HomeMy WebLinkAboutC2009-588 - 10/20/2009 - Approved~ 7. I
DEPARTMENT OF STATE HEALTH SERVICES
This contract, number 2010-033567 (Contract}, is entered into by and between the Department
of State Health Services (DSHS or the Department), an agency of the State of Texas, and
CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT CITY (Contractor),
a Government Entity, (collectively, the Parties).
1. Purpose of the Contract. DSHS agrees to purchase, and Contractor agrees to provide,
services or goods to the eligible populations as described in the Program Attachments.
2. Total Amount of the Contract and Pa ment Methods . The total amount of this Contract
is $8~S,S00.00. and the payment method(s) shall be as specified in the Program Attachments.
3. Fundine Obligation. This Contract is contingent upon the continued availability of funding.
If funds become unavailable through lack of appropriations, budget cuts, transfer of funds
between programs ox health and human services agencies, amendment to the Appropriations Act,
health and human services agency consolidation, or any other disruptions of current appropriated
funding for this Contract, DSHS may restrict, reduce, or terminate funding under this Contract.
4. Term of the Contract. This Contract begins on 10/01/2009 and ends on 09/3012010. DSHS
has the option, in its sole discretion, to renew the Contract as provided in each Program
Attachment. DSHS is not responsible for payment under this Contract before both parties have
signed the Contract ox before the start date of the Contract, whichever is later.
5. Authority. DSHS enters into this Contract under the authority of Health and Safety Code,
Chapter 1001.
6. Documents Formina,Contract. The Contract consists of the fallowing:
a. Core Contract (this document)
b. Program Attachments:
2010-033567-OOi NSS-WIC LOCAL AGENCY-NOIMM
c. General Provisions (Sub-recipient}
d. Solicitation Document(s), and
e. Contractor's response(s) to the Solicitation Document(s).
f. Exhibits
Any changes made to the Contract, whether by edit or attachment, do not form part of the
Contract unless expressly agreed to in writing by DSHS and Contractor and incorporated herein.
2oa9-sss
Res. 028353
10/20/09
Dept. of State Health Svcs. ~~n~~~
7. Conflictin Terms. In the. event of conflicting terms among the documents forming this.
Contract,~the order of control is first the Core Contract, then the Program Attachments}, then the
General Provisions; then the Solicitation Document, if any, and then Contractor's response to the
Solicitation Document, if any.
8. Payee. The Parties agree that the following payee is entitled to receive payment for services
rendered by Contractor or goods received under this Contract:
Name: CITY OF CORPUS CHRISTI
Address: PO BOX 9277
CORPUS CHRISTI, TX 78469-9277
Vendor Identification Number: 17460005741027
9. Entire Agreement. The Parties acknowledge that this Contract is the entire agreement of
the Parties and that there are no agreements or understandings, written or oral, between them
with respect to the subject matter of this Contract, other than as set forth in this Contract.
By signing below, the Parties acknowledge that they have read the Contract and agree to its
teams, and that the persons whose signatures appear below have the requisite authority to execute
this Contract on behalf of the Warned party.
DEPARTMENT OF STATE HEALTH SERVICES CORPUS CHRISTI-NUECES COUNTY PUBLIC
HEALTH DISTRICT (CITY}
~ ,
By: By. .eJ
Signature ofrAuthorized Official Sigrl ur
Date Date -
Bob Burnette, C.P.M-, CTPM ~ 1 ~~ ~ ' ~ LG / v~~
Print Name and Title
Director, Client Services Contracting Unit .~.~~~~ t
Address /~ j
1100 WEST 49TH STREET ~~ 1.~ C-~i~"ls-hT~ ~~
AUSTIN, TEXAS 78756 Cirty, fate, Zip
(512) 458-7470 ( ~} ~ a~~.P "- ~ c~,~
Telephone Number
Bob.Burnette@dshs.state.tx.us
E m~~I Address for Offic~aI Corr spa ence ' ~ ~j (7~~~
. POV~Bd` 815 t® fpflTi' r'' ~ "' '
9zr~as-~ Asst rtt Cry AttomBy
Far ity Attorney
CONTRACT NO. 2010-0335b7
PROGRAM ATTACHMENT N0.001
PURCHASE ORDER NO. 0000355682
CONTRACTOR: CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT
(CITY}
DSHS PROGRAM NSS-WIC LOCAL AGENCY-NOIMM
TERM: 10/01/2009 THRU:09/30/2010
SECTION I. STATEMENT OF WORK:
Contractor shall administer the Department of State Health Services (DSHS} Special
Supplemental Nutrition Program for Women, Infant, and Children {WIC} to provide
supplemental food instruments, nutrition education, and counseling to enhance good health care
at no cost to low-income pregnant and postpartum women, infants and children identified to be at
nutritional risk. Contractor shall:
A. Perform professional, administrative and clerical services necessary to determine
eligibility, provide food instruments, and provide appropriate nutrition education and
counseling to qualified women, infants and children in a specified geographic area.
Contractor shall ensure adequate staff coverage and uninterrupted delivery of services.
Services shall be performed according to the statures, rules, policies, and directives of
DSHS Special Supplemental Nutrition Program for Women, Infants, and Children
(WIC) and/or as directed by the United States Department of Agriculture {USDA) as
referenced in this Program Attachment. During the term of this Program Attachment,
USDA may issue regulations, instructions, policies and/or directives, which may be
incorporated into the DSHS WIC Program Policy and Procedures Manual and program
rules.
B. Provide services in the authorized geographic service area(s) described in Contractor's
application and agreed to by DSHS. Contractor may change the authorized geographic
service area{s) tivith written approval from DSHS. If DSHS does not approve
Contractor's proposed change of geographic service area(s), Contractor may terminate
this Program Attachment with at least thirty (30} days written notice.
C. Assist DSHS or USDA in the collection of data that will identify benefits of this nutrition
intervention program and furnish financial, health, nutrition education and any other
special reports in a timely manner as required by DSHS WIC Program's written rules and
policies for the compilation of such data.
D. Determine eligibility of applicants through assessment of their categorical income,
residence and nutritional status, and provide nutrition education and counseling to
eligible participants.
PROGRAM ATTACHMENT -Page 1
E. Appoint a Contractor WIC Director/Supervisor.
F. Train Contractor's Local Agency staff.
G. Submit the following reports/plans by the due date:
1. Monthly Incentive Funding Summary Report by the 15`h day of the following
month;
2. WIC Local Agency Performance Measure Report by the 15`h day of the following
month; and
3. WIC Information System Environment (WISE) Cost Report by Apri130, 2010.
H. Conduct outreach to potential participants.
I. Complete surveys as requested.
7. Within ten days of receiving a DSHS request for a Vendor Evaluation, Contractor shall
contact vendor applicant to set up an appointment to conduct the evaluation. Contractor
shall conduct on-site evaluation, completing WIC Vendor Evaluation Forms
and fax/return forms to the DSHS no later than one business day after the on-site
evaluation.
K. Determine participants' access to health care, medical care and other human services, and
make appropriate referrals. Contractor shall have a system in place to provide
participants with appropriate health services or make appropriate referrals to health care
providers under written agreements that ensure confidentiality of participants' personal
information.
L. Issue pre-numbered food instruments furnished by DSHS to qualified participants who
shall use such instruments to obtain specified food items from participating vendors;
maintain complete accountability and security of all food instruments received from
DSHS. Contractor shall be held financially responsible for all unaccounted for food
instruments and/or for the redeemed value of those issued to ineligible participants. In
addition, Contractor shall be held financially liable for issuance of infant formula
instruments that are not authorized or prescribed according to the WIC Policy and
Procedures Manual.
M. Permit DSHS or its agent to install a Very Small Aperture Terminal (VSAT) at all
Contractor WIC clinics and administrative offices using Texas-WIN software on a
network or stand alone personal computer. Installation at all Contractor permanent WIC
sites is required. VSAT installation for new sites or sites moving from one location to
another requires a minimum of 30 days notice.
N. Connect portable computers (notebook or laptop) that use Texas-WIN software daily to a
(VSAT) and transfer data to DSHS. Daily is defined as Monday -Friday and Saturday if
PROGRAM ATTACHMENT -Page 2
W1C services are provided. Portable computers may go to any of the Contractor's WIC
sites for data transfer.
O. Review the immunization records of WIC Program applicantslparticipants to ensure that
immunizations are current. Make appropriate referrals to health care providers for
necessary immunizations.
P. Offer services during extended hours of operation outside the traditional times of 8:00
a.m. to 5:00 p.m., Monday through Friday, according to the Contractor's Annual Plan of
Operations as approved by DSHS and incorporated by reference in this Program
Attachment
Q. Implement or expand Contractor's Breastfeeding Feer Counseling program to provide
training and salary of peer counselors who assist pregnant and breastfeeding WIC
participants in normal breastfeeding situations. If Contractor requests participation in the
Breast Feeding Peer Counseling program, funding for this activity will be contingent on
availability and written approval by DSHS.
R. Implement special projects according to DSHS-approved plan related to nutrition
education, outreach or breastfeeding if project is requested by Contractor and approved
by DSHS. Funding for special projects is contingent upon availability and approval in
writing by DSHS of the Contractor's plan for the special project.
S. Implement lactation services for WIC participants who have breastfeeding problems that
are beyond the expertise of Contractor's local WIC staff and/or peer counselors using
International Board Certified Lactation Consultants or the most qualified equivalent.
Lactation services may also include Contractor's Local WIC Agency staff training and
the provision of lactation equipment. DSHS will provide written approval of
Contractor's plan to use lactation funding. Contractor's plan shall include qualifications
of any non-board certified lactation consultant, which is included in the proposal.
T. Ensure adequate staff coverage and uninterrupted delivery of WIC services if any
member of Contractor's staff is approved in writing by DSHS to participate in the DSHS
Dietetic Internship program. This internship will consist of no less than 1200 hours of
supervised learning experiences in a variety of nutrition-related facilities and will prepare
Contractor's selected staff member to better meet the needs of WIC participants.
U. Stock DSHS-provided manual pumps, single-user and multi-user electric breast pumps
and collection kits and distribute the appropriate pumps and/or kits to eligible WIC
participants.
V. Implement or expand Contractor's use of a Registered Dietitian (RD} who is registered
with the Commission on Dietetic Registration to provide far Contractor that include, or
not limited to: assistance with quality assurance, staff training, assistance with the Annual
Nutrition Education and Breastfeeding plan, individual counseling for high-risk
participants, and facilitated discussion classes.
PROGRAM ATTACHMENT -Page 3
Contractor shall comply with all applicable federal and state laws, rules, regulations, standards,
and guidelines in effec# on the beginning date of this Attachment as amended, including, but not
limited to:
1. Uniform Federal Assistance Regulations, 7 CFR Parts 15, 15a, 15b, 246, 248, 3016, 3017
and 3018;
2. WIC Program and Farmers' Market Nutrition Program Rules, 25 Texas Administrative
Code, § § 31.11-31.37; and
3. Child Nutrition Act of 1966, as amended, 42 USC 1786.
The fallowing documents are incorporated by reference and made a part of this Program
Attachment:
1. DSHS Standards for Public Health Clinic Services, revised January 31, 2004;
2. USDA Food and Nutrition Service (FNS} Guidelines;
3. USDA FNS Instructions issued under the FNS Directives Management System; and
4. Current WIC Policy and Procedures Manual.
Within thirty (30} days of receipt of an amended standard(s) or guideline(s), Contractor shall
inform DSHS, in writing, if it shall not continue performance under this Program Attachment in
compliance with the amended standard(s) or guideline(s). DSHS may terminate the Program
Attachment immediately ar within a reasonable period of time as determined by DSHS.
All activities related to WIC, including timeframes, budget, and any revisions shall be approved
by DSHS.
SECTION II. PERFORMANCE MEASURES
The following performance measures will be used to assess, in part, Contractor's effectiveness in
providing the services described in this Program Attachment, without waiving the enforceability
of any of the other terms of the contract.
Contractor shall ensure:
1} An average of 95% of families a quarter who participate in DSHS WIC Program by
receiving food instruments shall also receive nutrition education classes or individual
counseling services to coincide with food instrument issuance;
2) Of ail pregnant women who enter DSHS WIC Program, an average of 20% a quarter
shall be certified as eligible during the period of the first trimester of their pregnancy;
3) An average of 85.5% of clients a quarter who are enrolled in the DSHS WIC Program,
excluding dual participants, transfer locked andlor migrant clients, shall participate as
food instrument recipients each month (breast-feeding infants are .also included in the
client count}; and
PROGRAM ATTACHMENT -Page 4
4) 98% of participants who indicate during the enrollment process for the DSHS WIC
Program that they have no source of health care shall be referred to at least one (1) source
of health care at certification of eligibility.
Contractor shall submit the WIC Local Agency Performance Measure Report which describes
Contractor's efforts towards meeting performance measures. The report shall be in an approved
format as provided by DSHS, and shall be completed and submitted to DSHS within fifteen (15)
calendar days after the end of each month.
SECTION III. SOLICITATION DOCUMENT: NIA
SECTION N. RENEWALS: DSHS may renew this contract for one renewal period if funds are
available.
SECTION V. PAYMENT METHOD: Cost reimbursement
SECTION Vi. BILLING INSTRUCTIONS:
Contractor shall request payment using the State of Texas Purchase Voucher (Form B-13) and
Financial Status Reports (FSR) and submit by electronic mail to DSHS Contract Development
and Support Branch at WicVouchersC~dshs.state.tx.us
SECTION.VII. BUDGET:
SOURCE OF FUNDS: CFDA # 10.557
All categories of costs billed to DSHS WIC Program, and allocation of such costs, shall be in
accordance with the "Plan to Allocate Direct Costs" (PADC) submitted by Contractor and
approved by the DSHS WIC Program. This document is incorporated herein by reference and
made a part of this Program Attachment.
Total reimbursements will not exceed $845,500.00.
SECTION VIII. SPECIAL PROVISIONS:
General Provisions, Compliance and Reporting Article I, Section 1.07, Statutes and
Standards of General Applicability, is hereby amended to include the following:
Contractor shall comply with all provisions required by implementing the regulations of
the Department of Agriculture, 7 CFR Part 246, 248; Department of 3ustice Guidelines
for Enforcement of Title VI, Civil Rights Act of 1964; 28 CFR § 50.3 and 28 CFR Part
42; and Food & Nutrition Service (FNS) directives and guidelines, to the effect that no
person will, on the grounds of race, color, national origin, sex, age, or disability be
excluded from participation under any program or activity for which Contractor receives
PROGRAM ATTACHMENT -Page 5
federal financial assistance from FNS; and hereby gives assurance that it shall
immediately take measures necessary to implement this Program Attachment.
Contractor shall compile data, maintain records and submit reports, as required, to permit
effective enforcement of the nondiscrimination laws and permit authorized USDA and
State of Texas personnel, during normal working hours, to review such records, books,
and accounts as needed to ascertain compliance with the nondiscrimination laws. The
Department of Agriculture, Food and Nutrition Service (USDA), has the right to seek
judicial enforcement if Contractor violates any nondiscrimination laws. This Assurance
is binding on Contractor, its successors, transferees, and assignees, as long as they
receive assistance or retain possession of any assistance from the Department of
Agriculture. The person or persons whose signatures appear on the Core Contract are
authorized to sign this Assurance on behalf of Contractor.
Contractor shall comply with alI of the requirements of the current WIC Policy and
Procedures Manual and Program rules as well as state and federal laws and amendments
governing or regulating the WIC Program. A copy of the current WIC Policy and
Procedures Manual has been made available to Contractor. The WIC Policy and
Procedures Manual, and alI revisions made to the WIC Policy and Procedures Manual are
incorporated into this Agreement by reference. Contractor has a duty to remain familiar
with the contents within the WIC Policy and Procedures Manual.
Contractor is responsible far ensuring that employees or agents acting on behalf of
Contractor comply with all of the requirements of the WIC Policy and Procedures
Manual, Program rules and all state and federal laws and amendments governing and
regulating the WIC Program.
General Provisions, Payment Methods and Restrictions Article IV, Section 4A1, Payment
Methods, is hereby modified to include the following paragraphs:
The participant caseload will be assigned by DSHS by giving written notice to
Contractor. The participant caseload is subject to change upon written notice to
Contractor from DSHS with Contractor's concurrence. Contractor assumes liability for
all food costs resulting from Contractor exceeding its assigned caseload. The number of
individuals served in excess of assigned caseload are not to be included in the calculation
of earned administrative funds as described below.
DSHS will reimburse Contractor for administrative costs incurred when determining
eligibility, providing appropriate nutrition education and counseling, issuing food
instruments, making participant referrals, vendor evaluation, outreach, start-up costs and
general administrative support.
Administrative costs will be reimbursed based on actual costs, but not to exceed the
"maximum reimbursement" set out below, based upon the sum of the participants who
actually receive food instruments each month plus infants who do not receive any food
instruments whose breastfeeding mothers were participants to the extent that the total so
PROGRAM ATTACHMENT -Page 6
derived does not exceed Contractor's total assigned caseload within any given month.
Surplus funds (the amount by which maxirrium reimbursements exceed actual costs) can
be accumulated and carried forward within the Program Attachment term. Surplus
encumbered by September 30 shall be billed and vouchers received by DSHS no later
than sixty (60} calendar days following the terra of the program attachment.
PARTICIPANTS SERVED PER MONTH MAXIMUM REIMBURSEMENT:
During the term of the Program Attachment, Contractor shall earn administrative funds at
the rate of $11.81 far each participant served as defined above.
DSHS may pay for additional goods or services as specified in this Attachment if
provided by Contractor during the term of this Attachment {but not otherwise paid during
the term of this Attachment) if it is in the best interest of DSHS to do so, and funds are
available.
The Contractor will be notified if a change in funding occurs and will have thirty (30)
days to provide written notice to the DSHS if it intends to terminate this Program
Attachment.
Contractor agrees that:
{1} Contractor shall identify and document separately not less than 19% of total
administrative costs as expenditures directly related to nutrition education and
counseling. Nutrition education and counseling expenditures shall be supported
by documentation of participant attendance or non-attendance within the DSHS
WIC Program.
(2) DSHS will reimburse Contractor for administrative expenses at a rate not greater
than 5.26 times the amount of properly documented expenditures for nutrition
education and counseling, but not more than is earned based on actual
participation not to exceed Contractor's assigned participant caseload, plus any
incentive funds allocated to Contractor by DSHS.
{3) DSHS will limit (cap) reimbursement of Contractor's indirect costs at twenty (20)
percent applied to Contractor's total direct salaries plus benefits reimbursed by
DSHS.
(4) DSHS will identify annually to Contractor an amount of funds that shall be spent
for breastfeeding promotion. The allocation of breastfeeding funds to Contractor
will be based on Contractor's proportional share of the statewide combined total
of pregnant and breastfeeding participants as reported to DSHS WIC Program.
{5) DSHS WIC Program also reserves the right to withhold a proportionate amount of
earned administrative funds when evidence exists that nutrition education and/or
PROGRAM ATTACHMENT -Page 7
breastfeeding promotion is not being provided by Contractor, or Contractor is not
complying with the provisions of USDA and/or DSHS directives.
(6) DSHS reserves the right to utilize a competitive offering for the award of any
future contracts at the end of the term of this Program Attachment.
(7} DSHS may amend or terminate this Program Attachment if available funds
become reduced, depleted, or unavailable during the term of the Program
Attachment to the extent that the WIC Program is unable to provide
administrative funding at the rate(s) stated in this Program Attachment. DSHS
will provide written notification to Contractor of such fact.
($) DSHS may pay for additional services as specified in this Frogram Attachment if
provided by Contractor during the term of this Program Attachment (but not
otherwise paid during the-term of this Program Attachment) if it is in the best
interest of DSHS and DSHS WIC Program to do so. If Contractor exceeds the
amount of earned administrative funds as stated above, Contractor shall continue
to bill DSHS for the services provided. If additional funds become available at a
later date for the provision of these services, DSHS WIC Program may pay
Contractor a share of these funds.
(9) DSHS may provide incentives to Contractor's Local WiC Agencies for
participants who are provided WIC services outside the normal traditional hours
to the extent that federal funding is available.
{ 10) During the term of this Program Attachment, DSHS may adjust the base
reimbursement rate as defined in' this Program Attachment if it is in the best
interest of DSHS and the DSHS WIC Program and if administrative WIC Grant
funds change.
Contractor shall indicate separately on the face of the claim for reimbursement (State of
Texas Purchase Voucher, Form B-13} the costs associated with nutrition education,
breast-feeding, and other administrative costs.
General Provisions, Payment Methods and Restrictions Article IV, Section 4.04, Working
Capital Advance, is not applicable to this Program Attachment. However, Contractor will be
allowed the option of receiving a two (2) month cash advance in accordance with WIC Program
Policy and Procedures.
General Provisions, Records Retention Article VIII, Section $.01, Retention shall be replaced
with the following:
Recordkeeping requirements. Contractor shall maintain full and complete records concerning
Program operations. Such records shall comply with 7 CFR Part 3016 and the following
requirements:
PROGRAM ATTACHMENT -Page $
(1) Records shall include, but not be limited to, information pertaining to financial
operations, food delivery systems, food instrument issuance and redemption, equipment
purchases and inventory, certification, nutrition education, civil rights and fair hearing
procedures.
(2) All records shall be retained for a minia~x~um of three years following the date of
submission of the final expenditure report for the period to which the report pertains. If
any litigation, claim, negotiation, audit ar other action involving the records has been
started before the end of the three-year period, the records shall be kept until all issues are
resolved, or until the end of the regular three-year period, whichever is later. If USDA
deems any of the WIC program records to be of historical interest, it may require DSHS
or the Contractor to forward such records to the USDA whenever either entity is
disposing of them.
