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Backup Documents 02/27/2024 Item #16L 2 1 6L 2 • ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 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 Attorney Office. Route to Addressee(s) (List in routing order) Office Initials Date 1 County Attorney Office County Attorney Office R-r-r/ML 2/27/ZY 2. BCC Office Board of County Commissioners GN 1h/' i/Z7/z' 3 Minutes and Records Clerk of Court's Office 112,9)4 q�� 4. Daniel Rodriguez Immokalee CRA Office/County Manager a/a 401/ Office PRIMARY CONTACT INFORMATION Normally the primary contact is the person who created/prepared he Executive Summary. Primary contact information is needed in the event one of the addressees above,may need to contact staff for additional or missing info i i ation. Name of Primary Staff Daniel Rodriguez Phone Number 239-252-8366 Contact/ Department Agenda Date Item was 02.27.24 i Agenda Item Number 16.L.2 Approved by the BCC Type of Document Direct Deposit Number of Original 1 Attached Documents Attached PO number or account N/A 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? DR 2. Does the document need to be sent to another agency for additional signatures? If yes, N/A 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 DR 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 DR 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 DR 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 DR signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip DR 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 date above and all changes made during DR the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. Please email a completed copy to / 2-S:d eJ Madison.Bird@Colliercountyfl.gov I:Forms/County Forms/BCC Fon Madison. yfl.gov 15,Revised 2.24.05;Revised 11/30/12 1 6L 2 Ett fict0td Pam 1109A(CO) C#,I a Nv.1610-000T tem Ane 1P87) Prig<tboi tyY,T49.,-, Dtponwen? DIRECT DEPOSIT SIGN-UP FORM Tvi;;Jry Dili C1.1070 DIRECTIONS • To sign up for Direct DepOtil,the payee is to reed the bads of this form io The claim number rid type of payment are printed on Government and le In the Information requested In Sections 1 and 2.Then take or checks. (See the sample check on the beak of this form.) This mat this form to the financial institution, The fnanoW Institution wit information Is also stated on beneficlarylannuttant award lettere and verify the Information In Sections 1 end 2,end win complete Section 3. other documente from the Government agency. The completed form wit be returned to the Government agency identified bekviv. * Payees must keep the Government agency Informed of any addreSS changes In order to receive Important information about benefits end to • A separate form must he completed for each type of payment to be ternein qualified for payments. sent by Direct Deposit SECTION I (TO BE COMPLETED BY PAYEE) A NAME OF PAYEE east,fire,micidit en lie!) D TYPE OF DEPOSITOR ACCOUNT CHECKING — SAVINGS ODLLIER COUNTY BOARD OF COUNTY COMISS TONERS E DEPOSITOR ACCOUNT NUMBER - , ADDRESS(slnlef,n>uie,P,O,Box,APO/FPO) ' 1056401 3299 TAMIMI TRAIL E, STE 700 CITY STATE ZIP CODE F 'TYPE OF PAYMENT(Check only one) NAPLES FL 34112 0 Soda!Soanty El Fad,Salary/MU.CUltbm Pay T 0 SuppLstrinnkniSnatitty lAorYnit 0 tAl,A.,..riyo ELEPHONE NUMBER 0 Reit oed Retkiert 0 MIL Rohe. AREA CODE 239-252-7607 0 CM1 51W/be Ratkarryint(OM) 0 MIL SUIVtiVt B NAME OF PERSON(S)ENTITLE°TO PAYMENT C-22-CP-FL-0233 ID VA Con %nation rr PonskA 0 Othv 1 GRAtiT CPF-G nt COLLMR COUNTY BOARD OF COUNTY COVHISSIOITERS (cP*4Ya) C CLAIM OR PAYROLL ID NUMBER THIS BOX FOR ALLOTMENT OF PAYMENT ONLY Of appk4b41) TYPE AMOUNT Nolo< 9 stiffu 60oo550 --- PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS CERTIFICATION(opilonel) I certify that I ern entitled to the payment idenlifeci above,and that I have I certify that I have read end understood the back of this form. read and understood the back of this form. In enir-rj this form, I including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS, athhorlze my payment to be 68r11 to the finsocial Institution named below to be deposited to the designated account, „ .... SIGNATURE — reworee-ie-se PATE SIGNATURE PATE Derek N.)ohns:en Or.141.11M0.41.11n SIGNIAittlifr. 