HomeMy WebLinkAboutBack-Up DocumentsM I AM I•DADE
COUNTY
March 10, 2023
Mr. Arthur Noriega, City Manager
The City of Miami
444 SW 2nd Avenue
Miami, Florida 33130
Re: 2022-2023 Primary Care Program
HMIS Staffing Program PC-2223-STAFF-1
ID Assistance Program PC-2223-ID-1
Dear Mr. Noriega:
Homeless Trust
111 NW 1st Street • 27th Floor
Miami, Florida 33128
T 305-375-1490
miamidade.gov
Enclosed, please find the Agreement between Miami -Dade County, through Miami -Dade County
Homeless Trust and The City of Miami for the following programs:
• HMIS Staffing Program PC-2223-STAFF-1
• ID Assistance Program PC-2223-ID-1
The authorized agency signatory must sign the Agreement in blue ink 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
Agreement or notarize it accordingly. The Agreement must be returned to the Homeless Trust office,
via email scan (all pages scanned in one document) no later than March 27, 2023.
Please feel free 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
for
Executive Director
Enclosures
Signature below confirms receipt of the enclosed documents.
Signature of Authorized Agency Representative Date
ATTACHMENT A, SCOPE OF SERVICES
EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM
PC-2021-HTMT-1
SCOPE OF SERVICES
EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM
The Provider agrees to provide emergency hotel/motel placement of homeless
families with children for a period of up to seven (7) days in area hotels/motels.
Thereafter, the provider must obtain the approval of the Miami -Dade County
Homeless trust for additional days as needed on a case -by -case basis.
Families may be provided food vouchers on an as -needed basis of up to $20.00
per diem while residing in hotels/motels. Families with more than four (4)
members may be provided an additional $5.00 per person per day.
Reimbursement will only be made for properly documented disbursement of
food vouchers.
All reimbursements must be submitted to the County by the 10t" day of each
month following the month of service.
All reimbursement requests must be approved by the County prior to the
disbursement of funds.
Scope A-2
Scope of COVID-19 Expenditures
The County is instructing Provider to undertake protective measures to prevent or mitigate the spread of COVID-
19 during the period in which public officials advise COVID-19 special measures should be taken. The County
will reimburse Provider for expenses incurred in taking such protective measures during such time period.
Allowable COVID-19 expenditures are set forth below. The County has sole discretion to determine if
expenditures were made for the purpose of preventing or mitigating the spread of COVID-19 and the dates of the
period in which public officials advise that COVID-19 special measures should be taken. Total reimbursement for
incurred COVID-19 costs under this Agreement shall not exceed $ N/A without the County's prior written
approval.
Allowable COVID-19 Expenditures:
• Personal Protection Equipment (PPE).
• Testing and screening for COVID-19.
• Cleaning supplies and/or cleaning services by outside vendors, including application of an antimicrobial
surface protectant.
• Physical modifications specifically undertaken to prevent or mitigate COVID-19 spread within the facility.
• Ventilation -related supplies or modifications, except for substantial modification or replacement, and
installation and maintenance of UV lighting.
• Educational material and signage specific to COVID-19.
• Additional food costs incurred for children in residence attending school remotely.
• Staff overtime incurred due to staff absences resulting from their COVID-19 infection, quarantine after
exposure to another person tested positive for COVID-19 or care of a household member with COVID-
19 infection. Provider may request reimbursement for the cost of temporary staffing necessary to cover
the absent permanent employee's hours that is above and beyond the budgeted cost of the absent
permanent employee.
• Other COVID-19 justified expenditures.
Payment Processes and Documentation Requirements:
Payment Processes:
Provider must submit a monthly invoice with back-up documentation attached, comprised of Provider's account
ledger for COVID-19 expenditures, invoices and receipts which include proof of invoice payment, canceled
checks, time sheets and payroll registers and other documentation as requested. The County will pay Provider
within thirty (30) days of the County's receipt of the invoice.
Additional Documentation Requirements:
• Provider must establish a cost center or the equivalent specifically for COVID-19 expenditures. The
account ledger for the cost center or the equivalent must be submitted with Provider's invoice. Such
ledger must list: (a) the purchased item or service, (b) vendor name; (c) vendor's invoice number with
purchase order date or receipt with same; (d) payment amount; (e) payment date; (f) check number
unless paid online.
• Vendor invoices, purchase orders or receipts must have a notation that they are COVID-19
expenditures.
• Request for reimbursement of costs incurred due to a permanent employee's absence must be
supported by Human Resource documentation of the basis for the employee's absence and period of
absence with the employee's name and any other identifying information redacted. Time sheets and
payroll records documenting an employee's overtime must be included in the reimbursement request
and indicate that such overtime was necessary to cover the absent permanent employee's hours.
Invoices for temporary staffing must match the period in which the permanent employee was absent and
indicate that such staffing was necessary to over the hours of the absent permanent employee as well
as include Human Resource record of permanent employee's budgeted salary.
• For any expense not expressly described above, Provider must provide a narrative justification that the
expense was incurred in response to COVID-19.
4
IDENTIFICATION ASSISTANCE PROGRAM
HMIS STAFFING PROGRAM
FY-2022-2023
Budget Narrative
These funds should cover the Identification Assistance Services and a HMIS one outreach staff person. The
Identification Assistance program must be provided, the Florida Identification Cards and Birth Certificates
services for the total amount of $12,500.00
The HMIS outreach staff position provides HMIS services and input, the purpose of this position is to maintain
data current in the HMIS. The amount of $24,666.00 would cover the salaries + Fica of the one Information and
Referral Specialist, the other amount will be covered by City of Miami.
THE CITY OF MIAMI HOMELESS ASSISTANCE PROGRAM
BUDGET
2021-2022 PRIMARY CARE PROGRAM- IDENTIFICATION ASSISTANCE PROGRAM
HMIS STAFFING PROGRAM
IDENTIFICATION ASSISTANCE PROGRAM
DESCRIPTION
BUDGET
STAFF SALARY
$ 3,750.00
IDENTIFICATION SERVICES
$ 8,750.00
TOTAL
$ 12,500.00
HMIS Staffing Program
COST
Staffing
MDHT
(52.3136%)
CITY OF MIAMI
(47.6864%)
1 Information and Referral
Specialist -Homeless
Program (Salaries+ Fica) -
HMIS ADMINISTRATOR
$ 47,150.27
24,666.00
22,484.27
TOTAL
$ 47,150.27
$ 24,666.00
$ 22,484.27
TOTAL (ID+HMIS Staffing)
$ 37,166,00
14
Miami -Dade County's Affidavits and Declarations
M IAM I -DADS
COUNTY
Miami -Dade County requires each party desiring to enter into a contract with Miami -Dade County to;
(1) Sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This
form contains both Affidavit forms for matters requiring the entity to sign under oath and Declaration
forms for matters requiring only an affirmation or declaration for other matters.
Each section of this form must be read, and initialed in the top right hand box indicating acceptance
and/or compliance with the County's policy related to the particular affidavit. For affidavit sections that
you do not believe are applicable to your organization, please indicate this by placing "Q" in the box next
to N/A.
ALL SECTIONS MUST BE COMPLETED
THE FOLLOWING MATTERS REQUIRE THE ENTITY TO SIGN AN AFFIDAVIT UNDER OATH:
STATE OF (
COUNTY OF (
COUNTRY OF (
Before me the undersigned authority appeared
(Print Name), who is personally known to
as identification and who did swear to the following:
me or who has provided
That he or she is the duly authorized representative of (Name of Entity)
(Address of Entity)
addresses are not acce table.
r
Federal Employment Identification Number
(hereinafter referred
"entity"), and that he or she is the entity's (Sole Proprietor)(Partner)(President or
That he or she has full authority to make this affidavit, and that the information given
attached hereto are true and correct; and
That he or she says for the following fifteen (16) Affidavits and Declarations:
Post Office
to as the contracting
Other Authorized Officer)
herein and the documents
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 1 of 11
Miami -Dade County's Affidavits and Declarations
1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (SECTION 2-8.1
OF THE COUNTY CODE)
Pertains O
N/A O
Initial (_)
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 address are outlined
below: Post Office addresses are not acceptable.
(Full Legal Name, Address, % Ownership)
(Full Legal Name, Address, % Ownership)
(Full Legal Name, Address, % Ownership)
(Full Legal Name, Address, % Ownership)
The full legal names and business address of any other individual
suppliers, laborers, or lenders) who have, or will have, any
the contract or business transaction with Miami Dade County
(other than subcontractors, material person,
interest (legal, equitable beneficial or otherwise) in
are:
required herein, or who knowingly discloses false
up to five hundred dollars ($500.00) or imprisonment
Post office addresses are not acceptable
Any person who willfully fails to disclose the information
information in this regard, shall be punished by a fine of
in jail for up to sixty (60) days or both.
ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 2 of 11
Miami -Dade County's Affidavits and Declarations
2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (COUNTY
ORDINANCE 90-133, AMENDING SECTION 2.8-1; SUBSECTION (d)(2) OF THE
COUNTY CODE)
Pertains O
N/A O
Initial (_)
Except where precluded by Federal or State laws or regulations, each contract or business transaction or
renewal thereof which involves the expenditure of then thousand dollars ($10,000) or more shall require the
entity contracting or transaction business to disclose the following information. The foregoing disclosure
requirements do not apply to contracts with the United States or any department or agency thereof, the State or
any political subdivision or agency thereof or any municipality of this State.
