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Home My WebLink About20143349MEMORANDUM DATE: October 23, 2014 TO: Douglas Rademacher, Chair, Board of County Co is loners FROM: Judy A. Griego, Director, Human Service RE: Respite Agreements between the Weld County Department of Human Services and Various Providers for Placement on the Consent Agenda Enclosed for Board approval are Respite Agreements between the Department and Various Providers. The template for this agreement was approved by the Board July 15, 2014, these providers were reviewed under the Pass -Around Memorandum dated October 8, 2014, for placement on the Consent Agenda. The major provisions for these Agreements are as follows: No. Provider Term Rate 1 Serna, Carol July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 2 Stone, Mary July 1, 2014 — June 30, 2015 $16.75 per each four hour Period. Max. $67.00 per month for 16 hours 3 Wyatt, Tracy 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. donsenf Q ends /0 - a7- Aoiy 2014-3349 f -/R0085 AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY. ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, CAROL SERNA THIS AGREEMENT is made and entered into this 21 day of Odgideiby 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 Carol Serna, 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 11 ao14'-33V9 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 11 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 11 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 11 negligent acts or omissions of Care Provider while performing duties described in this Agreement. 2. County shall not indemnify Care Provider for any loss incurred by Care Provider as a result of services performed under this Agreement. 3. County shall pay Care Provider in accordance with the terms set forth in Exhibit B, reference), as long as services are rendered satisfactorily and in accordance with the Agreement. 4. Payment pursuant to this Agreement is subject to, and contingent upon, the continuing availability of funds made available for the purposes hereof. No portion of this Agreement shall be deemed to create an obligation on the part of County to expend funds not otherwise appropriated. The County may terminate this Agreement at any time if said source of funding is no longer available to County 5. County may withhold payment under this Agreement if Care Provider fails to comply with any part of the Agreement. In the event County withholds payment, Care Provider may appeal such circumstance in writing to the Weld County Director of Human Services. The decision of the Weld County Director of Human Services shall be final. GENERAL PROVISIONS: I. The term of this Agreement shall commence on the date of County's execution of this Agreement and shall continue for a period of one (1) year. This Agreement may be renewed by the mutual agreement of the parties for up to three (3) additional one (1) year periods. Renewal of the Agreement shall be documented by the execution of the "Renewal of Agreement" form, a copy of which is attached hereto as "Exhibit C" and made a part hereof by this reference. Z. 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 11 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 11 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 Oc1071401:42p Owner 970-460-0181 p.1 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST „rakAJ G:JC,Lfo;ck. BOARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board BY: °tab 41-6S APPROVED AS TO DING: Controller APPRD AS TO FO County Attorney CAROL SERNA WELD COUNTY, COLORADO 4 Ltut sic, ; L/C/A--k. t Barbara Kirkme er, Pro- em APPRIVE A TO TBSTANCE: Offi al orDi.artmen/Head CA -1,d ✓_, _ c..-cii Carol Serna OCT 2 7 2014 Page 8 of tt 2oi4-3349 EXHIBIT A SCOPE OF SERVICES 1. Care Provider will provide up to sixteen (16) hours of Respite care services per month per child for foster children residing in Weld County certified foster homes. 2. Care Provider will, at the time of entering into this Agreement, ensure he/she has completed all the necessary paperwork and has in effect all necessary licenses, approvals, insurance, etc., required to provide the Respite services covered by this Agreement. Care Provider will have: a. Completed and submitted the Colorado Department of Human Services Application and signed as "Foster Parent/Home" PRIOR to completing the PRIDE classes. b. Successfully completed fifteen (15) hours PRIDE training through the County prior to the performance of services under this Agreement. c. Provided a copy of their current Colorado driver's license indicating Care Provider is at least eighteen (18) years of age; and d. Completed and submitted a fingerprint card for a background check through the Colorado Bureau of Investigation (CBI) and the Federal Bureau of Investigation (FBI). The fingerprinting expense must be paid by the Care Provider. Background checks will be paid by the County. e. Provided three (3) reference forms completed by non -relatives. f. Provided proof of current CPR and First Aid