Backup Documents 10/12/2010 Item #16D 5
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO I
Print on pink paper~~~~~~~~~o?~~;~~~~<?e~~ 2~~~!~~co~~~~u~andmA D 5
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
exceotion of the Chairman's sil!Dature. draw a line througl: routing lines #1 through #4, complete the checklist, and forward to Sue Filson (line #5).
Route to Addressee(s) Office Initials Date
(List in routinl!: order)
1.
2.
3.
4.
5. Ian Mitchell, Executive Manager Board of County Commissioners ~ (Of (1.-\ 10
6. Minutes and Records Clerk of Court's Office
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/pR:pare the executive
summary. PrimaIy contact information is needed in the event one of the addressees above. including Sue Filson. need to contact staff for additional or missing
inftmJatiOll. AIl original documents needing the Bee Chairman's signature are to he delivered to the Bee office only after the BCC has acted to approve the
item.)
Name of Primary Staff
Contact
Agenda Date Item was
ved b the BCC
Type of Document
Attached
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
riate.
1. Original docurl1ent 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. 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 Bee
Chairman and Clerk to the Board and ossibl State Officials.)
2. All handwritten strike-through and revisions have been initialed by the County Attorney's
Office and all other arties exce t 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 the final ne otiated contract date whichever is a licable.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si ture and initials are r uired.
5. In most cases (some contracts are an exception), the original document and this routing slip
should be provided to Sue Filson in the BCe office within 24 hours of Bce 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-W8S-appro~-b.y~e-BCC-on. ----- -------(enter-date)-and-aII-c-hanges
made during the meeting have been incorporated in the attached documenL The
Coun Attorne's Office has reviewed the chan es, if a licable.
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.:;f Z.r~-~~~
~ ~ _ A.- L..o'_....__
Number of Original
Documents Attached
Phone Number
~J
(0
Agenda Item Number
4.
;J
Yes
(Initial)
N/ A (Not
A licable)
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16D5'
MEMORANDUM
Date: October 14, 2010
To: Vicky Ahmad, Project Manager
Parks & Recreation Department
From: Teresa Polaski, Deputy Clerk
Minutes & Records Department
Re: Grant Agreement
Attached, please find four (4) originals of the grant agreement referenced above,
(Item #16D5) approved by the Board of County Commissioners on October 12,
2010.
Please forward a fully executed original back to the Minutes and Records
Department for the Board's official record.
If you have any questions, please call me at 252-8411.
Thank you.
Attachments (4)
.
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STATE OF FLORIDA
DIVISION OF EMERGENCY MANAGEMENT
CHARUE CRIST
Governor
DAVID HALSTEAD
Director
September 17, 2010
Ms. Vicky Ahmad, Project Manager
Collier County
15000 Livingston Road
Naples, Florida 34109
Re: HGMP 17SS-028-R (State Project Number 1785-22), Collier County, East Naples Community
Center, Wind Retrofit, Request for review and approval of Contract
Dear Ms, Ahmad:
The Division of Emergency Management (OEM) is pleased to inform you that the Federal Emergency
Management Agency has approved the obligation of Hazard Mitigation Grant Program funds for the
project number(s) listed above, Please note that this is an eligible cost-reimbursement contract, and as
such, the recipient must make other funding arrangements to complete this project. However, the
recipient may submit periodic requests for payment throughout the project process, consistent with the
tenns of the contract.
Please print four copies of the proposed contract between the Collier County Engineering Department and
OEM. The official representative, as listed below, will need to sign the signature Page (page 14) and the
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion form (page 33).
All four (4) copies of the contract should then be sent to the Tallahassee address listed below for full
execution no later than ninety (90) days after receipt of this letter for final execution. One fully executed
contract will be returned to the Collier County Engineering Department for its files.
OfflciIIJ Representatives:
County:
City:
Indian Tribe:
Water Management District:
Non-Profit:
Chairman of the Board of Commissioners
Mayor
Chief or President
Chainnan
Chairman of the Board
If there is an official that is not listed above who is authorized to sign the modifications for your
organization, please provide a copy of the organization's resolution or charter that specifically identifies
the person or position that is authorized to sign.
FLORIDA RECOVERY OFFICE
38 Skyline Drive
Lake Mary, FL 32746-6201
. DIVISION HEADQUARTERS'
2555 Shumud Oak Boulevard
Tallahanee, FL 32399.2100
Tel: 850-413-9969. Fax: 850-488-1016
www. FICJ"da O'sasl~ig,
STATE LOGISTICS RESPONSE CENTER
2702 Directors Row
Orlando, FL 32809-5631
16D5
Ms. V icky Ahmad
September 17, 20] 0
Page Two
If you have questions regarding this contract or who is authorized to sign it, please call Olivette Carter at
(407) 268-8618.
Respectfi~U~Y'
-----V . ,~.
Miles E, Anders .
Bureau Chief, Mitigation
State Hazard Mitigation Officer
MEA/mt
cc: Jason McCright
Attachment
l6D5
Contract Number: 11 HM-3E-09-21-01-005
CFDA Number: 97.039
FEDERALLY FUNDED SUBGRANT AGREEMENT
THIS AGREEMENT is entered into by the State of Florida, Division of Emergency Management,
with headquarters in Tallahassee, Florida (hereinaftef referred to as the "Division"), and Collier County,
(hereinafter referred to as the "Recipient").
THIS AGREEMENT IS ENTERED INTO BASED ON THE FOLLOWING REPRESENTATIONS:
A. The Recipient represents that it is fully qualified and eligible to receive these grant funds to
provide the services identified herein; and
8. The Division has received these grant funds from the State of Florida, and has the authority to
subgrant these funds to the Recipient upon the terms and conditions below; and
C. The Division has statutory authority to disburse the funds under this Agreement.
THEREFORE, the Division and the Recipient agree to the following:
(1) SCOPE OF WORK
The Recipient shall perform the work in accordance with the Budget and Scope of Work,
Attachment A of this Agreement.
(2) INCORPORATION OF LAWS, RULES. REGULATIONS AND POLICIES
The Recipient and the Division shall be governed by applicable State and Federal laws,
rules and regulations, including those identified in Attachment S.
(3) PERIOD OF AGREEMENT
This Agreement shall begin August 12, 2010 and shall end August 12,2012 unless
terminated earlier in accordance with the provisions of Paragraph (12) of this Agreement.
(4) MODIFICATION OF CONTRACT
Either party may request modification of the provisions of this Agreement. Changes
which are agreed upon shall be valid only when in writing, signed by each of the parties, and attached to
the original of this Agreement.
(5) RECORDKEEPING
(a) As applicable, Recipient's performance under this Agreement shall be subject to the
federal "Common Rule: Uniform Administrative Requirements for State and Local Governments" (53
Federal Register 8034) or OMS Circular No. A-11 0, "Grants and Agreements with Institutions of Higher
Education, Hospitals, and Other Nonprofit Organizations," and either OMS Circular No. A-87, "Cost
Principles for State and Local Governments," OMS Circular No. A-21. "Cost Principles for Educational
Institutions," or OMB Circular No. A-122, "Cost Principles for Nonprofit Organizations." If this Agreement
is made with a commercial (for-profit) organization on a cost-reimbursement basis, the Recipient shall be
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subject to Federal Acquisition Regulations 31.2 and 931.2.
(b) The Recipient shall retain sufficient records to show its compliance with the terms of
this Agreement, and the compliance of all subcontractors or consultants paid from funds under this
Agreement, for a period of five years from the date the audit report is issued, and shall allow the Division
or its designee,the State Chief Financial Officer or the State Auditor General access to the records upon
request. The Recipient shall ensure that audit working papers are available to them upon request for a
period of five years from the date the audit report is issued, unless extended in writing by the Division.
The five year period may be extended for the following exceptions:
1. If any litigation, claim or audit is started before the five year period expires,
and extends beyond the five year period,the records shall be retained until all litigation, claims or audit
findings involving the records have been resolved.
2. Records for the disposition of non-expendable personal property valued at
$5,000 or more at the time it is acquired shall be retained for five years after final disposition.
3. Records relating to real property acquired shall be retained for five years after
the closing on the transfer of title.
(c) The Recipient shall maintain all records for the Recipient and for all subcontractors or
consultants to be paid from funds provided under this Agreement, including documentation of all program
costs, in a form sufficient to determine compliance with the requirements and objectives of the Budget
and Scope of Work-Attachment A-and all other applicable laws and regulations.
(d) The Recipient, its employees or agents, including all subcontractors or consultants to
be paid from funds provided under this Agreement, shall allow access to its records at reasonable times
to the Division, its employees, and agents. "Reasonable"shall ordinarily mean during normal business
hours of 8:00 a.m.to 5:00 p.m., local time, on Monday through Friday. "Agents"shall include, but not be
limited to, auditors retained by the Division.
(6) AUDIT REQUIREMENTS
(a) The Recipient agrees to maintain financial procedures and support documents, in
accordance with generally accepted accounting principles,to account for the receipt and expenditure of
funds under this Agreement.
