MARICOPA - NEW IGA - COFC - DI18-002178-CURRENT.PDF

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DEPARTMENT OF ECONOMIC SECURITY

Your Partner for A Steonger Arizona

KR18° 0728

INTERGOVERNMENTAL AGREEMENT (IGA)

Agreement between the Arizona Department of Economic Security ("ADES") and the Clerk of the Superior
Courtin and for Maricopa County ("the Clerk").

WHEREAS ADES is duly authorized to execute and administer contracts under A.R.S § 41-1954; and
Clerk is duly authorized to execute and administer contracts under A.R.S § 12-283; and

ADES and the Clerk are authorized by A.R.S, § 11-952 et seq. to enter into agreements for joint or cooperative
action to contract for the services specified in this Agreement.

The term of this Agreement shall begin on the date of July 1 2018'and shall end on September 30, 2023, unless
otherwise amended.

JHEREFORE, ADES and Glerk (the "Parties*) agree to abide by all the terms and conditions set forth In this
Agreement.

BY SIGNING THIS FORM ON BEHALF OF A PARTY, THE SIGNATORY CERTIFIES POSSESSING THE AUTHORITY TO BIND THE

PARTY TO THIS AGREEMENT.
FOR AND ON BEHALF OF THE ARIZONA "FOR AND ON BEHALF OF THE GLERK OF THE
DEPARTMENT OF ECONOMIC SECURITY: SUPERIOR COURT IN MARIGOPA COUNTY:
Sit (} = laa Ze —
Procurement <_<. 7 aah
Printed Name _ Printed MM
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itle By, ae
Date Date
Ot ‘ 8 - 002178
ADES Contract Number Contract Number

IN ACCORDANCE WITH A.R.S. § 11-952, THIS AGREEMENT IS IN APPROPRIATE FORM AND WITHIN THE
POWERS AND AUTHORITY GRANTED TO EAGH RESPECTIVE PUBLIC BODY,

RIZONA ATTORNEY GENERAL'S OFFICE

Assistant Attomey General Public Agency Legal Counsel

Date: A Ih Dolf Date:

Page - 7 ~of 20

°

OFFICE OF THE ARIZONA ATTORNEY GENERAL
MARK BRNOVICH

ATTORNGY GENERAL STATE GOVERNMENT DIVISION :
AGENCY COUNSEL SECTION :

Mar igppa Coumly sce TGA

rimmncovaninra AGREEMENT pemmawixarion

7 » KRI8~0728
Attorney General Contract No. which is an Agreement
between public agencies, has been reviewed pursuant to A.R.S. § 11-952 by the undersigned
Assistant Attorney General, who has determined that it is in the proper form and is within the
powers granted under the laws of the State of Arizona to those Parties to the Agreement

xepresented by the Attorney General,

Dated this "7 ia day of OD ne > 201%

MARK BRNOVICH
ATTORNEY GENERAL

S. Aha/\ VV fo gt ae

Assistant Mttomey General

4564921

4.0 ADES VisiON AND Mission STATEMENTS

1.1. ADES Vision: Opportunity, assistance and care for Arizonans In need,

4.2. | ADES Mission: The Arizona Department of Economic Security makes Arizona stronger by helping Arizonans
reach their potential through temporary assistance for those in need and care for the vulnerable.

2.0 PURPOSE OF AGREEMENT

24. The purpose of this agreement |s to establish responsibilities between the parties regarding Title IV-D
operations and other required functions, with regard to reimbursable chitd support activities.

3.0 DEFINITIONS

3.1. Arizona Tracking and! Location Automated System (ATLAS): The mainframe based statewide automated
system for IV-D child support cases,

3.2, Automated Clearing House (ACH): An electronic funds-transfer system run by the National Automated
Clearing House Association (NAGHA).

3.3, Business Day: Every official workday of the week. Typleally, these are the days between and including
Monday fo Friday excluding official Arizona State holidays as defined by DCSS Locations. The Clerk will
have "read only” access on its Columbus day holiday. :

Observed State holidays may be found at this site:
hitp‘//www.hr.az.gov/additionalpages/ad_state_holidays.asp

3.4. Business Hours: 8:00 a.m. to 5:00 p.m. All hours are Arizona Mountain Standard Time (MST)

3.5. Certified Public Expenditure Statement (CPES): A form to certify any public expenditure spent.

3.8, Child Support IV-D case: A case In which a state provides child support services as directed by the state or
tribal child support program that Is authorized by title iv-d of the social security act,

3.7. _Non-IV-D case: A child support order that is not being enforced by the State/tocal child support enforcement
(IV-D) agency,

3.8. Natlonal Automated Clearing House Association (NAGHA): The association that establishes the standards,

_tules, and procedures that enable financial institutions to exchange payments on a national basis. The
Electronic Funds Transfer and the child support Electronic Data Interchange formats are established by
NACHA. NACHA also establishes rules and procedures that govern use of the stored value cards

3.9. Support orders: include both child support and spousal maintenance orders. Support means the provision of
maintenance or subsistence and Includes medical Insurance coverage, or chase medical support, and
uncovered medical costs for the child, arrearages, interest on arrearages, past support, interest on past
support and reimbursement for expended public assistance. In a title IV-D, support includes spousal
maintenance that is included in the same order that directs child support.

4.0 SERVICE DESCRIPTION

44. The Clerk engages In court-related records management and financial services fo support the court in the
administration and processing for supportrelated proceedings in Superior Court. This includes the
management of Non IV-D support cases in ATLAS.

5.0 RESPONSIBILITIES
ADES and the Clerk agree as follaws:

The Clerk shall: .

5.1. GENERAL REQUIREMENTS

5.1.1, Forward all support payments, Including purge payments, to the Arizona Child Support Payment
Clearinghouse for posting within two (2) business days of receipt,

5.1.2. Ensure that County issued checks with multiple obligor payments are accompanied by a document
containing information necessary to post the payments accurately. The dacumented information shall
include at a minimum:

A. Obligor name, .

B. ATLAS case number, or court order number,

G. Amount paid,

D. Date payment received, and

E. Information on whether it is for a {V-D or Non-IV-D case.
4

Page 2 of 20

5.4.3,
6.1.4.
5, 1.6,

6.1.6.
6.1.7.

