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FY2005 10/20/2004DANNY L. KOLHA GE CLERK OF THE CIRCUIT COURT DATE: October 22, 2004 TO: Salvatore Zappulla, Director Office of Management & Budget ATTN: Dave Owens Grants Management FROM: Pamela G. Hanc Deputy Clerk LVV�VVJJ������ At the October 20, 2004, Board of County Commissioner's meeting the Board granted approval and authorized execution of the following: Agreements with non -profit service organizations funded by the County for Fiscal Year 2005: The Exotic and Wild Bird Rescue of Florida Keys, Inc., in the amount of $14,000.00; The Florida Keys Wild Bird Rehabilitation Center, Inc., in the amount of $14,000.00; Monroe Council of the Arts Corporation d/b /a Florida Keys Council of the Arts, in the amount of $72,500.00; and Rural Health Network of Monroe County, Florida, Inc., in the amount of $232,000.00. Agreements with Human Service Organizations funded by the County for Fiscal Year 2005: Big Brothers and Big Sisters, Inc. to provide funding to perform and carryout children's services, including companionship and development services to young persons living in Monroe County, in the amount of $23,000.00; The Care Center for Mental Health, to provide an annual appropriation that provides funding for mental health and guidance services for Monroe County citizens, in the amount of $310,000.00; Florida Keys Area Health Education Center, Inc. to provide funding for health- related services and health education, in the amount of $5,000.00; Florida Keys Children's Shelter, Inc. to provide funding to perform services such as shelter, and early intervention and prevention programs for youths and their families, in the amount of $95,000.00; Habitat for Humanity of the Upper Keys, Inc. to provide funding for housing services for disadvantaged citizens, in the amount of $5,000.00; Helpline Inc. to provide funding for crisis intervention and referral services, in the amount of $17,000.00,zospice of the Florida Keys, Inc., to provide funding for medical psychological, physical, and social needs of terminally ill persons and their families in Monroe County, in the amount of $45,000.00; The Monroe Association for Retarded Citizens, Inc. (MARC) to provide funding for services for retarded citizens of Monroe County, in the amount of $65,000.00; Rural Health Network of Monroe County, Florida, Inc. to provide funding for administration and promotional activities related to the Florida KidCare program in Monroe County, in the amount of $38,000.00; The U.S. Fellowship of Florida, Inc. to provide fundng for assisted living facilities with limited mental health support, in the amount of $50,000.00; Wesley House Family Services, Inc. to provide funding for day care, education, and skill development services for children of Monroe County, in the amount of $100,000.00; and Womankind, Inc., to provide funding for women's health care services, in the amount of $28,000.00. Enclosed is a duplicate original of each of the above - mentioned for your handling. Should you have any questions please do not hesitate to contact this office. cc: County Administrator w/o documents County Attorney Finance File AGREEMENT This Agreement is made and entered into this �—' day of �-'' '!' 2004, between the BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA, reinafter referred to as "Board" or "County," and HOSPICE OF THE FLORIDA KEYS, INC., hereinafter referred to as "PROVIDER." WHEREAS, the PROVIDER is a not - for - profit corporation established for the provision of home health care, and WHEREAS, it is a legitimate public purpose to provide facilities and services related to home health care, now, therefore, IN CONSIDERATION of the mutual promises and covenants contained herein, it is agreed as follows: FUNDING 1. AMOUNT OF AGREEMENT. The Board, in consideration of the PROVIDER substantially and satisfactorily performing and carrying out the duties of the Board as to providing facilities and services for home health care for persons living in Monroe County, Florida, shall pay to the PROVIDER the sum of FORTY -FIVE THOUSAND AND NO /100 DOLLARS ($45,000.00) for fiscal year 2004 -2005. 2. TERM. This Agreement shall commence on October 1, 2004, and terminate September 30, 2005, unless earlier terminated pursuant to other provisions herein. 