Michigan Department of Human Services (hereinafter referred to as “DHS”)
235 South Grand Avenue
P.O. Box 30037
Lansing, Michigan 48909
Name and address of current or past foster/adoptive/kinship parent here. (hereinafter referred to as “Contractor”)
This Agreement is effective October 1, 2012 through September 30, 2014.
From this point on. DO NOT USE TAB . Press CONTROL F to move to next typing location.
I. CONTRACTOR RESPONSIBILITIES A. Email Address The Contractor authorizes DHS to use the contact information below to send Agreement related notifications/information. The Contractor shall provide DHS with updated contact information if it changes.
Contact email address: CONTACT EMAIL HERE.
B. Geographic Area The Contractor shall provide services described herein in the following geographic area: COUNTY NAME HERE.
C. Location of Facilities The Contractor shall provide services described herein at the following location(s):
Various locations within COUNTY NAME HERE.
D. Client Eligibility Criteria
Support Services shall be provided to:
Current and potential foster/adoptive/kinship parents in COUNTY NAME HERE.
AFPRR – 100%
2. Determination of Eligibility
DHS shall determine eligibility.
E. Credentials The Contractor shall assure that appropriately credentialed or trained staff under its control, including contractor employees and/or subcontractors, shall perform functions under this Agreement.
The Contractor shall possess a minimum of an associate’s degree (a bachelor’s degree is preferred) in Social Work or one of the following human services related fields: Sociology, Psychology, Family Ecology, Consumer/Community Services, Family Studies, Family And/or Child Development, Guidance/School Counseling, Counseling Psychology, or Criminal Justice, shall have 2 years of experience as a foster/adoptive/kinship parent, and be in good standing with their agency. Five year experience as a foster/adoptive/kinship parent can replace the minimum educational background requirement.
F. Services to be Delivered
Service #1 of 1: FOSTER/ADOPTIVE/KINSHIP PARENT SUPPORT GROUP
1. Activities the Contractor shall perform:
The Contractor shall:
Coordinate with the COUNTY NAME HERE DHS and local private agency Foster Care Licensing Unit to develop, implement, and facilitate monthly Foster/Adoptive/Kinship Parent Support Group meetings;
Administer a survey quarterly to Foster/Adoptive/Kinship Support Group members to assess and evaluate the success of the program.
2. Volume of Service
a. Clients - The estimated number of unduplicated eligible clients to be served during the period of this Agreement shall be: XX for fiscal year 2012, XX for fiscal year 2013, and XX for fiscal year 2014. THESE GOALS ARE BASED ON THE COUNTY/AGENCY SIZE. b. Unit Definition(s): One unit equals one (1) hour of Contractor’s time engaged in the facilitation of foster/adoptive/kinship parent support group meetings, mentoring new foster parents, or writing the newsletter. The Contractor can bill up to 5 hours for planning and organizing a support group meeting. The Contractor may bill for partial units in increments of one-tenth of one (1) hour.
c. Units: The maximum number of units of service to be provided per term of Agreement shall be: DETERMINED BY THE COUNTY/AGENCY.
From the total amount, the maximum number of units that may be provided during the following periods is:
Fiscal YearMaximum Number of Units
October 1, 2011 through September 30, 2012 xx
October 1, 2012 through September 30, 2013 xx
October 1, 2013 through September 30, 2014 xx
NUMBER OF CLIENTS AND NUMBER OF UNITS WILL VARY BY COUNTY AND AFPRR FUND ALLOCATION G. Evaluation Reporting Requirements
The Contractor shall submit to DHS monthly reports that indicate the status and effectiveness of activities performed under this Agreement as indicated:
The dates, the names of attendees, and the topic of discussion for each Foster/Adoptive/Kinship Parent Support Group meeting.
A list of all hours and activities by date that identify Support Group activities facilitated for the month.
List of new foster/adoptive/kinship parents contacted.
List of families mentored and services provided.
The results from the quarterly surveys.
H. Audit Requirements
Determine whether the Contractor is a vendor or sub-recipient, then select the appropriate audit language and delete the remaining audit language. If the contract is 100% state funds, delete audit language in its entirety. | Vendor Relationship This Agreement constitutes a vendor relationship with DHS. No audit requirements are imposed by DHS as a result of this Agreement. No audit costs are allowed to be billed to this Agreement. In the event the Contractor elects to have a financial audit performed, the submission of the audit report to DHS is not required nor desired.
