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Home My WebLink AboutResidential Repair ProgramSouthold Town Board - Letter Board Meeting of June 30, 2009 RESOLUTION 2009-570 ADOPTED Item # 5.31 DOC ID: 5123 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2009-570 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 30, 2009: 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 County Office for the Aging and the Town of Southoid for community services for the Elderly Residential Repair Program, regarding aone year extension for the period April 1, 2009 through March 31, 2010, subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Louisa P. Evans, 3ustice SECONDER: Thomas H. Wickham, Councilman AYES: Ruland, Orlando, Krupski Jr., Wickham, Evans, Russell Generated July 1, 2009 Page 36 County of Suffolk Steve Levy Suffolk County Executive Office for the Aging Holly S. Rhodes-Teague Director August19,2009 The Honorable Scott A. Russell Supervisor Town of Southold 53065 Main Road, PO Box 1179 Southold, New York 11971 RE: Community Services for the Elderly - Residential Repair IFMS No. SC EXE 09000000605 Dear Supervisor Russell: The fully executed Agreement referenced above is enclosed for your files. Attached is a copy of All Department Heads Memorandum 30-97 explaining budget modification requirements. Any budget modification not meeting these requirements may be delayed or rejected by the Budget Office. Also enclosed find the Notification of Rights, which must be posted as part of your compliance with Local Law No. 12-2001, the Living Wage Law. If you require any further information, please contact Mary-Valerie Kempinski at 853-8209. Sincerely, Joanne Kandell Principal Accountant JK:MVK:sl Enc. cc: Karen McLaughlin G:ISLEV~MVKformle~erstLtr4Bfullyexec ADH NOR TownCC dOc H LEE DENNISON BUILDING · 100 VETERANS MEMORIAL HIGHWAY · PO BOX6100 · HAUPPAUGE, N. Y. 11788-0099 · (631) 853-8200 FAX 853-8225 OVER 35 YEARS AS THE DESIGNATED AREA AGENCY ON AGING PROVIDING SERVICES FOR OLDER CITIZENS OFFICE OF THE COUNTY EXECUTIVE .This memorandum applies to those departments who pay contract agencies from ~¢ Operating Budget 4770 or 4980 objects. On August 29, 1995, ADH 47-95 was issued to resolve pwblems whic~ had developed regarding thc procodures and requirements for modifying contra~t agency budgets. In early 1997, there were again prob.[le.~ with timeliness and the reasons for modifications for ce~ain departments invol~,ing 1996 contracts. - Departments who 'deal with contract agencies have a major responsibility i~ the processing of contract budget modifications. Therefore, the attached procedures, which take effect with all 1997 contracts should be elnsely followed. Please distribute these pmc. edmes to all of your contract agencies. If there are any questions regarding this ADH, please contact your'depaxtmenfs Budget Ex~miner. ERIC'A. KOPek'; Chief Deputy County ExeCutive Distribution Department Heads Attachment BUD GE T MOD IFIC,4 TION8 Non-equipment requeS~ for contract budget modifications/nusl be ~,eivcd ~t th~ Coui~ty Executive's Budget Offic,~ no later than 45 calendar days prior to the end of the contract fiscal year. Equipment modifications must be received 90 calendar days prior to the end of the contract fiscal year. - Under no cimumstances eat expenditures for which a budget modification is being requested be made prior to the approval of the modification by the Budget Office. 3. An agency will be reslricted to three approved modifications per year. Each line item requested to be modified must be'fullyjns6fied and must be directly related to the htent of the program. ' Any transfers to htcrease ~alary rates of contract employee~, create new posit/ous, or change the title of a position, must be subm/tted prior to the ra/e increase be/ag given or the position bring filled. The Budget Office w/ll ~ot approve retroactive salary increuses[ The only exception applies to a retroactive labor agreement between an agency and their' union bargaining unit(s). ' 6. Budget modifications cannot increase the dollar amount of the'contract. o ;Fo.ur ~pies.ofthe prop.osed budget modifi, cation and one copy of the justification, . mc~uolng a ~etter from thc agency requesting the change, should be forwarded to the Budget Office with the d~partmenfs recommendation wlt~;, fifteen'(15) calendar days of receipt of the request by the department. The justification must include the effect of the modification on the program/changes in the available rdmbur~ment to the County, if any, the additional dollar amount whi6h will ba paid to the agency, and the dollar amount of reimbursement to the County, if'the modification is approved. ' If.the eonh-act is funded under a Federal or State grant, or State reimbursement, the Department Head must hdvise in the ~r~n~mitial memo whether State or Federal approval for the modification is required and whether the aiiaohexi dooumentation showing the change has been approved by the funding agency. The budget modification format must indicate the line item, the current budget amount, thc amount spent year to date, thc new amount of the l/ne item and the dollar amount of the change.. 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. Ail inquiries will remain confidential. Law No. AG006M/0029-11 RC Rev. 6123109 Community Services for the Elderly - Residential Repair IFMS No. SC EXE 09000000605 No. 001-6777-4980-95285-0605 Third Amendment Amendment of Agreement This is a Third Amendment of an Agreement. (Agreement). last dated June 30, 2006, 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 - 3r~ Floor, 100 Veterans Memorial Highway, Hauppauge, New York (Mailing address: P.O. Box 6100, Hauppauge, New York 11788-6099), 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 CSE Residential Repair Program from Apdl 1, 2009 through Mamh 31, 2010 (the period Apdl 1, 2009 through Mamh 31, 2010 being hereinafter called the "2009/2010 Budget Pedod") and to add and amend certain contract provisions to comply with currant County Standards, as set forth herein. Term of Agreement: Shall be April 1, 2006 through March 31, 2010, with one one-year extension at the County's option. Units of Service: 1,100 Units of Residential Repair Service Total Cost of Agreement: Shall not exceed $ 81,600 (of which $20,400 is for the 2009/2010 Budget Period). Terms and Conditions: Shall be as set forth in Exhibit A-2009/2010, C-2009/2010 and the "Suffolk County Legislative Requirements Exhibit" revised 11/08, attached. In Witness Whereof, the parties hereto have executed this Third Amendment of Agreement as of the latest date written below. Town of South,... Supervisor Fed. Taxpayer ID #: 11-6001939 Date: ~ -! ~-~'-'~(~ 7 ~'OOtt/t~. ffO~/] ., hereby ce~ifies under p~alties ofpe~ ~at I~ ~ ~mer of ~0~ O~O[~at I have read ~d I ~ famili~ with ~A5-7 of ~icle V of~ Suffolk ~o~ C~e, ~d~at ~0~ O~ ~0/~ mee~'~l requffemen~ t~i~ for e~pdon ~er~er.~ / ~ppm~*d ~ to ~lli~: Christine Malafi Suffolk County Attorney By: Jacqueline Cap~i ~--~, Assistant County Attorney County of Suffolk Name: RN Deputy County .Ex'ecuave Date: ~--~]/'~/0 '~ y .(~ ' - g ~e Director, Office for the Aging Recomm?~d: R~ginalDeTuro Date Administrator I 0003120 AG 6 AG6 CSE RR Sohld ext 09 rev 6-8-09 'Law No. AG006M/0029-11RC Rev. 6123/09 Community Services for the Elderly - Residential Repair IFMS No. SC EXE 09000000605 No. 001-6777-4980-95285-0605 Third Amendment Exhibit A-200912010 Whereas, the County and Contractor have entered into an Agreement (Law No. AG006M/0029-11R), last dated June 30, 2006, for a term from April 1, 2006 through March 31, 2007 with four one-year extensions at the County's option, for a CSE Residential Repair Program for the eldedy at a Total Cost of $20,400; and Whereas, the County and Contractor have entered into a First Amendment of Agreement (Law No. AG006M/0029-111RA), extending the term from April 1, 2007 through March 31, 2008 (at an additional cost of $20,400) and increasing the Total Cost of the Agreement to $40,800; and Whereas, the County and Contractor have entered into a Second Amendment of Agreement (Law No. AG006M/0029-111RA), extending the term from April 1, 2008 through March 31, 2009 (at an additional cost of $20,400) and increasing the Total Cost of the Agreement to $61,200; and Whereas, the parties hereto desire to modify the Agreement to extend the term from April 1, 2009 through March 31, 2010 (at an additional cost of $20,400), to increase the Total Cost of the Agreement to $81,600 and to add and amend certain contract provisions to comply with current County Standards, as set forth below; Now, Therefore, in consideration of the covenants, promises and consent herein contained, the parties hereto agree as follows: 1. Term of Agreement: The Term of Agreement paragraph on page 1 of the Agreement is amended to read Apdl 1, 2006 through March 31, 2010 as set forth on page 1 of this Third Amendment of Agreement. 2. Payment for Services: The Total Cost of Agreement $81,600 is comprised as follows: a. $20,400 for the 2006~2007 contract term; b. $20,400 for the 2007/2008 Budget Period; c. $20,400 for the 2008~2009 Budget Period; d. $20,400 for the 2008/2009 Budget Period; 3. Poverty Threshold: For the 2009/2010 Budget Period, the Poverty Threshold in Exhibit B to the Agreement, the paragraph entitled "Reporting Requirements, Low Income" is hereby amended to read as follows: 4. Budget: Size of Family Unit 1 2 150% of Poverty Threshold $16,245/year $21,855/year The Budget annexed hereto as Exhibit C - 2009/2010, including advance payment schedule, if any, is made part of the Agreement. The Contractor shall comply with the following amended provisions in conformance with current County Standards. 5. Agreement Subject to Appropriation of Funds Subparagraph e of Paragraph 4 of Exhibit A1 to the Agreement is deleted in its entirety and replaced with the following: AG 6 Page 2 AG6 CSE RR Sohld ext 09 rev 6-8-09 *Law No. AG006M/0029-1 t RC Rev. 6112/09 Community Services for the Elderly - Residential Repair IFMS No. SC EXE 09000000605 No. 001-6777-4980-95285-0605 Third Amendment So e. Subject to Appropriation and Receipt of Funds 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. 1. 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 for any reason, 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 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. 2. 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. 3. Any Budget Deficiency Plan shall be deemed to be incorporated by reference and made part of the Contract. 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." 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). 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 6 Page 3 AG6 CSE RR Sohld ext 09 rev 6-8-09 *Law No. AG006M/0029-11RC Rev. 6112/09 Community Services for the Elderly - Residential Repair IFMS No. SC EXE 09000000606 No. 001-6777-4980-95285-0606 Third Amendment Exhibit C-200912010 Budget Town of Southold CSE Residential Repair Program April 1, 2009 - March 31, 20t0 PERSONNEL Mechanic I Mechanic I ~18,600 15,500 3,100 FRINGE 1 ~300 OTHER Gas & Oil Supplies/Small tools 3,000 1,500 1,500 TOTAL $22~900 Less Anticipated Income (2,5oo) NET REIMBURSEMENT AG 6 Page 4 AG6 CSE RR Sohld ext 09 rev 6-8-09 Exhibit Suffolk County Legislative Requirements revised 11108 Contractor's/Vendor's Public Disclosure Statement It shall be the duty of the Contractor to read, 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 A5-7 of ^rticle V of the Suffolk County Code, the Contractor represents and warrants that it has filed with the Comptrol;er 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 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 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 f'~teen percent (15%) of the 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 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 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 (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 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. No 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 ara performed on County property the Contractor must adopt a raasonable access agraement, a neutrality agraement, fair communication agreement, non-intimidation agreement, and a majority authorization card agreement. If the Services ara for the provision of human services and ara 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 raquiraments 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 theraof, 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, whera such compensation is one hundred percent (100%) funded by the County, shall submit a completed swom affidavit (under penalty of perjury), the form of which is attached, cert'rrying that they have complied, in good faith, with the requirements of Title 8 of the United States Code Section 1324a with raspect to the hiring of coverad employees (as defined) and with respect to the alien and nationality status of the owners thereof. The affidavit shall be executed by an authorized reprasentative of the coverad employer or owner, as the case may be; shall be part of any executed contract, subcontract, license agreement, lease or other financial compensation agraement with the County; and shall be made available to the public upon request. All contractora and subcontractors (as defined) of coverad employers, and the owners theraof, 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, whera 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 requiraments of Title 8 of the United States Code Section 1324a with raspect to the hiring of coverad employees and with raspect to the alien and nationality status of the owners theraof, as the case may be. The affidavit shall be executed by an authorized rapresentative 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 coverad employer and the County; and shall be made available to the public upon request. An updated affidavit shall be submitted by each such employer, owner, contractor and subcontractor no later than January I of each year for the duration of any contract and upon the renewal or 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 ara 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 Hidng 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 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. Required Forms: Suffolk County Lawful Hiring of Employees Law Form LHE-1; entitled 'Suffolk County Department of Labor-"Notice Of Application To*Certify Compliance W'~h 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 W'~h 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 represents 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 the 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 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 the Contract with regard to child sexual abuse reporting policy. Non Responsible Bidder It shall be the duty of the Contractor to read, 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 Mconviction' 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. 11. 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 Webeite Address Suffolk COunty Local Laws, Rules and Regulations can be found on the Suffolk County website at http://www,co.suffolk.ny,us,' End of Text for Exhibit Suffolk County, New York Departmmt of Labor SUFFOLK COUNTY DEPARTMENT OF LABOR- LABOR M~DIATION uNiT UNION ORGANIZING CERTIFICATION/DECLARATION- SUBJECT TO AUDIT If the following definition of "County Contractor" (Union Organizing Law Chapter 4662) nppUes to the contractor's/beneflciacy's business or transaction with Suffolk County, the contractor/beneficinF~ must complete Sections !, III, and IV below. If the following definitions do not apply, the contractor/beneflcJaFy must complete Sections II, !II and IV below. Completed forms must be submitted to the award!ng 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 gnmt; pursuant to a Suffolk County program; pursuant to a Suffolk County reimbursement for services provided in any calendar year;, or pursuant to a $ubeuntract with any of the abevc." Section I Chcek if Applicable Section II The Union Organizing Law applies to this con~ract. I/we hereby agree to comply with all thc pmvisiuns of Suffolk County Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) and, as to the goods and/or servicos that are the subject of the contract with the County of Suffolk shall not usc County funds to assist, promote, or deter union organizing (Chapter 4663 A), nor sunk rcimbursem~t from the County for costs incurred to assist, pmmoto, or deter union organizing. (Chapter 466-3 B) I/we flmher 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 properly to hold meetings to assist, pmmote, 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 fimds 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 tho 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: · l/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, explicltiy or implioitiy, in selecting or not selceting 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 dismptinns caused by prerecognltiun labor disputes through the adoption of nunconfrontatiooel procedures for the re. solution of prerecognition labor disputes with emplcye~a engaged in the pmduction of goods or the rendering of services for the County; and · I/we have or will adept any or all of the above-roferenced 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 suid procedures in such certification. The Union Organizing Law does not apply to this contract for the following renson(s): Check if Applicable DOL-LO I (3/5/08) Suffolk County, New York De~tment of Labor Section IH contrnctor Name: Contractor Address: Town of Southold 53095 Main Road P.O. Box 1179 Southold, New York 11971 Contractor Phone #: Description of project or service: Federal Employer ID#: 11-6001939 AmountofAssistance: $ 20,400.00 Vcndor #: Contact ~erson: Karen McLaughlin, Director CSE Residential Repair Program 631 298-4460 Section IV In the event any part of the Union OrganiZing Law, Chapter 466 orthe Laws of Suffolk County, is found by a court of competent jurisdiction to be preempted by federal and/or state law, this certification/declaration shall be void ab initio. Section V I declare under penalty.of perjury under the Laws of the . certification, and ~t l~'above is hue and con'ecL State of New York that the undersigned is author/zed to provide this Authorized S~atu~e ' ' Date Scott.. A. Russell, S0uthold Town Supervisor Print Name and Title of Authorized Representative DeL-LO 1 (3/5/08) CONTRACTOR..NAME ADDRESS CONTACT BTATF. MENT OF OTHERCONTRACTS 7S0 Pacific'Street, P.O. BoxBS, Matt~tuck, New York 12952. ' .' -: · ' 'NUMBER' ' *coNTRAcT WITH / = TERM OF AGREEMENT AMOUNT ~NO-00~ 679?-4980 SufEolk Count.¥ OEEJ. ce ~o: 1/1/08 - 12/31/08 ~:=i~:,,to~ :~'=%r~ ,-.. 9s ~B~,-;~7~ · ~":~' - ~. ~3,o~4.oo [11-C~2 -~ ~[~ve~d' 'NO-~[-67'76-3330 'Sa~[A County O~ce ~o~ [/[Z08 - ~,2/3[/08 $ ~59,607.00 . '.. M~i'P=Qg=~ '-'. ' ' ' '95 284-1792 ' . .. :the ~gia9 · . · N0',- 001-6806' ' sU~f01k ~y Office : a980-95'28~-1389' :he AgOg: · · ~4/~/08 h 3/31/09 $ "10,361.00. ' .ao-o0z-~'~-4~o CBS Residential'Re,air., ~ 9S'285-0605 "' SuffoZk CoWry o~fice for '4/1/08 - 3~31/09 $ 20,400.00 "Proqr~ .. ' ' ~e AgOg · *Indicate (a) type of Organization - County,-state, Federal or Other and (b) name of Department, Agency: or Organization~.~ ~,, . KB:eh t4c~au~h]f.~ Direc~or, PHONE'NUMBER 631 KAREN MeLAUGHLI~ Town Director of Human Services Town of Southold 750 Pacific Street P.O. Box 85 Maltit~ck, NY 11952 Tel. (631) 298-4460 Fax (631) 298-4462 Nutrition Program Home Delivered Meals Case Management Essential Transportation Senior Adult Day Care Alzh¢imer's Day Care Telephone Reassurance Residential Repair July 15, 2009 Elizabeth Tesoriero, CPA Executive Director of Auditing Services Contract Compliance Unit Room S-232 Evans K. G-tiffing Building 300 Center Drive Riverhead, NY 11901 Dear Ms. Tesoriero: Enclosed please find the completed Contract Agency Disclosure Forms for the CSE Residential Repair, IH-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 information 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 yom cc: John Cushman, Southold Town Comptroller Elizabeth Neville, Southold Town Clerk v,~ RECEIV£D JUL 2 7 2009 ~oulhol4 Town 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 631-852-2062. 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 lC GRIFFING BUILDING · 300 CENTER DRIVE · RIVERItEAD, NY 11901 (631) 852-2064 Fax (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. Control Number 116098 Activity Code [ Suffolk County Office Use Only Financial Statement Type: [ Notes: Department [EXECUTIVE Division [Office for the Aging Fund [001 Agency [EXE Org 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: 2008 Actual $10,361 2009 Estimate: I $10,361 Contractor Name: ITo of Southold Program Name: [Transportation Assistance Contractor Phone Number: [(631) 298-4460 Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Program Extension: [Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold [NY Contractor Zip Code: [ 11971 Control Number [ Activity Code [ Contract Program Revenues Part 1 - Government Grants 2008 Actual 1) Total amount of revenue received fi.om Suffolk County for Contract I $ 8,633.79 Program. Page 2 of 4 2009 Estimated I $ 4,986.00 2) Total revenue received directly from State Government for the [ Contract Program. Please identify names and amounts of grant(s): 0 3) Total revenue received directly from Federal Govermnent for the ] 0 I Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directly from all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Town of Southold I * 31.s~ I $ ~o,2~o.oo Part 2 - Medicare/Medicaid, Fundraising and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract I I I 0 I 0 Program. 6) Total Fund Raising revenue received for the Contract Program. I ' o I 0 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 , - 7) Ib- 11,'68o.30 l* ~s,88~.o0 Control Number I Activity Code I Contract Program Expenses Part 3 - Direct Contract Program Expenses 2008 Actual 9) Direct Contract Program Salaries ~ I $ 9,695.61 10) Direct Contract Program Fringe Benefits I 777.69 11) Direct Contract Program Fee for Service I o 12) Direct Other Contract Program Expenses 1,207.00 13) Total Direct Contract Program Expenses I $ 11,68 o. 30" ' (Add Lines 9 through 12) Page3 of 4 2009 Estimated l$ 14,289.00' 592.00 ''0 1,000.00 15,881.00 Part 4 - Administrative Contract Program Expenses 2008 Actual 2009 Estimated 14) Administrative Contract Program Salaries I I 15) Administrative Contract Program Fringe Benefits 16) Administrative Contract Program Fees I ' ' 17) Other Administrative Contract Program Expenses 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 Employee Name Employee Title 3. Charged to the 2008 Salary Contract Program Control Number [ Activity Code [ Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 2008 Actual Page4 of 4 2009 Estimated l, 32,3s4,833. l, 34,991,755 23) Total Agency Net Income/(Loss) CLine21 minus Line 22) Nat In,oma Oalculater -> 24) Please indicate your fiscal year if it is not the calendar year: I 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: ($1,727,438.) ,010,000. ) NO 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses ]~'~''''~7916~9} 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 federal, state or other pass through funding [] Disseminate educational materials for a public purpose [] Administer the collection and distribution of food to the needy [] Not Applicable for my Agency Form Prepared By I Karen McLaughlin Agency Program Contact 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 required financial report is not enclosed my Agency will be deemed/~gCompliant ~ ~4r I have submitted the required report to the Comptroller's Office. Title Phone Number I Town Director of Human Services 631 298-4460 Title Phone Number ........ I ;0W~ D~recto; Of HU''' Se'vices 63:1_ 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): karen, mc laughlin@town, southo ld. ny. us I certify, to/~e best of my knowledge and belief, that all of the information provided on this form is true and correct//~ _ Z~ ~~ Supervisor, Town of Southold Sign Name Title Date CONTRACT AGENCY DISCLOSURE FORM (For 2010 Budget Process) Contract Agency Information Page ~ oC4 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 116086 Activity Code [ Suffolk County Office Use Only Entered By [ Reviewed By I Date Received I Financial Statement Type: [ Notes: [ Department IEXECUTIVE Division IOeace for the Aging Fund 1001 Agency IEXE Org 16790 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: I $232,701 2009 Estimate: I $237,335 Contractor Name: ITown of Southold Program Name: Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: IIIIC Nutrition (631) 298-4460 IKaren McLaughlin 53095 Main Road, P.O. Box 1179 Southold Extension: I Contractor Zip Code: I11971 Control Number ] Activity Code Contract Program Revenues Part 1 - Government Grants 1) Total amount of revenue received fi.om Suffolk County for Contract Program. Page 2 of 4 2008 Actual 2009 Estimated $ 232~701. $ 241,678.00 2) Total revenue received directly fi.om State Government for the Contract Program. Please identify names and amounts of grant(s): ' 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 from all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): I * 47o,s27.12 l* 4og,s46.s8 Town of Southold 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. I 7) Total amount of other revenues received for the Contract Program. Please identify types of revenues and amounts below: ~v°!~ntarycontributions/partic%Pant income 0 0 5101,028.28 $ 132,200.00 8) Total Contract Program Revenue (Add Lines 1 - 7) l$8o4,2s6.40 [ $783,424.55 Control Number [ Activity Code I Contract Program Expenses Part 3 - Direct Contract Program Expenses 2008 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 Page 3 of 4 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 2009 Estimated $ 576,163.97 $ 535,647.54 ] $ 44~;076.54I, 40,977.04 I$184,0 5.89 I $ 206,800.o0 [ $ 804,256.40]' $ 783,424.58 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) 2008 Actual 2009 Estimated I I 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Top 5 Agency Salaries Exceeding $100~000 Amount of Salary Charged to the 2008 Salary Contract Program Employee Name Employee Title 2. Control Number I Activity Code I Agency Information Part 6 - Financial and Other Al~ency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 2008Actual l$ 32~354,833. I' 34,0795~271. 23) Total Agency Net Income/(Loss) (Line2~ 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: Page 4 of 4 2009 Estimated I $ 34,991,755. I 37,001,755. I( $2,010,000. ) 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses [ $ 5,479,659. I, 5,853,1~0. 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administer a corps of volunteers ~ Administer federal, state or other pass through funding [] Disseminate educational materials for a public purpose [] Administer the collection and distribution of food to the needy [] 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 Pro.am Contact I Karen McLaughlin Title Human Services Title Director of Human Services Phone Number 631 298-4460 Phone Number 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, t53a)he best of my knowledge and belief, that all of the information provided on this form is tree and correcy/ ~~ Supervisor, Town of Southold 7/~/~ Sign Name Title Date 631 298-4460 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 Activity Code [N/A Suffolk County Office Use Only Entered By [ Reviewed By [ Date Received Financial Statement Type: I Notes: ] Department [EXECUTIVE Division [Office for the Aging Fund [001 Agency IEXE Org [6777 Object [4980 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: 2008 Actual: I ITown of Southold Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: $20,400 2009 Estimate: I $25,700 ICSE - Residential Repair [(631) 298-4460 [Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold IN¥ 11971 Extension: I C. ontrol Number [ Activity Code I Page 2 of 4 Contract Program Revenues Part 1 - Government Grants 1) Total mount of revenue received from Suffolk County for Contract Program. 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 o I 0 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 from 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 - MedicarefMedicaid~ 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 1- 7) I $18,0s8.80 I * 24,3s2.34 Control Number I Page 3 of 4 Activity Code ] Contract Program Expenses Part 3 - Direct Contract Program Expenses 2008 Actual 9) Direct Contract Program Salaries I $ 16,187.45 10) Direct Contract Program Fringe Benefits I 1,238.34 11) Direct Contract Program Fee for Service I o 12) Direct Other Contract Program Expenses I ' 663.01 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 2009 Estimated I$ 22,621.77 1,730.57 o 0 I $ 18,088.80 I $ 24,352.34 Part 4 - Administrative Contract Program Expenses 2008 Actual 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) .2009 Estimated I ' ' I I I 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Too 5 Agency Salaries Exceeding $100,000 Amount of Salary Charged to the Employee Name Employee Title 2008 Salary Contract Program Control Number I Activity Code [ Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 23) Total Agency Net Income/(Loss) {Line 21 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 expla'm your agency's affiliation: Page4 of 4 2008 Actual2009 Estimated I $ 32,354,833. I$ 34,991,755. ($ 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) [] Administer a corps of volunteers [~rAdminister federal, state or other pass through funding [] Disseminate educational materials for a public purpose [] Administer the collection and distribution of food to the needy [] 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 requi.red financial r. eport is not enclosed my Agency will be deemed No~mpliant until I have subnutted the reqmred report to the Comptroller's Office. /~[6. ) Form Prepared By Karen McLaughlin Agency Program Contact I Karen McLaughlin Title PhoneNumber I Director of .Human Services] 631 298-4460 Title Phone Number I Director of Human servicesl 631 298-4460 If you would prefer to be contacted via E-mall, 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 I certify, to the best of my knowledge and belief, that all of the information provided on this form is true and correct. ~gn~NCa~~ Supervisor, Tow~ of Southold ,~/~/O~. S Title Date KAREN MeI. AUGHLIN Town Director of Human Se~ices Town of Southold 750 Pacific Street P.O. Box 85 Matfituck, NY 11952 Tel. (631) 2984460 Fax (631) 2984462 Nutrition Program Home Delivered Meals Case Maaagemeat Essential Transportation Senior Adult Day Caxe Alzheimer's Day Care Telephone Reassurance Residential Repair July 15, 2009 Elizabeth Tesofiero, CPA Executive Director of Auditing Services Contract Compliance Unit Room S-232 Evans K. Gtiffing Building 300 Center Drive Riverhead, NY 11901 Dear Ms. Tesoriero: Enclosed please find the completed Contract Agency Disclosure Forms for the CSE Residential Repair, IH-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 information regarding the enclosed disclosure forms, please contact me at 298 ~.~.60 or call John Cushman, Town Comptroller at 765-4333. We would be happy to assist you. ~n McLaughh"ff Director of Human See cc: John Cushman, Southold Town Comptroller Elizabeth Neville, Southold Town Clerk ~/~ RECEIVED JUL 2 7 ~euthol~ To~ Cie& 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 631-852~2062. 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 K. GRIFE1NG BUILDING · 300 CENTER DRIVE · RIVERHEAD, NY ! 1901 (631) 852-2064 Fax (631) 8~2-2066 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 Offic~ Use Only Entered By Financial Statement Type: 16098 I IEXECU~IVE Ioffice for the Aging Control Number Activity Code Department Division Notes: I Object 4980[~ 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: 2008 Actual: I Town of Southold Program Name: ITransportation Assistance Program I Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: $10,361 2009 Estimate: l(631) 298-4460 IKaren McLaughlin 53095 Main Road, P.O. Box 1179 ISouthold 11971 Extension: I $10,361 Control Number i Activity Code I Contract Program Revenues Part 1 - Government Grants 1) Total amount of revenue received fi.om Suffolk County for Contract Program. Page 2 of 4 2008 Actual 2009 Estimated 8,633.79 1 $ 4,986. O0 Total revenue received directly fi.om State Government for the [ 2) Contract Program. Please identify names and amounts of grant(s): Total revenue received directly fi.om Federal Government for the [ 3) 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 0 I 0 Part 2 - Medicare/Medicaid, Fundraising and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract ~] .... o I 0 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 I~nes 1-7) I$ l1,680,30 I ~5,881.00 Control Number [ Activity Code [ Contract Program Expenses Part 3 - Direct Contract Program Expenses 2008 Actual 9) Direct Contract Program Salaries I $ 9,695.61 10) Direct Contract Program Fringe Benefits [ 777.69 11) Direct Contract Program Fee for Service I 0 12) Direct Other Contract Program Expenses I 1,2 o7. o o ' 13) Total Direct Contract Program Expenses I $ 11,680.30 (Add Lines 9 through 12) Page 3 of 4 2009 Estimated I$ 14,289.00 592.00 o 1,000.00 $ 15,881.00 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) 2008 Actual 2009 Estimated I$ 15,881.00 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Top 5 Agency Salaries Exceeding $100,000 Employee Name Employee Title Amount of Salary Charged to the 2008 Salary Contract Proi/ram ! Control Number I Activity Code I Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 23) Total Agency Net Income/(Loss) (Line 2~ ~us Li.e 22) Net Income Calculator --> 24) Please indicate your fiscal year if it is not the calendar year: 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: Page 4 of 4 2008 Actual 2009 Estimated 32,354,833. ]$ 34,991,755: 134,079,27x. ] 37,001,755. 2008 Actual 26) Total Agency Administrative Expenses I * 4 7 9,6 9. 2009 Estimated $ 5,853,150. 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administer a co~s 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 Form Prepared By I 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 th~ t if the required financial report is not enclosed my Agency will be deemed.,afln~Compliant ~- ~i~ I have submitted the required report to the Comptroller's Office. Title Phone Number I Town Director of Human Serv]ces 631 298-4460 Title Phone Number ..... i':owL D~r C o; Of Hu~a~ ' I , .... e t Serv ces 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): karen, mc laughlin@town, southold, ny. us I certify, to/~e best of my knowledge and belief, that all of the information provided on this form is true and Supervisor, Town of Southold Sign Name Title Date CONTRACT AGENCY DISCLOSURE FORM (For 2010 Budget Precess) 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 Activity Code Department Division Fund 1001 16086 I EXECUTIVE 10ffice for the Aging Agency IEXE Suffolk Coun~ Or, ce Use Only Entered By I Reviewed By I Date Received Financial Statement Type: Notes: Org [6790 Object [4980 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: I Contractor Name: [Town of Southold Program Name: [IIIC Nutrition Contractor Phone Number: [(631) 298-4460 Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: $232,701 2009Estimate: I $237,335 Extension: Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold [NV 11971 (Jontrol Number [ Page 2 of 4 Activity Code I Contract Program Revenues Part 1 - Government Grants 1) Total amount of revenue received from Suffolk County for Contract Program. 2008 Actual $ 232/701. 