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Backup Documents 09/11-12/2012 Item #16K 5ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16K5 TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original documents are to be forwarded to the Board Office only after the Board has taken action on the item.) ROUTING SLIP Complete routing lines #1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the Axoe of the Chairman'c cianntnre elmw a lino thronah rontinu lines # 1 through #4- comnlete the checklist - and forward to Sue Filson (line #5). Route to Addressee(s) (List in routing order Office Initials Date 1. (Initial) Applicable) 2. 09/11/12 Agenda Item Number 16K5 3. Chairman, with the exception of most letters, must be reviewed and signed by the Office of the 4. Colleen M. Greene, ACA County Attorney Number of Original 3 5. Ian Mitchell, BCC Executive Manager Board of County Commissioners Documents Attached 6. Minutes and Records Clerk of Court's Office n (( q I' 2 PRIMARY CONTACT INFORMATION (The primary contact is the holder of the original document pending BCC approval. 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, including Sue Filson, need to contact staff for additional or missing information. All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the item ) Name of Primary Staff Colleen M.Greene, ACA Phone Number 252 -2966 Contact (Initial) Applicable) Agenda Date Item was 09/11/12 Agenda Item Number 16K5 Approved by the BCC Chairman, with the exception of most letters, must be reviewed and signed by the Office of the Type of Document Settlement Agreement - Magana Number of Original 3 Attached County Attorney's Office and signature pages from contracts, agreements, etc. that have been fully Documents Attached INSTRUCTIONS & CHECKLIST I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05 «matter number» /<<document_ number» Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is appropriate. Yes N/A (Not (Initial) Applicable) 1. Original document has been signed/initialed for legal sufficiency. (All documents to be signed by the CMG Chairman, with the exception of most letters, must be reviewed and signed by the Office of the County Attorney. This includes signature pages from ordinances, resolutions, etc. signed by the County Attorney's Office and signature pages from contracts, agreements, etc. that have been fully executed by all parties except the BCC Chairman and Clerk to the Board and possibly State Officials.) 2. All handwritten strike - through and revisions have been initialed by the County Attorney's Office and N/A all other parties except the BCC Chairman and the Clerk to the Board 3. The Chairman's signature line date has been entered as the date of BCC approval of the document or CMG the final negotiated contract date whichever is applicable. 4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's signature and CMG initials are required. 5. In most cases (some contracts are an exception), the original document and this routing slip should be N/A provided to Ian Mitchell in the BCC office within 24 hours of BCC approval. 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! 6. The document was approved by the BCC on 09/11/12 and all changes made during the meeting CMG i have been incorporated in the attached document. The County Attorney's Office has reviewed the changes, if applicable. I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05 «matter number» /<<document_ number» 16K5 MEMORANDUM Date: September 19, 2012 To: Colleen Greene, Assistant County Attorney County Attorney's Office From: Teresa Cannon, Deputy Clerk Minutes & Records Department Re: Settlement Agreement & Mutual Release - Magana Attached is two (2) originals of the document referenced above, (Item #16K5) approved by the Board of County Commissioners on September 11, 2012. The Minutes & Records Department will hold the third original release for the Board's Official Record. If you have any questions please feel free to contact me at 252 -8411. Thank you. Attachment 16K5t, � SETTLEMENT AGREEMENT AND MUTUAL RELEASE THIS SETTLEMENT AGREEMENT AND MUTUAL RELEASE (hereinafter referred to as the "Agreement and Release ") is entered into and made on this ''t1 day of September, 2012 by and between MARIA DE LOS ANGELES DIAZ, As Parent and Natural Guardian of JORGE MAGANA, a Minor, (hereinafter referred to as "Plaintiffs ") and Board of County Commissioners for Collier County (hereinafter referred to as the "County ") WITNESSETH: WHEREAS, Plaintiffs filed a lawsuit against the County in the Circuit Court for the Twentieth Judicial Circuit in and for Collier County, Florida, styled Jorge Magana, by and through his parent and natural guardian, Maria De Los Angeles Diaz v. Collier County, A Political Subdivision of the State of Florida, Case No. 11- 2441 -CA (hereinafter referred to as the "Lawsuit "); and WHEREAS, Plaintiffs and the County, without either party admitting any liability or fault, desire to settle the Lawsuit and any and all disputes that arise from, relate or refer in any way, whether directly or indirectly, known or unknown, to the incidents described or allegations made in the Complaint filed in the Lawsuit; and, WHEREAS, Plaintiffs and the County desire to reduce their settlement to a writing so that it shall be binding upon them as well as their respective owners, principals, elected officials, officers, employees, ex- employees, agents, attorneys, representatives, insurers, spouses, successors, assigns, heirs and affiliates; and WHEREAS, Plaintiffs agree and covenant to fully comply with all applicable Medicare laws and liens specifically including 42 USC § 1395y. 1 16K5 NOW, THEREFORE, in consideration of the mutual covenants, promises and consideration set forth in this Agreement and Release, and with the intent to be legally bound, Plaintiffs and the County agree as follows: 1. Plaintiffs and the County adopt and incorporate the foregoing recitals, sometimes referred to as "Whereas Clauses ", by reference into this Agreement and Release. 