ORDER N0.29139 KERR COUNTY JUVENILE DETENTION NATIONAL SCHOOL LUNCH PROGRAM Came to be heard this the 25t" day of April 2005, with a motion made by Commissioner Williams, seconded by Commissioner Letz. The Court unanimously approved by vote of 4-0-0 the Renewal Agreement with the National School Lunch Program through the Texas Health and Human Services and authorizes the County Judge to sign. z ~t 3~ ,~ COMMISSIONERS' COURT AGENDA RE UEST ~~, PLEASE FURNISH ONE ORIGINAL AND NINE COPIES OF TffiS REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT. MADE BY: J~~iG°~L /1~ga2~2ZS y MEETING DATE: ~ ~~ S OFFICE: ~C~ TIlvIE PREFERRED: SUBJECT: CON 5 I A h2 X111 ~ ,q~~2o d t %~~ I~E~tI Eul A-~C. ~6~~rn~N T ~- J1J~T.~N~~-~j~h/oD~c, ~-uN~~ ~2a6,eA~ ~~/lau~;~ T~~ ~Xgs h~~~~-r~ GUSiN 7~~ ~uD ~umA~ SCRU.~~65 ~~ ~~N->9/L~z~ ~ou~vTy,Jab6~ d ~.rG.~l SA~~ . EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON) NAME OF PERSON ADDRESSING THE COURT: .~F~ky ~i4lLQ.~'S ESTIMATED LENGTH OF PRESENTATION: 02 lyJ~1J - IF PERSONNEL MATTER -NAME OF EMPLOYEE: Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapter S51 and 552, Government Code, is as follows: Meeting scheduled far Mondays: THIS REQUEST RECEIVED BY: THIS REQUEST RECEIVED ON: 5:00 P.M. previous Tuesday. All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has been prepazed for the Court's formal consideration and action at time of Court Meetings. Your cooperation will be appreciated and contribute towazds you request being addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners' Court. Texas Health and Human Services Commission National School Lunch Program and School Breakfast Program Application for Participation and Policy Statement School Program Year: July 1, 2005 Through .lure 30, 2008 Form 1610 March 2003 r'ART 1-APPLICATION Texas ID Number Contract Number Program Number 17460014941022 75 88008 TX 133 - 2004 Name of School Food Authority Contact Person Kerr County Michelle Irby Address {Street or P. 4. Box, C'dy, State, Z'ip) 3501 legion Drive Kenville TX 78028 Telephone Number Fax Number Email Address { 830 ) 257-6110 ( 830 ) 257-3755 irbykcjf~yahoo.com Name of SchoollFacility (If more than one site, complete a DHS Form 1609 for each site.) Kerr County Juvenile FaciNty School Address Crf d'rfferent from School Food Authority address) Telephone Number Same ( ) Type of ScfiooUFacility (check all that apply) ^ Day School ^ Boarding School ^ Combination Day School ® Residential Chikf ^ Combination Day School and and Boarding School Care Institution Residential Child Care instituton ^ Special Education School ^ Afterschooi Care Snack Site ^ Other (specify): SchooUResidential child care institution (RCCI) is; ® Public ^ Private b If "Private," is the schooURCCI nonprofit and tax exempt ^ Yes ^ No ~ If "Yes," attach copy of under the Internal Revenue Code of 1954? letter from the dRS. Total Enrollment for Ail Schools/RCCls ~ 76 Total Number of All Schools/RCCis ~ 1 Administered by Food Authority: Administered by School Food Authority: 1. is the above schooUresidentialchfld care institution licensed? (If yes, attach copy of license.) ..................................................... ® Yes ^ iVo 2. Program(s) that you are apptying for. ® National School Lunch Program ® Afterschool Care Snack program (must be participating in National School Lunch Program) ® School Breakfast Program ® Severe Need School Breakfast Program Rates ` Available to schods/residential child care institutions meeting fhe fdlowing eligibility aiteria: 1. 40% or more total lundres served in seca~d precx3ding year were free or reduced price; and 2. Breakfast costs exceed fhe regular reimbursement rates available under the Sdwal Breakfast Progr~n. Number of Months Beginning Date of Operation Ending Date of Operation 3. Number of months the school wd1 be operating a food service program :................. 12 07/01/2005 06/30/2006 4. Number of children enrolled at schooUresidential child care instihrtion :........................................................................................ 76 A. Age Range of Children Enrolled 5. From: 10 To: 17 B. Grade Levels Taught (schools onry) From: To: AVERAGE DAILY PA RTICIPATION OF CHIL DREN IN PROGRAM TIMES OF FOOD SERVICE Food Service: Free Reduced Price Paid Beginning Ending Breakfast 76 0700 0745 Lunch 76 1200 1245 Area Eligible Afterschool Care Snack Not Area Eligible Afterschooi Cane Snack 76 1700 1745 6. Attendance (for residential child care institutions onty) A. Are ap of the children at the institution all day? .................................................................................................................. ® Yes ^ No ff no, do all or some of the children attend public school? ................................................................................................. ® Ail ^ Some if only some attend publ'~c school, how many? .................................................................................................................. If some or all attend public school, which meals do these student eat at the institution? ...... ^ Breakfast ^ Lunch ^ Afterschool Snack B. Check if the children attend the institution on holidays and/or weekends .......................................................................... ®Holidays ~ Weekends Form 1610 Page 2, 03-2003 7. Tvpe of Meal Service A. Meal Preparation ® On-Site IGtchen ^ Central Kitchen ^ Food Service Management Company ^ Vended Meals (submit copy of contract and checklist) (submit copy of agreement) ^ Other (explain): B. Meal Planning System ^ Enhanced Food Based ® Traditional Food Based ^ Nutrient Standard Menu ^ Assisted Nutrient Standard Menu Planning Planning (NSMP or NuMenus) (ANSMP or Assisted NuMenus) (See instntctions for documerr~ to submit) ^ Other (explain: NOTE: Snacks served in the Afterschod Care Snack program must follow the food based supplement paltem regardless of your menu planning method for breakfast and/or lunch. 8. Type of Program ^ Separate Charges ® No Separate Charge; Cost of Meals is Included ^ Combination of Separate Charges and Made for Meals in Required Payment PIan/Fee No Separate Charges 9. Daily Price Charged for Each Meal f th t ilt h l CHILDREN ( or programs a w c arge separate y only): Reduced Price Paid ADULTS Breakfast Lunch Not Area Eligible Afterschool Care Snack NOTE: Area Eligible Atterschool Care Snack program sites must provide snacks free of charge to all students partiapating in the after schod care program. 10. A. If applyin4 for the National School Lunch Program. indicate whether Offer versus Serve will be irnnlerrwntrari~ High School (mandatory) Junior High (optonal) Elementary (optional) Preschool {optional} Residential Child Care Institution (optional) ^ Yes ^ Yes ^ No ^ Yes ^ No ^ Yes ^ No ^ Yes ® No B. If applying for the School Breakfast Program, indicate whether Offer versus Serve wiN be imofemented: High School (optional) Junior High (option) Elementary (optional) Preschool (optional) Residential Child Care Institution (optional) ^ Yes ^ No ^ Yes ^ No ^ Yes ^ No ^ Yes ^ No ^ Yes ® No 11. Describe your training in food service program requirements for personnel (use an attachment rt necessary): All food service personnel are trained under the Texas Department of Health-NSLP guidelines as to nutrition, food nutrition values, and portion size under the direct supervision of our School Lunch Program Coordinator. A8 empbyees are required to complete the Texas Department of Health Food Manager Certification. 12. Will supplemental (a la carte or snack bar) food service be available in addition to the school lunch? ......................................... ^ Yes ® No Questions 13 through 18 apply only to the Afterschoo! Care Snack program. 13. How will the school food authority operate the after school care program? Ifnon-school personnel, what organization is responsible for day-today operations? ® Will Use School Personnel ^ Will Use Non-school Personnel: 14. Total number of sites administered by School Food Authority offering the Afterschool Care Snack program? ............................... 