HomeMy WebLinkAboutFishers Island Resurfacing Basketball & Tennis Courts
RESOLUTION 2018-371
ADOPTED DOC ID: 14033
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2018-371 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
APRIL 24, 2018:
RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs
Supervisor Scott A. Russell to execute a Grant Distribution Agreement with the Dormitory
Authority of the State of New York (“DASNY”) in connection with a State and Municipal
Facilities Program (“SAM”) grant to be utilized for the reconstruction and resurfacing of the
Basketball and Tennis courts on Fishers Island, New York in the amount of $50,000.00 for
which funds will be advanced from the General Fund until Grant reimbursements are received.
Elizabeth A. Neville
Southold Town Clerk
RESULT: ADOPTED \[UNANIMOUS\]
MOVER: Robert Ghosio, Councilman
SECONDER: Louisa P. Evans, Justice
AYES: Dinizio Jr, Ruland, Doherty, Ghosio, Evans, Russell
RECEIVED .
DEC 1 9 2018
% Southold Town Clerk
o� 4
Office of the Town Attorney
Town of Southold
Town Hall Annex, 54375 Route 25
P.O. Box 1179
Southold, New York 11971-0959
Telephone : 631-765-1939
Facsimile: 631-765-6639
MEMORANDUM
To: Ms. Elizabeth A. Neville, Town Clerk
From: Mary Silleck
Secretary to the Town Attorney
Date: December 19, 2018
Subject: State and Municipal Facilities Program (SAM) Grant
Reconstruction and Resurfacing of Basketball and Tennis
Courts at Fishers Island
With respect to the above-referenced matter, I am enclosing the original
Agreement regarding the above matter.
If you have any questions regarding the enclosed, please do not hesitate to call
me. Thank you.
/ms
Enclosures
r
This GRANT DISBURSEMENT AGREEMENT includes
all exhibits and attachments hereto and is made on the terms and by the parties listed below
and relates to the Project described below:
DORMITORY AUTHORITY OF THE STATE OF 515 Broadway
NEW YORK ("DASNY"): Albany, New York 12207
Contact: Sara Richards, Esq.
Phone: (518) 257-3177
Fax: (518) 257-3475
E-mail: grants@dasny.org
THE GRANTEE: Town of Southold
P.O. Box 1179
53095 Main Rd
Southold, NY 11971
Contact: Mr. Denis Noncarrow
Phone: (631) 765-5806
Fax: (631) 765-1823
THE PROJECT: Reconstruction and Resurfacing of
Basketball and Tennis Courts at Fishers
Island
PROJECT LOCATION: Fox lane, Fishers Island, NY
GRANT AMOUNT: $50,000
FUNDING SOURCE: State and Municipal Facilities Program
("SAM")
For Office Use Only:
PRELIMINARY APPLICATION OR PROJECT
INFORMATION SHEET DATE: 04/11/18
DATE GDA SENT TO GRANTEE: /15/18
DATE AGREEMENT SIGNED BY GRANTEE: CR�
DATE AGREEMENT SIGNED BY DASNY: 1211 .41$
EXPIRATION DATE OF THIS AGREEMENT: t21ly121
PROJECT ID #: 12972 FMS#: 143044
GranteelD: 3210
GrantID: 14044
Updated 7-28-14 1
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TERMS AND CONDITIONS
1. The Project
The Project description, including tasks and a timeline with respect thereto, is set forth in
Exhibit A. The Grantee will perform the tasks on the schedule and as described in Exhibit A to
this Agreement.
2. Project Budget and Use of Funds
a) The Grantee will undertake the Project in accordance with the overall Project budget,
which includes the Grant funds, as set forth in Exhibit A to this Agreement. The
Grant will be applied only to Eligible Expenses, which are separately identified, as
described in the Preliminary Application or Project Information Sheet and in Exhibit A
hereto.
b) Grantee agrees and covenants to apply the Grant proceeds only to capital works or
purposes, which shall consist of the following:
(i) the acquisition, construction, demolition, or replacement of a fixed asset or
assets;
(ii) the major repair or renovation of a fixed asset, or assets, which materially
extends its useful life or materially improves or increases its capacity; or
(iii) the planning or design of the acquisition, construction, demolition,
replacement, major repair or renovation of a fixed asset or assets, including
the preparation and review of plans and specifications including engineering
and other services, field surveys and sub-surface investigations incidental
thereto.
c) Grantee agrees and covenants that the Grant proceeds shall not be used for costs
that are not capital in nature, which include, but shall not be limited to working
capital, rent, utilities, salaries, supplies, administrative expenses, or to pay down debt
incurred to undertake the Project.
3. Books and Records
The Grantee will maintain accurate books and records concerning the Project for six (6)
years from the date the Project is completed and will make those books and records available to
DASNY, its agents, officers and employees during Grantee's business hours upon reasonable
request. In the event of earlier termination of this Agreement, such documentation shall be
made available to DASNY, its agents, officers and employees for six (6) years following the date
of such early termination.
4. Conditions Precedent to Disbursement of the Grant
No Grant funds shall be disbursed until the following conditions have been satisfied:
Updated 7-28-14 2
(a) DASNY has received a description of the Project, budget and timeline in the form
of Exhibit A, and an opinion of Grantee's counsel, in substantially the form
appended to this Agreement as Exhibit B; and
(b) The requirements of the SAM Program have been met; and
(c) The monies required to fund the Grant have been received by DASNY; and
(d) In the event of disbursement pursuant to paragraph 5(b) below, the Grantee has
provided DASNY with documentation evidencing that a segregated account has
been established by the Grantee into which Grant funds will be deposited (the
"Segregated Account"). Eligible Expenses incurred in connection with the Project
to be financed with Grant proceeds that are to be paid on invoice shall be paid
out of the Segregated Account. The funds in such account shall not be used for
any other purpose.
(e) The Grantee certifies that it is in compliance with the provisions of the SAM and
this Agreement and that the Grant will only be used for the Project set forth in the
Preliminary Application or Project Information Sheet and in Exhibit A hereto.
(f) Not-for-profit organizations are required to register and prequalify on the New
York State Grants Gateway (www.grantsreform.ny.gov) in order to receive Grant
funds. The Grantee's Document Vault must be in prequalification status prior to
any disbursements of the grant funds.
5. Disbursement
Subject to the terms and conditions contained in this Agreement, DASNY shall disburse
the Grant to the Grantee, in the manner set forth in Exhibit D, as follows:
(a) Reimbursement: DASNY shall make payment directly to the Grantee in the
amount of Eligible Expenses actually incurred and paid for by the Grantee, upon
presentation to DASNY of (i) the Payment Requisition Forms attached to this
Agreement as Exhibit E and its attachments; (ii) copies of invoices for Eligible
Expenses from the Grantee's contractor and/or vendor and proof of payment
from the Grantee to the contractor and/or vendor in a form acceptable to DASNY;
and (iii) such additional supporting documentation as DASNY may require in
order to clearly demonstrate that Eligible Expenses were incurred and paid by
the Grantee in connection with the Project described herein; or
(b) Payment on Invoice:
(1) DASNY may make payment directly to the Grantee in the amount of
Eligible Expenses actually incurred by the Grantee, upon presentation to DASNY
of (i) the Payment Requisition Forms attached to this Agreement as Exhibit E and
its attachments; (ii) copies of invoices for Eligible Expenses from the Grantee's
contractor and/or vendor in a form acceptable to DASNY evidencing the
completion of work; and (iii) such additional supporting documentation as DASNY
may require in order to clearly demonstrate that Eligible Expenses were incurred
by the Grantee in connection with the Project described herein.
Updated 7-28-14 3
y .
(2) The Grantee must deposit all Grant proceeds paid on invoice pursuant to
this paragraph (b) into the Segregated Account established pursuant to
Paragraph 4(d). All Eligible Expenses incurred in connection with the Project to
be financed with Grant funds that are to be paid on invoice must be paid out of
this account. The account shall not be used for any other purpose.
(3) The Grantee must provide proof of disbursement of Grant funds to the
respective contractor and/or vendor in a form acceptable to DASNY, within sixty
(60) days of the date that Grant funds are disbursed to the Grantee to pay for
such costs. DASNY will not make any additional disbursements from Grant
funds until such time as proof of payment is provided.
(4) Utilizing the Grant funds paid to the Grantee pursuant to this section for
any purpose other than paying the contractors and/or vendors identified in the
requisition documentation in the amounts set forth in the requisition shall
constitute a default under this Agreement and shall, at a minimum, result in the
denial of payment on invoice for subsequent requisitions.
(5) DASNY may deny payment on invoice at its sole and absolute discretion,
thereby restricting the method of payment pursuant to this contract to
reimbursement subject to the terms of Section 5(a).
(c) Electronic Payments Program: DASNY reserves the right to implement an
electronic payment program ("Electronic Payment Program")for all payments to
be made to the Grantee thereunder. Prior to implementing an Electronic
Payment Program, DASNY shall provide the Grantee written notice one hundred
twenty days prior to the effective date of such Electronic Payment Program
("Electronic Payment Effective Date"). Commencing on or after the Electronic
Payment Effective Date, all payments due hereunder by the Grantee shall only
be rendered electronically, unless payment by paper check is expressly
authorized by DASNY. Commencing on or after the Electronic Payment Effective
Date the Grantee further acknowledges and agrees that DASNY may withhold
any request for payment hereunder, if the Grantee has not complied with
DASNY's Policies and Procedures relating to its Electronic Payment Program in
effect at such time, unless payment by paper check is expressly authorized by
DASNY.
(d) In no event will DASNY make any payment which would cause DASNY's
aggregate disbursements to exceed the Grant amount.
(e) The Grant, or a portion thereof, may be subject to recapture by DASNY as
provided in Section 9(c) hereof.
6. Non Discrimination and Affirmative Action
The Grantee shall make its best effort to comply with DASNY's Non-Discrimination and
Affirmative Action policies set forth in Exhibit F to this Agreement.
Updated 7-28-14 4
7. No Liability of DASNY or the State
DASNY shall not in any event whatsoever be liable for any injury or damage, cost or
expense of any nature whatsoever that occurs as a result of or in any way in connection with the
Project and the Grantee hereby agrees to indemnify and hold harmless DASNY, the State and
their respective agents, officers, employees and directors (collectively, the "Indemnitees") from
and against any and all such liability and any other liability for injury or damage, cost or expense
resulting from the payment of the Grant by DASNY to the Grantee or use of the Project in any
manner, including in a manner which, if the bonds are issued on a tax-exempt basis, (i) results
in the interest on the bonds issued by DASNY the proceeds of which were used to fund the
Grant (the "Bonds") to be includable in gross income for federal income tax purposes or (ii)
gives rise to an allegation against DASNY by a governmental agency or authority, which
DASNY defends that the interest on the Bonds is includable in gross income for federal income
tax purposes, other than that caused by the gross negligence or the willful misconduct of the
Indemnitees.