2. In consideration of the resolution of all disputes or claims arising from or referring or relating in any way, whether directly or indirectly, to the Lawsuit, and for and in consideration of the sum of Seven Thousand Five Hundred Dollars and 00/100 ($7,500.00) and other valuable consideration, the receipt and adequacy of which is hereby acknowledged by Plaintiffs, Plaintiffs agree to dismiss the Lawsuit with prejudice. 3. In consideration of the resolution of the Lawsuit, and for other good and valuable consideration, the receipt and adequacy of which is hereby acknowledged, Plaintiffs, on behalf of themselves, their attorneys, agents, representatives, insurers, heirs, successors and assigns, hereby expressly releases and forever discharges the County, as well as its elected officials, officers, employees, ex- employees, agents, attorneys, representatives, successors, assigns, insurers and affiliates from any and all claims, demands, causes of actions, damages, costs, attorney's fees, expenses and obligations of any kind or nature whatsoever that they have asserted or could have asserted in the Lawsuit or that arise from or relate or refer in any way, whether directly or indirectly, to the Lawsuit or any incident, event or allegation referred to or made in the Complaint in the Lawsuit. N 16K5 4. Notwithstanding anything that may be to the contrary in Paragraph 3 of this Agreement and Release, Plaintiffs and the County agree that either of them (as well as any other persons or entities intended to be bound) shall, in the event of any breach, retain the right to enforce the terms and conditions of this Agreement and Release. 5. Plaintiffs agree and covenant to fully comply with all applicable Medicare laws and liens specifically including 42 USC § 1395y. 6. Plaintiffs and the County acknowledge and agree that this Agreement and Release is intended to and shall be binding upon their respective owners, principals, officials, officers, employees, ex- employees, agents, attorneys, representatives, insurers, successors, assigns, spouses, heirs, and affiliates. 7. Plaintiffs and the County recognize and acknowledge that this Agreement and Release memorializes and states a settlement of disputed claims and nothing in this Agreement and Release shall be construed to be an admission of any kind, whether of fault, liability, or of a particular policy or procedure, on the part of either Plaintiffs or the County. 8. Plaintiffs and the County acknowledge and agree that this Agreement and Release is the product of mutual negotiation and no doubtful or ambiguous language or provision in this Agreement and Release is to be construed against any party based upon a claim that the party drafted the ambiguous provision or language or that the party was intended to be benefited by the ambiguous provision or language. 3 16K5 9. This Agreement and Release may be amended only by a written instrument specifically referring to this Agreement and Release and executed with the same formalities as this Agreement and Release. 10. In the event of an alleged breach of this Agreement and Release, Plaintiffs and the County agree that all underlying causes of action or claims of Plaintiffs have been extinguished by this Agreement and Release and that the sole remedy for breach of this Agreement and Release shall be for specific performance of its terms and conditions or any damages arising from the breach. In this regard, Plaintiffs and the County further agree that the sole venue for any such action shall be in the Twentieth Judicial Circuit in and for Collier County, Florida in Naples, Florida. 11. This Agreement and Release shall be governed by the laws of the State of Florida. 12. Plaintiffs and Plaintiffs' attorney shall be solely responsible for any Medicare lien or other liens as referenced in the attached Addendum. IN WITNESS WHEREOF, Plaintiffs, and the County have signed and sealed this Agreement and Release as set forth below. Date: q - I I I )'D— ATTEST: DWI '0H.1` 1-5ROCK, Clerk R. Aek"9?rk A�proyed.as to form and legal sufficiency: e kai--km Colleen M. Greene Assistant County Attorney BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA By: FRED W. COYLE, Chairm By: a4l i A MA I OS ANGELES DIAZ, As Parent and Natural Guardian of Jorge Magana, a Minor, Plaintiff 11 16K5 STATE OF Flo(-Scc COUNTY OF Le- -.e-- THIS SETTLEMENT AGREEMENT AND RELEASE BETWEEN PLAINTIFFS AND COLLIER COUNTY, FLORIDA WAS SWORN TO and subscribed by MARIA DE LOS ANGELES DIAiZ, As Parent and Natural Guardian of JORGE MAGANA, a Minor, before me on this l day of '7 i S nature of Notary Public Rae 0 : e Commissioned Name of Notary Public (Please print, type or stamp) My Commission expires: 11- 2441- CA/5238 5 Personally Known or Produced Identification fhr- k ;(n Q d C`>.