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Home My WebLink Aboutbocc.con.001.1986 ,4r�� . �.��M . • � . J�._•i. . . , a . �� j�.yf� ��fx� � t .t;. �y�1 ,�y �r , .. n3 � !!:� �&�i i+,Fhb I'!�R 4`_r'!tt r:.�� '. .t�� F� ��. � r;'� �.i b,� �'y�{ .��,'�7��,�f��sx - � ��'� 4�y� s rD �1 `C� ;%t� `Z'..� i�.�y��Y r KS ;� � , •.:.. x'� �.. �. �,} }. f � �r./ �';$.T�..�.+�.. {'�S::e��..�.. •lu�°+Y��"AF�J? A` p,. Q._, �J""�� . J6�1} ��.� ..._ . i�.. . ._. .. . . �.... .,. w � ... .. . -•J�':�. .. .. � �RECORDEAS NOTE****ORIGINAL NEVER RETURNED TO CLERK BY TOM STEPHEtVSON DEPUTY SHERIFF CONTRACT ' CA 1(86) THIS CONTRACT, made this lst day of February, 1986 by and between the State of Colorado. for the use and benefit of the Department of Institutions, Division of Youth Services, 4255 South Knox Court, Denver, � . . Colorado 80236, hereinafter referred to as the State, and the Pitkin County Board of Commissioners, and the Pitkin County Sheriff on behalf of Pitkin '—" County, Colorado, hereinafter referred to as the Contractor. ,a WHfiRHAS, authority existing in the Law and Funds has been budgeted, t'"s ' _ ' appropriatad and otherwise made available and a sufficient unencumbered `°3 balance thereof remains available for payment in Fund Number ,: ... -----------' ;.,. . : G/L Account Number ___________ Contract Hncumbrance Number ' _ ' ---------� and : . �;+� WHERSAS, required approval, clearance and coordination have been . v; accomplished from and with appropriate agencies; and �� WHEREAS, the County has the authoritq to budget the graat funds - ' � allocated herein for expenditure consistent with the purposes of the grant and to perform the services set £orth herein; and i� ' �^ WHBREAS, the �Sheriff hss the ability to coordinate the use o£ off-duty �; � �' personnel and other ualified q provide s� Sheriff's q personnel when re uired to '_ • � monitoring and security for juveniles being held pursuant to S19-2-101, et. �,r. ' �� seq., C.R.S.; and �- � WHEREAS, the personnel so utilized will be given upon request Fs� specialized training by the Division of Youth Services in order to provide �;�' �� securit in a tem orar holdin unit for Y P y g juveniles; and ."'�� WHBRBAS, the Department of Institutions' Division of Youth Services � � y�? has received a grant from the Criminal Justice office, # ± . - "� to provide 24 hour supervision of youths temporarily being held in a county �_ '� designated holding unit outside the adult jail facility and sufficient - �..'y�' ��3 funds remain in said grant to continue services for youths through fiscal f'� year 1985-86; and • t'' ..i::: � WHEREAS, these personnel will be available on an on-call basis and used in the facility when required for the security and supervision of ,:`� youths when deemed necessary by the District Judge or designated appointee: sw I, � NOW THSRSFOR6, it is hereby agreed that t.:�.' : � � 1. STATHMSNT OF WORK =?�.' � The Contractor will provide off-duty Sheriff's personnel and • � other qualified personnel for security and supervision of youths � being held in a juvenile holding facility when ordered by the ��; ',� llistrict Court. These personnei shall be given technical assistance and training by the Division of Youth Services as �,. _ r requested. Direct supervision of the personnel will be provided - '�' by the County Sherif£'s Department. The Contractar will provide a designated holding unit outside the adult facility. The , � Contractor will be responsible for any medical needs of the � youths being held in the holding unit. The Contractor will also be responsib2e for the youths' meals while in the holding unit. Specifications for this unit are attached as "fixhibit A" and made .._, � a part hereof and incorporated as if fully set forth herein by � reference. <�"•' •?' 2. STATSMBNT OF DOLLARS � e'Y ---- — —' . �;} a. For the Juvenile Security Officers the State will pay the - County directly a sum of twelve dollars (�12.00) per hour for each hour worked by "off-duty" Sheriff's personnel upon de�* receipt of the approved-personnel time sheet (see attached as "fixhibit B"). The total amount payable to the County '�, under this contract shall not exceed three thousand dollars +�r ($3,000.00). �� .3� �';•.',I page _1_ of _6 pages (,4''.� ��,�� . � _� ...��.