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02/13/2002 Agreement CLERK OF THE CIRCUIT COURT MONROE COUNTY BRANCH OFFICE MARATHON SUB COURTHOUSE 3117 OVERSEAS HIGHWAY MARATHON, FLORIDA 33050 TEL. (305) 289-6027 FAX (305) 289-1745 MONROE COUNTY COURTHOUSE 500 WHITEHEAD S1REET KEY WEST, FLORIDA 33040 TEL. (305) 292-3550 FAX (305) 295-3663 BRANCH OFFICE PLANTATION KEY GOVERNMENT CENTER 88820 OVERSEAS HIGHWAY PLANTATION KEY, FLORIDA 33070 TEL. (305) 852-7145 FAX (305) 852-7146 MEMORANDUM DATE: February 19,2002 TO: Louis Latorre, Director Social Services Division Pamela G. H~ Deputy Clerk V FROM: At the February 13, 2002, Board of County Commissioners meeting the Board granted approval and authorized execution of the 2002/2003 Low-Income Home Energy Assistance Program Federally Funded Subgrant Agreement, Contract No. 02EA-2J-II-54-01-018, between Monroe County and the Florida Department of Community Affairs. Enclosed are four duplicate originals, executed on behalf of Monroe County, for your handling. Please be sure that the fully executed "Clerk's Original" is returned as soon as possible. Should you have any questions please feel free to contact our office. Cc: County Administrator w/o document County Attorney Finance File I CLERK'S ORIGINAL L1HEAP FY 2002-2003 CONTRACT NUMBER: 02EA-2J-11-54-01-018 (March 1, 2002-March 31, 2003) CFDA NUMBER 93.568 LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM FEDERALLY FUNDED SUBGRANT AGREEMENT THIS AGREEMENT is entered into by and between the State of Florida, Department of Community Affairs, with headquarters in Tallahassee, Florida (hereinafter referred to as the "Department"), and MONROE COUNTY BOARD OF COUNTY COMMISSIONERS (hereinafter referred to as the "Recipient"). THIS AGREEMENT IS ENTERED INTO BASED ON THE FOLLOWING FACTS: A. WHEREAS, the Recipient represents that it is fully qualified and eligible to receive these grant funds to provide the services identified herein; and B. WHEREAS, the Department has received these grant funds from the federal government, and has the authority to sub-grant these funds to the Recipient upon the terms and conditions hereinafter set forth; and C. WHEREAS, the Department has authority pursuant to Florida law to disburse the funds under this Agreement. NOW, THEREFORE, the Department and the Recipient do mutually agree as follows: (1) SCOPE OF WORK The Recipient shall fully perform the obligations in accordance with the Scope of Work, Attachment A and Budget Summary and Workplan, Attachment H of this Agreement. (2) INCORPORATION OF LAWS. RULES. REGULATIONS AND POLICIES C. Both the Recipient and the Department shall be governed by applicable State and Federal laws, rules and regulations, including but not limited to those identified in Attachment B. (3) PERIOD OF AGREEMENT This Agreement shall begin upon execution by both parties or March 1. 2002. whichever is later, and shall end March 31. 2003. unless terminated earlier in accordance with the provisions of paragraph (9) of this Agreement. 1 (4) MODIFICATION OF CONTRACT: REPAYMENTS Either party may request modification of the provisions of this Agreement. Changes which are mutually agreed upon shall be valid only when reduced to writing, duly signed by each of the parties hereto, and attached to the original of this Agreement. All refunds or repayments to be made to the Department under this Agreement are to be made payable to the order of "Department of Community Affairs", and mailed directly to the Department at the following address: Department of Community Affairs Cashier Finance and Accounting 2555 Shumard Oak Boulevard Tallahassee FL 32399-2100 In accordance with 9 215.34(2), Fla. Stat.. if a check or other draft is returned to the Department for collection, the Department must add to the amount of the check or draft a service fee of Fifteen Dollars ($15.00) or Five Percent (5%) of the face amount of the check or draft, whichever is greater. (5) RECORDKEEPING (a) As applicable, Recipient's performance under this Agreement shall be subject to the federal "Common Rule: Uniform Administrative Requirements for State and Local Governments" (53 Federal Register 8034) or OMB Circular No. A-11 0, "Grants and Agreements with Institutions of High Education, Hospitals, and Other Nonprofit Organizations," and either OMB Circular No. A-87, "Cost Principles for State and Local Governments," OMB Circular No. A-21 , "Cost Principles for Educational Institutions," or OMB Circular No. A-122, "Cost Principles for Nonprofit Organizations." If this Agreement is made with a commercial (for-profit) organization on a cost-reimbursement basis, the Recipient shall be subject to Federal Acquisition Regulations 31.2 and 931.2. (b) All original records pertinent to this Agreement shall be retained by the Recipient for three years following the date of termination of this Agreement or of submission of the final close-out report, whichever is later, with the following exceptions: 2 1. If any litigation, claim or audit is started before the expiration of the three year period and extends beyond the three year period, the records will be maintained until all litigation, claims or audit findings involving the records have been resolved. 2. Records for the disposition of non-expendable personal property valued at $5,000 or more at the time of acquisition shall be retained for three years after final disposition. 3. Records relating to real property acquisition shall be retained for three years after closing of title. (c) All records, including supporting documentation of all program costs, shall be sufficient to determine compliance with the requirements and objectives of the Scope of Work, Attachment A, Budget Summary and Workplan, Attachment H and all other applicable laws and regulations. (d) The Recipient, its employees or agents, including all subcontractors or consultants to be paid from funds provided under this Agreement, shall allow access to its records at reasonable times to the Department, its employees, and agents. "Reasonable" shall be construed according to the circumstances but ordinarily shall mean during normal business hours of 8:00 a.m. to 5:00 p.m., local time, on Monday through Friday. "Agents" shall include, but not be limited to, auditors retained by the Department. (e) Any additional terms and conditions pertaining to Property Management and Procurement are set forth in forth in Attachment D of this Agreement. (6) REPORTS (a) At a minimum, the Recipient shall provide the Department with quarterly reports, and with a close-out report. (b) Quarterly reports are due to be received by the Department no later than 30 days after the end of each quarter of the program year and shall continue to be submitted each quarter until submission of the administrative close-out report. The ending dates for each quarter of the program year are March 30, June 30, September 30 and December 31. 3 (c) The close-out report is due 45 days after termination of this Agreement or upon completion of the activities contained in this Agreement. (d) If all required reports and copies, prescribed above, are not sent to the Department or are not completed in a manner acceptable to the Department, the Department may withhold further payments until they are completed or may take such other action as set forth in paragraph (9). The Department may terminate the Agreement with a Recipient if reports are not received within 30 days after written notice by the Department. "Acceptable to the Department" means that the work product was completed in accordance with generally accepted principles and is consistent with the Budget and Scope of Work. (e) Upon reasonable notice, the Recipient shall provide such additional program updates or information as may be required by the Department. (f) The Recipient shall provide additional reports and information as identified in Attachment C. (7) MONITORING The Recipient shall constantly monitor its performance under this Agreement to ensure that time schedules are being met, the Scope of Work and Budget Summary and Workplan is being accomplished within specified time periods, and other performance goals are being achieved. Such review shall be made for each function or activity set forth in Attachment A to this Agreement. (8) LIABILITY (a) Unless Recipient is a State agency or subdivision, the Recipient shall be solely responsible to parties with whom it shall deal in carrying out the terms of this agreement, and shall save the Department harmless against all claims of whatever nature by third parties arising out of the performance of work under this agreement. For purposes of this agreement, Recipient agrees that it is not an employee or agent of the Department, but is an independent contractor. (b) Any Recipient who is a state agency or subdivision, as defined in Section 768.28, Fla. Stat., agrees to be fully responsible to the extent provided by Section 768.28 Fla. Stat. for its negligent acts or omissions or tortious acts which result in claims or suits against the Department, and 4 agrees to be liable for any damages proximately caused by said acts or omissions. Nothing herein is intended to serve as a waiver of sovereign immunity by any Recipient to which sovereign immunity applies. Nothing herein shall be construed as consent by a state agency or subdivision of the State of Florida to be sued by third parties in any matter arising out of any contract. (9) DEFAULT: REMEDIES: TERMINATION (a) If the necessary funds are not available to fund this Agreement as a result of action by Congress, the state Legislature, the Office of the Comptroller or the Office of Management and Budgeting, or if any of the following events occur ("Events of Default"), all obligations on the part of the Department to make any further payment of funds hereunder shall, if the Department so elects, terminate and the Department may, at its option, exercise any of its remedies set forth herein, but the Department may make any payments or parts of payments after the happening of any Events of Default without thereby waiving the right to exercise such remedies, and without becoming liable to make any further payment: 1. If any warranty or representation made by the Recipient in this Agreement or any previous Agreement with the Department shall at any time be false or misleading in any respect, or if the Recipient shall fail to keep, observe or perform any of the terms or covenants contained in this Agreement or any previous agreement with the Department and has not cured such in timely fashion, or is unable or unwilling to meet its obligations thereunder; 2. If any material adverse change shall occur in the financial condition of the Recipient at any time during the term of this Agreement from the financial condition revealed in any reports filed or to be filed with the Department, and the Recipient fails to cure said material adverse change within thirty (30) days from the time the date written notice is sent by the Department. 