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HomeMy WebLinkAboutNutrition ProgramRESOLUTION 2009-400 ADOPTED DOC ID: 5017 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2009-400 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MAY 19, 2009: RESOLVED that the Town Board of the Town of Southold hereby amends Resolution No. 2009-365 dated May 5~ 2009 to read as follows: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Scott A. Russell to execute the Amendment of Agreement between the Suffolk Countw Office for the Aging and the Town of Southoid for the IIIC Nutrition Programs, regarding a one year extension for the period January 1, 2007 2009 through December 31, 2009, for congregate and home delivered meals for the elderly, subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESULT: . ADOPTED [UNANIMOUS] MOVER: Vincent Orlando, Councilman SECONDER: Albert Krnpski Jr., Councilman AYES: Ruland, Orlando, Krupski Jr., Wickham, Evans, Russell COUNTY OF SUFFOLK Steve Levy COUNTY EXECUTIVE OFFICE FOR THE AGING Holly S. Rhodes-Teague DIRECTOR April 16, 2009 The Honorable Scott A. Russell Supervisor Town of Southold 53095 Main Road, PO Box 1179 Southold, New York 11971 RE: IlIC Nutrition Program IFMS'No. SC EXE 09000001792 Dear Supervisor Russell: Enclosed are three copies of the above referenced agreement to be signed and returned to this office. Also enclosed for your review is §A5-7 of Article V of the Suffolk County Code. It explains whether your agency is required to submit a full disclosure statement or qualifies for an exemption. If you qualify for an exemption, please sign the certification located on the cover page of each agreement. Please be advised that if you are providing services without a fully executed contract, you do.so at your own risk as an exemise of your indel~ndent business judgment and without any guarantee of payment. In order te avoid delay in the execution of your agreement, please return the signed originals as soon as possible. One fully executed agreement will be forwarded to you as soon as the signature process has been completed. if you need further information, please contact Mary-Valerie Kempinski, Contracts Examiner, at 631-853- 8209. dell ountant JK:MVK:sl Enclosures cc: Mary-Valede Kempinski Karan McLaughlin H. LEE DENNISON BUILDING · 100 VETERANS MEMORIAL HIGUWAY 4~ P,O, BOX 6100 · HAUPPAUGE, N. Y, 11788-0099 + (63 I) a53-8200 OVER 35 YEARS AS TIlE DESIGNATED AREA AGENCY ON ACING PROVIDING SERVICES ]?OR OLDER CbTIZEN$ CODE ARTICLE V, Department of Audit and Control § A5-4. Authorization to sell capital notes. [Derived from Res. No. 766-~972] (7) ' ' (8) (9) (10) Any .and all Comptroller shall C. The delegations of revoked by of the notes. af execution of the notes. · ' relating to the terms, form and contents of the notes which said County ' or desirable. in full force and effect until modified, amended or County Legislature· § A5-5. Deductions from wages c for federal credit anion authorized. [Derived from LL. No. 3-1963 A. · Deductions from wages union is hereby authorized. employees for the following purposes of the federal credit County any amount with the federal credit union of County employees and 1 such written authorization may be withdrawn by withdrawal with the Comptroller. teduct from the Wages or salary of an employee of the filed with the Comptroller for dues or savings fund leducted to the said credit union. Any at any time by filing written notice of such C. Deductions and withdrawals made pursuant to this Comptroller may provide. subject to such rules and regulations as the § A5-6. Deductions from Wages or salaries for [Derived frOm L.L No. 4-1969] A. Deductions from wages or salaries of certain county employees for the County teachers federal credit union is hereby authorized. B. The Comptroller is hereby authorized and directed to Suffolk County Community College who are members or desire membership i credit union any amount that such employe6s may specify in writing filed with the fund with fue Suffolk County teachers federal credit union and to transmit the sum union. Any such written authorization may be withdrawn by such employee at any such withdrawal with the Comptroller. I credit union authorized. Suffolk of employees of the teachers federal dues or savings said credit ce of C. Deductions and withdrawals made pursuant to this section are subject to such rules the § A5-7. Contractors and vendors required to submit full disclosure statement. [Derived from L.L. No. 1976, as amended 2-27-1979 by L.L. No. 6-1979] A. Definitions. As used in this section, the following terms shall have the meanings indicated: http://gcp.esub.net/cg~-bm/om ~sap~.dll?chentlD=83626&depth=3&httsperheadtng-on&mfobase-suff... 11/5/2008 LAWS OF SUFFOLK COUNTY, NEW YORK, v82 Updated 10-t5~2008 PART II ADMINISTRATIVE CODE ARTICLE V, Department of Audit and Control §AS* 7. Contractors and vendors required to submit full disclosure statement. [Derived from L.L. No. t976, as amended 2-27-1 ' CONTRACT -- AnY written agreement between. Suffolk County and.a contractor or vendor to do or perform ar kind of labor, service,.pumhase, construction or public work, unless the contract is for a federally or state-aided in whole or in part, program required to be bid pursuant to § 103 of the New York.General Municipal Law. [Amended 6-29-1993 by L.L. No. 28-1993 ~] NOTE: L.L. No. 28-1993 also provided aa ~ollows: Section 1. Legislative Intent. . This Legislature hereby finds and determines that Suffolk County's comprehensive ContrectorNendor Public DIsclocure Statement Law currently applle: to · broad array of contracts that exceed $t,000 in value, subject to exemptions for contractor~ doing business with the County Department of Social Services; hoepltale; educational, medical, and governmental antlfiea; end not4or-pmflt corporatione. This Legislature further finds end detmmlnes that these axempttana prevent full disclosure of Important Information that may ba useful to elected count, officials In determining whether or not specific types of contmcta are In the public interest, especially In light of recent trends towards prlvatlzatlon and u: of outside