Item C21
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY ~.cvv--
Louis LaTorre
Meeting Date: March 20-21/2002
Division: Community Services
Bulk Item: Yes -L No
Department: Social Services
AGENDA ITEM WORDING: Approval for Monroe County to re-enroll in a Provider Agreement
with the Florida Medicaid Program.
ITEM BACKGROUND: Bayshore Manor currently provides daytime respite services for
medicaid recipients. Re-enrollment will allow these recipients to continue to
receive these services and be paid for them by the Florida Medicaid Program.
PREVIOUS RELEVANT BOCC ACTION: The Monroe County Board of County Commissioners
granted approval and authorized execution of a Medicaid Provider Agreement between Monroe
County and the Agency for Health Care Administration to participate in the Medicaid Program
on February 11, 1998.
CONTRACT/AGREEMENT CHANGES: None
STAFF RECOMMENDATION: Approval
TOTAL COST: N/A
BUDGETED: Yes
No
COST TO COUNTY: $ None
REVENUE PRODUCING: Yes X
No
AMOUNT PER MONTH$1798.00 YEAR$21576.00_
DOCUMENTATION: Included:-1L- 0 Follow:_ Not Required:
I!
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IS anagemen j,,:,.,' I '. '
APPROVED BY: County Atty /
DIVISION DIRECTOR APPROVAL:
DIVISION DIRECTOR NAME: James . a loch, Division Director/Community Services
DISPOSITION:
Agenda Item #:
~~//
MONROE COUNTY BOARD OF COUNTY COMMISSIO~'TERS
CONTRACT SUMMARY
Contract #
Contract with:Florida Medicaid Program Effective Date:
Expiration Date:Ongoing
Contract Purpose/Description:To enable Monroe County to re-enroll in a Provider Agreement to
accept Medicaid clients and be paid for this service by the Florida Medicaid Program
Contract Manager:Louis LaT OITe () f/~ Social Services
(Name~\V (Ext.) (Department)
for BOCC meeting on 3/20-3/21/02
Agenda Deadline: 3/6/02
CONTRACT COSTS
Total Dollar Value of Contract: $N/A Current Year Portion: $N/A
Budgeted? YesD No D Account Codes: _ _ __
Grant: $-0-
County Match: $N/ A
Estimated Ongoing Costs: $-O-/yr
(Not included in dollar value above)
ADDITIONAL COSTS
For: N/A
(eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes
lat~In Needed
Division Director ~ II 0 I Y esD No~
~ ~
Risk Management ~ \ (, 1\ () L YesD No[j)"/ 0 ,\,j (}~~'0I...L '\ (l~--=:t:::.}~"
~ .
O.M.B./Purchasing ~q),YesDNoW"'~~.
County Attorney I'! _' YesD NoD -','" (I
Date Out
We'
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Mill
Comments:
OMB Form Revised 9/11/95 Mep #2
STATE OF FLORIDA
ReA
AGENCY FOR HEALTH CARE ADMINISTRATION
JEB BUSH, GOVERNOR
RHONDA M. MEDOWS, MD, FAAFP, SECRETARY
Dear Medicaid Provider:
It is time for you to re-enroll in the Medicaid Program. Enclosed is a Profile Verification and
provider agreement that we are asking you to verify, sign and return for re-enrollment. Once you
have returned the information to us, you will have completed the re-enrollment requirements.
If you have more than one Medicaid provider number, you will receive a Profile Verification for
each number. We are sending out the re-enrollment packages over the next few months so you
may not receive all the packets for your numbers at the same time. However, you must re-enroll
each provider number.
If you still receive your checks manually, we are requesting you to sign up for electronic
payments. Medicaid sends all payments to providers every Thursday. Electronic payments have
an advantage over paper because they are deposited directly into your account on the same
day that the paper checks are mailed.
Please review the Profile Verification and verify that the information printed on it is
correct. Please complete the Profile Verification and return it to ACS State Healthcare
(ACS) within 30 days. If you do not return the information requested, the Agency will
terminate your provider number.
The Re-enrollment process is one of the ways Medicaid is able to ensure our records are
correct and that they accurately reflect your provider demographics. We understand that the
process represents time for you but please consider it as an investment in an improved working
relationship. We would like to thank you for your cooperation and assistance in this process,
and thank you for the services you provide to Florida's Medicaid citizens.
