Backup Documents 06/08/2010 Item #16K3K
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP l63
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
print on pink paper. Attach to original document. Original (1ocuntealS 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 kl through #4 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 routine lines #1 thnweh #4 ema Irle Ihr chrrkfi,t and 6--d n, s— Pilo ., 11—A;,
Route to Addressee(s)
(List in routing order)
Office
Initials
Date
1.
(Initial)
Applicable)
2.
June 8, 2010
Agenda Item Number
16 -K -3
3.
Chairman, with the exception of most letters, must be reviewed and signed by the Office of the
4 Jeff E. Wright, Assistant County
Attorne y
County Attorney
.---
2— �p
5. tan Mitchell, BCC Office Supervisor
Board of County Commissioners
Documents Attached
6. Minutes and Records
Clerk of Court's Office
PRIMARY CONTACT INFORMATION
( Fhe 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 he delivered to the BCC office only after the BCC has acted to approve the
item )
Name of Primary Staff
Jeff E. Wright, ACA
Phone Number
252 -8400
Contact
(Initial)
Applicable)
Agenda Date Item was
June 8, 2010
Agenda Item Number
16 -K -3
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 & Mutual Release -
Number of Original
3
Attached
Belanger
Documents Attached
INSTRUCTIONS & CHECKLIST
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip W WS Original 9.03.04, Revised 1.26.05, Revised 2.24 05
«matter number) /adocument number,)
Initial the Yes column or mark °N /A" in the Not Applicable column, whichever is appropriate.
Yes
N/A (Not
(Initial)
Applicable)
I.
Original document has been signed /initialed for legal sufficiency. (All documents to.be signed by the
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-
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.
1 h Chairman's signature line date has been entered as the date of BCC approval ofthe document or
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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
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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 06/08/10 and all changes made during the meeting
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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 W WS Original 9.03.04, Revised 1.26.05, Revised 2.24 05
«matter number) /adocument number,)
16K3
MEMORANDUM
Date: July 6, 2010
To: Jeff Wright, Asst. County Attorney
Office of the County Attorney
From: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Belanger Settlement Agreement & Mutual Release
Attached, are two original copies of the agreement referenced above, (Item #16K3)
approved by the Board of County Commissioners on Tuesday, June 8, 2010.
The third original agreement will be held on file in the Minutes and Records
Department as part of the Board's Official Record.
If you have any questions, please call 252 -8406.
Thank you
Attachments (2)
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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 day of QUIrt6l 2010 by and between DOUGLAS BELANGER,
SR. As Parent and Natural Guardian of DOUGLAS BELANGER, JR., 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 Douglas
Belanger, Sr., as Parent and Natural Guardian of Douglas Belanger, Jr. v. Collier
County Board of Commissioners, Case No. 08- 6276 -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
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WHEREAS, Plaintiffs agree and covenant to fully comply with all applicable
Medicare laws and liens specifically including 42 USC § 1395y.
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 Eight Thousand Dollars and 00/100 ($8,000.00) 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
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16K3
or indirectly, to the Lawsuit or any incident, event or allegation referred to or made in the
Complaint in the Lawsuit.
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.
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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.
IN WITNESS WHEREOF, Plaintiffs, and the County have signed and sealed
this Agreement and Release as set forth below.
Date:
ATTES�, .
DWIf;}il` - -E� JCK, Clerk
Q�.
tlMit r1' `.1 ty Clerk
Approved; a's,f6 form and
leg ufficiency:
Co le M. Greene
As ' ant County Attorney
BOARD OF COUNTY COMMISSIONERS
OF COLLIER COUNTY, FLORIDA
El
ID;
DOVeGLAS BN.ANGER, SR., As Parent
and Natural Guardian of Douglas
Belanger, Jr. a Minor, Plaintiff
160
STATE OF LZP t n/
COUNTY OF C` L L 1 e C
THIS SETTLEMENT AGREEMENT AND RELEASE BETWEEN PLAINTIFFS AND
COLLIER COUNTY, FLORIDA WAS SWORN TO and subscribed by DOUGLAS
BELANGER, SR. As Parent and Natural Guardian of DOUGLAS BELANGER, JR., a
Minor, bef re me on this day of sj Q N , 2010.
Personally Known
or
MILAN NIKOLIC Produced Identification
My COMMISSION # D0969668
EXPIRES March 09, 2014
led Name o o ary ublic Type of Identification Produced
(Please print, type or stamp)
My Commission expires:
08- 6276- CA/3606
5
Item a ,a.-3
Agenda
Date w ° J
Date Recd q� -tD
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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.
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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
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.
to the releaser only:
A ZYC'sor Name Date
Douglas Belanger, ., as parent and natural guardian of
Douglas Belanger, J a minor
Releasor Address
STATE OF
COUNTY OF
THIS ADDENDUM TO SETTLEMENT AGREEMENT AND MUTUAL RELEASE BETWEEN PLAINTIFFS AND COLLIER
COUNTY, FLORIDA WAS SWORN TO and subscribed by DOUGLAS BELANGER, SR. As Parent and
Natural Guardian of DOUGLAS BELANGER, JR., a Minor, before me on this X-y day of
LEAPersonally Known
Iq LIC or
MY COMMISSION # DD969688 Produced Identification _
EXPIRES March 09, 2014
Type of Identification Produced
(Please print, type or stamp)
My Commission expires:
3
380652.1
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As to the releasee only:
BOARD OF COUNTY COMMISSIONERS
OF COLLIER COUNTY, FLORIDA
4
W.
Releasee Date
Fred W. Coyle, Chairman
Releasee Address
ATTEST:
Dz?vt�iF`TEi ,ROCK, Clerk
4 Clerk
Approved as to form and
legal sufficiency:
Co
/� ll M. Greene
() Assist t County Attorney
08- 6276 -CA /3604
4
380652.1