8. Warranties and Covenants
The Grantee warrants and covenants that:
(a) The Grant shall be used solely for Eligible Expenses in accordance with the
terms and conditions of this Agreement.
(b) No materials, if any, purchased with the Grant will be used for any purpose other
than the eligible Project costs as identified in Exhibit A.
(c) The Grantee agrees to utilize all funds disbursed in accordance with this
Agreement in accordance with the terms of the SAM Program.
(d) The Grantee is solely responsible for all Project costs in excess of the Grant.
The Grantee will incur and pay Project costs and submit requisitions for
reimbursement in connection with such costs.
(e) The Grantee has sufficient, secured funding for all Project costs in excess of the
Grant, and will complete the Project as described in the Preliminary Application
or Project Information Sheet and in this Agreement.
(f) The Grantee agrees to use its best efforts to utilize the Project for substantially
the same purpose set forth in this Agreement until such time as the Grantee
determines that the Project is no longer reasonably necessary or useful in
furthering the public purpose for which the grant was made.
(g) There has been no material adverse change in the financial condition of the
Grantee since the date of submission of the Preliminary Application or Project
Information Sheet to DASNY.
(h) No part of the Grant will be applied to any expenses paid or payable from any
other external funding source, including State or Federal grants, or grants from
any other public or private source.
Updated 7-28-14 5
•1
(i) The Grantee owns, leases, or otherwise has control over the site where the
Project will be located. If the Project includes removable equipment or
furnishings including but not limited to, computer hardware and software, air
conditioning units, lab equipment, office furniture and telephone systems,
Grantee will develop, implement and maintain an inventory system for tracking
such removable equipment and furnishings.
(j) The Project to be funded by the Grant will be located in the State of New York. If
the Grant will fund all or a portion of the purchase of any type of vehicle, such
vehicle will be registered in the State of New York and a copy of the New York
State Vehicle Registration documents will be provided to DASNY's Accounts
Payable Department at the time of requisition.
(k) Grantee is in compliance with, and shall continue to comply in all material
respects, with all applicable laws, rules, regulations and orders affecting the
Grantee and the Project including but not limited to maintaining the Grantee's
document vault on the New York State Grants Reform Gateway
(www.grantsreform.ny.gov).
(1) The Grantee has obtained all necessary consents and approvals from the
property owner in connection with any work to be undertaken in connection with
the Project.
(m) All contractors and vendors retained to perform services in connection with the
Project shall be authorized to do business in the State of New York and/or filed
such documentation, certifications, or other information with the State or County
as required in order to lawfully provide such services in the State of New York. In
addition, said contractor/vendors shall possess and maintain all professional
licenses and/or certifications required to perform the tasks undertaken in
connection with the Project.
(n) Neither the Grantee nor any of the members of its Board of Directors or other
governing body or its employees have given or will give anything of value to
anyone to procure the Grant or to influence any official act or the judgment of any
person in the performance of any of the terms of this Agreement.
(o) The Grant shall not be used in any manner for any of the following purposes:
(i) political activities of any kind or nature, including, but not limited to,
furthering the election or defeat of any candidate for public, political or
party office, or for providing a forum for such candidate activity to promote
the passage, defeat, or repeal of any proposed or enacted legislation;
(ii) religious worship, instruction or proselytizing as part of, or in connection
with, the performance of this Agreement;
(iii) payments to any firm, company, association, corporation or organization
in which a member of the Grantee's Board of Directors or other governing
body, or any officer or employee of the Grantee, or a member of the
immediate family of any member of the Grantee's Board of Directors or
other governing body, officer, or employee of the Grantee has any
Updated 7-28-14 6
ownership, control or financial interest, including but not limited to an
officer or employee directly or indirectly responsible for the preparation or
the determination of the terms of the contract or other arrangement
pursuant to which the proceeds of the Grant are to be disbursed. For
purposes of this paragraph, "ownership" means ownership, directly or
indirectly, of more than five percent (5%) of the assets, stock, bonds or
other dividend or interest bearing securities; and "control" means serving
as a member of the board of directors or other governing body, or as an
officer in any of the above; and
(iv) payment to any member of Grantee's Board of Directors or other
governing body of any fee, salary or stipend for employment or services,
except as may be expressly provided for in this Agreement.
(p) The relationship of the Grantee (including, for purposes of this paragraph, its
officers, employees, agents and representatives) to DASNY arising out of this
Agreement shall be that of an independent contractor. The Grantee covenants
and agrees that it will conduct itself in a manner consistent with such status, that
it will neither hold itself out as, nor claim to be, an officer, employee, agent or
representative of DASNY or the State by reason hereof, and that it will not by
reason thereof, make any claim, demand or application for any right or privilege
applicable to an officer, employee, agent or representative of DASNY or the
State, including without limitation, worker's compensation coverage,
unemployment insurance benefits, social security coverage or retirement
membership or credit.
(q) The information contained in the Preliminary Application or Project Information
Sheet submitted by the Grantee in connection with the Project and the Grant, as
such may have been amended or supplemented and any supplemental
documentation requested by the State or DASNY in connection with the Grant, is
incorporated herein by reference in its entirety. In the event of an inconsistency
between the descriptions, conditions, and terms of this Agreement and those
contained in the Preliminary Application or Project Information Sheet, the
provisions of this Agreement shall govern. The Grantee hereby acknowledges
that DASNY has relied on the statements and representations made by the
Grantee in the Preliminary Application or Project Information Sheet and any
supplemental information in making the Grant. The Grantee hereby represents
and warrants that it has made no material misstatement or omission of fact in the
Preliminary Application or Project Information Sheet, supplemental information,
or otherwise in connection with the Grant and that the information contained in
the Preliminary Application or Project Information Sheet and supplemental
information continues on the date hereof to be materially correct and complete.
(r) The Grantee hereby represents and warrants that it has made no material
misstatement or omission of fact in the Grantee Questionnaire ("GQ"), attached
hereto as Exhibit C,or the Grantee's document vault in the New York State's
Grants Reform Gateway completed by the Grantee in connection with the Project
and the Grant, and that the responses in the GQ and the document vault
continue on the date hereof to be materially correct and complete. The Grantee
hereby acknowledges that DASNY has relied on the statements and
representations made by the Grantee in the GQ in making the Grant, and that the
Updated 7-28-14 7
Grantee will be required to reaffirm the information therein each time a requisition
for grant funds is presented to DASNY.
(s) The Grantee is duly organized, validly existing and in good standing under the
laws of the State of New York, or is duly organized and validly existing under the
laws of another jurisdiction and is authorized to do business and is in good
standing in the State of New York and shall maintain its corporate existence in
good standing in each such jurisdiction for the term of this Agreement, and has
full power and authority to execute and deliver the Agreement and to perform its
obligations thereunder;
(t) The Grantee agrees to provide such documentation to DASNY as may be
requested by DASNY in its sole and absolute discretion to support a requisition
for payment, to determine compliance by the Grantee with the terms of this
Agreement or otherwise reasonably requested by DASNY in connection with the
Grant, and further acknowledges that if documentation requested in connection
with a requisition for payment does not, in the sole and absolute discretion of
DASNY, provide adequate support for the costs requested, that such requisition
request shall be denied and payment shall not be made to the Grantee.
(u) The Agreement was duly authorized, executed and delivered by the Grantee and
is binding on and enforceable against the Grantee in accordance with its terms.
9. Default and Remedies
(a) Each of the following shall constitute a default by the Grantee under this Agreement:
(i) Failure to perform or observe any obligation, warranty or covenant of the
Grantee contained herein, or the failure by the Grantee to perform the
requirements herein to the reasonable satisfaction of DASNY and within
the time frames established therefor under this Agreement.
(ii) Failure to comply with any request for information reasonably made by
DASNY to determine compliance by the Grantee with the terms of this
Agreement or otherwise reasonably requested by DASNY in connection
with the Grant.
(iii) The making by the Grantee of any false statement or the omission by the
Grantee to state any material fact in or in connection with this Agreement
or the Grant, including information provided in the Preliminary Application
or Project Information Sheet or in any supplemental information that may
be requested by the State or DASNY.
(iv) The Grantee shall (A) be generally not paying its debts as they become
due, (B) file, or consent by answer or otherwise to the filing against it of, a
petition under the United States Bankruptcy Code or under any other
bankruptcy or insolvency law of any jurisdiction, (C) make a general
assignment for the benefit of its general creditors, (D) consent to the
appointment of a custodian, receiver, trustee or other officer with similar
powers of itself or of any substantial part of its property, (E) be
Updated 7-28-14 8
adjudicated insolvent or be liquidated or (F) take corporate action for the
purpose of any of the foregoing.
(v) An order of a court having jurisdiction shall be made directing the sale,
disposition or distribution of all or substantially all of the property
belonging to the Grantee, which order shall remain undismissed or
unstayed for an aggregate of thirty (30) days.
(vi) The Grantee abandons the Project prior to its completion.
(vii) The Grantee is found to have falsified or modified any documents
submitted in connection with this grant, including but not limited to
invoice, contract or payment documents submitted in connection with a
Grantee's request for payment/reimbursement.
(viii) Utilizing the Grant funds paid to the Grantee pursuant to Section 5(b)for
any purpose other than paying the contractors and/or vendors identified in
the requisition documentation in the amounts set forth in the requisition.
(b) Upon the occurrence of a default by the Grantee and written notice by DASNY
indicating the nature of the default, DASNY shall have the right to terminate this
Agreement.
(c) Upon any such termination, DASNY may withhold any Grant proceeds not yet
disbursed and may require repayment of Grant proceeds already disbursed. If
DASNY determines that any Grant proceeds had previously been released
based upon fraudulent representations or other willful misconduct, DASNY may
require repayment of those funds and may refer the matter to the appropriate
authorities for prosecution. DASNY shall be entitled to exercise any other rights
and seek any other remedies provided by law.
10. Term of Agreement
Notwithstanding the provisions of Section 9 hereof, this Agreement shall terminate three
(3) years after the latest date set forth on the front page hereof without any further notice to the
Grantee. DASNY, in its sole discretion, may extend the term of this Agreement upon a showing
by the Grantee that the Project is under construction and is expected to be completed within the
succeeding twelve (12) months. All requisitions must be submitted to DASNY in proper form
prior to the termination date in order to be reimbursed.
