Loading...
Amendment No. 2 to the Agreement with Miami-Dade County PC-1718-ID-241C( THE CITY OF MIAMI BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1718 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT # PC- 1718- STAFF -2 AMENDMENT #2 OF THE AGREEMENT BETWEEN MIAMI -DADE COUNTY AND THE CITY OF MIAMI BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1617- HTMT -3 HMIS STAFFING PROGRAM CONTRACT #: PC- 17].8- STAFF -2 THIS AMENDMENT #2 OF THE AGREEMENT (the "Agreement Amendment #2 ") is made as of by and between Miami -Dade County, through the Miami -Dade County Homeless Trust (the "County ") and The City of Miami Beach, (the "Provider), a recipient of grant funds to serve homeless individuals. WIT•ESSETH: WHEREAS, on January 19, 2016, the County and the Provider entered into a Grant Agreement ( "Agreement ") which provides funding for the provision of emergency housing and supportive services to homeless individuals and families in Miami -Dade County. WHEREAS, on March. 29, 2017, said Agreement was amended and extended for one (1) additional year (2016- 2017); and WHEREAS, the Agreement provides for certain rights and responsibilities of the County; and WHEREAS, the Agreement allows for amendments and extensions at the sole discretion of the County; and WHEREAS, the County is desirous of extending and amending the Agreement for one (1) additional year pursuant to the terms of the Agreement; NOW, THEREFORE, BE IT RESOLVED, for and consideration of the mutual agreements between the County and the Provider, which are set forth in this Amendment #2 of the Agreement, the receipt and sufficiency of which are acknowledged, the County and the Provider amend this Agreement as follows: ARTICLE I — Recitals The foregoing recitals are true and correct and constitute a part of this Amendment #2 of the Agreement. ARTICLE H — Amendments The Agreement is hereby amended as follows: Article 2 is replaced as follows: ARTICLE 2. AMOUNT PAYABLE. Subject to available funds, the maximum amount payable for services rendered under this contract shall not exceed: • HOTEL/MOTEL PLACEMENT PROGRAM $ 10,000.00 • HMIS STAFFING PROGRAM $ 12,333.00 TOTAL $ 22,333.00 THE CITY OF MIAMI BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1718 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT # PC- 1718- STAFF -2 Article 10 is replaced as follows: 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, color., religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age, ancestry, national origin, disability, gender identity, gender expression or actual or perceived status as a victim of domestic violence, dating violence or stalking; 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. §6141, 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. §1210 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 sew 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 fine 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 terur of any contract the Provider has with the County, such contract shall be voidable by the County, even if the Provider was not in violation at the time it submitted its affidavit. The Provider agrees that it is in compliance with the Domestic Violence Leave, codified as § 11A -60 et seq. of the Miami -Dade County Code, which requires an employer, who in the regular course of business has fifty (50) or more employees working in Miami -Dade County for each working day during each of twenty (20) or more calendar work weeks to provide domestic violence leave to its employees. Failure to comply with this local law may be grounds for voiding or terminating this Contract or for commencement of debarment proceedings against Provider. ARTICLE III — Ratification of the Agreement Other than expressly modified or amended herein, all other terms and conditions of the Agreement shall remain in full force and effect. SIGNATURES APPEAR ON THE FOLLOWING PAGE 3 THE CITY OF MIAMI BEACH HOTEL /MOTEL PLACEMENT PROGRAM PC- 1718 - HTMT -2 HMIS STAFFING PROGRAM PC- 1718- STAFF -2 THE CITY OF MIAMI BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM GRANT #: PC -1718- HTMT -2 The Provider agrees to provide emergency hotel /motel placement of homeless families, transgendered individuals, chronically homeless individuals or individuals who have a high vulnerability index score on an as- needed basis. Clients may be provided with food vouchers on an as- needed basis of up to $20.00 per person, per day. Reimbursement will only be made for properly documented disbursement of food vouchers. All reimbursement must be submitted to the County by the 10th day of each month following the month of service. All reimbursement requests must be approved by the County prior to the disbursement of