The URL can be used to link to this page

Home My WebLink AboutYouth Services Grant . .,mq'..... f.;".'~ l;.II;1 ~?y RESOLUTION 2007-549 ADOPTED DOC ID: 2962 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2007-549 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTH OLD TOWN BOARD ON JUNE 19,2007: RESOLVED that the Town Board of the Town of South old hereby authorizes and directs Supervisor Scott A. Russell to execute an Al!rcement with the Countv of Suffolk for the 2007 Youth Services I!rant in the amount of$1O,316. for the term January 1, 2007 through December 31, 2007, all in accordance with the approval of the Town Attorney. f"7~~a2;l~tt.. Elizabeth A. Neville South old Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Louisa P. Evans, Justice SECONDER: Thomas H. Wickham, Councilman AYES: Krupski Jr., Edwards, Ross, Wickham, Evans, Russell Law No. Y0002M/0002-08YA Development Delinquency Prevention Program IFMS No. SCS EXE 07000002839 Amendmeut No.1 Amendment of Agreement This is the First Ameudment of an Agreement, between lbe County of Suffolk (County), a municipal corporation of lbe State of New York, having its principal office at lbe County Center, Riverhead, New York 1190 I, acting tbrough its duly constituted Youth Bureau (Department), having its principal office at H. Lee Dennison Building-3" 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, Soulbold, New York 11971, acting tbrougb 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, 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 lbe 2007 Suffolk County Operating Budget. -, Term of Agreement: Shall be January 1,2006 through December 31, 2007 with one (I) 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 forlbe 2007 Budget Period) Terms and Conditions: Shall be as set forth in Exhibit A-I attached. In Witness Whereof, lbe parties hereto have executed lbis First Amendment of Agreement as ofthe latest date written below. Town of Southold County of Suffolk By: Name: 560+T /I. f<-US5CC (( Title: 5"'-PeA"'U 15 0 V Fed. Taxpayer ID #: ({- 6 oD { 73 '1 Date: By: Paul Sabatino II Chief Deputy County Executive Date: Family Service League Approved: Youth Bureau By: Name: Title: Fed. Taxpayer ID#: Date: By: Louis A. Medina M.S.W. Executive Director Approved as to Legality: Christine Malafi Suffolk County Attorney By: Patricia M. Jordan Assistant County Attorney Date: Y02 Page 1 of 4 pages Law No. Y0001MJ@-08YA Rev. 01130/07 Development Delinquency Prevention Program IFMS No. SCS EXE OXOOOO Amendment No.1 Exhibit A-l 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 ofthe 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 of this 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 peIjury), 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 (as defined) and with respect to the alien and nationality status of the owners thereof. The affidavit shall be executed by an authorized representative ofthe covered employer or owner, as the case may be; shall be part of any executed contract, subcontract, license YOI (1/07) 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 defined) 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 ofpeJjury), the form of which is attached, certifying that they have complied, in good faith, with the requirements of Title 8 ofthe 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 I of each year for the duration of any contract and upon the renewal or amend- ment ofthe 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 ofthis 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-I; entitled "Suf- folk County Department of Labor -"Notice Of Application To Certify Com- pliance With Federal Law (8 U.S.c. SECTION 1324a) With Respect To Law- ful Hiring of Employees" "Affidavit Of Compliance With The Requirements Of8 U.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 ofthe 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-I Page 4 of 4 pages State of New York Office of Children and Family Services Form OCFS-3105 (91SBI INDIVIDUAL PROGRAM APPUCA nON YIDP /SERVICE Funding Category: Sponsoring Municipality; Implementing Agency: Program Title: Agency Address: m SUFFOLK Mill OCFS Central Office Utili only Program Code: 07470010S004 County: SUFFOLK 'illWN OF SOUI'HOLD ~~~=~am Budget $ Iq_~/6_ 1100%) OCFS Funds ,"" r<'o ~.- Requested $_ ~~..:::J.::r <-_~.% of total) SOUTHOLD YOUI'H SERVICES 'illWN HALL MAIN RD Streot SOUIHOLD City NY Slate 11971 zip Code. Federal 10 #: Charities Reg #: 11-6001939 Not Applicable Period of Actual Program Operation - To: 12/31/07 Mr. Scott A. Russell, Supervisor o Executive Director Board Chairperson Mr. JAMES MCMAHON Signature (~) 7(0 'S" - I ~.f<f TelephoRo Number DIROCIOR WJ765-1283 T elaphon. Number Contact Person Title ;rMf&s IJ1c/Jfll/flJAl Fiscal Officer r<J II( ~C-7;JJ ~ Trtle Telephone Number ~/) 7~5-1P?