6.1.9,

Review, take action and initiate suspense requests to the State Disbursement Unit within ten (10) days for
final approval. . :
Adhere to United State Deparment of Health and Hunan Services and the Office of Child Support
Enforcement federal guidelines in the handling of collections held in suspense and undisbursed,
Be responsible for activating the court action pending recelpt ("R”) narrative on ATLAS for all Non-IV-D court
orders or filings requiring monies to be held based on a court order or a minute entry.
Be responsible for the removal of the “R” narrative In Non- [\V-D cases upon resolution of the court action.
Be responsible for all payments misapplied due to the action or Inaction of the Clerk and shail be the amount
equal fo any ADES’ loas. Prior to making a claim for reimbursement to the Clerk, ADES will Issue a letter to
the Custodial Parent that received the erroneous payment. {f the Custodial Parent does not return the
misapplied payment in full or make satisfactory payment arrangements within thirty (30) calendar days,
ADES will invoice the Clerk for the uncollected portion. The Clerk shall have thirty (80) calendar days to pay
or to challenge the Invoice by sending an email to DCSSPIE@azdes.gov. lf ADES recovers any amounts
from the Custodial Parent after the Clerk has pald the invoice, ADES will refund the money to the Clerk.
Ensure all debts for all Non-}V-D cases have accurate and defensible balances. The Clerk shall:

A. Make any changes to the debts screens In ATLAS for Non IV-D cases. Debts sereens include DELN,

DEDN, SUOD and SUCL.

B, Make any debt adjustments or payment adjustmanis in ATLAS. Debt and payment adjustment ATLAS

screens include DARN, DEHA, DEDR, RNRE, SURE, SUPR and PAAR.
Perform all duties assigned pursuant to A.R.S. § 25-510 for Non IV-D cases including:

A. Load all new support orders in ATLAS ;

B. Modify order amounts In ATLAS

GC. Respond to payment inquiries

D. Research payment related issues

E, Release payments pursuant to orders of the court

6.1.40. Update and maintain demographic and new employer information for the partles in ATLAS pursuant to

ARS. § 25-510(C).

6.1.14. Accept child support payments at each courthouse facility, The Clerk may limit payment types (e.g. cash or

money orders), but must provide to the payor a reasonable method for making payments.

5.1.42. Accept checks made payable to the Arizona Child Support Payment Clearinghouse and forward the checks

to Clearinghouse for processing.

5.1.13. Complete ADES required forms and ATLAS security training before being assigned "log on” identifiers for

ATLAS. This applies to all Clerk staff assigned to IV-D Child Support:
A. J-125, Request for Terminal Access,
B. J-129, Affirmation Statement, :
C. CS$-189, Conflict of Interes/Confidentialily Statement,
D. State of Arizona Access Agreement Form,

6.1.14, Request the above electronic forms from ADES, complete the forms, and send electronically to

ISAADMIN: DES.GOV

5.1.45. Work all ATLAS suspense codes for the county's Non IV-D cases daily.

6.2,
5.2.4,

5.2.2,

6.2.3,

6.2.4.

OTHER REQUIREMENTS
The Clerk shall: .
Provide the Office of the Attorney General or the Office of an Arizona County Attorney operating a NV-D
program with electronic remote access to those records pursuant to Rules of the Supreme Court 123(g) for
all 1V-D case records if the Clerk maintains its court records electronically pursuant to the Rules of the
Supreme Court 94,
Minute entiles shall:
A. Include ATLAS numbers, If available,
B. Be delivered electronically; and
C. In 1V-D cases, endorse the Office of the Attorney General or the Office pf the County Attorney, not the
individual attorney.
In both IV-D and Non-IV D cases, in accordance with A.R.S. § 25-504(E), mail or fax all Income Withholding
Orders signed by the Court upon entry of a new or modified child support order or an Order to Stop Income
Withholding promptly unless the docurnent must be returned to the Judicial Officer for clarification.
Income Withholding Orders containing the Social Security Number of the Obligor shall not be transmitted by
electronic mail In accordance to A.R.S. § 44-4373(A)(3), Unless transmitted using a secure connection or

encryption.
Page 3 of 20

6.3.

§.3.1.
5.3.2.

63,3.

53.4,
5.3.5,

5.3.6.

6.3.7.

5.3.8.

5.3.9,

Make all appropriate ATLAS entries reflecting entry of support orders, orders of assignment or income
withholding orders promptly. Guidelines for what constitutes appropriate entries can be found in Exhiblt A,
which is attached hereto and incorporated herein by reference.

Shall not delete unpaid Clearinghouse fees in a case unless there is an explicit court order waiving the fees.
Provide information regarding the dates and case numbers of adoptions and termination of parental rights as
requested by ADES, County Attorneys or the Attorney General's Office so support orders may be stopped or
modified.

GUSTOMER SERVICE

The Clerk shalt:
Respond to ADES' Inquiries concerning support cases within two (2) business days.
Provide customer service for Non IV-D cases and access during regular business hours of 8:00 A.M, to 5:00
P.M., Monday through Friday, excluding holidays. Customer Service includes answerlng telephone calls,
serving walk-in customers, and returning telephone calls within one business day. The Clerk is solely
responsible for customer service Inquiries on its county caseload. These inquires include questions
regarding payments and distribution, debt balances, debt adjustments, and case status,
Shai) not direct customer telephone calls regarding Non- !V-D inquiries to ADES’ staff. Clerk staff shall,
within two (2)-business days, email the appropriate ADES email address with a request for information.
Send email addresses for these Inquiries to Clerk staff upon the execution of this Agreement.
Provide to ADES names of Non- IV-D customer service representatives to whom Inquiries and complaints
can be directed for Investigation and response to ADES upon execution of this Agreement.
Upon request by ADES, its agent the Office of the Attorney General operating a IV-D program, the Clerk
shall provide, free of charge, copies of case records [as defined by Rules of the Supreme Court
423(b)(16)(B)],, Records shalt be delivered or made accessible by mall, facsimile, or an electronically
scanned format, to the requesting party within five (5) calendar days of the request.
Provide certified copies of court documents to ADES within fifteen (15) calendar days of the request at no
charge when required. Copies requested by parties shall be provided in the same timely manner but the
Court may charge for copies as permitted by law.
Update ATLAS upon receipt of new information by close of business promptly, Changes include, but are not
limited to, names, addresses of the parties, telephone numbers, placement of the domestic violence.
indicator (NDI), job information, sources of Income, and Soclal Security numbers. The Clerk shall add alert
codes to the Case Activity List (CAAL) In ATLAS, upon processing all orders in Non-lV cases.
Requests to open cases in which a Notice of Change in Status is received shall be processed promptly.

5.3.10. Notify employers in writing, within five (5) business days, of the change in the case number. When the

status of the case Is changed from IV-D to Non IV-D. This is to ensure proper payment credit on an Income
Withholding Order.

6.3.11. Review these cases within thirty (30) business days of receipt of the report.
5.3.12. Submit a Cost Allocation Plan for the state fiscal year, and a Budget that includes incentive plan, Job

descriptions, projected Clerk expenditures for child support activities for review and approval. Thereafter, Ihe
Cost Allocation Plan and Budget shall be submitted, no later than, July 31" annually.

5.3.13. Submit updated Budget, within five (6) business days for review and approval, upon the Clerk's

6.4,

5.5.

5.6.

57.

5.7.1,
5.7.2,
5.7.3,

determination that the Clerk is goirig to exceed ADES approved budget amount
{solate Incentive payments Teceived from other funding and dedicate the use of such payments solely for the
enhancement of the Clerk’s IV-D program. Expenditure of incentive payments rust follow the requirements of
Section 7309 of the Deficit Reduction Act of 2005,
Shall pay ADES in an amount equal to the amount of the disallowance, if ADES conducts a financial audit and
disallows expenses reimbursed under this agreement.
Shall pay ADES an amount equal to any disallowance of expenses within 30 calendar days, if the Federal
Office of Child Support Enforcement conducts a financial audit and disallows the Clerk expenses already
reimbursed by ADES.

ADES will:

GENERAL REQUIREMENTS

Respond to email inquirles within two (2) business days
Be responsible for the removal of ihe “R” narrative on IV-D cases, :
Relmburse the Clerk for costs incurred in the delivery of contract services during the term of this Agreement.
Under this Agreement, the relmbursement rate shall be at the applicable amount established by the federal
government in accordance with 42 U.S. Code, Section 655(a)(2}. .

Page 4 of 20

5.7.4.

6.8,
5.8.1.

5.8.2,
5.8.3,

6.0

6.2.
6.3.

6.4,

Review and approve incentives based upon the methodology set forth in ADES' current Incentive policy that
is incorporated by reference into this Agreement. /
A. The incentive system for State child support programs measure State performance in five (5) areas:
Establishment of paternities;
Establishment of child support orders;
Collections on current child support due;
Collection on past child support due (arrears); and
Cost effectiveness.
Pay to the Clerk, as required by law, a proportionate share of Incentives at the end of each
quarter,
All planned incentive expenditures shail be reviewed and must be approved by ADES.

N SAsoNs

TRAINING:

ADES will: ,
Provide ATLAS training to the Clerk of the Court staff sufficient for the staff to comply with their duties under
this agreement. Within thirty (30) calendar days of contract award, the Clerk shall designate two (2) Subject
Matter Experts (SME) to be trained by ADES. Thereafter it shall be the responsibility of the SME in the Clerk
of the Court Office to train new personnel, as necessary, to become a SME.
Other training may be Identified and the price(s) shall be mutually agreed upon by the parties.
Provide one-time instruction to the designated employees from the Clerk at no charge. All training shall be
conducted in the Phoenix metro area. For Clerk staff who must travel, costs will be relmbursed by
submitting a claim on the Certified Public Expenditure Statement (CPES) for travel, lodging, and per diem, if
necessary. Reimbursement shall be in accordance with the State of Arizona Accounting Manual.

COMPENSATION FOR SERVIGE

Actual, allowable expenditures shall be determined in accordance with provisions of this agreement, and CFR
Title 45, Subtitle B, Chapter flf, Part 304,

Payment will be Issued within 30 business days from receipt of a correct CPES submittal; defined at 7.2.

‘The services set forth in this Agreement may be reimbursed only for matters brought in IV-D cases, and on
behalf of a judicial officer whe fs not a Judge of the court. Clerical, secretarial, court reporter staffing and court
interpreters shall be allowable expenses for a judicial officer or referee. This may-include clerical time for the
completion of minute entries mandated by court rule.

Under this agreement, the reimbursement rate shall be at the applicable amount established by the federal
government in accordance with 42 U.S, Cada, Section 655(a)(2).

REPORTING REQUIREMENTS
Provide to ADES the following reports referencing the contract number:
Submit monthly CPES and IV-D Compensation Form, Exhibit A with sufficient supporting expense

_ documentation Including employee time and récelpts for purchases.

7.5,

8.0
8.1.

8.2.
8.3,

Submit quarterly Sub Recipient Incentive Report, Exhibit B by the 5" business day of the quarter end.
The Clerk shail submit ail reports stectronically to:

Aslzona Department of Economic Security

Division of Child Support Services

Via email to: DGSSIGACIaims@azdes.gov
Other reports may be required by ADES through the Contract term.

PAYMENT REQUIREMENTS
The Clerk shall submit monthly a CPES and IV-D Compensation Form, Exhibit A, for costs incurred in the
delivery of Contracted Services.
The Clerk shall submit supporting expense documents each month with the CPES to support the expenses
each month.
CPES and IV-D Compensation Form shall be submitted no later than the 30th" day after the end of the
previous month in which services were provided and sent electronically to:

Arizona Department of Economic Security

Division of Child Support Services

Via email to: DCSSIGACIaims@azdes.gov

Page 5 of 20

84,

8.5,

9.0

9.2.

10.0
10.1,

12.0
424.

12.2,
12.3,
12.4,
72.5,
13.0
13.1,

14.0
44.1.

14.2,

Per Federal Register at 65 FR 82178, ADES, Federal auditors, central and regional office shall have the right
fo monitor the Clerks compliance with reinvestment requirement. Non-compliance could result in
disallowances of incentive amounts equal to the amount of funds supplanted, including closed cases with
State owned monies. Per Federal Register 65 FR 821678, non-compliance could result in disallowances of
incentive amount equal fo the amount of funds supplanted, Including closed cases with state owed monies.

