Agenda 10/14/2025 Item #16D 5 (CDBG Subrecipient Grant Agreement #CD25-02 between Collier County and Collier Health Services, Inc. dba Healthcare Network)10/14/2025
Item # 16.D.5
ID# 2025-2692
Executive Summary
Recommendation to approve and authorize the Chair to sign the Community Development Block Grant Subrecipient
Grant Agreement #CD25-02 between Collier County and Collier Health Services, Inc., dba Healthcare Network, in the
amount of $290,000 to fund the Marion E. Fether Medical Center HVAC Replacement Project. (Housing Grant Fund
1835).
OBJECTIVE: To support low-to moderate-income citizens of Collier County and advance the County’s strategic plan
by supporting access to health, wellness, and human services,
CONSIDERATIONS: The U.S. Department of Housing and Urban Development (HUD) Community Development
Block Grant (CDBG) program funds locally defined requests for program specific needs in the community and
infrastructure improvements. Every five years the County is required to submit a Consolidated Plan to HUD outlining
the goals and activities to be undertaken with HUD entitlement funds over the five-year period as well as the Annual
Action Plans.
On June 22, 2021, the Board of County Commissioners (Board) approved the County’s Five-Year Consolidated Plan for
the use of entitlement funds for Program Years (PY’s) 2021-2025 (Agenda Item #16.D.7). As part of the County’s 5-
year Consolidated Plan, the Community and Human Services (CHS) Division is required to adopt and submit an Annual
Action Plan each year. This is the fifth (5th) year of the Five-Year Consolidated Plan. The Annual Action Plan was
developed in accordance with the County’s Citizen Participation Plan (CPP).
The Annual Action Plan and Citizen Participation Plan public notice was advertised on May 22, 2025, in the Naples
Daily News. A public hearing was held on June 5, 2025, with a (30) day comment period beginning June 6, 2025, and
ending on July 6, 2025. There were no public comments received. The Boad approved PY25 Action Plan on July 8,
2025 (Agenda Item #16. D.2).
The County’s process for project selection begins with an application cycle annually in January, followed by a
recommendation by the Review and Ranking Committee and conditional approval by the County Manager.
Recommended projects are then outlined and described in the Action Plan and eventually finalized in subrecipient
agreements for activities to be approved by the Board. There may be non-material changes in project descriptions and
scope of service between the initial application, development of the action plan, and finalizing the contractual
agreements presented to the Board for approval.
The annual HUD CDBG Application Cycle commenced on January 7, 2025, with applications due on February 24,
2025. On March 26 & 27, 2025 applications for funding were reviewed and ranked. The Review and Ranking
Committee, who were approved by the County Manager’s Office, scored the applications and made recommendations
for approval. Collier Health Services, Inc. dba Healthcare Network’s (“Healthcare Network”) grant application for
CDBG entitlement grant funding was not originally ranked for award by the Review and Ranking committee but
additional funding became available and was awarded to Healthcare Network as the next highest ranked applicant. On
April 18, 2025, CHS notified Healthcare Network that its application was recommended for funding.
The proposed agreement with Healthcare Network will provide $290,000.00 in funding for the replacement of HVAC
(Heating, Ventilation, and Air-Conditioning) units at the Marion E. Fether Medical Center in Immokalee, Florida. The
project aims to improve public facilities in Immokalee, Florida by contributing to the renovations of the Marion E.
Fether Medical Center that serves the community of Immokalee, many of which are low-to-moderate income. This
investment supports essential infrastructure upgrades and aligns with ongoing efforts to preserve and enhance Collier
County’s support of access to health, wellness, and human services. The agreement term is from October 1, 2025,
through September 30, 2026.
This item is consistent with the Collier County strategic plan objective of supporting access to health, wellness, and
human services,
FISCAL IMPACT: The proposed action has no new fiscal impact. The $290,000.00 for this CDBG agreement is
Page 3208 of 6526
10/14/2025
Item # 16.D.5
ID# 2025-2692
budgeted in Housing Grant Fund (1835). Funds may be allocated from CDBG Projects PY21 33763, PY22 33823,
PY23 33855, PY24 33915 or PY25 33950.
GROWTH MANAGEMENT IMPACT: This item has no impact on the Housing Element of the Growth Management
Plan of Collier County.
