HOUSTON-GALVESTON AREA COUNCIL
AREA AGENCY ON AGING
Fiscal Year 2010
REQUIRED ATTACHMENTS
Documents that require annual completion and signature and submission.
A- Authorized Signature Form
B- Certification Regarding Debarment
Federal Executive Order 12549 requires funding agencies to screen each covered potential
contractor / subcontractor to determine whether each has a right to obtain a contract / grant in
accordance with federal regulations on debarment, suspension, ineligibility and voluntary
exclusion. Each covered contractor / subcontractor must also screen each of its covered
subcontractors / providers. Failure to comply with this request will result in the rejection of an
applicant’s proposal. An eligible organization meets one of the following criteria if:
o Any organization proposed to contract or subcontract to render goods or services
receiving in excess of $25,000 in federal funds; or
o Any organization proposed to contract or subcontract, regardless of the amount, that will
have a critical influence on or substantive control over that covered transaction; such as
principal investigators, providers of audit services, and researchers.
Code of Federal Regulations Title 45 Part 74.13 (45CFR734.13) and Part 76 (45CFR76).
C- Affirmative Action Plan
Affirmative action is a management responsibility to take necessary steps to eliminate the effects
of past and present job discrimination, intended or unintended, which is evident from an analysis
of employment practices and policies. It is the policy of this agency that equal employment
opportunity is afforded to all persons regardless of race, color, ethnic origin, religion, sex or age.
This applicant is committed to uphold all laws related to Equal Employment Opportunity
including, but not limited to, the following.
o Title VI of the Civil Rights Act of 1964
ACT: http://www.usdoj.gov/crt/cor/coord/titlevistat.htm
http://www.usdoj.gov/crt/grants_statutes/titlevi.txt
United States Code Title 42 Section 2000e-2 (42USC2000e-2) and Section 2000d –
2000d-7 (42USC2000d). Cross Reference: United States Code Title 29 Section 621
(29USC621)
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o The Equal Pay Act of 1963
Code of Federal Regulations Title 29 Part 1620 (29CFR1620) and Part 1621
(29CFR1621) Procedures and Part 1604 (29CFR1604) Guidelines on discrimination
because of sex..
o The Age Discrimination Act
http://www.tc.unl.edu/enemeth/adea.html
United States Code Title 29 Section 621 (29USC621)
Federal Executive Order 11246
Administration of Aging Program Instruction AoA PI-75-11
o Section 504 of the Rehabilitation Act of 1973
ACT: http://www.hud.gov/progdesc/s-504.cfm
Code of Federal Regulations Title 45 Part 84.1 (45CFR84.1) and Part 84.11
(45CFR84.11).
D- Title VI of the Civil Rights Act of 1964 –
The vendor and their subcontractors shall ensure that benefits and services available under
this contract are provided in a non-discriminatory manner as required by Title VI of the Civil
Rights Act of 1964, as amended.
ACT: http://www.usdoj.gov/crt/cor/coord/titlevistat.htm
http://www.usdoj.gov/crt/grants_statutes/titlevi.txt
United States Code Title 42 Section 2000e-2 (42USC2000e-2) and Section 2000d –
2000d-7 (42USC2000d). Cross Reference: United States Code Title 29 Section 621
(29USC621)
E- Assurances
Please review the list of assurances and sign, date, and complete the last page of the assurances.
F- H-GAC Authorization Agreement for Direct Deposit
Direct deposit is available to Title III vendors who wish to receive their reimbursements
electronically. Direct deposit ensures your organization’s funds are securely deposited. Direct
deposit will also help vendors with their cash flow and cash management. New vendors are
encouraged to participate. If you are a new vendor or a current H-GAC vendor affiliated with
new bank you should complete an Authorization Agreement for Direct Deposit. To get your
organization set up for direct deposit complete the Authorization Agreement for Direct Deposit.