Does your firm have a collective bargaining agreement with its employees? O Yes O No
Does your firm provide paid health care benefits for its employees? O Yes O No
Provide a current breakdown (number of persons) of your firm's work force and ownership (below):
White:
Males
Females
Black:
Males
Females
Hispanic:
Males Females
Asian:
Males
Females
American Native:
Males
Females
Aleut (Eskimo):
Males Females
ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 3 of 11
Miami -Dade County's Affidavits and Declarations
3. MIAMI-DADE COUNTY AFFIRMATIVE ACTION /
NONDISCRIMINATION OF EMPLOYMENT, PROMOTION AND
PROCUREMENT PRACTICES (COUNTY ORDINANCE 98-30 CODIFIED
AT 2-8.1.5 OF THE COUNTY CODE)
Pertains O
N/A O
Initial (_)
Pursuant to Miami -Dade County's Ordinance No. 98-30, Section 2-8.1.5, entities with annual gross revenue in
excess of $5,000,000 seeking to contract with the County shall, as a condition of receiving a County contract, have:
1) 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 2) 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, not withstanding, corporate
entities whose board 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 a written
affirmative action plan and procurement policy in order to receive a County contract. The foregoing presumption
may be rebutted. The requirements of this section may be waived upon written recommendation of the County
Manager that it is in the best interest of the County to do so and approval of the County Commission by majority
vote of the members present. Based on the above, please complete the affidavit as directed and return the
completed affidavit along with a cover letter on your company's letterhead, listing the company's address, phone
and fax numbers, and any required documents, to: Miami -Dade County, Department of Procurement
Management Affirmative Action Plan Unit 111 NW 1st Street, l3th Floor Miami, FL 33128
Yes O No O
My company has an affirmative action plan and procurement policy and is
available for review.
Yes O No O
My company has annual gross revenues in excess of $5,000,000.
Therefore, our company's affirmative action plan and procurement policy
is available for review.
Yes O No O My company has annual gross revenues less than $5,000,000.
If at any time the Miami Dade County has reason to believe that any person or firm has willfully and knowingly
provided incorrect information or made false statements, the County may refer the matter to the State Attorney's
Office and/or other investigative agencies. The County may initiate debarment and/or pursue other remedies in
accordance with Miami -Dade County policy and/or applicable federal, state and local laws.
4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT
(SECTION 2-8.6 OF THE COUNTY CODE)
Pertains O
N/A O
Initial (_)
The individual or entity entering into a contract or receiving funding from Miami -Dade County 0 has 0 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 officer of the entity entering into a contract or receiving funding from Miami -Dade
County 0 has 0 has not as of the date of this affidavit been convicted of a felony during the past ten (10) years.
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 4 of 11
Miami -Dade County's Affidavits and Declarations
5. PUBLIC ENTITY CRIMES AFFIDAVIT (SECTION
287.133(3) (a), FLORIDA STATUTES)
Pertains O
N/A O
Initial (_)
The individual or entity entering into a contract or receiving funding from Miami -Dade County understands the
following: That a "public entity crime" as defined in Paragraph 287.133 (1) (g) Florida Statutes, means a violation
of any state or federal law by a person with respect to and directly related to the transaction of business with any
public entity or with an agency or political subdivision of any other state of the United States of America, including
but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or
political subdivision of any other state of the United States of America and involving antitrust, fraud, theft, bribery,
collusion, racketeering, conspiracy, or material misrepresentation.
That "Convicted" or "conviction" as defined in Paragraph 287.133 (1) (b) Florida Statutes means a finding of guilt
or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal state trial court of
record relating to charges brought by indictment or information after July 1,1989, as a result of a jury verdict, non -
jury trial, or entry of plea of guilty or nolo contendere.
That an "affiliate" as defined in Paragraph 287.133 (1) (a) Florida Statutes means a) a predecessor or successor of a
person convicted of a public entity crime; or b) an entity under the control of any natural person who is active in
the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes
those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the
management of an affiliate. The ownership by one person of shares constituting a controlling interest in another
person, or pooling of equipment or income among persons when not for fair market value under an arm's length
agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters
into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding
36 months shall be considered an affiliate.
That a "person" as defined in Paragraph 287.133 (1) (e) Florida Statutes means any natural person or entity
organized under the laws of any state or of the United States of America with the legal power to enter into a
binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public
entity, or which otherwise transacts or applies to transact business with a public entity. The term "person"
includes those officers, directors, executives, partners, shareholders, employees, members and agents who are
active in the management of an entity.
Based on information and belief, the statement as marked below, is true in relation to the entity submitting this
sworn statement. (Please indicate which statement applies by applying the individual initials near the box).
O Neither the entity submitting this sworn statement nor any of its officers, directors, executives, partners,
shareholders, employees, members or agents who are active in the management of the entity, nor an affiliate of the
entity has been charged with and convicted of a public entity crime within the past 36 months.
O The entity submitting this sworn statement or one or more of its officers, directors, executives, partners,
shareholders, employees, members or agents who are active in the management of the entity, or an affiliate of the
entity has been charged with and convicted of a public entity crime within the past 36 months; and
O yes an additional statement is applicable or O no an additional statement is not applicable.
O The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity has been charged
with and convicted of a public entity crime within the past 36 months. However, there have been subsequent
proceedings before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting
this sworn statement on the "Convicted Vendor List".
The individual or entity entering into a contract or receiving funding from Miami -Dade County understands that he
or she is required to inform the public entity prior to entering into a contract in excess of the threshold amount
provided in Section 287.017 Florida Statues for Category 2 of any change in the information contained in this form.
