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HomeMy WebLinkAboutA6512 - JEWISH FAMILY SERVICES OF THE DESERT - SUBRECIPENT AGREEMENTSUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this 21'day of 0G0 6-L 2019, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Jewish Family Service of the Desert herein"Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R.Section 570 et seg. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW,THEREFORE,the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application and this Agreement. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.0, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive $20,000.00 or more from the City during the 2019 — 2020 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Directorcompletedwithinthemostrecenttwelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 315t of the current fiscal year. 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed TWENTY-FIVE THOUSAND FIVE HUNDRED TWENTY-THREE DOLLARS 25 523.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City periodic statements, in the form of Exhibit F, on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Providers respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter(September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25%of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Maureen Forman, Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the City Manager of City. 3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred,voluntarily or by operation of law,without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as 2- may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable,and as may be amended from time to time: a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; c) Section 3 of the Housing and Urban Development Act of 1968, as amended; d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; g) The Age Discrimination Act of 1975 (P.L. 94-136, as amended, and implementing regulations; h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 a); Q) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c) and 570.503(b)(8); 1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604; nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); o) The regulations, policies, guidelines and requirements of 24 CFR 570; the"Common Rule", 24 CFR Part 85 and subpart J; OMB Super 3- Circular 2 CFR 200 as they relate to the acceptance and use of federal funds under the federally-assisted program; p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C.4801 et seg.); s) Procure, use, manage and dispose of personal property in accordance with 2 CFR 200.310 and 2 CFR 200.312 through 2 CFR 200.316; t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan)in excess of$25,000 is either: i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or ii) Not used in accordance with paragraph (t)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (t) of this section.) u) Conflict of Interest. The Provider is required to disclose to the City in writing any potential conflict in accordance with 24 CFR Part 570.611; and v) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers'Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the 4- foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars($1,000,000). 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys' fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 CITY OFFICERS AND EMPLOYEES: NON-DISCRIMINATION, TERMINATION, AND ENFORCEMENT. 6.1 Non-Liability of City Officers and Employees. No officer or employee of City shall be personally liable to the Provider, or any successor-in-interest, in the event of any default or breach by City or for any amount which may become due to the Provider or its successor, or for breach of any obligation of the terms of this Agreement. 6.2 Conflict of Interest. Provider acknowledges that no officer or employee of the City has or shall have any direct or indirect financial interest in this Agreement nor shall Provider enter into any agreement of any kind with any such officer or employee during the term of this Agreement and for one year thereafter. Provider warrants that Contractor has not paid or given, and will not pay or give, any third party any money or other consideration in exchange for obtaining this Agreement. 6.3 Covenant Against Discrimination. In connection with its performance under this Agreement, Provider shall not discriminate against any employee or applicant for employment because of actual or perceived race, religion, color, sex, age, marital status, ancestry, national origin i.e., place of origin, immigration status, cultural or linguistic characteristics, or ethnicity), sexual orientation, gender identity, gender expression, physical or mental disability, or medical condition each a "prohibited basis"). Provider shall ensure that applicants are employed, and that employees are treated during their employment, without regard to any prohibited basis. As a condition precedent to City's lawful capacity to enter this Agreement, and in executing this Agreement, Provider certifies that its actions and omissions hereunder shall not incorporate any discrimination arising from or related to any prohibited basis in any Provider activity, including but not limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship; and further, that Provider is in full compliance with the provisions of Palm Springs Municipal Code Section 7.09.040, including without limitation the provision of benefits, relating to non-discrimination in city contracting. 6.4 Term. Unless earlier terminated in accordance with Section 6.5 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1)year from the date hereof. 6.5 Termination Prior to Expiration of Term. a. In accordance with 2 CFR 200.339, the City may suspend or terminate, in whole or in part, this Agreement if Provider fails to comply with any term of this Agreement or the terms and conditions of the subaward; b. In accordance with 2 CFR 200.339, the City may terminate this Agreement with the consent of the Provider after both parties have 5- agreed upon the termination conditions, including the effective date and, in the case of a partial termination,the portion to be terminated; and C. The Provider may terminate this Agreement at any time, with or without cause, upon thirty (30) days' notification setting forth the reason(s) for such termination, the effective date and, in the case of partial termination, the portion to be terminated. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. However, if the City determines in the case of partial termination that the reduced or modified portion of the subaward will not accomplish the purposes for which the subaward was made, the City may terminate the subaward in its entirety. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, consent, approval, or communication that either party desires, or is required to give to the other party or any other person shall be in writing and either served personally or sent by pre-paid, first-class mail to the address set forth below. Notice shall be deemed communicated seventy-two (72) hours from the time of mailing if mailed as provided in this Section. Either party may change its address by notifying the other party of the change of address in writing. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Jewish Family Service of the Desert 490 S Farrell Dr. Ste C208 Palm Springs CA 92262-7944 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. End—Signatures on Next Page] 6- CITY OF PALM SPRINGS ATTEST nicipal corpolAtion By: B Ci erk City Manager APPROVED AS TO FORM:APPROVED BY COUNCIL st2 fq City Attorney PROVIDER: Check one: _Individual _Partnership _Corporation Corporations require two notarized signatures: One signature must be from the Chairman of Boar President, or any Vice President. The second signature must be from the Secretary, Assi to t Sec tary,Tree r, Ass v,fant Treasurer, or Chief Financial fficer). B By: otprized 1 nature of Cfid(hpah of Board, Notarized Sigirtature Secrets y,Asst Secretary, Presi nt or nil esident Treasurer,Asst' reas' er or C ief inancial Officer Name: Name: Titre: Title: G >V State of (Ziam-• ) State of County of ss County of ss A notary public or other officer completing this certificate A notary public orcther officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that document. the truthfulness,accuracy,or validity of that document. State of CAt.lf-o1.Nm ) County of (AIJG&ATk1F- )ss.State of 1-lt -(LN A H County of R-`"f -%njS )I ss. On C)C . Z3i W5 before me, On O C. , 13 ' before me,lgiDJ r to 1 ' 1P 10yo fl f,.,Now PJ1 ht,.personally appeared nn5 personally appeared p,A•+ or who proved to VJO.frlt%4V a^ who proved to jho on the basis of sat actory evidence to be tha personl, me on the sis of satisfactory evidence to be the personj) se names) re su bed tothewithin instrument ndwhose name( j i'are sub ed to the within instrument and nowled ed totha he helthe executed same in owledged me tha he/ he/theyexecuted the same in her/their authored ca a i and thtb lhiser/theirhrs erltheir authorized ca ty(i-and than der/their atur ) on the,instru ( a person, orra entity sr natureO on the instrument the personV, of the entitynbehalfofwhichtheperson(J5)' acted, executed the upon behalf of which the person-acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of theStateofCaliforniathattheforegoingparagraphIstrueandStateofCaliforniathattheforegoingparagraphistrueand correct. correct. WITNESS my hand a official seal. WITNESS my hand and official seal. Notary Signature: Notary Signature: Notary Seal: Notary Seal: mm 4afon Na 21 l 8643 €t J )i BEFiGST OM d; NOTARY PUBLIC CAy1pORNIA CommisstontJa,Z19864 3 iA1 yyQammE.gei7UME40021 f9RR%rtR3 78 arw NEg, 3021.A6rCOmm.EaWres'JU CITY OF:PALM SPRINGS EXHIBIT A Scope of Services Pro'ect/Actiyity Title: Project Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 Oblectives/Activities The intent of this program is to provide extremely low income to low-income seniors, individuals and families with emergency assistance who are experiencing a severe financial crisis and at-risk for housing insecurity or becoming homeless. The program will serve 1180 clients Valley-wide and 381 Palm Springs'residents that will include seniors-55+years of age and individuals and families-underage 55. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely Providing any additional information requested TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise market and publicize the program to facilitate positive promotion for all parties i.e., Provider, City. CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income gualify at least a total of three hundred and eighty-one (381) extremely low income to low-income Palm Springs' residents in accordance with Exhibit D for new access to services. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming to three hundred and eighty-one (381) extremely low income to low-income Palm Springs' residents. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports — referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31s, and program completion, June 30th. Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination/EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors Individuals and Families. At-Risk Youth Severely Disabled Adults. and Special need Population. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in this Agreement. Objective 8: Provide an evaluation within fifteen (15)calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/20 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary ProiecttActivity Title: Project Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BUUGETI3UMMARY COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 I Personnel 0- 237,732. 237,732 2 ConsultanUContract Services 0- 0- 0- 3 Travel 0- 880. 880. 4 Space Rental 0- 19,239. 19,239. 5 Consumable Supplies 0- 12,383. 12,383. 6 Rental, Lease or Purchase of 0-3,938. 3,938. Equipment 7 Insurance 0-3,766. 3,766. 8 Other— 12,761.50 55,000 67,761.50 Emergency Assistance for Seniors Emergency Assistance for 12,761.50 0- 12,761.50 Individuals and Families Indirect Cost 10% 0-36,294 TOTALS . 125,523. 369,232. 358,461 If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding,grantor4ending agency,and cost category information. Other funding sources include fundraising activities conducted by JFSD's through other local and non- governments[grants,all totaling$55,000 The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The Subreciplent recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subreciplent is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over a twelve month period of July 1, 2019 through June 30, 2020 with funds allocated from 2019—20 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Proiect/ActivitV Title: Proiect Number: Jewish Family Service of the Desert/0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Non-profits' Ins Alliance Effective Dates of Policy 02/23/2019 to 02/23/2020 Claims Made Policy / / Per Occurrence Policy Limits of Liability 2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) I3 Yes No Original Certificate of Insurance Attached Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 06/1/2019 to 06/1/2020 Limits of Liability 1M Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes 0 No CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number: Jewish Family Service of the Desert! 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described project(activity. Please answer each of the following questions. 1. How many persons are In your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be Included as household members. 2. Circle your combined gross annual income(Riverside-San Bemardino-Ontario,CA MSA—06128119) AREA MEDIAN- NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5r$66650+ 7 8 LEVEL-$65,800 EXTREMELY LO INCOME $15,100 $17.250 $21,330 $25,750 $30,170 39,010 $43.430 0-30%ofAMI LOW INCOME $25,150 $28,750 $32,350 $35,900 $38,800 44,550 $47,400 30-50%ofAMI MODERATE INCOME $40,250 $46.000 $51,750 $57,450 $62,050 71,260 $75,850 50-8D•-ofAMI NON LOW&MOD INCOME $40,250+ $46,000+ $51,750+ $57,450+ $62,050+ 71,250+ $75,850+ 80% 3. What race/ethnicity do you identify yourself as;please note that this seifddentification Is voluntary In accordance with equal opportunity laws? While American Indian or Alaska Native AND White Black/Afdcan American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/Afdcan American Native Hawaiian or Other Pacific Islander Other. HISPANIC/LATINO ETHNICITY Yes No If yes,check one: Mekican/Chicano Puerto Rican Cuban Other. 4. Are you female Head of Household? YES NO 5. Do you have a disability? YES NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form Is confidential and Is only utilized for Community Development Block Grant(CDBG)program purposes,a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF'PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report ProiecUActivity Title: Proiect Number: Jewish Family Service of the Desert/0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT Number of First-Time Program Beneficiaries Serviced: of Households of Persons or=30%:30-50%: 50-80%: 80%: Number of First-Time Female Headed Households: Counts by Race/Ethnicity: White American Indian or Alaska Native AND While Black/African American Asian AND While Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other. Number of Disabled: Number of Homeless Persons Given Overnight Shelter: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY .OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT A roved Current Prlor ENMierlod(s Reimbursement Relmburs - It Over/iUnder ther Emergency Assistance to $12,761.50 Seniors(Ages 55+ Emergency Assistance to $12,761.50 Individuals and Families Under 55 years of age) TOTAL ,25,523. I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b)funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 & 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name,Title, Date Name,Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: If necessary,additional sheet(s)must be attached detailing cost breakdowns,and verified by original signatures. SUBRECIPIENT AGREEMENT alp A,bve«,bW THIS AGREEMENT (herein "Agreement'), is made and entered into thisOdtay of 96 + A9 2018, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Jewish Family Service of the Desert herein 'Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act'), and the regulations promulgated thereunder(24 C.F.R. Section 570 et sec. ('Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed underthe Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein, NOW, THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application and this Agreement. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.0, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive $20,000.00 or more from the City during the 2018 — 2019 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shallbe furnished not later than January 31 s`of the current fiscal year. ORIGINAL DID ANDIOR AGREEMENT 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed FIFTEEN THOUSAND DOLLARS ($15,000.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City periodic statements, in the form of Exhibit F, on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Provider's respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25% of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Maureen Forman Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the City Manager of City. 3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred, voluntarily or by operation of law, without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 2 - 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable, and as may be amended from time to time: a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; c) Section 3 of the Housing and Urban Development Act of 1968, as amended; d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part42. i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0), Q) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c) and 570.503(b)(8); 1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604, nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); o) The regulations, policies, guidelines and requirements of 24 CFR 570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB Super Circular 2 CFR 200 as they relate to the acceptance and use of federal funds under the federally-assisted program; 3 - p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et sue.); s) Procure, use, manage and dispose of personal property in accordance with 2 CFR 200.310 and 2 CFR 200.312 through 2 CFR 200.316; t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan)in excess of$25,000 is either: i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or ii) Not used in accordance with paragraph (t)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (t) of this section.) u) Conflict of Interest. The Provider is required to disclose to the City in writing any potential conflict in accordance with 24 CFR Part 570.611: and v) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's 4 - obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars ($1,000,000). 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys' fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractors performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 CITY OFFICERS AND EMPLOYEES: NON-DISCRIMINATION, TERMINATION, AND ENFORCEMENT. 6.1 Non-Liability of City Officers and Employees. No officer or employee of City shall be personally liable to the Provider, or any successor-in-interest, in the event of any default or breach by City or for any amount which may become due to the Provider or its successor, or for breach of any obligation of the terms of this Agreement. 6.2 Conflict of Interest. Provider acknowledges that no officer or employee of the City has or shall have any direct or indirect financial interest in this Agreement nor shall Provider enter into any agreement of any kind with any such officer or employee during the term of this Agreement and for one year thereafter. Provider warrants that Contractor has not paid or given, and will not pay or give, any third party any money or other consideration in exchange for obtaining this Agreement. 6.3 Covenant Against Discrimination. In connection with its performance under this Agreement, Provider shall not discriminate against any employee or applicant for employment because of actual or perceived race, religion, color, sex, age, marital status, ancestry, national origin i.e., place of origin, immigration status, cultural or linguistic characteristics, or ethnicity), sexual orientation, gender identity, gender expression, physical or mental disability, or medical condition each a "prohibited basis"). Provider shall ensure that applicants are employed, and that employees are treated during their employment, without regard to any prohibited basis. As a condition precedent to City's lawful capacity to enter this Agreement, and in executing this Agreement, Provider certifies that its actions and omissions hereunder shall not incorporate any discrimination arising from or related to any prohibited basis in any Provider activity, including but not limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising, layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship; and further, that Provider is in full compliance with the provisions of Palm Springs Municipal Code Section 7.09,040, including without limitation the provision of benefits, relating to non-discrimination in city contracting. 6.4 Term. Unless earlier terminated in accordance with Section 6.5 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1)year from the date hereof. 6.5 Termination Prior to Expiration of Term. a. In accordance with 2 CFR 200.339, the City may suspend or terminate, in whole or in part, this Agreement if Provider fails to comply with any term of this Agreement or the terms and conditions of the subaward; b. In accordance with 2 CFR 200.339, the City may terminate this Agreement with the consent of the Provider after both parties have agreed upon the termination conditions, including the effective date and, in the case of a partial termination, the portion to be terminated; and 5- C. The Provider may terminate this Agreement at any time, with or without cause, upon thirty (30) days' notification setting forth the reason(s) for such termination, the effective date and, in the case of partial termination, the portion to be terminated. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. However, if the City determines in the case of partial termination that the reduced or modified portion of the subaward will not accomplish the purposes for which the subaward was made, the City may terminate the subaward in its entirety. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, consent, approval, or communication that either party desires, or is required to give to the other party or any other person shall be in writing and either served personally or sent by pre-paid, first-class mail to the address set forth below. Notice shall be deemed communicated seventy-two (72) hours from the time of mailing if mailed as provided in this Section. Either party may change its address by notifying the other party of the change of address in writing. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Jewish Family Service of the Desert 490 S Farrell Dr, Ste C208 Palm Springs CA 92262-7944 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. End —Signatures on Next Page] 6 - CITY OF PALM SPRINGS ATTEST, a municipal corporation By: By: C erk City Manager APPROVED AS TO FORM:APPROVED BY CITY COUNCIL B : c a.A. at S 11o51a City Attorney PROVIDER: Check one: _Individual _Partnership _Corporation Corporations require two notarized signatures: One signature must be from the Chairman of Boar President, or any ice President. The second signature must be from the Secretary, Assis nt Secr tary, Tr su r, As Treasurer, or Chief Financia Officer) By: 8t9 y: R 14 L 4Se 4 o riz g ature of Chairman o Board, Notarized Sig ature Secr tary,Asst Secretary, Presid or any Vice Presiden Treasurer,Asst Treasurer or Chief Financial Officer Name::SAVAf_OY[A S` CNW Name: arEw KGI.LFI'` an Title: ( rmrck P vp_md i? yYTitle: 130 ca-6 T req Surer State of 1.w11 IkX flt(A State of CQI t rn County of NVeAe1ZICj 0 ss County of . ( VIA n ss A notary public or other officer completing this certificate A notary public or other officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that deCGment. the truthfulness,accuracy,or validity of that document. State of Ifu fn iG ) State of` Ilfvini ) County of ss. County of Wiy P(5, R. )ss. On GC1 UI/t( c? i ao 11 ir/ before me. On ucfUbPf c?`;,rw before me, 00floNor) personally appeared \h 0of'(I Dear)- Wujf0NG"ersonallyappeared f1f Lf Sf nl(4y1 who proved to CX, r f Lu K(I Uf ry\Cf r -) who proved to me on the basis of satisfactory evidence to be the person(s) me on the asis of satisfactory evidence to be the person(s) whose name(s)is/are subscribed to the within instrument and whose name(s)is/are subscribed to the within instrument and acknowledged to me that helshelthey executed the same in acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their his/hedtheir authorized capacity(ies), and that by hisiher/their signature(s) on the instrument the person(s), or the entity signature(s) on the instrument the person(s). or the entity upon behalf of which the person(s) acted. executed the upon behalf of which the person(s) acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and correct. correct. WITNESS my hand and ofrci WITNESS my hand and official seal J\ CrNotarySignature: J' Notary Signature: NotaryS Y- Notary Seal: VICTORIA DEAN-WALTERS VICTORIA DEAN-WALTERS Notary Public -California Notary Public -California Riverside County i Riverside County = Commission #2186710 z Commission #2186710 s My Comm.Expires Apt 13.2021 + My Comm.Expir l021 oeecfooecraisJFso_sw,eapM et cone 7 . CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Proiect Number: Jewish Family Service of the Desert/ 0006 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 Objectives/Activities The intent of this program is to provide extremely low income to low-income seniors with emergency assistance who are experiencing a severe financial crisis and at-risk for housing insecurity or becoming homeless. The program will serve 50 seniors Valley-wide and 25 Palm Springs' seniors - 55+ years of age. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise market and publicize the program to facilitate positive promotion for all parties i.e., Provider. City. CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income qualify at least a total of twenty-five (25) extremely low income to low- income Palm Springs' seniors in accordance with Exhibit D for new access to services TARGET DATE ACTIVITY#1 On-Going Provide direct client programming to fifty (50) Valley-wide seniors. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports — referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31", and program completion, June 30`". Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination/ EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors At-Risk Youth, Severely Disabled Adults and Special need Pooulaticn. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in this Agreement. Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/19 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0006 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 IEGETSUMMARY COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel 0 - 207,638. 207,638. 2 Consultant/Contract Services 0 - 0- 0- 3 Travel 0 - 765. 765. 4 Space Rental 0 -14,580. 14,580- 5 Consumable Supplies 0- 5,820.5,820. 6 Rental, Lease or Purchase of 0 - 315. 315. Equipment 7 Insurance 0 - 2,520.2,520. 8 Other— 15,000. 27,000. 42,000. Emergency Assistance 0 -25,864. 25,864. Indirect Cost 10% TOTALS 15,000. 284,502. If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding,grantor/lending agency, and cost category information. Other funding sources include fundraising activities conducted by JFSD's through other local and non- governmental grants,all totaling$36,000. The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The Subrecipient recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over a twelve month period of July 1, 2018 through June 30, 2019 with funds allocated from 2018—19 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0006 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Non-profits' Ins Alliance Effective Dates of Policy 02/23/18 to 02/23/19 Claims Made Policy I I Per Occurrence Policy I ! Limits of Liability 2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) Rl Yes No Original Certificate of Insurance Attached Yes Z No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 06/01/18 to 06/01/19 Limits of Liability 1 M Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes Q No JEWIS-2 OF to:NY CERTIFICATE OF LIABILITY INSURANCE DA O 10/23/1231201818 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: 0 the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder In lieu of such endorsements . PRODUCER CONTACT William Levin Pennbrook Insurance Services NAME: PHONE e 394-83320License#0622553 www.pbcis.com CNa w415 P.O.Box 26849 EMAIL San Francisco,CA 94126.6849 ADDRESS: William Levin INSURER(S)AFFORDING COVERAGE _ NAICe INSURER A:Nonpmrits'Ins milance INSURED Jewish Family Service INSURER B: of the Desert 490 So.Farrell Drive#C-208 INSURER C: Palm Springs,CA 92262 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXP LT, TYPE OF INSURANCE POLICY NUMBER POLICY EFF MWDDYIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 CLAIMS-MADE 1XI OCCUR X 2018-15000 0212312018 02/2312019 PREMISES _ RFM D_ $ 500,00 A X Prod esslariat Us 2018-15000 02123/2018 02/23/2019 MED EXP(Anyone person) $ 20,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00 X POLICY PRO ECT LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER I I PE&O 2,000,00 AUTOMOBILE LIABILITY COMBINE Ee D SINGLE LIMIT accident 1,000,00 A ANY AUTO 2018.15000 02/23/2018 02123/2019 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON OWNED AUTOS PROPERTY DAMAGEXHIREDAUTOSNAUTOSPeraccident)._,__-__ X UMBRELLA LIAB OCCUR EACH OCCURRENCE 4,000,00 A EXCESS LIAB CLAIMS-MADE 2018-15000-UMB 02/2312018 02/2312019 AGGREGATE 4,000,00 DED X RETENTIONS 10,000 D&O UMB g 4,000,00 WORKERS COMPENSATION AND EMPLOYERS'LIABID In YIN STATUTE ER ANY PROPRIETDRJPARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ Ilyee,desctlbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A 'D&O Liability z018-15000-DO-NPO 02123/'2018 02/2312019 Each Act 1,000,00 Aggregate 2,000,00 DESCRIPTON OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may W attached If more space Is required) Certificate holder is hereby included as additional insured with repects to the General Liability policy per written contract. CERTIFICATE HOLDER CANCELLATION CITYOPS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. Attn: City Clerk P.O. Box 2743 AUTHORMED REPRESENTATIVE Palm Springs,CA 92262 O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD JEWIS-2 PAGE 2NOTEPADINSURED'S NAME Jewish Family Service OP ID: NY D.te 10/23/2018 CCIDENT INSURANCE MASTER POLICY - MHH010307 Underxritten by: rQ E Insurance Corporation Coverage Term: 02/23/2018 to 02/23/2019 Accidental Death: $50,000 Accidental Dismemberment Maximum: $50,000 cidenta1 Paralysis: $25,000 gregate Limit of Liabilityp: $1,000,000 Excess Accident Medical: $500,000 Deductible: 250 COVERED PERSONS: Participants & Volunteers IMPROPER SEXUAL CONDUCT AND PHYSICAL ABUSE LIABILITY Coverage Term: 02/23/2018 to 02/23/2019 GENERAL AGGREGATE LIMIT: $1,000,000 EACH CLAIM LIMIT $1,000,000 UMBRELLA Limit for Improper Sexual Conduct is $2,000,000 POLICYHOLDER COPY SP STATE, QMFFNSATION P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10-23-2018 GROUP: POLICY NUMBER: 1396208-2018 CERTIFICATE ID: 31 CERTIFICATE EXPIRES: 08-01-2019 08-01-2018108-01-2019 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 30 DATED 10-23-2018 CITY OF PALM SPRINGS SP PO BOX 2743 PALM SPRINGS CA 92263-2743 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 30 days advance written notice to the employer. We will also give you 30 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 dbbyythe policy describedherein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-10-23 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF PALM SPRINGS ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018-10-23 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF PALM SPRINGS EMPLOYER dEWISH FAMILY SERVICE OF THE DESERT (A SP NON-PROFIT PUBLIC BENEFIT CORP) 490 5 FARRELL OR STE C208 PALM SPRINGS CA 92262 P1 G,SPj REV.7-20141 PRINTED : 10-23-2018 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement ProiectlActivity Title: Project Number: Jewish Family Service of the Desert/ 0006 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described project/activity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual Income(Riverside-San Bernardino-Ontario,CA MSA—04101/18) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(Al 1 2 3 4 1 5 6 7 8 LEVEL-$65,800 EXTREMELY LO INCOME $14,150 $16,460 $20,780 $25,100 I $29,420 $33,740 $38,060 $42,380 0-30%of AMI LOW INCOME $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 30-50%ofAMI MODERATE INCOME $37,750 $43,150 $48,550 $53,900 $58250 $62,550 $66,850 $71,150 50-80%ofAMl NON LOW&MOD INCOME $37,751+ $43,151+ $48,551+ $53,901+ $58251+ $62,551+ S66,851+ $71,151+ 80% 3. What race/ethnicity do you identify yourself as; please note that this self-identification is voluntary in accordance with equal opportunity laws? White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANICILATINO ETHNICITY Yes No If yes,check one: Mexican/Chicano Puerto Rican CubanOther: 4. Are you female Head of Household? YES NO 5. Do you have a disability?YES NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes, a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Project/Activity Title: Project Number: Jewish Family Service of the Desert/ 0006 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT Number of First-Time Program Beneficiaries Serviced: of Households of Persons or=30%:30-50%: 50-80%: 80%: Number of First-Time Female Headed Households: Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African Amercan Asian AND White_ Asian Black7African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: Number of Disabled: Number of Homeless Persons Given Overnight Shelter: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Proiect Number: Jewish Family Service of the Desert/ 0006 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT Current ' Prmc 1i II I Reimbursement Retm6arserrfeM°- I ,,l pefiod her Emergency Assistance 15,000. I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b) funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 8 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name, Title, Date Name, Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: If necessary, additional sheet(s)must be attached detailing cost breakdowns,and verified by original signatures. SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this,,day of SKa *v9K, 2016, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charte city,and the Jewish Family Service of the Desert. , (herein "Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et seq. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW, THEREFORE,the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application and this Agreement. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.0, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive $20,000.00 or more from the City during the 2016 — 2017 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than 20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 31 s'of the current fiscal year. ORIGINAL BID AND/OR AGREEMENT 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed FIFTEEN THOUSAND DOLLARS ($15,000.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided.The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%,without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City periodic statements, in the form of Exhibit F,on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Provider's respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25% of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Maureen Forman, Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the City Manager of City. 3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred,voluntarily or by operation of law,without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 2 - 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable, and as may be amended from time to time: a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; c) Section 3 of the Housing and Urban Development Act of 1968, as amended; d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); j) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c) and 570.503(b)(8); I) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604; nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); o) The regulations, policies, guidelines and requirements of 24 CFR 570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB Super Circular 2 CFR 200 as they relate to the acceptance and use of federal funds under the federally-assisted program; 3 - p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.); s) Procure, use, manage and dispose of personal property in accordance with 2 CFR 200.310 and 2 CFR 200.312 through 2 CFR 200.316; t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan) in excess of$25,000 is either: i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or II) Not used in accordance with paragraph (t)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (t) of this section.) u) Conflict of Interest. The Provider is required to disclose to the City in writing any potential conflict in accordance with 24 CFR Part 570.611; and v) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also cant' Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation 4 - to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars ($1,000,000). 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys' fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 DISCRIMINATION TERMINATION,AND ENFORCEMENT. 6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, gender identity, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, sexual orientation, gender identity, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal, state or local law. 6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1)year from the date hereof. 6.3 Termination Prior to Expiration of Term. a. In accordance with 2 CFR 200.339, the City may suspend or terminate, in whole or in part, this Agreement if Provider fails to comply with any term of this Agreement or the terms and conditions of the subaward; b. In accordance with 2 CFR 200.339, the City may terminate this Agreement with the consent of the Provider after both parties have agreed upon the termination conditions, including the effective date and, in the case of a partial termination, the portion to be terminated; and c. The Provider may terminate this Agreement at any time, with or without cause, upon thirty (30) days' notification setting forth the reason(s) for such termination, the effective date and, in the case of partial termination, the portion to be terminated. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. However, if the City determines in the case of partial termination that the reduced or modified portion of the subaward will not accomplish the purposes for which the subaward was made, the City may terminate the subaward in its entirety. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. 5- TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Jewish Family Service of the Desert -JFSD 490 S. Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. End—Signatures on Next Page ] 6 - CITY OF PALM SPRINGS ATTEST: nrni I cor o lion By. BY'/ ity Clerk City Manager APPROV D APPROVED BY CITY COUNCIL By. a b \a City Attorne PROVIDER: Check one: _ Individual _Partnership _Corporation Corporations require two notarized signatures: One signature must be from the Chairman of Board, President, or any Vice President. The second signature must be from the Secretary, Assistant Secretary, Treasurer, Assistant Treasurer, or Chief Financial O fAfic er) r). By: 47 f By: Gt1 Notarized Signature of Chairman of Board, N z= Signature Secreta sst Secretary, President or any Vice President Tre urer,As st'Treasurer or Chief Financiiall Officer Name:mG1 GA'ree 7 yr-k 0• J1Name: O /CL ITan l — Title: 2iX, L 2)lre / Or- Title: L(1T GC/iG/ State of Cali t n G ) Stateof . lufhl4 ) County of j()ss County of V ( as A notary public or other officer completing this certificate A notary public or other officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that document. the truthfulness,accuracy,or validity of that document. Stateof 0.)1f fl ) Stateof C4114ofirlo ) County of V ss. County of 1/Qf61 )Ss- on SQ.P#mhe 0-7 e-*B1& before 7ae, On Stpitrnbrf 7,,ao/Lf before me S A Gfy r SIC.N p t yublitVlrioflLlLJP4f1• wall pers6nally appE2re Vi T U I I G { Call Wp(j tf5personallyappeared r OL A( 14fL) fdtmall who proved to 304 f who proved to me on the basis of satisfactory evidence to be the person(s) me on the basis of satisfactory evidence to be the person(s) whose name(s)is/are subscribed to the within instrument and whose name(s)is/are subscribed to the within instrument and acknowledged to me that helshelthey executed the same in acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their his/her/their authorized capacity(ies),and that by his/her/their signature(s) on the instrument the person(s), or the entity signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the upon behalf of which the person(s) acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of Califomia that the foregoing paragraph is true and correct. correct. WITNESS my hand a`ndlofficial WITNESS my hand and official t Notary Signature: V W C' 7QYt U1 t,l Wt,L Notary Signature: LV se W U Notary Seal:VICTORIA DEAN-WALTERS Notary Seal: Commission Ar 2019626 VICTORIA DEAWWALTERS Notary Public California. z Commission#t 7019628 Riverside County '— 004 COMM EX Notvy Public-California. COMM.. Es Tres A r 13.2017 Riverside County 7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0009 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 O b i ectives/Activities The intent of this program is to provide extremely low income to low-income seniors with emergency assistance who are experiencing a severe financial crisis and at-risk for housing insecurity or becoming homeless. The program will serve 75 seniors Valley-wide and 50 Palm Springs' seniors - 55+ years of age. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise, market and publicize the program to facilitate positive promotion for all parties i.e., Provider, City. CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income qualify at least a total of fifty (50) extremely low income to low-income Palm Springs' seniors in accordance with Exhibit D for new access to services. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming to fifty (50) Palm Springs' seniors. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports — referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31s`, and program completion, June 301h. Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination / EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors, At-Risk Youth, Severely Disabled Adults, and Special need Population. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in this Agreement. Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/16 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0009 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel 0 - 144,692. 144,692. 2 Consultant/Contract Services 0 - 3,000.3,000. 3 Travel 0 - 375. 375. 4 Space Rental 0 - 13,125. 13,125. 5 Consumable Supplies 0 - 1,050.1,050, 6 Rental, Lease or Purchase of 0 - 0- 0 - E ui ment 7 Insurance 0 - 0- 0- 8 Other— 15,000. 19,450. 34,450. Emergency Assistance 0 - 18.169. 18,169. Indirect Cost @ 10% TOTALS 15,Q00. 199,861. 224,86 If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding, grantor/lending agency, and cost category information. Other funding sources include fundraising activities conducted by JFSD's through other local governmental grants, all totaling$20,000. The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The Subrecipient recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over a twelve month period of July 1, 2016 through June 30, 2017 with funds allocated from 2016—17 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/0009 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Providers Insurance Company Non-profits' Ins Alliance Effective Dates of Policy 02/23/16 to 02/23/17 Claims Made Policy / / Per Occurrence Policy Limits of Liability 2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 0 Yes No Original Certificate of Insurance Attached Yes d No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 06/01/16 to 06/01/17 Limits of Liability 1 M Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached Yes Q No JEWIS-2 OP ID: NY A R CERTIFICATE OF LIABILITY INSURANCE DA09/2812016TEY) o9rzarzol6 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Pen nbrookrCAIB Insurance Svcs. NAME: William Levin License#0622553wWw.pbcis.com uc°wE .415-820.2200 FAX No; 415.'i94.8332P.O.Box 26849 E-MAIL San Francisco,CA 94126-6849 ADDRESS: Wllliam Levin INSURER(S)AFFORDING COVERAGE NAIL# NSURERA:Nonprofits'Ins Alliance INSURED Jewish Fa mily Service INSURER B:of the Desert 490 So.Farrell Drive#C-208 INSURERC: Palm Springs,CA 92262 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. S TYPE OF INSURANCE D POUCYNUMBER suffil MMNDY FF MIDDPIYYFY LIMITS A X COMMERCIAL GENERAL I BILITY EACH OCCURRENCE 1,000,00 CLAIMS-MADE OCCUR X 2016.15000-NPO 02/2312016 0212312017 PREMISES Ea occurrence E 500,00 00 A X Professional Lia 2016.15000-NPO 02123/2016 02123/2017 MED EXP(Anyone person) It 20,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIM IT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY JET LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER: POMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00Eaamident AANY AUTO 2016.15000-NPO 02/23/2016 0212312017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Par accdem) $ HIRED AUTOS X NON-OWNED PROPERTY DAMAGEAUTOSPeraccident) a X UMBRELLA LIAR OCCUR EACH OCCURRENCE 4,000,00 A EXCESS LIAB CLAIMS-MADE 2016-15000-UMB-NPO 02123/2016 02/23/2017 AGGREGATE S 4,000,00 DED I X I RETENTION$ 10,000 D&O UMB 4,000,00 WORKERS COMPENSATION PER OT - AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR,PARTNEWEXECUTIVE E.L.EACHACCIDENTOFFICERIMEMBEREXCLUDED' NIA Mandatory in NMI If E.L.DISEASE-FA EMPLOYE Eyee,describe unde DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A D&O Liability 2016-15000-DO-NPO 0212312016 1212312117 Each Act 1,000,00 Aggregate 2,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) Certificate holder is hereby included as additional insured with repects to the General Liability policy per written contract. CERTIFICATE HOLDER CANCELLATION CITYOPS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. Attn: City Clerk P.O. Box 2743 AUTHORIZED REPRESENTATIVE Palm Springs,CA 92262 I ' 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Commercial General Liability Endorsement Example POLICY NUMBER: GL00000000 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Palm Springs PO Box 2743 Palm Springs,CA 92262 Attn:City Clerk If no entry appears above, the information required to complete this endorsement will be shown in the Declaration as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. a. The City of Palm Springs,its officers,officials,employees and volunteers are to he covered as additional insureds. b. For any claims related to this project,named insured's insurance coverage shall be primary and non-contributory to any insurance maintained by the certificate holder. C. Each insurance policy required shall be endorsed that a thirty(30)day notice be given to CITY in the event of cancellation or modification to the stipulated insurance coverage. CG 20 10 10 93 t POLICYHOLDER COPY SP STATE P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06-01-2016 GROUP: POLICY NUMBER: 1396208-2016 CERTIFICATE 10: 22 CERTIFICATE EXPIRES: 06-01-2017 06-01-2016/08-01-2017 CITY OF PALM SPRINGS SP PO BOX 2743 PALM SPRINGS CA 92263-2743 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 30 days advance written notice to the employer. We will also give you 30 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 bby.the policy dedescribed Aherein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT X0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2015-06-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF PALM SPRINGS ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT M2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2016-08-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF PALM SPRINGS EMPLOYER JEWISH FAMILY SERVICE OF THE DESERT (A SP NON-PROFIT PUBLIC BENEFIT CORP) 490 S FARRELL DR STE C208 PALM SPRINGS CA 92282 P19,SK] REV.7-2014) PRINTED 09-23-2016 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/0009 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described project/activity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA-03128116) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL-$61,400 EXTREMELY LO INCOME $13,450 $16,020 $20,1600 $24,300 $28,440 $32,580 $36,730 $40,890 0 30%of AMI LOW INCOME $22,400 $25.600 $28,800 $31,950 $34,550 $37,100 $39,650 $42,200 30-50%of AMI MODERATE INCOME $35,800 $40,900 $46,000 $51,100 $55,200 $59,300 $63,400 $67,500 50-80%of AMI NON LOW&MOD INCOME $35,801 $40,901 $46,001 $51,101 $55,201 $59,301 $63,401 $67,501 80% 3. What racelethnicity do you identify yourself as; please note that this self4dentification is voluntary in accordance with equal opportunity laws? White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY Yes No If yes, check one: Mexican/Chicano Puerto Rican CubanOther: 4. Are you female Head of Household? YES NO 5. Do you have a disability? YES NO If YES, please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG) program purposes, a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Proiect Number: Jewish Family Service of the Desert/ 0009 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT Number of First-Time Program Beneficiaries Serviced: of Households of Persons or= 30%:30-50%: 50-80%: 80%: Number of First-Time Female Headed Households: Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African American Asian AND White_ Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/Afncan American _ Native Hawaiian or Other Pacific Islander —Other HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: Number of Disabled: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0009 Senior Care Emergency Assistance Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT her Emergency Assistance 15,000. 