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HomeMy WebLinkAboutBack-Up DocumentsMIA�MI-DADE March 10, 2023 Mr. Arthur Noriega, City Manager The City of Miami 444 SW 2nd Avenue Miami, Florida 33130 Re: 2022-2023 Primary Care Program HMIS Staffing Program PC-2223-STAFF-I ID Assistance Program PC-2223-ID-1 Dear Mr. Noriega: Homeless Trust 111 NW 1 st Street • 27th Floor Miami, Florida 33128 T 305-375-1490 miamidade.gov Enclosed, please find the Agreement between Miami -Dade County, through Miami -Dade County Homeless Trust and The City of Miami for the following programs: HMIS Staffing Program PC-2223-STAFF-1 • ID Assistance Program PC-2223-ID-1 The authorized agency signatory must sign the Agreement in blue ink and the relevant attachments. Miami -Dade County requires that the President/Chairman of the Board execute the Agreement on behalf of the agency. However, the Executive Director may execute the Agreement if approved by a resolution of the agency's Board. A copy of the applicable Board resolution(s) must be submitted with the Agreement. In addition, the agency must affix the corporate seal to the signature page of the Agreement or notarize it accordingly. The Agreement must be returned to the Homeless Trust office, via email scan (all pages scanned in one document) no later than March 27, 2023. Please feel free to contact us at (305) 375-1490 if you any questions or require additional information. Thank you for your continued efforts with addressing the needed of the homeless of our community. Sincerely, Victoria L. Mallette for Executive Director Enclosures Signature below confirms receipt of the enclosed documents. Signature of Authorized Agency Representative Date ATTACHMENT A, SCOPE OF SERVICES EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM PC-2021-HTMT-1 SCOPE OF SERVICES EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM The Provider agrees to provide emergency hotel/motel placement of homeless families with children for a period of up to seven (7) days in area hotels/motels. Thereafter, the provider must obtain the approval of the Miami -Dade County Homeless trust for additional days as needed on a case -by -case basis. Families may be provided food vouchers on an as -needed basis of up to $20.00 per diem while residing in hotels/motels. Families with more than four (4) members may be provided an additional $5.00 per person per day. Reimbursement will only be made for properly documented disbursement of food vouchers. All reimbursements must be submitted to the County by the 101" day of each month following the month of service. All reimbursement requests must be approved by the County prior to the disbursement of funds. Scope A-2 Scope of COVID-19 Expenditures The County is instructing Provider to undertake protective measures to prevent or mitigate the spread of COVID- 19 during the period in which public officials advise COVID-19 special measures should be taken. The County will reimburse Provider for expenses incurred in taking such protective measures during such time period. Allowable COVID-19 expenditures are set forth below. The County has sole discretion to determine if expenditures were made for the purpose of preventing or mitigating the spread of COVID-19 and the dates of the period in which public officials advise that COVID-19 special measures should be taken. Total reimbursement for incurred COVID-19 costs under this Agreement shall not exceed $ N/A without the County's prior written approval. Allowable COVID-19 Expenditures: • Personal Protection Equipment (PPE). • Testing and screening for COVID-19. • Cleaning supplies and/or cleaning services by outside vendors, including application of an antimicrobial surface protectant. • Physical modifications specifically undertaken to prevent or mitigate COVID-19 spread within the facility. • Ventilation -related supplies or modifications, except for substantial modification or replacement, and installation and maintenance of UV lighting. • Educational material and signage specific to COVID-19. • Additional food costs incurred for children in residence attending school remotely. • Staff overtime incurred due to staff absences resulting from their COVID-19 infection, quarantine after exposure to another person tested positive for COVID-19 or care of a household member with COVID- 19 infection. Provider may request reimbursement for the cost of temporary staffing necessary to cover the absent permanent employee's hours that is above and beyond the budgeted cost of the absent permanent employee. • Other COVID-19 justified expenditures. Payment Processes and Documentation Requirements: Pavment Processes Provider must submit a monthly invoice with back-up documentation attached, comprised of Provider's account ledger for COVID-19 expenditures, invoices and receipts which include proof of invoice payment, canceled checks, time sheets and payroll registers and other documentation as requested. The County will pay Provider within thirty (30) days of the County's receipt of the invoice. Additional Documentation Requirements • Provider must establish a cost center or the equivalent specifically for COVID-19 expenditures. The account ledger for the cost center or the equivalent must be submitted with Provider's invoice. Such ledger must list: (a) the purchased item or service, (b) vendor name; (c) vendor's invoice number with purchase order date or receipt with same; (d) payment amount; (e) payment date; (f) check number unless paid online. • Vendor invoices, purchase orders or receipts must have a notation that they are COVID-19 expenditures. Request for reimbursement of costs incurred due to a permanent employee's absence must be supported by Human Resource documentation of the basis for the employee's absence and period of absence with the employee's name and any other identifying information redacted. Time sheets and payroll records documenting an employee's overtime must be included in the reimbursement request and indicate that such overtime was necessary to cover the absent permanent employee's hours. Invoices for temporary staffing must match the period in which the permanent employee was absent and indicate that such staffing was necessary to over the hours of the absent permanent employee as well as include Human Resource record of permanent employee's budgeted salary. • For any expense not expressly described above, Provider must provide a narrative justification that the expense was incurred in response to COVID-19. 