LEGAL CONSIDERATIONS: This item is approved as to form and legality and requires a majority vote of the Board
for approval. – CLD
RECOMMENDATIONS: Recommendation to approve and authorize the Chair to sign the Community Development
Block Grant Subrecipient Grant Agreement #CD25-02 between Collier County and Collier Health Services, Inc., dba
Healthcare Network, in the amount of $290,000 to fund the Marion E. Fether Medical Center HVAC Replacement
Project. (Housing Grant Fund 1835).
PREPARED BY: Parker Smith, Grant Coordinator I, Community and Human Services Division
ATTACHMENTS:
1. FFATA_Sub_Awards_12-19_Revised - signed
2. CHSI CD25-02 HVAC Agreement - Subrecipient Signed
Page 3209 of 6526
12/19 Revised
Federal Funding Accountability and Transparency Act (FFATA) Reporting Form
FFATA was signed into law on September 26, 2006 and is intended to increase federal transparency through the creation
of a publicly available and easily searchable online database. As a prime recipient of federal funds, DHS is required to
collect sub-award and executive compensation information from sub-recipients for entry into that database.
DUNS Number
Subrecipient Organization Name
DBA Name
Address
Parent DUNS Number
Amount of Sub Award
CFDA Program Number
Program Title
Federal Agency Name
Project Description
Sub Agreement Number
Primary Site Where Work is Performed
Principal Place of Performance Address
Zip Code plus 4 digits
https://tools.usps.com/zip-code-lookup.htm?byaddress
Check one of the following:
___ The organization does not meet the applicability requirements to report the total
compensation of the top five subgrantee executives and will not report total
compensation for the preceding completed fiscal year.
___ The organization meets the applicability requirements to report the total compensation
of top five subgrantee executives for the preceding completed fiscal year.
Name
1.Jamie Ulmer________________
2.Jaimie Khemraj_____________
3.Salvatore Anzalone__________
4.John Fletcher_______________
5.Tami Raznoff
Total Compensation
$433,699.45________
$374,500.84________
$353,279.89________
$240,072.45________
$224,519.39________
____________________________________
Signature (Official who can verify status of information provided)
____________________________________
Print Name and Title
____________________________________
Date
Tami Raznoff (Aug 18, 2025 12:49:46 EDT)
085019511
Collier Health Services, Inc
Healthcare Network
1425 Madison Ave, Immokallee, FL 34142
085019511
290000
14.218
CDBG
HUD
Marion E Fether Medical Center HVAC
CD-2502
1425 Madison Ave, Immokalee, FL
34142-2200
4
Tami Raznoff, CFO
8/18/2025
Page 3210 of 6526
FFATA_Sub_Awards_12-19_Revised
Final Audit Report 2025-08-18
Created:2025-08-18
By:Pamela Baker (pbaker@healthcareswfl.org)
Status:Signed
Transaction ID:CBJCHBCAABAACA2hx_PbKWMV5q8qGpHp0qDDst86JHC9
"FFATA_Sub_Awards_12-19_Revised" History
Document created by Pamela Baker (pbaker@healthcareswfl.org)
2025-08-18 - 4:41:56 PM GMT
Document emailed to Tami Raznoff (TRaznoff@healthcareswfl.org) for signature
2025-08-18 - 4:43:10 PM GMT
Email viewed by Tami Raznoff (TRaznoff@healthcareswfl.org)
2025-08-18 - 4:49:14 PM GMT
Document e-signed by Tami Raznoff (TRaznoff@healthcareswfl.org)
Signature Date: 2025-08-18 - 4:49:46 PM GMT - Time Source: server
Agreement completed.
2025-08-18 - 4:49:46 PM GMT
Page 3211 of 6526
FAIN #B-21-UC-12-0016
B-22-UC-12-00t6
B-23-UC-12-0016
B-24-UC-12-0016
B-25-UC-I2-0016
Federal Award Date 1012025
Federal Award Agency HUD
CFDA Name Community
Development Block
Grant
CFDA/CSFA#14.218
Total Amount of Federal
Funds Awarded
$290,000.00
Subrecipient Name Collier Health Services,
Inc. dba Healthcare
Network
UEI#GPXBQKU6AJA5
FEIN 59-1741277
R&D NA
Indirect Cost Rate NA
Period of Performance 101011202s - 913012026
Fiscal Year End 313t
Monitor End t2l203t
AGREEMENT BETWEEN COLLIER COUNTY
AND
Collier Health Services, Inc. dba Healthcare Network
CDBG Grant Program - Rehabilitation
THIS AGREEMENT is made and entered into this _ duy of _ 2025-, by and between Collier
County, a political subdivision of the State of Florida, (COIINTY) having its principal address at 3339
Tamiami Trail East, Suite 213, Naples FL 341 12, and Collier Health Services, Inc. dba Healthcare Network
(SUBRECIPIENT), a private non-profit (or other type) organization having its principal office at 1454
Madison Avenue W., Immokalee, FL 34142.