If you have any questions, please call the ACS Enrollment Unit at 1-800-377-8216 for
assistance. I look forward to continuing our work together.
Sincerely,
~
Headquarters
2727 Mahan Drive
Tallahassee. FL 32308
Alan Strowd, Chief
Medicaid Contract Management
Enclosures
Medicaid Contract Management
2308 Killearn Center Blvd., Suite 200
Mail Stop 22, Tallahassee. FL 32309
1l'Ql'QV. fdhc.state. t1. us
FLORIDA MEDICAID PROVIDER RE-ENROLLMENT
BACKGROUND SCREENING REQUIREMENTS
NEW SCREENINGS (see enclosed form: Criminal History Check)
Submit a completed Criminal History Check form (enclosed). Include the complete name, home
address, city, state, zip code, Social Security Number, date of birth, race and sex along with a
$15.00 check made payable to A CS State H ealthcare for each background screening.
PRIOR SCREENINGS
If an individual had a state and/or national criminal history check completed within the last 12
months, attach proof in the form of a letter or screen print from the agency that required the
screening. This documentation must include the individuals name, social security number, level
of screening and the date the screening was completed.
ORGANIZA TION EXEMPTION (see enclosed form: FDLE Criminal History Check and Fingerprinting
Exemption Request)
The following organizations are exempt from fingerprinting and criminal history check
requirements under Chapter 409, Florida Statutes:
School District
Hospital
Nursing Home
Hospice
Assisted Living Facility
Unit of Local Govermnent
Organization that derives more than 50% of its revenue from the sale of goods to final customers AND
is required to file a form 10K OR has a net worth of $50 million or more
To obtain this exemption, the CEO must submit an FDLE Criminal History Check and
Fingerprinting Exemption Request (enclosed).
BOARD MEMBER EXEMPTION (see enclosed form: Organization Affidavit for Exemption from
Medicaid Criminal History Checks)
Board members of a not-for-profit corporation are exempt from the criminal history check if
they meet all of the following criteria:
Serve solely in a voluntary capacity,
Do not regularly take part in the day-to-day operational decision of the corporation or organization.
Receive no remuneration from the corporation or organization for their service on the board of directors.
Have no financial interest in the corporation or organization. and
Have no family members with financial interest in the corporation or organization.
To obtain this exemption, the CEO must submit a notarized Organization Affidavit for
Exemption from Medicaid Criminal History Checks (enclosed). A listing of the board members
must accompany this form.
LICENSED PRACTITIONER EXEMPTIONS
Physicians. Chiropractors and Podiatrists are screened as part of the licensing process through the Department of
Health (DOH). No further background screening is required. Please submit a copy of the screen print from the DOH
web site to verify the current license status for each practitioner owner.
(www.doh.state.fl.us/IRMOOPRAESIPRASLIST . ASP)
~
Florida Medicaid Re-enrollment
Facility Profile Verification
This is the information as it appears in your Provider File as of 01/11/2002.
Please review and update if necessary using the space provided. No red ink please!
Provider Number and Type
676448700
H & C BASED SERVICES
Provider Name
BA YSHORE MANOR
Monroe County
Doing Business As Name
Bayshore Manor
fur ~ ~ ~Q~~~ ~~~ ~~~ ~~~ ~~~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~: ~ ~ ~ ~
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Business Address
(P.O. Boxes not accepted)
5200 COLLEGE ROAD
KEY WEST, FL 33040
Payment Address
5200 COLLEGE ROAD
KEY WEST, FL 33040
County of Operation
MONROE
Telephone Number
305-294-4966
Tax ID or SSN 59-6000749
(Documentation required for changes only)
Attach copy of SS Card or an
original W-9 - for changes only
Ownership:
Please list below all partners or shareholders with ownership interest of five percent or more
AND all officers, directors, billing agents, and managers of this business. Use an additional
sheet if necessary.
Print Each Name
SSN
License #
% Own
Change in Ownership:
Has this facility had a change in ownership? (A change in ownership occurs whenever
the stock or assets/liabilities of a business are purchased or transferred by the existing
owners to new owners.)
o Yes fJ No If yes, list the date of change in ownership. Please provide bill
of sale or stock transfer documentation.
