HomeMy WebLinkAboutPR 11699: ADDING MEDICAL STAFF MEMORANDUM
CITY OF PORT ARTHUR
TO: Steve Fitzgibbons, City Manage~
I/'.---' ) 'X
FROM: Ernestine. Wade, RN, Director~/~,J ~)
SUBJECT: Proposed Resolution NO. 11699 --
Amendment of Contract between the City of
Port Arthur and Texas Department of Health
DATE: March 11, 2002
FILE: z:\data\wp51d~dh01-02\
brhlo.cam
FOR
ADMINISTRATION
USE
ONLY
COMMENTS
* REQUESTED BY: Ernestine Wade, RN, Director
* PURPOSE EXPRESSED BY REQUESTOR:
* Approval of amendment of contract bet~veen the City of Port
* Arthur and Texas Department of Health to increase the amount
* of financial assistance
* LOCATION: N/A
RECOMMENDATION
It is recommended that the City Council adopt Proposed Resolution No. 11699 authorizing the
City Manager to execute a contract between the City of Port Arthur and Texas Department of
Health to increase the amount of financial assistance on Attachment 1, Office of Public Health
Practice.
BACKGROUND
As a result of the retirement of a state paid employee on December 31, 2001, the Texas
Department of Health has agreed to convert the employee's remaining salary for the fiscal year
from direct state paid to additional financial assistance for the City of Port Arthur. The total
conversion amount is $28,944.
BUDGETARY/FISCAL EFFECT:
The present grant amount is $146,244. With the additional financial assistance, the grant will total
$175,188.
STAFFING/EMPLOYEE EFFECT:
It is proposed that the additional funds will be used to contract with the former state employee to
provide consultant services for the laboratory and maintenance of the health department's
computer system and Health Alert Network, and to possibly hire a temporary public health nurse
for the remainder of the fiscal year.
Port Arthur Health Department
MEMORANDUM
CITY OF PORT ARTHUR
Stephen Fitzgibbons, City Manager
March 11, 2002
Page 2
SUMMARY:
It is recommended that the City Council adopt P.R. No. 11699, authorizing the City Manager to
accept and execute an amendment to the contract between the City of Port Arthur and Texas
Department of Health. Said amendment increases the amount of financial assistance the state
has appropriated to the City by $28,944.
Port Arthur Health Department
P.R. NO. 11699
3/11/02-YDA
RESOLUTION NO.
A RESOLUTION APPROVING AN AMENDMENT (ATTACHMENT 2) TO THE
CONTRACT BETWEEN THE CITY OF PORT ARTHUR AND TEXAS DEPARTMENT
OF HEALTH AS TO REBUDGET THE FINANCIAL ASSISTANCE BY $28,944 FOR
ADDITIONAL MEDICAL STAFF
WHEREAS, a contract between the City of Port Arthur and Texas Department of
Health was approved on September 4, 2001, Resolution No. 01-248 to provide for a broad
range of public health services; and,
WHEREAS, Attachment 2, Office of Public Health Practice, is being amended to
rebudget the amount of financial assistance by $28,944 for FY 2002 to provide for the
continuance and enhancement of these public health services; now therefore,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR:
THAT the Contract Amendment, a copy of which are attached hereto and made a
part hereof as Exhibits "A" are hereby approved; and,
THAT said Contract Amendment is an exact duplicate of a City Standard Form
Contract except for the changes described in the Certificate of Standard Form Contract,
a copy of which is attached hereto as Exhibit "B" and is hereby incorporated by reference,
and said changes are hereby approved; and,
THAT the City Manager of the City of Port Arthur and Ernestine Wade, RN, Director
of the City's Health Department are hereby authorized and directed to execute said
Contract Amendment on behalf of the City of Port Arthur; and,
THAT a copy of this Resolution be spread upon the Minutes of the City Council.
