HomeMy WebLinkAboutA6667 - SENIOR ADVOCATES OF THE DESERTSUBRECIPIENT AGREEMENT
THIS AGREEMENT (herein "Agreement"), is made and entered into this_day of &
2017, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter
city, and the Senior Advocates 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 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 2017 — 2018 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 fumished not later than
January 31st of the current fiscal year.
ORIGINAL BID
AND/OR AGREEMENT
2.0 COMPENSATION.
2.1 t Contract Sum. The City shall pay to the Provider on a reimbursable basis for its
services a sum not to exceed FOURTEEN THOUSAND, ONE HUNDRED AND FORTY-ONE
DOLLARS ($14,141.001 (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-1 22 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:
Chris O'Hanlon, MSW, 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 ofithe program.
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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);
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 Super
Circular 2 CFR 200 as they relate to the acceptance and use of
federal funds under the federally-assisted program;
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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 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
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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 attomeys'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.
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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:
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
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]
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CITY OF PALM SPRINGS
ATT a municipal corpgration
By'
Ity Clerk City Manager
APPROV AS O F APP p BY CITY COUNCIL
By: Y14 2-A. AUkl
City Attorney P194 L
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 ecretary, Treasurer, Assistant Treasurer, or Chief Fi ancial Officer .
By: y w"By: C-, g(-'a
Notarized Signature of Chairman of Board, Notarized Signature Secretary,Asst Secretary,
nPresident or any Vice President Treasurer,As st Treasurer or Chief Financial Officer
Name: br"440 fher ® H6n10,1 Name: .1,, 2 t u--
Title: I're rf AC4 Title: J t'_a at e
State of Cq/-1 i'>- )4- ) State of CAS w• 4- )
County of 1 V' L 11)(? )ss County of I f -5 1 )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 CAL11Zl,in/ A- ) State of CAL 1 ',',A )
County of 1k1 Ln f C )ss.County of ( ilC )ss.
On (gC TatStry'— au/ before me, O DC-TD "L U 1
77
before me,
AiZecp F((G1 c rplq J NJ1Rnfpersonally appeared Aita J JCY? ,l -/; /'1 J1 ier5onally appeared
C RRI S ro pllf{j U1(!} t c`J
who proved to 30 H J f• A)y'LJvJ 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) islare subscribed to the within instrument and whose name(s)is/are subscribed to the within instrument and
acknowledged to me that he/she/they 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 California that the foregoing paragraph is true and
correct. correct.
WITNESS my hand an official se I. WITNESS my hand an official seal.
Notary Signature '514 W Notary Signature: L`t
Not@ry Seal . Notary•Seal:
HAROLOFtERGHOI)Ul:,i
Commission 2055704 ei ' ( 5 n
Notary Public California `
h' Not ryPuli r -.
Riverside County Rivcr otr ,
YNy Comm.Fx FcluMComm.Ex Tres Feb 19,201C ii
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DaIeCJCDD 171a'51Adwc ft—a GeupAgm,rR.O 1
7
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/0005
Senior Emergency Assistance
Name/Address of Provider:
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
Objectives/Activities
The intent of this program is to provide one-time emergency financial assistance to low-income seniors to
alleviate an extreme hardship affecting their health, safety or well-being. The program will serve fifty (50)
seniors city-wide.
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.
CITY OF PALM SPRINGS
EXHIBIT B
Budget Summary
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/0005
Senior Emergency Assistance
Name/Address of Provider.
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
it ,w,.. a.? .n s,.i: Aug +:•.w
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel Services 0 - 3,000. 3,000.
2 Consultant/Contract Services 0 - 0 - 0 -
3 Travel 0 - 0 - 0 -
4 Space Rental & Utilities 0 - 0 - 0 -
5 Consumable Supplies 0 - 0 - 0 -
6 Rental, Lease or Purchase of 0 - 0 - 0 -
Equipment
7 Other 14,141. 0 - 14,141.
Financial Assistance
TOTALS1 $14,141. 1 $3,000. 1 $17,141.