1ffi===== I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b)funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 8 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name, Title, Date Name, Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: If necessary, additional sheet(s)must be attached detailing cost breakdowns, and verified by original signatures. SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this rNday of A LWS4- 2015, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Jewish Family Service of the Desert , (herein "Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et seg.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et sea. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW, THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application and this Agreement. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.0, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive $20,000.00 or more from the City during the 2015 — 2016 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 31 sc of the current fiscal year. 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed FIFTEEN THOUSAND DOLLARS ($15.000.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City periodic statements, in the form of Exhibit F, on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Providers respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25%of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Maureen Forman, Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the City Manager of City. 3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred, voluntarily or by operation of law, without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 2 - 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable: a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; c) Section 3 of the Housing and Urban Development Act of 1968, as amended; d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); 0) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c) and 570.503(b)(8); 1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604; nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); o) The regulations, policies, guidelines and requirements of 24 CFR 570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB Circular Nos. A-102, Revised, A-87, A-110 and A-122 as they relate to the acceptance and use of federal funds under the federally- assisted program; 3 - p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.); s) Maintain property inventory system to numerically identify HUD purchased property and document its acquisition date as is set forth in OMB Circular A-110 Attachment N Property Management Standard 6d; and t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan) in excess of$25,000 is either: i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or ii) Not used in accordance with paragraph (t)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (t) of this section.) u) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars($1,000,000). 4 - 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys' fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 DISCRIMINATION, TERMINATION, AND ENFORCEMENT. 6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal, state or local law. 6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one(1)year from the date hereof. 6.3 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Jewish Family Service of the Desert—JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 5 - 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. End—Signatures on Next Page ] 6 - CITY OF PALM SPRINGS ATTEST: a municipal corporation By By. ity Clerk / City Manager APPROV (5 TOFORM: APPROVED BY CITY COUNCIL By: City At rney PROVIDE Check one: _ Individual _Partnership )_Corporation Corporations require two notarized signatures: One signature must be from the Chairman of Board, President, or any Vice President. The second signature must be from the Secretary, Assistant Secretary, Treasurer, Assistant Treasurer, or Chief Financial Officer). J By: 1 K 0'I n By: J Notarized Signature of Chairman o Board, Nott ed ignature Secretary, As ecretary, President or any Vice President Treasurer, As Treasurer or Chief financial Officer Name: T n Nam Title: ea 1 ( } J}Title: State of 'A7, -D p-, - State off", OCountyof )4yFR51OF -ss County of Fr\IL9,mr -ss A notary public or other officer completing this certificate A notary public or other officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that document. the truthfulness,accuracy,or validity of that document. State of •{ i ' r' ) State of 1FUFO2nt n- ) County of ( V U' 1aC )ss.County of IZnw,r-slor— )ss. O 1243ii ' before me, Onnn,, 69.t I I 2ol6 before me, er onatlyappeared IcLbE L NA)Q, W upersonally appeared l .A72DL E2Af-Ew1 who proved to f 4.1(- r[ F who proved to me on the basis of satisfactory evidence to be the person(93 me on a basis of satisfactory evidence to be the personKwhosenameo)6hmm-subscribed to the within instrument and whose name 4 eve"subscribe to the within instrument and acknowledged to me that-he theT executed the same in acknowledged to me that Ae1ieuey-executed the same in44yriAheirauthorizedcapacity#oe), and that by er 4* Itheir authorized capacity(ies), and that byifise*ftrsignature(,$) on the instrument the person(yf, or t to entity signature(%) on the instrument the person($), or the entity upon behalf of which the person(g) acted, executed the upon behalf of which the person(p'f acted, executed theinstrument.instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true andcorrect. correct. WITNESS my hand and official sea[. WITNESS my hand and Jof fcial sea]. f Notary Signature: d h•tlD Notary Signature: D Notary Seal: Notary Seal: ROSE L.GRANADO ROSE L.GRANADO+([ Commisslon# 1986906 jAnkCommission# 1986986 L Notary Public•CalHornla zZ San Bernardino County Notary Public-California San Bernardino County omm. a 1S1&JFS 91be 1Ag MJU15 7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Pro6ect/Actiyity Title: Project Number: Jewish Family Service of the Desert/ 0008 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert -JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 O bi ectives/Activities The intent of this program is to provide substance abuse resistance education and training to fourth and fifth grade students in the Palm Springs Unified School District. It is an innovative program which Counselors offer a comprehensive evidence based alcohol, tobacco, and substance abuse prevention training and education to students. The program will serve eight hundred and fifty (850) youth city-wide within the Palm Springs schools of which five hundred and thirty-seven (537)will be Palm Springs' youth. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise, market and publicize the program to facilitate positive promotion for all parties i.e., Provider, City, CDBG. etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income qualify at least a total of five hundred and thirty-seven (537) extremely low income to moderate-income Palm Springs youth in accordance with Exhibit D for new access to services. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming to five hundred and thirty-seven (537) Palm Springs' youth. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports — referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31", and program completion, June 30`n Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination / EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors At-Risk Youth Severely Disabled Adults. and Special need Population. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in this Agreement. Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/16 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0008 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert- JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel 0 - 45,490. 45,490. 2 Consultant/Contract Services 0 - 0 - 0 - 3 Travel 0 - 0 - 0 - 4 Space Rental & Utilities 0 - 6,500. 6,500. 5 Consumable Supplies 0 - 10,455. 10,455. 6 Rental, Lease or Purchase of 0 - 1 ,180. 1,180. Equipment 7 Other 0 - 16,375. 16,375. Curriculum/Evaluation 8 Other 15,000. 0 - 15,000. Scholarships $27.94 TOTALS $15,000. 80,000. 95,000. If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding,grantor/lending agency, and cost category information. Other funding sources include fundraising activities conducted by JFS's through other local governmental grants, all totaling$20,000. The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The program will pay for $27.94 per Palm Springs' student, at a total amount not to exceed $15,000. Payments approved by the Subrecipient and based upon the actual number of very-low to moderate income eligible scholarships awarded in the prior period, shall be paid by the 301" day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. The Subrecipient recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over the twelve-month period of this 2015 — 16 Program Year — July 1, 2015 through June 30, 2016. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Title: Project Number: Jewish Family Service of the Desert/0008 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Nonprofits' Ins Alliance Effective Dates of Policy 02/23/15 to 02/23/16 Claims Made Policy I / Per Occurrence Policy / I Limits of Liability 2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 10 Yes No Original Certificate of Insurance Attached Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 06/01/15 to 06/01/16 Limits of Liability 1 M Per Occurrence Underlying Coverage Limits Unlimited Original Certificate of Insurance Attached Yes 10 No CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title: Protect Number: Jewish Family Service of the Desert/0008 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert -JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described projectlactivity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA-03106/15) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL-$60,500 EXTREMELY LOW INCOME $13,100 $15,930 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 0 30%of AMI LOW INCOME $21,750 $24,850 $27,950 $31,050 $33,550 $36,050 $38,550 $41,000 30-50%of AMI MODERATE INCOME $34,800 $39,800 $44,750 $49,700 $53.700 $57,700 $61,650 $65,650 50-800/of AMI NON LOW 8 MOD INCOME $34.801 $39,801 $44,750 $49,701 $53,701 $57,701 $61,651 $65,651 80% 3. What racelethnicity do you identify yourself as; please note that this self-identification is voluntary in accordance with equal opportunity laws? White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY Yes No If yes, check one: 0 Mexican/Chicano Puerto Rican CubanOther: 4. Are you female Head of Household? YES NO S. Do you have a disability? YES 0 NO If YES, please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes, a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/0008 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT Number of First-Time Program Beneficiaries Serviced: of Households of Persons or=30%:30-50%: 50-80%: 80%: Number of First-Time Female Headed Households: Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Havfaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: Number of Disabled: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/0008 Kids First Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 BENEFICIARY QUALIFICATION STATEMENT ff Other Scholarships 15,000.00 I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the Cl has not previously been billed for the costs covered by this invoice, (b) funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 & 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name, Title, Date Name, Title, Date City o Use Unly Audited by: Examined by: Approved by: If necessary, additional sheet(s)must be attached detailing cost breakdowns, and verified by original signatures. Dal eC/CDBG 1516/JFS_Subae lantExhbtst,Jul 15 M I I* SUBRECIPIENT AGREEMENT 4n THIS AGREEMENT(herein "Agreement'), is made and entered into this day of Y tl F rNL7 , 2014, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Jewish Family Service of the Desert , (herein "Provider'). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et seg.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 at sea. ("Regulations");and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW. THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.2, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive or due to receiver 20,000.00 or more from the City during the 2014 — 2015 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Providers financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 31"of the current fiscal year. 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed EIGHTEEN THOUSAND, ONE HUNDRED AND FORTY-FIVE DOLLARS 18 145.00)(the"Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City monthly statements on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Provider's respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25%of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Maureen Forman, Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the chief administrative officer of City. 3.3/ Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred, voluntarily or by operation of law,without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of city. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 2- 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable: a) Submit to City through its Community and Economic Development Department semi-annual reports on program status, b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; c) Section 3 of the Housing and Urban Development Act of 1968, as amended; d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; g) The Age Discrimination Act of 1975 (P.L. 94-135. as amended, and implementing regulations; h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); Q) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c) and 570.503(b)(8); 1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604, nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234). o) The regulations, policies, guidelines and requirements of 24 CFR 570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB Circular Nos. A-102, Revised, A-87, A-110 and A-122 as they relate to the acceptance and use of federal funds under the federally- assisted program; 3 - p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et sec.); s) Maintain property inventory system to numerically identify HUD purchased property and document its acquisition date as is set forth in OMB Circular A-110 Attachment N Property Management Standard 6d; and t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan) in excess of$25,000 is either: i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or ii) Not used in accordance with paragraph (s)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (s) of this section.) u) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars($1,000,000). 4 - 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys'fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 DISCRIMINATION, TERMINATION AND ENFORCEMENT. 6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal, state or local law. 6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one(1)year from the date hereof. 6.3 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Jewish Family Service of the Desert—JFS 801 E Tahguitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 5- 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. End — Signatures on Next Page] 6 - CITY OF PALM SPRINGS ATTEST: a municipal corporation City Clerk City Manager AP*DFORM: APPROVED BY CriY COUNCIL By: 44Ab51) PROe: _Individual _Partnership _Corporation Corporations require two notarized signatures: One signature must be from the Chairman of Board, President, or any Vice President. The second signature must be from the Secretary, Assistant Secretary, Treasurer, Assistant Treasurer, or Chief Financial OOfficer). By:C l By: Y . dU Notarized Signature of Chairma of Board, Notarized Si nature Secretary Asst Secre ry, President or any Vice President Treasurer,As Treasurer or Chief Financial Officers f Name: D C)rC K . rn[] Name:,LQgk 1" K /-11 V Title: Vr—c t Title:7` 1)v-1f s 7 F—/Z State of LAL4ECO_LhL a State of County of 1211A.!F.,of =ss County of JZr.'W--ss O7n7_,f l Sf 2t] /before me. On ps at. rfww2,01-4 before me, I/`^ckg L. S7- . 9,4 /i, personally appeared (t,C L 51 tiI,w• J.e.:r personally appeared L--f' oj-,1. K . -FAAyy ,% who proved to B^V. R-A .r< M r who proved to me on the basis of satisfactory evidence to be the person(81 me on the basis of satisfactory evidence to be the person(sf whose name( I are subscribed to the within instrument and whose name(A)&O w subscribed to the within instrument and acknowledged to—me that sh mey executed the same in acknowledged to me that( peFtpey-executed the same inhiseritauthorizedcapaciy-yes), and that byAis ef'ipeir p'ker!w&*authorized capacity(iec), and that Is signatureg) on the instrument the person(j), or the entity signature($) on the instrument the person($), or the entity upon behalf of which the personol acted, executed the upon behalf of which the person(g) acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and correct. correct. WITNESS my hand and official seal. , y A WITNESS my hand and official weal. 1 Notary Signature:yQ _ xo.l' J Notary Signature: Notary Seal: Notary Seal: RO SE L. GRANADO Motary GRANADO commission # 1986986 1986986za, Notary Public-California s i. c -California izSanBernardinoCountySanBernardinoCountyn My Comm. Expires Aug3,2016 My Camm. Expires Aug 3, 2016 Da4s=DBG 14-I&JFS_SubrecipAgmmt Juh 4 7- CITY OF PALM SPRINGS EXHIBIT A Scope of Services ProiectlActivity Title: Proiect Number: Jewish Family Service of the Desert/ 0006 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 O bi ectives/Activities The intent of this program is to provide substance abuse resistance education and training to fifth grade students in the Palm Springs Unified School District. It is an innovated which Counselors offer a comprehensive evidence based alcohol, tobacco, and substance abuse prevention training and education to students. The program will serve five hundred and ninety-five (595) youth city-wide within the Palm Springs schools of which four hundred fifty (450)will be Palm Springs' youth. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise market and publicize the program to facilitate positive promotion for all parties i.e., Provider. City CDBG etc TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income qualify at least a total of four hundred fifty (450) very low income to moderate-income Palm Springs youth with new access to services TARGET DATE ACTIVITY#1 On-Going Provide direct client programming to four hundred fifty (450) Palm Springs' youth. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports—referenced Exhibit E. Objective 6: Manage/monitor program activities TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination / EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors At-Risk Youth Severely Disabled Adults. and Special need Population TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in the proposal. Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/13 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0006 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 BUDGETSUMMARY COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel 0 - 35,464. 35,464. 2 Consultant/Contract Services 0 - 0 - 0 - Travel 0 - 0 - 0 - 4 Space Rental & Utilities 0 - 3,300. 3,300. 5 Consumable Supplies 0 -700. 700. 6 Rental, Lease or Purchase of 0 -400. 400. Equipment 7 Other 0 - 1,025. 1,025. Training/Conferences 8 Other 18,145. 0 - 18,145. Scholarships $40.32 TOTALS1 $18,145. 40,889. 1 $59,034. If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding,grantor/lending agency, and cost category information. Other funding sources include fundraising activities conducted by JFS's through other local governmental grants, all totaling$20.000. The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The program will pay for$40.32 per Palm Springs' student, at a total amount not to exceed$18,145. Payments approved by the Subrecipient and based upon the actual number of income eligible scholarships awarded in the prior period, shall be paid by the 3dh day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. The Subrecipient recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over the twelve-month period of this 2014 — 15 Program Year— July 1, 2014 through June 30, 2015. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory ProiectlActivity Title: Proiect Number: Jewish Family Service of the Desert/0006 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Nonprofits' Ins Alliance Effective Dates of Policy 02/23/14 to 02/23/15 Claims Made Policy _ / / Per Occurrence Policv Limits of Liability 2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 0 Yes No Original Certificate of Insurance Attached Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 06/01/14 to 06/01/15 Limits of Liability 1 M Per Occurrence Underlying Coverage Limits Unlimited Original Certificate of Insurance Attached 0 Yes 10 No JEWIS-2 OP ID: NY A Ro CERTIFICATE OF LIABILITY INSURANCE 1211811412/18l14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER 416-820.2200 CONTACT Pennbrook/CAIB Insurance Svcs. w 415-394.8332 PHONE FAXLicense#0622553 ww.pbcis.com A/C No.Eat: AIX No: P.O.Box 26849 E-MAIL San Francisco,CA 94126-6849 ADDRESS: William Levin INSURE S AFFORDING COVERAGE HAND INSURER A:Nonprofits'Ins Alliance INSURED Jewish Family Service INSURER B: of the Desert 801 E.Tahquitz Canyon Wy#202 INSURERC: Palm Springs,CA 92262 1.M ERD: U..: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR RML WON POLICY EFF POLICY EX LTR TYPE OF INSURANCE POLICY NUMBER iMMIDDNYYYI (MMNDDfYYY`Y1LIMITS GENERAL LIABILITY EACH OCCURRENCE E 1,000,00 A X COMMERCIAL GENERAL LIABILITY X 201415000NPO 02/23114 02123//5 PREMISES Ee ocwnence s 500,00 CLAIMS-MADE OCCUR MEDEXP( one Person) It 20,00 A X Professional LIB 201415000NPO 02(23H4 02123115 PERSONAL B AM INJURY f 1,000,00 GENERAL AGGREGATE f 2,000,00 GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,00 PoLICY PRO- LOC S AUTOMOBILE LIABILITY COMBINED 69NULtLIMIT 1'000'0FoEsscader A ANY AUTO 201415000NPO 02123/14 02123115 BODILY INJURY(Pw Person) f AUTOSOS AUTOS SCHEDULED AU BODILY INJURY Per aoostem) ItXHIREDAUTOSIxNON-OWNED pR ER AUTOS PereW i X UMBRELLA LIAB OCCUR EACH OCCURRENCE 2,000,00 A MESS LAB CLAIMS-MADE 201415MUMBNPO 02=14 02123/15 AGGREGATE S 2,000,00 DED X I RETENTIONS 10000 D&O UMB s 4,000,00 WORKERS COMPENSATION 7 wCSTATU- T H- AND EMPLOYERS'LIABIUTY YIN VER ANY PROPRIETORIPARTNER/ ECUTNE E.L.EACH ACCIDENT fOFFICERIMEMBEREXCLUDED'NIA Mandatory In NH) E.L DISEASE-EA EMPLOYE f II yas,deacdln under E.L DISEASE-POLICY LIMIT EDESCRIPTIONOFOPERATIONSDalow A D&O Liability 201415000DONPO 02123114 02123115 Liability 1,000,00 Aggregate 2,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES (Attach ACORD 101,Additional Remarks Schedule,K more space Is required) Certificate holder is hereby included as additional insured with repects to the General Liability policy per written contract. CERTIFICATE HOLDER CANCELLATION CITYOPS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. Attn: City Clerk P.O.Box 2743 AUTHORIZED REPRESENTATIVE Palm Springs,CA 92262 19T88-201100 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 11 0196 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Designation of Premises (Part Leased to You): 2. Name of Person or Organization (Additional Insured): Any person or organization acting as a manager or lessor of a covered premises that you are required to name as an additional insured on this policy, under a written contract, lease or agreement currently in effect, or becoming effective during the term of this policy. 3. Additional Premium: Included If no entry appears above, the information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the prem- ises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any"occurrence"which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 1101 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 12 07 98 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Political Subdivision: Any State or Political Subdivision that issues a permit to the named insured. If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an insured any state or political subdivi- a. 'Bodily injury,""property damage"or"personalsionshownintheSchedule, subject to the following and advertising injury" arising out of opera- provisions: tions performed for the state or municipality; 1. This insurance applies only with respect to opera- or tions performed by you or on your behalf for b. 'Bodily injury" or "property damage" includedwhichthestateorpoliticalsubdivisionhasissuedwithinthe "products-completed operationsapermit. hazard". CG 20 12 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the fallowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izatio n s : Locations Of Covered Operations Any person or organization that you are required to All insured premises and operations add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" ordamage" or "personal and advertising injury" property damage" occurring after:caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts equip- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work' out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 2010 07 04 ISO Properties, Inc., 2004 Page 1 of 1 POLICYHOLDER COPY SK STATECQM E145ATION P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 12-18-2014 GROUP: POLICY NUMBER: 1396208-2014 CERTIFICATE ID: 20 CERTIFICATE EXPIRES: 06-01-2015 08-01-2014/00-01-2015 CITY OF PALM SPRINGS SK PO BOX 2743 06-01-2014 PALM SPRINGS CA 92263-2743 SK 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 30 days advance written notice to the employer. We will also give you 30 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 dbby the policy describedooliiccydescribed herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative% President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2014-12-18 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF PALM SPRINGS ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2014-12-18 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF PALM SPRINGS EMPLOYER JEWISH FAMILY SERVICE OF THE DESERT (A SK NON-PROFIT PUBLIC BENEFIT CORP) 801 E TAHQUIT2 CANYON WAY STE 202 PALM SPRINGS CA 92282 IP19,SK] REV.7-2014) PRINTED : 12-18-2014 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1 . Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job:5, 000 . 00 Sample Rate : 13 . 30e Regular Premium equals : 665 . 00 Surcharge :3 . 0096 Additional Waiver charge : $ 19 . 95 Total premium equals 684 . 95 (665 . 00 + 19 . 95) CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement ProiecUActivity Title: Project Number: Jewish Family Service of the Desert/ 0006 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described projectlactivity. Please answer each of the following questions. 1. How many persons are In your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual Income(Rivenside-San Bernardino-Ontario,CA MSA—12118113) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL-$60 700 EXTREMELY LO INCOME $12,750 $15.730 $19,790 $23,850 $27,910 $31,970 $36,030 $40,090 0-30%of AMI VERY LOW INCOME $21,250 $24,300 $27.350 $30,350 $32,800 $35,250 $37,650 $40,100 31-50%of AMI LOW INCOME $34,000 $38,850 $43,700 $48,550 $62,450 $56,350 $60,260 $64,100 51-80%of AMI MODERATE INCOME $60,990 $58,270 $65,560 $72,840 $78,670 $84.500 $90,320 $96.150 81-120% 3. What racelethnicity do you Identify yourself as; please note that this self-Identification is voluntary In accordance with equal opportunity laws? White American Indian or Alaska Native AND White Black/African American Asian AND White Asian 0 Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY Yes No If yes,check one: 0 Mexican/Chicano 0 Puerto Rican CubanOther: 4. Are you female Head of Household? YES NO 5. Do you have a disability?YES 0 NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME:DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG) program purposes,aFederally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Protect Number: Jewish Family Service of the Desert/ 0006 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT Number of First-Time Program Beneficiaries Serviced: of Households of Persons 0-30%below: 31-50%below: 51-80%below: 81-120%below: Number of First-Time Female Headed Households: Counts by Race/Ethnicity: White _ American Indian or Alaska Native AND White _ BlacklAfrfcan American Asian AND While_ Asian _ Black/African American AND White_ American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American _ Native Hawaiian or Other Pacific Islander —Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: Number of Disabled: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Protect Number: Jewish Family Service of the Desert/ 0006 KidsFirst Healthy Life Program Name/Address of Provider: Jewish Family Service of the Desert-JFS 801 E Tahquitz Canyon Way, Ste 202 Palm Springs, CA 92262-6763 BENEFICIARY QUALIFICATION STATEMENT Approved Current Prior Total Grant Description Grant Reimbursement Reimbursement YTD Balance Amount Period Period(s) Reimbursement (Over?under) Other Scholarships 18,145400 TOTAL 18,145.00 i CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b) funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 & 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name, Title, Date Name, Title, Date Ulty Or se Unly Audited by: Examined by: Approved by: If necessary, additional sheet(s)must be attached detailing cost breakdowns,and verified by original signatures. DaleCICDBG14-161JFS SWrecpnntF_ Ns1.JJ14 CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 SIP CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06-01-2024 CITY OF PALM SPRINGS PO BOX 2743 PALM SPRINGS CA 92263-2743 SIP GROUP: POLICY NUMBER: 1396208-2024 CERTIFICATE ID: 35 CERTIFICATE EXPIRES: 06-01-2025 06-01-2024/06-01-2025 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 30 days advance written notice to the employer. We will also give you 30 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. ,7 Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2023-06-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF PALM SPRINGS ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2023 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER JEWISH FAMILY SERVICE OF THE DESERT (A SIP NONPROFIT MUTUAL BENEFIT CORP.) (A NONPROFIT MUTUAL BENEFIT CORP.) DBA: JEWISH FAMILY SERVICE OF THE DESERT 490 S FARRELL DR STE C208 PALM SPRINGS CA 92262 RECEIVED MAY 2 8 2R2 -' vICE OF THE CITY CLERK M0408 PRINTED : 05-16-2024 (REV.7-2014) 1J..-rtie ' ,d ILr - i� - _ . r -a ram_. . Nrr b T — _, .-. 'r_ J, i_r} Ia i:y