P.R. NO. 11699
3/11/02-YDA
READ, ADOPTED AND APPROVED THIS DAY OF
A.D., 2002, at a Meeting of the City Council of the City of Port
Arthur, Texas, by the following vote: Mayor:
Councilmembers:
NOES:
ATTEST:
Mayor
Acting City Secretary
APPROVED AS TO FORM:
Mark Sokolow, City Attorney
APPROVED FOR ADMINISTRATION:
Stephen Fitzgibbons, City Manager
Ernestine Wac~e, RN~ [~irectol~
TEXAS DEPARTMENT OF HEALTH
1100 WEST 49TH STREET
AUSTIN, TEXAS 78756-3199
EXHIBIT "A"
STATE OF TEXAS
COUNTY OF TRAVIS
TDH Document No. 7460018850 2002
Contract Change Notice No. 03
The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing
witl~ PORT ARTHUR CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto
now desire to amend such contract attachment(s) as follows:
SUMMARY OF TRANSACTION:
ATT NO. 02A: OFFICE OF PUBLIC HEALTH PRACTICE
By:
Date:
RECEIVING AGENCY:
TEXAS DEPARTMENT OF HEALTH
(Signature of person authorized to sign)
Melanie A. Doyle, Director
Grants Management Division
GMD - Rev. 12/00
Cover Page 1
DETAILS OF ATTACHMENTS
Att/ TDH Term Financial Assistance Direct Total Amount
Amd Program Assistance (TDH Share)
No. ID Begin End Source of Amount
Funds*
01 PHR 6/5S 01/01/01 12/31/01 93.977 44,719.00 0.00 44,719.00
02A OPHP 09/01/01 08/31/02 State 93.991 175,188.00 14,472.00 189,660.00
03 I IMM/LOCALS 09(01/01 08/31/02 State 93.268 80,618.00 0.00 80,618.00
04 BNS/WIC-CARD 10/01/01 09/30/02 10.557 0.00 0.130 0.00
05 TPC 09/01/01 08/31/02 State 67,000.00 0.00 67,000.00
06 ACFH/POP 09/01/01 08/31/02 State 15,000.00 0.00 15,000.00
TDII Document No.7460018850 2002 Totals
$382,525.00 $ 14,472.00 $396,997.00
Change No. 03
*Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO
BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS.
Cover Page 2
TEXAS DEPARTMENT OF HEALTH
RECEIVING AGENCY PROGRAM: OFFICE OF PUBLIC HEALTH PRACTICE
PERFOIUVIING AGENCY: PORT ARTHUR CITY HEALTH DEPARTMENT
CONTKACT TERM: 09/01/01 THRU: 08/31/02
TDII DOC. NO. 7460018850 200202A CIIG. 03
BUDGET PERIOD: 09/01/01 THRU: 08/31/02
REVISED CONTRACT BUDGET
DIRECT ASSISTANCE
CURRENT APPROVED CHANGES NEW OR REVISED
BUDGET REQUESTED BUDGET
PERSONNEL $43,416.00 $( 28,944.00 ) $14,472.00
TRAVEL 0.00 0.00 0,00
VACCINE 0.00 0.00 0.00
OTHER: 0.00 0.00 0.00
TDH DIRECT ASSISTANCE 43,416.00 ( 28,944.00 ) 14,472.00
TDH FINANCIAL ASSISTANCE 146,244.00 28,944.00 175,188.00
TOTAL TDH SHARE 189,660.00 0.00 189,660.00
TOTAL CONTRACT AMOUNT $ 189,660.00 $0.00 $189,660.00
FINANCIAL ASSISTANCE
OBJECT CLASS CATEGORIES CURI~ENT APPROVED CHANGES NEW OR REVISED
BUDGET REQUESTED BUDGET
PERSONNEL $102,613.00 $28,944.00 $131,557.00
FRINGE BENEFITS 36,631.00 0.00 36,631.00
TRAVEL 3,000.00 0.00 3,000.00
EQUIPMENT * 0.00 0.00 0.00
SUPPLIES 2,000.00 0.00 2,000.00
CONTRACTUAL 0.00 0.00 0.00
OTHER 2,000.00 0.00 2,000.00
TOTAL $146,244.00 $28,944.00 $175,188.00
PERFORMING AGENCY SHARE:
Program Income 0.00 0.00 0.00
Other Malch 0.00 0.00 0.00
RECEIVING AGENCY SI{ARE: $146,244.00 $28,944.00 $175,188.00
PERFORMING AGENCY SHARE: $0.00 $0.00 $0.00
Detail on Indirect Cost Rate Type:
Rate 0.00% Base $0.00 Total $0.00
Budget Justification: Increase in Financial Assistance due to conversion of Direct Assistance (Program Specialist
lll/1572/010/$3,859 monthly; resulting in a decrease in Direct Assistance.
Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November.
The undersigned
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS~ GRANTS~
LOANS AND COOPERATIVE AGREEMENTS
certifies, to the best of his or her knowledge and belief that:
(l)
(2)
(3)
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 in co. nnection 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 any federal contract, grant, loan, or cooperative
agreement.
If any funds other than federal appropriated funds have been paid or will be paid to
any persou 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-Ill, "Disclosure Form to Report Lobbying," in accordance with it's
instructions.
The undersigned shall require that the language of this certification be included in the
award documents for all subawards at all 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 impose, d by Section 1352, Title 31, U.S. Code.
Any person who fails to file the required certification shall be subject to a civil penalty of not
less than $10,000 and not more than $100,000 for each such failure.
Signature
Priut Name of Authorized Individual
7460018850 2002-02
Application or Contract Nnmber
Date
PORT ARTHUR CITY HEALTH DEPARTMENT
Organization Name and Address
603 5TH ST
PORT ARTHUR, TX 77640-6540
(City or Port A~thur)
(Law Depadment)
(Required Form)
(7/9/88)
(1015199)
(3/15/90)
(9-8-94)
(p.2 Revised 9/18/90)
CERTIFICATE OF STANDARD FORM CONTRACT FOR LAW
DEPARTMENT REVIEW AND CITY COUNCIL AGENDA
I certil'/thai the contract (hmeinalter called 'said conlract") affixed to the attached proposed Cily Council Resolulion
No. ! ].699 is an exact dupficele of an applicable standard form conlract ({he title o[ which ia shown below)
previously approved by the Law department and adopted as a standard form by City Council Resolul[o~, excepl for the
blanks [hat have been filled In with all necessary information and except [or Ihe changes described below.
The title of tho applicable srandmd form contract is:
[ J Fedola[ly Funded Conslrucfion Contract, Revised 1/5/88, 7/89, 8/99; 4/28/94
[ ] Non-Federally Funded Conslrucfion Contracl, Revised 1/5/88, 7/89, 8/89; 4/28/94
[ ] Federal - ProlessionaJ Services * Engineering Contract, Revised I/5/88, 5/89 (§10) 7/89/({8); 10/89; 2/91
[ ] Non Federal - Professional Services - Engineering Contract, Revised 1/5/88, 5/89(§10), 7/89(f~8), 10/89; 2/91(~8)
[ ] CDBG - Professional Services - Engineering Contract, Revised 1/5/88, 5/~]9 (§10), 7/89{§8), 10/89; 2/9t (r~8)
[ ] Federal - Prolessiona[ Services -
Non-Engineering (Consultant) Contract, Revised 1/5/08. 5/89 (§10), 7/89 (~8); 10/89; 2/9t (§8)
[ ] Non-Federal - Prolesslonal Services -
Non-Engineering (Consullant) Contract, Revised 1/5/85, 5/89 (§10), 7/89 (~8); 10/89; 2/91
[ ] CDBG - Professional services -
Non-Engfimering (Consultant) Contract, Revised 1/5/88, 5/89 (§10), 7/89 (~8); 10/89; 2/91 (~O)
tX] Olher Slandard Form Contract, described es follows:
FY2002 CONTRACT BETt4EEN THE CITY OF PORT ARTHUR AND TEXAS
DEPARTHENT OF HEAETH, RESOLUTION NO 0].-248 DATED 9/4/0]..
The changes are es follows: (Put an 'X' [n the appropriale [ })
[~ None.
[ ] The tollowin!l described provisions at the indlcaled page, section, elc. al the standard form have been deleled
from said contract:
DELETIONS
Page Number Seclion or Paragraph No, Subsection or
Wl'~ere and Caption Subparagraph No,
Deleted Piovis~on Which and Caption
Is Conlains Provision Which Conlalns Provision Description
Found On Slandard Form Deleted From Form Deleled From Form Provision Deleled
Page 1 of 2
(p.2 Revised g/18/90)
(Certificate ol Slsndard Form Contract. page 2)
The following described provisions a[ Ibc Indicated page, seclion, elc. ol Ihe slandard Iorm have been altered,
moditied, replaced o~ otherwise changed:
ALTERATIONS, MODIFICATIONS. REPLACEMENTS, ETC.
Page § & capllon
sub § & caption, etc.
Sub § or Sub ¶ No. ol said contract
Page No. § or ¶ No. & Capllon & Caplion Descriplion which contalr~s
PIovislon Found Standmd'Form Slandard Form Provision provision; &
on which which in Description ol
Slandard Fom~ Contains Provision Contains Provision Standard Form Altmetion elc,
[ ] The following provisions have been added to Said Conlract:
Page, Section and Caption
Subsecllon and Caption, etc. of Said Contract Which
Contains the Added Provision and Description Thereof
I lurther certify that said attached proposed Cily Council Resolulion contains the following provision:
Signed this /[ dayot ,~. ~:,L~ ~.~
Page 2 ol 2
TEXAS DEPARTMENT OF HEALTH
1100 WEST 49TH STREET
AUSTIN, TEXAS 78756-3199
STATE OF TEXAS
COUNTY OF TRAVIS
TDH Document No. 7460018850 2002
Contract Change Notice No. 03
The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing
with PORT ARTHUR CITY HEALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto
now desire to amend such contract attachment(s) as follows:
SUMMARY OF TRANSACTION:
ATT NO. 02A: OFFICE OF PUBLIC HEALTH PRACTICE
By:
Date:
RECEIVING AGENCY:
TEXAS DEPARTMENT OF HEALTH
(Signature of person authorized to sign)
Melanie A. Doyle, Director
Grants Management Division
GMD - Rev. 12/00
Cover Page 1
DETAILS OF ATTACHMENTS
Att/ TDH Term Financial Assistance Direct Total Amount
Amd Program Assistance (TDH Share)
No. ID Begin End Source of Amount
Funds*
01 PHR 6/55 01/01/01 12/31/01 93.977 44,719.00 0.00 44,719.00
02A OPHP 09/01/01 08/31/02 State 93.991 175,188.00 14,472.00 189,660.00
03 IMM/LOCALS 09/01/01 08/31/02 State 93.268 80,618.00 0.00 80,618.00
04 BNS/WIC-CARD 10/01/01 09/30/02 10.557 0.00 0.00 0.00
05 TPC 09/01/01 08/31/02 State 67,000.00 0.00 67,000.00
06 ACFH/POP 09/01/01 08/31/02 State 15,000.00 0.00 15,000.00
TDH Document No.7460018850 2002 Totals
Change No. 03 $382,525.00 $14,472.00 $396,997.00
*Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO
BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS.
