Backup Documents 07/28/2009 Item #16F 1
ORIGINAL DOCUMENTS CHECKLIST & ROUTING s116 F 1
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office The completed TOuting slip and origll1al
documents are to be forwarded to the Board Office only lifter the Board has taken action on the item.)
ROUTING SLIP
Complete TOuting lines # I through #4 as appropriale lor additional signatures, dates, and/or information needed. [I' the document is already complete with the
exce tion of the Chairman's si nature, draw a line throu h routin lines #[ throu #4, com lete the checklist, and forward to Sue Filson (line #5 .
Route to Addressee(s) Office Initials Date
(List in routin order)
1.
2.
3.
4. Ian Mitchell, Supervisor Board of County Commissioners
5.
6. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pcnding BeC 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 stalffor additional or missing
information. All original documents needing the Bee Chairman's signature are to be delivered to the BCe office only alter the BCe has acted to approve the
item.)
Name of Primary Staff Joshua Thomas Phone Number 252-8989
Contact
Agenda Date Item was 07/28/09 Agenda Item Number 16 F-l
Approved by the BCC
Type of Document Grant Application Number of Original I
Attached Documents Attached
INSTRUCTIONS & CHECKLIST
lnitial the Yes column or mark "N/A" in the Not Applicable column, whichever is Yes N/ A (Not
a ro riate. (Initial) A licable)
1. Original document has been signed/initialed for legal suftlciency. (All documents to be .......
signed by the Chairman, with the exception of most letters, must be reviewed and signed J\
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 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 '-.l"\
3. The Chairman's signature line date has been entered as the date of BCC approval of the
document or the final ne 10tiated contract date whichever is a licable.
4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si nature and initials are re 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 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 BCe's actions are nullitied. Be aware of our deadlines!
6. The document was approved by the Bee on "l'''Z,,",'' (f' renter date) and all changes
made during the meeting have been incorpora ed In the attached document. The
Count Attorne 's Office has reviewed the chan es, if a Iicable.
[: Forms/ County Forms! Bee Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised] .26.05, Revised 2.24.05
16F 1
MEMORANDUM
DATE: July 28, 2009
TO: Josh Thomas,
Administrative Services Dept.
FROM: Teresa Polaski,
Minutes and Records
RE: V olunteer Fire Assistance Grant Application
Enclosed please find one (1) original of the document, as referenced above
(Agenda Item #16Fl), approved by the Board of County Commissioners on July
28, 2009.
If you should have any questions, please contact me at 252-8411.
Thank you.
Enclosures
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16F 1
hA. . Florida Department of Agriculture and Consumer Services ..' .
.. Division of Forestry
~H.BRONSON VOLUNTEER FIRE ASSISTANCE GRANT APPLICATION
COII__
FORM OF ORGANIZATION: (Municipal, Fire District, Non-Profit, County)
Board of Commissioners
ri Blvd. Isles of Ca ri Fire Rescue District
IF COUNTY, LIST VFD'S BENEFITING FROM GRANT:
ZIP 34113
COUNTY #
IS FIRE DEPARTMENT LOCATED IN AN INCORPORATED TOWN? ~___
---- .---____._____ WHAT IS THE FIRE DEPARTMENT ISO RATING? I 4
YES 0 NO mI IF YES, NAME OF TOWN: I
IS FIRE DEPARTMENT NIMS COMPLIANT? YES ~ NO 0
POPULATION OF TOWN: r-----..----
CURRENT COOPERATIVE AGREEMENT WITH DOF? YES KI NO 0
PROTECTED AREA: EST. POPULATlON:r------ SIZE: (SQ. MILES)/
I 3,200 19 DISTANCE OF CLOSEST MUTUAL AID FIRE DEPARTMENT:I) rm.
NAME OF FIRE DEPARTMENT: I
Marco Island
NUMBER OF FIREFIGHTERS: PAID: ~ VOLUNTEERS: [5--- HAS APPLICANT RECEIVED GRANT FUNQ~ FROM ANY SOURCE IN
I 12 THE PAST 12 MONTHS? YES 0 NO Ell
NO. OF INCIDENTS PAST YEAR: WILDLAND FIREr-ii-- OTHER: r-677- IF YES, WHERE? r-----. ___..____H____________________..__
NO. OF FIREFIGHTERS CERTIFIED~~: _ AMOUNT
WILDLAND FIREFIGHTER I r 1:Z WILDLAND FIREFIGHTER 1/ ~ . $ I
LIST TOTAL FUNDS RECEIVED FROM OTHER TAXING AUTHORITIES
SUCH AS CITY, COUNTY, TAXING DISTRICTS (Past 12 Months)
AMOUNT: $ I
LIST OF FIREFIGHTlNG VEHICLES:
TYPE MAKElYR.MODEl PUMP CAPACITY (GPM) WATER CAPACITY (GAl.)
Engine E-Dne 2005 Typhoon 1500 780
Enqine E-Dne 2005 Tvnhoon 1500 780
Brush Humvee 1997 250 310
ESTIMATED GRANT FUNDING REQUEST: LIST OF EQUIPMENT OR SUPPLIES TO PURCHASE WITH GRANT FUNDS:
FEDERAl $ 2. 721. 25 NUMBER DESCRIPTION AMOUNT
APPLICANT $ 2,721. 25 3 VHF Portable Radios 2,460.00
COUNTY $ 5 VHF Mobile Radios 2,982.50
TOTAL $ 5.442 50
(Federal not more than 50% of total. Applicant at least 50% of
total in matching funds.)
We understand that this is a 50 percent maximum cost-share program (Cooperative Forestry Assistance Act of 1978, PL95-313), and that funds on
deposit up to 50 percent of the actual purchase price of the items approved will be committed to our project. TO THE BEST OF MY KNOWLEDGE AND
BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE GOVERNING BODY OF THE APPLICANT HAS DULY AUTHORIZED
THIS DOCUMENT.
Type Name of Authorized Representative Title Chairman. Collier TelephoneNumber: (239 )394-8770
Donna Fiala County Board of County
Commissioners FAX: (239 ) 394-5862 '.'
Date Signed and Submitted 'l-~&-.ct ~ail: ."" " ,Jar., - . .'".'
15 to form & legal sufficiency UO'IV) a F ,~ ,~ ~J:.~o'i',~, ~ t.;sOlJi:.!J)
t. .' . .
~ DWIGHT E. BAtlC~k
:leen Greene, '-:) '., . ".. '"
ItCount~~~~~_"__. ~.~~. ..' ., '. .
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OMB Approval No. 0348-0040
ASSURANCES - NON-CONSTRUCTION PROGRAMS
Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency.
Further, certain Federal awarding agencies may require applicants to certifY to additional assurances. If such is the case, you will be
notified.
As the dulv authorized representative of the applicant I certifY that the apolicant:
I. Has the legal authority to apply for Federal assistance, and the 7. Will comply, or has already complied, with the requirements of
institutional, managerial and financial capability (including funds Titles II and III of the Uniform Relocation Assistance and Real
sufficient to pay the non-Federal share of project costs) to ensure Property Acquisition Policies Act of 1970 (Pol. 961-646) which
proper planning, management and completion of the project provide for fair and equitable treatment of persons displaced or
described in this application. whose property is acquired as a result of Federal or federally assisted
programs. These requirements apply to all interests in real property
2. Will give the awarding agency, the Comptroller General of the acquired for project purposes regardless of Federal participation in
United States, and if appropriate, the State, through any authorized purchases.
representative, access to and the right to examine all records, books,
papers, or documents related to the award; and will establish a proper 8. Will comply with the provisions of the Health Act (5 U.S.c. ~~
accounting system in accordance with generally accepted accounting 1501-1508 and 7324-7328) which limit the political activities of
standards or agency directives. employees whose principal employment activities are funded in
whole or in part with Federal funds.
3. Will establish safeguards to prohibit employees from using
their positions for a purpose that constitutes or presents the 9. Will comply, as applicable, with the provisions of the Oavis-
appearance of personal or organizational conflict of interest, or Bacon Act (40 U.S.C ~~ 276a to 276a-7), the Copeland Act (40
personal gain. U.S.C ~ 276c and 18 USC. ~~ 874), and the Contract Work Hours
and Safety Standards Act (40 U.S.C ~9 327-333), regarding labor
4. Will initiate and complete the work within the applicable time standards for federally assisted construction subagreements.
frame after receipt of approval of the awarding agency.
10. Will comply, if applicable, with flood insurance purchase
5. Will comply with the Intergovernmental Personnel Act of 1970 requirements of Section 102 (a) of the Flood Disaster Protection Act
(42 U.S.C. ~~ 4728-4763) relating to prescribed standards for merit of 1973 (P.L. 93-234) which requires recipients in a special flood
systems for programs funded under one of the nineteen statutes or hazard area to participate in the
regulations specified in Appendix A of OPM's Standards for a Merit program and to purchase flood insurance if the total cost of insurable
System of Personnel Administration (5 CF.R. 900, Subpart F). construction and acquisition of $1 0,000 or more.
6. Will comply with all Federal statutes relating to 11. Will comply with environmental standards which may be
nondiscrimination. These include but are not limited to: (a)Title VI prescribed pursuant to the following: (a) institution of environmental
of the Civil Rights Act of 1964 (Pol. 88-352) which prohibits quality control measures under the National Environmental Policy
discrimination on the basis of race, color or national origin; (b) Title Act of 1969 (P.L. 91-\90) and Executive Order (EO) 11514; (b)
IX of the Education Amendments of \972, as amended (20 U.S.c. ~9 notification of violating facilities pursuant to EO 11738; (c)
1681-1683, and 1685-1686), which prohibits discrimination on the protection of wetlands pursuant to EO 11990; (d) evaluation of flood
basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as hazards in floodplains in accordance with EO 11988; (e) assurance of
amended (29 U.S.C 9 794), which prohibits discrimination on the project consistency with the approved State management program
basis of handicaps; (d) the Age Discrimination Act of 1975, as developed under the Coastal Zone Management Act of 1972 (16
amended (42 U.S.C ~& 6101-6107), which prohibits discrimination U.S.C 99 1451 et seq.); (f) conformity of Federal actions to State
on the basis of age: (Clear Air) Implementation Plans under Section I 76(c) of the Clear
Air Act of 1955, as amended (42 U.S.C 9 7401 et seq.); (g)
(e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92- protection of underground sources of drinking water under the Safe
255), as amended, relating to nondiscrimination on the basis of drug Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h)
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism protection of endangered species under the Endangered Species Act
Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), of 1973, as amended, (P.L. 93-205).
as amended, relating to nondiscrimination on the basis of alcohol
abuse or alcoholism; (g) 99 523 and 527 of the Public Health Service 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16
Act of 1912 (42 USC 290-dd-3 and 290 ee-3), as amended, relating U.S.C ~9 127\ et seq.} related to protecting components or potential
to confidentiality of alcohol and drug abuse patient records; (h) Title components of the national wild and scenic rivers system.
VIII of the Civil Rights Act of 1968 (42 U.S.C ~ 360] et seq.), as V, 8-5 (02105)
amended, relating to nondiscrimination in the sale. rental or financing Authorized for Local Reproduction
of housing; (I) any other nondiscrimination provisions in the specific Standard Form 424B (9-03)Prescribed by OMB Circular A-102
statute(s) under which application for Federal assistance is being
made; and (j) the requirements of any other nondiscrimination
stalute(s) which may apply to the application.
'-"-"-.<
16F 1
research, teaching, or other activities supported by this award of
13. Will assist the awarding agency in assuring compliance with assistance.
Section 106 of the National Historic Preservation Act of 1966, as
amended (16 U.S.C 470), EO 11593 (identification and protection of 16. Will comply with the Lead-Based Paint Poisoning Prevention
historic properties), and the Archeological and Historic Preservation Act (42 U.S.C !is 4801 et seq.) which prohibits the use oflead based
Act of 1974 (16 U.S.C 469a-1 et seq.). paint in construction or rehabilitation ofresidence structures.
14. Will comply with P.L. 93-348 regarding the protection of 17. Will cause to be performed the required financial and
human subjects involved in research, development, and related compliance audits in accordance with the Single Audit Act of 1984.
activities supported by this award of assistance.
18. Will comply with all applicable requirements of all other
IS. Will comply with the Laboratory Animal Welfare Act of 1966 Federal laws, executive orders, regulations and policies governing
(Pol. 89-544, as amended, 7 U.S.C 2131 et seq.) pertaining to the this program.
care, handling, and treatment of warm blooded animals held for
THORIZED CERTIFYING OFFICIAL TITLE ~~\rl'"\o.~
J~
APPLICANT DATE 1 Zlr-<r
<:I \ \', t'r CCJ" ~G.r 0 ~c. CCl\~~ SS ;0'\ rrS SUBMITTED -
V, 8-6 (02/05)
Authorized for Local Reproduction)
Standard Form 424B (9-03
Prescribed by OMB Circular A-I 02
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Approved as to form & legal sufficiency ~ ' J
---1~P~~ . 4
~'
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,.
Colleen Greene,
Assistant County Attorney
-.--;._,..._-- """-~ _._.,~. ---....
16F 1
Form AD-1047 (1/92)
U. S. DEPARTMENT OF AGRICULTURE
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,
7 CFR Part 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part IV of the
January 30, 1989, Federal Rei!ister(pages 4722-4733). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the proposed covered transaction.
(Before completing certification, read instructions on reverse.)
(I) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) have not within a three-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under a
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;
(c) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State or Local) with commission of any of the offenses enumerated in paragraph (I )(b) of this
certification; and
(d) have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State or Local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
: U!iCANIZATIONNAME PRlA WARD NUMBER OR PROJECT NAME
CO l~\ l'r (.oC1(11 y ~~ qr 0 O{.. COP\l\~{.sj~l\l'r S
NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
\) 0 f'tf) q ~ ..
\ q ,~
SIGNATURE DATE
1-2.~-&q
1 .~ ill .. '( ~ ..... ~
< \'<.~.
~.
Approved as to form & legal sufficlerl-';Y ~~).. ..'
-
lL~~
'Jileen reene,
Assistant County Attorney
--=, "'~""_-,""',~
16F 1
Form AD-l 047(1/92) (REVERSE)
INSTRUCTIONS FOR CERTIFICATION
I. By signing and submitting this form, the prospective primary participant is providing the certification set out
on the reverse side in accordance with th.ese instructions.
2. The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective participant shall submit an explanation of why it
cannot provide the certification set out on this form. The certification or explanation will be considered in
connection with the department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such
person from participation in this transaction.
3. The certification in this clause is a material representation offact upon which reliance was placed when the
department or agency determined to enter into this transaction. If it is later determined that the prospective
primary participant knowingly rendered an erroneous certification, in addition to other remedies available to
the Federal Government, the department or agency may terminate this transaction for cause or default.
4. The prospective primary participant shall provide immediate written notice to the department or agency to
whom this proposal is submitted if at any time the prospective primary participant learns that its certification
was erroneous when submitted or has become erroneous by reason of changed circumstances.
5. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as
used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may contact the department or agency to which this proposal is
being submitted for assistance in obtaining a copy of those regulations.
6. The prospective primary participant agrees by submitting this form that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person
who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency entering into this transaction.
7. The prospective primary participant further agrees by submitting this form that it will include this clause
titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier
Covered Transactions," provided by the department or agency entering into this covered transaction, without
modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may, but is not required to,
check the Nonprocurement List.
9. Nothing contained in the foregoing shall be construed to require establishment ofa system of records in order
to render in good faith the certification required by this clause. The knowledge and information ofa
participant is not required to exceed that which is normally possessed by a prudent person in the ordinary
course ofbusiness dealings.
10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency may terminate this transaction for cause or
default.
2
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