HomeMy WebLinkAboutR-1990-110 !
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RESOLUTION N0. 110-90
A RESOLUTION OF THE CITY OF DANIA, FLORIDA,
APPROVING THAT CERTAIN AGREEMENT BETWEEN
BROWARD COUNTY AND THE CITY OF DANIA RELATING
TO AFTER SCHOOL CARE; AND PROVIDING FOR AN
EFFECTIVE DATE.
BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF DANIA,
FLORIDA:
Section 1 . That that certain Agreement between Broward
County and The City of Dania relating to after school care, a copy
Of which is attached hereto as Exhibit "A" , be and the same is
hereby approved , and the appropriate city officials are hereby
directed to execute same .
Section 2. That Michael W. Smith, as Personnel Director, and
Mardie Holloway, as Recreation Coordinator, are hereby authorized
to sign monthly invoices and certification statements as required
by said agreement.
Section 3. That this resolution shall be in force and take
effect immediately upon its passage and adoption.
PASSED and ADOPTED this 13th day of November
1990 .
ATTEST: "^ OR U UM M I ON ER
CITY CLERK - AUDITOR
APPROVED AS TO FORM AND CORRECTNESS:
FRANK C. AD1,ER, Ctty Attorney
Resolution No. 110-90
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A G R E E ti E N T
between
BROWARD COUNTY
and
CITY OF DANIA, FLORIDA
Contract #91_7
After School Care
EXHIBIT "A"
L_ �
AGREEMENT
between
BROWARD COUNTY
and
CITY OF DANIA, FLORIDA
This Agreement, entered into this day of ,
19 , by and between BROWARD COUNTY, a political subdivision of
the State of Florida, hereinafter referred to as "COUNTY" ;
AND
- CITY OF DANIA, FLORIDA, a political subdivision of the State of
Florida, hereinafter referred to as "PROVIDER" .
WHEREAS, this funding agreement will enable PROVIDER to
provide after school care services, not otherwise funded by any
other public and private funding source ; and
WHEREAS, expenditures given to the PROVIDER have been found,
a determined and declared to be a county and public purpose by the
Board of County Commissioners of COUNTY;
NOW, THEREFORE, the parties agree as follows:
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ARTICLE I
SCOPE OF SERVICES
THE PROVIDER agrees to provide on a monthly basis the services
set forth in Exhibit "A" attached hereto and made a part hereof .
ARTICLE II
FUNDING AND METHOD OF PAYMENT
2. 1 The maximum amount reimbursable to the PROVIDER by the
COUNTY under this Agreement shall be twenty four thousand
eight hundred dollars ($24,800) .
2.2 COUNTY agrees to reimburse for units actually delivered,
correctly invoiced and documented at unit price specified in
Exhibit A. Original invoice plus one copy are due on or
before the fifteenth of the following month, beginning on
the fifteenth of the first month following Agreement
execution by COUNTY.
PROVIDERonn amonthly bi a to reimburse
billing basis. No monthly bill shall
exceed that amount obtained by dividing the maximum amount
payable under this agreement by the number of months set
forth is
"TE
OF SRVICS" ,
exxcept1forRTICLE III of those agencieshwhosereeentclient �flow v�arriesEwithEthe
funding period and the COUNTY agrees to a monthly payment
schedule as specified in the Activity/Payment Schedule in
Exhibit A, attached hereto and made a part hereof. h
In order to be deemed proper as defined in the Florida
Prompt Payment Act, all invoices must comply with the
requirements set forth in this Agreement and must be
submitted on the form and pursuant to instructions
prescribed by the COUNTY, attached hereto and incorporated
herein.
2. 3 Monthly invoices submitted by PROVIDER shall include a
certification statement signed by an authorized person as
referenced in Exhibit B, attached hereto and made a part
hereof, that each client served by the PROVIDER is eligible
under this agreement. Should it become necessary for
PROVIDER to replace signatory, a notarized copy of the
authorizing resolution as passed by PROVIDER's Commissioners
shall be submitted to COUNTY's Agreement Administrator for
this Agreement. A letter from the City Commission setting
forth the reason for the action must accompany the notarized
COPY. Both items must be submitted to COUNTY's Agreement
Administrator for this Agreement on or before the fifteenth
of the following month.
All documentation required by this section shall be
reported, maintained and presented upon forms prescribed by
or approved by COUNTY Agreement Administrator.
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Invoices shall be submitted on Broward County Form 4600-15
revised 1991 as shown in Exhibit C and calendar
documentation shall be submitted on Broward County Form
#600-16 bearing the appropriate fiscal year designation on
its face as shown in Exhibit D attached and made-a part
hereof, or other such form pre-approved by the Agreement
Administrator.
2. 4 PROVIDER may choose to document units delivered in excess of contracted levels and not paid by any other source. Units
of service so documented may be used to augment subsequent
months' billings when service levels are lower than
contracted amounts . Written justification for failing to
deliver contracted service levels must be submitted with
billing whenever this deficit occurs . Adjustments enabling
PROVIDER to collect maximum monthly payment(s) for the
month(s) showing unit shortages will be made so long as
written justification for uneven service delivery is
submitted and justification is not in violation of the
requirements for delivery of services specified in Exhibit
A.
2. 5 Submission of accurate, timely documentation, and other
requested information as required by COUNTY shall be
considered a factor in evaluating future funding requests.
2.6 Invoices not acceptably submitted within forty-five (45)
days of the closing date of this Agreement shall not be
reimbursable.
2.7 PROVIDER shall provide signature authorization to COUNTY as
shown in Exhibit B, pages one ( 1) and two ( 2) , attached
hereto and made a part hereof.
2.6 PROVIDER represents to COUNTY that no other funds are used
for services invoiced to the COUNTY constituting duplication
�• #' of funding, including banked units and COUNTY has relied
upon that representation.
2.9 PROVIDER shall keep accurate and complete records of any
fee, reimbursement, or compensation of any kind, assessed
against or collected from any client or other third party,
for any service covered by this Agreement; shall report such
fee, reimbursement or compensation to COUNTY on a monthly
basis; and shall deduct from its invoices to COUNTY all such
fees, reimbursements, or compensation in excess of 1008 of
the actual cost of the unit of service as specified in
Exhibit A.
2. 10 In the event the PROVIDER receives funding, from a source
other than the COUNTY, for the same services as covered by
this Agreement, the PROVIDER shall keep similar records of
such funding and services, as required under Section 2. 3 of
this Agreement, and shall make all such records available to
COUNTY upon demand .
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2. 11 Reimbursements and notices shall be sent or given to the
PROVIDER at the following address :
City of Dania, Florida
Post Office Box 1708
Dania, Florida 33044
ARTICLE III
TERM OF SERVICE
Services shall be provided under this Agreement from October 1 ,
1990 through September 30, 1991 .
ARTICLE IV
MONITORING
The PROVIDER agrees:
4. 1 To assign appropriate staff as necessary to attend meetings
with COUNTY staff to assess the quality of service and make
recommendations for improvement.
4 .2 To maintain the confidentiality of client services in full
accord with any Federal or State laws or regulations
mandating such confidentiality and in full accord with any
applicable professional standards of ethics requiring
confidentiality .
4. 3 To give access and make available to COUNTY representatives
all records and data pertaining to the services which are
funded by the COUNTY under this Agreement, provided,
however, client case files shall not be accessible to the
COUNTY to the extent such access is in violation of federal
or state law, or professional standards of ethics .
4. 4 To give access and make available to COUNTY representatives
records and data pertaining to services performed by the
PROVIDER which are the same or similar to the services
covered by this Agreement, to the extend that is necessary
for the COUNTY to determine that such services are not
duplicative of the services funded by the COUNTY, provided ,
however, client case files shall not be accessible to the
COUNTY to the extent such access is in violation of federal
or state law, or professional standards of ethics.
4 .5 That monitoring reports originated periodically by
designated COUNTY staff and all the performance requirements
of this Agreement and timeliness of requested information
shall be considered a factor in evaluating future funding
requests .
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4 .6 To give representatives of the COUNTY full access to
PROVIDER's facilities for announced and unannounced site
visits for the purpose of observation of services and
examination of all records and data covered by this
Agreement, provided, however, client services shall not be
accessible to the COUNTY to the extent such access is in
violation of federal or state law, or professional standards
of ethics .
4 . 7 To provide the COUNTY at the mid point of the Term of
Services set forth in Article III, and again within thirty
(30) days of the close of that Term of Services, a progress
report on the aspect of their agency 's activities specified
in the Scope of Service set forth in Exhibit A, attached
hereto and made a part hereof.
4 .8 To provide COUNTY Agreement Administrator with information
to contact recipients of contractual services ( legal
guardians on behalf of young or mentally handicapped
children) so that COUNTY staff may verify the provision of
services. This section shall not apply to any services for
which federal or state law, or professional standards of
ethics mandates client confidentiality.
ARTICLE V
TERMINATION OF AGREEMENT
5 . 1 This Agreement may be terminated by either party upon thirty
(30) days written notice.
5. 2 COUNTY's Board of County Commissioners shall be the final
r .k authority as to the availability of funds and the allocation
of available funds among social service providers . The
COUNTY reserves the right to terminate the services covered
by this Agreement in the event funds are unavailable.
5.3 If the PROVIDER fails to provide services called for by this
Agreement within the time specified herein or any extension
thereof, or if the PROVIDER fails to perform any of the
other provisions of this Agreement the COUNTY may, by
written notice of breach of the PROVIDER, terminate this
Agreement.
5.4 Termination, pursuant to Section 5. 2 or 5.3 shall be upon no
less than twenty-four ( 24) hours notice, in writing,
delivered by certified mail, or in person, to the address
specified in Section 2. 9 .
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ARTICLE
RETENTION OF RECORDS
The PROVIDER shall preserve and make
records, supporting documents available all financial
documents pertinent to this Agreementtforlarecords
Years after and any other
termination of the term Period of three (3 )
Section 2. 9, or, if an audit has °f service specified in
findings have not been resolved at initiated and
years , the records end of audit
audit findings . shall be retained until resolution of
(3 )
of the
ARTICLE
INDEPENDENT CONTRACTOR
The PROVIDER is an independent contractor under
Services provided by the PROVIDER shall be b this agreement.PROVIDER and subject to sof
e
Officers, supervision b y employees of the
employees, or agents of COUNTyhe PROVIDER, and not as
personnel policies Employee com io
health insurance , tax responsibilities, social Pensation,
and other similar employee benefits, travel security and
administrative pro' travel , diem policies
services rendered under this Agreement shall be those
to
PROVIDER. those of the
ARTICLE
FINANCIAL STATEMENTS rr
8. 1 The CONTRACTOR shall provide a Certified Public Accountantthe COUNTY a special re
auditor on the , or by the entity'sPort lby
elements specified in the financial internal Presentation described in Section 8 .3 below.
8. 2 If the special report is prepared by an independent
Certified Publi
Section 623 of c Accountant, it shall be in accordance with
the Codification of Statements
on
Standards as promulgated by the American Instituteuofting
Certified Pubic Accountants. If the special report is
Prepared by an internal auditor, it shall be as nearly in
accordance with that Section as the status of the internal
auditor permits, realizing that the internal auditor may not
issue the opinions required therein.
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8.3 The financial presentation shall show all revenues, by
source and all expenditures to include the classification
set forth in Exhibit "A" for each specific PROGRAM/PROJECT
for which grant funds were provided. The financial
presentation shall specifically disclose any funds received
which were not expended in accordance with the AGREEMENT (or
with any regulations incorporated by reference therein) . It
shall specifically disclose the interest computed as earned
on these funds . It shall identify the total of noncompliant
expenditures and interest earned as due back to the COUNTY.
8 .4 The reporting period for the financial disclosure
information described in 8 . 1 and 8 .2 above shall be the
CONTRACTOR'S fiscal year. The information shall be filed
with the COUNTY within ninety (90) days after the close of
each of the CONTRACTOR's fiscal years in which the
CONTRACTOR accounts for funds under this Agreement .
8. 5 Late submission of the financial statement shall result in
suspension of payment under this Agreement until the
financial statement is received and accepted by COUNTY, and
- , shall be a factor in evaluating future funding requests .
w Suspension of payment shall not excuse PROVIDER from
continued delivery of services although COUNTY will not
accept invoices until financial statements are received and
accepted by COUNTY.
ARTICLE IX
MANAGEMENT LETTERS
'^ 9. 1 PROVIDER shall provide to COUNTY' s Agreement Administrator
for this Agreement any and all management letters arising
from audited financial statements within ten ( 10) days of
receipt by PROVIDER.
9. 2 PROVIDER shall provide to COUNTY's Agreement Administrator
for this Agreement the schedule of corrections developed in
response to said management letter(s ) within thirty (30)
days of development.
9.3 PROVIDER shall provide to COUNTY's Agreement Administrator
for this Agreement any compliance audits required by law
within ninety (90) days after the close of each of the
PROVIDER's fiscal years in which PROVIDER accounts for funds
under this Agreement.
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ARTICLE X
EQUAL OPPORTUNITY FOR EMPLOYMENT OF SERVICES
10. 1 PROVIDER shall not discriminate applicant for employment because a Of
any employee or
color, gender, national °f race, age, religion,mental handicapERshall
origin, marital status
insure • PROVIDER shall take affirmative
or
employmentapplicants are employed and em to action to
without regard to race P yees treated during
gender, national origin, marital f age' religion, color,
handicap. Such actions shall status, ph sical
the followin include y or mental
g employment but not be limited to
recruitment or recruitmentuPgrading, demotion
rates of a advertising, transfer,
conditions of other forms of com ti layoff, termination,
employment and Pensation, terms and
a PP renticeship, training, including
10. 2 Decisions regarding cli
regard ent eligibility shall be made without
to, or consideration Of
gender, national on . race, age, religion,
handicapg , marital status Sion, color,
or other factors which , Physical or mental
appropriately used as basis for cannot be lawfully or
service delivery.
ARTICLE
INDEMNIFICATION CLAUSE
PROVIDER shall indemnify and save
agents, se vants and employeesharmless and defend COUNTY
action of whatsoever
against an its
error, omission kind or nature y claim, demand
PROVIDER negligent act, conduct arising out of
»..1` service under agents, servants °Y misconduct of
this A or employees in the performance of
Agreement.
ARTICLEx
DESIGNATED REPRESENTATIVES
The Agreement Administrator for the COUNTY
the Director of Broward County's Public Services De
desi for this Agreement is
designee. The representative of the PROVIDER
administration of the res i sithenfo�rthe
Director, Personnel program this Agreement
P 9 under
and Community Developmen is the
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ARTICLE XIII
INSURANCE
13. 1 PROVIDER will maintain in force for term of this Agreement,
comprehensive general liability in the minimum amount of
three hundred thousand dollars ($300, 000. 00) per occurrence
combined single limit of bodily injury and property damage
liability. Such policy will name Broward County Board of
County Commissioners as additional insured. Further, the
PROVIDER will maintain professional liability insurance in
the minimum amount of three hundred thousand dollars
($300, 000.00) , subject to insurance market availability.
Such policies as required will be evidenced to the COUNTY by
certificate(s ) of insurance which will reflect thirty (30)
day prior written notice of cancellation and/or non renewal .
13. 2 The PROVIDER shall be liable, and agrees to be liable for,
and shall indemnify, defend and hold the COUNTY harmless
from all claims, suits , judgements or damages including
court costs and attorney's fees arising out of intentional
acts, negligence or omissions by the PROVIDER in the course
of the services and operations of this Agreement .
ARTICLE XIV
AMENDMENTS, ASSIGNMENTS
14. 1 No modification, amendment or alteration in the terms or
conditions contained herein shall be effective unless
contained in a written document executed with the same
formality and of equal dignity herein.
•, 14. 2 The PROVIDER shall not transfer or assign the performance of
services called for in the Agreement without the prior
written consent of the COUNTY.
ARTICLE XV
WAIVER OR BREACH
Waiver or breach of any provision of this Agreement shall not be
deemed to be a waiver of any other subsequent breach and shall
not be construed to be a modification of the terms of this
Agreement .
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ARTICLE XVI
REPRESENTATIONS AND ACKNOWLEDGMENTS
16. 1 PROVIDER acknowledges that:
a) There have been no irregularities involving its
management or employees that could have a material
affect on PROVIDER's operations or stability .
b) There are no violations or possible violations of laws
or regulations the effects of which should be
considered.
c) There are no material transactions that have not been
properly recorded in the appropriate document(s) .
d ) Related party transactions and related amounts
receivable or payable have been properly recorded or
disclosed.
16.2 PROVIDER acknowledges that:
1� a ) In order to obtain execution of this Agreement by the
Board of County Commissioners , PROVIDER's most recent
audited financial statements, compliance audit as
required by law, and management letter, if generated,
must be provided to, and reviewed and accepted by
COUNTY.
b) Submission of audited financial statements, compliance
audit as required by law and management letter(s) if
generated to any Department, Division, Office or other
entity of Broward County as a requirement for any
..,i transaction or agreement with that Department, Division,
Office or other entity does not constitute compliance
with the requirements of this Agreement insofar as
submission of material to the Agreement Administrator
for this Agreement is concerned.
c) Information, guidance and technical assistance offered
by COUNTY's Agreement Administrator for this Agreement,
the Contract Monitor and any other staff, whether
written or verbal, in no way constitutes a guarantee of
execution of this Agreement by the Board of County
Commissioners .
d ) Information guidance and technical assistance provided
prior to contract execution at the Contract Workshop
should not be relied upon as a basis for doing business,
delivering service, expending financial resources or
expectation of reimbursement or receipt of payment.
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ARTICLE XVII
RENEWAL
PROVIDER understands and acknowledges that, although its
successful and scrupulous performance under this Agreement will be
a factor considered by the COUNTY in evaluating future funding
requests, COUNTY funding under this Agreement relates exclusively
to the term of service specified in ARTICLE III herein and that
the COUNTY, by entering into this Agreement with the PROVIDER,
assumes no obligation whatsoever with respect to further or future
funding to this PROVIDER. Notice of renewal shall be given to
PROVIDER in writing no later than thirty ( 30) days before the
expiration of the initial term.
ARTICLE XVIII
RENEGOTIATION
The parties agree to renegotiate this Agreement if COUNTY
revisions of any applicable laws, regulations or increase/decrease
in allocations makes changes in this Agreement necessary.
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IN WITNESS WHEREOF, the parties hereto have made and executed
this agreement on the respective dates under each signature:
BROWARD COUNTY through its BOARD OF COUNTY COMMISSIONERS, signing
by and through its Chairman, authorized to execute same by Board
action on the day of , 1990, and the CITY OF DANIA,
signing by and through its Mayor, City Manager and City
Clerk-Auditor.
COUNTY
BROWARD COUNTY, through its
ATTEST: BOARD OF COUNTY COMMISSIONERS
County Administrator and Ex- By:
Officio Clerk of the Board Scott I . Cowan, Chairman
of County Commissioners of
Broward County, Florida day of , 1990.
Approved as to form and
legality by Office of General
tr� Counsel, Broward County, Florida
r Governmental Center, Suite 423
115 South Andrews Avenue
Fort Lauderdale, Florida 33301
By:
Assistant General Counsel
CITY
CITY OF DANIA, a municipal
corporation of the State of
Florida
By:
Charles K. McElyea,
Mayor - Commissioner
Attest:
By:
Robert F. Flatley
City Manager
Wanda Mullikin
City Clerk-Auditor
APPROVED AS TO FORM AND CORRECTNESS
By: c.. G �. a let
Frank C. Adler, City Attorney
EXHIBIT A
I. Scope of Service : (Reference Article I )
The PROVIDER agrees to provide a variety of structured
supervised after school activities which will focus on
enhancing and increasing academic and life skills and
various recreational activities .
II . Definition of Units of Service:
A) A unit of service is defined as attendance at one to four (4 )
hours of daily after school day care by an eligible child and
his/her sibling(s ) if enrolled in same school, in grades K-5
or in a Pre-K program.
B) Subject to the deductions provided for in Subsection (C)
below, the COUNTY agrees to reimburse the PROVIDER for each
unit of service during TERM OF SERVICE set forth in ARTICLE
III of this Agreement, at a cost not to exceed $1 .00 per unit
at a maximum of $2, 480 monthly or one tenth (1/10) the amount
of this Agreement. The COUNTY will reimburse in addition
beyond the one (1 ) hour of after school care for each minute r
of the hour of service at $ .0166 per subunit. No monthly F!
payment will exceed the amount arrived at by dividing the
maximum amount payable under this Agreement by the number of
months set forth in ARTICLE III of this Agreement, as "TER?1
OF SERVICE" .
C) In the event the PROVIDER collects any fee or collects any
reimbursement from a third party for services provided under
a# this Agreement, PROVIDER shall keep accurate and complete
records of all such fees collected and report such collection
to COUNTY, and the amounts collected shall be deducted from
COUNTY's reimbursement to PROVIDER.
D) It is understood that per unit cost from PROVIDER is $1 .00 .
In residential placements, the COUNTY agrees to pay for the
day of admission but not for day of departure if departure
occurs before noon.
III . Monthly Invoices: (Reference Funding and Method of Payment
ARTICLE II )
Client Case Files:
The PROVIDER agrees to maintain updated case files on all
clients. Files shall include, but not be limited to: name,
date of birth, entry date, statement verifying client
eligibility for service, exit date and exit time .
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EXHIBIT B
Appearing below are samples of signatures authorized by the City
Commission of the City of nan; a Florida
as required by Broward County.
Signature Signature
MICHAEL W. SMITH, as MARDIE HOLLOWAY, as
Type Name Type Name
Personnel Director STATE OF FLORIDA Recreation Coordinator
COUNTY OF BROWARD
Before me personally appeared
MICHAEL W. SMITH, as Personnel Director
- Name
and MARDIE HOLLOWAY, as Recreation Coordinator
Name
to me well known and known to me to
be the person described in and who
executed the foregoing instrument,
and acknowledged to and before me that
MICHAEL W. SMITH, as Personnel Director
and MRDIE HOLLOWAY. as Recreation Coordinator
Executed said instrument for the
purpose therein expressed .
(NOTARY SEAL) WITNESS my hand and official seal,
this _ day of ,A.D. , 19 go
Notary Public
State of Florida
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PUBLIC S. .rs nr:rn uTnl:rrr/L'U n.mtl:ll,e1 :a:ev lr cs F:XII76IT C
Instructions for Contrnr-tLd :'e ry{,. !�Oe 2
anon-IS e_vined 7 .,n
1. Legal name of agency under contract with ❑row,rrd Pounty,
2• Agency's Federal Identification Number,
3. Agency's contract number as r.Latcl on page I of contract.
4. Name of contracted program as ntuted no pu,le I of
contract.
S. Month and Year for reimbursement request,
6• Date the Invoice was prepared.
7. Maximum contract dollar amount as stated In the alntract.
8. Monthly maximum contract dollar amount as :.Late,] L, thn contract.
90 (Scope of Service) As stated in rxhlble A-1 of the contract under
definition.
10. (Unit of Servlee) An defined In I:xhiI1IL A-I1 of the contract under
definition.
Maximum
uni
11. senth
rvice aretnotftoeexcecdttotalotnitneal L+wt,i Ira n kr•,i). Thn unit., or
contract end not to Inc Lido bull k,ud tolls, hOC m""th,
puce ua nt to Cho
12. Bolmbu[some nt In dollar: from II. Thin in:,l when only lhn L1l labli.
amount for units of 'crvieu 1.d;un from box 11, n"l In cxcued
alltwa b10 amount and not to Include hankcq unit'.
mootLiy
13e. Indicate amount he fe
deducting from the on collected for invok
e month and IndiCa LC by
amount. number of monthly units of survlce to equal Cho
120. If deduction of fees
Indicate in blank is below monthly Ca us
c halanee of banked unit:.
epacos p
the number of units to equal the amount taken
from the balance of banked units. ///
13• Banked unite earned for Invoice month only,
14. Banked unite used for Invoice month only,
15• Year to date used units (the cumulativa of numburn In 14.).
16. Balance of banked units available, !!!
17• Banked reimbursement request in dollars for 111101co :month.
"' Year to date reimbursement In dollars (Cho cumulativo of ,]tilers 1n 17)•
18• Tatel units 00excer9od thle month (including banked vnitn used for Invoice
month) not to exceed totel units allowed per uni 20. Year to date total unit' of nervlcu from execution of contract lhrnugh
current Involco (include YTD used banke,l unl t::).
21. Total reimbursement s quested for lnvoleo month,and deduction of fsoe eullocted, 1f any) not to excucA nkoil units
amount. (1nc Lid(., hn
monthly allowable
22. Total cumulative doll from execution of contract through current
Invoice. ,
23. Legal name of agency under contract with nrnward county.
24. Name of authorized elgnator as state,, L, Nxhil,it 11, ""Co 2 M contract.
25• Title of e,tDorlred elgnator.
26. Signature of Person, as authorize,, 1n Ez hlhlt N, pago 2 of contract.
27• Date invoice was signed by authorized elgnator.
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EXOIIiI'I' D (Page 2)
Public Services Department/Children' s Services
Instructions for Calendar Documentation Form #600-16 (Revised 7/90
1 . Invoice month and year.
2• Location of Service.
3 . Hame of client (or confidential code number or participant .
4 . Date of birth of client .
S. Date of client' s entry into Contracted program.
6• Exit date of client (only if terminated or discharged ) .
7. Original initials of authorized signator for certification.
+ 8. Each block represents a day of the month. Indicate dayss
hours, per day, that services were rendered Cont
or
Agreement - Exhibit A) . (as per Contractual
9 • Total units (for the month) .
10. Fees collected ( for the month ) .
11. Grand total units (for the whole page ) .
12. Grand total fees collected
( for the whole page )
-19-