��. _.,. _ :��,,� , • '�.. - ��, � ; D � `j� r �" 3�� r ' �y 1�'hy� *�� • a� �.,. "; , � . � �+;�,�r�4 . ��, � s�� c�; � - � -.t} tic. � ' � �. '.3ta•..r.o "P'`' ui.. :;��.�. . . _ ... ��+�d¢ua�•z-.. ':'s �� 3. MSTHOD OF PAYMHNT � a. The Contractor shall maintain copies of all personnel time ; sheets with proper approval by the JRI Coordinator in Grand 1 Junction, Colorado. �? � ; - � b. The State shall pay actual cost incurred by the Contractor ! for provision of services under this contract in the ��:_-� following manner: 4 " . . .,� Payment will be made monthly. Reimbursement requests shall �� ' �� be submitted between the first and tenth of the following month. Payment is made upon the receipt of a monthly •; - � invoice and copies of the personnel time sheets from the ;}��, • Contractor which show the number o£ hours of personnel time ' . to be reimbursed at twelve dollars ($12.00) per hour. This invoice shall contain the following certification: , We certi£y that the attached expenditures totalling . ,; -•, , ,; $_________________ represent actual and necessary "`' 1�,:`� expenditures in providing the services under this contract. . �,: ' "0 � �� ------------------------------ �' � Fiscal Officer For the purpose of this Paragraph, "actual cost" and "actual .�`� ec e nditures" shal b s 'n - � � and n essary xpe 1 e ubject to the i ter � pretation set forth in "Sxhibit B." r.� 4. FISCAL RECORDS i ':f . ,. �,.y�-•• The Contractor shall maintain adequate fiscal records £or a period of three (3) years following the termination of this �' '�.' i� contract subject to inspection and audit by the State or its �� designee. Any audit exception, if substantiated, shall be ;, subject to an immediate refund to the State by the Contractor. (`;; 5. TIME OF PBRFORMANCfi The Contractor shall render services under this cantract '=;� commending the lst day of February, 1986 and shall complete such � services on the 30th day of June, 1986. ..z� ��`,; . 6. CONTRACT TBRMINATION - � _ :� This contract may be terminated by either Party by giving a '�- .� � thirty (30) day notice in writing, delivered by certified mail, �: !,� return receipt requested, to the above address or delivered by �� personal service upon the Party. If notice is so given, this contract shall terminate on the expiration of the thirty (30) 1, days and the liability of the Parties hereunder for further �`. ;.� performance of the terms of this contract shall thereupon cease, �' � hut the Parties shall not be relieved of the duty to perform � , � their obligation up to the date of termination. ;,, ° =j ` _'� 7. SUBCONTRACTS �' •--- , The Parties recognize that the services provided by the °2 Contractor are personal in nature; and therefore, none of the , rights, duties, or obligations arising under this contract may be �' assigned or delegated without prior written consent of the State. z' X i �. �; i• � page _2_ of 6 pages :�. r r}� C� „;�-�, . - ;:�. '�. �' ' ' �+��`��' , , E-�"fi�.� "S^. :�` r-�, i-y{?.:4 _ ' �' ! '{ � .i � - '��x� .•7� : � : . ' .,,_... 4A .. ..':i?g .•,.� >:.:..:.: . ,��'. . �' �'..��. . . .�� r'�a s��'�3'�. .. 8. INDfiP6NDSNT CONTRACTOR ' The Contractor shall render services under this contract as an independent coatractor and shall be accountable to the State for the ultimate results of its actions, but shall not be subject to r direction and control of the State as ta dstails or to articu2ar n P n-- hours of work except as provided herein. The employees of the a ;a ; Contractor shall not be construed as employees of the State for �� any parpose. �, 9. RULfiS The Contractor shall comply with aII rules, regulations, and � standards as may be promulgated and amended by the State. 10. REPRBSBNTATIVSS ''}�” x,.`:..' For the purpose of tkis cantract, the individuals identified below are hereby designated representatives of the respective k•:�'� Parties. Either Party may, from time to time, designate in writing new or substitute representatives: For the State: For the Contractor: , v • . . �:, �, ------------------------------ ----------------------------- � ,' Larry Grauberger, Director Name � Community Services ' � ----------------- . " ------------ i `. Title ,�'. 11. INTfiGRATION CLAUSS This contract is intended as the complete integration of all ;+ understandings between the Parties. No prior or contemporaneous . � addition, deletion, or other amendment hereto shall have any ',r '""z force or effect whatsoever unless embodied herein in writing. No • ��%?. :i subsequent novation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied in a written contract executed and approved pursuant to the State ' Fisca� Rules. _� RECOMMENDED FOR APPROVAL: 'I � Tom Stephenson .� Juvenile Officer � .'�� j �,. � ,; _ J r: ! Dick Kienast r . �� i Sheriff � �:: i �. ..`�', APPROVE TO FORM: • � I . �, a �" , �--� Gary sa� �: �"` ' Assist• Pitkin County Attorney �;';;':.... � �. � � � -� . ;d Tom Oken ; Finance Director • 9 � r )F I ;' page _3_ of 6_ pages �� t�. �,. . -.�.��.:y_'+ , ' ' . f��K�^ . i��'+' � � .j7r'."%tY: . e . a .w,.,� c a:�t j ':'+.G { 7�>,Y -- " a'�'a y�y` �,+ ,r�F,x .l.tE,r L��Y'�T�"'`t�jvS�.'�} '' ,�i 1 . 7�. � +1, � yfYiY'�' gy J� �. � ` y:;'.. g,;��' � ��. �.�y('�� ,yx.�. �� 1 �� 7 � , � � �3��'��kN4 S:.'/ .. � � ...+��;,��.�, .r::..i,Y T�`.:5 �; J '��: i � '.a;�i.'�„�.s•i T♦` � .+ , �. , �3� _. ..,. , �L.�..=.r"sr:: �.�r_ . '} . .a . . • SPECIAL PROVISIONS ,? CONTRQLLBEt'S APPROVAL � 1. This contract shall not be deemed valid until it shall have been �, '-i approved by the Controller of the State of Colorado or such assistant as he may designate. This provision is applicable to any contract involving the �,,,_ - payment of money by the State. �:;;�: ' �i . . FUND AVAILABILITY E. ,>r� 2. Financial obligations of the State payahle after the current =� fiscal year are contingent upon funds for that purpose being appropriated, ?"� • .:'�� budgeted and otherwise made available. ` , . �. BOND RBQUIREMfiNT ,�, 3. If this contract involves the payment of more than fifty thousand ' dollars for the construction, erection, repair, maintenance, or improvement �'�� of an buildin +`�:'' � • y g, road, bridge, viaduct, tunnel, excavation or other public . ;%; works for this State, the contractor shall, before entering the performance � of any such work included in this contract, duly execute and deliver to and • ' £ile with the official whose signature appears below for the State, a good ' ',;,� and sufficient bond or other acceptable surety to be approved by said � ,<;;� official in a penal sum not less than one-half of the total amount payable � by the terms of this contract. Such bond shall be duly executed by a .^�� qualified corporate sureCy, conditioned for the due and faithful performance of the contract, and in addition, shall provide that if the ';_;� contractor or his subcontractors fail to duly pay for any labor, materials, �3 team hire, sustenance, provisions, provendor or other supplies used or -�� consumed by such contractor or his subcontractor in performance of the work � �q contracted to be done, the surety will pay the same in en amount not "' exceeding the sum specified in the bond, together with interest at the rate ~ :� of eight percent per annum. Unless such bond, when so required, is y� executed, delivered and filed, no claim in favor of the contractor arising ' under this contract shall be audited, allowed or paid. A certified or. cashier's check or bank money order payable to the Treasurer of the State of Colorado roay be accepted in lieu oY a bond. This provision is in �� compiiance with 38-26-IQ6 CRS, as amended. • � '� • � MINIMUM WAGE :�,� 4. Fsxcept as otherwise provided by law, if this contract is in ' excess of one hundred fifty thoasand dollars and requires or involves the �� employment of laborers or mechanics in the construction, alteration or F` ' _� repair of any building or other public works (except highways, highway .. � bridges, underpasses and highway structures of all kinds or contracts for � any purpose to which the State Departmeot of Highways or the chief engineer =' 1S 8 8Tt . 'Y'� p y) within the geographical limits of the State, the rate of wages -,�'� for all laborers and mechanics employed by the contractor or any a sabcontractor on the building or other pu6lic works covered under the ' � contract shall not be less than the prevailing rate of wages for work of a ;:`r� similar nature in the county, city and county, or municipality of the State :� in which the building or other public works is located. The prevailing ; � • rate of wages and the resolution of any disputes resulting therefrom shall `;% ;�`� be as prescribed by 8-16-101 CRS, as ameaded. �'s� ' - �;;� DISCRIMINATION AND AFFIHMATIVS ACTION .. . . -'� 5. The contractor agrees to comply with the letter and spirit of the ;r�,`� Colorado Antidiscrimination Act of 1957, as amended, and other applicable ' �.:�. law respectipg discrimination and unfair employment practices (24-34-402, •�:` CRS 1982 Replacement Voi.), and as required by fixecutive Order, Squal .