HomeMy WebLinkAboutResolution - 2014-R0396 - Grant Agreement - TX ADS, SPAG - US HHS - 12/04/2014Resolution No. 2014-RO396
Item No. 6.2.1
December 4, 2014
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 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
for said grant, and related documents. Said grant 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 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 this 4th day of December '2014.
ATTEST:
Rebec t
Garza, City Secretat
APPROVED AS TO CONTENT:
APPROVED AS TO FORM:
Attorney
-SPAG 14-15 11.17.14
GL . RO RTSON, MAYOR
Ulrector
Resolution No. 2014-R0396
The South Plains Association of Governments Area Agency on Aging Area Agency
Direct Purchase of Service ��
Fiscal Year 2015 Vendor Application/Renewal Update ///� V Aging
Please type or clearly print application information.
City of Lubbock
Vendor Name/Legal Entity
DBA (if applicable)
Physics[ Address:
2001 19th Street Lubbock Senior 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 E]Privale For Profit
Wily Government County Government Other:
Authorizing Official:
Title:
Glen C. Robertson
Mayor
Email Address:
Telephone:
limixftsonfii
806-775-2010
Billing Contact Person and billing address:
Title:
Nancy Neill, City of Lubbock, PO Box 2000, 79457
Indoor Recreation Coordinator
Email Address:
Telephone:
nneill@inylubbock.us
806-775-2685
Number of Years Organization has been in business:
Is Organization Bonded?
(Attach certificate of bonding insurance)
35 Years
-in
■ Yes No
Has anyone involved direct provision of client services
If Yes, Explain
been convicted of a felony (In-home Services
only)? N/A
N/A
■ Yes ■ No
Does Or anization have liability insurance?
Attach a coot/ of all applicable State and Federal
licenses and /or certifications for your business.
Yes Li No
Conflicts of Interest: Attach information of applicable names and relationship of any employees) 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
I:
2.
3.
4.
Service and Bidding Information:
OF t-u1319ak-
C. Proposed DADS A&I AAA cost per unit: Whole cost per unit:
$ 6.97 $ 7.41
A. Proposed Service:
Home Delivered Meals
B. Service Area:
NIA
C. Proposed DADS A&I AAA cost per unit: Whole cost per unit:
A. Proposed Service:
Transportation
B. Service Area:
GIT`( OF L1 -05i
C. Proposed DADS A&I AAA cost per unit: Whole cost per unit:
$ 5.85 $ 6.50
A. Proposed Service:
NIA
B. Service Area:
NIA
C. Proposed DADS A&I AAA cost per unit: Whole cost per unit:
Signature:
1, Glen r Rnhertenn , certify that the information provided in this application is true and
Pnnted Name
correct to the best of my knowledge.
Wednesday, October 01, 2014
A taoriaed Signature Date
DPS Application
Page 2
Attest: Approved as to Content: Approveda o
eb cca Garza Bridget Fau, K/- -M�ilkenberry Laur Pratt
Cit Secretary- Parks and Recreation Directo Assistant City Attorney
ilk
City of
4 Lubbock
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 #791-00-02-30-0005 which expires on 10101115. The
current net asset balance of the self-insurance fund is $5,577,031. The existing
cash asset balance is $9,502,180 as of the date stated below.
By:
Lainey Castleberry
Risk Management Coordinator
Date: September 30, 2014
"►� City of
L-*.**
ubbock
TEXAS
PARKS AND RECREATION
DATE October 1, 2014
TO South Plains Association of Government
FROM City of Lubbock — Senior Center Programs
SUBJECT FY 2014-15 Operating Hours and Holidays for SPAG Grant
Holidays Observed
Number of
Days and Hours
Name of Sites
Servina Days
of Operation
Lubbock Senior Center
251
M -F 8:00 am - 5:00 pm
Rawlings Community Center
251
M -F 8:30 am - 4:00 pm
Simmons Senior Center
251
M -F 8:30 am - 4:00 pm
Trejo Supercenter
251
M -F 8:30 am - 4:00 pm
Homestead Senior Program
251
M -F 10:00 am - 1:00 pm
Holidays Observed
Dates
Thanksgiving Day
November 27, 2014
Day After Thanksgiving
November 28, 2014
Christmas Day
December 25, 2014
Christmas Holiday
December 26, 2014
New Year's Day
January 1, 2015
Martin Luther King, Jr. Day
January 19, 2015
Good Friday
April 3, 2015
Memorial Day
May 25, 2015
4th of July
July 3, 2015
Labor Day
September 7, 2015
Area Agency
Aging SOUTH PLAINS ASSOCIATION OF GOVERNMENTS
// AREA AGENCY ON AGING
VENDORAGREEMENT
City of Lubbock, hereinafter referred to as Vendor, and the South Plains Association of Governments Area
Agency on Aging (AAA) do hereby agree to provide services effective beginning October 1, 2014, in
accordance with the Older Americans Act of 1965 (OAA), as amended, regulations of the Department of Aging
and Disability Services (DADS), 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 DADS 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 Vendor.
1. SCOPE OF SERVICES
A. The Vendor agrees to provide the following service(s) as identified below to program participants
authorized by the AAA staff, in accordance with the vendor 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%3 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.
Unit Definition:
FoemM AIAAA VA .0
Edition Date: 9119/11
CONGREGATE MEALS: One Meal
TRANSPORTATION — Demand/Response: One One-way Trip
G t iY OF L L166o K -
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
h"://www.aoa.rov/AoARoot/AbouUAuthorizinp Statutes/index aspx.
Tareetine: 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)
Variable Rate
(identity range)
Cost
Reimbursement
Congre ate 6.97
N/A
N/A
Transportation 5.85
N/A
N/A
Fo,m N: AIAAA VA .0 z
Hilion Daze: 9/119/11
TERMS OF AGREEMENT
A. The Vendor agrees to:
1. provide services in accordance with current or revised DADS policies and standards and the OAA.
2. submit billings with appropriate documentation as required by the AAA by the close of business on
the 2nd working day day of each month following the last day of the month in which services were
provided.
a. If the 2"d working day falls on a weekend or holiday, the information shall be delivered by the
close of business on the preceding 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 vendor payment invoices are not
submitted to the AAA within 45 days of service delivery.
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 Vendor'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.
Vendor 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 Vendor 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 vendor'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 DADS 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 Vendor 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 funds.
3. Vendor is an independent provider, NOT an agent of the AAA. Thus, the Vendor indemnifies saves
and holds harmless the South Plains Association of Governments AAA against expense or liability
Foran #: AIAAA_VA2.0 3
Edition Date: 9/19/11
of any kind arising out of service delivery performed by the Vendor. Vendor must immediately
notify the AAA if the Vendor becomes involved in or is threatened with litigation related to program
participants receiving services funded by the AAA.
4. Employees of the Vendor 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 Vendor, as applicable, to
determine program participant eligibility. Service authorization is based on program participant
need and the availability of funds.
2. provide timely written notification to Vendor 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 Vendor 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 DADS, reimburse the
Vendor 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
Vendor's invoice.
Foran #: AIAAAVA2.0
Edition Date: 9/_19/11
ASSURANCES
The Vendor shall comply with:
A. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et.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 at seq.)
G. Drug Free Workplace Act of 1988
H. Texas Senate Bill 1 - 1991, as applicable
1. DADS administrative rules, as set forth in the Texas Administrative Code, to the extent applicable to
this Agreement
J. Certification Regarding Debarment - 45CFR §92.35 Sub awards 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 #09-001
regarding Individuals or Entities Excluded from Participation in Federal Health Care Programs
L. DADS Information Letter 11-07 — Obligation to Identify Individuals or Entities Excluded from
Participation in Federal Health Care Programs
4. ATTACHMENTS
A. Description of Assurances 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 performance of the terms of this agreement, the parties affix their signatures and bind
themselves elle r 1, 2014.
orized Vendor Signature
Glen C. Robertson
Print Name
Mayor
Title
October 1, 2014
Date
Form k: AIAAA VA2.0
Edition Daze: 91119111
ywaer4'-
Autho Zrize
signature
South Plains Association of Governments
Agency
P.O. Box 3730 — Freedom Station
Address
Lubbock. Texas 79452
City, State, Zip
October 1, 2014
Date
ttest: Approved
1a'slnitjlo Content: Approved as t r
LLItil4
becea Garza - Bridget Faulkenberry Laur Pratt
Secretary Parks and Recreation Director Assistant City Attorney
ASSURANCES ATTACHMENT
A. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et.seg.), 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. U2101 et seq.), 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. Age 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 et 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 Department of Aging and Disability
Services (TDADS)) to screen each covered potential vendor/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 vendor/grantee
must also screen each of its covered sub vendors/providers.
In this certification "vendor/grantee" refers to both vendor/grantee and sub-vendor/sub-
grantee: "contract/grant" refers to both contract/grant and subcontract/sub-grant.
By signing and submitting this certification the potential vendor/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 vendor/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 Department of Aging and Disability Services may pursue
available remedies, including suspension and/or debarment.
2. The potential vendor/grantee shall provide immediate written notice to the person to
whom this certification is submitted if at any time the potential vendor/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 vendor/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? k— YES NO
5. 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 required 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, 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 we presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this contract/gram 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 vendor/grantee must attach an explanation
for each of the above terms to which it 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
Sign re o Authorized Representative
Laura Pratt
Printed/Typed Name of Authorized Representative
Assistant City Attornev October 1, 2014
Title of Authorized Representative Date
This certificate is for FY 2015, period beginning October 1, 2014 and ending
September 30, 2015.
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 Department of Aging and Disability Services 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(8) (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 Department of Aging
and Disability Services or federal funding 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 Department of Aging and
Disability Services or federal funding 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.
9/23/141 e4 PM
ProMer Name. COY of Lubbock
AAA Name. Amo Agency on Aging of Scale Plains
Congregate Meals
BUDGET WORKSHEET CALCULATION OF THE PER MEAL UNIT RATE
1. Total Bidgem! E,moses for Caamlt Year 1. $ 214,923.41
2. Total Number of Antin:mW Meals to W Pmyldetl by Funding Source
Other Furls
DADS A81 AAA 14,355 Eligible Meals 9.273 Other Scarcas 5 0
Other FuMs-
Non{Igible
Pmgmm Income 5,372 Meets 0 Other Scarces6 0 2. 29,000
3. 'Ame, Und Rate (Line I divMea by Line 2) 3. S 7.41
Rambursemenl Calculation
DADS All AAA
4. Pmlodetl NSIP per Meal Value 0.89
5, Rale Lass NSIP per Meal Value $ 8.72
6. Mandatory Local Motch a 10%, S 0.07
If Appli ale, Maul, Retlection
From Ore In4lrd Match
CertHMatdn form S (0.23)
Requlree Cash Match S 0.44
7. Pagroseri Meal Rate (line 3 minus Line 6) S 8.97
If any Porgon of the requiretl mal is in-kind, you must complete an In -1 Match Cerlifcamb form.
By algnielf bat , Win PFVdef aLI{naN Ld9e9 that all bell rec:mis are subject to saint In acoartlame mth
canbaG reguira Barb; end all applicable fetleral am state sm.
City of Lubb Glen C. Robertson
Legal Name of Conir Pmyitler Penled/fyped Name of Signer
October 1, 2014
/ lgn hnne Daae
Area Agency, on Aging of South Plains
Name of Area Agency on Aging
PIP C E!1 -
t Nlig.
i Ao,a
Signature
October 1, 2014
Data
Attest: Approved as to Content: Approved as t o
Re cca Garza - Bridget Faulkenbeny aur Pratt
Cif ecretary- - Parks and Recreation Direc or Assistant City Attorney
9/23/14 1:45 PM
Provider Name: City of Lubbock
AAA Name: Area Agency on Aging of South Plains
Congregate Meals
BUDGET WORKSHEET CERTIFICATION
I HEREBY CERTIFY THAT:
• I have read the note below and the instructions applicable to this budget worksheet.
• 1 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.
• 1 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 Competed Provider
October I
Date
Signer Authuritp ❑ We Pmpricmr
Idmrk onq ❑ Panner
❑ Corporn.Omrer
Client' Rnhemcn
Pdnned/ryWd Name of Suer
"gimi re
❑
A...Win. omen
❑
Spud Member
Guvemmemal Omeial
Attest: Approved as to Content: Approved Wrm:
JRe.cca Gana --Bridget Faulkenberry a PrattSecretary Parks and Recreation Director Assistant City Attorney
923/14 1:46 PM
AAA Name: Area Agency on Aging of South Plains
Congregate Meals
IN-KIND ?IATCH CERTIFICATION
Provider.
In-kind Contribution(s): $5,459
For any item identified below, you must maintain support documentation.
ITEM
DATE OF RECEIPT VALUE
RSVP Volunteers @ Lubbock Senior Center
3 Volunteers x I br/day X 251 X $7.25/hr Minimum Wage
$5,459
TOTAL $5,459
Note: All contributions must meet the requirements of IRS Publication 561
htto://..irsgov/pub/i,-ndf/,561 p_df
Examples of Documentation Include:
Rent: 1. Letter of Agreement with Owner
2. Adequate Valuation of Property on a Current Basis (this should be reviewed at least every two years
and if senior center, based on property value and center participation)
Labor: I. Minimum wage
2. Documented prevailing wage in the Area For prevailing wage information visit the Texas Workforce
Commission'swebsiteal Mtn:✓n wwtmc r'_.cum
All in-kind labor must be required for the smite to be provided. If you would not hire someone to perform the labor if it
were not in-kind then you cannot count it.
Utilities: 1. Copy of Bill
2. Agreement of Amount Paid if Partial
City of Lubbock
Name of Connected Provider
October 1, 2014
Date
Glen C. Robertson
Printedrr p B Name of Signer
r
Signature
Attest: _ — Approved as to Content: Approved asqLFo:
16
Rebe ca Garza Bridget Faulkenb'Z Assistant
Pratt
City cretary Parks and Recreation Director Assistant City Attorney
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Attest: A�ppprrovveeedd as to Content: Appro ed
Reb cca Garza - Bridget Faulkenberry Laur Pratt
Cit ecretary. - _ Parks and Recreation Direc r Assistant City Attorney
9/23/141:50 PM
Provider Name: City of Lubbock
AAA Name: Area Agency on Aging of South Plains
Transportation
BUDGET WORKSHEET CERTIFICATION
OF THIS BUDGET
• 1 have read the note below and the instructions applicable to this budget worksheet
• 1 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 rale 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 sale 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 me), 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
N.me.f Cona.ne4 Pmma<r
October 1. 2014
M,er Aurhorky. ❑ sok PmprhAor
(ehak oncl ❑ Panner
❑ Cerver.m Omar
Glen C. Robertson
Prh ndlfyped N.me of Sk.,r
tan.wre
❑
Arw<�un�omar
❑
Be.rd Member
(brernmenulOmchl
Attest: - Approved
as to Content: - Approved as to FeRe cca GarzaBridga Pratt
Ci Secretary Parks or Assistant City Attorney