certifications. g. Completed and signed Confidentiality, Discipline and Mandated Reporter Policies. h. Provided proof that Care Provider has procured at least the minimum amount of automobile liability insurance required by the State of Colorado. County provides no automobile liability coverage for Care Provider. Copies of all documentation relating to the foregoing requirements shall be provided to the County by Care Provider prior to the performance of any services covered under this Agreement. County shall determine eligibility for certification based upon the successful completion of all required training and receipt of current documentation. Care Provider further acknowledges that he/she will remain current with all documentation or certifications for the term of this Agreement. Should an item expire or otherwise become invalid, Care Provider will submit current documentation to the County to avoid a lapse in documentation and/or certification. Page 9 of 11 3. Care Provider acknowledges that the County shall not compensate Care Provider for said training; including time spent traveling to and from training, time spent in attendance at the training, or any associated costs paid by Care Provider for such training, unless specifically agreed to in writing in advance by County. 4. Care Provider acknowledges that arrangements to provide Respite services must be communicated to the child's Caseworker and the Foster Care Coordinator prior to Respite taking place in order to discuss arrangements and ensure all the child's needs are met. 5. Care Provider will become familiar with and follow all the State and Federal rules and regulations as applicable to the services provided under this Agreement. 6. Care Provider will complete and submit the Respite Care Payment Form each month by the 10th of the month following the month of service. The Respite Care Payment Form is available on the Foster Parents Internet Database and On-line System (FIDOS). Page 10 of 11 EXHIBIT B PAYMENT SCHEDULE Funding and Method of Payment The County agrees to reimburse the Care Provider in consideration of the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to the Care Provider during the term of this Agreement shall be reported by the County after June 30, 2015. Expenses incurred by the Care Provider prior to the term of this agreement are not eligible County expenditures and shall not be reimbursed by the County. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the County, the County may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Respite care is limited to four (4) hours per week per child. The hours of care may be provided in any combination throughout a month, but may not exceed 16 hours per month. Payment will be $16.75 per each four hour period, but may not exceed $67.00 per month for 16 hours. Human Services referrals will not be sent to collections by Care Provider for default of co-pay/fees. Services will be performed regardless of client's refusal or inability to pay co -pay. Care Provider will collect any applicable sliding scale co -pays and credit Human Services for any payments received on the monthly billing statements. 3. Submittal of Vouchers Care Provider shall prepare and submit a Respite Care Payment Form each month to certify that the services authorized were provided on the date(s) indicated and the charges made were pursuant to the terms and conditions of Exhibit A. The Respite Care Payment Form is available online through the Foster Parent Internet Database and On-line System (FIDOS). Page 11 of 11 Apr 21 14 09.18a Owner Important Information GEICO.. -iere are your Policy Identification Cards. Two cards lave been provided for each vehicle insured. lease destroy your old cards when the new cards 3ecorne effective. Due to space limitations on the ID card, only the \lamed 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 (page 11). Please notify us promptly of any change in your address to be sure you receive all important policy documents. Prompt notification will enable us to service you better. Your policy is recorded under the name and policy number shown on the card. If you would like additional ID cards, you can go online to geico.com or call us at 1-800-841-3000. geico.com GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 Policy Number Effective Date 4177-96-30-65 05-12-14 Year Make 2003 CHEV Insured: Carol A Sema Lee Serna 1020 Cottonwood Or Windsor CO 80550-4806 970-460-0181 p.1 Cotorae nsurance Identification Card 1-80,,1s41-3000 Expiration Date 11-12-14 Model Vehicle ID No. SUBRBN1500 1 GNFK16ZX3J142443 CAROL A SERNA AND LEE SERNA 1020 COTTONWOOD OR WINDSOR CO 80550-4806 GEICO. geicc-com GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego. CA 92150-9090 Policy Number Effective Date 4177-96-30-65 Year Make 2003 CHEV Insured: Carol A Sema Lee Sema 1020 Cottonwood Dr Windsor CO 80550-4806 05-12-14 Model Colorado Insurance Identification Card 1-800-841-3000 Expiration Date 11-12-14 Vehicle ID No. SUBRBN1500 1 GNFK16ZX3J142443 Oct 03 14 02:38p Owner 970-460-0181 