Item D4BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date:FEBRUARY 20, 2013Division:TDC _____________
Bulk Item: Yes XNo Department:_ _________
Staff Contact Person/Phone #:Maxine Pacini
296-1552
AGENDA ITEM WORDING:
Approval to advertise a Request for Applications for FY 2014 Capital Project Funding.
ITEM BACKGROUND:
TDC approved same at their meeting of January 29, 2013
PREVIOUS RELEVANT BOCC ACTION:
CONTRACT/AGREEMENT CHANGES:
__________________________________________________________________________________
STAFF RECOMMENDATIONS:
Approval
TOTAL COST: N/ABUDGETED:
Yes XNo
COST TO COUNTY: N/ASOURCE OF FUNDS:
TDC
REVENUE PRODUCING:AMOUNT PER MONTHYear ____
Yes No
APPROVED BY:
County Atty XOMB/Purchasing N/ARisk Management N/A
DOCUMENTATION:
Included XNot Required_____
DISPOSITION:AGENDA ITEM #
Revised 11/06
MONROE COUNTY TOURIST DEVELOPMENT COUNCIL
CAPITAL PROJECT (BRICKSAND MORTAR)
FUNDING APPLICATION
REQUEST FOR APPLICATIONS FOR CAPITAL PROJECTS (BRICKSAND MORTAR)
All respondents must use the current application downloaded from the website www.demandstar.com.
Use of any other application will result in your application being rejected.
APPLICATION DEADLINE APRIL 30, 2013
All applications should be received no later than 5:00 p.m. (close of business day) April 30, 2013
All applications submitted in response to this solicitation should be addressed to:
Monroe County Purchasing Department
nd
1100 Simonton Street, 2Floor, Room 2-213
Key West, Florida 33040
ATTENTION: CAPITAL PROJECT FUNDING APPLICATION
Applicants must submit:
A.One (1) disc OR(1) USB flash drive with complete copy of application as a .pdf
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ÌÛÕ×É ÛÎØ··
B.One (1) signed and marked as ORIGINAL paper copy PLUS…….
C.The correct number of paper copies for the district for which you are applying:
District I requires 5paper copies of application
District II requires 6paper copies of application
District III requires 5paper copies of application
District IV requires 5paper copies of application
District V requires 6paper copies of application
All inquiries and correspondence should be made to the Monroe County Tourist Development
Council. Contact Maxine Pacini or Lynda Stuart at (305) 296-1552. All email correspondence
should be addressed to adminasst@fla-keys.com.
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CAPITAL PROJECTFUNDING PROCESS
TDC
The Monroe County Tourist Development Council () administers the four (4) cent bed tax
collected for the purpose of promoting the Florida Keys as a tourist destination. Each year, the
TDC advertises a Request for Applications (RFA) forcapital project funding through the TDC.
governmental entitynon-profit
Projects must be owned and operated by either a or
organizationare not eligible
. Individuals and for-profit organizations to apply for Capital
Projects funds.Applicantsmust be registered to do business in Florida.All applications will be
DAC’s
reviewed by the appropriate District Advisory Committees (), who shall make
recommendations on funding the project to the TDC. Upon approval of recommended funding
allocation by the TDC, the administrative office will coordinate with the project coordinator to
establish a contract for the project, and will present the proposed contract to the County for final
approval.
This applicationwill be funded as a fifty percent (50%) reimbursement of funds expended
by any individual organization. The applicant must show that all funds (100%) are
available for the project at the time of application so that there is no delay in the progress
of the project, and that TDC funding is not used as “matching” funds.
IMPORTANT INFORMATION
All information furnished or disclosed as part of the application process is considered public
record by the laws of the State of Florida.
The applicant shall not lobby, solicitor act to influence TDC Board and/or advisory committee
membersin any way that may have an effect on the outcome of the competition, discussion or
negotiations leading to the award of a contract.Such action could lead to an automatic
withdrawal of the application from consideration.
Prior to filling out application, please go to www.sunbiz.orgto ensure that your organization is
registered to do business in the state of Florida. Only applicants that are duly registered will be
accepted.
Cost of preparation and submission of the application is the responsibility of the applicant.
Applicant shall complete, copy, sign (by an authorized officer) and submit the correct number of
copies of the application to the Monroe County Purchasing Department. (Please DO NOT use
three (3) ring HARD binders, soft binders or spiral binding; no binders are preferred.)
All attachments should be noted as such in the top right hand corner of each sheet –please do
not use tab inserts.
