HomeMy WebLinkAbout2022-244JOBS GRANT AGREEMENT BETWEEN INDIAN RIVER COUNTY
AND
KESSEL MEDICAL, INC.
THIS INDIAN RIVER COUNTY JOBS GRANT AGREEMENT ("Agreement") is made as
of the 22nd day of November, 2022 (the "Effective Date") by and between Indian River County, a
political subdivision of the State of Florida, by and through its Board of Commissioners, hereinafter
referred to as COUNTY, and Kessel Medical, Inc, a company authorized to do business in the State of
Florida, hereinafter referred to as COMPANY.
BACKGROUND RECITALS:
WHEREAS, it is the policy of COUNTY to stimulate economic growth in COUNTY by either
attracting new businesses to COUNTY or by encouraging the expansion of existing businesses within
COUNTY; and
WHEREAS, the creation of new employment opportunities for residents of COUNTY and the
increased tax revenues resulting from such business expansions or relocations within COUNTY is
beneficial to the local economy; and
WHEREAS, COUNTY has determined that offering a Jobs Grant Program encourages
businesses to expand within or new businesses to locate in COUNTY and thereby creates new
employment opportunities for the residents of COUNTY; and
WHEREAS, COUNTY, through its Board of County Commissioners, has created a local Jobs
Grant Program; and
WHEREAS, COMPANY, in accordance with the COUNTY's Jobs Grant Program criteria, is a
Existing Business that will expand its business in COUNTY to create 20 additional full-time jobs which
pay at least 75% of COUNTY's average annual wage level; and
WHEREAS, COUNTY has determined that COMPANY is eligible to receive a Jobs Grant; and
WHEREAS, COMPANY acknowledges that this Agreement shall be based upon compliance
with COUNTY Jobs Grant Program requirements; and,
WHEREAS, COUNTY finds and declares that it is in the public interest to award a Jobs Grant
to COMPANY pursuant to the terms of this Agreement.
NOW, THEREFORE, in consideration of the premises and mutual covenants hereinafter
contained, the parties do agree as follows:
Definitions. As used in this Agreement, the following terms shall mean:
a. "Adjacent Counties" means Brevard, Osceola, St. Lucie, Okeechobee, and Martin
Counties.
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b. "Annual Wage" - includes salary, bonuses, and commissions.
c. "Default" - failure to comply with the terms of this Agreement.
d. "Expanding Business" — shall be defined as a business expanding its operation
over and above its base employment amount at the time of jobs grant approval
by 5 or more new jobs to employ 5 or more new full-time employees in the
COUNTY within the term of the Grant.
e. "Full-time Equivalent Job" - shall be defined as a position that is scheduled for
at least 35 hours per week.
f. "Indian River County Average Annual Wage" — shall be defined as the average
annual wage per job in COUNTY as determined by Florida Agency for
Workforce Innovation, Labor Market Statistics Center, Quarterly Census of
Employment and Wages Program, in cooperation with the U.S. Department of
Labor, Bureau of Labor Statistics. Currently, the COUNTY's average annual
wage is $46,289 (effective January 1' 2022 for the state QTI Tax Refund
Program). This dollar value shall be used for the duration of this Agreement for
determining local jobs grant incentives.
g. "New Business" — shall be defined as a business establishing 5 or more new jobs
to employ 5 or more new full-time employees in the COUNTY within the term
of the Grant (as such term is hereinafter defined), provided that such business
first begins operations on a site in the COUNTY clearly separate from any other
operation owned by the same business.
h. Commencement Date" — the date that the COUNTY begins tracking qualifying
jobs for potential local jobs grant payments. Such date shall start on one of the
following dates: January 1St, April 11, July 1St, or October 1St of a year agreed to
by COUNTY as established within this Agreement or as otherwise modified in
accordance with this Agreement.
i. "Qualifying job" — a full-time equivalent job having an annual wage equal to or
greater than 75% of Indian River County's Average Annual Wage. Such jobs
must be filled by people who live in COUNTY or Adjacent Counties.
j. "Quarterly Reemployment Compensation Report (RT -6 form)" — Form from the
Florida Department of Revenue that businesses in the state of Florida must
complete and submit to the state on a quarterly basis. Information collected on
the form includes the names of employees, their social security numbers, and the
gross wages paid to each employee on a quarterly basis. The information is used
for reemployment compensation should employees cease to be employed. For
purposes of this Agreement, this definition shall also include other similar
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COUNTY approved certified forms from COMPANY or COMPANY's
professional employer organization.
k. "Relocation of a business" — a business relocating to COUNTY and
employing 5 or more full-time employees in the COUNTY.
1. "Target Industry" — An industry identified within the Target Industry List of the
Economic Development Element of COUNTY's Comprehensive Plan (Policy
2.5 of the Economic Development Element).
2. Term: Termination. This Agreement shall be effective as of the date of this
Agreement stated on page 1 and shall automatically terminate after one of the
following has occurred (whichever occurs first), unless terminated earlier by
COUNTY because of a Default by COMPANY.
a. COUNTY has made the last payment to COMPANY;
b. COMPANY did not employ a minimum of 5 new Qualifying Jobs by the
Commencement Date, as may be modified; or
c. COMPANY failed, for a period of 3 consecutive years (12 quarters), to provide
required Quarterly Reemployment Compensation Reports (RT -6 form) to
COUNTY.
3. Grant Eligibility; PaMent Schedule.
a. COMPANY will be eligible for total Jobs Grant Funding (hereinafter a "Grant")
in an amount of up to $106,000. COMPANY acknowledges and agrees that the
initial Grant under this Agreement is payable on a re -imbursement basis. The
number of jobs estimated to be provided is listed below. Jobs grant payments
are dependent upon the number of employees exceeding the company's
employment level at the time that this Agreement is approved by the Indian
River County Board of County Commissioners, and by the criteria set forth
below.
(i) For Phase I, 5 new qualifying jobs meeting the wage level commitment
in Section 5 of this Agreement shall be provided by the phase
commencement date 1/01/24. For each of the three successive annual
periods that those jobs are maintained at the required wage level,
COMPANY shall receive 1/3 of the Grant amount for those 5 jobs.
(ii) For Phase II, 6 new qualifying jobs meeting the wage level commitment
in Section 5 of this agreement shall be provided by the phase
commencement date 01/01/25. For each of the three successive annual
periods that those jobs are maintained at the required wage level,
COMPANY shall receive 1/3 of the Grant amount for those 6 jobs.
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(iii) For Phase III, 9 new qualifying jobs meeting the wage level
commitment in Section 5 of this agreement shall be provided by the phase
commencement date 01/01/26. For each of the three successive annual
periods that those jobs are maintained at the required wage level,
COMPANY shall receive 1/3 of the Grant amount for those 9 jobs.
(iv) It is understood that the quantity of jobs proposed above, their annual
wages, and dates of hire are estimates. Because of that, the quantity of jobs
provided may be less than 20, and the Commencement Date (for Grant
tracking) may be extended. Proposed jobs will remain eligible for Grant
incentives provided:
a. The minimum number of qualifying jobs provided in Phase I is
5.
b. The maximum number of jobs eligible for local jobs grant funds
for Phases I, II, and III is 20.
c. The maximum extension for a phase commencement date shall
be one year. Such commencement date extension may be
approved administratively by the County Community
Development Director or his designee provided the extension
date meets the requirements of Section 3 of this agreement. If
any of the 20 eligible jobs proposed for Phases I, II, and III are
created after the Phase III commencement date or, if applicable,
after an administratively approved extension to the Phase III
commencement date, those jobs shall not be eligible for local
jobs grant funds.
In no case shall the total Grant exceed $106,000.
(v) Failure of COMPANY to maintain claimed jobs for at least 3 years at
required wage levels will result in the reduction of the Grant amount paid
to COMPANY, as set forth herein. If, by the end of any of the annual
periods, COMPANY has not maintained the total number of claimed jobs
required or if COMPANY has provided the total jobs required, but the
annual wage for any of those jobs is less than required for that year, the
Community Development Department Director, or his designee, will lower
the jobs grant award for the respective year by the amount allocated in such
year for each job for which the requirements of this agreement are not met.
