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Home My WebLink AboutNutrition ProgramRESOLUTION 2010-387 ADOPTED DOC ID: 5929 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2010-387 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MAY 18, 2010: 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 Southold for the IIIC Nutrition Programs, regarding a one year extension for the period January 1, 2010 through December 31, 2010, 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: Albert Krupski Jr., Councilman SECONDER: William Ruland, Councilman AYES: Ruland, Orlando, Talbot, Krupski Jr., Evans, Russell Law No. AG004MI0003-11 RC Rev. 513110 IIIC Nutrition Program IFMS No. SC EXE 10000001792 No. 001-67901679716774-4980, 6776-3330-96284-1792 Third Amendment Amendment of Agreement This is the Third 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, Riverheed, 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 Mernorial Highway, Hauppauge, New York (Mailing address: P.O. Box 6100, Hauppauge, New York 11788-0099), and the Town of Southold (Contractor), a New York municipal corporation, having its principal place of business at 53095 Main Road, P.O. Box 1179, Southold, New York 11 g71. The parties hereto desire to modify the Agreement to extend the term of the Agreement from January 1, 2010 through December 31, 2010 (the period January 1, 2010 through December 31, 2010 being hereinafter called the "2010 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, 2010 for Congregate Meals, and Apdl 1, 2007 through December 31, 2010 for Home-Delivered Meals, with one one- year extension at the Count, s option. Total Meals: Dally Congregate Meals: 57 Not to Exceed $76,075 Annually Dally Home-Delivered Meals: 112 Not to Exceed $166,038 Annually Total Cost of Agreement: Shall be on a fee-for- service basis, not to exceed $901,835 (with $242,113 for the 2010 Extension Period), as set forth in Exhibits A-2010, and C-2010 attached. Terms and Conditions: Shall be as set forth in Exhibits A-2010, C-2010, and the "Suffolk County Legislative Requirements Exhibit" revised 11/09 attached. In Witness Whereof, the parties hereto have executed this Third Amendment of Agreement as of the latest date By: ~ Scott A, Russell Supervisor Fed. Taxpayer ID~; 11-60/01939 Date: %/'~/ r~ · fC~o'~ ,~. ~.~ [( , hereby certifies under penalties of perimy that I am an officer of :~r'-o ~,~ ~:~,~ _~o c~(~ that I have read and I am familiar with §A5-7 of Article V of th; SuffoJk County Code, and that ~--~r~J~ C~ ,.~e~"~"(~c::~t/8/ meatsall requir.,em~uali~ fo~mption thereunder. ~ ~' Approved as to Legality: Christine Malafi Suffolk County Attorney ~ By: JacquelineCaputi ~.~' ('~ (°~la}~/IU ^ssistant County Attorney County of ~J~k/ Name: 0_,~;r: Deputy C~nt~ Date: Executive Approved: / / Holly S. I~odes-Teague ~ Date Director, Office for the Aging Recommended: /~nna Prencipe Date Food Service Supervisor IIIIilllllll 0005644 AG 4 (7/06) Page 1 AC-4M Sohld ext 10 rev 3-10 Law No. AG004MI0003-11 RC Rev. 513110 IIIC Nutrition Program IFMS No. SC EXE 10000001792 No. 001-67901679716774-4980, 6776-3330-95284-1792 Third Amendment Exhibit A-2010 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/0003-11PA), 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 County and Contractor have entered into a Second Amendment of Agreement (Law No. AG004M/0003-11RB), extending the term from January 1, 2009 through December 31, 2009 and (at an additional cost of $237,336) increasing the Total Cost of the Agreement to $659,722; and Whereas, the parties hereto desire to modify the Agreement, to extend the term from January 1, 2010 through December 31, 2010 and (at an additional cost of $242,113) to increase the Total Cost of the Agreement to $901,835, 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: I. Term of Agreement: The Term of Agreement paragraph on page I of the Agreement is amended to read January 1, 2007 through December 31, 2010 as set forth on the page I of this Third 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 Third Amendment of Agreement. 3. Payment for Services: The Total Cost of Agreement $901,835 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; d. $242,113 for the 2010 Extension Period; 4. Rate Page: The rate at which the Contractor shall be paid for this Extension Period is set forth in Exhibit C-2010, which is attached and made part of the Agreement. - 5. Contributions Paragraph 3 of Exhibit B to the Agreement is replaced in its entirety with the following: Contributions The Contractor has the obligation to inform each recipient of the service of the opportunity to make a free, willing and anonymous contribution toward the cost of the service. Service may not be denied if a person is unable or unwilling to make a contribution. The Contractor must maintain an audit trail of all incoming contributions and make monthly reports of any contributions received. Monthly contributions will be deducted from monthly expenditures to arrive at net reimbursement. All contributions must be used to enhance services. All printed materials used for the program must include the sources of funding for the Program and must include the following information: AG 4 (7/06) Page 2 AG4M Sohid ext 10 rev 3-10 Law No. AG004M/0003-1'I RC Rev. 513110 IIIC Nutrition Program IFMS No. SC EXE 10000001792 No. 00t-6790/6797/6774-4980, 6776-3330-95284-1792 Third Amendment Contributions to this (these) service(s) are free and voluntary. Service will not be denied because of inability or unwillingness to contribute. Any contribution you wish to make will be used to expand the program and will be greatly appreciated. Each recipient of service must be informed in writing of the opportunity to contribute at least annually. In the congregate setting, the Contractor must provide a locked box and envelopes for the suggested meal donations for the participants in order to protect the confidentiality of program participants' identities and the amount which they contribute. The suggested donation amount will be determined through consultation with the Suffolk County Office for the Aging and the Site Council. 6. 