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Applicant shall familiarize itself with referenced online materials noted in this application (sample
contract): http://www.monroecounty-fl.gov/pages/MonroeCoFL_TDC/index.
Any part of the project for whichthe applicant wishes to seek reimbursement from the County,
must NOT commence prior to the date of County approval.
Be advised that if your organization is awarded funding you will be required to enter into a
contract which delegates you to maintain accurate and complete documentation of the project.
You will be required to obtain a signed amendment to the contract before making any
substantive changes to the project or you may nullify the County’s obligation to pay. You will be
required tocomply with the following reimbursement procedures outlined in the sample contract
which can be found at http://www.monroecounty-fl.gov/pages/MonroeCoFL_TDC/index.
The recipient ofTDC capital project funding shall designate a project manager if no licensed
architect, engineer or general contractor is involved in the project.If the project is performed by
County or City personnel, the project manager shall be the Engineer, Building Official or
Construction Manager of that local government.
Taxes:
The TDC/County is exempt from Federal, Excise and State of Florida Sales Tax.
Maintenance:
The applicant shall be responsible for all maintenance and operational costs of
the premises improved or constructed with the use of funding from the TDC/County. The
applicant shall be responsible to the TDC/County for the safekeeping and proper use of the
property entrusted to applicant's care, to include any and all insurance for the value of the
equipment and any maintenance or service contracts relating to such equipment for its service
life. Any disposal of assets procured through funding under this contractshall comply with
chapter 274, F.S. or chapter 617, F.S., dependent upon the type ofentity funded under this
contract.
Permits:
Applicant shall be responsible for securing all federal, state and local development
approval and permits necessary to complete the project.Award of funds under this application
donot indicate any development approval by the County and applicant shall be required to
comply with all County concurrency requirements under land use laws of the County and State.
Performance Guarantee:
A successful applicant shall warrant, by signing this application, that
applicant has the financial capability of completing the project as planned without the need to
request further funding from TDC/County for same.Applicant shall warrant by signing this
application and confirm in writing (in the form of bank statements; signed letter from the bank
stating that funds are in the bank for the specified project; documentation provided by a financial
institution of a line of credit assigned to the specific project within the application) that applicant
has the funds in place at the time of the application for grant funds to be able to complete the
project prior to seeking reimbursement of TDC funds. A governmental applicant shall provide a
line item budget for the project in question, and proof that the budget has been adopted by the
governing board of that entity.The applicant by signing the application certifies that: applicant,
its principals, and any previously owned business is/are not and have never been in default to
Monroe County under the terms of any contract.(Default means failure to fulfill contractual
obligations where County had to take legal action to obtain remedy or where a bonding company
had to make good for applicant.)
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In-kind services:
In-kind services (donated/free/volunteered labor; materials; goods;services)
up to 25% of the total cost of the project may be considered to meet the 100% funding of the
project. Applicant shall provide a schedule of values for each unit of in-kind service and/or
goods at the time of the application. Should funding be allocated, County/TDC reserves the
right to deny the application of certain in-kind services and goods and to negotiate a revised
schedule of values for permissible items. For example, county will not accept as in-kind, the
waiver of governmental fees.The amount of in-kind services you note within your application
shall be entered into your final contract. Applicants will not be able to introduce a request to
allow in-kind services after submission of the application.
Construction and Other Contracts:
Applicant, by signing the application, warrants that, if
awarded funds for the project, all contracts, for construction or otherwise, to complete the project
shall be met in compliance with all applicable laws and County purchasing policy and to comply
.
particularly with F.S. Chapter 255, Chapter 274 and Chapter 287Applicant further agrees to
provide TDC/County and their designated representatives with:
a)access to the project premises for inspection of the progress of the project;
b)documentation including copies of all sub-contracts/Request For Bids verifying
compliance with purchase/construction/architectural contract requirements of the
County [Notice to owner: list of sub-contractors, and release of liens must be
provided to County];and
c)access to all records concerning the project.These records must be retained by
applicant for a minimum of four (4) years after the termination date of contract.
This requirement may be for a different time period than that required by other
government agencies. All records must be kept in accordance with Generally
Accepted Accounting Principles.
Termination for Default/Convenience
: The TDC/County reserves the right to terminate any
contract if, in its opinion, there shall be a failure at any time to properly perform faithfully any
portion of the project as funded by TDC/County according to the plan presented with the
application, or as modified and accepted in writing by TDC/County. Further, TDC/County
reserves the right to terminate payments under this contract should the anticipated funding
become unavailable for any reason.Should termination occur under this provision, TDC/County
shall give applicant thirty (30) days notice prior to termination.
Payments:
Applicant shall submit all documentation required by the County Finance
Department in accordance with instructions from said department, prior to payment of any funds
The TDC Application for Payment forms provided in the TDC reimbursement
awarded.
package shall be used.
Ten percent (10%) of every progress payment shall be withheld by
County until certification of completion of project.
Contractor and Sub-Contractor Bonding:
Applicant shall require all contractors and sub-
contractors to post such performance bonds as are required by such contractors/sub-contractors
entering into contract with the TDC/County.
Design/Architectural Fees:
Design plans and architectural fees will be paid upon completion
of the physical bricksand mortar portion of the project outlined within the contract.Applicant
shall submit for reimbursement of design plans and architectural services within the last
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segment of their proposed project (Exhibit A).This is to ensure that TDC dollars are used for
completed projects that are open to the public.
Acknowledgements:
Applicant shall be required to display an appropriate public
acknowledgment of the support of the Monroe County Tourist Development Council in a publicly
prominent area of the project.
PERMISSIBLE USES FOR CAPITAL PROJECT FUNDS
governmental
All capital projects funded by TDC shall be owned and operated by either a
entitynon-profit organizationare not eligible
or .Individuals and for-profit organizations to
apply for Capital Projects funds.Tourist Development capital project funds may be used in
Monroe County as follows:
1.To acquire, construct, extend, enlarge, remodel, repair, or improve one or more publicly
owned and operated convention centers, sports stadiums, sports arenas, coliseums,
auditoriums,aquariums,or museumswithin the boundaries of the taxing district in which the tax
is levied.
2.To finance beach improvement, maintenance, re-nourishment, restoration, and erosion
control.
3.To acquire, construct, extend, enlarge, remodel, repair, improve, or promote one or more
museums, zoological parks,or nature centers which are publicly owned and operated by non-
profit organizations and open to the public.
4.To finance fishing piers.
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APPLICATION FOR CAPITAL PROJECT FUNDING
This application is to request funding from the following District(s):
District I
: Key West -(shall encompass the city limits of Key West)
District II
: Lower Keys -(city limits of Key West to West end of Seven Mile Bridge)
District III
: Marathon –(west end of Seven Mile Bridge to Long Key Bridge)
District IV
: Islamorada -(between Long Key Bridge and Mile Marker 90.939)
District V
: Key Largo -(from Mile Marker 90.940to the Dade/Monroe County line and any
portions of mainland Monroe County)
APPLICANT ORGANIZATION
:
(Registered business nameexactlyas it appears on www.sunbiz.org).
DESIGNATED PROJECT CONTACT PERSON
(Please note that the TDC Administrative Office conducts most of its correspondence, including
contract and reimbursement material by email, so the person listed below should be able to
accept responsibility for receipt of this information).
Name & Title:
Telephone/mobile no:
E-mail:
Address:
TYPE OF APPLICANT
:Non-ProfitGovernmentalEntity
PROJECT TITLE
:
LOCATION OR ADDRESS OF PROJECT: ÛÎØ
ìÊÍÆÓØ× ÌÔÃÉÓÙÛÐ ÌÍÉÈÛÐ É×ÊÆÓÙ× ÛØØÊ×ÉÉ ê÷
Ð×ÕÛÐ Ø×ÉÙÊÓÌÈÓÍÎ ÐÍÈ ÚÐÍÙÑ ÉÇÚØÓÆÓÉÓÍÎ ÛÎØ ÛÈÈÛÙÔ ÏÛÌ
WHICH OF THE FOLLOWING APPLIES TO YOUR PROJECT?
Publicly owned and operated Owned and operated by a non-profit organization
Publicly owned and operated by a non-profit organization
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WHICH OF THE FOLLOWING BEST DESCRIBES YOUR PROJECT?
Convention CenterSports StadiumSports ArenaColiseum
Auditorium AquariumMuseumZoological Park
*
Nature CenterFishing PierBeach or Beach Park Facility
WHICH OF THE FOLLOWING APPLIES TO YOUR PROJECT?
AcquireConstructExtendEnlargeRemodel
RepairImprove
*IF YOU CHECKED THE BOX FOR BEACH OR BEACH PARK FACILITY, WHICH OF THE
FOLLOWING APPLIES?
