City of Miami Beach Grant in the amount of $37,333.00 22011 - 3o726
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
f) The words "Effective Term" shall mean the date on which this Contract is effective, including
start date and end date.
g) The words "Extra Work" or "Change Order" or "Additional Work" shall mean resulting in
additions or deletions or modifications to the amount, type or value of the Work and Services
as required in this Contract, as directed and/or approved by the County.
h) "HIPAA" means Health Insurance Portability and Accountability Act of 1996.
i) The words "Scope of Services" shall mean the document appended hereto as Attachment A,
which details the work to be performed by the Provider.
j) The word "subcontractor" or "sub consultant" shall mean any person, entity, firm or
corporation, other than the employees of the Provider, who furnishes labor and/or materials, in
connection with the Work, whether directly or indirectly, on behalf and/or under the direction of
the Provider and whether or not in privities of contract with the Provider.
k) The words "Work", "Services" "Program", or "Project" shall mean all matters and things required
to be done by the Provider in accordance with the provisions of this Contract.
ARTICLE 2. AMOUNT PAYABLE. Subject to available funds, the maximum amount payable for
services rendered under this contract shall not exceed:
1. HMIS Staffing Program $ 12,333.00
2. Identification Assistance Program $ 25,000.00
Total Award: $ 37,333.00
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.
Availability of funding shall be determined in the County's sole discretion.
All services undertaken by the Provider before the County's execution of this Contract shall be at the
Provider's risk and expense.
It is the responsibility of the Provider to maintain sufficient financial resources to meet the expenses
incurred during the period between the provision of services and payment by the County.
The County, at its sole discretion and approval, may allow Provider an advance of up to two (2)
months once the Provider has submitted an appropriate request and submitted an invoice in the form
required by the County.
ARTICLE 3. SCOPE OF SERVICES
The Provider shall render services in accordance with the Scope of Services incorporated
herein and attached hereto as Attachment A.
Page 2 of 27
i
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#:. PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
GRANT CONTRACT
(,.This Grant Contract ( the "Contract" or"Grant Agreement") is made and entered into as of this
20 day of \ L0-( A-%._ , 20 l(, by and between Miami-Dade County, through the Miami-Dade
County Homeless Trust, a political subdivision of the State of Florida (the "County"), having its
principal office at 111 N.W. 1st Street, 27th Floor, Miami, Florida 33128 and The City of Miami
Beach/FEIN#: 59-6000372, a corporation organized and existing under the laws of the State of
Florida, having its principal office at 1700 Convention Center Drive, Miami Beach, Florida 33139
("Provider"), states conditions and covenants for the rendering of human and social services
("Services") for the County.
WHEREAS, the Provider provides or will develop social services of value to the County and
has demonstrated an ability or desire to provide these services; and
WHEREAS, the County is desirous of assisting the Providers and the affected programs with
funding to continue the provision of those essential services and the Provider is desirous of providing
such services; and
WHEREAS, the County has appropriated grant funds for the proposed services;
NOW, THEREFOREk, in consideration of the mutual covenants and agreements herein
contained, the parties hereto agree as follows:
ARTICLE 1. DEFINITIONS
The following words and expressions used in this Grant Agreement shall be construed as follows,
except when it is clear from the context that another meaning is intended:
a) The words "Agreement" "Contract" or "Contract Documents" shall mean collectively these
terms and conditions, the Scope of Services (Attachment A) and the Budget Documents
(Attachment B) and all other attachments hereto, as well as all amendments or budget
revisions issued hereto.
b) The words "Contract Manager" shall mean Miami-Dade County's Director of the Homeless
Trust ("County") or the Director's designee, or the duly authorized representative designated
to manage the Contract.
c) The word "Days" shall mean Calendar Days, unless otherwise specifically noted.
d) The word "Deliverables" shall mean all documentation and any items of any nature submitted
by the Provider to the County for review and approval pursuant to the terms of this Contract.
e) The words "directed", "required", "permitted", "ordered", "designated", "selected", "prescribed"
or words of like import to mean respectively, the direction, requirement, permission, order,
designation,- selection or prescription of the County's Contract Manager; and similarly the
words "approved", acceptable", "satisfactory", "equal", "necessary", or words of like import to
mean respectively, approved by, or acceptable or satisfactory to, equal or necessary in the
sole discretion of the County's Contract Manager.
Page 1 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
The Provider shall implement the Scope of Services as described in Attachment A in a
manner deemed satisfactory to the County. Any modification or amendment to the Scope of Services
shall not be effective until approved by the County and Provider in writing.
ARTICLE 4. BUDGET SUMMARY
The Provider agrees that all expenditures or costs shall be made in accordance with the
Budget for the provision of services in accordance with Attachment A, the "Scope of Services". The
Budget is attached hereto and incorporated herein as Attachment B.
The parties agree that the Provider may, with the County's prior written approval; revise the
schedule of payments or the line item budget, and such revision shall not require an amendment to
this Contract.
Pursuant to Board of Miami-Dade County Commissioners Resolution 630-13, the Provider will submit
a detailed project budget, and sources and uses statement as Attachment B-1, which shall be
sufficiently detailed to show (i) the total project cost, (ii) the amount of funds to be used for
administrative and overhead costs, (iii)whether the County funds will be 'gap'funds meaning that they
would be the last remaining funds needed to ensure funding for the total project cost, (iv) any profit to
be made by the Provider, and (v) the amount of funds devoted toward the provision of the desired
services or activities.
The County Mayor or Mayor's designee may make unannounced, on-site visits during normal working
hours to the Provider's headquarters and any location or site where the services contracted for under
this Agreement are performed.
ARTICLE 5. EFFECTIVE TERM
Both parties agree that the Effective Term of this Contract shall commence on
October 1, 2018 and terminate at the close of business on September 30, 2019. Contingent on the
existence of sufficient funding, performance and the approval of the County, this Contract may be
extended at the County's sole discretion.
ARTICLE 6. INDEMNIFICATION BY PROVIDER
A. Government Entity. Government entity shall indemnify and hold harmless the County
and its officers, employees, agents and instrumentalities from any and ail liability, losses or damages,
including attorneys' fees and costs of defense, which the County or its officers, employees, agents or
instrumentalities may incur as a result of claims, demands, suits, causes of actions or proceedings of
any kind or nature arising out of, relating to or resulting from the performance of this Contract by the
government entity or its employees, agents, servants, partners, principals or subcontractors.
Government entity shall pay all claims and losses in connection therewith and shall investigate and
defend all claims, suits or actions of any kind or nature in the name of the County, where applicable,
including appellate proceedings, and shall pay all costs, judgments, and attorney's fees which may
issue thereon. Provided, however, this indemnification shall only be to the extent and within the
limitations of Section 76.8.28, Fla. Stat.
Page 3 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
B. All Other Providers. Provider shall indemnify and hold harmless the County and its
officers, employees, agents and instrumentalities from any and all liability, losses or damages,
including attorneys' fees and costs of defense, which the County or its officers, employees, agents or
instrumentalities may incur as a result of claims, demands, suits, causes of actions or proceedings of
any kind or nature arising out of, relating to or resulting from the performance of this Contract by the
Provider or its employees, agents, servants, partners principals or subcontractors. Provider shall pay
all claims and losses in connection therewith and shall investigate and defend all claims, suits or
actions of any kind or nature in the name of the County, where applicable, including appellate
proceedings, and shall pay all costs, judgments, and attorney's fees which may issue thereon.
Provider expressly understands and agrees that any insurance protection required by this Contract or
otherwise provided by Provider shall in no way limit the responsibility to indemnify, keep and save
harmless and defend the County or its officers, employees, agents and instrumentalities as herein
provided.
C. Term of Indemnification. The provisions of Article 6 shall survive the expiration or
termination of this Contract.
ARTICLE 7. INSURANCE
If the total dollar value of all County contracts with the Provider exceeds $25,000 then the following
insurance coverage is required:
A. Government Entity. If the Provider is the State of Florida or an agency or political
subdivision of the State as defined by section 768.28, Florida Statutes, the Provider shall furnish the
County, upon request, written verification of liability protection in accordance with section 768.28,
Florida Statutes. Nothing herein shall be construed to extend any party's liability beyond that provided
in section 768.28, Florida Statutes. The provider shall also furnish the County, upon request, written
verification of Workers Compensation protection in accordance with Chapter 440, Florida Statutes.
B. All Other Providers.
1. Minimum Insurance Requirements: Certificates of Insurance. The Provider
shall submit to Miami-Dade County, do Miami Dade County Homeless Trust (COUNTY), 111 N.W. 1St
Street, 27th Floor, Miami, Florida 33128-1994, original Certificate(s) of insurance indicating that
insurance coverage has been obtained which meets the requirements as outlined below:
A. All insurance certificates must list the County as "Certificate Holder" in the following
manner:
Miami-Dade County
111 N.W. 1st Street, Suite 2340
Miami; Florida 33128
B. Worker's Compensation Insurance for all employees of the Provider as required by
Chapter 440, Florida Statutes.
C. Commercial General Liability Insurance in an amount not less than $300,000 combined
single limit per occurrence for bodily injury and property damage. Miami-Dade County
must be shown as an additional insured with respect to this coverage.
Page 4 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
D. Automobile Liability Insurance covering all owned, non-owned, and hired vehicles used
in connection with the Work provided under this Contract, in an amount not less than
$300,000* combined single limit per occurrence for bodily injury and property damage.
*NOTE: For Providers supplying vans or mini-buses with seating capacities of fifteen
(15) passengers or more, the limit of liability required for Auto Liability is $500,000.
E. Professional Liability Insurance in the name of the Provider, when applicable, in an
amount not less than $250,000.
F. All insurance policies required above shall be issued by companies authorized to do
business under the laws of the State of Florida, with the following qualifications:
1. The company must be rated no less than "B" as to management, and no less
than "Class V" as to financial strength, according to the latest edition of Best's
Insurance.Guide published by AM. Best Company, Oldwick,:New Jersey, or its
equivalent, subject to the approval of the County's Risk Management Division.
OR
2. .The company must hold a valid Florida Certificate of Authority as shown in the
latest "List of All Insurance Companies Authorized or Approved to Do Business
in Florida," issued by the State of Florida Department of Insurance, and must be
a member of the Florida Guaranty Fund.
G. Certificates will indicate that no modification or change in insurance shall be made
without thirty (30) days advance written notice to the Certificate Holder.
H. Compliance with the foregoing requirements shall not relieve the Provider of its liability
and obligations under this Section or under any other section of this Contract.
The County reserves the right to inspect the Provider's original insurance policies at
any time during the term of this Contract.
J. Applicability of this Article to Providers whose combined total award for all services
. funded under this Contract exceeds a $25,000 threshold. In the event that the Provider
whose original total combined award in less than $25,000, but receives additional
funding during the contract period which makes the total combined award exceed
$25,000, then the requirements in this Article shall apply.
K. Failure to Provide Certificates of Insurance. The Contractor shall be responsible for
assuring that the insurance certificates required in conjunction with this Section remain
in force for the duration of the effective term of this Contract. If insurance certificates
are scheduled to expire during the effective term, the Provider shall be responsible for
submitting new or renewed insurance certificates to the County prior to expiration.
In the event that expired certificates are not replaced with new or renewed certificates
which cover the effective term, the County may suspend the Contract until such time as
the new or renewed certificates are received by the County in the manner prescribed
herein; provided, however, that this suspended period does not exceed thirty (30)
Page 5 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
calendar days. Thereafter, the County may, at its sole discretion, terminate this
Contract.
ARTICLE 8. PROOF OF LICENSURE/CERTIFICATION AND BACKGROUND SCREENING
A. Licensure. If the Provider is required by the State of Florida or Miami-Dade County or any
federal, state or local law or regulation to be licensed or certified to provide the services or operate the
facilities outlined in the Scope of Services (Attachment A), the Provider shall furnish to the County a
copy of all required current licenses or certificates. Examples of services or operations requiring such
licensure or certification include but are not limited to childcare, day care, nursing homes, and
boarding homes.
If the Provider fails to furnish the County with the licenses or certificates required under this
Section, the County shall not disburse any funds until it is provided with such licenses or certificates.
Failure to provide the licenses or certificates within sixty (60) days of execution of this Agreement may
result in termination of this Agreement at the County's discretion.
B. Background Screening. The Provider agrees to comply with all applicable federal,
state and local laws, regulations, ordinances and resolutions regarding background screening of
employees, volunteers and subcontractors. Provider's failure to comply with any applicable laws,
regulations, ordinances and resolutions regarding background screening of employees, volunteers
and subcontractors is grounds for a material breach and termination of this contract at the sole
discretion of the County.
The Provider agrees to comply with all applicable laws (including but not limited to Chapters
39, 402, 409, 394, 408, 393, 397, 984, 985 and 435, Florida Statutes, as may be amended form time
to time), regulations, ordinances and resolutions, regarding background screening of those who may
work or volunteer with vulnerable persons, as defined by section 435.02, Florida Statutes, as may be
amended from time to time.
In the event criminal background screening is required by law, the State of Florida and/or the
County, the Provider will permit only employees and subcontractors with a satisfactory national
criminal background check through an appropriate screening agency (i.e., the Florida Department of
Juvenile Justice, Florida Department of Law Enforcement or Federal Bureau of Investigation) to work
or volunteer in direct contact with vulnerable persons.
The Provider agrees to ensure that employees, volunteers and subcontracted personnel who
work with vulnerable persons satisfactorily complete and pass Level 2 background screening before
working or volunteering with vulnerable persons. Provider shall furnish the County with proof that
employees, volunteers and subcontracted personnel, who work with vulnerable persons, satisfactorily
passed Level 2 background screening, pursuant to Chapter 435, Florida Statutes, as may be
amended from time to time.
If the Provider fails to furnish to the County proof that an employee, volunteer or
subcontractor's Level 2 background screening was satisfactorily passed and completed prior to that
employee or subcontractor working or volunteering with a vulnerable person or vulnerable persons,
Page 6 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
the County shall not disburse any further funds and this Contract may be subject to termination at the
sole discretion of the County.
ARTICLE 9. CONFLICT OF INTEREST
A. The Provider agrees to abide by and be governed by Miami-Dade County Ordinance
No. 72-82 (Conflict of Interest Ordinance codified at,Section 2-11.1 et al. of the Code of Miami-Dade
County), as amended, which is incorporated herein by reference as if fully set forth herein, in
connection with its contract obligations hereunder.
B. No person under the employ of the County, who exercises any function or
responsibilities in connection with this Contract, has at the time this Contract is entered into, or shall
have during the term of this Contract, any personal financial interest, direct or indirect, in this Contract.
C. Nepotism. Notwithstanding the aforementioned provision, no relative of any officer,
board of director, manager, or supervisor employed by the Provider shall be employed by the Provider
unless the employment preceded the execution of this Contract by one (1) year. No family member of
any employee may be employed by the Provider if the family member is to be employed in a direct
supervisory or administrative relationship either supervisory or subordinate to the employee. The
assignment of family members in the same organizational unit shall be discouraged. A conflict of
interest in employment arises whenever an individual would otherwise have the responsibility to
make, or participate actively in making decisions or recommendations relating to the employment
status of another individual if the two individuals (herein sometimes called "related individuals") have
one of the following relationships:
1. By blood or adoption: Parent, child, sibling, first cousin, uncle, aunt, nephew, or niece;
2. By marriage: Current or former spouse, brother- or sister-in-law, father- or mother-in-
law, son- or daughter-in-law, step-parent, or step-child; or
3. Other relationship: A current or former relationship, occurring outside the work setting
that would make it difficult for the individual with the responsibility to make a decision or
recommendation to be objective, or that would create the appearance that such individual
could not be objective. Examples include, but are not limited to, personal relationships and
significant business relationships.
For purposes of this section, decisions or recommendations related to employment status
include decisions related to hiring, salary, working conditions, working responsibilities,
evaluation, promotion, and termination.
An individual, however, is not deemed to make or actively participate in making decisions
or recommendations if that individual's participation is limited to routine approvals and the
individual plays no role involving the exercise of any discretion in the decision-making
processes. If any question arises whether an individual's participation is greater than is
permitted by this paragraph, the matter shall be immediately referred to the Miami-Dade
County Commission on Ethics and Public Trust.
This section applies to both full-time and part-time employees and voting members of the
Provider's Board of Directors.
D. No person, including but not limited to any officer, board of directors, manager, or supervisor
employed by the Provider, who is in the position of authority, and who exercises any function or
Page 7 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
responsibilities in connection with this Contract, has at the time this Contract is entered into, or shall
have during the term of this Contract, received any of the services, or direct or instruct any employee
under their supervision to provide such services as described in the Contract. Notwithstanding the
before mentioned provision, any officer, board of directors, manager or supervisor employed by the
Provider, who is eligible to receive any of the services described herein may utilize such services if he
or she can demonstrate that he or she does not have direct supervisory responsibility over the
Provider's employee(s) or service program. Staff members, or their immediate family members
(spouse, children, siblings, mother or father) of Homeless Trust funded programs, who are eligible for
and wish to receive services from a Homeless Trust funded program must receive the approval of the
Executive Director of their employer (i.e. the Provider) prior to applying for and receiving those
services. This approval must be in writing and accompany any referral for such services. Any Provider
knowingly accepting a referral of an employee of a Homeless Trust funded program, and providing
services without the written approval of the Executive Director of the Provider, will be subject to the
recoupment/disallowance by the County of any funds paid for services to this individual and/or their
immediate family member. When the services are to be provided at the same agency the employee
works for, this information must be disclosed in writing to the director of the Homeless Trust, which
shall be reviewed for eligibility determination and a sign off must come from the County. This provision
does not apply to staff members seeking emergency shelter, medical or legal services. Providers
must complete a Client Services Authorization Form (Attachment P) for staff members seeking
services.
