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HomeMy WebLinkAboutCommunity Projects App.#TM00834 STATE OF NEW YORK D~'PARTM~"NT OF STATI~ ,4 I STATE: .-e'TREg-"T ALBANY. N~ I ~31-000 GEORGE: E, PATAKI September 10, 2002 RANDY A, DANIE~L~ Mr. Joshua Horton Supervisor Town of Southold 53095 Main Road Southold, NY 11971 Dear Mr. Horton: Re: Community Projects Appropriation Agreement #TM00834 Enclosed is a fully-executed copy of the subject Agreement for your records. Also enclosed are Vouchering Procedure Guidelines and a Payment Request Package consisting of Documentation Forms and a Standard Voucher to be used when requesting reimbursements. Please read the instructions carefully and submit payment requests in accordance with Appendix C of the approved Agreement. Please call our office at 518-486-3905 if you have questions regarding the payment forms. KB:es Enclosures Sincerely, Keith Barney Supervisor of Contract Administration 2o00-2o0I Lump Sum CONTRACT FACE PAGE STATE AGENCY (Name and Address): New York State Department of State 41 State Street Albany, New York 12231 BOX 1 CONTRACTOR (Name and Business Address~: Town of Southold 53095 Main Road Southo!d, New York 11971 BOX 2 CHARITIES REGISTRATION # EXEMPT: 5~ BOX 3 FEDERAL TAX ID: 11-6001939 BOX 4 STATUS: Sectarian entity? Yes __ No J(_ Not-for-profit organization? Yes -X- No __ APPENDICES ATTACHED TO AND PART OF THIS AGREEMENT APPENDIX A: Standard Clauses as Required by the Attorney General for all State contracts APPENDIX A1: Agency-specific Clauses APPENDIX B: Budget APPENDIX C: Payment and Reporting Schedule APPENDIX D: Program Workplan APPENDIX X: Modification Agreement Form (to accompany modified appendices for changes in term or consideration on an existing period or for renewal periods) SIGNATURE PAGE IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below their signatures. CONTRACT #TM00834 CONTRACTOR STATE AGENCY TOWN OF SOUTHOLD Title: Date: Joshua Y. Horton (Print N~ Superv,sor/.,~ '.7'~'/,,,,,~'""--'--------- August 20,/2002 STATE OF NEW YORK ) COUNTY OF ) ss.: New York State Department of State , / (Print Name) . Title: _ _,,,,.,u q State Agency Certification "In addition to ~e aecepr~ce of~s Con~act, [ ~so ce~ that ofigin~ copies of this sign~t~e page be a~ached to ~1 o~er exact copies of~s Con~act." On this day of ,20__., before me personally appeared · to me known, who being by me duly swum, did depose and say that (s)he resides at ;that. (s)he is the of , the corporation described herein which executed the foregoing instrument; and that (s)he signed (her)his name thereto by order of the board of directors of said corporation. NOTARY PUBLIC STATE OF NEW YORK ) COUNTY OF~'U FP0c(c- ) ss.: On th~.is Zo*-~ day of /~tl~(s ) ,20 0 2__ , before me personally cme ~]~ 7' ~K~ , to me ~own to be the ~'~oerof'~o~ of !oW~ ~ ~a+Aold , the ~inco~oraed association described in ~d w~ch executed ~e ab6ve a~eemem; ~d who ac~owledged to me ~at (s)he executed the foregoing a~eement for ~d ~ behalf of said uninco~orated association. NOISY PUBLIC, StYe ai New~ No. 01 DO46M870 ~81ifi~ in Sugolk Coun~ ~ LIC ~i~Sep~ber 80. , , ATTORNEY GENERAL'S SIGNATURE: STATE COMPTROLLER'S SIGNATURE: Title: Title: Date: Date: STATE OF NEW YORK AGREEMENT This AGREEMENT is hereby made by and between the State of New York agency (STATE) and the public or private agency (CONTRACTOR) identified on the face page hereof, WITNESSETH: WHEREAS, the STATE has the authority to regulate and provide Rmding for the establishment and operation of program services and desires to contract with skilled parties possessing the necessary resources to provide such services; and WHEREAS, the CONTRACTOR is ready, willing and able to provide such program services and possesses or can make available all necessary qualified personnel, licenses, facilities and expertise to perform or have performed the services required pursuant to the terms of this AGREEMENT; NOW, THEREFORE, in consideration of the promises, responsibilities and covenants herein, the STATE and the CONTRACTOR agree as follows: I. Conditions of Agreement This AGREEMENT may consist of successive periods (PERIOD), as specified within the AGREEMENT or within a subsequent Modification Agreemem(s) (Appendix X). Each additional or superseding PERIOD shall be on the forms specified by the particular State agency, and shall be incorporated into this AGREEMENT. Funding for the first PERIOD shall not exceed the funding amount specified on the face page hereof. Funding for.each subseqUent PERIOD, if any, shall not exceed the amount specified in the appropriate appendix for that PERIOD. C. This AGREEMENT incorporates the face pages attached and all of the marked appendices identified on the face page hereof. For each succeeding PERIOD of this AGREEMENT, the parties shall prepare new appendices, to the extent that any require modification, and a Modification Agreement (the attached Appendix X is the blank form to be used). Any terms of this AGREEMENT not modified shall remain in effect for each PERIOD of the AGREEMENT. 2 To modify the AGREEMENT within an existing PERIOD, the parties shall revise or complete the appropriate appendix form(s). Any change in the amount of consideration to be paid, or change in the term, is subject to the approval of the Office of the State comptroller. Any other modifications shall be processed in accordance with agency guidelines as stated in Appendix Al. The CONTRACTOR shall perfOrm all services to the satisfaction of the STATE. The CONTRACTOR shall provide services and meet the program objectives summarized in the Program Workplan (Appendix D) in accordance with: provisions of the AGREEMENT; relevant Iaws, rules and regulations, administrative and fiscal guidelines; and where applicable, operating certificates for facilities or licenses for an activity or program. Fo If the CONTRACTOR enters into subcontracts for the performance of work pursuant to this AGREEMENT, the CONTRACTOR shall take full responsibility for the acts and omissions of its subcontractors. Nothing in the subcontract shall impair the rights of the STATE under this AGREEMENT. No contractual relationship shall be deemed to exist between the subcontractor and the STATE. G. Appendix A (Standard Clauses as required by the Attorney General for all State contracts) takes precedence over all other parts of the AGREEMENT. II. Payment and Reporting The CONTRACTOR, to be eligible for payment, shall submit to the STATE's designated payment office (identified in Appendix C) any appropriate documentation as required by the Payment and. Reporting Schedule (Appendix C) and by agency fiscal guidelines, in a manner acceptable to the STATE. Bo The STATE shall make payments and any reconciliations in accordance with the Payment and Reporting Schedule (Appendix C). The STATE shall pay the CONTRACTOR, in consideration of contract services for a given PERIOD, a sum not to exceed the amount noted on the face page hereof or in the respective Appendix designating the payment amount for that given PERIOD. This sum shall not duplicate reimbursement from other sources for CONTRACTOR costs and services provided pursuant to this AGREEMENT. C. The CONTRACTOR shall meet the audit requirements specified by the STATE. 