HILLSBOROUGH COUNTY HOSPITAL AUTHORITY REQUEST FOR PROPOSALS FOR CONTACT PERSON:

Transcription

1 HILLSBOROUGH COUNTY HOSPITAL AUTHORITY REQUEST FOR PROPOSALS FOR DIRECT HEALTH CARE SERVICE GRANTS CONTACT PERSON: Ms. Renee Warmack, Administrator Hillsborough County Hospital Authority c/o Operations & Legislative Affairs 601 E. Kennedy Blvd., 26 th Floor Tampa, FL RFP ISSUE DATE: September 1, 2016 PROPOSAL SUBMITTAL DEADLINE 5:00 pm (EST) OCTOBER 3, 2016

2 HILLSBOROUGH COUNTY HOSPITAL AUTHORITY REQUEST FOR PROPOSALS (RFP) FOR DIRECT HEALTH CARE SERVICE GRANTS I GENERAL INFORMATION ABOUT THE HILLSBOROUGH COUNTY HOSPITAL AUTHORITY The Hillsborough County Hospital Authority (the Authority ) is a dependent special district of the State of Florida whose powers and duties are identified in Chapter , Laws of Florida, as amended (the Special Act ). The Authority s governing body is a fifteen (15) member Board appointed by the Hillsborough County Board of County Commissioners. The Authority was established for the purpose of benefiting the people of the State of Florida and Hillsborough County and has a health-related mission. The Authority previously operated Tampa General Hospital ( TGH ), which is located on Davis Island, Tampa, Florida. Effective October 1, 1997, the Authority transferred hospital operations to Florida Health Sciences Center, Inc. ( FHSC ), a not-for-profit corporation, but retained ownership of the Davis Island property and improvements. Pursuant to a Lease Agreement, dated as of June 20, 1997, the Authority leased the real property and improvements on Davis Island to FHSC. In addition to its statutory healthrelated mission, the Authority monitors FHSC s progress in attracting business from, and awarding contracts to, minority and women-owned business enterprises through a report describing such progress that the Lease requires FHSC to provide to the Authority on a quarterly basis. II Request for Proposals for Direct Health Care Service A. The Authority is soliciting written proposals from eligible Florida not-for-profit corporations for limited grants to provide direct health care service for the Authority s October 1, 2016 September 30, 2017 fiscal year. B. The Authority has budgeted thirty thousand dollars ($30,000) that may be awarded through this RFP process. A maximum of three (3) grants may be awarded pursuant to this RFP. However, the Authority in its discretion, may elect not to award any grants. The number of grants awarded by the Authority shall be determined by the Authority in its discretion. All funding awarded pursuant to this RFP will be paid on a reimbursement basis of costs and expenses only. Request for payment must be accompanied by supporting documentation satisfactory to the Authority. 1

3 C. Grant funding awarded to any applicant pursuant to this RFP shall be for one grant term only. Applicants seeking funding from the Authority for more than one grant term must reapply for funding on an annual basis. The award of a grant to an applicant in any one grant term shall not be a guaranty that the Authority will award a grant to the same applicant in the next or any future year. D. All proceeds from this grant shall go to the provision of direct health care service. III PROPOSAL SUBMITTAL INFORMATION THE PROPOSAL SUBMITTAL DEADLINE FOR THIS RFP IS: 5:00 pm (EST) October 3, 2016 The Authority reserves the right to extend the Proposal Submittal Deadline to allow for clarifications or amendments to the initial RFP, or in the event all submitted proposals are rejected. PROPOSAL CONTACT AND PROPOSAL SUBMITTAL ADDRESS: Applicant Eligibility Ms. Renee Warmack, Administrator Hillsborough County Hospital Authority c/o Operations & Legislative Affairs 601 E. Kennedy Blvd., 26 th Floor Tampa, FL To be eligible to receive funding from the Authority, an applicant must be a Florida not-for-profit corporation which has been awarded a favorable IRC 501(c)(3) determination letter and a certification from the chief executive officer ( CEO ) or other officer of the applicant certifying that the determination letter is in full force and effect and has not been revoked. Project Eligibility A. To be eligible for funding from the Authority, a project must provide a direct health care service to the residents of Hillsborough County. A direct health care service is defined as the delivery of a direct service that improves a client s physical or mental health condition. The service must be delivered and quantified; and its impact measured, during the grant contract period. Examples include, but are not limited to, screening functions such as blood pressure; hearing and eye exams; delivery of immunizations and distribution of child safety equipment. Note: No grant funds shall be used for administrative overhead or acquisition of equipment or systems for the applicant. 2

