HomeMy WebLinkAbout20161642.tiffhi)-b-m,t /Ditto
MEMORANDUM
D 1 FE: July 26, 2016
TO: Board olCounty Commissioners — Pass -Around
FR: Judy V Griego. Director, ((Liman Services
RE:
Weld County Department of Human Services' Child Welfare
2016-2017 Respite Care Provider Renewals
Please review and indicate it you would like a work session prior to placing these items on the
Board's agenda.
Request Board Approval of the Renewal for Respite Services between the Department and
Various Providers. The Department's Division of Child Welfare contracts annually with
individuals and couples, primarily Weld County certified foster parents. for respite care services.
Respite care is limited to tour (4) hours per week per child. The hours of care may he provided in
any combination throughout a month, but may not exceed 16 hours per month. Payment is $16.75
per each four hour period, but may not exceed $67.0O per month for 16 hours. The list of providers
that would like to renew for the term of July I. 2016 through June 30, 201 7, are as follows:
Brown
Rachel
Greeley
Irwin
Kasi (Jeremiah)
Severance
Koepp
Jenna (Kristopher)
[vans
Maronek
Patricia (Dennis)
Greeley
Miller
Pamela
Greeley
Ripka
Gary Steven
It. Collins
Stone Mary Kav (Jamie David)
Greeley
Tauber - Nicole (Jon 4i ri`ght)
Greeley
Tay ita
Jacquelyn (Bruce)
Greeley
Van Den Elren
Dawn
Greeley
Ft. Collin
Walker
lenniter Lynne
r Walker Renac
Windsor 4
Workman -W urt, Jitathry n
Greeley
I do not recommend a Work Session
Sean Conway
Steve \toren°
Barbara Kirkmever
\like 1-reeman
(_ilia, Co/ad
I recommend approval of these Renewals.
Approve Request
BOO: enda Work Session
i1o
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CONTRACT AGREEMENT AMENDMENT BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND BRUCE AND JACQUELYN TAVITA (NON -CORE)
This Agreement Amendment, made and entered into
od Au 1151
day °flute, 020✓ by and between
the Board of Weld County Commissioners, on behalf of the Weld County Department of Human
Services, hereinafter referred to as the "Department", and Bruce and Jacquelyn Tavita, hereinafter
referred to as the "Contractor".
WHEREAS the parties entered into an Agreement for Respite Care Provider Services, (the
"Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as
document No. 2016-1642, approved on May 23, 2016.
WHEREAS the parties hereby agree to amend the term of the Original Agreement in
accordance with the terms of the Original Agreement, which is incorporated by reference herein, as
well as the terms provided herein.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as
follows:
• The Original Agreement ended on June 30, 2016.
The Amendment, together with the Original Agreement, constitutes the entire
understanding between the parties. The following change is hereby made to the Contract
Documents:
1. Term
This agreement shall become effective on July 1, 2016 upon proper execution of this
Agreement and shall expire June 30, 2017, unless sooner terminated as provided herein.
2. None
• All other terms and conditions of the Original Agreement remain unchanged.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
COUNTY:
ATTEST: [/;ei
Weld County Clerk to the Board
By
eputy Clerk to the Board
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
Mike Freeman, Chair AUG 2 2 2016
CONTRACTOR:
ruce and Jacquelyn Tavita
416 40`" Avenue
Greeley, CO 80634
(907) 252-6047
By:
Date:
By:
Date:
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servicing5.progressive.com
INSURANCE IDENTIFICATION CARD - Colorado
Policy Number 908271046 NAIC Number: 16322
Effective Date: 06/21/2016 Expiration Date: 12/21/2016
Insurer. Progressive Direct Insurance Co 1-800-776-4737
PO Box 31260 Tampa, FL 33631
Named Insured(s):
Bruce E Tavita
Jacquelyn C Tavita
Year Make Model VIN
2011 Dodge Ram 2500 3D7UT2CL1BG554467
2013 Gmc Yukon/Denali 1GICS2EEF4DR265748
1998 Ford Escort 1FAFP13P7WW266602
Bruce E Tavita
Jacquelyn C Tavita
Platinum Membership
Valued Customer Since 2012
Form A022 (03/11)
IF YOU'RE IN AN ACCIDENT
1 Remain at thascene_Don'tadmitfault
A'i/ract IDS ya-9
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER. BRUCE AND JACQUELYN TAVITA
THIS AGREEMENT is made and entered into this 23rdday of Max, 2016, by and
between the Board of County Commissioners of the County of Weld, State of Colorado, on behalf
of the Weld County Department of Human Services, whose address is 1150 "O" Street, Greeley,
Colorado 80631, hereinafter referred to as "County", and Bruce and Jacquelyn Tavita whose
address is 1416 40' Avenue, Greeley, Colorado, 80634, hereinafter referred to as "Care Provider."
WITNESSETH:
WHEREAS, required approval, clearance, and coordination have been accomplished from
and with appropriate agencies; and
WHEREAS, the Colorado Department of Human Services has provided funding to the
County for respite care for Weld County certified foster care homes; and
WHEREAS, County has determined that due to the significant challenges often
experienced by certified foster care providers, it is necessary to offer them respite services, as
described in Exhibit A, "Scope of Services", a copy of which is attached hereto and made a part
hereof by this reference), to allow them to continue to provide high quality care for the children in
their charge, and
WHEREAS, Care Provider is willing and able to abide by the terms and conditions
required by County, as more fully set forth in this Agreement,
WHEREAS, Care Provider is able and available to provide respite services as defined in
this Agreement at the rates set forth in Exhibit B, "Rate of Reimbursement" a copy of which is
attached hereto and made a part hereof by this reference),
NOW, THEREFORE, in consideration of the mutual promises and covenants contained
herein, the parties hereto agree as follows:
RESPITE CARE PROVIDER'S RIGHTS AND RESPONSIBILITIES:
1. As used in this Agreement "Respite Care" is defined as those child care services
required by one or more children who are in the care of a certified foster home,
which services are provided by Care Provider in order to give foster parents an
opportunity to address matters which cannot be addressed while caring for the
child(ren) in their care. These services are described in Exhibit A. These services
may also include transporting the child to school and other appointments previously
arranged by the foster parent. Transportation services are provided at the sole
risk, responsibility and liability of Care Provider.
/-8p(
Page 1 of 13
2016-1642
2. Care Provider may provide up to sixteen (16) hours of Respite Care per child per
month for certified Weld County foster homes seeking respite care, as approved by
the Depai tiuent. The hours of respite care may be provided in any combination
(schedule) throughout the month so long as the total hours provided does not exceed
sixteen (16) hours per month.
3. At all times from the effective date of the Agreement until completion of the
Agreement, Care Provider shall comply with the administrative requirements, cost
principles and other requirements set forth in the Financial Management Manual
adopted by the State of Colorado. The required annual audit of all funds expended
under this Agreement must conform to the Single Audit Act of 1984 and OMG
Circular A-133.
4. Care Provider agrees to accept payment by either County warrant or ACH direct
deposit.
5. Care Provider agrees to obtain a criminal background check, and warrants that if
any previous criminal charge filed against Care Provider does not appear in the
background check, he/she shall disclose such charges.
6. Care Provider assures that it will fully comply with all applicable Federal and State
laws which govern the ability of the County to comply with the relevant funding
requirements.
7. Care Provider assures and certifies as follows:
a. He/She is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation with any
program with a Federal or State department or agency; and
b. He/She has not, within a three-year period preceding this Agreement, been
convicted of or had a civil judgment rendered against him/her for
commission of fraud or criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or Local),
transaction or contract under public transaction; or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property; and
c. He/She is not presently indicted for or otherwise criminally or civilly
charged by a government entity (federal, state or local) with commission of
any of the offenses enumerated in this certification; and
d. He/She has not, within a three-year period preceding this Agreement, had
one or more public transactions (federal, state, or local) terminated for cause
or default.