ARTICLE 10. CIVIL RIGHTS
•
The Provider agrees to abide by Chapter 11A of the Code of Miami-Dade County ("County
Code"), as amended, which prohibits discrimination in employment, housing and public
accommodations on the basis of race, color, religion, ancestry, national origin, sex, pregnancy, age,
disability, marital status, familial status, gender identity, gender expression, sexual orientation, or
actual or perceived status as a victim of domestic violence, dating violence or stalking; Title VII of the
Civil Rights Act of 1968, as amended, which prohibits discrimination in employment and public
accommodation; the Age Discrimination Act of 1975, 42 U.S.C. §6101, as amended, which prohibits
discrimination in employment because of age; the Rehabilitation Act of 1973, 29 U.S.C. §794, as
amended, which prohibits discrimination on the basis of disability; the Americans with Disabilities Act,
42 U.S.C. §12101 et seq., which prohibits discrimination in employment and public accommodations
because of disability; the Federal Transit Act, 49 U.S.C. §1612, as amended; and the Fair Housing
Act, 42 U.S.C. §3601 et seq. It is expressly understood that the Provider must submit an affidavit
attesting that it is not in violation of the Acts. If the Provider or any owner, subsidiary, or other firm
affiliated with or related to the Provider is found by the responsible enforcement agency, the Courts or
the County to be in violation of these acts, the County will conduct no further business with the
Provider.
Any contract entered into based upon a false affidavit shall be voidable by the County. If the Provider
violates any of the Acts during the term of any contract the Provider has with the County, such
contract shall be voidable by the County, even if the Provider was not in violation at the time it
submitted its affidavit.
The Provider agrees that it is in compliance with the Domestic Violence Leave, codified as § 11A-60
et seq. of the Miami-Dade County Code, which requires an employer, who in the regular course of
business has fifty (50) or more employees working in Miami-Dade County for each working day during
each of twenty (20) or more calendar work weeks to provide domestic violence leave to its
employees.
Page 8 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
Failure to comply with this local law may be grounds for voiding or terminating this Contract or for
commencement of debarment proceedings against Provider.
ARTICLE 11. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT;
Any person or entity that performs or assists Miami-Dade County with a function or activity
involving the use or disclosure of"individually identifiable health information (IIHI)" and/or"Protected Health
Information (PHI)" shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of
1996 and the Miami-Dade County Privacy Standards Administrative Order. HIPAA mandates for privacy,
security and electronic transfer standards, include but are not limited to:
1. Use of information only for performing services required by the contract or as required by law;
2. Use of appropriate safeguards to prevent non-permitted disclosures;
3. Reporting to Miami-Dade County of any non-permitted use or disclosure;
4. Assurances that any agents and subcontractors agree to the same restrictions and conditions that
apply to the Provider and reasonable assurances that IIHI/PHI will be held confidential;
5. Making Protected Health Information (PHI) available to the customer;
6. Making PHI available to the client for review;
7. Making PHI available to Miami-Dade County for an accounting of disclosures; and
8. Making internal practices, books, and records related to PHI available to Miami-Dade County for
compliance audits.
PHI shall maintain its protected status regardless of the form and method of transmission (paper
records and/or electronic transfer of data). The Provider must give its clients written notice of its privacy
information practices, including specifically, a description of the types of uses and disclosures that would
be made with protected health information. Provider must post, and distribute upon request to service
recipients, a copy of the County's Notice of Privacy Practices.
ARTICLE 12. NOTICE REQUIREMENTS
Notice under this Contract shall be sufficient if made in writing, delivered personally or sent via U.S.
mail, electronic mail, facsimile, or certified mail with return receipt requested and postage prepaid, to the
parties at the following addresses (or to such other party and at such other address as a party may specify
by notice to others) and as further specified within this Contract. If notice is sent via electronic mail or
facsimile, confirmation of the correspondence being sent will be maintained in the sender's files.
If to the COUNTY:
Miami-Dade County
Homeless Trust 111 N.W. 1st Street, 27th Floor
Miami, Florida 33128
Attention: Victoria Mallette, Executive Director
Electronic mail: VMallette@miamidade.gov
If to the PROVIDER:
Mr. Jimmy L. Morales
City Manager
The City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
Electronic mail: JimmyMorales@miamibeachfl.gov
Page 9 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
Either party may at any time designate a different address and/or contact person by giving written
notice as provided above to the other party. Such notices shall be deemed given upon receipt by the
addressee.
ARTICLE 13. AUTONOMY
Both parties agree that this Contract recognizes the autonomy of the contracting parties and
implies no affiliation between the contracting parties. It is expressly understood and intended that the
Provider is only a recipient of funding support and is not an agent or instrumentality of the County.
Furthermore, the Provider's agents and employees are not agents or employees of the County.
ARTICLE 14. SURVIVAL
The parties acknowledge that any of the obligations in this Contract, including but not limited to
Provider's obligation to indemnify the County, will survive the term, termination, and cancellation
hereof. Accordingly, the respective obligations of the Provider under this Contract, which by nature
would continue beyond the termination, cancellation or expiration thereof, shall survive termination,
cancellation or expiration hereof.
ARTICLE 15. BREACH OF CONTRACT: COUNTY REMEDIES
A. Breach. A breach by the Provider shall have occurred under this Contract if: (1) the
Provider fails to provide the services outlined in the Scope of Services (Attachment A) within the
effective term of this Contract; (2) the Provider ineffectively or improperly uses the County funds
allocated under this Contract; (3) the Provider does not furnish the Certificates of Insurance required
by this Contract or as determined by the County's Risk Management Division; (4) if applicable, the
Provider does not furnish upon request by the County proof of licensure/certification or proof of
background screening required by this Contract; (5) the Provider fails to submit, or submits incorrect
or incomplete, proof of expenditures to support disbursement requests or advance funding
disbursements or fails to submit or submits incomplete or incorrect detailed reports of expenditures or
final expenditure reports; (6) the Provider does not submit or submits incomplete or incorrect required
reports; (7) the Provider refuses to allow the County access to records or refuses to allow the County
to monitor, evaluate and review the Provider's program; (8) the Provider discriminates under any of
the laws outlined in Article 10 of this Contract; (9) the Provider, attempts to meet its obligations under
this Contract through fraud, misrepresentation, or material misstatement; (10) the Provider fails to
correct deficiencies found during a monitoring, evaluation, or review within the specified time as
described and defined in its Performance Improvement Plan (PIP); (11) the Provider fails to issue
prompt payments to small business subcontractors or follow dispute resolution procedures regarding
a disputed payment; (12) the Provider fails to submit the Certificate of Corporate Status, Board of
Directors requirement, or proof of tax status; or (13) the Provider fails to fulfill in a timely and proper
manner any and all of its obligations, covenants, agreements, and stipulations in this Contract; (14)
the Provider fails to meet any of the terms and conditions of the Miami-Dade County Affidavits
(Attachment C) and the State Affidavits (Attachment D) D Applicable 0 Not Applicable or
(15) the Provider fails to fulfill in a timely and proper manner any or all of its obligations, covenants,
agreements and stipulations in this Contract. Waiver of breach of any provisions of this Contract shall
not be deemed to be a waiver of any other breach and shall not be construed to be a modification of
the terms of this Contract.
Page 10 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
In the event that the County determines certain Contract goals (as defined in the Scope of Services)
are not being met then the County, in its sole discretion may place the Provider on a Performance
Improvement Plan (PIP). The following is a delineation of some instances where a PIP may be
required:
a. HMIS- Based on Provider's past performance on prior contracts in the area of
Homeless Management Information System compliance it is subject to a PIP during
this contract term. The Provider is required to submit a Monthly Progress Report
and an HMIS-generated Monthly Progress Report for each month of the contract.
Compliance will be determined when it is deemed that the two (2) reports are in
substantial conformity with each other for a period of two consecutive months.
(Substantial conformity as meaning a minimum of 95% accuracy on all elements).
At the time of compliance, the Provider shall only be required to submit the HMIS-
generated Monthly Progress Report.
❑ Applicable N Not Applicable
b. Utilization — Based on Provider's past performance on prior contracts in-the area of
utilization compliance, this contract is subject to a PIP. During this contract term,
the Provider must submit all invoices in a timely manner. The Provider shall invoice
at a rate of 95% of targeted expenditures for the invoicing period. If the Provider
fails to comply, all rights to payments will be forfeited if the County so chooses.
Failure to submit accurate invoices for appropriately documented and eligible
expenditures at a rate of 95% of targeted expenditures by the end of the third
quarter of this contract term may result in the termination of this contract by the
County.
❑ Applicable N Not Applicable
c. Program Performance — Based on Provider's past performance on prior contracts
in the area of program goals and outcome objectives, this Contract is subject to a
PIP. During this Contract term, the Provider must achieve those goals specified in
the Contract. Performance against these annual goals shall be evaluated on a
quarterly basis, and if by the end of the third quarter of the contract period
substantial compliance (meeting the targeted goals) is not achieved, it may result in
the termination of this contract with the County.
❑ Applicable N Not Applicable
The above is subject to the review and approval of the County
B. County Remedies. If the Provider breaches this Contract, the County may pursue any
or all of the following remedies:
1. The County may terminate this Contract by giving written notice to the Provider
of such termination and specifying the effective date thereof. In the event of termination, the County
may: (a) request the return of finished or unfinished documents, data studies, surveys, drawings,
maps, models, photographs, reports prepared and secured by the Provider with County funds under
this Contract; (b) seek reimbursement of County funds allocated to the Provider under this Contract;
(c) terminate or cancel any other contracts entered into between the County and the Provider. The
Provider shall be responsible for all direct and indirect costs associated with such termination,
including attorney's fees;
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THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
2. The County may suspend payment in whole or in part under this Contract by
providing written notice to the Provider of such suspension and specifying the effective date thereof.
If payments are suspended, the County shall specify in writing the actions that must be taken by the
Provider as condition precedent to resumption of payments and shall specify a reasonable date for
compliance. The County may also suspend any payments in whole or in part under any other
contracts entered into between the County and the Provider. The Provider shall be responsible for all
direct and indirect costs associated with such suspension, including attorney's fees;
3. The County may seek enforcement of this Contract including but not limited to
filing an action in a court of appropriate jurisdiction. The Provider shall be responsible for all direct
and indirect costs associated with such enforcement, including attorney's fees;
4. The County may debar the Provider from future Miami-Dade County
contracting;
5. If, for any reason, the Provider should attempt to meet its obligations under this
Contract through fraud, misrepresentation or material misstatement, the County shall, whenever
practicable terminate this Contract by giving written notice to the Provider of such termination and
specifying the effective date. The County may terminate or cancel any other contracts which such
individual or entity has with the County. Such individual or entity shall be responsible for all direct and
indirect costs associated with such termination or cancellation, including attorney's fees. Any
individual or entity who attempts to meet its contractual obligations with the County through fraud,
misrepresentation, or material misstatement may be debarred from county contracting for up to five
(5) years;
6. Any other remedy available at law or equity.
C. Authorization to Terminate Contract. The Mayor or the Mayor's designee is
authorized to terminate this Contract on behalf of the County.
D. Failures or waivers to insist on strict performance of any covenant, condition, or
provision of this Contract by the County shall not be deemed a waiver of any rights or remedies, nor
shall it relieve the Provider from performing any subsequent obligations strictly in accordance with the
term of this Contract. No-waiver shall be effective unless in writing and signed by the parties. Such
waiver shall be limited to provisions of this Contract specifically referred to therein and shall not be
deemed a waiver of any other provision. No waiver shall constitute a continuing waiver unless the
writing states otherwise.
E. Damages Sustained. Notwithstanding the above, the Provider shall not be relieved of
liability to the County for damages sustained by the County by virtue of any breach of the Contract,
and the County may withhold any payments to the Provider until such time as the exact amount of
damages due the County is determined. The County may also pursue any remedies available at law
or equity to compensate for any damages sustained by the breach. The Provider shall be responsible
for all direct and indirect costs associated with such action, including attorney's fees.
Page 12 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
ARTICLE 16. TERMINATION FOR CONVENIENCE
The County may terminate this Contract, in whole or part, when both parties agree that the
continuation of the activities would not produce beneficial results commensurate with further
expenditure of the funds. Both parties shall agree upon the termination conditions, including the
effective date and in the case of partial termination, the portion to be terminated. However, if the
County determines in the case of partial termination that the reduced or modified portion of the grant
will not accomplish the purposes for which the grant was made it may terminate the grant in its
entirety.
This Contract is subject to the ratification and approval by the Miami-Dade County Board of
County Commissioners and shall be void unless approved by the Board of County Commissioners.
The County may also, in its sole discretion, terminate the contract.
The Provider understands and acknowledges that if the County determines in its sole
discretion that termination of the Contract is necessary for the healthy, safety, or welfare of the County
then it may due so upon twenty-four(24) hours notice to the Provider.
ARTICLE 17. PAYMENT PROCEDURES
The County agrees to pay the Provider for services rendered under this Contract based on the
payment schedule, timely provision by the Provider of required reports and of supporting
documentation of expenses and activities as described in this Contract, and the line item budget
(Attachment B). Payment shall be made in accordance with procedures outlined below and if
applicable, the Sherman S. Winn Prompt Payment Ordinance (Ordinance 94-40).
1. How payment will be made. Payment requests shall be made to the County on a
monthly basis and shall be signed by the Executive Director and the Financial Officer of
the Provider, unless otherwise approved in writing, on the form incorporated herein as
Attachment E "Primary Care Invoice for Services". The payment request for the
previous month is due by the 10th of the month following the month for which payment is
invoiced.
2. Payment will be processed as follows: a) The HMIS Staffing Program funds will be
paid in twelve (12) equal monthly installments of $1,027.75. b) The Identification
Assistance Program will be paid on a reimbursement basis for the provision of
identification services.
3. Any reimbursement may be withheld pending the receipt and approval by the County of
all reports and documents required herein.
4. The parties agree that payment will be based upon the provision of services outlined in
Attachment A, the "Scope of Services", for each program.
5. Maximum monthly reimbursements are limited to actual amounts incurred each month,
unless the Provider has obtained prior, written consent from the County to modify the
Budget.
6. As applicable, during the period of N/A through N/A , the Provider will submit a
record of those individuals served utilizing Social Security Administration repayments as
specified in the Scope of Services. The Provider will utilize these funds to serve those
clients as specified and authorized in the Scope of Services
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THE CITY OF MIAMI BEACH •
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
7. N/A Providers with cumulative utilization rates greater than ninety percent (90%)
during the first nine (9) months of this Contract may exceed this maximum number of
billable bed days during the last quarter of the Contract term, up to the total Contract
award amount, with the prior approval of the Executive Director of the Homeless Trust.
8. N/A Providers with cumulative utilization rates lower than ninety percent (90%) may be
subject to a reduction in funding and beds, if deemed necessary by the Miami-Dade
County Homeless Trust. Beds and funding may be reprogrammed as necessary and
needed within the Continuum of Care. The Miami-Dade County Homeless Trust will
conduct a review of the utilization of beds within the first six (6) months of the contract
period.
9. Within thirty (30) days of the termination or expiration of this Contract, a final report of
expenditures shall be submitted to the County. If after the receipt of such final report, the
County determined that the Provider has been paid funds not in compliance with the
Contract, and to which it is not entitled, the Provider will be required to return such funds
to the County or submit documentation demonstrating that the expenditure was in
compliance with this Contract. The County shall have the sole and absolute discretion to
determine if the Provider is entitled to such funds and the County's decision in this matter
shall be final and binding.
B. Monies Owed to the County: The County reserves the right, in its sole
discretion, to reduce payments to the Provider in order to recapture any monies owed to the County.
In accordance with County Administrative Order No. 3-29, the Provider that is in arrears to the County
is prohibited from obtaining new County contracts or extensions of contracts until such time as the
arrearage has been paid in full or the County has agreed in writing to an approved payment plan.
This is a cost-based Contract in which the Provider shall be paid through reimbursement payment
based on the budget approved under this Contract and when documentation of completed and
satisfactory service delivery is provided. Thus, it is imperative that the Provider maintain appropriate
supporting documentation for all expenditures from the beginning of the Contract term (i.e., receipts,
bank statements, cancelled checks, employee timesheet, etc.).
The Provider shall submit to the Contract Manager, the Monthly Reimbursement form provided by the
County on a monthly basis. Monthly reimbursement requests (both retroactive and current) and
accompanying supporting documentation must be received by the County no later than the 15th of the
month following the month for which reimbursement is requested.
C. No Payment of Subcontractors. In no event shall County funds be advanced or paid
by the County directly to any subcontractor hereunder. Payment to approved subcontractors shall be
made by the Provider following requirements and limitations as detailed in Article 21 of this Contract.
D. Processing the Request for Payment. After the County staff reviews the payment
request, the County will submit a payment request to the County's Finance Department. The County's
Finance Department will issue payment via Automated Clearing House (ACH) or mail the check
directly to the Provider at the address listed in Article 12 of this Contract, unless otherwise directed by
the Provider in writing. The parties agree that the processing of a payment request from date of
submission by the Provider shall take a maximum of thirty (30) days from receipt of a complete and
accurate payment request, pursuant to the County's Sherman S. Winn Prompt Payment Ordinance
(Ordinance 94-40), Section 2-8.1.4 of the Code of Miami-Dade County, Administrative Order No. 3-19,
and the Florida Prompt Payment Act, if supporting documentation/invoices are properly documented
Page 14 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
as determined by the County in its sole discretion. It is the responsibility of the Provider to maintain
sufficient financial resources to meet the expenses incurred during the period between the provision
of services and payment by the County.
E. Reporting Requirements. Failure to submit to the County the reports listed below in a
manner deemed correct and acceptable by the County by the 15th day after the end of the month in
which the service was delivered, or failure to submit to the County supporting documentation of
Contract expenditures or activities within fourteen (14) days of any County request, shall be
considered a breach of this Contract and may result in withholding payment, non-payment, or
termination of this Contract.
