09/18/2002 Agreement
Clerk oldie
Circul COUd
Danny L. Kolhage
Clerk of the Circuit Court
Phone: (305) 292-3550
FAU{: (305)~3663
e-mail: phancock@monroe-clerk.com
Memnrandum
TO: Sheila Barker, Director
Administrative Services
A TTN: Maria Fernandez, Administrator
Group Insurance
FROM:
Pamela G. H3J1~
Deputy Cler~
DATE:
October 28, 2002
At the September 18,2002, Board of County Commissioner's meeting the Board granted approval
and authorized execution of the Group Insurance Program Agreement for Third Party Administration
Services between Monroe County and Acordia National, effective 10101/02 through 09/30/03.
Enclosed is a duplicate original of the above mentioned for your handling. Should you have any
questions please do not hesitate to contact this office.
cc: County Administrator wlo document
County Attorney
Finance
File/
MC!llrne COlmty Oerkr9 Oftice Original
ADMINISTRA TIVE SERVICE AGREEMENT
/5.1-
THIS AGREEMENT, made and entered into the day of
~ I ~d- by and between Momoe Connty (hereinafter called "Employer")
and ACORDIA NATIONAL of602 Virginia Street, East, Charleston, WV 25301, is
hereinafter set forth:
WITNESSETH
WHEREAS, Employer has established an employee welfare benefit plan
(hereinafter called "Plan") for the purpose of providing medical, dental, vision, utilization
review, Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Health
Insurance Portability and Accountability Act of 1996 ("HIPAA"), and other benefits for
its employees;
WHEREAS, Employer desires to engage the services of Acordia National
as agent for the Employer for the purpose of effecting claim administration under its
Plan; and
NOW, THEREFORE, in consideration of the mutual covenants and
promises hereinafter contained, the parties hereto agree as follows:
1)
2)
The effective date of the Employer's Plan shall be October 1.
The Plan Year shall be from October 1 thru September 30 of each
year.
3)
4)
The Employer's Tax Identification Number is 596000749
For each Plan Year, the Employer shall provide monies sufficient
to pay benefits under the Employer's Plan on a timely basis. "Timely"
shall be defined as within thirty (30) days of Acordia National's
notification, oral or written, that benefit claims have been processed for
payment. In the event Employer shall fail to provide sufficient monies to
fund its claims in a timely manner, a ten percent (10%) surcharge shall be
added to the monthly administrative fee due Acordia National, which
surcharge shall become chargeable beginning on the thirty-first (3151) day
after Acordia National's notification, as described herein. Employer
acknowledges and agrees that Acordia National shall not have any
financial duty or responsibility to release claim payments if Employer has
not sufficiently funded the same.
5) Employer acknowledges and agrees that Acordia National shall not
have any financial duty or responsibility to see that the Employer deposit
meets the Employer's Plan requirements; however, Acordia National shall
keep the Employer advised as to the amount of deposit needed to meet
said requirements on a timely basis. Employer further acknowledges and
agrees that Acordia National shall not be deemed a fiduciary for the Plan
within the meaning of the Employee Retirement Income Security Act of
1974 ("ERISA"). Accordingly, the services to be performed by Acordia
National hereunder shall be limited to the ministerial services set forth
herein and the performance by Acordia National shall be subject in all
respects to review by Employer within the framework of Plan provisions
as well as polices, interpretations, rules, practices and procedures
established by Employer. Acordia National shall not have any
2
discretionary authority or control with regard to the management of Plan
assets. To the extent permitted by law, Acordia National shall not incur
any liability for any acts or for failure to act except for its own willful
misconduct in administering the Plan.
The monthly capitation fee for administrative services will be:
October 1. 2002
6)
Medical Claims Administration
Dental Claims Administration
Vision Claims Administration
Pre-certification Administration
HIP AA Administration
$10.19 PEPM*
$ 1.80 PEPM*
$ 0.41 PEPM*
PERFORMED BY KPHA
$ 0.40 PEPM*
· Per Employee, Per Month
The above monthly capitation fee shall apply to renewal effective October 1,
2002, and will remain the same for renewals effective October 1, 2003 and October 1,
2004.
