Backup Documents 09/23/2025 Item #16C 2 I 6 C 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 Alp and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. MI 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
1. Initials Date
2.
3. County Attorney Office County Attorney Office W 4. BCC Office Board of County 04c
Commissioners ;�/�' 1
5. Minutes and Records Clerk of Court's Office Vr f (��^3 `�
PRIMARY CONTACT INFORMATION MA16
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 aril."
�
Contact/ Department `1a ae_p k ar l f ar a Phone Number
Agenda Date Item was 2"602Ft
Approved by the BCC 9l /ZS Agenda Item Number
Type of Document i 6 C'Z (z 'n S'fJ
Attached Number of Original
PO number or account
S""' Documents Attached I (3 gyp' 4b'
number if document is ,-/Oz)YQOD�pa -
to be recorded Z1"f r -6ti 903 9
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate.
1. Does the document require the chairman's original signature? (Ini 'al) Applicable)
2. Does the document need to be sent to another agency for additional signatures? If yes, it
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet. {' ig
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney. it
4. All handwritten strike-through and revisions have been initialed by the County Attorney's Office and all other parties except the BCC Chairman and the Clerk to the Board CO
5. The Chairman's signature line date has been entered as the date of BCC approval of the document or the final negotiated contract date whichever is applicable. �j
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's e signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip V
should be provided to the County Attorney Office at the time the item is input into SIRE. v 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 9.(Z� and all changes made during N/A is not
the meeting have been incorporated in the attached document. The County
en
Attorney's Office has reviewed the changes, if applicable. option fmi
thiJ
9. Initials of attorney verifying that the attached document is the version approved by the N/s lis n
ot
BCC,all changes directed by the BCC have been made,and the document is ready for the , ' an option foil
Chairman's signature. p
this line.'
1: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
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CONTRACT BETWEEN
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
AND
STATE OF FLORIDA DEPARTMENT OF HEALTH
FOR OPERATION OF THE
COLLIER COUNTY HEALTH DEPARTMENT
CONTRACT YEAR 2025-2026
This contract is made and entered into between the State of Florida, Department of Health
("State"), and the Collier County Board of County Commissioners ("County"), through their
undersigned authorities, effective October 1, 2025. State and County are jointly referred to as
the "parties".
RECITALS
A. Pursuant to Chapter 154, Florida Statutes, the intent of the legislature is to
"promote, protect, maintain, and improve the health and safety of all citizens and visitors of this
state through a system of coordinated county health department services."
B. County Health Departments were created throughout Florida to satisfy this
legislative intent through the "promotion of the public's health, the control and eradication of
preventable diseases, and the provision of primary health care for special populations."
C. Collier County Health Department ("CHD") is one of the created County Health
Departments.
D. It is necessary for the parties hereto to enter into this contract to ensure
coordination between the State and the County in the operation of the CHD.
NOW, THEREFORE, in consideration of the mutual promises set forth herein, the
sufficiency of which is hereby acknowledged, the parties hereto agree as follows:
1. RECITALS. The parties mutually agree that the foregoing recitals are true and correct
and incorporated herein by reference.
2. TERM. The parties mutually agree that this contract shall be effective from October 1,
2025, through September 30, 2026, or until a written contract replacing this contract is entered
into between the parties, whichever is later, unless this contract is otherwise terminated
according to the termination provisions outlined in paragraph 8. below.
3. SERVICES MAINTAINED BY THE CHD. The parties mutually agree that the CHD shall
provide those services as outlined in Part Ill of Attachment II hereof, to maintain the following
three levels of service pursuant to section 154.01(2), Florida Statutes, as defined below:
a. "Environmental health services" are those services that are organized and operated to
protect the health of the general public by monitoring and regulating activities in the
environment that may contribute to the occurrence or transmission of disease. Environmental
health services shall be supported by available federal, state, and local funds and shall include
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those services mandated on a state or federal level. Examples of environmental health
services include but are not limited to, food hygiene, safe drinking water supply, sewage, and
solid waste disposal, swimming pools, group care facilities, migrant labor camps, toxic material
control, radiological health, and occupational health.
b. "Communicable disease control services" are those services that protect the health of
the general public through the detection, control, and eradication of diseases that are
transmitted primarily by human beings. Communicable disease services shall be supported by
available federal, state, and local funds and shall include those services mandated on a state
or federal level. Such services include, but are not limited to, epidemiology, sexually
transmissible disease detection and control, HIV/AIDS, immunization,tuberculosis control, and
maintenance of vital statistics.
c. "Primary care services" are acute care and preventive services that are made available
to well and sick persons who are unable to obtain such services due to lack of income or other
barriers beyond their control. These services are provided to benefit individuals, improve the
collective health of the public, and prevent and control the spread of disease. Primary health
care services are provided at home, in group settings, or in clinics. These services shall be
supported by available federal, state, and local funds and shall include services mandated on
a state or federal level. Examples of primary health care services include but are not limited to
first contact acute care services; chronic disease detection and treatment; maternal and child
health services; family planning; nutrition; school health; supplemental food assistance for
women, infants, and children; home health; and dental services.
4. FUNDING. The parties further agree that funding for the CHD will be handled as follows:
a. The funding to be provided by the parties and any other sources is outlined in Part II of
Attachment II hereof. This funding will be used as shown in Part I of Attachment II.
i. The State's appropriated responsibility(direct contribution excluding any state fees,
Medicaid contributions, or any other funds not listed on the Schedule C) as provided in
Attachment II, Part II is an amount not to exceed $6,740,797 (State General
Revenue, State Funds, Other State Funds and Federal Funds listed on the Schedule C).
The State's obligation to pay under this contract is contingent upon an annual
appropriation by the Legislature.
ii. The County's appropriated responsibility (direct contribution excluding any fees,
other cash,or local contributions)as provided in Attachment II, Part II is an amount
not to exceed $1,120,900 (amount listed under the "Board of County Commissioners
Annual Appropriations section of the revenue attachment).
b. Overall expenditures will not exceed available funding or budget authority, whichever is
less, (either the current year or from surplus trust funds) in any service category. Unless
requested otherwise, any surplus at the end of the term of this contract in the County Health
Department Trust Fund that is attributed to the CHD shall be carried forward to the next contract
period.
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c. Either party may establish service fees as allowed by law to fund activities of the CHD.
Where applicable, such fees shall be automatically adjusted to at least the Medicaid fee
schedule.
d. Either party may increase or decrease funding of this contract during the term hereof by
notifying the other party in writing of the amount and purpose for the change in funding. If the
State initiates the increase or decrease, the CHD will revise Attachment II and send a copy of
the revised pages to the County and the State's Office of Budget and Revenue Management.
If the County initiates the increase or decrease, the County shall notify the CHD in writing. The
CHD will then revise Attachment II and send a copy of the revised pages to the State's Office
of Budget and Revenue Management.
e. The name and address of the official payee to whom payments shall be made is:
County Health Department Trust Fund
Collier County Health Department
3339 E. Tamiami Trail East
Naples, FL 34112
5. CHD DIRECTOR or ADMINISTRATOR. Both parties agree the director or administrator
of the CHD shall be a State employee or under contract with the State and will be under the
day-to-day direction of the State's Deputy Secretary for County Health Systems. The director
or administrator shall be selected by the State with the concurrence of the County. The director
or administrator of the CHD shall ensure that non-categorical sources of funding are used to
fulfill public health priorities in the community and the Long-Range Program Plan.
6. ADMINISTRATIVE POLICIES AND PROCEDURES. The parties hereto agree that the
following standards should apply in the operation of the CHD:
a. The CHD and its personnel shall follow all State policies and procedures, except to the
extent permitted for the use of County purchasing procedures as outlined in subparagraph b.,
below. All CHD employees shall be State or State-contract personnel subject to State
personnel laws, rules, and procedures. Employees will report time in the Health Management
System compatible format by program component as specified by the State.
b. The CHD shall comply with all applicable provisions of federal and state laws and
regulations relating to its operation with the exception that the use of County purchasing
procedures shall be allowed when it will result in a better price or service and no statewide
purchasing contract has been implemented for those goods or services. In such cases, the
CHD director or administrator must sign a justification, therefore, and all County purchasing
procedures must be followed in their entirety,and such compliance shall be documented. Such
justification and compliance documentation shall be maintained by the CHD following the terms
of this contract. State procedures must be followed for all leases on facilities not enumerated
in Attachment IV.
c. The CHD shall maintain books, records, and documents following the Generally
Accepted Accounting Principles, as promulgated by the Governmental Accounting Standards
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Board, and the requirements of federal or state law. These records shall be maintained as
required by the State's Policies and Procedures for Records Management and shall be open
for inspection at any time by the parties and the public, except for those records that are not
otherwise subject to disclosure as provided by law which is subject to the confidentiality
provisions of paragraphs 6.i. and 6.k., below. Books, records, and documents must be
adequate to allow the CHD to comply with the following reporting requirements:
i. The revenue and expenditure requirements in the Florida Accounting
Information Resource System; and
ii. The client registration and services reporting requirements of the minimum
data set as specified in the most current version of the Client Information
System/Health Management Component Pamphlet; and
iii. Financial procedures specified in the State's Accounting Procedures
Manuals, Accounting memoranda, and Comptroller's memoranda; and
iv. The CHD is responsible for assuring that all contracts with service providers
include provisions that all subcontracted services be reported to the CHD in
a manner consistent with the client registration and service reporting
requirements of the minimum data set as specified in the Client Information
System/Health Management Component Pamphlet.
d. All funds for the CHD shall be deposited In the County Health Department Trust Fund
maintained by the state treasurer. These funds shall be accounted for separately from funds
deposited for other CHDs and shall be used only for public health purposes in Collier County.
e. That any surplus or deficit funds, including fees or accrued interest, remaining in the
County Health Department Trust Fund account at the end of the contract year shall be credited
or debited to the State or County, as appropriate, based on the funds contributed by each and
the expenditures incurred by each. Expenditures will be charged to the program accounts by
State and County based on the ratio of planned expenditures in this contract and funding from
all sources is credited to the program accounts by State and County. The equity share of any
surplus or deficit funds accruing to the State and County is determined each month and at the
contract year-end. Surplus funds may be applied toward the funding requirements of each
party in the following year. However, in each such case, all surplus funds, including fees and
accrued interest, shall remain in the trust fund until accounted for in a manner that clearly
illustrates the amount which has been credited to each party. The planned use of surplus funds
shall be reflected in Attachment II, Part I of this contract, with special capital projects explained
in Attachment V.
f. There shall be no transfer of funds between the three levels of services without a contract
amendment unless the CHD director or administrator determines that an emergency exists
wherein a time delay would endanger the public's health and the State's Deputy Secretary for
County Health Systems have approved the transfer. The State's Deputy Secretary for County
Health Systems shall forward written evidence of this approval to the CHD within 30 days after
an emergency transfer.
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g. The CHD may execute subcontracts for services necessary to enable the CHD to carry
out the programs specified in this contract. Any such subcontract shall include all
aforementioned audit and record-keeping requirements.
h. At the request of either party, an audit may be conducted by an independent certified
public accountant on the financial records of the CHD, and the results made available to the
parties within 180 days after the close of the CHD fiscal year. This audit will follow requirements
contained in OMB Circular A-133, as revised, and may be in conjunction with audits performed
by the County government. If audit exceptions are found, then the director or administrator of
the CHD will prepare a corrective action plan and a copy of that plan and monthly status reports
will be furnished to the contract managers for the parties.
i. The CHD shall not use or disclose any information concerning a recipient of services
except as allowed by federal or state law or policy.
j. The CHD shall retain all client records, financial records, supporting documents,
statistical records, and any other documents (including electronic storage media) pertinent to
this contract for five years after termination of this contract. If an audit has been initiated and
audit findings have not been resolved at the end of five years, the records shall be retained
until the resolution of the audit findings.
k. The CHD shall maintain the confidentiality of all data, files, and records that are
confidential under the law or are otherwise exempted from disclosure as a public record under
Florida law. The CHD shall implement procedures to ensure the protection and confidentiality
of all such records and shall comply with sections 384.29, 381.004, 392.65, and 456.057,
Florida Statutes,and all other state and federal laws regarding confidentiality. All confidentiality
procedures implemented by the CHD shall be consistent with the State's Information Security
Policies, Protocols, and Procedures. The CHD shall further adhere to any amendments to the
State's security requirements and shall comply with any applicable professional standards of
practice concerning client confidentiality.
