Backup Documents 02/10/2015 Item #16E6 16E
6
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office JAB 2/12/15
4. BCC Office Board of County -11 b
Commissioners 2-\\3 V
5. Minutes and Records Clerk of Court's Office
-1171 2.lt3115 2:30e01
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff Linda Swisher,Ochopee Fire Phone Number \239-695-41 4
Contact/ Department
Agenda Date Item was 2/10/15 J Agenda Item Number 16-E-6
Approved by the BCC
Type of Document Volunteer Fire Assistance Grant Number of Original Two
Attached Application Documents Attached
PO number or account n/a
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not
appropriate. _ (Initial) Applicable)
1. Does the document require the chairman's original signature? Q.Yy:vr■s JAB
2. Does the document need to be sent to another agency for additional signatures? If yes, JAB
provide the Contact Information(Name;Agency; Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be JAB
signed by the Chairman, with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's JAB
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the JAB
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's JAB
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip JAB
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 2/10/15 and all changes made during the JAB
meeting have been incorporated in the attached document. The County Attorney's
Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for t - r %�
Chairman's signature.
PLEASE CONTACT LINDA WHEN READY—SHE WILL TRANSMIT T I ' " ' GENCY
l: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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MEMORANDUM
Date: February 17, 2015
To: Linda Swisher, Administrative Secretary
Ochopee Fire Control District
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: A Volunteer Fire Assistance Grant Application
Attached is an original grant application referenced above (Item#16E6)
approved by the Board of County Commissioners on Tuesday,
February 10, 2015.
An original has been kept on file in the Minutes and Record's Department
for the Board's Official Record.
If you should have any questions, please contact me at 252-7240.
Thank you.
Attachment
16E 6
Florida Department of Agriculture and Consumer Services
Florida Forest Service
ADAM H.PUTNAM VOLUNTEER FIRE ASSISTANCE GRANT APPLICATION
COMMISIONER
LEGAL NAME FORM OF ORGANIZATION:(Municipal,Fire District,Non-Profit,County)
Ochopee Fire Control District
ADDRESS MSTU De endant Fire District
201 Buckner Ave N p
CITY IF COUNTY,LIST VFD'S BENEFITING FROM GRANT:
Everglades City
STATE ZIP
Florida 34139
COUNTY COUNTY 11
Collier
EMPLOYER IDENTIFICATION NUMBER(EIN)
5 9 6 0 0 0 5 5 8
IS FIRE DEPARTMENT LOCATED IN AN INCORPORATED TOWN? --------
. WHAT IS THE FIRE DEPARTMENT ISO RATING? 1 4-4x
YES 51 NO IDIF YES,NAME OF TOWN: [E—
verglades City
IS FIRE DEPARTMENT NIMS COMPLIANT? YES I4k NO 0
POPULATION OF TOWN:1431
CURRENT COOPERATIVE AGREEMENT WITH FES? YES Q NO 0
PROTECTED AREA: EST POPULATION SIZE (SQ.MILES)
14100 i 1100 DISTANCE OF CLOSEST MUTUAL AID FIRE DEPARTMENT:) 16
NAME OF FIRE DEPARTMENT:
I Greater Naples Fire District
NUMBER OF FIREFIGHTERS: PAID: 125 VOLUNTEERS: 14 HAS APPLICANT RECEIVED GRANT FUNDS FROM ANY SOURCE IN
THE PAST 12 MONTHS? YES® NO®
NO.OF INCIDENTS PAST YEAR: WILDLAND FlRE:j 12 OTHER.' 618 IF YES,WHERE? I FDOT for 1-75 Fire Station Operation
NO.OF FIREFIGHTERS CERTIFIED AS: !
WILDLAND FIREFIGHTER! 129 WILDLAND FIREFIGHTER 11 r AMOUNT: $ 3,259,335
LIST TOTAL FUNDS RECEIVED FROM OTHER TAXING AUTHORITIES
SUCH AS CITY,COUNTY,TAXING DISTRICTS(Past 12 Months)
AMOUNT: $ 1 'so
LIST OF FIREFIGHTING VEHICLES:
TYPE MAKE/YR.MODEL PUMP CAPACITY(GPM) WATER CAPACITY(GAL.)
ENGINE (3) Emergency One 98,05,05 1250 1000
Water tender Emergency One 2012 , 1250 2500
Brush (2) FFS Loan 6x6 77,77 150,250 750, 1000
ESTIMATED GRANT FUNDING REQUEST: 2,100 LIST OF EQUIPMENT OR SUPPLIES TO PURCHASE WITH GRANT FUNDS:
FEDERAL $ 1,050 NUMBER DESCRIPTION AMOUNT
APPLICANT $ 1 050 30 5 gallon cans Class A foam 2,100
COUNTY $
TOTAL $ 2,100
(Federal not more than 50%of total. Applicant at least 50%of
total in matching funds.)
We understand that this is a 50 percent maximum cost-share program(Cooperative Forestry Assistance Act of 1978,PL 95-313),and that funds on
deposit up to 50 percent of the actual purchase price of the items approved will be committed to our project. TO THE BEST OF MY KNOWLEDGE AND
BELIEF,ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE GOVERNING BODY OF THE APPLICANT HAS DULY AUTHORIZED
THIS DOCUMENT.
Type Name of Authorized Representative Title Telephone Number: ( 239 ) 695-4114
Tim Nance Chairman FAX: ( 239 ) 695-3473
Signatur_e,oLAethorized R pr ntative -D,pte Signed and Submitted Email:
DACS- 1484 REV. 3/06
nom^ Appro d as to for an egal sufficiency
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16E 6
Form AD-1047 0/92
U. S. DEPARTMENT OF AGRICULTURE
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters -Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549,Debarment and Suspension,
7 CFR Part 3017, Section 3017.510,Participants'responsibilities. The regulations were published as Part IV of the
January 30, 1989,Federal Register(pages 4722-4733). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the proposed covered transaction.
(Before completing certification,read instructions on reverse.)
(1) The prospective primary participant certifies to the best of its knowledge and belief,that it and its principals:
(a) are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) have not within a three-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain,or performing a public(Federal, State or Local)transaction or contract under a
public transaction;violation of Federal or State antitrust statutes or commission of embezzlement,theft,
forgery,bribery,falsification or destruction of records,making false statements,or receiving stolen
property;
(c) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal,State or Local)with commission of any of the offenses enumerated in paragraph(1)(b)of this
certification;and
(d) have not within a three-year period preceding this application/proposal had one or more public
transactions(Federal,State or Local)terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
ORGANIZATIONNAAIE i PR/AWARD NUMBER OR PROJECT NAME
Collier County Board of County Commissioners
Ochopee Fire Control District
NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
Tim Nance, Chairman 200115
SIGNATURE i DATE
6(ld/te
f tf Approved as to form and legal sufficiency:
It T .;'� ,. Q0.rk •
Mak Jeffeipileeietellear County Attorney
Attest as to Chairman s� �N t, K A, e c L P£t‘D
signature only.
16E 6
Form AD-1047(1/92)(REVERSL7
INSTRUCTIONS FOR CERTIFICATION
. By signing and submitting this form,the prospective primary participant is providing the certification set out
on the reverse side in accordance with these instructions.
2. The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective participant shall submit an explanation of why it
cannot provide the certification set out on this form. The certification or explanation will be considered in
connection with the department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such
person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency determined to enter into this transaction. If it is later determined that the prospective
primary participant knowingly rendered an erroneous certification, in addition to other remedies available to
the Federal Government,the department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the department or agency to
whom this proposal is submitted if at any time the prospective primary participant learns that its certification
was erroneous when submitted or has become erroneous by reason of changed circumstances.