Thus, the total jobs grant award could be less than $106,000 by the end of
this Agreement.
(vi) If COMPANY changes the products or services it provides in such a
way that would make COMPANY no longer qualify as a "Target Industry"
or if COMPANY relocates outside of Indian River County, COMPANY
shall be in Default of this Agreement. COMPANY shall reimburse
COUNTY for payments made to COMPANY while COMPANY was not a
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"Target Industry or if while COMPANY was not relocated within Indian
River County."
(vii) During the Term of this Agreement, COMPANY shall have a majority
(greater than 50%) of its goods and services, attributable to the Indian River
County location, sold or distributed outside of Indian River County.
COMPANY shall reimburse COUNTY for payments made to COMPANY
while COMPANY did not meet this requirement.
b. Performance Evaluation for Payment. Prior to the submittal of COMPANY's 1 '
Quarterly Reemployment Compensation Report COMPANY shall provide to
the COUNTY Community Development Director, or his designee, an employee
census and a copy of the Quarterly Reemployment Compensation Report for the
Effective Date of this Agreement. That employee census must list employee
name, job title, city and state in which the employee lives, annual salary,
location where employee works, and date of hire.
COMPANY's performance evaluation will be conducted on an annual basis
using the information provided on the Quarterly Reemployment Compensation
Report (RT -6 form) and COMPANY's quarterly updates to its employee
census. Each updated employee census must include the information referenced
above plus the date of termination for each employee (if the employee
terminates employment with the COMPANY). COMPANY shall supply
additional documentation to the Community Development Director, or his
designee, in a form acceptable to the Community Development Director, or his
designee, showing that positions for which Grant funds will be awarded are
filled by people who live in COUNTY or Adjacent Counties.
The Grant eligibility determinations will cover one year periods, with each
yearly period beginning and ending as follows:
Phase
Grant Eligibility
Determinations
ist
2°a
V(final)
Be in
End Begin
End
Be in End
I
1/01/2025
12/31 /2025 1/01/2026
12//31 /2026
1/01/2027 12/31 /2027
II
1/01/2026
12/31 /2026 1/01/2027
12/31 /2027
1/01/2028 12/31 /2028
III
1/01/2027
12/31 /2027 1/01/2028
12/31 /2028
1/01/2029 12/31 /2029
(i) Each job must meet the minimum wage requirements
specified in this Agreement. Payment of Grant funds shall be made based
on the County's current adopted payment calculation methodology
(methodology approved by the BCC on 10-24-2017) within forty-five (45)
days after the date COMPANY submits the latest Quarterly Reemployment
Compensation Report comprising the Annual Job Status Report (as defined
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in Paragraph 6), and this payment obligation shall survive the termination
of this Agreement. Notwithstanding the foregoing, should the date for filing
the last Quarterly Reemployment Compensation Report, as described
above, not coincide with the date that an eligibility determination is made,
COMPANY shall have the right to file a Quarterly Reemployment
Compensation Report, in a form substantially similar to a Quarterly
Reemployment Compensation Report, and such Quarterly Reemployment
Compensation Report shall constitute the Annual Job Status Report, the
filing of which shall begin the running of the forty-five (45) -day period
within which payment shall be made.
If COMPANY applies for a Qualified Target Industry (QTI)
Tax Refund from the State of Florida and if COMPANY has that QTI Tax
Refund approved by the State, the Community Development Director or his
designee will reduce the Grant amount paid directly to COMPANY for each
eligibility determination in an amount sufficient to cover COUNTY's QTI
Tax Refund 20% contribution obligation to the State for COMPANY's QTI
Tax Refund agreement. The Community Development Director or his
designee will submit the 20% payment obligation to the State for placement
in the Florida Economic Development Trust Fund.
(ii) If at the time of performance evaluation for payment as
described in subsection 3.b COMPANY is not current on COUNTY Real
Estate and Tangible Personal Property Taxes, COUNTY shall withhold
Grant payments for that eligibility determination time period and
COMPANY shall automatically forfeit its right to collect Grant payments
for that eligibility time period. COMPANY shall remain eligible for any
remaining future Grant payments for future eligibility time periods provided
COMPANY is current on such taxes referenced above at the time of future
Grant eligibility determination time periods.
4. Job Creation Commitment. COMPANY estimates that it will provide 20 new
Qualifying Jobs within COUNTY as set forth in Exhibit `B", which is attached
hereto and made a part hereof. The exact number of jobs actually supplied and their
salaries, however, may vary. Grant funds will be awarded up to a maximum of
$106,000. The Grant award will be based on the following:
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Amount Per Job
Category*
75% to 99.99% of Indian River County
$3,000
Average Annual Wage
100% to 149.99% of Indian River County
$5,000
Average Annual Wage
150% of Indian River County Average
$7,000
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Amount Per Job
Category*
Annual Wage (or greater)
*One average annual wage category will be utilized consistent with Exhibit "ll" and the
County's current adopted payment calculation methodology.
Wage Level Commitment. COMPANY estimates that it will pay 0 employees
whose jobs are eligible for a Grant hereunder an annual wage of not less than
$34,716.75, will pay 17 employees an annual wage of not less than $46,289, and
will pay 3 employees an annual wage of not less than $69,433.50. The annual wage
of the positions will be determined without taking into account the value of any
benefits. COMPANY shall, in accordance with the provisions of paragraph 6
below, provide written verification of such wages satisfactory to the Community
Development Director or his designee.
6. Annual Job Status. COMPANY must provide the Community Development
Director or his designee with Quarterly Reemployment Compensation Reports
(Form RT -6) of its business operations within COUNTY on State form RT -6, as
amended, a sample of which is attached hereto and made a part hereof as Exhibit
"C". COMPANY must also provide the Community Development Director or his
designee with quarterly updates to its employee census for employees working at
its Indian River County location(s) (see section 3.b. of this Agreement). The
cumulative Quarterly Reemployment Compensation Reports required to be filed
for the annual period, correlated with each eligibility determination and the
corresponding quarterly employee census shall collectively comprise the Annual
Job Status Report. Quarterly, COMPANY must also provide the Community
Development Director or his designee a signed statement indicating the percent of
its total sales/services from the Indian River County location provided outside of
Indian River County for the jobs grant payment time period.
Starting with calendar quarter 2 in 2024, quarterly reports must be submitted for
Grant eligibility determination. Those quarterly reports must be submitted no later
than 60 days after the end of each quarter, until the termination of this Agreement.
Submittal deadline may be waived by the Community Development Director, for
good cause.
7. Default; Termination. Except as set forth herein, in the event that COMPANY
defaults in the performance of its guarantees and commitments as provided for in
this Agreement, COUNTY may, at its option, terminate this Agreement.
8. Indemnification. COMPANY shall indemnify and hold harmless and defend
COUNTY, its agents, servants, and employees from and against any and all claims,
liabilities, losses, and/or causes of action which may arise from any negligent act
or omission of COMPANY, its agents, servants, or employees in the performance
of services under this Agreement.
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9. Forum; Venue. This Agreement shall be governed by the laws of the State of
Florida. Any and all legal action necessary to enforce the Agreement will be held
in Indian River County or the Federal District Court for the Southern District of
Florida. No remedy herein conferred upon any party is intended to be exclusive of
any other remedy, and each and every such remedy shall be cumulative and shall
be in addition to every other remedy given hereunder or now or hereafter existing
by law or in equity or by statute or otherwise. No single or partial exercise by any
party of any right, power, or remedy hereunder shall preclude any other or further
exercise thereof. Parties hereby waive their right for a jury trial.
10. Lobbyist Certification. COMPANY warrants that it has not employed or retained
any company or person, other than a bona fide employee working solely for
COMPANY, to solicit or secure this Agreement and that it has not paid or agreed
to pay any person, company, corporation, individual, or firm, other than a bona fide
employee working solely for COMPANY, any fee, commission, percentage, gift,
or any other consideration contingent upon or resulting from the award or making
of this Agreement.
11. No Discrimination Certification. COMPANY warrants and represents that all of its
employees are treated equally during employment without regard to race, color,
religion, disability, sex, age, national origin, ancestry, marital status, or sexual
orientation.
12. Attorneys Fees. If any legal action or other proceeding is brought for the
enforcement of this Agreement, or because of an alleged dispute, breach, default or
misrepresentation in connection with any provisions of this Agreement, each party
shall bear its own costs.
13. Enforceability. If any term or provision of this Agreement, or the application
thereof to any person or circumstances, shall to any extent be held invalid or
unenforceable, the remainder of this Agreement, or the application of such terms or
provision, to persons or circumstances other than those as to which it is held invalid
or unenforceable, shall not be affected, and every other term and provision of this
Agreement shall be deemed valid and enforceable to the extent permitted by law.
The COMPANY's failure to maintain its job creation commitment or annual wage
level commitment for any one year will result in the decrease of the Grant amount
it was scheduled to receive for that year; however, such decrease will not preclude
the COMPANY's receipt of scheduled Grant amounts for those subsequent years
in which it is able to maintain its job creation and wage level commitment.
14. Assignment. COMPANY shall not, directly or indirectly, assign or transfer any
of its rights or obligations under this Agreement, or any interest therein (the
foregoing herein collectively "Transfer"), without the express prior written consent
of the Community Development Director. The Community Development Director
shall not unreasonably withhold its consent to any Transfer. Any such attempted
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Transfer without the express prior written Community Development Director
consent shall be null and void and may, at the option of the County Community
Development Director, be deemed a Default under this Agreement. COMPANY
acknowledges and agrees that the Community Development Director has the right,
in granting or withholding consent to any Transfer, to consider, among other things,
the financial responsibility and business reputation of the proposed assignee or
transferee (the foregoing herein collectively "Transferee"); and any other items that
the COUNTY Community Development Director, in his sole discretion, deems
appropriate.
If COMPANY seeks the Community Development Director's consent for a
Transfer, COMPANY shall submit to the Community Development Director a
written request therefore, accompanied by the following documentation: (i) the
name, address, and telephone number of the proposed Transferee; (ii) a description
of the business and jobs, including wages, to be created in COUNTY; and (iii) a
financial statement or other reasonably detailed financial information concerning
the proposed Transferee. If the Community Development Director withholds the
consent to Transfer, COMPANY may appeal to the County Administrator. If the
County Administrator withholds the consent to Transfer, COMPANY may appeal
to the Board of County Commissioners. COMPANY acknowledges and agrees
that: (a) the County Administrator or his designee, or the Indian River County
Board of County Commissioners, has the right to request any additional
information deemed necessary to make the decision relating to consent to the
Transfer; and (b) if appealed to the Board of County Commissioners such request
for a Transfer is expressly subject to the approval of the Transfer by the Board of
County Commissioners, and such Transfer shall become effective only when
signed by the Transferee and approved by the Board, which consent shall not be
unreasonably withheld.
The foregoing covenant shall be binding on the permitted successors or assigns of
COMPANY. The prohibition on Transfers shall not prohibit a change in the form
in which COMPANY conducts business. COMPANY will be released from further
liability under this Agreement in the event of an approved Transfer; provided that
the COUNTY's consent to any Transfer will not otherwise relieve COMPANY
from any pre-existing obligation to COUNTY under this Agreement.
15. Conflict of Interest. COMPANY represents that it presently has no interest and
shall acquire no interest, either direct or indirect, which would conflict in any
manner with the performance of services required hereunder, as provided for in
Florida Statutes Part III, Chapter 112. COMPANY further represents that no
person having any interest shall be employed for said performance.