(b) These records shall be available at reasonable times for inspection, review, or audit
by state personnel and other personnel authorized by the Department or the Division. "Reasonable"shall
ordinarily mean normal business hours of 8:00 a.m.to 5:00 p.m., local time, Monday through Friday.
(c) The Recipient shall provide the Department with the records, reports or financial
statements upon request for the purposes of auditing and monitoring the funds awarded under this
Agreement.
(d) If the Recipient is a State or local government or a non-profit organization as defined
in OMB Circular A-133, as revised, and in the event that the Recipient expends$500,000 or more in
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Federal awards in its fiscal year, the Recipient must have a single or program-specific audit conducted in
accordance with the provisions of OMB Circular A-133, as revised. EXHIBIT 1 to this Agreement shows
the Federal resources awarded through the Division by this Agreement. In determining the Federal
awards expended in its fiscal year, the Recipient shall consider all sources of Federal awards. including
Federal resources received from the Division. The delermination of amounts of Federal awards
expended should be in accofdance with the guidelines established by OMB Circular A-133. as revised.
An audit of the Recipient conducted by the Auditor General in accordance with the provisions of OMB
Circular A-133, as revised, will meet the requirements of this paragraph.
In connection with the audit requirements addressed in this Paragraph 6 (d) above, the
Recipient shall fulfill the requifements for auditee responsibilities as provided in Subpart C of OMB
Circular A-133, as revised.
If the Recipient expends less than $500,000 in Federal awards in its fiscal year, an audit
conducted in accordance with the provisions of OMB Circular A-133, as revised, is not required. In the
event that the Recipient expends less than $500,000 in Federal awards in its fiscal year and chooses to
have an audit conducted in accordance with the provisions of OMB Circular A-133, as revised, the cost of
the audit must be paid from non-Federal funds.
(e) Send copies of reporting packages for audits conducted in accordance with OMB
Circular A-133, as revised, and required by subparagraph (d) above, when required by Section .320 (d).
OMB Circular A-133, as revised, by or on behalf of the Recipient to:
The Division at each of the following addresses:
Department of Community Affairs
Office of Audit Services
2555 Shumard Oak Boulevard
Tallahassee, Florida 32399-2100
[also send an electronic copy to aurllla.Darrlsh@dca.state.fl.usl
and
Division of Emergency Management
Bureau of Recovery and Mitigation
2555 Shumard Oak Boulevard
Tallahassee, Flofida 32399-2100
The Federal Audit Clearinghouse designated in OMB Circular A-133, as revised (submit the number of
copies required by Sections .320(d)(1) and (2), OMB Circular A-133, as revised), at the following address:
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffefsonville, IN 47132
Other Federal agencies and pass-through entities in accordance with Sections .320 (e) and (t), OMB
Circular A-133, as revised.
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(f) Pursuant to Section .320 (f), OMB Circular A-133, as revised, the Recipient shall send
a copy of the reporting package described in Section .320 (c), OMB Circular A-133, as revised, and any
management letter issued by the auditor, to the Division at the following addresses:
Department of Community Affairs
Office of Audit Services
2555 Shumard Oak Boulevard
Tallahassee, Florida 32399-2100
[also send an electronic copy to aurilla.Darrlsh@dca.state.fl.usl
and
Division of Emergency Management
Bureau of Recovery and Mitigation
2555 Shumard Oak Boulevard
Tallahassee, Florida 32399-2100
(g) By the date due, send any reports, management letter, or other information required
to be submitted to the Division pursuant to this Agreement in accordance with OMB Circular A-133,
Florida Statutes, and Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for-profit
organizations), Rules of the Auditor General, as applicable.
(h) Recipients should state the date that the reporting package was delivered to the
Recipient when submitting financial reporting packages to the Division for audits done in accordance with
OMB Circular A-133 or Chapters 10.550 (local governmental entities) or 10.650 (nonpfofit and for-profit
organizations), Rules of the Auditor General,
(i) If the audit shows that all or any portion of the funds disbursed were not spent in
accordance with the conditions of this Agreement, the Recipient shall be held liable for reimbursement to
the Division of alt funds not spent in accordance with these applicable regulations and Agreement
provisions within thirty days after the Division has notified the Recipient of such non-compliance.
(j) The Recipient shall have all audits completed by an independent certified public
accountant (IPA), either a certified public accountant or a public accountant licensed under Chapter 473,
Fla. Stat. The IPA shall state that the audit complied with the applicable provisions noted above. The
audit must be received by the Division no later than nine months from the end of the Recipient's fiscal
year.
(7) REPORTS
(a) The Recipient shall provide the Division with quarterly feports and a close-out report.
These reports shall include the current status and progress by the Recipient and all subrecipients and
subcontractors in completing the work described in the Scope of Work and the expenditure of funds under
this Agreement, in addition to any other information requested by the Division.
(b) Quarterly reports are due to the Division no later than 15 days after the end of
each quarter of the program year and shall be sent each quarter until submission of the
administrative close-out report. The ending dates for each quarter of the program year are March
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31. June 30. September 30 and December 31.
(c) The close-out report is due 60 days after termination of this Agreement or 60 days
after completion of the activities contained in this Agreement, whichever first occurs.
(d) If all required reports and copies are not sent to the Division or are not completed in a
manner acceptable to the Division, the Division may withhold further payments until they are completed or
may take other action as stated in Paragraph (11) REMEDIES. "Acceptable to the Division" means that
the work product was completed in accordance with the Budget and Scope of Work.
(e) The Recipient shall provide additional program updates or information that may be
required by the Division.
(f) The Recipient shall provide additional reports and information identified in
Attachment F.
(8) MONITORING
The Recipient shall monitor its performance under this Agreement, as well as that of its
subcontractors and/or consultants who are paid from funds provided under this Agreement, to ensure that
time schedules are being met, the Schedule of Deliverables and Scope of Work are being accomplished
within the specified time periods, and other performance goals are being achieved. A review shall be
done for each function or activity in Attachment A to this Agreement, and reported in the quarterly report.
In addition to reviews of audits conducted in accordance with paragraph (6) above.
monitoring procedures may include, but not be limited to, on-site visits by Division staff, limited scope
audits, and/or other procedures. The Recipient agrees to comply and cooperate with any monitoring
procedures/processes deemed appropriate by the Division. In the event that the Division or the
Department determines that a limited scope audit of the Recipient is appropriate, the Recipient agrees to
comply with any additional instructions provided by the Division or the Department to the Recipient
regarding such audit. The Recipient further agrees to comply and cooperate with any inspections,
reviews, investigations or audits deemed necessary by the Florida Chief Financial Officer or Auditor
General. In addition, the Division will monitor the performance and financial management by the
Recipient throughout the contract term to ensure timely completion of all tasks.
(9) LIABILITY
(a) Unless Recipient is a State agency or subdivision, as defined in Section 768.28, Fla,
Stat.. the Recipient is solely responsible to parties it deals with in carrying out the terms of this
Agreement, and shall hold the Division harmless against all claims of whatever nature by third parties
arising from the work performance under this Agreement. For purposes of this Agreement, Recipient
agrees that it is not an employee or agent of the Division, but is an independent contractor.
(b) Any Recipient which is a state agency or subdivision, as defined in Section 768.28.
Fla. Stat., agrees to be fully responsible for its negligent or tortious acts or omissions which result in
claims or suits against the Division, and agrees to be liable for any damages proximately caused by the
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acts or omissions to the extent set forth in Section 768.28, Fla. Stat. Nothing herein is intended to serve
as a waiver of sovereign immunity by any Recipient to which sovereign immunity applies. Nothing herein
shall be construed as consent by a state agency or subdivision of the State of Florida to be sued by third
parties in any matter arising out of any contract.
(10) DEFAULT
If any of the following events occur ("Events of Default"), all obligations on the part of the
Division to make further payment of funds shall, if the Division elects, terminate and the Division has the
option to exercise any of its remedies set forth in Paragraph (11). However, the Division may make
payments or partial payments after any Events of Default without waiving the right to exercise such
remedies, and without becoming liable to make any further payment:
(a) If any warranty or representation made by the Recipient in this Agreement or any
previous agreement with the Division is or becomes false or misleading in any respect, or if the Recipient
fails to keep or perform any of the obligations, terms or covenants in this Agreement or any previous
agreement with the Division and has not cured them in timely fashion, or is unable or unwilling to meet its
obligations under this Agreement;
(b) If material adverse changes occur in the financial condition of the Recipient at any
time during the term of this Agreement, and the Recipient fails to cure this adverse change within thirty
days from the date written notice is sent by the Division.
(c) If any reports required by this Agreement have not been submitted to the Division or
have been submitted with incorrect, incomplete or insufficient information;
(d) If the Recipient has failed to perform and complete on time any of its obligations
under this Agreement.
(11) REMEDIES
If an Event of Default occurs, then the Division may, after thirty calendar days written
notice to the Recipient and upon the Recipient's failure to cure within those thirty days. exercise anyone
or more of the following remedies, either concurrently or consecutively:
(a) Terminate this Agreement, provided that the Recipient is given at least thirty days
prior written notice of the termination. The notice shall be effective when placed in the United States, first
class mail, postage prepaid, by registered or certified mail-return receipt requested. to the address in
paragraph (13) herein:
(b) Begin an appropriate legal or equitable action to enforce performance of this
Agreement;
(c) Withhold or suspend payment of all or any part of a request for payment;
(d) Require that the Recipient refund to the Division any monies used for ineligible
purposes under the taws, rules and regulations governing the use of these funds.
