HomeMy WebLinkAboutExhibit 4ATTACHMENT D
NOT APPLICABLE
ATTACHMENT E
NOT APPLICABLE
Miami -Dade County Homeless Trust
Invoice For Services
NAME OF AGENCY:
SERVICE PERIOD:
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
The City of Miami
cK
Attachment F
�i Dj 3)
Emergency Hotel/MoteI Placement
PC-0910-HTMT-1
$ 75,000.00
AMOUNT OF FUNDS REQUESTED THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE:
BALANCE REMAINING ON GRANT: $
(following payment of this request)
Signature of Agency Representative Date
Printed Name of Agency Representative
Miami -Dade County Homeless Trust
Invoice For Services
NAME OF AGENCY:
SERVICE PERIOD:
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
The Citv of Miami
TO
HMIS Staffing Program
PC-0910-HMIS-1
AMOUNT OF FUNDS REQUESTED THIS MONTH:
AMOUNT OF FUNDS RECEIVED TO DATE:
BALANCE REMAINING ON GRANT:
(following payment of this request)
Signature of Agency Representative
Printed Name of Agency Representative
Date
Attachment F
(2 3 )
$ 24,666.00
Miami -Dade County Homeless Trust
Invoice For Services
NAME OF AGENCY:
SERVICE PERIOD:
NAME OF GRANT:
TOTAL AWARD AMOUNT:
The Citv of Miami
TO
Attachment F
°J ?-)
FeedinV Coordination Program
PC -0910 -FC
$ 12,500.00
AMOUNT OF FUNDS REQUESTED THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $
(following payment of this request)
Signature of Agency Representative
Printed Name of Agency Representative
Date
ATTACHMENT G
ATTACHMENT H
ATTACHMENT I
ATTACHMENT J
ATTACHMENT K
NOT APPLICABLE
ATTACHMENT L
( .13)
Miami -Dade County Homeless Trust
Annual Actual Expenditure Report
The City of Miami
Contract Period: October 1, 2009 - September 30, 2010
Name of Agency The City of Miami
Contract Number: PC-0910-HTMT-1
$ 75,000.00
Month of Services Amount Paid
October -09
November -09
December -09
January -10
February -10
March -10
April -10
May -10
June -10
July -10
August -10
September -10
Total Requested
D
Balance Remaining $ 75,000.00
ATTACHMENT L
Miami -Dade County Homeless Trust
Annual Actual Expenditure Report
The City of Miami
Contract Period: October 1, 2009 - September 30, 2010
Name of Agency The City of Miami
Contract Number: PC -0910 -FC
$ 12,500.00
Month of Services Amount Paid
October -09
November -09
December -09
January -10
February -10
March -10
April -10
May -10
June -10
July -10
August -10
September -10
Total Requested
D
Balance Remaining $ 12,500.00
ATTACHMENT L
Miami -Dade County Homeless Trust
Annual Actual Expenditure Report
The City of Miami
Contract Period: October 1, 2009 - September 30, 2010
Name of Agency The City of Miami
Contract Number: PC-0910-HMIS-1
$ 24,666.00
Month of Services I Amount Paid
October -09
November -09
December -09
January -10
February -10
March -10
April -10
May -10
June -10
July -10
August -10
September -10
Total Requested
R
Balance Remaining $ 24,666.00
1'11 I ti\1111'✓llil\ 1 1V1
Form. I Re nest for Taxpayer Give form to the
z:•
—=Dc, 'oc''
identification Number andrertiiicatiDll requester. Dc not
send to the IRS.
!`;ame fa Ln0.7`: U': v07: Incor.-:a: rele'rv;
_.:smecs nam<, v different iron, above
C! eci. aporoorat=_ bo,:: CI
i_i Limped iiabiiity company. cniei the tar. classification (D=disregarded entity. C=corporation, P>partnerza;)) ....... r� `.<_Inp.
Nowidual/Sole propnoor � ,' cwporai,on LJ Panrersnlp
— payee
Other js,e insiruciicnsl �- ,
Adores (nurnUer, street• and apl or sure no)
List account number{'s) here ioptional)
✓er Identiiicatlon T,4umber
Requester's name aha aaorees (optionali
Enter your T1N in the appropriate box. Tbs. TIN provided must match the name given ori Line t to avoid social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor. or disregarded entity, see the Pail i instructions on page 3. For other entities, it is
your employer identification number (EII'J). if ,you do not have a number, see How to gel a TlAi on page 3. or
Note. If the account is in more than one name, see the chart on cage 4 for guidelines on whose Employer identncation number
number to enter.
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number for 1 am waiting for 2 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 tmernal
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. t am a U.S. citizen or other U.S. person (defined below).
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 inierest and dividends on vour tax return. For real estate transactions, hem 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 sjon the Certification, but you must
provide your correct TIN. See the instructions on page 4.
SignSignature of
I
Here US nP.Mnn 1, -
General
Genera[ fnstructixns
Section references are to the Internal Revenue Code unless
otherwise noted.
r urposs or Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIN)
to report, for example, income paid to you, real estate
transactions, morgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Use Porm W-9 only if you are a U.S. person (including a
resident alien), to provide your correct T114 to the person
requesting it (the requester) and, when applicable. to:
1. Certify that the TIiJ you are giving is correct (or you are
waiting for a number to be issued;,
2. C::rtify that you are no: subject to backup vvit;hhoidinc, or
3: Claim exemption from backup vvithhclding if you are a U.S.
e, empt payee, h applicable, you are ajso certifying that as a
U.S. person, your aliocable share of ,any partnership income from
a U.S. trade or business is not Subject to the withholding tax on
iortign partners' stare o` ePecnvely connected inc orae
Note. If a requester gives VOL) a fora) other than Form VV -CI to
request your TIN, you mustthe req >ster's farm if ii is
SUbstal;t,ally simi;ar lo this Form
Cate V
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person ff you are: y
e An individual who is a U.S. citizen or U.S. resident aiien,
6 A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United
States,
* An estate (other than a foreign estate), or
a A domestic trust (as defined in Regulations section
301.7701-7).
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required to
pay a withholding tax on any foreign partners' share of income
from such business. Further, in certain cases where a Form w-9
has not+peen received, a partnership Is required to presw)e thgt
a partner is a ioreign person, and pay the witht)ofding tax:
Therefore, it you are a U.S. person that Is a partner in a
partnership conducting a trade or business in the Un!ted States.
provide Form W-9 to the partnership to establish Your U.S.
status and avoid withholding on your share of partnership
income.
The person who Form,) VV -9, to the pt:ririerstnp for
purposes o`: estabLshing its U.S. status and avoidiric withholding
on its allocable share o' flet income from the r;artnershio
conductin1,1 a Lade or business in the United States is u-: lite
foHowinn cases:
6- The U.S. ovIlle o`, a arded eniity and not the enhit;,
L'at.l•�o t_•t::
Form VV -9 Me% - --X71
a The U.S. gramoi drQtner mmei „c oiantor trt]. Eric nor the
irL's i, aril
The U.S. Trus! (other than a grani•cr trust) an:: not `h --
beneficiaries of',he trust.
Foreign person. Ir you are a ror--ion person, cc not use Form
W-9. Instead, use the appropriate Form Vt'-B Isee Publication
515, VVithhoidino of Tar. on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate -U.S. tax on certain types of income.
However, most tar. treaties contain a provision known as a
''saving clause." Exceptions specified in the saving clause may
permit an exemption irorn tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for ta)- purposes.
If you are a U.S. resident alien who is relyinq on an exception
contained in the saving clause of a tar, treaty 1 claim an
exemption from U.S. tax on certain types of .income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tar, as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
eyemotion from tax.
5. Sufficient facts to justify the exemption from tai, under the
terms of the treaty article.
Example. Article 20 of the U.S.-China income 'tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tar.
purposes if his or her stay in the United States exceeds tax-
purposes
years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even atter the Chinese student
becomes a resident alien of the United States. A Chinese .
student who qualifies for this exception (under paragraph 2 of
the first protocol) and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28010 of such payments. This is called "backup withholding."
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay. and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give thN requester your correct TIN. make the
proper certificat-orrs, and report all your taxable interest a,nc
dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TINT to the requ.z2ter,
1'ou do not certify your TIN when required isee the Far',, Ii
Instructions on page 3� for details;.