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 5 of 11
Miami -Dade County's Affidavits and Declarations
6. MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT
(County Ordinance No.142-91 codified as Section 11A-29 et.
seq of the County Code)
Pertains O
N/A O
Initial (_)
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. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION
AFFIDAVIT (County Resolution R-385-95)
Pertains O
N/A O
Initial (_)
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 Accommodation 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,
or the State or any political subdivision or agency thereof or any municipality of this State.
8. MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE
FEES OR TAXES (Sec. 2-8.1(c) of the County Code)
Pertains O
N/A O
Initial (_)
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.
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 6 of 11
Miami -Dade County's Affidavits and Declarations
9. CURRENT ON ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS
Pertains O
N/A O
Initial (_)
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 (Resolution 185-00; 99-5 Codified At 11A-
60 Et. Seq. of the Miami -Dade County Code).
Pertains O
N/A O
Initial (_)
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.
11. MIAMI-DADE COUNTY EMPLOYMENT DRUG -FREE WORKPLACE
AFFIDAVIT (County Ordinance No. 92-15 codified as Section 2-
8.1.2 of the County Code)
Pertains O
N/A O
Initial (_)
That in compliance with Ordinance No. 92-15 of the Code of Miami -Dade County, Florida, the above
or entity is providing a drug -free workplace. A written statement to each employee shall inform the
about:
1. danger of drug abuse in the workplace;
2. the firm's policy of maintaining a drug -free environment at all workplaces;
3. availability of drug counseling, rehabilitation and employee assistance programs;
4. penalties that may be imposed upon employees for drug abuse violations.
named person
employee
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.
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 7 of 11
Miami -Dade County's Affidavits and Declarations
12. ATTESTATION REGARDING DUE AND PROPER ACKNOWLEDGEMENT OF
COUNTY FUNDING SUPPORT
Pertains O
N/A O
Initial (_)
By initialing this subsection and accepting County funds, the above named firm, corporation, organization or
individual agrees to abide by the grant contract requirement to recognize and acknowledge Miami -Dade County's
grant support in a manner commensurate with all contributors and sponsors of its activities at comparable dollar
levels.
13. MIAMI-DADE COUNTY RESOLUTION NO. R-630-13 REQUIRING A DETAILED
PROJECT BUDGET, SOURCES AND USES STATEMENT, CERTIFICATIONS AS
TO PAST DEFAULTS ON AGREEMENTS WITH NON -COUNTY FUNDING
SOURCES, AND DUE DILIGENCE CHECK
Pertains O
N/A O
Initial (_)
Pursuant to Miami -Dade County Resolution No. R-630-13, requiring a detailed project budget, sources and uses
statement, certifications as to past defaults on agreements with non -county funding sources and due diligence
check prior to the County Mayor or County Mayor's designee recommending a commitment of Miami -Dade County
funds to Social Services, Economic Development, Community Development, and Affordable Housing Agencies and
Providers.
The undersigned entity certifies, to the best of his or her knowledge and belief, that:
1. Within the past five (5) years, neither the Agency nor its directors, partners, principals, members or board
members:
(i) have been sued by a funding source for breach of contract or failure to perform obligations under a
contract;
(ii) have been cited by a funding source for non-compliance or default under a contract;
(iii) have been a defendant in a lawsuit based upon a contract with a funding source.
Please list any matters which prohibit the Agency from making the certifications required and explain how the
matters are being resolved (use separate sheet if necessary):
14. MIAMI-DADE COUNTY RESOLUTION No. R-478-12 NOT TO USE PRODUCTS
OR FOODS CONTAINING "PINK SLIME"
Pertains O
N/A O
Initial (_)
Pursuant to Miami -Dade County Resolution No. R-478-12, the undersigned certifies, not to use meat products
containing "Pink Slime" in food provided or served as part any food program; urging all who provide food services
or operate a food program to immediately discontinue using meat products containing "pink slime" in food
provided or served in these programs.
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 8 of 11
Miami -Dade County's Affidavits and Declarations
15. MIAMI-DADE COUNTY REQUIRED LOBBYIST REGISTRATION FOR
ORAL PRESENTATION Section 2-11.1(i)(2) CONFLICT OF INTEREST
AND CODE OF ETHICS ORDINANCE
Pertains O
N/A O
Initial (_)
All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5) business days of
being retained as a lobbyist or before engaging in any lobbying activities, whichever shall come first. Every person
required to so register shall:
1. Register on forms prepared by the Clerk;
2. State under oath his or her name, business address and the name and business address of each person or entity
which has employed said registrant to lobby. If the lobbyist represents a corporation, the corporation shall also be
identified. Without limiting the foregoing, the lobbyist shall also identify all persons holding, directly or indirectly,
a five (5) percent or more ownership interest in such corporation, partnership, or trust. Registration of all
lobbyists shall be required prior to January 15 of each year and each person who withdraws as a lobbyist for a
particular client shall file an appropriate notice of withdrawal.
