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Home My WebLink About20142913.tiffMEMORANDUM DATE: September 18, 2014 TO: Douglas Rademacher, Chair, Board of1Couty Cc mi)ioners FROM: Judy A. Griego, Director, Human RE: Respite Agreements between the We 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 Allen, Teresa July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 2 Buck, Jamie & Lynne July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 3 Miller, Linda July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 4 Tovar, Nyriah July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 5 Van Den Elzen, Dawn July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 6 Walker, Jennifer 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. 0.7✓\f-a 9-zi- (5- 2014-2913 \-A 1,0025 AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY, ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, TERESA ALLEN THIS AGREEMENT is made and entered into this 10thday of fune2014, 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 Teresa Allen, whose address is 10910 Turning Boulevard, #26, Longmont, Colorado 80504, 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 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. i 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 children) 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 5ofl0 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. ATTES. tt ' W/6k Weld County Clerk to the Board By: ty Att. rncy WELD COUNTY DEPART,ENT By: BOARD OF COUNTY COMMISSIONERS WELD COUNTY: C ORADO ouglas Rademacher, Chair SEP 2 2 2014 TERESA ALLEN % 4E By: Teresa Allen Page 7 of 10 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 . 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 (F1DOS). Page 10 of 10 ocZ Declaration of Independent Contractor Status Form We certify UNDER PENAL- OF PERJURY that: (mime antteude name) f C.r., C S A I � 'e performing (typo of work) T.P. , T e . r Social Security or Federal Employs den Address: JO /a 7"tlllls/Oj/Vet 'z 26 Loa e,gnl'PhumE 1Ze, 21 1 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 fix which the above individual performs s rviccs mutt following criteria: IC PH. I. The business DOES NOT require the individual to work ONLY for the business for whom services are performed V�/ ,.,,..'' (except that the individual may DECIDE to work only for the bitten for a definite period); IC�jn_2 The business DOES NOT establish a quality standard for the individual (extern that the business may provide plans and specifications regarding work but cameot oversee the actual work or instruct the individual as to how work will be perforated); IC P}I✓3. The business DOES NOT pay the individual a salary or m hourly rate instead eta fixed or eminent rate: IC 4. The business DOES NOT terminate the work or the service provided dating the coatmct period mime. the individual violates the terns of the contract or fails to produce a melt that meets the specifications of the contract; IC S PH 5. The business DOES NOT provide more than minimal training for the individual; IC-N.—PH6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipmentm ay be supplied), IC %( PH 7. The braises. DOES NOT dictate the time ofperformance (except tint a completion schedule sad a range of agreeable work bows may be established); IC )IS PH —S. The businees DOES NOT pay the individual personally instead of making payment or rh.rttg payable to the trade or business name of the individual; IC X PH9. The business DOES NOT combine the business operations in any way with the individual's business operations instead of maintaining all such operations sepeately and distinctly. CERTIFICATION BY INDEPENDENT CONTRACTOR j}IEINDEPENDENT CONTRACTORUNDERSTANDS THAT HEISHE • WIL. NOT BE ENTITLED TD ANY WORKERS' COIWINSAUON BENEFITS IN THE EVENT OF INJURY. • IS OBUDATED TO PAY ALL FEDERAL AND STATE NONE TALON ALL MONEY EARNED WHILE PERFORMING SERVICES FOR THE BUSINESS. • IS IRE_D TO PROVIDE WORKERS COWPENSATION INSURANCE FOR ALL WORKERS INATHEISHE HIRES. ..czost.k 410 37 7 -92- Title Social Security N STATE OF COLORADO, COUNTY OF rote gar Su ' .rl and sworn before yin by The'rQ M t l en {,cs .L NOTARY PUBBLI p C Aespteacc of the Iadepeedeet Contractor Bard oe this farm dos not change say party's respedbitty under the Worker: Cospe•eaau Act. If mdt4dush or ergeofutbns hired or coeiraotld by the ladepeadeta Cnatractor we rat wowed by Woe workers' step. ndma Warne" the policyholder specified ea this term will be charged premium ter wearer of ass IndIvIduala w urgaoltatlooe. .. thin jVNrday of .44.40<t• oozy Commission expires' Mane 31 ac,19 CERTIFICATION BY BUSINESS f certify [bath= um autwaized by the business listed above to state that all of the information on this form is true and accurate. I understand that it the above person does not qualify for independent contractor stains, the proper premium can be assessed. Signature STATE OF COLORADO, COUNTY OF _ Subscribed and sworn