HomeMy WebLinkAboutState Pharmaceutical Assist Program
. (tit)
~I
RESOLUTION 2006-675
ADOPTED
DOC ID: 2083
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2006-675 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
AUGUST 8, 2006:
RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs
Supervisor Scott A. Russell to execute the Al!reement between the Suffolk County Office
for the Al!inl! aud the Town of South old for the State Pharmaceutical Assistance Prol!ram
(SPAP), I FMS No. SCS EXE 00000010087 for the term of April I ,2005 through September 30,
2006, in the amount not to exceed $24,600 (with $19,600 for the IO/I! 05-9/30/06 budget period)
all in accordance with the approval of the Town Attorney.
a~J.itltQ.Q~tJ~
Elizabeth A. Neville
South old Towu Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: Louisa P. Evans, Justice
SECONDER: Thomas H. Wickham, Councilman
AYES: Evans, Wickham, Ross, Edwards, Russell, Krupski Jr.
. ,
Law No. AG006M/0038-09NA
Rev. 8/1/2006
State Pharmaceutical Assistance Program
IFMS No. SCS EXE 0&000010087
No. 001-6804-4980-95285-10087
First Amendment
Amendment of Agreement
This is the First Amendment of an Agreement (Agreement), last dated
September 26, 2005, 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: P.O. Box 6100, Hauppauge, New York 11788-0099), and the Town of South old
(Contractor), a New York municipal corporation, having its principal place of business at 53095 Main
Road, P.O. Box 1179, Southold, New York 11971-0959.
The parties hereto desire to modify the Agreement to extend the term from
September 30, 2005 through September 30, 2006, (the period October 1, 2005 through
September 30, 2006 being hereinafter called the "2005/2006 Budget Period")and to amend other
contract provisions to comply with current County Standards, as set forth herein. Sufficient funding
exists in the 2006 Suffolk County Operating Budget.
Term of Agreement: Shall be April 1, 2005, through September 30, 2006, with three
one-year extensions at the County's option.
Total Cost of Agreement: Shall not exceed $ 24,600 (with $19,600 for the 2005/2006
Budget Period).
Terms and Conditions: Shall be as set forth in Exhibits A-2005/2006 and C-2005/2006
attached.
In Witness Whereof, the parties hereto have executed this First Amendment of Agreement as of
the latest date written below.
Town of so~uthOld
By: ~ 1'1/ ,.1/
- ~
Scott A: Russell 8/:/"/06
Supervisor
County of Suffolk
/j
/ ,,' (" /L(~L ,
By: (J~ ~?~)
Paul Sabatino II '
Chief Deputy County Executive
Fed. Taxpayer ID #: 11-6001939
Date:
Date:
q / 'C } ?-eJL,
L I
Samantha N. McEachin
Assistant County Attorney
Approved:
By: ~~~~~d~~g/2~o;;
Director, Office for the Aging
Recommended: ()
By: ~~
Maureen Porta Date
Senior Citizens Program Administrator II
'i?( J-. '1 /0 ,
Approved as to Form, Legality:
AG6M (7/06)
AG6 SPAP exl Sohld 06
..
Law No. AG006M/0038-09NA
Rev. 7/26/2006
State Pharmaceutical Assistance Program
IFMS No. SCS EXE 00000010087
No. 001-6804-4980-95285-10087
First Amendment
Exhibit A-2005/2006
Whereas, the County and Contractor have entered into an Agreement (Law No. AG004M10026-06R),
last dated September 26, 2005, for a term from April 1 , 2005, through September 30, 2005 for State
Pharmaceutical Assistance Program at a Total Cost of $5,000; and
Whereas, the parties hereto desire to modify the Agreement extending the term from
September 31,2005 through September 31,2006 and (at an additional cost of $19,600)
increasing the Total Cost of the Agreement to $24,600, as set forth below, and;
Now, therefore, in consideration of the covenants, promises and consent herein contained, the
parties hereto agree as follows:
1. Term of Aareement:
The Term of Agreement paragraph on page 1 of the Agreement is amended to read
April 1 , 2005, through September 30, 2006 as set forth on the page 1 of this First Amendment of
Agreement.
2. Pavment of Services:
The Total Cost of Agreement $24,600 is comprised as follows:
(a) $ 5,000 for program year 2005;
(b) $19,600 for program year 2005/2006;
3. Budaet:
The Budget annexed hereto as Exhibit C - 2005/2006, including advance payment
schedule, if any, is made part of the Agreement.
4. Paragraph 7 of Exhibit A 1 to the agreement is amended to read as follows:
7. Addresses for Notices, Claims and Reports
(a) Notices, Relating to Payments, Reports or Other Submissions.
Any communication, notice, claim for payment, report, or other submission
necessary or required to be made by the parties regarding this Agreement shall be in
writing and shall be given to the County or the Contractor or their designated representative
at the following addresses or at such other address that may be specified in writing by the
parties and must be delivered as follows:
For Aqinq:
By Registered or Certified Mail in Postpaid Envelope or
by Nationally Recognized Courier Service
Holly S. Rhodes-Teague, Director
Suffolk County Office for the Aging
H. Lee Dennison Building
100 Veterans Memorial Highway
P.O. Box 6100
Hauppauge, New York 11788-0099
and
Page 2
AG6 SPAP exl Sohld 06
Law No. AG006M/0038-09NA
Rev. 7/26/2006
State Pharmaceutical Assistance Program
IFMS No. SCS EXE 00000010087
No. 001-6804-4980-95285-10087
First Amendment
For the Contractor:
By Registered or Certified Mail in Postpaid Envelope or
by Nationally Recognized Courier Service
At the address set forth on page one of this Agreement, attention of the person who
executed this Agreement or such other designee as the parties may agree in writing.
(b) Notices Relating to Insurance
Any communication, notice or other submission regarding insurance
requirements under this Agreement shall be in writing and shall be given to the County or
the Contractor or their designated representative at the following addresses or at such
other addresses that may be specified in writing by the parties and must be delivered as
follows:
For Aaina:
By Registered or Certified Mail in Postpaid Envelope or
by Nationally Recognized Courier Service
Holly S. Rhodes-Teague, Director
Suffolk County Office for the Aging
H. Lee Dennison Building
100 Veterans Memorial Highway
P.O. Box 6100
Hauppauge, New York 11788-0099
and
Christine Malafi, County Attorney
Suffolk County Department of Law
H. Lee Dennison Building
100 Veterans Memorial Highway
P.O. Box 6100
Hauppauge, New York 11788-0099
and
For the Contractor:
By Registered or Certified Mail in Postpaid Envelope or
by Nationally Recognized Courier Service
At the address set forth on page one of this Agreement, attention of the person who
executed this Agreement or such other designee as the parties may agree in writing.
(c) Notices Relating to Indemnification and Termination
Any communication or notice regarding indemnification or termination shall be
in writing and shall be given to the County or the Contractor or their designated
representative at the following addresses or at such other addresses that may be specified
in writing by the parties and must be delivered as follows:
Page 3
AG6 SPAP ex! Sohld 06
Law No. AG006M/0038-09NA
Rev. 7/26/2006
State Pharmaceutical Assistance Program
IFMS No. SCS EXE 00000010087
No. 001-6804-4980-95285-10087
First Amendment
For the County:
By Registered or Certified Mail in Postpaid Envelope or
by Nationally Recognized Courier Service
Holly S. Rhodes-Teague, Director
Suffolk County Office for the Aging
H. Lee Dennison Building
100 Veterans Memorial Highway
P.O. Box 6100
Hauppauge, New York 11788-0099
and
Christine Malafi, County Attorney
Suffolk County Department of Law
H. Lee Dennison Building
100 Veterans Memorial Highway
P.O. Box 6100
Hauppauge, New York 11788-0099
and
For the Contractor:
By Registered or Certified Mail in Postpaid Envelope or
by Nationally Recognized Courier Service
At the address set forth on page one of this Agreement, attention of the person who
executed this Agreement or such other designee as the parties may agree in writing.
Notices sent under paragraphs a, b, and, c above shall be deemed to have been duly given
(i) if mailed by registered or certified mail, upon the seventh business day after the mailing thereof;
or (ii) if by nationally recognized overnight courier service, upon the first business day subsequent
to the transmittal thereof.
Each party shall give prompt written notice to the other party of the appointment of
successor(s) to the designated contact person(s) or his or her designated successor(s).
(d) Notices Relating to Litigation
i. Any notice by either party to the other with respect to the
commencement of any lawsuit or legal proceeding against the other, shall be
effected pursuant to and governed by the New York State Civil Practice Law and
Rules or the Federal Rules of Civil Procedure, as applicable.
ii. In the event the Contractor receives a notice or claim or becomes a
party (plaintiff, petitioner, defendant, respondent, third party complainant, third party
defendant) to a lawsuit or any legal proceeding related to this Agreement, the
Contractor shall immediately forward to the County Attorney, at the addresses set
forth in sub-paragraph b above, copies of all papers filed by or against the
Contractor. Notices shall be as provided in paragraph (c) above.
Page 4
AG6 SPAP exl Sohld 06
..
Law No. AG006M/0038-09NA
Rev. 7/26/2006
State Pharmaceutical Assistance Program
IFMS No. SCS EXE 00000010087
No. 001-6804-4980-95285-10087
First Amendment
5. Subparagraph (g) of Paragraph 13 of Exhibit A 1 to the Agreement is replaced in its entirety with
the following:
(g) The Contractor agrees that it shall protect, indemnify and hold harmless the County
and its officers, officials, employees, contractors, agents and other persons from and against all
liabilities, fines, penalties, actions, damages, claims, demands, judgments, losses, costs,
expenses, suits or actions and reasonable attorney's fees, arising out of the acts or omissions or
the negligence of the Contractor in connections with the services described or referred to in this
Agreement. The Contractor shall defend the County and its officers, officials, employees,
contractors, agents and other persons in any suit, including appeals, or at the County's option, pay
reasonable attorney's fees for defense of any such suit arising out of the acts or omissions or
negligence of the Contractor, its officers, officials, employees, subcontractors or agents, if any, in
connection with the services described or referred to in this Agreement.
6. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the State
of New York, without regard to conflict of laws. Venues shall be designated in Suffolk County, New
York or the United States District Court for the Eastern District of New York.
7. Force Majeure
Neither party shall be held responsible for any delay or failure in performance hereunder to
the extent such delay or failure is caused by fire, flood, explosion, war, strike, embargo, civil or
military authority, act of God, act or omission of carriers, power failure or similar causes beyond its
control ("force majeure conditions"). If any force majeure condition occurs, the party delayed or
unable to perform shall give immediate notice to the other party.
8. 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 ofText-
Page 5
AG6 SPAP exl Sohld 06
:
Law No. AG006M/0038-09NA
Rev. 7/26/2006
State Pharmaceutical Assistance Program
IFMS No. SCS EXE 00000010087
No. 001-6804-4980-95285-10087
First Amendment
Exh i bit C-2005/2006
BUDGET
Town of Southold
State Pharmaceutical Assistance Program
October 1, 2005 - September 30, 2006
PERSONNEL
Senior Citizen Aide & Director
~18.728
18,728
872
$19.600
FRINGE
NET REIMBURSMENT
Page 6
AG6 SPAP ex! Sohld 06
..
Suffolk County Form SCEX 22
Contractor'sNendor's Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement
must be completed by all contractors/vendors that have a contract with Suffolk County. In the event
contractor/vendor is exempt from completing paragraphs numbered 1 through 11 below, so indicate at
paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt
status, you must execute this form below before a notary public.
1.
2.
3.
4.
S.a
S.b
6.
7.
8.
9.
Contractor'sNendor's Name 73>>n fa~ ..5tJUTHOL.J)
Address 5"''i()9.5 /Vja Ro
Cityand.State 5Y..i71lnl]) , f~ ~~.} Zip Code / /17/
Contractmg Department's ~ame ~. Irh EAVJ('i?:"S
Address 7 SO PM Jf7 {t S'T A/f -4-7JI TlA (' r 1II.!f J /9 S,J
Payee Identification or Social Security No. ' .
Type of Business_Corporation _Partnership_Sole Proprietorship ....()ther
Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk
County in excess of$I,OOO? _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, 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'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 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 II 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.
Verification. This section must be signed by an officer or principal of the contractor/vendor
authorized to sign for the company for the purpos of executing contracts. The undersigned
being sworn, affirms under the penalties of perj that he/she has read and understood the
foregoing statements and that they are, to his/her knowl dge, true.
Dated: ~/;?, ~t
Printed Name ot Signer:
Title of Signer:
Name ofContractorNendor:
13.
. 'YlIA TH1'\Ll\ -r;iJIA IN , StA 11 E ~ viS (')((
Ii>wtJ oil StJU77-f{)L i'\
,
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW YORK)
COUNTY OF ) ss.:
On the It. day in the year 20 L;tbefore me, the undersigned, personally appeared
CAi personally known to me or proved to me on the basis of satisfactory evidence
to be the individua (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.
~d~ () (? ~1-:f1d/1 )
(signature and offic of individual taking acknowledgement)
LINDA J CUe., =R
NOTARY PUBLIC, S;"" of clew York
NO.Oloo4822562 ,c:, Couj),ly
Term expires DC'""",,,, 31, 20"-l2
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 20_ 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'sNendor's Public Disclosure Statement Form (Rev. 3/04)
Page 3 of 3 Public Disclosure Form
SCEX 22 Disci S-04
,
30-97
OFFICE OF THE COUNTY EXECUTIVE
ALL-DEPARTMENT-HEADS MEMORANDUM
DATE: June 10, 1997
CONTRACf AGENCY BUDGET MODlFICA nONS
.This memorandum applies to those departments who pay contract agencies from the Operating
Budget 4770 or 4980 objects.
On August 29, 1995, ~H 47-95 was issued to resolve problems whicIi had developed regarding
the procedures and requirements for modifYing contract agency budgets. In early 1997, there
were again problems with timeliness and the reasons for modifications for certain departments
involving 1996 contracts.
")
Departments who deal with contract agencies have a major responsibility in the processing of
contract budget modifications. Therefore, the attached procedures, which take effect with all
1997 contracts should be closely followed. Please distribute these procedures to all of your
contract agencies.
If there are any questions regarding this ADH, please contact your department's Budget
Examin~. .
~f~
ERIC A. KOP . .
Chief Deputy County Executive
Distribution
Department Heads
Attachment
,,~~~~~
-' .
....,,-_......,---
.'
BUDGET MODIFICATIONS
REOUIREMENTS:
I. Non-equipment requests for contract budget modifications must be received at the County
Executive's Budget Office no later than 45 calendar days prior to the end of the contract
fiscal year. Equipment modifications must be received 90 calendar days prior to the end
of the contract fiscal year. -
2. Under no circumstances can expenditures for which a budget modification is being
requested be made prior to the approval of the modification by the Budget Office.
3. An agency will be restricted to three approved modifications per year.
4. Each line item requested to be modified must be fully justified and must be directly
related to the intent of the program. -
5.
Any transfers to increase saIlI1)' rates of contract employees, create new positions, or
change the title of a position, must be submitted prior to the rate mcrease being given or
the position beiI!g filled. The Budget Office will not appro"Ve retroactive salll1)' increases~
The only exception applies to a retroactive labor agreement between an agency and their -
- union bargaining unites).
-)
6. Budget modifications cannot increase the dollar amount of the contract.
PROCEDURE:
I. ~our copies of the proposed budget modification and one copy of the justification,
including a letter from the agency requesting the change, should be forwarded to the
Budget office with the department's recommendation within fifteen- (IS) calendar
days of receipt of the request by the department .-
2. The justification must include the effect of the modification on the program;changes in
the available reimbursement to the County, if any, the additiOnal dollar amount whicp.
will be paid to the agency, and the dollar amount of reimbursement to the County, if the
modification is approved. /' _
3. If the contract is funded under a Federal or State grant, or State reimburselfient, the
Department Head must advise in the transmittal memo whether State or Federal approval
for the modification is required and whether the attached documentation showing the
change has been approved by the funding agency.
4. The budget modification format must indicate the line item, the current budget amount,
the amount spent year to date, the new amount of the line item and the dollar amount of
the change.
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 of2001, a living wage rate was established. The Living
Wage shall be adjusted each year in proportion to the increase of the area
Consumer Price Index. The increase in the area Consumer Price Index for 2005 is
3.9%. Effective July 1,2006, the Living Wage will increase to $10.02 per hour
with health benefits and $11.41 per hour without health benefits for covered
employees of an agency receiving financial compensation through the County.
The law also mandates that full time 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 ofthe Living Wage law may be obtained by
contacting this Unit (631 853-3808) or accessing the Suffolk County web page at
www.co.suffolk.nv.us/labor and following the link to the Living Wage section. All
inquiries will remain confidential.
Suffolk County, New York
Department of Labor
SUFFOLK COUNTY DEPARTMENT OF LABOR- LABOR MEDIATION UNIT
UNION ORGANIZING CERTIFICATION/DECLARATION - SUBJECT TO AUDIT
If the following definition of "County Coutractor" (Union Organizing Law Chapter 466-2) applies to the
contractor's/beneficiary's business or transaction 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, 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 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
Check if
0'
The Union Organizing Law applies to this contract. I1we hereby agree to comply with all the provisions of Suffolk
County Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) and, as such shall not use
County funds to assist, promote, or deter union organizing (Chapter 466-3 A), nor seek reimbursement from the
County for costs incurred to assist, promote, or deter union organizing. (Chapter 466-3 B)
I1we 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 0)
I/we further agree that if any expenditures or costs incurred to assist, promote, or deter union organizing are made,
I1we 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. I1we 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:
. I1we will not express to employees any false or misleading information that is intended to influence the
detennination of employee preferences regarding union representation;
. I/we will not coerce or intimidate employees, explicitly or implicitly, in selecting or not selecting a bargaining
representative;
. I/we will not require an 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;
. I1we 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. I1we 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.
I1we 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 l/we adopt, at the least, a neutrality agreement.
I1we 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 (6105)
. Suffotk County. New York
Department of Labor
Section II The Union Organizing Law does not apply to this contract for the following reason(s):
D
Check if
Applicable
Section III
Contractor Name:
-;OWN 0 f' So u77+tJl-/\
S30 C;S /lftl/~;f;J fo6dxll7f
SOu nMl(j M V. /) q 7/
, V
Contractor Phone II: (G3/,)7t:5-1,f't"'l // 61/)d'J/?< '-!I/(PO
Description of project or service: ,')-!TJfp jJ/Yll?m/l(>f'u17t'ol ;f>s,.,lzul ('e.
Federal Employer lOll: 11(; Or? 193 r
Amount of Assistance: -.Dr / ~, 0 0 . 00
Contractor Address:
Vendor II:
ff<{) {'tV"!
Section IV
I declare under penalty of perjury under the Laws of the State of New York that the undersigned is authorized to provide this
certification, and that the above is true and correct.
Authorized Signature
ScotT;1. ;(u~se//
Print Name and Title of Authorized Representative
Date
DOL-LOI (6/05)