Backup Documents 06/23/2020 Item #16D11ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16011
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines # 1 through #2 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
exception of the Chairman's signature, draw a line through routinglines # 1 through #2 complete the checklist and forward to the Coun Attorney Office
Route to Addressees (List in routing order)
Office
Initials
Date
1. Wendy Klopf
Community and Human
Services
Wk
06/23/20
2. Minutes and Records
Clerk of Court's Office
—T�A
UZUm—
q:Afr,
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above, may need to contact staff for additional or missine information.
Name of Primary Staff
Wendy Klopf/CHS
Phone Number
252-2901
Contact / Department
Agenda Date Item was
06/23/20
Agenda Item Number
16DI I
Approved by the BCC
Type of Document
Amendment OAA 203.20.003
Number of Original
1
Attached
Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
Yes
N/A (Not
a ro riate.
Initial
Applicable)
1.
Does the document require the chairman's original signature?
NA
2.
Does the document need to be sent to another agency for additional signatures? If yes,
NA
rovide the Contact Information(Name; Agency; Address; Phone on an attached sheet.
3.
Original document has been signed/initialed for legal sufficiency. (All documents to be
WK
signed by the Chairman, with the exception of most letters, must be reviewed and signed
bv the Office of the County Attorney.
4.
All handwritten strike -through and revisions have been initialed by the County Attorney's
NA
Office and all other parties except the BCC Chairman and the Clerk to the Board
5.
The Chairman's signature line date has been entered as the date of BCC approval of the
NA
document or the final negotiated contract date whichever is applicable.
6.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
WK
si nature and initials are required.
7.
In most cases (some contracts are an exception), the original document and this routing slip
NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8.
The document was approved by the BCC on 06.23.20 and all changes made during
WK
the meeting have been incorporated in the attached document. The County
Attorne 's Office has reviewed the changes, if applicable.
9.
Initials of attorney verifying that the attached document is the version approved by the
WK
BCC, all changes directed by the BCC have been made, and the document is ready for the
Chairman's signature.
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05; Revised 11/30/12
16011
OAA 203,20.003
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
OLDER AMERICANS ACT TITLE III
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
TIiIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. ("Agency") and Collier County
Board of County Commissioners ("Contractor"), amends agreement OAA 203.20.
The purpose of this amendment is to add Families First Act COVID-19 C I & C2 funding by amending 4. Contract Amount,
Collier County: increase allocations for COViD-19 Cl by $ 91,668.32, increase allocations for COVID-19 C2 by $ 170,293.92; add
Shopping Assistance and Telephone Reassurance; include billing report documentation; and revise ATTACHMENT II -EXHIBIT 2-
Funding Summary and revise ATTACHMENT IX BUDGET AND RATE SUMMARY.
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 SI,492,677.23 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.
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed to conform
to this Amendment.
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the contract.
This Amendment and all its attachments are hereby made part of the contract.
IN WITNESS THEREOF, the Parties hereto have caused this amendment, to be executed by their undersigned officials as duly
authorized; and agree to abide by the terms, conditions and provisions of this OAA contract as amended. The Telephone Assurance
and Shopping Assistance is effective as of March 23, 2020 and the C I and C2 Meals are effective
April 1, 2020.
Contractor: COLLIER COUNTY BOARD
OF COUNTY C MI IONrRS
SIGNED BY:
NAME: STEPHEN Y CARNELL
TITLE: PUBLIC SERVICE DEPARTMENT HEAD
F
DATE: 041 .' 1 12020
Federal Tax ID: 59-6000558
Fiscal Year Ending Date: 09/30
Duns: 076997790
AREA AGENCY ON AGING FOR
SOUTHWEST FLORIDA, INC.
