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HomeMy WebLinkAboutTransportation Assistance ProgramRESOLUTION 2008-925 ADOPTED DOC ID: 4291 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2008-925 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON OCTOBER 7, 2008: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Scott A. Russell to execute an Amendment of Agreement between the Suffolk County Office for the Aging and the Town of Southold for the Transportation Assistance Program, IFMS No. SC EXE 08000001389, for the period April 1, 2006 through March 31, 2009, subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Thomas H. Wickham, Councilman SECONDER: Louisa P. Evans, Justice AYES: Ruland, Orlando, Kmpski Jr., Wickham, Evans, Russell NOTIFICATION OF RIGHTS UNDER THE LIVING WA GE LAW According to the provisions of Local Law # 12-2001 (the Living Wage law) enacted by Suffolk County in July of 2001, 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. Effective July 1, 2008, the Living Wage will increase to $10.69 per hour with health benefits and $12.17 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 of the Living Wage law may be obtained by contacting this Unit (631-853-3808) or accessing the Suffolk County web page at www.co.suffolk.ny.us/labor and following the link to the Living Wage section. All inquiries will remain confidential. '~La~ No. AG006M/0061-09NB Rev. 9/.19/2008 Transportation Assistance Program IFMS No. SC EXE 0800000'1389 No. 001-6806-4980-95285-1389 Second Amendment Amendment of Agreement This is the Second Amendment of an Agreement (Agreement) last dated March 26, 2007, 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 Southold (Contractor), a New York municipal corporation, having its principal place of business at 53095 Main Road, P.O. Box 1179, Southold, New York 11971. The parties hereto desire to modify the Transportation Assistance Program to extend the term from April 1, 2008 through March 31,2009 (the period April 1, 2008 through March 31,2009 being hereinafter called the "2008/2009 Budget Period") and to add and amend certain contract provisions to comply with current County Standards, as set forth herein. Term of Agreement: Shall be April 1,2006 through March 31, 2009. Service Levels: 3,150 Units of Transportation Service 141 Elderly Served, Unduplicated Total Cost of Agreement: Shall not exceed $26,318 ($10,361 for the 2008/2009 Budget Period). Terms and Conditions: Shall be as set forth in Exhibits A-2008/2009, C-2008/2009 and the "Legislative Requirements Exhibit for Contracts revised 12/07," attached. In Witness Whereof, the parties hereto have executed this Second Amendment of Agreement as of the latest date written below. Town of South Scott A. Russell Supervisor Fed. Taxpayer ID #: 11-6001939 Date: ! O -- ./' ~'~ - Approved as to Legality: Christine Malafi Suffolk County Attorney By: Jacqueline Cap,ti' Assistant Counfy. A-ttorney Date County of S~.~lk~ By: Name.' ~,~ Deputy Date: ///1( Approved: y F,,xecutive Holly S.(J~hodes-Teague ~ Date Director, Office for the Aging Recommended: cipe~ Date Food Service Supervisor AG6M (8/06) AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 Law No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment Exhibit A-2007 Whereas, the County and Contractor have entered into an Agreement (Law No. AG006M/0061-09N), last dated March 26, 2007, for a term from April 1,2006, through March 31, 2007, with two one-year extensions at the County's option, for Transportation Assistance Program at a Total Cost of $4,600; and Whereas, the County and Contractor have entered into an Agreement (Law No. AG006M/0061-09NA), extending the term from April 1,2007 through March 31, 2008 (at an additional cost of $11,357) increasing the Total Cost of the Agreement to $15,957; and Whereas, the parties hereto desire to modify the Agreement to extend the term from April 1,2008 through March 31,2009 and (at an additional cost of $10,361 ) increasing the Total Cost of the Agreement to $26,318, and to add and amend certain contract provisions to comply with current County standards, 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 Agreement: The Term of Agreement paragraph on page 1 of the Agreement is amended to read April 1, 2006 through March 31, 2009 as set forth on the page 1 of this Second Amendment of Agreement. 2. Payment for Services: The Total Cost of Agreement $26,318 is comprised as follows: (a) $ 4,600 for the 2006/2007 contract term; (b) $11,357 for the 2007/2008 Budget Period; (c) $10,361 for the 2008/2009 Budget Period: 3. Budget: The Budget annexed hereto as Exhibit C - 2008/2009 is made part of the Agreement. The Contractor shall comply with the following amended provisions in conformance with current County Standards. 4. Notices and Contact Persons Paragraph 7 of Exhibit A1 to the Agreement, entitled, "Addresses for Notices, Claims and Reports" is deleted in its entirety and replaced with the following: Notices and Contact Persons 1. Notices Relating to Payments, Reports, Insurance, or Other Submissions Any communication, notice, claim for payment, report, insurance, or other submission necessary or required to be made by the part[es 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 the Department: By First Class and Certified Mail, Return Receipt Requested in Postpaid Envelope or by Courier Service or by Fax or by Email Holly $. Rhodes-Teague, Director Suffolk County Office for the Aging H. Lee Dennison Building 100 Veterans Memorial Highway Hauppauge, New York 11788 Page 2 AG6 TRANSPORT Program Soh[d EXT 08-09 rev 8-26-08 La~ No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment For the Contractor: By First Class and Certified Mail, Return Receipt Requested in Postpaid Envelope or by Courier Service or by Fax or by Email 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 Relating to Termination and/or Litigation 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 deliver to the County Attorney, at the address set forth below, copies of all papers filed by or against the Contractor. Any communication or notice regarding 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: For the County: By First Class and Certified Mail, Return Receipt Requested in Postpaid Envelope or by Nationally Recognized Courier Service or Personally and by First Class Mail Holly S. Rhodes-Teague, Director Suffolk County Office for the Aging H. Lee Dennison Building 100 Veterans Memorial Highway Hauppauge, New York 11788 and Christine Malafi, County Attorney Suffolk County Department of Law H. Lee Dennison Building 100 Veterans Memorial Highway Hauppauge, New York 11788 For Contractor: By First Class and Certified Mail in Postpaid Envelope or by Nationally Recognized Courier Service or Personally and by First Class Mail At the address set forth on page one of this Agreement, attention to the person who executed this Agreement or such other designee as the parties may agree in writing. Notices shall be deemed to have been duly delivered (i) if mailed, 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; or (iii) if personally, pursuant to New York Civil Practice Law and Rules Section 311; or (iv) if by fax or email, upon the transmittal thereof. "Business Day" shall be defined as any day except a Saturday, a Sunday, or any day in which commercial banks are required or authorized to close in Suffolk County, New York. 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). Page 3 AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 Lav~ No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment Indemnification Subparagraph (g) of Paragraph No. 13 of Exhibit A1 to the Agreement entitled "Insurance and Indemnification" is deleted in its entirety and replaced with the following: Indemnification a. General 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 attorneys' fees, arising out of the acts or omissions or the negligence of the Contractor in connection 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. b. Federal Copyright Act The Contractor hereby represents and warrants the Contractor, will not infringe upon any copyrighted work or material in accordance with the Federal Copyright Act during the performance of this Contract. Furthermore, 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 connection 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, lessees, licensees, invitees or agents, if any, in connection with the services described or referred to in this Agreement. Cooperation on Claims Paragraph No. 30 of Exhibit A1 to the Agreement entitled "Cooperation on Claims" is deleted in its entirety and replaced with the following: Cooperation on Claims The Contractor hereto agrees to render diligently to the County, without additional compensation, any and all cooperation, that may be required to defend the County, its employees and designated representatives against any claim, demand or action that may be brought against the County, its employees or designated representatives in connection with this Agreement. Term and Termination Paragraph No. 32 of Exhibit A1 to the Agreement entitled "Termination" is deleted in its entirety and replaced with the following: Page 4 AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 Law No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment Term a. Co and Termination Term This Agreement shall cover the period set forth on page one of this Agreement, unless sooner terminated as provided below. Upon receipt of a Termination Notice, as that term is defined below, the Contractor shall promptly discontinue all Services affected, unless otherwise directed by the Termination Notice. Termination for Cause i. A failure to maintain the amount and types of insurance required by this Agreement may result in immediate termination of this Agreement, in the sole discretion of the County. ii. Failure to comply with federal, state or local laws, rules, regulations, or County policies or directives, may result in immediate termination of this Agreement, in the sole discretion of the County. iii. If the Contractor becomes bankrupt or insolvent or falsifies its records or reports, or misuses its funds from whatever source, the County may terminate this Agreement in whole or with respect to any identifiable part of the program, effective immediately, or, at its option, effective at a later date specified in the notice of such termination to the Contractor. iv. In the event of a failure on the part of Contractor to observe any of the other terms and conditions of this Agreement, this Agreement may be terminated in whole or in part in writing by the County provided that no such termination shall be effective unless Contractor is given five (5) calendar days' (or longer, at the County's option) written notice of intent to terminate ("Notice of Intent to Terminate"), delivered in accordance with the Exhibit entitled "Notices and Contact Persons." During such five (5) day period, (or longer, at the County's option) the Contractor will be given an opportunity for consultation with the County and an opportunity to cure all failures of its obligations prior to termination by the County. In the event that the Contractor has not cured all its failures to fulfill its obligations to the satisfaction of the County by the end of the (5) day period (or longer, at the County's option), the County may issue a written termination notice ("Termination Notice"), effective immediately. Termination for Emergencies An emergency or other condition involving possible loss of life, threat to health and