Backup Documents 03/26/2024 Item #16D 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
1 6 D 5
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. Mark Kadlec, Grants Accountant Community & Human ,7i , 04/02/24
Services
2. Derek D. Perry County Attorney Office 0 0 1412.4
3. BCC Chairman Board of County
Commissioners C4 pp,fr f .t f /Z`(
4. Minutes and Records Clerk of Court's Office \(\k()
/( '$�'"f
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 Mark Kadlec/CHS Grants Accountant Phone Number 239-252-5213
Contact/ Department
Agenda Date Item was March 26,2024 Agenda Item Number 16 D.5
Approved by the BCC
Type of Document HOME Grant Close-out Form SF-425 Number of Original 6
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?STAMP is OK MK N/A
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 MK
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 N/A
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 N/A
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 MK
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip MK
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 03/26/24 and all changes made during MK N/A is not an
the meeting have been incorporated in the attached document. The County option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the r N/A is not an
BCC,all changes directed by the BCC have been made,and the document is ready for the 00 option for
Chairman's signature. this line.
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
16D 5
Cofler County
Public Services Department
Community & Human Services Division
MEMO
April 02, 2024
TO: BCC—Minutes & Records
FROM: Mark Kadlec, Grants Accountant
RE: BCC Agenda Item 16D.5
HOME Closeout Form SF-425
Please have the Chairman sign with original signature, of the six attached HOME Closeout Form
SF-425. Once the forms have been signed, please return one original and e-mail a scanned copy
to me at Mark.Kadlec@colliercountyfl.gov. Please contact me when the original is ready for
pickup.
If you have any questions, please call me at: X-5213
Thank You!
•
Community&Human Services Division•3339 Tamiami Trail East,Suite 211•Naples,Florida 34112-5361
239-252-CARE(2273)•239-252-CAFE(2233)•239-252-4230(RSVP)•www.colliergov.netlhumanservices
16D 5
FEDERAL FINANCIAL REPORT
(Follow form instructions)
1.Federal Agency and Organizational Element '2.Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants,use FFR Attachment)
Department of Housing and Urban Development M11UC120217 9 21
pages
3.Recipient Organization:
COLLIER COUNTY,FL
3301 Tamiami Trl E
Naples,FL 34112-4961
4a.UEI Number 4b.EIN 5.Recipient Account Number or Identifying Number 6.Report Type 7.Basis of Accounting
(To report multiple grants,use FFR Attachment) Quarterly Cash
596000558 Semi-Annual X Accrual
Annual
Final
8.Project/Grant Period To:(Month,Day,Year) 9.Reporting Period End Date:
From:10/12/2011 n/a 01/31/2024
10.Transactions Cumulative
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants,also use FFR Attachment):
a. Cash Receipts N/A
b. Cash Disbursements N/A
c. Cash on Hand(line a minus b) N/A
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized $493,138.85
e. Federal share of expenditures $493,138.85
f. Federal share of unliquidated obligations
g. Total Federal share(sum of lines e and f) $493,138.85
h. Unobligated balance of Federal funds(lined minus g) $0.00
Recipient Share:
i. Total recipient share required N/A
j. Recipient share of expenditures N/A
k. Remaining recipient share to be provided(line i minus j) N/A
Program Income:
I. Total Federal program income earned $13.398.00
m.Program income expended in accordance with the deduction alternative N/A
n. Program income expended in accordance with the addition alternative $13,398.00
o. Unexpended program income(line I minus line m or line n) $0.00
11.Indirect a.Type b.Rate c.Period Period To d.Base e. Amount Charged f.Federal Share
From
Expense
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13.Certification: By signing this report,I certify to the best of my knowledge and belief that the report is true,complete,and accurate,and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents.I am aware that any false,fictitious,or fraudulent information
may subject me to criminal,civil,or administrative penalties.(U.S.Code,Title 18,Section 1001)
a. Typed or Printed Name and Title of Authorized i Official c. Telephone(Area code,number and exter i l- 252-8602
d. Email address chris.hall@colliercountyfl.gov
b. t Chris llall, Chairman al e. Date Report Submitted (Month,Day,Year)
Attest: •r p ved•s to fo 1 and legality: 14.Agency use only
CRYSTAL K.KINZEe CLERK Or Standard Form 425-Revised 10/11/2011
OMB�' Approval E pratonDate:2/28 0�40-0014
may: Dere D.Perry
q De !�1 y Assistant County Attorney
,gyp J Paperwork Burden Sfatertrknt
Ce r� According to the Pape Reduction Act,as amended,no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.The valid OMB control number
`r.
for this information co on is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response,including time for reviewing instructions,searching
v! a existing data sources,gathering and maintaining the data needed.and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of this
� collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0060).Washington,DC 20503.
C�'
15D 5 •, .
FEDERAL FINANCIAL REPORT
(Follow form instructions)
1.Federal Agency and Organizational Element 2.Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants,use FFR Attachment)
Department of Housing and Urban Development M12UC120217 10 21
pages
3.Recipient Organization:
COLLIER COUNTY,FL
3301 Tamiami Trl E
Naples,FL 34112-4961
4a.UEI Number 4b.EIN 5.Recipient Account Number or Identifying Number 6.Report Type 7.Basis of Accounting
(To report multiple grants,use FFR Attachment) Quarterly — Cash
596000558 Semi-Annual X Accrual
Annual
Final
8.Project/Grant Period To:(Month,Day,Year) 9.Reporting Period End Date:
From:09/28/2012 nia 01/31/2024
10.Transactions Cumulative
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants,also use FFR Attachment):
a. Cash Receipts N/A
b. Cash Disbursements N/A
c. Cash on Hand(line a minus b) N/A
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized $136,777.00
e. Federal share of expenditures $136,777.00
f. Federal share of unliquidated obligations
g. Total Federal share(sum of lines e and f) $136,777.00
h. Unobligated balance of Federal funds(lined minus g) $0.00
Recipient Share:
i. Total recipient share required N/A
j. Recipient share of expenditures N/A
k. Remaining recipient share to be provided(line i minus j) N/A
Program Income:
I. Total Federal program income earned $0.00
m.Program income expended in accordance with the deduction alternative N/A
n. Program income expended in accordance with the addition alternative $0.00
o. Unexpended program income(line I minus line m or line n) $0.00
11,Indirect a.Type b.Rate c.Period Period To d.Base e. Amount Charged f.Federal Share
From
Expense
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13.Certification: By signing this report,I certify to the best of my knowledge and belief that the report is true,complete,and accurate,and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents.I am aware that any false,fictitious,or fraudulent information
may subject me to criminal,civil,or administrative penalties.(U.S.Code,Title 18,Section 1001)
a. - c. Telephone(Area code,number and extension)
Chris Hall, Chairman (239) 252-8602
d. Email address
�7/Alsollaik
chris.hall(a,colliercountyfl.gov
b. Signature of Authorized Certifying Official `/ e. Date Report Submitted (Month,Day,Year)
4w
Attest: A ro d s to a le ali 14.Agency use only
,,CRYSTAL K.KINZEL,CLE 8 Ty
a;
•
Standard Form 425-Revised 101 tl2011
"���.LL '' �, OMB ration vat Number:4040-0014
-By: IflN!/'„��" / Expiration Date:2J2&'2025
Dere .Pe
U rj d'cplr,'C; ' Assistant County Attorney
Paperwork Burden Steltagiie n
/
According to the Papervrgtk duction Act,as amended,no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.The valid OMB control number
fly (- for this information colic io s 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response,including time for reviewing instructions,searching
.ti •0) existing data sources,g ring and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of this
Qry y collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0060),Washington,DC 20503.
V`
1 6 D 5
FEDERAL FINANCIAL REPORT
(Follow form instructions)
1.Federal Agency and Organizational Element 2.Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants,use FFR Attachment)
Department of Housing and Urban Development M13UC120217 11 21
pages
3.Recipient Organization:
COLLIER COUNTY,FL
3301 Tamiami Trl E
Naples,FL 34112-4961
4a.UEI Number 4b.EIN 5.Recipient Account Number or Identifying Number 6.Report Type 7.Basis of Accounting
(To report multiple grants,use FFR Attachment) — Quarterly ' Cash
596000558 _ Semi-Annual x Accrual
Annual
Final
8.Project/Grant Period To:(Month,Day,Year) 9.Reporting Period End Date:
From:10/23/2013 nia 01/31/2024
10.Transactions Cumulative
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants,also use FFR Attachment):
a. Cash Receipts N/A
b. Cash Disbursements N/A
c. Cash on Hand(line a minus b) N/A
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized $474,031.00
e. Federal share of expenditures $474,031.00
f. Federal share of unliquidated obligations
g. Total Federal share(sum of lines e and f) $474,031.00
h. Unobligated balance of Federal funds(line d minus g) $0.00
Recipient Share:
i. Total recipient share required N/A
j. Recipient share of expenditures N/A
k. Remaining recipient share to be provided(line i minus j) N/A
Program Income:
I. Total Federal program income earned $40,000.00
m.Program income expended in accordance with the deduction alternative N/A
n. Program income expended in accordance with the addition alternative $40,000.00
o. Unexpended program income(line I minus line m or line n) $0.00
11.Indirect a.Type b.Rate c.Period Period To d.Base e. Amount Charged f.Federal Share
From
Expense
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13.Certification: By signing this report,I certify to the best of my knowledge and belief that the report is true,complete,and accurate,and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents.I am aware that any false,fictitious,or fraudulent information
may subject me to criminal,civil,or administrative penalties.(U.S.Code,Title 18,Section 1001)
a. Typed or Printed Name and Title of Authorized Certifying ft ial c. Telephone(Area code,number and extension)
(2. 9) 252-8602
d. Email address
b r�.'$ -1t11Critl1 an chris.hall@colliercountyfl.gov
N.t i e. Date Report Submitted (Month,Day,Year)
Attest: . ro •d a fo]) and le_• 14.Agency use only
.&t't RYSTAL K.KINZEL,CLERK R
Standard Form 425-Revised 10/11/2011
•
W OMB Approval Number:4040-0014
��.4.By:_ P- ek D.Petry - Expiration Date:2/28/2025
5-
4r '`•"D ty. Assistant County Attorney
•
Paperwork Burden Slat' M
C According to the Paporwo Reduction Act,as amended,no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.The valid OMB control number
w for this information collection is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response,including time for reviewing instructions,searching
0+� y existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of this
collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0060),Washington,DC 20503.
•4 n
V'
16D 5
FEDERAL FINANCIAL REPORT
(Follow form instructions)
1.Federal Agency and Organizational Element 2.Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants,use FFR Attachment)
Department of Housing and Urban Development M14UC120217 12 21
pages
3.Recipient Organization:
COLLIER COUNTY,FL
3301 Tamiami Trl E
Naples,FL 34112-4961
4a.UEI Number 4b.EIN 5.Recipient Account Number or Identifying Number 6.Report Type 7.Basis of Accounting
(To report multiple grants,use FFR Attachment) Quarterly Cash
596000558 Semi-Annual El Cash
Annual
Final
8.Project/Grant Period To:(Month,Day,Year) 9.Reporting Period End Date:
From:09/24/2014 nia 01/31/2024
10.Transactions Cumulative
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants,also use FFR Attachment):
a. Cash Receipts N/A
b. Cash Disbursements N/A
c. Cash on Hand(line a minus b) N/A
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized $501,110.00
e. Federal share of expenditures $501,110.00
f. Federal share of unliquidated obligations
g. Total Federal share(sum of lines e and f) $501,110.00
h. Unobligated balance of Federal funds(lined minus g) $0.00
Recipient Share:
i. Total recipient share required N/A
j. Recipient share of expenditures N/A
k. Remaining recipient share to be provided(line i minus j) N/A
Program Income:
I. Total Federal program income earned $76,478.86
m.Program income expended in accordance with the deduction alternative N/A
n. Program income expended in accordance with the addition alternative $76,478.86
o. Unexpended program income(line I minus line m or line n) $0.00
11.Indirect a.Type b.Rate c.Period Period To d.Base e. Amount Charged f.Federal Share
From
Expense
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13.Certification: By signing this report,I certify to the best of my knowledge and belief that the report is true,complete,and accurate,and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents.I am aware that any false,fictitious,or fraudulent information
may subject me to criminal,civil,or administrative p aft' s.(U.S.Code,Title 18,Section 1001)
a. Typed or Printed Name and Title of Authorized C i g fficial c. Telephone(Area code,number and extension)
(239) 252-8602
*1 gym l r•^"+�•,1' d. Email address
chris.hall(aicolliercountyfl,gov
luis 1�`all, C1YLttrrnin; e. Date Report Submitted (Month,Day,Year)
Attest: 4prov d a f and legality: 14.Agency use only
eRYSTAL K.KINZEL,CLEILK R�
Standard Form 425-Revised 10'11/2011
\✓ OMB Approval Number:4040-0014
r0 C 3y: • - rek D.Perry Expiration Date:2/28/2025
V d l�c u r sistant County Attorney
J Paperwork Burden Sla nt
4y 7 According to the Pape Reduction Act,as amended,no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.The valid OMB control number
QC for this information cotle n is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response,including time for reviewing instructions,searching
4 h existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of this
collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0060),Washington,DC 20503.
��b
16D 5
FEDERAL FINANCIAL REPORT
(Follow form instructions)
1.Federal Agency and Organizational Element 2.Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants,use FFR Attachment)
Department of Housing and Urban Development M15UC120217 13 21
pages
3.Recipient Organization:
COLLIER COUNTY,FL
3301 Tamiami Tri E
Naples,FL 34112-4961
4a.UEI Number 4b.EIN 5.Recipient Account Number or Identifying Number 6.Report Type 7.Basis of Accounting
(To report multiple grants,use FFR Attachment) — Quarterly Cash
596000558 Semi-Annual X Accrual
Annual
Final
8.Project/Grant Period To:(Month,Day,Year) 9.Reporting Period End Date:
From:11/04/2015 09/30/2023 01/31/2024
10.Transactions Cumulative
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants,also use FFR Attachment):
a. Cash Receipts N/A
b. Cash Disbursements N/A
c. Cash on Hand(line a minus b) N/A
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized $453,588.00
e. Federal share of expenditures $453,588.00
f. Federal share of unliquidated obligations
g. Total Federal share(sum of lines e and f) $453,588.00
h. Unobligated balance of Federal funds(lined minus g) $0.00
Recipient Share:
i. Total recipient share required N/A
j. Recipient share of expenditures N/A
k. Remaining recipient share to be provided(line i minus j) N/A
Program Income:
I. Total Federal program income earned $80,219.26
m.Program income expended in accordance with the deduction alternative N/A
n. Program income expended in accordance with the addition alternative $80,219.26
o. Unexpended program income(line I minus line m or line n) $0.00
11,Indirect a.Type b.Rate c.Period Period To d.Base e. Amount Charged f.Federal Share
From
Expense
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13.Certification: By signing this report,I certify to the best of my knowledge and belief that the report is true,complete,and accurate,and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents.I am aware that any false,fictitious,or fraudulent information
may subject me to criminal,civil,or administrative penalties.(U.S.Code,Title 18,Section 1001)
a. Typed or Printed Name and Title of Authorized Certi 0 icial c. Telephone(Area code,number and extension
(2 9) 252-8602
d. Email address chris.hall0),colliercountyfl.gov
f9lairman ✓
e. Date Report Submitted (Month,Day,Year)
Attest: A( ppro e porn and leg 14.Agency use only
CRYSTAL K.KINZEL,CLERK
Standard Form 425-Revised 10/11/2011
•
OMB Approval Number:4040-0014
By: Derek D.Perry \ l Expiration Date:2'28/2025
pt( ark Assistant County Attorney \✓
Paperwork Burden St ii ent
p`. According tothe'Pager}rprk Reduction Act,as amended,no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.The valid OMB control number
�
rDy t:'` for this information cotldption is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response,including time for reviewing instructions,searching
existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of this
y h collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0060),Washington,DC 20503.
r
16D 5
FEDERAL FINANCIAL REPORT
(Follow form instructions)
1.Federal Agency and Organizational Element 2.Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants,use FFR Attachment)
Department of Housing and Urban Development M17UC120217 15 21
pages
3.Recipient Organization:
COLLIER COUNTY,FL
3301 Tamiami Trl E
Naples,FL 34112-4961
4a.UEI Number 4b.EIN 5.Recipient Account Number or Identifying Number 6.Report Type 7.Basis of Accounting
(To report multiple grants,use FFR Attachment) '—' Quarterly -- Cash
596000558 _- Semi-Annual X Accrual
Annual
- Final
8.Project/Grant Period To:(Month,Day,Year) 9.Reporting Period End Date:
From:10/19/2017 09/30;2025 01/31/2024
10.Transactions Cumulative
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants,also use FFR Attachment):
a. Cash Receipts N/A
b. Cash Disbursements N/A
c. Cash on Hand(line a minus b) N/A
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized $491,703.00
e. Federal share of expenditures $491,703.00
f. Federal share of unliquidated obligations
g. Total Federal share(sum of lines e and f) $491,703.00
h. Unobligated balance of Federal funds(lined minus g) $0.00
Recipient Share:
i. Total recipient share required N/A
j. Recipient share of expenditures N/A
k. Remaining recipient share to be provided(line i minus j) N/A
Program Income:
I. Total Federal program income earned $63.796.11
m.Program income expended in accordance with the deduction alternative N/A
n. Program income expended in accordance with the addition alternative $63,796.11
o. Unexpended program income(line I minus line m or line n) $0.00
11.Indirect a.Type b.Rate c.Period Period To d.Base e. Amount Charged f.Federal Share
From
Expense
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13.Certification: By signing this report,I certify to the best of my knowledge and belief that the report is true,complete,and accurate,and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents.I am aware that any false,fictitious,or fraudulent information
may subject me to criminal,civil,or administrative penalties.(U.S.Code,Title 18,Section 1001)
a. Typed or Printed Name and Title of Authorized Ce g tidal c. Telephone(Area code,number and extension)
(239) 252-8602
d. ::':::s:ubs
l
,�fr rcount@l.gov
Ch6ll $1' a1r1T]all e. mitted (Month,Day,Year)
•
Attest: r rvr'.as r fn s and le • ity: 14.Agency use only
R,YSTAL K.KINZEL,CLERK
m: I Standard Form 425-Revised 10/11/2011
�,�.y:� _ OMB Approval Number:4040-0014
•• Derek D.Perry �� Expiration Date:2/28/2025
�� De t '4� . •ssistant County Attorney
�4+ Paperwork Burden Stalem of
a0, J According to the Paperwork eduction Act,as amended,no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.The valid OMB control number
m m for this information collection 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response,including time for reviewing instructions,searching
(le existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate or any other aspect of this
w! r collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0060),Washington,DC 20503.
(CjI))