H-GAC’s Finance Department will contact your organization when your direct deposit account
has been established. If you have detail questions related to H-GAC’s direct deposit contact
please Ms. Marivic Keenan , H-GAC Chief Accountant at (713) 993-2415, by email
mkeenan@h-gac.com. If your organization has completed this form and there are no changes it
is not necessary to complete this form again
G- H-GAC Authorization Agreement for Emailing Invoice
Vendors are encouraged to email their invoices. If vendors are not able to email their invoice,
original invoices must be mailed. Faxed invoices will not be accepted for reimbursement.
Email invoices to the following: rgreer@h-gac.com, If your organization has completed this
form in the past and there are no changes it is not necessary to complete this form again
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H- H-GAC Authorization Agreement for Fax Reporting
Vendors that are providing a service that requires a monthly service log and/or other supporting
documentation may fax their service log(s) and/or other supporting documentation. Vendor
authorized staff must sign each service log before faxing. If vendors are not able to fax their
service log(s), signed service logs must be mailed. Emailed service logs will not be accepted for
reimbursement UNLESS the vendor has scanned the signed service log. Service Logs must be
signed. If your organization has completed this form in the past and there are no changes it is not
necessary to complete this form again
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Attachment A
Houston-Galveston Area Council
Area Agency on Aging
Authorized Signature Form
For Request for Payment
Direct Purchase of Service Program
Name and Address of Vendor Agency:
Signature of individuals authorized to sign Vendor Agreement and/or Vendor Invoice
Vendor Agreement Vendor Agreement
1. Print/ Type Name, Title, and Signature 2. Print/ Type Name, Title, and Signature
_______________________________________ _____________________________
Signature Signature
Vendor Invoices Vendor Invoices
1. Print/ Type Name, Title, and Signature 2. Print/Type Name, Title, and Signature
______________________________________ _________________________________
Signature Signature
Name of Contacts at your organization
1. Name of Administrative Contact Person 2. Name of Billing Contact Person
______________________________ _____________________________
Signature Signature
I certify that the signatures above are of the individuals authorized to sign for Vendor Agreement and/or Vendor
Invoice.
____________________________________________________________
Print/ Type Name and Title of Authorized Official
____________________________________________________________
Signature of Authorized Official
_ _________________________________________
Date
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Attachment B
FY 2009
CERTIFICATION
REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION FOR COVERED CONTRACTS AND GRANTS
Federal Executive Order 12549 requires the Texas Department on Aging (TDoA) to screen each covered potential
contractor/grantee to determine whether each has a right to obtain a contract/grant in accordance with federal
regulations on debarment, suspension, ineligibility, and voluntary exclusion. Each covered contractor/grantee must
also screen each of its covered subcontractors/providers.
In this certification "contractor/grantee" refers to both contractor/grantee and subcontractor/subgrantee;
"contract/grant" refers to both contract/grant and subcontract/subgrant.
By signing and submitting this certification the potential contractor/grantee accepts the following terms:
1. The certification herein below is a material representation of fact upon which reliance was placed when this
contract/grant was entered into. If it is later determined that the potential contractor/grantee 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 Texas Department on Aging may pursue available remedies, including
suspension and/or debarment.
2. The potential contractor/grantee shall provide immediate written notice to the person to which this
certification is submitted if at any time the potential contractor/grantee 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/grantee agrees by submitting this certification that, should the proposed covered
contract/grant be entered into, it shall 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 Texas Department on Aging, as applicable.
Do you have or do you anticipate having subcontractors/subgrantees under this proposed
contract?......... YES NO
5. The potential contractor/grantee further agrees by submitting this certification that it will include this
certification titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
for Covered Contracts and Grants" without modification, in all covered subcontracts and in solicitations for
all covered subcontracts.
6. A contractor/grantee may rely upon a certification of a potential subcontractor/subgrantee that it is not
debarred, suspended, ineligible, or voluntarily excluded from the covered contract/grant, unless it knows
that the certification is erroneous. A contractor/grantee must, at a minimum, obtain certifications from its
covered subcontractors/subgrantees upon each subcontract's/subgrant's initiation and upon each renewal.
7. Nothing contained in all the foregoing shall 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/grantee is not required to exceed that which is normally possessed by a prudent
person in the ordinary course of business dealings.
