HomeMy WebLinkAboutExhibitHomeless Trust
111 N.W. 1st Street • 27th Floor Suite 310
Miami, Florida 33128-1930
T 305-375-1490 F 305-375-2722
miamidade.gov
October 14, 2015
Mr, Daniel Alfonso, City Manager
c/o Mr. Sergio Torres, Program Administrator
The City of Miami
444 SW 2nd Avenue
Miami, FL 33136
RE: 2015-16 Hotel/Motel Placement Program, Feeding Coordination, HMIS Staffing
Grant Number: PC-1516-HTMT-2, PC-1516-FC, and PC-1516-STAFF-1
Dear Mr. Alfonso:
Enclosed, please find for your review, the Agreement between Miami -Dade County, through the Miami -Dade County
Homeless Trust and The City of Miami for the abovementioned programs. Please review the Agreement thoroughly, as well
as the attachments and become familiar with the amended contract language.
Please sign and complete all three (3) copies of the Contract Agreement and return it to our office, attention Mrs. Terrell T.
Ellis, Contracts Manager, as soon as possible. One fully executed Contract 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, Contracts Manager at (305) 375-1490.
Sincerely,
Victoria L. Mallette
ecutive Director
Enclosures
I have received the Agreements for the abovementioned grant.
Signature of Authorized Agency Representative Date
Printed Name of Agency Representative
The City of Miami
Hotel/Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program. PC-ISM-STAFF-2
Feeding Coordination PC-1516-FC
GRANT CONTRACT
This Contract made and entered into as of this day of , 20_, by
and between Miami -Dade County, a .political subdivision of the State of'Florida (the "County"), having
its principal office at 111 N.W. 1st Street, 27th Floor, Miami, Florida 33128 and The City of Miami
/IF:E.I.N #59-6000375, a corporation organized and existing under the laws of the State of Florida,
having its principal office 444 SW 2nd Avenue, Miami, FL 33130 ("Provider"), states conditions and
covenants for the rendering of human and social services ("Services") for the County.
WHEREAS, the Provider provides or will develop social services of value to the County and
has demonstrated an ability or desire to provide these services; and
WHEREAS, the County is desirous of assisting the Provider in providing those services and
the Provider is desirous of providing such services; and
WHEREAS, the County has appropriated grant funds for the proposed services;
NOW, THEREFORE, in consideration of the mutual " covenants and agreements herein
contained, the parties hereto agree as follows:
ARTICLE 1. DEFINITIONS
The following words and expressions used in this Grant Agreement shall be construed as follows,
except when it is clear from the context that another meaning is intended:
a) The words "Agreement" "Contract" or "Contract Documents" shall mean collectively these
terms and conditions, the Scope of Services (Attachment A) and the Budget Documents
(Attachment B) and all other attachments hereto, as well as all amendments or budget
revisions issued hereto.
b) The words "Contract Manager" shall mean Miami -Dade County's Director of the Homeless
Trust ("County") or the Director's designee, or the duly authorized representative designated
to manage the Contract.
c) The word "Days" shall mean Calendar Days, unless otherwise specifically noted.
d) The word "Deliverables" shall mean all documentation and any items of any nature submitted
by the Provider to the County for review and approval :pursuant to the terms of this Contract.
e) The words "directed", "required", "permitted", "ordered", "designated", "selected", "prescribed"
or words of like import to mean respectively, the direction, requirement, permission, order,
designation, selection or prescription of the County's Contract Manager; and similarly the
words "approved", acceptable", "satisfactory", "equal", "necessary", or words of like import to
mean respectively, approved by, or acceptable or satisfactory to, equal or necessary in the
sole discretion of the County's Contract Manager.
f) The words "Effective Term" shall mean the date on which this Contract is effective, including
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g)
The City of Miami
Hotel/Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-PC .
start date and end date.
The words "Extra Work" or "Change Order" or "Additional Work' shall mean resulting in
additions or deletions or modifications to the amount, type or value of the Work and Services
as required in this Contract, as directed and/or approved by the County.
"HIPAA" means Health Insurance Portability and Accountability Act of 1996.
i) The words "Scope of Services" shall mean the document appended hereto as Attachment A,
which details the work to• be performed by the Provider.
j) The word "subcontractor" or "sub consultant" shall rnean any person, entity, firm or
corporation, other than the employees of the Provider, who furnishes,labor and/or materials, in
connection with the Work, whether directly or indirectly, on behalf and/or under the direction of
the Provider and whether or not in privities of contract with the Provider. •
k) The words 'Work", "Services" "Program", or "Project" shall mean all matters and things required
to be done by.the Provider in accordance with the provisions of this Contract.
ARTICLE 2. AMOUNT PAYABLE. Subject to available funds, the maximum amount payable for
services rendered under this contract shall not exceed:
Emergency Hotel/Motel Placement Program
HMIS Staffing Program
Feeding Coordination Program
$459,960.00
$24,666.00
$15,000.00
Total Award $499,626.00
Both parties agree, that should available County funding be reduced, the amount payable under this
Contract may be proportiionatelyreduced at the sole discretion and option of the County. Availability
of funding shall be determined in the County's sole discretion.
All services undertaken by the Provider .before the County's execution of this Contract shall be at the
Provider's risk and expense.
• It is the responsibility of the Provider to maintain sufficient financial resources to meet the expenses
incurred during the period between the provision of services and payment by the County.
The County, at its sole discretion, may allow Provider an advance of N/A once the Provider has
submitted an appropriate request and submitted an invoice in the form required by the County.
ARTICLE 3.. SCOPE OP SERVICES
The Provider shall render services in accordance with the Scope of Services incorporated
herein and attached hereto as Attachment A.
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Hotel/Motel Placement Program PC-1516-HTMT-2
7MS Staffing Program PC-151.6-STAFF-2
Feeding Coordination PC-1516-FC
The Provider shall implement the Scope of Services as described in Attachment A in a
manner deemed satisfactory to the County. Any modification or amendment to the Scope of Services
shall not be effective until approved by the County and Provider in writing.
ARTICLE 4. BUDGET SUMMARY
The Provider agrees that all expenditures or costs shall be made in accordance with the
Budget for the provision of services in accordance with Attachment A, the "Scope of Services". The
Budget is attached hereto and incorporated herein as Attachment B.
The parties agree that the Provider may, with the County's prior written approval; revise the
schedule of payments or the line item budget, and such revision shall not require an amendment to
this Contract.
Pursuant to Board of Miami -Dade County Commissioners Resolution 630-13, the Provider will submit
a detailed project budget, and sources and uses statement as Attachment B-1, which shall be
sufficiently detailed to show (i) the total project cost, (ii) the amount of funds to be used for
administrative and overhead costs, (iii) whether the County funds will be 'gap' funds meaning that they
would be the last remaining funds needed to ensure funding for the total project cost, (iv) any profit to
be made by the Provider, and (v) the amount of funds devoted toward the provision of the desired
services or activities.
The County Mayor or Mayor's designee may make unannounced, on -site visits during normal working
hours to the Provider's headquarters and any location or site where the service's contracted for under
this Agreement are performed.
ARTICLE 5. EFFECTIVE TERM
Both parties agree that the Effective Term of this Contract shall commence on
October 1, 2015 and terminate at the close of business on September 30, 2016. Contingent on the
existence of sufficient funding, performance and the approval of the County, this. Contract may be
extended at the County's sole discretion for two (2) additional one (1) year terms, at the County's
sole discretion.
ARTICLE 6. INDEMNIFICATION BY PROVIDER
A. Government Entity. Government entity shall indemnify and hold harmless the County
and its officers, employees, agents and instrumentalities from any and all liability, losses or damages,
including attorneys' fees and costs of defense, which the County or its officers, employees, agents or
instrumentalities may incur as a result of claims, demands, suits, causes of actions or proceedings of
any kind or nature arising out of, relating to or resulting from the performance of this Contract by the
government entity or its employees, agents, servants, partners, principals or subcontractors.
Government entity shall pay all claims and losses in connection therewith and shall investigate and
defend all claims, suits or actions of any kind or nature in the name of the County, where applicable,
including appellate proceedings, and shall pay all costs, judgments, and attorney's fees which may
issue thereon. Provided, however, this indemnification shall only be to the extent and within the
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The City of Miami
Hotel/Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
limitations of Section 768.28, Fla. Stat.
B. All Other Providers. Provider shall indemnify and hold harmless the County and its
officers, employees, agents and instrumentalities from any and all liability, losses or damages,
including attorneys' fees and costs of defense, which theCounty or its officers, employees, agents or
instrumentalities may incur as a result of claims, demands, suits, causes of actions or proceedings of
any kind or nature arising out of, relating to or resulting from the performance of this Contract by the
Provider or its employees, agents, servants, partners principals or subcontractors. Provider shall pay
all claims and losses in connection therewithand shall investigate and defend all claims, suits or
actions of any kind or nature in the name of the County, where applicable, including appellate
proceedings, and shall pay all costs, judgments, and attorney's fees which may issue thereon.
Provider expressly understands and agrees that any insurance protection required by this Contract or
otherwise provided by Provider shall in no way limit the responsibility to indemnify, keep and save
harmless and defend the County or its officers, employees, agents and instrumentalities as herein
provided.
C. Term of Indemnification. The provisions of Article .6 shall survive the expiration or
termination of this Contract.
ARTICLE 7. . INSURANCE
If the total dollar value of all County contracts with the Provider exceeds $25,000 then the following
insurance coverage is required:
A. Government Entity. If the .Provider is the State of Florida or anagency or political
subdivision of the State as defined by section 768.28, Florida Statutes, the Provider shall furnish the
County, upon request, written verification of liability protection in accordance with section 768.28,
Florida Statutes. Nothing herein shall be construed to extend any party's liability beyond that provided
in section 768.28, Florida Statutes. The provider shall also furnish the County, upoh request, written
verification of Workers Compensation protection in accordance with Florida Statutes, Chapter 440.
B. All Other Providers.
1. Minimum Insurance Requirements: Certificates of Insurance. The. Provider
shall submit to Miami -Dade County, c/o Miami Dade County Homeless Trust (COUNTY), 111 N.W. 1st
Street, 27th Floor, Miami, Florida 33128-1994, original Certificate(s) of Insurance indicating that
insurance coverage has been obtained which meets the requirements as outlined below:
A. All insurance certificates must list the County as "Certificate Holder" in the following
manner:
Miami -Dade County
111 N.W. 1st Street, Suite 2340
Miami, Florida 33128
B. Worker's Compensation Insurance for all employees of the Provider as required by
Florida Statutes, Chapter 440.
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The City of Miami
Hotel/Motel Placement Program. PC-1516-HTMT-2
HMtS Staffing Program. PC-1516-STAFF-2
Feeding Coordination PC-1516-PC
C. Commercial General Liability Insurance in an amount not less than $300,000 combined
single limit per occurrence for bodily injury and property damage. Miami -Dade County
must be shown as an additional insured with respect to this coverage.
D. Automobile Liability Insurance covering all owned, non -owned, and hired vehicles used
in connection with the Work provided under this Contract, in an amount not less than
$300,000* combined single limit per occurrence for bodily injury and property damage.
*NOTE: For Providers supplying vans or mini -buses with seating capacities of fifteen
(15) passengers or more, the limit of liability required for Auto Liability is $500,000.
E. Professional Liability Insurance in the name of the Provider, when applicable, in an
amount not less than $250,000.
F. All insurance policies required above shall be issued by companies authorized to do
business under the laws of the State of Florida, with the following qualifications:
1. The company must be rated no less than "B" as to management, and no less
than "Class V" as to financial strength, according to the latest edition of Best's
Insurance Guide published by A.M. Best Company, Oldwick, New Jersey, or its
equivalent, subject to the approval of the County's Risk Management Division.
OR
2. The company must hold a valid Florida Certificate of Authority as shown in the
latest "List of All Insurance Companies Authorized or Approved to Do Business
in Florida," issued by the State of Florida Department of Insurance, and must be
a member of the Florida Guaranty Fund.
G. Certificates will indicate that no modification or change in insurance shall be made
without thirty (30) days advance written notice to the Certificate Holder.
H. Compliance with the foregoing requirements shall not relieve the Provider of its liability
and obligations under this Section or under any other section of this Contract.
1. The County reserves the right to inspect the Provider's original insurance policies at
any time during the term of this Contract.
J. Applicability of this Article to Providers whose combined total award for all services
funded under this Contract exceeds a $25,000 threshold. In the event that the Provider
whose original total combined award in less than $25,000, but receives additional
funding during the contract period which makes the total combined award exceed
$25,000, then the requirements in this Article shall apply.
1<. Failure to Provide Certificates of Insurance. The Contractor shall be responsible for
assuring that the insurance certificates required in conjunction with this Section remain
in force for the duration of the effective term of this Contract. If insurance certificates
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The City of Miami
Hotel/Motel Placement Program. PC-1516-FTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
are scheduled to expire during the effective term, the provider shall be responsible for
submitting new or renewed insurance certificates to the County prior to expiration.
In the event that expired certificates are not replaced with new or renewed certificates
which cover the effective term, the County may suspend the Contract until such time as
the new or renewed certificates are received by the County in the manner prescribed
herein; provided, however, that this suspended period does not exceed thirty (30)
calendar days. Thereafter, the County may, at its sole discretion, terminate this
Contract.
ARTICLE 8. PROOF OF LICENSURE/CERTIFICATION AND BACKGROUND SCREENING
A. Licensure. If the Provider is required by the State of Florida or Miami -Dade County or any
federal, state or local law or regulation to be licensed or certified to provide the services or operate the
facilities outlined in the Scope of Services (Attachment A), the Provider shall furnish to the County a
copy of all required current licenses or certificates. Examples of services or operations requiring such
licensure or certification include but are not limited to childcare, day care, nursing homes, and
boarding homes.
If the Provider fails to furnish the County with the licenses or certificates required under this
Section, the County shall not disburse any funds until it is provided with such licenses or certificates.
Failure to provide the licenses or certificates within sixty (60) days of execution of this Agreement may
result in termination of this Agreement at the County's discretion.
B. Background Screening. The Provider agrees to comply with all applicable federal,
state and local laws, regulations, ordinances and resolutions regarding background screening of
employees, volunteers and subcontractors. Provider's failure to comply with any applicable laws,
regulations, ordinances and resolutions regarding background screening of employees, volunteers
and subcontractors is grounds for a material breach and termination of this contract at the sole
discretion of the County.
. The Provider agrees to comply with all applicable laws (including but not limited to Chapters
39, 402, 409, 394, 408, 393, 397, 984, 985 and 435, Florida Statutes, -as may be amended form time
to time), regulations, ordinances and resolutions, regarding background screening of those who may
work or volunteer with vulnerable persons, as defined by section 435.02, Florida Statutes, as may be
amended from time to time.
In the event criminal background screening is required by Law, the State of Florida and/or the
County, the Provider will permit only employees and subcontractors with a satisfactory national
criminal background check through an appropriate screening agency (i.e., the Florida Department of
Juvenile Justice; Florida Department of Law Enforcement or Federal Bureau of Investigation) to work
or volunteer in direct contact with vulnerable persons.
