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HomeMy WebLinkAboutbocc.con.308.2008 CLERK'S CHECK LIST FOR CONTRACTS SUBMTTTED TO CLERK AND RECORDER FOR SCANNING/ARCHIVING CONTRACT 3 O 8. ~ °O~ ORIGINATING DEPARTMENT/DIVISION: Ike n), 6 F ~Fu"'~ ~ rv' ~ ~J CONTACT PERSON: (<j iry~ HI ~I de ~~'"'c~HONE (G`7a7 ~F~ 9 - a ~ `i 3 PROJECTNAME:~~F 'f11P/xtriy- ~4 /~1Cke(~Ha~~ ? BOCC AGENDA ITEM [STAFF AUTHORIZE SIGNATURE (Requires BOCC Signature) (per Revised Procurement Code 7/2005) ? Over $50,000 (Requires County Manager's Signature) ? CHECK PROCUREMENT TYPE: ?None ?Informal ?Formal [~ole Source ?Emergency ?State Bid ? compliance with House Bills 06-1343 and 07-.1073 -Immigration Form (Under $10,000, Letters of Engagement, etc DOLLAR AMOUNT: J~OU. DO BUDGET LINE ITEM/LEDGER NUMBER: I l ] , y ~j" , ga O° J ? CHECK CONTRACT TYPE: ©Services/Maintenance ?Employment (for county employees) ?License/Use ?Intergovermnental Agreement (Requires BOCC Action) ?Lease ?Non-Profit ?Construction ?Quasi-Public ?Goods, Equipment, Supplies ?Grant Agreements (Requires BOCC Action) ?Other (e.g. revenuet)~' ?Change Order/Contract Amendment b Gii P~L~c~`~. /~o h / l~r i ~d,~c_ fiYu~~~~~ CONTRACTOR: C ETE E AL OF 1~AME OF BUSINESS (if different from contractor) Contract Execution Date: q~l 'R9~ontract End Date: 5e(~t ~ 1 ~ 20 Sam/ Automatic Renewal: Yes [~No Term of Contract: / . TD All Contracts should be proofed for the following: ? QNo-Pages Missing ? ~If a Page is Left Intentionally Blank -Note on Page ? ,?Page numbered consecutively ? All Signatures Affixed ? All Dates Filled In ? O'All Other Blanks Filled In ? ?All Exhibits Attached ? [~1B 06-1343 and 07-1073 (Immigration Legislation) Included in RFP and/or Contract ? All Legal Descriptions Attached (if applicable) ? ®Notice of Awazd/Notice to Proceed Attached (if applicable) ? ©Warranty (if applicable) ? [~pecial Instructions for Finance Department: ? [~$ent to Clerk and Recorder for Scanning/Archiving ~ ? ?Authorized Staff Person's Name:fjiM ~LIC (hY~-=~ 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 `'S ARCHIVES RETAINAGE SCHEDULE. AMENDED 04/23/08 ~D~ Rev 03/OS/OSjs l w ~ t LETTER OF ENGAGEMENT September 1, 2008 Project Name TANF (Temnorarv Aid to Needy Families)• TANF Counseline Provider Business Name Mickey Hohl Address P.O. Box 2701 City, State Zip Code Basalt CO 81621 Re: Provision of Counseling utilizing TANF Funding Dear Ms. Hohl: The purpose of this letter is to summarize 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 Mickey Hohl 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 e]igible 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 Mickey Hohl 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 Mickey Hohl 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. 1 Rev 03/OS/OSjs QUALIFICATION OF INDIVIDUAL OR FAMILY FOR SERVICES Mia Hohl 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 onpre-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 yeazs 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 aze 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 Bi1106-1343 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/08js 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`s 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 eazlier. 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 subparagraph (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 aze 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, 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 Hilderbrand. Witnessed my hand and official seal. My commission expires: Notazy Public AGREED: /Iy`;, Mickey Ho I 6< Date STATE OF COLORADO ) ss. COUNTY OF PITKfN ) N The forgoing instrument was acknowledged before me this~J 'day of g4enEFi, Fear, by Name of Other ParCy's Name to Agreements Y1'1 i UcY I Witnessed my hand and official seal. ,~PFtY P(~e~/ O:' ~'•.O My commission expires: l ~ KATHRYN • Z ERICKSON Notary Publ~-LL q~OF CO~-~ 4 Under lOK HB# Com liance with House Bi1106-1343 and House Bi1107-1073 A. In compliance with House Bill 06-1343 and House Bill 07-1073 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 Bill 06-1343 and House Bill 07-1073 enacted by the General Assembly of the State of Colorado: 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' 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 subparagraph (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. Signed and dated this ~ day of ~n ~r ~ • 20 ~ ~ CONTRACTOR: PITKIN COUNTY: ~ I~ By'-----iti U' Authorized Singner Title: ~ L ~ Department: {L ~ % ~ Company Name : ~ ~ lease riot d~ JZ@4' t~~12-{~n°o S `a ~j-~ r• Pitkin County Risk Management Department Workers' Compensation Waiver for Individuals I ~ ~ ~ " L, / , as sole proprietor or partner of ~c P (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. Request for Taxpayer Give form to the Form J requester. Do not (Rev. January 2005) Identification Number and Certification send to the IRS. Department of Me Treasury Internal Revenue Service N Name (as show on our Income tax retu ~ c ~ / d Ir r - m Business n e, if different from aba c 0 N Exempt from backup e ntlivitluaV ? wbhholdirg ~~o Check appropriate box: Sole proprietor ? Corporation ? Partnership ? Olher ~ Requester's name and address (optional) ~ ~ Atldress (nu bar, street, antl apt. or suke no.) a ~ ~0 D U Ciry, state, and ZIP code ~ ~ ~ Y I List account number(s) h~(optionap Tax a er Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid social security number / backup wtthholding. For individuals, this is your social security number (SSN). However, for a resident „2 p 1 f 7 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 to get a TIN on page 3. Employer identification number Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose number to enter. Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identfication 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 noYrfied 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). Cert'rfication instructions. You must cross out Item 2 above 'rf you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends 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 on page 4.) Sign Signature of ' j~ w ~ Dace ? 9 ~I Here u s arson ? l ~i Purpose of Form A person who is required to file~n information return with the • Any estate (other than a foreign estate) or trust. See IRS, must obtain your correctESxpayer identification number Regulations sections 301.7701-5(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. pereon. 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 terms of a tax treaty to reduce or eliminate U.S. tax on 1. Certify that the TIN you are giving is correct (or you are certain types of income. However, most tax treaties contain a waiting for a number to be issued), 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 or continue for certain types of income even after the recipient 3. Claim exemption from backup withholding if you area has otherwise became 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 to exception contained in the saving clause of a tax treaty to request your TIN, you must use the requester's /orm if it is claim an exemption from U.S. tax on certain types of income, substantially similar to this Form W-9. you must attach a statement to Form 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 VV-9 (Rev. 1-2005)