(3) Records for nonexpendable property acquired in whole or in part with WIC program
funds shall be retained for three years after its final disposition.
(4} All records shall be available during normal business hours for representatives of the
USDA, DSHS and the Comptroller General of the United States to inspect, audit, and
copy. Any reports or other documents resulting from the examination of such records that
are publicly released may not include confidential applicant or participant information.
General Provisions, Notice Requirements Article X, Section 10.01, Child Abuse Reporting
Requirement, is hereby amended to include the following:
If Contractor chooses to interview a client to determine if an affirmative defense to
prosecution exists, as defined by DSHS, which would allow them under the DSHS
policy to not make a report of child abuse, the Contractor shall conduct these interviews
in the following manner:
• For ineligible clients, the interview shall be conducted after the entire WIC visit is
done. For eligible clients, the interview may occur at the point in time when all
WIC activities, including communication of eligibility and individual counseling,
are completed with the exception of food instrument issuance.
_ • The interview shall be conducted only by a competent authority ar a supervisor and
in a confidential setting.
• Prior to asking the client any questions, the interviewer shall inform the client that
the questions have no bearing on the client's WIC eligibility and receipt of services.
General Pravisions, General Business Operations of Contactor Article XII, Section 12.02,
Management and Control Systems, Item a, regarding internal budgeting and Item c, regarding
billing, collection, and fee schedules are not applicable to this Program Attachment.
General Provisions, General Business Operations of Contractor Article XII, Section 12.06,
Overtime Compensation, is not applicable to this Prograrn Attachment.
PROGRAM ATTACHMENT -Page 9
General Provisions, General Business Operations of Contractor Article XII, the last three
sentences of Section 12.20, Equipxnent (including Controlled Assets) Purchases, are not
applicable to this Program Attachment.
General Provisions, General Business Operations of Contractor Article XII, Sectian 12.23,
Property Inventory and Protection of Assets, is amended to include the fallawing:
Contractor shall also maintain an inventory of equipment and designated reportable assets
placed in the custody of the Contractor by DSHS. Contractor shall submit an annual
cumulative report to DSHS Property Management Group in a format and upon a delivery
date designated by DSHS. Contractor shall administer a program of maintenance, repair
and protection of assets under this Contract so as to assure their full availability and
usefulness. In the event Contractor is indemnified, reimbursed, or otherwise compensated
for any loss of, destruction of, or damage to the assess provided under this Contract, it
shall use the proceeds to repair or replace said assets.
General Provisions, General Business Operations of Contractor Article XII, Section 12.26,
Property Acquisitions, is not applicable to this Program Attachment.
General Provisions, General Terms Article XIII, Section 13.15, Amendment,. shall be replaced
with the following:
Parties agree that the Department may unilaterally reduce funds pursuant to the terms of
this Contract without the written agreement of Contractor. All other amendments to this
contract must be in writing through letters of amendment. By signing this Contract,
Contractor agrees to abide by all letters of revisions to the Contract.
PROGRAM ATTACHMENT -Page 10
TEXAS DEPARTMENT 4F STATE HEALTH SERVICES
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS GRANTS LOANS AND COOPERATIVE
AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief that:
(1} No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or an employee of any agency, a
member of Congress, an officer or employee of Congress, or an employee of a member of Congress in
connection with khe 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 any federal contract, grant, loan, or cooperative agreement.
(2} If any funds other than federal appropriated funds have been gold ar will be paid to any person for
Influencing or attempting to influence an officer or employee of any agency, a member of Congress,
an officer or employee of Congress, or an employee of a member of Congress in connection with this
federal contract, grant. loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification 6e included in the award
documents for all subawards at al] tiers (including subcontracts, subgrants, and contracts under grants,
loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by Section 1352, Title 3I, U.S. Code. Any person who fails to file the required
certification shah be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each
such failure.
/R
G%~1.~~
Sign r
Print ma of Authorized Individual
~~ ~d~~
Date
t0
201x-033567
Application or Contract Number
CORPUS CHRISTI-NUEC)MS COUNTY
PUBLIC HEALTH DISTRICT (CITY)
Organization Name
Ass'nt C'lty Attorney
For Ci#y Attorney
CSCU # EF29-12374 -Revised 48.10.07