11. Project Audit
DASNY shall, upon reasonable notice, have the right to conduct, or cause to be
conducted, one or more audits, including field inspections, of the Grantee to assure that the
Grantee is in compliance with this Agreement. This right to audit shall continue for six (6) years
following the completion of the Project or earlier termination of this Agreement.
12. Survival of Provisions
The provisions of Sections 3, 7, 8(n), 8(o) and 11 shall survive the expiration or earlier
termination of this Agreement.
Updated 7-28-14 9
13. Notices
Each notice, demand, request or other communication required or otherwise permitted
hereunder shall be in writing and shall be effective upon receipt if personally delivered or sent
by any overnight service or three (3) days after dispatch by certified mail, return receipt
requested, to the addresses set forth on this document's cover page.
14. Assignment
The Grantee may not assign or transfer this Agreement or any of its rights hereunder.
15. Modification
This Agreement may be modified only by a written instrument executed by the party
against whom enforcement of such modification is sought.
16. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the
State of New York. This Agreement shall be construed without the aid of any presumption or
other rule of law regarding construction against the party drafting this Agreement or any part of
it. In case any one or more of the provisions of this Agreement shall for any reason be held to
be invalid, illegal or unenforceable in any respect, such invalidity, illegality or unenforceability
shall not affect any other provision hereof and this Agreement shall be construed as if such
provision(s) had never been contained herein.
17. Confidentiality of Information
Any information contained in reports made to DASNY or obtained by DASNY as a result
of any audit or examination of Grantee's documents or relating to trade secrets, operations and
commercial or financial information, including but not limited to the nature, amount or source of
income, profits, losses, financial condition, marketing plans, manufacturing processes,
production costs, productivity rates, or customer lists, provided that such information is clearly
marked "confidential" by the Grantee that concerns or relates to trade secrets, operations and
commercial or financial information, including but not limited to the nature, amount or source of
income, profits, losses or expenditures, financial condition, marketing plans, manufacturing
processes, production costs, productivity rates, or customer lists, which is determined by
DASNY to be exempt from public disclosure under the Freedom of Information Law, shall be
considered business confidential and is not to be released to anyone, except DASNY and staff
directly involved in assisting the Grantee, without prior written authorization from the Grantee,
as applicable. Notwithstanding the foregoing, DASNY will not be liable for any information
disclosed, in DASNY's sole discretion, pursuant to the Freedom of Information Law, or which
DASNY is required to disclose pursuant to legal process.
18. Executory Clause
This Agreement shall be deemed executory to the extent of monies available for the
SAM Program to DASNY.
Updated 7-28-14 10
This agreement is entered into as of the latest date written below:
DORMITORY AUTHORITY OF THE STATE OF NEW YORK
Authorized Officer
1'I►chcaeI --r, Corymcv.?,
(Printed Name)
Date: 12 11%4
I
GRANTEE: TOWN OF SOUTHOLD
J4446
(Signature)
6 MW O ."k(a (!. Su�elvu,3 nr
(Printed name and title)
Date:
Updated 7-28-14 11
1
GRANT DISBURSEMENT AGREEMENT
EXHIBITS
EXHIBIT A Project Budget
EXHIBIT B Opinion of Counsel
EXHIBIT C Grantee Questionnaire
EXHIBIT D Disbursement Terms
EXHIBIT E Payment Requisition Form and Dual Certification
EXHIBIT E-1 Payment Requisition Cover Letter
EXHIBIT E-2 Payment Requisition Back-up Summary
EXHIBIT F Non-Discrimination and Affirmative Action Policy
Updated 7-28-14 12
EXHIBIT A: Project Budget
Town of Southold
Reconstruction and Resurfacing of Basketball and Tennis Courts at Fishers Island
Project ID 12972
USE OF FUNDS TIMELINE SOURCES TOTAL
DASNY
Anticipated Dates Share In-Kind/Equity/Sponsor Other Sources
TASKS` Start End Amount Source Amount Entity Name Amount
Name
Reconstruction and I $50,000 Town of $17,000 $67,000
resurfacing of d �Oj ( � :)Oil Southold
basketball and 0(
tennis courts at
Fishers Island
Total Project Cost $50,000 $17,000 $67,000
Please note that the tasks set forth in this column must be those for which reimbursement or payment on invoice will be sought. Please
ensure that the task list is complete and includes all the tasks for which you will be submitting requisitions. The failure to do so may delay
payment.
Updated 7-28-14 l3
WILLIAM McQUAID DUFFY SCOTT A.RUSSELL
TOWN ATTORNEY O� OF SO!/rol Supervisor
C t
bill.duffyown.southold.ny.us y
DAMON A. RAGAN ~ O Town Hall Annex, 54375 Route 25
ASSISTANT TOWN ATTORNEY P.O. Box 1179
damonhC southoldtownny.gov Southold, New York 11971-0959
Telephone (631) 765-1939
"OUNTY���•` Facsimile (631) 765-6639
OFFICE OF THE TOWN ATTORNEY
TOWN OF SOUTHOLD
November 27, 2018
DASNY
515 Broadway
Albany, NY 12207
ATTN: Michael E. Cusack, General Counsel
RE: State and Municipal Facilities Program ("SAM") Grant
Reconstruction and Resurfacing of Basketball and Tennis Court at Fishers Island
Project ID 12972
Ladies and Gentlemen:
I have acted as counsel to the Town of Southold (the "Grantee") in connection with the Project
referenced above. In so acting, I have reviewed a certain Grant Disbursement Agreement
between you and the Grantee, executed by the Grantee on November 21, 2018 (the
"Agreement") and such other documents as I consider necessary to render the opinion expressed
hereby.
Based on the foregoing, I am of the opinion that:
1. The Grantee is duly organized, validly existing and in good standing under the laws of
the State of New York, and has full power and authority to execute and deliver the
Agreement and to perform its obligations thereunder; and
2. The Agreement was duly authorized, executed and delivered by the Grantee and is
binding on and enforceable against the Grantee in accordance with its terms.
Very T ly Yours,
VVI
Wil iam M. Duffy, s .
Southold Town Attorney
14
EXHIBIT C: Grantee Questionnaire
Updated 7-28-14 15
-Davi �
NEW YORK DASNY
STATE OF
OPPORTUNITY_
Grant Programs
Grantee Questionnaire
THIS QUESTIONNAIRE MUST BE COMPLETED IN FULL BEFORE DASNY WILL
PROCESS YOUR GRANT APPLICATION
If you have previously submitted a Grantee Questionnaire in the past six (6) months and there are no
changes since your last submission, please attach a signed and notarized Affidavit of No Change Form
along with your most recent copy of the previously submitted Grantee Questionnaire.The Form is attached
to the back of this document.
SECTION I: GENERAL INFORMATION j
1. GRANTEE(LEGALLY INC.NAME): /ID O f So LA0
2. FEDERAL EMPLOYER ID NO.(FEIN): V v D 1�3
3. D/B/A-DOING BUSINESS AS(IF APPLICABLE)::
COUNTY FILED: Sv f-(3 1 r
4. WEBSITE ADDRESS(IF APPLICABLE): S-0 U7 OI �O(,1/NNY.3 0 U
5. BUSINESS E-MAIL ADDRESS: vev/Sn @.S ou-A JJ DLVn/ '9 6V
6. PRINCIPAL PLACE OF BUSINESS ADDRESS: J O G S� !`y `�5 '!�o✓I' O N
! - �vV W-)v�`37. TELEPHONE NUMBER: / /bJ
8. DOES THE GRANTEE USE,OR HAS IT USED IN THE PAST FIVE(5)YEARS,ANY OTHER BUSINESS NAME,FEIN,
OR D/B/A OTHER THAN WHAT IS LISTED IN QUESTIONS 1-4 ABOVE?
❑ YES WNo
If yes, provide the name(s), FEIN(s) and d/b/a(s) and the address for each such entity on a
separate piece of paper and attach to this questionnaire.
9. AUTHORIZED CONTACT: //o
NAME: I/ '5 !1/cIff-0 V
TITLE: �� y L,/q/so j 0 f I (CCIA
TELEPHONE NUMBER: 4I / J �/ 6 FAX NUMBER:
E-MAIL: Vw/Sn �'9av
10. How MANY YEARS HAS THIS GRANTEE BEEN IN BUSINESS? /0 y
Page 1 of 8
12/4/2012
Grantee FEIN: l! COO [�3 f
11. TYPE OF BUSINESS (PLEASE CHECK APPROPRIATE BOX):
a) ❑ BUSINESS CORPORATION
b) ❑ PUBLIC RESEARCH INSTITUTION
C) ❑ ACADEMIC RESEARCH INSTITUTION
d) ❑ NOT-FOR-PROFIT RESEARCH INSTITUTION
e) ❑ NOT-FOR-PROFIT CORPORATION CREATED ON BEHALF OF
A PUBLIC,NOT-FOR-PROFIT PRIVATE OR ACADEMIC RESEARCH INSTITUTION
f) ❑ NOT-FOR-PROFIT CORPORATION CHARITIES REGISTRATION NUMBER:
g) ❑ LOCAL DEVELOPMENT CORPORATION OR INDUSTRIAL DEVELOPMENT AGENCY
h)49 MUNICIPALITY
1) ❑ UNrVERSI `Y/EDUCATIONAL ORGANIZATION
D ❑ OTHER—SPECIFY
12. PLEASE INDICATE WHETHER YOU BELIEVE THAT ANY OF THE INFORMATION SUPPLIED HEREIN IS
CONFIDENTIAL AND SHOULD BE EXEMPT FROM DISCLOSURE UNDER THE FREEDOM OF INFORMATION LAW:
❑YES @9 No
IF YOU CHECKED"YES"YOU MUST IDENTIFY THE INFORMATION YOU FEEL IS CONFIDENTIAL BY
PLACING AN ASTERISK IN FRONT OF THE APPROPRIATE QUESTION NUMBER(S)AND YOU ARE
REQUESTED TO ATTACH AN ADDITIONAL SHEET(S)UPON WHICH THE BASIS FOR SUCH CLAIM(S)IS
EXPLAINED.
YOU MAY ALSO REQUEST THAT THE CONFIDENTIAL DOCUMENTATION BE REVIEWED AND RETURNED
TO YOU AND NOT RETAINED BY THE AUTHORITY. PLEASE BE ADVISED,HOWEVER,THAT THE
AUTHORITY MUST COMPLY IN ALL RESPECTS WITH THE FREEDOM OF INFORMATION LAW.
