Backup Documents 10/27/2020 Item #16D17 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 Q 17
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 County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Wendy Klopf Community and Human �WW`k 10.27.20
Services v�e
2. Minutes and Records Clerk of Court's Office ' / 'O I,�Q I0 ,,,}a
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff Wendy Klopf/CHS Phone Number 252-2901
Contact/Department
Agenda Date Item was 10.27.20 Agenda Item Number 16D17
Approved by the BCC
Type of Document Amendment EHEAP 203.19.002 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
appropriate. (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
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be WK
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's NA
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the NA
document or the fmal negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's WK
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 10.27.20 and all changes made during WK
the meeting have been incorporated in the attached document. The County
Attorney'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 op''
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
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AREA AGENCY ON AGING FOR SOUTIIWF,ST FLORIDA,INC.
EMERGENCY HOME ENERGY ASSISTANCE,PROGRAM
This Amendment,entered into between the Area Agency on Aging for Southwest Florida, inc.(Agency)and
Collier County Board of County Commissioners(Contractor),hereby amends contract FHI-AP 203.19,
WHEREAS,Section 51.of the Standard Contract States"Modifications of the provisions of this contract shall he effective
October 1,2020.
WHEREAS,pursuant to Chapter 287.057(12),Florida Statutes,the Department is hereby exercising its option to extend
the current contract for a period not to exceed 6 months.
WHEREAS, the purpose of this Amendment is to extend the contract term, increase services and funding, and replace
attachments of the 2019 F,HEAP Contract. The Contract ending date of September 30, 2020 will be replaced with
March 31, 2021, wherever stated throughout the contract, The previous total contract arnnunt of S73,218.87 is hereby
increased by S23,329.35.The total contract amount is hereby amended to read$96,548,22 wherever stated throughout the
contract.
NOW THEREFORE,in consideration of the mutual covenants and obligations set forth herein,the receipt and sufficiency
of which are hereby acknowledged,the Parties agree to the following:
56. 011icial Payee and Representatives(Names,Addresses,and Telephone Numbers): Updated information for the Agency.
The section and location within the Agency where Area Agency on Aging for Southwest Florida,inc.
d. Requests for Payment and Receipt and Expenditure Fiscal Department
forms arc to be mailed is: 2830 Winkler Ave.,Suite 112
Fort Myers,Fl,33916
The name,address,and telephone number of the Maricela Morado,Director of Program&Planning
e. Contract Manager for this contract is: Area Agency on Aging for Southwest Florida,Inc.
2830 Winkler Ave.,Suite 112
Fort Myers,F1,33916
239-652-6900
1. Attachment ii, Financial and Compliance Audit
The Contractor shall submit a copy of any management letter issued by the auditor,to the Area Agency on Aging ler
Southwest Florida, ine.at the following address:
Area Agency on Aging fur Southwest Florida, Inc.
Attn: Chad Tripp,CFO
2830 Winkler Ave.,Suite 112
Fart Myers,FL 33916
Additionally, copies of financial reporting packages required by PART 11 of this contract's Financial and
Compliance Audit Attachment shall he submitted by or on behalf of the Contractor directlyto 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: Chad Tripp,CFO
2830 Winkler Ave.,Suite 112
Fort Myers,FI,33916 ��
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October 2019-March 2021 EHEAP 203,19.002
1 Attachment 1,Scope of Work, is hereby replaced;
3. Attachment II Exhibit 2,Funding Summary,is hereby replaced;
4. Attachment IX, Budget Summary,is hereby replaced;
5. Attachment XIII, El[RAP Invoice Report Schedule, is hereby replaced;
6. Attachment XIV, Poverty Income Guidelines, is hereby replaced;
7. Attachment XVI,EHEAP Sources of Income, is hereby replaced;
8. Attachment XVIII,El IEAP Application and Eligibility Worksheet, is hereby replaced;
9. Attachment XIX,EI LEAP Application and Eligibility Worksheet Instructions,is hereby replaced;and
10. Attachment XX,FHFAP Client File Content Checklist, is hereby replaced.
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and arc hereby changed
to conform to this Amendment.
All provisions not in conflict with this Amendment are still in effect and are In be performed at the level specified in the
contract.
This Amendment and all its attachments arc hereby made part of the contract.
IN WITNESS THEREOF,the Parties have caused this Amendment to be executed by their officials as duly authorized,
and agree to abide by the terms, conditions and provisions of Contract as amended. This Amendment is effective
October 1 2020.
CONTRACTOR: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA,INC,
SIGNED HY: SIGNED HY:
(4:/
NAME: STEPHEN Y CARNELL NAME: NORMA ADORNO
TITLE:PUBLIC SERVICE DEPARTMENT HEAT) TITLE: INTERIM CEOIPRESIDENT&COO
DATE: (t)(dr? how DATE: 10 - `Z_ 2 0G_O .
Federal Tax II):::: 59-6000558
Fiscal Year Ending Date: 09/30
DUNS 076997790 _
Approved as to tbrm and legality
Assistant County Attui y 1 D �/ 'a °
2 Yw�
0:C.)
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October 2019-March 2021 EHEAP 203.19.002
ATTACHMENT I
STATEMENT OF WORK
EMERGENCY HOME ENERGY ASSISTANCE FOR TiHE ELDERLY PROGRAM
SERVICES TO BE PROVIDED
A. DEFINITION OF TERMS
1. Eighteen (18) hour rule The timeframe within which all applications for life-threatening crisis assistance
shall he acted upon,with an eligible action to mediate the crisis being taken and documented in the client the
within eighteen(I8)hours of the application date stamp.
2. Forty-eight(48) hour rule--The timeframe within which all applications for standard crisis assistance shall
be acted upon,with an eligible action to mediate the crisis being taken and documented in the client file within
forty-eight(48)hours of the application date stamp.
3. Caseworker— Person who is responsible for determining program eligibility by completing the Emergency
Home Energy Assistance for the Elderly Program (F.HF.AP) Eligibility Worksheet (Attachment XVI) and
awarding crisis benefits.
4, Caseworker Signature Date — "I'hc date that the client's completed application is processed, eligibility
determined,and the crisis resolved. This date shall not be changed. Signatures must he in ink. Rubber-stamped
signatures will not be accepted.
5. Client Application Date-The date the 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. 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.
6. Crisis-A home cooling or heating crisis exists when an elder has no access to,or is in danger of losing access
to,needed home energy.
7. Crisis Assistance—Assistance provided to an elder who has no access to,or is in danger of losing access to,
needed home energy.
8. 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 Enrol Intent 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 or forty-eight(18/48)hour rule was met.
b. Vendors must be paid within forty-five(45)days of the date of resolution.
9. 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 18/48-hour rule for crisis resolution
begins when the application is date stamped.
In, Disability A disabling condition that causes an elder to be determined eligible to receive Supplement Security
Income(SS1)or Social Security Disability Income(SSDi)from the Social Security Administration.
11. Elder An individual aged sixty(60)years or older.
12. 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; �O
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October 2019-March 2021 EHEAP 203.19,002
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.
13. Energy Subsidy - Utility costs paid directly or indirectly to the elder who lives in government—subsidized
housing.
14, 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,
IS, Household Member—Persons in a household who share a common kitchen or bath and purchase residential
energy in common.
16, Intake Worker—Person who accepts the EHEAP application and required documentation and may have the
responsibility to determine eligibility or award crisis benefits.
17. Minimum Level of Service—Service to a minimum of one household per month.
18. Crisis Assistance Benefit—Payment of heating/cooling energy bill; the purchase of a heating/cooling device;
and/or the repair of a heating/cooling device.
19. 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.
20. 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.
21, Reasonable Promptness-Within fifteen(15)working days of receiving the client's completed application.
22, Request for Payment—Submission of actual monthly expenditures for reimbursement.
23. Service Unit—One individual(cider)served.
24, 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.
25, 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 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.
26. Verification Date The date the caseworker verified previous Low-income Home Energy Assistance Program
(LIHEAP)crisis benefits with the LIHEAP provider or the minimum amount necessary to resolve the crisis
with the utility company,ibis date shall not be changed.
B. GENERAL DESCRIPTION
1, General Statement
The Emergency Honrc Energy Assistance for the Elderly Program(El lEAP)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.
The primary purpose of the EHEAP program is to prevent,prepare for, and respond to coronavirus; including
assisting low-income households with at least one member aged sixty(60)or older experiencing a heating or
cooling emergency.
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October 2019-March 2021 EHEAP 203.19.002
2. Authority
The relevant federal and state authorities governing EHEAP arc:
a. Low Income Home Energy Assistance Act of 1981 ('Title X X V I of the Omnibus Budget Reconciliation Act
of 1981,N.L.97-35),as amended;
b. 42 (Jailed States Code(11.S.C.)§ 8621 et seq.;
c. 45 Code of Federal Regulations(CFR)Part 96,Subpart II(§§96.80-96,89);
d. Section 409.508,Florida Statutes(F.S.)and Rule 73C-26.021(3),Florida Administrative Code(F.A.C.);
e. Rule Chapter 73C-26,F.A.C.;
f. State of Florida LII lEAP Policies and Procedures Manual;and
g. I.IHEAP State Plan.
3. Scope of Service
The Contractor is responsible for the programmatic, fiscal, and operational management of EHEAP. Eligible
elders may receive multiple crisis assistance benefit(s), that combined not to exceed S3,500,00 during the term
of this agreement. Eligible,elders may receive crisis assistance benefits during the period from October 1,2019
to March 31,2021.
a. The services provided under this contract shall be in a manner consistent with and described in
Attachment 1, Section 11: Manner of Service Provision. Contractor, in collaboration with its El lEAP
program partners,shall ensure the following service tasks arc completed:
(1) Consumer Outreach;
(2) Program Partners and Stakeholders Coordination;
(3) Elder's Benefit Eligibility Determination;and
(4) Benefit Disbursement.
4. Major Program Goals
t.HI?AP 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 Summer and Winter Crisis seasons
are waived until the funding is fully expended.
a. Standard Crisis
A standard home cooling or heating crisis exists when an elder has no access to,or is in danger of losing
access to,needed home energy because one or more of the l'ellowing conditions is present:
(1) The elder has been notified that the energy source for cooling or heating is going to he disconnected;
(2) The elder has received a notice indicating the energy source is delinquent or past due;and/or
(3) The elder has an energy bill for which the due date has lapsed;
b. Life-Threatening Crisis
A life-threatening home cooling or heating crisis exists if one of the following conditions is present:
(1) The elder's home cooling or heating energy source has been disconnected;
(2) The elder is unable to get delivery of fuel for heating,is out of fuel for heating,or is in danger of being
out of fuel for heating;or
(3) The elder has other problems with lack of cooling or heating in the home, such as needing to pay a
deposit,needing a repair of heating or cooling equipment,or needing an interim emergency measure to
avoid further crisis.
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October 2019-March 2021 EHEAP 203,19.002
C. CLIEN'I'STO DESERVED
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 EITEAP 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. lie aged sixty(60)or older;
h. Reside in the CHEAP service area(Planning and Service Area)at the time the home energy costs were incurred;
c. Complete and return an H,HI AP application with all required information and verification to Contractor, while
lands remain available;
d. Provide a fuel hill or other documentation evidencing an energy emergency and an obligation to pay far home
energy costs for the home in which they live;
c. 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 ot'the household, in accordance with Section
1.C.3,d.of this contract;
t. Re experiencing one or more verifiable home cooling or heating crises;
g. Not he 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.
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 Department-provided applications for assistance and determining
eligibility;
h. 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 necupants of
the household annualized or the elder's current economic situation and reference the current year EHEAP
Sources of income(Attachment XVI) to determine what is considered allowable income,Contractor shall
proceed as follows;
(I) Total household income cannot exceed one hundred fifty percent(150%)of the current federal
Poverty Income Guidelines(Attachment XIV);
i. Stimulus payments from the federal government in relation to the Coronavirus Disease will not be
considered income and will not he considered in determining a household's Federal Poverty
Level(150%or below).
ii. Any type of unemployment payments will not be counted as income.
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(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.
i. Zero income can be determined with proof of client employment termination or self-declaration.
ii. Zero income can be determined at the time of application and projected forward(current economic
•
status), instead of using the past 30 days. If applicable, clients should note the reason for zero
income related to COVIDI9.
Although not counted as income for eligibility purposes,excluded income sources may be used to
determine how a household is meeting its expenses.
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 government-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(I lousing 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 front the allowable El IEAP benefit calculated for the household.
I'. 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%ofihe OMB federal
poverty level for the size of the household. The benefit level to be provided to elders receiving SNAP or
SSl 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., fond,
shelter,and transportation are being provided)if the total household income is less than fitly percent(50%)
of the current federal poverty guidelines and no one in the household is receiving SNAP;
h. Ensure elders receive no more than the household crisis assistance cap of$3,500.00.
(1) Elders may apply for and receive multiple crisis assistance benefit.
(2) Water,sewer,garbage,and tire, etc. charges may not be paid.
(3) Crisis assistance benefit may consist of payment of more than one energy obligation in the following
allowable categories for a household to resolve a single crisis:
(i) Utility payments for heatingicooling bill assistance for electric, gas, propane, wood, coal, or
refillable fuels;
(ii) Temporary emergency shelter(if needed due to energy-related crisis);
(fit) Payment to landlords(when utility costs are included in rent);
(iv) Repairs or replacements to heating/cooling units (as long as the amount is within the benefit
limits and the work is done by a licensed contractor);
(v) Deposits to connect or restore energy;
(vi) Late fees,disconnect fees,and reconnect fees;
(vii) Charges from a previous account held by the applicant that is now closed;
(viii) Blankets and fans;
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(ix) Taxes and fees associated with the client's utility bill towards the energy portion. In some cases,
where the utility vendor combines all the other fees and taxes, which also includes non-home •
energy services,such taxes and fees can be paid with EHEAP funding. •
Example: In a case where taxes for other services are commingled with taxes for home energy
services,proceed with paying the taxes portion of the bill;
(x) Other allowable payments are those related to the start-up of services, including reasonable
connection or reconnection fees,delivery fees,deposits,and other fees related to the start-up of
service;
(xi) Pre-pay home energy usage:
a. 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.
b. The benefit amount for pre-paid account shall be for one month's energy usage and may
include other allowable costs;
(xii) The purchase or repair of fans,blankets,air conditioners,and/or portable heaters in addition to •
heating/cooling bill assistance;and
(xiii) 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.