Applicable as indicated
1. Monthly Payment Requests/Invoice For Services (Attachment E) • ❑
2. Monthly Payment Request/Invoice For Services (Attachment F) lI
3. Monthly Performance Reports (Attachment G) ❑x
4. Outcome Performance Measurements Monthly Report (Attachment H) lI
5. Client Contribution Report (Attachment I) ❑
6. Client Attendance Roster (Attachment J) ❑
7. Quarterly Vacancy/ Permanent Housing Placement Report(Attachment K) ❑
Performance Reports. The Provider agrees to participate in the Homeless Management
Information System (HMIS) selected and established by the County. Participation will
include, but is not limited to, input of client data upon intake, daily updates of bed
availability information, as well as updates of client files upon client contact, and
maintaining current data for statistical purposes. The Provider understands that they are
responsible for any ongoing cost to access the HMIS system. The Provider shall furnish
the County with Monthly, Quarterly, and Annual Performance Reports in accordance with
the activities and goals detailed in the Scope of Services. The reports shall explain the
Provider's progress for the quarter. The data should be quantified when appropriate. The
final progress report shall be due no later than thirty (30) days after the expiration or
termination of this Contract. Continuation of this Contract and funding is contingent upon
meeting established performance goals. Progress reports, produced through the
Homeless Management Information System (HMIS) invoices for services and client
attendance rosters signed by the Executive Director of the agency shall by submitted by
the Provider, as required.
F. Final Report/Recapture of Funds. Upon the expiration or termination of this
Contract, the Provider shall submit the final Annual Performance Report and Annual Actual
Expenditure Report (Attachment L) to the County no later than thirty (30) days after the expiration or
termination of this Contract. If after receipt of such final reports, the County determines that the
Provider has been paid funds not in accordance with the Contract, and to which it is not entitled, the
Provider shall return such funds to the County, or the County may reduce, by the amount of such
funds, from any subsequent payment to which the Provider is entitled, or the Provider may submit
appropriate documentation within seven (7) days of notice from the County. The County shall have
the sole discretion in determining if the Provider is entitled to such funds and the County's decision on
this matter shall be final and binding. Additionally, any unexpended or unallocated funds shall be
recaptured by the County.
Additionally, the Provider agrees to assign any proceeds to the County from any contract, including
Page 15 of 27
THE CITY OF MIAMI BEACH •
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
this Contract, between the County, its agencies or instrumentalities and the Provider or any firm,
corporation, partnership or joint venture in which the Provider has a controlling financial interest in
order to secure repayment of any reimbursements for services provided under this or any other
contract for which the County discovers was not reimbursable through its inspection, review and/or
audit pursuant to this Contract.
ARTICLE 18. PROHIBITED USE OF FUNDS
A. Adverse Actions or Proceeding. The Provider shall not utilize County funds to retain
legal counsel for any action or proceeding against the County or any of its agents, instrumentalities,
employees, or officials. The Provider shall not utilize County funds to provide legal representation,
advice, or counsel to any client in any action or proceeding against the County or any of its agents,
instrumentalities, employees, or officials.
B. Religious Purposes. County funds shall not be used for religious purposes.
C. Commingling Funds. The Provider shall not commingle funds provided under this
Contract with funds received from any other funding sources. The Provider shall establish a separate
account exclusively for receipt of the funds received pursuant to this Contract.
D. Double Payments. Provider costs claimed under this Contract may not also be
claimed under another contract or grant from the County or any other agency. Any claim for double
payment by Provider shall be considered a material breach of this Contract.
ARTICLE 19. REQUIRED DOCUMENTS, RECORDS, REPORTS, AUDITS, MONITORING AND
REVIEW
A. Certificate of Corporate Status. The Provider must submit to the Contract Manager,
within thirty (30) days from the date of execution of this Contract, a certificate of corporate status in
the name of the Provider, which certifies the following: that the Provider is organized under the laws of
the State of Florida; that all fees and penalties have been paid; that the Providers most recent annual
report has been filed; that its status is active; and that the Provider has not filed Articles of Dissolution.
B. Board of Director Requirements. The Provider shall ensure that the Provider's
Board of Directors is apprised of the programmatic, fiscal, and administrative obligations under this
Contract funded through County Funds by passage of a formal resolution authorizing execution of this
Contract with the County. A copy of this corporate resolution must be submitted to the County prior to
contract execution. A current list of the Provider's Board of Directors and officers must be included
with the submission. The Provider acknowledges and understands that all contract documents shall
be signed by either the Provider's President or Vice President. The Provider's resolution shall at a
minimum: list the name(s) of the Board's President, Vice President and, only in the event that the
President or Vice President is not available to execute the contract documents, any other persons
authorized to execute this Contract on behalf of the Provider; affirmatively state that a quorum was
present at the time of adoption of the resolution; and reference the service categories and dollar
amounts in the award, as may be amended.
C. Proof of Tax Status. The Provider is required to submit to the County the following
documentation: (a) W-9 Form (Attachment M); (b) The I.R.S. tax exempt status determination letter;
(c) the most recent I.R.S. form 990; (d) the annual submission of I.R.S. form 990 within (6) months
Page 16 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
after the Provider's fiscal year end; (e) IRS form 941 - Quarterly Federal Tax Return Reports within
thirty-five (35) days after the quarter ends and if the form 941 reflects a tax liability, proof of payment
must be submitted within forty-five (45) days after the quarter ends.
D. Conflicts of Interest. Section 2-11.1(d) of Miami-Dade County Code as amended,
requires any County employee or any member of the employee's immediate family who has a
controlling financial interest, direct or indirect, with Miami-Dade County or any person or agency
acting for Miami-Dade County competing or applying for any such contract as it pertains to this
solicitation, to first request a conflict of interest opinion from the County's Ethic Commission prior to
their or their immediate family member's entering into any contract or transacting any business
through a firm, corporation, partnership or business entity in which the employee or any member of
the employee's immediate family has a controlling financial interest, direct or indirect, with Miami-
Dade County or any person or agency acting for Miami-Dade County. Further, any such contract,
agreement or business engagement.entered in violation of this subsection, as amended, shall render
this Contract voidable.
E. Accounting Records. The Provider shall keep accounting records which conform to
generally accepted accounting principles. All such records will be retained by the Provider for no less
than three (3) years beyond the term of this Contract, and shall be made available for review upon
request from County authorized personnel.
F. Financial Audit. If the Provider has or is required to have an annual certified public
accountant's opinion and related financial statements, the Provider agrees to provide these
documents to the County no later than one hundred eighty (180) days following the end of the
Provider's fiscal year, for each year during which this Contract remains in force or until all funds
received pursuant to this Contract have been so audited, whichever is later.
G. Access to Records: Audit. The County reserves the right to require the Provider to
submit to an audit by an auditor of the County's choosing or approval. The Provider shall provide
access to all of its records which relate to this Contract at its place of business during regular
business hours. The Provider agrees to provide such assistance as may be necessary to facilitate
their review or audit by the County to ensure compliance with applicable accounting and financial
standards.
H. Quarterly Reviews of Expenditures and Records. The County Commission Auditor
may perform quarterly reviews of Provider's expenditures and records. Subsequent payments to the
Provider shall be subject to a satisfactory review of Provider's records and expenditures by the
County Commission Auditor, including but not limited to, review of supporting documentation for
expenditures and the existence of sufficient documentation to support eligible expenditures. The
Provider agrees to reimburse the County for ineligible expenditures as determined by the County
Commission Auditor.
I. Quality Assurance / Recordkeeping. The Provider shall maintain, and shall require
that the Provider's subcontractors and suppliers maintain, complete and accurate program and fiscal
records to substantiate compliance with the requirements set forth in the Attachment A, Scope of
Services, of this Contract. The Provider and its subcontractors and suppliers, shall retain such
records, and all other documents relevant to the Services furnished under this Contract for a period of
❑x three (3) years or ❑ years (for State contracts) from the expiration date of this Contract.
Page 17 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
The Provider agrees to participate in evaluation studies, quality management activities,
Corrective Action Plan activities, and analyses carried out by or on behalf of the County to evaluate
the effectiveness of client service(s) or the appropriateness and quality of care/service delivery.
Accordingly, the Provider shall allow authorized County staff involved in such efforts to examine and
review the Provider's premises and records.
J. Confidentiality Requirements. The Provider shall establish and implement policies
and procedures which ensure compliance with the following security standards and any and all
applicable State and Federal statutes and regulations for the protection of confidential client records
and electronic exchange of confidential information. The policies and procedures must ensure that:
(1) There is a controlled and secure area for storing and maintaining active
confidential information and files, including but not limited to medical records;
(2) Confidential records are not removed from the Provider's premises, unless
otherwise authorized by law or upon written consent from the County;
(3) Access to confidential information is restricted to authorized personnel of the
Provider, the County, the United States Department of Health and Human
Services, the United States Comptroller General, and/or the United States
Office of the Inspector General;
(4) Records are not left unattended in areas accessible to unauthorized individuals;
(5) Access to electronic data is controlled;
(6) Written authorization, signed by the client, is obtained for release of copies of
client records and/or information. Original documents must remain on file at the
originating Provider site;
(7) An orientation is provided to new staff persons, employees, and volunteers. All
employees and volunteers must sign a confidentiality pledge, acknowledging
their awareness and understanding of confidentiality laws, regulations, and
policies;
(8) Procedures are developed and implemented that address client chart and
medical record identification, filing methods, storage, retrieval, organization and
maintenance, access and security, confidentiality, retention, release of
information, copying, and faxing.
K. Monitoring: Management Evaluation and Performance Review. The Provider
agrees to permit County authorized personnel to monitor, review and evaluate the program/work
which is the subject of this Contract. The County shall monitor fiscal, administrative, and
programmatic compliance with all the terms and conditions of the Contract. The Provider shall permit
the County to conduct site visits, client assessment surveys, and other techniques deemed
reasonably necessary to fulfill the monitoring function. A report of the County's findings will be
delivered to the Provider and the Provider will rectify all deficiencies cited within the period of time
specified in the report. If such deficiencies are not corrected within the specified time the County may
suspend payments or terminate this Contract. The County may conduct one or more formal
management evaluation and performance reviews of the Provider. Continuation of this Contract and
Page 18 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
funding are dependent upon the County being satisfied with the results of the evaluations.
L. Client Records. The Provider shall maintain a separate individual client chart for each
client/family served, where appropriate. This client chart shall include all pertinent information
regarding case activity. At a minimum, the client chart shall contain referral and intake information,
treatment plans, and case notes documenting the dates services were provided and the type of
service provided. These client charts shall be subject to the audit and inspection requirements under
Article 19, Sections F, G and H of this Contract.
M. Disaster Plan/Continuity of Operations Plan (COOP). The Provider shall develop
and maintain an Agency Disaster Plan/COOP. At a minimum, the Plan will describe how the Provider
establishes and maintains an effective response to emergencies and disasters, and must comply with
any Florida Statutes related to Emergency Management that are applicable to the Provider. The
Disaster Plan/COOP must be submitted to the County no later than April 1st of the contract term and is
also subject to review and approval of the County in its sole discretion. The Provider will review the
Plan annually, revise it as needed, and maintain a written copy on file at the Provider's site.
N. Continuum of Care (CoC) Coordinated Intake and Assessment Process
The Provider shall participate in the Continuum of Care's (CoC) Coordinated Intake and
Assessment process, to include, but not limited to: participation in the CoC's defined process to
make and receive referrals for housing and/or services (including the use of the Homeless
Management Information System (HMIS) for such, if required in the Standards of Care); use of
any forms required (e.g. Release of Information, Homeless Verification Form, Chronic Homeless
Verification Form, etc.); compliance with established Standards of Care (and any revisions
thereof) relating to eligibility criteria and timely processing of referrals; and cooperation with
established prioritizations for placement.
O. Public Records
Pursuant to Section 119.0701, Florida Statutes, if the Provider meets the definition of "Contractor" as
defined in Section 119.0701(1)(a), the Provider shall:
(a) Keep and maintain public records that ordinarily and necessarily would be required by the
public agency in order to perform the service;
(b) Upon request from the County's custodian of public records identified herein, provide the
County with a copy of the requested records or allow the public with access to the public
records on the same terms and conditions that the County would provide the records and at a
cost that does not exceed the cost provided in the Florida Public Records Act, Miami-Dade
County Administrative Order No. 4-48, or as otherwise provided by law;
(c) Ensure that public records that are exempt or confidential and exempt from public records
disclosure requirements are not disclosed except as authorized by law for the duration of this
Agreement's term and following completion of the services under this Agreement if the
Contractor does not transfer the records to the County; and
(d) Meet all requirements for retaining public records and transfer to the County, at no County
cost, all public records created, received, maintained and or directly related to the
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THE CITY OF MIAMI BEACH
HMIS STAFFING.PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
performance of this Agreement that are in possession of the Provider upon termination of this
Agreement. Upon termination of this Agreement, the Provider shall destroy any duplicate
public records that are exempt or confidentialand exempt from public records disclosure
requirements. All records stored electronically must be provided to the County in a format that
is compatible with the information technology systems of the County.
For purposes of this Article, the term "public records' shall mean all documents, papers,
letters, maps, books, tapes, photographs, films, sound recordings, data processing software,
or other material, regardless of the physical form, characteristics, or means of transmission,
made or received pursuant to law or ordinance or in connection with the transaction of official
business of the County.
Provider's failure to comply with the public records disclosure requirement set forth in Section
119.0701, Florida Statutes, shall be a breach of this Agreement.
In the event the Provider does not comply with the public records disclosure requirement set forth in
Section 119.0701, Florida Statutes, the County may, at the County's sole discretion, avail itself of the
remedies set forth under this Agreement and available at law.
If the Provider has questions regarding the application of Chapter 119,
Florida Statutes, to the Provider's duty to provide public records relating to
this Agreement, contact Miami-Dade County's Custodian of Public Records at:
Miami-Dade County
Homeless Trust
111 NW 1st Street, 27th Floor, Suite 310
Miami, Florida 33128
Attention: Victoria L. Mallette, Executive Director
Email: vmallette@miamidade.gov
ARTICLE 20. Office of Miami-Dade County Inspector General
Miami-Dade County has established the Office of the Office of Inspector General which is empowered
to perform random audits on all County contracts throughout the duration of each contract. The
Miami-Dade County Inspector General is authorized and empowered to review past, present and
proposed County and Public Health Trust programs, contracts, transactions, accounts, records and
programs. In addition, the Inspector General has the power to subpoena witnesses, administer oaths,
require the production of records and monitor existing projects and programs. Monitoring of an
existing project or program may include a report concerning whether the project is on time, within
budget and in compliance with plans, specifications and applicable law.
The Inspector general is empowered to analyze the necessity of and reasonableness of proposed
charge orders to the Contract. The Inspector General is empowered to retain the services of
independent private sector inspectors general (IPSIG) to audit, investigate, monitor, oversee, inspect
and review operations, activities, performance and procurement process including but not limited to
project design, bid specifications, proposal submittals, activities of the Provider, its officers, agents
and employees, lobbyists, County staff and elected officials to ensure compliance with contract
specifications and to,detect fraud and corruption.
Page 20 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
Upon ten (10) days prior written notice to the Provider from the Inspector General or IPSIG retained
by the Inspector General, the Provider shall make all requested records and documents available to
the Inspector General or IPSIG for inspection and copying. The Inspector General and IPSIG shall
have the right to inspect and copy all documents and records in the Provider's possession, custody or
control which, in the Inspector General or IPSIG's sole judgment, pertain to performance of the
contract, including, but not limited to original estimate files, worksheets, proposals and agreements
from and with successful and unsuccessful subcontractors and suppliers, all project-related
correspondence, memoranda, instructions, financial documents, construction documents, proposal
and contract documents, back-charge documents, all documents and records which involve cash,
trade or volume discounts, insurance proceeds, rebates, or dividends received, payroll and personnel
records, and supporting documentation for the aforesaid documents and records.
The provisions in this section shall apply to the Provider, its officers, agents, employees,
subcontractors and suppliers. The Provider shall incorporate the provisions in this section in all
subcontractors and all other agreements executed by the Provider in connection with the performance
of the contract.
Nothing in this contract shall impair any independent right of the County to conduct audit or
investigative activities. The provisions of this section are neither intended nor shall they be construed
to impose any liability on the County by the Provider or third parties.
ARTICLE 21. ' SUBCONTRACTORS and ASSIGNMENTS
A. Subcontracts. The parties agree that no assignment or subcontract will be made or
let in connection with this Contract without the prior written approval of the County in its sole
discretion, which shall not be unreasonably withheld, and that all subcontractors or assignees shall be
governed by all of the terms and conditions of this Contract.
1) If the Provider will cause any part of this Contract to be performed by a
Subcontractor, the provisions of this Contract will apply to such Subcontractor
and its officers, agents and employees in all respects as if it and they were
employees of the Provider; and the Provider will not be in any manner thereby
discharged from its obligations and liabilities hereunder, but will be liable
hereunder for all acts and negligence of the Subcontractor, its officers, agents,
and employees, as if they were employees of the Provider. The services
performed by the Subcontractor will be subject to the provisions hereof as if
performed directly by the Provider.
2) The Provider, before making any subcontract for any portion of the services, will
state in writing to the County the name of the proposed Subcontractor, the
portion of the Services which the Subcontractor is to perform, the place of
business of such Subcontractor, and such other information as the County may
require. The County will have the right to require the Provider not to award any
subcontract to a person, firm, or corporation disapproved by the County in its
sole discretion.
3) Before entering into any subcontract hereunder, the Provider will inform the
Subcontractor fully and completely of all provisions and requirements of this
Contract relating either directly or indirectly to the Services to be performed.
Page 21 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
Such Services performed by such Subcontractor will strictly comply with the
requirements of this Contract.
4) In order to qualify as a Subcontractor satisfactory to the County in its sole
discretion, in addition to the other requirements herein provided, the
Subcontractor must be prepared to prove to the satisfaction of the County that it
has the necessary facilities, skill and experience, and ample financial resources
to perform the Services in a satisfactory manner. To be considered skilled and
experienced, the Subcontractor must show to the satisfaction of the County in
its sole discretion that it has satisfactorily performed services of the same
general type which is required to be performed under this Contract.