consultants On an Increased bahia by muulclpelgbe. Therefore, the purpose of this law Is to eliminate many of the exemptions from completing end filing verified public disclosure statements with the Coun: Comptroller available to certain contractam providing social services or health services contracts. CONTRACTOR or vENDoR [Amended 12-18-1990 by L.L. No. 4 l-l.990enr~l 6-29-1993 by L.L. No. 28- 1993en~] -~ Any proprietorship, partnership or closely held corporation which has a contract with Suffo k County in excess of $1,000 or which has three or more contracts with Suffolk County, any three of which, whe combined, exceed $1,000, except: (1) Hospitals.. (2) Educational or governmental entities. (3) Not-for-profit corporations. (4) Contracts providing for foster care, family day-care providers or child protective consulting services. FULL DISCLOSURE CLAUSE -- A proviso to be included as a material part of a contract imposing upon the contractor or vendor a material, contractual and statutory duty.to file a verified public disclosure statement. VERIFIED PUBLIC DISCLOSURE STATEMENT -- A declaration, the contents of which are acknowledged before a notary public, containing information required under this section. B. A full disclosure clause is to be included in all future contracts between Suffolk County and a contractor or vendor. Such full disclosure clause shall constitute a material part of the contract. C. Notice of the full disclosure clause shall be included and made a part of the specifications, if any, which are submitted to interested potential bidders. htt~://gcp~esub.net/~gi-bin/~m-isapi.d~~~c~ient~D=83626&depth=3&hitsperheading=~n&inf~base=st/~... 11/5/200 LAWS OF SUFFOLK COUNTY, NEW YORK, v82 Updated 10-15-2008 PART II ADMINISTRATIVE CODE ARTICLE V, DepaH. iiient of Audit and Control § 7. Contractors and vendors required to submit full disclosure statement. [Derived from L.L. No. 14- 1976, as amended 2-27-1 D. Each contractor or vendor shall file a verified public disclosure statement with the Comptroller of Suffolk County as soon as practicable prior to being awarded the contract. An updated disclosure statement shall be filed by the contractor or vendor with the Comptroller by the 31st day of January in each year of the contract's duration. It shall be the duty of the Comptroller to accept and file such statements. E. No contract shall be awarded to any contractor or vendor, as defined in this section, unless prior to such award a verified public disclosure statement is filed with the Comptroller as provided in this section. Any verified pUblic disclosure statement containing fraudulent information shall constitute, for all purposes, a failure to file such statement in the first instance. F. The verified public disclosure statement required by this section shall include: (1) A complete list of the names and addresses of those indiVidual shareholders holding more than five- percent interest in the firm. (2) The table of organization for the company shall include the names and addresses of all individuals serving on the board of directors or comparable body, the names and addresses of all partners and the names and addresses of all corporate officers. The contractor or vendor shall conspicuously identify any such person in this table of organization who is an officer or an employee of Suffolk County. (3) A complete financial statement listing all assets and liabilities as well as a profit-and-loss statement, certified by a certified public accountant. Such statement shall be the most current available and in no event shal have been prepared more than six months prior to the date of the filing of the bid. No financial statement or profit-and-loss statement shall be required from any contractor or vendor having 50% or more of their gross revenues from soumes other than the County of Suffolk. G. A separate folio for each company shall be maintained alphabetically for public inspection by the Comptroller. H. RemedieS. The failure to file a verified public disclosure statement as required under this section shall constitute a material breach of contract. Suffolk County may resort, use or employ any remedies contained in Article 2 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 15% of the amount of the contract. 1. Under no circumstances shall the county be precluded from invoking any remedy contained in the preceding section by reason of its failure to invoke promptly its remedies. A. The County-'C'fftl~t~lle/~ hereby authorized, pursuant to § C5-21 of thc Suffolk County Charter, to withhol~ an~t any vendorsa ments to an vendOrs oror con~rcon nder ccontract with the County of Suffolk in any instances in'which it is d~n real pr~"op~t x_~Tx~e~s, said withholding to be limited, in the aggregate, to the amount of said arrears (inclusive of interest, penalties and~ . B. Said moneys so withheld shall be kept in a separate account for periodic distribution to the.. asurer htt~://gcl~.esub.net/cgi-bin/om isapi.dll?clientlD=83626&depth=3&hitsperheading=on&infobase=suff... 11/5/200~ Law,No. AG004M/0003-11 RB Rev. 41t6109 IIIC Nutrition Program IFMS No. SC EXE 09000001792 No. 001-67901679716774-4980, 6776-3330-95284-1792 Second Amendment Amendment of Agreement This is the Second Amendment of an Agreement (Agreement), last dated July 27, 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-O099), 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 Agreement to extend the term of the Agreement from January 1, 2009 through December 31, 2009 (the period January 1, 2009 through December 31, 2009 being hereinafter called the "2009 Extension Period") and to add and amend other contract provisions to comply with current County Standards, as set forth herein. Term of Agreement: Shall be January 1,2007 through December 31, 2009 for Congregate Meals, and April 1, 2007 through December 31, 2009 for Home-Delivered Meals, with two one- year extensions at the County's option. Total Meals: Daily Congregate Meals: 57 Not to Exceed $74,514 Annually Daily Home-Delivered Meals: 112 Not to Exceed $162,822 Annually Total Cost of Agreement: Shall be on a fee-for- service basis, not to exceed $659,722 (with $237,336 for the 2009 Extension Period), as set forth in Exhibits A-2009, and C-2009 attached. Terms and Conditions: Shall be as set forth in Exhibits A-2009, C-2009, and the "Suffolk County Legislative Requirements Exhibit" revised 11/08 attached. In Witness Whereof, the parties hereto have executed this Second Amendment of Agreement as of the latest TowndateBy: writteno~below. Scott A. Russell Supervisor Fed. Taxpayer ID #: 11-6001939 Date: .