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2004-229L
/ u eddy d�l • 22gL Indian River County Grant Contract This Grant Contract ("Contract") entered into effective this 1st day of October 2004 by and between Indian River County, a political subdivision of the State of Florida , 1840 25th Street, Vero 32960 ("County") and Center for Emotional & Behavioral Health ( Recipient) , of: 119037 1h Street Vero Beach , Florida 32960 Background Recitals A . The County has determined that it is in the public interest to promote healthy children in a healthy community. B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance" ) and established the Children 's Services Advisory Committee to promote healthy children in a healthy community and to provide a unified system of planning and delivery within which children 's needs can be identified , targeted , evaluated and addressed . C . The Children 's Services Advisory Committee has issued a request for proposals from individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling its purpose . D . The proposals submitted to the Children 's Services Advisory Committee and the recommendation of the Children 's Services Advisory Committee have been reviewed by the County. E . The Recipient , by submitting a proposal to the Children 's Services Advisory Committee , has applied for a grant of money ("Grant") for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged , the parties agree as follows : 1 . Background Recitals The background recitals are true and correct and form a material part of this Contract . 2 . Purpose of Grant The Grant shall be used only for the purposes set forth in the complete proposal submitted by the Recipient attached hereto as Exhibit "A" and incorporated herein by this reference (such purposes hereinafter referenced as "Grant Purposes") , 3 . Term The Recipient acknowledges and agrees that the Grant is limited to the fiscal year 2004/2005 ("Grant Period") . The Grant Period commences on October 1 , 2004 and ends on September 30 , 2005 . - 1 - 4 . Grant Funds and Payment The approved Grant for the Grant Period is Seventy-Six Thousand Dollars ($76 , 000 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for Grant Purposes provided in accordance with this Contract . Reimbursement requests may be made no more frequently than monthly. Each reimbursement request shall contain the information , at a minimum , that is set forth in Exhibit "B" attached hereto and incorporated herein by this reference . All reimbursement requests are subject to audit by the County. In addition , the County may require additional documentation of expenditures , as it deems appropriate . 5 . Additional Obligations of Recipient 5 . 1 Records , The Recipient shall maintain adequate internal controls in order to safeguard the Grant . In addition , the Recipient shall maintain adequate records fully to document the use of the Grant funds for at least three (3 ) years after the expiration of the Grant Period . The County shall have access to all books , records , and documents as required in this Section for the purpose of inspection or audit during normal business hours at the County's expense , upon five (5 ) days prior written notice . 5 . 2 Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws , rules , and regulations . 5 . 3 Quarterly Performance Reports . The Recipient shall submit Quarterly Performance Reports to the Human Services Department of the County within fifteen ( 15 ) business days following : December 31 , March 31 , June 30 , and September 30 . 5 .4 Audit Requirements . If Recipient receives $25 , 000 or more in the aggregate from all Indian River County government funding sources , the Recipient is required to have an audit completed by an independent certified public accountant at the end of the Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the Recipient shall submit the audit to the Indian River County Office of Management and Budget. The fiscal year will be as reported on the application for funding , and the Recipient agrees to notify the County prior to any change in the fiscal period of Recipient . The Recipient acknowledges that the County may deny funding to any Recipient if an audit required by this Contract for a prior fiscal year is past due and has not been submitted by May 1 , 5 .4 . 1 The Recipient further acknowledges that, promptly upon receipt of a qualified opinion from it's independent auditor, such qualified opinion shall immediately be provided to the Indian River County Office of Management and Budget . The qualified opinion shall thereupon be reported to the Board of Commissioners and funding under this Contract will cease immediately. The foregoing termination right is in addition to any other right of the County to terminate this Contract. 5 .4 .2 The Indian River County Office of Management and Budget reserves the right at any time to send a letter to the Recipient requesting clarification if there are any questions regarding a part of the financial statements , audit comments , or notes . 5 . 5 Insurance Requirements . Recipient shall , no later than September 21 , 2004 , provide to the Indian River County Risk Management Division a certificate or certificates issued by an insurer or insurers authorized to conduct business in Florida that is rated not less than category A- : VII by A. M . Best, subject to approval by Indian River County's risk manager, of the following types and amounts of insurance : 2 - (i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 , 000 combined single limit for bodily injury and property damage , including coverage for premises/operations , products/completed operations , contractual liability, and independent contractors ; (ii ) Business Auto Liability Insurance in an amount not less than $ 1 , 000 , 000 per occurrence combined single limit for bodily injury and property damage , including coverage for owned autos and other vehicles , hired autos and other vehicles , non-owned autos and other vehicles ; and (iii) Workers ' Compensation and Employer's Liability (current Florida statutory limit) 5 . 6 Insurance Administration . The insurance certificates , evidencing all required insurance coverages shall be fully acceptable to County in both form and content, and shall provide and specify that the related insurance coverage shall not be cancelled without at least thirty (30 ) calendar days prior written notice having been given to the County. In addition , the County may request such other proofs and assurances as it may reasonably require that the insurance is and at all times remains in full force and effect. Recipient agrees that it is the Recipient's sole responsibility to coordinate activities among itself, the County, and the Recipient's insurer(s ) so that the insurance certificates are acceptable to and accepted by County within the time limits set forth in this Contract . The County shall be listed as an additional insured on all insurance coverage required by this Contract, except Workers' Compensation insurance . The Recipient shall , upon ten ( 10) days ' prior written request from the County, deliver copies to the County, or make copies available for the County's inspection at Recipient's place of business , of any and all insurance policies that are required in this Contract. If the Recipient fails to deliver or make copies of the policies available to the County; fails to obtain replacement insurance or have previous insurance policies reinstated or renewed upon termination or cancellation of existing required coverages ; or fails in any other regard to obtain coverages sufficient to meet the terms and conditions of this Contract , then the County may, at its sole option , terminate this Contract . 5 . 7 Indemnification . The Recipient shall indemnify and save harmless the County, its agents , officials , and employees from and against any and all claims , liabilities , losses , damage , or causes of action which may arise from any misconduct , negligent act, or omissions of the Recipient , its agents , officers , or employees in connection with the performance of this Contract . 5 . 8 Public Records , The Recipient agrees to comply with the provisions of Chapter 119 , Florida Statutes ( Public Records Law) in connection with this Contract . 