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R25-145 RESOLUTION NO. R25-145 3 A RESOLUTION OF THE CITY COMMISSION OF BOYNTON BEACH, 4 FLORIDA, APPROVING MODIFICATION NO. 3 TO EXTEND THE 5 SUBRECEIPIENT GRANT AGREEMENT NO. H0861 WITH FLORIDA 6 DIVISION OF EMERGENCY MANAGEMENT ("FDEM") HAZARD 7 MITIGATION GRANT PROGRAM ("HMGP") FOR THE CITY'S 8 WATERSHED MANAGEMENT PLAN TO SEPTEMBER 30, 2025 AND 9 EXECUTE ALL FUTURE DOCUMENTS ASSOCIATED WITH THE GRANT, 10 SUBJECT TO THE APPROVAL OF THE CITY ATTORNY; AND FOR ALL 11 OTHER PURPOSES. 12 13 WHEREAS, the Community Rating System ("CRS") is a voluntary program under the 14 Federal Emergency Management Agency ("FEMA") allowing communities to earn flood insurance I5 discounts of up to 45%; and 16 WHEREAS, under FEMA's National Flood Insurance Program ("NFIP"), cities and non- 17 incorporated areas can earn points for conducting floodplain management activities that surpass 18 the minimum NFIP requirements; and 19 WHEREAS, the Watershed Planning Initiative ("WPI") is federally funded through the 20 Hazard Mitigation Grant Program ("HMGP") and administered by the Florida Division of 21 Emergency Management ("FDEM") to assist Florida Communities to improve CRS Class ranking, 22 which in turn reduces National Flood Insurance rates for Florida residents and enhances mitigation 23 practices in communities that are vulnerable to flood risks; and 24 WHEREAS, the City of Boynton Beach ("CITY") is currently a CRS Class 5 community, 25 achieving up to 25% discount on flood insurance policies, but seeks to achieve a CRS Class 4 26 ranking in order to increase the flood insurance discount to 30%; and 27 WHEREAS, for the City to achieve a CRS Class 4 ranking, the City needs to create and 28 adopt a Watershed Master Plan; and 29 WHEREAS, on June 16, 2022, the City submitted an application for funding to prepare a 30 Watershed Master Plan, coordinating with FEMA reviewers to ensure acceptance and approval of 31 the Master Plan documents to fulfill CRS Class 4 requirements; and 32 WHEREAS, the Executed Contract Agreement No. H0861, dated December 1, 2022, 33 provided a period of performance ("POP") ending on September 30, 2023, and gave the City 34 insufficient time to accomplish the goals and objectives of the WMP; and 35 WHEREAS, a period of performance extension of 12-months was granted to Amendment 36 No. 1 and was signed by the Mayor on July 12, 2022; and 37 WHEREAS, the City required additional time, and thus Amendment No. 2 included a 6- 38 month extension with a completion date of March 31, 2024; and 39 WHEREAS, the City's Utilities Department and Grants Office seek approval of Modification 40 No. 3 to provide a 6-month extension with a completion date of September 30, 2025, to complete 41 the project and finalize the grant; and .42 WHEREAS, the City Commission, upon the recommendation of staff, has deemed it in the 43 best interests of the City's citizens and residents to approve Modification No. 3 to the Hazard 44 Mitigation Grant Program Contract No. H0861 between the City and the Florida Division of 45 Emergency Management to extend the term until September 30, 2025. 46 47 NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF BOYNTON 48 BEACH, FLORIDA, THAT: 49 SECTION 1. The foregoing "Whereas" clauses are hereby ratified and confirmed as 50 being true and correct and are hereby made a specific part of this Resolution upon adoption. 51 SECTION 2. The City Commission of the City of Boynton Beach, Florida, does hereby 52 approve Modification No. 3 to the Hazard Mitigation Grant Program Contract No. H0861 between 53 the City and the Florida Division of Emergency Management to extend the term until September 54 30, 2025, in form and substance similar to that attached as Exhibit A. 55 SECTION 3. The City Commission of the City of Boynton Beach, Florida, hereby 56 authorizes the Mayor to execute the Modification. The Mayor is further authorized to execute any 57 ancillary documents required under the Agreement or necessary to accomplish the purposes of 58 the Agreement and this Resolution, including any term extensions as provided in the Agreement, 59 provided such documents do not modify the financial terms or material terms. 60 SECTION 4. The Mayor-executed Modification shall be forwarded to Mirna Crompton 61 to obtain execution of the Modification by the Florida Division of Emergency Management. Mirna 62 Crompton shall be responsible for ensuring that one fully executed Modification is returned to 63 the City, to be provided to the Office of the City Attorney for forwarding to the City Clerk for 64 retention as a public record. 65 SECTION 5. This Resolution shall take effect in accordance with the law. 66 `- - 67 PASSED AND ADOPTED this 0 day of -lKQ.. 2025. 