HomeMy WebLinkAboutPR 19141: APPROVING FY 2015-2016 WITH DEPARTMENT OF STATE HEALTH SERVICES , HEALTH CARE PROGRAM City of
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Texas
DATE: September 2, 2015
To: Brian McDougal, City Manager
From: Judith A. Smith, RN, BSN
RE: Approval of Contract Between the Department of State Health Services Primary
Health Care Program and the City of Port Arthur
Nature of the Request: This is a renewal contract with the Texas Department of State Health
Services for funding to provide preventive health services including immunizations, diagnosis
and treatment of acute illnesses, family planning, health education, and diagnostic tests including
lab and x-ray for eligible participants at or below 150% of the current federal poverty guidelines.
Analysis, Considerations: The contract period starts 09/01/2015 and ends 08/31/2016 and
provides for salaries and fringe benefits for one full-time eligibility/billing clerk.
Recommendations: It is recommended that the City Council approve P.R. No. 19141 for the FY
2016 contract between the Department of State Health Services Primary Health Care Program
and the City of Port Arthur program to provide primary and preventive health care services to
eligible participants.
Budget Considerations: The total budget is $70,000 to cover the cost of salaries, fringe benefits,
supplies, contractual and travel.
"REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR"
P.O.BOX 1089•PORT ARTHUR,TX 77641-1089.409/983-8101•FAX 409/982-6743
P. R. NO. 19141
09/02/2015-jas
RESOLUTION NO.
A RESOLUTION APPROVING THE FY 2015-2016 CONTRACT
BETWEEN THE CITY OF PORT ARTHUR AND THE
DEPARTMENT OF STATE HEALTH SERVICES PRIMARY
HEALTH CARE PROGRAM IN THE AMOUNT OF $70,000.00
WHEREAS, the contract between the City of Port Arthur and the Department of
State Health Services provides financial assistance to the Port Arthur City Health
Department to supplement the delivery of public health services; and,
WHEREAS, this program provide preventive health services including
immunizations, diagnosis and treatment of acute illnesses, family planning, health
education, and diagnostic tests including lab and x-rays for eligible participants at or
below 150%of the current federal poverty guidelines: and,
WHEREAS, total payments from this contract shall be in the amount of$70,000
for the period September 1, 2015 through August 31, 2016.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF PORT ARTHUR:
Section 1. That,the facts and opinions in the preamble are true and correct.
Section 2. That, the City Council of the City of Port Arthur hereby approves
the contract amendment between the City of Port Arthur and the Department of State
Health Services.
P. R. NO. 19141
Page 2 — 09/02/2015
Section 3. That, the City Council deems it is in the best interest of the City to
approve and authorize the City Manager to execute the contract amendment between the
Department of State Health Services and the City of Port Arthur for Primary Health Care
Services, as delineated in Exhibit"A."
Section 4. That, a copy of the caption of this Resolution be spread upon the
Minutes of the City Council.
READ, ADOPTED, AND APPROVED, this day of September, 2015
A.D., at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the
following Vote:
AYES: Mayor:
Councilmembers:
NOES:
Mayor
ATTEST:
Sherri Bellard, City Secretary
P. R. NO. 19141
Page 3—09/02/2015
APPROVED AS TO FORM:
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APPROVED FOR ADMINISTRATION:
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Brian McDougal Juh Smith, RN, BSN
City Manager Director of Health Services
EXHIBIT "A"
DEPARTMENT OF STATE HEALTH SERVICES
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This contract, number 2016-048585 (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 CITY
OF PORT ARTHUR (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 Payment Method(s). The total amount of this Contract
is $70,000.00, and the payment method(s) shall be as specified in the Program Attachments.
3. Funding 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 or 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 09/01/2015 and ends on 08/31/2016. 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 or 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,
Section 12.051.
6. Documents Forming Contract. The Contract consists of the following:
a. Core Contract(this document)
b. Program Attachments:
2016-048585-001 CHS - PRIMARY HEALTH CARE
c. General Provisions (Sub-recipient)
d. Solicitation Document(s) -NA
e. Contractor's response(s)to the Solicitation Document(s) -NA
f. Exhibits -NA
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.
92648-1
7. Conflicting 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 Attachment(s), 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: PORT ARTHUR CITY HEALTH DEPT
Address: 449 AUSTIN AVENUE
PORT ARTHUR, TX 77640-5802
Vendor Identification Number: 17460018850011
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.
92648-1
By signing below, the Parties acknowledge that they have read the Contract and agree to its
terms, and that the persons whose signatures appear below have the requisite authority to execute
this Contract on behalf of the named party.
DEPARTMENT OF STATE HEALTH SERVICES CITY OF PORT ARTHUR
By: By:
Signature of Authorized Official Signature
Date Date
Evelyn Delgado
Printed Name and Title
Assistant Commissioner for Family and
Community Health Services Address
1100 WEST 49TH STREET
AUSTIN, TEXAS 78756 City, State, Zip
512.776.7321
Telephone Number
Evelyn.Delgado@dshs.state.tx.us
E-mail Address for Official Correspondence
92648-1
2016-048585-001
Categorical Budget:
PERSONNEL $33,804.00
FRINGE BENEFITS $10,141.00
TRAVEL $1,843.00
EQUIPMENT $0.00
SUPPLIES $3,212.00
CONTRACTUAL $21,000.00
OTHER $0.00
TOTAL DIRECT CHARGES $70,000.00
INDIRECT CHARGES $0.00
TOTAL $70,000.00
DSHS SHARE $70,000.00
CONTRACTOR SHARE $0.00
OTHER MATCH $0.00
Total reimbursements will not exceed $70,000.00
Financial status reports are due: 12/31/2015, 03/31/2016, 06/30/2016, 10/17/2016
DOCUMENT NO. 2016-048585
ATTACHMENT NO. 001
PURCHASE ORDER NO. 0000418814
CONTRACTOR: CITY OF PORT ARTHUR
DSHS PROGRAM: CHS -PRIMARY HEALTH CARECHS/PHC - FY16 PHC Categorical
TERM: 09/01/2015 THRU: 08/31/2016
SECTION I. STATEMENT OF WORK:
The purpose of the Department of State Health Services (DSHS) Primary Health Care (PHC)
Program is to provide comprehensive preventive and primary health care services to Texas residents
with a gross family income at or below 200 percent of the federal poverty level (FPL). Contractor
shall provide the following priority services: diagnosis and treatment,emergency medical services,
family planning services,preventive health services,including immunizations,health education,and
laboratory,x-ray,nuclear medicine,or other appropriate diagnostic services.In addition to priority
services, Contractor may provide the following optional PHC services: nutrition services, health
screening, home health care, dental care,transportation, prescription drugs, environmental health,
podiatry, and social services.
Contractor shall comply with all applicable federal and state laws,rules,regulations,standards,and
guidelines in effect on the beginning date of this Program Attachment unless amended,including,but
not limited to:
• Texas Health and Safety Code, Chapter 31, Primary Health Care; and
• DSHS Primary Health Care (PHC) Program Rules, 25 TAC, §§39.1-39.11.
The following documents are incorporated by reference and made a part of this Program Attachment:
• DSHS FY 2016 Primary Health Care Competitive Request for Proposal (RFP) 537-16-
142081, issued April 1, 2015, and any revisions;
• Contractor's response to DSHS FY 2016 Primary Health Care Competitive RFP, and any
revisions;
• Current DSHS Primary Health Care Program Policy Manual, and any revisions;
• Department of State Health Services Standards for Public Health Clinic Services, revised
August 2004, or latest revision;
• Current DSHS Quality Management Core Tool Onsite Evaluation Report,and any revisions,
and current Quality Management Core Tool Monitoring Instructions, and any revisions;
• Current DSHS Quality Management Primary Health Care Onsite Evaluation Report,and any
revisions, and current Quality Management PHC Tool Monitoring Instructions, and any
revisions.
ATTACHMENT—Page 1
• Current DSHS Quality Management Clinical Record Review Tool, and any revisions; and
• Current DSHS Quality Management Eligibility and Billing Record Review Tool, and any
revisions.
Contractor shall notify DSHS in writing,within thirty(30)days of the vacancy of a position funded
under this Program Attachment. Contractor's contract award may be subject to a decrease equal to
the salary savings (salary and benefits) realized as a result of the vacancy.