4164j4 DIIE / SIGNATURE -ATE 2/2•7 TV' - . SECTION 2(TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION) GDVERNMTVNTMV GOVERNMENT AGENCY ADDRESS HUD/Office of cPD 451-7th Street,SE,Washington,DC 20410 SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK DIGIT /‘ i, ‘)\ \.)00V,ItyyNct el LW_ k•IP' — — T 90e 4 r4J\0P- ,1 ) ,C. DEPOSITOR ACCOUNT t.,.cx-ct\ Z:.-iA:, )\,(\Itt , ., 1 \ 4 iie,) .vk, „ ' )D i '.. ‘.\ 4- cttON)ef CO\ir VI pre,a 0 (,\,)(0t)r)e-i''3 %.1._'.....:._ ) FINANCIAL INSTITUTION CERTIFICATION I confirm the idertey of the above-named payee(a)end the account number and title. As repreeentative of the above-named financial irwtilidion,I certify that the financial Inatesition egrets lo receive and depoirt the payment Identified above In accordance with 31 CFR Parts 240,209.and PNNT OR T-PE NAME SIOPATURW REfiltEp8NTATFird T-ETEPTONE NUMBER Dr ,...„, , , 4 a( Wyl ri..e t;) Fkrerictet 1 3 haluttons aboui.J rofor to Ile GREEN t.1W,L Kfulfuottroi Instivo2c:111' THE FRIANCIAL INSTITUTION SHOULD MAIL THE COW,LEM°FORM TO TILE GOVERNMENT AGENOYIOEtinereo ABOVE, t4Sti 7s.toot.os,....on4 FINANCIAL INBTITUI ION COPY 1199.207 15riv4.:tistv vellum I-No,V.1 CAillNi ,42.t'd 1 C.) 1 6L Standard Form 11UaA(EG) Ort8140.1510-000T Ow,ant WV) Prr"''tvi"rr:s,ry DIRECT DEPOSIT SIGN-UP FORM (k,�trtt'tN T ws�ry Dtrc Cs:1070 DIRECTIONS • To sign up for Direct Deposit,the payee is to read the bade of this form • The claim number ark! type of payment are printed on Gos,emment and 111 In the InformatIon requested In Sections 1 ond2.Then take or checks. (See the sample check on the book of this form) Thls hail this form to the fsnamtal institution. The Wendel Institution wtl Information is also stated on benefictarytannillarrt award lettere and verify the Information in Sections I and 2,and w'ril compfeta Section 3. other doctmen a from the Government agency. The completed ftxm wit be retuned to the Govemment agency Idontitod below. • Payees must keep the Government agency Informed of any address change?in order to receive important information about benefits end to • A separate form must be completed for each type of payment to be remain qualified for payments. 011p,� l Adtff888: sent by Direct Depose. i SECTION 1 (TO BE COMPLETED BY PAYEE) lrevrpttft rvliierclerk,cotlh • !a NAME OF PAYEE{last,lost,mkklJe?n111en D TYPE OF DEPOSITOR ACCOUNT' i J CHECKING C SAVINGS COLLIER COUNTY BOARD Or COUNTY COr4ti.I88I ONE RS E DEPOSITOR ACCOUNT NUMBER ADDRESS(street,mule,P.O.Box,APO/FPO) I 0 5 6 4 0 7 3299 TAHIA14I TRAIL E, STE 700 CITY STATE ZIP CODE F TYPE OF PAYMENT(Check only one) NAPLES [Z 34112 ❑SodelStxvrty D Pod,9ekrryA.LCh11anPry TELEPHONE NUMBER C3 supprernrrntat Security Inowre 0 it Ar,IHa CODE 239.252^7007 ❑RerntudRatkenrera ❑MlIMirirtr. AREA B NAME OF PERSON(S)ENTITLED TO PAYMENT ❑CN;t SwamRetkemery(CPU) 0N9t gun era B-22-CP-FL-0233 ❑VA Compormagon or Ponslm 0 OUwr GRANT CPF-C nI COLLIER COUNTY BOARD Or COUNTY COINI99I0NER9 (speco C CLAJM OR PAYROLL ID NUMBER t THIS BOX FOR ALLOTMENT OF PAYMENT ONLY(rfepplcabfe) TYPE AMOUNT Prefix 59 SUrru 6000558 PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS'CERTIFICATION(optiorrelf I certify that I am entitled to the payment Identified above,and that I have I certify that I have read end understood the beck of this form, read and understood the bark of tNa form. In elgnfng this form, I including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS authorize my payment to be sent to the Mandel Imtitylien named below to be depoalted to the designated aceoU7I. SIGNATURE Derek hl.lDhnssenin.u,Jr,II,n.,tIt. DATE SIGNATURE DATE te,:ttrUKNtrrrsr44r SIGNATURE' ,`�// a • D�y1E 'f Z SIGNATURE DATE y'�lJl�l, Z 1� SECTION 2(TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION) GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS HUD/Office of CPD 415-7th Street,SW,Washington,DC 20410 SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITU770N) NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK -4- FK)L4,1 0. t+n ciCif1 DIGIT =1tI � �� 15G1 q CA• ci \e)l`" 1 DEPOSITOR ACCOUNT TITLE f I ', tit, t'a, IZe ��7P5 1 - 3t. 17 \\1rr^ (���rr�� f.