Page 2 of 13
8. Contract Professional certifies, warrants, and agrees that it does not knowingly
employ or contract with an illegal alien who will perform work under this
contract. Contract Professional will confirm the employment eligibility of all
employees who are newly hired for employment in the United States to perform
work under this Agreement, through participation in the E -Verify program or the
State of Colorado program established pursuant to C.R.S. §8-17.5-
102(5)(c). Contract Professional shall not knowingly employ or contract with an
illegal alien to perform work under this Agreement or enter into a contract with a
subcontractor that fails to certify with Contract Professional that the subcontractor
shall not knowingly employ or contract with an illegal alien to perform work under
this Agreement. Contract Professional shall not use E -Verify Program or State of
Colorado program procedures to undertake pre -employment screening or job
applicants while this Agreement is being performed. If Contract Professional
obtains actual knowledge that a subcontractor performing work under the public
contract for services knowingly employs or contracts with an illegal alien Contract
Professional shall notify the subcontractor and County within three (3) days that
Contract Professional has actual knowledge that a subcontractor is employing or
contracting with an illegal alien and shall terminate the subcontract if a
subcontractor does not stop employing or contracting with the illegal alien within
three (3) days of receiving notice. Contract Professional shall not terminate the
contract if within three days the subcontractor provides information to establish that
the subcontractor has not knowingly employed or contracted with an illegal
alien. Contract Professional shall comply with reasonable requests made in the
course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the
Colorado Department of Labor and Employment. If Contract Professional
participates in the State of Colorado program, Contract Professional shall, within
twenty days after hiring a new employee to perform work under the contract, affirm
that Contract Professional has examined the legal work status of such employee,
retained file copies of the documents, and not altered or falsified the identification
documents for such employees. Contract Professional shall deliver to County, a
written notarized affirmation that it has examined the legal work status of such
employee, and shall comply with all of the other requirements of the State of
Colorado program. If Contract Professional fails to comply with any requirement
of this provision or of C.R.S. §8-17.5-101 et seq., County, may terminate this
Agreement for breach, and if so terminated, Contract Professional shall be liable
for actual and consequential damages.
9. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-
103(3), if Contract Professional receives federal or state funds under the contract,
Contract Professional must confirm that any individual natural person eighteen (18)
years of age or older is lawfully present in the United States pursuant to C.R.S. §
24-76.5-103(4), if such individual applies for public benefits provided under the
Page 3 of 13
contract. If Contract Professional operates as a sole proprietor, it hereby swears or
affirms under penalty of perjury that it: (a) is a citizen of the United States or is
otherwise lawfully present in the United States pursuant to federal law, (b) shall
produce one of the forms of identification required by C.R.S. § 24-76.5-101, et seq.,
and (c) shall produce one of the forms of identification required by C.R.S. § 24-
76.5-103 prior to the effective date of the contract.
10. Care Provider certifies that, at the time of entering into this Agreement, he/she has
currently in effect all necessary licenses, approvals, insurance, etc., required to
properly provide the services covered by this Agreement. These requirements
include the following:
a. Current Colorado driver's license indicating Care Provider is at least
eighteen (18) years of age; and
b. Completed fingerprint card for a background check through the Colorado
Bureau of Investigation (CBI) and the Federal Bureau of Investigation
(FBI). The fingerprinting expense must be paid by the Care Provider.
Background checks will be paid by the County.
c. Current CPR and First Aid certifications. If either certification expires
during the term of this Agreement, Care Provider shall renew the
certification ensuring that there is no lapse in certification. County will pay
for certification through select CPR and First Aid trainers identified by the
County.
d. Care Provider shall procure at least the minimum amount of automobile
liability insurance required by the State of Colorado. County provides no
automobile liability coverage for Care Provider. Proof of said automobile
liability insurance shall be provided to County prior to the performance of
any services under this Agreement.
e. Copies of all documentation relating to the foregoing requirements shall be
provided to the County by Care Provider prior to the performance of any
services covered under this Agreement. County shall determine eligibility
for certification based upon the successful completion of all required
training and receipt of current documentation.
11. Care Provider shall attend fifteen (15) hours PRIDE training through the Weld
County Department of Human Services prior to the performance of services under
this Agreement. County shall not compensate Care Provider for said training;
including time spent traveling to and from training, time spent in attendance of the
training, or any associated costs paid by Care Provider for such training, unless
specifically agreed to in writing in advance by County.
12. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
Page 4 of 13
for any damages caused by his/her actions while performing services pursuant to
this Agreement, and shall hold County harmless from any loss occasioned as a
result of the performance of this Agreement.
13. Care Provider shall be totally responsible to provide whatever personal liability
and/or other insurances, he/she deems necessary to cover his/her personal liability
for any injuries caused by Care Provider in the course of providing services under
this Agreement.
14. Care Provider shall perform his/her duties hereunder as an independent contractor
and not as an employee of County. Care Provider shall be solely responsible for
his/her acts performed pursuant to this Agreement. Under no circumstances shall
Care Provider be deemed to be an agent or employee of Weld County. Care
Provider is not entitled to unemployment insurance or workers' compensation
benefits through Weld County and Weld County shall not pay for or otherwise
provide such coverage for Care Provider. Unemployment insurance benefits will
not be available to Care Provider for services provided under this Agreement. Care
Provider shall pay when due any/all applicable employment taxes and income taxes
and local head taxes (if applicable) incurred as a result of the services provided
under this Agreement.
15. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding_
16. Care Provider agrees that he/she shall not use alcohol, illegal drugs, marijuana,
whether for recreational or medical purposes, or any other drugs which have the
potential of impacting Care Provider's ability to supervise the children in his/her
care while providing services under this Agreement or within five (5) hours prior
to the provision of said services.
17. Care Provider shall protect the confidentiality of all records and other materials to
which he/she has access relating to the foster family and child(ren) to whom the
services are provided, which are maintained in accordance with this Agreement
except for purposes directly connected with the administration of Child Protection.
COUNTY'S RIGHTS AND RESPONSIBILITIES:
I. Weld County, the Board of County Commissioners of Weld County, its officers
and employees, shall not be held liable for injuries or damages caused by any
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
Page 5 of 13
2. County shall not indemnify Care Provider for any loss incurred by Care Provider
as a result of services performed under this Agreement.
3. County shall pay Care Provider in accordance with the terms set forth in Exhibit B,
reference), as long as services are rendered satisfactorily and in accordance with
the Agreement.
4. Payment pursuant to this Agreement is subject to, and contingent upon, the
continuing availability of funds made available for the purposes hereof. No portion
of this Agreement shall be deemed to create an obligation on the part of County to
expend funds not otherwise appropriated. The County may terminate this
Agreement at any time if said source of funding is no longer available to County
5. County may withhold payment under this Agreement if Care Provider fails to
comply with any part of the Agreement. In the event County withholds payment,
Care Provider may appeal such circumstance in writing to the Weld County
Director of Human Services. The decision of the Weld County Director of Human
Services shall be final.
.GENERAL PROVISIONS:
1. This Agreement shall become effective on April 1, 2016, upon proper execution of
this Agreement, and shall expire on June 30, 2016, unless sooner terminated as
provided herein. This Agreement may be renewed by the mutual agreement of the
parties for up to two (2) additional one (1) year periods. Renewal of the Agreement
shall be documented by the execution of the "Renewal of Agreement" form, a copy
of which is attached hereto as "Exhibit C" and made a part hereof by this reference.
2. Either party may terminate this Agreement at any time for any reason by providing
the other party with a 30 -day written notice thereof. Furthermore, this Agreement
may be terminated by County at any time without notice upon a material breach by
Care Provider of the terms of the Agreement.
3. Care Provider may not assign or transfer this Agreement, any interest therein or
claim hereunder, without the prior written approval of County.
It is expressly understood and agreed that the enforcement of the terms and
conditions of this Agreement, and all rights of action relating to such enforcement,
shall be strictly reserved to the undersigned parties and nothing in this Agreement
shall give or allow any claim or right of action whatsoever by any other person not
included in this Agreement. It is the express intention of the undersigned parties
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
Page 6 of 13
4. No term or condition of this contract shall be construed or interpreted as a waiver,
express or implied, of any of the immunities, rights, benefits, protections or other
provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq.,
as applicable now or hereafter amended.