3 IH. Terminations A. This AGREEMENT may be terminated at any time upon mutual written consent of the STATE and the CONTRACTOR. The STATE may terminate the AGREEMENT immediately, upon Written notice of termination to the CONTRACTOR, if the CONTRACTOR fails to comply with the terms and conditions of this AGREEMENT and/or with any taws, rules, regulations, policies or procedures affecting this AGREEMENT. C. The 'STATE may also terminate this AGREEMENT for any reason in accordance with provisions set forth in Appendix Al. Written notice of termination, where required, shall be sent by personal messenger service or by certified mail, return receipt requested. The termination shall be effective in accordance with the terms of the notice. Upon receipt of notice of termination, the CONTRACTOR agrees to cancel, prior to the effective date ofanyprospective termination, as many outstanding obligations as possible, .and agrees not to incur any new obligations after receipt of the notice without approval by the STATE. The STATE shall be responsible for payment on clakns pursuant to services provided and costs incurred pursuant to terms of the AGREEMENT. In no event shall the STATE be liable for expenses and obligations arising from the program(s) in this AGREEMENT after the termination date. IV. Indemnification The CONTRACTOR shall be solely responsible and answerable in damages for any and all accidents and/or injuries to persons (including death) or property, arising out of or related to the services to be rendered by the CONTRACTOR or its subcontractors pursuant to this AGREEMENT. The CONTRACTOR shall indemnify and hold harmless the STATE and its officers and employees from claims, suits, actions, damages and costs of every nature arising out. of the provision of services pursuant to this AGREEMENT. The CONTRACTOR is an independent contractor and may neither hold itself out nor claim to be an officer, employee or subdivision of the STATE nor make any claim, demand or application to or for any right based upon any different status. 4 V. Property - Any equipment, furniture, supplies or other property purchased pursuant to this AGREEMENT is deemed to be the property of the STATE except as may otherwise be governed by Federal or State laws, rules or regulations, or as stated in Appendix Al. VI. Safegrmrds for Services and Confidentiali _ty Services performed pursuant to this AGREEMENT are secular in nature and shall be performed in a manner that does not discriminate on the basis of religious belief, or promote or discourage adherence to religion in general or particular religious beliefs. Funds provided pursuant to this AGREEMENT shall no~ be used for any partisan political activity, or for activities that may influence legislation or the election or defeat of any candidate for public office. Information relating to individuals who may receive services pursuant to this AGREEMENT shall be maintained and used only for the purposes intended under the Contract and in conformity with applicable provisions of laws and regulations, or specified in Appendix Al. APPENDIX A Standard Clauses for All New York State Contracts A-1 The parties to the attached contract, license, lease, amendment or other agreement of any kind (hereinafter, "the contract" or "this contract") agree to be bound by the following clauses which are hereby made a part of the contract (the word "Contractor" herein refers to any parry other than the State, whether a contractor, linenser, licensee, lessor, lessee or any other party): 1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the State shall have no liability under this contract to the Contractor or to anyone else beyond kinds appropriated and available for this contract. 2. NQN-ASSIGNMENT CLAUSE. In accordance with Section 138of the State Finance Law, this contract may not be assigned by the Contractor or its right, title or interest therein assigned, transferred conveyed, sublet or otherwise disposed of without the previous consenL in writing, of the State and any attempts m assign the contract without the State's written consent are null and void The Contractor may, however, assign its right to receive payment without the State[s prior written consent unless this contract concerns Certificates of Partinipation pursuant to Article 5-A of the State Finance law, 3. COMPTROLLER'S APPROVAL In accordance with Section 1 ~2 of the State Finance Law (or, if this contract is with the State University or City University of New York, Section 355 or Section 6218 of the Education Law), if this contract exceeds $15,000 [or the minimum thresholds agreed to by the Office of the State Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an amendment for ant, amount m a contract which, as so amended, exceeds said statutory amount, or if, by this contract, the State agrees to give something other than money when the value or reasonably estimated '~aiue of such consideration exceeds $10,000,At shall not be valid, effective or binding upon the State untilit has been approved by the State Comptroller and filed in his office. 4. WORKERS' COMPENSATION BENEFITS. In accordance with Seetion 142 of the State Finance Law, this contract shall be void and of no force and effect unless the Contractor shall provide and maintain coverage during the life of this cuntmct for the benefit of such employees as are required to be covered by the provisions of the Workers' Compensation Law, 5. NON-DISCRIMINATION REQUIREMENTS. In accor- dance with Article I5 of the Executive Law (also known as the Human Rights Law) and all other State and Federal statutory and constitutional non-discrimination provisions, the Contractor will not discriminate against any employee or applicant for em- ployment because of race, creed, color, sex, national origin, age, disability or marital stares. Furthermpre, in accordance with Section 220-e 'of the Labor Law, if this is a contract for the construction, alteration or repair of any public building or public work or for the manufacture, sale or distribution of materials, 11/00 equipment or supplies, and to the extent that this comract shall be performed within the State Of New Yorlq Contractor agrees that neither it nor its subcontractors shall, by reason of race, creed., color, disability, sex, or national origin: (a) discriminate in hiring against any New York State citizen who is qualified and available m perform the work; or (b) discriminate against or intimidate any employee hired for the performance of work under this contract. If this is a building sermce contract as defined in Section 230 of the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees that neither it nor its subcontractors shall by reason of race, creed, color, national origin, age~ sex, or disability: (a) discriminate in hiring against any New York State citizen who ~s qualified and available to perform the work; or Cb) discriminate against or intimidate any employee hired for the performance of work under this contract. Contractor is subject to fmcs 0f$50.00 per person per day for any violation of Section 220-e or Section 239 as well as possible termination of this contractand forfeiture of all moneys duehereunder for a second or subsequent viulation. 6. WAGE AND HOURS PROVISIONS. If this isapublic work contract covered by Article 8 of the Labor Law or a building service contract covered by Article 9 thereof, neither Contractor's employees nor the employees of its subcontractors maybe required or permitted to work more than the number of hours or days stated in said statutes, except as otherwise provided in the Labor law and as set forth in prevailing wage and supplement schedules issuedby the State Labor Department. Fttrthermore, Contractor and its subcontractors must pay; at least the prevailing wage rate andpay or provide the pr evailingpupplem4i~ts, in~luding the premium rates for overtime pay, as determined by the State LaborDepartment in accordance with the Labor Law. 7. NON-COLLUSIVE BIDDING REQUIREMENT. In accor- dance with Sectio~i 139-d of the State Finance Law, if this contract was awarded based upon the submission of bids, Contractor warrants, under penairy of perjury, that its bid was arrived at independently and without collusion aimed at restricfmg com- petition. Contractor ~rther warrants that, at the time Contractor subraitted its bid, an authorized and responsible persoh executed and delivered to the State a non-collusive bidding certification on Contractor's behalf. 8. INTERNATIONAL BOYCOTT PROIIlBITION. In accor- dance with Section 220-fof the Labor Law and Section 139~h of the State Finance Law, if this contract exceeds $5,000, the Contractor agrees, as a material condition of the contract, that neither the Contractor nor any substantially owned or affiliated person, fttm, partnership or corporation has participated, is participating, or shall participate in an international boycott in violation of the federal Export Admiiaistration Act of 1979 (50 USC App. Sections 2401 er seq.) or regulations thereunder. If such Contractor, or any of the aforesaid affiliates of Contractor, is convicted or is otherwise found to have violated said laws or regulations upon the final determination of the United States Commerce Department or any other appropriate agency of the United States subsequent to the commctors execution, such contract, amendment or modification thereto shall be rendered forfeit and 'void. The Contractor shall so notify the State Comptroller within five (5) business days of such conviction, determination or cUtspnsition of appeal (2NYCRR 105.4). 