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R-13-01-24-K4 - 1/24/2013RESOLUTION NO. R -13-01-24-K4 WHEREAS, the Capital Area Council of Governments/Area Agency on Aging offers funding for transportation services which provide bus trips for seniors; and WHEREAS, the Demand Response Bus Service transports seniors on a daily basis; and WHEREAS, the City of Round Rock wishes to enter into a Vendor Agreement with the Capital Area Council of Governments/Area Agency on Aging to receive reimbursement for trips given to persons age 60 and over, Now Therefore BE IT RESOLVED BY THE 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 with Capital Area Council of Governments/Area Agency on Aging, a copy of same 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 24th day of January 2013. ATTEST: r m � 6t SARA L. WHITE, City Clerk O:\wdox\SCC1nts\0112\ 1304\MUNICIPAL\00265877.DOC City of Round Rock, Texas KViS WICi+" e- Lt) ,k4yDFPSD-k EXHIBIT AreaAgency �` i� V n Aging Capital Area Council of Governments of the Capital Area Area Agency on Aging VENDOR AGREEMENT City of Round Rock , hereinafter referred to as Vendor, and the Capital Area Council of Governments (CAPCOG)/Area Agency on Aging of the Capital Area (AAACAP), do hereby agree to provide services effective beginning October 01, 2012, in accordance with the Older Americans Act of 1965 (OAA), as amended, regulations of the Department of Aging and Disability Services (DADS), the AAA Direct Purchase of Services program and the stated Scope of Services. The CAPCOG/AAACAP Direct Purchase of Services program is designed to promote the development of a comprehensive and coordinated service delivery system to meet the needs of older individuals (60 years of age or older) and their caregivers. This agreement provides a mechanism for the creation of an individualized network of community resources accessible to a program participant in compliance with the OAA and DADS AAA Access and Assistance guidelines. The Capital Area Council of Governments, in accordance with the requirement in the Older Americans Act, Section 102 (42 U.S.C. 3001) and Section 306 (42 U.S.C. 3026), 45 CFR §1321, and the Texas Administrative Code, designates the Area Agency on Aging of the Capital Area as the focal point for comprehensive service delivery and coordination of services for older individuals in State Planning Region 12. The purpose of the system of Access and Assistance is to develop cooperative working relationships with service providers to build an integrated service delivery system that ensures broad access to and information about community services, maximizes the use of existing resources, avoids duplication of effort, identifies gaps in services, and facilitates the ability of people who need services to easily find the most appropriate Vendor. 1. SCOPE OF SERVICES A. The Vendor agrees to provide the following service(s) as identified below to program participants authorized by the CAPCOG/AAACAP staff, in accordance with the vendor application, all required assurances, licenses, certifications and rate setting documents, as applicable. Service: TRANSPORTATION Service Definition: Taking an older individual from one location to another but does not include any other activity. There are two types of transportation services: Demand/Response - transportation designed to carry older individuals from specific origin to specific destination upon request. Older individuals request the transportation service in advance of their need, usually twenty-four to forty-eight hours prior to the trip. Fixed Route - transportation service that operates in a predetermined route that has permanent transit stops, which are clearly marked with route numbers and departure schedules. The fixed -route does not vary and the provider strives to reach each transit stop at the scheduled time. The older individual does not reserve a ride as in a demand -response system; the individual simply goes to the designated location and at the designated time to gain access to the transit system. Form #: AIAAA VA2.0 Edition Date: 9/19/11 Unit of Service: One, One-way Trip Service Area: Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, Travis, and Williamson counties All Texas Administrative Code standards are located at the Texas Secretary of State website: www. so s. state. tx. us. All Older Americans Act and other required rules and regulations are located at http://ww-\v.aoa.i4ov/AoARoot/About/Authorizing Statutes/index.aspx. Targeting: CAPCOG/AAACAP services are designed to identify eligible program participants, with an emphasis on high-risk program participants and to serve older individuals with greatest economic and social need, low-income minorities and those residing in rural areas, as required by the OAA. B. Services & Reimbursement Methodology: 2. TERMS OF AGREEMENT A. The Vendor agrees to: 1. provide services in accordance with current or revised DADS policies and standards and the OAA. 2. submit billings with appropriate documentation as required by the CAPCOG/AAACAP by the close of business on the fifth 5thday of each month following the last day of the month in which services were provided. a. If the fifth_(Lthj day falls on a weekend or holiday, the information shall be delivered by the close of business on the preceding business day. b. The AAA cannot guarantee payment of a reimbursement request received for more than 45 calendar days of service delivery. c. No reimbursement for services provided will be made if vendor payment invoices are not submitted to the CAPCOG/AAACAP within 45 days of service delivery. 3. encourage program participant contributions (program income) on a voluntary and confidential basis. Such contributions will be properly safeguarded and accurately accounted for as receipts and expenditures on Vendor's financial reports if contributions are not required to be forwarded to the CAPCOG/AAACAP. Client contributions (program income) will be reported fully, as required, to the CAPCOG/AAACAP. Vendor agrees to expend all program income to expand or enhance the program/service under which it is earned. 4. notify the CAPCOG/AAACAP Director within 24 hours if, for any reason, the Vendor becomes unable to provide the service(s). 5. maintain communication and correspondence concerning program participants' status. 6. establish a method to guarantee the confidentiality of all information relating to the program participant in accordance with applicable federal and state laws, rules, and regulations. This provision shall not be construed as limiting CAPCOG/AAACAP or any federal or state authorized representative's Form #: AIAAA_VA2.0 2 Edition Date: 9/19111 Fixed Variable Cost Service Rate Rate Reimbursement (include (identify rate) ran e) TRANSPORTATION(DEMAND/RESPONSE) $1.00 2. TERMS OF AGREEMENT A. The Vendor agrees to: 1. provide services in accordance with current or revised DADS policies and standards and the OAA. 2. submit billings with appropriate documentation as required by the CAPCOG/AAACAP by the close of business on the fifth 5thday of each month following the last day of the month in which services were provided. a. If the fifth_(Lthj day falls on a weekend or holiday, the information shall be delivered by the close of business on the preceding business day. b. The AAA cannot guarantee payment of a reimbursement request received for more than 45 calendar days of service delivery. c. No reimbursement for services provided will be made if vendor payment invoices are not submitted to the CAPCOG/AAACAP within 45 days of service delivery. 3. encourage program participant contributions (program income) on a voluntary and confidential basis. Such contributions will be properly safeguarded and accurately accounted for as receipts and expenditures on Vendor's financial reports if contributions are not required to be forwarded to the CAPCOG/AAACAP. Client contributions (program income) will be reported fully, as required, to the CAPCOG/AAACAP. Vendor agrees to expend all program income to expand or enhance the program/service under which it is earned. 4. notify the CAPCOG/AAACAP Director within 24 hours if, for any reason, the Vendor becomes unable to provide the service(s). 5. maintain communication and correspondence concerning program participants' status. 6. establish a method to guarantee the confidentiality of all information relating to the program participant in accordance with applicable federal and state laws, rules, and regulations. This provision shall not be construed as limiting CAPCOG/AAACAP or any federal or state authorized representative's Form #: AIAAA_VA2.0 2 Edition Date: 9/19111 right of access to program participant case records or other information relating to program participants served under this agreement. 7. keep financial and program supporting documents, statistical records, and any other records pertinent to the services for which a claim for reimbursement was submitted to the CAPCOG/AAACAP. The records and documents will be kept for a minimum of five years after close of vendor's fiscal year. 8. make available at reasonable times and for required periods all fiscal and program participant records, books, and supporting documents pertaining to services provided under this agreement, for purposes of inspection, monitoring, auditing, or evaluations by CAPCOG/AAACAP staff, the Comptroller General of the United States and the State of Texas, through any authorized representative(s). 9. if applicable, comply with the DADS process for Centers for Medicare and Medicaid Services (CMS) screening for excluded individuals and entities involved with the delivery of the Legal Assistance and Legal Awareness services. B. The Vendor further agrees: 1. The agreement may be terminated for cause or without cause upon the giving of thirty 30 days advance written notice. 2. The agreement does not guarantee a total level of reimbursement other than for individual units/services authorized; contingent upon receipt of funds. 3. Vendor is an independent provider, NOT an agent of the CAPCOG/AAACAP. Thus, the Vendor indemnifies, saves and holds harmless CAPCOG/AAACAP against expense or liability of any kind arising out of service delivery performed by the Vendor. Vendor must immediately notify the CAPCOG/AAACAP if the Vendor becomes involved in or is threatened with litigation related to program participants receiving services funded by the CAPCOG/AAACAP. 