3. If any reports required by this Agreement have not been submitted to the Department or have been submitted with incorrect, incomplete or insufficient information; 4. If the Recipient has failed to perform and complete in timely fashion any of the services required under the Scope of Work attached hereto as Attachment A and the Budget Summary and Workplan attached hereto as Attachment H. 5 (b) Upon the happening of an Event of Default, then the Department may, at its option, upon thirty (30) calendar days prior written notice to the Recipient and upon the Recipient's failure to timely cure, exercise anyone or more of the following remedies, either concurrently or consecutively, and the pursuit of anyone of the following remedies shall not preclude the Department from pursuing any other remedies contained herein or otherwise provided at law or in equity: 1. Terminate this Agreement, provided that the Recipient is given at least thirty (30) days prior written notice of such termination. The notice shall be effective when placed in the United States mail, first class mail, postage prepaid, by registered or certified mail-return receipt requested, to the address set forth in paragraph (10) herein; 2. Commence an appropriate legal or equitable action to enforce performance of this Agreement; 3. Withhold or suspend payment of all or any part of a request for payment; 4. Exercise any corrective or remedial actions, to include but not be limited to, requesting additional information from the Recipient to determine the reasons for or the extent of non- compliance or lack of performance, issuing a written warning to advise that more serious measures may be taken if the situation is not corrected, advising the Recipient to suspend, discontinue or refrain from incurring costs for any activities in question or requiring the Recipient to reimburse the Department for the amount of costs incurred for any items determined to be ineligible; 5. Exercise any other rights or remedies which may be otherwise available under law; (c) The Department may terminate this Agreement for cause upon such written notice as is reasonable under the circumstances. Cause shall include, but not be limited to, misuse of funds; fraud; lack of compliance with applicable rules, laws and regulations; failure to perform in a timely manner; and refusal by the Recipient to permit public access to any document, paper, letter, or other material subject to disclosure under Chapter 119, Fla. Stat.. as amended. 6 (d) Suspension or termination constitutes final agency action under Chapter 120, Fla. Stat.. as amended. Notification of suspension or termination shall include notice of administrative hearing rights and time frames. (e) In addition to any other remedies, the Recipient shall return to the Department any funds which were used for ineligible purposes under the program laws, rules, and regulations governing the use of the funds under the program. (f) This Agreement may be terminated by the written mutual consent of the parties. (g) Notwithstanding the above, the Recipient shall not be relieved of liability to the Department by virtue of any breach of Agreement by the Recipient. The Department may, to the extent authorized by law, withhold any payments to the Recipient for purpose of set-off until such time as the exact amount of damages due the Department from the Recipient is determined. (10) NOTICE AND CONTACT (a) All notices provided under or pursuant to this Agreement shall be in writing, either by hand delivery, or first class, certified mail, return receipt requested, to the representative identified below at the address set forth below and said notification attached to the original of this Agreement. (b) The name and address of the Department contract manager for this Agreement is: Ms. Hilda Frazier, Planning Manager Florida Department of Community Affairs Division of Housing and Community Development Bureau of Community Assistance 2555 Shumard Oak Boulevard Tallahassee, FI 32399-2100 Email: hilda.frazier@dca.state.fl.us (c) The name and address of the Representative of the Recipient responsible for the administration of this Agreement is stated in Recipient Information, Attachment G of this Agreement. (d) In the event that different representatives or addresses are designated by either party after execution of this Agreement, notice of the name, title and address of the new representative will be rendered as provided in (10)(a) above. 7 (11) OTHER PROVISIONS (a) The validity of this Agreement is subject to the truth and accuracy of all the information, representations, and materials submitted or provided by the Recipient in this Agreement, in any subsequent submission or response to Department request, or in any submission or response to fulfill the requirements of this Agreement, and such information, representations, and materials are incorporated by reference. The lack of accuracy thereof or any material changes shall, at the option of the Department and with thirty (30) days written notice to the Recipient, cause the termination of this Agreement and the release of the Department from all its obligations to the Recipient. (b) This Agreement shall be construed under the laws of the State of Florida, and venue for any actions arising out of this Agreement shall lie in Leon County. If any provision hereof is in conflict with any applicable statute or rule, or is otherwise unenforceable, then such provision shall be deemed null and void to the extent of such conflict, and shall be deemed severable, but shall not invalidate any other provision of this Agreement. (c) No waiver by the Department of any right or remedy granted hereunder or failure to insist on strict performance by the Recipient shall affect or extend or act as a waiver of any other right or remedy of the Department hereunder, or affect the subsequent exercise of the same right or remedy by the Department for any further or subsequent default by the Recipient. Any power of approval or disapproval granted to the Department under the terms of this Agreement shall survive the terms and life of this Agreement as a whole. (d) The Agreement may be executed in any number of counterparts, anyone of which may be taken as an original. (e) The Recipient agrees to comply with the Americans With Disabilities Act (Public Law 101-336,42 U.S.C. Section 12101 et seQ.), if applicable, which prohibits discrimination by public and private entities on the basis of disability in the areas of employment, public accommodations, transportation, State and local government services, and in telecommunications. (f) A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime or on the discriminatory vendor list rjpay not submit a bid on a 8 contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity, and may not transact business with any public entity in excess of Category Two for a period of 36 months from the date of being placed on the convicted vendor or discriminatory vendor list. (g) With respect to any Recipient which is not a local government or state agency, and which receives funds under this Agreement from the federal government, by signing this Agreement, the Recipient certifies, to the best of its knowledge and belief, that it and its principals: 1. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency; 2. have not, within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 3. are not presently indicted or otherwise criminally or civilly charged by a governmental entity (federal, state or local) with commission of any offenses enumerated in paragraph 11 (g)2. of this certification; and 4. have not within a three-year period preceding this Agreement had one or more public transactions (federal, state or local) terminated for cause or default. Where the Recipient is unable to certify to any of the statements in this certification, such Recipient shall attach an explanation to this Agreement. 9 (12) AUDIT REQUIREMENTS (a) The Recipient agrees to maintain financial procedures and support documents, in accordance with generally accepted accounting principles, to account for the receipt and expenditure of funds under this Agreement. (b) These records shall be available at all reasonable times for inspection, review, or audit by state personnel and other personnel duly authorized by the Department. "Reasonable" shall be construed according to circumstances, but ordinarily shall mean normal business hours of 8:00 a.m. to 5:00 p.m., local time, Monday through Friday. (c) The Recipient shall also provide the Department with the records, reports or financial statements upon request for the purposes of auditing and monitoring the funds awarded under this Agreement. (d) In the event that the Recipient expends $300,000 or more in Federal awards in its fiscal year, the Recipient must have a single or program-specific audit conducted in accordance with the provisions of OMS Circular A-133, as revised. In determining the Federal awards expended in its fiscal year, the Recipient shall consider all sources of Federal awards, including Federal funds received from the Department. The determination of amounts of Federal awards expended should be in accordance with the guidelines established by OMS Circular A-133, as revised. An audit of the Recipient conducted by the Auditor General in accordance with the provisions OMS Circular A-133, as revised, will meet the requirements of this part. In connection with the above audit requirements, the Recipient shall fulfill the requirements relative to auditee responsibilities as provided in Subpart C of OMS Circular A-133, as revised. If the Recipient expends less than $300,000 in Federal awards in its fiscal year, an audit conducted in accordance with the provisions of OMS Circular A-133, as revised, is not required. In the event that the Recipient expends less than $300,000 in Federal awards in its fiscal year and elects to have an audit conducted in accordance with the provisions of OMS Circular A-133, as revised, the cost of the audit must be paid from non-Federal funds (i.e., the cost of such an audit must be paid from Recipient funds obtained from other than Federal entities). 10 1. The annual financial audit report shall include all management letters and the Recipient's response to all findings, including corrective actions to be taken. 2. The annual financial audit report shall include a schedule of financial assistance specifically identifying all Agreement and other revenue by sponsoring agency and Agreement number. 3. Copies of audit reports for audits conducted in accordance with OMB Circular A-133, as revised, and required by subparagraph (d) above shall be submitted, when required by Section .320 (d), OMB Circular A-133, as revised, by or on behalf of the Recipient directlv to each of the following: (a) The State of Florida at each of the following addresses: Department of Community Affairs Office of Audit Services 2555 Shumard Oak Boulevard Tallahassee, Florida 32399-2100 and State of Florida Auditor General Attn: Ted J Sauerbeck Room 574, Claude Pepper Building 111 West Madison Street Tallahassee, Florida 32302-1450 (b) The Federal Audit Clearinghouse designated in OMB Circular A-133, as revised (the number of copies required by Sections .320(d)(1) and (2), OMB Circular A-133, as revised, should be submitted to the Federal Audit Clearinghouse), at the following address: Federal Audit Clearinghouse Bureau of the Census 1201 East 101h Street Jeffersonville, IN 47132 (c) Other Federal agencies and pass-through entities in accordance with Sections .320 (e) and (f), OMB Circular A-133, as revised. 11 4. In the event that a copy of the audit report for an audit required by subparagraph (d) above and conducted in accordance with OMB Circular A-133, as revised, is not required to be submitted to the Department for the reasons pursuant to Section .320(e)(2), OMB Circular A-133, as revised, the Recipient shall submit the required written notification pursuant to Section .320(e)(2) and a copy of the Recipient's audited schedule of expenditures of Federal awards directlv to each of the following (If the State agency, pursuant to Section .320(f), OMB Circular A-133, wants a copy of the reporting package described in Section .320(c) and/or a management letter, the State agency should replace the above language with the following language). Pursuant to Section .320(f), OMB Circular A- 133, as revised, the Recipient shall submit a copy of the reporting package described in Section .320(c), OMB Circular A-133, as revised, and any management letters issued by the auditor, to the Department at the following program address: Department of Community Affairs 2555 Shumard Oak Boulevard Tallahassee, Florida 32399-2100 (e) In the event the audit shows that the entire funds disbursed hereunder, or any portion thereof, were not spent in accordance with the conditions of this Agreement, the Recipient shall be held liable for reimbursement to the Department of all funds not spent in accordance with these applicable regulations and Agreement provisions within thirty (30) days after the Department has notified the Recipient of such non-compliance. (f) The Recipient shall retain all financial records, supporting documents, statistical records, and any other documents pertinent to this contract for a period of three years after the date of submission of the final expenditures report. However, if litigation or an audit has been initiated prior to the expiration of the three-year period, the records shall be retained until the litigation or audit findings have been resolved. (g) The Recipient shall have all audits completed by an independent certified public accountant (IPA) who shall either be a certified public accountant or a public accountant licensed under Chapter 473, Fla. Stat. The IPA shall state that the audit complied with the applicable provisions noted above. 12 (h) The audit is due seven (7) months after the end of the fiscal year of Recipient or by the date the audit report is issued by the state Auditor General, whichever is later. (i) An audit performed by the State Auditor General shall be deemed to satisfy the above audit requirements. (13) SUBCONTRACTS (a) If the Recipient subcontracts any or all of the work required under this Agreement, a copy of the executed subcontract must be forwarded to the Department within thirty (30) days after execution of the subcontract. The Recipient agrees to include in the subcontract that (i) the subcontractor is bound by all applicable state and federal laws and regulations, and (ii) the subcontractor shall hold the Department and Recipient harmless against all claims of whatever nature arising out of the subcontractor's performance of work under this Agreement, to the extent allowed and required by law. (14) TERMS AND CONDITIONS The Agreement contains all the terms and conditions agreed upon by the parties. (15) ATTACHMENTS. (a) All attachments to this Agreement are incorporated as if set out fully herein. (b) In the event of any inconsistencies or conflict between the language of this Agreement and the attachments hereto, the language of such attachments shall be controlling, but only to the extent of such conflict or inconsistency. (c) This Agreement has the following attachments: A. Scope of Work B. Program Statutes and Regulations C. Reports D. Property Management and Procurement E. Statement of Assurances F. Special Conditions G. Recipient Information 13 H. Budget Summary and Workplan I. Budget Detail J. Multi-County Fund Distribution K. Justification of Advance Payment (16) FUNDING/CONSIDERATION (a) This is a cost-reimbursement Agreement. The Recipient shall be reimbursed for costs incurred in the satisfactory performance of work hereunder in an amount not to exceed $72.905 subject to the availability of funds. (b) Any advance payment under this Agreement is subject to s. 216.181(16), Florida Statutes. The amount which may be advanced may not exceed the expected cash needs of the Recipient within the first three (3) months, based upon the funds being equally disbursed throughout the contract term. For a federally funded contract, any advance payment is also subject to federal OMB Circulars A-87, A-110, A-122 and the Cash Management Improvement Act of 1990. If an advance payment is requested, the budget data on which the request is based and a justification statement shall be included in this Agreement as Attachment K. Attachment K will specify the amount of advance payment needed and provide an explanation of the necessity for and proposed use of these funds. (c) After the initial advance, if any, payment shall be made on a reimbursement basis as needed. The Recipient agrees to expend funds in accordance with the Scope of Work, Attachment A of this Agreement and the Budget Summary and Workplan, Attachment H of this Agreement. Fixed Fee Agreements: (17) STANDARD CONDITIONS The Recipient agrees to be bound by the following standard conditions: (a) The State of Florida's performance and obligation to pay under this Agreement is contingent upon an annual appropriation by the Legislature, and subject to any modification in accordance with Chapter 216, Fla. Stat. or the Florida Constitution. 14 (b) If otherwise allowed under this Agreement, the Agreement may be renewed on a yearly basis for period of up to two (2) years after the initial agreement or for a period no longer than the yearly basis for a period term of the original agreement, whichever period is longer, specifying the terms under which the cost may change as determined in the invitation to bid, request for proposals, or pertinent statutes or regulations. (c) All bills for fees or other compensation for services or expenses shall be submitted in detail sufficient for a proper preaudit and postaudit thereof. (d) If otherwise allowed under this Agreement, all bills for any travel expenses shall be submitted in accordance with Section 112.061, Fla. Stat. (e) The Department of Community Affairs reserves the right to unilaterally cancel this Agreement for refusal by the Recipient to allow public access to all documents, papers, letters or other material subject to the provisions of Chapter 119, Fla. Stat.. and made or received by the Recipient in conjunction with this Agreement. (f) If the Recipient is allowed to temporarily invest any advances of funds under this Agreement, any interest income shall either be returned to the Department or be applied against the Department's obligation to pay the contract amount. (g) The State of Florida will not intentionally award publicly-funded contracts to any contractor who knowingly employs unauthorized alien workers, constituting a violation of the employment provisions contained in 8 U.S.C. Section 1324a(e) [Section 274A(e) of the Immigration and Nationality Act (UlNA")). The Department shall consider the employment by any contractor of unauthorized aliens a violation of Section 274A(e) of the INA. Such violation by the Recipient of the employment provisions contained in Section 274A(e) of the INA shall be grounds for unilateral cancellation of this Agreement by the Department. (18) LOBBYING PROHIBITION (a) No funds or other resources received from the Department in connection with this Agreement may be used directly or indirectly to influence legislation or any other official action by the Florida Legislature or any state agency. 15 (b) The Recipient certifies, by its signature to this Agreement, that to the best of his or her knowledge and belief: 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 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 representative 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 $100,000 for each such failure. 16 (19) ASSURANCES The Recipient shall comply with any Statement of Assurances incorporated as Attachment E. (20) BUDGET SUMMARY AND SCOPE OF WORK CERTIFICATION The Recipient certifies that the data in Attachment H of this Agreement and its various data, including budget data, are true and correct to the best of its knowledge and that the filing of this attachment has been duly authorized and understands that it will become part of the Agreement between irley W. C lins, Director Division of ousing and Community Development Date: o/a;ftr- the Department and the Recipient. (21) LEGAL AUTHORIZATION The Recipient certifies with respect to this Agreement that it possesses the legal authority to receive the funds to be provided under this Agreement and that, if applicable. its governing body has authorized, by resolution or otherwise, the execution and acceptance of this Agreement with all covenants and assurances contained herein. The Recipient also certifies that the undersigned possesses the authority to legally execute and bind Recipient to the terms of this Agreement. IN WITNESS WHEREOF, the parties hereto have caused this contract to b~ executed by their undersigned officials as duly authorized. RECIPIENT STATE OF FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS Monroe BY: Date: -~ '::J 0 :<<: J> ;-.g ~ :;;: rt""i :.~ =2 (-) . r- c:: s: . ~~~ ;:0 ;-~ ~~ CJ CJr- :<,...,::r: .". ~. r- C".) l> ITl 17 1'..) N Q "-> C-'!'t C::) 1'-.-' ~ -;;;;) N lV ..." r- f"1'1 CJ ..." Q ;;0 -u 3: ::T.J P"1 o o :;0 o L1HEAP ATTACHMENT A SCOPE OF WORK The Recipient shall utilize the funds provided under this Agreement to: A. Conduct outreach activities designed to ensure that eligible households, especially households with elderly individuals or disabled individuals, or both, are made aware of the assistance available under this Agreement. B. Coordinate services between programs for potential clients living in the service area, with the Department's Weatherization Assistance Programs and Emergency Home Energy Assistance for the Elderly Program (EHEAP) providers. C. Provide assistance to clients in completing state provided applications for assistance in determining eligibility. D. Make home visits or conduct telephone interviews to home-bound clients, especially the elderly or disabled, for completion of the program application or eligibility determination when other assistance is not adequate. E. Make L1HEAP home energy assistance payments based on a state-provided payment matrix and worksheet. The payment amount is based on the household's income level as compared to the national poverty guidelines. This takes into account both gross income and family size. The lower the income, the higher the benefit level. F. Make vendor payments directly to fuel providers or recipients on behalf of eligible clients, or in instances where vendor agreements cannot be negotiated, make payments directly to clients in the form of a one or two party check. G. Determine the correct amount of each crisis benefit based on the minimum necessary to resolve the crisis, but not more than the maximum per household and maximum per item limits set by the Department. H. Establish Memoranda of Agreement with service area Emergency Home Energy Assistance for the Elderly Program (EHEAP) providers. The Agreement will ensure coordination of services, avoid duplication of assistance, and increase the quality of services provided to elderly participants 18 L1HEAP ATTACHMENT A SCOPE OF WORK I. Check L1HEAP records and Emergency Home Energy Assistance for the Elderly Program (EHEAP) records (for households with elderly members) to avoid duplicate crisis assistance payments during the same heating or cooling season. J. When the applicant is not in a life threatening situation, take actions that will resolve an emergency within 48 hours of the application approval for a crisis benefit. K. When the applicant is in a life threatening situation, take actions that will resolve an emergency situation within 18 hours of the application approval for a crisis benefit. L. The Recipient will make home energy payments within 45 days of the date all requested information is received. M. The Recipient will, within 15 working days of receiving the client's application, furnish in writing to all applicants a Notice of Approval which includes the type and amount of assistance to be paid on their behalf or a Notice of Denial which includes appeal information. N. Recipients are required to have written applicant appeal procedures. Any applicant denied L1HEAP services must be provided a written notice of the denial which includes the appeal process and the reason(s) for the denial. At a minimum, the written Notice of Denial and Appeals shall contain the reason for the denial, under what circumstances the client may reapply, what information or documentation is needed for the person to reapply, the name and address to whom the re-application or appeal should be sent, and the phone number of the Recipient. Appeal provisions must be posted in a prominent place within the office where it is on view for all applicants. O. The Recipient will make payments to those applicants with the "highest home energy needs and lowest household income," which will be determined by taking into account both the energy burden and the unique situation of such households that results from having members of vulnerable populations, including very young children, the disabled, and frail older individuals. 