(e) Exercise any corrective or remedial actions, to include but not be limited to:
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1. request additional information from the Recipient to determine the reasons for
or the extent of non-compliance or lack of performance,
2. issue a written warning to advise that more serious measures may be taken if
the situation is not corrected,
3. advise the Recipient to suspend, discontinue or refrain from incurring costs for
any activities in question or
4. require the Recipient to reimburse the Division for the amount of costs incurred
for any items determined to be ineligible;
(f) Exercise any other rights or remedies which may be available under law.
(9) Pursuing any of the above remedies will not stop the Division from pursuing any other
remedies in this Agreement or provided at law or in equity. If the Division waives any right or remedy in
this Agreement or fails to insist on strict performance by the Recipient, it will not affect, extend or waive
any other right or remedy of the Division, or affect the later exercise of the same right or remedy by the
Division for any other default by the Recipient.
(12) TERMINATION
(a) The Division may terminate this Agreement for cause after thirty days written notice.
Cause can include misuse of funds, fraud, lack of compliance with applicable rules, laws and regulations,
failure to perform on time, and refusal by the Recipient lo permit public access to any document, paper,
letter, or other material subject to disclosure under Chapter 119, Fla. Stat., as amended.
(b) The Division may terminate this Agreement for convenience or when it determines, in
its sole discretion, that continuing the Agreement would not produce beneficial results in line with the
further expenditure of funds, by providing the Recipient with thirty calendar days prior written notice.
(c) The parties may agree to terminate this Agreement for their mutual convenience
through a written amendment of this Agreement. The amendment will state the effective date of the
termination and the procedufes for proper closeout of the Agreement.
(d) In the event that this Agreement is terminated, the Recipient will not incur new
obligations for the terminated portion of the Agreement after the Recipient has received the notification of
termination. The Recipient will cancel as many outstanding obligations as possible. Costs incurred after
receipt of the termination notice will be disallowed. The Recipient shall not be relieved of liability to the
Division because of any breach of Agreement by the Recipient. The Division may, to the extent
authorized by law, withhold payments to the Recipient for the purpose of set-off until the exact amount of
damages due the Division from the Recipient is determined.
(13) NOTICE AND CONTACT
(a) All notices provided under or pursuant to this Agreement shall be in writing, either byu
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hand delivery, or first class, certified mail, return receipt requested. to the representative named below, at
the address below, and this notification attached to the original of this Agreement.
(b) The name and address of the Division contract manager for this Agreement is:
Ms. Kathleen Marshall, Planning Manager
Bureau of Recovery and Mitigation
Division of Emergency Management
2555 Shumard Oak Boulevard
Tallahassee, Florida 32399
Telephone: (850) 922-5944
Fax: (850) 922-1259
Email: kathleen.marshall@em.myflorida.com
(c) The name and address of the Representative of the Recipient responsible for the
administration of this Agreement is:
Ms. Vicky Ahmad
Project Manager
Collier County
15000 Livingston Road
Naples, Florida 34109
Telephone: (239) 252-4047
Fax: (239) 252-3973
Email: VickyAhmad@colliergov.net
(d) In the event that different representatives or addresses are designated by either party
after execution of this Agreement, notice of the name, title and address of the new representative will be
provided as outlined in (13)(a) above.
(14) SUBCONTRACTS
If the Recipient subcontracts any of the work required under this Agreement, a copy of the
fully executed subcontract must be forwarded to the Division within ten days of execution for review and
approval. The Recipient agrees to include in the subcontract that (i) the subcontractor is bound by the
terms of this Agreement, (ii) the subcontractor is bound by all applicable state and federal laws and
regulations, and (iii) the subcontractor shall hold the Division and Recipient hannless against all claims of
whatever nature arising out of the subcontractor's performance of work under this Agreement, to the
extent allowed and required by law. The Recipient shall document in the quarterly report the
subcontractor's progress in performing its wOfk under this Agreement.
For each subcontract, the Recipient shall provide a written statement to the Division as to
whether that subcontractor is a minority vendor, as defined in Section 288.703, Fla. Stat.
(15) TERMS AND CONDITIONS
This Agreement contains all the tenns and conditions agreed upon by the parties.
(16) ATTACHMENTS
(a) All attachments to this Agreement are incorporated as if set out fully.
(b) In the event of any inconsistencies or conflict between the language of this
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Agreement and the attachments, the language of the attachments shall control, but only to the extent of
the conflicl or inconsistency.
(c) This Agreement has the following attachments:
Exhibit 1 - Funding Sources
Attachment A - Budget and Scope of Work
Attachment B - Program Statutes and Regulations
Attachment C - Statement of Assurances
Attachment D - Request for Reimbursement
Attachment E - Justification of Advance Payment
Attachment F - Quarterly Report Form
Attachment G - Warranties and Representations
Attachment H - Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion
(17) FUNDING/CONSIDERA TION
(a) This is a cost-reimbursement Agreement. The Recipient shall be reimbursed for
costs incurred in the satisfactory performance of work hereunder in an amount not to exceed $55.980.00
subject to the availability of funds. All requests for reimbursement of administrative costs must be
accompanied by the back-up documentation evidencing all such administrative costs.
(b) Any advance payment under this Agreement is subjecl to Section 216.181 (16),
Fla.Stat.. and is contingent upon the Recipient's acceptance of the rights of the Division under Paragraph
(12}(b) of this Agreement. The amount which may be advanced may not exceed the expected cash
needs of the Recipient within the first three (3) months of the contract term. For a federally funded
contract, any advance payment is also subject to federal OMB Circulars A-87, A-110, A-122 and the Cash
Management Improvement Act of 1990. If an advance payment is requested, the budget data on which
the request is based and a justification statement shall be included in this Agreement as Attachment E.
Attachment E will specify the amount of advance payment needed and provide an explanation of the
necessity for and proposed use of these funds.
An advance payment of $ is requested.
(c) After the initial advance, if any, payment shall be made on a reimbursement basis as
needed. The Recipient agrees to expend funds in accordance with the Budget and Scope of Work,
Attachment A of this Agreement.
If the necessary funds are not available to fund this Agreement as a result of action by the
United States Congress, the federal Office of Management and Budgeting, the State Chief Financial
Officer or under subparagraph (19}(h) of this Agreement, all obligations on the part of the Division to
make any further payment of funds shall terminate, and the Recipient shall submit its closeout report
within thirty days of receiving notice from the Division.
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(18) REPAYMENTS
All refunds or repayments due to the Division under this Agreement are to be made
payable to the order of "Department of Community Affairs", and mailed directly to the following address:
Department of Community Affairs
Cashier
Finance and Accounting
2555 Shumard Oak Boulevard
Tallahassee FL 32399-2100
In accordance with Section 215.34(2), Fla. Stat., if a check or other draft is returned to the
Division for collection, Recipient shall pay the Division a selVice fee of $15,00 or 5% of the face amount of
the returned check or draft, whichever is greater.
(19) MANDATED CONDITIONS
(a) The validity of this Agreement is subject to the truth and accuracy of all the
information, representations, and malerials submitted or provided by the Recipient in this Agreement, in
any later submission or response to a Division request. or in any submission or response to fulfill the
requirements of this Agreement. All of said information, representations, and materials is incorporated by
reference. The inaccuracy of the submissions or any material changes shall, at the option of the Division
and with thirty days written notice to the Recipient, cause the termination of this Agreement and the
release of the Division from all its obligations to the Recipient.
(b) This Agreement shall be construed under the laws of the State of Florida, and venue
for any actions arising out of this Agreement shall be in the Circuit Court of Leon County. If any provision
of this Agreement is in conflict with any applicable statute or rule, or is unenforceable. then the provision
shall be null and void to the extent of the conflict, and shall be severable, but shall not invalidate any other
provision of this Agreement.
(c) Any power of approval or disapproval granted to the Division under the terms of this
Agreement shall sUlVive the term of this Agreement.
(d) The Agreement may be executed in any number of counterparts, anyone of which
may be taken as an original.
(e) The Recipient agrees to comply with the Americans With Disabilities Act (Public Law
101-336,42 U.S.C. Section 12101 et sea.), which prohibits discrimination by public and private entities on
the basis of disability in employment, public accommodations, transportation, State and local government
selVices, and telecommunications.
(f) Those who have been placed on the convicted vendor list following a conviction for a
public entity crime or on the discriminatory vendor list may not submit a bid on a contract to provide any
goods or selVices to a publiC entity, may not submit a bid on a contract with a public entity for the
construction or repair of a public building or public work, may not submit bids on leases of real property to
a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or
10
16D5
consultant under a contract with a public entity, and may not transact business with any public entity in
excess of $25,000.00 for a period of 36 months from the date of being placed on the convicted vendor list
or on the discriminatory vendor list.