~'-/' 4/¢ -~:) c~ ~"~'~1~,~ ~>(~ ge ~, hereby ce~ifies under ~lfies of pe~u~ that I ~ a~ officer of O~ ~~ , that I have read ~d I ~ famil~i~h ~5-7 of ~,V~f ~e Suffolk Coun~ Code, and that ' ~ ~ ~ ~ h ~ ~)~] meets all Sig~tu~ t I Approved as to [egality: Christine Malafi By: Jacqueline Caput/ ¢ ~;l:'~/'~ Assistant County Attorney County of Suf~ ~ By: · A_MINI~ Approved: Holly S. ~odes-Taague Oate Director, Office for the Aging Recom~ed: Food Se~ice Supe~sor 0002298 AG 4 (7/06) Page 1 AG4M Sohld ext 09 t~aw No. AG004MI0003-'11RB Rev. IIIC Nutrition Program IFMS No. SC EXE 09000001792 No. 001-67901679716774-4980, 6776-3330-95284-'1792 Second Amendment Exhibit A-2009 Whereas, the County and Contractor have entered into an Agreement (Law No. AG004M/0003- 11R), last dated July 27, 2007, for a term from January 1, 2007 through December 31, 2007 for a senior citizens' nutrition program at a Total Cost of $189,685; and Whereas, the County and Contractor have entered into a First Amendment of Agreement (Law No. AG004M/0003-11RA), extending the term from January 1, 2008 through December 31, 2008 and (at an additional cost of $232,701) increasing the Total Cost of the Agreement to $422,386; and Whereas, the parties hereto desire to modify the Agreement, to extend the term from January 1, 2009 through December 31, 2009 and (at an additional cost of $237,336) to increase the Total Cost of the Agreement to $659,722, and to add and amend other 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 January 1, 2007 through December 31, 2009 as set forth on the page 1 of this Second Amendment of Agreement. 2. Meals: Effective as of the beginning of the Extension Period, the approximate daily number, and the maximum annual number, if any, of Congregate and/or Home-Delivered Meals included in the Program shall be as set forth on the cover page of this Second Amendment of Agreement. 3. Payment for Services: The Total Cost of Agreement $6591722 is comprised as follows: a. $189,685 for the 2007 contract term; b. $232,701 for the 2008 Extension Period; c. $237,336 for the 2009 Extension Period; 4. Rate Page: The rate at which the Contractor shall be paid for this Extension Period is set forth in Exhibit C-2009, which is attached and made part of the Agreement. 5. Poverty Threshold Paragraph 8 (3) of Exhibit B to the Agreement entitled "Reporting Requirements, Demographics", referring to the Poverty Threshold, is amended to read as follows: '100 % of Poverty Threshold '150% of Poverty Threshold Size of Family Unit (for IIIC Nutrition program(s)) (for SNAP Program(s)) 1 $10,830/year $16,245/year 2 $14,570/year $21,855/year The Contractor will comply with the following added provisions in conformance with current County requirements 6. A new subparagraph B. is inserted under Paragraph~ 8. "Reporting Requirements" of Exhibit B to the Agreement: AG 4 (7~06) Page 2 AG4M Sohld ext 09 Law No. AG004M/0003-11 RB Rev. 4113/09 ilIC Nutrition Program IFMS No. SC EXE 09000001792 No. 001-67901679716774-4980, 6776-3330-95284-1792 Second Amendment B. Electronic Reporting i. The Contractor shall maintain electronic records on all program participants using the most currently approved form provided by Aging and compliant with State and Federal reporting requirements. Data for all participants must be updated monthly, ii, In order to comply with electronic reporting requirements, the Contractor must have adequate computer equipment and software available to support the approved form. iii. NAPIS required registration must be completed for all congregate participants. The congregate NY Short Form and home delivered NY Comprehensive AFM form or subsequent approved assessment tool(s) must be entered electronically in SAMS 2000 or in subsequent County approved computer systems. All participant data must be entered completely by the 12Ih of each month for the previous month's data. iv. Home-delivered meal participants must have eligibility determined prior to the delivery of service using the NAPIS required NY Comprehensive AFM form or subsequent approved assessment tool, Each participant receiving home- delivered meals must be reassessed at appropriate intervals based on each participant's situation, but in no instance less frequently than at least once in each twelve-month period. The Contractor will also make a six-month reassessment in the form of a home visit or a telephone call. The assessment and subsequent reassessments must be entered electronically and completed by the 12Ih of each month for the previous month's data. 7. Contractor's Staff Subparagraph b of Paragraph 9. "Contractor's Staff" of Exhibit B to the Agreement is deleted in its entirety and replaced with the following: b. The County shall have the right to prior approval of the filling of any site manager position and the assessor managing the electronic records. The Contractor'shall comply with the following amended provisions in conformance with current County Standards. 