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
January 8, 2019
Mr. Emilio T. Gonzalez, City Manager
The City of Miami
444 SW 2nd Avenue
Miami, Florida 33130
Re: 2018-2019 Primary Care Program
Feeding Coordination Program • PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance Program PC-1819-ID-1
Dear Mr. Gonzalez:
Enclosed, please fmd three (3) original sets of the Agreement between Miami -Dade County, through
Miami -Dade County Homeless Trust and The City ofMianxi for the following programs:
• Feeding Coordination Program • PC-1819-FC
• HMIS Staffing Program PC-1819-STAFF-1
• Identification Assistance Program PC-1819-ID-1
The authorized agency signatory must sign all three (3) copies of the Agreements and the relevant
attachments. Miami -Dade County requires that the President/Chairman of the Board execute the
Agreement on behalf of the agency. However, the Executive Director may execute the Agreement if
approved by a resolution of the agency's Board. A copy of the applicable Board resolution(s) must be
submitted with the Agreement. In addition, the agency must affix the corporate seal to the signature page
of the Agreements or notarize them accordingly. All three (3) completed copies must be returned back to
the Homeless Trust office no later than January 15, 2019.
Please feel five to contact us at (305) 375-1490 if you any questions or require additional information.
Thank you for your continued efforts with addressing the needed of the homeless of our community.
Sincerely,
Victoria L. Mallette
xecutive Director
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Enclosures
Signature below confirms receipt of the enclosed documents.
Signature of Authorized Agency Representative Date
• Printed Name of Agency Representative
The City of Miami
Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
GRANT CONTRACT
This Grant Contract ( the "Contract" or "Grant Agreement") is made and entered into as of this
day of , 20, by and between Miami -Dade County, through the Miami -Dade
County Homeless Trust, 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/FEIN#:
59-6000375, a corporation organized and existing under the laws of the State of Florida, having its
principal office at 444 SW 2nd Avenue, Miami, Florida 33136 ("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 Providers and the affected programs with
funding to continue the provision of those essential 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.
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The City of Miami
-Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
f) The words "Effective Term" shall mean the date on which this Contract is effective, including
start date and end date.
g)
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.
h) "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 mean 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:
• Feeding Coordination Program
• HMIS Staffing Program
• Identification Assistance Program
$15,000.00
$24,666.00
$12,500.00
Total Award: $52,166.00
Both parties agree that should available Miami -Dade County funding be reduced, the amount payable
under this Contract may be proportionately reduced 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 and approval, may allow Provider an advance of up to two (2)
months once the Provider has submitted an appropriate request and submitted an invoice in the form
required by the County.
ARTICLE 3. SCOPE OF 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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The City of Miami
Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
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 services 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, 2018 and terminate at the close of business on September 30, 2019. 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.
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
limitations of Section 768.28, Fla. Stat.
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The City of Miami
Feeding Coordination Program
HMIS Staffing Program
Identification Assistance
PC-1819-FC
PC-1819-STAFF-1
PC-1819-ID-1
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 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
Provider or its employees, agents, servants, partners principals or subcontractors. Provider 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.
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 an agency 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, upon request, written
verification of Workers Compensation protection in accordance with Chapter 440, Florida Statutes.
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
Chapter 440, Florida Statutes.
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The City of Miami
Feeding Coordination Program PC-1819-FC
IIMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
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.
I. 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.
K. 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
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.
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The City of Miami
Feeding Coordination Program PC-1819-FC
ffiVIIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
substantiate such costs. The program requirements and relevant services are outlined in
the Scope of Services (Attachment A).
3. Any reimbursement may be withheld pending the receipt and approval by the County of
all reports and documents required herein.
4. As applicable, during the period of NIA 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
5. 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 of the Homeless Trust.
6. 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.
7. 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 Owed to 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.
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
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The City of Miami
Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
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) il
2. Monthly Payment Request (Attachment F) t]
3. Monthly Performance Reports (Attachment G) I]
4. Outcome Performance Measurements Monthly Report (Attachment H) lI
5. Client Contribution Report (Attachment I) ❑
6. Client Attendance Roster (Attachment J) ❑
7. 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 system. 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.
F. Final Report/Recapture of Funds. Upon the expiration or termination of this
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Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
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 payment 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 fundsshall 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.
ARTICLE 19. 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.
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
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Feeding Coordination Program PC-1819-FC
I MIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
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 Provider's 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
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
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Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-1D-1
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.
I. Quality Assurance / Recordkeeping. The Provider shall maintain, and shall 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
® 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 information. 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;
(3) Access 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;
(7) 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;
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(8)
Feeding Coordination Program PC-1819-FC
HMIS Staffing Program PC-1819-STAFF-1
Identification Assistance PC-1819-ID-1
Procedures are developed and implemented that address client chart and
medical record identification, filing 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.
O. Public Records
Pursuant to Section 119.0701, Florida Statutes, if the Provider meets the definition of "Contractor" as
defined in Section 119.0701(1)(a), the Provider shall:
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(a) Keep and maintain public records that ordinarily and necessarily would be required by the
public agency in order to perform the service;
(b) Upon request from the County's custodian of public records identified herein, provide the
County with a copy of the requested records or allow the public with access to the public
records on the same terms and conditions that the County would provide the records and at a
cost that does not exceed the cost provided in the Florida Public Records Act, Miami -Dade
County Administrative Order No. 4-48, or as otherwise provided by law;
(c) Ensure .that public records that are exempt or confidential and exempt from public records
disclosure requirernents are not disclosed except as authorized by law for the duration of this
Agreement's term and following completion of the services under this Agreement if the
Contractor does not transfer the records to the County; 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, 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, 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.
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If the Provider has questions regarding the application of Chapter 119,
Florida Statutes, to the Provider's duty to provide public records relating to
this Agreement, contact Miami -Dade County's Custodian of Public Records at:
Miami -Dade County
Homeless Trust
111 NW lst Street, 27th Floor, Suite 310
Miami, Florida 33128
Attention: Victoria L. Mallette, Executive Director
Email: vmallette@ miamidade.gov
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
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 IPSIG'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.
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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.
2) 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
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.
3) 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 such Subcontractor will strictly comply with the
requirements of this Contract.
4) 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 satisfaction of 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.
5) 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
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Subcontractors are required to protect the confidentiality of the County's and
County's proprietary 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 its obligations 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 Act, payments 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
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.
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, color,
religion, ancestry, national origin, sex, pregnancy, age, disability, marital status, familial
status, gender identity, gender, expression, sexual orientation, or actual or perceived
status as a victim of domestic violence, dating violence or stalking. The aforesaid
provision shall include, but not be limited to, the following: employment, upgrading,
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.
Conflict of Interest and Code of Ethics Ordinance, Section 2-11.1 et seq. of the Code of
Miami -Dade County, as amended.
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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
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. Provider 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 the 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
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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 shall 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.
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 rnay, 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.
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 following are identified as critical incidents as defined in CF-OP 215-6
(Attachment N-1):
• Child -on -Child Sexual Abuse
• Child Arrest
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• Child Death
• Adult Death
• Elopement refers to court ordered clients that run away and do not return
• Employee Arrest
• Employee Misconduct
• Escape
• Missing Child
• Security Incident - Unintentional
• Significant Injury to Clients
• Significant Injury to Staff
• Suicide Attempt
• Sexual Abuse/Sexual Battery
II. 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 / 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.
K. Third Party Beneficiaries. The Parties agree that this contract has no intended or
unintended third party beneficiaries.
L. 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
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
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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.
Attachment A: Scope of Services
Attachment B: Budget
Attachment C: Miami Dade County Affidavits
Attachment D: State Affidavits (Not Applicable)
Attachment E: Primary Care Invoice for Services Not Applicable)
Attachment F: Monthly Payment Requests Reports
Attachment G: Monthly Performance Reports
Attachment H: Outcome Performance Measurements Monthly Report
Attachment I: Client Contribution Report (Not Applicable)
Attachment J: Client Attendance Roster (Not Applicable)
Attachment K: Vacancy/Permanent Housing Placement Report (Quarterly) (Not Applicable)
Attachment L: Annual Performance Report & Annual Actual Expenditure Report
Attachment M: W-9 Form
Attachment N: Incident Report
Attachment N-1: CF Operating Procedure 215-6 — Incident Reporting
Attachment 0: Provider Asset Inventory Report
Attachment P: Client Services Certification Form
M. Entire Agreement. 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 to conform to the terms and requirements of applicable law and
ordinance.
SIGNATURES MAY BE FOUND ON THE FOLLOWING PAGE
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The City of Miami
IN WITNESS WHEREOF, the parties
effective as of the contract date herein
WITNESSES:
BY:
Feeding Coordination Program
HMIS Staffing Program
Identification Assistance
PC-1819-FC
PC-1819-STAFF-1
PC-1819-ID-1
have executed this Contract, along with all of its Attachments,
above set forth.
TODD B. HANNON
CITY CLERK
Approved as to "Form and Correctness:
BY:
VICTORIA MENDEZ
CITY ATTORNEY
ATTEST:
HARVEY RUVIN, CLERK
BY:
DEPUTY CLERK
DATE
ENTITY: CITY OF MIAMI, FLORIDA
A municipal corporation of
The State of Florida
BY:
EMILIO T. GONZALEZ
CITY MANAGER
Approved as to Insurance Requirements:
BY:
ANN-MARIE SHARPE
RISK MANAGEMENT
Affix Incorporation SEAL here
Miami -Dade County, a political subdivision of
The State of Florida
CARLOS A. GIMENEZ
MAYOR
Affix Miami -Dade County Seal Here
Approved as to form and legal sufficiency. See memorandum dated November 28, 2018.
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ATTACHMENT A, SCOPE OF SERVICES
FEEDING COORDINATION PC-1819-FC
HMIS STAFFING PROGRAM PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PC-1819-ID-1
SCOPE OF SERVICES
FEEDING COORDINATION PROGRAM PC-1819-FC
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 pf each quarter, distribute correspondence as needed to participating organizations and
ensure the coordination of outreach activities at the feeding site listed below:
• Miami Rescue Mission
• Mount Zion Baptist Church
• Mother Theresa's
The Feeding Coordinator must:
2020 NE 1' Avenue, Miami, Florida 33127
301 NW 9th Street, Miami, Florida 33136
724 NW 17th Street, Miami, Florida 33127
a. 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.
b. Maintain a daily list of contacts made, with the name of the organization, contact name
and contact information.
c. Produce a daily report on the number of persons fed at Miami Rescue Missions and is
possible, at Mother Theresa's.
d. Produce a report of the 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.
e. Report the result of any outreach engagement at the feeding location sites.
f. Coordinate a monthly "survey" of individuals. requesting feeding services to determine
whether they are homeless or are just working poor.
g. 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 basis.
ATTACHMENT A, SCOPE OF SERVICES
FEEDING COORDINATION
HMIS STAFFING PROGRAM
IDENTIFICATION ASSISTANCE
HMIS STAFFING PROGRAM PC-1819-STAFF-2
PC-1819-FC
PC-1819-STAFF-2
PC-1819-ID-1
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
included, 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 by HMIS generated Monthly Progress, Reports (MPRs) submitted to
the County each month under the USHUD Continuum of Care (CoCO sub -recipient Agreement
and the Primary Care services Agreements may result in the termination of this Agreement.
ATTACHMENT A, SCOPE OF SERVICES
FEEDING COORDINATION
HMIS STAFFING PROGRAM
IDENTIFICATION ASSISTANCE
PC-1819-FC
PC-1819-STAFF-2
PC-1819-ID-1
THE CITY OF MIAMI IDENTIFICATION ASSISTANCE PROGRAM
PC-1819-ID-1
The Provider agrees to provide identification assistance services to 300 homeless persons in Miami -
Dade County. The following services must be provided under this Agreement:
➢ Identification document replacement services for homeless persons in Miami -Dade County.
Documents to be replaced include but are not limited to:
1. Florida Identification Cards
2. Birth Certificates
3. Marriage Certificates
4. School Records
5. Court Documents (judgments, orders, related documents)
6. Lawful Permanent Resident Cards
7. Naturalization Certificates
8. Florida Driver's Licenses
Note: The cost of replacing the documents specified above may be funded via this grant or where
applicable fee waivers may be obtained via the appropriate source.
➢ Staff shall deliver identification services to homeless individuals.
➢ Staff shall maintain a regular working schedule, as may be modified from time to time as
mutually agreed upon in writing, with an intake specialist/case worker providing services.
Staffing will be provided primarily in the City of Miami Office of Homeless Programs in
Miami, Florida.
➢ Provide referral services for community -based resources including but not limited to: legal
and medical services, food, employment, vocational training and clothing.
➢ Provide follow-up and tracking of each person assisted to determine outcome measures.
PERFORMANCE MEASURES
EXPECTED OUTCOMES
INDICATORS
1. Homeless participants will be assessed
150 participants will be assessed
2. Homeless participants will obtain vital
personal identification documents.
101 or 67% of homeless participants will obtain
vital personal identification documents.
3. Homeless participants will obtain
official photo identification.
75 or 50% of homeless participants will obtain
official photo identification.
ATTACHMENT B, BUDGET
2018-2019 IDENTIFICATION ASSISTANCE PROGRAM
DESCRIPTION
BUDGET
STAFF SALARY
$ 3,750.00
IDENTIFICATION SERVICES
.$ 8,750.00
TOTAL
$12,500.00
2018-2019 FEEDING COORDINATION PROGRAM
STAFFING
COST
MDHT
44%
CITY OF MIAMI
56%
1 FT INFORMATION AND
REFERRAL SPECIALIST
HOMELESS PROGRAM
FEEDING COORDINATOR
$34,474.00
$15,000.00
$19,474.00
$15,000.00
2018-2019 HMIS STAFFING PROGRAM
STAFFING
COST
MDHT
72%
CITY OF MIAMI
28%
1 FT INFORMATION AND
REFERRAL SPECIALIST
HOMELESS PROGRAM
FEEDING COORDINATOR
$34,474.00
$24,666 00
$9,808.00
$24,666.00
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 MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY
EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI-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 MIAMI-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
municipalities of the State of Florida. All other contracting entities or individuals shall read carefully each affidavit to
determine whether or not it pertains to this contract.
I, , 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 (If none, Social Security)
Name of Entity, Individual(s), Partners, or Corporation
Doing Business As (if same as above, leave blank)
Street Address City State Zip Code
1. MIAMI-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
ATTACHMENT`C
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County Ordinance 90-133,
Amending sec. 2.8-1; Subsection (d)(2) of the County Code).
Except where precluded by federal or State laws or regulations, each contract or business transaction or renewal thereof which
involves the expenditure of ten thousand 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 depat fluent or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State.
a. 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. 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 and procurement practices. The foregoing notwithstanding, corporate
entities whose boards of directors are representative of the population make-up of the nation shall be presumed to have non-
discriminatory employment and procurement policies, and shall not be required to have 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 Finn does not have annual gross revenues in excess of $5,000,000.
The Firm does have annual revenues in excess of $5,000,000; however, its Board of Directors is representative of the
population make-up of the nation and has submitted a written, detailed
listing of its Board of Directors, including the race or ethnicity of each board member, to the County's Department of Business
Development, 175 N.W, 1st Avenue, 28th Floor, Miami, Florida 33128.
The Firm 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. 1st 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-DADE COUNTY REQUIRED AFFIDAVITS
4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2-8.6 of the County Code)
The individual or entity entering into a contract or receiving funding from the County has has not 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 _(has /has not), as
of the date, of this affidavit been convicted of a felony during the past ten (10) years.
5. MIAMI-DADE EMPLOYMENT DRUG -FREE WORKPLACE 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 fum's policy of maintaining a drug -free enviromnent 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 requirements of those governmental entities.
6. MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance 142-91 codified as
Section 11A-29 et. seq of the County Code)
That in compliance with Ordinance No. 142-91 of the Code of Miami -Dade County, Florida, an employer with fifty (50) or
more employees working in Dade County for each working day during each of twenty (20) or more calendar work weeks, shall
provide the following information in compliance with all items in the aforementioned ordinance:
An employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) days of family leave
during any twenty-four (24) month period, for medical reasons, for the birth or adoption of a child, or for the care of a child,
spouse or other close relative who has a serious health condition without risk of termination of employment or employer
retaliation.
The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the
State of Florida or any political subdivision or agency thereof. It shall, however, pertain to municipalities of this State.
7. DISABILITY 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. 12101-12213 and 47 U.S.C. Sections
225 and 611 including Title I, Employment; Title II, Public Services; Title III, 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-DADE COUNTY REQUIRED AFFIDAVITS
8. MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE FEES OR TAXES (Sec. 2-
8.1(c) of the County Code)
Except for small purchase orders and sole source contracts, that above named firm, corporation, organization or individual
desiring to transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes -
- including but not limited to real and property taxes, utility taxes and occupational licenses -- which are collected in the normal
course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of
the firm, corporation, organization or individual have been paid.
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
instrumentalities.
10. DOMESTIC VIOLENCE LEAVE AND REPORTING AFFIDAVIT (Resolution 185-00; 99-5 Codified At
11A-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
fifty (50) or more employees working in Miami -Dade County for each working day during each of twenty (20) or more
calendar work weeks in the current or proceeding calendar years, to provide Domestic Violence Leave to its employees.
NEXT PAGE SIGNATURE PAGE
ATTACHMENT C "Miami -Dade County Required Affidavits" Page 4 of 5
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 this contract and completed all required information.
BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO AFFIDAVITS ONE
(1) THROUGH ELEVEN (11)
MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
By: , 20
Signature of Witness or Secretary Seal Date
Signature of Affiant Federal Employer Identification Number
Printed Name of Affiant and Name of Agency
Address of Agency
SUBSCRIBED AND SWORN TO (or affirmed) before me this day of , 20
He/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
Notary Public — State of
County of
Expiration Date
Notary Seal
ATTACHMENT C "Miami -Dade County Required Affidavits" Page 5 of 5
ATTACHMENT D
THIS ATTACHMENT IS
NOT APPLICABLE
TO THIS AGREEMENT
ATTACHMENT E
THIS ATTACHMENT IS
NOT APPLICABLE
TO THIS AGREEMENT
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: THE CITY OF MIAMI
SERVICE PERIOD: TO
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
AMOUNT OF FUNDS REQUESTED
THIS MONTH:
THE CITY OF MIAMI -
FEEDING
COORDINATION
PROGRAM
PC-1819-FC
$ 15,000.00
$
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $
(following payment of this request)
Signature of Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: THE CITY OF MIAMI
SERVICE PERIOD: TO
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
AMOUNT OF FUNDS REQUESTED
THIS MONTH:
THE CITY OF MIAMI -
HMIS STAFFING
PROGRAM
PC-1819-STAFF-1
$ 24,666.00
$
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $
(following payment of this request)
Signature of Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: THE CITY OF MIAMI
SERVICE PERIOD: TO
NAME OF GRANT:
GRANT NUMBER:
TOTAL AWARD AMOUNT:
AMOUNT OF FUNDS REQUESTED
THIS MONTH:
THE CITY OF MIAMI -
IDENTIFICATION
ASSISTANCE PROGRAM
PC-1819-ID-1
$ 12,500.00
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $
(following payment of this request)
Signature of Executive Director or Date
Authorized Agency. Representative
Printed Name of Executive Director or
Authorized Agency Representative
ATTACHMENT G
Continuum of Care Homeless Assistance Program
Performance Report Master Document
(Please check the box to indicate either monthly or annual report submitted)
0625 — HUD CoC Monthly Performance Report
0625 — HUD CoC Annual Performance Report
(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) HMIS & Fiscal
ATTACHMENT H
THIS ATTACHMENT IS
NOT APPLICABLE
TO THIS AGREEMENT
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
THE CITY OF MIAMT-FEEDING COORDINATION PROGRAM
GRANT NUMBER #: PC-1819-FC
OCTOBER 1, 2018 — SEPTEMBER 30, 2019
Name of Agency:
THE CITY OF MIAMI-
FEEDING COORDINATION
PRO GRAM
$ 15,000.00
Month of Services
Amount Paid
OCTOBER-2018
NOVEMBER-2018
DECEMBER-2018
JANUARY-2019
FEBRUARY-2019
' MARCH-2019
APRIL-2019
MAY-2019
JUNE-2019
JULY-2019
AUGUST-2019
SEPTEMBER-2019
Total Requested
Balance Remaining
0.00
$ 15,000.00
Signature of Executive Director or Date
Authorized Representative
Printed Name of Executive Director or
Authorized Representative
ATTACHMENT L
MIAMI-DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
THE CITY OF MIAMI-H1VIIS STAFFING PROGRAM
GRANT NUMBER #: PC-1819-STAFF-1
OCTOBER 1, 2018 — SEPTEMBER 30, 2019
Name of Agency:
THE CITY OF MIAMI-
HMIS STAFFING PROGRAM
$ 24,666.00
Month of Services
Amount Paid
OCTOBER-2018
NOVEMBER-2018
DECEMBER-2018
JANUARY-2019
FEBRUARY-2019
MARCH-2019
APRIL-2019
MAY-2019
JUNE-2019
JULY-2019
AUGUST-2019
SEPTEMBER-2019
Total Requested
Balance Remaining
0.00
$ 24,666.00
Signature of Executive Director or Date
Authorized Representative
Printed Name of Executive Director or
Authorized Representative
ATTACHMENT L
MIAMI-DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
THE CITY OF MIANII-IDENTIFICATION ASSISTANCE PROGRAM
GRANT NUMBER #: PC-1819-ID-1
OCTOBER 1, 2018 — SEPTEMBER 30, 2019
Name of Agency:
THE CITY OF MIAMI-
HMIS STAFFING PROGRAM
$ 12,500.00
Month of Services
Amount Paid
OCTOBER-2018
NOVEMBER-2018
DECEMBER-2018
JANUARY-2019
FEBRUARY-2019
MARCH-2019
APRIL-2019
MAY-2019
JUNE-2019
JULY-2019
AUGUST-2019
SEPTEMBER-2019
Total Requested
Balance Remaining
0.00
$ 12,500.00
Signature of Executive Director or Date
Authorized Representative
Printed Name of Executive Director or
Authorized Representative
ATTACHMENT M
Form W-9
(Rev. December2014)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: .