Page 2of8
12/4/2012
SECTION H: GRANTEE CERTIFICATION AS TO PUBLIC PURPOSE
A. DEFINITIONS
AS USED HEREIN IN THIS GRANT PROGRAMS GRANTEE QUESTIONNAIRE:
1. "AFFILIATE"MEANS ANY PERSON OR ENTITY THAT DIRECTLY OR INDIRECTLY CONTROLS OR IS CONTROLLED
BY OR IS UNDER COMMON CONTROL OR OWNERSHIP WITH THE GRANTEE.
2. "GRANTEE" MEANS THE PARTY OR PARTIES RECEIVING FUNDS PURSUANT TO THE TERMS OF A GRANT
DISBURSEMENT AGREEMENT("GDA")TO BE ENTERED INTO BETWEEN THE GRANTEE AND DASNY OR
THEIR EMPLOYEES AND AFFILIATES.
3. "GRANT-FUNDED PROJECT" MEANS THE WORK THAT WILL BE FULLY OR PARTIALLY PAID FOR WITH THE
PROCEEDS OF THE GRANT, AS DESCRIBED IN THE PRELIMINARY APPLICATION, PROJECT INFORMATION
SHEET AND THE GDA,AND INCLUDES,BUT IS NOT LIMITED TO,ARCHITECTURAL,ENGINEERING AND OTHER
PRELIMINARY PLANNING COSTS,CONSTRUCTION,FURNISHINGS AND EQUIPMENT.
4. "RELATED PARTY"MEANS:(I)THE PARTY'S SPOUSE,(II)NATURAL OR ADOPTED DESCENDANTS OR STEP-
CHILDREN OF THE PARTY OR OF THE SPOUSE,(III)ANY NATURAL OR ADOPTED PARENT OR STEP-PARENT OR
ANY NATURAL,ADOPTED,OR STEP-SIBLING OF THE PARTY OR OF THE SPOUSE,(IV)THE SON-IN-LAW,
DAUGHTER-IN-LAW,BROTHER-IN-LAW,SISTER-IN-LAW,FATHER-IN-LAW OR MOTHER-IN-LAW OF THE PARTY
OR OF THE SPOUSE,(V)ANY PERSON SHARING THE HOME OF ANY OF THE PARTY OR OF THE SPOUSE,(VI)ANY
PERSON WHO HAS BEEN A STAFF MEMBER,EMPLOYEE,DIRECTOR,OFFICER OR AGENT OF THE PARTY WITHIN
TWO(2)YEARS OF THE DATE OF THIS GRANTEE QUESTIONNAIRE, AND(VII)AFFILIATES OR
SUBCONTRACTORS OF THE PARTY.
5. "SPONSORING MEMBER(S)" MEANS THE ASSEMBLY MEMBER OR STATE SENATOR WHO SPONSORED,
ARRANGED FOR AND/OR PROCURED THE GRANT.IN ADDITION,"SPONSORING MEMBER(S)"SHALL INCLUDE
THE GOVERNOR WHEN APPROPRIATE AS LISTED HEREIN.
B. GRANT AWARD
1. HAS THE GRANTEE OR ANY OF THE GRANTEE'S RELATED PARTIES PAID ANY THIRD PARTY OR AGENT,EITHER
DIRECTLY OR INDIRECTLY,TO AID IN THE SECURING OF THIS GRANT? ❑YES NNO
IF ANSWER IS"YES" PLEASE EXPLAIN:
F_
2. HAS THE GRANTEE OR ANY OF THE GRANTEE'S RELATED PARTIES AGREED TO SELECT SPECIFIC
CONSULTANTS, CONTRACTORS, SUPPLIERS OR VENDORS TO PROVIDE GOODS OR SERVICES IN CONNECTION
WITH THE GRANT-FUNDED PROJECT AS A CONDITION OF RECEIVING THE GRANT? ❑YES ANO
IF ANSWER IS"YES",PLEASE EXPLAIN:
3. WILL ALL CONSULTANTS, CONTRACTORS, SUPPLIERS AND VENDORS SELECTED TO PROVIDE GOODS OR
SERVICES IN CONNECTION WITH THE GRANT FUNDED PROJECT BE CHOSEN IN ACCORDANCE WITH THE
GRANTEE'S CONFLICT OF INTERESTS POLICY, OR IF CONSULTANTS, SUPPLIERS AND VENDORS RETAINED IN
CONNECTION WITH THE GRANT FUNDED PROJECT HAVE ALREADY BEEN SELECTED, WAS THE SELECTION
L3
UNDERTAKEN IN ACCORDANCE WITH THE GRANTEES CONFLICT OF INTEREST POLICY? ES ❑NO
IF GRANTEE'S GOVERNING BOARD HAS NOT ADOPTED A CONFLICT OF INTERESTS POLICY,PLEASE
STATE NONE.
IF ANSWER IS"NO" PLEASE EXPLAIN:
Page 3 of 8
12/4/2012 17
4. DOES THE SPONSORING MEMBERS) OR ANY RELATED PARTIES TO SPONSORING MEMBER(S) HAVE ANY
FINANCIAL INTEREST,DIRECT OR INDIRECT,IN THE GRANTEE OR IN ANY OF THE GRANTEE'S EQUITY OWNERS,OR
WILL THE SPONSORING MEMBERS OR ANY RELATED PARTIES TO SPONSORING MEMBERS RECEIVE ANY
FINANCIAL BENEFIT,EITHER DIRECTLY OR INDIRECTLY,FROM THE PROJECT FUNDED IN WHOLE OR IN PART WITH
GRANT PROCEEDS? ❑YES Z.NO
IF THE ANSWER IS"YES",PLEASE PROVIDE DETAILS IN SEPARATE APPENDIX ATTACHED TO THIS
CERTIFICATION.
SECTION III: DUE DILIGENCE QUESTIONS
1. DOES THE GRANTEE POSSESS ALL CERTIFICATIONS, LICENSES, PERMITS, APPROVALS, OR OTHER
AUTHORIZATIONS ISSUED BY ANY LOCAL, STATE, OR FEDERAL GOVERNMENTAL ENTITY IN CONNECTION WITH
THE PROJECT,GRANTEE'S SERVICES,OPERATIONS,BUSINESS,OR ABILITY TO CONDUCT ITS ACTIVITIES? PLEASE
NOTE THIS DOES NOT INCLUDE CONSTRUCTION RELATED ACTIVITIES SUCH AS BUILDING PERMITS AND
CERTIFICATES OF OCCUPANCY.
tQ YES ❑NO
IF THE ANSWER IS "NO", PLEASE SET FORTH ON A SEPARATE DOCUMENT ATTACHED HERETO THE
CERTIFICATIONS, LICENSES, PERMITS, APPROVALS, OR OTHER AUTHORIZATIONS THAT ARE
REQUIRED AND THE DATE(S) THAT SUCH CERTIFICATIONS, LICENSES, PERMITS, APPROVALS, OR
OTHER AUTHORIZATION IS EXPECTED.
2. ON A SEPARATE DOCUMENT ATTACHED HERETO,LIST ALL CONTRACTS THE GRANTEE HAS ENTERED INTO WITH
ANY NEW YORK STATE AGENCY, PUBLIC AUTHORITY, OR OTHER QUASI-STATE ENTITY, IN THE PAST FIVE (5)
YEARS. PLEASE LIST THE NAME, ADDRESS AND CONTACT PERSON FOR THE CONTRACTING ENTITY, AS WELL AS
THE CONTRACT EFFECTIVE DATES. ALSO PROVIDE STATE CONTRACT IDENTIFICATION NUMBER,IF KNOWN. ❑ N/A
3. ON A SEPARATE DOCUMENT ATTACHED HERETO,LIST ALL GRANTS RECEIVED FROM FEDERAL, STATE,AND
LOCAL ENTITIES TO FUND ALL OR A PORTION OF ANY COMPONENT OF THE PROJECT WITHIN THE PAST S YEARS. N/A
4. WITHIN THE PAST FIVE(S)YEARS,HAS THE GRANTEE, ANY PRINCIPAL,OWNER,DIRECTOR, OFFICER,MAJOR
STOCKHOLDER(10%OR MORE OF THE VOTING SHARES FOR PUBLICLY TRADED COMPANIES,25%OR MORE OF THE
SHARES FOR ALL OTHER COMPANIES), RELATED COMPANY OR AFFILIATE BEEN THE SUBJECT OF ANY OF THE
FOLLOWING:
(a) A JUDGMENT OR CONVICTION FOR ANY BUSINESS RELATED CONDUCT CONSTITUTING A CR]v
UNDER FEDERAL,STATE OR LOCAL GOVERNMENT LAW? ❑YES W NO
(b) BEEN SUSPENDED,DEBARRED OR TERMINATED BY A LOCAL,STATE OR FEDERAL AUTHORITY IN
CONNECTION WITH A CONTRACT OR CONTRACTING PROCESS? ❑YES W NO
(o) BEEN DENIED AN AWARD OF A LOCAL,STATE OR FEDERAL GOVERNMENT CONTRACT,HAD A
CONTRACT SUSPENDED OR HAD A CONTRACT TERMINATED FOR NON-RESPONSIBILITY? �
11YES FiNo
(d) HAD A LOCAL,STATE,OR FEDERAL GOVERNMENT CONTRACT SUSPENDED OR TERMINATED FOR
CAUSE PRIOR TO THE COMPLETION OF THE TERM OF THE CONTRACT? ❑YES % NO
(e) A CRIMINAL INVESTIGATION OR INDICTMENT FOR ANY BUSINESS RELATED CONDUCT CONSJTTUTING
A CRIME UNDER FEDERAL,STATE OR LOCAL GOVERNMENT? 1:1 YES NO
(fl AN INVESTIGATION FOR A CIVIL VIOLATION FOR ANY BUSINESS RELATED CONDUCT BY ANY
FEDERAL,STATE OR LOCAL AGENCY? ❑YES IN NO
Page 4of8
12/4/2012
(g) AN UNSATISFIED JUDGMENT,INJUNCTION OR LIEN FOR ANY BUSINESS RELATED CONDUCT
OBTAINED BY ANY FEDERAL STATE OR LOCAL GOVERNMENT AGENCY INCLUDING,BUT NOT
LIMITED TO,JUDGMENTS BASED ON TAXES OWED AND FINES AND PENALTIES ASSESSED BY ANY
FEDERAL,STATE OR LOCAL GOVERNMENT AGENCY? ❑ YES BNO
(h) A GRANT OF IMMUNITY FOR ANY BUSINESS-RELATED CONDUCT CONSTITUTING A CRIME UNDER
FEDERAL,STATE OR LOCAL LAW INCLUDING,BUT NOT LIMITED TO ANY CRIME RELATED TO
TRUTHFULNESS AND/OR BUSINESS CONDUCT? ❑ YES kl No
(1) AN ADMINISTRATIVE PROCEEDING OR CIVIL ACTION SEEKING SPECIFIC PERFORMANCE OR
RESTITUTION IN CONNECTION WITH ANY FEDERAL,STATE OR LOCAL CONTRACT OR LEASE?