ImprovementRe-nourishmentRestorationErosion control
MaintenanceConstructRepair
If the TDC/County requires a Conservation Easement Deed or mortgage note requiring
repayment of TDC monies in the event of transfer of ownership or change in use of the
premises, would you be agreeable to executing same?
YesNo
Application is for % of total funds to be obtained from all sources.
Has applicant received previous TDC assistance: Yes No
If yes, please specify year, amount,and nature of project.
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List any previous grant-in-aid assistance received by the applicant or for the property from any
government agency.Indicate year of award, amount, division which awarded the grant, and a
brief description of the project assisted by each.
For purposes of this application
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Ì×ÊÙ×ÎÈ ÍÖ ÈÍÈÛÐ ÌÊÍÒ×ÙÈ ÙÍÉÈ ÉÔÛÐÐ
TDC requires confirmation in writing that project funds are
Ú× ÍÖ ÓÎÑÓÎØ É×ÊÆÓÙ×É ÛÎØ ÏÛÈ×ÊÓÛÐÉ
in place at the time of this application for grant funds (see Performance Guarantee on page 3).
Payment is a 50% reimbursement of the total cost of each segment of the project, subject to the
cap on expenditures for that segment as set forth in the contract. Applicant must be prepared to
pay the entire cost of segment in advance of seeking the 50% reimbursement. (The project may
be broken down into 2 or 3 segments. When one segment is completed, reimbursement of 50%
of that cost can be applied for through the TDC.)
a)TDC funds Confirmed/Available Confirmed Total Project
requested:Hard-Dollar fundsIn-kind Funds Cost
(Up to a maximum of
25% of project)
$$$$
b)State source of resources for the project specified in this application:
(i)Hard-dollar:
(ii)In-kind:
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Projected in-kind services and goods shall be allocated the following values, subject to
negotiation with TDC/County. List here all such anticipated values:
In the space below, write a brief description of the overall project:
and
In the space below write a list of specific items/services, the dollar amount for each of those
items/services that your requested TDC funds will be spent on:
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PROJECT DESCRIPTION
1.Use:
a)Original use of structure and date of construction:
b)Modifications to the present date including date & description:
c)Present use:
d)Any other uses between original and present:
e)Proposed use:
f)Insert or attach photograph of existing site:
Historic designation:
g)Indicate whether the property has been listed in the
National Register, is located in a National Register district, is a locally designated historic
landmark or is located in a locally designated historic district. If located within a historic district,
provide the official name ofthe district.This information is available from the planning agency
having jurisdiction over the property.
All Capital projects funded by TDC shall be owned and operated by a governmental entity or
non-profit organization. Applicant shall provide proof of property ownership or long-term lease
for consideration of funding.
2.Ownership or other interest in property by applicant:
a)Official records reference for ownership documentation
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b)If not owned by applicant, provide long-term lease of propertyand provide notarized
consent letter from owner for use of property as outlined in this application
3.If proposed project calls for transfer of title of real property to County, two (2) current real
estate appraisals and one (1) environmental assessment shall be provided.The TDC/County
shall ascertain, prior to acceptance of any donation or prior to purchase, that the property will
pose no environmental hazardor liability for same, to County.The TDC/County must also
ascertain permissible governmentalinterest in the transfer of title.Indicate any such proposed
title transfers here.
4.This paragraph applies only to an acquisition funding request, but you will still need to
complete items 5 through 13, whether this is new construction or renovations, additions, or
exhibits.The purchase amount shall not exceed the value of the property as determined by the
average of two appraisals, or the average of the closest two appraisals if more than two are
NOTE:
obtained.The maximum grant amount from tourist development revenue for an
acquisition project shall not exceed 50% of the purchase amount.Indicate the area of the
property to be acquired in acres.
In evaluating applications for acquisition funding, an important consideration is the
appropriateness of the size of the site to be acquired.Determinations of the appropriateness of
site size will be made on a case-by-case basis and will depend on the characteristics for which
the property is considered to be significant.Sufficient property should be acquired to assure that
the historic relationship of a structure or archaeological site to its surrounding environment is
preserved.However, it is important that no more property than is necessary to achieve
established preservation objectives be included in the acquisition project application.As this
factor is crucial to favorable consideration of your grant application and will have substantial
impact on the cost of the required application documentation, we encourage prospective
applicants to consult with the staff of the TDC Administrative Office prior to initiating the required
documentation.
