Item C15
p~
Louis LaTorre, Senior Director
Social Services/tabt
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
MEETING DATE: 5/15-16/02
DIVISION: COMMUNITY SERVICES
BULK ITEM:
YES X
NO
DEP ARTMENT: SOCIAL SERVICES
AGENDA ITEM WORDING: Approval for County Commissioner Mayor's signature on two forms that are
prerequisite to contract negotiations for the 7/1/02 thru 6/30/03 Community Care for Disabled Adults contract
between the State of Florida, Department of Children & Families and the Monroe County Board of County
Commissioners/Monroe County Social Services (Monroe County In Home Service Program, The Case
Management Agency).
ITEM BACKGROUND: The approval for signature of these documents is a prerequisite to contract
negotiations with the State of Florida, Department of Children & Families.
PREVIOUS RELEVANT BOCC ACTION: None
CONTRACT/AGREEMENT CHANGES: N/ A
STAFl<' IUX':OMMENDATION: Approval
TOTAL COST: N/A BUDGETED: YES_ NO
COST TO COUNTY: N/A
REVENUE PRODUCING: YES
NO-X- AMT.PERMONTH
YEAR
APPROVED BY: COUNTY A TTY.l OMB/Purchasing l RISK MANAGEMENT --X
DOCUMENTATION:
TO FOLLOW
NOT REQUIRED_
DIVISION DIRECTOR APPROVAL:
DISPOSITION:
AGENDA ITEM#: ~/~
.
Revised 2/27/01
Contract No.
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTSffiUBCONTRACTS
This certification is required by the regulations implementing Executive Order 12549, Debarment
and Suspension, signed February 18, 1986. The guidelines were published in the May 29, 1987
Federal Register (52 Fed. Reg., pages 20360 - 20369).
INSTRUCTIONS
1. Each provider whose contract/subcontract equals or exceeds $25,000 in federal monies must
sign this certification prior to execution of each contract/subcontract. Additionally, providers
who audit federal programs must also sign, regardless of the contract amount. Children &
Families cannot contract with these types of providers if they are debarred or suspended by
the federal government.
2. This certification is a material representation of fact upon which reliance is placed when this
contract/subcontract is entered into. If it is later determined that the signer knowingly rendered
an erroneous certification, the Federal Government may pursue available remedies, including
suspension and/or debarment.
3. The provider shall provide immediate written notice to the contract manager at any time the
provider learns that its certification was erroneous when submitted or has become erroneous
by reason of changed circumstances.
4. The terms "debarred", "suspended", "ineligible", "person", "principal", and "voluntarily
excluded", as used in this certification, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the
contract manager for assistance in obtaining a copy of those regulations.
5. The provider agrees by submitting this certification that, it shall not knowingly enter into any
subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract unless authorized by the Federal
Government.
6. The provider further agrees by submitting this certification that it will require each subcontractor
of this contract/subcontract, whose payment will equal or exceed $25,000 in federal monies,
to submit a signed copy of this certification.
7. The Department of Children and Families may rely upon a certification of a
provider that it is not debarred, suspended, ineligible, or voluntarily excluded from
contracting/subcontracting unless it knows that the certification is erroneous.
8. This signed certification must be kept in the contract manager's contract file. Subcontractor's
certifications must be ke t at the contractor's business location.
(1) The prospective provider certifies, by signing this certification, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this contract/subcontract by any federal department
or agency.
(2) Where the prospective provider is unable to certify to any of the statements in this
certification, such prospective provider shall attach an explanation to this certification.
Signature
Date
Name
r.hrlrlpc:: McCoy
Mrlynr
roe Count Board of
County Commissioners
l,t:.K Ilrll,A IIUN Kt:.lJAKUINlJ LU~t::S YINu
Attachment
CERTIFI~ATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE
AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or an employee of any agency,
a member of congress, an officer or employee of congress, or an employee of a member of
congress in connection with the awarding of any federal contract, the making of any federal
grant, the making of any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any federal contract, grant,
loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a member of
congress, an officer or employee of congress, or an employee of a member of congress in
connection with this federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in
accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than $10,000
and not more than $1 00,000 for each such failure.
Signature
Date
Charles McCoy
Name of Authorized Individual
Application or Contract Number
Monroe County Board of County
CA! !J It-
Name of Organization
1100 Simonton Street Key West FL 33040
Address of Organization
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