<f3 ThlJ Agency Is: 0 Private. Not-for-Profit []J 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 'IDWN HALL MAIN RD 1 1 SOUIHOLD 11971 . NYC ONLY PROGRAM SUMMARY: (MAXIMUM OF 350 CHARACTERS - approximately 45 Words) PRCXffiAM IS DESIGNED 'ill DELIVER INDIVIDUAL CDUNSELIN8 AND CRISIS INTERVENTION SERVICES 'ill 50 YOUIH. PROGRAM PROFILE Problem! Target Number lif Youth Need Population Service Methods To be Served Primary 519 840 524 I 530 50 Seconda!y I Unduplicated Count of Youth and Clients Served (All Activities) 50 o Direct Services will NOT be provided by this program Sex of program participants Male :~% Female: 55 % Ethnlcity - Whltes:~% Black:-----1Q % Hispanic: 10 % NativeAmerican:~% Asian:--.Q% Other:--.Q% Age - 0-4: ---.Q % 5-9: ~ % 10-15: ---.Q % 16.20:--.JL% Problem Need: Target Population: Service Methods: BEHAVIOR PROBLEMS IN HC1\1E mS'IORY OF INVOLVEMENT W/CDURT/NOI'PIACED INDIVIDUAL mUNSELIID CRISIS INI'ERVENTION mUNSELIID .. OCFS-31 Q7 (Rev. 03l2002) FRONT ,\GSNCYIMUNICIPAL/T':': It) W,J ?ROGRAMTITLE: <So u71foLd PERSONAL SERVICES: POsmoN TTTI.E , . $ $ '.$ $ $ $ ". $ TOTAL PERSONAL SERVICES (1) CONTRAClED. SERVICES AND. STIPENDS 1Yl'E OF SERvleE'OR CONsUlTANnrriE ~. (t;$ $ '," $ . ... . --.-.--. .~','. ..."... . $ TOTAL CONTRACTED SERVICES (2) Mill NEW YORK STATE . OFFICE OF CHILDREN AND FAMII..Y SERVICES PROGRAM BUDGET APPENDIX B PROGRAM CODE: Le.J 7' I tf I 7 I 0 I 0 i I CONTRACT NUMBER: I I I D i~ 10 ID I~_ j L___ f) ~. SD U/J-h td- Yo JT}f SE,et/lc.~ FUND iY?::: RATE OF PAY TOTAL OCFS PROGRAM AMOUf{f (1). TOTAL OCFS fUNDS REQUESTED FORUlJS PROGRAM $ $ $ $ $ $ $' TOTAL SAlARIES ANO WAGE!f $ TOTAL fRINGE BENEFITS $ $ -f!) - :- t!) - "$,'" $ $ -&--....... .1 RATE OF PAY. . BASE (S.M.HR) TOTAL OCFS pROGlWJ AMOUf{f ('): t!) jHtJ~ .~ $ /~ 3/~ , $ ;', $ $ TQTAL MAINTENANCE & OPERATION (3) I $ - O- usT EQUIPMENT TO BE PURCHASED OR RENTED: (UNIT COST OVER $200 AND LIFE EXPECTANCY o.F OVER TWO. YEARS) FACIU1Y REPAIRS I PROGRAM SITE ADDRESS I I $ I. I ~ '" 1~~~~~~J%~!f ':'. ~ft.:-'-~~~I......~~~~1?ii~,J.~~' : - ."'f'''''::'~'7':~~'~j..:...s.c..~~j(,~...~1. ,.::. _ -c!) ~ To.TAL OCFS PROGRAM AMOUNT I I ~ .:3/ t;.. s I ___.. . . G? TOTAL OCFS UNDS REQUESTED L S 2. 4-..b.f' i -. , . - TOTAL FACILITY REPAIRS (4) $ s LIST OF OTHER FUNDING SOURCES S /~3/4:> REIMBURSABLE TOTAL $ t;? u,.o e MUNICIPAL FUNDING $ , OTHER SOURCES .Suffolk County, New York Department of Labor SUFFOLK COUNTY DEPARTMENT OF LABOR- LABOR MEDIATION UNIT UNION ORGANIZING CERTIFICA TIONffiECLARATION _ SUBJECT TO AUDIT If the following definitiOn of "Connty Contractor" (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/heneficiary 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 pursnant 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." Seetion 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 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) 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 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 influence the determination 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; . I/we understand my/our obligation to limit disruptions caused by prerecognition labor disputes through the adoption of non confrontational 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 . 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 gonds 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 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-La I (6/05) 'Suffolk County, New York Department of Labor Section II The Union Organizing Law does '}Ot aPll.ly to this contract for the following reason(s): 0 G <<- r1;: ~:f-(' ~ "1 15 f/9+QJt ~f(o'f/~ r:3€.11ey. ~ Check if Applicable Section III , / Contractor Name: .-r;;w r1 O-P 5~ r.A +ho fr.j Federal Employer 10#: (f - 000 { r J ( Contractor Address: ;J. 0, (7<0)( (( '7 ? Amount of Assistance: )()u..+/...oll, NY //91/-n?n Vendor#: ContractorPhone#: (/J. ;/- 1'?,l"::- (Yr'! Description of project or service: 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 Date Print Name and Title of Authorized Representative DOL-La! (6/05) . Suffolk County, 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 "Connty Contractor" (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 defiuitions 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 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 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) 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 H) D I/we further agree that if any expenditures or cost~ 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 rrom County funds has been sought for such costs. l/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) I1we further affirm to the following: . I1we will not express to employees any false or misleading information that is intended to influence the determination of employee preferences regarding union representation; . l/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; . I/we understand my/our obligation to limit disruptions caused by prerecognition labor disputes through the adoption of nonconrrontational 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 ofthe 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. 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 I1we 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 nonconrrontational procedures for the orderly resolution oflabor 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-LOI (6/05) 'Suffolk 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: Contractor Address: Federal Employer ID#: Amount of Assistance: Vendor #: Contractor Phone #: Description of project or service: 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 Date Print Name and Title of Authorized Representative DOL-LOI (6/05) 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. 1. Contractor'sf\l&f1por's Namel6"WN of.[;;ufio IJ Address (1"//1 /AJ S'-I~;~€T. / City and StateJo doLo 1";1 AJ-{tJ YO.L( Zip Code/I'I?/ 2. Contracting Department's Name Address 3. Payee Identification or Social Security No. 4. Type of Business_Corporation_Partnership_Sole Proprietorship_Other 5.a Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk County in excess of $1,000? _Yes_No. 5.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 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 perjury, that he/she has read and understood the foregoing statements and that they are, to his/her own knowledge, true. Dated: Printed Name of Signer: Title of Signer: Name of ContractorNendor: Signed: )('~-t->t- /1-. A(LHU (( ~u/~w e:c './;'.~~ 0 (d UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF 5(AFP~ ss.: On the _ d~ of Y'--<-. LV in the year 2001'before me, the undersigned, personally appeared y~ /f. (<" A (\fie.! ( pers6nally known to me or proved to me on the basis of satisfactory evidence to be the individua1(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 individua1(s) acted, executed the instrument. (signature and office of individual taking acknowledgement) 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 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'slVendor'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 S.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. Ctf(j/~t=' L6J16{J6~ C 1. Zip Code Contractor'sNe Address City and State IJ 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 $1,0001 _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. S.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 detennination 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 --X 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 hislher own knowledge, true. Dated: Printed Name of Signer: Title of Signer: Name of ContractorNendor: Signed: UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: 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 capacitYCies) 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. (signature and office of individual taking acknowledgement) Page 2 of 3 Public Disclosure Form DmFORMCERTIfiCATEOFACKNOWLEDGEMENT (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 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's/Vendor's Public Disclosure Statement Form (Rev. 31M) Page 3 of 3 Public Disclosure Form H:\MUNLA W\Pmj\Master Forms\Public disclosure SOP 04 form.doc u 0 ouny o e, apLer To Be Completed By Applicant! Covered Employer//Owner EMPLOYER/CORP./BUSINESS/COMP ANY NAME: 1) ADDRESS: 2) NOT-FOR-PROFIT: YES_ NO_ (SUBMIT CERTIFICATE OF INCORPORATION) 3) VENDOR #: 4) CONTRACT In: (Iflrnown) (Iflrnown) 5) CONTACT: 6) TELEPHONE #: 7) TERM OF CONTRACT OR EXTENSION (pROVIDE DATES): 8) BRIEF DESCRIPTION OF COMPENSATION, PROJECT OR SERVICE SUBCONTRACTOR: 1) ADDRESS: 2) VENDOR#: 3) TELEPHONE #: 4) CONTACT: 5) DESCRIPTION OF COMPENSATION, PROJECT OR SERVICE EVIDENCE OF COMPLIANCE: COPIES OF THE FOLLOWING MUST BE MAINTAINED BY COVERED EMPLOYERS OR THE OWNERS THEREOF FOR EACH EMPLOYEE FOR THE TIME PERIODS SET FORTH IN SUFFOLK COUNTY CODE SECTION 234-5: A. United States passport; or B. resident alien card or alien registration card; or C. birth certificate indicating that person was born in the United States; or D. (1) a driver's license, ifit contains a photograph of the individual; and (2) a social security account number card (other than such a card which specifies on its face that the issuance oCthe card does not authorize employment in the United States); or E. employment authorization documents such as an H-1B visa, H-2B visa, and L-1 visa, or other work visa as may be authorized by the United States Government at the time the County contract is awarded for all covered employees. Form LHE-1 SUFFOLK COUNTY DEPARTMENT OF LABOR NOTICE OF APPLICATION TO CERTIFY COMPLIANCE WITH FEDERAL LAW (8 U.S.C. SECTION 1324a) WITH RESPECT TO LAWFUL HIRING OF EMPLOYEES S ffi lk C t C d Ch t 234 (2006) . AFFIDAVIT OF COMPLIANCE WITH THE REQUIREMENTS OF 8 V.S.C. SECTION 1324a WITH RESPECT TO LA WFVL HIRING OF EMPLOYEES State of New York ) ss: County of ) (Print Name of Deponent) , being duly sworn, deposes and says: 1. I am the owner/authorized representative of (Circle one) (Name of Corp., Business, Company) 2. I certify that I have complied, in good faith, with the requirements of Title 8 of the United States Code (D.S.C.) Section 1324a (Aliens and Nationality) with respect to the hiring of covered employees and with respect to the alien and nationality status ofthe owners thereof, as set forth in Suffolk County Code Chapter 234. (Signature of Deponent) Sworn to before me this _ day of ,20_ (Notary Public) Form LHE-2 . "' ~ COUNTY OF SUFFOLK .,"' OFFICE OF THE COUNTY EXECUTIVE H. Lee Dennison Building 100 Veterans Memorial Highway P.O. Box 6100 Hauppauge, New York 11788-0099 Steve Levy SUFFOLK COUNTY EXECUTIVE Louis A. Medina EXECUTIVE DIRECTOR YOUTH BUREAU (631) 853-8270 TO: Contract AgenCie~ (t- ) Louis A. Medina tl,.{ Executive Director FROM: DATE: February 9, 2007 SUBJECT: 2007 Youth Bureau Agreement and Advance Voucher (if applicable) Attached are the above items for the signature ofthe Board President or Chairperson or the agency executive authorized to sign for the agency. Please sign all copies of the Agreement on page 1. on the line on the left hand side of the ill!@, and return them to the Suffolk County Youth Bureau Office in Hauppauge along with the signed county voucher. Please make sure you do the following: 1. Sign the County Payment Voucher where it is highlighted (Payee Certification). Return all copies to the Youth Bureau as soon as possible so that we may facilitate your advance. 2. Review the Agreement and check the amount of money in Exhibit C-l which is the budget. 3. Please note that if you receive an advance you will receive a three (3) month advance which will be recouped by the county towards the end of the agreement. 4. Check your organization's Federal LD.# in the Vendor Code Box on the advance voucher. We cannot process your advance or future claims without your Federal I.D.#. In addition, please submit the Suffolk County Department of Labor's Union Organizing CertificationIDeclaration by FULLY completing sections III and IV on page two. . ... . 2 ..' . Also, included in the mailing are four (4) Suffolk County Public Disclosure Statements for each contract agency listed in Exhibit B. Do not fill-in any information on this statement. All that is needed, on ALL four (4) statements, is to fully complete the verification section #13 on page 2 of each statement. Include an ori!!:inal simature for each statement. Then, have ALL four (4) statements notarized. (The notary section appears at the bottom ofthe second page on each statement). New this year is the Suffolk County Department of Labor Notice of Application to Certify Compliance (Form LHE-I) and an accompanying Affidavit of Compliance (Form LHE-2). Relative to Form LHE-I, please indicate the name of your agency and complete items one through eight (I through 8). PLEASE NOTE: You do not have to submit a Certificate of Corporation nor do yOU have to complete the subcontractor's section. With respect to Form LHE-2, the enclosed affidavit MUST be notarized. Lastly, it is the employer's responsibility to maintain the appropriate records for audit purposes that provides the requisite evidence of compliance as listed A through E at the bottom of Form LHE-l. ALL APPLICABLE FORMS MUST BE RETURNED TO THE SUFFOLK COUNTY YOUTH BUREAU. If you have any questions, please call Patrick Policastro at 853-8269. Please contact your field representative if you need more claim forms. LAM:PP:tar