I. The CHD shall abide by all State policies and procedures, which by this reference are
incorporated herein as standards to be followed by the CHD.
m. The CHD shall establish a system through which applicants for services and current
clients may present grievances over denial, modification, or termination of services. The CHD
will advise applicants of the right to appeal a denial or exclusion from services, of failure to take
account of a client's choice of service, and right to a fair hearing to the final governing authority
of the CHD. Specific references to existing laws, rules, or program manuals are Included in
Attachment I of this contract.
n. The CHD shall comply with the provisions contained in the Civil Rights Compliance and
Non-Discrimination Certificate, hereby incorporated into this contract as Attachment III.
o. The CHD shall submit quarterly reports to the County that shall include at least the
following:
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i. The DE385L1 Contract Management Variance Report and the DE580L1
Analysis of Fund Equities Report; and
il. A written explanation to the County of service variances reflected in the year-
end DE385L1 report if the variance exceeds or falls below 25 percent of the
planned expenditure amount for the contract year. However, if the amount
of the service-specific variance between actual and planned expenditures
does not exceed three percent of the total planned expenditures for the level
of service in which the type of service is included, a variance explanation is
not required. A copy of the written explanation shall be sent to the State's
Office of Budget and Revenue Management.
p. The dates for the submission of quarterly reports to the County shall be as follows unless
the generation and distribution of reports are delayed due to circumstances beyond the CHD's
control:
i. March 1, 2026, for the reporting period of October 1, 2025, through
December 31, 2025; and
ii. June 1, 2026, for the reporting period of October 1, 2025, through
March 31, 2026; and
iii. September 1, 2026, for the reporting period of October 1, 2025
through June 30, 2026; and
iv. December 1, 2026, for the reporting period of October 1, 2025
through September 30, 2026.
7. FACILITIES AND EQUIPMENT. The parties mutually agree that:
a. CHD facilities shall be provided as specified in Attachment IV to this contract and the
County shall own the facilities used by the CHD unless otherwise provided in Attachment IV.
b. The County shall ensure adequate fire and casualty insurance coverage for County-
owned CHD offices and buildings and all furnishings and equipment in CHD offices through
either a self-insurance program or insurance purchased by the County.
c. All vehicles will be transferred to the ownership of the County and registered as County
vehicles. The County shall ensure insurance coverage for these vehicles is available through
either a self-insurance program or insurance purchased by the County. All vehicles will be
used solely for CHD operations. Vehicles purchased through the County Health Department
Trust Fund shall be sold at fair market value when they are no longer needed by the CHD and
the proceeds returned to the County Health Department Trust Fund.
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8. TERMINATION.
a. Termination at Will. This contract may be terminated by either party without cause upon
no less than 180 calendar days' notice in writing to the other party unless a lesser time is
mutually agreed upon in writing by both parties.
b. Termination Because of Lack of Funds. In the event funds to finance this contract
become unavailable, either party may terminate this contract upon no less than 24 hours'
notice.
c. Termination for Breach. This contract may be terminated by either party for a material
breach of an obligation hereunder, upon no less than 30 days' notice. Waiver of a breach of
any provisions of this contract shall not be deemed to be a waiver of any other breach and shall
not be construed to be a modification of the terms of this contract.
9. MISCELLANEOUS. The parties further agree:
a. Availability of Funds. If this contract, any renewal hereof, or any term, performance, or
payment hereunder, extends beyond the CHD fiscal year beginning July 1, 2026, it is agreed
that the performance and payment under this contract are contingent upon an annual
appropriation by the Legislature, under section 287.0582, Florida Statutes.
b. Contract Managers. The name and addresses of the contract managers for the parties
under this contract are as follows:
For the State: For the County:
Kimberly Kossier, MPH, RN. CPH Joseph Bellone, MBA
Name Name
Administrator& Health Officer Division Director
Title Title
3339 E. Tamiami Trail, Suite 145 3339 E. Tamiami Trail, Suite 301
Naples, FL 34112 Naples, FL 34112
Address Address
Kimberly.Kossler(7FLHealth.gov Joseph.Bellone colliercountyfi.gov
Email Address Email Address
239-252-8201 239-252-6028
Telephone Telephone
If different contract managers are designated after the execution of this contract, the name,
address, email address, and telephone number of the new representative shall be furnished in
writing to the other parties and attached to the originals of this contract.
c. Captions. The captions and headings contained In this contract are for the convenience
of the parties only and do not in any way modify, amplify, or give additional notice of the
provisions hereof.
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d. Notices. Any notices provided under this contract must be delivered by certified mail,
return receipt requested, in person with proof of delivery, or by email to the email address of
the respective party identified in Section 9.b., above.
In WITNESS THEREOF, the parties hereto have caused this 8 page contract, with its
attachments as referenced, including Attachment I (two pages), Attachment II (six pages),
Attachment III (one pages), Attachment IV(one pages), and Attachment V (one pages), to be
executed by their undersigned officials as duly authorized effective the 1st day of October 2025.
BOARD OF COUNTY COMMISSIONERS STATE OF FLORIDA
FOR COLLIER COUNTY DEPARTMENT OF HEALTH
SIGNED BY: 4" SIGNED BY:
Burt L. Saunders. Chairman NAME: Joseph A. Ladapo, M.D., Ph.D.
TITLE: State Surgeon General
DATE: 1/2 31Z,5 DATE:
ATTESTED TO:
SIGNED BY: SIGNED BY: �7� Sb L---7
NAME: NAME: %OY1 SS,C'.ar
TITLE: TITLE: CHD Director or Administrator
DATE: DATE: SVaaValW‘S
cs 9' ppr ved as to d legality
ATTE'r -K.
Clerk Sco .Teach, eputy County Attorney
Mkt e,,to:Chairman's
Signature only
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ATTACHMENT I
COLLIER COUNTY HEALTH DEPARTMENT
PROGRAM SPECIFIC REPORTING REQUIREMENTS AND PROGRAMS REQUIRING
COMPLIANCE WITH THE PROVISIONS OF SPECIFIC MANUALS
Some health services must comply with specific program and reporting requirements in addition to the Personal Health
Coding Pamphlet(DHP 50-20),Environmental Health Coding Pamphlet(DHP 50-21)and FLAIR requirements because of
federal or state law,regulation or rule. If a county health department is funded to provide one of these services,it must
comply with the special reporting requirements for that service. The services and the reporting requirements are listed
below:
Service Requirement
1. Sexually Transmitted Disease Requirements as specified in F.A.C.64D-3,F.S.381 and F.S.384.
Program
2. Dental Health Periodic financial and programmatic reports as specified by the
program office.
3. Special Supplemental Nutrition Service documentation and monthly financial reports as specified in
Program for Women,Infants and DHM 150-24*and all federal,state and county requirements
Children(including the WIC detailed in program manuals and published procedures.
Breastfeeding Peer Counseling
Program)
4. Healthy Start/Improved Pregnancy Requirements as specified in the 2007 Healthy Start Standards and
Outcome Guidelines and as specified by the Healthy Start Coalitions In
contract with each county health department.
5. Family Planning Requirements as specified in Public Law 91-572,42 U.S.C.300,et
seq.,42 CFR part 59,subpart A,45 CFR parts 74&92,2 CFR 215
(OMB Circular A-110)OMB Circular A-102,F.S.381.0051,F.A.C.
64F-7,F.A.C.64F-16,and F.A.C.64F-19. Requirements and
Guidance as specified in the Program Requirements for Title X
Funded Family Planning Projects(Title X RequirementsX2014)and
the Providing Quality Family Planning Services(QFP):
Recommendations of CDC and the U.S.Office of Population Affairs
published on the Office of Population Affairs website.
Programmatic annual reports as specified by the program office as
specified in the annual programmatic Scope of Work for Family
Planning and Maternal Child Health Services,including the Family
Planning Annual Report(FPAR),and other minimum guidelines as
specified by the Policy Web Technical Assistance Guidelines.
6. Immunization Periodic reports as specified by the department pertaining to
immunization levels in kindergarten and/or seventh grade pursuant
to instructions contained in the Immunization Guidelines-Florida
Schools,Childcare Facilities and Family Daycare Homes(DH Form
150-615)and Rule 64D-3.046,F.A.C. In addition,periodic reports
as specified by the department pertaining to the
surveillance/investigation of reportable vaccine-preventable
diseases,adverse events,vaccine accountability,and assessment
of immunization
ATTACHMENT I(Continued)
Attachment_I-Page 1 of 2
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levels as documented in Florida SHOTS and supported by CHD
Guidebook policies and technical assistance guidance.
7. Environmental Health Requirements as specified in Environmental Health Programs
Manual 150-4"and DHP 50-21'
•
8. HIV/AIDS Program Requirements as specified In F.S.384.25 and F,A.C.640-3.030
and 64D-3,031.Case reporting should be on Adult HIV/AIDS
Confidential Case Report CDC Form DH2139 and Pediatric
HIV/AIDS Confidential Case Report CDC Form DH2140.
Requirements as specified in F.A.C.64D-2 and 64D-3,F.S.381 and
F.S.384. Soclo-demographic and risk data on persons tested for
HIV in CHD clinics should be reported on Lab Request OH Form
1628 in accordance with the Forms Instruction Guide.
Requirements for the HIV/AIDS Patient Care programs are found in
the Patient Care Contract Administrative Guidelines.
9. School Health Services Requirements as specified in the Florida School Health
Administrative Guidelines(May 2012). Requirements as specified
in F.S.381.0056,F.S.381.0057, F.S.402.3026 and F.A.C.64F-6.
10. Tuberculosis Tuberculosis Program Requirements as specified in F.A.C.64D-3
and F.S.392.
11. General Communicable Disease Carry out surveillance for reportable communicable and other acute
Control diseases,detect outbreaks,respond to Individual cases of
reportable diseases,investigate outbreaks,and carry out
communication and quality assurance functions,as specified in
F.A.C.64D-3,F.S.381,F.S.384 and the CHD Epidemiology Guide
to Surveillance and Investigations.
12. Refugee Health Program Programmatic and financial requirements as specified by the
program office.
'or the subsequent replacement if adopted during the contract period.
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Attachment I-Page 2 of 2
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ATTACHMENT II
COLLIER COUNTY HEALTH DEPARTMENT
PART I.PLANNED USE OF COUNTY HEALTH DEPARTMENT TRUST FUND BALANCES
Estimated State Estimated County
Share of CHD Trust Share of CHO Trust
Fund Balance Fund Balance Total
1, CHD Trust Fund Ending Balance 09/30/25 1077858 4695930 5773788
2. Drawdown for Contract Year -1077858 -1042685 -2120543
October 1,2025 to September 30,2026
3. Special Capital Project use for Contract Year 0 0 0
October 1,2025 to September 30,2026
4. Balance Reserved for Contingency Fund 0 3653245 3653245
October 1,2025 to September 30,2026
Special Capital Projects are new construction or renovation projects and new furniture or equipment associated with these projects,and mobile health vans.