Payment of the fees established above is due from the Employer on or before the
loth day of each month, beginning on the 10th day of October, 2002. The fee quoted is a
three (3) year guarantee effective October 1, 2002. The cost of any additional services
rendered by Acordia National on behalf of the Employer necessitated by a change in
federal or state law will also be charged to the Employer in addition to the monthly fee.
Employee counts for purposes of monthly administrative fee billing may not be reduced
by more than 10% of the billed enrollment unless an explanation is provided.
Administrative fee adjustments must be done monthly and cannot be adjusted
3
retroactively in excess of 90 days prior to the month invoiced. Acordia National reserves
the right to withhold any fees due to the client if administrative fees are outstanding.
Acordia National shall provide generic enrollment forms, claim forms and other
administrative and plan forms. In the event Employer desires customized administrative
and plan forms, Acordia National will direct the printing of same, however, the cost of
such printing shall be paid solely by the Employer.
7) Acordia National shall provide the following services in connection with
the administration of Employer's Planes):
a) Provide assistance to enroll all eligible Employees (as
defined in the Employer's Plan) in Employer's Plan, as agreed
with Employer;
b)
Design and obtain other coordinating or supplemental types
of insurance coverage, where necessary, as requested by Employer
in writing;
Assist and advise employer in revising Plan Document.
Provide prototype Plan Documents and Identification Cards (ID
Cards) for the Employer. Arrange for printing and preparation of
such documents. The cost of the printing will be the responsibility
of the Employer;
d) Conduct information programs for all eligible Employees
to fully explain the benefits available under the Employer's Plan,
as requested by Employer;
c)
4
e) Respond to telephone and mail inquiries from Plan
participants regarding benefits available to them and their
dependents.
f) Provide information concerning Plan benefits and
participants, based upon information provided by Employer;
g) Review and analyze all claims and determine whether the
charges of health care providers submitted are within reasonable
payment guidelines and/or are related to diagnostic related groups,
preferred provider organization agreements or other industry
standards;
Correspond with claimants, as necessary, to prove claims
h)
i)
and to ascertain whether other coverage exists which might pay the
claim in whole or part;
Receive, review, and administer all claims for benefits
under the Employer's Plan, including the evaluation of claims
made; standard evaluation of the eligibility status of all claimants,
coordination of and at least annual auditing of the Utilization
Review and Case Management function, provide the County with
results of Utilization Review audit, appropriate Coordination of
Benefits evaluation of all claims, supply data to Health Recoveries,
Inc. necessary for subrogation and other functions usual to the
efficient and cost effective administration of claims;
5
j)
Aid the employer in developing an efficient claims control
program;
k) Provide information, on request, for the completion by the
Employer of all necessary IRS and ERISA filings;
1) Provide Employer with a monthly report of claims paid;
m) Do all things necessary to properly effect the
responsibilities of a claims administrator under the Employer's
Plan, provided that all such actions/non-actions not otherwise
required by this Agreement shall first be approved by Employer.
Provide assistance and resources to Monroe County in
n)
identifying, analyzing and maintaining the Employer's Plan in
accordance with state and federal laws, industry standards,
regulations and changes that affect the Plan;
0) Report all potential excess claims to the excess insurer, and
provide Employer with monthly updates;
p) Make documents available to the Employer and/or their
Consultants for periodic audit of files for accuracy and efficiency
of Acordia National's claims administration, and;
q) Process, authorize, and issue payment of all complete and
eligible claims within twenty (20) days of receipt;
r) Provide the County with adequate training and make
available access to its on-line computerized claim system.
6
Acordia agrees that this contract is not assignable by
Acordia without prior written permission from Monroe County.