9. ~;ET-OFF RIGHTS. The State shall have all of its common law, equitable and statutory rights of set-off. These rights shalI include, but not be limited to, the. State's option to withhold for the purposes of set-off any moneys due to the Contractor under this contract up m any amounts due and owing to the State with regard to this contract, any other contract with any State department or agency, including any contraetfor a term commencing prior to the term nf this conU-act,.plus any amounts due and owing to the State for any other reason including, without limitation, tax delinquencieS3 fee delinquencies or monetary penalties relative thereto. :]?he State shall exercise its set-off rights in accordance with norr~alState~ practices including, in eases of set-offpursuant to an andig the finalization of such audit by the State agency, its representatives, or the State Comptroller. 10. RECORDS. The Contractor shall establish and maintain completeian~ accurate books, records, documents, accounts and other evidenae directly pertinent to performance under this contract (hereinafter, collectively, "the Records"). The Records must be kept for t~:~alance, ofthe calendar year in which they were made and for iix (6) additional years thereafter. The State Comptrollgr, the Auora~ey~ General and any other person or entity authorized to conduct/an examination, as well as the agency or agencies involved, in&his contract, shall have access to the Records during unfmal Business hours at an office of the Contractor within the State nfNew York er, if no such office is available, at a mutually agueeal~I~ ahd reasonable venue within the State, for the term spbcified above for the purposes of inspection, auditing and copying, ~The State shall take reasonable steps m protect from public disolosnre any of the Records which are exempt from disclosure ~ander Section 87 of the Public Officers Law (the "~atute!') ~ovided that: (i) the Contractor shall timely inform an al~propi'iat~ State official, in writing, that said records should not be disolo.Se~d; and (ii) said records shall be sufficiently identified; and (iih. d6~ignati0n of said records as exempt under the Statute is re~sr}rr~Ue~Nothing contained herein shall diminish, or in anyway adversely tffect, the State's right to discovery in any pending or futore l~t~g~ifion. 11. IDENTIFYING INFORMATION AND PRIVACY NOTIlWiI~TION. (a) FEDERAL EMPLOYER IDEN- TiFICAtION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. All invoieas or New York State standard vouchers submitted ~'or payment for the sale of goods or services or the lease of real or personal property to a New York State agency must ificlud~e~.~e payee's identification number, i.e., the seller's or lessogs identification number. The number is either the payee's F~edeml,einployer identification number or Federal social security number, 'c~r both such numbers when the payee has both such unmbers, Failure to include this number or numbers may delay payment~ Where the payee does not have such number or numbers, flue payee, on its invoice or New-York State standard voucher, A-2 must give the reason or reasons why the payee does not have such number or numbers. (b) PRIVACY NOTIFICATION. (1) The authority ro request the above personal information from a seller of goods or services or a lessor of real or personal property, and the authority m maintain such information, is found in Section 5 of the State Tax Law. Disclosure of this information by the seller or lessor to the State is mandatory. The principal purpose for which the information is collected is to enable the State to identify individuals, businesses and others who have been delinquent in filing tax returns or may have understated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. The information will be used for tax administration purpose and for any other purpose authorized by · law. (2) The personal information is requested by the purchasing unit of the agency contracting topurchase the goods or servmes or lease the malor personalpmperty covemdbyrhis contract or lease. The information is mu'retained in New York State's Central Accounting System bY the Dlseetor of Accounting Operations, Office of the State Comptroller, AESOB, Albany, New York 12236. 12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with Section 312 of the ]Executive taw, if this contract is: (i) a written agreement or purchase order instrument, providing ['or a total expenditure in excess of $25,000.00, whereby a contracting agency is enmmitted to expend or. does expend funds in return for labor, servmes, supplies, equipment, materials or any combination of the foregoing, to be performed for, or rendered or furnished to the contracting agency; or (ii) a written agreement in excess of $100.000.00 whereby acontmcting agency ]s committed to expend or does expend funds for the acquisition, construction, demolition, replacement, major repair or renovation of real property and improvements thereon; or (iii) a written agreement in excess of $100,000.00 whereby the owner of a State assisted housing pro jets is committed to expend or does expend funds for the acquisition, construction, demolition, replacement, major repair or renovation of real property and improvements thereon for such project, then: (a) The Contractor Mil not discriminate against employees or applicants for employment because nfmce, creed, color, nation~l origin, sex, age, disability or marital status, and will undertake or cont'mue existing programs of affnTnative action to ensure that minority group ~embers and women are afforded equal employment opportunities without discrimination. Affmmative action shall mean recruitment, employment, job assignment., promotion, upgradings, demotion, transfer, layoff, or termination and rates of pay or other forms of compensation; (b) at the request of the contracting agency, the Contractor shall request each employment agency, labor union, or authorized representative of workers with which it has a Collective bargaining or other agreement or understanding, to fiarnlsh a written statement that such employmem agency, labor union or representative will not discriminate on the basis of men, creed, color, national origin, sex, age, disakility or marital status and that such union or representative will affirmatively cooperate in the implementation of the e6ntractofs obligations here'm/; and(c) the Contractor shall stare, in all sdiialtations or adYertisements for employees, that, in the performance of the State contract, all qualified applicants will 11100 be afforded equal employment opportunities without dis- criminatiun because of race, creed, color, national origin, sex, age, disability or marital stems. Contractor will include the provisions of "a, "b", and"e" above, in every subcontract over $25,000.00 for the construction, demalition, replacement, major repair, renovation, planning or design of real property and improvements thereon (the Worl~) except where the Work is for the benef~al use of the Contractor. Section 312 does not apply to: (9 work, goods or sevaces unrelated to this contract; or (ii) employment outaide New York. State; or (iii) banking services, insurance policies or the sale of securities. The state shall, consider compliance by a ctntmctor or Subcontrantor with the requirements of any federal lawconcerning equal employment opportunity which effectuates the purpose of this section. "glue contracting agency shall determine whether the imposition of ~e requirement~ of the provisions hereof duplicate or conflictlwith any such federal law and if such duplication or conflict eX/tsls, the contracting agency shall w';a!ve the applicability of Section 312 to the extent of such duphcation or conflict. Contractor will comply witkall duly promulgated and hwful rotes and m~ons of the Di~sion cf Minority and Women's Business Develo~ent pertaining hereto. 13. CONFLICTING TERMS. Intheeventofaconflictbetween the term~ ~fthe ¢0ntract (including any and all attachments thereto and amendments thereof) and the terms of this Appendix A, the terms or'this Appendix A shall control. 14. GOVERNING LAW. This contract shall be governed by the laws of the~ State of New York except where the FedemI supremacy clause requires otherwise. 15. LAT~ PAYM[ENT. Timeliness of payment and any interest to be paid to Contractor for late payment shall be governed by Article XI-A of the State Finance Law to the extem required by law. 16. NO ARBITRATION. Disputes involving this contract, including the breach 'or alleged breach thereof, may not be submitttd to binding arbitration (except where statutorily authorized), but must, instead., be heard in a court of compctem jurisdiction of the State of New York. 17. SERVICE OF PROCES~S. In addition to the methods of service allowed by the State Civil Practice Law & Rules ("CPLR"), Contractor hereby consents re service of process upon it by registered or certified mail, remm receipt requested. Service hereunder shall be complete upon Contractor's actual receipt of process: or upon the State's receipt of the retnm thereof by the United States Postal Service as refused or undeliverable. Contractor must promptly notify the State, in writing, of each and every change of address to which service of process can be made. Service;by the State to the last known address shall be sufficient. Contractor will have thirty (30) calendar days after service hereunder is complete in which to respond. 18. PROHIBITION ON PURCHASE OF TROPICAL It~WOODS The Contractor certifies and warrants that all A-3 wood products to be used under this contract award will be in accordance with, but not limited to, the specifications and provisions of State Finance Law §165. (Use of Tropical Hardwoods) which prohibits purchase and use of tropical hardwoods, unless specifically exempted, by the State or any governmental agency or political subdivision or public benefit corporation. Qualifieation for an exemption under this law will be the responsibility of the contractor to establish to meet with the approval of the State. In addition, when any portion of this contracl involving the use of woods, whether supply or installation, is to be performed hy any subcontractor~ the prime Contractor will indicate and ceffffyin thesubmittedbid proposal that the subcontractor has been informed and is in compliance with specifications and provtsiuns regarding use of tropical hardwoods as detailed in § 165 State Finance Law. Any such use must meet with the approval of the State, otherwise, the bid may not be considered responsive. Under bidder certifications, proof of quaFtfication for exemption will be the responsibility of the Contractor to meet with the approval of the State. i9. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In accordance with the MacBride Fair Employment Principles (Chapter 807 of the Laws of 1992), the Contractor hereby stipulates that the Contractor either (a) has no business operations in Northern Ireland, or (b) shall take lawful steps in good faith to conduct anybusiness operations inNorthem Ireland in accordance with the MacBride Fair Employment Principles (as described in Section 165 of the New York State Finance Law), and shall permit independent monitoring of compliance with such pfintiples. 20. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New ?fork State to maximize opportunities for the participation of New York State business enterprises, including minority and women-owned business enterprises as bidders, subcontractors and suppliers on its procmemenr contracts. Information on the availability of New York State subcontractors and suppliers is available from: Department of Economic Developmenr Division for Small Business 30 South Pearl Street Albany, New York 12245 518-292-5220 A directory of certiiied minority and women-owned business enterprises is available from: Department of Economic Development Minority and Women's Business Development Division 30 South Pearl Street Albany, New York 12245 htrp://www.empire.stata.ny.us The Onm~us Procurement Act of 1992 requires that by nighing this bidproposal or contract, as applicable, Contractors certify that whenever the total bid amount is greater than $1 million: (a) The Contractor has made reasonable efforts to encourage the participation of New York State Business Enterprises as suppliers 11/00 and subcontractors, including certified minority and women-owned business enterprises, on this project, and has retained the docu- mentation ofthase efforts to be provided upon request to the State; (b) The C(~ntractor has complied with the Federal Equal Opportunity Act of 1972 (P.L. 92-261), as amended; (e) The Contractor agrees to make reasonable efforts re provide notification to New York Stare residents of employment opportanities on this project through listing any such positions with the Job Service Division of the New York State Department of Labor, or providkug such hetification in such manner as is consistent with existing collective bargaining contracts or agreements. The Coraractor agrees to document these efforts and to provide said:documentation to the State upon request; and (d) The ~Contractor acknowledges notice that the State may seek to obtair; offset credits from foreign countries as a result of this contract and agrees to anoperate with the State ~u these efforts, 21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if their principal place of business is located in a country, nation, province, state or political subdivision that penalizes New York State vendors, and if the goods or services they offer will be substantially produced or performed outside New York State, the Omnibus Procurement Act 1994~ amendments and 2000 amendments (Chapter 684 and Chapter 383, respectively) require that they be dcafied contracts whioh they would otherwise obtain. Contact the Department of Economic De?elopmem, Division for Small Business, 30 South Pearl Street; Albany New York 12245, for a current list of jurisdictions snbject to this prey/sion. A-4 Revised November 2000 11/00 APPENDIX A1 Agency-Specific Clauses Ai-I General A. For the purposes of this Agreement, the terms "State" and "Department" are inter-changeable, unless the context requires otherwise. The Contract Period as set forth on the Face Page is the inclusive period withiri which the provisions of this Agreement shall be performed. Costs incurred for project activities conducted prior to or after the Contract Period will not be reimbursed under this Agreement. The Contractor and Project (as described in the Legislative Initiative Form provided to the Contractor by the Department and incorporated herein by references and as detailed in the Program Workplan, Appendix D) have been identified to the Department for receipt of a local grant award not to exceed the Funding Amount as set forth on the Contract Face Page. The Department shall not be liable for expenses of any kind incurred in excess of the Funding Amount, and shall not be responsible for seeking additional appropriations or other sources of funds for the Project. The Contractor shall perform all services to the satisfaction of the Department. The Contractor shall provide all services and meet the program objectives set forth in Appendix D in accordance with: provisions of this Agreement; relevant laws, rules and regulations, administrative and fiscal guidelines; and where applicable, operating certificates for facilities or licenses for an activity or program. Pursuant to the provisions set forth in Section V., page 3 of this Agreement, the ownership of all property described thermn shall reside with the Contractor unless otherwise specified in writing by the Department at anytime during the term of this Agreement and up to thirty (30) days following the issuance of the final payment. II. Funding Funding for this project has been appropriated in the Community Projects Fund as established by Section 99-d of the State Finance Law (Chapter 474 of the Laws of 1996). Pursuant to Paragraph 6(a) of Section 99-d, "The state Al-2 shall not be liable for paymems pursuant to any contract, grant or agreement made pursuant to an appropriation in any account of this fund if insufficient monies are available for transfer to such account of this fund, after required transfers, pursuant to subdivision three of this section." Bo Absent reappropriation in the subsequent State budget, funds for this project will cease to be available for payments on September 15, 2003; therefore, to afford reasonable assurance that payment can be made by the Department, final payment requests must be received by the Department's payment office by not later than August 20, 2003. I[I..Terminations In addition to any other actions authorized by this Agreement, the Department may terminate the Agreement in the best interests of the State of New York by providing written notice to the Contractor as provided in this Agreement. The Contractor shall complete the project as set forth in this Agreement, and failure to render satisfactory progress or to complete the project to the satisfaction of the State may be deemed an abandonment of the project and may cause the suspension or termination of any obligation of the State. In the event the Contractor should be deemed to have abandoned the project fo any reason or cause other than a national emergency or an Act of God, all monies paid to the Contractor by the State and not expended in accordance with this Agreement shall be repaid to the State upon demand. If such monies are not repaid within one year after such demand, the State Comptroller of the State of New York may cause to be withheld from any State assistance to which the Contractor would otherwise be entitled an amount equal to the montes demanded. In the .event that the Department has provided written notice to the Contractor directing that the Contractor correct any failure to comply with this Agreement, the Department reserves the right to direct that the Contractor suspend all work during a period of time to be determined by the Department. If the Contractor does not correct such failures during the period provided for in the notice, this Agreement shall be deemed to be term'mated after expiration of such time period. During any such suspension, the Contractor agrees not to incur any new obligations after receipt of the notice without approval by the Department. IV. Fully-Executed Agreement or Amendment Thereto Bo Al-3 If this Agreement, or amendments thereto, allocates funds totaling $15,000 or less, it shall be deemed to be fully executed when approved and signed by the Contractor and the Department. If this Agreement, or amendments thereto, allocates funds totaling more than $15,000, it shall be deemed to be fully executed when approved by the Office of the State Comptroller. Attachment 1 to Appendix A1 Article 15-A of the New York State Executive Law The Department of State administers a Minority and Women-owned Business Enterprises (MWBE) Program as mandated by Article 15-A of the New York State Executive Law. This law supersedes any other provision in state law authorizing or requiring an equal employment opportunity program or a program for securing participationby minority and women-owned business enterprises. Under this law, all state agencies must, subject to certain exceptions, establish goals for minority and women-owned business participation in certain state contracts and grants. Where MWBE goals are required, even in circumstances where this goal is zero, a Quarterly Gramme Report is required to be submitted to the Affn'mative Action Office of the Department on forms provided by the Department. Article t5-A requires that rules and regulations be established for contracts entered into by the Department. In accordance with Article 15-A, goals must be set for contracts entered into by the Department in excess of $25,000 for labor, services, supplies, equipment, and materials, or any combination of the foregoing, and for contracts entered into by the Deparunent in excess of $100,000 for acquisition, construction, demolition, replacement, major repair, renovation or improvement of real property. In applying these rules and regulations, the Department must consider the availability of certified minority and women-owned businesses in the region in which the state contract will be performed, the total dollar value of the Contract, the scope of work to be performed, and the project size and term. The contractor will, when required as a part of the bid or proposal, submit a StaffingPtan on the form provided by the Department. This Plan will detail the work force anticipated in the performance of the state contract broken down by ethnic background, gender, and Federal Occupational Categories. After a bid opening and prior to the award ora state contract, the contractor will submit an Equal Employment Opportunity (EEO) Policy Statement to the Department within the time frame established by the Department. The law requires that, as a precondition to entering into a valid and binding state contract, the contractor shall agree to the following stipulations and will include them in the EEO Policy Statement: ® The contractor will not discriminate against any employee or applicant for employment because of race, creed, color, national origin, sex, age, disability or marital status. · The contractor willundertake or cont'mue existing programs of affirmative action to ensure that minority group members and women are afforded equal employment opportunities without discrimination because of race, creed, color, national origin, sex, age, disability or marital stares. For these pmposes~ affirmative action applies in areas of recruitment, employment,job assigmuent, promotion, upgrading, demotion, transfer, layoff, or termination and rates of pay or other forms of compensation. · The contractor will make active and conscientious efforts to employ and to utilize minority group members and women at all levels and in all segments of its work force on state contracts, and the contractor will document these efforts. · The contractor will state in all solicitations and advertisements for employees that, in the performance of the state contract, all qualified applicants will be afforded equal employment opportunities without discrimination because of race, creed, color, national origin, sex, age, disability or marital status. · The contractor will, at the request of the Department, request each employment agency, labor union, or authorized representative of workers at which it has a collective bargaining or other agreement or understanding, to furnish a written statement that such employment agency, labor union, or representative will not discriminate because of race, creed, color, national origin, sex, age, disability or marital status, and that such union or representative will affirmatively cooperate in the implementation of the contractor's obligations herein. · The comractor will include the provisions regarding the EEO Policy Statement and the Staffing Plan enumerated above in each and every subcontract of a state contract in such a manner that the subcontractor is bound by these requirements. · Failure to provide an EEO Policy Statement and a Staffing Plan without reasonable written justification or commitment to provide these requirements by a specified date will result in rejection of the contractor's bid or proposal. · After the award of a state contract, the contractor will submit to the Department a Work Force Employment. Utilization Report, on the form supplied by the Department, detailing the work force actually utilized on the state contract, by ethnic background, gender and Federal Occupational Categories, as specified on the form. This Report will be submitted to the Department on a quarterly basis throughout the life of the contract. · The contractor, and any of its subcontractors, may be required to submit compliance reports relating to their operations and implementation of their affirmative action or equal employment opportunity program in effect as of the date the state contract is executed. Questions regarding this program should be directed to the New York State Department of State's Affirmative Action Office, 41 State Street, Albany, New York 12231, 518-474-2752. To assist potential contractors, a copy of the iVYS Directory of Certified Minority and Women-owned Business Enterprises is made available for inspection at the Department's Affm'native Action Office. The Department makes no representation with respect to the availability or capability of any business listed in the Directory. APPENDIX B Budget Budget Summary Sheet B-I A. SALARIES, WAGES AND FRINGE $ B. TRAVEL $ C. SUPPLIES/MATERIALS $ D. EQUIPMENT $ E. CONTRACTUAL SERVICES '$ F. OTHER $ TOTAL $ 7~000.00 500,00 7,500.00 The TOTAL o£your BUDGET must equal the amount of your allocation as shown in BOX 6 on the CONTRACT FACE PAGE! The BUDGET is intended to show the items of expense which will be funded under this Contract. Please do not show the entire cost of the project if it exceeds the amount of funding provided by this Contract. Questions regarding Budget preparation? Call 518-486~3905 Budget Detail Sheet B-2 A. SALARIES, WAGES AND FRINGE .Title Amount Charged to this Project TOTAL SALARIES, WAGES AND FRINGE B. TRAVEL Please indicate destination, purpose and cost of such travel. .J TOTAL TRAVEL $ Budget Detail Sheet B-3 C. SUPPLIESfMATERIALS Please use general categories such as office supplies, printing supplies, small tools, bul!ding materials and like category descriptions. Indicate the cost of each category: Art Supplies Paint Vinyl Transfers Paper TOTAL SUPPLIES/MATERIALS 7,000.00 D. EQUIPMENT Please list each item of equipment that exceeds $200.00 per item and has a useful life of one year or more. Group items of less than $200.00 each into general categories indicating total cost per category. TOTAL EQUIPMENT Budget Detail Sheet B-4 E. CONTRACTUAL SERVICES This category includes items such as telephone, postage, rent, utilities, rental or repairs to equipment, lease of equipment, contracted services and contracted construction Costs. Digital Photograph, Computer Sizing and Disc Transfer Services are for hard costs only, time will be donated by Michael Croteau TOTAL CONTRACTUAL SERVICES $ 500.00 F. OTHER Please specify what these costs are. TOTAL OTHER $ APPENDIX C C-1 Payment and Reporting Schedule This is a cost reimbursement Agreement. The Contractor may claim and be reimbursed for eligible project costs incurred (costs of eligible project activities conducted, and goods and services received and accepted by the Contractor) within the Contract Period. The total of such reimbursement shall not exceed the Funding Amount for this Agreement and shall be claimed by the Contractor in accordance with one of the three payment options set forth below. Option A: Payment-In-Full For Completed Project In the event that the project has been completed and all eligible project costs incurred within the Contract Period and prior to the submission of this Agreement to the Department for execution, the Contractor may request a one- time payment-in-full with the submission of the Agreement. Complete the contract documents in accordance with the instructions, making sure that the contract budget categories add up to the total Funding Amount regardless of the total costs to be claimed. If the total costs to be claimed are less than the Funding Amount, the claim on the Standard Voucher (A.4. below) will reflect actual expenditures. Complete the Program Workplan (Appendix D) making sure it accurately describes the project activities completed and the dates of completion. If the project was on-going in nature, specify the time- frame (start and end dates) that costs were incurred. If the project was for equipment, supplies or commodities purchases, specify the delivery date(s) of the item(s) purchased. Complete the Standard Voucher received with the contract'documents in accordance with the instructions, with the exception of Section 6. Put the following statement in Section 6: "Requesting payment-in-full for eligible project costs incurred pursuant to all terms and conditions of Contract #Onsert contract number) submitted herewith." 5. Submit the completed contract documents and voucher claiming payment-in~full in accordance with the instructions. Upon full execution of the Agreement, payment will be made pursuant to the schedule set forth in II. below, and a copy of the fully-executed Agreement will be sent to you for your records. C-2 Option B: Periodic Progress Payments Contractor may request periodic progress payments for eligible project costs incurred following full execution of the Agreement by both parties. 2. Complete the .contract documents and 'submit them to the Department in accordance with the instructions. Do not submit a voucher or other payment documents at this time. 3. Upon full execution, a copy of the fully-executed Agreement and payment request documents and instructions for claiming progress payments will be sent to you. Reimbursement for eligible project costs incurred will be made upon receipt and approval of properly completed payment requests submitted in accordance with III. below. Option C: Advance and Progress Payment(s) 1. Contractor may request an advance equal to twenty-five percent (25%)'of the Funding Amount. Complete the contract documents in accordance with the instructions. Complete the Standard Voucher in accordance with the instructions inserting the statement "25 percent advance" in Section 6. Submit the completed contract documents and advance voucher to the Department in accordance with the instructions. 3. Upon full execution ofthe Agreement, the advance will be issued in accordance with the schedule set forth in II. below and a copy of the fully-executed Agreement and payment request documents and instructions for claiming progress payments will be sent to 'you. 4. Upon receipt of a progress payment request submitted in accordance with III. below, the Department will determine the total eligible costs, deduct 25 percent of that amount to document advance funds received, and pay the balance to the Contractor. 5. Upon termination of this contract, the full amount of undocumented advance funds shall become immediately due and owing to the Department. II. C-3 The payment-in-full provided for in I.A. above or the advance provided for in I.C. above will be paid by no later than November 25, 2002. In the event that the Department does not receive a properly completed contract package from the Contractor by September 25, 2002, the payment date will be recalculated to be no later than sixty (60) days .following receipt of the properly completed contract package. III. Progress payment requests as provided for in I.B. and I.C. above shall be · submitted tothe Department's designatedpayment office atthe following address: New York State Department of State Contract Administration Unit - LMI 41 State Street / 10th Floor Albany, New York 12231-0001 A. Payments shall be made to the Contractor upon the submission by the Contractor of properly executed progress payment requests. Each such request shall contain the following: (1) "Summary Sheet Documentation Forms" as provided by the Department, for documentation of actual and eligible expenditures; (2) a narrative progress report describing in detail all significant project accomplishments for which reimbursement is claimed, with dates of completion (NOTE: If this agreement is for the purchase of tangible goods, commodities or equipment only, a narrativeis not required for payments; however, a listing of all items purchased and dates received must be detailed on the Summary Sheet Documentation Forms.); and (3) a properly completed Standard Voucher. Notwithstanding the above requirements, upon written notification by the Department, the Contractor may be required to submit source documentation and additional verification of allowable expenditures. Payment requests as described in III.A. above shall be certified by a duly