Cover Page 2
TEXAS DEPARTMENT OF HEALTH
RECEIVING AGENCY PROGRAM: OFFICE OF PUBLIC HEALTH PRACTICE
PERFORMING AGENCY: PORT ART}tUR CITY HEALTH DEPARTMENT
CONTRACT TERM: 09/01/01 THRU: 08/31/02
TDH DOC. NO. 7460018850 200202A CHG. 03
BUDGET PERIOD: 09/01/01 THRU: 08/31/02
REVISED CONTRACT BUDGET
DIRECT ASSISTANCE
CURRENT APPROVED CHANGES NEW OR REVISED
BUDGET REQUESTED BUDGET
PERSONNEL $43,416.00 $( 28,944.00 ) $14,472.00
TRAVEL 0.00 0.00 0.00
VACCINE 0.00 0.00 0.00
OTHER: 0.00 0.00 0.00
TDH DIRECT ASSISTANCE 43,416.00 ( 28,944.00 ) 14,472.00
TDH FINANCIAL ASSISTANCE 146,244.00 28,944.00 175,188.00
TOTAL TDH SHARE 189,660.00 0.00 189,660.00
TOTAL CONTRACT AMOUNT $189,660.00 $0.00 $189,660.00
FINANCIAL ASSISTANCE
OBJECT CLASS CATEGORIES CURRENT APPROVED CHANGES NEW OR REVISED
BUDGET KEQUESTED BUDGET
PERSONNEL $102,613.00 $28,944.00 $131,557.00
FRINGE BENEFITS 36,631.00 0.00 36,631.00
TRAVEL 3,000.00 0.00 3,000.00
EQUIPMENT * 0.00 0.00 0.00
SUPPLIES 2,000.00 0.00 2,000.00
CONTRACTUAL 0.00 0.00 0.00
OTHER 2,000.00 0.00 2,000.00
TOTAL $146,244.00 $28~944.00 $175,188.00
PERFORMING AGENCY SHARE:
Program Income 0.00 0.00 0.00
Off,er Match 0.00 0.00 0.00
RECEIVING AGENCY SHARE: $146,244.00 $28,944.00 $175,188.00
PERFORMING AGENCY SHARE: $0.00 $0.00 $0.00
Detail on Indirect Cost Rate Type:
Rate 0.00% Base $0.00 Total $0.00
Budget Justification: Increase in Financial Assistance due to conversion of Direct Assistance (Program Specialist
llI/1572/010/$3,859 monthly; resulting in a decrease in Direct Assistance.
Financial status reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November.
Form No. GC-9a
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 in co. nnection 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 any federal contract, grant, loan, or cooperative
agreement.
(2)
If any funds other than federal appropriated funds have been paid or 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-Ill, "Disclosure Form to Report Lobbying," in accordance with it's
instructions.
(3)
The undersigned shall require that the language of this certification be included in the
award documents for all subawards at all 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 impose, d by Section 1352, Title 31, U.S. Code.
Any person who fails to file the required certification shall be subject to a civil penalty of not
less than $10,000 and not more than $100,000 for each such failure.
Signature
Print' Name of A~thorized-Individual
Date
7460018850 2002-02
Application or Contract Number
PORT ARTHUR CITY HEALTH DEPARTMENT
Organization Name and Address
603 5TH ST
PORT ARTHUR, TX 77640-6540
TEXAS DEPARTMENT OF HEALTH
1100 WEST 49TH STREET
AUSTIN, TEXAS 78756-3199
Sql'ATE OF TEXAS
COUNTY OF TRAVIS
TDIt Document No. 7460018850 2002
Contract Change Notice No. 0~3
The Texas Department of Health, hereinafter referred to as RECEIVING AGENCY, did heretofore enter into a contract in writing
with PORT ARTHUR CITY H~ALTH DEPARTMENT hereinafter referred to as PERFORMING AGENCY. The parties thereto
now desire to amend such contract attachment(s) as follows:
SUMMARY OF ql'P, ANSACTION:
ATT NO. 02A: OFFICE OF PUBLIC HEALTH PRACTICE
By:
RECEIVING AGENCY:
TEXAS DEPARTMENT OF ItEALTH
(Signature of person authorized to sign)
Melanie A. Doyle, Director
Grants Management Division
GMD - Rev. 12/00
Cover Page 1
DETAILS OF ATTACHMENTS
Att/ TDH Term Financial Assistance Direct Total Amount
Amd Program Assistance (TDH Share)
No. ID Begin End Source of Amount
Funds*
01 'HR 6/5S 01/01/01 12/31/01 93.977 44,719.00 0.00 44,719.00
02A OPHP 09/01/01 08/31/02 State93.991 175,188.00 14,472.00 189,660.00
03 lMM/LOCALS 09/01/01 08/31/02 State 93.268 80,618.00 0.00 80,618~00
04 BNS/W1C-CARD 10/01/01 09/30/02 10.557 0.00 0.00 0.00
05 TPC 09/01/01 08/31/02 State 67,000.00 0.00 67,000.00
06 ACFIt/POP 09/01/01 08/31/02 State 15,000.00 0.00 15,000.00
TDH Document No.7460018850 2002 Totals $382,525.00 $ 14,472.00 $396,997.00
Change No. 03
*Federal funds are indicated by a number from the Catalog of Federal Domestic Assistance (CFDA), if applicable. REFER TO
BUDGET SECTION OF ANY ZERO AMOUNT ATTACHMENT FOR DETAILS.
Cover Page 2
TEXAS DEPARTMENT OF ItEALTIt
RECEIVING AGENCY PROGRAM: OFFICE OF PUBLIC HEALTH PRACTICE
PERFOI.tdMING AGENCY: PORT ARTHUR CITY HEALTH DEPARTMENT
CONTILACT TERM: 09/01/01 THRU: 08/31/02
TDH DOC. NO. 7460018850 200202A CHG. 03
BUDGET PERIOD: 09/01/01 TIIRU: 08/31/02
[~EV1SED CONTRACT BUDGET
DIRECT ASSISTANCE
CURRENT APPROVED CHANGES NEW OR REVISED
BUDGET REQUESTED BUDGET
PERSONNEL $43,416.00 $( 28,944.00 ) $14,472.00
TRAVEL 0.00 0.00 0.00
VACCINE 0.00 0.00 0.00
OTItER: 0.00 0.00 0.00
TDtt DIRECT ASSISTANCE 43,416.00 ( 28,944.00 ) 14,472.00
TDH FINANCIAL ASSISTANCE 146,244.00 28,944.00 175,188.00
TOTAL TD H SH ARE 189,660.00 0.00 189,660.00
TOTAL CONTRACT AM OUNT $189,660.00 $0.00 $189,660.00
FINANCIAL ASSISTANCE
OBJECT CLASS CATEGORIES CURRENT APPROVED CHANGES NEW OR REVISED
BUDGET REQUESTED BUDGET
PERSONNEL $102,613.00 $28,944.00 $131,557.00
FRINGE BENEFFFS 36,631.00 0.00 36,631.00
TRAVEL 3,000.00 0.00 3,000.00 ~,
EQUIPMENT * 0.00 0.00 0.00
SUPPLIES 2,000.00 0.00 2,000.00
CONTRACTUAL 0.00 0.00 0.00
OTIIER 2,000.00 0.00 2,000.00
TOTAL $146,244.00 $28,944.00 $175,188.00_..
PERFORMING AGENCY SItARE:
Program Income 0.00 0.00 0.00
Other Match 0.00 0.00 0.00
RECEIVING AGENCY SllARE: $146,244.00 $28,944.00 $175,188.00
PERFORMING AGENCY SHARE: $0.00 $0.00 $0.00
Detail on Indirect Cost Rate Type:
Rate 0.00% Base $0.00 Total $0.00
Budget Justification: Increase in Financial Assistance due to conversion of Direct Assistance (Program Specialist
111/1572/010153,859 monthly; resulting in a decrease in Direct Assistance.
Financial slatus reports are due the 30th of December, 30th of March, 30th of June, and the 30th of November.
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)
(2)
(3)
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 au
employee of any agency, a member of Congress in co. nnection with tbe 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.
If any funds other than federal appropriated funds have been paid or 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-Ill, "Disclosure Form to Report Lobbying," in accordance with it's
instructions.
The undersigned shall require that the language of this certification be included in the
award documenti for ali subawards at all 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 traasactiou was made or entered into. Submission of this certification is a prerequisite
for making or entering into this transaction impose, d by Section 1352, Title 31, U.S. Code.
Any person who fails to file the required certification shall be subject to a civil penalty of not "
less than $10,000 and not more than $100,000 for each such failure.
Signature Date ~O.~,q~
Print Name of Authorized Individual
7460018850 2002-02
Application or Contract Number
PORT ARTHUR CITY HEALTH DEPARTMENT
Organization Name and Address
603 5TH ST
PORT ARTHUR, TX 77640-6540