8) Acordia National shall provide COBRA administrative services, if desired by
s)
Employer (check one blank below). It is agreed and understood that COBRA
administration services are provided for medical and dental plans only and are not
provided for 125 Reimbursement Account Plans.
Applicable
Non-applicable
x
In the event Employer desires Acordia National to provide COBRA
administration services, Acordia National agrees to:
a)
Provide initial notification of continuation of coverage
option to all employees;
b) Provide notification, enrollment information and
enrollment forms to all qualified beneficiaries within 14 days of
notification of Employer of a qualifying event;
c) Provide monthly billing and collection services for all
qualified beneficiaries who elect to continue coverage under the
program and supply monthly reports of premiums collected by
Employer;
d) Track participating beneficiaries and notify them of their
right to convert if a conversion option is available under
Employer's Plan;
7
e) Process all claims for continuing beneficiaries under a
segregated category and report, through regular monthly reporting
series, claims experience of continuing beneficiaries (COBRA
claims will be aggregated during the normal check processing
cycle but reported separately at month's end);
f) On an annual basis, at the beginning of Employer's Plan
Year, provide rates to be charged continuing participants for
coverage in the new Plan Year;
g) Provide prototype language to be included in t.he Plan
document to ensure compliance with COBRA legislation;
h) Provide prototype language for inclusion in Employer's
Summary Plan Description and coordinate, at Employer's option,
the printing of new plan booklets at employer's expense; and
i) Mail all correspondence to Plan participants or qualified
beneficiaries directly to the last known address of the employee
and/or dependent by first class mail.
In consideration for receipt of these services from Acordia National, Employer
agrees to:
a) Notify Acordia National within thirty (30) days of
qualifying events for which the Employer has knowledge.
Qualifying events include:
Termination of employment for any reason short of gross
misconduct; and employee's reduction of work hours, the
8
Employer's filing for reorganization under Chapter XI of the
Bankruptcy Code; an Employee's divorce or legal separation;
death of an employee; an employee's child ceasing to be a
dependent; and a beneficiary's entitlement to Medicare. If the
Employer is not notified and does not have knowledge of a
qualifying event, the employee has sixty (60) days from the
qualifying event in which to notify Acordia National of the same to
be eligible or the continuation of coverage option; and
b) Notify Acordia National of any address chang~s or other
pertinent information regarding employee participation in the
Employer's Planes) to allow Acordia National to properly fulfill
the requirements of COBRA legislation.
It is acknowledged by employer that future legislation related to continuation of benefit
coverage or other matters not currently required by COBRA legislation and COBRA
regulations on the date of this Agreement may necessitate an adjustment in the fee for
COBRA administration.
9) In the event Employer does not desire COBRA administration services by
Acordia National, but instead the development of COBRA rates applicable to its Plan,
Acordia National shall provide the same upon terms, and for a fee, to be agreed upon
between Employer and Acordia National.
10) Acordia shall provide the following services related to HIP AA
administration for the Employer's Plan:
9
a)
Provide for the Employer's review, prototype modifications
to the plan document and SPD (Booklet) to address HIP AA
requirements;
b) Perform programming required to the Multi-Claim System
to track the applicable eligibility information and maintain credited
coverage information on both a current and future basis;
c) Coordinate the receipt of all certificates of coverage, or
other proof of coverage, for all new employees enrolling in the
benefit plan;
d) Perform the administrative requirements to analyze the
determination of pre-existing conditions and establish the waiting
periods that would apply for all new employees and existing
employees having pre-existing conditions;
Develop and distribute to all required parties the
e)
notifications and correspondence documenting pre-existing
conditions;
Issue certificates of coverage for all employees and their
dependents upon termination or upon request;
g) Prepare and distribute standard reports documenting
completed HIP AA activities; and
f)
10
h)
Serve as an information resource for HIP AA questions.
