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AGENDA ITEM SUMMARY FORM FILE ID: DK -IJ9S) g Date: 5/27/2008 Commission Meeting Date: 6/1 2/2008 Type: Z Resolution ❑ Other CA.17 Requesting Department: NET/ Homeless District Impacted: All Ordinance ❑ Emergency Ordinance ❑ Discussion Item Subject: 2008 Memorandum of Understandine for the Miami Homeless Assistance Prozrarn's Discharne Planning Grant Purpose of -Item: It is respectfully requested that the Honorable Mayor and City Commission adopt the attached resolution to create a Special Revenue Project to accept the Miami -Dade County Homeless Trust's Miami Homeless Program grant, awarded to the City of Miami's Homeless Assistance Programs in the amount of $ l 1 3,333 for a period of four months, and authorizes the City Manageer to execute all documents necessary. The grant was awarded to the City of Miami to provide outreach, information, referral, assessment and placement services to homeless individuals discharged from the Miami -Dade County's judicial court and public health systems. Background Information: The Miami -Dade County Homeless Trust, recopj i7ing the need for intervention to prevent those discharged from the criminal justice and public health systems from becoming homeless, established the Discharge Planning grant to fund a service provider to provide a range of services designed to address the needs of the temporarily and chronically homeless. The Homeless Trust, after a competitive review process, chose Miami Homeless Programs as the grantee, to provide evening and weekend outreach, housing assistance, and coordinate with the jail, prison, hospital, foster care, mental health and emergency room facilities to provide appropriate interventions. Budget Impact Analysis NO Is this item related to revenue? Is this item an expenditure? If so, please identify funding source below. General Account No: Special Revenue Account No: CIP Project No: Is this item funded by Homeland Defense/Neighborhood Improvement Bonds? Start Up Capital Cost: Maintenance Cost: Total Fiscal Impact: Final Approvals (SIGN AND DATED CIP , / er Budget/ If using or recyr l funds Grants2/ Risk Manage nt Purchasing Dept. Directo Chief City Manager Page 1 of 1 /\,„u,i2.,c3A2 City of Miami Legislation. Resolution City Hall 350D Pan American Drive Miami, FL 33133 Nww.miamigov.com Fite Numbcr: OS-0U51S Final .Action Date: A RESOLUTION OF THE MIAMI CITY COMMISSION ESTABLISHING A NEW SPECIAL REVENUE PROJECT ENTITLED: "2008 MEMORANDUM OF UNDERSTANDING FOR THE MIAMI HOMELESS ASSISTANCE PROGRAM'S DISCHARGE PLANNING GRANT', AUTHORIZING ACCEPTANCE OF THE MIAMI-DADE COUNTY HOMELESS TRUST GRANT AWARD IN THE AMOUNT OF $113,333 FOR A FOUR MONTHS PERIOD, TO PROVIDE EXTENDED OUTREACH, AND HOUSING SERVICES TO HOMELESS INDIVIDUALS REFERRED THROUGH MIAMI-DADE COUNTY JUDICIAL AND THE HEALTH SYSTEM; AUTHORIZING THE CITY MANAGER TO ACCEPT THE GRANT AND TO EXECUTE ALL NECESSARY DOCUMENTS, IN A FORM ACCEPTABLE TO THE CITY ATTORNEY; AUTHORIZING THE EXPENDITURE OF THE GRANT FUNDS FOR THE OPERATION OF THE FUNDED ACTIVITIES BY THE CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM. BE IT RESOLVED BY THE COMMISSION OF THE CITY OF MJAMI, FLORIDA: Section 1. The following Special Revenue Fund is established and resources are appropriated as described below: Fund Titie: "2008 Memorandum of Understanding for the Miami Homeless Assistance Program's Discharge Planning Grant" Resources_ Miami -Dade County Homeless Trust Appropriation: $113,333 Section 2. The Appro riation is contingent upon the receipt of the grant from the Miami -Dade County Homeless Trust and the City Manager's acceptance. Section 3. The City Manager is authorized{1) to accept the grant from Miami -Dade County Homeless Trust, to provide extended outreach and housing services to homeless individuals referred through the Miami -Dade County Judicial a, -id the Health System, and to execute all necessary documents, in a form acceptable to the City Attorney. Section 4. The expenditure of these grant funds is authorized{1} for the operation of the City of Miami Homeless -Assistance Program: Section 5. These authorizations shall remain valid and outstanding even if the grant award is reduced or increased. Section 5. This Resolution shalt become effective immediately upon its adoption and signature of the Mayor. (2) ...Footnote C"r n) Miami Page l of .2 Printed On: 6/3/2008 File Number: 08-00518 {1) The herein authorization is further subject to compliance with all requirements that may be imposed by the Crty Attorney, including but not limited to those prescribed by applicable City Charter and Code provisions. {2) if the Mayor does not sign this Resolution, it shalhbecome effective of the, end of ten calendar days from the date it was passed and adopted, If the Mayor vetoes this Resolution, it shall become effective immediately upon override of the veto by the City Commission. Footnotes: {1) The herein authorization is further subject to compliance with all requirements. that may be imposed by. the City Attorney, including but not limited to those prescribed by applicable City Charter and Code provisions. {2) If the Mayor does not sign this Resolution, it shalt become effective at .the end of ten calendar days from the date it was passed and adopted. If the Mayor vetoes this Resolution, it shall become effective immediately upon override of the veto by the City Commission. • Ciq ofmamf Pnge 2 of 2 Printed On: 6f3/2008 ._Title A RESOLUTION OF THE MIAMI CITY COMMISSION ESTABLISHING A NEW SPECIAL REVENUE PROJECT ENTITLED: "2008 MEMORANDUM OF UNDERSTANDING FOR THE MIAMI HOMELESS ASSISTANCE PROGRAM'S DISCHARGE PLANNING GRANT", AUTHORIZING ACCEPTANCE OF THE MIAMI-DADE COUNTY HOMELESS TRUST GRANT AWARD IN THE AMOUNT OF S113,333 FOR A FOUR MONTHS PERIOD, TO PROVIDE EXTENDED OUTREACH, AND HOUSING SERVICES TO HOMELESS INDIVIDUALS REFERRED THROUGH MIAMI-DADE COUNTY TUDICLAL AND THE HEALTH SYSTEM; AUTHORIZING THE CITY MANAGER TO ACCEPT THE GRANT AND TO EXECUTE ALL NECESSARY DOCUMENTS, IN A FORM ACCEPTABLE TO THE CITY ATTORNEY; AUTHORIZING THE EXPENDITURE OF THE GRANT FUNDS FOR THE OPERATION OF THE FUNDED ACTIVITIES BY THE CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM. ..Body WHEREAS, the City of Miami ("City") has been awarded a grant, in the amount of Sl 13,333, for the operation of the Miami Homeless Assistance Programs for 2008; and WHEREAS, said funds will be used by the Miami Homeless Assistance Programs to hire staff competent in providing intervention services for the ternporarily and chronically homeless as well as provide housing, transportation and other supportive services as necessary; and WHEREAS, it is appropriate for the City Manager to accept said.7ant:and to establish a special project fund for the appropriate of said grant award; NOW, THEREFORE, BE IT RESOLVED BY THE COMMISSION OF THE CITY OF MLAMI, FLORLDA: Section 1. The following Special Revenue Project is established and resources are appropriated as described below: Fund Title: "2008 Memorandum of Understanding for the Miami Homeless Assistance Program's Discharge Planning Grant" Resources: Miami -Dade County Homeless Trust Appropriation: $113,333 Section 2. The Appropriation is contingent upon the receipt of une grant from the Miami -Dade County Homeless Trust and the City Manager's acceptance. Section 3. The City Manager is authorized; 1 } to accept the grant from Miami -Dade County Homeless Trust, to provide extended outreach and housing services to homeless individuals refer-ed throunh the Miami -Dade Court v Judicial and the Health System, and to execute all necessary documents, in a form acceptable to the City Attorney. Section 4. The expenditure of these grant funds is authorized; 1 } for the operation of the City of Miami Homeless Assistance Program. Section 5. These authorizations shall remain Valid and outstanding even if the rant award is reduced or increased. Section 6. This Resolution shall become effective immediately upon its adoption and signature of the Mayol. 1 i; ...Footnote l 1; The herein authorization is further subject to compliance with all requirements that may be imposed by the City Attorney, including but not limited to those prescribed by applicable Coy Charter and Code provisions. 2} lithe Mayor does not sign this Resolution, it shall become effective at the end of ten calendar days from the date it was passed and adopted. If the Mayor vetoes this Resolution, it shall become effective immediately upon override of the veto by the City Commission. ATTACHMENT B Re: Revised Budget Modification /Justification for Memorandum of Agreement Services Miami Homeless Assistance Program, J\4iami Homeless Assistance Program is respectfully submitting for your review and approval the enclosed Budget Arnendnnent Request for Memorandum of Agreement Services Contract. The program is requesting shift in funding activities for the MCA program. Supportive Services Expense Current Budget Modification Difference 6.0FTE Community- Outreach Specialist S12.00/hour to cover for nights and weekends (approximately S25,000 per annual per staff member). reduce to 2.49 1-1.b. Total Salary FICA 150.000 71.411.59 66,336.82 5,074,77 (78.588.41) Intake and Referral Specialist for add 0.80 F 1 E @ Total Salary FICA 25.000.00 233.41 1,776.59 25.000.00 2.0 FTE Housing Specialist @ S 15.81 / hour Requestine. reduce to 1.62 FTE Total 60.000 0 Program Clerk. add 1.56 FTE @ Total Salary FICA 50.000.00 46,446,82 3,553.18 50.000.00 1.68TE Housing Specialist Supervisor @ 524.73/ Bour. Total Salary FICA 40.000 43.588.4 40,490.86 3,097.55 3.588.41 Hotel / Motel (temporary emergency housing for families) Shelter Beds 10,000 10,000.00 65,700 I 65,700.00 Transportation (bus tokens for clients Indirect Adrninistrative Costs 4,300 1 4,300.00I 0.000 10,000.00 TOTAL 340,000 340,000.00 0 A ' iALI-01E1N 1 L MIAMI-DADE COUNTY AFFIDAVITS The contracting individual or entity (government or otherwise) shall indicate by an "X" all affidavits that pertain to this contract and shall indicate by an "N/A" all affidavits that do not pertain to this contract. All blank spaces must be filled. The MIAM!-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI-DADE CRIMINAL RECORD AFFIDAVIT; DISABILITY NON-DISCRIMINATION AFFIDAVIT; and the PROJECT FRESH START AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies thereof, the State or any political subdivision or agency thereof; it shall however, pertain to municipalities of the State of Florida. All other contracting entities or individuals shall read carefully each affidavit to determine whether or not it pertains to this contract. Affiant , being first duly swom state: The full legal name and business address of the person(s) or entity contraction or transacting business with Miami -Dade County are (Post Office addresses are not acceptable.): Federal Employer Identification Number (If none, Social Security). Name of Entity, Individual(s), Partners, or Corporation Doing Business As (if same as above, leave blank) Street Address City State Zip Code 1. MIAM!-DADS COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code) 1. 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 perce- (5%) or more of the corporation's stock. If the contra'' or business transaction is with a partnership, the foregoing information shall be provided for eacn partner. It 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 forgoing requirements shall not pertain to contracts with publicly -traded corporations or to contracts with the United States or any department or names and addresses are (Post Offices - add resses are not acceptable): Full Legal Name Address 1 Ownership Page 1 of 5 2. The full legal names and business address of any other individual (other than subcontractors, material men, supplies, laborers, or lenders) who have, or will have, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Dade County are (Post Office addresses are not acceptable): 3. 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 the County jail for up to sixty (60) days or both. II. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County Ordinance No. 90-133, amending Sec. 2.8-1; Subsection (d)(2) of the County Code). Except where precluded by federal or State laws or regulations, each contract or business transaction or renewal thereof which involves the expenditure of ten thousand dollar ($10,000) or more shall require the entity contracting or transacting 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 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 No 3. Provide a current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender. White: Males: Females: Asian: Males: Females: Black: Males: Females: American Indian: Males: Females: Hispanics: Males: Females: Aleut (Eskimo): Males: . Females: Males: Females: Males: Females: Ill. AFFIRMATIVE ACTION/NON-DISCRIMINATION OF EMPLOYMENT, PROMOTION AND PROCUREtviENT PRACTICES (County Ordinances 98-30 codified at 2-8.1.5 of the County Code) In accordance with County Ordinance No. 98-30, entities with annual gross revenues in excess of $5,000,000 seeking to contract with the County shall, as condition receiving a County contract, have I) a written affirmative action plan which sets forth the procedures the entity utilizes to assu:a that it does not discriminate in its employment and promotion practices; and ii) 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 affirmatives 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 notwithstanding, corporate entities whose boards of directors are representatives 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 written affirmative action plans and procurement policies in order to receive a County contract. The foregoing presumption may be rebutted: The requirements of County Ordinance No. 98-30 may be waived upon the written recommendation of the County Manager that it is in the best interest of the County to do so and upon approval of the Board of County Commissioners by majority vote of the members present. Page 2of5 The firm does not have annual gross revenues in excess of 55,000,000. The firm does have annual revenues in excess of'55,000,000; however, its Board of Directors is representative of the population make-up of the nation and has submitted a'written, detailed listing 'of its Board of Directors, including the race of ethnicity of each board member, to the County's. Department of Business Development, .175 NW 151 Avenue, 28'h Floor, Miami, Florida 33128. The firm has annual gross revenues in excess of 55,000,000 and the firm does have a written affirmative action plan and procurement policy as described above, which includes periodic review to determine effectiveness, and has submitted the plan and policy to the County's Department of Business Development, 175 NW 151Avenue, 28`h Floor, Miami, Florida 33128. The firrn does not have an affirmative action plan and/or a procurement policy as described above, but has been granted a waiver. IV. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2-8.6 of the County Code) The individual or entity entering into a contract or receiving funding from the County has has not of the date of this affidavit been convicted of a felony during the past ten (10) years. V. MIAMI-DADE EMPLOYMENT DRUG -FREE WORKPLACE AFFIDAVIT (County Ordinance no. 92-15 codified as Section 2-8.1.2 of the County Code) 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. g ,-': 5 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...fundine, which is provided in whole or in part by the United States of 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 government entities. . VI. MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Crdinances No. 142-91 • codified as Section 1 IA-29 et. Seq of the County Code) 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 workweeks, shall provide the following information in compliance with all items in the aforementioned ordinance: Page 3 of 5 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 serious health condition without risk of termination of 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. VII. DISABILITY NON-DISCRIMINATION AFFIDAVIT (County Resolution R385-95) That the above names firm, corporation or organization is in compliance with the 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 provisions 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. 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, the State or any political subdivision or agency thereof or any municipality of this State. VIII. MIAMI-DADE COUNTY REGARDING DELIQUENT AND CURRENTLY DUE FEES OR TAXES (Sec. 208.1 (c) of the County Code) Except for small purchase orders and sole source contracts, that above named firm, corporation, organization or individual desiring to transact business or enter 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 Coiiector as well as Dade County issued parking tickets for vehicles registered in the name of the firm, corporation, organization or individual have been paid. IX. CURRENT OR ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS 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 or any contract, promissory note or other loan documents with the County or any of its agencies or instrumentalities. X. PROJECT FRESH START (Resolution R-702-98 and 358-99) Any firm that has a contract with the County that results in actual payment of $500,000 or more shall contribute to Project Fresh Start, the County's Welfare to Work Initiative. However, if five percent '((5%)-of the- firms-work-force-consists-of individuals.who_reside,in.Miami-D,ade_._...._ County and who have lost or will loose cash assistance benefits (formerly Aid to Families with dependent Children) as a result of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, the firm may request waiver from the requirement of R-702098 and R-358-99 by submitting a waiver request affidavit. The foregoing requirement does not pertain to government entities, not for profit organizations or recipients of grant awards. Page 4 of 5 XI. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified at 11A-60 Et. Seq. of the Miami -Dada County Code). 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. 1 have carefully read this entire five (5) page document entitled Miami -Dade County Affidavits and have indicated by an "X" all affidavits that pertain to his contract and have indicated by an "N/A" all affidavits that do not pertain to this contract. By: (Signature of Affiant) (Date) SUBSCRIBED AND SWORN TO (or affirmed) before me this day of 90 by . He/She is personally known to me or has presented as identification. (Type of Identification) (Signature of Notary) (Serial Number) (Print of Stamp of Notary) (Expiration Date) Notary Public — State of (State) Page 5 of 5 SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a) FLORIDA STATUTES ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1. This form statement is submitted to by. (Print individuars name and tide) for (Print name of entity submitting sworn statement) whose business address is and if applicable its Federal Employer Identification Number (FEIN) is If the entity has not FEIN, include the Social Security Number of the individual signing this sworn statement. 2. I understand that a "public entity crime" as defined in paragraph 287.133(1)(g), Florida Statues, means a violation of any state or federal law by a person with respect to an directly related to the transactions of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to any bid or contract for goods or services to be provided to public entity or agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misinterpretation. 3. I understand 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 an federal or 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 a plea of guilty or nolo contendere. 4. 1 understand that an "Affiliate" as defined in paragraph 287.133(1)(a), Florida Statutes means: 1. A predecessor or successor of a person convicted of a public entity crime, or 2. An entity under the control of any natural person who is active in the management of the entity and who has been .convir'rFd 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 a 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. • 5. ! understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statues. means any • natural person or entity organized under the laws of any state or of the United States within the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or entity. The term "person" includes those officers, executives, partners, shareholders, employees, members, and agents who are active in management of an entity 6. Based on information and belief, the statement which 1 have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.) Neither the entity submitting sworn statement, nor any of its officers, director, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. 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, or an affiliate of the entity had been charged with and convicted of a public entity crime subsequent to July 1, 19B9, AND (please indicate which additional statement applies. The entity submitting this sworn statement, Cr one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent proceeding before a'Hearing Officer of the State 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. (attach e copy of the final order). 1 UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 {ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND THAT THIS FORM IS VALID THROUGH DECEMBER 31 OR THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT i AM REQUIRED TO INFORM THAT PUBLIC EN T IiYPRIOR TO ENTERING INTO A CON i PACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN . SECTION 287.017 FLORIDA STATUTES FOR A - CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. (Signature) Sworn to and subscribed before me this day of , 20 Personally known Or produced identification Notary Public -State of My commission expires (Type of identification) (Printed, typed or stamped commissioned name of notary public) ATTACHMENT D NOT APPLICABLE ATTACHMENT E NOT APPLICABLE Attachment F Miami -Dade County Homeless Trust Invoice For Services NAME OF AGENCY: The City of Miami SERVICE PERIOD: TO NAME OF GRANT: Memoranda of Agreement (MOA) Program GRANT NUMBER: PC-0910-MOA TOTAL AWARD AMOUNT: AMOUNT OF FUNDS REQUESTED THIS MONTH: AMOUNT OF FUNDS RECEIVED TO DATE: BALANCE REMAINING ON GRANT: (following payment of this request) $ 340,000.00 $340,000.00 Signature of Agency Representative Date Printed Name of Agency Representative i 12_perating Persons Served during the oyear- Miami , r u t Lace nterinn Data AS: Currently Shadavding: Home J ClientPoint I ResourcePoint ShelterPoint Logoff Setter I:Vey :nar Li' 57•00Gs1Sj SkanPoint wetter Way Shsre (FLiti 30(?-j) Glenn f erna_ir. FRePorts `— I$UD Annual Progress Report (HUD-40118) (ServicePoint 4.05 version) eport Options: rovider Operating Year Date Range Legal Adult Age r: This provider AND its children. le This provider ONLY. to (mm/dd/YYYy) i.(as defined by foster rare law in your state) -Select- Or Or iNumber of Singles !Not in Families Number of Adults in Families Number of Children in Families a. Number on the first day .of the operating year. �b. Number entering program during the.operating year. c. Number who left the program during the operating year. d. Number in the program on the last day of the operating year. (a+b-c=d) Capacity. �. I. ff Number of Singles �Not in Families a. Number on last day (from 2d, ?columns 1 and 4) I ' 14. Non -homeless persons. (Sec. S SRC projects only) . ?How many income -eligible non -homeless persons were housed by the SRO program during the operating year? 0 0 0 0 0 I 0 D !Number of Adults in Families 0 Number,-•f Childre;, :n Families Number of 11 Families 5. Age and Gender. Of those who entered during the operating year, how many people are in the fo llowing owing age and gender categories: !Single Persons (from 2b, column i) • !Age a. 52 and ove 0 0 0 0 0 {Male Female I D Other/Not given 0 b. 51 - ht l :,i\y\\�\ 4.sL'i\ C'.kilt.con-ifrn;a1]ii'gcri'iLS�ti\'� Tc'j10i1�1LP!;(I: �')lh 0 0 ika. Mental illness �b. Alcohol abuse c. Drug abuse r; ci. HPJIAIDS or related diseases !le, Developmental disability if.Physicaldisability a. Domestic violence jc. 37 • 5U 161. 18 30 ie.1 ; and under 0 0 • 0 ll i( ;Not given i1Per-sons in Families (from 2b, columns 2 & C) if. 62 and over I o 0 0 0 0 0 g.51 -61 0 0 0 .. i Ih.31-50 0 0 0 i.18-30 0 0 1 0 I ii.13-17 0 0 0 1 Ik.6-12 0 0 p ( 11.1-5 0 0 0 m. Under 1 0 _ 0 0 Not given 0 0 0 6 - 10. Participants who entered during the operating year. ii6a. Veterans Status. IA veteran is anyone who has ever been on active military duty status. Ob. Chronically Homeless. How rnany participants were chronically homeless individuals? l' 7. Ethnicity. a. Hispanic or Latino 1b. Non -Hispanic or Non -Latino IS. Race. la. American Indian or Alaskan Native ! 0 b. Asian i p � c. Black or African American —, d. Native Hawaiian or Other Pacific Islander e. White f. American Indian/Alaskan Native la. Asian & White th. Black/African American & White White °i. American Indian/Alaskan Native 6. Black/African American j. Other Multi-Racia lc. Other/Unknown (aIl that do not match) 9a. Special Needs. �._G.�.__..._•---._._.-...__.,..., jh. Other (please specify) . r i9b. Disabled. i'How many o` the participants are disabled? 'J10. Prior Living Situation. Participants slept in the following places the weekprior to entering. All 0 0 0 0' 0 Chronic 0 j11 0 0 0 0 0 blips Y\\'fit.:Scl'V]C'.CIA.c•!1111'111iLII111,`SGTiptsisvpr porihud4):'.phri (/ i s: 200Q /Ib.1 to 2 months c. 3 - 6 months i Chroni: 'a.Non-housing(str Sttit, prk, C_.rbus on, b. Emergency shelter Transitional housing for homeless prsons 0 o d. sychatrc facility Ie. Subsnce. abuse treatment facity f. Hospitl . Jail/prison h. Domestic violence situation 0 i. Living wth relatives/friends j. Rental housng ic. Other (please specify) 0 IL. Amount and Source of Monthly Income at Entry and Exit. Participants who left during the operating yar. Amount A. Monthy Income at S.Monthly income a Entry I Eit • Chronic Ail ! Chronic a. NoIncome b. $1-150 0 c. $151 - $250 0 0 d. $2 - $500 0 0 e. $501 51000 0 001 51500 0 0 g. $1501 - $2000 0 0 0 h. $2000 0 10 0 So urce C. Income Sourcs at + D. Inome Source= at Entry I Exit AI Chronc Chronic a. supplemental Seurity Income (SS b. Socal Security pisability Insurance .(SSDI) 0 c. Social Security 0 0 d. Generl Public Assistance e. Temporary Aid to Needy Fmilies (TANF) f State Childrens Heath Insurance Program (SCHIP) 9- veterans benefits h "'mpioyment Income 0 0 0 0 0 0 0 i. Unemployment Benfits 0 0 j. vtern's Heth Care O p ! 0 I 0 Ic. Medicad I. Food Stamps O ( 0 I01 0 O 0 .i0 0 m. 0ther (please speiy) n. No finncil resources O 0 0 0 12a. Length of Stay in Program. Participants who left during the operating year. Al Chronic 0 hri s:liwww4.servietptcon liarnis:Tipts/q Treporthucl405,php Id. 7 months - ._ months le. 33 months - 24 months 25 months - 3 ears lIg. 4 years - 5 years i h. 6 years - 7 years li. 8 years - 10 years f l D 0 0 0 0 0 0 0 0 j. over 10 years 12b. Length of Stay in Program. Participants who did not leave du 0 0 g the operating year. 0 0 1+ All Chronic a. Less than 1 month b. 1 to 2 months 0 lc. 3 - 6 months id. 7 months - 12 months 0 0 e. 13 months - 24 months 0 0 f. 25 months - 3 years 0 0 g. 4 years - 5 years 0 0 h. 6 years - 7 years 0 0 i_ 8 years - 10 years 0 0 j. over 10 years 0 0 3. Reasons for Leaving, Participants who left during the operating year. I All I Chronic a. Left for a housing opportunity before completing program 0 b. Completed program c. Non-payment of rent/occupancy charge d. Non-compliance with project e. Criminal activity / destruction of property / violence . Reached maximum time allowed in project 0 I 0 g. Needs could not be met by project h. Disagreement with rules/persons i. Death j. Other (please specify) 0 0 0 0 0 0 !I Unknown/disappeared + 4 lfk. (14. Destination. Participants who left during the operating year., I Ar Chronic !PERMANENT (a - h) a. Rental house or apartment (no subsidy) ) 0 1 0 1 ;b. Public Housing 1 0 I 0 I i Ic. Section 8 10 ` 0 rti I TRANSITLONAL (i - j) I_IN_TITUTION (k - rn) If Id. Shelter Plus Care Ie.- HOME -subsidized -house or.epartrnent If. 0ther subsidized house or adornment lg. Homeownership Ih. gloved in with family or friends • Ii. Transitional housing for homeless persons lj. Moved in with family or friends II;. Psychiatric hospital L Inpatient alcohol/drug treatment laciiity h)LLpS_/'/\vw'Sv',.Senicept.GO1T7 /I111amit'isl"Ipt;/svprej)Ort)IUC.I•+(l).p1)1 l0� 0 0.... IdI I as] 51'1009 !EMERGENCY SHELTER (xi) In. emergency shelter OTHER - o) I io. ()Thai supportive housing ip. Plates not meant for human habitation (e.g. street) lq. abler (please, specify) I 0 i 0 it o UNKNOWN ir. Unknown 15. Supportive Services. Participants who left during the operating year. NOTE:The below services were given to participants who left during the operating year. Add the following counts into the appropriate category for question 1E.. Service Service Code f MI Chronic Transitional Housing/Shelter SH-6600 ServicePoint version 4.06.022 (db build 41222) • Licensed to: Mmi Dade Homeless Trust ©19.99-2009 Bowman Systems AI! Rights Reserved. CPT only ?2D04 American Medical Association. All Rights, Reserved. (9/10/2004) IDSM and 05M-1V-Tif are registered trademarks of the American Psychiatric Association, and are used with permission herein.(2000 ?1994 National Center for Health Statistics (1CD-9 ?World Haalt.ti Organization). All Rights Reserved. Taxonomy of Human services ?1983-2006 Information and Referral Federation of Los Angeles County, Inc, Al Rights Reserve.d. (6/.25/700 httr)5)://isrirwv,r4.si•cirVicept.con-ifiTiliainit:iici- priepon.huci405.plip • 1 5120i:i9 ATTACHMENT H NOT APPLICABLE ATTACHMENT I NOT APPLICABLE ATTACHMENT J NOT APPLICABLE ATTACHMENT K NOT APPLICABLE ATTACHMENT L Miami -Dade County Homeless Trust Annual Actual Expenditure Report The City of Miami -.Memoranda. of Agreement (MOA) Contract Period: October 1, 2009 - September 30, 2010 Name of Agency Contract Number: The City of Miami PC-0910-MOA $ 340,000.00 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 Balance Remaining. 0 $ 340,000.00 i J 1. iiiiCa lcn Niimber and C:.ir(iica; ✓il Give form is.; the- ,: requester. _e., -end to ii•:e v • . enn_.., i.. fie.. ln: co..: Ri:0er,!: tL1 50 :Jala87 2. I_ �, Is_c ina:cCle;n:, P'o3re:;: Inumbs. mre ii. an. one Ur :unt- n n.L tiu-Q__ . rn• City, :::11_', and:ZIP 00 51 numper(st hcrr rnplicra l; s; tLire aoso to i 3�t��• rice fin Taxpayer identification Number (TN) Enter your TIN in the appropriate box. The: TIN provided mosi match the name givenoir Line 1 le avoid backup withholding. For individuals. this is your social security number (SSId). However, for a resident ' alien, sole proprietor. or disregarded entity, see the Par, 1 instructions on page 3. Foi other entities, is your employer identification number (Ells!). If you do not have a number, sea How io ;51 a TIN on page 3. Nola. Ii the account is in more than one name. see the chart or. cage 4 for guidalin, on whose number to enter. Snciat security number Dr Employer ioentifical.ion number Goad 3->S . Ce.rifcafion Under penalties of perjury. I certify that: 1. The number shown on this form is my correct taxpayer identification number (or l am waning, for a number to be issued to me). and 2. ! am not subject to backup withholding because: (a) I am exempt from backup virbedldinq, or (b) I have not been notified by the ln':ernal Revenue Service (IRS) that f am subject to backup withholding as a result of e falure to report al! interest or dividends. or tc) the IRS has notified me that I am no longer subject so backup withholding, and - 3. I 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 tailed to report all interest and dividends on your tax retum. For tea! estate transactions hem 2 does not apply. For morgaoe interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirarnanl 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 on page 4. Sign I Here J U.S. person h- Gerleraf Instructions Section references are to the internal Revenue Code unless otherArise noted. Purpose of Form Cate H I�rISQ�1"( e��1 t act a • Definition of a US. person. For federal >; purposes, you are considered a U.S. person if you are: E An individuat who is a U.S. citizen or U.S. resident alien, s A partnership. corporation, company. or association created or organized in the United States or under the taws of the United A parson who is required to file an information return with the Stales, IRS must obtain your correct taxpayer identification number !TIIl) • .4n eoate (other than a foreign estate). or io report, for example: income paid to you, real ^sate transactions, morgaoe interest you paid, acq.^°r11.on or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use norm !4r-9 only if you urea L'.S. person (including a resident alien). to provide your correct TIN to the person ;Roue ting it (the requester) 'and; vflun cn¢;iccb» e, 1. Certify that the TIN you are givrrlci is corm:at for you are waiting inn .1 num;: ,r to be cued;). Certify thni i.bi; ale nor. subject its 'ine:h g ✓ 11h01iding. a; L`.I0I7. .v, p1!DIl fl'Ctr. _..,.;I.: :'101111 Jt=1., 1.. li 2i',,' ` 1i;a1 _. .::lrr r!/! w.. S!;; 1': - _ in_,,, _ .I.t.. �nl• iron.: ri U.S. . 'trade _.. oustneh , n. I .1.. line n Ir l:!n1Oin:. :';:Ill Icnt_. _ - J .t:. ,[+rrl ri' :7, :r-. t A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnership_, that obvious) a trade or business in the United Stales are garle.ully required iv pay a withholding tar on any foreign canners' share of income from such business. Further, in cerlain c..c_s where is Form V:f- . 31. not teen r1.Cei050, a partnership !;. required ID Dresurl_ It',at banner is a lnreign person, ono pay the withholding t3.. . Tiler for-_, (you are a U.S. ;person that is a p3niter in 3 ;:3nner:his conducting a tra;13 or business in the :inAsta f;grin^• ;^11, It, iv-Az:Nish l fur _Vorc. ,:!hlrl,nta11_c au. allay ... _ aI.•ri it:: .fate =Ureign person.. :'q1• a.c - c - Ir:sts - _tr usetn-.._...gx�_,:= .arm 111ilninDadz' T_ . or. t::nra;,:es; L..i:_.fix and =errpn Eniiti Nonresident aiien who becomes a resident alien. Generally, only a nonresroe:nt aiien I:ncfivrotJ rcay :.,_e the terms t a tay treaty toreduco or eliminate U.S. to>: Cr. ce:-ou. types a inronl5. However, most tax ireo`Leo oontaln a pr0vslor: known saving clause." E>:cepiions specified In the saying C:I3LIse may permit an exemption from to : to continue for certain type: of 'income even atter the payee has otl'lerv:':ce become e. U.S. resident alien for is,: r Jrpo es. If you are a U.S. resident alien v;Pio is relying on an el;_ option contained in the saving clause of a tat:. treaty to claim an exemption from U.S. tax on certain Types of .income, you must attach a statement to Form W-0 that specifies the following five items: 1. The treaty country. Generally, this must be the same.treaty under which you claimed exemption from tau: 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 exemption from: tax. 5. Sufficient facts to justify the exemption from ta:: under the terms of the treaty articie. • 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 tax purposes if his or her stay in the United States exceeds 5 caiendar years. However,.paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1964) allows the provisions of Article 20 to continue to apply even ewer 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 tar, 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 lit%-8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 289,6 of such payments. This is; called "backup withholding." Payments that may be subject to backup withholding include 'terest, tax-exempt interest, dividends. broker and barter exchange transactions, rents, royalties, nonemployee pay. and certain payments from fishing boat operators. Real estate transactions are rot subject to backup withholding. You will not Inc subject to backup withholding on payment:; ..r; r'c'•"y-wa•i1 .you owe: the r'eeveslef your correct TIN. make: the. proper ce:ificaticnc, and repot! ail ,'our taxanre interest dividends on your tax return. Payments you receive will be s.uoject to backup with hotdinp if: • t You nOi ftir!> 1,'._slit Tilt ii tits IYS:j:!:Ji::", . ru,..,; - .',ur TII . �n�", re-re-tiro-ed.nr�r: _: 'xn't I Ir._i!LE 11-7)H :: ., 1`,7 T ,e!i n .-._ .. ..Ira =r. •ice. --- s. are .. Lad yr:into:sin,g. .0:1 - .•_o0c0:uk s,rd-y ' . p3' men:s are t,.err.,c . fro . inhoidlr,q 2' theinstruction. betaw an: the. . Instruc i n: io: the P U,wster 0; Fora, SSG se- �81 ruin:, io7 Penalties failure• fa furnish TIN. If you tail to lurnisll your correct TIN to a requ=_ctci, you ar su:ije71 io a penalty of is 0 for each such failure unless. your failure✓ is due to rsrsonabie cause and not 1u vailliul neglect. Civil penalty for false information with respect to withholding. 11 too make a false siaiemenl with no reasonable basis that resultein no backup withholding, you are subject to a S500 penalty. Criminal pe.naliy for falsifying information. VVillfully falsifying certifications or afftmlatiorS may subject you to criminal penalties including fines and/or imprisonment. Misuse of 'Mils. If the requester discloses or uses Tih's. in violation of fader/ law, the requester may be subject to civil and criminal penalties. Specific instructions Warne If you are an individual, you must generally enter the name shown on your income tax return. However, 'r,' you have changed your last name, for instance, due to marriage without informino the Soca! Security .Administration of the name change, enter your firs: name, the last name shown on your social security card, and your new last name. the account is in joint names, iist first, and then circle, the name CI the person or entity whose number you entered in Peri I of the, form. Sole proprietor. Enter your individual name as shown on your. income ia>:•retum on the "Name" line. You may enter your business, trade, or "doing business as (DEA)" name on the "Business name' line. Limited liability company (LLC). Check the "Limited iiabiiity company' bo>, only and enter the appropriate code Tor the tax classification ("I)" for disregarded entity, "C"for corporation, "P" for partnership) in the space provided. Fora singie-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate iram its owner under Regulations section 301.7701-3, enter the owner's name on the "Name" line. Enter the LLC's name on the 'Business name" hne. an LLC classified as a partnership or a corporation, amen the LLC's name on the "Name" line and any business, trade, or p=;`. name on the "Business name" line. Other entities. Enter your business name ar shown on required reuera, tax doccmeta on tn2'bIame" line. This name rhnuld match the name shown on. rite. ; ttter.l0{ial dacurneint creating Ilti' entriv. You met enter an,/ business. trade. or 11E;> name or:llr_ cusi!:etc her: `ins Nnie. 'sin, Zee rqus:beCi k: cliecti the Jnproprlate 1;m. ' :'C;metoi.,:0rn, nlli,5n. :lie... _Exempt Payee ekempt. from....::i::,_, v.:nhh.,l:i:n' :..,r, anti ..... ., : ..-.,..._; .._..._..,..... ..I-. st,e or Note.. !Du ore - -.... roc. _;i n, •-r; s .�.. _.,.::,._._ ._ :.,.,..._ _._,,isle efrc,rieouz. t_tiowiiic (:r:dee:. ere so:ern;:'. from .re c1:10 tircanization exempt from : unoer section;Oita;, any IF:A or a cuSlao:al account finder section 4J3(b)(1) ii the account cai!;iiee the repuiremen1L of .._dior, 401E)(21. 2. The United Mates or any ni it ag_ncieo. or insfrumentant:e,, 3. A state, the District of Columbia, a pos0 ecsion of the United Stales, 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 o1 is agencies or instrumentalities. Other payees that may be exempt from backup withholding include: - 6. A corporation, 7. A foreign central bank of issue, 8. 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 584(a). 13. A financial institution, 14. A middleman known in the investment community as a nominee or custodian, or 15. A trust exempt from ta>: under section 664 or described in section 4947. Tne 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. IF the payment is for .. . THEN the payment is exempt for... Interest and dividend payments All exempt payees except for 9 - Broker transactions I Exempt payees-1 through 13. Also. e person registered under the Investment Advisers Act of 194(1 who regularly acts as a i broker ;saner exchange 1rar1_.7ctiOns and patronage dividends Exomp1 payees 1 i hrough 5 . 9:r .t:_,n:o cive,- 9,,.59 r._oui,r'ci it, ir(: reonr,ed and direct soles i , .ocr!1\ _ ontut nay, i though _ . tint I,.LI nn,•„ u: ..5,111' 1,.. CU •'r'I:i'„v i:•i:..IG rr n.� F:gnoi.-amc. .(1_i era::Urn '1:. on„nr.:;::. .Y.:C. n•`y:. ;:...... _:C rovr, •,1;- i:r r. ,c.. , ,:I, ..._..air. ; .•r:vily„ I... rarj i. iE;E'ybr ic�nti ic_tisi Num ;3r FIN) UN) Enter yes: 7IN in the appropriate box. l; _.. e' res;oerr: ari `. ;au' GTI!d.. Eni : :rl :.'Ic 1,.<el a__urm' rc:,.._, ...,,.. I1 - ,c.. ❑aa5 ar, GINI see Hoe io der a Tit! beiti .' li you Er-: a sot _rrepnclor and ou ha,„5 ar, EFT •,':,c may ernes e;'..he; vclw SSN of EIP!. However. the IR prefers _ Ih31 you c:e your',S1J. li you are a smote -member LL that is di regarded es on entity sep rase from its. owner (see Limiled Ii&burly company (LC) on pane 2), enter the owner's SSN for EIIJ, r the ov:ner has one). Do no; enter the disregarded entity's, DN. li the LLC :. ciacsifiec as a corporation or partnership, enter the entity's EIN` Note. Sec thre chart on page 4.for further clarification, of name. and TIN 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 iorm online at www,cce.00'. You may also oat this form by calling'-o00-772-1213. Use Form VI-7, Application for IFS Individual Taxpayer Identification Number,to apply for an ITIN, or Form SS-4. Application tor Employer identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS websiie at w> na.irs.00vlbusinesses and clicking on Employer Identification Number FIN) under.Starting a Business. You can gel Fonns 141-7 and SS-4 from the IRS by visiting wwvr.irs.gov or by calling 1-300-TAX-FORM (1-600-829-3676). If you are asked to complete Form W-9 but do not have a TIN, write "Applied For' 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 respeci io readily tradable instruments, generally you will have 6D days to gel a TIN and give ii to the requester before you are subject to backup . withholding on payments. Tne 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 regtester. 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 LISP the appropriate Form Vie-o. - art U. Certiiicaticin To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form V1/4,-9. You may be requested to sign by the withholding agent even if items 1, 4, and 5 below indicate otherwise. For a joint account, only the person whose Tl!'l is shown in Part I should sign (when required). Exempt payees, see Exempt Payee on page 2. Signature requirements. r-.-:plele the certification as indicated ,n 1 through 5 below. 1. interest, dividend. and barter exchange accounts opened before 1964 and broker accounts considered active duff i w. •''tiff _ - ,.,, eesi' e! b.i.ft yciti do have t, sign the Cr'lii%IC3lion.-• • 2. Interest, dividend, broker, and barter oxoilange accounts opened attar 19E3 and broker accounts considered inactive during 1953. Ytn: muc: ;'•0qn the pen i:t.. li,,r::1 fast,: v.'ith`1 d m? -.i: c:,:n}. I: '' 1,are funk,,t t'. i t,: ..il.ic,i tin:: and )"U a .• nietety pr5VIairl0 yo: 1' '.orr5:: TIN tc 0r. Mot.: ciittco:1.I1iteni f;:::!1;11:. 1•'.c, LiLni. • E t.).--;• Roe ! ectate transactions. sen:f:eabr. tiDt: =.10::E. triutt ;tam tne seibfisat:pn. 4. Dther payments. rritfE.7 yOul nry. neve ab7.r. trie risve beer. no:ii?ed 1r2f you oreviouzn„, oY-fer. ar. Tte. "Dtre7 c)ayrriem.z." n Lj520"n,9rsls, maoe. :Y 119cource EittODE Or Gut-Artier:Er.: tor reras, rcyailE. goods bather than biiis far rnerchanolree.;, medic57 and health care- service:. Onc.iuding payments to corooretions;. payments 12 a ripnemoicvee for servIses, payment: lI ce.bair1 fisrrind boa) crew members anc fishermen, and drciceproceeds paid to attorneys (including payments 5c corporaiinnOl. 5. Morigage interest paid by you, -acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer IV:SA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, bul you do ripl have to sign the ceriitication. What Name and Number To Give the Requester For this type of account Give name and SSN of: 2. Two or more individuals ()rant account) 2. Custodian account ol a minor (Uniform Gill to Minors Ac1) 4. a. The usual revocable is:airings trust (grantor Jr., also trucitee) b. Go -called trust account trial la not a legal or valid trust under state law 5. Sole proprietorship Of disregarded entity owned by an individual The inclivieual The actual ovone 05 the account or, il combined funds, the first individual on triE account The minor The. oranior-trustee The actual owner • The owner For this type of account Give ;name and 915102 5. Disregarded e.ntiry nol cterned by an individual 7. A valid trust, esnete, or pension tnitil 2. Corporate or LLG eletaing corporate. status on Form 8E32 9. Association, club, religious. • The organization charible. educational, or other tan-exernot organization 11). Partnership or multi -member LLC 11. A broke+ or registered nominee 12. Account with the Department of Agrictiture the name of a public entity (Such as a state or local government, school district, or prison) that receives agricultural grog racrt oar -Fonts The owner Legal erne), The corporator The: partnership The broker or nominee The puble. entity • one circle Inc namo o/ 11. rcrron whoor number you tro.h. 11 only flnr ocmon On a joint 01100011 hart an 5E.314, that pea:on', number thin hO, 1011,1.11011. CIrcle It. rumor*, Sons ant) lurnish 11,0 neloorlz 520, You muni yon, mdlyiclust nom, one you nwly Also •,r buonos, "ODA- nom, On Itl. 5CLand narru: 1,00, Yoll may uso vilocr your t.1.9.1 tit EN 130 11. 1117 Ol1.2,1p. you 10 unr you, Ettin•r, norr. ol cron,, I run:. ff. not 11,7111 riorrroml tcoror.n1311vo flr 111,1,1, Org., in, Moor nnIrly OoO11111,I1Od accoun1 1111, Al, Ilp,ulrolc,, 4,1 1.1,. r - Note: If no name- is .circteor.w:!,teri more Nen one nPme is ±irned. the nomener will be considered ic be that 01 the firs) ineme 07001 S.2::ure Vciur Tax Fle.,,cords from itity Thstt : iceriub :het ciscJrs someor.e uriet yr:Jr oeyscna. itririrt-iEti:r a:. your -one, soca: securny run.:Der orner trilEarriEtraiit, oerm:ccion ts dornmr. 'tsuc 7.tritsi rs.su use ylrlir 1C• F.DC, reiurr: Sl;'.1;1.1 E r5tUriC. rettuee 1124Il 41. FFIN, • ErISUre youi employer rs ',Drolacting your aud • Be careful When 2ri0Ot2n2 15Z prepver Cal: the IRE at 1-803-629-1040 h you think yoin identqy hos - been USeC/ Inappropriately for too: purpon.es. ViC/IMS ol identity theft who ar0 experiencing economic, horm tUr a system problem, or are seeKing he!rai in resolving tax problems that have not been resoived through norma: channeis, may be eligible for Taxpayer Advocate Service (TA,S) 510511515100. You can reattb TAS'hy calling the TAS toll -free case 'Make line •1 1-977-774778 or 1-"Ni7DD 1-800-C29-4059. Protect yourself from suspicious ernails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emaila and websft.es. Tho most common act is sending an email to z user falsely claiming to be an established legitimate enterprise in an anemic)t to scam the user into surrendering private information that w4 be used for identity theft. The IRS does not initiate contacts with taxpayers via emeiis. Also, the IRS 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 iron the053, forward this message, to phishing4irs.gtov. You may also radon misuss of the IRS name, loco, or other IRS personal property to the, Treasury Inspector General for Tay. Administration at 1-800-356-454. You can forward suspicious emails to Inc Federal Trade Commission at: spair@uce.gev or contact them at www.consurnergavlidthek or 1-377-IDTHEFT(432-4338). Visit the IRS website al WWW .irE.gov to barn more about identity theft and how to reduce your risk. Privacy Art Notice I7571-0r, I7/OlClo vuu, n,,00n2 1 I It; vmr, la• rlivitirnr.in. r)rrtatii itnornii• ir• ypvripirloapti inintest yriit riant. liir uitetitenititi tit etientionment cit seri/run nrci, env cait..ritetirit uent Rin 11, D117:1Olu:O:1311:1 lre YOU: ct,L, nlv, n.;:noriul IV:V.1C. n11.1 . iry• titrotp. tr,/, . ;a, mrd, nnt• inttviitirtizr 31nnto= 11.• i,r1:1117.11 .11, :T.::: r)ptyin, Tlt: i•.rietritv :it ivit• e•t• liir Lyi ft:1;r,, tti.•,,,,nt lonllruon ott,••.•-r. vror• Jur, INCIDENT REI)C_JRT CHECK IF CRIT1 CAI VII I rDENTIFVENC; INFO RMA Ti ON .Reponine l'any Phone • Repo1iiy2 Pariy Name Contract Provider Nallle. ProLt-ram Narn PIDV/Ch.:.1" LOCaliOn Dalt of inc TimeTini i Incicleir ann Specific Prozram: (check all that apply) 0 .HT 0 Primary Care 111 SHP L Emergency 0 Challenge S:nectficlocazion/ arldrcss jpJj cre inLidezrzt occarrcd: TITE OF INCIDENT Li ALTERCATION E CLIENT DEATH Li CLIENT INJURY OR ILLNESS THEFT SEXUAL BATTERY 0 SUICIDE ATTEMPT Li PR OPER 7.).. 1).4A/14 GE OTHER INCIDENT PAR TICIPAP•117(S) i WITNESS (ES) IP Ic:rst• mark \ V or I'(or C 121: W:1111'..:5S Or Pdll iCip:1711 I - LAST NA ro R E. FIST • I PE..NTIFIER # CLIENT Eivill.,Cr\ Tf.. OTHER • 0.. fil 0 Li 0 illi ' Li D I L I D Y.= DESCRIPTI ONOF ENCIDD-T — Ivirzn WhY h(,v, p2.2t!. CGRRECTFVE ACTION AND FOLLOV\' UP Jrnmed. te corrective action taken Is follow up action needed? • • 1f yes, specify D Yes No INDIVIDUALS NO TITLED Abuse Registry 1-R00-962-2R73 Applicable Law Enforcement Department Indicate name c),-rattrson contacted, if repori was accepted, the date and time f callcd or copy ofreporI idiii1i.•:eporrg — Thc rims., report Ivilarni-Dade County 1-lonicles3 Trust inform:pit») relaiLtd ;thy criftezil duriny he adminisiTatitart term preerams. In aciciittim 11rcpunim; this incident to hi atiproprittic :IIItuiriiits It. Sttitccipkni must wir:titt. ,t,tchry-foint (24) im1t7 of any incident,. sithinti itt \Hi try, uttrounl orate 1M:id:Mi. Thi incicicnl r.zpori ticket t 11,:* ACI111iniIars!liv::: [.)11-1::•:2;* ;!s;;I::2!)::d.iL 11 rcrtIi7 IL, fvii;irnI-DzKif Counly hmelcss "Trust, ; ): Firtti Floor. Suite 31(.). Jud f) cfinitiiins i1f heil(ii"tul)ie IrlcldenrS a. . ile.rcat.ion. physleal cc]?ircni ii n occurrins betw_:e]7 n client and empinvee ( r TWO OT mora C:1)c'n,s ai il'le intin-ie services art beer ' rendered. or when a di ni is in ay: physical custody of the department. which results in one or move clients c.r employed: receiving n,edicaJ treatment by a licensed health care professional. h. Client Death. .A person whose life terminates due to or allegedly due to an accident. act of abuse. neglect or (-der incident nccun-inf4 while in the presence of an en;plovet. in Homeless Trust contracted prcnzram 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 iliciden accurrin;, 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 ordinate- such as a tornado, kidnapping, riot, or hostage situation_ which _jeopardizes the health, safety and welfare of clients. e. Sexual Battery. 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 law enforcement . involvement. f. .Suicide ,Attemnt. 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 depanment or a departmental contracted or certified provider, which results in bodily injury .requiring medical treatment by a licensed health care professional. Property Damage An incident involving '' rnasre to property procured with Homeless Trust funding.. Proyikr Nntne: 1\1:inw: Funding bernd I ID Number MIAMI-DADE COU.NTY HONIF,LESS 'TRUST PROVIDER ASSET IMTENTORY Acquisition Acquisition Cost A'cutior Nilille o .Purcluise cos( front Gunut Luc:1(km or Property Use mut Condition or Propetly ,\ Mich invwccs tor nil pnrcluises (Ids g luit reporting period, lvho how:, Tide ot Propci.i• is _' i TIA.DE C:';t'' T Y 1-i TRI ST L1E. T SII.P.ViCES Cri;TIFiCATION REFERRAL FC}3 M FOi: E\9PLO ';'L_=S'iF HOMELESS TRUST FLi'iL%1) PROO AiYIS L1;ST1,1LCTi0NL: Provider mal;in^ rei'erral must complete tlusr -jm2r.tc ii rm includin:,; siwrstures by Ar,jriicnnt find Provider- Repr-es:.•ntativrs. Fax emit ploted forms rri ite;eri-si co, Hou.sm and or Services. Bate: Referrine Provider: Contact Person: Mine INFORMATION ON HEAL? OF HOUSEHOLD: Last Name: First Name: Date of Binh: SS i1/: Title Phone. Number INFORMATION ON OTHER HOUSEHOLD MEMBERS: ?fame. A^e j Sex 1 Relationship i mp1-oN,er I I I IS ANY MEMBER OF THE HOUSEHOLD EMPL0YED BT, OR RELATED TO AN EMPLOYEE OF,.4 HOMELESS TRUST FUNDED PROGRAM? Yes No Jfves: Name of Employee: Ennio:'in .Provider: Relationship to Applicant: r_rr;T1F?C.AT)CN the indersigned. do her cis\ ect-rifv that the ahoy e iniormati<m ornvided hit nt0 i.c u!te and enure; u, the hest rtf my Knox icdoe. Anpiicunt s Name I limo: rill ?1;,, i i:,• =t;rhr:: •: d F:em-esen;:civ: �.IL`rial ur _ Date PRO \ H;Ei? .,..El -_ lithe Applieant or a mcrnher cif their household i.s an empio\;' to the rcfcrriuc2 proridcr, rpprorul Gf the I'rrr, itler 1?irecior.is hcr'eh'; hrdie.;ted hcsi_naiurc: ?,am :"Title Daft Ji the Applicant nr a member of their household is nil em)ilovec of the provider where services wilt he provided. the appro:1 of The Provider Executive Dircclor, the Nunciess Trust .Executive Director, ,rnd tilt Homeless Trust Board Chair are hereby indicated by 0g7:21urc: Provider Executive r)irector Date Miami -Dade CpunryHomeless Trust Chairperson Date R4iami-Dade County Homeless Trust Executive Director ADDITIONAL HOUSEHOLD INFORMATION: Where is the household living now? (Facility name, exact address) Date of present homelessness: Explain the homeiess_situation, and what caused hmnelessness: u Date NOTE TO REFERRING' PROVIDER: PROVIDING THE ABOVE INFORMATION DOES NOT ENSURE APPROVAL FOR HOUSING OR OTHER SERVICES REQUEST.ED. A DETERMINATJON WILL EEMADE FOLLOWING A COMPLETE ASSESSMENT OF THE APPLICANT'S CASE. TFILS'SECTIOA'FOk.SEEJ-f 'Ef'ROi71)ER STA r.SbOtLI`: �9rc;,c EIi ihilirt' Crifcrir.: )ES NO ."1'0/71C of f'rm•iucr,S'cr_ e,yu;g Staff: PLEASE MA INT.4.IN T=.;E E:NECL'TE1l CO?'; OF TI ir(C'Un ENT IN TI.!E.CL1E^:T FILE OF THE SERVICING' PROVE .-ND I'LIONNEL FILE OF LEFERRIN(.; I'ROVIi)EI:. ATTAQ MF! r B Re: Revised Budget Modification / Justification for Memorandum of Arrreemcnt Services Miami Homeless Assistance Program, Miami Homeless Assistance Prosrrain is respectfully submitting for your review and approval the enclosed Budget Amendment Request for Memorandum of Agreement Services Contract. The program is requesting shift in funditig activities for the MOA program. Supportive Services Expense Current Budget Modification Difference 6.0FTE Community Outreach Specialist al $12.00/hour to cover for nights and weekends (approximately $25,000 per annual per staff member). reduce to2.49 HI. Total Salary FICA Intake and Referral Specialist for add 0.801- it @ Total Salary FICA 2.01- it. Housing Specialist @ $15.5 ] (hour Requesting. reduce to 1.621.1t. Total 150.000 60:000 71.411.59 66,336.82 5,074.77 25.000.00 23,223.41 1,776.59 (78.58II.41) • 25.000.00 0 Pro„gato Clerk. add 1.56 } lh @ Total Salary FICA 50.000.00 46,446.82 3.553. ] S 50.000.00 1.6STE Housing Specialist Supervisor @ S24.73/ Hour. Total Salary FICA Note! / Motel (temporary emergency housing for I families) Shelter Beds Transportation (bus tokens for clients) 10.000 43.588.4) 40,490.86 3,697.55 10,000.00 65,700.00 10.000.00 3.588.41 Indirect Administrative Costs 4,300 4,500.00 TOTAL 540,000 340.000.00 1 0 Carlos Alvarez, Mayor October 15, 2010 Mr. Carlos Migoya, City Manager c/o Sergio Torres, Program Director City of Miami 1490 NW 3rd Avenue, Suite 103 Miami, FL 33130 RE: 2010-2011Primary Care Program — The City of Miami Extension and Amendment of the Grant Agreement for the Memorandum of Agreement (MOA) Program Dear Mr. Migoya: Homeless Trust i 1 1 NW 1st Street • 27th Floor • Suite 310 Miami, Florida 33128-1930 T 305-375-1490 F 305-375-2722 miamidade.gov Enclosed, please find for your review, the Amendment of the Agreement between Miami -Dade County, through the Miami -Dade County Homeless Trust and The City of Miami to provide housing and services to the homeless individuals in Miami -Dade County. Please review the Agreement thoroughly, as well as the attachments and become familiar with the amended contract language. In addition, please include an updated Attachment A, Scope of Services, and Attachment B, Budget for the 2010-2011 contract year. Please sign and complete all three (3) copies of the Extension and Amendment Agreement and return it to our office, attention Terrell T. Ellis, Contract Monitoring and Management Supervisor no later than Tuesday. October 26, 2010. One fully executed Agreement will be returned to your agency for your files. 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 corporate seal must be affixed to the signature page of the document. The Miami -Dade County Homeless Trust looks forward to continuing work with your agency in implementing this project. If you have any questions, please contact me or Terrell T. Ellis, Contract Monitoring and Management Supervisor at 5-1490 Sincer avi. ' aymond Executive Director Enclosures I have received the Agreements for the abovement>oiled grants. Signature of Authorized Agency Representative Date Printed Name of Agency Representative