5. If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement
is for any reason held or decided to be unconstitutional, such decision shall not
affect the validity of the remaining portions. The parties hereto declare that they
would have entered into this Agreement and each and every section, subsection,
paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one
or more sections, subsections, paragraphs, sentences, clauses, or phrases might be
declared to be unconstitutional or invalid.
6. No officer, member or employee of County and no member of their governing
bodies shall have any pecuniary interest, direct or indirect, in the approved
Agreement or the proceeds thereof. The appearance of conflict of interest applies
to the relationship of a Care Provider with County when the Care Provider also
maintains a relationship with a third party and the two relationships are in
opposition. In order to create the appearance of a conflict of interest, it is not
necessary that the Care Provider gain from knowledge of these opposing interests.
It is only necessary that the Care Provider knows that the two relationships are in
opposition. During the term of the Agreement, Care Provider shall not enter into
any third party relationship that gives the appearance of creating a conflict of
interest. Upon learning of an existing appearance of a conflict of interest situation,
Care Provider shall submit to the Department, a full disclosure statement setting
forth the details that create the appearance of a conflict of interest. Failure to
promptly submit a disclosure statement required by this paragraph shall constitute
grounds for the Department's termination, for cause, of its Agreement with the Care
Provider. Care Provider certifies that no Federally appropriated funds have been
paid or will be paid, by or on behalf of Care Provider, to any person for influencing
or attempting to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of
any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of an Federal contract, loan, grant, or cooperative agreement.
7. This Agreement, together with Exhibits A and B, constitutes the entire
understanding between the parties with respect to the subject matter hereof, and
may not be changed or modified, unless by a written amendment executed by both
parties. This Agreement shall be binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
Page 7 of 13
assign any of its rights or obligations hereunder without the prior consent of the
other party.
9. This Agreement shall not be valid until it has been approved by the Board of County
Commissioners of Weld County, Colorado.
10. Colorado law, and rules and regulations established pursuant thereto, shall be
applied in the interpretation, execution, and enforcement of this Agreement. Any
provision included or incorporated herein by reference which conflicts with said
laws, rules and/or regulations shall be null and void. In the event of a legal dispute
between the parties, Care Provider agrees that the Weld County District Court shall
have exclusive jurisdiction to resolve said dispute.
11. In the event of a dispute between County and Care Provider, concerning this
Agreement, the parties agree that each party shall be responsible for the payment
of attorney fees and/or legal costs incurred by or on its own behalf.
12. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement,
where such failure is due to any cause beyond its reasonable control, including but
not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental
actions.
13. All work and information obtained by Contract Professional under this Agreement
or individual work order shall become or remain (as applicable), the property of
County. In addition, all reports, documents, data, plans, drawings, records and
computer files generated by Contract Professional in relation to this Agreement and
all reports, test results and all other tangible materials obtained and/or produced in
connection with the performance of this Agreement, whether or not such materials
are in completed form, shall at all times be considered the property of the County.
Contract Professional shall not make use of such material for purposes other than
in connection with this Agreement without prior written approval of County.
14. Contract Professional acknowledges that County has entered into this Agreement
in reliance upon the particular reputation and expertise of Contract Professional.
Contract Professional shall not enter into any subcontractor agreements for the
completion of this project without County's prior written consent, which may be
withheld in County's sole discretion.
15. Upon completion of the work, the Contractor shall submit to Department originals
of all tests and results, reports, etc., generated during completion of this work.
Acceptance by Department of reports and incidental material(s) furnished under
this Agreement shall not in any way relieve the Contractor of responsibility for the
quality and accuracy of the services. In no event shall any action by the Department
hereunder constitute or be construed to be a waiver by the Department of any breach
of covenant or default which may then exist on the part of the Contractor, and the
Department's action or inaction when any such breach or default shall exist shall
Page 8 of 13
not impair or prejudice any right or remedy available to the Department with respect
to such breach or default; and no assent, expressed or implied, to any breach of any
one or more covenants, provisions or conditions of the Agreement shall be deemed
or taken to be a waiver of any other breach. Acceptance by the Department of, or
payment for, any services performed under this Agreement shall not be construed
as a waiver of any of the Department's rights under this Agreement or under the
law generally.