Attachment II_Part_I-Page 1 of 1
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ATT,�CENTII
, COI T.TER COUNTY HEALTH DEPARTMENT
Part IT,Sources of Contrlbptlone to County Health Department
October 1 2,021E to Septomber�80,2028
Tr(etFu d CHD T t'i d Other
laeeh) Trust Fund ;(crib :.;I 0iollltrlbu41on r Tot
1.GENERAL REVENUE•STATE
015041l AIDS PATIENT CARE 1.10,0(8) 0 140,00)) 0 (-(0,000
(115010 AIDS PREVENTION&SURVEILL ANCE-(.1ENERAl.I(EVF.NI lE 05,821 0 60,821 0 (15,821
015040 CHD•TB COMMUNITY PROGRAM 222,022 0 222,622 0 222,622
015040 UENTAI,SPECIAL INITIATIVE PROJECTS 6,082 0 6,082 0 6,082
015041) FAMILY ILANNING CJENEI(AI,REVENUE 1211,608 0 126,6118 0 126,608
015010 HEPATITIS AND LIVER FAILURE PREVENTION&CONTROL 88,612 0 88,612 0 88,612
015010 MIGRANT LABOR CAMP SANITATION 2,1,355 0 24,:365 0 2.1,355
0150,10 PRIMARY CARE PROGRAM 32I,348 0 321,348 (1 321,3,18
0150.10 RACIAL,ÐNIC DISPARITIES•CHD EXPENSES 52.090 0 52,(0) (1 52,000
01511,10 SCHOOL HEALTH SERVICES 218,07:1 0 218,073 0 218,073
015050 CHI)GENERAL REVENUE NON•CATEGOI)ICAL 3,234,274 0 3,234,274 0 3,234,274
GENERAL REVENUE TOTAL 1,499,71)5 0 4,499,795 0 -I,'199,795
2.NON GENERAL REVENUE•STATE
015010 ENVIRONMENTAL BIOMEDICAL WASTE PROGRAM 8,578 0 8,578 0 8,578
0151110 TOBACCO STATE AND COMMUNITY INTERVENTIONS I84,-166 0 18.1,460 0 184,406
NON GENERAL REVENUE TOTAL 193,044 0 193,044 0 10:3,044
8.FEDERAL FUNDS-STATE
007000 AIDS DRUG ASSISTANCE PROGRAM ADMIN HQ 10.1,2:37 0 10'1,2:17 0 104,237
007000 WIC 131{EASTFEEDINO PEER COIINSEI.IN(.:1'R01 1 80,07(1 0 80,070 0 80,070
007000 COASTAL BEACH WATER QUALITY MONITORING 12.663 6 1.2,663 0 12,663
007(100 COMPREHENSIVE COMMUNITY CARDIO•PHB(1 :35,000 o :35,000 0 35,000
(8)7000 FAMILY PLANNING TITLE X•GRANT 122.441 0 122,4.11 0 122,441
007000 PUBLIC HLTH 1NPRAS'rRtlu71111F&WORKFORCIJCI:N.1'11AI,1 208,348 0 208,348 0 208,348
007000 INFANT MORTALITY 25,405 0 211,405 0 25,405
007000 IMMUNIZATION AC'I'H)N PLAN 1'20,0(18 0 120,008 0 120,008
007000 MEDICAL HOME FOR CHILI)&AI)O1.FSCF.NT HEALTH 22.399 0 22,399 0 22,399
007000 MCH SPECIAL PROJECTS 1)HNTAI, 30.222 0 30,222 0 30,222
007009 BASE COMMUNITY PREPAREDNESS CAPABILITY 161.781 0 161,781 0 161,781
007009 BASF,P1.JB FILTH SURVEILLANCE&EP1 INVESTIGATION 81.5011 0 81,566 0 81,566
007000 AIDS PREVENTION :117.1811 0 317,189 0 317,189
(I(17000 RYAN WHITE TITLE 11(GRANT/CHI)CONSORTIUM :305,147 0 :1115,147 0 305,147
007000 WIC PROGRAM ADMINISTRATION 1,399,805 . 0 1,:399,805 0 1,399,805
015075 SCHOOL HEALTH SERVICES :13.61() 0 3:3,691) 0 33,690
015075 REFUGEE HEALTH SCREENING REIMBURSEMENTAD\IlN 19,994 0 19,99,1 0 19,99.4
015075 REFUGEE HEALTH SCREENING REIMBURSEMENT SERVICES 7(I,859 0 70,859 0 70,859
FEDERAL FUNDS TOTAL :3,150.82-I 0 3,I50,82.I (1 11.150,824
4.FEES ASSESSED BY STATE OR FEDERAL RULES•STATE
101020 CHI)STATEWIDE ENVIRONMENTAL FEES -193,320 0 -19:3,320 0 493,320
(101092 (IN SITE SEWAGE IlISPOSA1,PERMIT FEES 210,051 0 210,(351 0 21(1,651
001092 (.HI)STATEWIDE ENVIRONMENTAL FEES 8,5011 0 8,5((0 0 8,500
001206 ON SITE SEWAGE DISPOSAL PERMIT FEES 15,(NI(1 0 15,000 0 15,000
Allachmant_II_Part It-Page 1 of 3
16C2
t'OU EJ U 1TY HEALTH DEPAR E if
• PAr .�outxleea lof trim*but ooa t3)County Hee I pep1irtment
-to 3tQ8� ��teAtbex;"SD,a RB
8tete QHD Total CC
,oio and ^ � Tru33t FilmicJIIre)E '
;- _ -_ ...: _ : -_- (cwi Truat Fund fcnalil r4Ji lbBtto$- ... :`t'Qtii1
001200 SANITATION CER'I'IPICATES(I'I)01)INSPECTION) 33,600 0 3,1300 0 3,600
00120E SEPTIC TANK RESEARCH SURCHAMB!: 3.000 0 :3,010 0 3,000
001206 SEPTIC TANK VARIANCE FEES 5014 231) 0 250 0 250
001206 PUBLIC SWIMNIINO POOL PERMIT FEES•10%HQ TRANS PI) 30,000 0 30,000 0 :30,000
001206 DRINKING WATER PROGRAM OPERATIONS 1,119 0 1.11E1 0 1,119
001200 REGULATION OF BODY PIERCING SALONS 83 0 83 11 83
001206 'PANNING FACILITIES 225 0 2.25 1) 225
001206 (.)NSITE SEWAGE TRAINING CENTER 1,000 0 1,000 0 1,000
001206 TATI'O PROGRAM ENVIRONMENTAL HEALTH 4,IN10 0 4,000 (1 '1,000
001206 MOBILE HOME&RV PARK FEES 2,3.10 0 2,310 0 2,3411
FEES ASSESSED BY STATE OR FEDERAL RULES TOTAL 773,1-18 0 773,118 0 773,148
5.OTHER CASH CONTRIBUTIONS•STATE:
031005 GENERAL CLINIC RABIES SERVICES&1)RUG PURCHASES 40,000 (1 40,000 0 40,1100
090001 I)IIAW DO\VN PROM PUBLIC 11EALTH UNIT 1,077,858 0 1,077,858 (1 1,077,858
OTHER CASH CONTRIBUTION TOTAL 1,11 7,85)1 0 1,117,858 0 1,117,858
6.MEDICAID•STATE/COUNTY:
001050 OH))CLINIC FEES 0 10,077 131,077 0 10,077
(101057 CHI)CLINIC FEES 0 12,115 19,115 0 12,115
1101147 CR1)CLINIC FEES 0 5 5 0 5
3101148 CHD CLINIC FEES 0 616,560 616,560 0 616,560
0011,18 GENERAL CLINIC RA13IES SERVICES&DRUG PURCHASES 0 2,000 2,000 0 2,000
MEDICAID TOTAL 0 610,757 0.10,757 0 610,757
7.ALLOCABLE REVENUE-STATE:
018000 CHD CLINIC FEES 1 0 1 (1 1
ALLOCABLE REVENUE TOTAL 1 0 1 0 1
8.OTHER STATE CONTRIBUTIONS NOT IN CHD TRUST FUND•STATE
ADAP I) 0 0 1,118,30,1 1448,304
PHARMACY DRUG PROGRAM 0 0 O 12,758 12,758
WIC PROGRAM 0 0 II 6,572,3:37 (3,57.2,337
BUREAU OP PUBLIC HEALTH LABORATORIES 0 0 0 7,918 7,918
IMLMUNI7'1VI'IONS 0 0 0 1,(173,708 1,1173,708
OTHER STATE CONTRIBUTIONS TOTAL 0 0 0 9,115.025 9,115,025
9.DIRECT LOCAL CONTRIBUTIONS•BCC/TAX DISTRICT
•
008005 CHD LOCAL REVENUE&ESPI:NDITURI,S 0 1,120,900 1,120,900 0 1,1211,900
DIRECT COUNTY CONTRIBUTIONS TOTAL o 1,120,900 1,120,900 0 1,120,900
•
10.FEES AUTHORIZED BY COUNTY ORDINANCE OR RESOLUTION•COUNTY
!' 001077 CHI)CLINIC FEES 0 286,712 286,712 0 288,712
001077 GENERAL CLINIC RABIES SERVICES&1)103G PURCHASES 0 1,600 1,000 0 1,600
00109•I CHI)LOCAl,E:NVIRONMENTAI.FEES 0 852.1(45 852,615 0 852,015
I1(11I10 VITAL STATISTICS CERTIFIED RECORDS 0 700,000 700,0(10 II 71)0,000
11 AI(achmenl_II_Part_II-Pegs 2 of3_
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16C2
OQ JRRI UNTYREAII t.DEPA$' » .
2arttjy Sp -0- cn butulns to Oaunty I moat x*.
ber•,SO2 to tewbsrBO, 88, x
;
BtRta�IXD {o unt�y �..#1 .HD
�.` _�11E 1?und � � �Ct'nnt� OthQr
aosa1 i'', n 'teed') ! lntrilulaan
FEES AUTHORIZED BY COUNTY TOTAL 0 1,840,957 1,840,957 0 1,840,957
1
11.OTHER CASH AND LOCAL CONTRIBUTIONS•COUNTY
001029 :340B PRESCRIPTION DRUG SERVICE A IREEMENT 0 190,000 190,0(10 0 19(1,0(10
001029 CHI)CLINIC FEES 0 51,9:18 51,938 0 51,1)38
001029 GENERAL CLINIC RA131ESSERVICES&1)1(UG Plll(CHASES 0 18,000 18,0(10 0 18,000
001090 011I)CLINIC)1'IIIR) 0 3,358 3,358 0 3,358
00109(1 GENERAL CLINIC RABIES SERVICES&1)121G PURCHASES 0 3,200 3,200 0 3,200
010300 MIGRANT LAIR)11 HOUSING INSI'IO)'ION H"2A PROGRAM 0 7,412 7,412 0 7,412
01100(1 RYAN WHITE 0 4(1,0111 40,000 0 10.000
011001) EARLY LEARNING COALITION OF SOUTHWEST FLOI(IDA 0 (10,900 60,900 0 00,900
011001 CHD HEALTHY START COALITION CONTRACT (1 701,051 701,051 0 701,051
000002 1)RAW DOWN FROM PUBLIC HEALT14 UNIT 0 1.042,985 1,042,0)85 0 1,042,985
OTHER CASH AND LOCAL CONTRIBUTIONS TOTAL 0 2,118,5.1.1 2.118,544 02,118,544
12.ALLOCABLE REVENUE•COUNTY
018000 CHD CLINIC FEES 0 1 1 0 1
COUNTY ALLOCABLE REVENUE TOTAL 0 1 1 0 1
18.BUILDINGS•COUNTY
ANNUAL I(EN1':1L EQUIVALENT VALI IE II 0 0 525,048 525,048
IT ALLOCATION 0 0 0 69,300 09,300
UTILITIES (1 0 0 210,000 21(1,000
BUILDING MAINTENANCE 0 0 0 0 0
GROUNDS MAINTENANCE 0 0 0 195,149 195,1,19
INSURANCE 0 0 0 0 0
OTHER(Specify) 0 0 0 0 0
OTHER(,Specify) 0 0 0 0 0
BUILDINGS TOTAL 0 0 11 999,497 9119,497
14,OTHER COUNTY CONTRIBUTIONS NOT IN CHD TRUST FUND•COUNTY
EQUIPMENTI VEHICLE PURCHASES 0 0 0 0 0
VEHICLE INSURANCE 0 0 0 0 0
VEHICLE MAINTENANCE 0 0 • 0 0 0
OTHER COUNTY CON'PR(IBUTION(SPECIFY/ (1 0 0 0 0
OTHER COUNTY CONTRIBUTION(SPECIrY) 0 0 0 0 0
OTHER COUNTY CONTRIBUTIONS TOTAL 0 0 0 ❑ 0
GRAND TOTAL CHD PROGRAM 9.73,1,070 5.721,1511 15,155,829 1(1,11.1,522 25,570,351
Allacl ment_II_Part_II-Page 3 of 3
16C2
' s ATTACHMENT II .,
„' COL1,(ER COUNTY HEALTH DEPARTMENT : fV
' 3. a { , Part III,PlannsdStlting Clients,Services and Expenditures By Program Service Area Within Each Level of Service 'x, = '
1 . .:A o� u G�,<. - t.. `a"`x,. 4. '- October 1 2020 to September 30,2026 - ras `.