3. Prior to conducting any lobbying, all principals must file a form with the Clerk of the Board of County
Commissioners, signed by the principal or the principal's representative, stating that the lobbyist is authorized to
represent the principal. Failure of a principal to file the form required by the preceding sentence may be
considered in the evaluation of a bid or proposal as evidence that a proposer or bidder is not a responsible
contractor. Each principal shall file a form with the Clerk of the Board at the point in time at which a lobbyist is no
longer authorized to represent the principal.
OBy initialing here, the principals or principal's representative have filed with the Clerk of the Board of
County Commissioners stating that a lobbyist is authorized to represent the principal.
4. Any public officer, employee or appointee who only appears in his or her official capacity shall not be required to
register as a lobbyist.
5. Any person who only appears in his or her individual capacity for the purpose of self -representation without
compensation or reimbursement, whether direct, indirect or contingent, to express support of or opposition to any
item, shall not be required to register as a lobbyist.
6. Any person who only appears as a representative of a not -for -profit corporation or entity (such as a charitable
organization, or a trade association or trade union), without special compensation or reimbursement for the
appearance, whether direct, indirect or contingent, to express support of or opposition to any item, shall register
with the Clerk as required by the Ordinance subsection, but, upon request, shall not be required to pay any
registration fees.
The Clerk of the Board of County Commissioners shall notify the Commission on Ethics and Public Trust of the
failure of a lobbyist or principal to file a report and/or pay the assessed fines after notification. A lobbyist or
principal may appeal a fine and may request a hearing before the Commission on Ethics and Public Trust. A request
for a hearing on the fine must be filed with the Commission on Ethics and Public Trust within fifteen (15) calendar
days of receipt of the notification of the failure to file the required disclosure form. The Commission on Ethics and
Public Trust shall have the authority to waive the fine, in whole or part, based on good cause shown. The
Commission on Ethics and Public Trust shall have the authority to adopt rules of procedure regarding appeals from
the Clerk of the Board of County Commissioners.
Except as otherwise provided in subsection of the Ordinance, the validity of any action or determination of the
Board of County Commissioners or County personnel, board or committee shall not be affected by the failure of any
person to comply with the provisions of this subsection(s). (Ord. No. 00-19, § 1, 2-8-00; Ord. No. 01-93, § 1, 5-22-
01; Ord. No. 01-162, § 1, 10-23-01; Ord. No. 03-107, § 1, 5-6-03)
ATTACHMENT C "Miami -Dade County Affidavits and Declarations"
Page 9 of 11
Miami -Dade County's Affidavits and Declarations
16. Disclosure SUBCONTRACTOR / SUPPLIER LISTING (ORDINANCE 97-104)
Pertains O
N/A O
Initial (_)
This form, or a comparable form meeting the requirements of Ordinance 97-104, must be completed by all bidders and
proposers on Miami -Dade County contracts for purchase of supplies, materials or services, including professional
services which involve expenditures of $100,000.00 or more, and all bidders and proposers on County or Public
Health Trust construction contracts which involve expenditures of $100,000.00 or more. This form or a comparable
form meeting the requirements of Ordinance 97-104, must be completed and submitted even though the
bidder or proposer will not utilize subcontractors or suppliers on the contract. The bidder or proposer
should enter the word "NONE" under the appropriate heading, in those instances where no subcontractors or
suppliers will be used on the contract. A bidder or proposer who is awarded the contract shall not change or
substitute first tier subcontractors or direct suppliers or the portions of the contract work to be performed or
materials to be supplied from those identified except upon written approval of the County.
Business Name and Address
of First Tier
Sub co ntra cto r/ S ub c o n sulta nt
Principal Owner
Scope of Work to be Performed by
Subcontractor/Subconsultant
(Principal Owner)
Gender Race
Business Name and Address
of Direct Supplier
Principal Owner
Supplies/Materials/Services to be
Provided by Supplier
(Principal Owner)
Gender Race
I certify that the representations contained in this Subcontractor/Supplier Listing are to the best of my knowledge
true and accurate.
( ) ( )
Signature of Authorized Representative
Print Name
(Duplicate if additional space is needed)
Date
Print Title
ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 10 of 11
Miami -Dade County's Affidavits and Declarations
M IAM I-DADE
COUNTY
I have carefully read this entire 11-page document entitled, "Miami -Dade County's Affidavits and Declarations" and
agree to; (1) sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This
form contains both Affidavit forms for matters requiring the entity to sign under oath and Declaration forms for
matters requiring only an affirmation or declaration for other matters.
BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO AFFIDAVITS AND
DISCLOSURES 1-16
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 Expiration Date
Notary Public — State of
County of
Notary Seal
ATTACHMENT C "Miami -Dade County Affidavits and Declarations" Page 11 of 11
ATTACHMENT D
THIS ATTACHMENT IS NOT APPLICABLE TO THIS
CONTRACT AGREEMENT
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: THE CITY OF MIAMI
SERVICE PERIOD: TO
NAME OF GRANT:
THE CITY OF MIAMI -
ID ASSISTANT
PROGRAM
GRANT NUMBER: PC-2223-ID-1
TOTAL AWARD AMOUNT: $12,500.00
AMOUNT OF FUNDS REQUESTED
THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINIG 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:
THE CITY OF MIAMI -
HMIS STAFFING
PROGRAM
GRANT NUMBER: PC-2223-STAFF-1
TOTAL AWARD AMOUNT: $24,666.00
AMOUNT OF FUNDS REQUESTED
THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINIG 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 (CoC) HOMELESS ASSISTANCE
PROGRAM
o HUD MONTHLY CoC MONTHLY PERFORMANCE
REPORT (MPR) — HMIS GENERATED MONTHLY
REPORTS
o HUD ANNUAL CoC ANNUAL PERFORMANCE
REPORT (APR) — HMIS GENERATED ANNUAL
REPORTS
Reports must be generated from the ServicePoint HMIS
reporting system or HMIS system approved by the
Miami -Dade County Homeless Trust.
ATTACHMENT G, PERFORMANCE REPORTS (MONTHLY AND ANNUAL) APR AND HMIS
ATTACHMENT H
THIS ATTACHMENT IS NOT APPLICABLE TO THIS
CONTRACT AGREEMENT
ATTACHMENT I
THIS ATTACHMENT IS NOT APPLICABLE TO THIS
CONTRACT AGREEMENT
ATTACHMENT J
THIS ATTACHMENT IS NOT APPLICABLE TO THIS
CONTRACT AGREEMENT
ATTACHMENT K
THIS ATTACHMENT IS NOT APPLICABLE TO THIS
CONTRACT AGREEMENT
ATTACHMENT L
MIAMI DADE COUNTY
ANNUAL ACTUAL EXPENDITURE REPORT
THE CITY OF MIAMI-IDENTIFICATION PROGRAM
GRANT NUMBER #: PC-2223-STAFF-1
OCTOBER 1, 2022 - SEPTEMBER 30, 2023
Name of Agency:
Budget
THE CITY OF MIAMI -
HMIS STAFFING
PROGRAM
$ 24,666.00
Month of Services
Amount Paid
OCTOBER -2022
NOVEMBER-2022
DECEMBER-2022
JANUARY-2023
FEBRUARY-2023
MARCH-2023
APRIL-2023
MAY-2023
JUNE-2023
JULY-2023
AUGUST-2023
SEPTEMBER-2023
Total Requested
Balance Remaining
$
0.00
$ 24,666.00
Signature of Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
ATTACHMENT L
MIAMI DADE COUNTY
ANNUAL ACTUAL EXPENDITURE REPORT
THE CITY OF MIAMI-IDENTIFACTION PROGRAM
GRANT NUMBER #: PC-2223-ID-1
OCTOBER 1, 2022 - SEPTEMBER 30, 2023
Name of Agency:
Budget
THE CITY OF MIAMI-
ID-PROGRAM
$ 12,500.00
Month of Services
Amount Paid
OCTOBER-2022
NOVEMBER-2022
DECEMBER-2022
JANUARY-2023
FEBRUARY-2023
MARCH-2023
APRIL-2023
MAY-2023
JUNE-2023
JULY-2023
AUGUST-2023
SEPTEMBER-2023
Total Requested
Balance Remaining
$
0.00
$ 12,500.00
Signature of Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
FormRequest
(Rev. October2018)
Department of the Treasury
Internal Revenue Service
for Taxpayer
a Certification $
Identification Number and Ce1 tiiication
- Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
Print or type.
See Specific Instructions on page 3.
f 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 of the person whose name is entered on line 1. Check only one of the
following seven boxes.
4 Exemptions
certain entities,
instructions
Exempt payee
Exemption
code (if any)
(Applies to accounts
(codes apply only to
not individuals; see
on page 3):
code (if any)
• Individual/sole proprietor or • C Corporation ❑ S Corporation ❑ Partnership 111 Trust/estate
single -member LLC
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
Note: Check the appropriate box in the line above for the fax classification of the single -member owner.
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
NI Other (see instructions) ►
to
from FATCA reporting
Do not check
of the LLC is
-member LLC that
maintained outside the dJ.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
Requester's name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part l 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 instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
or
Employer identification number
Part 1!
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 I 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. 1 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 for Part 1l, later.
Sign
Here
Signature of
I.I.S. person
Date ►
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
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 return 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 earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MIISC (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 return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 10-2018)
MIAMI•DADE
Memorandum Co�Nn
Date: September 27, 2019
To: Miami -Dade County Homeless Trust Board Members
From: Victoria Mallette, Executive Director
Homeless Trust Homeless Trust
Subject: Revised Incident Reporting Form
On September 9, 2015, the Homeless Trust Board passed a policy to define the process for
receiving and processing incident reports. The policy outlined the types of critical incidents
which must be reported to the Continuum of Care's Incident Report Coordinator, Miguel
Pimentel. For each critical incident, a report must be submitted to the Miami -Dade County
Homeless Trust within one business day. When a critical incident occurs, subcontracted
provider staff should 1) take action to ensure the health, safety and welfare of all individuals
involved in the incident, and 2) contact law enforcement, emergency responders of the Abuse
Hotline.
