Backup Documents 07/13/2021 Item #16D 2 crfiauktailiturammENTs AT 3•. i c TING SLIP 1 6 D 2
TO ACCOMPANY ALL ORI fl A7 Ts SENT TO
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 routingzlines#1 through#2,complete the checklist,and forward to the County Attomey Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Wendy Klopf Community and Human 611/°
Services
2. Minutes & Records Clerk of Court's Office
(/SIG `7 :3
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/ Department
Agenda Date Item was 07/13/2021 Agenda Item Number 16D2
11-2Approved by the BCC
;Type of Document Amendment EHEAP 203.21.001 Number of Original 1
4-Attached Documents Attached
APO number or account NA
Slumber if document is
0-to be recorded
u.5 INSTRUCTIONS & CHECKLIST
▪ Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not
�▪.`-1 appropriate. (Initial) Applicable)
;i. 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 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 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_07/13/2021 and all changes made WK
during 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
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
16Q2
April 2021 —September 2023 EHEAP 203.21.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
WHEREAS,the purpose of this Amendment is to amend contract language and replace attachments of Contract
EHEAP 203.21.
NOW THEREFORE,in consideration of the mutual covenants and obligations set forth herein,the receipt and sufficiency of
which are hereby acknowledged,the Parties agree to the following:
1.ATTACHMENT I,Section ILE.l.g.,EHEAP Outreach Activity Report, is hereby replaced.
g. EHEAP Outreach Activity Report
The Contractor shall ensure the use of outreach efforts that will inform potentially eligible households about EHEA P
to the Agency Contract Manager or its designee by the 9`1' day following the end of each quarter. The EHEAP
Outreach Activity Report shall consist of the following:
(1) Date;
(2) County;
(3) Location Address;
(4) Description of Activity;and
(5) Name and Position of Staff.
2,ATTACHMENT XVIII,EHEAP Application and Eligibility Worksheet, is hereby replaced.
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and are hereby changedto
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 THEREOF,the Parties hereto have caused this amendment,to be executed by their officials as duly authorized;
and agree to abide by the terms,conditions and provisions of this EHEAP amendment as amended. This Amendment is effective
on the last date the Amendment has been signed by both Parties.
IN WITNESS WHEREOF, the Parties hereto have caused this contract to be executed by their undersigned officials as duly
authorized.
CONTRACTOR: COLLIER COUN � AREA AGENCY ON AGING FOR
BOARD OF/E U CO g.' ERS SOUTHWEST +LORIDA,INC. N n �w
SIGNED B SIGNED BY: "�• L
NAME: DANIEL R RO IGUEZ NAME: NORMA ADORNO
TITLE: PUBLIC SERVICE DEPARTMENT HEAD TITLE: If`feRfi►i PRESIDENT/CEO
DATE: Old/ 'a /2021 DATE: La 2 - 2D 21
Federal Tax ID:59-6000558
Fiscal Year Ending Date:09/30
DUNS: 076997790
Approved as to form and legality
A , stunt County A
1 6 0 2
April 2021 —September 2023 EHEAP 203.21.001
ATTACHMENT XVIII
Emergency Home Energy Assistance for the Eldertyr Program -Application
Section One: Applicant(Aged 6O and older)Information
Name:1 rss,k1,Ca Y -HrailnpSeason -Ccarnp Season-,
Dale or berth:
genre acidness: Dat slag
Ronda County: zt CoCe: .........___._.... i':a a vocrker aname:
sex: itewe Female hklrn ec of people In rie house/tad: Phone:
Marital'.:.Status: Mar::ged Parlrrer'ed 'S ig a Detlarated Divorced' Va1DO ed Phone:
Rom: Wilts elactL".tm1cail Arrieri an As:'a1 Native HawailarrPaaSfl tdander Amerlcanhittar1IAJaska Nallhe Other
EthrOcttr. Fispentcl_alno Other I ?'rtrlary Language: English a'lsh Ot er
Does Weill have Smiled abittty reading,writing,srea)1r ,oar trnderatandng the Engfsh language? Yes. No
Is the client a veteran? Yes No I Was client rer'er ed to the local'VelerarYs Araks Mae? Yes No WA.
Apptcarrs Inconr a type(s): Applicants montgly Income.aruhrtt
Section Two: Additional Household Members information
Name: Income type;s):
1 Age: *4: r Morn lty MLA id amount
Marne: Income typets):
Age: tv; I IlActI frly ticorhe•amount:
Name: Income ty<p.e(s):
e: SON: I Mortny t*tcocrte amount
Name: Inrxime.type4s):
Age: N: I McnT1lytd.a.ma a'rcarrt
Marne: inoane typers)
Age: sd: Monthly(Income amount:
Section Thee: Ftousehoid Characteristics
Is there a'zmhi 5 years at age or younger In the household? Yes ND
If Yes.select.ail Thal apgrtes: 0-2 years old .3-5 yeas olid
Is Mere an Ind 1ttUal-atlh a d sa 51tty Ir 1s household? Yes No
Is the applicant a U.S.dozen or an aten.Iavafuty aotminsd Tor perraneri;residence? Yes No
Is the applicant a homeowner? Yes No
Does applicant ive'n government srrbsrdzed housing.such.as Section 5? Yes No
If yes,provide the,xrlrroiex name:
If yes,does the tdusehnld receive an eie. y subsidy? Yes No
Does.applicant tl\re n a student dorrnrnry.aditt Tartly care borne,or any frnil or group i•r1ng-witty' Yes No
If yes,provide We facility name:
Section Four_ Heating and Cooling Information •
Have ytxj or arty n-pvt•iber of your'household reoelved energy assistance s n:re c iricnt season? Yes No
If yes,provide the raarte or.Agency:
.
