HomeMy WebLinkAbout20142484.tiffMEMORANDUM
D \ 1F: July 26, 2016
TO' Board of County Commissioners — Pass -,sound
K. Judy A. Griego, Director. I luman Services
RE:
Weld County Department of Human Services' Child Welfare
'_016-201 7 Respite Care Prov ider Renewals
Please review and indicate if 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 tester parents, for respite care services.
Respite care is limited to for.rr (4j 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 is $16.75
per each four hour period. but may not exceed $67.00 per month for 16 hours. fhe list of providers
that would like to renew for the term of July I, 2016 through .tune 30, 201 7, arc as follows:
Last
Firms Name
Brown
Rachel
Greeley
Irwin
Kasi (Jeremiah)
Severance
Koepp
Jenna (Kristopher)
Evans
1 Maronek
Patricia (Dennis)
Greeley
1 ;tililler
Pamela
Greeley
Ripka
Clary Steven
Ft. Collins
stone Mary Kay (Jamie David)
Greeley
Tauber Nicole (Jon Wright)
Greeley
Tavita
l-
Jacquelyn (Bruce) i
Greeley
Van Den Ellen
Dawn
Greeley
Walker
.Jennifer Lynne
Ft. Collins
Walker
Renac ,
Windsor
Workman -Wertz
Kathryn j
(Greeley
do not recommend a Work Session
Sean Conway
Steve Moreno
Barbara Kirkmever
�ltike trceman
Julie Co/ad
0_,101%svid
f recommend approval of these Renewals.
Approve Request
BOCC genda Work Session
Pass -Around Memorandum; July 26. 201.6 .31)
s6- c6.
Page 1
as/ii-oN81
CONTRACT AGREEMENT AMENDMENT BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND PAMELA MILLER (NON -CORE)
Of List'
This Agreement Amendment, made and entered into 9(/t day oflafSe 2016, 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 Pamela Miller, 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. 2014-2484, approved on August 11, 2014.
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, 2015.
• The Original Agreement was renewed for the term of July 1, 2015 -June 30, 2016. The
Agreement Amendment is identified by the Weld County Clerk to the Board of County
Commissioners as document No. 2015-2195(2), approved on July 20 2015.
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:
Weld County Clerk to the Board WELD COUNTY, COLORADO
d Wes,(.
BOARD OF COUNTY COMMISSIONERS
By:
eputy Clerk to the Board
d -ad.
Mike Freeman, Chair AUG 2 2 ZU\6
CONTRACTOR:
atricia and Dennis Maronek
929 56th Avenue
reeley, CO 80634
(970) 775-0064
By:
Patricia Maronek
Date: 6 - Z/ /C
( By: 1 .( z/L-vc
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Dennis Maronek
Date: c - �/ l
IMPORTANT - IDEN
STATE
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INSURED MILLER, PAM MUTL
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PHONE (970)356.8700 NAIC 25178
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MEMORANDUM
DA FE: July, 26, 2016
TO: Board of County Commissioners — Pass -Around
FR: Judy A. Griego, Director, [luman Services
T Y
`t--� RE: Weld County Department ot Human Services' Child Welfare
2016-2017 Respite Care Provider Renewals
Please review and indicate if 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 sery ices.
Respite care is limited to tour (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 is $16.75
per each four hour period, but may not exceed $67.00 per month for 16 hours. fhe list of providers
that would like to renew for the term of July I. 2016 through June 30, 201 7, arc as follows:
;, LW mime First
Brown
Rachel
Greeley
Irwin
Kasi (Jeremiah)
Severance
Koepp
Jenna (Kristopher)
Evans
tMaronek
Patricia (Dennis)
Greeley
Miler
Pamela
Greeley
Ripka
CiAn, Sh,A,orl
f'. f'__II'.
Stone
Tauber
Tav ita
Van Den Elien Dawn
Mary Kay (Jamie David)
Nicole (Jon Wright)
Jacquelyn (Bruce)
Walker
Walker
Jennifer Lynne
Renac
Greeley
Greeley
(ireeley
Greeley
Ft. Collins
Windsor
Work man- Vs, urtr
Kathryn
Greeley
do not recommend a Work Session. I recommend approval of these Renewals.
Sean Conway
Steve Moreno
Barbara Kirkmeyer
Mike Freeman
.Julie Co/ad
Approve Request
BOCC lgenda Work Session
Pass -Around Memorandum; July 26, 201 (TE3D)
Page 1
CONTRACT AGREEMENT AMENDMENT BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND PATRICIA AND DENNIS MARONEK (NON -CORE)
This Agreement Amendment, made and entered into /I C day of June 2016, 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 Patricia and Dennis Maronek, 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. 2014-2484 approved on August 11, 2014.
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, 2015.
The Original Agreement was renewed for the term of July 1, 2015 -June 30, 2016. The
Agreement Amendment is identified by the Weld County Clerk to the Board of County
Commissioners as document No. 2015-2707approved on August 10, 2015.
• 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:
Weld County Clerk to the Board
B
eputy Clerk to the Board
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
Mike Freeman, Chair AUG 2 2 2016
CONTRACTOR:
atricia and Dennis Maronek
929 56th Avenue
reeley, CO 80634
(970) 775-0064
By:
Date:
By:
Patricia Maronek
AEG
Dennis Maronek
Date: �- lc
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MEMORANDUM
DATE: August 7, 2014
TO: Douglas Rademacher, Chair, Board of County 9gn issioners
FROM: Judy A. Griego, Director, Human
RE: Respite Agreements between the Weld County Department
of Human Services and Various Providers for Placement on
the Consent Agenda
Enclosed for Board approval are Respite Agreements between the Department and Various
Providers. The template for this agreement was approved by the Board July 15, 2014, for
placement on the Consent Agenda.
The major provisions for these Agreements are as follows:
No.
Provider
Term
Rate
1
Aragon, Susan
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
2
Brown, Rachel
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
3
Maronek, Patricia
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
4
Miller, Pamela
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
5
Ripka, Gary
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
6
Rouse, Megan
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
7
Tauber, Nicole
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
8
Lee, Kimberly and
Willert, Melody
July 1, 2014 — June 30, 2015
$16.75 per each four hour
Period. Max. $67.00 per
month for 16 hours
If you have any questions, give me a call at extension 6510.
2014-2484
at list) (s/r)
q�ay
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, SUSAN ARAGON
THIS AGREEMENT is made and entered into this 11y of/14 2014, 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 Susan Aragon, whose address is 155
Hawthorne Avenue, Johnstown, Colorado 80534, 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.
Page 1 of 10
.0701
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 Department. 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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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:
1. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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. The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) additional one
(I) 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 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.
4. 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
parties. This Agreement shall he binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
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.
II. In the event of a dispute between County and Care Provider, concerning this
Agreement, the parties agree that each party shall he responsible for the payment of
attorney fees and/or legal costs incurred by or on its own behalf.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTF T:::
,LuwfJ J. dO4
Weld County Clerk to the Board
By:
By:
WELD COUNTY D,EPA M ENT
BOARD OF COUNTY COMMISSIONERS
WELD COUNT COLORADO
�r�n �APN Ate '
Douglds Rademach r, Chair
SUSAN ARAGON
By:
AUG 1 1 2014
)11444
Susan
S
Page 7 of 10
ao1y- av1y
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 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 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 8 of 10
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 9 of 10
EXHIBIT B
PAYMENT SCHEDULE
I. 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, 2015.
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 10 of 10
COLORADO AUTOMOBILE INSURANCE IDENTIFICATION CARD
METROPOLITAN CASUALTY INSURANCE
COMPANY
POLICY NUMBER
1134231250
EFFECTIVE DATE EXPIRATION DATE
07/09/2014 07/09/2015
SUSAN J ARAGON
155 HAWTHORNE AVE
JOHNSTOWN CO 80534
YEAR MAKE VEHICLE IDENTIFICATION NUMBER
2003 CHEVROLET 1GNDT13S032335450
COVERAGE PROVIDED MEETS THE MINIMUM PRESCRIBED BY
LAW.
MPL 1066-005 Printed in U.S.A. 0899
COLORADO AUTOMOBILE INS
RANCE IDENTIFICATION CARD
METROPOLITAN CAtUALTYINSURANCE
COMPANY
POLICY NUMBER EFFECTIVE BATE EXPIRATION DATE
1134231250 07/09/2013 07/09/2014
SUSAN J ARAGON
155 HAWTHORNE AVE
JOHNSTOWN CO 80534
YEAR MAKE : VEHICLE IDENTIFICATION NUMBER
2003 CHEVROLET 1GNDT135032335450
COVERAGE PROVIDED MEETS THE MINIMUM PRESCRIBED BY
LAW.
MPL1066-005 Printed in U.S.A. 0899
KEEP THIS CARD IN YOUR MOTOR VEHICLE AT ALL TIMES
IMPORTANT TELEPHONE NUMBERS
CLAIMS
TO REPORT A CLAIM, CALL TOLL FREE 800-854-6011
IN CANADA, REFER TO THE CLAIMS DIRECTORY.
CUSTOMER SERVICE - -
TO MAKE A CHANGE TO YOUR POLICY, OR IF YOU HAVE
ANY QUESTIONS, CALL 800-231-8411
MONDAY - FRIDAY
8:00 AM TO 11:00 PM, ET
SATURDAY, 9:00 AM TO 5:00 PM, ET
KEEP THIS CARD IN YOUR MOTOR VEHICLE AT ALL TIMES
IMPORTANT TELEPHONE NUMBER
CLAIMS
TOREPORT A CLAIM, CALL TOLL FREE 800-854-6011
CANADA, REFER
INTO THE CLAIMS DIRECTORY.
CUSTOMER SERVICE ""'
TO MAKE A CHANGE TO YOUR ANY QUESTIONS, CALL 800-231-' OR IF YOU HAVE
8411
MONDAY - FRIDAY
8:00 AM TO 11:00 PM. ET
SATURDAY, 9:00 AM TO 5:00 PM, ET
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY F PERJUR that: S 4 rasp A/
performing (type of work) 'f'
Social Security or Federdl Employer dentiff t n
Address: /SS
is an independent contractor (IC) and is not an employee of the following policyholder (PH):
Address: Policy H Phone:
Phone: S
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
me the following criteria:
IC 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�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);
IC PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;
ICZQ 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 &I, 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 Y8/I 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 541— 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 HEISHE:
• 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.
n
ndepeContractor/ Contractractor' ignature
STATE OF COLORADO, COUNTY OF1�(tt/J!j'
scribed and swgsn-before me by C . i (It fir R 90 );
Title
AL A- h' iS OW
NOTARY PUBLIC
t/'1
ki(R /�g/))Jf)`7v.C�
Acceptance of the Independ n ontractor named on tln/form does not change any party's res
individuals or organizations hired or contracted by the Independent Contractor are not covert
specified on this form will be charged premium for coverage of those individuals or organizatio
CERTIFICATION BY BUSINESS
I certify that I am authorized by the business listed above to state that all of the
understand that if the above person does not qualify for independent contractor
Social Security #
this/iv _ day of (loft(
Commission expires: Or l 1 r1 7
onsibili ' under the Workers' Compensation Act. If
policyholder
y
er fl
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 2O134O21741
MY COMMISSION EXPIRES
APRIL 3, 2O17
information on this form is true an• accurate. I
status, the proper premium can be assessed.
