HomeMy WebLinkAboutNutrition ProgramCounty of Suffolk
Steve Levy
Suffolk Coun[y Executive
Office for the Aging
Holly S. Rhodes-Teague
Director
July 29, 2O04
The Honorable Joshua Y. Horton
Supervisor
Tmvn of Soufl~old
53095 Main Road, P.O. Box 1179
Southold, New York 11971
RE: I]~C Nutrition Pro.am
IFMS No. SCS EXE 00000009288
Dear Supervisor Horton:
The fully executed agreement referenced above is enclosed for your files.
Also enclosed find the Notice of Rights, which must be posted as part of your compliance with
Local Law No. 12-2001, the Living Wage Law.
Sincerely,
Leonor Hunter
Fiscal Administrator
LH:TMB:Iw
Enclosure
cc: Karen McLaughliu
(631) 853-8200
H. LeeDennisen Building · 1O0 Veterans Memorial Highway - P.O. Box6100 · Hauppauge, NewYork 11788~)099 · FAX 853-8225
Over 30 years as the designated Area Agency on Aging Providing Services i'or Older Citizens
NOTIFICATION OF RIGHTS UNDER
THE LIVING WAGE LAW
According to the provisions of Local Law #12-2001 (the Living Wage law) enacted
by Suffolk County in July of 2001, a wage rate has been established of $9.00 per
hour with health benefits or $10.25 without health benefits for covered employees
of an agency receiving financial assistance through the County. The law also
mandates that these workers receive at least 12 compensated days off per year
through any combination of sick, vacation or personal leave and includes paid
holidays provided by the employer.
The Suffolk County Department of Labor has been designated as the agency to
administer this law and to this end has established a Living Wage Unit. Further
information concerning the parameters of the Living Wage la~v may be obtained by
contacting this Unit (631-853-6530) or accessing the Suffolk County web page at
ww~v.co.suffolk.ny.us/labor and following the link to the Living Wage section. All
inquiries will remain confidential.
AG004M/0003-06R
Rev, 5~5~04
IIIO Nutrition Program
IFMS No. SCS EXE 0000000q21~R
No. 001.6790-4980-95284- ~Z~t~
Agreement
This Agreement (Agreement) is between the County of Suffolk (County), a municipal
corporation of the State of New York, having its principal office at the County Center,
Riverhead, New York 11901, acting through its duly constituted Office for the Aging (Aging),
having its principal office at the H. Lee Dennison Building - 3rd Floor, 100 Veterans Memorial
Highway, Hauppauge, New York (Mailing address: Box 6100, Hauppauge, New York 11788-
0099, and the Town of Southold (Contractor), a New York municipal corporation, having its
principal place of business at 53095 Main Road, P.O. Box 1179, Southold, New York 11971.
The parties hereto desire to make a senior citizens nutrition program available to the
County. Sufficient funding exists in the 2004 Suffolk Counbj Operating Budget.
Term of Agreement: Shall be January 1, 2004 through December 31, 2004 with two
one-year extensions at the County's option.
Total Meals: Daily Congregate Midday Meals: 52
Not to Exceed $57,878 Annually
Total Cost of Agreement: Shall be on a fee-for- service basis, not to exceed $57,878 for the
current contract year, as set foKh in Exhibits A, A1 and C aEached.
Terms and Conditions: Shall be as set forth in Exhibit A through E and the Exhibit entitled
"Suffolk County Legislative Requirements Exhibit for Contracts"
revised 2/5/04, attached.
In Witness Whereof, the parties hereto have executed this Agreement as of the latest date
written below.
Town of Tutholdj
By: /'/,/~ ~,,
,~sOShUa Y. Horton
upervisor
Fed. TaxBay,er I1~ #: ~1-6001939
Date:
Approved as to Legality:
Christine Malafi
Suffolk County Attorney
A',C~stan[ Count}, Attorney
County of Suffolk
By:
Paul Sabatino II
Chief Deputy County Executive
Date:
Approved:
By:
Holly ,~JRhod~s-Teague (.._~ ' ~Date
Director, Office for the Aging
Reco~ended:~
~/Anna Prencipe ;/ Date
/ Assistant Food Se~ice Supe~isor
AG 4 (7/03)
AG4 sohJd 3c 04
· , %~---~ ~r, io. AG004MI00 -0G/TY IFMS No. SCS EXE 0000000
R~v. 4/7/04 No. 00t-6790/6774-4980.95284-
IIIC Nutrition Program (Supplemental Nutrition Assistance Program)
Exhibit A
Services To Be Performed - Payment By County
A. The Contractor shall furnish Aging with one or more nutrition programs for senior
citizens of Suffolk County (separately or collectively the "Program"), under (i) the
Nutrition Program for the Eldedy pursuant to T'Cde I11, Part C of the Federal Older
Americans Act (42 U.S.C.A. §3030e et seq.) in accordance with the rules and
regulations of the Administration on Aging, United States Department of Health and
Human Services, or (ii) the New York State Supplemental Nutrition Assistance
Program (SNAP), as indicated on the cover page of this Agreement. The Contractor
shall furnish the Program as further provided in this Exhibit A, Exhibit Al, the
Contractor's Response to Section IV, paragraph .3 a through h, to the RFQ Request
for Qualifications No. 3/15524VH (the RFQ) and the follo~ng Appendices to the
RFQ and additional Exhibits, which are attached to and made part of this
AG 4 (9/00)
Agreement:
EXHIBIT A1
EXHIBIT B
EXHIBIT B1
EXHIBIT C
EXHIBIT D
EXHIBIT
Appendix K
Appendix L
Appendix M
Appendix N
Appendix O
Standard Contract Clauses
Program Specifications
Special ·Clauses (if any)
Rate Page(s) {Contractor's Response to Section V of the RFQ)
Grievance Procedures
Suffolk County Legislative Requirements Exhibit for
Contracts" revised 2/5/04
Technical Assistance Packet (revised 7/03)
Policy and Procedure Manuals: Congregate Meals and
Home Delivered Meals (revised 7/03)
Holiday Schedule
Summary Form for each Catchment Area
Client Assessment Provider Data System (PDS - Form:
revised 5/5/00)
The approximate daily number of Congregate and/or Home-delivered Meals
included in the Program shall be as set forth on the cover page of this Agreement.
Payments wil~ be made in accordance with the Rate Page(s) attached as Exhibit C
to this Agreement, but only as provided in Exhibit Al.
If, under prior similar agreements with the County, the Contractor has received
nonconsumable furniture, equipment or other tangible personal property or funds to
purchase any such items, or received any of such items in connection with this
Agreement, the Contractor shall comply with Exhibit D annexed to and made part of
this Agreement.
The provisions of Exhibit B1 shall prevail over inconsistent provisions of any other
Exhibit, the provisions of this Exhibit A and of Exhibits A1 and B shall prevail over
inconsistent provision of any other Exhibit except B1, and the provisions orA, Al
and B1 shall prevail over any other document not specifically referred to in this
Page 1 of 2 pages of Exhibit A
AG4M 03 RFP Model AGRMNT
~L,av~l~o. AG004M/00 -06/7Y IFMS No'. SCS EXE 0000000
Rev. 4/7/04 No. 001-6790/6774.4980-95284-.
IIIC Nutrition Program (Supplemental Nutrition Assistance Program)
Agreement or made part thereof by this Exhibit A or by subsequent amendment in
writing and signed by both parties except to the extent that provisions of this Exhibit
A, or Exhibit A1 or B1 are specifically referred to and amended or superseded by
such amendment.
Exhibit B is made part of this Agreement for the contract year to which it relates and
for any contract period thereafter unless it is modified by Extension Agreement or
Amendment.
m
m
'4.
Contract Year
The term of this Agreement shall be as set forth on the cover page, unless extended as
provided below or terminated as provided in Exhibit Al.
Reports
The Contractor shall submit reports as reasonably requested by the County, including
without limitation those required by the Technical Assistance Packet (Appendix K to the
RFQ), and the Policy and Procedure Manuals (Appendix L to the RFQ).
Limit Of County's Obligations
The maximum amount to be paid by the County as set forth on the cover page of this
Agreement or any amendment thereof shall constitute the full obligation of the County in
connection with this Agreement and any matter arising therefrom for the contract year to
which such cover page relates.
Insurance
Subparagraph 14.A (1) of Exhibit A1 is deleted and the following provision is substituted in
its place:
(1) COMMERCIAL GENERAL LIABILITY INSuRANcE, including contractual
and food products liability coverage, in an amount not Jess than Two
Million Dollars ($2,000,000.00) combined single limit for bodily injury and
property damage per occurrence.
Extension Of Term
The services of the contractor under this Agreement shall be subject to review by Aging
not less often than annually. If Aging, in its sole discretion, is satisfied with the
Contractor's services, Aging shall notify the Contractor in writing on or before the
expiration of the term (as same may have been extended), and the parties shall negotiate
an Extension Agreement, which shall take effect for the extension period specified therein,
but in no event beyond the time Jimits specified on the cover page of this Agreement, upon
signature on behalf of the County. Such Extension Agreement shall include the Total Cost
of Agreement for the extension period, adjustment of the annual and daily average number
of meals, if necessary, and such other modifications of the Agreement as may be agreed
upon between the parties.
- END OF TEXT OF EXHIBIT A -
AG 4 (9~00) Page 2 of 2 pages of Exhibit A
AG4M 03 RFP Model AGRMNT
· ,: . .'. TABLE OF CONTENTS
"ExhibitA1 -Standard Contract Clauses ..... ' ......... ; ............... ; ................ ......... i .... 1
· i. Contractor Responsibilities ....... :.' ......... : .............. : ............. '...-.: ........ i ......... ~ ...... '.i.:..~....1
..: (a)' Services ................. : ................. .... ....... '....:.....' .................................................... ;1
(d) Level of Service ............................................................... ' .............. i ................. 1
... (e) Compliance with Law ............................................. ' ......................... ' ................. 1
2. Term of Agreement.i ............. i..' ....................... ' .................................................. i ......... 2
3. Payment for Services ............................................. ; ......................... ; ......................... 2
· ' (a) Claims ......... ; ................................................................ ' .................................... 2
(b) Final Request for Payment ........................... ~ .................................................. 2
(c) Payment of Claims'. ................. ~ ............................................................. i.' ......... 2
· .' (d) payments Not To Exceed Net Expenditures ...................... ......: ........................ 2
(e) Taxes..~ ...................... ; ................................................................. ; ................... 3
(f) Agreement Subject to Appropriation of Funds ................................................. 3
(g) Payments Contingent upon State/Federal Funding ....................... ' .................. 3
(h)· Payments Contingent upon Receipt of State/Federal Aid ......................... : ...... 3
(i) Other Governmental Funding .................................. ' ......... i ............ . .................. 3
(j) Post-Audit ........ ' ................................................................................................ 3
4. ACcounting Procedures ............................................... ~ .............................................. 4
5. Financial Statements and Audit Requirements ........................................................... 4
6. Furniture, Fixtures, Equipment, etc ................................... '...: ............. i ........................ 5
(a) Purchases, Etc. Requiring Prior Approval..... ........... ;.; ................................... :..5
(b) Purchase Practices .................................................................. :.: ..................... 6
(c) Proprietary Interest of County ............................................. : ........... i ................ 6
(d) Inventory Records, Controls and Reports ............ :....: ............. i ........................ 6
(e) Protection of Property in Contractor's Custody ................... , ....... ' ..................... 7
(f) Disposition of Property in ContractoCs Custody ............................................... 7
7. Addresses for Notices, Claims and Reports .............................. ; ................ ' ...... ;: ........ 7
8. Statement of Other Contracts ......................................... : .......... ' ....................... :.: ....... 7
.., . 9. Offset ofArrears or Default ....... ~ ........................ :.~ .................. . ................. '...:..;.....i ...... 7
.' :.' 10. Confidentiality of Re(~ords ................ :...., ..................... ~ .......... ' ......... :..... ....... : ............... 7
· . 11. Independent Contractor...- ....................... ~ ......................... ' ................. ' ....... :..i ........... '._8
· ... 12. Certificate of Incorporation .................... '....' ................. '. ..... : ......................................... 8
AG A1F (5/00)
20.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Insurance and Indemnification....i ............. J ............ ' ................... : .............. '...'...;.....' ....... 8
Incident Reporting'. ................... ..'~...: ............................
Nondiscrimination in Employment ............... ' ........................... ~...,..~.i ............ : ......... 10
Nondiscrimination in Services ........... ~ ........... : ...................... :..: .................... 10
Nonsectarian/Nonpartisan Declaration .......... '.....: ..... '.~ ...................... ~ ...................... 11
Suffolk county Living Wage Law.' ............ ' .......... : ....... ~ ...... ~.; .................. i .............. '....11
Child Sexual Abuse Reporting Policy ..... : .......... ' ............ : ................... :....i ................. 12
Gratuities .......................... :...-..;...~.' ....... ' ........................ ~...'...i~ .............................. :....12
Public Disclosure ............................................... :...~....; ................. ;.: ......................... 12
· Work Experience Participation....: ...... :..i ................................................... i ............... 12
Publications. Copyrights and Patents ................................................. · ...................... 12
Qualifications of Personnel .......................... ;..i .................... '.' ......................... : .......... 13
Certification Regarding Lobbying .............................................................................. 13
Cooperation On Claims ............................................................................................ 13
Assignment and Subcontracting ............................................................................... 13
Terrnin ation ...................................... '...' ................................ ' ...................................... 14
Severability; No Implied Waiver ..............
Merger; No Oral Changes ...... ; .................................................................... · ............. 14
AG A1F (5~00)
· ·Exhibit A1 -Standard Contract clauses · ·
Contractor Responsibilities ·.
(a) Services .... ' .
· .' · : · The' Contractor shall Perform such Services as may be necessary to accomplish the work
required to be performed under and in ~ccordance with this Agreement, as more Particularly pro-
vided in Exhibits A and B, in a skillful manner and to the best of its ability. .'
(b) Qualifications and Licenses ' ~
· The Contractor specifically repres&nts and warrants that it has and shall possess, and
that, to the extent applicable, its employees, agents and subcontractors have and shall'possess,
the required education, knowledge, experience and character necessary to qual[fythem individu-
· ally for the particular duties they perform and that the Contractor has and shall have, and, to the
extent applicable, its employees, agents and subcontractors have and shall have, all required au-
thorization(s), registration(s), license(s), certificate(s) or permit(s) required by State, County or
· local authoritieS for the Services (hereinafter called "License"). The Contractor shall immediately
· .' notify Aging in writing of any disciplinary proceedings against the holder of any License by the
New.York State Department of Education or the New York State Department of Health or other
" issuer of a License~ In the event that the Contractor or such other holder of a License is no longer
".= licensed for any one or more of the Services, the Contractor must .immediately so notify Aging. It
'" is understood that the Contractor shall not be reimbursed for any Services rendered after the ef-
fective date of termination of such License. The remainder of this Ag.reement, or its application to
.' persons or circumstances other than those as to which said License'has been terminated, shall
· not be affected thereby, and every other term and provision of this Agreement shall be valid and
enforceable to the fullest extent permitted by law. (c) County Review
It.is agreed that the nature and extent of'the services provided pursuant to this Agreement
shall be _subject to the general supervision of Aging and that Aging, .through its duly authorized
representatives, has the right to monitor and evaluate the program. Aging shall be the sole arbiter
as to what constitutes acceptable performance under this Agreement..
· (d) Level of Service. ..
The Contractor agrees that where a minimum level of service is not provided as set forth in
· Exhibit B, Aging may require the reduction of Contractor staff and costs or terminate this Agreement
after, giving notice in accordance with the provisions headed, "Termination", of Exhibit Al.. ..
(e) . Compliance with Law ....
The Contractor shall Comply with all applicable local, County, State and Federal laws,
rules and regulations, including without limitation the rules and regulations of the New York State
:.. Office for the Aging, Suffolk County local preference and other applicable Suffolk County local.
laws. and resolutions of the Suffolk County Legislature and the rules, regulations, criteria, and
· guidelines for expenditure controls heretofore adopted or to be adopted by the County New York
3ursuant to law. · '
.... State and the Federal government
· .. AG.Ai E (2/04)
· Page 1 'of 14 pages of Exhibit A'IF
Term of Agreement . . . ... .'-
". This Agreement shall cover the peri'od provided on the first'page thereof, unless sooner
terminated as otherwise provided in this Agreement. . .. ' ' '
3. Payment for Services .' · .'.' '..' .. .' . . , · ·
· la) Claims
· .. (i) The Contractor shall prepare and present claim forms supplied by the
County (standard Suffolk County Payment Voucher and any other form(s)
required by Aging or the Department of Audit and Control) within eight (8)
days after the close of the month in which the expenditure was made, except
· the claim for the last month of the initial Term of Agreement and of each suc-
ceeding Extension Period, if any, for.which the claim shall be submitted as
provided in paragraph B below.
(ii)Ail claim forms must be signed in ink by duly authorized persons, and certifica-
tion of such authorization with certified specimen signatures thereon must be
filed with Aging by a Contractor official empowered to sign this Agreement.
(ii!) Monthly vouchers shall be submitted directly to the Suffolk Coun~ Office for
the Aging at H. Lee Dennison Building, 100 Veterans Memorial Highway,
P. O. Box 6100, Hauppauge, New York 11788-0099. ·
(iv) No claims shall be payable until the Contractor complies with all 'require-
ments in this Agreement that should have been complied with on or before
submission' of such claims and also submits evaluative and such other data in
the manner, and form as shall be required and accepted by Aging, the
County; State or Federal Government.
(v) The amount of the Total Cost of the Agreement to be paid by the County as
set forth on the cover page of this Agreement or of any extension or amend-
.merit thereof shall constitute the full obligation of the County in connection
with this Agreement for the period there indicated.
lb) Final Request for Payment
A final claim for payment shall be submitted no later than thirty (30) days after the end Of
the initial Term of Agreement and of each 'succeeding Extension Period, if any, unless otherwise
directed by Aging. .. lc) Payment of Claims.
The County agrees to pay the Contractor monthly for services provided and costs in-.
curred pursuant to this Agreement up tO the maximum agreed amount as provided in paragraph
3(a)(5) above, upon receipt of monthly claims in such form as prescribed by the County and after
audit and approval by the County. Claims shall be documented by sufficient, competent and evi- .
dential matter. Payment by the County shall be made within thirty (30) days afte[ approval by the
Comptroller of the County of Suffolk.
(d) Payments Not To Exceed Net Expenditures
The Contractor agrees that if, for any reason whatsoever, the'Contractor Shall spend dur-
ing the term of the Agreement for the purposes set forth herein an amount less than agreed, the
- AG A1F (2/04)
Page 2 of 14 pages of Exhibit A1F
ag31F
.' total County payment herein shall be reduced to the amount of approved actual Contractor ex-
.... penditures made for such purposes, and that the total amount to be paid by the County during the
Contract term shall not exceed approved actual net expenditures or the Total Cost Of the Agree-
· : rnent on the cover p~g~ and in the Budget. whichever is less. ..... . '.
'(e) Taxes · . ' ... .. '.
· .::The charges payal~le to the Contractor under this Agreement are exclusive of federal,
State and local taxes, the County being a municipality exempt from the payment Of such taxes.
'(f) Agreement Subject to App'ropriatio'n of Funds " · ·
'.This Agreement is subject to the amount of funds appropriated and any subsequent modifi-
· cations thereof by the Suffolk County Legislature, and no liability shall be incurred, by the County
.. ' under this Agreement beyond the amount of funds appropriated by the Legislature for the program
covered by this'Agreement. .
· (g) PaymentS.C0ntingent upon State/Federal Funding
"'Payments under this Agreement are subject to and contingent upon continued funding by
the State and/or Federal Government(s). If, for any reason; the full amount of such funding is not
· made available to the County, this Agreement may be terminated in whole or in part, or the
amount payable to the Contractor may be reduced, at the discretion of Aging,' provided that any
such termination or reduction shall not apply to allowable costs incurred by the Contractor prior to
· · such termination or reduction to the extent that funds are availab!e to Aging for payment of such
costs. ..'.. '.
· . (h) Payments Contingent upon Receipt of State/Federal Ai.d
If any State or Federal government department or agency funding this Agreement in whole
Or in part should fail to approve aid in reimbursement to the County for payments made here-
under by the County to the Contractor for expenditures made during the term of this Agreement
because of any act, omission or negligence on the part of the Contractor, then the County may
deduct and withhold from any payment due to the Contractor an amount equal to the reimburse-
ment denied by such department or agency, and the County's obiigation shall be reduced by any
such amounts. In such an event, if there should be a balance due to the.County after it has made
a final payment to the Contractor, the Contractor agrees prOmptly to reimburse the County the
amount of the balance due the County by check to the order of the Suffolk CountyTreasurer. The
provisions of this subparagraph shall survive the expiration or terminat on of the Agreement.
(i) Other Governmental Funding . .
If the program of the Contractor which is the subject of this Agreement is funded in whole
or in part by contracts with other governmental .agenCies, it is agreed that the funds of the County
under this Agreement shall be refunded to the County to the extent that the local funding from all
such soumes exceeds the total expenditures of the Contractor for the program..
(j) Post-Audit '
. Ali.payments made under this Agreement are subject to audit by the SuffOlk County Comptrol;
let pursuant to Article V of the Suffolk County Charter. The Contractor further agrees fiat the County
· Comptroller .and Aging shall have access to and the right to examine, audit, excerpt, copy or tran-
"scribe any pertinent transactions or other reco'rds relating to services under this Agreement. If such an
.. audit discloses overpayments by the County to the Contractor, within thirty (30) days after the issu-
AG A1F (2/04) ". Page 3 of 14 pages 0~f Exhibit A;I F · · a~
anco of an official audit, report by the Comptroller or his duly designated representatives, the Contrac-
tor shall repay the amount of such overpayment by check to the order of the Suffo k County Treasurer
or shall submit a proposed plan of repayment to the Comptrol!er.. If there is no response or if satisfac~
tory repayments are not made, the County may recoup overpayments from any amounts due or be-
Calming due to the Contractor from the County Under this Agreement or otherwise. · ·
:4. Accounting'Procedures . .
· . la') The Contractor Shall maintain separate records of account concerning all costs in-
curred by the Contractor in the.performance of this Agreement and all income relating to the pro-
gram funded under this Agreement and consents to audit and inspection by the County, New
York State and. the Federal Government of all facilities, books and other financial and statistical
data, whether related to this Agreement or otherwise (in the case of towns or other municipal cor-
porations, only as they relate to this Agreement). Such records shall be maintained for a per!od of
seven (7) years from the date of termination or. expiration' of this Agreement. Specific records
shall be kept as to the hours of all personnel. .. ,
lb) The Contractor'shall comply, for the program funded under, this Agreement, with the
"Regulations for Accounting Procedures for Contract Agencies," promulgated by the DePartment
of Audit and Control of Suffolk County, and any amendments during the Term of this Agreement.
5.'.Financial Statements and Audit Requirements
la) Notwithstanding any other reporting or certification requirements of Federal, State or
local :authorities, the Contractor shall obtain the services of an independent licensed public ac- '
countant or certified public accountant (the "Auditor") to audit its financial statements for each
Contractor fiscal Year in which the Contractor has received, or will receive, $500,000 or more
from the County, whether under this Agreement or otherwise, and shall submit a report on the
overall financial condition and operations of the Contractor, including a balance sheet and state-
ment'of income and expenses, attested by the Auditor as faidy and accurately reflecting the ac-
. counting records of the Contractor in accordance with generally accepted accounting principles.
The Contractor is encouraged to solicit requests for proposals (RFPs) from a number of qualified
· accoanting firms and to review carefully the costs of, and qualifications for, this type of work be-
fore selecting the Auditor.
lb) The Auditor should be required to meet the following minimum requi?ements:
'(i) a current license issued by the New York State Education Department;
(ii) sufficient auditing experience, in the 'nonprofit, governmental or
profit-making areas, as applicable; .and
(iii)a satisfactory peer review issued within not more than three years prior
to the date when the Auditor was selected to conduct the audit.
: lc) The audit must be' conducted in accordance with generally accepted governmental
· auditing standards (GAGAS). Financial statements must clearly differentiate between
· County-funded programs and other programs that the Contractor may be operating. The use of
subsidiary schedules should be encouraged for this purpose. The Auditor must als0 prepare a
management letter based on the audit.
(d)' Furthermore, if the Contract0r. isa non-prOfit organization or unit of local govern-
ment and expends $500,000 or more of Federal monies, whether as a recipient expending awards
AG Al F (2/04) Page 4 of 14 pages of Exhibit A1F ,g,~F
· . rece!ved directly from Federal· awarding agencies, or as a subrecipient expending Federal awards
:..re.ceil/ed from a pass-through entity, such as New York State or Suffolk County, during any fiscal
· period within which it receives funding under this Agreement ("fiscal year"), the audit must be con-
ducted, and the audit report ("Single Audit Report") must be, in accordance with OMB Circular No.
A-133 (revised June 24, 1997). Single Audit Reports must also be submitted to the designated·
Clearinghouse, cognizant agency·and/or pass-through entity, to the extent required by the' OMB
· Circular just referred to. · ~ ':.' '...-
· '.' (e) The Contractor must submit a statement in writing, certified by its chief financial
· officer, which States the amount of Federal funding expended by the Contractor during such fiscal
year. The Contractor must mail or d'eliver the certified statement to Aging and to Elizabeth
Tesoriero, Executive Director of Auditing Serv!ces, Suffolk County Department of Audit and
Control, H. Lee Dennison Bu!lding; 100 Veterans Memorial Highway, P. O. Box 6100, Hauppauge,
New York 11788-0099, as soon as possible after the end of the Contractor, s fiscal year. The
statement should include ALL Federal funding received directly from the Federal g0vemment and
ALL Federal funds passed through from the County and oth,r pa~s-th.rough entities
(f) ' Co'Pies of all financial statements, management letters, Single Audit Reports (if ap-
· plicable) and other audit reports, if required, must be transmit[ed to Aging and to Ms. Tesoriero at
· the address just set forth. The reports must be submitted within thirty (30) days after completion
of the audit, but in no event later than nine (9) months after the end of the Contractor's fiscal pe-
do:d to which the audit relates. ·
(g) These requirements'do not preclude Aging Or the Suffolk County Co~nptroller or
their authorized representatives or Federal or State auditors from auditing the records of the Con-
tractor. Therefore, the records of the Contractor must be made available to authorized represen-
tatives of Federal, State or county government for that purpose.
(h) Ail payments made under this Agreement are subject to audit by the Suffolk County
Comptroller pursuant to Article V of the Suffolk County Charter. If the Contractor fails to cooper-
ate with an audit by the Comptroller, the County shall have the right to Suspend or partially with-
hold payments under this Agreement or under any other agreement between the parties until such
cooperation is forthcoming. If·such an audit discloses overpayments by the Countyto the Con-
tra(~tor, within thirty (30) days after the issuance of an official audit report by the Comptroller or his
duly designated representatives, the Contractor sh~ll repay the amount of such overpayment by
c'heck to the order of the Suffolk County Treasurer or shall submit a proposed plan of repayment
to the Comp·troller. If thei'e is no response or if satisfactory repayments are not made, the County
may recoup·overpayments from any amounts due or becoming due to the Contractor from the
County under this Agreement or otherwise. ~ . ·
'(i) The provisions of this paragraph shall survive the expiration or termination of the
Agreement. "..
..6. Furniture, Fixtures, Equipment, etc.
(a) Purchases, Etc. Requiring prior Approval · ·
· Prior to placing any order to purchase, rent or lease any furniture, fixtures, Or equipment, (i)
Valued in excess of five hundred dollars ($500.00) per unit, Qr (ii) included but not itemized, in the
Budget, the Contractor shall submit to the County a written request for approval to make such a
proposed purchase, rental, or !ease, with. a list showing the quantity and description of each item,
AG'A1F (2/04) Page 5 of 14 pages of Exhibit AIF ~,
· . its. intended location and use, estimated Unit price Or cost, extended Price or cost and estimated
· "total cost' of the proposed order. Written approval of the county is required' before the Contrac-
tot may proceed with the proposed purchase, rental, or lease.of furniture, fixtures, or equipment..
All items purchased will be new unless specifically described otherwise in the Budget.
· -.' (b) Purchase Practices
· The Contractor agrees to follow all of the general practices that'are designed to obtain fur-
niturel fixtures, equipment, materials or supplies at the most reasonable price or cost poss!ble.
The County reserves the right.to purchase or obtain for the Contractor furniture, fixtures, equip-
.merit, materials or supplies which shall be in accordance with the programmatic needs of this
Agreement. If the County exercises this right, the amount budgeted for the !terns so pUrchased or
obtained by the County for the Contractor shall not be available to the Contractor for any pur-
pose whatsoever..Titl.e to any such items purchased or otherwise obtained by the County for the
Program and entrusted to the Contractor shall remain in the County, and the Contractor shall
attach labels indicating the County's. . ownership if the County. . has not done so.
· ' i (c) ProprietarY Interest of County ..
.' The County shall retain a proprietary interest in all furniture, removable fixtures, equip-
merit, materials or supplies purchased er obtained by the Contractor and paid for or reimbursed
to the Contractor pursuant to the terms of this Agreement or any prior agreement. Upon the ter-
mination of this Agreement, or of any renewal thereof, the discontinuance of the business of the
Contractor, the failure of the Contractor to comply with the terms of this Agreement, the bank-
ruptcy of the Contractor an assignment for the benefit of its creditors, or the failure of the Con-
tractor to satisfy any judgment against it within thirty (30) days of filing, the County shall have the
right, to take title to and possession of all such furniture, removable fixtures, equipment materials
and supplies, and the same shall thereupon become the property of the County without any claim
for reimbursement on the part of the Contractor. As directed by the County, the Contractor
shall attach identifying labels on all furniture, removable fixtures and equipment'indicating the pro-
pr etary, interest of the. County. ' · · : . · ' '
· (d). Inventory Records, Controls and Reports
The Contractor shall maintain proper and accurate inventory records and controls for all
such furniture, removable fixtures and equipment acquired pursuant to this Agreement and all
· prior.agreements, if any, covering the Program. Three (3) months before the termination date of
.this Agreement, the Contractor shall make a physical count of all items of furniture, removable
fixtures 'and equipment in its custody, checking each item against the aforesaid inventory records.
A report setting forth the results of such physical count shall be prepared by the Contractor on a
form or forms designated by the County, certified and signed by an authorized official of the Con-
tractor, ~ind one (1) copy thereof shall be delivered to the County within five (5) days after the
'date se[ for the aforesaid physical count. Within five (5) days afle[ the termination date of this
Agreement, the Contractor shall submit to the County six (6) copies of the same report updated
to the term nation date of this Agreement, certified and signed by an authorized official of the Con-
tractor, based On a p.hYSlcal count of all items of furniture, removable fixtures and equipment on.
the aforesaid termination date, and revised, if necessary, to include any inventory.changes during
the last three (3) months of the term of this Agreement. ... ..
AG A1F (2/04)
page 6 of 14 pages of Exhibit A1F
agalF
· · (e) . Protection Of Property in Contractor's CustodY · .. .'...
· The contractor shall rnaint~in vigilance and take all reasonable precautions to protect the
"' · .'furniture, fixtures, equipment, materials or supplies in its custody against damage or loss by fire,
:' burglary, theft, disappearance vandalism or misuse.' In the.event of burglary, theft, vandalism or
"'disappearance of any item of furniture fixtures, equipment: materials or supplies, the Contractor
shall immediately notify the police and make a record thereof, including a record of the results of
any investigation which may be made thereon. In the event of loss of or damage to any item of
· ' furniture, fixtures, equipment, materials or supplies from any cause, the Contractor immediately
shall send the County a detailed, written report thereon. ..
...: (f) "Disposition of Property in Contractor's Custody. . .
· · . · Upon termination of the County's funding of the Program Covered by this Agreement or by
any renewal hereof, or at any other time that the County may direct, the Contractor shall make
access available and render all necessary assistance for physical removal by the County or its
designee of any or all furniture, removable fixtures, equipment, materials or supplies in the Con-
tractor's custody in which the County has a proprietary interest, in the same condition as such
property was received by the Contractor, reasonable wear and tear excepted. Any disposition,
settlements or adjustments connected with such property shall be in accordance with the rules
and .regulat!ons of the County and the State of New York. '. · ·
· · 7. ' Addresses for Notices, Claims and Reports
· "· · · The'contractor shall mail any communication, notice, claim for payment, reports, or other
· .. submission to: Suffolk County Office. for the Aging at its address on the cover page of this Agree-
''' ment, or such other address of which the County shall have given the Contractorwritten notice.
· ... The County sha!l mail any communication, notice, or other submission to the Contractor at its
address on the cover page of this Agreement or such other address of which the Contractor shall
have given the County written notice. . .
8. Statement of Other Contracts
" The Contractor has attached, and in t~e event of any change will attach to any extension
agreement/amendment of this Agreement, a Statement of Other Contracts in the form apnexed to this
Agreement. The Contractor represents and warrants that any such Statement of Other Contracts is
and will be a complete list of all other contracts (i) which are currently in effect or (ii) which have ex-
pired within the past 12 months and have not been renewed, and under which funds have been, are
being orwiil be received by the Contractor from any department or agency of the County, the United
States of America, the State of New York Or other municipalities or funding organizations.
9. Offset of Arrears or De[ault
The Contractor warrants that it is not, and shall not be 'during the term of this Agreement,
"in arrears to the County for.taxes or upon debt or contract and is not, and shall not be dudng the
.... term of'this Agreement, in default as surety, contractor or otherwise on any obligation to the
County, and the Contractor agrees that the County may withholdthe amount of any such ar-
rearage or default from amounts payable to the Contractor under this Agreement.
10. ConfidentialitY of Records
'(a) The Contractor expressly agrees to preserve the confidentiality of all data and in-
formation.shared, ~eceiyed, collected, or obtained as a result of this Agreement. No disclosure,
AG A1F (2/04) · Page 7.ef 14 pages of Exhibit A1F . · ~F
· rediscl0sure or release· of Such data or information is to be made, permitted, or encouraged by the
Contractor or its officers or employees, except as expressly authorized by law. It is further under-
stood and agreed that no such data or information is to be used for personal benefit. The Con-
tractor further agrees that its employees shall be specifically instructed in regard to their 0bliga-
tion to keep such data and information in confidence and their liability'upon breach of confidential-
ity to all the penalties. prescribed by law.. .. · ' ' i: ' . .' . . . .
~.. · (b) · ' The Contractor further agrees to implement such procedures for safeguarding in-
formation as the Department shall require. The Contractor further agrees to indemnify and hold
the County and Aging harmless against any loss, damage, cost or expense arising out of'any
suit, claim or demand which may be brought or made against the County or Aging by reason of a
breach of these provisions. " "' · ' · '. ' ·
... (c) · In addition, the Contract_or agrees to maintain the confidentiality of all information in
conformity with the provisions of applicable local, State and Fedem.l.laws and regulations. '
1t. Independent ContractOr
The relationship of the Contractor to the County shall be that of an 'independent contrac-
tor..The Contractor, in accordance with its status as an independent contractor, covenants and
agrees that neither the Contractor nor any of its .officers, directors or employees will hold itself or
themselves out as, or claim to be, an officer or employee of the County by reason of this Agree~
merit, and that neither it nor any of them will, by reason thereof, make any claim, demand or appli-
cation to or for any right or privilege applicable to an officer or employee of the County, including,
but not limited to, Workers' Compensation coverage, unemployment insurance benefits, Social
SecuritY coverage, Or retirement membership or credits.
i2. Certificate of Incorporation
.The Contractor (if not a town or other municipal corporation) shall furni'sh Aging with certi-
fied copies of its Certificate of Incorporation and by-laws, including any amendments thereto, at
the time it signs this Agreement, to the extent not already on file with Aging, and any amend-
ments thereto during the term of this Agreement promptly upon their adoption, and a list of the
board members governing the Contractor from time to time. The Contractor shall not dissolve
any existing corporation or establish any new corporation with the responsibility forthe operation
of the program without the prior written approval of Aging.
13, Insurance and Indemnification. ..
" (a) The Contractor agrees to procure, pay the entire premium for and maintain
throughout the term of this Agreement insurance in amounts and types specified by the County.
· Unless otherwise specified by the County and agreed to by the Contractor, in writing, such in-
Surance will be as follows: ' '
(i) COMMERCIAL GENERAL LIABILITY INSURANCE, includingcontrac-
tual coverage, in an amount not less than Two Million Dollars ·
($2,000,000.00) combined single limit for bodily injucy and property
damage per occurrence.
(ii) AUTOMOBILE LIABILITY INSURANCE (if any vehicles are used in the
'. performance of this.Agreement) in an amount not less than Three.
AG A1 F (2/04)
Page 8 of ~14 pages Of Exhibit A'IF '
· ' Hundred Thousand Dollars ($300,000.00) Combined single limit for
· · bodily injury.and property damage per occurrence.
(iii)PROFESSIONAL LIABILITY/ERRORS AND OMISSIONS INSUR-
· ANCE in an amount not less than Two Million Dollars ($2,00~,000.00)
·. . on either apec occurrence or claims made basis.. · .