(g) Any Recipient which is not a local government or state agency, and which receives
funds under this Agreement from the federal government, certifies, to the best of its knowledge and belief,
that it and its principals:
1. are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by a federal department or agency;
2. have not, within a five-year period preceding this proposal been convicted of or
had a civil judgment rendered against them for fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or contract under public
transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving stolen property;
3. are not presently indicted or otherwise criminally or civilly charged by a
governmental entity (federal, state or local) with commission of any offenses enumerated in paragraph
19(9)2. of this certification; and
4. have not within a five-year period preceding this Agreement had one or more
public transactions (federal, state or local) terminated for cause or default.
If the Recipient is unable to certify to any of the statements in this certification, then the
Recipient shall attach an explanation to this Agreement.
In addition, the Recipient shall send to the Division (by email or by facsimile
transmission) the completed "Certification Regarding Debarment, Suspension, Ineligibility And
Voluntary Exclusion" (Attachment H) for each Intended subcontractor which Recipient plans to
fund under this Agreement. The form must be received by the Division before the Recipient
enters Into a contract with any subcontractor.
(h) The State of Florida's performance and obligation to pay under this Agreement is
contingent upon an annual appropriation by the Legislature, and subject to any modification in
accordance with Chapter 216, Fla. Stat. or the Florida Constitution.
(i) All bills for fees or other compensation for services or expenses shall be submitted in
detail sufficient for a proper preaudit and postaudit thereof.
(j) Any bills for travel expenses shall be submitted in accordance with Section 112.061,
Fla. Stat.
(k) The Division reserves the right to unilaterally cancel this Agreement if the Recipient
refuses to allow public access to all documents, papers, letters or other material subject to the provisions
of Chapter 119, Fla. Stat., which the Recipient created or received under this Agreement.
(I) If the Recipient is allowed to temporarily invest any advances of funds under this
11
J6D5
Agreement, any interest income shall either be returned to the Division or be applied against the
Division's obligation to pay the contract amount.
(m) The State of Florida will not intentionally award publicly-funded contracts to any
contractor who knowingly employs unauthorized alien workers, constituting a violation of the employment
provisions contained in 8 U.S.C. Section 1324a(e) [Section 274A(e) of the Immigration and Nationality Act
("INA")]. The Division shall consider the employment by any contractor of unauthorized aliens a violation
of Section 274A(e) of the INA. Such violation by the Recipient of the employment provisions contained in
Section 274A(e) of the INA shall be grounds for unilateral cancellation of this Agreement by the Division.
(n) The Recipient is subject to Florida's Government in the Sunshine Law (Section
286.011. Fla. Stat. ) with respect to the meetings of the Recipient's governing board or the meetings of
any subcommittee making recommendations to the governing board. All of these meetings shall be
publicly noticed, open to the public, and the minutes of all the meetings shall be public records, available
to the public in accordance with Chapter 119, Fla. Stat.
(0) All unmanufactured and manufactured articles, materials and supplies which are
acquired for public use under this Agreement must have been produced in the United States as required
under 41 U.S.C. 10a, unless it would not be in the public interest or unreasonable in cost.
(20) LOBBYING PROHIBITION
(a) No funds or other resources received from the Division under this Agreement may be
used directly or indirectly to influence legislation or any other official action by the Florida Legislature or
any state agency.
(b) The Recipient certifies. by its signature to this Agreement. that to the best of his or
her knowledge and belief:
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 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 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 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 Recipient shall complete
and submit Standard Form-LLL, "Disclosure Form to Report Lobbying."
3. The Recipient shall require that this certification be included in the award
documents for all subawards (including subcontracts, subgrants, and contracts under grants, loans, and
12
1605
cooperative agreements) and that all subrecipients shall certify and disclose.
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. Code. 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.
(21) COPYRIGHT. PATENT AND TRADEMARK
ANY AND ALL PATENT RIGHTS ACCRUING UNDER OR IN CONNECTION WITH
THE PERFORMANCE OF THIS AGREEMENT ARE HEREBY RESERVED TO THE STATE OF
FLORIDA. ANY AND ALL COPYRIGHTS ACCRUING UNDER OR IN CONNECTION WITH THE
PERFORMANCE OF THIS AGREEMENT ARE HEREBY TRANSFERRED BY THE RECIPIENT TO
THE STATE OF FLORIDA.
(a) If the Recipient has a pre-existing patent or copyright, the Recipient shall retain all
rights and entitlements to that pre-existing patent or copyright unless the Agreement provides otherwise.
(b) If any discovery or invention is developed in the course of or as a result of work or
services performed under this Agreement, or in any way connected with it, the Recipient shall refer the
discovery or invention to the Division for a determination whether the State of Florida will seek patent
protection in its name. Any patent rights accruing under or in connection with the performance of this
Agreement are reserved to the State of Florida. If any books, manuals, films, or other copyrightable
material are produced, the Recipient shall notify the Division. Any copyrights accruing under or in
connection with the performance under this Agreement are transferred by the Recipient to the State of
Florida.
(c) Within thirty days of execution of this Agreement, the Recipient shall disclose all
intellectual properties relating to the performance of this Agreement which he or she knows or should
know could give rise to a patent or copyright. The Recipient shall retain all rights and entitlements to any
pre-existing intellectual property which is disclosed. Failure to disclose will indicate that no such property
exists. The Division shall then, under Paragraph (b), have the right to all patenls and copyrights which
accrue during performance of the Agreement.
(22) LEGAL AUTHORIZATION
The Recipient certifies that it has the legal authority to receive the funds under this
Agreement and that its governing body has authorized the execution and acceptance of this Agreement.
The Recipient also certifies that the undersigned person has the authority to legally execute and bind
Recipient to the terms of this Agreement.
(23) ASSURANCES
The Recipient shall comply with any Statement of Assurances incorporated as
Attachment C.
13
16D5
IN WITNESS WHEREOF, the parties hereto have executed this Agreement.
RECIPIENT: COUIER COUNTY "A,,J.., W c. _. ~ ".
BY: :...a=
Name and title: Fred W. Coyle, Chairman
Date:
FID#
~
E....... .~ ~
,,~~hC
. ,~,. .-
AU-It 4t.._~.ia.- -
t. . . ,;.I . <..r. .~~....
6 tNt~..~h ":':;, '
~ ,. -'. . " ,\..
;., - ....."... ~ ,,\~--;,
'li",1.J.:'J -.'-~ -.
...,. . .,JW ~ .
STATE OF FLORIDA
DIVISION OF EMERGENCY MANAGEMENT
BY:
Date:
Name and Title: David Halstead, Director
ApproVed as to form & legal SuffIciency
\'\~"L '""'-I '-y
U L.J"\.....)~
AssIstant County Attorna}
14
16D5
EXHmIT - 1
THE FOLLOWING FEDERAL RESOURCES ARE AWARDED TO THE RECIPIENT UNDER THIS
AGREEMENT:
NOTE: "the resources awarded to the Recipient are from more than one Federal program, provide
the same infonnation shown below for each Federal program and show total Federal resources
awarded.
Federal Program: Federal Emergency Management Agency, Hazard Mitigation Grant
Catalog of Federal Domestic Assistance Number: 97.039
Amount of Federal Funding: $55,980.00
THE FOLLOWING COMPLIANCE REQUIREMENTS APPLY TO THE FEDERAL RESOURCES
AWARDED UNDER THIS AGREEMENT:
NOTE: "the resources awarded to the Recipient represent more than one Federal program, list
applicable compliance requirements for each Federal program in the same manner as shown
below.
Federal Program:
List applicable compliance requirements as follows:
1. Recipient Is to use funding to perform the following eligible activities; Include mitigation
projects that will result In protection of public or private property from natural hazards.
Eligible projects Include, but are not limited to:
. Acquisition of hazard prone properties
. Retrofitting of existing buildings and facilities
. Elevation of flood prone structures
. Infrastructure protection measures
. Stonn water management improvements
. Minor structural flood control projects
. Relocation of structures from hazard prone areas
. Retrofitting of existing buildings and facilities for shelters
. Vegetative managementlsoil stabilization
. Mitigation Planning Project
. Other projects that reduce future disaster losses
2. Recipient is subject to all administrative and financial requirements as set forth In this
Agreement, or will be In violation of the terms of the Agreement.
NOTE: Instead of listing the specific compliance requirements as shown above, the State awarding
agency may elect to use language that requires the Recipient to comply with the requirements of
applicable provisions of specific laws, rules, regulations, etc. For example, for Federal Program 1, the
language may state that the Recipient must comply with specific laws, rules, or regulations that pertain to
how the awarded resources must be used or how eligibility determinations are to be made. The State
awarding agency, if practical, may want to attach a copy of the specific law, rule. or regulation referred to.
NOTE: Section .400(d) of OMS Circular A-133, as revised, and Section 215.97(5)(a), Florida Statutes,
require that the information about Federal Programs and State Projects included in Exhibit 1 be provided
to the Recipient.