The Contractor must immediately report to the DHS Office of Monitoring and Internal Controls accounting irregularities including noncompliance with provisions of this Agreement.
| Subrecipient Relationship This Agreement constitutes a subrecipient relationship with DHS. The Contractor is required to comply with all federal regulations related to the accounting and auditing of the federal award used to fund this Agreement. This includes, but is not limited to, compliance with OMB Circular A-133.
Regulations applicable to funding sources are included in the Catalog of Federal Domestic Assistance (CFDA). The Federal Program Title, CFDA number, and federal financial participation (FFP) rate DHS will use for this Agreement are:
Federal Program Title
|Tab here if entering multiple CFDA#
However, DHS may change the CFDA number and/or FFP rate during the course of this Agreement. CFDA numbers and FFP rates for this Agreement shall be posted monthly on the DHS website. The Contractor is required to check the website to obtain up to date information regarding the CFDA numbers (unless notified otherwise by the DHS Division of Logistics and Rate Setting).
The Contractor shall consult the following website to obtain CFDA numbers, payments, program updates, and other audit information:
DHS agrees to participate in audit cost related to the audit as described in other sections of this Agreement.
Reporting Requirements The Contractor must immediately report to the DHS Office of Monitoring and Internal Controls accounting irregularities including noncompliance with provisions of this Agreement.
If the Contractor is required per OMB Circular A-133 to have a single audit performed, the Contractor must submit the reporting package and an audit transmittal letter to the DHS Office of Monitoring and Internal Controls at the address that follows and in accordance with the time frame established in the Circular.
The reporting package includes:
1. Financial statements and schedule of expenditures of federal awards
2. Summary schedule of prior audit findings
3. Auditor’s report(s)
4. Corrective action plan, if applicable
Audit Transmittal Letter The Contractor is responsible to identify in the audit transmittal letter all organizations it operates that administer DHS subrecipient programs and the different names the Contractor may use to contract with DHS. The Contractor is responsible for proper completion and submission of the audit transmittal letter. This letter, to be accurately processed by DHS, must include the following information:
1. Contractor’s name as reported in the DHS contract(s)
2. Contractor’s Federal Identification number(s) as reported in the DHS contract(s)
3. Contractor’s fiscal year end
4. Other name(s) and other Federal Identification number(s) used by the Contractor
If a single audit is not required per OMB Circular A-133, the Contractor must still submit an audit transmittal letter stating why a single audit was not required and the Contractor’s fiscal year to which the letter pertains. The audit transmittal letter should include the four items described above. The letter may be mailed to the address below or FAX to (517) 373-8771.
Mailing address for all information:
Michigan Department of Human Services
Office of Monitoring and Internal Controls
Grand Tower, Suite 1112
PO Box 30037
Lansing, MI 48909
If the Contractor is a subrecipient of DHS, but asserts it is not required to have a single audit performed, the Contractor shall submit an audit transmittal letter to the DHS Office of Monitoring and Internal Controls stating the reason the single audit is not required. Failure by the Contractor to submit the audit transmittal letter shall result in invoking the same sanctions on the Contractor as failure to submit the single audit report.
Cost of the single audit can only be charged to this Agreement if there is a provision within this Agreement that allows payment for the single audit cost. No audit cost may be charged to this Agreement if the Contractor is not required to have a single audit.
No audit costs may be charged to DHS when audits required by this Agreement have not been performed or have not been performed in accordance with OMB Circular A-133 requirements. Late submission (as defined in OMB Circular A-133) of the single audit report and/or audit transmittal letter is considered non-compliance with this section and may be grounds to impose sanctions.
Sanctions DHS may impose sanctions if the Contractor fails to adhere to any of the audit requirements in this Agreement, including the audit transmittal letter. In cases of continued inability or unwillingness on the part of the Contractor to comply with audit requirements, DHS may impose sanctions such as:
1. Withholding a percentage of the federal award until the audit is completed satisfactorily.
2. Withholding or disallowing overhead costs.
3. Suspending federal awards until the audit is conducted.
4. Terminating the federal award.
5. Recouping the federal payments made to the Contractor under this or any other agreements between DHS and the Contractor.