❑ YES 10'NO
(j) THE WITHDRAWAL,TERMINATION OR SUSPENSION OF ANY GRANT OR OTHER FINANCIAL SUPPORT
BY ANY FEDERAL,STATE,OR LOCAL AGENCY,ORGANIZATION OR FOUNDATION?
❑YES ffNo
(k) A SUSPENSION OR REVOCATION OF ANY BUSINESS OR PROFESSIONAL LICENSE HELD BY THE
GRANTEE,A CURRENT OR FORMER PRINCIPAL,DIRECTOR,OR OFFICER OF THE GRANTEE,OR ANY
MEMBER OF THE ANY CURRENT OR FORMER STAFF OF THE GRANTEE? ❑YES 9 No
(1) A SANCTION IMPOSED AS A RESULT OF JUDICIAL OR ADMINISTRATIVE PROCEEDINGS RELATIVE TO
ANY BUSINESS OR PROFESSIONAL LICENSE? ❑YES > No
(m) A CONSENT ORDER WITH THE NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL
CONSERVATION,OR A FEDERAL,STATE OR LOCAL GOVERNMENT ENFORCEMENT DETERMINATION
INVOLVING A VIOLATION OF FEDERAL,STATE OR LOCAL LAWS? ❑YES Uj NO
(n) A CITATION,NOTICE,VIOLATION ORDER,PENDING ADMINISTRATIVE HEARING OR PROCEEDING OR
DETERMINATION FOR VIOLATIONS OF:
- FEDERAL,STATE OR LOCAL HEALTH LAWS,RULES OR REGULATIONS ❑YES NO
- UNEMPLOYMENT INSURANCE OR WORKERS'COMPENSATION ❑YES NO
- COVERAGE OR CLAIM REQUIREMENTS ❑YES [!7NO
- ERISA(EMPLOYEE RETIREMENT INCOME SECURITY ACT) ❑YES R NO
- FEDERAL,STATE OR LOCAL HUMAN RIGHTS LAWS ❑YES li�NO
- FEDERAL INS(IMMIGRATION AND NATURALIZATION SERVICE)AND
ALIENAGE LAWS,SHERMAN ACT OR OTHER FEDERAL ANTI-TRUST LAWS ❑YES [R NO
- A FEDERAL,STATE,OR LOCAL DETERMINATION OF A WILLFUL VIOLATION
OF ANY PUBLIC WORKS OR LABOR LAW OR REGULATION? ❑YES 51 No
- AN OCCUPATIONAL SAFETY AND HEALTH ACT CITATION AND
NOTIFICATION OF PENALTY CONTAINING A VIOLATION CLASSIFIED
AS SERIOUS OR WILLFUL? ❑YES 5�No
FOR EACH YES ANSWER TO QUESTIONS 4 A-N, PROVIDE DETAILS ON ADDITIONAL SHEETS REGARDING THE
FINDING,INCLUDING BUT NOT LIMITED TO CAUSE,CURRENT STATUS,RESOLUTION,ETC.
Page 5 of 8
12/4/2012
5. DURING THE PAST THREE(3)YEARS,HAS THE GRANTEE FAILED TO:
(4-1) FILE ANY RETURNS,INCLUDING,IF APPLICABLE,FEDERAL FORM 990,WITH ANY FEDERAL,STATE OR
LOCAL GOVERNMENT ENTITY? ❑YES *NO
IF YES,IDENTIFY THE RETURN THAT WAS NOT FILED,THE TYPE OF FORM,THE YEAR(S)IN WHICH THE REQUIRED
RETURN WAS NOT FILED,AND THE REASON WHY THE RETURN WAS NOT FILED:
(a-2) PAY ANY APPLICABLE FEDERAL,STATE,OR LOCAL GOVERNMENT TAXES? ❑YES QW0
IF YES,IDENTIFY THE TAXING JURISDICTION,TYPE OF TAX,LIABILITY YEAR(S)AND TAX LIABILITY AMOUNT
THE GRANTEE FAILED TO PAY AND THE CURRENT STATUS OF THE LIABILITY
(b) FILE RETURNS OR PAY NEW YORK STATE UNEMPLOYMENT INSURANCE? ❑YES WO
IF YES, INDICATE THE YEARS THE GRANTEE FAILED TO FILE/PAY THE INSURANCE AND THE CURRENT
STATUS OF THE LIABILITY:
(o) FILE DOCUMENTATION REQUESTED BY ANY REGULATING ENTITY SET FORTH IN SECTION III,QUESTION 1
ABOVE,WITH THE ATTORNEY GENERAL OF THE STATE OF NEW YORK,OR WITH ANY OTHER LOC,A�L/
STATE,OR FEDERAL ENTITY THAT HAS MADE A FORMAL REQUEST FOR INFORMATION? Fl YES VNO
IF YES, INDICATE THE YEARS THE GRANTEE FAILED TO FILE THE REQUESTED INFORMATION AND THE
CURRENT STATUS OF THE MATTER:
6. HAVE ANY BANKRUPTCY PROCEEDINGS BEEN INITIATED BY OR AGAINST THE GRANTEE, RELATED
ORGANIZATIONS, ENTITIES OR ITS AFFILIATES WITHIN THE PAST SEVEN (7) YEARS (WHETHER OR NOT
CLOSED) OR IS ANY BANKRUPTCY PROCEEDING PENDING BY OR AGAINST THE GRANTEE, RELATED
ORGANIZATIONS,ENTITIES OR ITS AFFILIATES,REGARDLESS OF THE DATE OF FILING? ❑YES M&O
IF YES,INDICATE IF THIS IS APPLICABLE TO THE SUBMITTING GRANTEE OR ONE OF ITS AFFILIATES:
IF IT IS AN AFFILIATE, RELATED ORGANIZATION OR ENTITY, INCLUDE THE AFFILIATE'S NAME AND
FEIN:
PROVIDE THE COURT NAME,ADDRESS AND DOCKET NUMBER:
INDICATE IF THE PROCEEDINGS HAVE BEEN INITIATED, REMAIN PENDING OR HAVE BEEN
CLOSED:
IF CLOSED,PROVIDE THE DATE CLOSED:
7. DOES GRANTEE HAVE THE FINANCIAL RESOURCES (IN EXCESS OF THE GRANT) TO FULFILL THE
REQUIREMENTS OF THE PROJECT�ESCRIBED IN THE PRELIMINARY APPLICATION OR PROJECT INFORMATION
SHEET? ❑YES ❑NO CZ/A,PROJECT IS FULLY FUNDED BY GRANT
IF YES, PLEASE SET FORTH ON A SEPARATE DOCUMENT ATTACHED HERETO THE SOURCE(S) OF THE
ADDITIONAL FUNDS NECESSARY TO COMPLETE THE PROJECT, THE TIMING OF THE AVAILABILITY OF THE
FUNDING, AND A CONTACT PERSON FOR EACH SOURCE. PLEASE BE ADVISED THAT DASNY MAY
CONTACT ONE OR MORE OF THE LISTED SOURCES TO VERIFY FUNDING AVAILABILITY.
IF NO,INDICATE HOW THE GRANTEE WILL FULFILL THE REQUIREMENTS OF THE PROJECT DESCRIBED IN THE
PRELIMINARY APPLICATION OR PROJECT INFORMATION SHEET AND THE TERMS OF THE GRANT
DISBURSEMENT AGREEMENT.
Page 6of8
12/4/2012
r
CERTIFICATION
THE GRANTEE CERTIFIES THAT ALL FUNDS THAT WILL BE EXPENDED PURSUANT TO THE TERMS OF THE
GDA TO BE ENTERED INTO BETWEEN DASNY AND THE GRANTEE ARE TO BE USED SOLELY AND DIRECTLY
FOR THE PUBLIC PURPOSE OR PUBLIC PURPOSES DESCRIBED IN THE PRELIMINARY APPLICATION,PROJECT
INFORMATION SHEET AND GDA.THE GRANTEE FURTHER CERTIFIES THAT ALL SUCH FUNDS WILL BE USED
SOLELY IN THE MANNER DESCRIBED IN THE PRELIMINARY APPLICATION,PROJECT INFORMATION SHEET,
AND GDA. THE GRANTEE FURTHER CERTIFIES THAT IT WILL UTILIZE THE REAL PROPERTY,
EQUIPMENT, FURNISHINGS, AND OTHER CAPITAL COSTS PAID FOR WITH GRANT PROCEEDS UNTIL SUCH
TIME AS THE GRANTEE REASONABLY DETERMINES THAT SUCH REAL PROPERTY, EQUIPMENT,
FURNISHINGS AND OTHER CAPITAL COSTS ARE NO LONGER REASONABLY NECESSARY OR USEFUL TO
FURTHER THE PUBLIC PURPOSE FOR WHICH THE GRANT WAS MADE.
THE UNDERSIGNED RECOGNIZES THAT THIS QUESTIONNAIRE IS SUBMITTED FOR THE EXPRESS PURPOSE OF
INDUCING DASNY TO MAKE PAYMENT TO THE GRANTEE FOR SERVICES RENDERED BY THE UNDERSIGNED
AND THAT DASNY MAY IN ITS DISCRETION,BY MEANS WHICH IT MAY CHOOSE,DETERMINE THE TRUTH
AND ACCURACY OF ALL STATEMENTS MADE HEREIN. THE UNDERSIGNED FURTHER ACKNOWLEDGES
THAT INTENTIONAL SUBMISSION OF FALSE OR MISLEADING INFORMATION MAY CONSTITUTE A FELONY
UNDER PENAL LAW SECTION 210.40 OR A MISDEMEANOR UNDER PENAL LAW SECTION 210.35 OR
SECTION 210.45,AND MAY ALSO BE PUNISHABLE BY A FINE OF UP TO$10,000 OR IMPRISONMENT OF UP TO
FIVE YEARS UNDER 18 U.S.C. SECTION 1001; AND STATES THAT THE INFORMATION SUBMITTED IN THIS
QUESTIONNAIRE AND ANY ATTACHED PAGES IS TRUE, ACCURATE AND COMPLETE.