WHERIAS, the COUNTY has entered into an Agreement with the United States Department of
Housing and Urban Development (HUD) for a grant to execute and implement a Community Development
Block Grant (CDBG) Program in certain areas of Collier County, pursuant to Title I of the Housing and
Community Development Act of 1974 (as amended); and
WHEREAS, the Board of County Commissioners of Collier County (Board) approved the Collier
County Consolidated Plan - One-year Action Plan for Federal Fiscal Year 2025-2026 for the CDBG
Program with Resolution 2025-134 on July 8,2025 - Agenda Item 16.D.2; and
WHEREAS, in accordance with HUD regulations and the Collier County Consolidated Plan
concerning the preparation of various Annual Action Plans, the COUNTY advertised the 2025-2026
Annual Action Plan, on May 22,2025,with a 30-day Citizen Comment period from June 6,2025, to July
6,2025;
CAO
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PART V
EXHIBITS
2
EXHIBIT A
INSURANCE REQUIREMENTS
The SUBRECIPIENT shall fumish to Collier County Board of County Commissioners, c/o Community
and Human Services Division,3339 Tamiami Trail East, Suite 213, Naples, Florida 34112, Certificate(s)
of Insurance evidencing insurance coverage that meets the requirements as outlined below:
1. Workers' Compensation as required by Chapter 440, Florida Statutes
Commercial General Liability, including products and completed operations insurance, in the
amount of $ 1,000,000 per occurrence and $2,000,000 aggregate. Collier County Board of County
Commissioners must be shown as an additional insured with respect to this coverage.
Automobile Liability Insurance covering all owned. non-owned and hired vehicles used in
connection with this Agreement, in an amount not less than $1,000,000 combined single limit for
combined Bodily lnjury and Property Damage.
DESIGN STAGE (IF APPLICABLE)
In addition to the insurance required in I - 3 above, a Certificate of Insurance must be provided as follows:
Professional Liability Insurance, in the name of the SUBRECIPIENT or the licensed design
professional employed by the SUBRECIPIENT, in an amount not less than $1,000,000 per
occurrence/$ 1,000,000 aggregate providing for all sums which the SUBRECIPIENT and/or the
design professional shall become legally obligated to pay as damages for claims arising out ofthe
services performed by the SUBRECIPIENT or any person employed by the SUBRECIPIENT in
connection with this Agreement. This insurance shall be maintained for a period of two (2) years
after the certificate ofOccupancy is issued.
CONSTRUCTION PHASE (IF APPLICABLE)
In addition to the insurance required in I - 4 above, the SUBRECIPIENT shall provide, or cause its
Subcontractors to provide, original certificates indicating the following types of insurance coverage prior
to any construction:
Completed Value Builder's Risk Insurance on an "All Risk" basis, in an amount not less than one
hundred (100%) percent ofthe insurable value ofthe building(s) or structure(s). The policy shall
be in the name of Collier County Board of County Commissioners and the SUBRECIPIENT.
ln accordance with the requirements ofthe Flood Disaster Protection Act of I 973 (42 U.S.C. 4001),
the SUBRECIPIENT shall assure that for activities located in an area identified by the Federal
Emergency Management Agency (FEMA) as having special flood hazards, flood insurance under
SUBRECIPIENT NAME
cDxx-xx
Project Name
1
5
6
cAO
Page 3257 of 6526
the National Flood Insurance Program is obtained and maintained, as a condition of financial
assistance for acquisition or construction purposes (including rehabilitation).
OPERATION/MANAGEMENT PHASE (IF APPLICABLE)
After the Construction Phase is completed and occupancy begins, the following insurance must be kept in
force throughout the duration ofthe loan and/or Agreement:
7. Workers' Compensation as required by Chapter 440, Florida Statutes.
Commercial General Liability including products and completed operations insurance in the
amount of $ 1 ,000,000 per occurrence and $2,000,000 aggregate. Collier County Board of County
Commissioners must be shown as an additional insured with respect to this coverage.