11) Subrogation and Fee Negotiation:
a) This will serve to confirm our understanding that the
Employer desires to utilize the subrogation and related services
offered by Healthcare Recoveries, Inc. in connection with the
Employer's health plan.
The administrative fee for Acordia National's Fee
b)
Negotiation Services with health care providers shall be 25% of
savmgs.
12) In the absence of a designation by the Employer and except for disposition
of disputed claims, Acordia National shall determine the manner in which payment of
benefits shall be made as it shall deem it to be necessary and appropriate in accordance
with provisions of Employer's Plan, and shall not be responsible in the exercise of such
judgment in the absence of willful misconduct on the part of Acordia National.
13) To the extent required by law to purchase such coverage, each Employer
shall name Acordia National as an additional insured under its fiduciary bond which shall
be conditioned upon faithful performance of its duties hereunder, and such fiduciary bond
shall in all respects comply with the requirements of the Employee Retirement Income
Security Act of 1974, as amended.
14) Acordia agrees to defend, indemnify and hold harmless Employer against
all claims, damages, liabilities and expenses actually and reasonably incurred or imposed
on Employer in connection with any actual or threatened claim, action, suit, proceeding,
settlement or compromise thereof which arises from Acordia's administration of claims
11
under Employer Planes) other than in accordance with Plan provisions as well as the
negligence, willful misconduct of Acordia, its employees, representatives, or agents. The
right to be defended, indemnified and held harmless shall extend to Employer's affiliates
as well as the employees of Employer, their estates, executors, administrators, guardians,
conservators and heirs and shall apply after the employee cease employment with
Employer with respect to acts or omissions of Acordia prior to such cessation.
15) The terms of this Agreement shall be from the effective date hereof and
continue for a period of one year. This Agreement shall be renewed for two (2)
successive one-year periods at the sole discretion of the Employer, unless either party
gives the other notice of cancellation in accordance with the terms set forth below. If
either party desires to modify or terminate this Agreement, it shall notify the other in
writing at least thirty (30) days prior to the effective date of such modification or
termination. In the case of proposed modification the party receiving the notification of
the proposed modification shall itself notify the other party within ten (10) days notice of
its agreement to the proposed modification. Failure to do so shall terminate this
Agreement as of the end of the Employer's Plan Year.
16) This Agreement may be terminated by either the Employer or Acordia
National at any time provided that Acordia National gives the Employer ninety (90) days
prior written notice or that the Employer gives Acordia National at least thirty (30) days
prior written notice. The prior written notice will state the prospective effective date of
the termination. Termination of this Agreement will not terminate the rights or
obligations of either party arising out of the period during which this Agreement was in
effect. Upon the termination of this Agreement, and if the same is not renewed, Acordia
12
National shall return all files of closed or pending claims covered by this Agreement to
the Employer or their designee.
17) Employer agrees that during the term of this Agreement and for a period
of three years after its termination it will not induce any employee of Acordia National to
leave Acordia National's employment or directly or indirectly assist any other person or
entity in requesting or inducing any such employee of Acordia National to leave such
employment.
18) Monroe County's performance and obligation to pay under this contract is
contingent upon an annual appropriation by the Board of County Commissioners.
19) Acordia National Warrants that it is not employed, retained or otherwise
had acted in its behalf any former County officer subject to the prohibition in Sec 2 of
Ordinance no 10-1990 or any County officer or employee in violation of Sec 3 Ordinance
10-1990 and that no employee or officer of the County had any interest, financially or
otherwise, in Acordia National except for such interest, permissible by law and fully
disclosed by affidavit attached hereto. For breach or violation of this paragraph, the
County may, in its discretion, terminate this agreement without liability and may also, in
its discretion, deduct from the contract or purchase price, or otherwise recover, the full
amount of any fee, commission, percentage, give or consideration paid to the former
County officer or employee.