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 source received by Senior Advocates was private donations, all totaling $3,000.
The Subrecipient shall submit monthly reimbursement based on prorated and actual costs in
accordance with the aforementioned cost categories and pay items. In no month shall the
Subrecipient submit for reimbursement more than %of the total annual budget.
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 2017 — 18 Program Year— July
1, 2017 through June 30, 2018.
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/ 0005
Senior Emergency Assistance
Name/Address of Provider:
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Non Profits Insurance Alliance of California (NIAC)
Effective Dates of Policy 12/10/16 to 12/10/17
Claims Made Policy / / Per Occurrence Policy I 1
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 Q No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company Twin City Fire Ins. Co.
Effective Dates 06/25/17 to 06/25/18
Limits of Liability 1 M Per Occurrence
Underlying Coverage Limits Unlimited
Original Certificate of Insurance Attached 0 Yes Q No
ACORU®
DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 1 012 0/2 01 7
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(ies)must have ADDITIONAL INSURED provisions or 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 endorsement(s).
PRODUCER CONTNAME: 1st Community Insurance Services
Ist Community Insurance Services PHONEAICNo EXt: AIC No):
PO Box 2408 E-MAIL service r@cisps.comADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC e
Palm Springs CA 92263 INSURERA: Non Profits Insurance Alliance of California NIAC
INSURED INSURERB:
Senior Advocates of the Desert INSURER C:
P.O.Box 2827 INSURER D:
INSURERE:
Cathedral City CA 92235 INSURERF:
COVERAGES CERTIFICATE NUMBER: 2016-2017 Liability REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
ILTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MM/DD/WYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE FRI OCCUR PREMISES Ea occurrence $
500.000
MED EXP(Any oneperson) $
20,000
A Y 2016-38222 12/10/2016 12/10/2017 PERSONAL BADVINJURY $ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
X JERCT LOG PRODUCTS-COMP OP AGG $ 2,000,000POLICYEl
OTHER: Liquor Liability s 1,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANY AUTO BODILY INJURY(Per person) $
A OWNED F SCHEDULED 201638222 12/10/2016 12JI012017 BODILY INJURY(Peraceident) $
AUTOS ONLY AUTOS
HIRED NON-OWVNED PROPERTY DAMAGE
X AUTOS ONLY X AUTOS ONLY Pe-accident
UMBRELLA LAB OCCUR EACH OCCURRENCE
EXCESS LIAR CLAIMS-MADE AGGREGATE
DED RETENTION S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
YIN
ANY PROPRIETORiPARTNER/EXECUTIVE El E.L.EACH ACCIDENT
OFFICERIMEMBER EXCLUDED?
Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below L E,L,DISEASE-POLICY LIMIT $
1,000,0DO
Directors and Officers Liability
A 201 Cr38222 12/10/2016 12/10/2017
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1e1,Additional Remarks Schedule,may be attached R more apace is required)
Certificate holder is named as additional insured V indicated by"Y"above. Additional insured status applies only to the extent that the
work is performed under or subject to a written agreement or contract. The policy provisions govern in all situations.
Additional Insureds:The City of Palm Springs,its officers,officials,employees and volunteers.
CERTIFICATE HOLDER CANCELLATION
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
AUTHORIZED REPRESENTATIVE
P.O.Box 2743
Palm Springs CA 92262
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
NMINONPROFITSINSURANCE
ALLIANCE OF CALIFORNIA
A Head for Insurance.A Heart for Nonprofits.
POLICY NUMBER: 2016-38222
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT
FOR PUBLIC ENTITIES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. SECTION II —WHO IS AN INSURED is amended to include any public entity as an additional insured for whom
you are performing operations when you and such person or organization have agreed in a written contract or
written agreement that such public entity be added as an additional insured(s) on your policy,
but only with respect to liability for"bodily injury", "property damage"or"personal and advertising injury"
caused, in whole or in part, by:
1. Your negligent acts or omissions; or
2. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing
operations.