8. Contractor Responsibilities Paragraph 1 of Exhibit A1 is deleted in its entirety and replaced with the following: Contractor Responsibilities a, Duties and Obligations i.) It shall be the duty of the Contractor to discharge, or cause to be discharged, all of its responsibilities and to administer funds received in the interest of the County in accordance with the provisions of the Contract. ii.) The Contractor shall promptly take all action as may be necessary to render the Services. iii.) The Contractor shall not take any action that is inconsistent with the provisions of the Contract. b. Qualifications, Licenses, and Professional Standards i.) The Contractor represents and warrants that it has, and shall continuously AG 4 (7/06) Page 3 AG4M Sohld ext 09 Law No. AG004MI0003-11RB Rev. 4113109 IIIC Nutrition Program IFMS No. SC EXE 0900000'1792 No. 00'1-67901679716774-4980, 6776-3330-95284-'1792 Second Amendment possess, during the Term, the required licensing, education, knowledge, experience, and character necessary to qualify it to render the Services. ii.) The Contractor shall continuously have dudng the Term of the Contract all required authorizations, certificates, certifications, registrations, licenses, permits, and other approvals required by Federal, State, County, or local authorities necessary to qualify it to render the Services. c. Notifications i.) The Contractor shall immediately notify the County, in writing, of any disciplinary proceedings, commenced or pending, with any authority relating to a license held by any person necessary to qualify him or the Contractor to perform the Services. ii.) In the event that a person is no longer licensed to perform the Services, the Contractor must immediately notify the Department, but in no event shall such notification be later than five (5) days after a license holder has lost the license required to qualify him or the Contractor to perform the Services. iii.) In the event that the Contractor is not able to perform the Services due to a loss of license, the Contractor shall not be reimbursed for the Services rendered after the effective date of termination of such license. Without limiting the generality of the foregoing, if any part of the Contract remains to be performed, and the termination of the license does not affect the Contractor's ability to render the Services, every other term and provision of the Contract shall be valid and enforceable to the fullest extent permitted by law. d. Documentation of Professional Standards The Contractor shall maintain on file, in one location in Suffolk County, all records that demonstrate that it has compiled with sub-pa[agraphs (b) and (c) above. The address of the location of the aforesaid records and documents shall be provided to the County no later than the date of execution of the Contract. Such documentation shall be kept, maintained, and available for inspection by the County upon 24 hours notice. Agreement Subject to Appropriation of Funds Subparagraph f. of Paragraph 4 of Exhibit A1 to the Agreement is deleted in its entirety and replaced with the following: Subject to Appropriation of Funds a. The Contract is subject to the amount of funds appropriated and any subsequent modifications thereof by the Legislature, and no liability shall be incurred by the County beyond the amount of funds appropriated by the Legislature for the Services. b. If the County fails to receive Federal or State funds originally intended to pay for the Services, or to reimburse the County, in whole or in part, for payments made for the Service, the County shall have the sole and exclusive right to: i,) Determine how to pay for the Services; ii,) Determine future payments to the Contractor; and AG 4 (7~06) Page 4 AG4M Sohld exl 09 Law No. AG004M/0003-1'I RB Rev. 4/t 3~09 IIIC Nutrition Program IFMS No. SC EXE 09000001792 No. 00t-67901679716774-4980, 6776-3330-95284-1792 Second Amendment iii.) Determine what amounts, if any, are reimbursable to the County by the Contractor and the terms and conditions under which such reimbursement shall be paid. c. The County may during the Term impose a Budget Deficiency Plan. In the event that a Budget Deficiency Plan is imposed, the County shall promptly notify the Contractor in writing of the terms and conditions thereof, which shall be deemed incorporated in and made a part of the Contract, and the Contractor shall implement those terms and conditions in no less than 14 days. d. Any Budget Deficiency Plan shall be deemed to be incorporated by reference and made part of the Contract. 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." ~ 1~. 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). 12. 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 -- AG 4 (7/06) Page 5 AG4M Sohld ext 09 Law No. AG004MI0003-11RB Rev. 4/t 3~09 IIIC Nutrition Program IFMS No. SC EXE 09000001792 No. 001-67901679716774-4980, 6776-3330-96284-1792 Second Amendment Exhibit C-2009 Rate Page TOWN OF SOUTHOLD Schedule of Fees for Services Congregate Midday Meals Home-Delivered Meals Third Contract Year 2009 $5.25 $5.57 AG 4 (7/06) Page 6 AG4M Soh~d ex[ 09 Exhibit Suffolk County Legislative Requirements revised '1'1/08 Contractor's/Vendor's Public Disclosure Statement It shall be the duty of the Cor~tractor to mad, become familiar with, and comply with the requirements of section A5-7 of Article V of the Suffolk County Code. Unless certified by an officer of the Contractor as being exempt from the requirements *of section ^5-7 of Article V of the Suffolk County Code, the Contractor represents and warrants that it has filed with the Comptroller 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 Comptroller on or before the 31 st day of January in each year of the Contract's duration. The Contractor acknowleclges that such filing is a material, contractual and statutory duty and that the failure to file such statement shall constitute a material breach of the Contract, 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 tl~e amount of the Contract. Required Form: Suffolk County Form 'SCEX 22; entitled "Contractor's/Vendor's Public Disclosure Statement" Living Wage Law It shall be the duty of the Contractor to read, become familiar with, and comply with the requirements of Chapter 347. of the Suffolk County Code. This Contract 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 provlde 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 the Contract and to seek other remedies as set forth therein, for violations of this 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 IContract)" 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 It shall be the duty of the Contractor to read, become familiar with, and comply with the requirements of Chapter 466 of the Suffolk County Code. County Contractors (as defined by section 466-2) shall comply with all requirements of Chapter 466 of the Suffolk County Code including the following prohibitions: a. The Contractor shall not use County funds to assist, promote, or deter union organizing. b. ~1o County funds shall be used to reimburse the Contractor for any costs incurred to assist, promote, or deter union organizing. c. The Contractor shall not use County funds to assist, promote, or deter Union organizing. d. No employer shall use County property to hold a meeting with employees or supervisors if the purpose of such meeting is to assist, promote, or deter union organizing. If the Services are performed on County properly the Contractor must adopt a reasonable access agreement, a neutrality agreement, fair communication agreement, non-intimidation agreement, and a majority authorization card agreement. If the Services are for the provision of human services and are not to be performed on County property, the Contractor must adopt, at the least, a neutrality agreement. Under the provisions of Chapter 466, the County shall have the authority, under appropriate circumstances, to terminate the Contract 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 It shall be the duty of the Contractor to read, become familiar with, and comply with the requirements of Chapter 234 of the Suffolk County Code. The Contract is subject'to the Lawful Hiring of Employees Law of the County of Suffolk. 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, cbntract, 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 shatl 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 132~1a with respect to the hiring of covered employees and with respect to the alien and nationality status of the owners thereof, as the case may be. The affidavit shall be executed by an authorized representative of the contractor, subcontractor, or owner, as the case may be; shall be part of any executed contract, subcontract, license agreement, lease or other financial compensation agreement between the covered employer and the County; and shall be made available to the public upon request. An updated affidavit shall be submitted by each such employer, owner, contractor and subcontractor no later than January 1 of each year for the duration of any contract and upon the renewal or 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 the Contract. Under the provisions of the Lawful Hiring of Employees Law, the County shall have the authority to terminate the Contract for violations of this Law and to seek other remedies available under the law, The documentation mandated to' be kept by this law shall at all time be kept on site. Employee sign-in sheets and registedlog 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/~og books to indicate their presence on the site during such working hours. . 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 with the Requirements of 8 U.S.C, Section 1324a With Respect To Lawful Hiring Of Employees" Form LHE-2.. Gratuities It shall be the duty of the Contractor to read, become familiar with, and comply with the requirements of Chapter 386 of the Suffolk County Code. The Contractor represents and warrants that it has not offered or given any gratuity to any official, employee or agent of the County or the 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. Prohibition Against Contracting with Corporations that Reincorporate Overseas It shall be the duty of the Contractor to read, become familiar with, and comply With the requirements of §§ A4-13 and A4-14 of Article IV of the Suffolk County Code The Contractor rep~-esents that it is in compliance with §§ A4-13 and A4-14 of Article IV of the Suffolk County Code. 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 It shall be t.he duty of the Contractor to read, become familiar with, and comply with the requirements of Article IV of Chapter 577 of the Suffolk County Code. . The Contractor shall comply with Article IV of Chapter 577, of the Suffolk County Code, entitled "Child Sexual Abuse Repoding Policy," as now in effect or amended hereafter or of any other 'Suffolk County Local Law that may become appl'icable during the term of the Contract with regard to child sexual abuse repoding policy. Non Responsible Bidder It shall be the duty of the Contractor to reade become familiar with, and comply with the requirements of Article II of Chapter 143 of the Suffolk County Code. Upon signing the Contract, the Contractor certifies that it has 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." Use of Funds in Prosecution of Civil Actions Prohibited It shall be the duty of the Contractor to read, become familiar With, and comply with the requirements of section 590-3 of Article III of Chapter 590 of the Suffolk County Code. The Contractor shall not use any of the moneys, in part or in whole, and either directly or indirectly, received under the Contract in connection with the prosecution of any civil action against the County in any jurisdiction or any judicial or administrative forum. 10. Il. Work Experience Participation If the Contractor is a nonprofit or governmental agency or institution, each of the Contractor's locations in the County at which the Services are provided 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 the Contract. 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 the Contract, 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 the Contract and failure to enter into or to perform in accordance with such MOU shall be deemed to be a failure to perform in accordance with the Contract, for which the County may withhold payment, terminate the Contract 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 website at htr p://www, co.suffolk, ny. us." End of Text for Exhibit S~ffolk County, New York Depar~raeet 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 Snffolk Counly~ the contractor/beneficiary must complete Sections I, III, attd IV' below. If the following definitions do not apply~ the contractor/beneficiary must complete Sections II, III attd IV below. Completed forms must be submitted to the awardlug agency. County Contractor: "Any employer that receives more than $50,000 in County fimds for supplying goods or services pursuaut to a written contract with the County of Suffolk or any of its agencies; pursuant to a Suffolk County grant; pursuant to a Suff61k 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 II Check if Section 1 Cheek if Applicable The Union Organizing Law applies to this contract. I/we hereby ag~'~o to comply with all the p/'ovisions 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 nsc 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 It.) 