Backup Documents 10/12/2021 Item #16D4 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP ! 6 4
TO ACCOMPANY ALL ORIGINAL DOCUMENTS 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 routin_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 Community and Human 6WK, 10/12/2021
Services
2. Minutes & Records Clerk of Court's Office
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 10/12/2021 Agenda Item Number 16D4
Approved by the BCC
Type of Document Amendment-ADI 203.21.001 Number of Original 1
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? 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_10/12/2021 and all changes made WK
during the meeting have been incorporated in the attached document. The County n option
Attorney's Office has reviewed the changes,if applicable, his lin
9. Initials of attorney verifying that the attached document is the version approved by the WK /A is
BCC,all changes directed by the BCC have been made,and the document is ready for the n option
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
1604
(JULY 2021 —JUNE 2022) ADI 203.21.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
ALZHEIMER'S DISEASE INIATIVE 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 202.21.
The purpose of this amendment is to increase allocation funding by amending 4.Contract Amount,Collier County:
increase allocations by $171,440.00; revise ATTACHMENT II-EXHIBIT 2-Funding Summary; and revise
ATTACHMENT IX BUDGET AND RATE SUMMARY.
4. 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$676,408.54; subject to the availability of funds. Any costs or services paid for under any other contract
or from any other source are not eligible for payment under this contract.
All provisions in this 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 of 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,and agree to abide by the terms,conditions and provisions of ADI contract as amended.
This Amendment is effective on the last date the Amendment has been duly signed by both Parties.
Contractor: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COM SIONERS FLORIDA,INC.
r
SIGNED BY: SIGNED BY: M1A-1(3
NAME: Daniel R Rodrigu NAME: Norma Adorno
TITLE: _Public Service Department Head TITLE: CEO 2 ^ '1
DATE: _08/11/2071 DATE: — 3 0�a.
Federal Tax ID;59-6000558 Approved as to .u:..: : .
Fiscal Year Ending Date:09/30 `
Assis County At!.
16D4
(JULY 2021—JUNE 2022) ADI 203.21.001
ATTACHMENT II-EXHIBIT 2
FUNDING SUMMARY(2021-2022)
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 offunding sources
and related amounts based on the contract budget.
1. FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS
CONTRACTCONSIST OF THE FOLLOWING:
GRANT AWARD(FAIN#): FEDERAL AWARD DATE:
DUNS NUMBER:
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL FEDERAL AWARD
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANTTO
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 General Revenue 65.004 $676,408.54
TOTAL AWARD $676,408.54
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
GPD
1604
(JULY 2021 —JUNE 2022) ADI 203.21.001
ATTACHMENT IX
ANNUAL BUDGET SUMMARY
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
for
Collier County Board of County Commissioners
Collier
TOTAL: $676,408.54
C40
i6D �
(JULY 2021 —JUNE 2022) ADI 203.21.001
Attestation Statement
Agreement/Contract Number: ADI 202.21
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, Inc. and
Cnllier Cnunty Rnard of Cnunty Cnmmissinnerc •
(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 effect on the agreement/contract content.
08/r i/2021
Signature of eci e resentative Date
Approved as to form and legality
Assistant County AttornA
T- lik•
CAO