HomeMy WebLinkAboutResolution - 2016-R0413 - AAA Direct Purchase Services Program Grant Agreement - TXDADS, SPAG - HHS Funds - 11/17/2016Resolution No. 2016-RO413
Item No. 6. 1.1
November 17, 2016
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for
and on behalf of the City of Lubbock, an Area Agency on Aging Direct Purchase of Services
Program Grant Agreement and related documents from the State of Texas, acting by and
through the Texas Department of Aging and Disability Services and the South Plains
Association of Governments (SPAG), for funds passed through the U.S. Department of
Health and Human Services to the State of Texas. Said Grant Agreement will be used to
provide an integrated service delivery system to meet the needs of older individuals and their
caregivers, and the grant funds will be used only for the purposes for which they are
intended under the grant. Said Grant Agreement is attached hereto and incorporated in this
resolution as if fully set forth herein and shall be included in the minutes of the City
Council.
Passed by the City Council on November 17, 2016
L�- —
DANIEL M. PO E, MAYOR
ATTEST:
ebecca 4Garz,ty ecretary
APPROVED AS TO CONTENT:
ks & Recreation
Hr r IX" V r.L [ia it v r vruvl:
S
Justi Ci , Assist nt City Attorney
ccdocs.--RES. Grant Agreement 2017 SPAG Aging Grant
October 28, 2016
Resolution No. 2016-R0413
44 The South Plains Association of Governments Area Agency on Aging
SP AG Direct Purchase of Service
Fiscal Year 2017 Vendor Application/Renewal Update
South Pains Assacl�bn
of Goremmeau
Please type or clearly print application information.
City of Lubbock
Vendor Name/Legal Entity
DBA (if applicable)
//AreaAgency
)jZon
Aging
Physical Address:
2001 19th Street (Lubbock Activit Center), Parks Administration, 1611 10th Street, Lubbock, TX 79401
Mailing Address (complete even if same as above):
PO Box 2000, Lubbock, TX 79457
Tax Identification Number (SSN or Federal ID):
Fax Number (including area code):
17560005906
(806) 775-2686
Type of Provider (check one):
Governmental Agency Private Non -Profit Private For Profit
■City Government County Government Other:
Authorizing Official:
Title:
Daniel M. Pope
Mayor
Email Address:
Telephone:
d o e&mvlubbock.us
(806) 775-2050
Billing Contact Person and billing address:
Title:
Nancy Neill, City of Lubbock, PO Box 2000, 79456
Indoor Recreation Coordinator
Email Address:
Telephone:
nneillrr mvlubbock.us
(806) 775-2685
Number of Years Organization has been in business:
Is Organization Bonded?
(Attach certificate of bonding insurance)
37 Years
1:1 Yes ■ No
Has anyone involved in the direct provision of client services
If Yes, i~xpl`a n:
been convicted of a felony (In-home Services
only)? Not Applicable
Not Applicable
Im Yes 21No
Does Organization have liability insurance?
Attach a copy of all applicable State and Federal
(Attach certificate of all insurances)
■ Yes El No
licenses and /or certifications for your business.
Conflicts of Interest: Attach information of applicable names and relationship of any employee(s) or officers of
your organization that may have a conflict of interest with the South Plains Association of Governments
Area Agency on Aging staff person or Advisory Council member.
DPS Application
Page 1
1;
2.
3.
4.
Service and Bidding Information:
A. Proposed Service:
Congregate Meals
B. Service Area:
ilii -FY OF LU131306-tL
C. Proposed DADS A&I AAA cost per unit:
$ 7.51
A. Proposed Service:
Home Delivered Meals
B. Service Area:
N/A
C. Proposed DADS A&I AAA cost per unit:
A. Proposed Service:
Transportation
B. Service Area:
(tel T -Y OF L UPJ�3bC-�
C. Proposed DADS A&I AAA cost per unit:
$ 8.76
A. Proposed Service:
N/A
B. Service Area:
N/A
C. Proposed DADS A&I AAA cost per unit:
Signature:
Whole cost per unit:
$ 8.27
Whole cost per unit:
Whole cost per unit:
$ 9.73
Whole cost per unit:
I, Daniel M. Pope certify that the information provided in this application is true and
Printed Name
correct to the best of my k wledge.
Saturday, October 01, 2016
Authorized Signatu Date
DPS Application
Page 2
Attest: Approved as ttontent: Approved as to Form:
A� de��e, I � �r-� 4�i �-,
e e ca Garza ridget FaulkenberryJOtinPruittiCity cretary Parks and Recreation Director Ant City Attorney
bbock
TEXAS
CERTIFICATE OF SELF-INSURANCE
The undersigned officer of the City of Lubbock, Texas, a Texas home rule
municipality, hereby certifies that the City of Lubbock has a $500,000.00 self-
insured retention for Automobile and General Liability in accordance with the laws
of the State of Texas. The City of Lubbock has a policy that covers Property/Bodily
Injury over $500,000.00 per occurrence with One Beacon America Insurance
Company under policy #791-000-230-0001 which expires on 10/01/17. The current
net asset balance of the self-insurance fund is $6,885,448. The existing cash asset
balance is $10,589,353 as of the date stated below.
Lainey Mor, ison
Risk Management Coordinator
Date: September 30, 2016
DATE
TO
FROM
SUBJECT
4 94001Cit.
y of
Lubbock
TEXAS
PARKS AND RECREATION
October 1. 2016
South Plains Association of Government
City of Lubbock - Senior Center Programs
FY 2016-17 Operating Hours and Holidays for SPAG Grant
Holidays Observed
Number of
Name of Sites
Serving Days
Lubbock Adult Activity Center
250
Rawlings Community Center
250
Simmons Senior Center
250
Trejo Supercenter
250
Homestead Senior Program
250
Holidays Observed
Dates Observed
Thanksgiving Day
November 24, 2016
Day After Thanksgiving
November 25, 2016
Christmas Eve
December 23, 2016
Christmas Day
December 26, 2016
New Year's Day
January 2, 2017
Martin Luther King, Jr. Day
January 16. 2017
Good Friday
April 14, 2017
Memorial Day
May 29, 2017
4th of July
July 4. 2017
Labor Day
September 4, 2017
Days and Hours
of Operation
M -F 8:00 am - 5:00 pm
M -F 8:30 am - 4:00 pm
M -F 8:30 am - 4:00 pm
M -F 8:30 am - 4:00 pm
M -F 10:00 am - 1:00 pm
hkea Agency SOUTH PLAINS ASSOCIATION OF GOVERNMENTS
on Aging AREA AGENCY ON AGING
SUBRECIPIENT AGREEMENT
City of Lubbock, hereinafter referred to as Subrecipient, and South Plains Association of Governments Area
Agency on Aging (AAA) do hereby agree to provide services effective beginning October 1, 2016. in accordance
with the Older Americans Act of 1965 (OAA), as amended, regulations of the Health and Human Services
Commission (HHSC), the AAA Direct Purchase of Services program and the stated Scope of Services.
The AAA Direct Purchase of Services program is designed to promote the development of a comprehensive and
coordinated service delivery system to meet the needs of older individuals (60 years of age or older) and their
caregivers. This agreement provides a mechanism for the creation of an individualized network of community
resources accessible to a program participant in compliance with the OAA and HHSC AAA Access and
Assistance guidelines.
The purpose of the system of Access and Assistance is to develop cooperative working relationships with service
providers to build an integrated service delivery system that ensures broad access to and information about
community services, maximizes the use of existing resources. avoids duplication of effort, identifies gaps in
services, and facilitates the ability of people who need services to easily find the most appropriate Subrecipient.
1. SCOPE OF SERVICES
A. The Subrecipient agrees to provide the following service(s) as identified below to program participants
authorized by the AAA staff, in accordance with the Subrecipient application, all required assurances,
licenses, certifications and rate setting documents, as applicable.
Service:
CONGREGATE MEALS
TRANSPORTATION
Service Definition:
CONGREGATE MEAL - A hot or other appropriate meal served to an eligible older individual which
meets 33 iii percent of the dietary reference intakes established by the Food and Nutrition Board of the
Institute of Medicine of the National Academy of Sciences and complies with the most recent Dietary
Guidelines for Americans, published by the Secretary of Agriculture, and which is served in a
congregate setting. The objective is to reduce food insecurity and promote socialization of older
individuals. There are two types of congregate meals:
• Standard meal - A regular meal from the standard menu that is served to the majority or all of the
participants.
• Therapeutic meal or liquid supplement - A special meal or liquid supplement that has been prescribed
by a physician and is planned specifically for the participant by a dietitian (e.g., diabetic diet, renal
diet, pureed diet, tube feeding).
TRANSPORTATION - Taking an older individual from one location to another but does not include
any other activity. There are two types of transportation services:
• Demand/Response - transportation designed to carry older individuals from specific origin to specific
destination upon request. Older individuals request the transportation service in advance of their need,
usually twenty-four to forty-eight hours prior to the trip.
Form #: AIAAA VA2.0
Edition Date: 9' 19:11
Unit Definition:
CONGREGATE MEALS: One Meal
TRANSPORTATION — Demand/Response: One One-way Trip
Service Area (To be filled in by provider. Please type or print neatly):
C cn'
_*1 P W <
All Texas Administrative Code standards are located at the Texas Secretary of State website:
www.sos.state.tx.us.
All Older Americans Act and other required rules and regulations are located at
http_l/wwtiv.aoa.acl.gov`AoA_Pro�_,rams'OAA.'Introduction.asp .
Targeting: AAA services are designed to identify eligible program participants, with an emphasis on high-
risk program participants and to serve older individuals with greatest economic and social need, low-
income minorities and those residing in rural areas, as required by the OAA.
B. Services & Reimbursement Methodology:
Fixed Rate
Service (include rate)
teP- 7.51
.ation 8.76
Form #: AIAAA VA2.0
Edition Date: 91:19:11
Variable Rate Cost
(identify range) Reimbursement
2. TERMS OF AGREEMENT
A. The Subrecipient agrees to:
1. provide services in accordance with current or revised HHSC policies and standards and the OAA.
2. submit billings with appropriate documentation as required by the AAA by the close of business on
the 2"1 working day of each month following the last day of the month in which services were
provided.
a. If the 2nd working day falls on a weekend or holiday, the information shall be delivered by the
close of business on the following business day.
b. The AAA cannot guarantee payment of a reimbursement request received for more than 45
calendar days of service delivery.
c. No reimbursement for services provided will be made if Subrecipient payment invoices are not
submitted to the AAA within 45 days of service delivery.
d. Reimbursement checks must be cashed or deposited within 30 days from date received.
3. encourage program participant contributions (program income) on a voluntary and confidential basis.
Such contributions will be properly safeguarded and accurately accounted for as receipts and
expenditures on Subrecipient's financial reports if contributions are not required to be forwarded to
the AAA. Client contributions (program income) will be reported fully, as required, to the AAA.
Subrecipient agrees to expend all program income to expand or enhance the program/service under
which it is earned.
4. notify the AAA Director immediately if, for any reason, the Subrecipient becomes unable to provide
the service(s).
5. maintain communication and correspondence concerning program participants' status.
6. establish a method to guarantee the confidentiality of all information relating to the program
participant in accordance with applicable federal and state laws, rules, and regulations. This provision
shall not be construed as limiting AAA or any federal or state authorized representative's right of
access to program participant case records or other information relating to program participants served
under this agreement.
7. keep financial and program supporting documents, statistical records, and any other records pertinent
to the services for which a claim for reimbursement was submitted to the AAA. The records and
documents will be kept for a minimum of five years after close of Subrecipient's fiscal year.
8. make available at reasonable times and for required periods all fiscal and program participant records,
books, and supporting documents pertaining to services provided under this agreement, for purposes
of inspection, monitoring, auditing, or evaluations by AAA staff, the Comptroller General of the
United States and the State of Texas, through any authorized representative(s).
9. if applicable, comply with the HHSC process for Centers for Medicare and Medicaid Services (CMS)
screening for excluded individuals and entities involved with the delivery of the Legal Assistance and
Legal Awareness services.
B. The Subrecipient further agrees:
1. The agreement may be terminated for cause or without cause upon the giving of 30 days advance
written notice.
2. The agreement does not guarantee a total level of reimbursement other than for individual
units/services authorized; contingent upon receipt of fields.
Form #: AIAAA_VA2.0
Edition Date: 9/19/11
3. Subrecipient is an independent provider, NOT an agent of the AAA. Thus, the Subrecipient
indemnifies, saves and holds harmless the South Plains Association of Governments AAA against
expense or liability of any kind arising out of service delivery performed by the Subrecipient.
Subrecipient must immediately notify the AAA if the Subrecipient becomes involved in or is
threatened with litigation related to program participants receiving services funded by the AAA.
4. Employees of the Subrecipient will not solicit or accept gifts or favors of monetary value by or on
behalf of program participants as a gift, reward or payment.
C. Through the Direct Purchase of Services program, the South Plains Association of Governments AAA
agrees to:
1. review program participant intake and assessment forms completed by the Subrecipient, as applicable,
to determine program participant eligibility. Service authorization is based on program participant
need and the availability of finds.
2. provide timely written notification to Subrecipient of program participant's eligibility and
authorization to receive services.
3. maintain communication and correspondence concerning the program participants' status.
4. provide timely technical assistance to Subrecipient as requested and as available.
5. conduct quality -assurance procedures, which may include on-site visits, to ensure quality services are
being provided and if applicable, CMS exclusion reviews are conducted.
6. provide written policies, procedures, and standard documents concerning program participant
authorization to release information (both a general and medical/health related release), client rights
and responsibilities, contributions, and complaints/grievances and appeals to all program participants.
7. contingent upon the AAA's receipt of funds authorized for this purpose from HHSC, reimburse the
Subrecipient based on the agreed reimbursement methodology, approved rate(s), service(s) authorized,
and in accordance with subsection (A)(2) of this document, within 45 days of the AAA's receipt of
Subrecipient's invoice.
Form #: AIAAAVA2.0
Edition Date: 9/719/11
3. ASSURANCES
The Subrecipient shall comply with:
A. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d el.seq.)
B. Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794)
C. Americans with Disabilities Act of 1990 (42 U.S.C. §12101 el seq.)
D. Age Discrimination in Employment Act of 1975 (42 U.S.C. §§6101-6107)
E. Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688)
F. Food Stamp Act of 1977 (7 U.S.C. §200 el seq.)
G. Drug Free Workplace Act of 1988
H. Texas Senate Bill 1 - 1991, as applicable
I. HHSC administrative rules, as set forth in the Texas Administrative Code. to the extent applicable to this
Agreement
J. Certification Regarding Debarment - 45CFR §92.35 Subawards to debarred and suspended parties; this
document is required annually as long as this agreement is in effect
K. Centers for Medicare and Medicaid Services (CMS) State Medicaid Director Letter SMDL 909-001
regarding Individuals or Entities Excluded from Participation in Federal Health Care Programs
L. HHSC Information Letter 11-07 - Obligation to Identify Individuals or Entities Excluded from
Participation in Federal Health Care Programs
4. ATTACHMENTS
A. Description of Assurance A - H listed in section 3 of this document.
B. List of Focal Points in the AAA planning and service area.
5. SIGNATURES
For the faithful per ance of the terms of this agreement,
effective ctober 1, 2 16.
Authorized Subrec pient Signature
Daniel M. Pope
Print Name
MAYOR
Title
October 1. 2016
Date
Form #- AIAAA VA?.tt
Edition Date 9.'19:11
the parties affix their signatures and bind themselves
Authorized Signature
South Plains Association of Governments
(Agency)
P.O. Box 3730 - Freedom Station
(Address)
Lubbock, Texas 79452
(City, State, Zip)
October 1, 2016
(Date)
Attest:
tcet)gcca cJarz,
City'Secretary
Approved as to Content:
Bridget Faulkenberry
Parks and Recreation Director
Approved as to Form:
Ju in 'ruitt
As ' ant City Attorney
ASSURANCES ATTACHMENT
A. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et.seq.), which prohibits any
person from being excluded from participation in, denied the benefits of, or subjected to
discrimination under any program or activity receiving Federal financial assistance.
B. Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794), which states that employers
may not refuse to hire or promote handicapped persons solely because of their disability.
C. Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seg.), which prohibits a
covered entity from discriminating against a qualified individual on the basis of disability in
regard to job application procedures, the hiring, advancement, or discharge of employees,
employee compensation, job training, and other terms, conditions, and privileges of
employment.
D. Aize Discrimination in Employment Act of 1975 (42 U.S.C. §6101-6107), prohibits
discrimination on the basis of age in programs and activities receiving federal financial
assistance.
E. Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688), which prohibits
the use of federal money to support sexually discriminatory practices in education
programs such as sexual harassment and employment discrimination, and to provide
individual citizens effective protection against those practices.
F. Food Stamp Act of 1977 (7 U.S.C. §200 el seg.), whose purpose is to strengthen the
agricultural economy; to help to achieve a fuller and more effective use of food abundances;
to provide for improved levels of nutrition among low-income households through a
cooperative Federal -State program of food assistance to be operated through normal
channels of trade; and for other purposes.
G. Drug Free Workplace Act of 1988, which requires that all organizations receiving federal
grants, regardless of amount granted, maintain a drug-free workplace.
H. Texas Senate Bill 1 - 1991, as applicable, which refers to proper reporting of contributions
as addressed in OAA §315 and TAC, Title 40, §85.201.
Certification Regarding Debarment
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS
Federal Executive Order 12549 requires the Texas Health and Human Services Commission
(HHSC) to screen each covered potential subrecipient/grantee to determine whether each has
a right to obtain a contract/grant in accordance with federal regulations on debarment,
suspension, ineligibility, and voluntary exclusion. Each covered subrecipient/grantee must
also screen each of its covered sub-subrecipients/providers.
In this certification "subrecipient/grantee" refers to both subrecipient/grantee and sub-
subrecipient/sub-grantee: "contract/grant" refers to both contract/grant and subcontract/sub-
grant.
By signing and submitting this certification the potential subrecipient/grantee accepts
the following terms:
1. The certification herein below is a material representation of fact upon which reliance
was placed when this contract/grant was entered into. If it is later determined that the
potential subrecipient/grantee knowingly rendered an erroneous certification, in
addition to other remedies available to the federal government, the Department of
Health and Human Services, United States Department of Agriculture or other federal
department or agency, or the Texas Health and Human Services Commission may
pursue available remedies, including suspension and/or debarment.
2. The potential subrecipient/grantee shall provide immediate written notice to the
person to whom this certification is submitted if at any time the potential
subrecipient/grantee learns that the certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
3. The words "covered contract", "debarred". "suspended", "ineligible", "participant',
"person", "principal", "proposal" and "voluntarily excluded", as used in this
certification have meanings based upon materials in the Definitions and Coverage
sections of federal rules implementing Executive Order 12549. Usage is as defined in
the attachment.
4. The potential subrecipient/grantee agrees by submitting this certification that, should
the proposed covered contract/grant be entered into, it shall not knowingly enter into
any subcontract with a person who is debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized
by the Department of Health and Human Services, United States Department of
CERTIFICATION REGARDING DEBARMENT
Page 2
Agriculture or other federal department or agency, and/or the Texas Department of
Aging and Disability Services, as applicable.
Do you have or do you anticipate having sub vendors/sub-grantees under this
proposed contract? Yes X No
The potential vendor/grantee further agrees by submitting this certification that it will
include this certification titled "Certification Regarding Debarment, Suspension,
Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without
modification, in all covered subcontracts and in solicitations for all covered
subcontracts.
6. A vendor/grantee may rely upon a certification of a potential sub vendor/sub-grantee
that is not debarred, suspended, ineligible, or voluntarily excluded from the covered
contract/grant, unless the vendor/grantee knows that the certification is erroneous. A
vendor/grantee must, at a minimum obtain certifications from its covered sub
vendors/sub-grantees upon each subcontract's/sub-grant's initiation and upon each
renewal.
7. Nothing contained in all the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification by this certification
document. The knowledge and information of a vendor/grantee is not required to
exceed that which is normally possessed by a prudent person in the ordinary course of
business dealings.
8. Except for contracts/grants authorized under paragraph 4 of these terms, if a
vendor/grantee in a covered contract/grant knowingly enters into a covered
subcontract/subgrant with a person who is suspended, debarred, ineligible, or
voluntarily excluded from participation in the transaction, in addition to other
remedies available to the federal government, Department of Health and Human
Services, United States Department of Agriculture, or other federal department or
agency, as applicable, and/or the Texas Department of Aging and Disability Services
may pursue available remedies, including suspension and/or debarment.
CERTIFICATION REGARDING DEBARMENT
Page 3
Indicate which statement applies to the covered potential vendor grantee:
X The potential vendor/grantee certifies by submission of this certification that neither it
nor its principals are presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this contract./grant by any
federal department or agency or by the State of Texas.
The potential vendor/grantee is unable to certify one or more of the terms in this
certification. In this instance, the potential vendorgrantee must attach an explanation
for each of the above terms to which he,! she is unable to make certification. Attach
the explanation(s) to this certification.
NAME OF POTENTIAL VENDOR/GRANTEE City of Lubbock
VENDOR ID NO. /FEDERAL EMPLOYER'S ID NO. 1-75-6000590-6
t
Signature f uthorized Re esentative
Justin Pruitt
Printed./Typed Name of Authorized Representative
Assistant City Attorney October 1, 2016
Title of Authorized Representative Date
This certificate is for FY 2017, period beginning October 1, 2016 and ending
September 30, 2017.
CERTIFICATION REGARDING DEBARMENT
Page 4
DEFINITIONS
Covered Contract/Grant and Subcontracts/Sub-grants.
(1) Any non -procurement transaction which involves federal funds (regardless of
amount and including such arrangements as sub -grants) and is between the
Texas Health and Human Services Commission or its agents/grantees and
another entity.
(2) Any procurement contract for goods or services between a participant and a
person, regardless of type, expected to equal or exceed the federal
procurement small purchase threshold fixed at 10 U.S.C. 2304(g) and 41
U.S.C. 253(g) (currently $25,000) under a grant or sub -grant.
(3) Any procurement contract for goods or services between a participant and a
person under a covered grant, sub -grant, contract or subcontract, regardless of
amount, under which that person will have a critical influence on or
substantive control over that covered transaction including:
a. Principal investigators.
b. Providers of audit services required by the Texas Health and Human
Services Commission or federal fielding source.
C. Researchers.
DEBARMENT
An action taken by a debarring official in accordance with 45 CFR Part 76 (or
comparable federal regulations) to exclude a person from participating in covered
contracts/grants. A person so excluded is "debarred."
GRANT
An award of financial assistance, including cooperative agreements, in the form of
money, or property in lieu of money, by the federal government to an eligible grantee.
INELIGIBLE
Excluded from participation in federal non -procurement programs pursuant to a
determination of ineligibility under statutory, executive order, or regulatory authority,
other an Executive Order 12549 and its agency implementing regulations: for
example, excluded pursuant to the Davis -Bacon Act and its implementing regulations,
the equal employment opportunity acts and executive orders, or the environmental
protection acts and executive orders. A person is ineligible where the determination
of ineligibility affects such person's eligibility to participate in more than one covered
transaction.
CERTIFICATION REGARDING DEBARMENT
Page 5
PARTICIPANT
Any person who submits a proposal for, enters into, or reasonably may be expected to
enter into a covered contract. This term also includes any person who acts on behalf
of or is authorized to commit a participant in a covered contract/grant as an agent or
representative of another participant.
PERSON
Any individual, corporation, partnership, association, unit of government, or legal
entity, however organized, except: foreign governments or foreign governmental
entities, public international organizations, foreign government owned (in whole or
part) or controlled entities, and entities consisting wholly or partially of foreign
governments or foreign governmental entities.
PRINCIPAL
Officer, director, owner, partner, key employee, or other person within a participant
with primary management or supervisory responsibilities: or a person who has a
critical influence on or substantive control over a covered contract/grant whether or
not the person is employed by the participant. Persons who have a critical influence
on or substantive control over a covered transaction are:
(1) Principal investigators.
(2) Providers of audit services required by the Texas Health and Human Services
Commission or federal finding source.
(3) Researchers.
PROPOSAL
A solicited or unsolicited bid, application, request, invitation to consider or similar
communication by or on behalf of a person seeking to receive a covered
contract/grant.
SUSPENSION
An action taken by a suspending official in accordance with 45 CFR part 76 (or
comparable federal regulations) that immediately excludes a person from participating
in covered contracts/grants for a temporary period, pending completion of an
investigation and such legal, debarment, or Program Fraud Civil Remedies Act
proceedings as may ensue. A person so excluded is "suspended."
VOLUNTARY EXCLUSION OR VOLUNTARILY EXCLUDED
A status of nonparticipation or limited participation in covered transactions assumed
by a person pursuant to the terms of a settlement.
9/28/16 10:07 AM
Provider Name: City of Lubbock
AAA Name: Area Agency on Aging of South Plains
Congregate Meals
BUDGET WORKSHEET CALCULATION OF THE PER MEAL UNIT RATE
1. Total Budgeted Expenses for Contract Year 1. $ 260,643.21
2. Total Number of Anticipated Meals to be Provided by Funding Source
Other Funds
DADS A&I AAA 17,561 Eligible Meals 0 Other Sources 5 0
Other Funds -
Non -Eligible
Program Income 4,240 Meals 9,699 Other Sources 6 0 2- 31,500
3. Whole Unit Rate (Line 1 divided by Line 2) 3- $ 8.27
Reimbursement Calculation
DADS A&I AAA
4. Projected NSIP per Meal Value 0.69
5. Rate Less NSIP per Meal Value $ 7.58
6. Mandatory Local Match of 1091, $ 0.76
" If Applicable, Match Reduction
From the In-kind Match
Certification form $ -
Required Cash Match
$ 0.76
7. Proposed Meal Rate (Line 3 minus Line 6) $ 7.51
If any portion of the required match is in-kind, you must complete an In -Kind Match Certification form.
By signing below, the provider acknowledges that all related records are subject to audit in accordance with
contract requirements and all applicable federal and state laws.
City of LublWck
L al Name of Con a ,tProvider
Signa re
Area Agency on Aging of South Plains
Name of Area Agency on Aging
nm C
!'� Pri ted/Ty me o Signer
Signature
June 30, 2016
Date
Daniel M. Pope, Mayor
Printed/Typed Name of Signer
October 1, 2016
Date
Attest: Approved as to Content: Approved as to Form:
Rebecca Garz,
Cit} cretary
Bridget Faulkenberry
Parks and Recreation Di
Just' uitt
AssV City At orney
9/28/16 10:07 AM
Provider Name: City of Lubbock
AAA Name: Area Agency on Aging of South Plains
Congregate Meals
BUDGET WORKSHEET CERTIFICATION
AS SIGNER OF THIS BUDGET WORKSHEET, I HEREBY CERTIFY THAT:
• I have read the note below and the instructions applicable to this budget worksheet.
• I have reviewed this budget worksheet after its preparation.
• To the best of my knowledge and belief, this budget worksheet is true, correct and
complete, and was prepared in accordance with the instructions applicable to this
budget worksheet.
This budget worksheet was prepared from the books and records of the contracted
provider.
• I acknowledge that all books and records related to this rate setting process are
subject to audit in accordance with contract requirements and all applicable federal
and state laws.
Note: The person legally responsible for the conduct of the contracted provider must
sign this Budget Worksheet Certification. If a sole proprietor, the owner
must sign the Budget Worksheet Certification. If a partnership, a partner must
sign the Budget Worksheet Certification. If a corporation, the person authorized by the
Board of Directors Resolution must sign the Budget Worksheet Certification.
Misrepresentation of information contained in the budget worksheet may result in
adverse action, up to and including contract termination. Furthermore, falsification of
information in the budget worksheet may result in a referral for prosecution.
City of Lubbock Daniel M. Pope. Mayor
Name of Contracted Provider Printedrryped Name of Signer
October 1, 2016 6
Date Signature
Signer Authority: Sole Proprietor Association Officer
(check one) �� Partner ❑ Board Member
( orporate Officer El Got ernmental Official
Attest: Approved as to Content:
Rebcca Garza Bridget Faulkenberry
City Secretary Parks and Recreation Director
Approved as to Form:
w
Jus ' ruit
AsVnt City Attorney
9/28/16 10:10 AM
Provider Name: City of Lubbock
AAA Name: Area Agency on Aging of South Plains
Transportation
BUDGET WORKSHEET CALCULATION OF THE UNIT RATE
1.Total Budgeted Expenses for Contract Year
2.Total Number of Anticipated Units to be Provided
DADS A&I AAA - 10 %
Program
Match Required 4,560
Income
DADS A&I AAA - 25 %
Local Funds -
Match Required 0
Eligible Trips
Other Funds -
DADS A&I AAA - Full Unit
Non -Eligible
Rate 0
Trips
3. Cost per unit (Line 1 divided by Line 2) - Full Unit Rate
140 Other Sources 6 0
2,900 Other Sources 7 0
0 Other Sources 8 0
Reimbursement Calculation for Contracts Requiring Unit Rate Match Reduction
1 $ 73,925.80
2. 7,600
3. $ 9.73
4. Mandatory Local Match of 10% $ 0.97
"* If Applicable, Match Reduction From the In-kind Match Certification form $
Required Match 4. $ 0.97
5.Full Unit Rate Less Required Match (Line 3 minus Linea 5. $ 8.76
4. Mandatory Local Match of 25% $ 2.43
" If Applicable, Match Reduction From the In-kind Match Certification form $
Required Match 4. $ 2.43
5.Full Unit Rate Less Required Match (Line 3 minus Linea 5. $ 7.30
"If any portion of the required match is in-kind, you must complete an In -Kind Match Certification form.
Contract Reimbursed at Full Cost Per Unit Rate. Match Requirements Will Be Met Through Provision of Additional Units
$ 9.73
Contractor Initial AAA Initial
City of Lubbock
Legal Name of Contracted Provider
Signature
Daniel M. Poe Mayor
Printed/Typed Name of Signer
10/01/16
Date
Arqa-4gency on AgipalMuth Plains
Na a of Ala Age y on Aging
C
Signature
Tim C. Pierce
Printed/Typed Name of Signer
06/30/16
Date
Attest:
Reb cca Garza
City Secretary
Approved as to Content:
Bridget Faulkenberry
Parks and Recreation Dire ter
Approved as to Form:
R
Justi ruitt
Ass' t t City Attorney
9/28/16 10:13 AM
Provider Name; City of Lubbock
AAA Name: Area Agency on Aging of South Plains
Transportation
BUDGET WORKSHEET CERTIFICATION
AS SIGNER OF THIS BUDGET WORKSHEET, I HEREBY CERTIFY THAT:
• I have read the note below and the instructions applicable to this budget worksheet.
• I have reviewed this budget worksheet after its preparation.
• To the best of my knowledge and belief, this budget worksheet is true, correct and
complete, and was prepared in accordance with the instructions applicable to this
budget worksheet.
• This budget worksheet was prepared from the books and records of the contracted
provider.
• I acknowledge that all books and records related to this rate setting process are
subject to audit in accordance with contract requirements and all applicable federal
and state laws.
Note: The person legally responsible for the conduct of the contracted provider must
sign this Budget Worksheet Certification. If a sole proprietor, the owner
must sign the Budget Worksheet Certification. If a partnership, a partner must
sign the Budget Worksheet Certification. If a corporation, the person authorized by the
Board of Directors Resolution must sign the Budget Worksheet Certification.
Misrepresentation of information contained in the budget worksheet may result in
adverse action, up to and including contract termination. Furthermore, falsification of
information in the budget worksheet may result in a referral for prosecution.
City of Lubbock
Name of Contracted Provider
October 1, 2016
Date
Signer Authority: F� Sole Proprietor
(check one) F-1 Partner
Corporate Officer
Daniel M. Pope, Mayor
Printed/Typed Name of Signer
Signat re
Association Officer
Board Member
Governmental Official
Attest: Approved as to Content:
i�
l
Reb cca Garza Bridget Faulkenberry
City 'ecretary Parks and Recreation Director
Approved as to Form:
4
r f
Justin ruitt
Asshsbt City Attorney