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Certification Regarding Debarment, Suspension, …
Page 2
8. Except for contracts/grants authorized under paragraph 4 of these terms, if a contractor/grantee in a covered
contract/grant knowingly enters into a covered subcontract/subgrant with a person who is suspended,
debarred, ineligible, or voluntarily excluded from participation in the transaction, in addition to other
remedies available to the federal government, Department of Health and Human Services, United State
Department of Agriculture, or other federal department or agency, as applicable, and/or the Texas
Department on Aging may pursue available remedies, including suspension and/or debarment.
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION FOR COVERED CONTRACTS AND GRANTS
Indicate which statement applies to the covered potential contractor/grantee:
The potential contractor/grantee certifies, by submission of this certification, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this contract/grant by any federal department or agency or by the State of
Texas.
The potential contractor/grantee is unable to certify to one or more of the terms in this certification. In this
instance, the potential contractor/grantee 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.
NAME OF POTENTIAL CONTRACTOR/GRANTEE
VENDOR ID NO./FEDERAL EMPLOYER'S ID NO.
_____________________________________
Signature of Authorized Representative Printed/Typed Name of Authorized Representative
Date Title of Authorized Representative
THIS CERTIFICATION IS FOR FY 2010, PERIOD BEGINNING October 1, 2009 and ENDING September 30,
2010.
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Attachment C
AFFIRMATIVE ACTION PLAN
HEREBY AGREES THAT IT WILL ENACT
Name of Applicant
AFFIRMATIVE ACTION PLAN. Affirmative action is a management responsibility to take necessary steps to
eliminate the effects of past and present job discrimination, intended or unintended, which is evident from an
analysis of employment practices and policies. It is the policy of this agency that equal employment opportunity is
afforded to all persons regardless of race, color, ethnic origin, religion, sex or age.
This applicant is committed to uphold all laws related to Equal Employment Opportunity including, but not limited
to, the following.
Title VI of the Civil Rights Act of 1964 which prohibits discrimination because of race, color, religion, sex or
nations origin in all employment practices including hiring, firing, promotions, compensation, and other terms,
privileges, and conditions of employment.
The Equal Pay Act of 1963 which covers all employees who are covered by the Fair Labor Standards Act. The act
forbids pay differentials on the basis of sex.
The Age Discrimination Act which prohibits discrimination because of age against anyone between the ages of 40
and 70.
Federal Executive Order 11246 which requires every contract with Federal financial assistance to contain a clause
against discrimination because of race, color, religion, sex or national origin.
Administration of Aging Program Instruction AoA PI-75-11 which requires all grantees to develop affirmative
action plans. Agencies, which are part of an “umbrella agency,” shall develop and implement an affirmative action
plan for single organizational unit on aging. Preference for hiring shall be given to qualified older persons (subject
to requirements of merit employment systems).
Section 504 of the Rehabilitation Act of 1973 which states that employers may not refuse to hire or promote
handicapped persons solely because of their disability.
is the designated person with executive authority responsible for the implementation of this affirmative action
plan. Policy information on affirmative action and equal employment opportunity shall be disseminated through
employee meetings, bulletin boards, and any newsletters prepared by this agency.
Work Force Analysis: Paid Staff
Total Staff: # Full Time # Part Time
Older Persons (60+) #____ ____% #____ ____%
Minority #____ ____% #____ ____%
Women #____ ____% #____ ____%
Date Signature and Title of Authorized Official
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Attachment D
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES REGULATION UNDER
TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
(hereinafter called the “Applicant”)
Name of Applicant (Type or Print)
HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 880352) and all
requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R.
Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and the Regulation, no
person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in,
be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the
Applicant receives Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it
will immediately take any measures necessary to effectuate this agreement.
If any real property or structure thereon is provided or improved with the aid of Federal financial assistance
extended to the Applicant by the Department, this Assurance shall obligate the Applicant, or in the case of any
transfer of such property, any transferee, for the period during which the real property or structure is used for a
purpose for which the Federal Financial assistance is extended of for another purpose involving the provision of
similar services or benefits. If any personal property is so provided, this Assurance shall obligate the Applicant for
the period during which it retains ownership or possession of the property. In all other cases, this Assurance shall
obligate the Applicant for the period during which the Federal financial assistance is extended to it by the
Department.
