HomeMy WebLinkAboutDelinquency Prevention ProgramLaw No. YO002M/0002-05Y/t IFMS No. SCS EXE 05000002839
Oevelopment Delinquency Prevention Program Amendment No. 2
Amendment of Agreement
This is the Second Amendment of an Agreement, 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 Youth Bureau (Department), having its principal office at H, Lee Dennison Building-
3rd Floor, 100 Veterans Memorial Highway, Hauppauge, New York (Mailing Address: Box 6100, Hauppauge, New York
l 1788-0099), and Town Of Southold (Contractor), a New York municipal corporation, having its principal place of
business at Southold Town Hall, Main Street, Southold, New York 11971 acting through its duly constituted agency;
and Family Service League (Implementing Agency), a New York not-for-profit corporation, having its principal place
of business at 790 Park Avenue, Huntington, New York 11743.
The parties hereto desire to modify the Agreement by extending the term from December 31, 2004, through
December 31, 2005 (1/1/05 to 12/31/05 = 2005 Budget Period). Sufficient funding exists in the 2005 Suffolk County
Operating Budget.
Term of Agreement: Shall be January 1, 2003 through December 31, 2005
Percentage of State Aid: 18%
Percentage of Advance: 25%
Total Cost of Agreement: Shall not exceed $28,584 (of which $9,985 is for the 2005 Budget Period)
Terms and Conditions:
Shall be as set forth in Exhibit A-I attached.
In Witness Whereof, the parties hereto have executed this Second Amendment of Agreement as of the latest date wriuen
below.
Town of
Name: /r
Title:
Fed. Taxpayer ID #:
Date:
Family~ue
Name:
Title:
Fed. Taxpayer ID ~:
Approved as to Legality:
Christine Malafi
Suffolk County ~ttorney/.~/~?.. //~ ~. ~-~'~-~
By: ,oS;'F'f_-~,'~./~ ~
Patricia M. Jordan ~/~" '~'"'"
Assistant County Attorney
Date ~//~_~ f"
County of Suffolk
Paul Sabatino, II
Chief Deputy Count), Executive
Date: c? /~1.~_/590 6 ~
Approved:
Youth Bureau
f.~annette ~'ahtos
Executive Director
Date
Recommended: .~
Fred Verbarg (] Date
Principal Planner - Youth Services
YO 1 Page I of 2 pages
. Law No. YO001M/J~-05YB
Rev. 01/19/05
Development Delinquency Prevention Program
IFMS No. SCS EXE 0X0000
Amendment No. 2
Exhibit A-2
Whereas, the County and Contractor have entered into an Agreement, for a term from January 1, 2003
through December 31, 2003, with two (2) one-year extensions at the County's option, to provide a
development delinquency prevention program; and
Whereas, the County and Contractor have entered into a First Amendment of Agreement to extend the term
of the Agreement from December 31, 2003 through December 31, 2004 with one (1) one-year extension at
the County's option; and
Whereas, the parties hereto desire to amend the Agreement and First Amendment of Agreement to extend
the term of Agreement from December 31, 2004 through December 31, 2005, increase the Total Cost of
Agreement for the 2005 Budget Period, update certain provisions to comply with current County standards
and add provisions in compliance with current County requirements as set forth below;
Now, Therefore, in consideration of the covenants, promises and consent herein contained, the parties
hereto agree as follows:
1. Term of Agreement
The Term of Agreement paragraph on page 1 of the Agreement is amended to read January l, 2003
through December 31, 2005 as set forth on page 1 of this Second Amendment of Agreement.
2. Payment of Services
The Total Cost of Agreement shall be increased by the amount specified on page one for the 2005
Budget Period.
3. Budget
The budget annexed hereto as Exhibit C-2 is made part of the Agreement for the 2005 Budget
Period.
The Contractor agrees to comply with the following amended provisions in compliance with current
County standards:
4. Insurance
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. The Contractor agrees to
require that all of its subcontractors, in connection with work performed for the Contractor related to
this Agreement, procure, pay the entire premium for and maintain throughout the term of this
Agreement insurance in amounts and types equal to that specified by the County for the Contractor.
Unless otherwise specified by the County and agreed to by the Contractor, in writing, such insurance
will be as follows:
¥o~ (vos) 2
i. Commercial General Liability insurance, including contractual liability coverage, in an
amount not less than Two Million Dollars ($2,000,000.00) per occurrence for bodily injury
and Two Million Dollars ($2,000,000.00) per occurrence for property damage.
ii, Automobile Liability insurance (if any vehicles are used by the Contractor in the
performance of this Agreement) in an amount not less than Five Hundred Thousand Dollars
($500,000.00) per person, per accident, for bodily injury and not less than One Hundred
Thousand ($ 100,000.00) for property damage per occurrence.
iii. Worker's Compensation and Employer's Liability insurance in compliance with all
applicable New York State laws and regulations and Disability Benefits insurance, if
required by law. Contractor shall furnish 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 coverage 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 maintain coverage during the
term of this Agreement for the benefit of such employees as are required to be covered by the
provisions of the Workers' Compensation Law.
iv. Professional Liability insurance in an amount not less than Two Million Dollars
($2,000,000.00) on either a per occurrence or claims made coverage basis.
b. All policies providing such coverage shall be issued by insurance companies with an A.M. Best
rating of A- or better.
c. The Contractor shall furnish to the County Declaration Pages for each such policy of insurance
and upon request, a tree and certified original copy of each such policy, evidencing compliance with
the aforesaid insurance requirements. In the case of commercial general liability insurance, the
County of Suffolk shall be named as an additional insured and the Contractor shall furnish a
Declaration Page and endorsement page evidencing the County's status as an additional insured on
said policy.
d. All such Declaration Pages, certificates and other evidence of insurance shall provide for the
County of Suffolk to be notified in writing thirty (30) days prior to any cancellation, nonrenewal or
material change in said policies. Such Declaration Pages, certificates, policies and other evidence of
insurance and notices shall be mailed to the Department at its address set forth in the paragraph
entitled "Addresses for Notices, Claims and Reports" or at such other address of which the County
shall have given the Contractor notice in writing.
e. 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 may provide self-funded coverage
and certificates or other evidence of such self-insurance in lieu of insurance issued by insurance
companies.
f. In the event Contractor shall fail to provide the Declaration Pages or certificates of insurance or
to maintain any insurance required by this Agreement, the County may, but shall not be required to,
obtain such policies and deduct the cost thereof from payments due Contractor under this Agreement
or any other agreement between the County and Contractor..
YOI(I~S) 3
5. Contractor's/Vendor's Public Disclosure Statemeat
The Contractor represents and warrants that Contractor has filed with the Comptroller of Suffolk
County the verified public disclosure statement required by Suffolk County Administrative Code Section
A5-7 and shall file an update of such statement with the said Comptroller on or before the 31st day of
January in each year of this Agreement's duration. The Contractor acknowledges that such filing is a
material, contractual and statutory duty and that the failure to file such statement shall constitute a material
breach of this Agreement, for which the County shall be entitled, upon a determination that such breach has
occurred, to damages, in addition to all other legal remedies, 0f fifteen percent (15%) of the amount of the
Agreement.
6. Financial Statement and Audit Provisions
(a) Notwithstanding any other reporting or certification requirements of Federal, State or local
authorities, the Contractor shall obtain the services of an independent licensed public accountant 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, $300,000 or mom 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 statement of income and
expenses, attested by the Auditor as fairly and accurately reflecting the accounting 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 accounting firms and
to review carefully the costs of, and qualifications for, this type of work before selecting the Auditor.
(b) The Auditor should be required to meet the following minimum requirements:
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.
(c) 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 also prepare a management letter based on
the audit.
(d) Furthermore, if the Contractor is a non-profit organization or unit of local government and
expends $500,000 or more of Federal monies, whether as a recipient expending awards received
directly from Federal awarding agencies, or as a subrecipient expending Federal awards received
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 conducted,
and the audit report ("Single Audit Report") must be, in accordance with OMB Circular No. A-133
(revised June 27, 2003). 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 deliver the certified statement to .the Department and to Executive Director
of Auditing Services, Suffolk County Department of Audit and Control, H. Lee Dennison Building,
Ym Otos) 4
100 Veterans Memorial Highway, P. O. Box 6100, Hauppauge, New York 117884)099, 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 government and ALL Federal funds passed through from
the Count3' and other pass-through entities.
(0 Copies of all financial statements, management letters, Single Audit Reports (if applicable)
and other audit reports, if required, must be transmitted to the Department and to the Executive
Director of Auditing Services 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 period to which the audit relates.
(g) These requirements do not preclude the Department or the Suffolk County Comptroller or
their authorized representatives or Federal or State auditors from auditing the records of the
Contractor. Therefore, the records of the Contractor must be made available to authorized
representatives of Federal, State or County government for that purpose.
The provisions of the foregoing subparagraphs (a) through (g) of this paragraph shall survive the
expiration or termination of this Agreement.
7. Non-Discrimination Requirements
In accordance with Article 15 of the New York State Executive Law (also known as the Human
Rights Law) and all other County, State and Federal administrative, statutory and constitutional
nondiscrimination provisions, the Consultant agrees he/she shall not discriminate against any employee or
applicant for employment because of race, creed, color, sex, national origin, age, disability, sexual
orientation, military status, or marital status.
8. Non-Discrimination in Services
During the performance of this Agreement the Consultant agrees he/she will not, on the grounds of
race, creed, color, national origin, sex, age, disability, sexual orientation, military status or marital status,
deny any individual any service(s) or other benefits provided under the program or provide any service(s) or
other benefits to an individual which are different, or are provided in a different manner from those provided
to others under the program.
Termination of Agreement
a. Termination by County in the Public Interest
Notwithstanding anything herein to the contrary, in the event that the Director of the Bureau
(hereinafter, the "Director"), or his/her designee, determines, in his/her sole discretion, that
termination is in the best interests of the County, the County reserves the right to terminate this
Agreement for any reason at any time. Such termination shall occur upon thirty (30) days notice of
intent to terminate to the Contractor. Contractor shall have an opportunity for consultation xvith the
Director prior to termination.
b. Termination for Cause
i. If the Contractor fails to fulfill in a timely and proper manner its obligations under
this Agreement, or if the Contractor becomes bankrupt or insolvent or falsifies its records or
YOI(I~5) 5
reports, or misuses its funds fi.om whatever source, the County may terminate this Agreement
in whole or with respect to any identifiable part of the program, effective immediately, or, at
its option, effective at a later date specified in the notice of such termination to the
Contractor.
ii. A failure to maintain the amount and types of insurance required by this Agreement
may result in immediate termination of this Agreement, in the sole discretion of the Director.
No prior notice to cure and of intent to terminate shall be required.
iii. An emergency or other condition involving possible loss of life, threat to health and
safety, destruction of property or other condition deemed to be dangerous, in the sole
discretion of the Director, may result in immediate termination of this Agreement, in whole or
with respect to any identifiable part of the program, in the sole discretion of the Director. In
such event, no prior notice to cure and of intent to terminate shall be required.
iv. Failure to comply with federal, State or local laws, roles, regulations, or County
policies or directives, may result in immediate termination of this Agreement, at the sole
discretion of the Director. In such event, no prior notice to cure and of intent to terminate shall
be required.
v. A failure on the part of Contractor to observe any of the other terms and conditions of
this Agreement on its part to be observed and performed, which failure persists after the
expiration of twenty (20) days from the date the Director gives notice to cure and of intent to
terminate to the Contractor shall be deemed a breach of contract; provided, however, that if
the matter which is the subject of the notice is of such a nature that it cannot reasonably be
corrected within twenty (20) days, then no breach of contract shall have been deemed to have
occurred if Contractor, before the expiration of the twenty-day period, diligently commences
and prosecutes the same to completion.
vi. The notice to cure and of intent to terminate shall call attention to the existence of the
failure and particularize the claimed failure in reasonable detail. The notice shall also state the
intended date of termination.
vii After a breach of contract has occurred, the Director or his/her designee, in his/her
sole discretion, may terminate the Agreement. The Director shall give written notice of such
termination and the Agreement shall expire as fully and completely as if that date were the
date herein originally fixed for the expiration of the term.
viii. Upon termination pursuant to the foregoing paragraph, Contractor acknowledges and
agrees that it shall not be entitled nor shall it make a claim for lost profits or loss of anticipated
earnings because of termination.
Notice of Termination
i. Notice of termination must be in writing, signed by an authorized official, and sent to
the other party by certified mail, or by messenger, and receipt shall be requested. Notice of
termination shall be deemed delivered as of the date of its posting by certified mail or at the time
it is delivered to the other party by messenger.
6
shall also relinquish title and possession of any furniture, fixtures, equipment, materials or sup-
plies as specified in this Agreement.
iii. Upon receipt of a termination notice pursuant to the foregoing p,aragraph, the Contrac-
tor shall promptly discontinue all services affected unless otherwise directed by the notice of
termination.
Payments upon Termination
i. The County shall be released from any and all responsibilities and obligations arising
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 the Agreement, that are pursuant to, and after the
Contractor's compliance with, the terms and conditions of this Agreement.
ii. Upon termination, the Contractor agrees to promptly reimburse to the County, by check
payable to the Suffolk County Treasurer, the balance of any funds paid to the Contractor by
the County. Upon termination, any funds paid to the Contractor by the County which were
used by the Contractor in a manner that failed to comply with the terms and conditions of this
Agreement must be promptly reimbursed. If there is no response or if satisfactory repay-
ments are not made, the County may recoup such payments from any amounts due or becom-
ing due to the Contractor from the County under this Agreement or otherwise. The provisions
of this subparagraph shall survive the expiration or termination of the Agreement.
e. Termination By Contractor
The Contractor may terminate this Agreement by giving not less than sixty (60) days prior
written notice (or thirty (30) days' written notice if substantial breach of contract is involved) to the
Bureau, specifying the reasons for termination and the effective date of termination.
The Contractor agrees to the following provisions in compliance with current County requirements:
10. Child Sexual Abuse Reporting Policy
The Contractor agrees to comply with Chapter 577, Article IV, of the Suffolk County Code, entitled
"Child Sexual Abuse Reporting Policy", as now in effect or amended hereafter or of any other Suffolk
County Local Law that may become applicable during the term of this Agreement with regard to child sex-
ual abuse reporting policy.
11. Living Wage Law
This Agreement is subject to the Living Wage Law of the County of Suffolk. The law requires
that, unless specific exemptions apply 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 set
forth in the Living Wage Law. 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 have the authority, under appropriate circumstances, to terminate this Agreement and to
seek other remedies as set forth therein, for violations of this Law.
vo~ OZ05) 7
12. Certification
The parties to this Agreement hereby certify that, other than the funds provided in this Agreement
and other valid Agreements with the County, there is no known relationship within the third degree of
consanguinity, life partner or business, commercial, economic, or financial relationshil~ between the parties,
the signatories to this Agreement, and any partners, members, directors, or shareholders of five percent (5%)
(or more) of any party to this Agreement.
13. Civil Actions
The Contractor represents that it shall not use any of the moneys received under this Agreement,
either directly or indirectly, in connection with the prosecution of any civil action against the County of
Suffolk or any of its programs, funded by the County, in part or in whole, in any jurisdiction or any judicial
or administrative forum.
14. 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 or intent
of securing an agreement or securing 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 he
has read and is familiar with the provisions of Local Law No. 32-1980 of Suffolk County (Chapter 386 of
the Suffolk County Code).
Except as herein amended, all other representations, terms and conditions of said Agreement, including any
and all amendments or budget modifications executed prior to the date hereof, are hereby ratified and
confirmed to be in full force and effect.
End of Text for Exhibit A-2
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERV1CES
PROGRAM BUDGET
APPENDIX B
CONTR~,CT NUMBER:
AGENCY/MUNICIPALITY:
PROG~M TITLE: ~~
PERSONAL SERVICES:
POSITION TTPd5
TOTAL PERSONAL SERVICES(I)
Io1~1o I o_1 z-/j
t I I I~
RATE OF ~ASIS
FAY
$
$
TOTAL SAJ-A~E~ S AND WAGES
TOTALI~NGE BENEFITS
$
$
$
$
$
$
$
$
CONTRACTED SERVICES AND STIPENDS _ _
PA~Y (S,M.HR~)
TOTAL CONIRACTED SERVICES {2)
TOTAL MAINTENANCE & OPERATION (3)I $ --~-
LIST EQUIPMENT TO BE PURCHASED OR RENTED:
(UNIT COST OVER $200 AND LIFE EXPECTANCY OF OVER TWO YEARS)
FACILITY REPAIRS
I PROGRAM SITE ADORESS
TOTAL FACILITY REPAIRS (4) $
TOTAL OCFS PROGRAM AMOUNT ~ S
~ TOTAL OCFS FUNDS REQUESTE'~-
LIST OF OTHER FUNOING SOURCES
MUNICIPAL FUNDING
OTHER SOURCES
· USE AN ASTERISK ~ TO THE FIGURES USrEO TO IDENTIFY THOSE rFEMS FOR WHIC.;'I OCFS REIMBURSEMENT IS NOT BEING REQUESTED.
USE gK) TO IDENTIFY ONLy IN KIND SERVICES. EQUIPMENT. ETC DONATEO TO PROGRAM, WHERE ALLOWEO.
Suffolk County Form 22
Contractor's/Vendor's Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement
must be completed by all contractors/vendors that have a contract with Suffolk County. In the event
contractor/vendor is exempt from completing paragraphs numbered 1 through 11 below, so indicate at
paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt
status, you must execute this form below before a notary public.
1. Contractor's/Vendor'sName ~-~M],4/ tot. ~-~U¢/6/c7
Address //fi/'.~ ]-0' (~-/~' ~ ~ 2]., ' -
City andState ,_~f"az~:Tgz~,~ ] & .,4~ ."2'/g'. Zip Code /ff? 4/
2. Contracting Department's Name
Address
o
5.b
Payee Identification or Social Security No.
Type of Business__Corporation__Partnership__Sole Proprietorship__Other
Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk
County in excess of $1,0007 Yes No.
Has contractor/vendor entered into three or more contracts, including the one for which you are
now completing this form, with Suffolk County, any three of which, when combined, exceed
$1,0007 Yes No.
Table of Organization. List names and addresses of all principals; that is, all individuals serving
on the Board of Directors 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 County. (Attach additional sheet if
necessary.)
List all names and addresses of those individual shareholders holding more than five percent
(5%) interest in the contractor/vendor. Conspicuously identify any shareholder who is also an
officer or an employee of Suffolk County. (Attach additional sheet if necessary).
10.
Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor
relationship with Suffolk County? __Yes__No.
If you answered yes to 8 above, 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's/Vendor's Public Disclosure Statement with the
contract. (Describe general nature of the contract.)_
Page 1 of 3 Public Disclosure Form
11.
12.
Remedies. The failure to file a verified public disclosure statement as required under local law
shall constitute a material breach of contract. Suffolk County may resort, use or employ any
remedies contained in Article II of the Uniform Commemial Code of the State of New York. In
addition to all legal remedies, Suffolk County shall be entitled, upon a determination that a
breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract.
If you are one of the entities listed below at a) through c) or you qualify under d) below, you are
exempt from completing paragraphs numbered I through 11 herein:
a) Hospital
b) Educational or governmental entities
__ c) Not-for-profit corporations
__ d) Contracts providing for foster care, family day-care providers or child protective
services
Please check to the left side of the appropriate exemption.
13. Verification. This section must be signed by an officer or principal of the contractor/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)lis/her OWl3 knowledge, tree.
Dated: ~/~[~/0~ Signed: /~_,.,~/t f/~ ~.~
Printed Name of Signer: ,/Joshua Y. Horton
Title of Signer: / Supervisor
Name of Contractor/Vendor: Town of Southold
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
Within New York State)
STATE OF NEW YORK)
COUNTY OF ) ss.:
,~O~,_5~°.-~(Y~ ~3;~onally k~;wthnetYoer~;2o0rOp~robev[~r~omme~t~ ~:ed;ra~7oe~'saP~:~ollr[ ;PviP;e~;de
to be the.ihdividual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s)
on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed
th~)~n~trument. ~/~ ~
(signature and offilze of individual taking acknowledgement)
BONNfE J. DOROSKI
Nobly Public, State Of NewYofk
No. 01[:)06095328, Suffolk Ce_Untlr
Ten, F. xpims July 7, 20 O~
Page 2 of 3 Public Disclosure Form
Law No. Y0002M/0002-08YA
~eveloJl'Pent Delinquency Prevention Program
IFMS No. SCS EXE 07000002839
Amendment No.1
.. .;
Amendment of Agreement
This is the First Amendment of an Agreement, 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 Youth Bureau
(Department), baving its principal office at H. Lee Dennison Building-3M Floor, 100 Veterans Memorial Highway, Hauppauge, New York
(Mailing Address: Box 6100 Hauppauge, New York 11788-0099), and Town of Southold (Contractor), a New York municipal corporation,
having its principal place of business at Southold Town Hall, Main Street, Southold, New York 11971, acting through its duJy constituted
agency; and Family Service League (Implementing Agency), a New York not-for-profit corporation, having its principal place of business
at 790 Park Avenue, Huntington, New York 11743.
The parties hereto desire to modify the Agreement by extending the term from December 31, 2006 through December 31, 2007 (1/1/07 to
12/31/07 = 2007 Budget Period) and adding a new provision in compliance with current County requirements. Sufficient funding exists in
the 2007 Suffolk County Operating Budget.
-J Term of Agreement: Shall be January 1, 2006 through December 31, 2007 with one (1) one-year extension at the County's
option.
State Aid Percentage: 18%
Percentage of Advance: 25%
Total Cost of Agreement:
Shall not exceed $20,501<Total Cost of2 budget periods> (of which $10,316 is for the 2007 Budget
Period)
Terms and Conditions: Shall be as set forth in Exhibit A-I attached.
In Witness Whereof, the parties hereto have executed this First Amendment of Agreement as of the latest date written below.
T~"fS~
By: ~ ~Itt!j/-
Name: SocH-+. /1. R<-lSS"e C;
Title: 5~ u cC.> 0 r q
Fed. Taxpayer ill #: ( l ~4:>O 0 { i:J (
Date:
County of Suffolk
By:
---
Date:-.l!: 1- 01
Family Service League
B~
Name: na.V..f1/"l BOdro"'--h.t.-ti\.
Title: f )(.~.c IJ Plcoo
Fed. TaxPayer ill#: I (-ll~ ollta."7
Date: 7 ~tlo 7
By:
L i . Medina M.S.W.
xecutive Director
Approved as to Legality:
Christine Malati
Suffolk County Attorney
f1ECE!V::>
By:
S...,...r'rrJr..," r' ,
. , ~ '~.~Lt
Patricia M. Jord
Assistant COUll
Date: 4
Y02
Page 1 of 4 pages
L.aw No. YOOOlM/@-08YA
Rev. 01130/07
Development Delinquency Prevention Program
IFMS No. SCS EXE OXOOOO
Amendment No.1
Exhibit A-I
Whereas, the County and Contractor have entered into an Agreement, for a term from January 1, 2006
through December 31,2006, with two (2) one-year extensions at the County's option, to provide a develop-
ment delinquency prevention program; and
Whereas, the parties hereto desire to modify the Agreement to extend the term from December 31, 2006
through December 31, 2007, add a new provision in compliance with current County requirements and in-
crease the Total Cost of Agreement for the 2007 Budget Period as set forth below;
Now, Therefore, in consideration of the covenants, promises and consent herein contained, the parties
hereto agree as follows:
1. Term of Agreement:
The Term of Agreement paragraph on page 1 of the Agreement is amended to read January 1, 2006
through December 31,2007 with one (1) one-year extension at the County's option as set forth on
page 1 ofthis First Amendment of Agreement.
2. Payment of Services:
The Total Cost of Agreement shall be increased by the amount specified on page one for the 2007
Budget Period.
3. Budget:
The budget annexed hereto as Exhibit C-l is made part of the Agreement for the 2007 Budget Pe-
riod.
4. The Contractor agrees to amend the Agreement to include the following provision in
compliance with current County requirements:
Lawful Hiring of Employees Law:
This Agreement is subject to the Lawful Hiring of Employees Law ofthe County of Suffolk (Local
Law 52-2006). It provides that all covered employers, (as defined), and the owners thereof, as the
case may be, that are recipients of compensation from the County through any grant, loan, subsidy,
funding, appropriation, payment, tax incentive, contract, subcontract, license agreement, lease or
other financial compensation agreement issued by the County or an awarding agency, where such
compensation is one hundred percent (100%) funded by the County, shall submit a completed sworn
affidavit (under penalty of peljury), the form of which is attached, certifying that they have complied,
in good faith, with the requirements ofTitIe 8 of the United States Code Section 1324a with respect
to the hiring of covered employees (as defined) and with respect to the alien and nationality status of
the owners thereof. The affidavit shall be executed by an authorized representative of the covered
employer or owner, as the case may be; shall be part of any executed contract, subcontract, license
YOl (1107)
Page 2 of 4 pages
agreement, lease or other financial compensation agreement with the County; and shall be made
available to the public upon request.
All contractors and subcontractors (as defmed) of covered employers, and the owners thereof, as the
case may be, that are assigned to perform work in connection with a County contract, subcontract, li-
cense agreement, lease or other financial compensation agreement issued by the County or awarding
agency, where such compensation is one hundred percent (100%) funded by the County, shall submit
to the covered employer a completed sworn affidavit (under penalty ofpe:rjury), the form of which is
attached, certifYing that they have complied, in good faith, with the requirements of Title 8 of the
United States Code Section 1324a with respect to the hiring of covered employees and with respect
to the alien and nationality status of the owners thereof, as the case may be. The affidavit shall be
executed by an authorized representative of the contractor, subcontractor, or owner, as the case may
be; shall be part of any executed contract, subcontract, license agreement, lease or other financial
compensation agreement between the covered employer and the County; and shall be made available
to the public upon request.
An updated affidavit shall be submitted by each such employer, owner, contractor and subcontractor
no later than January 1 of each year for the duration of any contract and upon the renewal or amend-
ment of the contract, and whenever a new contractor or subcontractor is hired under the terms of the
contract.
The Contractor acknowledges that such filings are a material, contractual and statutory duty and that
the failure to file any such statement shall constitute a material breach of this agreement.
Under the provisions ofthe Lawful Hiring of Employees Law, the County shall have the authority to
terminate this Agreement for violations ofthis Law and to seek other remedies available under the
law.
The Contractor represents and warrants that it has read, is in compliance with, and shall comply with
the requirements of Suffolk County Code Chapter 234, Suffolk County Local Law No. 52-2006, the
Lawful Hiring of Employees Law.
Required Forms:
Suffolk County Lawful Hiring of Employees Law Form LHE-1; entitled "Suf-
folk County Department of Labor -''Notice Of Application To CertifY Com-
pliance With Federal Law (8 D.S.C. SECTION 1324a) With Respect To Law-
ful Hiring of Employees"
"Mfidavit Of Compliance With The Requirements Of 8 D.S.C. Section 1324a
With Respect To Lawful Hiring Of Employees" Form LHE-2.
5. 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 or
intent of securing an agreement or securing 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 he has read and is familiar with the provisions of Local Law No. 32-1980 ofSuf-
folk County (Chapter 386 of the Suffolk County Code).
Page 3 of 4 pages
"
6. Except as herein amended, all other representations, terms and conditions of said Agreement, includ-
ing any and all amendments or budget modifications executed prior to the date hereof, are hereby
ratified and confirmed to be in full force and effect.
End of Text for Exhibit A-l
Page 4 of 4 pages
State ot'New York
, 'Office of Childnm and Family Services
Form OCFS-3105 {9198l
INDIVIDUAL PROGRAM APPLICATION
Funding Category: YDDP/SERVIrn
Sponsoring
Municipality:
Implementing
Agency:
Program
Title:
Agency
Address:
Mill
OCFS Central OfficI! use only
Program Code:
07470010S004
CD SUFFOLK
County: SUFFOLK
TOWN OF SOUTHOm
SOUTHOm YOUTH SERVIrnS
~~~~:am Budget $ 10 :3/cP_ (100%1
OCFS Funds.-2 .--,., ~,-
Requested $ _ ~ ~..::J6 <-_~*' of totall
TOWN HALL MAIN RD
Street
SOUIHom
c"'
NY
State
11971
Zip Code .
Federal ID #:
Charities Reg #:
11-6001939
Not Applicable
Period of Actual
To:
12/31/07
Mr. Scott A. Russell, Supervisor
o Executive Director Board Chairperson Sigtlature
(~) 7(P-S-l~&'r
Telephone Number
Mr. JAMES M::MAHON
DIREnOR
W}765-1283
Telephone NUmber
Contact Person
Title
Fiscal Officer
Trtle
~/) 7q,S-/;?<f3
;;r/t7J1~ IJfCjlfll-/!3lAl
.()II(~(,JJ~
Telephone Number
The Agency Is: D Private. Not~for.Profit Qg Public
PROGRAM SITES - Most Significant (3 Maximum)
o Religious Corporation
Assembly NYS Senate Local City Council
Type I . Address (Street,City,State,Zip) Dist. No. Dist No. Plan'g Bd. District
OFFICE 'ICWN HALL MAIN RD 1 1
SOUTHOm 11971
.
NYC ONLY
PROGRAM SUMMARY: {MAXIMUM OF 350 CHARACTERS - approximately 45 Words}
PRO:JRAM IS DESIGNED TO DELIVER INDIVIDUAL CDUNSELIN3 AND CRISIS
INI'ERVENTICIN SERVIrnB TO 50 YOUI'H.
PROGRAM PROFILE
Unduplicated Count
of Youth and
Clients Served
(All Activities]
50
''i.
Probleml Target Number of Youth
Need Population Service Methods 10 be Served
Primary 519 840 524 I 530 50
Secondary --c- I
o Direct Services will NOT be provided by this program
Sex of program participants Male: 45% Female: 55 %
Ethnicity - Whites:~% Black: 10 % Hispanic:, 10 % NativeAmerican:~% Asian:~% Other:~%
Age-0.4:~ % 5.9:~ % 10.15:~ % 16"20:~%
Problem Need:
Target Pcpulation:
SeIVice Methods:
BEHAVIOR PROBLEMS IN HCl\'l8
HISTORY OF INVOLVEMENT W/CDURT/NOI'PlArnD
INDIVIDUAL COUNSELIN3
CRISIS INIERVENI'ION CDUNSELIID
,/pet/I
OCFS-3107 (Re". 03l2OO2) FRONl
NEWYORKSTA1E
. OFFICE OF CHILDREN AND FAMI~Y SERVICES
PROGRAM BUDGET
APPENDIX B
PROGRAM CODE: LQJ 7" if I 7 10 10 i /
CONTRACT NUMBER: I I
's ,
D "":' ,0
\0 I~
1_-
"GENCYIMUNICIPALlT':': It) W,J
?ROGRAMllRE: <So cJ7lloLd
PERSONA~ SERVICES:
POSmONllRE
0/ SDcJ7J-htd.
Yo J7}f S&eLl/C.~
FUN.:) n'?:::
RATE OF
PAY
lOTAL OCFS PROGRAM AMOUNT (1). TOTALOCFS PONDS REQUESTEE
~WlS PROGRAM
"$;.'
$
$
, '
$ $
$ $
~$ $
$ $
$ $
$ $
$ $'
. TOTALsAlAAIESANDWAGES $
. . 'j
TOTALFRINGEBENB'ITS $
TOTAL PERSONAL SERVICES (1) $
-19 -
:...... tf) -:-
-&~
CONTRACTED SERVICES AND STIPENDS
TY\'E OF SERvitloOR OONsULTANT.nri..E
.1
(t:# $
',' ..$
, ., ~' q.-'" ,~,c' ',' '"c, . $
TOTAL CONTRACTED SERViCES (2)
RATE OF 'BASE
PAY. (S.M.HR).
t) ,1lftPU//fL
TOTAL OCFS PROGRAM AMOUNT e,r
, -~
i .~
$ / t:), ,g I t,P -.
$ ,
$
$ ~3/~
1$
TQTAL MAINTENANCE & OPERATION (3) I $ - 0-
LIST EQUIPMENT TO BE PURCHASED OR RENTED:
(UNIT COST OVER S200 AND LIFE EXPECTANCY OF OVER TWO YEARS)
FACILITY REPAIRS
PROGRAM SITE ADDRESS
I
TOTAL FACILITY REPAIRS (4)
,~
I;
-&-
ItJil~fill!~~~!~F:' ,
I'~";-"'""'%~"""~-""'W".;>;:' ;.'" ]
TOTAL OCFS PROGRAM AMOUNT I I ~ 3/4- s L . -----
. . G? TOTAL OCFS UNDS REQUESTED L1... ~ (P..s-~ __i
LIST OF OTHER FUNDING SOURCES S /tJ.3/t.P REIM8URSAB~E TOTA~
$ Cf (PStP MUNICIPAL FUNDING
$ OTHER SOURCES
_ _ _ __,~ ___ .... ,,~.. ,...,,,...~<'" nCtrIOflo<:-c:rrcuT' Ie:: /.JnT Rf=INr:; REDUESTED_
Suffolk Cdunty, New York
Department of Labor
SUFFOLK COUNTY DEPARTMENT OF LABOR - LABOR MEDIATION UNIT
UNION ORGANIZING CERTIFICATlON/DECLARATION - SUBJECT TO AUDIT
If the following definition of "County Contractor" (Union Organizing Law Chapter 466-2) applies to the
contractor's/beneficiary's business or trausaction with Suffolk County, the contractor/beneficiary must complete Sections I,
III, and IV below. If the following definitions do not apply, the contractor/beneficiary must complete Sections II, ill and IV
below. Completed forms must be submitted to the awarding agency.
County Contractor: "Any employer that receives more than $50,000 in County funds for supplying goods or services pursuant to a
written contract with the County of Suffolk or any of its agencies; pursuant to a Suffolk County grant; pursuant to a Suffolk County
program; pursuant to a Suffolk County reimbursement for services provided in any calendar year; or pursuant to a subcontract with
any of the above."
Section I
The Union Organizing Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk
County Local Law No. 26-2003, the Suffolk Couuty Union Organizing Law (the law) and, as such shall not use
County funds to assist, promote, or deter uniou organizing (Chapter 466-3 A), nor seek reimbursemeut from the
County for costs'iucurred to assist, promote, or deter uniou organiziug. (Chapter 466-3 B)
Check if
Applicable
I/we further agree to take all action necessary to ensure that County fuuds are uot used to assist, promote, or deter
uniou organiziug. (Chapter 466-3 H)
D
I/we further agree that if any expeuditures or costs ,incurred to, assist, promote, or deter union organizing are made,
I/we shall maintain records sufficient to show that no County funds were used for those expenditures and, as
applicable, that no reimbursement from County funds has been sought for such costs. I/we agree that such records
shall be made available to the pertinent County agency or authority, the County Comptroller, or the County
Department of Law upon request. (Chapter 466-3 I)
I/we further affirm to the following:
. I/we will not express to employees any false or misleading information that is intended to iufluence the
determination of employee preferences regarding union representation;
. I/we will not coerce or intimidate employees, ~xplicitly or implicitly, in selecting or not selecting a bargaining
representative;
. I/wewill not require an employee, individually or in a group, to attend a meetiug or an event that is intended to
iuflo'ence his or her decision iu selecting or not selecting a bargaining representative;
. I/we understand my/our obligation to limit disruptions caused by prerecognition labor disputes through the
adoption of nonconfrontational procedures for the resolution of prerecognition labor disputes with employees
engaged in the production of goods or the rendering of services for the County; and
. I/we have or will adopt any or all of the above-referenced procedures, or their functional equivalent, to ensure
the efficient, timely, and quality provision of goods and services to the County. I/we shall include a list of said
procedures in such certification.
I/we further agree that every County contract for the provision of services, when such services will be performed on
County property, shall include a requirement that I/we adopt a reasonable access agreement, a neutrality agreement,
fair communication agreement, no intimidation agreement, and a majority authorization card agreement.
I/we further agree that every County contract for the provision of human services, when such services are not to be
performed on County property, shall include a requirement that I/we adopt, at the least, a neutrality agreement.
I/we understand that the efficient, timely, and nondisruptive provision of goods and services is a paramount financial
interest of the County of Suffolk and as such, the County expects the potential County contractor to protect the
County's financial interest by adopting nonconfrontational procedures for the orderly resolution oflabor disputes,
including, but not limited to, neutrality agreements, majority authorization card agreements, biuding arbitratiou
agreements, fair communication agreements, nonintimidation agreements, and reasonable access agreements.
DOL-LOJ (6/05)
" .
Suffolk County, New York
Department of Labor
Section II
The Union Organizing Law does 'l"t appJytothis contract for the following reason(s): 0 C3 'Gl.I"1( l:A.., fr' q "1
(5 f1?+~^ ~f(o'fr:!J ~e-ney- '
o
Check if
Applicable
'-;;wn oil SD vt+ho () Federal EmployerID#:
I- 0, (JoX (('1 Y Amount of Assistance:
)(")(A+t..o/r( jJY (r9'1I-n9;)t Vendor#:
Contractor Phone #: (jJ, JI- 7?,Y-:::- ( '?r(
Description of project or service:
Section ill
Contractor Name:
((-000{tJ'I
Contractor Address:
Section IV
I declare under penal
certification, and th
of perjury under the Laws of the State of New York that the undersigned is authorized to provide this
e above is true and correct.
~"'7
Authorized Ignature
Date
Print Name and Title of Authorized Representative
DOL-WI (6/05)
Suffolk Connly, New York
Department of Labor
SUFFOLK COUNTY DEPARTMENT OF LABOR - LABOR MEDIATION UNIT
UNION ORGANIZING CERTIFICA TIONillECLARATION - SUBJECT TO AUDIT
If the following definition of "County Contractor" (Union Organizing Law Chapter 466-2) applies to the
contractor'slbeneficiary's business or transaction with Suffolk County, the contractorlbeneficiary must complete Sections I,
III, and IV below. If tbe following definitions do not apply, the contractorlbeneficiary must complete Sections II, III and IV
below. Completed forms must be submitted to the awarding agency.
County Contractor: "Any employer that receives more than $50,000 in County funds for supplying goods or services pursuaut to a
written contract with the County of Suffolk or any of its agencies; pursuaut to a Suffolk County graut; pursuaut to a Suffolk County
program; pursuaut to a Suffolk County reimbursement for services provided in auy calendar year; or pursuaut to a subcontract with
any of the above."
Section I
The Union Orgauizing Law applies to this contract. Vwe hereby agree to comply with all the provisions of Suffolk
County Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) aud, as such shall not use
County funds to assist, promote, or deter union orgauizing (Chapter 466-3 A), nor seek reimbursement from the
County for costs incurred to assist, promote, or deter union orgauizing. (Chapter 466-3 B)
Check if
Applicable
I/we further agree to take all action necessary to ensure that County funds are not used to assist, promote, or deter
union organizing. (Chapter 466-3 II)
D
I/we further agree that if any expenditures or costs jncurred to assist, promote, or deter union orgauizing are made,
I/we shall maintain records sufficient to show that no County funds were used for those expenditures aud, as
applicable, that no reimbursement from County funds has been sought for such costs. I/we agree that such records
shall be made available to the pertinent County agency or authority, the County Comptroller, or the County
Department of Law upon request. (Chapter 466-3 I)
I/we further affirm to the following;
. Vwe will not express to employees any false or misleading information that is intended to infiuence the
determination of employee preferences regarding union representation;
. Vwe will not coerce or intimidate employees, explicitly or implicitly, in selecting or not selecting a bargaining
representative;
. Vwe will not require au employee, individually or in a group, to attend a meeting or an event that is intended to
influence his or her decision in selecting or not selecting a bargaining representative;
. Vwe understaud my/our obligation to limit disruptions caused by prerecognition labor disputes through the
adoption of none on fro ntationa I procedures for the resolution of pre recognition labor disputes with employees
engaged in the production of goods or the rendering of services for the County; and
. Vwe have or will adopt auy or all of the above-referenced procedures, or their functional equivalent, to ensure
the efficient, timely, aud quality provision of goods and services to the County. I/we shall include a list of said
procedures in such certification.
Vwe further agree that every County contract for the provision of services, when such services will be performed on
County property, shall include a requirement that Vwe adopt a reasonable access agreement, a neutrality agreement,
fair communication agreement, no intimidation agreement, and a majority authorization card agreement.
Vwe further agree that every County contract for the provision of humau services, when such services are not to be
performed on County property, shall include a requirement that I/we adopt, at the least, a neutrality agreement.
Vwe understand that the efficient, timely, and nondisruptive provision of goods and services is a paramount tinancial
interest of the County of Suffolk and as such, the County expects the potential County contractor to protect the
County's tinancial interest by adopting nonconfrontational procedures for the orderly resolution of labor disputes,
including, but not limited to, neutrality agreements, majority authorization card agreements, binding arbitration
agreements, fair communication agreements, nonintimidation agreements, and reasonable access agreements.
DOL-WI (6/05)
Suffolk County, New York
Department of Labor
Section II
The Union Organizing Law does not apply to this contract for the following reasonCs): 1
D
Check if
Applicable
Section III
Contractor Name:
Contractor Address:
Federal Employer ID#:
Amount of Assistance:
Vendor #:
Contractor Phone #:
Description of project or service:
der penalty of perjury under the Laws of the State of New York that the undersigned is authorized to provide this
and th t the above is true and correct.
Au horize Signature"
tJ/~~ /30DIWAJo,)
Prini Name ,md Title of Authorized Representative
Date
DOL-LOl (6/05)
Suffolk County Form 22
Conlractor'sNendor's Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement
must be completed by all contractors/vendors that have a contract with Suffolk County. In the event
contractor/vendor is exempt from completing paragraphs numbered 1 through 11 below, so indicate at
paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt
status, you must execute this form below before a notary public.
1. ContraGtor's~por's Name7f}W,J of .J;;uf-J..o I)
Address 1'1/1 /JJ S'-I-,e~E 'I . I
CityandStateJod.Lc/d. AJ.{w YOL( Zip Code II <t 71
2. Contracting Department's Name
Address
3. Payee Identification or Social Security No.
4. Type of Business_Corporation_Partnership_Sole Proprietorship_Other
S.a Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk
County in excess of$I,OOO? _Yes_No.
S.b Has contractor/vendor entered into three or more contracts, including the one for which you are
now completing this form, with Suffolk County, any three of which, when combined, exceed
$1,000? _Yes_No.
6. Table of Organization. List names and addresses of all principals; that is, all individuals serving
on the Board of Directors or comparable body,;ames 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 County. (Attach additional sheet if
necessary.)
7. List all names and addresses of those individual shareholders holding more than five percent
(5%) interest in the contractor/vendor. Conspicuously identify any shareholder who is also an
officer or an employee of Suffolk County. (Attach additional sheet if necessary).
8. Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor
relationship with Suffolk County?_Yes_No.
9. If you answered yes to 8 above, 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.)
10. The undersigned shall include this Contractor'sNendor's Public Disclosure Statement with the
contract. (Describe general nature of the contract.)
Page 1 of 3 Public Disclosure Form
11. Remedies. The failure to file a verified public disclosure statement as required under local law
shall constitute a material breach of contract. Suffolk County may resort, use or employ any.
remedies contained in Article IT of the Uniform Commercial Code of the State of New York. In
addition to all legal remedies, Suffolk County shall be entitled, upon a deterruination that a
breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract.
12. If you are one of the entities listed below at a) through c) or you qualify under d) below, you are
exempt from completing paragraphs numbered 1 through 11 herein:
a) Hospital
-* b) Educational or governmental entities
_ c) Not-for-profit corporations
_ d) Contracts providing for foster care, family day-care providers or child protective
services
Please check to the left side ofthe appropriate exemption.
Verification. This section must be signed by an officer or principal of the contractor/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 ow owledge, true.
Dated: )'~.,,47
Printed Nanfe of Signer:
Title of Signer:
Name of ContractorNendor:
13.
(
fOw~~~~U;~~o(r/
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW YORK)
COUNTY OF 5LAFf'~ ss.:
On the../.3- d~ of y,-,-- LV in the year 20Ofbefore me, the undersigned, personally appeared
rc.....Pf- /f ,( (JPJ ( persbnally known to me or proved to me on the basis of satisfactory evidence
to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s)
on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed
the i trument.
~.
e of individual taking acknowledgement)
BONNIEJ. DOROSKI
NotalY Public, State Of New Yurt
No. 01006095328, Suffolk County
Term Expires July 7. 20 ~
Page 2 of 3 Public Disclosure Form
UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT
(Without New York State)
STATE OF
)
)ss.:
)
COUNTY OF
On the day of in the year 2004 before me, the undersigned, personally
appeared personally known to me or proved to me on the basis of
satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies) and that by
his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the
individual(s) acted, executed the instrument, and that such individual(s) made such appearance before
the undersigned in
(Insert the city or other political subdivision and the state or country or other place the acknowledgement
was taken)
(signature and office of individual taking acknowledgement)
Contractor'sN endor's Public Disclosure Statement Form (Rev. 3/04)
Page 3 of 3 Public Disclosure Form
H:\MUNLA W\Pmj\Master Forms\Public disclosure SOP 04 form.doc
5.b
6.
Suffolk County Form 22
Contractor'sNendor's Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement
must be completed by all contractors/vendors that have a contract with Suffolk County. In the event
contractor/vendor is exempt from completing paragraphs numbered 1 through 11 below, so indicate at
paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt
status, you must execute this form below before a notary public.
~~U/~~-~6Jq6v6~
{/{-
.t.
1.
Zip Code
Contractor'sNe dor's N
Address
City and State AJ
Contracting Department's Name
Address
Payee Identification or Social Security No.
Type of Business_Corporation_Partnership_Sole Proprietorship_Other
Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk
County in excess of $1,000? _Yes_No.
Has contractor/vendor entered into three or more contracts, including the one for which you are
now completing this form, with Suffolk County, any three of which, when combined, exceed
$1,000? _Yes_No.
Table of Organization. List names and addresses of all principals; that is, all individuals serving
on the Board of Directors or comparable body,;ames 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 County. (Attach additional sheet if
necessary.)
2.
3.
4:
5.a
7. List all names and addresses of those individual shareholders holding more than five percent
(5%) interest in the contractor/vendor. Conspicuously identify any shareholder who is also an
officer or an employee of Suffolk County. (Attach additional sheet if necessary).
8. Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor
relationship with Suffolk County?_Yes_No.
9. If you answered yes to 8 above, 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.)
10. The undersigned shall include this Contractor'sNendor's Public Disclosure Statement with the
contract. (Describe general nature of the contract.)
Page 1 of 3 Public Disclosure Form
11. Remedies. The failure to file a verified public disclosure statement as required under local law
shall constitute a material breach of contract. Suffolk County may resort, use <;lr employ any
remedies contained in Article II of the Uniform Commercial Code of the State of New York.. In
addition to all legal remedies, Suffolk County shall be entitled, upon a determination that a
breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract.
12. If you are one of the entities listed below at a) through c) or you qualify under d) below, you are
exempt from completing paragraphs numbered 1 through 11 herein:
_a) Hospital
_ b) Educational or governmental entities
~ c) Not-for-profit corporations
_ d) Contracts providing for foster care, family day-care providers or child protective
services
Please check to the left side of the appropriate exemption.
13. Verification. This section must be signed by an officer or principal of the contractor/vendor
authorized to sign for the company for the purpose of executing contracts. The undersigned
being sworn, affirms under the penalties of peIjury, that he/she has read and understood the
foreg/ing statements and that they a; to' er own knowledge, true.
Dated: -1lQrlDl .:
Printed Name of Signer: ( e. VI
Title of Signer: ){
Name of ContractorN endor:
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW XQRK)
COUNTY OF ~~ ) ss.:
~ the ~ day of.:ll ~ in the year 200ft-before me, the undersigned, personally appeared
C~V\ ~4rt~11'\ persJnally known to me or proved to me on the basis of satisfactory evidence
to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in hislher/their capacity(ies) and that by hislher/their signature(s)
on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed
~O"' ~
J1M i.A.. !
(signature and office of individual taking cknowledgement)
MAUREEN R CROWLEY
Notary Public, Stale of New Yolk
No.01CR6137647 Z/
Qualified In Suffolk CountY 20;'1
Commission expires December 6. -
Page 2 of 3 Public Disclosure Form
UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT
(Without New York State)
STAlE OF
).
)ss.:
)
COUNTY OF
On the day of in the year 2004 before me, the undersigned, personally
appeared personally known to me or proved to me on the basis of
satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in hislher/their capacity(ies) and that by
hislher/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the
individual(s) acted, executed the instrument, and that such individual(s) made such appearance before
the undersigned in
(Insert the city or other political subdivision and the state or country or other place the acknowledgement
was taken)
(signature and office of individual taking acknowledgement)
Contractor'sNendor's Public Disclosure Statement Form (Rev. 3/04)
Page 3 of 3 Public Disclosure Form
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