safety, destruction of property or other condition deemed to be dangerous, in the sole discretion of the County, may result in immediate termination of this Agreement, in whole or with respect to any identifiable part of the program, in the sole discretion of the County. Termination for Convenience The County shall have the right to terminate this Agreement at any time and for any reason deemed to be in its best interest, provided that no such termination shall be effective unless the Contractor is given thirty (30) calendar days' prior written notice termination notice ("Termination Notice"). In such event of termination, the County shall pay the Contractor for the services rendered through the date of termination. Page 5 AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 ' Law No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment e. Payments upon Termination i. Upon receiving a Termination Notice, the Contractor shall promptly discontinue all services affected unless otherwise directed by the Termination Notice. ii. The County shall be released from any and all responsibilities and obligations arising from the services provided in accordance with by this Agreement, effective as of the date of termination, but the County shall be responsible for payment of all claims for services provided and costs incurred by the Contractor prior to termination of this Agreement, that are pursuant to, and affer the Contractor's compliance with, the terms and conditions of this Agreement. iii. Upon termination, the Contractor agrees to promptly reimburse to the County, by check payable to the Suffolk County Treasurer, the balance of any funds advanced to the Contractor by the County. Upon termination, any funds paid to the Contractor by the County which were used by the Contractor in a manner that failed to comply with the terms and conditions of this Agreement must be promptly reimbursed. If there is no response or if satisfactory repayments are not made, the County may recoup such payments from any amounts due or becoming due to the Contractor from the County under this Agreement or otherwise. The provisions of this subparagraph shall survive the expiration or termination of the Agreement. The Contractor will comply with the following added provisions in conformance with current County requirements. 8. Conflicts of Interest a. The Contractor agrees that it will not during the term of this Agreement engage in any activity that is contrary to and/or in conflict with the goals and purposes of the County. b. The Contractor is charged with the duty to disclose to the County the existence of any such adverse interests, whether existing or potential. This duty shall continue so long as the Contractor is retained on behalf of the County. The determination as to whether or when a conflict exists or may potentially exist shall ultimately be made by the County Attorney after full disclosure is obtained. 9. No Intended Third Party Beneficiaries This Agreement is entered into solely for the benefit of County and Contractor. No third party shall be deemed a beneficiary of this Agreement, and no third party shall have the right to make any claim or assert any right under this Agreement. 10. Non Responsible Bidder The Contractor represents and warrants that it has read and is familiar with the provisions of Suffolk County Code Chapter 143, Article II, §§143-5 through 143-9. Upon signing this Agreement the Contractor certifies that he, she, it, or they have not been convicted of a criminal offense within the last ten (10) years. The term "conviction" shall mean a finding of guilty after a trial or a plea of guilty to an offense covered under the provision of Section 143-5 of the Suffolk County Code under "Nonresponsible Bidder." 11. 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 Page 6 AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 ' Lav~ No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment 12. the awarding or amending of an agreement or the making of any determinations with respect to the performance of an agreement, and that the signer of this Agreement has read and is familiar with the provisions of Local Law No. 32-1980 of Suffolk County (Chapter 386 of the Suffolk County Code). Full Force and Effect Except as herein amended, all other representations, terms and conditions of said Agreement, including any and all amendments or budget modifications executed prior to the date hereof, are hereby ratified and confirmed to be in full force and effect. -- End of Text of Exhibit -- Page 7 AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 ' Law No. AG006M/0061-09NB Rev. 9/19/2008 Transportation Assistance Program IFMS No. SC EXE 08000001389 No. 001-6806-4980-95285-1389 Second Amendment Exhibit C-2008/2009 Town of Southold Transportation Assistance Program April 1, 2008 - March 31, 2009 PERSONNEL $9,654 Driver 9,654 FRINGE 400 OPERATING EXPENSES 736 Gas & Oil 736 SUBTOTAL $10,790 Less Anticipated Income (429) NET REIMBURSMENT $10.361 Page 8 AG6 TRANSPORT Program Sohld EXT 08-09 rev 8-26-08 Exhibit Suffolk County Legislative Requirements revised 12/07 Contractor's/Vendor's Public Disclosure Statement The Contractor represents and warrants that it has filed with the Comptroller of Suffolk County the verified public disclosure statement required by Suffolk County Administrative Code Article V, Section A5-7 and shall file an update of such statement with the said Comptroller on or before the 31st day of January in each year of this ^greement's duration. The Contractor acknowledges that such filing is a material, contractual and statutory duty and that the failure to file such statement shall constitute a material breach of this Agreement, for which the County shall be entitled, upon a determination that such breach has occurred, to damages, in addition to all other legal remedies, of fifteen percent (15%) of the amount of the Agreement. Required Form: Suffolk County Form SCEX 22; entitled "Contractor's/Vendor's Public Disclosure Statement" Living Wage Law This Agreement is subject to the Living Wage Law of the County of Suffolk. The law requires that, unless specific exemptions apply all employers (as defined) under service contracts and recipients of County financial assistance, (as defined) shall provide payment of a minimum wage to employees as set forth in the Living Wage Law. Such rate shall be adjusted annually pursuant to the terms of the Suffolk County Living Wage Law of the County of Suffolk. Under the provisions of the Living Wage Law, the County shall have the authority, under appropriate circumstances, to terminate this Agreement and to seek other remedies as set forth therein, for violations of this Law. The Contractor represents and warrants that it has read and shall comply with the requirements of Suffolk County Code Chapter 347, Suffolk County Local Law No. 12-2001, the Living Wage Law. Required Forms: Suffolk County Living Wage Form LW-1; entitled "Suffolk County Department of Labor- Living Wage Unit Notice of Application for County Compensation (Contract)" Suffolk County Living Wage Form LW-38; entitled "Suffolk County Department of Labor - Living Wage Unit Living Wage Certification/Declaration - Subject To Audit" Use of County Resources to Interfere with Collective Bargaining Activities Local Law No. 26-2003 The Contractor represents and warrants that it has read and is familiar with the requirements of Chapter 466, Article 1 of the Suffolk County Local Laws, "Use of County Resources to Interfere with Collective Bargaining Activities". County Contractors (as defined) shall comply with all requirements of Local Law No. 26-2003 including the following prohibitions: a. The Contractor shall not use County funds to assist, promote, or deter union organizing. b. No County funds shall be used to reimburse the Contractor for any costs incurred to assist, promote, or deter union organizing. c. The County of Suffolk shall not use County funds to assist, promote, or deter union organizing. d. No employer shall use County prepedy to hold a meeting with employees or supervisors if the purpose of such meeting is to assist, promote, or deter union organizing. If Contractor services are performed on County property the Contractor must adopt a reasonable access agreement, a neutrality agreement, fair communication agreement, nonintimidation agreement and a majority authorization card agreement. If Contractor services are for the provision of human services and such services are not to be performed on County property, the Contractor must adopt, at the least, a neutrality agreement. Under the provisions of Local Law No. 26-2003, the County shall have the authority, under appropriate circumstances, to terminate this Agreement and to seek other remedies as set forth therein, for violations of this Law. Required Form: Suffolk County Labor Law Form DOL-LO1; entitled "Suffolk County Department of Labor - Labor Mediation Unit Union Organizing Certification/Declaration - Subject to Audit" 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 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, license 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 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 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 pad of any executed contract, subcontract, license agreement, lease or other financial compensation agreement between the covered employer and the County; and shall be made available to the public upon request. An updated affidavit shall be submitted by each such employer, owner, contractor and subcontractor no later than January 1 of each year for the duration of any contract and upon the renewal or amendment 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. This Agreement is subject to the Lawful Hiring of Employees Law of the County of Suffolk, Suffolk County Code Chapter 234, as more fully set forth in the Exhibit collectively referred to as the "Suffolk County Legislative Requirements." In accordance with this law, Contractor or employer, as the case may be, and any subcontractor or owner, as the case may be, agree to maintain the documentation mandated to be kept by this law on site at all times. Contractor or employer, as the case may be, and any subcontractor or owner, as the case may be, further agree that employee sign-in sheets and register/log books shall be kept on site at all times during working hours and all covered employees, as defined in the law, shall be required to sign such sign in sheets/register/log books to indicate their presence on the site during such working hours. The Contractor represents and warrants that it has read, is in compliance with, and shall comply with the requirements of Suffolk County Code Chapter 234, Suffolk County Local Law No. 52- 2006, the Lawful Hiring of Employees Law. Required Forms: Suffolk County Lawful Hiring of Employees Law Form LHE-1; entitled "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" "Affidavit Of Compliance W~th The Requirements Of 8 U.S.C. Section 1324a With Respect To Lawful Hiring Of Employees" Form LHE-2. 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 the signer of this Agreement has read and is familiar with the provisions of Local Law No. 32-1980 of Suffolk County (Chapter 386 of the Suffolk County Code). Prohibition Against Contracting with Corporations that Reincorporate Overseas The Contractor represents that it is in compliance with Suffolk County Administrative Code Article IV, §§A4-13 and A4-14, found in Suffolk County Local Law No. 20-2004, entitled "A Local Law To Amend Local Law No.~5-1993, To Prohibit The County of Suffolk From Contracting With Corporations That Reincorporate Overseas." Such law provides that no contract for consulting services or goods and services shall be awarded by the County to a business previously incorporated within the U.S.A. that has reincorporated outside the U.S.A. Child Sexual Abuse Reporting Policy The Contractor agrees to comply with Chapter 577, Article IV, of the Suffolk County Code, entitled "Child Sexual Abuse Reporting Policy", as now in effect or amended hereafter or of any other Suffolk County Local Law that may become applicable during the term of this Agreement with regard to child sexual abuse reporting policy. Non Responsible Bidder The Contractor represents and warrants that it has read and is familiar with the provisions of Suffolk County Code Chapter 143, Article II, {}{}143-5 through 143-9. Upon signing this Agreement the Contractor certifies that he, she, it, or they have not been convicted of a criminal t0. 11. offense within the last ten (10) years. The term "conviction" shall mean a finding of guilty after a trial or a plea of guilty to an offense covered under the provision of Section 143-5 of the Suffolk County Code under "Nonresponsible Bidder." Use of Funds in Prosecution of Civil Actions Prohibited Pursuant to the Suffolk County Code Section §590-3, the Contractor represents that it shall not use any of the moneys received under this Agreement, either directly or indirectly, in connection with the prosecution of any civil action against the County of Suffolk or any of its programs, funded by the County, in part or in whole, in any jurisdiction or any judicial or administrative forum. Work Experience Participation If the Contractor is a nonprofit or governmental agency or institution, each of the Contractor's locations in Suffolk County at which services are provided under this Agreement shall be a work site for public-assistance clients of Suffolk County pursuant to Local Law No. 15-1993 at all times during the term of this Agreement. If no Memorandum of Understanding ("MOU") with the Suffolk County Department of Labor for work experience is in effect at the beginning of the term of this Agreement, the Contractor, if it is a nonprofit or governmental agency or institution, shall enter into such MOU as soon as possible after the execution of this Agreement and failure to enter into orto perform in accordance with such MOU shall be deemed to be a failure to perform in accordance with this Agreement, for which the County may withhold payment, terminate this Agreement or exercise such other remedies as may be appropriate in the circumstances. Suffolk County Local Laws Website Address Suffolk County Local Laws, Rules and Regulations can be found on the Suffolk County web site at www.co.suffolk<http://www.co.suffolk.n¥.us>. Click on "Laws of Suffolk County" under "Suffolk County Links." End of Text for Exhibit Suffolk County Form SCEX 22 Contractor's/Vendor's Public Disclosure Statement Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement must be completed by all contractors/vendors that have a contract with Suffolk County. In the event contractor/vendor is exempt from completing paragraphs numbered I through 11 below, so indicate at paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt status, you must execute this form below before a notary public. 1. Contractor's/Vendor's Name '7-Okf/9 0 Address ,5'~O~0''~ ,~40/~ /:/d. too BOX 117~ City and State ,~Ot.~ -tt-/90/iff /i/~e' 2. Contracting Department's Name ~r?l'Or Address 70'-0/t~¢/te'~k2 ._~7~W_x~.g-- /O0~OA' ,~'_~7' //4~/t'/t/'/t'td~/c' IVY ilq~- 3. Payee Identification or Social Security No. 4. Type of Business Corporation._Partnership._.Sole Proprietorship vrOther 5.a Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk Countyin 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 $1,0007 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.) List all names and addresses of those individual shareholders holding more than five percent (5%) interest in the contractor/vendor. Conspicuously identify any shareholder who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary). 10. Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor relationship with Suffolk County?__Yes No. If you answered yes to 8 above, you must submit with this disclosure statement, a complete financial statement listing all assets and liabilities as well as a profit and loss statement. These statements must be certified by a Certified Public Accountant. (Strike this out if not applicable.) The undersigned shall include this Contractor's/Vendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.). Page I 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 I through 11 herein: __. a) Hospital ~,~ b) Educational or governmental entities __ c) Not-for-profit corporations d) Contracts providing for foster care, family day-care providers or child protective services Please check to the left side of the appropriate exemption. 13. Verification. This section must be signed by an officer or principal of the contractor/vendor authorized to sign for the company for the purpose of executing contracts. The undersigned being sworn, affirms under the penalties of perjury, that he/s~ has read and understood the foregoing statements and that they are, to his/her own kno~'dge, true. Dated: ,./0-/~.-0~ Signed: .~~ Printed Name of Signer: Title of Signer: Name of Contractor/Vendor: UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF.5 On the /&"¥~ay, of ~ in the year 20 O~before me, the undersigned, personally appeared ~C,o'tt~"~- ~sx'~[( personally known to me or proved to me on the basis of satisfactory evidence to be the individual(t/) whose name(~ is (.ar-e) subscribed to the within instrument and acknowledged to me that he/.e&egd~ executed the same in hi~ capacity(-ies.) and that by his~.