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 $21,855/year 7. Electronic Reporting Paragraph 8 B, subparagraph iv. of Exhibit B is replaced in its entirety to read as follows: iv. Home-delivered meal participants must have eligibility determined 1) prior to the delivery of service using the NAPI$ required NY Comprehensive AFM form or subsequent approved assessment tool, or 2) in cases where there is a documented emergency, the assessment must be done within five (5) working days of service delivery. The Contractor shall contact Aging's Nutrition Unit of any occurrence whereby the assessment is not completed under 1) or 2) above. 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 12t' of each month for the previous month's data. The Contractor shall comply with the following added provisions in conformance with current County Standards. 8. Budget and/or Services Revisions i.) The parties shall use the Contract BudgetJServices Revision Approval Form (Budget /Services Revisions) for revisions to the Budget and Services involving any change to the total cost of the Contract via resolution of the Legislature or by the County's adopted annual budget. The Contractor shall submit to the County, proposed revisions for either Budget or any necessary changes of Services to be provided. ii.) When the County and the Contractor agree as to such revisions, the Contractor shall execute the BudgetJServices Revisions form. The Contractor shall return it to the County. AG 4 (7~06) Page 3 AG4M Sohld ext 10 rev 3-10 Law No. AG004MI0003-11 RC Rev. 513110 lilC Nutrition Program IFMS No. SC EXE 10000001792 No. 001-6790/6797/6774-4980, 6776-3330-95284-t792 Third Amendment iii.) Upon complete execution of the form by the parties, the County shall retum a copy to the Contractor. The revision shall not be effective until the Budget/Services Revisions is completely executed. 9, Comptroller's Rules and Regulations The Contractor shall comply with the "Comptroller's Rules and Regulations for Consultant Agreements" as promulgated by the County Department of Audit and Control and any amendments thereto during the Term. The County shall provide the Contractor with a copy of any amendments to the "Comptroller's Rules and Regulations for Consultant Agreements" during the Term. 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." tl. 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 fome and effect. -- End of Text of Exhibit -- AG 4 (7/06) Page 4 AG4M Sohld ext 10 rev 3-10 Law No. AG004M/0003-11 RC Rev. 5117/10 IIIC Nutrition Program IFMS No. SC EXE 10000001792 No. 001-67901679716774-4980, 6776-3330-95284-1792 Third Amendment Exhibit C-2010 Rate Page TOWN OF SOUTHOLD Schedule of Fees for Services Congregate Midday Meals Home-Delivered Meals Fourth Contract Year 2010 $5.36 $5.68 Meals in excess of the number stated on the cover page will be used as local match for the Title IIIC program Suffolk County Legislative Requirements Exhibit revised 11/09 Contractor's/Vendor's Public Disclosure Statement It shall be thc duty of the Contractor to read, become familiar with, and comply with thc requirements of sectiun A$-7 of Article V of the Suffolk County Code. Unless certified by an officer of the Contractor as being exempt from thc requirements of section 3,5-7 of A~iclc V of thc Suffolk County Code, the Contractor represants and warrants that it has filed with thc 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 thc Cpmptrollcr on or before thc 31 st day of January in each year of thc Contract's duration. The Contractor acknowledges that such filing is a material, contractual and statutory duty and that thc failure to file such statement shall constitute a material breach of thc Contract, for which thc County shall be cotifled, upon a determination that such breach has occurred, to damages, in addition to all othar legal remedies, of fifieen percent (I 5%) of the amount of the Contract. Required Form: Suffolk County Form SCEX 22; entitled "Contractor's/Vendor's Public Disclosure Stutcment' Living Wage It shall be the duty of thc Contractor to read, become familiar with, and comply with the requirements of Chapter 347, of the Suffolk County Code. This Contract is subject to thc Living Wage Law of thc County of Suffollc The law requires that, unless specific exemptions apply, all employers (as defined) under service contracts and recipients of County financial assistance, (as defined) shall pmvide payment of a minimum wage to employees as set forth in the Living Wage Law. Such rate shall be adjusted annually pursuant to thc terms of thc Suffolk County Living Wage Law of thc County of Suffolk. Under the provisions of thc Living Wage Law, thc County shall have the authority, under appropriate circumstances, to resinate thc Contract and to seek other remedies as set forth therein, for violations of this Law. Required Forms: Suffolk County Living Wage Form LW-I; 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 Activitias It shall be the duty of thc Contrector to read, become familiar with, and comply with thc 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 Contrsc~r shall not use County funds to assist, promote, or deter union organizing. No County funds shall be used to reimburse tho Contractor for any costs incurred to assist, promote, or deter union organizing. c. Thc Contractor shall not use County funds to assist, promote, or deter union organizing. do No employer shall usc 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 property, thc Contractor must adopt a reasonable access agreement, a neutrality agreement, fair communication agreement, non-intimidation agreement, and a majority authorization card agreement. If the Scrviees are for thc provision of human services and arc not to be performed on County property, the Contractor must adopt, at thc least, a neutrality agreement. Under thc provisions of Chapter 466, thc County shall have the authority, under appropriate cimumstancos, to tcrminatc thc Contract end to seek other remedies as set forth therein, for violations of this Law. Required Form: Suffolk County Labor Law Form DOL-LO 1; entitled "Suffolk County Department of Labor- Labor Mediation Unit Union Organizing Certification/Declaration - Subject to Audit." Lawful Hiring of Employees Law It shall be thc duty oftbe Contractor to read, become familiar with, and comply with thc requircments of Chapter 234 of thc Suffolk County Code. This Contract is subject to the Lawful Hiring of Employees Law of the County of Suffolk. It provides that all covered employers, (as defined), end the owners thereof, as the ease may be, that arc 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 en awarding agency, where such compensation is one hendred percent (100%) funded by the County, shall submit a completed sworn affidavit (under penalty of perjury), thc form of which is attached, certifying that they have complied, in good faith, with tho requirements ofTitie g of the United States Code Section 1324a with respect to the hiring of covered employees (as defined) end with respect to the alien and nationality status of the owners thereof. The affidavit shall be executed by en authorized representative of the covered employer or owner, as the case may be; shall be prat of any executed contract, subcontract, license agreement, lease or other financial compensation agreement with the County; end shall be made available to the public upon requast. All contractors and subcontractors (as defined) of eavered employers, end the owners thereof, as thc case may be, that ate assigned to perform work in connection with a County contract, subcontract, license agreement, lease or other financial compensation agreement issued by thc County or awarding agency, where such compensation is one hundred percent (100%) funded by thc County, shall submit to thc covered employer a completed sworn affidavit (under penalty of perjaty), thc form of which is attached, certifying that they havc complied, in good faith, with thc requirements of Title 8 of thc United States Code Section 1324a with respect to the hiring of covered employees end with respect to the alien end nationality status of the owners thereof, as thc ~ may be. The affidavit shall be executed by en authorized representative of the contractor, subcontractor, or owner, as thc casc may be; shall be part of any cxecuted contract, subcontract, license agreement, lcasc or other financial compensation agreement between tho covered employer and the County; end shall bc made available to thc public upon requcst. An updated affidavit shall be submitted by each such employer, owner, contractor and subcontractor no later than lanua~ I of each year for the duration of any contract end upon the renewal or amendment of the contrast, and whenever a new contractor or subcontractor is hired under the terms of the contract. Thc Contractor acknowlcdges that such filings are a material, contractual end statutory duty and that the failure to file any such statcment shall constitutc a material breach of thc Contract. Under tho provisions of tho 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 times be kept on site. Employee sign-in sheets end 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 With Federal Law (8 U.S.C. SECTION 1324a) With Respect To Lawful Hiring of Employees." "Affidavit Of Compliance With The Requirements Ofg U.S.C. Section 1324a With Respect To Lawful Hiring Of Employees" Form LHE-2. Grntuities It shall be the duty of thc Contractor to read, become familiar with, and comply with thc 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 secoring en agreement or securing favorable treatment with respect to the awarding or emending of es agreement or the making of any determinations with respect to the performance of an agreement. 10. 11. Prohibition Against Contracting with Corporations that Reincorporate Overseas tt shall be the duty of the Contractor to read, become familiar with, and comply with the requirements of sections A4-13 and A4- 14 of Article IV of the Suffolk County Code. Thc Contractor represents that it is in compliance with ~ctions A4-13 ~lnd 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 reinenrporated outside the U.S.A. Child Sexual Abuse Reporting Policy It shall be the duty oftbe Contractor to read, become familiar with, and comply with thc requirements of Article IV of Chapter 577 of the Suffolk County Code. The Contractor shall comply with Articlo IV of Chapter 577, bfthe Suffolk County Code, entitled "Child Sexual Abuse Reporting Policy," as now in effect or amended bereaf~er or of any other Suffolk County Local Law that may become applicable during the term oftbe 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 thc Contract, ~e 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 aRer a trial or a plea of guilty to an offense covered under the provision of section 143-5 of the Suffolk County Code under "Noraesponsible 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 thc Contract in couneetion with the prosecution of any civil action against the County in any jurisdiction or any judicial or administrative forum. Work Experience Participation If the Contractor is a nonprofit or govemmental agency or institution, each of the Contractor's locations in thc County at which the Services are provided shall be a work site for public-assistance clients of Suffolk County pursuant to Chapter 211 of the Suffolk County Code at all times during the Term of the Contract. If no Memorandum of Understanding CMOU") 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 bo 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 end Regulations can be found on the Suffolk County website at ht~p://www.co.suffolk.nv.us. SUFFOLK COUNTY DEPARTMENT OF LABOR- LIVING WA GE UNIT NOTICE OF APPLICABILITY OF LIVING WAGE LAW Living Wage Law, Suffolk County Code, Chapter 347 (2001) To Be Completed By The Living Wage Unit DATE: February 11, 2010 TO: Mary-Valerie Kempinski, S.C. Dept. of Human Services, Office of the Aging ,! / FROM4t4 L/Brenda Rosenberg, Director of Living Wage Compliance Unit TELEPHONE ti: 853-2063 VENDOR #: 11-6001939 REF.#: IIIC Nutrition Program You are hereby notified that the response from Town of Southold has been evaluated by the Living Wage Unit of the Suffolk County Department of Labor. We fred: X The documents submitted with this contract / proposal are complete and conform to the requirements of the Living Wage Law (Local Law #12-2001). The Awarding Agency may proceed with the normal and customary procedure for administering contracts. The documents submitted with this contract / proposal are not complete, or do not conform to the requirements of the Living Wage Law (Local Law # 12-2001 ). Employers who fail to submit documents or information required to demonstrate compliance with the Law shall be deemed non-responsive and subject to disqualification. If the employer is presently under contract, the contractor shall be deemed non-compliant and the appeals process shall be made available to said employer (Chapter 347-5 A & B). LW-13 ~ultnlk C.4m~, Nm Y~rk U ~ ~'~ ORGAN~a~IG t~___~tTun CA~Io~_ ~"I~BAT[ON - 8UBd=gCT TO AUD1T bd~. Comldetd forms rout be submlbd to the awanlbg, qeuc~. Coun~ Csaltne~. "Any mido,~' ~,-, tmslves mnre ~han 1.~0,000 In Coun~ fnnds fur ___~_ · soods ,t sm.i~s lmmmt ~,a Banlore ! ~ if Apl~able dMl be mmb Iv~dsblo to the peflinent Courtly asmcY m. m~hofity, the (~ bier, m the Coumy Courtly of ~ · l/we will m ~oerce ar JntJmbhte anpJoyeu, e~dJcMy oc implJci#y, h sde~ or not sde~ a ber~ · i/we will not requlw m anployee, bx~ or in a sroup, 1o attend a mm~ins or n event Iht~ is htended to influence hb or bet decbl~ h ~ ar not md~ a bephins ~ · IAvo ~ m~m' ob~dicm to 1M dimlqj4ioal Ciuled b~ prem:x)gflMoll hmbci, diaputu thlm]gh the ~ag~d in tim im~in~ion of goods ot lira mml~ing ofse~./m~ foe I!~ C. oun~, and The Union Or~-. i-i,~S Law does nm q:~ly ~o this c~.m For the ~lowin8 reuae(s): Applicable DOL~LOI New ¥o~ Contmct~'N~me: Town of Southold 53095 Main Road, P.O. Box 1179 D~w:riptioa ofpmjec~ or me, vice,: Southold, New York 11971 contact person: ~d~ritl]~{lp~t~]D~: 31-6001939 AmountofA~i~mnm: $ 242,112-00 V~l~'#: Karen McLaughlin, Director of Human Services - 631 298-4460 III~C Nutrition Programs for the Elderly (Home Delivered and Congregate; Scott A. R.'ussell, Southold Town Supervisor ~ N~nm mad Tit~ of Authorimd l{.epa~mtmtive DOL.-LOI(~.~{/O{) SUFFOLK COUNTY DEPARTMENT OF LABOR NOTICE OF APPLICATION TO CERTIFY COMPLIANCE WITH FEDERAL LAW (8 U.S.C. SECTION 1324A) WITH RESPECT TO LA WFUL HIRING OF EMPLOYEES VERIFICATION OF SUBMISSION OF LAWFUL HIRING OF EMPLOYEES Suffolk County Code, Chapter 234 (9006) To Be Completed By the Local Law Compliance Unit DATE: TO: FROM~Brenda Rosenberg, Director TELEPHONE# 631 853-3808 EMPLOYER: Town of Southold VENDOR #: 11-6001939 February lit 2010 Mary Valerie Kempinski~ S. C. Office of the A~ing REF. #: IIIC Nutrition Program You are hereby notified that the submission from Town of Southold has been received by the Lawful Hiring of Employees Unit of the Suffolk County Department of Labor. We fred that this submission is complete and is in compliance with the requirements set forth by the Suffolk County Lawful Hiring of Employees Law (Local Law #52-2006),. LHE-3 (0]/07) Certification Regarding LobbYing For Contracts, Grants, Loans and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No State or Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence legislation or appropriation actions pending before local, State and Federal executive and/or legislative bodies in connection with the awarding of any contract, the making of any grant, the making of any loan, the entering of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any contract, grant loan, or cooperative agreemenL (2) If any funds other than State or Federal appropriated funds have bc=n paid or will be paid to any person for influencing or attempting to influence iegisiet~m or appropriation actions bending before local, State and Federal executive and/or legislative bodies in connection with this contract, grant, loan or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Dtsciosure Form to Report Lobbying", in accordance with its instructions. · (3) The undersigned shall require that the language of'this certification be included in the award documents for all subawards at all tiers (including subcontmots, aubgrante, and contracts under gmnte, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This ce, iii;cation is a material representation of faot upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, T'~ie 31, U.S. Code. Failure to file the required certification shall be subject to civil penalty by the Federal government of not less than $10,000 and not more than $100,000 for each such failure. To Sign Application Date: /'- 2~-/O For: Town of Southold Name of Grantee COUNTY OF SUFFOLK OFFICE OF BUDGET AND MANAGEMENT CONTRACT BUDGET MODIFICATION REQUEST The program budget contained in the Agreement of COUNTYOF SUFFOLKand between the Program Name is hereby amended as follows: Contract No. LINE NUMBER $ CHANGE (HEADING) DESCRIPTION $ BEFORE $ AFTER OR - NET CHANGE ~ Except as set forth above, this budget modification shall not be deemed to change any condition or provision in the said Agreement. By: By: Name: Name: Holly Rhodes-Teague Title: Title: Director Date: Dept: AGING Agency: Date: FOR THE COUNTY OF SUFFOLK APPROVED BY: DATE: BUDGET DIRECTOR NOTE: This form is not to be used to affect any net increase in the budget. USE REVERSE FOR SUPPORTING STATEMENTS Revision No: Department: Contract Budget Approval Form Contractor: Agreement No. Agreement Period: Date last executed/amended: Budget Period to which this revision applies: Identify the items that are being changed by this revision: Budget: Period Adopting Amount of increase Amount of decrease New Budget amount for the period: Revising Copies of supporting documentation are attached as follows (check all that apply): Resolution Budget Other Approvals: Department: By: Name: Title: Date: Fiscal Unit: By: Name: Title: Date: Division: By: Name: Title: Date: Contractor: By: Name: Title: Date: Federal Tax ID #: County Executive Budget Office: Approved __ Disapproved By: Name: Title: Date: Contract Budget Approval Form 2010 COUNTY OF SUFFOLK OFFICE OF THE COUNTY COMPTROLLER JOSEPH SAWICKI, JR. Comptroller DEPARTMENT OF AUDIT AND CONTROL Comptroller's Rules and Regulations for Consultant's Agreements Revised 12/2009 TABLE OF CONTENTS Purpose ....................................................................................... 1 Scope .......................................................................................... 1 Definitions .................................................................................... 1 Allowable Claims ........................................................................... 1 Claim Submission ........................................................................... 2 Out of Pocket Expenses ................................................................... 3 Sub-Contractor Claims ..................................................................... 5 Certified Statements ........................................................................ 6 EXHIBITS EXHIBIT A EXHIBIT B EXHIBIT C County of Suffolk, standard Payment Voucher FORM PV ...................................................... 8 Consultant's Time Summary FORM A & C 108 ............................................. 9 Consultant's Expense Summary FORM A & C 109 ............................................ I0 1 1. Purpose- This manual establishes procedures for the reimbursement of expenditures for consultants under contract with the County. 2. Scope - These instructions apply to all County departments and agencies utilizing consultant services. 3. Definitions a. Consultant - An individual or firm engaged to provide outside professional services to Suffolk County departments and agencies. b. Consultant's Agreement - A written contract describing the specific services to be rendered by the consultant and the amount und terms of payment for the services to be made by the County. The consultant's agreement shall constitute the sole authorization for payment of claims. The consultant's agreement shall be prepared in accordance with the County Executive's Operating Procedures, SOP # 1-05. Non-specific general purpose or lump sam payment agreements are not recommended. 4. Allowable Claims - Only claims which are submitted for expenditures specifically identified in the agreement will be approved for payment. Generally, the agreement will stipulate a maximum fee for services rendered which is based upon a rate per day or per hour. Accordingly, a rate schedule is an integral part of each consultant's agreement. Increases will be allowed only by amendment to the agreement. Out-of-pocket expenditures are reimbursable if it is so stipulated in the consultant's agreement. 2 Claim Submission - Consultants should submit their claims for reimbursement through the County department or agency ~esponsible for the consultant's assignment, using appropriate forms, as indicated below: a. .Claim Voucher- A County of Suffolk Standard Payment Voucher Form (Exhibit A) must accompany each consultant claim. The claim voucher should refer to the consultant's agreement under which payment is requested and indicate the category of expenses or contract covenant applicable to the claim voucher. It should be initialed by the depermaental unit representative under whose supervision or jurisdiction the work was performed, signifying that the consultant has complied with all the terms and conditions of the agreement under which the payment is requested. The voucher must then be signed by the department head or his duly authorized representative and forwarded to the Department of Audit and Control for payment. b. Consultant's Time Surmnary, FORM A&C 108 (Exhibit B) - The Consultant's Time Summary should be used to record daily hours worked by each staff member of the consultant working on the project. Space is provided to record and extend the hours and wages of each staff member assigned to the project on one form. The completed FORM A&C 108 must be signed by and authorized individual of the consultant's firm. It should then be attached to the County of Suffolk Standard Payment co 3 voucher form. A copy of the consultant's payroll register with a cover letter indicating the individuals charged to the project for the claim period will be accepted as a substitute for the Consultant's Time Summary. Consultant's Expense Summary, FORM A&C 109 (Exhibit C) - The Consultant's Expense Summary should be used to detail expenses for travel, meals, lodging or other necessary and reasonable out-of-pocket expenditures incurred on the project. Each expense item should be documented by a receipted bill, sales slip or invoice which totals the daily expenditures shown on the form. The completed FORM A&C 109 must be signed by an authorized individual of the consultant's firm. It should then be attached to the County of Suffolk Standard Payment Voucher Form. 6. Out-of-Pocket Expenses - If these expenses are reimbursable under the consultant's agreement, the following rules and guidelines should be considered before incurring such expenses and submitting claims: a. Meals - Meals are reimbursable under a consultant's contract only if the purpose of the meal is valid, that is, authorized under the contract as sustenance while Iraveling. Effective October l, 2009, the per diem meal allowance shall be in accordance with the current maximum reimbursement rate for food as established by the U.S. General Services Administration for the New York region. As published in IRS Publication 1542 (rev. October 2009), the 2009 per diem meal and incidental rate is 4 $71.00 per diem including tax. Audit and Control should be contacted for allowable rotes for future riscal periods. (Gratuities, at a reasonable and customary rate, shall be reimbursed over and above the state limiks). The County will not honor claims for the reimbursement of "business meals" submitted by members of the consultant's firm who are not traveling out of town (overnight) in performance of the contract. Where a consultant meets the necessary criteria to be reimbursed for meals, no receipts will be necessary but a certified statement will be required. b. Lodeine - Effective October 1,' 2009, claims for lodging will be reimbursed at a rate not to exceed the current maximum reimbursement rate for lodging as established by the U.S. General Services Administration for the New York region as published in the IRS Publication'1542 (rev. October~ 