5. The terms"covered transaction," "debarred,""suspended,""ineligible," "lower tier covered transaction,"
"participant,""person,""primary covered transaction,""principal,""proposal,"and"voluntarily excluded,"as
used in this clause,have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which this proposal is
being submitted for assistance in obtaining a copy of those regulations.
6. The prospective primary participant agrees by submitting this form that,should the proposed covered
transaction be entered into,it shall not knowingly enter into any lower tier covered transaction with a person
who is debarred,suspended,declared ineligible,or voluntarily excluded from participation in this covered
transaction,unless authorized by the department or agency entering into this transaction.
7. The prospective primary participant further agrees by submitting this form that it will include this clause
titled"Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion-Lower Tier
Covered Transactions,"provided by the department or agency entering into this covered transaction,without
modification,in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred,suspended,ineligible,or voluntarily excluded from the covered
transaction,unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may,but is not required to,
check the Nonprocurement List,
9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order
to render in good faith the certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a prudent person in the ordinary
course of business dealings.
10. Except for transactions authorized under paragraph 6 of these instructions,if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended,debarred,
ineligible,or voluntarily excluded from participation in this transaction,in addition to other remedies
available to the Federal Government,the department or agency may terminate this transaction for cause or
default.
2
16E b
OMB Approval No.0348-0040
ASSURANCES--NON-CONSTRUCTION PROGRAMS
Note: Certain of these assurances may not be applicable to your project or program. If you have questions,please contact the awarding agency.
Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be
notified.
As the duly authorized representative of the applicant 1 certify that the applicant;
1. Has the legal authority to apply for Federal assistance,and the 7. Will comply,or has already complied,with the requirements of
institutional, managerial and financial capability (including funds Titles II and IiI of the Unifonn Relocation Assistance and Real
sufficient to pay the non-Federal share of project costs) to ensure Property Acquisition Policies Act of 1970 (P.L. 961-646) which
proper planning, management and completion of the project provide for fair and equitable treatment of persons displaced or
described in this application. whose property is acquired as a result of Federal or federally assisted
programs. These requirements apply to all interests in real property
2. Will give the awarding agency,the Comptroller General of the acquired for project purposes regardless of Federal participation in
United States, and if appropriate, the State, through any authorized purchases.
representative,access to and the right to examine all records,books,
papers,or documents related to the award;and will establish a proper 8. Will comply with the provisions of the Health Act(5 U.S.C.§§
accounting system in accordance with generally accepted accounting 1501-1508 and 7324-7328) which limit the political activities of
standards or agency directives. employees whose principal employment activities are funded in
whole or in part with Federal funds.
3. Will establish safeguards to prohibit employees from using
their positions for a purpose that constitutes or presents the 9. Will comply,as applicable, with the provisions of the Davis-
appearance of personal or organizational conflict of interest, or Bacon Act (40 U.S.C. §§ 276a to 276a-7), the Copeland Act (40
personal gain. U.S.C. §276c and 18 U.S.C. §§874),and the Contract Work Hours
and Safety Standards Act (40 U.S.C. §§ 327-333), regarding labor
4. Will initiate and complete the work within the applicable time standards for federally assisted construction subagreements.
frame after receipt of approval of the awarding agency.
10. Will comply, if applicable, with flood insurance purchase
5. Will comply with the Intergovernmental Personnel Act of 1970 requirements of Section 102(a)of the Flood Disaster Protection Act
(42 U.S.C. §§4728-4763) relating to prescribed standards for merit of 1973 (P.L. 93-234) which requires recipients in a special flood
systems for programs funded under one of the nineteen statutes or hazard area to participate in the
regulations specified in Appendix A of OPM's Standards for a Merit program and to purchase flood insurance if the total cost of insurable
System of Personnel Administration(5 C.F.R.900,Subpart F). construction and acquisition of$10,000 or more.
