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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 ,t-->r 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. Page 1 of 28 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. Page 2 of 28 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. Page 3 of 28 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. Page 4 of 28 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. Page 5 of 28 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 Page 14 of 28 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 Page 15 of 28 The City of Miami 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 Page 16 of 28 The City of Miami 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 Page 17 of 28 The City of Miami 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; Page 18 of 28 The City of Miami (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: Page 19 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 (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. Page 20 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 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. Page 21 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 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 Page 22 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 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. Page 23 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 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 Page 24 of 28 The City of Miami Feeding Coordination Program PC-1819-FC IIMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 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 Page 25 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 • 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 Page 26 of 28 The City of Miami Feeding Coordination Program PC-1819-FC HMIS Staffing Program PC-1819-STAFF-1 Identification Assistance PC-1819-ID-1 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 Page 27 of 28 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. Page 28 of 28 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. 2 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. 3 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. 4 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. 5 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 6 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