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Amendment No. 1 to the Agreement between CMB and MDC No- / MIAMI•DADE COUNTY AMENDMENT #1 OF THE AGREEMENT BETWEEN MIAMI-DADE COUNTY AND THE THE CITY OF MIAMI BEACH HMIS STAFFING PROGRAM PC-1920-STAFF-2 IDENTIFICATION ASSISTANCE PROGRAM PC-1920-ID-2 HMIS STAFFING PROGRAM-GRANT NUMBER: PC-1920-STAFF-2 IDENTIFICATION ASISTANCE PROGRAM-GRANT NUMBER: PC-1920-ID-2 AMENDMENT#1 OF THE AGREEMENT BETWEEN • MIAMI-DADE COUNTY AND THE CITY OF MIAMI BEACH FOR THE HMIS STAFFING PROGRAM-GRANT NUMBER: PC-1920-STAFF-2 IDENTIFICATION ASSISTANCE PROGRAM-GRANT NUMBER: PC-1920-ID-2 THIS A1IENDMENT #1 OF THE AGREEMENT the "Agreement Amendment") is made as of / , 2 ( , 201'20, by and between Miami-Dade County, through the Miami-Dade County Homeless Trust("the County") and The City of Miami Beach,a recipient of grant funds to serve homeless individuals,hereinafter referred to as the"Provider. WITNESSETH: WHEREAS,On March 20,2019,the County and the Provider entered into a grant Agreement("Agreement") which provides funding for the provision of identification and HMIS staffing services to homeless individuals and families in Miami-Dade County. WHEREAS,this Agreement provides for certain rights and responsibilities of the County; and WHEREAS,the Agreement allows for amendment and extensions at the sole discretion of the County; and WHEREAS, the County is desirous of amending the Agreement to extend said Agreement for one (1) additional year(2019-2020) pursuant to the terms of the Agreement. NOW, THEREFORE, be it resolved, for and consideration of the mutual agreements between the County and the Provider,which are set forth in this Amendment#1 of the Agreement,the receipt and sufficiency of which are acknowledged,the County and the Provider amend this Agreement as follows: ARTICLE I-Recitals The foregoing recitals are true and correct and constitute a part of this Amendment#1 of the Agreement. ARTICLE II-Ratification of the Agreement Other than expressly corrected or amended herein,all other terms and conditions of the Agreement shall remain in full force and effect. ARTICLE III-Amendments The Agreement is hereby amended as follows: Article 2 is replaced as follows: 2 ' Page HMIS STAFFING PROGRAM-GRANT NUMBER: PC-1920-STAFF-2 IDENTIFICATION ASISTANCE PROGRAM-GRANT NUMBER: PC-1920-ID-2 ARTICLE 2. AMOUNT PAYABLE Subject to available funds, the maximum amount payable for services rendered under this contract shall not exceed: • HMIS Staffing Program $ 12,333.00 • Identification Assistance Services 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 maybe proportionately reduced at the sole discretion and option of the County. All services undertaken by the Provider before the County's execution of this Contract shall be at the Provider's risk and expense. It is the responsibility of the Provider to maintain sufficient financial resources to meet the expenses incurred during the period between the provision of services and the payment by the County. The County, at its sole discretion, may allow Provider an advance of N/A once the Provider has submitted an appropriate request and submitted an invoice in the form required by the County. Article 5 is replaced as follows: ARTICLE 5. EFFECTIVE TERM Both parties agree that the Effective Term of this Contract shall commence on October 1. 2019 and terminate at the close of business on September 30, 2020. 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 16 is replaced as follows: ARTICLE 16. TERMINATION FOR CONVENIENCE I. 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. II. At Will. This Contract may be terminated by the County upon no less than ten (10) working days' notice when the County determines, in the sole and absolute discretion of the County,that it would be in the best interest of the County. Said notice shall be delivered by certified mail,return receipt requested,or in person with proof of delivery.The County may also,in its sole discretion,terminate the contract. 3jPage HMIS STAFFING PROGRAM-GRANT NUMBER: PC-1920-STAFF-2 , IDENTIFICATION ASISTANCE PROGRAM-GRANT NUMBER: PC-1920-ID-2 1.1°' III. Due to Lack of Funds. In the event of a funding short-fall, or a reduction in the funding appropriations, or should funds to finance this Contract become unavailable,the County may terminate,in its sole discretion and absolute authority,this Contract upon no less than twenty-four (24) hours written notification to the Provider.Said notice shall be delivered by certified mail, return receipt requested, or in person with proof of delivery. The County shall be the final authority to determine whether or not funds are available. The County may at its discretion terminate, renegotiate and/or adjust the Contract award, whichever is in the best interest of the County. IV. Due to Substantial Funding Reduction. In the event of a substantial funding reduction of the allocation to the Provider through Board of County Commissioners' (BCC) action, the Provider may, at its discretion,request in writing from the Director of the Department a release from its contractual obligations to the County. The Director of the Department will review the effect of the request on the community and the County prior to making a final determination. VI. Bankruptcy. If, during the term of any contract the Provider has with the County, the Provider becomes involved as a debtor in a bankruptcy proceeding, or becomes involved in a reorganization, dissolution,or liquidation proceeding or if a trustee or receiver is appointed over all or a substantial portion of the property of the Provider under federal bankruptcy law or any state insolvency law. The Provider understands and acknowledges that if the County determines in its sole discretion that termination of the Contract is necessary for the health,safety,or welfare of the County or its residents then it may do so upon twenty-four(24) hours'notice to the Provider. The remaining language in the original Agreement remains unchanged. SIGNATURES APPEAR ON THE FOLLOWING PAGE 4JPage HMIS STAFFING PROGRAM-GRANT NUMBER: PC-1920-STAFF-2 IDENTIFICATION ASISTANCE PROGRAM-GRANT NUMBER: PC-1920-ID-2 IN WITNESS WHEREOF,the parties have caused this five (5)page Amendment#1 of the Agreement to be executed by their respective and duly authorized officers the day and year first above written. THE CITY 0; MIAMI B " CH MIAMI-DADE COUNTY l� 9'7/ By: .r r—� By (Sign, re ofAut .rizedAgency Representative) (Signature) Name: IM.ull J .