Signature
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by
NOTARY PUBLIC
Title
this day of
Commission expires:
Page 2 of 2
ZAUCCIF007 R-02-06
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, RACHEL BROWN
THIS AGREEMENT is made and entered into this 1/y 2014, 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 Rachel Brown, whose address is 2809
West E Street, Greeley, Colorado 80631, 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.
Page 1 of 10
ajyy- a4'15/
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 Department. 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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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. The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) 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 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.
4. 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
Page 5of10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
parties. This Agreement shall be binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
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.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTEST:
Weld County Clerk to the Board
By:
Deputy CIerlGCo the Board
VED AS TO FORM:
inty Attorney
By:
WELD CO . TY DEP • R ENT
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
demacher, Chair
AUG 1 1 2014
RACHEL BROWN
By: add au
Rachel Brown
Page 7 of 10
0,9D/V-42V89
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 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 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 8 of 10
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
10`h 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 9 of 10
EXHIBIT B
PAYMENT SCHEDULE
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, 2015.
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 10 of 10
COLORADO
INSURANCE CARD
INSURE" BROWN, RACHEL MULL
VOL
POLICY NUMBER 169 2559•E21.06A EFFECTIVE
YR 2009 MAKE FOREST RP/ MAY 212014 TO MAY 212015
MODEL ROCKWOOD VIN 4X4C FM4419 D277526
AGENT RICK WALLACE INS AGENCY INC 25178
PHONE (970)856-6237 NAIC
INSURANCE DOES NOT LIABILITY
L500
INSURED
SEE REVE RSE SIDE FOR ADDITIONAL COVERAGE INFORM 4110N
COLORADO
INSURANCE CARD
BROWN, RACHEL
MULL
VOL
POLICY NUMBER 167 6179-E21.06A EFFECTIVE
YR 1997 MAKE PONTIAC MAY 21 2014 TO NOV 21 2014
MODEL GRAND PRIX VIN 102WJ52K8VF226539
AGENT RICK WALLACE WS AGENCY INC
PHONE (970)3564237 NAIC 25178
THE COVERAGE PROVIDED BY THE POLICY MEETS THE
MINIMUM LIABILITY UNITS PRESCRIBED BY LAW.
A BODILY INJURY/PROPERTY DAMAGE LIABILITY
H, U1.250
INSURED
SEE REVERSE SIDE FOR ADDITIONAL COVERAGE INFORMATION
COLORADO
INSURANCE CARD
BROWN RACHEL-�'
P0UCY
YR NUMBER 0605491•C30.06G MUTE
MDDE9957/ UAKE TOYOTA EFFECTIVE VOL
A(VEN 7- �K WALLACE INS AO wry JT9VD12EXSOOp TO SEP 392019
PHONE l
THE cOVERACE PROVIDED BY }1566BBJ-11B237 NAIC ENC Y 51 6528
78
OMNIMA U LL NC UN; LIMITS
DAMAGE POLICY
LIB Y MEETS THE
MD URY/P MG I
U500 DEDUCT COL ORICOMPRONENSIV AOE LIABILITY
SEEREYfRSE SIDE FOR A001)10N41. CUVERAGF INf0RMAR0N
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY OF PERJURY that: (name and trade name) F4Lhv-I fj/ALL ,1
performing (type of work) 2ec i (C
Social Security or Federal Employer Identification # 472C- C& - y(vv z
Address: t Sccr Cc` r- S f E 5 !` Phone;q 94/Or.0 7 3 7 _
is an ind endent contractor (IC) and is not an employee of the following policyholder (PH): (tie/ d c r f
Address:: -) Policy /4 Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
meepthpIhe following criteria:
.YIC t+' PH. 1. 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 1-" 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);
IC 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 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);
ICS! 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 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 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.
Independent Contractor Signature
STATE OF COLORADO, COUNTY QF
Subscribedudsaorn before me ,by_
onnp/f(
NOTARY PUBLIC
Title Social Security #
this 2`hlhday of
Commission expires:
Acceptance of the Independent Contractor named on this form does not change any party's responsibility Roder the Workers' Compensation Act. If
individuals or organizations hired or contracted by the Independent Contractor are not covered by other workers' corn • 'nation Insurane th .olieybolder
specified on this form will be charged premium for coverage of those individuals or organizations.
CERTIFICATION BY BUSINESS
I certify that 1 am authorized by the business listed above to state that all of the information
understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed.
RHIAIN ON VANDER
Stall of Colorado
Notary ID 20144014340
ommitalon E ' Ires A 2 2018
Signature
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by this day of
Title
NOTARY PUBLIC
Commission expires:
Page 2 of 2
ZAUCCIF007 R-02-06
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, PATRICIA MARONEK
11
THIS AGREEMENT is made and entered into this/l day of4, 2014, 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 Patricia Maronek, whose address is 2929
56th 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.
