Contract - CAPCOG - Area Agency on Aging - 10/27/2016�r �� e ey
�� on ging
Capital Area Council of Governments of the Capital Area
Area Agency on Aging
SUBRECIPIENT-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 1, 2017, in accordance with the Older Americans Act of 1965
(OAA), as amended, regulations of the Texas Health and Human Services (HHS), 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
yearsorage 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 HHS -AAA Access and Assistance guidelines.
The Capital Area Council of Governments (CAPCOG), 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 , rate setting documents, and
HHS services definitions, 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
Form #: AIAAA VA2.0
Edition Date: 9/2/16
provider strives to reach each transit stop at the scheduled time. The older individual doe t.v 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.
Unit of Service: One, One-way trip
Service Area: Senior Support Services of Austin Texas to serve the 60+ population within the City of Austin
city limit boundary.
All Texas Administrative Code standards are located at the Texas Secretary of State website:
http://vAvw.sos.state.tx.us/tac/index.shtml.
All Older Americans Act and other required rules and regulations are located at
http://www.aoa.gov/AoARoot/About/Authorizing_ Statutes/index aspx
TarjZetin : CAPCOG/AAACAP services are designed to identify eligible program participants, with an
emphasis on high-risk program participants and to serve older individuals with special emphasis on: (1)
older individuals residing in rural areas, (2) older individuals with greatest economic need (with
particular attention to low-income minority and older individuals residing in rural areas), (3) older
individuals who have greatest social need (with particular attention to low-income minority individuals
and residing in rural areas), (4) older individuals with severe disabilities, (5) older individuals with
limited English proficiency, (6) older individuals with Alzheimer's disease and related disorders with
neurological and organic brain dysfunction and the caretakers of such individuals, and (7) older
individuals at risk for institutional placement.
B. Services & Reimbursement Methodology:
Fixed Rate Variable Rate Cost
Service (include rate) (identify range) Reimbursement
Transportation — Demand/Response $2.00
Transportation — Demand/Response $3.00
With Extraten•itorial Jurisdiction
TERMS OF AGREEMENT
A. The Vendor agrees to:
1. Provide services in accordance with current or revised HHS policies and standards and the
OAA.
a. 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.
b. 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.
c. The AAA cannot guarantee payment of a reimbursement request received for less
than 45 calendar days from the vendor payment invoices are received at CAPCOG.
2. 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.
Form #: AIAAAVA2.0
Edition Date: 9/27/16
op Y
3. Encourage program participant contributions (program income) on a volt. t y
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 frilly, 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, in the
same month 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 right of access to program participant case records or other
information relating to program participants served under this agreement.
7. To abide by the terms and conditions as previously agreed and signed in the Data Usage Agreement
(DUA) Attachment 1, Subcontractor Agreement Form, which is attached to this contract and on file at
the Agency;
a. Data Use Agreement The Health and Human Services (HHS) Data Use Agreement
(DUA), Attachment 1, is hereby incorporated by reference and made therefore, a part
of the Subrecipient Vendor Agreement. The DUA, will, as of the effective date of this
contract, govern the handling of "Confidential Information," as that term is defined in
the DUA, under the Subrecipient Vendor Agreement.
b. Liability By signature and acceptance of this amendment and the Data Use
Agreement, Vendor agrees to fully cooperate with the direction of the HHS and the
Office of the Attorney General of Texas in any claim arising from a disclosure of
information subject to this DUA. To the extent permitted by the Texas Constitution,
laws and rules, Vendor will hold harmless CAPCOG/AAACAP and its workforce
against all actual and direct losses, suffered by the Vendor and its workforce arising
from or in connection with any breach of this DUA or from any acts or omissions
related to this DUA by Vendor or its employees, directors, officers, subcontractors, or
agents or other members of its workforce, including, without limitation the costs of
reasonable attorneys' fees, required notices and mitigation of a breach and any fines
or penalties imposed on CAPCOG/AAACAP by any regulatory authority. Vendor
will be solely responsible for any damages resulting from its disclosure of
information made in violation of this DUA.
c. Insurance Vendor either maintains commercial insurance or self -insures with policy
limits in an amount sufficient to cover Vendor's liability arising under this DUA and
under which policy CAPCOG/AAACAP is a beneficiary. Vendor shall identify the
CAPCOG as an additional insured under any and all insurance policies used to satisfy
this provision and provide proof to CAPCOG/AAACAP, upon request. The Agency
reserves the right to consider alternative means for Vendor to satisfy Vendor's
financial responsibility under this DUA. Nothing herein shall relieve Vendor of its
financial obligations set forth in this DUA if Vendor fails to maintain insurance.
Vendor will provide CAPCOG/AAACAP with written proof that required insurance
coverage is in effect, at the request of the Agency.
8. 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
Form #: AIAAA_VA2.0 3
Edition Date: 9/2/16
CAPCOG/AAACAP. The records and documents will be kept for a minimum o1 0-sp
after close of vendor's fiscal year.
9. 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).
10. If applicable, comply with the HHS 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.
A. 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.
B. 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
HHS, reimburse the Vendor based on the agreed reimbursement methodology, approved
rate(s), service(s) authorized, and in accordance with subsection (A)(2) of this document,
within 45 days of the CAPCOG/AAACAP's receipt of Vendor's invoice.
Form #: AIAAA_VA2.0 4
Edition Date: 9/2/16
2. 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 and Nutrition Act 01'2008 (7 U.S.C. §2011 et. seq.);
G. Drug Free Workplace Act of 1988, 41 U.S.C. §§701-704, and 28 TAC Chapter 169, as
applicable.
H. Texas Senate Bill 1 - 1991, as applicable
I. The HHS agency's 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 409-
001 regarding 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 ctive October 01, 2016.
Aut orized Vendor Signature
iaW Olt- CV& W
`'�rPrint ame
(�� V r
Q Title
lD Z -L - tG
Date
Form #: A[AAA_VA2.0
Edition Date: 9/2/16
(Authorized Signature)
(Date)
Capital Area Council of Governments
(Agency)
6800 Burleson Rd., Bldg. 310 Ste. 165
(Address)
Austin, TX 78444
(City, State, Zip)
Affirmative Action Plan COPY
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, tiring, 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+) #41 4.87% #19 35.19_%
Minority 4252 29.89% #17_ 31.48_%
Women #221 26.22% #28 51.85%
ASSURANCE OF COMPLIANCE WITH TIIE DEPARTMENT OI+' HEAL' -1 A� D
HUMAN SERVICES REGULATION UNDER TITLE VI OF THE CIVIL RIGC" f
OF 1964
City of Round Rock (hereinafter called the "Applicant")
Name of Applicant (Type or Print)
APPLICANT 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.
10 -
Date
221 E. Main Street
Round Rock, Texas 78664
Applicant's Mailing Address
City of Round Rock
Applicant (Type or Print)
017? /L, ----
By (Authorized Signature)
CERTIFICATION COPY
REGARDING DEBARMENT, SUSPENSION, INELIGIBUTY
AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRAN'T'S
Federal Executive Order 12549 requires the Texas Agency 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/sub grantee;
"contract/grant" refers to both contract/grant and subcontract/sub grant.
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
Agency of Health and Human Services, United States Agency of Agriculture or other federal Agency or
agency, or the Texas Agency of Aging and Disability Services may pursue available remedies, including
suspension or debarment.
2. The potential Contractor/grantee shall provide immediate written notice to the person to whom 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 transaction," "debarred," "suspended," ineligible," "participant," "person,"
"principal," 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 2 CFR Part 180.
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 Agency of Health and Human Services, United States Agency of
Agriculture or other federal Agency or agency, or the Texas Agency of Aging and Disability Services, as
applicable.
Do you have or do you: anticipate having subcontractors/sub grantees 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/sub grantee 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/sub grantees upon each subcontract's/sub grant'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/sub grant 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, Agency of Health and Human Services, United State
Agency of Agriculture, or other federal Agency or agency, as applicable, and the Texas Agency
of Aging and Disability Services may pursue available remedies, including suspension 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 Agency 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
VEN O/RRIID NO/FEDERAL EMPLOYER'S ID NO. 74-6017485
M/,M, ( Mayor Alan McGraw
Signature of Authorized Representative Printed/Typed Name of Authorized Representative
to -71-(,6 Mayor
Date Title of Authorized Representative
THIS CERTIFICATION IS FOR FFY2017 PERIOD BEGINNING October 1, 2016 and ENDING
September 30, 2017.
CERTIFICATION COPY
REGARDING DEBARMENT, SUSPENSION, INELIGIBIITY
AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS
Federal Executive Order 12549 requires the Texas Agency 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/sub grantee;
"contract/grant" refers to both contract/grant and subcontract/sub grant.
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 detennined that the potential Contractor/grantee knowingly
rendered an erroneous certification, in addition to other remedies available to the federal government, the
Agency of Health and Human Services, United States Agency of Agriculture or other federal Agency or
agency, or the Texas Agency of Aging and Disability Services may pursue available remedies, including
suspension or debarment.
2. The potential Contractor/grantee shall provide immediate written notice to the person to whom 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 transaction," "debarred," "suspended," ineligible," "participant," "person,"
"principal," 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 2 CFR Part 180.
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 Agency of Health and Human Services, United States Agency of
Agriculture or other federal Agency or agency, or the Texas Agency of Aging and Disability Services, as
applicable.
Do you h re or do you: anticipate having subcontractors/sub grantees 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/sub grantee that it is not
debarred, suspended, ineligible, or voluntarily excluded from the covered contract/grant, unless it !mows
that the certification is erroneous. A Contractor/grantee must, at a minimum, obtain certifications from its
covered subcontractors/sub grantees upon each subcontract's/sub grant'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/sub grant 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, Agency of Health and Human Services, United State
Agency of Agriculture, or other federal Agency or agency, as applicable, and the Texas Agency
of Aging and Disability Services may pursue available remedies, including suspension 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:
1 -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 Agency or agency or by the State of Texas.
The potential Contractor/grantee is unable to certify to one or more of the terns in this certification.
In this instance, the potential Contractor/grantee must attach an explanation for each of the above terms to
which Ile is unable to make certification. Attach the explanation(s) to this certification.
NAME OF POTENTIAL CONTRACTOR/GRANTEE
VENDOR ID NO/FEDERAL EMPLOYER' NO.
Signature of A
Ill I It 144 Ike
Printed/Typed Name of Authorized Representative
Title of Authorized
CCb
THIS CERTIFICATION IS FOR FFY2017 PERIOD BEGINNING October 1, 2016 and ENDING
September 30, 2017.
INSTRUCTIONS FOR CERTIFICATION
The inability of a Contractor/grantee to provide the certification required above will not necessarily result
in denial of participation in this covered transaction. The prospective Contractor/grantee shall submit an
explanation of why it cannot provide the certification set out below. The certification or explanation will
be considered in connection with the Agency or Agency's determination whether to enter into this
transaction. However, failure of the prospective Contractor/grantee to furnish a certification or an
explanation shall disqualify such Contractor/grantee from participation in this transaction.
:Area Agency
\' ort Aging
COPY
dthe C.plhl Area
AUTHORIZED SIGNATURE FORM
REQUEST FOR PAYMENT
DIRECT PURCHASE OF SERVICE PROGRAM
Name, Address and Phone of Vendor Agency:
Citv of Round Rock
221 E. Main Street
Round Rock, TX 78664
Signature of Individuals authorized to sign for request for Reimbursement
Typed Name: Caren Lee I Typed Name:
Signature:
Typed Name:
Signature:
Signature:
Typed Name:
Signature:
I certify that the signatures above are of the individuals authorized to sign the
Request for Reimbursement.
-,one u I sc:31C
Typed Name and Title of Authorized Official
Signature of Auth rized Official
Date