► Name: MAURICE L. KEMP (Priinnnte:''\ ame of Au ,orized Agency Representative) (Printed) DEPUTY MAYO Title: QJ1 1 �ikN h' cam '-- Title: M1A f- �1�DE FL Date: 1( °I he aco Date: c)A q 12_4)2-D ;t Attest: 4 i 1'� 2.G O Attest: HARVEY RUVIN, Clerk Au' orize. 'erson/ ota Public Board of County Commissio Print Name: 'F-AVIA., E, C r -i"* By: (DEPUTY CLERK Signature) Title: 2 c:. Print Name: L e- ItTber.Cey- Date: Z-2 20 • Affix Corporate SEAL or Notary SEAL Affix Miami-Dade County Seal here here • .. . cavil Di '.Ii'�:0R1"'jL�(lsg1Eij ..i: 2 '�®�:" I APPROVED AS TO FORM & LANGUAGE & FOR EXECU ION See mn or du ate' i cto;er 8 2019)approved as to form and legal sufficiency. City Attorney ,. Date ' 5 ! Page ATTACHMENT A,SCOPE OF SERVICES THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE PROGRAM PC-1920-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 A,SCOPE OF SERVICES THE CITY OF MIAMI BEACH HMIS STAFFING PROGRAM PC-1920-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 B, Budget City of Miami Beach HMIS Staffing Program Category Requested Funding Justification Annual Salary 1 HMIS Administrator $ 47,944.26 • 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 $ 15,619.00 Case Worker: 12 Hours per week X 52 weeks x$25.03 Supplies $ 300.00 General Office Supplies Identification Document Fees $ 9,081.00 Identification Document Replacement Fees Total Grant Award $ 25,000.00 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-1920-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-1920-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 L MIAMI-DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT CITY OF MIAMI BEACH—HMIS STAFFING PROGRAM GRANT NUMBER#: PC-1920-STAFF-2 OCTOBER 1,2019—SEPTEMBER 30,2020 Name of Agency: THE CITY OF MIAMI BEACH $ 12,333.00 Month of Services Amount Paid OCTOBER-2019 NOVEMBER-2019 DECEMBER-2019 JANUARY-2020 FEBRUARY-2020 MARCH-2020 APRIL-2020 MAY-2020 JUNE-2020 JULY-2020 AUGUST-2020 SEPTEMBER-2020 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-1920-ID-2 OCTOBER 1,2019—SEPTEMBER 30,2020 Name of Agency: THE CITY OF MIAMI BEACH $ 25,000.00 Month of Services Amount Paid OCTOBER-2019 NOVEMBER-2019 DECEMBER-2019 JANUARY-2020 FEBRUARY-2020 MARCH-2020 APRIL-2020 MAY-2020 JUNE-2020 JULY-2020 AUGUST-2020 SEPTEMBER-2020 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 • Miami-Dade County's Affidavits and Declarations 411AM!DADE COUNTY 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"Q" 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 ( ) COUNTY OF ( ) COUNTRY OF ( ) Before me the undersigned authority appeared (Print Name), who is personally known to me or who has provided as identification and who did swear to the following: That he or she is the duly authorized representative of(Name of Entity) (Address of Entity) Post Office addresses are not acceptable. 59 - ( ooa3 } a Federal Employment Identification Number rn m y L - Morales (hereinafter referred to as the contracting "entity"), and that he or she is the entity's (Sole Proprietor)(Partner)(President or Other Authorized Officer) Au+hori$ed of-f; CPQ 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 C"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 Pertains O N/A OF THE COUNTY CODE) Initial ) If the contract or business transaction is with a corporation,the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent(5%) or more of the corporation's stock. If the contractor 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 C"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 Pertains A ORDINANCE 90-133,AMENDING SECTION 2.8-1; SUBSECTION (d)(2) OF THE N/A f I 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 require 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 O 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: Males 301.4- Females (1 Black: Males 3 3 Females l et s Hispanic: Males 8t Females 3 t �. Asian: Males Females 5 American Native: Males 3 Females Aleut(Eskimo): Males oZ Females 0 • ATTACHMENT C"Miami-Dade County Affidavits and Declarations" Page 3 of 11 Miami-Dade County's Affidavits and Declarations 3. MIAMI-DADE COUNTY AFFIRMATIVE ACTION/ NONDISCRIMINATION OF EMPLOYMENT,PROMOTION AND Pertains PROCUREMENT PRACTICES (COUNTY ORDINANCE 98-30 CODIFIED N/A AT 2-8.1.5 OF THE COUNTY CODE) Initial ) Pursuant to Miami-Dade County's Ordinance No.98-30,Section 2-8.1.5,entities with annual gross revenue in 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 may be 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 ll 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 Attorney's Office and/or other investigative agencies.The County may initiate debarment and/or pursue other remedies in accordance with Miami-Dade County policy and/or applicable federal,state and local laws. 4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT Pertains O (SECTION 2-8.6 OF THE COUNTY CODE) N/A Initial ) The individual or entity entering into a contract or receiving funding from Miami-Dade County O has O ha ot, 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 Miami-Dade County O has Q has not as of the date of this affidavit been convicted of a felony during the past ten (10)years. ATTACHMENT C"Miami-Dade County Affidavits and Declarations" Page 4 of 11 • Miami-Dade County's Affidavits and Declarations 5. PUBLIC ENTITY CRIMES AFFIDAVIT(SECTION Pertains O 287.133(3)(a),FLORIDA STATUTES) N/AInitial The individual or entity entering into a contract or receiving funding from Miami-Dade County understands(f,ty following: That a"public entity crime"as defined in Paragraph 287.133 (1) (g) Florida Statutes,means a violation 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). ® Neither the entity submitting this sworn statement nor any of its officers,directors,executives,partners, shareholders,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 crime within the past 36 months. O 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 O yes an additional statement is applicable or O no an additional statement is not applicable. O 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 C"Miami-Dade County Affidavits and Declarations" Page 5 of 11 Miami-Dade County's Affidavits and Declarations 6.MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT Pertains O (County Ordinance No.142-91 codified as Section 11A-29 et. N/AO seq of the County Code) Initial ) That in compliance with Ordinance No. 142-91 of the Code of Miami-Dade County,Florida,an employer wit fty (50) or more employees working in Dade County for each working day during each of twenty(20) or more calendar work weeks,shall provide the following information in compliance with all items in the aforementioned ordinance: An employee who has worked for the above firm at least one (1)year shall be entitled to ninety(90) days of family leave during any twenty-four(24)month period,for medical reasons,for the birth or adoption of a child,or for the care of a child,spouse or other close relative who has a serious health condition without risk of termination of employment or employer retaliation. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State of Florida or any political subdivision or agency thereof. It shall,however,pertain to municipalities of this State. 7. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION Pertains O N/A AFFIDAVIT (County Resolution R-385-95) Initis ) That the above named firm, corporation or organization is in compliance with and agrees to continue to co with, and assure that any subcontractor,or third party contractor under this project complies with all applicable requirements of the laws listed below including,but not limited to,those provisions pertaining to employment, provision of programs and services,transportation,communications,access to facilities,renovations,and new construction in the following laws:The Americans.with Disabilities Act of 1990 (ADA),Pub.L. 101-336, 104 Stat. 327,42 U.S.C. 12101-12213 and 47 U.S.C.Sections 225 and 611 including Title I,Employment;Title 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) N/A O Initial ) Except for small purchase orders and sole source contracts,that above named firm, corporation, organizatio or individual desiring to transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes--including but not limited to real and property taxes,utility taxes and occupational licenses--which are collected in the normal course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of the firm,corporation,organization or individual have been paid. ATTACHMENT C"Miami-Dade County Affidavits and Declarations" Page 6 of 11 Miami-Dade County's Affidavits and Declarations Pertai s O 9. CURRENT ON ALL COUNTY CONTRACTS,LOANS AND OTHER OBLIGATIONS N/A O Initia ) The individual entity seeking to transact business with the County is current in all its obligations to the Cou -y and is not otherwise in default of any contract,promissory note or other loan document with the County or any of its agencies or instrumentalities. 10. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A- Pertains O 60 Et.Seq.of the Miami-Dade County Code). N/AlfInitiThe firm desiring to do business with the County is in compliance with Domestic Leave Ordinance, Ordin - 5,codified at 11A-60 et.seq.of the Miami Dade County Code,which requires an employer which has in the r 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- N/AO 8.1.2 of the County Code) Initial ) That in compliance with Ordinance No. 92-15 of the Code of Miami-Dade County,Florida,the above named p son or entity is providing a drug-free workplace.A written statement to each employee shall inform the employee 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 maybe waived if the special characteristics of the product or service offered by the person or entity make it necessary for the operation of the County or for the health,safety,welfare economic benefits and well-being of the public. Contracts involving funding which is provided in whole or in part by the United States or the State of Florida shall be exempted from the provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental entities. ATTACHMENT C"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 Pertai O COUNTY FUNDING SUPPORT N/A O _ Initial Ilk ) 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 Co.nty's grant support in a manner commensurate with all contributors and sponsors of its activities at comparable dollar levels. 13.MIAMI-DADE COUNTY RESOLUTION NO.R-630-13 REQUIRING A DETAILED PROJECT BUDGET,SOURCES AND USES STATEMENT,CERTIFICATIONS AS Pertai s 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 es 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): 14.MIAMI-DADE COUNTY RESOLUTION No.R-478-12 NOT TO USE PRODUCTS Pertai s O OR FOODS CONTAINING"PINK SLIME" N/A O Initial ) Pursuant to Miami-Dade County Resolution No.R-478-12,the undersigned certifies,not to use meat produc containing"Pink Slime"in food provided or served as part any food program;urging all who provide food services or operate a food program to immediately discontinue using meat products containing"pink slime"in food provided orserved in these programs. ATTACHMENT C"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 2-111(i)(2) CONFLICT OF INTEREST N/A O AND CODE OF ETHICS ORDINANCE Initial ) All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5) business da f being retained as a lobbyist or before engaging in any lobbying activities,whichever shall come first. Every rson 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. JBy 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 C"Miami-Dade County Affidavits and Declarations" Page 9 of 11 Miami-Dade County's Affidavits and Declarations Pertai s 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 bi ers and proposers on Miami-Dade County contracts for purchase of supplies, materials or services, including professional 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 performedor 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 Business Name and Address Principal Owner Supplies/Materials/Services to be (Principal Owner) of Direct Supplier Provided by Supplier Gender Race I certify that the representations contained in this Subcontractor/Supplier Listing are to the best of my knowledge true and accu ate. Sign''"e "uth ed Representative Date [ ) IG3imm, L• Hora,les ) ei4 (Ylanavr- P; nt Name Print Title (Duplicate if additional space is needed) APPROVED AS TO FORM & LANGUAGE & F011 EXECUTION dbjzsra .: (?)