}t 4(,a 0 —Crovtin c)fctl FINANCIAL INSTITUTION CERTIFICATION I confirm the Ideriity of the above-named peyee(e)and the account number end title, As representative of the above-named tinanctei Institution,I certify that the f narxiel institution agrees to reserve end deposit the payment identified above in accordance hdIh 31 CFR Parte 240,209.end 210. PRINT oR TYPE REPR SENTA VE`S NAME Sl Ep RE1�7ATTATIVE j, TELEPHONE NUMBER OAT, ^ � AI l .5 f lj ... {(�-fit PiLJ has37 a 9 51 a z Ftsnawn.,ttrilortsdloukirc(ertot uoREEN=i.• Iorrwtlwrhdrucibrrt. THE FINANCIAL tN3rUTl01r SHOULD PAIL THE COMPLETED FORM TO THE GOVERNMENT AOENOY IOENT1FED ABOVE. NMI MO GOVERNMENT AGENCY COPY I1611.207 I.e-r jw utrvPntor9 n NJeituvtt use?! CAp SUWard Form 11D9A(EG) Cf.413.thi 1610-0007 .kflt gel) Prswritvi Torlsurf Deprowa DIRECT DEPOSIT SIGN-UP FORM T-sc sir/Dort Cr.1074.1 DIRECTIONS • To sign up for Direct Deposit,the payee is to read the bac*of this form • The claim number end type of payment are printed on Government and lit in the Information requetted in Sectlom 1 and 2,Then take or checks. (See the sem* check on the bEr.* of this form.) This mat thle form to the filanclat Institution. The friancial InstItufen with Information Is also slated on beneticiary/anmilant award letters and verify tha information In Sections 1 and 2,and will complete Section 3. other documents from the Government agency. The oampleted form MI be retuned to the Government agency kientified below. • Payees must keep the Government agency Informed of any address ohangee in order to receive important information about benefits and to o A separate form must be completed far each type of payment to be remeln qualified for payments, sent by Direct Depost, SECTION 1 (TO SE COMPLETED BY PAYEE) A NAME OF PAYEE Vast fast, middle initie9 B TYPE OF DEPOSITOR ACCOUNT CHECKING SAVINGS COLLIER COUNTY BOARD OF COUNTY COMNISSIONERS E DEPOSITOR ACCOUNT NUMBER ADDRESS(street,route,P.O.Box,APO/FPO) 1056401 3299 'I/WINO TRAIL E, STE 700 CITY STATE ZIP CODE F TYPE OF PAYMENT(Check only one) NAPLES FL 34112 0 Sethi txmity 0 Fed Miran Pny TELEPHONE NUMBER 0 sup pri.mentatSrsowily Inorrm 0 ML Mut-, 239,-252-7007 LI 114th iNd Rtitlruinv it 0 PAL null's,. AREA CODE CO Soo RellrornonI(0#1,9 t Survb B NAME OF PERSON(S)ENTITLED TO PAYMENT C-22-CP-FL-0233 0VA Comppmalion 04 P041100 0 Other awn CPF-Grant COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS OPOCk C CLAIM OR PAYROLL ID NUMBER 0 THIS BOX FOR ALLOTMENT OF PAYMENT ONLY(f appket]Je) TYPE AMOUNT NON 5 9 sum 6000550 PAYEE/JOINT PAYEE CERTIFICATION JOINT ACCOUNT HOLDERS CERTIFICATION(op?ional) I certify that I em entitled to the payment Identified above,and that I have I certify that I have read end understood the back of (Na form, read end understood the back of the form, In signing No form, I Including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDER$. authorize my payment to be sent to the financial Institution named be(ew to be deposited to the designated account. SIGNATURE 000,14,/Ir,f0.1r1 Y DATE S • IRE DATE Derek M.Johnssen AP.41 N.4,?4L1.111110.01{.1“.4 SIGNATUR ..))4,„At 847/_., SIGNATURE DATE SECTION 2(TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION) GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS HUD/Office of CPD 451-7th Street,SW,Washington,DC 20410 SECTION 3(TO BE COMPLETED BY FINANCIAL INSTITUTION) NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER CHECK v.\ . Ar‘da4ct) Pcx . DIGIT 1,0 r) "W t)V\ Ilf*Mt.1(‘ 4 S re , 110. 