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Backup Documents 02/23/2021 Item #16D 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 b D 3 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 routinglines#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 Community and Human _Yr k Services 2. Minutes & Records Clerk of Court's Office aJqjj D- `,gyp, 3. 4. 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/CHS Phone Number 252-2901 Contact/ Depaitment Agenda Date Item was 02/23/2021 Agenda Item Number 16.D3 Approved by the BCC Type of Document ADI Amendment 203.20.001 Number of Original Attached Documents Attached PO number or account NA 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? WK 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 WK 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 fmal 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 02/23/2021 and all changes made during WK the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. 9. Initials of attorney verifying that the attached document is the version approved by the WK 11 BCC,all changes directed by the BCC have been made, and the document is ready for the Chairman's signature. 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 i603 July 2019—June 2020 ADI 203.20.001 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 Arca Agency on Aging for Southwest Florida,Inc.("Agency")and Collier County Board of County Commissioners("Contractor"),amends agreement ADI 203.20. The purpose of this amendment is to increase allocation funding by amending 4.Contract Amount,Collier County: increase allocations by$24,815.42; revise ATTACHMENT II-EXHIBIT 2-Funding Summary; and revise ATTACHMENT IX BUDGET AND RATE SUMMARY. Contract Amount: The Agency agrees to pay for contracted services according to the terms and conditions of this contract in an amount not to exceed S474,670.42 subject to the availability of funds. Any costs or services paid for under any other contract or born any other source are not eligible for payment under this contract. All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and arc 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 TIIEREOF,the Parties hereto have caused this amendment,to be executed by their undersigned officials as duly authorized;and agree to abide by the terms,conditions and provisions of this ADI contract as amended. This Amendment is effective on December 29,2020 upon having been duly signed by both Parties. Contractor: COLLIER COUNTY BOARD AREA AGENCY ON AGING FOR OF COUNTY COMMISSIONERS SOUTHWEST FLORIDA,IN . SIONF.I) Y:— — c -rK-4.e4• { SIGNED BY: NAME: JAMES C FRENCH NAME: NORMA ADORN() TITLE:PUBLIC SERVICE DEPARTMENT HEAD TITLE: CEO DATE: 01J (q 12021 DATE: 1- 2 0 212A, Federal Tax ID: 59-6000558 Fiscal Year Ending Date: 09/30 Duns: 076997790 Approved as to form and legality C � , istant County Atton 1, 1603 July 2019—June 2020 ADI 203.20.001 ATTACHMENT II-EXHIBIT 2 FUNDING SUMMARY Note: Title 2 CFR,as revised,and Section 215.97,F.S.,require that the information about Federal Programs and State Projects included in Attachment II,Exhibit 1,be provided to the recipient.Information contained herein is a prediction of funding sources and related amounts based on the contract budget. 1. FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS CONTRACT CONSIST OF THE FOLLOWING: GRANT AWARD(FAIN#): FEDERAL AWARD DATE: DUNS NUMBER: 076997790 PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT TOTAL FEDERAL AWARD COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT TO THIS CONTRACT ARE AS FOLLOWS: FEDERAL FUNDS: 2 CFR Part 200—Uniform Administrative Requirements,Cost Principles,and Audit Requirements for Federal Awards. OMB Circular A-133—Audits of States,Local Governments,and Non-Profit Organizations 2. STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS CONTRACT CONSIST OF THE FOLLOWING: MATCHING RESOURCES FOR FEDERAL PROGRAMS PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT TOTAL STATE AWARD STATE FINANCIAL ASSISTANCE SUBJECT TO SECTION 215.97,F.S. PROGRAM TITLE FUNDING SOURCE CSFA AMOUNT Alzheimer's Disease Initiative-Collier General Revenue—TSTF 65.004 $ 474,670.42 TOTAL AWARD $ 474,670.42 COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO THIS CONTRACT ARE AS FOLLOWS: STATE FINANCIAL ASSISTANCE Sections 215.97&215.971,F.S.,Chapter 69I-5,F.A.C.,State Projects Compliance Supplement Reference Guide for State Expenditures Other fiscal requirements set forth in program laws,rules,and regulations fr- 2 I6D3 July 2019—June 2020 ADI 203.20.001 ATTACHMENT IX ANNUAL BUDGET SUMMARY ALZHEIMER'S DISEASE INITIATIVE PROGRAM for Collier County Board of County Commissioners Collier TOTAL: $474,670.42 ALLOCATION TOTAL: $ 474,670.42 l603 Revised August 2007 Attestation Statement Agreement/Contract Number ADI 203.20 Amendment Number .001 I,,TAMES C FRENCH ,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. Si -ature of Recipient/Contractor representative Date Approved as to form and legality Revised August 2007 Awls nt County At .y