SIGNED BY: OatA2__ry-ommuL
TITLE: PRESIDENT/CEO
DATE: 0 q- 2 9- 2 0 2 0
Approved as to form and legality
Assistant County Altvnl y--
16011
OAA 203.20.003
ATTACHMENT II -EXHIBIT 2
FUNDING SUMMARY
Note: Ti tie 2 CFR § 20033 I,as revised, and Section 215 97(5), F,S,, requi re that the information about federal programs and State Projects be
provided tothe Recipient and are stated in The Financial And Compliance Audit Attachment 11, Exhibit I provided to the recipient. Information
contained herein is a predict ion offinding sources and related amounts based on the contract budget.
FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS CONTRACT CONSIST
OF THE FOLLOWING:
COLLIER COUNTY
GRANT AWARD FAIN#): 2001FLOASS, 2001 FLOACM, 2001FLOAHD, 2001FLOAPH, 2001FLOAFC
DUNS NUMBER-076997790
FEDERAL AWARD DATE: OCTOBER 01, 2019
PROGRAM TITLE
FUNDING SOURCE
CFDA
AMOUNT
Older Americans Act Title 11I13 —
Transportation
U.S. Health and Human Services
93,044
$ 9,863.90
Support Services
$ 375,156.79
$ 385,020.69
Total IIIB
OAA Title I11C 1 — Congregate Meals
U.S. Health and Human Services
93.045
$ 341,322.29
Total HIC1
OAA Title III C2 -- Home Delivered Meals
U.S. Health and Human Services
93.045
$ 301,442.67
Total IIIC2
Older Americans Act Title III E
Services (Title III E)
93AS2
$ 96,240.61
Supplement Services (Title III ES)
U.S. Health and Human Services
$ 53,951.15
Grandparent Services (Title III EG)
$ 6,000.55
Total IIIE
$ 15G 192.31
Nutrition Services Incentive Program (NSIP)
U.S. Health and Human Services
93.053
$ 46,737.03
Family First Act
U.S. Health and Human Services
93.045
$ 91 668.32
'
COVID-19 Congregate Meals"
Family First Act
U.S. Health and Human Services
93.045
$ 170,293.92
COVID-19 Home Delivered Meals"
TOTAL FEDERAL AWARD
$1,492,677.23
"Effective April 1, 2020
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT TO
THIS CONTRACT ARE AS FOLLOWS:
FEDERAL FUNDS:
2 CFR Part 200Uniform 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.
COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO THIS
CONTRACT ARE AS FOLLOWS:
STATE FINANCIAL ASSISTANCE
Section 21597 & 215.971, 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
S,
16011
OAA 203.20.003
ATTACHMENT IX
BUDGET AND RATE SUMMARY
OLDER AMERICANS ACT BUDGET SUMMARY
CONTRACTOR: COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY
1. Title III B Support Services
$
385,020.69
2. Title III C1 Congregate Meals**
$
341,322.29
3. Title III C2 Home Delivered Meals**
$
301,442.67
4. Title III E Services
$
156,192.31
5. NSIP
S
46,737.03
6. COVID-19 CI**
$
91,668.32
7. COVID-19 C2**
$
170,293,92
TOTAL
$
1,492,677.23
** Effective April 1, 2020: All current CI clients will be converted to the COVID-19 C1 funds for their meals.
** Effective April 1, 2020: All current C2 clients will be converted to the COVID-19 C2 funds for their meals.
** Effective April 1, 2020: All new clients will be added to the COVID-19 C2 funds for their meals. All new 60+
and Adults with disabilities receiving meals (Must have a 701C completed).