Contractor shall begin operations within thirty(30)days of contract execution. Contractor's failure
to begin operations within thirty (30) days of contract execution may result in a decrease in
Contractor's contract award. DSHS reserves the right to adjust funding allocations pursuant to the
terms of the contract. Funding may vary and is subject to change each budget period.All activities
shall be performed in accordance with Contractor's final approved work plan.
Within thirty(30)days of receipt of an amended standard(s)or guideline(s),Contractor shall inform
DSHS in writing if it will not continue performance under this Program Attachment in compliance
with the amended standard(s) or guideline(s). DSHS may terminate the Program Attachment
immediately or within a reasonable period of time as determined by DSHS.
DSHS Health Service Regional Director or designee,as coordinator of regional services,will assist
DSHS staff in providing direction to Contractor. DSHS personnel may,from time to time,provide
technical assistance and training to Contractor. Contractor shall cooperate with DSHS staff to attain
the goals of policy application, coordinated services, and quality assurance.
Eligible Population
For an individual to receive PHC services,three(3)criteria shall be met:
• Texas resident;
• Gross family income at or below 200%of the adopted Federal Poverty Level (FPL); and
• Not eligible for other non-DSHS programs/benefits providing the same services.
Service Area:
Location: Multiple clinic locations identified on DSHS website at: https://www.txclinics.com.
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 contract Attachment,without waiving the enforceability of
any of the other terms of the contract.
Contractor shall provide services to a minimum of 389 unduplicated clients who live or
receive services in the following county(ies): Jefferson
ATTACHMENT—Page 2
The number of unduplicated clients to be served is the target number that Contractor will be
expected to reach to meet the performance measure.
Performance measure data shall be reported in accordance with requirements set forth in the table in
Section VIII. SPECIAL PROVISIONS.
Number of Unduplicated Clients Served:DSHS will monitor Contractor's performance measure
activity. If the number of unduplicated clients served is less than that projected in Contractor's final
approved work plan, Contractor's funding award may be subject to a decrease for the remainder of
the Program Attachment period.
SECTION III. SOLICITATION DOCUMENT: Request for Proposal for Primary Health Care
issued on April 1, 2015, RFP# 537-16-142081.
SECTION IV. RENEWALS:
The Program Attachment may be renewed for up to four (4) additional one-year budget periods.
Continued funding of the project in future years is contingent upon the availability of funds and the
satisfactory performance of the contractor during the prior budget period. Funding may vary and is
subject to change each budget period.
Failure to expend funds, submit billing and data in a timely manner, and failure to meet program
performance measures and other requirements may result in reduction and/or termination of funding.
SECTION V. PAYMENT METHOD: Cost Reimbursement(Categorical)
SECTION VI. BILLING INSTRUCTIONS:
Contractor shall submit requests for reimbursement on a State of Texas Purchase Voucher(Form B-
13)and Supporting Schedule for DSHS Categorical Reimbursement Voucher(Form B-13P)monthly
within thirty(30)days following the end of the month in which the costs were incurred. Contractor
shall submit a reimbursement request as a final purchase voucher no later than forty-five(45)days
following the end of the applicable Program Attachment term(s)for costs encumbered on or before
the last day of the Program Attachment term. Reimbursement requests received in DSHS offices
more than forty-five(45)following the end of the applicable Program Attachment term will not be
paid.
Forms B-13 and B-13P shall either be e-mailed to the Family and Community Health Services
Division, Performance Management Unit, Contract Development & Support Branch (CDSB) at
cdsb@dshs.state.tx.us,or faxed to CDSB at: (512) 776-7521.
Forms B-13 and B-13P shall be emailed also to the DSHS Claims Processing Unit (CPU) at
invoices@dshs.state.tx.us,or faxed to CPU at(512)776-7442.
ATTACHMENT—Page 3
Forms B-13 and B-13P shall be submitted each month even if there are zero expenditures.Forms B-
13 and B-13P shall be submitted each month for actual expenditures of the program even if the
contract limit has been reached.
A Financial Status Report(Form 269a)shall be submitted at the end of the Program Attachment term
in accordance with the modified schedule outlined in Section VIII. SPECIAL PROVISIONS. The
original Form 269a shall be signed and emailed, faxed or mailed to the DSHS Claims Processing
Unit at:
Claims Processing Unit, Mail Code 1940
Department of State Health Services
P.O. Box 149347
Austin, Texas 78714-9347
In addition, Contractor shall submit an electronic version of Form 269a to CDSB via email at
cdsb@dshs.state.tx.us.