No such public entity is an additional insured for liability arising out of the "products-completed
operations hazard" or for liability arising out of the sole negligence of that public entity.
B. With respect to the insurance afforded to these additional insured(s), the following additional exclusions
apply.
This insurance does not apply to "bodily injury" or"property damage" occurring after:
t. All work, including materials, parts or equipment furnished in connection with such work, on the
project (other than service, maintenance or repairs) to be performed by or on behalf of the additional
insured(s) at the location of the covered operations has been completed; or
2. That portion of"your work" out of which injury or damage arises has been put to its intended use by
any person or organization other than another contractor or subcontractor engaged in performing
operations for a principal as a part of the same project.
C. The following is added to SECTION III—LIMITS OF INSURANCE:
The limits of insurance applicable to the additional insured(s) are those specified in the written contract
between you and the additional insured(s), or the limits available under this policy,whichever are less.
These limits are part of and not in addition to the limits of insurance under this policy.
D. With respect to the insurance provided to the additional insured(s), Condition 4. Other Insurance of
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following:
4. Other Insurance
a. Primary Insurance
This insurance is primary if you have agreed in a written contract or written agreement:
NIAC-E61 12 15 Page 1 of 2
1) That this insurance be primary. If other insurance is also primary, we will share with all that
other insurance as described in c. below; or
2) The coverage afforded by this insurance is primary and non-contributory with the additional
insured(s)'own insurance.
Paragraphs (1) and (2) do not apply to other insurance to which the additional insured(s) has
been added as an additional insured or to other insurance described in paragraph b. below.
b. Excess Insurance
This insurance is excess over:
1. Any of the other insurance,whether primary, excess, contingent or on any other basis:
a) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for
your work";
b) That is fire, lightning, or explosion insurance for premises rented to you or temporarily
occupied by you with permission of the owner;
c) That is insurance purchased by you to cover your liability as a tenant for"property
damage"to premises temporarily occupied by you with permission of the owner; or
d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the
extent not subject to Exclusion g. of SECTION I —COVERAGE A—BODILY INJURY
AND PROPERTY DAMAGE.
e) That is any other insurance available to an additional insured(s) under this Endorsement
covering liability for damages arising out of the premises or operations, or products-
completed operations, for which the additional insured(s) has been added as an
additional insured by that other insurance.
1) When this insurance is excess, we will have no duty under Coverages A or B to defend the
additional insured(s) against any"suit"if any other insurer has a duty to defend the additional
insured(s) against that"suit". If no other insurer defends,we will undertake to do so, but we
will be entitled to the additional insured(s)'rights against all those other insurers.
2) When this insurance is excess over other insurance,we will pay only our share of the amount
of the toss, if any, that exceeds the sum of:
a) The total amount that all such other insurance would pay for the loss in the absence of
this insurance; and
b) The total of all deductible and self-insured amounts under all that other insurance.
3) We will share the remaining loss, if any, with any other insurance that is not described in this
Excess Insurance provision and was not bought specifically to apply in excess of the Limits
of Insurance shown in the Declarations of this Coverage Part.
c. Methods of Sharing
If all of the other insurance available to the additional insured(s) permits contribution by equal
shares,we will follow this method also. Under this approach each insurer contributes equal
amounts until it has paid its applicable limit of insurance or none of the loss remains,whichever
comes first.
If any other the other insurance available to the additional insured(s)does not permit contribution
by equal shares, we will contribute by limits. Under this method, each insurer's share is based on
the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers.
NIAC-E61 12 15 Page 2 of 2
POLICY NUMBER: 2016-38222 COMMERCIAL GENERAL LIABILITY
Named Insured: Senior Advocates of the Desert CG 20 10 04 13
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 following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)Location(s)Of Covered Operations
City of Palm Springs All insured premises and operations.
