Amendment No. 2 to the Agreement with Miami-Dade County PC-1718-ID-2 2erli -,)590
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-7718-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
THISNDMENT #2 OF THE AGREEMENT (the "Agreement Amendment #2") is made as of
l.�aCJ Q 2a(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 S 25,000.00
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-1718-ID-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 are
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
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 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. §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 I.S.C. §17101 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 seth It is expressly understood that the Provider must submit an affidavit
attesting that it is not in violation of the Acts. If the Provider or any owner, subsidiary, or other firm affiliated
with or related to the Provider is found by the responsible enforcement agency,the Courts or the County to be in
violation of these acts,the County will conduct no further business with the Provider.
Any contract entered into based upon a false affidavit shall be voidable by the County. If the Provider violates
any of the Acts during the term of any contract the Provider has with the County, such contract shall be voidable
by the County,even if the Provider was not in violation at the time it submitted its affidavit.
The Provider agrees that it is in compliance with the Domestic Violence Leave, codified as § 11A-60 et seq. of
the Miami-Dade County Code, which requires an employer, who in the regular course of business has fifty(50)
or more employees working in Miami-Dade County for each working day during each of twenty (20) or more
calendar work weeks to provide domestic violence leave to its employees.
Failure to comply with this local law may be grounds for voiding or terminating this Contract or for
commencement of debarment proceedings against Provider.
ARTICLE 111—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 PROGRAM CONTRACT#: PC-1718-ID-2
IN WI[NESS WHEREOF, the parties have caused this four (41 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 01 MIAMI : ACH MIAMI-DADE COUNTY
By: �����` By: 77 bla
,
Name: J1 `-1 L. YVlol2t -t ES Name: MAURICE L. KEMP
DEPUTY MAYOR
Title: G+ rnWr-1 AGES Title:
MIAMI DADE CTY. FL
Date: 3/I r/C _ Date: 4 frok
Attest: Attest
3
���JJJ )I` �IY HARVEY RUVIN, Clerk
Authorized Person OR Notary Board of County Commissioners
Public
Print Name: TRPPPLT . caBy:
nrnPu
Title: a 17 C t_CA 4. Print Name: _et/ S
G� v,
Corporate Seal OR Notary Seal/Stamp:
ISI ; Js i
f\
i U 'qat -,!", -
This Agreement is approved as fa form and legal sufficiency. See memorandum dated 1/Ltd/0• .
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
City Auorne:�t„ _ D�o4
THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE GRANT
GRANT It: 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 17ih 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 200 or 66% of homeless clients will obtain vital personal
identification documents. identification documents.
3. I tameless clients will obtain official photo 150 or 50% of homeless clients will obtain official photo
identification. identification.
PLEASE INSERT
AN UPDATED
ATTACHMENT "B"
BUDGET
FOR THE 2017-2018 GRANT YEAR
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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: S
AMOUNT OF FUNDS RECEIVED TO DATE: S
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
3- l4- lis
City Attorney 11, Dote
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 MIAMI BEACH
S 25,000.00
Month of Services Amount Paid
October 2017
November 2017
December 2017
January 2018
February 2018
March 2018
April2018
May 2018
June 2018
July-2018
August 2018 I
September 2018
Total Requested S 0.00
Balance Remaining S 25,000.00
Executive Director Signature or Authorized
Agency Representative Signature
Executive Director or Authorized Agency
Representative-Printed Name
Signature Date
APPROVED AS TO
FORM & LANGUAGE
& FO E UTION
City Attorney 11 Date
Foes W-9 Request for Taxpayer , Give Form to the
(Rev.Novernber2017) identification Number and Certificationrequester.Do not
trepanned of the Twaysend to the IRS.
Internal Revenue Service •Go to wescirs.gov/FormW9 for instructions and the latest information.