15
1605
Attachment A
Budget and Scope of Work
ScoDe of Work
As a Hazard Mitigation Grant Program project, the Recipient, Collier County, shall wind retrofit two (2)
buildings located at 3500 Thomasson Drive, Naples, Florida 34112. Specifically, the entire facility will be
protected with a waterproof membrane Yz inch Durak Panel and % in stucco to be installed 1 foot below
and shall extend 2 feet above grade around the two buildings' exterior finish. The two buildings are as
follows:
1. East Naples Community Center by purchasing and installing motorized roll-down shutters and
waterproofing.
2. Senior Center by waterproofing.
Glazing in buildings shall be impact resistant or protected with an impact resistant covering meeting
the requirements of SSTD 12, ASTM E 1886 and ASTM E 1996, ANSI/DASMA 115 (for garage doors
and rolling doors) or Miami-Dade TAS 201, 202 and 203 or AAMA 506 referenced therein as follows:
a) Glazed openings located within 30 feet (9. 1 m) of grade shall meet the
requirements of the Large Missile Test.
b) Glazed openings located more than 30 feet (9. 1 m) above grade shall meet
the provisions of the Small Missile Test.
c) Louvers protecting intake and exhaust ventilation ducts not assumed to be
open that are located within 30 feet (9144 mm) of grade shall meet
requirements of the Large Missile Test.
Impact-resistant coverings shall be tested at 1.5 times the design pressure (positive or
negative) expressed in pounds per square feet as determined by the Florida Building Code,
Building Section1609 for which the specimen is to be tested.
It deemed necessary, wind protection will be provided on any other openings such as skylights. vents,
louvers and exhaust fans. The components used for this wind retrofit will meet the Florida Building Code
specifications. All materials will be certified to meet the wind and impact standards tor wind up to 150
mph. The local municipal or county building department will inspect and certify installation according to
the manufacturer's specifications.
This is FEMA Project 1785-028-R, funded under 1785-DR-FL.
The Period of Performance for this project ends on August 12, 2012.
Schedule of Work
Design and Engineering:
Permitting:
Bidding Process:
Installation:
Final Inspection:
Weather Delav:
Total Period of Perfonnance
4 Months
3 Months
3 Months
7 Months
4 Months
3 Months
24 Months
The materials and work funded pursuant to this Subgrant Agreement are intended to decrease the
vulnerabifity of the building to property losses and are specifically not intended to provide for the safety of
inhabitants before, during or after a natural man made disaster.
16
16D5 J
The funding provided by the Division of Emergency Management under this subgrant shall compensate
for the materials and labor for the installation of storm shutters and/or other hardening activities as a
retrofit measure for the Recipient's building to reduce and/or mitigate the damage that might otherwise
occur from severe weather or other hazards. The funding of this project by the Department does not
confer or imply any warranty of use or suitability for the work performed pursuant to this agreement. The
State of Florida disclaims all warranties with regard to this mitigation project, express or implied, including
but not limited to, any implied warranties and/or conditions of satisfactory quality and fitness for a
particular purpose, merchantability, or merchantable quality.
This project has not been evaluated by the criteria contained in the standards of the Department of
Homeland Security, Federal Emergency Management Agency (FEMA) guidance manual FEMA 361-
Design and Construction for Community Shelter, and tllUS does not provide "near absolute protection.' It
is understood and agreed by the Department and the Recipient that the building may have vulnerabilities
due to age, design and location which may result in damage to the building from wind events even after
the installation of the mitigation measures funded under this Subgrant Agreement. It is further understood
and agreed by the Department and the Recipient that the level of wind protection provided by the
mitigation action, although meeting State standards and codes and enhancing the structural integrity of
the building, does not ensure the safety of survival of building occupants.
Budaet
Line Item Budaet*
Project Cost
$38,373.00
$35,000.00
$ 1,267.00
$74,640.00
Federal Share
$28,780.00
$26,250.00
$ 950.00
$55,980.00
Local Share
$ 9,593.00
$ 8,750.00
$ 317.00
$18,660.00
Materials:
Labor:
Fees:
Total:
* Any line item amount in this Budget may be increased or decreased 10% or less without an amendment
to this Agreement being required, so long as the overall amount of the funds Obligated under this
Agreement is not increased.
Funding Summary
Federal Share:
Local Share:
Total Project Cost"
$55.980.00 (75%)
$18.660.00 (25%)
$74,640.00 (100%)
UThe project cost is inclusive of administrative cost.
17
08112/2010
12:36
FEOEA.\L ElfERGl!NCY IlANAGl!MEMT AOEftCY
HAZARD IIITIGATIOH GRANTS PROGRAM
0bIlQMi0n RlIpol't wi Slgrgbtrn
'oD5
OiInWr FeMA Amertdrnilnt ~
No PtqIct MIa No AppIicatIan 10
1786 28.R 0 22
Subgrantw C'" (COUIlty)
Su~ FIPS Coda: 021-88021
Action Suppl8mllfllal
No No SIll.
31 Fl. ShiMide
Project TIIa: ~rCounty, e.t Naples C<lmmunty ClIllllr, Wind R8Irt:lIt
Gtutee
Total Amount
PrwitMlltt AIIocad
S55.UO
Total Amount
PtevlollelyOblipted
T"1omou~
Pending ODIig1t1on
Total Amount AAiIII*
lor Netw Obllgnon
$U.eeo
$0
$0
PftljKt Amount
$55.9150
o..n... Admin Est
~Adm" Est
TataI 0tI11g1llon IFMlS 0... If\IS &nit FY
so
so
155,980 0811212010
~ 2010
eonun...ta
on: 081'1012010
u.r lei; VGEER
CammlInt: per 1fle sr.te Gf floQdII. oblicIate ~ funcM for prajtcl implernlfUllon
OalB: 0811212010
User 10 DIUlKETT
~rrlW1l: CClIlar county. E-t NIpIa Comm~itr Centllf. WInd R_1roIl ~ed HMO
Aulhaolulb1
Preperer NaIM: 'IlCTOR GEER
Pt'epllration Date: 08l1CW2Q10
HMO AulhoriutJon Date: 08/1212010
....0 AUIt1OriZIIUon N8me: O~ 9URtCETI'
~~=
CJ.ije}j #./hfA ~~
Authorizing Official Title
,~ ).2 - l'b
Authonzatfor1 Dale
_ Authorizing Official Signature
Auttlorizlng Otnci8l Title
Authorization Date
17A
16D5
Attachment B
Program Statutes and Regulations
The parties to this Agreement and the Hazard Mitigation Grant Program (HMGP) are generally
governed by the following statutes and regulations:
(1) The Robert T. Stafford Disaster Relief and Emergency Assistance Act;
(2) 44 CFR Parts 7,9,10,13,14,17,18,25,206,220, and 221, and any other applicable
FEMA policy memoranda and guidance documents;
(3) State of Florida Administrative Plan for the Hazard Mitigation Grant Program;
(4) Hazard Mitigation Long-term Recovery Guidance; and
(5) All applicable laws and regulations delineated in Attachment C of this Agreement
In addition to the above statues and regulations, the Recipient must comply with the following:
The Recipient shall fully perform the approved hazard mitigation project, as described
in the Application and Attachment A (Budget and Scope of Wor1<) attached to this Agreement, in
accordance with the approved scope of wor1< indicated therein, the estimate of costs indicated therein, the
allocation of funds indicated therein, and the terms and conditions of this Agreement. Recipient shall not
deviate from the approved project and the terms and conditions of this Agreement. Recipient shall
comply with any and all applicable codes and standards in performing wor1< funded under this Agreement,
and shall provide any appropriate maintenance and security for the project.
Any development permit issued by, or development activity undertaken by, the Recipient
and any land use permitted by or engaged in by the Recipient, shall be consistent with the local
comprehensive plan and land development regulations prepared and adopted pursuant to Chapter 163,
Part II, Florida Statutes. Funds shall be expended for, and development activities and land uses
authorized for, only those uses which are permitted under the comprehensive plan and land development
regulations. The Recipient shall be responsible for ensuring that any development permit issued and any
development activity or land use undertaken is, where applicable, also authorized by the Water
Management District, the Florida Department of Environmental Protection, the Florida Department of
Health, the Florida Game and Fish Commission, and any federal, state, or local environmental or land
use permitting authority, where required. Recipient agrees that any repair or construction shall be in
accordance with applicable standards of safety, decency, and sanitation, and in conformity with
applicable codes, specifications and standards.
Recipient will provide and maintain competent and adequate engineering supervision at the
construction site to ensure that the completed worl< conforms with the approved plans and specifications
and will furnish progress reports and such other information to HMGP as may be required.
If the hazard mitigation project described in Attachment A includes an acquisition or relocation
project, then Recipient shall ensure that, as a condition of funding under this Agreement, the owner of the
affected real property shall record in the public records of the county where it is located the following
covenants and restrictions, which shall run with and apply to any property acquired, accepted, or from
which a structure will be removed pursuant to the project:
1. The property will be dedicated and maintained in perpetuity for a use that is compatible
with open space, recreational, or wetlands management practices;
2. No new structure will be erected on pfoperty other than:
18
16D5
(a) a public facility that is open on all sides and functionally related to a
designated open space;
(b) a restroom; or
3. A structure that the Director of the Federal Emergency Management Agency approves in
writing before the commencement of the construction of the structure;
4. After the date of the acquisition or relocation no application for disaster assistance for any
purpose will be made to any Federal entity and no disaster assistance will be provided for
the property by any Federal source; and
5. If any of these covenants and restrictions is violated by the owner or by some third party
with the knowledge of the owner, fee simple title to the Property described herein shall be
conveyed to the Board of Trustees of the Internal Improvement Trust Fund of the State of
Florida without further notice to the owner, its successors and assigns, and the owner, its
successors and assigns shall forfeit all right. title and interest in and to the property.