Page 1 of 10
aoiy- a fcP9
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 Department. 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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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:
I . The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) additional one
(I ) 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 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.
4. 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
parties. This Agreement shall be binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
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.
II. 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.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTEST:
serdivti
Weld County Clerk to the Board
By:
fly ttorncy
o the Board
WELD CO. TY DE ART NT
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
emacher, Chair
AUG 1 1 2014
PATRICIA MARONEK
By.
Patricia Maronek
Page 7 of 10
an/e/- GS/S9
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 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 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 8 of 10
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 9 of 10
EXHIBIT B
PAYMENT SCHEDULE
t. 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, 2015.
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 10 of 10
DeArk\ S 3 Pr-i-r; c) (p (Per
4s urance_
INSURANCE IDENTIMCA71OM CARD • C.l.ndo
Porky Numbr. 7591616)-1 IwC Number: 77760
Effective Da.: 01/15/2014 E.p&ation Date: 0705/1017
Inver. Dorm** * CawaR9 turn, Co 1-900d763561
P.O.Oo. 6601 C1r.Nnd. ON 44101
Named lnaa.d(.k
0O11115 MAPONEX
PATRICIA IAMOOM
Your Nor¢
POPA INC 1-)0367)-0700
P01OA 101
LON0MONT, Co 60501
Veer MAE Model vin
1996 Oak} Ram 1500 317NE1675XM506661
7007 0.d9. Caravan IDWP75P111I69973
1006 Mendel 6twtM f1DN56076U301719
TIM ant must he red in the parni.n .t a in dr Slide el the
named Mewed Mahan that the named insured N operating • Skis.
7Mb policy provides the minimum Surma pr.aai0.db/ In.
•
1911 on 11 P 34
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY OF PERJUR h(�_(name and trade name) __a_1�lf
performing (type of work) (j;7L1IC L[
Social Security or Federal Employer ldenti -cation # - 7
Address: J4 5Q, nCUP (--ereP t:Li ('r SS hone:Th_ - 1]5=Llf)tci(
is an independent contractor (IC) and is not an 'employee 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
lie following criteria:
IC,..L1 1 PH. __ J. 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);
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);
I¢ Ji,� 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;
PH 5. The business DOES NOT provide more than minimal training for the individual;
ICPH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
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);
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;
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 distinctA — — — — — — — —
i GARRETT CARMACK
CERTIFICATION BY INDEPENDENT CONTRACTOR
THE INDEPENDENT CONTRACTOR UNDERSTANDS THAT HEISHE;
• WILL NOT BE ENTITLED TO ANY WORKERS' COMPENSATION BENEFITS IN THE EVENT OF INJURY,
•,-. , 'T•: Y IF r_' ilr 1 E , .• ETAX •NALL NE!WHL '_;! •'MIN R4 ES FOR THE
BU E
• I;i
nary ruanc
State of Colorado
Notary ID 20124066903
My Commission Expires Oct 17, 2016
0
IN RAN EF•R uP.i 'STr TH S. HIRES.
if
Independent Contrac rr Signature Ti le Social Security #
STATE OF COLORADO, COUNTY OF Uji `t CI
Subscribed and swum before me by V 4 r .c er :. t c t_
Commission expires: t,-- it 7/1 L^ 4'
NOTARY PUBLIC
Acceptance of the Independent Counselor named on this form does not chant say party's responsibility tinder the Worker,' Compensation Act. If
individeals or organizations hired or toolrarted by the Independent Contractor are not covered by other workers' compensation insurance, the policyholder
specified on this form will be charged premium for coverage of those individuals or organizations.
this The. day of "5-c,
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:
Page 2 of 2
ZAUCCIF007 R-02-06
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, PAMELA MILLER
ll
THIS AGREEMENT is made and entered into this /� lay otr7? 2014, 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 Pamela Miller, whose address is 5151
West 29th Street, Unit 2004, 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.
Page 1 of 10
aor�/ 4x/89
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 Department. 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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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
cam while providing services under this Agreement or within five (5) hours prior to
the provision of said services.
16. 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:
1. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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:
I. The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) 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 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.
4. 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
parties. This Agreement shall be binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
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.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTEST:
dacktv
Weld County Clerk to the Board
By:
WELD COUNTY DE ART NT
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
DouglatIZademacher, Chair
AUG 1 1 2014
PAMELA MILLER
By:
Pamela Miller
Page 7 of 10
owl- x'89
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 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 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 8of10
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 9 of 10
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, 2015.
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 10of10
SMtetvm COLORADO
INSURANCE CARD
INSURED MILLER, PAM MUTL
VOL
POLICY NUMBER 162O0A•80240E EFFECTIVE
YR 2006 MAKE NISSAN MAR WI 2014 TO AUG022114
MODEL XTERRA YIN O111ANOBW00C950E08
AGENT LARSON INS AGENCY MC
PHONE (070 4700 MC 25170
TLOHN� COY ED pBEY 1HE gP�OOLICC�Y LAW.