6 , Termination , This Contract may be terminated by either party, without cause , upon thirty (30 ) days prior written notice to the other party. In addition , the County may terminate this Contract for convenience upon ten ( 10) days prior written notice to the Recipient if the County determines that such termination is in the public interest . 7 . Availability of Funds . The obligations of the County under this Contract are subject to the availability of funds lawfully appropriated for its purpose by the Board of County Commissioners of Indian River County. 8 , Standard Terms , This Contract is subject to the standard terms attached hereto as Exhibit C and incorporated herein in its entirety by this reference . 3 - IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS s - By. • r. , .,. Caroline D . Ginn , Chairm &Ig 1 BCC Approved : r , Yn„ '11, . Attest: J . K . Barton , Clerk Raw f f X u By: , Deputy Clerk Approved : Joseph A. Baird County Administrator pr form s i ri n E . Fell , Ai'sty Attorney i RECIPIENT: By: Ce ter for Emotional & Behavioral Health 4 - EXHIBIT A [Copy of complete proposal/application] - 1 - The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC 8 ' PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @ IRMH Executive Director : Dr. Raymond Dean MD E-mail : raymond . dean cirmh org Address : 1190 37"' Street Telephone : 772- 563 -4666 ext 1809 Vero Beach FL 32960 Fax : 772- 770-2025 Program Director : Mariamma Pyngolil RN E-mail : mariamma. pyn olilc irmh org Address : 1190 37t1i Street Telephone : 772 - 563 -4666 ext 1838 Vero Beach FL 32960 Fax : 772 - 770-2025 Program Title : Child/Adolescent Psychiatric Mental Health Clinic Priority Need Area Addressed: Therapeutic evaluation and interventions program for underinsured and uninsured school age children in Indian River County diagnosed with psychiatric or mental health problems . Brief Description of the Program : RR480 Early Intervention for Mental Illness • Programs that identify and provide treatment for individuals whose personal conditions and social experience could potentially produce mental emotional or social dysfunctions with the objective of preventing their development ; or which conduct general screen efforts to achieve early identification and treatment of 3 children who have incipient problems to ensure the best possible prognosis RM 650 Outpatient Mental Health Facilities : Programs that provide walk-in walk-out diagnostic and treatment services k for children adolescents and/or adults who have acute chronic mental or emotional disturbances but who do not need twenty-four hour care ,• and/or counseling services for individuals couples families and extended family group who may be experiencing difficulty resolving personal or interpersonal conflicts or making personal adjustments to stressful life situations such as separation divorce widowhood , loss of a child poor health unemployment, family violence delinquency or substance abuse . RR-680 Psychopharmacology Programs that utilize mood altering drugs and other medication in the control and/or treatment of mental or emotional disturbances . Services mav include an evaluation to determine the need for medication , prescription in modifying the individual ' s behavior, to ensure that undesirable side effects are minimized and to veriffy that medication is in fact being taken as prescribed k ! £L1 3 5 The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC SUMMARY REPORT — (Enter Information In The Black Cells Onl Amount Requested from Funder for 2004 /05 : $ 76 , 000 . 00 Total Proposed Program Budget for 2004 /05 : $ 252 , 777 . 64 Percent of Total Program Budget : 30 . 1 % Current Program Funding ( 2003 /04 ) : $ 76 , 000 Dollar increase/ ( decrease ) in request : $ _ Percent increase /( decrease ) in request0 . o Unduplicated Number of Children to be served Individually : 10 /o Unduplicated Number of Adults to be served Individually : 100 Unduplicated Number to be served via Group settings : Total Program Cost per Client : 2527 . 78 * *If request increased 5 % or more, briefly explain why : If these funds are being used to match another source, name the source and the $ amount : The Organization 's Board of Directors s� approved this application on ( ate). to ' V ChCwlt?5 V 5heshon Name of President/Chair of the Board Signatur T(fkFe. rN L . S us ; Name of Executive Director/CEO i 4 AT The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section . In responding to each section of the proposal narrative, please retain the section-label and/or question that you are addressing . Type using 12 pt . font on 8 '/2" X 11 " paper and number each page. These directions and the graphic boxes may be deleted if space is needed . A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization . Indian River Memorial Hospital strives to be the finest community based health care organization anywhere . Our values are compassion, respect, and teamwork . The Center for Emotional and Behavioral Health ( IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community . Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team . We will continue to support the Quality First process while working together as a team . The vision of the Child/Adolescent Psychiatric mental health clinic program is to provide compassionate, competent, accessible, and affordable psychiatric care to children of Indian River County. 2. Provide a brief summary of your organization including areas of expertise, accomplishments, and population served. CE13H provides Mental Health services to children, adolescents and adults . Psychiatric clinicians are located in the Emergency Department of IRMH and provide a comprehensive psychiatric assessment to determine appropriate level of care . In patient services are provided on a voluntary or involuntary basis to all three age groups . Inpatient services provide short term acute care and crisis stabilization for all patients who cannot be safely managed in an outpatient setting . The outpatient services provide psychiatric t and mental health care for about 350 children and adolescents . A board eligible psychiatrist trained in the child and adolescent needs and unique developmental characteristics provides psychiatric care which includes comprehensive evaluation, treatment planning and medication management . Masters and doctoral level prepared therapists provide psychotherapy and counseling services to children , adolescents, and their families to enable them to cope with the emotional and behavioral issues . The out-patient services also include a summer camp (Camp Manatee Therapeutic Summer Camp ) for ADHD children, Experiential (ROPES teambuilding) , parenting classes, EAP services, urine drug screens/drug free workplace services, and k community outreach . The children receiving services range from 3 to 18 years of age . This program has demonstrated success in providing early intervention for children suffering form any emotional, behavioral disorder or acute and traumatic stress . This program also helps to maintain the children in the natural environment , thus preventing acute care hospitalization . The medical director and staff of the outpatient clinic collaborates with the school system and the other health care providers in Indian River County to provide clinical and consultative services . 5 n , y The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC B . PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change ? B) Who has the need ? I c) Where do they live? d ) Provide local, state, or national trend data, with reference source, that corroborates that this is an area of need . Loss of function in a child ' s life as a result of stress or psychiatric disorder interferes with their ability to perform in school, maintain relationships and meet the ordinary demands of life . As reported in the proceedings based on the surgeon general ' s conference on the mental health, the nation is facing a public crisis in mental healthcare for infants, children, and adolescents . Many children have mental health problems that interfere with normal development and functioning . "In the United States, one in ten children and adolescents suffer form mental illness severe enough to cause some level of impairments (Burns et al . , 1995 ; Shaffer, et al . , 1996 ) Yet in any given year, it is estimated that about one in five of such children receive specialty mental health services (Burns et al . , 1995 ) . Unmet need for services remains as high now as it was 20 years ago . Recent evidence compiled by the World Health Organization indicates that by the year 2020, childhood neuropsychiatric disorders will rise proportionately by over 50 percent, internationally, to become one of the five most common causes of morbidity, mortality, and disability among children . There is broad evidence that the nation lacks a unified infrastructure to help these children who are not identified as having mental health problems and who do not receive services end up in jail . Children and families are suffering because of missed opportunities for prevention and early identification, fragmented treatment services, and low priorities for resources . " ( Surgeon Generals Conference on Mental Health, June 2000) This program seeks to provide early intervention for children suffering form psychiatric & mental health disorders to prevent debilitation effects of mental illness and maintain function . 2. a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these existing programs are under-serving the targeted population of your program . Similar programs available for Indian River County residents are limited to Suncoast Mental Health Center which provides a child psychiatrist for 2 days a month for up to 8 - 16 hours a month . Center for Emotional and Behavioral Health currently has 350 patients in the outpatient clinic . The number of children enrolled in fiscal year 2003 was 300, representing a 16 percent increase in children accepting service . As per the national trend data, this may only represent 50 percent of the children needing services . Pediatricians in the area re not comfortable treating psychiatric disorders and defer such treatment to psychiatrists . Therefore it is a reasonable assumption that children ' s mental health services will continue to be a priority need . Center for Emotional and Behavioral Health was able to accommodate for the growth because of funding from the Children ' s Services Advisory Committee . 6 U :. The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC s x C. PROGRAM DESCRIPTION (Entire Section C, I — 61 not to exceed tw)ohages) 1 . List Priority Needs area addressed . Therapeutic evaluation and interventions program for underinsured and uninsured school age children in Indian River County diagnosed with psychiatric or mental health problems . 2 . Briefly describe program activities including location of services . Any child or adolescent from Indian River County seeking evaluation and treatment of psychiatric or mental health issues will be provided a comprehensive evaluation by the psychiatrist . Based on the findings of the evaluation, a treatment plan is formulated and discussed with the child/adolescent and family. The treatment may include psychopharmacology, counseling and/or both . In addition all families are encouraged to attend and participate in the parenting classes . The psychiatrist will collaborate with family, school and other health care providers to coordinate the care . The child will be followed up that clinic at regular intervals based on the unique needs of each child . The services are provided at the Center for Emotional and Behavioral Health . 3. Briefly describe how your program addresses the stated need/problem . Describe how your program follows a recognized " best practice" ( see definition on page 12 of the Instructions) and provide evidence that indicates proposed strategies are effective with target population . Providing comprehensive treatment involving medication management, psychotherapy, active involvement with the family and school and teaching specific social skills and behavior program will provide the child or adolescent with an opportunity to regain and maintain function. Recent research shows that certain types of psychotherapy, particular cognitive behavior therapy (CBT), can help relieve depression in children and adolescents . (Birmaher B , Brent DA, Benson, RS , 1998 ) (Jayson D, Wood A, Kroll C. et all 1998 ) In addition safety and efficacy of six general classes of medication have been researched , psycho stimulants ( Greenhill et al . , 1998 ), mood stabilizers (Ryan et al . , 1999) selective serotonin reuptake inhibitors ( SSRI ' s) (Emslie et al . , 1999), antidepressants (Geller et al , 1998 ) , antipsychotic agents (Campbell et al, 1999), and other miscellaneous agents (Riddle et all , 1998 ) . Review of comprehensive body of research indicates strong support for safety and efficacy of SSRI ' s for childhood depression and psycho stimulants for ADHD . However, for many other disorders and medication, information from rigorously controlled trials is sparse or absent ( Surgeon Generals Conference on Mental Health, June 2000 ) . Addressing these, NIMH has initiated a large scale study involving clinical trials at 10 sites across the US to compare the long term effectiveness of medication, CBT and a combination of these for treatment of depression in adolescents . 7 r, f The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC 4. List staffing needed for your program , including required experience and estimated hours per week in program for each staff member and /or volunteers (this section should conform with the information in the Position Listing on the Budget Narrative Worksheet) . { Child/adolescent psychiatrist for 8 hours per week . This includes comprehensive evaluation, follow up visits, treatment plan coordination, and collaboration with school and family . 5. How will the target population be made aware of the program ? The target population will be made aware of the program through active collaboration with Indian River County Schools, health department, mental health association, substance abuse council , mental health program office, and local health care providers . In addition, information will be mailed to all of the above agencies along with all other agencies receiving funds from Indian River County Children ' s Services Advisory Committee . Ongoing community outreach programs at schools and others communities will also be utilized to market the program . 6. How will the program be accessible to target population (i. e., location, transportation , hours of operation ) ? The outpatient clinic is located at Center for Emotional and Behavioral Health, across the street from Indian River Memorial Hospital and easily accessible from US 1 or Indian River Boulevard . Parents or responsible adults will be expected to provide transportation . The program is available Monday through Friday 10 a . m . to 5 p . m . 8 The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC D . MEASURABLE OUTCOMES (Description gflntent) U.se the Heasurable Outcoines ,form. This description page does not need to be includedin the proposal. In order to show the impact that your program is having on the target population and the community, the funders are requiring measurable outcomes . Please review the examples and summaries below to insure your understanding of what is expected . OUTCOMES : Describes what you want to achieve with the target population . Indicates the results of the services you provide, not the services you provide . Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower . ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes . Activities utilize action words such as complete, establish, create, provide, operate, and develop . The activities should reflect the services described in the PROGRAM DESCRIPTION (C2) . Ilse the following elements to develop your outcomes. All elements must be included.• • Direction Of change • Time frame • Area of change As measured by • Target population • Baseline: The number that you will be • Degree of chane measuring against i.. Example 1 (Outcome) : To decrease (direction of change) number of unexcused absences (area of change ) of enrolled boys and girls (target population) by 75 % (degree of change) in one year (time frame) as reported by the 2003 School Board attendance records (as measured by) . Baseline : 2003 School Board attendance records for enrolled boys and girls . Example 1 (Activity) , To provide anger management classes to enrolled boys and girls 2 times a week for 12 weeks . Example 2 (Outcome) , 75 % (degree of change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (time flame), will improve (direction of change) their scores in one or more subject area (area of change) . 