Payments shail be paid via ACH by using the ACH process. Instructions and downloadable forms are found at

https://qa0.az.gow/sites/defautt/tiles/GAO-618%20ACH%20Vendar%20Authorization%20030215-S%26S. pdf

Notices
All notices to the Clerk regarding this agreement shall be sent to the following address
Glerk of the Superior Court of Maricopa County
ATTN: Ms. Kathleen McClaning, Deputy Director
Downtown Justice Center
Clerk of the Court «
820 West Jackson, Sulte 3017
Phoenix, AZ 85003

All notices fo ADES regarding this agreement shall be sent electronically to:
Arizona Department of Economic Security
Division of Child Support Services
Via email to: DOSSIGACIalns@azdes.gov

EXTENSION
This Agreement may be extended through a written amendment by mutual Agreement of the parties, but in no
event for a total periad that exceeds ten (10) years..

TERMINATION

This agreement may be terminated by mutual agreement of the parties at any time during the term of this
agreement.

€ach party shall have the right to terminate this agreement by written notice of termination to the other party at
least thirty (30) days prior to the effective date of sald termination. The other party shall provide written
acknowledgement of sald termination,

AMENDMENTS

This Agreement may be amended at any time by mutual written agreement. No agent, empfoyee or other
representative of elther Parly is empowered to alter any of the terms of the Agreement, unless amended in
writing and signed by the authorized representative of the respactive Parties.

Either party shall give written notice to the other party of any non-material alteration that affects the provisions
of this Agreement. Non-material alterations that do not require a written amendment are as follows:

Change of telephone number;

Change In authorized signatory; and/or

Change In the name and/or address of the person to whom notices are to be sent.

NIANNER OF FINANCING
These services are financed by an annual grant from the Department of Health and Human Services,
Administration for Children and Families.

DISPOSITION OF PROPERTY

If the Clerk is authorized to purchase equipment, it is to be iternized In the contract for utilization In the delivery
of contract services. if equipment is purchased as authorized by this contract, the Clerk shall maintain
complete and up-to-date inventory records for all Equipment purchased hereunder. Equipment specifically
designated within this contract, to be purchased in whole or part with ADES funds, shall be reported in
accordance with Department inventory policies and procedures.

ADES shail retain an equitable Interest equal to the purchase price paid, or fair estimate or appraisal of current
market value, whichever is greater, in all Equipment purchased under this contract, ADES shail be included
as a co-Insured on any insurance policy that covers Equipment purchased under this cantract.

Page 6 of 20

14.3,

14.4,
14.6.

15.0

15-4,

16.0

16.1.

17.0

471.

18.0

18.4.

19.0

19.1.

20.0

The Clerk shall not dispose of any Equipment purchased under this contract without the prior written consent
of ADES during and after the contract term. Such consent, if given, may include direction as ta the means of
disposition and the utilization of proceeds, including any necessary adjustments to the contract. _

Upon termination of this contract, any Equipment purchased under this contract shall be disposed of as
diracted by ADES and, if sold, ADES shalf be compensated in the amount of its equitable interest.

Under a fixed price contract, Section 13.1 through 13.4 do not apply unless specifically required by federal or
state law.

APPLICABLE LAW

This Agreement shall be governed and Interpreted by the laws of the State of Arizona. The materials and
services supplied under this Agreement shall comply with all applicable Federal, State and Jocal laws, and
each Party shall maintain all applicable licenses and permit requirements.

ARBITRATION

The Parties to this Agreement agree to resolve all disputes arising out of or relating to this Agreement through
arbitration, after exhausting applicable administrative review, to the extent required by AR.S.§§ 412-1618(B)
and 12-133, except as may be required by other applicable statutes.

Aunt

in accordance with AR.S. § 35-214, each Party shall retaln and shall contractually require each subcontractor
to retain all data, books and other records ("records") relating to this Agreement for a period of five (5) years
after the completion of the Agreement except if subject to Health Insurance Portability & Accountabillty Act
which Is six (6) years from the date of final payment, All records maintalned by a Party shall be subjact to
inspection and audit by the State at reasonable times, Upon request of a Party, the other Party shall produce
the original of any or all such records.

CONFLICT OF INTEREST

In accordance with AR.S, § 38-511, the State may within three years after executlon terminate the
Agreement, without penalty or further obligation, if any person significantly involved In iniliating, negotiating,
securing, drafting or creating the Agreement on behalf of either party, at any tme while the Agreement is In
effect, becomes an employee or agent of any other party to the Agreement in any capacily or a consultant to
any other party to the Agreement with respect to the matter of the Agreement.

E-VERIFY .
In accordance with A.R.S. § 41-4401, each Party warrants compliance with all Federal immigration laws and
regulations relating to employees and warrants its compliance with A.R.S. § 23-214, Subsection A.

INDEMNIFICATION: .
Each party (as "Indemnitor’) agrees to defend, indemnify, and hold harmless the other party (as "Indemnitea")
from and against any and all claims, losses, lability, costs, or expenses (including reasonable attorney's fees)
(hereinatter collectively referred to as “Clalms") arising out of bodily injury of any person (including death) or
property damage, but only to the extent that such Claims which result in vicarlaus/derivative fiability to the
Indernitee are caused by the act, omission, negligence, misconduct, or other fault of the Indermitor, its
officers, officials, agents, employees, or volunteers. The State of Arizona, Department of Economic Security Is
self-insured per A.R.S, 474-621.

In addition, should Maricopa Clerk of Court utilize a contractor(s) and subconiractor(s) the indemnification
clause betwean Maricopa County Clerk of Court and Its contractor(s) and subcontractor(s) shall Include the
following; : :

To the fullest extent permitted by law, Contractor shall defend, indemnify, and hold harmfess the Maricopa
County Clerk of Court and the State of Arizona, and any jurisdiction or agency Issuing any permits for any
work arising out of this Agreement, and its departments, agencies, boards, commissions, universities, officers,
officials, agents, and employees (hereinafter referred to as “Indemnitee") from and against any and all claims,
actions, liabilities, damages, losses, or expenses (including court costs, altorneys’ fees, and costs of clalm
processing, investigation and litigation) (hereinafter referred to as “Claims’) for bodily injury or personal injury
{including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in
whole or In part, by the negligent or wilful acts or omissions of the contractor or any of the directors, officers,

Page 7 of 20

20.1.

20.2.

20.3.

agents, or employees or subcontractors of such contractor, This indenmity includes any clalm or amount
arising out of or recovered under the Workers’ Compensation Law or arising out of the failure of such
contractor to conform to any federal, state or local law, statute, ordinance, rule, regulation or court decree. It is
the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely
from the negligent or wilful acts or omissions of the Indemnitee, be indemnified by such contractor from and
against any and all claims, It is agreed that such contractor will be responsible for primary loss investigation,
defense and judgment costs where thls indemnification is applicable. Additionally on all applicable insurance
policies, contractor and its subcontractors shai name the State of Adzona, and its departments, agencies,
boards, commissions, unlverstties, officers, officials, agents, and employees as an additional insured and also
include a waiver of subrogation in favor of the State.

INSURANCE REQUIREMENTS FOR GOVERNMENTAL PARTIES TO AN IGA

.¢ None

INSURANCE REQUIREMENTS FOR ANY CONTRACTORS USED BY A PARTY TO THE INTERGOVERNMENTAL AGREEMENT
(Note: this applies only to Contractors used by a governmental entily, not to the governmental entity itself.)
The insurance requirements herein are minimum requirements and in no way limit the Indemnity covenants
contained In the Intergovernmental Agreement. The State of Arizona in no way warrants that the minimum
liralts contained herein are sufficient to protect the governniental entity or Contractor from Jlabilitles that might
arise out of the performance of the work under this Contract by the Contractor, his agents, representatives,
employees or subcontractors, and Contractor and the governmental entity are free to purchase additional
insurance.

Vinimum SCoPE AND Limits OF INSURANCE
Contractor shall provide coverage with limits of liability not less than those stated below.

20.3.1. Commercial General Liability - Occurrence Form

Policy shail include bodily injury, property damage, and bread form contractual liability coverage.

* General Aggregate $2,000,000
e Products Completed Operations Aggregate $4,000,000
» Personal and Advertising injury $1,000,000
» Damage to Rented Premises $ §0,000
e Each Occurrence $1,000,000

i} The policy shall be endorsed, as required by this written agreement, to include the State of
Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees as additional insureds with respect to liability arising out of the activities
performed by or on behalf of the Contractor.

i.) Policy shall contain a waiver of subrogation endorsement, as required by this written agreement,
in favor of the State of Arizona, and Its departments, agencies, boards, commissions, universities,
officers, officials, agents, and employees for losses arising from work performed by or on bahalf of
the Contractor. ‘

(Note that the other governmental entily{ies) is/are also required to be additional insured(s) and
they should supply the Contractor with their own list of persons to be insured.)

20.3.2, Business Automoblle Liability

Bodily Injury and Property Damage for any owned, hired, and/or non-owned automobiles used in the
performance of this Contract,

* Combined Single Limit (CSL) $1,000,000

1.) Policy shall be endorsed, as required by this written agreement, fo include the State of Arizona,
and its departments, agencies, boards, comraissions, unlversities, officers, officials, agents, and
employees as additional insureds with respect to Hlability arising out of the activities performed by,
or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the
Contractor. :

1.) Policy shall contain a waiver of subrogation endorsement as required by this written agreement in
favor of the State of Arizona, and its departments, agencies, boards, commissions, universilles,

Page 8 of 20

20.3.3, Workers’ Compensation and Employers’ Liability

20.4.

officers, officials, agants, and employees for losses arising from work performed by or on behalf of

the Contractor.
(Note that the other governmental entity(ies) is/are also required to be additional insured(s) and
they should stipply the Contractor with their own list of persons to be insured.)

Workers’ Compensation Statutory
Employers’ Liability

» Each Accident $1,000,000
e Disease ~ Each Employee $1,000,000
» Dlsease — Policy Limit $1,000,000

i.) Policy shall contain a waiver of subrogation endorsement, as required by this written agreement,
in favor of the State of Arizona, and its departments, agencles, boards, commissions, universities,
officers, officials, agents, and employees for losses arising from work performed by or on behaif of
the Contractor.

ii.) This requirement shall not apply to each Contractor or subcontractor that is exempt under A.R.S. §
23-901, and when such Contractor or subcontractor executes the appropriate walver form (Sole
Proprietor or Indepandent Contractor).

ADDITIONAL INSURANCE REQUIREMENTS
The policies shail include, or be endorsed to Inchide, as required by this written agreement, the following
provisions:

20.4.1, The Contractor's policies, as applicable, shall stipulate that the insurance afforded the Contractor shall be

primary and that any insurance carried by the Department, its agents, officials, employees or the State of
Arizona shall be excess and not contributory insurance, as provided by A.R.S. § 44-621 (E).

20.4.2. Insurance provided by the Conttactor shall not limit the Contractor’s liability assumed under the

20.5.

20.8,

20.7.

Indemnification provisions of this Contract.

Notice OF GANGELLATION

Applicable to all insurance policies required within the Insurance Requirements of this Contract, Contractor's
Insurance shall not be permitted to expire, be suspended, be canceled, or be materially changed for any
reason without thirly (30) days prior written notice fo the State of Arizona. Within two (2) business days of
recelpt, Contractor must provide notice fo the State of Arizona if they receive nolice of a policy that has been
or will be suspended, canceled, materially changed for any reason, has expired, or will be expiring. Such
notice shall be sent directly to the Department and shall be malled, emailed, hand delivered or sent by
facsimile transmission to (State Representative's Name, Address & Fax Number).

ACCEPTABILITY OF INSURERS

Contractor's Insurance shall be placed with companies licensed in the State of Arizona or hold approved non-
admitted status on the Arizona Department of Insurance List of Qualified Unauthorized Insurers. Insurers shall
have an "A.M. Best’ rating of not less than A- VII. The State of Arizona in no way warrants that the above-
required minimum insurer rating is sufficient to protect the Contractor from potential insurer insolvency.

VERIFICATION OF COVERAGE

Contractor shail furnish the State of Arizona with cerlificates of insurance (valid ACORD form or equivalent
approved by the State of Arizona) evidencing that Contractor has the insurance as required by this Contract.
An authorized representative of the insurer shall sign the certificates.

20.7.1. All such certificates of insurance and policy endorsements must be recelved by the State before work

commences. The State's receipt of any certiffcates of insurance or policy endorsements that do not comply
with this weltten agreement shall not walve or otherwise affect the requirements of this agreement.

20,7.2. Each Insurance policy required by this Contract must be in effect at, or prior to, commencement of work

under this Contract. Failure to maintain the insurance policies as required by this Contract, or to provide
evidence of renewal, Is-a material breach of contract.

