Miscellaneous CorrespondenceOUNTY jo'
MONROEKEY WEST,LORIDA 33040
(305) 294-4641 s
October 10, 1984
Honorable Danny L. Kolhage
Clerk of the Circuit Court
Monroe County Courthouse
500 Whitehead Street
Key West, FL 33040
Re: Agreement between Hospice of the
Florida Keys and Monroe County
Dear Danny:
Enclosed herewith please find
the above -referenced agreement, all
executed. I have already retained
my file.
LCPJr/brp
Enclosures
BOARD OF COUNTY COMMISSIONERS
Wilhelrnina Harvey, District 1
Ed Swift, District 2
Jerry Hernandez, District 3
Mayor Pro tern Alison Fahrer, District 4
Mayor Ken Sorensen, District 5
the original and two copies of
of which are now fully
a copy of said agreement for
Ver truly yours,
LUCIEN C. PROBY, JR. /
County Attorney
f
HOSDI
January 26, 1987
THE FLORIDA KEYS 91
Swan M, Cook* ?laming Manager
1. 1- ity services Section
2571 Executive Center Circle, not
Tallahassea, Florida 32399
U.- Comwimity Services Block Grant (CSBG) -
Moasoe Cemty Board of County Comadasioners
Dow Dr. Cooks
Inclosed please find an application for C830 funds (two origisal 0*1e8 of
the application and ono copy of supporting documents). The applicant is do
Moaros County 8aard of County Comeissioners, with 10spiae of the norida lCsys
as the , pptw*d by the CEe�isel onaL/ at a meating on January
200 1981 and signed by the County Mayor, Jerry vermandes.
Tba application is for $6,483 of ONG funds, with a match of 20Z (52 in cash
and 152 is -kind) for a total project of $7,780. If you bare any futther
questions, etc., please sontaat as at (305) 294-8812. Wa are looking forward
to begirming the project on April 1, 1907, the start of the grant period.
Stacerely yours,
Usbetb Krum
amseutive Director
Ut/br
to: Damp► z0bl.age s, Clark of Court
Mow" County
P.O. Box 190, Key West, FL 33041
(305) 294-8812
Page '. of _17
ATTACHMENT A
COMMUNITY SERVICES BLOCK GRANT APPLICATION
FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS
FEDERAL FISCAL YEAR 1987
APPLICATION SUBMISSION FORM
SUBMITTED BY: Monroe County Board of Commissioners
(APPLICANT)
Application is hereby made for funding through the Community Services Block
Grant under the Community Services Block Grant Act of 1981 (PL 97-35), as
amended, and the Community Services Block Grant Program Administration
Rule 9B-22, Florida Administrative Code, effective March 1984.
THE APPLICANT CERTIFIES THAT THE DATA IN THIS APPLICATION AND IT VARIOUS
SECTIONS, INCLUDING BUDGET DATA, ARE TRUE AND CORRECT TO THE BEST OF HIS
OR HER KNOWLEDGE AND THAT THE FILING OF THIS APPLICATION HAS BEEN DULY
AUTHORIZED AND UNDERSTANDS THAT IT WILL BECOME PART OF THE AGREEMENT
BETWEEN THE DEPARTMENT AND THE APPLICANT.
Jerry Hernandez (70'ed , - 044 090A
Name (typed) gnature •
Mavor and Chairman of Monroe Coun
Board of County Commissioners
tle:
A00
ATTESTED BY: _Rosalie L. Connolly
Name (typed) Sign q.Kire
Deputy Clerk
Title
APPLICATIONS MUST BE POSTMARKED BY THE DUE DATE, FEBRUARY 1, 1987 � AND
RECEIVED WITHIN FIVE DAYS AFTER THAT DATE TO BE CONSIDERED FOR FUNDING.