4 Exemptions
ein
n t ulctionns
Exempt payee
Exemption
code (if any)
(Applies to accounts
(codes apply only to
ition page viduals; see
code (If any)
IndividuaVsole proprietor or C Corporation MI S Corporation MI Partnership III Trust/estate
single -member
LLC
company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
-member LLC that is disregarded, do not check LLC; check the appropriate box in
of the single -member owner.
h
IIII Limited liability
Note. For a single
the tax classification
iiiii Other (see instructions)
from FATCA reporting
the line above for
maintained outside the US.)
5 Address (number, street, and apt. or suite no.)
Requester's name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
PartL Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
Social security number
or
Employer identification number
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that 1 am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign
Here
Signature of
U.S. person r
Date 0-
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/fw9.
Purpose of Form
An individual or entity (Form W-9 requester) who Is required to file an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSN), Individual taxpayer identification
number (ITIN), adoption taxpayer Identification number (ATIN), or employer
identification number (EIN), to report on an Information retum the amount paid to
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following:
• Form 1099-INT (Interest eamed or paid)
• Form 1099-DIV (dividends, Including those from stocks or mutual funds)
• Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by .
brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (Including a resident alien), to
provide your correct TIN.
if you do not retum Form W-9 to the requester with a 77N, you might be subject
to backup withholding. See What is backup withholding? on page 2.
By signing the filled -out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding If you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected Income, and
4. Certify that FATCA code(s) entered on thls form (if any) indicating that you are
exempt from the FATCA reporting, Is correct. See What is FATCA reporting? on
page 2 for further information.
Cat. No. 10231X Form W-9 (Rev. 12-2014)
Form W-9 (Rev. 12-2014) Page 2
Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, 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 (other than aforeign estate); or
• A domestic trust (as defined In Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section
1446 on any foreign partners' share of effectively connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been received,
the miles under section 1446 require a 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 a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership Income.
In the cases below, the following person must give Form W-9 to the partnership
for purposes of establishing its U.S. status and avoiding withholding on its
allocable share of net income from the partnership conducting a trade 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 grantor 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. trust (other than a
grantor trust) and not the beneficiaries 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 Form 8233 (see Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entities). •
Nonresident alien who becomes a resident alien. Generally, only a nonresident
alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a provision known 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 alien for tax purposes.
If you are a U.S. resident alien who Is relying on an exception contained In the
saving clause of a tax treaty to claim an exemption from U.S. tax on certain types
of income, you must attach a statement to Form W-9 that specifies the following
five items:
1. The treaty country. Generally, this must be the same treaty under which you
claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the saving
clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty
article.
Example. Article 20 of the U.S.-China Income tax treaty allows an exemption
from tax for scholarship Income received by a Chinese student temporarily present
in the United States. Under U.S. law, this student will become a resident alien for
fax purposes If his or her stay in the 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 Article 20 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 support 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 IRS 28% of such payments. This
is called "backup withholding." Payments that may be subject to backup
withholding include interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, 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 subject to backup withholding on payments you receive if you
give the requester your correct TIN, make the proper certifications, and report all
your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not 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 incorrect TIN,
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 do not certify to the requester that you are not subject to 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 for the Requester of Form
W-9 for more information.
Also see Special rules for partnerships above.
What is FATCA reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign
financial institution to report all United States account holders that are specified
United States persons. Certain payees are exempt from 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 longer are tax exempt. In addition, you must furnish a new
Form W-9 if the name or TIN changes for the account; for example, if the grantor
of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fall to furnish your correct TIN to a requester, you are
subject to a penalty of $50 for each such failure unless your failure is due to
reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a
false statement with no reasonable basis that results in no backup withholding,
you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying certifications or
affirmations may subject you to criminal penalties including fines and/or
imprisonment.
Misuse of TINs. If the requester discloses or uses TINS in violation of federal law,
the requester may be subject to civil and 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-9 Is for a joint account, list first, and then circle, the name of the
person or entity whose number you entered in Part I of Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If you have
changed your last name without informing the Social Security Administration (SSA)
of the name change, enter your first name, the last name as shown on your social
security card, and your new last name.
Note. ITIN applicant; Enter your individual name as it was entered on your Form
W-7 application, line la. 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 name as
shown on your 1040/1040A/1040EZ on line 1. You may enter your 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. Enter the entity's name as shown on the entity's tax return on line 1
and any business, trade, or DBA name on line 2.
d. Other entities. Enter your name as shown 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 from its owner is treated as a "disregarded
entity." See Regulations section 301.7701-2(c)(2)(ili). Enter the owner's name on
line 1. The name of the entity entered on line 1 should never be a disregarded
entity. The name on line 1 should be the name shown on the income tax return on
which the income should be reported. For example, if a foreign LLC that is treated
as a disregarded entity for U.S. federal tax 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. If the
direct owner of the entity is also a disregarded entity, enter the first owner that is
not disregarded for federal fax purposes. Enter the disregarded entity's name on
line 2, "Business name/disregarded entity name." If the owner of the disregarded
entity is a foreign person, the owner must complete an appropriate Form 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 line 2.
Line 3
Check the appropriate box in line 3 for the U.S. federal tax classification of the
person whose name 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. If the LLC 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 "IndividuaVsole 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 exempt 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(f)(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 dealer 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 financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust 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 52
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
t 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, attorneys' 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 apply to persons
submitting this form for accounts maintained outside of the United 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 form If you are uncertain if the 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(a)(37)
B—The United States or any of Its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or possession, 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)(i)
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)(i) •
F—A dealer in securities, commodities, or derivative financial instruments
(including notional principal contracts, futures, forwards, and options) that is
•
registered as such under the laws of the United States or any state
G—A real estate investment trust
H—A regulated investment company as defined In section 851 or an entity
registered at at times during the tax year under the Investment Company Act of
1940
I —A common trust fund as defined In section 584(a)
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)
M—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 6
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 (ITIN). Enter it in the social security number box. If you do not
have an ITIN, see 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 (LLC) on this page), enter the owner's SSN
(or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC
is classified as a corporation or partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name and TiN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply
for an SSN, get Form SS-5, Application for a Social Security Card, from your local
SSA office or get this form online at www.ssa.gov. You may also get this form by
calling 1-800-772-1213. Use Fomi W-7, Application for IRS Individual Taxpayer
Identification Number, to apply for an ITIN, 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.irs.gov/businesses and clicking on Employer
Identification Number (EIN) 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).