5) The County shall have the right to withdraw its consent to a subcontract if it
appears to the County that the subcontract will delay, prevent, or otherwise
impair the performance of the Contractor's obligations under this Contract. All
Subcontractors are required to protect the confidentiality of the County's and
County's proprietary and confidential information. Provider shall furnish to the
County copies of all subcontracts between Provider and Subcontractors and
suppliers hereunder. Within each such subcontract, there shall be a clause for
the benefit of the County permitting the County to request completion of
performance by the Subcontractor of its obligations under the subcontract, in
the event the County finds the Contractor in breach of its obligations; and the
option to pay the Subcontractor directly for the performance by such
subcontractor. The foregoing shall neither convey nor imply any obligation or
liability on the part of the County to any subcontractor hereunder as more fully
described herein.
B. Prompt Payments to Subcontractors. The Provider shall issue prompt payments to
subcontractors that are small businesses (annual gross sales of $750,000 or less with its principal
place of business in Miami-Dade County) and shall have a dispute resolution procedure in place to
address disputed payments. Pursuant to the County's Sherman S. Winn Prompt Payment Ordinance
(Ordinance 94-40), Section 2-8.1.4 of the Code of Miami-Dade County, Administrative Order No. 3-19,
and the Florida Prompt Payment Act, payments must be made within thirty (30) days of receipt of a
proper invoice. Failure to issue prompt payments to small business subcontractors or adhere to
dispute resolution procedures may be grounds for suspension or termination of this Contract or
debarment.
ARTICLE 22. LOCAL, STATE, AND FEDERAL COMPLIANCE REQUIREMENTS
Provider agrees to comply, subject to applicable professional standards, with the provisions of
any and all applicable Federal, State and the County's orders, statutes, ordinances, rules and
regulations that may pertain to the Services required under this Contract, including but not limited to:
a) Miami-Dade County Florida, Department of Business Development Participation
Provisions, as applicable to this Contract.
b) Miami-Dade County Code, Chapter 11A, including but not limited to Articles III and IV.
All Providers and subcontractors performing work in connection with this Contract shall
provide equal opportunity for employment and services without regard to race, color,
religion, ancestry, national origin, sex, pregnancy, age, disability, marital status, familial
Page 22 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
status, gender identity, gender expression, sexual orientation, or actual or perceived
status as a victim of domestic violence, dating violence or stalking. The aforesaid
provision shall include, but not be limited to, the following: employment, upgrading,
demotion or transfer, recruitment advertising; layoff or termination; rates of pay or other
forms of compensation; and selection for training, including apprenticeship. The
Provider agrees to post in a conspicuous place available for employees and applicants
for employment, such notices as may be required by the Dade County Equal
Opportunity Board or other authority having jurisdiction over the work setting forth the
provisions of the nondiscrimination law.
c) Conflict of Interest and Code of Ethics Ordinance, Section 2-11.1 et seq. of the Code of
Miami-Dade County, as amended.
d) Miami-Dade County Code Section 10-38, Debarment of contractors from County work.
e) Miami-Dade County Ordinance 99-5, codified at 11A-60 et seq. Code of Miami-Dade
County pertaining to complying with the County's Domestic Leave Ordinance.
f) Miami-Dade County Ordinance 99-152 codified at Section 21-255 et seq. prohibiting
the presentation, maintenance, or prosecution of false or fraudulent claims against
Miami-Dade County.
g) Miami-Dade County Resolution 478-12. The Provider will not use products or foods
containing "pink slime," as defined in Resolution 478-12 of the Board of Miami-Dade
County Commissioners, in food that is provided or served pursuant to this agreement."
Notwithstanding any other provision of this Contract, Provider shall not be required pursuant to this
Contract to take any action or abstain from taking any action if such action or abstention would, in the
good faith determination of the Provider, constitute a violation of any law or regulation to which
Provider is subject, including but not limited to laws and regulations requiring that Provider conduct its
operations in a safe and sound manner.
ARTICLE 23. MISCELLANEOUS
A. Publicity. It is understood and agreed between the parties hereto that this Provider is
funded by Miami-Dade County. Further, by the acceptance of these funds, the Provider agrees that
events funded by this Contract shall recognize and adequately reference the County as a funding
source. The Provider shall ensure that all publicity, public relations, advertisements and signs
recognizes and references the County (by inserting the Miami-Dade County Homeless Trust Logo on
all materials) for the support of all contracted activities. This is to include, but is not limited to, all
posted signs, pamphlets, wall plaques, cornerstones, dedications, notices, flyers, brochures, news
releases, media packages, promotions, and stationery. The use of the official Miami-Dade County
Homeless Trust logo is permissible for the publicity purposes stated herein. Provider shall submit
sample or mock up of such publicity or materials to the County for review and approval. The Provider
shall ensure that all media representatives, when inquiring about the activities funded by this Contract,
are informed that the County is its funding source.
B. Governing Law and Venue. This Contract is made in the State of Florida and shall be
governed according to the laws of the State of Florida. Venue for this Contract shall be Miami-Dade
County, Florida.
Page 23 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
C. Modifications. Any alterations, variations, modifications, extensions, or waivers of
provisions of this Contract including, but not limited to, amount payable and effective term shall only
be valid when they have been reduced to writing, duly approved and signed by both parties and
attached to the original of this Contract.
The County and Provider mutually agree that modification of the Scope of Services, schedule
of payments, billing and cash payment procedures, set forth herein and other such revisions may be
made as a written amendment to this Contract executed by both parties.
The Mayor or the Mayor's designee is authorized to make modifications to this Contract as
described herein on behalf of the County.
The Office of the Inspector General shall have the power to analyze the need for, and the
reasonableness of proposed modifications to this Contract.
D. Counterparts. This Contract is executed in three (3) counterparts, and each
counterpart shall constitute an original of this Contract.
E. Headings, Use of Singular and Gender. Paragraph headings are for convenience
only and are not intended to expand or restrict the scope or substance of the provisions of this
Contract. Wherever used herein, the singular shall include the plural and plural shall include the
singular, and pronouns shall be read as masculine, feminine, or neuter as the context requires.
F. Review of this Contract. Each party.hereto represents and warrants that they
have consulted with their own attorney concerning each of the terms contained in this
Contract. No inference, assumption, or presumption shall be drawn from the fact that one
party or its attorney prepared this Contract. It shall be conclusively presumed that each party
participated in the preparation and drafting of this Contract.
G. The County's Consultant. The Provider understands that in order to facilitate the
implementation of this Contract, the County may from time to time designate in writing a development
consultant to work with the Provider. The County's consultant shall be considered the County's
designee with respect to all portions of this Contract with the exception of those provisions relating to
payment of the Provider for services rendered. The County shall provide written notification to the
Provider of the name, address, and employees of the County's consultant.
H. Contracts with Municipalities or Counties Outside Miami-Dade County to Provide
Homeless Housing in Miami-Dade County. The Provider desiring to transact business or enter into
a Contract with the County for the provision of homeless housing and/or services swears, verifies,
affirms and agrees that (1) it has not entered into any current contract, arrangement of any kind, or
understanding with any municipality outside of Miami-Dade County or any County (collectively
"locality") to provide housing and services for homeless persons in Miami-Dade County who are
transported to Miami-Dade County by or at the behest of such locality and (2) during the term of this
Contract, it will not enter into any such contract, arrangement of any kind, or understanding; provided,
however, upon the written request of the Provider prior to entering into such contract, understanding
that the County may, in its sole and absolute discretion, find and determine within sixty (60) days of
such request that a proposed contract should not be prohibited hereby, as the best interests of the
Page 24 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
homeless programs undertaken by and on behalf of Miami-Dade County would not be negatively
affected by such contract, arrangement, or undertaking.
I. Incident Reports. The Provider must report to the Miami-Dade County Homeless
Trust information related to any critical incidents occurring during the administration of
its programs. The following are identified as critical incidents as defined in CF-OP 215-6
(Attachment N-1):
• Child-on-Child Sexual Abuse
• Child Arrest
• Child Death
• Adult Death
• Elopement refers to court ordered clients that run away and do not return
• Employee Arrest
• Employee Misconduct
• Escape
• Missing Child
• Security Incident- Unintentional
• Significant Injury to Clients
• Significant Injury to Staff
• Suicide Attempt
• Sexual Abuse/Sexual Battery
II. The Provider is to utilize the "Incident Report" form attached as Attachment N. In
addition to reporting this incident to the appropriate authorities, the Provider must
within twenty-four (24) hours of any incident, submit in writing a detailed account of the
incident. This incident report should be addressed to the County. This incident report
should be addressed to Miami-Dade County Homeless Trust, 111 NW First Street, 27th
Floor, Suite 310, Miami, Florida 33128; telephone (305) 375-1490 and facsimile (305)
375-2722.
J. Totality of Contract / Severability of Provisions. This Contract and Attachments,
with it recitals on the first page of the Contract and with its attachments as referenced below contain
all the terms and conditions agreed upon by the parties.
K. Third Party Beneficiaries. The Parties agree that this contract has no intended or
unintended third party beneficiaries.
L. Property. This section applies to equipment with an acquisition cost of $5,000 or more
per unit and all real property.
1. Any real property under the Provider's control that was acquired/improved in
whole or in part with funds from the Homeless Trust and any equipment
purchased for $5,000 or more shall be disposed of, at the expiration or
termination of this contract, in accordance with instruction from the Homeless
Trust. Real Property is defined as land, including land improvements, structures,
Page 25 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-ID-2
and appurtenances thereto, including movable machinery and equipment.
Equipment means tangible, nonexpendable, personal property having a useful.
life of more than one year and an acquisition cost of$5,000 or more per unit.
2. All equipment with an acquisition cost of $5,000 or more per units and all real
property purchased in whole or in part with funds from this and previous
contracts with the Homeless Trust, or transferred to the Provider t after being
purchased in whole or in part with funds from the Homeless Trust shall be listed
in the property records of the Provider and shall include a legal description, size,
date of acquisition, value at time of purchase, owner's name if different from the
Provider, information on the transfer or disposition of the property, and map
indicating whether property is in parcels, lots or blocks and showing adjacent
streets and roads. Notwithstanding documentation required for reimbursement
purposes, a copy of the purchase receipt for any asset described above
purchased with Homeless Trust funds must also be included in the Provider's
monthly reimbursement package submitted to the Homeless Trust in the month
in which the item was purchased along with the "Provider Asset Inventory"
(Attachment 0).
3. All equipment with an acquisition cost of $5,000 or more per unit and all real
property shall be inventoried annually by the Provider and an inventory report
shall be submitted to the Homeless Trust. This report shall include the elements
listed in the paragraph listed above.
Attachment A: Scope of Services
Attachment B: Budget
Attachment C: Miami Dade County Affidavits
Attachment D: State Affidavits (Not Applicable)
Attachment E: Primary Care Invoice for Services(Not Applicable)
Attachment F: Monthly Payment Requests Reports
Attachment G: Monthly Performance Reports
Attachment H: Outcome Performance Measurements Monthly Report
Attachment I: Client Contribution Report (Not Applicable)
Attachment J: Client Attendance Roster(Not Applicable)
Attachment K: Vacancy/Permanent Housing Placement Report(Quarterly) (Not Applicable).
Attachment L: Annual Performance Report&Annual Actual Expenditure Report
Attachment M: W-9 Form
Attachment N: Incident Report
Attachment N-1: CF Operating Procedure 215-6—Incident Reporting
Attachment 0: Provider Asset Inventory Report
Attachment P: Client Services Certification Form
M. Entire Agreement. No other agreement, oral or otherwise, regarding the subject matter of
this Contract shall be deemed to exist or bind any of the parties hereto. If any provision of this
Contract is held invalid or void, the remainder of this Contract shall not be affected thereby if such
remainder would then continue to conform to the terms and requirements of applicable law and
ordinance.
Page 26 of 27
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM GRANT#: PC-1819-STAFF-2
IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1819-1D-2
IN WITNESS WHEREOF, the parties have executed this Contract, along with all of its Attachments,
effective as of the contract date herein above set forth.
THE CITY OF MIS.MI BEASH MIAMI-DADE COUNTY
Signed By: Signed
�r 7 By.
Name:', ✓1/ly t'VIoS I�ba� ,6s L. KEN/
1P
Name:
C�I t/► .'cIJP- Ei2
Date: lu fy Title: MIAMI-DADE CTY. FL
Date: e.,)? Izote)
Attest: Nal-titcook. Attest:
HARVEY RUVIN, Clerk
Authorized Person OR Board of County Commissioners
Notary Public
Print Name: I\a l iv' la le Iihe o By:
Title: OV-Ci Print Name:
� �\G�i1Gt C��P L�
Affix Corporate mili ry SEAL here Affix Miami-Dade County Seal here
\ E P!N b0� i O• h.......
.
o ,BION4'i /i ER AT .�G M /ss�•.
• #tGG 222116q.15 @,�`4"
04,;:::V°4 de d°A:
APPROVED AS TO
FORM & LANGUAGE
& FOR EXE UTION
City Attorneybtr- Date
Approved as to form and legal sufficiency. See memorandum dated November 28, 2018.
Page 27 of 27
ii:.
ATTACHMENT A,SCOPE OF SERVICES
THE CITY OF MIAMI BEACH
HMIS STAFFING PROGRAM
PC-1819-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 Housing
and Urban Development sub-recipient Agreement between The City of Miami
Beach and the Miami-Dade County Homeless Trust may result in the termination
of this Agreement.
ATTACHMENT A,SCOPE OF SERVICES
THE CITY OF MIAMI BEACH
IDENTIFICATION ASSISTANCE PROGRAM
PC-1819-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 (judgments,orders, related documents)
6. Lawful Permanent Resident Cards
7. Naturalization Certificates
8. Florida Driver's Licenses
Note: The cost of replacing the documents specified above may be funded via this grant or where
applicable fee waivers may be obtained via the appropriate source.
> Staff shall deliver identification services to homeless individuals.
> Staff shall maintain a regular working schedule, as may be modified from time to time as
mutually agreed upon in writing, with an intake specialist/case worker providing services.
Staffing will be provided primarily in the Miami Beach Office of Homeless Programs located
at 555 17th Street, Miami Beach, Florida.
> Provide referral services for community-based resources including but not limited to: legal
and medical services,food, employment,vocational training and clothing.
> Provide follow-up and tracking of each person assisted to determine outcome measures.
PERFORMANCE MEASURES
EXPECTED OUTCOMES INDICATORS
1. Homeless participants will be assessed 300 participants will be assessed
2. Homeless participants will obtain vital 200 or 66%of homeless participants will obtain
personal identification documents. vital personal identification documents.
3. Homeless participants will obtain 150 or 50%of homeless participants will obtain
official photo identification. official photo identification.
Attachment B, Budget
City of Miami Beach -
HMIS Staffing Program
Category Requested Funding Justification
Annual Salary 1 HMIS Administrator $ 45,634.94
This amount represents a portion of the annual
Total Grant Award $ 12,333.00 salary per this contract Agreement.
Attachment B, Budget
City of Miami Beach
Identification Assistance Program
•
Category Requested Funding Justification
Salaries 1 CaseWorker $ 14,000.00 Case Worker: 14 Hours per week X 52 weeks
Supplies $ 300.00 General Office Supplies
Identification Document
Fees $ 10,700.00 Identification Document Replacement Fees
Total Grant Award $ 25,000.00 •
Miami-Dade County's Affidavits and Declarations
•
MIAM!DADE `;.
Miami-Dade County requires each party desiring to enter into a contract with Miami-Dade County to;
(1) Sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This
form contains both Affidavit forms for matters requiring the entity to sign under oath and Declaration
forms for matters requiring only an affirmation or declaration for other matters.
Each section of this form must be read, and initialed in the top right hand box indicating acceptance
and/or compliance with the County's policy related to the particular affidavit. For affidavit sections that
you do not believe are applicable to your organization,please indicate this by placing"Il"in the box next
to N/A.
ALL SECTIONS MUST BE COMPLETED
THE FOLLOWING MATTERS REQUIRE THE ENTITY TO SIGN AN AFFIDAVIT UNDER OATH:
STATE OF( F6 &t\J )
COUNTY OF( I.11:c1 m i -bad2-• )
COUNTRY OF( (J 111 d -445 )
Before me the undersigned auth rity a peared
(Print Name), 4.1 IYl/Y► .,�• Oralvc who is personally known to me or who has provided
as identification and Who did swear to the following: / ,� �/J
That he or she is the duly authorized representative of(Name of Entity) e� O�U/Q I S�GLC
(AddressEntity) I '0 �f I2.(/J O11 OP r,fie-/° b 3g/d o Office
of U�M"Cf/l7! Q � Post O
addressesaare not acce table.
SI - 1(,000.3-1
Federal Employment Identification Number
-1Cr,...tr"`� L . 0(\c-s•rQS (hereinafter referred to as the contracting
"enti '), and that he or she is t entity's (Sole Proprietor)(Partner)(President or Other Authorized Officer)
--Nr12--201 o-I
That he or she has full authority to make this affidavit, and that the information given herein and the documents
attached hereto are true and correct;and
That he or she says for the following fifteen (16)Affidavits and Declarations:
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 1 of 11
Miami-Dade County's Affidavits and Declarations
1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT(SECTION 2-8.1 Pertain O
1N/A4741 ,
OF THE COUNTY CODE)
Inrnal •e
If the contract or business transaction is with a corporation,the full legal name and business address sh 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 address are outlined
below:Post Office addresses are not acceptable.
(Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership)
(Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership)
The full legal names and business address of any other individual (other than subcontractors,material person,
suppliers,laborers,or lenders)who have,or will have,any interest(legal,equitable beneficial or otherwise)in
the contract or business transaction with Miami 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 jail for up to sixty(60)days or both.