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 organ zing 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 tho pertinent County agency or authority, the Connty Comptroller, or the County Department of Law upon request. (Chapter 466-3 1) l/we furthar 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 itt selecting or not selecting a bargaining representative; · I/we ufiderstand my/our obligation to limit disruptions caused ay prerecognifion labor disputes through the adoption of noneonfmntational 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 prowsion &goods and Services to the County. I/we shall include a list &said procedures in such certification. The Union Organizing Law does not apply to this contract for the following reason(s): Applicable DOL-LO I (3/5/08) Suffolk County, New York Sectiou III Contractor Name: Contractor Address: Contractor Phone #: Town of Southold 53095 Main Road' P.O. Box 1179 Southold, NY 11971 contact person: Karen McLaughlin, Federal Employer ID#: 11r6001939 Amount afAssistanee: $ 237', 335.00 Vendor #: Director 631 298-4460 Description of project or service: ~I.II-C CongregaEe, Nutrition and Home Delivered Meal Programs for the Elderly Section IV In thc event ally part of the Union Organizing Law, Chapter 466 of thc Laws of Suffolk County, ia found by a court of competent jurisdlclion to be preempted bY federal and/or state law, this eertification/dec/aralion shall be void ab initio. Section V I declare under penalty ofp~ury under the Laws of the State of New York that the undersigned is authorized to provide this certificat!on, and thafflle.~e is true and~'~ct. AUthorized Signatfffe - " Dalet.-i--- Scott A. Russell, SouEhold Town Supervisor Print Name ~nd Title of Autho~'ized Representative DOL-LOI (3/5108) CONTRACTOR NAME ADDRESS STATEMENT OF OTHER CONTRACTS Town of Southold Senior Services 750 Pacific-Street, P.O. Box 85, Mattituck, New York 11952 CONTACT Karen McLaughlin, Director PRONENUMBER 631 298-4460 AGREEMENT PROGRAM NUMBER *CONTRACT WITH · TERM OF AGREEMENT AMOUNT III-C-1 Congregate N°-001-6797-4980 Suffolk County Office for. Nutrition Program 95 284-1792 the'Aging 1~1/08 12/31/08 $ 73,094.00 111-C~2 Home Delivered N°-001-6776-3330 Suffolk County Office for 1/1/08 - 12/31/08 $ ~59,607.00 Meal Program ' '95 284-1792 the Aging T~ansportation N0 - 001-6806 Suffolk County Office for Assistance Program .4980-95285-1389 the Aging. 4/1/08 - 3/31/09 $ 10,361.00 No-001_6777_4980 · CSE Residential Repair' Program 95285-0605 Suffolk County office for 4/1/08 - 3/31/09 $ 20,400.00' the Aging *Indicate (a) type of organization - County, State, Federal or Other and (b) name of Department, Agency or Organization STATEMENT OF OTHER CONTRACTS 05 KAREN M~LAUGHLIN Town Director of Human Services Town of Southold 750 Pacific Street P.O. Box 85 Mattituck, NY 11952 Tel. (631) 298-4460 Fax (631) 2984462 Nutrition Program Home Delivered Meals Case Management Essential Transportation Senior AduR Day Cate Alzheimer's Day Care Telephone R~ssurance Residential Repair July 15, 2009 Elizabeth Tesoriem, CPA Executive Director of Auditing Services Contract Compliance Unit Room S~232 Evans K. Griffing Building 300 Center Drive Riverhead, NY 11901 Dear Ms. Tesoriero: Enclosed please find the completed Contract Agency Disclosure Forms for the CSE Residential Repair, III-C Nutrition and Transportation Assistance programs for the Town of Southold. I have not included the Town's audited financial statements for 2008 as they are not yet completed. Our Town Comptroller, John Cushman, informed me that once the statements are completed we would gladly forward them to you. In closing, if you have any questions or need further ~ormation regarding the enclosed disclosure forms, please contact me at 298-4460 or call John Cushman, Town Comptroller at 765-4333. We would be happy to assist you. Sincerely ),ours, //~ Director of Human Sem~e'6s cc: John Cushman, Southold Town Comptroller Elizabeth Neville, Southold Town Clerk v// RECEIVED J U L 2 7 2009 COUNTY OF SUFFOLK OFFICE OF THE COUNTY COMPTROLLER JOSEPH SAWICKI, JR. Comptroller June 12, 2009 Ms. Karen McLaughlin Town of Southold Town Hall - Main Road Southold, NY 11971 Dear Ms. McLaughlin: In accordance with Suffolk County Local Law No. 9-2001, "A Charter Law To Require Annual Expenditure Disclosure For Contract Agency Funding," your agency is required to complete the attached Contract Agency Disclosure Form(s). Instructions for the completion of the form are attached for your convenience. Each form includes agency and program data that was entered based on information provided by the County department responsible for the oversight of your contract. A separate form should be completed for each of your contracts with Suffolk County. If you have any questions regarding completion of the form, please call either 631-852-2064 or 631-85242062. Please complete and return the disclosure form(s), along with a copy of your agency's most recent audited financial statements to the following address, no later than July 31, 2009. Suffolk County Comptroller's Office Contract Compliance Unit - Room S-232 Evans K. Griffing Building 300 Center Drive Riverhead, NY 11901 Failure to comply with this request may result in a recommendation to eliminate funding for your program(s) in the County's 2010 operating budget. Thank you for your anticipated cooperation. Very truly yours, Elizabeth Tesoriero, CPA Executive Director of Auditing Services CONTRACT COMPLIANCE UNIT- ROOM S-232 · EVANS IC GRIFF1NG BUILDING · ~0~ CENTER DRIVE · RIVERHEAD, NY 11901 (631) 852-2064 Pax (631) 852-2066 CONTRACT AGENCY DISCLOSURE FORM (For 2010 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 Entered By Financial Statement Type: I16098 I IEXECUTIVE Office for the Aging Agency IEXE Control Number Activity Code Department Division Fund i001 Notes: Org 168o6 Object 14980 If any of the information below has changed, you may cross out the printed information and f'fll in the correct information. Contract Amount: 2008 Actual: I Contractor Name: ITown of Southold Program Name: ITransportation Contractor Phone Number: 1(631) 298-4460 Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: $10,361 2009 Estimate: I $10,361 Assistance Program Contractor Zip Code: Extension: [Karen McLaughlin 53095 Main Road, P.O. Box 1179 ISouthold 11971 Control Number Page 2 of 4 I Activity Code I Contract Program Revenues Part 1 - Government Grants 1) Total amount of revenue received from Suffolk County for Contract Program. 2008 Actual 2009 Estimated I* 8,633.79 I* 4,986.00 2) Total revenue received directly fi'om State Government for the I o Contract Program. Please identify names and amounts of grant(s): 3) Total revenue received directly from Federal Government for the Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directly fi.om all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Town of Southold I $ 31.51 I $ 10,210.00 Part 2 ~ Medicare/Medicaid, Fundraising and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract Program. 6) Total Fund Raising revenue received for the Contract Program. 7) Total amount of other revenues received for the Contract Program. Please identify types of revenues and amounts below: Voluntary Participant Contributions 8) Total Contract Program Revenue (Add Lines I - 7) I$ 11,680.30 Control Number [ Activity Code [ Contract Program Expenses Part 3 - Direct Contract Program Expenses 2OO8 Actual 9) Direct Contract Program Salaries 10) Direct Contract Program Fringe Benefits 11) Direct Contract Program Fee for Service 12) Direct Other Contract Program Expenses 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 9,695.61 777.69 o 1,207.00 11,680.30 Page 3 of 4 2009 Estimated 14,289.00 ' 592.00 o J 1,000.00 J $ 15,881.00 Part 4 - Administrative Contract Program Expenses 2008 Actual 14) Administrative Contract Program Salaries J 15) Administrative Contract Program Fringe Benefits J 16) Administrative Contract Program Fees J 17) Other Administrative Contract Program Expenses 18) Total Administrative Contract Program Expenses (Add Lines 14 through 17) 2009 Estimated. 19) Total Contract Program Expenses (Add Lines 13 and 18) 20) Please provide a short description of your Direct Contract Program Expenses: 1.1 2. J 3. l 4. J 5.I Part 5 - Top 5 Agency Salaries Exceeding $100~000 Amount of Salary Charged to the Employee Name Employee Title 2008 Salary Contract Proeram Control Number I Activity Code Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses Page 4 of 4 2008 Actual 2009 Estimated 32,354,833. I$ 34,991,755, 23) Total Agency Net Income/(Loss) (Line 2~ minus Line 22) Net Income Calculator --> 24) Please indicate your fiscal year if it is not the calendar year: 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: I ($1,727,438.) I(i 2,010,000.) NO 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses I* 5,4?9,659. I $ 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administer acorosofvolunteers [] Administer the collection and distribution offood to [~ Administer federal, state or other pass through funding the needy [] Not Applicable for my Agency [] Disseminate educational materials for a public purpose Form Prepared By Karen McLaughlin Agency Program Contact I Karen McLaughlin 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 requi.red financial r. eport is not enclosed my Agency will be deemed/~Compliant ~ ~i~ I have submitted the reqmred report to the Comptroller's Office. ~ Title Phone Number Town Director of Human Serv cee 631 298-4460 Title Phone Number ......... [";ow2 Director Of Human Services 631 ;98-4~60 ' ' 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 karen, mc laughlin@town, southo id. ny. us ~.,~:?' ~o~, ~t o~m~t' ~y ~ow,~d~ ~d ~,~. that ~. o~ ~ in~o~o. ~o~ o. ~ ~o~ i~ ~ ~ ~~ Supervisor, Town of southold 7/..;90/07 Sign Name Title Date CONTRACT AGENCY DISCLOSURE FORM (For 2010 Budget Process) Contract Agency Information Page 1 of 4 Before completing this form, please read the instructions in order to ensure that accurate, relevant a d consistent ~nformat~on ~s 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. Control Number [16086 Activity Code I ..... Suffolk County Office Use Only Entered By I Reviewed By [ Date Received Financial Statement Type: I Notes: [ Department IEXECUTWE Division IOffice for the Aging Fund 1001 Agency IEXE Org 16~0 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: 2008 Actual $232,701 2009 Estimate: I $237,335 Contractor Name: Program Name: Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: ITown of Southold IIIC Nutrition l(631) 298-4460 Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold [NV Extension: I Contractor Zip Code: [11971 (Jontrol Number [" Activity Code Contract Program Revenues Part 1 - Government Grants 1) Total mount of revenue received from Suffolk County for Contract Program. Page 2 of 4 2008 Actual 2009 Estimated I $ 232~;701. I$ 241,678.00 2) Total revenue received directly from State Govemment for the Contract Program. Please identify names and amounts of grant(s): 3) Total revenue received directly from Federal Government for the Contract Program. Please identify names and amounts of grant(s): I o I 4) Total revenue received directly from all other Municipalities for the [ $ 470,5 27'. 12 Contract Program. Please identify names and amounts of grant(s): Town of Southold Part 2 - Medicare/Medicaid~ Fundraising and All Other Revenues I $ 409,546.58 5) Total revenue received from Medicare/Medicaid for the Contract Program. 6) Total Fund Raising revenue received for the Contract Program. 7) Total amount of other revenues received for the Contract Program. Please identify types of revenues and amounts below: ~V°!untarY.contributions/participant income $ 0 ,o28.28 Ii 8) Total Contract Program Revenue (Add Lines l - 7) $804,256.40 I $783,424.58 Control Number Page 3 of 4 Activity Code I Contract Program Expenses Part 3 - Direct Contract Program Expenses 2008 Actual. 9) Direct Contract Program Salaries [ '$ 576, ~63.97 10) Direct Contract Program Fringe Benefits I $ 44,~076.54 11) Direct Contract Program Fee for Service ] $ 184,015.89" 12) Direct Other Contract Program Expenses [ 804,256.40 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 2009 Estimated 535,647.54 I$ 40,977.04 '1 $ 206,800.00 $ 783,424.58 Part 4 - Administrative Contract Program Expenses 2008 Actual 2009 Estimated 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) Totai Contract Program Expenses (Add Lines 13 and 18) I I 20) Please provide a short description of your Direct Contract Program Expenses: Amount of Salary Charged to the Contract Program Part 5 - Top 5 Agency Salaries Exceeding $100,000 Employee Name Employee Title 2008 Salary 4.[ ' .... ] '' i~ ~ 5.1 ....... I .... i ' Control Number I Activity Code [" Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses Page 4 of 4 2008 Actual 2009 Estimated 32}354,833. I $ 34,991,755. 23) Total Agency Net Income/(Loss) (i.i.e 2t mi..s ri.e 22) Net Income Calculator --> 24) Please indicate your fiscal year if it is not the calendar year: 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: i~$ 1,724,'4~8'.)' I($2,010,000.) 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses [i 5'479,659. I $ 5,853,1501 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administer acorps ofvolunteers [] Administer the collecfion and distribution offood 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. ~ Initials Form Prepared By I Karen McLaughlin Agency Program Contact I Karen McLaughlin Title Phone Number i al "' re Human Services , 631 298-4460 Title Phone Number Director of Human Services 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 karen, mclaughlin@town, southold, ny. us I certify, t~ljhe best of my knowledge and belief, that all of the information provided on this form is tree and Supervisor, Town of Southold ~ Sign Name Title Date CONTRACT AGENCY DISCLOSURE FORM (For 2010 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. Control Number ] 16962 I' Activity Code N/A Suffolk County Office Use Only Entered By I Reviewed By I Date Received Financial Statement Type: I Notes: I Department IEXECUTIVE Division Office for the Aging Fund 1001 Agency IEXE Org 16777 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: Contractor Name: Program Name: Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: 2008 Actual: [ $20,400 ITown of Southold ICSE - Residential Repair [i631) 298-4460 IKaren McLaughlin 53095 Main Road, P.O. Box 1179 ISouthold IN¥ 2009 Estimate: [ Extension: I $25,700 Contractor Zip Code: [11971 C. ontrol Number Activity Code [ Contract Program Revenues Part 1 - Government Grants 1) Total amount of revenue received from Suffolk County for Contract Program. Page2 of 4 2008 Actual 2009 Estimated, I $ 12,756.93 20,400.00 2) Total revenue received directly from State Government for the Contract Program. Please identify names and amounts of grant(s): I 0 [ 0 3) Total revenue received directly fi.om Federal Government for the Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directly fi.om all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Town of Southold I $ 3,901.87 I $ 452.34 Part 2 - Medicare/Medicaid~ Fundraising and All Other Revenues 5) Total revenue received fi.om Medicare/Medicaid for the Contract i o ..... I 0 Program. I I 6) Total Fund Raising revenue received for the Contract Program. 7) Total amount of other revenues received for the Contract Program. Please identify types of revenues and amounts below: Voluntary participant cOntributions 8) Total Contract Program Revenue (^aaun¢s,-7) I, 18,058.80 I $ 24,352.34 Control Number [ Page 3 of 4 Activity Code I Contract Program Expenses Part 3 - Direct Contract Program Expenses 2oo8 Actual 9) Direct Contract Program Salades I $ 16,187.45 " 10) Direct Contract Program Fringe Benefits [ 1,238.34 11) Direct Contract Program Fee for Service I 0 12) Direct Other Contract Program Expenses I 663. O1 13) Total Direct Contract Program Expenses I $ 18,088.8o (Add Lines 9 through 12) 2009 Estimated I$ 22,621.77 1,730.57 o 0 24,352.34 Part 4 - Administrative Contract Program Expenses 2008 Actual 2009 Estimated 14) Administrative Contract Program Salaries I I 15) Administrative Contract Program Fringe Benefits I I 16) Administrative Contract Program Fees I I 17) Other Administrative Contract Program Expenses I I 18) Total Administrative Contract Program Expenses (Add Lines 14 through 17) 19) Total'Contract Program Expenses (Add Lines 13 and 18) 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Top 5 Agency Salaries Exceeding $100~000 Amount of Salary Charged to the Employee Name Employee Title 2008 Salary Contract Program 5.1 I ' ' I I Control Number I Activity Code Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses Page4 of 4 2008 Actual 2009 Estimated I , 32,354,833. [$ 34,991,755. 34,079,271. 37,001,755. 23) Total Agency Net Income/(Loss) (Line21 minus Line22) Net Income Calculator -> 24) Please indicate your fiscal year if it is not the calendar year: 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: I ' I ($ 1,724,433.) ($2,010,000.) 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses { $ 5,479,659. $ 5,853,150. 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administeracorpsofvolunteers [] Administer the collection and distribution offood 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 No~ll~ompliant until I have submitted the required report to the Comptroller's Office. Form Prepared By I Karen McLaughlin Agency Program Contact I Karen McLaughlin Title Phone Number Director of .Human Services ] 631 298-4460 Title Phone Number i Director of Human Services I 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 the best of my knowledge and belief, that all of the information provided on this form is true and correct. ~~ S-pervisor, Town of Southold y/~//~ S Title Date NOTIFICATION OF RIGHTS UNDER THE LIVING WAGE LAW According to the provisions of Local Law # 12-2001 (the Living Wage law) enacted by Suffolk County in July 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.