4. Employees of the Vendor will not solicit or accept gifts or favors of monetary value by or on behalf of program participants as a gift, reward or payment. C. Through the Direct Purchase of Services program, the Capital Area Council of Governments (CAPCOG) Area Agency on Aging of the Capital Area (AAACAP) agrees to: 1. review program participant intake and assessment forms completed by the Vendor, as applicable, to determine program participant eligibility. Service authorization is based on program participant need and the availability of funds. 2. provide timely written notification to Vendor of program participant's eligibility and authorization to receive services. 3. maintain communication and correspondence concerning the program participants' status. 4. provide timely technical assistance to Vendor as requested and as available. 5. conduct quality -assurance procedures, which may include on-site visits, to ensure quality services are being provided and if applicable, CMS exclusion reviews are conducted. 6. provide written policies, procedures, and standard documents concerning program participant authorization to release information (both a general and medical/health related release), client rights and responsibilities, contributions, and complaints/grievances and appeals to all program participants. 7. contingent upon the CAPCOG/AAACAP's receipt of funds authorized for this purpose from DADS, reimburse the Vendor based on the agreed reimbursement methodology, approved rate(s), service(s) Form #: AIAAA_VA2.0 3 Edition Date: 9/19/11 authorized, and in accordance with subsection (A)(2) of this document, within 45 days of the CAPCOG/AAACAP's receipt of Vendor's invoice. 3. ASSURANCES The Vendor shall comply with: A. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et.seq.) B. Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794) C. Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seq.) D. Age Discrimination in Employment Act of 1975 (42 U.S.C. §§6101-6107) E. Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688) F. Food Stamp Act of 1977 (7 U.S.C. §200 et seq.) G. Drug Free Workplace Act of 1988 H. Texas Senate Bill 1 - 1991, as applicable I. DADS administrative rules, as set forth in the Texas Administrative Code, to the extent applicable to this Agreement J. Certification Regarding Debarment - 45CFR §92.35 Subawards to debarred and suspended parties; this document is required annually as long as this agreement is in effect K. Centers for Medicare and Medicaid Services (CMS) State Medicaid Director Letter SMDL #09-001 regarding Individuals or Entities Excluded from Participation in Federal Health Care Programs L. DADS Information Letter 11-07 — Obligation to Identify Individuals or Entities Excluded from Participation in Federal Health Care Programs 4. SIGNATURES For the faithful performance of the terms of this agreement, the parties affix their signatures and bind themselves effective October 01, 2012. Authorized Vendor Signature Print Name Title Authorized Signature Capital Area Council of Governments (Agency) 6800 Burleson Rd., Bldg. 310, Ste. 165 (Address) Austin, TX 78444 (City, State, Zip) Form #: AIAAA VA2.0 Edition Date: 9/19/1 I Area Agency lw�.ifth.C,fii„nt Ang AUTHORIZED SIGNATURE FORM REQUEST FOR PAYMENT DIRECT PURCHASE OF SERVICE PROGRAM Name and Address of Contract/Vendor Agency: City of Round Rock - 221 E. Main St., Round Rock, TX 78664 Signature of Individuals authorized to sign for request for Reimbursement Typed Name: Claudia Tapia Typed Name: Caren Lee s Signature: Signature: I certify that the signatures above are of the individuals authorized to sign the Request for Reimbursement. Sherri Crone, Accounting Supervisor Typed Name and Title of Authorized Official 4 Signature of Auth rized Official sisal 9/02 /a- 6 -1 �, Date MONTHLY BILLING/REPORTING CUTOFF Please complete the following information for FY2013 (October 1, 2012 — September 30, 2013) and return to the Area Agency on Aging of the Capital Area no later than the close of business on October 1, 2011. 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 s` to the 31s' Sherri Crone, Accounting Supervisor Printed Name of Authorized Official Signature oirAuthorized Official /a -/o -)D- Date )D. Date Please note that requests for reimbursements and backup documentation must arrive at the AAA office no later than 5:00 p.m. the 7th of each month. If the 7th 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+) # 42 4.6% #20 2.2% Minority #191 20.9% #42 4.6% Women #213 23.28% #94 10.27% 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 contractor/grantee must also screen each of its covered subcontractors/providers. In this certification "contractor/grantee" refers to both contractor/grantee and subcontractor/subgrantee; "contract/grant" refers to both contract/grant and subcontract/subgrant. By signing and submitting this certification the potential contractor/grantee accepts the following terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If it is later determined that the potential contractor/grantee knowingly rendered an erroneous certification, 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 and/or debarment. 