COMPLETED BOARD ORDER�"�l�19
Before the Board of Supervisors in and for the
County of Monterey, State of California
Agreement No: A 10748
Authorize the Purchasing Manager for Natividad Medical Center NMC) to
execute Amendment No. 4 to the Agreement A-10748) with Jennifer L. D'Attilio
MS for Speech Language Pathology Services at NMC in an amount not to exceed
$711,000 an increase of $255,000) for the period April 1, 2010 and extending the
term date to June 30, 2011.
Upon motion of Supervisor Potter, seconded by Supervisor Armenta, and carried by those
members present, the Board hereby:
Authorized the Purchasing Manager for Natividad Medical Center NMC) to execute
Amendment No. 4 to the Agreement A-10748) with Jennifer L. D'Attilio MS for Speech
Language Pathology Services at NMC in an amount not to exceed $711,000 an increase of
$255,000) for the period April 1, 2010 and extending the term date to June 30, 2011.
PASSED AND ADOPTED this 11th day of May, 2010, by the following vote, to wit:
AYES: Supervisors Armenta, Calcagno, Salinas, Potter
NOES: None
ABSENT: Supervisor Parker
I, Gail T. Borkowski, Clerk of the Board of Supervisors of the County of Monterey, State of California, hereby
certify that the foregoing is a true copy of an original order of said Board of Supervisors duly made and entered in
the minutes thereof of Minute Book 75 for the meeting on May 11, 2010.
Dated: May 13, 2010 Gail T. Borkowski, Clerk of the Board of Supervisors
County of Monterey, State of California
BY F i- d'
Deputy
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SIGNED BOARD REPORTX��"�n�MONTEREY COUNTY BOARD OF SUPERVISORS
MEETING: May 11, 2010 AGENDA NO.:
SUBJECT: Authorize the Purchasing Manager for Natividad Medical Center NMC)
to execute Amendment #4 to the Agreement A-10748) with Jennifer L.
D'Attilio MS for Speech Language Pathology Services at NMC in an
amount not to exceed $711,000 an increase of $255,000) for the period
April 1, 2010 and extending the term date to June 30, 2011.
DEPARTMENT: Natividad Medical Center
RECOMMENDATION:
It is recommended that the Board of Supervisors authorize the Purchasing Manager for Natividad
Medical Center NMC) to execute Amendment #4 to the Agreement A-10748) with Jennifer L.
D'Attilio MS for Speech Language Pathology Services at NMC in an amount not to exceed
$711,000 an increase of $255,000) for the period April 1, 2010 and extending the term date to June
30, 2011.
SUMMARY/DISCUSSION:
Jennifer D'Attilio has been providing speech language pathology services at NMC for a period of six
years. Services provided include assessment and treatment for both adult and pediatric patients.
Also included are Inpatient Neonatal Intensive Care Unit NICU) and outpatient services for
children with suspected feeding, swallowing or cognitive deficits as well as language disabilities and
autism. Adult services include inpatient and outpatient evaluation of dysphagia, aphasia post stroke,
traumatic brain injury and treatment for deficits resulting from surgery, Alzheimer's, Parkinson's
disease and trauma.
Speech pathologists work as part of the Natividad team of physicians, nurses and rehabilitation staff
to provide services and education. Patients receiving speech and language services have faster
recovery and increased functioning in overall communication, language and feeding skills.
The speech therapy department has experienced substantial growth have exceeded budget by more
than 30% for the first two quarters of fiscal year 2010) this fiscal year, and as a result, NMC requests
an increase in the previously established purchase order for Jennifer D'Attilio in the amount of
$255,000 which will cover the remainder of FY 2010 and all of FY 2011. The increased workload
requires additional staffing provided by the contractor under this contract.
OTHER AGENCY INVOLVEMENT:
The Amendment has been reviewed and approved by County Counsel, the Auditor/Controller's
office and the Natividad Medical Center Board of Trustees.
FINANCING:
The cost for this Amendment is $255,000: $60,000 is included in the approved FY 2009-10 Budget
and $195,000 will be included in the 2010-2011 Recommended Budget. This action will not require
any additional General Fund subsidy.
Prepared by:
Sid Cato, Management Analyst/Contracts
March 25, 2010
Attachments: Agreement, Amendment #4, Board Order
Harry Weis
Chief Executive Officer
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AGREEMENT - JENNIFER L. D ATT�p�Original Agreement No or PO # A-10748)
RENEWAL AMENDMENT NO. 4
FOR PROFESSIONAL SERVICE AGREEMENT
BETWEEN Jennifer L. D'Attilio MS AND
THE NATIVIDAD MEDICAL CENTER
FOR
Speech Therapy SERVICES
The parties to Professional Service Agreement, dated July 1, 2006 between the County of Monterey, on
behalf of Natividad Medical Center NMC"), and Jennifer L. D'Atillio Contractor), hereby agree to
renew their Agreement No. A- 10748) on the following amended terms and conditions:
1. Contractor will continue to provide NMC with the same scope of service as stated in the original
Agreement No. A-10748).
2. This Renewal Amendment shall become effective on April 1, 2010 and shall continue in full force
and extending the term date until June 30, 2011.
3. The total amount payable by County to Contractor under Agreement No. A-10748) shall not
exceed the total sum of $711,000 for the full term of the Agreement; $235,000 for fiscal year
2009-2010 and $195,000 for fiscal year 2010-2011.
4. All other terms and conditions of the Agreement shall continue in full force and effect.
5. A copy of this Amendment shall be attached to the original Agreement No. A-10748).
IN WITNESS WHEREOF, the parties hereto are in agreement with this Amendment and
Professional Service Agreement on the basis set forth in this document and have executed this
amendment on the day and year set forth herein.
CONTRACTOR.,
Signature r__. Dated
Printed ii t 4, 6'LlL-- Title C~ o Jam'`'
J
NATIVIDAD MEDICAL CENTER
Signature Dated
Purc, asing Manager
Signature t Y L.= Dated r l t
NMC CEO
Approved as to Legal Form:
Charles J_ McKee, County Counsel
By
Aevia led j4s Ito fiscai provisions
Dated: TS~ 2010
A R r.Con t-oilier
County of Mon' erey
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AGREEMENT - JENNIFER L. D ATT�p�Original Agreement No or PO#. A- 10748)
RENEWAL AMENDMENT NO.3
FOR PROFESSIONAL SERVICE AGREEMENT
BETWEEN Jennifer L. D'Attilio MS AND
THE NATIVIDAD MEDICAL CENTER
FOR
Saeaech Therapy SERVICES
The parties to Professional Service Agreement, dated July 1, 2006 between the County of Monterey, on
behalf of Natividad Medical Center NMC"), and Jennifer L. D'Attilio Contractor), hereby agree to
renew their Agreement No. A-10748) on the following amended terms and conditions:
1. Contractor will continue to provide NMC with the same scope of service as stated in the original
Agreement No. A-10748).
2. This Renewal Amendment shall become effective on July 1, 2009 and shall continue in full force
and extending the term date until June 30, 2010.
3. The total amount payable by County to Contractor under Agreement No. A-10748) shall not
exceed the total sum of $456,000 for the full term of the Agreement and $175,000 for fiscal year
2009-2010.
4. All other terms and conditions of the Agreement shall continue in full force and effect.
5. A copy of this Amendment shall be attached to the original Agreement No. A-10748).
IN WITNESS WHEREOF, the parties hereto are in agreement with this Amendment and
Professional Service Agreement on the basis set forth in this document and have executed this
amendment on the day and year set forth herein.
Dated /O 91
Title &j
Litt, Deputy
ttorneys for County and NMC
Dated: J/ 2009
SI00
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AGREEMENT - JENNIFER L. D ATT�p�Original Agreement No. A- 10748)
RENEWAL AMENDMENT NO.
FOR PROFESSIONAL SERVICE AGREEMENT
BETWEEN Jennifer L D'Attilio MS AND
THE COUNTY OF MONTEREY
FOR
Ve of s iee-hire SERVICES
SP i-t T}~(LAp1
The parties to Professional Service Agreement, dated between the County of Monterey, on
behalf of Natividad Medical Center NMC"), and Jennifer L D'Attilio MS Contractor), hereby agree
to renew their Agreement No. A-10748) on the following amended terms and conditions:
1. Contractor will continue to provide NMC with the same scope of service as stated in the original
Agreement No. A-10748).
2. This Renewal Amendment shall become effective on July 1, 2008 and shall continue in full force
and extending the term date until June 30, 2009.
3. The total amount payable by County to Contractor under Agreement No. A-10748)shall not
exceed the total sum of $M,00r the full term of the Agreement; and $91,500 for fiscal year
2006-200q.
4. All other terms and conditions of the Agreement shall continue in full force and effect.
5. A copy of this Amendment shall be attached to the original Agreement No. A- 10748
IN WITNESS WHEREOF, the parties hereto are in agreement with this Amendment and
Professional Service Agreement on the basis set forth in this document and have executed this
amendment on the day and year set forth herein.
CONTRACT
Signature Dated
Printed Name Title
Dated
vv. Hnen tsiowen, uepuly
/
Attorneys for County and NMC Dated: Y3 Z/a-, 2008
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AGREEMENT - JENNIFER L. D ATT�p�Original Agreement No. PO# B960767471)
RENEWAL AMENDMENT NO. 1
FOR PROFESSIONAL SERVICE AGREEMENT
BETWEEN Jennifer D'Attilio AND
THE COUNTY OF MONTEREY
FOR
Speech Language Pathology SERVICES
The parties to Professional Service Agreement, dated July 10, 2006 between the County of Monterey, on
behalf of Natividad Medical Center NMC"), and Jennifer D'Attilio(Contractor), hereby agree to renew
their Agreement. PO# B960767471 on the following amended terms and conditions:
1. Contractor will continue to provide NMC with the same scope of service as stated in the original
Agreement. PO# B960767471.
2. This Renewal Amendment shall become effective on December 12, 2006, and shall continue in
full force until June 30, 2007.
4. The total amount payable by County to Contractor under Agreement PO# B960767471 shall not
exceed the total sum of $66,500.
5. All other terms and conditions of the Agreement shall continue in full force and effect.
6. A copy of this Amendment shall be attached to the original Agreement PO# B960767471.
IN WITNESS WHEREOF, the parties hereto are in agreement with this Amendment and
Professional Service Agreement on the basis set forth in this document and have executed this
amendment on the day and year set forth herein.
Purchasin
Approved as to Legal Form:
Ch les J. cKee, County Couns
By
W. Allen Bidwell, Deputy
Attorneys forCounty,and NMC.
L
Dated: 10 o 2006
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AGREEMENT - JENNIFER L. D ATT�p�i
&-*4)/v 6 Z-
PROFESSIONAL SERVICES AGREEMENT
BETWEEN JENNIFER D'ATTILIO, SLP
AND NATIVIDAD MEDICAL CENTER
THIS AGREEMENT is made and entered into effective July 1, 2006, by and between the
County of Monterey on behalf of Natividad Medical Center, County") and Jennifer D'Attilio,
SLP Contractor") for the provision of Speech Language Pathology services.
RECITALS
1. The County of Monterey owns and operates NATIVIDAD MEDICAL CENTER, a
general acute care, teaching hospital located in Salinas, CA, requiring the services of a
Speech Language Pathologist.
2. Hospital and CONTRACTOR desire that CONTRACTOR provide temporary Speech
Language Pathology services, all in the capacity of an independent CONTRACTOR and
in accordance with the terms and conditions of this Agreement.
3. CONTRACTOR is. a qualified provider of the required professional services.
NOW, THEREFORE,:the parties mutually agree as follows:
4. CONTRACTOR will perform-the following professional services:
Speech Language Pathology services as scheduled and mutually agreed- upon by
both parties. The scope of services is more fully described in Exhibit B,". attached
hereto and incorporated herein by this reference.
5. Compensation.
a. As full and total compensation for the performance of Speech Language Pathology
services including expenses) by CONTRACTOR pursuant to this Agreement, County
shall pay CONTRACTOR at the rate of sixty-five dollars $65.00) per hour. The total.
amount payable by County to CONTRACTOR under this agreement shall not exceed the
sum of twenty-five thousand dollars $25,000.00).
b. CONTRACTOR shall submit to the Hospital an invoice on a form acceptable to
county. If not otherwise specified, the CONTRACTOR may submit such invoice
periodically or at the completion of services, but in any event, not later than 30 days after
completion of services. The invoice shall set forth the amounts claimed by
CONTRACTOR for the previous period, together with an itemized basis for the amounts
claimed, and such other information pertinent to the invoice as the County may require.
The Hospital or its designee shall certify the invoice, either in the requested amount or in
such other amount as the County approves in conformity with this Agreement, and shall
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AGREEMENT - JENNIFER L. D ATT�p�promptly submit such invoice to the County Auditor-Controller. The Auditor shall pay
the certified amount within 30 days of receiving the certified invoice.
c. The parties agree that CONTRACTOR shall not bill or charge any other party or
entity including, without limitation, the Medicare program or any other third party payor,
for contractual services. To the extent permitted by law, Hospital shall be solely
responsible for billing and collecting fees and charges from patients, payers or other
responsible third parties for any professional services performed by CONTRACTOR
under this Agreement.
6. The term of thus Agreement shall commence on July 1, 2006 through June 30, 2007.
However, either party to this Agreement may terminate the Agreement without cause at
any time by giving the other party hereto written notice, as specified above, of such
termination at least thirty 30) days prior to said termination.
7. In the performance of the work, duties and obligations devolving upon Contractor, it is
mutually understood and agreed that the above parties are at all times acting and
performing as independent CONTRACTOR practicing their profession of Speech
Pathologist, and nothing in this Agreement shall be construed to create among County,
Hospital and CONTRACTOR an employer/employee relationship, a joint venture
relationship, or a lease or landlord/tenant relationship. Without limiting the foregoing, no
offer or obligation of permanent employment'with the County or with any department or
agency of the County is intended or implied in any manner by this Agreement.
CONTRACTOR and its employees or agents, shall not become entitled by virtue of this
Agreement, to any form or type of employee fringe benefits whatsoever, including but
not limited to, workers compensation, unemployment compensation or insurance,
vacation pay, annual leave, sick leave, overtime pay, Public Employee Retirement
System H'ERS") retirement benefits, social security benefits, disability insurance
benefits, or any other employee benefits.
Neither County nor Hospital shall have or exercise any control or direction over the
methods by which CONTRACTOR. shall perform its work and functions. The sole
interest of County and Hospital is to assure that the Service and the clinic is operated in a
competent, efficient and satisfactory manner, and that all applicable provisions or law and
other rules and regulations of any and all governmental authorities relating to licensure,
accreditation and regulation of allied professional staff and hospitals and to the operation
of the Service and the Office shall be fully complied with by all parties hereto.
8. CONTRACTOR shall be solely liable for and obligated to pay directly all applicable
taxes, including, but not limited to, Federal and State income taxes, social security
withholding FICA"), state disability and unemployment insurance. In connection
therewith, CONTRACTOR shall indemnify and hold County harmless from any and all
liability, including interest and penalties, which County may incur because of
CONTRACTOR's failure to pay such taxes.
BIB]
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AGREEMENT-U02
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5/3/2010-U011
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2010-U012
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TERM-U012
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2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�9. No offer or obligation of permanent employment with the particular County department
or agency or with the County is intended or implied in any manner by this contractual
agreement. CONTRACTOR shall not become entitled, by virtue of this Agreement to any
form of benefits whatever such as, e.g. workers' compensation, retirement, health care,
unemployment and/or disability), other than those specifically set forth herein.
10. Professional and Provider Services. For purposes of this Agreement, Contractor's
professional services shall constitute professional services" which are outlined and fully
described in Exhibit B," attached hereto and by reference made a part of this
Agreement.
11. Insurance. CONTRACTOR and County each acknowledge that appropriate professional
liability insurance will be provided by the CONTRACTOR as shown in Exhibit A,"
which is attached hereto and made a part of this Agreement by this reference.
12. Indemnification. CONTRACTOR agrees to indemnify and hold the County harmless in
the manner and to the extent set forth in Exhibit A," which is attached hereto and
incorporated herein by this reference.
13. CONTRACTOR agrees for a period of four 4) years after furnishing services herein to
make available, upon written request, to the Secretary of Health and Human Services, the
Comptroller General of the United States, or to any of their duly authorized
representatives, copies of this Agreement, documents, records and other data necessary to
certify the nature and extent of costs incurred by County under this Agreement as
required under the Omnibus Reconciliation Act, or any other law.
14. All necessary supplies and equipment required will be provided by the County; however,
any specific supplies and/or equipment requested by CONTRACTOR for use at this
facility shall be referred to the Product Standardization/Cost Containment Committee
prior to decision regarding purchase approval.
15. It is agreed and understood by the parties hereto that this Agreement has been arrived at
through negotiation and that neither party is to be deemed the party which prepared this
agreement within the meaning of Civil Code Section 1654.
16. Notices to parties in connection with the Agreement shall be given in writing, in person,
or by regular mail addressed as follows:
COUNTY: CONTRACTOR:
Natividad Medical Center Jennifer D'Attilio
1441 Constitution Blvd. 1760 Havana St.
Salinas, Ca. 93906 Seaside, Ca. 93955
17. This Agreement may be amended at any time by subsequent written mutual Agreement,
duly executed by both parties
BIB]
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5/3/2010-U011
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AGREEMENT - JENNIFER L. D ATT�p�IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the
dates set forth below.
COUNTY OF MONTEREY
By:
By:
CONTRACTOR
Date: 2006 Datel~~l 2006�
County ounseI's Office
By:
W. Allen Bidwell,
Deputy County Counsel
Date: 05-- 02-.20
RISK MANAGEMEN'I
COUNTY OF MONTEREY
APPROVED AS TO INDEMNITY/
INSURANCE LANGUAGE
Mike Derr
Purchasing Manager
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AI91095-U03
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5/14/2010-U04
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AGREEMENT - JENNIFER L. D ATT�p �EDIT A"
INSURANCE & INDEMNIFICATION PROVISIONS
1. INDEMNIFICATION. CONTRACTOR shall indemnify, defend, and hold harmless the
County, its officers, agents, and employees, from and against any and all claims, liabilities, and
losses whatsoever including damages to property and injuries to or death of persons, court costs,
and reasonable attorneys' fees) occurring or resulting to any and all persons, firms or
corporations furnishing or supplying work, services, materials, or supplies in connection with the
performance of this Agreement, and from any and all claims, liabilities, and losses occurring or
resulting to any person, firm, or corporation for damage, injury, or death arising out of or
connected with the CONTRACTOR's performance of this Agreement, unless such claims,
liabilities, or losses arise out of the sole negligence or willful misconduct of the County.
CONTRACTOR's performance" includes CONTRACTOR's action or inaction and the action
or inaction of CONTRACTOR's officers, employees, agents and subcontractors.
II. INSURANCE.
A. Insurance Coverage Requirements: Without limiting CONTRACTOR's duty to
indemnify, CONTRACTOR shall maintain in effect throughout the term of this Agreement a
policy or policies of insurance with the following minimum limits of liability:
1. Commercial general liability insurance, including but not limited to premises and
operations, including coverage for Bodily Injury and Property Damage, Personal Injury,
Contractual Liability, Broadform Property Damage, Independent Contractors, Products and
Completed Operations, with a combined single limit for Bodily Injury and Property Damage of
not less than $1,000,000 per occurrence.
Exemption/Modification Justification attached; subject to approval).
2. Business automobile liability insurance, covering all motor vehicles, including
owned, leased, non-owned, and hired vehicles, used in providing services under this Agreement,
with a combined single limit for Bodily Injury and Property Damage of not less than $500,000
edurrence.
xemption/Modification Justification attached; subject to approval).
Justification: Contractor is not required to use vehicle in performing services in the
contract. Contractor agrees to indemnify, defend and hold harmless, to the extent
provided by applicable law, the County, Hospital, their officers, trustees,
supervisors, employees and agents from and against any liability that accrues from
actions that are beyond the scope of contractual duties, as set forth in this
Agreement. Contractor will only be required to carry personal auto insurance at
traditional combined single limit of $300,000.
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AT-U012
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AN-U012
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AGREEMENT - JENNIFER L. D ATT�p
�3. Workers' Compensation Insurance, if CONTRACTOR employs others in the
performance of this Agreement, in accordance with California Labor Code section 3700 and with
Employer's Liability limits not less than $1,000,000 each person, $1,000,000 each accident and
$1,00,000 each disease.
Exemption/Modification Justification attached; subject to approval).
Justification: Contractor is not required to have Worker's Compensation insurance at this
time as she is not currently hiring any employees. Contractor will be required to provide
Worker's Compensation Insurance and required endorsements PRIOR to the hiring of
additional employees.
4. Professional liability insurance, if required for the professional services being
provided, e.g., those persons authorized by a license to engage in a business or profession
regulated by the California Business and Professions Code), in the amount of not less than
$1,000,000 per claim and $2,000,000 in the aggregate, to cover liability for malpractice or errors
or omissions made in the course of rendering professional services. If professional liability
insurance is written on a claims-made" basis rather than an occurrence basis, the
CONTRACTOR shall, upon the expiration or earlier termination of this Agreement, obtain
extended reporting coverage tail coverage") with the same liability limits. Any such tail
coverage shall continue for. at least three years following the expiration or earlier termination of
this Agreement.
Exemption/Modification Justification attached; subject to approval).
B. Other Insurance Requirements. All insurance required by this Agreement shall be
with a company acceptable to the County and issued and executed by an admitted insurer
authorized to transact Insurance business in the State of California. Unless otherwise specified by
this Agreement, all such insurance shall be written on an occurrence basis, or, if the policy is not
written on an occurrence basis, such policy with the coverage required herein shall continue in
effect for a period of three years following the date CONTRACTOR completes its performance
of services under this Agreement.
Each liability policy shall provide that the County shall be given notice in writing at least
thirty days in advance of any endorsed reduction in coverage or limit, cancellation, or intended
non-renewal thereof. Each policy shall provide coverage for CONTRACTOR and additional
insureds with respect to claims arising from each subcontractor, if any, performing work under
this Agreement, or be accompanied by a certificate of insurance from each subcontractor
showing each subcontractor has identical insurance coverage to the above requirements.
Commercial eneral liability and automobile liability policies shall provide an
endorsement naming the County of Monterey, its officers, agents, and employees as Additional
Insureds with respect to liability arising out of the CONTRACTOR'S work, including ongoing
and completed operations, and shall further provide that such insurance is primary insurance to
any insurance or self-insurance maintained by the County and that the insurance of the
Additional Insureds shall not be called upon to contribute to a loss covered by the
CONTRACTOR'S insurance. The required endorsement form for Commercial General Liability
Additional Insured is ISO Form CG 20 10 11-85 or CG 20 10 10 01 in tandem with CG 20 37
BIB]
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AI91095-U03
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C1-U03
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DOCUMENTS-U03
5/14/2010-U04
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AGREEMENT - JENNIFER L. D ATT�p
�1 0 01 2000). The required endorsement form for Automobile Additional Insured endorsement is
ISO Form CA 20 48 02 99.
Prior to the execution of this Agreement by the County, CONTRACTOR shall file
certificates of insurance with the County's contract administrator and County's
Contracts/Purchasing Division, showing that the CONTRACTOR has in effect the insurance
required by this Agreement. The CONTRACTOR shall file a new or amended certificate of
insurance within five calendar days after any change is made in any insurance policy that would
alter the information on the certificate then on file. Acceptance or approval of insurance shall in
no way modify or change the indemnification clause in this Agreement, which shall continue in
full force and effect.
CONTRACTOR shall at all times during the term of this Agreement maintain in force the
insurance coverage required under this Agreement and shall send, without demand by County,
annual certificates to County's Contract Administrator and County's Contracts/Purchasing
Division. If the certificate is not received by the expiration date, County shall notify
CONTRACTOR and CONTRACTOR shall have five calendar days to send in the certificate,
evidencing no lapse in coverage during the interim. Failure by CONTRACTOR to maintain
such insurance is a default of this Agreement that entitles County, at its sole discretion, to
terminate this Agreement immediately.
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AGREEMENT - JENNIFER L. D ATT�p
�EXTIIBIT 41399
SCOPE OF SERVICES
Among the results to be achieved are these key objectives:
1. Provide Bilingual Speech/Language Therapy.
2. Participate in Feeder Retraining Program.
3. Participate in Quality Assurance Program.
4. Participate in mandatory in-services.
5. Provision of adult and pediatric therapy materials i.e. toys, workbooks, etc.).
6. Provision of adult and pediatric tests and protocols.
7. Provision of the marketing of speech/language therapy services.
8. Provision of typing services for speech/language evaluations.
9. CONTRACTOR shall return phone calls left on answering machine by' MD. offices,
parents, adult patients, MCOE, schools, Head Start, and Elks regarding patient referrals.
10. CONTRACTOR shall make referrals to other Speech Therapy sources, including sending
copy of evaluation or physician's prescription if child is unable to be evaluated by
Natividad Medical Center Speech Therapist), as well as, a letter to Head Start, a SELPA
form to school district, and a phone call to Ellcs; Also, includes verifying correct school
district via a phone call(s).
11. CONTRACTOR shall be prepare charts.
12. CONTRACTOR shall send for written prescription from referring. physicians outside
Natividad Medical Center.
13. CONTRACTOR shall proofread and type, if necessary, evaluation reports, print required
number
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AGREEMENT - JENNIFER L. D ATT�p
�ACORD CERTIFICATE OF LIABILITY INSURANCE
TM DATE(MM/DD/YYY`)
03/25/2010
PRODUCER 831.624.1234 FAX 831.624.4605
Carmel Insurance Agency, Inc.
San Carlos 2 NW of 8th THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 6117
Carmel, CA 93921-6117
INSURERS AFFORDING COVERAGE
NAIC #
INSURED D'ATTILIO, JENNIFER INSURERA: Nationwide Mutual 3787
13250 MIDDLE CANYON RD INSURER B:
CARMEL VALLEY, CA 93924-9462 INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITH
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUE
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION:
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR DD'
NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE
DATE MM/DD POLICY EXPIRATION
DATE MM/DD LIMITS
GENERAL LIABILITY ACP7842191255 04/07/2010 04/07/2011 EACH OCCURRENCE
$ 11000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEIT
PR EMISES Ea occurrence) $ 100,00d
CLAIMS MADE M OCCUR MED EXP Any one person) $ 5,00(
A X PERSONAL & ADV INJURY $ 1,000,00(
GENERAL AGGREGATE $ 2,000,00(
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
X POLICY PRO-
JECT LOC
AUTOMOBILE LIABILITY ACP7842191255 04/07/2010 04/07/2011
COMBINED SINGLE LIMIT
$
ANY AUTO Ea accident) INCLUDE
ALL OWNED AUTOS BODILY INJURY
A
X SCHEDULED AUTOS Per person) $
X HIREDAUTOS
BODILY INJURY
X
NON-OWNED AUTOS
Per accident) $
PROPERTY DAMAGE
$
Per accident)
GARAGE LIABILITY EA ACCIDENT
AUTO ONLY-- $
F ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/ UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR D CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION W C STATU- H
EMPLOYERS' LIABILITY TORY LIMITS ER
ER
Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE LJ E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
Mandatory In NH) E.L. DISEASE EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
E COUNTY OF MONTEREY, ITS OFFICERS, AGENTS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED AS RESPECTS
NSURED'S ONGOING OPERATIONS. IT IS UNDERSTOOD THAT THIS INSURANCE IS PRIMARY AND ANY OTHER INSURANCE
MAINTAINED BY THE ADDITIONAL INSURED SHALL BE EXCESS ONLY AND NOT CONTRIBUTING WITH THIS INSURANCE IN
REGARDS TO ALL OPERATIONS AS PERTAINS TO THE NAMED INSURED.
CERTIFICATE HOLDER CANCELLATION
County of Monterey
Natividad Medical Center
Sid Cato
1441 Constitution Blvd.
Salinas, CA 93902
I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Matthew Little CIC LMR'
ACORD 25 2009/01) FAX: 755.6254 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
BIB]
40312-U01
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AS86994-U03
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AI91095-U03
DO91368-U03
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DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
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EXECUTE-U07
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NO.-U07
4-U07
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960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
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$711,000-U012
AN-U012
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$255,000)-U012
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1,-U012
2010-U012
EXTENDING-U012
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JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Pax Sant by 1894 62#4685 COMM 7NSURANOO 84-B7-B6 is Ila ft; 9,04
QOMI~ERctal. CO ERAGE cO M ROIAL GENERAL LIABILITY
POLICY. PLEASE I rr CAREFULLY.
THIS ENDORSEWMT.CHANGES Tfl
POLICY AMENDMENT ADDITIONAL INSURED OWNERS,
lea7Cb7(> s)
SCHEDULE
NAME OF PERSON OR ORGANIZATION: MM 00 MM 01 MQ XT v CE30, AG 1
AND NI F Y90. IT 1.8 1INDEABT00D MW T 7110 INb'D',(NCE x$ 11IZ Z AZ 0TUt
X T U ANOR %= BY T9 1DITIONATD INatmED SHLLX, I 0065 QNI A18 X OM.
CONTRtj[TTINt( WI='Mm3 YEgII:ROM IN BEGrAIWO TO ALL Mtdl'>:ION(g AS P k=Ifg TO
l Wwrmn II48C1It M
I
Prq acr Name:
NATIVIDAD MOAT, O
P 1 41
t
rnjaa
cn,
7kf 1 ODN9TITUTXCN ELVD,) SALLRAS, OA 93902
Ifno entry appears above, Jnforinatlon ragulradto oomp/ete.thla endor e1nenf will be ehOM7 In the Deolaraflorrs
is applloable to fhIs�endoreement
WFid 16 AN INSLIFtBD 9egfon DIY emohded o Ineluda n iuund to peipn ar arrAAut z dol%Ihnwn n the Sphedue1 but dny wNh retp.ot to beta
oroml se ee hrnmmd I In o0nne ijun w9hthe A1med maimed', anpoI gapa,CM
N reepeeb eeYetnpe prov-d~i by thle srtdorawment lv Ina parr an oro~nizagon ohovm in thi:olaeduM, gawniee dam-not ep01y to'ho0VUdan}+'to am
hmgtl4ytaT etlhr nomett Urovrt4
May UM. aft
A�?P78Q 1 X1.255
1Nt~URANCa CO f ANY
NA.~XO1IWIDIJ
INSURaD
1NN $'E D'M LIQ
EFF Q1'11
*�-7-Q6
PFIOOUOPR
OAKS TNa Asr0A J IQI, IND.
LESSEES OR CONTRACTORS
$CHLGUL.$D PER$�N OR
ORGANIZATION
I
CQ 70 67 03-88) Gflrit a Oopyrfphtad Mated*l of Inaw nav r?arvioaa Ofoe, Ina., 1934
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�
624 4605 CARMEL INSURANCE
Declaration Page 1 of 3
Company:
Unigard Insurance Company
Policy Number:
10065325
P%VQ4IL JVIJY
0010832
Named Insured: Agent:
Jennifer D'attilio & Anthony Herro Carmel Insurance Agency, Inc.
13250 Middle Canyon Rd PO Box 6117
Carmel Valley CA 93924 Carmel CA 93921
831) 624-1234
Policy period from 02/25/10 to 08/25/10
at 12:01 A.M. standard time at the
address of the named insured.
Coverage Part
A. Liability
Bodily Injury
Property Damage
B. Medical Payments
C. Uninsured Motorist
Bodily Injury
D. Damage To Your Auto
Other Than Collision
Transportation Expense
Collision
Additional Coverages:
Waiver of Collision Deductible
Limits of Liability
$100,000 each person
$300,000 each accident
$100,000 each accident
$ 5,000 limit
$100,000 each person
$300,000 each accident
actual cash value
minus deductible
x$20 per day/$600 maximum
actual cash value
minus deductible
Total premium by vehicle
Total premium for policy period
10:01:11 a.m. 03-26-2010
1 /3 139
UNIGARD
P.O. Box 90701
Bellevue, WA 98009
Renewal Declaration Issued on 01/22/10
replaces all prior declarations, if any, and with
policy provisions and endorsements, if any,
issued to form a part thereof completes this
Personal Auto Policy.
Coverage is provided only where a premiun
and a limit of liability is shown for the
coverage.
Vehicle Premiums
1 2
09 VOLK 08 TOYT
$178 $ 80
$112 $ 50
$ 18 $ 9
$110 $ 41
$ 93 $ 33
$250 ded $250 dad
included included
$ 286 $ 130
$500 ded $500 dad
10.0 10.0
THANK YOU FO CHOOSING UNIGARD FOR YOUR INSURANCE NEEDS.