4 B. All proceeds of the grants shall go to the provision of direct health care service. Minimum Submission Requirements The following minimum submission requirements must be met in order for a proposal to be eligible for Authority Subcommittee review: 1. The proposal must be received by the Proposal Submittal Deadline of 5:00 pm (EST) October 3, 2016 via certified mail, return receipt requested, or by hand delivery, or by overnight express delivery, to the Proposal Contact at the proper Proposal Submittal Address given on Page 2 of this RFP. 2. Applicant must be a Florida not-for-profit corporation. 3. Applicant must have a copy of the applicant s favorable IRC 501(c)(3) determination letter and a certification from the chief executive officer ( CEO )or other officer of the applicant certifying that the determination letter is in full force and effect and has not been revoked. 4. Applicant must complete the Application Checklist. (Exhibit D) Contract Requirement Each applicant selected to receive an award must execute a contract substantially in the form attached as Exhibit A and incorporated by reference herein. A contract awarded as a result of this RFP shall commence on the date of execution by both parties and shall terminate on September 30, 2017, hereinafter referred to as the grant term. Each applicant must certify in its proposal that it will accept the contract in the attached form. The failure to provide such a certification will disqualify the proposal from funding consideration by the Authority. Failure to execute the contract in its approved form after award may result in the revocation of the award. Affiliate Disclosure Requirement Each applicant shall disclose in its proposal its Affiliated Entities. The Authority, or its designee, in their sole discretion, shall make the determination that two or more applicants are related as Affiliated Entities. No applicant, including its parent organization, affiliates, and subsidiaries (collectively, the Affiliated Entities ), may submit more than one proposal pursuant to this RFP. Multiple submissions 3

5 by an applicant and/or its Affiliated Entities may disqualify from consideration all proposals submitted by that applicant and/or its Affiliated Entities. Disclosure of Relationships with Authority Members, the Administrator or Legal Counsel In order for the Authority to comply with Section , Florida Statutes and its prohibition against voting when there is a conflict of interest, each applicant shall disclose in its proposal any current, past or potential relationship with a member of the Authority or its Administrator or Legal Counsel. See attached list of Authority members and their Administrator and Legal Counsel. (Exhibit B) IV Application and Checklist for Authority Grant Funding All applicants for Authority grant funding must complete the attached application and checklist (Exhibit C and Exhibit D) and provide the following attachments: 1. the applicant s most recent annual fiscal report; and 2. a copy of the applicant s favorable IRC 501(c)(3) determination letter and a certification from the chief executive officer ( CEO )or other officer of the applicant certifying that the determination letter is in full force and effect and has not been revoked; and 3. a certification from the applicant s CEO or other officer of the applicant that the applicant agrees to be bound by the contract in the form attached as Exhibit A; and 4. a list of the applicant s Board of Directors; and 5. applicant s latest 990 filing with the IRS. Please do not provide any additional attachments as they will not be considered. B. Original and Number of Copies to be Submitted 1. ONE (1) MANUALLY SIGNED ORIGINAL of its proposal and ONE (1) COPY OF THE SIGNED ORIGINAL of its proposal in an electronic format (compact disc (cd) or flash/jump drive). 2. The manually signed original of the proposal and the copy in an electronic format must be sent pursuant to III. B. 1. 4

6 3. The timely delivery of a proposal submission on or before the PROPOSAL SUBMISSION DEADLINE is solely and strictly the responsibility of the applicant. The Authority shall not be responsible in any way for any delays in the delivery of or the receipt of a proposal, including but not limited to delays caused by the United States Postal Service, other delivery services, or by any other occurrence. THE ORIGINAL OF THE SUBMITTED PROPOSAL RESPONSE MUST BE MANUALLY AND DULY SIGNED BY AN AUTHORIZED CORPORATE OFFICER OF THE APPLICANT. In the event of a discrepancy or conflict between the manually signed original of the proposal and the copy submitted in an electronic format, the manually signed original shall govern. C. Disqualification. 1. The failure to comply with the format, information requirements, or time lines described in this RFP may result in the disqualification of a proposal. 2. Solicitation of Authority members, or Authority Administrator or Legal Counsel regarding the selection process will result in immediate removal from further consideration of the applicant and the proposal on whose behalf the solicitation was made. V PROPOSAL SELECTION PROCESS A. Eligibility. The Chair of the Authority, or the Chair s designee(s), will first review each submitted proposal to determine if the proposal meets the minimum submission requirement. B. Review and Ranking. The Subcommittee will review the proposals and rank them in recommended order of funding priorities before forwarding to the Authority for final selection or rejection. The proposals will be ranked utilizing the following evaluation criteria: Maximum Score 1. Applicant Information 10 points 2. Statement of Need 20 points 3. Project Description 20 points 4. Goals, Outcomes, and Evaluation of Project 20 points 5

