Agenda 01/11/2011 Item #16D 9
Agenda Item No. 1609
January 11, 2011
Page 1 of 12
EXECUTIVE SUMMARY
Recommendation to approve and authorize the Chairman to sign certifications required by
the State of Florida, Department of Children and Families (DCF) in order to be eligible to be
awarded 2011 Challenge Grant funding.
OBJECTIVE: For the Board of County Commissioners to approve and authorize the Chairman
to sign the State of Florida, Department of Children and Families certifications and
documentation required to be eligible for 2011 Challenge Grant funding.
CONSIDERATIONS: On May 27, 2003, the Board of County Commissioners (BCC) gave
approval for the County to become the Lead agency and to apply, on behalf of the County's
social service agencies, for annual homeless assistance. On September 28, 2010, the BCC
provided after the fact approval (Item 16D07) for the 2011 Challenge Grant application
submission. Recently the Department of Housing, Human and Veteran Services received
notification that Collier County will receive a total award amount of $63,397 pending receipt of
Collier County's signed certifications and backup documentation. This Challenge Grant funding
will be used to provide assistance to Collier County citizens experiencing homelessness through
three non-profit entities: St. Matthew's House, The Shelter for Abused Women and Children,
Youth Haven, Inc and to increase information management reporting systems through the Collier
County Housing, Human and Veteran Services Department.
FISCAL IMPACT: Completion of these certifications will allow Collier County to receive a
total of $63,397 in Challenge Grant funding. The Challenge Grant, and the certifications and
documentation associated with it have no effect on ad valorem or general fund dollars.
GROWTH MANAGEMENT IMPACT: Challenge Grant funding will further the goals,
objectives and policies of the County's Growth Management Plan's Housing Element.
LEGAL CONSIDERATIONS: The required celiifications and documentation have been
reviewed by the County Attorney's Office and are legally sufficient for Board action. This item
requires a simple majority vote. - JBW
RECOMMENDATION: To approve and authorize the Chainnan to sign the State of Florida,
Department of Children and Families certifications and documentation required to be eligible for
2011 Challenge Grant funding.
Prepared by: Nick Green, Grants Coordinator
Housing, Human and Veteran Services Department
Agenda Item No. 16D9
January 11, 2011
Page 2 of 12
COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
Item Number:
Item Summary:
1609
Recommendation to approve and authorize the Chairman to sign certifications required by
the State of Florida, Department of Children and Families (DCF) in order to be eligible to be
awarded 2011 Challenge Grant funding.
1/11/2011 9:00:00 AM
Meeting Date:
Prepared By
Nick Green Grants Coordinator
Date
Housing & Human Services Housing & Human Services
12/22/201011:12:40 AM
Approved By
Marcy Krumbine
Director - Housing & Human Services
Date
Public Services Division
Human Services
12/22/20103:10 PM
Approved By
Colleen Greene
Assistant County Attorney
Date
County Attorney
County Attorney
12/23/201010:53 AM
Approved By
Marla Ramsey
Administrator - Public Services
Date
Public Services Division
Public Services Division
12/23/2010 11 :50 AM
Approved By
Marlene J. Foard
Grant Development & Mgmt Coordinator
Date
Administrative Services
Division
Administrative Services Division
12/29/20105:12 PM
Approved By
Jeff Kiatzkow
County.Attorney
Date
12/31/20104:05 PM
Approved By
Sherry Pryor
Management/ Budget Analyst, Senior
Date
Office of Management &
Budget
Office of Management & Budget
1/4/20119:18 AM
Approved By
Mark Isackson
Management/Budget Analyst, Senior
Date
Office of Management &
Budget
Office of Management & Budget
1/4/2011 11 :23 AM
Agenda Item No. 16D9
January 11, 2011
Page 3 of 12
SCR Provider Required Information/Documents
60A-1.006, F.A.C., Vendors and Contractors
The integrity, reliability and qualifications of a bidder or offeror, with regard to the capability in all
respects to perform fully the contract requirements, shall be determined by the agency prior to the award
of the contract.
, ,,~Legal (Corporate) Name of
Provider Agency and fictitious
name, if conducting business under
a different name
b. Address including City, County,
State and Zip Code
c. Mailing address of the official
payee to whom payment shall be
made as indicated on the
MyFloridaMarketPlace registration
d. Name and title of
Authorized Official Signer
Delegation of Authority required, to
include sample signature, if not
President, Chariman, or CEO
e. Cr ,tact person
.,/ Name and title;
.,/ street address (where financial and
administrative records are
maintained)
.,/ electronic address (e:mail);
.,/ telephone number, and
.,/ fax number
f. Representative for the
administration of the program
.,/ Name and titie:
.,/ street address;
.,/ electronic address (e:mail);
.,/ telephone number, and
.,/ fax numbers
g. Type of Entity
SCR 082610
3299 Tamiami Trail East
Naples, Florida 34112
3299 Tamiami Trail East
ih Floor
Naples, FL 34112
Fred W. Coyle, Chairman, Collier County Board of County Commissioners
n Att<:>"horl
L-.J ' \'"'"~"'" l~""
Marcy Krumbine, Director, Housing, Human and Veteran Services
3339 Tamiami Trail East, Suite 211
MarcvKrumbine(Ci2collierqov. net
Phone: 239-252-8442
Fax: 239-252-2638
Nick Green, Grants Coordinator, Housing Human and Veteran Services
3339 Tamiami Trail East, Suite 211
NickGreen@collierqov,net
Phone: 239-252-2376
Fax: 239-252-6668
D State
C8J Count
D Other (Describe)
D
D
D Nonprofit Organization
(Attach IRS 501 c 3 or other support
document
Agenda Item No. 16D9
January 11, 2011
Page 4 of 12
Board of Directors
Listing of board members, to
include address, phone number
and e:mail address, and their term
expiration.
./ Copies of By-Laws
./ Copies of prior year meeting
minutes.
http://www.collieroov.netllndex.aspx?paoe=30 List of BCC
and related information
http://www.collierclerk.com/RecordsSearch
Board Minutes
D Attached
i. Co, es of applicable
facility licenses
D Attached
D Attached
o Attached
NA - Not a facility
j. Copies of all applicable
facility accreditations
D Attached
NA - Not a facility
k. Organizational Chart
l3J Attached
Proof of registration with Internal
Revenue Services (IRS)
o Attached
./ Federal Employer Identification
Number (FEIN)
./ Provider's Fiscal Year
End Date
(Mnnth and Day only)
FEIN-59-6000558
09/30
b. Proof of registration with
Department of Revenue (DOR)
(if taxable activities)
o Attached [gJ Not applicable Per 12/15/10 instruction from IRS
phone line representative, government agencies are exempt as reference in IRS
Publication 557
./ Most recent 990
c. Proof of registration with
Department of Financial Services
(DFS)
D Attached
[gJ Attached
[gJ Not a plicable
D Not applicable
Note: Vendors must file a W-9 with
DFS.
d. Proof of registration with the
Florida Department of State
Division of Corporations
D Attached
NA - Government Agency
2
Agenda Item No. 16D9
January 11. 2011
Page 5 of 12
SCR Provider Required InformationlDocun1ents
e. Proof of registration on
MyFloridaMarketPlace
[gJ Attached
Rule 60A-1.030, FAC. requires http://dms.mvflorida.com/business operations/state purchasinq/mvflorida
vendors doing business with the state of marketplace/mfmp_vendors/vendor_toolkit/mfmp_vendor_registration
Florida to register with MFMP.
f. Proof of registration as a Minority
Vendor or Disabled Veteran, when
applicable.
o Attached
[gJ Not applicable
:~1W~lij"irisu ra nCEf,~h
a. Department of Business and
Prufessional Regulations (DBPR)
Certain businesses must be
licensed by DBPR.
b. Department of Agriculture and
Consumer Services (DOACS)
Certain services are regulated by
DOACS.
o Attached
[gJ Not applicable
Government Agency
o Attached
[gJ Not applicable
Government Agency
Proof of registration~~~tl9{li<:lp~ 0 Attached
orqanization.