I. Client Records For each eligible client served under this Agreement, the Contractor shall maintain client case records consisting of:
-Eligibility certification documents.
-Date of contact with client.
-Methods of service delivery.
-Significant contacts with client and significant events.
-Other material related to this Agreement as may be specified by DHS.
J. Service Documentation The Contractor agrees to maintain program records required by DHS, program statistical records required by DHS, and to produce program narrative and statistical data at times prescribed by, and on forms furnished by, DHS.
K. Fiscal Requirements
The Contractor shall maintain a record system that documents the total number of units of service as defined in this Agreement and delivered during the term of this Agreement. These records shall also document the specific units billed to DHS under this Agreement.
L. Billing Method As used in this Agreement, “Cost Documentation” refers to the CM-468 Total Program Budget Summary, and the Contract Budget Detail sheets attached hereto.
As used in this Agreement, “Cost Documentation” refers to the CM-469 Small Dollar Contract Budget (For Contracts Under $25,000) attached hereto.
The Unit Rate Billing Method shall be used in claiming reimbursement under this Agreement.
The Unit Rate and Actual Cost (UR/AC) Billing Method shall be used in claiming reimbursement under this Agreement. The Actual Cost Reimbursement Method shall be used in claiming reimbursement for mileage/transportation and the Unit Rate Billing Method shall be used in claiming reimbursement for allowable expenditures included in the unit definition.
If this Agreement includes travel costs, including mileage, meals, and lodging, DHS shall reimburse the Contractor at State of Michigan (SOM) premium established rates or the Contractor’s usual travel reimbursement rate for employees, whichever is less. Current SOM premium rates may be obtained at the following website:
The Contractor cannot charge DHS more for a provision of service than is charged to other entities for whom the Contractor provides services.
M. Billing Procedure
The Contractor shall submit a monthly “Statement of Expenditures” (DHS-3469) to DHS. This Statement of Expenditures shall accurately represent the units of service delivered, the reimbursement rate by type of service, and the total amount being claimed. The total number of units (by service type) for each bill must be rounded down to the nearest whole or tenth of a unit. This Statement shall be submitted to DHS within 30 days from the end of the monthly billing period. For the month of September, billings shall be submitted as reasonably directed by the contract administrator to meet fiscal year end closing deadlines. In no event shall DHS make a payment to the Contractor for billings submitted more than 90 days after the end of a billing period.
Obligations incurred prior to or after the period covered by this Agreement shall be excluded from the Contractor’s monthly invoices. The unit rate(s) established in this Agreement shall remain fixed for the entire period of the Agreement.
|N. Federal Guidelines for Use of Temporary Assistance to Needy Families (TANF) For federally funded contracts, federal guidelines may need to be inserted from the federal grant language. If so, enter the name of the funding source above. For example, if TANF funds are used, the heading should read as follows: Federal Guidelines for Use of Temporary Assistance to Needy Families (TANF) Funds
If there are no federal guidelines for the funding source, this part can be deleted in its entirety.
This Agreement is subject to the following terms, conditions, and provisions:
|Insert the appropriate federal guidelines (e.g., TANF) here
|O. Criminal Background Check
The background check language below is for contracts with private or public agencies. For contracts with individuals or universities, replace the language below with the appropriate criminal background check language, which is on the DLRS website.
As a condition of this Agreement, the Contractor certifies that the Contractor shall, prior to any individual performing work under this Agreement, conduct or cause to be conducted for each new employee, employee, subcontractor, subcontractor employee, or volunteer who works directly with:
1. clients under this Agreement, or who has access to client information, an Internet Criminal History Access Tool (ICHAT) check and a National and State Sex Offender Registry check.
Information about ICHAT can be found at http://apps.michigan.gov/ichat.
The Michigan Public Sex Offender Registry website address is http://www.mipsor.state.mi.us.
The National Sex Offender Public website address is http://www.nsopw.gov.
2. children under this Agreement, a Central Registry (CR) check.
Information about CR can be found at http://www.mi.gov/dhs/0,1607,7-124-5452_7119_48330-180331--,00.html.
The Contractor shall require each new employee, employee, subcontractor, subcontractor employee, or volunteer who works directly with clients or who has access to client information under this Agreement to notify the Contractor in writing of criminal convictions (felony or misdemeanor) and/or pending felony charges or placement on the Central Registry as a perpetrator at hire or within 10 days of the event after hiring.
Additionally, the Contractor shall require each new employee, employee, subcontractor, subcontractor employee, or volunteer who works directly with clients under this Agreement or who has access to client information and who has not resided or lived in Michigan for each of the previous 10 years to sign a waiver attesting to the fact that they have never been convicted of a felony or identified as a perpetrator, or if they have, the nature and recency of the felony.
The Contractor further certifies that the Contractor shall not submit claims for or assign duties under this Agreement to any new employee, employee, subcontractor, subcontractor employee, or volunteer based on a determination by the Contractor that the results of a positive ICHAT and/or a CR response or reported criminal felony conviction or perpetrator identification make the individual ineligible to provide the services.
The Contractor must have a written policy describing the criteria on which its determinations shall be made and must document the basis for each determination. The Contractor may consider the recency and type of crime when making a determination. Failure to comply with this provision may be cause for immediate cancellation of this Agreement. In addition, the Contractor must further have a written policy regarding acceptable screening practices of new staff members and volunteers who have direct access to clients and/or client’s personal information, which serve to protect the organization and its clients that is clearly defined. The Contractor must also assure that any subcontractors have both of these written policies.
If DHS determines that an individual provided services under this Agreement for any period prior to completion of the required checks as described above, DHS may require repayment of any and/or all billed services for the period that the required checks had not been completed.
II. DHS RESPONSIBILITIES A. Payment DHS shall make payments to the Contractor within 45 days after receipt by DHS of the Contractor’s Statement of Expenditures, based upon the following rates per unit of services delivered:
Unit TitleRate Foster/Adoptive Support Group Facilitator $20.00 OR AS DETERMINED BY THE AGENCY. B. Maximum Amount of Agreement DHS hereby agrees to pay the Contractor an amount not to exceed two thousand and four hundred dollars and 00/100 ($2,400.00) for services performed in accordance with the terms of this Agreement exclusively during the period October 1, 2011 to September 30, 2014.
From the total amount, the maximum amount that may be expended during the following periods is:
Error: Reference source not found through September 30, 2012 $X,XXX.XX
October 1, 2012 through September 30, 2013 $ X,XXX.XX
October 1, 2013 through September 30, 2014 $ X,XXX.XX
In addition to the rate(s) established here, but as a part of the total dollar amount of this Agreement, DHS shall reimburse the Contractor to a maximum of AMOUNT OF MONEY GOES HEREand 00/100 ($XXX) for Transportation and AMOUNT OF MONEY GOES HERE and 00/100 ($XXX) for Supplies for the period Error: Reference source not found through September 30, 2014.
From the total amount, the maximum amount that may be expended during the following periods is:
Error: Reference source not found through September 30, 2012 $ XXX.XX $ XXX.XX
October 1, 2012 through September 30, 2013 $ XXX.XX $ XXX.XX
October 1, 2013 through September 30, 2014 $ XXX.XX $ XXX.XX
DHS shall reimburse the Contractor for mileage incurred by the Contractor for:
Driving to or from a Foster/Adoptive Support Group meeting
The point of origin for mileage shall be the Contractor’s home or normal place of business or the DHS local office location, whichever is closer to the client’s home. No mileage may be charged or reimbursement received for mileage to or from a client’s home if face-to-face contact between the Contractor and client does not occur. That is, the Contractor shall not be reimbursed for mileage which occurs as a result of a missed appointment. The Contractor may not bill for mileage incurred by the Contractor driving to/from their home to/from the DHS local office.
CAN VARY BY COUNTY
C. Evaluation Criteria
The services provided by the Contractor under this Agreement shall be evaluated by DHS on the basis of the following criteria:
The number of Foster/Adoptive Support Group members will increase by at least 5 during each year of the contract.
Positive reviews are received from Foster/Adoptive Support Group member quarterly surveys.
IN WITNESS WHEREOF, the DHS and the Contractor have caused this Agreement to be executed by their respective officers duly authorized to do so.
The Undersigned has the lawful authority to bind the Contractor to the terms set forth in this Agreement.
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DEPARTMENT OF HUMAN SERVICES
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CM-F111 (Rev.12-11) Previous edition obsolete. MS Word