25 % of participants in academic enrichment activities will maintain the initial level of performance assessed at entry . Baseline : Pre-test scores from the academic enrichment test . Example 2 (Activity ) : . 1 ) Provide pre and post-test exercises on the Advanced Learning System software ; 2) Participants will go through the one lesson per week and be graded for 10 weeks . IMPORTANT NOTE : r Keep in mind when developing your PROGRAM OUTCOMES , that if funded , this will be what you are held accountable to accomplish . Also , the PROGRAM OUTCOMES should reflect the 's information described in the PROGRAM NEED STATEMENT (B 1 ) . All Program Need Statements should flow from the Mission & Vision . Measurable Outcomes should be based on and measure program needs . Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your Program Need Statement . 9 N • The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic4RC CSAC - D . MEASURABLE OUTCOMES (Entire Section D not to exceed tivo pages) OUTCOMES ACTIVITIES Add all (Lf the elements or the Alleasurahle Outcome (s) Add the tacks to accom lish the Outcome (, ) 1 . Children ' s Functional Assessment rating 1 . CFARS will be administered by the scale ( CFARS ) will demonstrate improvement psychiatrist upon admission and every 3 in primary areas identified - months thereafter. Depression, anxiety, hyperactivity, thought process, cognitive performance, traumatic stress, interpersonal relationships, substance abuse, family relationships, family environment, ADL (activities of daily living) functioning, school performance, danger to others, and security and management needs . 2 . Improvement in C -GAS (Children Global 2 . C -GAS scores will be collected initially and Assessment of Functioning Scale) by at least quarterly thereafter. 10 points in 6 months . 10 Yell Tire Center for Emotional and Behavioral Health-Child/Adolescent Psvchiatric Mental Health Clinic-IRC CSAC a E. COLLABORATION (Entire .Section E not to exceed one page) 1 . List your program ' s collaborative partners and the resources thata they are providing to the program beyond referrals and support. ( See individual funder requirements for inclusion of collaborative a reement letters.) Collaborative A enc Resources proj4ded to the program Indian River Memorial Provides physical plant for the outpatient clinic, Hospital/CEBH provides secretarial and administrative support for the program, provides support for the incremeptal growth of the program, through availability of the psychiatrist . Indian River County Health Provide consultation and follow-through for continuum Department of care . Indian River County Schools Provide consultation and follow-through for continuum of care . Mental Health Association Provide consultation and follow-through for continuum of care . Substance Abuse and Mental Health Provide consultation and follow-through for continuum Division of Department of Children of care, provides support for children ' s psychotherapy & and Families counseling services for uninsured children . Local Health Care Providers Provide consultation and follow-through for continuum of care . a 11 a 19 - gr f S The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC F. PROGRAM EVALUATION (Entire .Section F not to exceed tivo pages) I . DEMOGRAPHICS : What information (data elements ) will you need to collect in order to accurately describe your target population including demographics ( age, gender, and ethnic background ) required by the funder in Section H? What are the pieces of §" information that qualify them for your target population ? How do you document their need for services or their " unacceptable condition requiring change" from Section B19 The demographics collected include : age, gender, ethnic background, address, insurance status, school attending, medications & prior treatment, family and other support, monthly income, number of days spent in school . The services will be made available to uninsured and underinsured children needing psychiatric services . The severity rating in CFARS along with the psychiatric evaluation will document the need . 2 . MEASURES : What data elements will you need to collect to show that you have achieved ( or made progress toward ) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades , survey scores , attendance, absences, skill levels ) for your program ? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented ? How often do you need to collect or follow- up on this data ? a CFARS (Children ' s Functional Assessment rating scale) is an outcome evaluation used by the state of Florida to measure mental health outcomes . This tool rates severity of illness along symptom and functional areas e . g . Depression, anxiety, hyper affect, thought process, cognitive performance, traumatic stress, interpersonal relationships, substance abuse, family relationships, family environment, ADL (activities of daily living) functioning, school performance, danger to others, and security management needs . By administering this tool upon admission and quarterly thereafter, we will be able to measure improvement in clinical outcome . In addition C -GAS scores will report global assessment of functioning in children along the same time intervals . 3. REPORTING : What will you do with this information to show that change has occurred ? How will you use or present these results to the consumer, the funder, the program , and the community ? How will you use this information to improve your program ? The results of the CFARS will be shared with children and family to discuss progress towards goals . The results will be included in the quarterly report to the funder . The results will help the psychiatrist and the clinicians to modify treatment approaches to address specific problem areas . k 12 The Center for Emotional and Behavioral Health-Child/Adoleseent Psychiatric Mental Health Clinic-IRC CSAC G. TIMETABLE (Section G not to exceed one page ) I . List the major action steps , activities , or cycles of events that will occur within the program year. New programs should include any start- up planning that may occur outside the funding year. In completing the timetable, review information detailed in prior sections . Month/Period Activities August- September Marketing, develop & mail flyers notifying potential parents, school 2004 professionals and community health providers of the program October 2004 - Continues enrolling children in the program, provide treatments, collect September 2005 initial evaluation CFARS and C-GAS and 3 month CFARS and C - GAS January 2005 Compile report, evaluate clinical outcomes, revise program and clinical approaches if necessary, evaluate other needs of the program, and collaborate with funder and county health department . r January — September Repeat above steps . 2005 13 The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC .. H. PROJECTIONS FOR UNDUPLICATED CLIENTS Number of Unduplicated Clients by Location . . . . . . . . . ::«<:.:: Current Fiscal Year :::< : :> �.� :��1� Location .. Bud et 2003/04 .:. . . :. . ..:::; . g tp - at . . Unduplicated Clients Unduplicated Clients Unduplicated Clients N. Indian River County - 18 42 iw S . Indian River County - 28 58 Indian River Co. Total - 46 100 Greater Stuart Hobe Sound Indiantovm _ Jensen Beach Palm City Martin County Total Fort Pierce _ Port Saint Lucie St. Lucie Co. Total Other Locations _ TOTAL SERVED - 46 100 Number of Unduplicated Clients by Age � . . Current Fiscal Year Location anon .E > < # ' > Budget 2003/04 _: . . . . .: : : >> > .. : Individual Gr ou dn�da 0 to 4 - (Pre-school ) - - 3rr 5 to 10 - (Elementary) - - 8 - 30 - 11 to 14 - ( Middle) - - 25 - 45 - 15 to 18 - ( High School ) - - 10 - 20 - Total Children - - 46 - 100 - 19 to 59 - (Adults ) 60 + ( Seniors) Total Adults ,. TOTAL SERVED t - _ 46 _ 100 _ a, 14 The Center for Emotional and Behavioral Health-Child/Adolescent Psychiatric Mental Health Clinic-IRC CSAC BUDGET FORMS - To open the Budget Forms, please double- click on the icon below. " Core Budget Forms " s 15 t CEBH@IRMW CWAdolescent psydil8triC Medal Health C& k UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET /MPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder specific Budget Forms. AGENCY/PROGRAM NAME : CE13H@lRMH/ Child/Adolescent Psychiatric Mental Health Clinic FUNDER: IRC=CSAC CA UTION : Do not enter any figures where a cell is colored In dark blue - Formulas and/or links are In place, Gray areas should Lbe used for calculations and to write Information oniv,OWN -a- I :.: . .. . . . ::#.fid . ; •::: . . . . . . . . . . . . . . . .. . . . . . . . . . . .. .. . r. .. .. . :: . . . . . . . v.;iii:•i:•i.:ti{:}.i::i�F;:i::r•:i}:�i:;:::;.}:.;-•� . .. . . 1 1 Children's Services CouncilSt. Lucie 2 Children's Services Council-Martin 3 Advisory Committee-Indian River 76000.00 4 United WaySt. Lucie County76 000. 152,605.0 5 United Way-Martin County 6 United Way-Indian River County , :^ f 7 Department of Children & Families 8 County Funds 9 Contributions-Cash .... . ,. 10 Program Fees 7500000 11 Fund Raisin Events-Net 6.700.000• . . . . .. . . . . . . . 12 Sales to Public - Net :::>: : >:•>:;;>: 13 Membership Dues > >. 14 Investment Income 15 Miscellaneous : • •. :• • .• 16 Legacies & Bequests 17 Funds from Other Sources 29000 18 Reserve Funds Used for Operating 19 In-Kind Donations - IRMH j ` <y' 101 777.00 20 TOTAL REVENUES ::`•: % % downy include tine 19 $151 ,000.00 576,000.00 56,854,605.0 Ss, .. .. . .�::.�:.::,-.�:::::.:�: -::•i:�:•i:•::•:i;:}'i::::r.:•:::.;r:.:::::::::•:: l.•:�:L?>:i::}:?:i>::. .,:i:5:;•i:�:•i::::i:;•}:.� ..: .�:.v:::::::.:.:,•. •:r:::•:•i:iiia•};i; ;.}::;::•:::::::•::•i:{•:-iii' . : . . . . . . . . . .. . . . . . . . . . . . ..:. . .: }� . . . :;;:.;•:::. ::::::;vii;.}•: , . . . . ::. :... .::.�:Ri:•:;;: i:•:i;::, . . . . .. .v : . .. . . . . ... . ... .... . :�•:. :. :;;:;;;;;<::.i:;•;ilii:.i:;;;.i:<;.;iiiom ::::::::::::: . . .. . . . . . . . •i:•i..�.•..•.•�-.- .-.-i�.iiii i:•;:.i:•i:;.:;;•i:;•::•:;- �i : :; .;;:}•;:«:;•i:.;::.;�.;::.ii••i:•;:: :: :; :.::::::. 21 Salaries - (must complete chart on next page) . ��:•:r:=� :;< ;:» : >:; :.>: >:;•<: >:: >:.:<.: : s>s:.> i;:::<:»>::»:>::;::<ii:<:.,;i: •ii:;;•i;i::: ::.:: . 184 67.00 7 3,551 ,447.21 �:::::x�:::.;ilii:-iii>•ri;;<::< <: :• :. :::::ilii::'^:::;•ii;:•i:-:;•:;: ;:-::;.: . ::.. . .: .,. . :.:•. ,. : . . . . . . . . . ... . . ..�: :; ::. . .:. . . . .;: ., . .: . r. . . .... ., ,;. .;. . . .: •:.:;:; : : ::;:;: : :.; : : : : ::i;> . i::-::••i:iii;-:.,, :: -. ::.:._ . . ,�: .; . .; . . . . . . . . . . . . . .. . .. . ..,.. . :. . . . . .. .. . . :. :::. # ::;•;•::; . ..:.�;i:-iii•:.,::.: . ... ;;;:, . . :. . . :.. :::.... :.: •:::::. :::.:::.._::::.:::.:�;;•.:<?..: iii: » a:•iii:S: _: : :oa>.::a::;;:::;S:r:::v::,:r:•ixii +: 22 FICA - Total salaries x 0.0765 :::;... ... i:<:: .. :.: . . .. . e Yemen - Hua q 7• •� pension or ua I I Sj400.84 271 ,685.71 23 staff Life/Heal : . Ica affil 8863.24 0.00 1709824.61 24 Disab. Workers ompensa ion - employees x— :' 29g943.39 0.00 577,110.17 25 rate 3 261 .53 n oa Hemp oymen - pr 0.001 62,860.62 26 employees x $7,000 x UCT-6 rate ' #:' "lilt 884.48 0.00 17,046.95 05242004 U-1 n�Y . N `n 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ry Mi: • 0 5 •'• ;? a cD qO �+ CA # 'k cz :•:moi ' E < fn Zoo : 315•:•:�::;': ::ii::}:•}?; :}: � ;?}:+{3i:;{:;:• 44 64 ir::^L•: tD O O o 0 O O O O O V N p pp � : S SiSS O p S S .� •: �{ M :: :ti::• :r:: ;:A:. ,;.• ::::� 000000000PIP � :` � �s 0 �'• `' `i `? :< a3:: ; 5 ::�>:� ';iii . :':L•. A v N O ' Wool O S iq 1q ho O V 8 8 J y• am : :' :•: �:•'•:�•:: r z ve ak � O O O a � z O 0 O O O O O O O O 0 O O O O O O O yp :W �a :c: :2':•`::>:'• _ - ; �' � V Of � A W N ,'A,� • Cl) N D on p ; at Z H a m 3 N _ owl m $ a s �O m M x Z q N G A yryl► kQ' ym CL Ci N A) t�l N k v 44 iii::;}.:::•}: '•: :::: •:. : ::.4.4;: ': 8 {: :•1ti':! 3 r .4 . . �rtiV ?{i x N �p 'i+:i '•Sv� '• Q3 : g O c O 8 :•: M i:Kx.•: (� : %'+<"•'''' - %: ::: 't' is `!i::i: :%S':;:i? N :':�':v}:{:;:: OD t O N rr fJl l^ $ m tnq � e Ca1*"11.°° CWAMhicurt Prydwdnc M! WH&sM r}nc UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME:CEBH IRMH/ Child/Adolescent Ps chiatric Mental Health Clinic FY 023 FY 03104 FY 04105 % INCREASE FYE 913W200a FYE 9/30/2004 FYE 9/30/2005 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (COL Ge°L BI/c°L a REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt Lucie 0.00 #DNro! 2 Children's Services Council-Martin 0.00 #OIVro! 3 Advisory Committee-Indian River 200000. 0 2444600-St 152 605.07 52q•28°� 4 United Wa Lucie County 5 United Way-Martin County 0.00N101 6 United Way-India River Coun 0.00 #DIV/0! 7 Department of Children d, Families 0100 #W101 8 County Funds 0.00 #DIV/0! r 9 Contributions Cash 0.00 #DN10!0.00 #DIV/O! 10 Program Fees 6 931 136.00 690000000 6 700,000.00 -2.90% 11 Fund Raising Events-Net 12 Sales to Public-Net 0.00 #DNro! 13 Membership Dues 0'00 #DIVro! 14 Investment income 0.00 #DIVro! 15 Miscellaneous 0.00 #DIVro! 0.00 #Dlvro! 16 Legacies & Bequests 17 Funds from Other Sources 2 000.00 #DIV/01 18 Reserve Funds Used for Operating 0.00 #DN/O! 19 In-Kind Donations 0.00 #DNro! 20 TOTAL 6 951136 00 619241445-00 6 854 605.07 -1 .01 . . . . ::. :::::::. . :•:.::. :::::::. . :•:::. :. ' •.:•:: . . . .:: . . . :. .:..:. :. ::..�•::: :;i::;: iii:• EXPENDITURES 21 Salaries 3t446,298,00 3 007.00 3 651 7.21 3.00% 22 FICA 240 .00 263 902.00 271 685.71 2.95% 23 Retirement 166,766.9316584914. 170,824.61 3.00°k 24 LifeMeallh 5601023A3 560 301 .14 677110.17 3.00% 25 Workers Compensation 60 999A7 61029.72 6286062 3.00% 26 Florida Unemployment 16 542.23 1655OA3 17 046.95 3,00%27 Travel-Daily 2t389,00 21659,00 2 635.77 3.00°�6 29 TraveUConferences/Trainin 49 649.00 49 549.0050 035.64 0.98%29 Office Supplies 47 051 .00 4824900 48 249.00 0.00% ao Telephone 42,167.02 - 44 805.00 3.09• a2 Utilities 31 Postage/Shipping1647.00 1 638.00 1 ,638,00 0.00% 65182.00 61 700.00 6663600 8.00% 33 Occupancy (Building & Grounds 11135,899,00 1 119712.00 11121 ,909,12 0.20% 34 Printingb Publications 3145.00 31331 .00 3p464,24 4.00°�6 35 Subscription/Dues/Memberships 1 ,705,00 11524.00 1 524.00 0.00% 36 Insurance 390 200.00 355 200.00 360 000.00 1 .35°6 37 E ui ment:Rental 8 Maintenance 8 614.00 91650,00 9 650.00 0.00°�6 38 Advertising4,996.661 51000.00 5 000.00 0.00% as Equipment Purchases:Ca ital Expense 13115.00 17 567.00 17 557.00 0.00°�, 40 Professional Fees (Legal, Consulting) 303 850.00 303 850.00 303 653.00 10.06% 41 Books/Educational Materials 24 349.00 28j657,00 28 657.00 0100%4z Food 8 Nutrition 117 636.00 110 880.00 112 720.00 1 .66% 43 Administrative Costs 651 085.00 559 351 .28 567 617.55 1 ,480/944 Audit Expense 0.00 0.00 0.00 #DIV/0! 45 Specific Assistance to Individuals 0.00 0.00 0.00 #DNro! 46 Other/Miscellaneous 800.00 800.00 11676.00 96.88% 47 Other/contract 739 421 .00 740 000.00 740 000.00 0.00 ° 48 TOTAL 7 993 676.09 7o9789307.66 8138 301 .59 2.01 %k:.' . . . . . . . . . . . .nw.�::::::..� . . . . . . . w ::. ... :.: .. . . :..:.: . f:.�: .n:::::.;'.�:.�:tii:ti:.�.:.:ti•:::i:i:.:::r;::':::i}'ii:::itiy :):visit::i:::isi::'i:::i::::}:ri{:::i:::i: :::X: ::S:•i::i:::::i tiry�:�:::::::;::ti:::::j :::r::::y���.ii:;:::::i i:i:::tiii iii;:::��: i:::}:::i:::•:ti:":i':i:ii:::j:S:i :i:iii:ji; 49 REVENUES OVE UNDER EXPENDITURES -1 042 540.09 4 ,053,862.56 1 ,283,696.52 21 .81 % ovlwrmH as 3 �[ ➢ F t i UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME:CEBH IRMH/ Child/Adolescent Psychiatric Mental Health Clinic FY 02/03 FY 03104 FY 04105 % INCREASE FYEL.gf30UM FYE 9/30/2004 FYE 9/30MM CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (coL C-coL BNcoL B REVENUES BUDGETED BUDGETED 1 Children's Services Counc%St Lucie 0.00 #DN/0I ,y 2 Children's Services Council Martin 0.00 #DN/0! 3 Advisory Committee Indian River 76 000.00 S76 000.00 p,pp•� 4 United Wa t Lucie County a United Way-Martin County 0.00 #DN/Ot 6 United Way-Indian River County 0.00 #DIV/0! 7 Department of Children & Families 0.00 #DN/O! s county Funds 0.00 #DIV/O! - V - . 9 Contributions.Cash 0.00 #DN/0l 10 Pr ram Fees 0.00 #DN/0! 49l839,00 7600000 76 000.00 0,00•,y 11 Fund Raising Events-let 12 Sales to Public-Net 0.00 #DIYlO! 13 Membershi Dues 0.00 #DN/O! 14 Investment Income 0.00 #DN/0l 15 Miscellaneous 0.00 #DIV/0I 1s Legacies & Bequests 0.00 #DIV/Of 17 Funds from Other Sources 0.00 #DN/01 0.00 #DIV/0! 1s Reserve Funds Used forOperating0.00 #DN/O! 19 In Kind Donations Mu tnebaoe in tOW4 13105.00 94 396.00 101 777.00 7,8296 20 TOTAL 49 839.00 151 000.00 151000-00 0.00% EXPENDITURES 21 Salaries 44w684.75q29 184 267.00 3.09% 22 FICA 3 18.38 7 956.00 6.06°� 23 Retirement 2149.34 8 863.24 3.09°,6 24 L!fe/Health 7A1 ,27 29 943.39 3.09°k 25 Workers Compensation 790.92 3261 .53 3.09°� 26 Florida Unemployment 214.49 . 