1 Is attendance in after school care program limited to students enrolled in your schooURCCI? ...................................................... H no: In which ind+vidual public school attendance area (not district) is the site bated? NOTE: You must attach an information statement from the ISD (see instructions). 16. Indicate your schooVRCCI or the public school free or reduced price enrollment percentage :................................. Free or Reduced Price: 100 ~ 17. Which required activities are included in your after school program? ....................................... ® Educational Activities ® Enrichment Activities 18. Licensing (For schools only) A. Is a Texas Child Care License required for your after school care program? .................................................................... ^ Yes ^ No If yes, attach copy of license. If no, attach written confirmation from TDPRS that your facility is not subject to licensure. B• If after school care sfte is not on a school campus and is exempt from licensure, are all state and local health and safety standards met? (Attach copy of most recent inspections.) ................................................................................................ ^ Yes ^ No ® Yes ^ No Form 1610 Page 3, 03-2003 PART II --POLICY STATEMENT FOR FREE AND REDUCED-PRICE MEALS If the school food authority operates a program that requires separate charges for meals, it must comply with Sections A and B. f the school food authority operates a program that does not require separate charges for meals, it must comply with Sections B and C. If the school food authority operates a program that require both a separate charge and no separate charge for meals, it must comply with Sections A, B, and C. SECTION A -Programs that Charge Separate ONLY 1. The school food authority accepts responsibility for providing free and reduced-price meals to eligible children. 2. The school food authority assures DHS that it will uniformly implement the following policy to determine children's eligibility for free and reduced- price meals in the National School Lunch Program and School Breakfast Program. In fulfilling its responsibilities, the school authority agrees to: a. Serve free meals to children from households whose income is equal to or less than the income eligibility standard for free meals on Form 4504, Standards (or Determining Free and ReducerNprice Eligibility, applicable to the contract period, or to children from food stamp households or TANF assistance units that provide a case number. b. Serve reduced-price meals to children from households whose income is above the income eligibility standard for free meals but equal to or less than the standard for reduced-price meals on Fonm 4504, Standards for Determining Free and Reduced-price Eligibility, applicable to the contract period. c. Provide these benefits to children from families submitting completed applications, whose income meets the criteria on Form 4504, and to foster children and to children from families whose income meets the criteria on Form 4504, because of strikes, layoffs, or unemployment d. Designate to review applications and detem-ine NAME TITLE eligibility. This official must use the criteria in this policy to determine which children are eligible forfree orreduced-price meals. e. Prohibit physical segregation of, or any other discrimination against, any child because of his eligibility for free or reduced-price meals. The names of these children must not be published, posted, or announced in any manner. They must not be overtly identified by special tokens or tickets or by any other means. They must not be required to (1) work for their meals; (2) use a separate lunchroom; (3} go through a separate serving line; (4} enter the lunchroom through a separate entrance; (5) eat a meal different from the one sold to chikdren paying the full price; or (ti) eat meals at a different time from the other children. f. Establish and use a fair hearing procedure for parents who appeal the school'sIRCCI`s decisions on applications and for officials of schoolslRCCls who dispute information in an application or the eligibility of children for free or reduced-price meals. During the appeals and hearing, the child must continue to receive free or reduced-price meals. Records must be kept according to record retention requirements in the National School Lunch/Breakfast Programs Handbook and agreement. Before beginning the hearing procedure, the parent or local schooURCCI official may request a vonference. The conference should provide an opportunity for the parent and schooVRCCI official to discuss the situation, present information, and obtain an explanation of data submitted in the application and decisions made. A conference must not prejudice or diminish the right to a fair hearing. The hearing procedure must provide: (1) A simple, publicly announced method for making an oral or written request for a hearing. (2) An opportunity to be assisted or represented by an attorney or other person. (3) An opportunity to examine, before and during the hearing, the documents and records presented to support the decision being appealed. (4} Reasonable promptness and convenience in scheduling a hearing and adequate notice of the time and place of hearing. (5) An opportunity to present oral or documentary evidence and arguments supporting a position, without undue interference. (6) An opportunity to question or refute testimony and evidence and to confront and cross-examine adverse witnesses. (7) A decision made by a hearing official conducting the hearing who was not involved in the decision being appealed or in any previously held conference. (8} A decision by the hearing official based on oral and documentary evidence presented at the hearing that is made a part of the hearing record. (9) Written notification of the hearing official's decision, including the household's right to reapply any time during the year, provided to the parties concerned and their designated representatives. (10) A written record that includes the decision being appealed, documentary evidence, and a summary of oral testimony presented at the hearing, the hearing official's decision and the reasons for the decision, and a copy of the notification of the hearing offiaal's decision to the parties concerned. Form 1610 Page 4, 03-2003 (11) Record retention of the hearing for three years and 90 days after the end of the fiscal year to which it pertains. If audit Endings have not yet been resolved, the records must be kept until the audit issues are resolved. The record must be available for examination by the parties concerned, or their representatives, at any reasonable time and place during the retention period. g. Submit information for public release to the news media, local unemployment offices, and major employers contemplating large layoffs in the area served by the school/RCCI. The school food authority must send the information for public release by letter at the beginning of each school year and when eligibility standards change. A11 changes in eligibility criteria must be publicly announced. The school food authority must keep a copy of the letter transmitting the public release information for three years and 90 days after the end of the fiscal year to which it pertains or until audit issues are resolved. The public release must include: (1) A sample of the letter to the parents (Form 1625). (2) Form 4504. The information for public release was or will be provided to the organizations on the dates that fol{ow (attach a sheet if more space is needed): Public News Media Date Organization Date Organization Date h. Establish a procedure to collect money from children who pay for their meals and a procedure to accurately record the number of free, reduced-price, and full-price meals served. The procedure described in this item must be used so that children will not be aware of who is receiving free and reduced-price meals. Check the collection procedure the school food authority uses. ^ Collection Procedure 1-Each day children can buy tickets in the cafeteria manager's