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 2 of 11
Miami-Dade County's Affidavits and Declarations
2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT(COUNTY Pertai
ORDINANCE 90-133,AMENDING SECTION 2.8-1;SUBSECTION(d)(2) OF THE N/A
COUNTY CODE) Initial'
Except where precluded by Federal or State laws or regulations,each contract or business transaction or
renewal thereof which involves the expenditure of then thousand dollars ($10,000) or more shall requir he
entity contracting or transaction 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.
Does your firm have a collective bargaining agreement with its employees? Yes ,0 No
Does your firm provide paid health care benefits for its employees? Yes O No
Provide a current breakdown (number of persons)of your firm's work force and ownership (below):
White: r Females // 5/
Black: Females '"/g
Hispanic: Males • Females 32s
Asian: Males ' Females
•
American Native: Males 3 Females /
Aleut(Eskimo): Males a Females v
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 3 of 11
Miami-Dade County's Affidavits and Declarations
3. MIAMI-DADE COUNTY AFFIRMATIVE ACTION/ pertarns O
NONDISCRIMINATION OF EMPLOYMENT,PROMOTION AND
PROCUREMENT PRACTICES(COUNTY ORDINANCE 98-30 CODIFIED
;
Initral
AT 2-8.1.5 OF THE COUNTY CODE) = )
Pursuant to Miami-Dade County's Ordinance No.98-30,Section 2-8.1.5,entities with annual gross revenue i
excess of$5,000,000 seeking to contract with the County shall,as a condition of receiving a County contract,have:
1)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 2) 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,not withstanding,corporate
entities whose board 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 a written
affirmative action plan and procurement policy in order to receive a County contract.The foregoing presumption
maybe rebutted.The requirements of this section maybe waived upon written recommendation of the County
Manager that it is in the best interest of the County to do so and approval of the County Commission by majority
vote of the members present. Based on the above,please complete the affidavit as directed and return the
completed affidavit along with a cover letter on your company's letterhead,listing the company's address,phone
and fax numbers,and any required documents,to: Miami-Dade County,Department of Procurement
Management Affirmative Action Plan Unit 111 NW 1st Street,13th Floor Miami,FL 33128
Yes No O My company has an affirmative action plan and procurement policy and is
available for review.
My company has annual gross revenues in excess of$5,000,000.
Yes:O No O , Therefore,our company's affirmative action plan and procurement policy
is available for review.
Yes.O No O My company has annual gross revenues less than$5,000,000.
If at any time the Miami Dade County has reason to believe that any person or firm has willfully and knowingly
provided incorrect information or made false statements,the County may refer the matter to the State AIttorney's
Office and/or other investigative agencies.The County may initiate debarment and/or pursue other rerr�edies in
accordance with Miami-Dade County policy and/or applicable federal,state and local laws. -
Pertain Or `
4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT N/A
(SECTION 2-8.6 OF THE COUNTY CODE) f
-.Imtral
The individual or entity entering into a contract or receiving funding from Miami-Dade County O 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 officer of the entity entering into a contract or receiving funding from iam Dade
County 0 has Gras not as of the date of this affidavit been convicted of a felony during the past ten (10)years.
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 4 of 11
Miami-Dade County's Affidavits and Declarations
5. PUBLIC ENTITY CRIMES AFFIDAVIT(SECTION gr Pertains O
N/A O
287.133(3)(a),FLORIDA STATUTES) Initial:w �) �,,
The individual or entity entering into a contract or receiving funding from Miami-Dade County understa .•the
following: That a"public entity crime"as defined in Paragraph 287.133 (1) (g) Florida Statutes,means a olation
of any state or federal law by a person with respect to and directly related to the transaction of business with any
public entity or with an agency or political subdivision of any other state of the United States of America,including
but not limited to,any bid or contract for goods or services to be provided to any public entity or an agency or
political subdivision of any other state of the United States of America and involving antitrust,fraud,theft,bribery,
collusion,racketeering,conspiracy,or material misrepresentation.
That"Convicted"or"conviction"as defined in Paragraph 287.133 (1) (b) Florida Statutes means a finding of guilt
or a conviction of a public entity crime,with or without an adjudication of guilt,in any federal state trial court of
record relating to charges brought by indictment or information after July 1, 1989,as a result of a jury verdict,non-
jury trial,.or entry of plea of guilty or nolo contendere.
That an"affiliate"as defined in Paragraph 287.133 (1) (a) Florida Statutes means a)a predecessor or successor of a
person convicted of a public entity crime;orb)an entity under the control of any natural person who is active in
the management of the entity and who has been convicted of a public entity crime. The term"affiliate"includes
those officers,directors,executives,partners,shareholders,employees,members,and agents who are active in the
management of an affiliate. The ownership by one person of shares constituting a controlling interest in another
person,or pooling of equipment or income among persons when not for fair market value under an arm's length
agreement,shall be a prima facie case that one person controls another person. A person who knowingly enters
into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding
36 months shall be considered an affiliate.
That a"person"as defined in Paragraph 287.133 (1) (e) Florida Statutes means any natural person or entity
organized under the laws of any state or of the United States of America with the legal power to enter into a
binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public
entity,or which otherwise transacts or applies to transact business with a public entity. The term"person"
includes those officers,directors,executives,partners,shareholders,employees,members and agents who are
active in the management of an entity.
Based on information and belief,the statement as marked below,is true in relation to the entity submitting this
sworn statement. (Please indicate which statement applies by applying the individual initials near the box).
either the entity submitting this sworn statement nor any of its officers,directors,executives,partners,
areholders,employees,members or agents who are active in the management of the entity,nor an affiliate of the
entity has been charged with and convicted of a public entity crimewithin the past 36 months.
0 The entity submitting this sworn statement or one or more of its officers,directors,executives,partners,
shareholders,employees,members or agents who are active in the management of the entity,or an affiliate of the
entity has been charged with and convicted of a public entity crime within the past 36 months;and
0 yes an additional statement is applicable or O no an additional statement is not applicable.
0 The entity submitting this sworn statement,or one or more of its officers,directors,executives,partners,
shareholders,employees,members,or agents who are active in the management of the entity has been charged
with and convicted of a public entity crime within the past 36 months. However,there have been subsequent
proceedings before a Hearing Officer of the State of Florida,Division of Administrative Hearings and the Final
Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting
this sworn statement on the"Convicted Vendor List".
The individual or entity entering into a contract or receiving funding from Miami-Dade County understands that he
or she is required to inform the public entity prior to entering into a contract in excess of the threshold amount
provided in Section 287.017 Florida Statues for Category 2 of any change in the information contained in this form.
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 5 of 11
Miami-Dade County's Affidavits and Declarations
6.MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT Pertai O
(County Ordinance No.142-91 codified as Section 11A-29 et. N/$ O
seq of the County Code) 1nttia
That in compliance with Ordinance No. 142-91 of the Code of Miami-Dade County,Florida,an employerwi 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 aforementi ned
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. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION Pertai
AFFIDAVIT (County Resolution R-385-95)
k �� ;' �y,; Nf1� � O
Initial )
That the above named firm,corporation or organization is in compliance with and agrees to continue to com ly
with,and assure that any subcontractor,or third party contractor under this project complies with all applic le
requirements of the laws listed below including,but not limited to,those provisions pertaining to employment,
provision of programs and services,transportation,communications,access to facilities,renovations,and new
construction in the following laws:The Americans with Disabilities Act of 1990 (ADA),Pub.L.101-336, 104 Stat.
327,42 U.S.C.12101-12213 and 47 U.S.C.Sections 225 and 611 including Title I,Employment;Title II,Public
Services;Title III,Public Accommodation 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,
or the State or any political subdivision or agency thereof or any municipality of this State.
8.MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE Pertai
FEES OR TAXES(Sec.2-8.1(c) of the County Code) NJA O
initial J .
Except for small purchase orders and sole source contracts,that above named firm,corporation,organizatio r
individual desiring to transact business or enter into a contract with the County verifies that all delinquent an
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.
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 6 of 11
Miami-Dade County's Affidavits and Declarations
Pertains O
9. CURRENT ON ALL COUNTY CONTRACTS,LOANS AND OTHER OBLIGATIONS N/A
Initic" )
The individual entity seeking to transact business with the County is current in all its obligations to the Co ty and
is not otherwise in default of any contract,promissory note or other loan document with the County or any f its
agencies or instrumentalities.
10. DOMESTIC VIOLENCE LEAVE(Resolution 185-00;99-5 Codified At 11A- Pertains '°
60 Et.Seq.of the Miami-Dade County Code).
_ ° Imtia )
The firm desiring to do business with the County is in compliance with Domestic Leave Ordinance,Ordin ce 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.
11. MIAMI-DADE COUNTY EMPLOYMENT DRUG-FREE WORKPLACE Pertains O
AFFIDAVIT(County Ordinance No.92-15 codified as Section 2-
O
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 name erson
or entity is providing a drug-free workplace.A written statement to each employee shall inform the emplo ee
about:
1. danger of drug abuse in the workplace;
2. the firm's policy of maintaining a drug-free environment at all workplaces;
3. availability of drug counseling,rehabilitation and employee assistance programs;
4. penalties that may be imposed upon employees for drug abuse violations.
The person or entity shall also require an employee to sign a statement,as a condition of employment that the
employee will abide by the terms and notify the employer of any criminal drug conviction occurring no later than
five(5) days after receiving notice of such conviction and impose appropriate personnel action against the
employee up to and including termination.
Compliance with Ordinance No.92-15 may be waived if the special characteristics of the product or service offered
by the person or entity make it necessary for the operation of the County or for the health,safety,welfare economic
benefits and well-being of the public.Contracts involving funding which is provided in whole or in part by the
United States or the State of Florida shall be exempted from the provisions of this ordinance in those instances
where those provisions are in conflict with the requirements of those governmental entities.
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 7 of 11
Miami-Dade County's Affidavits and Declarations
12. ATTESTATION REGARDING DUE AND PROPER ACKNOWLEDGEMENT OF
Pertamss O ' ,
COUNTY FUNDING SUPPORT N/A �1:; O
Iriihal ,�11)
By initialing this subsection and accepting County funds,the above named firm,corporation,organization '
individual agrees to abide by the grant contract requirement to recognize and acknowledge Miami-Dade C i nty's
grant support in a mannercommensurate with all contributors and sponsors of its activities at comparable dollar
levels.
E
13.MIAMI-DADE COUNTY RESOLUTION NO.R-630-13 REQUIRING A DETAILED
PROJECT BUDGET,SOURCES AND USES STATEMENT,CERTIFICATIONS AS & Pertains O
TO PAST DEFAULTS ON AGREEMENTS WITH NON-COUNTY FUNDING N/A \: O
SOURCES,AND DUE DILIGENCE CHECK Initial )
Pursuant to Miami-Dade County Resolution No.R-630-13,requiring a detailed project budget,sources and ses
statement,certifications as to past defaults on agreements with non-county funding sources and due diligence
check prior to the County Mayor or County Mayor's designee recommending a commitment of Miami-Dade County
funds to Social Services,Economic Development,Community Development,and Affordable Housing Agencies and
Providers.
The undersigned entity certifies,to the best of his or her knowledge and belief,that:
1. Within the past five (5)years,neither the Agency nor its directors,partners,principals,members or board
members:
(i) have been sued by a funding source for breach of contract or failure to perform obligations under a
contract;
(ii) have been cited by a funding source for non-compliance or default under a contract;
(iii) have been a defendant in a lawsuit based upon a contract with a funding source.
Please list any matters which prohibit the Agency from making the certifications required and explain how the
matters are being resolved (use separate sheet if necessary):
1'6'f ails O
14.MIAMI-DADE COUNTY RESOLUTION No.R-478-12 NOT TO USE PRODUCTS :NJA O
OR FOODS CONTAINING"PINK SLIME" Initial' ')
Pursuant to Miami-Dade County Resolution No.R-478-12,the undersigned certifies,not to use meat produc-s
containing"Pink Slime"in food provided or served as part any food program;urging all who provide food Arvices
or operate a food program to immediately discontinue using meat products containing"pink slime"in food
provided or served in these programs.
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 8 of 11
•
Miami-Dade County's Affidavits and Declarations
15.MIAMI-DADE COUNTY REQUIRED LOBBYIST REGISTRATION FOR Pertain O
ORAL PRESENTATION Section 2-11.1(1)(2)CONFLICT OF INTEREST N/A O„
AND CODE OF ETHICS ORDINANCE )
All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5) business d s of
being retained as a lobbyist or before engaging in any lobbying activities,whichever shall come first.Ever erson
required to so register shall:
1.Register on forms prepared by the Clerk;
2.State under oath his or her name,business address and the name and business address of each person or entity
which has employed said registrant to lobby.If the lobbyist represents a corporation,the corporation shall also be
identified.Without limiting the foregoing,the lobbyist shall also identify all persons holding,directly or indirectly,
a five (5)percent or more ownership interest in such corporation,partnership,or trust.Registration of all
lobbyists shall be required prior to January 15 of each year and each person who withdraws as a lobbyist for a
particular client shall file an appropriate notice of withdrawal.
3.Prior to conducting any lobbying,all principals must file a form with the Clerk of the Board of County
Commissioners,signed by the principal or the principal's representative,stating that the lobbyist is authorized to
represent the principal.Failure of a principal to file the form required by the preceding sentence may be
considered in the evaluation of a bid or proposal as evidence that a proposer or bidder is not a responsible
contractor.Each principal shall file a form with the Clerk of the Board at the point in time at which a lobbyist is no
longer authorized to represent the principal.
❑By initialing here,the principals or principal's representative have filed with the Clerk of the Board of
County Commissioners stating that a lobbyist is authorized to represent the principal.
4.Any public officer,employee or appointee who only appears in his or her official capacity shall not be required to
register as a lobbyist.
5.Any person who only appears in his or her individual capacity for the purpose of self-representation without
compensation or reimbursement,whether direct,indirect or contingent,to express support of or opposition to any
item,shall not be required to register as a lobbyist.
6.Any person who only appears as a representative of a not-for-profit corporation or entity(such as a charitable
organization,or a trade association or trade union),without special compensation or reimbursement for the
appearance,whether direct,indirect or contingent,to express support of or opposition to any item,shall register
with the Clerk as required by the Ordinance subsection,but,upon request,shall not be required to pay any
registration fees.
The Clerk of the Board of County Commissioners shall notify the Commission on Ethics and Public Trust of the
failure of a lobbyist or principal to file a report and/or pay the assessed fines after notification. A lobbyist or
principal may appeal a fine and may request a hearing before the Commission on Ethics and Public Trust.A request
for a hearing on the fine must be filed with the Commission on Ethics and Public Trust within fifteen(15) calendar
days of receipt of the notification of the failure to file the required disclosure form.The Commission on Ethics and
Public Trust shall have the authority to waive the fine,in whole or part,based on good cause shown.The
Commission on Ethics and Public Trust shall have the authority to adopt rules of procedure regarding appeals from
the Clerk of the Board of County Commissioners.
Except as otherwise provided in subsection of the Ordinance,the validity of any action or determination of the
Board of County Commissioners or County personnel,board or committee shall not be affected by the failure of any
person to comply with the provisions of this subsection(s). (Ord.No.00-19,§1,2-8-00; Ord.No.01-93,§ 1,5-22-
01;Ord.No.01-162,§ 1, 10-23-01;Ord.No.03-107,§ 1,5-6-03)
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 9 of 11
Miami-Dade County's Affidavits and Declarations
Pertains O
16. Disclosure SUBCONTRACTOR/SUPPLIER LISTING(ORDINANCE 97-104) N/A O
Initial` )
This form,or a comparable form meeting the requirements of Ordinance 97-104,must be completed by all b c ders and
proposers on Miami-Dade County contracts for purchase of supplies, materials or services, including p fessional
services which involve expenditures of $100,000.00 or more, and all bidders and proposers on County or Public
Health Trust construction contracts which involve expenditures of$100,000.00 or more. This form or a comparable
form meeting the requirements of Ordinance 97-104, must be completed and submitted even though the
bidder or proposer will not utilize subcontractors or suppliers on the contract. The bidder or proposer
should enter the word"NONE"under the appropriate heading,in those instances where no subcontractors or
suppliers will be used on the contract. A bidder or proposer who is awarded the contract shall not change or
substitute first tier subcontractors or direct suppliers or the portions of the contract work to be performed or
materials to be supplied from those identified except upon written approval of the County.
Business Name and Address Principal Owner Scope of Work to be Performed by (Principal Owner)
of First Tier Subcontractor/Subconsultant Gender Race
Subcontractor/Subconsultant
`) 7/U; .
Business Name and Address Principal Owner Supplies/Materials/Services to be (Principal Owner)
of Direct Supplier Provided by Supplier Gender Race
- )/161)C6
I certify the t the repres tations contained in this Subcontractor/Supplier Listing are to the best of my knowledge
true and a(1curate.
( ^ ) ( 27211 )
Sipa tore of orizRepre entative Date
( .rn .�. � Ii mak( ( .1 Qn:Air
not Name Print Ti r e
(Duplicate i.additional space is heeded),
ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 10 of 11
Miami-Dade County's Affidavits and Declarations
MIAMI•DADE 3.
.w f .
I have carefully read this entire 11-page document entitled, "Miami-Dade County's Affidavits and Declarations" and
agree to; (1)sign an affidavit as to certain matters and (2)make a declaration as to certain other matters. This
form contains both Affidavit forms for matters requiring the entity to sign under oath and Declaration forms for
matters requiring only an affirmation or declaration for other matters.
BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO AFFIDAVITS AND
DISCLOSURES 1-16
c£.? r,•� .%" u 3 mm m ;amen' cw xw .m =,3 `n
MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
6410
By: �4�1 ( ii -, ate9v(5()) , 20
Sign,Lure of Wit ess or Secretary Seal Date
Si_"t:ture o` • fian Federal Employer Identification Number
Printed Name of Affiant and Name of Agency
Address of Agency f
SUBSCRIBED AND SWORN TO (or affirmed) before me thi day of bY'L((� , 201
He/She
personally known to me or has presented as identification.