3. The IRS tells In,-, recu:ater feat you furnished an incorrect
Tfill.
- 2
The IRS tell `2g!; trial you ar-_ subject iS bace'up
v✓�tnno!drnc Jeca L...- .,ou did not . epOr- all your interest 3nG
dividends on your tar return iior reportable interect and
dividends Ont f;. or
J. You do not cei'Wv lc the requester that you al's not suo;ec.
iv bacrup Witn'Noi0lrig Under 4 above ifor reportarile Inleresi ano
dividend accounts opened after 1963 oniyi.
Certain payees and paymemc are exec i from backup
withholding. See the instructions below and the separate
nstrucbon; for the Requester of Form Vel -9,
Asc see Specia.r rules for partnerships on page
Penalties
Failure to furnish TIN. 11 you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not to
vvillid neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINS. V the requester discloses or uses TINS in
violation of federal law, the requester may be subject to civil and
criminal penalties.
Specific tnstr( adonis
Marne
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Pari I
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the "Name" line. You may enter your
business, tiad" or "doing business as (Ii name on the
"Business name" line.
Limited fabiiity company (LLC). Check the "Limited liability
company" box only and enter the appropriate code for the tax
classification ("C" for disregarded entity, "C" for corporation, "P"
for partnership) in the space provided.
For a single -member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an eniity separate from
its owner under Regulations section 301.7701-3, enter the
owner's name on the "IJame" line. Enter the LLC's name on the
"Business name" line.
For an LLC classified as a partnership or a corporation, enter
the LLC's name on the "Name" line and any business, trade, or
DEA name on the "Business name" line.
Other entities. Enter vour business name as shown on required
tacieral tax documents on the "Name" line. his name should
match the name shown on the charier or otherdeoa1 docume4it
creating the entity. You may enter art\, business, trade, of DSIA
name on the "Business name" line.
Note. You are requested to check the appropriate box for y our
Status (Ilidl'✓IdUa'Shce proprietor, corporation.
Exempt Payee
If you ere exempt from backup withhoidinc, enter .-our name a.
described above grid check the dpproprlate bo>: for your status.
then check the "Exempt payea' bo): in the lin;; tollow;nq ine
business name. stun and date tine torr.
^Ur..-iJi:.
Generali;-, individual-, (inciuciirc so!e proprieiers) are not exempt
from ba�_i:up mthholdine. GorpDratlons a''& exempt fmrn bac%:up
v:itithDl . c for cerTmin payments. sura as int=res and dividenos
Note. If ✓ou are exemo, from backur: withholding. you should
sail! complete th!; fern; ,c, avalc pocsible erroneous bacrup
w:thhoid ng.
Tit_ fdlowing pay&es are exempt from backup wahhokiing:
1. An organi_ation exempt from iax under section 501(a), any
IFA, or a custadia! account under section 403!b)(7) t'9 the account
satisfies the requirements of section 401,(f),121),
2. The United States or any of its agerrcie<s or
instrumentalities,
3. A slate, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
7. A foreign central bank of issue,
S. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under
the investment Company .Act of 1940,
12. A common trust fund operated by a bank under section
53.4(a),
13. A financial institution,
14. A, middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
1F the payment is for ... !HEN the payment is exempt
for...
Interest and dividend payments All exempt payees except
j for 9
Broker transactions Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions i Exempt payees 1 through 5
and patronage dividends
to be reportcd arid direct 1 through 7
sales over 5;5.000'
See Form i0?8-MISC, I✓!:;r:ell:vreou;. In;:cttne, and its. rn5rocimnc.
However, vic. !olovono payrTiernr. mane ir, a comora; on iusLroirm cross
oroceeds peed ic, an ;:Mnrnoy antler s action 6045(f), evon 11 tae, atio!'neY is a
cnrporoi,on; Ono r;:aoriaC,i . C,, Fern,.. it!516-r,arSC are nn: exE:11101 fron'i
oaakup v-'dhnuidino n"ieci,cat and nealln cza. navn;eni ,. arta net's" fees. a:iC
,nvn,cntr, for r„ions n.nid. rw •r. ieonral _recuhvP ap�nny-
Part I, Ta~,,,payer idem iTicaticn
Number ( T INTI)
Enter your TIN in the appropriate box. If you are resioent
alien and you do !tot have and air rip: ahglble to cel an Ssrd,
your TIP! your IRS individual iaxpavei identification nurnbe!
(1TIN). Enrer ii in Ine social security number bo):. If you do not
nave an ITIIU, see How to set a TIN below.
If you are a sole proprietor and you have an FIN, you may
enter eltnei dour SSP: or EIN. However. the IRS preiers that you
use your SSIJ.
If you are a smaie-member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(.LC) on page 2), enter the owner's SSN! (or EIN, if the owner
has one). Do not enter the disregarded entity's ON. If the LLC is
classified as a corporation or partnership, enter the entity's Elki.
Note. See the char? on page 4 for further clarification of name
and Tird combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS -5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www-�sa.00v. You
may also get this form by calling 1-600-772-1213. Use Form
W-7, Application for IRS individual Taxpayer Identification
Number, to apply for an TIN', or Form SS -4, Application for
Employer Identification Number, to apply for an EIN. You can
apply for an EIN online by accessing the IFS website at
wwwJrs.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business.You can get Forms Iri1-7
and SS -4 from the IRS by visiting www.f;,.gov or by calling
1 -600 -TV FORAM (1-300-529-3676).
If you are asked to complete Form W-9 but do not have a TIN,
write "Applied f=or” in the space for the TIN, sign and date the
form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily
tradable instruments, generally you will have o0 days to Det a
TIN and give it to the requester before you are subject to backup
withholding on payments. The 60 -day rule does not apply to
other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to
the requester.
Note. Entering "Applied For` means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner
must' use the appropriate Form W-8.
Patt 11. Ceritficati
To establish to the withholding agent that you are a U.S. person,
orresidant alien, sign f=orm WI -9. Ycu may be requested to sign
by the withhoiding agent even if items 1, 4, and 5 below indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
F'aVee on paps 2.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1964 and broker accounts considered active
C$ifiir,-` tau.--,. Vbts Musl glviE
Vvui .scree( TUrb
i, u .., d: not
have to s rqn the certific-mion.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts considered
in during 1953. You must sign the certification or backup
withholding will apply. If you are subiect to backup.wilhhoiding
and you ar merely providing your correct TIN to the requester
you must cross out iteM ^ in the cE�rtlficatior, sinning the
forni.
Form t ' (Ren,. 10 2M7,
3. Rea I estate transactions. `.bu mu31 sign in-- cer,if,cauon.
You mai,, eros„ out tier, _ ci rhe ceni;icaiiol
4. Other payments. You mu, -,i g ve your correct TlW but you
oc not have to sign the certr!caiign unless ;lou have been
notified that you hays previous'!, given an incorrect TIN. "'Diner
oayments' Include pay mento made In the course of the
requesier'5 trade or business for rents, ro;raltjes, goods (other
than bills for merchandise), medical and health cars: services
(including payments to corporaionsj, payments to a
nonempioyee for services, payments to certain fishing beat cl ev✓
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,
Coverdell EESA, Archer fvtSA or HSP, contributions or
distributions, and pension distributions. You must give your
correct TIN, but you do riot have to sign the certification.
What Mame and plumber To Give the Requester
For this type of account
Give name and SSN of:
1. Individual
The individual
2. Two or more indivitluals tioini
The actual owner of the acoounl or,
account)
it combined funds, the first
individual on the account'
3. Custodian account of a minor
Tne minor '
(Uniform Gift to 10mors Act)
4. a. Tne usual revocable savings
The grantor -trustee
trust (grantor is also trustee)
I
b. So-called irusl account that is
I The a; teal ov✓rer
not a Legal or valid trust under
state law
J. Sole proprietorship or d:sregarcied
The owner
entity owned by an individual
For this type of account
Give name and EIN of:
o. Disregarded entry not owned by an
Th=_ owner
individual
i. A valid trust. estate, or pension trust
Legal entity
a. Corporate or L C electing
The corporation
corporate status on Form SF32
9. Association, club, religious_,
The organization
charitable, educational, or other
tax-exempt organization
10. Partnership or multi -member LLC
The partnership
i 1. A broker or registered .nominee
The broker or nominee
12. Account with the Department of
Toe public entity
Agriculture in the name of a puolic
entity {such as a state or local
government, school district, or
prison? that receives agricultural
program payments
'Usl first arrt circle the name of the person whose number you lurrdsh. If only one person
on a joint an=Dnt has ar SSN, that pCmoris number must be furnished.
Gioia ft a minor's name and furnish Um nrnor's sSN.
You must slim, your individual name and you may also enter your business or "DOA'
name on the: second name line. You may use either your SSN or DW (f you have
but the IRS enrourager. you to use yore S&A.
' List firs( ancJ cirde the name It the irusl. e;,nte, or pension t rus!. Ito nor lurm,h the 7(W
al the personal representor lure or trustee unto. (he legal entity itself is not desipnaled ,n
tho accwnt lila) Also sic- Sper101 rule:. fru Jsonnc¢hin on pans 1.
Note, if no nam8 is circled when more tnar, ane rla.me is ljslc-d_
the number will be consicered to be that of the first name listed.
ao� 4
Secure Your Tax records from Identity T left
Ioe- ithy thea occurs vii:en sone one uses 'your persona.
miormation such a --Your name; social security nurnoer'SSI'Ji, or
other Idemiiving Irnaimanzin, vv,thoul volts- permission. is comm,
fraud or diner crimes. An identity thie` mail use your SSN' 10 get
E job or may file e tar: return �2slno ),Dur SSN io receive z relunc.
I o reduce your risk:
E Protect you SSP:,
r -Ensure your employer Is protecting your SSJd, and
F Be careful when choosing a tar. preparer.
Cali the IRS at 1-800-8,219-104'0 if you think your identity has
been used inappropriately for tax purposes.
Viciims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving ta>;
problems that have not beer; resolved through normal channels,
may be eligible for Taxpayer Advocate Service (TAS) assistance.
You can reach 7P.S by calling the TAS toll-free case intake line
at 1-877-777-4778 or Til'ATDD 1-800-829-4059. .
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt to scam the user into surrendering private information
that will be used for identify theft.
The IRS does not initiate contacts with taxpayers via emails.
/also, the IR5 does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts,
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishingl--irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tar: Administration at
1-800-366-4484. You can forward suspicious emaiis to the
Federal Trade Commission at: sparnwc-=.gov of contact them at
wv✓w.corsumer.gov/idfhe i or 1-877-I1DTHEFi-(4138-4338).
Visit the IRS vvebsite at www.irs.gov to learn more about
identity theft and how to reduce your risk.
Privacy Act Notice
Section u10? of Int! iiferna; nevnnut+ C;r>de vo:; to provide you, canscl TIN to person:. w,nc. mus; iiia tni1 irmn 5nn return wish ine IR2 to rcoort rnlonis(,
dividends. and certain othm
er income paid to you, mortgage mteiesf you oa,d, the: acooMlion o' abandonment o1 scour .d ;aropenV. cancaCahon of den:. or
contribution.; you mad^ to art IR/+. o Archer MS,. or !-LSA. -Itj� IRS uses the number_ for rdsntimalor, purpose;: and to het;• veniv Ane accuracy of your ta>, ri�l;,rn.
-U,e IRS may also provide lnsc ,nforrnaiton 1, Inc., [)epznnlenf of Jus1JCF: for avii and crunmn liugauon. onc( r0 r,t es. states, the District o' Ca'ur;t:a. Ono U.S,
rtosses;srons to carry out tner tax lax,ince may else d:scicse this Inlormal(on to othe, under is t ). treaiv, to faders' and malt, agenc,e-.. to cruor;:,
nonta>: con;ens i.nrs, or t:' Isderai Iavr eniorcerer,; anC nttclf,pence agencie. to combat terronstc.
You nnus' provide your TI^.' vvnether rx n'vl •,rots arc' r=cuuer! It, iiia a tat: raiur., ray„ mus! a^neral,; wrllirt(ud all ta:::fr'_ inlerest, div,ocnd. anti .=-=ince: otos;^
:,ayr:nls t;, F pay ---e wno rine,.. not give a TI F1 m .. ,. 'Y=..::eCa,r res ;u -2s n -,a, els, apo'
MIAMI,
Dr_I�E�
.�TTACHIvrE-NT N
INCIDENT REPORT
CHECK IF CRITJ CAL IXIH
IDENTIFYING iNFORMATIONT
Reporting Party Phone Date of Incident �!_/ Tine of Incident ' am/1311-1
Repcmin Parry Name
Contract Provider Name
Pro—lam Name
Provider Location
Specific Prog,-am: (check all that appy)
EJHT E]Primary Care ❑ SHIP 7 E]hCTEency C❑ Challenge
.Srlecifric Location/ address where ua.ciderif nca{rred:
❑ ALTERCATION
TI'L'E OF INCIDENT
❑ CLIEYT DE,4TH
❑ CLIE ATT INJUR IT OR ILLNESS C❑ THEFT
❑ SES U,4 L -8,4 ITER J
❑ FR OPER -T) T D.4A14 GE
❑ SUICIDE ATTEAJIT T
❑ OTHER II'\ICIDEA T
Specify
i P,A RTICIPANT (S) / WITNESS (ES) j
(plcase marls W or T'' for either \Vnness or Participa)t)
LAST NAME. FIRST IDENTIFIER 4 CLIENT
17
I c. 1, ;
EMPLOYEE OTHER
71 %1
❑ ❑
} ,
1 i 1A W f DA -DE
ATTACHMENT ,vi
DESCRH'TI ON OF TNCIDE., T
Give derailed account — wh% Sm. what, when, why how — add page if mcnary
COPJI -ECTBT ACTIONANTI) FOLLOW DF I
linmediate corrective action taken
Is follow up action needed? ❑ Yes ❑ No
If yes, specify
1 J DB71D GALS NOTIFIED
Abuse Registry 1-800-962-2S73 Applicable Laa'Enorceanent Department
Indicate nai»e of person contacted, if report was accepted, the date and time WHO or copy of report
lucidcni Rcports— The Subrecipicnt must report to Mi rni-Dade CmmV Homeless Trust informant m mkod to my
critIN Acidents occurring„ during the admirlkw tion term of its pro_*rams. in addition to rep«nin�' this insider, It7
theqppmKiate authorities the Subre.cipaw muss "Alin twenty -foto (_4) hours of any incident_ subnol in "Wing a
detailed accoum Of the incident. This incident rcpon should be addressed to the Contraci Officer m Adminis mbet
Onto assi_ned. This 06&m rTon should be addressed to hI moi -Dade Count, Hornons Trust, 1 11 N\V First
Street 27" Floor, Suite 310. Miami. Florida 3021 telephone 005135-1400 and facsmilie (305) 3750722.
2of3,
Dcfiniiiorrs of Reportable Incidents
ATT^- CHN4EI T N
a. :",ltercation. physical confrontation occ:urrijlf-� bet `e: -In a client and tnnployee or
5MC) or more clitnts at the tine ser -,,ices a -e beim, rendered, or wi,,en a client is in the
physical custody of the department; Ihich results in oiie or more clients or- ennployees
rec.eivin . medical treatment by a licensed health care professional.
b. Client Death. A person ~Those life terminates due to or allegedly due to an accident,
act of abuse, neglect or other incideni occuriino )vhilet in the presence of an employee,
in Homeless Trust contracted program facility.
c. Client Iniury or Illness. A medical condition of a client requiring medical treatment
by a licensed health care professional sustained or allegedly sustained due to a»
accident, act of abuse, neglect or other incident occurring while in the presence of an
enaplo_yee, in a Homeless Trust contracted program.
d.
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, vvlalch jeopardizes the health; safety and welfare of clients.
e. Sexual Batterv. An allegation of sexual battery by a client on a client, employee on a
client, or client on an employee as evidenced by medical evidence or la -w enforcement
involvement.
f Suicide Attempt. Ari act which- clearly reflects the physical attempt by a client to
cause his or her o` in death while in the physical custody of the department or a
departmental contracted or certified provider, which results in bodily iqury requiring
medical treatment by a licensed health care professional.
Property Dama_,e
:1n incident involvino damage io property procured with I-1omeless T���st fundis-
t,f,
I'vovidQr Nanw:
Program Name,
hulding' Source:
RcIml- ing Pi riod:
ItcSci'ii�l
UI l'1`Uj1C
i`a.`!"6'1o't f li ¢ iq rr u
PROVIDER ASS E'r.IN)TEN,.r anA7
r\llncli invoices Dir nil lnn•chases (Ids grant reporting period.
1'Isv Iulcls
•l•illc (0
I'�'uhcrf ti•
4TTACHINIEP,'T P
MLIL MIT D:4 -DE COUNTY HOMELESS TRUST
CLIENT SEPVICES CERTIFICATION REFERFL, L FURL FOP, EMPLO'r'EES OF
HOMELESS TRUST FUNDED PROCRA)\lS i
INSTP.UCTIO.N'�S: i'ro�ider making referral mu t complete Phis nvo-pale form, including signatures
by Applicant and Provider Represcntativ,s. Fas completed forms to Provider Ptecejvinr Referral for
Housing and or Services,
Date: P,eferrillL Provider:
Contact Person:
Name Title Prone Number-
INFORMATIO)J ON 1iEAD OF HOUSEHOLD:
Last Name: First Name:
Date of Binh: SS #:
INFORJAAT10N ON OTHER HOUSEHOLD MEMBERS:
Name +� A e Sex + Pclationship ✓mplayer,
I I I
1 C
i
I
I
I t
IS ANY MEMBER OF THE HOUSEHOLD EMPLOYED BY, OR RELATED TO AN EMPLOYEE
OF, A HOI fELESS TItiC)ST FUN''DED PROGP.,AM? Yes_ No
)f ves:
Name of Employee:
Emp)oying Provider:
Reiationship to Applicant:
CEPMFIC.ATION
1. the undersi,ned. do that t)r . above information provided by me is true and cma-eci.r.o fire
gest of nny know ledLc.
Applicant's Name
Si<_ricTure: Date:
> efer'rin T'rovider Authorized Representative
?dame: Si`*nature Date --
ATTACi P�4DIVI i'
FROV !DER REFERRAL FG RIM PACE TWO
-:ppli-am s Nan e
If the .b,pplicanI or a member of their household is an employce of the refcrrin, providcr, the
approval o; the I'm vider E;:ecutive Duce[ -or is hereby indicated by signature:
Name/Title
Date
If the Applicant or a member oftheir household is an employee of the provider - whare services will be
provided, the approval of The Provider Execufivc Director, the fi(mieless Trus, Executive Director,
and the Homeless Trust Board Chair nre hereby indicated bysigmature:
Provider Executive Director
Date
hfiami-Dade Cpunty T,-Iomc)css Tmsf Chaq)erson Date
Miami -Dade County Homeless Trust Executive Director Date
ADDITIONAL HOUSEHOLD INFORMiATION:
lAl-re is the household ]ruing now? (Facilivy name, exact address)
Date ofpresenthomelessness:
Explain the homeless situation, and what caused the current
homelessness:
NOTE TO REFER PJAIC PR F-IDER :
PROVIDING THE ABOVE I NTFORMATION' DOES NOT ENSURE APPROVAL FOR HOUSING
OR OTHER SERVICES REQUESTED. A DETERMINATION WILL BE MADE FOLLOWING A
COMPLETE ASSESSMENT OF THE APPLI Ca NIT'S CASE.
TRIS,YECTIOA,' FOI SERJ ICE P' 01IDEIi' ST4FF USE e'7ATY.,
1s1ecic Eli d/ri/irr' Crilcrirr:
YES .>•'O
;14nnc of I'rrrricl�r Scree;, tri, :Staff'
PLE,4SE Ivt.4INTAIN —,PE E,KECUTEI) COPD OF TJ;IS DOCUMENT IN TI -17 CLIENT FILE OF
THE SLJ:\'ICING I'RO\ IDER AND PEP,SONINEL FILL• OT REFERRING I'T,'O\FIDEP..