Provider Profile Verification
Page I
CNlR91 FRM J1'1"02
Provider Number
676448700
Criminal History:
Have all partners or shareholders with ownership interest of five percent or more and
all officers, directors, billing agents, managers and financial custodians of this business
submitted fingerprints for background screening within 12 months of the date found on
page one 3'd line from the top?
o Yes 0 No
EXEMPT - LOCAL
rov'1'
If yes, attach proof of the screening from the agency that submitted it.
If no, then complete the criminal history information form and a check
for $15 made payable to ACS State Healthcare for each person. Return
the form and check with your Profile Verification. See the provider Re-
Enrollment Background Screening Requirements form for details (enclosed).
Provider Agreement
o Check here if... all partners or shareholders with ownership interest of five percent or
more and all officers, directors, billing agents, managers and financial
custodians of this business have signed the enclosed Medicaid Provider
Agreement. Please submit the original signed agreement with your
Profile Verification.
I have reviewed this information and have made any necessary updates. I understand
that it is my responsibility to notify Medicaid's fiscal agent of any change to the
information in my provider file, including but not limited to, a change of address, group
affiliation, ownership, officers, directors, or tax identification number. All attachments
required to update my file are included with this re-enrollment packet.
I further understand that under Section 409.920(2)(f), Florida Statutes, the filing of
materially incomplete or false information with this re-enrollment verification is a third
degree felony and is sufficient cause for termination from the Florida Medicaid Program.
Provider or Authorized Agent's Signature
JN1ES L. ROBEKrS
Printed name of signatory above
Date
CDUNTY A!l1INISTRATOR
Title
The Final Step:
Mail your re-enrollment packet and any required attachments to the address below. If
you have any questions, please call the ACS State Healthcare Enrollment Unit at
800-377 -8216.
ACS State Healthcare
Provider Re-enrollment
P.O. Box 13800
Tallahassee, FL 32317-3800
Provider Profile Verification
Page 2
=.~u~!:: ~l:;l~-,
IS'. TE uF FLORIDA
~lAHCA
AGENCY FOR HEALTH CARE ADMINISTRATION
NON-INSTITUTIONAL
MEDICAID PROVIDER AGREEMENT
The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions:
(1) Discrimination, The parties agree that the Agency for Health Care Administration (AHCA) may make
payments for medical assistance and related services rendered to Medicaid recipients only to a person or
entity who has a provider agreement in effect with AHCA; who is performing services or supplying goods in
accordance with federal, state. and local law; and who agrees that no person shall, on the grounds of sex.
handicap, race. color. national origin, other insurance. or for any other reason. be subjected to discrimination
under any program or activity for which the provider receives payment from AHCA,
(2) Quality of Service. The provider agrees that services or goods billed to the Medicaid program must be
medically necessary, of a quality comparable to those furnished by the provider's peers, and within the
parameters permitted by the provider's license or certification. The provider further agrees to bill only for the
services performed within the specialty or specialties designated in the provider application on file with AHCA.
The services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to
submitting the claim,
(3) Compliance. The provider agrees that the submission for payment of claims for services will constitute a
certification that the services were provided in accordance with local, state and federal laws, as well as rules
and regulations applicable to the Medicaid program, including the Medicaid Provider Handbooks issued by
. AHCA.
(4) Term and signatures. The parties agree that this is a VOluntary agreement between AHCA and the
provider, in which the provider agrees to furnish services or goods to Medicaid recipients. Provided that all
requirements for enrollment have been met, this agreement shall remain in effect for five (5) years from the
effective date of the provider's eligibility unless otherwise terminated. This agreement shall be renewable
only by mutual consent. The provider understands and agrees that no AHCA signature is required to make
this agreement valid and enforceable.
(5) Provider Responsibilities. The Medicaid provider shall:
(a) Possess at the time of the signing of the provider agreement, and maintain in good standing throughout
the period of the agreement's effectiveness, a valid professional, occupational. facility or other license
appropriate to the services or goods being provided. as required by law,
(b) Keep, maintain, and make available in a systematic and orderly manner all medical and Medicaid-related
records as AHCA requires for a period of at least five (5) years.
(c) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients as
required by law.
(d) Send. at the provider's expense, legible copies of all Medicaid-related information to authorized state and
federal employees, including their agents. The provider shall give state and federal employees, including
their agents. access to all Medicaid patient records and to other information that can not be separated from
Medicaid-related records.
(e) Bill other insurers and third parties, including the Medicare program. before billing the Medicaid program,
if the recipient is eligible for payment for health care or related services from another insurer or person,
(f) Within 90 days of receipt, refund any moneys received in error or in excess of the amount to which the
provider is entitled from the Medicaid program.
(g) Be liable for and indemnify, defend, and hold AHCA harmless from all claims, suits. judgments. or
damages. including court costs and attorney's fees. arising out of the negligence or omissions of the provider
in the course of providing services to a recipient or a person believed to be a recipient.
MPA Revised August 2001
:~llRE5 j;:~M 01/10/0::
(h) Accept Medicaid payment as payment in full. and not bill or collect from the recipient or the recipient's
responsible party any additional amount except, and only to the extent AHCA permits or requires.
co-payments. coinsurance. or deductibles to be paid by the recipient for the services or goods provided,
This includes situations in which the provider's Medicare coinsurance claims are denied in accordance with
Medicaid's payment.
(i) Agrees to submit claims to AHCA electronically and to abide by the terms of the Electronic Claims
Submission Agreement.
(j) Agrees to receive payment from AHCA by Electronic Funds Transfer (EFT), In the event that AHCA
erroneously deposits funds to the provider's account. then the provider agrees that AHCA may withdraw the
funds from the account.
(6) AHCA Responsibilities, AHCA:
(a) Is required to make timely payment at the established rate for services or goods furnished to a recipient
by the provider upon receipt of a properly completed claim.
(b) Will not seek repayment from the provider in any instance in which the Medicaid overpayment is
attributable solely to error in the state's determination of eligibility of a recipient.
(7) Termination For Convenience, This agreement may be terminated without cause upon thirty (30) days
written notice by either party,
(8) Ownership, The provider agrees to give AHCA Sixty (60) days written notice before making any change in
ownership of the entity named in the provider agreement as the provider. The provider is required to maintain
and make available to AHCA Medicaid-related records that relate to the sale or transfer of the business
interest. practice. or facility in the same manner as though the sale or transaction had not taken place, unless
the provider enters into an agreement with the purchaser of the business interest. practice. or faCility to fulfill
this requirement.
(9) Complete Information, All statements and information furnished by the prospective provider before
signing the provider agreement shall be true and complete. The filing of a materially incomplete. misleading
or false application will make the application and agreement voidable at the option of AHCA and is sufficient
cause for immediate termination of the provider from the Medicaid program and/or revocation of the provider
number.
(10) Interpretation, This agreement shall not be construed against either party on the basis of this agreement
having been prepared by one of the parties.
(11) Governing Law, This agreement shall be governed by and construed in accordance with the laws of the
State of Florida.
(12) Amendment. This agreement, the application and other documents being executed and delivered
pursuant hereto constitute the full and entire agreement and understanding between the parties hereto with
respect to the subject matter hereof. No amendment shall be effective unless it is in writing and signed by
each party,
(13) Severability, If one or more of the provisions contained in this agreement or application shall be invalid,
illegal or unenforceable. the validity. legality and enforceability of the remaining provisions shall not in any
way be affected or impaired,
(14) Agreement Retention, The parties agree that AHCA may only retain the signature page of this
agreement. and that a copy of this standard provider agreement will be maintained by the Director of
Medicaid. or his designee. and may be reproduced as a duplicate original for any legal purpose and may also
be entered into evidence as a business record.
(15) Funding. This contract is contingent upon the availability of funds,
MPA Revised August 2001
2
.c PARTIES AGREE THAT THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS FULLY
eNFORCEABLE IN A COURT OF COMPETENT JURISDICTION. THE SIGNATORIES HERETO
REPRESENT AND WARRANT THAT THEY HAVE READ THE AGREEMENT, UNDERSTAND IT, AND ARE
AUTHORIZED TO EXECUTE IT ON BEHALF OF THEIR RESPECTIVE PRINCIPALS OR CO-OWNERS.
THIS AGREEMENT BECOMES NULL AND VOID UPON TRANSFER OF ASSETS; CHANGE OF
OWNERSHIP; OR UPON DISCOVERY BY AHCA OF THE SUBMISSION OF A MATERIALLY INCOMPLETE,
MISLEADING OR FALSE PROVIDER APPLICATION UNLESS SUBSEQUENTLY RATIFIED OR APPROVED
BY AHCA.
ALL PRINCIPALS. PARTNERS AND SHAREHOLDERS HAVING AN OWNERSHIP INTEREST OF FIVE
PERCENT (5%) OR GREATER ARE REQUIRED TO SIGN THIS AGREEMENT. FAILURE TO DO SO WILL
MAKE THIS APPLICATION, AGREEMENT AND PROVIDER NUMBER VOIDABLE BY AHCA.
FOR OFFICE USE ONLY
The provider's name is:
The facility's name is:
The provider number is:
IN WITNESS WHEREOF. the undersigned have caused this agreement to be duly executed under the
penalties of perjury, swear or affirm that the foregoing is true and correct.
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
LL
...
<
(
Signature of Provider
Date
'-.J
(legibly print the above signature) Title
Signature of Provider
Date
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
(legibly print the above signature) Title
Signature of Provider
Date
MPA Revised August 2001
(USE ADDITIONAL PAGES IF NECESSARY)
()r~~rii~~e;'~~~~yl~l~~!~~a;~I~I,!!'?}}
from Medicaid GriDlinallIistof"YU;hecRS ..
Under penalty of perjury, I.
, do hereby certify
(Print ;'Iiame)
that
, Medicaid Number
, IS
(Print ;'Iiame 01' Organization)
a not-for-profit corporation or organization as defined in Florida Statutes. I further certify
that the members of the board of directors of the organization listed above meet all of the
following criteria:
1. Serves solely in a voluntary capacity for the above-named organization;
2. Receives no remuneration from the above-named organization;
3. Does not take part in the day-to-day operational decisions of the above-named
organization;
4. Has no financial interest in the above-named organization; and
5. Has no family members with a financial interest in the above-named organization.
Signature of Chief Executive Officer
o Check here if CEO meets the five requirements listed above.
Please attach a list of board members if using this exemption form.
STATE OF FLORIDA
COUNTY OF
BEFORE ME, the undersigned authority,
personally appeared, and after first being duly sworn in, did depose and say that he/she did
execute the foregoing Organization Affidavit to the Agency for Health Care Administration and
that the same is true, accurate and correct to the best of his/her knowledge, information and
....
belief.
SWORN TO AND SUBSCRIBED before me this
day of
NOT AR Y PUBLIC
My commission expires:
Personally known
or Produced identification
Type of identification produced
AHCA Form 2200-0003 (October 2()() I)
..-..-..... ". ""....- - ......,..., ,.".. "....",.
FDLECrilDinallIisto"'Y(2lteCk.aII~
>Fingcrprin tingExclDptionReqllest
has applied to become a
(prim nam~ of organizatIOn or individual provider)
Medicaid provider.
This organization is requesting exemption from the fingerprinting and criminal history check
requirements under Chapter 409, Florida Statutes, on the following basis:
(Check all that apply and include copy of license)
o This organization is a school district, and is exempt under Section 409.908, Florida Statutes.
o This organization is a hospital licensed under Chapter 395, Florida Statutes.
o This organization is a nursing home licensed under Chapter 400, Florida Statutes.
o This organization is a hospice licensed under Chapter 400, Florida Statutes.
o This organization is an assisted living facility licensed under Chapter 400, Florida Statutes.
o This organization is a unit oflocal government.
o This organization derives more than 50% of its revenue from the sale of goods to final
consumers AND
o 1. Is required to file a form 10K with the Securities and Exchange Commission OR
o 2, Has a net worth of $50 million or more,
Documentation (annual report including audited financial statements and/or IOK form) must be
submitted with an~' exemption request under this catego~'.
Under penalty of perjury, I do hereby certify that
(Name of Organization or Individual Provider)
meets one or more of the criteria specified above,
Signature of CEO of Organization or
Superintendent of School District
Date
Print name of above signatory party
FDLE ExceptIon Form Noycmbcr 2(\() 1
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: March 20-21/2002
Division: Community Services
Bulk Item: Yes ---X- No
Department: Social Services
AGENDA ITEM WORDING: Approval to remove surplus inventory via advertising for bids as
described in attached schedule regarding items 5 - 17, and to award the inventory to the highest
bidder.
ITEM BACKGROUND: See Monroe County Purchasing Department's Recap of Bid Opening-Sale
Of Surplus Property dated February 28, 2002, at 11 :00 A.M., attached hereto.
PREVIOUS RELEVANT BOCC ACTION: N/A
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATION: Approval
TOTAL COST: N/A
BUDGETED: Yes N/A No
COST TO COUNTY: $ None
REVENUE PRODUCING: Yes
No
AMOUNT PER MONTH_ YEAR_
APPROVED BY: County Atty
DIVISION DIRECTOR APPROVAL:
DIVISION DIRECTOR NAME: James E alloch, Division Director/Community Services
DOCUMENTATION: Included:L- To Follow:_ Not Required:
DISPOSITION:
Agenda Item #:
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MONROE COUNTY PURCHASING OFFICE
11 00 SIMONTON STREET
KEY WEST, FLORIDA 33040
BID FOR SALE OF SURPLUS PROPERlY
Item # County 10 # Description of Equipment
1 0210-024 Computer
2 0211-038 NCR S-16 Tower Server
3 0940-11 0 184 Ford F700
4 141906-3 194 Ford E350 Ambulance
5 1801-103 Dell Computer
6 1801-105 Dell Computer
7 1801-108 Dell Computer
8 1801-109 Dell Computer
9 1801-110 Dell Computer
;\
10 1801-111 Dell Computer
11 1801-113 Dell Computer
12 1801-115 Dell Computer
13 1803-570 Dell Computer
14 1805-11 Dell Computer
15 1809-018 Dell Computer
16 1809-019 Dell Computer
17 1810-042 Dell Computer
18 0976-045 Paper Container
19 0977 -013 Paper Container
20 0977-014 Paper Container
21 0977-051 Paper Container
22 0977-050 Paper Container (15 yd)
23 0977 -045 20 yd roll off box
I
I
Bid Price
$9..05
4$
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4 o~
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$
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\ . DS'
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MONROE COUNTY PURCHASING OFFICE
11 00 SIMONTON STREET
KEY WEST, FLORIDA 33040
BID FOR SALE OF SURPLUS PROPERTY
24 0977-055 20 yd roll off box
25 0977-057 20 yd roll off box
26 0977-059 20 yd roll off box
27 0977 -094 20 yd roll off box
28 0977-095 20 yd roll off box
29 0977-058 30 yd roll off box (homemade)
30 0977 -063 30 yd roll off box (homemade)
31 0977-038 35' conveyor attached to 0977-134(see
below)
32 0977-134 International Harvester Baler wi
0977-038 (see above)
33 0977-143 Metal Baler
.\ >
34 0977-155 Tire Slicer
35 0977-156 Wheel Crusher
I
BIDDERS A I '^ 11 \" L
. "'-0 f'--C C) I v \ C. 6- C-
NAM E._____ _____.;..________________________~----------------_____________________
ADDRE55:----2-1Q_~~_C___;[t~___92~____t2lEJ~~~___f{____~_Qj 3
PHONE:-t:l?!2_}______:{z~_=_2~L________________
f
FtlX:_____________________~________________________________________________________
FED I D NU M BER/ 55 N UM B ER:______________________________________________________
~~~/t-/~
---~-==~~--~--- ------------------------------------------------------
AUTHORIZED 51GNATUR .
MONROE COUNTY PURCHASING OFFICE
11 00 SIMONTON STREET
KEY WEST, FLORIDA 33040
BID FOR SALE OF SURPLUS PROPERTY
Item # County 10 # Description of Equipment Bid Price
1 0210-024 Computer I C: , ()Q
2 0211-038 NCR S-16 Tower Server -" ()O
.: 0,
3 0940-110 84 Ford F700 I
4 141906-3 94 Ford E350 Ambulance
5 1801-103 Dell Computer 3,DO
6 1801-105 Dell Computer 3, DO
7 1801-108 Dell Computer 3;00
8 1801-109 Dell Computer 3,00
9 1801-110 Dell Computer ]..{)O
" ,
.\ .
10 1801-111 Dell Co'mputer 3~OO
11 1801-113 Dell Computer 3~()O
12 1801-115 Dell Computer 3 ' DC)
13 1803-570 Dell Computer 3.00
14 1805-11 Dell Computer J ,(JQ
15 1809-018 Dell Computer 3 r C)Q
16 1809-019 Dell Computer :5 ,00
17 1810-042 Dell Computer .J ' [)()
18 0976-045 Paper Container
19 0977 -013 Paper Container
20 0977-014 Paper Container
21 0977-051 Paper Container
22 0977-050 Paper Container (15 yd)
23 0977 -045 20 yd roll off box
MONROE COUNTY PURCHASING OFFICE
11 00 SIMONTON STREET
KEY WEST, FLORIDA 33040
BID FOR SALE OF SURPLUS PROPERlY
24 0977-055 20 yd roll off box
25 0977-057 20 yd roll off box
26 0977-059 20 yd roll off box
27 0977 -094 20 yd roll off box
28 0977-095 20 yd roll off box
29 0977-058 30 yd roll off box (homemade)
30 0977 -063 30 yd roll off box (homemade)
31 0977-038 35' conveyor attached to 0977-134(see
below)
32 0977-134 International Harvester Baler wi
0977-038 (see above)
33 0977-'143 Metal Baler
.\
34 0977-155 Tire Slicer
35 0977-156 Wheel Crusher
~~~::~--~--L~L'~_l:~___~~~__L5C_~I(,?_______________________________
ADDREss:--2J./)-g----lJ~!LliL___!tt~1___Ko/-LJ~!.tfL.:1lP2()
PHONE:-]-Q-~:~_ZJ_=_Q_'L~_'i__________~1_~__:__'i~1_~L______________
FAJ(:__~_~~~~_~st_~~~_~~:t___________________________________________
FED ID NUMBER/55 NUMBER:___2-_22_=__1_t_=_~J_~&>__________________
-~~~~------------------------------------
AUTHORIZED SIGNATURE
MONROE COUNTY PURCHASING OFFICE
11 00 SIMONTON STREET
KEY WEST, FLORIDA 33040
BID FOR SALE OF SURPlUS PROPERTY
Item # County 10 # Description of Equipment Bid Price
1 0210-024 Computer
2 0211-038 NCR S-16 Tower Server
3 0940-11 0 84 Ford F700
4 141906-3 94 Ford E350 Ambulance
5 1801-103 Dell Computer
6 1801-105 Dell Computer
7 1801-108 Dell Computer
8 1801-109 Dell Computer
9 1801-110 Dell Computer
,
-1.
10 1801-111 Dell Computer
11 1801-113 Dell Computer
12 1801-115 Dell Computer
13 1803-570 Dell Computer
14 1805-11 Dell Computer
15 1809-018 Dell Computer
16 1809-019 Dell Computer
17 1810-042 Dell Computer
18 0976-045 Paper Container
19 0977-013 Paper Container
20 0977-014 Paper Container
21 0977-051 Paper Container
22 0977-050 Paper Container (15 yd)
23 0977 -045 20 yd roll off box
MONROE COUNlY PURCHASING OFFICE
11 00 SIMONTON STREET
KEY WEST, FLORIDA 33040
BID FOR SALE OF SURPLUS PROPERTY
24 0977-055 20 yd roll off box
25 0977-057 20 yd roll off box
26 0977 -059 20 yd roll off box I
I
27 0977 -094 20 yd roll off box
28 0977-095 20 yd roll off box
29 0977-058 30 yd roll off box (homemade)
30 0977 -063 30 yd roll off box (homemade)
- - i
( 3'y 0977-038 35' conveyor attached to 0977-134(See, JSI D Fo (2.. oW I
below) n
(V 0977-134 International Harvester Baler wi / Vfl5,DOO. ~
0977-038 (see above)
33 0977-143 Metal Baler "#'S 31,\ 3::l
,
.\
34 0977-155 Tire Sliter
35 0977-156 Wheel Crusher
..
BIDDERS
NAM E:___42JX~~__$-U-~~~-_.m..f}ci!.!t!g1?--'1_.:r-.n.c._:-_______
ADDREss:_3_Q-"-_~__iL~_;!?oJIQ_~~J-~r:LJJ~J________
PHONE:__~l~l]~_?-=-~'1:J.:L_________________________
F~:_~~!f2~_~_~~_~_~_~l_~_________________________________________________
FED I D N U M B ER/SS NUM BER:___l_QJ._lj__L9._<i~_~______________________________
---------------------------------------------------