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.
Il. MANNER OF SERVICE PROVISION
A. SERVICE TASKS
In order to achieve the goals of HEAP,Contractor shall ensure the following tasks are performed:
I. 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 ILA,f 4.d.of this agreement;
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 or forty-eight (18/48)
hours of the application date stamp, and document in the client file that the crisis was resolved within eighteen
or forty-eight(181,18)hours;
4. Provide all elders approved for EHEAP funding with a written Notice of Approval and Appeal on contractor
letterhead within fifteen (1.5) 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 he paid on elder's behalf;
c. The next date when the elder be eligible to apply for further assistance;and
d. Contractor's appeal process.
e. Signature,date and contact information of contractor's authorized representative.
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5. Provide all elders whose EHEAP applications were denied with a written Notice of Denial and Appeal on
contractor letterhead 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;
h. Date of application;
c, Type of benefit sought;
d. Reason(s)for denial;
e. Statement on Contractor's benefit limits,it'applicable;
f. Contractor's appeal process;
h. Explanation of circumstances under which the elder may reapply;
b. 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.
k. Signature,date and contact information of contractor's authorized representative.
6. Maintain consumer appeal procedures that provide an opportunity for a fur 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 tiled 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 tiled 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.
8. Post appeal provisions in a prominent place and in plain view at all locations where El LEAP applications are
received;
9. Ensure all ineligible applicants and applicants denied crisis assistance,when EHEAP funds are not available or
arc 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 El LEAP 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 department head."
11. Compare LIiIEAP records and EHEAP records for households with elderly members to avoid exceeding the
household crisis benefit cap and maintain documentation sufficient to ensure compliance with this requirement;
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October 2019-March 2021 EHEAP 203.19.002
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 1071113-1-I-SWCBS,
http://elderaffairs.state.11.us!doea/notices/July 13/L1 HEAP%20Notice%20re%20Social%20Security%20Numb
ers%20Final.pdf). The Notice Regarding Collection of Social Security Numbers shall he 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 arc in regular contact
with the low-income population about the EHEAP program,especially those serving seniors;
h, Encouraging EHEAP program participation through local television and radio programs, and placing
announcements of the EI-IEAP 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 making presentations about F.HEAP in response to requests by
local congregational centers serving elderly or disabled persons; •
e. Providing information concerning the local Nveatherization program to all persons who request it(including •
organizations that provide outreach activities);
f. Updating the AAA's digital footprint to reflect current eligibility requirements and benefits available
through EHEAP;and
g. Developing and implementing an El IF.AP education campaign in conjunction with the provision of other
services.
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 LIIIEAP contractors in their respective service areas to prevent exceeding
the household crisis assistance cap to elders;
b. Developing a new,or continuing an existing,MOU with the Weathcrization 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 whichelders
who have received more than three EHEAP or 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;
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October 2019-March 2021 EHEAP 203.19.002
c. Establishing a new, or continuing an existing, MOU with service area lit lEAP contractor. Each MOU
shall ensure coordination of services, avoid duplication of assistance, and increase the quality of services
provided to elders. The MOU shall direct LII MAP providers to refer elders aged sixty (60) or older to
EHEAP providers for energy assistance. '1'hc MOU shall he reviewed and renewed at least every five(5)
years.Contractor shall maintain copies of all MOUs. MOUs with local LIHEAP agencies shall he updated
if the contracting parties change. The MOIJs must be applicable to Contractor's current EHEAP
requirements and guidelines;
d. Developing agreements with home energy vendors that benefit elders, Contractor shall maintain copies of
all vendor agreements. All current EHEAP agreements between Contractor and home energy vendors are
valid under the El lEAP contract. Al: 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 he 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 El lEAP assistance will he 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;
(7) A statement that only energy-related elements ol'a utility bill are to be paid.Water,sewer,garbage,and
fire, etc. charges are not covered as part of the utility bill of the household. 1 lowever, EHEAP does
allow an exception with water that is used for air conditioning, i.e. an evaporated cooler;
(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 from 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 he 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 hinds 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 El II:AP Data from each eligible elder and ensure the signed releases are
available for inspection by the home energy vendor;
(14) Assurance that the home energy vendor 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 Io DEO;
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(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:/isunbiz.org/search.html).The business name on the vendor agreement must
match the legal business name on the State of Florida Sunbiz website;and
15. Comply with the Federal Financial Accountability and 'l'rnnsparency Act (FFATA) by securing a Dun and
Bradstreet Numbering System(DUNS)numher(www.dnb.com)and maintaining an active and current profile
in the System for Award Management(SAM)(www.sam.gov).
B. STAFFING REQUIRI MEr'f rS
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 arc 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
(5) A State Community Services Agency.
b. 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.
c. Entities providing any service required under this contract must comply with the FFATA. This includes
securing a DUNS number(w,cw.(hrh.com)and maintaining an active and current profile in the System for
Award Management(SAM) (trwi .sain..gov).
d. Entities must maintain current written agreements in the following formats with service providers:
(1) A MOIL shall be executed by both parties ifa 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.
Contractor shall submit a copy of all MOUs to the Agency's contract Manager within thirty(30)days
of the contract execution date;and
(2) An EHEAP suheontract 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 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.
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c. 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.
f. 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.
g. 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 EHE:AI'. In accordance with Sections
25-26 of the Standard Contract,the Agency shall not be responsible or liable for any obligations or claims
restating from any subcontract.
h. Contractor shall document the subcontractor's progress in performing its work under this contract in the
quarterly report.
i. 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.
j. 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
I. Service Delivery Location
Contractor shall ensure that the services provided under this contract are available to residents within each
county in the Planning and Service Area(PSA)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.).
D. DELIVERABLES
1. Deliverables
a. Certification that Contractor must operate during its regular business hours,as identified in Section tl.C.2.
ul'this contract.
b. Contractor shall provide the minimum level of service per month in each county served, as defined in
Section I.A.I7.
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October 201 9-March 2021 EHEAP 203.19.002
2, Source Documentation
The deliverables shall he reported monthly on Contractor's monthly financial status reports. Successf l
completion of the deliverables shall he determined by the Agency's receipt of Contractor's EHEAP Receipts
and Expenditure Report (Attachment XI) and EHEAP Request for Payment(Attachment XI1) containing the
number of individuals served with crisis assistance; number of individuals ineligible or denied assistance;
number ofapplicants served by referral to other community resources for energy assistance;a summary of funds
expended per county for the reporting month using the EllliAP Cost Reimbursement Summary form
(Attachment XXI);and the certification required in Section III, E.2.