�' Opportunity and Affirmative Action, dated April 16, 1975. Pursuant r}�,_ thereto, the following provisions sh�ell be contained in a1.1 State cantracts :�=:; or subcontt-acts. �;`;"; .v<"` ��x p }'� f.�=,, �,;.� page 4_ of _6 pages �Y.� _ � 1•':� :..cs,;� . � . .�t'r�t, ��. ' ��ir,�� , � .:S��Y�.A: . . � �,a�. ��µth�` . , _ �+a�`+' k r, + � u r.�� ! � '�, .i 7 F x{ �';+{t��s��.;F�r ' .�.��- * ' r�� . �� ,�F x�i��'"j rd�W , ��-��'�iSw �"�.�-rx. x��t ^� r s 4rc . �'�,. r �s 1t�. , x �s �a' . $• . v+�, � ,�+ � _t',�"-j�i�?7��q�'��_ ;��'; .z...i�i�1" ;i`"S�,_ �+n=Ss,N� ,. :� .�'�}��i,.,*,',��'*- �, ... , 3 . ! " During the performance of this contract, the co�tractor agrees as follows: (1) The contractor will not discriminate against any employee or applicant for employment because of race, creed, color, national " n origin, sex, marital status, religion, ancestry, mental or physical ` handicap, or age. The contractor will take affirmative action to insure that applicants are employed, and that employees are treated �''':� '� " ' during employment, without regard to the above mentioned character- � '? istics. Such action shall include, but not be limited to the follow- � ,::. ing: Employment, upgrading, demotion, or transfer, recruitment or -,� recruitment advertisings; lay-offs or terminations; rates of pay or �� other forms of compensation; and selection for training, including ,i apprenticeship. The contractor agrees to post in conspicuous places, • � - available to employees and applicants for employment, notices to be - - provided by the contracting officer setting forth provisions of this non-discrimination clause. ;;;. (2) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all =;,[� qualified applicants will receive consideration for employment without : regard to race, creed, color, national origin, sex, marital status, � religion, ancestry, mental or physical handicap, or age. •M •�� (3) The contractor will send to each labor union or representative of 'Y �;�� workers with which he has collective bargaining agreement or other � ,;'� contract or understanding, notice to be provided by the contracting officer, advising the labor union or workers' representative of the � contractor's commitment under the Executive Order, 6qua1 Opportunity and Affirmative Action, dated April 16, 1975, and of the rules, "� regulations, and relevant Orders of the Governor. � -�� (4) The contractor and labor unions will furnish all information and r = '"'� reports required by Bxecutive Order, fiqual Opportunity and Affirmative Action of April 16, 1975, and by the rules, regulations and Orders of ;_� the Governor, or pursuant thereto, and will permit access to his • ' books, records, and accounts by the contracting agency and the office •.i..: of the Governor or his designee for purposes of investigation to " ascertain compliance with such rules, regulations and Orders. �'r` , _ (5) A labor organization will not exclude any individual otherwise . � qualified from full membership rights in such labor organization, or +� :.� expel any such individual from membership in such labor organization � or discriminate against any of its members in the full enjoyment of ?-. '?awork opportunity, because o£ race, creed, color, sex, national origin, � or ancestry. i :,. y (6) A labor organization, or the employees or members thereof will �` � not aid, abet, incite, compel or coerce the doing of any act defined � a in this contract to be discriminatory or obstruct or prevent any person from complying with the provisions of this contract or any �# s Order issued thereunder; or attempt, either directly or indirectly, to 3 commit any act defined in this contract to be discriminatory. , a (7) In the event of the contractor's non-compliance with the non- �� discrimination clauses of this contract or with any of such rules, � , � regulations, or Orders, this contract may be cancelled, terminated or suspended in whole or in part and the contractor may be declared ,__, � ineligible for further State contracts in accordance with procedures, suthorized in Executive Order, 6qua1 Opportunity and Affirmative . , � Action of April 16, 1975, and the rules, regulations, or Orders promulgated in accordance therewith, and such other sanetions as may be imposed and remedies as may be invoked as provided in �ixecutive , Order, Squal Oppnrtunity and Affirmative Action of April 16, 1975, or by rules, regulations, or Orders promulgated in accordance therewith, or as otherwise provided by law. z: j.� � . J" .:� page _5_ of _6_ pages ':P it i �4 rf �'� ',y�.,,�.. ' ` , '. � ,. �� , �-`' '�� ^' - " r' ' �, v�+r' ^, ` ' '. �'$�.�„� y'��- ��aY�y'��':�j�4'��'��'� � '� •hy�*.�, s '�d�'��tc. . ,�.`5��` E � . ��. .i:�,� , � Pf.. 1 �. �J J �_ �... �9�' "" ` ti:_, �. !'..".:�:. � . � (8) The contractor will include the provisions of paragraph (1) � through (8) in every sub-contract and sub-contractor purchase order unless exempted by rules, regulations, or Orders issued pursuant to Executive Order, Squal Opportunity and Affirmative Action of April 16, � 1975, so that such provisions will be binding upon each sub-contractor � �' or vendor. The contractor will take such action with respect to any ; sub-contracting or purchase order as the contracting agency may : direct, as a means of enforcing such provisions, including sanctions '� £or non-compliance; provided, however, that in the event the ------- contractor becomes involved in, or is threatened with, litigation with :: � the sub-contractor or vendor as a result of such direction by the ��, contracting agency, the contractor may request the State of Colorado 1 to enter into such litigation to protect the interest of the State of � ��-;� Colorado. � ' • �i COLORADO LABOR PRSFfiRENCS � - <.�.i:� 6. Provisions of 8-17-101, & 102 CRS for preference of Colorado # , -�;` labor are applicable to this contract if public works within the State are . ��=' undertaken hereunder and are financed in whole or in part by State funds. i::i:` ��'j :�=y GSNBRAL �'_:� . T�-iA� 7. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation, execution `.?;�:`� and enforcement of this contract. Any provision of this contract whether ''=;'�'' . or not incor orated herein b reference which p y provides for arbitration by any extra-judicial body or person or which is otherwise in con£lict with '��'�- said laws, rules and regulations shall be considered null and void. � :� Nothing contained in any provision incorporated herein 6y reference which purports to negate this or any other special provision in whole or in part ` � shall be valid or enforceable or available in any action at law whether by way of complaint, defense or otherwise. Any provision rendered null and � _;';,,� void by tne operation of this provision will not invalidate the remainder . -� of this contract to the extent that the contract is capable of execution. 8. At all times during the performance of this contract, the -- contrector shall strictly adhere to all applicable federal and state laws, rules and regulations that have been or may hereafter be established. }" t'-,, . t' ' 9. The signatories aver that to their knowledge, no State employee ` �'� has any personal or beneficial interest whatsoever in the service or : property described herein. ` �� IN WITNSSS WHBREOF, the Parties hereto have executed this contract on "4�� the day first above written. .;� (Full Legal Na _len .__1 _ ____ STATS OF COLORADO � � RICHARD D. LAMM, GOVBRNOR ' ;; =. ; . -, Contractor By __ r r,�.. ...�::r� - . . ' ... gn re� By ___________________________ ' Y For the fixecutive Director <-;:� Positi n (Title} Ch 'r f the Board o Co y Commissioners ! '- '. - DBPARTM6NT OF INSTITUTIONS i • ; ;:� --------#84 6000794_ � T,`:I Social Security Number or Federal I.D. �' Number : _; - :� (If Corporation) � Attest: (Sea�l) 4 �,,�.�,� ` . . :: ;,,.t, _•..�.� _ IIY ----- -- ------ ------v----- `*`"` County Clerk or Secretary ,�:1.;;_ APPROVALS -" ATTORNEY GfiNfiRAL CONTROLLfiR �� ,,.,.�: :.:;:, ..,;: .�,,.: By --------------------------------- BY --------------------------- i�`'p y „�r.i�'.:'`I page _ 6_ which is the last of 6_ pages .,.i -- -- ::'-�1 .'3 1 �;,;:,i >7:.: r. • ` ' . :�, � a,� _ ry .. �, �,. �„a(��;e!?at �w'��i . �� " � �.�.i °�-� '� '��.� f. � � 4�-y�`3'd . ::.t.. � . �(R�y,1 , r ..f : y.. .: . , .; � i .' #� � t E �'j �'f� 'v �'�. ` p: �,: '� �� :ij.,.; . ..... .... •`�3 ... . .. -�- 4i. ry • :::�i rl � � .F BXHIBIT A �-3 SPSCIFICATIONS FOR DSSIGNATED 24-HOUR HOLDING UNIT - � t _� ::':i a) The Juvenile Holding Unit must be located outside of the adult `4_,� �:.-+: . jail facility. ,. . . '�-;� b) There must be seventy (70) square feet of floor space per �� ,,-; j• .. youth being held (based on present standards). �' -. �•. '`'' �: _,�; c) fixit doors cannot be locked when any youth is 6eing held due i °:.�! f.'" �. �+'�. to grant money availability for "non-secure" programs only. ,, . i . , d) Twenty-four (24) hour "in-sight" supervision must be provided �. y :';. ?�' by specially trained and supervised "off-duty" law enforcement f � , ;'�,; personnel for needed security. i `. ir e) The Juvenile Holding Unit must have a bathroom with a shower. i� � �. :,`:� f) The 7uvenile Holding Unit must have a telephone for emergencies. �: � . • (,• �:�: �. r,,. : g) The Juvenile Holding Unit must have adequate sleeping 4: . `�� accoremodations for each juvenile held there. � {t_� } J. wtt� PROVISION OF SfiRVICES i �::: ; Contractor shall be reimbursed at the rate of $12.00 per hour for each hour of personnel time incurred by Contractor in providing services as G'. set forth herein. Contractor may, at its option, contract for � personnel services, utilize part-time or permanent employees, or any ��'. ' ;;�� combination thereof to perform such services, the qualifications of '�+'� such personnel to be established and approved by the Sheriff. Any '` � differential between salaries or contract rates paid such personnel ! _ � and reimbursement under this contract shall be retained by County as `? � reimbursement for administrative expenses incurred by County in � providing services under this Contract, including but not limited to � insurance, employers' contributions to social security, and ibookkeeping and payroll administration. ! � - -_�'� ( .r,-. '� � � . ;� i. r� i , '] � a� � 9 � � j . ,;..Y_ , ' , . �� . � � ...`rbi:i ' , • .; '�.� t` 4' i.:-y�� 2 lH . �.��, � 4� � .V t � ��.1 .-� ' .:' 3! y� }` ly�+s 'w.7 , � lt.: ` ... Y.'. r � , �;T.�� ♦ ,_ . .. , ,.�r _ ., _ . w-�''Z��'=. . .� ' >.. . . . ..;. , . . q:... .- .., . _. � -' . . . . . . ....__ _.., ,____.______ ...__ . __... _. _.._. . ._ ... . -___..-._.. .__.. . . .,�� '. . • � e �; , . B%HIBIT B t �...--� PERSONNBL TIMH SHSBTS � ,:. . � Name: -------------------------------------- � �.., • DATE TIMH STARTSD TIME ENDfiD HOURS WORKfiD . _ �,''." :: ,. --------------- --------------- --------------- ------- ---- ' ---- �=.�� --------------- --------------- --------------- --------------- ' , " si i:-' _______________ ____---________ ____—__________ • . . .' __�____________ _______________ ___—____--_—___ ____—__________ z. S L _______________ _______________ ____'______'___ _______________ �• • . ,�:� j �� --------------- --------------- --------------- --------------- �i .. � . � , � . .:u. . �. . _ ,� . . .� � _______________ ______________ _ ,_, . ,:� . . . .: . _________ . ,t ______ _______________ _______________ _______________ . ,. .�,.: ,:: � .:, . _______________ _______________ _______________ _______________ �_ . _______________ ____ .. ... . �� . . � .. . . ,-, _______________ _______________ _______________ _______________ , : , . . .. . , : , _______________ _______________ _______________ _______________ , , : a _______________ _______________ _______________ _______________ � . { -, _______________ _______________ _______________ _______________ . . . � _______________ _______________ _______________ . _______________ . . .� � . ,, _______________ � ; _______________ _______________ .. � _______________ _______________ _______________ _______________ : � ,. . ,_ Q : _. _ � _ . . . _______________ _______________ _______________ _______________ �. : .�,. . x::: . - �i :' ________ TOTAL HOURS: :- ----------------------------- ----------------- ' : Signature of Person Providing Service ;. @ $12.00 per hour = $_________ `' APPROVED: '= ------------------------------ ��3 JRI Coordinator r, �. �;, ':� '� �.