Type of identification
s ♦♦�\ TIg1,11 /111
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Signatu.oof �gR� i
�
Serial Number
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Expiration Date
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ATTACHMENT D"Miami-Dade County Affidavits and Declarations" Page 11 of 11
ATTACHMENT D
THIS ATTACHMENT IS
NOT APPLICABLE TO
THIS AGREEMENT
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-1819-ID-2
TOTAL AWARD AMOUNT: $ 25,000.00
AMOUNT OF FUNDS REQUESTED
THIS MONTH: $
AMOUNT OF FUNDS RECEIVED TO DATE: $
BALANCE REMAINING ON GRANT: $
(following payment of this request)
Signature of Executive Director or Date
Authorized Agency Representative
Printed Name of Executive Director or
Authorized Agency Representative
ATTACHMENT F
Miami-Dade County Homeless Trust
Monthly Payment Request
NAME OF AGENCY: THE CITY OF MIAMI BEACH
SERVICE PERIOD: TO
NAME OF GRANT: HMIS STAFFING PROGRAM
GRANT NUMBER: PC-1819-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
ATTACHMENT G
Continuum of Care Homeless Assistance Program
Performance Report Master Document
(Please check the box to indicate either monthly or annual report submitted)
0625 — HUD CoC Monthly Performance Report
( J 0625 —HUD CoC Annual Performance Report
(This is a template designed to assist grantees required to complete the Full CoC
APR. It is a model of the data collected in e-snaps. It is not intended to replace
electronic data collection in e-snaps. Field layout in e-snaps may differ from the
layout presented in this document.)
ATTACHMENT G"Performance Reports (Monthly and Annual) HMIS &Fiscal
ATTACHMENT H, OUTCOMES/PERFORMANCE MEASURES
PERFORMANCE MEASURES
EXPECTED OUTCOMES INDICATORS
4. Homeless participants will be assessed 300 participants will be assessed
5. Homeless participants will obtain vital 200 or 66%of homeless participants will obtain
personal identification documents. vital personal identification documents.
6. Homeless participants will obtain 150 or 50%of homeless participants will obtain
official photo identification. official photo identification.
ATTACHMENT I
THIS ATTACHMENT IS NOT
APPLICABLE
TO THIS AGREEMENT
ATTACHMENT J
THIS ATTACHMENT IS NOT
APPLICABLE
TO THIS AGREEMENT
ATTACHMENT K
THIS ATTACHMENT IS NOT
APPLICABLE
TO THIS AGREEMENT
ATTACHMENT L
MIAMI-DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI BEACH—HMIS STAFFING PROGRAM
GRANT NUMBER#: PC-1819-STAFF-2
OCTOBER 1,2018—SEPTEMBER 30,2019
Name of Agency: THE CITY OF MIAMI BEACH
$ 12,333.00
Month of Services Amount Paid
OCTOBER-2018
NOVEMBER-2018
DECEMBER-2018
JANUARY-2019
FEBRUARY-2019
MARCH-2019
APRIL-2019
MAY-2019
JUNE-2019 • . . • • .
JULY-2019
AUGUST-2019
SEPTEMBER-2019
Total Requested $ 0.00
Balance Remaining $ 12,333.00
Signature of Executive Director or Date
Authorized Representative
Printed Name of Executive Director or
Authorized Representative
ATTACHMENT L
MIAMI-DADE COUNTY HOMELESS TRUST
ANNUAL ACTUAL EXPENDITURE REPORT
CITY OF MIAMI BEACH—IDENTIFICATION ASSISTANCE PROGRAM
GRANT NUMBER#: PC-1819-ID-2
OCTOBER 1, 2018—SEPTEMBER 30,2019
Name of Agency: THE CITY OF MIAMI BEACH
$ 25,000.00
Month of Services Amount Paid
OCTOBER-2018
NOVEMBER-2018
DECEMBER-2018
JANUARY-2019
FEBRUARY-2019
MARCH-2019
APRIL-2019
MAY-2019
JUNE-2019
JULY-2019
AUGUST-2019
SEPTEMBER-2019
Total Requested $ 0.00
Balance Remaining $ 25,000.00
Signature of Executive Director or Date
Authorized Representative
Printed Name of Executive Director or
Authorized Representative
•
Form W-9 Request for Taxpayer Give Form to the
(Rev.December2014) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
1 Name(as s own on your income tax ret rn).Name is requir this line;do got leave this line blank.
N 2 Business nam disregarded entity name,if different from above
rn
m
a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
° ❑Individual/sole proprietor or ❑ C Corporation certain ionsentition,not individuals;see
rn p ❑ S Corporation ❑ Partnership ❑Trust/estate instructions on page 3):
m c single-member LLC
° ° Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► Exempt payee code(if any)
`p Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting
the tax classification of the single-member owner. code(if any)
E• ❑Other(see instructions)► (Applies to accounts maintained outside the U.S.)
E. 5 Address(number,kttiet,and apt.or suite no.i Requester's name and address(optional)
Cl) 6 Ci state,and ZIP code
a)
7 List account number(s)here optional)
Part I Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other — -
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Imployer identification number
guidelines on whose number to enter. — t% a 3: 3
Part II Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. I am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report a interest and divide .s on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abando ment of secured p J perry,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than inte est and dividends,l ou are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 3. ,1
Sign Signature of Here U.S.person 10- Date O. Zi2_ JL /
General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T
(tuition)
Section references are to the Internal R enue Code unless otherwise noted. •Form 1099-C(canceled debt)
Future developments.Information abo t developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release it)is at www.irs.gov/fw9.
Use Form W-9 only if you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you:
number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
identification number(EIN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or
•Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If
•Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership income from a U.S.trade or business is not subject to the
•Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
•Form 1099-S(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form W-9(Rev.12-2014)
Form W-9(Rev.12-2014) Page 2
Note.If you are a U.S.person and a requester gives you a form other than Form 3.The IRS tells the requester that you furnished an incorrect TIN,
W-9 to request your TIN,you must use the requester's form if it is substantially 4.The IRS tells you that you are subject to backup withholding because you did
similar to this Form W-9. not report all your interest and dividends on your tax return(for reportable interest
Definition of a U.S.person.For federal tax purposes,you are considered a U.S. and dividends only),or
person if you are: 5.You do not certify to the requester that you are not subject to backup
•An individual who is a U.S.citizen or U.S.resident alien; withholding under 4 above(for reportable interest and dividend accounts opened
•A partnership,corporation,company,or association created or organized in the after 1983 only).
United States or under the laws of the United States; Certain payees and payments are exempt from backup withholding.See Exempt
•An estate(other than a foreign estate);or payee code on page 3 and the separate Instructions for the Requester of Form
W-9 for more information.
•A domestic trust(as defined in Regulations section 301.7701-7). Also see Special rules for partnerships above.
Special rules for partnerships.Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section What is FATCA reporting?
1446 on any foreign partners'share of effectively connected taxable income from
such business.Further,in certain cases where a Form W-9 has not been received, The Foreign Account Tax Compliance Act(FATCA)requires a participating foreign
the rules under section 1446 require a partnership to presume that a partner is a financial institution to report all United States account holders that are specified
foreign person,and pay the section 1446 withholding tax.Therefore,if you are a United States persons.Certain payees are exempt from FATCA reporting.See
U.S.person that is a partner in a partnership conducting a trade or business in the Exemption from FATCA reporting code on page 3 and the Instructions for the
United States,provide Form W-9 to the partnership to establish your U.S.status Requester of Form W-9 for more information.
and avoid section 1446 withholding on your share of partnership income.
In the cases below,the following person must give Form W-9 to the partnership Updating Your Information
for purposes of establishing its U.S.status and avoiding withholding on its You must provide updated information to any person to whom you claimed to be
allocable share of net income from the partnership conducting a trade or business an exempt payee if you are no longer an exempt payee and anticipate receiving
in the United States: reportable payments in the future from this person.For example,you may need to
•In the case of a disregarded entity with a U.S.owner,the U.S.owner of the provide updated information if you are a C corporation that elects to be an S
disregarded entity and not the entity; corporation,or if you no longer are tax exempt.In addition,you must furnish a new
Form W-9 if the name or TIN changes for the account;for example,if the grantor
•In the case of a grantor trust with a U.S.grantor or other U.S.owner,generally, of a grantor trust dies.
the U.S.grantor or other U.S.owner of the grantor trust and not the trust;and
•In the case of a U.S.trust(other than a grantor trust),the U.S.trust(other than a Penalties
grantor trust)and not the beneficiaries of the trust. Failure to furnish TIN.If you fail to furnish your correct TIN to a requester,you are
Foreign person.If you are a foreign person or the U.S.branch of a foreign bank subject to a penalty of$50 for each such failure unless your failure is due to
that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use reasonable cause and not to willful neglect.
the appropriate Form W-8 or Form 8233(see Publication 515,Withholding of Tax • Civil penalty for false information with respect to withholding.If you make a
on Nonresident Aliens and Foreign Entities). false statement with no reasonable basis that results in no backup withholding,
Nonresident alien who becomes a resident alien.Generally,only a nonresident you are subject to a$500 penalty.
alien individual may use the terms of a tax treaty to reduce or eliminate U.S.tax on Criminal penalty for falsifying information.Willfully falsifying certifications or
certain types of income.However,most tax treaties contain a provision known as affirmations may subject you to criminal penalties including fines and/or
a"saving clause."Exceptions specified in the saving clause may permit an imprisonment.
exemption from tax to continue for certain types of income even after the payee ,
has otherwise become a U.S.resident alien for tax purposes. Misuse of TINs.If the requester discloses or uses TINs in violation of federal law,
If you are a U.S.resident alien who is relying on an exception contained in the the requester may be subject to civil and criminal penalties.
saving clause of a tax treaty to claim an exemption from U.S.tax on certain types Specific Instructions
of income,you must attach a statement to Form W-9 that specifies the following P
five items:
1.The treaty country.Generally,this must be the same treaty under which you Line 1
claimed exemption from tax as a nonresident alien. You must enter one of the following on this line;do not leave this line blank.The
2.The treaty article addressing the income. name should match the name on your tax return.
3.The article number(or location)in the tax treaty that contains the saving If this Form W-9 is for a joint account,list first,and then circle,the name of the
clause and its exceptions. person or entity whose number you entered in Part I of Form W-9.
4.The type and amount of income that qualifies for the exemption from tax. a. Individual.Generally,enter the name shown on your tax return.If you have
5.Sufficient facts to justify the exemption from tax under the terms of the treaty changed your last name without informing the Social Security Administration(SSA)
article. of the name change,enter your first name,the last name as shown on your social
security card,and your new last name.
Example.Article 20 of the U.S.-China income tax treaty allows an exemption Note.ITIN applicant Enter your individual name as it was entered on your Form
from tax for scholarship income received by a Chinese student temporarily present W-7 application,line 1a.This should also be the same as the name you entered on
in the United States.Under U.S.law,this student will become a resident alien for the Form 1040/1040 i1040EZ you filed with your application.
tax purposes if his or her stay in the United States exceeds 5 calendar years.
However,paragraph 2 of the first Protocol to the U.S.-China treaty(dated April 30, b. Sole proprietor or single-member LLC.Enter your individual name as
1984)allows the provisions of Article 20 to continue to apply even after the shown on your 1040/1040A/1040EZ on line 1.You may enter your business,trade,
Chinese student becomes a resident alien of the United States.A Chinese student or"doing business as"(DBA)name on line 2.
who qualifies for this exception(under paragraph 2 of the first protocol)and is c. Partnership,LLC that is not a single-member LLC,C Corporation,or S
relying on this exception to claim an exemption from tax on his or her scholarship Corporation.Enter the entity's name as shown on the entity's tax return on line 1
or fellowship income would attach to Form W-9 a statement that includes the and any business,trade,or DBA name on line 2.
information described above to support that exemption. d. Other entities.Enter your name as shown on required U.S.federal tax
If you are a nonresident alien or a foreign entity,give the requester the documents on line 1.This name should match the name shown on the charter or
appropriate completed Form W-8 or Form 8233. other legal document creating the entity.You may enter any business,trade,or
DBA name on line 2.
Backup Withholding e. Disregarded entity.For U.S.federal tax purposes,an entity that is
What is backup withholding?Persons making certain payments to you must disregarded as an entity separate from its owner is treated as a"disregarded
under certain conditions withhold and pay to the IRS 28%of such payments.This entity." See Regulations section 301.7701-2(c)(2)(iii).Enter the owner's name on
is called"backup withholding." Payments that may be subject to backup line 1.The name of the entity entered on line 1 should never be a disregarded
withholding include interest,tax-exempt interest,dividends,broker and barter entity.The name on line 1 should be the name shown on the income tax return on
exchange transactions,rents,royalties,nonemployee pay,payments made in which the income should be reported.For example,if a foreign LLC that is treated
settlement of payment card and third party network transactions,and certain as a disregarded entity for U.S.federal tax purposes has a single owner that is a
payments from fishing boat operators.Real estate transactions are not subject to U.S.person,the U.S.owner's name is required to be provided on line 1.If the
backup withholding. direct owner of the entity is also a disregarded entity,enter the first owner that is
You will not be subject to backup withholding on payments you receive if you not disregarded for federal tax purposes.Enter the disregarded entity's name on
give the requester your correct TIN,make the proper certifications,and report all line 2,"Business name/disregarded entity name."If the owner of the disregarded
your taxable interest and dividends on your tax return. entity is a foreign person,the owner must complete an appropriate Form W-8
instead of a Form W-9. This is the case even if the foreign person has a U.S.TIN.
Payments you receive will be subject to backup withholding if:
1.You do not furnish your TIN to the requester,
2.You do not certify your TIN when required(see the Part II instructions on page
3 for details),
Form W-9(Rev.12-2014) Page 3
Line 2 'However,the following payments made to a corporation and reportable on Form
If you have a business name,trade name,DBA name,or disregarded entity name, 1099-MISC are not exempt from backup withholding:medical and health care
you may enter it on line 2. payments,attorneys'fees,gross proceeds paid to an attorney reportable under
section 6045(f),and payments for services paid by a federal executive agency.
Line 3 Exemption from FATCA reporting code.The following codes identify payees
Check the appropriate box in line 3 for the U.S.federal tax classification of the that are exempt from reporting under FATCA.These codes apply to persons
person whose name is entered on line 1.Check only one box in line 3. submitting this form for accounts maintained outside of the United States by
Limited Liability Company(LLC).If the name on line 1 is an LLC treated as a certain foreign financial institutions.Therefore,if you are only submitting this form
partnership for U.S.federal tax purposes,check the"Limited Liability Company" for n account you
hold inrequestinghe United States,if youu may leave thisn if theh blank.
box and enter"P"in the space provided.If the LLC has filed Form 8832 or 2553 to Consultinstitutionwith the ec to t se requirements.
qthismform rqare uncertain indicatenif financiala
be taxed as a corporation,check the"Limited Liability Company"box and in the oeqis subjectyproviding to these rwith a Form A with"NotNr may ible"(tor a code is
not required by you with a Form W-9 with Applicable"(or any
space provided enter"C"for C corporation or"S"for S corporation.If it is a similar indication)written or printed on the line for a FATCA exemption code.
single-member LLC that is a disregarded entity,do not check the"Limited Liability
Company"box;instead check the first box in line 3"Individual/sole proprietor or A—An organization exempt from tax under section 501(a)or any individual
single-member LLC." retirement plan as defined in section 7701(a)(37) •
Line 4,ExemptionsB—TheUnited States or any of its agencies or instrumentalities
If you are exempt from backup withholding and/or FATCA reporting,enter in the C—A state,the District of Columbia,a U.S.commonwealth or possession,or
any of their political subdivisions or instrumentalities
appropriate space in line 4 any code(s)that may apply to you.
Exempt payee code. D—A corporation the stock of which is regularly traded on one or more
established securities markets,as described in Regulations section
• Generally,individuals(including sole proprietors)are not exempt from backup 1.1472-1(c)(1)(i)
withholding. E—A corporation that is a member of the same expanded affiliated group as a
• Except as provided below,corporations are exempt from backup withholding corporation described in Regulations section 1.1472-1(c)(1)(i)
for certain payments,including interest and dividends. F—A dealer in securities,commodities,or derivative financial instruments
• Corporations are not exempt from backup withholding for payments made in (including notional principal contracts,futures,forwards,and options)that is
settlement of payment card or third party network transactions. registered as such under the laws of the United States or any state
• Corporations are not exempt from backup withholding with respect to attorneys'. G—A real estate investment trust
fees or gross proceeds paid to attorneys,and corporations that provide medical or H—A regulated investment company as defined in section 851 or an entity
health care services are not exempt with respect to payments reportable on Form registered at all times during the tax year under the Investment Company Act of
1099-MISC. 1940
The following codes identify payees that are exempt from backup withholding. I—A common trust fund as defined in section 584(a)
Enter the appropriate code in the space in line 4.
1—An organization exempt from tax under section 501(a),any IRA,or a J—A bank as defined in section 581
custodial account under section 403(b)(7)if the account satisfies the requirements K—A broker
of section 401(f)(2) L—A trust exempt from tax under section 664 or described in section 4947(a)(1)
2—The United States or any of its agencies or instrumentalities M—A tax exempt trust under a section 403(b)plan or section 457(g)plan
3—A state,the District of Columbia,a U.S.commonwealth or possession,or Note.You may wish to consult with the financial institution requesting this form to
any of their political subdivisions or instrumentalities determine whether the FATCA code and/or exempt payee code should be
4—A foreign government or any of its political subdivisions,agencies,or completed.
instrumentalities
Line 5
5—A corporation
6—A dealer in securities or commodities required to register in the United Enter your address(number,street,and apartment or suite number).This is where
States,the District of Columbia,or a U.S.commonwealth or possession the requester of this Form W-9 will mail your information returns. •
7—A futures commission merchant registered with the Commodity Futures Line 6 .
Trading Commission Enter your city,state,and ZIP code.