68 CITY OF BOYNTON BEACH, FLORIDA 69 YES NO 70 Mayor- Rebecca Shelton 71 72 Vice Mayor-Woodrow L. Hay 1/ 73 74 Commissioner-Angela Cruz 75 76 Commissioner-Thomas Turkin 77 78 Commissioner-Aimee Kelley - S e 79 80 VOTE L-O 81 AT ST: 82 83 1:&A,I� . .i 84 Maylee e isus, MPA, C Rebecca Shelton 85 City Clerk Mayor 86 ` 87 .'OFB9Y!VTo`,, APPROVED AS TO FORM: 88 (Corporate Seal) 01 SEA ••GORPpR�T�2��,I • ►, 89 f SEAL .� ,/, 90 'I NCDRPDRATED:• i 91 .14 + • .••1920 Shawna G. Lamb 92 1��� ••••••• ••• City Attorney SUB-RECIPIENT AGREEMENT CHECKLIST DIVISION OF EMERGENCY MANAGEMENT MITIGATION BUREAU FISCAL OPERATIONS UNIT HMGP REQUEST FOR REVIEW AND APPROVAL SUB-RECIPIENT: City of Boynton Beach PROJECT#: 4337-004-Pg PROJECT TITLE: Boynton Beach Watershed Management Plan CONTRACT#: H0861 MODIFICATION#: Three SUB-RECIPIENT REPRESENTATIVE(POINT OF CONTACT) Eduardo Garcia Engineer I 124 E. Woolbright Road Boynton Beach, Florida 33435 Enclosed is your copy of the proposed contract/modification between City of Boynton Beach and the Florida Division of Emergency Management (FDEM). COMPLETE ® This form is required to be included with all Reviews, Approvals, and Submittals ® Reviewed and Approved ® Signed & Dated Electronic Copy by Official Representative ® Copy of the organization's resolution or charter that specifically identifies the person or position that is authorized to sign, if not Chairman, Mayor, or Chief Attachment I - Federal Funding Accountability and Transparency Act (FFATA) - completed, signed, and dated ® N/A for Modifications or State Funded Agreements ❑ Attachment K— Certification Regarding Lobbying - completed, signed, and dated ® N/A for Modifications or State Funded Agreements ® Attachment L — FACTS - completed, signed, and dated ❑ N/A for Modifications or State Funded Agreements ❑ Attachment M — Foreign County of Concern Affivadit completed, signed, and dated ® N/A for Modifications or State Funded Agreements ® Electronic Submittal to the Grant Specialist If you have any questions regarding this contract, or who is authorized to sign it, please contact your Project Manager at (850) 325-5736 or email me at Caitlyn.Stroik©em.myflorida.com. Contract Number: H0861 Project Number: 4337-004-Pg MODIFICATION TO SUBGRANT AGREEMENT BETWEEN THE DIVISION OF EMERGENCY MANAGEMENT AND CITY OF BOYNTON BEACH This Modification Number Three made and entered into by and between the State of Florida, Division of Emergency Management ("the Division"), and City of Boynton Beach ("the Sub-Recipient")to modify Contract Number H0861, dated, December 1, 2022 ("the Agreement"). WHEREAS, the Division and the Sub-Recipient have entered into the Agreement, pursuant to which the Division has provided a subgrant to the Sub-Recipient under the Hazard Mitigation Grant Program of$246,832.50, in Federal Funds; and WHEREAS, the Division and the Sub-Recipient intend to modify the Agreement; and WHEREAS, the Agreement expired on March 31, 2025; and WHEREAS, the Division and the Sub-Recipient intend to reinstate and extend the terms of the Agreement. NOW, THEREFORE, in consideration of the mutual promises of the parties contained herein, the parties agree as follows: 1. The Agreement is hereby reinstated and extended as though it had never expired. 2. Paragraph 8 of the Agreement is hereby amended to read as follows: (8) PERIOD OF AGREEMENT This Agreement shall begin December 1, 2022 and shall end September 30, 2025, unless terminated earlier in accordance with the provisions of Paragraph (17) of this Agreement. 3. The Budget and Scope of Work, Attachment A to the Agreement, are hereby modified as set forth in 3rd Revision Attachment A to this Modification, a copy of which is attached hereto and incorporated herein by reference. 4. All provisions of the Agreement being modified and any attachments in conflict with this Modification shall be and are hereby changed to conform with this Modification, effective on the date of execution of this Modification by both parties. 5. All provisions not in conflict with this Modification remain in full force and effect, and are to be performed at the level specified in the Agreement. 6. Quarterly Reports are due to the Division no later than 15 days after the end of each quarter of the program year and shall be sent each quarter until submission of the administrative close-out report. The ending dates for each quarter of the program year are March 31, June 30, September 30 and December 31. 7. Attachment L- Florida Accountability Contract Tracking System (FACTS) Requirements for Non- profit Organizations Under Section 216.1366, Florida Statutes, Instructions and Worksheet is hereby incorporated into the Agreement and is required to be completed by the subrecipient and returned the Division. IN WITNESS WHEREOF, the parties hereto have executed this Modification as of the dates set out below. SUB-RECIPIENT: CITY OF BOYNTON BEACH By: CITY ATT RNEY'S 0 FI Approve to form an' -47 ity Name and Title: Rebe ��cc.c. sv, tv,�.) 014(.04 By: 014(.04B 6 Y: Date: , )Us�Q. 5 I D0 i�J�•••ORf'�, 1 STATE OF FLORIDA i /NCQRpp , :.L ' DIVISION OF EMERGENCY MANAGEMENT sig •;•• j 92 RgTEO: By: ���oRIDA Name and Title: Kevin Guthrie, Director Date: Attachment A Watershed Master Planning Initiative Boynton Beach Watershed Management Plan Scope of Work and Budget Statement of Purpose The Florida Division of Emergency Management's (the Division) Bureau of Mitigation prioritizes flood risk management as an integral part of its mission. The goals of this project are to assist local communities in developing a Watershed Master Plan for the purposes of moving up in the Community Rating System (CRS) of the National Flood Insurance Program (NFIP) and to increase resiliency in Florida communities. This project is funded through the Hazard Mitigation Grant Program (HMGP) DR-4337-004-P, as approved by the Division and the Federal Emergency Management Agency (FEMA)to create and update Watershed Master Plans (WMPs)throughout the state of Florida. The Project Manager for the Division will be: Laura Dhuwe, Project Manager Hazard Mitigation Grant Program Florida Division of Emergency Management 850-879-0872 watershedplanninqAem.myflorida.com Scope of Work The Division will coordinate with eligible Florida entities to produce a Watershed Master Plan (WMP)for credit under CRS. This project is preceded by the WMP Pilot Program, which consisted of research and the creation of guidance materials to ensure a consistent statewide approach to WMP development. Guidance materials produced in the WMP Pilot Program can be found at: https://www.floridadisaster.orq/dem/mitiqation/watershed-planninq-initiative or https://www.fau.edu/enqineering/research/cwr3/clearinqhouse/. The Sub-Recipient may use other materials provided by ISO and located at https://fema.gov. The Sub-Recipient shall follow the Credit Criteria for Element WMP under CRS Activity 452.b (please refer to the 2017 CRS Coordinator's Manual' and the 2021 Addendum to the Coordinator's Manual2). The Sub-Recipient will finalize the process by submitting their WMP to ISO/CRS for review and providing the Division with a signed letter from their applicable county's Local Mitigation Strategy (LMS) Chairperson attesting that the WMP will be adopted in the Sub-Recipient's next LMS update. Tasks necessary to the completion of a WMP include: Task 1 —Create Preliminary Project Plan based on Initial Flood Modeling, and Submit Draft WMP The Sub-Recipient shall create a preliminary Project Plan, which is a narrative detailing how the initial flood modeling has sufficient detail on the data that went into the model, model specifications, and possible solutions for addressing flood risks that the model identified. There must be enough detail in the preliminary Project Plan to verify the required analysis has been completed. Specifically, the required 1 https://www.fema.gov/sites/default/files/documents/fema_community-rating-system_coordinators- manual_2017.pdf 2 https://www.fema.gov/sites/default/files/documents/fema_community-rating-system_coordinator- manual_addendum-2021.pdf analysis for the preliminary Project Plan shall include all the Minimum Criteria required for a creditable WMP3 under the two categories of Data Inventory and Collection and Initial Flood Modeling as follows: Data Inventory and Collection: 1. Data inventory (used for initial flood modeling): a. Inventory of ground characteristics (e.g., soil type, impervious surfaces, wetlands) b. Inventory of existing drainage system c. Inventory of data availability 2. Locations of: a. critical facilities, cultural/historical, and other places/areas of interest b. vulnerable areas and their descriptions c. natural and constructed drainage systems and channels 3. Existing regulations and plans in place for reducing flood risks Initial Flood Modeling 4. For current/existing conditions land use, future land use, and the fully developed watershed scenarios: a. Evaluations of the existing drainage system's runoff response from design storms using a hydrologic and hydraulic study with a hydrograph approach under current and predicted future land use conditions with assessments of the impacts of climate change and sea level rise for 10-, 25-& 100-year storm events b. For currently fully developed watersheds: studies of existing development and the potential impact of any redevelopment c. Evaluations of different management scenarios for at least the 100-year rainfall event for a fully developed watershed at a scale sufficient to determine local problems. d. Determinations of the change in runoff from current to future, fully developed conditions e. Recommendations for managing at least the 10-year and the 25-year rainfall events 5. For communities impacted by sea level rise: evaluations of the impacts of the NOAA Intermediate 2100 sea level rise scenario on the 100-year rainfall event a. It is highly recommended to include 2 other scenarios up to 2100, which could be based on sea level for 2 time frames into the future or a number of feet of sea level rise within this timeframe. 