office but they do not receive the tickets. The cafeteria manager then sends the purchased tickets and the tickets for free or reduced-price meals to the classroom. The teacher distributes the tickets just before meal time. The tickets are coded for accounting purposes. ^ Collection Procedure 2 -Each day children pay for their meals in the office. A list of all children who paid or are eligible for free or reduced-price meals is prepared and sent to the cafeteria. A cashier familiar with the children checks names as children pass through the fine. After the meal service, the list is returned to the office for accounting purposes. This method works only in a small schooVRCCI where the cashier knows all the children. ^ Collection Procedure 3 -The homeroom teacher gives each child an envelope for daily, weekly, or monthly payments. Children return the envelopes with the payments enclosed or empty if eligible for free meals. The envelopes are collected in the office and coded tickets are issued to each child. ^ Collection Procedure 4 -Parents pay in advance by the month. Each teacher receives a list of those children who have paid. Children who receive free meals are marked paid, so only the bookkeeper knows which children receive a free meal. Teachers keep daily records of each child served and send the records to the office for accounting purposes. ^ Collection Procedure 5 -Meal payments are collected in the secretary's office. Payments can be made by children or parents daily, weekly, or monthly. The secretary records payments and knows which children qualify for free or reduced-price meals. In the classrooms, the secretary distributes identical tickets labeled only with the children's names, Since the parents may pay, even the children may not know whether their meals are free, full- orreduced-price. ^ Collection Procedure 6 -Parents are billed monthly for full- or reduced-price meals these children are served. All payments are mailed in. All participating children receive a coded ticket each month, which is punched at each meal service. At the end of the month, the tickets are collected and a clerk calculates the amount to be billed. ^ Collection Procedure 7 -Other. Explain in detail. (Use an attachment if necessary.) Form 1610 Page 5, 03-2003 Describe how the daily numbers of free, reduced-price, and full-price meals are identified and counted, and the numbers recorded. {Use an attachment if necessary,) J. Describe how daily point-of-service counts are taken. The point-of-service in the food service operation is the point at which it can be accurately determined that a meal is reimbursable. This is usually the end of the line. If tickets or tokens are collected at the beginning, explain how you assure that a reimbursable meal was taken. {Use an attachment if necessary.) SECTION B -Programs that Charge Separately AND Programs that DO NOT Charge Separately In fulfilling its responsibilities, the school food authority agrees to: 1. Prohibit discrimination against people who are eligible to participate in the child nutrition programs because of race, color, national origin, sex, age, disability, religion, or political belief. Anyone who believes that they have been discriminated against should write immediately to: Director, Civil Rights Division, MC W-206, Texas Department of Human Services, P. 0. Box 149030, Austin, Texas 78714-9030 or to USDA, Director, Office of Civil Rights, Room 32fi-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5960 (voice and TDD). Note: Discrimination complaints based on religion or political beliefs must be referred only to the Director, Civil Rights Division, Texas Department of Human Services. 2. (Applicable only if operating day schools and boarding schools) -Develop and distribute to each child's parent or guardian a letter, according to the sample attached, and an application form for free or reduced-price meals. These must be distributed at the beginning of each year and when eligibility criteria change. a. The school food authority must complete (1) or (2) as applicable: (1) Fonm 1625 is a sample of the letter to parents whose children are in a program that charges separately for meals, Is the school food authority using the attached sample? ........................................................................ ^ Yes ® No (2) Form 1626 is a sample of the letter to parents whose children are in a program that does not charge separately for meals. Is the school food authority using the attached sample? ................................................. ® Yes ^ No If the answer to either (1) or (2) is "No," the school food authority must submit to DHS, with this application form, a copy of the letter they send to parents. DHS must approve this letter before the school food authority sends it to parents. On approval, the school food authority must attach Form 1625-A to the letter and send tx~th documents to patents. b. Forth 4524 is a sample of the application for free and reduced-price meals. Is the school food authority using the attached sample? ......................................................................................................................................................... ^ Yes ® No The school food authority must ask parents to complete the application and return it to the determining official named in Section A of this form. Applications and documentation of action taken are kept for three years and 90 days after the end of the fiscal year to which they pertain. If audit findings are not resolved, the records are kept until the issues are resolved. Applications may be filed at any time during the year, The school food authority must supply an application to parents enrolling a child in an schooVRCCI for the first time, at any time during the year. If a child transfers from one schooURCCI to another under the jurisdiction of the same school food authority, hismer eligibility for a free or reduced-price meal is also transferred. Note -Programs that Charge Separately ONLY: • All children from the same family must receive the same benefits. Within 10 workdays of receiving applications, parents or guardians must be notfied individually of the decision on their applications. Children are served meals as soon as they are determined eligible. • Form 1623 is a sample of the notification letter to the parents about the application for free and reduced- price meals. Is the school food authority using the attached sample? ............................................................... ^ Yes ^ No If "No," the school food authority must attach a copy of the letter being sent to parents. • When an application if denied, parents or guardians are informed in writing of the reason for denial and the hearing procedure. The designated hearing official is Name Title This person must be someone not involved in the original eligibility determination. It is suggested that the hearing official hold a position superior to the determining official's. The hearing official and the determining official cannot be the same person. 3. Submit to DHS any proposed changes to this policy statement before it is implemented. Changes are effective only when they are approved by DHS, Form 1610 Page 6, 03-2003 4. Verify eligibility according to the National School LunchlSchool Breakfast Program Handbook and program regulations. 