Form:DCA/css
87-1
Page 2 of 7
COMMUNITY SERVICES BLOCK GRANT APPLICATION
FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS
FEDERAL FISCPI, YEAR 1— 987
FOR DCA USE ONLY
POST11ARK DATE: CONTRACT NO:
DATE RECEIVED: ALLOCATION AMOUNT $
REVISION REC'D: CASH MATCH$ IN -KIND$
DATE APPROVED: FROM TO
DCA CONSULTANT: 90% [ ] 5% [ J D & R ( ]
INSTRUCTIONS Please complete all parts in this Application which are
applicable to your organization. If any part does not apply, write "N/A".
Do not use white -out (correction fluid) on any part of this application.
I. APPLICANT CATEGORY: [ ] Eligible Entity TK Local Government
[ ] Migrant/Seasonal Farmworker Organization
II. GENERAL ADMINISTRATIVE INFORMATION
a. Name of Applicant: Monroe County Board of County Commissioners
b. Applicant's Address: 500 Whitehead Street
City: Key West, Florida Zip Code
Telephone: (305) 294-4641 County : Monroe
c. Applicant's Mailing Address (if different from above):
same
Zip Code,
d. Chief Official or Executive Director's Name: Lisbeth Kern
Title:
Executive Director
e. Name of Official to Receive State Warrant: Lisbeth Kern
Address: P•0. Box 190
33040
Key West, Florida Zip Code 33041
f. Name of Person(s) Authorized to Sign Fiscal Reports:
Belinda Rodriguez (Hospice), Office Manager
g. Contact Person: Belinda Rodriguez Title: Office Manager
Mailing Address: P.O. Box 190
Key West, Florida Zip Code: 33041
Telephone: ( 305) 294-8812
h. Federal ID f: 59 23Rfi2R9
III. SUBGRANTEE INFORMATION
a. Will these funds be transferred to a subgrantee? jx] Yes [ ] No
h. Give the number of subgrantees included in this application: one (1)
List for each (attach additional pages if necessary:)
Sitbgrantee -N?me: Hospice of the Florida Keys, Inc.
Address: P.O.Box 190 Key West Florida 33041
Contact Person: Lisbeth Kern Telephone:(305) 294-8812
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V
CSBG BUDGET SUMMARY
Monroe CounCy Board of County Commissioners__
- — ;-, F.NUE SOURCE PERCENT MATCH TOTAL AMOUNT
u,a................. — -- $6 483.00
Cas^. Yatch................. �r
--- ,d Match .............. 1
al Match (lines 2+3)... 7O '�
( lines 1+L)........ $7,780.00
Page 4 of 7
-'` FUNDED PROGRAM ONLY
(1) CSBG FUNDS
(2) CASH MATCH
(3) IN -KIND MATCH
(4) TOTAL
=y1*;.S;r TIVE E)=,'SES
Ea_aries including fringe..
'. .......and Utilities.........
�-- rh:cl.....................
I----- — ..........................
_
—
:.:,,TAL (lines 6-9).......
ADNa4ISTR4TIVE EXP
i,. Se:aries including fringe..
�. Rent and Utilities.........
1? Travel .....................
14. Other ......................
205.00
205.00
1i. E,-°?'OTAL (lines 11-14).....
205.00
205.00
W AI ADM�1N.EXP.(line 10+15)
205.00
205.00
1'. T,", AL CSBG ADMIN. EXP. %
(not to exceed 15% of line 1)
'P EE FROGRAM EXPENSE
18. Sa_aries including fringe..
pent and Utilities.........
ravel .....................
2:. her .....................
2 :7,DTAL (lines 18-21).
FROGp.AM E)CPENSE
^Sa:aries including fringe..
760 00
_ 768.00
6,528.00
-t end Utilities.........
.....................
723.00
324.00
1 ,047.00
......................
?7. .,,BMTAL (lines 23-26).....
8 r_"'AL PROGRAM EXPENSE......
lines 22+27)
6
324.00
768.00
7 575.00
29� FCOPDARY ADMIa. EXPENSE..
I -pA;C DTAL EXPENSE
.............
M403.00
_ - --
$ 324.00 $ 973.00
$7,780.00
$6,483.00
***NOTE: Budget Detail must be attached --see instructions.
5 7
Pa�c o�
iN/_STK'! �y.��x1)_yK0(l{6> UU]iE1 ULi8lL
!.i./!" I 23 - Sal n,ic,
is(. red rsc F s |97 hr'
920.00
x 192 hrs �.9Z(>.0U
0"oyu, innx 11`rrap�..� ` S!0/hr
i,9?oo(/
5xhLptui '
�5.7m`.o'.
in -Kind UaLd` - R. o.1�.k. and CouoSelm
value (Volu,ceery)
� 768.00
lFoLal ijoe Tu"m #2-
�6,5Z8Oo
Lbue Item o25 - 7rav,L
CSD<" - T,a"e] in Service 6r,o (3'615 miles @ 20c/mile) 72].U0
Cash Match - 1ravci in Service Area (1.620 miles @ 2OQ/mi|e) 324.00
7ocal Line Item #25
$l,O47.OU
Line Item #14 - 0ther �d i i i - '^ ~`^�` "`^ ) � 205.00
[^tal Ciur Ituo #l�
$ 205.00
Page of 7
IN -KIND
AND CASH MATCH
DOCUMENTATION
In -Kind Documentation
Line Item
Number
— Source —
Type
Amount of
Contribution
Value/
Unit
_ fo_ta_J_
14
Vendor & Hospice
Supplies/
Donations
Equipment
$205.00
$10/Avg. ` $205.00
23
Hospic,� Volun-
Direct
teer: (RN,
Service
$768.0U
)10,/hr. $768.00-
OTR, Counse-
lor)
Cash Match Documentation
Line Item
- Numb-- er
Source
_
Amount
25
Hospice Donation
_
$324.00
CSBG SUBGRANTEE BUDGET
f FAr6 0,iji)o'"nrp" •m.St---mplot-e th, C pago)
,All OF APPLICANT: Monroe County Board of County Commissioners
;AME-- OF SUBGRANTEE: Hospice of the Florida Keys, Inc.
.AILING ADDRESS OF SUBGRANTEE: P.O. Box 190
Key West, Florida 33041
-AX EXEMPT NUMBER: 59-2386289
(If none, attach a copy of the certificate of incorporation)
04"TACT PERSON: Lisbeth Kern
TITLE:
Executive Director
TELEPHONE: (305) 294-8812
Page 7 of 7
';OTE: The following line items (11-15 and 23-27) must correspond to the CSBG BUDGET SLZ ARY
of the applicant. If there is more than one subgrantee, it is the applicant's
responsibility to ensure that the total of all subgrantee budget add correctly so that
they correspond to the CSBG BUDGET SUMARY.
CSBG FUNDED PROGRAM ONLY
(1) CSBG FUNDS
(2) CASH MATCH
(3) IP-KIND MATCH
(4) TOTAL
SUBGRAUN-7EE ADMINISTRATIVE M.
11. Salaries including fringe..
12. Rent and Utilities.........
13. Travel .....................
14. Other ......................
$ 205.00
$ 205.00
15. SUBTOTAL (lines 21-14).....
205.00
205.00
sUBGRANTEE PROGRAM EXPE:4SE
23. Salaries including fringe..
$5,760.00
768.00
6,528.00
24. Rent and Utilities.........
25. Travel .....................
723.00
$ n4.00
1,047.00
26. Other ......................
27. SUBTOTAL (lines 23-26).....
6,483.00
324.00
768.00
7,575.00
TOTAL CSBG EXPINDITURES
(lines 15+27)
$6,483.00
$ 324.00
$ 973.00
$7,780.00
ine subgrantee certifies that the data included in the Subgrantee Budget and the Subgrantee
work Plan are true and correct. The Subgrantee agrees to comply with all rules and
regulations relating to the Community Services Block Grant and understands that this budget
and work plan will become a part of the Agreement between the Applicant and the Department
of Community Affairs.
APPPOVED
BY: [tichard J. Fowler
(President of the Board)
DATE: .tanuary 13, 1987
Ail STED BY:
L sbeth Kern
Executive Director
1000,
SIGNATURE: