Backup Documents 12/08/2020 Item #16D 7 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 0 7
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 routing lines#1 through#2,complete the checklist,and forward to the County Attomey Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Wendy Klopf Community and Human aWK, 12.08.2020
Services
2. Minutes & Records Clerk of Court's Office
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 12.08.2020 Agenda Item Number 16D
Approved by the BCC
Type of Document Amendment EHEAP 203.20.001 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? WK
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 WK
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's WK
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 12.08.20 and all changes made during WK
the meeting have been incorporated in the attached document. The County p,i
Attorney's Office has reviewed the changes,if applicable. 1'R
9. Initials of attorney verifying that the attached document is the version approved by the WK ' is`
BCC,all changes directed by the BCC have been made,and the document is ready for the an
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
607
(June 2020—September 2021) CARES EHEAP 202.20.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
CARES EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
This Amendment, is entered into between the Area Agency on Aging for Southwest Florida, Inc. (Agency) and Collier
County Board of County Commissioners Contractor),collectively referred to as the"Parties," hereby amends the contract
CARES EHEAP 203.20.
WHEREAS, Section 51. of the Standard Contract States "Modifications of the provisions of this contract shall be valid
only when they have been reduced to writing and duly signed by both parties;" and
WHEREAS, the purpose of this Amendment is to amend contract language and replace attachments of the CARES
EHEAP 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:
1. Attachment I, Section I.B.3., Scope of Service, is hereby replaced.
The Contractor is responsible for the programmatic,fiscal, and operational management of EHEAP CARES Act.
Eligible elders may receive multiple crisis assistance benefit(s),that combined not to exceed$3,500.00 during the
term of this agreement. Eligible, elders may receive crisis assistance benefits during the period from June 1,2020
to September 30, 2021.
2. Attachment I, Section I.C.3.h., is hereby replaced.
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 fire, 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 heating/cooling bill assistance for electric, gas, propane, wood, coal, or
refillable fuels;
(ii) Temporary emergency shelter(if needed due to energy-related crisis);
(iii) 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;
(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 CARES Act funding.
1 mac')
f6D7
(June 2020—September 2021) CARES El-LEAP 202.20.001
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 cuncutly disconnected/shut off;or the elder needs adeposit.
h. The benefit mount for pre-paid account shall he for one month's energy usage and may
include other allowable costs;
(xli) 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.
3. Attachment 1,Section Ii.F.2.,is hereby replaced.
Determine the correct amount of each crisis benefit based on the minimum necessary amount needed to resolve
the crisis,but not snore than the item limits or total limit set by the Department.The maximum crisis assistance
cap for this contract is$3,500.00 per household.
4. Attachment VIII,EHEAP CARES Act Budget Summary,is hereby replaced.
5. Attachment XV,EHEAP CARES Act Application and Eligibility Worksheet,is hereby replaced.
6. Attachment XVI,EHEAP CARES Act Application Eligibility Instructions,is hereby replaced.
7. Attachment XVII,EHEAP CARES Act Client File Content Checklist,is hereby replaced.
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed
to conform to this Amendment,
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the
contract,
This Amendment and all its attachments are hereby made part of the contract.
IN WITNESS TIIEREOF, 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 CARES EHEAP contract,as amended.This Amendment is
effective on the last date the Amendment has been signed by both Parties.
CONTRACTOR: COLLIER COUNTY BOARD OF AREA AGENCY ON ACiNG FOR SOUTHWEST
COUNTY COMMMISSIONERS FLORIDA,INC.
SIGNS; SI ED: GLayou,sa akg
NAME: NAME: NORMA ADORNO
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DATE:l ! l I aOaD DATE: ( 7/ c1 0(9.U'
FEID: 59-6000558 p'
Fiscal Yenr Ending Date; 09i30
DUNS:076997790 Approved as to form and legality
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I 13 7
(June 2020—September 2021) CARES EHEAP 202.20.001
ATTACHMENT VIII
EHEAP CARES ACT BUDGET SUMMARY
AGENCY: AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
CARES ACT
Total Award
TOTAL ADMINISTRATIVE BUDGET
Collier $ 4,656.31
TOTAL OUTREACH BUDGET
Collier $ 7,770.10
CRISIS ASSISTANCE
Collier $ 43,979.79
TOTAL
Collier $ 56,406.20
Projected minimum number of Individuals to be served Crisis Energy Assistance*
Collier= 154
*Eligible households may be provided with more than one benefit,totaling no more than $3,500.00. The minimum
number of individuals to be served crisis energy assistance may reflect duplicated consumers if a consumer
receives multiple benefits.