5. Indicate which of the provisions of this section, if any, the school food authority wants to participate in, for free and reduced-price meals. Three special provisions are available b school food authorities that affect free and reduced-price meal policy and procedures. a, Provision 1 -The annual certification of children eligible to receive FREE meals may be reduced to once every two years in schools/RCCIs. This period can be reduced if 80% of the children in attendance are eligible for flee and/or reduced-price meals based on data from March of the previous year. Applications must still be sent annually to students who pay full- or reduced-price or who are newly enrolled. For claiming purposes, school staff must continue to keep a daily record of the number of paid, free, and reduced-price meals served to children. ® We choose NOT to participate in Provision 1. ^ We will participate in Provision 1, and certify that the following schools had 80°k or above free and/or reduced-price recipients participating: Our first year under Provision 1 will be school year ............................................................................................. b. Provision 2 -School food authorities may choose to serve all children at no charge. Any schooVRCCI which chooses to serve all children meals at no charge may reduce the frequency of certification for children eligible for free and/or reduced-price meals to once every four years. School food authorities must submit socioeconomic data from an approved source with their base year (first year) application to implement Provision 2, and socioeconomic data from the same source with their application for extension at the end of the four year cycle. The base year, or first year, that a school is on Provision 2 is part of the four year cycle. If DHS determines at the end of the four year cycle that there has been negligible improvement (5 percent or less improvement after adjusting for inflation) in the socioeconomic status of that school food authority's population, the Provision 2 period may be extended another four years. School food authorities choosing Provision 2 must use bcal sources other than federal reimbursement to absorb the cost of (1) meals served to children not eligible for free or reduced-price meals; and (2) the difference between the cost of the meal and the federal reimbursement received for each free or reduced-price meal served to children eligible for meals. School food authorities of schoolslRCCls using Provision 2 are required to send letters and applications to parents only at the beginning of thefour-year period. School food authorities must maintain al4 approved applications and eligibility documentation from the designated base year at least three years and 90 days after the final Claim for Reimbursement of the final School Year which employed base year data, or longer if required for audit resolution. Schools/RCCIs are required to determine daily during the first year of the four-year period the actual number of meats served to all attending children, by type (free, reduced-price, and paid). In the second, third, and fourth years, monthly claims for meals served, by type (free, reduced-price, and paid), are based on a percentage of the total number of meals served by type in the corresponding month of the first year. ® We choose NOT to participate in Provision 2. ^ The following schools/RCCIs will participate in Provision 2: Our base year or first year under Provision 2 will be school year .......................................................................... Provision 2 will be in effect for three successive school years after the base year, including school years and The school year that we will be reconsidered for an extension for Provision 2 is in the fourth year or school year Form 1610 Page 7, 03-2003 We will use and submit the following approved source of socioeconomic data with our application for our base year and when being considered for an extension (check source being used): ^ Local data collected by the city or county zoning and economic planning office. ^ Unemployment data. ^ Local Food Stamp Program certification data. ^ Temporary Assistance for Needy Families (TANF) data (provided that eligibility standards were the same or more restrictive in the base year as current year with allowance for inflation). Form 1626 is a sample of the letter to parents whose children are in programs with no separate charges for meals. It can be sent to parents for Provision 2 participants. If participating in Provision 2, you must answer the following question: Is the school food authority using the attached sample Form 1626? .............................................................. ^ Yes ^ No if °No," the school food authority must attach a copy of the letter being sent to parents. c. Provision 3 -School food authorities may choose to serve all children meals at no charge. Any schooURCCI which chooses to serve all children meals at no charge will conduct certification of children eligible for free andlor reduced-price meals during a designated base year and will not conduct eligibility certification during the successive four-year period following the base year. The school food authority must submit socioeconomic data from an approved source with their base year application, and from the same source with their application for extension at the end of the four year cycle. If I)HS determines after the initial four-year period of Provision 3 that there has been negligible change (5 percent or less improvement after adjusting for inflation) in the socioeconomic status of that school food authority's population, the Provision 3 period may be extended an additional successive four years. School food authorities choosing Provision 3 must use local sources other than federal reimbursements to absorb the cost of {1) meals served to children not eligible for free or reduced-price meals; and (2) the difference between the cost of the meal and the federal reimbursement received for each free orreduced-price meal served to children eligible for meals. School food authorities of schools/RCCIs using Provision 3 are required to send letters and applications to parents only at the beginning of the designated base year. School food authorities must notify households of enrolled students that all meals will be available at no charge to students during the Provision 3 four-year period. School food authorities must maintain all approved applications, eligibility documentation, and enrollment data from the designated base year at least three years and 90 days after the final Claim for Reimbursement of the final school year which employed base year data, or longer if required for audit resolution. School food authorities must determine any increase or decrease in enrollment each year of Provision 3 based upon the school's enrollment on October 31 annually. Schools/RCCIs are required to determine daily during the designated base year for Provision 3 the actual number of meals served to ~I attending children, by type (free, reduced-price, and paid). During the four successive years after the designated base year, schools will prepare monthly claims for meals served by type (free, reduced-price, and paid) based on the total meals claimed for the corresponding month of the designated base year and reflecting the percent increase or decrease in enrollment based on the school's/RCCI's enrollment on October 31 of the current school year, and must take total meal counts of reimbursable meals served to participating children at the point of service. ® We choose NOT to participate in Provision 3. ^ The following schoolslRCCls will participate in Provision 3: Our first year under Provision 3 will be school year ............................................................................................... Our designated base year will be school year ....................................................................................................... Provision 3 will be in effect for four successive school years after the base year, including school years ,and The school year that we will be reconsidered for an extension for Provision 3 is in the fourth year or school year Form 1610 Page 8, 03-2003 We will use and submit the following approved source of socioeconomic data with our application for our base year and when being considered for an extension (check source being used): ^ Local data collected by the city or county zoning and economic planning office. ^ Unemployment data. ^ Local Food Stamp Program certification data. ^ Temporary Assistance for Needy Families (TANF) data (provided that eligibility standards were the same or more restrictive in the base year as current year with allowance for inflation}. Form 1626 is a sample of the letter to parents whose children are in programs with no separate charges for meals. It can be sent to parents for Provision 3 participants. If participating in Provision 3, you must answer the following question: Is the school food authority using the attached sample Form 1626? .............................................................. ^ Yes ^ No If "No," the school food authority must attach a copy of the fetter being sent to parents and describe how it will nofrfy households that meals will be available free of charge to all enrolled students. SECTION C -Programs that DO NOT Charge Separately ONLY 1. The school food authority is responsible for providing program benefits to eligible children. 2. The school food authority assures DHS that although no identifiable charge is established for meals, it wiN uniformly implement the following policy. In fulfilling its responsibilities, the school food authority agrees to: a. Claim as free meals only those meals served to children from families whose income is equal to or less than the income eligibility standarct for free meals on Fonm 4504, Standards for Deten»ining Free and Reduced-price Eligibility, applicable to the contract period, or to children from food stamp households or TANF assistance units that provide a case number. b. Claim as reduced-priced meals only those meals served to children fn~m families whose income is above the income eligibility standard for free meals but equal to or less than the standard for reduced-price meals on Form 4504, Standard for Determining Free and Reduceal priced Eligiblltty, applicable to the contract period. c. Keep documentation to support individual eligibility decisions for three years and 90 days after the end of the fiscal year to which they pertain. if audit findings are not resolved, the records must be kept until audit issued are resolved. d. Prevent physical segregation of, or any other discrimination against, any child. The names of the children eligible for free or reduced-price meais may not be published, posted, or announced in any manner and children must not be overtly identified. Children must not be required to (1) work for their meats; (2) use a separate lunchroom; (3} go through a separate serving line; (4}enter the lunchroom through a separate entrance; (5) eat meals at a different time; or (6} eat a different meas. e. Designate Becky Hams Facility Administrator to determine eligibility for free and Name Title reduced-price meals. This official will use the criteria outlined in this policy to determine which individual children's claims maybe made for free or reduced-price meals. f. Develop and keep a I'~st with the following information about each child (for school food authorities operating RCCIs only): (1) name; (2) birth date; (3) dates of admission and release; (4) income; (5) eligibility determination and data (initialed by official making determination). Note: Children at RCCIs are considered a family of one. Exceptions to this are children of house parents living at the institution. These children must have an application en file as described in Section B, number 2. g. Describe how daily point-of-service counts are taken. The point-of-service in the food service operation is the point at which it can be accurately determined that a meal is reimbursable. This is usually the end of the line. If tickets or tokens are collected at the beginning, explain how you assure that a reimbursable meal was taken (attach a sheet if needed). Form 1610 Page 9, 03-2003 SECTION D -The following attachments are a part of the policy statement for free and reduced-price meats: Form 1623, Notification Letter to Parents Regarding Application for Free and Reduced-price Meals Form 1625, Letter to Parents (programs that charge separately for meals) Form 1625A, Standards for Determining Free and Reduced-price Eligibility to be provided to parents (will be forwarded as soon as USDA publishes) Form 1626, Letter to Parents (programs that do not charge separately for meals} Form 4524, Application for Free and Reduced-price Meals Form 4504, Standards for Determining Free and Reduced-price Eligibility (will be forwarded as soon as USDA publishes} A sample Press Release (see page 10 of this form) f CERTIFY that the information on this form is true and correct to the best of my knowledge. I understand that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. ff our school food authority has applied and is approved to participate in one of the Provisions, I certify that our school food authority will follow ail rules and regulations for the Provision for which we have been approved. FOR DHS USE ONLY Title "r' S' E~ School Lunch Program Coordinator Date Signature--0HS Representative Title Date Texas Health and Human Special Nutrition Programs Form 1569 services Commission SINGLE AUDIT {DENTIFiCATION DATA May 2004 For Program Year (SNP Use Only) wnuauor rvame Contact Person .Cerr County Suvenile Facility Michelle Irby Address (Street or P.O. Box, City, State, ZIP) 3501 Legion Drive Kerrville TX 78028 Telephone No. Texas ID No. (Payee ID No.) Contract No. (830) 257-6110 17450014941022 75- s8oos Contractor Fiscal Year End (mm/ddlyyyy) Type of Contract 09/30/2005 ^ For Profit ^ Non-Profrt ®Governmental Check the appropriate box(es) to indicate the type(s) of program(s) in which you currently participate or far which you are applying: COMMODITY ASSISTANCE PROGRAMS PROGRAM NOS. CASH REIMBURSEMENT PROGRAMS PROGRAM NOS. ®A -National School Lunch 133-2004 ^ AD -Adult Day Care TX - ^ B -Charitable Institutions ®BL-National School LunchBreakfast TX -133-2004 ^ C -Area Agency on Aging ^ CC -CACFP Center TX - ^ G -Summer Camps ^ DH -CACFP Day Home TX - ^ H -Summer Food Service ^ SF -Summer Food TX - ^ J -Jails ^ SM -Special Milk TX - ^ I -TEXCAP ^ TE -TEXCAP TX - ^ CS -Commodity Supplemental Food Prog. ^ CS -Commodity Supplemental Food Prog. TX - Give the source and amount of any federal funds that your agency expends other than from those programs listed above: SINGLE AUDIT EXEMPTION - I certify that 1 am not required to submit an audit under the Single Audit Act for the following reason(s): ^ I am afor-profit organization. ®I expend less than x500,000 annually in total federal funding. ^ SINGLE AUDIT ASSURANCE - I understand tha# if I meet the requirements of the Single Audit Act, I will agree to submit an audit as a condition of eligibility to participate in the Special Nutrition Programs, and that failure to do so as required could result in adverse action, including the withholding of my claim for reimbursement payments and termination of my contract. I also understand that if I am a private non-profit organization subject to the requirements of the Single Audit Act and have a financial audit performed annually, I must also obtain a sin le audit on an annual basis. - ~+~~~ Date (please type or print) ~ Title elle Irby School Lunch Program Coordinator HEALTH AND HUMAN SERVICES (HHSC) CLIENT SERVICES HUB SUBCONTRACTING PLAN HUB STATUS DETERMINATION !C-HSD) Contract Identifier: Health and Human Services Commission Description of Goods/Services Purchased: (C-HSD) PREAMBLE: HHSC and other Health and Human Services Agencies are committed to promoting full and equal business opportunities to ail businesses in state contracting. To better promote these opportunities, it is imperative that we collect information on Respondents and their subcontractors to determine if an entity meets the Texas Building and Procurement Commission (TBPC) Historically Underutilized Business (HUB) certification criteria. TBPC has determined that for purposes of participating in Special Nutrition Programs, HHSC may employ its "Client Services Hub Subcontracting Ptan Best Practices" guidelines and reporting procedures. Asa result of TBPC's determination, HHSC will not require respondents to submit HUB Subcontracting Plans with their applications. Instead, respondents will be required to submit the "HUB Status Determination" form. PURPOSE: The purpose of the HUB Status Determination form (C-HSD) is to collect HUB-related information about the Respondent. PROCEDURE: Please complete this form with information about the Respondent. Return the signed and