before me by Title this _day of Commission expires: NOTARY PUBLIC LCUISE A GEE NOhry Public -.tat 010101100 Mabry 1D 20144000443 My CommkawN Eiplres Mit 3.2014 Page 2of2 ZAUCt,I}u07 R.02 06 6EEE-Z9V-E0£ 8V:4T VIOZ/IZ/80 Z0/Z0 39tid 890 SaBd00S 9NI)i 7n/Tn �C*A statmFarm COLORADO INSURANCE CARD INSURED ALLEN,TEN68A MUTL VOL POUCY NUMBER 2050040.8144YA EFFECTNE YR 1088 MAKE OLDSMOBILE JUL1020T4 TO FE8142015 MOM BRAVADA VIN 1GHDTI5WTW2750902 AGENT GENE WATADA PHONE (393054-1504 NAIC 25170 WIEBC�LWEE�BAAIIILEEiPyR�OgVIDDgE BBYT EEPAUOM�P�OpBy EMAW THE AwB• MEDICALOlur sPIU PEIWY DAMAGE UAwsni O SYMENTS • 500DEEDDUCTCOuMP6� GIVE 101,13 SEE REVERSE RICE FOR ADDRIONN.CDVERAOE INFORMATION 89# S13d00S 9NIN 4££E-ZS4-£0£ 84:PI 4T0Z/TZ/80 AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY, ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, JAMIE BUCK AND LYNNE BUCK onna THIS AGREEMENT is made and entered into thisa day of, M4, 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 Jamie Buck and Lynne Buck, whose address is 6455 Chardonnay Street, #3, Evans, Colorado 80620, 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 11 x014 -a 13 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. 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: Page 4 of 11 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: 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 Page 5 of 11 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 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 Page 6 of 11 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. Al EST: f•adt4/A Weld County Clerk to the Board By: puty Clerk to the Board D AS rney BOARD OF COUNTY COMMISSIONERS LYNNE BUCK By: By: LDCaUNTY "• cRADO ademacher, Ch J ie Buck e Buck SEP 2 2 2014 Page 8 of 11 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. Completed and submitted the Declaration of Independent Contractor Status form. The form must be notartized f. Provided three (3) reference forms completed by non -relatives. g. Provided proof of current CPR and First Aid certifications. h. Completed and signed Confidentiality, Discipline and Mandated Reporter Policies. 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 II Declaration of Independent Contractor Status Form We certify UNDER PENALTY OF PERJURY that: (name and trade name) LL. . iLL-' J Qi?'1 ! performing (type of work) Re. p i i e. airt tiirosle-r- CD l�ld.Social Security or Federal Em loyer'dentification #4 -y3 -to` e- 52 3 3 - S-7/. 7 Address: 15 2.5— Setyt Ik>2ct CLr Le Phone: c' 70- ,314 770 ? q 7u 31/"'(2-/Z is an independent contractor (IC) and is not an employee of the following policyholder (PH): I (J 2.Co Address: I R) 2 S San j u a_J\ (1 C Policy # Phone: We also certify, by OUR initials W1{ERE APPLICABLE, that the above business for which the above individual performs services meet e 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 j7 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); PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate; 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; PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be supplied); JOIC PH 7. The business DOES NOT dictate the time of performance (except that a completion schedule and a range of `I agreeable work hours may be established); IC (#111'f 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; 00, '{CI1 fl 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 PERFO BUSINESS. • IS RE ED TO OVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HEISHE HI ' I4,4v✓,.) Q O4rOe'' tependent Contractor Signature ,fjTitle Social Security # ATE OF COLORADO, COUNTY OF ae d sworn before me byj,/irse.,1 f i1'I J ,8 j/ this _day of k , Commission expires: 2 ,D/p•/0 NCSTA` ''UBLIC Acceptance of the Independent Contractor named on this form does not change soy party's responsibility under the Workers' Compensation Act. U individuals or orgruiadons hired or contracted by the Independent Contractor are not covered by other workers' compensation insurance, the policyholder specified on tbis form will be charged premium for coverage of those individuals 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 undt stand that if the above person does not qualify for independent contractor status, the proper premium can be assessed. lure STATE OF COLORADO, COUNTY OF Subscr 4 a • sworn before me by NOT IC Title •S0T Fib' . e •tjmmission expires: ,� of lv • l5 daY (3f64#164142,12.1.1 / Page 2 of 2 2AUCCtF007 R-02-06 AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY, ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, LINDA MILLER TI11S AGREEMENT is made and entered into this?? day of �, 014, 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 Linda Miller, whose address is 2034 Birch Avenue, 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 temis 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 t of JO o�oi�� ,913 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 (1 6) 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. 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. 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 4of10 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 he 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 ( 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 he 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 Pages of 10 that any entity other than the undersigned parties receiving services or benefits under this Agreement shall bean 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 he 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 he 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 6ofi0 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: dattif4A) xii.0;g1 Weld County Clerk to the Board By: WELD COUNTY DEPART ►I ENT By: D puty Clerk to the Board go, Direc BOARD OF COUNTY COMMISSIONERS WELD COUNTY, i ' DO By: glas R. semacher, Chai SEP 2 2 2014 Linda Miller Page 7 of 10 A0 r114 -A9/3 EXHIBIT A SCOPE OF SERVICES I. 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 he 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 arc 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 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 l0ofl0 Declaration of Independent Contractor Status Form We certify UNDER PENALTY OF PERJURY that: (name and trade name) L U' ltitn1 i.i performing (type of work)-(-c��e, C '-i' -- Social Security or Fedcral Employer Identification # wig .pc.,O1 -7 L Address: �ti n`i 0 -�' ; (.i• 4.1 C.ii do 3, Phone: 30 :3i 35,1 I `{3 1 is an independent contractor (IC) and is not an employee of the following policyholder (PH): ---- Address: —`- Policy # — Phone: • We Iso certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services vm t following criteria: I 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); It Pl l 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); 14.; PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate; IC r 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 S. 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); ]C, 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 l7._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 /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. ERIN NEUFELD 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 OBLI ED TO PAY ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING SERVICES FOR THE BUSIN • IS R'• • R'_ r TO PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HEISHE HIRES. NOTARY PUBUC STATE OF COLORADO NOTARY ID 20124065823 MY COIIISSION EXPIRES OCTOBER 12, 2016 Independent Contractor Signature ,�r Title Social Security # STATE OF COLORADO, COUNTY OF ,1/U✓� Subscribed all sworn b fore jby - �_' ,� . lC this gday of 2b14 Commission expires: i Dl 12--1 Le NOTARY PUBLIC 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 workers' compensation insurance, the policyholder specified on this form will be charged premium for coverage of those individuals 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 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, NYRIAH TOVAR Anal THIS AGREEMENT is made and entered into this( day oI G ! 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 Nyriah Tovar, whose address is 1020 Cottonwood Drive, Windsor, Colorado 80550, 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 8)014-agi3 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 (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. 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 Jun 11 14 10:22a Owner 970-460-0181 p.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 Courtly, 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. ATTESTw Weld County Clerk to the Board By: unty A By: BOARD OF COUNTY COMMISSIONERS ELD COUNTY, • LORADO WELD COUNTY DEPART NT ademacher, C r SEP 2 2 2014 NYRIAH(T�IOVARp By: RA l IM Nyri Toyer Page 7 of ID £014-28/3 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 GEIGO. geioo.corn Colorado Insurance Identification Card 1400441-3000 GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 Policy Number Effective Date 4177-96-30-65 05-12-14 Year 2003 Insured: Carol A Serna Lee Sema 1020 Cottonwood Dr Windsor CO 80550-4B06 Make Model FORD FOCUSEZTW Expiration Date 11-12-14 Vehicle ID No. 1FAFP34P03W325608 un301401:20p Owner 970-460-0181 p.1 Declaration of Independent Contractor Status Form We certify UNDER PENAL1 rJRR OF PERJY that: (name and trade name) LI.- Y� 4� r performing (type of work) (G Social Security or Federal Employer Identification #_5 S Address:jMO ( (An nail( id cm 'it Phone: _ is an independent contractor (IC) and es 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 m following criteria: ICPR 1. The business DOES NOT require the individual to work ONI.Y for the business for whom services are performed (except that the individual may DECIDE to work only for the business for a definite period); 1C Nr 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 I •r will be performed); 1C[ v P11 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate; IC .r 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 J\.'1 -PH 5. The business DOES NOT provide more than minimal training for the individual; IC I\: •T PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be supplied); IC )4: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 -1- 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 NJ. 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 HEJSHE: • 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 HEISHE HIRES. } Indepl;rndent Contractor Signature .t Title Social Security iE STATE OF COLORADO, COUNTY OF W e lei Subs ed and sw bet re me by Fvt �cvc�r thisateI=day of-MH'4. Commission expires: J.k't12D\S‹ NOTARY PUBLIC Acceptance of the Independent Contractor named on this form doe not change any party's responsibility wider the Workers' Campe option Act. If individnab or organizations hired or contracted by the Independent Contactor are not covered b -' notion insurane% the policyholder specified on this form wilt be charged premium for coverage of lane individnab or organizations USA DeNOOY CERTIFICATION BY BUSINESS I certify that I am authorized by the business listed above to state that all of the in understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed. n�rRtvi PtfBLic STATE OF COLORADO NOTARY ID 20144000366 MY CO Signature STATE OF COLORADO, COUNTY OF Subscribed and sworn before me by this day of Title NOTARY PUBLIC Commission expires: Page 2 of 2 ZAtJCCIFOO7 R -02-O6 AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY, ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, DAWN VAN DEN ELZEN THIS AGREEMENT is made and entered into this 22, day of 8, 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 "0" Street, Greeley, Colorado 80631, hereinafter referred to as "County", and Dawn Van Den Elzen, whose address is 5819 West 16th Street Lane, 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 kliia Age 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 (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 frill 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 6of10 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: c e°. L Weld County Clerk to the Board By: D on a .end uty Clerk to the Board D -/1 Coty ttomey ORM: Douglas/Rademacher, Chair BOARD OF COUNTY COMMISSIONERS ELD COUNTS'; EQLORADO WELD COUNTY DEPARTMENT DAWN VAN DEN ELZEN By: By: itcSut-J SEP222014 It/.a"...41;" Alain 4Cv- Dawn Van Den Elzen a Page 7 of 10 %o,i-X913 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 prig" 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 10 of 10 Declaration of Independent Contractor Status Form We certify UNDER PENALTY OF PERJURY that: (name and trade name) performing (type of work) /?4-3-„, , r� C'•9,( E Social Security or Federal Employer Identification t# 522- 9 - Z eo 9 5/ l Address: S. E1. 19 tel./ /e 7 --NS •r /9,m/4- Phone: e' 9 7o) zi - 79 76 is an independent contractor (IC) and is not an employee of the following policyholder (PH): Address: Policy # — D�--�Y lJ Eir 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 i0t/ 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 01/ 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 IA/ PH 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate; IC IN/ 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 IA/ PH 5. The business DOES NOT provide more than minimal training for the individual; IC pt/ PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be supplied); IC 1Dt/ 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 Qt/ 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 0/ 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 SE BUSINESS. • IS REQUIRED TO PaOVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES. Independent Contractor Signature Title Social Security # STATE OF COLORADO, COUNTY OF Jt1 -& bscribed and sworn before me by�t't,.,. f I zc t • this . J• Ii day of ,ate, Conunission expires: t �� ROTARY PUBLIC Acceptance of the Independent Contractor named on this form does not change soy party's responsibility under the Workers' Compensation Act. If individuate or organizations bired or contracted by the Independent Contractor are not covered by other workers' compensation insurance, the policyholder apedfied on this form will be charged premium for coverage of those individuals 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 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 StateFarm a. COLORADO INSURANCE CARD INSURED VAN DEN ELZEN,DAWN M MUTL VOL POLICY NUMBER 2578171 -F06 -06R EFFECTIVE YR 2003 MAKE PONTIAC JUN 06 2014 TO DEC 06 201, MODEL MONTANA VIN 1GMDXOaE28D276887 AGENT LARSON WS AGENCY INC PHONE (970)8568700 NAIC 25178 MINIMUM LIABILITY LIMITS PREYSCRIBPED BY MEETS W THE A BODILY INJURY/PROPERTY DAMAGE LIABRITY C MEDICAL PAYMENTS D COMPREHENSIVE G 100 DEDUCT COLLISION H, U, S SEE REVERSE SIDE FOR ADDITIONAL COVERAGE INFORMATION StateFa,m COLORADO INSURANCE CARD INSURED VAN DEN ELZEN, DAWN M MUTL VOL POLICY NUMBER 0986855.818-05D EFFECTIVE YR 2001 MAKE FORD AUG 182014TDFEB 1820/: MODEL ECONOLJNE VIN 1FB5681671HB46608 AGENT LARSON INS AGENCY WC PHONE (970)856.8700 NAIC 25178 MEETS MINIMUM WLBILITY LIMITS PRESCRIBED BY LLAW THE A BODILY INJURY/PROPERTY DAMAGE LABILITY C MEDICAL PAYMENTS D COMPREHENSIVE G 100 DEDUCT COLLISION H SEE REVERSE SIDE FOR ADDITIONAL COVERAGE INFORMATION AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY~ ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, JENNIFER WALKER THIS AGREEMENT is made and entered into this ! day o14, 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 Jennifer Walker, whose address is 519 Trout Creek Court, Windsor, Colorado 80550, 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 children) 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 Ai014-aq 13 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 QMG 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 othervvise 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 2of10 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. 1i. 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 he held liable for injuries or damages caused by any Page 4of10 1. negligent acts or omissions of Care Provider while performing duties described in this Agreement. 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. 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 inununities, 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 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. 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 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. 7 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 GEICO. Colorado Insurance Idemilication card gel co. corn 3-800-84i-3000 GEICO CASQALTY COMP S PO BOX 509090`DIEGO, CA 92150-9090 Policy Number Effective Dpta. Expiration pate 4229536943 05-01 14>'N` 11-01-14 Year Make ModeN • Vehicle ID No. 2005 CHEV EXP;-"T500 1GBJG31U551228990 Insured: KURT LEROY AND JENNIFEitaYNNE WALKER 519 WINDSOR,TROCO CREEK CO80550-?i94 �' The abocwmsumucsamspacy has eaxdso tusmencopolicy whwb mmplies with the mmtmum liability limits prescribed bylne. 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 aH 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 geico.com or call us at 1-800-8414000. What to do at the time of an accident • Do not admit fault. • Do not reveal the Iknks of your liability coverage to anyone. • Exchange contact Information; get year, make, model, plate number, Insurance canter and policy number of all Involved. Also, Identify witnesses and collect contact information. • Contact the police or 9t1 If applicable. • Contact GEICO by calling 14004414000 or visit geico.com to report the accident. U -4-00 (12-091 Declaration of Independent Contractor Status Form We certify UNDER PENAI.TYIOF PER{ 1RY that: (name and trade name) 7 1-0 L? 1 L,V-I L�'1 C performing (type of work) Lit Ylt 1C ( O 12' 04' I--()•;•- ;: Social Security or Federal Employerldentification # 5s. r( -F 1 el �. z _ Address: 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. 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; 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); IC_J'H_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 HP/SHF- • 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 r IS�� REQUIRED TO PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES ! f.y-„ x , R 1 ;cr'(�— -DJ 1 \ 91k =."z` Indep kdent CoAlfactor Signature Title Social Security # STATE OF COLORADO, COUNTY OF Subscribed and worn before me by r this day of Commission expires: NOTARY PUBLIC Acceptance of the Independent contractor nomad on lids fans does not change say party's responsibility nadet the Worker' Compensation Act. If iodbviduab or orgniviloaa hired or restricted by the Independent Contractor ere not covered by other workers' compensation laminate. the policyholder specified on this corn will be charged premium for coverage of those Indivldust 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 uttderstand that if the above does not qualify for independent contractor tmtus, the proper premium can be assessed. \ Y�lJ11T�I 1 V l.L Signature \ °.1 Title SuATEOF ednndsw bfore me by IN INT\tc"& tt(t\\LQ I' this in day of (-iK'Q- 1\ Subscribed and swum before me by \ Q At; r\ ((_ �t' ` 1 �."1 Commission expires: 0' �' NOTARY PUBLIC Page 2 of 2 ERIN K JOHNSON NOTARY PUBLIC STATE OF COLORADO I NOTARY ID 20044033926 I MY COMMISSION EXPIRES OCTOBER 8, 2016 ZAUCCIFom] R-02.06 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. 1 I. 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: - J %ek, Weld County Clerk to the Board By: D puty Clerk to the Board nt orney RM: WELD COUNTY DEPARTMENT By: J d A. Grie ;o, Direct JENNIFER WALKER BOARD OF COUNTY COMMISSIONERS D COUNTY, COLORADO demacher, Chair SEP 2 2 2014 By: JIlkl,,t4Url iferker Page 7of10 A014 --A3 Hello