20.7.3. All certificates required by this Contract shall be sent directly to the Department, The State of Arizona

20.8.

project/contract number and project description shall be noted on the certificate of insurance. The State of
Arizona reserves the right to require complete copies of all insurance policies required by this Contract at
any time, .

SUBCONTRACTORS .
Page 9 of 20

20.9.

Contractor's certificate(s) shall include all subcontractors as insureds under its policies or Contractor shall be
responsible for ensuring and/or verifying that all subcontractors have valid and collectable insurance as
evidenced by the certificates of insurance and endorsements for each subcontractor. All coverages for
subcontractors shall be subject to the minimum Insurance Requirements Identified above. The Department
reserves the right to require, at any time throughout the life of the Contract, proof from the Contractor that its
subcontractors have the required coverage.

APPROVAL AND MODIFICATIONS

The Gontracting Agency, in consultation with State Risk, reserves the right to review or make modifications to
the insurance limits, required coverages, or endorsements throughout the life of this contract, as deemed
necessary. Such action will not require a formal Contract amendment, but may be made by administrative
action. ,

20.10, EXCEPTIONS

22.0
22.1.

23.0
23.1.

23.2,

24.0

28.0
25.1.
25.2.
26.3,

26.0
26.1.
26.2.
26.3,
26.4,

27.0

27.4.

In the event the Contractor or subcontractor(s) is/are a public entity, then the Insurance Requirements shall
not apply. Such public entity shall provide 4 certificate of self-insurance. If the Contractor or subcontractor(s)
isfare a State of Arizona agency, board, commission, or university, none of the above shall apply.

IT 808 ComPLIANCE

Unless specifically authorized in the Agreement, any electronic or information technology offered to the State
of Atizona under thls agreement shall comply with A.R.S. §§ 18-131 and 132 and Section 508 of the
Rehabilitation Act of 1973, which requires that employees and members of the public shall have access to and
use of Information technology that Is comparable to the access and use by employees and members of the
public who are not individuals with disabilltles.

NON-AVAILABILITY OF FUNDS

in accordance with A.R.S. § 35-154, every payment obligation of the State under the Agreement is conditioned
upon the availability of funds appropriated or allocated for payment of such obligation. If funds are not
allocated and available for the continuance of this Agreement, this Agreement may be terminated by the State
at the end of the period for which funds are avallable. No liability shall accrue to the State in the event this
provision is exercised, and the State shall not be obligated or liable for any future payments or for any
damages as a result of termination under this paragraph,

NON-DISCRIMINATION
Each Party shall comply with State Executive Order No. 2009-09 and ail other applicable Federal and State
Jaws, rules and regulations, including the Americans with Disabilities Act,

Not apply to indirect or ‘overhead! services, redundant back-up services or services that are incidental to the
performance of the Agreement. This provision applies to work performed by subcontractor at all tiers,

THIRD- PARTY ANTITRUST VIOLATIONS
A. The Clerk assigns to ADES any claim for overcharges resulting from antitrust violations concerning
materials or services supplied by third parties to the Clerk, toward fulfillment of this Agreement.

ATTACHMENTS

The following list of attachments constitutes an Integral part of subject agreement:
Attachment 1- Certification Regarding Maintenance of Effort

Attachment 2 - Certification Regarding Lobbying

Exuisits

The following list of exhibits constitutes an integral part of subject agreement:

Exhibit A - Certified Public Expenditure Statement (CPES) CS-016-FF and IV-D Compensation Form
Exhibit B - Sub Recipient Incentive Report

Exhibit C ~ Sub Recipient Fact Sheet

GONFIDENTIALITY
Each Party shall observe and abide by all applicable State and federal statutes, rules and regulations
regarding the use or disclosure of information including, but not limited to, information conceming applicants

Page 10 of 20
>

27.2.

28.0

28.1.

29.0

29.1.

30.0

31.0

for and recipients of contract services. To the extent permitted by law, the Clerk shail release information to
ADES and to the Attorney General's Office as required by the terms of this Agreement, by law or upon their
request

The Clerk shall comply with the requirements of Arizona Address Confidentiallty Program, ARS, § 44-161 et.
seg. ADES will advise the Clerk as to applicable polices and procedures ADES has adopted for such
compliance.

DATA SHARING AGREEMENT |

When determined by ADES that sharing of confidential data will occur with the Clerk, the Clerk shall comptete
ADES Data Sharing Request Agreement and submit the completed Agreement to ADES Program Designated
Staif prior fo any work commencing or data shared. A separate Data Sharing Request Agreement shail be
required between the Clerk and each ADES Program sharing confidential data.

SAFEGUARDING OF TAX INFORMATION PER IRS PUBLICATION 1075
The judicial officer and ADES agree to corply with all federal statutory and regulatory provisions requiring that

‘Information be safeguarded and kept confidential. These statutes and regulations include, but are not limited

to, 45 CFR § 309.80; 45 GFR §303.21 (Safeguarding information); 45 CFR § 303.30 (Securing Medical
Support information); and the United States Internal Revenue Code (IRC) 6103.

PERFORMANCE

In performance of this contract, the Clerk and ADES agree to comply with and assume responsibility for
compliance by his or her employees with the following requirements:

All work will be done under the supervision of the judicial officer, the Clerk officer's employees or the ADES.or
the ADES employees:

Any return or return Information made available in any format shall be used only for the purpose of carrying out
the provisions of this contract. Information contained in such material will be treated as confidential and will not
be divulged or made known in any manner fo any person except as may be necessary in the performance of

this contract. Disclosure to anyone other than an officer or employee of the Clerk and ADES will be prohibited.

All returns and return information will be accounted for upon receipt and properly stored before, during, and
after processing. In addition, all related output will be given the same level of protection as required for the
source material.

The Clerk and ADES certify that the data processed during the performance of this contract will be completely
purged from all data storage components of his or her computer facility, and no output will be retained by the
Clerk and ADES at the time the work Is completed. If Immediate purging of all data storage components Is not
possible, the Judiclal officer and ADES certify that any IRS data remaining in any storage component will be
safeguarded to prevent unauthorized disclosures. .

Any spollage or any intermediate hard copy printout that may result during the processing of IRS data will be
given to the agency or his or her designee. When this is not possible, the judiclal officer and ADES will be
responsible for ihe destruction of the spollage or any intermediate hard copy printouts, and will provide the
agency or his or her designge with a statement containing the date of destruction, description of material
destroyed, and the method used.