19 L1HEAP ATTACHMENT A SCOPE OF WORK P. Recipients serving multi-county areas must provide the Department with a description of how direct client assistance funds will be allocated among the counties. The allocation methodology must be based at least in part on poverty population within each of the counties served. This information must be reported in Attachment J to this Agreement. a. When L1HEAP funds are not available or are insufficient to meet the emergency home energy needs of an applicant, the Recipient will assist the applicant to secure help through other community resources. R. The Recipient shall agree to treat owners and renters equitably under the agreement. S. The Recipient shall be responsible for entering into written agreements with home energy suppliers which include all of the following requirements: (1) Provisions to assure that no household receiving assistance will be treated adversely because of such assistance under applicable provisions of state law or public regulatory requirements. (2) Any home energy supplier receiving direct payments agrees not to discriminate, either in the cost of goods supplied or the services provided, against the eligible household on whose behalf payments are made. (3) Only energy related elements of a utility bill are to be paid. In no instance may water and sewage charges be paid except if required by the vendor under the crisis category to meet the requirement of resolving the crisis. Vendors must be made aware that those charges are the responsibility of the client. (4) The Recipient shall make vendors aware that when the benefit amount to the client does not pay for the complete charges owed by a client, that the client is responsible for the remaining amount owed. 20 LIHEAP ATTACHMENT A SCOPE OF WORK T. The Recipient will be responsible for determining the eligibility of the clients applying for the L1HEAP program and its crisis components. Client eligibility is based on the following eight factors: (1) The Recipient may only assist households who are or were residing in their L1HEAP service area at the time the home energy costs were incurred. (2) The client must complete an application and return all required information and verification to the Recipient while funds remain available. (3) The client must provide a fuel bill for home energy or provide other documentation proving an obligation to pay for home energy costs. (4) The client must have a total household income of not more than 150% of the OMB federal poverty level for their household's size. (5) Applicants receiving Food Stamps or have applied for and are currently eligible for Weatherization Assistance Program (WAP) and Community Services Block Grant (CSBG) funds automatically qualify for L1HEAP, however, the benefit levels are the same as other qualified applicants. (6) The client must have a verifiable home energy crisis (crisis component). (7) The client must not live in government subsidized housing projects where home heating and cooling costs are totally included in their rent and they have no obligation to pay any portion of the home heating and cooling costs. (8) The client must not reside in a group living facility or a home where the cost of residency is at least partially paid through any foster care or residential program administered by the state. (9) The client must not be a student living in a dormitory. U. OTHER SPECIAL REQUIREMENTS (1) The Recipient shall ensure that no person shall be excluded from participation in any activity of the program on the grounds of race, color, national origin, sex or age, and such person shall not be subjected to discrimination under any activity funded in whole or in part with these funds. 21 L1HEAP ATTACHMENT A SCOPE OF WORK (2) The Recipient will define what criteria and verification will be used in its local area to determine if a household is in danger of losing home energy. This criteria must be set in a manner to encourage households to seek assistance prior to incurring non-energy penalties such as disconnecUreconnect fees, additional deposit, interest or late payment penalties, etc. (3) The Recipient will not charge applicants a fee or accept donations from an applicant to provide L1HEAP benefits. (4) The Recipient will be in a location and operate during hours available-to clients. (5) The Recipient will refund, with non-federal funds, to the Department all funds incorrectly paid on behalf of clients that cannot be collected from the client. (6) The Recipient will have appropriate staff attend training sessions, as scheduled by the Department to cover L1HEAP policies and procedures. (7) The Recipient will furnish training for all staff members assigned responsibilities for the program. (8) The Recipient will add information such as the Recipient's name, address, and times of operation to the forms provided by the Department or similar Recipient-developed forms and duplicate as needed. (9) The Recipient will provide information to local media and agencies in contact with low- income individuals announcing the beginning of both the crisis program component and the heating and cooling assistance program with information stating how, where, and when to apply, as well as the benefits available and eligibility criteria. (10) The Recipient will take applications when it has a signed Agreement and adequate funding, and continue taking applications until the Agreement expires or funds are exhausted. 22 L1HEAP ATTACHMENT A SCOPE OF WORK (11) The Recipient must have adequate procedures in place to ensure that L1HEAP funds are appropriately budgeted and expended to sufficiently allow for energy assistance benefits in both the heating and cooling seasons. (12) The Recipient will operate both program components in a manner that makes them available to all potentially eligible clients in their service area. (13) Prior to July 1, 2002, the Recipient shall submit to the Department a Performance Plan. This plan shall include performance measures, performance goals, specific actions to be taken by the Recipient to achieve these goals, and identify data sources and methods for measuring the results for the contract period. Once approved by the Department, the Performance Plan shall become part of this Agreement. (14) The Recipient shall secure and maintain an internet computer service and notify the Department of their e-mail address. 23 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS A INCORPORATION OF LAWS. RULES. REGULATIONS AND POLICIES The applicable documents governing service provision regulations are in the Common Rule, 45 CFR Part 74,76 and 92, or OMB Circular No. A-110, "Grants and Agreements with Institutions of Higher Education, Hospitals, and Other Nonprofit Organizations," and either OMB Circular No. A-87, "Cost Principles for State and Local Governments," OMB Circular No. A-21 , "Cost Principles for Educational Institutions," or OMB Circular No. A-122, "Cost Principles for Nonprofit Organizations," and OMB Circular A-133, "Audits of States, Local Governments, and Non-Profit Organizations." If this Agreement is made with a commercial (for-profit) organization on a cost-reimbursement basis, the Recipient shall be subject to Federal Acquisition Regulations 31.2 and 931.2. Low-Income Home Energy Assistance Act of 1981 (Title XXVI of the Omnibus Budget Reconciliation Act of 1981, Public Law 97-35) as amended and the L1HEAP Manual. The following Federal Department of Health and Human Services regulations codified in Title 45 of the Code of Federal Regulations are also applicable under this agreement: 1. Part 16 - Department Grant Appeals Board 2. Part 30 - Claims Collection 3. Part 75 - Informal Grant Appeals Procedure 4. Part 76 - Debarment and Suspension from Eligibility for Financial Assistance Subpart F. Drug-Free Workplace. 5. Part 80 - Nondiscrimination under programs receiving Federal assistance through the Department of Health and Human Services (HHS) effectuation of Title VI of the Civil Rights Act of 1964. 6. Part 81 - Practice and procedure for hearings under Part 80 of this title. 7. When the applicant is not in a life threatening situation, take actions that will resolve an emergency within 48 hours of the application approval for a crisis benefit. 24 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS 8. Part 84 - Nondiscrimination on the basis of handicap in programs and activities receiving Federal financial assistance. 9. Part 86 - Nondiscrimination on the basis of sex in education programs and activities receiving Federal financial assistance 10. Part 91 - Nondiscrimination on the basis of age in HHS programs or activities receiving Federal financial assistance 11. Part 93 - New restrictions on lobbying 12. Part 96 - Block Grants. 13. Consolidation of grants to the insular areas B. PROJECTS OR PROGRAMS FUNDED IN WHOLE OR PART WITH FEDERAL MONEY The Recipient assures, as stated in Section 508 of Public Law 103-333, that all statements, press releases, requests for proposals, bid solicitations and other documents describing projects or programs funded in whole or in part with Federal money, all grantees receiving Federal funds, including but not limited to State and local governments and recipients of Federal research grants, shall clearly state: (1) the percentage of the total costs of the program or project which will be financed with Federal money, (2) the dollar amount of Federal funds for the project or program, and (3) percentage and dollar amount of the total costs of the project or program that will be financed by non-governmental sources. C. INTEREST FROM CASH ADVANCES Recipients shall invest cash advances in compliance with section .21 (h) (2) (i) of the Common Rule and section .22 of OMB Circular A-11 0 as revised. Recipients shall maintain advances of Federal funds in interest-bearing accounts unless (1), (2), or (3) apply: NON-PROFITS ONLY: 1. The Recipient receives less than $120,000 in Federal awards per year. 2. The best reasonably available interest bearing account would not be expected to earn interest in excess of $250 per year on Federal cash balances. 25 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS 3. The depository would require an average or minimum balance so high that it would not be feasible within the expected Federal and non-Federal cash resource. Interest earned oft cash advances shall be reflected on the monthly financial status report and the close-out report. LOCAL GOVERNMENTS ONLY: Except for interest earned on advance of funds exempt under the inter-governmental Cooperation Action (31 U.S.C 6501 et. seq.) and the Indian Self-Determination Act (23 U.S.C. 450), grantees and sub-grantees shall promptly, but at least quarterly, remit interest earned on advances to the Federal agency. The grantee or sub-grantee may keep interest amounts up to $100 per year for administrative expenses. D. PROGRAM INCOME The Recipient may reapply program income for eligible program projects or objectives. The amount of program income and its disposition must be reported to the Department at the time of submission of the final close-out report. E. MODIFICATIONS (1) The Department shall not be obligated to reimburse the Recipient for outlays in excess of the funded amount of this Agreement unless and until the Department officially approves such expenditures by executing a written modification to the original Agreement. (2) Either party may request modification of the provisions of this Agreement. Changes which are mutually agreed upon, with the exception of the items listed in (3) below, shall be valid only when reduced to writing, duly signed by each of the parties hereto, and attached to the original of this Agreement. (3) The line item budget, as given in Attachment I of this Agreement and reported on the quarterly financial status reports may not be altered without a written budget modification with the exceptions of the items listed below: 26 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS (a) The Recipient may transfer unobligated budgeted line items within a budget category as long as the budget category subtotal remains the same. Each line item must meet all contractual budget requirements. For the purpose of transferring funds, the following are considered budget categories: Administrative Expenses, Outreach Expenses, Direct Client Assistance, and Leveraging Expenses. (b) Any and all Administrative Expenses and Outreach Expenses may be transferred to any Direct Client Assistance line item without additional written authorization. Each line item must meet all contractual budget requirements. (c) A letter of explanation and a revised budget summary and workplan page must be provided to the Department for any line item changes prior to the submission of a financial status report in which the changes are implemented. This is not a formal modification, but will provide the Department with advance notice and a description of information concerning your budget revisions. (d) None of the budget transfers may violate this Agreement or OMB Circulars A-110, Common Rule, A-121 or A-87. Your information will be reviewed by the Department for compliance with these circulars. (4) All requests for formal modifications must be submitted to the Department for approval in writing at least thirty (30) days prior to the anticipated implementation date. The Recipient must use a L1HEAP modification package, approved by the Department, which includes an amended budget summary and workplan page and amended budget detail page. (5) Only unobligated funds may be transferred from one line item to another line item. F. BONDING (1) Non-Profit Oraanizations: The Recipient agrees to purchase a blanket fidelity bond covering all officers, employees and agents of the Recipient holding a position of trust and authorized to handle funds received or disbursed under this Agreement. Individual bonds apart from the blanket bond are not acceptable. The amount of the bond must cover each officer, employee or agent up to an amount equal to at least one-half of the total L1HEAP contract amount. 27 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS (2) Local Governments: The Recipient agrees to purchase a fidelity bond in accordance with Section 113.07, Fla. Stat. The fidelity bond must cover all officers, employees and agents of the Recipient holding a position of trust and authorized to handle funds received or disbursed under this Agreement. G. MONITORING (1) The Recipient shall allow the Department to carry out monitoring, evaluation and technical assistance and shall ensure the cooperation of its employees, and of any subrecipients with whom the Recipient contracts to carry out program activities. (2) Training and technical assistance shall be provided by the Department, within limits of staff time and budget, upon request by the Recipient and/or upon determination by the Department of Recipient need. H. OTHER PROVISIONS (1) The Recipient must budget a minimum of twenty-five (25) percent of the total Agreement funds for Home Energy Assistance. (2) The Recipient must budget a minimum of two (2) percent of the total Agreement funds for Weather Related/ Supply Shortage emergency assistance. These funds must be held in this budget line item category until December 15 of the program year for use in response to a possible disaster. These funds will only be used during state or federal emergencies declared by the President, the Governor or the Secretary of the Department as he/she deems necessary. In the event of emergency being officially declared, if the Recipient or the Department finds that two percent of the budget is not sufficient to meet the emergency, the Recipient may draw on other Agreement categories, up to fifty percent (50%) of the total Agreement budget, without additional written authorization. After December 15, if no emergency has been declared, the Recipient may allocate these funds to the crisis or the home energy category of the program without additional written authorization from the Department. When funds are distributed for a weather-related/supply shortage emergency, the Department will provide binding directives as to the allowable expenditures of the funds. The Recipient will comply with these directives or agree that these funds will remain with the Department. 28 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS (3) In addition to the audit and record keeping requirements contained in Section (12) of this Agreement, the books, records, and documents required under this Agreement must also be available for copying and mechanical reproduction on or off the premises of the Recipient. (4) If the U.S. Department of Health and Human Services initiates a hearing regarding the expenditure of funds provided under this Agreement, the Recipient shall cooperate with, and upon written request, participate with the Department in the hearing. A. As applicable, Recipient's performance under this Agreement shall be subject to the Common Rule, 45 CFR Part 74,76 and 92 or OMS Circular No. A-110, "Grants and Agreements with Institutions of Higher Education, Hospitals, and Other Nonprofit Organizations," and either OMB Circular No. A-87, "Cost Principles for State and Local Governments," OMS Circular No. A-21 , "Cost Principles for Educational Institutions," or OMS Circular No. A-122, "Cost Principles for Nonprofit Organizations," If this Agreement is made with a commercial (for-profit) organization on a cost-reimbursement basis, the Recipient shall be subject to Federal Acquisition Regulations 31.2 and 931.2. B. All original records pertinent to this Agreement shall be retained by the Recipient for three years following the date of termination of this Agreement or of submission of the final close-out report, whichever is later, with the following exceptions: (1) If any litigation, claim or audit is started before the expiration of the three year period and extends beyond the three year period, the records will be maintained until all litigation, claims or audit findings involving the records have been resolved. (2) Records for the disposition of non-expendable personal property valued at $1,000 or more at the time of acquisition shall be retained for three years after final disposition. (3) Records relating to real property acquisition shall be retained for three years after closing of title. C. All records, including supporting documentation of all program costs, shall be sufficient to determine compliance with the requirements and objectives of the Scope of Work, Attachment A, and all other applicable laws and regulations. 29 L1HEAP ATTACHMENT B PROGRAM STATUTES AND REGULATIONS D. The Recipient, its employees or agents, including all subrecipients or consultants to be paid from funds provided under this Agreement, shall allow access to its records at reasonable times to the Department, its employees, and agents. "Reasonable" shall be construed according to the circumstances but ordinarily shall mean during normal business hours of 8:00 a.m. to 5:00 p.m., local time, on Monday through Friday. "Agents" shall include, but not be limited to, auditors retained by the Department. 30 L1HEAP ATTACHMENT C REPORTS A. Annual reports - Within 45 days after the end of the contract the Recipient shall submit a L1HEAP Close-out Report, including the L1HEAP Final Financial Report, a refund check for any unspent funds, and the L1HEAP Final Program Report. B. Monthly reports - The L1HEAP Monthly Financial Status Report must be provided to the Department by no later than the twenty-first (21 st) of each month following the end of the reporting month in which funds were expended. C. Quarterly Reports - For each county the Recipient serves, the L1HEAP Household Quarterly Program Report must be provided to the Department by no later than the twenty-first (21st) of the month following the end of the last month of the quarterly reporting period. D. Upon reasonable notice, the Recipient shall provide such additional program updates or information as may be required by the Department, including supporting or source documentation for any reports identified above in this section. The reports shall be submitted to: Ms. Hilda Frazier, Planning Manager Florida Department of Community Affairs Division of Housing & Community Development Bureau of Community Assistance 2555 Shumard Oak Boulevard Tallahassee, FL 32399-2100 31 L1HEAP ATTACHMENT D PROPERTY MANAGEMENT AND PROCUREMENT A. All such property purchased under this Agreement shall be inventoried annually and an inventory report shall be submitted to the Department as part of the close-out report. B. All property purchased under this Agreement shall be listed on the property records of the Recipient. Said listing shall include a description of the property, model number, manufacturer's serial number, funding source, information needed to calculate the federal and/or state share, date of acquisition, unit cost, property inventory number and information on the location, use and condition, transfer, replacement or disposition of the property. C. Title (Ownership) to all nonexpendable property acquired with funds from this Agreement shall be vested in the Department upon completion or termination of the Agreement. The Recipient agrees to comply with Section 507 of Public Law 103-333. As stated in this section, it is the sense of Congress that, to the extent practicable, all equipment and products purchased with funds made available in this Act should be American made. D. The Recipient agrees to comply with Section 507 of Public Law 103-333. As stated in this section, it is the sense of Congress that, to the extent practicable, all equipment and products purchased with funds made available in this Act should be American made. 32 L1HEAP ATTACHMENT E STATEMENT OF ASSURANCES A. Interest of Certain Federal Officials No member of or delegate to the Congress of the United States, and no Resident Commissioner, shall be admitted to any share or part of this Agreement