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Home My WebLink Aboutexhibit1DATTACHMENT D ATTACHAIlENT D DEPARTMENT OF HUMAN �STRA YON SERVICES BYRNE GRANT All MIAMI-DADE COUNTY AFFIDAVITS all The contracting individual or entity (governmentalall affidavits that dootherwise) shall yndicate by an not pertain to this' contract. Ail that pertain to this contract and shall indicate by an blank spaces must be filled. The MIAMI-DADE COUNTY OWNERSHI'DI MSCL OSURE DADS CRIMINAL AFFIDAVIT; _ RECORDADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT; IT; DISABILITY NONDISCRIMINATION AFFIDAVIT; of and the departments is or agenclies thereof, RAFFIDAVIT F eStAate or LEAVE Y not tical su to contracts with the reof do States o y olitrcal subdivision or agency thereof or any mutheiUnited States or an of its d pa D�ts orE A Senc es oILY tie AFFIDAVIT shall not pertain to contracts with pertain to municipalities of State of Florida or All o herrcontractting entitiesoragency vidualslshalllread careful each affidavit to determine State of Florida.lo. whether or not it pertains to this contract. 1, Aftiant The full legal n ame a nd b usiness a ddress o f the p o on(s) to r e able) ntity c ontracting o r transacting b usiness with Miami -Dade County are (Post Office addresses are n p Federal Employer Identification Number (If none, Social Security) , being first duly sworn state: Name of Entity, individual(s), Partners, or Corporation Doing Business As (if same as above, leave blank) Street Address City State Zip Code 1. N11AM1 DADS COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code) us a dress 1. If the contract or business transaction is rand each stockholder with a corporation, the full lwho holds di al name and ec lylor inch ectly shall provided for each officer and director ecto five percent (5%) or more of the corposlat�r�ln�estQovidcdthe for each partner. business the h-ansaction is with a business partnership, the fwith information a trust, the full lu the ts shaladdress d be to rcontractsfor with publiclYand traded corporations n The foregoing rthe United corporations or to contracts with the UStates or municipdality rl ty of thartment is Str ate. Allreof, suchthe nameste or and any political subdivision or agency thereof addresses are (Post Office addresses are not acceptable): Full Legal Name Address Ownership 1 of 5 2. The full legal names and business address of any other individual (other than subcontractorse , material men, suppliers, laborers, or lenders) who have, or will have, any interest alCegal, g stable beneficial or otherwise) in the contract or business transaction with Dade County Offi addresses are not acceptable): w ho kn 3. Any p erson w ho w illfully fails to d isclose t hei bepunishby a fine of up toon r equired h ,fv a hundred dollars owingly discloses false information in this regard, shall ($500.00) or imprisonment in the County jail for up to sixty (60) days or both. II. MIAMI-DADE COUNTY EMPLOYMENT DISCLOe SURE Cod AFFIDAVIT (County Ordinance No. 90- 133, Amending sec. 2.8-1; Subsection (d)(2) Except where precluded by federal or State laws or regulations, each contract or business 000) or more shalls transaction orr the thereof which involves the egxbusiness etof ten disclose theddollars follow following information. The foregoing the entity contracting s oran transacting disclosure requirements do not apply to contracts with the United States or any departmentagency thereof, the State or any political subdivision or agency thereof or any municipality of this State. 1 Does your firm have a collective bargaining agreement with its employees? Yes No 2. Does your firm provide paid health care benefits for its employees? _ Yes ersons) of s 3. workProvideo a current as to race, natir of onal origin your nd 'r: work force andownership Males Females White: Males Females Asian: Males Females Black: Males Females American Indian: Males Females Hispanics: Males Females Aleut (Eskimo): Males Females _ _Males Females: AFFIRMATIVE ACTION/NONDISCRIMINATION OF EMPLOYMENT, PROMOTION AND III. Ordinance 98-30 codified at 2-8.1.5 of the County Code.) PROCUREMENT PRACTICES (County In accordance with County Ordinance No. 98-30, entities with annual gross reva County enues in econts of ract, aa writtseekingen to contract withowhich sets forth the proshall, as a cedures theition of entityutilizes to assure that have:oi) a written affirmative acts plan it does not discriminate in its employment andpromotion to assure that it does not discriminate coagaenst mtment nolrity which sets forth the procedures the entity utilizes ative and women -owned businesses in its own provide for pcurement of eriodicoods, srev�ew to determine their effectiveness action plans and procurement policies shallp in assuring the entity does not discriminate in its employment, promotion and procurement practices. The foregoing notwithstanding, corporate entities whose boards of directors are representative of the o ulation make-up of the nation shall be presumed�ttenave affirmatale act on plans and 1prorcuremerlt ent and procurement policies, and shall not be required to havetion be rebutted. policies in order to receive a County contract. The foregoing presume may 2 of 5 on The requirements of County Ordinance No. 98-30 may be waived upon the written approval of date Board the County Manager that it is in the best voteinterest of the methe mbers present. so andup of County Commissioners by majority The firm does not have annual revenues in excess oss revenues in excess of $5 000,000; however, its Boardn, detailed of Directors is 0. The firm does have thpopeof the nation and has submitted representative of the population make-up listing of its Board of Directors, including the race or ethnicity of each board member, to the e artment of Business Development, 175 N.W, 1st Avenue, 28th Floor, Miami, County' s D p Florida 33128. has annual gross revenues in excess of $ 5,0 0 0 0 a the ee firm hhavewritten periodic in The firmmplan and procurement policyd which includes the Ce iod s arffirmative action Department m o determine BusinesscDevelopmentt has 175 N.W. submitted tAvenplan ue, 28th Floor, Miami, Florida Department of Business 33128; d The firm d oes n of have a n a ffirmative action plan a ndlor a p rocurement p olicy a s d escribe above, but has been granted a waiver. IV. M1AM1-DAD E COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2-8.6 of the County Code) has The individualtsf oda1c of entering into a contract or receiving funding from past (10) years. has not as of the date of this affidavit been convicted of a felony duri�act og the Preceiving funding from the has not as of the date of this affidavit been convicted of a felony during the past An officer, director, or executive of the entity entering into a con County has ten (10) years. Ordinance No. _V . MIAMI-DADE EMPLOYMENT DRUG -FREE County C p R)KPLACE AFFIDAVIT (County 92-15 codified as Section 2-8.1.2 ofthe fiance with Ordinance No. 92-15 of the Code of Miami -Dade statement Floeach employee abovee namThated in persocompn is providing a drug -free workplace. named person or entity shall inform the employee about: 1. danger of drug abuse in the workplace • 2, the firm's policy of maintaining a r habilitat on and employee ass sta-free environment at all ncle programs 3, availability of drug counseling, on employees for drug abuse violations 4, penalties that may be imposed up to ee to sign a statement, as a conditiion of t drug conviction The person l Yee will abidel orequireby erms aemnd notify the employer of any that the employee n notice of such conviction and impose appropriate occurring no later than five (5) days fuerto and including termination. personnel action against the employeeP be waived if the special characteristics at acton rif tees of the pro or Complianceefe with the e� on or entity make it necessary for the op service offered by the p public. Contracts involving funding health, safety, welfare, economic benefits and well-being of the whole or in part by the United States or the e t Ttavi°s,flns ode in all be onflict with the whichted is provided in from the provisions of toVernmordinance ent 1 ant tiiesse instances where t p requirements of those g 3 of 5 VI. MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance No. r` 142-91 codified as Section 11 A-29 et. seq of the County Code) Florida, an That in compliance with Ordinance 1 °' 142-91 of working hn Dade Coe Code ofunty forI Miami-Dade h working day during employer with fifty (50)r or more employees each of twenty (20) or more calendar work ordenatice all provide the fallowing information in compliance with all items in the aforementioned employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) daysAn of Y . twenty-four (24) month period, for medical reasons, for the birth or oio family a child, or forng any spouse or other close relative who has a serious health adoption of a child, the care of a child, condition without risk of termination of employment or employer retaliationtracts with the United states or any department or The foregoing ng thereof, or the State hof Floridaall not or any rtain to opolitical subdivision or agency thereof. it shall, agency or however, pertain to municipalities of this State. VII DISABILITY NON-DISCRIMINATION AFFIDAVIT (County Resolution R-385-95) iance with and Thattheyabove named refirm, corporation r g, or third party oon is in ntractorr under this agrees oject compl ss es to comply with, and assure that any subcontractor,but not limited to, those with all applicable requirements of the laws listed below including, transportation, provisions pertaining to employment, provision of programs and services, communications, access to facilities, renovations, and ub new construction cons 336io104 the St following llow n laws:42 TCe Americans with. Disabilities Act of 1990 (ADA), to ant; Title II, Public 12101-12213 and 47 U.S.C. Sections 225 and 611 including Title 1bE Employment; Title Public Services; Title III, Public Accommodations and Services Operated The Rehabilitation Act of Title 29 Telecommunications; and Title V, Miscellaneous Provisions; U.S.C. Section 794; The Federal Transit Act, 3631amended 49 U.S.C. Section The foregoing requirements shall notlpe pertain Housing Act as amended, 42 U.S.C. Section 3601political contracts with the United States orany department ef thoris Sagency thereof, the State or any subdivision or agency thereof Y VIII. MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE FEES OR TAXES (Sec. 2-8.1(c) of the County Code) Except for small purchase orders and sole source contracts, that above named firm, corporation, ntract with organization or individual desiring to transact d ue fees o r t axesr- enter ncluding b ut n of limited t oaCounty r eaSea nd verifies that all d elinquent a nd currently theprotaxes, yutility x Coll and occupational as Dade County issued parking tickets foreveh normal les registered the Dade County Tax Collector as weaid. in the name of the firm, corporation, organization or individual have been p IX. CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS obligations to The individual entity Bother to tndefault of any contract, ct business with the prom sort of current or other loan document the County and is not otherwise in with the County or any of its agencies or instrumentalities. 4 of 5 200_ by known to me or has presented (Type of Identification) (Signature of Notary) (Print or Stamp of Notary) Notary Public — Stamp State of (State) (Date) _X. PROJECT FRESH START (Resolutions R-702-98 and 358-99) that results in actual payment of $500,000 or more shall Any firm tot has a contract with the County that Welfare to Work Initiative. However, if five who have percent contribute 4)/0fProject Fresh Start, the County 5st of the ftwork force consistsofindividuals formerly Aid reside in with Miami -Dade 5 Children)asmay lost or will loseecash assistance ben ( Opportunity Reconciliation Act of submitting a waiver request result t the Personal Responsibility and Work p and government entities,nnoti for profit request waiver from thei requirements does Onot Bpertain -to 8g 9 by affidavit. The foregoing organizations or recipients of grant awards. IC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A-60 Et. Seq. of the _XI. DOMESTIC Miami -Dade County Code). to do business with the County is in compliance with Domestic Leave Ordinance, The firm desiring of the Miami Dade County Code, which requires an Ordinance 99-5, codified at l 1 A-60 et. seq. (50)or more employees working in Miami- Dadeda during each of twenty (20) or more calendar work weeks in the employer which has working regular course of business fifty iolence Leave to its employees. County for years, to provide Domestic current or proceeding calendar e document entitled, "Miami -Dade County Affidavits" and 1 have carefully. read this entire five (5) page have indicated by an "X" all affidavits that pertain to this contract and have indicated by an "N/A" all affidavits that do not pertain to this contract. By: (Signature of Affiant) TO (or affirmed) before me this day of SUBSCRIBED AND SWORN He/She is personally as identification. (Serial Number) (Expiration Date) Notary Seal