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The City of Miami
Hotei/Mote1 Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
The Provider agrees to ensure that employees, volunteers and subcontracted personnel who
work with vulnerable persons satisfactorily complete and pass Level 2 background screening before
working or volunteering with vulnerable persons. Provider shall furnish the County with proof that
employees, volunteers and subcontracted personnel, who work with vulnerable persons, satisfactorily
passed Level 2 background screening, pursuant to Chapter 435, Florida Statutes, as may be
amended from time to time.
If the Provider fails to furnish to the County proof that an employee, volunteer or
subcontractor's Level 2 background screening was satisfactorily passed and completed prior to that
employee or subcontractor working or volunteering with a vulnerable person or vulnerable persons,
the County shall not disburse any further funds and this Contract may be subject to termination at the
sole discretion of the County.
ARTICLE 9. CONFLICT OF INTEREST
A. The Provider agrees to abide by and be governed by Miami -Dade County Ordinance
No. 72-82 (Conflict of Interest Ordinance codified at Section 2-11.1 et al. of the Code of Miami -Dade
County), as amended, which is incorporated herein by reference as if fully set forth herein, in
connection with its contract obligations hereunder.
B. No person under the employ of the County, who exercises any function or
responsibilities in connection with this Contract, has at the time this Contract is entered into, or shall
have during the term of this Contract, any personal financial interest, direct or indirect, in this Contract.
C. Nepotism. Notwithstanding the aforementioned provision, no relative of any officer,
board of director, manager, or supervisor employed by the Provider shall be employed by the Provider
unless the employment preceded the execution of this Contract by one (1) year. No family member of
any employee may be employed by the Provider if the family member is to be employed in a direct
supervisory or administrative relationship either supervisory or subordinate to the employee. The
assignment of family members in the same organizational unit shall be discouraged. A conflict of
interest in employment arises whenever an individual would otherwise have the responsibility to
make, or participate actively in making decisions or recommendations relating to the employment
status of another individual if the two individuals (herein sometimes called "related individuals") have
one of the following relationships:
1. By blood or adoption: Parent, child, sibling, first cousin, uncle, aunt, nephew, .or niece;
2. By marriage: Current or former spouse, brother- or sister-in-law, father- or mother-in-
law, son- or daughter-in-law, step-parent, or step -child; or
3. Other relationship: A current or former relationship, occurring outside the work setting
that would make it difficult for the individual with the responsibility to make a decision or
recommendation to be objective, or that would create the appearance that such individual
could not be objective. Examples include, but are not limited to, personal relationships and
significant business relationships.
For purposes of this section, decisions or recommendations related to employment status
include decisions related to hiring, salary, working conditions, working responsibilities,
evaluation, promotion, and termination.
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Hotel/Motel Placement Program. PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
An individual, however, is not deemed to make or actively participate in making decisions
or recommendations if that individual's participation is limited to routine approvals and the
individual plays no role involving the exercise of any discretion in the decision -making
processes. If any question arises whether an individual's participation is greater than is
permitted by this paragraph, the matter shall be immediately referred to the Miami -Dade
County Commission on Ethics and Public Trust.
This section applies to both full-time and part-time employees and voting members of the
Provider's Board of Directors.
D. No person, including but not limited to any officer, board of directors, manager, or supervisor
employed by the Provider, who is in the position of authority, and who exercises any function or
responsibilities in connection with this Contract, has at the time this Contract is entered into, or shall
have during the term of this Contract, received any of the services, or direct or instruct any employee
under their supervision to provide such services as described in the Contract. Notwithstanding the
before mentioned provision, any officer, board of directors, manager or supervisor employed by the
Provider, who is eligible to receive any of the services described herein may utilize such services if he
or she can demonstrate that he or she does not have direct supervisory responsibility over the
Provider's employee(s) or service program. Staff members, or their immediate family members
(spouse, children, siblings, mother or father) of Homeless Trust funded programs, who are eligible for
and wish to receive services from a Homeless Trust funded program must receive the approval of the
Executive Director of their employer (i.e. the Provider) prior to :applying for and receiving those
services. This approval must be in writing and accompany any referral for such services. Any Provider
knowingly accepting a referral of an employee of a Homeless Trust funded program, and providing
services without the written approval of the Executive Director of the Provider, will be subject to the
recoupment/disallowance by the Courity of any funds paid for services to this individual and/or their
immediate family member. When the services are to be provided at the same agency the employee
works for, this information must be disclosed in writing to the director of the Homeless Trust, which
shall be reviewed for'elgibility determination and a sign off must come from the County. This provision
does not apply to staff members seeking emergency shelter, medical or legal services. Providers
must complete a Client Services Authorization Form (Attachment P) for staff members seeking
services.
ARTICLE 10. CIVIL RIGHTS
The Provider agrees to abide by Chapter 11A of the Code of Miami -Dade County ("County
Code"), as amended, which prohibits discrimination in employment, housing and public
accommodations on the basis of race, creed, religion, color, sex, familial status, marital status, sexual
orientation, pregnancy, age, ancestry, national origin or handicap; Title VII of the Civil Rights Act of
1968, as amended, which prohibits discrimination in employment and public accommodation; the Age
Discrimination Act of 1975, 42 U.S.G. §6101, as amended, which prohibits discrimination in
employment because of age; the Rehabilitation Act of 1973, 29 U.S.C. §794, as amended, which
prohibits discrimination on the basis of disability; the Americans with Disabilities Act, 42 U.S.C.
§12101 et seq., which prohibits discrimination in employment and public accommodations because of
disability; the Federal Transit Act, 49 U.S.C. §1612, as amended; and the Fair Housing Act, 42 U.S.C.
§3601 et seq. It is expressly understood that the Provider mist submit an affidavit attesting that it is
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Hotel./Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
not in violation of the Acts. If the Provider or any owner, subsidiary, or other firm affiliated with or
related to the Provider is found by the responsible enforcement agency, the Courts or the County to
be in violation of these acts, the County will conduct no further business with the Provider.
Any contract entered into based upon a false affidavit shall be voidable by the County. If the Provider
violates any of the Acts during the term of any contract the Provider has with the County, such
contract shall be voidable by the County, even if the Provider was not in violation at the time it
submitted its affidavit.
The Provider agrees that it is in compliance with the Domestic Violence Leave, codified as § 11A-60
et seq. of the Miami -Dade County Code, which requires an employer, who in the regular course of
business has fifty (50) or more employees working in Miami -Dade County for each working day during
each of twenty (20) or more calendar work weeks to provide domestic violence leave to its
employees. •
Failure to comply with this local law may be grounds for voiding or terminating this Contract or for
commencement of debarment proceedings against Provider,
ARTICLE 11. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT;
Any person or entity that performs or assists Miami -Dade County with a function or activity
involving the use or disclosure of "individually identifiable health information (IIHI)" and/or "Protected Health
Information (PHi) shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of
1996 and the Miami -Dade County Privacy Standards Administrative Order. HIPAA mandates for privacy,
security and electronic transfer standards, included but are not limited to:
1. Use of information only for performing services required by the contract or as required by law;
2. Use of appropriate safeguards to prevent non -permitted disclosures;
3. Reporting to Miami -Dade County of any non -permitted use or disclosure;
4. Assurances that any agents and subcontractors agree to the same restrictions and conditions that
apply to the Provider and reasonable assurances that IIHUPHI will be held confidential;
5. Making Protected Health Information ,(PHI) available to the customer;
6. Making PHI available to the client for review;
7. Making PHI available to Miami -Dade County for an accounting of disclosures; and
8. Making internal practices, books, and records related to PHi available to Miami -Dade County for
compliance audits.
PHI shall maintain its protected status regardless of the form and method of transmission (paper
records and/or electronic transfer of data). The Provider must give its clients written notice of its privacy
information practices, including specifically, a description of the types of uses and disclosures that would
be made with protected health information. Provider must post, and distribute upon request to service
recipients, a copy of the County's Notice of Privacy Practices.
ARTICLE 12. NOTICE REQUIREMENTS
Notice under this Contract shall be sufficient if made in writing, delivered personally or sent via U.S.
mail, electronic mail, facsimile, or certified mail with return receipt requested and postage prepaid, to the
parties at the following addresses (or to such other party and at such other address as a party may specify
by notice to others) and as further specifed within this Contract. If notice is sent via electronic mail or
facsimile, confirmation of the correspondence being sent will be maintained in the sender's files.
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If to the COUNTY:
If to the PROVIDER:
The City of Miami
Hotel/Motel Placement Program P C-15 16-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
Miami -Dade County
Homeless Trust 111 N.W. 1st Street, 27th Floor
Miami, Florida 33128
Attention: Victoria Mallette, Executive Director
Electronic mail: VMallette@miamidade.gov
Mr. Daniel J. Alfonso
City Manager
The City of Miami
444 SW 2nd Avenue
Miami, Florida 33130
Electronic mail: citymahagercmiamigov.com
Either party may at any time designate a different address and/or contact person by giving written
notice as provided above to the Other•party: Such riofices shall be deemed given upon receipt by the
addressee.
ARTICLE"13, AUTONOMY
Both parties agree that this Contract recognizes the autbadmy of the contracting parties and
implies no affiliation between the contracting parties: It is' expressly understood and intended that the
Provider is only a recipient of funding support andis not an agent or instrumentality of the County.
Furthermore, the Provider's agentsard employees are not agents or employees of the County.
ARTICLE 14. SURVIVAL
The parties acknowledge. that any of the obligations in this Contract.. including... but not limited to
Provider's obligation to indemnify the County, will survive the term,termination, and cancellation
hereof. Accordingly, the respective obligations of the Provider under this Contract,' Which by nature
would continue beyond the termination; cancellation or expiration thereof,, shall survive termination,
cancellation or expiration hereof.
ARTICLE 15. BREACH OF CONTRACT: COUNTY REMEDIES
A. Breach. A breach by the Provider shall have :occurred under this Contract if: (1) the
Provider fails to provide the services outlined in the Scope of Services (Attachment A) within the
effective terrn of this Contract; (2) the Provider ineffectively or improperly uses the County funds
allocated under this Contract; (3) the Provider does not furnish the Certificates of Insurance required
by this Contract or as determined by the County's Risk Management Division; (4) if applicable, the
Provider does not furnish upon request by the County proof of licensure/certification or proof of
background screening required by this Contract; (5) the Provider fails to Submit, or submits incorrect
or incomplete, proof of expenditures to support disbursement requestsor advance funding
disbursements or fails to submit or submits incomplete or incorrect detailed reports of expenditures or
final expenditure reports; (6) the Provider does not submit or submits incomplete or incorrect required
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Hotel/Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
reports; (7) the Provider refuses to allow the County access to records or refuses to allow the County
to monitor, evaluate and review the Provider's program; (8) the Provider discriminates under any of
the laws outlined in Article 10 of this Contract; (9) the Provider, attempts to meet its obligations under
this Contract through fraud, misrepresentation, or material misstatement; (10) the Provider fails to
correct deficiencies found during a monitoring, •evaluation, or review within the specified time as
described and defined in its Performance improvement Plan (PIP); (11) the Provider fails to issue
prompt payments to small business subcontractors or follow dispute resolution procedures regarding
a disputed payment; (12) the Provider fails to submit the Certificate of Corporate Status, Board of
Directors requirement, or proof of tax status; or (13) the Provider fails to fulfill in a timely and proper
manner any and all of its obligations, covenants, agreements, and stipulations in this Contract; (14)
the Provider fails to meet any of the terms and conditions of the Miami -Dade County Affidavits
(Attachment C) and the State Affidavits (Attachment D) 0 Applicable Q Not Applicable or
(15) the Provider fails to fulfill in a timely and proper manner any or all of its obligations, covenants,
agreements and stipulations in this Contract. Waiver of breach of any provisions of this Contract shall
not be deemed to be a waiver of any other breach and shall not be construed to be a modification of
the terms of this Contract.
In the event that the County determines .certain Contract goals (as defined in the Scope of Services)
are not being met then the County, in its sole discretion may place the Provider on a Performance
Improvement Plan (PIP). The following is a delineation of some instances where a PIP may be
required:
a. HIVIIS- Based on Provider's past performance on prior contracts in the area of
Homeless Management information System compliance it is subject to a PIP during
this contract term. The Provider is required to submit a Monthly Progress Report
and an HMIS-generated Monthly Progress Report for each month of the contract.
Compliance will be determined when it is deemed that the two (2) reports are in
substantial conformity with each other for a period of two consecutive months.
(Substantial conformity as meaning a minimum of 95% accuracy on all elements).
At the time of compliance, the Provider shall only be required to submit the HMIS-
generated Monthly Progress Report.
0 Applicable El Not Applicable
b. Utilization — Based on Provider's past performance on priorcontracts in the area of
utilization compliance, this contract is subject to a PIP. During this contract term,
the Provider must submit all invoices in a timely manner. The Provider shall invoice
at a rate of 95% of targeted expenditures for the invoicing period. If the Provider
fails to comply, all rights to payments will be forfeited if the County so chooses.
Failure to submit accurate invoices for appropriately documented and eligible
expenditures at a rate of 95% of targeted expenditures by the end of the third •
quarter of this contract term may result in the termination of this contract by the
County.
❑ Applicable d Not Applicable
c. Program Performance — Based on Provider's past performance on prior contracts
in the area of program goals and outcome objectives, this Contract is subject to a
PIP. During this Contract term, the Provider must achieve those goals specified in
the Contract. Performance against these annual goals shall be evaluated on a
quarterly basis, and if by the end of the third quarter of the contract period
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substantial compliance (meeting the targeted goals) is not achieved, it may result in
the termination of this contract with the County.
0 Applicable Q Not Applicable
The above is subject to the review and approval of the County
B. County Remedies. If the Provider breaches this Contract, the County may pursue any
or all of the following remedies:
1. The County may terminate this Contract by giving written notice to the Provider
of such termination and specifying the effective date thereof. In the event of termination, the County
may: (a) request the return of finished or unfinished documents, data studies, surveys, drawings,
maps, models, photographs, reports prepared and secured by the Provider with County funds under
this Contract; (b) seek reimbursement of County funds allocated to the Provider under this Contract;
(c) terminate or cancel any other contracts entered into ,between the County and the Provider. The
Provider shall be responsible for all direct and indirect costs associated with such termination,
including attorney's fees;
2. The County may suspend payment in whole or in part under this Contract by
providing written notice to the Provider of such suspension and specifying the effective date thereof.
If payments .are suspended, the County shall specify in writing the actions that must be taken by the
Provider as condition precedent to resumption of payments and shall specify a reasonable date for
compliance. The County may also suspend any payments in whole or in part under any other
contracts entered into between the County and the Provider. The Provider shall be responsible for all
direct and indirect costs associated with such suspension, including attorney's fees;
3. The County rnay seek enforcement of this Contract including but not limited to
filing an action in a court of appropriate jurisdiction. The Provider shall be responsible for all direct
and indirect costs associated with such enforcement, including attorney's fees;
4. The County may debar the Provider from future County contracting;
5. If, for any reason, the Provider should attempt to meet its obligations under this
Contract through fraud, misrepresentation or material misstatement, the County shall, whenever
practicable terminate this Contract by giving written notice to the Provider of such termination and
specifying the effective date. The County may terminate or cancel any other contracts which such
individual or entity has with the County. Such individual or entity shall be responsible for all direct and
indirect costs associated with such termination or cancellation, including attorney's fees. Any
individual or entity who attempts to meet its contractual obligations with the County through fraud,
misrepresentation, or material misstatement may be debarred from county contracting for up to five
(5) years;
6. Any other remedy available at law or equity.
C. ' Authorization to Terminate Contract. The Mayor or the Mayor's designee is
authorized to terminate this Contract on behalf of the County.
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D, Failures or waivers to insist on strict performance of any covenant, condition, or
provision of this Contract by the County shall not be deemed a waiver of any rights or remedies, nor
shall it relieve the Provider from performing any subsequent obligations strictly in accordance with the
term of this Contract. No waiver shall be effective unless in writing and signed by the parties. Such
waiver shall be limited to provisions of this Contract specifically referred to therein and shall not be
deemed a waiver of any other provision. No waiver shall constitute a continuing waiver unless the
writing states otherwise.
E. Damages Sustained. Notwithstanding the above, the Provider shall not be relieved of
liability to the County for damages sustained by the County by virtue of any breach of the Contract,
and the County may withhold any payments to the Provider until such time as the exact amount of
damages due the County is determined. The County may also pursue any remedies available at law
or equity to compensate for any damages sustained by the breach. The Provider shall be responsible
for all direct and indirect costs associated with such action, including attorney's fees.
ARTICLE 16. TERMINATION FOR CONVENIENCE
The County may terminate this Contract, in whole or part, when both parties agree that the
continuation of the activities would not produce beneficial results commensurate with further
expenditure of the funds. Both parties shall agree upon the termination conditions, including the
effective date and in the case of partial termination, the portion to be terminated. However, if the
County determines in the case of partial termination that the reduced or modified portion of the grant
will not accomplish the purposes for which the grant was made it may terminate the grant in its
entirety.
This Contract is subject to the ratification and approval by the Miami -Dade County Board of
County Commissioners and shall be void unless approved by the Board of County Commissioners.
The County may also, in its sole discretion, terminate the contract.
The Provider understands and acknowledges that if the County determines in its sole
discretion that termination of the Contract is necessary for the healthy, safety, or welfare of the County
then it may due so upon twenty-four (24) hours notice to the Provider.
ARTICLE 17. PAYMENT PROCEDURES
The County agrees to pay the Provider for services rendered under this Contract based on the
payment schedule, timely provision by the Provider of required reports and of supporting
documentation of expenses and activities as described in this Contract, and the line item budget
.(Attachment B). Payment shall be made in accordance with procedures outlined below and if
applicable, the Sherman S. Winn Prompt Payment Ordinance (Ordinance 94-40).
1. How payment will be made. Payment requests shall be made to the County on a
monthly basis and shall be signed by the Executive Director and the Financial Officer of
the Provider, unless otherwise approved in writing, on the form incorporated herein as
Attachment E "Invoice for Services". The payment request for the previous month is
due by the 10th of the month following the month for which payment is invoiced.
2. Payment will be processed as follows: a) The Hotel/Motel Placement funds will be
paid on a reimbursement basis for the provision of hotel/motel placement services. B)
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The HMIS Staffing Program funds will be paid in twelve (12) equal monthly installments
of $2,055.50, with supporting documentation to substantiate said costs. c) The Feeding
Coordination Program will be paid in twelve equal monthly installments of $1,250.00 with
supporting documentation to substantiate said costs.
3. Any reimbursement may be withheld pending the receipt and approval by the County of
all reports and documents required herein.
4. The parties agree that payment will be based upon the provision of services outlined in
Attachment A, the "Scope of Services", for each program.
5. As applicable, during the period of.... N/A through N/A •...; the Provider will submit a
record of those individuals served utilizing Social Security Administration repayments as
specified in the Scope of Services:. The Provider will utilize these funds to serve those
.clients as specified and authorized in the Scope of Services,
6. N/A Providers with cumulative utilization rates greater than ninety percent (90%)
during the first nine (9) months of this Contract may exceed this maximum number of
billable bed days during the last quarter of the Contract term, up to the total Contract
award amount, with the prior approval of the Executive Director ofthe Homeless Trust.
7. N/A Providers with cumulative utilization rates lower than ninety percent (90%) may be
subject to a reduction in funding and beds, if deemed, necessary by the Miami -Dade
County Homeless Trust.Beds and funding may be reprogrammed as necessary and
needed within the Continuum of Care. The Miami -Dade County Homeless Trust will
conduct a review of the utilization of beds within the first six (6) months of the contract
period. .
8. Within thirty. (30) days of the termination or expiration, of this Contract, a final report of
expenditures shall be submitted to the County. If after the receipt of such final report, the
County determined that the Provider has been paid funds not in compliance with the
Contract, and to which it is not entitled, the Provider will be required to return such funds
to the County or submit documentation demonstrating that the expenditure was in
compliance with this Contract, The County shall have the sole and absolute discretion to
determine if the Provider is entitled to such funds and the County's decision in this matter
shall be final and binding. '
B. Monies Owedto the County: The County reserves the right, in its sole
discretion, to reduce payments to the Provider in order to recapture any.monies owed to the County.
In accordance with County Administrative Order No. 3-29, the Provider that is in arrears to the County
is prohibited. from obtaining new County contracts or extensions of contracts until such time as the
arrearage has been paid in full or the. County has agreed in writing to an approved payment. plan.
This is a cost -based Contract in which the Provider shall be paid through reimbursement payment
based on the budget ..approved. under this. Contract and when documentation of completed and
satisfactory service delivery is provided. Thus, it is imperative that the Provider maintain appropriate
supporting documentation for all expenditures from the beginning of the Contract term (i.e., receipts,
bank statements, cancelled checks, employee timesheet, etc.).
The Provider shall submit to the Contract Manager, the Monthly Reimbursement form provided by the
County on a monthly basis. Monthly reimbursement requests ,(both retroactive and current) and
accompanying supporting documentation must be received by the County no later than the 15th of the
month following the month for which reimbursement is requested.
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C, No Payment of Subcontractors. In no event shall County funds be advanced or -paid
by the County directly to any subcontractor hereunder. Payment to approved subcontractors shall be
made by the Provider following requirements and limitations as detailed in Article 21 of this Contract.
D. Processing the Request for Payment. After the County staff reviews the payment
request, the County will submit a payment request to the County's Finance Department. The County's
Finance Department will issue payment via Automated Clearing House (ACH) or mail the check
directly to the Provider at the address listed in Article 12 of this Contract, unless otherwise directed by
the Provider in writing. The parties agree that the processing of a payment request from date of
submission by the Provider shall take a maximum of thirty (30) days from receipt of a complete and
accurate payment request, pursuant to the County's Sherman S. Winn Prompt Payment Ordinance
(Ordinance 94-40), Section 2-8.1.4 of the Code of Miami -Dade County, Administrative Order No. 3-19,
and the Florida Prompt Payment Act, .if supporting documentation/invoices are properly documented
as determined by the County in its sole discretion. It is the responsibility of the Provider to maintain
sufficient financial resources to meet the expenses incurred during the period between the provision
of services and payment by the County.
E. Reporting Requirements. Failure to submit to the County the reports listed below in a
manner deemed correct and acceptable by the County by the 15th day after the end of the month in
which the service was delivered, or failure to submit to the County supporting documentation of
Contract expenditures or activities within fourteen (14) days of any County request, shall be
considered a breach of this Contract and may result in withholding payment, non-payment, or
termination of this Contract.
Applicable as indicated
1. Monthly Payment Requests/Invoice For Services (Attachment E)
2. Monthly Performance Reports (Attachment G) El
3. Outcome Performance Measurements Monthly Report (Attachment H) El
4. Client Contribution Report (Attachment I) ❑
5. Client Attendance Roster (Attachment J) ❑
6. Quarterly Vacancy / Permanent Housing Placement Report(Attachment K) ❑
Performance Reports. The Provider agrees to participate in the Homeless Management
Information System (HMIS) selected and established by the County. Participation will
include, but is not limited to, input of client data upon intake, daily updates of bed
availability information, as well as updates of client files upon client contact, and
maintaining current data for statistical purposes. The Provider understands that they are
responsible for any ongoing cost to access the HMiS systems The Provider shall furnish
the County with Monthly, Quarterly, and Annual Performance Reports in accordance with
the activities and goals detailed in the Scope of Services. The reports shall explain the
Provider's progress for the quarter. The data should be quantified when appropriate. The
final progress report shall be due no later than thirty (30) days after the expiration or
termination of this Contract. Continuation of this Contract and funding is contingent upon
meeting established performance goals. Progress reports, produced through the
Homeless Management Information System (HMIS) invoices for services and client
attendance rosters signed by the Executive Director of the agency shall by submitted by
the Provider, as required.
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F. Final Report/Recapture of Funds. Upon the expiration or termination of this
Contract, the Provider shall submit the final Annual Performance Report and Annual Actual
Expenditure Report (Attachment L) to the County no later than thirty (30) days after the expiration or
termination of this Contract. If after receipt of such final reports, the County determines that the
Provider has been paid funds not in accordance with the Contract, and to which it is not entitled, the
Provider shall return such funds to the County, or the County may reduce, by the amount of such
funds, from any subsequent paYfent to which the Provider is entitled, or the Provider may submit
appropriate documentation within seven (7) days of notice from the County. The County shall have
the sole discretion in determining if the Provider is entitled to such funds and the County's decision on
this matter shall be final and binding. Additionally, any unexpended or unallocated funds shall be
recaptured by the County.
Additionally, the Provider agrees to assign any proceeds to the. County from any contract, including
this Contract, between the County, its agencies or instrumentalities and the Provider or any firm,
corporation, partnership or joint venture in which the Provider has a controlling financial interest in
order to secure repayment of any reimbursements for services provided under this or any other
contract for which the :County discovers was not reimbursable through its inspection, review and/or
audit pursuant to this Contract.
ARTICLE 18. PROHIBITED USE OF FUNDS
A. Adverse Actions or Proceeding. The Provider shall not utilize County funds to retain
legal counsel for any action or proceeding against the County or any of its agents, instrumentalities,
employees, or officials. The Provider shall not utilize County funds to provide legal representation,
advice, or counsel to any client in any action or proceeding against the County or any of its agents,
instrumentalities, employees, or officials.
B. Religious Purposes. County funds shall not be used for religious purposes.
C. Commingling Funds. The Provider shall not commingle funds provided under this
Contract with funds received from any other funding sources. The Provider shall establish a separate
account exclusively for receipt of the funds received pursuant to this Contract.
D. Double Payments. Provider costs claimed under this Contract may not also be
claimed under another contract or grant from the County or any .other agency. Any claim for double
payment by Provider shall be considered a material breach of this Contract.
ARTiCLE19. REQUIRED DOCUMENTS, RECORDS, REPORTS, AUDITS, MONITORING AND
REVIEW
A. Certificate of Corporate Status. The Provider must submit to the Contract Manager,
within thirty (30) days from the date of execution of this Contract, a certificate of corporate status in
the name of the Provider, which certifies the following: that the Provider is organized under the laws of
the State of Florida; that all fees and penalties have been paid; that the Providers most recent annual
report has been filed; that its status is active; and that the Provider has not filed Articles of Dissolution,
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B. Board of Director Requirements. The Provider shall ensure that the Provider's
Board of Directors is apprised of the programmatic, fiscal, and administrative obligations under this
Contract funded through County Funds by passage of a formal resolution authorizing execution of this
Contract with the County. A copy of this corporate resolution must be submitted to the County prior to
contract execution. A current list of the Provider's Board of Directors and officers must be included
with the submission. The Provider acknowledges and understands that all contract documents shall
be signed by either the Provider's President or Vice President. The Providers resolution shall at a
minimum: list the name(s) of the Board's President, Vice President and, only in the event that the
President or Vice President is not available to execute the contract documents, any other .persons
authorized to execute this Contract on behalf of the Provider; affirmatively state that a quorum was
present at the time of adoption of the resolution; and reference the service categories and dollar
amounts in the award, as may be amended.
C. Proof of Tax Status. The Provider is required to submit to the County the following
documentation: (a) W-9 Form (Attachment M); (b) The I.R.S. tax exempt status determination letter;
(c) the most recent I.R.S. form 990; (d) the annual submission of I.R.S. form 990 within (6) months
after the Provider's fiscal year end; (e) IRS form 941 - Quarterly Federal Tax Return Reports within
thirty-five (35) days after the quarter ends and if the form 941 reflects a tax liability, proof of payment
must be submitted within forty-five (45) days after the quarter ends.
D. Conflicts of Interest. Section 2-11.1(d) of Miami -Dade County Code as amended,
requires any County employee or any member of the employee's immediate family who has a
controlling financial interest, direct or indirect, with Miami -Dade County or any person or agency
acting for Miami -Dade County competing or applying for any such contract as it pertains to this
solicitation, to first request a conflict of interest opinion from the County's Ethic Commission prior to
their or their immediate family member's entering into any contract or transacting any business
through a firm, corporation, partnership or business entity in which the employee or any member of
. the employee's immediate family has a controlling financial interest, direct or indirect, with Miami -
Dade County or any person or agency acting for Miami -Dade County. /Further, any such contract,
agreement or business engagement entered in violation of this subsection, as amended, shall render
this Contract voidable.
E. Accounting *Records. The Provider shall keep accounting records which conform to
generally accepted accounting principles. All such records will be retained by the Provider for no less
than three (3) years beyond the term of this Contract, and shall be made available for review upon
request from County authorized personnel.
F. Financial Audit. If the Provider has or is required to have an annual certified public
accountant's opinion and related financial statements, the Provider agrees to provide these
documents to the County no later than one hundred eighty (180) days following the end of the
Provider's fiscal year, for each year during which this Contract remains in force or until all funds
received pursuant to this Contract have been so audited, whichever is later.
G. Access to Records: Audit. The County reserves the right to require the Provider to
submit to an audit by an auditor of the County's choosing or approval. The Provider shall provide
access to all of its records which relate to this Contract at its place of business during regular
business hours. The Provider agrees to provide such assistance as may be necessary to facilitate
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(3)
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their review or audit by the County to ensure compliance with applicable accounting and financial
standards.
H. Quarterly Reviews of Expenditures and Records. The County Commission Auditor
may perform quarterly reviews of Provider's expenditures and records. Subsequent payments to the
Provider shall, be subject to a satisfactory review of Provider's records and expenditures by the
County Commission Auditor, including but not limited to, review of supporting documentation for
expenditures and the existence of sufficient documentation to support eligible expenditures. The
Provider agrees to reimburse the County for ineligible expenditures as determined by the County
Commission Auditor.
1. Quality Assurance / Recordkeeping. The Provider shall maintain, andshall require
that the Provider's subcontractors and suppliers maintain, complete and accurate program and fiscal
records ,to substantiate compliance with the requirements set forth in the Attachment A, Scope of
Services, of this Contract. The Provider and its subcontractors and suppliers, shall retain such
records, and all other documents relevant to the Services furnished under. this Contract for a period of
El three (3) years or ® .years (for State contracts) from the expiration date of this Contract.
The Provider agrees to participate in evaluation studies,. quality management activities,
Corrective Action Plan activities, and analyses carried 'out by or on behalf of the County to evaluate
the effectiveness of client service(s) or the appropriateness and quality of care/service delivery.
Accordingly, the Provider shall allow authorized County staff involved in such efforts to examine and
review the Provider's premises "and records.
J. Confidentiality Requirements. The Provider shall establish and implement policies
and procedures which ensure compliance "with 'the following security standards and any and all
applicable State and Federal statutes and regulations for the protection of confidential client records
and electronic exchange of confidential informations The policies and procedures must ensure that:
(1)
There is a controlled and secure area for storing and maintaining active
confidential information and files, including but not limited to medical records;
(2) Confidential records are not removed from the Provider's premises, unless
'otherwise`authorized by law or upon written consent from the County;
Abbess to confidential information is restricted to authorized personnel of the
Provider, the County, the United States Department of Health and Human
Services, the United States Comptroller General, and/or the United States
Office of the Inspector General;
(4) Records are not left unattended in areas accessible to unauthorized individuals;
(5) Access to electronic data is controlled;
(6) Written authorization, signed by the client, is obtained for release of copies of
client records and/or information. Original documents must remain on file at the
originating Provider site;
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An orientation is provided to new staff persons, employees, and volunteers. All
employees and volunteers must sign a confidentiality pledge, acknowledging
their awareness and understanding of confidentiality laws, regulations, and
policies;
Procedures are developed and implemented that -address client chart and
medical record identification, ;Ming methods, storage, retrieval, organization and
maintenance, access and security, confidentiality, retention, release of
information, copying, and faxing..
K. Monitoring: Management Evaluation and Performance Review. The Provider
agrees to permit County authorized personnel to monitor, review and evaluate the program/work
which is the subject of this Contract. The County shall monitor fiscal, administrative, and
programmatic compliance with all the terms and conditions of the Contract. The Provider shall permit
the County to conduct site visits, client assessment surveys, and other techniques deemed
reasonably necessary to fulfill the monitoring function. A report of the County's findings will be
delivered to the Provider and the Provider will rectify all deficiencies cited within the period of time
specified in the report. If such deficiencies are not corrected within the specified time the County may
suspend payments or terminate this Contract. The County may conduct one or more formal
management evaluation and performance reviews of the Provider. Continuation of this Contract and
funding are dependent upon the County being satisfied with the results of the evaluations.
L. Client Records. The Provider shall maintain a separate individual client chart for each
client/family served, where appropriate. This client chart shall include all pertinent information
regarding case activity. At a minimum, the client chart shall contain referral and intake information,
treatment plans, and case notes documenting the dates services were provided and the type of
service provided. These client charts shall be subject to the audit and inspection requirements under
Article 19, Sections F, G and H of this Contract.
M. Disaster Plan/Continuity of Operations Plan (COOP), The Provider shall develop
and maintain an Agency Disaster Plan/COOP. At a minimum, the Plan will describe how the Provider
establishes and maintains an effective response to, emergencies and disasters, and must comply with
any Florida Statutes related to Emergency Management that are applicable to the Provider. The
Disaster Plan/COOP must be submitted to the County no later than April 1st of the contract term and is
also subject to review and approval of the County in its sole discretion. The Provider will review the
Plan annually, revise it as needed, and maintain a written copy on file at the Provider's site.
N. Continuum of Care (CoC) Coordinated Intake and Assessment Process
The Provider shall participate in the Continuum of Care's (CoC) Coordinated Intake and
Assessment process, to include, but not limited to: participation in the CoC's defined process to
make and receive referrals for housing and/or services(including the use of the Homeless
Management Information. System (HMIS) for such, if required in the Standards of Care); use of
any forms required (e.g. Release of Information, Homeless Verification Form, Chronic Homeless
Verification Form, etc.); compliance with established Standards of Care (and any revisions
thereof) relating to eligibility criteria and timely processing of referrals; and cooperation with
established prioritizations for placement.
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O. Public Records
Pursuant to Section 119.0701 of the Florida Statutes, if the Provider meets the definition of
"Contractor" as defined in Section 119.0701(1)(a), the Provider shall:
(a) Keep and maintain public records that ordinarily and necessarily would be required by the
public agency in order to perform the service;
(b) Provide the public with access to public records on the same terms and conditions that the
public agency would provide the records and at a cost that does not exceed the cost provided
in this chapter or as otherwise provided by law;
(c) Ensure that public records that are exempt or confidential and exempt from public records
disclosure requirements are not disclosed except as authorized by law; and
(d) Meet all requirements for retaining public records and transfer to the County, at no County
cost, all public records created, received, maintained and or directly related to the
performance of this Agreement that are in possession of the Provider upon termination of this
Agreement. Upon termination of this Agreement, the Provider shall destroy any duplicate
public records that are exempt or confidential and exempt from public records disclosure
requirements. All records stored electronically must be provided to the County in a format that
is compatible with the information technology systems of the County.
For purposes .of this Article, the term "public records" shall mean all documents, papers,
letters, maps, books, tapes, photographs, films, sound recordings, data processing software,
or other material, regardless of the physical form, characteristics, or means of transmission,
made or received pursuant to law or ordinance or in connection with the transaction of official
business of the County.
Provider's failure to comply with the public records disclosure requirement set forth in Section
119.0701 of the Florida Statutes shall be a breach of this Agreement.
In the event the Provider does not comply with the public records disclosure requirement set 'forth in
Section 119.0701 of the Florida Statutes, the County may, at the County's sole discretion, avail itself
of the remedies set forth under this Agreement and available at law.
ARTICLE 20. Office of Miami -Dade County Inspector General
Miami -Dade County has established the Office of the Office of Inspector•General which is empowered
to perform random audits on all County contracts throughout the duration of each contract. The
Miami -Dade County Inspector General is authorized and empowered to review past, present and
proposed County and Public Health Trust programs, contracts, transactions, accounts, records and
programs. In addition, the Inspector General has the power to subpoena witnesses, administer oaths,
require the production of records and monitor existing projects and programs. Monitoring of an
existing project or program may include a report concerning whether the project is on time, within
budget and in compliance with plans, specifications and applicable law.
The Inspector general is empowered to analyze the necessity of and reasonableness of proposed
charge orders to the Contract. The Inspector General is empowered to retain the services of
independent private sector inspectors general (IPSIG) to audit, investigate, monitor, oversee, inspect
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and review operations, activities, performance and procurement process including but not limited to
project design, bid specifications, proposal submittals, activities of the Provider, its officers, agents
and employees, lobbyists, -County staff and elected officials to ensure compliance with contract
specifications and to detect fraud and corruption.
Upon ten (10) days prior written notice to the Provider from the Inspector General or IPSIG retained
by the inspector General, the Provider shall make all requested records and documents available to
the Inspector General or IPSIG for inspection and copying. The Inspector General and IPSIG shall
have the right to inspect and copy all documents and records in the Provider's possession, custody or
control which, in the Inspector General or IPS1G's sole judgment, pertain to performance of the
contract, including, but not limited to original estimate files, worksheets, proposals and agreements
from and with successful and unsuccessful subcontractors and suppliers, all project -related
correspondence, memoranda, instructions, financial documents, construction documents, proposal
and contract documents, back -charge documents, all documents and records which involve cash,
trade or volume discounts, insurance proceeds, rebates, or dividends received, payroll and personnel
records, and supporting documentation for the aforesaid documents and records.
The provisions in this section shall apply to the Provider, its officers, agents, employees,
subcontractors and suppliers. The Provider shall incorporate the provisions in this section in all
subcontractors and all other agreements executed by the Provider in connection with the performance
of the contract.
Nothing in this contract shall impair any independent right of the County to conduct audit or
investigative activities. The provisions of this section are neither intended nor shall they be construed
to impose any liability on the County by the Provider or third parties.
ARTICLE 21. SUBCONTRACTORS and ASSIGNMENTS
A. Subcontracts. The parties agree that ,no assignment or subcontract will be made or
let in connection with this Contract without the prior written approval of the County in its sole
discretion, which shall not be unreasonably withheld, and that all subcontractors or assignees shall be
governed by all of the terms and conditions of this Contract.
1) If the Provider will cause any part of this Contract to be performed by a
Subcontractor, the provisions of this Contract will apply to such Subcontractor
and its officers, agents and employees in all respects as if it and they were
employees of the Provider; and the Provider will not be in any manner thereby
discharged from its obligations and. liabilities hereunder, but will be liable
hereunder for all acts and negligence of the Subcontractor, its officers, agents,
and employees, as if they were employees of the 'Provider. The services
performed by the Subcontractor will be subject to the provisions hereof as if
performed directly by the Provider.
The Provider, before making any subcontract for any portion of the services, will
state in writing to the County the name of the proposed Subcontractor, the
portion of the Services which the Subcontractor is to perform, the place of
business of such Subcontractor, and such other information as the County may
Page 21 of 27
The City of Miami
Hotel/Motel Placement Program, PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
require. The County will have the right to require the Provider not to award any
subcontract to a person, firm, or corporation disapproved by the County in its
sole discretion.
Before entering into any subcontract hereunder, the. Provider will inform the
Subcontractor fully and completely of all provisions and requirements of this
Contract relating either directly or indirectly to the Services to be performed.
Such Services performed by suchSubcontractor will strictly comply with the
requirements of this Contract,
In order to .qualify as a Subcontractor satisfactory to the County in its sole
discretion, in addition to the other., requirements herein provided, the
Subcontractor must be prepared to prove to the satisfaction of the County that it
has the necessary facilities, skill: and experience, and ample financial resources
to;:perform the: Services in a .satisfactory manner. To be considered skilled and
experienced, the Subcontractor must show to the satisfactionof the County in
its sole discretion that it has satisfactorily performed services of the same
general type which is required to be performed under this. Contract.
The County shall . have the right to withdraw .its. consent to a ,subcontract if it
appears to the County that the subcontract will delay, prevent,, or otherwise
impair the performance of the Contractor's obligations under this Contract." All
Subcontractors are required.: te protect the., confidentiality ot the County's and
County's proprietaly:and confidential information, Provider shall. furnish to the
County copies of all subcontracts between Provider and Subcontractors and
suppliers hereunder. Within each such subcontract, there shall be a clause for
the benefit of the County permitting the County to request completion of
performance by the Subcontractor of itsobligations under: the subcontract, in
the event the County finds the Contractor in breach of its Obligations; and the
option to , pay, the Subcontractor directly for the . performance by such
subcontractor.. The foregoing ;shall neither, convey nor imply any obligation or
liability on the. part of the County to any subcontractor hereunder as more fully
described herein.
B. Prompt Payments to Subcontractors. The Provider shall issue prompt payments to
subcontractors that are small businesses (annual gross sales of $750,000 or less with its principal
place of business in Miami -Dade County) and shall have a dispute resolution procedure in place to
address disputed payments. Pursuant to the County's Sherman S. Winn Prompt Payment Ordinance
(Ordinance 94-40), Section 2-8.1.4 of the Code of Miami -Dade County, Administrative Order No. 3-19,
and the Florida Prompt Payment Actspayments must be`made within thirty (30) days of receipt of a
proper invoice. Failure to, issue prompt payments to small business subcontractors or adhere to
dispute resolution procedures may be grounds for suspension or termination of this Contract or
debarment.
ARTICLE 22. LOCAL., STATE, AND FEDERAL COMPLIANCE REQUIREMENTS
Provider agrees to comply, subject to applicable professional standards, with the provisions of
Page 22 of 27
The ,City ,of Miami
Hotel Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-PC
any and all applicable Federal, State and the County's orders, statutes, ordinances, rules and
regulations that may pertain to the Services required under this Contract, including but not limited to:
a) Miami -Dade County Florida, ,Department of Business Development Participation
Provisions, as applicable to this Contract.
b) Miami -Dade County Code, Chapter 11A, including but not limited to Articles III and IV,
All Providers and subcontractors performing work in connection with •this Contract shall
provide equal opportunity for employment and services without regard to race, creed,
religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age,
ancestry, gender identity, gender expression, source of income, national origin or
handicap. The aforesaid provision shall include, but not be limited to, the following:
employment, uprading, demotion or transfer, recruitment advertising; layoff or
termination; rates of pay or other forms of compensation; and selection for training,
including apprenticeship. The Provider agrees to post in a conspicuous place available
for employees and applicants for employment, such notices as may be required by the
Dade County Equal Opportunity Board or other authority having jurisdiction over the
work setting forth the provisions of the nondiscrimination law.
c) Conflict of Interest and Code of Ethics Ordinance, Section 2-11.1 et seq. of the Code of
Miami -Dade County, as amended.
d) Miami -Dade County Code Section 10-38, Debarment of contractors from County work.
e) Miami -Dade County Ordinance 99-5, codified at 11A-60 et seq. Code of Miami -Dade
County pertaining to complying with the County's Domestic Leave Ordinance.
f) Miami -Dade County Ordinance 99-152 codified at Section 21-255 et seq, prohibiting
the presentation, maintenance, or prosecution of false or fraudulent claims against
Miami -Dade County.
g)
Miami -Dade County Resolution 478-12. The Provider will not use products or foods
containing "pink slime," as defined in Resolution 478-12 of the Board of Miami -Dade,
County Commissioners, in food that is provided or served pursuant to this agreement."
Notwithstanding any other provision of this Contract, Provider shall not be required pursuant to this
Contract to take any action or abstain from taking any action if such action or abstention would, in the
good ,faith determination of the Provider, constitute a violation of any law or regulation to which
Provider is subject, including but not limited to laws and regulations requiring that Provider conduct its
operations in a safe and sound manner.
ARTICLE 23. MISCELLANEOUS
A. Publicity. It is understood and agreed between the parties hereto that this Provider is
funded by Miami -Dade County. Further, by the acceptance of these funds, the Provider agrees that
events funded by this Contract shall recognize and adequately reference the County as a funding
source. The Provider shall ensure that all publicity, public relations, advertisements and signs
Page 23 of 27
The City of Miami
Hotel/Motel Placement Program PC-1516-HTMT-2
IDES I[S Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
recognizes and references the County (by inserting the Miami -Dade County Homeless Trust Logo on
all materials) for the support of all contracted activities. This is to include, but is not limited to, all
posted signs, pamphlets, wall plaques, cornerstones, dedications, notices, flyers, brochures, news
releases, media packages, promotions, and stationery. The use of the official Miami -Dade County
Homeless Trust logo is permissible for the publicity purposes stated herein. Proyider shall submit
sample or mock up of such publicity or materials to the County for review and approval. The Provider
shall ensure that all media representatives, when inquiring about the activities funded by this Contract,
are informed that the County is its funding source.
B. Governing Law and Venue. This Contract is made in the State of Florida and shall be
governed according to the laws of th•e State of Florida. Venue for this Contract shall be Miami -Dade
County, Florida.
C. Modifications. Any alterations, variations, modifications, extensions, or waivers of
provisions of this Contract including, but not limited to, amount payable and effective term shall only
be valid when they have been reduced to writing, duly approved and signed by both parties and
attached to the original of this Contract.
The County and Provider mutually agree that modification of the Scope of Services, schedule
of payments, billing and cash payment procedures, set forth herein and other such revisions may be
made as a written amendment to this Contract executed, by both parties.
The Mayor or the Mayor's designee is authorized to make modifications to this Contract as
described herein on behalf of the County.
The Office of the Inspector General shall have the power to 'analyze the need for, and the
reasonableness of proposed modifications to this Contract.
D. Counterparts. This Contract is executed in three (3) counterparts, and each
counterpart shall constitute an original of this Contract.
E. Headings, Use of Singular and Gender. Paragraph headings are for convenience
only and are not intended to expand or restrict the scope or substance of the provisions of this
Contract. Wherever used herein, the singular shall include the plural and_ plural shall include the
singular, and pronouns shall be read as masculine, feminine, or neuter as the context requires.
F. Review of this Contract. Each party hereto represents and warrants that they
have consulted with their own attorney concerning each of the terms contained in this
Contract. No inference, assumption, or presumption shall be drawn from the fact that one
party or its attorney prepared. this Contract. It shall be conclusively presumed that each party
participated in the preparation and drafting of this Contract.
G. The County's Consultant. The Provider understands that .in .order to facilitate the
implementation of this Contract, the County may from time to time designate in writing a development
•consultant to work with the Provider. The County's consultant shah be considered the County's
designee with respect to all portions of this Contract with the exception of those provisions relating to
payment of the Provider for services rendered. The 'County shall provide written notification to the
Provider of the name, address, and employees of the County's consultant.
Page 24 of 27
The City of Miami
Hotel/Motel Placement Program PC-1516-HTMT-2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-15166-FC
H. Contracts with Municipalities or Counties Outside Miami -Dade County to Provide
Homeless Housing in Miami -Dade County. The Provider desiring to transact business or enter into
a Contract with the County for the provision of homeless housing and/or services swears, verifies,
affirms and agrees that (1) it has not entered into any current contract, arrangement of any kind, or
understanding with any municipality outside of Miami -Dade County or any County (collectively
"locality") to• provide housing and services for homeless persons in Miami -Dade County who are
transported to Miami -Dade County by or at the behest of such locality and (2) during the term of this
Contract, it will not enter into any such contract, arrangement of any kind, or understanding; provided,
however, upon the written request of the -Provider prior to entering into such contract, understanding
that the County may, in its sole and absolute discretion, find and determine within sixty (60) days of •
such request that a proposed contract should not be prohibited hereby, as the best interests of the
homeless programs undertaken by and on behalf of Miami -Dade County would not be negatively
affected by such contract, arrangement, or undertaking.
I. Incident Reports. The Provider must report to the Miami -Dade County Homeless
Trust information related to any critical incidents occurring during the administration of its programs.
The Provider is to utilize the "Incident Report" form attached as Attachment N. In addition to
reporting this incident to the appropriate authorities, the Provider must within twenty-four (24) hours of
any incident, submit in writing a detailed account of the incident. This incident report should be
addressed to the County. This incident report should be addressed to Miami -Dade County Homeless
Trust, 111 NW First Street, 27th Floor, Suite 310, Miami, Florida 33128; telephone (305)` 375-1490 and
facsimile (305) 375-2722.
J. Totality of Contract 1 Severability of Provisions. This Contract and Attachments,
with it recitals on the first page of the Contract and with its attachments as referenced below contain
all the terms and conditions agreed upon by the parties.
1. No 3rd Party Beneficiaries. The Parties agree that this contract has no intended or
unintended third party beneficiaries.
K. Property. This section applies to equipment with an acquisition cost of $5,000 or more
per unit and all real property.
1. Any real property under the Provider's control that was acquired/improved in
whole or in part with funds from the Homeless Trust and any equipment
purchased for $5,000 or more shall be disposed of, at the expiration or
termination of this contract, in accordance with instruction from the Homeless
Trust. Real Property is defined as land, including land improvements, structures,
and appurtenances thereto, including movable machinery and equipment.
Equipment means tangible, nonexpendable, personal property having a useful
life of more than one year and an acquisition cost of $5,000 or more per unit.
2. All equipment with an acquisition cost of $5,000 or more per units and all real:
property purchased in whole or in part with funds from this and previous
contracts with the Homeless Trust, or transferred to the Provider t after being
purchased in whole or in part with funds from the Homeless Trust shall be listed
Page 25 of 27
The City of 1Vliami
Hotel/Motel Placement Program PC-1516-HTMT-2
BMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
in the property records of the Provider and shall include a legal description, size,
date of acquisition, value at time of purchase, owner's name if different from the
Provider, information on the transfer or disposition of the property, and map
indicating *whether property is in parcels, lots or blocks and showing adjacent
streets and roads. Notwithstanding documentation required for reimbursement
purposes, a copy of the purchase receipt for any asset described above
purchased with Homeless Trust funds must also be included in the Provider's
monthly reimbursement package submitted to the Homeless Trust in the month
in Which, the item was purchased along with the "Provider Asset Inventory"
(Attachment 0), • " •
• •
3. All equipment with an acquisition cost of. $5,000 or more per unit and all real
property shall. be inventoried annually by the Provider and an inventory report
shall be submitted to the Homeless Trust. This report shall include the elements
listed in the paragraph listed above.
• AttachmentA:
• Attachment
Attachment C:
• Attathient D:
AttaChMehg E:
Attaahrnerit F:
Attachment G:
Attachment H:
Attachment I:
Attadhrnent J:
Attach m ent K:
Attachment L:
Attachment M:
Attachnient N:
Attachment 0:
Attachment P:
Scope of Services
Budget •.,s.
Miami Dad e County Affidavits
State Affidavits (NOT APPLICA8LE)'
Primary bk6 lnvoice for $6rV(66';';''
MANY Payment ReOeti Repo'rts.(NOT APPLICABLE)
Monthly Performance Reports
Outcome Performance Measurements Monthly Report
Client Contribution Report (NOT APPLICABLE)
Client Attendance Roster (NOT APPLICABLE)
Vacancy/Permanent Housing Placerneht,Report (Quarterly) (NOT APPLICABLE)
Annual Performance Repot & Annual Actual Ependiture Report
VV7.9.: Form ..•
Incident Report •
Provider Asset Inventory Report
Client Services Certification Form
No other agreement, oral or otherwise, regarding the subject matter of this Contract shall be
deemed to exist or bind any of the parties hereto. If any provision of thiS Contract is held invalid or
void, the remainder of this Contract shall not be affected thereby if such remainder would then
continue toconform to the terms and requirements of applicable law and ordinance.
SIGNATURES APPEAR ON THE FOLLOWING PAGE
Page 26 of 27
The City of Miami
Hotel/Motel Placement Program PC-1516-HTMT 2
HMIS Staffing Program PC-1516-STAFF-2
Feeding Coordination PC-1516-FC
IN WITNESS WHEREOF, the parties have executed this Contract, along with all of its Attachments,
effective as of the contract date herein above set forth.
WITNESSES:
ENTITY: CITY OF MIAMI, FLORIDA
A municipal corporation of
The State of Florida
By: By:
TODD B. HANNON DANIEL J. ALFONSO
CITY CLERK CITY MANAGER
Approved as to Form and Correctness: Approved as to Insurance Requirements:
By: By:
VICTORIA MENDEZ ANN-MARTS SHARPE
CITY ATTORNEY RISK MANAGEMENT
Affix
Incorporation SEAL
here
AI LEST: Miami -Dade County, a political subdivision of
The State of Florida
HARVEY RUVIN, CLERK.
BY:
DEPUTY CLERK CARLOS A. GIMENEZ
(DATE)
MAYOR
See memorandum dated approved for form and legal sufficiency.
Page 27 of 27
ATTACHMENT A, SCOPE OF SERVICES
HOTEUMOTEL PLACEMENT PROGRAM, HMIS STAFFING PROGRAM AND
FEEDING COORDINATION PROGRAM
PC-1516-HTMT-1, PC-1516-STAFF-1, and PC-1'516=FC
SCOPE OF SERVICES
1. EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM
The Provider agrees to provide emergency hotel/motel placements of homeless families
with children for a period of up to seven (7) days in area hotels/motels. Thereafter, the
Provider must obtain the approval of the Miami -Dade County Homeless Trust for
additional days as needed on a case -by -,case basis.
Families may be provided food vouchers on an as -needed basis of up to $20.00 per
diem while residing in hotels/motels. Families with more than four (4) members may be
provided an additional $5.00 per person per day.
Reimbursements will only be made for properly documented disbursement of food
vouchers.
All reimbursements must be submitted to the County by the 15th day of each month
following the month of service.
All reimbursement requests must be approved by the County prior to the disbursement
of funds.
2. FEEDING COORDINATION PROGRAM
The Provider shall coordinate feeding programs for the homeless in the City of Miami to
ensure feeding is conducted in a clean, convenient and humane environment.
The Feeding Coordinator/Community Liaison shall develop and maintain a list of all
participating organizations and homeless individuals no later than thirty (30) days prior
to the end of each quarter, distribute correspondence as needed to participating
organizations and ensure the coordination, of outreach activities at the feeding sites
listed below:
• Miami Rescue Mission
• Mount Zion Baptist Church
• Mother Theresa's
2020 NE 1st Avenue, Miami, Florida 33127
301 NW 9th Street, Miami, Florida 33136
724 NW 17th Street, Miami, Florida 331-27
ATTACHMENT A, SCOPE OF SERVICES
HOTEL/MOTEL PLACEMENTPROGRAM, HMIS STAFFING PROGRAM AND
FEEDING COORDINATION PROGRAM
PC-1516-HTMT-1, PC-1516-STAFF-1, and PC-1516-FC
The Feeding Coordinator must:
1) Maintain a running list of feeding groups identified, with the date(s) they were
observed feeding and the location of where they provided feeding services,
2) Maintain a daily list of contacts made, with name of organization, contact name
and contact information
3) Produce a daily report on number of persons fed at Miami Rescue Mission and, if
possible, at Mother Theresa .
4) Produce a report of Tuesday feedings at Mount Zion: (1) the number of persons
served and (2) the name of the organization and/or feeding group who provided
feeding services for the assigned evening/night.
5) Report the result of any outreach engagement at the feeding location sites.
6) Coordinate a monthly '.'survey" of Individuals requesting feeding services to
determine whether they are homeless or are just working poor:
7) The Feeding Coordinator must also'ensure that outreach teams`are present at
Mt.Zion, Miami Rescue Mission and Mother Theresa's (outside). on a regular
(preferably daily) and consistent bsis.
3. HMIS STAFFING PROGRAM
The Provider shall provide a 'dedicated HMIS Outreach staff person to provide HMIS
services and input. The purpose of this staff position is to maintain data current in the
HMIS and includes, but is not limited to input of client data upon intake, updates of client
files, compilation of reports and entering of data for statistical purposes. Failure to
maintain this data current, as evidenced *HMIS generated Mbnthly Progress Reports
(MPRs) submitted to the County each month under the USHUD Continuum of Care
(CoC )sub-reci ient Agreements andthe Prlma'ry Care services Agreements I -nay result
in the termination of this Agreement. 0
Attachment B, Page 1 of 3
The City of Miami
Emergency Hotel/Motel Placement — PC-1516-HTMT-1
CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM
Emergency Hotel/Motel Placement
2015-2016 Contract Amendment
BUDGET
Object Class
.
.
Cost
MDHT
%
City of
Miami
%
Justification
Emergency
Housing,
Hotel/Motel
7,499 days/units @
$60.00 per day
$449,960
•
100%
Emergency Hotel/Motel
placements for eligible
families due to
unavailability of beds
within the continuum of
care
Food Vouchers
500 vouchers @
$20.00 per voucher
$10,000
100%0
Food vouchers for eligible
families.
TOTAL
•
$459,960
1
Hotel/Motel Placement Locations:
Name of Hotel/Motel
1.
Address # of rooms available Daily Cost
2.
3.
4.
2
Attachment B
The City of Miami
HMIS Staffing — PC-1"516-STAFF-1
CITY OF MIAIVII HOMELESS ASSISTANCE PROGRAM
Homeless Management Information System
2015-2016 Contract
BUDGET
Object Class
Cost
>'
MDHT'.:✓o:.•'.
City of
Miami
%
Justification
1. Supportive
Service Costs
Personnel -Salary
1 FT Homeless
Program Clerk. HMIS
Administrator
@$14,49/h
$32,445
'+'° i
!Vo:.:, ' `
24 %
Salaries for the City of
Miami Homeless Program
HMIS Administrator
TOTAL
:$24.$666 . '
$7,779
1
•
Attachment B-Page 2 of 3
The City of Miami
Feeding Coordinator Program-PC-1516-FC
CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM
s. Feeding Coordinator
2015-2016 Contract Agreement
BUDGET'°'
Object
Class
Cost
MDHT
Feeding
Contract
City of
Miami
Justification
1. Staffing
Personnel -Salary
1 FT Homeless
Program Feeding
Coordinator @
$14.49/h
$32,445
46 %
54%
Salaries for the City of
Miami
Homeless Program
Feeding Coordinator
TOTAL
•
.,
$32,445
`$15,000
$17,445
ATTACHMENT C
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
The contracting individual or entity (governmental 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 MIAIYII-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAIYIQ DARE COUNTY
EMPLOYMENT DISCLOSURE AIIIDAVIT; MIAIVI DADE CRIMINAL RECORD AFFIDAVIT; DISABILITY
NONDISCRIMINATION AFFIDAVIT`; and the PROJECT FRESH START AFFIDAVIT shall not pertain to contracts
with. the United States government or any of its departments or agencies thereof, the State or any political subdivision or
agency thereof or any municipality of this State. The MIAMC-DADE FAMILY LEAVE AFFIDAVIT and MIAMI DADE
DOMESTIC LEAVE AND REPORTING AFFIDAVIT shall not pertain to contracts with the United States or any of its
departments or agencies or the State of Florida or any political subdivision or agency thereof; it shall, however, pertain to
mmnnicipalities 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.
pa r\le.i • 4-I 'ACci being first duly sworn state:
The full. legal name and business address of the person(s) or entity contracting or transacting business with Miami -Dade
County are (Post Office addresses are not acceptable):
Federal Employer Identification Number (Ifnone, Social Security)
•
CI 4
Name of Entity, Ind►yidual(s)'; Partners, or Corporation
Doing Business As (if same as above, leave blank)
Street Address City State Zip Code
1AM[-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code)
If the contract or. business transaction is with a corporation, the full legal name and business address shall be provided for each
officer and director and each stockholder who holds directly or indirectly five percent (5%) or more of the corporation's stock.
If the contract or business transaction is with a partnership, the foregoing information shall be provided for each partner. If the
contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each
beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded corporations or to contracts with the
United States or any department or agency thereof, the State or any political subdivision or agency thereof or any municipality
of this State. All such names and addresses are (Post Office addresses are not acceptable):
Full Legal Name Address Ownership
The full legal names and business address of any other individual (other than subcontractors, material men, suppliers, 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):
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.
ATTACHMENT C "Miami -Dade County Required Affidavits" Page 1 of 5
4
ATTACHMENT C •
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
2. N17AMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County Ordinance 90-133,
Ame ding 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 often. thousand dollars ($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 thereo the State or any political subdivision or agency thereof or any municipality of this State.
Does your firm have a collective bargaining agreement with its employees?
Yes . No
b. Does your firm provide paid health care benefits for its employees?
Yes No
c. Provide a current breakdown (number of persons) of your firm's
work force and ownership as to race, national origin and gender:
White: Males:_ Female:
Black: ® Males: Female:_
Hispanic: _ Males:_ Female:_
Asian: _ Males: Female:_
American Native: _ Males Female:_
Aleut (Eskimo): — Males: Female:
3. C1 AFFIRMATIVE ACTION/NONDISCRIMINATION OF EMPLOYMENT, PROMOTION AND
PROCUREMENT PRACTICES (County Ordinance 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 a condition of receiving a County contract, have: i) a written affirmative action plan which
sets forth the procedures the entity utilizes to assure that it does not discriminate in its employment and promotion practices;
and 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 affirmative
action plans and procurement policies shall provide for periodic review to determine their effectiveness in assuring the entity
does not discriminate in its employment, promotion andprocurement practices. The foregoing notwithstanding, corporate
entities whose boards of directors are representative of thepopulation'inake-up of the nation shall be presumed to ha-Ve 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.