16. The Contractor warrants that services performed under this Agreement will be
performed in a manner consistent with the professional standards governing such
services and the provisions of this Agreement. The Contractor shall faithfully
perform the work in accordance with the standards of care, skill, training, diligence
and judgment provided by highly competent individuals and entities that perform
services of a similar nature.
17. This Agreement does not guarantee any work nor does it create an exclusive
agreement for services.
18. Contractor agrees that authorized local, Federal, and State auditors and
representatives shall, during business hours, have access to inspect and copy
records, and shall be allowed to monitor and review through on -site visits, all
activities related to this Agreement, supported with funds under this Agreement, to
ensure compliance with the terms of this Agreement. Contracting parties agree
that monitoring and evaluation of the performance of the Agreement shall be
conducted by appropriate funding sources. The results of the monitoring and
evaluation activities shall be provided to the appropriate and interested parties.
Page 9 of 13
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
COUNTY:
ATTEST: �' " "jeli'11 BOARD OF COUNTY COMMISSIONERS
Weld Cc my Clerk to the Bard WELD COUNTY, COLORADO
By:
Mike Freeman, Chair
NAY 2 3 2016
CONTRACTOR:
Bruce and Jacquelyn Tavita
1416 40th Avenue
Greeley, Colorado 80634
907-252-6047
By:
Date:
By:
JaAulyn Tavita
J
Date: 15 fy\cLa 4. 2011,
Page 10 of 13
EXHIBIT A
SCOPE OF SERVICES
1. Care Provider will provide up to sixteen (16) hours of Respite care services per month per
child for foster children residing in Weld County certified foster homes.
2. Care Provider will, at the time of entering into this Agreement, ensure he/she has completed
all the necessary paperwork and has in effect all necessary licenses, approvals, insurance,
etc., required to provide the Respite services covered by this Agreement. Care Provider
will have:
a. Completed and submitted the Colorado Department of Human Services
Application and signed as "Foster Parent/Home" PRIOR to completing the
PRIDE classes.
b. Successfully completed fifteen (15) hours of PRIDE training through the
County prior to the performance of services under this Agreement.
c. Provided a copy of their current Colorado driver's license indicating Care
Provider is at least eighteen (18) years of age; and
d. Completed and submitted a fingerprint card for a background check through
the Colorado Bureau of Investigation (CBI) and the Federal Bureau of
Investigation (FBI). The fingerprinting expense must be paid by the Care
Provider. Background checks will be paid by the County.
e. Provided three (3) reference forms completed by non -relatives.
f. Provided proof of current CPR and First Aid certifications.
g. Completed and signed the Confidentiality, Discipline and Mandated
Reporter Policies.
h. Provided proof that Care Provider has procured at least the minimum
amount of automobile liability insurance required by the State of Colorado.
County provides no automobile liability coverage for Care Provider.
Copies of all documentation relating to the foregoing requirements shall be provided to the
County by Care Provider prior to the performance of any services covered under this
Agreement. County shall determine eligibility for certification based upon the successful
completion of all required training and receipt of current documentation.
Care Provider further acknowledges that he/she will remain current with all documentation
or certifications for the term of this Agreement. Should an item expire or otherwise
become invalid, Care Provider will submit current documentation to the County to avoid a
lapse in documentation and/or certification.
Page 11 of 13
3. Care Provider acknowledges that the County shall not compensate Care Provider for said
training; including time spent traveling to and from training, time spent in attendance at
the training, or any associated costs paid by Care Provider for such training, unless
specifically agreed to in writing in advance by County.
4. Care Provider acknowledges that arrangements to provide Respite services must be
communicated to the child's Caseworker and the Foster Care Coordinator prior to Respite
taking place in order to discuss arrangements and ensure all the child's needs are met.
5. Care Provider will become familiar with and follow all the State and Federal rules and
regulations as applicable to the services provided under this Agreement.
6. Care Provider will complete and submit the Respite Care Payment Form each month by
the 10th of the month following the month of service. The Respite Care Payment Form is
available on the Foster Parents Internet Database and On-line System (FIDOS).
Page 12 of 13
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
The County agrees to reimburse the Care Provider in consideration of the work and services
performed under this Agreement at the rate specified in Paragraph 2, below. The total
amount to be paid to the Care Provider during the term of this Agreement shall be reported
by the County after June 30, 2016.
Expenses incurred by the Care Provider prior to the term of this agreement are not eligible
County expenditures and shall not be reimbursed by the County.
Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent
upon the continuing availability of said funds for the purposes hereof. In the event that said
funds, or any part thereof, become unavailable as determined by the County, the County may
immediately terminate the Agreement or amend it accordingly.
2. Fees for Services
Respite care is limited to four (4) hours per week per child. The hours of care may be
provided in any combination throughout a month, but may not exceed 16 hours per month.
Payment will be $16.75 per each four hour period, but may not exceed $67.00 per month for
16 hours.
Human Services referrals will not be sent to collections by Care Provider for default of co-
pay/fees. Services will be performed regardless of client's refusal or inability to pay co -pay.
Care Provider will collect any applicable sliding scale co -pays and credit Human Services for
any payments received on the monthly billing statements.
3. Submittal of Vouchers
Care Provider shall prepare and submit a Respite Care Payment Form each month to certify that
the services authorized were provided on the date(s) indicated and the charges made were
pursuant to the terms and conditions of Exhibit A. The Respite Care Payment Form is available
online through the Foster Parent Internet Database and On-line System (FIDOS).
Page 13 of 13
EXHIBIT C
RENEWAL OF AGREEMENT FORM
CONTRACT AGREEMENT AMENDMENT
BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND (name of vendor as indicated on current agreement)
This Agreement Amendment, made and entered into JDATE] day of JMONTH], IYEARj, by and between the Board
of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the
"Department", and «Agency», hereinafter referred to as the "Contractor".
WHEREAS the parties entered into an Agreement to , (the "Original Agreement") identified by the
Weld County Clerk to the Board of County Commissioners as document No. [TYLER #j, approved on jBOCC Approval
Date].
WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of
the Original Agreement, which is incorporated by reference herein, as well as the terms provided herein.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
• The Original Agreement will end on June 30, 2016.
• The Amendment, together with the Original Agreement, constitutes the entire understanding between the parties.
The following change is hereby made to the Contract Documents:
2.
• All other terms and conditions of the Original Agreement remain unchanged.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above
written.
COUNTY:
ATTEST: BOARD OF COUNTY COMMISSIONERS
Weld County Clerk to the Board WELD COUNTY, COLORADO
By:
Deputy Clerk to the Board Barbara Kirkmeyer, Chair
CONTRACTOR:
«Agency»
«Agency Mailing Address»
«Agency_ City_ State_ Zip»
By:
Contractor's (or designee's) Signature
and Date
e certify UNDER PENALTY � RJnURy that„-. (name and trade name)
performing (type of work) t' ((..emu(
Social - a = or Federal Emplo er Identi ication #
Address:
is an independent contractor (IC) and is not an emp ee of the following policyholder (PH):
Address: Policy #
Declaration of Independent Contractor Status Form
rt4C TAV i-)c�
Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
mee following criteria:
IC PH. 1. The business DOES NOT require the individual to work ONLY for the business for whom services are performed
q�(" (except that the individual may DECIDE to work only for the business for a definite period);
IC 'J' PH 2. The business DOES NOT establish a quality standard for the individual (except that the business may provide
plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to how work
will be performed);
C PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;
IC PH 4. The business DOES NOT terminate the work or the service provided during the contract period unless the
individual violates the terms of the contract or fails to produce a result that meets the specifications of the contract;
IC PH 5. The business DOES NOT provide more than minimal training for the individual;
IC PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
IC Dr PH 7. The business DOES NOT dictate the time of performance (except that a completion schedule and a range of
r agreeable work hours may be established);
IC a PH 8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade
or business name of the individual;
IC Or PH 9. The business DOES NOT combine the business operations in any way with the individual's business operations
instead of maintaining all such operations separately and distinctly.
