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Grant Contract with Miami-Dade County (2)r 2015 —. 29 o32_ The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 GRANT CONTRACT a This Grant Contract ( the "Contract" or "Grant Agreement") is made and entered into as of this II day of Jed , 20/6 , by and between Miami-Dade County, a political subdivision of the State of Florida (the "County"), having its principal office at 111 N.W. 1st Street, 27th Floor, Miami, Florida 33128 and The City of Miami Beach/FEIN#: 59-6000372, a corporation organized and existing under the laws of the State of Florida, having its principal office at 1700 Convention Center Drive, Miami Beach, Florida 33139 ("Provider"), states conditions and covenants for the rendering of human and social services ("Services") for the County. WHEREAS, the Provider provides or will develop social services of value to the County and has demonstrated an ability or desire to provide these services; and WHEREAS, the County is desirous of assisting the Provider in providing those services and the Provider is desirous of providing such services; and WHEREAS, the County has appropriated grant funds for the proposed services; NOW, THEREFORE, in consideration of the mutual covenants and agreements herein contained, the parties hereto agree as follows: ARTICLE 1. DEFINITIONS The following words and expressions used in this Grant Agreement shall be construed as follows, except when it is clear from the context that another meaning is intended: a) The words "Agreement" "Contract" or "Contract Documents" shall mean collectively these terms and conditions, the Scope of Services (Attachment A) and the Budget Documents (Attachment B) and all other attachments hereto, as well as all amendments or budget revisions issued hereto. b) The words "Contract Manager" shall mean Miami-Dade County's Director of the Homeless Trust ("County") or the Director's designee, or the duly authorized representative designated to manage the Contract. c) The word "Days" shall mean Calendar Days, unless otherwise specifically noted. d) The word "Deliverables" shall mean all documentation and any items of any nature submitted by the Provider to the County for review and approval pursuant to the terms of this Contract. e) The words "directed", "required", "permitted", "ordered", "designated", "selected", "prescribed" or words of like import to mean respectively, the direction, requirement, permission, order, designation, selection or prescription of the County's Contract Manager; and similarly the words "approved", acceptable", "satisfactory", "equal", "necessary", or words of like import to mean respectively, approved by, or acceptable or satisfactory to, equal or necessary in the sole discretion of the County's Contract Manager. f) The words "Effective Term" shall mean the date on which this Contract is effective, including Page 1 of 27 1 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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: Emergency Hotel/Motel Placement Program $10,000.00 HMIS Staffing Program $12,333.00 Total Award $22,333.00 Both parties agree that should available 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, may allow Provider an advance of N/A once the Provider has submitted an appropriate request and submitted an invoice in the form required by the County. ARTICLE 3. SCOPE 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 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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, 2015 and terminate at the close of business on September 30, 2016. Contingent on the existence of sufficient funding, performance and the approval of the County, this Contract may be extended at the County's sole discretion for two (2) additional one (1) year terms, at the County's sole discretion. ARTICLE 6. INDEMNIFICATION BY PROVIDER A. Government Entity. Government entity shall indemnify and hold harmless the County and its officers, employees, agents and instrumentalities from any and all liability, losses or damages, including attorneys' fees and costs of defense, which the County or its officers, employees, agents or instrumentalities may incur as a result of claims, demands, suits, causes of actions or proceedings of any kind or nature arising out of, relating to or resulting from the performance of this Contract by the government entity or its employees, agents, servants, partners, principals or subcontractors. Government entity shall pay all claims and losses in connection therewith and shall investigate and defend all claims, suits or actions of any kind or nature in the name of the County, where applicable, including appellate proceedings, and shall pay all costs, judgments, and attorney's fees which may issue thereon. Provided, however, this indemnification shall only be to the extent and within the limitations of Section 768.28, Fla. Stat. Page 3 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 • HMIS Staffing PC-1516-STAFF-2 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 Florida Statutes, Chapter 440. B. All Other Providers. 1. Minimum Insurance Requirements: Certificates of Insurance. The Provider shall submit to Miami-Dade County, c/o Miami Dade County Homeless Trust (COUNTY), 111 N.W. 1st Street, 27th Floor, Miami, Florida 33128-1994, original Certificate(s) of Insurance indicating that insurance coverage has been obtained which meets the requirements as outlined below: A. All insurance certificates must list the County as "Certificate Holder" in the following manner: Miami-Dade County 111 N.W. 1st Street, Suite 2340 Miami, Florida 33128 B. Worker's Compensation Insurance for all employees of the Provider as required by Florida Statutes, Chapter 440. Page 4 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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 q ualifications: 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. 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 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 In the event that expired certificates are not replaced with new or renewed certificates which cover the effective term, the County may suspend the Contract until such time as the new or renewed certificates are received by the County in the manner prescribed herein; provided, however, that this suspended period does not exceed thirty (30) calendar days. Thereafter, the County may, at its sole discretion, terminate this Contract. ARTICLE 8. PROOF OF LICENSURE/CERTIFICATION AND BACKGROUND SCREENING A. Licensure. If the Provider is required by the State of Florida or Miami-Dade County or any federal, state or local law or regulation to be licensed or certified to provide the services or operate the facilities outlined in the Scope of Services (Attachment A), the Provider shall furnish to the County a copy of all required current licenses or certificates. Examples of services or operations requiring such licensure or certification include but are not limited to childcare, day care, nursing homes, and boarding homes. If the Provider,fails to furnish the County with the licenses or certificates required under this Section, the County shall not disburse any funds until it is provided with such licenses or certificates. Failure to provide the licenses or certificates within sixty (60) days of execution of this Agreement may result in termination of this Agreement at the County's discretion. B. Background Screening. The Provider agrees to comply with all applicable federal, state and local laws, regulations, -ordinances and resolutions regarding background screening of employees, volunteers and subcontractors. Provider's failure to comply with any applicable laws, regulations, ordinances and resolutions regarding background screening of employees, volunteers and subcontractors is grounds for a material breach and termination of this contract at the sole discretion of the County. The Provider agrees to comply with all applicable laws (including but not limited to Chapters 39, 402, 409, 394, 408, 393, 397, 984, 985 and 435, Florida Statutes, as may be amended form time to time), regulations, ordinances and resolutions, regarding background screening of those who may work or volunteer with vulnerable persons, as defined by section,435.02, Florida Statutes, as may be amended from time to time. In the event criminal background screening is required by law, the State of Florida and/or the County, the Provider will permit only employees and subcontractors with a satisfactory national criminal background check through an appropriate screening agency (i.e., the Florida Department of Juvenile Justice, Florida Department of Law Enforcement or Federal Bureau of Investigation) to work or volunteer in direct contact with vulnerable persons. The Provider agrees to ensure that employees, volunteers and subcontracted personnel who work with vulnerable persons satisfactorily complete and pass Level 2 background screening before working or volunteering with vulnerable persons. Provider shall furnish the County with proof that employees, volunteers and subcontracted personnel, who work with vulnerable persons, satisfactorily Page 6 of 27 '. • l':: The City of Miami Beach : Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 passed Level 2 background screening, pursuant to Chapter 435, Florida Statutes, as may be amended from time to time. If the Provider fails to furnish to the County proof that an employee, volunteer or subcontractor's Level 2 background screening was satisfactorily passed and completed prior to that employee or ! . subcontractor working or volunteering with a vulnerable person or vulnerable persons,the County shall not -: disburse any further funds and this Contract may be subject to termination at the sole discretion of the r._ County. - . ARTICLE 9. CONFLICT OF INTEREST, "The provisions of this Article 9(C) shall only apply to those employees or independent contractors of Provider • who directly administer this Grant Agreement or any services funded pursuant to this Grant Agreement." A.The Provider agrees to abide by and be governed by Miami-Dade County Ordinance No.72- 82 (Conflict of Interest Ordinance codified at Section 2-11.1 et al. of the Code of Miami-Dade County), as amended, which is incorporated herein by reference as if fully set forth herein, in connection with its . contract obligations hereunder. • • B. No person under the employ of the County, who exercises any function or responsibilities in connection with this Contract, has at the time this Contract is entered into, or shall have during the term of this Contract,any personal financial interest,direct or indirect, in this Contract. C. Nepotism. Notwithstanding the aforementioned provision, no relative of any officer, ?:: board of director, manager, or supervisor employed by the Provider shall be employed by the Provider t':;• unless the employment preceded the execution of this Contract by one(1)year. No family member of any employee may be employed by the Provider if the family member is to be employed in a direct supervisory or administrative relationship either supervisory or subordinate to the employee. The assignment of family members in the same organizational unit shall be discouraged.A conflict of interest in employment arises whenever an individual would otherwise have the responsibility to make, or participate actively in making decisions or recommendations relating to the employment status of another individual if the two individuals (herein sometimes called"related individuals")have one of the following relationships: 1. By blood or adoption: Parent,child,sibling,first cousin,uncle,aunt, nephew,or niece; ::.- 2. By marriage: Current or former spouse, brother- or sister-in-law, father- or mother-in-law, v: son-or daughter-in-law,step-parent,or step-child;or • 3. Other relationship: A current or former relationship, occurring outside the work setting that _........_.__......__._wou{d make it_difficult for the individual_with_:the=_responsibility__to__:make _a decision or ::: _: recommendation to be objective, or that would create the appearance that such individual could not be objective. Examples include, but are not limited to, personal relationships and • significant business relationships. For purposes of this section, decisions or recommendations related to employment status • include decisions related to hiring, salary, working conditions, working responsibilities, _ evaluation,promotion,and termination. An individual, however, is not deemed to make or actively participate in making decisions or -:. recommendations if that individual's participation is limited to routine approvals and the :.: individual plays -no role involving the exercise of any discretion in the decision-making i, processes. If any question arises whether an individual's participation is greater than is is Page 7 of 27 jr The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 permitted by this paragraph, the matter shall be immediately referred to the Miami-Dade County Commission on Ethics and Public Trust. This section applies to both full-time and part-time employees and voting members of the Provider's Board of Directors. D. No person, including but not limited to any officer, board of directors, manager, or supervisor employed by the Provider, who is in the position of authority, and who exercises any function or responsibilities in connection with this Contract, has at the time this Contract is entered into, or shall have during the term of this Contract, received any of the services, or direct or instruct any employee under their supervision to provide such services as described in the Contract. Notwithstanding the before mentioned provision, any officer, board of directors, manager or supervisor employed by the Provider, who is eligible to receive any of the services described herein may utilize such services if he or she can demonstrate that he or she does not have direct supervisory responsibility over the Provider's employee(s) or service program. Staff members, or their immediate family members (spouse, children, siblings, mother or father) of Homeless Trust funded programs, who are eligible for and wish to receive services from a Homeless Trust funded program must receive the approval of the Executive Director of their employer (i.e. the Provider) prior to applying for and receiving those services. This approval must be in writing and accompany any referral for such services. Any Provider knowingly accepting a referral of an employee of a Homeless Trust funded program, and providing services without the written approval of the Executive Director of the Provider, will be subject to the recoupment/disallowance by the County of any funds paid for services to this individual and/or their immediate family member. When the services are to be provided at the same agency the employee works for, this information must be disclosed in writing to the director of the Homeless Trust, which shall be reviewed for eligibility determination and a sign off must come from the County. This provision does not apply to staff members seeking emergency shelter, medical or legal services. Providers must complete a Client Services Authorization Form (Attachment P) for staff members seeking services. ARTICLE 10. CIVIL RIGHTS The Provider agrees to abide by Chapter 11A of the Code of Miami-Dade County ("County Code"), as amended, which prohibits discrimination in employment, housing and public . accommodations on the basis of race, creed, religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age, ancestry, national origin or handicap; Title VII of the Civil Rights Act of 1968, as amended, which prohibits discrimination in employment and public accommodation; the Age Discrimination Act of 1975, 42 U.S.C. §6101, as amended, which prohibits discrimination in employment because of age; the Rehabilitation Act of 1973, 29 U.S.C. §794, as amended, which prohibits discrimination on the basis of disability; the Americans with Disabilities Act, 42 U.S.C. §12101 et seq., which prohibits discrimination in employment and public accommodations because of disability; the Federal Transit Act, 49 U.S.C. §1612, as amended; and the Fair Housing Act, 42 U.S.C. §3601 et seq. It is expressly understood that the Provider must submit an affidavit attesting that it is not in violation of the Acts. If the Provider or any owner, subsidiary, or other firm affiliated with or related to the Provider is found by the responsible enforcement agency, the Courts or the County to be in violation of these acts, the County will conduct no further business with the Provider. Any contract entered into based upon a false affidavit shall be voidable by the County. If the Provider violates any of the Acts during the term of any contract the Provider has with the County, such Page 8 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 contract shall be voidable by the County, even if the Provider was not in violation at the time it submitted its affidavit. The Provider agrees that it is in compliance with the Domestic Violence Leave, codified as § 11A-60 et seq. of the Miami-Dade County Code, which requires an employer, who in the regular course of business has fifty (50) or more employees working in Miami-Dade County for each working day during each of twenty (20) or more calendar work weeks to provide domestic violence leave to its employees. Failure to comply with this local law may be grounds for voiding or terminating this Contract or for commencement of debarment proceedings against Provider. ARTICLE 11. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT; Any person or entity that performs or assists Miami-Dade County with a function or activity involving the use or disclosure of"individually identifiable health information (IIHI)" and/or"Protected Health Information (PHI)" shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Miami-Dade County Privacy Standards Administrative Order. HIPAA mandates for privacy, security and electronic transfer standards, included but are not limited to: 1. Use of information only for performing services required by the contract or as required by law; 2. Use of appropriate safeguards to prevent non-permitted disclosures; 3. Reporting to Miami-Dade County of any non-permitted use or disclosure; 4. Assurances that any agents and subcontractors agree to the same restrictions and conditions that apply to the Provider and reasonable assurances that IIHI/PHI will be held confidential; 5. Making Protected Health Information (PHI) available to the customer; 6. Making PHI available to the client for review; 7. Making PHI available to Miami-Dade County for an accounting of disclosures; and 8. Making internal practices, books, and records related to PHI available to Miami-Dade County for compliance audits. PHI shall maintain its protected status regardless of the form and method of transmission (paper records and/or electronic transfer of data). The Provider must give its clients written notice of its privacy information practices, including specifically, a description of the types of uses and disclosures that would be made with protected health information. Provider must post, and distribute upon request to service recipients, a copy of the County's Notice of Privacy Practices. ARTICLE 12. NOTICE REQUIREMENTS Notice under this Contract shall be sufficient if made in writing, delivered personally or sent via U.S. mail, electronic mail, facsimile, or certified mail with return receipt requested and postage prepaid, to the parties at the following addresses (or to such other party and at such other address as a party may specify by notice to others) and as further specified within this Contract. If notice is sent via electronic mail or facsimile, confirmation of the correspondence being sent will be maintained in the sender's files. If to the COUNTY: Miami-Dade County Homeless Trust 111. N.W. 1st Street, 27th Floor Miami, Florida 33128 Attention: Victoria Mallette, Executive Director Electronic mail: VMallette @miamidade.gov Page 9 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 If to the PROVIDER: Mr. Jimmy Morales City Manager The City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 Electronic mail: JimmyMorales @miamibeachfl.gov Either party may at any time designate a different address and/or contact person by giving written notice as provided above to the other party. Such notices shall be deemed given upon receipt by the addressee. ARTICLE 13. AUTONOMY Both parties agree that this Contract recognizes the autonomy of the contracting parties and implies no affiliation between the contracting parties. It is expressly understood and intended that the Provider is only a recipient of funding support and is not an agent or instrumentality of the County. Furthermore, the Provider's agents and employees are not agents or employees of the County. ARTICLE 14. SURVIVAL The parties acknowledge that any of the obligations in this Contract, including but not limited to Provider's obligation to indemnify the County, will survive the term, termination, and cancellation hereof. Accordingly, the respective obligations of the Provider under this Contract, which by nature would continue beyond the termination, cancellation or expiration thereof, shall survive termination, cancellation or expiration hereof. ARTICLE 15. BREACH OF CONTRACT: COUNTY REMEDIES A. Breach. A breach by the Provider shall have occurred under this Contract if: (1) the Provider fails to provide the services outlined in the Scope of Services (Attachment A) within the effective term of this Contract; (2) the Provider ineffectively or improperly uses the County funds allocated under this Contract; (3) the Provider does not furnish the Certificates of Insurance required by this Contract or as determined by the County's Risk Management Division; (4) if applicable, the Provider does not furnish upon request by the County proof of licensure/certification or proof of background screening required by this Contract; (5) the Provider fails to submit, or submits incorrect or incomplete, proof of expenditures to support disbursement requests or advance funding disbursements or fails to submit or submits incomplete or incorrect detailed reports of expenditures or final expenditure reports; (6) the Provider does not submit or submits incomplete or incorrect required reports; (7) the Provider refuses to allow the County access to records or refuses to allow the County to monitor, evaluate and review the Provider's program; (8) the Provider discriminates under any of the laws outlined in Article 10 of this Contract; (9) the Provider, attempts to meet its obligations under this Contract through fraud, misrepresentation, or material misstatement; (10) the Provider fails to correct deficiencies found during a monitoring, evaluation, or review within the specified time as described and defined in its Performance Improvement Plan (PIP); (11) the Provider fails to issue prompt payments to small business subcontractors or follow dispute resolution procedures regarding a disputed payment; (12) the Provider fails to submit the Certificate of Corporate Status, Board of Page 10 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 Directors requirement, or proof of tax status; or (13) the Provider fails to fulfill in a timely and proper manner any and all of its obligations, covenants, agreements, and stipulations in this Contract; (14) the Provider fails to meet any of the terms and conditions of the Miami-Dade County Affidavits (Attachment C) and the State Affidavits (Attachment D) ❑ Applicable 0 Not Applicable or (15) the Provider fails to fulfill in a timely and proper manner any or all of its obligations, covenants, agreements and stipulations in this Contract. Waiver of breach of any provisions of this Contract shall not be deemed to be a waiver of any other breach and shall not be construed to be a modification of the terms of this Contract. In the event that the County determines certain Contract goals (as defined in the Scope of Services) are not being met then the County, in its sole discretion may place the Provider on a Performance Improvement Plan (PIP). The following is a delineation of some instances where a PIP may be required: a. HMIS- Based on Provider's past performance on prior contracts in the area of Homeless Management Information System compliance it is subject to a PIP during this contract term. The Provider is required to submit a Monthly Progress Report and an HMIS-generated Monthly Progress Report for each month of the contract. Compliance will be determined when it is deemed that the two (2) reports are in substantial conformity with each other for a period of two consecutive months. (Substantial conformity as meaning a minimum of 95% accuracy on all elements). At the time of compliance, the Provider shall only be required to submit the HMIS- generated Monthly Progress Report. ❑ Applicable © Not Applicable b. Utilization — Based on Provider's past performance on prior contracts in the area of utilization compliance, this contract is subject to a PIP. During this contract term, the Provider must submit all invoices in a timely manner. The Provider shall invoice at a rate of 95% of targeted expenditures for the invoicing period. If the Provider fails to comply, all rights to payments will be forfeited if the County so chooses. Failure to submit accurate invoices for appropriately documented and eligible expenditures at a rate of 95% of targeted expenditures by the end of the third quarter of this contract term may result in the termination of this contract by the County. ❑ Applicable © Not Applicable c. Program Performance — Based on Provider's past performance on prior contracts in the area of program goals and outcome objectives, this Contract is subject to a PIP. During this Contract term, the Provider must achieve those goals specified in the Contract. Performance against these annual goals shall be evaluated on a quarterly basis, and if by the end of the third quarter of the contract period substantial compliance (meeting the targeted goals) is not achieved, it may result in the termination of this contract with the County. ❑ Applicable M Not Applicable The above is subject to the review and approval of the County B. County Remedies. If the Provider breaches this Contract, the County may pursue any or all of the following remedies: Page 11 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 1. The County may terminate this Contract by giving written notice to the Provider of such termination and specifying the effective date thereof. In the event of termination, the County may: (a) request the return of finished or unfinished documents, data studies, surveys, drawings, maps, models, photographs, reports prepared and secured by the Provider with County funds under this Contract; (b) seek reimbursement of County funds allocated to the Provider under this Contract; (c) terminate or cancel any other contracts entered into between the County and the Provider. The Provider shall be responsible for all direct and indirect costs associated with such termination, including attorney's fees; 2. The County may suspend payment in whole or in part under this Contract by providing written notice to the Provider of such suspension and specifying the effective date thereof. If payments are suspended, the County shall specify in writing the actions that must be taken by the Provider as condition precedent to resumption of payments and shall specify a reasonable date for compliance. The County may also suspend any payments in whole or in part under any other contracts entered into between the County and the Provider. The Provider shall be responsible for all direct and indirect costs associated with such suspension, including attorney's fees; 3. The County may seek enforcement of this Contract including but not limited to filing an action in a court of appropriate jurisdiction. The Provider shall be responsible for all direct and indirect costs associated with such enforcement, including attorney's fees; 4. The County may debar the Provider from future County contracting; 5. If, for any reason, the Provider should attempt to meet its obligations under this Contract through fraud, misrepresentation or material misstatement, the County shall, whenever practicable terminate this Contract by giving written notice to the Provider of such termination and specifying the effective date. The County may terminate or cancel any other contracts which such individual or entity has with the County. Such individual or entity shall be responsible for all direct and indirect costs associated with such termination or cancellation, including attorney's fees. Any individual or entity who attempts to meet its contractual obligations with the County through fraud, misrepresentation, or material misstatement may be debarred from county contracting for up to five (5) years; 6. Any other remedy available at law or equity. C. Authorization to Terminate Contract. The Mayor or the Mayor's designee is authorized to terminate this Contract on behalf of the County. D. Failures or waivers to insist on strict performance of any covenant, condition, or provision of this Contract by the County shall not be deemed a waiver of any rights or remedies, nor shall it relieve the Provider from performing any subsequent obligations strictly in accordance with the term of this Contract. No waiver shall be effective unless in writing and signed by the parties. Such waiver shall be limited to provisions of this Contract specifically referred to therein and shall not be deemed a waiver of any other provision. No waiver shall constitute a continuing waiver unless the writing states otherwise. E. Damages Sustained. Notwithstanding the above, the Provider shall not be relieved of liability to the County for damages sustained by the County by virtue of any breach of the Contract, Page 12 of 27 The City of Miami Beach Hotel/Motel Placement,Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 and the County may withhold any payments to the Provider until such time as the exact amount of damages due the County is determined. The County may also pursue any remedies available at law or equity to compensate for any damages sustained by the breach. The Provider shall be responsible for all direct and indirect costs associated with such action, including attorney's fees. ARTICLE 16. TERMINATION FOR CONVENIENCE The County may terminate this Contract, in whole or part, when both parties agree that the continuation of the activities would not produce beneficial results commensurate with further expenditure of the funds. Both parties shall agree upon the termination conditions, including the effective date and in the case of partial termination, the portion to be terminated. However, if the County determines in the case of partial termination that the reduced or modified portion of the grant will not accomplish the purposes for which the grant was made it may terminate the grant in its entirety. This Contract is subject to the ratification and approval by the Miami-Dade County Board of County Commissioners and shall be void unless approved by the Board of County Commissioners. The County may also, in its sole discretion, terminate the contract. The Provider understands and acknowledges that if the County determines in its sole discretion that termination of the Contract is necessary for the healthy, safety, or welfare of the County then it may due so upon twenty-four (24) hours notice to the Provider. ARTICLE 17. PAYMENT PROCEDURES The County agrees to pay the Provider for services rendered under this Contract based on the payment schedule, timely provision by the Provider of required reports and of supporting documentation of expenses and activities as described in this Contract, and the line item budget (Attachment B). Payment shall be made in accordance with procedures outlined below and if applicable, the Sherman S. Winn Prompt Payment Ordinance (Ordinance 94-40). 1. How payment will be made. Payment requests shall be made to the County on a monthly basis and shall be signed by the Executive Director and the Financial Officer of the Provider, unless otherwise approved in writing, on the form incorporated herein as Attachment E "Invoice for Services". The payment request for the previous month is due by the 10th of the month following the month for which payment is invoiced. 2. Payment will be processed as follows: a) The Hotel/Motel Placement funds will be paid on a reimbursement basis for the provision of placement services. B) The HMIS Staffing Program funds will be paid in twelve (12) equal monthly installments of $1,027.75. 3. Any reimbursement may be withheld pending the receipt and approval by the County of all reports and documents required herein. 4. The parties agree that payment will be based upon the provision of services outlined in Attachment A, the "Scope of Services", for each program. 5. As applicable, during the period of N/A through N/A , the Provider will submit a record of those individuals served utilizing Social Security Administration repayments as specified in the Scope of Services. The Provider will utilize these funds to serve those clients as specified and authorized in the Scope of Services Page 13 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 6. N/A Providers with cumulative utilization rates greater than ninety percent (90%) during the first nine (9) months of this Contract may exceed this maximum number of 9 ( ) Y 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. 7. N/A Providers with cumulative utilization rates lower than ninety percent (90%) may be subject to a reduction in funding and beds, if deemed necessary by the Miami-Dade County Homeless Trust. Beds and funding may be reprogrammed as necessary and needed within the Continuum of Care. The Miami-Dade County Homeless Trust will conduct a review of the utilization of beds within the first six (6) months of the contract period. 8. Within thirty (30) days of the termination or expiration of this Contract, a final report of expenditures shall be submitted to the County. If after the receipt of such final report, the County determined that the Provider has been paid funds not in compliance with the Contract, and to which it is not entitled, the Provider will be required to return such funds to the County or submit documentation demonstrating that the expenditure was in compliance with this Contract. The County shall have the sole and absolute discretion to determine if the Provider is entitled to such funds and the County's decision in this matter shall be final and binding. B. Monies 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 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, Page 14 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1 5 1 6-STAFF-2 and the Florida Prompt Payment Act, if supporting documentation/invoices are properly documented as determined by the County in its sole discretion. It is the responsibility of the Provider to maintain sufficient financial resources to meet the expenses incurred during the period between the provision of services and payment by the County. E. Reporting Requirements. Failure to submit to the County the reports listed below in a manner deemed correct and acceptable by the County by the 15th day after the end of the month in which the service was delivered, or failure to submit to the County supporting documentation of Contract expenditures or activities within fourteen (14) days of any County request, shall be considered a breach of this Contract and may result in withholding payment, non-payment, or termination of this Contract. Applicable as indicated 1. Monthly Payment Requests/Invoice For Services (Attachment E) 2. Monthly Performance Reports (Attachment G) • 3. Outcome Performance Measurements Monthly Report (Attachment H) 4. Client Contribution Report (Attachment I) ❑ 5. Client Attendance Roster (Attachment J) ❑ 6. Quarterly Vacancy/ Permanent Housing Placement Report(Attachment K) ❑ Performance Reports. The Provider agrees to participate in the Homeless Management Information System (HMIS) selected and established by the County. Participation will include, but is not limited to, input of client data upon intake, daily updates of bed availability information, as well as updates of client files upon client contact, and maintaining current data for statistical purposes. The Provider understands that they are responsible for any ongoing cost to access the HMIS 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 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. Page 15 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 Additionally, the Provider agrees to assign any proceeds to the County from any contract, including this Contract, between the County, its agencies or instrumentalities and the Provider or any firm, corporation, partnership or joint venture in which the Provider has a controlling financial interest in order to secure repayment of any reimbursements for services provided under this or any other contract for which the County discovers was not reimbursable through its inspection, review and/or audit pursuant to this. Contract. ARTICLE 18. PROHIBITED USE OF FUNDS A. Adverse Actions or Proceeding. The Provider shall not utilize County funds to retain legal counsel for any action or proceeding against the County or any of its agents, instrumentalities, employees, or officials. The Provider shall not utilize County funds to provide legal representation, advice, or counsel to any client in any action or proceeding against the County or any of its agents, instrumentalities, employees, or officials. B. Religious Purposes. County funds shall not be used for religious purposes. C. Commingling Funds. The Provider shall not commingle funds provided under this Contract with funds received from any other funding sources. The Provider shall establish a separate account exclusively for receipt of the funds received pursuant to this Contract. • D. Double Payments. Provider costs claimed under this Contract may not also be claimed under another contract or grant from the County or any other agency. Any claim for double payment by Provider shall be considered a material breach of this Contract. 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 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 Page 16 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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 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. 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 Page 17of27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 records, and all other documents relevant to the Services furnished under this Contract for a period of M 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; (8) 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 • Page 18 of 27 The City of Miami Beach Hotel/Motel Placement Program • PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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 of the Florida Statutes, if the Provider meets the definition of "Contractor" as defined in Section 119.0701(1)(a), the Provider shall: (a) Keep and maintain public records that ordinarily and necessarily would be required by the public agency in order to perform the service; (b) Provide the public with access to public records on the same terms and conditions that the public agency would provide the records and at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law; (c) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law; and (d) Meet all requirements for retaining public records and transfer to the County, at no County cost, all public records created, received, maintained and or directly related to the performance of this Agreement that are in possession of the Provider upon termination of this Agreement. Upon termination of this Agreement, the Provider shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure Page 19 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 requirements. All records stored electronically must be provided to the County in a format that is compatible with the information technology systems of the County. For purposes of this Article, the term "public records- shall mean all documents, papers, letters, maps, books, tapes, photographs, films, sound recordings, data processing software, or other material, regardless of the physical form, characteristics, or means of transmission, made or received pursuant to law or ordinance or in connection with the transaction of official business of the County. Provider's failure to comply with the public records disclosure requirement set forth in Section 119.0701 of the Florida Statutes shall be a breach of this Agreement. In the event the Provider does not comply with the public records disclosure requirement set forth in Section 119.0701 of the Florida Statutes, the County may, at the County's sole discretion, avail itself of the remedies set forth under this Agreement and available at law. ARTICLE 20. Office of Miami-Dade County Inspector General Miami-Dade County has established the Office of the Office of Inspector General which is empowered to perform random audits on all County contracts throughout the duration of each contract. The Miami-Dade County Inspector General is authorized and empowered to review past, present and proposed County and Public Health Trust programs, contracts, transactions, accounts, records and programs. In addition, the Inspector General has the power to subpoena witnesses, administer oaths, require the production of records and monitor existing projects and programs. Monitoring of an existing project or program may include a report concerning whether the project is on time, within budget and in compliance with plans, specifications and applicable law. The Inspector general is empowered to analyze the necessity of and reasonableness of proposed charge orders to the Contract. The Inspector General is empowered to retain the services of independent private sector inspectors general (IPSIG) to audit, investigate, monitor, oversee, inspect 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. Page 20of27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 The provisions in this section shall apply to the Provider, its officers, agents, employees, subcontractors and suppliers. The Provider shall incorporate the provisions in this section in all subcontractors and all other agreements executed by the Provider in connection with the performance of the contract. Nothing in this contract shall impair any independent right of the County to conduct audit or investigative activities. The provisions of this section are neither intended nor shall they be construed to impose any liability on the County by the Provider or third parties. ARTICLE 21. SUBCONTRACTORS and ASSIGNMENTS A. Subcontracts. The parties agree that no assignment or subcontract will be made or let in connection with this Contract without the prior written approval of the County in its sole discretion, which shall not be unreasonably withheld, and that all subcontractors or assignees shall be governed by all of the terms and conditions of this Contract. 1) If the Provider will cause any part of this Contract to be performed by a Subcontractor, the provisions of this Contract will apply to such Subcontractor and its officers, agents and employees in all respects as if it and they were employees of the Provider; and the Provider will not be in any manner thereby discharged from its obligations and liabilities hereunder, but will be liable hereunder for all acts and negligence of the Subcontractor, its officers, agents, and employees, as if they were employees of the Provider. The services performed by the Subcontractor will be subject to the provisions hereof as if performed directly by the Provider. 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. Page 21 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 16-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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 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. b) Miami-Dade County Code, Chapter 11A, including but not limited to Articles III and IV. All Providers and subcontractors performing work in connection with this Contract shall provide equal opportunity for employment and services without regard to race, creed, religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age, ancestry, gender identity, gender expression, source of income, national origin or handicap. The aforesaid provision shall include, but not be limited to, the following: employment, 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. Page 22 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 c) Conflict of Interest and Code of Ethics Ordinance, Section 2-11.1 et seq. of the Code of Miami-Dade County, as amended. d) Miami-Dade County Code Section 10-38, Debarment of contractors from County work. e) Miami-Dade County Ordinance 99-5, codified at 11A-60 et seq. Code of Miami-Dade County pertaining to complying with the County's Domestic Leave Ordinance. f) Miami-Dade County Ordinance 99-152 codified at Section 21-255 et seq. prohibiting the presentation, maintenance, or prosecution of false or fraudulent claims against Miami-Dade County. g) Miami-Dade. County Resolution 478-12. The Provider will not use products or foods containing "pink slime," as defined in Resolution 478-12 of the Board of Miami-Dade County Commissioners, in food that is provided or served pursuant to this agreement." Notwithstanding any other provision of this Contract, Provider shall not be required pursuant to this Contract to take any action or abstain from taking any action if such action or abstention would, in the good faith determination of the Provider, constitute a violation of any law or regulation to which Provider is subject, including but not limited to laws and regulations requiring that Provider conduct its operations in a safe and sound manner. ARTICLE 23. MISCELLANEOUS A. Publicity. It is understood and agreed between the parties hereto that this Provider is funded by Miami-Dade County. Further, by the acceptance of these funds, the Provider agrees that events funded by this Contract shall recognize and adequately reference the County as a funding source. The Provider shall ensure that all publicity, public relations, advertisements and signs 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 Page 23 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 made as a written amendment to this Contract executed by both parties. The Mayor or the Mayor's designee is authorized to make modifications to this Contract as described herein on behalf of the County. The Office of the Inspector General shall have the power to analyze the need for, and the reasonableness of proposed modifications to this Contract. D. Counterparts. This Contract is executed in three (3) counterparts, and each counterpart shall constitute an original of this Contract. E. Headings, Use. of Singular and Gender. Paragraph headings are for convenience only and are not intended to expand or restrict the scope or substance of the provisions of this Contract. Wherever used herein, the singular shall include the plural and plural shall include the singular, and pronouns shall be read as masculine, feminine, or neuter as the context requires. F. Review of this Contract. Each party hereto represents and warrants that they have consulted with their own attorney concerning each of the terms contained in this Contract. No inference, assumption, or presumption shall be drawn from the fact that one party or its attorney prepared this Contract. It shall be conclusively presumed that each party participated in the preparation and drafting of this Contract. G. The County's Consultant. The Provider understands that in order to facilitate the implementation of this Contract, the County may from time to time designate in writing a development consultant to work with the Provider. The County's consultant 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 may, in its sole and absolute discretion, find and determine within sixty (60) days of such request that a proposed contract should not be prohibited hereby, as the best interests of the homeless programs undertaken by and on behalf of Miami-Dade County would not be negatively affected by such contract, arrangement, or undertaking. Incident Reports. The Provider must report to the Miami-Dade County Homeless Trust information related to any critical incidents occurring during the administration of its programs. The Provider is to utilize the "Incident Report" form attached as Attachment N. In addition to reporting this incident to the appropriate authorities, the Provider must within twenty-four (24) hours of any incident, submit in writing a detailed account of the incident. This incident report should be addressed to the County. This incident report should be addressed to Miami-Dade County Homeless Page 24 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1 5 1 6-HTMT-3 HMIS Staffing PC-1516-STAFF-2 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. 1. No 3rd Party Beneficiaries. The Parties agree that this contract has no intended or unintended third party beneficiaries. K. Property. This section applies to equipment with an acquisition cost of $5,000 or more per unit and all real property. 1. Any real property under the Provider's control that was acquired/improved in whole or in part with funds from the Homeless Trust and any equipment purchased for $5,000 or more shall be disposed of, at the expiration or termination of this contract, in accordance with instruction from the Homeless Trust. Real Property is defined as land, including land improvements, structures, and appurtenances thereto, including movable machinery and equipment. Equipment means tangible, nonexpendable, personal property having a useful life of more than one year and an acquisition cost of$5,000 or more per unit. 2. All equipment with an acquisition cost of $5,000 or more per units and all real property purchased in whole or in part with funds from this and previous contracts with the Homeless Trust, or transferred to the Provider t after being purchased in whole or in part with funds from the Homeless Trust shall be listed in the property records of the Provider and shall include a legal description, size, date of acquisition, value at time of purchase, owner's name if different from the Provider, information on the transfer or disposition of the property, and map indicating whether property is in parcels, lots or blocks and showing adjacent streets and roads. Notwithstanding documentation required for reimbursement purposes, a copy of the purchase receipt for any asset described above purchased with Homeless Trust funds must also be included in the Provider's monthly reimbursement package submitted to the Homeless Trust in the month in which the item was purchased along with the "Provider Asset Inventory" (Attachment 0). 3. All equipment with an acquisition cost of $5,000 or more per unit and all real property shall be inventoried annually by the Provider and an inventory report shall be submitted to the Homeless Trust. This report shall include the elements listed in the paragraph listed above. 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 Attachment F: Monthly Payment Requests Reports (NOT APPLICABLE) Page 25 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 Attachment G: Monthly Performance Reports(NOT APPLICABLE) 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 0: Provider Asset Inventory Report Attachment P: Client Services Certification Form No other agreement, oral or otherwise, regarding the subject matter of this Contract shall be deemed to exist or bind any of the parties hereto. If any provision of this Contract is held invalid or void, the remainder. of this Contract shall not be affected thereby if such remainder would then continue to conform to the terms and requirements of applicable law and ordinance. SIGNATURES APPEAR ON THE FOLLOWING PAGE Page 26 of 27 The City of Miami Beach Hotel/Motel Placement Program PC-1516-HTMT-3 HMIS Staffing PC-1516-STAFF-2 IN WITNESS WHEREOF, the parties have executed this Contract, along with all of its Attachments, effective as of the contract date herein above set forth. THE CITY OF MIAMI BEACH MIAMI-DADE COUNTY Signed By: I Si : _9 Y Signed 9 I Name: +lam .P'M o R a.t By: - - Title: Name: �_=- :_!�'.L. ark/ C i Y M A NI AC—•R Title: Date: i I IL-6AVII) ( 7,--z-7,--z- I r I S Date: tirBille Attest: ilibtAW-) a644_, Authorized Person OR Attest: HARVEY RUVIN, Clerk Notary Public Board of County Commissioners Print Name: ] orl atboSt.) Title: 1 By. �o-) ry Print Name: G Corporate Seal OR Notary Seal/Stamp: .�•°°"(� ****••• ,11..11/,, DINORAH ALONSO n.... ,.... /A0r i ji-i; k0° o (t% Notary Public-State of Florida i Z `C---0-- 6'' 18,2018 ' D �"���! • • _My Comm.Expires Sep . 0 \,n : ,,�.�j��� ,o;: Commission#FF 125324 • ii ",48;f- ` famed Through National Notary Assn. �• ``.°° ��/11111\I o o */.v�4 • APPROVED AS TO FORM & LANGUAGE & FOR EX CUTION k&DirV% %.1._-t t." ‘5 City Attorney plc Date See memorandum dated Jo ) /f approved for form and legal sufficiency. Page 27 of 27 • Attachment A • The City of Miami Beach Emergency Hotel/Motel Placement Program Scope of Services The Provider agrees to provide emergency hotel/motel placem b of homeless families with children for a period of up to seven (7) days in area hot?►Jmotels. In addition, the PROVIDER may also place chronic homeless individuals as well as hard-to-serve, transgender clients,on an as-needed basis. - Chronic homeless individuals as well as hard-to-serve• transgender clients may be provided food vouchers on an as-needed basis of up to $20.00 per diem. Families with two (2) to three (3) members may be provided food vouchers on an as-needed basis of $20.00 per diem while residing in hotels/motels. Families with four (4) to five (5) members maybe provided $25.00 per diem,'families with six (6).to eight (8) members may be provided $40.00 per diem, and families with nine(9).members may be provided $45.00 per diem while residing in hotels/moteLs. Reimbursements will only be made for properly documented disbursement of food . vouchers. • All reimbursements must be submitted to the County by the 15th day of each month following the month of service. All reimbursement requests must be aptloved by the County prior to the disbursement of funds. The City of Miami Beach • • EMS Staffing Scope of Services The PROVIDER shall provide a dedicated HMIS Outreach staff person. The purpose of ;this staff position is to maintain data current in the H I.IS and includes, but is not limited to input of client data upon intake, updates of client files, compilation of reports and entering data for statistical purposes. .Failure to maintain this data current, as evidenced by HMIS generated Monthly Progress Reports submitted to the County each month under the U S. HUD sub-recipient Agreement between the City of Miami Beach and the Miami-Dade County Homeless Trust may result in the termination of this Agreement Scope of Services Hotel/Motel Placement Program 2015 The City of Miami Beach has more than 10 years experience serving its homeless our city.The Hotel/Motel program grant has been awarded to us in prior years to provide emergency assistance for families who were homeless or at risk of becoming so and could not enter shelter at that point in time for a variety of reasons; including lack of available shelter space. Hotel/Motel placements historically were temporary placements until space at a shelter with appropriate case management would become available. In prior years,the City's Homeless Outreach Team would learn of a client in need through either a referral from the Miami Beach Police Department, a school within the Miami Beach Feeder Pattern, on-street engagement, or direct inquiry via the walk-in center or hotline. Upon making contact, the team would conduct an initial assessment including background screens to assess client homelessness, its causes and its possible remedy. Placement at a hotel would then be offered if no other viable shelter options were available as temporary assistance while other resources were acquired. Daily check- ins were then conducted by staff and food cards were provided until placement with proper case management could be initiated. Generally the entire process from initial call to appropriate shelter placement took from 1-7 days. Due to the City's lengthy history serving as a participant in the CoC, our 10-person staff is available at all times (in rotation) to answer the needs of this population within our community. The Program Coordinator is on call 24 hours a day, 7 days a week to answer calls that come in from the Miami Beach Police to address households that are encountered in vulnerable situations after hours. Case Workers have received a variety of trainings including Baker Act,Marchman Act and asset driven assessments. The City is trained in engagement strategies,proper assessment techniques, and Care Coordination, which is a client centered strategy for services. The Hotel/Motel program will continue to be managed as the past with acknowledging shelter placement as a possible action for those individuals who are in need of a more comprehensive cadre of services. Staff is trained and actively participates in the use of HMIS. The City has 2 SOARS-trained staff members that may assist on—site with disability benefits applications. The addition of the VI-SPIDAT along with the capacity of Hotel/Motel Program as a direct path to permanent housing has further expanded our services. The new agreement will include staff participation in the placement of appropriate clients from hotel directly into permanent housing. Collaborating agencies have been identified and through the City's Service Partnership are being contracted to provide the expansion of services and efforts beginning October 1, 2015. The Institute for Child&Family Health, Inc., AYUDA, Inc., Choices, et al, Inc.in conjunction with City staff who have more than 10 years experience working with the population providing Care Coordination will provide comprehensive assistance to identify the best path of sustainability for the client. Clients who receive Hotel/Motel Program assistance will fall under two strategies: Shelter Path or Rapid Rehousing Path. Both strategies will receive Care Coordination and • 1 daily food assistance; additionally, the Rapid Rehousing Path will receive rental relocation assistance into permanent housing as a new component not previously offered and will be awarded to clients who are identified as income-eligible for self- sustainability. The expected outplacement time for cases with Rapid Rehousing Path will be 15-20 days; cases that are Shelter Path are expected to transition in 1-7 days. Care Coordination will consist of an entry assessment followed by an action plan and daily check-ins by a counselor to successfully follow the plan. Assistance for rental relocation will be provided as part of the program inclusive of security deposit, first month's rent and last month's rent along with assistance for the connection of utilities, such as electricity. Program exit will be considered successful after placement in permanent housing for clients of the Rapid Rehousing Path. Clients who are geared toward the Shelter Path will be considered having a successful outplacement after transition into participating shelter program that will provide further assistance for successful outplacement. Clients who will be served through the Hotel/Motel Placement program are households with any of the following configurations: parent(s)w/minor children,transgendered individuals, the chronically homeless or vulnerable populations as identified by the CoC having a VI-SPIDAT score of 10 or higher. Those who are in need of more intensive care assistance will be tracked for Shelter Path assistance and those who have a source of income will be evaluated for Rapid Rehousing Path assistance. Clients must maintain daily contact with their counselors and abide by Hotel/Motel guidelines i.e. rules and responsibilities while in placement to maintain active status in the program. Discharge from the program for those who are identified as Shelter Path clients will occur when a shelter placement becomes available. Discharges from the Rapid Rehousing Path will occur upon successful completion of the program with entry into permanent housing. Voluntary termination occurs with a voluntary refusal or abandonment of the placement or,termination from the program for failure to comply with the action plan or agreed upon guidelines, termination standards cross both categories of program. Clients in the Hotel/Motel Program will receive Care Coordination inclusive of an entry assessment to identify assets,needs, and outline terms of service with benchmarks for client progress and will determine which program path will be appropriate. Shelter Path clients will receive daily check-ins from the attending Case Worker along with the provision of food assistance in the form of gift cards. Rapid Rehousing Path clients will participate in a comprehensive family support-guided assessment by the City contracted partnering agency providing Care Coordination. Daily check-ins by the Care Coordinator will be conducted for the purpose of counseling, referrals, and general needs along with the provision of food cards for daily meals. Furthermore, assistance with relocation leads will be provided requiring client follow-up. Upon the attainment of a binding contract for apartment lease, funding for rental relocation will be provided in the form of a check to the landlord in the amount of security deposit, first month's rent, and last month's rent. Deposits for utilities will also be provided on behalf of the client directly to the utility company along with a Publix food card for the acquisition of groceries. The City will work with community providers to ensure that key household goods (i.e.beds,tables, housewares) are obtained. 2 Hotel/Motel program participants will be assessed upon entry and will be advised for appropriate path placement. The initial assessment and interview will capture the client needs to ensure that the Case Worker provides appropriate guidance,referrals, and services. Those who are in the Rapid Rehousing Path will need to have at least one- income source upon entry into the program for qualification for the Rapid Rehousing component. Those with no sources of income will be directed toward the Shelter Path where assistance with employment referrals and temporary job placement assistance through collaborations with JCS and South Florida Workforce. Clients who do not qualify for Rapid Rehousing but receive assistance with Hotel/Motel emergency placement will transition to shelter placement for longer-term assistance with Care Coordination with the expected outcome of independent permanent self-sufficiency after a longer period of recovery and intervention. Any identified needs for increased income will be assessed and those persons referred to the appropriate program.Those who require entitlements assistance will be referred to partnering agencies like the Community Action Agency, Department of Children and Families, and our sister office, the Office of Community Services, to apply for benefits before entering shelter placement and during placement for entitlement access.. Hotel/Motel Program recipients who do not qualify for Rapid Rehousing and are awaiting space availability from a partnering shelter will receive an initial assessment from the Outreach Team that will serve as an action plan for the first seven days while placement services remain pending.Upon placement into an emergency shelter,the Client will be reevaluated by the shelter. Hotel/Motel Program Recipients who qualify for Rapid Rehousing will begin receiving immediate assistance and will be contacted the next business day to begin services. The proposed timeline for the project is to begin implementation on October 1, 2015 in conjunction with the City fiscal year. Contra ct s a n d/o r MO A's w ith partnering agencies will be in.place in advance of the date to begin providing services as needed immediately to individuals in need within the City. Hotel/Motel program clients who qualify for the Rapid Rehousing component will have an expected 15-20 day turnaround for placement. Clients who will be assisted through Hotel/Motel while awaiting placement at a shelter facility will have an expected 1-7 day turnaround. 3 ATTACHMENTA PROJECT SUMMARY MIAMI-DADS COUNTY HOMELESS TRUST Agency: City of Miami Beach • Director: Maria L. Ruiz Address: 1700 Convention Center Drive, Miami Beach, Fl. 33139 Phone: 305-604-4663 Fax: 305-604-2421 • Email: mariaruizmiamibeachfl.gov Project Name: Hotel/ Motel Placement Project Address: 555-17th Street, Miami Beach, Fl. 33139 Is this Project currently funded by F&B: X Yes ❑ No Type of Project: X Emergency Housing ❑ Permanent Supportive Housing Target Population Served: ❑ Supportive Services Type: ❑ Transitional Housing Target Population served: Program Description: The City of Miami Beach has 24 hour emergency response for homeless families with minor children and vulnerable populations within our jurisdiction. The services for Hotel/Motel Placement are for those who fall under this category when traditional shelter services cannot be provided. In keeping with HUD's priorities for 2014-2015, comprehensive support will be made available to these households who receive hotel /motel placement via Care Coordination which involves assessment, daily check-ins, food expenses, and shelter; or, rapid-rehousing, for eligible participants. Goals & Objectives: The objective of the 2015 City of Miami Beach participation in the Hotel/Motel Placement Program is to provide services to individuals who are in need of immediate assistance when traditional shelter placement is not available. Our goal is for 70% of the program participants to transition into permanent housing through either Rapid Rehousing in 1-15 days; or, subsequent permanent housing via shelter leading to successful outplacement over a period of 90-120 days. ATTACHMENT B City of Miami Beach/HMIS Staffing HMIS Staffing Grant Budget 1 HMIS Administrator Annual Salary $42,719.30 HMIS Staffing Grant Amount** $12,333.00 **This amount represent a portion of the annual salary per this contract agreement 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, "a M M Y L. M orA U5 ,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): 5c1 - GQoo 3 --2 Federal Employer Identification Number(If none, Social Security) a -ri oT MIAMI E AGN Name of Entity,Individual(s),Partners,or Corporation Doing Business As(if same as above,leave blank) -oo CONVENT I pawl GerVi-ET DR M AM I 6E-Act �L.. 33+3ci 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 N/A 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. )C 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 department 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? X Yes No b. Does your firm provide paid health care benefits for its employees? X 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:‘3C1 3 Males:2 Female: 10 Black: 446 Males:28 5 Female:]Z U NKt•O W N Hispanic: 1126 Males:g 12 Female:31 14 Asian: 16 Males: Female: 5 American Native: 2- Males: 2. Female: Aleut(Eskimo): 640 Males:a Female: rvN kry ovv N; r-1 : 3 1= 2.3 3. X 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 Firm 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. X 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. )C 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_Lhas not s 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. )A 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 firm's policy of maintaining a drug-free environment at all workplaces availability of drug counseling,rehabilitation and employee assistance programs penalties that may be imposed upon employees for drug abuse violations The person or entity shall also require an employee to sign a statement,as a condition of employment that the employee will abide by the terms and notify the employer of any criminal drug conviction occurring no later than five(5)days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Compliance with Ordinance No. 92-15 may be waived if the special characteristics of the product or service offered by the person or entity make it necessary for the operation of the County or for the health,safety,welfare,economic benefits and well-being of the public. Contracts involving funding which is provided in whole or in part by the United States or the State of Florida shall be exempted from the provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental entities. 6. X 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 — —=r-etal-iation. 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. X . 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. X 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. X 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. X 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 f 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: \."5- CtaitEN4 SEA 2 2 , 20 15 Signa e of I Witnes• "-ill or Secret. e ' ' _ .to :I ORP ORATED: .%W V.• (ol AAA -•. C:TJ tee/ Signa e of Af ant •/'IN.CH .....6" S Federal Employer Identification Number C crl Oc MIAMi BEADN Printed ame of Affiant and Name of Agency I C c:gvvOWTI Ov G --r∎i-r i•Z D i n e V • MI P 4 I C3EAc. , IZ1_ 331,3(1 Address of Agency SUBSCRIBED AND SWORN TO (or affirmed) before me this day of Dec , 20 /c He/She is personally known to me or has presented as identification. Type of identification / / is ature of Notary Serial Number �,1-145/"QL, Ql6k7s0 C--/e-I8 Print or Stamp Name of Notary Expiration Date Notary Public— State of County of W'1 ra 14 - 1)4q Notary Seal ��..........,, DINORAH ALONSO Aso `e`�:% Notary Public-State of FiorW,. •; ; My Comm.Expires Sep 18,201; Commission#FF 125324 ''�•�°;� Bonded Through National Notary Assn ATTACHMENT C "Miami-Dade County Required Affidavits" Page 5 of 5 • ATTACHMENT D "This Attachment Is Not Applicable To This Grant Agreement" ATTACHMENT E Miami-Dade County Homeless Trust Invoice For Services NAME OF AGENCY: The City of Miami Beach SERVICE PERIOD: TO NAME OF GRANT: HNIIS Staffing Program GRANT NUMBER: PC-1516-STAFF-2 TOTAL AWARD AMOUNT: $12,333.00 AMOUNT OF FUNDS REQUESTED THIS MONTH: $ AMOUNT OF FUNDS RECEIVED TO DATE: $ BALANCE REMAINING ON GRANT: $ (following payment of this request) Signature of Authorized Agency Representative Date Printed Name of Authorized Agency Representative ATTACHMENT E Miami-Dade County Homeless Trust Invoice For Services NAME OF AGENCY: The City of Miami Beach SERVICE PERIOD: TO NAME OF GRANT: Emergency Hotel/Motel Placement Program GRANT NUMBER: PC-1516-HTMT-3 TOTAL AWARD AMOUNT: $10,000.00 AMOUNT OF FUNDS REQUESTED THIS MONTH: $ AMOUNT OF FUNDS RECEIVED TO DATE:. $ BALANCE REMAINING ON GRANT: $ (following payment of this request) Signature of Authorized Agency Representative e Date Printed Name of Authorized Agency Representative ATTACHMENT F "This Attachment Is Not Applicable To This Grant Agreement" ATTACHMENT G "This Attachment Is Not Applicable To This Grant Agreement" ATTACHMENT H 7.. implementation Work Plan, PROJECT GOAL STATEMENT:To provide short term hotel placement for homeless families with minor children and transgendered individuals who cannot be placed into emergency shelter due to capacity issues until shelter space or an alternate type of housing option becomes available. OUTCOME#1: Homeless transgendered individuals and families will be assessed by outreach teams and placed in hotels when appropriate. Outcome#1 Work Plan •Transgendered individuals/families will be HMIS Homeless assessed by the City of Miami Beach Assessment As required Outreach Homeless Outreach Team(HOT) Team Contact homeless shelters for available When contact is made with Homeless beds family. Outreach Team HOT will transport and make placement into • When contact is made with Homeless appropriate hotel based on client needs - HMIS Service • individuallfamily needing Outreach assessment hotel placement Team • Copy of gift card s eleses Client will be provided food voucher when and receipt As needed Homeless needed signed by the Team client Homeless Families will be contacted daily HMIS Service Daily Outreach Team OUTCOME#2: Homeless transgendered individuals and families placed in hotels will be referred to various housing providers. Outcome#2 Work Plan ......... .... ....... . ... HMIS Referral Families will be referred to Chapman Hotel Within.24 hours of initial Homeless Case Management Program Client File assessment Outreach Documentation Team Families and individuals will be referred to Within 24 hours of initial Homeless various housing providers within the HMIS Referral assessment Outreach continuum of care Team OUTCOME#3:All homeless transgendered individuals&families will be placed in housing. Outcome#3 Work Plan :f3a 1`� � - ttvities :'..... ...:-::' . . ......- :..: _. ::;.,,•.:-::-:::::::°: ::-:: .:�-:� Once accepted into Homeless Clients will be transported to next housing HMIS Outreach placement placement Team • 5. Performance Measures Expected Outcomes Indicators Homeless transgendered individuals and A 100%of transgendered individuals and families will be assessed by outreach teams families will be assessed as and placed in hotels when appropriate. demonstrated in HMIS. • 100%of families will be referred to Chapman Partnership's Hotel Case Homeless transgendered individuals and Management Program as demonstrated by HMIS referrals. families will be referred to various housing providers 0 100% of families and individuals will be referred to various housing providers • within the continuum of care • 95% of transgendered individuals and families will enter into emergency shelter. Homeless transgendered individuals &families • 5%of transgendered individuals and will be placed in housing. families will enter into transitional or permanent housing. • ATTACHMENT I "This Attachment Is Not Applicable To This Grant Agreement" "This Attachment Is Not Applicable To This Grant Agreement" ATTACHMENT K "This Attachment Is Not Applicable To This Grant Agreement" ATTACHMENT L MIAMI-DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT ITNIIS STAFFING PROGRAM CITY OF MIAMI BEACH-GRANT NUMBER#: PC-1516-HNIIS-2 OCTOBER 1,2015—SEPTEMBER 30,2016 Name of Agency: The City of Miami Beach $ 12,333.00 Month of Services Amount Paid Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Total Requested $ 0.00 Balance Remaining $ 12,333.00 ATTACHMENT L MIAMI-DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT HOTEL/MOTEL PLACEMENT PROGRAM CITY OF MIAMI BEACH-GRANT NUMBER#: PC-1516-HTMT-2 OCTOBER 1,2015—SEPTEMBER 30,2016 Name of Agency: The City of Miami Beach $ 10,000.00. Month of Services Amount Paid Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Total Requested $ 0.00 Balance Remaining $ 10,000.00 ATTACHMENT M • Form W-9 Request for Taxpayer Give Form to the (Rev.December 2014) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. Ct-r-y Co N.4 AN 6EAC� N 2 Business name/disregarded entity name,if different from above a) cu Ca a- 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to ° ❑Individual/sole proprietor or ❑ C Corporation certain entities,not individuals;see p ❑ S Corporation ❑ Partnership ❑Trust/estate instructions on page 3): cu c single-member LLC a o Exempt payee code(if any) ❑Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► p 2 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting w the tax classification of the single-member owner. code(if any) ▪ c Q. 0 n Other(see instructions)► (Applies to accounts maintained outside the U.S.) :E 5 Address(number,street,and apt.or suite no.) Requester's name.and address(optional) 0 a 3-ac) aor vEnITI oNi CENTER C'g IVE a) 6 City,state,and ZIP code n MsAM1 f3tACN , F=L- 33i34 7 List account number(s)here(optional) Part I Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number 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. or Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number guidelines on whose number to enter. 59 - G00034- 2 Part II 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. 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 dividend on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured prop rty,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than inter t and dividends,yo are not required to sign the certification,but you must provide your correct TIN.See the instructions on page 3. Sign Signature of Here U.S.person► Date► 24 Z General Instructions •Form 1098(home mortgage-interest),1098-E(student loan interest),1098-T (tuition) Section references are to the Internal Reven e Code unless otherwise noted. •Form 1099-C(canceled debt) • Future developments.Information about d elopments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property) as legislation enacted after we release it)is a www.irs.gov/fw9. Use Form W-9 only if you are a U.S.person(including a resident alien),to Purpose of Form provide your correct TIN. An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject ' return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2. which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you: number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number identification number(EIN),to report on an information return the amount paid to to be issued), you,or other amount reportable on an information return.Examples of information returns include,but are not limited to,the following: . 2.Certify that you are not subject to backup withholding,or •Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If •Form 1099-DIV(dividends,including those from stocks or mutual funds) 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 •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and •Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on •Form 1099-S(proceeds from real estate transactions) page 2 for further information. •Form 1099-K(merchant card and third party network transactions) 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 3.The IRS tells the requester that you furnished an incorrect TIN, W-9 to request your TIN,you must use the requester's form if it is substantially 4.The IRS tells you that you are subject to backup withholding because you did similar to this Form W-9. • not report all your interest and dividends on your tax return(for reportable interest Definition of a U.S.person.For federal tax purposes,you are considered a U.S. and dividends only),or person if you are: 5.You do not certify to the requester that you are not subject to backup •An individual who is a U.S.citizen or U.S.resident alien; withholding under 4 above(for reportable interest and dividend accounts opened •A partnership,corporation,company,or association created or organized in the after 1983 only). United States or under the laws of the United States; Certain payees and payments are exempt from backup withholding.See Exempt •An estate(other than a foreign estate);or payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information. . •A domestic trust(as defined in Regulations section 301.7701-7). Also see Special rules for partnerships above. 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 What is FATCA reporting? 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 Foreign Account Tax Compliance Act(FATCA)requires a participating foreign the rules under section 1446 require a partnership to presume that a partner is a financial institution to report all United States account holders that are specified foreign person,and pay the section 1446 withholding tax.Therefore,if you are a United States persons.Certain payees are exempt from FATCA reporting.See U.S.person that is a partner in a partnership conducting a trade or business in the Exemption from FATCA reporting code on page 3 and the Instructions for the United States,provide Form W-9 to the partnership to establish your U.S.status Requester of Form W-9 for more information. 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 Updating Your Information for purposes of establishing its U.S.status and avoiding withholding on its You must provide updated information to any person to whom you claimed to be allocable share of net income from the partnership conducting a trade or business an exempt payee if you are no longer an exempt payee and anticipate receiving • in the United States: reportable payments in the future from this person.For example,you may need to •In the case of a disregarded entity with a U.S.owner,the U.S.owner of the provide updated information if you are a C corporation that elects to be an S disregarded entity and not the entity; 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 •In the case of a grantor trust with a U.S.grantor or other U.S.owner,generally, of a grantor trust dies. 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 Penalties . grantor trust)and not the beneficiaries of the trust. Failure to furnish TIN.If you fail to furnish your correct TIN to a requester,you are Foreign person.If you are a foreign person or the U.S.branch of a foreign bank subject to a penalty of$50 for each such failure unless your failure is due to that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use reasonable cause and not to willful neglect. the appropriate Form W-8 or Form 8233(see Publication 515,Withholding of Tax Civil penalty for false information with respect to withholding.If you make a on Nonresident Aliens and Foreign Entities). false statement with no reasonable basis that results in no backup withholding, Nonresident alien who becomes a resident alien.Generally,only a nonresident you are subject to a$500 penalty. alien individual may use the terms of a tax treaty to reduce or eliminate U.S.tax on Criminal penalty for falsifying information.Willfully falsifying certifications or certain types of income.However,most tax treaties contain a provision known as affirmations may subject you to criminal penalties including fines and/or a"saving clause."Exceptions specified in the saving clause may permit an imprisonment. 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. Misuse of TINs.If the requester discloses or uses TINs in violation of federal law, If you are a U.S.resident alien who is relying on an exception contained in the the requester may be subject to civil and criminal penalties. 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 Specific Instructions • five items: . 1.The treaty country.Generally,this must be the same treaty under which you Line 1 claimed exemption from tax as a nonresident alien. You must enter one of the following on this line;do not leave this line blank.The 2.The treaty article addressing the income. name should match the name on your tax return. 3.The article number(or location)in the tax treaty that contains the saving If this Form W-9 is for a joint account,list first,and then circle,the name of the clause and its exceptions. person or entity whose number you entered in Part I of Form W-9. 4.The type and amount of income that qualifies for the exemption from tax. 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) 5.Sufficient facts to justify the exemption from tax under the terms of the treaty of the name change,enter your first name,the last name as shown on your social article. security card,and your new last name. Example.Article 20 of the U.S.-China income tax treaty allows an exemption Note.ITIN applicant Enter your individual name as it was entered on your Form from tax for scholarship income received by a Chinese student temporarily present W-7 application,line la.This should also be the same as the name you entered on in the United States.Under U.S.law,this student will become a resident alien for the Form 1040/1040A11040EZ you filed with your application. tax 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, b. Sole proprietor or single-member LLC.Enter your individual name as 1984)allows the provisions of Article 20 to continue to apply even after the shown on your 1040/1040A11040EZ on line 1.You may enter your business,trade, Chinese student becomes a resident alien of the United States.A Chinese student or"doing business as"(DBA)name on line 2. who qualifies for this exception(under paragraph 2 of the first protocol)and is c. Partnership,LLC that is not a single-member LLC,C Corporation,or S relying on this exception to claim an exemption from tax on his or her scholarship Corporation.Enter the entity's name as shown on the entity's tax return on line 1 or fellowship income would attach to Form W-9 a statement that includes the and any business,trade,or DBA name on line 2. information described above to support that exemption. d. Other entities.Enter your name as shown on required U.S.federal tax If you are a nonresident alien or a foreign entity,give the requester the documents on line 1.This name should match the name shown on the charter or appropriate completed Form W-8 or Form 8233. other legal document creating the entity.You may enter any business,trade,or DBA name on line 2. Backup Withholding e. Disregarded entity.For U.S.federal tax purposes,an entity that is What is backup withholding?Persons making certain payments to you must disregarded as an entity separate from its owner is treated as a"disregarded under certain conditions withhold and pay to the IRS 28%of such payments.This entity." See Regulations section 301.7701-2(c)(2)(iii).Enter the owner's name on is called"backup withholding." Payments that may be subject to backup line 1.The name of the entity entered on line 1 should never be a disregarded withholding include interest,tax-exempt interest,dividends,broker and barter entity.The name on line 1 should be the name shown on the income tax return on exchange transactions,rents,royalties,nonemployee pay,payments made in which the income should be reported.For example,if a foreign LLC that is treated settlement of payment card and third party network transactions,and certain as a disregarded entity for U.S.federal tax purposes has a single owner that is a payments from fishing boat operators.Real estate transactions are not subject to U.S.person,the U.S.owner's name is required to be provided on line 1.If the backup withholding. direct owner of the entity is also a disregarded entity,enter the first owner that is You will not be subject to backup withholding on payments you receive if you not disregarded for federal tax purposes.Enter the disregarded entity's name on give the requester your correct TIN,make the proper certifications,and report all line 2, Business name/disregarded entity name. If the owner of the disregarded your taxable interest and dividends on your tax return. 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. Payments you receive will be subject to backup withholding it 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), I Form W-9(Rev.12-2014) Page 3 Line 2 2 However,the following payments made to a corporation and reportable on Form If you have a business name,trade name,DBA name,or disregarded entity name, 1099-MISC are not exempt from backup withholding:medical and health care you may enter it on line 2. payments,attorneys'fees,gross proceeds paid to an.attorney reportable under section 6045(f),and payments for services paid by a federal executive agency. Line 3 Exemption from FATCA reporting code.The following codes identify payees Check the appropriate box in line 3 for the U.S.federal tax classification of the that are exempt from reporting under FATCA.These codes apply to persons person whose name is entered on line 1.Check only one box in line 3. submitting this form for accounts maintained outside of the United States by Limited Liability Company(LLC).If the name on line 1 is an LLC treated as a certain foreign financial institutions.Therefore,if you are only submitting this form partnership for U.S.federal tax purposes,check the"Limited Liability Company" C for Consult account you person hold in requesting United ng t States,you may leave this field blank. box and enter"P"in the space provided.If the LLC has filed Form 8832 or 2553 to Consult with the person rese requi tmenorm if requ are uncertain ay indicate if the financial be taxed as a corporation,check the"Limited Liability Company"box and in the institution is by providing to these with a Form A 9 with"Not may lic ble"(oat a code is space provided enter"C"for C corporation or"S"for S corporation.If it is a not required indication)ti prwrit e g yep with a Form li 9 with"Not Applicable code. any single-member LLC that is a disregarded entity,do not check the"Limited Liability similar indication)written or printed on the line for a FATCA exemption code. Company"box;instead check the first box in line 3"Individual/sole proprietor or A—An organization exempt from tax under section 501(a)or any individual single-member LLC." retirement plan as defined in section 7701(a)(37) Line 4, Exemptions B—The United States or any of its agencies or instrumentalities If you are exempt from backup withholding and/or FATCA reporting,enter in the C—A state,the District of Columbia,a U.S.commonwealth or possession,or any of their political subdivisions or instrumentalities appropriate space in line 4 any code(s)that may apply to you. •Exempt payee code. D—A corporation the stock of which is regularly traded on one or more established securities markets,as described in Regulations section • Generally,individuals(including sole proprietors)are not exempt from backup 1.1472-1(c)(1)(i) withholding. E—A corporation that is a member of the same expanded affiliated group as a • Except as provided below,corporations are exempt from backup withholding corporation described in Regulations section 1.1472-1(c)(1)(i) for certain payments,including interest and dividends. F—A dealer in securities,commodities,or derivative financial instruments • Corporations are not exempt from backup withholding for payments made in (including notional principal contracts,futures,forwards,and options)that is settlement of payment card or third party network transactions. registered as such under the laws of the United States or any state • Corporations are not exempt from backup withholding with respect to attorneys' G—A real estate investment trust . fees or gross proceeds paid to attorneys,and corporations that provide medical or H—A regulated investment company as defined in section 851 or an entity health care services are not exempt with respect to payments reportable on Form registered at all times during the tax year under the Investment Company Act of 1099-MISC. 1940 The following codes identify payees that are exempt from backup withholding. I—A common trust fund as defined in section 584(a) Enter the appropriate code in the space in line 4. 1—An organization exempt from tax under section 501(a),any IRA,or a J—A bank as defined in section 581 custodial account under section 403(b)(7)if the account satisfies the requirements K—A broker of section 401(f)(2) L—A trust exempt from tax under section 664 or described in section 4947(a)(1) 2—The United States or any of its agencies or instrumentalities M—A tax exempt trust under a section 403(b)plan or section 457(g)plan 3—A state,the District of Columbia,a U.S.commonwealth or possession,or Note.You may wish to consult with the financial institution requesting this form to any of their political subdivisions or instrumentalities determine whether the FATCA code and/or exempt payee code should be 4—A foreign government or any of its political subdivisions,agencies,or completed. instrumentalities Line 5 5—A corporation • 6—A dealer in securities or commodities required to register in the United Enter your address(number,street,and apartment or suite number).This is where States,the District of Columbia,or a U.S.commonwealth or possession the requester of this Form W-9 will mail your information returns. 7—A futures commission merchant registered with the Commodity Futures Line 6 Trading Commission Enter your city,state,and ZIP code. 8—A real estate investment trust 9—An entity registered at all times during the tax year under the Investment Part I.Taxpayer Identification Number(TIN) Company Act of 1940 Enter your TIN in the appropriate box.If you are a resident alien and you do not 10—A common trust fund operated by a bank under section 584(a) have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer 11—A financial institution 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. 