THE UNDERSIGNED ALSO CERTIFIES THAT S/HE HAS NOT ALTERED THE CONTENT OF THE QUESTIONS IN
THE QUESTIONNAIRE IN ANY MANNER; HAS READ AND UNDERSTANDS ALL OF THE ITEMS CONTAINED IN
THE QUESTIONNAIRE AND ANY ATTACHED PAGES; HAS SUPPLIED FULL AND COMPLETE RESPONSES TO
EACH ITEM THEREIN TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF; IS
KNOWLEDGEABLE ABOUT THE SUBMITTING GRANTEE'S BUSINESS AND OPERATIONS;UNDERSTANDS THAT
DASNY WILL RELY ON THE INFORMATION SUPPLIED IN THIS QUESTIONNAIRE WHEN ENTERING INTO A
CONTRACT WITH THE GRANTEE;AND IS UNDER DUTY TO NOTIFY DASNYOF ANY MATERIAL CHANGES
TO THE GRANTEE'S RESPONSES HEREIN UNTIL SUCH TIME AS THE GRANT PROCEEDS HAVIR BEEN FULLY
PAID OUT T GRANTEE.
11112
Signa re of Authorized Officer Signature of Chair of the Board of Grantee
(or other Authorized Officer)
plitto-M P, kulalls
Printed Name of Authorized Officer Print Name of Chair of the Board of Grantee
(or other Authorized Officer)
'sem .emsc) 14--
Title o Authorized Offiger
Svi orn to before me this day-1 Swom to before me this),V day
of , ,201 , ofo4an4�/, , 201
f4oialy Public Notary Putflic
MICHELLE L. TOMASZ SKI
NOTARY PUBLIC-STATE OF NEW YORK MICHELLE L. TOMASZEWSKI
No. 01 T0615667 T NOTARY PUBLIC-STATE OF NEW YORK Page 7 of 8
12/4/2012 Qualified In Suffolk County No. 01T06156671 Print Form
My Commission Expires November 27,2018 Qualified in Suffolk County
My Commission Expires November 27, 2010
AFFIDAVIT OF NO CHANGE
Note: If you have previously submitted a Grantee*Questionnaire in the past six(6)months and there are
no changes since your last submission,please sign and notarize this Affidavit of No Change Form
and submit it along with your most recent copy of the previously submitted Grantee
Questionnaire.
If you have never filled out a Grantee Questionnaire you do not have to complete this form.
DASNY
GRANTEE:
The unders4mn l '
1. Iam
C� _(hereinafter the"Grantee"),
which is currently entt — 'NY.
2. Grantee pi �� •e within the past six
months pp in connection with the
Q,ryt v, (Grant Program)for
(Project).
3. Attached i nitted DASNY Grantee
Questionnaire.
4. I hereby cei material change in the information pertaining to
the Grantee Questionnaire:
U
AME
�J V1sa �
ITLE
Sworn
(.�before me this b
Notary Public, C
StaL. teofYork
�( da of �< No.OIS14984608
y is
Commission ExpiiresoJuly 29, �
)U
�o�I
otary Pu lic
rw
Page 8 of 8
12/4/2012
Town OT Southold
State Aid Contracts 2012-2016
Granting Agency Address Contact Information Contract No.
Description
Dormitory Authority of the State of New Sarah Antonacci,Grants Administrator(S18) —
York
1515 Broadway,Albany,NY 12207-296 .-- —4 257 3177 Pendin SAM Grant forPaysnc ReczmBa gviaevarc _
_ — g—._._..__..
New York Power Authority 123 Main Street,,White Plains.NY 10601 'Evan Kolkos,NYPA(914)681-6431 130407 Es$E N�aEn^DP,rr+nt
Division of Land and Water Resources,10B Airline David H.Behm,Farmland Protection Pro ram !— —'" --
NYS Department of A r g Maratooka North,LLC Farm Pro'ec - _g t
t-Development Right
jv _ g!culture Markets,Drive,Albany,NY 12235 Manager(518)485-7 29 _ IC800753 Easement
I Division of Land and Water Resources,10B Aldine !David H.Behm,Farmland Protection Program j Farmland Protection Implementation Grant-Round i3
NYS Department of Agriculture&Markets'Drive.Albany,NY 12235 `Manager(518)485-7729 Cg
00820 _ (RFP rant
1 'Division of Land and Water Resources,1 OB Airline iDavld H.Behm,Farmland Protection—Program — g
j NYS Department of Ag&Markets 'Drive,Albany NY 12235 !t g ! Farmland Protection Implementation Grant-Round 13
Manager(516j 485 7729 IC800821 IRFP grant
NYS Department of Environmental Division of Water,625 Broadway,Albany,NY 12233- !Karen Dauphinais,Bureau of Water
;i ---- -
Remediation Project in the Peconic Estuary
Conservation 3506 Stormwater Compliance(518)402-8177 !C303426 I
NYProgram
WS i -- -
!Dawn Mirabile,Division of Materials ; — --
iConservation :625 Broadway,9th Floor,Albany,NY 12233-7260 Management(518)402-8698 IT304525 ;HHW State Assistance Program(2011-2012)
NYS Department of Environmental _—
Dawn Mirabile,Division of Materials
Conservation --
-_—__...__._....._ 625 Broadway 9th Floor Albany NY 12233-7260 Management(518)402=8698 ;T304738 :HHW Assistance P .o ?�12-<<':1$j
YS Department of Environmental _ tate Assistan ar^( _
` ;Dawn Mirabile,Division of Materials i -
Conservation 1625 Broadway,9th Floor,Albany NY 12233 7260 Management(518)402-8698 _ ;T304909 WSW$ ce.ar_ora 713-20,14!
�—' :HHW Assistan _ m f2
!NYS Department of Environmental ""
;Dawn Mirabile,Division of Materials i ---
'Conservation 625 Broadway 9th Floor,Albany.NY 12233-7260 IMana�ement(518)402-8698 T305059 '.HHW State Assistance Program 201 20:5
(NYS Department of Environmental Dawn Mirabile,Division of Materials --
NYS De anon _ 625 Broadway 9th Floor Albany,NY 12233-7260 :Management(518)402-8698 .0 D,-^a
',--._._.....,. _...._ TOOD87GG ,,,riW State Assistamrr ,,,_r^;m 271=r
NYS Department of Environmental —_ —
Dawn Mirabile,Division of Materials
Conservation 625 Broadwa s 9th Floor,Albany NY 12233-7260 Management(518 402-8698
—. ...... *a" .... --" ) C304927 _ Screening Plant for Composting Facility
NYS Department of Environmental Dawn Mirabile,Division of Materials — —---
Conservation 625 Broadway,9th Floor,Albany,NY 12233-7260 Management 'MWRR State Assistance Program Project No 1-
.C305350 LMWRR-179(Windrow Turner)
_
County Of Suffolk-Office For The Aging,PO Box 6100, Joanne Kendall,Suffolk County Office for Aging;001-0000-000D-95285- `" f
I NYS Department of State Hauppauge NY 11788-0099 631 853-8212 010 (Distribution of Tablet Personal Computers to Seniors
One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources Planning,Design&Construction of 11 Storm-water
NYS Department of State �— Albany,NY 12231' _ :(518)486-9540 COD6793 (Management Protects
!One Commerce Plaza,99 Washington Ave.,Suite 1010,I Laurissa Parent Dnrision of Coastal Resources i
NYS Department of State Albany NY 12231 (518)486-9540 _ i C006877 I
— The Bittner Preserve Improvement Pro qct
I One Commerce Plaza,99 Washington Ave.,Suite 1010,f Laurissa Parent,Division of Coastal Resources: I — -
11 NYS Department of State Albany NY 12231 IStormwater Management in the Town of Southold
(516)466-9540 C006878 (Phase 11
i 'One Commerce Plaza,99 Washington Ave.,Suite 1010 Laurissa Parent,Division of Coastal Resources
NYS Department of State #Albany,NY 12231 (518)486-9540 1C006879 1Town of Southold LWRP Hamlet Study
,One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources
NYS Department of State Albenv,NY 12231 , Implementation of the Town of Southold Hamlet Study-1
{518)486 9540 1C007078 ?haze I!
One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources! — --- —
NYS Department of State Alban NY 12231: 486-9540
Washomomuck Po.;d Wa ars'ed Manage,rnent Plan
--- (518 488 9540 iC006880 imolemenat!on
J (One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources i Developing Priority lmoa+red Waterbody and SGA
NYS Department of State Albany NY 12231! 518 486-9540 1CO06975 Watershed Mama Plans
gem>_rt
One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources f '� --
`NYS Department of State Alban NY 12231 1CO06789 'Planning&Ge olooment n° cane Code Revisions i
r— 518 486-9540
One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources t Revisions of Town Code to Implement Stormwater
i NYSDem partment of State Albany,NY 12231 518 488-9540 C006792 Mana emant---
One
Commerce Plaza,99 Washington Ave.,Suite 1010,,Laurissa Parent,Division of Coastal Resources i —
__
NYS Department of State_ Alban NY 12231 5i8)486-9540 C007079 ;:Restoration of Goldsmiths Inlet
One Commerce Plaza,99 Washington Ave.,Suite 1010, Laurissa Parent,Division of Coastal Resources
NYS Department of State _ Alban NY 12231. 516),486-9540 ;710000269
( i
f Sputhofu Watershed and 9ewa:sneU tla1pj.2q
j State Office Building,Planning Room 5A•16,250 Brian Kraij,NYSDOT Regional CHt?�S !NYSDOT Municipal IConso(idated Local Si:..e:and Highway Improvement ,
NYS Department of Transportation Veterans Vternoliial'Highway,Hau u e,NY 11788 iRe resentative 631 952-6128
......._. Cade 070790 Prtram(CH3P5;
iStafe Office Building,Planning Room 5A-16,250 (Brian Kralj,NYSDOT Regional CHIPS INYS(DOT Municipal
NYS.Department of Transovrrtation `Veterans Memorta)Highway Ftauppacae NY 117'88 (Represemtat6ye(6'31 952-6126
Code 070790 Extreme Winteer Recovery;EY1R1 _
Page 1 oft
Town of oouthold
State Aid Contracts 2012-2016
I
Granting Agency I Address Contact Information
Contract No. Description
State Office Building,Planning Room 5A-16,250 ;Brian KraIj,NYSDOT Regional CHIPS TNYSDOT Municipal
NYS Department of Transportation ;Veterans Memorial Highway,Hauppauge,NY 11788 Resentative(631)952-6126 'Code 070790 PAVE NY
- _ --..._.
NYSDepartment of Transportation _50 Wolf Road,Aviation Bureau POD54 Albany 12232 !Denise Gerardi(518)457-8438 T034427 913.19 Environmental Study(PIED)
.. _.
*:YS o ra.ard Se urry and Emergency 11220 Washtngton,Avenue,State Office Building --' "- ------- --
Hurricane Sandy and its effects occuring in October
cm^"ce5 Campus,Bulldin '22,Suite 101,Albany,NY 12226- f Kristen Howle 518 292-2334
iN �(. 1 FEMA 4085 DR NY 12012
;NYS Homeland Security and Emergency 1220 Washington Avenue,State Office Building ' �� --" •-- to--
Severe Winter Storm and Snowsrm
Services Campus,Building 22,Suite 101,Albany NY 12226occuring in
_ Kristen Howley(518)292-2334 FEMA 4111 DR NY February 2013
NYS Homeland Security and Emergency ;1220 Washington Avenue,5tale Office Building -- -- ------ — ._._
i;Services !campus Buildin 22,Suite 10?,A-Ibanx,NY 12226- 'Kristen How% (518)292-2334 FEMA 1899 DR NY Severe Storms andFloodin of March 2010
NYS Homeland Security end Emergency '1220 Washington Avenue,State Office Building -- - ........... 9 -_
;Services !Campus,Building:22.Suite 101,Albany,NY 12226- :Kristen Howley(518)292-2334 FEMA 4020 DR NY !Hurricane Irene and its effects occuring in August 2011
Suffolk Coun Youth Bureau, �- - -_....__._�.. _.
3rd Floor PO Box 6100,eH.Lee Dennison Bullding,:Pat Policastro,Suffolk County Youth Bureau i Passed through i _ "
Gran-
NYS Homeland Security and Emergency 11220pWashingtonB lding 22enurt State Office
a 11788 (631)853 8269 Suffolk County QYDS :JAB Grant
NYS Division for Youth
Stale Office Building S W' rS d
Services a 101 Albany,NY 12226- :Kristen Howley(518 292-2334 !FEMA 1957.0 NY_ ;December 2�01D ter,,,and.,nov,"<.orm occur g
"' c r in in
Haun aOf Suffolk Office For The Aging,PO Box 6100, ;Joanne Kendall,Suffolk County Office for Aging I Pass through Suffolk
NYS Office farAginp _ 8-0099853-8212County Office for SNAP
�� - t e NY Suffolk
Office
-!Joan ' i
Hauppauge NY 1178
County Of Suffolk Office For The Aging,PO Box 6100, !Joanne Kendall,Suffolk County Office for Aging}Pass through Suffolk ; -"'-
I NYS Office for A ing 8-0099 ;(631)853-8212 County Office for dAAA Transportation
_. _ :- -
County Suffolk Office For The Aging,PO Box 6100, Joanne Kandell,Suffolk County Office for Aging taass 14�ournh Suffolk -
NYS.Office for Aging- Hauppauge NY 11786-0099 !(631)853-8212 icounty p,Bice!or <C$E Residential Repair
County Of Suffolk Office For The Aging,PO Box 6100,'Joanne Kendall,Suffolk County Office for Aging'Pass through Suffolk ---- -'
NYS Office for Aging Hauppauge NY 11788-0099 (631)853-8212 _ Cour ty Office for Wellness in Nutrition
Count/Qf Suffolk.t?ffice For The Aging,PO Box 6110, (Joanne Kandell,Suffolk County Office for Aging'Pass through Suffolk I '
NYS Office for Aging _ Hau cau e¢ NY 1178&0099 _x(631)853-8212 County Office for NYS Community Services for the Elderly
NYS Office of Children and Family (Suffolk County Youth Bureau,H.Lee Dennison Building,i 1Pat Policastro,Suffolk County Youth Bureau !Passed through 1
Services 3rd Floor.PO Boz 6100.Hauppauge,NY_11788 (631)853-8269 Suffolk County QYDS [Youth Bureau
_._....-
i Christa Vasto,Office of Justice Court Support '
-.._. _.
NYS Office of Court Administration 187 Wolf Road,Suite 103,Albany NY 12205 (5181 238 4347 !Application#2988 12014-2015 Justice Court Assrstaner. a-
_._
�Chnsta Vasto,Office of Justice Court Support I -
-
INYS Office of Court Administration 187 Wolf Road.Suite 103,Albany.NY 12205 (518)238-4347 (Application#3413 �2015-2016 Justice Court Assistance Pre �m
NYS Office of Parks,Recreation& Lf Region-Belmont State Park,PO Box 247,Babylon, 'Traci Christian,Grants Program Representative I ar` - -
I Historic Preservation - ;NY 11702-0247 : 1(631)321-3543 iEPF 540328-L2 Laurel Leke Preservat:an and Trail Plan
NYS Office of Parks,Recreation& 'Ll Reglon-Belmont State Park,PO Box 247,Babylon, 'Traci Christian,Grants Program RepresentativesHistoric Preservation NY 1/7020247 1 !(631)321-3543 IC112718 _ Pipes Cove Acuisition
NYS Divison of the Budget,State Capital,Albany,NY Welinda White,Division of Budget(518)474
NYS Office of the State Comptroller €12224 14747 (None Aid and Incentives for Mumai allies(AlfAl
,The University of he State of flew York,Grants I Mersa Dos Santos,Grants Finance(518)474- I -
l he State Education Deoartment Finance,Room S OW,Education 9uitdin .Albany.NY A815 Prosed#0580144561 ]GIs Implementation.
The University 5 the State of New York,Grants Mana Dos Santos,Grants Finance(518)474 `
jThe State Education Department {Finance Room 510W Education Building,Albany NY 14815 Prolect#0580155463 1Laserfi he PIO
Page 2 of 2
EXHIBIT D: Disbursement Terms
Town of Southold
Reconstruction and Resurfacing of Basketball and Tennis Courts at Fishers Island
Project ID 12972
Subject to the terms and conditions contained in this Agreement, DASNY shall disburse the
Grant to the Grantee as follows:
Standard Reimbursement
DASNY shall make payment to the Grantee, no more frequently than monthly, based
upon Eligible Expenses (as set forth and in accordance with the budget in Exhibit A) actually
incurred by the Grantee, in compliance with Exhibit A and upon presentation to DASNY of the
Payment Requisition Forms attached to this Agreement as Exhibit E and its attachments,
together with such supporting documentation as DASNY may require in order to clearly
demonstrate that Eligible Expenses were actually incurred by the Grantee in connection with
the Project described herein. Payment shall be made by reimbursement, subject to the terms
and conditions of Sections 4 and 5(a) of this Agreement or by payment on invoice subject to
the terms and conditions of Sections 4 and 5(b) of this Agreement.
Supporting documentation acceptable to DASNY must be provided prior to payment,
including invoices and proof of payment in a form acceptable to DASNY. If the fronts and backs
of canceled checks cannot be obtained from the Grantee's financial institution, a copy of the
front of the check must be provided, along with a copy of a bank statement clearly showing that
payment was made by the Grantee to the contractor. DASNY reserves the right to request
additional supporting documentation in connection with requests for payment, including the
backs of canceled checks, certifications from contractors or vendors, or other documentation to
verify that grant funds are properly expended. Please note that quotes, proposals, estimates,
purchase orders, and other such documentation do NOT qualify as invoices.
The Grantee agrees to provide such documentation to DASNY as may be requested by
DASNY in its sole and absolute discretion to support a requisition for payment, to determine
compliance by the Grantee with the terms of this Agreement or otherwise reasonably
requested by DASNY in connection with the Grant, and further acknowledges that if
documentation requested in connection with a requisition for payment does not, in the sole and
absolute discretion of DASNY, provide adequate support for the costs requested, that such
requisition request shall be denied and payment shall not be made to the Grantee.
All expenses submitted for reimbursement or payment on invoice must be for work
completed at the approved project location(s) and/or items received at the approved project
location(s) prior to the date of the request for reimbursement/payment. In addition, if funds are
requisitioned for the purchase of a vehicle, the New York State Vehicle Registration Documents
and title must be submitted along with the requisition forms.
Updated 7-28-14 16
EXHIBIT E: Payment Requisition Form and Dual Certification
Town of Southold
Reconstruction and Resurfacing of Basketball and Tennis Courts at Fishers Island
Project ID 12972
For Office Use Only:
FMS#: 143044 GranteeID: 3210 GrantID: 14044
Payment Request#
For work completed between / / and
THIS REQUEST:
A. B: DASNY SHARE' D:TOTAL E: B-C-D
TASK C:THIS REQUEST REQUESTED PRIOR BALANCE
TO THIS REQUEST
TOTAL:
Please note that the task numbers and DASNY Share amounts set forth in columns A and
B respectively must correspond to the tasks and DASNY Share amounts set forth in Exhibit
A. When submitting a requisition for payment, please remember that DASNY can
reimburse you for capital expenditures made by and invoiced to the Grantee set forth on
the cover page of this Agreement only. Capital expenditures include the costs of
acquisition, design, construction, reconstruction, rehabilitation, preservation, development,
improvement, modernization and equipping of a State and Municipal Facilities Program
facility.
DASNY may not reimburse Grantees or make payments on invoice for costs including, but
not limited to, the following: working capital, rent, utilities, salaries, supplies and other
administrative expenses.
Updated 7-28-14 17
EXHIBIT E: Payment Requisition Form and Dual Certification
DUAL CERTIFICATION
This certification must be signed by two Authorized Officers of the Town of Southold, for Project# 12972.
We hereby warrant and represent to DASNY that:
1. To the best of our knowledge, information and belief, the expenditures described in Payment
Requisition Request# attached hereto in the amount of$ for which Town of
Southold, is seeking payment and/or reimbursement comply with the requirements of the Agreement
between DASNY and Town of Southold (the "Agreement"), are Eligible Expenses, and that the
payment and/or reimbursement of expenditures for which it is seeking payment and/or reimbursement
from DASNY does not duplicate reimbursement or disbursement of costs and/or expenses from any
other source.
2. The warranties and covenants contained in Section 8 of the Agreement are true and correct as if made
on the date hereof.