� 14 ��— Type of Identification Produced ROSE MARIE SVVEENEY -ROSE Commission # DD 850009 Expires April 22, 2013 Bonded TMa Troy Fain Inyuwu Wa 18&7019 ' 16K5 ADDENDUM TO SETTLEMENT AGREEMENT AND GENERAL RELEASE Representations With Regard to Medicare's Interests Releasor hereby warrants and represents that I presently am not, nor have ever been enrolled in Medicare Part A or Part B. Further, I have no claim for Social Security Disability benefits nor am I appealing or re- filing for Social Security Disability benefits. Medicare's Interests In reaching agreement on the terms of this Release, the parties acknowledge Releasor's possible entitlement to Social Security disability benefits pursuant to 42 U.S.C. § 423, and receipt of Medicare or Medicaid benefits under 42 U.S.0 § 1395y, as well as the entitlement of the Centers for Medicare and Medicaid Services ( "CMS ") to subrogation and intervention, pursuant to 42 U.S.C. § 1395y(b) (2) to recover any overpayment made by CMS. The parties to this Release agree that this Release is not intended to shift to CMS the responsibility for payment of medical expenses for the treatment of injury related conditions. The parties agree that this settlement is intended to provide Releasor a lump sum and /or future periodic payment which will foreclose Releasee's responsibility for future payment of all injury related medical expenses. Non - reimbursable Expenses (where there is an MSA or other future medical expense consideration) The parties to this Release understand that many common medical expenses are not payable or reimbursable under the Medicare program. These medical expenses, not covered by Medicare but necessary in the ongoing treatment of the Releasor's injury, and without an admission of liability on the part of the Releasee, have been taken into consideration in the calculation and settlement of Releasor's future medical expenses. Funds for these non - Medicare covered medical expenses have been included in the lump sum settlement amount and shall not be paid from any Medicare allocation amount. 16K5 Benefit Eligibility Releasor acknowledges that any decision regarding entitlement to Social Security benefits or Medicare or Medicaid benefits, including the amount and duration of payments and offset reimbursement for prior payments is exclusively within the jurisdiction of the Social Security Administration, the United States Government, and the U.S. Federal Courts, and is determined by Federal law and regulations. As such, the United States Government is not bound by any of the terms of this Release. Future Benefits Releasor has been apprised of his /her right to seek assistance from legal counsel of his /her choosing or directly from the Social Security Administration or other government agencies regarding the impact this Release may have on Releasor's current or future entitlement to Social Security or other governmental benefits. Releasor acknowledges that acceptance of these settlement funds may affect Releasor's rights to other governmental benefits, insurance benefits, disability benefits, or pension benefits. Notwithstanding this possibility, Releasor desires to enter into this Release agreement to settle his /her injury claim according to the terms set forth in this Release. Medicare Recovery Action Releasor agrees to hold harmless, indemnify and defend Releasee from any cause of action, including, but not limited to, an action by CMS to recover or recoup Medicare benefits or loss of Medicare benefits, if CMS determines that the money set -aside has been spent inappropriately or for any recovery sought by Medicare, including past, present, and future and /or conditional payments. Releasor agrees not to use designated Medicare allocation funds to pay claims for conditional payments that may have been made by Medicare. 2 380652.1 16K5 Complete Understanding Releasor hereby declares that the terms of this Release have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final settlement of any and all claims, disputed or otherwise, on account of injuries and /or damages related to the Claims set forth herein, and for the express purpose of precluding forever any further additional claims against the Release arising out of the aforesaid incident, accident or occurrence. As to the releaser only: V I I_ 0-�c ( 2 Releasor Name Date Maria De Los Ang les Diaz, as parent and natural guardian of Jorge Magana, a minor Su 3 c-A s_�JA Releasor Address STATE OF (- ICr � 4c— COUNTY OF �-o THIS ADDENDUM TO SETTLEMENT AGREEMENT AND MUTUAL RELEASE BETWEEN PLAINTIFFS AND COLLIER COUNTY, FLORIDA WAS SWORN TO and subscribed by MARIA DE LOS ANGELES DIAZ, As Parent and Natural Guardian of JORGE MAGANA, a Minor, before me on this I t day of I g2 Ac L22 2012. Z� AL Personally Known Si nature of Notary Public or Produced Identification D /-y Commissioned Name of N >tary Public Type of Identification Produced (Please print, type or stamp) My Commission expires: 380652.1 16K5 As to the releasee only: BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA W. " Releasee Date Fred W. Coyle, Chairman 3299 —1 1 V-Al L. 1CA4f, SuiTe �03 , NAPc.ES, Fuoe- A r Releasee Address ATTEST: DWIGHT E,BROC , rJc De Ciik it':te as Approved as to form and legal sufficiency: U&Ofl ��� Colleen M. Greene Assistant County Attorney 11- 2441- CA/5239 al 380652.1