2. The potential contractor/grantee 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 contract," "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 is as 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 ineligible, or voluntarily excluded from 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 subcontractors/subgrantees under this proposed contract? YES NO 5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modification, 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, unless it knows that the certification is erroneous. A contractor/grantee must, at a minimum, obtain certifications from its covered subcontractors/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 contractor/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 contractor/grantee in a covered contract/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 in/dice which statement applies to the covered potential contractor/grantee: 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 voluntarily 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 contractor/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/GRANTEE VENDOR ID NO./FEDERAL EMPLOYER'S ID NO. 12-.5_ /Z Date Printed/typed Name of Authorized Representative Title of Authorized Representativ THIS CERTIFICATION IS FOR FFY 2013, PERIOD BEGINNING October 1, 2012 and ENDING September 30, 2013. ter w Form W -!J Request for Taxpayer Give form to the tnev. October of Identification Number and Certification requester. Do not i e Tres o°P'n11te of the Treasury send to the IRS. tntarnal rteVM1U0 Bonito c�i Name (as reported on your income tax return) m City of Round Rock CL Business name, 0 different from above C 0 0 0 ` IndiviauaV Muniei aht Check appropriate box: Sole proprietor L� Corporation ❑Partnership ©Other ► p y Exempt from backup ✓ withholding 0 3 ................. c Address (number, street• and apt. or suite no.) R equester's name and address (opt,onat) 221 East Main St City, state, and ZIP code v a !A Round Rock, TX 78664 ——____--__-_.__ y L.ist account numbe(ls) here (optional) _ _•- —�—� N N li� taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line Ito avoid social security number ,—� backup withholding. For individuals, this is your social security number (SSN). However, for a resident l T 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. or Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number to enter. 7 14.6101 1 17141815 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. 1 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. 1 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 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 I Signature of Here U.S. parson ► Purpose of F A person who is required to file an information return 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. U.S. person. 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. 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. For federal tax purposes you are considered a person if you are: • an individual who is a citizen or resident of the United States, • a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or Date ►.J. — • any estate (other than a foreign estate) or trust. See Regulation section 301.7701-6(a) for additional information. Foreign person. If you are a foreign person, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income. you must attach a statement that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. Cat. No. 10231x Form W-9 JAev. 10-2004) :K, TEXAS J PROSPERITY. City Council Agenda Summary Sheet Agenda Item No. K4. Consider a resolution authorizing the Mayor to execute a Vendor Agreement with Capital Area Council of Governments/Area Agency on Aging regarding demand bus service Agenda Caption: delivery system to meet needs of older individuals. Meeting Date: January 24, 2013 Department: Transportation Staff Person making presentation: Gary Hudder Transportation Director Item Summary: The Area Agency on Aging offers funding for transportation services which provide bus trips for seniors. The Demand Response Bus Service transports seniors on a daily basis. The funding will provide reimbursement for any type of trips given to persons age 60 and over. The amount of the funding will be dependent on the number of those trips. The City will be able to request a monthly reimbursement of the fares paid by any rider age 60 and over. The execution of this Vendor Agreement will allow the City to receive this reimbursement. Cost: Recommended Action: N/A Approval I 1 l E 3 t j 1 { f t d tto X i 3' u i f E 4 RECEIVED FEB 0 41013 Area Agency TZ:n Aging Capital Area Council of Governments of the Capital Area Area Agency on Aging VENDOR AGREEMENT City of Round Rock , hereinafter referred to as Vendor, and the Capital Area Council of Governments (CAPCOG)/Area Agency on Aging of the Capital Area (AAACAP), do hereby agree to provide services effective beginning