Backup Documents 01/10/2017 Item #16D4 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 160
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 Attorrley Office no later
�Y
than Monday preceding the Board meeting. / /
8 r/
**NEW** ROUTING SLIP 1
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 „ el I(t \c
4. BCC Office Board of County Commissioners e'(:>
5. Minutes and Records Clerk of Court's Office 1Y 1\ 2417 1'51rM
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 Michelle Arnold/Yousi Cardeso) Phone Number 252-5841 or 252-5886
Contact/ Department PTNE Division old ATM Dept)
Agenda Date Item was 1-10-17 Agenda Item Number 16D4 (#2498)
Approved by the BCC
Type of Document JPA Notification of Funding &Standard Number of Original (1) JPA
Attached Lobbying Certification Form Documents Attached (1)Certification
PO number or account
number if document is to Fed Ex#
be recorded
Special instructions: email a copy to ;michellearnold n;colliergov.net&tessiesillery c colliercov.net&
vousicardeso cr col liergov.net -
Fed Ex;(1 certified copy of JPA&Certification form)
FDOT-Attn: Pamela Barr,POS II
10041 Daniels Parkway
Fort Myers,Fla.33913 p
INSTRUCTIONS&CHECKLIST it,52-3
Initial the Yes column or mark"N/A”in the Not Applicable column,whichever is appropriate. Yes N/A(Not
(Initial) Applicable)
1. Does the document require the chairm ri in ature? miS
2. Does the document need to be sent to anot er agency for additional signatures? If yes,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 signed by
the Chairman,with the exception of most letters,must be reviewed and signed by the Office of ,,
the County Attorney. in-r`
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 .
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. /)?T
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's signature
and initials are required. A -
7. In most cases(some contracts are an exception),the original document and this routing slip
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! X17
8. The document was approved by the BCC on 1-10-17 and all changes made during the
meeting have been incorporated in the attached document. The County Attorney's Office
has reviewed the changes,if applicable. I'? "
9. Initials of attorney verifying that the attached document is the version approved by the BCC,all Gt_
changes directed by the BCC have been made,and the document is ready for the 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
160 4
}1:_g-, �__. _II
Count ofCol1ir
CLERK OF THE CICU , COURT
COLLIER COUNTY C( ,1RTHO SE
Z,
3315 TAMIAMI TRL E STE 102 Dwight E.Brock-Clem f Circuit Court P.O.BOX 413044
NAPLES,FL 34112-5324
NAPLES,FL 34101-3044
iJ e
Clerk of Courts • Comptroller • Auditor • s odian of County Funds
January 13, 2016
FDOT
Attn: Pamela Ball, POS II
10041 Daniels Parkway
Fort Myers, Florida 33913
Re: Multi-Year JPA Notification of Funding for FY 2015/16 & Standard
Lobbying Certification Form
Transmitted herewith are the originals of the above referenced document for your
records per request, as adopted by the Collier County Board of County
Commissioners of Collier County, Florida on Tuesday, January 10, 2017, during
Regular Session.
Please forward/e-mail a copy of the fully executed aformentioned documents to
(martha.vergara@collierclerk.com) for the Boards Official Records.
Very truly yours,
DWIGHT E. BROCK, CLERK
nitwis s.:_---\41
4.0•P
diary
Martha Vergara, De. lerk
Enclosure
Phone- (239) 252-2646 Fax- (239) 252-2755
Website- www.CollierClerk.com Email-CollierClerk@collierclerk.com
II 160 4
fedex.com 1.800.GoFedEx 1.800.463.3339
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160 4
FDDT
......- ----- -
Florida Department of Transportation
RICK SCOTT 801 North Broadway JIM BOXOLD
GOVERNOR Bartow,FL 33830 SECRETARY
January 31, 2017
Ms. Michelle Edwards-Arnold, Director
Alternative Transportation Modes Department
Growth Management Division
2885 South Horseshoe Drive
Naples, Florida 34104
RE: Multi-Year Joint Participation Agreement Notification of Funding Form
Fiscal Year 2016/2017— FTA Section 5311- Operating Funding
Financial Project Number: 410120-1-84-35
Contract Number: G0738
Dear Ms. Arnold:
Enclosed please find the fully executed Multi-Year Joint Participation Agreement Notification of
Funding form. Please always reference the Financial Project Number and Contract Number
identified above when calling or writing about this project.
We look forward to continuing to work with you to carry out the terms of this Agreement. If you
have any questions, please contact Pam Barr, Transit Projects Coordinator at (239) 225-1972 or
by e-mail at pamela.barr@dot.state.fl.us.
,p cerely,
./ CeNt_01
Pam Barr
Transit Projects Coordinator
Enclosures
cc: Michelle Peronto, FDOT
www.dot.state.fl.us
160 4
FDOT
RICK SCOTT 801 North Broadway Avenue JIM BOXOLO
GOVERNOR Bartow,FL 33830 SECRETARY
Fiscal Year 2016/2017
MULTI-YEAR JOINT PARTICIPATION AGREEMENT
NOTIFICATION OF FUNDING
In accordance with the terms of the Joint Participation Agreement between Collier
County Board of County Commissioners 3299.Tam iami Trail East Suite 700 Naples.,
Florida 34112 and the Department, FTA Section 5311 -Operating Funding
identified by contract number GQ738 and project number 410120-1-84-35: the
Department has encumbered$3.64,222 using project number 410120 -84-35
Upon signaturc by your agency and the Dela tmcnt. eligible project costs may be
incurred. Costs incurred prior to full execution of this form will not be eligible
for reimbursement.
DEPARTMENT REPRESENTATIVE AGENCY REPRESENTATIVE
Paul A. Simmons Penny Taylor, Chairman
Name;Typed or Printed Name:Typed or Printed
Signature Si nature
/ 3c) / k/lo/i?
D e Date
ATii~ST . •
""IG E BR b:C r Approved as to form and legality
/# t • n. Wit# ,�
Attest.15 i01,T18NliM •S Assistant County At"147 \lU
•sigliture only.
v;7udv.dot.state.fl.
160 4
Page 1 of 2
Financial Project Number:410120-1-84-35
Original Contract G0738
Standard Lobbying Certification Form
The undersigned [Contractor] certifies,to the best of his or her knowledge and belief,that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,to
any person for influencing or attempting to influence an officer or employee of an agency,a Member of
Congress,an officer or employee of Congress,or an employee of a Member of Congress in connection
with the awarding of any Federal contract,the making of any Federal grant,the making of any Federal
loan,the entering into of any cooperative agreement,and the extension,continuation, renewal,
amendment,or modification of any Federal contract,grant,loan,or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
making lobbying contacts to an officer or employee of any agency,a Member of Congress,an officer or
employee of Congress,or an employee of a Member of Congress in connection with this Federal
contract,grant,loan,or cooperative agreement,the undersigned shall complete and submit Standard
Form--LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions[as amended by
"Government wide Guidance for New Restrictions on Lobbying,"61 Fed. Reg. 1413(1/19/96). Note:
Language in paragraph (2) herein has been modified in accordance with Section 10 of the Lobbying
Disclosure Act of 1995 (P.L. 104-65,to be codified at 2 U.S.C. 1601,et seq.))
(3)The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers(including subcontracts,subgrants,and contracts under grants,
loans,and cooperative agreements)and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by 31,U.S.C. § 1352(as amended by the Lobbying Disclosure Act
of 1995). Any person who fails to file the required certification shall be subject to a civil penalty of not
less than$10,000 and not more than$100,000 for each such failure.
[Note: Pursuant to 31 U.S.C. § 1352(c)(1)-(2)(A),any person who makes a prohibited expenditure or fails
to file or amend a required certification or disclosure form shall be subject to a civil penalty of not less
than$10,000 and not more than$100,000 for each such expenditure or failure.]
The Contractor,Collier County Board of County Commissioners,certifies or affirms the truthfulness and
accuracy of each statement of its certification and disclosure,if any. In addition,the Contractor
understands and agrees that the provisions of 31 U.S.C.A 3801,et seq., apply to this certification and
disclosure, if any.
vi
- 10
CO `*1 (4/11
Signature of Contractor's Authorized Official
Steve Carnell, Public Services Department Head Name and Title of Contractor's Authorized Official
111( �213('2 Date
Approved as to form and legality
A�, ant County icy
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Page 2 of 2
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