Backup Documents 10/22/2024 Item #16K 1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 K 1
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents arc to be torwarded 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 llonday preceding the Board meeting.
**NEW**ROUTING SLIP
Complete routing lines#I 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.
2.
3 County Attorney Office County Attorney Office W
2 7(21
4. BCC Office Board of County I
Commissioners 01/4 to/zWzy
5. Minutes and Records Clerk of Court's Office 4A4., 1O123/114 bOUVI
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 Derek D. Perry/County Attorney's Office Phone Number 252-8066
Contact/ Department
Agenda Date Item was , Agenda Item Number ib.K.3 '�
Approved by the BCC I' .2 2-
Type of Document Property Damage Release 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?
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 DDP
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 DDP
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 DDP
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip DDP
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 1•4-8 and all changes made during the l 4f
meeting have been incorporated in the attached document)The CountyAttorney's p 0 ", t
3 � ttoltack
Office has reviewed the changes,if applicable. > j C• Al+ t I rie'
9. Initials of attorney verifying that the attached document is the version approved by the NJA ' pt
BCC,all changes directed by the BCC have been made,and the document is ready for the O P :
Chairman's signature. a 0 au:. '
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised I.26.05,Revised 2.24.05;Revised 11/30/12
1 6 K 1
United UNITED AUTOMOBILE INSURANCE COMPANY
PO Box 694120, Miami, FL 33269-1120
Phone: 305-940-7299 Web: www.uaig.net
September 23, 2024
COLLIER COUNTY BOARD OF COUNTY COMMISIONERS
Claim No.: 0100331918-002-035
Policy No.: UAH 371472
PROPERTY DAMAGE RELEASE
The undersigned, for and in consideration of sum of two thousand eighteen AND 50/XX DOLLARS $2,018.50, do hereby
release and discharge ABIGAIL ARIAS PEREZ, his/hers heirs, executors and administrators (hereinafter referred to as
"Releases"), of and from any obligation, liability or responsibility arising out of his/her Property Damage claims and/or
actions for an accident, which occurred on or about February 24, 2023. The execution of this Release does not affect the
Bodily Injury portion of this claim, if any.
The undersigned acknowledges that they have read this Release and understand the terms outlined herein.
Signed, sealed and delivered this 22nd day of Octoh0r 2024.
CAUTION: READ BEFORE SIGNING BELOW
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FL,O IDA"
�•��� App ed as to form atlti legality:
7,/
Chris HaII:,:tChairman ,M AT"t F_aT: Derek D. Perry +s
"' CRY TAL K.KIN7EL, CLERK Assistant County Attorney \,� '
State of Florida �0
Countyof Collier `'"l'° ;•• '� .. "`J` s
�pcti Cl
signature 0 lY
t {ai -�
�('r s{.fir.
On this 22 day of October 2024, before me personally appeared Chris Hall, as Chairman of the Board of County
Commissioners of Collier County, to me known to be the person named herein and who executed the foregoing Release
and has acknowledged to me that the Board of County Commissioners of Collier County voluntarily executed the same.
My term expires Ay.,54- ZL{ , 20 25 ___.‘a?2
f NOTARY PUBLIC
Stamp/Seal AO0..4 MADISON BIRD
* ; , 4.
* Commission#NH 168717
Expires August 24,2026
a'44F�o��e Banded TNu Budget Nataryservices
Should you have any concerns regarding the release language or if you would like to add or subtract any language in the
Release, please contact us so we can discuss any proposed changes.
Any person who knowingly and with intent to injure,defraud,or deceive any insurer files a statement of claim
or an application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree. PDSUR
Please visit us at www.uaig.net to check claim status or report a claim.