3. PAYMENT. Payment will be made periodically, but no more frequently than monthly, as hereinafter set forth. Reimbursement requests will be submitted to the Board via the Clerk's Finance Office. The COUNTY shall only reimburse, subject to the funded amounts below, those reimbursable expenses which are reviewed and approved as complying with Florida Statutes 112.061 and Attachment A - Expense Reimbursement Requirements. Evidence of payment by the PROVIDER shall be in the form of a letter, summarizing the expenses, with supporting documentation attached. The letter should contain a certification statement. An example of a reimbursement request cover letter is included as Attachment B. The organization's final invoice must be received within sixty days after the termination date of this contract shown in Article 2 above. After the Clerk of the Board examines and approves the request for reimbursement, the Board shall reimburse the PROVIDER. However, the total of said reimbursement expense payments in the aggregate sum shall not exceed the total amount shown in Article 1, above, during the term of this agreement. 4. AVAILABILITY OF FUNDS. If funds cannot be obtained or cannot be continued at a level sufficient to allow for continued reimbursement of expenditures for services specified herein, this agreement may be terminated immediately at the option of the Board by written notice of termination delivered to the PROVIDER. The Board shall not be obligated to pay for any services or goods provided by the PROVIDER after the PROVIDER has received written notice of termination, unless otherwise required by law. S. CLAIMS FOR FEDERAL OR STATE AID. PROVIDER and County agree that each shall be, and is, empowered to apply for, seek, and obtain federal and state funds to further the purpose of this Agreement; provided that all applications, requests, grant proposals, and funding solicitations shall be approved by each party prior to submission. Contract - Hospice FY05; page 1 6. PURCHASE OF PROPERTY. All property, whether real or personal, purchased with funds provided under this agreement, shall become the property of Monroe County and shall be accounted for pursuant to statutory requirements. RECORDKEEPING 7. RECORDS. PROVIDER shall maintain all books, records, and documents directly pertinent to performance under this Agreement in accordance with generally accepted accounting principles consistently applied. Each party to this Agreement or their authorized representatives shall have reasonable and timely access to such records of each other party to this Agreement for public records purposes during the term of the Agreement and for four years following the termination of this Agreement. If an auditor employed by the County or Clerk determines that monies paid to PROVIDER pursuant to this Agreement were spent for purposes not authorized by this Agreement, the PROVIDER shall repay the monies together with interest calculated pursuant to Sec. 55.03, FS, running from the date the monies were paid to PROVIDER. S. PUBLIC ACCESS. The County and PROVIDER shall allow and permit reasonable access to, and inspection of, all documents, papers, letters or other materials in its possession or under its control subject to the provisions of Chapter 119, Florida Statutes, and made or received by the County and PROVIDER in conjunction with this Agreement; and the County shall have the right to unilaterally cancel this Agreement upon violation of this provision by PROVIDER. 9. COMPLIANCE WITH COUNTY GUIDELINES. The PROVIDER must furnish to the COUNTY: (a) evidence of the organization's 501(c)(3) status; (b) a list of the organization's Board of Directors of which there must be five or more; (c) evidence of annual election of Officers and Directors; (d) an annual audited financial report ; (e) a copy the organization's Corporate Bylaws, which must address the organization's mission, board and membership composition, election of officers, and so on; (f) a copy of the organization's Corporate Policies and Procedures Manual which must include hiring policies for all staff, drug and alcohol free workplace provisions, equal employment opportunity provisions, and so on; (g) cooperation with County monitoring visits; (h) semi - annual performance reports. These reports should include performance measurements which will demonstrate the level of accomplishment of goals for which funding has been provided. (i) other reasonable reports and information related to compliance with applicable laws, contract provisions and the scope of services that the County may from time to time request. RESPONSIBILITIES 10. SCOPE OF SERVICES. The PROVIDER, for the consideration named, covenants and agrees with the Board to substantially and satisfactorily perform and provide the services outlined in Attachment C to residents of Monroe County, Florida. 