HomeMy WebLinkAboutDelinquency Prevention Program Amendment
Law No. Y0002M10002-08YA
Development Delinqnency Prevention Program
. 'jf
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), having its principal office at H. Lee Dennison Building-3'" Floor, 100 Veterans Memorial Highway, Hauppauge, New York
(Mailing Address: Box 6100 Himppauge, 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 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 modif'y 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 (I) one-year extension at the County's
option.
State Aid Percentage: 18%
Percentage of Advance: 25%
Total Cost of Agreement:
Shall not exceed $20,50l<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.
TownOfS~_____
By: ~ ~'4.p.{
Name: S6D~ /7. R <-<sse I(
Title: 5~ (/(c.> Or q
Fed. Taxpayer ID #: ([ ~ <pO 0 ( {;3 (
Date:
Connty of Suffolk
By #it}. it
Jeffr . b.
Deputy County Executive
-----
Date:J!: 1- D 1
Family Service League
B~
Name: f\Q."..rV'\ ~"'drot\..tu..V\
Title: t J(.4!.C 1J p/COO
Fed. TaxPayer ID#: I (-Ile 0 Ii"a.. 7
Date: 1 ~t1o 7
By:
L i . Medina M.S.W.
xecutive Director
Approved as to Legality:
Christine Malafi
Suffolk County Attorney
~~C::!V:J
By:
Patricia M. Jord
Assistant Conn
Date: 4
s,..,,,~~ ,.- r J r.. -.,., r' I
, ',,":.1
Y02
Page 1 of 4 pages
, .
L'-Iw No. YOOOIMl@-08YA
Rev. 01/30/07
Development Delinquency Prevention Program
IFMS No. SCS EXE OXOOOO
Amendment No. I
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 ofthe 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 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 of the 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 perjury), 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 of the covered
employer or owner, as the case may be; shall be part of any executed contract, subcontract, license
YOl (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 ofpeIjury), 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 I 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 of the Lawful Hiring of Employees Law, the County shall have the authority to
terminate this Agreement for violations of this 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 Certif'y Com-
pliance With Federal Law (8 D.S.C. SECTION 1324a) With Respect To Law-
ful Hiring of Employees"
"Affidavit Of Compliance With The Requirements Of8 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 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 otNew York
. 'Office of Chlldrlln and Family Services
Form OCFS-3105 (9/981
INDIVIDUAL PROGRAM APPLICATION
Funding Category: YDDP 1 SERVICE
Sponsoring
Municipality:
Implementing
Agency:
Program
Title:
Agency
Address:
Mill
OCFS Central Office use only
Program Code:
0747001OS004
co SUFFOLK
County: SUFFOLK
10WN OF SOUIHOLD
SOUIHOLD youm SERVICES
Total / rJ -:2 / /_
Program Budget $~_<7( CP_1100%)
OCFS Funds ,-;2 ~n ",,-
Requested $ _ ~ t?.:Jd' t_"""'l<> of total)
10WN HALL MAIN RD
Street
SOurnOLD
C;tv
NY
State
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
(ill) 7lo'S"-I&l.f'r
Telephone Numblll
DIROCIOR
W)765-1283
Telephone Number
Contact Person
r...
~/) 74>5'-/c?<f.3
-r/Mtu, JJtCJlflJ-lIPAl
c(}//(~737~
Fiscal Officer
r....
Telephone Number
The Agency is: D Private. Not-far-Profit rn P~blic
PROGRAM SITES -- Most Significant (3 Maximum)
o ReligiC)us Corporation
NYC ONLY
Assembly NYS Senate Local City Council
Type I. Address (Street,City,State,Zip) Dist. No. Oist No. Plan'g Bd. District
OFFICE 'IOWN HALL MAIN RD 1 1
SOUI'HOLD 11971 .
. .
PROGRAM SUMMARY: (MAXIMUM OF 350 CHARACTERS - approximately 45 Words)
PR03RAM IS DFSIGNED 10 DELIVER, INDIVIDUAL CXlUNSELIN3 AND CRISIS
INI'ERVENTION SERVICES 10 50 YOUIH.
PROGRAM PROFILE
Unduplicated Count
of Youth and
Clients Served
(All Activities)
50
Probleml Target Number of Youth
. . Need Population Service Methods To be Served
Primary' 519 840 524 I 530 50
Secondary I
o Direct Services will NOT be provided by this program
Sex of program participants Male :~% Female: ~%
Ethnicity - Whites:~% Black: 10 % Hispanic: 10 % NativeAmerican:~% Asian:~% Other:~%
Age-O-4:~ % 5-9:~ % 10-15: 0 % 16'20: 0 %
Problem Need:
Target Population:
Service Methods:
BEHAVIOR PROBLEMS IN HeME:
HIS10RY OF INVOLVEMENT W/COURT/NOI'PIACED
INDIVIDUAL CDUNSELIN3
CRISIS INI'ERVENITON COUNSELIN3
."
'.
Mill
OCFS-3107 (Re". 03l2OO2) FRONT
NEWYORKSTA1E
, OFFICE OF CHILDREN AND FAMI~Y SERVICES
PROGRAM BUDGET
APPENDIX B
PROGRAM CODE: LQ..J 7' I tf I 7 I 0 I 0 i I
CONTRACT NUMBER: I I
D:.fIOIOI~
I
"GENCYIMUNICIPALlT':': f() UJ,J
?ROGRAMllTLE: 060 u7lfoLd
PERSONAL SERVICES:
POsmONTlTlE
f);:: SD u7J;' tel.
Yo J7}f SE;et//G~<:;'
PUND TY?:::
RATE of
PAY
TOTALOCFS PROGRAM AMOUNT (I). lOTALOCFS HJNOS REQUESTd
~UlIS PROGRAM
. '
$ $
$ $
,$ $
$ $
$ $
$ $
$ $'
, TOTAL SAI.ARIES AND WAGES $
'j
TOTAl FRfNGE BENEFITS $
TOTAL PERSONAL SERVICES (1) $
-6) -
:-,f) -:-
-&--.......
CONTRAClEDSERVlCES AND STIPENDS
lYf'E OF SERvitE'OR CONsUCrmrTrlLE
,I
(C$ $
'.' .. '$
.- .. ..
,..:' '"-.-- ,<, ',' '"" '$
TOTAL CONTRACTED SERVICES (2)
~,
...i~. ."
$ /~.g/~'
,
$
;"1 $"
$
&I'- 3/ ~
:~
RATE OF 'BASE
PAY. (S.M.HR)
o ,df#~
TOTAL OCFS PROGRAM AMOUNT (1):
, -~
I $
TOTAL MAUllTENANCE & OPERATION (3) I $ - 0-
LIST EQUIPMENT TO BE PURCHASED OR RENTED:
(UNIT COST OVER $200 AND LIFE EXPECTANCY OF OVER lWO YEARS)
,
FACILITY REPAIRS
PROGRAM SITE ADDRESS
I
f:~;'!f:.}~~~~i:i.~r~~fr..F~ -
b;-:>-.~=<-,...T~r-=-5"""~--~''''<- .
~~l~~!~t~~:~:~;;.l'~
I ~
"
TOTAL FACILITY REPAIRS (4) ,
$
-<9 ~
s
TOTAL OCFS PROGRAM AMOUNT I / ~ .:3/ t;. , 5 r~ ----,
, 'iff' TOTAL OCFS UNDS REQUESTED l2. 2. (pS-<f' j
- , .--
LIST OF OTHER FUNDING SOURCES I $ /~314:> REIMBURSABLE TO I AL
$ C? {p.s-e MUNICIPAL FUNDING
$ , OTHER SOURCES
.. _ _ _.,~ ~~~ ."...~., ...,.......-... nC'UO'fO"ClfCU,'C: IJnTRt=fNR REQUESTED.
,
"
Suffolk Cdunty, 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 Contractor" (Union Organizing Law Chapter 466-2) applies to the
contractor'slheneficiary's business or transaction with Suffolk County, the contractorlheneficiary must complete Sections J,
In, and IV below. If the following definitions do not apply, the contractorlheneficiary 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 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 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, ~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 meeting or an event that is intended to
infl6ence 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 nonconftontational 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.
Ifwe further agree that every County contract for the provision of services, when slich 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 nonconftontational 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-LQl (6/05)
" .
'.
Suffolk County, New York
Depiutment of Labor
Section II
o
The Union Organizing Law does '}"t app"ly to this contract for the following reason(s): i:J G .a../1( ~fr' q '1
(5 /19+~^ &hf(o'f~ ':3e-n~- .
Check if
Applicable
Section III
Contractor Name:
'-;;wn 0-(1 So lA..+Ao (r! Federal EmployerID#:
I.. o. (lox (( ~ '( Amount of Assistance:
7("){.A+t-.olrr; NY {191/-0?,J! Vendor#:
ContractorPhone#: - (j), )1- 1?,F {Yr'(
Description of project or service:
Contractor Address:
((-000('{J'I
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.
Section IV
I declare under penal
certification, and th
~~7
Authorized Ignature
Date
Print Name and Title of A\lthorized Representative
DOL-LOt (6/05)
Suffolk County, New York
Depa;tment hfLabor
SUFFOLK COUNTY DEPARTMENT OF LABOR - LABOR MEDIATION UNIT
UNION ORGANIZING CERTIFICATION/DECLARATION - 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 the 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 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 ofthe 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 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)
I1we further affirm to the following:
. I/we will not express to employees any false or misleading information that is intended to infiuence 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 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
. 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 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-LO] (6/05)
Suffolk C6unty, 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:
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 horized Signature
!JA~,.J /JO OM A~ biJ
Prini Name and Title of Authorized Representative
Date
DOL-WI (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 Name/"6"/..V..J oFf;;ufio I j
Address ('1/1 /AJ S'-I~-(€ '/ . /
CityandStateJod,l.old. J./.{w YOL( Zip Code Ii ,7/
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 $1,000? _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, "'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.)
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 footer 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 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 0 owledge, true.
Dated: 7~~7
Printed Nanfe of Signer:
Title of Signer:
Name of ContractorNendor:
13.
-row~L-,~~U;~~~o(r!
.
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW YORK)
COUNTY OF 5(AFf"~ ss.:
On the -/.3- da.x of y,--,,--LV in the year 20Ofbefore me, the undersigned, personally appeared
fenf+- A. (<'LA rJ"fi'j( 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 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
th~~trument. ~ .
(signature and 0 f e of individual taking acknowledgement)
BONNIEJ. DOROSKI
Notary Public, State Of NewYorll
No. 01006095328, Suffolk Counly
Term Expires July 7. 20~
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 iudividual(s) whose name(s) is (are) subscribed to the within instrument
and acknowledged to me that helshelthey 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
H:\l\IIUNLA W\Pmj\Master Fonns\Public disclosure SOP 04 form.doc
S.b
6.
Suffolk County Form 22
Contractor'slV endor'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/~~-~6;q6v6~
{/(-
1.
Zip Code
Contractor'slVe dor's N
Address
City and State ft.)
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:
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'slVendor'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 9r 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 determination that a
breach has occurred, to damages equal to fifteen percent (15%) of the amountofthe 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 fOBter 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
:;rreg ing statements and that they a; to' er own knowledge, true.
Dated: _3r/~1 ':
Printed Name of Signer: (t Ul
Title of Signer: ){
Name of ContractorN endor:
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW XQ]1K)
COUNTY OF ~f;.. ) ss.:
~ the ~ day of JI.t9.L\ in the year 200J-before me, the undersigned, personally appeared
C.eV1 ~-4rtP I ~ 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
~'~
AJAR. P ""
(signature and office of individual taldng cknowledgement)
MAUREEN R CROWLEY
Notary Public, Stale of New Yodl
No.01CR6137647 Z/
Qualified I~ Suffolk CountY 20/'1
Commission Exp""" December 5. -
Page 2 of 3 Public Disclosure Form
UNlFORM 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 helshelthey 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
H:\l\1UNLA W\Pmj\l\1aster FormsWublic disclosure SOP 04 form.doc