/ City A torney���r 'V Date ATTACHMENT C"Miami-Dade County Affidavits and Declarations" Page 10 of 11 . Miami-Dade County's Affidavits and Declarations • MIAMI•DADE COUNTY 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 , MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE 7Sf By: i 1 1320 2.0 _`�!.Bkq'�k�j�/2a 2e] , 20 Signat e of Witn- s or Secretary Seal - ' A � CORP ORATED,, s'q: 6 Ot�t7`3�2 9 ... Signa e o A fiant �H•26M,__ eral-Employer Identification Number , al v&>-1 L, r&t:› Lt S) C CC -i tom(—' wrw 6€-Pc -) Printed Name of Affiant and Name of Agency loco C04-1UEp c c - .CE.t TE 2 012.4 UL, ,rvtc+ A ot I, :(2 33)3 Address of Agency SUBSCRIBED AND SWORN TO (or affirmed)before me this /3 day of JcNk4rS/ , 20 00 He/She is,personally known to me or has presented as identification. Type of identification iee Signature of o7tary Serial Number Print or Stamp Name of Notary Expiration Date Notary Public—State of County of Notary Seal. tr;;v,,..,,. MIA CARDILLO T' • •,,. MY COMMISSION#GG 230433 K EXPIRES:Aug� 27,2022 =�' -�:. X "'A¢d•fiRP' Bonded Thin Nobly Publb rAtt°rs ATTACHMENT C"Miami-Dade County Affidavits and Declarations" Page 11 of 11 . Request for Taxpayer Give Form to the Form (Rev.October 2018) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service ►Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. G(-�y o rn k is r/m roc N 2 Business name/disregarded entity name,if different from above 0) 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to mfollowing seven boxes. certain entities,not individuals;see a instructions on page 3): o ❑ Individual/sole proprietor or ❑ C Corporation 0 S Corporation 0 Partnership 0 Trust/estate single-member LLC c Exempt payee code(if any) ai ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► `p i Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code(if any) another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that n o is disregarded from the owner should check the appropriate box for the tax classification of its owner. xOther(see instructions) PA-L,IT-I (Apples to accounts maintained outside the U.S.) rn 5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) 1100 C NVe . j1vtJ C� t&jpco 6 City,state,and ZIP code 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 instructions for Part I,later.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN,later. or Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. -1',0310031-1 2-- Part 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 all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,y u are not r:. uired to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later. Sign Signature of A Here U.S.person► -,— Date► t'q A aZ' General Instructs irns •Form 1099-DIV(dividends,including those from stocks or mutual 1funds) Section references are to the Int,i nal Revenue Code unless otherwise •Form 1099-MISC(various types of income,prizes,awards,or gross noted. proceeds) Future developments.For the latest information about developments •Form 1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to www.irs.gov/FormW9. •Form 1099-S(proceeds from real estate transactions) Purpose of Form •Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TIN)which may be your social security number •Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(ITIN),adoption •Form 1099-A(acquisition or abandonment of secured property) taxpayer identification number(ATIN),or employer identification number (EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you a e r a�qq I u pg a resident amount reportable on an information return.Examples of information alien),to provide your correcn{Ft�t'fi�nn"�tU(HI�I ��QI r�� � returns include,but are not limited to,the following. If you do not return Fo IIt P1Mh 1 u s P1 4tfi` 'i v,you might •Form 1099-INT(interest earned or paid) be subject to backup withhol&n5.30' (gtgs pia•I a. . ithholding, later. Cat.No.10231X Form W-9(Rgv.10-2 181 City Attor Date✓I^f Form W-9(Rev.10-2018) Page 2 By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an 1.Certify that the TIN you are giving is correct(or you are waiting for a exemption from tax for scholarship income received by a Chinese number to be issued), student temporarily present in the United States.Under U.S.law,this 2.Certify that you are not subject to backup withholding,or student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years.However,paragraph 2 of 3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April 30,1984)allows payee.If applicable,you are also certifying that as a U.S.person,your the provisions of Article 20 to continue to apply even after the Chinese allocable share of any partnership income from a U.S.trade or business student becomes a resident alien of the United States.A Chinese is not subject to the withholding tax on foreign partners'share of student who qualifies for this exception(under paragraph 2 of the first effectively connected income,and protocol)and is relying on this exception to claim an exemption from tax 4.Certify that FATCA code(s)entered on this form(if any)indicating on his or her scholarship or fellowship income would attach to Form that you are exempt from the FATCA reporting,is correct.See What is W-9 a statement that includes the information described above to FATCA reporting,later,for further information. support that exemption. Note:If you are a U.S.person and a requester gives you a form other If you are a nonresident alien or a foreign entity,give the requester the than Form W-9 to request your TIN,you must use the requester's form if appropriate completed Form W-8 or Form 8233. it is substantially similar to this Form W-9. Backup Withholding Definition of a U.S.person.For federal tax purposes,you are considered a U.S.person if you are: What is backup-withholding?Persons making certain payments to you •An individual who is a U.S.citizen or U.S.resident alien; must under certain conditions withhold and pay to the IRS 24%of such payments.This is called"backup withholding." Payments that may be •A partnership,corporation,company,or association created or subject to backup withholding include interest,tax-exempt interest, organized in the United States or under the laws of the United States; dividends,broker and barter exchange transactions,rents,royalties, •An estate(other than a foreign estate);or nonemployee pay,payments made in settlement of payment card and •A domestic trust(as defined in Regulations section 301.7701-7). third party network transactions,and certain payments from fishing boat operators.Real estate transactions are not subject to backup Special rules for partnerships.Partnerships that conduct a trade or withholding. business in the United States are generally required to pay a withholding You will not be subject to backup withholding on payments you tax under section 1446 on any foreign partners'share of effectively receive if you give the requester your correct TIN,make the proper connected taxable income from such business.Further,in certain cases certifications,and report all your taxable interest and dividends on your where a Form W-9 has not been received,the rules under section 1446 tax return. require a partnership to presume that a partner is a foreign person,and pay the section 1446 withholding tax.Therefore,if you are a U.S.person Payments you receive will be subject to backup withholding if: that is a partner in a partnership conducting a trade or business in the 1.You do not furnish your TIN to the requester, United States,provide Form W-9 to the partnership to establish your 2.You do not certify your TIN when required(see the instructions for U.S.status and avoid section 1446 withholding on your share of Part II for details), partnership income. In the cases below,the following person must give Form W-9 to the 3.The IRS tells the requester that you furnished an incorrect TIN, partnership for purposes of establishing its U.S.status and avoiding 4.The IRS tells you that you are subject to backup withholding withholding on its allocable share of net income from the partnership because you did not report all your interest and dividends on your tax conducting a trade or business in the United States. return(for reportable interest and dividends only),or •In the case of a.disregarded entity with a U.S.owner,the U.S.owner 5.You do not certify to the requester that you are not subject to of the disregarded entity and not the entity; backup withholding under 4 above(for reportable interest and dividend •In the case of a grantor trust with a U.S.grantor or other U.S.owner, accounts opened after 1983 only). generally,the U.S.grantor or other U.S.owner of the grantor trust and Certain payees and payments are exempt from backup withholding. not the trust;and See Exempt payee code,later,and the separate Instructions for the •In the case of a U.S.trust(other than a grantor trust),the U.S.trust Requester of Form W-9 for more information. (other than a grantor trust)and not the beneficiaries of the trust. Also see Special rules for partnerships,earlier. Foreign person.If you are a foreign person or the U.S.branch of a What is FATCA Reporting? foreign bank that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use the appropriate Form W-8 or Form 8233(see The Foreign Account Tax Compliance Act(FATCA)requires a Pub.515,Withholding of Tax on Nonresident Aliens and Foreign participating foreign financial institution to report all United States Entities). account holders that are specified United States persons.Certain Nonresident alien who becomes a resident alien.Generally,only a payees are exempt from FATCA reporting.See Exemption from FATCA nonresident alien individual may use the terms of a tax treaty to reduce reporting code,later,and the Instructions for the Requester of Form or eliminate U.S.tax on certain types of income.However,most tax W-9 for more information. . treaties contain a provision known as a"saving clause."Exceptions Updating Your Information specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise You must provide updated information to any person to whom you become a U.S.resident alien for tax purposes. claimed to be an exempt payee if you are no longer an exempt payee If you are a U.S.resident alien who is relying on an exception and anticipate receiving reportable payments in the future from this contained in the saving clause of a tax treaty to claim an exemption person.For example,you may need to provide updated information if from U.S.tax on certain types of income,you must attach a statement you are a C corporation that elects to be an S corporation,or if you no to Form W-9 that specifies the following five items. longer are tax exempt.In addition,you must furnish a new Form W-9 if 1.The treaty country.Generally,this must be the same treaty under the name or TIN changes for the account;for example,if the grantor of a which you claimed exemption from tax as a nonresident alien. grantor trust dies. 2.The treaty article addressing the income. Penalties 3.The article number(or location)in the tax treaty that contains the saving clause and its exceptions. Failure to furnish TIN.If you fail to furnish your correct TIN to a 4.The type and amount of income that qualifies for the exemption requester,you are subject to a penalty of$50 for each such failure from tax. unless your failure is due to reasonable cause and not to willful neglect. 5.Sufficient facts to justify the exemption from tax under the terms of Civil penalty for false information with respect to withholding.If you the treaty article. make a false statement with no reasonable basis that results in no backup withholding,you are subject to a$500 penalty. Form W-9(Rev.10-2018) Page 3 Criminal penalty for falsifying information.Willfully falsifying IF the entity/person on line 1 is THEN check the box for... certifications or affirmations may subject you to criminal penalties a(n)... including fines and/or imprisonment. Misuse of TINs.If the requester discloses or uses TINs in violation of • Corporation . Corporation federal law,the requester may be subject to civil and criminal penalties. • Individual IndividuaVsole proprietor or single- • Sole proprietorship,or member LLC Specific Instructions • Single-member limited liability company(LLC)owned by an Line 1 individual and disregarded for U.S. You must enter one of the following on this line;do not leave this line federal tax purposes. blank.The name should match the name on your tax return. • LLC treated as a partnership for Limited liability company and enter If this Form W-9 is for a joint account(other than an account U.S.federal tax purposes, the appropriate tax classification. maintained by a foreign financial institution(FFI)),list first,and then • LLC that has filed Form 8832 or (P=Partnership;C=C corporation; circle,the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S=S corporation) Part I of Form W-9.If you are providing Form W-9 to an FFI to document or a joint account,each holder of the account that is a U.S.person must • LLC that is disregarded as an provide a Form W-9. entity separate from its owner but a. Individual.Generally,enter the name shown on your tax retum.If the owner is another LLC that is you have changed your last name without informing the Social Security not disregarded for U.S.federal tax Administration(SSA)of the name change,enter your first name,the last