Automobile Liability Insurance covering all owned, non-owned and hired vehicles used in
connection with this Agreement in an amount not less than $1,000,000 combined single limit for
combined Bodily Injury and Property Damage.
Properry" lnsurance coverage on an "All Risk" basis, in an amount not less than one hundred ( 100%)
ofthe replacement cost ofthe property. Collier County Board of County Commissioners must be
shown as a Loss payee, with respect to this coverage A.T.l.M.A.
8
9
11.
SUBRECIPIENT NAME
CDXX.XX
Project Name
cAO
10.
Flood Insurance coverage for those properties found to be within a flood hazard zone, for the full
replacement values of the structure(s) or the maximum amount of coverage available through the
National Flood Insurance Program QTIFIP). The policy must show Collier County Board ofCounty
Commissioners as a Loss Payee A.T.l.M.A.
Page 3258 of 6526
EXHIBIT B
COLLIER COUNTY COMMUNITY & HUMAN SERYICES
SECTION I: REQUEST FOR PAYMENT
SUBRECIPIENT Name: Collier Health Services, Inc. dba Healthcare Network
SUBRECIPIENT Address: 1454 Madison Ave W., Immokalee, FL 34142
Project Name: Marion E. Fether Medical Center HVAC Replacement
Project No: CD25-02_ Payment Request #
Total Payment Minus Retainage
Period of Availabitity: October 1, 2025, through September 30, 2026
Period for which the Agency has incurred the indebtedness through
SECTION II: STATUS OF FUNDS
Subrecipient CHS Approved
I . Grant Amount Awarded $$
2. Total Amount ofPrevious Requests $$
3. Amount ofToday's Request (Total expenditures this
period minus retainage, if applicable)
$
4. Current Grant Balance (Grant Amount minus previous
requests minus today's request)
$
By signing this report, I certi! to the best of my knowledge and beliefthat the information contained in
this report is true, complete, and accurate. I am aware that the provision ofany false, fictitious, or fraudulent
information, or the omission of any material fact, may subject me to criminal, civil, or administrative
penalties for fraud, false statements, false claims, or otherwise (U.S. Code Title 18, Sections 2, I001, 1343
and Title 3 l, Sections 3729-3730 and 3801-3812).
Signature Date
Title
Authorizing Grant Coordinator Authorizing Grant Accountant
Supervisor (Approval required $ 14,999 and
below)
Division Director (Approval Required
$ 15,000 and above)
SUBRECIPIENT NAME
cDxx-xx
Proj€ct Name
CAO
$
$
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EXHIBIT C
QUARTf,RLY Pf,RFORMANCE REPORT DATA
The COUNTY is required to submit Perlormance Reports to HUD through the Integrated Disbursement
and Information System (lDlS). The COTINTY reports information on a quarterly basis. To facilitate in the
preparation ofsuch reports, SUBRECIPIENT shall submit the information contained herein within ten ( l0)
days ofthe end ofeach calendar quarter. At COUNTY's discretion, SUBRECIPIENT may be required to
enter the information collected on this exhibit into an online grant management system.
Subrecipient Name Date:
Proiect Titie
Program Contact l elephone Number
ActiviW Reportins Period Report Due Date
Ocrober l" December 3 l'r January l0'h
January l't - March 3l't April l0'h
April I'i June 30th July I 0'h
July I't September 30th October l0'h
REPORT FOR QUARTER ENDNG: (check one that applies to the corresponding grant period):
Itzctrzoxx ltntzoxx I atnaoxx ! ez:orzoxx Final I t20
Please note: The HUD Program year begins October l, 2025 - September 30,2026. Each quarterly report must include
cumulative data beginning from the start ofthe program year October l, 2025.
ss
l Please list the outcome goal(s) fiom your approved application and SUBRECIPIENT Agreement and indicate your
progress in meeting those goals since October l, 2025.
T Outcome Goals: list the outcome goal(s) from your approved application and SUBRECIPIENT Agreement
Outcome i: Procurement/Bid Packaee Completed. Submitted, and Approved
Outcome 2: Purchase and lnstallation of2 HVAC Systems at Marion E. Fether Medical Center in Immokalee, FL
and related construction, permitting. installation, etc.
Outcome 3: Document Achievement of LMA National Obiective
Coal Progress: Indicate the Droqress to date in meetinq each outcome goal
Outcome I
Outcome 2
Outcome i
2 Is this project still in compliance with the original proiect schedule: Yes No
lf No, Explain
Since October l, 20XX; ofthe persons assisted, how many...