completed forms with the Respondent's Proposal. After HHSC has awarded a contract, a representative will contact you to share additional information about the reporting and compliance guidelines. Information on the State of Texas HUB program can be found on the TBPC website at http://www.tbpastate.tx.us or by contacting the following HHSC Administrative Services Development (ASD) HUB Administrators: Larry Nunn (512) 424-6896, Larry;nunn(u,~,hhsc.state.tx.us. 1. Print Legal Name o[ Respondent/Prime Contractor: e~r U 2. Print the 14- digit Vendor Identification Number assigned by the State of eaas Comptroller or enter a 9-digit Federal Taz ID #: 3. Is the applicant afor-profit entity or Non-Profit entity? (Check one) For-Profit Non-Profit Enti ^ Enti 4. Is the Respondent a TBPC certified HUB? Yes ^ No ^ If yes, please provide your TBPC Certification No. 5. Does the respondent intend to subcontract any portion of the contract? y~ ^ No ^ 6. Is the Respondent certified as a minority/women-own business from an agency y~ ^ No ^ other than the TBPC? If yes, please provide the name of the certifying agency: 7. As applicable, please indicate which group best describes the individuals who own at least 51% of the assets and interest and/or classes of stock and equitable securities. These individuals must demonstrate an active participation in the control, o eration and mana ement of the o anization's dal business affairs. Grou Male Female Asian Pacific Americans AS Black Americans L His anic Americans HI Native Americans A American Women O Not A licable A 8. Is your primary place of business in Tezas? yes No ^ 9. The Respondent/Prime Contractor agrees to participate in a post-award meeting to discuss the requirements associated with the Client Services HUB yeS ^ No ^ Subcontractin Plaa Best Practices. If no, attach a written ez lanation. o the b~st of ppSi, kn ge I c~tify tJte above information to be true and complete. of Respondent's ~u~ori e~l Representative Date Texas Health and Human Services Commission Special Nutrition Program Certification of Authority Form 4508 May 2000 This is to certify that the following person(s): Name of Authorized Representative (please type or print) Title Michelle Irb School Lunch Pro ram Coordinator X Si nature . Authori Re resentative Name of Authorized Representative (please type or print) Title Roland Valverde Assistant Facili Administrator ~ / V Signature -Authorized Representative is (are) designated as an Authorized Representative of Name of Contracting Organization Kerr Coun Juvenile Facili Address (Street, City, State, ZIP) 3501 Le ion Drive Kerrville TX 78028 The representative(s) designated above, and myself, acknowledge that each is individually authorized on behalf of the contracting organization to make written agreements with the Texas Department of Human Services to operate a food program, to sign documents or reports about the agreement, and to present claims for reimbursement, when appropriate, to the department. By signing this document, we certify individually and collectively that to the best or our knowledge and belief, all documents submitted physically or electronically on behalf of the above named Contracting Organization pursuant to our participation in any and all programs administered by Special Nutrition Programs, TDHS, are/will be true and correct in all respects, that they are/will be completed according to the terms and conditions of existing agreements including amendments, that 1 records are/will be available to support any and all claims, and that we will not submit claims (excluding amended/adjusted claims) far goods or services for which we have already received payment. We recognize that we are fully responsible for any excess amounts which may result from errors made in relation to the completion and submission of claims. We are also aware that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes. Name of Official of Contracting Agency (please type or print) Title Jud a Pat Tinle Kerr Coun Jud e X i ~na ure -Official of Contractin A e DELETED AUTHORIZED REPRESENTATIVES: Acontracting organization may not have more than three (3) Authorized Representatives, including the Official of the Contracting Agency. If you are replacing or deleting an Authorized Representative, fist the name(s) of the individual(s) to be removed as Authorized Representative(s) below: Name of Deleted R resentative Name of Deleted Re resentative Name of Deleted Re resentative eP P P Art Swan Tanna Brown .-fit DHS USE ONLY Contract No. 75 - Received By Date Received CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS Federal Executive Orders 12549 and 12689 require the Texas Health and Human Services Commission (HHSC) to screen each covered potential contractor to determine whether each has a right to obtain a contract in accordance with federal regulations on debarment, suspension, ineligibility, and voluntary exclusion. Each covered contractor must also screen each of its covered subcontractors. In this certification "contractor" refers to both contractor and subcontractor, "contract" refers to both contract and subcontract. By signing and submitting this certification the potential contractor accepts the following terms: 1. The certification herein below is a material representation of fact upon which reliance was placed when this contract was entered into. If it is later determined that the potential contractor knowingly rendered an erroneous certification, in addition to other remedies available to the federal government, the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, or the HHSC may pursue available remedies, including suspension and/or debarment. 2. The potential contractor will provide immediate written notice to the person to which this certification is submitted if at any time the potential contractor learns that the certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 3. The words "covered contract", "debarred", "suspended", "ineligible", "participant", "person", "principal", "proposal", and "voluntarily excluded", as used in this certification have meanings based upon materials in the Definitions and Coverage sections of federal rules implementing Executive Order 12549. Usage is as defined in the attachment. 4. The potential contractor agrees by submitting this certification that, should the proposed covered contract be entered into, it will not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Department of Health and Human Services, United States Department of Agriculture or other federal department or agency, and/or the HHSC, as applicable. Do you have or do you anticipate having subcontractors under this proposed contract? ........................................................................ ^ Yes No 5. The potential contractor further agrees by submitting this certification that it will include this certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts" without modification, in all covered subcontracts and in solicitations for all covered subcontracts. 6. A contractor may rely upon a certification of a potential subcontractor that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered contract, unless it knows that the certification is erroneous, A contractor must, at a minimum, obtain certifications from its covered subcontractors upon each subcontract's initiation and upon each renewal. 7. Nothing contained in ail the foregoing will be construed to require establishment of a system of records in order to render in good faith the certification required by this certification document. The knowledge and information of a contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 8. Except for contracts authorized under paragraph 4 of these terms, if a contractor in a covered contract knowingly enters into a covered subcontract with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, Department of Health and Human Services, United States Department of Agriculture, or other federal department or agency, as applicable, and/or the HHSC may ptusue available remedies, including suspension and/or debarment. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS Indicate in the appropriate box which statement applies to the covered potential contractor: ^ The potential contractor certifies, by submission of this certification, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded form participation in this contract by any federal department or agency or by the State of Texas. ^ The potential contractor is unable to certify to one or more of the terms in this certification. In this instance, the potential contractor must attach an explanation for each of the above terms to which he is unable to make certification. Attach the explanation(s) to this certification. Contractor I Vendor [D No. or Social Security No. HHSC Contract No. (if applicable) of tedlfyped Name and Title of Authorized Representative ~~_ i Date Page I of 2 5/22/95 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS DEFINITIONS Covered Contracts/Subcontract. (1) Any nonprocurement transaction which involves federal funds (regardless of amount and including such arrangements as subgrant and are between HHSC or its agents and another entity. (2) Any procurement contract for goods or services between a participant and a person, regardless of type, expected to equal or exceed the federal procurement small purchase threshold fixed at 10 U.S.C. 2304(g) and 41 U.S.C. 253(8) (currently $25,000) under a grant or subgrant. (3) Any procurement contract for goods or services between a participant and a person under a covered grant, subgrtnt, contract or subcontract, regardless of amount, under which that person will have a critical influence on or substantive control over that covered transaction: a. Principal investigators. b. Providers of audit services required by the I-IHSC or federal funding source. c. Researchers. Debarment. An action taken by a debarring official in accordance with 45 CFR Part 76 (or comparable federal regulations) to exclude a person from participating in covered contracts. A person so excluded is "debarred". , Grant. An award of fu-ar-cial assistance, including cooperative agreements, in the form of money, or property in lieu of money, by the federal government to an eligible grantee. ineligible. Excluded from participation in federal nonprocurement programs pursuant to a determination of ineligibility under statutory, executive order, or regulatory authority, other than Executive Order 12549 and its agency implementing regulations; for example, excluded pursuant to the Davis-Bacon Act and its implement regulations, the equal employment opportunity acts and executive orders, or the environmental protection acts and executive orders. A person is ineligible where the determination of ineligibility affects such person's eligibility to participate in more than one covered transaction. Participant. Any person who submits a proposal for, enters into, or reasonably may be expected to enter into a covered contract. This term also includes any person who acts on behalf of or is authorized to commit a participant in a covered contract as an agent or representative of another participant. Person. Any individual, corporation, partnership, association, unit of government, or legal entity, however organized, except: foreign governments or foreign governmental entities, public international organizations, foreign government owned (in whole or in part) or controlled entities, and entities consisting wholly or partially of foreign governments or foreign governmental entities. Principal. Officer, director, owner, partner, key employee, or other person within a participant with primary management or supervisory responsibilities; or a person who has a critical influence on or substantive control over a covered contract whether or not the person is employed by the participant. Persons who have a critical influence on or substantive control over a covered transaction are: (1) Principal investigators. (2) Providers of audit ser. ices required by the IiHSC or federal funding source. (3) Researchers. Proposal. A solicited or unsolicited bid, application, request, invitation to consider or similar communication by or on behalf of a person seeking to receive a covered contract. Suspension. An action taken by a suspending official in accordance with 45 CFR Part 76 (or comparable federal regulations) that immediately excludes a person from participating in covered contracts for a temporary period, pending completion of an investigation and such legal, debarment, or Program Fraud Civil Remedies Act proceedings as may ensue. A person so excluded is "suspended". Voluntary exclusion or voluntarily excluded. A status of nonparticipation or limited participation in covered transactions assumed by a person pursuant to the terms of a settlement. Page 2 of 2 5(22!45 CERTIFICATION REGARDING FEDERAL LOBBYING (Certification for Contracts, Grants, Loans, and Cooperative Agreements) PREAMBLE Federal legislation, Section 319 of Public Law 101-121 generally prohibits entities from using federally appropriated funds to lobby the executive or legislative branches of the federal government. Section 319 specifically requires disclosure of certain lobbying activities. A federal government-wide rule, "New Restrictions on Lobbying", published in the Federal Register, February 26, 1990, requires certification and disclosure in specific instances and defines terms: Covered Awards and Subawards--Contracts, grants, and cooperative agreements over the $100,000 threshold need (1) certifications, and (2) disclosures, if required. (See certification term number 2 concerning disclosure.) Lobbying--To lobby means "to influence or attempt to influence an officer or employee of any agency (federal), a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with any of the following covered federal actions: • the awazding of any federal contract, • the making of any federal grant, • the making of any federal loan, • the entering into of any cooperative agreement, and • the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement". Limited Use of Appropriated Funds Not Prohibited--The prohibition on using appropriated funds does not apply to activities by one's own employees with respect to: • liaison activities with federal agencies and Congress not directly related to a covered federal action; • providing any information specifically requested by a federal agency or Congress; • discussion and/or demonstration or products or services if not related to a specific solicitation or a covered action; or • professional and technical services in prepazing, submitting or negotiating any bid, proposal or application for a federal contract, grant loan or cooperative agreement or for meeting legal requirements conditional to receipt of any federal contact, grant, loan or cooperative agreement. ('The prohibition also does not apply to such services provided by nonemployees for the same purposes.) Professional and Technical Services--Professional and technical services shall be advice and analysis directly applying any professional or technical expertise. Note that the professional and technical services exemption is specifically limited to the merits of the matter. Other Allowable Activities--The prohibition on use of federally appropriated funds does not apply to influencing activities not in connection with a specific covered federal action. These activities include those related to legislation and regulations for a program versus a specific covered federal action. Funds Other Than Federal Appropriations--There is no federal restriction on the use of nonfederal funds to lobby the federal government for contracts, grants, and cooperative agreements. Applicability of Other State and Federal Requirements--Neither the government-wide rule nor the law affect either (1) the applicability of cost principles in OMB circulars A-87 and A-122, or (2) riders to the Texas State Appropriations Acts which disallow use of state funds for lobbying. TERMS OF CERTIFICATION This certification applies only to the instant federal action for which the certification is being obtained and is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $100,000 for each such failure. The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No federally appropriated funds have peen paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. 2. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with these federally funded contract, subcontract, subgrant, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its instructions. (If needed, contact your Health and Human Services Commission procurement officer of contract manager to obtain a copy of Standard Form-LLL.) 3. The undersigned shall require that the language of this certification be included in the award documents for all covered subawazds at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all covered subrecipients will certify and disclose accordingly. Do you have or do you anticipate having covered subawards under this transaction? ............................................................................^ Yes ~ No Nana of Contractor/Potential Coturactor Vendor ID No. or Social Security No. HHSC Contract No. (if applicable) e of Authorized Representitative (type or print) i ~ ~ - 1 ~ ~!(1 ( Q(OO~f ' ' ~~ Signature--Auth Re tative ~ Date HHSC 5/245 ~,~E ~ State of Texas '~ Health & Human Services Commission Nondisclosure Statement Acknowledgment As a contractor to the Texas Health & Human Services Commission, I have been provided access to information, systems, operations, or procedures that are security sensitive or have been identified as confidential by the Health & Human Services Commission, the State of Texas, or the United States Government. As such, I acknowledge the following: • that my access to this information is provided solely in my capacity as a contractor to the Texas Health 8~ Human Services Commission; • that access to this information is solely for the purpose of discharging my duties or the duties of my employer under Texas Health & Human Services Commission contract number HHSC-_-= _' • that premature or unauthorized disclosure of this information will irreparably harm the interests of the State of Texas and the Texas Health & Human Services Commission and may constitute a violation of Section 39.02 of the Texas Penal Code, the antitrust laws of the United States and the State of Texas, and the Texas Public Information Act [chapter 552, Texas Government Code); • that the information may represent confidential or proprietary information, the release of which may restricted or rohibited b law. Agreement In view of the foregoing, I agree that I shalt use any information that I receive in my capacity as a contractor to the Texas Health & Human Services Commission -whether written or oral, formal or informal -for the following purposes only: • to provide the services and/or deliverables required or requested under contract number HHSC-= - • to provide advice, opinion or recommendation requested by the Texas Health & Human Services Commission in the course of fulfilling the duties prescribed under the contract; • to assist the Texas Health & Human Services Commission in developing any documents, reports, working papers, evaluations, schedules, or instruments necessary to fulfill the requirements of the contract. I further agree that I shall regard any such information as confidential and that I shall not disclose, reveal, communicate, impart or divulge the information or any summary or synopsis of the information in any manner or any form whatsoever, except under the following circumstances: • when authorized in writing by the Project Manager employed by the Texas Health & Human Services Commission; • when required by court order, subpoena, or ruling of the Attorney General of Texas; • when advised by legal counsel that disclosure is required by law or legal process; • when the information has previously been released to the general public by the Project Manager, the Texas Health & Human Services Commission; • when required to brief or inform a superior, provided the superior is informed of and has also executed a non-disclosure statement. In the event I receive a request for information relating to contract number HHSC-= ~ _, either during or after the performance of this contract, I agree to do the following: • notify the Project Manager or the Texas Health & Human Services Commission as soon as practical following receipt of the request; • seek advice from ap ropriate le al counsel re ardin m abi{it to disclose the information. 13y si ni g this statement, I acknowledge that I understand and agree to adhere to the limitations on di I ure des ribe abo , • (1.-- ~pa~tu Date ll ML ~ Printed Name TE ,. , State of Texas _:~~ Heatth & Human Services Commission Child Support Certification 1. Section 231.006, Texas Family Code, as amended by Section 82 of House Bill No. 433, 74th Regular Legislative Session (Acts 1995, 74th Leg., R.S., ch. 751), prohibits the payment of state funds under a grant, contract, or loan to • a person who is more than 30 days delinquent in the payment of child support, and • a business entity in which such a person is the sole proprietor, partner, shareholder or owner with an ownership interest of at least 25%. Section 231.006 further provides that a person or business entity that is ineligible to receive payments for the reasons stated above shall continue to be ineligible to receive payments from the state under a contract, grant, or loan until • all arrearages have been paid, or • the person is in compliance with a written repayment agreement or court order as to any existing delinquency. Section 231.006 further requires each bid, or application for a contract, grant, or loan to include • the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of at least 25% of the business entity submitting the bid or application, and • the statement in Part III below. Section 231.006 authorizes a state agency to terminate a contract if it determines that statement required below is inaccurate or false. fn the event the statement is determined to be false, the vendor is liable to the state for attorney's fees, costs necessary to complete the contract [including the cost of advertising and awarding a second contract], and any other damages provided by law or contract. II. In accordance with Section 231.006, the names and social security numbers of the individual identified in the contract, bid, or application, or of each person with a minimum 25% ownership interest in the business entity identified therein are provided below. Name Social Security # III. As required by Section 231.006, the undersigned certifies the following: "Under Section 23!.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan, or payment, and acknowledges that this contract maybe terminated and yment withheld if this certification is inaccurate." t ( ~ l~f l `~ nature Title S `OS ~~ I i ~ rioted Name Date ~ d p i~ { °~~ ~ ~~`I ~ ~ii~,~IIII ~ i II ~If~111i~~ ~i~'I~ ~.IY.~ ~~ I~ a c ~~~ \~,. . ~/ Certificate Qf Be it known that Kerr County is hereby registered to operate the Kerr County juvenile Facility Pre Adjudication STATE OF TEXAS City of Kerrville Rated Capacity of 25 The aforementioned Secure )uvenile Facility has completed all registration requirements of the Texas )uvenile Probation Commission, as required by the Texas Family Code, and is hereby officially registered by the undersigned. REGISTRATION is issued this the 1~ Day of February, 2005 Expiration ate: January 31, 2006 with current Board Certification Vicki Spriggs, Executiv Dire Texas )uvenile Probation Commission ~~,~, ~ •C~ O C ~ > /~\+r 0~. "rT[ yy .~ ~tr ~,. ~ . ~~~ Certificate of RE8ISTRATION Be it known that Kerr County is hereby registered to operate the Kerr County Juvenile facility Post Adjudication STATE OF TEXAS City of Kerrville Rated Capacity of 51 The aforementioned Secure Juvenile Facility has completed all registration requirements of the Texas Juvenile Probation Commission, as required by the Texas Family Code, and is hereby officially registered by the undersigned. REGISTRATION is issued this the 1~` Day of February, 2005 Expiration ate: January 31, 2006 with current Board Certification Vicki Spriggs, Executiv Direc Texas)uvenile Probation Commission