!
Tbe document was approved by tbe BCC on November to. 2002(enter date) and all
cbanges made during tbe meeting bave been incorporated in tbe attached document.
Tbe Count Attorne 's Office bas reviewed the cban es, if a licable.
Yes
(Initial
WK
N/ A (Not
A licable)
2.
3.
4.
5.
6.
WI<
WK
WI<
NA
WI<
I: Forms! County Forms! Bee Forms! Original Document.. Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
16D4
MEMORANDUM
Date:
November 13, 2009
To:
Wendy Klopf, Operations Coordinator
Housing & Human Services
From:
Teresa Polaski, Deputy Clerk
Minutes & Records Department
Re:
Challenge Grant
Attached are three originals of the document referenced above (Item
#16D4) that was approved by Board of County Commissioners on
Tuesday, November 10, 2009.
If you should have any questions, please contact me at 252-8411.
Thank you.
Attachments
16 D 4: '.
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Fk>rtd..Dep...~Qf
(hikJren & FannIMt
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State of Florida
Department of Children and Families
Cherlte Crist
Governor
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,
Robert A. Butt_ortl'!
Secretary
,
.
VERIFICATION OF
PROVlDERSUBCONTRACTINGSTATUS
CONTRACT MANAGER COMPLETE THE FOLLOWING:
Provider Name:
Grant Number:
In accordance with the provisions of Section 1.1 of the Standard Contract:
o This contract allows the provider to contract for the provision of all services under this
contract.
Nicholas B. Cox
SunCoast Region Director
o This contract does not allow the provider to subcontract for the provision of any services
under this contract,
o This contract allows the provider to subcontract for the provision of the following services
under this contract:
Contract Mananer Sinnatura
Date
PROVIDER SELECT ONE OF THE FOLLOWING:
_No work is currently performed by subcontractors for the services which are under
contract or there is currently no intent to subcontract for contracted services being
negotiated with the department.
_X Subcontractors are currently performing services which are under contract or there is an
rntentto subcontract for conlracted services being negotiated with the department.
X Please provide a list of those services: 0 e-t' 0 l+c. c \-, c>, 1
The provider understands that if the Department allows subcontracting, and the provider .
chooses tCj!flubcontract any of the contracted services, the provider snail submit a written
~~~~e~n:::.~:~ct f~:;~~~'~:o;:ton of services to the Contract Manager f~r Department
~ - \\~\L;\lC;(j'1
Signature of provider personnel authorized ate
to legally bind the provider n, ..; ~ 1 ~ ,,'" ~ ;
o
Pr ram Office Si natura
Date
Approved as to form & legal sufficiency P.O. Box 60085. Fort Myers, Florida 33906-00
\ '
\ Vulnerable, Promote Strong and Economically ~~_' &'lCl8rk. r
Colleen Greene, dvance Personal and Family Recovery and Resl n '" l:Jr::....
'-' ' .
Assistant County Attorney .. W ' ..-,
l'lJf\.tllr'tOfl'" '
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16D4
AlIachment
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND
COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or an employee
of any agency, a member of congress, an officer or employee of congress, or an employee of
a member of congress in connection with the awarding of any federal contract, the making of
any federal grant. the making of any federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any
federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a member of
congress, an officer or employee of congress, or an employee of a member of congress in
connection with this federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in
accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.
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Signature
~8BRh~ifzl~ ~R~irffiaB
eme 0 U or ze rfdlv us
Appllcatlon or Contract Number
Collier County, Board of Commissioners
Name of Organization
i~g1 ~ Ta~~3mi Trail, N3~leE, FL, 34112
(tress oTOrgan za Ion
CF 1123. PDF 03196
Approved as to form & legal sufficiency
0j)(~~
U Colleen Greene.
Assistant County Attorney
E.3HOC Glei'!;.pa~
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.I' to. CJl4-'"- .
16D4
Attachment
Contract No.
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,
signed February 18, 1986. The guidelines were published in the May 29, 1987 Federal Register (52 Fed. Reg., pages
20360 - 20369).
INSTRUCTIONS
1. Each provider whose contract/subcontract equals or exceeds $25,000 in federal moneys must sign
this certification prior to execution of each contract/subcontract. Additionally, providers who audit
federal programs must also sign, regardless of the contract amount. The Department of Children
and Families cannot contract with theselypes of providers if they are debarred or suspended by the
federal government.
2. This certification is a material representation of fact upon which reliance is placed when this
contract/subcontract is entered into. If it is later determined that the signer knowingly rendered an
erroneous certification, the Federal Government may pursue available remedies, including
suspension and/or debarment.
3. The provider shall provide immediate written notice to the contract manager at any time the
provider learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
4. The terms "debarred", "suspended", "ineligible", "person", "principal", and "voluntarily excluded", as
used in this certification, have the meanings set out in the Definitions and Coverage sections of
rules implementing Executive Order 12549. You may contact the department's contract manager
for assistance in obtaining a copy of those regulations.
5. The prOVider agrees by submitting this certification that, it shall not knowingly enter into any
subcontract with a person who is debarred. suspended, declared ineligible, or voluntarily excluded
from participation in this contract/subcontract unless authorized by the Federal Government.
6. The provider further agrees by submitting this certification that it will require each subcontractor of
this contract/subcontract, whose payment will equal or exceed $25,000 in federal moneys, to
submit a signed copy of this certification.
7. The Department of Children and Families may rely upon a certification of a provider that it is not
debarred, suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it
knows that the certification is erroneous.
8. This signed certification must be kept in the contract manager's contract file. Subcontractor's
certification must be kept at the provider's business location.
CERTIFICATION
(1) The prospective provider certifies, by signing this certification, that neither he nor his principals is
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract by any federal department or agency.
(2) Where the prospective provider is unable to certify to any of the statements in this certification,
such prospectil/EYProvider shall attach an explanation to this certification.
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Date
Signature
D{)nn~ F;~l;:t
Name (type or print)
Ch~irmrln
. Tille
CF 1125, PDF 09/20
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