(iv) WORKERS' COMPENSATION and EMPLOYER'S LIABILITYINSUR-
ANCE in compliance with all applicable New'York State laws and regu-
lations and DISABILITY BENEFITS INSURANCE if required by law
and shall have furnished to the County prior to its execution of this
Agreement the documentation required, by the .State of New York
Workers' Compensation Board of coverage or exemption from cover-
age pursuant to §§ 57 and 220 of the Workers' Compensation Law. In
accordance with General Municipal Law § 108; this Agreement shall be
· void and of no effect unless the Contractor shall provide and n~aintain
coverage during the term of this Agreement for the benefit of such em-
ployees as are required to be covered by the provisions oftheWork-
ers' ComPensation Law.
(v) FIDELITY BONDS (if a Budget and paYment schedule are attached to
this Agreement) providing comprehensive coverage, in an amount not
less than the greater of (i) Five Thousand Dollars ($5,000) or (ii) the
amount of the advance to the Contractor under this Agreement,
against dishonesty, disappearance and destruction of money and se-
curities for all personnel who have access to or sign checks, or have
care, custody or control of funds or property entrusted to the Contrac-
tot under the terms of the Agreement.
(b) All policies providing.such coverage shall be issued by insurance cornpanies ac-
ceptable to the County. · ' :
'. (c) The COntractor Shall furnish to the County certificates of insurance or, on request,
original policies, evidencing compliance with the aforesaid !nsurance requirements. In the case of
commercial general liability insurance said certificates or other evidence of insurance shall name
the County of Suffolk as an additional insured. All such certificates or other eviden~ of insurance
shall provide for the County of Suffolk to be a certificate holder and to be notified in writing thir[y
(30) days prior to any cancellation, nonrenewal or material change. Such certificates, policies or
other evidence of insurance and notices shall be mailed to Aging at the address atthe head of
this Agreement or at such other address of which the County shall have given the Contractor no-
tice in writing. If the Contractor is a town or other municipal corporation and has a self-insurance
program under which it acts as a Self-insurer for any of such required coverage, it r~ay provide
self-funded coverage and certificates or other eyidence o[ such self-insurance in lieu of insurance
issued by insurance companies.... ' .'
(d) ' Furthermore, to the extent permitted by law, the Contractor shall indemnify and hold
harmless the County, its consultant (if any). employees, agents and other persons from and
against all losses, claims, costs, judgments, liens, encumbrances and expenses, including attor-
neys' fees. by reason of liability imposed by law, for damage because of bodily injur,/, including
death at any time resulting therefrom, sustained by any person or persons, or on account of dam-
AG A1 F (2/04)
Page 9 0{ 14 pages of Exhibit A1F
· ... age to' property, arising out of the acts or omissions or negligence Of the. Contractor its agents,
'. 'employees or subcontractors or of other persons; in connection with the services described or re-
· ferred to in this Agreement, even if such injuries to persons or damage to property are due, or are
· Claimed to be due, to Passive negligence of the County, its employees, agents or sub.contractors
" or other Persons, except only !n cases of the County's sole active negligence.
'14'.' Incident Reporting' .. ' '.' ' "" ' ' ' .. ' "" ' '
The. Contractor agrees tO provide Aging with reports of all instances of claims, costs,
'damages, and injuries to persons or property of whatsoever kind arising out of services provided
under this Agreement.' All.such notifications should be given to Aging immediately after the inci-
dent, if possible, but in no case longer than five (5) days after the incident. -The Contractor fur-.
· ther agrees to send Aging copies of all 'notices of claim'.' relating to the program covered in this
Agreement.. . · .... . .
15. NOndiscrimination in Employment '" '
(a) The Contractor agrees in connection with the performance of this Agreement as follows:
.'(i) The Contractor shall not discriminate against employees or applicants for
· employment because of race, creed, color, national origin, sex age, disability,
Vietnam Era Veteran status or marital status, and will undertake or continue
exist!rig programs of affirmative action to.ensure that women.and minority
· group members are afforded equal employment opportunities ~vithout dis-
crimination. Affirmative action shall mean recruitment, employment, job as-
signment, promotion, upgradings, demotion, transfer, layoff, or termination
and rates of pay or other forms of compensation.
· ' (ii) The Contractor shall require each employment agency, labor union or authorized
representative of w0rkers, with which it has a collective bargaining or other
agreement or understanding, to furnish a written statement that such employment
agency, labor union or representative will not discriminate on the basis of race,
· creed, color, national origin, sex, age, disability, Vietnam Em Veteran status or
marital status and that such union or representative will affirmatively cooperate in.
· the implementation of the Contractor's obligations herein.
(iii) The Contractor shall state, in all solicitations or advertisements for employ-
ees, that, in the performance.of this Agreement, all qualified applicants will be
afforded equal employment opportunities without discrimination because of
race, creed, color, national origin, sex, age, disability, Vietnam Era Veteran
status or marital status..
16. Nondiscrimination in Services · . ' ·
(a) . Fudhermore, the Contractor, in providing services under this Agreement, shall not,
on the grounds of race,, creed, color, national origin, sex, age, disability or marital status:
... (i) Deny an individual.any services'or other benefits provided under the program:
(ii) Provide. any Services or other benefits to an individual which ate different; or are
· · provided in a different manner, from those provided to others..under the program;
· (iii)Subject an individual to segregation or separate treatment in any matter related
to his/her receipt of any se.rvices or other benefits provided underthe program;
AG A1F (2/04) ...' Page'10 of 14 pages of Exhibit AI'F
(iv) .Restrict an individual in any way in the enjoyment of any advantage or privi-
' lege enjoyed by others 'receiving any serv!ces or other benefits provided un- '
"der the program; .' .... .
(v) Treat an individual differently from others in determining whether or not the
individual satisfies any eligibility or other requirements or conditio~)s Which in-
dividual.s must meet in order to receive any aid, care, services, or other bene-
fit~' provided under the program. '-.
(b) The Contractor shall not utilize crite}ia or methods of'administration which have the
effect of subjecting individuals to discrimination because of their race; cree~l, national origin, sex,'
age, disability or mad[al status or have the effect of defeating or substantially impairing accom-
· . plishment of the objectives of the'program in respect to individua!s of.a particular race, creed, ha- .
'tional origin; sex, age, disability or marital status, in determining: · ·
(i) The types Of services or other' benefits to be provided under the program, or
·. · · (ii) The class of individuals to'whom, or the situations in which, such services or
· other benefits will be proyided under the Pr0gram,.or
(iii) .' The Class of individuals'to be afforded an opportunity to pa¢icipate.in the program.
(c) The Contractor also agrees to observe all applicable Federal Regulations contained
in 45 CFR, Part 84 and Part 85 entitled "Non-Discrimination on the Basis of Handicap in Program
"Activities Receivir)g or Benefiting from Federal Financial Assistance." ·.
(d) The Contractor agrees to comply with the requirements of the Civil Rights Act of 1964.
(e) In addition (unless Otherwise indicated, or not applicable to the Program described,
in Exhibit B), pursuant to § 306(a)(5)(A)(ii) of the Older Americans Act, as added by P. L. 100-175,
42 U.S.C.A. § 3026(a)(5)(A)(ii), the Contractor shall
(i) specify how the Contractor intends to satisfy the'service needs of
Iow-income minority individuals in the area served by the Contractor; and
(ii) aEempt to provide Services to Iow-income minority individuals in at least the
same proportion as the population of Iow-income minodty older individuals bears
· to the population of older individuals of the area served by the Contractor.
17. Nonsectarian/Nonpartisan Declaration
The Contractor agrees that all services performed under this Agreement are .secular and
nonpartisan in nature and that no funds received pursuant to this Agreement will be used for sec-
tarian purposes or to further the advancement of any reiigion, candidate or partisan effort. Fur-
thermore, the Contractor' agrees that all program services are and will be available to all eligible
individuals regardless or religious belief or political affiliation.
18. Suffolk CountY Living Wage Law " '.
The Contractor represents and warrants that it has read and is familiar'with the requirements of
Section 6 of Chapter 347 of the Suffolk County Cede, the Living Wage Law, attached hereto as part of
the "Suffolk County Legislative Requirements Exhibit for contracts" and made a part hereof...
'. 'AG A1F (2/04) · Page 11 of 14 pages of Exhibit'A1F
agalF
. Child SexUal Abuse Reporting ·pOlicy· "
': The Contractor agreeS to comply with the SuffOlk county Child Sexual Abuse RePorting
' Policy, Chapter 577, Article IV, of the Suffolk County Code, attached hereto as part of the "Suffolk
· County Legislative Requirements Exhibit for Contracts" and made a part hereof, as now in effect
· or amended 'hereafter or of any other Suffolk County Local Law that may become applicable dur-
a' lng the term of this Agreement with regard to child sexual abuse reporting policy.
20.. Gratuities "' : .... '..
The Contractor represents' and warrants that it has not offered or given any gratuity to any
official, employee or'agent of Suffolk County or New York State or of any political party, with the
purpose of intent of securing favorable treatment with respect to the awarding or amending of an
· ~greement or the making of any determinations with respect to the performance of an agreement,
and that the signer of this Agreement has read and is familiar with the provisions of'Local Law No.
'. 32-1980 of Suffolk County. (Chapter 386 of the Suffolk County Code).
21. public DisClosure . "
The' Contractor represents and warrants that, unless exempt, it has filed with the
· Comptroller of Suffolk County the verified public disclosure statement, required by Local Law No.
· 14 of 1976, as amended (§A5-7 of the Suffolk County Code) and acknowledges that such filing is
· a. matertal, contractual and statutory duty and that the failure to file such statement shall constitute
a material breach of this.Agreement, for w~hich the County shall be entitled upon a determination
that such breach has Occurred, to damages, in addition to all other legal remedies, of fifteen per-
cent (15%) of the amount of the Agreement. (Such fi!lng is not required if the Contractor is a
· not-for-proft corporation.) . ..
22. Work Experience Participation
If the ContraCtor is a nonprofit agency or institution, each of the Contractor's locations in
Suffolk. County at which services are provided under this Agreement shall be a work site for pub-
lic-assistance clients of Suffolk County pursuant to Local Law No. 15-1993 at all times during the
term of this Agreement. If no Memorandum of Understanding ("MOU") with the Suffolk County
Department of Labor ~:or work experience !s in effect at the beginning of the term of this Agree-
merit, the Contractor, if it is a nonprofit agency or institution, shall enter into such MOU as soon
as possible after the execution of this Agreement and failure to enter into or to perform in accor-
dance with such MOU shall be deemed to be a failure to perform in accordance with this Agree-
ment, for which the Contractor may withhold payment, terminate this Agreement or exercise such
other remedies as may be appropriate in the circumstances. ..
23. Publications, Copyrights and Patents . ..
(a) The Contractor shall not'issue or publish any book, article', announcement, report or
other publication relating to the subject program without prior v~ritten permission fmrn the County.
Any such publication shall bear a statement acknowledging the cooperation and/or funding by the
County of Suffolk- Steve Levy, County Executive.
(b) ' If the work of the Contractor under this Agreement should result'in the production of
.original books, manuals, films or other materials for which a copyright may be granted, the Con-
tractor may secure copyright protection. However, the County reserves, and the Contractor
hereby glves to the County, and to any other municipality or government agency or body desig-
AG A1F (2/04) .' Page 12 of 14 pages of Exhibit A1F ~g,~,
· hated by the County, a royalty-free 'nonexciusive license to p(0duce, reproduce, publish, tranS-
late or otherwise use any such materials. · . · . "
.. -.. '(c) if the ContractOr under this Agreement makes'any discovery er invention in'the
..' course of or as a result of work performed under this Agreement, the Contractor may.apply for
and secure for itself patent protection. However. the County.reserves .and the Contractor hereby '
'gives to the County. and to any other municipality'or government agency or body designated by
.the County,' a royalty-free, nenexclusive license to produce.or otherwise use.any item so discov- ·
ered or patented '
'. 24~ · Qualifications of PerSonnel ..
... '. · · · The Contractor agrees that it will provide the County With relevant policies regarding the
personnel qualifications for professional employees and that these policies shall .be subject to ap-
25. CertifiCation Regarding Lobbying '
· Together with this Agreement and as a condition precedent to its execution bY the County,
the Contractor shall have executed and delivered to Aging the Certification Regarding Lobbying
(if payment under this Agreement may exceed $100,000 - SEE FORM A-I-rACHED) required by
31 U.S.C. Section 1352 and regulations thereunder, shall promptly advise the County of any ma-
terial change in any of the information reported on such Certification and.shall otherwise comply
with, and shall assist the County in complying with, said regulations as now in effect or as
amended dur!ng the Term of this Agreement. . .
26. Cooperation On Claims
The contractor agrees to render diligently to the. County any and all cooperation, without
additional compensation, that may be required to defend the County against any claims, demand,
or action that maY be brought against the County in connection with this Agreement.
27. .Assignment and Subcontracting " . · ·
·. (a) The Contractor shall not assign, transfer, convey, sublet, or otherwise dispose of
this Agreement, or any of its right, title or interest therein, or its power to execute this Agreement,
or assign all or any portion of the monies that may be due or become due thereunder, to any other
person, or corporation, without the prior consent in 'writing of the County. and any attempt to do
any of the foregoing without such consent shall be of no effect.
(b) The Contractor shall not enter into subcontracts for any of the work contemplated un-
der this Agreement without obtaining prior written approval of Aging. Such subcontracts shall be sub- .
ject to all of the provisions of this Agreement and to such other conditions and provisions as Aging
may deem necessary; provided, however, that nc~twithstanding the foregoing, unless Otherwise pro-
vided in this Agreement, such prior written approval shall not be required for the purchase of articles,
suppliesl equipment and services Which are incidental to, but necessary for, the performance of the
work required under this Agreement. No approval by Aging of any subcontract shall provide for the
incurrence of anY obligation by the County in addition to the total agreed upon price. The Contractor
· shall be responsible for the performance of any subcontractor for the delivery of.service.
AG A1F' (2104)
Page 13 of 14 pages of Exhibit'AIF
28 "T mi ati "' ....... '' "' "
.' er n on · . ". · .
'' · : (a) If the Contractor faiis to'fulfill in a timely apd proper manner its Obligations under
"this Agreement, or !f the Contractor becomes bankrupt or insolvent or falsifies its records or re-
ports,' or misUses its funds from' whatever source, the County may terminate th sAgreement n
.whole or with respect to any identifiable part of the program, effective immediately, Or, at its op- .
tion, effective at a later date specified in the notice of such termination to the Contractor.
· -. · (b) 'If the County shall deem it in its best interest tb terminate thiS'Agreement in whole
'or with respect to any identifiable part of the program, it shall have the right to do so by giv!ng not
less than thirty (30) days' prior wdtten notice to the Contractor. -. . ."
' ' (c) The Contracto~ may terminate this Agreement by giving' not less than sixty (60) days'
prior wdEen notice (or thir[y (30) days' prior wr!tten notice if substantial breach Of contract is invo!ved)
to the Director of~Aging, specifying the reasons for termination and the effective date of termination.
(d) . The County Shall be released from any and all responsibilities and obligations aris-
' lng from the Program covered by this Agreement; effective as of the date of termination, but the
County shall be responsible for payment of all claims for services provided and costs incurred by
the Contractor prior to termination of this Agreement, that are pursuant to, and after.the Contrac-
tot's compliance with, the terms and conditions of this Agreement. '.
(e) . Notice of termination must be in Writingl signed by an authorized official, and sent to
the other party by certified mail, or. by messenger, and receipt shall be requested.. Notice of termi-
nation shall be deemed delivered as.of the date of its posting by Certified mail or atthe time it is
delivered to .the other party by messenger. :
29. 'Severability; No Implied Waiver ..
(a) ' It is expressly agreed that if any term or provision of this Agreement, or the applica-
tion thereof to any person or circumstance, shall, to any extent, be held invalid or unenforceable,
· the remainder of this Agreement, or the application of such term or provision to persons or cir-
cumstances other than those as to which it is held invalid or unenforceable, shall not be affected
thereby; and every other term and provision of this Agreement shall be valid and shall be enforced
to the fullest extent permitted bY law.
(b) No waiver shall be inferred from any failure or forbearance of the County to enforce
any provision of this Agreement in any particular !nstance or instances, but the same shall other-
wise remain in full force and 'effect notwithstanding anY such failure or forbearance.
30. Merger; No Oral Changes
It is expressly agreed that this Agreement represents the entire agreement'of the parties,
that all previous understandings are merged in this Agreement, and that no modification of this
Agreement shall be valid unless written and executed by both parties.
END OF TEXT OF EXHIBIT A1
AG A1F (2/04)
Page 14 0f 14 pages of Exhibit AIF
Law No. AGOO4MIOO__-O617Y IFMS No. SCS' EXE 0000000
iI~cV. 4/7/04 'No. 001-6790/6774-4980-95284-
Nutrition Program (Supplemental Nutrition Assistance Program)
Exhibit B
Program Specifications For Nutrition Programs
1. Goals Of Program
The intended outcome of the Nutrition Program for the Elderly is to improve, maintain or
delay the decline in the nutritional status of persons 60 years of age and older and help them
to remain independent in their own homes and communities.
2. General
In general, but without limitation, the Contractor shall be required to meet the criteria
listed below:
^. .The Contractor will adhere to the requirements of the Suffolk County Office for
the Aging Policy .and Procedure Manuals and the Technical Assistance Packet.
B. Each meal must meet 1/3 of the recommended dietary allowance, special Iow
salt and basic diabetic diets must be provided to those clients requiring such
upon physician's order. The meal pattern and the amounts must follow those set
forth by the New York State Office for the Aging. All aspects of food preparation
and service must meet the standards of the Suffolk County Department of Health
Services, e.g., safe temperature of food - hot entr6e always served at a
minimum of 140"F, salad and other cold items served at 42°F or below, and
home-delivered meals delivered in 2 hours or under.
C. All nutrition programs which cook on site must hold a complete sample of each
day's meal(s), including all components except milk and bread, in the refrigerator
for 5 days for testing purposes. All nutrition programs which serve catered meals
must hold a complete sample of each day's meal(s), including all components
except milk and bread, if possible, or hold 3 tablespoons of each meal
component, in the refrigerator for 5 days for testing purposes.
D. All congregate sites will develop and maintain a Site Council to operate in an
advisory capacity for the program. The Site Council shall be composed of
participants in the nutrition program.
3. Contributions
The Contractor has the obligation to inform each recipient of the service of the
opportunity to make a free, willing and anonymous contribution toward the cost of the
service. Service may not be denied if a person is unable or unwilling to make a'
contribution. The Contractor must maintain an audit trail of all incoming contributions
and make monthly reports of any contributions received. All contributions must be used
to enhance services. All printed materials used for the program must include the
sources of funding for the Program and must include the following information:
Contributions to this (these) service(s) are free and voluntary. Any contribution
you wish to make will be used to expand the program and will be greatly
appreciated.
