Backup Documents 02/23/2021 Item #16D 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 b D 3
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 _Yr k
Services
2. Minutes & Records Clerk of Court's Office aJqjj
D- `,gyp,
3.
4.
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/ Depaitment
Agenda Date Item was 02/23/2021 Agenda Item Number 16.D3
Approved by the BCC
Type of Document ADI Amendment 203.20.001 Number of Original
Attached Documents Attached
PO number or account NA
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 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 NA
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 02/23/2021 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
11
BCC,all changes directed by the BCC have been made, and the document is ready for the
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
i603
July 2019—June 2020 ADI 203.20.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
ALZHEIMER'S DISEASE INITIATIVE PROGRAM STANDARD CONTRACT
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Arca Agency on Aging for Southwest Florida,Inc.("Agency")and Collier
County Board of County Commissioners("Contractor"),amends agreement ADI 203.20.
The purpose of this amendment is to increase allocation funding by amending 4.Contract Amount,Collier County: increase
allocations by$24,815.42; revise ATTACHMENT II-EXHIBIT 2-Funding Summary; and revise ATTACHMENT IX
BUDGET AND RATE SUMMARY.
Contract Amount:
The Agency agrees to pay for contracted services according to the terms and conditions of this contract in an amount not to
exceed S474,670.42 subject to the availability of funds. Any costs or services paid for under any other contract or born any
other source are not eligible for payment under this contract.
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and arc 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 hereto have caused this amendment,to be executed by their undersigned officials as duly
authorized;and agree to abide by the terms,conditions and provisions of this ADI contract as amended. This Amendment is
effective on December 29,2020 upon having been duly signed by both Parties.
Contractor: COLLIER COUNTY BOARD AREA AGENCY ON AGING FOR
OF COUNTY COMMISSIONERS SOUTHWEST FLORIDA,IN .
SIONF.I) Y:— — c -rK-4.e4• { SIGNED BY:
NAME: JAMES C FRENCH NAME: NORMA ADORN()
TITLE:PUBLIC SERVICE DEPARTMENT HEAD TITLE: CEO
DATE:
01J (q 12021 DATE: 1- 2 0 212A,
Federal Tax ID: 59-6000558
Fiscal Year Ending Date: 09/30
Duns: 076997790
Approved as to form and legality
C � ,
istant County Atton
1,
1603
July 2019—June 2020 ADI 203.20.001
ATTACHMENT II-EXHIBIT 2
FUNDING SUMMARY
Note: Title 2 CFR,as revised,and Section 215.97,F.S.,require that the information about Federal Programs and State
Projects included in Attachment II,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 THIS CONTRACT
CONSIST OF THE FOLLOWING:
GRANT AWARD(FAIN#): FEDERAL AWARD DATE:
DUNS NUMBER: 076997790
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL FEDERAL AWARD
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT
TO THIS CONTRACT ARE AS FOLLOWS:
FEDERAL FUNDS:
2 CFR Part 200—Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards.
OMB Circular A-133—Audits of States,Local Governments,and Non-Profit Organizations
2. STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS CONTRACT CONSIST OF
THE FOLLOWING:
MATCHING RESOURCES FOR FEDERAL PROGRAMS
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL STATE AWARD
STATE FINANCIAL ASSISTANCE SUBJECT TO SECTION 215.97,F.S.
PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT
Alzheimer's Disease Initiative-Collier General Revenue—TSTF 65.004 $ 474,670.42
TOTAL AWARD $ 474,670.42
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 69I-5,F.A.C.,State Projects Compliance Supplement
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws,rules,and regulations
fr-
2
I6D3
July 2019—June 2020 ADI 203.20.001
ATTACHMENT IX
ANNUAL BUDGET SUMMARY
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
for
Collier County Board of County Commissioners
Collier
TOTAL: $474,670.42
ALLOCATION TOTAL: $ 474,670.42
l603
Revised August 2007
Attestation Statement
Agreement/Contract Number ADI 203.20
Amendment Number .001
I,,TAMES C FRENCH ,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.
Si -ature of Recipient/Contractor representative Date
Approved as to form and legality
Revised August 2007 Awls nt County At .y