Amendment No. 2 to the Agreement with Miami-Dade County PC-1718-HTMT-3 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-17181ITMT-3
HMIS STAFFING PROGRAM CONTRACT#: PC-1718-STAFF-2
THIS AMEND 'NT #2 OF THE AGREEMENT (the "Agreement Amendment #2") is made as of
c1 �� ala by and between Miami-Dade County, through the Miami-Dade County Homeless Trust
(the " oun ,") 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 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 S 10,000.00
• HMIS STAFFING PROGRAM S 12,333.00
TOTAL S 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 1IA 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. §5 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 thc 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 s 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-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 UPDATED
ATTACHMENT "B"
BUDGET
FOR THE 2017-2018 GRANT YEAR
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ATTACHMENT F
Miami-Dade County Homeless Trust
Invoice For Services
NAME OF AGENCY: The City of Miami Beach
SERVICE PERIOD: TO
NAME OF GRANT: HMIS Staffing Program
GRANT NUMBER: PC-1718-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 Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
APPROVED AS TO
FORM & LANGUAGE
&FOR CUTION
3 CA — 1r4
C Attorney °'j -6r
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
S 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 S 0.00
Balance Remaining S 12,333.00
Arrl<vvw no
FORM & LANGUAGE
&FOR EXECUTION
�I1� City Homey Dote
Fon,, Y 1-9 Request for Taxpayer Give Form to the -
(Rev.November 2017) Identification Number and Certification requester.Do not
In�ternnaal Revenue theTreasury
I•Go to www.irs. send to the IRS.
gov/FormlVe for instructions and the latest information.
1 Name as shown on your income tax return).Name is required on this line:do not leave this line blank
CAT`{ Gly Ml An/11 13EIQc l t
2 Business name/disregarded entity name,if different from abovevg
3 Check appropriate box for federal tax classification of the person whPse name Is entered on line I.Check only one of the 4 Exemptions(codes apply only to
following seven boxes. certain entities,not individuals;see
instructions on page 3):
Individual/sole proprietor or ❑ e Corporation ❑ S Corporation ❑ Parmeship ❑Tarstleatate
• single-member LLC Exempt payee code(ll anyi_
2«r O Limited liability company.Enter the tax classification(C=C corporation,SS corporation,P=Partnership)1
Note:Check the appropriate box in the line above tar the tax classification of the single-member owner. Do not check Exemption Iron,FATCA reporting
LLC if the LLD is davtifed es a single-member LW that is disregarded tram the owner unless the owner of the LLC is code(ti an4
another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,asingle-member LLC that
0 is disregarded from the owner should check the appropriate box for the tax classification of Its owner.
❑ Other(see instructions)6 - roes rm,erre maamcmgovi,e ae List
ys Address(number,street,and apt or suite no)See instructions. Requester's name and address(opJonal)
O l'1o0 CACka IENTt )\T cEN'r> 2 C;$12_
• 16 City,state,and ZIP code •
I MIWrnI Geicict- - 3313c _
7 List account number(s)here(optional)
j Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security numb&
backup withholding.For individuals,this is generally your social security number(SSN).However,for a m III
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 geta
TIN,later. - or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
S� &koc3h2
Part II Certification
Under penalties of perjury,I certify that
I.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 foml(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 seer ed property,can ion of debt,contributions to an individual retirement arrangement IRA),and generally,payments
other than interest and dividends,you are not required o sign the cerlificafion,but you must provide your co red TIN.See the instructions for Part II,later.
Sign Signature of -- G
Here U.S.person 1- Date 0.
General Instructi✓ s •Form 1099-D1V(dividends,including those from stocks or mutual
funds)
Section references are to the Intenal Revenue Code unless otherwise
•Form 1099-MISC(various types of income,prizes,awards,or gross
noted. •
proceeds)
Future developments.Fore latest information about developments
•Form tons (stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted after they were published,go to www.irs.gov/FormW9. brokers)
•Form 1099-S(proceeds from real estate transactions)
Purpose of Form •Fonn 1099-K(merchant card and wird party network transactions)
An individual or entity(Form W-9 requester)who is required to file an -Form 1098(home mortgage interest 1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
ISSN),individual taxpayer identification number°TINN),adoption •Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number use Form W-9 only if you are a U.S.person(including a resident
(EIN),to report on an information return the amount paid to you,or other alien),to provide your correct TIN.
amount reportable on an information return.Examples of information
returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
•Form 1099-INT(interest earned or paid) be subject to backup withholding.See Vi hat is backup withholding,
later
Cat.No.10231& 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"R" 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.