The incident reporting form has been significantly updated to include both wrong -doing, as well
as allegations of wrongdoing. Reporting is required for both client related and staff related
incidents.
Of particular note, sexual battery has been included in the listing as State law has outlined
"Failure to report any known or suspected abuse of any kind of a child is a third-degree felony
that may result in a prison sentence of 5 years, and a fine of $5,000 (Refer to Chapter 39 &
415 of the Florida Statutes). "
The revised Incident Reporting Form is attached. This is an information only item.
Attachment
c: Maurice L. Kemp, Deputy Mayor
Shannon Summerset, Esq., Assistance County Attorney
Pagel ofl
MbAMla
COUNTY COUNTY
Zc(1>yri &rc
INCIDENT REPORT
ATTACHMENT N
CHECK IF CRITICAL ❑
IDENTIFYING INFORMATION
Reporting Party Phone # ( ) Date of Incident / / Time of Incident : am/pm
Reporting Party Name
Contract Provider Name
Program Name
Provider Location
Specific Category: (check all that apply)
❑ Allegation or wrongdoing ❑ Wrongdoing (as acknowledged by a
third party designated to investigate these claims i.e. law enforcement
detained individual, or DCF accepted abuse report)
Specific location/ address where incident occurred:
TYPE OF INCIDENT
CLIENT RELATED
❑ ALTERCATION
❑ CLIENT DEATH
❑ CLIENT INJURY OR ILLNESS ❑ THEFT
❑ SEXUAL BATTERY ❑ SUICIDE ATTEMPT
❑ PROPERTY DAMAGE ❑ ABUSE OR NEGLECT*
❑ OTHER INCIDENT
Specify
1 of 4
MIAMI=
COUN
TY
ATTACHMENT N
* Failure to report any known or suspected abuse of any kind of a child is a third-degree
felony that may result in a prison sentence of 5 years, and a fine of $5,000 (Refer to Chapter 39
& 415 of the Florida Statutes).
STAFF RELATED
❑ INAPPROPRIATE EMPLOYEE ACTS OR OMISSIONS THAT
RESULT IN CLIENT INJURY, ABUSE, NEGLECT, OR DEATH
❑ FRAUD ❑ THEFT
❑ BREACHES OF CONFIDENTIALITY
0IMPROPER EXPENDITURE OR COMMITMENT OF PUBLIC
FUNDS -OR-CONTRACT MISMANAGEMENT
0 COMPUTER RELATED MISCONDUCT
OANY VIOLATION UNDER §435, F.S., TITLE X XI, EMPLOYEE
SCREENING, THAT WOULD RESULT IN DISQUALIFICATION
FROM CLIENT CONTACT DUTIES
❑ FALSIFICATION OF OFFICIAL RECORDS
❑ MISUSE OF POSITION OR STATE PROPERTY, EMPLOYEES,
EQUIPMENT, OR SUPPLIES FOR PERSONAL GAIN OR PROFIT
❑ FAILURE TO REPORT KNOWN OR SUSPECTED NEGLECT OR
ABUSE OF A CLIENT
❑ OTHER INCIDENT THAT WOULD BE A VIOLATION OF
STATUTE, RULE, REGULATION OR POLICY
Specify
2 of 4
MIAMKO
COUNTY OUNTY
bc6erI 5 c c//cxtc E*, c7y
ATTACHMENT N
PARTICIPANT (S) / WITNESS (ES)
(Please mark W or P for either Witness or Participant)
Staff ID # or Client HMIS # CLIENT EMPLOYEE OTHER
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
W/P
❑ Wor❑P
❑ Wor❑P
❑ Wor❑P
DESCRIPTION OF INCIDENT
Give detailed account — who, what, where, when, why, how — add pages if necessary
CORRECTIVE ACTION AND FOLLOW UP
Immediate corrective action taken
Is follow up action needed?
❑ Yes ❑ No
If yes, specify
INDIVIDUALS NOTIFIED
Abuse Registry 1-800-962-2873
Applicable Law Enforcement Department
Indicate name of person contacted, if report was accepted, the date and time if called or copy of report
Incident Reports — The Subrecipient must report to Miami -Dade County Homeless Trust information related to my
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.
3 of 4
MIAMI•�
COUN
TY
Dejorrn6 Exelleitce El.cry
Definitions of Reportable Client Incidents
ATTACHMENT N
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, kidnapping, riot, or
hostage situation, which jeopardizes the health, safety and welfare of clients.
e. Sexual Battery. Any allegation of a program participant or program staff
intentionally touching a minor or another person without their consent. This includes
incidents of inappropriate verbal offenses, incidents that occur outside of the
residence, and incidents were the program participant was victimized by someone
outside of the residence. Incidents involving a minor, person who is 60 or older, or
someone who is disabled must be reported to the DCF.
f. Abuse or Neglect. Any physical maltreatment of a child, disabled person, or someone
age 60 or older. Any failure to act on the part of the parent or care taker, which results
in harm to a child, disabled person, or someone age 60 or older.
g.
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 depail.inent or a
departmental contracted or certified provider, which results in bodily injury requiring
medical treatment by a licensed health care professional.
h. Property Damage. An incident involving damage to property procured with Homeless
Trust funding.
4 of 4
ZrirErer o
■
Real Property and Equipment Asset Inventory
Equipment � an acquisition crest afgreater t .t 0.06 per trillit and an real prey rustA
inventoried. Real property includes land, laud mp ns. structures and appurtenance%
Plowable machinery and equipment,
Property and Property improsement Recent
Legal Description;
Size
Date aff
Vahe at TIME of Pan:base
Owne'4 .s Name (if id. than the 1, Hi ill III-1 611 13:
wax (attach tom) indicate where property is in para,is 1lots our blocks and Strallir adjacenit streets and
roads
Equipment 1:
Sena' 1 f ID Number
Dam..
F. ;IFilr' �.
Cost
Vendor Name
�; Sa of Purchase from Grant
Eoctlt. l SiPYg'5��t.1.
Use Condition of PIl ty:
Who Holds r?
Equipment 2:
rip/ir-r`lta
of Property:
SerialID limber;
Cost
Vr Name
Parobase Cost from Grant
Location of Pmparty:
Used Condition of Properly:
Tide?Who Holds
Equipment3:
Description of Property:
Sandal / ID litinitt
Acq 'McMinn
Cost
Vendor Name
etviPurchase Cost from Grant
LaSegian of Property:
Use and of
Who Holds "fie?
Vitiease create additional pages as required)
ArrAciotorri
Courtly l Property and Equipment Asset Inventory'
AT . CtIMEN'r P
MIAMI DADE ODUNT Y' HOMELESS *`RUST
• CLIEN #`SERRV/MS CERTIF'MCA710 REFERRAL'FORM FOR EMPLOYEES OF
1:I0ME1 SS TRUST FlUNDEUPROaRAlvlS
IRS3RUCJ 1WNS: Provider paling referral must Complete this two -page form, *jading- signatorss
by Applicant and 1'roriderRep resentatives. Fax completed forms to PviderReceivingReferral for
o�se;.ar}dar5esclees. -
Date: Refuting Provides. -
Contact Parson:
Naive
INF0RMATIQN ON HEAD OF HOUSEHOLD: _
FiistName:
SS
Last Nance:
Date of $itch:
Title - ' • - .. Phone Nurrkb ' .
• I1,I17O1 MATION ON arlimIKVSEHOLD MOW&
Relationship ttployer
Name
Age
•
IS. ANY MS3VIBER OP THE 11011SILHOLH RivIPLOYKD'B ?, QREZLATlgi TOANEMPLOYEE
0?, A HtiM1FL US'T RU IDPI».R0GRAMY Yeses ' Na
1 -
IVarne of Ernployee:-
Employing Provider.
Relationzhipto•Applicarit
GHRTIFIGATION .
I, the undersigned, do Hereby certify that Se above:informatian p i•Otlul-lxj! me,ir3r ee:EreetV the
rest of irry kt►oaledge: '
Applicant's Name -
'�ifurec-
Referring Provider Author/v.4_Representative
Nance: .Sirrnar€.
a
ATTACHMENT P
- PROVIDER REFERRAL FORM. PACE TWO .
- Appl canf s Nam -
If the Applicant or a Member oatheir h beld is an employeeef the refrrriag provider, the
• apprcrral of the Prorir r E*e�ye Director is hereby indit:ited by rgnature:
Narnelritle Date
•
If the Applicant ar.a member of their housthald is'in employett of the provider where services -will be
provided,. the approval nine Prdvider)?zeeutive nectar, tl a Homeless Trust xe c tive Dir:#or;
and the Homeless Treat Board Chair -are hereby it lusted by signature:
•
ProdiderExecutive Director '
l+Ilanii-Dade Comity Homeless Trast Chairperson
i i-pade Comity Homeless trastExecative Disector
ADD1T' O:NAL. HouSEHoLD INFORMATION. _
Where is the household livg nc ? (Fasility Hanle, and *Tr*
Date
Date of prtsetrt homelessness:
Explain the homeless simal3on, and what caused the c rrett
homelessness:
Date
PROVIDII 3 Tl of:WE-INFORMATION DOES NOT ENSURE APPROVAL FOR HOUSING
• OROT R SERViC$S RNQUEESTRD.'A DETERMINATION WILL OE MADE FOLLOWING A
-COMPLM �SMENT OF MX APPLICANT'S CASL -
THIS SECTION FOR SERVICE PROVIDER STAFF USE ONLY.
Medc YES �- NO •
l yrinse-of Ftrovfder-Seresting. `:
PLEASE MAINTAIN THE EXECUTED -COPY -OF THIS DOCUMENT IN THECLIEN'r FILE 4F
1'IiE $Ea%'ICING PROVIDER AND PEItSONNEi<Fi l.E OF REFER` ING PRO1VlMR. •