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R-13-10-10-F8 - 10/10/2013RESOLUTION NO. R -13-10-10-F8 WHEREAS, the City of Round Rock (the "City") has previously entered into a vendor agreement with The Capital Area Council of Governments Area Agency on Aging ("Agreement"); and WHEREAS, The Capital Area Council of Governments Area Agency on Aging has submitted a Vendor Agreement Extension ("Extension") to extend the Agreement on the terms and conditions set forth in the Extension; and WHEREAS, the City Council desires to approve the Extension with The Capital Area Council of Governments Area Agency on Aging, Now Therefore BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ROUND ROCK, TEXAS: That the Mayor is hereby authorized and directed to execute on behalf of the City a Vendor Agreement Extension with The Capital Area Council of Governments Area Agency on Aging, a copy of said Agreement being attached hereto as Exhibit "A" and incorporated herein for all purposes. The City Council hereby finds and declares that written notice of the date, hour, place and subject of the meeting at which this Resolution was adopted was posted and that such meeting was open to the public as required by law at all times during which this Resolution and the subject matter hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act, Chapter 551, Texas Government Code, as amended. RESOLVED this 10th day of October, 2013. JTh ALAN MCGRAW, Mayor City of Round Rock, Texas ATTEST: SARA L. WHITE, City Clerk 0112.1304;00283606 ROUND ROCK, TEXAS PURPOSE. PASSION PROSPERITY City of Round Rock Agenda Item Summary Agenda Number: F.8 Title: Consider a resolution authorizing the Mayor to execute a Vendor Agreement Extension with the Capital Area Council of Governments Area Agency on Aging regarding the Demand Response Bus Service. Type: Resolution Governing Body: City Council Agenda Date: 10/10/2013 Dept Director: Gary Hudder, Transportation Director Cost: $0.00 Indexes: Attachments: Resolution, Exhibit A, 2014 Assurances- Civil Rights Act of 1964, 2014 Certificate Regarding Debarment - City Text of Legislative File 13-799 Item Summary: On January 24, 2013 Council approved a Vendor Agreement with the Area Agency on Aging (AAA); this agreement allowed for the City to be reimbursed for nutrition trips provided by the City's Demand Response Bus Service. Under the agreement, the City is reimbursed for nutrition trips provided to persons age 60 and over, to and from any location where low-cost meals are provided. The City is reimbursed at the adopted fare structure, which is currently $2.00 per trip for persons living in the city limits and $3.00 per trip for persons living in the extraterritorial jurisdiction. The total amount of the monthly reimbursements is dependent on how many nutrition trips are made for that month. The execution of this Vendor Agreement Extension will provide nutrition trip funding through September 30, 2014. Staff recommends approval. City of Round Rock Page 1 Printed on 10/8/2013 CAPITAL AREA COUNCIL OF GOVERNMENTS VENDOR AGREEMENT EXTENSION BETWEEN: The Capital Area Council of Governments Area Agency on Aging of the Capital Area AND City of Round Rock Background EXHIBIT nA» A. The Capital Area Council of Governments and City of Round Rock (the "Parties"), entered into the vendor agreement (the "Agreement") effective October 1, 2013, for the purpose of service provision for clients of the Area Agency on Aging of the Capital Area, a program of the Capital Area Council of Governments. B. The Capital Area Council of Governments desires to extend the Agreement on the terms and conditions set forth in this Extension (the "Extension"). C. This Extension is the first to the Agreement. Agreement Amendments The Vendor Agreement is amended as follows: A. The terms of the Agreement are hereby amended to extend the terms of the Agreement to September 30, 2014. C. The following unit rates apply for the term of the extension: Service Unit Rate Transportation (Demand/Response) $2.00 Transportation (Demand/Response) within Extraterritorial Jurisdiction $3.00 CAPITAL AREA COUNCIL OF GOVERNMENTS Betty Voights Date Executive Director Accepted By: City of Round Rock Authorized Signature Title Date ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 City of Round Rock (hereinafter called the "Applicant") Name of Applicant (Type or Print) HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 880352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45C.F.R. Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this Assurance shall obligate the Applicant, or in the case of any transfer of such property, and transferee, for the period during which the real property or structure is used for a purpose for which the Federal Financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property. In all other cases, this Assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it by the Department. THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by the Department, including installment payments after such a date on account of applications for Federal financial assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in the Assurance, and that the United States shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the Applicant, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the Applicant. City of Round Rock Date Applicant (Type or Print) Authorized Signature 221 E. Main Street Round Rock, TX 78664 Applicant's Mailing Address 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 (DADS) to screen each covered potential contractor/grantee to determine