100777O
120901 07-07
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
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ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
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TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Fax Server
3/25/2010 11:28:32 AM PAGE
2/003
Fax Server
CERTHOLDER COPY
STATE
CO MAENS AT ION
I N S U R A N C E
FUND
ISSUE DATE: 06-01-2009
NATIVIDAD HOSPITAL
PO BOX 81611
SALINAS CA 93912-1611
GROUP:
POLICY NUMBER: 1847499-2009
CERTIFICATE ID: 5
CERTIFICATE EXPIRES: 06-01-2010
06-01-2009/06-01-2010
NG
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
THORIZED REPRESENTATIVE-, PRESIDENT
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
EMPLOYER
JENNIFER D'OTTILIO MS CCC
13250 MIDDLE CANYON RD
CARMEL VALLEY CA 93924
NG
EM1,CN]
P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
NG
RE V.2 05i PRINTED 03-25-2010
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
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$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Aug. 27. 2008 1:53PM
MONTEREY COUNTY
VENDOR REGISTRATION FORM
RETURN THIS FORM TO,
Cuntrao(s Purchaatap Division 188 W. Ansel 3t4rd Floor 6aNnot CA 93901
PH 831) V88.490 FAX(031)7594261
BUSINE38 NAME
A-19
TAXPAYER IDENTIFICATION Fedmei b No or sod.l alw41y
mar Aplpeebl&NU~nb.r) 7 y 3
No. 1687 P. 3
HUSINE$S OROANIZlTION M Corporation
ICh.ckon. Mdtc$cw Preddent
me tnsbueeen.
eea.tay
Tc. Pr tdmt
Tnesurer
C3 Subeldtary of-
parent COMMA
0 Partnership
Porter Nems
BUSINESS LOCATION
Must be Cempf.ta&
Telephone No
PadnerNamw
$'3 2-29
PAYMIENT TERM S
BUSINESS TYPE Rela9
Check spp9 aWe boxer) C] Whcieaele
I DisUlbutor
C] MenuacUuer
LICENSES Conlgele(/ Ue.t No
Ol.cvanr.09.Md:
mat ouslhe.a
Mlnodty I Woman owned
VoWmtrewned
R4)!ed zrzM9 I
BIB]
40312-U01
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FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
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RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
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IN-U012
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TO-U012
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AN-U012
INCREASE-U012
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$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Aug. 27. 2008 1:54PM
MONTEREY COUNTY
VENDOR REGISTRATION FORM
RETURN THIS FORM TO.,
Cohtmote Purohaetng Division.188 K A11881 Stang Floor- Salinas % CA' 13901
PH(131)7$9-4M FAX(43f)704540
No. 1687 P. 4
Careltdfy examine the Vat of Commodltlee". LIat the DESCRIPTION and NUMERIC CODE of each camnrodlty
product &Ibr Service(:)) that you Wish to provide the cm*. See aliaehed Nat.)
Numeric Code ReseripUon
1 3 1
2 2
3 3
4 4
8 8
7 7
8 8
9 S
10 10
Use the spaces below for Commodities/ Merchandise oat Ilsled OR to dedN a commodity you have already selected
Please feel free to attach any additional Information you would Was us o have. Is Brochures, Una Cards, etc J
Daps
Vr) 1''Z Z 7/r i
R4vl,QV21400a 2
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AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
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DOCUMENTS-U03
5/14/2010-U04
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PURCHASING-U07
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5/3/2010-U011
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A-10748)-U012
JENNIFER-U012
L.-U012
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30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Aug. 27. 2008 1:54PM
W-9
ptov oateberebOT)
bseemna of Me T�rm.I
muaar MWW emrw
94
Request for Taxpayer
Identification Number and Certification
yew More to
cud ran awM"Oftet rat tram
Cheek pacepesh beet ImdMdtreuSsIe impd.la tbrporollan Pedn�raup
D t.4d id limity mpmq enter the lee otosagtcylbn p.dteegerdd.Nhy. 0aeorpoaOo P.psrb�Mbj
Ada u+ skin. and apt a
d slate red ZF code
cow oneov%glorol
Taxpayerlden
oetlon
t
No. 1687 P. 5
We Grin to iita
requester. Do not
Rana to time tae,
0 eaemh
sell
Requeefe?s nor" end d&ea ap4Pons4
& hr your TIN In the appropdals boot. The YIN provided trust metan the name Given on Una 1 to avoid
beckvp w hhoid4t4 For Indlv(duale. We Is your social security number sMM. However, fora resident
a( opr(eior or disagerdad amply s�� the part I instructions an nags 3 For other enddes. It Is
t
tle
a
SeaM eeoudtr number
I I
1
a
p
n
yaw employer AA1111oatlon numbs[ EIN) it you do not have a number. see Maw to gat a rhV an page 3 or
Note. It the account I. In morn than one nuns. Ras the chart on page 4 for guideline on whose
number to enter
Qe tNlcation
Under penat(i�s or pujwy. I certify lhaI
I The number shown on fhb form Is my correct taxpayer Idanttioetion number ef I am waving fora raanber tabs sued to me), and
t. 1 am not subject to backup withholding because: a) lam exempt lentil backup withholdng, or(b) I have not been notMed b the Intemel
Revenue eafte ORS) that I and subject to backup wI hholdbt9 as a result or a failure to report all Interest or dividends, or a)j the IRS hit
nottted me that i am no longat subject to backup withholding, and
3. 1 sm a U 9 a-gxen or other U S, person dsDflW beIow~
Cergftcatlon Inelrucltona. You must cross ail Item a aboVo K you have been notified by the IRS that you eta ewnahpy subject to backup
withholding because you have fatted to report in Interest and dividends on your tax retum For reel estate Ireneaotlons. Item 2 does net sppty.
For mortgage IMrke�t paid, a lskbn ter abendonnwnt of e�eutad property, canatafon of debt, oenidbddfons to en lndMduti retirement
arrangement t M. end eaneratly, payments other than Interest and dnvldande. you are not required to sign the Cerftloadon, but you must
t TI
provide your correc
General Ins
Section reiereno6ara'lothe Internal Revenue Code unless
otherwise hated
Purpose of Form
A person who is required to fie an i 6ormallon return with the
IRS must obtain your correct taxpayer IdentUkallon number flN)
to report, for exempts, Income pal! to you, real estate
transactions, mortgage Interest ypou paid, acquisition or
abandonment of secured propmty. cancellation of debt. or
conlrlbutions you made to an Ii tAA
Use Farm W-9 only II you em a U B~pperson Gnctuding a
resident all to provide your correct TW to the person
requesting it the requester) and. when applicable, to:
1 Certtly that the TIN you are giving I. correct or you are
wpking for a number to be Ieeued).
2. Carey that you era not subject to backup withholding, or
3 Clain exemption from backup witiholdkmg U you are a U 8
exempt payee. X apppbcable, you ere also certifying that as a
U 8 Arson. your attmabie share of any partnership Income from
a U S trade or business Is not subject to the withholding lax an
foreign partners' shera of effectively connected income
Note. X e roltseter gives you a form other than Form W-9 to
request yyoouur TiN, you must use the requester`. form It it Is
aubsteMlNAr stmtar to him Form W-9
Def ninon of a U.S. parson. For federal tax pzrpoaes, you are
considered a U S person if you are:
An individual who Is a U B. citizen or U.S resident don.
o A partnership, norporatio company. or association created or
organized In the United States or under the laws of the United
states,
An sateta other thin a foreign estate), or
A domestic trust es defined In Regulations section
3017701.7)
Specrel rules for Partnerships. Partn�rshipa that conduct a
tirade or business In the United States are generally required to
pay a withholding tax on arty foreign partners' share of income
from such business Further. In ceerrteln oases where a Form W-9
his not boon received, a partnership Is required to presume trial
a partner Is a foreign person, and pay the withholding tax.
Therefore, K you are a U S person that is a partner In e
partnership conducting to trade or business in the United States.
dreg~d i d withholding on your share of partnership
Income
The person who gIvves town W-9 to the partnership tot
pthposee of eslablIs h(ng Ira U.S. statue and avoiding wltlsiotding
artne
o- n Its allocable thus of net income from the
conducting a trade or business in the United States Is in the
Mowing oases:
bite U S. owner of a disregarded entry and not the entity,
of idenlingallan
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�COUNTY OF MONTEREY
DETERMINATION OF
CONTRACTOR'S STATUS FORM
Department: / 9 t L le Contact: LI1W'( l4 i41
AOL.
l
Tit
e.
Phone:
Contractor: J Lte tft;t
Contact:
Title:
Phone:
b
Brief description of contract work: fib/ Xy73
Purpose of Form:
The purpose of this form is to determine for each proposed agreement or contract with a provider of
services, the exact nature of the relationship between the contractor and the County.
Department Certification:
I certify that the contractor providing these services is 1) a non-profit organization, a
partnership or a corporation, and 2) has two or more employees, and 3) the services of a
specific individual are not required to fulfill the contract. Therefore, an employment tax
status questionnaire is not required.
Date:
Department Representative
Title
I hereby certify that the answers to the following questions in the attached employment tax status
questionnaire accurately reflect the anticipated working relationship for this contract. After reviewing
the completed questionnaire, I have determined that:
Under the IRS/EDD rules, an employment relationship exists;
Contractor is properly classified an independent contractor.
Score:
out of possible 33 points IC))
Date:
Revised 01/29/08
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Departments are encouraged to discuss the need for each professional/personal services agreement with the
Personnel Division at the earliest possible point in time, in order to determine the appropriate means for
obtaining the services sought.
If the questionnaire determines that an employment relationship exists, and if the contractor disagrees with
this determination, the contractor may elect to submit a Form #SS-8 to the IRS. The IRS will then review the
facts and determine the proper employment tax status. If any payments become due before the County is
notified of the IRS determination, the individual will be deemed to be an employee and withholding
deductions will be made from those payments, pending notification of the determination.
If you have determined that under IRS/EDD rules, an employment relationship exists, the use of an
independent contractor for rendering this professional/personal service will not be allowed unless the IRS
reviews the Form #SS-8 and determines that the individual is an independent contractor.
Section I Contractor Information-
1. What is the legal status of the contractor? ndividual
Yartnership
If the expectation of the Department is that a particular individual will perform Incorporated
the work personally as opposed to having his/her partner or employees do the Other
work, we are really contracting with an individual, and the contract should be
written to reflect this relationship.
2. What is the contractor's Social Security Number SSN) or Taxpayer
Identification Number TIN)? SSN
Possession of a TIN does not necessarily mean that a contractor is a partnership s'3f// av
or corporation. It may only mean that the contractor has or has had employees.
If an individual owns a business as a sole proprietor, the contract must be either
with the individual or with the individual doing business as" the firm name.
Regardless of tax status, payments must be made to the individual and reported
to the IRS using the individual's Social Security Number not the Taxpayer
Identification Number).
3 4 A'` r T'F i~ i r 6. 3 l$h~' /'F{~' 3~
r 0511A.
fiction II Yhat is the nature of t e or 2
Y.,h 4
i
M4. Mi!12
g-g
UP-
VM. 2~W_-1ld: $v__ 12
15:i Vff
3. Are personal services of the contractor required?
o IC) 2 pts
If the expectation of the Department is that a particular individual will perform
the work personally as opposed to having his/her partner or employees do the
work, the answer is yes. This is a strong indicator that the contractor should
be treated as an employee for employment tax purposes.
If the contractor has the right to substitute other workers without prior
permission from the County, the answer is no. This is a strong indicator
that the contractor is an independent contractor.
4. Has the contractor been employed by the County to perform similar
services? o IC) 1 pt
If the contractor is a current or former employee of the County and work done as
an employee was similar to, even if not identical to, the contract services, the
answer is yes.
Page 2
20 Questions; Employment Tax Status Questionnaire
Revised 07/21/08 By: Kristen Aldrich
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�5. Do County employees perform similar work? s
No C) 2 pts
If the contract work is similar to work done now or in the past) by County
employees, the answer is yes.
If the contractor is doing work created by a vacant County position, extended
leaves or layoffs, the answer is es.
6. Are the contract services similar in nature to the normal operations of
the department? IC) 2 pts
An employee's services are usually integrated into the employer's operations. An
independent contractor's services are not usually related to the employer's
normal operations.
The more integrated the contractor is with the normal operations of the County, the
more likely the IRS would consider the contractor an employee.
Section III Does the contractor operateaa business
7. Does contractor offer services to the general public? o
Yes C)2pts
Offering services to the general public is a strong indicator of independent
contractor status.
For a small practitioner, consider the presence or absence of signs such as listings
in the yellow pages, other advertising, and the presence of business facilities such
as office; clinic or stores open to others.
8. Does the contractor work for others?
es 1 pt
If the contractor works only for the County, the answer is no.
If the contractor works for others, but only for one firm at a time, the answer is
no.
9. Does the contractor have a risk of loss?
IC) l
t
If the contractor's business incurs revenues and expenses such that it could result p
e
in either profits or losses, the answer is yes.
If the contractor's business is primarily providing services to the County and the
contractor has no significant business expenses, the answer is no.
10. Does the contractor have a significant investment in his/her business?
Yes pts
If the contractor's business has offices, stores, clinics, etc. that are furnished and
equipped by the business not by the County) the answer is probably yes.
If the contractor provides his/her own tools or other equipment, the answer is
probably yes.
If the contractor normally incurs regular business expenses such as rent,
depreciation, and liability insurance, the answer is probably yes.
Note that investment in education is not considered in this factor.
Page 3
20 Questions; Employment Tax Status Questionnaire
Revised 07/21/08 By: Kristen Aldrich
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Section IV- ffWat control does the=:County rave overwork
performed?