HMGP Contract Manager will evaluate requests for cost overruns and submit to the Regional
Director written determination of cost overrun eligibility. Cost overruns shall meet Federal regulations set
forth in 44CFR 206.438(b).
The National Environmental Policy Act (NEPA) stipulates that additions or amendments to a
HMGP Recipient Scope of Work (SOW) shall be reviewed by all State and Federal agencies participating
in the NEPA process. You are reminded that no construction may occur in this phase, that a full
environmental review must be completed prior to funding Phase II.
As a reminder, the Recipient must obtain prior approval from the State, before implementing
changes to the approved project Scope of Work (SOW). Per the Uniform Administrative Requirements for
Grants and Cooperative Agreements to State and Local Governments:
1. For construction projects. the grantee must "obtain prior written approval for any budget
revision which result in a need for additional funds" (44 CFR 13 (c));
2. A change in the scope of work must be approved by FEMA in advance regardless of the
budget implications; and
3. The Recipient must notify the State as soon as significant developments become known,
such as delays or adverse conditions that might raise costs or delay completion, or favorable
conditions allowing lower cost or earlier completion. Any extensions of the period of
performance must be submitted to FEMA 60 days prior to the project expiration date.
STATEMENT OF ASSURANCES
The Recipient assures that it will comply with the following statues and regulations. to the extent
applicable:
1) 53 Federal Register 8034
2) Federal Acquisition Regulations 31.2 and 031.2
3) Section 1352, Title 31, US Code
4) OMB Circulars A-21. A-87, A-110. A-122
5) Chapter 473, Florida Statutes
6) Chapter 215. Florida Statutes
7) Section 768.28, Florida Statutes
8) Chapter 119, Florida Statutes
9) Section 216.181 (6), Florida Statutes
10) Cash Management Improvement Act Of 1990
11) American with Disabilities Act
12) Section 112.061, Florida Statutes
13) Immigration and Nationality Act
19
16D5
14) Section 286.011, Florida Statutes
15) E.O. 12372 and Uniform Administrative Requirements for Grants and Cooperative Agreements
28 CFR, Part 66, Common rule,
16) Uniform Relocation Assistance and Real Property Acquisitions Act of 1970
17) Title I of the Omnibus Crime Control and Safe Streets Act of 1968,
18) Juvenile Justice and Delinquency Prevention Act, or the Victims of Crime Act
19) 28 CFR applicable to grants and cooperative agreements
20) Omnibus Crime Control and Safe Streets Act of 1968, as amended,
21) 42 USC 3789(d), or Victims of Crime Act (as appropriate);
22) Section 504 of the Rehabilitation Act of 1973, as amended;
23) Subtitle A, Title II of the Americans with Disabilities Act (ADA) (1990);
24) 28 CFR Part 42, Subparts C,D,E, and G
25) Department of Justice regulations on disability discrimination, 28 CFR Part 35 and Part 39.
20
16D5
Attachment C
Statement of Assurances
To the extent the following provisions apply to this Agreement, the Recipient certifies that:
(a) It possesses legal authority to enter into this Agreement, and to carry out the proposed program;
(b) Its governing body has duly adopted or passed as an official act a resolution, motion or similar
action authorizing the execution of the hazard mitigation agreement with the Division of
Emergency Management (OEM), including all understandings and assurances contained in it,
and directing and authorizing the Recipient's chief administrative officer or designee to act in
connection with the application and to provide such additional information as may be required:
(c) No member of or delegate to the Congress of the United States, and no Resident Commissioner,
shall receive any share or part of this Agreement or any benefit. No member, officer, or
employee of the Recipient or its designees or agents, no member of the governing body of the
locality in which the program is situated, and no other public official of the locality or localities who
exercises any functions or responsibilities with respect to the program during his tenure or for one
year after, shall have any interest, direct or indirect, in any contract or subcontract. or the
proceeds, for work be performed in connection with the program assisted under this Agreement.
The Recipient shall incorporate, in all contracts or subcontracts a provision prohibiting any
interest pursuant to the purpose stated above:
(d) All Recipient contracts for which the State Legislature is in any part a funding source, shall
contain language to provide for termination with reasonable costs to be paid to the Recipient for
eligible contract work completed prior to the date the notice of suspension of funding was
received by the Recipient. Any cost incurred after a notice of suspension or termination is
received by the Recipient may not be funded with funds provided under this Agreement unless
previously approved in writing by the Division. All Recipient contracts shall contain provisions for
termination for cause or convenience and shall provide for the method of payment in such event;
(e) It will comply with:
(1) Contract Work Hours and Safety Standards Act of 1962, 40 U.S.C. 327 et seq., requiring
that mechanics and laborers (including watchmen and guards) employed on federally
assisted contracts be paid wages of not less than one and one-half
times their basic wage rates for all hours worked in excess of forty hours in a work week;
and
(2) Federal Fair Labor Standards Act, 29 U.S.C. Section 201 et seq., requiring that covered
employees be paid at least the minimum prescribed wage, and also that they be paid one
and one-half times their basic wage rates for all hours worked in excess of the prescribed
work-week.
(f) It will comply with:
(1) Title VI of the Civil Rights Act of 1964 (P.L. 88-352), and the regulations issued pursuant
thereto. which provides that no person in the United States shall on the grounds of race,
color, or national origin, be excluded from participation in, be denied the benefits of, or be
otherwise subjected to discrimination under any program or activity for which the
Recipient receives Federal financial assistance and will immediately take any measures
necessary to effectuate this assurance. If any real property or structure thereon is
provided or improved with the aid of Federal financial assistance extended to the
Recipient, this assurance shall obligate the Recipient, or in the case of any transfer of
such property, any transferee, for the period during which the real property or structure is
21
16D5
used for a purpose for which the Federal financial assistance is extended, or for another
purpose involving the provision of similar services or benefits;
(2) Any prohibition against discrimination on the basis of age under the Age Discrimination
Act of 1975, as amended (42 U.S.C.: 6101-6107) which prohibits discrimination on the
basis of age or with respect to otherwise qualified handicapped individuals as provided in
Section 504 of the Rehabilitation Act of 1973;
(3) Executive Order 11246 as amended by Executive Orders 11375 and 12086, and the
regulations issued pursuant thereto, which provide that no person shall be discriminated
against on the basis of race, color, religion, sex or national origin in all phases of
employment during the performance of federal or federally assisted construction
contracts; affinnative action to insure fair treatment in employment, upgrading, demotion,
or transfer; recruitment or recruitment advertising; layoff/termination, rates of payor other
forms of compensation; and election for training and apprenticeship;
(g) It will establish safeguards to prohibit employees from using positions for a purpose that is or
gives the appearance of being motivated by a desire for private gain for themselves
or others, particularly those with whom they have family, business, or other ties pursuant to
Section 112.313 and Section 112.3135, FS;
(h) It will comply with the Anti-Kickback Act of 1986, 41 U.S.C. Section 51 which outlaws and
prescribes penalties for "kickbacks" of wages in federally financed or assisted construction
activities;
(i) It will comply with the provisions of 18 USC 594, 598, 600-605 (further known as the Hatch Act)
which limits the political activities of employees;
(j) It will comply with the flood insurance purchase and other requirements of the Flood Disaster
Protection Act of 1973 as amended, 42 USC 4002-4107, including requirements regarding the
purchase of flood insurance in communities where such insurance is available as a condition for
the receipt of any Federal financial assistance for construction or acquisition purposes for use in
any area having special flood hazards. The phrase "Federal financial assistance" includes any
form of loan, grant, guaranty, insurance payment, rebate, subsidy, disaster assistance loan or
grant, or any other form of direct or indirect Federal assistance;
(k) It wilt require every building or facility (othef than a privately owned residential structure)
designed, constructed, or altered with funds provided under this Agreement to comply with the
"Unifonn Federal Accessability Standards," (AS) which is Appendix A to 41 CFR Section 101-
19.6 for general type buildings and Appendix A to 24 CFR Part 40 for residential structures. The
Recipient will be responsible for conducting inspections to ensure compliance with these
specifications by the contractor;
(I) It will, in connection with its performance of environmental assessments under the National
Environmental Policy Act of 1969, comply with Section 106 of the National Historic Preservation
Act of 1966 (U.S.C. 470), Executive Order 11593, 24 CFR Part 800, and the Preservation of
ArChaeological and Historical Data Act of 1966 (16 U.S.C. 469a-1, et seq.) by:
(1) Consulting with the State Historic Preservation Office to identify properties listed
in or eligible for inclusion in the National Register of Historic Places that are
subject to adverse effects (see 36 CFR Section 800.8) by the proposed activity;
and
(2) Complying with all requirements established by the State to avoid or mitigate
22
16D5
adverse effects upon such properties,
(3) Abiding by the terms and conditions of the "Programmatic Agreement Among
the Federal Emergency Management Agency, the Florida State Historic
Preservation Office, the Florida Division of Emergency Management and
the Advisory Council on Historic Preservation, (PA)" which addresses roles
and responsibilities of Federal and State entities in implementing Section 1 06 of
the National Historic Preservation Act (NHPA), 16 U.S.C. 470f, and implementing
regulations in 36 CFR part 800.
(4) When any of Recipient's projects funded under this Agreement may affect a
historic property, as defined in 36 CFR 800. (2)(e), the Federal Emergency
Management Agency (FEMA) may require Recipient to review the eligible scope
of work in consultation with the State Historic Preservation Office (SHPO) and
suggest methods of repair or construction that will conform with the
recommended approaches set out in the Secretary of Interior's Standards for
Rehabilitation and Guidelines for Rehabilitating Historic Buildings 1992
(Standards), the Secretary of the Interior's Guidelines for Archeological
Documentation (Guidelines) (48 Federal Register 44734-37), or any other
applicable Secretary of Interior standards. If FEMA determines that the eligible
scope of work will not conform with the Standards, Recipient agrees to
participate in consultations to develop, and, after execution by all parties, to
abide by, a written agreement that establishes mitigation and recondition
measures, including but not limited to, impacts to archeological sites, and the
salvage, storage. and reuse of any significant architectural features that may
otherwise be demolished,
(5) Recipient agrees to notify FEMA and the Division if any project funded under this
Agreement will involve ground disturbing activities, including, but not limited to:
subsurface disturbance; removal of trees; excavation for footings and
foundations; and installation of utilities (such as water, sewer, storm drains,
electrical, gas, leach lines and septic tanks) except where these activities are
restricted solely to areas previously disturbed by the installation, replacement or
maintenance of such utilities, FEMA will request the SHPO's opinion on the
potential that archeological properties may be present and be affected by such
activities. The SHPO will advise Recipient on any feasible steps to be
accomplished to avoid any National Register eligible archeological property or
will make recommendations for the development of a treatment plan for the
recovery of archeological data from the property.
If Recipient is unable to avoid the archeological property, develop, in consultation
with the SHPO, a treatment plan consistent with the Guidelines and take into
account the Advisory Council on Historic Preservation (Council) publication
"Treatment of Archeological Properties", Recipient shall forward information
regarding the treatment plan to FEMA, the SHPO and the Council for review. If
the SHPO and the Council do not object within 15 calendar days of receipt of the
treatment plan, FEMA may direct Recipient to implement the treatment plan. If
either the Council or the SHPO object, Recipient shall not proceed with the
project until the objection is resolved.
(6) Recipient shall notify the Division and FEMA as soon as practicable: (a) of any
changes in the approved scope of work for a National Register eligible or listed
property; (b) of all changes to a project that may result in a supplemental DSR or
modify an HMGP project for a National Register eligible or listed property; (c) if it
appears that a project funded under this Agreement will affect a previously
23
16D5
unidentified property that may be eligible for inclusion in the National Register or
affect a known historic property in an unanticipated manner. Recipient
acknowledges that FEMA may require Recipient to stop construction in the
vicinity of the discovery of a previously unidentified property that may be eligible
for inclusion in the National Register or upon learning that construction may
affect a known historic property in an unanticipated manner. Recipient further
acknowledges that FEMA may require Recipient to take all reasonable measures
to avoid or minimize harm to such property until FEMA concludes consultation
with the SHPO. Recipient also acknowledges that FEMA will require, and
Recipient shall comply with, modifications to the project scope of work necessary
to implement recommendations to address the project and the property.
(7) Recipient acknowledges that, unless FEMA specifically stipulates otherwise, it
shall not receive funding for projects when, with intent to avoid the requirements
of the PA or the NHPA, Recipient intentionally and significantly adversely affects
a historic property, or having the legal power to prevent it, allowed such
significant adverse affect to occur.
(m) It will comply with Title IX of the Education Amendments of 1972, as amended (20 U.S.C.: 1681-
1683 and 1685 - 1686) which prohibits discrimination on the basis of sex;
(n) It will comply with the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970, (42 U.S.C. 4521-45-94) relating to nondiscrimination on the basis of
alcohol abuse or alcoholism;
(0) It will comply with 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and
290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records;
(p) It will comply with Lead-Based Paint Poison Prevention Act (42 U.S.C.: 4821 et seq.) which
prohibits the use of lead based paint in construction of rehabilitation or residential structures;
(q) It will comply with the Energy Policy and Conservation Act (P.L. 94-163; 42 U.S.C. 6201-6422),
and the provisions of the state Energy Conservation Plan adopted pursuant thereto;
(r) It will comply with the Laboratory Animal Welfare Act of 1966. 7 U.S.C. 2131-2159, pertaining to
the care, handling, and treatment of warm blooded animals held for research, teaching, or other
activities supported by an award of assistance under this agreement;
(s) It will comply with Title VIII of the Civil Rights Act of 1968,42 U.S.C. 2000c and 423601-3619, as
amended, relating to non-discrimination in the sale, rental, or financing of housing, and Title VI of
the Civil Rights Act of 1964 (P.L. 88-352), which prohibits discrimination on the basis of race,
color or nation origin;
(t) It will comply with the Clean Air Act of 1955, as amended, 42 U.S.C. 7401-7642;
(u) It will comply with the Clean Water Act of 1977, as amended, 42 U.S.C. 7419-7626;
(v) It will comply with the Endangered Species Act of 1973,16 U.S.C. 1531-1544;
(w) It will comply with the Intergovernmental Personnel Act of 1970,42 U.S.C. 4728-4763;
(x) It will assist the awarding agency in assuring compliance with the Nalional Historic Preservation
Act of 1966, as amended, 16 U.S.C. 270;
24
1605
(y) It will comply with environmental standards which may be prescribed pursuant to the National
Environmental Policy Act of 1969,42 U.S.C. 4321-4347;
(z) It will assist the awarding agency in assuring compliance with the Preservation of Archeological
and Historical Preservation Act of 1966, 16 U.S.C. 469a, et seq;
(aa) It will comply with the Rehabilitation Act of 1973. Section 504, 29 U.S.C. 794, regarding non-
discrimination;
(bb) It will comply with the environmental standards which may be prescribed pursuant to the Safe
Drinking Water Act of 1974, 42 U.S.C. 300f-300j, regarding the protection of underground water
sources;
(cc) It will comply with the requirements of Titles II and III of the Uniform Relocation Assistance and
Property Acquisition Policies Act of 1970, 42 U.S.C. 4621-4638, which provide for fair and
equitable treatment of persons displaced or whose property is acquired as a result of Federal or
federally assisted programs;
(dd) It will comply with the Wild and Scenic Rivers Act of 1968, 16 U.S.C. 1271-1287, related to
protecting components or potential components of the national wild and scenic rivers system;
(ee) It will comply with the following Executive Orders: EO 11514 (NEPA); EO 11738 (violating
facilities); EO 11988 (Floodplain Management); EO 11990 (Wetlands); and EO 12898
(Environmental Justice);
(ff) It will comply with the Coastal Barrier Resources Act of 1977,16 U.S.C. 3510;
(gg) It will assure project consistency with the approved State program developed under the Coastal
Zone Management Act of 1972, 16 U.S.C. 1451-1464; and
(hh) It will comply with the Fish and Wildlife Coordination Act of 1958; 16 U.S.C. 661-666.
(ii) With respect to demolition activities, it will:
1. Create and make available documentation sufficient to demonstrate that the Recipient
and its demolition contractor have sufficient manpower and equipment to comply with the
obligations as outlined in this Agreement.
2. Return the property to its natural state as though no improvements had ever been
contained thereon.
3. Furnish documentation of all qualified personnel, licenses and all equipment necessary to
inspect buildings located in Recipient's jurisdiction to detect the presence of asbestos
and lead in accordance with requirements of the U.S. Environmental Protection Agency,
the Florida Department of Environmental Protection and the County Health Department.
4. Provide documentation of the inspection results for each structure to indicate:
a. Safety Hazards Present
b. Health Hazards Present
c. Hazardous Materials Present
5. Provide supervision over contractors or employees employed by Recipient to remove
asbestos and lead from demolished or otherwise applicable structures.
6. Leave the demolished site clean, level and free of debris.
25
16D5
7. Notify the Division promptly of any unusual existing condition which hampers the
contractors work.
8. Obtain all required permits.
9. Provide addresses and marked maps for each site where water wells and septic tanks
are to be closed along with the number of wells and septic tanks located on each site.
Provide documentation of closures.
10. Comply with mandatory standards and policies relating to energy efficiency which are
contained in the State energy conservation plan issued in compliance with the Energy
Policy and Conservation Act (Public Law 94-163).
11. Comply with all applicable standards, orders, or requirements issued under Section 112
and 306 of the Clean Air Act (42 U.S.C. 1857 (h), Section 508 of the Clean Water Act (33
U,S. 1368), Executive Order 11738, and the U.S. Environmental Protection Agency
regulations (40 CFR Part 15 and 61). This clause shall be added to any subcontracts.
12. Provide documentation of public notices for demolition activities.
26
16D5
Attachment D
DIVISION OF EMERGENCY MANAGEMENT
REQUEST FOR ADVANCE OR REIMBURSEMENT OF
HAZARD MITIGATION GRANT PROGRAM FUNDS
RECIPIENT NAME:
Collier County
ADDRESS:
CITY, STATE, ZIP CODE:
PAYMENT No:
DEM Agreement No: 11 HM-3E-09-21-01-005
FEMA T k' N b
1785028 R
rac mo um ers: - -
Eligible Obligated Obligated DEM Use Only
Amount Federal Non-Federal Previous Current
100% 75% 25% Payments Reauest Aooroved Comments
TOTAL CURRENT REQUEST $
I certify that to the best of my knowledge and belief the above accounts are correct, and that all
disbursements were made in accordance with all conditions of the Division agreement and payment is
due and has not been previously requested for these amounts.
RECIPIENT SIGNA lURE
NAME AND
DATE:
TO BE COMPLETED BY DIVISION OF EMERGENCY MANAGEMENT
APPROVED PROJECT TOTAL $
ADMINISTRATIVE COST
$
GOVERNOR'S AUTHORIZED REPRESENTATIVE
APPROVED FOR PAYMENT $
DATE
27
16D5
Attachment D
(continued)
DIVISION OF EMERGENCY MANAGEMENT
SUMMARY OF DOCUMENTATION IN SUPPORT OF AMOUNT
CLAIMED FOR ELIGIBLE DISASTER WORK UNDER THE
HAZARD MITIGATION GRANT PROGRAM
Applicant: Collier County
OEM Agreement No. 11HM-3E.09-21-01-005
Disaster No. 1785
FEMA Tracking # 1785-028-R
Applicant's Date of delivery DOCUMENTATION Applicant's
Reference No. of articles, List Documentation (Applicant's payroll, material out of Eligible Costs
(Warrant, Voucher, completion of applicant's stock, applicant owned equipment and name of 100%
Claim Check, or work or vendor or contractor) by category and line item in the
Schedule No.) performance approved project application and give a brief description of
services. the articles or services.
TOTAL
--_._-_.- ..-" -,-_._--,.,--- -------. -.. ~__ _____u___ . _.._--~-.
28
1605
Attachment E
JUSTIFICATION OF ADVANCE PAYMENT
RECIPIENT:
Indicate by checking one of the boxes below, if you are requesting an advance. If an advance payment is
requested, budget data on which the request is based must be submitted. Any advance payment under this
Agreement is subject to s. 216.181(16). Florida Statutes. The amount which may be advanced shall not exceed
the expected cash needs of the recipient within the initial three months.
[ ] NO ADVANCE REQUESTED
[ ] ADVANCE REQUESTED
No advance payment is requested.
Payment will be solely on a
reimbursement basis. No additional
information is required.
Advance payment of $ is requested. Balance of
payments will be made on a reimbursement basis. These funds
are needed to pay staff, award benefits to clients, duplicate forms
and purchase start~up supplies and equipment. We would not be
able to operate the program without this advance.
ADVANCE REQUEST WORKSHEET
If you are requesting an advance, complete the following worksheet.
DESCRIPTION
(A)
FFY
2008-2009
(B)
FFY
2009-2010
(C)
FFY
2010-2011
(D)
Total
3
1
2
MAXIMUM ADVANCE ALLOWED CALULATION:
x $
Cell 03 HMGP Award
(Do not include match)
=
MAXIMUM
ADVANCE
REQUEST FOR WAIVER OF CALCULATED MAXIMUM
[
] Recipient has no previous HMGP contract history. Complete Estimated Expenses chart
and Explanation of Circumstances below.
] Recipient has exceptional circumstances that require an advance greater than the Maximum
Advance calculated above. Complete estimated expenses chart and Explanation of Circumstances
below. Attach additional pages if needed.
[
29
16D5
ESTIMATED EXPENSES
BUDGET CATEGORY
ADMINISTRATIVE COSTS
PROGRAM EXPENSES
TOTAL EXPENSES
2009.2010.........--- --
Anticipated Expenditures for First Three Months of Contract
ExDlanatlon of Circumstances:
30
16D5
Attachment F
DIVISION OF EMERGENCY MANAGEMENT
HAZARD MITIGATION GRANT PROGRAM
QUARTERLY REPORT FORM
RECIPIENT: Collier County
Project Number # 1785-028-R
PROJECT LOCATION: Wind Retrofit
DEM ID #: 11HM-3E-09-21-01-005
QUARTER ENDING:
DISASTER NUMBER: FEMA-1785-DR-FL
Provide amount of advance funds disbursed for period (if applicable) $
Provide reimbursement projections for this project:
July-Sep, 200_$
July-Sep, 200_$
Oct-Dee, 200_$
Oct-Dee, 200_$
Jan-Mar, 200_$_ Apr-June, 200_$_
Jan-Mar, 200_$
Apr-June, 200_$_
Percentage of Work Completed (may be confirmed by state inspectors):
%
Project Proceeding on Schedule: [] Yes [] No
Describe milestones achieved during this quarter:
Provide a schedule for the remainder of work to project completion:
Describe problems or circumstances affecting completion date, milestones, scope of work, and cost:
Cost Status: [] Cost Unchanged
[] Under Budget
[ ] Over Budget
Additional Comments/Elabofation:
NOTE: Division of Emergency Management (DEM) staff may perform interim inspections and/or audits at
any time. Events may occur between quarterly reports, which have significant impact upon your
project(s), such as anticipated overruns, changes in scope of work, etc. Please contact the Division as
soon as these conditions become known, otherwise you may be found non-compliant with your subgrant
award.
Name and Phone Number of Person Completing This Form
31
16D5
Attachment G
Warranties and Representations
Financial Manaaement
Recipient's financial management system shall provide for the following:
(1) Accurate, current and complete disclosure of the financial results of this project or program
(2) Records that identify the source and use of funds for all activities. These records shall
contain information pertaining to grant awards, authorizations, obligations, unobligated
balances, assets, outlays, income and interest.
(3) Effective control over and accountability for all funds, property and other assets. Recipienl
shall safeguard all such assets and assure that they are used solely for authorized purposes.
(4) Comparison of expenditures with budget amounts for each Request For Payment. Whenever
appropriate, financial information should be related to performance and unit cost data.
(5) Written procedures to determine whether costs are allowed and reasonable under the
provisions of the applicable OMS cost principles and the terms and conditions of this
Agreement.
(6) Cost accounting records that are supported by backup documentation..
ComDetition.
All procurement transactions shall be done in a manner to provide open and free competition. The
Recipient shall be alert to conflicts of interest as well as noncompetitive practices among contractors that
may restrict or eliminate competition or otherwise restrain trade. In order to ensure excellent contractor
performance and eliminate unfair competitive advantage, contractors that develop or draft specifications,
requirements, statements of work, invitations for bids and/or requests for proposals shall be excluded
from competing for such procurements. Awards shall be made to the bidder or offeror whose bid or offer
is responsive to the solicitation and is most advantageous to the Recipient, considering the price, quality
and other factors. Solicitations shall clearly set forth all requirements that the bidder or offeror must fulfill
in order for the bid or offer to be evaluated by the Recipient. Any and all bids or offers may be rejected
when it is in the Recipient's interest to do so.
Codes of conduct.
The Recipient shall maintain written standards of conduct governing the performance of its employees
engaged in the award and administration of conlracts. No employee, officer, or agent shall participate in
the selection, award, or administration of a contract supported by public grant funds if a real or apparent
conflict of interest would be involved. Such a conflict would arise when the employee, officer, or agent,
any member of his or her immediate family, his or her partner, or an organization which employs or is
about to employ any of the parties indicated, has a financial or other interest in the firm selected for an
award. The officers, employees, and agents of the Recipient shall neither solicit nor accept gratuities,
favors, or anything of monetary value from contractors, or parties to subcontracts. The standards of
conduct shall provide for disciplinary actions to be applied for violations of such standards by officers,
employees, or agents of the Recipient.
Business Hours
The Recipient shall have its offices open for business, with the entfance door open to the public, and at
least one employee on site, from 8:00 a.m. to 5:00 p.m., local time, Monday through Friday.
licensina and PermittinQ
All subcontractors or employees hired by the Recipient shall have all current licenses and permits
required for all of the particular work for which they are hired by the Recipient.
32
16D5
Attachment H
Certification Reg_nllng
Debarmel1t.. SU.penslon..I~ellglblllty
. And Volunta'rV Excluilon
.
Contractor Covered Transactions
(1) The prospective contractor of the Recipient, , certifies, by
submission of this document, that neither it nor its principals is presently debarred, suspended.
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department or agency.
(2) Where the Recipient's contractor is unable to certify to the above statement, the prospective
contractor shall attach an explanation to this form.
CONTRACTOR:
By:
Signature
Recipient's Name
Name and Title
Division Contract Number
Street Address
City, State, Zip
Date
33