whether each has a right to obtain a contract/grant in accordance with federal regulations on debarment, suspension. ineligibility, and voluntary exchtsion. Each covered contractodgtantee must also screen each of its covered subcontractors/providers. In this certification "contractodgrantee" refers to both contractor/grantee and subcontractor/subgrantee; "conttact/gnrnt" refers to both contract/grant and subcontract/subgrant. By signing and submitting this certification the potential contractor/grantee accepts the following terns: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/gtant was entered into. If itis later determined that the potential contractor/grantee knowingly rendered an erroneous certification, is addition to other remedies available to the federal government, the Department of Health and Hurnan Services, United States Department of Agriculture or other fedetnl department or agency. or the Texas Department of Aging and Disability Services may pursue available remedies, including suspension and/or debarment. 2. The potential contractodgrantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential contractor/grantee learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contact." "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 leas defined in the attachment. 4. The potential contractor/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 ineligt'bie, or voluntarily excluded nom participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of 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 subcontract ors/subgranteea under this proposed contract? X YES NO 5. The potential contractodgrantee further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarrneat, Suspension. Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modification. in all covered subcontracts and in solicitations for all coveted subcontracts. 6. A contractodgrantee may rely upon a certification of a potential subcontractor/subgrantee that it is not debarred, suspended, ineligible, or voluntarily excluded hem the covered contract/grant, unless it knows that the certification is erroneous. A contractodgrantee must, at a minimum, obtain certifications from its covered subcontractora/subgrantees upon each subcontract's/subgrant'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 contractodgrantee 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 contractor/grantee in a covered contact/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 State Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Aging and Disability Services may pursue available remedies, including suspension and/or debarment. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Indicate which statement applies to the covered potential contractor/grantee: X The potential contractodgrantee certifies, by submission of this certification, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation hr this contract/grant by any federal department or agency or by the State of Texas. The potential contractor/grantee is unable to certify to one or more of the terms m this certification. hi this instance, the potential contractor/grantee must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanations) to this certification. NAME OF POTENTIAL CONTRACTOR/GRANTEE City of Round Rock VENDOR ID NO./FEDERAL EMPLOYERS ID NO. 74-6017485 Signature of Authorized Representative Primed/ typed Name of Authorized Representative Mayor Date Title of Authorized Representative THIS CERTIFICATION IS FOR FFY 2014, PERIOD BEGINNING October 1. 2013 and ENDING September 30. 2014. EXECUTED ORIGINAL DOCUMEN1S FOLLOW CAPITAL AREA COUNCIL OF GOVERNMENTS VENDOR AGREEMENT EXTENSION BETWEEN: The Capital Area Council of Governments Area Agency on Aging of the Capital Area AND City of Round Rock Background A. The Capital Area Council of Governments and City of Round Rock (the "Parties"), entered into the vendor agreement (the "Agreement") effective October 1, 2012, for the purpose of service provision for clients of the Area Agency on Aging of the Capital Area, a program of the Capital Area Council of Governments. B. The Capital Area Council of Governments desires to extend the Agreement on the terms and conditions set forth in this Extension (the "Extension"). C. This Extension is the first to the Agreement. Agreement Amendments The Vendor Agreement is amended as follows: A. The terms of the Agreement are hereby amended to extend the terms of the Agreement to September 30, 2014. B. A new service, , is added with the following definition and -description: C. The following unit rates apply for the term of the extension: Service Unit Rate Transportation (Demand/Response) $2.00 Transportation (Demand/Response) within Extraterritorial Jurisdiction $3.00 t2-13-10-co- CAPITAL AREA C a UNCIL OF GOVERNMENTS Betty V• ights Executive Direc Accepted By: Alan McGraw or City of Round Rock tr) Authorized Signature Mayor Title 14.10 • (3 Date Date ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 City of Round Rock (hereinafter called the "Applicant") Name of Applicant (Type or Print) HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 880352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45C.F.R. Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this Assurance shall obligate the Applicant, or in the case of any transfer of such property, and transferee, for the period during which the real property or structure is used for a purpose for which the Federal Financial assistance is extended or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property. In all other cases, this Assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it by the Department. THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by the Department, including installment payments after such a date on account of applications for Federal financial assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in the Assurance, and that the United States shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the Applicant, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the Applicant. �v • to • 13 City of Round Rock Date Applicant (Type or Print) Authorized Signature 221 E. Main Street Round Rock, TX 78664 Applicant's Mailing Address 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 (DADS) to saeen each coveted potential contractodgrantee n determine whether each has a right to obtain a contract/grant in accordance with federal regulations on debarment, suspension, ineligibility, and voluntary exclusion. Each coveted connactodgnmtee must also screen each of its coveted /providers. In this certification "contractodgrantee" refers to both connactodgrantee and subcomtractodaubgiantee; "contract/grant" refbs to both contract/grant and subconnactkubpant By asphalt and submitting this cartifiattion the potenthd cow accepts the fallowing terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/pant was entered into. If it is later dntamhud that the potential contractodgrantee knowingly rendered an erroneous cedflcadou, is addition to other roulades available to the federal government, the Department of Health and Hun= Services, United States Department of Agriculture another federal department or agency, or the Texas Department of Aging and Disability Services any pursue available remedies, including suspension and/or debarment 2. The potential connecter/grantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential c on�tractor/gnmtee learns that the ce:dfieadon was erroneous when submitted o has become erroneous by reason of deluged circumstances, . 3. The words"coveted contract,""debarred,""suspended.""ineligible,""participan,"" ""principal"" "and"VO�rilyexclludded,"asusedin this ardfcation have nteaninga haled upon menials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is as defined in the attachment 4. The potential contractadgrsntee 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 coveted transaction, rnleas authorized by the Department of Health and Human Services, United States Department of Agrlculuae 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 aabcontracton u1tgrantees under this proposed contract? X YES NO 5. The potential contractodgrantee father agrees by submitting this aadfcadon that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Vohmtary Exclusion for Coveted Contracts and Grants" without modiflcadon. in all covered submerses and in solcitatlons for all coveted subcontracts. 6. A cont actodgtaatee may rely upon a certification of a potential subcontractodsubgtamtee that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract/grant. unless it knows that the certification is erroneous. A contractodgrantee must, at a minimum, obtain catif>aftan from hs covered subconlractaa/subgrantees upon each subs onhac t s/subgrant's Madan 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 certific adon tequled by this catifcadon document. The knowledge and information of a contractodgrantee is not required to exceed that which is normally possessed by a patten person in the ordinary comae of business dealings. 8. Except for contracts/pants authorized under paragraph 4 of these tams, if a contractodgrantee in a covered contract/grant knowingly emus into a covered subcontncVaubgnat with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in the transaction, in adcdon to other remedies available to the federal government. Department of Health and Human Services, United State Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Aging and Disability Services may pursue available retnedies. including suspension an dhr debarment. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Indicate which statement applies to the covered potential contractor/grantee: X The potential contractodgrantee catiftes. by submission of this certification, that neither it nor its principals is pasenhly debated, suspended. proper for debarment, declared ineligible, or vohmtarily excluded from participation in this contract/grant by any federal deparone t or agency or by the State of Texas. The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this instance, the potential contractor/pant= must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanatio(s) to this certification. NAME OF POTENTIAL CONTRACTOR/GRANTEE City of Round Rock VENDOR NOJFEDERAL EMPLOYERS ID NO. 74-6017485 Ahs .U`C mv✓ Signature of Authorized Representative 10•(0•( Mayor Date Printed/Typed Name of Authorized Representative Title of Authorized Representative THIS CERTIFICATION IS FOR FFY 2014, PERIOD BEGINNING October 1.2013 and ENDING September 30. 2014. 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 (DADS) to screen each covered potential contractor/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 contractodgrantee must also screen each of its covered subcontractors/providers. In this certification "contractor/grantee" refers to both contractor/grantee and subcontractodsubgrantee; "contract/grant" refers to both contract/grant and subcontract/subgn rat. By signing and submitting this motion the potential contractor/grantee accepts the following terms: I. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If itis later determined that the potential contractor/grantee knowingly rendered an erroneous certific adon, 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 anchor debarment. 2. The potential contractadgrantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential coniractorlgrantee learns that the eerdflcatioa was erroneous when submitted or has become erroneous by reason of changed circumstances. 3 The worsts "covered contract. "debatred," "suspended." "ineligible" "participant," "person," "principal,* "proposal,' and "voluntarily excluded," as used in this certlfcadon have meanings based upon rmterlals in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is as defined in the attachment 4 The potential contractor/grantee agrees by submitting this catiflcation 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 ineligtble or voluntarily excluded from participadwr in this covered Iransacdon, unless authorized by the Department of Health and Human Services, United States Department of 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 anddpate having aubcontradorssambgrantees under this proposed contract? X YES ' NO 5 The potential contractor/grantee further agrees by submitting this certification that h will include this certification tided "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modific adon. in all covered subcontracts and in solicitations for all covered subcontracts. 6. A contractor/grantee may rely upon a certification of a potential subcontractor/subgrantee that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract/grant, unleas it knows that the certification is erroneous. A contractodgrantee :mutate minimum, obtain certifications from its covered subcontractora/subgrantees upon each subcontract's/subgraat's initiadon 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 co:pactor/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 cootractodgrantee in a covered contract/grantknowingy enters into a covered subcantract/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 State Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas Department of Aging and Disability Services may pursue available remedies, includ'mg suspension and/or debarment CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS Indicate which statement applies to the covered potential contractor/grantee: X The potential contractor/grantee certifies. by submission of this certification. that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or vokmtarily excluded from participation in this contract/grant by any federal department or agency or by the State of Texas. The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this instance, the potential contactor/grantee must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanation(s) to this certification. NAME OF POTENTIAL CONTRACTOR/GNTEE Star Shuttle VENDOR ID NOJFEDERAL EMPLOY ' , ID NO. 74-2624739 John P. Walker Printed/Typed Name of Authorized Representative President/CEO Title of Authorized Representative THIS CERTIFICATION IS FOR FFY 2014, PERIOD BEGINNING October 1.2013 and ENDING September 30.2014. Area Agency ^�n Aging eel.. Capital Area A program of the Capital Area Council of Governments www.capcog.org AUTHORIZED SIGNATURE FORM REQUEST FOR PAYMENT DIRECT PURCHASE OF SERVICE PROGRAM Name and Address of ContractlVendor Agency: City of Round Rock 221 E. Main Street Round Rock, Texas 78664 Signature of Individuals authorized to sign for request for Reimbursement Typed Name: Caren Lee Typed Name: _Claudia Tapia 111 Signature: ��j�,;.% . Signature: _ Typed Name: Typed Name: 1ilUc1ijZ ! ACL Signature: Signature:���4 a&41.41, I certify that the signatures above are of the individuals authorized to sign the Request for Reimbursement. Ne t o I�er�U �n t - PE � LSe- . Typed Name and Title of Authorized Official ? Signature of Autho revised 9/02 'zed Official Date MONTHLY BILLING/REPORTING CUTOFF Please complete the following information for FY 2014 (October 1, 2013 — September 30, 2014) and return to the Area Agency on Aging of the Capital Area no later than the close of business on September 27, 2013. Select a date during the month that will be the cutoff date for the reporting of service units for each month. For example, do you intend to count units of service from the 1st through the 31st, or from the 1st to the 25th, or cutoff on the 4th Thursday, etc.? You may select any cutoff date you like. However, you will need to be consistent in your reporting and must let us know in writing of any changes in the reporting method you have selected. The (agency name) City of Round Rock has selected a billing/reporting cutoff date as the last day of each month. This means the agency reporting period each month will run from the 1" to the 31s` . Sherri Crone, Accounting Supervisor Printed Name of Authorized Official SJA__Q,L, Signature of Authorized Official Date Please note that requests for reimbursements and backup documentation must arrive at the AAA office no later than 5:00 p.m. the 5th of each month. If the 5th falls on a weekend or holiday, the request is due the previous business day. Failure to have a request in on time will result in a delay or denial of reimbursement. Affirmative Action Plan The City of Round Rock hereby agrees that it will enact (Name of Applicant) affirmative action plan. Affirmative action is a management responsibility to take necessary steps to eliminate the effects of past and present job discrimination, intended or unintended, which is evident from an analysis of employment practices and policies. It is the policy of the agency that equal employment opportunity is afforded to all persons regardless of race, color, ethnic origin, religion, sex or age. This applicant is committed to uphold all laws related to Equal Employment Opportunity including, but not limited to, the following. Title VI of the Civil Rights Act of 1964, which prohibits discrimination because of race, color, religion, sex or nations origin in all employment practices including hiring, firing, promotion, compensation and other terms, privileges and conditions of employment. The Equal Pay Act of 1963, which covers all employees who are covered by the Fair Labor Standards Act. The act forbids pay differentials on the basis of sex. The Age Discrimination Act, which prohibits discrimination because of age against anyone between the ages of 50 and 70. Federal Executive Order 11246, which requires every contract with Federal financial assistance to contain a clause against discrimination because of race, color, religion, sex or national origin. Administration on Aging Program Instruction AoA PI -75-11, which requires all grantees to develop affirmative action plans. Agencies, which are part of an "umbrella agency," shall develop and implement an affirmative action plan for single organizational unit on aging. Preference for hiring shall be given to qualified older persons (subject to requirements of merit employment systems). Section 504 of the Rehabilitation Act of 1973, which states that employers may not refuse to hire or promote handicapped persons solely because of their disability. Valerie Francois is the designated person with executive authority responsible for the implementation of this affirmative action plan. Policy information on affirmative action and equal employment opportunity shall be disseminated through employee meetings, bulletin boards, and any newsletters prepared by this agency. Work Force Analysis: Paid Staff Total Staff: # Full Time # Part Time Older Persons (60+) # 39 5 % # 14 30 % Minority # 198 26 % # 10 21 % Women # 210 27 % # 29 62 % STARSHU-01 'yam"" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1/29/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER (800) 935-2442 American Highways Insurance Agency, Inc. 3250 Interstate Drive Richfield, OH 44286 NAME: CT Customer Service (a"coNri , Ext):(800) 935-2442 FAX No): (330) 659-8912 E-MAIL ADDRESS: customerservice@ahiains.com LIMITS INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :National Interstate Insurance Company 32620 INSURED Star Shuttle, Inc. dba Star Shuttle & Charter PO Box 17967 San Antonio, TX 78217- INSURER B : INSURER C : EACH OCCURRENCE INSURER D: A INSURER E : COMMERCIAL GENERAL LIABILITY INSURER F : • • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 A X COMMERCIAL GENERAL LIABILITY X XPP2400020-092/1/2013 2/1/2014 DAMAGE TO REM ED PREMISES $ 250,000 CLAIMS -MADE X OCCUR (Ea occurrence) MED EXP (Any one $ 5,000 person) PERSONAL & ADV INJURY $ 5,000,000 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 5,000,000 POLICY IDRO- JECT JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 A X ANY AUTO ALL OWNED SCHEDULED X XPP2400020-09 2/1/2013 2/1/2014 BODILY INJURY (Per person) $ AUTOS AUTOS BODILY INJURY(Per accident)$ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE _(PER ACCIDENT) $ $ UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 4,000,000 A X EXCESS UAB CLAIMS -MADE XEX2400020-10 2/1/2013 2/1/2014 AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N WC STATU- TORY LIMITS OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A A Phys.Dam. Deductibles:Charter All Other: $5,000 Spec.Perils/ XPP2400020-09 XPP2400020-09 2/1/2013 2/1/2013 2/1/2014 2/1/2014 Spec. Perils/Coll. $20,000 $10,000 CoII.;PP/SVC $2,500 Comp/Coll DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) $4M X $1 M Excess Auto Liability applies to Charter Buses, Charter Minis, Charter Vans, and School Buses (Charter buses are defined with passenger capacity >29, Charter Minis are defined as Charters with passenger capacity >15 and <30, Charter Vans are defined as Charters with passenger capacity <16 CANCELLATION City of Round Rock, its officers and employees 221 East Main Round Rock, TX 78664-5299 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 77-1- ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Form w-9 (Rev. October 2007) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give form to the requester. Do not send to the IRS. a) rn m c 0 d 0 a0 0 4"0 ▪ 2 o� C .0 0. 0 0 0. rn at a) Name (as shown on your income tax return) City of Round Rock Business name, if different from above Check appropriate box: 0 Individual/Sole proprietor 0 Corporation 0 Partnership 0 Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ► ® Other (see instructions) ► Municipality ✓❑ Exempt payee Address (number, street, and apt. or suite no.) 221 East Main Street City, state, and ZIP code Round Rock, TX 78664 Requester's name and address (optional) List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification Social security number or Employer identification number 74 6017485 Under penalties of perjury, 1 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. citizen or other U.S. person (defined below). 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 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 instruction on page 4. Sign I Signature of Here u.s. person ► Date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information retum with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. ,Qc-//,3 Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: • The U.S. owner of a disregarded entity and not the entity, Cat. No. 10231X Form W-9 (Rev. 10-2007)