Answer ONLY for Public Facilities & Inftastructure Activities *03 Matrix Codes
a now have new access (continuinq) to this service or benefit?0
b now have improved access to this service or benefit?0
c now receive a service or benefit that is no longer substandard?0
Total 0
4 What tunding sources did the SUBRECIPIENT apply lirr this period?
Section 108 Loan Guarantee S CDBG s
Other Consolidated Plan Funds s HONIE s
Other Federal Funds s ESG S
$HOPWA S
SUBRECIPIENT NAME
cDxx-xx
Project Name
Total Entitlement
Funds
CAO
IDIS #:
b.
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5 What is the total number of UNDUPLICATED Persons (LMC) or Households (LMH) served this QUARTER, if
applicable? Answer question 5a or 5b; pfboth
For LMC activities: people, race/ethnicity, and income data are reported by persons.
For LMH activities: households, race/ethnicity, and income level are reported by households, regardless
the number ofpersons in the household.
0aTotal No. Persons/Adults
served (LMC)
0 Total No. persons served under I 8
(LMC)
Quarter Total No. of Persons 0 Quarter Total No. of Persons 0
Total No. of Households
served
0 Total No. offemale head ofhousehold
(r_Mu)
0
What is the total number of [,NDUPLICATED clients served since October, if applicable?
Answer question 6a or 6b, Nq[ both
For LMC activities: race/ethniciry and income data are reported by persons.
a.Total No. Persons/Adults
served (LMC)
0 Total No. Persons served under l8
(LMC)
0
YTD Total:0 YTD Total 0
b Total No. Households
served (LMH)
0 TotalNo. female head ofhouschold (LMH)0
YTD Total 0 YTD Total 0
Complete EITHER question 7 or 8, NgI both
Complete question ZZ_4!!LZ! ifyour program qfly serves clients in one or more ofthe listed HUD Presumed
Benefit categories.
1 PRESUMED BENEFICIARY DATA ONLY
(LMC) Ouarter
PRESUMED BENEFICIARY DATA ONLY
(LMC) YTD
Indicate the total number of UNDUPLICATED percons
served this quarter who fall into each presumed benefit
category (he total should equql the total in question #6a
or 6b):
Indicate the totaf number of UNDUPLICATED
persons served since October I who fall into each
presumed benefit category fthe totql should equal the
total in question #6a or 6b):
a Presumed Benefit Activities Onlv (LMC) QTR b Presumed Benefit Activities Only (LMC) YTD
0 Ahused Ch ildren ELI 0 Abused Children ELI
0 Homeless
Person
ELI 0 Homeless Person ELI
0 Migrant Farm
workers
LI 0 Migrant Farm Workers T,I
0 Battered
Spouses
LI 0 Battered Spouses LI
0 Persons
w/HlV/AIDS
LI 0 Persons wIHMAIDS LI
0 Elderlv Persons LI or MOD Elderly Persons LI or
MOD
0 Illiterate Adults LI 0 llliterate Adults LI
0 Severely
Disabled Adults
LI 0 Severely Disabled Adults LI
0 Quarter Total 0 YTD Total
8 Complete question 8a and 8b ifany client in your program does not fall into a Presumed Benefit category
Other Beneficiary Data: lncome Range Other Beneficiary Data: Income Range
Indicate the total number of UNDUPLICATED persons
seryed this Quarter who fall into each income category
(the total should equql the btal in question #6):
Indicate the total number of UNDUPLICATED
persons served since October I (YTD) who fall into
each income category (the total should equal the total
SUBRECIPIENT NAME
cDxx-xx
Project Name
CAO
b.
6.
I
0
I
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in question #6).
a ILI Extremely Lo\!
Income (0-30%)
0 b LLI Il\trcnlcl) Low
Income (0-307o)
0
I,I Low lncome (31-
50%\
0 I,I [,o$ Income 0
MOD Moderate Income
(5 r-80%)
0 N,tot)Modcratc Incomc
(5r-80%)
0
NON.I,iM Abo!e Moderate
Incomc (>8070)
0 NON-t-/M Abovc Moderate
Income (>807o)
0
Quarter Total 0 \-TD Total 0
I hereby certifu the above information is true and accurate
Name:
Signature:
Title:
Your tyDed name here reDresents vour electronic signalure
9 Is this pro.ject in a LoN/Mod Area (LMA)?YL]S \o
Was project completed this quarter?YI]S \o lf),es, complete all ofthis section 9
Dale project completed
Census Tract 'lbt.l Ilcncficiaries Low/Mod
Bcnctlciaries Low/Mod Percentagc
0 0 0 0
Date LMA Narrative approved by CHS?