3 r-4),
•
(June 2020—September 2021) CARES EHEAP 202.20.011 6 D 7
ATTACHMENT XV
EHEAP CARES ACT APPLICATION AND ELIGIBILITY WORKSHEET
Emergency Home Energy Assistance for the Elderly Program CARES Act -Application
Section One: Applicant(Aged 60 and older) Information
Name: (First,M,Last) ❑EHEAP CARES Act
Date of birth: Age: SSN:
Service address: Date Stamp
City: Florida County: ZIP Code: Intake worker's name:
Sex: ❑ Male ❑ Number of people in the household: Phone:
Marital Status: ❑ Married ❑ Partnered ❑ Single ❑ Separated 0 Divorced ❑Widowed Phone:
Race: ❑White ❑ Black/African American ❑Asian ❑ Native Hawaiian/Pacific Islander❑American Indian/Alaska Native ❑ Other
Ethnicity: ❑ Hispanic/Latino❑ Other Primary Language: ❑ English ❑ Spanish ❑ Other
Does client have limited ability reading,writing, speaking, or understanding the English language? ❑Yes❑ No
Is the client a veteran? ❑Yes ❑ No Was client referred to the local Veteran's Affairs office?❑Yes ❑ No ❑
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 ❑ No
If Yes, select all that applies: ❑ 0-2 years old ❑ 3-5 years old
Is there an individual with a disability in the household?0 Yes ❑ No
Is the applicant a U.S. citizen or an alien lawfully admitted for permanent residence? ❑Yes ❑ No
Is the applicant a homeowner?❑Yes❑ No
Does applicant live in government subsidized housing,such as Section 8? ❑Yes ❑ No
If yes, provide the complex name:
If yes, does the household receive an energy subsidy?0 Yes ❑ No
Does applicant live in a student dormitory, adult family care home, or any kind of group living facility? ❑Yes ❑ 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? ❑Yes 0 No
If yes, provide the name of Agency:
4
lout
(June 2020—September 2021) CARES EHEAP 202.20.001
What is the primary source of home heating?(select one) ❑ Electricity ❑ Natural Gas El Propane ❑Wood/Coal El Refillable Fuels
Does household use supplemental heating source?❑Electricity❑Wood/Coal ❑ N/A
Air conditioning unit type?❑ Central NC ❑Window/Wall A/C ❑ Fans ❑ Other—specify(including evaporative cooler)
Section Five: Energy Crisis Explanation Client Attestation and Signature
❑ Home cooling or heating energy source has been The information provided on this application, is to the best of my
disconnected. (Life-Threatening/18-hour) knowledge, true and complete. I understand that priority in providing
assistance will be given to those households with the lowest income
CI to get delivery of fuel, is out of fuel, or is in danger and greatest need, i.e. those households in which the elderly,
of being out of fuel for heating.(Life-Threatening/18-hour) disabled, medically needy, or children reside. I authorize the agency to
make benefit payments directly to my energy supplier. I am aware that
CI Other problems with lack of cooling or heating in the home, after I have provided all the information requested to determine my
such as needing to pay a deposit, repair of equipment, or 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. I am also
aware that if I am not approved or denied within the time allowed, or
(Life-Threatening/18-hour) not approved for the correct amount, I have a right to appeal the
❑ Notified that the energy source for cooling or heating is decision. (If you sign with an "X"two witnesses are required.)
going to be disconnected. (Standard/48 hour)
El Received a notice indicating the energy source bill is Client Signature:
delinquent or past due. (Standard/48-hour)
Date:
❑ Has an energy source bill for which the due date has
lapsed. (Standard/48-hour)
ALL CLIENTS SHOULD SIGN THE WAIVER,AUTHORIZING THE RELEASE OF GENERAL AND/OR CONFIDENTIAL INFORMATION FOR
LIHEAP/EHEAP FEDERAL REPORTING.
DOEA Form 114—06/01/2020
5
(June 2020—September 2021) CARES EHEAP 202.2011015 r
Emergency Home Energy Assistance for the Elderly Program CARES Act-Eligibility Worksheet
Section Six: Income Eligibility Determination
Annualize all household income. Staple calculator tape here showing Poverty Guidelines effective 07/01/2020.
income calculations or write calculations
1. Add all gross monthly earned and in this space. Select the annual income limit by household size:
unearned 150%of Poverty 50%of Poverty
0 1 $19,140 $ 6,380
2. Add Medicare Premium($135.50), ❑2 $25,860 $ 8,620
if not included in SSA amount. 0 3 $32,580 $10,860
3. Add Medicare Part D, if applicable. 0 4 $39,300 $13,100
4. To annualize, multiply the monthly 0 5 $46,020 $15,340
total by 12 months. 0 6 $52,740 $17,580
Annual Household Income ❑7 $59,460 $19,820
❑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.,food,shelter and
transportation)are provided for the household.
Section Seven: Vendor, Benefit, and Verification Information
Energy Vendor#1 Other Vendor#1 Contact made with LIHEAP provider to verify
Name: Name: previous crisis assistance.
Account/Voucher Contact Person:
Account Number: Number: Date: Date of contact:
Has the applicant received LIHEAP crisis
assistance under the CARES Act Contract?
Minimum Amount Due: Amount Due:
❑Yes ❑ No
Verification and Commitment ❑Blanket 0 Repair Existing Heating
❑Portable Fan or Cooling Equipment If the minimum amount due is more than
Contact Person: 0 Space Heater ❑Emergency Shelter the past due amount, did the energy
Date: ❑Window A/C ❑Other vendor verify that this amount is required?
Energy Vendor#2 Other Vendor#2 ❑Yes ❑ No ❑ N/A
Name: Name:
Account/Voucher
Account Number: Number: Date: If the minimum amount due to resolve the
crisis is more than the maximum allowed
Minimum Amount Due: Amount Due: ($3,500), explain how the balance of the
amount due will be paid if approved for
Verification and Commitment 0 Blanket 0 Repair Existing Heating EHEAP crisis assistance.
❑Portable Fan or Cooling Equipment
Contact Person: 0 Space Heater 0 Emergency Shelter
Date: ❑Window NC 0 Other
(1)Total Energy Vendors $ (4)Total Other Vendors $ Is the name on the fuel bill that
(2) Energy Subsidy $ Total EHEAP Benefit of the applicants?
Yes ❑ No
(3) Water,Sewer,Garbage, Add $ ❑
Fire,etc. $ Total Energy Vendor(4) If no, provide name on bill:
(4) Deduct(2&3)from(1) &Total Other Vendor(4)
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?
Fl Yes No ❑ N/A
If the answer to the previous question is"yes",was the applicant referred to WAP? ❑ Yes ❑ No 0 N/A
If the answer to the last question is"no", explain:
Section Nine: Resolution of Crisis
Resolution of the Energy Crisis occurred within 18/48 hours, by the following eligible action(s): (Select all that apply)
❑Approval of application ❑ EHEAP CARES Act benefit prevented disconnection
El Commitment made to vendor ❑ EHEAP CARES Act benefit restored energy already
disconnected
j,o
t D7
(June 2020—Sestember 2021) CARES EHEAP 202.20.001
❑ Denial of Application, pending additional information ❑Yes, client signed waiver
❑ Denial of Application, ineligible ❑ No, client refused to sign waiver
❑Written referral and assistance to access other community resources
Case Worker Signature Approval Signature
have determined the eligibility of the applicant. I am not the The application and eligibility determination must be reviewed for errors and
I applicant,nor am I a friend,relative,or employee of the applicant. appropriate file documentation prior to making payment. I have reviewed
and approved this application for crisis assistance.
Case Worker's Name: Supervisor/Peer's Name:
Case Worker's Signature: Supervisor/Peer's Signature:
Date: Date:
Agency Name: Agency Name:
DOEA Form 114—0610112020
7
(June 2020—September 2021) CARES EHEAP 202.20.001 6 0 7
ATTACHMENT XVI
EHEAP CARES ACT APPLICATION ELIGIBILITY INSTRUCTIONS
Section One: Applicant(Age 60 and older) Information
Complete Section One in its entirety.
Special notes:
✓ The Winter and Summer Seasons are waived under the CARES Act.
✓ The Date Stamp is the official application date;
✓ The Intake Worker(with name and phone number recorded) is the person who accepts the application and
required documentation;
✓ The applicant's income type(s)and monthly income amount is recorded in this section,and
✓ If any field is determined to be not applicable, complete the field by 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;
✓ You will be attaching a calculator tape of the household's income calculations in the section provided on
the EHEAP CARES Act Eligibility Worksheet; and
✓ If any field is determined to be not applicable, complete the field 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:
V If any field is determined to be not applicable, complete the field by entering N/A.
Section Four: Heating and Cooling Information
Complete Section Four by answering each question.
Special note:
✓ If any field is determined to be not applicable, complete the field by entering N/A.
Section Five: Energy Crisis Explanation
Section Five is completed by choosing the best possible explanation for the applicant's crisis and obtaining their signature
and date of signature.
Special note:
✓ If any field is determined to be not applicable, complete the field by 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.
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 CARES Act federal reporting. CIRTS will require you to verify that either
the waiver has been signed or that the client has refused to sign.
(June 2020—September 2021) CARES EHEAP 202.20.001 1 6 D 7
J HEAP CARES Act Eligibility Worksheet Instructions
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 CARES Act,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 any field is determined to be not applicable, complete the field by entering N/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.
✓ 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 CARES Act
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 CARES Act 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;
• 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;
ro
9 %
(June 2020—September 2021) CARES EHEAP 202.20.001 6 11 7
• 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 CARES Act funds. Utility bills that
include charges 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 CARES Act funds.
✓ If any field is determined to be not applicable, complete the field by entering N/A.
Section Eight: Weatherization Assistance Program (WAP)Referral
Complete Section Eight in its entirety.
Special notes:
✓ When determining the number of LIHEAP or EHEAP CARES Act crisis benefits the applicant has had,
you will include the current application in the count, provided the application is approved. Refer back to
Section Seven,to the information obtained from the LIHEAP provider.
✓ If any field is determined to be not applicable, complete the field by entering N/A.
Section Nine: Resolution of Crisis
Complete Section Nine by selecting all that applies to this applicant and application for services.
Special notes:
✓ The left-hand selections indicate that the application has been acted upon within the 18/48 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.
✓ If any field is determined to be not applicable, complete the field by entering N/A.
Case Worker Signature
To complete this section, the individual who completes the EHEAP CARES Act Eligibility Worksheet, determines
income eligibility, and provides the commitment to the utility vendor must sign and complete the requested information.
Special note:
✓ If you are the applicant, or a friend, relative, or employee of the applicant,you cannot determine the
eligibility or award EHEAP CARES Act 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 he/she has reviewed the application for completeness, determined that
all required documentation is included, and verified that the annual household income calculation and EHEAP CARES
Act benefit awarded are correct.
10 4,3
(June 2020—September 2021) CARES EHEAP 202.20.116 U 7
ATTACHMENT XVII
EHEAP CARES ACT CLIENT FILE CONTENT CHECKLIST
ELDER'S NAME PSA# AGENCY APPROVAL
DENIAL
NAME OF WORKER APPLICATION DATE CRISIS RESOLUTION DATE CHECK DATE
PROGRAM REQUIREMENTS MONITORED Yes No N/A COMMENTS
•
I. Individual client file for the elder includes consumer's name,address,sex,and age.
2. Household contains a member 60 or older.
3. The household is in the Florida county covered by the contract.
4. All household members are listed and their name,age,DOB,and income(s)are included.
5 Client file contains documentation of Social Security numbers for all household members,or citation
to the applicable exemption.
6 Client file contains signed notice,or case worker's indication of virtual signature in lieu of,regarding
collection of social security number(s).
7. The client file contains official income documents for all household members.
If income is self-declared,is there a self-declaration form signed by each individual household
8. member(18 years of age or older),or case worker's indication of virtual signature in lieu of,lacking
income verification or claiming zero income?
9 The household's total gross income is calculated correctly and is at or below 150%of the OMB
Federal Poverty Level for the household size.
Statement of how basic living expenses(i.e.,food,shelter and transportation)are being provided if
10. total household income is less than 50%of the current Federal Poverty Guidelines and no one in the
household is receiving SNAP assistance.
11 Checked that elder does not live in student dormitory,adult family care home,or any kind of group
living facility.
12 Verified and documented household has not received combined LIHEAP and EHEAP CARES Act
Crisis Assistance exceeding the crisis assistance cap of$3,500.00.
13. Documentation of Weatherization Assistance Program(WAP)referral,ifapplicable.
14 Copies of fuel bills,or other supporting documentation as proof of energy crisis,for the residence in
which they reside.
15. Signed copy of Authorization for Release of General and/or Confidential Information,or case
worker's indication of virtual signature in lieu of.
16. Only eligible components of the utility bill are paid to resolve the crisis.
17. Only the minimum necessary to resolve the crisis is paid.If a different amount is required by the
utility company,provide additional information on the Eligibility Worksheet.
18 Crisis energy benefit was reduced by unallowable charges,such as:water,sewer,garbage,fire,etc.,if
applicable.
19. Crisis energy benefit was reduced by energy subsidy,if applicable.
20. Energy crisis resolved within 18/48 hours by an eligible action.
21 Written notice of approval or denial for services that includes appeal procedures is issued within 15
working days of eligibility determination.
22. Appropriate benefit provided,at or below the EHEAP CARES Act crisis assistance cap of$3,500.00.
23 All required sections of the application are signed and dated by the elder,staff,and supervisory/peer
PRIOR to payment,or case worker's indication of virtual signature(s)in lieu of.
24. Proof of payment to vendor.
25. Place completed DOEA Form 211(06/01/2020)in client file.
INSTRUCTIONS:A check mark in the Yes column indicates the requirement has been met.A check mark in the No column indicates the requirement has not
been met or is questionable.Each"No"mark must be explained under"COMMENTS".
Supervisor/Peer Signature Consumer File Monitoring Date
AGENCY FORM 211 06/01/2020
• 11 ,y,
1607
Revised August 2007
Attestation Statement
Agreement/Contract Number CARES EHEAP 203.20
Amendment Number .001
I,STEPHEN Y CARNELL ,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 COUNTY 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.
a
I le.°Z0
Signature of ecipient/Co tractor representative Date
Approved as to form and legality
Ass t County Attu ey
It I laoao
Revised August 2007
011