19) A person or affiliate who has been placed on the convicted vendor list
following a conviction for public entity crime may not submit a bid on a contract with a
public entity for the construction or repair of a public building or public work, may not
submit bids on leases of real property to public entity, may not be awarded or perform
13
work as a contractor, supplier, subcontractor, or consultant under a contract with any
public entity, and may not transact business with any public entity in excess of the
threshold amount provided in Section 287.017, for CATEGORY TWO for a period of36
months from the date of being placed on the convicted vendor list.
20) All notices hereunder shall be in writing and mailed by certified mail,
return receipt requested. Notices to the Employer shall be at the address first above
written and to Acordia National at 602 Virginia Street, East, Charleston, WV 25301,
Attention: President, at such other addresses as the parties may from time to time
designate in writing.
20) The Employer and Acordia National agree that this agreement shall be
administered and construed according to the laws of the State of Florida. In the event
that any matter of disagreement arises, it shall be decided by a court of competent
jurisdiction with venue in Monroe County, Florida.
21) In the event this Agreement is terminated, the parties will have the option
of agreeing to completion of claims administration services for claims existing at
termination for a ninety (90) day period following termination of this Agreement upon
terms negotiated between the parties.
22) This Agreement, together with the written proposal submitted by Acordia
and the Plan constitute the entire Agreement between the Employer and Acordia
National.
14
IN WITNESS WHEREOF, the Employer and Acordia National have
caused this Agreement to be executed by their respective proper corporate officers,
effective as of the / j.t- of ()ckL , 20()~
ATTEST:
ATTEST:
COUNTY OF ~'ftJ:WE
By
Mayor Charles 'Sonny"
Its
McCoy
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15
1996 Edition
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
· Premises Operations
· Products and Completed Operations
· Blanket Contractual Liability
· Personal Injury Liability
· Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date ofthis contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
GL2
Administration Instruction
#4709.3
55
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less
than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-
insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
WC2
Administration Instruction
#4709.3
89
1996 Edition
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be;
$500,000 per Occurrence/$l ,000,000 Aggregate
PR02
Administration Instruction
#4709.3
78
1996 Edition
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, as a minimum, liability coverage for:
· Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
VL2
Administration Instruction
#4709.3
82
1996 Edition
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Acordia National
The Contractor shall purchase and maintain, throughout the term of the contract, Employee Dishonesty
Insurance which will pay for losses to County property or money caused by the fraudulent or dishonest
acts of the Contractor's employees or its agents, whether acting alone or in collusion of others.
The minimum limits shall be:
$100,000 per Occurrence
ED2
Administration Instruction
#4709.3
46
DRUG-FREE \VORKPLACE FORM
Th<: undl'rsign<:d \<:nJor In ,lccorJanc<: with florlda Statute 287087 her<:by c<:nili<:s that
Acord ."0 Md 1;0 '1al
(Nal11e of f3usiness)
I. Publish a statcmcnt l1C1lii"ying cl11plo)'l:cS that the unL1\1'Cul ll1:1nllL1Cllll'C. JistributiclIl. disflCl1sil1:,!.
poss<:ssion. or L1SC or J conlrolkd sllbst:1llCe is prohibiteJ ill thc II 11rki,IilCC ilnJ ~r)cclf: ing the a,IIOI1S 1;,,\,
\I ill bl: lak<:n ag:linst cmployces Cor \illlations I,Csuch prohibition.
2. Inform cmr1o)'ces about the J:1ngers of drug abuse in the workplace, thl: busincss's ro1icy oC mainlainlllg
a drug-free \l'orkfllacc. all)' available drug counseling. rehabilitation, ailJ cl11plo;'c~ assistance progral11s.
and the penalties that may be imfloscd upon employees for drug abuse violations.
3. Give each el11plo)'ee engaged in providing the commodities or contractual services that are under bid <l
copy of the statement specified in subsection (I).
4. In the statement specified in subsection (I), notify the employees that, as a condition of working on the
commodities or contractual services that are under bid, the employee will abide by the terms of the
statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to. any
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or an)'
state, for a violation occurring in the workplace no later than five (5) days after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or any employee who is so convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this
section.