1, Ji Wl M'1 L .vvv:::r'-SU 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):
Federal Employer Identification Number(If none,Social Security)
C-19 c Vhtwrit ✓3t.acr1 __
Name of Entity,Individual(s),Partners,or Corporation
Doing Business As(if same as above,leave blank)
V100 rterrttctJ cC=,rSr&jt 012 yn u w.t Ilj E1 -C-t+1 67-331 '
Street Address City State Zip Code
1.AJAI-DARE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT(Sec.2-8.1 of the County Code)
Ifthe 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.
Ifthe contract or business transaction is with a partnership,the foregoing information shall be provided for each partner. Ifthe
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 contacts 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 contact 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 F"Miami-Dade County Required Affidavits" Page 1 of 5
ATTACHMENT F
4 . MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
4. Y 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 Y2-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
ofthe date,of this affidavit been convicted of a felony during the past ten(10)years.
5. N ed MIAMI-DADE EMPLOYMENT DRUG-FREE WORKPLACE AFFIDAVIT(County Ordinance 92-15
codi as Section 2-8.1.2 of the County Code)
That in compliance with Ordinance No.92-15 ofthe Code of Miami-Dade County,Florida,the above named person or entity
E 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 maybe waived if the special characteristics ofthe 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. I MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance 142-91 codified as
Section 11A-29 et. seq of the County Code)
'Chat 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. f' DISABILITY NON-DISCRIMLNA'TION 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 ofthe 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 Stat327,42 Ii-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 F"Miami-Dade County Required Affidavits" Page 3 of 5
ATTACHMENTF
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: t 11 3(l 415 `,a,.cw I I' , 20.It
Signau Witness o Secretary Seal Date
-- cat— (or'mez,r,3-1
Signature Affiant) Federal Employer Identification Number
31 vvnrw"i Ma
L. o -ate on S CET E- u' . (\-, (PCN
Printed Nam of Affiant and Name of Agency
1'100 cQ1.hlli \C tv1ce rce2 Ot&JE n MA-rnk iraj19C.H
Address of Agency �,
SUBSCRIBED AND SWORN TO (or affirmed)before me this\'O ' day of_LAU it(' ,20 I?
He/She i. ersonally known o me or has presented_ as identification.
Type of identification
�
� _
Sir --.-- •—"!D DEPINEDO Serial Number
._.
'� �kx MY COMMISSION 4 F 126641
ap p E%PIRES'.Septembar26. 11
e,. �needrn,e xo�.N Puurunaer«mers
Pri =�°°�.:. : e - Io . y Expiration Date
Notary Public State of p c7Yi cit
County of_ k I /7 brick_
`�f3"' Notary Seal
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Nt... ,
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yq............- , t
4 ,2H -
ATTACHMENT F"Miami-Dade County Required Affidavits" Page 5 of 5
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-1718 HTMT-3
RYHS STAFFING PROGRAM CONTRACT#: PC-1718-STAFF-2
THIS AMENDMENT #2 OF THE AGREEMENT (the "Agreement Amendment #2") is made as of
PUJJ 'Zenby and between Miami-Dade County, through the Miami-Dade County Homeless Trust
(the " ounfy") 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, I HEREFORE, BE IT RESOLVED, for and consideration of the mutual agreements between the
County and the Provider, which are set forth in this Amendment 42 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
Both parties agree that should available Miami-Dade County funding be reduced,the amount payable under this
Contract may be proportionately reduced at the sole discretion and option of the County.
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 4 is replaced as follows:
ARTICLE 4. BUDGET SUMMARY
The Provider agrees that all expenditures or costs shall be made in accordance with the revised
2017-2018 Budget, which 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 line item
budget, and such revision shall not require an amendment to this Contract.
Pursuant to Board of Miami-Dade County Commissioners' Resolution Number R-630-13, the Provider will
submit a detailed project budget, and sources and uses statement as Attachment B, 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 arc
performed.