1 Name(as sown on your income tax raft Name b required on this line;do not reeve the in.bed.
07-1 dF rAnCifiht 13cIACH
2 Business mane/disregarded amity name.Il different M1ana:4w,
e) 3 Check apgnprWa box for Waal tax classification of thewhom name person whonm bur
ened on line I.Check only one of thea Exemptions(codes apply only to
following seven boxu calash sets,not iSiuiduW:see
st,ucitns on page 31:
o 0 Indedayepb proprietor or 0 cC w..ton 0 s Cowrmen 0 Partnership 0 Trust/estate
• singe-Member LLC Exempt payee code(If any)
re c
n 9 0 Limited W
ited liability mnY.En the tax classification(G=.corporation,S.5 corporation,P.PannenMp)e
Note:Cock to appropriate box in the Gov above for the to dev'SOAIan of the singe-member owns. Do net check Eunpden from FATCA reporting
LLL vLW theG dawdled aa akgrame^her LLC that w
disregarded from the owner unless the anew of the LLC 4
L= wo
another tic aha Is rot 6vegarded from the owner for for U.S.lateral tax purposesOdwwlse.a,in9hmembe LLC that stlsm
a. o b disregarded for the owner should cheek the appropriate box for the tax dasalliodo of its owner.
P fl Other sem tioner- Woes leso t messed,SSI,sUu
ar 5 Address(numbs,Stet,and so,�a�W� no.)See insmma.taRecuatees name and address(ocea(oceans()da
rE (100 Co)-a C}I Ttc}J CE I-s tet Q 21&
e City.sate aairt4 R_ '31.f 1
(iy�cphrl^i 'Je - 1
7 List account nLtthII1)1w.(optona
Lai Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on lire 1 to avoid I Social mowing number I
backup withholding.For individuals,this S generally your social security number(SW.However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other - 1 -
entities,it is your employer identification number(EIM.H you do not have a number.see How to get a
TIN.later. or -
Note:If the account S in more than one name.see the instructions for tine 1.Also see Whet Name and I Endorser Identification manger 1
Number To Give the Requester for guidelines on whose number to enter. l" _ L`J['CO 31 21
LULU Certification
Under penalties of perjury,I cartiy that
1.The number shown on this form S 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 wihholdirg because:(a)I am exempt from backup withholding,aro)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 dMdends.or(c)the IRS has notified arc that I am
no longer subject to backup wilttoking:and
3.1 am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form et aiM indicating that I am exempt from FATCA reporting a correct
Certification instructions You must ours out Rem 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 •dMdends on • r tax ream.For real estate transactions,item 2 does not apply.For mortgage interest paid,
tions to an IndNidual retirement
angement OITA).and
ents
outer than interest and dMdeerds, • are enot�requied •sign the ccarficaon,n,but you must provide your wnectTIN.See the Instructions Pat�II,,nlater.
Sign 3lgmbeeW �r _
person oat.a
Here us.person a
General Instructio1 s •Form 1099-DW(dividends,including those from stocks or mutual
funds)
Section references are to the I - Revenue Code unless otherwise •Form 1099-MISC(various hyper of Income,prizes,awards,or gross
noted. - proceeds)
Future developments.For the lat-t information about developments •Form 1099-B(stock or mutual fund salesand certain other
to
related to Form W-9 and Its i ,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.9ov/FnmW9. •Form 1099-S(proceeds from real estate transactions)
Purpose of Form •Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who S required to file m 'Form 1098(home mortgage interest),1098-E(student loan interest).
information return d m with the IRS muobtain your correct taxpayer . 1098-T(Witton)
IdentMcaon number(Dr)which may be you social security number •Form 10990(canceled debt)
(SSM,individual taxpayer identification number 01133,adoption •Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIM,or employer Identification number Use Form W-9 on'y if you are a U.S.pawn(nctdirg a resident
(EIM,to report ori an idm
aaon realm the amount paid to you,or other alien).to provide your correct TIN.
amount reportable on an information ream.Examples of information tt do not realm 901111W-9 M the requester with a TIN,you might
•Form include,but are not limited to,the following. be�to backup withholding.See What is backup withholding,
•Form 1099-NT(interest earned or paid) later.
Cat.No.10231X Fonn W-9(Rev.1t-2oit)
•
form W-9(Rev.11-2017) Paget
By signing the filled-out form,you: Example.Article 20 of the U.S.-Gina income tax treaty allows an
1.Certify that the TIN you are giving is correct(or you are waiting for a exemption from tax for scholarship income received by a Chinese
number to be the u
student temporarily present in the United States.Under U.S.law,this
student will become a resident alien for tax purposes H his or her stay in
2.Certify that you are not subject to backup withholding,or the United States exceeds S calendar years.However,paragraph 2 of
3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated Apnl 30,1984)allows
the provisions of Artcle 20 to continue to apply even after thechirese
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 U.S.trade or business student who qualifies for this exception(under paragraph 2 of the fist
Is not subject to the withholding tax on foreign partners'share of protocol)and S relying on thisexceptbn to claim an exemption from tax
effactively connected Income,and on his or her scholarship or fellowship income would attach to Form
4.Cerny that FATCA code(s)entered on this form Of echo intlir tltl W-9 a statement that incudes the Information described above to
that you are exempt from the FATCA rti support that nonresm.
epodirg,is correct See Wiener If you are a no^rcteent alien or foreigna
FATCA reporting,later,for further intimation. entity,give the requester the
appropriate completed Form W-6 or Form 8233.
Note:If you are a U.S.person and a requester gives you a fern other
than Form W-9 to request your TIN,you must use the requesters form if Backup Withholding
it is substantially similar to this Form W-9. What is backup wtthhokling2 Persons making certain payments to you
Definition of a U.S.person.For federal tax purposes,you am 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•Wckup withholding? Payments that may be
•An individual who is a U.S.citizen or U.S.resident alien; subject to b Jatp 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
•M estate(other than a foreign estate);or operators.Real estate transactions are not subject to backup
•A domestic trust(as defined in Regulations section 301.7701-7). withholding.
Special rules for partnerships.Partrherships 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 tyou 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 trade'income from such business.Further,in certaincases 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 if:
require a partnership to presume that a partner is a foreign person,and
pay the section 1448 withholding tax.Therefore,if you are a U.S.PelsonI.You do not finish your TIN to the requests,
that is a partner in a partnership conducting a trade or business in the 2.You do not certify your TlN when required(see the instructions for
United States,provide Fara W-9 to the partnership to establish your Part H for details),
U.S.status and avoid section 1446 wNrholdiig on your share of 3.The IRS tells the requester that you furnished an incorrect TIN,
partnership income. 4.The IRStell 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. baclghp wpttplding under 4 above(for reportable interest and dividend
•In the case of a disregarded entity with a U.S.owner,the US.owner accents opened after 1983 only).
of the disregarded entity and not the entity
Certain yeas and payments are ex from backup withholding.
gInthe y,tta of. .grantor or thenaU.S. nr ofor or^tineU.S.owner,d Req ester ofpayeerm W-9f more information. for the
generally,the U.S.grantororother U.S.owner the grantor Wet and RequastetFmn W-9 for more in/motion.
not the Susi and Sao see Special rules for partnerships,earlier.
•In the case of a U.S.trust(other than a grantor trout),the U.S.trust
(other than a grantor must)and not the beneficiaries or the trust What is FATCA Reporting?
Foreign person.if you are a foreign person orthe U.S.branch of a The Foreign Account Tax Compliance Act(FATCA)requires a
foreign bank that has elected to be treated as a U.S.person,do not use Participating foreign financial institution to report as United States
Form W-9.Instead,use the appropriate Form W-8 or Form 6233(see a en rot holders that are specified United States persons.Certain
Pub.515,Withholding of Tax on Nonresident Aliens and Foreign payees am 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
or eliminate U.S.tax on certain types of income.However,most tax Updating Your Information
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 U.S.resident alien for tax purposes. person.For example,you mayneed toprovide updatedinformation if
ni
Ifyou d U.S.nesidstslieo who is relying on an nexception you are aCxexeaptI that elects[oDeus Scmh corporation,Foryou W9i
contained U.S.E in the saving clause of a tax treaty to claim a exemption longer are tax N exempt In for thac you must furnish l new Form grantor
from U. tax on certain types of income you must attach a statement gra t or TIN changes for the account for example,if the of a
to Form W-9 that specifies the following five items, grantor trust dies.
t.The
you
treaty la ed eGenerally,frothis must bethe same treat'under
which ver,clamed exemption from tax as a nonresident alien. PenahieS
2.The treaty article addressing the income. Failure to furnish TIN.C you fail to furnish your correct TIN to a
3.The article number(or location)in the tax treaty that contains the requests,you are subject to a penalty of$SO 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 qualifies for the exemption Civil penalty for false information with respect to withholding.if you
from tax.
5.Sufficient facts to justify the exemption from tax under the terms of make a false statement with no reasonable basis that result/in no
the treaty article. backup withholding,you are sublet to a SSoO penalty.
•
MIAMI-DADE COUNTY REQUIRED AFFIDAVITS ATTACHMENT F
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-DADS
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, l \My L .✓Yting 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):
re
Federal Employer Identification Number(If none,Social Security)
U T`I el- vvkl i t3EA r1
Name of Entity,Individual(s),Partners,or Corporation
Doing Business As(if same as above,leave blank)
'loo OIL) C€)JY&2 Ole y v4Mn' ,3LC/4Ct44 62331 �Sj'
Street Address City State Zip Code
1.AleMIAMI-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 lull legal names and business address of any other individual(other than subcontractors,material men,suppliers,laborers,
or lenders)who have,or will have,any interest(legal,equitable beneficial or otherwise) in the contract or business transaction
with Dade County are(Post Office addresses are not acceptable):
Any person who willfully fails to disclose the information required herein,or who knowingly discloses false information in this
regard,shall be punished by a fine of up to five hundred dollars($500.00)or imprisonment in the Countyjail for up to sixty
(60)days or both.
ATTACHMENT F "Miami-Dade County Required Affidavits" Page 1 of 5
ATTACHMENT F
V MIAMI-DADE COUNTY REQUIRED AFFIDAVITS .
2. /� MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT(County Ordinance 90-133,
Amending see 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 often 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. [Xs your firm have a collective bargaining agreement with its employees?
Yes No
b. Dvyour firm provide paid health care benefits for its employees?
J 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:
Ifispanic: Males: Female:
Asian: _ Males: Female:
American Native: Males: Female:
r / Aleut(Eskimo): _ Males: ' Female:
3. AFFIRMATIVE ACTION/NONDISCRIMINATION OF EMPLOYMENT,PROMOTION AND
iyi
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 in its employment,promotion and procurement practices. The foregoing notwithstanding,corporate
entities whose boards of directors are representative of the population make-up of the nation shall be presumed to have non-
discriminatory employment and procurement policies,and shall not be required to have written affirmative action plans and
procurement policies in order to receive a County contract. The foregoing presumption may be rebutted.
The requirements of County Ordinance No.98-30 may be waived upon the written recommendation of the County Manager
that it is in the best interest of the County to do so and upon approval of the Board of County Commissioners by majority vote
of the members present.
The Firm does not have annual gross revenues in excess of$5,000,000.
The Firm does have annual revenues in excess of$5,000,000;however, its Board of Directors is representative of the
population make-up of the nation and has submitted a written, detailed
listing of its Board of Directors,including the race or ethnicity of each board member,to the County's Department of Business
Development, 175 N.W, 1st Avenue,28th Floor,Miami,Florida 33128.
TYThe Finn has annual gross revenues in excess of$5,000,000 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.W. 1st Avenue,28th Floor,
Miami,Florida 33128;
The Firm does not have an affirmative action plan and/or a procurement policy as described above,but has been
granted a waiver.
ATTACHMENT F"Miami-Dade County Required Affidavits' Page 2 of 5
ATTACHMENT
( 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 j'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-DADE EMPLOYMENT DRUG-FREE WORKPLACE AFFIDAVIT(County Ordinance 92-15
codified as Section 2-8.1.2 of the County Code)
That in compliance with Ordinance No. 92-15 of the Code of Miami-Dade County,Florida,the above named person or entity
is providing a drug-free workplace. A written statement to each employee shall inform the employee about:
danger of drug abuse in the workplace
the firm's policy of maintaining a drug-free environment at all workplaces
availability of drug counseling,rehabilitation and employee assistance programs
penalties that may be imposed upon employees for drug abuse violations
The person or entity shall also require an employee to sign a statement,as a condition of employment that the employee will
abide by the terms and notify the employer of any criminal drug conviction occurring no later than five(5)days after receiving
notice of such conviction and impose appropriate personnel action against the employee up to and including termination.
Compliance with Ordinance No.92-15 maybe 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
Section 11A-29 et.seq of the County Code)
That in compliance with Ordinance No. 142-91 of the Code of Miami-Dade County,Florida,an employer with fifty(50)or
more employees working in Dade County for each working day during each of twenty(20)or more calendar work weeks, shall
provide the following information in compliance with all items in the aforementioned ordinance:
An employee who has worked for the above firm at least one(1)year shall be entitled to ninety(90)days of family leave
during any twenty-four(24)month period,for medical reasons,for the birth or adoption of a child,or for the care of a child,
spouse or other close relative who has a serious health condition without risk of termination of employment or employer
retaliation.
The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof,or the
State of Florida or any political subdivision or agency thereof. It shall,however,pertain to municipalities of this State.
7. . DISABILITY NON-DISCRIMINATION AFFIDAVIT(County Resolution R-385-95)
That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and
assure that any subcontractor,or third party contractor under this project complies with all applicable requirements of the laws
listed below including,but not limited to,those provisions pertaining to employment,provision of programs and services,
transportation,communications,access to facilities,renovations,and new construction in the following laws: The Americans
with Disabilities Act of 1990(ADA),Pub.L.101-336, 104 Stat 327,42 U.S.C. 12101-12213 and 47 U.S.C. Sections
225 and 611 including Title I,Employment;Title 11,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
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
....------------
8. .k MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE FEES OR TAXES(Sec.2-
8.1(c)of the County Code)
Except for small purchase orders and sole source contracts,that above named firm,corporation,organization or individual
desiring to transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes-
-including but not limited to real and property taxes,utility taxes and occupational licenses—which are collected in the normal
course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of
the firm,corporation,organization or individual have been paid.
9. 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 ELSeq.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
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ATTACHMENT F"Miami-Dade County Required Affidavits" Page 4 of S
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)
i MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
By: 31l IITy `�wocas, 1 4' , 20 It
Signa/".:7"-Witness o Secretary Seal Date
CI— (ot 3-1
Signature .Affiant Federal Employer Identification Number
J11^^^. L. nba-e L S C1-C`1 CJ E- r t/q„A. 4ePCti
Printed Nam: of Affiant and Name of Agency
1100 c .aA 3TtorJ cute 00-la rvMAlrnt frernC H
Address of Agency
-1
SUBSCRIBED AND SWORN TO (or affirmed)before me this b day of j .,(Ct �I ,20
�,
He/She i ersonally known do me or has presented as identification.
Type of identification
(a-F( ' —'ll t t-
Sr? .12,!., 7,--;T .t ADADADEPINEDO Serial Number
"0.' MY COMMISSION eFH2€641
'aiwiF EXPIRES:SBPIemfer 26.2010
'" �' BE TNu notaryaecunderNe.
Pri 1-- ---:-.-71-1.1 e e 10 y Expiration Date
Notary Public— State of 1 CY (.11
County of Irl I rlrn-t -I'n- e
i 7417.BFq Notary Seal
INCORP ORATED[ */
CH 26
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ATTACHMENT F "Miami-Dade County Required Affidavits" Page 5 of 5