74,7 P ACCOUNT TITLE CiP\o DEOSITOR CC 35(00 fi vs? FINANCIAL INSTITUTION CERTIFICATION I confirm the Idertky of the above-named payee(a)and the account number and life. As representative of the ebove•namod fir institution,I certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Prate 290,209.end 210, PRINT Ofi TYPVEVESENTATivE'S NAME SiliaNATURE Of RE oRE4ENTATIvl TELEPHONE NUMBER DATE , A e \ LA'1-11/ 42' fo< 3 a-s: 0-13 Financ4a1b11.Items should(Vol lo the GREEN for fuilbor THE FINANCIAL INSTITUTION SHOIJI-0 MAIL THE COWPLE1'EO FORM TO THE GOVERNMENT AGENCY IDEUTtFIEO ABOVE, liSti?VG 01.05.5.7224 PAYEE COPY 1109.207 Oroyitc uirg c...1.ADIt,Ma-g/ 16L2 SF 1199A(Back) BURDEN ESTIMATE STATEMENT The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property & Supply Section, Room B-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of Management and Budget, Paperwork Reduction Project(1510-0007), Washington, D.C. 20503. PLEASE READ THIS CAREFULLY All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 209 and/or 210. The information is confidential and is needed to prove entitlement to payments. The information will be used to process payment data from the Federal agency to the financial institution and/or its agent. Failure to provide the requested information may affect the processing of this form and may delay or prevent the receipt of payments through the Direct Deposit/Electronic Funds Transfer Program. INFORMATION FOUND ON CHECKS Most of the information needed to complete boxes A, ls C, and F in Section 1 is printed on your government United States Treasury ss Check: Twiny:La)Year AU5I N,TEXAS Check No. oa�( ea 0000 415785 OA Be sure that payee's name is written exactly as it ap- QOM 0 O 28 28 DOLLARS CTS pears on the check. Be sure current address is shown. Payfo 4111.0 $"`"100 160 the order of © Claim numbers and suffixes are printed here on checks beneath the date for the type of payment shown here. Check the Green Book for the location of prefixes and suffixes for other typos of payments. 0 NOT NEGOTIABLE, OF Type of payment is printed to the left of the amount. 00000518:041571926^ SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS Joint account holders should immediately advise both the Government agency and the financial institution of the death of a beneficiary. Funds deposited after the date of death or ineligibility, except for salary payments, are to be returned to the Government agency. The Government agency will then make a determination regarding survivor rights, calculate survivor benefit payments, if any,and begin payments. CANCELLATION The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the Federal agency or by the death or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient should notify the receiving financial institution that he/she is doing so. The agreement represented by this authorization may be cancelled by the financial institution by providing the recipient a written notice 30 days in advance of the cancellation date. The recipient must immediately advise the Federal agency if the authorization is cancelled by the financial institution. The financial institution cannot cancel the authorization by advice to the Government agency. CHANGING RECEIVING FINANCIAL INSTITUTIONS The payee's Direct Deposit will continue to be received by the selected financial institution until the Government agency is notified by the payee that the payee wishes to change the financial institution receiving the Direct Deposit. To effect this change, the payee will complete a new SF 1199A at the newly selected financial institution. It is recommended that the payee maintain accounts at both financial institutions until the transition is complete, i.e. after the new financial institution receives the payee's Direct Deposit payment. FALSE STATEMENTS OR FRAUDULENT CLAIMS Federal law provides a fine of not more than $10,000 or imprisonment for not more than five (5) years or both for presenting a false statement or making a fraudulent claim. 1 ��U x�u~ 2 ATTEST Si El" Ap q I(.s 171 rm and egality: Ronald T. Tomasko Assistant County Attorney