P_ 1 Declaration of Independent Contractor Status Form We certify UNDER PENALTY OF PERJURY that: (name and trade name) C'.L C'r)k S e i performing (type of work) 2� S 2i -}-� Social Security or Federal Employer Identification r/ Address: /0 I) (' Al t trig � �t rC Phone: - 3 X 6 =-2. / S Z) `76 is an independent contractor (IC) and is not an employee of the following policyholder (PH): Phone: Address: Policy # We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services meet the following criteria: ICC() PH. 1. The business DOES NOT require the individual to work ONLY for the business for whom services are performed (except that the individual may DECIDE to work only for the business for a definite period); IC 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); ICY 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 CS PH 7. The business DOES NOT dictate the lime of performance (except that a completion schedule and a range of agreeable work hours may be established); IC� PH 8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade or business name of the individual; ICQ3 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: • WLL 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 PERFORMRJG SERVICES FOR THE USINESS. • IS REQUIRED l ) PR VIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT IiE?SHE HIRES. I Independent Contractor Signature Title Social Security # STATE OF COLORADO, COUNTY OF _\ scribed and�vum br,�ore me by Cf-, ,21\, Sc� y this day of _C) —\ C----- — LISA DoNQOV ComrnTss� In expires: 1-11��o1SS NOTARY PUBLIC ARY PUBLIC Acceptance of the Indscendent Contractor named ca this f individuals or organisations hired or contracted by !brj tad specified on thin form will be charged premium for co4iXit TA suability i oder the Workers Compensation Act II y 71; .corkers• compensatl" 61"1""34 tie policYboldar QIli1�8i�IiJt�biia'lf�iiltirOttft�/2 018 CERTIFICATION BY BUSINESS I certify that I am authorized by the business listed above to state that all of the information on this form is true and accurate. I understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed. Signature STATE OF COLORADO, COUNTY OF Subscribed and sworn before me by this day of Title NOTARY PUBLIC Commission expires: Page 2 oft ZAUCCIF007 R -O2-06 AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY, ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, MARY STONE THIS AGREEMENT is made and entered into this z] day ottel. 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 "0" Street, Greeley, Colorado 80631, hereinafter referred to as "County", and Mary Stone, whose address is 10112 West 13th Street, Greeley, Colorado 80634, hereinafter referred to as "Care Provider." WITNESSETH: WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided funding to the County for respite care for Weld County certified foster care homes; and WHEREAS, County has determined that due to the significant challenges often experienced by certified foster care providers, it is necessary to offer them respite services, as described in Exhibit A, "Scope of Services", a copy of which is attached hereto and made a part hereof by this reference), to allow them to continue to provide high quality care for the children in their charge, and WHEREAS, Care Provider is willing and able to abide by the terms and conditions required by County. as more fully set forth in this Agreement, WHEREAS, Care Provider is able and available to provide respite services as defined in this Agreement at the rates set forth in Exhibit B, "Rate of Reimbursement" a copy of which is attached hereto and made a part hereof by this reference), NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties hereto agree as follows: RESPITE CARE PROVIDER'S RIGHTS AND RESPONSIBILITIES: 1. As used in this Agreement "Respite Care" is defined as those child care services required by one or more children who are in the care of a certified foster home, which services are provided by Care Provider in order to give foster parents an opportunity to address matters which cannot be addressed while caring for the child(ren) in their care. These services are described in Exhibit A. These services may also include transporting the child to school and other appointments previously arranged by the foster parent. Transportation services are provided at the sole risk, responsibility and liability of Care Provider. Page 1 of 10 2tI'- 3349 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. Care Provider shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents for any damages caused by his/her actions while performing services pursuant to this Agreement, and shall hold County harmless from any loss occasioned as a result of the performance of this Agreement. 12. Care Provider shall be totally responsible to provide whatever personal liability and/or other insurances, he/she deems necessary to cover his/her personal liability for any injuries caused by Care Provider in the course of providing services under this Agreement. 13. Care Provider shall perform his/her duties hereunder as an independent contractor and not as an employee of County. Care Provider shall be solely responsible for his/her acts performed pursuant to this Agreement. Under no circumstances shall Care Provider be deemed to be an agent or employee of Weld County. Care Provider is not entitled to unemployment insurance or workers' compensation benefits through Weld County and Weld County shall not pay for or otherwise provide such coverage for Care Provider. Unemployment insurance benefits will not be available to Care Provider for services provided under this Agreement. Care Provider shall pay when due any/all applicable employment taxes and income taxes and local head taxes (if applicable) incurred as a result of the services provided under this Agreement. 14. Care Provider shall not have authorization, express or implied, to bind County to any agreement, liability or understanding. 15. Care Provider agrees that he/she shall not use alcohol, illegal drugs, marijuana, whether for recreational or medical purposes, or any other drugs which have the potential of impacting Care Provider's ability to supervise the children in his/her care while providing services under this Agreement or within five (5) hours prior to the provision of said services. 16. Care Provider shall protect the confidentiality of all records and other materials to which he/she has access relating to the foster family and child(ren) to whom the services are provided, which are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. COUNTY'S RIGHTS AND RESPONSIBILITIES: 1. Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any Page 4 of 10 negligent acts or omissions of Care Provider while performing duties described in this Agreement. 2. County shall not indemnify Care Provider for any loss incurred by Care Provider as a result of services performed under this Agreement. 3. County shall pay Care Provider in accordance with the terms set forth in Exhibit B, reference), as long as services are rendered satisfactorily and in accordance with the Agreement. 4. Payment pursuant to this Agreement is subject to, and contingent upon, the continuing availability of funds made available for the purposes hereof. No portion of this Agreement shall be deemed to create an obligation on the part of County to expend funds not otherwise appropriated. The County may terminate this Agreement at any time if said source of funding is no longer available to County 5. County may withhold payment under this Agreement if Care Provider fails to comply with any part of the Agreement. In the event County withholds payment, Care Provider may appeal such circumstance in writing to the Weld County Director of Human Services. The decision of the Weld County Director of Human Services shall be final. GENERAL PROVISIONS: 1. The term of this Agreement shall commence on the date of County's execution of this Agreement and shall continue for a period of one (1) year. This Agreement may be renewed by the mutual agreement of the parties for up to three (3) additional one (I) year periods. Renewal of the Agreement shall be documented by the execution of the "Renewal of Agreement" form, a copy of which is attached hereto as "Exhibit C" and made a part hereof by this reference. 2. Either party may terminate this Agreement at any time by providing the other party with a 30 -day written notice thereof. Furthermore, this Agreement may be terminated by County at any time without notice upon a material breach by Care Provider of the terms of the Agreement. 3. Care Provider may not assign or transfer this Agreement, any interest therein or claim hereunder, without the prior written approval of County. 4. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties Page 5of10 that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 5. No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 6. If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 7. No officer, member or employee of County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The appearance of conflict of interest applies to the relationship of a Care Provider with County when the Care Provider also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary that the Care Provider gain from knowledge of these opposing interests. It is only necessary that the Care Provider knows that the two relationships are in opposition. During the term of the Agreement, Care Provider shall not enter into any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Care Provider shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Care Provider. Care Provider certifies that no Federally appropriated funds have been paid or will be paid, by or on behalf of Care Provider, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 8. This Agreement, together with Exhibits A, B, and C, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified, unless by a written amendment executed by both Page 6 of 10 9. panics. 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. 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 (tithe day, month, and year first above written. ATTEST: -4= Cs `d ;� WELD COUNTY, COLORADO GamG / Weld County Clerk to the Board �l�Lt S.ri _ y�Ck//1-1 rbara Kirkmeyer, Pro-Tem 272014 13v: D: putt' Clerk to the Board APP,..,ED AS TO O M:•'`- - County Attorney WELD COUNTY DEPA13TMENT MARY TONE l, By: BOARD OF COUNTY COMMISSIONERS Page 7 of 10 2o/y-33q 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 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 (FIDOS). Page 10 of 10 PLACE IN YOUR VEHICLE AMERICAN FAMILY MUTUAL INSURANCE COMPANY 6000 American Pkwy • Madison, WI 53783 CLAIMS: 1-800-MYAMFAM (1-800.892.6326) COLORADO MOTOR VEHICLE PROOF OF INSURANCE CARD Policy No: 2105-1481-01.47-FPPA-CO Effective Date: 8.15.2014 Expiration Date: 2-15-2015 2003 CHEV TXT VIN: IGNET16S936132663 Coverages: BIPD UM UIM COMP COLL ERS STONE, JAMIE D 8 MARY K Agent: Keith D Montey Jr Agency, Inc. Agent Phone: (970) 353-1533 This card must be carried in the insured motor vehicle for production upon demand. -C—_ Important message on reverse side. 6rtgarc+- IMPORTANT INFORMATION . Examine Policy exclusions carefully. This form does not constitute any part of your insurance policy or bond. If this is a 'Basic Car Policy or "Miscellaneous Vehicle Policy' it may not provide coverage for vehicles you do not own. Except in Kansas, this policy does not provide coverage it the operator is an excluded person. If you carry the coverages required by state law, the limits represented by this card meet or exceed the mihimum financial responsibility requirements. If you do not carry or it you discontinue the required coverages, this card is not valid. ARIZONA POLICYHOLDERS: Coverage meets the limits required by law. Arizona law requires evidence of insurance be in the vehicle • at all times. GEORGIA POLICYHOLDERS: The current status of actual motor vehicle liability insurance coverage is maintained by the GA DMVS and is accessible to law enforcement agencies upon a check of the vehicle information. NOTE: This card is issued solely to satisfy the terms of the law in your state. The policy term shown is sub)ect to the insured's compliance with general policy provisions. KEEP THIS CARD IN YOUR MOTOR VEHICLE WHILE IN OPERATION. U-339 Ed. 12/08 We certify UNDER PI \AI.TY OF PERJURY that (ii.unc and trade name) t lit _ r i performing (type of v ork) ..._ : Declaration of Independent Contractor Status Form Social Security or Federal Employer Identification a •. !" t :.7 r r L t r. U. i ,t, 'Phone: l 1 ` /l Address:: I t i � ii:—.� r f is an independent contractor (IC) and is not an eniploSTe of the following policyholder Phone: (PH): Address: Policy # We also certify. by OUR initials WHERE APPLICABLE. that the above business for which the above individual performs services meet the following criteria: 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 (ri> PH _2. The business DOES NOT establish a quality standard for the individual (except that the business may provide plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to how work will be performed): �i ': )(- Pl( 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate; IC' )ti:S 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; Phi 5. The business DOES NOT provide more than minimal training for the individual; IC •_PllLi. 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 fPH 8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade t., or business name oldie individual: IC !t t--' 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. ALEX WILLIAM DUTTON CERTIFICATION BY INDEPENDENT CONTRACTOR NOTARY PUBLIC STATE OF COLORADO THE INDEPENDENT CONTRACTOR UNDERSTANDS THAT HE/SHE: NOTARY ID 20144027465 • WILL NOT BE ENTITLED TO ANY WORKERS' COMPENSATION BENEFITS iN THE EVENT OF INJURY. MY COMMISSION EXPIRES 07.14-2018 • IS OBLIGATED TO PAY ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING BUSINESS. • i �tEQUIRED T PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES. c./ Ea t UK t Tit Indc Conirecto tSignature STATE Of COLOR. !O, COUNTY OF VJ eld Subscribed o w(rtbed an sK J.e�►---� b� i ao.rbed NOTARY PUBLIC Title Social Security a this t bfhday of 3tQ'relh'wir , t4 --- Commission expires: O:1 �i 201F5 tcceptance of the independent Contractor named on this form does not change any party's responsibility under the Workers' Compensation Act. if individuals or organisations hired or contracted by the Independent Contractor are not covered by other workers' compensation insurance. the policyholder specified on ibis form wili be charged premium for coverage of those individuals or organirations. 