MilWA
sr . . Quarterly Lxpenditure Plan ` � - r-
FTB'e ' CNNeata Services/:; 2nd (3rd 4tlt s �
_,.I . _. .. __ (0.00) Unite-...; V,iette' : (Whole dollars only) ,State Cp un y
G
`llOtltN
•
A. COMMUNICABLE DISEASE CONTROL: •
ISIMIINI6ATION(101) 7.42 7,06.1 11(527 1931,678 106,11211 193,678 1(18,7135 449,1233 273,018 722,141
SEXUALLY TRANS.D1S. (11131 6.32 646 884 1.1(3,1322 125.684 146,622 127,761 419,940 126.7-49 546.1381)
HIV/AIDS PREVENTION (03r11) 0.70 0 .1,9117 162,613 139,311 162,613 1.11,1391 589.8313 16.475 6481:311
HIV/AIDS SURVEILLANCE 013A2) 1..11 0 2:3 32,398 27,771 32,308 28,231 120788 tl 12(1,708
IIIV/AI1)S PATIENT emu,: (03A3) 8.313 480 1,762 273,830 23.1,726 273,830 2341,006 779,486 241,506 1.02(1,18)2
A1MP (113A4) 1.72 7 134 45,018 318.5101 45,018 39228 167,851 0 107,854
TUBERCULOSIS(11)0 9.39 395 3.938 210.830 206,4131 240.83G 209,805 835,89.1 02,076 897.970
COMM.0)6.SURV. (10(3) 5.81 11 10.215 175,185 150,168 175,185 152,651 612,258 40,931 65'3,189
i1EPATITIS (1os) 1.(E1 2,124 2,389 47,709 4(1,896 47.709 41,571 177,885 0 177,885
PREPAREDNESS AN))RESPONSE (116) 3.23 0 0 107,917 92.532 107,9.17 94,1830 318,367 8.1,119 402,486
REFUGEE HEALTH (118) 0.133 255 (315 313,676 28,867 33,6713 29,345 125,56.1 0 125,501
VITA I,RECORDS (I WA 3,91 15,436 72,0)11 116,357 82,597 96,357 83,9631 II 359,274 359,271
COMMUNICABLE DISEASE SUBTOTAL 57.11 211.407 107,1)57 1,555,869 1,133,685 1,555,869 1,355,730 4,597,005 L201,118 6,801,153
B, PRIMARY CARE:
CHRONIC DISEASE PREVENTION PRO (210) 1.11 0 0 33,2.17 28..1111) 33,217 '18,(169 75,851 48,111 123,1)62
WIC (21W1) 27,05 11.731 77.887 1320,858 532,197 ((90,858 5-411,1193 2,311,0183 0 2,314,11013
TOBACCO USE INTERVENTION (212) 3.15 0 0 75,000 (35,11.1 75,996 G41,221 283,357 0 283.:357
Will HI(1':ASTFEEUING PEER COUNSELING (2 1W2) 3.68 0 5,1360 49,811 42,608 •19,811 .13,403 185,723 (1 185,723
FAMI IA'I'LANNINR (2231 .1.137 956 2,1418) 144,174 123,580 1.14,174 125,11211 401,-199 130,061 537,563
IMI'IIOVED PREGNANCY OUTCOME (225) 0.38 18 21 1(1.007 8.578 10,007 8,720 37.312 0 37.:312
HEALTHY START PRENATAL(227) 3.71 1,750 6,271) 121,702 101.32:3 121,702 HI6.017 81,609 3419.165 453,77.1
COMPREHENSIVE CIIII.!)HEALTH (2211) 1..11 123 205 341,306 311,264 35,306 3976:1 22,399 109,240 1111.4139
HEALTHY START CHILI) (231) (3.10 913 3,577 149.106 127,813 149,10(3 129,924 0 555,949 555,11.11)
SCHOCIL HEALTH (2311 7.70 0 66:3.71.I 150.818 12:L31m 150,848 131.443 251.763 310,682 562,4.15
CO,l1PltE11ENSIVEA111'•1.THEALTH (237) 6.73 2,39.1 3.549 2(38,243 2211.937 268.243 23:4.739 160.675 839,487 13)00,162
COMAMIINITY(IEAI:f11 DEVELOPMENT(2:181 4.4.1 0 I 128.250 109,936 128.250 111,75:3 478.189 0 478,189
DENTAL HEALTH (210) 9.50 2,593 5,739 299,830 257,1111 299,830 2(31,291 36,3111 1,1181,630 1,117,934
PRIMARY CARE SUBTOTAL 79.66 20.478 7(38,7411 2,087.378 1,789,294 2,087,378 1.818,865 4,332.587 3,450,328 7,782,9111
C. ENVIRONMENTAL HEALTH:
Water and Oneite Sewage Programs
COSTAL (317) 0.44 930 1132 13,:34(3 11,441) 13,346 11.629 49,761 0 49,7(31
LIMITED USE P1.1131,111 WATER SYSTEMS (357) 1.55 213 1.453 39,095 :13,51113 39.090 34.965 9,718 13)1,049 145,767
PUBLIC WATER SYSTEM (:358) 0111 0 0 392 :336 392 :1.11 0 1.401 1.461
PRIVATE WATER SYS'I'EAI (359) (1.67 0 0 2,358 2,(121 2,358 2.054 0 8.791 8.791
li ONSITE SEWAGE TIUIATM ENT K DISPOSAL 1:931) 13.713 :1,000 4.6132 1(18,039 312.1111 1418,039 91,142 189,231) 213.601 41)2,831
Croup Total 5.83 .1.1.13 7,077 10:1,230 139,1)20 163,230 142,231 248,7(6) 111090)2 608,611
Facility Programs
'1'ATTl7O 1'AL'I1.1'I'V SERVICES' 13,14) 0.III 3:13 2911 9,984 8,5,11 9,98,1 8.1181 37,150 0 137.I5))
FOI)I)IIYGIENE 13.18) (1,831 811 2,581 21,013 18,013 21,0143 18.311 32,810 1.1,510 78,350
I
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Aaaclment(I Part III-Page 1 o12
16C2
S 0: - `'Zia . 4 -W" 3 ..c ---.A,
..-^-ar < 5'L' ".:
, - - awl-" E `* - -+` -- ; ;.f C, wtA 4 a -
atMi'Al
1 riWy V , W z _ _T " x £'
1 9.r +o o -c - ,� Y-- T = � iG. Y ,. +1 a.'-r4t.."-,s volt c I�' �1F r'V:
.M ac� t y tl ti 9_ T 1'4R57!m 0AY -�~ Y"ie ,4� tI i Grald
- � .�_.43 •_.;',-. ..__._ (O.cO). ' guile 'V31IIt31`W (4Pbo16 dollare on�7 i I stag County
BODY PIERCING FACILITIES SERVICES (349) 0.01 2 7 41I1 34(3 401 352 I.509 0 1,50(3
GROUP CARE FACILITY (a51) 0.51 548 344 13,512 11,582 13,512 11,774 0 50.380 50380
MIGRANT M13013 CAMP(3521 1.34 65 508 35,880 30,756 35,880 31,266 .11,080 92,702 13:1,782
HOUSING&PUB,l3LDG, (353) 0.00 Il (1 0 0 0 0 0 0 0
510131LE 1105111 AND PARE (350 (1.54 248 584 14,289 12,249 1,1,280 12.452 21,019 32.260 53,279
POOISf13ATllING PACES (3(341) 0.81 2,1(17 I0,623 180.881 155,053 180,88.1 157,615 279.697 391,739 07,1.436
141051EDICM,WASTE SERVICES(36,1) 1.74 1,994 19131 42,507 36,437 .12,507 37,0,10 78,878 711,4113 158,491
TANNING FACILITY SERVICES (369) 0.02 0 0 701 600 701 010 2,612 11 2.3i12
Group Total 12.20 0.198 113,907 319.151 273,577 319,15.1 278,101 195,752 (7)1.234 1,189,1180
Groundwater Contamination
STORAGE TANK CODIPLIANCE SERVICES 0I55) 0.00 0 0 II (I (1 0 0 0 0
SUPER ACT SERVICES (3510 0.02 0 (1 912 781 912 791 0 3,399 3,399
Group Total 002 0 0 912 781 912 704 0 3,309 3,3911
Community Hygiene
COMMUNITY ENTER.HEALTH 1345) 0.00 0 0 0 it 0 0 0 0 0
INJURY PREVENTION(3461 0181 0 (I 2,159 1,851 2,151) 1,881 0 8,050 8,050
LEAD MONITORING SERVICES (350) 0,00 0 II 0 0 0 0 0 0 0
PUBLIC SEWAGE(362) 9.181 0 II 0 11 0 0 O 0 0
SOLID WASTE DISPOSAL SERVICE(363) 0.00 0 (I 79 68 79 G9 0 295 205
SANITARY NUISANCE (Mil 0.01 0 0 215 185 215 188 0 803 803
RABIES SURVEILLANCE (3661 000 0 0 0 0 ❑ 0 0 (I (1
ARRORVIRUSSUIIVEII,. (367) 000 0 (I 0 (1 . 0 0 0 (1 0
RODENT/ARTHROPODCONTROL(368) 0.00 (1 (I (I 0 0 0 0 0 0
WATER POLLUTION (370) (1,00 0 11 II I) (1 0 0 0 0
INDOOR AIR (370 (1,00 0 0 (1 (1 0 0 0 0 0
•
RADIOLOGICAL HEALTH (372) 0.00 0 0 Cl (1 0 0 0 0 0
I
TOXIC SUBSTANCES (373) (1,0(1 0 11 0 (1 (1 0 0 0 0
Group Total 0.01 0 0 2,453 2.1(14 2,153 2,138 0 0,148 11,148
ENVIRONMENTAL HEALTH SUBTOTAL 18.06 10:141 23,11184 485.740 .110.389 485,7.19 .123,264 74.1,401 1.099,089 1.811.I.14
is
D. NON-OPERATIONAL COSTS:
NON'OPEIIATIONAL COSTS (5910 0.00 (1 0 1) 0 0 0 0 0 0
INVIRONMEN1•ALHEALTIISLIRCIIARGII (3f19) 0.00 (1 (1 16,957 33.1)39 l0,257 14,167 ((I,lil7 0 E(l,1i17
MEDICAID IAIVIIACE (61I) (I.0D Il 0 0 (1 (1 (1 0 0 0
is NON-OPERATIONAL COSTS SUBTOTAL 0.00 0 0 16,287 13,93(3 16,257 1,1,167 00,617 0 601317
is
I: TOTAL CONTRACT 15.1.83 57.226 900.081 4,1.15,25:1 3,553,297 .1.145,253 41,612.026 9.73.1,670 5,721,159 15.455.829
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c Attatttrnant_II_Part 111-Page 2 of 2
1602
ATTACHMENT III
TRAINING COUNTY HEALTH DEPARTMENT
CIVIL RIGHTS COMPLIANCE AND NON-DISCRIMINATION CERTIFICATE
1. The CHD agrees to complete the Civil Rights Compliance Questionnaire,DH Forms 946 A and B(or the
subsequent replacement if adopted during the contract period),if so requested by the Department.
2. The CHD assures that it will comply with the Omnibus Budget Reconciliation Act of 1961,P.L.97-35,
which prohibits discrimination on the basis of sex and religion in programs and activities receiving or
benefiting from federal financial assistance.
3. Assurance of Civil Rights Compliance: The CHD hereby agrees that it will comply with Title VI of the
Civil Rights Act of 1964(42 U.S.C.2000d et seq.);Title IX of the Education Amendments of 1972(20
U.S.C.1681 et seq.);Section 504 of the Rehabilitation Act of 1973(29 U.S.C.794);the Age
Discrimination Act of 1975(42 U.S.C.6101 et seq.);Title iI and Title Ill of the Americans with Disabilities
Act(ADA)of 1990,as amended by the ADA Amendment Act of 2008(42 U.S.C.12131-12189)and as
implemented by Department of Justice regulations at 28 CFR Parts 35 and 36;Executive Order 13166,
"Improving Access to Services for Persons with Limited English Proficiency(August 11,2000);all
provisions required by the implementing regulations of the U.S.Department of Agriculture(7 CFR Part
15 et seq.);and FNS directives and guidelines to the effect that no person shall,on the ground of race,
color,national origin,age,sex,or disability,be excluded from participation In,be denied the benefits of,
or otherwise be subjected to discrimination under any program or activity for which the agency receives
Federal financial assistance from FNS;and hereby gives assurance that it will immediately take
measures necessary to effectuate this agreement.
By providing this assurance,the CHD agrees to compile data,maintain records and submit records and
reports as required to permit effective enforcement of the nondiscrimination laws,and to permit
Department personnel during normal working hours to review and copy such records,books and
accounts,access such facilities,and interview such personnel as needed to ascertain compliance with
the non-discrimination laws. If there are any violations of this assurance,the Department of Agriculture
shall have the right to seek Judicial enforcement of this assurance.
This assurance is given in consideration of and for the purpose of obtaining any and all Federal
financial assistance,grants,and loans of Federal funds,reimbursable expenditures,grant or donation
of Federal property and interest in property,the detail of Federal personnel,the sale and lease of,and
the permission to use Federal property or interest In such property or the furnishing of services without
consideration or at a nominal consideration,or at a consideration that is reduced for the purpose of
assisting the recipient,or in recognition of the public interest to be served by such sale,lease,or
furnishing of services to the recipient,or any improvements made with Federal financial assistance
extended to the Program applicant by USDA. This includes any Federal agreement,arrangement,or
other contract that has as one of Its purposes the provision of cash assistance for the purchase of food,
and cash assistance for purchase or rental of food service equipment or any other financial assistance
extended in reliance on the representations and agreements made in this assurance.
This assurance is binding on the CHD,Its successors,transferees,and assignees as long as it receives
or retains possession of any assistance from the Department. The person or persons whose
signatures appear below are authorized to sign this assurance on the behalf of the CHD.
4. Confidentiality of Data,Files,and Records:The CHD agrees to restrict the use and disclosure
of confidential USDA,Women,Infant,and Children(WIC)applicant and participant information as specified
in 7 CFR§246.26(d)(1)(i)In accordance with 7 CFR§246.26(d)(1)(ii),as applicable.
Attachment III-Page 1 of 1
16C2
li
1 •
Attachment IV
Fiscal Year-2025.2026
Collier County Health Department
Facilities Utilized by the County Health Department
Complete Location Facility Description Lease/ Type of Complete SQ Employee
(Street Address,City.Zip) And Offlcal Building Agreement Agreement Legal Name Feet Count
Name(if applicable) Number (Private Lease lieu of Owner (PrEropsr
(Admin,Clink,Envn HIM. Slate or County,other• Contract)
etc.) please donne)
3339 E.Tamiemi Trail,Bldg.H Department and Public Services Board of County
Naples,Florida 34112 (Building fit 011:0005 County Core Contract Commissioners 54,160 142
410 N,1st Street Immokatoo, Board of County
Florida 34142 tmmokslee Satellite 011:9008 County Core Contract Commissioners 14,778 18
_ I
Facility-a axed site managed by DOH/CHD personnel for the purpose of providing or supporting public health services.Includes county-owned,state-owned,and
leased facilites.Includes DOH/CHD warehouse and administrative sites.Includes facilities managed by DOH/CHD that may be shared with other organizations,
Does not Include schools,falls or other facilities where DOH/CHD staff are out-posted or sites where services are provided on an episodic basis. Atlachment_)V-Page 1 of 1
16C2
•
ATTACHMENT V
COLLIER COUNTY HEALTH DEPARTMENT
SPECIAL PROJECTS SAVINGS PLAN
CASH RESERVED OR ANTICIPATED TO BE RESERVED FOR PROJECTS
CONTRACT YEAR STATE COUNTY TOTAL
2024-2025' $ 0 $ 0 $ 0
2025-2026" $ 0 $ 0 $ 0
2026.2027*** $ 0 $ 0 $ 0
2027-2028"' $ 0 $ 0 $ 0
PROJECT TOTAL $ 0 $ 0 $ 0
SPECIAL PROJECTS CONSTRUCTION/RENOVATION PLAN
PROJECT NUMBER:
PROJECT NAME:
LOCATION/ADDRESS:
PROJECT TYPE: NEW BUILDING ROOFING
RENOVATION PLANNING STUDY
NEW ADDITION OTHER
SQUARE FOOTAGE: 0
PROJECT SUMMARY: Describe scope of work in reasonable
START DATE (Initial expenditure of funds) :
COMPLETION DATE:
DESIGN FEES: $ 0
CONSTRUCTION COSTS: $ 0
FURNITURE/EQUIPMENT: $ 0
TOTAL PROJECT COST: $ 0
COST PER SC)FOOT: $ 0
Special Capital Projects are new construction or renovation projects and new furniture or equipment associated with these projects and
mobile health vans_
'Cash balance as of 9/30/25
Cash to be transferred to FCO account.
'"Cash anticipated for future contract years.
Atlachment_V-Page 1 of 1
16C2
B. in the construction or alteration of any improvements on or over the Premises and
the furnishing of services thereon. no person on the grounds of race. color, or national origin, shall be
excluded from participation in.denied the benefits of.or otherwise be subjected to discrimination.
C. the Tenant shall use the Premises in compliance with all other requirements
imposed by or pursuant to 49 CFR Part 2 I. Nondiscrimination in Federally-assisted Programs of the
1.DOT, and as those regulations may he amended.
39. GOVERNING LAW.
This Lease shall he governed by and interpreted according to the laws of the State of
Florida. Any litigation involving this Lease. or the use and occupancy of the Premises, shall be filed and
litigated in Collier County. Florida. in a non;jury proceeding. Tenant hereby waives and releases any
right it has or may have to a trial by jury of any issue.
40. BINDING EFFECT.
This Lease shall be binding upon and inure to the benefit of the Parties hereto and their
successors and such assigns as may be approved hs the Authority. This reference does not authorize an
assignment or subletting by 'Tenant that is inconsistent with the restrictions on assignments and subletting.
stated heretofore.
41. REMEDIES CUMULATIVE NO WAIVER.
A. Cumulative Rights. 'i'hc rights and remedies granted to Authority hereunder shall
be deemed to be cumulative and non-exclusive. The failure by Authority at any time to assert any such
right or remedy shall not he deemed to he a waiver and shall not preclude the entitlement to or the
assertion of such right or remedy at a later date.
B. Acceptance of Partial Payments. I he Authrrriry may. at its exclusive option.
accept partial or late lease rental payments from 'tenant. without waiving any rights concerning collection
of the full amount due. and without waiving the 'Tenant's default for non-payment. Authority may
simultaneously accept partial payments due hereunder and still proceed to dispossess 'Tenant and/or
terminate this Lease or its right to occupy the Premises. Nothing in this provision shall excuse Tenant
from making timely payments as they are due.
42. NOTICE TO PARTIES.
it is understood and agreed heisseen the Parties hereto that written notice, mailed by-
certified mail. return receipt requested. or hand delivered to Authority or Tenant or Tenant's agent shall
constitute proper and sufficient notice if sent to the places designated in Section i or at such other address
as either party may designate to the other by notice in writing.
43. SEVERABILITY.
In the event any provision of this Lease is determined by a proper judicial authority to he
unenforceable. such provision shall he considered separate and severable from the remaining provision of
this Lease, which shall remain in force and he binding as though such unenforceable provision had not
been included, unless the Authority in the reasonable exercise of its discretion determines that the
- 26 -
16C2
provision found to be unenforceable goes to the essence of the Lease and its absence renders the Lease
defective, then this Lease shall terminate and be oflto further force or effect.
44. ENTIRE AGREEMENT.
This Lease constitutes the entire agreement between the Parties hereto. supersedes all
prior written or oral agreements or understandings. and may be modified only by a writing executed by
the Parties hereto.
45. DOMINANT AGREEMENTS.
Tenant hereby covenants and agrees that all of Tenant's rights and privileges under this
Lease arc subject and subordinate to any and all rights. liens. licenses, leases, tenancies. mortgages. uses.
encumbrances and other restrictions which may now or hereafter hind the Authority or encumber the
Airport(or any part of the Premises), and to all renewals. modifications and extensions thereof. Without
limiting the generality of the foregoing. Tenant expressly understands and agrees that this Lease is
subordinate and subject to the lease Manual, Rules and Regulations. and any and all lending, bonding or
certificate of participation. and any and all agreements between the Authority and the FAA. State of
Florida. Collier County or other governmental entity or agency. whether presently existing or hereinafter
created. During times of war or national emergency. the Authority shall have the right to lease the
landing area or any part thereof to the United States Government for military or naval or similar use. and.
if such lease is executed. the provisions of this Lease insofar as they arc inconsistent with the provisions
of the lease to the United States Government. shall he suspended. Any executed lease, including this one.
shall be subordinate to the provisions of any. existing or future agreement between Authority and the
United States. relative to the operation or maintenance of the Airport. the execution of which has been or
may he required as a condition precedent to the expenditure of federal funds for the Airport. Tenant
hereby covenants and agrees to modify any of the terms and conditions of this Lease that may be determined
to be in violation of existing or future laws. regulations.grant assurances or other requirements. In the event
the Parties are unable to mutually agree to a reasonable modification of the teens and conditions of this
Lease pursuant to this Section 45.the Authority may rescind this(..ease by providing thirty(30)days written
notice to Tenant.
46. RADON DISCLOSURE.
Radon is naturally occurring radioactive gas that. when it has accumulated in a building
in sufficient quantities. may present health risks to persons who are exposed to it over time. Levels of
radon that exceed federal and State guidelines have been found in buildings in Florida. Additional
information regarding radon and radon testing may he obtained from the Collier County Public Health
Unit.
47, HEADINGS.
The Section headings arc included in this Lease for reference purposes only and shall not
be employed to interpret or to construe this Lease.
48. AUTHORIZATION.
Each entity executing this l..easc warrants and covenants that this Lease and its execution
has been duly authorized and approved by its respective governing hoard or authorized agents.
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49. AMENDMENT.
This Lease shall not he altered, changed. or amended except by instrument in writing
executed by the Authority and the Tenant.
50. FAA REQUIRED CONTRACT PROVISIONS.
A. Civil Rights General. ['he Tenant and its transferee agree to comply with
pertinent statutes. Executive Orders and such rules as arc promulgated to ensure that no person shall. on
the grounds of race,creed.color. national origin. sex, age. or disability he excluded from participating in
any activity conducted with or benefiting from Federal assistance. This provision obligates the Tenant or
its transferee for the period during which Federal assistance is extended to the Authority through the
Airport Improvement Program. in cases where Federal assistance provides, or is in the form of personal
property: real property or interest therein: structures or improvements thereon. this provision obligates the
party or any transferee for the longer of the following periods: (a)the period during which the property is
used by the Authority or any transferee for a purpose for which Federal assistance is extended. or for
another purpose involving the provision of similar services or benefits: or(b)the period during which the
Authority or any transferee retains ownership or possession of'the property
B. Civil Rights — Title VI Assurances - Compliance with Nondiscrimination
Requirements. During the performance of this Lease. Tenant. for itself, its assignees. and successors in
interest agrees as follows:
(1) Como Lance with Regulations: The Tenant (hereinafter includes
consultants) will comply with the Title VI List of Pertinent Nondiscrimination Acts and Authorities, as
they may he amended from time to time. which arc herein incorporated by reference and made a part of
this contract.
(2) Non-discrimination: The Tenant. with regard to the work performed by
it during this Lease. will not discriminate on the grounds of race. color. or national origin in the selection
and retention of subcontractors. including procurements of materials and leases of equipment. The
Tenant will not participate directly or indirectly in the discrimination prohibited by the Nondiscrimination
Acts and Authorities, including employment practices when the contract covers any activity. project. or
program set forth in Appendix B of 49 CFR part 21.
(3) Solicitations for Subcontracts, Including Procurements of Materials and
Equipment: In all solicitations. either by competitive bidding. or negotiation made by the Tenant for
work to be performed under a subcontract. including procurements of materials, or leases of equipment,
each potential subcontractor or supplier will he notified by the Tenant of the Tenant's obligations under
this Lease and the Nondiscrimination Acts And Authorities on the grounds of race, color, or national
origin.
(4) Information and Reports: The 'Tenant will provide all information and
reports required by the Acts. the Regulations. and directives issued pursuant thereto and will permit
access to its books. records. accounts,other sources of information.and its facilities as may be determined
by the Authority or the Federal Aviation Administration to be pertinent to ascertain compliance with such
Nondiscrimination Acts and Authorities and instructions. Where any information required of a Tenant is
in the exclusive possession of another who fails or refuses to furnish the information. the Tenant will so
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certify to the Authority or the Federal Aviation Administration, as appropriate. and will set forth what
efforts it has made to obtain the information.
(5) Sanctions for Noncompliance: In the event of Tenant's noncompliance
with the Non-discrimination provisions of this Lease. the Authority will impose such contract sanctions as
it or the Federal Aviation Administration may determine to be appropriate, including. but not limited to:
(a) withholding any payments to the Tenant under this Lease until the Tenant complies: and/or (h)
cancelling,terminating,or suspending this Lease. in whole or in part.
(6) Incorporation of Provisions: The Tenant will include the provisions of
Subsections 50.13.(I) through (6) in every subcontract. including procurements of materials and leases of
equipment. unless exempt by the Acts. the Regulations and directives issued pursuant thereto. The
Tenant will take action with respect to any subcontract or procurement as the Authority or the Federal
Aviation Administration may direct as a means of enforcing such provisions including sanctions for
noncompliance. Provided, that if the Tenant becomes involved in. or is threatened with litigation by a
subcontractor, or supplier because of such direction, the Tenant may request the Authority to enter into
any litigation to protect the interests of the Authority. In addition. the Tenant may request the United
States to enter into the litigation to protect the interests of the United States.
C. Transfer of Real Property Ac aired or Improved Under the Activity. Facility.
or engrain,
(I) Tenant for its/his/her heirs. personal representatives, successors in
interest, and assigns, as a part of the consideration hereof. dues hereby covenant and agree (as a covenant
running with the land during the term or this Lease)that:
(a) In the event facilities are constructed. maintained, or otherwise
operated on the property described in this Lease for a purpose for which a Federal Aviation
Administration activity, facility, or program is extended or for another purpose involving the provision of
similar services or benefits. Tenant will maintain and operate such facilities and services in compliance
with all requirements imposed by the Nondiscrimination Acts and Regulations listed in the Pertinent List
of Nondiscrimination Authorities (as may be amended) such that no person on the grounds of race. color.
or national origin. will he excluded from participation in. denied the benefits of. or he otherwise subjected
to discrimination in the use of said facilities.
(2) With respect to licenses. leases. permits. etc.. in the event of breach of
any of the above Nondiscrimination covenants, the Authority ill have the right to terminate the licenses.
leases, permits. etc. and this Lease and to enter, re-enter, and repossess said lands and facilities thereon,
and hold the same as lithe licenses. leases, permits. etc. and this Lease had never been made or issued.
D. ConstructionlUse/Access to Real Property Acquired Under the Activity,
Facility or Program.
(I) Tenant for itself/himselflhersclf, its/his/her heirs, personal
representatives. successors in interest. and assigns. as a part of the consideration hereof, does hereby
covenant and agree(as a covenant running with the land during the term of this Lease) that: (a)no person
on the ground of race,color, or national origin. will be excluded from participation in. denied the benefits
of. or be otherwise subjected to discrimination in the use of said facilities. (h) that in the construction of
any improvements on, over. or under such land. and the furnishing of'services thereon. no person on the
ground of race. color. or national origin. will be excluded from participation in. denied the benefits of. or
- -
1 6 C2
otherwise be subjected to discrimination. and (el that Tenant will use the premises in compliance with all
other requirements imposed by or pursuant to the List of Nondiscrimination Acts And Authorities.
(2) In the event of breach of any of the above nondiscrimination covenants.
the Authority will have the right to terminate the licenses. leases, permits, etc. and this Lease and to enter
or re-enter and repossess said land and the facilities thereon. and hold the same as if the licenses, leases.
permits,etc.and this Lease had never been made or issued
E. Title VI List of Pertinent Nondiscrimination Acts and Authorities.
During the performance of this Lease. Tenant, for itself its assignees. and successors in
interest, agrees to comply with the following nondiscrimination statutes and authorities. including but not
limited to:
• Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq.. 78 scat. 252).
(prohibits discrimination on the basis of race,color, national origin):
• 49 CFR part 21 (Non-discrimination In Federally-Assisted Programs of The
Department of Transportation—F iTeeuration o1"1'itic VI of The Civil Rights Act of 1964).
• The Uniform Relocation Assistance and Real Property Acquisition Policies Act of
1970. (42 U.S.C. § 4601). (prohibits unfair treatment of persons displaced or whose properly has been
acquired because of Federal or Federal-aid programs and projects):
• Section 504 of the Rehabilitation Act of 1973. (29 U.S.C. § 794 et seq.). as amended.
(prohibits discrimination on the basis of disability): and 49 CFR part 27:
• The Age Discrimination Act of 1975. as amended. (42 U.S.C. § 6101 et seq.),
(prohibits discrimination on the basis of age):
• Airport and Airway Improvement Act of 1982. (49 USC § 471. section 471231. as
amended. (prohibits discrimination based on race.creed.color. national origin,or sex):
• Fhe Civil Rights Restoration Act of 1987. (Pl.. 100-209). (Broadened the scope,
coverage and applicability of Title VI of the Civil Rights Act of 1964. The Age [)iscrimination Act of
1975 and section 504 of the Rehabilitation Act of 1973. by expanding the definition of the terms
"programs or activities.' to include all of the programs or activities of the Federal-aid recipients, sub-
recipients and contractors. whether such programs or activities arc Federally funded or not):
• Titles II and 111 of the Americans with Disabilities Act of 1990, which prohibit
discrimination on the basis of disability in the operation of public entities. public and private
transportation systems. places of public accommodation. and certain testing entities (42 U.S.C. §§ 12131
- 12189)as implemented by Department of Transportation regulations at 49 CFR parts 37 and 3.8:
• The Federal Aviation Administration's Non-discrimination statute (49 U.S.C. §
47123)(prohibits discrimination on the basis of race,color. national origin.and sex);
• Executive Order 12898. Federal Actions to Address Environmental Justice in
Minority Populations and Low-Income Populations. which ensures non-discrimination against minority
populations by discouraging programs. policies. and activities with disproportionately high and adverse
human health or environmental effects on minority and low-income populations:
• Executive Order 13166. Improving Access to Services for Persons with Limited
English Proficiency,and resulting agency guidance. national origin discrimination includes discrimination
because of limited English proficiency (LEP). '1'o ensure compliance with Title VI. you must take
reasonable steps to ensure that LEP persons have meaningful access to your programs (70 Fed. Reg. at
74087 to 74100): and
• Title IX of the Education Amendments of 1972. as amended. which prohibits you
from discriminating because of sex in education programs or activities(20 U.S.C. 1681 et seq),
- 30 -
16C2
F. federal Fair Labor Standards Act. All contracts and subcontracts that result from
this solicitation (including this Lease) incorporate by reference the provisions of 29 CFR part 201. the
Federal Fair Labor Standards Act (FI.SA). with the same force and effect as if given in full text. The
FLSA sets minimum wage. overtime pay. recordkeeping. and child labor standards for full and part time
workers. Tenant has full responsibility to monitor compliance to the referenced statute or regulation.
Tenant must address any claims or disputes that arise from this requirement directly with the U.S.
Department of Labor- Wage and !lour Division,
C. Occupational Sala\ and ilcalth Act. All contracts and subcontracts that result
from this solicitation (including this Lease) incorporate by reference the requirements of
29 CFR Part 1910 with the same ti►rce and effect as if given in full text. Tenant must provide a work
environment that is free from recognized hazards that may cause death or serious physical harm to the
employee. Tenant retains full responsibility. to monitor its compliance and their subcontractor's
compliance with the applicable requirements of the Occupational Safety and I lealth Act of 1970 (20 CFR
Part 1910). Tenant must address any claims or disputes that pertain to a referenced requirement directly
with the U.S. Department of Labor—Occupational Safety and 1 lealth Administration.
51. FLORIDA PUBLIC RECORDS LAWS.
A. IF TENANT HAS QUESTIONS REGARDING THE APPLICATION
OF CHAPTER 119, FLORIDA STATUTES, TO TENANT'S DUTY TO PROVIDE
PUBLIC RECORDS RELATING TO THIS LEASE, CONTACT THE AUTHORITY'S
CUSTODIAN OF PUBLIC RECORDS AT: COLLIER COUNTY COMMUNICATIONS
& CUSTOMER RELATIONS, 3299 TAMIAMI TRAIL EAST, SUITE 102, NAPLES, FL
34112; TELEPHONE: (239) 252-8999; EMAIL: PUBLICRECORDSREQUEST
in COLLIERCOUNTYFL.GOV.
13. Tenant acknowledges and agrees that Tenant shall be required to comply with
Florida's Public Records Laws. Chapter 119. Florida Statutes. Specifically. Tenant hereby covenants and
agrees that it shall:
(I) keep and maintain public records required by the Authority to perform
the services under this Lease:
(2) upon request from the Authority's custodian of public records. provide
the Authority with a copy of the requested records or allow the records to be inspected or copied within a
reasonable time at a cost that does not exceed the cost provided in Chapter 119, Florida Statutes. or as
otherwise provided by law;
(3) ensure that public records that are exempt or confidential and exempt
from public records disclosure requirements are not disclosed except as authorized by law for the duration
of the term of this Lease and following completion of this Lease if Tenant does not transfer the records to
the Authority;and
(4) upon completion of this Lease. transfer, at no cost. to the Authority all
public records in possession of'tenant or keep and maintain public records required by the Authority to
perform the services under this Lease. if Tenant transfers all public records to the Authority upon
completion alibis Lease.Tenant shall destroy any duplicate public records that are exempt or confidential
and exempt from public records disclosure requirements. if-i'cnant keeps and maintains public records
- 31 -
16C2
upon completion ot'this Lease. tenant shalt meet all applicahk requirements for retaining public records
All records stored electronientb must he pros ided to the Authorit>. upon request from the Authority's
custodian ot'public records. in a lima' that is compatible ssith the information technolot} stems of the
\uthorits.
IN WITNESS WIIEKEOF. the Parties hale caused this Lease to be mooed as ol'the I:1lietlse
Date,
Al'I S1': At"tllOttttl':
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Exhibit"B"
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16C2
Exhibit,.C"
(ti-VI RIFY ENROLLMENT
S
1 6 C2
El/Verify .4.p
Company ID Number: 1659268
THE E-VERIFY
MEMORANDUM OF UNDERSTANDING
FOR EMPLOYERS
ARTICLE I
PURPOSE AND AUTHORITY
The parties to this agreement are the Department of Homeland Security (DHS) and the
Global Flight Training Solutions INC (Employer). The purpose of this agreement is to set forth terms
and conditions which the Employer will follow while participating in E-Verify.
E-Verify is a program that electronically confirms an employee's eligibility to work in the United States
after completion of Form 1-9, Employment Eligibility Verification (Form 1-9). This Memorandum of
Understanding (MOU) explains certain features of the E-Verify program and describes specific
responsibilities of the Employer, the Social Security Administration (SSA), and DHS.
Authority for the E-Verify program is found in Title IV, Subtitle A, of the Illegal Immigration Reform and
Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208, 110 Stat. 3009, as amended (8 U.S.C.
§ 1324a note). The Federal Acquisition Regulation (FAR) Subpart 22.18, "Employment Eligibility
Verification" and Executive Order 12989, as amended, provide authority for Federal contractors and
subcontractors (Federal contractor) to use E-Verify to verify the employment eligibility of certain
employees working on Federal contracts.
ARTICLE II
RESPONSIBILITIES
A. RESPONSIBILITIES OF THE EMPLOYER
1. The Employer agrees to display the following notices supplied by OHS in a prominent place that is
clearly visible to prospective employees and all employees who are to be verified through the system.
a. Notice of E-Verify Participation
b. Notice of Right to Work
2. The Employer agrees to provide to the SSA and DHS the names, titles, addresses, and telephone
numbers of the Employer representatives to be contacted about E-Verify. The Employer also agrees to
keep such information current by providing updated information to SSA and DHS whenever the
representatives' contact information changes.
3. The Employer agrees to grant E-Verify access only to current employees who need E-Verify access.
Employers must promptly terminate an employee's E-Verify access if the employer is separated from
the company or no longer needs access to E-Verify.
Page 1 of 17 E-Verify MOU for Employers I Revision Date 08101/13
16C2
Everify
Company ID Number: 1659266
4. The Employer agrees to become familiar with and comply with the most recent version of the
E-Verify User Manual.
5. The Employer agrees that any Employer Representative who will create E-Verify cases will
complete the E-Verify Tutorial before that individual creates any cases.
a. The Employer agrees that all Employer representatives will take the refresher tutorials when
prompted by E-Verify in order to continue using E-Verify. Failure to complete a refresher tutorial
will prevent the Employer Representative from continued use of E-Verify.
6. The Employer agrees to comply with current Form 1-9 procedures, with two exceptions:
a. If an employee presents a "List B"identity document, the Employer agrees to only accept "List
B"documents that contain a photo. (List B documents identified in 8 C.F.R. § 274a.2(b)(1)(B)) can
be presented during the Form 1-9 process to establish identity.) If an employee objects to the photo
requirement for religious reasons, the Employer should contact E-Verify at
888-464-4218.
b. If an employee presents a DHS Form 1-551 (Permanent Resident Card), Form 1-766
(Employment Authorization Document), or U.S. Passport or Passport Card to complete Form 1-9,
{ the Employer agrees to make a photocopy of the document and to retain the photocopy with the
employee's Form 1-9. The Employer will use the photocopy to verify the photo and to assist OHS
with its review of photo mismatches that employees contest. DHS may in the future designate
other documents that activate the photo screening tool.
Note: Subject only to the exceptions noted previously in this paragraph, employees still retain the right
to present any List A, or List B and List C, document(s) to complete the Form 1-9.
7. The Employer agrees to record the case verification number on the employee's Form I-9 or to print
the screen containing the case verification number and attach it to the employee's Form 1-9.
8, The Employer agrees that, although it participates in E-Verify, the Employer has a responsibility to
complete, retain, and make available for inspection Forms 1-9 that relate to its employees, or from other
requirements of applicable regulations or laws, including the obligation to comply with the
antidiscrimination requirements of section 274B of the INA with respect to Form 1-9 procedures.
a. The following modified requirements are the only exceptions to an Employer's obligation to not
employ unauthorized workers and comply with the anti-discrimination provision of the INA: (1) List B
identity documents must have photos, as described in paragraph 6 above; (2)When an Employer
confirms the identity and employment eligibility of newly hired employee using E-Verify procedures,
the Employer establishes a rebuttable presumption that it has not violated section 274A(a)(1)(A) of
the Immigration and Nationality Act(INA) with respect to the hiring of that employee; (3) If the
Employer receives a final nonconfirmation for an employee, but continues to employ that person,
the Employer must notify OHS and the Employer is subject to a civil money penalty between $550
and $1,100 for each failure to notify OHS of continued employment following a final
nonconfirmation; (4) If the Employer continues to employ an employee after receiving a final
nonconfirmation, then the Employer is subject to a rebuttable presumption that it has knowingly
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employed an unauthorized alien in violation of section 274A(a)(1)(A); and (5) no E-Verify participant
is civilly or criminally liable under any law for any action taken in good faith based on information
provided through the E-Verify.
b. OHS reserves the right to conduct Form 1-9 compliance inspections, as well as any other
enforcement or compliance activity authorized by law, including site visits, to ensure proper use of
E-Verify.
9. The Employer is strictly prohibited from creating an E-Verify case before the employee has been
hired, meaning that a firm offer of employment was extended and accepted and Form 1-9 was
completed. The Employer agrees to create an E-Verify case for new employees within three Employer
business days after each employee has been hired (after both Sections 1 and 2 of Form 1-9 have been
completed), and to complete as many steps of the E-Verify process as are necessary according to the
E-Verify User Manual. If E-Verify is temporarily unavailable, the three-day time period will be extended
} until it is again operational in order to accommodate the Employer's attempting, in good faith, to make
inquiries during the period of unavailability.
10. The Employer agrees not to use E-Verify for pre-employment screening of job applicants, in
support of any unlawful employment practice, or for any other use that this MOU or the E-Verify User
Manual does not authorize.
11. The Employer must use E-Verify for all new employees. The Employer will not verify selectively
and will not verify employees hired before the effective date of this MOU. Employers who are Federal
contractors may qualify for exceptions to this requirement as described in Article I1.B of this MOU.
12. The Employer agrees to follow appropriate procedures (see Article III below) regarding tentative
nonconfirmations. The Employer must promptly notify employees in private of the finding and provide
them with the notice and letter containing information specific to the employee's E-Verify case. The
Employer agrees to provide both the English and the translated notice and letter for employees with
limited English proficiency to employees. The Employer agrees to provide written referral instructions
to employees and instruct affected employees to bring the English copy of the letter to the SSA. The
Employer must allow employees to contest the finding, and not take adverse action against employees
if they choose to contest the finding, while their case is still pending. Further,when employees contest
a tentative nonconfirmation based upon a photo mismatch, the Employer must take additional steps
(see Article 111.8. below) to contact DHS with information necessary to resolve the challenge.
13. The Employer agrees not to take any adverse action against an employee based upon the
employee's perceived employment eligibility status while SSA or DHS is processing the verification
request unless the Employer obtains knowledge (as defined in 8 C.F.R. § 274a.1(I))that the employee
is not work authorized. The Employer understands that an initial inability of the SSA or DHS automated
verification system to verify work authorization, a tentative nonconfirmation, a case in continuance
(indicating the need for additional time for the government to resolve a case), or the finding of a photo
mismatch, does not establish, and should not be interpreted as, evidence that the employee is not work
authorized. In any of such cases, the employee must be provided a full and fair opportunity to contest
the finding, and if he or she does so, the employee may not be terminated or suffer any adverse
employment consequences based upon the employee's perceived employment eligibility status
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(including denying, reducing, or extending work hours, delaying or preventing training, requiring an
employee to work in poorer conditions, withholding pay, refusing to assign the employee to a Federal
contract or other assignment, or otherwise assuming that he or she is unauthorized to work) until and
unless secondary verification by SSA or OHS has been completed and a final nonconfirmation has
been issued. If the employee does not choose to contest a tentative nonconfirmation or a photo
mismatch or if a secondary verification is completed and a final nonconfirmation is Issued, then the
Employer can find the employee is not work authorized and terminate the employee's employment.
Employers or employees with questions about a final nonconfirmation may call E-Verify at 1-888-464-
4218 (customer service) or 1-888-897-7781 (worker hotline).
14. The Employer agrees to comply with Title VII of the Civil Rights Act of 1964 and section 274E of
the INA as applicable by not discriminating unlawfully against any individual in hiring, firing,
employment eligibility verification, or recruitment or referral practices because of his or her national
origin or citizenship status, or by committing discriminatory documentary practices. The Employer
understands that such illegal practices can include selective verification or use of E-Verify except as
provided in part D below, or discharging or refusing to hire employees because they appear or sound
"foreign" or have received tentative nonconfirmations. The Employer further understands that any
violation of the Immigration-related unfair employment practices provisions in section 2748 of the INA
could subject the Employer to civil penalties, back pay awards, and other sanctions, and violations of
Title VII could subject the Employer to back pay awards, compensatory and punitive damages.
Violations of either section 274B of the INA or Title VII may also lead to the termination of its
participation in E-Verify. If the Employer has any questions relating to the anti-discrimination provision,
it should contact OSC at 1-800-255-8155 or 1-800-237-2515 (TOD).
15. The Employer agrees that it will use the information it receives from E-Verify only to confirm the
employment eligibility of employees as authorized by this MOU. The Employer agrees that it will
safeguard this information, and means of access to it (such as PiNS and passwords), to ensure that it
is not used for any other purpose and as necessary to protect its confidentiality, including ensuring that
it is not disseminated to any person other than employees of the Employer who are authorized to
perform the Employer's responsibilities under this MOU, except for such dissemination as may be
authorized in advance by SSA or DHS for legitimate purposes.
16. The Employer agrees to notify OHS immediately in the event of a breach of personal information.
Breaches are defined as loss of control or unauthorized access to E-Verify personal data. All
suspected or confirmed breaches should be reported by calling 1-888-464-4218 or via email at
E-Verifvc dhs.vov. Please use "Privacy Incident—Password" in the subject line of your email when
sending a breach report to E-Verify.
17. The Employer acknowledges that the information it receives from SSA is governed by the Privacy
Act (5 U.S.C. § 552a(i)(1) and (3)) and the Social Security Act(42 U.S.C. 1306(a)). Any person who
obtains this information under false pretenses or uses it for any purpose other than as provided for in
this MOU may be subject to criminal penalties.
18. The Employer agrees to cooperate with DHS and SSA in their compliance monitoring and
evaluation of E-Verify,which includes permitting DHS, SSA, their contractors and other agents, upon
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reasonable notice, to review Forms 1-9 and other employment records and to interview it and its
employees regarding the Employer's use of E-Verify, and to respond in a prompt and accurate manner
to OHS requests for information relating to their participation in E-Verify.
19. The Employer shall not make any false or unauthorized claims or references about its participation
in E-Verify on its website, in advertising materials, or other media. The Employer shall not describe its
services as federally-approved, federally-certified, or federally-recognized, or use language with a
similar Intent on its website or other materials provided to the public. Entering into this MOU does not
mean that E-Verify endorses or authorizes your E-Verify services and any claim to that effect is false.
20. The Employer shall not state in its website or other public documents that any language used
therein has been provided or approved by OHS, USCIS or the Verification Division, without first
obtaining the prior written consent of DHS.
21. The Employer agrees that E-Verify trademarks and logos may be used only under license by
DHS/USCIS (see M-795 (Web)) and, other than pursuant to the specific terms of such license, may not
be used in any manner that might imply that the Employer's services, products, websites, or
publications are sponsored by, endorsed by, licensed by, or affiliated with DHS, USCIS, or E-Verify.
22. The Employer understands that if it uses E-Verify procedures for any purpose other than as
authorized by this MOU, the Employer may be subject to appropriate legal action and termination of its
participation in E-Verify according to this MOU.
B. RESPONSIBILITIES OF FEDERAL CONTRACTORS
1 If the Employer is a Federal contractor with the FAR E-Verify clause subject to the employment
verification terms in Subpart 22.18 of the FAR, it will become familiar with and comply with the most
current version of the E-Verify User Manual for Federal Contractors as well as the E-Verify
Supplemental Guide for Federal Contractors.
2. In addition to the responsibilities of every employer outlined In this MOU, the Employer understands
that if it is a Federal contractor subject to the employment verification terms in Subpart 22.18 of the
FAR it must verify the employment eligibility of any"employee assigned to the contract"(as defined In
FAR 22.1801). Once an employee has been verified through E-Verify by the Employer, the Employer
may not create a second case for the employee through E-Verify.
a. An Employer that is not enrolled in E-Verify as a Federal contractor at the time of a contract
award must enroll as a Federal contractor in the E-Verify program within 30 calendar days of
contract award and, within 90 days of enrollment, begin to verify employment eligibility of new hires
using E-Verify. The Employer must verify those employees who are working in the United States,
whether or not they are assigned to the contract. Once the Employer begins verifying new hires.
such verification of new hires must be initiated within three business days after the hire date. Once
enrolled in E-Verify as a Federal contractor, the Employer must begin verification of employees
assigned to the contract within 90 calendar days after the date of enrollment or within 30 days of an
employee's assignment to the contract, whichever date is later.
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b. Employers enrolled in E-Verify as a Federal contractor for 90 days or more at the time of a
contract award must use E-Verify to begin verification of employment eligibility for new hires of the
Employer who are working in the United States, whether or not assigned to the contract, within
three business days after the date of hire. If the Employer Is enrolled in E-Verify as a Federal
contractor for 90 calendar days or less at the time of contract award, the Employer must, within 90
days of enrollment, begin to use E-Verify to initiate verification of new hires of the contractor who
are working in the United States, whether or not assigned to the contract. Such verification of new
hires must be initiated within three business days after the date of hire. An Employer enrolled as a
Federal contractor in E-Verlfy must begin verification of each employee assigned to the contract
within 90 calendar days after date of contract award or within 30 days after assignment to the
contract, whichever is later.
c. Federal contractors that are institutions of higher education (as defined at 20 U.S.C. 1001(a)),
state or local governments, governments of Federally recognized Indian tribes, or sureties
performing under a takeover agreement entered into with a Federal agency under a performance
bond may choose to only verify new and existing employees assigned to the Federal contract. Such
Federal contractors may, however, elect to verify all new hires, and/or all existing employees hired
after November 6, 1986, Employers in this category must begin verification of employees assigned
to the contract within 90 calendar days after the date of enrollment or within 30 days of an
employee's assignment to the contract, whichever date is later.
d. Upon enrollment, Employers who are Federal contractors may elect to verify employment
eligibility of all existing employees working in the United States who were hired after November 6,
1986, instead of verifying only those employees assigned to a covered Federal contract. After
enrollment, Employers must elect to verify existing staff following DHS procedures and begin
E-Verify verification of all existing employees within 180 days after the election.
e. The Employer may use a previously completed Form 1-9 as the basis for creating an E-Verify
case for an employee assigned to a contract as long as:
i. That Form 1-9 is complete (Including the SSN) and complies with Article II.A.6,
ii. The employee's work authorization has not expired, and
iii. The Employer has reviewed the Form 1-9 information either in person or in
communications with the employee to ensure that the employee's Section 1, Form 1-9
attestation has not changed (including, but not limited to, a lawful permanent resident alien
having become a naturalized U.S. citizen).
I. The Employer shall complete a new Form 1-9 consistent with Article II.A.6 or update the
previous Form 1-9 to provide the necessary information if:
i. The Employer cannot determine that Form 1-9 complies with Article II.A.6,
ii. The employee's basis for work authorization as attested in Section 1 has expired or
changed, or
iii. The Form 1-9 contains no SSN or is otherwise incomplete.
Note: If Section 1 of Form 1-9 is otherwise valid and up-to-date and the form otherwise complies with
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Article II.C.5, but reflects documentation (such as a U.S. passport or Form 1-551) that expired after
completing Form 1-9, the Employer shall not require the production of additional documentation, or use
the photo screening tool described in Article II.A.5, subject to any additional or superseding instructions
that may be provided on this subject in the E-Verify User Manual.
g. The Employer agrees not to require a second verification using E-Verify of any assigned
employee who has previously been verified as a newly hired employee under this MOU or to
authorize verification of any existing employee by any Employer that is not a Federal contractor
based on this Article.
3. The Employer understands that if it is a Federal contractor, its compliance with this MOU is a
performance requirement under the terms of the Federal contract or subcontract, and the Employer
consents to the release of information relating to compliance with its verification responsibilities under
this MOU to contracting officers or other officials authorized to review the Employer's compliance with
Federal contracting requirements.
C. RESPONSIBILITIES OF SSA
1. SSA agrees to allow DHS to compare data provided by the Employer against SSA's database. SSA
sends DHS confirmation that the data sent either matches or does not match the information in SSA's
database.
2. SSA agrees to safeguard the information the Employer provides through E-Verify procedures. SSA
also agrees to limit access to such information, as is appropriate by law, to individuals responsible for
the verification of Social Security numbers or responsible for evaluation of E-Verify or such other
persons or entities who may be authorized by SSA as governed by the Privacy Act (5 U.S.C. § 552a),
the Social Security Act (42 U.S.C. 1306(a)), and SSA regulations (20 CFR Part 401).
3. SSA agrees to provide case results from its database within three Federal Government work days of
the initial inquiry. E-Verify provides the information to the Employer.
4. SSA agrees to update SSA records as necessary if the employee who contests the SSA tentative
nonconfirmation visits an SSA field office and provides the required evidence. If the employee visits an
SSA field office within the eight Federal Government work days from the date of referral to SSA, SSA
agrees to update SSA records, if appropriate, within the eight-day period unless SSA determines that
more than eight days may be necessary. In such cases, SSA will provide additional instructions to the
employee. If the employee does not visit SSA in the time allowed, E-Verify may provide a final
nonconfirmation to the employer.
Note: If an Employer experiences technical problems, or has a policy question, the employer should
contact E-Verify at 1-888-464-4218.
D. RESPONSIBILITIES OF OHS
1. OHS agrees to provide the Employer with selected data from DHS databases to enable the
Employer to conduct, to the extent authorized by this MOU:
a. Automated verification checks on alien employees by electronic means, and
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b. Photo verification checks (when available) on employees.
2. DHS agrees to assist the Employer with operational problems associated with the Employer's
participation in E-Verify. OHS agrees to provide the Employer names, titles, addresses, and telephone
numbers of DHS representatives to be contacted during the E-Verify process.
3. DNS agrees to provide to the Employer with access to E-Verify training materials as well as an
E-Verify User Manual that contain instructions on E-Verify policies, procedures, and requirements for
both SSA and OHS, including restrictions on the use of E-Verify.
4. DHS agrees to train Employers on all important changes made to E-Verify through the use of
mandatory refresher tutorials and updates to the E-Verify User Manual. Even without changes to
E-Verify, OHS reserves the right to require employers to take mandatory refresher tutorials.
5. OHS agrees to provide to the Employer a notice, which indicates the Employer's participation in
E-Verify. DHS also agrees to provide to the Employer anti-discrimination notices issued by the Office of
Special Counsel for Immigration-Related Unfair Employment Practices(OSC), Civil Rights Division,
U.S. Department of Justice.
6. OHS agrees to issue each of the Employer's E-Verify users a unique user identification number and
password that permits them to log in to E-Verify.
7. OHS agrees to safeguard the information the Employer provides, and to limit access to such
Information to individuals responsible for the verification process, for evaluation of E-Verify, or to such
} other persons or entities as may be authorized by applicable law. Information will be used only to verify
the accuracy of Social Security numbers and employment eligibility, to enforce the INA and Federal
criminal laws, and to administer Federal contracting requirements.
8. OHS agrees to provide a means of automated verification that provides (in conjunction with SSA
verification procedures) confirmation or tentative nonconfirmation of employees' employment eligibility
within three Federal Government work days of the initial inquiry.
9. DHS agrees to provide a means of secondary verification (including updating OHS records)for
employees who contest DHS tentative nonconfirmations and photo mismatch tentative
nonconfirmations. This provides final confirmation or nonconfirmation of the employees' employment
eligibility within 10 Federal Government work days of the date of referral to DHS, unless OHS
determines that more than 10 days may be necessary. In such cases, DHS will provide additional
verification instructions.
ARTICLE III
REFERRAL OF INDIVIDUALS TO SSA AND DHS
A. REFERRAL TO SSA
1. If the Employer receives a tentative nonconfirmation issued by SSA, the Employer must print the
notice as directed by E-Verify. The Employer must promptly notify employees in private of the finding
and provide them with the notice and letter containing information specific to the employee's E-Verify
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case. The Employer also agrees to provide both the English and the translated notice and letter for
employees with limited English proficiency to employees. The Employer agrees to provide written
referral instructions to employees and instruct affected employees to bring the English copy of the letter
to the SSA. The Employer must allow employees to contest the finding, and not take adverse action
against employees if they choose to contest the finding, while their case is still pending.
2. The Employer agrees to obtain the employee's response about whether he or she will contest the
tentative nonconfirmation as soon as possible after the Employer receives the tentative
nonconfirmation. Only the employee may determine whether he or she will contest the tentative
nonconfirmation.
3. After a tentative nonconfirmation, the Employer will refer employees to SSA field offices only as
directed by E-Verify. The Employer must record the case verification number, review the employee
information submitted to E-Verify to identify any errors, and find out whether the employee contests the
tentative nonconfirmation. The Employer will transmit the Social Security number, or any other
corrected employee information that SSA requests, to SSA for verification again if this review Indicates
a need to do so.
4. The Employer will instruct the employee to visit an SSA office within eight Federal Government work
days. SSA will electronically transmit the result of the referral to the Employer within 10 Federal
Government work days of the referral unless it determines that more than 10 days is necessary.
5. While waiting for case results, the Employer agrees to check the E-Verify system regularly for case
updates.
6. The Employer agrees not to ask the employee to obtain a printout from the Social Security
Administration number database (the Numident) or other written verification of the SSN from the SSA.
B. REFERRAL TO OHS
1. If the Employer receives a tentative nonconfirmation issued by DHS, the Employer must promptly
notify employees in private of the finding and provide them with the notice and letter containing
information specific to the employee's E-Verify case. The Employer also agrees to provide both the
English and the translated notice and letter for employees with limited English proficiency to
employees. The Employer must allow employees to contest the finding, and not take adverse action
against employees If they choose to contest the finding, while their case Is still pending.
2. The Employer agrees to obtain the employee's response about whether he or she will contest the
tentative nonconfirmation as soon as possible after the Employer receives the tentative
nonconfirmation. Only the employee may determine whether he or she will contest the tentative
nonconfirmation.
3. The Employer agrees to refer individuals to DHS only when the employee chooses to contest a
tentative nonconfirmation.
4. If the employee contests a tentative nonconfirmation issued by DHS, the Employer will instruct the
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employee to contact DHS through its toll-free hotline (as found on the referral letter)within eight
Federal Government work days.
5. If the Employer finds a photo mismatch, the Employer must provide the photo mismatch tentative
nonconfirmation notice and follow the instructions outlined in paragraph 1 of this section for tentative
nonconfirmations, generally.
6. The Employer agrees that if an employee contests a tentative nonconfirmation based upon a photo
mismatch, the Employer will send a copy of the employee's Form 1-551, Form 1-766, U.S. Passport, or
passport card to DHS for review by:
a. Scanning and uploading the document, or
b. Sending a photocopy of the document by express mail (furnished and paid for by the employer).
7. The Employer understands that if it cannot determine whether there is a photo match/mismatch, the
Employer must forward the employee's documentation to DHS as described in the preceding
paragraph. The Employer agrees to resolve the case as specified by the DHS representative who will
determine the photo match or mismatch.
8. OHS will electronically transmit the result of the referral to the Employer within 10 Federal
Government work days of the referral unless it determines that more than 10 days is necessary.
9. While waiting for case results, the Employer agrees to check the E-Verify system regularly for case
{
updates.
ARTICLE IV
SERVICE PROVISIONS
A. NO SERVICE FEES
1. SSA and DHS will not charge the Employer for verification services performed under this MOU. The
Employer is responsible for providing equipment needed to make inquiries. To access E-Verify, an
Employer will need a personal computer with Internet access.
ARTICLE V
MODIFICATION AND TERMINATION
A. MODIFICATION
1. This MOU is effective upon the signature of all parties and shall continue in effect for as long as the
SSA and DHS operates the E-Verify program unless modified in writing by the mutual consent of all
parties.
2. Any and all E-Verify system enhancements by DHS or SSA, including but not limited to E-Verify
checking against additional data sources and instituting new verification policies or procedures, will be
covered under this MOU and will not cause the need for a supplemental MOU that outlines these
changes.
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