authorized representative of the Contractor as accurately representing such accomplishments and expenses as recorded in the Contractor's accounting records, including, where goods or services are provided by third parties not party to this Agreement, a certification that any payment obligations arising from the provision of such goods or services have been paid by the Contractor and do not duplicate reimbursement or costs and services received from other sources. C~4 Do Claimed expenditures per cost category may exceed the mounts indicated in the Budget, Appendix B, by ten pement (10%) or $t,000, whichever is greater, without approval of the Departmem, provided that the Funding Amount is not exceeded. Any expenditure in excess of such 10% or $1,000 shall require an amendment to the Project Budget submitted in writing by the Contractor. No expenditures shall be allowed for items not Set forth in the Project Budget without prior written approval of the Department. Any payment request for any period during which all Project activities shall have been completed shall be submitted as the Contractor's final payment request and shall be clearly labeled FINAL. If a final progress narrative report is required to be submitted, it must describe in reasonable detail, the nature and degree of the ProjeCt's completion and results. If the Contractor has received prior payments exceeding total eligible expenditures, Contractor shall remit such excess to the Department with such FINAL request. IV. Notwithstanding the submission of timely and properly executed paymem requests, the Department shall be under no obligation to make payment for expenditures incurred without the prior Department approvals and/or amendments required under this Agreement and, further, shall have the right to withhold any such payment pending the execution of such approval and/or amendment. Interest income earned on funds received pursuant to this Agreement shall be used to further the purpose of this Project or shall be deducted from total eligible costs to determine the net eligible costs to be reimbursed by the Department. The Department shall have the right to conduct on-site progress assessments and reviews of the Project and Contractor's books and records during the life of this Agreement and for a reasonable time following issuance of the FiNAL payment. The Department shall be entitled to disallow any cost or expense, or terminate or suspend this Agreement, if found that the Contractor has misrepresented any expenditures or Project activities in this Agreement, or in any progress reports or payment requests made pursuant hereto. C-5 The Contractor shall maintain separate fiscal books and records for all funds received through the Department and Project activities conducted pursuant to this Agreement, and shall make all such books and records available to the Department, the Office of the State Comptroller, or their designated representatiYes for inSPection and audk for a period of six (6) years following tenuination of ttiis Agreement. APPENDIX D Program Workplan D-1 ~ecipient Organization Name: Program Contact Person: Daytime Phone: (631) Fax: (6_3!) Town of Southold Type: M Ioqhua Y. Norton 765-1889 765-1823 NARRATIVE {MUST BE COMPLETED FOR ALL PROJECT TYPES AND PAYMENT OPTIONS) ~4OTE: If payment Option A: Payment-In-FuI1 for completed project was selected, make sure that this Narrative complies with Section 3 of Option A. "With You, Southold Can" is a project that will increase awareness and reduce the amount of littering throughout the Town of $outhold. 50 of the town's big cylindrical garbage cans will be decorated with art by schoolchildren, artists, photographers~ seniors, civic groups and anyone who wants to join in. The art wil be reproduced on vinly material and wrapped around the circumference of a can. Each can will be placed in a prominent spot throughout the ~hamlets in the Town off Southold. The program is about encouraging people to use the cans and not litter, but it is also a message about having community spirit, to "pitch in" any way you can, (ATTACH ADDITIONAL PAGES AS NEEDED) APPENDIX X Agency Code Contract Period ' Contract Number Funding for Period This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the New York State Department of State, having its principal office in Albany, New York (hereinafter referred to as the STATE), and (hereinafter referred to as the CONTRACTOR), for' modification of Contract Number , as amended above. All other provisions of said AGREEMENT shall remain in full fome and effect. ['N WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under their signatures. CONTRACTOR SIGNATURE By: STATE AGENCY SIGNATURE By: (print name) (print name) Title: Title: Date: Da[e: State A~enc¥ Certific,tion: "In addition to the acceptance of this Contract, I also certify that original copies o~'this signature page will be attached to all other exact copies of this Contract." STATE OF NEW YORK COUNTY OF On this day o[ and say that (s)he resides at SS: · in the year 20 , before me personally appeared · to me known, who, being by me duly sworn, did depose ; that (s)he is the of , the corporation described herein which executed the foregoing instrument; and that (s)he signed (her)his name thereto by order of the board of directors of said corporation. STATE OF NEW YORK ) COUNTY OF ) ss: On this day of of NOTARY PUBLIC · in the year 20 , before me personally appeared ., to me known and known to me to be the ., the unincorporated association described .in and which executed the above agreement; and who acknowledge to me that (s)he exeCUted the foregoing agreement for and in behalf of said uninco~orated association. STATE COMPTROLLER'S SIGNATURE NOTARY PUBLIC Title: Date: NEW YORK STATE DEPARTMENT OF STATE CONTRACT ADMINISTRATION UNIT VOUCHERING PROCEDURES GUIDELINES FOR LEGISLATIVE MEMBER INITIATIVES 1. These guidelines exptain xvhat supporting documentation is required to be submitted for each payment request to be considered a proper invoice. 2. For the purpose of this Program the designated payment office is: New York State Department of State Contract Administration Unit - LMI 41 State Street, 10th Floor Albany, New York 12231-0001 A payment request consists of a properly completed and signed Standard Voucher, a Summary Sheet and Forms 1 through 4. A desk audit must be completed before payment can be made. Generally, payments will be made approximately twenty (20) working days from receipt ora complete claim provided ail requirements are met and, your agency is meeting all other contractual obligations. Care should be taken to insure that all forms are legible and completely filled out. Please note that when signing the Voucher, you are also certifying to the statements in the certification section of the Summary Sheet, which is an integral part of our payment review, allowing you to maintain source documentation at your local office versus our requiring copies of all documentation to be submitted to the Department of State for review. The certification also places the responsibility of assuring that appropriate expenditures are being made in relation to the project with your organization. Please take care in completing all documents as any errors can and will result in the rejection of your payment request. If assistance is needed in completing the Documentation Forms, please call the number below. NOTE: Please photocopy the Voucher, Summary Sheet and Forms to use for subsequent payment requests. If you have any questions regarding these gUidelines, please contact the Contract Administration Unit at 518-486-3905. SUMMARY SHEET Insert your contract number, as it appears on the Contract Face Page, of your contract in the space provided. Insert the inclusive (start and end) dates within which the expenditures claimed this report were incurred (goods and services received or completed) in the spaces provided. SECTION I: Column #1 - Please insert the current budget mounts reflected in the most recently approved budget. Column #2 - These figures must reflect the expenditures being documented on Forms 2-4 in this payment request only. Column #3 - These figures represent the cumulative expenditures documented tc date including this payment request and previous payment requests in which expenditures were documented. If this is the first payment.request, Columns #2 and #3 will be the same. Column #4 - The Available Balance to Document can be calculated by subtracting the Cumulative Expenditures to Date (Column #3) from the Current Budget Amounts (Column #I). If this results in a negative balance which exceeds the budget amount by 10 percent or $1,000.00, whichever is greater, or there is no budget amount for the category of expense, a budget amendment is required in accordance with Appendix C of your Contract. SECTION II: Interim Claims - If your organization chose to receive an advance payment, interim Claims will be reimbursed in an amount equal to 75 percent of the Expenditures Documented this Report (Column #2 in Section I). The 25 percent balance will be applied toward documenting the advance payment. Otherwise, reimbursement will be made in an amount equal to 100 percent of the total, acceptable expenditures claimed in Column #2. 