JocuSign Envelope ID: TANF 2019 511331595 [Pl?l 7?6484 FORM 10]! Revised 11133016 MISSISSIPPI DEPARTMENT OF HUMAN SERVICES SUBGRANTEE CLOSEOUT CHECKLIST Name MS Community Education Center Agreement Nam. in compliance with the MDHS Subgrantee Closeout Procedures and the terms and conditions of the subgrant, the following closeout documents are enclosed: (Check the appropriate hoses concerning each of the closeout documents. Explain fully any item not submitted or any item to be sent separately. separate sheet, if necessary.) Type of Document _l Enclosed Sending .. Sent: to tel) Fu rn Ish 1. Certi?cation of Suharaot Compliance 2. Final Claim Support Sheet NIA 3. Copy ofWorkeI-s' Compensation or other Audit 10 be performed in DecemberiJanuaty Com of Cancellation Atliustment Fidelity Bontl 5. Outstanding Claimants List 6. Refund Check NIA Equipment Retention Bequest Letter 3. Uthertsneci?l im??w were Weed Subgrintee Gi?einl . . Subg raFitE "at Similt? tutti}?! '0 be competed brisyg 73595-0 3?9"at??e Date Federal ?gure gum Grant Award '3 - Authorized Expenditures - Unexpended Balance 55 3 Comments This is to certify and authorize decreasing the obligation for Agreement No - by the amount of the unexpendet] balance as shown. Douu?lpnod by: SW AW Acct/Aud'i tor' 1/21/2020 1 mt ?gigyiil??rogram Reviewer Title Date . 1729/2020 DWD D'l rector Signature, MDHS Authorized Of?cial Title Date DOGUSl?l'lad by; (Pt-Ml'r Bureau Director II 1/29/2020 )ocuSign Envelope ID: MISSISSIPPI FORM Revised 11/ 3/ 2016 Mississippi Department of Human Services CERTIFICATION OF SUBGRANT COMPLIANCE Subgrantee Name M8 Community EducatIOn Center Agreement A.RELEASE Pursuant to the terms of said subgrant and in consideration 'pp (Total Amount Paid 8i Payabie by MDHS Total Authorized EXpenditures) which has been or is to be paid to the Subgrantee or to its assignees, If any, the Subgrantee, upon payment of the said sum does remise, release, and discharge MDHS, its officers, agents, and employees, of and from all liabilities, obligations, claims, and demands whatsoever under or arising from the said subgrant, except: 1. Specified claims in stated amount or in estimated amounts where the amounts are not susceptible to exactstatement by the Subgrantee, as follows: 5 none (If none, please state) 2. Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Subgrantee to third parties arising out of the performance of the said subgrant, which are not known to the Subgranteeon the date of execution of this release and of which the Subgrantee gives notice in writing to the MDHS Funding Division Director within the period specified in the said subgrant. 3- Claims, after closeout, for costs which result from the liabiity to pay Unemployment insurance costs under a reimbursement system or to settle Workers' Compensation claims. BASSIGNMENT 0F REFUNDS, REBATES AND CREDITS Pursuant to the terms of said subgrant and in consideration ofthe reimbursement of costs and payments of fees as provided in the said subgrant and any assignment thereunder, the Subgrantee does hereby: 1. Assign, transfer, set over and release to MDHS all rights, titles, and interests to all refunds, rebates, credits or other amounts (Including any interest thereon) arising or which may hereafter accrue thereunder. 2. Agree to take whatever action may be necessary to effect prompt collection of all such refunds, rebates, credits or other amounts (including interest thereon due or which may become due) and to forward to MDHS any proceeds so collected. The reasonable costs of any such collection action shall constitute allowable costs when approved by the MDHS Funding Division Director as stated in the said subgrant and may be applied to reduce any amounts otherwise payable to MDHS under the terms hereof. 3. Agree to cooperate fully with MDHS on any claim and/or suit in connection with such refunds, rebates, credits or other amounts due (including any interest thereon); to execute any protest, pleading, application, power of attorney or other papers in connection therewith; and to permit MDHS, the State Attorney General?s Office or the Federal Grantor Agency to represent it at any hearing, trial or other proceeding arising out of such claim and/or suit. )ocuSign Envelope ID: MISSISSIPPI FORM Revised 11/3/2016 C. INVENTORY CERTIFICATION (Select: as Applicable} 1. The Subgrantee hereby certifies that no property or equipment was furnished or acquired under the terms and conditions of said subgrant. 2. The Subgrantee hereby certifies that all items of property or equipment purchased, furnished or transferred to said Subgrantee were dune in accordance with the terms and conditions of said subgrant. The inventory Control List Is enclosed. D. CERTIFICATION OF CASH BALANCE The Subgrantee hereby certifies that the cash balance applicable to Subgrant No. 5014973 as of the date of execution of this document is: 1. Total MDHS funds requested and received: Less final MDHS cumulative cost reported: Equals unexpected balance: Plus balance unexpended funds (Refund due to Minus balance funds due subgrantee (Subgrantee submits Request for Cash] Balance must equal Zero *Refund check must include: Unexpended funds amount lb) Outstanding claimants amount {as applicable) Total amount refunded (check no13.392.345.13 5 13.392.345.13 5 0.00 0.00 5 0-00 3 NA 5 MIA DocuSign Envelope ID: MISSISSIPPI FORM Revised 11/3/2016 E. General Statement of Compliance The Subgrantee further certifies that all terms and conditions of said subgrant have been met. IN WITNESS THEREOF, this Certification of Subgrant Compliance has been executed this day of December 20 19 MS Community Education Cir WITNESSED BY: ?79 NAME OF SUBGRANTEE 1. at; ?74 Wizard/OFFICIAL 2. _Dmr?af' TITLE )ocuSign Envelope ID: MISSISSIPPI FORM REVISED 11/7/2016 Mississippi Department of Human Services OUTSTANDING CLAIMANT Subgrantee MS Community Education Cent Agreement Numberfs) Claimant?s Name ?ecks! Amount Date - Pay Period Hours 8: Other Contact Name Address Rate Address Telephone number TeIephone Number E-mall Address I I E-mail Address STATE OF MISSISSIPPI CLAIM SUPPORT FORM: ADVANCED LCD 11:05:2019 CLAIM. SUBMISSION 132.13: 5703? CLAIM FOR THE PERIOD or: FUNCTIONAL AREA 1651 Human Services CLAIM NUMBER- - 5-71513 cosr CENTER 1651010008/Fia1d Operations GRANTEE ID 3100013559 15mm WEB. '6014978 CLAIM AMOUNT: - AMT PERIOD :,October 1. 2018 1.1th September 30, 2019 PROGRAM mm: I VENDOR Mississippi Community Education Center 4mm DESCRIPTIW: nEmr 19 fPre-ventive ADDRESS 9.0. 30:: 12347 Jackson. MS 39236 EXPENSE cm: ms mam om '1'ka DESCRIPTION savanna nouns-m: To mm: cum momm- mu mom we um: arm-c: 50 3.9 1.393.933.1531 Sig on Am Pam:- 13.892.645.13 17,498,7142-36 FM 13.892.645.33I I 55" TOTALS: 13.392.545-13 ?17.498.714.49 amt:- o. ~1a.892.645.13 FINAL AUDIT OF THIS PROJECT WILL INCLUDE VERIFICATICDC OF ABOVE CLAIMED PAYMENT FEW It mam-m by: 1mm: or ?ftimzm arr-1cm mm mm 9:33 BucuSlqn@in DocuSign Envelope ID: PROJECT SOURCE RECORDS 12/5/2019 12/5/2019 12/5/2019 12/5/2019 t. - I STATE OF MISSISSIPPI SUB-GRANTEE EXPENDITURE REPORT For Period Endim__ 1130,1203 (month, day 8. year] Name: M35155: Community Educ-Um Center 512th Date: 121312019 Address: 15:11:02,515 39236 Grant Name 81 Year: Famiis Prat 2019 Agreement?umhu: 6011977 MOW Pragram ID: 700200005157 4 Pit-glam Discrip?on: TANF llfapp?cahlel ??9150 mam gm LA - LAM Pm" 53M Mum 555190.505: 1-2 SALARIES 410,750.00 5 352,915.57 27,916.57 5 390,033.34 5 27391566 FRINGES 5 11159113 5 96,717.29 7,439.79 5 105,157.08 7,439.80 TRAVEL 5 5 5 - comma-ram506510165, Lows 12 GRANTS 5 5 INDIRECT COST 5500175707113 330 459,633.95 95,355.05 495550.42 5 445$.? Agraemm?umm HON . .1. Program 19: 7000000051114 4 to Program TANF {lflm?abh} 9112116110 01.50515 LAWN 2 565mm 5mm mm 5111-0411151 :2 05111051 8 SALARIES 1.2.6.97500 5 1,050,525.00 69,125.00 1,153,750.00 5 59,125.00 FHINEES 332,292.19 5 257,955.56 22,152.61 5 310,135.97 5 2,151.32 mm 32,437.50 5 71.44503 5 5,495.09 5 76,941.65 5 5,495.04 CONTRACTSERV 5 1,163,250.00 971,112.99 5 55,930 as 1,027,043.34 5 136,206.66 COMMODITIES 279,000.00 5 256,207.49 5 9,315.47 5 276023.95 5 1976.04 15.695.040.44 5 3,237,363.94 1,251,991.75 14,539,35572 010105135057 5 - 5 9,250.00 5 9250.00 5 {9.250001 muggy}; 6001 en: 5 75000 75,090.00 5 - 75,000.00 5 15,750.30 W107 16.099.751.11 1.457.762.19 171mg?: 5 1.115.141.1111127172019 51::an 051107 5005511151. 02175 7110505515 nevuswm DATE 3? CD UJ .92 U) tt'; ??asa'IT GE: Lt sve'zaa'at 91 . ET ?n n?n ua.? 90 c?u'cu: n1nruw =2 050 S: 1 45:? I 1.9533000! I my?? 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