Passport Broker Assignment: Agreement Terms and Authorization 2017-2018

Brokering Agency: / Cornerstones Special Needs Services
Passport Recipient Name: / *
Guardian/Primary Contact Name: / *
Guardian/Primary Contact Address: / *

Terms:

Funding Option Selected By Recipient: / ☒ Direct Funding with Broker
Full Annualized Amount: / *
Amount of Funds Brokered: (if Different) / *

Service Details:

Admin Costs (up to max 10% of total funding):
Description of Service Provided:
Example:
Resourcing Support Workers
Resourcing Day Programming
Completing monthly claim submissions
Person Centered Plans

Authorizations and Signatures by Passport Recipient or Passport Primary Contact:

Authorization / Initial
I authorize the use of my funding in the manner described above and that these services are consistent with the Ministry’s Passport Guidelines and allowable uses of Passport funding (see attachment for details) / *
I authorize the brokering agency to directly invoice Contact Hamilton and receive reimbursement from Contact Hamilton on my behalf up to the total amount of funding identified in this Agreement / *
I acknowledge that the administration fee collected by the broker is up to a maximum of10% of the recipient’s annualized funding amount, based on the service start date. I am aware that this fee is negotiable and we as the recipient and/or guardian/primary contact agree to the collected administration fee. / *
I authorize that I am at least 18 years of age or older / *
I will direct all questions, comments and concerns about the services provided directly to the brokering agency managing my funding / *
I acknowledge that Contact Hamilton is not responsible for the provision of service by the brokering agency nor its quality; its role is to reimburse allowable Passport expenses as per the Passport Broker Assignment: Agreement Terms and Authorization Form / *
I acknowledge that this agreement acts as “release and receive” consent between the Passport office and the brokering agency. / *

Signature of Passport Recipient or Guardian/ Primary Passport Contact:

Full Name: (Please Print) / *
Relationship: / *
Full Address: / *
Phone Number: / *
Email Address: / *
Date: / *
Signature: / *

Authorizations and Signatures by the Brokering Agency:

Authorization / Initial
The broker agrees to provide the services as described above and that these services are consistent with the Ministry’s Passport Guidelines and allowable uses of Passport funding
The broker agrees to directly invoice Contact Hamilton and receive reimbursement from Contact Hamilton on behalf of the Passport recipient up to the total amount of funding identified in this Agreement ☐ Yes ☐No
The broker acknowledges that the administration fee collected by the brokerisup to a maximum of10% of the recipient’s annualized funding amount, based on the service start date. If the agreement is terminated by either party, the broker is required to inform the Passport Office so that the account can be reconciled. The broker will be required to rebate on a pro-rata basis, the portion of the brokerage fees for the remainder of that year, based on service end date.
The broker agrees that the submission of an invoice means that the agreed-upon service was provided to the Passport recipient
The Broker agrees that it will manage all questions, comments and concerns about the services provided from the Passport Recipient and/or their contact person
The Broker acknowledges that Contact Hamilton is not responsible for the provision of service by the agency nor its quality; Contact Hamilton’s role is to reimburse allowable Passport expenses as per the Passport Broker Assignment: Agreement Terms and Authorization Form

Reimbursement Details:

Brokering Agency Voided Cheque Attached: / ☐ Yes ☐No ☐On File
Invoice Frequency: Monthly or Quarterly / ☐ Monthly or ☐Quarterly
Please Note All Year End Invoices are due by Friday April 13th, 2018

Broker Authorized Representative:

Name and Position: / Paul Harrison – Owner
Agency Name: / Cornerstones Special Needs Services
Full Address: / 21 Summerberry Way Hamilton On L9B0G2
Phone Number: / 905-921-0655
Email Address: /
Date:
Signature:

Contact Hamilton Use Only:

Agreement reviewed by (print name/position):

Review Date: