HomeMy WebLinkAboutbocc.con.307.2008 CLERK'S CHECK LIST
FOR CONTRACTS SUBMITTED TO CLERK AND RECORDER FOR SCANNING/ARCHIVING
CONTRACT 3 b q ao o ~
ORIGINATING DEPARTMENT/DIVISION: 7C' (Jl. U ~ I-(u ~rv~ C~,~, Sc~ rv~ ' .
CONTACT PERSON: K iirl Hl I Ue ~jYyn~HONE ~C1'7a7 ~ ~ ~ _ a U `1 3
PROJECT NAME: ~~tJF
~lrn~ - . M r'4 W Jsvr,
? BOCC AGENDA ITEM [STAFF AUTHORIZED SIGNATURE
(Requires BOCC Signature) (per Revised Procurement Code 7/2005)
? Over $50,000 (Requires County Manager's Signature)
? CHECK PROCUREMENT TYPE•
?None ?Informal ?Formal [~8role Source ?Emergency ?State Bid ?
~f'ompliance with House Bills 06-1343 and 07-1073 -Immigration Form (Under $10,000, Letters of Engagement, etc
DOLLAR AMOUNTc~T~ D~ BUDGET LINE ITEM/LEDGER NUMBER: /~q~ , N , ~a
? CHECK CONTRACT TYPE:
Ivlaervices/Maintenance ?Employment (for county employees)
?License/Use ?Intergovernmental Agreement (Requires BOCC Action)
?Lease ?Non-Profit
?Construction ?Quasi-Public
?Goods, Equipment, Supplies ?Grant Agreements (Requires BOCC Action)
?Other (e.g. revenue ?Change Order/Contract Amendment
CONTRACTOR: O LETE LEGAL OF NAME OF BUSINESS tf different from contractor)
Contract Execution Date: 9~/ a7OQ jfContract End Date: Sc~(~I , 1 ~ ZO €~y
Automatic Renewal: Yes dNo Term of Contract: ~ .
All Contracts should be proofed for the following:
? QNo Pages Missing
? ~If a Page is Left Intentionally Blank -Note on Page
? ,Page numbered consecutively
? All Signatures Affixed
? ?'All Dates Filled In
? ?'All Other Blanks Filled In
? ?All Exhibits Attached
? [.FHB 06-1343 and 07-1073 (Immigration Legislation) Included in RFP and/or Contract
? [All Legal Descriptions Attached (if applicable)
? [Notice of Award/Notice to Proceed Attached (if applicable)
? [v]Warranty(ifapplicable)
? [Special Instructions for Finance Department:
? ~Sentto Clerk and Recorder for Scanning/Archiving
? [Authorized StaffPersodsName:~~M ~Clf (rjy~`/
BY CHECKING ABOVE AND ENTERING NAME, THE AUTHORIZED STAFF PERSON INDICATES THAT
THE ATTACHED DOCUMENT HAS BEEN PROOFED AND READY FOR SCANNING.
NOTE: CLERK'S OFFICE WILL KEEP ORIGINAL DOCUMENTS IN COMPLIANCE WITH COLORADO STATE
ARCHIVES RETAINAGE SCHEDULE.
AMENDED 04/23/08 q
~a~
Rev 03/OS/08js
LETTER OF ENGAGEMENT
September 1, 2008
Project Name TANF (Temporary Aid to Needv Families); TANF Counselin¢ Provider
Business Name Mia Wilson
Address 100 Elk Run Drive, Suite 124/P.O. Box 4224
City, State Zip Code Basalt, CO 81621
Re: Provision of Counseling utilizing TANF Funding
Dear Ms. Wilson:
The purpose of this letter is to summazize the pertinent terms of Pitkin County's arrangement
with you to provide the specified services enumerated in the following paragraph. The
County's obligation under the Workers' Compensation Statute requires Pitkin County and
you to formalize the terms of this engagement in a notarized writing.
SCOPE OF SERVICE
Mia Wilson will provide apre-determined number of counseling sessions (not to exceed 12
without written permission from the Youth and Family Services Manager) for approved
TANF/Colorado Works Participants and TANF eligible residents. Treatment will focus on or
more of the following goals:
• strategies for self improvement and change,
• marriage and family counseling,
• and/or individual mental health counseling.
COMPENSATION AND METHOD OF PAYMENT
Mia Wilson will submit monthly invoices of services to be paid through Pitkin County
Human Services. Monthly invoice will include the following information:
A. # of sessions
B. rate of payment for each session not to exceed $100.00/hourly session
C. Dates and subject of sessions
D. Names of participants in sessions
E. Documentation of Participant Progress
TIME FRAME OF AGREEMENT
Mia Wilson shall perform services commencing on September 1, 2008 and shall be
undertaken and completed in such sequence as to ensure completion by the 315 day of
August 2009.
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Rev 03/OS/08js
QUALIFICATION OF INDIVIDUAL OR FAMILY FOR SERVICES
Mia Woodis Wilson and/or qualified individuals can apply for funding through Pitkin County
Youth and Family Services Manager. Services must be approved prior to provision of
services.
The Department shall determine eligibility based on pre-existing procedures. Qualified
individuals must meet the following requirements:
Applicant has a total family income of less than $75,000.00
Applicant receiving treatment is lawfully present.
Applicant has dependent children under 18 years old in the home.
INDEPENDENT CONTRACTOR
It is mutually agreed that the County does not have an exclusive right to your services and it
is contemplated that you may provide similar work to other businesses, governments and
non-profit organizations. You acknowledge that the work performed for Pitkin County will
be that of an independent contractor and that no employee-employer relationship is created.
You have full control over how the services are performed and it is expected that work will
be conducted in accordance with industry standards by applying professional judgment. The
County will provide, if necessary, documents and information to complete the work
described in the preceding paragraph. The County representative signing this letter is
available to you to discuss any details related to this engagement. This letter of engagement
will be in effect for one year and will terminate on September 1, 2009 and will require a new
document in succeeding years to be effective. Contract will not exceed a total of $9,000.00
in any given calendar year unless an updated agreement is generated.
You acknowledge and agree by signing the attached waiver that you shall not be
entitled to workers' compensation benefits in connection with this project and that you
shall be responsible for the payment of all state and federal income taxes.
Compliance with House Bill 06-1343 and House Bill 07-1073
A. In compliance with House Bi1106-1343 and House Bi1107-1073 amending
Title 8 of the Colorado Revised Statutes by the addition of Article 17.5, Illegal Aliens-Public
Contract for Services, enacted by the General Assembly of the State of Colorado, the
Contractor shall not:
1. Knowingly employ or contract with an illegal alien to perform work
under this contract or;
2. Enter into a contract with a subcontractor that fails to certify to the
Contractor that the subcontractor shall not knowingly employ or
contract with an illegal alien to perform work under this contract.
B. In compliance with House Bi1106-1343 and House Bi1107-1073 enacted by the
General Assembly of the State of Colorado:
2
Rev 03/OS/OSjs
1. The Contractor has confirmed or attempted to confirm the employment
eligibility of all employees who are newly hired for employment in the United States
through participation in the Basic Pilot Program [created in Public Law 208, 104th
Congress, or its successor and expanded in Public Law 156, 108`h Congress, or its
successor, that is administered by the United States Department of Homeland
Security] and, if the Contractor is not accepted into the Basic Pilot Program prior to
entering into this contract, the Contractor shall apply to participate in the Basic Pilot
Program every three months until the Contractor is accepted or this contract has been
completed, whichever is earlier. This provision shall not be required or effective if
the Basic Pilot Program is discontinued.
2. The Contractor shall be prohibited from using Basic Pilot Program
procedures to undertake pre-employment screening of job applicants while this
contract is being performed.
3. If the Contractor obtains actual knowledge that a subcontractor
performing work under this contract knowingly employs or contracts with an illegal
alien, the Contractor shall be required to:
a. Notify the subcontractor and the County within three days that
the Contractor has actual knowledge that the subcontractor is employing or
contracting with an illegal alien; and
b. Terminate the subcontract with the subcontractor if within
three days of receiving the notice required pursuant to subpazagraph (a) of this
paragraph (3) the subcontractor does not stop employing or contracting with
the illegal aliens; except that the Contractor shall not terminate the contract
with the subcontractor if during such three days the subcontractor provides
information to establish that the subcontractor has not knowingly employed or
contracted with an illegal alien.
4. The Contractor shall comply with any reasonable request by the Department
of Labor and Employment made in the course of an investigation that the Department of
Labor and Employment is undertaking pursuant to the authority established in Subsection
(5) of C.R.S. § 8-17.5-102.
In all other respects the Agreement is in full force and effect and remains unchanged
by this Amendment.
If you are in agreement with the terms of this letter, please sign below in the presence of a
notary and return a copy to us for our files. We appreciate the opportunity of working with
you.
Sincerely,
~i-1- X008
Kim Hilderbrand Date
Youth and Family Services Manager
3
' Rev 03/OS/08js
STATE OF COLORADO )
ss.
COUNTY OF PITKIN )
The forgoing instrument was acknowledged before me this _1 st_ day of September, 2008,
by Kim Elilderbrand.
Witnessed my hand and official seal. ~~pp,,,,pp~~
My commission expires: ~O~J
No lic _ -
Mia
W_
i~~~ Date
STATE OF COLORADO )
ss.
COUNTY OF PITKIN ) ~
The forgoing instrument was acknowledged before me this day o nth, Year, by
Name of Other Party's Name to Agreement.
Witnessed my hand and official seal.
My commission expires: 0(u 2 3 ' ZO ~ y
yNo Public
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Pitkin County Risk Management Department
Workers' Compensation Waiver
for Individuals
I ~1Gt (SITlti, , as sole proprietor or
partner of ~ (a~- (business name),
represent that I have no person or persons in my employ, but that I shall obtain and
maintain workers' compensation protection pursuant to those insurance
requirements as set forth in the Workers' Compensation Act of Colorado (Articles
40 to 54 of Title 8 of the Colorado Revised Statutes) for any and all persons as I
may employ in performing any work in the future. I shall also require any
subcontractor as I may contract with or obtain for any work to maintain workers'
compensation protection for its employees.
Date signed Signature of Contractor
W-9 Request for Taxpayer Give form to the
Form requester. Do not
(Rev. January 2005) Identification Number and Certification send to the IRS.
Depanmen[ of the Treasury
Internal Revenue Service
N Name (as hown on your income ~ return)
~ A - W ~ ~~v~,
Business name, if different from above
C
O
d ~
p IntlivitluaV Exempt from backup
Check appropriate box: Sole proprietor ? Corporation ? Partnership ? Other ? ? wkhholding
o ~ Requester's name and adtlress (optionap
Adtlress (n ~mber, s eet, and apt. or suitor ~ ~ ~il
C ~ V 2 `1 N, U
U
!e City, state, a d ZIP code ~ rt I
N List account number(s) here (optional) V
u!
Tax ayer Identification Number IN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident ~ ~ ~ 8'
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is or
your employer identification number (EIN). If you do not have a number, see How fo get a TIN on page 3.
Note. I/the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identiricatlan number
to enter.
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dlvidentls on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions n page 4.)
Sign Signature of ~ ( ~1 v
Here u s pea Date ? D 1 1
Purpose of Form
A person who is required to file an information return with the • Any estate (other than a foreign estate) or trust. See
IRS, must obtain your correct taxpayer identification number Regulations sections 301.7701-6(a) and 7(a) for additional
(TIN) to report, for example, income paid to you, real estate information.
transactions, mortgage interest you paid, acquisition or Foreign person. If you are a foreign person, do not use
abandonment of secured property, cancellation of debt, or Form W-g. Instead, use the appropriate Form W-8 (see
contributions you made to an IRA. Publication 515, Withholding of Tax on Nonresident Aliens
U.S. person. Use Form W-9 only if you are a U.S. person and Foreign Entities).
(including a resident alien), to provide your correct TIN to the Nonresident alien who becomes a resident alien.
person requesting it (the requester) and, when applicable, to: Generally, only a nonresident alien individual may use the
1. Certify that the TIN you are giving is correct (or you are terms of a tax treaty tc reduce or eliminate U.S. tax on
waiting for a number to be issued), certain types of income. However, most tax treaties contain a
provision known as a "saving clause." Exceptions specified
2. Certify that you are not subject to backup withholding, in the saving clause may permit an exemption from tax to
or3. Claim exemption from backup withholdin If ou area continue for certain types of income even after the recipient
9 y has otherwise become a U.S. resident alien for tax purposes.
U.S. exempt payee. If you are a U.S. resident alien who is relying on an
Note. If a requester gives you a form other than Form W-9 [o exception contained in the saving clause of a tax treaty to
request your TIN, you must use the requester's form if it is claim an exemption from U.S. tax on certain types of income,
substantially similar to this Form W-g. you must attach a statement to Farm W-9 that specifies the
For federal tax purposes you are considered a person if you following five items:
are: 1. The treaty country. Generally, this must be the same
• An individual who is a citizen or resident of the United treaty under which you claimed exemption from tax as a
States, nonresident alien.
• A partnership, corporation, company, or association 2. The treaty article addressing the income.
created or organized in the United States or under the laws 3. The article number (or location) in the tax treaty that
of the United States, or contains the saving clause and its exceptions.
Cat. No. 10231X Form W-g (Rev. 1-2005)