11. Does the County have the right to control the way in which the work
will be done? C) 3 pts
If the contractor is subject to possible County control over methods and
procedures, even if the control is not exercised, the answer is yes. This right to
control is considered a very strong indicator that the contractor is an employee for
employment tax purposes.
If the County can only ensure that a result conforms to the agreed-upon contract
specifications and cannot control how the result is achieved, the answer is no.
If the County can specify the sequence of steps or the methods and procedures to
be used to generate results, the answer is yes.
If the County can direct the contractor to do a variety of jobs that differ from the
primary activity, the answer is probably yes.
12. Will the contract work be done on County premises? es
No IC) 1 pt
Working on site in County facilities whether owned, leased, or otherwise
operated by the Coun is indicative of employee status.
13. Will the County control when the contractor will work?
I 1p
If the contractor is expected to work specific hours, whether itemized in the
contract or not the answer is es.
14. Will the County provide staff support to the contractor includes Yes
clerical, technical, professional, or similar help)? No IC) 2 pts
If the contractor hires his/her own assistants and pays them from his/her own
resources, the answer is no.
An independent contractor should perform all duties required of the job from
beginning to end without any direction or assistance from the County.
Integration of the contractor into the County's operations could create a level of
control over the contractor's performance, which is indicative of an
employer/employee relationship. If County employees do typing, develop forms,
write computer programs, or provide other similar assistance to the contractor,
the answer is yes.
15. Will the County provide or pay for training for the contractor?
If the County provides internal training other than rudimentary orientation, the
answer is probably yes.
If the County pays for external training such as seminars, college courses, or
conferences, which will teach the contractor how to perform the contracted
services, the answer is yes.
Seminars or conferences which are attended on behalf of the County or which will
enhance the contractor's performance are NOT considered how-to" training.
Page 4
20 Questions; Employment Tax Status Questionnaire
Revised 07/21/08 By. Kristen Aldrich
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�16. Will the contractor provide training or supervision to County a
employees? o IC) 1 pt
If the contractor is providing routine supervision to County employees, the
answer is yes.
If County employees report to the contractor, the answer is yes.
17. Will the contractor be responsible for making decisions to hire or fire a
County employees? No C) 2 pts
If the contractor has the power to hire, fire, evaluate or direct the activities of
County employees, the answer is yes.
18. Will the contractor provide regular reports to the County? Yes
No IC) 1 pt
If the individual attends regular staff meetings, the answer is probably yes.
If the individual makes regular reports, either written or oral, to the County, the
answer is probably yes.
If the contractor's only reports are progress reports on specific jobs or projects,
the answer is no.
Section V- TCVhat"ls:the tame frarrce.of the contract?
did
19. Is the relationship between the County and the contractor intended to Yes
be ongoing? No IC) 2 pts
If the contract is for a specific job or project, the answer is no.
If the intent of department is to renew a contract after it has expired, or if the
department has previously renewed a contract for essentially the same services
with the contractor, the answer is es.
20. Is there an expectation that the contractor will work for a specific Y
number of hours, days, or weeks? o l pt
If the intent of the department is to arrange specific work schedule with the
contractor, the answer is yes. This is a strong indicator of employment status.
If the department will rely on the contractor to staff an office or clinic, the
answer is yes.
21. Does the contract provide for termination without cause?
1 p
The IRS considers the right to terminate at will, by either party, an indication of
T
employer-employee relationship. For the contractor, if the right to terminate the I
relationship with the County exists without the contractor incurring any liability,
such a right indicates that an employer/employee relationship exists. If an
independent contractor terminates the relationship with the County, the
contractor has likely breached the contract with the County and the County may
be entitled to damages.
Page 5
20 Questions; Employment Tax Status Questionnaire
Revised 07/21/08 By: Kristen Aldrich
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012
AGREEMENT - JENNIFER L. D ATT�p�Section 17 How will the contractor be paid?
22. Will the contractor be paid by a time period such as bi-weekly or s
monthly?
No C) 1 pt
If the contractor will be paid based on time periods such as hour, day, week, or
month, the answer is yes.
Contractors that are truly independent are generally paid by the job, not by time.
Payment by the job can include periodic payments based on a percentage of the
job completed. Payment can be based on the number of hours needed to do the job
times a fixed hourly rate; however, the contract maximum must remain fixed. If
it takes more hours than anticipated to complete the contract, the contractor
could not receive any additional payment for those hours.
28. Will the contractor report time worked to the County? Yes
No IC) 1 pt
Even if not used to control pay, reporting time is an indicator of employment
status. If the contractor reports time worked to the County, the answer is yes.
24. Will the contractor bill the County for normal business expenses?
o(I lpt
Billing for overhead costs such as meals, clothing, transportation, rent, and
insurance indicates status as an employee.
An independent contractor generally includes these overheads as part of costs to
be covered when developing fee schedules.
25. Does the County provide any benefits" to the contractor?
o(I 1pt
If the County provides any leave periods similar to vacation or sick time, the
answer is yes.
If the County provides any liability, disability, health, life, etc., insurance, to the
contractor unless the benefit results from some other relationship, such as the
relationship of the contractor's spouse to the County), the answer is yes.
Page 6
20 Questions; Employment Tax Status Questionnaire
Revised 07/21/08 By: Kristen Aldrich
BIB]
40312-U01
AGREEMENT-U02
U02
JENNIFER-U02
L.-U02
D-U02
ATTILIO-U02
MS-U02
LI21329-U03
FO21330-U03
FO85769-U03
FO86930-U03
MG86968-U03
AS86994-U03
AS86995-U03
AI91095-U03
DO91368-U03
C1-U03
GENERAL-U03
DOCUMENTS-U03
5/14/2010-U04
RIVASR-U04
14953-U05
3-U06
AUTHORIZE-U07
PURCHASING-U07
MANAGER-U07
NATIVIDAD-U07
MEDICAL-U07
CENTER-U07
NMC)-U07
TO-U07
EXECUTE-U07
AMENDMENT-U07
NO.-U07
4-U07
TO-U07
960-NMC-U08
RUIZ-IGNACIO-U09
MAEGAN-U09
RUIZ-IGNACIOM-U10
5/3/2010-U011
AGREEMENT-U012
A-10748)-U012
JENNIFER-U012
L.-U012
D-U012
ATTILIO-U012
MS-U012
SPEECH-U012
LANGUAGE-U012
PATHOLOGY-U012
SERVICES-U012
AT-U012
NMC-U012
IN-U012
AN-U012
AMOUNT-U012
TO-U012
EXCEED-U012
$711,000-U012
AN-U012
INCREASE-U012
OF-U012
$255,000)-U012
PERIOD-U012
APRIL-U012
1,-U012
2010-U012
EXTENDING-U012
TERM-U012
DATE-U012
TO-U012
JUNE-U012
30,-U012
2011.-U012