Backup Documents 07/09/2024 Item #16D1 16D1
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. Mark Kadlec, Grants Accountant Community & Human ,71 07/09/24
Services
2. Carly Sanseverino County Attorney Office
7/23/2ti
3. BCC Chairman Board of County
Commissioners C4f47mkt
7/2`f(Zy
4. Minutes and Records Clerk of Court's Office pit
744/4r
OF
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 July 9,2024 Agenda Item Number 16 D.1
Approved by the BCC
Type of Document ESG Grant Close-out Form SF-425 Number of Original 3
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 on07/09/24 and all changes made during the MK N/A is not an
meeting have been incorporated in the attached document. The County Attorney's option for
Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not an
BCC,all changes directed by the BCC have been made,and the document is ready for the 054, 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
16D1
Federal Financial Report OMB Number:4040-0014
(Follow form Instructions) Expiration Date:02/28/2025
1.Federal Agency and Organizational Element to Which Report is Submitted 2.Federal Grant or Other Identifying Number Assigned by Federal
Agency(To report multiple grants,use FFR Attachment)
US Housing and Urban Development
E-20--UC-12-0016
3.Recipient Organization(Name and complete address including Zip code)
Recipient Organization Name: collier County Board of County Commissioners
Streetl: 3339 East Tamiami Trail
Street2:
City: Naples County: Collier
State: FL: Florida Province:
Country: USA: UNITED STATES ZIP/Postai Code: 34112-5361
4a.UEI 4b.EIN 5.Recipient Account Number or Identifying Number
JVIKJKYRPLLU6 596000558 (To report multiple grants,use FFR Attachment)
6.Report Type 7.Basis of Accounting 8.Project/Grant Period 9.Reporting Period End Date
Quarterly ® Cash From: To: 07/23/2023
Semi-Annual D Accrual 01/25/2021 07/23/2023
El Annual
®Final
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 205,067.00
b.Cash Disbursements 205,067.00
c.Cash on Hand(line a minus b) o.00
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d.Total Federal funds authorized 205,067.00
e.Federal share of expenditures 205,067.00
f.Federal share of unliquidated obligations 0.00
g.Total Federal share(sum of lines e and f) 205,067.00
h.Unobllgated balance of Federal Funds(lined minus g) 0.00
Recipient Share:
i.Total recipient share required 205,067.00
j.Recipient share of expenditures 205,0 69.69
k.Remaining recipient share to be provided(line I minus J) 0.00
Program Income:
I.Total Federal program income earned 0.00
m.Program Income expended In accordance with the deduction alternative 0.00
n.Program Income expended In accordance with the addition alternative 0.00
o.Unexpended program income(line I minus line m and line n) 0.00
's�CJ 1
16D1
11,Indirect Expense
a.Type b.Rate c.Period From Period To d.Base e.Amount f.Federal Share
Charged
— i
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
Add Attachment' Delete Attachment View Attachment` I
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 objectives set forth In the terms and conditions of the Federal award.
am aware that any false,fictitious,or fraudulent information,or the omission of any material fact,may subject me to criminal,civil or
administrative penalties for fraud,false statements,false claims or otherwise.(U.S.Code Title 18,Section 1001 and Title 31,Sections 3729-3730
and 3801-3812).
a.Name and Title of Authorized Certifying Official
Prefix: First Name: Chris Middle Name:
Last Name: Hall Suffix:
Title: LCommissioner District 2
b.Signature of A o' ed Certifying Official c.Telephone(Area code,number and extension)
(239) 252-2792
d,Email A ss e.Date Report Submitted 14.Agency use only:
chris.hall@colliercountyfl.gay
• Standard Form 425
CRC. z �, , . RK .
L�e,poty,Clerk
Attest a• to e airman
sinn*' !.trc
r
AO
16D1
Federal Financial Report OMB Number:4040-0014
(Follow form Instructions) Expiration Date:02/28/2025
1.Federal Agency and Organizational Element to Which Report Is Submitted 2.Federal Grant or Other Identifying Number Assigned by Federal
Agency(To report multiple grants,use FFR Attachment)
us Housing and Urban Development
E-21-UC-12-0016
3,Recipient Organization(Name and complete address Including Zip code)
Recipient Organization Name: collier County Board of County Commissioners
Street1: 3339 East Tamiami Trail
Street2:
City: Naples County: Collier
State: FL: Florida Province:
Country; USA: UNITED STATES ZIP/Postal Code: 34112-5361
4a.UEI 4b.EIN 5.Recipient Account Number or Identifying Number
(To report multiple grants,use FFR Attachment)
J[WWKJKYRFLLU6 596000558
6.Report Type 7,Basis of Accounting 8,Project/Grant Period 9.Reporting Period End Date
Quarterly ® Cash From: To: 03/31/2029
Semi-Annual ❑ Accrual 09/10/2021 03/31/2029
❑Annual
®Final
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 217,796.00
b.Cash Disbursements 217,796.00
O.Cash on Hand(line a minus b) 0.00
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d.Total Federal funds authorized 217,796.00
e.Federal share of expenditures 217,796.00
f,Federal share of unliquidated obligations a.00
g.Total Federal share(sum of lines e and f) 217,796,00
h.Unobligated balance of Federal Funds(lined minus g) 0.00
Recipient Share:
i.Total recipient share required 217,796.00
I.Recipient share of expenditures 220,973.05
k.Remaining recipient share to be provided(line i minus j) 0.00
Program Income:
I.Total Federal program income earned 0.00
m.Program Income expended in accordance with the deduction alternative o.00
n.Program Income expended in accordance with the addition alternative 0.00
o.Unexpended program income(line I minus line m and line n) 0,0o
(CA ;
16D11
11.Indirect Expense
a.Type b.Rate c.Period From Period To d.Base e:Amount f.Federal Share
Charged
g.Totals:
12.Remarks:Attach any explanations deemed necessary or Information required by Federal sponsoring agency In compliance with governing legislation:
Add Attachment:i Delete Attachment View Attachment:
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 objectives set forth in the terms and conditions of the Federal award.I
am aware that any false,fictitious,or fraudulent Information,or the omission of any material fact,may subject me to criminal,civil or
administrative penalties for fraud,false statements,false claims or otherwise.(U.S.Code Title 18,Section 1001 and Title 31,Sections 3729-3730
and 3801-3812).
a.Name and Title of Authorized Certifying Official
Prefix: First Name: Chris Middle Name:
Last Name: Ba11 Suffix:
Title: Commissioner District 2
b,Signature of A on ed Certifying Official c,Telephone(Area code,number and extension)
(239) 252-2792
d.Email Ad s e.Date Report Submitted 14,Agency use only:
chris.hall@colliercountyfl.gov
Standard Form 425
A fTF ': •
•
CRY ,
- •
Deputy Clerk
t a &Chairman's
nature orit ;
1 6 D 1,
Federal Financial Report OMB Number:4040-0014
(Follow form Instructions) Expiration Date:0 212 812 0 2 5
1.Federal Agency and Organizational Element to Which Report is Submitted 2.Federal Grant or Other Identifying Number Assigned by Federal
Agency(To report multiple grants,use FFR Attachment)
US HOUSING AND URBAN DEVELOPMENT
E--20--uW-12-0016
3.Recipient Organization(Name and complete address including Zip code)
Recipient Organization Name: Collier County Board of County Commissioners
' I
Streetl: 3339 TAMIAMI TRL E
Street2: Public Services Department Ste 211
City: Naples County: Collier
State: FL: Florida Province:
Country: USA; UNITED STATES ZIP/Postal Code: 34112-5361
4a.UEI 4b.EIN 5.Recipient Account Number or Identifying Number
(To report multiple grants,use FFR Attachment)
JWKJKYRPLLU6 596000558
E-20-UN-12-0016
6.Report Type 7.Basis of Accounting 8.Project/Grant Period 9.Reporting Period End Date
Quarterly ® Cash From: To: 09/30/2023
Semi-Annual Accrual 09/22/2020 09/30/2023
Annual
®Final
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 3,183,770.00
b.Cash Disbursements 3,183,770.00
c.Cash on Hand(line a minus b) 0.00
(Use fines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d.Total Federal funds authorized 3,183,770.00
e.Federal share of expenditures 3,183,770.00
f.Federal share of unliquidated obligations o.0o
g.Total Federal share(sum of lines a and f) 3,183,770.00
h.Unobligated balance of Federal Funds(fine d minus g) 0,00
Recipient Share:
i.Total recipient share required 0.00
j.Recipient share of expenditures 0.00
k.Remaining recipient share to be provided(line i minus j) 0.00
Program Income:
I.Total Federal program income earned o,00
m.Program Income expended in accordance with the deduction alternative 0.00
n.Program Income expended in accordance with the addition alternative 0.00
o.Unexpended program income(line I minus line m and line n) o,00
16D1
11.Indirect Expense
a.Type b.Rate c.Period From Period To d,Base e•Amount Charged f.Federal Share
g.Totals:
12.Remarks:Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation,
Add Attachment Delete Attachment View Attachment:,
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 objectives set forth in the terms and conditions of the Federal award.
am aware that any false,fictitious,or fraudulent information,or the omission of any material fact,may subject me to criminal,civil or
administrative penalties for fraud,false statements,false claims or otherwise.(U.S.Code Title 18,Section 1001 and Title 31,Sections 3729-3730
and 3801-3812).
a.Name and Title of Authorized Certifying Official
Prefix: First Name: Chris Middle Name:
Last Name: Ha11 Suffix:
Title: Commissioner District 2
b.Signature of o zed Certifying Official c.Telephone(Area code,number and extension)
(239)252-2792
d.Email A ress e.Date Report Submitted 14.Agency use only:
•
Chris.Hall@colliercountyfl.gov
„ '}}.. Standard Form 425
a 1
ATTF*.-
CR r fp •
�.iC
:v!!' ,t thy`Clerk
A' •st. - to`Chairrrian's
Signature.only':