8—A real estate investment trust
9—An entity registered at all times during the tax year under the Investment Part I.Taxpayer Identification Number(TIN)
Company Act of 1940 Enter your TIN in the appropriate box.If you are a resident alien and you do not
10—A common trust fund operated by a bank under section 584(a) have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer
11—A financial institution identification number(ITIN).Enter it in the social security number box.If you do not
have an ITIN,see How to get a TIN below.
12—A middleman known in the investment community as a nominee or If you are a sole proprietor and you have an EIN,you may enter either your SSN
custodian or EIN.However,the IRS prefers that you use your SSN.
13—A trust exempt from tax under section 664 or described in section 4947 If you are a single-member LLC that is disregarded as an entity separate from its
The following chart shows types of payments that may be exempt from backup owner(see Limited Liability Company(LLC)on this page),enter the owner's SSN
withholding.The.chart applies to the exempt payees listed above,1 through 13. (or EIN,if the owner has one).Do not enter the disregarded entity's EIN.If the LLC
is classified as a corporation or partnership,enter the entity's EIN.
IF the payment is for... THEN the payment is exempt for... Note.See the chart on page 4 for further clarification of name and TIN
combinations.
Interest and dividend payments All exempt payees except How to get a TIN.If you do not have a TIN,apply for one immediately.To apply
for 7 for an SSN,get Form SS-5,Application for a Social Security Card,from your local
SSA office or get this form online at www.ssa.gov.You may also get this form by
Broker transactions Exempt payees 1 through 4 and 6 calling 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer
through 11 and all C corporations.S Identification Number,to apply for an ITIN,or Form SS-4,Application for Employer
corporations must not enter an exempt Identification Number,to apply for an EIN.You can apply for an EIN online by
payee code because they are exempt accessing the IRS website at www.irs.gov/businesses and clicking on Employer
only for sales of noncovered securities Identification Number(EIN)under Starting a Business.You can get Forms W-7 and
acquired prior to 2012. SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM
(1-800-829-3676).
Barter exchange transactions and Exempt payees 1 through 4 If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN
patronage dividends and write"Applied For"in the space for the TIN,sign and date the form,and give it
over$600 required be Generally,exempt payees to the requester.For interest and dividend payments,and certain payments made
Payments
reported and direct sales over to be 1 through 52 with respect to readily tradable instruments,generally you will have 60 days to get
a TIN and give it to the requester before you are subject to backup withholding on
payments.The 60-day rule does not apply to other types of payments.You will be
Payments made in settlement of Exempt payees 1 through 4 subject to backup withholding on all such payments until you provide your TIN to
payment card or third party network the requester.
transactions Note.Entering"Applied For"means that you have already applied for a TIN or that
1 See Form 1099-MISC,Miscellaneous Income,and its instructions. you intend to apply for one soon.
Caution:A disregarded U.S.entity that has a foreign owner must use the
•
appropriate Form W-8. •
•
Form W-9(Rev.12-2014) Page 4
•
Part II.Certification You must show your individual name and you may also enter your business or DBA name on
To establish to the withholding agent that you are a U.S.person,or resident alien, the"Business name/disregarded entity"name line.You may use either your SSN or EIN(if you
sign Form W-9.You may be requested to sign by the withholding agent even if <have one),but the IRS encourages you to use your SSN.
items 1,4,or 5 below indicate otherwise. List first and circle the name of the trust,estate,or pension trust.(Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
For a joint account,only the person whose TIN is shown in Part I should sign title.)Also see Special rules for partnerships on page 2.
(when required).In the case of a disregarded entity,the person identified on line 1 'Note.Grantor also must provide a Form W-9 to trustee of trust.
must sign.Exempt payees,see Exempt payee code earlier. Note.If no name is circled when more than one name is listed,the number will be
Signature requirements.Complete the certification as indicated in items 1 considered to be that of the first name listed.
through 5 below. Secure Your Tax Records from Identity Theft
1.Interest,dividend,and barter exchange accounts opened before 1984
and broker accounts considered active during 1983.You must give your Identity theft occurs when someone uses your personal information such as your
correct TIN,but you do not have to sign the certification. name,SSN,or other identifying information,without your permission,to commit
2.Interest,dividend,broker,and barter exchange accounts opened after fraud or other crimes.An identity thief may use your SSN to get a job or may file a
1983 and broker accounts considered inactive during 1983.You must sign the tax return using your SSN to receive a refund.
certification or backup withholding will apply.If you are subject to backup To reduce your risk:
withholding and you are merely providing your correct TIN to the requester,you •Protect your SSN,
must cross out item 2 in the certification before signing the form.
3.Real estate transactions.You must sign the certification.You may cross out •Ensure your employer is protecting your SSN,and
item 2 of the certification. •Be careful when choosing a tax preparer.
4.Other payments.You must give your correct TIN,but you do not have to sign If your tax records are affected by identity theft and you receive a notice from
the certification unless you have been notified that you have previously given an the IRS,respond right away to the name and phone number printed on the IRS
incorrect TIN."Other payments"include payments made in the course of the notice or letter.
requester's trade or business for rents,royalties,goods(other than bills for If your tax records are not currently affected by identity theft but you think you
merchandise),medical and health care services(including payments to are at risk due to a lost or stolen purse or wallet,questionable credit card activity
corporations),payments to a nonemployee for services,payments made in or credit report,contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit •
settlement of payment card and third party network transactions,payments to Form 14039.
certain fishing boat crew members and fishermen,and gross proceeds paid to For more information,see Publication 4535,Identity Theft Prevention and Victim
attorneys(including payments to corporations). Assistance.
5.Mortgage interest paid by you,acquisition or abandonment of secured
property,cancellation of debt,qualified tuition program payments(under Victims of identity theft who are experiencing economic harm or a system
section 529),IRA,Coverdell ESA,Archer MSA or HSA contributions or problem,or are seeking help in resolving tax problems that have not been resolved
distributions,and pension distributions.You must give your correct TIN,but you through normal channels,may be eligible for Taxpayer Advocate Service(TAS)
do not have to sign the certification. assistance.You can reach TAS by calling the TAS toll-free case intake line at
1-877-777-4778 or TTY/TDD 1-800-829-4059.
What Name and Number To Give the Requester Protect yourself from suspicious emails or phishing schemes. Phishing is the
creation and use of email and websites designed to mimic legitimate business
For this type of account: Give name and SSN of: emails and websites.The most common act is sending an email to a user falsely
1.Individual The individual claiming to be an established legitimate enterprise in an attempt to scam the user
into surrendering private information that will be used for identity theft.
2.Two or more individuals point The actual owner of the account or, The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does
account) if combined funds,the first not request personal detailed information through email or ask taxpayers for the
individual on the account' PIN numbers,passwords,or similar secret access information for their credit card,
3.Custodian account of a minor The minor' bank,or other financial accounts.
(Uniform Gift to Minors Act) If you receive an unsolicited email claiming to be from the IRS,forward this
4.a.The usual revocable savings The grantor-trustee' message to phishing@irs.gov.You may also report misuse of the IRS name,logo,
trust(grantor is also trustee) or other IRS property to the Treasury Inspector General for Tax Administration
b.So-called trust account that is The actual owner' (TIGTA)at 1-800-366-4484.You can forward suspicious emails to the Federal
not a legal or valid trust under Trade Commission at:spam@uce.gov or contact them at www.ftc.gov/idtheft or
state law 1-877-IDTHEFT(1-877-438-4338).
5.Sole proprietorship or disregarded The owner' Visit IRS.gov to learn more about identity theft and how to reduce your risk.
entity owned by an individual
6.Grantor trust filing under Optional The grantor' Privacy Act Notice
Form 1099 Filing Method 1(see
Regulations section 1.671-4(b)(2)(i) Section 6109 of the Internal Revenue Code requires you to provide your correct
(A)) TIN to persons(including federal agencies)who are required to file information
returns with the IRS to report interest,dividends,or certain other income paid to
For this type of account: Give name and EIN of: you;mortgage interest you paid;the acquisition or abandonment of secured
7.Disregarded entity not owned by an The owner property;the cancellation of debt;or contributions you made to an IRA,Archer
individual MSA,or HSA.The person collecting this form uses the information on the form to
8.A valid trust,estate,or pension trust Legal entity' file information returns with the IRS,reporting the above information.Routine uses
of this information include giving it to the Department of Justice for civil and
. 9.Corporation or LLC electing The corporation criminal litigation and to cities,states,the District of Columbia,and U.S.
corporate status on Form 8832 or commonwealths and possessions for use in administering their laws.The
Form 2553 information also may be disclosed to other countries under a treaty,to federal and
10.Association,club,religious, The organization state agencies to enforce civil and criminal laws,or to federal law enforcement and
charitable,educational,or other tax- intelligence agencies to combat terrorism.You must provide your TIN whether or
exempt organization not you are required to file a tax return.Under section 3406,payers must generally
11.Partnership or multi-member LLC The partnership withhold a percentage of taxable interest,dividend,and certain other payments to
a payee who does not give a TIN to the payer.Certain penalties may also apply for
12.A broker or registered nominee The broker or nominee providing false or fraudulent information.
13.Account with the Department of The public entity
Agriculture in the name of a public
entity(such as a state or local
government,school district,or
prison)that receives agricultural
program payments
14.Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2(see
Regulations section 1.671-4(b)(2)(i)
(B)) •
List first and circle the name of the person whose number you furnish.If only one person on a
Joint account has an SSN,that person's number must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
•
,F.1 IA MODADE
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TYPE OEINCIDENT
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critical inejilentsouputring-cfparig.the administration term of its programs in addition to repcn ting this incident to
1110:•4150444*164ttiOtitip§,.A ::Sii*Oi0:44".0.:4#'*iti*:**514*(z4).Aoto:Jotan incident,submit in'it i iting a
detailed account,otte iffeident This incident report should be addressed to the Conttact Officer or Administrative
Officer assigned. Thisluseideutreporvshoutet.be addressed to Miami-Dade Countr'lloniOless..:•Tivgt; ill NW First
Stied',27'4 Frorida.:IM:14telephone,(3 05).35751490 and.facsrnilie(305)375-2722.
DOT9itiO4-.4.400040k4)40600
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services afe;being.iendered,'Of:VlienU client is in thephysical custody df the department,which results in one:ef
lnoo,elientSorempleyees.receivirigtneclical treatment by:allfeensect health,care professional.,
b. :,C1 leaf illeath.A0Tyoy'A?;/fieSe,:fifeteUiVikgeS.efuele.or,allegethy4uelei.:auaccidentk,aet.o.fabute ,neglect ot other
ii40i4e0oppgging:qitpfliqTresppceppi:pmployep;10110**1.eiTr94; 6ritiOcteCt'..go044kojliti.,
:d, Client Injury or illness. 2‘,..bedied conditidn ota efieutleqUiiiiigfiiediCaf treatment by al.ieense'ef,heUltfv.cure
4Jf6f*iO4-41:***4:0Y4111"g01S1,;S(*taffkcV-44efii.an accident,act of abuse',neglect or other incident occurring
liliitg:in'tiipi-pseope.of an employee,in alIotuejessliust:.epntragfea program.
d. Gthei'IricidenL An th-ctitastaticeiriitiatea-ily sdifiettiiigotifee-thaff natutal bauSes:,aliut.ot
the ordinary Such asa tornadOcrkiffnappiug;:4et,or hostage situation ihich jeopardizes the health safety and
welfare of clients..
Battery; allegation of client on a client, employee on a 004;;0.clienton an
crnployee.as evidenced by medical evidence or Iaw',enforc'ement involvement. . .
,Sifieief&-Atternot.Aii-.bot:WhiCiftlea4t6fiect§:thelitvieal:attetept by aelfetuto causelit%bt her oWn.deAth while
in the physical custody of the department oi a departmental 644004];*certified provider wiuch results in
bodily'injury requiring medical tteatnient..tvuiieepsed.hea*cat.e.lirdfessioppi.
-
Otidotiooiinvolving damage with..Miainillade.ebuuty HOtheless,
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-..4:T.TACIMENT.2.1fulgtiC4q. dOiflgOpprtforni" • Page 2 o12
. .
MIAMI-DADE COUNTY HOMELESS TRUST POLICY &PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFFECTIVE DATE: 9/9/2015
REVISED DATE:
PURPOSE: The purpose of this policy is to define the process for receiving and
processing incident reports.
SCOPE: Miami-Dade County Homeless Continuum of Care
PROCEDURES:
1. Homeless CoC providers contracted with Miami-Dade County Homeless Trust must
report the following types of critical incidents,via fax(305)375-2722 or email,to
the attention of our Incident Report Coordinator: Miguel Pimentel.These incidents
are defined and outlined in CF-OP 215-6.
• Child-on-Child Sexual Abuse
• Child Arrest
• Child Death
• Adult Death
• Elopement refers to court ordered clients that run away and do not return
• Employee Arrest
• Employee Misconduct
• Escape
• Missing Child
}
• Security Incident-Unintentional
• Significant Injury to Clients
• Significant Injury to Staff
• Suicide Attempt
• Sexual Abuse/Sexual Battery
2. For each critical incident,an incident report must be submitted to Miami-Dade
County Homeless Trust within one business day. The incident report needs to
include:
• Facility/Home
• Clients Name
• CIients Age
• Date&Time of Accident/Incident
• Place of Accident/Incident
• Description of Accident/Incident
• Description or nature of injury
• Witness(es) to Accident/Incident
MIAMI-DADE COUNTY HOMELESS TRUST POLICY&PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFFECTIVE DATE: 9/9/2015
REVISED DATE:
• What action(s)were taken?
• Parent/Guardian information,and if they were contacted?Time? How?
• Other Persons Contacted
• Describe Medical Treatment/First Aid •
• Signature of Staff Completing Form, Date and Time
• Signature of Director/Person in Charge, Date and Time
3. When a critical incident occurs, subcontracted provider staff should:
• Take action to ensure the health,safety,and welfare of all individuals
involved in the incident,and
• Contact law enforcement, emergency responders, or the Abuse Hotline.
TOOLS: Miami-Dade County Homeless Trust Incident Report Form
M:\Policies-Miami-Dade County Homeless Trust\Incident Reporting Process.0515
}
MIAMI-DADE COUNTY HOMELESS TRUST POLICY&PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFFECTIVE DATE: 9/9/2015
REVISED DATE:
PURPOSE: The purpose of this policy is to define the process for receiving and
processing incident reports.
SCOPE: Miami-Dade County Homeless Continuum of Care
PROCEDURES:
1. Homeless CoC providers contracted with Miami-Dade County Homeless Trust must
report the following types of critical incidents,via fax(305)375-2722 or email,to
the attention of our Incident Report Coordinator:Miguel Pimentel.These incidents
are defined and outlined in CF-OP 215-6.
• Child-on-Child Sexual Abuse
• Child Arrest
• Child Death
• • Adult Death
• Elopement refers to court ordered clients that run away and do not return
• Employee Arrest
• Employee Misconduct
• Escape
• Missing Child
• Security Incident--Unintentional
• Significant Injury to Clients
• Significant Injury to Staff
• Suicide Attempt
• Sexual Abuse/Sexual Battery
2. For each critical incident,an incident report must be submitted to Miami-Dade
County Homeless Trust within one business day. The incident report needs to
include:
• Facility/Home
• Clients Name
• Clients Age
• Date&Time of Accident/Incident
• Place of Accident/Incident
• Description of Accident/Incident
• Description or nature of injury
• Witness(es)to Accident/Incident
•
MIAMI-DADE COUNTY HOMELESS TRUST POLICY& PROCEDURES
SUBJECT: INCIDENT REPORTING PROCEDURES
EFFECTIVE DATE: 9/9/2015
REVISED DATE:
• What action(s)were taken?
• Parent/Guardian information,and if they were contacted?Time?How?
• Other Persons Contacted
• Describe Medical Treatment/First Aid
• Signature of Staff Completing Form,Date and Time
• Signature of Director/Person in Charge, Date and Time
3. When a critical incident occurs,subcontracted provider staff should:
• Take action to ensure the health,safety,and welfare of all individuals
involved in the incident,and
• Contact law enforcement, emergency responders, or the Abuse Hotline.
TOOLS: Miami-Dade County Homeless Trust Incident Report Form
M:\Policies-Miami-Dade County Homeless Trust\Incident Reporting Process.0515
}
CFOP 215-6
STATE OF FLORIDA
DEPARTMENT OF
CF OPERATING PROCEDURE CHILDREN AND FAMILIES
NO. 215-6 TALLAHASSEE,April 1, 2013
(
Safety
{
INCIDENT REPORTING AND ANALYSIS SYSTEM (IRAS)
1. Purpose. This operating procedure establishes the guidelines for reporting and analyzing critical
incidents as defined below. The analysis of incidents should be considered part of the overall risk
management program and quality improvement process of the Department, its employees, and its
licensed and contracted service providers.
2. Scope.
a. This operating procedure applies to all critical incidents occurring within the following
Department of Children and Families program areas:
(1) ACCESS;
(2) Administration;
(3) Adult Protective Services;
(4) Family Safety;
(5) Mental Health; and,
(6) Substance Abuse.
b. Incidents to be reported are those that occur: .
(1) Involving a client, Department employee, or a licensed or contracted provider
serving clients of the Department, or involving an employee of a licensed or contracted provider serving
clients of the Department in the identified program areas; or,
(2) Involving any licensed public or private substance abuse provider agency licensed in
accordance with Chapter 397, Florida Statutes(F.S.), and Chapter 65D-30, Florida Administrative Code
(F.A.C.),and their employees. Compliance with this procedure is a condition of substance abuse
licensure regardless of whether or not the provider serves any clients funded by the Department.
c. The Incident Reporting and Analysis System (IRAS) allows for the timely notification of
critical incidents, provision of details of the incident and immediate actions taken, and the ability to track
and analyze incident-related data.
d. The IRAS is not a case management system, and cannot be utilized to capture ongoing and
specific case management information, such as the progression of events and actions following the
occurrence of a critical incident. .
This operating procedure supersedes CFOP 215-6 dated December 1, 2012.