funds. THE CITY OF MIAMI BEACH HMIS STAFFING GRANT #: PC- 171.8- STAFF -2 The Provider shall provide a dedicated HMIS Outreach staff person. The purpose of this staff position is to maintain data current in the HMIS and includes, but is not limited to input of client data upon intake, updates of client files, compilation of reports and entering 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 United States Depai tuient of Housing and Urban Development (HUD) Agreement between the City of Miami Beach and the Miami -Dade County Homeless Trust may result in the termination of this Agreement. PLEAS F, IN 1-i;RT AN UPDATED ATTACHMENT "B" BUDGN;T FOR THIi; 2017 -2018 GRANT YEAR NAME OF AGENCY: ATTACHMENT F Miami -Dade County Homeless Trust Invoice For Services The City of Miami Beach SERVICE PERIOD: TO NAME OF GRANT: GRANT NUMBER: TOTAL AWARD AMOUNT: AMOUNT OF FUNDS REQUESTED THIS MONTH: Emergency HotelJlVlotel Placement Program PC- 1718- HTMT -3 $ 10,000.00 AMOUNT OF FUNDS RECEIVED TO DATE: BALANCE REMAINING ON GRANT: $ (following the payment of this request) Signature of Executive Director or Date Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative APPROVED AS TO FORM & LANGUAGE & FOR EXECUTION City Attorney Dote ATTACHMENT L MIAMI -DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT ' HMIS STAFFING PROGRAM CITY OF MIAMI BEACH- GRANT NUMBER #: PC- 1718 - STAFF -2 OCTOBER 1, 2017 — SEPTEMBER. 30, 2018 Name of Agency: The City of Miami Beach $ 12,333.00 Month of Services Amount Paid Oct -17 Nov -17 Dec -17 Jan -18 Feb -18 Mar -18 Apr -18 May -18 Jun -18 Jul -18 Aug -18 Sep -18 Total Requested Balance Remaining 0.00 $ 12,333.00 THE CITY OF MIAMI BEACH EMERGENCY HOTEL /MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1718- HTMT -3 HMIS STAFFING PROGRAM CONTRACT # PC -1718- STAFF -2 AMENDMENT #2 OF THE AGREEMENT BETWEEN MIAMI-DADE COUNTY AND THE CITY OF MIAME BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1617 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT #: PC- 1718 - STAFF -2 THIS AMENDMENT #2 OF THE AGREEMENT (the "Agreement Amendment #2 ") is made as of by and. between Miami -Dade County, through the Miami -Dade County Homeless Trust (the "County ") and The City of Miami Beach, (the "Provider), a recipient of grant funds to serve homeless individuals. WITNESSETH: WHEREAS, on January 19, 2016, the County and. the Provider entered into a Grant Agreement ( "Agreement ") which provides funding for the provision of emergency housing and supportive services to homeless individuals and families in Miami -Dade County. WHEREAS, on March 29, 2017, said Agreement was amended and extended for one (1) additional year (2016- 2017); and WHEREAS, the Agreement provides for certain rights and responsibilities of the County; and WHEREAS, the Agreement allows for amendments and extensions at the sole discretion of the County; and. WHEREAS, the County is desirous of extending and amending the Agreement for one (1) additional year pursuant to the terms of the Agreement; NOW, THEREFORE, BE IT RESOLVED, for and consideration of the mutual agreements between the County and the Provider, which are set forth in this Amendment #2 of the Agreement, the receipt and . sufficiency of which are acknowledged, the County and the Provider amend. this Agreement as follows: ARTICLE I — Recitals The foregoing recitals are true and correct and constitute a part of this Amendment #2 of the Agreement. ARTICLE 11 — Amendments The Agreement is hereby amended as follows: Article 2 is replaced as follows: ARTICLE 2. AMOUNT PAYABLE. Subject to available funds, the maximum amount payable for services rendered under this contract shall not exceed: HOTEL/MOTEL PLACEMENT PROGRAM $ 10,000.00 • HMIS STAFFING PROGRAM $ 12333.00 TOTAL $ 22,333.00 THE CITY OF MIAMI BEACH EMERGENCY HOTEL /MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1718 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT # PC -1718- STAFF -2 Article 10 is replaced as follows: 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, color, religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age, ancestry, national origin, disability, gender identity, gender expression or actual or perceived status as a victim of domestic violence, dating violence or stalking; 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. §1014 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 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 III — Ratification of the Agreement Other than expressly modified or amended herein, all other terms and conditions of the Agreement shall remain in full force and effect. SIGNATURES APPEAR ON THE FOLLOWING PAGE 3 THE CITY OF MIAMI BEACH HOTEL /MOTEL PLACEMENT PROGRAM PC- 1718 - HTMT -2 HMIS STAFFING PROGRAM PC -1718- STAFF -2 THE CITY OF MIAMI BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM GRANT #: PC- 1718 - HTMT -2 The Provider agrees to provide emergency hotel/motel placement of homeless families, transgendered individuals, chronically homeless individuals or individuals who have a high vulnerability index score on an as-needed basis. Clients may be provided with food vouchers on an as- needed basis of up to $20.00 per person, per day. Reimbursement will only be made for properly documented disbursement of food vouchers. All reimbursement must be submitted to the County by the 10th day of each month following the month of service. All reimbursement requests must be approved by the County prior to the disbursement of funds. THE CITY OF MIANII. BEACH IIMJS STAFFING GRANT #: PC- 1718-STAFF -2 The Provider shall provide a dedicated HMIS Outreach staff person. The purpose of this staff position is to maintain data current in the HMIS and includes, but is not limited to input of client data upon intake, updates of client files, compilation of reports and entering 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 United States Department of Housing and Urban Development (HUD) Agreement between the City of Miami. Beach and the Miami -Dade County Homeless Trust may result in the termination of this Agreement. PLEASE INSERT AN UPDATIH,D ATTACHMENT "B" BUDGF,T FOR THE 2017-2018 GRANT YI-41,AR ATTACHMENT F Miami -Dade County Homeless Trust Invoice For Services NAME OF AGENCY: The City of Miami Beach SERVICE PERIOD: NAME OF GRANT: GRANT NUMBER: TOTAL AWARD AMOUNT: AMOUNT OF FUNDS REQUESTED THIS MONTH: AMOUNT OF FUNDS RECEIVED TO DATE: TO IIMIS Staffing Program PC- 1718- STAFF -2 $12,333.00 $ BALANCE REMAINING ON GRANT: $ (following payment of this request) Signature of Executive Director or Date Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative APPROVED AS TO FORM & LANGUAGE & FOR ECUTION C Attorney 3 -(A— Dates ATTACHMENT L MIAMI -DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT HMIS STAFFING PROGRAM CITY OF MIAMI: BEACH- GRANT NUMBER #: PC -1718- STAFF -2 OCTOBER 1, 2017 — SEPTEMBER 30, 2018 Name of Agency: The City of Miami Beach $ 12,333.00 Month of Services Amount Paid Oct -17 Nov -17 Dec -17 Jan -18 Feb -18 Mar -18 Apr -18 May -18 Jun -18 Jul -18 Aug -18 Sep -18 Total Requested Balance Remaining 0.00 $ 12,333.00 THE CITY OF MIAMI BEACH EMERGENCY HOTEL /MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1718 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT # PC- 1718- STAFF -2 AMENDMENT #2 OF THE AGREEMENT BETWEEN MIAMI -DADE COUNTY AND THE CITY OF MIAMI BEACH EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1617 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT #: PC- 1718- STAFF -2 THIS AMENDMENT #2 OF THE AGREEMENT (the "Agreement Amendment #2 ") is made as of by and between Miami -Dade County, through the Miami -Dade County Homeless Trust (the "County ") and The City of Miami Beach, (the "Provider), a recipient of grant funds to serve homeless individuals. WITNESSETH: WHEREAS, on January 19, 2016, the County and the Provider entered into a Grant Agreement ( "Agreement ") which provides funding for the provision of emergency housing and supportive services to homeless individuals and families in Miami -Dade County. WHEREAS, on March 29, 20] 7, said Agreement was amended and extended for one (1) additional year (2016- 2017); and WHEREAS, the Agreement provides for certain rights and responsibilities of the County; and WHEREAS, the Agreement allows for amendments and extensions at the sole discretion of the County; and WHEREAS, the County is desirous of extending and amending the Agreement for one (1) additional year pursuant to the terms of the Agreement; NOW, THEREFORE, BE IT RESOLVED, for and consideration of the mutual agreements between the County and the Provider, which are set forth in this .Amendment #2 of the Agreement, the receipt and sufficiency of which are acknowledged, the County and the Provider amend this Agreement as follows: ARTICLE I — Recitals The foregoing recitals are true and correct and constitute a part of this Amendment #2 of the Agreement. ARTICLE II Amendments The Agreement is hereby amended as follows: Article 2 is replaced as follows: ARTICLE 2. AMOUNT PAYABLE. Subject to available funds, the maximum amount payable for services rendered under this contract shall not exceed: • HOTEL/MOTEL PLACEMENT PROGRAM $ 10,000.00 • HMIS STAFFING PROGRAM $ 12,333.00 TOTAL $ 22,333.00 THE CITY OF MIAMI BEACH EMERGENCY HOTEL /MOTEL PLACEMENT PROGRAM CONTRACT #: PC- 1718 - HTMT -3 HMIS STAFFING PROGRAM CONTRACT # PC -1718- STAFF -2 Article 10 is replaced as follows: 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, color, religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age, ancestry, national origin, disability, gender identity, gender expression or actual or perceived status as a victim of domestic violence, dating violence or stalking; 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 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 § 1.1A -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 teiininating this Contract or for commencement of debarment proceedings against Provider. ARTICLE HI — Ratification of the Agreement Other than expressly modified or amended herein, all other terms and conditions of the Agreement shall remain in full force and effect. SIGNATURES APPEAR ON THE FOLLOWING PAGE 3 THE CITY OF MIAMI BEACH HOTEL /MOTEL PLACEMENT PROGRAM PC- 1718 - HTMT -2 HMIS STAFFING PROGRAM PC -1718- STAFF -2 THE CITY OF MIAMI BEACH EMERGENCY HOTEL /MOTEL PLACEMENT PROGRAM GRANT #: PC- 1718 - HTMT -2 The Provider agrees to provide emergency hotel/motel placement of homeless families, transgendered individuals, chronically homeless individuals or individuals who have a high vulnerability index score on an as-needed basis. Clients may be provided with food vouchers on an as- needed basis of up to $20.00 per person, per day. Reimbursement will only be made for properly documented disbursement of food vouchers. All reimbursement must be submitted to the County by the 10th day of each month following the month of service. All reimbursement requests must be approved by the County prior to the disbursement of funds. THE CITY OF MIAMI BEACH IIMIS STAFFING GRANT #: PC -1718- STAFF -2 The Provider shall provide a dedicated HMIS Outreach staff person. The purpose of this staff position is to maintain data current in the HMIS and includes, but is not limited to input of client data upon intake, updates of client files, compilation of reports and entering 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 United. States Department of Housing and Urban Development (HUD) Agreement between the City of Miami Beach and the Miami -Dade County Homeless Trust may result in the termination of this Agreement. PLEASF INSFRT AN UPDATF,D ATTACHMF,NT "B" BUDGF,T FOR THE 2017-2018 GRANT YF4',AR ATTACHMENT F Miami -Dade County Homeless Trust Invoice For Services NAME OF AGENCY: The City of Miami Beach SERVICE PERIOD: NAME OF GRANT: GRANT NUMBER: TOTAL AWARD AMOUNT: AMOUNT OF FUNDS REQUESTED THIS MONTH: TO H IIS Staffing Program PC- 1718 - STAFF -2 $12,333.00 $ AMOUNT OF FUNDS RECEIVED TO DATE: $ BALANCE REMAINING ON GRANT: (following payment of this request) Signature of Executive Director or Date Authorized Agency Representative Printed Name of Executive Director or Authorized Agency Representative APPROVED AS TO FORM & LANGUAGE & FOR ELUTION 3- C City Attorney 'T Date ATTACHMENT L [ MIAMI -DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT HMIS STAFFING PROGRAM CITY OF MIA BEACH- GRANT NUMBER #: PC -1718- STAFF -2 OCTOBER 1, 2017 -- SEPTEMBER 30, 2018 Name of Agency: The City of Miami Beach $ 12,333.00 Month of Services Amount Paid Oct -17 Nov -17 Dec -17 Jan -18 Feb -18 Mar -18 Apr -18 May -18 Jun -18 Jul-18 Aug -18 Sep -18 Total Requested Balance Remaining $ 0.00 $ 12,333.00 FORM & LANGUMvt & FOR EXECUTION City Attorney' Dote Form W-9 (Rev. November 2017) Department of the Treasury Internal Revenue Service Request for Taxpayer q Identification Number and Certification - Go to www.irs.gov /FormW9 for instructions and the latest information. Give Form to the `orm to requester. Do not send to the IRS. Print or type. See Specific Instructions on page 3< 1 Name (as shown on your income taxi return). Name is required on thisls linee; do riot leave this line blank. re 2 Business name /disregarded entity name, if different from above 3 Check appropriate box for federal tax classitication of the person whose name is entered on line 1. Check only one of the following seven boxes. 4 Exemptions certain entities, Instructions Exempt payee Exemption code (if any) (Applies to accounts (codes apply only to not individuals; see on page 3): code (if any) • IndividuaVsole proprietor or ❑ C Corporation III S Corporation ❑ Partnership: 111 Trust/estate single- member LLC ❑ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= Partnership) Note: Check the appropriate box in the line above for the tax classification of the single- member owner. LLC if the LLC is classified as a single - member LLC that is disregarded from the owner unless the owner another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (see instructions)). - from FATCA reporting Do not check of the LLC is - member LLC that maintained outside the U.S.) 5 Address (number, street, and apt, or s� � ) �p uite no.) See instructions. t Requester's name and address (optional) 6 City, state, and ZIP code ON VCIV IM 1 ICjI` ir4C. t°1-. • (-L - 3 1 S‘ 7 List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. 1 Social security number or Employer identification number Cc\ 3 1 Part 11 Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U,S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest :nd dividends on yo tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secu ed property, canoe ation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, y. u are not required o sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Signature of Here , U.S, person - General Instruct • s Section references are to the Inte noted. Future developments. For the latest information about developments related to Form W -9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov /FormW9. Purpose of Form An individual or entity (Form W -9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer . Identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099 -INT (interest earned or paid) al Revenue Code unless otherwise Date. 3/1 f /S • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099 -MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099 -B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099 -S (proceeds from real estate transactions) • Form 1099 -K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098 -E (student loan interest), 1098 -T (tuition) • Form 1099 -0 (canceled debt) • Form 1099 -A (acquisition or abandonment of secured property) Use Form W -9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W -9 to the requester with a TiN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev, 11 -2017) ATTACHMENT F 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, 3-11Ari r `-t L. . ono ing 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): ®CQDoo ?'12- Federal Employer Identification Number (If none, Social Security) Name of Entity, Individual(s), Partners, or Corporation Doing Business As (if same as above, leave blank) Street Address City State Zip Code 1. MIAMI -DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2 -8.1 of the County Code) If the contract or business transaction is with a corporation, the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent (5 %) or more of the corporation's stock. If the contract or business transaction is with a partnership, the foregoing information shall be provided for each. partner. If the contract or business transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. 'The foregoing requirements shall . not pertain to contracts with publicly traded corporations or to contracts with the United States or any department or agency thereof, the State or any political subdivision or agency thereof or any municipality of this State. All such names and addresses are (Post Office addresses are not acceptable): Full Legal Name Address Ownership % The full legal names and business address of any other individual (other than subcontractors, material men, suppliers, laborers, or lenders) who have, or will have, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Dade County are (Post Office addresses are not acceptable): Any person who willfully fails to disclose the information required herein, or who knowingly discloses false information in this regard, shall be punished by a fine of up to five hundred dollars ($500.00) or imprisomnent in the County jail for up to sixty (60) days or both. ATTACHMENT F "Miami -Dade County Required Affidavits" Page 1 of 5 ATTACHMENT F MIAMI -DADE COUNTY REQUIRED AFFIDAVITS 4. MIAMI -DADE COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2 -8.6 of the County Code) The individual or entity entering into a contract or receiving funding from the County ___ has as not as of the date of this affidavit been convicted of a felony during the past ten (10) years. An officer, director, or executive of the entity entering into a contract or receiving funding from the County _(has /has not), as of the date, of this affidavit been convicted of a felony during the past ten (10) years. 5. MIAMI -DADE EMPLOYMENT DRUG -FREE WORKPLACE AFFIDAVIT (County Ordinance 92 -15 codi ed as Section 2 -8.L2 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: clanger 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 finding which is provided in whole or in part by the United States or the State of Florida shall be exempted from the provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental entities. 6. MIAMI -DARE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance 142 -91 codified as Section 11A -29 et. seq of the County Code) That in compliance with Ordinance No. 142 -91 of the Code of Miami -Dade County, Florida, an employer with fifty (50) or more employees working in Dade County for each working day during each of twenty (20) or more calendar work weeks, shall provide the following information in compliance with all items in the aforementioned ordinance: An employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) days of family leave during any twenty-four (24) month period, for medical reasons, for the birth or adoption of a child, or for the care of a child, spouse or other close relative who has a serious health condition without risk of termination of employment or employer retaliation. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State of Florida or any political subdivision or agency thereof It shall, however, pertain to municipalities of this State. 7. DISABILITY NON - DISCRIMINATION AFFIDAVIT (County Resolution R- 385 -95) That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities, renovations, and new construction in the following laws: The Americans with Disabilities Act of 1990 (ADA), Pub. L. 101 -336, 104 Stat 327, 42 U.S.C. 12101 -12213 and 47 U.S.C, Sections 225 and 611 including Title 1, Employment; Title 1I, 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 F "Miami -Dade County Required Affidavits" Page 3 of 5 ATTACHMENT F 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 AFFIDAVTTS ONE (1) THROUGH ELEVEN (11) By: MIAMI -DADE COUNTY AFFIDAVTTS SIGNATURE PAGE 3 t Vir Signa u'" r Witness o r Secretary Seal Signature o fiant Arrt-cusr 1 S , 20 It Date Federal Employer Identification Number Printed Nam of Affiant and Name of Agency "i00. c_epT . tZ ilk . »E- Address of Agency rnt Ott Vie- H SUBSCRIBED AND SWORN TO (or affirmed) before me this ay of i �(1"m , 20 1? He /She i personally known -o me or has presented as identification. Se WZOLIPLAak I y`�04�Y �Ue <n ADEPINEDO MY COMMISSION Ik FE 126641 EXPIRES; September 26, 2018 Bonded Thu Notary Public Underwriters Prl '':. :` ' . 0 -... 0 ary Notary Public — State of Pt 0Y‘'( County of I\, 010/Li - Type of identification Serial Number Expiration Date Notary Seal ATTACHMENT F "Miami -Dade County Required Affidavits" Page 5 of 5 Form M� (Rev. November 2017) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Go to www.irs.gov /FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. Print or type. See Specific Instructions on page 3. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name /disregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. 4 Exemptions certain entitles, Instructions Exempt payee Exemption code (if any) (Applies to accounts (codes apply only to not individuals; see on page 3): code (if any) I' IndividuaVsole proprietor or 0 C Corporation II S Corporation 0 Partnership • Trust/estate single- member LLC [] Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= Partnership) Note: Check the appropriate box In the line above for the tax classification of the single- member owner. LLC if the LLC is classified as a single- member LLC that is disregarded from the owner unless the another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single Is disregarded from the owner should check the appropriate box for the tax classification of its owner. 0 Other (see instructions) I► R from FATCA reporting Do not check owner of the LLC is - member LLC that maintained outside the. U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 6 City, state, and ZIP code 7 List account number(s) here (optional) Part 1 Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account Is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. MEI Certification Social security number or Employer identification number Under penalties of perjury, I certify that: 1. The number shown on thls 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 dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later, Sign Here Signature of U.S. person V Date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W -9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov /FormW9. Purpose of Form An individual or entity (Form W -9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer . Identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1 099 -INT (interest earned or paid) • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099 -MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099 -B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099 -S (proceeds from real estate transactions) • Form 1099 -K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098 -E (student loan interest), 1098-T (tuition) • Form 1099 -0 (canceled debt) • Form 1099 -A (acquisition or abandonment of secured property) Use Form W -9 only if you area U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W -9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 11 -2017)