Type or Assistance: Crisis iomc 5rtergy. 'rve.3he--Rel ted Date:
Mal is try prim aryr source or home healing?(select one; Elec$Idiy Natirral r -c Prot-a.le Woortrt cal Fleellatile Fuels
Does household r sr.prpiemental heating source? Eernictt)f Wood/Coal WA
Alr oond''baning emit type? Cenira6 A1C Volndowelfral AJC Fans CWher-specify(including evaporative cool
Section Five: Energy Crisis Explanation Client Attestation and Signature
Horne cooing or he rig Energy.sorr^ce alas bean Tine Irrorrtatan provided on this application,Is to the best or my
dlsoorlra =ri€.it!te T7r'eaferr". ) kr 'rige'.k-ue and com plete.. I understand"tit priority in providing
assistance'alit De green to!hose households with Me lowest inocorne.
Uhab:e to get dellvery offuei,is cul of fuel.or's In dangE-of and greatest:need,I.e."close rtcus€t'ordss n whlcNl trle Elderly.
be out or uei ttlr:heating.i2.hle-?7rrear±er►!rtg) drsatled,rredl airy needy,or d did en recycle_ I.ar Boni d agency
to make Decent payments dredty to cry energy supplier. t am,aware
Other problems„min tack ofcooli tg„:!aeang in, ne :lean air I naive provided al the Irrformali`n rerp esied 10 determine
suchas ne°ringlnpay a:deposit repair or equhpr-aert.or my eflglbilny.if am applying:%ircrisis assishanoe.'irte agencyrhas 18
Interim im emergency pay-a rye to rlttT"lrtx'er'cusps. his to act upon n y apptt ca-on th!n an e1I tee action. 1 am also
(,Cteri emergency
aware Mat If t am not approved or dented wrttihti the dine allowed.or
not approved'Pr Me o amount,I have a r rt to apclea the
Alotilied that lire energy source for cooling or heafrig Is going declsian. (r'you sill WI rl ail'x"7610 wftnessEe are.egLilr ear:)
ID Pe cite amneo eci.j ancremj
1teceivect a:notice Ind catarig the energy source ill:Is
deli'nquentt or past due. il%ancrarig _-.�._..- _._. .._ ._....__..._._.._.._._._
Has an energy.source bill Tor which the due date has f eased_
e.staevera1"GaJ same- —
.ILL cuereru JnOtA..0%,o1 rutsOrWilredy AlithrAWAErto`ftf.e R.L'iEAs .ma'(.hEMGr4MC AW0oOlteo nVeREA AL..[![P.CAe*4 h•on.rtat LUYeAA•Ef e.At'-a•5 l ALL AZEPOR 1pt(i.
..,..[.,,,h. .r..., .... a.y .s.n _.4c.L .
! .*r... 4 1a... s N.'.'..'. ..aex tObto. .[.�[.
-.u:..:w..ear,.+a..a..+ [.e..r.... ..r....�-.�r..,...•es�........r ter°-z..J 1....-r+..».a..s�«.* ,....r.»r.r.w.... n..m,..w.a.....•.cir!ar. ....ew.wn,.r.u....a.�..1
.LM_.Yil/.y�M�1.b.se.[Y.�.��r-Lr.[4 rat...tat twit.T a..:Y.�r,.a-t am.a....Y.c..L+_N w:,....e 4d1.�u.
2
16 02
April 2021 —September 2023 EHEAP 203.21.001
Em,er g end Horne Erbere. Assistant for thee E I cl a rl Pro to ram - ±iBDili 'ifti°orksheet
Section Six: Income Detterrnenation
Am-maize of hou"benolyd'anOQdil2. taale C.;'[Lf?:..r tape here:snow"C Poverty°madenneac er;lmetaa errectf.27a+2a.
,t. Add al gross monthly earned and l Ms S: c Select the,annuat income rL-it.LLI hcm.nehotd stae
unearned income roof,itle past 32 150%at Pliveryj c5-tt#6 srf Paverry
days or all'.teouse'1o1d members �-?f....-_.....:'}'1'Q,:S 4a7 7' rs,asa
2. Add:Medir re Prem6Lrfl(5,1413"50), -2"........:S=zero s asap
tr not i?icuded t^1 fir`-,A,.armount. -a ...._.*22.5.63 *mesa
3. Add:Medicare Part D,n applicable
4. To,arnpaIlze„multiply the monthly 1 t!3,aaa
y' months.