THIS ASSURANCE is give in consideration of and for the purpose of obtaining any and all Federal grants, loans,
contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by
the Department, including installment payments after such a date on account of applications for Federal financial
assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial
assistance will be extended in reliance on the representations and agreements made in the Assurance, and that the
United States shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the
Applicant, its successors, transferees, and assignees, and the person or persons whose signatures appear below are
authorized to sign this Assurance on behalf of the Applicant.
Date Signature of Authorized Official
Printed Name of Authorized Official
Applicant’s Mailing Address
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Attachment E
ASSURANCES
Houston-Galveston Area Council, Area Agency on Aging –
Elderly & Caregiver Support Services
The vendor and their subcontractors shall adhere to the following assurances listed below.
All Texas Administrative Code standards may be accessed at: http://www.sos.state.tx.us/
All Codes of Federal Regulations (CFR) may be accessed at: http://www.gpoaccess.gov/cfr/index.html
All United States Codes (USC) may be accessed at: http://www.gpoaccess.gov/uscode/index.html
a. Health Insurance Portability and Accountability Act of 1996 (HIPAA) –
The vendor and their subcontractors shall adhere to Health Insurance Portability and Accountability Act of 1996
(HIPAA). HIPAA provides legislation to protect workers who leave their jobs from losing their ability to be
covered by health insurance (Portability), and to protect the integrity, confidentiality, and availability of
electronic health information (Accountability). The HIPAA regulations protect medical records and other
individually identifiable health information, whether it is on paper, in computers or communicated orally.
Civil and criminal penalties for covered entities that misuse personal health information: For civil violations of
the standards, monetary penalties up to $100 per violation, up to $25,000 per year, for each requirement or
prohibition violated. Criminal penalties apply for certain actions such as knowingly obtaining protected health
information in violation of the law. Criminal penalties can range up to $50,000 and one year in prison for
certain offenses; up $100,00 and up to five years in prison if the offenses are committed under “false pretenses”;
and up to$250,000 and up to 10 years in prison if the offenses are committed with the intent to sell, transfer, or
use protected health information for commercial advantage, personal gain, or harm.
http://www.cms.hhs.gov/hipaa/hipaa2
The Vendor and their subcontractors shall have procedures to protect the confidentiality of information about
older persons collected in the conduct of its responsibilities. The procedures shall ensure that no information
about an older person, or obtained from an older person by a service provider or the State or area agencies, is
disclosed by the provider or agency in a form that identifies the person without the informed consent of the
person or of his or her legal representative, unless the disclosure is required by court order, or for program
monitoring by authorized Federal, State, or local monitoring agencies (45CFR1321.51 and TAC270.1).
Vendors are not required to provide client nor detailed information to the general public. The Federal Freedom
of Information Act (5 United States Code, 552) does not apply to such records. Unless required by Federal,
State, or local law, grantees or vendors are not required to permit public access to such records. Vendors may
be required to provide information that is summary or deidentified.
b. Americans with Disabilities Act of 1990 –
The vendor and their subcontractors shall comply with the requirements established under the American with
Disabilities Act in meeting statutory deadlines established under the Act as they pertain to operations for
employment, public accommodations, transportation, state, and local government operations and
telecommunications.
ACT: http://www.usdoj.gov/crt/ada/statue.html
Home Page: http://www.ada.gov/
c. Section 504 of the Rehabilitation Act of 1973 –
The vendor and their subcontractors shall ensure compliance with Section 504 of the Rehabilitation Act of
1973, in regard to discrimination of the handicapped.
ACT: http://www.hud.gov/progdesc/s-504.cfm
Code of Federal Regulations Title 45 Part 84.1 (45CFR84.1) and Part 84.11 (45CFR84.11).