What documentation suppons project completion? (i.e..
Certificate of Completion or Cenificate of Occupancy.
etc.)
r0.Racial & Ethnic Data (if applicable)
Please indicate how many UNDUPLICATED
clients served this Quarter fall into each race
category. tn addition to each race category, please
indicate how many persons in each race category
consider themselves Hispanic. (Total Rqce column
should equal the total in question 6.)
Please indicate how many UNDUPLICATED clients
served since October (YTD) fall into each race category. In
addition to each race category please indicate how many
persons in each race category consider themselves
Hispanic. (Total Roce column should equal the total in
question 6..)
a.RACE ETHNICITY
/HISPANIC
b RACE ETHNICITY
lHISPANIC
White 0 0 \\ hirc 0 0
BlacUAfrican Anrerican 0 0 Black/African American 0 0
Asian 0 0 0 0
American Indian/Alaska Native 0 0 American Indiar/Alaska
Native
0 0
Native Ha*aiian/Other Pacifi c lslander 0 0 Native Hawaiiarrother Pacifi c
lslander
0 0
Black/African American & While 0 0 Black/African American &
Whie
0 0
Americar lndian/Alaska Native &
BlacUAfrican American
0 0 American Indian/Alaska
Native & Black/African
American
Othcr Multi-racial 0 0 Other Multi-racial 0 0
0 0 0 0
SUBRECIPIENT NAME
CDXX-XX
Project Name
cAo
Block Group
0
010
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EXHIBIT C-l
Community Development Block Grant (CDBG)
Leverage Funds Report
Leverage Funds must be identified, tracked, and verifiable. Resources must be fully identified and described
as submitted with SUBRECIPIENT's application.
Subrecipient Name:
Report Period:
Fiscal Year:
Contract/Project Number:
Project Name:
Contact Name:
Contact Number:
Leverage Funds
See EXAMPLE below for how to complete this form.
EXAMPLE
Source Amount Typ"Use
Total Project Cost Ratio:
Source Amount Typ"Use
CDBG $1,000,000 Other Federal
Funds
Land Acquisition
HOME $870.000 Federal Funds Infrastructure
Private Donation $1,200,000 Cash & In-Kind lnfrastructure
Philanthropic $3,500,000 Cash local funds 52 units Affordable Housins
Total Project Cost $6,s70,000 Ratio:$1 Federal Dollar $2.51 Local
Funds
SUBRECIP]ENT NAME
cDxx-xx
Project Name
ISignature Page to Follow]
CAO
Page 3263 of 6526
I hereby certifu the above information is true and accurate.
Signature:
Printed Name:
Title:
Your tvDed name here represents vour electronic signature.
Date:
SUBRECIPIENT NAME
cDxx-xx
Project Name
CAO
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EXHIBIT D
INCOME CERTIFICATION
INSTRUCTIONS
Complete this form and retain appropriate supporting documentation proving CDBG
COLINTY, to the COLINTY, assistance to an eligible beneficiary. Please retain
organization's records and have on hand for future monitoring visits.
Effective Date
A. Household Information
Member Names - All Household Members Relationship Age
l
2
3
4
5
6
7
8
B. Assets: All Household Members, Including Minors
to the
in vour
Member Asset Description Cash Value Income
from Assets
I
2
4
6
7
8 0.00
B(a)0.00
Total Income from Assets B(b)0.00
If line B(a) is greater than $5 1,600*, multiply that amount by the rate
specified by HUD (applicable rate 0.45%*) and enter results in B(c),
otherwise leave blank.B(c)
*The asset amount and applicable rate above are subject to change annually.
SUBRECIPIENT NAME
CDXX.XX
Project Name
CAO
3
5
Total Cash Value of Assets
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C. Anticipated Annual Income: Includes Unearned Income and Support Paid on
Behalf of Minors
Member Wages /
Salaries
(include tips,
commissions,
bonuses, and
overtime)
Benefits /
Pensions
Public
Assistance
Asset
Income
(Enter the
greater of
box B(b) or
box B(c),
above, in
box C(e)
below)
l
2
3
4
5
6
1
Totals (a)(b)(c)(d)(e)
0.00 0.00 0.00 0.00
Enter total of items C(a) through C(e).