If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN
and write "Applied For" in the space for the TIN, sign and date the form, and give it
to the requester. For Interest and dividend payments, and certain payments made
with respect to readily tradable Instruments, generally you will have 60 days to get
a TIN and give it to the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you provide your TIN to
the requester.
Note. Entering "Applied For" means that you have already applied for 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-8.
Form W-9 (Rev. 12-2014)
Page 4
Part Ii. 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 ajointaccount, only the person whose TIN is shown in Part I should sign
(when required). In the case of a disregarded entity, the person identified on line 1
must sign. Exempt payees, see Exempt payee code 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 not 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 subject to 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 correct TIN, but you do not 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 than bills for
merchandise), medical and health care services (Including payments to
corporations), payments to a nonemployee for services, payments made In
settlement of payment card and third party network transactions, payments to
certain fishing boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured
property, cancellation of debt, qualified tuition program payments (under
section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your con-ect 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 (joint
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 Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(h)(2)(i)
(A))
The individual
The actual owner of the account or,
if combined funds, the first
individual on the account'
The minor'
The grantor -trustee'
The actual owner'
The owner'
The grantor'
For this type of account
Give name and EIN 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 multi -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)(i)
(B))
The owner
Legal entity'
The corporation
The organization
The partnership
The broker or nominee
The public entity
The trust
' List first and circle the name of the person whose number you fumish. If only one person on a
Joint account has an SSN, that person's number must be furnished.
'Circle the minor's name and fumish the minor's SSN.
3You must show your individual name and you may also enter your business or DBA name on
the "Business name/disregarded entity" name line. You may use either your SSN or EIN (f you
have one), but the IRS encourages you to use your SSN.
°-List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.) Also see Special rules for partnerships on page 2.
'Note. Grantor also must provide a Form W-9 to trustee of trust.
Note. If no 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
Identity theft 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. An Identity thief may use your SSN to get a job or may file a
tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, 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 affected 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 who are experiencing economic harm or a system
problem, or are seeking help in resolving tax problems that have not been resolved
through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
assistance. You can reach TAS by calling the TAS toll -free case intake line at
1-877-777-4778 orTTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes. Phishing is the
creation and use of email and websites designed to mimic legitimate business
emails and websites. The most common act is sending an email to a user falsely
claiming to be an established legitimate enterprise in an attempt to scam the user
into surrendering private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does
not request personal detailed Information through email or ask taxpayers for the
PIN numbers, passwords, or similar secret access Information for their credit card,
bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this
message to phishing@irs.gov. You may also report misuse of the IRS name, logo,
or other IRS property to the Treasury Inspector General for Tax Administration
(TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal
Trade Commission at: spam®uce.gov or contact them at www.ftc.govlidtheft or
1-877-IDTHEFT (1-877-438-4338).
Visit IRS.gov to learn more about identity theft and how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your 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 HSA. The person collecting this form uses the information on the form to
file information retums with the IRS, reporting the above information, Routine uses
of this information include giving it to the Department of Justice for civil and
criminal litigation and to cities, states, the District of Columbia, and U.S.
commonwealths and possessions for use in administering their laws. The
Information also may be disclosed to other countries under a treaty, to federal and
state agencies to enforce civil and criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers must 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.
M®DAAE
Dr/rot4s:dimeErr7 ry
INCIDENT REPORT
IDENTIFYING 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)
❑ Miami -Dade County 0 Primary Care ❑ CoC Program 0 Emergency ❑ Challenge 0 Other
Specific location/address where incident occurred:
TYPE OF INCIDENT
❑ ALTERCATION
❑ CLIENT INJURY OR ILLNESS
❑ SEXUAL BATTERY
❑ PROPERTY DAMAGE
❑ CLIENT DEATH
❑ THEFT
❑ SUICIDE ATTEMPT
❑ OTHER INCIDENT
Specify
PARTICIPANT (S) / WITNESS (ES)
(Please mark W or P for either Witness or Participant)
LAST NAME, FIRST
IDENTIFIER # CLIENT
El
0
0
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 H "MDC-HT Incident Report Form" Page 1 oft
MIA WADE
EIMEI
8,1 renog &cal N. Ex7 3.y
CORRECTIVE ACTION AND FOLLOW UP
Immediate corrective action taken
Is follow up action needed?
❑ Yes 0 No
If yes, specify
INDIVIDUALS NOTIFIED
*Abuse Registry 1-800-962-2873 *Applicable Law Enforcement Department
Indicate person contacted, if report was accepted, the date and the time, 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 any
critical incidents occurring during the administration term of its programs. In addition to reporting this incident to
the appropriate authorities the Subrecipient must within twenty-four (24) hours of any incident, submit in writing a
detailed account of the incident. This incident report should be addressed to the Contract Officer or Administrative
Officer assigned. This incident report should be addressed to Miami -Dade County Homeless Trust, 111 NW First
Street, 27th Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsmilie (305) 375-2722.
g•
Definitions of Reportable Incidents
a. Altercation. A physical confrontation occurring between a client and employee or two or more clients at the time
services are being rendered, or when a client is in the physical custody of the department, which results in one or
more clients or employees receiving medical treatment by a licensed health care professional.
b. Client Death, A person whose life terminates due to or allegedly due to an accident, act of abuse, neglect or other
incident occurring while in the presence of an employee, in Homeless Trust contracted program facility,
c. Client Injury or Illness. A medical condition of a client requiring medical treatment by a licensed health care
professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring
while in the presence of an employee, in a Homeless Trust contracted program,
d. Other Incident. An unusual occurrence or circumstance initiated by something other than natural causes or out of
the ordinary such as a tornado, Iddnapping, riot, or hostage situation, which jeopardizes the health, safety and
welfare of clients.
e. Sexual Battery. An allegation of sexual battery by a client on a client, employee on a client, or client on an
employee as evidenced by medical evidence or law enforcement involvement.
f. Suicide Attempt. An act which clearly reflects the physical attempt by a client to cause his or her own death while
in the physical custody of the department or a departmental contracted or certified provider, which results in
bodily injury requiring medical treatment by a licensed health care professional,
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 H "MDC-HT incident Report Form"
Page 2 of 2
MIAMT-DADE COUNTY HOMELESS TRUST POLICY & PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFFECTIVE DA'1'L: 9/9/2015
REVISED DAI :
PURPOSE: The purpose of this policy is to define the process for receiving and
processing incident reports.
SCOPE: Miami -Dade County Homeless Continuum of Care
PROCEDURES:
1. Homeless CoC providers contracted with Miami -Dade County Homeless Trust must
report the following types of critical incidents, via fax (305)375-2722 or email, to
the attention of our Incident Report Coordinator: Miguel Pimentel. These incidents
are defined and outlined in CF-OP 215-6.
• Child -on -Child Sexual Abuse
• Child Arrest
• Child Death
• Adult Death
Elopement refers to court ordered clients that run away and do not return
• Employee Arrest
• Employee Misconduct
• Escape
• Missing Child
• Security Incident - Unintentional
• Significant Injury to Clients
• Significant Injury to Staff
• Suicide Attempt
• Sexual Abuse/Sexual Battery
2. For each critical incident, an incident report must be submitted to Miami -Dade
County Homeless Trust within one business day. The incident report needs to
include:
• Facility/Home
• Clients Name
• Clients Age
• Date & Time of Accident/Incident
• Place of Accident/Incident
• Description of Accident/Incident
• Description or nature of injury
• Witness [es) to Accident/Incident
MIAMI-DADE COUNTY .HOMELESS TRUST POLICY & PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFI+'ECTIVE DA'1`I : 9/9/2015
REVISED DATE:
• What action(s) were taken?