Ail computer systems processing, storing, or transmitting Federal tax information must meet the requirements
defined in IRS Publication 1075. To meet functional and assurance requirements, the security features of the
environment must provide for the managerial, operational, and technical controls. All security features must be
available and activated to pratect against unauthorized use of and access to Federal tax Information.

No work Involving Federal tax information furnished under this contract will be subcontracted without prior
wilten approval of the IRS.

The Clerk and ADES will maintain a [Ist of employees authorized access. Such list will be provided to the
agency and, upon request, to the IRS reviewing office.

CRININALICIVIL SANCTIONS:

Each officer or employee of any person to whom returns or return information Is or may be disclosed will be
notified in wilting by such person that returns or return information disclosed to such officer or employee can
ba used only for a purpose and to the extent authorized herein, and that further disclosure of any such returns
or return information for a purpose or to an extent unauthorized herein constitutes a felony punishable upon
conviction by a fine of as much as $5,000 or imprisonment for as long as 5 years, or both, together with the
costs of prosecution. Such person shall also notify each such officer and employee that any such unauthorized
further disclosure of returns or return information may also result in an award of civil damages against the

Page 11 of 20

32.0

33.0

33.0

within

officer or employee in an amount not less than $1,000 with respect to each instance of unauthorized
disclosure. These penalties are prescribed by IRC sections 7213 and 7431 and set forth at 26 CFR
301.6103(n)-1. .

Each officer or employee of any person to whom retusns or return information js or may be disclosed shall be
notified in writing by such person that any return or return Information made avaliable in any format shal] be
used only for the purpose of carrying out the provisions of this contract. {nformation contained in such material
shail be treated as confidential and shall nat be divulged or rade known In any manner to any person except
as may be necessary in the performance of the contract. Inspection by or disclosure to anyone without an
official need to know constitutes a criminal misdemeanor punishable upon conviction by a fine of as much as
$41,000 or imprisonment for as ong as 1 year, or both, together with the costs of prosecution, Such person
shall also notify each such officer and employee that any such unauthorized inspection or disclosure of returns
or return information may also result in an award of civil damages against the officer or employee [United
States for Federal employees] in an amount equal to the sum of the greater of $1,000 for each act of
unauthorized inspection or disclosure with respect to which such defendant is found liable or the sum of the
actual damages sustained by the plaintlif as a result of such unauthorized inspection or disclosure plus in the
case of a willful Inspection or disclosure which Is the result of gross negligence, punitive damages, plus the
costs of the action. These penalties are prescribed by IRC section 7213A and 7431.

Additionally, it is incumbent upon the Judicial officer and ADES to Inform Its officers and employees of the
penaities for Improper disclosure imposed by the Privacy Act of 1974, 6 U.S.C, 552a. Specifically, 5 U.S.C.
562a(i(1), which Is made applicable to the Courts by 5 U.S.C. 652a (m)(1), provides that any officer or
employee of a the Court, who by virtue of his/her employment or official position, has possession of or access
to agency records which contain individually identiffable Information, the disclosure of which |s prohibited by
the Privacy Act or regulations established thereunder, and who knowing that disclosure of the specific materlat
is prohibited, willfully discloses the material in any manner to any person or agency not entitled to receive it,
shall be guilty of a misdemeanor and fined not more than $5,000. The agency will have the right to vold the
contract if either party fails to provide the safeguards described above,

INSPECTION .

The IRS and the ADES shall have the right fo send {ts officers and employees Into the offices and plants of
either party for inspection of the facilities and operations provided for the performance of any work under this
contract. On the basis of such Inspection, specific measures may be required in cases where elther party is
found to be noncompliant with contract safeguards.

SIGNATURES IN COUNTERPART
This agreement may be executed in any number of counterparts, each of which when executed and delivered
shall constitute a duplicate original, but all counterparts together shall coristitute a single agreement.

OFFSHORE PERFORMANCE OF WORK PROHIBITED

Due to security and identify protection concerns,’ direct services under this Agreement shall be performed
the borders of the United States. Any services that are desertbed in the specifications or scope of work that
directly serve the State of Arizona or Its clients and may Involve access to secure or sensitive data or personal
client data or development or modification of software for the State shail be performed within the borders of the
United States. Unless specifically stated otherwise in the specification, this detinition does not apply to indirect
or “overtiead” services, redundant back-up services or services that are incidental to the performance of the
Agreement. This provision applies to work performed by subcontractors at all tlers.

Page 12 of 20

ATTACHMENT 4

CERTIFICATION REGARDING MAINTENANCE OF EFFORT

In accordance with the applicable program statute(s) and regulation(s), the undersigned certifies
that financial assistance provided by the Administration for Children and Families, for the specified

activities to be performed under the Grants for Judicial Services by

_ Will be in addition to, and not in

ppheant Organization)
substitution for, comparable activities previously carried on without Federal assistance.

Signature of Authorized Certifying Official

Title

Date

Page 13 of 20

ATTAGHMENT 2
CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRASTS, GRANTS, LOANS,
AND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be pald, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.

(2) if any funds other than’ Federat appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress, an officer of employee of
Gongress, or an employee of a Member of Gongress In connection with this Federal contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report
Lobbying,” in accordance with its instructions.

(3) The undersigned shail require that the language of this certification be included In the award documents for all
sub-awards at all tlers (Including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) and that all subreciplents shall certify and disclose accordingly,

This certification is a materlal representation of fact upon which rellance was placed when this transaction was made
or entered inte. Submission of this certification Is a prerequisite for making or entering Into this transactlon imposed by
section 1352, title 31, U.S. Gode, Any person who falls to file the required certification shall be subject to a civil
penalty of not less than $10,000 and not more than $100,000 for each such failure.