The Firm does not have annual gross revenues in excess of $5,000,000.
The Firma does have annual revenues in excess of $5,000,000; however, its Board of Directors is representative of the
p • 'illation make-up of the nation and has submitted a written, detailed
listing of its Board of Directors, including the race or ethnicity of each board member, to the Comaty's Department of Business
Development, 175 N.W, lst Avenue, 28th Floor, Miami., Florida 33128.
The Finn has annual gross revenues in excess of $5,000,000 and the firm does have a written affirmative action
plan and procurement policy as described above, which includes periodic reviews to determine effectiveness, and has
submitted the plan and policy to the County's Department of Business Development 175 N.W. lst Avenue, 28th Floor,
Miami, Florida 33128;
The Firm does not have an affirmative action plan and/or a procurement policy as described above, but has been
granted a waiver.
ATTACHMENT C "Miami -Dade County Required Affidavits" Page .2 of 5
ATTACHMENT C
MIAMI-DADS COUNTY REQUIRED AFFIDAVITS
4. MIANII-DARE 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 as of the date of
this affidavit been convicted of a felony during the past ten (10) years.
•
An officer, director, or executive of the entity entering into a contract or receiving funding from the County Jaas /has not), as
of the date, of this affidavit been convicted of a felony during the past ten (10) years.
5.MCAMI-DADE EMPLOYMENT DRUG-FREEWOR.'LACE AFFIDAVIT (County Ordinance 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:
danger of drug abuse in the workplace
the firm's policy of maintaining a drug -free environment at all workplaces
availability of drug counseling, rehabilitation and employee assistance programs
penalties that may be imposed upon employees for drug abuse violations
The person or entity shall also require an employee to sign a statement, as a condition of employment that the employee will
abide by the terms and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving
notice of such conviction and impose appropriate personnel action against the employee up to and including termination.
Compliance with Ordinance No. 92-15 may be waived if the special characteristics of the product or service offered by the
person or entity make it necessary for the operation of the County or for the health, safety, welfare, economic benefits and.
well-being of the public. Contracts involving funding which is provided in whole or in part by the United.States or the State of
Florida shall be exempted from the provisions of this ordinance in those instances where those provisions are in conflict with
the r; quirements of those governmental entities.
6 ; ,►., MIA11'II-DADS EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance 142-91 codified as
Sect on 11A-29 et. seq of the County Code)
That in compliance with Ordinance No. 142-91 of Code of Miami -Dade County, Florida, an employer with fifty (50) or
more employees working in Dade County for each working day during each of twenty (20) or more calendar work weeks, shall
provide the following information in compliance with all items in the aforementioned ordinance:
An employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) days of family leave
during any twenty-four (24) month period, for medical reasons, for the birth. or adoption of a child, or for the care of a child,
spouse or other close relative who has a serious health condition without risk of termination of employment or employer
reta1 aation.
The foregoing requirements shall not pertain to contracts with. the United States or any department or agency thereof, or the
State rf Florida or any political subdivision or agency thereof. It shall, however, pertainto municipalities of this State.
1.-\15ISA 3ILITY NON-DISCRIMINATION AFFIDAVIT (County Resolution R:-385-95)
That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and
assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws
listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services,
transportation, communications, access to facilities, renovations, and new construction in the following laws: The Americans
with Disabilities Act of 1990 (ADA), Pub. L.101-336, 104 Stat 327, 42 U.S.C. 1210 1-122 13 and 47 • U.S.C. Sections
225 and 611 including Title I, Employment; Title If, Public Services; Title DI, Public Accommodations and Services Operated
by Private Entities; Title IV, Telecommunications; and Title V, Miscellaneous Provisions; The Rehabilitation Act of 1973, 29
U.S.C. Section 794; The Federal Transit Act, as amended 49 U.S.C. Section 1612; The Fair Housing Act as amended, 42
U.S.C. Section 3601-3631. The foregoing requirements shall not pertain to contracts with the United States or any department
or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State.
ATTACHMENT C "Miami -Dade County Required Affidavits"
Page 3 of 5
ATTACHMENT C
MIAMI-D.ADE COUNTY REQUIRED AFFIDAVITS
8. ✓ 1\& AIM -TRADE COUNTY REGARDING DELINQUENT AND CURRENTLY DTJE NEES 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, organization or individual
desiring to transact business or enter into a contract with the County verifies that. all delinquent and currently due fees or taxes -
- including but not limited to real and property taxes, utility •taxes andoccupational licenses — which are collected in the normal
course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of
the firm, corporation, organization or individual have been paid.
9. ✓ CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS (Ordinance 99-162)
The individual entity seeking to transact business with the County is current in all its obligations to the County and is not
otherwise in default of any contract, promissory note or other loan document with the County or any of its agencies or
instrument ies.
10. DOIVIESTIC VIOLENCE LEAVE AND REPORTING AFFIDAVIT (Resolution 185-00; 99-5 Codified At
I1A-60 Et.Seq. of the Miami -Dade 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
f fty (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.
NEXT PAGE SIGNATOZE PAGE
ATTACHMENT C "Miami -Dade County Required Affidavits" Page 4 of S
ATTACHMENT C
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
I have carefully read this entire five (5) page document entitled, "Miami -Dade County Affidavits"
(Affidavits 1-10) and have indicated by "X" all affidavits that pertain to this contract and have indicated
by an "N/A" all affidavits that do not pertain to ibis contract and completed all required information.
BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATI. ESTING TO AFFIDAVITS ONE
• (1) TROUGH ELEVEN (11)
HUM-DADE COUNTY AFFID.AVTTS SIGNATURE PAGE
By:
‘,01\ ccic)
Signature of Witness or Secretary Seal Date
Signature of Affiant
Printed Name of Affiant and Name of Agency
,2095`'"
Federal Employer Identification Number
Address of Agency
SUBSCRIBED AND SWORN TO (or affirmed) before me this _ day of , 20
Ike%She is personally known to me or has presented . as identification.
Type of identification
Signature of Notary Serial Number
Print or Stamp Name of Notary Expiration Date
Notary Public — State of
County of
Notary Seal
ATTACHMENT C "Miami -Dade County Required Affld.avits" Page 5 of 5
ATTACHMENT D
THIS ATTACHMENT IS
NOT APPLICABLE TO
THIS AGREEMENT
ATTACHMENT E
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: The City of Miami
SERVICE PERIOD:
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
AMOUNT OF FUNDS REQUESTED
THIS MONTH:
TO
Hotel/Motel Placement Program
PC-1516-HTMT-1
$ 459,960.00
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $ 459,960.00
(following payment of this request)
Signature of Agency Representative Date
Printed Name of Agency Representative
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: The City of Miami
SERVICE PERIOD:
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
AMOUNT OF FUNDS REQUESTED
THIS MONTH:
TO
Bi\HS Staffing Program
PC-1516-STAFF-1
$ 24,666.00
$
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $ 24,666.00
(following payment of this request)
Signature of Agency Representative Date
Printed Name of Agency Representative
ATTACHMENT E
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OFF AGENCY: The City of Miami
SERVICE PERIOD:
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
AMOUNT OF FUNDS REQUESTED
THIS MONTH:
TO
Feeding Coordination Programs
PC-1516-FC
$ 15,000.00
$
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $ 15,000.00
(following payment of this request)
Signature of Agency Representative Date
Printed Name of Agency Representative
Continuum of Care Homeless Assistance Program
Performance Report Master Document
(Please check the box to indicate either monthly or annual report submitted)
O
0625 — HUD CoC Monthly Performance Report
C J 0625 — HUD CoC Annual Performance Report
Supplemental pages on Financial and Objectives
(This is a template designed to assist grantees required to complete the Full CoC
APR. It is a model of the data collected in e-snaps. It is not intended to replace
electronic data collection in e-snaps. Field layout in e-snaps may differ from the
layout presented in this document.)
ATTACHMENT G "Performance Reports" (Monthly and Annual) APR & HMIS •
ATTACHMENT I
THIS ATTACHMENT IS
NOT APPLICABLE TO
THIS AGREEMENT
ATTACHMENT J
THIS ATTACHMENT IS
NOT APPLICABLE TO
THIS AGREEMENT
ATTACHMENT K
THIS ATTACHMENT IS
NOT APPLICABLE TO
THIS AGREEMENT
ATTACHMENT L
MIAMI-DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM
HOTEL/MOTEL PLACEMENT PROGRAM — GRANT NUMBER PC-1516-HTMT.1
OCTOBER 1, 2015 — SEPTEMBER 30, 2016
Name of Agency:
THE CITY OF IMAM[
$ 459,960.00
Month of Services
Amount Paid
OCTOBER 2015
NOVEMBER 2015
DECEMBER 2015
JANTJARY 2016
FEBRUARY 2016
MARCH 2016
APRIL 2016
JUNE 2016
JULY 2016
AUGUST 2016
SEPTEMBER 2016
Total Requested
Balance Remaining
Executive Director or Authorized
Agency Representative Signature
Executive Director or Authorized
Agency Representative -Printed Name
Signature Date
$
0.00 .
$ 459,960.00
ATTACHMENT L
MIAMI-DARE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM
}MS STAFFING PROGRAM— GRANT NITIVIBER. PC-1516-HIVIIS-1
OCTOBER 1, 2015 — SEPTEMVIBER 30, 2016
Name of Agency:
THE CITY OF MIAMI
$ 24,666.00
Month of Services
Amount Paid.
OCTOBER 2015
NOVEMBER 2015
DECEIVIBER 2015
.
JANUARY 2016
IIEBRUARY'2016
MARCH 2016
APRIL 2016
DUNE 2016
DULY 2016
AUGUST 2016
SEPTEMBER 2016
Total Requested
Balance Remaining
Executive Director or Authorized
Agency Representative Signature
Executive Director or Authorized
Agency Representative -Printed Name
Signature Date
0.00
24,666.00
ATTACiV1ENT L
M[AMI-DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF NIIAMI HOMELESS ASSISTANCE PROGRAM
FEEDING COORDINATION PROGRAM - GRANT NUMBER PC-1516-FC
OCTOBER 1, 2015 -- SEPTEMBER 30, 2016
Name of Agency:
TN H, CITY OF MANI
$ 15,000.00
Month of Services
Amount Paid
OCTOBER 2015
NOVEMBER 2015
DECEMBER 2015
JANUARY 2016
k'EBRUARY 2016
MARCH 2016
APRIL 2016
JUNE 2016
JULY 2016
AUGUST 2016
SEPTEMBER 2016
Total Requested
Balance Remaining
Executive Director or Authorized
Agency Representative Signature
Executive Director or Authorized
Agency Representative -Printed Name
Signature Date
$
0.00
$ 15,000.00
•Form w.,.9
(Rey. Dapernber g014)
OsP,intrierit Of the Treasury
IntemarRevenuo Seivfoe
. Request for Taxpayer
Identification Number and Certificatio.n
Give Form to the
.requester. Do not
'eel-1dt.° the IR5,
— ..
0.1
a).
go
c
o
so
a) o
o
',...
,a 2
v. 4
4
a,
ti)
d,
memaname
1 Narria,(as.showli on yOur Income tax return). Nato is required ow-Vila:line; donot leave -this line blank,
citsi.pflViloWil.., .. . ., .... .
2- Buslneastiameidisregarded entity name, If differentfrofn above --- .-- - -.-. . ,
3 Ohocll apprelOrlate'box
Indiviqual/acle
SinOle-MarriberILLO
Lirlted liability
Note,.For a ainjlef,Metriber
the tax clasSification
i3 1 . Other!. fees insfructIons)*
for federal taIX classifioatiom-cheok only one:of the followlng ewer). b.oxes:
• Trusttestate
Y,
4 EgernPlibria
.P€1.411_,PrAltfaS)
ns ructions
Retriptpayeebede'clf
.i;eroption
code (If-anY)
oppik.ra accounts
COodeSepPly. Only- to
Oct incit,y1c)uslqsSe
on page4
any)
proprietor or 00 Corporation .0 $ Cairporetfon III Partnership
derrilierty. Enter. the tax blab:Siltation ,(0.0 cOrporation,6*8 corporation, Pppartnership)
LLC that I atilareparded, do not check1_t,,Q; check.the appropriate box. In
Of 'the Sirfglernernberewricir;
Mtf 014.04
roMPATCA repotting
f
'the:fine abovalor
onaintatnectouilde6lostAS)
5 AcidresS (nurnher street and apt or suite no.)
.444.s.Wnei Avenue,. 0.flbor
.
'Reqciestet'S nam end address (Optional)
0 :city; srte, :and 2Ip code
NI lanil„, Florida 331.36,
T List account mirahee(s) hare (Optional)
Taxpayer I entrf optIon Number (TIN)
.1.)ter.y.pur TIN hithe„g:lproprlate box. The TIN orpvicleOtnUst Metall theberrte given on. line 1 TO aVOid
backup withholding Ppr inerivIdUals4thJA Isgenerally your socia1seoufity;ruMber (SSN). ROWevar, for a
ree)c)ent alen aoleproorietpr, or disregarded arattSr, see the PO)) thetruCtiOne.on pae k For other
entateer it ie your employer Identification number (E1N). if yOu cIa not have a rpoloy/s14 How to et 4
TIAtgri,PagPs S.
.00t0.). e account ietitmore.than one name; se,ethe.instructipns for** 1 and the .phart On page 4 for
soliclefinespn whose amber to enter.
*)o,lat seourityliamber
or
Employer identification nurriber
5
0.
0
3
7
Part 11
Ce rtifibati on
penalties Of `perjtf(y.,1 certifY'that:.
1. The fitirtibee hoWn dn thldfortn is m Orrentlaxpayer identification number (orfarn waiting for a numertobo ssued to rae);and
am not su.bjectito bacicupvithholding because: (a)) arThekerriptfrOmbacktiO4ithholilinb:, 61' (b) 1 have not bean notified by:te Internal ReVenUe
$ercliP#R0 that') pat subjeot to backup Withhelcita0 as a result OA fa1ipretoleppt.t.0 interest or dividends, or (c) The IRS MS notified rnothat I am
nqlongersqbjept4p6aPtsuo wjthholcling; anti
k lam athk citliewor other U,.k pereortidefined helCw): and.
4 The PAtoA:code(S) entered onthle. farm (if any) indicating th0.1:qm.enmptfrprr) FATCAl'OpOtiing is correct
Certficatio InatruPtione; You must proaeout:citV,i above; if you havebpar?'119,1fiad.Py.the,IF:that-YoqereopOiiyyttibj0046:Pap1i90:WitlitipidIN
becapae,y9,1)11ave failed to:!"pport,ali interes) an ivic)eriOa,ph ypOr ta*eet(0-4;Fiskreale,State tlineedflOne,-Iterri,2 ()Peeridt aPPWFPr1110b440
intprott:.paid,'acqtileitron.orabando men) of Ou)",ed,:property,..,,aarlodliat)Pli. of debt, Contributions to an fetiemerit "(IRAVartid
enerally,,.payments 001arThanipt 08 8 dividends ; ypt) ars not required to sign tk66011ficat16n) but you hitiOV'Prp V1c14:YOUrcorrect TIN See, the
instructions 9n page,
Si§,n :19,ria.ture
Here 0;6, person
Gederal Institidrio
Section ref aranOb§liew tei.thr).lnt FI6vatilfe Code tinfesadthenvtae holed,
ktura!develpornents., Information .ebout,deyelopments.affectinirormW 90,41
aeledislation.enaeted after WeL•feleaai it) !Slit 4.ligpoirlfW9‘,
. .