16011
OAA 203.20.003
ATTACHMENT IX
BUDGET AND RATE SUMMARY
COLLIER
IIIB
SERVICE
REIMBURSEMENT
UNIT RATE
METHOD OF
PAYMENT
UNIT
TYPE
CASE MANAGEMENT
$54.00
Fixed Fee/Unit Rate
HOURS
CHORE
$22.29
Fixed Fee/Unit Rate
HOURS
EMERGENCY ALERT RESPONSE
$ 1.35
Fixed Fee/Unit Rate
DAYS
HOMEMAKER
$22.55
Fixed Fee/Unit Rate
HOURS
HOUSING IMPROVEMENT
Cost Reimbursement
90% of Cost
EPISODE
MATERIAL AID
Cost Reimbursement
90% of Cost
EPISODE
PERSONAL CARE
$23.48
Fixed Fee/Unit Rate
HOURS
RESPITE IN - HOME
$23.27
Fixed Fee/Unit Rate
HOURS
SKILLED NURSING SERVICES
$38.06
Fixed Fee/Unit Rate
HOURS
SPECIALIZED MEDICAL
EQUIPMENT, SERVICES,
Cost Reimbursement
90% of Cost
EPISODE
TRANSPORTATION
Cost Reimbursement
100% of Cost
TRIPS
SHOPPING ASSISTANCE***
$34.12
Fixed Fee/Unit Rate
ONE-WAY
TELEPHONE REASSURANCE***
$13.40
Fixed Fee/Unit Rate
EPISODE
***Effective Match 23, 2020
16011
OAA 203.20.003
ATTACHMENT IX
BUDGET AND RATE SUMMARY
COLLIER COUNTY
IIIE, IIIES, & IIIEG
SERVICE
REIMBURSEMENT
UNIT RATE
METHOD OF
PAYMENT
UNIT
TYPE
IIIE-- ADULT DAY CARE
$12.76
Fixed Fee/Unit Rate
HOURS
RESPITE IN -HOME
$23.27
Fixed Fee/Unit Rate
HOURS
RESPITE IN -FACILITY
$11.05
Fixed Fee/Unit Rate
HOURS
SCREENING & ASSESSMENT
$55.17
Fixed Fee/Unit Rate
HOURS
SHOPPING ASSISTANCE***
$34.12
Fixed Fee/Unit Rate
ONE-WAY
"TELEPHONE REASSURANCE***
$13.40
Fixed Fee/Unit Rate
EPISODE
IIIES-- CHORE
$22.29
Fixed Fee/Unit Rate
HOURS
Specialized Medical Equipment,
Service & Supplies
Cost Reimbursement
90% of Cost
EPISODE
MATERIAL AID
Cost Reimbursement
90% of Cost
EPISODE
IIIEG--CHII.D DAY CARE
$15.00
Fixed Fee/Unit Rate
HOURS
SCREENING AND ASSESSMENT
$55.17
Fixed Fee/Unit Rate
HOURS
SHOPPING ASSISTANCE***
$34.12
Fixed Fee/Unit Rate
ONE-WAY
TELEPHONE REASSURANCE***
$13.40
Fixed Fee/Unit Rate
EPISODE
***Effective March 23, 2020
16011
OAA 203.20.003
ATTACHMENT IX
BUDGET AND RATE SUMMARY
C-I & C-2
COLLIER COUNTY
SERVICE
REIMBURSEMENT
UNIT RATE
UNIT TYPE
Cl -- CONGREGATE MEALS
$11.72
MEALS
NUTRITION EDUCATION
$ LS9
PARTICIPANTS
CONGREGATE MEAL SCREENING
$28.00
HOUR
OUTREACH
$4.32 PER PERSON
EPISODE
SHOPPING ASSISTANCE***
$34.12
ONE-WAY TRIPS
TELEPHONE REASSURANCE***
$13.40
EPISODE
SERVICE
REIMBURSEMENT
UNIT RATE
UNIT TYPE
C2 -- HOME DELIVERED MEALS
$ 8.07
MEALS
NUTRITION EDUCATION
$ 1.59
PARTICIPANTS
SCREENING & ASSESSMENT
$48.76
HOUR
OUTREACH
$4.32 PER PERSON
EPISODE
SHOPPING ASSISTANCE***
$34.12
ONE-WAY TRIPS
TELEPHONE REASSURANCE***
$13.40
EPISODE
***Effective March 23, 2020
16011
OAA 203.20.003
ATTACHMENT IX
BUDGET AND RATE SUMMARY
FAMILIES FIRST ACT
COLLIER COUNTY
COVID-19 C1 & C2
FA\-IILIES
CONGREGATE NIEALS***
Cost Reimbursement
Cost
Reimbursement
MEALS
FIRST ACT
HO\4E DELIVERED NPIEALS***
Cost Reimbursement
Cost
14EALS
Reimbursement
***Effective April 1, 2020
f f��
16011
OAA 203.20.003
Page 1
REQUEST FOR PAYMENT
OLDER AMERICANS ACT
TYPE OF REPORT:
PROVIDER NAME, ADDRESS, PHONE & FED ID
Contract #
Advance
Contract Period:
Reimbursement
Report Period
Report #
PSA
Invoice #
CERTIFICATION: I hereby certify to the beMJ my kn mVedge that this request conforms with the terms and the purposes set forth In the above contract.
