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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! 'kM t.\n 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' ! j ~i it; CZ- 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~~~ ~~~ ~~~ ~~~ ~~~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~r:~~~~ ~ m~~ e~~m~~~~ ~ ~ ~ ~f.:dleCkei:i;::att2icb:on::"io.videf: Jeti:er.h:&.8d:a:Writtfm:~1 i;ies.C::: tlldlcatln' ::' : . . . ::ilew:b~~iness::: ^y<p: s' .~.. . !n.yo\Jt.t' :';'A~;';';';",:,ou;..,;c-:-:-:-:-:. .~:- .. . '''~''l-.&.~~I:,!,~:~~:~S:.;;,;':: ~~m~~~~~~m~~~~~~~~~~~~r~~t:: tbe:~er:m~st:be:notar.ited:::: ~. . . . . . . . . 6:(,;,.' . . .". . :'n.H<': . '0" .... ,Qr.: ~our.: .tl~:tc): ue: .~.\ot.<<te :::::::::: Witt.!:: . o~i: new: :atlar.esi(:::::::::::::::: ...........:~.........:.....:..::.. ........:........~.:.:.:.:.:::::.: 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 #: ~A/""'./ _ I- Z W ~ ~ ~ I- oe( ~ ~ 0 oe( W <;:? Cl.. Cl.. W ~ 0 ....-I ....-I CJz ~ I- ~H Cl.. oe( Zz V) N HW ::> 0 V)Cl.. -J oe(O Cl.. 0 ~ N ICJ ::> , \..)HV) 00 ~CO N ::>LLLL > Cl..OO C:l. ~ Cl..W oe( oe(-J ::> Z \..)oe( ~ ::> wV) CO 0 ~ W \..) WLL.. -J .. W I-W 0 J::~ C:l. z CJ 0 ~ ,.... ~ 0 Ln W ~ ~ ~ (V') - ~ ~ ..0 ~ 0 Ln W ~ ~ I- (V') ..0 H ~ ~ 10 ~ 0 Ln W ~ ~ I- (V') N H ~ ~ V) ~ CJ ~ H CO W 0 ~ Z . 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W o VI :.::i >- CO -0 t\l s::: t\l 0- o ""0 CO 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 $9..05 4$ jJ I. ....1' 0') _} l. __~ !. is- 4 o~ '---* I. .11 (, oS- ~ fe. C~J J (. d'~ jj ~ $ j I 0 S <.c. 05' \ . DS' \ . DC:; \ . fJ~ \ .aC;- 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~_~______________________________ ---------------------------------------------------