4 IDENTIFICATION ASSISTANCE PROGRAM HMIS STAFFING PROGRAM FY-2022-2023 Budget Narrative These funds should cover the Identification Assistance Services and a HMIS one outreach staff person. The Identification Assistance program must be provided, the Florida Identification Cards and Birth Certificates services for the total amount of $12,500,00 The HMIS outreach staff position provides HMIS services and input, the purpose of this position is to maintain data current in the HMIS. The amount of $24,666.00 would cover the salaries + Fica of the one Information and Referral Specialist, the other amount will be covered by City of Miami. THE CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM _ _..._.. BUDGET 2021-2022 PRIMARY CARE PROGRAM- IDENTIFICATION ASSISTANCE PROGRAM HMIS STAFFING PROGRAM I - � IDENTIFICATION ASSISTANCE PROGRAM DESCRIPTION BUDGET STAFF SALARY $ 3,750.00 IDENTIFICATION SERVICES $ 8,750.00 TOTAL $ 12,500.00 + l HMIS Staffi COST MDHT CITY OF MIAMI Staffing (52.3136%) (47.6864%) 1 Information and Referral Specialist -Homeless $ 47,150.27 $ 24,666.00 $ 22,484.27 Program (Salaries+ Fica) - HMIS ADMINISTRATOR TOTAL 1 $ 47,150.27 1 $ 24,666.00 1 $ 22,484.27 1 TOTAL (ID+HM,IS Staffing) 1 $ 37,166.00 1 1 14 Miami -Dade County Is Affidavits and Declarations Miami -Dade County requires each party desiring to enter into a contract with Miami -Dade County to; (1) Sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This form contains both Affidavit forms for matters requiring the entity to sign under oath and Declaration forms for matters requiring only an affirmation or declaration for other matters. Each section of this form must be read, and initialed in the top right hand box indicating acceptance and/or compliance with the County's policy related to the particular affidavit. For affidavit sections that you do not believe are applicable to your organization, please indicate this by placing " Q" in the box next to N/A. ALL SECTIONS MUST BE COMPLETED THE FOLLOWING MATTERS REQUIRE THE ENTITY TO SIGN AN AFFIDAVIT UNDER OATH: STATE OF ( COUNTY OF ( COUNTRY OF ( Before me the undersigned authority appeared (Print Name), who is personally known to me or who has provided as identification and who did swear to the following: That he or she is the duly authorized representative of (Name of Entity) (Address of Entity) addresses are not acce table. Federal Employment Identification Number Post Office (hereinafter referred to as the contracting "entity"), and that he or she is the entity's (Sole Proprietor) (Partner) (President or Other Authorized Officer) That he or she has full authority to make this affidavit, and that the information given herein and the documents attached hereto are true and correct; and That he or she says for the following fifteen (16) Affidavits and Declarations: ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 1 of 11 Miami -Dade County's Affidavits and Declarations Pertains O 1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (SECTION 2-8.1 N/A O OF THE COUNTY CODE) Initial (_) If the contract or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a partnership, the foregoing information shall be provided for each partner. If the contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded corporations or to contracts with the United States or any department or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. All such names and address are outlined below: Post Office addresses are not acceptable. (Full Legal Name, Address, % Ownership) (Full Legal Name, Address, % Ownership)Y (Full Legal Name, Address, % Ownership) (Full Legal Name, Address, % Ownership) The full legal names and business address of any other individual (other than subcontractors, material person, suppliers, laborers, or lenders) who have, or will have, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Miami Dade County are: Post office addresses are not acceptable Any person who willfully fails to disclose the information required herein, or who knowingly discloses false information in this regard, shall be punished by a fine of up to five hundred dollars ($500.00) or imprisonment in jail for up to sixty (60) days or both. ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 2 of 11 Miami -Dade County 's Affidavits and Declarations 2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (COUNTY Pertains D ORDINANCE 90-133, AMENDING SECTION 2.8-1; SUBSECTION (d)(2) OF THE N/A D COUNTY CODE) Initial (_) Except where precluded by Federal or State laws or regulations, each contract or business transaction or renewal thereof which involves the expenditure of then thousand dollars ($10,000) or more shall require the entity contracting or transaction business to disclose the following information. The foregoing disclosure requirements do not apply to contracts with the United States or any department or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. Does your firm have a collective bargaining agreement with its employees? D Yes D No Does your firm provide paid health care benefits for its employees? D Yes D No Provide a current breakdown number ofpersons) of your firm's work force and ownership (below): White: Males Females Black: Males Females Hispanic: Males Females Asian: Males Females American Native: Males Females Aleut (Eskimo): Males Females ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 3 of 11 Miami -Dade County's Affidavits and Declarations 3. MIAMI-DADE COUNTY AFFIRMATIVE ACTION / Pertains O NONDISCRIMINATION OF EMPLOYMENT, PROMOTION AND N/A O PROCUREMENT PRACTICES (COUNTY ORDINANCE 98-30 CODIFIED Initial (_) AT 2-8.1.5 OF THE COUNTY CODE Pursuant to Miami -Dade County's Ordinance No. 98-30, Section 2-8.1.5, entities with annual gross revenue in excess of $5,000,000 seeking to contract with the County shall, as a condition of receiving a County contract, have: 1) a written affirmative action plan which sets forth the procedures the entity utilizes to assure that it does not discriminate in its employment and promotion practices and 2) a written procurement policy which sets forth the procedures the entity utilizes to assure that it does not discriminate against minority and women -owned businesses in its own procurement of goods, supplies and services. Such affirmative action plans and procurement policies shall provide for periodic review to determine their effectiveness in assuring the entity does not discriminate in its employment, promotion and procurement practices. The foregoing, not withstanding, corporate entities whose board of directors are representative of the population make-up of the nation shall be presumed to have non-discriminatory employment and procurement policies, and shall not be required to have a written affirmative action plan and procurement policy in order to receive a County contract. The foregoing presumption may be rebutted. The requirements of this section may be waived upon written recommendation of the County Manager that it is in the best interest of the County to do so and approval of the County Commission by majority vote of the members present. Based on the above, please complete the affidavit as directed and return the completed affidavit along with a cover letter on your company's letterhead, listing the company's address, phone and fax numbers, and any required documents, to: Miami -Dade County, Department of Procurement Management Affirmative Action Plan Unit 111 NW 1st Street,13th Floor Miami, FL 33128 Yes O No O My company has an affirmative action plan and procurement policy and is available for review. My company has annual gross revenues in excess of $5,000,000. Yes O No O Therefore, our company's affirmative action plan and procurement policy is available for review. Yes O No O My company has annual gross revenues less than $5,000,000. If at any time the Miami Dade County has reason to believe that any person or firm has willfully and knowingly provided incorrect information or made false statements, the County may refer the matter to the State Attorney's Office and/or other investigative agencies. The County may initiate debarment and/or pursue other remedies in accordance with Miami -Dade County policy and/or applicable federal, state and local laws. 4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT Pertains O (SECTION 2-8.6 OF THE COUNTY CODE) N/A O Initial f 1 The individual or entity entering into a contract or receiving funding from Miami -Dade County O has O has not, as of the date of this affidavit, been convicted of a felony during the past ten (10) years. An officer, director, or executive officer of the entity entering into a contract or receiving funding from Miami -Dade County O has O has not as of the date of this affidavit been convicted of a felony during the past ten (10) years. ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 4 of 11 Miami -Dade County's Affidavits and Declarations 5. PUBLIC ENTITY CRIMES AFFIDAVIT (SECTION Pertains D 287.133(3)(a), FLORIDA STATUTES) N/A D Initial (_) The individual or entity entering into a contract or receiving funding from Miami -Dade County understands the following: That a "public entity crime" as defined in Paragraph 287.133 (1) (g) Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state of the United States of America, including but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state of the United States of America and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. That "Convicted" or "conviction" as defined in Paragraph 287.133 (1) (b) Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal state trial court of record relating to charges brought by indictment or information after July 1,1989, as a result of a jury verdict, non - jury trial, or entry of plea of guilty or nolo contendere. That an "affiliate" as defined in Paragraph 287.133 (1) (a) Florida Statutes means a) a predecessor or successor of a person convicted of a public entity crime; or b) an entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. That a "person" as defined in Paragraph 287.133 (1) (e) Florida Statutes means any natural person or entity organized under the laws of any state or of the United States of America with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members and agents who are active in the management of an entity. Based on information and belief, the statement as marked below, is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies by applying the individual initials near the box). D Neither the entity submitting this sworn statement nor any of its officers, directors, executives, partners, shareholders, employees, members or agents who are active in the management of the entity, nor an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. D The entity submitting this sworn statement or one or more of its officers, directors, executives, partners, shareholders, employees, members or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months; and D yes an additional statement is applicable or D no an additional statement is not applicable. D The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity has been charged with and convicted of a public entity crime within the past 36 months. However, there have been subsequent proceedings before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the "Convicted Vendor List". The individual or entity entering into a contract or receiving funding from Miami -Dade County understands that he or she is required to inform the public entity prior to entering into a contract in excess of the threshold amount provided in Section 287.017 Florida Statues for Category 2 of any change in the information contained in this form. ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 5 of 11 Miami -Dade County's Affidavits and Declarations 6. MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT Pertains D (County Ordinance No.142-91 codified as Section 11A-29 et. N/A D seq of the County Code) Initial (_) That in compliance with Ordinance No. 142-91 of the Code of Miami -Dade County, Florida, an employer with fifty (50) or more employees working in Dade County for each working day during each of twenty (20) or more calendar work weeks, shall provide the following information in compliance with all items in the aforementioned ordinance: An employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) days of family leave during any twenty-four (24) month period, for medical reasons, for the birth or adoption of a child, or for the care of a child, spouse or other close relative who has a serious health condition without risk of termination of employment or employer retaliation. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State of Florida or any political subdivision or agency thereof. It shall, however, pertain to municipalities of this State. 7. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION Pertains D AFFIDAVIT (County Resolution R-385-95) N/A D Initial (_) That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities, renovations, and new construction in the following laws: The Americans with Disabilities Act of 1990 (ADA), Pub. L. 101-336,104 Stat. 327, 42 U. S. C. 12101-12213 and 47 U. S. C. Sections 225 and 611 including Title I, Employment; Title II, Public Services; Title III, Public Accommodation and Services Operated by Private Entities; Title IV, Telecommunications; and Title V, Miscellaneous Provisions: The Rehabilitation Act of 1973, 29 U.S.C. Section 794: The Federal Transit Act, as amended 49 U.S. C. Section 1612: The Fair Housing Act as amended, 42 U.S.C. Section 3601-3631. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State or any political subdivision or agency thereof or any municipality of this State. 8. MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE Pertains D FEES OR TAXES (Sec. 2-8.1(c) of the County Code) N/A D Initial (_) Except for small purchase orders and sole source contracts, that above named firm, corporation, organization or individual desiring to transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes -- including but not limited to real and property taxes, utility taxes and occupational licenses -- which are collected in the normal course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of the firm, corporation, organization or individual have been paid. ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 6 of 11 Miami -Dade County's Affidavits and Declarations Pertains D 9. CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS N/A D Initial (_) The individual entity seeking to transact business with the County is current in all its obligations to the County and is not otherwise in default of any contract, promissory note or other loan document with the County or any of its agencies or instrumentalities. 10. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A- Pertains D 60 Et. Seq. of the Miami -Dade County Code). N/A D Initial (_) The firm desiring to do business with the County is in compliance with Domestic Leave Ordinance, Ordinance 99- 5, codified at 11A-60 et. seq. of the Miami Dade County Code, which requires an employer which has in the regular course of business fifty (50) or more employees working in Miami -Dade County for each working day during each of twenty (20) or more calendar work weeks in the current or proceeding calendar years, to provide Domestic Violence Leave to its employees. 11. MIAMI-DADE COUNTY EMPLOYMENT DRUG -FREE WORKPLACE Pertains D AFFIDAVIT (County Ordinance No. 92-15 codified as Section 2- N/A D 8.1.2 of the County Code) Initial (_) That in compliance with Ordinance No. 92-15 of the Code of Miami -Dade County, Florida, the above named person or entity is providing a drug -free workplace. A written statement to each employee shall inform the employee about: 1. danger of drug abuse in the workplace; 2. the firm's policy of maintaining a drug -free environment at all workplaces; 3. availability of drug counseling, rehabilitation and employee assistance programs; 4. penalties that may be imposed upon employees for drug abuse violations. The person or entity shall also require an employee to sign a statement, as a condition of employment that the employee will abide by the terms and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Compliance with Ordinance No. 92-15 may be waived if the special characteristics of the product or service offered by the person or entity make it necessary for the operation of the County or for the health, safety, welfare economic benefits and well-being of the public. Contracts involving funding which is provided in whole or in part by the United States or the State of Florida shall be exempted from the provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental entities. ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 7 of 11 Miami -Dade County's Affidavits and Declarations 12. ATTESTATION REGARDING DUE AND PROPER ACKNOWLEDGEMENT OF Pertains D COUNTY FUNDING SUPPORT N/A D Initial (_) By initialing this subsection and accepting County funds, the above named firm, corporation, organization or individual agrees to abide by the grant contract requirement to recognize and acknowledge Miami -Dade County's grant support in a manner commensurate with all contributors and sponsors of its activities at comparable dollar levels. 13. MIAMI-DADE COUNTY RESOLUTION NO. R-630-13 REQUIRING A DETAILED PROJECT BUDGET, SOURCES AND USES STATEMENT, CERTIFICATIONS AS Pertains D TO PAST DEFAULTS ON AGREEMENTS WITH NON -COUNTY FUNDING N/A D SOURCES, AND DUE DILIGENCE CHECK Initial (_) Pursuant to Miami -Dade County Resolution No. R-630-13, requiring a detailed project budget, sources and uses statement, certifications as to past defaults on agreements with non -county funding sources and due diligence check prior to the County Mayor or County Mayor's designee recommending a commitment of Miami -Dade County funds to Social Services, Economic Development, Community Development, and Affordable Housing Agencies and Providers. The undersigned entity certifies, to the best of his or her knowledge and belief, that: 1. Within the past five (5) years, neither the Agency nor its directors, partners, principals, members or board members: (i) have been sued by a funding source for breach of contract or failure to perform obligations under a contract; (ii) have been cited by a funding source for non-compliance or default under a contract; (iii) have been a defendant in a lawsuit based upon a contract with a funding source. Please list any matters which prohibit the Agency from making the certifications required and explain how the matters are being resolved (use separate sheet if necessary): 14. MIAMI-DADE COUNTY RESOLUTION No. R-478-12 NOT TO USE PRODUCTS Pertains D OR FOODS CONTAINING "PINK SLIME" N/A D Initial (_) Pursuant to Miami -Dade County Resolution No. R-478-12, the undersigned certifies, not to use meat products containing "Pink Slime" in food provided or served as part any food program; urging all who provide food services or operate a food program to immediately discontinue using meat products containing "pink slime" in food provided or served in these programs. ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 8 of 11 Miami -Dade County's Affidavits and Declarations 15. MIAMI-DADE COUNTY REQUIRED LOBBYIST REGISTRATION FOR Pertains O ORAL PRESENTATION Section 2-11.1(i)(2) CONFLICT OF INTEREST N/A O AND CODE OF ETHICS ORDINANCE Initial (_) All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5) business days of being retained as a lobbyist or before engaging in any lobbying activities, whichever shall come first. Every person required to so register shall: 1. Register on forms prepared by the Clerk; 2. State under oath his or her name, business address and the name and business address of each person or entity which has employed said registrant to lobby. If the lobbyist represents a corporation, the corporation shall also be identified. Without limiting the foregoing, the lobbyist shall also identify all persons holding, directly or indirectly, a five (5) percent or more ownership interest in such corporation, partnership, or trust. Registration of all lobbyists shall be required prior to January 15 of each year and each person who withdraws as a lobbyist for a particular client shall file an appropriate notice of withdrawal. 3. Prior to conducting any lobbying, all principals must file a form with the Clerk of the Board of County Commissioners, signed by the principal or the principal's representative, stating that the lobbyist is authorized to represent the principal. Failure of a principal to file the form required by the preceding sentence may be considered in the evaluation of a bid or proposal as evidence that a proposer or bidder is not a responsible contractor. Each principal shall file a form with the Clerk of the Board at the point in time at which a lobbyist is no longer authorized to represent the principal. OBy initialing here, the principals or principal's representative have filed with the Clerk of the Board of County Commissioners stating that a lobbyist is authorized to represent the principal. 4. Any public officer, employee or appointee who only appears in his or her official capacity shall not be required to register as a lobbyist. 5. Any person who only appears in his or her individual capacity for the purpose of self -representation without compensation or reimbursement, whether direct, indirect or contingent, to express support of or opposition to any item, shall not be required to register as a lobbyist. 6. Any person who only appears as a representative of a not -for -profit corporation or entity (such as a charitable organization, or a trade association or trade union), without special compensation or reimbursement for the appearance, whether direct, indirect or contingent, to express support of or opposition to any item, shall register with the Clerk as required by the Ordinance subsection, but, upon request, shall not be required to pay any registration fees. The Clerk of the Board of County Commissioners shall notify the Commission on Ethics and Public Trust of the failure of a lobbyist or principal to file a report and/or pay the assessed fines after notification. A lobbyist or principal may appeal a fine and may request a hearing before the Commission on Ethics and Public Trust. A request for a hearing on the fine must be filed with the Commission on Ethics and Public Trust within fifteen (15) calendar days of receipt of the notification of the failure to file the required disclosure form. The Commission on Ethics and Public Trust shall have the authority to waive the fine, in whole or part, based on good cause shown. The Commission on Ethics and Public Trust shall have the authority to adopt rules of procedure regarding appeals from the Clerk of the Board of County Commissioners. Except as otherwise provided in subsection of the Ordinance, the validity of any action or determination of the Board of County Commissioners or County personnel, board or committee shall not be affected by the failure of any person to comply with the provisions of this subsection(s). (Ord. No. 00-19, § 1, 2-8-00; Ord. No. 01-93, § 1, 5-22- 01; Ord. No. 01-162, § 1,10-23-01; Ord. No. 03-107, § 1, 5-6-03) ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 9 of 11 Miami -Dade County's Affidavits and Declarations Pertains O 16. Disclosure SUBCONTRACTOR / SUPPLIER LISTING (ORDINANCE 97-104) F N/A O Initial (_) This form, or a comparable form meeting the requirements of Ordinance 97-104, must be completed by all bidders and proposers on Miami -Dade County contracts for purchase of supplies, materials or services, including professional services which involve expenditures of $100,000.00 or more, and all bidders and proposers on County or Public Health Trust construction contracts which involve expenditures of $100,000.00 or more. This form or a comparable form meeting the requirements of Ordinance 97-104, must be completed and submitted even though the bidder or proposer will not utilize subcontractors or suppliers on the contract. The bidder or proposer should enter the word "NONE" under the appropriate heading, in those instances where no subcontractors or suppliers will be used on the contract. A bidder or proposer who is awarded the contract shall not change or substitute first tier subcontractors or direct suppliers or the portions of the contract work to be performed or materials to be supplied from those identified except upon written approval of the County. Business Name and Address of First Tier Subcontractor Subconsultant Principal Owner Scope of Work to be Performed by Subcontractor/Subconsultant (Principal Owner) Gender Race Business Name and Address of Direct Supplier Principal Owner Supplies/Materials/Services to be Provided by Supplier (Principal Owner) Gender Race I certify that the representations contained in this Subcontractor/Supplier Listing are to the best of my knowledge true and accurate. Signature of Authorized Representative Date Print Name Print Title (Duplicate if additional space is needed) ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 10 of 11 Miami -Dade County's Affidavits and Declarations M IAM l-DADE I have carefully read this entire 11-page document entitled, "Miami -Dade County's Affidavits and Declarations" and agree to; (1) sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This form contains both Affidavit forms for matters requiring the entity to sign under oath and Declaration forms for matters requiring only an affirmation or declaration for other matters. BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO AFFIDAVITS AND DISCLOSURES 1-16 MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE Signature of Witness or Secretary Seal Signature of Affiant Printed Name of Affiant and Name of Agency Address of Agency 20 Date Federal Employer Identification Number SUBSCRIBED AND SWORN TO (or affirmed) before me this day of 720 He/She is personally known to me or has presented Signature of Notary Print or Stamp Name of Notary Notary Public — State of County of Type of identification Serial Number Expiration Date as identification. Notary Seal ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 11 of 11 ATTACHMENT D THIS ATTACHMENT IS NOT APPLICABLE TO THIS CONTRACT AGREEMENT ATTACHMENT F Miami -Dade County Homeless Trust Monthly Payment Request NAME OF AGENCY: THE CITY OF MIAMI SERVICE PERIOD: TO NAME OF GRANT: THE CITY OF MIAMI - ID ASSISTANT PROGRAM GRANT NUMBER: PC-2223-ID-1 TOTAL AWARD AMOUNT: $12,500.00 AMOUNT OF FUNDS REQUESTED THIS MONTH: $ AMOUNT OF FUNDS RECEIVED TO DATE: $ BALANCE REMAINIG ON GRANT: (following payment of this request) Signature of Executive Director or Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative 15 Date ATTACHMENT F Miami -Dade County Homeless Trust Monthly Payment Request NAME OF AGENCY: THE CITY OF MIAMI SERVICE PERIOD: TO NAME OF GRANT: THE CITY OF MIAMI - HMIS STAFFING PROGRAM GRANT NUMBER: PC-2223-STAFF-1 TOTAL AWARD AMOUNT: $24,666.00 AMOUNT OF FUNDS REQUESTED THIS MONTH: $ AMOUNT OF FUNDS RECEIVED TO DATE: $ BALANCE REMAINIG ON GRANT: (following payment of this request) Signature of Executive Director or Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative 15 Date ATTACHMENT G CONTINUUM OF CARE (CoC) HOMELESS ASSISTANCE PROGRAM o HUD MONTHLY CoC MONTHLY PERFORMANCE REPORT (MPR) — HMIS GENERATED MONTHLY REPORTS o HUD ANNUAL CoC ANNUAL PERFORMANCE REPORT (APR) — HMIS GENERATED ANNUAL REPORTS Reports must be generated from the ServicePoint HMIS reporting system or HMIS system approved by the Miami -Dade County Homeless Trust. ATTACHMENT G, PERFORMANCE REPORTS (MONTHLY AND ANNUAL) APR AND HMIS ATTACHMENT H THIS ATTACHMENT IS NOT APPLICABLE TO THIS CONTRACT AGREEMENT ATTACHMENT I THIS ATTACHMENT IS NOT APPLICABLE TO THIS CONTRACT AGREEMENT ATTACHMENT J THIS ATTACHMENT IS NOT APPLICABLE TO THIS CONTRACT AGREEMENT ATTACHMENT K THIS ATTACHMENT IS NOT APPLICABLE TO THIS CONTRACT AGREEMENT ATTACHMENT L MIAMI DADE COUNTY ANNUAL ACTUAL EXPENDITURE REPORT THE CITY OF MIAMI-IDENTIFICATION PROGRAM GRANT NUMBER #: PC-2 2 2 3 -STAFF-1 OCTOBER 1, 2022 - SEPTEMBER 30, 2023 Name of Agency: THE CITY OF MIAMI - HMIS STAFFING PROGRAM Budget $ 24,666.00 Month of Services Amount Paid OCTOBER -2022 NOVEMBER-2022 DECEMBER-2022 JANUARY-2023 FEBRUARY-2023 MARCH-2023 APRIL-2023 MAY-2023 JUNE-2023 ULY-2023 AUGUST-2023 SEPTEMBER-2023 Total Requested $ 0.00 Balance Remaining $ 24,666.00 Signature of Executive Director or Date Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative MIAMI DADE COUNTY ANNUAL ACTUAL EXPENDITURE REPORT THE CITY OF MIAMI-IDENTIFACTION PROGRAM GRANT NUMBER #: PC-2223-ID-1 OCTOBER 1, 2022 - SEPTEMBER 30, 2023 Name of Agency: THE CITY OF MIAMI- ID-PROGRAM Budget 12,500.00 ATTACHMENT L Month of Services Amount Paid OCTOBER-2022 NOVEMBER-2022 DECEMBER-2022 ANUARY-2023 FEBRUARY-2023 MARCH-2023 APRIL-2023 MAY-2023 UNE-2023 ULY-2023 AUGUST-2023 SEPTEMBER-2023 Total Requested Balance Remaining Signature of Executive Director or Date Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative 0.00 12,500.00 for Taxpayer Give Form to the i=armRequest (Rev. October2018) + # $ a Certification Identification Number and Ce1 tiiication requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ® Go to www.irs.gov/FormW9 for instructions and the latest information. f Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business namo/disregarded entity name, if different from above �P 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the Y 4 Exemptions codes apply only to p� ( pP Y Y following seven boxes. certain entities, not individuals; see a o ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate instructions on page 3): single -member LLC Exempt payee code (if any) o. o ,i�, v ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) 0- 0 « Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting W c LLC if the LLC is ciassified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is LLC that is disregarded from the for U.S. federal code (if any) a another not owner tax purposes. Otherwise, a single -member LLC that ir_Af is disregarded from the owner should check the appropriate box for the tax classification of its owner. Ci ❑ Other (see instructions)► (Applies to accounts mainlined outside the US) rn 5 Address (number, street, and apt, or suite no.) See instructions. Requester's name and address (optional) m m U) 6 City, state, and ZIP code 7 List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding. For individuals, this is generally your hems security number (S. However, fora resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (ElN). If you do not have a number, see Now to get a TIN, later. or Note; If the account is in more than one name, see the instructions for line 1. Also see What Name and employer identification number Number To Give the Requester for guidelines on whose number to enter. m Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. tilgn Signature of Here U.S. person ► pate ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov1FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Farm 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No, 10231X Form W-9 (Rev. 10-2018) MIAMI- E Memorandum = Date: September 27, 2019 To: Miami -Dade County Homeless Trust Board Members From: Victoria Mallette, Executive Director Homeless Trust Homeless Trust Subject: Revised Incident Reporting Form On September 9, 2015, the Homeless Trust Board passed a policy to define the process for receiving and processing incident reports. The policy outlined the types of critical incidents which must be reported to the Continuum of Care's Incident Report Coordinator, Miguel Pimentel. For each critical incident, a report must be submitted to the Miami -Dade County Homeless Trust within one business day. When a critical incident occurs, subcontracted provider staff should 1) take action to ensure the health, safety and welfare of all individuals involved in the incident, and 2) contact law enforcement, emergency responders of the Abuse Hotline. The incident reporting form has been significantly updated to include both wrong -doing, as well as allegations of wrongdoing. Reporting is required for both client related and staff related incidents. Of particular note, sexual battery has been included in the listing as State law has outlined "Failure to report any known or suspected abuse of any kind of a child is a third-degree felony that may result in a prison sentence of 5 years, and a fine of $5,000 (Refer to Chapter 39 & 415 of the Florida Statutes). " The revised Incident Reporting Form is attached. This is an information only item. Attachment c: Maurice L. Kemp, Deputy Mayor Shannon Summerset, Esq., Assistance County Attorney Pagel of MIA ,a INCIDENT REPORT IDENTIFYING INFORMATION Reporting Party Phone # Reporting Party Name Contract Provider Name Program Name Provider Location Specific Category: (check all that apply) ATTACHMENT N CHECK IF CRITICAL ❑ Date of Incident / / Time of Incident am/pm ❑ Allegation or wrongdoing ❑ Wrongdoing (as acknowledged by a third party designated to investigate these claims i.e. law enforcement detained individual, or DCF accepted abuse report) Specific location/ address where incident occurred: TYPE OF INCIDENT CLIENT RELATED ❑ ALTERCATION ❑ CLIENT INJURY OR ILLNESS ❑ SEXUAL BATTERY ❑ PROPERTY DAMAGE ❑ OTHER INCIDENT Specify ❑ CLIENT DEATH ❑ THEFT ❑ SUICIDE ATTEMPT ❑ ABUSE OR NEGLECT* 1 of 4 MIAM11DOADE ATTACHMENT N * Failure to report any known or suspected abuse of any kind of a child is a third-degree felony that may result in a prison sentence of 5 years, and a fine of $5,000 (Refer to Chapter 39 & 415 of the Florida Statutes). STAFF RELATED ❑ INAPPROPRIATE EMPLOYEE ACTS OR OMISSIONS THAT RESULT IN CLIENT INJURY, ABUSE, NEGLECT, OR DEATH ❑ FRA UD ❑ THEFT ❑ BREACHES OF CONFIDENTIALITY OIMPROPER EXPENDITURE OR COMMITMENT OF PUBLIC FUNDS -OR-CONTRACT MISMANAGEMENT a COMPUTER RELATED MISCONDUCT OANY VIOLATION UNDER §435, F. S., TITLE XXXI, EMPLOYEE SCREENING, THAT WOULD RESULT IN DISQ UALIFICA TION FROM CLIENT CONTACT DUTIES ❑ FALSIFICATION OF OFFICIAL RECORDS ❑ MISUSE OF POSITION OR STATE PROPERTY, EMPLOYEES, EQUIPMENT, OR SUPPLIES FOR PERSONAL GAIN OR PROFIT ❑ FAILURE TO REPORT KNOWN OR SUSPECTED NEGLECT OR ABUSE OF A CLIENT ❑ OTHER INCIDENT THA T WO ULD BE A VIOLA TION OF STATUTE, RULE, REGULATION OR POLICY Specify 2of4 MIM in L"'direri E,yec&htc PARTICIPANT (S) / WITNESS (ES) (Please mark W or P for either Witness or Participant) Staff ID # or Client HMS # CLIENT EMPLOYEE OTHER ❑ ❑ ❑ DESCRIPTION OF INCIDENT Give detailed account — who, what, where, when, why, how — add pages if necessary CORRECTIVE ACTION AND FOLLOW UP Immediate corrective action taken Is follow up action needed? ❑ Yes ❑ No If yes, specify INDIVIDUALS NOTIFIED ATTACHMENT N W/P ❑Wor❑P ❑Wor❑P ❑Wor❑P Abuse Registry 1-800-962-2873 Applicable Law Enforcement Department Indicate name of person contacted, if report was accepted, the date and time if called or copy of report Incident Reports — The Subrecipient must report to Miami -Dade County Homeless Trust information related to any critical incidents occurring during the administration term of its programs. In addition to reporting this incident to the appropriate authorities the Subrecipient must within twenty-four (24) hours of any incident, submit in writing a detailed account of the incident. This incident report should be addressed to the Contract Officer or Administrative Officer assigned. This incident report should be addressed to Miami -Dade County Homeless Trust, I I I NW First Street, 271 Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsmilie (305) 375-2722. 3 of 4 MIAMIND=ADE I cyrxerr E;V611encc +c ATTACHMENT N Definitions of Reportable Client Incidents a. Altercation. A physical confrontation occurring between a client and employee or two or more clients at the time services are being rendered, or when a client is in the physical custody of the department, which results in one or more clients or employees receiving medical treatment by a licensed health care professional. b. Client Death. A person whose life terminates due to or allegedly due to an accident, act of abuse, neglect or other incident occurring while in the presence of an employee, in Homeless Trust contracted program facility. c. Client Injury or Illness. A medical condition of a client requiring medical treatment by a licensed health care professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring while in the presence of an employee, in a Homeless Trust contracted program. d. Other Incident. An unusual occurrence or circumstance initiated by something other than natural causes or out of the ordinary such as a tornado, kidnapping, riot, or hostage situation, which jeopardizes the health, safety and welfare of clients. e. Sexual Battery. Any allegation of a program participant or program staff intentionally touching a minor or another person without their consent. This includes incidents of inappropriate verbal offenses, incidents that occur outside of the residence, and incidents were the program participant was victimized by someone outside of the residence. Incidents involving a minor, person who is 60 or older, or someone who is disabled must be reported to the DCF. f. Abuse or Neglect. Any physical maltreatment of a child, disabled person, or someone age 60 or older. Any failure to act on the part of the parent or care taker, which results in harm to a child, disabled person, or someone age 60 or older. g. Suicide Attempt. An act which clearly reflects the physical attempt by a client to cause his or her own death while in the physical custody of the department or a departmental contracted or certified provider, which results in bodily injury requiring medical treatment by a licensed health care professional. h. Property Damage. An incident involving damage to property procured with Homeless Trust funding. 4of4 XTlrAM Real Property and Equipment Asset Inventory F-,qmpnwnt Wfth = aaw5ftian cast afgreater dun SSAG&Mreal trey ammr be niovea a winery and equipuwnt I�;n :aa�,• ..,a lra+'as.� �:� "a;r,,i.a�i�aa, s, A >,ra�,r� u 1►Suoc ]) ADE COf�"TY HQlff-USS fZMT " �.t 1 CI..LEI-rSERVI -S C£RTMC.k'i`f0'q REFERRAL FORM YOR EMPLOYEES 4F I FHOMMESS TRL T Fl�l�1TlEUPROGRls1�1S Ig�S3RTJCJ IONS: Provii4riaaling rAWral muA eomp%ts this twb page form, igjndia!T sihna�rss by kpgiirant and Prf►eiderReoresenfative& ljax oampleted forogtoProvidesRceeivingRe ferrid ts2r Date- Refuting Providcn Trtie Phone Nui ibex . iNFoRMATIQN oo HEAD of I Do-usEHOLD: _ Lam A mm. Fi�s�ame` Date of E iWh• _ sS"I ` ATTACHMENT P PRONT UER R.itAL FDRM. PACE TWO, If the Applicant or a Member dtl�eir hhold is an employecef the refrsrex�g provider, the . apprac'al orthe Prorit}er E itir-�a Direetor is hereby indieited by rtaature: Narno Ti le " Date If thr Applieant ar.a member of their household Wan employrr of the provider where scrvioes-will be provided, the approval ofiThe F6 mvld}r aer Rxewtive factor, t>-Homeless Tr�ist�x�tive j}irt#or; and the Homeless TMI Ba;ard eTe,berci�y it ilitatcd by si mature: Fmdil±xecutiveDirector Mils Si -Dade QoUrdy 90Meless Trust CWR=M Date -V.D&&CoulayHomckuTTustExwmmeDveem Date ADDITlt311� 1401MM©LD IWORMAI'I YN. " Whm is the household n6VO. (Famft name" exams ad8re�s� Date of "rat homelessness Explain the homeiess sitna96n, and avhst eaused ibc M rent _ home3estness NOTE Tio RRF RMG�PAO MFW- PRUV]DM T.qX A.W:VE UgFORMATION DOES I40T 1Xs5Rg A"pgVJlL FOR BOWING OROTMR SMVICES REQUl✓�MD--A DETSR'h1CtN R i3E MADE FOLLOWING A CoJV;!PLM' AssmpgENT QF TIIE ATPUCANT"S CASE. 7WSSEMON FOR Si?RI?CE FRQ1YIDER STAFF USE Qli'LY. �l4eelc £rigiir,dit}�riferia Yes rro '��unr-afF►ravider�e�isg.�`ai�:.....� _ ., . "` l' lw aSE rdAINTAIN THE F-X T`ED•COPI` OF THIS. DDCuMENT IN THE C€,1�l� i it[LE 4F 1"HE $Eli\" lC1NG PR•OVIDHR A 13 PRR-S(j NF-l-rF1 LE OF RTFE'it`f ING PROViD ;