6. The plan must include a strategy and action plan to address the results of the studies for: a. controlling the timing of peak flows to prevent or minimize problems for the entire watershed due to new development, redevelopment, and fully developed conditions 3 See 2017 CRS Coordinator's Manual at https://www.fema.gov/sites/default/files/documents/fema community-rating-system coordinators- manual 2017.pdf; the 2021 Addendum to the Coordinator's Manual at https://www.fema.gov/sites/default/files/documents/fema community-rating-system coordinator- manual addendum-2021.pdf; and other materials provided by ISO located at https://fema.gov. b. the impact of climate change and sea level rise on fully developed conditions c. at least the 25-year rainfall event in fully developed conditions, with a list of possible solutions for addressing at least the 25-year rainfall event d. at least one event larger than the 25-year rainfall event, with a list of possible solutions for addressing this event e. ensuring that flood hazards from the 10-year and the 25-year events are not increased by future development (the 2-year storm is also recommended). 7. The community must adopt the final plan. 8. If applicable, WMP plans more than 5 years old must be evaluated to ensure that they remain applicable to current conditions. For instance, are previous assumptions on hydrology, sea level rise and future land use still applicable. Deliverable 1: An (1) electronic copy of the preliminary Project Plan; (2) a separate electronic document listing how and where in the preliminary Project Plan the Minimum Criteria listed above are met; and (3) a separate electronic document clarifying the Sub-Recipient's existing data inventory at the time of contract execution, how the data are used, and which tasks and efforts have already been completed prior to contract execution. These three electronic documents must be submitted to the Division for review no later than 25 months after the beginning of the Period of Performance. The Sub-Recipient will provide Deliverable 1 to the Division via email to watershedplanninq(c�em.myflorida.com. Payment for Task 1 will occur once the Sub-Recipient has received feedback from the Division confirming that their preliminary Project Plan has been approved. To be approved, the preliminary Project Plan must show how all the listed Minimum Criteria required for a creditable WMP are intended to be met. The Period of Performance begins with the date of execution of the subgrant agreement by both parties, and the Sub-Recipient shall provide the Division with the following no later than 25 months from the beginning of the Period of Performance before payment will be processed. Jurisdiction Specific Comments for Task 1: Data collection for structures -The Sub-Recipient's project will include a high-quality stormwater inventory which is a critical foundational dataset for any stormwater program. It enables the government to more efficiently operate and maintain the system, evaluate capital improvement projects, adapt to climate change, apply for funding, and markedly improve public safety—among many other benefits. Specifically, the project will include conducting a survey to create a stormwater inventory that includes: • Diameters • Pipe Material • Inverts and other key elevations • Structure information and photos • Pipe Length • A geodatabase/GIS with the information. This dataset will directly interface with, and greatly enhance, the City's existing ICPR model. Initial Flood Modeling and Draft WMP Project Plan -The Sub-Recipient's project will evaluate the future conditions, including the impacts of a median projected sea level rise (based on the National Oceanic and Atmospheric Administration's (NOAA's) "intermediate-high" projection for the year 2100) on the local drainage system during multiple rainfall events, including the 100-year rainfall event. This option is for coastal communities with no natural or constructed channels. Guidance on sea level rise projections for CRS purposes can be found in Section 404 of the CRS Coordinator's Manual. Future-conditions should include a projected change in land use to determine the change in runoff from current to future, fully developed conditions. The NOAA intermediate high projection for Boynton Beach is 3.9 ft NAVD88 of sea level rise which must at a minimum be used for the SLR evaluation. During the project, the Sub-Recipient's project team will submit preliminary data for a courtesy review to identify any areas where the project needs to focus on or modify. Additionally, the Sub-Recipient will clarify in writing which tasks and efforts have already been completed prior to contract execution. With the mapping efforts, the Sub-Recipient shall provide the source and dates of data acquisition, locational accuracy, and map projection and coordinate system information of geospatial data. Task 2—Revise Draft WMP and Submit Completed WMP After receiving feedback from the Division on the preliminary Project Plan from Task 1 (Deliverable 1), the Sub-Recipient shall finalize the flood modeling process and submit their completed WMP. At a minimum, the modeling and WMP must meet the Minimum Criteria required for a creditable WMP shown above. The Sub-Recipient shall update their WMP, if revisions are necessary based on the Division's feedback, and submit the completed WMP to the Division for review. Throughout the activities for Task 2, the Sub-Recipient shall coordinate with the applicable LMS working group to ensure that the working group will adopt the WMP as an annex in the next LMS update, and use the data to inform the risk assessment and mitigation strategy. Deliverable 2: An electronic copy of the completed WMP will be submitted to the Division no later than 33 months after the beginning of the Period of Performance. If applicable, the Sub-Recipient will revise the submitted WMP to comply with required revisions and feedback from the Division, and then resubmit the WMP to the Division no later than 33 months after the beginning of the Period of Performance. The Period of Performance begins with the date of execution of the subgrant agreement by both parties, and the Sub-Recipient shall provide the Division with the following no later than 33 months from the beginning of the Period of Performance before payment will be processed: 1. the completed WMP4 (after incorporating comments from the Division, if applicable); and 2. a signed letter from the applicable county's Local Mitigation Strategy (LMS) Chairperson attesting that the completed WMP will be adopted and used to update the risk assessment and mitigation strategy during the next LMS plan update. The Sub-Recipient will provide Deliverable 2 to the Division via email to watershedplanning(a�em.myflorida.com. Method of Compensation: All deliverables submitted to the Project Manager or to the Division shall be completed by the Sub- Recipient and approved for completeness and accuracy by the Project Manager or the Division to qualify as reaching the minimum required criteria for each invoice period. All tasks shall be performed under the direct supervision of the Division. The project shall be reimbursed upon receipt of invoices submitted at the completion and acceptance of each deliverable defined above unless this agreement is terminated early. This is a cost reimbursement agreement, which will be reimbursed on a fixed-fee, fixed-price agreement as follows: 4 See the Minimum Criteria required for a creditable WMP listed above. Deliverables Total Due Date Deliverable Value Task 1 —Create Preliminary Project Plan based $191,920.00 25 Months after on Initial Flood Modeling, and Submit Draft beginning of POP WMP Task 2—Revise Draft WMP and Submit $137,190.00 33 months after Completed WMP beginning of POP Total $329,110.00 Financial Consequences for Non-Performance: The failure to provide the Division with the required deliverables within the stated timelines shall result in a penalty of 5 % of the determined deliverable amount for each late deliverable. Penalty may be waived based upon reasonable explanation with documentation by Sub-Recipient. Should the Sub-Recipient determine that there are significant barriers to conduct any of the minimum deliverables due to extenuating circumstances, the Division may re-evaluate performance expectations upon a formal request from the Sub-Recipient. If the Sub-Recipient fails to comply with any terms of the agreement, the Division shall take one or more of the following actions: 1. Temporarily withhold cash payments pending correction of the deficiency by the Sub-Recipient; 2. Disallow all or part of the cost of the activity or action not in compliance; 3. Wholly or partially suspend or terminate the current agreement for the Sub-Recipient's project; 4. Withhold further agreements for the project; or 5. Take other actions that are legally allowed. Schedule of Work Task(s) Number of Months to Complete Field work and data collection for structures (Task 1) 8 Initial Flood Modeling (Task 1) 9 Preliminary Project Plan (Task 1) 8 Revise Draft WMP and Submit Completed WMP (Task 2) 8 Total Period of Performance: 33 Total Period of Performance The Period of Performance for this project begins on the date of execution of the subgrant agreement by both parties and ends no later than September 30, 2025. Budget Cost Item Project Cost Federal Share Non-Federal Share Personnel Fringe Benefits Travel Equipment Supplies Contractual $329,110.00 $246,832.50 $82,227.50 Other Project Total: $329,110.00 $246,832.50 $82,227.50 Funding Summary Totals Federal Share: $246,832.50 75.00% Non-Federal Share: $82,227.50 25.00% Total Project Cost: $329,110.00 100.00% Attachment L Florida Accountability Contract Tracking System (FACTS) Requirements for Non-profit Organizations Under Section 216.1366, Florida Statutes Instructions and Worksheet PURPOSE: Section 215.985, Florida Statutes (F.S.), amended in 2023, requires that each contract for which a state entity makes a payment pursuant to a contract executed, amended, or extended on or after July 1, 2023, the Division shall post any documents submitted pursuant to s. 216.1366, F.S., which indicates the use of state funds as remuneration under the contract or a specified payment associated with the contract on the contract tracking system. CONTRACT DOCUMENTATION REQUIREMENTS Section 216.1366, F.S., amended in 2023, establishes new documentation requirements for any contract for services executed, amended, or extended on or after July 1, 2023, with non-profit organizations as defined in s. 215.97 (2)(m). F.S. The contract must require the contractor to provide documentation that indicates the amount of state funds: • Allocated to be used during the full term of the contract for remuneration to any member of the board of directors or an officer of the contractor. • Allocated under each payment by the public agency to be used for remuneration of any member of the board of directors or an officer of the contractor. The documentation must indicate the amounts and recipients of the remuneration. Such information must be included in the contract tracking system maintained pursuant to s. 215.985 F.S. and must be posted on the contractor's website if the contractor maintains a website. • As used in this subsection, the term: o "Officer" means a Chief Executive Officer (CEO), Chief Financial Officer(CFO), Chief Operating Officer (COO), or any other position performing an equivalent function. o "Remuneration" means all compensation earned by or awarded to personnel, whether paid or accrued, regardless of contingency, including bonuses, accrued paid time off, severance payments, incentive payments, contributions to a retirement plan, or in-kind payments, reimbursements, or allowances for moving expenses, vehicles and other transportation, telephone services, medical services, housing, and meals. o "State funds" means funds paid from the General Revenue Fund or any state trust fund, funds allocated by the Federal Government and distributed by the state, or funds appropriated by the state for distribution through any grant program. The term does not include funds used for the state Medicaid program. Note: This "Instructions and Worksheet" is meant to explain the requirements of the Section 216.1366, F.S., amended in 2023, and give clarity to the attached form distributed to recipients and sub-recipients for completion. All pertinent information below should be filled out, signed, and returned to the project manager. NON-PROFIT ORGANIZATION REMUNERATION INFORMATION 1. Is your business or organization a non-profit organization as defined in s. 215.97 (2)(m). F.S.? Yes ❑ No ❑ If the answer to Question 1 is "Yes," continue to Question 2. If the answer to Question 1 is "No", move to the signature block below to complete the certification and submittal process. 2. Will state funds be used as remuneration to any member of the board of directors or an officer in your business or organization? Yes ❑ No ❑ If the answer to Question 2 is "Yes," provide the information required in the "Total Compensation Paid to Non-Profit Personnel Using State Funds" form below. A separate form should be completed for each member of the board of directors or officer being compensated using state funds. If the answer to Question 2 is "No", move to the signature block below to complete the certification and submittal process. Total Compensation Paid to Non-Profit Personnel Using State Funds Name: Title: Agency Agreement/Contract# Total Contract Amount Contract Term: Line Item Budget Category Total Amount Paid Amount Paid from State Funds Salaries Fringe Benefits Bonuses Accrued Paid Time Off Severance Payments Retirement Contributions In-Kind Payments Incentive Payments Reimbursements/Allowances Moving Expenses Transportation Costs Telephone Services Medical Services Costs Housing Costs Meals CERTIFICATION: I certify that the amounts listed above are true and accurate and in accordance with the approved budget. Name: Signature: Title: Date: