R98-047RESOLUTION NO. R98-,¢'/,~'-
A RESOLUTION OF THE CITY COMMISSION OF THE
CITY OF BOYNTON BEACH, FLORIDA, AUTHORIZING
AND DIRECTING THE MAYOR AND CITY CLERK TO
EXECUTE AN AGREEMENT WITH THE SCHOOL
DISTRICT OF PALM BEACH COUNTY DEPARTMENT OF
CURRICULUM AND INSTRUCTION PROVIDING FOR
CHILD CARE SERVICES TO LOW INCOME FAMILIES
THROUGH THE LATCHKEY AFTERSCHOOL PROGRAM;
AND PROVIDING AN EFFECTIVE DATE.
WHEREAS, the City Commission of the City of Boynton Beach, upon
recommendation of staff, deems it to be in the best interests of the citizens of the
City of Boynton Beach to enter into an Agreement with the School District of Palm
Beach County to provide child care services to Iow income families through the
Latchkey Afterschool program.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
THE CITY OF BOYNTON BEACH, FLORIDA, THAT:
Section 1 The City Commission of-the City of Boynton Beach hereby
authorizes and directs the Mayor and City Clerk to execute an Agreement between
the City of Boynton Beach and the School District of Palm. Beach County to provide
child care services to Iow income families through the Latchkey Afterschool program
.Section 2. This Resolution shall become effective immediately upon passage.
PASSED AND ADOPTED this ,-~
day of March, 1998.
CITY OF BOYNTON
FLORIDA
Mayor
ATTEST:
c~mmis2~idner~./ / ~
~ ~6mmissioner
Cite Clerk
s:ca\reso\agreements\grantsSchjool District Agreement - Latchkey
2/23198
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SCHOOL DISTRICT OF PALM BEACH COUNTY
/� DEPARTMENT OF CURRICULUM AND INSTRUCTION
, 1 CHILD CARE SERVICES
4 PROVIDER APPLICATION
Section I. Provider Information
A. Full Legal Name Boynton Beach Latchkey Afterschool Program
Address 550 Miner Road, Boynton Beach, FL 33435
Federal I.D. Number: 596000282 Telephone: (561) 375 -6241
Name of Authorized Representative: (person responsible for
compliance with contractual requirements)
B. Legal Status:
Check one of the following
4
Proprietary
x Non- Profit
If non - profit, attach proof of your tax status and a list
of Board Members with titles.
Check one of the following
Unincorporated
Incorporated
If incorporated, attach a copy of your Certificate
of Status (see sample page 13) and a copy of your
Articles of Incorporation. Also complete the following:
Full Legal Name
of Corporation:
Doing Business As
(DBA) :
Date of Incorporation: State:
Corporation Address:
C. Signatu a of • ent /Chairman /Owner:
J S�� COMB MAYOR, CITY OF BOYNTON BEACH
D. o you p city taxes? Yes No x
If yes, what city (ies) .
E. Check the programs for which you are requesting to provide
services.
Subsidized Child Care
Job Training Partnership Act
Teenage Parent Program
Refugee /Entrant
Child Care Investment Fund
Child Care Purchasing Pool
F. Reimbursement checks may be mailed (indicate the address
below) or may be picked up at The Fulton - Holland Educational
Services Center, Child Care Services Office, 3310 Forest Hill
Blvd., C -223, West Palm Beach, FL 33406 -5813. Please
indicate your choice below:
x Mail to: Boynton Beach Latchkey Afterschool Program
P.O. Box 310
Boynton Beach, FL 33425
Pick up at Fulton - Holland Educational Service Center
G. Please provide a brief history of your agency or program.
(Additional pages may be attached.)
This program was originally created based on the 1988 report by the Federally
Mediated North Boynton Task Force which addressed the need for youth
programming in these areas during afterschool hours. It has successfully
been in operation for eight years, expanding several times since its inception.
The Boynton Beach Latchkey Afterschool Program is held at Rolling Green
Elementary School because the school center does not offer a SACC program.
It is designed to provide affordable afterschool care for low income families.
Eligibility requirements are that the child attends Rolling Green Elementary
and the parent /guardian(s) be employed during the programs hours of operation.
Work verification forms and other procedures are utilized to ensure the families
of greatest need are being served. Under the direction of lead person
Debbie Majors, who has ran the Latchkey Program since 1990, staff plan activities
to meet our objectives. Daily activities include homework assistance, snacktime,
outdoor games, physical fitness and various indoor activities, including arts
and crafts, music appreciation, and games. Special presentations occur seasonally.
H. Please provide a concise list of your program goals.
(Additional pages may be attached.)
1. To provide quality structured recreational, leisure, cultural, and educational
activities elementary age latchkey children during out of school hours.
2. To provide supervised activities to 115, (licensed capacity) elementary age
children at Rolling Green from 2:00 p.m.- 6:00 p.m. (early release days at 11:30 a.m
3. To maintain a ratio of no more than 20 children to 1 adult.
4. To provide activities such as; homework assistance, sports /physical fitness,
arts and crafts, cultural activities, and indoor games.
-2-
Attachment for Item G
History Continued
The program staff are trained, qualified personnel who have up to
seven years of experience with our program. They are familiar
with the children and ready to assist parents in identifying and
solving behavioral or school related problems.
Our organization has successfully operated the Latchkey
Afterschool Program for the past seven years, expanding to meet
increased demand. We have met our goal of providing afterschool
care to children who would otherwise go home to unsupervised
situations by offering a varied recreational program that
addresses children's physical, emotional, and intellectual well-
being.
4
I. Please provide a statement concerning the financial solvency
of your agency or program. (Additional pages may be attached.)
The City of Boynton Beach is a Governmental Agency. We have managed the Boynton
Beach Latchkey Afterschool program budget through Children's Services Council grant
funds for the past eight years. Our total operating budget for our agency
(Recreation and Park Department 1997 -98)is $1,934,091. Our total program budget
is $225,475. Parents pay fees based on the Department of Children and Families
Subsidized Child Care fee schedule. The City of Boynton, Rolling Green Elementary,
and Children's Services Council provide cash and in kind services to sustain the
program budget.
J. Please provide a statement concerning your reputation in the
community, including special achievements and awards.
(Additional pages may be attached.)
The Recreation Department is highly respected in our community. The following
are associations & awards received that relate to youth and /or the effective
management of our program. 4
1. Dedicated service and special citations as Chairman of Revenue Sources
Management School Board of Regents from NRPA and North Carolina State University:
Recreation Superintendent 1991, 1993
2. Graduates of Boynton Beach Chamber of Commerce Leadership Program 1992, 1996
3. Members of the International Festival and Events Association, Florida
Festivals and Events Association, International Society of Arboriculture,
National Youth Sports Coaches Association and the Boynton Beach Chamber of
Commerce.
4. Recognized for innovative programming in the Florida League of Cities,Inc.
City Innovations Showcase annual publication.
5. Palm Beach County Youth Sports Commission Members
6. 1993 FRPA Dorothy Mullen Award for Boynton's G.A.L.A. festival Youth Art.
K. Please provide a description of the developmentally
appropriate curriculum used by your program. (Additional pages
may be attached.)
1. Staff prepare weekly activity plans with input from the children, which
are reviewed by their supervisor weekly and quarterly by CSC.
2. Our curriculum consists of the following:
Homework Assistance
Sports /Physical Fitness activities
Arts and crafts projects
Cultural enhancement activities (storytelling, musical, and drama)
3. We provide 6 week activity modules through the Out -of- School consortium
to enhance learning opportunities for the children throughout the year.
-3-
PROVAPP.I
Attachment for Item J
Community Reputation Continued
Through effective budget management, we were able to provide 40 summer
camp scholarships to children enrolled in our program at the end of 1997.
Without this financial assistance, many low income families may have been forced
to leave their children unsupervised while they worked.
1
Section II: Center Information (Complete a separate Section II for
each site to be included in the contract)
A. Center Name: Boynton Beach Latchkey Afterschool Program
B. Center Address: 550 Miner Road (Rolling Green Elementary)
Boynton Beach, FL 33435
C. Mailing Address: P.O. Box 310- Recreation Dept.
Boynton Beach, FL 33425 -0310
D. Telephone: (561) 375 -6241 Fax: (561) 375 -6238
E. Center Director /Facility Supervisor: Debbie Majors /Janice Phillips
F. Schedule of Operation Hours G. Licensed Capacity
Monday 2 to 6 Infants
Tuesday 2 to 6
Wednesday 2 to 6 All Others 115
Thursday 2 to 6
Friday __,_ to 6 Total 115
Saturday closed to closed
Sunday closed to
H. List your rates charged to the general public.
Age Category Full Time (up to Part Time (up Registration
10 hrs a day) to 5 hrs a day) Fee
Infants Weekly Weekly N/A
(0 -12 mos.)
Daily Daily
Toddlers Weekly Weekly
(13 -23 mos.) N/A
Daily Daily
Toddlers Weekly Weekly
(24 -35 mos.) N/A
Daily Daily
Preschoolers Weekly Weekly N/A
(3 -5 years)
Daily Daily
-4-
Fees vary due to Dept. of Children and Families Subsidized Fee Scale in use.
Age Holiday/ Before & After Registration
Cat. Full Day Care Fee
School Weekly$1 - $50 Weekly $.50 -$25 N/A
Aged
Daily $.20 -$10 Daily $.10
Before Care After Care *Early Release
Weekly N/A Weekly N/A No additional
charge
Daily Daily
* 8 days during the school year when the public school system
releases children at 11:30 A.M.
I. Do your services include extended (non - traditional) hours of
care (evenings & weekends)? Yes X No
If yes, explain your rates for this type of care.
J. Do you give discounts to families with more than one child
enrolled? X Yes No
If yes, explain your discounted rates.
Siblings pay 50% of predetermined rate for primary enrolled child.
K. List your adult to child ratios that are consistently
maintained. Only direct supervision may be counted.
1 adult to infants (age 0 to 12 mos.)
1 adult to toddlers (age 13 -23 mos.)
1 adult to toddlers (age 24 -35 mos.)
1 adult to preschoolers (age 3 -5 yrs.)
1 adult to 20 school -aged children
L. Transportation Services
(Please answer yes or no to the following questions.)
Do you transport children? yes (If answer is no, go to N.)
Do you provide transportation for field trips? yes
Do you provide transportation to your after school
program? no
Do you provide transportation to and from children's _
homes? no
Do you own your transportation vehicles? yes
Do you lease your transportation vehicles? no
—5—
M. List the ele. tary schools for which r center provides
transportation services for school -aged cnildren:
Rolling Green Elementary
N. Do you receive subsidy from the Child and Adult Care Food
Program for meals served? Yes x No
0. What meals /snacks do you provide? snack only
P. Is there a separate charge for meals? Yes x No
If yes, list charges.
Q. List the days your center will be closed in 1998. (12 holidays
per calendar year are reimbursable)
New Years Day Memorial Day Veteran's Day Labor Day
Martin Luther King Day Thanksgiving Christmas Eve
President's Day Independence Day Day After Thanksgiving Christmas Day
R. List names of staff member(s) with a college degree or
recognized credential, if a CDA, designate if National or
State of Florida:
Name Type of Credential
Debbie Majors B.A.
Rita Leidner B.A.
Stephanie Hodovan B.A.
—6—
For staff not credentialed, how many hours of training were
attained for the last year July 1, 1997 through the present
time. List names and number of hours.
Name Number of hours
Janice Phillips 8
Tina Bostick 4
Andrene Beckford -May 20
Venise Charles 20
Barbara Bridgett 10
Holli Mayrsohn 6
S. List any special accreditations your center has earned (such
as NAEYC, Gold Seal, etc.). Attach a copy to your application.
We are currently pursuing NSACA accreditation.
T. Attach a copy of your Center's License to your application.
U. Attach an original Certificate of Insurance to your
application. (See insurance requirements Attachment V)
V. Attach a parent handbook to your application.
W. Attach a published rate sheet to your application.
-7-
PROVAPP II
Section III - Provider Qualification and Information
A. The provider shall meet all licensing standards to provide
center -based child care services and shall meet any other
applicable local requirements.
B. The provider shall conform to Chapter 65C -21, Florida
Administrative Code, Subsidized Child Care as required by the
Department of Children and Families. (See Attachment VI which
you may keep.)
C. Award of vendor agreement does not guarantee placement of any
child to a particular center. Placement is contingent upon
parental choice and availability of funds.
D. The final agreement between the School District of Palm Beach
County and the provider will follow a standard School District
Child Care Services vendor agreement format, and can be
expected to contain those performance requirements and terms`
and conditions normal to the conduct of a child care program.
The following will familiarize the prospective applicant with
those particular vendor agreement terms and conditions.
E. The provider shall be qualified and eligible to receive a
vendor agreement under applicable public policy law, Chapter
65C -21, Florida Administrative Code, Subsidized Child Care, or
Federal requirements, whichever is more stringent. The center
must be maintained at all times so as to be in compliance with
state and local licensing and fire regulations.
F. The provider agrees that the child care facility shall not
exceed the licensed or allowable capacity designated on the
license or the certificate of compliance at any given time.
All children under the supervision of the facility at any one
time, whether or not on the premises, including children
related to staff members, shall be counted in determining
compliance with the licensed or allowable capacity.
G. The provider agrees to require all credentialed staff to
complete 12 hours of in- service training annually and non -
credentialed staff to complete 40 hours of in- service training
annually. (Credentialed staff who work 20 hours or less per
week must complete 6 hours of training annually and non -
credentialed staff who work 20 hours or less per week must
complete 20 hours of training annually.)
H. Convenient hours of operation must be maintained in order to
meet the needs of working parents. The program must operate
a minimum of ten hours per day to begin no later than 7:30
A.M. and close no earlier than 5:30 P.M.
-8-
I. Client eligibility and authorization for service must be made
by the School District Child Care Services office only. No
eligible child may be denied service when space and funding
are available. Clients are determined eligible as per each
program's guidelines.
J. A current record must be maintained on each child in the
program. The record must include current Application for
Services, Addendum bearing valid authorization for the
provision of services, release of information form, enrollment
and attendance data, appropriate documentation of prolonged
excused absences, information pertaining to the child's health
and immunization record, and pertinent information regarding
the child's parents or caretaker. The provider must identify
specific staff to maintain and submit appropriate
documentation.
K. The provider must demonstrate the ability to provide year -
round services in a healthy and safe environment that is
conducive to creative development and promotion of exploration
and experimentation by the child.
The indoor /outdoor equipment, supplies, and educational aids
must be suitable to the size and age of the children
contracted for, and in a variety and sufficiency to serve the
total enrollment. Parents must be provided with opportunities
convenient to them to observe their children in the program,
and to work with the program whenever possible.
L. The provider shall maintain books, records and documents in
accordance with appropriate accounting procedures and
practices which sufficiently and properly reflect all
expenditures of funds and revenues. These books, records and
documents shall be available at all times to inspection,
review, or audit by the funding agencies.
M. The provider shall not assign the responsibility of this
vendor agreement to another party nor subcontract with another
party without prior written approval of the School District.
In the event of a change in ownership the prospective buyer
may submit as application for vendor agreement, subject to
approval of the School District. This process may take up to
six weeks.
N. Subsidized Child Care is federally and state funded through
the State of Florida, Department of Children and Families.
There is an 8% local donor requirement.
The Refugee /Entrant Program is federally funded through
the State of Florida, Department of Children and Families.
The Teenage Parent Program is funded by the Florida Education
Finance Plan and managed by the Department of Education.
-9-
The Job Training Partnership Act (JTPA) is federally funded
and is administered locally by the Palm Beach County Workforce
Development Board.
The Child Care Purchasing Pool is federally funded through the
Department of Children and Families. This program promotes
public /private partnerships in child care. There is a 50%
local donor requirement.
The Child Care Investment Fund is funded by the Children's
Services Council in collaboration with District IX Department
of Children and Families and the School District of Palm Beach
County. To be eligible to provide services under the Child
Care Investment Fund providers must meet one of the following
criteria:
1. Child Care Centers accredited by the National Association
for the Education of Young Children.
2. Child Care Centers funded by the Children's Services
Council for other programs.
3. Child Care Centers actively involved in the "Quality F
Assurance Project" meeting established criteria.
4. Child Care Centers actively pursuing NAEYC accreditation
meeting established criteria.
0. Payment for services will be negotiated for each funding
source up to the maximum daily rates allowed for child care
services established by the funder.
Following are the approved current maximum daily rates
allowed by the Department of Children and Families. Rates
paid from state funding cannot exceed those charged to the
general public. Rates must be justified by the program.
Full Time Daily Part Time Daily
Infants $23.00 $18.00
Toddler (13 -23 mos.) $22.00 $18.00
Toddler (24 -35 mos.) $19.00 $15.80
Preschool $18.60 $14.40
School -Age $15.00 $ 9.00
Following are the approved current maximum daily rates allowed
by the Children's Services Council.
Full Time Daily Part Time Daily
Infant $23.00 N/A
Toddler (13 -23 mos.) $22.00 N/A
Toddler (24 -35 mos.) $20.00 N/A
Preschooler $20.00 N/A
Schoolage $20.00 $10.00
The rates listed above must cover all fees required by the
vendor except transportation fees and late pick -up fees.
-10-
P. The School District shall reimburse the provider on a monthly
basis for services rendered. Reimbursement will be based on
attendance of eligible children enrolled using the State of
Florida, Department of Children and Families' definition of
enrollment.
Noncompliance or failure to maintain accurate attendance data
will be considered a breach of contract and may result in
immediate termination of the vendor agreement.
The submission and verification of expenses and the payment of
same by the School District Finance Department often require
several weeks. IT IS ADVISABLE, THEREFORE, THAT ORGANIZATIONS
CONTRACTING WITH THE SCHOOL DISTRICT HAVE AVAILABLE SUFFICIENT
WORKING CAPITAL TO MEET INTERIM EXPENSES FOR A PERIOD OF AT
LEAST EIGHT (8) WEEKS.
Q. The School District reserves the right to request clarifica-
tion of information submitted in any application, as well as
to request additional information from any applicant.
R. Unless the provider's breach is waived by the School District
in writing, the School District may, by written notice to the
provider, terminate this vendor agreement upon no less than
twenty -four (24) hours notice. Said notice shall be delivered
by certified mail, return receipt requested, or in person with
proof of delivery.
S. In the event any of the provisions of this application are
violated by the provider, the Superintendent or her designee
shall give written notice to the provider stating the
deficiencies and unless the deficiencies are corrected within
ten (10) days, recommendation will be made to the School
District for immediate cancellation. Upon cancellation
hereunder the School District of Palm Beach County, Florida,
may pursue any and all legal remedies as provided herein and
by law. The School District of Palm Beach County, Florida,
reserves the right to terminate any vendor agreement resulting
from this invitation at any time and for any reason, upon
giving thirty (30) days prior written notice to the other
party. If said vendor agreement should be terminated for
convenience as provided herein, the School District shall be
relieved of all obligations under said vendor agreement. The
School District of Palm Beach County shall only be required to
pay to the provider that amount of the agreement actually
performed to the date of termination.
T. Awardee by virtue of signature on page one (1) of the
Application (authorized signature must be done manually),
certifies that he or she has not been convicted of a public
entity crime as defined in Section 287.133 of the Florida
State Statutes. A public entity crime as defined in Section
-11-
287.133 of the Florida State Statutes includes a violation of
any state or federal law by a person with respect to and
directly related to the transaction of business with any
public entity in Florida or with any agency or political
subdivision of any other state or with the United States,
including, but not limited to, any bid or contract for goods
or services to be provided to any public entity or such agency
or political subdivision and involving antitrust, fraud,
theft, bribery, collusion, racketeering, conspiracy or
material misrepresentation. Attached is a certificate to be
completed and submitted with the application. (Attachment I)
U. The School District of Palm Beach County must be named
additional insured on the provider's general liability policy.
Vendor agreements will not be released until the certificate
of insurance meeting the requirements is received. (See
Attachment V for insurance requirements which you may keep.)
V. The provider shall notify the School District in writing of
any change in the authorized representative and /or Center
Director responsible for the administration of the program
under said vendor agreement.
W. The provider must, prior to vendor agreement execution,
complete the Certification Regarding Lobbying form. Attached
is the form to be completed and submitted with the
application. (Attachment II) -
X. The provider must, prior to vendor agreement execution,
complete the Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion form. Attached is the
form to be completed and submitted with the application.
(Attachment III)
Y. The provider must achieve a minimum score of 70% on the last
monitoring with the Child Care Program Assessment Tool or 70%
on a pre- service monitoring. (See Attachment VII which you may
keep.)
Z. Centers owned by minorities, and /or women, may apply for
Minority Vendor Status by contacting Alfred Jones at 434 -8508.
I have read Section III of the Child Care Services Provider
Application and understand its contents.
W.s/8
Sig ture of President /Chairman /Owner Date
...69n7E.5 .
Name Typed or Printed -
Title
PROVAPP.M -12-
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed on the day
and year written above
ATTEST
By By
J ES TITCUMB, VICE MAYOR Carmen A Alfonso, Program Planner
City of Boynton Beach School District of Palm Beach County
Approved as to form and
legal sufficiency
9J Chu/
mes Cherof, City ACtorney
City of Boynton Beach
2 20 08 y in \M
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Attachment I
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted to The School Dristrict of Palm RParh Colinry
[print name of the public entity]
by
[print individual's name and title]
for Boynton Beach Latchkey Afterschool Program
[print name of entity submitting sworn statement]
whose business address is
Rolling Green Elementary School, 550 Miner Road, Boynton Beach, FL 33435
and (if applicable) its Federal Employer Identification Number (FEIN) is 596000282
(If the entity has no FEIN, include the Social Security Number of the individual signing this
sworn statement: .)
2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of
business with any public entity or with an agency or political subdivision of any other state or of the United
States, including, but not limited to, any bid or contract for goods or services to be provided to any public
entity or an agency or political subdivision of any other state or of the United States and involving antitrust,
fraud, theft, br collusion, racketeering, conspiracy, or material misrepresentation.
3. I understand that 'convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means
a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
federal or state trial court of record relating to charges brought by indictment or information after July 1,
1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. I understand that an °affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the management of-the entity and
who has been convicted of a public entity crime. The term °affiliate° includes those officers, directors,
executives, partners, shareholders; employees, members, and agents who are active in the management of
an affiliate. The ownership by one person of shares constituting a controlling interest in another person,
or a pooling of equipment or income among persons when not for fair market value under an arm's length
agreement, shall be a prima facie case that one person controls another person. A person who knowingly
enters into a joint venture with a person who has been convicted of a public entity crime in Florida during
the preceding 36 months shall be considered an affiliate.
5. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural
person or entity organized under the laws of any state or of the United States with the legal power to enter
into a binding contract and Which bids or applies to bid on contracts for the provision of goods or services
let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The
term °person° includes those officers, directors, executives, partners, shareholders, employees, members, and
agents who are active in management of an entity.
Attachment II
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and
belief, that:
(1) No federal appropriated funds have been paid or will be paid, by
or on behalf of the undersigned, to any person for influencing or
attempting to influence an officer or an employee of any agency,
a member of congress, an officer or employee of congress, or an
employee of a member of congress in connection with the awarding
of any federal contract, the making of any federal grant, the
making of any federal loan, the entering into of any cooperative
agreement, and'the extension, continuation, renewal, amendment,
or modification of any federal contract, grant, loan, or
cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid
or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a member of
congress, an officer or employee of congress, or an employee of a
member of congress in connection with this federal contract,
grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form -LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this
certification be included in the award documents for all
subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans and cooperative agreements) and
that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which
reliance was placed when this transaction was made or entered into.
Submission of this certification is a prerequisite for making or
entering into this transaction imposed by section 1352, Title 31, U.S.
Code. Any person who fails to file the required certification shall
be subject to a civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
Y u g7,fAv iv /996
Sign ure Date
Ti!>WS ;i
Name of Authorized Individual Application or Contract Number
City of Boynton Beach, 100 East Boynton Beach Blvd., Boynton Beach, FL 33435
Name and Address of Organization
At tachment III
Contract No. -
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS /SUBCONTRACTS
This certification is required by the regulations implementing Executive
Order 12549, Debarment and Suspension, signed February 18, 1986. The
guidelines were published in the May 29, 1987 Federal Register (52 Fed.
Reg., pages 20360 - 20369).
INTRR1JCTIONS
1. Each provider whose contract /subcontract equals or exceeds $25,000 in federal monies must sign this certification
prior to execution of each contract/ subcontract. Additionally, providers who audit federal programs must also
sign, regardless of the contract amount. HRS cannot contract with these types of Providers if they are debarred or
suspended by the federal oovemment
2. This certification is a material representation of fact upon which reliance is placed when this contract/subcontract is
entered into. If it Is later determined that the signer knowingly rendered an erroneous certification, the Federal
Govemment may pursue available remedies, including suspension and /or debarment.
3. The provider shall provide immediate written notice to the contract manager at any time the provider fears that its .
certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms 'debarred,' . suspended.' 'Ineligible,' 'person,' 'principal,' and voluntarily excluded,' as used in this
certification, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. You may contact the contract manager for assistance in obtaining a copy of those regulations.
5. The provider agrees by submitting this certification that, it shall not knowingly enter into any subcontract with a
person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this
contract/subcontract unless authorized by the Federal Government.
6. The provider further agrees by submitting this certification that it will require each subcontractor of this
contract/ subcontract, whose payment will equal or exceed $25,000 in federal monies, to submit a signed copy of
this certification.
7. The Department of Health and Rehabilitative Services may rely upon a certification of a provider that it is not
debarred, suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it knows that the
certification is erroneous.
8. This signed certification must be kept in the contract manager's contract file. Subcontractor's certifications must
be kept at the contractor's business location.
CERTIFICATION
(1) The prospective provider certifies, by signing this certification,
that neither he nor his principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this contract /subcontract by any federal
department or agency.
(2) Where the prospective provider is unable to certify to any of the
statements in this certification, such prospective provider shall
attach an e lanation to this certification.
✓/.:.... -�- 119E
Signature Date