or to any benefit to arise from the same. B. Interest of Members. Officers. or Emplovees of Recipient. Members of Local GoverninQ Bodv. or Other Public Officials No member, officer, or employee of the Recipient, or its delegates or agents, no member of the governing body of the locality in which the program is situated, and no other public official of such locality or localities who exercises any functions or responsibilities with respect to the program during his tenure or for one year thereafter, shall have any interest, direct or indirect, in any contract or subcontract, or the proceeds thereof, for work to be performed in connection with the program assisted under this Agreement. The Recipient shall incorporate or cause to be incorporated in all such Agreements, a provision prohibiting such interest pursuant to the purposes of this subsection. No board member, officer or employee will be permitted to receive any remuneration or gift in any amount. Board members may receive travel expenses in accordance with s. 112.9061, Florida Statutes. C. Nepotism The Recipient agrees to abide by the provisions of s. 112.3125, Florida Statutes. pertaining to nepotism in their performance under this Agreement. D. L1HEAP Assurances The Recipient hereby assures and certifies as a condition of receipt of Low Income Home Energy Assistance Program funds, that it and its subrecipients will comply with the applicable requirements of Federal and State laws, rules, regulations, and guidelines. As part of its acceptance and use of L1HEAP funds, the Recipient assures and certifies that: (1) The Recipient possesses the legal authority to apply for the grant, and that the contract proposal has been approved by the Recipient's governing body, including all assurances contained herein. 33 L1HEAP ATTACHMENT E STATEMENT OF ASSURANCES (2) The Recipient possesses the sound controls and fund accounting procedures necessary to adequately safeguard the assets of the agency, check the accuracy and reliability of accounting data, promote operating efficiency and maintain compliance with prescribed management policies of the agency. (3) The Recipient will permit and cooperate with Federal and State investigations designed to evaluate compliance with the law. (4) The Recipient will give the Department, the Auditor General or any authorized representatives, complete access to examine all records, books, papers or documents related to all program operations of the grant, including those of any sub-recipient. (5) The Recipient will comply with non-discrimination provisions, in accordance with Florida Statutes; Section 677 of P.L. 97-35; Titles VI and VII of the Civil Rights Act of 1964; and 45 C.F.R. Parts 84, 86 and 90. (6) The Recipient will comply with section 680 of Public Law 97-35, as amended, which prohibits use of L1HEAP funds for purchase or improvement of land, or the purchase, construction, or permanent improvement of any building or other facility. (7) The L1HEAP application and all its attachments, including budget data, are true and correct. (8) The Recipient will prohibit any political activities in accordance with Section 678F(b) of 42 USC 9918, as amended. (9) This Agreement has been approved by the Recipient's governing body by official action, and the officer who signs it is duly authorized to sign this Agreement. (10) The Recipient agrees to comply with Public Law 103-227, Part C, Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act). This Act requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through States or local governments. Federal programs include grants, cooperative agreements, loans or loan guarantees, and contracts. The law does not apply to children's services provided in private residences, facilities funded solely by 34 L1HEAP ATTACHMENT E STATEMENT OF ASSURANCES Medicare or Medicaid funds, and portions of facilities used for inpatient drug and alcohol treatment. The Recipient further agrees that the above language will be included in any subawards which contain provisions for children's services and that all subrecipients shall certify compliance accordingly. Failure to comply with the provisions of this law may result in the imposition of a civil monetary penalty of up to $1,000 per day. (11) The Recipient shall assure that all parts of their service area have toll-free telephone access to the agency during all normal working hours. This may be achieved by use of a published and publicized local outreach office number when the outreach office is open a minimum of 40 hours per week, or toll-free telephone number. 35 L1HEAP ATTACHMENT F SPECIAL CONDITIONS A. The Recipient and its subrecipients shall comply with the following special conditions: NONE B. Failure of the Recipient or its subrecipients to comply with the special conditions under this Agreement shall be cause for the immediate suspension of payments, and may be cause for the immediate termination of this Agreement. 36 . . L1HEAP ATTACHMENT G RECIPIENT INFORMATION FEDERAL YEAR: 02 CONTRACT PERIOD: March 1. 2002 TO March 31. 2003 - FOR DCA USE ONLY DATE RECEIVED: :2/AD/ ~2 REVISION(S): \ DCA CONSULTANT: CONTRACT NO: CP2EA -2 -roO J/-54-6>t-l)) 9 GRANT T.!P : Low-Income Home Energy Assistance Program I I. RECIPIENT CATEGORY: { } Non-Profit {X} Local Government Ii. COUt'!lIE~ 10 BE SERVl:L \.'11111' 1HE~E HJND~ Monroe III. GENERAL ADMINISTRATIVE INFORMATION a. Name of Recipient: Monroe County Board of Commissioners b. Name of Executive Director or Chief Administrator: Louis LaTorre c. Recipient Fiscal Year: From October to September d. Address: 1100 Simonton Street Ci~: Key West, FL Telephone: (30~ 292-4573 Fax: (3~ 292-4517 E-Mail Address: Mailing Address (if different from above): ,FL Zip Code: 33040 County: Monroe mcsswlOmail.Rtate.fl.uR e. ,FL Zip Code: f. Chief Elected Official (For local governments) or PresidenU Chairman of Board (for corporations): Name: Charles McCoy Title: Mayor, Board of County Commissioners Home or business address and telephone number other than Recipient's Mailing Address: 500 Whitehead Street Key West, ,FL Zip Code: 33040 Telephone (30~ 292-3430 g. Official to Receive State Warrant: Name: Danny Kolhage Tille: Clerk of Courts Mailing Address: 500 Whitehead Street Key West ,FL Zip Code: 11040 h. Contact Person: Name: T.nll;':: T ,,'I'n1"'1"'l'> Title: n;1"'<>('t-~t - ~Qci~t SQS~icQt Mailing Address: uu ~mon on ree Key Wes t ,FL Zip Code: 33040 Telephone: (30)5 292-4573 Fax: (3C)5 292-4517 E-Mail Address:mcssw@mail.state.fl.us i. Person(s) authorized to sign reports: Louis LaTorre or Susan Hawxhurst IV. AUDIT DUE DATE Agency Fiscal Year: October to September Seven months from end of agency fiscal year: April 37 ATTACHMENT H L1HEAP BUDGET SUMMARY AND WORKPLAN I. BUDGET SUMMARY . L1HEAP FUNDSONL Y BUDGETEOANlOUNT 72,905 1. L1HEAP FUNDS ..AOMINISTRATIVEEXPENSES 2. Salaries including Fringe, Rent, Utilities, Travel, Other (Total cannot exceed 7.5% of Line 1) 5,468.00 4. Home Energy Assistance Payments (Must be at least 25% of Line 1) 5. Crisis Payments 6. Weather Related/Supply Shortage (Must be at least 2% of Line 1) 7. SUBTOTAL DIRECT CLIENT ASSISTANCE (LINES 4+5+6) 8. GRAND TOTAL (Lines 2+3+7) 18,226.00 47,753.00 1,458.00 67,437.00 72 905.00 II. DIRECT CLIENT ASSISTANCE PLAN Type of Assistance: Estimated # of Estimated Cost Per Households to be Household Served Estimated Expenditures (Col. 1 x Col. 2) Home Energy 260 70 18,226 Crisis 271 176 47 753 Weather Relatedl Supply Shortage 10 140 1,458 TOTAL 541 125 67,437 38 L1HEAP ATTACHMENT I III. ADMINISTRATIVE AND OUTREACH EXPENSE BUDGET DETAIL (Lines 2-3) Line Item EXPENDITURE DETAIL L1HEAP FUNDS Number (Round up line items to dollars. Do not use cents and decimals in totals) ADMINISTRATIVE EXPENSES 2.A Travel 468~00 2.B Other 5,000.00 (1) Phone/Postage.......... 600.00 (2) Renta1/Copy............1,100.00 (3) Office Supplies........ 800.00 (4) Operating Supp1ies.....2,500.00 TOTAL ADMINISTRATIVE EXPENSES 5,468.00 OUTREACH EXPENSES N/A DIRECT CLIENT ASSISTANCE 4. Home Energy Assistance............ 18,226.00 5. Crisis Payments................... 47,753.00 6. Weather Related/Supply............ 1,458.00 TOTAL DIRECT CLIENT ASSISTANCE 67,437.00 GRANT TOTAL............................... 72,905.00 39 , . >oot CIl -.- !!. a; !2. ~~m Dl 0 C ::J-Q. n -. CD ell ell ell ::J _ -ell Q. itt ~ o ~ o ~ o <ft. ~ o ~ o ~ o ~ o ~ o ~ o ~ o z - i:J> ~ o > o<ft. -Ir- >-0 :!:r-oen~." enOo~O> o~r-en-lG) e:O-l!;);!om zm:;oz!:z -Ioenomo -<-I mZ~ o -I en m > en en ." o -1:;0 00 o- men -1-1 m2:! :;om 3:C:: --I z- mO >~ r-o r-> Or- 00 >e: -Ir- -> 0..... z- o z e: en m o o o c:: z :;! ~5" CD;:r III CD !!t_ _. 0 :::l .., "0 3 III 0- ;:+CD 0-0 ~ _:IE CD Q. Q.CD g ~ .., -0: 1ECD ~c: (]I "0 00 ~:::l o :IE "O::T ~ ~ CD 0- ~~ "0 iii' 0,< "0 0 !:..c: ~"O o. or :::l :::l 2,0 CD CD 1ll.Cl ("') c: =r::. ("') III o Q: C:'< ~Ill '<5' "'Og .., - o CD ~, r g-I .., m CD )> ~ "'0 g CD -' en :::l 0 to c: III 0 :::l CD Q.en ~ 8" 3 CD ~ ~ c)' ::T ~, 0 c: -.. en - ::!;:::r ~CD ("') ("') ~o 0' 3 :::l _ 0' Cii. .., en 9:~ !!tc: ~. CJ) O-CD ~< o CD :::l' "0-1 - :::l" III _. :::l en "0 iii" :::l 3 c: !!t 0- CD 3: c:: r- ~ n o e:> ~::t -<> .,,0 C::::I: Z3: Om OZ --I enc... ..... 2:! m c:: ~ o z > r- r- o o > -I o Z L1HEAP ATTACHMENT K JUSTIFICATION OF ADVANCE PAYMENT Indicate if you are requesting an advance or if no advance is being requested by placing an X in the appropriate brackets below. If you are requesting an advance, you must also complete the calculation of the advance amount below. [ 1 ADVANCE REQUESTED We are requesting an advance of $ for the operation of the first three months of the program. These funds are needed to pay staff, award benefits to clients, duplicate forms and purchase start up supplies and equipment. We would not be able to operate the program without this advance. Calculation of the advance amount: Total Allocation $ X 25 % (.25) = $ (Requested Advance) [Xl NO ADVANCE REQUESTED I:\BCA\CASTICSP _UNITI2002_L1HEAP\CONTRACT _L1HEAP _2002.wpd 11/08/01 41 . e~,':'~' STATE OF FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS "Dedicated to making Florida a better place to call home" JEB BUSH Governor STEVEN M. SEIBERT Secretary March 17,2002 Mr. Louis Latorre Director - Social Services Monroe County Board of County Commissioners 11 00 Simonton Street Key West, Florida 33040 Dear Mr. Latorre: Enclosed is your fully executed FY 2002-2003 Low Income Home Energy Assistance Program (LIHEAP) contract. Also enclosed are the updated forms for the monthly financial reports, the quarterly household reports, and the FY 2002-2003 poverty income guidelines. These forms were already mailed out on March 8, however, another copy is enclosed. Should you need additional information, please contact your community assistance consultant at (850) 488-7541. Sincerely, 7~J~tl~ Hilda S. Frazier, Planning Manager Community Assistance Section HF/hc/amb 2555 SHUMARD OAK BOULEVARD -TALLAHASSEE, FLORIDA 32399-2100 Phone: (650) 466-6466/Suncom 276-6466 FAX: (650) 921-0761/Suncom 291-0761 Internet address: http://www.dca.state.fl.us CRITICAL STATE CONCERN FIELD OFFICE 2796 Overseas Highwey, Suite 212 Marathon, FL 3305lJ..2227 (305) 289-2402 COMMUNITY PLANNING 2555 Shumerd Oak Boulevard Tallahassee, FL 32399-2100 (850) 488-2356 EMERGENCY MANAGEMENT 2555 Shumard Oak Boulevard Tellahassee, FL 32399-2100 (850) 413-9969 HOUSING & COMMUNITY DEVELOPMENT 2555 Shumard Oak Boulevard Tallahassee, FL 32399-2100 (850) 488-7956 .~ .~ STATE OF FLORIDA DEPARTMENT OF COMMUNITY AFFAIRS "Dedicated to making Florida a better place to call home" JEB BUSH Governor STEVEN M. SEIBERT Secretary MEMORANDUM TO: Low Income Home Energy Assistance Program (LIHEAP) Recipients F~na A. Price, Chief tyNffD:'~~eau of Community Assistance DATE: March 8, 2002 RE: FY 2002-2003 Report Forms, Intake Application Forms, Home Energy Benefit Matrix and Poverty Income Guidelines Enclosed are the following documents for the FY 2002-2003 Low Income Home Energy Assistance Program (LIHEAP): - Monthly Financial Status Report (no change from prior year) - Quarterly Household Report - Revised Applicant Intake Forms - New Home Energy Benefit Matrix - FY 2002 IllIS Poverty Guidelines All LIHEAP programs are required to follow the enclosed poverty guidelines which were effective February 14,2002. If you have not already implemented the FY 2002-2003 poverty guidelines, please do so immediately. Please discard all prior year report and application forms. Reports submitted on prior year forms will be not be approved and may result in delay of receipt of reimbursement funds. The enclosed forms were generated in WordPerfect for Windows. Call or e-mail your community assistance consultant if you would like an electronic copy of these forms. The forms are templates only and do not contain mathematical formulas. If you have any questions, please contact your community assistance consultant at (850) 488-7541. LAPlhc/sl Enclosures 2 555 S HUM A R D 0 A K B 0 U LEVA RD. TAL LA HAS SEE. F LOR IDA 32399 - 2 1 00 Phone: (850) 488-8466/Suncom 278-8466 FAX: (850) 921-0781/Suncom 291-0781 Internet address: hllp:/Iwww.dca.state.fl.us CRITICAL STATE CONCERN FIELD OFFICE 2796 Overseas Highway. Suije 212 Marathon. FL 33050-2227 (305) 2B9-2402 COMMUNITY PLANNING 2555 Shumard Oak Bouleverd Tallahassee, FL 32399-2100 (B5O) 488-2356 EMERGENCY MANAGEMENT 2555 Shumard Oak Boulevard Tallahassee, FL 32399-2100 (B5O) 413-9969 HOUSING & COMMUNITY DEVELOPMENT 2555 Shumard Oak Boulevard Tallahassee. FL 32399-2100 (B5O) 488-7956 . FOR DCA US E ON LY GRANTEE : A PP ROVED BY DATE CONTRACT # YTD DCA D IS B $ PMT. # - REPORTING MO NTH TH IS PMT $ BA L$ L1H EAP FU N OS BU DGET Budget C urrent Total Unexpended CATEGORY AI I ocation Month To Date Ba lance A B C 0 (A-C) 1 LI H EAP Funds (No Leveraging Funds) 2. Salaries including Fringe. Rent, Utilities, Travel , Other IT otal cannot exceed 7.5% of Line 1 } 3. Salaries including Fringe, Rent. Utilities, Travel, Other (Cannot exceed Line 1 minus Line 2 x 1 5) 4. Home Energy Assistance Payments (Must be at least 25% of Line 1 ) 5. Crisis Benefits Payments 6. Weather Related/Supply Shortage (Must be at least 2% of Line 1 ) 7. SUBTOTAL (Lines 4+5+6) 8. Home Energy Assistance 9. Crisis Assistance 1 O. SUBTOTAL (Lines 8 + 9) 1 1 .G RA N 0 TOTAL All EXPENSES (lines 2 + 3 + 7 + 1 0) L1HEAP r ME ENERGY ASSISTANCE PRe RAM (lIHEAP) MONTHLY FINANCIAL STATUS REPORT 1. Total Received from DCA.................................................................................................. $ 2. Plus: Interest Income...... ................................:.... ..... ...................... .... .... ........ ....... ... ....... $ 3. Program Income Received to Date:................................................................................... $ 4. Amount of Reimbursement Requested..... ............. ... ............ ................ .... ......... ..... .... ....... $ CASH POSITION I certify that lam authorized to sign financial reports and the information provided herein is true and accurate to the best of my knowledge. Name and Title (please type or print) Signature Date Effective 3/1/02 GRANTEE: REPORTING PERIOD (CHECK ONE) CONTRACT #: COUNTY: - Contract Start Date - June 30 - (See footnote) Oct. 1 - Dec. 31 July 1 - Sept. 30 Jan. 1 - March 31 LOW INCOIV HOME ENERGY ASSISTANCE F )GRAM (LlHEAP) FY 2001-2002 HOUSEHOLD REPORT ASSISTED HOUSEHOLD REPORT (REQUIRED DATA) Home Energy Assistance Summer Crisis Winter Crisis Weather Related I Supply Shortage Di ster LEVERAGING ACTIVITIES Home Energy Assistance Summer Crisis Winter Crisis 1. Number of Households Assisted 3jH~J~~H6Id~~~~i~t.#~~ith~~~~Si"~~rr1~~i A. Under 75% poverty level B. 75% - 100% poverty level C. 101% - 125% poverty level D. 126% - 150% poverty level E. Over 150% poverty level A. Birth to 2 years of age B. Age 3 - 5 ::lirii~JA~'\lTiiA'I"~lgJf.l~tlijllll!faillll~~[I~i~~1111!III~:I!! ...........-...................., .............. ............................-.................... .........-.....-....................................... ................. ..................",..... .......... ,...................................... .............. .... ...........-...... .......... ............'................................... ...........-........-................................ .............. ...-...................-...... ....,..,.............-................ .......... ...........- ............,...................... ...............-.. ......,................ ........ .......................-........................- '.. ............ .... ......................... ..............}........@:~ij~~~~~lj............. ... . --........,...... APPLICANT HOUSEHOLD REPORT DIRECTIONS: Provide statistics on all households a I in for L1HEAP assistance, whether the did or did not receive assistance. APPLICANT HOUSEHOLD REPORT (REQUIRED DATA) Home Energy Summer Assistance Crisis Winter Crisis Weather Relatedl Supply Shortage Disaster LEVERAGING ACTIVITIES Home Energy Summer Assistance Crisis Winter Crisis A. Under 75% poverty level B. 75% - 100% poverty level C. 101% - 125% poverty level D. 126% -150% poverty level E. Over 150% poverty level F. No Income Data Available SIGNATURE: DATE: Monitor: Data Entry: Date: _} DCA Date: _} Only TITLE: -The first household report must include all program activities for the beginning of the 02 EA contract (FY 2002 funds). include activities paid for with FY 2001 funds. I:\BCAICASncsp _UNIT\2002_L1HEAPIHOUSEHOLD _RPT _LI_FY2002.wpd Do not Effective 3/1102 . . ., 1002 Federal Poverty Guidf es Page 1 of3 THE 2002 HHS POVERTY GUIDELINES One Version of the [U .8.] Federal Poverty Measure [ Summary Figures and Federal Register References - Poverty Guidelines Since 1982] [ lnimmation Contacts/References - Poverty Guidelines & Th.reshoJds - History of U.S. PovertY Lines] [ Is There a Single Definition of "Income" That is Used with the Poverty Guidelines?] [ ~gI11Putatio\1s for the 2002 Poverty Guidelines] There are two slightly different versions of the federal poverty measure: . The poverty thresholds, and . The poverty guidelines. The poverty thresholds are the original version of the federal poverty measure. They are updated each year by the Census Bureau (although they were originally developed by Mollie Orshansky of the Social Security Administration). The thresholds are used mainly for statistical purposes - for instance, preparing estimates of the number of Americans in poverty each year. (In other words, all official poverty population figures are calculated using the poverty thresholds, not the guidelines.) Poverty thresholds since 1980 and yveighted average poverty thresholds since 1959 are available on the Census Bureau's Web site. The poverty guidelines are the other version of the federal poverty measure. They are issued each year in the Federal Register by the Department of Health and Human Services (HHS). The guidelines are a simplification ofthe poverty thresholds for use for administrative purposes - for instance, determining financial eligibility for certain federal programs. (The full text of the Federal Register notice with the 2002 poverty guidelines is available here.) The poverty guidelines are sometimes loosely referred to as the "federal poverty level" (FPL), but that phrase is ambiguous and should be avoided, especially in situations (e.g., legislative or administrative) where precision is important. A more extensive discussion of pover!yJL1fesholds and poverty guidelines is available 011 the Institute for Research on Poverty's Web site. ._,...._. ~ 'V'~' ,,~. ".... ..... ~ -.-" ,- Page 2 of3 2002 Federal poverty Guide! s 2002 HHS poverty Guidelines Size of 48 Contiguous Family Unit States and D.C. Alaska Hawaii 1 $ 8,860 $11,080 $10,200 2 11,940 14,930 13,740 " 15,020 18,780 17,280 j 4 18,100 22,630 20,820 5 21 , 180 26,480 24,360 6 24,260 30,330 27,900 7 27,340 34,180 31,440 8 30,420 38,030 34,980 F or each additional 3,080 3,850 3,540 person,add---~.- - -~--- . ...... I.. SOURCE: Federal Register, Vol. 67, No. 31, February 14,2002, pp. 6931-6933. The separate poverty guidelines for Alaska and Hawaii reflect Office of Economic Opportunity . administrative practice begilming in the 1966-1970 period. Note that the poverty thresholds -the original version of the poverty measure - have never had separate figures for Alaska and Hawaii. The poverty guidelines apply to both aged and non-aged units. The guidelines have never had an aged/non-aged distinction; only the Census Bureau (statistical) poverty thresholds have separate figures for aged and non-aged one-person and two-person units. Programs using the guidelines (or percentage multiples of the guidelines - for instance, 125 percent or 185 percent of the guidelines) in determining eligibility include Head Start, the Food Stamp Program, the National School Lunch Program, the Low-Income Horne Energy Assistance Program, and the Children's Health Insurance Program. Note that in general, cash public assistance programs (Temporary Assistance for Needy Families and its predecessor Aid to Families with Dependent Children, and Supplemental Security Income) do NOT use the poverty guidelines in determining eligibility. The Earned Income Tax Credit program also does NOT use the poverty guidelines to determine eligibility. The poverty guidelines (unlike the poverty thresholds) are designated by the year in which they are issued. For instance, the guidelines issued in February 2002 are designated the 2002 poverty guidelines. However, the 2002 HHS poverty guidelines only reflect price changes through calendar year 2001; accordingly, they are approxilnately equal to the Census Bureau poverty thresholds for calendar year 2001. (The 2001 thresholds are expected to be issued in final form in September or October 2002; a preliminary version of the 2001 thresholds is now available from the Census Bureau.) The~om~utations for the 2002QQvelty. g~i~elinesftfeavailable. .. Go to the page of Information Contacts and References on the Poverty Guidelines, the Poverty Page 3 01 j .. 2.002 Federal poverty Guide ~s Thresholds, and the Development and History ofD.S. poverty Lines. Return to the main POY.rrty G\JidsJLIJ~. Research. ;:l11d JvI.easuren-,;nr page. Last updated 02/14/02 FY 2002-2003 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM POVERTY INCOME GUIDELINES* PEOPLE IN THE MAXIMUM HOUSEHOLD INCOME IN DOLLARS PER YEAR HOUSEHOLD 1 2 3 4 5 6 7 8 Add this amou nt for each additional person in the household with more than 8 people. * These income limits are based on 100% of the national poverty income guidelines as published in the Federal Register, Vol. 67, Number 31, February 14, 2002. 1:IBCAICAsncsp _UNIn2002_L1HEAPIPovetL Guidelines_2002_2003.wpd ~ 0 0 II) - .c>o cn~ 0 ::s Q) o > I{) ... 0 Et')- , ;0. ~ 0 CD N - ~ 0 II) N a:: - en c( "5~ ....I W I{) :E W >- ::s Q) I'- > o > Et')- c( W a:: .c 0 a:: ....I W -a. C) >- a. ~ 0 0 ~ en - a:: a:: 0 a. W W c( - W > :E ....I 0 0 0 ....I Z a. 0 0 c( C Z C I- Z Z ~ en C 0 c( 0 en en z W 0 en c( ::& - c( !:: W 0 "5~ LL ~ 0-- 0 >- W ::s Q)- 0 C) z en z o > ..... - ... 0 Et')- a:: W C C ;0. W m ....I ....I Z >- 0 0 ~ W C) :I: :I: 0 II) W a:: W W ,... :E W en en 0 z :J :J :I: W 0 0 - W W :I: :I: ::s :E :E >- .c 0 0 m >0 0 :I: ~~ Q)II) Z C"') >,... -; 0 o c I{) ~ 0 a.ca N N 0 I -.c ..... ....I N 0_ Et')- 0 ~II) 0 o II) N o Q) 11)....1 ... Q) > 0 ... 