purposes. name as shown on your social security card,and your new last name. Note:ITIN applicant:Enter your individual name as it was entered on ' Partnership Partnership your Form W-7 application,line 1 a.This should also be the same as the • Trust/estate Trust/estate name you entered on the Form 1040/1040N1040EZ you filed with your Line 4, Exemptions application. b. Sole proprietor or single-member LLC.Enter your individual If you are exempt from backup withholding and/or FATCA reporting, name as shown on your 1040/1040A/104OEZ on line 1.You may enter enter in the appropriate space on line 4 any code(s)that may apply to your business,trade,or"doing business as"(DBA)name on line 2. you. c. Partnership,LLC that is not a single-member LLC,C Exempt payee code. corporation,or S corporation.Enter the entity's name as shown on the • Generally,individuals(including sole proprietors)are not exempt from entity's tax return on line 1 and any business,trade,or DBA name on backup withholding. line 2. • Except as provided below,corporations are exempt from backup d. Other entities.Enter your name as shown on required U.S.federal withholding for certain payments,including interest and dividends. tax documents on line 1.This name should match the name shown on the • Corporations are not exempt from backup withholding for payments charter or other legal document creating the entity.You may enter any made in settlement of payment card or third party network transactions. business,trade,or DBA name on line 2. • Corporations are not exempt from backup withholding with respect to e. Disregarded entity.For U.S.federal tax purposes,an entity that is attorneys'fees or gross proceeds paid to attorneys,and corporations disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exempt with respect "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii).Enter to payments reportable on Form 1099-MISC. the owner's name on line 1.The name of the entity entered on line 1 codes identify payees that are from backup should never be a disregarded entity.The name on line 1 should be the ith The followingolEnter the identify y appropriateacode ins the space exemptin liner4. name shown on the income tax return on which the income should be reported.For example,if a foreign LLC that is treated as a disregarded 1—An organization exempt from tax under section 501(a),any IRA,or entity for U.S.federal tax purposes has a single owner that is a U.S. a custodial account under section 403(b)(7)if the account satisfies the person,the U.S.owner's name is required to be provided on line 1.If requirements of section 401(f)(2) the direct owner of the entity is also a disregarded entity,enter the first 2—The United States or any of its agencies or instrumentalities owner that is not disregarded for federal tax purposes.Enter the 3—A state,the District of Columbia,a U.S.commonwealth or disregarded entity's name on line 2,"Business name/disregarded entity possession,or any of their political subdivisions or instrumentalities name."If the owner of the disregarded entity is a foreign person,the owner must complete an appropriate Form W-8 instead of a Form W-9. 4—A foreign government or any of its political subdivisions,agencies, This is the case even if the foreign person has a U.S.TIN. or instrumentalities Line 2 5—A corporation If you have a business name,trade name,DBA name,or disregarded 6—A dealer in securities or commodities required to register in the entity name,you may enter it on line 2. United States,the District of Columbia,or a U.S.commonwealth or possession Line 3 7—A futures commission merchant registered with the Commodity Check the appropriate box on line 3 for the U.S.federal tax Futures Trading Commission classification of the person whose name is entered on line 1.Check only 8—A real estate investment trust one box on line 3. 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known in the investment community as a nominee or • custodian 13—A trust exempt from tax under section 664 or described in section 4947 Form W-9(Rev.10-2018) Page 4 The following chart shows types of payments that may be exempt M—A tax exempt trust under a section 403(b)plan or section 457(g) from backup withholding.The chart applies to the exempt payees listed plan above,1 through 13. Note:You may wish to consult with the financial institution requesting IF the payment is for... THEN the payment is exempt this form to determine whether the FATCA code and/or exempt payee for... code should be completed. Interest and dividend payments All exempt payees except Line 5 for 7 Enter your address(number,street,and apartment or suite number). Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W-9 will mail your information through 11 and all C corporations. returns.If this address differs from the one the requester already has on S corporations must not enter an file,write NEW at the top.If a new address is provided,there is still a exempt payee code because they chance the old address will be used until the payor changes your are exempt only for sales of address in their records. noncovered securities acquired Line 6 prior to 2012. Enter your city,state,and ZIP code. Barter exchange transactions and Exempt payees 1 through 4 patronage dividends Part I. Taxpayer Identification Number (TIN) Payments over$600 required to be Generally,exempt payees Enter your TIN in the appropriate box.If you are a resident alien and reported and direct sales over 1 through 52 you do not have and are not eligible to get an SSN,your TIN is your IRS $5,0001 individual taxpayer identification number(ITIN).Enter it in the social security number box.If you do not have an ITIN,see How to get a TIN Payments made in settlement of Exempt payees 1 through 4 below. payment card or third party network If you are a sole proprietor and you have an EIN,you may enter either transactions your SSN or EIN. 1 See Form 1099-MISC,Miscellaneous Income,and its instructions. If you are a single-member LLC that is disregarded as an entity 2 separate from its owner,enter the owner's SSN(or EIN,if the owner has However,the following payments made to a corporation and one).Do not enter the disregarded entity's EIN.If the LLC is classified as reportable on Form 1099-MISC are not exempt from backup a corporation or partnership,enter the entity's EIN. withholding:medical and health care payments,attorneys'fees,gross Note:See What Name and Number To Give the Requester,later,for proceeds paid to an attorney