12—A middleman known in the investment community as a nominee or If you are a sole proprietor and you have an EIN,you may enter either your SSN custodian or.EIN.However,the IRS prefers that you use your SSN. 13—A trust exempt from tax under section 664 or described in section 4947 If you are a single-member LLC that is disregarded as an entity separate from its The following chart shows types of payments that may be exempt from backup owner(see Limited Liability Company(LLC)on this page),enter the owner's SSN withholding.The chart applies to the exempt payees listed above,1 through 13. (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. IF the payment is for... THEN the payment is exempt for... Note.See the chart on page 4 for further clarification of name and TIN combinations. Interest and dividend payments All exempt payees except How to get a TIN.If you do not have a TIN,apply for one immediately.To apply for 7 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 Broker transactions Exempt payees 1 through 4 and 6 calling 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer through 11 and all C corporations.S Identification Number,to apply for an ITIN,or Form SS-4,Application for Employer corporations must not enter an exempt Identification Number,to apply for an EIN.You can apply for an EIN online by payee code because they are exempt accessing the IRS website at www.irs.gov/businesses and clicking on Employer only for sales of noncovered securities Identification Number(EIN)under Starting a Business.You can get Forms W-7 and acquired prior to 2012. SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676). • Barter exchange transactions and Exempt payees 1 through 4 If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN patronage dividends and write"Applied For"in the space for the TIN,sign and date the form,and give it Payments over$600 required to be Generally,exempt payees to the requester.For interest and dividend payments,and certain payments made i 2 with respect to readily tradable instruments,generally you will have 60 days to get reported and direct sales over$5,000 1 through 5 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 Payments made in settlement of Exempt payees 1 through 4 subject to backup withholding on all such payments until you provide your TIN to payment card or third party network the requester. transactions Note.Entering"Applied For"means that you have already applied for a TIN or that 1 See Form 1099-MISC,Miscellaneous Income,and its instructions. 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. r Form W-9(Rev.12-2014) Page 4 Part II.Certification 'You 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(if you To establish to the withholding agent that you are a U.S.person,or resident alien, have one),but the IRS encourages you to use your SSN. sign Form W-9.You may be requested to sign by the withholding agent even if items 1,4,or 5 below indicate otherwise. `List first and circle the name of the trust,estate,or pension trust.(Do not fumish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account For a joint account,only the person whose TIN is shown in Part I should sign title.)Also see Special rules for partnerships on page 2. (when required).In the case of a disregarded entity,the person identified on line 1 *Note.Grantor also must provide a Form W-9 to trustee of trust must sign.Exempt payees,see Exempt payee code earlier. Note.If no name is circled when more than one name is listed,the number will be Signature requirements.Complete the certification as indicated in items 1 considered to be that of the first name listed. through 5 below. • 1.Interest,dividend,and barter exchange accounts opened before 1984 Secure Your Tax Records from Identity Theft and broker accounts considered active during 1983.You must give your Identity theft occurs when someone uses your personal information such as your correct TIN,but you do not have to sign the certification. name,SSN,or other identifying information,without your permission,to commit 2.Interest,dividend,broker,and barter exchange accounts opened after fraud or other crimes.An identity thief may use your SSN to get a job or may file a 1983 and broker accounts considered inactive during 1983.You must sign the tax return using your SSN to receive a refund. certification or backup withholding will apply.If you are subject to backup To reduce your risk: withholding and you are merely providing your correct TIN to the requester,you •Protect your SSN, • 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 •Ensure your employer is protecting your SSN,and item 2 of the certification. •Be careful when choosing a tax preparer. 4.Other payments.You must give your correct TIN,but you do not have to sign If your tax records are affected by identity theft and you receive a notice from the certification unless you have been notified that you have previously given an the IRS,respond right away to the name and phone number printed on the IRS incorrect TIN."Other payments"include payments made in the course of the notice or letter. requester's trade or business for rents,royalties,goods(other than bills for If your tax records are not currently affected by identity theft but you think you merchandise),medical and health care services(including payments to are at risk due to a lost or stolen purse or wallet,questionable credit card activity corporations),payments to a nonemployee for services,payments made in or credit report,contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit settlement of payment card and third party network transactions,payments to Form 14039. certain fishing boat crew members and fishermen,and gross proceeds paid to For more information,see Publication 4535,Identity Theft Prevention and Victim attorneys(including payments to corporations). Assistance. 5.Mortgage interest paid by you,acquisition or abandonment of secured Victims of identity theft who are experiencing economic harm or a system property,cancellation of debt,qualified tuition program payments(under problem,or are seeking help in resolving tax problems that have not been resolved section 529),IRA,Coverdell ESA,Archer MSA or HSA contributions or through normal channels,may be eligible for Taxpayer Advocate Service(TAS) distributions,and pension distributions.You must give your correct TIN,but you assistance.You can reach TAS by calling the TAS toll free case intake line at do not have to sign the certification. 1-877-777-4778 or TTY/TDD 1-800-829-4059. What Name and Number To Give the Requester Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business For this type of account Give name and SSN of: 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 1.Individual The individual into surrendering private information that will be used for identity theft. 2.Two or more individuals(joint The actual owner of the account or, The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does account) if combined funds,the first • individual on the account' not request personal detailed information through email or ask taxpayers for the PIN numbers,passwords,or similar secret access information for their credit card, 3.Custodian account of a minor The minor" bank,or other financial accounts. (Uniform Gift to Minors Act) If you receive an unsolicited email claiming to be from the IRS,forward this 4.a.The usual revocable savings The grantor-trustee' message to phishing@irs.gov.You may also report misuse of the IRS name,logo, trust(grantor is also trustee) or other IRS property to the Treasury Inspector General for Tax Administration b.So-called trust account that is The actual owner' (TIGTA)at 1-800-366-4484.You can forward suspicious emails to the Federal not a legal or valid trust under Trade Commission at:spam @uce.gov or contact them at www.ftc.gov/idtheft or state law 1-877-IDTHEFT(1-877-438-4338). 5.Sole proprietorship or disregarded The owner" Visit IRS.gov to learn more about identity theft and how to reduce your risk. entity owned by an individual 6.Grantor trust filing under Optional The grantor" Privacy Act Notice Form 1099 Filing Method 1(see Regulations section 1.671-4(b)(2)(i) Section 6109 of the Internal Revenue Code requires you to provide your correct (A)) • 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 For this type of account Give name and EIN of you;mortgage interest you paid;the acquisition or abandonment of secured 7.Disregarded entity not owned by an The owner property;the cancellation of debt;or contributions you made to an IRA,Archer individual MSA,or HSA.The person collecting this form uses the information on the form to 8.A valid trust,estate,or pension trust Legal entity° file information returns with the IRS,reporting the above information.Routine uses of this information include giving it to the Department of Justice for civil and 9.Corporation or LLC electing The corporation criminal litigation and to cities,states,the District of Columbia,and U.S. corporate status on Form 8832 or commonwealths and possessions for use in administering their laws.The Form 2553 information also may be disclosed to other countries under a treaty,to federal and 10.Association,club,religious, The organization state agencies to enforce civil and criminal laws,or to federal law enforcement and . charitable,educational,or other tax- intelligence agencies to combat terrorism.You must provide your TIN whether or exempt organization not you are required to file a tax return.Under section 3406,payers must generally 11.Partnership or multi member LLC The partnership 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 12.A broker or registered nominee The broker or nominee providing false or fraudulent information. 13.Account with the Department of The public entity • Agriculture in the name of a public entity(such as a state or local government,school district,or prison)that receives agricultural program payments 14.Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2(see Regulations section 1.671-4(b)(2)(i) (B)) 'List first and circle the name of the person whose number you furnish.If only one person on a joint account has an SSN,that person's number must be furnished. 2 Circle the minor's name and furnish the minor's SSN. • • HAM ® ATTACHMENT N COUNTY- INCIDENT REPORT IDENTIFYING INFORMATION Reporting Party Phone# Date of Incident`/ ! Time of Incident_amlprn Reporting Party Name Contract Provider Name Program Name Provider.Location . Specific Program(check all that apply) ❑ HT 0 Primary Care ❑ SHP ❑l Emergency ❑ Challenge Specific location address where incident occurred: TYPE OF INcip NT ❑ALTERCATION ❑ CLIENT DEATH ® CLIENT INJURY OR ILLNESS ❑ THEFT ❑ SEXUAL BATTERY ❑ SWCIDE ATTEMPT 0 PROPERTY DAMAGE 0 OTHER INCIDENT Specify PARTICIPANT(S)!WitNESS(ES) (Please mark W or P for either Witness or Participant) LAST NAME,FIRST IDENTIFIER# CLIENT EMPLOYEE OTHER W I P ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ Q I of M '' • COUNTY DESCRIPTION INCIDENT Give detailed account—who,w had where,whe n,why,haw— add pages if necessary CORRECTWE 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 person contacted,if report was accepted,the date and the time,and ifby telephone or if copy • available. Y PY of report 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 mast 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_ 2 of 3 MIAM P.-i ' . - MIOT 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,at 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. An allegation of sexual battery by a client on a client,employee on a client,or client on an em ployee as evidenced by medical evidence or law enforcement involvement. f. Suicide Attempt An act which clearly reflects the physical attempt by a client in 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 property procured with Homeless Trust funding. Print Name of Person Submitting Report Signature • 3 of 3 in $ > = o �a, t °' 0 a` 0 c , Q 0 CO `0 0. Z D U a du 2 o u '' Q ° g. 0 ° Q ...I a d en ea s E u L c 0 0. U- 4. C 0 U1 CO N D c I- r 0 w -0 w z w Z O > = Z C 0 I_ w 0 N - Z N Q u O O W Q U W o 0 0 Q > O O C� a. .a a) G r+cu Q . Q 0 a 0 0. 0 C CO E Da 3 N Z v, N ea ca .` _ d u e/, 'i o. ea 0 V. vi u • i .L 0.2 u �0 to (13 7O a_ o C z z N 40 C L ++ u to 'a cfl C e` 0. • L- O .- • Q 0 0 C Q. in * a_ a. u GC 0 1 ATTACHMENT P J. MIAMI DADE COUNTY HOMELESS TRUST _ CLIENT SERVICES CERTIFICATION REFERRAL FORM FOR EMPLOYEES OF HOMELESS TRUST FUNDED-PROGRAMS - INSTRUCTIONS: Provider making referral must complete this two-page form,inciudin�signatures by Applicant and Provider Representatives. Fax completed forms to Provider Receiving Referral for • Housing and Or Services. Date: - • Referring-Provider: . Contact Person: . . Nave Title • • Phone Number INFORMATION ON HEAD OF HOUSEHOLD: _ . Last Name: First Name: Date of Birth: SS#: • . • INFORMATION ON OTHER HOUSEHOLD MEMBERS: • ( Name .j Age Sex _ Relationship ' . Employer I i. • • 1 IS AN Y MEMBER OF THE HOUSEHOLD EMPLOYED RN,OR RELATED TO AN EMPLOYEE OF,A HOMELESS TRUST FUNDED PROORAM? Yes No w if yes: `' Name of Employee: . • Employing Provider: ' • Relationship to Applicant: CERTIFICATION • I.the undersi(rned.do hereby certify that the above-information provided by.mom,is'tne'and correct to the hest of my knowledge. Applicant's Name Si<_.nature: Date: Refer;inL Provider Authorized Representative Signature . • Date • Name: . 1 ill ATTACHMENT P PROVIDER RE-FERRAL FORM PAGE TWO oplicant's Name If the Applicant or a member of their household is an employee of the referring.provider,the. " approval of the Provider E;:ec&tive Director is hereby indicted by signature: . • Name/Title Date if the Applicant or a member of their household is'an employee of the provider where services will be rt- 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 Miarrii-Dade County Homeless Trust Chairperson - Date Miami-Dade County Homeless Trust Executive Director Date - ADDITIONAL HOUSEHOLD INFORMATION; There is the household livin.g now? (Facility name,exact address) • . Date of present homelessness: Explain the homeless situation,and what caused the current homelessness: • • • NOTE TO REFERRING PRO VIDER: PROVIDING THE ABOVE INFORIVIATION DOES NOT ENSURE APPROVAL FOR HOUSING OR OTHER SERVICES REQUESTED. A DETERMINATION WILL BE MADE FOLLOWING A COMPLETE ASSESSNfENT OF THE APPLICANT'S CASE. • • THIS SECTION FOR SERVICE PROVIDER STAFF USE ONLY: Meets Efi ihilrty Criteria:- YES NO • A'tzni.e'r f Provider-Sereeniirg Stiff.'.. _. • PLEASE MAINTAIN THE EXECUTED COPY OF THIS DOCUMENT IN THE-CLIENT FILE OF THE SERVICING PROVIDER AND PERSONNEL:FILE OF REFERRING PROVIDER. r.a LA.) -