7 5. Project Budget 15 points 6. Project Marketing 10 points 7. Accuracy and Completeness of Application 5 points TOTAL POSSIBLE POINTS 100 points C. Selection. The proposals will be reviewed and considered for approval by the Authority at its November 2016 meeting. In its deliberations, the Authority may take into consideration any recommendations from the Subcommittee. The Authority is not bound by the recommendations of the Subcommittee, and may, after deliberation, select a proposal for grant award which has not been recommended for funding by the Subcommittee, except that no award shall be made to any applicant or project which has been determined to be ineligible. The Authority will select a maximum of three proposals for the grant award. The Authority, in its discretion, however, may elect to award a total of fewer than three grants or no grants at all. Following, the November Hospital Authority meeting, the Chair or the Chair s delegee shall send written notice to all grant applicants advising whether their grant application was approved. VI REJECTION OF PROPOSALS The Authority reserves the right to reject any and all proposals submitted and may waive any deviation from the RFP. VII INQUIRIES Shall be directed to: Ms. Renee Warmack, Administrator at Warmackr@hillsboroughcounty.org Responses to questions submitted about the RFP shall be provided via . 6

8 EXHIBIT A AGREEMENT BY AND BETWEEN THE HILLSBOROUGH COUNTY HOSPITAL AUTHORITY AND, a Hillsborough County Hospital Authority Direct Health Care Service Grant awardee for the Hillsborough County Hospital Authority s grant. THIS AGREEMENT dated this day of, 2016, (the Effective Date ) is made and entered into by and between the Hillsborough County Hospital Authority, a public entity and special district of the State of Florida (the AUTHORITY ) and, a whose address is (the ORGANIZATION ). RECITALS WHEREAS, the AUTHORITY, a dependent special district of the State of Florida, has a health-related mission and was established for the purpose of benefiting the people of the State of Florida and Hillsborough County; and WHEREAS, The AUTHORITY S governing body is a fifteen (15) member Board appointed by the Hillsborough County Board of County Commissioners. WHEREAS, the AUTHORITY previously transferred operations of Tampa General Hospital ( TGH ) to Florida Health Sciences Center, Inc. ( FHSC ), a not-for-profit corporation, but retains ownership of the Davis Island property and improvements and leases them to FHSC; and WHEREAS, in addition to its statutory, health-related mission, the AUTHORITY monitors the progress of Tampa General Hospital in attracting business from, and awarding contracts to, minority and women-owned business enterprises pursuant to its lease with FHSC; and WHEREAS, the AUTHORITY deems it to be in the best interest of the residents of Hillsborough County and a public purpose to provide financial support to Florida not-for-profit corporations to implement projects which provide a direct healthcare service to the residents of Hillsborough County; and WHEREAS, to carry out such purpose the AUTHORITY issued a 1

9 Request for Proposal ( RFP ) dated September 1, 2016, soliciting written proposals from eligible Florida not-for-profit corporations for limited funding for Direct Health Care Service Grant for the AUTHORITY S October 1, 2016 September 30, 2017 fiscal year; and WHEREAS, in response to the RFP, ORGANIZATION submitted a proposal for grant funding; and WHEREAS, the proposals submitted in response to the RFP, including ORGANIZATION S proposal, have been reviewed and evaluated in accordance with AUTHORITY policy; and WHEREAS, as a result of such review, the AUTHORITY S Board has selected ORGANIZATION to receive a grant award to be used toward implementation of the project described in ORGANIZATION S submitted proposal (the Project ). NOW THEREFORE, in consideration of the mutual covenants, promises and representations contained herein, additional to those heretofore made, the parties agree as follows. ARTICLE 1 Incorporation of Recitals, RFP and Exhibits The above recitals are true and correct. Such recitals, Exhibits A and B attached hereto, and the provisions of the RFP, are incorporated by reference herein. ARTICLE 2 Scope of Service The ORGANIZATION shall implement the Project described in ORGANIZATION S proposal, a copy of which is attached hereto as Exhibit C, in accordance with the timeframes and requirements described therein and herein. ARTICLE 3 Term of Agreement The term ( Term ) of this Agreement shall commence on the Effective Date and shall expire on September 30, 2017, unless sooner terminated in accordance with this Agreement. 2