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 he registered in
CiRTS using the RHEA'Application and Eligibility Worksheet(Attachment XVIIi);or
(2) If Contractor denies an application, the elder must be registered in CUR'l'S 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;
c. Signed notice regarding the collection of Social Security numbers (Notice of instruction 4071113-1-T-
SWCRS,_
http:/lelderaffairs.state.fl.us/doea/notices/July 13/LIHEAP%20Notice%20rc%20Social%20Sccurity%20N
umbers%2QFinal.pdf);
1: 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;
It. Statement of sell'declaration of income,if applicable;
i. A signed statement of how basic living expenses(i.e.,food,shelter, and transportation)arc being provided
if the total household income is less than filly 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;
(1) The elder's utility bill must include detail to identify unallowable categories of assistance resulting
from charges for water, sewer, garbage, and fire, etc.; charges resulting from meter-tampering and
returned checks;and other charges that are not energy-related and arc not required for cooling/heating
the household.
(2) Use of the most current utility bill(s)which provides the vendor's mime 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, 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 El lEAP Application and Eligibility Worksheet(Attachment XVIII).
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October 2019-March 2021 EHEAP 203,19.002
k. Signed Authorization for Release of General and/or Confidential Information for LII LEAP/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
arc provided to the elder;
m. If preference is given due to a disability, documentation of such disability that includes disability income
or a physician's statement;
a, 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 exceeding the individual crisis cap 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
I. 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 EHEAP Request for Payment(Attachment X I f)as delineated
in Section II.E.I.e.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 EHEAP Administrative and Outreach Expense
Budget Detail shall clearly delineate planned expenditures for funds retained by the Contractor and funds
subcontracted. The EHEAP Administrative and Outreach Expense Budget Detail shall include all
Contractor positions, by title, to be paid with these hinds 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 used to pay less than one
hundred percent(100%)of the salary.
c. Provider Cost Analysis
State of Florida Chief Financial Officer Meutorandtun No.02(released October 3,2012),requires Agency
to provide assistance to the Contractor's Contract Manager in completing the DOER Cost Analysis lbr
Non-Competitively Procured Contracts In Excess of Category II.
(1) The Contractor shall submit a completed Cost Analysis which shall reflect Administrative, Outreach, and Crisis
Service allocations as delineated on the Ei IEAP Budget Summary(Attachment IX)and must be sufficient to explain
the expenditures'allowahility,allncahility,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 he
submitted and approved by the Agency prior to any change.
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d. EHEAP Quarterly Report
The quarterly EHEAP Summary Report shall be submitted based on the following schedule:
REPORT REPORTING PERIOD (DATE DUE TO AGENCY
10/01/19--- 12/31/19 January 15,2020
2 0 1/01/20—03/31/20 April 15,2020
3 04/01/20• •06/30/20 July 15,2020
4 -- 07/01/20 09/30/20 October 15,2020
5 10/01/20 12/31/20 January 15,2021
6 01/01/21 —.03/31/21 April 15,2021
(1) The Contractor shall ensure timely and accurate CIRTS data entry of'EHEAP activity and submit to the
Agency's EHEAP Contract Manager the service report entitled"El lEAP Summary"from CARTS.The
report shall reflect the use of EHEAP in each contractor county in the PSA and shall be inclusive of all
elders applying Ibr crisis energy assistance during the reporting month or period.The El LEAP Summary
Report parameters for the program year shall he:
(i) PSA;
(ii) All Providers;
(iii) All Locations;
(iv) Start Date(first date of reporting period);and
(v) End Date(last date of reporting period).
e. For the term of this contract, each month Contractor shall provide to the Agency,by the 9111 of each month
for the preceding month,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 fin•energy assistance
during the reporting month;and
(4) The total amount of funding expended for crisis assistance per county for the reporting month,
f. 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.
2. Monitoring and Evaluation Methodology
Contractor shall monitor its performance under this contract,as well as that of its subcontractors,subrecipients
and consultants who arc paid from finds 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 arc achieved. Such review shall be made for each function or activity set forth in this contract and
reported in the quarterly report.
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October 2019-March 2021 EHEAP 203,19.002
(
n. Contractor shah review completed EIIEAP applications in accordance.with the E1-IEAP Client File Content
Checklist (Attachment XX),
h. The Agency shall, at its own discretion, conduct investigations concerning any aspect of Contractor's
pertcrl'mance of this contract.
e. The Agency shall conduct a full onsite review of Contractor at least once during each three-year period.
Contractor shall allow the Agency to carry 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 onsitc monitoring visits and desk review activities, the Agency shall review it sample
of completed EIJEAP client files in accordance with the Ellli,AP 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.
Je. CONTRACTOR RESPONSI73I1.I'I`IES
J.. Make vendor payments directly to fuel andior 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 lira it set by the Agency.The maximum crisis assistance cap
for this contract is$3,500.00 per household. {{' •
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 RI-11AP crisis services to households with elders in every county within the service area.
a. Contractor shall ensure that each county within their service area receives a minimum level of crisis services
monthly, as delineated in Section LA.I7,: 1;HEAP funded staff shall make themselves available in all
underserved counties as needed, to ensure that the minimum level of service is met; mid
•
b. Contractor shall provide oversight to ensure that the minimum level of service is provided monthly in each
county in 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 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 FIIEAP funds arc appropriately budgeted and expended in allcounties
within Contractor's 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
ElffiAP administrative award to Contractor or Subcontractor are paid from non-federal sources,
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October 2019-March 2021 EHEAP 203.19.002
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.
I. 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.
13. 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 EI fEAP 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 Slate of Florida LII LEAP Policies and Procedures Manual;
b. An MOU or Subcontract with El MAP 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 arc appropriately budgeted 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;
j. Policies and procedures to secure applicant Social Security Numbers in order to protect applicants'
identities;
Ic. Procedures for computer system backup and recovery;
I, 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 El-lEAP;
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;
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October 2019-March 2021 EHEAP 203.19.002
s. A resource guide, or the utilization of the Information and Referral database(Rcfe•NE l),to access other
energy assistance resources available at the local level to provide referrals to elders when EFIEAP funding
is not available or they do not qualify; •
t, Consumer appeal procedures that provide an opportunity fora fur 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 lbr 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 perfbrming 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 perlbrm pursuant to this contract.
G. AGENCY RESPONSIBILITIES
E. 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 HI lEAP Policies and Procedures Manual will provide information and procedures needed to
administer El'RAP in Florida.
a. This contract excludes all provisions of the State of Florida LTHEAP Policies and Procedures Manual in
reference to LIE lEAP Regular Home Energy Annual Benefits,
b. 'Co the extent any conflict arises between this contract and any incorporated reference contained herein,this
contract shall have precedence.
HI. MF;I'HOD OF PAYMENT
A. PAYMENT METHOD USED
'['he Method of Payment for this contract is cost reimbursement,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 11, 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 El lEAP Budget Summary(Attachment IX)attached
to this contract. Any change in allocation of categorical or total amounts of funds identified on the EHEAP
Budget Summary form require a contract amendment. Payment may he authorized only for allowable
expenditures, which are in accordance with the limits specified in Attachment IX. All Cost Reimbursement
El IEAP Requests for Payment must include the actual El'NAP 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 EHEAP Budget Summary
(Attachment iX). An amendment is required to change category allocations or the total amount of this
contract.
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October 2019-March 2021 EHEAP 203.19.002
(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 he 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 arc 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 perfiirnting
outreach and intake. Outreach expense shall not include senior management expense, except when
outreach and intake involving direct contact with elders occurs. Documentation to support this
exception shall be maintained by Contractor and available upon request.
•
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 Suhrecipient shall have either a rate negotiated with the Agency(in compliance with 2
C.F.R. Part 200), or a de minimis indirect cost rate as defined in 2 C.F.R, §200.414(0, Subrecipient shall
maintain its current Indirect Cost Rate Proposal and make the proposal available upon request. If
Subrecipient chooses to use the de minimis 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
Advance payments will not be issued for this project.
13. The final request for payment is due to the Agency no later than April 1 5,2021.
C. METHOD 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;
I. Have Remittance Address that corresponds exactly to the "Remit 'I'o" address provided to My Florida
MarketPlace(MFMP)during registration;
2. Request payment for services as established in the El IliAP Service Rate Report(Attachment XXIII);
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 the EHEAP Receipts and
Expenditure Report (Attachment XI), EHEAP Request for Payment (Attachment XII), and EllEAP Cost
Reimbursement Summary(Attachment XXI);
4. Contractor shall include required supporting documentation as delineated in Section lll.t:. with the cost
reimbursement portion of the invoice,
D. PAYMENT WITHHOLDING
Any payment due by the Agency under the terms of this contract may he withheld pending the receipt and approval
by the Agency of all financial and programmatic reports due from the Contractor and any adjustments thereto,
including any disallowance not resolved.
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E. SUPPORTING DOCUMENTATION REQUIREMENTS
For the reporting month, Contractor shall include the following with Request for Payment:
I. 'l'he 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;
e, 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;
3. The total amount of funding expended for crisis assistance per county for the reporting period;and
F. 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.
I. The Agency shall not reimburse any expenditures associated with Deliverables not accepted by 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 bails to be open and available for services according to its regular business hours as identified in
Section 1l.C.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 he paid by Contractor out of non-federal funds.
C. 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,
I. 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 infractionthal compromises Contractor's ability to
provide participant services, to achieve programmatic performance,or to provide sound financial management
of the program.
II. CONSEQUENCES FOR NON-COMPLIANCE
Contractor shall ensure that one hundred percent(100%)of the deliverables identified in this contract are performed
pursuant to contract requirements.The deliverables described in Section 11.i). are identified as major deliverables
in this contract.
21
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October 2019-March 2021 El-LEAP 203.19.002
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 i%of the monthly
value of the administrative funds in the contract for each day the CAP is overdue,beginning the I Id'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, i%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, I%of the monthly value of
the administrative funds in the contract for each day the Contractor fails to timely submit a CAP.
IV. SPECIAL PROVISIONS
A. The following is incorporated by reference:
I. State of Florida LIIILAP Policies Lind 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 a Agency approved budget modification process.
2. For the purpose of transferring funds, the following are considered budget categories: (I)Administration, (2)
Outreach,and(3)Crisis Assistance.
END OF ATTACHMENT
•
22 •
16► D17
October 2019-March 2021 EHEAP 203,19.002
ATTACHMENT lI-EXHIBI"I'2
FUNDING SUMMARY(2019-2021)
NoLel Title 2 CFR,as revised,and Section 215.97, F.S.,require that the information about Federal Programs and State
•
Projects included in Attachment 11,Exhibit 1,be provided to the recipient. Information contained herein is a prediction of •
funding sources and related amounts based on the contract budget.
1, FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO'I'HISCONTRACT
CONSIST OF THE FOLLOWING:
•
•
GRANT AWARD(FAIN#): 17EA-OF-1J-00-16-003 FEDERAL AWARD DATE: April 2019
DUNS NUMBER:076997790
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
Emergency Home Energy Assistance United States Department of Health and 93.568
for the Elderly Program _ Human Services
EHEAP Collier 93.568 $ 96,548.22
TOTAL FEDERAL AWARD $ 96,548.22
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT •
TO THIS CONTRACT ARE AS FOLLOWS:
FEDERAL FUNDS:
2 CFR Pail 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 CONSISTOF
THE FOLLOWING:
MATCHING RESOURCES FOR FEDERAL PROGRAMS
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL STATE AWARD
STATE FINANCIAL ASSISTANCE SUBJECT TO SECTION 215.97,F.S.
PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT
TOTAL AWARD
COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO THIS
CONTRACT ARE AS FOLLOWS:
STATE FINANCIAL ASSISTANCE,
Sections 215.97&215.971,F.S.,Chapter 691-5,F.A.C.,State Projects Compliance Supplement
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws,rules,and regulations
•
23
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October 2019-March 2021 EIIEAP 203.19.002
ATTACI1MENT IX
BUDGET SUMMARY
EMERGENCY IIOMl; ENERGY ASSISTANCE PROGRAM
for
Collier County Board of County Commissioners
Collier
EHEAP ADMINISTRATION BUDGET $ 8,421.82
EIIEAP OUTREACH BUDGET $ 13,468.60
EHEAP CRISIS ASSISTANCE $ 74,657.80
TOTAL S 96,548.22
Projected minimum number of individuals to be served
Energy Assistance* 269
*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.
Page 24 of 34
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October 2019-March 2021 EHEAP 203.19.002
ATTACHMENT XIII
EHEAP INVOICE REPORT SCHEDULE
Report Number Based Upon Date Due to the Agency
1 October Advance* Upon receipt of executed contract
2 November Advance* Upon receipt of executed contract
3 October Invoice November 09,2019
4 November invoice December 09, 2019
5 December Invoice January 09,2020
6 January Invoice February 09,2020
7 February Invoice March 09,2020
8 March Invoice April 09, 2020
9 April Invoice May 09, 2020
i 0 May Invoice June 09,2020
I 1 June invoice July 09,2020
12 July Invoice August 09, 2020
13 August invoice September 09,2020
14 September Invoice October 09,2020
I S October Invoice November 09, 2020
16 November invoice December 09,2020
17 December Invoice January 09, 2021
I January Invoice February 09, 2021
19 February Invoice March 09, 2021
20 March Invoice April 09,2021
21 Final Request for Payment April 15,2021
* Advance based on projected cash need.
Note# I: Report ii I and 42 for advance basis invoices,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 voucher's to the Agency is dependent on the accuracy of the Receipts and
Expenditure Report.
Note 112: Report numbers 5 through 14 shall reflect an adjustment of one-tenth of the total advance amount,on
each of the reports,repaying advances issued the first one or two months of the agreement. The
adjustment shall be recorded in Part C. 1 of the report(ATTACIIMI NT Xll).