This amount is the Annual Anticipated Household Income
0.00
D. Recipient Statement: The information on this form is to be used to determine maximum
income for eligibility. I/we have provided, for each person set forth in ltem A, acceptable
verification of current and anticipated annual income. I/we certifo that the statements are true
and complete to the best ofmy/our knowledge and belief, and are given under penalty of perjury.
WARNING: Florida Statutes Chapter 817, 18 U.S.C. $ l00l and 3l U.S.C. $ 3729 provides that
willful false statements or misrepresentations concerning income and assets or liabilities relating to
financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment
provided under Sections 775.082 and 775.083,
Document in Conlext - tJ SCODE-20 l0{itle3 1 -subtitlelll-chap3 7-subchap I I l-sec3 729 1govin&.goo
Signature of Head of Household Date
Florida Statutes. I I I.i.S.C. 3729 - Falsc claims -
Signature of Spouse or Co-Head of Household Date
SUBRECIPIENT NAME
CDXX.)C\
Project Name
DateAdult Household Member (if applicable)
CAO
Other
Income
8
Adult Household Member (if applicable) Date
Page 3266 of 6526
E. CDBG Grantee Statement: Based on the representations herein, the family or individual(s)
named in ltem A of this lncome Certification is/are eligible under the provisions ofthe
CDBG Program. The family or individual(s) constitute(s) a:
tr Extremely Low-lncome (ELI) Household means and individual or family whose annual income
does not exceed 30/50'h ofthe Very Low-lncome (60 percent of VLI) percent ofthe area median
income as determined by the U.S. Department of Housing and Urban Development with
adjustments for household size. (Maximum Income Limit $_).
tr Very Low-lncome (VLl) Household means and individual or family whose annual income does
not exceed 50 percent ofthe area median income as determined by the U.S. Department ofHousing
and Urban Development with adjustments for household size.
(Maximum Income Limit $ ).
Low-lncome (LI) Household means and individual or family uhose annual income does not
exceed 80 percent ofthe area median income as determined by the U.S. Department ofHousing
and Urban Development with adjustments for household size.
(Ma-ximum Income Limit $ ).
Based on the _(year) income limits for the Naples-Marco Island Metropolitan
Statistical Area (MSA) of Collier County, Florida.
Signature of the CDBG Administrator or His/[Ier Designated Representative:
Signature Date
Printed Name Title
F. Household Data
NOTE: Information concerning the race or ethnicity of the occupants is being gathered for statistical
use only. No benefrciary is required to give such information, and refusal to give such information
will not affect any right he or she has to the CDBG program.
Number of Persons
By Race / Ethnicitv By Age
American
Indian Asian Black
Native
Hawaiian or
Other Pac.
Islander
White
other
025 2.6 40 4t 4t 62+
H ispanic
Non-
Hispanic III
SUBRECIPIENT NAMI.:
cDxx-xx
Project Name
CAO
Page 3267 of 6526
EXHIBIT E
ANNUAL AUDIT MONITORING REPORT
Circular 2 CFR Part 200332 requires Collier County to monitor subrecipients of Federal awards to determine if
subrecipients are compliant with established audit requirements (Subpart F). Accordingly, Collier County requires
that all appropriate documentation is provided regarding the organization's compliance. ln determining Federal
awards expended in a fiscal year, the subrecipient must consider all sources of Federal awards, based on when
the activity related to the Federal award occurs, including any Federal award provided by Collier County. The
determination of amounts of Federal awards expended shall be in accordance with the guidelines established by
2 CFR Part 200, Subpart F - Audit Requirements. This form may be used to monitor Florida Single Audit Act
(Statute 21 5.97) requirements.
Subrecipient
Name
First Date of Fiscal Year (MM/DD/YY)Last Date of Fiscal Year (MM/DD/YY)
Total Federal Financial Assistance Expended
during most recently completed Fiscal Year
Total State Financial Assistance Expended during
most recently completed Fiscal Year
$$
Check A. or B. Check C if applicable
A. The federal/state expenditure threshold for our fiscal year ending as indicated above has been
met, and a Single Audit as required by 2 CFR Part 200 Subpart F has been completed or will be
completed by Copies of the audit report and management letter are attached
or will be provided within 30 days of completion
B. We are not subject to the requirements of OMB 2 CFR Part 200, Subpart F because we:
n Did not exceed the expenditure threshold for the fiscal year indicated above
! Are a for-profit organization
! Are exempt for other reasons - explain
An audited financial statement is attached and if applicable, the independent auditor's
manaqement letter.