• Parent/Guardian information, and if they were contacted? Time? How?
• Other Persons Contacted
• Describe Medical Treatment/First Aid
• Signature of Staff Completing Form, Date and Time
• Signature of Director/Person in Charge, Date and Time
3. When a critical incident occurs, subcontracted provider staff should:
• Take action to ensure the health, safety, and welfare of all individuals
involved in the incident, and
• Contact law enforcement, emergency responders, or the Abuse Hotline,
TOOLS: Miami -Dade County Homeless Trust Incident Report Form
M:\Policies-Miami-Dade County Homeless Trust \Incident Reporting Process.O515
MIAMI-DADE COUNTY HOMELESS TRUST POLICY & PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EJ I/ECTIVE DATE: 9/9/2015
REVISED DATE:
PURPOSE: The purpose of this policy is to define the process for receiving and
processing incident reports.
SCOPE: Miami -Dade County Homeless Continuum of Care
PROCEDURES:
1. Homeless CoC providers contracted with Miami -Dade County Homeless Trust must
report the following types of critical incidents, via fax (305)375-2722 or email, to
the attention of our Incident Report Coordinator: Miguel Pimentel. These incidents
are defined and outlined in CF-OP 215-6.
• Child -on -Child Sexual Abuse
• Child Arrest
• Child Death
• Adult Death
• Elopement refers to court ordered clients that run away and do not return
• Employee Arrest
• Employee Misconduct
• Escape
• Missing Child
• Security Incident -- Unintentional
• Significant Injury to Clients
• Significant Injury to Staff
• Suicide Attempt
• Sexual Abuse/Sexual Battery
2. For each critical incident, an incident report must be submitted to Miami -Dade
County Homeless Trust within one business day. The incident report needs to
include:
• Facility/Home
• Clients Name
• Clients Age
• Date & Time of Accident/Incident
• Place of Accident/Incident
• Description of Accident/Incident
• Description or nature of injury
• Witness (es) to Accident/Incident
MIAMI-DARE COUNTY HOMELESS TRUST POLICY & PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFFECTIVE DATE: 9/9/2015
REVISED DATE:
• What action(s) were taken?
• Parent/Guardian information, and if they were contacted? Time? How?
• Other Persons Contacted
• Describe Medical Treatment/First Aid
• Signature of Staff Completing Form, Date and Time
• Signature of Director/Person in Charge, Date and Time
3. When a critical incident occurs, subcontracted provider staff should:
• Take action to ensure the health, safety, and welfare of all individuals
involved in the incident, and
• Contact law enforcement, emergency responders, or the Abuse Hotline.
TOOLS: Miami -Dade County Homeless Trust Incident Report Forin
M:\Policies-Miami-Dade County Homeless Trust \Incident Reporting Process.0515
CF OPERATING PROCEDURE
NO. 215-6
Safety
CFOP 215-6
STATE OF FLORIDA
DEPARTMENT OF
CHILDREN AND FAMILIES
TALLAHASSEE, April 1, 2013
INCIDENT REPORTING AND ANALYSIS SYSTEM (IRAS)
1. Purpose. This operating procedure establishes the guidelines for reporting and analyzing critical
incidents as defined below. The analysis of incidents should be considered part of the overall risk
management program and quality improvement process of the Department, its employees, and its
licensed and contracted service providers.
2. Scope.
a. This operating procedure applies to all critical incidents occurring within the following
Department of Children and Families program areas:
(1) ACCESS;
(2) Administration;
(3) Adult Protective Services;
(4) Family Safety;
(5) Mental Health; and,
(6) Substance Abuse.
b. Incidents to be reported are those that occur:.
(1) Involving a client, Department employee, or a licensed or contracted provider
serving clients of the Department, or involving an employee of a licensed or contracted provider serving
clients of the Department in the identified program areas; or,
(2) Involving any licensed public or private substance abuse provider agency licensed in
accordance with Chapter 397, Florida Statutes (F.S.), and Chapter 65D-30, Florida Administrative Code
(F.A.C.), and their employees. Compliance with this procedure is a condition of substance abuse
licensure regardless of whether or not the provider serves any clients funded by the Department.
c. The Incident Reporting and Analysis System (IRAS) allows for the timely notification of
critical incidents, provision of details of the incident and immediate actions taken, and the ability to track
and analyze incident -related data,
d. The IRAS is not a case management system, and cannot be utilized to capture ongoing and
specific case management information, suoh as the progression of events and actions following the
occurrence of a critical incident.
This operating procedure supersedes CFOP 215-6 dated December 1, 2012.
OPR: Assistant Secretary for Operations
DISTRIBUTION: A
April 1, 2013 CFOP 215-6
e. State mental health treatment facilities, public and private, are required to adhere to
CFOP 155-25, Critical Event Reporting in State Mental Health Treatment Facilities, and are specifically
excluded from compliance with this operating procedure.
f. The incident reporting procedures do not replace:
(1) The mandatory reporting requirements to the Florida Abuse Hotline for abuse,
neglect and exploitation reporting protocols, as required by law. Allegations of abuse, neglect, or
exploitation must always be reported immediately to the Florida Abuse Hotline.
(2) The investigation and review requirements provided for in CFOP 175-17, Child
Fatality Review Procedures.
(3) The reporting requirements provided for in CFOP 175-85, Prevention, Reporting and
Services to Missing Children.
(4) The reporting requirements provided for in CFOP 180-4, Mandatory Reporting
Requirements to the Office of the Inspector General.
3. Definitions.
a. Abuse. Any willful or threatened actor omission that causes or is likely to cause significant
impairment to a child or vulnerable adult's physical, mental or emotional health.
b. Department. The Department of Children and Families.
c. Hospital. A facility licensed under Chapter 395, F.S. This includes facilities licensed as
specialty hospitals under Chapter 395, F.S.
d. Incident Coordinator. The designated Department or provider/agency staff whose role is to
add and update incidents, create and send initial and updated notifications and change the status of an
incident. Department Incident Coordinators are designated by their respective
Circuit/Region/Headquarters leadership.
e. Neglect. The failure or omission on the part of the caregiver to provide the care, supervision
and services necessary to maintain the physical and mental health of a child or vulnerable adult; or the
failure of a caregiver to make reasonable efforts to protect a child or vulnerable adult from abuse,
neglect, or exploitation by others.
f. Restraint. Any manual method or physical or mechanical device, materials, or equipment
attached or adjacent to the individual's body so that he or she cannot easily remove the restraint and which
restricts freedom of movement or normal access to one's body.
g. Seclusion. The physical segregation of a person in any fashion, or involuntary isolation of a
person in a room or area from which the person is prevented from leaving. The prevention may be by
physical barrier or by a staff member who is acting in a manner, or who is physically situated, so as to
prevent the person from leaving the room or area.
4. Policy. It is the responsibility of all Departmental personnel, and Department licensed or contracted
providers, to promptly report within one business day all critical incidents in accordance with the
requirements of this operating procedure. Failure by a Department employee to comply with this
operating procedure may lead to disciplinary action. Failure by a Department licensed or contracted
provider to comply with this operating procedure constitutes a lack of compliance with Iicensure status
or contract provisions.
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April 1, 2013 CFOP 215-6
5. Critical Incidents To Be Reported.
a. Adult Death, An individual 18 years old or older whose life terminates while receiving
services, during an investigation, or when it is known that an adult died within thirty (30) days of
discharge from a Treatment facility. For the Adult Protective Services program, deaths that are a result
of the vulnerable adult's documented condition are not subject to critical incident reporting
requirements. The manner of death is the classification of categories used to define whether a death is
from intentional causes, unintentional causes, natural causes, or undetermined causes.
(1) The final classification of an adult's death is determined by the medical examiner,
However, in the interim, the manner of death will be reported as one of the following:
(a) Accident. A death due to the unintended actions of one's self or another.
(b) Homicide. A death due to the deliberate actions of another.
(c) Suicide, The intentional and voluntary taking of one's own life.
(d) Undetermined. The manner of death has not yet been determined.
(e) Unknown. The manner of death was not identified or made known.
(2) [f an adult's death involves a suspected overdose from alcohol and/or drugs, or
seclusion and/or restraint, additional information about the death will need to be reported in IRAS.
b. Child Arrest. The arrest of a child in the custody of the Department.
c. Child Death. An individual less than 18 years of age whose life terminates while receiving
services, during an investigation, or when it is known that a child died within thirty (36) days of
discharge from a residential program or treatment facility or when a death review is required pursuant
to CFOP 175-17, Child Fatality Review Procedures. The manner of death is the classification of
categories used to define whether a death is from intentional causes, unintentional causes, natural
causes, or undetermined causes.
(1) The final classification of a child's death is determined by the medical examiner.
However, in the interim, the manner of death will be reported as one of the following:
(a) Accident. A death due to the unintended actions of one's self or another.
(b) Homicide. A death due to the deliberate actions of another,
(c) Natural Expected, A death that occurs as a result of, or from complications
of, a diagnosed illness for which the prognosis is terminal.
(d) Natural Unexpected. A sudden death that was not anticipated and is
attributed to an underlying disease either known or unknown prior to the death.
(e) Suicide. The intentional and voluntary taking of one's own life.
(f) Undetermined. The manner of death has not yet been determined.
(g) Unknown. The manner of death was not identified or made known.
(2) If a child's death involves a suspected overdose from alcohol and/or drugs, or
seclusion and/or restraint, additional information about the death will need to be reported in IRAS.
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April 1, 2013 CFOP 215-6
d. Child -on -Child Sexual Abuse, Any sexual behavior between children which occurs without
consent, without equality, or as a result of coercion. This applies only to children receiving services from
the Department or by a licensed, contracted provider, e.g. children in foster care placements or in
residential treatment.
e. Elopement.
(1) The unauthorized absence beyond four hours of an adult during involuntary civil
placement within a Department -operated, Department -contracted or licensed service provider.
(2) The unauthorized absence of a forensic client on conditional release in the
community.
(3) The unauthorized absence of any individual in a Department contracted or licensed
residential substance abuse and/or mental health program.
f. Employee Arrest. The arrest of an employee of the Department or its contracted or licensed
service providers for a civil or criminal offense.
g. Employee Misconduct. Work -related conduct or activity of an employee of the Department
or its contracted or licensed service providers that results in potential liability for the Department; death
or harm to a client; abuse, neglect or exploitation of a client; or results in a violation of statute, rule,
regulation, or policy. This includes, but is not limited to, misuse of position or state property;
falsification of records; failure to report suspected abuse or neglect; contract mismanagement; or
improper commitment or expenditure of state funds.
h. Escape. The unauthorized absence of a client who is committed by the court to a state
mental health treatment facility pursuant to Chapter 916 or Chapter 394, Part V, Florida Statutes.
i. Missing Child. When the whereabouts of a child in the custody of the Department are
unknown and attempts to locate the child have been unsuccessful.
j. Security Incident Unintentional. An unintentional action or event that results in
compromised data confidentiality, a danger to the physical safety of personnel, property, or technology
resources; misuse of state property or technology resources; and/or denial of use of property or
technology resources. This excludes instances of compromised client information.
k. Sexual Abuse/Sexual Battery. Any unsolicited or non-consensual sexual activity by one
client to another client, a DCF or service provider employee or other individual to a client, or a client to
an employee regardless of the consent of the client. This may include sexual battery as defined in
Chapter 794 of the Florida Statutes as "oral, anal, or vaginal penetration by, or union with, the sexual
organ of another or the anal or vaginal penetration of another by any other object; however, sexual
battery does not include an act done for a bona fide medical purpose." This includes any unsolicited or
non-consensual sexual battery by one client to another client, a DCF or service provider employee or
other individual to a client, or a client to an employee regardless of consent of the client.
I. Significant Injury to Clients. Any severe bodily trauma received by a client in a
treatment/service program that requires immediate medical or surgical evaluation or treatment in a
hospital emergency department to address and prevent permanent damage or loss of life.
m. Significant Injury to Staff, Any serious bodily trauma received by a staff member as a result
of work related activity that requires immediate medical or surgical evaluation or treatment in a hospital
emergency department to prevent permanent damage or loss of life.
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April 1, 2013 CFOP 215-6
n, Suicide Attempt. A potentially lethal act which reflects an attempt by an individual to cause
his or her own death as determined by, a licensed mental health professional or other licensed
healthcare professional.
o. Other. Any major event not previously identified as a reportable critical incident but has, or is
likely to have, a significant impact on client(s), the Department, or its provider(s). These events may
include but are not limited to:
(1) Human acts that jeopardize the health, safety, or welfare of clients such as
kidnapping, riot, or hostage situation;
(2) Bomb or biological/chemical threat of harm to personnel or property involving an
explosive device or biological/chemical agent received in person, by telephone, in writing, via mail,
electronically, or otherwise;
(3) Theft, vanda[ism, damage, fire, sabotage, or destruction of state or private property
of significant value or importance;
(4) Death of an employee or visitor while an the grounds of the Department or one of its
contracted or licensed providers;
(5) Significant injury of a visitor (who is not a client) while on the grounds of the
Department or one of its contracted, designated, or licensed providers; or,
(6) Events regarding Department clients or clients of contracted or licensed service
providers that have led to or may lead to media reports.
6. Guidelines for Reporting Incidents.
a. Notification/Reporting and Actions Taken — Staff Discovery of an Incident.
(1) Any employee of the Department, or one of its contracted or licensed providers, who
discovers that a reportable critical incident, as described herein, has occurred, will report the incident as
outlined in this operating procedure.
(2) The employee's first obligation is to ensure the health, safety, and welfare of all
individual(s) involved.
(3) The employee must immediately ensure contacts are made for assistance as
dictated by the needs of the individuals involved. These types of contacts may include, but are not
limited to: emergency medical services (911), law enforcement, or the fire department. When the
incident involves suspected abuse, neglect, or exploitation, the employee must call the Florida Abuse
Hotline to report the incident. The employee must ensure that the client's guardian, representative or
relative is notified, as applicable.
(4) Once the situation is stabilized and the staff has addressed any immediate physical
or psychological service needs of the person(s) involved in the incident, the employee must report the
incident to the Incident Coordinator. Each service provider/agency will use their internal reporting
process and timeframes for notifying provider/agency leadership of incidents. All critical incidents must
be entered into IRAS within one business day of the incident occurring.
(5) In the case of subcontractors, Managing Entities, or Lead Agencies, the
responsibility for reporting critical incidents to the Department rests with the Department's contracted
provider.
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April 1, 2013 CFOP 215-6
b. Notification/Reporting and Actions Taken by the Provider's/Agency's Incident Coordinator or
the Coordinator's Designee.
(1) Each Department licensed or contracted service provider will designate one staff
person to be the Incident Coordinator for the provider/agency. This person will manage the
provider's/agency's incident notification process. Additional staff may be designated to enter incident
information into the IRAS at the discretion of the service provider/agency.
(2) When a supervisor is informed of a critical incident, that person shall verify what has
occurred, confirm the known facts with the discovering employee, and ensure that appropriate and
timely notifications and actions occurred. The service provider/agency shall develop internal
procedures regarding reporting incidents to their Incident Coordinator or designee.
(3) If the incident qualifies as a critical incident according to the definitions contained in
this operating procedure, the provider's/agency's Incident Coordinator will review the incident
information and clarify or obtain any necessary information before forwarding the incident report to the
Department's designated Incident Coordinator or designee. The provider's/agency's Incident
Coordinator will provide the information regarding the incident to the Department's Incident Coordinator
or designee via the IRAS.
(4) The service provider/agency will ensure timely notification of critical incidents is
made to appropriate individuals or agencies such as emergency medical services (911), law
enforcement, the Florida Abuse Hotline, the Agency for Health Care Administration (AHCA), or Center
for Mental Health Services (for licensed mental health facilities), as required. The IRAS reporting
process does not replace the reporting of incidents to other entities as required by statute, rules or
operating procedure.
c. Notification/Reportinq and Actions Taken by Department's Incident Coordinator(s) or the
Coordinator's Designee.
(1) The Department's incident Coordinator or designee at the Circuit/Region level will
review the incident information and clarify or obtain any necessary additional information from the
applicable service provider and make revisions as necessary.
(2) The Department's Incident Coordinator or designee will make a determination
regarding any required notifications that should be sent to Department leadership. The Department's
Incident Coordinator or designee is responsible for ensuring appropriate notification is provided and
serves as the contact person regarding the IRAS. In addition to Department's leadership staff, the
Department's Incident Coordinator or designee will notify the Circuit/Region Public Information Officer
within two (2) hours of any incident that may have Department impact or media coverage.
(3) The entry of the incident into iRAS does not substitute for a direct phone call to the
Department's leadership staff when the incident type or severity of the incident warrants such contact.
This determination is to be made by the Department's Incident Coordinator or designee in consultation
with other Department leadership staff, as needed.
(4) The Department's incident Coordinator or designee should submit incidents in IRAS
even in cases where there is missing information not readily available. When the information is
obtained, the Incident Coordinator or designee should submit an update in IRAS as soon as possible.
(5) The Department's Incident Coordinator or designee shall ensure all necessary
information is entered into the IRAS in order to have a complete notification. The incident report is
considered to be "complete" when the initial notifications have been made and sufficient information
regarding the incident has been submitted. Additional information, such as from an autopsy or medical
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April 1, 2013 CFOP 215-6
examiner report regarding an incident can be submitted into the IRAS after the incident has been
determined to be "complete."
(6) Each Circuit/Region shall develop an internal process for reviewing and analyzing
trends regarding critical incidents within their Circuit/Region across ail Department program areas.
Each service provider/agency including Managing Entities will establish a system for reviewing critical
incidents to determine what actions need to be taken, if any, to prevent future occurrences and a follow-
up process to assure such needed actions are implemented.
BY DIRECTION OF THE SECRETARY:
(Signed original copy on file)
PETER DIGRE
Assistant Secretary for
Operation s
SUMMARY OF REVISED, ADDED, OR DELETED MATERIAL
This operating procedure was revised to specify the Department of Children and Families programs
which are subject to the requirements of this operating procedure, and to separate the requirements for
reporting adult deaths and child deaths.
7
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.
ATTACI- MENT P
PROVIDER REFERRAL FORM PAGE TWO
applicant'sName •
lithe Applicant or a ineniber of their household is an employee of the referring provider, the
' approval of the Provider Executive Director is hereby indicated by signature:
Narne/Title Dare
If the Applicant or a member of their household is :an employee of the provider where services will be
provided, the approval of The Provider Executive Director, the Homeless Trust .Executive Director,
and the Homeless Trust Board Chair are hereby indicated by signature:
•
Provider Executive Director Date
Miami -Dade County Homeless Trust Chairperson Date
Miami -Dade County Homeless Trust Executive Director
ADDITIONAL TIOUS$HOLD INFORMATION:
Where is the household living noun? (Facility name, exact address)
Date of present homelessness:
Explain the homeless situation, and what caused the current
homelessness: •
Date
IVOTE TO REFERRING PROVIDER: 1D.EER:
PROVIDING THE ABOVE INFORIVIATION DOES NOT ENSURE APPROVAL FOR HOUSING
OR OTHER SERVICES REQUESTED. A DETERMINATION WILL BE MADE FOLLOWING A
COMPLETE ASSESSMENT OF THE APPLICANT'S CASE.
THIS SECTION FOR SERVICE PROVIDER STAFF USE ONLY:
Meets Eligibility Crileric:. YES NO
l`iiiflzLDf Provider -Screening Staff: ..
PLEASE. MAINTAIN THE EXECUTED CC)PY OF THIS DOCUMENT IN THE•CLIENT FILE OF
THE SERVICING PROVIDER AND PERSONNEL FILE OF REFERRING PROVIDER.
ATTACHMENT P
NMLIM DADE COUNTY HOMELESS 'FRL'ST
I. CLIENT SERVICES CERTIFICATION REFERRAL FORM FOR EMPLOYEES OF
1 BOMELESS TRUST FUNDEIIPROGRAMS l
INSTRUCTIONS: Provider malting refei-raI must complete this two -page form, including signatures
• by AppIit:ant and Provider Representatives. Fax completed farms to ProviderReceiving, Referral for
Housing au'd'br Services.
Date:
Contact Person:
Referring Provider:
•
Naive Title Phone Number
.INFORMAT]QN ON HEAD OF HOUSE] -TOLD:
Last Name:
Date of Birth:
First Name:
SS #:
INFORMATION ON OTHER I OUSEHOLD MEMBERS:
Name
Age
Sex
Relationship '
Employer
IS ANY MEMBER OF THE HOUSEHOLD EMPLOYED B-Y, pR. RELATBD TO A.N EMPLOYEE
OF, A HOMELESS TRUST FUNDED PROGRAM? Yes
If yes:
Name of Employee:
Employing Provider:
Relationship to Applicant:
CERTIFICATION
I, the undersigned, do hereby certify that the above -information pro.vided.bay.mc,is..Srue.and correct t.othe
best of my I:novvIedlge,
Applicant's Name
Signature: Date:
Referring Provider Authorized Representative
Name: Sig*nature Date