884.48 3.09°A° 27 Travel-Daily 0.00 0.00 #ON/O! 2e Travel/Conferences/Traini 376.00 1600.00 1600.00 0.00% 29 Office Su ies 712.75 11600.00M 732.00 g,25P 30 Telephone 217.60 870.00 870.00 0.00% 31 Posta elShi in 20.00 100.00 100.00 0.00% 32 Utilities 450.00 500.00 33 Occupancy Buildin & Grounds 1 250.00ww� 67000,00 5 000.00 0.00% 34 Printing & Publications 0.00 0.00 #DIV/O! 35 Subscri tiorWues/Membershi s0.00 200.00 200.00 0100%36 Insurance l260,00 61000,00 500000 0.00% 37 E ui ment:Rental ✓L Maintenance 0.00 #DN/O! 38 Advertising0.00 200.00 200.00 0100%39 Equipment Purchases:Ca ital ExDense 0.00 #DIV/Ot 40 Professional Fees (Leqal, Consulting) 0.00 #DIV/O! 47 Books/Educational Materials 100.00 500.00 600.00 0.00% 42 Food & Nutrition 0.00 0.00 #DN/O! 43 Administrative Costs 500.00 200000 29000.00 0.000% 44 Audit Expense 45 SPecifiC, Assistance to Individuals 0.00 #pry/p! 0.00 #DIV/O! 46 Other/Miscellaneous 0.00 0.00 #DN/01 47 Other/Contract 48rROE TAL 0.00 #DN/O! 62 944A0 245 396.05 252 777.64 3.01 °k 49VENUES OVER/ UNDER EXPENDITURES 43105AO -94,396.05 401777.64 7.82% ov:alaw e� T • CEBH@IRMWChWAddesceM psychiatric Mental Health CWc UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : CEBH@IRMH/ Child/Adolescent Psychiatric Mental Health Clini FUNDER : IRC - CSAC A B C FY 04/05 FY 04/05 % OF TOTAL FUNDER TOTAL VS, PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET col. B/col. A = EXLzENDITURES 21 Salaries 184,267.00 70,599.16 38 .31 % 22 FICA 79956.00 5,400.84 67.88% 23 Retirement 8 ;863n24 0.00 0 .00% 24 Life/Health 29,94339 0.00 0.00% 25 Workers Compensation 31261 .53 0.00 0.00% 26 Florida Unemployment 884.48 0.00 0 .00% 27 Travel-Daily0.00 0.00 #DN/01 2s Travel/Conferences/Training 11500.00 . 0.00 0.00% 29 Office Supplies 11732.00 0.00 0.00% 3o Telephone 870.00 0.00 0.00% 31 Posta e/Shipping 100.00 0.00 0.00% 32 Utilities 500.00 0.00 0.00% 33 Occupancy (Building & Grounds) 59000.00 0.00 0 .00% 34 Printing & Publications 0.00 0.00 #DN/0! 35 Subscription/Dues/Memberships 200.00 0.00 0000% 36 Insurance 50000.00 0 .00 0.00% 37 Equipment: Rental & Maintenance 0 .00 0 .00 #DN/01 38 Advertising 200.00 0.00 0 .00% 39 Equipment Purchases : Ca ital Expense 0.00 0.00 #DN/01 40 Professional Fees (Legal, Consulting) 0 .00 0.00 #DN/0! 41 Books/Educational Materials 500 .00 0.00 0 .00% 42 Food & Nutrition 0.00 0.00 #DN/01 43 Administrative Costs 29000.00 0.00 0.00% 44 Audit Expense 0 .00 0.00 #DN/01 f, 45 Specific Assistance to Individuals 0.00 0.00 #DN/O! 46 Other/Miscellaneous 0 .00 0.00 #DN/OI ` 47 Other/Contract 0 .00 0.00 #DIV/O! 4E TOTAL $252,777 .64 $760000.00 30 .07% 05242004 Bd + r C® 4@NtWVChK4^dAeruM Psyd** MmtM HvWh CNk UNIFORM GRANT APPLICATION w� fk« EXPLANATION FOR VARIANCES OF 15% OR MORE y, , TOTAL PROGRAM BUDGET 5� AGENCY/PROGRAM NAME: CE13H@IRMH1 Child/Adolescent Psychiatric Mental Health Clinic FUNDER: IRC - CSAC \� `�'+ t '/�t# `.a'^"..:•. .'~. . .. , . -,' :. .. . . . : :C.lv,.wri^2''.'•v'.'L. '1 � '. �ti.�`.} :`~`£'�tv`:!.{'. ` 2%v ti„ ,. 4: ..}'•f , .yt``yA' .`YYY•'• .;r!•M1tvv^.•.J .2.:.v. ,;yy .., . • ,.. :. �. i '..t'�i'�i'� �tir.!F.'a:9( �,. , _•• , , ,•;``u"�.`,�>..6 }.��,�}.20.x.::.\'%ii45 .2"' 4•�,.•`j`.2 v"".vv\"}^,'!'v���ri� v , � n �1Vroy s' #D!Vrol #Droro! #D!Vrw #Dtvro! #Dnrrol #DIVro! #DIVroI #DIVrol #Drorol #D!V1o! #DNroI #W/O! #avro! #DIV/O! #D1Vro! #DIVrof #D!Vro! #D!Vro! #Dnrro! #D1Vro1 5 � #Divro! #Drano± M412M sa CWHGM"CMId0A0WZCWd Paydd0 MMMHpWhclic UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE FUNDER SPECIFIC BUDGET AGENCY/PROGRAM NAME: CEBH@IRMH/ Child/Adolescent Psychiatric Mental Health Clinic FUNDER: IRC - CSAC \ :: .:v. v .. .. \h YJvk'�.. .:. `2 : . . . : v . .\.v.v.. .` :v • 2 }vv:•Y.vv ^} Salaries ....... .. . . .M1. . . ...: . . :. : ..t•. }�: . . M1 ::}>. •.v ; { On requesting a Portion of the salaries > FICA Only requestinga portion of the FICA #DN/Or #DN101 #DN/O! #DIV/O! XDIV/0! !DN/O! #DIVIO! #DN/O! #DIV/O! MIMI a os MAN B•6 EXHIBIT B [From policy adopted by Indian River County Board Of County Commissioners on February 19 , 2002] " D . Nonprofit Agency Responsibilities After Award of Funding Indian River County provides funding to all nonprofit agencies on a reimbursement basis only. All reimbursable expenses must be documented by an invoice and/or a copy of the canceled check . Any expense not documented properly to the satisfaction of the Office of Management & Budget and/or the County Administrator may not be reimbursed . If an agency repeatedly fails to provide adequate documentation , this may be reported to the Board of Commissioners . In the event an agency provides inadequate documentation on a consistent basis , funding may be discontinued immediately. Additionally, this may adversely affect future funding requests . Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For example , no expenditures prior to October 1St may be reimbursed with funds from the following year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not carried over to the next year unless expressly authorized by the Board of Commissioners . All requests for reimbursement at fiscal year end (September 30th) must be submitted on a timely basis . Each year, the Office of Management & Budget will send a letter to all nonprofit agencies advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early to mid October, since the Finance Department does not process checks for the prior fiscal year beyond that point . Each reimbursement request must include a summary of expenses by type . These summaries should be broken down into salaries , benefits , supplies , contractual services , etc. If Indian River County is reimbursing an agency for only a portion of an expense (e . g , salary of an employee ) , then the method for this portion should be disclosed on the summary. The Office of Management & Budget has summary forms available . Indian River County will not reimburse certain types of expenditures . These expenditure types are listed below . a . Travel expenses for travel outside the County including but not limited to ; mileage reimbursement , hotel rooms , meals , meal allowances , per Diem , and tolls . Mileage reimbursement for local travel (within Indian River County) is allowable . b . Sick or Vacation payments for employees . Since agencies may have various sick and vacation pay policies , these must be provided from other sources . c . Any expenses not associated with the provision of the program for which the County has awarded funding . d . Any expense not outlined in the agency's funding application . The County reserves the right to decline reimbursement for any expense as deemed necessary. " - 1 - EXHIBIT C STANDARD TERMS FOR GRANT CONTRACT 1 . Notices : Any notice , request, demand , consent, approval or other communication required or permitted by this Contract shall be given or made in writing , by any of the following methods : facsimile transmission ; hand delivery to the other party; delivery by commercial overnight courier service ; or mailed by registered or certified mail (postage prepaid ), return receipt requested at the addresses of the parties shown below: County: Joyce Johnston -Carlson , Director Indian River County Human Services 184025 th Street Vero Beach , Florida 32960-3365 Recipient : Miriamma Pygnol Center for Emotional & Behavioral Health 119037 th Street Vero Beach , Florida 32960 2 . Venue : Choice of Law: The validity, interpretation , construction , and effect of this Contract shall be in accordance with and governed by the laws of the State of Florida , only. The location for settlement of any and all claims , controversies , or disputes , arising out of or relating to any part of this Contract, or any breach hereof, as well as any litigation between the parties , shall be Indian River County, Florida for claims brought in state court, and the Southern District of Florida for those claims justifiable in federal court . 3 . Entiretv of Aqreement : This Contract incorporates and includes all prior and contemporaneous negotiations , correspondence , conversations , agreements , and understandings applicable to the matters contained herein and the parties agree that there are no commitments , agreements , or understandings concerning the subject matter of this Contract that are not contained herein . Accordingly, it is agreed that no deviation from the terms hereof shall be predicated upon any prior representations or agreements , whether oral or written . It is further agreed that no modification , amendment or alteration in the terms and conditions contained herein shall be effective unless contained in a written document signed by both parties . 4 . Severability: In the event any provision of this Contract is determined to be unenforceable or invalid , such unenforceability or invalidity shall not affect the remaining provisions of this Contract, and every other term and provision of this Contract shall be deemed valid and enforceable to the extent permitted by law. To that extent, this Contract is deemed severable . 5 . Captions and Interpretations : Captions in this Contract are included for convenience only and are not to be considered in any construction or interpretation of this Contract or any of its provisions . Unless the context indicates otherwise , words importing the singular number include the plural number, and vice versa . Words of any gender include the correlative words of the other genders , unless the sense indicates otherwise . 6 . Independent Contractor. The Recipient is and shall be an independent contractor for all purposes under this Contract. The Recipient is not an agent or employee of the County, and any and all persons engaged in any of the services or activities funded in whole or in part performed pursuant to this Contract shall at all times and in all places be subject to the Recipient's sole direction , supervision , and control . 7 . Assignment . This Contract may not be assigned by the Recipient without the prior written consent of the County. - 1 - t • y ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID $ DATE (MM/DD/YYYY) PRODUCER INDIA - 1 11 04 04 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Marietta GA 30067 Phonee 800 - 476 - 7601 Faxe770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Admiral Insurance CO . Indian River Memorial Hospital INSURER 8: American Automobile xna . Co . Greg Morgan INSURER C: 1000 36th Street Vero Beach FL 32960 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR JNSRI TYPE OF INSURANCE POLICYNUMBER DATE (MM?DDI ATE MWD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ $ 510001000 i X X COMMERCIALGENERALLIASILITY CAPTIVE SIR 10 / 01 / 04 10 / 01 / 05 III I U ICU PREMISES Eaoccvrer>ce i X CLAIMS MADE OCCUR MED EXP (Any one Person) S PERSONAL d ADV INJURY 2 $ 5 , 0 0 0 , 0 0 0 GENERAL AGGREGATE 5 $ 1510001000 GEN'L AGGREGATELIMITAPPLIES PER PRODUCTS - COMPI AGG $ $ 510000000 POLICY El JPECT 0 LOC AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT (Es accident) S $ 2 , 000 , 000 ALL OWNED AUTOS B X SCHEDULED AUTOSMZA808333b7 10 / 12 / 04 10 / 1BODILY INJURY s (Per Person) B X HIRED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 BODILY INJURY B X NON-0WNEDAUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 (Peracddent) $ PROPERTY DAMAGE : GARAGE LIABILITY (Per acddeM) AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC 5 AUTO ONLY: AGG S IXCESSIUMBRELLA UABIITTY EACH GA A OCCUR aCLAIMSMADE CRL - FL - 10013 - 1002 - 03 10 / 12/ 04 11 / 01/ 05 AGGREGATTE� S $ 20 , 000 , 000 Excess $ DEDUCTIBLE Above SIR S RETENTION s $ 534/ $ 1514 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I TORY LIMITS I JWR ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT s OFFICERNEMBER EXCLUDED? Vyes, describe under E.L. DISEASE - EA EMPLOYEE S SPECIAL PROVISIONS below OTHER E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate Holder is added as Additional Insured with respect to their interest in contract with the Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATBIES. Vero Beach FL 32960 AUT ITEDRtPRE TA VE ACORD 25 (2001108) I © ACORD CORPORATION 1968 � c ACORDOP ID GATE (MMrDWYYYY) ,„ CERTIFICATE OF LIABILITY INSURANCE INDIA - 1 11 / 04 / 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF IN FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phone : 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Continental casualty company INSURER 8: Indian River Memorial Hospital INSURERC: Gregg Morgan - 1000 36tH Street INSURER D: Vero Beach FL 32960 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR r SR - POLICY EFFECTIVE POLICY EXPIUMN TYPE OF INSURANCE POLICY NUMBER DATE (MWDDrM DATE (MM/DDrM UMITS GENERAL LIABILITY EACH OCCURRENCE S — COMMERCIAL. GENERAL LIABILITY PREMISES Es occurence f CLAIMS MADE F ] OCCUR MED EXP (Any one person) $ PERSONAL d ADV INJURY S GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S POLICYF'j M LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Fa acddenl) S ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) f HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Peraccldent) $ PROPERTY DAMAGE S (Peracddent) rAAUTOEA LIABILITY AUTO ONLY - EA ACCIDENT S OTHF�t THAN ACC $ AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR EICLAIMS MADE AGGREGATE f S DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AMD X TORY LIMITS I I FR FP A EMPLOYERS' LIABILITY W- 128588438 01 / 01 / 04 01 / 01/ 05 E.L. EACH ACCIDENT S $ 100001000 ANY PROPRIETORIPARTNERIEXECUTNE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOY - $ $ 110001000 a � E.L. DISEASE - POLICY LIMIT $ 1 0 0 0 x 0 0 0 under SPECIAL PROVISIONS below $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Proof of coverage for above Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERE-OF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATIVFS. Vero Beach FL 32960 Aur IZEDR£PRE TA VE ZwooiACORD 25 (2001108) © ACORD CORPORATION 1988 Internal Revenue Service District Director Department of the Treasury Date: '71V R 2 6 1985 Employer Identification Number. 59- 2496294 Accounting Period Ending. September 30 Form 990 Required. ® Yes No Indian River Memorial Hospital , Inc . 1000 36th Streep Person to Contact: Vero Beach , FL 32960 Brenda Wilcox/cdt Contact Telephone Number. (404) 221 - 4516 File Folder Number : 580062333 Dear Applicant : 1 Based on information supplied - in your application for recd itiett and assuming your operations will be as stated Ze from Federal - income tax under*.sectionf501 ( c ) ( 3 ) -ofwtheave Internalmined Revenue Code . We have further determined that you are not meaning of section 509 ( a ) of the Code@ becaus . a private foundation within the section 170 (b) ( 1 ) (A) (iii) & 509 (a) ( Q You are an organization described in ' If your sources of support , or your Purposes . change , please let us know so we can consider the • effectcof the ch method of operation exempt status and foundation status . Also e ° a Your Your name or address . . You should inform us of all changes in As of January 1 , 19849 you are liable for taxes under the Federal Insuranc Contributions Act ( social security -taxes ) on remuneration of $ 100 or more e each of your employees during a calendar 3'ta PaY to Year ' Imposed under the Federal Unemployment You are not liable for the tax P Ymettt Tax Act ( FUTA ) . Since you are not a private foundation , You are not subject to the excise taxes under Chapter 42 of the Code . However • }*ou are not automatically exempt from other Federal excise taxes . If Federal taxes you have any questions about excise , employment , or other please let us know . Donors may deduct contributions to YOU as 4 ' Bequests , legacies , devises , transfers , orgiftsrtoiouded or section 1s of the Code . deductible for Federal estate and gift tax You or for your use are pif Provisions of sections 2055 , 2106 , and 2522pofthe sCodethey meet the applicable The box checked in the heading of this letter shows whether you must file Form 9900 Return of Organization Exempt from Income Tax . If Yes is checked , you are required to file Form 990 only if your than $ 25 , 000 . If a return is required , itomust ss ebeifiled pts aby the ch r15th dayare ofheofift month after the end of your annual accountingh $ 10 a day , up to a maximum of $ 5 , 000 , when areturndisTfiledwlateimposunlesses a ethere nalty of i Is reasonable cause for the delay . s iuu arc l/ uL 1 -cqulrva to Ille reaeral income tax returns unless you are subject to the tax on unrelated business income under section 511 of the Code . If you are subject to this tax , you must file an income tax return on Form 990-T , Exempt Organization Business Income Tax Return . In this letter , we are not determining whether any of your present or proposed activities are unrelated trade or business as defined in section 513 of the Code . You need an employer identification number even if you have no employees . If an employer identification number was not entered on your application , a number will be assigned to you and you will ' be advised of it . Please use that number on all returns you file and -in all correspondence with the Internal Revenue Service . Because this letter could help resolve any . questions about your exempt status . and foundation status , you should keep it in your permanent records . If you have any questions , please contact the person whose name and telephone number are shown in the heading of this letter . Sincerely yours , 4#0 400 District ector CC .* Edward J . Hopkins William J . Stewart I Letter 947 ( UO) ( Rev. 10-83) (' y ACORD. CERTIFICATt OF LIABILITY INSURANCE OP ID E DATE (MMIDDIYYYY) PRODUCER INDIA - 1 11 04 ( THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Florida Hospital Ins Svc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1675 Terrell Mill Assocss HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phone * 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE INSURED NAIC # INSURER A: Admiral Insurance Co . INSURER B: American Automobile Ins . Co . Indian River Memorial Hospital Greg Morgan INSURER C: 1000 36th Street Vero Beach FL 32960 INSURER D: COVERAGES INSURER E. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSRr TYPE OF INSURANCE POLICY NUMBER DATE MMI 71M�iWD LIMITS GENERALLIABILITY EACH OCCURRENCE S $ 5r000 , 000 X X COMMERCIAL GENERAL LIABILITY CAPTIVE SIR 10 / 01 / 04 UAMAGE 10 PREMISESEREMUrloe i X CLAIMS MADE F-IOCCUR MED EXP (Any one person) j PERSONAL 6 ADV INJURY $ $ 54001000 GENERAL AGGREGATE S $ 1510001000 GEWL AGGREGATE LIMIT APPLIES PER POLICY PROFLOC PRODUCTS - COMP/OP AGG S $ 510001000 AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT (Eascddent) $ $ 2 , 000 , 000 ALL OWNED AUTOS B X SCHEDULED AUTOS XZA8 0 8 3 3 3 6 7 BODILY INJURY 5 10 / 12 / 04 10 / 12 / 05 ( mon) B X HIRED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 B X NON-OWNEDAUTOS MZA80833367 BODILY INJURY 10 / 12 / 04 10 / 12 / 05 (Per accident) s PROPERTY DAMAGE j (Peracdderd) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT j ANY AUTO OTHER THAN EA ACC 5 AUTO ONLY: AGG i EXCESSRIMBRELLA LIABILITY EACH OCCURRENCE 1 $ 20o0001000 A OCCUR XI CLAIMSMADE CRL - FLm10013 - 1002 - 03 10 / 12 / 04 11 / 01/ 05 AGGREGATE 5 $ 20 , 0001000 Excess j DEDUCTIBLE Above SIR j RETENTION S WORKERS COMPENSATION AND $ 5M/ $ 15M j EMPLOYERS' LIABILITY T7ACCIDEN7T ANY PROPRIETOR/PARTNERIEXECUTNE E.L. EOFFICER/MEMBER EXCLUDED?Wyes, describe under E.L. Di SPECIAL PROVISIONS below OTHER E.L. DISEASE - POLICY LIMIT j DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT !SPECIAL PROVISIONS Certificate Holder is added as Additional Insured with respect to their interest in contract with the Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATWES. _ Vero Beach FL 32960 AUT W.LIJ RtPHEV"TAjPVE ACORD 25 (2001 /08) © ACORD CORPORATION 1988 ACORD, CERTIFICATE OF LIABILITY INSURANCE OP ID DATE (MMIDD/YYYY) PRODUCER INDIA. 1. Milli 11 / 04 / 04 THIS CERTIFICATE IS ISSUED AS A MATTER OF IN FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phone * 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED _ INSURER A: Continental Casualty company Indian River Memorial Hospital INSURER B. - Greg Morgan INSURERC: 1000 36th Street Vero Beach FL 32960 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENTe TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMro MUCM�DATE MMI LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY UAMAk3ftTO RENTED'—'--• PREMISES Es ocarenee S CLAIMS MADE OCCUR MED EXP (Any one person) S PERSONAL & ADV INJURY $ GENERAL AGGREGATE f GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG f POLICY F1 29 0 LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT f (Ea acddent) ALL OWNED AUTOS BODILY INJURY i SCHEDULED AUTOS (Per person)) HIRED AUTOS 7 - -- — NON-OWNEDAUTOS BODILYINJURY i (Per ao*lent) PROPERTY DAMAGE f (Per acddent) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT f ANY AUTO OTHER THAN FA ACC f AUTO ONLY: AGG f EXCESWUMBRELLA LIABILITY EACH OCCURRENCE i OCCUR CLAWS MADE AGGREGATE $ DEDUCTIBLE S RETENTION f i WORKERS COMPENSATION AND S A EMPLOYERS' LIABILITY 7C TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE W- 128588438 01 / 01 / 04 01 / 01/05 E.L. EACH ACCIDENT s $ 1 , 000 , 000 OFFICER/MEMBER EXCLUDED? V yes, desatbe under E.L. DISEASE - FA EMPLOYEE 1 , 0 0 0 , 0 0 0 SPECIAL PROVISIONS below OTHER E.L. DISEASE - POLICY LIMIT S $ 1 , 0 0 0 , 0 0 0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT ! SPECIAI- PROVISIONS Proof of coverage for above Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATLVES. Vero Beach FL 32960 AU 1. IVRIZEDREPRE TA VE ACORD 25 (2001 /06) © ACORD CORPORATION 1988 Interna ( Revenue Service District Director Department of the Treasury Gate: 'MA 2 6 1985 Employer Identification Number. 59- 2496294 Accounting Period Ending: September 30 Form 990 Required: ® yes (J No Indian River Memorial Hospital , Inc . 1000 36th Street Person to Contac Vero Beach , FL 32960 Brenda Wilcox/cdt Contact Telephone Number. (404) 221 - 4516 File Folder Number , 580062333 Dear Applicant ; Based on information supplied '. ' in your application for recognition and assuming your operations will be as stated from Federal income tax Xemption , we have determined under . -section 501 ( c ) ( 3 ) -Of the Internal Revenue uCode . are exempt We have further determined that ca meaning of section 509 ( a ) of the Codepobeareof a private foundation within the section 170 (b) ( 1 ) (A) (iii) 6 509 (a) ( 1 use Y° u ' are an organization described in If Your sources of support , or change , please let us Your purposes , character , or method of operation know so we can consider the effect of the change on exempt status and foundation status . Also , you should inform us of all changesYour in As of January 1 , 19849 You are liable for taxes under the Contributions Act ( social Federal Insurance security taxes on remuneration each of your employees during a calendar YOU areon of X100 or more y ou Imposed under the Federal Unemployment year . You arTax Act ( FUTA ) ,e not liable for the tax to Since you are not a Private foundation , You are not subject the excise taxes under Chapter 42 of the CodeHowever , you are not automatically exempt empt from other Federal excise taxes . If Federal taxes You have any questions about excise , employment , or other . please let us know , Donors may Bequests , legacies , devises estatebutions YOU as provided in section 170 of the Code . deductible for Federal estate and gift , tar gifts to you or for provisions of sections 2055 land Your use are Purposes Code ,they meet the applicable ' • and 2522 of the Code . The box checked in the heading of this letter shows whether 990 , Return of Organization Exempt from Income Tax , IP Yes is checked , required to file Form 990 only if your y011 must file Form than gross receipts each normally ll are $ 25 , 000 . If a return is required , it must be filed by the 15th dayofLheofiPt month after the end of your annual accountin $ 10 a da p g period . The law imposes a h . Y . u to s maximum of $ 5 , 000 , when a return is filed late , unless penalty of is reasonable cause for the delay . i iuu arc 11Ul ! 'Cl� Ull 'CQ Lo ' Ile reoeral income tax returns unless you are subject to the tax on unrelated business income under section 511 of the Code . If subject to this tax you are YOU must file an income tax return on Form 990- T , . Exempt Organization Business Income Tax Return . In this letter , we are not determining whether any of your present or proposed activities are unrelated trade or business as defined in section 513 of the Code . You need an employer identification number even if you have no employees . If an employer identification number was not entered on your application , a number will be assigned to you and you will ' be advised of it . Please use that number on all returns You file and in all correspondence with the Internal Revenue Service . Because this letter could help resolve any . questions about your exempt status . and foundation status , you should keep it in your permanent records . If you have any questions , please contact the person whose name and telephone number are shown in the heading of this letter . / Sincerely yours , Districtector cc : Edward J . Hopkins William J . Stewart Letter 947( OO) ( Rev. 10-83)