SECTION VII. BUDGET: Cost Reimbursement(Categorical)
Funding is further detailed in the attached Categorical Budget.
Contractor is allocated through this contract Attachment for reimbursement of allowable PHC
costs on a cost reimbursement basis.
Contractor shall include funds in the Travel budget category for a minimum of two(2)staff
members to attend one required in-state meeting for two (2)days.
Contractor shall not move funds from the Contractual budget category into any other budget
category without prior approval from DSHS.
Contractor's DSHS PHC share of fringe benefits shall not exceed 30% of the approved
DSHS PHC share of direct Personnel costs.
Contractor's DSHS PHC share of indirect costs shall not exceed 15%of the approved DSHS
PHC share of direct Personnel costs.
Total payments will not exceed $70,000.00.
SOURCE OF FUNDS: State of Texas
DUNS Number: 137134909
SECTION VIII. SPECIAL PROVISIONS:
ATTACHMENT—Page 4
For purposes of this Program Attachment,the following provisions shall apply:
General Provisions,Compliance and Reporting Article,Reporting Section,is revised to include:
Desk Reviews: Contractor shall provide information and supporting documentation as
requested by DSHS to conduct desk reviews to verify accurate reporting/billing for the PHC
Program. Failure to submit requested information in a timely manner may result in sanctions
as authorized by the contract. If Contractor's desk review results in a finding of
misappropriation of DSHS PHC co-payment (co-pay) policy, Contractor shall reimburse
client(s).
Contractor shall submit monthly,quarterly,and annual programmatic reports and/or financial
vouchers/reports as required in the PHC Policy Manual. Other data and/or reports deemed
necessary by DSHS may be required, upon reasonable notice to Contractor.
Contractor shall provide the following routine reports to DSHS in compliance with the dates
and conditions specified below:
Report Title Submission Frequency Due Date
PHC 250 Report Monthly By the last working day of the
month following service;
submit simultaneously with
the corresponding monthly B-
13 Purchase Voucher.
Program Promotion Plan One time (beginning of October 15
fiscal year)
Program Promotion Report Quarterly December 31
March 31
June 30
August 31
Staff Training Plan Annually—within 45 days October 15
of the beginning of the
contract year
Contractor's Co-pay Policy One time (beginning of September 30
and Fee Schedule fiscal year)
ATTACHMENT—Page 5
State of Texas Purchase Monthly By the last working day of the
Voucher(Form B-13)and month following service;
corresponding supporting submit simultaneously with
document, Supporting the corresponding final,
Schedule for DSHS PHC complete monthly report, PHC
Categorical Reimbursement 250.
Voucher(Form B-13P),
B-13P Supporting Monthly By the last working day of the
Documentation month following service;
submit simultaneously with
the corresponding monthly B-
13 Purchase Voucher and the
PHC 250 monthly report.
Financial Status Report Quarterly
(FSR) Sept—Nov December 31
Dec—Feb March 31
Mar—May June 30
June—Aug October 15
PHC 350 Annual Report Annually-within sixty (60) October 30
days after the end of the
contract term
Monthly Report: The Monthly Report(Form PHC 250)shall be sent to cdsb@dshs.state.tx.us
by the last working day of the month following the month of service.Contractor shall provide
requested data according to specified criteria(e.g.,age,gender,number of unduplicated clients,
etc.)as detailed in PHC 250 report.Vouchers will not be paid until the corresponding monthly
PHC 250 report is received and approved.
Annual Report:Contractor shall provide an annual program report(Form PHC 350)to DSHS
no later than sixty (60) days after the end of the contract term. Contractor shall provide
requested data according to specified criteria (e.g., age, gender, race, ethnicity, number of
unduplicated clients, etc.) as detailed in PHC 350 report.
Failure to submit required reports in a timely manner may result in sanctions according to
provisions of the contract. Voucher will not be paid until the corresponding monthly report
is received/approved.
Data Collection:Contractor shall maintain data and management information systems that are
compatible with accurate reporting of contract performance.
General Provisions, Compliance and Reporting Article,Client Financial Eligibility Section, is
revised to include:
ATTACHMENT— Page 6
Eligibility: All individuals considered for the PHC program shall be screened and
determined eligible using a DSHS-approved screening process in accordance with the
PHC Policy Manual. Contractor may not alter DSHS eligibility form(s) or use another
eligibility form unless it is submitted to and approved by DSHS PHC Program.
General Provisions, Services Article, Fees for Personal Health Services Section, is revised to
include:
Contractor shall make reasonable efforts to investigate and apply for all other sources of third
party funding available to, or identified by, the patient before submitting DSHS Program
claims for allowable costs.
Fee Collection: Contractor is responsible for implementation of policies and procedures for
charging,billing,and collecting fees for individual client services provided.These policies and
procedures shall be reviewed by Contractor's policy board or advisory committee.
Co-payment:Contractor may assess a co-payment(co-pay)from clients who receive services
under this Program Attachment, in accordance with the DSHS PHC policy manual. A client
shall not be denied a service due to inability to pay.
If Contractor charges client co-pay, Contractor shall adhere to the PHC fee schedule in the
PHC Policy Manual.Contractor shall submit the entity's FY16 PHC client co-pay policy and
fee schedule to the PHC mailbox(nrimaryhealthcare(2i dshs.state.tx.us)for review and approval
by September 30,2015.The Contractor shall waive the fee if a client self-declares an inability
to pay.No client shall be denied services based on an inability to pay.
Client co-pays shall be reported as program income on the monthly State Purchase Voucher
Supporting Document(Form B-13P)and the quarterly Financial Status Report(FSR or Form
269a). See Appendices in the DSHS PHC Policy and Procedure Manual for the DSHS client
co-pay fee schedule.
General Provisions, Funding Article,Program Income Section, is revised to include:
Client co-pays collected as a result of the Program Attachment(s) during the term of the
Program Attachment(s)are considered program income. Contractor shall identify and report
program income monthly and annually as specified in the DSHS Contractor's Financial
Procedures Manual (CFPM)and in the DSHS PHC Policy Manual.
This section shall not be construed to apply to funds raised by Contractor from fund-raising
activities or donations.Fund raising includes membership drives or special events used to raise
program funds. Donations include monies donated to the program by individuals and private
groups, such as churches or other organizations.
ATTACHMENT—Page 7
Program income generated under this contract shall be used to further the program objectives
of the State/Federal statute under which the Statement of Work for the Program Attachment
was made. The receipt and expenditure of all program income shall also be reported monthly
on the Supporting Schedule for DSHS Categorical PHC Reimbursement Vouchers(Form B-
13P).
General Provisions, Payment Methods and Restrictions Article, Payment Methods Section, is
revised to include:
Submission
Report Title Frequency Due Date
B-13 State Purchase Voucher Monthly Within 30 days following the end of the
month of service and within 45 days after
the end of the contract term
B-13P Supporting Monthly Within 30 days following the end of the
Documentation month of service and within 45 days
after the end of the contract term
Financial Status Report Quarterly December 31,2015
(FSR) Sept—Nov 2015 March 31, 2016
Dec—Feb 2016 June 30,2016
Mar—May October 15, 2016
June-Aug
Funds made available in the above funding period shall be used only for services performed during
the same period. Funds that are not expended for services during that period cannot be used for
services in any other period, or any other Program Attachment term.
Billing Activity:DSHS shall distribute funds to maximize the delivery of authorized services
to eligible clients.DSHS will monitor Contractor's billing activity. Contractor may be subject
to contract amount decreases if Contractor's billing activity is less than projected.
General Provisions, Payment Methods and Restrictions Article, Working Capital Advance
Section, is revised to include:
The Primary Health Care Program Attachment does not allow a working capital advance.
General Provisions, Payment Methods and Restrictions Article is revised to include:
Contractor shall submit quarterly FSRs to CDSB and the Claims Processing Unit by the last
business day of the month following the end of each quarter of the Program Attachment term
for Department review and financial assessment.Vouchers for the corresponding month will
not be processed until the quarterly FSR is received, reviewed, and approved by DSHS
Contractor shall submit the final FSR no later than forty-five(45)days following the end of
ATTACHMENT—Page 8
the applicable term. The final voucher of the fiscal year will not be processed for payment
until the final FSR is received, reviewed, and approved by DSHS.
General Provisions,Terms and Conditions of Payment Article,Withholding Payments Section,is
revised to include:
The final voucher of the fiscal year will not be processed for payment until the final FSR is
received, reviewed, and approved by DSHS.
General Provisions,Terms and Conditions of Payment Article,Acceptance as Payment in Full
Section, is replaced with:
Contractor shall accept reimbursement or payment from DSHS and any applicable fees
from clients for clinical services as payment in full for services or goods provided to
clients. Contractor shall not seek additional reimbursement or payment for services or
goods from clients other than applicable fees for clinical health services.
•
General Provisions,Access Article,Inspection and Audit of Records Section, is revised to include:
Contractor shall allow DSHS to conduct on-site quality assurance reviews as deemed necessary
by DSHS. Unsatisfactory review findings may result in implementation of General Provisions,
Breach of Contract and Remedies for Non-Compliance.
General Provisions, General Business Operations of Contractor Article, Notice of
Organizational Change Section, is revised to include:
Contractor shall notify the Performance Management Unit,Contract Development and Support
Branch, of any clinic site information changes, e.g., changes in contact person, hours of
operation, address, National Provider Identification (NPI) number, Texas Provider
Identification (TPI) number,and the closure, relocation, and/or opening of clinic site(s).
General Provisions,General Business Operations of Contractor Article,Equipment Section,is
revised to include:
Contractor shall initiate the purchase of all equipment approved in writing by DSHS by the last
business day of November 2015.
ATTACHMENT—Page 9
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
As the duly authorized representative(Signor)of the Contractor, I hereby certify that
the statements made by me in this certification form are true, complete and correct to
the best of my knowledge.
Did your organization have a gross income, from all sources, of less than $300,000 in
your previous tax year? ❑ Yes x No
If your answer is "Yes", skip questions "A", "B", and "C" and finish the certification.
If your answer is "No", answer questions "A" and "B".
A. Certification Regarding%of Annual Gross from Federal Awards.
Did your organization receive 80% or more of its annual gross revenue from federal
awards during the preceding fiscal year? ❑ Yes 13 No
B. Certification Regarding Amount of Annual Gross from Federal Awards.
Did your organization receive $25 million or more in annual gross revenues from federal
awards in the preceding fiscal year? I I Yes ❑x No
If your answer is "Yes" to both question "A" and "B", you must answer question "C".
If your answer is "No" to either question "A" or "B", skip question "C" and finish the
certification.
C. Certification Regarding Public Access to Compensation Information.
Does the public have access to information about the compensation of the senior
executives in your business or organization (including parent organization, all branches,
and all affiliates worldwide) through periodic reports filed under section 13(a) or 15(d)
of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the
Internal Revenue Code of 1986? ❑ Yes n No
If your answer is "Yes"to this question,where can this information be accessed?
If your answer is "No" to this question, you must provide the names and total
compensation of the top five highly compensated officers below.
For example:
John Blum:500000;Mary Redd:50000;Eric Gant:400000;Todd Platt:300000;
Sally Tom:300000
Provide compensation information here:
-2 -
Department of State Health Services Form 4734—June 2013
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
The certifications enumerated below represent material facts upon which DSHS relies when reporting
information to the federal government required under federal law. If the Department later determines
that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available
remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate
written notice to DSHS if at any time Signor learns that any of the certifications provided for below were
erroneous when submitted or have since become erroneous by reason of changed circumstances. If the
Signor cannot certify all of the statements contained in this section, Signor must provide written
notice to DSHS detailing which of the below statements it cannot certify and why.
Legal Name of Contractor: City of Port Arthur FFATA Contact#1 Name, Email and Phone Number:
Jerry W. Dale
jerry.dale@portarthurtx.gov
(409)983-8164
Primary Address of Contractor: 449 Austin Avenue FFATA Contact#2 Name, Email and Phone Number:
Judith A. Smith, RN, BSN
judith.smith@portarthurtx.gov
(409) 983-8832
ZIP Code:9-digits Required www.usps.com DUNS Number:9-digits Required www.sam.gov
7 7 6 4 0 - 5 8 6 2 1 3 7 1 3 4 9 0 9
State of Texas Comptroller Vendor Identification Number(VIN) 14 Digits
Printed Name of Authorized Representative Signature of Authorized Representative
Brian McDougal
Title of Authorized Representative Date
City Manager
- 1-
Department of State Health Services Form 4734—June 2013