October 01, 2012, in accordance with the Older Americans Act of 1965 (OAA), as amended, regulations of the Department of Aging and Disability Services (DADS), the AAA Direct Purchase of Services program and the stated Scope of Services. The CAPCOG/AAACAP Direct Purchase of Services program is designed to promote the development of a comprehensive and coordinated service delivery system to meet the needs of older individuals (60 years of age or older) and their caregivers. This agreement provides a mechanism for the creation of an individualized network of community resources accessible to a program participant in compliance with the OAA and DADS AAA Access and Assistance guidelines. The Capital Area Council of Governments, in accordance with the requirement in the Older Americans Act, Section 102 (42 U.S.C. 3001) and Section 306 (42 U.S.C. 3026), 45 CFR §1321, and the Texas Administrative Code, designates the Area Agency on Aging of the Capital Area as the focal point for comprehensive service delivery and coordination of services for older individuals in State Planning Region 12. The purpose of the system of Access and Assistance is to develop cooperative working relationships with service providers to build an integrated service delivery system that ensures broad access to and information about community services, maximizes the use of existing resources, avoids duplication of effort, identifies gaps in services, and facilitates the ability of people who need services to easily find the most appropriate Vendor. I. SCOPE OF SERVICES A. The Vendor agrees to provide the following service(s) as identified below to program participants authorized by the CAPCOG/AAACAP staff, in accordance with the vendor application, all required assurances, licenses, certifications and rate setting documents, as applicable. Service: TRANSPORTATION Service Definition: Taking an older individual from one location to another but does not include any other activity. There are two types of transportation services: Demand/Response - transportation designed to carry older individuals from specific origin to specific destination upon request. Older individuals request the transportation service in advance of their need, usually twenty-four to forty-eight hours prior to the trip. Fixed Route - transportation service that operates in a predetermined route that has permanent transit stops, which are clearly marked with route numbers and departure schedules. The fixed -route does not vary and the provider strives to reach each transit stop at the scheduled time. The older individual does not reserve a ride as in a demand -response system; the individual simply goes to the designated location and at the designated time to gain access to the transit system. Form #: AIAAA_VA2.0 Edition Date: 9/19/11 Unit of Service: One, One-way Trip Service Area: Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, Travis, and Williamson counties All Texas Administrative Code standards are located at the Texas Secretary of State website: www. sos. state. tx. us. All Older Americans Act and other required rules and regulations are located at http://www.aoa.gov/AoARoot/About/Authorizing Statutes/index aspx. Targeting: CAPCOG/AAACAP services are designed to identify eligible program participants, with an emphasis on high-risk program participants and to serve older individuals with greatest economic and social need, low-income minorities and those residing in rural areas, as required by the OAA. B. Services & Reimbursement Methodology: 2. TERMS OF AGREEMENT A. The Vendor agrees to: 1. provide services in accordance with current or revised DADS policies and standards and the OAA. 2. submit billings with appropriate documentation as required by the CAPCOG/AAACAP by the close of business on the fifth 5th day of each month following the last day of the month in which services were provided. a. If the fifth (5th) day falls on a weekend or holiday, the information shall be delivered by the close of business on the preceding business day. b. The AAA cannot guarantee payment of a reimbursement request received for more than 45 calendar days of service delivery. c. No reimbursement for services provided will be made if vendor payment invoices are not submitted to the CAPCOG/AAACAP within 45 days of service delivery. 3. encourage program participant contributions (program income) on a voluntary and confidential basis. Such contributions will be properly safeguarded and accurately accounted for as receipts and expenditures on Vendor's financial reports if contributions are not required to be forwarded to the CAPCOG/AAACAP. Client contributions (program income) will be reported fully, as required, to the CAPCOG/AAACAP. Vendor agrees to expend all program income to expand or enhance the program/service under which it is earned. 4. notify the CAPCOG/AAACAP Director within 24 hours if, for any reason, the Vendor becomes unable to provide the service(s). 5. maintain communication and correspondence concerning program participants' status. 6. establish a method to guarantee the confidentiality of all information relating to the program participant in accordance with applicable federal and state laws, rules, and regulations. This provision shall not be construed as limiting CAPCOG/AAACAP or any federal or state authorized representative's Form #: AIAAA_VA2.0 2 Edition Date: 9/19/11 Fixed Variable Cost Service Rate Rate Reimbursement (include (identify TRA NSPORTATION(DEMAND/RESPONSE) rate $1.00 ran e) 2. TERMS OF AGREEMENT A. The Vendor agrees to: 1. provide services in accordance with current or revised DADS policies and standards and the OAA. 2. submit billings with appropriate documentation as required by the CAPCOG/AAACAP by the close of business on the fifth 5th day of each month following the last day of the month in which services were provided. a. If the fifth (5th) day falls on a weekend or holiday, the information shall be delivered by the close of business on the preceding business day. b. The AAA cannot guarantee payment of a reimbursement request received for more than 45 calendar days of service delivery. c. No reimbursement for services provided will be made if vendor payment invoices are not submitted to the CAPCOG/AAACAP within 45 days of service delivery. 3. encourage program participant contributions (program income) on a voluntary and confidential basis. Such contributions will be properly safeguarded and accurately accounted for as receipts and expenditures on Vendor's financial reports if contributions are not required to be forwarded to the CAPCOG/AAACAP. Client contributions (program income) will be reported fully, as required, to the CAPCOG/AAACAP. Vendor agrees to expend all program income to expand or enhance the program/service under which it is earned. 4. notify the CAPCOG/AAACAP Director within 24 hours if, for any reason, the Vendor becomes unable to provide the service(s). 5. maintain communication and correspondence concerning program participants' status. 6. establish a method to guarantee the confidentiality of all information relating to the program participant in accordance with applicable federal and state laws, rules, and regulations. This provision shall not be construed as limiting CAPCOG/AAACAP or any federal or state authorized representative's Form #: AIAAA_VA2.0 2 Edition Date: 9/19/11 right of access to program participant case records or other information relating to program participants served under this agreement. 7. keep financial and program supporting documents, statistical records, and any other records pertinent to the services for which a claim for reimbursement was submitted to the CAPCOG/AAACAP. The records and documents will be kept for a minimum of five years after close of vendor's fiscal year. 8. make available at reasonable times and for required periods all fiscal and program participant records, books, and supporting documents pertaining to services provided under this agreement, for purposes of inspection, monitoring, auditing, or evaluations by CAPCOG/AAACAP staff, the Comptroller General of the United States and the State of Texas, through any authorized representative(s). 9. if applicable, comply with the DADS process for Centers for Medicare and Medicaid Services (CMS) screening for excluded individuals and entities involved with the delivery of the Legal Assistance and Legal Awareness services. B. The Vendor further agrees: 1. The agreement may be terminated for cause or without cause upon the giving of thirty 30 days advance written notice. 2. The agreement does not guarantee a total level of reimbursement other than for individual units/services authorized; contingent upon receipt of funds. 3. Vendor is an independent provider, NOT an agent of the CAPCOG/AAACAP. Thus, the Vendor indemnifies, saves and holds harmless CAPCOG/AAACAP against expense or liability of any kind arising out of service delivery performed by the Vendor. Vendor must immediately notify the CAPCOG/AAACAP if the Vendor becomes involved in or is threatened with litigation related to program participants receiving services funded by the CAPCOG/AAACAP. 4. Employees of the Vendor will not solicit or accept gifts or favors of monetary value by or on behalf of program participants as a gift, reward or payment. C. Through the Direct Purchase of Services program, the Capital Area Council of Governments (CAPCOG) Area Agency on Aging of the Capital Area (AAACAP) agrees to: 1. review program participant intake and assessment forms completed by the Vendor, as applicable, to determine program participant eligibility. Service authorization is based on program participant need and the availability of funds. 2. provide timely written notification to Vendor of program participant's eligibility and authorization to receive services. 3. maintain communication and correspondence concerning the program participants' status. 4. provide timely technical assistance to Vendor as requested and as available. 5. conduct quality -assurance procedures, which may include on-site visits, to ensure quality services are being provided and if applicable, CMS exclusion reviews are conducted. 6. provide written policies, procedures, and standard documents concerning program participant authorization to release information (both a general and medical/health related release), client rights and responsibilities, contributions, and complaints/grievances and appeals to all program participants. 7. contingent upon the CAPCOG/AAACAP's receipt of funds authorized for this purpose from DADS, reimburse the Vendor based on the agreed reimbursement methodology, approved rate(s), service(s) Forth #: AIAAA VA2.0 3 Edition Date: 9/19/11 authorized, and in accordance with subsection (A)(2) of this document, within 45 days of the CAPCOG/AAACAP's receipt of Vendor's invoice. 3. ASSURANCES The Vendor shall comply with: A. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et.seq.) B. Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794) C. Americans with Disabilities Act of 1990 (42 U.S.C. § 12101 et seq. ) D. Age Discrimination in Employment Act of 1975 (42 U.S.C. §§6101-6107) E. Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688) F. Food Stamp Act of 1977 (7 U.S.C. §200 et seq.) G. Drug Free Workplace Act of 1988 H. Texas Senate Bill 1 - 1991, as applicable 1. DADS administrative rules, as set forth in the Texas Administrative Code, to the extent applicable to this Agreement J. Certification Regarding Debarment - 45CFR §92.35 Subawards to debarred and suspended parties; this document is required annually as long as this agreement is in effect K. Centers for Medicare and Medicaid Services (CMS) State Medicaid Director Letter SMDL #09-001 regarding Individuals or Entities Excluded from Participation in Federal Health Care Programs L. DADS Information Letter 11-07 — Obligation to Identify Individuals or Entities Excluded from Participation in Federal Health Care Programs 4. SIGNATURES For the faithful performance of the terms of this agreement, the parties affix their signatures and bind themselves ef9fieltive October 01, 2012. C Aut rized Vendor Signature Kos U\Ihi4-PieLy Print Name Alla ' Fro -lem Title Form #: AIAAA VA2.0 4 Edition Date: 9/19/11 Auth ized Si nature Capital Area Council of Governments (Agency) 6800 Burleson Rd Bldg 310 Ste 165 (Address) Austin, TX 78444 (City, State, Zip) A A reg enc} %n Aging tf e,w� c,p+m A. AUTHORIZED SIGNATURE FORM REQUEST FOR PAYMENT DIRECT PURCHASE OF SERVICE PROGRAM Name and Address of Contract/Vendor Agency: City of Round Rock - 221 E. Main St., Round Rock, TX 78664 Signature of Individuals authorized to sign for request for Reimbursement Typed Name: Claudia Tapia Signature: Typed Name: Caren Lee Signature: I certify that the signatures above are of the individuals authorized to sign the Request for Reimbursement. _Sherri Crone Accounting Supervisor Typed Name and Title of Authorized Official Signature of Auth rized Official revisal 9/02 /a -6-/;L, Date MONTHLY BILLING/REPORTING CUTOFF Please complete the following information for FY2013 (October 1, 2012 — September 30, 2013) and return to the Area Agency on Aging of the Capital Area no later than the close of business on February 28, 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 St to the 31St Sherri Crone Accounting Supervisor Printed Name of Authorized Official Signature of Auorizfficial� Date Please note that requests for reimbursements and backup documentation must arrive at the AAA office no later than 5:00 p.m. the 7th of each month. If the 7th 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+) # 42 4.6% #20 2.2% Minority #191 20.9% #42 4.6% Women #213 23.28% #94 10.27% 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 contracts/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 contractor/grantee must also screen each of its covered subcontractors/providers. In this certification "contractor/grantee" refers to both contractor/grantee and subcontractor/subgrantee; "contract/grant" refers to both contract/grant and subcontract/subgrant. By signing and submitting this certification 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 it is later determined that the potential contractor/grantee knowingly rendered an erroneous certification, 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 and/or debarment. 2. The potential contractor/grantee shall provide immediate written notice to the person to which this certification is submitted if at any time the potential contractor/grantee leams that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract," "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 is as defined in the attachment. 4. The potential contractor/grantee agrees by submitting this certification that, should the proposed covered contract/punt 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 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 subcontractors/subgrantees under this proposed contract? --� YES NO 5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modification, 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, unless it knows that the certification is erroneous. A contractor/grantee must, at a minimum, obtain certifications from its covered subcontractors/subgrantees upon each subcontractl;/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 contractor/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 contractor/grantee in a covered contract/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 contractor/grantee 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 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 contractor/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/GRANTEE City of Round Rock VENDOR ID NO./FEDERAL EMPLOYER'S ID Signature of Zi Date Alan McGraw Printed/Typed Name of Authorized Representative Title of Authorized Representative THIS CERTIFICATION IS FOR FY 2013, PERIOD BEGINNING October 1, 2012 and ENDING September 30, 2013. 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 contractor/grantee must also screen each of its covered subcontractors/providers. In this certification "contractor/grantee" refers to both contractor/grantee and subcontractor/subgrantee; "contract/grant" refers to both contract/grant and subcontract/subgrant. By signing and submitting this certification the potential contractor/grantee accepts the following terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract/grant was entered into. If it is later determined that the potential contractor/grantee knowingly rendered an erroneous certification, 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 and/or debarment. 2. The potential contractor/grantee 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 contract," "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 is as 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 ineligible, or voluntarily excluded from 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 subcontractors/subgrantees under this proposed contract? _X_ YES NO 5. The potential contractor/grantee further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants" without modification, 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, unless it knows that the certification is erroneous. A contractor/grantee must, at a minimum, obtain certifications from its covered subcontractors/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 contractor/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 contractor/grantee in a covered contract/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 contractor/grantee 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 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 contractor/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/GRANTEE VENDOR ID NO./FEDERAL EMPLOYER'S ID NO. Signature of Authorized Representative Date John P. Walker Printed/Typed Name of Authorized Representative President/CEO Title of Authorized Representative THIS CERTIFICATION IS FOR FY 2013, PERIOD BEGINNING October 1. 2012 and ENDING September 30, 2013. Form *9 Request for Taxpayer PevUe" octooet a 04) lma Identification Number and Certification Uepannwnt of the iroaswy Internal Revenue Se"" Name fay reported on your income tax return) City of Round Rock —1-- .111, 1, . —x warn amve Give form to the requester. Do not serld to the IRS. Indtv dual! -- -- Check appropriate boxpropnetor L_ i Corporation L Partnership other ► ;✓ wxt hold from bac p i sole I / MunicipalityemDt j x� Address (number, street, and apt- or suites ns ot ' ------ -------`._—_-_ — —----- hame—and 'n -a— -- Ne4uester address (opt,onat) 221 East Main St City. state, and ZIP code --_----.._-------- Round Rock, TX 78664 -- - -- t'st account )umoer sI dere (opto iaf rucnuncetrVn r4umoer I Enter your TIN in the appropriate box. The TIN provided must match the name given on Line t 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 Now to get a TIN on page 3. Note. If the account is to more than one name, see the chart on page 4 for guidelines on whose number to enter. Under penalties of perjury, I certify that: ' Soclial Security number �_ -----`---�--- T.._...t_.._.-._i.---� or Employer identification number 714�6 01117 4i8�51 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. 1 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 1 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 1 am no longer subject to backup withholding, and 3. 1 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 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 I Signature of Here U.S. parson ► Purpose of For A person who is required to file an information return 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. U.S. person. 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) arid, 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. 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. For federal tax purposes you are considered a person if you are: • an individual who is a citizen or resident of the United States. ♦ a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or Date IN. _i--72 .3 — • any estate (other than a foreign estate) or trust. See Regulation section 301.7701-6(a) for additional information. Foreign person. If you are a foreign person, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of incofne even after the recipient has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income. you must attach a statement that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. Cat. No. 10231x l W-9 (Rev. 10-20047