0 0 >Oil) 0 o t:: II) I{) Q) Q) ..... II)~....I Et')- a. LLZC W O-a ::i>-I- OC)- D::W:I: :I:a::tl:i W....IW mQ.en a.WZ :EO:J c(ZW :JWO Wwm Za.:I: :I: ~ FY 2002-2003 LIHEAP INTAKE APPLICATION FORMS LIHEAP ASSISTANCE APPLICATION Page One of Three 1. Give the following information for the applicant first, then for each person living in your home. If more than seven persons live in your home, list the additional persons, giving the same information, on a separate sheet of paper and attach it to this form. FOR OFFICE USE ONLY HOME ENERGY DATE STAMP: SUMMER CRISIS WINTER CRISIS WEA mER RELATED! Name Social Date of Relationship Source of Monthly Security Age Birth (First, Middle, Last) Number M/DfY to Applicant Income* Income (Applicant's Name) o//h * Source of income: Wages, self employment, social security, child support, regular gifts, unemployment compensation, retirement benefits, SSI, TANF/WAGES, pensions, and interest on savings, etc. 2. If your monthly household income is less than $738 per month, explain how you pay for food, shelter, clothing, transportation and home utilities. 3. How many disabled persons live with you? 4. If you share your living or mailing address with others who are not part of your household, list their names: 5. If you or anyone in your home are not a U.S. citizen or an alien lawfully admitted for permanent residence, give the person's name and alien status under the Immigration and Naturalization Act. Name: Alien Status: Name: Alien Status: 6. Are you or any member of your household a member of the Porch Creek Indian Tribe? YES NO LIHEAP ASSISTANCE APPLICATION Page Two of Three 7. The address where you are living: ,FL Street Number and Name, RFD, Apt. or Lot Number City or Town Zip Code County 8. Your mailing address, if different from above: ,FL Street Number and Name, RFD, Apt. or Lot Number City or Town Zip Code County 9. Day time telephone number where you can be reached: ( ) 10. Check the programs that anyone in your household is currently eligible for or receiving assistance from: [ ] CSBG [ ] Weatherization [ ] Food Stamps 11. If you or any member of your household has received energy assistance in the last 13 months, complete the information below: Name of Agency Type of help (elderly, crisis, emergency) Date Name of Agency Type of help (elderly, crisis, emergency) Date 12. Do any of the following situations currently apply to you? (Check appropriate box below.) [ ] My electricity has been disconnected. [ ] My current electric bill is delinquent. [ ] I have a shut-off notice from the electric company. [ ] None of the above currently apply to my household. [ ] I have little or no propane, fuel oil or wood for heating. [ ] I have a shut-off notice from my gas company. [ ] My current natural gas bill is delinquent. [ ] Other energy crisis - Describe: 13. If your cost of home energy is included in your rent, give name and telephone number of your landlord. Attach a copy of a letter from the landlord confirming that your rent includes utilities. Landlord: Landlord's Telephone Number ( ) 14. If you live in a government subsidized housing complex, Section 8 housing, dormitory, nursing home, adult foster home, or any kind of group living facility, complete the following: Name of place where you live: ,FL Street Number and Name, RFD, Apt. or Lot Number City or Town Zip Code County LIHEAP ASSISTANCE APPLICATION Page Three of Three 15. Provide the following information about the primary source of energy you use to heat your home. Give only one company. Energy Company's Name Customer's Name on the Customer's Company's Source Account Account Telephone Number Number Electric Natural Gas Propane Fuel Oil Wood Other - Specify: 1 6. Provide-the ollowing informatlon-a out t e nmary source 0 energy)i ou use to coo your orne. Energy Company's Name Customer's Name on Customer's Company's Source the Account Account Telephone Number Number Air Conditioning ---- Fans fI b h f I h 17. Ifnot iven above in uestions 15 or 16, rovide the followin information about our electric com an . Company's Name Customer's Name on the Account Customer's Account Number Company's Telephone Number 18. Attach a copy of your current bills for all companies listed above in questions 15, 16 and 17. FRAUD STATEMENT: The information above is, to the best of my knowledge, true and complete. I understand that priority in providing assistance will be given to those households with the lowest income and greatest need, i.e, those households in which the elderly, disabled, medical needy or children reside. I authorize the agency to make benefit payments directly to my energy supplier. I am aware that after I have provided all the information requested, if! am applying for crisis assistance, the agency has 48 hours; 18 hours if my situation is life threatening, to approve or deny my application, and, if! am applying for Home Energy Assistance, the agency has 45 days to approve or deny my application. I am also aware that if I am not approved or denied within the time allowed, or not approved for the correct amount, I have a right to an appeals hearing. APPLICANT SIGNATURE DATE CASEWORKER DATE SUPERVISORlEDIT STAFF DATE LIHEAP/EHEAP ENERGY ASSISTANCE CLIENT ELIGIBILITY WORKSHEET INSTRUCTIONS 1. If the LIHEAP/EHEAP application is signed and dated and contains all required information, continue. If not, check all sections with missing information and call or write the applicant and request the missing information. Keep the original application. 2. If all required information is in the client file, continue. If not, give or send the applicant a Request for Information/Appointment Notice form. 3. Check the program component from which the applicant is seeking assistance (EHEAP Crisis or LIHEAP home energy, summer or winter crisis or disaster.) 4. Complete the Client Eligibility Worksheet. HOME ENERGY, CRISIS OR DISASTER ASSISTANCE CALCULATIONS WORKSHEET INSTRUCTIONS II. Crisis Assistance: Check agency records for prior EHEAP and LIHEAP crisis assistance. If an EHEAP or LIHEAP crisis benefit has already been paid this season, deny the application. Check verification of a crisis. If not an eligible crisis, deny. Verify that the benefit will resolve the crisis. If the maximum will not resolve the crisis and arrangements to resolve it cannot be made, deny. If the household is eligible, call the vendor to verify the minimum amount needed. III. Disaster Assistance: If a disaster has been declared by the President, Governor or the Department of Community Affairs and the household is eligible, check agency records for duplication. If the household is eligible, complete the information. Specific client eligibility and services available will be specific to the event and will determined by Department of Community Affairs at the time the disaster is declared. Refer to the disaster announcement for details. LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM (L1HEAP) CLIENT ELIGIBILITY WORKSHEET APPLICANT: SOCIAL SECURITY NUMBER: I I Use this table to calculate the Total Gross Income. List sources and amount of all earned and unearned income below. Total all sources of income. Multiply the Total Monthly Income by 12 to calculate the Total Gross Income. Source of Income Monthly Income Gross Earned Income ----- - Gross Unearned Income Total Gross Monthly Income Multiply Total Gross Monthly Income by 12 X 12 Total Gross Annualized Income U f se the ollowinQ chart to determine if the household is eliQible for assistance. Number of persons in household Maximum Household Income in Dollars per Year for Household size. See current Poverty Income Guidelines. If the Total Gross Annualized Income is less than the Eligible: Maximum Household Income allowed, the household is eligible. [ ] Yes [ ] No HOME ENERGY, CRISIS OR DISASTER ASSISTANCE CALCULATIONS I. HOME ENERGY a. Number of persons in household: b. Total Gross Annualized Income from Client Eligibility Worksheet: $ c. Home Energy Benefit Amount from Matrix: $ Company's Name Customer's Name on the Customer's Company's Account Account Telephone Number Number II. CRISIS ASSISTANCE Company's Name Customer's Name Customer's Company's Service or Amount on the Account Account Telephone Product * Paid from Number Number L1HEAP Funds * Examples: Electricity, deposit, propane, fuel oil, wood, blanket, fan, repair to heating system, repair to cooling system, late fees/penalties. III. DISASTER ASSISTANCE Company's Name Customer's Name Customer's Company's Service or Amount on the Account Account Telephone Product * Paid from Number Number L1HEAP Funds IV. SUMMARY If the application was denied, record the reason: v. SIGNATURE SECTION I have determined the eligibility of the applicant. I am not the applicant, nor am I a friend, relative or employee of the applicant. Caseworker Effective Date: 3/1102 Date Supervisor/Edit Staff Date (Agency Letterhead) LOW INCOME HOME ENERGY ASSISTANCE PROGRAM DATE: TO: Re: Notice of Approval Dear Applicant: The action taken on your application for the Low Income Home Energy Assistance Program is checked below. If you have questions, please call or write the agency. [ ] Your household is eligible for a one-time Home Energy Assistance Program benefit of$ based on your households's gross annual income of $ . Payment will be made to in the your name or [ ] Your household is eligible for a Crisis Energy Assistance Program benefit of $ based on your household's gross annual income of$ Payment will be made to in your name or If you have not been credited with this payment on a future utility bill, you must notify the agency. This benefit is to help with the heating and cooling costs. If you believe this payment is incorrect you may request a reconsideration or a hearing by contacting the agency within 30 days of this notice at (telephone number). Sincerely, (Agency Letterhead) Low Income Home Energy Assistance Program (LIHEAP) Date: TO: Re: Notice of Denial Dear Applicant: We regret that your application for assistance from the Low Income Home Energy Assistance Program (LlHEAP) has been denied in accordance with Florida Statutes Chapters 400.026 and 409.508. If you have any questions or wish further explanation, please call or write our agency at Your application was denied based on the following: [ l-:Vour-household's gross-annual-income of$--.--- is more than the $ allowed. [ ] Your household's home energy costs are at least partially paid through a program administered by the state or your household lives in a government subsidized housing project and your home energy costs are totally included in the rent. [ ] You did not provide information needed to process your application within the specified time. [ ] You did not provide information needed to process your application while funds remained available. [ ] You did not apply while funds remained available. [ ] You did not have a home energy crisis as defined by this program. [ ] You have already received a crisis benefit this season. [ ] You have received home energy assistance within the last 13 months. [ ] We are not permitted to provide LIHEAP services where you live. [ ] No one in your household meets the citizenship/alienage requirements. [ ] You requested withdrawal of your application for assistance. [ ] You are a member of an Indian Tribe that distributes the LIHEAP benefits directly to its members. If you believe this action is incorrect, you may request a reconsideration or a hearing by contacting the agency by telephone at within 30 days of the date of this letter. Sincerely,