[XJ Not applicable
c. Department of Health (DOH) 0 Attached
Determines whether health care
practitioners meet minimum licesure
requirements.
d. Copy of required applicable
insura'lce coverage:
./ Liability
./ Automobile
./ Workers Compensation
./ Employee Dishonesty
./ Additional bonds or letters of
credit, when required
Written documentation of both the
determination and existence of such
insurance is required.
~ Not applicable
Government Agency
o Attached
o Attached
o Attached
o Attached
o Attached
o Not applicable
o Not applicable
~ Attached
SCR 082610
3
~ Geo raphic Area Served Counties)
Service description to include, but
not be limited to:
../ types of service to be provided
../ service delivery location
../ times of service
../ staff qualifications
../ unit cost.
c. Copy of the provider's policies and
procedures relating to the reporting of
suspicion or knowledge of
abuse/neglect or abandonment
accordin to Florida Statutes
d. Applicable ACHA-Program Medicaid
Certification
e. List of Subcontractors,
when applicable
f. Program Operating Budget and
supporting narrative
g. A\:;~ncy Operating Budget and
supporting narrative
t,. Match plan/sources,
len applicable
Collier Count
o Attached
o Attached
o Attached
o Attached: Youth Haven, St.
Matthew's House, Shelter for
Abused Women and Children
o Attached
o Attached
D Attached
Agenda Item No. 16D9
January 11, 2011
Page 6 of 12
Youth Haven
Shelter for Abused Women and Children
St. Matthew's House
BCC (HHVS)
Refer to grant application HFZ1 D
NA - will not be providing direct services
NA - Government Agency
o Not applicable
See grant application HFZ1 D
http://www.colliergov.net/Modules/Sh
owDocument.asDx?documentid=28191
[8J Not applicable
../ Checklist
../ Deaf or Hard of Hearing
compliance attestation
b. Documentation to support financial
viability, such as
../ most recent audit,
../ balance statements
[8J Attached
[8J Attached - on file with DCF
D Attached
D Attached
c. Tv qualify as Preferred Provider, the
new agency must submit an affidavit 0 Attached
attesting to the following:
../ Agrees to offer the state of
Florida the most advantageous
price offered to any of its
customers
../ Has a principal place of
business in Florida
http://www.collierclerk.com/ClerkToT
heBoard/lnternalAudit
[8J Not applicable
4
SCR Provider Required Information/Documents
Agenda Item No. 16D9
January 11, 2011
Page 7 of 12
./ Commits contractually to
maximize the use of Florida
residents, products and other
Florida-based businesses
d. Other documents determined
required by contract manager, such as
Cost Analysis/Method of Rate Setting, o Attached ~ Not applicable
Medicaid rates, etc.
e. In accordance with Section Contract #, starting and ending
287.0575(2), F.S., providers must notify dates, total amount, brief
the Dept. of any contracts with the description of the purpose and
following agencies: services provided, and name
and contact info. of the
agency's contract manager.
./ Department of Children and 0 Attached - Grant HFZD1 0 Not applicable
Families (DCF);
./ Agency for Persons with Disabilities 0 Attached ~ Not applicable
(APD);
./ Department of Health (DOH); 0 Attached ~ Not applicable
./ Department of Elderly Affairs 0 Attached ~ Not applicable
(DEA), and
./ C...partment of Veterans (DOV) 0 Attached ~ Not applicable
f. Copies of prior year monitoring http;L/w\\'Yi,fPUierclerk.com/odt!2009C AFR. od f ,
reports issued by any agency, including The Single Audit Section begins on page 177 of
DCF. 389.
The organization certifies that the facts and information contained in this application and any
attached documents are true and correct.
Collier County Board of County Commissioners
Name of Organization
Signature of Authorized Official
Date
Chairman, Collier County Board of County Commissioners
Title
Please return the completed form and required documentation to:
Department of Children and Families
2295 Victoria Avenue, Fort Myers, Florida 33901
Attn. Robert Farr, Contract Management Unit
a~; W Torm &0 tegal 8ufi'lc!an:::,
SCR 082610
ftUTESll;
DWiGHT e.