3. The Eligible Expenses for which reimbursement is sought in connection with this requisition were
actually incurred by the Grantee named on the cover page of this Agreement, and/or will be paid by
the Grantee solely from the Segregated Account established pursuant to paragraph 4(d)of the Grant
Disbursement Agreement to the contractor named on the invoices submitted in connection with this
requisition and shall not be used for any other purpose.
4. All Project costs described in any contractor/vendor invoice submitted pursuant the payment
requisition form have been completely and fully performed prior to the date hereof.
5. Proof of disposition of funds from the Segregated Account to the contractor and/or vendors that are
being paid on invoice, if any, will be provided to DASNY within sixty(60) days of the date that Grant
funds are disbursed to the Grantee to pay for such costs. We understand that in the event that
acceptable proof of payment is not provided, DASNY will not make any additional disbursements from
Grant funds until such time as such proof of payment is provided.
6. We have the authority to submit this requisition on behalf of Town of Southold. The tasks have been
completed in the manner outlined in the Agreement.
7. The following documents are hereby attached for DASNY approval, in support of this requisition, and
are accurate images of the original documents (Please check off all that apply):
❑ Readable copies of both front and back of canceled checks
❑ Readable copies of the front of the checks and copies of bank statements showing that the checks
have cleared.
❑ Copy of New York State Vehicle Registration and Title documents for all vehicles purchased with
Grant funds.
❑ Invoices/receipts for eligible goods/services that have been received/performed at the approved
project location(s) and a completed Exhibit E-2: Payment Requisition Back-up Summary.
❑ Other-
Authorized Officer Signature: Date:
Print Name:
Title:
Authorized Officer Signature: Date
Print Name:
Title:
Updated 7-28-14 18
EXHIBIT E-I: Payment Requisition Cover Letter
ON GRANTEE'S LETTERHEAD
Date
Attention: Accounts Payable - Grants
DASNY
515 Broadway
Albany, New York 12207
Re: State and Municipal Facilities Program ("SAM') Grant
Reconstruction and Resurfacing of Basketball and Tennis Courts at Fishers Island
Project No. 12972
To Whom it May Concern:
Enclosed please find our request for payment/reimbursement. The package includes completed
Exhibits E and E-2, including a Dual Certification with original signatures from two authorized
officers. I have also included supporting documentation and invoices, as summarized in Exhibit
E-2.
Below I have checked off the relevant payment option and completed the required payment
information. This information is complete and accurate as of the date of this letter:
1) ❑ We would like to be paid by reimbursement pursuant to section 5(a) of the grant
disbursement agreement. Proof of payment is enclosed for all invoices submitted in this
request. Please remit payment by check.
OR
2) ❑ We would like to be paid by reimbursement pursuant to section 5(a) of the grant
disbursement agreement. Proof of payment is enclosed for all invoices submitted in this
request. Please remit payment by wire. The wire instructions for our account are as
follows:
BANK NAME: ACCOUNT#:
ACCOUNT NAME: ABA#:
OR
3) ❑ We would like to be paid on invoice pursuant to Section 5(b)of the grant disbursement
agreement.We have not paid the invoice(s) included in this request.We have established
a segregated account to be used solely for accepting and disbursing funds from
DASNY for this grant and for no other purpose. The wire instructions for this account
are as follows:
BANK NAME: ACCOUNT#:
ACCOUNT NAME: ABA#:
If any further information is needed, please contact me at ( )
Signature:
Print Name: Title:
Updated 7-28-14 19
EXHIBIT E-2: Payment Requisition Back-up Summary
Please list below all invoice amounts totaling the amount for which you are seeking reimbursement in this request.
Invoices should be organized and subtotaled by task#. Please use additional sheets if necessary.
Task#: Task Description:
VENDOR/ INVOICE/ AMOUNT REQUESTED COMMENT
CONTRACTOR NAME APPLICATION # FROM GRANT FUNDS
TOTAL Requested for Task: (Transfer to Exhibit E)
Task#: Task Description:
VENDOR/ INVOICE/ AMOUNT REQUESTED COMMENT
CONTRACTOR NAME APPLICATION# FROM GRANT FUNDS
TOTAL Requested for task: (Transfer to Exhibit E)
Task#: Task Description:
VENDOR/ INVOICE/ AMOUNT REQUESTED COMMENT
CONTRACTOR NAME APPLICATION # FROM GRANT FUNDS
TOTAL Requested for task: (Transfer to Exhibit E)
Updated 7-28-14 20
EXHIBIT F
NON-DISCRIMINATION AND AFFIRMATIVE ACTION POLICY FOR THE PROJECT
It is the policy of the State of New York and DASNY, to comply with all federal, State and local
law, policy, orders, rules and regulations which prohibit unlawful discrimination because of race,
creed, color, national origin, sex, sexual orientation, age, disability or marital status, and to take
affirmative action to ensure that Minority and Women-owned Business Enterprises (M/WBEs),
Minorities Group Members and women share in the economic opportunities generated by
DASNY's participation in projects or initiatives, and/or the use of DASNY funds.
1 ) The recipient of State funds represents that its equal employment opportunity policy
statement incorporates, at a minimum, the policies and practices set forth below:
a) Grantee shall (i) not unlawfully discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, sexual orientation, age,
disability or marital status, (ii) undertake or continue existing programs of affirmative
action to ensure that Minority Group Members and women are afforded equal
employment opportunities, and (iii) make and document its conscientious and active
efforts to employ and utilize M/WBEs, Minority Group Members and women in its
workforce on contracts. Such action shall be taken with reference to, but not limited to,
solicitations or advertisements for employment, recruitment, job assignment, promotion,
upgrading, demotion, transfer, layoff or termination, rates of pay or other forms of
compensation, and selection for training or retraining, including apprenticeship and on-
the-job training.
b) At the request of the AAO, the Grantee shall request each employment agency, labor
union, or authorized representative of workers with whom it has a collective bargaining
or other agreement or understanding, to furnish a written statement that such
employment agency, labor union, or representative does not unlawfully discriminate, and
that such union or representative will affirmatively cooperate in the implementation of the
Grantee's obligations herein.
2) The Grantee is encouraged to include minorities and women in any job opportunities
created by the Project; and to solicit and utilize M/WBE firms for any contractual
opportunities generated in connection with the Project.
3) Grantee represents and warrants that, for the duration of the Agreement, it shall furnish all
information and reports required by the AAO and shall permit access to its books and
records by DASNY, or its designee, for the purpose of ascertaining compliance with
provisions hereof.
4) Grantee shall include or cause to be included, paragraphs (1) through (3) herein, in every
contract, subcontract or purchase order with a Contracting Party executed in connection
with the Project, in such a manner that said provisions shall be binding upon each
Contracting Party as to its obligations incurred in connection with the Project.
NON-DISCRIMINATION AND AFFIRMATIVE ACTION DEFINITIONS
Affirmative Action
Shall mean the actions to be undertaken by the Borrower, Grantee and any Contracting Party in
connection with any project or initiative to ensure non-discrimination and Minority/Women-
owned Business Enterprise and minority/female workforce participation, as set forth in
paragraph 2) herein, and developed by DASNY.
Updated 7-28-14 21
Affirmative Action Officer ("AAO")
Shall mean DASNY's Affirmative Action Officer or his/her designee, managing the affirmative
action program for DASNY.
Contracting Party
Shall mean (i) any contractor, subcontractor, consultant, subconsultant or vendor supplying
goods or services, pursuant to a contract or purchase order in excess of$1,500, in connection
with any projects or initiatives funded in whole or in part by DASNY and (ii) any borrower or
Grantee receiving funds from DASNY pursuant to a loan or Grant document.
Minority Business Enterprise ("MBE")
Shall mean a business enterprise, including a sole proprietorship, partnership or corporation
that is (i) a lease fifty-one percent (51%) owned by one or more Minority Group Members; (ii) an
enterprise in which such minority ownership is real, substantial and continuing, (iii) an enterprise
in which such minority ownership has and exercises DASNY to control and operate,
independently, the day-to-day business decisions of the enterprise; (iv) an enterprise authorized
to do business in the State of New York and is independently owned and operated; and (v) an
enterprise certified by New York State as a minority business.
Minority Group Member
Shall mean a United States citizen or permanent resident alien who is and can demonstrate
membership in one of the following groups: (i) Black persons having origins in any of the Black
African racial groups; (ii) Hispanic persons of Mexican, Puerto Rican, Dominican, Cuban,
Central or South American descent of either Indian or Hispanic origin, regardless of race; (iii)
Asian and Pacific Islander persons having origins in any of the Far East countries, South East
Asia, the Indian subcontinent or the Pacific Islands; and (iv) Native American or Alaskan native
persons having origins in any of the original peoples of North America.
Minority and Women-Owned Business Enterprise Participation
Minority and Women-owned Business Enterprise participation efforts are not limited to the
efforts suggested herein, and the role of M/WBE firms should not be restricted to that of a
subcontractor/subconsultant. Where applicable, M/WBE firms should be considered for roles as
prime contractors. Such efforts may include but not be limited to:
(a) Dividing the contract work into smaller portions in such a manner as to permit
subcontracting to the extent that it is economically and technically feasible to do so;
(b) Actively and affirmatively soliciting bids from qualified M/WBEs, including circulation of
solicitations to Minority and Women's trade associations;
(c) Making plans and specifications for prospective work available to M/WBEs in sufficient
time for review;
(d) Utilizing the services and cooperating with those organizations providing technical
assistance to the Contracting Party in connection with potential M/WBE participation on
DASNY contract;
(e) Utilizing the resources of DASNY Affirmative Action Unit to identify New York State
certified M/WBE firms for the purpose of soliciting bids and subcontracts;
(f) Encouraging the formation of join ventures, associations, partnerships, or other similar
entities with M/WBE firms, where appropriate, and
(g) The Contracting Party shall remit payment in a timely fashion.
Updated 7-28-14 22
t . :♦`
Women-owned Business Enterprise ("WBE")
Shall mean a business enterprise, including a sole proprietorship, partnership or corporation
that is: (i) at least fifty-one percent (51%) owned by one or more citizens or permanent resident
aliens who are women; (ii) an enterprise in which the ownership interest of such women is real,
substantial and continuing, (iii) an enterprise in which such women ownership has and exercises
DASNY to control and operate, independently, the day-to-day business decisions of the
enterprise; (iv) an enterprise authorized to do business in the State of New York and is
independently owned and operated; and (v) an enterprise certified by New York State as
woman-owned.
Updated 7-28-14 23