THE
A BBODIIL J PRIMUM OPERTY DAMAGE UABIUTY
O 250 DEDUCT LUSIONCOMPREHENSIVE
H, U
SEE RASE MOE WI ADDITIONAL COYEIAGE IMEORNATION
Declaration of Independent Contractor Status Form
We certify UNDER PENALTX OF PERJURY ' that: (name prnd trade naive Rcty k.Cia2 , YYl.tller
performing (type of work) lC-tS f te._ ear C'- 4 -or `I'Oky deal& ten
Social Security or Fede I Empployer Identtifi tion # 5 4
Address: 515) (1) � j " St liAmo4 (,tEeley 1) ti3 Phone:
is an independent contractor (IC) and is not an employee 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 the following criteria:
IC PH._ 1. 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);
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);
IC_ 9 PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;
IC p .,_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 DTA.. PH 5. The business DOES NOT provide more than minimal training for the individual;
IC0ppp„_PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
IC 9W..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 Q t PH_8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade
ERA,
,yy� or business name of the individual;
IC f . 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 ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING SERVICES FOR THE
BUSINESS.
• IS UIRED TO PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES.
Independent Contractor Signature I Title Social Security #
STATE OF COLORADO, CO OF CS
scribed and ssyom,bejbre
NOTARY PUBLIC
this '• •ay of
Commission expires:
Acceptance of the Independent Contractor named on this form does not change any party's responsibility under the Workers' Compensation Act. If
individuals or organizations hired or contracted by the Independent Contractor are not covered by other wrlsgrs,Eompeggatijn ilsurancj the policyholder
specified on this form will be charged premium for coverage of those individuals or organizations. JANICE L PEREKRESTENKO
CERTIFICATION BY BUSINESS
I certify that I am authorized by the business listed above to state that all of the informatio
understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed.
Notary Public
State of Colorado
Notary ID 20081032815
Commission Expges Aup14 2016
Signature
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by
NOTARY PUBLIC
Title
this day of
Commission expires:
Page 2 of 2
ZAUCCIF007 it -02-06
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY.
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, GARY RIPKA
THIS AGREEMENT is made and entered into this!! ay of/412014, 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 Gary Ripka, whose address is 1026 23rd
Street Road, Greeley, Colorado 80631, 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.
Page 1 of 10
aorY- '4'J7
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 Department. 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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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:
1. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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:
I . The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) 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 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.
4. 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
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 lees and/or legal costs incurred by or on its own behalf.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTEST:
Weld County Clerk to the Board
By:
WELD COUNTY DEPARTME
GARY RIPKA
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
By:
EXHIBIT A
Radema her, hair
AUG 1 1 Z014
ary Ripka
Page 7 of II
020/5-CQ5189
EXHIBIT A
SCOPE OF SERVICES
E 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 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 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 8 of 10
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 9 of 10
EXHIBIT B
PAYMENT SCHEDULE
t. 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, 2015.
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 10 of 10
INSURANCE IDENTIFICATION Policy CARD Colorado
Number; 85598182.5
Effettiva 0ate: 07tpgRpl4 NAIL Number; 37834
Insurer: Progressive Prefened Insurance CoEej--800417 Date: 01
P.O. Box 6807 Cleveand. 6 5581 N9R01 S
Named Innnedlsl: and. OH a4I01
GARY RIPIW
Your Agent.
SECUkiTYpisu •j I -97O.351.7837
8219 W HITN51'5TE A '
GREEIEY. C380634
Year Make
2003 Volkswagen Model
Passat YIN
WYWPD63643P035591
This card must be carried possession
named insured in [Ste Possession of s in the M all times that the named i wattle of the
This insured is operating a while.
Policy provides the minimum insurance prescribed by law,
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY OF PERJURY that: (name and trade name)
performing (type of work)
Social Security or Federal Employer Identification #
Address: Phone: is an independent contractor (IC) and is not an employee
of the following policyholder (PH):
Address : Policy 4 Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
meet the following criteria:
IC t 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 04. 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);
IC Q'2 PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;
IC 4 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 fit PH S. The business DOES NOT provide more than minimal training for the individual,
IC fat PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
IC (j4 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 i}( 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 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 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
jiIRES.
Indepen ' e ontractor
COUNTY OF
Subscribed and sworn before me by
i2tfri / hxA' 511 -/5 - $o y/
iggnature Title Social Security # STATE OF COLORADO,
this 3C4!` day ofTUC'e... 2 C�f iy
7ommission expires: FC.1O 21. 2c
NOTARY PLJBI.IC
BRANDY GRIEGO
rsy ,14,'T
STATE OF COLORADO
NOTARY ID 20144006362
MY CtOA*IlSSlOl EXPIRES FEBRUARY 27.2011
Acceptance of the Independent Contractor named on his form doer not change any parry s responsibility under the Workers' Compensation Act. If
individuals or organizations hired or contracted by the Codependent Contractor are not covered by other workers' compensation insurance, the policyholder
specified on this form will be charged premium for coverage of those individuate or organizations.
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
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by this day of
Title
Commission expires:
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, MEGAN ROUSE
THIS AGREEMENT is made and entered into this/- ay o 2014, by and between
the Board of County Commissioners of the County of Weld, State of Co orado, on behalf of the
Weld County Department of Human Services, whose address is 1150 "0" Street, Greeley,
Colorado 80631, hereinafter referred to as "County", and Megan Rouse, whose address is 3911
West 14th Street Road, 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:
I. 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.
Page 1 of 10
0719/5/-0798
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 Department. 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 -I 33.
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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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:
1. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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:
I . The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) additional one
( I ) 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 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.
4. 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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. sec,,
as applicable now or hereafter amended.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
parties. This Agreement shall be binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
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.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTEST:
Wedtri ti xim'44.
Weld County Clerk to the Board
By:
WELD COUNTY DEPART
BOARD OF COUNTY COMMISSIONERS
ELD COUN Y, COLORADO
d eL-ory4rik.V—
ouglas.demac er, Chair
MEGAN ROUSE
By:
AUG 1 1 2014
Page 7 of 10
O,7O/1- O? 9J'7
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 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 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 8of10
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
I0'h 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 9of10
EXHIBIT B
PAYMENT SCHEDULE
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, 2015.
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 10 of 10
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06/30/2014 12:41 19703306121
WELD SCHOOLS CU
Declaration of Independent Contractor Status Form
We certify UNDER PENALTY OF PERJURY that: (name and trade name) 1y ' Rouse.,
PAGE 02/02
performing (type of work) fiic C0.Ff
Social Security or Federal Employer Identification #
Address; Phone:
is an independent contractor (IC) and is not an employee of the following policyholder (PH):
Amass; Policy # Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
meet the following criteria:
iC ➢H. 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. ItPH_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);
IC � 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 ._I t PH^5. The business DOTS NOT provide more than minimal training for the individual;
IC H 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
������//]1 supplied);
IC wIt^ PH 7. The business DOES NOT dictate the time ofperformance (except that a completion schedule and a range of
agreeable work hours may be established);
IC IYAtPE7;_S. 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 MM'!-PH9. 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 OBUOATED TO PAY ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFOOf JUNG SERVl
BUSINESS.
• IS REQUIRED TO PROVIDE WORKERS' COMPENSATIONJNSURANCE FOR ALL WORKERS THAT HE/SHE HIRES.
f(A_
Jndepcndnden ntractor Signature
STATE OF COLORADO, COUNTY O F
Subscribed and sworn a by,
NOT�UBLIC
lc apt
Sao-a3-a3c1
Title Social Security #
F this AO day of J7jt/
Commission expires: O.j�feRD/S
Acceptance of the Independent Contractor named an this fern does not dodge any party's rapoaiibmty ender dieWorker+' Ceapaasatloa Act. If
iadMduals or oriatnindof bird or manacled by the Independent Contractor are net covered by ether workers' compensation la urrom. the policyholder
specified an tbb form will be ehareed premium far woman of those Individuals or emanations.
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
STATE OP COLORADO, COUNTY OF
Subscribed and sworn before me by
Title
this day of
Commission expires;
NOTARY PUBLIC
Page 2 of 2
ZAUCCIFae7 R-02-46
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, NICOLE TAUBER
tt
THIS AGREEMENT is made and entered into this 1l day of 2014, by and between
the Board of County Commissioners of the County of Weld, State of Co orado, 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 Nicole Tauber, whose address is 3919
West 22nd Street, 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.
Page 1 of 10
atr51- acn
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 Department. 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 10
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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
Page 3 of 10
specifically agreed to in writing in advance by County.
11. Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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:
1. 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
Page 4 of 10
negligent acts or omissions of Care Provider while performing duties described in
this Agreement.
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:
I . The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (I ) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) 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 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.
4. 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
Page 5 of 10
that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
5. 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.
6. 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.
7. 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.
8. This Agreement, together with Exhibits A, B, and C, 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
Page 6 of 10
2014-06-30 11:10
Wells Fargo 970 330 1004 » 970 346 7667 P 2/2
parties. This Agreement shall be binding upon the parties hereto, their successors,
heirs, legal representatives, and assigns. Neither County nor Care Provider may
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.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
A E T:
sc .:es:ei
Weld County Clerk to the Board
By:
WELD COUNTY DEP.�,RT
By:
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO n /
Rademacher, Chair
AUG 1 12014
NICOLE USER
By:
icole auber
Page 7of10
&ciV-a '8'
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 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 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 8 of 10
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
10°i 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 9 of 10
EXHIBIT B
PAYMENT SCHEDULE
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, 2015.
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 10 of 10
Galen, Colorado Insurance Identification Card
gel cc . COtn 1-800-841-3000
GEPOI BOX50909U
GENERAL0090 SDIEGO,
AN CE 7NY
CA 92150-9090
Policy Number Effective Data Expiration Date
4154463311 02 -07 -JA 08-07-14
Year Make Model Vehicle ID No.
2011 TOYOTA SIENNA LE 5TDKK3DC1B5062967
Mowed:
NICOLE MARIE TAUBER
JON MICHAEL WRIGHT
3919 w 22ND ST
APT 1107
ISR€ d,Eilf,yetE0or i4,a3Bdfe ez ce policy which complies with
the minimum Lability lirmu prescnbed by law.
Important Information
Here are your Policy Identification Cards. Please destroy
your old cards when the new cards become effective.
Due to space limitations on the ID card, only the Named Insured and
the Co -Insured are listed. For a full list of drivers covered under this
policy, please reference the Drivers section of your Declarations
Page, which Is Included with your Insurance packet.
Please notify us promptly of any change in your address to be sure
you receive all important policy documents. Prompt notification will
enable us to service you better.
Your policy Is recorded under the name and policy number shown
on the card.
If you would like additional ID cards, you can go online to
gelco.com or call us at 1-800.841-3000.
What to do at the time of an accident
• Do not admit fault
• Do not reveal the Ilmlts of your liability coverage to anyone.
• Exchange contact Information; get year, make, model, plate
number, Insurance carder and policy number of all involved.
Also, identify witnesses and collectcontact Information.
• Contact the police or 911 If applicable.
• Contact GEICO by calling 14004414000 a visit
gelco.com to report the accident
u4CO pawl
GEICO. Colorado Insurance Identification card
geico.cofr 1-800-841-3000 Here
GEICO GENERAL INSURANCE COMPANY
PO BOX 5090 SAN: .D -EC -0, CA 92150-9090 your
Policy Number Effective Data Expiration Data DUB
-15-=53311 C2-07-14. C& -07-1L �
Year Make Modal Vehicle ID No.
2008 NISSAN ALT:MA 1N-AL21E88NSC70o9 polio
Insured: Pegt
NICOLE MARIE TAUBER Plea
JON MICHAEL =RIGHT
3919 22NC ST vOUl
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L15--53311 C" -C7 -1L
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2011 TOYOTA Model
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2014-06-30 11:10 Wells Fargo
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A/n: T61 ihj
Declaration of Independent Contractor Status Form
W c certify UNDER PENALTY F PERBJ,RY that: (name and trade name) k C� \ 1 0.l.^*' e r
performing (type of work) \S cs'\J
Social Secu4 .,Qr F,e Icral 1E',lo cr Idcn if cation N �') �, - L'; - ) \0 ct 3
Address: J"l i ` U72 S'kC Phone: Clio. 4-10c). S rill
is an independent contractor (IC) and is not an employee of the following policyholder (PH):
Address: Policy N
Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs service:
meet t e following criteria:
1C� PH. 1. 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);
IC1/1-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);
IC PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate:
IC /I Ili 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:
C PH S. The business DOES NOT provide more than minimal training for the individual;
ICPH�6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
ICPH7, The business DOES NOT dictate the time of performance (except that a completion schedule and a range of
agreeable work hours may be established);
PH S. 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 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 ENYRLED 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 TQ PRQVIDF.YI(( KERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES.
kklb-e/\_ RP,s f It9 52-1-4 — 1-1 73- 2117G 3
lndeper ent Contractor Sinai \ _a Title Social Security N
CO OF V \l'`i Jt
this,c__,„--,-... of
STA1tOF COLO
sw
NOTARY PUBLIC
Acceptance of the Independent Contractor small as fhb foes don not th ate any party. ref
Individualsor ortansntkts bind or contracted by Ire mot rid Contractor are not coven
i• fo specified on Ibrm will be charted premium dune for coverage of e MIAMI'S ororywiatia
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.
Commission expires: 4/ ife.
nvillalty U. ate tlforrrtarlfoa Act If
h by other war' meya' the poacyh Ida
STATE OF COLORADO
NOTARY ID 2014401:.000
MY COMMISSION EXPIRES APRIL 14, 2018
Signature
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by
Title
NOTARY PUBLIC
this day of
Commission expires:
Page 2 of 2
AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY,
ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND
RESPITE CARE PROVIDER, KIMBERLY LEE AND MELODY WILLERT
THIS AGREEMENT is made and entered into this//- ay oAO, 2014, 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 Kimberly Lee and Melody Willert,
whose address is 219 North 4th Street, La Salle, Colorado 80645, 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.
Page 1 of 11
aary-ayPi
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 Department. 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
Page 2 of 11
cause or default.
8. Care Provider certifies that he/she is in compliance with the provisions of the
Colorado Revised Statutes (C.R.S.) 8-17.5-101, et. seq., and hereby affirms under
penalty of perjury that he/she is a citizen of the United States or is otherwise
lawfully present in the United States. Care Provider agrees to produce one or more
forms or identification as required by the Department, in order to affirm his/her
legal status. Care Provider further affirms that he/she is not an illegal alien. If Care
Provider fails to comply with any of the above requirements, the Department may
terminate this Agreement for breach and Care Provider shall be liable for actual and
consequential damages to the Department.
9. 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.
10. 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;
Page 3 of 11
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.
1 I . Care Provider shall indemnify, defend and hold harmless Weld County, the Board
of County Commissioners of Weld County, its employees, volunteers and agents
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.
12. 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.
13. 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.
14. Care Provider shall not have authorization, express or implied, to bind County to
any agreement, liability or understanding.
15. 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.
16. 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.
Page 4 of 11
COUNTY'S RIGHTS AND RESPONSIBILITIES:
1. 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.
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:
l . The term of this Agreement shall commence on the date of County's execution of
this Agreement and shall continue for a period of one (1) year. This Agreement may
be renewed by the mutual agreement of the parties for up to three (3) 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 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.
Page 5 of II
4. 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.
5. 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.
6. 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.
7. 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
Page 6 of 11
any cooperative agreement, and the extension, continuation, renewal, amendment,
or modification of an Federal contract, loan, grant, or cooperative agreement.
8. This Agreement, together with Exhibits A, B, and C, 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
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
Page 7 of 11
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month, and year first above written.
ATTEST:
Weld County Clerk to the Board
By:
Deputy Clerk
Attorney
WELD CO TY DEP; RT
By:
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
DawicitIC
demacher, Chair
AUG 1 1 2014
KIMBERLY EE
By:
Kimberly Lee
MELODY WILLERT
By: meN-s-4)
Melody W i ert
Page SofII
02D/4' aV811
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 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 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 9 of 11
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 10 of 11
EXHIBIT B
PAYMENT SCHEDULE
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, 2015.
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 11 of 11
Your Insurance Coverage Summary
PROOF OF INSURANCE CARDS ATTACHED BELOW
Please see your bill for current balance and payment options.