reportable under section 6045(f),and 4 payments for services paid by a federal executive agency. further clarification of name and TIN combinations. Exemption from FATCA reporting code.The following codes identify How to get a TIN.If you do not have a TIN,apply for one immediately. payees that are exempt from reporting under FATCA.These codes To apply for an SSN,get Form SS 5,Application for a Social Security apply to persons submitting this form for accounts maintained outside Card,from your local SSA office or get this form online at of the United States by certain foreign financial institutions.Therefore,if www.SSA.gov.You may also get this form by calling 1-800-772-1213. you are only submitting this form for an account you hold in the United Use Form W-7,Application for IRS Individual Taxpayer Identification States,you may leave this field blank.Consult with the person Number,to apply for an ITIN,or Form SS-4,Application for Employer requesting this form if you are uncertain if the financial institution is Identification Number,to apply for an EIN.You can apply for an EIN subject to these requirements.A requester may indicate that a code is online by accessing the IRS website at www.irs.gov/Businesses and not required by providing you with a Form W-9 with"Not Applicable"(or clicking on Employer Identification Number(EIN)under Starting a any similar indication)written or printed on the line for a FATCA Business.Go to www.irs.gov/Forms to view,download,or print Form exemption code. W-7 and/or Form SS-4. Or,you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 A—An organization exempt from tax under section 501(a)or any business days. individual retirement plan as defined in section 7701(a)(37) If you are asked to complete Form W-9 but do not have a TIN,apply B—The United States or any of its agencies or instrumentalities for a TIN and write"Applied For"in the space for the TIN,sign and date C—A state,the District of Columbia,a U.S.commonwealth or the form,and give it to the requester.For interest and dividend possession,or any of their political subdivisions or instrumentalities payments,and certain payments made with respect to readily tradable D—A corporation the stock of which is regularly traded on one or instruments,generally you will have 60 days to get a TIN and give it to more established securities markets,as described in Regulations the requester before you are subject to backup withholding on section 1.1472-1(c)(1)(i) payments.The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until E—A corporation that is a member of the same expanded affiliated you provide your TIN to the requester. group as a corporation described in Regulations section 1.1472-1(c)(1)(i) Note:Entering"Applied For"means that you have already applied for a F—A dealer in securities,commodities,or derivative financial TIN or that you intend to apply for one soon. instruments(including notional principal contracts,futures,forwards, and options)that is registered as such under the laws of the United Caution:A disregarded U.S.entity that has a foreign owner must use States or any state the appropriate Form W-8. G—A real estate investment trust Part II. Certification H—A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S.person,or entity registered at all times during the tax year under the Investment resident alien,sign Form W-9.You may be requested to sign by the Company Act of 1940 withholding agent even if item 1,4,or 5 below indicates otherwise. I—A common trust fund as defined in section 584(a) For a joint account,only the person whose TIN is shown in Part I J—A bank as defined in section 581 should sign(when required).In the case of a disregarded entity,the K—A broker person identified on line 1 must sign.Exempt payees,see Exempt payee L—A trust exempt from tax under section 664 or described in section code,earlier. 4947(a)(1) Signature requirements.Complete the certification as indicated in items 1 through 5 below. • i Form W-9(Rev.10-2018) Page 5 , 1.Interest,dividend,and barter exchange accounts opened For this type of account: Give name and EIN of: before 1984 and broker accounts considered active during 1983. 14.Account with the Department of The public entity You must give your correct TIN,but you do not have to sign the Agriculture in the name of a public certification. entity(such as a state or local 2.Interest,dividend,broker,and barter exchange accounts government,school district,or opened after 1983 and broker accounts considered inactive during prison)that receives agricultural 1983.You must sign the certification or backup withholding will apply.If program payments you are subject to backup withholding and you are merely providing your correct TIN to the requester,you must cross out item 2 in the 15.Grantor trust filing under the Form The trust certification before signing the form. 1041 Filing Method or the Optional • 3.Real estate transactions.You must sign the certification.You may Form 1099 Filing Method 2(see cross out item 2 of the certification. Regulations section 1.671-4(b)(2)(1)(B)) 4.Other payments.You must give your correct TIN,but you do not 'List first and circle the name of the person whose number you furnish. have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN,that person's number have previously given an incorrect TIN."Other payments"include must be furnished. payments made in the course of the requester's trade or business for 2 Circle the minor's name and furnish the minor's SSN. rents,royalties,goods(other than bills for merchandise),medical and health care services(including payments to corporations),payments to 3 You must show your individual name and you may also enter your a nonemployee for services,payments made in settlement of payment business or DBA name on the"Business name/disregarded entity" card and third party network transactions,payments to certain fishing name line.You may use either your SSN or EIN(if you have one),but the boat crew members and fishermen,and gross proceeds paid to IRS encourages you to use your SSN. attorneys(including payments to corporations). 4 List first and circle the name of the trust,estate,or pension trust.(Do 5.Mortgage interest paid by you,acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the secured property,cancellation of debt,qualified tuition program legal entity itself is not designated in the account title.)Also see Special payments(under section 529),ABLE accounts(under section 529A), rules for partnerships,earlier. IRA,Coverdell ESA,Archer MSA or HSA contributions or `Note:The grantor also must provide a Form W-9 to trustee of trust. distributions,and pension distributions.You must give your correct Note:If no name is circled when more than one name is listed,the TIN,but you do not have to sign the certification. number will be considered to be that of the first name listed. What Name and Number To Give the Requester Secure Your Tax Records From Identity Theft For this type of account: Give name and SSN of: Identity theft occurs when someone uses your personal information 1.Individual The individual such as your name,SSN,or other identifying information,without your 2.Two or more individuals Qoint The actual owner of the account or,if permission,to commit fraud or other crimes.An identity thief may use account)other than an account combined funds,the first individual on your SSN to get a job or may file a tax return using your SSN to receive maintained by an FFI the account a refund. 3.Two or more U.S.persons Each holder of the account To reduce your risk: Qoint account maintained by an FFI) •Protect your SSN, 4.Custodial account of a minor The minor2 •Ensure your employer is protecting your SSN,and (Uniform Gift to Minors Act) •Be careful when choosing a tax preparer. 5.a.The usual revocable savings trust The grantor-trustee' If your tax records are affected by identity theft and you receive a (grantor is also trustee) notice from the IRS,respond right away to the name and phone number b.So-called trust account that is not The actual owner printed on the IRS notice or letter. . a legal or valid trust under state law If your tax records are not currently affected by identity theft but you 6.Sole proprietorship or disregarded The owner3 think you are at risk due to a lost or stolen purse or wallet,questionable entity owned by an individual credit card activity or credit report,contact the IRS Identity Theft Hotline 7.Grantor trust filing under Optional The grantor at 1-800-908-4490 or submit Form 14039. Form 1099 Filing Method 1(see For more information,see Pub.5027,Identity Theft Information for Regulations section 1.671-4(b)(2)() Taxpayers. (A)) Victims of identity theft who are experiencing economic harm or a For this type of account: Give name and EIN of: systemic problem,or are seeking help in resolving tax problems that 8.Disregarded entity not owned by an The owner have not been resolved through normal channels,may be eligible for individual Taxpayer Advocate Service(TAS)assistance.You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 9.A valid trust,estate,or pension trust Legal entity4 1-800-829-4059. 10.Corporation or LLC electing The corporation Protect yourself from suspicious emails or phishing schemes. corporate status on Form 8832 or Phishing is the creation and use of email and websites designed to Form 2553 mimic legitimate business emails and websites.The most common act 11.Association,club,religious, The organization is sending an email to a user falsely claiming to be an established charitable,educational,or other tax- legitimate enterprise in an attempt to scam the user into surrendering exempt organization private information that will be used for identity theft. 12.Partnership or multi-member LLC The partnership 13.A broker or registered nominee The broker or nominee Form W-9(Rev.10-2018) Page s The IRS does not initiate contacts with taxpayers via emails.Also,the Privacy Act Notice IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers,passwords,or similar secret access Section 6109 of the Internal Revenue Code requires you to provide your information for their credit card,bank,or other financial accounts. correct TIN to persons(including federal agencies)who are required to If you receive an unsolicited email claiming to be from the IRS, file information returns with the IRS to report interest,dividends,or forward this message to phishing@irs.gov.You may also report misuse certainqother income paid ntto you;f o interest the ycaou paid;the of the IRS name,logo,or other IRS property to the Treasury Inspector debt;acquisition or babaons you made secured tan IRA,Archer cancellation of General for Tax Administration(rIGTA)at 1-800-366-4484.You can nsn contributions this you us to information the f r HSA.The forward suspicious emails to the Federal Trade Commission at person tionectiur this form uses the reportingthe on the form to file spam@uce.gov or report them at www.ftc.gov/complaint You can information returns this with the tionIRSinclude ngabove information. contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT(877-438-4338). JusticRoutine or civil information and it s,to sttates,he Department of If you have been the victim of identity theft,see www.ldentityTheft.gov Columbia,FaraU.S.ad criminal litigationeland to cities,onsfor the District of and Pub.5027. and Ucommonwealths and possessions for use in administering their laws.The information also may be disclosed to other Visit www.irs.gov/IdentityTheft to learn more about identity theft and countries under a treaty,to federal and state agencies to enforce civil how to reduce your risk. and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN whether or not you are required to file a tax return.Under section 3406,payers must generally 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 providing false or fraudulent information. Homeless Trust 111 NW 1st Street•27th Floor M I A M I•DADE Miami, Florida 33128 COUNTY T 305-375-1490 miamidade.gov March 4,2020 Mr.Jimmy Morales,City Manager The City of Miami Beach 1700 Convention Center Drive Miami Beach,Florida 33139 RE: 2019-2020 Primary Care Program HMIS Staffing Program Grant Number: PC-1920-STAN14-2 Identification Assistance Program Grant Number: PC-1920-ID-2 Dear Mr.Morales: . Enclosed,please fmd for your file, one(1)fully executed original of the Agreement between Miami-Dade County, through the Miami-Dade County Homeless Trust and The City of Miami Beach for the abovementioned programs. Please feel free to contact us at(305)375-1490 if you have any questions or require additional information. Thank you for your continued efforts with addressing the needs of the homeless of our community. Sin erely, a Victoria L.Mallette 4,, cutive Director 'ami-Dade County Homeless Trust Enclosures I have received the executed Agreement for above-referenced grants. Signature of Authorized Agency Representative Date Printed Name of Agency Representative