By: .-
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5
Agenda Item f'llo, 16D9
January 11, 2011
Page 8 of 12
DCF USAGE ONI...Y
Suspended Vendor List
o Checked
http://dms.mvflorida.comlbus iness operations/state purchasing/vend or inform ation/col1 v
icted suspended discriminatorv complaints vendor lists/suspended vendor list
Convicted Vendor List
o Checked
http://dms.mvfl oricla.com/bus iness operations/state purchas ing/vendor inform ation/conv
icted suspended discriminatorv complaints vendor lists/convicted vendor list
lrchase Agreement or other legal
JcuITJentation of the transfer of
prev! us provider's assets and
liabilities to the new rovider
Contract Assignment
o .A.ttached
./ DCF Approval of contract
assignment
o Attached
o Attached
Program Administrator
Signature Date
I
Contract Administrator
Signature Date
-
6
SCR Provider Required Information/Documents
Agenda Item No. 16D9
January 11, 2011
Page 9 of 12
Contract Director
Signature Date
Program Director
Signature Date
Legal Counsel
Signature Date
SCR 082610
7
Agenda Item No. 16D9
January 11, 2011
Page100f12
Attachment IV
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS
This certification is required by the regulations implementing Executive Order 12549: Debarment and Suspension,
signed February 18, 1986. The guidelines were published in the May 29, 1987 Federal Register (52 Fed. Reg., pages
20360 - 20369).
INSTRUCTIONS
1. Each provider whose contract/subcontract equals or exceeds $25,000 in federal moneys must sign
this certification prior to execution of each contract/subcontract. Additionally, providers who audit
federal programs must also sign, regardless of the contract amount. The Department of Children
and Families cannot contract with these types of providers if they are debarred or suspended by the
federal government.
2. This certification is a material representation of fact upon which reliance is placed when this
contract/subcontract is entered into, If it is later determined that the signer knowingly rendered an
erroneous certification, the Federal Government may pursue available remedies, inclurling
suspension and/or debarment.
3. The provider shall provide immediate written notice to the contract manager at any time the
provider learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
4. The terms "debarred", "suspended", "ineligible", "person", "principal", and "voluntarily excluded", as
used in this certification, have the meanings set out in the Definitions and Coverage sections of
rules implementing Executive Order 12549, You may contact the department's contract manager
for assistance in obtaining a copy of those regulations,
Contract No. J::!fZ1 D__
5. The provider agrees by submitting this certification tt-lat, it shaii not knowingly enter into any
subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded
from participation in this contract/subcontract unless authorized by the Federal Government.
6. The provider further agrees by submitting this certification that it will require each subcontractor of
this contract/subcontract, whose payment will equal or exceed $25,000 in federal moneys, to
submit a signed copy of this certification.
7. The Department of Children and Families may rely upon a certification of a provider that it is not
debarred, suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it
knows that the certification is erroneous.
8. This signed certir:cation must be kept in the contract manager's cont,act fila. SubcDntractor's
certification must be kept at the provider's business location.
CERTIFICATION
(1) The prospective provloer certlties, by signing this certification, that neither he nor his principals is
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract by any federal department or agency.
(2) Where the prospective provider is unable to certify to any of the statements in this certification,
such prospective provider shall attach an explanation to this certification.
Signature
Date
Name (type or print)
C:,airman
Title
CF '~"';:',...i'o{)9!2003
Au I i:i::j ! ;
DWIGHT E. BROCK~ C(~C'~
Appwov&d (!I.l'>'; !O form &. lega~ SuffIciency
-'....~
~ -eN y~"...____.
A.."'~~ta'=:"-;""o'''.,+v ".t~r-"".
,~.;.;..';:#r;:j, Trr"%.~, Wilt._ '~Il,t) :te-.~I
.::s- 'L1'0 r--.:J \ ~'C. e.. t?:>. ~ \\t...
Agenda Item No. 16D9
January 11, 2011
Page 11 of 12
State of Florida
Department of Children and Families
Charlie Crist
Governor
Robert A. Butterworth
Secretary
VERI FICA TION OF
PROVIDER SUBCONTRACTING STA TUS
CONTRACT MANAGER COMPLETE THE FOLLOWING:
\. Provider Name: Collier County Board orCOmmrssloners
Grant Number: HFZ 1 D
I In accordance with the provisions of Section I.H of the Grant Agreement terms and Conditions:
o This contract allows the provider to contract for the provision of all services under this
contract.
Nicholas B. Cox
Sun Coast Region Director
I 0 This contract does not allow the provider to subcontract for the provision of any services
I under this contract.
i
I [8J This grant allo""'$ the provider to subcontract for the provision of the following services
I under this grant: As apolied for in the Chalienae Grant solicitation # LPZ01 and 8Doroved
I bv award
!
I
i
L Contra::;l Manager SIgnature
:)ate
PROVIDER SELECT ONE OF THE FOLLOWiNG:
----.No \^/ork is currently perio6iled bv sUbcorlfraCtors-foTfne--s-ervlce-s whrcli- areunder--
-conn-act or there is cun-entlv no intent to subcontract for contracted services beina
neootiated with the department. ~
Subcontractors ai'e currentlv periormrno services vl'hich are under contract or there is an
x-iiltent to subcontract br cO:ltracted services beinq neaotiated with the department.
- - -
Please provide a !ist of these ser.,lIees: bs aO:Jiled for:relatina to solicitation '# LPZO 1
The provider ~nderstands that if the Departrnent a1!::nr\!s subcontractin9, and thi? prov(der
ch08ses to 2.uticontract an'! of the co,'1trac:ed services, the pro\/\oer shall subrnlt a vlntten
reouest to subconti'act for the provision of services Ic the C:ntract lv,anager 'or DeDartrnent
ap~xoval. '
to
PROGRAM OFFICE:
,- D"'/~,~r5pr6'\!'es'e.r0c-es'~rooe s u S"6c)"nfr--aci'ea:
,i\ll (Jistea' abovr:...;) _ E,xceoUon
services to be subcontracted
PO, Box
Fort r-~4ye;st FIDnca 33B05-0Q85
Mssion: Protect the Vulne~able, Promote STrang and Economicslly Seif-Sufflc:ient Families and
~~~~~ E. BROCK,A~~:~~ Persona! and Fami!y Recovery ~__. to iel
~~:.~ (J :f)rJ ~!~_
.....
......A~s'm~~....... ..;.....-'-....-.h...'r:'nl~.~-.. ------..--..-...- --
.. -c"'c- .'\ ) 1\) i Ff (2. l~ t,..) HIT <.
By:
Agenda Item No. 16D9
January 11, 2011
Page 12 of 12
Attachment
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND
COOPERATIVE AGREEMENTS
The undersigned 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 an 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 the awarding of any federal contract. the making of
o.any fed9ralgr.e.nt, the making of ar.yJederalloan, 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 influencing or attempting to influence 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.
(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
ritC:r""olf"l~O ~,...,....-....rttnr1I\1
_........''lJ.................. I.,..4,V~VII",AIII~IJ'
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 section 1352, Title 31, U.S. Cede. /\ny p'::rson \vho
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.
~;rgnatur8
Date
(Jam" of-AUi"i,orf"ied In~n
H FZ 1 D
,t.,Llp:icolion or Contrilct r,umbor
Collier County Board of County Commissioners
~;am€ of Organiz.ation
3299 Tamiami Trail East, Naples, FL 34112
AdoressOfOrgal1izfllion _'0
App~ Q to form & iegal Sufficiency
~~"""
~'f)u~ Page__
Assistant Countv Attorn;V--
-YE ('0...;) (\..) \ 'FE. ~ . G ~ \, 'l
CF 1123, PDF 03186
ATTeST:
DWIGHT e. BROOK, Cler~
By: