Backup Documents 09/10/2019 Item #16D 7 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 16 D 7
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Wendy Klopf CHS WK 09.10.19
2. Minutes and Records Clerk of Court's Office 4� 1 IC O
PRIMARY CONTACT INFORMATION
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,may need to contact staff for additional or missing information.
Name of Primary Staff Wendy Klopf Phone Number 239.252.2901
Contact/ Department
Agenda Date Item was September 10,2019 Agenda Item Number 16D7
Approved by the BCC
Type of Document ADI Amendment 203.19.001 Number of Original 1
Attached Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? NA
2. Does the document need to be sent to another agency for additional signatures? If yes, NA
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be �G
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's NA
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the NA
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's NA
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
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!
8. The document was approved by the BCC on 09/10/19 and all changes made -7� N/A is not
during the meeting have been incorporated in the attached document. The County an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the -r'�v' N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the an option for
Chairman's signature. this line.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
July 2019 to June 2020 ADI 203.19.001
1607
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
ALZHEIMER'S DISEASE INITIATIVE PROGRAM STANDARD CONTRACT
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. ("Agency") and Collier
County Board of County Commissioners ("Contractor"), amends agreement ADI 203.19.
The purpose of this amendment is to correct the following items that are in the 2019-2020 contract:
ATTACHMENT I
C. Clients to be Served
6. Clients Served—should be deleted
This contract does not provide for direct services to clients other than intake, information and referral services
and screening.
ATTACHMENT I
E. Deliverables
b. Memory Disorder Clinics (MDCs)—should be deleted
The Agency shall maintain coordination with the MDCs, the Alzheimer's Disease and Related Disorders
Research Brain Bank (Brain Bank), and all other components of the ADI, as well as Silver Alert, in the
designated PSA. MDCs are required to provide annual in-service training to all respite, in-facility respite,
and model day care center staff in their designated service areas, and to plan and develop service-related
research projects with model day care and respite providers. The Contractor shall respond to requests for
statistical data concerning its consumers, based on information requirements of the MDCs and the Brain
Bank, and assist the MDCs in carrying out Silver Alert protocol activities to include return of the Aging
and Disability Resource Center (ADRC) Silver Alert Services Referral Form to the referring MDC
within fourteen(14) days of receipt.
ATTACHMENT I
F. Reports
1. CIRTS Reports
2. Annual Service Cost Reports—should be#2 vs#1 in contract
3. Surplus/Deficit Report
1
July 2019 to June 2020 ADI 203.19.001 1 6 U
ATTACHMENT II-EXHIBIT 2,FUNDING SUMMARY—CSFA #65.002—should be deleted
STATE FINANCIAL ASSISTANCE SUBJECT TO SECTION 215.97, F.S.
PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT
Alzheimer's Disease Initiative General Revenue—TSTF 65.002 $
65.004
TOTAL AWARD $
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed to
conform to this Amendment.
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the contract.
This Amendment and all its attachments are hereby made part of the contract.
IN WITNESS WHEREOF, the Parties hereto have caused this amendment to be executed by their undersigned officials
as duly authorized.
CONTRACTOR: COLLIER COUNTY AREA AGENCY ON AGING FOR
BOARD OF COUNTY COMMISSIONERS SOUTHWEST FLORIDA, INC.
7/7
SIGNED BY: to ' („A i SIGNED BY: WeA-11, /
Ni
NAME: ST-tkit (,i 11 NAME: MARIANNE G LORINI
TITLE: ft( ç ()elf �(C TITLE: PRESIDENT/CEO
DATE: C'7 (2� l ZO ( �f DATE: 7/30/2
Federal Tax ID: 59-6000588
Fiscal Year Ending Date: 09/30
Duns: 076997790 Approved as to form and legality
Assistant County orney
\22`lCI
2
0
Revised August 2007 16 0 7
Attestation Statement
Agreement/Contract Number ADI 203.19
Amendment Number QQ.
I,Stephen Y Carnell ,attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreement/contract or amendment between the Area Agency on Aging for
Southwest Florida and
Collier County Board of Commissioners
(Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting,due to the differences in
electronic data processing media,which has no affect on the agreement/contract content.
v41/4 '` fir'C
/ 7/ s� /)
Signature of Reci ient/Contractor representative Date
Approved as to form and legality
Assistant Count ttorney
-112.2_\`Ci
Revised August 2007