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d. Age Discrimination in Employment Act of 1967 –
The Vendor shall comply with Age Discrimination in Employment Act of 1967. The ADEA prohibits
employment discrimination against persons 40 years of age or older.
www.eeoc.gov/policy/adea.html
United States Code Title 29 Section 621 (29USC621)
e. Child Support and Medical Support Enforcement –
The vendor and their subcontractors shall ensure compliance with the Texas Family Code, Title 5, Chapter 231,
Section 231.006, Ineligibility to Receive State Grants or Loans or Receive Payment on State Contracts. The
vendor shall ensure 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 may be
terminated and payment may be withheld if the individual or business entity named in this contract, bid, or
application is not in compliance.
http://www.capitol.state.tx.us/statutes/fatoc.html
Texas Family Code, Title 5, Chapter 231, Section 231.006
f. Reporting Abuse –
The vendor and their subcontractors shall ensure that all suspected cases of abuse, neglect, and exploitation of
older persons be reported to the Texas Department of Protective and Regulatory Services at (1-800-252-5400)
within 24 hours of awareness. Vendors and their subcontractors shall also report appropriate types of suspected
abuse cases to local police officials
g. Participant Involvement & Grievances –
The vendor and their subcontractors shall ensure compliance with the Texas Administrative Code 254.19
Grievance Procedures for Participants in Older American Act Programs. Participants in Older Americans Act
Programs may submit grievances regarding specific actions or activities affecting their personal participation in
the program or the conduct of the program as it relates to all participants at that site or location.
Signature of Authorized Official Date
Print Name Title
Organization Name
Mailing Address
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Attachment F
Houston-Galveston Area Council
AUTHORIZATION AGREEMENT
FOR DIRECT DEPOSIT
Section 1 (TO BE COMPLETED BY PAYEE)
Individual/Company Name Tax ID Number (SSN or Fed ID)
The Houston-Galveston Area Council is hereby authorized to credit the following account in lieu of any other
payment method for amounts owed to us for goods delivered or services rendered. Furthermore, the Houston-
Galveston Area Council is also authorized to debit the same account in an amount not to exceed the original credit
for any erroneous deposits. The vendor agrees to notify the Houston-Galveston Area Council of any changes, which
may affect this agreement within 24 hours.
Check One
Bank Credit Union Savings and Loan
This authorization will remain in effect until written notification has been provided to the Houston-Galveston
Area Council with different instructions.
Authorized Signature: Date:
Name:
Title:
Telephone Number:
Mailing Address:
Section 2 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
_______________________________________ _______________________________________
Depository Name (Financial Institution) Transit/ABA Number
___________________________________________ ______________________________
Depository Address Account Number
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above named payee(s) and the account number and title. As representative of the
above-named financial institution, I certify that the financial institution agrees to receive and deposit the payment
identified above in accordance with 31 CFR Parts 240, 209, and 210.
Print or Type Representative Name Signature Date
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Attachment G
Houston-Galveston Area Council
EMAIL INVOICE
AUTHORIZATION AGREEMENT
Please Type or Print
VENDOR NAME:
ADDRESS:
TELEPHONE:
Name of Employees Certifying Employee’s Email Address Employee’s Signature
Documents
1.
2.
3.
4.
5.
Certification
As a representative of the organization identified above, I confirm that the person(s) named are employees of our
organization and are approved to sign and submit monthly invoice(s) and supporting documentation to the
Houston-Galveston Area Council. I understand that this authorization will remain in effect until written
notification has been provided to the Houston-Galveston Area Council within 24 hours with different
instructions.
Print or Type Representative Name Signature Date
Please submit this original form, faxed or a copy of this form will not be accepted. Please
make a copy for your records.
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Attachment H
Houston-Galveston Area Council
FAX REPORTING
AUTHORIZATION AGREEMENT
Please Type or Print
VENDOR NAME:
ADDRESS:
TELEPHONE:
FAX NUMBER:
Name of Employee(s) Certifying Logs Employee’s Signature
1.
2.
3.
4.
5.
6.
Certification
As a representative of the organization identified above, I confirm that the person(s) named are employees of our
organization and are approved to sign service delivery logs. I understand that this authorization will remain in
effect until written notification has been provided to the Houston-Galveston Area Council within 24 hours with
different instructions.
Print or Type Representative Name Signature Date
Please submit this original form, faxed or a copy of this form will not be accepted. Please
make a copy for your records.
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