;1 f',580
7._.........•=T. h4fi11 41i,e2a
Annual household Incomeszat n
ea
"cid*H;e 33 nor ea:Ch. aidtkaanal.....xslser cria:rtr
unit nth mane Man a!nerbers-
ti'�Y_Letai annuei household!mare b less;than AY%S a'the current Federal:Poverty'sudeines.for haactehotd.size
caIegortcat:ty Eligible rtr.:rrg chart ateaxeh and ro rrne fl the i`rouseSxid is nice:vim SbtAP Ltaf ce_the apFdl[ard provide a:'Paned
statement kV haw tack tutng expense rLe:..,toed,she ter and tansperlabora,7 ate premecteditar the trote-e:hotti
Section Seven: Vendor. B3eneft.and Verification Information
Emmen•Venetce Other Vendor t•1
Contact made vent Lit= provider wer'yr
Name: Name: previous cnsit=..sttance.
.�tcourtG'��'c;uchic pomace Person:
Ann aunt Number: Number Date- Date,arccrrtae1 ...
Ham the aRolaaarrt.?meelwed LIFEAP crisis
.._._--------.__ •
assistance durra�t'th+e current seamen.
Mht cirr Amount Due: --------- Amount
-
.. Yes No
Verifcanor.;and aoc nlmerst -Barka: Repair Eaistn:g Heating:
_ Palma*Fan or Cacdrra Equpmere
:Sheber' !line rrin r1Jm 31noun Pile Is rri 'I e M
Crr;:Yati-1.Per3aRm.: - Space Heater .^-xerpe»7cy Itte past due amount.•PIP tvtie energy
Dale: yr lcnn+sty -Cther ,.-en .M iIt(Lnat tilts amount s requirer17,
,i mernr i.!entioor fie Other M'enderJAg Yes No ritA
Name:: Name:
.Mcaour7t Numbs: hos taint eou •
`'l^'t' � Oat= i'the rrr n r-tum 3rnotin:.aue Ix)b..nree the
crls:'e Is more than tne maxirnu•r a loved,
minim m.Ars vount;Due; Amount cue: explain how 11 e i ante a"the arnoun
clue Alf Pe palct tt.approoe*i ro E-IEAP
Vertflcattoe and Corranitment s ass:stance.
P:+tad!e or Coaling Equipment
Contact.Persarn: _. space Heaoer =_i=raergencY Shelter
Date: W'rekw _.Cher
• . r
11 I Total Ensrt p Vendo a• 1M 441:Total Other Vendee& Is the mane mri'tile Tue.!
that of the applicants?
a?
431 Energy adbaldl'
Total EHEAP.&anaRt Yes LID
181°Nadler.>seerer,Garbage. # Add IT no,provide name on bill:
Fire.,grim. Total Energy Vendor t4
8.Total Other v endor(44
I+tl Deduct:121.14 4 from(1) _....---.----------
Seection Eight: Wearther nation Assistance Program MAP)Referral
If rie ap zeicar'tt is a.homeowner,has Fx sT a received more than trim Lit EAP or EHEAP bene",is In The Fast 1$months,
Yee !lo IlA.
If tie answer to The preVous question's"yes',was the applicant r-elerred to INAPT Yes No IsteA
If !ie answer to The last question Is'no".explain:
Section NBinec Resolution of Crisis
Ftescrutcri or t11e itiealincl oofng Energy Cisls odrtxrrr'ext wthin 18/4a Hours,toy the rob:swing eligt tea cs i[s::k` eect all 1l 31..apply:,
Approval or appication be-lent prettent:ed crsocr eon wt
Commitment made to vendor EflEAa benefit restcced.energy a:ready disconnected:
Der fa of Application...pendIng adcfnonal Inforn alion .Yes.°tent signed 1w
Derfa of foplloatkln,Ines lore No..dlettt refused to sign waiver
Witten referral and assistance to ass carer c cr irrr jnlb reaoccoes
Case Worker Signature Approval Signature
1 an roadie
The ep Alicobae and~Mgr uefenr must be aerrea®1 ttr mops
Tate odipharrt and allIghlrelste rre drmmeerte tan primly malting aaL1*ronIL___
Case Walters Nome: 0L 'hisor.=rc s Name-
Case Workers r uper.t:s.or.'Prers.Htinahre:
Date: Date:
Aaener Name: Agency Nra:^fe:
sr-,w,w......•.. a.c....
3
1602
Revised August 2007
Attestation Statement
Agreement/Contract Number: EHEAP CARES 203.21
Amendment Number .001
I, DANIEL R RODRIGUEZ , 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 COUNTY 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.
06/Cj /2021
Signature of Recipient Co .cte7entative Date
Approved as to form and legality
‘ Cj%"-A"
AP •
Ass stant County Att ,v
Revised August 2007
0