Amendment No. 2 to the Agreement with Miami-Dade County PC-1617-HTMT-31o1((, -222.4 -
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -2
AMENDMENT #2 OF THE AGREEMENT
BETWEEN
MIAMI -DADE COUNTY AND
THE CITY OF 1VfTA1%1 BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -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 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:
IDENTIFICATION ASSISTANCE PROGRAM
$ 25,000.00
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -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 § 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 te.uninating 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 IDENTIFICATION ASSISTANCE GRANT
GRANT #: PC- 1718 -ID -2
ATTACHMENT A, SCOPE OF SERVICES
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM
GRANT #: PC- 1718 -ID-2
The provider agrees to provide identification assistance services to 300 homeless persons in Miami -Dade
County. The following services must be provided under this Agreement:
■ Identification document replacement services for homeless persons in Miami -Dade County.
Documents to be replaced include, but are not limited to:
1. Florida Identification Cards
2. Birth Certificates
3. Marriage Certificates
4. School Records
5. Court Documents (judgements, orders, related documents)
6. Lawful Permanent Resident Cards
7. Naturalization Certificates
8. Florida Driver's Licenses
Note: The costs of replacing the documents specified above may be funded via this grant or where
applicable fee waivers may be obtained via the appropriate source.
■ Staff shall deliver identification services to homeless individuals.
■ Staff shall maintain a regular working schedule, as may be modified from time to time as
mutually agreed upon in writing, with an intake specialist /case worker providing services.
Staffing will be provided primarily in the Miami Beach Office of Homeless Programs located at
555 17th Street, Miami Beach, Florida..
■ Provide referral services for community - based resources including but not limited to: legal and
medical services, food, employment, vocational training and clothing
■ Provide follow -up and tracking of each person assisted to determine outcome measures.
PERFORMANCE MEASURES
EXPECTED OUTCOMES
INDICATORS
1.
Homeless clients will be assessed
300 clients will be assessed.
2.
Homeless clients will obtain vital personal
identification documents,
200 or 66% of homeless clients will obtain vital personal
identification documents.
3.
Homeless clients will obtain official photo
identification.
150 or 50% of homeless clients will obtain official photo
identification.
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: The City of Miami Beach
SERVICE PERIOD: TO
NAME OF GRANT: Identification Assistance Program
GRANT NUMBER: PC- 1718-ID -2
TOTAL AWARD AMOUNT: $ 25,000.00
AMOUNT OF FUNDS REQUESTED
THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $ 25,000.00
(following payment of this request)
Signature of Executive Director or Date
Agency Authorized Representative
Printed Name of Executive Director or
Authorized Agency Representative
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
y -\
Date
City Attorney
ATTACHMENT L
MIAMI -DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI BEACH HOMELESS ASSISTANCE PROGRAM
IDENTIFICATION ASSISTANCE PROGRAM — GRANT NUMBER PC- 1718 -1D -2
OCTOBER 1, 2017 — SEPTEMBER 30, 2018
Name of Agency:
THE CITY OF MIAMI BEACH
$ 25,000.00
Month of Services
Amount Paid
October 2017
November 2017
December 2017
January 2018
February 2018 .
March 2018
April 2018
May 2018
June 2018
July -2018
August 2018
September 2018
Total Requested
Balance Remaining
Executive Director Signature or Authorized
Agency Representative Signature
Executive Director or Authorized Agency
Representative- Printed Name
Signature Date
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
City Attorney
Date
$
0.00
$ 25,000.00
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -2
AMENDMENT #2 OF '1'IIE AGREEMENT
BETWEEN
MIAMI -DADE COUNTY AND
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -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 teems 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:
IDENTIFICATION ASSISTANCE PROGRAM $ 25,000.00
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -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 Co urts 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 at 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 teiiuinating 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 teens and conditions of the Agreement shall remain
in full force and effect.
SIGNATURES APPEAR ON TIIE FOLLOWING PAGE
3
THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE GRANT
GRANT #: PC- 1718 -ID -2
ATTACHMENT A, SCOPE OF SERVICES
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM
GRANT #: PC- 1718 -ID-2
The provider agrees to provide identification assistance services to 300 homeless persons in Miami -Dade
County. The following services must be provided under this Agreement:
• Identification document replacement services for homeless persons in Miami -Dade County.
Documents to be replaced include, but are not limited to:
1. Florida Identification Cards
2. Birth Certificates
3. Marriage Certificates
4. School Records
5. Court Documents (judgements, orders, related documents)
6. Lawful Permanent Resident Cards
7. Naturalization Certificates
8. Florida Driver's Licenses
Note: The costs of replacing the documents specified above may be funded via this grant or where
applicable fee waivers may be obtained via the appropriate source.
• Staff shall deliver identification services to homeless individuals.
• Staff shall maintain a regular working schedule, as may be modified from time to time as
mutually agreed upon in writing, with an intake specialist /case worker providing services.
Staffing will be provided primarily in the Miami Beach Office of Homeless Programs located at
555 17th Street, Miami Beach, Florida.
• Provide referral services for community-based resources including but not limited to: legal and
medical services, food, employment, vocational training and clothing
• Provide follow -up and tracking of each person assisted to determine outcome measures.
PERFORMANCE MEASURES
EXPECTED OUTCOMES
INDICATORS
1.
Homeless clients will be assessed
300 clients will be assessed. _
2.
Homeless clients will obtain vital personal
identification documents.
200 or 66% of homeless clients will obtain vital personal
identification documents.
3.
Homeless clients will obtain official photo
identification.
150 or 50% of homeless clients will obtain official photo
identification.
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
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
Identification Assistance Program
PC- 1718 -ID -2
$ 25,000.00
$
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $ 25,000.00
(following payment of this request)
Signature of Executive Director or Date
Agency Authorized Representative
Printed Name of Executive Director or
Authorized Agency Representative
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
City Attorney
3 -t��
�V•1.
Date
CZ
ATTACHMENT L
MIAMI -DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI BEACH HOMELESS ASSISTANCE PROGRAM
IDENTIFICATION ASSISTANCE PROGRAM — GRANT NUMBER PC- 1718 -ID -2
OCTOBER 1, 2017 SEPTEMBER 30, 2018
Name of Agency:
THE CITY OF MTA.NH BEACH
$ 25,000.00
Month of Services
Amount Paid
October 2017
November 2017
December 2017
January 2018
February 2018
March 2018
April 2018
May 2018
June 2018
July -2018
August 2018
September 2018
Total Requested
Balance Remaining
Executive Director Signature or Authorized
Agency Representative Signature
Executive Director or Authorized Agency
Representative- Printed Name
Signature Date
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
(4 - -c
City Attorney
Date
0.00
$ 25,000.00
6/ V(16/-
THE CITY OF MIAMI REACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID-2
AMENDMENT #2 OF THE AGREEMENT
BETWEEN
MIAMI -DADE COUNTY AND
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -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 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:
IDENTIFICATION ASSISTANCE PROGRAM $ 25,000.00
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT #: PC- 1718 -ID -2
Article 10 is replaced as follows:
ARTICLE 10. CIVIL RIGHTS
The Provider agrees to abide by Chapter 1 1A 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. §61(114 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 seen 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 tettninating 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
o
3
THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE GRANT
GRANT #: PC-1718-ID-2
ATTACHMENT A, SCOPE OF SERVICES
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM
GRANT #: PC- 1718 -ID -2
The provider agrees to provide identification assistance services to 300 homeless persons in Miami -Dade
County. The following services must be provided under this Agreement:
■ Identification document replacement services for homeless persons in Miami -Dade County.
Documents to be replaced include, but are not limited to:
1. Florida Identification Cards
2. Birth Certificates
3. Marriage Certificates
4. School Records
5. Court Documents (judgements, orders, related documents)
6. Lawful Permanent Resident Cards
7. Naturalization Certificates
8. Florida Driver's Licenses
Note: The costs of replacing the docurnents specified above may be funded via this grant or where
applicable fee waivers may be obtained via the appropriate source.
■ Staff shall deliver identification services to homeless individuals.
■ Staff shall maintain a regular working schedule, as may be modified from time to time as
mutually agreed upon in writing, with an intake specialist /case worker providing services.
Staffing will be provided primarily in the Miami Beach Office of Homeless Programs located at
555 1:7a' Street, Miami Beach, Florida.
■ Provide referral services for community -based resources including but not limited to: legal and
medical services, food, employment, vocational training and clothing
■ Provide follow -up and tracking of each person assisted to determine outcome measures.
PERFORMANCE MEASURES
EXPECTED OUTCOMES
INDICATORS
300 clients will be assessed.
1.
Homeless clients will be assessed
2.
Homeless clients will obtain vital personal
identification documents.
200 or 66% of homeless clients will obtain vital personal
identification documents.
3.
Homeless clients will obtain official photo
identification.
150 or 50% of homeless clients will obtain official photo
identification.
ATTACHMENT F
Miami -Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: The City of Miami Beach
SERVICE PERIOD: TO
NAME OF GRANT: Identification Assistance Program
GRANT NUMBER: PC- 1718 -ID -2
TOTAL AWARD AMOUNT: $ 25,000.00
AMOUNT OF FUNDS REQUESTED
THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $ 25,000.00
(following payment of this request)
Signature of Executive Director or Date
Agency Authorized Representative
Printed Name of Executive Director or
Authorized Agency Representative
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
,
• 7 -
"\ -�
City Attorney , Date
ATTACHMENT L
MIAMI -DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI BEACH HOMELESS ASSISTANCE PROGRAM
IDENTIFICATION ASSISTANCE PROGRAM — GRANT NUMBER PC- 171.8 -ID -2
OCTOBER 1, 2017 — SEPTEMBER 30, 2018
Name of Agency:
THE CITY OF MIAMI BEACH
$ 25,000.00
Month of Services
Amount Paid
October 2017
November 2017
December 2017
January 2018
Februay 2018
March 2018
April 2018
May 2018
June 2018
July -2018
August 2018
September 2018
Total Requested
Balance Remaining
Executive Director Signature or Authorized
Agency Representative Signature
Executive Director or Authorized Agency
Representative- Printed Name
Signature Date
APPROVED AS TO
FORM & LANGUAGE
& FORE ECUTION
City Attorney �r�it Date
0.00
25,000.00
FoForm ,w9
(Rev. November2017)
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.
C1-r -k In E ,n\t k r4 0-3
2 Business name /disregarded entity name, if different from'above
3 Check appropriate
following seven boxes.
E] Individual/sole
single - member
[] Limited liability
Note: Check the
LLC if the LLC
another LLC that
is disregarded
LJ Other (see instructions)
box for federal tax classification of the person whose name is entered on line 1. Check only one of the
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)
proprietor or 1 C Corporation • S Corporation El Partnership IN Trust/estate
LLC
company. Enter the tax classification, (C =C corporation, S =S corporation, P=Partnershlp)
appropriate box in the line above for the tax classification of the single- member owner.
is classified as a single - member LLC that is disregarded from the owner unless the
is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single
from the owner should check the appropriate box for the tax classification of its owner.
1.-
it-
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.
171'00 c_,)}- Ttco Ce 1,-51----e.._ Q ek
Requester's name and address (optional)
6 City, state, and ZIP
relli -rte
code
L
v : i y3 13
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.
Certification
Social security number
or
Employer identification number
O
3�I
2
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that 1 am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the iRS that you are currently subject to backup withholding because
you have failed to report all interest nd dividends on yo r tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secu -d property, can 'ation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, ye` are not required o sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Here
Signature of
U.S. person 10-
Date 0-
General lnstructio� s �F
Section references are to the inter,.l Revenue Code unless otherwise
noted.
Future developments. For the late • t information about developments
related to Form W -9 and its instructons, such as legislation enacted
after they were published, go to www.irs.gov /FormW9.
Purpose of Form
An individual or entity (Form W -9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer .
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099 -INT (interest earned or paid)
• Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
• Form 1099 -MISC (various types of Income, prizes, awards, or gross
proceeds)
• Form 1099 -B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099 -S (proceeds from real estate transactions)
• Form 1099 -K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098 -E (student loan interest),
1098 -T (tuition)
• Form 1099 -C (canceled debt)
• Form 1099 -A (acquisition or abandonment of secured property)
Use Form W -9 only if you 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 77N, 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 AFI'1BAVIT 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, 311 V `i L- rvI.012-Att5Deing first duly sworn state:
The full legal name and business address of the person(s) or entity contracting or transacting business with Miami -Dade
County are (Post Office addresses are not acceptable):
Federal Employer Identification Number (If none, Social Security)
CM-1 VVt vornAt l Er4C
Name of Entity, Individual(s), Partners, or Corporation
Doing Business As (if same as above, leave blank)
1 °P. Dc) 1t-.1 E tJ r t �� PA- ®1a- p tin 1 -rvt 31
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 (S500.00) or imprisonment 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 ) has not as of the date of
this affidavit been convicted of a felony during the past ten (10) years.
An officer, director, or executive of the entity entering into a contract or receiving funding from the County _(has /has not), as
of the date, of this affidavit been convicted of a felony during the past ten (10) years.
5. _MIAMI -D.ADE EMPLOYMENT DRUG -FREE WORKPLACE AFFIDAVIT (County Ordinance 9245
codified as Section 28.1.2 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. MIAMI -DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance 142 -91 codified as
Sec ion 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 61.1 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 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 AFFIDAVITS ONE
(1) THROUGH ELEVEN (11)
By:
MIAMI -DADE COUNTY AFFIDAVITS SIGNATURE PAGE
3�
Si. a Witness Secretary Seal.
Sign a:of•`ia
Printed e of Affiant and Name of Agency
Address of Agency
C4-0. „- 1f
Date
,20 1P"
Federal Employer Identification Number
CI't `-1 n w■A.+4tv■l
SUBSCRIBED AND SWORN TO (or affirmed before me this \ , 20
( ) � day of ��� ���
He /She 's personally known ,o me or has presented as identification.
_s)
S
•ADEPINEDO
MY COMMISSION 6 FF 126641
EXPIRES; September 26, 20.18
d Thru Notary Public Underwriters
PrrE ., o ary
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County of IQ( i--,( ,t
Notary Public — State of
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INCORP
ORATED;
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Type of identification
Serial Number
Expiration Date
Notary Seal
ATTACHMENT F "Miami -Dade County Required Affidavits"
Page 5 of 5