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 he assessed. Signature STATE. OF COLORADO, COUNTY OF Subscribed and sworn before me by this day of Commission expires: Title NOTARY PUBLIC Page 2 of 2 Lot:CCiRttn7 R -02-0b AGREEMENT FOR RESPITE SERVICES BETWEEN WELD COUNTY, ON BEHALF OF WELD COUNTY DEPARTMENT OF HUMAN SERVICES, AND RESPITE CARE PROVIDER, JUSTIN AND TRACY WYATT THIS AGREEMENT is made and entered into this Al day of W ibl4, 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 Justin and Tracy Wyatt, whose address is 418 Dogwood Court, Eaton, Colorado 80615, 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. Pagel of 11 93o►'4-339 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 2offt 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 Pagc3all 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 11 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 5of11 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-I01 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 11 parties. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. Neither County nor Care Provider may assign any of its rights or obligations hereunder without the prior consent of the other party. 9. This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 10. Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Care Provider agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 11. In the event of a dispute between County and Care Provider, concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. Page 7 of 11 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST: V,4attif.") .zki;e,k Weld County Clerk to the Board By: DL uty Clerk to the Board APPRO ED AS TO FO M: County Attorney WELD COUNTY DEPART By: J ENT BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO , _-- L {•hut Barbara Kirkmeyer, Pro-Tem OCT 2 7 2014 JUSTIN AND TRACY WYATT By: By: Page 8ofIi EXHIBIT A SCOPE OF SERVICES 1. Care Provider will provide up to sixteen (16) hours of Respite care services per month per child for foster children residing in Weld County certified foster homes. 2. Care Provider will, at the time of entering into this Agreement, ensure he/she has completed all the necessary paperwork and has in effect all necessary licenses, approvals, insurance, etc., required to provide the Respite services covered by this Agreement. Care Provider will have: a. Completed and submitted the Colorado Department of Human Services Application and signed as "Foster Parent/Home" PRIOR to completing the PRIDE classes. b. Successfully completed fifteen (15) hours PRIDE training through the County prior to the performance of services under this Agreement. c. Provided a copy of their current Colorado driver's license indicating Care Provider is at least eighteen (18) years of age; and d. Completed and submitted a fingerprint card for a background check through the Colorado Bureau of Investigation (CBI) and the Federal Bureau of Investigation (FBI). The fingerprinting expense must be paid by the Care Provider. Background checks will be paid by the County. e. Provided three (3) reference forms completed by non -relatives. f Provided proof of current CPR and First Aid certifications. g. Completed and signed Confidentiality, Discipline and Mandated Reporter Policies. h. Provided proof that Care Provider has procured at least the minimum amount of automobile liability insurance required by the State of Colorado. County provides no automobile liability coverage for Care Provider. Copies of all documentation relating to the foregoing requirements shall be provided to the County by Care Provider prior to the performance of any services covered under this Agreement. County shall determine eligibility for certification based upon the successful completion of all required training and receipt of current documentation. Care Provider further acknowledges that he/she will remain current with all documentation or certifications for the term of this Agreement. Should an item expire or otherwise become invalid, Care Provider will submit current documentation to the County to avoid a lapse in documentation and/or certification. Page 9 of 11 3. Care Provider acknowledges that the County shall not compensate Care Provider for said training; including time spent traveling to and from training, time spent in attendance at the training, or any associated costs paid by Care Provider for such training, unless specifically agreed to in writing in advance by County. 4. Care Provider acknowledges that arrangements to provide Respite services must be communicated to the child's Caseworker and the Foster Care Coordinator prior to Respite taking place in order to discuss arrangements and ensure all the child's needs are met. 5. Care Provider will become familiar with and follow all the State and Federal rules and regulations as applicable to the services provided under this Agreement. 6. Care Provider will complete and submit the Respite Care Payment Form each month by the 10th of the month following the month of service. The Respite Care Payment Form is available on the Foster Parents Internet Database and On-line System (FIDOS). Page 10 of 11 EXHIBIT B PAYMENT SCHEDULE Funding and Method of Payment The County agrees to reimburse the Care Provider in consideration of the work and services performed under this Agreement at the rate specified in Paragraph 2, below. The total amount to be paid to the Care Provider during the term of this Agreement shall be reported by the County after June 30, 2015. Expenses incurred by the Care Provider prior to the term of this agreement are not eligible County expenditures and shall not be reimbursed by the County. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof In the event that said funds, or any part thereof, become unavailable as determined by the County, the County may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Respite care is limited to four (4) hours per week per child. The hours of care may be provided in any combination throughout a month, but may not exceed 16 hours per month. Payment will be S16.75 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. 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 11ofll TEMPORARY AUTO IDENTIFICATION CARD STATE FARM° This card is invalid if the policy for which it was issued lapses or is terminated. Statef:vm I CAR INSURANCE CARD POLICY NUMBER 076 3876-D09-061. State Farm Mutual Automobile Insurance Company INSURED WYATT,JUSTIN 8 TRACY EFFECTIVE DATE AUG-12-2014 EXPIRATION DATE OCT-09-2014 CAR-YEAR/MAKENEHICLE IDENTIFICATION NUMBER 2006 NISSAN PATHFINDER SPORT WG 5N)AR18W36C672310 COVERAGES A BODILY INJURY/PROPERTY DAMAGE LIABILITY C MEDICAL PAYMENTS D COMPREHENSIVE $500 G COLLISION $500 H, R1, U, S AGENT DARYL ALEXANDER INS AGCY Daryl Alexander. Agent 5205 S College Ave FORT COLLINS, CO 80525 PHONE# 970-493-2196 STATE FARM' NAIC #25178 IF YOU HAVE AN ACCIDENT - NOTIFY POLICE IMMEDIATELY 1. Get names, addresses, and phone numbers of persons involved and witnesses. Also get driver license numbers of persons involved and license plate numbers/states of vehicles. 2. Don't admit fault or discuss the accident with anyone but State Farm or police. 3. Promptly notify your agent, log on to statefarm.com®, or visit State Farm Pocket Agent® to file a claim. For Emer•ency Road Service call 1-877-627-5757 A or AB C. M D DWG E F,G,or J H N P, O R RI. R2 S T HOW TO IDENTIFY YOUR COVERAGES SEE POLICY FOR FULL NAME AND DEFINITION (All coverages not available in all states.) Liability (Bodily Injury/Property Damage) Medical Payments Comprehensive or Other Than Collision (OTC) Comprehensive with Full Glass Fire. Theft, Other Specified Perils Collision Emergency Road Service Physical Damage Properly Protection (Name vanes by state) Personal Injury/No Fault (Name varies by state) Car Rental Car Rental and Travel Expense Death, Dismemberment Disability U Uninsured Motor Vehicle U Underinsured Motor Vehicle in Washington U Uninsured and Underinsured Motor Vehicle-BI/PD in Alaska U7 Uninsured Motor Vehicle -PD U1 Uninsured and Underinsured Motor Vehicle -in Alaska U1 Uninsured Motor Vehicle-BI/PD in Indiana U1 Underinsured Motor Vehicle -PD in Washington U2 Uninsured and Underinsured Motor Vehicle -PD UNOC Use of Nonowned Cars W Underinsured Motorist Y Limited Properly Damage Liability (Michigan) 2 loss of Earnings Because many states require evidence of insurance on demand, one copy of this form should be carried in the vehicle at all times. A toll free number is available for Emergency Road Service and is located on your insurance card. 1mC'02 2006 136168 205 05-07-2012 eclaration of Independent Contractor Status Form We certify UNDER PENALTY -9F PERJURY that: (name and trade name) cJ L' '1,,'/ _ z, Li t"r_7 performing (type of work) _• • +Vie:` •�o m=rte Social Security or Federal Employer Identification Address: // 1:-)t _-2 1._ C_ C'C) C4-, J tfir\l ? 11t Phone: E- ) f 7 - 9i' C 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 me�Tt)te following criteria: 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); 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; 1C PH 5. The business DOES NOT provide more than minimal training for the individual; 1 PH 6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be supplied); PH _7. The business DOES NOT dictate the time of performance (except that a completion schedule and a range of agreeable work hours may be established); PH 8. The business DOES NOT pay the individual personally instead of making payment or checks payable to the trade or business name of the individual; PH 9. The business DOES NOT combine the business operations in any way with the individual's business operations instead of maintaining all such operations separately and 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 !NJ +f, • IS OBLIGATED TO PAY ALL FEDERAL AND STATE INCOME TAX ON ALL MONEY EARNED WHILE PERFORMING S,ENICES FOR THE BUSINESS. • IS REQUIRED TO PROVIDE WORKERS' COMPENSATION INSURANCE FOR ALL WORKERS THAT HE/SHE HIRES. UNDSEY E. STONEMETS -LEAF NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20124042508 MY COMMISSION EXPIRES JULY 12, 2016 Independent C actu S'tgna ti4 STATE OF COLORADO, COUNTY OF 1. Subscribed and sworn before me by_ ti— Title NOTARY ►, • B Social Security this, ir:1 day of A.'_�� t� Commission expires:J,t Iy 19 gel t p 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 bw 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 STATE OF COLORADO, COUNTY OF Subscribed and sworn before me by this day of Title Commission expires: NOTARY PUBLIC Page 2 of 2 ZAUCCIF007 R-02-06 Hello