AG 4 (7/03)
Page '1 of 8 pages of Exhibit B
AG4M 03 RFP Model AGRMNT
L~,w No. AG004M/00__-0$/TY IFMS No. SCS EXE 0000000
· Rev. 4/7/04 No, 001-6790/6774-4980-95284.
IIIC Nutrition Program (Supplemental Nutrition Assistance Prograro)
Each recipient of service must be informed in wr!ting of the opportunity to contribute at
least annually.
In the congregate setting, the Contractor must provide a locked box and envelopes for
the suggested meal donations for the participants in order to protect the confidentiality of
program participants' identities and the amount which they contribute. The suggested donation
amount will be determined through consultation with the .Suffolk County Office for the Aging
and the Site Council.
(1) All sites must post the suggested contribution for program participants.
(2) Price of the meal for guests must b.e posted.
(3) The above two amounts are to be posted near the locked box.
For home-delivered meal participants, The Contractor must provide envelopes for the
suggested meal donations of the participants in order to protect the confidentiality of the
program participants' identities and the amount which they contribute.
4. Targeting And Outreach
The Contractor must give preference to providing services to older individuals with the
greatest economic or social needs .with particular attention to Iow-income minority individuals,
(42 U.S.C. §3025 (a) (1) (E)). The term "greatest economic need'! is defined as the need
resulting from an income at or below the poverty levels as established annually by the Office of
Management and Budget. The term "greatest social need" refers to the need caused by non-
economic factors which include physical and mental abilities, language barriers, social or
geographical isolation including that caused by racial or ethnic status which restricts an
individual's ability to perform normal daily tasks or which threatens such individual's capacity to
live independently (42 U.S.C.§302(21)).
The following four target groups have been identified as having the greatest economic
and social needs: minorities, Iow income, frail and vulnerable.
In order to comply with Targeting requirements, the Contractor must employ Outreach
Strategies which may include, but are not limited to, locating target populations using Census
or other resource data, translated printed materials, location of services in catchment areas for
targeted populations, publicity to community-based groups, and minority staff/volunteers.
5. Coordination
The Contractor must coordinate the delivery of services with other providers and
organizations to provide the most suitable outcomes and minimize possible duplication of
effort. In order to accomplish this, the Contractor will undertake activities such as, but not
limited to, participation in inter-agency meetings, coordination of referrals and follow-ups with
other local service providers, entering into agreements with other organizations for joint efforts
and/or funding, centralized assessment and maintaining up-to-date resource materials both
within and outside the Contractor's organization.
AG 4 (7/03)
Page 2 of 8 pages of Exhibit B
AG4M 03 RFP Mode[ AGRMNT
LaW No. AG004M/00__-06/7Y IFMS No. SCS EXE 0000000
Rev. 4/7/04 No. 001-6790/6774-4980-95284-
IIIC Nutrition' Program (Supplemental Nutrition Assistance Program)
Congregate Meal Program
A. The nutrition site shall be open as stated on the Summary Sheet, which is attached
and made part of this Agreement; fully staffed, during regular business hours based
on local need and available funding. Holiday schedules are to be posted one month in
advance at the nutrition site. The Contractor shall submit copies of all holiday
schedules and staff vacations to Aging.
B. The Contractor must provide participant transportation as needed and
supportive services as appropriate to the needs and abilities of each participant.
Supportive services mean education and training, information and referral,
outreach, public information, recreation, shopping assistance, socialization and
volunteer activities.
When viewed as a whole, transportation services must be accessible to people
with disabilities as required by the Americans with Disabilities Act of 1990 (P.L.
101-336) and the regulations thereunder (49 CFR part 37).
C. The Contractor must abide by standards set forth under both Section 504 of the
Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 (P.L.
101-336) and the regulations thereunder (28 CFR Parts 35 and 36) which require
that all programs and facilities (buildings, bathrooms, etc.) must be accessible to
the handicapped.
D. The site manager shall work closely with Aging's staff and other local agency
staff to provide a full array of supportive services for participants.
Home-Delivered Meal Program
A. Eligibility must be determined prior to the delivery of service by using the
standardized Client Assessment Provider Data System (PDS) (see Form -
Appendix O and Policy & Procedures Manual - Appendix L). Each client
receiving home-delivered meals must be reassessed at appropriate intervals
based on each client's situation, but in no instance less frequently than at least
once in each twelve-month period. The Contractor will also make a six-month
contact in the form of a home visit or a telephone call.
B. The packaging of meals must meet the standards of the Suffolk County
Department of Health Services. Aluminum foil partitioned containers are
recommended. In order to maintain safe food temperatures in delivery,
equipment approved by the National Sanitation Foundation must be purchased.
Menus, whenever possible and feasible, should be sent to the clients.
C. The Contractor must provide supportive services to the homebound client
according to his or her specific needs..The frequency of the supportive services
will be determined by the individual assessment. Nutritional counseling and
education must be included in this service.
D. . The Contractor shall provide a meal for those holidays and/or weather
emergencies that fall on a weekday. The holiday/emergency meals may be
frozen or canned and must be delivered the last business day before the holiday
AG 4 (7/03)
Page 3 of 8 pages of Exhibit B
AG4M 03 RFP Model AGRMNT
L~w No. AG004M/00__-06/TY IFMS No. SCS EX£ 0000000
Rev. 4/7/04 No. 001-6790/6774-4980-95284.
IIIC Nutrition Program (Supplemental Nutrition Assistance Program)
Sa
or weather emergency. In addition, an emergency supply· of shelf-stable food
should be made available twice a year for weather related emergencies. A list of
suggested food items is available from Aging, (see Policy & Procedure Manuals) ·
Reporting ReqUirements
A. The following forms and reports are required by the County to meet the
standards of the Nutrition program:
(1) Monthly Program Reports
Copies of the participant daily sign-in sheets must be received in Aging by
the eighth day following month's end.
The units of service/unduplicated count report, including targeting results,
(Nutrition or S.N.A.p. Services) is due the eighth day following month's end.
The activity report is due one week pdor to the month reported.
Menu forms are due four weeks pdor to the serving cycle.
(2) Monthly Fiscal Reports
SCOFA Forms NPAG 2 (congregate), NPAG 3 (home-delivered), NPAG 4
and NPAG 5 are due the eighth day following month's end. NPAG 4 and 5
are to be signed in ink by the site manager where indicated. The forms
listed above are found in the Policy and Procedure Manual (Appendix L).
(3) Demographics
The Contractor must at a minimum determine and maintain the following
specific type of demographic information for each individual receiving
services:
· Name.
Age.
Disabled/Frail.
Disabled - Any person who has a physical or mental impairment
which substantially limits one or more major life activities, has a
record of such impairment, or is regarded as having such an
impairment. This includes alcoholism and drag addiction.
Frail - A person with one or more functional deficits in the following
areas: physical functions; mental functions; activities of daily living
(ADL) (eating, bed/chair transfer, dressing, bathing, toileting and
continence); instrumental activities of daily living (IADL) (meal
preparation, housekeeping, shopping, medications, telephone,
travel and money management).
Live Alone.
AG 4 (7/03)
Page 4 of 8 pages of Exhibit B
AG4M 03 RFP Model AGRMNT
LaW No. AG004M/00__-06/7Y IFMS No. SCS EXE 0000000__
Rev. 4/7/04 No. 001-6790/6774-4980-95284-
lllC Nutrition program (Supplemental Nutrition Assistance Program)
· Rural. ..
· Low Income - The need resulting from an income level at or below
· the Poverty threshold, as established by the Bureau of the.Census,
and updated annually as follows:
· 100 % of poverty Threshold 150% of Poverty Threshold
(for IIIC Nutrition program(s))(for SNAP Program(s))
Size of Family Unit
1
2
$9,31 O/year ..$13,965/year
$12,490/year $18,735/year
· Minority - Those individuals belonging to one of the following
groups: Native American/Alaskan Native, Asian, Black, Native
Hawaiian/Pacific Islander and Hispanic.
· Low Income Minority- Those minority persons whose income is at
or below the poverty threshold.
Contractor's Staff
A. The Contractor agrees to employ adequate numbers of qualified staff and
supervisory personnel to meet all the specifications and responsibilities of the
program in a orderly, punctual and reliable manner. Personnel involved in all
aspects of food handling and preparation are to be in good health and trained to
ensure the safety standards of the food prepared and served. A full-time
manager/supervisor will direct and coordinate the daily operations. All meetings
and trainings required by the County are to be attended by the appropriate staff.
The Contractor will have on file with Aging the procedures to be followed by
workers and other staff in case of emergency.
The County shall have the dght to pdor approval of the filling of any site manager
position and shall be advised by the Contractor of the duties and compensation of
all personnel assigned to the Nutrition Program for the Elderly Program.
10. Confidentiality
A. The Contractor agrees that-no personal information obtained from an individual in
conjunction with this program shall be disclosed in a form in which it is identified
with the individual without such individual's written consent to such discl0sum,
except to Aging.
B. In the case of a request by Aging for names and addresses of individuals
participating in the program, the Contractor shall furnish such information as
requested. Failure to comply with a request by Aging for such information shall
be deemed a material breach of this Agreement and shall result in a freeze on
all monies due and owing to the Contractor until compliance by the Contractor,
11. AdminiStration
A. Overall administration of this program will be the responsibility of the Contractor.
The Contractor or its designee will insure proper implementation and direction of the
AG 4 (7/03)
Page 5 of 8 pages of Exhibit B
AG4M 03 RfP Mode] AGRMNT
LaW-No. AG004MI00__-06/7Y IFMS No. SCS EXE 0000000
Rev. 4/7/04 No: 001-6790/6774-4980-95284.
IIIC Nutrition Program (Supplemental Nutrition Assistance Program)
service, act as liaison between Aging and the actual service and insure accuracy
and timeliness of submission of all repoKing forms and expenditures.
· B. Program staff shall attend meetings and training as requested by Aging.
C. Attendance by site managers at site managers' meetings and training sessions
is mandatory. Transportation to these meetings must be accomplished without
decreasing transportation services to the Program.
12. Grievance Procedures
In accordance With {}306 (a) (6) (P) of the Older Americans Act, as amended (OAA),
Aging has established a process for resolving complaints from older persons who are
dissatisfied with or denied services funded under Title III of the Act. The Contractor shall
comply with the requirements of the Grievance Procedures as set forth in Exhibit E-
Grievance Procedures.
.13.
14.
Monitoring
A. Financial Transactions
Aging's staff and staff of the New York State Office for the Aging may examine
or review evidence regarding the existence, timing and classification of financial
transactions that are charged to the program for reimbursement..To obtain this
evidence, such staff may examine documentary evidence, including financial
statements, financial reports, etc., and original records. Such staff may make physical
verification by actually observing or counting certain assets (e.g., cash, equipment and
supplies) to establish their physical existence. The Contractor shall cooperate in
Aging's periodic physical verification of cash, food, equipment, supplies and other
assets of the program.
B. Program
The Contractor agrees to permit Aging's staff and staff of the New York State
Office for the Aging to review program records and to monitor training, supervision and
services at any time.
Miscellaneous
A. It is the responsibility of the Contractor to have an identifying logo in equal sized
lettering on any printed materials and on all brochures, flyers, and advertisements
(including without limitation television graphics), and on Program vehicles, as follows:
Purchased with Federal Funding:
Funding provided by the
Suffolk County Office for the Aging
and the
U.S. Dept. of Health and Human Services
Through the New York State Office for the
Aging
Purchased with State/County Funding:
Funding provided by [the}
Suffolk County [Office for the Aging]
[through the New York State Office for the
Aging]*
Any announcement of the Program on radio or television must identify funding by
[the] Suffolk County [Office for the Aging]*, the U.S. Department of Health and
Human Services and/or through the New York State Office for the Aging, as
applicable.
AG 4 (7/03)
Page 6 of 8 pages of Exhibit B
AG4M 03 RFP Model AGRMNT
L,~w No. AG004M/00__-06/TY IFMS No. SCS EXE 0000000'
Rev. 4~7~04 No. 00'1-6790/6774-4980-95284-
IIIC Nutrition Program (Supplemental Nutrition Assistance Program)
B. The Contractor must establish a formal system of soliciting comments from the
participants concerning meals, transportation and supportive services.
C. The Contractor shall comply, and shall require its officers and directors,
partners, trustees or other members of its governing body and personnel
employed to render services under this Agreement, to comply with all applicable
rules, regulation and requirements of law, including without limitation, the
Americans with Disabilities Act, and the applicable Policy and Procedure manual
issued by Aging, and the Technical Assistance Packet, which have been made
part of this Agreement.
Omit the words that are not applicable.
AG 4 (7/03)
Page 7 of 8 pages of Exhibit B
AG4M 03 RFP Model AGRMNT
Law No. AG004M/00__-06/7Y IFMS No. SCS EXE 0000000
Rev. 4/7/04 . No. 001-6790/6774-4980-95284-
IIIC Nutrition Program (SupPlemental Nutrition Assistance Program)
GENERAL FOOD SPECIFICATIONS
FOOD SPECIFICATIONS FOR CYCLE MENUS
Meat or Alternate
Meats - USDA Choice or Better
: Preservatives, tenderizers, or coloring agents may not be added to any fresh meat or
fresh meat product.
Veqetables and Fruits
All fresh fruits and fresh vegetables must not contain bisulfates.
All fresh fruits and fresh vegetables must be washed.
Fresh Fruit
Minimum Size
Oranges 113
Apples 120
Bananas 150
~ cup represents drained weight of fruits and vegetables
Frozen Vegetables - Grade A - Fancy (USDA)
Canned Vegetables - Grade A - Fancy (USDA)
Marqadne -from liquid vegetable oil and fortified with Vitamin A
Bread/Alternate - whole grain or enriched
Instant Mashed Potatoes must be fortified with Vitamin C
Milk - Vitamin A & D fortified skim or Iow-fat milk - 3 days lead time from day of service
Desserts .
Gelatin - fortified with Vitamin C
Milk-based puddings used for pudding mix
canned Fruits - Grade A - Fancy (USDA)
Canned Fruit Juices - Grade A- Fancy (USDA) - fortified with Vitamin C
Frozen Fruits - Grade A - Fancy (USDA).
All foods shall be obtained from State or Federal inspected plants.
- END OF TEXT OF EXHIBIT
AG 4 (9/00)
Page 8 of 8 pages of Exhibit B
AG4M 03 RFP Model AGRMNT
IFMS No. SCS EXE 0000000
No. 001-6790-4980-95284-
,Law No. AG004M/0003-06R
Rev. 5/5/04
IIIC Nutrition Program
CONTRACTOR'S RESPONSE
TO SECTION IV
RFQ No. 3/15524VH
AG 4 (7/03)
AG4 sohid 3c 04
~., ~ ,, SC Purchasing RFQ No. 3/15524VH SC Law No.'AG__
RFQ For Nutrition Programs for the Elderly
Section IV
Technical Services Response Form
PROGRAM DESIGN, FACH,ITIES, DOCUMENTATION, SERVICES AND ACTIVITIES:
This response form will become incorporated into Exhibit B to the Agreement
1. Prouram Design
A/II. Southold Town Senior Services is a multipurpose senior center that has provided nutrition and
support services to Southold Town ~esid,e.nt's age 60 and older since 1974. The Center is located in the'
hamlet of Matlituck and is in close proximity to Mattituck village, public transportation, shopping, banking,
etc. The s~rvice eatchment area for Southold Town's nutritional program is the North Fork of Long lsland,
an area of approximately 70 square miles. Because of its vast rural nature, vital aansportation is provided
to our senior participants viabas or vain There are 13 vehicles assiguedto tho Senior Center for the
purpose of delivaring meals to ~he homebound and transporting seniors ~o the Center. Southold Town is
proposing to continue provicling nutrition and supportive services to senior citizens 60 yea~ of age and
older. Our intent is to improve, maintain or delay the decline in their nulritionel st~ while helping them
to remain independent at home and in their community. We currently serve an average of 69 congregate
meals and 156 home delivered meals daily.
Our center is a licensed.food aa-vice establishment with Suffolk County Deparanent of Health (see
attachedDOHcer#ficate/$e~ 1K3 #1). Our dedicated staffis committed to serving quelily meals with a
high nutritional value (see attachedmenux/,~ec. ]K3/~4). All meals and supportive services are pwvided to
Soathold Town reddems aged 60+ and meet the nulrifianal requiremants set forth in Exin'bit B Program
Specifications. Dietary modifications are provided for special health requirements (diabetic and low
sodium diets). We also reasunably accommodate participants who have particular divtary needs arising
from religious requkemants or ethnic backgrounds. All menus are submitted to ~he Registered Dietician
with Suffolk County Office for the Aging for prior approval.
Thc Center was recently ranovamt, fully accessible to persons with disabflitics and is in ~ compliance
with the g:inericemq with Disabilities Act. The Center has a maximum capacity allowa~e of 175 and is
cempl~c with dinhag room seating for 100. We also have a new, fully equipped commers~al ldtchcn, h
addition to the senior nutrition program, Southold Senior Services offers a full range of t~-~ational and
compmhansive supportive services to Town residents 60 years of age and older. (See attachment ff. 1.21.).
B. 1. Congregate Meal Program:
Soathold Town Senior Nutrition Canl~ is open 5 days a week, Monday through Friday (except for legal
holidays). Our hours of opecafian ace from gum - 4:00pm. Our objective is to provide senior residents
wi/h a nutritions daily meal, as wall as a comm~mity-meefing place where they can enjoy recreational
programs and social activities, with full supportive services available on site as needed. (,gee attachment
Sea ff. $ #5). All meals meet 1/3 of the RDA (Per E~hibit B. Program Specifications). Meals are served
at 12 noon and lransportation is available. The suggested confidential voluntary conto'bufian is $2.00
meal and no one is denied service due to inability or unwillingness to pay. All parficiparg conln'butions are
used to ~qmnd services. Our professional sto~is on site to assist seniors at all times.
Since safety is a high priority, the Senior Center is fully equipped wilh fire and smoke detection alarms and
fire suppression ~quipment. We are known to the local fire dapadmant and ar~ monitored by lhe C,~ntrsl
Si~ainn of Suffolk Security Systems. Fire eva~uatinn plans aw posted and fire drills am held twice yearly.
Our center is inspected ragu]arly and meets all fire safety standards for areas of public safety. (~ee
attachedSe~ ff.3 #2/6).
SC Purchasing RFQ No. 3/15524VH SC Law No. AG__
RFQ For NutritiOn Programs for the Elderly
Section IV
Technical Services Response Form
PROGRAM DESIGN, FACILITIES, DOCUM~ENTATION, SERVICES AND ACTIVITIES:
This response form will become incerpormed into Exhibit B to the Agreement
IV. 1. B. 2. HomeDelivered Meal Program:
Southold Town's NuUition Program furnishes home-delivered meals to senior residents aged 60 + under
the Supplemental Natrition Assistance Program (~¥.4P). Priority is given to the frail, unlritienally at-risk
elderly. All meals are cooked on site and meet 1/3 of the RDA. Our program adheres to all policies,
procedures and specifications for Nutrition Programs for the Elderly az set forth in Exln~it B. Elilp'bility is
determined prior to the delivery of service by using the standardized Client Asseazment/Provider Data
System (PDS). Each client receiving home~-delivered meals is reazsessed at appropriate intervals based on
the individual's situation. At a minimum, clients receive a six-month contact by telephone or in person and
an in-home annual review in each 12-month period. The PDS client assessment helps determine what
supportive senaces are needed and the frequency of ~hose services, l~luffifion screening (NSI), provided to
clients az part of the PDS in-home assessment has greatly assisted us in identifying those individuals
nutritionally at risk.
Hume-delivered meals are prepared on site and packaged in 3 compartment disposable aluminum trays.
All packing and meal delivery procedures meet fl~ safe food handling standards set forfl~ by Suffolk
County Department of Health and Nutrition Progrem specifications, (i. e., hot entrde's are served at
minimum of 140 degrees Fahrenheit with salad and other cold itevts served at 42 degrees Fahrenheit or
below. (Exhibit B)). The Towncen'entlyhaz five homebound meal routes throughottt our eatchmant area.
Meals are Wausported in special carriers to maintain temperatures and delivered in less thru 2 hours. Mcais
are provided for those holidays and/or wenther emergencies that fall on a weekday and are delivered the
last business day beforehanck Additionally, emergency abelf stable meals are distributed at least twice
yearly for. weather related emergencies.
2. Program Description & Methodology
A. Food Service:
Southold Town Senior Services Nutrition Preg~m has over 29 years experience in providing
institutional food service. Our professional kitchen staff prepares all meals on site. (All meals
meet the RD.4 and all specifications for nu~rition programs set forth in Eachibit B). Food is
uniformly portioned and served promptly at noon. The kitchen is a fully equipped commercial
Idtehen and offers suitable storage for food supplies, dry good% ~ozea and refiSg~rated food
produc~. All food and supplies are ordex~ in bulk for optimal prialng and availability. The
Centor follows the Town's precerc~nent policy az set forth in General Manieipal Law Section 103,
relative to formal bidding of food, supplies and equipment. The Center serves an average of 69
congregate and 156 home delivered meals davy. (Based on 2002 program year). A sample six-
week menu cycle is incinded for your review (see attachment Sec IE3 gl).
.2.
Southold Town Senior Services employs a full kitchen staff consistin4g of a cook, assistant cook,
five food service weske~ and one kitchen aide. (Title Venrollee). No component of our food
service opersXion will be subconlracted to outside services.
SC Purchasing RFQ No. 3/15524VIt SC Law No. AG
RFQ For Nutrition Programs for the Elderly
Section IV
Technical Services Response Form
PROGRAM DESIGN, FACH,rI'IES, DOCUMENTATION, SERVICES AND ACTIVITIES:
This response foun will become incarporated into Exhibit B ~ the Agreement
IV.2. B. Supportive Services:
In addition to our nutrition programs, seniors am provided with a comprehensive army of support
services designed to meet their many needs. Recreation programs, activities, trips and special
events are offered regulurly. Commur~ oatreanh and education i~ provided alcog with individual
c~e management service and entitlement counseling. Caregiver support programs are offered
along with full day Senior Adult Day Care; ot~ Residential Repair Program is available to assist
seniors with minor home repairs. We also have a Telcphoue Reassurance Progann in which
volunteers provide daily phone contac~ to homebound seniors.
In addition to regular route transportation services, we provide demand responsive Iraasportafion
for seniors W medical appoin~nant~ grocery shoppihg, etc. All support services/activities are
printed on a monflfly calendar, posted in the Center ~:I distributed to all homebouad meal
recipients (See attacl~ent ff .$ #5).
C. Transportation:
Soufl~oM Tox~ Senior Services provides both "Regular Route" and "Demand Responsive"
transportotion. Regular rou~e scrvice is provided to and from the Senior Center &fily. Regularly
schednied trips for shopping, senior citizen dub meetings and recreational events fall under this
service categoiy. Demand Responsive tl~xsportafien is reserved for seniors fo£ medical escort/
assistanea and is provided on a reservefion basis. Transportation setvises are avaiiahie to al/
seniors 60+ residing in Santhold Towm We currently have 13 vehicles dadicatedto this program,
four of which are handicapped!wheelchair access~le. Sure,ce is not restricted to Town boundaries
and we often Wansport seniors for medical services to R/verhead and point~ west ~ far as Stony
Brook University Hospilal. We have experienced an increased demand for tmmportation services
since last year and have worked diligently to service the needs of our senior residents to meet ~
demand. The average number o f one-way passenger trips provided mentldy ]m~ increased from
1,073 in 2002, to 1,383 in 2003, a 29% increase in service.
The Southold Town Highway Dapermaent maintains and repairs all vehicles as ~cessary. Our
Senio~ Clerk Typist schedules aH Iransportation services and maintains our fleet ~aventory, service
recerda, and mileage reports for all Town and Suffolk County owned vehictes.
D. Targeting:
Our goal in providing nutrition and support services to the elderly is to ~ as many seniors as
possible that need and can benefit from our program particularly the frail, low-income, minurity,
elderly who are nutritionally at-risk. We have broadened our efforts in comm~ll~ly otl~ee~h to
include a new web site dedicated to informing seniors, a speaker's bureau and regular
announcements in the Town Supervisor's newsleUer that highlights Senior Services. This
newsletter is distributed quarterly to all Town residents. We also continue e~ds~g practices of
public service aenounce~nents, guest appearances on cable television, dis~butien of program and
informational brochures and activities calandar throughout the Town, ongoing program
anentmcements in the Suffolk T/mos Community Calendar page, uad Senior Sourcebank_ We also
employ ongoing enu'cech efforts to medical fac'titles, deetur's offices, senior citizen club
meetings, local churches, and other special groups or organi~'~ioas th~ focus on ~erving our
senior population. Suffolk County Office for the Aging has also assisted ns in our ou~each
efforts.
~: SC Purchasing RFQ No. 3/15524VH 'SC Law No. AG__
RFQ For Nutrition Programs for the Elderly
Section IV
Technical Services Response Form
PROGRA3~ DESIGN, FACILITIES, DOCUMENTATION, SERVICES AND ACTIrVlTIES:
This response form will be~me incospura~ed into Exhibit B to the Agreement
Eu
Targeting the low-lncome miner~ elderly riving in Southold Town particularly in the Village of
Greenport (4% of seniar~ in our catchment area in this category) is a high prinri~y. We have
increased vis~ilRy and access to our programs, particularly in the Village of C~eenport. We have
provided additional bus service to the ama and have had frequent contact with church and
commmtity leader~, as well as other agencies serving the frail, low-income mienIily community. [
sit on the Board of Directors of Commul~ Action of Southold Tovn~ lo~ated ~ G-reanport. This
has afforded me an opportuaity to promote our services in the Greunpurt V'dlage. Our efforts have
been successful in that our service delivery to our targeted low income, minorRy popalatinn has
inereased beyond 4% for 2003.
Our additional target popu]afmn is the kosher population. Ouixunch efforts willinclude contact
v~.tha Rabbi Ulrych at the T/fereth Israel Synagogue in Groeupurt to schedule an informational
presentation to the congregation_ '
Coordination:
Southold Town sponsors a monthly me~ting of the Town's Commi~e on Health Care Issues and
tho Elderly. Thc committee meets regtdarly and has a diverse group membership representing
health care and commtmRy service providers ~m both the private and pubNc sectors, The
meel~g provides netwerldng opportunities for professionals and allows for a valuable exchange
ofinformatian and coordination of the resources available to our senior population_ The
commiV~eo also provides a mechanism for minimizing duplication of programming for improved
surviecs to seniors.
Within our agency, the PDS assessments allow us to maintain a comprehensive record on each
client we serve and assists us in optimizing coordination with formal service providers. Our
professional staffreviews and discusses our clientele at reguinr intervals in order to develop the
most appropriate, individualized care plan and follow-up services. Program s~ffshares common
office space, which provides for optimal information exchange and improved coordination of
service. A confidential log shvet is maintained in our main office that reflects daily status changes
thai occur with each individual client- Program staff accesses this log daily and provides follow-
up ~.curdingly. The log s~rvas as an internal mechanism to reduce duplication ofsurvicas
provided to our program participants by our stafl~
Client Assessment Provider Data System (PDS): '
Joaane $ohn~on and Phifftp Bel~ (See attached resume~ Sec ff.$ #7), serve as our prknary PDS
assessors. Ms. Johnson holds a BA degree in Behavioral Science/Commanity Mestal Health and
has completed ongoing training in completing client assessments with Suffolk County Office for
the Aging (SCOFA) and Southold Senior Services. Ms. Johnson has been with our agency for
four ye~s and has been ~oponsible for overseeing the home delivered meals program. PIfil]Jp
Beliz, MSW, has extensive experfence in Social Work practice and assists our agency en a part-
time basis completing in-home PDS assessments, in additien, both Carol Beale and myselfase
proficient in completing the PDS and offer assistance as m~led to avoid sen, ice interruption or
.PAGE..02
SC l'urchasing RFQ No. 3/!5524VH
· · SC Law No. AG
R~Q For Nutrition Programs for th~ Elderly
IV.2.-- g. -.. Addendum:
Client Assessment Provider Data System {lq}S)
PD$ A~sosment~·
Aa sum~d in RI:Q, Cheryl gas~a~ll Ixas be~ with o~ cL~'~t~t f~ ov~ a ~. ~a is
~ ~r~e h~ ~ ~e f~ ~g PDS' ~m 5~ ~ 75%. We also ~ gl~ Io ~ up
~old To~ ~1 e~r s mi.im,~ of2S= cli~ files ~m ~a PDS ~ b~e mo~y ~
I am ccmfid~. ~l~t We ~i]l re~h our 10~% mrg~ for PD$ ~nlry
'Onto ~he backlog of c. ss~ is cnzea~d zhe nc~mbea- of cases entered will colacMe ad
thc humbert ofn~v PDS' gcxtca'ared per month,
~ SC Purchasing RFQ No. 3/15524VH SC Law No. AG
RFQ For Nutrition Programs for the Elderly
Section IV
Technical Services Response Form
PROGRAM DESIGN, FACH.ITIES, DOCUMENTATION, SERVICES AND ACTIVITIES:
This response form will become inconporated into Exhihit B to the Agreement .
c~ient asseSSments (PDS) are completed on all seniors who request home deliv~.ed meal service,
service. Exceptions are made for emergenvy situations or hospital discharges, at which time a
PDS is completed within 72 honm Service is hritiated when a cliang family membex or other
eervice provider makes a referral by calllng the Cel~ter. An intake is completed ~th basic
information provided and an initial home visit is scheduled with the f~m{ly to complete the fur
PDS asses~nent- Once eligfbllity is determined, the client is provided service in a timely manner.
Each client is provided with a packet of information, which includes our program policies and
procedures, and a complete list of the supportive services we offer. Six month follow up contact is
made by telephone to each client and an in home visit is completed at least once annually by our
PDS assessors.
Cheryl Knswell, Account Clerk Typist, has been with our agency for over a year. She is proficient
with the computer and is responsible for entering all clients ia the PDS datebase. We are currently
using the Windows liT application. Technical nssistence has been provided by SCOFA on a
regular basis. Our computer equipment is suitable for PDS purposes.
Other Resources:
As a division of Soutlmld Town government, Senior Services is affordfa:l the many services and
resources of the Town. Our building cleaning and mainte~auee, both interior and exterior is
provided by our Department of public works. Our Highway Depaament mainteiss and repairs our
vehicle fleet, keeps our perldng lot and walk'ways clear of snow and ice in inclement weather, and
provides sanitation services. The Towns Accounting and Finance Department pn~cesses all
vouchers, revenues, expenses, payroll and fi~cinl records. The Town Police DeparUnent
provide emergency assistance as needed and maimains regular contact end makes appropriate
referrals to our department for frail elderly residents at risk Our Recreation Department provides
an array of scniur trips end recreational activities that our seniors participate in. They also have
two very active Senior Citizen Clubs that meet rogulgly and are politically active. Meny of our
program purficipants benefit from senior club membership. The Assessors Office provides home
vises to assist senier~ in completing senior tax exemption end STAR applications. Our Town
Supervisor is very supportiw of our programs and handles all public notices and f~atures our
department in his querterly town-wide newsletter.
Senior Service also ~oo~]|nates with outside agencies and human service provlde~ that serve the
senior population of Southold. Our agency has t~equent contact and coordinates many services
with the following agencies: San Simeon Nursing Home, Eastern Long Island & Central Suffolk
Hosphals, Peconic Lauding, Dominlcen Sister, Lew~ U/op/a, Peconic Bay and Catholic Sisters
Home Health Agencies; Catholic Charilies, North Fork Parish Otureueh, North Fork Honshg
Allimlce, Comm~mity Action of Senthold Town (CAST), American Red Cross, RSVP, Keyspan
Energy, Family Service League, Peconic Community Council, Sttffolk County Office for the
Aging, Department of Social So-viees, Adult Protective S~rvices and Mobile Crisis Team.
Our Center is also a host site for our local school districts for community service projects and a
field placement site for medical inten~ from Stony Brook Uniwrsity Hospital and Social Week
stndco{~{ from the Stony Bwok School of Social Welfare. Other voinnteer opportunities ere
provided to senio~ through our Telephone Reassoraneea[SVF pragl'am.
SC Purchasing RFQ No. 3/15524VH SC Law No. AG__
RFQ For Nutrition Programs.for the Elderly
Section IV
Technical Services Response Form
PROGRAM DESIGN, FACILITIES, DOCUMENTATION, SERVICES AND ACTIVIIIES:
This response form will become incorporated into Exhibit B to the Agreement
Contribution Policy:
Seniors participating in our nutrition programs are informed of their opportunity to make a
volunmxy and confidenfiaI conlau'bation for the cost of the meal. For congregate meal participants,
a contribution sign is posted and visible that states our funding sources, our sponsoring agency
(SCOFA), our $2.00 suggested contn'bution, end that NO one is ever denied a meal due to
unwillingness or inability to pay. Envelopes are provided for thek anonymous eantribmions and
placed next to a locked box in a private corner oumide efthe ma'm o~ee. Seaior~ place thek
conh-ibutien in the box if they desire. For home delivered meal participants, an unmarked
envelope is provided by their driver on Thursdays with their meal Clients have au opportunity to
return their envelope to their driver, who returns it to the Center ~fr All homebound meal
recipients are given a letter prior to start of service and ennually thereafter, explakfing our
contr~ufion poficy and procedures. The letter clearly states that all conlributions are voluntary
and anonymous and that NO one will be d~nied service for inability or enwJllingness to pay. Ail
nutrition program participants are also informed that all contrfi~ulions am used to expand services.
3. Documentation:
The following documen~fion is included as at~chments and referred to in our proposal.
1. Permit from Suffolk County Department of Health Services.
2. Permit Southold Town Building Department.
3. Food Handlers' Certificates.
4. Six-week sample menu_
5. One-month activity schedule & list of support services.
6. Notification to the Matlituck Fire Department
7. Project Staffresumes.
8. Exhibit B - Progrmn specifications for Nutrition Programs.
SC Purchasing RFQ No- 3/15524VH "'. SC Law No. AG __
RFQ For Nutrition Programs for the Elderly
SectiOn IV' · ' "
· T~hniul Services ResPOnse Form' .
pROGRAM DESIGN, FACILI]-I~, DOCubt]ENTATION, SERVlCF. S ~ ACTIVI'I'tES:
IV.I.B. 1. C, Emerl~eney Msnngement:.'
The Seagor Serlio-es Di~,a.tar is part of the ~y M~[ T~ ~ S~old T~ ~e H~
~ C~t~ is a ~s~*~ n~-m~c~ ~ ~ ~6on ~el~ for ~e T~. ~e ~or
. el~ly. ~c ~ ~d ~ss ~ ~ ~ shel~ ~1~ ~ ~fio~ ~ ~
~cim.
For all seniors, thc locaJ radio simions broadr~ instn~-t*ions for emerg~cy preparedness and direr the~
t~ ~he app, up~ialc ev~-u~|on centre. In ~ ~his [~s~ August our cerm~ ~a~ op.m~d as an cu~r~mcy
shc]~cr during the blackout_
Ifth~ Cea.let is cJosed e'~ly for a weather' r~l.f*~d ~, all ~i~ ~ ~s~~ to t~ ho~. If
&e ~ is clo~ ~io~ ~ al~ ~a te I~ ~o s~ff~. All se~ on hu~ ~Ii~ed ~d
co~ me~ ~ ~ ~d ~ a ~k~ of ~o~ ~ follow ~ ~e evmt of~ ~gm~
~_ m &c ~ close. ~ ~y ~, om ~ ~af~ ~n w~ ~o ~g~ ~vi~d. 'All
' home deli~r~ m~l ~ci~ ee ~vi~ ~t ~ ~m me~ to ~m M ~e ~t ~ v~
~v~ ~ ~ly ~li~ ~e ~ ~e ~, ~ ~ ~ ~l c~lcd ~ ~c ~ly m~g ~d
KAREN MCLAUGI:HJN
SENIOR CiTiZEN
PROGRAM DIRECTOR
Human Services
~pwn of Souflaold
P.O. Box 85
750 Pacific Slreet
Mattitucl~ NY 11952
Tel. (631) 29g-4460
Fax (63 D 298-4462
Attachment W.3 #6
Nu~ilion Program
Home Delivered Meals
· Case Management
Essential Transporlation
Senior Adult Day Care
Alzh¥~ner'$ Day Care
Telephone Reassurance
October 27, 2003
Chief Edward Hanus
Mattituck Fire Dept
1000 Pike Street
Mattituck, NY 11952
Dear Chief Hanus:
In compliance with our regulations from the Suffolk County Office for the Aging, I am
notifying you in writing of the nature and location of our Senior Center.
Southold Town Human Resource Center, located at 750 Pacific Street, Matfituck serves
as a multipttrpose center for senior residents of Southold Town. We offer a variety of
programs including a congregate dining program, community education and outreach,
recreational activities, home delivered meals program and transportations services.
Our social model Senior Adult Day Care Program operates in our artnex called
"Katinka House" and serves 20 frail elderly participants.
Our hours of operation are 8am to 4:30pm Monday flu:ough Friday. Out center's fire
system is monitored at a central station and regularly maintained by Suffolk Security
System. Our fire suppression system is also closely monitored and maintained by All
Island Fire Protectioxt
Please contact me at 298 !~60 if you have any questions or would like more information
about the Senior Center. Thank you.
Since y,
~MY~u§hlin
Director of Senior Services
· · IFMS No. SCS EXE 0000000
No. 001-6790-4980-95284-
Law No. AG004M/0003-06R
Rev. 5/5/04
IIIC Nutrition Program
Exhibit C
Rate Page
(Response to Section V of The RFQ)
· TOWN OF SOUTHOLD
CONGREGATE PR 0 GRAM
Proposed Schedule of Fees for Services
First Contract Year
Second Contract Year
Third Contract Year
Congregate Meals
$4.47
$4.60
$4.74
AG 4 (7/03)
AG4 sohld 3c04
Exhibit D
Grievance Procedures
1. Purpose ..' .
In accordance with §306 (a) (6) (P) of the Older Americans Act, as' amended (OAA), the
Suffolk County Office for the Aging has established a process for resolving complaints from
older persons who are dissatisfied with or denied services funded under Title III oflhe Act.
2. 'Notifying Participants of the Right to File a Grievance
(a) The contractor Shall inform all participants in the program Of the dght to file a
grievance. A summary of the procedures, including a statement that assistance to file shall be.
provided to older persons, must be prominently posted at service delivery sites or offices at
which participants and s.ervice applicants apply for services. Summaries must be in a format
approved by Aging and shall also be written in languages other than English where required to
serve the clienlJapplicant population. Service participants shall be informed of the grievance
procedures 1~hrough written and verbal statements provided to them upon.assessment and/or
reassessment for services. ·
(b) A participant or applicant who is denied Title Ill services by the Contractor and
the Aging program monitor must be given the reasons for the denial. The denial shall be
confirmed in writing and the applicant informed of the right to file a grievance and to whom the
· grievance shall be addressed. For services which are applied for by telephone or verbally, in
person, .the client may be told of the right to file a grievance verbally. '
3. Grievance Process
(a) Filing of grievances must follow the following process:
i. Pafficipants must submit their grievances in writing to Aging's Program
Administrator.
ii. The grievance should be filed within thirty (30) days of denial, reduction or
termination of services, or of the event or circumstances with which the
participant is dissatisfied. Aging's Program Administrator may grant an
extension for good cause shown.
iii. The grievance should be filed on the form approved by Aging, which shall
include a written statement setting forth in detail the date, time and
circumstances that are he basis of the complaint.
(b) Investigation and Response to Grievance:
· i. · The designated reviewer who performs theinitial review shall investigate
the grievance, including, as appropriate, meeting with the grievant and
-.. other persons involved.in the action(s) complained of or in the denial of
services. ..
· ii. The reviewer shall review all pertinent facts and/or documents, and shall
determine whether the agency action was made in accordance ~vith lawful
procedures (that is, consistent with applicable OAA and or State laws,
regulations and policies) and supported by the facts.. '.
Rev. 5121103
· ' Page I of 2 pages of Exhibit D
The designated reviewer shall prepare and send a written response to the
grievant and to Aging's Diregtor within fifteen (15) days after the · ..
grievance is fi]ed. The response shall set forth the circumstances relating '
to .the grievance, the action requested by the grievant, the findings of the
reviewer, a proposed remedial action., !f any, and. reason(s) for and facts
relied on in the determination. .
(c) ApPeal of Initial Response/Decision " "
" i. The' grievant may initiate a request for subseqUent review by Aging's
Director within twenty (20) calendar days following receipt of notification
by the Program Administrator of the decision.
ii. Aging's Director shall request copies of the initial file on the complaint in
question. Aging's Director will review the materials to ensure that
pertinent pglicies and procedures have been applied and followed. If
appropriate, Aging's Director or his/her designee will meet with the older
person to al!0w the grievant an opportunity to present !nformation about
the grievance. ·:
iii. If the policies and procedures have been adhered to, Agi'ng's DirectOr will
not overturn the decision of the Program Administrator. If proper policies
and procedures have not been applied, Aging reserves the right to
overturn the decision. The subsequent review shall be completed within
forty-five (45) days of receipt of the request by the older individual and the
· grievant will be notified in writing of the result of the subsequ.ent review.
4. Record Keeping
Aging shall keep the records of the grievance and its handling for six years following
the conclusion of the calendar year of the occurrence. The file shall contain, at a mthimum, but
not limited to the initial grievance, any investigative reports; any written response submitted by
Aging or the service provider aging; any documents or other records submitted by any party;
the written Initial Response of the agency, and, if applicable, the notice to the gdevant of the
right to an appeal.
5. Confidentiality
No information, documents or other records relating to a grievance shall be disclosed by
program staff or volunteers in a form that identifies the grievant without the written informed
consent of the grievant, unless the disclosure is required by court order or for program
monitoring by authorized agencies.
-- End of Text --
Rev. 5/21/03
Page 2 of 2 pages of Exhibit D
Exhibit E
Client sessment
Date: 04/21/2003 '.' I
Assessor's Name:· . . :. Ini[ialAssessmeJ]t Date: · .
· - - Agency Name: .. Intake Date: ' ' :'"
Reason forAssessment: . . : Agency Code: · · · ·
Source of Info.: : ' ' · · (Re)Assessment Date: . · .
,CLIENT INFORMATION
· Soc'Sec #:
' Name:
'Address:
Cit~.
Floor:
Phone:
DOB:
E-mail:
Marital. Status: [] Divorced
[] Married
[] Separa!ed
[] Single
[] WJd0wed
· .' · State:
Elevator:
Steps:
Age:
Zip:
Homeless:
Living Status: [] Alone
[] With Non-Relat
[] With Relatives
· [] With Spouse
ApL #:
CD Code:
Cross Street: ·
· Borough/County:
Gender:
Num in house:
Race/Ethnlc!ty: [] Amer. lndian/Nat. Alas
[] AsiaEPaci§c Islandel
[] Bla~ not Hispanic
[] Hispanic
[] Other
[] White/non-Minority
Veteran Status: Languages (Rate abi/ily Fluent, Ability
Moderafe, or Basic.)
Veteran? Primary:. Speaks
If yes, Disabled? . . Reads:
Understands:
Spouse a Veteran? Secondary:. Speaks
Reads:
Undemtands:
Language Comments: .
Country of Origin:
Does Client Have A Medicare Card?
Does Client Have A Medicaid Card? '
Is the Client Receiving Medicaid Homecare? .
[] Yes 'l-i No.
[] Yes [] No
[] Yes [] No
~ONTACT LIST
Please note the following contact classifications here: . ..
Emergency, Informal Suppor~ Lives With, Neighbor, Who Has the Key? ' ' · ' ' '
Client Assessment ...,
Date: 04/21/2003
contact list continued~)
Emer.qency Contact:
Name:' ':
Address:
Phone Number.
Relationship:
classifications: ·
Emerqency Contact:'
Name; . ..
Address:
Phone Number:
Relationship:
Classifications:
Classifications:
Name:
Address: .
Phone Numbe~
Relationship:
Classifications:
Name:
Address: ·
Phone Number:
Relationship:
Classifications:
Name:
Address:
Phone Number:
Relationship:
Classifications:
Name:
Address':
Phone Number.
Relationship:
Classifications:
Address:
Phons Number:
Relationship:
Classifications:
Name:..
Address:
Phone Number: '.
Relationship:
Contact Notes:
MEDICATIONS · ·
Medication Dose/Frequency : Comments
"'"' i'" ; Client AsseSsment
· . Date: 04/21/2003
Does [he client have any prohiems with medication?
[] Adverse Reaction/Allergies ' ' "· '
[] Cost of Medication '
· [] None ': [] Obtaining Medications
[] Other
How is medication adrninistered~ ' '
[] Admin by Health Professional
[] Admin/Moni~omd by Lay Pemon
[] Withou[Assistance · '. '
If client cannot administer medication who will?·
Name: ' ' ' '"
Address: . .
Phone Number:
Relationship:
Who obtains medication?·
· ' Name:
Address:.
Phone Number:
Rela[~onship;.
Pharmacy:.
Phone:
Medication Comments: ' ·
'{EALTH ' ·
Does the client have anychronic illnesses or impairments
[]
[]
[]
[]
[]
[]
[]
[]
[]
Alcoholism
AJzheimers . .
Anemia.
Anorexia
Arthritis
Cancer
Chronic constipation
Chronic diarrhea '
Colitis
[] Col•st•my
[] Congestive heart failure
[] Dental problems
[] Diabetes
[] Diverticulitis,
[] Gall b!adder disease
[] Hearing impairmen~
[] Heart disease
[] Hiatai hernia
[] High blood pressure
0. Hyperglycemia
[] Hypoglycemia
[] Incontinence
[] Liver disease
[] Lowblood pressure
[] Osteopomsis
[] Other'
[] Parkins0ns
[]
[]
[]
[]
[]
[]
[]
· :· []
[]
Doctor/Health Care Provider: .
Name:
Address:
Phone Number:
Health Care Proxy:.
Address:
Phone Number:
Recent fractures
Renal disease:
Respiratory problems
Smelling impairment
Speech problems
Stroke
Ulcer
Urinary fTact infection
Visual impairment
· ..... Client.Assessmeht
Date:· 04/21/2003
Current Problems: ' ' "'
: Health Care Events within the Last Six Months ... ' ' ." '
Events D_ate Reason for Service Comment ' '
Clinic Visit ."
:-mergency Room · ' ' . ... .'
PRI
Hospital Visit
DMS-1 ': ' '
Physician Visit
Other
Does the ~lient visit the doctor less than once a year? [] Yes I~.No. Frail/Disabled: [] Yes [] No
Does the client require a comprehensive medical exam? [] Yes [] No
Ass st ye Devices?
[] Hearing aid
[] Cane '. [] Dentures
[] Eyeglasses .
Does the client require training on assistive devices?
[] Yes [] No
[] Walker
[] Wheel chair
COGNITIVE STATUS
Profile:
[] Aler[
[] Appears lonely
[] Cooperative
[] Dementia
[] Depressed
[] Diagnosed mental health prob.
[] Disruptive socially
[] Evidence of substance abuse
[] Hallucinations
[] History of mental' health ~-eat'
Other (specify):
[] Impaired decision making
[] Memory deficit
[] Other
[] Physical aggression'
[] Problem behavior reported
[] Sleeping problems
[] Suicidal thoughts.
~1. Verbal disruption
[] Worried or anxious .
· nt'A6 m nt '. .' . '.' Date:' 04/2~t2003
· , . ... : ' .' '. Cfie sess e i
Aay stressful life events ~vithin the past year?
Does the client require amental health evaluation? [] Yes · [] N;
4UTRITION
Heighti 'i
Weight: . "
Body Mass Index:
Any weight changes within the last six months?
[] Yes: 'Howmuch?: ' [] No
How many meals does the client eat daily?
Does the client ever go wEhout food? [] Yes: Specify~: · [] No ' ·
Does the client have adequate food in the house? [] Yes [] No
Do~s the cl.[ent have a modified/therapeutic or ethnic diet? [] Yes: Specify: ' - [] No
If client has modified therapeutic'diet, does the client follow it? [] Yes [] No
Nutrition Problems:
[] Ap. Petite ·
[] Chewing/Swallowing
E~ Dehydration
[] Dental
[] Digestive problems
· [] Overweight
[] Taste impairment
[] Underweight
Nutrition Risk Screeninq
(Select all that apply)
Nutrition Profile: (Selec~ all that apply.)
[] Inadequate mfrigerator/fTeezer and cooking facilities
[] Unable to open containers/cartons and cut up food
[] Requires n~tritional Supplements
[] Has a physician-diagnosed food allergy·
[] Has a physician-proscribed modified/them ~eutic diet
[]
[]
[]
[]
[] Takes 3 or more prescribed or over the-counter drugs a day.
Client has an illness or condition tha! changes the kind and/or amount of iced eaten.
Eats fewer than 2 meals/day. · .. ·
Eats fewer than two daily servings of the fol!owing food g~oups.
[] Fruits ' ..
[] Vegetables ... . .'
[] Milk Product
Has 3 or more ddnks of beer, liquor or wine almost everyday.
Has tooth or mouth problems that make ii hard to eat.
Does not always have enouah money to buy food needed.
Ea{s alone most of the time. ' ....
Without Wanting to, lost or gained 10 pounds in the past six month~.
Not always physically able to shop, cook and/or feed self.
2
2
2
2
2
2
2
2
Nutritional Risk Status: ' ' . Nutrition Index:. " ' · ' :
Comments/Additional Notus: · ·
FUNCTIONAL STATUS· · ·
Status Codes: .. ·
1. Totally Able . .. · ' '. .' ' .
2. Needs some asst.
3. Needs maximal asst .... ·
4. Unwilling to perform
Instrumental Activities of Daily Living
IADLS) . .. ' ' · ' ".
Handle personal business/Finan
,Housework/Cleaning
Needs Met:' . .
-U Unmet -'
-I Informal supports
-F Formal service
-A Assi~ve Device
pctatusINeeds' Contact
ode IMet? NamelReJat onship
I u I
oum Frequency
.aundry
3repare and Cook meals .
~repare light meals/Reheat
~elf-admin. of Medication
Shopping
Jse telephone
Jse Transportation
'IADL Comments;
t I
IADL's:
lmpaired A~vitJes:
Met by Informal Suppo~:
Met by Formal Suppods: .
Met by Assistive Device:
Unmet Needs:
Activities of Daily Living .JStatus Needs ~Contact . ' ' IHours. Frequency
(ADLS) ~Code Met? INamelRelationship
IBathing I I I I I
Dressing ~ I "'' I I .'
--a~ng . I I I ' · I I
vlobility
=ersonal Hygiene
roileting .... I I I I I
rransfer
Assessm '" I
·" '" Client ent' ' '" " ' '.'
· -'. · '. ' '" . Da~e:' 04/21/200'3
ADLComments: · .'.' ' "' ' ' :' : : ADL's: '" . .'; ..
· ' ' '.". ' '...'.. . ' . .'.'. :. ."-..' ".:' '"" :"."'". '" Impaired Activities:"..' '
: · .' .. :' Met by Informal Supporls: ';
· ': ' ..i -. .... ' ' ' .' : Met by·Formal Supports:
· i. .' ' '." ' "·. ' ..." Met by Assist/Ye Device: ' ' .
.... ' ' " ' ' " " UnmetNeeds: · . ·
[ADL/ADL CAREGIVER LIMITATIONS ' ·
Activity Hame:· :" ' ' ' . ' Contact name: ' ' :
Does the client appea~ to have a good reiationship with this caregiver?. · [] Yes [] No
Any fa(~to~s which m!ght limit im'olvement? . . . '" ' '
Iscaregiverreliefneeded?. -~1 '(es ' [] No Ifyes, when? ' ' '' .'.'.. ..
Could other informal supports provide relief?. ' · .
Activity Name: , ' Contact name: ·
Does the client appear to have a good rela[ionship with this caregiver? . [] Yes [] No
Any factors which might limit involvement? . ·
Is caregiver relief needed? [] Yes [] No If yes, when? "'
Could other thforraal supports provide relief? · · . . .
Activity Name; ' · . Contact na~e:
Does the client appear to have a'good relationship with this caregiver? [] Yes [] No
Any factors wh!ch mighl ]irnit involvement? ' .
Is caregiver relief needed? L~ Yes E~. NO I~ yes, when? . .. ·
Could other informal supports provide relief? '
~OUSING · .
Type of Housing: ' ' · · Ownership Status:
[] Multi family Uni~ ' · [] Single Family Unit' [] Own dwelling
· ' ' [] Rent dweliing .
[] Other '
Home Safety Problem? · "' ' ·
[] Accumulated garbage/dir[y living areas [] Loose scatter rugs [] No working COdetsctors
[] Bedroom-bath tTaffic lane has obstacle.. [] No access to telephone/emergency numbers [] No Working sm0ke, detecto[s
[] Cluttered stairs/walkways [] No grab bar attoiletJbathtub [] Odors
[] .CordsA~ires across wall~vays [] No handrails on stairways [] Plumbing problem
[] Doorway widths too nanow [] No light in reach of bed [] Poor lighting in bathroom .
[] . Exposed wiring/elecf~ic cord~ . [] No locks on doors/windows ... [] Poor lighting in hallway ..
[] Inadequate heating/cooling [] .No rubber mat/decals in bathtub [] Staim are nctwell lighied..
[] Inadequate ho~/cold wate?. . [] Stairs in poor condifice! .
[] Inadequate lighting in living areas
[] Insects/vermin .... . : · ·
Other (specify): ' .. : . '
· Date: 04/21/2003
Is neighborhood safety an issue? ' ' '" ' · . : [] Yes '[] No · '
Landlord: !if available)
Namei
Address:
Phone Number:
Super: . (if available) ..
Name:
Phone Number:
Housin,q Comments:
BENEFITS
Code Status as follows: HB = Has Benefit ME = May Be Eligible · .
RA = Refuses to Apply AP = Application Pending
· ' D = Denied · NE = Not Eligible · ·
Benefit I Status code Ii Benefit I Status code
--P,C I IpMB -
=ood Stamps .. I IIRailroad Retirement
Health Insurance I IIReal Prop. Tax Exemption
~EAP I
IT214 I " I~scRIE
IIReverse Mortgage ·
Lifeline ~ I~section a
Long term care insurance
IrSLIMB
Medicaid
Medicare .. I
Med~igap Insurance/HMO
Private Health Insurance
Public Assistance
r~social Security
I~SD '
' IIssl '. I
I~VA Benefits ' I
[~feteran Tax Exemption
Other '1 I~RAP
..
~)ther
Notes: . ' · .
Does the client require counseling on entitlements and benefits? ' [] Yes [] No ..
'iEALTH INSURANCE INFORMATION
Insurance Company Identification .. Plan # . ·
: ~:"..'.. ""." '"'."".'": Client ASseSsment .... ': '..'" '''Oaie: 04/2~,2oo3
ICUP~ENT SERVICES
~List any service client received within the last 6 months, regard~ess of whether or not it Was authorized/arranged by;o~r agency.) '
Service ' ' ' ' ' Fur~ding Org. Provider/Contact Units Freq. Auth. Date End Date
kSSESSMENT SUMMARY '.
Evalua[e Informal Support System:
[] Adequa{e Can Expand
[] Adequate Not Expand
[] Inadequate/Lin~ited
[] Other ..
[] Temp Unavailable
Rate client's motivation to stay in the community?.:
[] Cannot Rate
[] Highly Motivated" ' · '. · ...
[] Molivated with Support
[] Needs Support
[] Resistive '
Would client accept help from the ~amily?
[] Never ''
[] Other .
[] Short Term
[] Uncertain
Disposition:
[] Eligible f~r AAA in-home
[] Other
[] Refer to CHHA
[] Refer to Medicaid Hornecare
[] Referto Nursing Home
[] Refer [LO Self-Pay service
Could neighborhood/community/religious affiliations· provide assistance?
SummarY:·
[] Yes
[] No
"~CARE pLAN
Care Plan Goals:
Care Plan Objectives:
client Outcomes:
CI[ ' es ment. :..; .... '..-
ant ASs s
· "'.' '. '. Date: 04/21/2003
· Proposed Time Frame: .'. - '
Clier~t self-directing/able to direc~ home care staff? . ..
Client Prefe.rences Regarding Service:
'~I-~NNED SERVICES
[] Yes [] No .
]
· To include services prpvided by Informal supporls in fhe Care Plan, put Contact nama under Provider andlist Infor~al as the
Funding Org. .. ' · .' .' ' '*: '.. .' ' ' . . · : ' "
Service Funding erg. Provider/Contact Units Freq. Start Date End Date
PLANNED TASKS
Task Comments -' Due Date
OK to discuss plans with informal supports?
Plans discussed and/or accepted by clien~nformal s'uppods?
Reassessment Due: '"
· ' ' ' Assesso~
· [] Yes [] No
" [] Yes [] No
Supervisor's Name:
· Da{e of Review:
., Supervisor
· ' ' ' essm - ' '' "':'
Client Ass ent ".' "Daie: O~/2~/~0D3
[FINANCIAL
Ilnfo Received From:
'. [] [Agency '.
· . [][~gent
[]~u.t
[] JBrother
[] IBrother-in-law
.. [] ~:HHA
[] ~ousin
[] ~aughter
[] ~Daughter-in-law
[~FTA
][Doctor
[] [Domestic Partner
[] ~:amily
· [] [Father
. [] [Father-in-law
[] IFriend
· [] IGrand Daughter
[]Grand Son
[] ~Grandfather
· [] ~Grandmother
· [] Hospital
[]Housing
[]Husband
~ ~ntemal
[] ~andlord
[] ~edicaid
[]'~,lother
[] ~other-in-law
[] ~leighbor
[~ephew
[] ~ficials
[] [Other
][Relative
[] [Religious Org.
[] [Sister
[] [Sister-in-law
[] [Social Serv Agc
[] ~Social Worker
[][Sen
[~ [son-in-law
[] [Step Daughter
[] [Step Father
[] [Ste~ Mother
[]~tep Son
[] ~Super
~=inancial Information:
MonthlyHousin.q Exp.. - ... . ,. · .: ':
SSNI: ' SSN2:
... IHeating/Cooking F.~_
[RenFMo~geg~Co-~
· ~elephone ~ ~
~Nater/Sewage
Monthly Income
· SSNI:
SSN2:
)ividends from tnv~ ~_
nterest ~
qon-cfien[Inc.not,~
~)ther ~$ ~_
3ension/Retiremen~
3alary/Wages from~$ - j~_
Social Security ' ~ d~
Supplemental Secu~$ ~$
~Vages ~
Monthly Medical Exp.
SSN 1:
"~{ealth Ins. Premiu~
SSN2:
Home Care
Nedication I$ ~$
IPhysician ~$
Resources . ...~
SSNI:
SSN2:
~Checking
[Life Insurance - Ca~ ~$
~ifelnsurance- Fa~_ ~
~)mer (IRAs) ~$ [~
· ~Other Cash Accts. ~_
[Real ProperbJ ~$ · IS
~tocks,Bonds,Mutu~_ · ' ~$
J
J
J.
J
J
J
'1
[] ~Visiting Nurse '.
Others Information: · "
S.S.N ' I Name
· I Rela§on ·
.I
Event: · ·
'D ~Eveni Based
[] ~ollow-up Assessment .
[] ~nilJal Assessment
.' ~]~eopening
[] Review prior to Discharge
[][Routine Reassessment
[Comments: " .' J
Client's Signature
CaseWorkers Signature
SEC. 20. HOLIDAYS
20.1 Full-time employees shall be entitled to the following holidays off with.pay, to
.wit:
the fa'st day of January, known as New. Year's Day
the third Monday of January, known as Martin Luther King. Jr. Day
the twelfth day of February, known as Lincoln's Birthday (delete, effecdve
January 1, 2000)
the third Monday in February, known as (President's Day) Washington's
Birthday
the last Monday in May, known as Memorial Day
the fourth day of July,' known as Independence Day
the first Monday in Septea'nber, known as Labor Day
the second Monday in October, known as Columbus Day
the Tuesday next succeeding the first Monday in November, known as
Election Day
the eleventh day of November, known as Vetcnm's Day
the fourth Thursday in November, known ~s Thanksgiving Day
the day after Thanksgiving Day, except for employees assign[ed to the
Landfill, who shall receive a tloating holiday to be ~cheduled as though it
Were a personal day (effective January 1, 2000)
the twenty-fifth day of December. known as Christmas Day
the eve of Thanksgiving Day, ~ day
the eve of Chris.nas Day, ~ day
the eve of New Year's Day, ~ day
SUMMARY - RFQ FOR NUTRITION PROGRAMS 2003
PROPOSER:-ToWn of Southolcl -~(sen±Or' S~r~ices)
GEOGRAPHIC CATCHMENT AREA: · ' .... .. '.
Town of Southold ( 2000 US Census Tracts 1700.01, 1.700.02,1701.01, 17.02.02)
PROVIDE ONE COPY OF THIS SUMMARY SHEET FOR EACH PkOGRAM CATCHMENT
AREA. YOU MAY MAKE PHOTOCOPIES .OF THIS FORM.
TARGET COMMUNITY: Southold Town [ includes Village Qf Greenport (1701.01)
"~lderl¥ Low I'ncome Minority and Kosher Communities.
· 52
105
' 5
8AM-4PM
[~ HOME-D.ELIVERED
Number of meals to be served each day_ congregate
Number of meals to be served each day- Home-Delivered
Number of days per week-for prq.aram
Circle days of program!~). '
Hours of operatign each
CATERED :~-~ Coon ON SITE
SA SU
Location for congregate site:
Southold Town Human Resource Center, 750 Pacific 'Street, M~ttltuck N.Y. 11952'
Location of program administration, if difference from. congregate site: ....
Saute
Please state any additional information affecting service delivery: '
OFFICE USE ONLY:
RevVed 9]25103
Southold Town
Senior Services
' 750 Pacific Street
Mattituck, New York 11952
Phone # 631 298-4460
SUMt~RY SHEET 03
S,u,ffolk county Legislative.Requirements Exhibit for Contracts; last rev. 2/5104
Suffolk County LegiSlative Requirements. Exhibit for Contracts
This exhibit is attached to and is made part of the contract executed with the County.
" ' "1 · ..Suffolk county Living Wage Requirements .
"Suffolk County Living Wage Requirements Exhibit As Last Revised bY the .
Suffolk County Department of Labor on 10/22~02I' (2 pages). "
· - '11 Child Sexual· Abuse Reporting Policy '
Chapter 577, Article IV, of the Suffolk County Code entitled "Child Sexual
Abuse Reporting policy" (3 pages).
III Gratuities
IV
Chapter 386 of the Suffolk County Code, entitled "Political Parties, Gifts to
Officials Of" (2 pages). .
Contractor's/Vendor's Public Disclosure Statement Form SCEX 22; rev.
7/16/02 (form consists of two pages; requires signature & notarization)
Note: The Contractor's/Vendor's Public Disclosure Statement Form SCEX 22;
rev. 7/16/02, references the following law, which is included with this Exhibit.
· Suffolk County Administrative Code Section A5-7 (consists of 3 pages).
'Z
SuffOlk. COUnty Living Wage Docurnents
,S'uffo[R County Living wage'Requirem'ents ......
· Exhibit '
As Last Revised by the Suffolk County Department of. Labor on. 10/22/02
-" .. . .'...~ ' Suffolk County Living Wage Requirements Exhibit
· As Last Revised by the Suffolk County Department'0f Labor on !0/22/02
Pursuant to Section 6 of Chapter 347 of the Suffolk County Local Law No; 12-2001, "A
Local Law to Implement Living Wage Policy for the County of Suffolk" (the "Living Wage
Law"), all RFPs, County contracts and financial assistance agreements subjectt0 the law
shall contain the fo Iow ng two paragraphs or substantially equivalent language;
This Agreement s subject to the Living Wage Law of the County of Suffolk. The law
· requires that, unless specific exemptions.apply, or a waiver is granted, all employers
(as defined) under service contracts and recipients of county financial assistance, (as .
defined) shall provide payment of a minimum wage to employees (as defined) of
$9.00 per hour with health benefits of at least $1.25 per hour or otherwise $10.25 per'
hour. Such rate shall be adjusted annually pursuant to the terms of the SuffOlk
County Living Wage Law_, of the County of Suffolk. "·
Under the' provisions of the Living wage Law, the.County Shall h'ave the authority, under
appropriate circumstances; to terminate this Agreement and to seek other remedies as
set forth therein, for violations of this Law. "'
Suffolk County Local Law No. 18-2002, "A Local Eaw to Implement L!ving Wage Pol!cy for the
· County of Suffolk" provided for certain amendments to the Living Wage Law.
' Forms for Completion'and/or Signature (as applicable)
· Suffolk County Department of Labor- Living Wage Unit
Notice of Application for County Assistance (Contract)
Form LW-I. (consists of I page)
SuffOlk County Department of Labor - Living Wage Unit'
Certification of Compliance.
Form LW-2.(consists of 1 page)
· Suffolk COunty Department of Labor- Living Wage Unit
Certification of the Non-Applicability of the Living Wage Law
Form LW-3 (consists of 2 pages) ..
· Suffolk County Department of Labor- Living Wage Unit
Request for General Living Wage Exemption
Form LW-4 (consists of I page) . · . . .
'Suffolk County Department of Labor - Living Wage Unit
Request for Specific Living Wage Exemption . .
Form LW-5 (consists of 2 pages)
1 of I pages
SuffqlkC0unty Living··Wage Requirements Exhibit .. ~. . ..
As Last Revised by the Suffolk County Department Of' Labor on 10122102
suffolk County Departm6ht of Labor" '"
· - Living Wage Unit
Declaration of Compliance- Subject to Audit· .....
Form LW-33 (consists of I page) · ' ..
· Note: Pursuant to Section 7 of Local Law No.18- 2002, "A Local Law' to
· .implement Living Wage Policy for County of Suffolk", all covered employers
subject to the provisions of the Living Wage LaW shall submit a completed and
sworn (under penalty of perjury) Certification of Compliance Subject to Audit
form, signed by an authorized representative, as part of an executed contract
· with the County of Suffolk. The complete Declaration of ComPliance form shall be
· made a part of any executed contract or project agreement and made available
to the public upon request. .. · .
· · To certify Living Wage compliance; Return Form EW-1, Form LW-2
and Form LW-33.
or
· To certify non-applicability of Living Wage law: Retum Form LW-3.
or
· ' To ·request and document a general·living wage exemPtiOn: Return Form LW-1
· LW-2 and Form LW-4.
or
.o To request and document a specific living wage exemption: Return Form LW-1,
LW-2 and Form LW-5.
· In the event that there is a change in circumstances, it i~ the Contractor's
responsibility to submit to the County additional Living Wage forms Which
either replace or Supplement prior submissions of Living Wage forms.
· Living Wage Law Information Fact Sheet, text of the Local Law, Frequently
·. Asked Questions, Forms, and Rules and Regulations .can be found on the Suffolk·
County web site at www. co.suffolk.ny.us
Click Department Directory '"
Labor . ·
·. · Living Wage. Eaw Info
· Suffolk County Department of Labor Living Wage Unit Tel. '(631) 853-3808
End of Text for Suffolk County Living Wage Requirements Exhibit
As Last Revised by the Suffolk County DePartment of Labor. on 10/22/02
2 of 2 pages '.
Child SeXual Abuse RePorting.Policy
, .'CfIAPTER 577, ARTICLE IV, Child"Sexual 'Abuse Eep0r~in9 Policy [Adopted 6-11- ·
"' "'2002' by Res.. No...543-2002]. ' " · . .
.:' The County of'Suffol~ hereby establishes a formal child sexual abuse .
reporting.policy as follows: · · '.. '
.~. Each County Department that has a contract or agreement with any individual,
' "i partnershipl corporation, ~olnt v.enturs, business organization, or 0tker entity
'" which receives payments' from the County of Suffolk, either directly or as a
. . '." .' .'conduit for payment from another level of government, shall notify such
individual, partnership, corporation, joint'venture, business organization, or ·
-other entity tha~ Suffolk County requires full compliance with the reportin9 and
disclosure, provisions of Subsection C of this section,' as .a condition precedent'.
· . ' to receipt of such payment and continuin9 receipt of such payment, in those
instances in Which an allegation has bsen. made of sexual abuse of a minor by any
..employe~ or member of such contract vendor, including any msmbe~ of the clergy,
. inv01vin~ any of the following sex offenses:
. (1)Rape in the third degree, § 130.25 '(less than 17 years old) of the New York
Penal Law; ·
(2)Rape in the second degree, § 130.30 (less than 14 years old) of the ~ew York
Penal Law; · · . ''
(3)Rape in the first degree, § 130.35 (less than 11 years old) of the New York
· Penal Law; ' .'
(4)Sod0my in the third degree, § 130.40 (les's than' 17 years old) of the New
· York Penal Law~ ·
(5)Sodomy in the second degree, ~ 130.45 (les's than 14 years old) of the New
York Penal Law;
(6)Sodomy in the first degree, S 130.50 (less than 11 years old) of the New
York Penal Law;
(~) Sex/~al abuse in the third degree, § 130.55
· New. York Penal Law;
(8) Sexual abase in the second degree, ~ 130.60
New York Penal Law;
(9) Sexual a~use in the first degree, § 130.65
New.York Penal Law;
(less than 17 yea~s ~ld) of the
(less than 14 ymars'old) of the
(less than 11 years old) of the
(10)Aggravated sexual abuse in the third degree, § 130.66 (less than 11 years
old). of the New York Penal Law;
(ll)A~gravated sexual abuse in the second'degree, § 130.67. (iess than 11 years
· old) of the New York Penal Law; ..
(12)Aggravate~ sexual abuse in the first degree,.§ 130.70 (~ess than 11 years. ·
01d) of the New. York Penal Law;
(l~)Course of sexual conduct a~ainst a child in the first degree, ~ 130.75
(less than 11 years old) of the ~ew York Penal Law; and
(14)Course of sexual conduct against a child in th8 second degree, § 13~.80
(less than 11 years eld) of the New York Penal Law;
(15) Sexual misconduct, § 130.20 (sexual intercourse without cdnsent) of the New
York Penal Law; . ..'
(16)Forcible touching, § 130.52 (sexual or intimate par~s)'.of the New York Penal Law;
(17)~ersistent sexual abuse, § 130.53 (two or more convictions within the past
'10 years f~r less than 17 years old or 14 years.old).of the New'.York Penal Law; ·
(18)Aggravated sexual abuse in the fourth degree, § {30.65a (less than 17 years ..
01d) of the. New York Penal Law; ' '
(19)Female. genital mutilation, Section 130.85 (less than 18 years old,
nonmedical procedure) of the New. York Penal.Law; ' ' ·
(20)Facilitating a sex offense wi~h a controlled substance, ~ 130.90 (without
consent to commit a. felony) of the New York Penal Law.
B. Definitioas. For the purposes of this article, the f~llowing terms shall
have the meanings indicated:
'~LERGY -- A'duly authorized bishop, pas~or,.rector, priest,"rabbi, minister, imam,
· nun, or a person having authority from,'.or in accordan'ce.with,.the ru~es and
· · . regulations of the.governing' ecclesiastical body of.the denomination o~ ''
' ' .' .' .' order, if .any,. to which the church belongs, or otherwise from the church,'..
"synagogue, or' mosque to preside over and direct the spiritual affairs of the
church, synagogue, or mosque, as the case. may be. ~' · .'.' ' · . ·
MINOR -- Anyone under, the. age of.'ie.yea~s of age; i'. ... '
. C. All supervisory, administrative, or mana~ement"employees of any individual,
' .' partnership, corp~rati0n, joint venture, business organization, or other entity.
receiving payment from the County of Suffolk, either directly or as a conduit for
payment from another level of government, under agreement.' or contract with the.
County of Suffolk, shall report or cause a report to be made to 911 or the pertinent
village, tow-n, or county Police Department when he/she, or it has reasonable cause'
to.suspect that a minor coming before them is or has been the vic'tis of sexual
abuse, or when another person or clergy person comes before them and states, from
personal, knowledge facts, conditions, or circumstances which, if correct, would
render the minor a victim of sexual abuse under any of the followin9 sex offenses,
said reporting to occur within 24 hours after forming the reasonable cause or first
.lear/llng of the allegations: [Amended 8-28-2002 by Res. No. 819-2002]
(1)Rape in ~ha thlrd degree~ ~ 130.25
Penal Law;
(2)Rape in the second degree, § 130.30
. Penal Law;
(3)Rape in the first degree, § 130.35
Penal Law; ....
(4)sodomy in the th'ird degree, ~ 130.40
York Penal Law;
'(5)sodomy in the second degree,
'York Penal Law;
(6) Sodomy in the first degree,
York Penal Law;
(iess than 17 years old)
(less. than 14 years old)
(less than 11 .years old)
of the New York
of the New York
of the New York
(less tha~ 17 years old) of the New
130.45 (less than 14 years old) of the New
130.50 (less than 11 years old) of the' New
(7)Sexual abuse in the third degree', § 130.55 (less than 17 years old) of the
New York Penal Law;
(8)Sexual abuse in the second degree, ~ 130.60 (less than 14 years 01d} of the
New York Penal Law;
(9)Sexual abuse in the first degree, ~ 130.65 (less than 1! years old) of the
New York Penal Law;
(10)Aggravated sexual abuse' in the third degree, § 130.66 (less than 11 years
old) of.the. New York Penal Law;
(il)Aggravated sexual abuse in the second degree, § t30.67 (less than i1 years
old) of the New York Penal Law;
(12)Aggravated sexual abuse in the first degree, § 13~.70 (less than 11 years
· old) of the New York Penal Law;
(13)Course of sexual conduct against, a child in the first degree, §
(less than 1! years old) of the New York Penal Law; and
(14)Cou3cse of sexual conduct against a child in the second degree, § 130.80
· ' (less than 11 yea~s old) of the New York Penal Law;
'(15)Sexual misconduct, ~ 130.20 (sexual intercourse without consent) of the New
York Penal Law;
(.16)Forcible touching, § 130.52 (sexual or intimate parts).of the New York
Penal Law;
(17)Persistent sexual abuse, ~ 130.53 (two or more convictions within the past
10 .years for less than 17 years old or 14 years old) of the New. York Penal Law;
(18)Aggravated sexual abuse in the fourth degree, .§ 130.65a (less than 17. years
· . old) of. the New York Penal Law;
(19)Female genital mutilation, ~ 130'.8'5 (less than 18 years old non-medicsl
procedure) of the New York Penal Law;
(20) Facilitating a Sex offense with a controlled substance, ~ 130.90 (without
consent to commit a felony) of the New York Penal Law;
~ Whenever a clergy person is '~equired to report.under this article', in his or her
capa.city as a member of the clef§y, he or she shall, immediately no%ify the ..
person in charge of such church, synagogue, or mosque, or his or her designated
· agent, who shall then also become' responsible to ~eport or cause reports to be
made to 911 or the pertinent village, town,'or c~unty Police Department when he
or she has reasonable cause to suspect that'a minor coming'before them is or has
been the victim of'sex-~al abuse, Or when another clergy person comes before them
and states from personal knowledge facts, 'conditions, or. circumstances.which, if
.correct, would render ths minor a victim'of sexual ab~se. [Amended 8-28-2002 bY
Res. No. 819-2002]
E. No informati6a derived from a confession or'confidential communication to a
clergyman shall be disclosed pursuant to the requirements of this article if the
confession or confidence is made to the clergyman in his .or her professional
capacity as a spiritual advisor, unless the person so confessing.or confiding
. waives this privilege..
F. All. contract vendors covered by this article shal~ inform all of their, employees
in writing as to the disclosure requirements.:of this article and shall also
inform them that each of them must report any allegations of child abuse covered
in paragraph.(A) of the 1st RESOLVED clause of this article to.sUPervisory,
management, or designated administrative personnel of the empl.oyer.
577-17. Failure to comp.ly; penaltles for offenses.
Failure to comply with the terms and conditions of this article shall result
in the follow~ng:
A. First violation: the contract vendor shall be issued a warning and all
supervisory, administrative, and management employees of such contract vendor
shall be required to attend a child sexual abuse prevention/education workshop
provided by a contract agency approved by the County of Suffolk'via duly enacted
re'solution, which workshop shall include specific skills for adults to help
prevent childhood sexual abuse; skills that adults can teach children ko help
protect themselves from childhood sexual abuse; skills for detectin~ the signs
of childl~ood sexual abuse; and how to report allegations of childhood se~cual
abuse. The cost of this training shall be paid for by the contract vendor. In
addition, the c~ntract vendor shall submit a corrective plan of action to the
Suffolk County Office of Labor Relatibns.
B. Second violation within a three-year period subsequent t'o a first violation: the
contract vendor Shall be subject to a fine of 10% percent of the contracts that
the pertinent violating individual supervisor, manager, or administrator
oversees,.uot to exceed $50,000.' In addition, the contract vendor shall, be put
on probation, fo~ three years. An annual review shall be conducted by the Suffolk
County Department of Audit and Control.
C. Third violation within a three-year period subsequent ~o a first violation: the
termination of the .agreements with such individual, partnership, corporation,
joint venture, business organization, or other entity overseen by the pertinent
violating individual supervisor, manager, or administrator and the withholding
of all payments to said individual, partnership, corporation, joint venture,.
. business organization, or other entity for such agreements regardless of whether
such payments are for past or future goods or services. The .contract vendor
shall not be eligible for funding from the County for three years from the date'
of such termination. . .. .
577-18'. Authority to issue rules a~ regulatlons~
The Suffolk County Department of Law 'is. hereby authorized~ empowered, and
directed to issue and promulgate such rules and regu/lations as shall be deemed'
'necessary and appropriate, to implement'the provisions of this article.
GratuitieS
.:.
§38'6-1.
§ 386-1.
§ 386-2.
... § 386-3.
· § 386-4.
§ 386-5.
GIFTS TO PARTY OFFICIALS ' ' {}386-1 '
- , .. CHAPTER 386.
. POLITICAL PgRTIES, GIFTS TO OFFIClAES OF '' '
Definitions. '"
Prohibited acts ....
Clause required in all contracts.
Penalties for offenses. , · ·
Excepted contributions. : '. '..
[HISTORY:".Adopted by the Suffolk County Legislature 12-9-80 as L.L. No: 32-1980.
Amendments noted where applicable.] '
9386-1. Definitions.
. -' As used in ~his chapterl the following terms shall have meani'ngs indicated:
. AGREEMENT -Any Written or oral contract or any implied contract, including but not
· · limited to a contract for the sale of goods or services, a construction contract or a
lease or contract relating to real or personal property. The term "agreement" shell
also include any transaction.whereby a person agrees to sell goods or services, or
both 'to the county Pursuant to a successful bid.
GRATUITY -Any money, benefit, entertainment, gift or any other'consideration
whatsoever.
. OFFICIAL OF A POLITICAL. PARTY -A party officer as. defined by §1-1.04,
Subdivision 5, of the Election Law.
PERSON -Any individual, partnership, firm; corporation or other legal entity, as well
as their employees, agents or representatives.
pOLITICAL pARTY -A party as defined bY § 1-104, Subdivision 3, of the Election
Law.
§ 386-2. .. Prohibited acts.
A. It shall' be a crime for any person to offer or give any gratuity to an official of any
political party with the purpose of intent of securing or obtaining an agreement
with the County of. Suffolk or secudng favorable treatment ;with respect to the
awarding or amending of such agreement or the making of any determination
with respect to the performance of an agreement.
Page I of I
· :: .". B. !t shall be a crime for an official.of a p01it!ca! party to solic!t, ~eceiye or accept a
· . . . gratuity in connection with securing or obtaining an agreement with the.County'.
'" 'o[ suffolk or securing favorable treatment with respect to the awarding or
'amending of such agreement or the making of a dete[m!nation.with. .respect.. to
"' ':' the performance of such agreement. .. ·
§ 386~3. · Cia.use required in.all'contracts. . .~
In all agreements with tt~e county of SuffOlk made after the effective date of this
Chapter, there shall be written representation by the persor~ entering the agreement .
· with the county that he has not offered or given any gratuity to any official,
· ' 'emPloYee or'~gent of Suffolk County or New York State or of any political party,.with
~ the purpose or. intent of securing an agreement or secudng favorable treatment with
respect to the awarding or amending of an agreement or the .making of any
determinations with respect to the performance of an agreement, and that such
person has read and is familiar with the provisions of this chapter.
§ 386-4. penalties for Offenses.. · · '" ·
A. Criminal. A violation of §386-2 of this chapter sh'all be a Class A misdemeanor'
and shall be punishable by a sentence of not more than one (1)year in prison or
a fine of not more than one thousand dollars ($1,000) er by both such fine and
'' imprisonment.
B. 'Civil rer~edies. A violation of § 386-2 or 386-3 of this chapter shall give the
county the option, among other Civil remedies, of either terminating the
agreement or deducting the value of the gratuity from any amount due or to
become due from the county thereunder..
§386-5. Excepted contributions.
· . This chapter shall not apply to contributions to political parties, committees or
candidates as defined by § 14-100, Subdivision 9, of the Election Law. Such
contributions shall be excluded from and shall not be in violation of this chapter.
Page 2 of 2 "
COntractor's/Vendor's Public· Disclosure
,. ,. ..: ..statement DocUments .~. ...
: .' ' . '"' Suffolk'CountySCEXForm 22 .... . .
· "" ContractOr's/Vendor's Public Disclosure Statement ' "" '" '
'. Pursuant to.Section A5-7 of the. Suffolk County. Administrative code, to be completed by all
pro~,iders which have a Contract with Suffolk County in Excess of $1,000 or have three or more
contracts with Suffolk County any~thr-ee.-oPwhich~n combined exceed $1,000 except: (1)
HoSpitals, (2) Educational. o,~'G-overnmental Entities~'(3)'Not-For-Profit Corporations, or (4)
Providers of Foster Care Fa~dy Da'"~-~- y Care oTC--hi'~'Protective Consulting Services. - ·
1. . Contractor'sJendor's Name'
Address · ·
· City and State · Zip Code
2. Contracting Department's Name
Address
=
4.
5.a
5.b
=
Payeeildentification or Social Security No.
Type of Business__Corporation__Partnership__Sole Proprietorship__Other.
IS you['firm entering into or has. your firm entered into a contract with Suffolk County in
eXcess of $1,000 Yes No. ' · '
Has your firm entered into three or more contracts, inclUding the one for which you are
now completing this form, with SUffolk County, any three of whi.ch, when combined,
· exceed $'1,000 Yes No. If you answered yes to either part 5a or 5b, you must
complete parts 6 through' 9. In any event you must answer parts 10 and 11.
'Table of Organization. List names and addresses of all principals; that is, all individuals
serving on the Board of Directers or comparable body, names and addresses of all
partners, and names and addresses of all corporate officers. Conspicuously identify any
person .in this table of organization who is also an officer or an employee of Suffolk
Count. (Attach ~,dditional sheet if necessary.)
=
List all names and addresses of those individual shareholders holding more than five
· percent (5%) interest in the firm. Conspicuously identify any shareholder who is also an
officer or an emploYee of Suffolk County. (Attach addit!onal sheet if necessary).
10,
Does your firm derive 50% or'more of its total revenue from your contractural or vendor
· relationship with Suffolk County?_ . Yes__ No.
If Yes, you must submit with this disclosure statement, a complete financial statement
· .listing all assets and liabilities as well as a profit and loss statement. These statements
must be certified by a Certified Public Accountant.. (Strike this out if not applicable.)
The undersigned.shall include this Contractor'sJendor's Public Disclosure Statement
· with the contract (describe general nature Of the'contract).
Page I of 2 SCEX Form 22
· ;' ~11.;" Remedies.~ The failure to file a'v~rified public disc['0sure statemeni "as required uhdei
· ~ "'. ' ··this.local law shall constitute a. material breach of contract. Suffolk County may resort,
use or employ any remedies contained in Article 11 of the Uniform· Commercial Code of
· · .. the State of New York. In addition to all legal mmedi'es, Suffolk County shall be entitled,
· upon a determination that a breach has occurred, to damages equal to fifteen percep!
· (15%) of the amount of the contract. ' '" ., . · ~
'12. Verification. This section must be signed by an officer or principal of the contractor or
· .' ' ' 'vendor authorized to sign for the company for the purpose Of executing contracts. The
undersigned being sworn', affirms under the penalties of perjury, that he/she has read
and understood the foregoing statements and that they are, to his/her own knowledge,
·
Dated: .7/13104 .' . "Signed:
Printed Name of Signor: ' f,~%~,,~ v. '
Hertr)n '
Title·of Signor: 5uoervisor ·
Name of Firm: . . · ,. · Town Scut-hold
Individual Proprietorsl~ip or partnership Acknowledgement·
)
)
State of
County Of'
On the
day of
SS:
,.20__ 'before me ~ersonally came
, to me known and known to me to be the person
described in, and who executed, the foregoing instrument, and du!Y acknowledged that he/she
executed the same.
Notary Public
Corporate Ack[mwledgement
State of New :York
Countyof Suffolk '
On the 13th. .. dayof . Ju~y ' ,.2004 , before me personally came
Joshua Y. Horton · ' , to me known, who being duly swom, did dispose and
say that he/~sh~resides in Greenpoi't. New Yo'rk , that he~s the SUpervisor
of Town of Southold corporation described in and which·executed the foregoing
instrument; that he/she knew the seal of said corporation; that the seal affixed to said
instrument Was such corporate Seal; that it was so affixed by the arder of the board of directors
of such corporation, and that he/she signed his/hew name thereto by like order. . .
SCEX Form 22 (Rev. 7116102) ' ' . "
Reference: Suffolk County Administrative Code Section A5-7
· . · page2of2 SCEXForm22
· .-·'. " .'.. SUFFOLK COUNTYADMINISTRATiVE CODE SECTION A5-7
§'A5-7. 'Contractors and vendors required to submit full disclosure...
statement. [Derived from L.L. No. 14-1976, as amended 2-27-1979 by L.L..
6 !979] '
No. - ... · : ....... .. ..
· A. Definitions. As Used in this section the following terms shall have th~' .... . '
CONTRACT - Any written agreement, between Suffolk County.and a.
"... contractor Or vendor to do or perform any.kind of labor,, service, .purchase.
..... 'construction or public work, unless the.contract is for a .federally or state-
aided, in whole or in part, program required to be bid pursuant to § 103 of
the New York General Municipal Law. [Amended 6-29-1993. by L.L. No.
28.1993~].- '. ... . · · ... ...,
NOTE: L.L. NO. 28-1993 also provided as follows: -'
: Section 1. Legislative Intent... ..
This Legislature hereby finds and determines that Suffolk County's. comprehensive
Contractor/Vendor Public Disclosure .Statement Law Currently applies to a broad array of
-. contracts that exceed one thousand dollars ($'I,000.) in value, subject to exemptions for
contractors doing business with the County Department of Social Services; hospitals;
educational, medical, and governmental entities; and not-for-profit corporations.
This Legislature further finds and determines that these exemptions prevent full
disclosure of important information that .may be useful to elected county officials in
determining whether or not specific.types of contracts are in the public interest, especially
in light of recent trends towards p.rivatization and use of outside consultants on an
increased basis by municipalities.
Therefore, the purpose of this law is to eliminate many of the exemptions from completing
and filing verified public disclosure statements with the County Comptroller available to
certain contractors' providing social services or health services contracts.
.CONTRACTOR or VENDOR [Amended. 12-18-1990 by L.L. No, 41-
'19902; 6-29-1993 by L.L. No. 28-!9933] -
Any proprietorship, partnership or closely held corporation which has a
· contract with Suffolk County. in excess of one thousand dollars ($1,000.) or
Which has three (3) or more contracts with Suffolk County, any three (3) of
'which, when combined, exceed one thousand dollars $1,000.), except:
(1) Hospitals. '
(2) Educational or governmental entities.
.Editor's Note: This local law was' adopted by the legislature after disapproval by the
Executive on 5-26-1993, . : . .' '"
2 Editor's Notei This local law was adopted by the Legislature after disapproval' by the
· Executive on 12-13-1990. See the note at § A4-12.
3 Editor's Note:. This local law was adopted by the Legislature after.disapp~'oval I~y the
Executive on 5-26-1993. See note above.
· Page ! .of 3 .,
: (3) Not-for-profit corporations.· · .i " ":""
.' (4) COntracts Prov 8 ng for foster caie, :i'arni'ly: day-ca'ie' provMers or child
· .. : . : p¢otective consulting services. · ': " . · '! · ' "':". ·"
' "FULL DISCLOSURE.CLAUSE - A pf0viso to. be 'included as a"material
". part of a"contract imposing Upon the contractor 'or Vendor a material,
· contractual and statutory duty to file a verified public disclosure stater~ent. ·
· VERIFIED PUBLIC DISCLOSURE STATEMENT ' A declaration, the '
contents of which are acknowledged before. 'a notary public, containing
information required under this section. "
· '" B."A full disclosure clause is to be included in all' future 'con'~racts between
· ' Suffolk County' and a contractor or vendor.. Such full disclosure clause
· shall constitute a material Part of.the contract.
c. Notice Of the full disclosure clause shall be included and made. apart 0f the
specifications, if any, which are Submitted to interested potential bidders.
D. 'EAch contractor or vendor shall file a Verified public disclosure statement
with the Comptroller of Suffolk County as soon as practicable, prior to
· being awarded the contract. An updated disclosure statement shall be
filed by the contractor or vendor with the Comptroller by the 31st day of
.January in each year of the contract's duration. It shall be the duty of the
Comptroller to accept and file such statements.
E. No contract shall be awarded to any contractor or vendor, as defined ih this
section, unless prior to such award a verified Public disclosure statement
is filed with the Comptroller as provided in this section. Any verified public
disclosure statement containing fraudulent information shali constitutel for
all purposes, a failure to file such statement in the first !nstance.
F. The verified public disclosure statement required by this section shall
· : include: -
(1) A complete list of the names and addresses of those individual
shareholders holding more than five-percent interest in the firm.
(2) The' ~al31e of organization for the company shall include the names 'and
addresses of all individuals serving on the board of directors or
comparable body', the names and'addresses of all partners and the
names.and' addresses of all corporate officers. The cont(acto( or
'vendor shall conspicuously identifY any such person in this table of
organization who is an officer or an employee of Suffolk County..
.Page 2 of 3 . :'
· ' (3) A ~omple'~e: financial statement listing, all assets and liabilities' as well
as. a. profit-and-loss statement,, certified by a. certified. public
accountant..Such statement shall be'the most current available and in'
no event shall have. been prepared more than six (6) months pdor to
=.. the date'of '(he filing of the bid. No financial statement or profit-and-loss
statement shall be required from any contractor or VendOr having fifty
percent (50%) or.more of.their gross revenues from sourcbs Otherthan
the County Of Suffolk. ' ...... '
A separate folio for each company Shall be maintained alphabetically for
public, inspection by the Comptroller. : '"'
Remedies. The failure' to file a verified public disclosure statement as
required under this section shall constitute a material, breach of contract.
Suffolk County may resort, use or employ any remedies contained in
Article 2 of the Uniform Commercial Code of the State of New .York. In
addition to all legal remedies, Suffolk County shal! be entitled, upon a
determination that a breach has occurred, to damages equal to fifteen
. percent (15%) of the amount of the contract. ' ' .. ·
Under no circumstances shall the county be precluded from. invoking any
. remedy contained in the preceding section by reason of its failure to
invoke Promptly its remedies. . .. .
Page 3'of 3
· Certification. Regarding Lobbying
For Contracts, Grants, Loans and CooPerativeAgreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No State or 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
legislation or appropriation actions pending before local, State and Federal executive
and/or legislative bodies in connection with the awarding of any contract, the making of
any grant, the making of any loan, the entering of any cooperative agreement, and the
extension, continuation, i-enewal, amendment, or modification of any contract, grant
loan, or cooperative agreement.
(2) If any funds other than State or Federal appropriated funds have been paid or will
be paid to any person for influencing or attempting to influence legislation or
'. appropriation actions pending before local, State and Federal executive and/or
legislative bodies in connection with this contract, grant, loan or cooperative agreement,
the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to
Report Lobbying", in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in
the award documents for all subawards at all tiers (including subcontracts, subgrants,
and contracts under grants, loans, and cooperative agreements) and that all
subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed
when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by Section 1352, Title
31, U.S. Code. Failure to file the required certification shall be subject to civil penalty by
the Federal government of not less than $10,000 and not more than $100,000 for each
such failure.
/
~./ To Sign Application
For:
Name of Grantee
Ce~t]cation Regarding Lobbying 04