16. Notices. All notices required in this Agreement shall be sent by certified mail,
return receipt requested and if sent to COUNTY shall be mailed to:
Community Development Director
Indian River County
180127"' Street
Vero Beach, Florida 32960
and if sent to COMPANY shall be mailed to (or current, official address):
2345 14th Ave., Suite 10
Vero Beach FL 32960
17. Entire Agreement. COUNTY and COMPANY agree that this Agreement sets forth
the entire Agreement between the parties, and that there are no promises or
understandings other than those stated herein. None of the provisions, terms and
conditions contained in this Agreement may be added to, modified, superseded or
otherwise altered, except by written instrument executed by the parties hereto.
18. No Pledge of Credit. COMPANY shall not pledge COUNTY's credit or make it a
guarantor of payment or surety for any contract, debt, obligation, judgment, lien, or
any form of indebtedness.
19. Public Records. COMPANY shall comply with the provisions of Chapter 119,
Florida Statutes (Public Records Law) in connection with this Agreement, as
modified by exemptions in Chapter 288, Florida Statutes.
20. Counterparts. This Agreement may be executed in one or more counterparts, each
of which shall be deemed to be an original copy and all of which shall constitute
but one and the same instrument.
21. General. The Background Recitals are true and correct and form a material part of
this Agreement.
22. TERMINATION IN REGARDS TO F.S. 287.135: COMPANY certifies that it and
those related entities of COMPANY as defined by Florida law are not on the
Scrutinized Companies that Boycott Israel List, created pursuant to s. 215.4725 of
the Florida Statutes, and are not engaged in a boycott of Israel. In addition, if this
agreement is for goods or services of one million dollars or more, COMPANY
certifies that it and those related entities of COMPANY as defined by Florida law
are not on the Scrutinized Companies with Activities in the Iran Petroleum Energy
Sector List, created pursuant to Section 215.473 of the Florida Statutes and are not
engaged in business operations in Cuba or Syria.
OWNER may terminate this Contract if COMPANY is found to have submitted a
false certification as provided under section 287.135(5), Florida Statutes, been
placed on the Scrutinized Companies with Activities in the Iran Petroleum Energy
Sector List, or been engaged in business operations in Cuba or Syria, as defined by
section 287.135, Florida Statutes.
OWNER may terminate this Contract if COMPANY, including all wholly owned
subsidiaries, majority-owned subsidiaries, and parent companies that exist for the
purpose of making profit, is found to have been placed on the Scrutinized
Companies that Boycott Israel List or is engaged in a boycott of Israel as set forth
in section 215.4725, Florida Statutes.
23. Contractor is registered with and will use the Department of Homeland Security's
E -Verify system (www.e-verify. ov) to confirm the employment eligibility of all
newly hired employees for the duration of this agreement, as required by Section
448.095, F.S. Contractor is also responsible for obtaining proof of E -Verify
registration and utilization for all subcontractors.
IN WITNESS WHEREOF, the Board of County Commissioners of Indian River County,
Florida has made and executed this Agreement on behalf of COUNTY and COMPANY has
hereunto set its hand the day and year above written.
y �on�rUr�Ssi•,
BOARD OF COUNTY COMMISSIONERS,:%y, .
OF EVJXAN RIVER COUNTY
BY:
Joseph H. tarmaA, C410rman
ATT BY: Jeffrey R. Smith, Clerk of Court and Comptroller
By:
Deputy Clerk
APPR D:
Jason E. r , County ministrator
APPROVED AS TO FORM AND LEGAL SUFFICIENCY
an Reingold, County Attorney
COMPANY: I l -dean, Nt'
BY: Title: Chief Technology Officer
Jack Griffis
Typed Name
WITNESS -
Title:
n }�
Title: Loft,(
Signature
EXHIBIT "A" TO THE JOBS GRANT AGREEMENT
BETWEEN INDIAN RIVER COUNTY & KESSEL MEDICAL, INC
COMPANY Identification and Information:
Application received date: October 12, 2022.
COMPANY description:
KESSEL MEDICAL, INC. is an existing manufacturer in the County that manufactures
surgical appliances and supplies.
COMPANY'S current mailing address:
2345 10' Ave., Suite 10
Vero Beach FL 32960
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EXHIBIT "B" TO THE JOBS GRANT AGREEMENT
BETWEEN INDIAN RIVER COUNTY & DIAMOND DRINKS OF FLORIDA, INC
I. Target Industry Categories eligible for application:
COMPANY qualifies for the Jobs Grant Program under the
"Manufacturing/Warehouse/Distribution" category. Under the North American Industrial
Classification System (NAICS), COMPANY's activities are classified in the category of
"Surgical Appliance and Supplies Manufacturing", NAICS Code #339113.
II. Employment Commitment:
The COMPANY is receiving this Grant based upon its representation that it will bring the
following employment opportunities to COUNTY:
1) 0 # of new, full-time employees whose annual wages are between 75% and
99.9% of Indian River County's average annual wage.
2)--L7 # of new, full-time employees whose annual wages are between 100% and
149.99% of Indian River County's average annual wage
3) 3 # of new, full-time employees whose annual wages are 150% or greater of
Indian River County's average annual wage
III. Maximum Potential Grant Amount
Category
Qualified Jobs
Amount per Job
Total
75% of county average wage
()
$3,000
$0
100% of county average wage
17
$5,000
$85,000
150% of county average wage
3
$7,000
$21,000
Sub -Total Grant Amount
$106,000
*The actual amount of the grant will depend upon the actual number of jobs provided and the salary paid for those
jobs. In no case shall the total amount of the grant exceed $106,000. As noted in the agreement, incremental payments
will be made for qualified jobs based upon phase dates and actual company performance in meeting local jobs grant
requirements.
FXommunity Development\Users\EDplannr\INCENTIVES & FUNDINGVOBS GRANT PROGRAM\ACTIVE JOBS GRANTS\Kessel Medical, Inc\BCC Agenda
Items\Proposed Jobs Grant Agreement - Kessel Medical, Inc.docx
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(From Line 2 above.) ■
AMOUNT ENCLOSED
(From Line 9b above.) , ■
Name PAYMENT FOR QUARTER
ENDING MM/YY
M ailing
Address Check here if you are electing to Check here if you transmitted
City/St/ZIP pay tax due in installments. funds electronically.
L 7 5009999999 0000 4
9100 0 99999999 0068054031
III II VIII I II III II II VIII I II IIII II III II Florida
oDepartment a Revenue Qu�or rtwthprt Ill
L Employers quarterly regardless Imewhether any taxes due. JR. 0/15
Black Ink fete This Form
QUARTER ENDING EMPLOYER'S NAME
10. EMPLOYEE'S SOCIAL SECURITY NUMBER
0
RT ACCOUNT NUMBER
11. EMPLOYEE'S NAME (pease i first twelve characters of lest name and first 12a EMPLOYEE'S GROSS WAGES PAID THIS QUARTER
eight characters of first name in boxes) 12b EMPLOYEE'S TAXABLE WAGES PAID THIS QUARTER
Onry1hetir9ST.000paidto Bad employee per calendar year istaxable. f
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In,
this and totals from additional es in Line 2 on a e 1. Ell
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13b. Total Taxable Wages (add Lines 12b only). Total this page only. ❑
Include this and totals from additional pages in Line 4 on page 1. f , j I F re __
DO NOT
DETACH----------------------------------�__����_�_��___���___��___���___
Mail Reply To -
Reemployment Tax
Florida Department of Revenue
5050 W Tennessee St Bldg L
Tallahassee FL 32399-0180
Social security numbers (SSNs) are used by the Florida Department of Revenue as unique
identifiers for the administration of Florida's taxes. SSNs obtained for tax administration
purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not
subject to disclosure as public records. Collection of your SSN is authorized under state
and federal law. Visit our website at www.myflorida.com/dor and select "Privacy Notice"
for more information regarding the state and federal law governing the collection, use, or
release of SSNs, including authorized exceptions.
Tease save your instructions!
Quarterly Report instructions (FT-6N/FTS-3) are only mailed
with new accounts or when there are changes. If you misplace
your instructions, you can download them from
www.mytiorida.com/dor