As the person authorized to sign the statement, I certify that this firm complies fully with the above
requirements.
Bidder's Signature
Cf /1/01
Date
ATTACHMENT C
OMf3 - ~lCP115
NON-COLLUSION AFFIDAVIT
I, Richard I-i LPS9
flco/"dio lJo/)"o'l.dl
of ~"~ c;itJ
of
according to law on my oath, and under
penalty of perjury, depose and say that;
1) I am Rid., cue{ H L-t"93
Proposal for the project described as follows:
, the bidder making the
fled If'h /3~1fef}.,.. PJiJ/1 (}./Ci/4t,s 1lcf.r11i/1/~r,~ 11.0'1
2) The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting cOlJlpetition, as
to any matter relating to such prices with any other bidder or with any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be disclosed by
the bidder prior to bid opening, directly or indirectly, to any other bidder or to any
competitor; and
4) No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
5) The statements contained in this affidavit are true and correct, and made with
full knowledge that Monroe County relies upon the truth of the statements contained in
this affidavit in awarding contracts for said pro!ect. (./
STATE OF W~,f Vi(qll\l~ U ;/. '-?.;
(Signature of Bidder)
c1i~JOl
COUNTY OF
\-) ClV\Cl.u...~
DATE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
Ricl1ava H. ~ who, after first being sworn by me, (name of
individual signingj;Jfixed his/her signature In the space provided above on this
1
day of 5~
14' 200 ,
,
l()~lS \-\. {~S
NOTARY PUSLI
OMS - MCP FORM #1
~:rrii~
V"-~- ....'
~~~i~~i~;
My commission expires:
OFfiCIAl. SSAI. " -i
NOTARY PUBLIC '\
Sr.'>T!: OF WEST VIRGINIA
C~i~rHS H. e.OGGS
1601 'i';~J~ p,;VUVi9"N Dr.
8.dl'1, 'NV 25015
My Ccmm,,,ion Explro. 7.14-2003
___-r-~~..-.--..~.- -A"~MENT 0
r
SWOR~ ST:\TL\1LNT UNDER ORDINANCE !\O, ]()-!Q90
iv10NRO[ COUNT'!'. fLORID.\
[TilleS CLAUSE
R.,'t h (I"d. If L~fj..!1
warrants that he/it has not employed. retaincd
or otherwise had act on his/its nehall' an)' fnnncr County officer or cmployee in violation of
Section:: of Ordinance no, 10-1 ()()O or :1I1Y County officer or employee in violation of
Seeti,ln :; of Ordinance No I (l-I tJ()() Fm hreach or violation of this provision the County
11\a\. in its discretion. term i'n;;te tllis l\llllr:lcl without liabilitv and mJv :llso. in its discretion
r ....
deduct from the contract or purch:lse price. or othcrwise recover. thc full amount of an)' fce.
commission. pcrcentage. gift. or consiJeration paid to the former County oflicer or employee,
7f~ ~"u~l
Date: 0:110/(01
STATE OF ~St V\r'~lnlG\
COUNTY or KCtY\U'\.I..W..
PERSONALLY APPEARED BEFORE ME. the undersigned authority,
~i~vc:t 1--\. ~
who, after first being sworn by me, affixed his/her
signature (name of individual signing) in the space provided above on this I
day of
Sept-
, ~ 2(.(,1.
I~L5 l-\. i~~
NOTARY PU8L1C
:-'ly cOl11l11ission expires:
O;~~;;~ -i
NOTARY PUBLIC t
STATE OF WEST VIRGINIA \
OfNNIS H. BOGGS
1801 W,., R1V1>rvi..... Dr.
&11.., WV 2S015
My Commi..ion expIres 7.14-2003
~ _____----.1
0\113 - Mep FORi\l #4
ATTACHI-1ENT E