Purpose fPrin
friat,.0.1at.or.atitiW(P:Orin W-9 iequested who is reqPired.to:flle an
l'etiirMWIttithalFi61:MUstOlotall) your:Correct taxpayorLiclaatlfloa)011'1114atar MN)
which May loe,your,sOdialsePliritY-huinb4r(StN),lndwldueliastnayEirIolghttfidatt6a
number adOptiontaipaYer itientNeatioariulnbcr(TIN),-eramPtoYPc
icIcIntittOdlortnumber (E!N), to report on aninfonpation rati,krn th0.aft1600t Paid to
you odthar amount mpOriable.an,''ae(inf61Mation'fauirn,':ExerripleS of inforrriatlert
returnsAkOludo;1?0t arenot limitefoit0.)1)12}y100,::
'..!.F0 MY109941NT „gritOreet earn &For Paid)
. . .
-IP :Form' 1639i.JI.V (dividends; including :Mose from 'stocks 9r mutual funds)
Form 16304)A180 (teriebt typoSOFfricdfrie., PrOSsliroteecta)
. .
4) Form.71.699‘a (stock or mOteaf 'hind 'safes anci,Peitaln oVIertraneaetionsby
broker-0
- .
Form 1339-!$,(proceeds from real estatetransa,ctions)
••ForY1.1090,K (Merchant bard and third panynetwork tranSaetiOrla)
.Pate'
;t-uOiloiorniniftigat.l)Prasi.malribqq.irttPr134.414§.E.0)1(1(41) 10AI:00190st), 1603-T-
'.F.'OrfrOd0:9-01qPDPPW
Ferhilt)63;K(adqUISItitier.t.trabahaitiment itadatired ptOpe'rtyy
'USE) VOtrri.W.aloriiy yott are et1.6..persch (InCtuditt'altaltiontallety„to
proVidelcur normal TiN.
Selftio.lieteetOrn.F,Prin 141,7,9!f0;!ifieM4iieetel'Ofth7a TIN ji.ou Yttht bf6.bt
fo backup ftvittl4oldklg.. Pae:KO/S...backup,withhordfo2on'pape,2'..
By 4Piiind the filled.4OUtforin,)ktxi
. „
1k 624.14' ;414t1h4°17iN -.You eroJi1106 Is90400-190(Pu are Walffu6'for-4 number
:•to :be
2.
Certify tat 'yottare.,notsubject to.backup, withhpid.rng, or
rorn.baCkup withholdinp,if 1ou are 0, „.akerriptpayee..lf
appkcable you.are:aleC OartffYingthat AS a 0.4parspn, your allocabie,shs(0 of
aPYparknersh,lp ln.ome frfsfri a 0 $ trede or bustnees Is nclatitijeot to the
Withhcldlngtat on ferefpfiloartriare' sitaie..Of'effeCtIVelyeennected irreorne, and
.4...Certlfy.,that;F6T0A code( entered on this- forty (if any) iridioatfed that you pre
txerlint feoffi the FATQA toPOrflO, 'fa .666.661. 'Sea Whatis PATO A MOrting? tr
pagq..fortijrthe,ririforrnatipa,
at,Nc• 1.62j-ix
Ford; W,,,9 .(Re9.1220-14)
Form W-9 (Rev. 12-2014) ' Page 2
Note. If you are a U.S, person and a requester gives you aform other than Form
W-9 to request yourTiN, you must use the requester's form 'if it Is substantially
similar to this Form W-9.
Definition of a U.S, person. for federal tax purposes, you are considered a U.S.
person if you are:
• An individual who Is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created or organized in the
United States or under the laws of the United States;
• An estate (otherthan a foreign estate); or
• A domestic trust (as defined in Regulations section 301.7701 7).
Special rules for partnerships. PaCnetshtps that conduct atrade or business in
the United States are generally required to pay a withholding tax under section
1446onany foreign parbners'share ofeffectively connected.taxableincomefrom
such business. Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 requirea'partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U.S. person that is a partner in a partnership conducting atrade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding oil your share of partnership income.
In the cases below, the following person must give Form W-9 to the partnership
for purposes of establishing ifs U.S. status and avoiding withholding on its •
allocable share of net income from the partnership conducting atade or business
in the United States:
• In the case of a disregarded entity with.a U.S. owner, the U.S. owner of the
'disregarded entity and not the entity;
• In the case of a graritor trust with a U.S. grantor or other. U.S. owner, generally,.
the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
• in the case of a U.S. trust (other than a grantor trust), the U.S. fi ist (other than a
grantor trust) and not the benefidlarfes of the trust
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank,
that has. elected to be treated as a U.S. person, do not use Form W-9. Instead, use
the appropriate Form W-8 or Forrn 8233 (see Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entitles), •
Nonresident alien who becomes a riesiclent heir •Generally, only a nonresident
alien individual mayuse:the temis'of a tax treaty to reduce or eliminate U.S. tax on
certain types of income: However, most tax treaties contain a provision (mown as
a "saving clause." Exceptions specified in the saving clause may permit an
exemption from tax to continue for certain types of income even after the payee
has otherwise become a U.S. resident lien for tax purposes.
If you are a U.S. resident alien who is retying on an exception contained in the
saving clause of a tax treaty to claim an exemption from U.S. fax on certain types
of income, you must attach a statementto Form W-9 that specifies the following
five items: ' •
1. The treatycountry. Generally, this must be the same treaty under which you
claimed exemption from tax as a nonresident mlen.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty,that contalns,the saving
clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficientfacis to„�ushfy the exerpptio{t from fax under the terms of the treaty
article.
Example. Article 20 of the U.S.-Cfifha income fax treaty allows ari 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 fief stay th'e United States exceeds 5 calendar years.
However paragraph 2 of the first Protocol to the U.S.-China treaty(dated April 30,
1984) allows the provisions of Article20 to continue to apply even after 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 stippbrt that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233. • '
Backup Withholding
What is backup withholding? Persons making certain payments to you must
under certain conditions withhold and pay to the IRS28% of such payments. This
is called "backup withholding." Payments that may be subject to backup
withholding include interest, tax-exempt inter mil, dividends, broker and barter
exchange transactions, rents; royalties, honemptoyee pay, payments made in
settlement of payment card and third party network transactions, and certain
payments from fishing boat operators. Real estate transactions are not subject to
backup withholding.
You will not be subjectto backup withholding on payments ydu receive if you
give the requester your correctTlN, make The proper certifications, and report all
your taxable interest and dividends on yourtax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TiN to the requester,
2. You do trot certify your TIN when required (see the Part II instructions on page
3 for details),
3. The IRS tells the requester that you furnished an lncorectllN,
4.The IRS tells you that you are subject to backup withholding because you did
not report all your interest and dividends on your tax return (for reportable interest
and dividends only), or
5. You de not certify to the requester that you are not subjectto backup
withholding under 4.above (for reportable interest and dividend accounts opened
after 1983 only).
Certain payees and payments are exempt from backup withholding. See Exempt
payee code on page 3 and the separate Instructions forthe Requester of Form
W-9 for more information.
Also see Special rules for partnerships above.
What is FATCA •reporting?
The ForeignAccountTax•Complianee Act (FATCA) requires a participating foreign
financial institution to report all United States account holders that are specified
United States pers'o'ns. Certain payees are exempt frnm FATCA reporting. See
Exemption from FATCA reporting code on page 3 and the instructions for the
Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be
an exempt payee if you are no longer an exempt payee and anticipate receiving
reportable payments in the future from this person. For example, you may need to
provide updated information if you are a C corporation that elects to be an S
corporation, or if you no longerare tax exempt. In addition, you nrust furnish a new
Forrn W-9 if the name orTIN changes for the account; for example, tithe grantor
of a grantor trust dies.
Penalties r•
Failure to furnish TIN. If you foil to furnish yourCorectllN fo a requester, you are
subject to a penalty of $50 for each slack failure~ unless your failure is due to
reasonable cause and not to willful neglect:
Civil penalty for false information with respect tc'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 penaltyforfalaifyiing information. Willfully falsifying certifications or
affirmations may subjectyou to criminal penalties Including fines and/or
linprisonment. .
Misuse of TINs. If the requester discloses or uses TVs In violation of federal law,
the requester may be subject to civil end: criminal penalties.
Specific Instructions
Line 1 - •
You must enter one of the following on this line; do not leave this line blank. The
name should match the name on your tax return.
If this Form W-gls fora joint acpount, list first, and then circle, the name of the
person or entity whose,,numberYou .entered in Part I of Form W-9.
• a. individuaL Generally enter the name shown on your tax return. If you have
changedyour Iasi namewrthout informing the Social Sedurity Administration (SSA)
of the trams bhange enter your first name; the last name es shown on your social
-r-•
'security card; and'your new last name: '
Note. ITIN appticarib Enter yew. individual name as It was entered on your Form
W-7 application, line 1a. This should also be the same as the name you entered on
the Form 1040/1040A/1040EZ you filed with your application.
b. Sole proprietor or single -member LLC. Enter your individual riaine as
shown on your 1040/1040A/1040EZ on line 1. You may enteryour business, trade,
or "doing business as" (DBA) name on line 2.
c. Partnership, LLC That is not a single -member LLC, C Corporation, or S
Corporation. Enterthe'entity's name as shown on the entity's tax return on Ilne 1
and any business, trade, or DBA name on line 2.
d. other entities. Enter your name as sown on required U.S. federal tax
documents on line 1. This name should match the name shown on the charter or
other legal document creating the entity. You may enter any business, trade, or
DBA name on line 2.
e. Disregarded entity For U.S. federal tax' purposes, an entity that is
disregarded as an entity separate front its 'owner Is treated as a "disregarded
entity." See Regulations section 301'.7.01-2(c)(2)(i ).•Enterthe owner's name on
line 1. lire name of the'entity ente'red on line 1 should never be a disregarded
entity. The name on 1 should be the name shown on the income tax return on
which the income should be reported. For example, if a foreign LC that is treated
as a disregarded entity for U.S. federaltaa purposes has a single owner that Is a
U.S. person, the U.S. owner's name is required to be provided on line 1. lithe
direct owner of the entity is also a disregarded entity, enter the first owner that Is
not disregarded for federal tax purposes. Enter the disregarded entity's name on
line 2, "Business name/disregarded entity name." lithe owner of the disregarded
entity is a foreign person, the owner must complete an appropriate Forth W-8
instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.
Form W-9 (Rev. 12-2014) Page 3
Line 2
If you have a business name, trade name, DBA name, or disregarded entity name,
you may enter it on line2.
Line 3
Check the appropriate box in line 3 for the U.S.'federal tax classification of the
person whose narne is entered on line 1. Check only one box in line 3,
Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a
partnership for U.S. federal tax purposes, check the "Limited Liability Company'
box and enter "P" in the space provided. tithe I:LC has filed Form 8832 or 2553 to
be taxed as a corporation, check the 'Limited Liability Company" box and in the
space provided enter "C" for'C corporation or "S" for S corporation. If it is a
single -member LLC that is a disregarded entity, do not check the "Limited liability
Company" box; instead check the first box in line 3 "Individual/sole proprietor or
single -member LLC."
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the
appropriate space in line 4 any code(s) that may apply to you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not from backup
withholding.
• Except as provided below, corporations are exempt from backup withholding
for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding for payments made in
settlement of payment card or third party network transactions.
• Corporations are not exempt from backup withholding with respect to attorneys'
fees or gross proceeds paid to attorneys, and corporations that provide medical or
health care services are not exempt with respect to payments reportable on Form
, 1099-MISC.
The following codes identify payees that are exempt from backup withholding.
Enter the appropriate code in the space In line 4.
1—An organization exempt from tax under section 501(a), any IRA, or a
custodial account under section 403(b)(7) if the account satisfies the requirements
of section 401(0(2)
2—The United States or any of its agencies or Instrumentalities
3—A state; the District of Columbia, a U.S. commonwealth or possession, or
any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies, or
Instrumentalities
5—A corporation
6—A healer in securities or commodities required to register In the United
States, the District of Columbia, or a U.S. commonwealth or possession
7—A futures commission merchant registered with the Commodity Futures
Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the Investment
Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A ftnancial institution
12—A middleman known in the investment community as a nominee or
custodian
13—Atrust exempt from tax under section 664 or described in section 4947
The following chart shows types of payments that may be exempt from backup
withholding. The chart applies to the exempt payees listed above, 1 through 13.
IF the payment is for...
THEN the payment is exempt for ...
Interest and dividend payments
•
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations. S
corporations must not enter an exempt
payee code because they are exempt
only for sales of noncovered securities
acquired prior to 2012.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over $5,0001
Generally, exempt payees
1 through 62
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
. •
See Form 1099-MISC, Miscellaneous Income, and its instructions.
•
•
'However, the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from backup withholding: medical and health care
payments, attomeys',fees, gross proceeds paid to an attorney reportable under
section 6045(f), and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes Identify payees
that are exempt from reporting under FATCA. These codes appiyto persons
submitting this form for accounts maintained outside of the Untied States by
certain foreign financial institutions, Therefore, if you are only submitting this form
for an account you hold in the United States, you may leave this field blank.
Consult with the person requesting this fort if you are uncertain lithe financial
institution is subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with "Not Applicable" (or any
similar Indication) written or printed on the line for a FATCA exemption code.
A —An organization exempt from tax under section 501(a) or any individual
retirement plan as defined in section 7701(aX37)
B—The United Sates or any of its agencies or instrumentalities
•
C—A state, the District of Columbia, a U.S. commonwealth or possesslon, or
any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or more
established securities markets, as described in Regulations section
1,1472-1(c)(1)O
E—A corporation that is a member of the same expanded affiliated group as a
corporation described in Regulations section 1.1472-1(c)(1)O
F—A dealer In securities, commodities, or derivative financial instruments
(inciuding notional principal contracts, futures, forwards, and options) that is
registered as such under the laws of the United Sates or any state
G—Areal estate Investment trust
H—A regulated Investment company as defined in section 851 or an entity
registered at all times during the tax year under the Investment Company Act of
1940
I —A common trust fund as defined in section 584(4
J—A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section 4947(a)(1)
14—A tax exempt trust under a section 403(b) plan or section 457(g) plan
Note. You may wish to consult with the financial institution requesting this form to
determine whether the FATCA code and/or exempt payee code should be
completed.
Line 5
Enter your address (number, street, and apartment or suite number). This is where
the requester of this Form W-9 will mail your information returns.
Line 8
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TiN in the appropriate box. If you are a resident alien and you do not
have and are not eligible to get an SSN, your TIN Is your IRS individual taxpayer
identification number (MN). Enter it in the social security number box. If you do not
have an MN, sea How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN
or EIN. However, the IRS prefers that you use your SSN.
If you are a single -member LLC that Is disregarded as an entity separate from its
owner (see Limited liability Company (11C) on this page), enter the owner's SSN
(or EIN, if the owner has one). Do not enter the disregarded entity's EiN. lithe U-0
Is classified as a corporation or partnership, enter the entity's EIN.
Note, See the ohart on page 4 for further clarification of narne 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
SSA office or get this form online at www.ssagov. You may also get this form by ,
calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
Identification Number, to apply for an MN, or Form SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN online by
accessing the IRS website at www.irsgov/businesses and clicking on Employer
Identification Number (Ell' under Starting a Business. You can get Forms W-7 and
SS-4 from the IRS by visiting IRS.gov or by. calling 1-800-TAX-FORM
(1-800-829-3676). •
tf you are asked to complete Form W-9 but do not have a TiN, apply for a T1N
and write "Applied For" in the space for the 11N, 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 60 days to get
aTiN and give it to the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to othertypes 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 aTiN or that
you intend to apply for one soon.
Caution: A disregarded U.S, entity that has a' foreign owner must use the
appropriate Form W-B.
Form W-9 (Rev. 12-2014)
Page 4
Part IL Certification
To establish to the withholding agent that you are a U.S. person, or resident alien,
sign Form W-9. You may be requested to sign by the withholding agent even if
items 1, 4, or 5 below indicate otherwise.
For a jolntaccount, onlythe person whose TIN is shown in Part t should sign
(when required). in the case of a disregarded entity, the person identified on line 1
must sign. Exempt paycco, see Exempt payee coda earlier.
Signature requirements. Complete the certification as indicated in items 1
through 5 below.
1. Interest, dividend, and barter exchange accounts. opened before 1984
and broker accounts considered active during 1983. You must give your
correct TIN, but you do riot have to sign the certification.
2. interest, dividend, broker, and 'barter exchange accounts opened after
1983 and broker accounts considered inactive during 1983. You must sign the
certification or backup Withholding will apply. if you are subjectto backup
withholding and you are merely providing your correct TIN to the requester, you
must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out
item 2 of the certification.
4. Other payments. You must give your correctTlN, but you do ric't have to sign
the certification unless you have been notified that you have previously given an
incorrect TiN. "Other payments include payments made in the course of the
requester's trade or business for rents, royalties, goods (other bills for
merchandise), medical and healthcare services (ncludng.paymentsto
. corporations), payments to a nonernpioyee for services; payments made in
settlement of payment card arid third party network transactions, payments to
certain fishing boat crew nietnbers and fishermen, and gross proceeds paid to
attorneys (Including payments to corporations). . ,. ,
5. Mortgage interest paid byyou, acquisition orabandonment of secured
property, cancellation of debt, qualified tutt on program payments (under
sectipn 529), IRA, Coverdelf ESA, Archer MSA or HSA'cbnfrtbutiOns o'r
distributions, and pension distributions. You must give your correct TIN, but you
do not have to sign the certification. ` '
What Name and Number To Give the Requester
For this type of account
. .,Give name and SSN of:
1. Individual
2. Two or more individuals Uoint
account)
3. Custodian account of a minor
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
entity owned by an individual
6. Grantor trust filing 'under Optjonal•
Form 1099 Fling Method 1(see
Regulations section 1,671-4(b)(2)()
(A))
The individual
The actual owner of the account or,
if cdrnbined funds, the first •
individual on the account'
The minor'
The grantor -trustee'
The actual owner'
The owner'
The grentor'.',.. ..,
• ,•
•
„
For this type of account;..
,. Give,name,and.ElN of ,
7. Disregarded entity not owned by an
individual .. • •
8. A'valid trust, estate, or pension trust.
9. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
10. Association, club, religious,
charitable, educational, or other tax.-
exempt organization
11. Partnership or mufti -member LLC
12. A broker or registered nominee
13. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
govemment, school district, or
prison) that receives agricultural
program payments
14. Grantor trust filing under the Form.
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)()
(S))
The owner.
.. ,
Legal entity'
The corporation
The organization
•
The partnership
The brokeror nominee
The.public entity
•
The trust•
•
.
.
.
•
' list first and circlets name of the person whose number you furnish. If only one person on a
joint account has an SSN, that person's number must be furnished.
'You must shbw your individual name and you may also enter your business or OBAname on
the "Business name/disregarded entity" name line. You may use either your SSN or EN (if you
have one), butte IRS encourages you to use yourSSN.
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the 11N of the
personal representative or trustee unless the legal entity itself is not designated tnthe acrount
title.) Also see Spoc al rules forperinershlps on page 2.
`Note. Grantor also must provide a Fonn W-9 to trustee retest
Note. If nb name is circled when more than one name is listed, the number will be
considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
identityth'eft occurs when someone uses your personal information such as your
name, SSN, or other identifying information, without your permission, to commit
fraud or other crimes: Art identity`thief may use yourSSN to get a job or may file a
tax return iusing'your SSN io receive a refund. •
To reduce your risk:
• Protect your SSN,
•'Ensure your employer is protecting yourSSN, and
• Be careful when choosing a tax preparer.
if your tax records are affected by Identity theft and you receive a notice from
the IRS, respond right away to the name and phone number printed on the IRS
notice or letter.
If your tax records are not currently afla..ted by identity theft but you think you
are at risk due to a lost or stolen purse or wallet, questionable credit card activity,
or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit
Form 14039.
For more information, see Publication 4535, identity Theft Prevention and Victim
Assistance.
Victims of identity theft whoaare eiperiencing economic harm or asystem
probletn, or are seeking help in resolving tax problems that have not been resolved
through normal channels, may be eligible for Taxpayer Advocate Service F'AS)
assistance; You can reach TAS by calling the TAS toll -free case intake linear
1-877-777-4778 orTTY/TDD 1-800-829-4059.
Protectyourself from suspicious emails.or phishieg schemes. Phishing Is the
creation and use of email and websttes designed to mimic legitimate business
smalls and Websites. The most common act is sanding an email to a user falsely
claiming to be an established legitimate enterprise in an atternptto wain the user
into surrendering private mforrnafion that will be used for identity theft.
The IRS'does not initiate contact's with taxpayers'via ernaiis. Also, the IRS does
riot request personal detailed fnforrnatidn through email oradk'taxpayers for the
PIN numbers, passwords; or similar secret aocees 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 phishing®iragov. You may also report misuse of the IRS name,. logo,
or other IRS propertyto the Treasury Ihspector General for TaxAdminisiratfdn
(TISTA) at 1-800-366-4484. You, can forward 'suspicious emaiisto the Federal
Trade Corrimisslon al miticeagov or contact them at www ftc.gov/idtheft or
1-877-IDTHEFT (1-877-438-4338).
Visit iRS.goVto Team more about identity theft and how to reduce your risk.
Privacy Act: Notice
Sectton 6109 of the Internal Revenue Code requires you to providayour correct
TIN to persons (including federal agencies).who are required to file information
returns with the IRS to report interest, dividends, or certain other income paid to
you; mortgage interest you paid; the acquisition or abandonment of secured
property the cancellation of debt; or contributions you made to an IRA, Archer
MSA, or NSA. Trip person collecting this form uses'the information on the form to
file information'rethina Withthe iRS, reporting the above information. Routine uses
of this information include giving it to the Department of Justice for civil and
criminal litigatioh •and to cities, states, the District of Columbia, and US.
commoriwealttis•and'possessfons for Use in administering their laws. The
information also may be disclosed to other countries under atreaty, to federal and
state agencies to enforcecwil and criminal laws, or fo federal law enforcement and
intelligence agencies to cornbatterrorism. You must provide your TIN whether or
not you are required to file atax return. Under section 3406, payers meet generally
withhold a percentage of taxable Interest, dividend, and certain other payments to
a payee who does not give a TiN to the payer. Certain penalties may also apply for
providing false or fraudulent information.
2 Circle the minor's name and furnish the minor's 55N.
MIAMID
'he%rert 4vrdleue Env bly
INCIDENT REPORT
ATTACJI ENT N
•
IDENTWYI NG INFORMATION
Reporting Party Phone # Date of Incident / / Time of Incident ® am/pm
Reporting Party Name
Contract Provider Name
Program Name
Provider Location
Specific Program (check all that apply)
El Miami -Dade County HT ❑ Primary Care ❑ CoC Program ❑ Emergency ❑ Challenge
Specc lo'cation/address where incident occurred:
TYPE OF INCIDENT
❑ ALTERCATION
❑ CLIENT IN.IURY OR ILLNESS
❑ SEXUAL BATTERY
® PROPERTY DAMAGE
❑ CLIENT DEATH
❑TIEh['
❑ SUICIDE ATTEMPT
O OTHER INCIDENT
Specify
PARTICIPANT (S) / WITNESS (ES)
(Please mark W or P for either Witness or Participant)
LAST NAME, k'1RST IDENDT ER # CLIENT EMPLOYEE OTHER W / P"
0 0 0
❑ 0 ❑
❑ 0 0
DESCRIPTION OF INCIDENT
Give detailed account — who, what, where, when, why, how — add pages if necessary
ATTACHMENT N feMDCHT Incident Report Form Page 1 of 2
Zdt er E,,tvdlure Sre Jury
ATTACHMENT N
r
CORRECTIVE ACTION AND FOLLOW UP
Immediate corrective action taken
Is follow up action needed?
❑ Yes 0 No
If yes, specify
]NDIVIDITALS,NOTIFIE.D
*Abuse Registry 1-800-962-2873 *Applicable Law Enforcement Department
Indicate person contacted, if report was accepted, the date and the tune,' and if by telephone or if copy of report
available.
Incident Reports — The Subrecipient must report to Miami -Dade County Homeless Trust information related to a
critical incidents occurring during the administration term of its programs. In addition to reporting this incident to
the appropriate authorities the Subrecipient must within twenty-four, (24) hours of any incident; submit in writing a
detailed account of the incident. This incident report should be addressed to the Contract Officer or Administrative
Officer assigned This incident report should be addressed to Miami -Dade County Homeless Trust, 111 NW First
Street, 27th Floor, Suite 310, Miami, Florida 33128; telephone (305) 375�.1490 and facsmilie (305) 375 2722.
5f,
Definitions of Reportable Incidents
•
a. Altercation. A physical confrontation occiirrm4 ;between a client and employee or ytwo,or more clients at the time services are
being rendered, or when a client is ui the physidal cuslociy"of fhe department; wlueli results4in one or more clients or employees
receiving medical treatment by a licensed health care professional. •
b, Client Death. A person whose life 'terminates due to or allegedly Op to an accident, act of abuse;: neglect or other incident.
occurring while in the presence of an employee; in Homeless Trost con „"`ted program facility. •
c. Client Injury or 111ness:. A medical ,codditiori of a client regwring' medical ti eatrnent by a licensed health care rpr'ofessional
sustained or allegedly sustained due to an accident act of abuse, neglect or other incident occurring while in the presence of an
employee, in aHomeless Trust contracted program.
d. Other Incident. An unusual occurrence or circumstance initiated by something other than natural causes or out of the ordinary
such as a tornado, kidnapping, riot, or hostage situation, which jeopardizes the health, safety and welfare of clients.
e. Sexual Battery. 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 orlaw enforceinent involvement
f Suicide Attempt. An act which clearly reflects7the physical attempt.by a client to cause his or her own death while in the
physical custody of the department or a d'epa-tmental contracted or certtiied provider, which results in bodily injury requiring
medical treatment by a licensed health care professional.
g. Property damage — an incident involving damage to any property procured with Miami Dade County Homeless Trust funding.
Print Name of Person Submitting Report Signature
ATTACHMENT N "MDCHT Incident'Report Form
Page 2of2
Provider Name:
Program Name:
Funding Source:
Reporting Period:
MIAMI-DADE COUNTY HOMELESS TRUST
PROVIDER ASSET INVENTORY
ATTACHMENT 0
Description of Property
Serial/ID Number
Acquisition
Date
Acquisition
Cost
Vendor
Name
of Purchase
Cost From
Grant
Location of
Property
Use and
Condition of
Property
•
Who Holds
Title of
Property
•
**Attach Invoices fro all purchases this grant period.
u".:
ATTACHMENT P
4 oila DADE CO T'Y HOMEL'ESS
CLIENT SERVICES CERTIFICATION REFERRAL FORM F'OR EMPLOYEES OF
HOMELESS TROST FUNDED -PROGRAMS •
LNSTR e]CTI NS: Provider malting referral must -complete this twtr rage form, including signatures
b•yAppilcantand Pros�iderRepreseiita•dves. Faxeompietedfarms toProvider Rceiving Referral tor
Housing add br Services.
Date:
Contact Person:
Referring Provider:.
Name
IN 'OR14ATl ON ON HEAD OF HOUSEHOLD:
,Title Phone Number
Last Nam e: • FlstName:
Date ofBir[h: SS #:
ORMAT'ION ON OTHER HOUSEHOLD IvfET,ER.S:
Name
Age • Sex Rel.ationship • •
Employer
IS ANY 1'Vi EJ BR'R OF Tsi g J OUSE OLD EMPLOYED WS', fE3R RPi:LATTD TO AN EMPL• OYEEE
OF, A EOMET ;i-TSS TRUST FUNDED PROGRAM? Yes 7•4b
If yes:
Name of Employee:;
Employing Provider:
Relationship to Applicant:
CERTIFICATION
I, the vnciersilmed, do hereby certify that the above -information providedby.m&is ni nd macaw the
hest ofnay krio eledge.
Applicant's Name
Signature: Date:
Referring Provider Authorized Representative
Name: Signature • Date
ATTACHMENT P
PROVIDER REFERRAL FORM PACE TWG
.4pplisrarit's Name '
fti. •
e Applicant or a inemlier of their household is an employee of the referring provider, the
• ' pproya.1 of the Provider Directcr is hereby inclitalted fry signature: .
••
Nameffitle Dae
If the Applicant rn a member of their household is ..a.n employee oldie provider where services will be
provided, the approval of The Provider riNecutivA bireetor, the Homeless Trust Executive Director,
2rd the _Homeless Trust Board Chair are hereby indicated by signature:
•
ProVider Executive Director
. •
•
Date
Miarni-Dade Comity Homeless Ili& Chairperson Date
Miami -Dade County Homeless Trust Executive Director
• ADDITIO•RA_LHOTigtHOLD INFORMATION:
Where Is the household Wong ndvy? (Facilitynarne, exact addres)
De ofpresent homelessness:
Ex -plain the homeless situation, and what caused the current
homelessness: •
Date
•
NOTE TO REFERREO PR.OMER: •
PROVIDTIqd liKE ABOVE INFORMATION DOES NOT ENSURE APPROVAL FOR BOICISING
OR OTPXR SERVICES REi2bESTED. A DETEkRIK4tidiq WELL M MA -DE FOLLOWING A •
' COMPLET. ASSESSMINT OF TEE APPLICANT'S CASE,
." •
THIS SECTIO.N FOR SEE:VICE PROVIDER STAFF USE ONLY:
Mds EligibiliCit CH/erica- YES .NO
Name nj Pro viderserearkg staff:
PLEASE MAINTAIN THE EXECUTED COPY OF THIS DOCIThilENT IN THSCIAENT FILE OF
THE SERVICING VROVIDER AND PEIZSONNEL FILE OF REFERRING PROVIDER.