Article 5 is replaced as follows:
ARTICLE 5. EFFECTIVE TERM
Both parties agree that the Effective Term of this Contract shall continue to commence on
October 1,2017 and terminate at the close of business on September 30,2018. Contingent on the existence of
sufficient funding,the provider's performance and the approval of the County may be extended at the County's
sole discretion.
2
THE CITY OF MIAMI BEACH
EMERGENCY HOTELIMOTEL 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 I IA 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(1L 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 § 11 A-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
EMERGENCY HOTEL/MOTEL PLACEMENT PROGRAM CONTRACT#: PC-1718-HTMT-3
HMIS STAFFING PROGRAM CONTRACT#PC-1718-STAFF-2
IN WITNESS WHEREOF, the parties have caused this four(4) page Amendment#2 of the Agreement to be
executed by their respective and duly authorized officers the day and year first above written.
THE CITY 0 MIAMI !EACH MIAMI-DADE/COOUNTY
By: By: ye
Name: jIm1 I .✓vtc7ERlf3 Name: MAURICE L. KE(.AP
DEPUTY MAYOR
Title: CFP-( MRhIACt€Q Title: MIAM, I-DDEECTY. FL
Date: 3I I S /I _ Date: I 18"
Attest: /t IY Attest: HARVEY RUVIN,Clerk
A ori 'erson OR Notary Board of County Commissioners
Public
Print Name: nFP, k-.. t-. CBy
M D➢
"Title: 117 C lrn Print Name: -
Corporate Seal OR Notary Seal/Stamp:
:
` : } r
sit \ca��r' �, y
� r � Tti� r
gEE
Igin .
ii X y .r
•
This Agreement is approved as to form and legal sufficiency. See memorandum dated P/I /& '.
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
__e•-z_,Q c, 3 (A- -(8
City Attorney J7[ Dote 4
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 hotellmotel 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-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 UPDATED
ATTACHMENT "B"
BUDGET
FOR THE 2017-2018 GRANT YEAR
on
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ATTACHMENT F
Miami-Dade County Homeless Trust
Invoice For Services
NAME OF AGENCY: The City of Miami Beach
SERVICE PERIOD: TO
NAME OF GRANT: HMIS Staffing Program
GRANT NUMBER: PC-1718-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 Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
APPROVED AS TO
FORM & LANGUAGE
& FOR CUTION
4111P __ 1(4
C Attorney r4- Date Date
• -
ATTACHMENT F
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-1718-HTMT-3
TOTAL AWARD AMOUNT: $ 10.000.00
AMOUNT OF FUNDS REQUESTED
THIS MONTH: S
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: S
(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
3- (A - \C(
CityAttorney $,�y— 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 $ 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-1718-HTMT-3
OCTOBER 1,2017— SEPTEMBER 30,2018
Name of Agency: The City of Miami Beach
S 10,000.00
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
Au1-18
Sep-18
Total Requested S 0.00
Balance Remaining S 10,000.00
Arrl<t.w[v no Is,,
FORM & LANGUAGE
& FOR EXECUTION
•
City kttomey,j l-" Date
Form W-9 Request for Taxpayer . Give Form to the
(Rev.November 2017) Identification Number and Certificationrequester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service t Go to www.irs.gov/ForrnW9 for instructions and the latest information.
1 Name(as shown on your income tax return).Name is required on this line;do riot leave this line blank
CIT`-( CD4 MuA.x1 13EAci H.
2 Business nama/tlisregaraed entity name,if different from above - -
m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
Or following seven boxescertain entNes.not individuals;see
0-
❑ Individuaysole proprietor or ❑ 0 Corporation ❑ a e instruTnna on page 3):
Corporation ❑ Partnership ❑Trust/estate
to
single-member LTC
Exempt p payee coda(if any)
fi- ❑ Limbed liabirrty company.Enter the tax classification(C=C corporation.5S corporation.F-Patnership) -
0
`0 2 Note:Check the appropriate box in to the above for the tax clas9Flration of the single-member owner. Do not check Exemption from FATCA reporting
E LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code if aryl
another LW that is not disregarded from the owner for as.federal tax purposes.Otherwise,a single-member LLC tat
O. e is disregarded from the owner should check the appropriate box for the tax classification of its owner.
o� Q Other(see Instructions)lib raves mbuyve m+.meham,a.us)
ys Address(number,street,and apt or suite no.)See instuctions. Requester's name and address(op]onaQ
(-foo Cq 1\(E-F-1-r t to I-3ca.) 441 2 012
iw sclry,state,and ZIP code
- W C.
t Gee4t- ; A33IS5
7 List account mailbags)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 Soda]security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a II
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 geta -_
TIN,later. or
Note:It the account is in more than one name,see the instructions for line 1.Also see What Name and I Employer identification number I
Number To Give the Requester for guidelines on whose number to enter. Si -16 t�0d3 1
''!
haul 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 wthholding because:(a)I am exempt from backup withholding,or(D)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 lam
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 Of 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 yo tax return.For real estate transactions,Item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of sealed properly,canoe'ation of debt,contributions to an individual retirement arrangement ORA),and generally.payments
other than interest and dNidends,yOu are not required o sign the certification,but you must provide your correct TIN.Sea The instructions for Part II,later.
Si ._'..__
9n I Signature of _ • - p
Here us.person. �L� Date le 34/5 (s--
General Instructios •Form 1099-D1V(dividends,including those from stocks or mutual
funds)
Section references are to the Int al Revenue Code unless otherwise .Form 1999-MISC(various 'mcome,prizes,awards,or r
noted types ofgross
proceeds)
Future developments.For the latest information about developments •Form 1099-B(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.gov/FormW9. •Form 10996(proceeds from real estate transactions)
Purpose of Form •Farm 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1998-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 19994(tuition)
identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITN),adoption •Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(AMC!),or employer identification number
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 onty if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information lien),to provide your correct TIN.
returns include,but are not limited to,the following. a If you do not return Form W-9 to the requester with a TIN,you might
•Form 1099-INT(interest eamed or paid) be subject to backup withholding.See What is backup withholding,
later
Cat.No. 0231X - Form W-9(Rev.11-2017)
Form W-9(Rev 11-2017) Page 2
By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an
1.Certify that the TIN you are giving is correct(or you are waiting for a ex ption from tax for scholarship income received by a Chin se
student temporarily present in the United States.Under U.S.law,this
number to be issued), student will become a resident alien for tax purposes if his or her stay in
2.Certify that you are not subject to backup withholding,or the United States exceeds 5 calendar years.However,paragraph 2 of
3.Claim exemption from backupwithholdingifyou are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April iter0, the)allows
p x the provisions of Article 20 to continue to apply even after Chinese
payee.If applicable,you are also certifying that as a U.S.person,your student becomes a resident alien of the United States.A Chinese
allocable share of any partnership income from a US.trade or business student who qualifies for this exception(under paragraph 2 of the first
is not subject to the withholding tax on foreign partners'share of protocol)and is relying on this exception to claim an exemption from tax
effectively connected income,and W 9ls or her a statementothatincludsor lthe intormation described aboincome would attach ve to
4.Certify that FATCA code(s)entered on this form(if any)indicating support that exemption.
that you are exempt from the FATCA reporting,is correct.See What r It you are a nonresident alien or a foreign entity,give the requester the
FATCA reporting,later,for further information. appropriate completed Form W-8 or Form 8233.
Note:If you are a U.S.person and a requester gives you a form other
than Form W-9 to request your TIN,you must use the requester's form if Backup Withholding
it is substantially similar to this Form W-9. What is backup withholding?Persons making certain payments to you
Definition of a U.S.person.For federal tax purposes,you are must under certain conditions withhold and pay to the IRS 28%of such
considered a U.S.person if you are: payments.This is called"backup withholding." Payments that may be
•An individual who is a U.S.citizen or U.S.resident alien; subject to backup withholding include interest,tax-exempt interest.
•A partnership,corporation,company,or association created or dividends,broker and barter exchange transactions,rents,royalties,
nonemployee pay,payments made in settlement of payment card and
organized in the United States or under the laws of the United States; third party network transactions,and certain payments from fishing boat
•An estate(other than a foreign estate);or operators.Real estate transactions are not subject to backup
•A domestic trust(as defined in Regulations section 301.7701-4 withholding.
Special rules for partnerships.Partnerships that conduct a trade or You will not be subject to backup withholding on payments you
business in the United States are generally required to pay a withholding receive if you give the requester your correct TIN,make the proper
tax under section 1446 on any foreign partners'share of effectively certifications,and report all your taxable interest and dividends on your
connected taxable income from such business.Further,in certain cases tax return.
where a Form W-9 has not been received,the rules under section 1446 Payments you receive will be subject to backup withholding it
require a partnership to presume that a partner is a foreign person,and 1.You do not furnish your TIN to the requester,
pay the section 1446 withholding tax.Therefore,if you are a U.S.person 2.You do not certify your TN when required(see the instrvdions for
that is a partner in a partnership conducting a trade or business in the Part II for details),
United States,provide Form W-9 to the partnership to establish your
U.S.status and avoid section 1446 withholding on your share of 3.The LRS tells the requester that you furnished an incorrect TIN,
partnership income. 4.The IRS tells you that you are subject to backup withholding
In the cases below,the following person must give Form W-9 to the because you did not report all your interest and dividends on your tax
partnership for purposes of establishing its U.S.status and avoiding return(for reportable interest and dividends only),or
withholding on its allocable share of net income from the partnership 5.You do not certify to the requester that you are not subject to
conducting a trade or business in the United States. backup withholding under 4 above(for reportable interest and dividend
•In the case of a disregarded entity with a U.S.owner,the U.S.ownera ccounts opened after 1983 only).
of the disregarded entity and not the entity; Certain payees and payments are exempt from backup withholding.
•In the case of a grantor trust with a US.grantor or other U.S.owner, See Exempt payee code,later,and the separate Instructions for the
generally,the U.S.grantor or other US.owner of the grantor trust and Requester of Form W-9 for more information.
not the trust;and Also see Special rules for partnerships.earlier.
•In the case of a U.S.trust(other than a grantor tryst),the U.S.trust
(other than a grantor trust)and not the beneficiaries of the trust. What is FATCA Reporting?
Foreign person.If you are a foreign person or the U.S.branch of a The Foreign Account Tax Compliance Act(FATCA)requires a
foreign bank that has elected to be treated as a US_person,do not use participating foreign financial institution to report all United States
Form W-9.Instead,use the appropriate Form W-S or Form 8233(see account holders that are specified United States persons_Certain
Pub.515,Withholding of Tax on Nonresident Aliens and Foreign payees are exempt from FATCA reporting.See Exemption from FATCA
Entities). reporting code,later,and the Instructions for the Requester of Form
Nonresident alien who becomes a resident alien.Generally,only a W-9 for more information.
nonresident alien individual may use the terms of a tax treaty to reduce Updating Your Information
or eliminate U.S.tax on certain types of income.However,most tax p g
treaties contain a provision known as a"saving clause'Exceptions You must provide updated information to any person to whom you
specified in the saving clause may permit an exemption from tax to claimed to be an exempt payee if you are no longer an exempt payee
continue for certain types of income even after the payee has otherwise and anticipate receiving reportable payments in the future from this
become a US.resident alien for tax purposes. person.For example,you may need to provide updated information R
If you are a U.S.resident alien who is relying on an exception you are a C corporation that elects to be an S corporation,or it you no
contained in the saving clause of a tax treaty to claim an exemption longer are tax exempt.In addition,you must furnish a new Form W-9 if
from US.tax on certain types of income,you must attach a statement the name or TIN changes for the account;for example,if the grantor of a
to Form W-9 that specifies the following five items. grantor trust dies.
1.The treaty country.Generally,this must be the same treaty under
which you claimed exemption from tax as a nonresident alien. Penalties
2.The treaty article addressing the income Failure to furnish TIN.If you fail to furnish your correct TIN to a
3.The article number(or location)in the tax treaty that contains the requester,you are subject to a penalty of$50 for each such failure
saving clause and its exceptions. unless your failure is due to reasonable cause and not to willful neglect.
4.The type and amount of income that qualities for the exemption Civil penalty for false information with respect to withholding.If you
from taei make a false statement with no reasonable basis that results in no
5.Sufficient facts to justify the exemption from tax under the terms of backup withholding,you are subject to a$500 penalty.
the treaty article
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-DADF.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. 31M-M'i L . v t2--Aging 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):
'Srel_cocoa-- .12-
Federal Employer Identification Number(Ifnone,Social Security)
CI T9 vh( w.etl PI •ec rl
Name of Entity,Individual(s),Partners, or Corporation
Doing Business As(if same as above,leave blank)
I'Ioo_ col x t YTtoo cLtJrC�2 01211 ✓Y.1 uA,✓.q 61_Z4ct+1 cc-L3 31 -1
Street Address City Stale Zip Code
1. 14IAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT(Sec.2-8.1 of the County Code)lA
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 arc(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 othenvise)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(5500.00)or imprisonment in the Countyjail 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
2.x 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. DDs your firm have a collective bargaining agreement with its employees?
Yes No
b. Diu'your firm provide paid health care benefits for its employees?
Yes No
c. Provide a current breakdown(number of persons)of your firm's
work force and ownership as to race,national origin and gender:
White: Males: Female:
Black: Males: Female:
Hispanic: _ Males: Female:
Asian: Males: Female:
American Native: __ Males: Female: _
Aleut(Eskimo): Males: ' Female:
3.V AFFIRMATIVE ACTION/NONDISCRIMINATION OF EMPLOYMENT,PROMOTION AND
CUREMENT 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 hi 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 ofthe Board of County Commissioners by majority vote
ofthe members present.
The Finn does not have annual gross revenues in excess of$5,000,000.
_ The Firm does have annual revenues in excess of 55,000.000;however,its Board of Directors is representative ofthe
population make-up ofthe 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 NM, 1st Avenue,28th Floor,Miami,Florida 33128.
The Finn has annual gross revenues in excess of S5,000,000 and the firm does have a written affirmative action
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.M. 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 F"Miami-Dade County Required Affidavits' Page 2 of 5
ATTACHMENT F
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
4. MIAMI-DADE COUNTY CRIMiFAL RECORD AFFIDAVIT(Section 2-8.6 of the County Code)
The individual or entity entering into a contract or receiving funding from the County _hashas 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. y 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 fan'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 ofthe 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 ofthis ordinance in those instances where those provisions are in conflict with
the requirements of those governmental entities.
6. 1/4f- MIAMI-DADS 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(I)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.
7.11 DISABILITY NON-DISCRIMLNA'TION AFFIDAVIT(County Resolution R-385-95)
That the above named firm, corporation or organisation 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 ofthe 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 IT,Public Services; Title Ill,Public Accommodations and Services Operated
by Private Entities;Title IV,Telecommunications;and Title V,Miscellaneous Provisions;The Rehabilitation Act of 1973,29
C.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 ofthis State.
ATTACHMENT F"Miami-Dade County Required Affidavits" Page 3 of 5
ATTACHMENT F
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS
8. k MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE FEES OR TAXES(Sec.2-
8.1(e)of the County Code)
Except for small purchase orders and sole source contracts,that above named firm,corporation,organization or individual
desiring to transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes-
-including but not limited to real and property taxes,utility taxes and occupational licenses--which are collected in the normal
course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of
the firm,corporation,organization or individual have been paid.
9. CURRENT ON ALL COUNTY CONTRACTS,LOANS AND OTHER OBLIGATIONS(Ordinance 99-162)
The individual entity seeking to transact business with the County is current in all its obligations to the County and is not
otherwise in default of any contract,promissory note or other loan document with the County or any of its agencies or
instrumentalities.
10. DOMESTIC VIOLENCE LEAVE AND REPORTING AFFIDAVIT(Resolution 185-00;99-5 Codified At
11A-6 F.t.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 F"Miami-Dade County Required Affidavits" Page 4 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)
YHAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
By: 311 I14 \�wr..+_ _ 1 t , 20 It
Sign ttness o Secretary Seal Date -
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Signature o Affiant Federal Employer Identification Number
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Printed MIA of Affiant and Name of Agency
1co C-O)..... l %c NJ cep-re 2 012ltlE - nAt An t H
Address of Agency ,�G�
SUBSCRIBED AND SWORN TO (or affirmed) before me this)' day of N,f SGiv ,20 1
He/She i ersonally lmown�o me or has presented _as identification.
Type of identification
Nati 4 o1-1d
Si DEPINEOO Serial Number
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ATTACHMENT F"Miami-Dade County Required Affidavits" Page 5 of 5