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

APPLICANT ORGANIZATION DATE SUBMITTED

Page 14 of 20

EXHIBIT A
CERTIFIED PUBLIC EXPENDITURE STATEMENT OF (CPES} GS-018-FF
AND
1V-D COMPENSATION FORM

CS-O16-FF (2-08) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Support Enforcement Contract Adminislration COUNTY
PO Box 40458 ?Phosnlx, Arizona 85067
. REPORTED MONTH
CERTIFIED PUBLIC EXPENDITURES STATEMENT.
AGUAL EXPENDITURE FOR

C1 County Attorney Glerk of Suparior Courl C1 Sheriff Family Law Commissioner
PERSON'S HAME PREPARING THIS REPORT DATE PHONE HO,

- : EXPENDITURE
{. Personal Services ( Number of FTE)
2. Employee-Related Expenses (ERE) ( FICA, Unemployment fasurance, Warker's Compensation,
Relirament, Health, Life & Acefdent Insurance)
3, Professional and Guiside Services (Spectfy} $ ~
3, Travel Number of

A, Mileage Rate Miles 1B, Perdiam and Other |g - $ .
&. Space (Sunt of 6A, %B, and 5C}

A. Rent B.Uulttes $ ed C. Use Allowance $ $ +
1G. Equipment {Sum of 6A, 6B, and 6C) A, MaintenancafRepalr, Non-AOP $ $ -

B, From CS-016-A, Ling & $ G, From GS-016-8, lines § $ -
FF, Materials and Supplles (Sam of 7A, 7B, 7C, and 7D)

A. Supplies § ~  #B Postage $ - C.PAntng 90,00 b. Photocopying $ $ -
3, Operating Expenses ( Sum of BA, 88, 80, 8D, amd 6E)

A. Telephone $ D, Membership Duas $

B, Insvrance/Banding $ Name:

G, Other (Pagar} £, Subscriptions $
Office Suppiles: Tools. Softwara Misc Leases FUM Grovads:

$ $$ - § $ - $ $_- Name $ - $ + $ -
9. Indirect Costs { Enier lhe budgeted rate end the dollar amount of | the base to which this vale is applied)

Rate J Base; $ = 3 -
40. Total Expenditures $ -
"44 Lass Disallowance Per $ ~
#43. ALLOWABLE EXPENDITURES{ *47 AND 1210 be completed only by DGSE. I completed, fae

42 Is basis tor lina 14 below and for tine 4 of the CS-105-D)
13. TOTAU GREDITS (Sum of al feas collected)
Other ( Specify}
Handling Fees $ 4. $ -
2. $ -
Lab Fees 3 3. $ - $ -
14. NEY EXPENDITURES (Aliowvable Expenditures minus Tolal Credits} $ ~
6. Relmbursament Ralo, According to Conlract { Multiply) 66.00%
48, TOTAL REIMBURSEMENT AMOUNT DUE $ -
IGERTIFICATION: } certify, under penailtles of porury, that this Gertiled Public Expenditures Statement 46 CFR 04.30 {a}(2)0i)
has been examinad by me and, fo the bast of ny knowledge and bellef, itis a true, correct and valid dain against the Slate of
|Anzona, and paymont has not bean fecelved,
AGTHORIZED SIGNATURE PPLE DATE

ISSUE WARRANY PAYABLE TO

RAILING ADDRESS (No, Sireat or PO Box Na, City, Slate, ‘PY

Page 18 of 20

EXHIBIT A
I¥v-D COMPENSATION FORM

Name of Your Agency
Clerk of Court
Enter Month and Year
; TOTALCOMPENSATION ee ; {VD COMPENSATION

re Hourly Avalighle  Moathly . Total Wo Monthly "Total
Jab Tie fame Rate Hours Salary ERE tompensetion} Hours Salary ERE campensation

4

»

a

ti

<=

ay

z

Q

g

2

a

oO
“eg -

b

E

3

8

Fs

a

%

ci

F

TOTAL
Total FrE's

Page 16 of 20

EXHIBIT B
SUB RECIPIENT INCENTIVE REPORT

ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Child Support Services
1789 W Jefferson St, Phaentx, AZ 85007 MD 7217

SUB REGIPIENT INCENTIVE FORM

Sub Recipient (County) Name
Sub Recipient DUNS Number
Reporting Month

Incentive Fund Account Number

The purpose of this report is to provide information reyarding the use of each sub recipient's portion
of their incentive dollars, Please provide only actual expenses that were paid with incentive dollars on
this report. This excludes ail [V-D dollars.

Please provide detailed explanation of what the expenditures in each section consist of under the
total In the explanation box.

Beginning Balance as of QE $ -
Prior Quarter Incentive Award

. Expenditure Amount
1. Personal Services : . $ -
(Salaries, bonuses, stipends, education assistance)
Explanation Box:

2. Employee Related Services g$ | ~
(Medical/Fringe benefits, Disability, etc.) :
Explanation Box:

3. Professional and Outside Services $ -
(Contractors, Education/training from vendor, etc.)
Explanation Box:

4. Travel Expenses $ -
(Mileage, Meais, Lodging, Airfare)

a Mileage

bMeals

c Lodging

d Airfare
Explanation Box:

Page 17 of 20

EXHIBIT B
SUS RECIPIENT INCENTIVE FORM

5. Operating Expenses $ -

(Risk Management, Postage, Telecommunications, otc.)
Explanation Box:

6, Occupancy $ -
(Space, rent, etc.)
a. Square feet $ -
b. Rate $ =

Explanation Box:

Non-Capital Furniture

$ -
(Furniture purchases under $5,000)

Explanation Box:

Capital Furniture $

(Furniture purchases above $5,000)

Explanation Box:

Indirect Administrative Costs §

(Cost allocated charges)

Explanation Box:

Total Actual Expenditures for Reporting Period ‘ $ .
Ending Balance as of QE ; $ ~

CERTIFICATION: | certify, under penalties of perjury, that this Incentives Report State has been
examined by me and, to the best of my knowledge and belief, It Is a true, correct and valid claim
against the State of Arizona.

Authorized Signature Title Date

Administration for Children and Families (OCSE) References/Links:
Incentives Purpose:
hittps://www.acf.bhs.gov/css/resource/child-support-incentive-funding

‘ Page 18 of 20

EXHIBIT B
SUB RECIPIENT INCENTIVE FORM

incentives background (Allowable/Non-Allowable expenses):
https://www.acf.hhs.gov/css/resource/reinvestment-of-child-support-incentive -

Equal Opportunity Employer/Program + Under Titles Vi and Vii of the Civil Rights Act of 1964 (Title VI &
Vil), and the Americans with Disabilitles Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973,
the Age Discrimination Act of 1975, and Title Ii of the Genetic Information Nondiscrimination Act (GINA) of
2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment
based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this
document in alternalive format or for further information about this policy, contact your toval office;
TTY/TDD Services: 7-4-4. + Free language assistance for DES services Is avallable upon request.

Disponible en espafiol en linea 0 en [a oficina local.