April 8, 2014
+0003402 169-305 000000340260053622
WILLERT, MELODY
219 N 4TH ST
LA SALLE CO 80645-3216
AMERICAN FAMILY
INSURANCE
Thank you for continuing to insure your vehicle with American Family Mutual Insurance Company.
Your business is important to us. Please review your coverages and limits to make sure they fit your
current needs. If you have any questions or corrections, please contact me.
Ken Sewald
Phone: (303) 451-7174
E-mail: ksewald@amfam.com
policy Number Vehicle Description
0744-3008-10-65-FPPA-CO 2006 CHRYSLER TOWN & COUNTRY
Renewal Coverage Tenn
5-1-2014 to 11-1-2014
Discounts Applied to Your Premium
• Air Bag • Multiple Vehicle
• Auto & Home Premium Advantage
• 50+ Premium Plan
Your Discounts Saved You: $262.30
Please see reverse side for addl tLinal information concerning your policy.
IMPORTANT: Some state laws require that you be able to show the proof of insurance cards provided
below.
PLACL tN YOUR VEHICLE SAVE [OH FUTURE HEFFRENCE
AMERICAN FAMILY MUTUAL INSURANCE COMPANY AMERICAN FAMILY MUTUAL NSURANCE COMPANY
6000 American Pkwy • Madison, WI 53783
CLAIMS:1-800-MYAMFAM (1.800-692.6326)
COLORADO MOTOR VEHICLE
PROOF OF INSURANCE CARD
Polcy No: 07443008 -lo -65-5 FPPA-CO
Effective Date: 5-1-2014 Expkatlon Date: 11-1-2014
2006 CHRY TWC VIN: 2A4GT54L66R738504
Coverages: BIPDUM UIM ME COMP COLL ERS
WILLERT, MELODY
219N 4TH ST
LA SALLE CO 80645-3216
Agent: KenSewald
Agent Phone: (303)451-7174
This card must be carried in the insured motor vehicle
for production upon demand. 1-
6000 American Pkwy • Madison, WI 53783
CLAIMS: 1.600-MYAMFAM (1-800-692-6326)
COLORADO MOTOR VEHICLE
PROOF OF INSURANCE CARD
Policy No: 07443008-10.65-FPPA-CO
Effective Data: 5-1-2014 Expiration Date: 11-1-2014
2006 CHRY TWC VIN: 2A4GT54L66R738504
Coverages: BIRD UM UIM ME COMP COLL ERS
WILLERT, MELODY
219 N 4TH ST
LA SALLE CO 80645-3216
Agent Ken Sewald
Agent Phone: (303)451-7174
n_ Use this card with your application for
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Declaration of Independent Contractor Status Form
We certify UNDER PENALfl OFF P
performing (type of work) KK--
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is an independent contractor (IC) and is not an amp oyee of the fo lowing policyholder (PH):
Address: Policy if Phone:
We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services
meet tpe following criteria:
IC 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);
ICt 'PH 2. The business DOES NOT establish a quality standard for the indivimsl (except that the business may provide
plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to bow work
like
will be performed);
IC PH_3. The business DOES NOT pry the individual a salary a an hearty rate Stead 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 , Pl _5. The business DOES NOT provide more Man minimal training for the individual;
\YY' PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be
supplied);
IC `kiVPN_.._7. The business DOES NOT dictate the time ofperfamance (except that a completion schedule and a urge of
agreeable work boors may be established);
IC ,,' PH_8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade
or business name of dee individual;
IC ��PH 9. The business DOES NOT combine the business operations m any way with the individual's business operations
instead of maintaining all such operations separately and distinctly.
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CERTIFICATION BY INDEPENDENT CONTRACTOR
TIE INDEPENDENT CONTRACTOR IS DERSTAi45 THAT Kee
• WLLNOT BE WILED TO ANY vanity COMPENSATION Bairn MINE EMFJR CF MIRY.
• IS OBLIGATED TO PAY ALL FEDERN. AIM L. -W NEY EASe MMIE PERFORII5Ni SEMSE3 FOR TM:
BUSINESS.
• ISREQUIRED TO PROVIDE N9RNER6 CWBaAT10N NSURANCE FOR ALL YYORIffRB THAT HF.ISNE MMES.
Ind.p.rkan Contractor Signature Tide MS . Social Security N 520 33.S STATE OF COLORADO, CO OF elf
Subscribed rgpwoo ber me by 1(•Y^ tlC this 47_day of IvLI 2n cti
✓(t/ Commission expires: _4{1y f it
NOTARY PUBLIC ( —
Artesian of the l.arpor+«e.ae.n...a.S or sir In Moo not =age may pora'a •qa• r w. Ss Warts& e.;..rrF.. Ace. a ANDREW LUCE RU .. .�_.. .—1
ytlµakr _prosaic Wrad s contracted by its idopedoa Conte ies art sit rased by Ober workers' saapaaaauaa+�rra, die poitcyneyARy piI BLIC
=tee rub tom mar er.rd premium a =saw of time lamM4atr or radoars STATE OF COLORADL.
NOTARY ID $OOB4012634
jCERTIFICATION BY BUSINESS MY COMMISSION E%PIKES APRIL 14, 01; �m
I certify that 1 am authorized by the business listed above to state that ad of the information on this form Is true and accurate. I
understand that if the above person does not qualify for independent contractor coma the proper pentium can be assessed.
Signature Title
STATE OF COLORADO, COUNTY OF
Subscribed and sworn before me by this day of
NOTARY PUBLIC
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Commission expires:
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