10 ARTICLE 4 Consideration and Limitation of Costs For its performance under this Agreement, the ORGANIZATION will receive funds from the AUTHORITY in an amount not to exceed dollars ($ ). ARTICLE 5 Reporting and Payment of Grant Funds The ORGANIZATION shall submit a written performance report to the Board within thirty (30) days of completion of its Project, or August 1, 2017, whichever occurs first. The ORGANIZATION may also be requested to make a presentation to the Board no later than the August 2017 Board meeting, regardless of the report submittal date. The performance report and presentation shall briefly describe the major Project goals, outcomes, and results, and how those outcomes and results were measured. The failure by the ORGANIZATION to timely submit its report or make its presentation to the Board may result in the loss of its award funding, regardless of whether the Project has been implemented in whole or in part. Expenditure of Grant funds by the ORGANIZATION shall be made in accordance with the Project Budget described in Exhibit C. All funding under this Agreement is subject to availability and the amount of consideration may be reduced. The AUTHORITY will not reimburse the ORGANIZATION for any expenditure made for items that were not included in the Project Budget or if the Project was not fully implemented. Payments of award funds made under this Agreement shall be on a reimbursement basis only. After the August 2017 Board meeting, but no later than September 1, 2017, the ORGANIZATION shall submit a completed Payment Request Form in the form attached hereto as Attachment 1, accompanied by appropriate documentation of expenses and performance (the Payment Request Form and accompanying documentation, collectively, the Payment Documentation ) to the individual (the Chair s Delegee ) designated by the Chair of the Board in the AUTHORITY S Grant award letter to receive the Payment Documentation. Award funds will only be released after the Payment Documentation is submitted to and reviewed and accepted by the Board s Chair or the Chair s Delegee. If an ORGANIZATION fails to comply with any applicable requirements stated in this Agreement or the RFP, including but not limited to submitting all of the Payment Documentation, on or before September 1, 2017, or if the Payment Documentation submitted is not accepted by the Chair or the Chair s Delegee in whole or in part, then the AUTHORITY shall 3

11 not be obligated to release any award funds to the ORGANIZATION and such funds may be awarded to another organization at a future time. The AUTHORITY shall not disburse award funds after September 30, 2017 and the AUTHORITY shall not honor, and will not be liable for, any request for payment by the ORGANIZATION if the Payment Documentation is not submitted to the AUTHORITY on or before September 1, ARTICLE 6 Maintenance and Review of Records The ORGANIZATION and any of its subcontractors providing any services required to be performed by the ORGANIZATION under this Agreement shall maintain adequate records and accounts to assure a proper accounting for all AUTHORITY funds received under this Agreement for a period of six years from the date of final payment to the ORGANIZATION under this Agreement. (Such six-year period is hereinafter referred to as the Audit Period. ). The AUTHORITY and its authorized agents shall have the right, and the ORGANIZATION and its subcontractors, as applicable, will permit the AUTHORITY and its authorized agents, to examine, inspect and audit all such records, accounts and documentation and to make copies thereof at any time during normal business hours. ORGANIZATION shall ensure that any subcontractor providing any services the ORGANIZATION is required to provide under this Agreement shall recognize the AUTHORITY S right to examine, inspect and audit its records, accounts and documentation in connection with its provision of services required to be provided by the ORGANIZATION under this Agreement. If an inspection or audit is begun by the AUTHORITY or other agency, whether local, state or federal, during the Audit Period, but is not completed by the end of the Audit Period, the Audit Period shall be extended until audit findings are issued. This Article 6 shall survive the expiration or earlier termination of this Agreement. ARTICLE 7 Indemnification The ORGANIZATION shall indemnify, hold harmless, and defend the AUTHORITY, its Board members, and the respective agents of the AUTHORITY (all of the foregoing, collectively, the Indemnified Parties ) from and against any and all liabilities, losses, claims, damages, demands, expenses or actions, either at law or in equity, including court costs and attorneys' fees, that may hereafter at any time be made or brought by anyone on account of personal injury, property damage, loss of monies, or other loss, allegedly caused or incurred, in whole or in part, as a result of any 4

12 negligent, wrongful, or intentional act or omission, or based on any act of fraud or defalcation by the ORGANIZATION, its agents, subcontractors, assigns, heirs, and employees in connection with ORGANIZATION S performance under this Agreement. If the ORGANIZATION is an entity to which Section , Florida Statutes, applies, then the provisions of this Article 7 shall be subject to the limitations and requirements thereof. The provisions of this Article 7 shall survive the expiration or earlier termination of this Agreement. ARTICLE 8 Equal Opportunity Clause The ORGANIZATION shall comply with Hillsborough County, Florida Code of Ordinances and Laws, Part A, Chapter 30, Article II (Hillsborough County Human Rights Ordinance) as amended, which prohibits illegal discrimination on the basis of actual or perceived race, color, sex, age, religion, national origin, disability, marital status, sexual orientation, or gender identity or expression, in employment, public accommodations, real estate transactions and practices, contracting and procurement activities, and credit extension practices. The ORGANIZATION shall also comply with the requirements of all applicable federal, state and local laws, rules, regulations, ordinances and executive orders prohibiting and/or relating to discrimination, as amended and supplemented. All of the aforementioned laws, rules, regulations, ordinances and executive orders are incorporated herein by reference. ARTICLE 9 Conflict of Interest The ORGANIZATION warrants to the AUTHORITY that no gifts or gratuities have been or will be given to any AUTHORITY Board member or agent, either directly or indirectly, to obtain the grant award and Agreement. The ORGANIZATION represents that it presently has no interest, and shall acquire no such interest, financial or otherwise, direct or indirect, nor engage in any business transaction or professional activity or incur any obligation of any nature which would conflict in any manner with the performance of the scope of services required hereunder. 5

13 ARTICLE 10 Governing Laws This Agreement shall be governed by the laws, rules, and regulations of the State of Florida and venue shall be in Hillsborough County, Florida. ARTICLE 11 Public Entity Crimes A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a bid, proposal or reply on a contract to provide any goods or services to a public entity; may not submit a bid, proposal, or reply on a contract with a public entity for the construction or repair of a public building or public work; may not submit bids, proposals or replies on leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity; and may not transact business with any public entity in excess of the threshold amount provided in Section , Florida Statutes, for CATEGORY TWO for a period of 36 months following the date of being placed on the convicted vendor list. The conviction of a public entity crime may cause the withdrawal of the ORGANIZATION S grant award. The AUTHORITY may make inquiries regarding alleged convictions of public entity crimes. The signature of the individual signing this Agreement on behalf of the ORGANIZATION is a representation by such individual and the ORGANIZATION that such individual and the ORGANIZATION are not, and during the past three years have not been, placed on the convicted vendor list required to be maintained by the Florida Department of Management Services, pursuant to Section (3) (d), Florida Statutes. ARTICLE 12 Compliance With Applicable Laws The ORGANIZATION shall comply with the requirements of all federal, state and local laws and the rules and regulations promulgated thereunder, including but not limited to, the Health Insurance Portability and Accountability Act ("HIPAA") (42 USC 1320d) and the regulations promulgated thereunder, which are applicable to the matters encompassed by this Agreement. 6

14 ARTICLE 13 Assignment This Agreement may not be assigned in whole or in part by the ORGANIZATION without the prior written consent of the AUTHORITY. ARTICLE 14 Headings Article headings have been included in the Agreement solely for the purpose of convenience and shall not affect the interpretation of any of the terms of this Agreement. ARTICLE 15 Waiver A waiver of any performance or default by either party shall not be construed to be a continuing waiver of other defaults or non-performance of the same provision or operate as a waiver of any subsequent default or non-performance of any of the terms, covenants, and conditions of this Agreement. The payment or acceptance of fees for any period after a default shall not be deemed a waiver of any right or acceptance of defective performance. ARTICLE 16 Additional Rights and Remedies Nothing contained herein shall be construed as a limitation on such other rights and remedies available to the parties under law or in equity which may now or in the future be applicable. ARTICLE 17 Order of Precedence In the event of any conflict between the provisions of this Agreement and the Exhibits, the provisions of the Agreement shall control over the provisions of the Exhibits. ARTICLE 18 Severability In the event any section, sentence, clause, or provision of this Agreement is held to be invalid, illegal or unenforceable by a court having jurisdiction over the matter, the remainder of the Agreement shall not be affected by such determination and shall remain in full force and effect. 7