2 Final Claims - Any claim for any period during which all project activities shall have been completed shall be considered the Final Claim. The final claim amount is calculated by subtracting the total payments including the advance from the total cumulative expenditures in Column#3 of Section I. If this results in a negative number (total payments exceed total expenditures), you must submit such excess to the Department with your Final Claim. FORMS 1-4 The purpose of these forms is to detail the expenditures claimed in Column #2 of the Summary Sheet. Although these forms are the same design and format as the forms used in Appendix B of the Agreement which detail the budget categories, please do not photocopy the budget pages to be used as' documentation forms in the payment requests. Since supporting documentation (receipts, invoices, etc.) is not required, unless requested, it is very important that these forms be completed as accurate and detailed as possible. Failure to do so will result in the rejection of your payment request. FORM 1: PROJECT NARRATIVE This report should describe in detail all project accomplishments and any problems encountered during the period being reported. Whereas the project narrative in the Agreement details the project intent, the project narrative in payment requests must detail what project accomplishments have been met with the funds being claimed for reimbursement in the payment request. If your Contract is for purchase of commodities or equipment only, this form is not required. , FORMS 2 - 4: ExpENDITURE DETAIL For each category claiming reimbursement, detail the types of expenses, the actual costs and the dates incurred. The items detailed must be the same as those included in the original budget, and must be shown in the same budget categories. The amount reflected in the Sub-total line of each category must be the same amount claimed in Column #2 of the Summary Sheet. 3 DETAIL: Except for equipment, it is not necessary to list each item purchased; like items can be combined. However, the expenditures being documented should be descriptive and itemizedto some extent. Listed below aresome examples for documenting expenditures. A. Salaries, Wages and Fringe: Include all pay periods covered by this report and list the mount paid (including Fringe) to each employee for the work done relating to this Contract during the pay periods covered by this report. B. Travel: Break-out the traveling expenses incurred, including date, destination and purpose of travel, in relation to the project. How much of the total travel amount was for taxi fare? or mileage reimbursement? How many miles were traveled? C. Supplies and Materials: List the different types of supplies and materials purchased, the cost of each and the dates received. Office Supplies (paper, pens, stationary) - $845.00 - received 06/30/99 Medical Supplies (splints, bandages, blankets) - $420.00 - received 06/30/99 Gas and Oil $35.00 - received 06/30/99 15 Gallons of Gas ~ $1.50/gallon = $22.50 - received 06/30/99 10 Quarts ofOil ~ $1.25/quart -~ $12.50 ~ received 06/30/99 D. Equipment: List each piece of equipment purchased, the cost of each piece and the dates received. Please give some description of the equipment such as make, year, model number, etc. Contractual Services: The contractual services category includes items such as telephone, postage, rent, utilities, rental or repairs to equipment, lease of eqmpment, sub-contracted services and construction costs. List the different types of contractual services, the cost for each and the dates services provided. Insurance (fire, theft, auto) $t500.00 - 06/01/99-12131799 Telephone $136.00 - June 1999 Lease (photocopying machine) $200.00 - June 1999 Construction contract $2,000.00 - 06/01/99-07/31/99 If there .are any questions on how to correctly document expenditures, please call the number listed on Page 1 of the instructions. 4 STANDARD VOUCHER ~ complete Sections 3, 4, 6 and 7 only In Section 3, Payee ID, indicate your Federal iD number as submitted on the CONTRACT FACE PAGE. NOTE: If the contract is with a county, city, town or village government, DO NOT COMPLETE SECTION 3. In Section 4, PayeeName and Address, indicate the organization's name and address'as it appears on the CONTRACT FACE PAGE. In Section 6, indicate your Contract Number, as it appears on the CONTRACT FACE PAGE of your contract, in the space provided. Indicate the total, expenditures claimed (total of Column 2 on the Summary Sheet) in the space provided to the far right. DO NOT put anything else in this Section. The Payee Certification, Section 7, must be an original signature by the responsible official authorized to certify claims. IftheVoucherisnot signedthepaymentrequestwill automatically be rejected. 5 DOCUMENTATION FORMS LEGISLATIVE MEMBER INITIATIVES CONTRACT # Expenditures Incurred During the Period / / through SUMMARY SHEET I. BUDGET/EXPENDITURE DATA A. Salaries, Wages and Fringe B. Travel C. Supplies and Materials D. Equipment E. Contractual Services F. Other Cumulative Current Expenditures Expenditures Available Budget Documented Documented Balance to Amount this Report to Date Document (1) (2) (3) (1-3) TOTAL II. CLAIM TYPE Interim Claim Final Claim IlL CERTIFICATION By signature on the attached voucher, I further certify that: 1) the mounts claimed accurately represent the expenses as recorded in our accounting records; 2) we are in compliance with all applicable provisions.of the above-referenced Contract; 3) the attached narrative report (if required) accurately represents project accomplishments; 4) funds received are being used solely for the purposes of the "Project" as described in Appendix D of the above-referenced Contract. FORM. 1 PROJECT NARRATIVE DETAILING PROJECT ACCOMPLISHMENTS AND THE DATES GOODS WERE RECEIVED AND SERVICES WERE COMPLETED FORM 2 - Expenditure Detail for this Payment Request. Be descriptive and specific. A. SALARIES, WAGES AND FRINGE BENEFITS REQUEST 2. 3. 4. 5. 6, PAY PERIODS TITLE FROM - TO SUBTOTAL AMOUNT CHARGED TO THIS PROJECT $ $ $ $ $ $ $ B, TRAVEL (include date, destination and purpose) SUBTOTAL $ FORM 3 C. SUPPLIESfM~ATERIALS (include dates received) SUBTOTAL $ D. EQUIPMENT (include dates received) SUBTOTAL $ FORM 4 E. CONTRACTUAL SERVICES (include dates services received) SUBTOTAL F. OTHER (include dates goods or services received) SUBTOTAL $ DEPARTMENT OF STATE V~uche~ No. STANDARD VOUCHER 'i9000 Refltnv. Date (M~t) (DD) (YY) Claiming reimbursement of expenditures incurred pursuant to Community Projects Contract # as detailed on the attached Documentation Forms, Total this claim (Total Summary Sheet Column #2) Payee Certification: I certify that the above bill is just. tree and correct; that no part thereof has been paid except as stated and that the balance ts actually' due and owing, end that taxes from which the State is exempt are excluded. Payee's Signature in I~ Tit~e Date Name of Company Net Pa~e NQ, FOR AGENCY USE ONLY ST,ATE COMPTROLLER'S PRE-AUDIT Expenditure Object Liquidation