•
Note 11 3: Submission of expenditure reports may or may not generate a payment request. If final expenditure
report reflects fluids due back to the Agency,payment is to accompany the final report. •
Note 114: Al.l, Expenditure Reports are due by 12:00 p.m,on the 9'1'of each month. IF the 9'''fails on a
Saturday,then the report will be due by the 8"'by 12:00 p.m. AND IF the 9''falls on a Sunday,the
report will he due by the 10'h 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 CIR'I'S
data only.
Page 25 of 34
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ATTACHMENT XIV
•
FLORIDA DEPARTMENT at
ECONOMIC OPPORTUNITY
POVERTY INCOME GUIDELINES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP) •
POVERTY INCOME GUIDELINES*
EFFECTIVE JULY 1,2020 •
•
PEOPLE IN THE HOUSEHOLD 150%
•
1 $19,140
2 $25,860
_ 3 $32,580
4 $39,300
5 $46,020
6 $52,740
7 $59,460
8 $66,180
For each additional person in the household $ 6,720
•
with more than 8 people, add: •
*These figures are based on the 2020 U.S.Department of Health and I-Iurnan Services (Ii!IS)
poverty guidelines published in the Federal Register on January 17,2020. •
Page 26 of 34
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October 2019-March 2021 E EILAP 203,19.002
ATTACHMENT XVi
EHEAP SOURCES OF INCOME
EMERGENCY HOME ENERGY ASSISTANCE FOR THE ELDERLY
FY 2020/2(121 SOURCES OF INCOME
EFFECTIVE June 1,2020
INCLUDED
SOURCES OF INCOME EXCLUDED
(Includes total annual cash receipts before taxes from all sources) SOURCES OF INCOME
1. Money wages and salaries before any deductions 1.CAPITAL GAiNS
Any Assets drawn down as withdrawals from a bank,the sale
2. Net receipts from non-farm employment(receipts from a of property,a house or a car.
person's own unincorporated business,professional 2. Tax Refunds
enterprise,or partnership,after deductions for business 3. Gifts
expensei) 4. boons
5. Lump-sum inheritances
3. Net receipts front farm self-employment(receipts from a 6. One-time insurance payments
farm which one operates its an owner,renter,or 7. Foster Care Payments'
sharecropper,after deductions for farm operating 8. Compensation for injury
expenses) 9. Combat none pay to the military
10.Adoption Subsidies
4. JtWGULAR PAYMENTS FltO2ij: 11.Reverse Mortgage Payments
Social Security 12. NON-CASTIBENEFITS
Railroad retirement (a) Employer-paid or union paid portion of health
Strike benefits from union fiords insurance or other employee benefits
Worker's compensation
Veteran's payments (b) Food or housing received in lieu of wages
Public Assistance or Temporary Assistance for Needy Families
(CANT),Supplemental Security Income,and non-federally funded (c) The value of food and furl produced and
General Assistance nr General Relief money payments. consumed on farms.
5. Payments to foster children age 18 or older received through the (d) The imputed value of rent from owner-occupied
Independent living Program nonfarm or farm housing.
G. Training stipends (e) Federal non-cash benefit programs such as Medicare,
7. Alimony Medicaid,Food Stamps,school lunches,and housing
8. Child Support assistance.
9. Social Security Benefit Ciantishes for Nun Payment of 13. Supplemental Security Income(SSI)benefits cannot be
School Loans.(I'he total amount of the Social Security Retirement garnished for any reason unless a recipient received an
benefit including the garnished deduction must be used when overpayment of benefits.
calculating the applicant's income.) The total amount of the SSi benefit minus the garnished
deduction for recoupment must be used when calculating
10. Military family allotment or other regular support from the applicant's income.
a family member or someone not living in the
household *Persons whose cost of residence is paid through a foster
care or residential program administered by the state
11. Private pensions cannot be rnunted as household members.
12. Government employee pensions(includingmilitary 14, Stimulus payments from the federal government in
retirement pay) relation to the Corouavirus Disease will not be
considered income and will not be considered in
13. Regular insurance or annuity payments determining a household's Federal Poverty Level
14. Educational Assistance: (150%or below).
Grants,Fellowships,Assistantships,College or 15. Any type of unemployment payments will not be
University Scholarships-Only count as income those funds counted as income.
specifically allotted for living exnmuss.
15. Dividends
16. Interest
17. Net rental income
18. Net royalties
19. Periodic receipts from estates or tests
20. Net gambling or lottery winnings
Page 27 of 34
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October 2019-March 2021 EHEAP 203.19.002
ATTACHMENT XVIII
EHEAP APPLICATION AND ELIGIBILITY WORKSHEET
Tnr:rgency ',Ionic: E Energy Assistance for the L (doily Program CARES Act Appylir.�itiart
.
Section One:Applicant(Aged 60 and older)Information
Name:(First.M,Last) ❑ Crio A `.•iiSt<it)EO
Date of birth: Age: SSN:
Service address: Date Stamp
City: Florida County: I ZIP Code: Intake worker's name:
Sex: ❑Male❑Female Number of people in the household: ` Phone: _
Marital Status: 0 Married 0 Partnered ❑Single ❑Separated 0 Divorced ❑Widowed Phone:
Race:0 White Ft Black/African American n Asian fl Native Hawaiian/Pacific Islander IA American Indian/Alaska Native Fl Other
Ethnicity:0 Hispanic/Latino❑Other [Primary Language: 0 English 0 Spanish ❑Other-_
Does client have limited ability reading,writing,speaking,or understanding the English language?D Yes Fl No
Is the client a veteran?n Yes U No . Was client referred to the local Veteran's Affairs office?0 Yes El No 13 N/A
Applicant's income type(s): Applicant's monthly income amount:
Section Two: Additional Household Members Information •
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:
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Section Three: Household Characteristics
Is there a child 5 years of age or younger in the household?❑Yes I I No
If Yes,select all that applies: 0 0-2 years old ❑3-5 years old
Is there an individual with a disability in the household?n Yes ti No
Is the applicant a U.S.citizen or an alien lawfully admitted for permanent residence?D Yes El No
Is the applicant a homeowner?❑Yes El No
Does applicant live in government subsidized housing,such as Section 8?t7 Yes U No
If yes,provide the complex name:
If yes,does the household receive an energy subsidy?D Yes Li No_ _-
Does applicant live in a student dormitory,adult family care home,or any kind of group living facility?El Yes EU No
If yes,provide the facility name:
Section Four:Heating and Cooling Information
Have you or any member of your household received energy assistance in the current season?D Yes Fri No
If yes,provide the name of Agency:
—
Type of Assistance: U Crisis Cl Home Energy 0 Weather-Related Date:
_ —
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October 20'19-March 2021 EHEAN 203,19.002
What Is the primary source of home heating?(select one) I Electricity❑Natural Gas L Propane 0 Wood/Coal fl Refillable Fuels
Does household use supplemental heating source?U Electricity C7 Wood/Coal 0 N/A
Air conditioning unit type?0 Central A/C U WindowAVall A/C 0 Fans 0 Other—specify(Including evaporative cooler)
Section Five: Energy Crisis Explanation Client Attestation and Signature
❑Home coolingor heating energyThe information provided on this application,is to the best of my
g source has been knowledge,true and complete.I understand that priority in providing
disconnected.(Life-Threatening/18-hour) assistance will be given to those households with the lowest Income
U Unable to gel delivery of fuel,is out of fuel,or is in danger of and greatest need,i.e those households In which the elderly,
being out of fuel for heating.(Life-Thraalening/18-hour) disabled,medically needy, or children reside.I authorize the agency
to make benefit payments directly to my energy supplier. I am aware
ID Other problems with lack of cooling or heating in the home, that after I have provided all the information.requested to determine
such as needing to pay a deposit,repair of equipment,or my eligibility,if I am applying for crisis assistance,the agency has 18
interim emergency measure to avoid further crisis. hours to act upon my application with an eligible action,(am also
(Life-Threatening/18-flour) aware(hat if I am not approved or denied within the time allowed,or
not approved for the correct amount,I have a right to appeal the
U Notified That the energy source for cooling or heating is going decision.(If you sign with an'X"two witnesses are required.)
to be disconnected.(Standard/48-hour)
i t Received a notice indicating the energy source billis Client
delinquent or past due.(Standard/48-hour) Signature:
U Has an energy source bill for which the due date has lapsed.
(Slanda r'i/48-IJour) Date:
DOEA F:a m'11—Qti,V12)24Revhed
C�`a
29
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October 2019-March 2021 EHEAP 203.19.002
r mc,rgeitt:y I'inrnr; Energy Astiistrtncc for Ylu. Elderly l'roc;rani CARES Act--Application
.Section Six: Income Eligibility Determination . -
Annualize all household income. -SliVie calra!i:errs r;p•:;i,:c.n: t;h;iWi e ireurrt`' Poverty Guidelines effective 7/1/2020,
calculatir:ns or."rite e;ak:ulalion,in ih --
1. Add all gross monthly earned and space Select the annual income limit by household
unearned income from the past 30 i size:
days of all household members. 150%of Poverty 50%of Poverty
2. Add Medicare Premium($144.60),if El 1 $10,140 S 6,380
not included in SSA amount. n 2 $25,860 $ 8,620
- U 3.,......,.$32,580 $10.860
3. Add Medicare Part D,if applicable.
r,4..........$39,300 S13,100
4. To annualize,multiply the monthly C 5 $46,020 $15,340
total by 12 months. 0 6 $52,740 $17,580
Annual Household Income 0 7 559,460 $19,820
11 8........_$66,180 $22,060
$ (Add$6,720 for each additional member of
family unit with more than 8 members.)
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(i.e.,fond,shelter and
transportation)are provided for the household.
Section Seven:Vendor, Benefit,and Verification Information
Enorgy Vendor/l1 Other Vendor tel Contact made with LIHEAP provider to
Name: Name: verify previous crisis assistance.
Contact Person:
AccountNoucher Date of contact:
Account Number: Number: Date: Has the applicant received CARES Are
EHEAP or LIHEAP crisis assistance?
Li Yes 0 No
Minimum Amount Due: Amount Due: If yes,provide total amount
&Date(s)
Verification and Commitment ❑Blanket n Repair Existing Heating or
fl Portable Fan Cooling Equipment If the minimum amount due is more
Contact Person: fl Space Heater 0 Emergency Shelter than the past due amount,did the
Date: n WndowNC L1 Other energy vendor verify that this amount
is required?
Energy Vendor#2 Other Vendor#2 Li Yes rl No Li N/A
Name: Name:
AccauntNoucher
Account Number: Number: Date: If the minimum amount due to resolve
the crisis is more than the maximum
Minimum Amount Due: Amount Due: _ allowedalanc ($3,500),fthea explaintdue
how the
---• --- balance of the amount due will be
Verification and Commitment 0 Blanket 0Repair Existing Heating or paid if approved for EHEAP Crisis
Cooling Equipment assistance.
0 Portable Fan '- -
Contact Person:_ ❑Space Heater ❑Emergency Shelter
Date: _. U Window NC ❑Other
(1)Total Enorgy Vendors $ (4)Total Other Vendors $ Is the name on the fuel
— . -- bill that of the
(2)Enorgy Subsidy $ applicants?
Total EHEAP Benefit ❑Yes ❑No
(3)Water,Sower,Garbage, Add
Fire,etc, $ _ _ Total Energy Vendor(4)& $ If no,provide name on
(4)Deduct(2&3)from(1) $ Total Other Vendor(4) bill:
; Section Eight:Weatherization Assistance Program (WAP)Referral ,
If the applicant is a homeowner,has he/she received more than three LIHEAP or EHEAP benefits in the last 18 months?
0 Yes iINo0N/A
If the answer to the previous question is"yes",was the applicant referred to WAP? U Yes 0 No❑N/A
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October 2019-March 2021 EHEAP 203.19.002
If the answer to the last question is`no",explain:
Section Nine: Resolution of Crisis •
Resolution of the Heating/Cooling Energy Crisis occurred within 18/48 hours,by the following eligible aclion(s):(Select all that apply)
U Approval of application U EHEAP benefit prevented disconnection
U Commitment made to vendor 0 EHEAP benefit restored energy already disconnected
U Denial of Application,pending additional information ❑Yes,client signed waiver
•
0 Denial of Application,ineligible C7 No,client refused to sign waiver
•
❑Written referral and assistance to access other community resources
Case Worker Signature Approval Signature •
I have determined the eligibility of the applicant.I am not the applicant, The application and eligibility determination must be reviewed for euors
nor am I a friend,relative,or employee of the applicant. and appropriate file documentation prior to making payment.I have
reviewed and approved this apnllcation for crisis assistance.
Case Worker's Name: SupervisoriPoer's Name:
Case Worker's Signature: Supervisor/Peer's Signature:
Date: Date:
Agency Name: Agency Name:
DOFAForm 1 1 4-68161/2620.Reviaed -- --_- ----
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October 2019-March 2021 EHEAP 203.19.002
ATTACHMENT XIX
EHEAP APPLICATION AND ELIGIBILITY INSTRUCTIONS
FHEAP Application instructions
Section One: Applicant Mae 60 and older)Jntormation
Complete Section One in its entirety.
Special notes:
✓ The Winter and Summer Seasons are waived.
✓ 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;pry fkrkl is(1elr'rntined li)ha riot applicable, cariipletc:the. hold by entering N/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;
v. You will be attaching a calculator tape of the household's income calculations in the section
provided on the EHEAP Eligibility Worksheet; and
II.'rrty tirad is dotermincd to he not applicable, complete the tick/by entering N/A.
Section Three: Household Characteristics
Complete Section Three by answering each "Yes"or"No"question and providing additional information if
applicable.
Special note:
If any hold is clefi:lrnirir>d to be not ril)1?fic01)1o, coinplute the fr(rkl by entering N/A.
Section Four: Heating and Cootina Information
Complete Section Four by answering each question.
Special note:
/ IF any field is determined to bu not applicable, corriplutu (lit: field by entering N/A,
Section Five: Enerav 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 riny liukf is(letcrrrui orl to be riot applicable, complete the lick(by entering N/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.
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October 2019-March 2021 EHEAP 203.19.002
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.
Section Six: Income 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.
✓ Specific to EHEAP,the following Is not counted as income when determining Income
eligibility for the household:
o Stimulus payments from the federal government in relation to the Coronavirus
Disease; and
o Any type of unemployment payments will not be counted as income.
If;my flak!is Ooloirnilied to be hot r.tf plioobie, coinplalo lite lif:lrl by entering IV/A.
Section Seven: Vendor. Benefit. and Verification Information
Complete Section Seven by completing in its entirety.
Special notes:
✓ Eligible elders may receive multiple crisis assistance benefit(s), that combined not to exceed
$3,500.00.
✓ The minimum amount due is the amount provided to you during the verification process with the
home energy vendor.
V 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
and/or one or more benefits from EHEAP funding. 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 crisis assistance cap of$3,500.
✓ 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.
✓ Allowable utility categories for heating/cooling bill assistance include the following:
■ Electricity;
■ Natural Gas;
• Propane;
• Wood/Coal; and
• Refillable fuels;
✓ Crisis benefits may also be used for the following:
■ Pre-pay energy;
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October 2019-March 2021 EHEAP 203.19.002
• Purchase of blankets, portable fans, space heaters, and window air conditioners;
• Repair of an existing heating/cooling unit;
• Deposits to connect or restore energy;
• Late fees and disconnect and reconnect fees;
• Charges from a previous account held by the elder that is now closed;
• Payment to landlord when utility costs are included in the elder's rent; and
• Temporary emergency shelter, if due to energy related crisis.
✓ Water, sewer, garbage, and fire, etc. MAY NOT be paid with EHEAP funds. Utility bills that
include cherries that are not directly related to cooling and heating will be reduced by the
amounts for these charges.
✓ Charges incurred due to illegal activities, such as a worthless check or meter tampering,MAY
NOT be paid with EHEAP funds.
✓ it lilt.liultl fS 0r(0rlrl',(."1 l)':lic); c; fl?pIr k(: (1v t1Cic1 by entering N/A.
Section Elaht: WeatherizationAssistance Program MAP) Referral
Complete Section Eight in its entirety.
Special notes:
✓ When determining the number of LIHEAP 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.
f /Pony&AI IS determined to be not nl)nlicr?bk;. complete 1t?v field by antr)ri,?g NIA.
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 18148 hour
requirement.
✓ If the selection is made to deny the application pending additional information from the client,
the 18/48 hours has been met and does not repeat itself when the client returns with the
pending information.You have already met the requirement.
✓ ft any hold Is cletoimttitled to be not ii,oplicabin, cnt► ntetr. the lick/by it1(C!1*K1 NIA.
Case Worker Signature
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:
I 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.
Approval Signature
To complete this section, the signer is attesting that helshe has reviewed the application for completeness,
determined that all required documentation is included, and verified that the annual household income 0'0
calculation and EHEAP benefit awarded are correct.
34
16017
October 2019-March 2021 EHEAP 203.19.002
ATTACHMENT XX
EHEAP CARES ACT CLIENT FILE CONTENT CHECKLIST
ELDER'S NAME 'PSAt AGENCY APPROVAL DENIAL
NAME OF WORKER APPLICATION DATE CRISIS RESOLUTION DATE CHECK DATE
I'ltOGUAnl REQUIREMENTS MONI'I'O1tbl Yes Na N/A CODIAIENTS
I Individual client tile thr the elder includes consumer's name,address,see,and age.
2 I lnusehnld contains a member60 or older.
1. The household is in the Florida county covered by the contract
4. gg household members are listed and their Fusee,use,DOB,and incuins(e)are included.
5 Client file contains documentation of Social Security numbers fur all household members,or citation
to the applicable exemption.
6. Client file contains signed notice regarding collection of social security nurnher(s)
7. The client file contains official income documents for all household members.
b If income is self-declared,is there a self-declination tuna signed by each individual household
member(1 g years ofage or older)lacking inmate verification or clamming soroince'nd7
9 1 he h ouselold's total gross inevw is calculated canectly and is at or below I SO5'of the OMi3
federal Poverty l.ecd for the household sure.
Statement of how basic I iv ing expenses(i.e.,loud,shelter and UM n spur Union)ore being provided if
1I). total household income is less Pau 50%of the current Federal Poverty Guidelines and nn one in the
household is rxcivmg SNAP assistance.
11 Checked that elder does riot live in student dormitory,ndult fnmiiy care home,or tiny kind of gratin
living facility.
12 Verified and documented household has riot received combined LIHEAP and EFTA Crisis
Assistance exceeding the crisis assistance cap nr$3,500 00.
13. Uucumentation of Weallerimtion Assistance Program(WAP)referral,ifupplicabk.
14 Copies offitcl bills,or utiles suppouliug documentation as proofof energy crisis,for the residence in
winch they reside.
15. Signed copy of Authorization for Release of(General nndrur Confidential hi fuunation.
16. Only eligible components of the utility hill are paid In resolve the crisis.
Only the minimum necessary to resolve the crisis is paid.if a different tarW alit is required by the
17. utility company,provide additional infonnation on the Fligibiliry Worksheet.
I R. Crisis energy benefit was reduced by unulluwable charges,siKh as.water,sewer,garbage,lire,cur,if
applicable.
19. Crisis energy benefit was reduced by energy subsidy,if applicable.
20. Energy en isis resoit ed within 18/48 hours by an eligiblc nett on
2I Written nopa:of approval Ur denial for services that includes appeal procedures is issued within 15
workinp,days nfeltguhihty determination.
22 Appropriate benefit provided,at or below the El'EA!,crisis assistance cap of$3 500.00.
�3 All required sections of the application um signed and dated by the elder,staff,and supervisory/peer
edial to payment.
2d. Proof of payment to vendor.
25. Place completed DULA Form 2l1(0 610 1/2 02 0)in client file.
1NSTItUCt'IONS:A check smirk In I he nu vulunun indicates the requirement lins been met.A check murk la the NI colunuu indicates the requirement has
not been met or is questionable.Faith"No"mark must he explained under"COMMENT S",
CAO
Supervisor/Peer Signature Consumer File 4fonlloring Date
DOEA FOAM 21 I realm I,zoo
35
16017
Revised August 2007
Attestation Statement
Agreement/Contract Number EI11 AP 203.19
Amendment Number .002
I, ,STEPHEN Y CARNEI.I. ,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,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
(o(07 t/z0zo
Signature of Rcc ient/Contracftrf representative
P Date
Approved as to form and legality
CU
A. awn'County At to cy
I 0 1t0 1a0zo
Revised August 2007