CERTIFICATION BY INDEPENDENT CONTRACTOR
THE INDEPENDENT CONTRACTOR UNDERSTANDS THAT HE/SHE:
• WILL NOT BE ENTITLED TO ANY WORKERS' COMPENSATION BENEFITS IN THE EVENT OF INJURY.
• IS OBLIGATED TO PAY AU. FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING SERVICES FOR THE
BUSINESS.
• Ijq ED TO PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES.
•--r-•-�.er'•�• Signature 1 Title Social Security #
STATE OF COLORADO, COUNTY OF W 0 �,
Subset" and sworn befofi me by " tr t..cp T � is this ILIday of na _ r c h ,112114,____
' u., _ \ CA-A---k...\�1-'- Commission expires: 1' b—� \ g
NOTARY P.fIBLIC
Acceptance of the Independent Contractor named on this form
individuals or organizations hired or contracted by the bide
specified on this form will be charged premium for coverage of
CERTIFICATION BY BUSINESS
the Workers' Compensation Act. U
' compensation insurance, the policyholder
I certify that I am authorized by the business listed above to state that all of the information on this form is true and accurate. I
understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed.
Signature
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by this day of
NOTARY PUBLIC
Title
Commission expires:
Pare 2 of 2
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY F PERJURY that and trade name) J 0, el utelmrr -TOW 1+_
performing (typo await) es p 1-Ve
Social Secorityor Federal
O '7 .25D. 60 t-17
is an independent contractor (IC) and is not an emph6yee of the following policyholder (PH):
Address: Policy #
Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
meet th following criteria:
IC ji PH. I. The business DOES NOT require the individual to work ONLY for the business for whom services are performed
(except that the individual may DECIDE to work only for the business for a definite period);
IC Ji PH 2. The business DOES NOT establish a quality standard for the individual (except that the business may provide
plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to how work
K will be performed);
IC Nl PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;
IC -KPH 4. The business DOES NOT terminate the work or the service provided during the contract period unless the
individual violates the terms of the contract or fails to produce a result that meets the specifications of the contract;
IC .)1 -"PH 5. The business DOES NOT provide more than minimal training for the individual;
IC J-(' PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
IC .X PH 7. The business DOES NOT dictate the time of performance (except that a completion schedule and a range of
agreeable work hours may be established);
IC LIT —PH 8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade
or business name of the individual;
9. The business DOES NOT combine the business operations in any way with the individual's business operations
instead of maintaining all such operations separately and distinctly.
CERTIFICATION BY INDEPENDENT CONTRACTOR
THE INDEPENDENT CONTRACTOR UNDERSTANDS THAT HE/SHE:
• WILL NOT BE ENTITLED TO ANY WORKERS' COMPENSATION BENEFITS IN THE EVENT OF INJURY.
• IS OBLIGATED TO PAY ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING SERVICES FOR THE
BUSINESS.
• IS REQUIRED TO PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES.
Signature Title Social Security #
STAF COLORADO, COUNTY OF t ) C 1 to
Subscrib&d and sworn ore me by Jo., q;.,,,,A y A 'i'tV 1 E 0. this 15t` day of r s , /4.0114)y� -'- '- Commission expires: \ - x.10 _ 1 Q
NOTARY PCBLIC
LYNETTE GAMIER
Acceptance of the Independent Contractor named on this form does not change any iisder the Worlen' Compensation Act If
individuals or organizations hired or contracted by the Independent Contactor are 1M� 1j ' compensation insurance, the policyholder
specified on this form will be charged premium for coverage of Chess indiveduals orNfaila bte.'rI01sI400psw
JY 2001
CERTIFICATION BY BUSINESS
I certify that I am authorized by the business listed above to state that all of the information on this form is true and accurate. I
understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed.
Signature Title
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by this day of
NOTARY PUBLIC
Commission expires:
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