6. Will comply with all Federal statutes relating to 11. Will comply with environmental standards which may be
nondiscrimination. These include but are not limited to: (a)Title VI prescribed pursuant to the following: (a)institution of environmental
of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits quality control measures under the National Environmental Policy
discrimination on the basis of race,color or national origin;(b)Title Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b)
IX of the Education Amendments of 1972,as amended(20 U.S.C.§§ notification of violating facilities pursuant to E0 11738; (c)
1681-1683, and 1685-1686), which prohibits discrimination on the protection of wetlands pursuant to EO 11990;(d)evaluation of flood
basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as hazards in floodplains in accordance with E0 11988;(e)assurance of
amended (29 U.S.C. § 794), which prohibits discrimination on the project consistency with the approved State management program
basis of handicaps; (d) the Age Discrimination Act of 1975, as developed under the Coastal Zone Management Act of 1972 (16
amended (42 U.S.C. §§ 6101-6107), which prohibits discrimination U.S.C. §§ 1451 et seq.); (f) conformity of Federal actions to State
on the basis of age; (Clear Air) Implementation Plans under Section 176(c)of the Clear
Air Act of 1955, as amended (42 U.S.C. § 7401 et seq.); (g)
(e)the Drug Abuse Office and Treatment Act of 1972(P.L.92- protection of underground sources of drinking water under the Safe
255),as amended,relating to nondiscrimination on the basis of drug Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h)
abuse; (0 the Comprehensive Alcohol Abuse and Alcoholism protection of endangered species under the Endangered Species Act
Prevention,Treatment and Rehabilitation Act of 1970(P.L.91-616), of 1973,as amended,(P.L.93-205).
as amended, relating to nondiscrimination on the basis of alcohol
abuse or alcoholism;(g)§§523 and 527 of the Public Health Service 12. Will comply with the Wild and Scenic Rivers Act of 1968(16
Act of 1912(42 U.S.C.290-dd-3 and 290 ee-3),as amended,relating U.S.C.§§ 1271 et seq.)related to protecting components or potential
to confidentiality of alcohol and drug abuse patient records;(h)Title components of the national wild and scenic rivers system.
VIII of the Civil Rights Act of 1968 (42 U.S.C. § 3601 et seq.), as V,B-5(02/05)
amended,relating to nondiscrimination in the sale,rental or financing Authorized for Local Reproduction
of housing;(1)any other nondiscrimination provisions in the specific Standard Form 42413 (9-03)Prescribed by OMB Circular A-102
statute(s) under which application for Federal assistance is being
made; and (j) the requirements of any other nondiscrimination
statute(s)which may apply to the application.
1 6E 6
research, teaching, or other activities supported by this award of
13. Will assist the awarding agency in assuring compliance with assistance.
Section 106 of the National Historic Preservation Act of 1966, as
amended(16 U.S.C.470),EO 11593(identification and protection of 16. Will comply with the Lead-Based Paint Poisoning Prevention
historic properties),and the Archeological and Historic Preservation Act(42 U.S.C. §§4801 et seq.)which prohibits the use of lead based
Act of 1974(16 U.S.C.469a-I et seq.). paint in construction or rehabilitation of residence structures.
14. Will comply with P.L. 93-348 regarding the protection of 17. Will cause to he performed the required financial and
human subjects involved in research, development, and related compliance audits in accordance with the Single Audit Act of 1984.
activities supported by this award of assistance.
18. Will comply with all applicable requirements of all other
15. Will comply with the Laboratory Animal Welfare Act of 1966 Federal laws, executive orders, regulations and policies governing
(P,L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the this program.
care,handling,and treatment of warm blooded animals held for
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
`- — (- - l// , Board of County Commissioners Chairman
APPLICANT ORGANIZATION DATE
Collier County Board of County Commissioners SUBMITTED Z fj10 `1 5
V,B-6(02/05)
Authorized for Local Reproduction)
Standard Fonn 424B (9-03
Prescribed by OMB Circular A-102
Approved as to form and legal sufficiency.
AresS 4 wNt-
mow,Coun Attorney
Attests t roma � Si t►.,..)t Fttt .A►• Y3t t-'PI b 1 O
signature only.