2009). The 2009 per diem rate for lodging is $130.00 including taxes. Claims for lodging must be accompanied by paid receipts. Audit and Control should be contacted for the allowable rate for future fiscal periods. c. Airfare - Airfare will only be reimbursed at the economy coach rate and a receipt will be necessary. Individuals choosing to fly first class will not be reimbursed for the premium expenses incurred. d. Mileage - The County will reimburse mileage claims in accordance with the applicable current rate allowed by the U.S. Internal Revenue Service. As of Sanuary 1, 2009 the rate is $.55 per mile and January 1, 2010 the 5 rote is $.50 per mile. The consultant must provide origin, destination and miles traveled for each trip. Audit and Control should be contacted for the allowable rote for future fiscal periods. e. Taxis - Taxi fares up to $25.00 will be reimbursed based on actual receipt or certified statement. Any taxi expenses in excess of $25.00 per trip will require receipts. Receipts and certified statements shall include origin and destination, as well as the purpose of the trip. f. Subways and Buses (local) - A certified statement will be adequate documentation for these expenses. g. Tolls- Receipts or certified statement will be adequate documentation for these expenses. h. Telephone Expenses - Telephone expenses up to $25.00 per month will be reimbursed based on a receipt or certified statement. Telephone expenses totaling over $25.00 will require copies oftbe telephone company bills with the appropriate calls circled. i. Photocopies- In lieu of a specific contract for photocopies, the County will reimburse at a cost not to exceed $.15 per copy, including labor. A certified statement will be adequate documentation for reimbursement. 7. Sub-Contractor Claims - When the consultant is authorized in the Consultant's Ag~ement to hire a sub-contractor, the Comptroller's Office should be supplied a copy of the sub-conU'actor's agreement. Claims will not be processed if they are 6 not in compliance with the contract between the Consultant and the County. The reporting requirement of the sub-contractor will be the same as~that of the Consultant. Details of ail expenditures claimed must be documented in the same manner. If the sub-contractor's agreement with the Consultant is a lump-sum payment agreement, detailed documentation reporting requirements are waived. g. Certified Statements- When the consultant incurs re'mar travel or other out--of- pocket expenses for which receipts are not available, he shall prepare an itemized statement detailing the type and amount of expense, including the time, date, and place incurred. After summarizing expenses claimed, the consultant must add and sign the following certification terminology: "The above expenses are true and just and are a result of business condueted ia accordance with the terms of the contr~et with SUffolk County, and have not be been previously paid? Signature of Authorized Person EXHmlT A CONSULTANT'S NAME 2 10 ~I 12 ~3 ,4 tS 16 ~OTAL ~s,'f'B TOTAL ~'~meofMMember 7 18 19 ~0 tl 22 3 M ,~ 26 ~ ~8 29 l0 J! ~ ?BItHR ~ $ COU~ULTANT'8 ~ SUMMARY DgPARTM]D~ Olr AUDIT & CONTROL - FOBM A~C 1~9 CONTRACTOR NAME ADDRESS CONTACT STATEMENT OF OTHER CONTRACTS Town of Southold Senior Services 750 Pacific Street, P.O. Box 85, Mattituck, New York Karen McLaughlin, Director 11952 PHONE NUMBER (631) 298-4460 A~k~.E:MENT ' PROGRAM NUMBER 'CONTRACT WITH TERM OF AGP~=U=NT AMOUNT III-C-1 Congregate NO-001-6797-4980 Suffolk County Office for 01/01/09 - 12/31/09 Nutrition Program 95 284-1792 the Aging ~ $ 74,514.00 III-C-2 Home Delivered No-001-6776-3330 Suffolk County Office for 01/01/09 - 12/31/09 $ 162,822.00 Meal Program 95 284~1792 the Aging Transportation No-001-6806 Suffolk County Office for 04/01/09 - 03/31/10 $4,986.00 Assistance Program 4980-95285-1389 the A~in~ CSE Residential Repair No-001-6777-4980 Suffolk County Office for 04/01/09 - 03/31/10 $ 20,400.00 .Pro~ram 95285-0605 the Aalna *Indicate (a) type of organization. County, State, Federal or Other and (b) name of Depe~i..ant. Agency or Organization STATEMENT OF OTHER CONTRACT8 05 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 January 1, 2010, the Living Wage will increase to $10.83 per hour with health benefits and $12.33 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.n¥.us/labor and following the link to the Living Wage section. All inquiries will remain confidential. STATE OF NEW YORK) SS: COUNTY OF SUFFOLK) ELIZABETH A. NEVILLE, Town Clerk of the Town of Southold, New York being duly sworn, says that on the _7th day of__July ,2010, she affixed a notice of which the annexed printed notice is a true copy, in a proper and substantial manner, in a most public place in the Town of Southold, Suffolk County, New York, to wit: Town Clerk's Bulletin Board, 53095 Main Road, Southold, New York. Re: Notification of Rights Under the Living Wage Law - (~ Elizabeth A. Neville Southold Town Clerk Sworn before me~this~ ~ dayof ~.x3/,..~ ,2010. v N~tary Public LYNDA M.~deK- lqOTARY PUBLIC, State of New York No. 01~,Q6020932 Qualified in Suffolk County Term Expires March 8, 20 I/_ County of Suffolk RECEIVED ~outhold Town Cie(~ Steve Levy Suffolk County Executive Office for the Aging Holly S. Rhodes-Teague Director June 28, 2010 The Honorable Scott A. Russell Supervisor Town of Southold 53095 Main Road, PO Box 1179 Southold, New York 11971 RE: IIIC Nutrition Program IFMS No. SC EXE 10000001792 Dear Supervisor Russell: The fully executed Agreement referenced above is enclosed for your files 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. Sincerely, Joanne Kandell Pnnc~pal Accountant JK:MVK:sl Enc. cc: Karen McLaughlin G ISLE~AMVKformletterstLtr4Afu#yexec NOR TownCC doc H. LEEDENNISON BUILDING · 100 VETERANS MEMORIAL HIGHWAY (, PO. BOX 6100 · HAUPPAUGE, N. Y. 11788-0099 · (631) 853-8200 OVER 35 YEARS AS THE DESIGNATED AREA AGENCY ON AGING PROVIDING SERVICES FOR OLDER CITIZENS KAREN MeJ~AUGllI,1N Town Dirggtor of Human Sea'vices Town of Southold 750 Pae~ffic Strut P.O. Box 85 Matfittmlg NY 11952 Tel. (631 ) 298-4460 Fax (631) 298-4462 Nutrition Program Hom~ De. liv~d blgals Cas~/¢~-~,~t Essential Traasportation Senior Adult Day Ca~ Kat/n~ Hou~ Telephone Reassuram~ R~sideatial Repair July 19, 2010 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. Tesofiero: Enclosed please find the completed Contract Agency Disclosure Forms for the CSE Residential R~pair, m-c Nutrition and Transportation Assistance programs for the Town of Southold. Southold Town's most rec~nt financial statements are currently on file wi~ the Suffolk County Office of the Comptroller and Community Development. It is also available for your review on the Southold Town web page; southoldtown.norttffork.net/Aect-Fin.htm. In closing, if you have any questions or need further informati~a regarding the enclosed disclosure forms, please contact me at 292 4~.60 or call John Cushman, Town Complroller at 765-4333. We would be happy to assist you. Director of Human Services ce: John Cushman, Southold Town Comptroller Elizabeth Neville, Southold Town Clerk Control Number Activity Code Department Division Fund [001 CONTRACT AGENCY DISCLOSURE FORM (For 2011 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 I Reviewed By I ' Date Received I Financial Statement Type: I Notes 17129 IEXECUTIVE IOffice for the Aging Agency IEXE Org 16790 Object ~ If any of the information below has changed, you may cross out the printed information and fill in the correct information. Contract Amount: 2009 Actual: ] Contractor Name: [Town of Southold Program Name: IIIIC Nutrition Contractor Phone Number: 1(631) 298-4460 Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: $237,336 2010 Estimate: I $242,112;': Extension: I ]Karen McLaughlin 53095 Main Road, P.O. Box 1179 ISouthold 11971 Control Number Activity Code I' Contract Program Revenues Part I - Government Grants 1) Total amount of revenue received from Suffolk County for Contract Program. Page 2 of 4 2009 Actual 2010 Estimated 237,336 [237,322 2) Total revenue received directly from State Government for the Contract Program. Please identify names and amounts of grant(s): 0 0 3) Total revenue received directly from Federal Government for the [ 0 Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directiy from all other Municipalities for the [ 437,339 Contract Program. Please identify names and amounts of grant(s): TOWN OF SOUTHOLD 0 441,173 Part 2 - Medicare/Medicaid, Fundraising and Ail Other Revenues 5) Total revenue received ~om Medicare/Medicaid for the Contract I 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: 0 119,117 122,000 Control Number Activity Code I .... Contract Program Expenses Part 3 - Direct Contract Program Expenses 2009 Actual 9) Direct ConUaet ~ogram Salaries [ 5417699 ....... 10) Direct Contract Program Fringe Benefits ] 41,4 4 0 11) Direct Contract Program Fee for Service ] 0 12) Direct Other Conm~t Program Expenses ] 210,6 5 3 13) Total Direct Contract Program Expenses I 7 9 3 7 9 2 (Add Lines 9 lb. rough 12) ' Page 3 of 4 2010 Estimated 539t800 41,295 219,400 800,495 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) 2009 Actual 2010 Estimated 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Too 5 Agency Salaries Exceeding $100,000 Employee Name Employee Title 2009 Salary Amount of Salary Charged to the Contract Pronram 'i 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 Page 4 of 4 2009 Actual 2010 Estimated i 33,670,826 135,852,711 [33,398,901 136,561,711 23) Total Agency Net IncomeJ(L°ss) (n~2t minus u~a) [ ( 709,000 ) 24) Please indicate your fiscal year if it is not the calendar year: [ 25a) Is your agency affiliated with any other'corporatlons ? (Yes / No) [ N0 2~b) If yes, name corporation(s), and explain your agency's affiliation: ,' 271,925 2009 Actual 2010 Estimated 26) Total Agency Administrative Expenses I 5,078,328 ] 6,542,365 27) Does your Agency: ('Check all that apply, if none apply please check the box marked not applicable) [] Administer acorpsofvolunteers [] Administerthecollectionanddisin~°uti°n°ff°°dt° the needy [~ Administer federal, state or other poss through funding [] Not Applicable for my Agency [] Disseminate educational materials fix a public purpose 28) I rertify that enclosed herein, along with my disclosure form, is my Agency's most recent financial repor~ (audited or unaudited Financial Statements, IRS form 990 or Profit/Loss Statement); audited Fimmeinl Statements a~e required, if avaiinbl~ I underscored that ff the required fiuaueinl .repor~ is not enclosed my Agency will be deemedzbI~m~Compliant until I have submitted the required repor~ to the Comptroller's Office. ~ Form Prepared By Title Phone Number Karen McLaughlin IT?~fector of Human Services 631 298-4460 Agency Program Contact ' Phone Number [ Karen McLaughlin ' IDirector of Human Serv'~ces631 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, best of my knowledge and belief~ that all of the information provided on this form is true and Sign Nnme Title Date CONTRACT AGENCY DISCLOSURE FORM (For 2011 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 l17296 Activity Code I Suffolk County Office Use Only Entered By I ! Reviewed By I '~ Date Received Financial Statement Type: I Notes I Department [EXECUTWE Division IOffice for the Aging Fund 100l Agency IEXE Org 16806 :, 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: 2009 Actuai:] $4,986 2010 Estimate: [ $4,952 ! Contractor Name: Program Name: Contractor Phone Number: ITown of Southold ITransportation Assistance Program 1(631) 298-4460 Extension: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: [Karen McLaughlin 53095 Main Road, P.O. Box 1179 [Southold 11971 · Control Number Page 2 of 4 I Activity Code I' ' ' Contract Program Revenues Part I - Government Grants 2009 Actual 1) Total amount of revenue received from SuffoLk County for Contract [ ...... Program. 8,754 2010 Estimated 1 5,000' 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 Government for the Contract Program. Please identify names and amounts of grant(s): 4) Total revenue received directly from all other Municipalities for the I Contract Program. Please identify names and amounts of grant(s): 3,5 7 5 I 8,374 Town o1: :~outhold Part 2 - Medicare/Medicaid, Fundraising and All Other Reven~es 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. ] 2,861 Please identify types of revenues and amounts below: 5,000 I 15,190 8) Total Contract Program Revenue (Add Lin~ I - 7) 18,374 Control Number I" Activity Code [ Contract Program Expenses .part 3 - Direct Contract Program Expenses 2009 Actual 9) Direct Contract Pi'ogram Salaries 10,574 10) Direct Contract Program Fringe Benefits [ 8 09 11) Direct Contract Program Fee for Service [' 12) Direct Other Contract Program Expenses 3,807 13) Total Direct Contract Pwgram Expenses (Add Lines 9 through 12) 1 5, 190 Page 3 of 4 2010Estimated 11,866 908 5,600 18,374 Part 4 - Administrative, Contract Program Expenses 2009 Actual 14) Administrative Contract Program Salaries 15) Admini.~rative 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) I 20) P1ease provide a short description of your Direct Contract Program Expenses: 2010 Estimated Part 5 - Top 5 Agency Salaries Excccding $100~000 Emnlovee Name Emolovee Title 2009 Salary I I Amount of Salary Charged to the Contract Pronram Control Number Activity Code [ Agency Information Part 6 ~ Financial and Other Agency Infomation 21) Total Agency Support and Revenues 22) Total Agency Expenses Page 4 of 4 2009 Actnai 2010 Estimated 133,670,826 135,852,711 33,398,901 36,561,711 23) Total Agency Net IncomeJ(Loss) c~ 2~ minus Line 22) 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) ffyes, name corporation(s), and explain your agency's affiliation: I 2009 Actual 2010 Estimated 26) Total Agency Administrative Expenses [ 5,078,328 [ 6,542,365 27) Does your Agency: (Check all that apply, if none app~ please check the box marked not applicable) [] Administer a corps of volunteors [] Administer ~he collection and distribution of food to [~ Administer federal, state or other pass through funding the needy [] Dissominato educational materials for a public purpose [] Not Applicable for my Agency 28) I certify that enclosed herein, ~long with my disclosure form, is my Agency's most recent financial report (audited or unaudited Financial St~temente, IRS form 990 or Profit/Less Sintoment); audited l~inancial Statements ~ reqaired, if avaiiable. I undersinnd that ffthe Form Prepared By I Karen McLaughlin Agency Program Contact required financial report is not enclosed my Agency will be deemed~-Compliant until I have submitted the required report to the Comptroller's Office. Title Phone Number IT?~erector of Human Services 631 298-4460 Phone Nuraber Karen McLaughl±n [D±rector of Human Serv~ 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 tree and ~~~-~ Supervisor, Town of Southold Sign Naw~ Title CONTRACT AGENCY DISCLOSURE FORM (For 2011 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 118!02 Activity Code Suffolk County Office Use Only Entered By I ~ Reviewed By I i Date Received Financial Statement Type: I Notes Department I~IECUTIVE Division IOffice for the Aging Fund 100! ~. Agency IEXE: Org 16777 Object If any of the information below has changed, you may cross out the printed information and fill in the correct information. Contract Amount: 2009 Actual: I $20,400 2010 Estimate: ] $20,400 Contractor Name: Town of Southold Program Name: Contractor Phone Number: Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: ICSE - Residential Repair 1(631) 298-4460 IKaxen McLaughlin 53095 Main Road, P.O. Box 1179 ISouthold 11971 Extension: I Control Number Part 1 - Government Grants Activity Code ] Contract Program Revenues 1) Total amount of revenue received from Suffolk County for Contract Program. 2009 Actual 16,898 Page 2 of 4 2010 Estimated 20,400 2) Total revenue received directly from State Government for the Contract Program. Please identify names and amounts of grant(s): 0 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): Part 2 - Medicare/Medicaid, Fundraising and Ali Other Revenues 5) Total revenue received fix)m Medicare/Medicaid for the Contract I I Program. ~ 0 ! 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: 0 981 o 0 1,500 8) Total Contract Program Revenue (Add Lines I- 7) ~ [ 21,900 Control Number Activity Code Contract Program Expenses .Part 3 - Direct Contract Program Expenses 2009 Actual 9) Direct Contract Pi~gram Salaries 10r57~ I0) Direct Contract Program Fringe Benefits 80 9 11) Dire~ Contract Program Fee for Service 0 12) Direct Other Contract Program Expenses 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 17,879 Page 3 of 4 2010 Estimated 11,866 908 0 9.126 21,900 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) 2009 Actual 2010 Estimated 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 - Top $ Agency Salaries Exceeding $100~000 Emnlovee Name Emniovee Tire 2009 Salary 3'1 ] I I Amount of Salary Charged to the Contract Prom-nm Con~rol Number ~ 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 Incomed(L°ss) 0a,~ 21 minus Live 22) ] 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 A~ual 201o Estimated 33,670,826 I35,852,711 33,398,901 136,561,711 271,925 ] (709,000) NO 2009 Aclual 2010 Estimated 26) Total Agency Administrative Expenses I 5,078,328 ] 6,542,365 27) Does your Agency: (Check ail that apply, if none apPtY please check the box marked not applicable) [] Administer acorpsofvolunteers [] Admlnister theeollectionanddis~utionoffoodto the needy [~ Administer federal, state or other pass through trading [] Not Applicable for my Agency [] 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 a~e required, if available. I understand that if the requi..r~d, financial report is not enclosed my Agency will be deem~_.__~t~,-Compllant until I have submitted the required report to the Comptroller's Offiee. Form Prepared By Title Phone Number Karen McLaughlin Agency Program Contact Ir?~ect°r of Human Services 631 298-4460 PhoueNumber Karen McLaughlin IDirector of Human Serv'~ces631 298-4460 If you would prefer to be contacted via E-mail, please enter an E-mail address where we may contact you in th~ event that we have any questions regarding the completion of this form (Optional): certify, to the best of my knowledge and belief~ that all of the information provided on this form is true and corr~t. ~ Supervisor, Town of Southold '7//~z~//O Sign Name Title Date