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Protection of property:
5.Indicate any typeof state or federal protection currently
afforded the property.It may be that more than one type may be applicable.Provide citations
for applicable local protective ordinances.Include copies of property-specific restrictive legal
warrants
instruments in an attachment. By signing and submitting this application, the proposer
allevery
that restrictions are disclosed.Failure to include restriction on the property may result
in immediate termination of any contractand demand for return of any monies paid thereunder.
6. Is the property threatened by imminent destruction, deterioration or other loss which may
includedemolition, vacancy, severe deterioration, loss of structural integrity, encroaching
development, adverse environmental conditions, vandalism,etc.?Be specific regarding the
nature of immediacy of the threat.If so, describe in detail:
7.a)Are there any building restrictions on the site?If so, describe. Attach copies of all
recorded easement and restrictive covenants. By signing and submitting this application, the
warrantsallevery
proposerthat restrictions are disclosed. Failure to include restriction on the
property may result in immediate termination of any contractand demand for return of any
monies paid thereunder.
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b)Is the proposed project compatible with the County's Concurrency
Requirementsunder the existing and proposed Land Use Comprehensive Plan?
Yes No
Describe below how you haveascertained such compatibility.(Note:If your description
does not provide information about existing permits and/or review by the County Planning
Department, your application shall be rejected.)
c)Is the proposed project compatible with Municipality under which you are applying
Concurrency Requirementsunder the existing and proposed Land Use Comprehensive Plan?
Yes No
Describe below how you haveascertained such compatibility.(Note:If your description
does not provide information about existing permits and/or review by the MunicipalityPlanning
Department, your application shall be rejected).
d)Does the site contain endangered or threatened species of flora or fauna?
Yes No Describe/Explain:
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e)Indicate whether or not the property will be accessible to the handicapped per
Chapter 553, Part V, Florida Statutes and the Americans with Disabilities Act, Public Law 1012-
336.If not, provide a brief explanation.Yes No
f)Monroe County thinks that recycling is important. Does your entity recycle?
Yes No Describe/Explain:
Public accessibility and use:
g)Indicate the extent to which the property is
currently or will bescheduled to be open to the public each year (hours per day, days per week
and weeks per year) upon project completion.Estimate the number of persons who will use or
visit the completed facility annually. For archaeological projects, if the site will not be accessible
to the public, estimate the number of persons annually who will be exposed to the interpretive
materials and reports resulting from the project.How was this estimate derived?
8.Describe present physical condition of site:(attach legal description per property tax
records).Indicatethe present condition of the propertyby checking the appropriate term below:
Excellent:The property is habitable and occupied; no repairs are needed.All
physical evidence indicates that the property is under continuous maintenance.Application is
for expansion and enhancement.
Good:The property is habitable and occupied; only cosmetic repairs are needed
(e.g., peeling paint, missing ornamental features, some deteriorated mortar, etc.)Property is
maintained but in need of minor repair.
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Fair:The property is habitable but may be vacant.Both the structural integrity
(foundation, framing, etc.) and weather tightintegrity of the property (siding, walls, roofing, etc.)
are in jeopardy because of prolonged neglect.
Poor:The property is uninhabitable and vacant.Major structural repairs are needed.
Weathertight integrity has been lost.The property is derelict, abandoned and not habitable
without major rehabilitation work.
Also, list any specific factors or problems which contribute to the present condition of the
property.
9.List and describe all major work items included in the proposed project.
10.Status of Project Planning:
Not yet initiatedInitiated
Schematics completeDesign development
Documents completeConstruction documents completed
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11.Name and Address of Project Consultant (architect, engineer, contractor, etc.).
Enclose planning or architectural documents completed to date (1 set).
12.Has a contract for architectural services or construction services been executed?
YesNo
If so, in the space provided on the following page, indicate the scope of services to be provided
under this contract and whether these services were obtained through competitive negotiations,
requests for applications or other process.
13.Please check one of the following boxes regarding architectural services for this project:
a signed, sealed bid process was utilized for acquiring architectural services
or
project does not require architectural services
14.Describe the means by which the structure(s) affected by this project will be maintained
subsequent to restoration/rehabilitation. Include sources and estimated amounts of funding for
not to fund operations and maintenance costs
such maintenance. It is the County's policy of
organizations notwithstanding any tourism promotional value of a project.
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PROJECT BUDGET AND TIMETABLE -ALL PROJECTS
1.Cost Estimates:List all major work items and the estimated costs of each.If the project
is phased, segregate clearly those costs for the phase to be assisted by the TDC funds
requested.All phases and total estimated cost of the entire project must be listed here.
Total cost of phase/project for which funds are requested:
a)Phase$
b)Project$
Amount of TDC funds requested: (Funds requested from TDC not to exceed 50% of the total
project cost).
a)Phase$
b)Project$
Total confirmed In-kind funds:$
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2.Outline of expansion opportunity for acquiring further grants.
3.Tentative timetable.Indicate all major project activities and the anticipated time required
tocomplete each stage of the project on the graph below.
Project Timetable (in months)
Project Activity1234 5678 9101112
a).
b).
c).
d).
e).
f).
g).
Please indicate any critical dates and explain why they are critical.
4.What is the total project cost:$
5.Length of time for project completion in months and year(s):
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PROJECT BENEFITS -ALL PROJECTS
1.Is the primary purpose of the project to promote tourism in Monroe County?
YesNo
2.How will the project promote tourism in Monroe County?
ADDITIONAL INFORMATION -ALL PROJECTS
1.District in which the project is located.
2.Population of city/district where project activity will take place.
3.Federal Employer's Identification Number of applicant's organization.
4.Permitting:List all permits required to complete this project.
5.Code Enforcement:Does your organization/property have any outstanding code
violations? YesNo If you have answered yes, please explain below:
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6.Outline of proposed programin which this project will promote tourism in Monroe County.
7.Applicant must demonstrate the ability to complete the project as proposed and to
maintain and operate the project as a viable and long-term tourist attraction thatis open to the
public.
Included in this demonstration should be a summary of the applicant's past grant
experience, past two (2) year's financial statements, proposed operational budget and
description of administrative resources available to applicant and committed to the project.
Attach financial statements, budgetary and other documents.
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NON-COLLUSION AFFIDAVIT and VERIFICATION
I, , of the city of ,according to
law on my oath, and under penalty of perjury, depose and say that:
1)I am , the applicant making the
application for the project described as follows:
2)The prices in this application have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting competition, as to any
matter relating to such prices with any other applicant or with any competitor;
3)Unless otherwise required by law, the prices which have been quoted in this
application have not been knowingly disclosed by the applicant and will not knowingly be
disclosed by the applicant prior to application opening, directly or indirectly, to any other
applicant or to any competitor; and
4)No attempt has been made or will be made by the applicant to induce any other
person, partnership or corporation to submit, or not to submit, an application 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 project.
VERIFICATION
I HEREBY CERTIFY that I have read the forgoing application and that the facts stated herein
are true and correct to the best of my knowledge and belief.
President's/Mayor’s Name Typed President's/Mayor’s Signature
Sworn to and subscribed before me thisday of20
personally appeared , ,and
known to be the person named in and who executed the foregoing document.
________________________________
My commission expires: Notary PublicState of
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DRUG FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
(Name of Business)
1.Publishes a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace and
specifying theactions that will be taken against employees for violations of such prohibition.
2.Informs employees about the dangers of drug abuse in the workplace, the business’s
policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and
employee assistance programs, and the penalties that may be imposed upon employees for
drug abuse violations.
3.Gives each employee engaged in providing the commodities or contractual services that
are under application a copy of the statement specified in subsection (1).
4.In the statement specified in subsection (1), notifies the employees that, as a condition of
working on the commodities or contractual services that are under application, 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 any state, for a violation occurring in the workplace no
later than five (5) days after such conviction.
5.Imposes 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.Makes 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.
Applicant’s Signature:
Date:
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ATTACHMENTS AND CERTIFICATIONS -ALL PROJECTS
1.The following supporting documents are attached.
a)Proof of ownership/consent of owner for use of property as outlined in this
application:
(i)Official record reference for ownership documentation; or
(ii)Consent letter from owner for use of property as outlined in this application
b)Citations to applicable protective ordinance if applicable
c)Copy of letter designating project manager
d)Map showing location and boundaries of project area (for all types of
projects involving specific site or area which cannot be identified by astreet
address)
e)Copies of photographs of existing conditions of project site(s) or area
f)Documentation of confirmed project funds
g)Annual operating budget upon completion
h)Plans and specifications, if completed (development projects only –one set)
i)All restrictive documents governing use of the property
j)Non-Collusion Affidavit and Verification Form (notarized)
k)Drug Free Workplace Form
l)Print out of Sunbiz.org“Detail by Entity”
m)Most recent copy of annual report
I certify that the information contained in this application is true and correct to the best of my
knowledge, and that I am the duly authorized representative of the applicant.
Signature:
Title:
Date:
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