15 ARTICLE 19 Project Publicity The ORGANIZATION shall recognize the AUTHORITY for its contribution to the Project in promotional material and at any events or workshops for which funds from this Agreement are allocated. Any news release or other type of publicity must identify the AUTHORITY as a funding source. ARTICLE 20 Survivability Any term, condition, covenant or obligation which requires performance by either party subsequent to termination of this Agreement shall remain enforceable against such party subsequent to such termination. ARTICLE 21 Third Party Beneficiaries/Independent Contractor This Agreement is for the benefit of the AUTHORITY and the ORGANIZATION. No third party is an intended beneficiary so as to entitle that person to sue for an alleged breach of this Agreement. ORGANIZATION acknowledges and agrees that it is acting as an independent contractor in performing its obligations hereunder and not as an agent, officer or employee of the AUTHORITY. ARTICLE 22 Modifications This Agreement embodies the entire agreement and understanding between the parties hereto and there are no other agreements and/or understandings, oral or written, with respect to the subject matter hereof, that are not merged herein and superseded hereby. This Agreement may only be amended or extended by a written instrument executed by the AUTHORITY and the ORGANIZATION expressly for that purpose. ARTICLE 23 Termination of Agreement In addition to the exercise of any other remedies available to it at law or in equity, the AUTHORITY may terminate this Agreement for the ORGANIZATION's non-performance, as determined by the AUTHORITY, upon no less than twenty-four (24) hours written notice to the ORGANIZATION. Either party may terminate this 8

16 Agreement with or without cause upon thirty (30) days advance written notice to the other party. ARTICLE 24 Access To Records If applicable, the ORGANIZATION shall comply with the requirements of Chapter 119, Florida Statutes, with respect to any documents, papers, and records made or received by the ORGANIZATION in connection with this Agreement. ARTICLE 25 Drug Free Workplace The ORGANIZATION shall assure the AUTHORITY that it will administer, in good faith, a policy designed to ensure that the ORGANIZATION is free from the illegal use, possession, or distribution of drugs or alcohol. ARTICLE 26 Political Endorsement Prohibition The ORGANIZATION shall not engage in political activities that promote or oppose a specific candidate. ARTICLE 27 Notice Any notices required or permitted to be given hereunder shall be sent by United States certified mail, return receipt requested, or by overnight delivery service or personal delivery with signature verification, to the attention of the following representatives of the parties, except that a written notice for the limited purpose of changing a party s contact and/or address information may be sent by A. AUTHORITY: For Certified Mail, Overnight or Personal Delivery: Hillsborough County Hospital Authority c/o Ms. Renee Warmack Operations & Legislative Affairs 601 E. Kennedy Blvd., 26 th Floor Tampa, FL

17 For Ms. Renee Warmack B. ORGANIZATION: Any notice sent in accordance with this Article 27 shall be deemed given two days after deposit in the U.S. Mail, if sent certified mail, or upon receipt, if sent by overnight delivery service, personal delivery, or . The act of refusal by a party of delivery of a notice sent in accordance with this Article 27 shall be deemed acceptance of such notice by such party. A change of a party s contact and/or address information sent by a written notice thereof in accordance with this Article 27 shall not require an amendment to this Agreement. THE REMAINDER OF THIS PAGE IS LEFT BLANK INTENTIONALLY 10

18 ATTACHMENT 1 PAYMENT REQUEST FORM HILLSBOROUGH COUNTY HOSPITAL AUTHORITY RFP: HEALTH CARE SERVICE GRANTS ORGANIZATION: PROJECT: BUDGET CATEGORIES FINANCIAL STATUS REPORT PROJECT BUDGET AMOUNTS EXPENDITURES OTHER FUNDING GRANT FUNDING TOTAL OTHER FUNDING GRANT FUNDING TOTAL GRANT BALANCE IF ANY AMOUNT TOTAL I certify that the above goods and/or services have been provided in accordance with the terms and conditions of the Agreement and are documented by the attachment(s). AUTHORIZED SIGNATURE TITLE DATE Please attach documentation substantiating expenditures. Reimbursement requests containing errors/omissions will be returned to the ORGANIZATION for correction. No award payments will be made by the AUTHORITY after September 30,

19 IN WITNESS WHEREOF, the ORGANIZATION and the AUTHORITY have each caused this Agreement to be executed by its respective, duly authorized representative, effective as of the Effective Date. AUTHORITY: HILLSBOROUGH COUNTY HOSPITAL AUTHORITY, A SPECIAL DISTRICT OF THE STATE OF FLORIDA BY: PRINTED NAME: TITLE: Chair DATE: ORGANIZATION: BY: PRINTED NAME: TITLE: DATE: 12

20 ACKNOWLEDGEMENT OF CORPORATE ORGANIZATION STATE OF FLORIDA ) COUNTY OF HILLSBOROUGH ) The foregoing instrument was acknowledged before me this day of by Name and Title of Officer or Agent of, a (Name of Corporation) corporation (State of Incorporation) on behalf of the corporation. He/she is personally known to me or has produced. (Type of Identification) Signature of Notary Name of Notary Typed, Printed or Stamped Title or Rank Serial Number, If Any 13

21 EXHIBIT B HILLSBOROUGH COUNTY HOSPITAL AUTHORITY BOARD OF TRUSTEES Chair Madeleine Courtney Vice-Chair Eddie Adams Jr. Secretary Lisa Decossas Treasurer J. Patrick Baskette Lesa Alkire Doyle John Evans Robert Gonzalez John A. Grant James Martin, Jr. Alander Ross Pierce Jerome Ryans Jay Wolfson, PhD Commissioner Lesley Les Miller Commissioner Sandy Murman Legal Counsel Jennie Granahan Tarr Administrator Renee Warmack

22 EXHIBIT C APPLICATION FOR HILLSBOROUGH COUNTY HOSPITAL AUTHORITY DIRECT HEALTH CARE SERVICE GRANTS Instructions for completion: Please download, complete and print the application (EXHIBIT C) and the checklist (EXHIBIT D). Applicants MUST RESPOND BY TYPING IN THE SPACES PROVIDED, using 12 point, Arial font. Applicant s Contact Information Please state the full legal name, address, phone number and address of the applicant. Please state the name, title and address of the individual to serve as the applicant s designated contact for the proposal, required reports and documentation. Direct Health Care Service Please identify your direct health care service. 1

23 Executive Summary Provide a brief overview of the project and the target population to be served by it. Disclosure Disclose any current, past or potential relationship with a member of the Authority or its Administrator or Legal Counsel. 2

24 Applicant Information Provide the history, mission, primary activity, and major past accomplishments of the applicant. Identify Affiliate Entities, if any. Statement of Need for Grants Provide a description of the need and/or problem the project will address. 3

25 Project Description Provide a description of the project including activities, methodologies, time line, the target population to be served and the qualifications of the key individuals who will be implementing the project for applicant. Goals, Outcomes, and Evaluation of Project Provide a description of major project goals, anticipated project outcomes, and how results will be measured. 4

26 Project Budget Provide a proposed budget description for the project, including specific revenue sources and amounts, and the anticipated use of Authority grant funds. Project Marketing Provide a brief description of the marketing methods that will be utilized to attract the target population. Name of Authorized Corporate Officer (Printed) Signature of Authorized Corporate Officer (Date) 5

27 EXHIBIT D HILLSBOROUGH COUNTY HOSPITAL AUTHORITY DIRECT HEALTH CARE SERVICE GRANT CHECKLIST Applicant has completed the enclosed application. YES NO Applicant certifies that applicant is a Florida not for profit corporation which has been awarded a favorable IRC 501 (3) determination letter which is in full force and effect and which a copy is attached. Applicant certifies that applicant will accept the contract in the attached form. YES YES NO NO Applicant has included a copy of the applicant s most recent annual fiscal report. Applicant has included the applicant s latest 990 filing with the IRS. YES NO YES NO Applicant has included a list of the applicant s Board of Directors. YES NO Applicant has previously received a grant from the Hospital Authority. YES NO Applicant does business with Tampa General Hospital. YES NO