OPR: Assistant Secretary for Operations
DISTRIBUTION: A
April 1, 2013 CFOP 215-6
e. State mental health treatment facilities, public and private, are required to adhere to
CFOP 155-25, Critical Event Reporting in State Mental Health Treatment Facilities, and are specifically
excluded from compliance with this operating procedure.
f. The incident reporting procedures do not replace:
(1) The mandatory reporting requirements to the Florida Abuse Hotline for abuse,
neglect and exploitation reporting protocols, as required by law. Allegations of abuse, neglect, or
exploitation must always be reported immediately to the Florida Abuse Hotline.
(2) The investigation and review requirements provided for in CFOP 175-17, Child
Fatality Review Procedures.
(3) The reporting requirements provided for in CFOP 175-85, Prevention, Reporting and
Services to Missing Children.
(4) The reporting requirements provided for in CFOP 180-4, Mandatory Reporting
Requirements to the Office of the Inspector General.
3. Definitions.
a. Abuse. Any willful or threatened act or omission that causes or is likely to cause significant
impairment to a child or vulnerable adult's physical, mental or emotional health.
b. Department. The Department of Children and Families.
c. Hospital. A facility licensed under Chapter 395, F.S. This includes facilities licensed as
specialty hospitals under Chapter 395, F.S.
d. Incident Coordinator. The designated Department or provider/agency staff whose role is to
add and update incidents, create and send initial and updated notifications and change the status of an
incident. Department Incident Coordinators are designated by their respective
Circuit/Region/Headquarters leadership.
e. .Neglect. The failure or omission on the part of the caregiver to provide the care, supervision
and services necessary to maintain the physical and mental health of a child or vulnerable adult; or the
failure of a caregiver to make reasonable efforts to protect a child or vulnerable adult from abuse,
neglect, or exploitation by others.
f. Restraint. Any manual method or physical or mechanical device,materials,or equipment
attached or adjacent to the individual's body so that he or she cannot easily remove the restraint and which
restricts freedom of movement or normal access to one's body.
g. Seclusion. The physical segregation of a person in any fashion, or involuntary isolation of a
person in a room or area from which the person is prevented from leaving. The prevention may be by
physical barrier or by a staff member who is acting in a manner, or who is physically situated, so as to
prevent the person from leaving the room or area.
4. Policy. It is the responsibility of all Departmental personnel, and Department licensed or contracted
providers, to promptly report within one business day all critical incidents in accordance with the
requirements of this operating procedure. Failure by a Department employee to comply with this
operating procedure may lead to disciplinary action. Failure by a Department licensed or contracted
provider to comply with this operating procedure constitutes a lack of compliance with licensure status
or contract provisions.
2
}
April 1, 2013 CFOP 215-6
5. Critical Incidents To Be Reported.
a. Adult Death. An individual 18 years old or older whose life terminates while receiving
services, during an investigation, or when it is known that an adult died within thirty(30) days of
discharge from a treatment facility. For the Adult Protective Services program,deaths that are a result
of the vulnerable adult's documented condition are not subject to critical incident reporting
requirements. The manner of death is the classification of categories used to define whether a death is
from intentional causes, unintentional causes, natural causes, or undetermined causes.
(1) The final classification of an adult's death is determined by the medical examiner.
However, in the interim,the manner of death will be reported as one of the following:
(a) Accident. A death due to the unintended actions of one's self or another.
(b) Homicide. A death due to the deliberate actions of another.
(c) Suicide, The intentional and voluntary taking of one's own life.
fi
(d) Undetermined. The manner of death has not yet been determined.
(e) Unknown. The manner of death was not identified or made known.
(2) If an adult's death involves a suspected overdose from alcohol and/or drugs, or
seclusion and/or restraint, additional information about the death will need to be reported in IRAS.
b. Child Arrest. The arrest of a child in the custody of the Department.
G. Child Death. An individual less than 18 years of age whose life terminates while receiving
services, during an investigation, or when it is known that a child died within thirty(30)days of
discharge from a residential program or treatment facility or when a death review is required pursuant
to CFOP 175-17, Child Fatality Review Procedures. The manner of death is the classification of
categories used to define whether a death is from intentional causes, unintentional causes, natural
causes,or undetermined causes.
(1) The final classification of a child's death is determined by the medical examiner.
However, in the interim,the manner of death will be reported as one of the following:
(a) Accident. A death due to the unintended actions of one'sself or another.
(b) Homicide. A death due to the deliberate actions of another.
(c) Natural Expected. A death that occurs as a result of, or from complications
of, a diagnosed illness for which the prognosis is terminal.
(d) Natural Unexpected. A sudden death that was not anticipated and is
attributed to an underlying disease either known or unknown prior to the death.
(e) Suicide. The intentional and voluntary taking of one's own life.
(0 Undetermined. The manner of death has not yet been determined.
(g) Unknown. The manner of death was not identified or made known.
(2) If a child's death involves a suspected overdose from alcohol and/or drugs,or
seclusion and/or restraint, additional information about the death will need to be reported in IRAS.
•3
April 1, 2013 CFOP 215-6
d. Child-on-Child Sexual Abuse. Any sexual behavior between children which occurs without
consent,without equality, or as a result of coercion.This applies only to children receiving services from
the Department or by a licensed, contracted provider, e.g.children in foster care placements or in
residential treatment.
e. Elopement.
(1) The unauthorized absence beyond four hours of an adult during involuntary civil
placement within a Department-operated, Department-contracted or licensed service provider.
(2) The unauthorized absence of a forensic client on conditional release in the
community.
(3)The unauthorized absence of any individual in a Department contracted or licensed
residential substance abuse and/or mental health program.
f. Employee Arrest. The arrest of an employee of the Department or its contracted or licensed
service providers for a civil or criminal offense.
g. Employee Misconduct. Work-related conduct or activity of an employee of the Department
or its contracted or licensed service providers that results in potential liability for the Department; death
or harm to a client; abuse, neglect or exploitation of a client;or results in a violation of statute, rule,
regulation, or policy. This includes, but is not limited to, misuse of position or state property;
falsification of records;failure to report suspected abuse or neglect; contract mismanagement; or
improper commitment or expenditure of state funds.
h. Escape. The unauthorized absence of a client who is committed by the court to a state
mental health treatment facility pursuant to Chapter 916 or Chapter 394, Part V, Florida Statutes.
i. Missing Child. When the whereabouts of a child in the custody of the Department are
unknown and attempts to locate the child have been unsuccessful.
j. Security Incident—Unintentional. An unintentional action or event that results in
compromised data confidentiality,a danger to the physical safety of personnel, property, or technology
resources; misuse of state property or technology resources;and/or denial of use of property or
technology resources. This excludes instances of compromised client information.
k. Sexual Abuse/Sexual Battery. Any unsolicited or non-consensual sexual activity by one
client to another client, a DCF or service provider employee or other individual to a client, or a client to
an employee regardless of the consent of the client. This may include sexual battery as defined in
Chapter 794 of the Florida Statutes as"oral, anal, or vaginal penetration by, or union with, the sexual
organ of another or the anal or vaginal penetration of another by any other object; however, sexual
battery does not include an act done for a bona fide medical purpose." This includes any unsolicited or •
non-consensual sexual battery by one client to another client, a DCF or service provider employee or
other individual to a client, or a client to an employee regardless of consent of the client.
I. Significant Injury to Clients. Any severe bodily trauma received by a client in a
treatment/service program that requires immediate medical or surgical evaluation or treatment in a
hospital emergency department to address and prevent permanent damage or loss of life.
m. Significant Injury to Staff. Any serious bodily trauma received bya staff member as a result
of work related activity that requires immediate medical or surgical evaluation or treatment in a hospital
emergency department to prevent permanent damage or loss of life.
4
April 1,2013 CFOP 215-6
n. Suicide Attempt. A potentially lethal act which reflects an attempt by an individual to cause
his or her own death as determined by a licensed mental health professional or other licensed
healthcare professional.
o. Other. Any major event not previously identified as a reportable critical incident but has, or is
likely to have, a significant impact on client(s), the Department, or its provider(s). These events may
include but are not limited to:
(1) Human acts that jeopardize the health, safety, or welfare of clients such as
kidnapping, riot, or hostage situation;
(2) Bomb or biological/chemical threat of harm to personnel or property involving an
explosive device or biological/chemical agent received in person, by telephone, in writing, via mail,
electronically, or otherwise;
(3) Theft, vandalism, damage, fire, sabotage, or destruction of state or private property
of significant value or importance;
(4) Death of an employee or visitor while on the grounds of the Department or one of its
contracted or licensed providers;
(5) Significant injury of a visitor(who is not a client)while on the grounds of the
Department or one of its contracted, designated, or licensed providers; or,
(6) Events regarding Department clients or clients of contracted or licensed service
providers that have led to or may lead to media reports.
6. Guidelines for Reporting Incidents.
a. Notification/Reporting and Actions Taken—Staff Discovery of an Incident.
(1) Any employee of the Department, or one of its contracted or licensed providers,who
discovers that a reportable critical incident, as described herein, has occurred,will report the incident as
outlined in this operating procedure.
(2) The employee's first obligation is to ensure the health, safety, and welfare of all
individual(s) involved.
(3) The employee must immediately ensure contacts are made for assistance as
dictated by the needs of the individuals involved. These types of contacts may include, but are not
limited to: emergency medical services (911), law enforcement, or the fire department. When the
incident involves suspected abuse, neglect, or exploitation,the employee must call the Florida Abuse
Hotline to report the incident. The employee must ensure that the client's guardian, representative or
relative is notified, as applicable.
(4) Once the situation is stabilized and the staff has addressed any immediate physical
or psychological service needs of the person(s) involved in the incident,the employee must report the
incident to the Incident Coordinator. Each service provider/agency will use their internal reporting
process and timeframes for notifying provider/agency leadership of incidents. All critical incidents must
be entered into IRAS within one business day of the incident occurring.
(5) In the case of subcontractors, Managing Entities, or Lead Agencies, the
responsibility for reporting critical incidents to the Department rests with the Department's contracted
provider.
5
April 1, 2013 CFOP 215-6
b. Notification/Reporting and Actions Taken by the Provider's/Agencv's Incident Coordinator or
the Coordinator's Designee.
(1) Each Department licensed or contracted service provider will designate one staff
person to be the Incident Coordinator for the provider/agency. This person will manage the
provider's/agency's incident notification process. Additional staff may be designated to enter incident
information into the IRAS at the discretion of the service provider/agency.
(2) When a supervisor is informed of a critical incident,that person shall verify what has
occurred, confirm the known facts with the discovering employee, and ensure that appropriate and
timely notifications and actions occurred. The service provider/agency shall develop internal
procedures regarding reporting incidents to their Incident Coordinator or designee.
(3) If the incident qualifies as a critical incident according to the definitions contained in
this operating procedure, the provider's/agency's Incident Coordinator will review the incident
information and clarify or obtain any necessary information before forwarding the incident report to the
Department's designated Incident Coordinator or designee. The provider's/agency's Incident
Coordinator will provide the information regarding the incident to the Department's Incident Coordinator
or designee via the IRAS.
(4) The service provider/agency will ensure timely notification of critical incidents is
made to appropriate individuals or agencies such as emergency medical services (911), law
enforcement, the Florida Abuse Hotline, the Agency for Health Care Administration (ANCA), or Center
for Mental Health Services (for licensed mental health facilities), as required.The IRAS reporting
process does not replace the reporting of incidents to other entities as required by statute, rules or
operating procedure.
c. Notification/Reporting and Actions Taken by Department's Incident Coordinator(s) or the
Coordinator's Designee.
(1) The Department's Incident Coordinator or designee at the Circuit/Region level will
review the incident information and clarify or obtain any necessary additional information from the
applicable service provider and make revisions as necessary.
(2) The Department's Incident Coordinator or designee will make a determination
regarding any required notifications that should be sent to Department leadership. The Department's
Incident Coordinator or designee is responsible for ensuring appropriate notification is provided and
serves as the contact person regarding the IRAS. In addition to Department's leadership staff,the
Department's Incident Coordinator or designee will notify the Circuit/Region Public Information Officer
within two(2) hours of any incident that may have Department impact or media coverage.
(3) The entry of the incident into IRAS does not substitute for a direct phone call to the
Department's leadership staff when the incident type or severity of the incident warrants such contact.
This determination is to be made by the Department's Incident Coordinator or designee in consultation
with other Department leadership staff, as needed.
(4) The Department's Incident Coordinator or designee should submit incidents in IRAS
even in cases where there is missing information not readily available. When the information is
obtained,the Incident Coordinator or designee should submit an update in IRAS as soon as possible.
(5) The Department's Incident Coordinator or designee shall ensure all necessary
information is entered into the IRAS in order to have a complete notification. The incident report is
considered to be"complete"when the initial notifications have been made and sufficient information
regarding the incident has been submitted. Additional information, such as from an autopsy or medical
6
April 1, 2013 CFOP 215-6
examiner report regarding an incident can be submitted into the IRAS after the incident has been
determined to be"complete."
(6) Each Circuit/Region shall develop an internal process for reviewing and analyzing
trends regarding critical incidents within their Circuit/Region across all Department program areas.
Each service provider/agency including Managing Entities will establish a system for reviewing critical
incidents to determine what actions need to be taken, if any,to prevent future occurrences and a follow-
up process to assure such needed actions are implemented.
BY DIRECTION OF THE SECRETARY:
(Signed original copy on file)
PETER DIGRE
Assistant Secretary for.
Operations
SUMMARY OF REVISED,ADDED, OR DELETED MATERIAL
This operating procedure was revised to specify the Department of Children and Families programs
which are subject to the requirements of this operating procedure, and to separate the requirements for
reporting adult deaths and child deaths.
•
7
MIAMI-DADE COUNTY HOMELESS TRUST
PROVIDER ASSET INVENTORY
ATTACHMENT 0
Provider Name:
Program Name:
Funding Source:
Reporting Period:
of Purchase Use and Who Holds
Acquisition Acquisition Vendor Cost From Location of Condition of Title of
Description of Property Serial/ID Number Date Cost Name Grant Property Property Property
**Attach Invoices fro all purchases this grant period.
. .
_ ,, . , • • • ATTACHMENT P
• . .
' •
. '
•
- :MIAMI DADE COUNTY HOMELESS TRUST .
i'''' • - .
CLIENT SERVICES CERTIFICATION REFERRAL FORM FOR EMPLOYEES OF
i .
HOMELESS TRUST FUNDEIYPROGR.A.MS . • . 1
. INSTRUCTIONS: Provider making referral must complete this twb-page form,including,signatures
• • by Applicant and Provider Represehtatives. Fax completed farms to ProviderReceiving Referral for . • - .
•
HoUsing alit!.or Services.
. .
. • .
. . •
.
Date: - - Referring Provider: • - •
. .
, .
. .
• Contact Person:
. .
.
N aMe Title ' • PhopeNuMber •
. . ..
. .
. .
INFORMATION ON HEAD OF HOUSEHOLD:. . . .
. . . .
. . - .
Last Name: • . - First Name: -
. • , . - .
- . Date of P..irt.h: --... . SS i,t: • • . . .
• -
• INFORMATION ON OTHER nOUSEHOLD MEMBERS:• ' . •- . ...
. .
. I Name •j Age . Sex Relationship ' . Employer
-
. .
... . , . .
. • •
. •
. .
. .
• ' .
- • - .
. .
- .
- • .
. • .
' .
' . • . . .. . .
• - .
1 .
• I
I
...,. . .
. . .
•
. . • . . .
. ..
• .• • .
•
I .
.
: 1 . •
. .
• .
.
. •
•
.
is ANY MEMBER OF THE HOUSEHOLD EMPLOYED RX,jDR RELATED TO AN EMPLOYEE . .
. .
OF,A HOMELESS TRUST FUNDED PROGRAM? Yes . NaNo ,,
• ifyes: ' . .
:.,
. • • .
•
Name of Em ' • • .ployee: .
•
• Employina, Prdvider: • .
•
.
• Relationship to APplicant: •
CERTIFICATION .
- I,the unciersicTned,do hereby certify that the above-information pro.vided by.m.e..is....true and correct to the .
best of my knowledge. •
Applicant's Name
. . . .
Signature: Date:
•
Referrim2 Provider Authorized Representative •
.
.
•
. .
1--- --"' Name: Signature . • Date -
. .... . • ' .
• • .
•
•
- .
- • • ,
•
r-' -
. ATTACHMENT' P
PROVIDER REFERRAL FORM PAGE TWO
'
.
Applicant s Name .
if the Applicant or a inember of.their household is an employee of the referring provider,the •
approval of the Provider EXecixtive Director is hereby indicated by signature: .
Name/Title Date. .
If the Applicant or a member of their household is. 11 employee of the provider where services will be ..
provided, the approval of The Provider Executive Director,the Homeless Trust Executive Director,
and the Homeless Trust Board Chair are hereby indicated by signature: • .
Provider Executive Director . Date .
Miami-Dade County Homeless Trust Chairperson . Date .
• Miami-Dade County Homeless Trust Executive Director Date
ADDITIONAL HOUSEIIOLD INFORIvIATJON: •
Where is the household living now? (Facility name,exact address) . •
t .
Date of present homelessness: •
•
Explain the homeless situation,and what caused the current •
• homelessness: • . . - .
NOTE TO REFERRING PROVIDER:
PROVIDING TI-IE ABOVE INFORMATION DOES NOT ENSURE APPROVAL FOR HOUSING
OR OTHER SERVICES REQUESTED. A DETERMINATION WILL BE MADE FOLLOWING A •
COMPLETE ASSESSMENT OF THE APPLICANT'S CASE.
• • THIS SECTION FOR SERVICE PROVIDER STAFF USE ONLY:
Meets Eligihility Criterir..:. - YES NO
Nr7nze rrf ProviderScreeiw7g Staff. .. .
PLEASE MAINTAIN THE EXECUTED COPY OF THIS DOCUMENT IN THE•CLIENT FILE OF
THE SERVICING PROVIDER AND PERSONNEL FILE OF REFERRING PROVIDER.
•