C. Findings were noted, a current Status Update of the responses and corrective action plan is
included separate from the written response provided within the audit report. While we
understand that the audit report contains a written response to the finding(s), we are reguesting
an updated status of the corrective action(s) being taken. Please do not provide just a copy of
the written response from your audit report, unless it includes details of the actions, procedures,
policies, etc. implemented and when it was or will be implemented.
Certification Statement
I hereby certify that the above information is true and accurate
Signature Date
Print Name and Title
06/L8
SUBRECIPIENT NAME
cDxx-xx
Project Name
C-AO
tr
tr
tr
Page 3268 of 6526
@
Collier County
Community & Human Servicds Division
f,XHIBIT F
INCIDENT REPORT FORM
I certifu under penalty ofperjury under F.S. 837.06 that the contents ofthis form are true and correct.
Orsanization Name:
Organization Address:
Project No:
Grant Coordinator:
Date of Incident Time of Incident:
Repo( Submitted By:
(Name & Phone)
Description of Incident:
Location/Address of Incident
Was Police Report Filed? E Yes E No
If Yes, Police Report Number:Jurisdiction:
Were there any waming signs that this type of Incident could occur? tr Yes I No
lf Yes, Explain
What actions will be taken to prevent a recurrence ofa similar incident?
Signature of Person Making Report Date
Printed Narre
Return compl€ted form to: Kristi Sonntag, Director, CHS
Collier Countv Community and Human Services Division
3339 Tamiami Trail East, Bldg. H, Suite 213
Naples, FL 341l2 Fax: (239) 252-2638 CAO
Title
Page 3269 of 6526
IIXHIBI'I'(;
COLI,IER COUNTY INVENTOITY FOR}'I
Subrecipient Name:
Subrecipient
Address:
Project Name:
Project Number:
Date:
Grant
FAIN
Name of
'l itle Holder
Acquisition
Date
Cost %
Federal
Funding
Location Use Condition Description of
Item
Serial
Number
or other
ID
Agency
Inventory
#
Expected
Retirement
Date
Date of
Disposition
(if
applicable)
Sale Price
(rt
applicabte)
o
o
Status
I
I
I
I
I
I
Page 3270 of 6526
EXHIBIT H
COLLIER COUNTY COMMUNITY & HUMAN SERVICES
WHISTLEBLOWER PROTECTIONS CERTIFICATION
SUBRECIPIENT Name: Collier Health Services, Inc. dba Healthcare Network
SUBRECIPIENT Address: 1454 Madison Ave W., Immokalee, FL 34142
Project Name: Marion E. Fether Medical Center HVAC Replacement
Project No: CD25-02
In accordance with 2 ('lrl{ 200.217 and,ll t.l.S.C. \ :l7ll, SUBRECIPIENT may not discharge,
demote, or otherwise discriminate against an employee in reprisal for disclosing to any of the list
of persons or entities provided below, information that the employee reasonably believes is
evidence ofgross mismanagement ofa federal contract or grant, a gross waste of federal funds, an
abuse ofauthoriry relating to a federal contract or grants, a substantial and specific danger to public
health or safety, or a violation of law, rule, or regulation related to a federal contract (including the
competition for or negotiation of a contract) or grant.
SUBRECIPIENT shall inform its employees in writing of whistleblower rights and remedies
provided under section 4l U.S.C. $ 4712,in the predominant native language ofthe workforce.
By signing this form, I certifu that Subrecipient Name will comply with all Whistleblower rights
and protections for its employees.
Name
Signature
Title:
cAo
The list ofpersons and entities referenced in the paragraph above includes the following:
o A member of Congress or a representative of a committee of Congress
o An Inspector General
. The Govemment Accountability Office
o A Treasury employee responsible for contract or grant oversight or management
o An authorized official ofthe Depa(ment of Justice or other law enforcement agency
o A court or grand jury
o A management olficial or other employee of SUBRECIPIENT, contractor, or
subcontractor who has the responsibility to investigate, discover, or address misconduct
Your tyoed name here represents your electronic siqnature
Page 3271 of 6526