Backup Documents 05/13/2014 Item #16D 6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 60 6
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. Lisa Carr HHVS It 5/13/2014
2. Jennifer B. Belpedio, ACA Office located in HHVS . I 1414
County Attorney Office Department
3. BCC Office Board of Count y
Commissioners \n47'5,/ S\ `\
4. Minutes and Records Clerk of Court's Office ' \
y
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 Lisa Can Phone Number 252-2339
Contact/ Department
Agenda Date Item was 5/13/2014 J Agenda Item Number 16.D.6
Approved by the BCC
Type of Document 1 Amendment w/Attestation Statement Number of Original 3 originals o&
Attached Documents Attached BBC
PO number or account
number if document is
to be recorded -v
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? LNC >S
2. Does the document need to be sent to another agency for additional signatures? If yes, LNC
provide the Contact Information(Name;Agency;Address; Phone)on an attached sheet. Coy. \CT Lt St\
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 LNC
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's LNC t/
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 LNC ■/
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 LNC
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip LNC
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 5/13/2014 tenter date)and all changes LNC ii
made during the 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 LNC
BCC,all changes directed by the BCC have been made,and the document is ready for he
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
X606
INSTRUCTIONS & CHECKLIST #2
Please send the original Chairman signed documents to additional agency for signature:
Kathy Gronberg, Fiscal Specialist III
Senior Choices of Southwest Florida, Inc.
15201 N Cleveland Ave Ste 1100
North Fort Myers, FL 33903
239-652-6900 Ext. 251
•
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
1606
MEMORANDUM
Date: May 16, 2014
To: Lisa Carr, Grants Coordinator
Housing, Human & Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Amendment #1 and Attestation Statement with the Area Agency
on Aging for SWFL, Inc. d/b/a Senior Choices of Southwest
Florida for the Alzheimer's Disease Initiative Program (ADI
203.12.007), Community Care for the Elderly Program (CCE
203.12.008) and Home Care for the Elderly Program (HCE
203.12.009)
Attached for further processing are three (3) original copies of the each amendment
document referenced above, (Item #16D6) approved by the Board of County
Commissioners May 13, 2014.
After the representative for Senior Choices has signed the documents, please return
one of the original copies to the Minutes & Records Department for the Board's
Official Record.
If you have any questions please call me at 252-8406.
Thank you
Amendment 007 ADI 203.12.007
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA 1 b D
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ("Agency") and Collier County Board of County Commissioners, ("Recipient"), amends agreement
ADI 203.12.
The purpose of this amendment is to amend Paragraph 2.4.2., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.2 of the Attachment I, is hereby amended to read:
2.4.2. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports, which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with
this amendment
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSI NERS FLORIDA,INC.DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED i� i/_
SIGNED BY:
NAME: Tom Henning / NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: 5/ 131 I`�
DATE:
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
Approved as to form and legality
00 ` 1 Assistant County rney of
r' as to Chairmanr3. .____-- 4\\4 6)
1606
Attestation Statement
Agreement/Contract Number: ADI 203.12
Amendment Number 007
1, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
5) /.31 /`J
Signature of Recipient/Contractor• esentative Date
Approved as to form and legality
Assistant County A rney
, test as to Chairman's
sinnatnrp only.
�9
Amendment 007 ADI 203.12.007
, AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
ALZHEIMER'S DISEASE INITIATIVE PROGRAM 1 6 13 6
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ("Agency") and Collier County Board of County Commissioners, ("Recipient"), amends agreement
ADI 203.12.
The purpose of this amendment is to amend Paragraph 2.4.2., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.2 of the Attachment I, is hereby amended to read:
2.4.2. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports,which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with
this amendment
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA,INC. DBA SENIOR CHOICES OF
/ SOUTHWEST FLORIDA
SIGNED BY-
• ./ SIGNED BY: ` `�0'�J
NAME: Tom Henning / NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: ?/13//L
DATE: '/D//
Federal Tax ID: 59-6000588
FFiscal Year Ending;Date:,09/30
- - Approved as to form and legality
7.3 yyi.�p,f'
I) i=' !- 5-p 5'0 K, Cleric
1 Assistant County Att y
4\
1606 0 6
Attestation Statement
Agreement/Contract Number: ADI 203.12
Amendment Number 007
1, Tom Henning attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
'gnature of Recipient Contract'� epresentative Date
Approved as to form and legality
rr= Assistant County rney
Attest as to rh,;rm,n's
)
Amendment 008 CCE 203.12.008
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA 1606
COMMUNITY CARE FOR THE ELDERLY PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ("Agency") and Collier County Board of County Commissioners, ("Recipient"), amends agreement
CCE 203.12.
The purpose of this amendment is to amend Paragraph 2.4.2., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.2 of the Attachment I, is hereby amended to read:
2.4.2. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports, which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with
this amendment
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMI SIGNERS FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED B : „ SIGNED BY:
NAME: Tom Henning NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: May 13, 2014
DATE:
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
Approved as to form and legality
1
ttestas to Chairman Assistant county ► NJ( Q
1606
Attestation Statement
Agreement/Contract Number: CCE 203.12
Amendment Number 008
I, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
/ /7 • ill 141—
Si nature f Recipient/Contra 4 . epresentative Date
Approved as to form and legality
Attest
p airman-&-___ Assistant County A 1:11 ey
as'�
'signature only.
0
menament 008 CCE 203.12.008
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC. ► ,
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
COMMUNITY CARE FOR THE ELDERLY PROGRAM 16
CO LLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ("Agency") and Collier County Board of County Commissioners, ("Recipient"), amends agreement
CCE 203.12.
The purpose of this amendment is to amend Paragraph 2.4.2., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.2 of the Attachment I, is hereby amended to read:
2.4.2. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports,which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with
this amendment
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA,INC.DBA SENIOR CHOICES OF
• SOUTHWEST FLORIDA
SIGNED B . L SIGNED BY: "„ C'=' 41' �'/�^
NAME: Tom Henning / NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: May 13,2014 �
DATE: efi
Federal Tax ID: 5Y-6000:588
Fiscal Yew:Ending Date: 09/30
t°= Approved as to form and legality
OK,
1
Assistant Conn . 'tto y 4- k`1 641)
1606
Attestation Statement
Agreement/Contract Number: CCE 203.12
Amendment Number 008
I, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
Signs e o efR ci .ee t/ ontracto e m esentative Date
'T: �i
•T Approved as to form and legality
D' g V
Assistant County +
• mey
Attest as to Chairman's
signature only.
(17)
Amendment 009 HCE 203.12.009
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA 1
HOME CARE FOR THE ELDERLY PROGRAM 1 6 D 6
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ("Agency") and Collier County Board of County Commissioners, ("Recipient"), amends agreement
HCE 203.12.
The purpose of this amendment is to amend Paragraph 2.4.2., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.2 of the Attachment 1, is hereby amended to read:
2.4.2. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports, which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with
this amendment
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: ii11111&._ SIGNED BY:
NAME: Tom Henning / NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: �� i i 7
DATE:
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
117�Ly3.y Approved as to form and legality
;HT . 3R0 ",
.+
- . Assistant County Att
airmen's - .e.
16136
Attestation Statement
Agreement/Contract Number: HCE 203.12
Amendment Number 009
1, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
Signa re of Recipient/ ontr'actor reprr esentative Date
•
Approved as to form and legality
. .1HT E. 9 OK, Clark _�►
110* d.wY
.. Assis ant County tney
4rtpst as to Chairman's
lgnature only,
l6 )
Am,-ndment 009 HCE 203.12.009
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
HOME CARE FOR THE ELDERLY PROGRAM 16 0 6
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ("Agency") and Collier County Board of County Commissioners, ("Recipient"), amends agreement
HCE 203.12.
The purpose of this amendment is to amend Paragraph 2.4.2., of the ATTACHMENT I.
Line denotes completion of above summary
ATTACHMENT I:
Paragraph 2.4.2 of the Attachment I, is hereby amended to read:
2.4.2. Service Costs Reports
The Recipient shall require subcontractors to submit to the Recipient annually service cost reports,which will
be due August 15 of each year and reflect actual costs of providing each service by program. This report
provides information for planning and negotiating unit rates.
This amendment shall be effective on the last day that this agreement is signed by both parties. All provisions in the
agreement and any attachments thereto in conflict with this amendment shall be and are hereby changed to conform with
this amendment
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 1 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA,INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: ----- SIGNED BY: Nit• A(
NAME: Tom Henning NAME: RONALD LUCCHINO, PhD
TITLE: Chairman TITLE: BOARD PRESIDENT
DATE: 51/3//�!
DATE: 674/
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
T ,.. Approved as to form and legality
DV, I-1T S. BR* n-, :lark
a 4, 1 Assistant County Attey
.a\� c5
1686
Attestation Statement
Agreement/Contract Number: HCE 203.12
Amendment Number 009
I, Tom Henning ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County 13oard of Commissioners •
(Signature of Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
Signa re of Recipient/Contractor repr. entative Date
Approved as to form:d legality
e..o LY
35`e . HT E. S CSC, Clerk
_ _ - Assis ant County they
Attest as to Chairman's an
'4gnature only,