~Zt, he~ signature('&) on the instrument, the individual(X), or the person upon behalf of which the individual(~ acted, executed the instrument. (signature and office of ~nd]wdual taking acknowledgement) ,,oer 31,20~ LINDA d COOPER NOTARY PUBLIC, State of Ne~, Y' NO. 01CO4822563, Suffolk <~ Term Expires December 31.; 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) Page I of 3 Public Disclosure Form Suffolk County, New York Deparanent 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'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 Applicable Section I1 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 to the goods and/or services that are the subject of the contract with the County of Suffolk shall not use County funds to assist, promote, or deter union organizing (Chapter 466-3 A), nor seek reimbursement fi.om the County for costs incurred to assist, promote, or deter union organizing. (Chapter 466-3 B) 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) I/we further agree that I/we will not use County property to hold meetings to assist, promote, or deter union organizing. (Chapter 466-3E) 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, 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) I/we further affirm to the following as to the goods and/or services that are the subject of the contract with the County of Suffolk: · 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 pm-recognition labor disputes through the adoption of nonconfi.ontatiunal procedures for the resolution of prerecognifion 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. The Union Organizing Law does not apply to this contract for the following reason(s): Check if Applicable DOL-LOI (3/5/08) Suffolk County, New York Department of Labor Section III Contractor Name: Contractor Address: ~O(.~'/'-j~O/d "~O/4//e'/ Federal Employer ID#: 5~oq~ ~aJn ~d. ~X i/Tq Amount of Assistance: Hy Iiq7/ Vendorg: Contraetor Phone g: ~-~0 ~ au hlin/D/rear Description of project or se~ice: ~ ~F~ ~/~ ~,~ ~c ~ Section ~ In the event any pa~ of the Union Organizing Law, Chapter 466 of the Laws of Suffolk Count, is found by a cou~ of competent jurisdiction to be preempted by federal m~or state law, this ce~ificatio~declamtion shall be void ab initio. Section V I declare under penalty o~erjury under the Laws of the State Authorized Signa"~e " - ~ Print Name and Title of Authorized Representative of New York that the undersigned is authorized to provide this Date DOL-LOI (3/5/08) Jo lc, _IJUo 11:85 -. · , ,,9~ f,,._ , , l 2: o ~, o. t:~ B!I[I"," REEVE .~GEHC",' ~t,E 132.' ACORD CERTIFICATE OF LIABILITY INSURANCE GlO SOLITHOLD TOWN HALL PO. BOX 1179 SOUTHOLD NY 11971 COVEBAGES THE POLI01ES OF I~SUf~/~.NCE LfSI~D BELOW HAVE 8EEI'~ I~UED TO T~E rNSURED NANIEO A~OVE [=OR THE POLICY PERIOD /NDIGATED. NOT~ITHS~'ANDING "!oTHEB' j i F ' DESCRIPTION O OPEPJ~'-TIONS,q-OCATIONS/VI~HICLES/EXCLUSIONS ADDED BY ~'NDORSEI~ENT/~PECIAL PROVISIONS THE COUNTY OF SUFFOLK [$ LISTED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY. CERTIFICATE HOLDER CANCELLATION ~UFFOLK COUNTY OFFICE FOR THE AGING P.O. BOX 6100 HAUPPAIJGE, NEW YORIK 11788 At'tentiom ACORD 2~ (20Ol/08) Certifi~te # 12006 Ar:ORB CORPORATION 19 bcd Z.~ ~d~b~ I'tl IY' P, EEVE AGEIIC'," PAGE 63/ IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, ,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemenl(s) DISCLAIMER The Certificate of Insurance on [he reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACOI~) 25-S (2001/08) Certifica[e #12006 Renewal of Pofioy Policy No. ~ H634900008~00 ~ Named Insured end Mailing Address (No. Street, Town er Oily, Ocu~. State~ Zip COMMON POLICY - DECLARATIONS PIL&ETORIAN INSURANCE COMPANY 500 Park Boulevard, Suite 1 Ita~ca, lll~ois 60143 Agent TO"grN OF SOUTHOLD P/O. Box l t79 Southold, NY 11971 NIF GOVERlkrMENTAL SERVICES, FNC, 103 SPRING VALLEY ROAD MONTVALE, NJ 07645 Pc~Ilcy Period: From C 01/01t0B ~ tO C 01/01/09 . "~ 12:01 Standard Time at your mailing addresS shown above. (Unless chef, ged by the Section Declarations.} Business Description: MUNICIPALITY IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE iNSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. Commercial Property Covora[~e Farm Commercial Inland Marine Coverage Form Equipmon! Breakdown Coverage Excess General Liabilfty Coverage Form (SJ.R.) Exceso At, to Liability Coverage Fon~ (S.I.R) E~c~ss Law Enforcement I~ability Coverage COMMeRCIaL CREv~.t COVERz'~GJ~ NY State ual0 surcharges 64,5 Premium shown is payable $139,476 at inoeptlon; $ TOTAL Anniversary; $ PREMIUM NOT APPLICABLE NOT APPMCABLE NOT APPLICABLE iNCLUDED INCLUDED INCLUDED NOT APPLICABLE 139,476 2~ Anniversary Form(s) and Endorsement(s) made a part of this policy at time of iosue*: PlO Jacket(O7/O7), NIF 1103, NtF 1105, NIF 1087, IL 0017 NIF 1045, NtF 1142 NY, NIF 11 Countersigned: Issue date: 01108108 *.,~ '- - - ~,~, L . ~ ~ ....... ,:. ,~. A~hor~.d Ropresentafiva NIF 11fl0 0399 Declaration GENERAL LIABILITY COVERAGE / LAW ENFORCEMENT LIABILITY COVERAGE FORM DECLARATIONS Effective Dale 01/01/08 Policy Nh. H634-000008~00 Schedule of Coverages x General LiabilHy: Each Occurrence Limit Personal and Advertising Injury Limit Products-Completed Operations, Aggregate Limit Fire Damage Limit Medical Expense Limit X l.aw Enforcement Liability: Each Occurreoce Limit Medical Expense Limit X General Aggregate Limit: (Law Enforcement and Genera! l.labitity including products and completed operatians) [] Stop Loss Aggregate; Z imtt o f lnsurance $ 1,000,000 $ 1,000,000 $ 1,000,000 $ 100,000 $ 5,000 $ 1,000,000 $ 3,000,000 Insurance is pro¥1ded only far the coverage indicated by an x and for which a sp~eiflc limit is shoxxn',. General Liability: Primary [] Deductible $ per {~ claim or [~ occurrence X Excess X Self-insured retention $ 50,000 per occurrence Law Enforcement !.~ability: Primary [] Deductible per [] claim or [] occurrence X Excess X Self-lnsured retention $ 50,000 per occurrence Forms and Endorsements NIF 1.088, NIF 1089, ~ 1012, NIF 1'029, NIF 1164 NIF 1164L, NIF 1156, CG2170(I.].-02),CG00~7(03/05) CG 00062(12-02), CO2149(07/98) NIF 1116(2) Premium $ included [] Deposit X... Non-Adjustable NlYll05 03/99 (7) Coercion, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, dlsorlmlnation or other employment-re,atari practices, policies, acts or omissions; or (8) Consequential "personal injury' as a result of (5) through (7) above, c. "Pemonat injury" arising out of any: (1) Refusal to employ; (2) Termination of employment; (3) Coemion, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination or other employmenbrelated practices, policies, acb~ or omissions; or (4) Consec~uential "personal Fnjury" as a result of (1) through (3) above. "Personal injuPJ" arising out of the providing et failure to provide professional health care services. This e×ciusfon does not apply to "personal injury" arising out of the emergency health care services of the paramedics, nurses or emergency medical technldans qualifying as an Insured under ~hls p~licy. e. "Pemanal injury" to: (1) Any volunteer, including but not limited to firemen or policemen, adsir~g OLIt of and in the course o1~ their duties for any insured; or (2) Ttm spouse, child, parent, brother or sister of any volunteer as a consequence of (1) above. "Personal injury" or "advertising injury" arising out of the activities of any Insured'a police department, law enforcement agency or any similar deparL'ment er agency, including their agents, volunteers and employees. g. "Personal injury" or "advertising injury" arising out cf the ownership, maintenance or use of any premises portJon of the premise used as a police department, enforcement department, Including jails, deten'don cells and/or holding facilities by the Insured. 1. The term Insured as used herein means the entity atate(~ In the Declarations as the Named Insured and except as excluded by endorsement to this i:mltcy: A governmental agency or subdivision, department, municipal body, board or commission, er not- Jor-proflt corporation which ]e owned and controlled by you. An Individual while acting in the capacity a~ a director, officer, trustee, employee or st~ff member of youm; A volunteer, but solely while acting within the scope of such duties and at your direction; A paramedic or emergency medical technician, but solely while acting within me course and scope of your employment or while acting as your volunteer and at :your direction, while providing emergency health care selvices. Visiting and school nurses, but solely while acting in the scope and c~urse or your employment. NIF 1088 0199 B of 10 8/208? 11:05 b312983U50 ROY Iq~EVE AGENC"/ PAGE An elected or appointed officer or a member of any board ur commission or agency of yours, but solely while acting within the scope of their duties as such; g. A partnemhip or islet venture, including a mutual assistant pact, joint powers agreement or similar arrangement, but only with respec~ to the conduct of your business and only to the extent of ye~Jr _ ~p.a?i_ci?at~on or interestS, ~ F h Any pemon or organization required to be an Insured under a written "insured contract," but only J respects ~ur operations, "your wor~" facilities owned or used by you. Such wri~en, insured J contract must be executed prior to the "bodily injury," "property damage," "personal injury" or J "advellising injury"~ i.911 dispatchers, but solely while acting within the scope of their employment by you. However, with the exception of activi[ies of the paramedic, visiting nurse, school nurse or emergency medical technician, none of the above will ba considered an "insured" for, "Bodily injury" or "personal injury' to you or to a co amp;oyes while in the course of his or her employment, or the spouse, child, parent, brother or sister of that co-employee as a consequence of such "bodily injury" or "Per~ona[ injury," or for any obligation to share dominoes with or repay someone else who must pay damages because of the injury. With respect to "mobile equipment" re§Is/areal In your name under any motor v~hicle registration la~, any person is an Insured while ddving such equipment along a public highway wi[h your permission. Any other person or organization responsible for the conduct of such pease rs also an Insured, but only with respect t~ liabilib] arising out of the operation of the equipment, and only if no other insurance of any kind is available to that per.~;3n er organization for this li;~bility. However, no p~rson or organization is an Insured with respect to: a. "Bodily Injury" to e co-employee of the person driving the equipment; or b_ "Property damage" to properly owned by, rented to, in the charge of or occupied by yea er the employer of any perso~ who is an insured under this provision. Any organ[zalion yO~ newly acquire or form, other than a partnership or j~nt venture, and [~ver which you maintain ownership or majority interest will be deemed an Insured if there is no other slmilarinsurance available to thatorganizatien. However, a. Coverage under this provisiJ3n is afforded only until the 90th day alt~r you acquire or form the organizaUon er, the end o~' the policy pedod, whichever is ea dior;, b. Coverage A does not apply to "bodily injury" or "property damage" that oCCUlted before you acquired or formed the organi~fion; and c. Coverage B does not apply to any "bodity inju~/" or "advertising injury" arising oul of an offense commil~ed before you acquired or formed the organization. This irmumnoe does not apply to any '~odily injury", 'property damage", "personal inju~' or "advertising injury" arising out of your police, law enforcement department or any other law enforcement agent7 of any insured including their agents, volunteers or employees. No person or organization Is an insured ~th respect to [he conduct at any curren[ or pas[ partnership or jo;et venture that is not ahc~vn as a Ne mad tnsured in Its Dec~ar~tons. SECTION Ill-LIMITS OF INSURANCE NIF 1088 0199 9 Of 10 CONTRACT AGENCY DISCLOSURE FORM (For 2009 Budget Process) Contract Agency Information Page 1 of 4 Before completing this form, please read the instructions in order to ensure that accurate, relevant and consistent information is provided. If you have any questions regarding completion of this form please refer to the contact information in the attached letter. Please Note: In addition to completing this form, please be sure to provide Audited or Unaudited Financial Statements, IRS Form 990 or a Profit/Loss Statement for your most recent fiscal year. ~ Suffolk County Office Use Only Control Number ] 13795 i . i Entered By I Reviewed By I Date Received I Activity Code [ i Financial Statement Type: I Notes: I Department ]EXECUTIVE Division Office for the Aging Fund 160 Agency [EXE Ors 16806 Object 14980 If any of the information below has changed, you may cross out the printed information and fill in the correct information. Contract Amount: 2007 Actual: I $11,357 2008 Estimate: $11,357 Contractor Name: ITown of Southold Program Name: Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: Transportation Assistance Program (631) 298-4460 ' Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold NY 11971 Extension: I Control Number I Activity Code Contract Program Revenues Part 1 - Government Grants 2007 Actual 1) Total amount of revenue received from Suffolk County for Contract 1 $ 9,315.81 Program. 2) Total revenue received directly from State Government for the I 0 Contract Program. Please identify names and amounts of grant(s): 3) Total revenue received directly from Federal Government for the I 0 Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directly from all other Municipalities for the ] $ 51.88 Contract Program. Please identify names and amounts of grant(s): Town o£ Southold Part 2 - Medicare/Medicaid, Fundraising and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract ] o I Program. 6) Total Fund Raising revenue received for the Contract Program. ] o ] 7) Total amount of other revenues received for the Contract Program. ] $ 2,235. oo ] Please identify types of revenues and amounts below: 8) Total Contract Program Revenue (Aaa Lines l~ 7) I $ 11,602.69 ] Page 2 of 4 2008 Estimated $ 11,357.00 o 0 0 0 $ 4,500;00 $ 15,857.00 conti-ol Number Activity Code I Contract Program Expenses Part 3 - Direct Contract Program Expenses 2007 Actual 9) Direct Contract Program Salaries ] $ 6,690.81 10) Direct Contract Program Fringe Benefits ] 511.88 11) Direct Contract Program Fee for Service [ 0 12) Direct Other Contract Program Expenses [ $ 4,400. oo 13) Total Direct Contract Program Expenses [ $ 11,602.69 (Add Lines 9 through 12) Page 3 of 4 2008 Estimated $ 10,497.00 803.00 0 4,557.00 15,857.00 Part 4 - Administrative Contract Program Expenses 14) Administrative Contract Program Salaries 15) Administrative Contract Program Fringe Benefits 16) Administrative Contract Program Fees 17) Other Administrative Contract Program Expenses 18) Total Administrative Contract Program Expenses (Add Lines 14 through 17) 19) Total Contract Program Expenses (Add Lines 13 and 18) 2007Actual 2008 Estimated 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Top 5 Agency Salaries Exceeding $100,000 Amount of Salary Charged to the Employee Name 3.1 Employee Title 2007 Salary Contract Program I Control Number 1 ........ Activity Code I Agency Information Part 6 - Financial and Other Agency Information 21 ) Total Agency Support and Revenues 22) Total Agency Expenses 2007 Actual 531,427,687.00 31,843,194.00 Page 4 of 4 2008 Estimated I$ 33,393,933.00 I 36,185,333.00 23) Total Agency Net Income/(Loss) (Li.*2~ mi~us[incn) [:( * 415,507.00, I, 24) Please indicate your fiscal year if it is not the calendar year: 1 ......... 25a) Is your agency affiliated with any other corporations ? (Yes / No) I No 25b) If yes, name corporation(s), and explain your agency's affiliation: 2,791,400.00 2007 Actual 2008 Estimated 26) Total Agency Administrative Expenses I I 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) ~ Administer a corps of volunteers ~ Administer the collection and distribution of food to ~ Administer federal, state or other pass through funding the needy ~ Disseminate educational materials for a public purpose [] Not Applicable for my Agency 28) I certify that enclosed herein, along with my disclosure form, is my Agency's most recent financial report (audited or unaudited Financial Statements, IRS form 990 or Profit/Loss Statement); audited Financial Statements are required, if available. I understand that if the required financial report is not enclosed my Agency will be deemed Non-Compliant until I have submitted the required report to the Comptroller's Office. Form Prepared By Title ] Karen McLaughlin I"ToWn Director of Agency Program Contact Title Initials Phone Number / Human Services 632 298-4460 Phone Number Karen McLaughlin ITown Director of Human Services 631 298-4460 If you would prefer to be contacted via E-mail. please enter an E-mail address where we may contact you in the event that we have any questions regarding the completion of this form (Optional): I certify, to~e best of my knowledge and belief, that all of the information provided on this form is true and correct ~/ /,~ Sig. Name Title Sq.u_t~pld Town Supervisor Date