Prepared By: Date: Approved By. Date:
PART A:
(1)
(2)
(3)
(4)
(5)
(6)
BUDGETSUMMARY
1116
IIICI
IIIC2
IIIE
NSIP
TOTAL
I. Approved
Contract Amount
0.00
0.00
0.00
0,00
0.00
0,00
2. Previous Funds
RECENED for
Contract period
0.00
0.00
O.OD
0.co
0.00
0.00
3. Contract Balance
0.00
0.00
0.00
000
0.00
0.00
(Line 1 minus fine 2)
4. Previous Funds
REQUESTED and
Not Received.
0,00
0.00
0.00
0.o0
0.00
0.00
S. Contract Balance
0.00
0.00
0.00
0.00
0.00
0.00
(Line 3 minus sne 4)
PART B:
FUNDS REQUESTED
1. 1 st-2nd Months
Request Only
0.00
0.00
0.00
0.00
0.00
0.00
2. Net Expenditures
For Month
0.00
0.00
0.00
0.00
0.00
0.00
3. Total
0.00
0.00
0.00
0.00
0.00
0,00
PART C:
NET FUNDS REQUESTED:
1. Less: Over -Advance
0.00
0.00
0.00
0.00
0.00
0.00
2. Contract Funds are
Hereby Requested
0.00
0.00
0.00
0.00
0.00
0,00
for page 1
C1-COVID19
C2-CO1,7D19
3. Contract Funds are
Hereby Requested
0.00
0.00
0.00
for page 2
GRAND TOTAL REQUESTED
0.00
0.00
0.01)
0.00
0.00
0.00
List of Services I Units 1 Rates provided - See attached report.
DOEA Use Only
DOER FORM 106A revised 4/20120
IV 11
OAA 203.20.003
Pape 2
REQUEST FOR PAYMENT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHONE & FED ID
Contract#
Contract Period:
Report Period
Report 0
Invoice#
CERTIFICATION: I hereby certify to the hest of my knoMedga that this request conforms with the terms
and the purposes set forth in the above contract.
Prepared By. Date:
Approved By:
Date:
PART A:
(1)
(2)
BUDGET SUMMARY
IIICI - COVIDI9
IIIC2 - COVIDIB
TOTAL
L Approved
Contract Amount
0.00
0.00
0,00
2. Previous Funds
RECEIVED for
Contract period
0.00
0.00
0,00
3. Contract Balance
0.00
0.00
0.00
(Line I minus tine 2)
4. Previous Funds
REQUESTED end
Nat Received.
0.00
0.00
0-00
5. Contract Balance
0.00
0.00
0.00
(Line 3 minus line 4)
PART 9:
FUNDS REQUESTED
1. 1 st-2nd Months
Request Only
0.00
0.00
0.00
2. Net Expenditures
For Month
0-00
0.00
0.00
3. Total
0.00
0.00
0.00
PART C:
NET FUNDS REQUESTED:
1. Less: Over -Advance
0.00
0.00
0.00
2. Contract Funds are
Hereby Requested
0.00
O.OD
0.00
for page2
List of Services 7 Units I Rates provided - See attached report -
ODEA Use Only
0011A FORM 106A revised 4120120
16011
OAA 203.20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHONE# ANO FEID#
PROGRAM FUNDING SOURCE:
Contract #
a
0
TiUe Ill
Contract Period:
0
0
I €!
B
Report Period
0
0
PSA
Report #
0
0
invoice #
0
CERTIFICATION: I certify to the best of my knowledge and
belief that this report is compete and all outlays herein are for purposes set forth
in the contract.
Prepared by : Date :
Approved by :
-Date:
PARTA : BUDGETED INCOME/ RECEIPTS
1. Approved Budget
2. Actual Receipts
3. Total Receipts
4. Percent of
For This Report
Year to Date
Approved Budget
1. Federal Funds
$0.00
$0.00
$0,00
#DIV/0!
2. State Funds
$0.00
$0.00
$0.00
#DIVI01
3. Program Income - Non Match
$0.00
S0.00
$0.00
4DIVI01
4. Local Cash Match
$0,00
$0.00
$0.00
#DIVIO!
5. SUBTOTAL: CASH RECEIPTS
$0.00
$0.00
$0,00
#DIVIO!
6. Local in -Kind Match
S0.00
$0.00
$0,00
#DIVIO!
7. TOTAL RECEIPTS
$0.00
$0.00
$0.00
#DIVIO!
PART B : EXPENDITURES
1. Approved Budget
2. Expenditures
3. Expenditures
4. Percent of
For This Report
Year to Date
Approved Budget
1. AAA Direct Services
$0.00
$0.00
SQ00
#DIVIO!
2. Subcontractor
$0.00
$0.00
$0.00
#DIVIO!
3. IIIB Set Aside
$0,00
$0.00
S0.00
#DIVIO!
4. IIIB Set Aside Di (Disaster Recovery Reserve)
$0.00
$0.00
50.00
#DIVIO!
5. TOTAL EXPENDITURES
$0.00
$0.00
$0.00
#DIVIO!
PART C : OTHER EXPENDITURES
1. Approved Budget
2. Expenditures
3. Expenditures
4. Percent of
(For Tracking Purposes only)
For This Report
Year to Date
Approved Budget
1. Match
a. Other and In -Kind
$0.00
$0.00
$0.00
#DIVIO!
b. Local Match
$0.00
$0.00
SO.00
#DIV10!
2. Program Income
$0.00
$0.00
$0.00
4DIV101
3. TOTAL OTHER
$0.00
$0.00
$0.00
4DIV10!
PART D: INTEREST
1. Earned on Advances $0.00
2. Return on Advances $0.00
3. Other Earned $0.00
OOEA FORM 105as418 lewd 4120120
10
P t
16011
OAA 203,20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHONE# AND FEID#
PROGRAM FUNDING SOURCE:
Contract #
0
0
Title III
Contract Period:
0
0
C1
Report Period
0
0
PSA
Report #
0
0
Invoice #
0
CERTIFICATION- I certify to the best of rrty knrnW,edge and
belief that this report is complete and al outlays herein are for purposes
set forth
in the contract.
Prepared by : Date :
Approved by
Date
PART A : BUDGETED INCOME! RECEIPTS
1. Approved Budget
2. Actual Receipts
3. Total Receipts
4. Percent of
For This Report
Year 10 Date
Approved Budget
1. Federal Funds
$0.00
$0.00
$0.00
#DIV101
2. Stale Funds
$0.00
SO.00
Saw
#DIVIO!
3. Program Income - Non Match
SO.00
$0.00
$0.00
#DIVIO!
4. Local Cash Match
$0.00
$0.06
KID
#DIVIO!
5. SUBTOTAL CASH RECEIPTS
$0.00
$0.00
S0.00
#DIV/O!
6. Local In -Kind Match
$0.00
$O.OD
$0.00
#DIV10!
7. TOTAL RECEIPTS
$0.00
$0.00
$0.00
#DIV10!
PART B : EXPENDITURES
1. Approved Budget
2. Expenditures
3. Expenditures
4, Percent of
For This Report
Year to Date
Approved Budget
1. Subcontractor
$0,00
$0.00
Saw
#DIV101
2. CI Set Aside ORR (Disaster Recovery Reserve)
$0.00
$0.00
$0.00
#DIVIO!
3. TOTAL EXPENDITURES
$0.00
$0.00
$0.00
#DIVI01
PART 0: OTHER EXPENDITURES
1. Approved Budget
2. Expenditures
3. Expenditures
4. Percent of
(For Tracking Purposes only)
For This Report
Year to Date
Approved Budget
1, Match
a. Other and In -Kind
$0.00
S0.00
SO.DO
#DIV101
b- Local Match
$0,00
$0.00
$O.DO
#DIVIO!
2, Program income
$0.00
$0.00
S0.D0
#DIV101
3. TOTAL OTHER
$0.00
$0.00
$0.00
#DIV/O!
PART D:INTEREST
1. Earned on Advances $0.00
2. Return on Advances $0.00
3. Other Earned $0.00
DOEA FOlud 1a$9s-01 (OsCd 4120120
t�
16011
OAA 203.20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHONE# AND FEID#
PROGRAM FUNDING SOURCE:
ConVact #
0
0
Title III
Contract Period:
0
0
C1- COVID19
Report Period
0
0
PSA
Report #
0
0
Invoice #
0
CERTIFICATION: I certify to the best of my knmVfedge and belief that this report is complete and all outlays herein are for purposes set forth
in the contract.
Prepared by: -Date: Approved by: Date
PART A . BUDGETED INCOME] RECEIPTS
1. Approved Budget
2. Actual Receipts
3. Total Receipts
4. Percent of
For This Report
Year to Date
Approved Budget
1. Federal Funds
$0.00
$0.00
U.00
#DIV101
2. Program Income - Non Match
$0.00
$0.00
$0.00
#DIVl01
3. SUBTOTAL CASH RECEIPTS
$0,00
$0.00
$0.00
#DIVIO!
4. TOTAL RECEIPTS
$0.00
$0.00
$0.00
#DIVIO!
PART B : EXPENDITURES
1. Approved Budget
2, Expenditures
3. Expenditures
4. Percent of
For This Report
Year to Date
Approved Budget
1. Subcontractor
$0.00
$0,00
SO.00
#DIVIO!
2. TOTAL EXPENDITURES
SO.00
$0.00
$0.00
#DIVIO!
PART C : OTHER EXPENDITURES
1. Approved Budget
2. Expenditures
3. Expenditures
4. Percent of
(For Tracking Purposes only)
For This Report
Year to Date
Approved Budget
1, Program Income
$0.00
$0.00
$0.00
#DIVIO!
2. TOTAL OTHER
$0.00
$0.00
$0.00
#DIVIO!
DOEA E0R11 105as-C 1-CV reused 4R0/2020
12>
16011
OAA 203,20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHDNE# AND FEID#
PROGRAM FUNDING SOURCE:
Contract #
0
0
Tice III
Contract Period:
0
0
C2
Report Period
0
0
PSA
Report #
0
0
Invoice #
0
CERTIFICATION: I certify to the best of my knoWedge and
befef that this report Is corrplele and al outlays herein are for purposes
set forth
in the contract.
Prepared by : -Date:
Approved by :
Dale
PARrA : BUDGETED INCOME/ RECEIPTS
1. Approved Budget
2. Actual Receipts
3. Total Receipts
4. Percent of
For This Report
Year to Date
Approved Budget
1. Federal Funds
$0.00
$0.DO
$0.00
NDIV101
2. State Funds
$0.00
$0.00
$0.00
#DIV101
3. Program Income - Non Match
$0.00
$0.00
$0.00
#DIV/01
4. Local Cash Match
$0.00
$0.00
$0.00
#DIV/01
5. SUBTOTAL: CASH RECEIPTS
$O.DD
$0.00
$0.00
#DIV101
6. Local In -Kind Match
$0.00
$0.00
$0.00
#DIVl01
7. TOTAL RECEIPTS
$0.00
$0.00
$0.00
#DIVI01
PART B : EXPENDITURES
1. Approved Budget
2. E)pendlures
3. F)erhdilures
4. Percent of
For This Report
Year to Date
Approved Budget
1. Subcontractor
WOO
S0.00
$0.00
#DIV101
2. C2 Set Aside DRR (Disaster Recovery Rose")
$0.00
$0.00
$0.00
#DIV101
3. TOTAL EXPENDITURES
$0.00
$0.00
$0.00
#DIVIO!
PART C : OTHER EXPENDITURES
1. Approved Budget
2. Expenditures
3. F)penditures
4. Percent of
(For Tracking Purposes only)
For This Report
Year to Dale
Approved Budget
1. Match
a. Other and In -Kind
$0.00
$0.00
$0.00
#D1VIOt
b. Local Match
$0.00
$0.00
$0.00
#DIV/01
2. Program Income
$0.00
$0.00
$0.00
#DIV101
3. TOTAL OTHER
$0.00
$O.OD
$0.00
#DIV01
PART D:INTEREST
1. Earned on Advances $0.00
2. Return on Advances $0.00
3. Other Earned $0.00
DOEA FORM 105ss.C2 reased 420120
13 /
4
16011
OAA 203.20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHONE# AND FEID#
PROGRAM FUNDING SOURCE:
Contract #
0
0
The III
Contract Period:
0
0
02 - COVID19
Report Period
0
0
PSA
Report#
0
p
Invoice #
0
CERTIFICATION: I certify to the best of my knoMedge and belief that this report is complete and all outlays herein are for purposes set forth
in the contract.
Prepared by : Date : Approved by : Date
PARTA : BUDGETED fNCOME/ RECEIPTS
1. Approved Budget
2. Actual Receipts
3. Total Receipts
4. Percent of
For This Report
Year to Date
Approved Budget
1. Federal Funds
$0.00
$0.00
$OAO
#DIV/0!
2, Program Income - Nan Match
S0.00
$0.00
$0.00
#DIV/O!
3. SUBTOTAL: CASH RECEIPTS
$0.00
$0.00
Sam
#DIV/0!
4. TOTAL RECEIPTS
$0.00
$0.00
$0.00
#DIV/Ot
PART B : EXPENDITURES
1. Approved Budget
2, E)penditures
3. E1penditures
4. Percent of
For This Report
Year to Date
Approved Budget
1. Subcontractor
$0.00
$0.00
SO-00
#DIV/01
2. TOTAL EXPENDITURES
WOO
$0.00
$0.00
#DIV/O!
PART C : OTHER EXPENDITURES
1. Approved Budget
2. Expenditures
3, E1penditures
4. Percent of
(For Tracking Purposes only)
For This Report
Year to Dale
Approved Budget
1. Program Income
$0,00
%00
$0.00
#DIV/01
2. TOTAL OTHER
$0.00
$0.00
$0.00
#DIV/O!
DOEA FOR7d 105as-GMV [Wsed 4120QD
14
16►011
OAA 203.20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROM DER NAME, ADDRESS, PHONEIIAND FEID#
PROGRAM FUNDING SOURCE:
Contract #
0
0
Title III
Contract Period:
0
0
IIIE
Report Period
0
0
PSA
Report #
0
0
Invoice #
0
CERTIFICATION: I ceNry to the best of my knoWedge and
belief that this report Is complete and all outlays herein are for purposes set forth
in the contract.
Prepared by: Date:
Approved by : -Date:
PARTA: BUDGETED INCOME/ RECEIPTS
1. Approved Budget
2. Actual Receipts
3. Total Receipts
4. Percent of
For This Report
Year to Date
Approved Budget
1. Federal Funds
SO.00
$0.00
S0.00
#DIV/0!
2. State Furxts
$0.00
$0.00
$0.00
NDIV/01
3. Program Income - Non Match
$0.00
$0.00
$0.00
11DIV/0!
4. Local Cash Match
$0.00
SO.00
$O.Oo
11DIV101
5. SUBTOTAL CASH RECEIPTS
$0.00
SO.00
Saw
#DIV101
6, Local In -Find Match
$0.00
SO.00
$0.00
#DIV/01
7. TOTAL RECEIPTS
$0.00
$0.00
$0.00
#DIV(0!
PARTS: EXPENDITURES
1. Approved Budget
2. E>Venditures
3. E)penditures
4. Percent of
For This Report
Year to Date
Approved Budget
1. AAA Direct Services
$0.00
50.00
$D,00
#DIV/U
2. Sub -Contracted Services
$0.00
$0.00
S0.00
#DIV/01
3. TOTAL EXPENDITURES
S0.0D
$0.00
$0.00
#DIV/01
PART C : OTHER EXPENDITURES
1. Approved Budget
2. E>g5enditures
3. E?venditures
4, Percent of
(For Tracking Purposes only)
For This Report
Year to Date
Approved Budget
1. Match ,
a. Other and In -Kind
$0.00
$0.00
$0.00
#D1V/o!
b. Local Match
$0.00
$0,00
S0.00
#DIV101
2- Program income
$0.00
$0.00
$0.00
fIDiV101
3. TOTAL OTHER
$0.00
$0,00
$0.00
#DIV101
PARTD: EXPENDITURES ANALYSIS
1. Expenditures by Services Year to Date:
2. Units of Services Year to Date
3. Number of People Served Year to Date
1. Information ...... ......... ...... $0.00
........................ 0
...........................
2. Assistance ...................... S0.00
...................:....0
..........................Q
3. Counseling .......... $0,0D
........................ O
..........................Q
4. Respite ......................... 0100
_...._.................. D
..........................Q
5. Supplemental Services...... , $0,00
........
..........................0
0. TOTAL .......................... $0,00
Part B Une 3, colurnn 3 should be equal to this total.
PART E : GRANDPARENT SERVICES (reported by Federal Fiscal Year)
FFY S FFY
S FFY
S
Match $
Match $
tJetch S
PART F: INTEREST
1, Earned on Advances $0.00
2. Returned on Advances SO.00
3. Other Earned $0.00
DDEA FORM tOSas•IIIE reNaed t120120
15
16011
OAA 203,20.003
RECEIPTS AND EXPENDITURE REPORT
OLDER AMERICANS ACT
PROVIDER NAME, ADDRESS, PHONE#ANDFEID#
PROGRAM FUNDING SOURCE:
Contract#
0
0
Title III
Contract Period:
0
0
NSIP
Report Period
0
0
PSA
Report 4
0
0
Invoice #
0
CERTIFICATION: I certify to the best of my
knowledge and belief that this report is complete and al outlays herein
are for purposes set forth
in the contract
Prepared by:
Date : Appraed by :
Date:
PARTA EXPENDITURE CQMPUTATION
YEAR TO DATE
CURRENT MONTH
CONGREGATE
HOME DELIVERED
CONGREGATE
HOME DELIVERED
t. Number of Meals Served
0
0
0
0
2. Line 5 Times $.72 cents per Meal
$0 00
$0.00
$0.00
$0.00
Year To Date Total Meals 0
Current Month Total Meals
0
Year To Date Total Expenditures SO.00
Total Current Expenditures
$0.00
PART B: CONTRACT SUMMARY
t. Approved Contract Amount
$0.00
2. Actual Expenditures for this Report
$0.00
3. Total Expenditures Year to Date
$0.00
4. Contract Balance
$0.00
DOEA FORV 105WNSIP reused 4120R0
16
16 011
OAA 203.20.003
Cost Reimbursement Summary
PSA TITLE Ci • COMO19_ Contract#_
Contract Period:
02 • COVIDI9_ _ Report Period _
Report # _
i J•...'
17
16011
Revised August 2007
Attestation Statement
Agreement/Contract Number OAA 203.20
Amendment Number .003
1, stephen Y Carvell , 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 statement would be for changes in page formatting, clue to the differences in
electronic data processing media, which has no affect on the agreement/contract content.
ON
signature of Recipien
tractor representative
Approved as to form and legality
Assistant County Att `
Revised August 2007
S