11. ATTORNEY'S FEES AND COSTS. The County and PROVIDER agree that in the event any cause of action or administrative proceeding is initiated or defended by any party relative to the enforcement or interpretation of this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, court costs, investigative, and out -of- pocket expenses, as an award against the non - prevailing party, and shall include attorney's fees, courts costs, investigative, and out -of- pocket expenses in appellate proceedings. Mediation proceedings initiated and conducted pursuant to this Agreement shall be in accordance with the Florida Rules of Civil Procedure and usual and customary procedures required by the circuit court of Monroe County. Contract - Hospice FY05; page 2 12. BINDING EFFECT. The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the benefit of the County and PROVIDER and their respective legal representatives, successors, and assigns. 13. CODE OF ETHICS. County agrees that officers and employees of the County recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. 14. NO SOLICITATION/ PAYMENT. The County and PROVIDER warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the PROVIDER agrees that the County shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. 15. INDEPENDENT CONTRACTOR. At all times and for all purposes hereunder, the PROVIDER is an independent contractor and not an employee of the Board. No statement contained in this agreement shall be construed so as to find the PROVIDER or any of its employees, contractors, servants or agents to be employees of the Board. COMPLIANCE ISSUES 16. COMPLIANCE WITH LAW. In providing all services pursuant to this agreement, the PROVIDER shall abide by all statutes, ordinances, rules and regulations pertaining to or regulating the provision of such services, including those now in effect and hereinafter adopted. Any violation of said statutes, ordinances, rules and regulations shall constitute a material breach of this agreement and shall entitle the Board to terminate this contract immediately upon delivery of written notice of termination to the PROVIDER. 17. PROFESSIONAL RESPONSIBILITY AND LICENSING. The PROVIDER shall assure that all professionals have current and appropriate professional licenses and professional liability insurance coverage. Funding by the Board is contingent upon retention of appropriate local, state and /or federal certification and /or licensure of the PROVIDER'S program and staff. 18. NON - DISCRIMINATION. County and PROVIDER agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action on the part of any party, effective the date of the court order. County or PROVIDER agree to comply with all Federal and Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VI of the Civil Rights Act of 1964 (PL 88 -352) which prohibits discrimination on the basis of race, color or national origin; 2) Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681 -1683, and 1685- 1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101 -6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91 -616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd -3 and 290ee -3), as amended, relating to confidentiality of alcohol and drug abuse Contract - Hospice FY05; page 3 patent records; 8) Title VIII of the Civil Rights relating to nondiscrimination in the sale, rental Disabilities Act of 1990 (42 USC s. 1201 Note), i nondiscrimination on the basis of disability; 10) Federal or state statutes which may apply to Agreement. AMENDMENTS, CHANGES, AND DISPUTES Act of 1968 (42 USC s. et seq.), as amended, or financing of housing; 9) The Americans with s maybe amended from time to time, relating to Any other nondiscrimination provisions in any the parties to, or the subject matter of, this 19. MODIFICATIONS AND AMENDMENTS. Any and all modifications of the services and /or reimbursement of services shall be accomplished by an amendment, which must be approved in writing by the COUNTY. 20. ADJUDICATION OF DISPUTES OR DISAGREEMENTS. County and PROVIDER agree that all disputes and disagreements shall be attempted to be resolved by meet and confer sessions between representatives of each of the parties. If no resolution can be agreed upon within 30 days after the first meet and confer session, the issue or issues shall be discussed at a public meeting of the Board of County Commissioners. If the issue or issues are still not resolved to the satisfaction of the parties, then any party shall have the right to seek such relief or remedy as may be provided by this Agreement or by Florida law. 21. COOPERATION. In the event any administrative or legal proceeding is instituted against either party relating to the formation, execution, performance, or breach of this Agreement, County and PROVIDER agree to participate, to the extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related to the substance of this Agreement or provision of the services under this Agreement. County and PROVIDER specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings related to this Agreement. ASSURANCES 22. COVENANT OF NO INTEREST. County and PROVIDER covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as recited in this Agreement. 23. NO ASSIGNMENT. The PROVIDER shall not assign this agreement except in writing and with the prior written approval of the Board, which approval shall be subject to such conditions and provisions as the Board may deem necessary. This agreement shall be incorporated by reference into any assignment and any assignee shall comply with all of the provisions herein. Unless expressly provided for therein, such approval shall in no manner or event be deemed to impose any obligation upon the Board in addition to the total agreed upon reimbursement amount for the services of the PROVIDER. 24. NON - WAIVER OF IMMUNITY. Notwithstanding he provisions of Sec. 286.28, Florida Statutes, the participation of the County and the PROVIDER in this Agreement and the acquisition of any commercial liability insurance coverage, self- insurance coverage, or local government liability insurance pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor shall any contract entered into by the County be required to contain any provision for waiver. 25. ATTESTATIONS. PROVIDER agrees to execute such documents as the County may reasonably require, to include a Public Entity Crime Statement, an Ethics Statement, and a Drug - Free Workplace Statement. Contract - Hospice FY05; page 4 26. AUTHORITY. Each party represents and warrants to the other that the execution, delivery and performance of this Agreement have been duly authorized by all necessary County and corporate action, as required by law. INDEMNITY ISSUES 27. INDEMNIFICATION AND HOLD HARMLESS. The PROVIDER covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners from any and all claims for bodily injury (including death), personal injury, and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the PROVIDER occasioned by the negligence, errors, or other wrongful act or omission of the PROVIDER'S employees, agents, or volunteers. 28. PRIVILEGES AND IMMUNITIES. All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules and pensions and relief, disability, workers' compensation, and other benefits which apply to the activity of officers, agents, or employees of any public agents or employees of the County, when performing their respective functions under this Agreement within the territorial limits of the County shall apply to the same degree and extent to the performance of such functions and duties of such officers, agents, volunteers, or employees outside the territorial limits of the County. 29. NO PERSONAL LIABILITY. No covenant or agreement contained herein shall be deemed to be a covenant or agreement of any member, officer, agent or employee of Monroe County in his or her individual capacity, and no member, officer, agent or employee of Monroe County shall be liable personally on this Agreement or be subject to any personal liability or accountability by reason of the execution of this Agreement. 30. LEGAL OBLIGATIONS AND RESPONSIBILITIES: Non - Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor shall it be construed as, relieving any participating entity from any obligation or responsibility imposed upon the entity by law except to the extent of actual and timely performance thereof by any participating entity, in which case the performance may be offered in satisfaction of the obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of the County, except to the extent permitted by the Florida constitution, state statute, and case law. 31. NON - RELIANCE BY NON - PARTIES. No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or attempt to enforce any third - party claim or entitlement to or benefit of any service or program contemplated hereunder, and the County and the PROVIDER agree that neither the County nor the PROVIDER or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this Agreement separate and apart, inferior to, or superior to the community in general or for the purposes contemplated in this Agreement. GENERAL 32. Execution in Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be regarded as an original, all of which taken together shall constitute one and the same instrument and any of the parties hereto may execute this Agreement by signing any such counterpart. 33. NOTICE. Any notice required or permitted under this agreement shall be in writing and hand - delivered or mailed, postage pre -paid, by certified mail, return receipt requested, to the other party as follows: Contract - Hospice FY05; page 5 For Board: David P. Owens, Grants Administrator and 1100 Simonton Street Key West, FL 33040 For PROVIDER Liz Kern, Executive Director Hospice of the Florida Keys, Inc. 1319 William St. Key West, FL 33040 305 - 294 -8812 305 -294 -9348 FAX Monroe County Attorney PO Box 1026 Key West, FL 33041 34. GOVERNING LAW, VENUE, INTERPRETATION, COSTS, AND FEES. This Agreement shall be governed by and construed in accordance with the laws of the State of Florida applicable to contracts made and to be performed entirely in the State. In the event that any cause of action or administrative proceeding is instituted for the enforcement or interpretation of this Agreement, the County and PROVIDER agree that venue will lie in the appropriate court or before the appropriate administrative body in Monroe County, Florida. The County and PROVIDER agree that, in the event of conflicting interpretations of the terms or a term of this Agreement by or between any of them the issue shall be submitted to mediation prior to the institution of any other administrative or legal proceeding. 35. NON - WAIVER. Any waiver of any breach of covenants herein contained to be kept and performed by the PROVIDER shall not be deemed or considered as a continuing waiver and shall not operate to bar or prevent the Board from declaring a forfeiture for any succeeding breach, either of the same conditions or covenants or otherwise. 36. SEVERABILITY. If any term, covenant, condition or provision of this Agreement (or the application thereof to any circumstance or person) shall be declared invalid or unenforceable to any extent by a court of competent jurisdiction, the remaining terms, covenants, conditions and provisions of this Agreement, shall not be affected thereby; and each remaining term, covenant, condition and provision of this Agreement shall be valid and shall be enforceable to the fullest extent permitted by law unless the enforcement of the remaining terms, covenants, conditions and provisions of this Agreement would prevent the accomplishment of the original intent of this Agreement. The County and PROVIDER agree to reform the Agreement to replace any stricken provision with a valid provision that comes as close as possible to the intent of the stricken provision. 37. ENTIRE AGREEMENT. This agreement constitutes the entire agreement of the parties hereto with respect to the subject matter hereof and supersedes any and all prior agreements with respect to such subject matter between the PROVIDER and the Board. Contract - Hospice FY05; page 6 IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed as of the day and year first written above. (SEAL) ATTEST: DANNY L. KOLHAGE, CLERK Deputy Clerk BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA El y yor /Chairman fitness Witness Hospice of the Florida Keys, Inc. (Federal ID No. B resident Contract - Hospice FY05; page 7 r"n NO v erg CD Contract - Hospice FY05; page 7 ATTACHMENT A EXPENSE REIMBURSEMENT REQUIREMENTS This document is intended to provide basic guidelines to Human Service Organizations, county travelers, and contractual parties who have reimbursable expenses associated with Monroe County business. These guidelines, as they relate to travel, are from Florida Statute 112.061. A cover letter summarizing the major line items on the reimbursable expense request needs to also contain a notarized certified statement such as: "I certify that the attached expenses are accurate and in agreement with the records of this organization. Furthermore, these expenses are in compliance with this organization's contract with the Monroe County Board of County Commissioners." Invoices should be billed to the contracting agency. Third party payments will not be considered for reimbursement. Remember, the expense should be paid prior to requesting a reimbursement. Only current charges will be considered, no previous balances. Reimbursement requests will be monitored in accordance with the level of detail in the contract. This document should not be considered all- inclusive. The Clerk's Finance Department reserves the right to review reimbursement requests on an individual basis. Any questions regarding these guidelines should be directed to 305 - 292 -3534. Data Processing, PC Time, etc. The vendor invoice is required for reimbursement. Inter - company allocations are not considered reimbursable expenditures unless appropriate payroll journals for the charging department are attached and certified. Payroll A certified statement verifying the accuracy and authenticity of the payroll expense is needed. If a Payroll Journal is provided, it should include: dates, employee name, salary or hourly rate, total hours worked, withholding information and payroll taxes, check number and check amount. If a Payroll Journal is not provided, the following information must be provided: check amount, check number, date, payee, support for applicable payroll taxes. Postage, Overnight Deliveries, Courier, etc. A log of all postage expenses as they relate to the County contract is required for reimbursement. For overnight or express deliveries, the vendor invoice must be included. Rents, Leases, etc. A copy of the rental or lease agreement is required. Deposits and advance payments are not allowable expenses. Reproductions, Copies, etc. A log of copy expenses as they relate to the County contract is required for reimbursement. The log must define the date, number of copies made, source document, purpose, and recipient. A reasonable fee for copy expenses will be allowable. For vendor services, the vendor invoice and a sample of the finished product are required. Supplies, Services, etc. For supplies or services ordered, a vendor invoice is required. Telefax, Fax, etc. A fax log is required. The log must define the sender, the intended recipient, the date, the number called, and the reason for sending the fax. Contract - Hospice FY05; page 8 Telephone Expenses A user log of pertinent information must be remitted including: the party called, the caller, the telephone number, the date, and the purpose of the call. Travel Expenses Travel expenses must be submitted on a State of Florida Voucher for Reimbursement of Travel Expenses. Travel must be submitted in accordance with Florida Statute 112.061. Credit card statements are not acceptable documentation for reimbursement. If attending a conference or meeting a copy of the agenda is needed. Airfare reimbursement requires the original passenger receipt portion of the airline ticket. A travel itinerary is appreciated to facilitate the audit trail. Auto rental reimbursement requires the vendor invoice. Fuel purchases should be documented with paid receipts. Taxis are not reimbursed if taken to arrive at a departure point: for example, taking a taxi from one's residence to the airport for a business trip is not reimbursable. Parking is considered a reimbursable travel expense at the destination. Airport parking during a business trip is not. A detailed list of charges is required on the lodging invoice. Balance due must be zero. Room must be registered and paid for by traveler. The County will only reimburse the actual room and related bed tax. Room service, movies, and personal telephone calls are not allowable expenses. Meal reimbursement is: breakfast at $3.00, lunch at $6.00, and dinner at $12.00. Meal guidelines state that travel must begin prior to 6 a.m. for breakfast reimbursement, before noon and end after 2 p.m. for lunch reimbursement, and before 6 p.m. and end after 8 p.m. for dinner reimbursement. Mileage reimbursement is calculated at .29 cents per mile for personal auto mileage while on County business. An odometer reading must be included on the state travel voucher for vicinity travel. Mileage is not allowed from a residence or office to a point of departure. For example, driving form one's home to the airport for a business trip is not a reimbursable expense. Non - allowable Expenses The following expenses are not allowable for reimbursement: capital outlay expenditures (unless specifically included in the contract), contributions, depreciation expenses (unless specifically included in the contract), entertainment expenses, fundraising, non - sufficient check charges, penalties and fines. Contract - Hospice FY05; page 9 ATTACHMENT B ORGANIZATION LETTERHEAD Monroe County Board of County Commissioners Finance Department 500 Whitehead Street Key West, FL 33040 Date The following is a summary of the expenses for ( Organization name for the time period of to Check # Payee Reason Amount 101 Company A Rent $ X,XXX.XX 102 Company B Utilities XXX.XX 104 Employee A P/R ending 05/14/01 XXX.XX 105 Employee B P/R ending 05/28/01 XXX.XX (A) Total $ X.XXX.XX (B) Total prior payments $ X,XXX.XX (C) Total requested and paid (A + B) $ X,XXX.XX (D) Total contract amount $ X,XXX.XX Balance of contract (D -C) $ X.XXX.XX I certify that the above checks have been submitted to the vendors as noted and that the expenses are accurate and in agreement with the records of this organization. Furthermore, these expenses are in compliance with this organizations_ contract with the Monroe County Board of County Commissioners and will not be submitted for reimbursement to any other funding source. Executive Director Attachments (supporting documentation) Sworn to and subscribed before me this day of 2001 by who is personally known to me. Notary Public Notary Stamp Contract -Hospice FY05; page 10 ATTACHMENT C Services to be provided: Health- related services for patients and their families or significant others who are experiencing life- threatening illnesses. These include, but are not limited to, pain and symptom management, medical consultation, skilled nursing, personal care, counseling, rehabilitation, nutrition counseling, medical social work, and bereavement programs. Services are offered to residents of Monroe County. Contract - Hospice FY05; page 11 PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a 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 public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." Contract - Hospice FY05; page 12