2009 Estimated I$ 243.,678.00 2) Total revenue received directly from State Government for the Contract Program. Please identify names and amounts of grant(s): 3) Total revenue received directly from Federal Govemment for the Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directly from all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Town of $outhold [ $ 470,527.3-2 [ $ 409,546.58 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: Volu~n~grY~ contributions/participant income 8) Total Contract Program Revenue (Add Lines 1 - 7) I I 0 3-32,200.00 15804,256-40 I $783,424.58 Control Number [ Activity Code I Contract Program Expenses Part 3 - Direct Contract Program Expenses 9) Direct Contract Program Salaries 10) Direct Contract Program Fringe Benefits 11) Direct Contract Program Fee for Service 12) Direct Other Contract Program Expenses 2008Actual I$ 576,163.97 l$184,o s.89 I $ 804,256.40 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) Page 3 of 4 2009 Estimated [ $ 535,647.54 l$ 40,977.04 $ 206,800.00 $ 783,424.58 Part 4 - Administrative Contract Program Expenses 2008 Actual 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) 2009 Estimated I 'l' 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Top 5 Agency Salaries Exceeding $100~000 Amount of Salary Charged to the Employee Name Employee Title 2008 Salary Contract Proeram Control Number ] Activity Code I Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 2008 Actual I$ 32~354,833. ' 34,079:;.271. 23) Total Agency Net Income/(Loss) (Li.c 2~ ,xmus Line 22) Net Income Galeulator --> 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: 1,724,438.) Page4 of 4 2009 Estimated I $ 34,991,755. I 37,001,755. I($2,010,000.) 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses [$ 5,479,659. I $ 5,853,150. 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administer a corps of volunteers [~ Administer federal, state or other pass through funding [] Disseminate educational materials for a public purpose 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 Title Phone Number Agency Program Contact Title Phone Number If you would prefer to be contacted via E-mail, please enter an E-mall address where we may contact you in the event that we have any questions regarding the completion of this form (Optional): karen, mc laughlin@town, southold, ny. us I certify, t~lhe best of my knowledge and belief, that all of the information provided on this form is true and correcy/ ~ Supervisor, Town of Southold Sign Name Title Date [] Administer the collection and distribution of food to the needy [] Not Applicable for my Agency 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 Activity Code Department Division Fund 1001 16962 N/A EXECUTWE [Office for the Aging Agency IEXE Suffolk County Office Use Only Entered By [ Reviewed By [ Date Received I Financial Statement Type: [ Notes: [ 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. 2008 Actual: I $20,400 2009 Estimate: I $25,700 Contract Amount: Contractor Name: Program Name: Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: ITown of Southold ICSE - Residential Repair [(631) 298-4460 IKaren McLaughlin 53095 Main Road, P.O. Box 1179 ISouthold 11971 Extension: I Control Number [ Page 2 of 4 Activity Code [ Contract Program Revenues Part 1 - Government Grants 1) Total amount of revenue received from Suffolk County for Contract Program. 2008 Actual 2009 Estimated [ $ 12,756.93 t $ 20,400.00 2) Total revenue received directly from State Government for the Contract Program. Please identify names and amounts of grant(s): I o I 0 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 $outhold [ o I o $ 3,901.87 I $ 452.34 Part 2 - Medicare/Medicaid~ Fundraising and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract I o I 0 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 1,400. I 3,500. 8) Total Contract Program Revenue (Add Lines l - 7) I $ 18,058.80 [ $ 24,352.34 Control Number [ Activity Code [ Contract Program Expenses Part 3 - Direct Contract Program Expenses 2008 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) Page 3 of 4 2009 Estimated I, 16,187.4s I$ 22,621.77 I 0 0 I $ 18,088.80 J $ 24,352.34 Part 4 - Administrative Contract Program Expenses 2008 Actual 2009 Estimated 14) Administrative Contract Program Salaries 15) Administrative Contract Program Fringe Benefits I n 16) Administrative Contract Program Fees I 17) Other Administrative Contract Program Expenses J 18) Total Administrative Contract Program Expenses J (Add Lines 14 through 17) I 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 $100~000 Amount of Salary Charged to the Employee Name Employee Title 2008 Salary Contract Program 3. Control Number I Activity Code [ Agency Information Part 6 - Financial and Other Agency Information 21) Total Agency Support and Revenues 22) Total Agency Expenses Page4 of 4 2008 Actual2009 Estimated I 34,079,271.I 37,00x,yss. 23) Total Agency Net Income/(Loss) (Li,e 21 minus Line 22) ($ 1,7 2 4,4 3 3. ) 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) I 25b) If yes, name corporation(s), and explain your agency's affiliation: I ($2,010,000.) 2008 Actual 2009 Estimated 26) Total Agency Administrative Expenses 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) [] Administer a corps of volunteers ~Administer federal, state or other pass through funding [] Disseminate educational materials for a public purpose [] Administer the collection and distribution of food to the needy [] 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~mpliant until I have submitted the required report to the Comptroller's Office. /e~}~. ) Form Prepared By Title Phone Number Karen Agency Program Contact Title Phone Number I I I Karen McLaughlin 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 the best of my knowledge and belief, that all of the information provided on this form is true and ColTeet. ~~ Supervisor, Tow~ of Southold 7/r~//O~. S Title Date