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 2. If coverage provided to the additional insured
include as an additional insured the person(s)or is required by a contract or agreement,the
organization(s)shown in the Schedule, but only insurance afforded to such additional insured
with respect to liability for"bodily injury", 'property will not be broader than that which you are
damage'or"personal and advertising injury" required by the contract or agreement to
caused, in whole or in part, by: provide for such additional insured.
1. Your acts or omissions; or B. With respect to the insurance afforded to these
2. The acts or omissions of those acting on your additional insureds, the following additional
behalf: exclusions apply:
in the performance of your ongoing operations for This insurance does not apply to"bodily injury"or
the additional insured(s)at the location(s) property damage"occurring after:
designated above.
7. All work, including materials, parts or
However: equipment furnished in connection with such
1. The insurance afforded to such additional work, on the project(other than service,
insured only applies to the extent permitted maintenance or repairs)to be performed by
by law; and or on behalf of the additional insured(s)at the
location of the covered operations has been
completed, or
CG 20 10 04 13 9 Insurance Services Office, Inc., 2012 Page 1 of 2
2. That portion of"your work"out of which the 2. Available under the applicable Limits of
injury or damage arises has been put to its Insurance shown in the Declarations,
intended use by any person or organization whichever is less.
other than another contractor or subcontractor
engaged in performing operations for a This endorsement shall not increase the
principal as a part of the same project. applicable Limits of Insurance shown in the
Declarations.
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III—Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement: or
CG 20 10 04 13 Insurance Services Office, Inc., 2012 Page 2 of 2
Policy no.: 2016-38222
SECTION IV—COMMERCIAL GENERAL LIABILITY b. To sue us on this Coverage Part unless all of
CONDITIONS its terms have been fully complied with.
1. Bankruptcy A person or organization may sue us to recover on
Bankruptcy or insolvency of the insured or of the an agreed settlement or on a final judgment
insured's estate will not relieve us of our obliga-
against an insured obtained after an actual trial;
tions under this Coverage Part. but we will not be liable for damages that are not
payable under the terms of this Coverage Part or
2. Duties In The Event Of Occurrence, Offense, that are in excess of the applicable limit of insur-
Claim Or Suit ante. An agreed settlement means a settlement
a. You must see to it that we are notified as soon and release of liability signed by us, the insured
as practicable of an "occurrence" or an offense and the claimant or the claimant's legal represen-
which may result in a claim. To the extent pos- tative.
sible, notice should include:4. Other Insurance
1) How, when and where the "occurrence" or If other valid and collectible insurance is available
offense took place, to the insured for a loss we cover under Cover-
2) The names and addresses of any injured ages A or B of this Coverage Part, our obligations
persons and witnesses; and are limited as follows:
3) The nature and location of any injury or a. Primary
damage arising out of the "occurrence" or This insurance is primary,except when b.below
offense. applies. If this insurance is primary our obliga_
b. If a claim is made or "suit" is brought against tions are not affected unless apy,of the other
any insured, you must: insurance is also primary. Then, we will share
1) Immediately record the specifics of the with all that other insurance by them' hod de-
claim or"suit" and the date received; and scribed in c.below.
2) Notify us as soon as practicable.
b. Excess Insurance
You must see to it that we receive written no-
This insurance is excess over:
tice of the claim or "suit" as soon as practica- 1) Any of the other insurance, whether pri-
bie. mary, excess, contingent or on any other
c. You and any other involved insured must:
basis:
1) Immediately send us copies of any de- a) That is Fire, Extended Coverage,
mands, notices, summonses or legal pa-
Builder's Risk, Installation Risk or similar
pens received in connection with the claim coverage for"your work";
or"suit"b) That is Fire insurance for premises
2) Authorize us to obtain records and other rented to you or temporarily occupied by
information, you with permission of the owner;
3) Cooperate with us in the investigation or c) That is insurance purchased by you to
settlement of the claim or defense against cover your liability as a tenant for "prop-
the"suit"; and erty damage" to premises rented to you
or temporarily occupied by you with
4) Assist us, upon our request, in the en-permission of the owner; or
forcement of any right against any person or
organization which may be liable to the in- d) the loss arises out of the maintenance
osuredbecauseofinjuryordamagetowhichor use of aircraft, "autos" or watercraft to
this insurance may also apply.
the extent not subject to Exclusion of
Section I — Coverage A — Bodily Injury
d. No insured will, except at that insured's own And Property Damage Liability.
cost, voluntarily make a payment, assume any 2) Any other primary insurance available toobligation, or incur any expense, other than for
you covering liability for damages arisingfirstaid, without our consent,
out of the premises or operations for which
3. Legal Action Against Us you have been added as an additional in-
No person or organization has a right under this sured by attachment of an endorsement.
Coverage Part:
a. To join us as a party or otherwise bring us into
a "suit" asking for damages from an insured; or
CG 00 0107 98 Copyright, Insurance Services Office, Inc., 1997 Page 9 of 13
alA
NV AN 1 1%V a 1. J
INSURANCE
ALLIANCE Of CALIrOR A
A Head for Insurance.A Heart for Nonprofits.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDED
NOTICE OF CANCELLATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
BUSINESS AUTO COVERAGE FORM
Cancellation: 30 Days Notice of Cancellation
Person or Organization
City of Palm Springs; Attn: City Clerk
If we cancel this policy for any statutorily permitted reason other than nonpayment of premium, we will mail notice of
cancellation to the person or organization shown above. We will mail such notice to the address shown at least the number
of days shown for cancellation.
KuAi 1n1 .n .n
d CMS
CERTIFICATE OF LIABILITY INSURANCE R054
DAT;(MNVDD/YYYY)
020/2017
THIS CERTIFICATEIS 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(ies)must have ADDITIONAL INSURED provisions or 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 endorsement .
PRODUCER CONTACT
M :
PAYCHEX INSURANCE AGENCY INC PA/°N.,EA)ic.Nae (888) 443-6112
210705 P: F: (888) 443-6112 AOR'ESS
PO BOX 33015 INSURER(S)AFFORDING COVERAGE NAICC
SAN ANTONIO TX 78265 INSURERA: Twin Ci'_Y .'ire Ins Co 29459
WSURED INSURER E
INSURER C:
SENIOR ADVOCATES OF THE DESERT DESERT INSURERD:
34300 DENISE WAY INSURER E:
RANCHO MIRAGE CA 92270 INSURERF'.
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 7TFF0FINSURAA'CE ADDL SUBR POLICYNUMBER
POLICYEFF POLICYE" LIMITS
INSR MOD/YYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
CLAIMS-MADE OCCUR
DAMAGE TO RENTED
PREMISES(Ea ocairrence
MED EXP(Any one person)
PERSONAL B ADV INJURY
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
POLICY PRO- LOC PRODUCTS-COMNOPAGG
JECT
OTHER.
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident)
ANY AUTO BODILY INJURY(Per Person)
OWNED SCHEDULED BODILY INJURY(Per accdent)
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOSONLY Peraccidenp
UMBRELLA LIAB d OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE AGGREGATE
DE RETENTIONS
RPIRRERSCWJ LNS4710N X PER OTH-
AADE,faPLJYERS'LLtff1= STATUTE .ER
ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT 1, 0 0 0, 0 0 0
OFFICERIMEMBER EXCLUDED?
A (Mandatory in NH)
NIA
76 WFG DS674] 06/25/2017 06/25/2018 E.L.DISEASE-EA EMPLOYEE 1, QQQ, QQQ
If yes,describe under
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT if QQQ, Q Q Q
13ESCMPTION OF OPERATIONS/LOCATIONS I VEMCLES(ACORD 101,Additional Remarks Schedule,maybe altached if more apace is required)
Those usual to the Insured's Operations.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
City of Palm Springs
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
YDELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: City Clerk AUTHORIZED REPRESENTATIVE
PO BOX 2743 V 4ee >C:7f
PALM SPRINGS, CA 92263
01988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/ 0005
Senior Emergency Assistance
Name/Address of Provider.
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
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-04101117)
AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME(AMI) 1 2 3 4 5 6 7 8
LEVEL-$60 500
EXTREMELY LOV%
INCOME $13,550 $16,240 $20,420 $24,600 $28,780 $32,960 $37,140 $41,320
0 30%of AMI
LOW
INCOME $22,600 $25,800 $29,050 $32,250 $34,850 $37,450 $40,000 $42,600
30-50%of AM!
MODERATE
INCOME $36,150 $41,300 $46,450 $51,600 $55,750 $59,900 $64,000 $68,150
50-80%OfAM!
NON LOW 8 MOD
INCOME $36,151 $41,301 $46,451 $51,601 $55,751 $59,901 $64,001 $68,151
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:
HISPANIC/LATINO ETHNICITY Yes No If yes,check one: Mexican/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
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/ 0005
Senior Emergency Assistance
Name/Address of Provider:
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
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 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: Proiect Number:
Senior Advocates of the Desert/ 0005
Senior Emergency Assistance
Name/Address of Provider:
Senior Advocates of the Desert
PO Box 2827
Cathedral City, CA 92235-2827
BENEFICIARY QUALIFICATION STATEMENT
fl
L
Financial Assistance
14,141.
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-744 & 24 CFR Part 581(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
lyo use Only
Audited by: Examined by: Approved by:
If necessary, additional sheet(s)must be attached detailing cost breakdowns, and verified by original signatures.
DaleC/CDBG 17-181SrAdvocates_SubrecpntEx hbtst.Oct
SUBRECIPIENT AGREEMENT
THIS AGREEMENT (herein "Agreement"), is made and entered into this j'24 day of Ao vi,
2015, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and
charter city, and the Senior Advocates 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 n 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 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:
Chris O'Hanlon, MSW, 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);
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 seg.);
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 Providers
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 parry 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:
Senior Advocates of the Desert
Post Office Box 2827
Cathedral City, CA 92235-2827
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: municipal corporation
if
qnClerk City Manager
APPRO DO FORM: LPPnRO VEDB1YCITYCOUNCIL
By: i L Q Liab Uf`'FJ d01
City Atto ey
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,
Assistan Secretary, Treasurer, Assistant Treasurer, or Chief Financial Officer .
By: By:
Notarized Ignature of Chairman of Board, Notarized Si ecretary st Secretary,
President or any Vice President Treasurer,Ass asurer or ChiefFinancial Officer
Name: Chrisfop{ff o Havi(Ct,'Name:__ P(r(rY S liiJCs
Title: PleS i J'e't
State of State of
County of ss County of 5s
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.
Stateor(44-r/eRA)T4 ) state of fil,
County oFit YVljn[IjG )ss.County of Gru sss.
On djLq'tnG before me, On S t Zo l before me,
t 1. Hak 7/
1 y
personalty appeared SSc'P • ,Jegn{, P„Wires ,personally appeared
CHRZ'S7,9PWtj? Q Aiu ' who proved to P Q , LtY g( who proved to/
me on the basis of satisfactory evidence to be the person) me on theyyss Gory eviid t ceeto be the person(3
whose name$is/am subscribed to the within instrument and whose name(Pr'is)are.rsubscrib to t ithin instrument and
acknowledged to me that helspfi/tl y executed the same in ackn ledge to me that she executed the dame iry
hislhu Pgir authorized capacay(ig4), and that by his(U&/t Qr eUth authorized capacity' and that by her u
signatureA on the instrument the person(', or the entity signature K on the instrument the p n(W or the entity
upon behalf of which the person(g acted, executed the upon behalf of which the persorlK 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. WITNESS my hand and official seal.
Notary Signature: Notary Signature:
Notary Seal: Notary Seal:
co.e i twala JOSEP14 T.JANZEN
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7..... c.r - .ocl m Notruy Public•California i
San Diego County
ExpiresMar 14 17+ —__I
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7
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/0005
Low Income Senior Services
Name/Address of Provider:
Senior Advocates of the Desert
801 E Tahquitz Canyon Way, Ste 202
Palm Springs, CA 92262-6763
O b i ect i ve s/Activities
The intent of this program is to provide low-income seniors with short-term case management and
assistance in applying for income, healthcare, housing, and Veterans benefits which clients may be
eligible, but have not been able to access on their own due to lack of knowledge about the programs or
an inability to navigate the complicated application process. Funding will allow for increase presence at
the Mizell Senior Center, and provide funds to assist clients suffering extreme financial hardship affecting
their health, safety or well-being. The program will serve three hundred and fifty(350) seniors city-wide.
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 three hundred and fifty (350) 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 three hundred and fifty (350) 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 with fifteen (15) calendar days of the
program mid-year, December 31st, and program completion, June 301".
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
Pro6ect/Activity Title: Proqect Number:
Senior Advocates uf the Desert/0005
Low Income Senior Services
Name/Address of Provider:
Senior Advocates nf the Desert
801 ETohquitz Canyon Way, Ste 2O2
Palm Springs, C/\ 02202'0703
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
Equipment
Financial Assistance
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-
OtherfundingsuurueorauievedbySeniurAdvocatenvverethroughChangeaLifeFnundatiunand
SCAN Health Plan grants, all totaling $10.O0V
The Subrenipient shall submit monthly reimbursement bayed on prorated and ootue| costs in
accordance with the aforementioned cost categories and pay items. In no nonntk shall the
Subrouipiant submit for reimbursement more than 1/4nf the total annual budget.
The Subreoipion1 recognizes that the CDBG Funds are received from the HUD, and that the
obligation of the City to make payment to Subrooipi*nt is contingent upon receipt of such funds
from HUD. |n the event that said funds, or any part thereof, are, or become, unavailable, then the
City may immediately terminate nr amend this Agreement.
Services are tobe performed over the twelve-month period uf this 2Ol5 - 1O Program Year — July
1' 2015 through June 3O' 2010
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/ 0005
Low Income Senior Services
Name/Address of Provider:
Senior Advocates of the Desert
801 E Tahquitz Canyon Way, Ste 202
Palm Springs, CA 92262-6763
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Non Profits Insurance Alliance of California(NIAC)
Effective Dates of Policy 12/10/14 to 12/10/15
Claims Made Policy / 1 Per Occurrence Policy I I
Limits of Liability 1 M General Aggregate
Deductibles:
Per Occurrence
Annual Aggregate
Additional Insured Endorsement (Certificate Holder) 2 Yes No
Original Certificate of Insurance Attached Yes 0 No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company Twin City Fire Ins. Co.
Effective Dates 06/25/15 to 06/225/16
Limits of Liability 1M Per Occurrence
Underlying Coverage Limits Unlimited
Original Certificate of Insurance Attached 0 Yes Z No
A CERTIFICATE OF LIABILITY INSURANCE
GATE(MMIDDIYYYV)
6/11/2015
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(ies) must be endorsed. If SUBROGATION IS WANED, 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 NAMEACT 13t COn'4minity Insurance Services
let ComInlnity Insurance Services Exti (760)325-7400 FAXletPHONE
United Valley Ins Services EpRILss,service@cisps.com
P. O. Box 2408 INSURERS AFFORDING COVERAGE NAIC#
Palm Springs CA 92263 INSURER A:Non Profits Insurance Alliance of NIAC
INSURED INSURER B:
Senior Advocates of the Desert INSURER C:
P.O. Box 2827 INSURER D:
INSURER E:
Cathedral City CA 92235 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:2014-2015 Liability 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.
Yyy,
INSR
TYPE OF INSURANCE
DL SUBR
POLICY NUMBER
PoLICY EFF POLICY EXP
LIMITSR
F COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000
DAMAGE TO RENTED 500,000ACLAIMS-MADE % OCCUR PREMISES(Ea occurrence) $
Y 2014-38222 12/10/2014 12/10/2015 MED EXP(Any one erson) S 20,000
PERSONAL&ADV INJURY $ 1,000,000
GE_N'L AGGREGATE LIMIT APPLES PER. GENERAL AGGREGATE $ 2,000,000
g POLICY
PRO
LOD PRODUCTS-COMPIOP AGG $ 2,000,000PRO
OTHER Directors and Offimm Liability $ 1,000,000
AUTOMOBILE LIABILITY COMBINEDL LIMIT $ 1,000,000EawadeM)._.___
A
ANY ADO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
2014-38222 12/10/2014 12/10/2015 BODILY INJURY(Per accidere) $AUTOS AUTOSNON-OMED PROPERTY DAMAGEgHIREDAUTOSHXAUTOSPeL ,sx ent
8
UMBRELLA LIAB
OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE
DEO RETENTION$
WORKERS COMPENSATION P O H-
AND EMPLOYERS'LIABILITY YIN
STATUTE ER
ANY PROPRIETOR,PARTNERIEXECUTIVE EL.EACHACCIDENT
OFFICER/MEMBER EXCLUDED?NIA
Mandatory in NH) EL.DISEASE-EA EMPLOY $
If es,describe under
D S RIPTIDN OF OPERATIONS be.EL.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101.Additional RemarMs Schedule,may be allached it more space is required)
Certificate holder is named as additional insured if indicated by nX" above. Additional insured status
applies only to the extent that the work is performed under or subject to a written agreement or
contract. The policy provisions govern in all situations.
Additional Insureds: The City of Palm Springs, its officers, officials, employees and volunteers.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Palm Springs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: City Clerk
ACCORDANCE WITH THE POLICY PROVISIONS.
P.O. Box 2743
Palm Springs, CA 92262 AUTHORIZED REPRESENTATIVE
Mike Beyex/MIKEB
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101)The ACORD name and logo are registered marks of ACORD
INS025(201401)
POLICY NUMBER:
2014 38222
COMMERCIAL GENERAL LIABILITY
CG 20 10 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 following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Or anization 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 re-
spect to liability arising out of or related to your activi-
ties as a real estate manager for that person or organ-
ization.
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
A. Section It — 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 or 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 oth-
er than another contractor or subcontractor
engaged in performing operations for a prin-
cipal as a part of the same project.
City of Palm Springs
PO Box 2743
Palm Springs, CA 92262
Attn: City Clerk
CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1
SHC nArE(MMmorcrrY)
CERTIFICATE OF LIABILITY INSURANCE R054 8/12/2015
THIS CERTIFICATEIS 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:Ifthe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATIONIS 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).
T
RME
PAYCHEX INSURANCE AGENCY INC PHOW WCM), (888) 443-6112
210705 P: F: (888) 443-6112 Eu
PO BOX 33015 MSU&eS)AEEIDNUINNr WY E PA.
SAN AN'TONIO TX 76265 N NERA: Twin City Fire ins co
wsu/rED nwRER e
SENIOR ADVOCATES OF THE DESERT DESERT esu NO:
34300 DENISE WAY pARIRERE.
RANCHO MIRAGE CA 92270 v Jrr<RP.
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.
MSW TYPEOF/.'ATL'RA.'1'Ct ADDL SUTR PoLICYNLMa£R PWACY POL/CYEV L,,(,q
COMMERCNLLGEHERJU-1- SILKY EACH OCCURRENCE
CLAIMSAIADE OCCUR DAMAGETORENTED
PREMISES JE9O Rene)
MED IXP)Arty me I,e,mO)
PERSONAL B AW INJURY
GEN'L AGGREGATE UMIT APPLIES PER GENE AGGREGATE
POLICY 0 PRO
Lac PRODUCTS-COMPIOP AGG
JECT
OTHER
A UTOMOSRX LIASIMFY
W MBINED SINGLE LIMIT
Ee ememB
ANY AUTO BODILY INJURY(Per Pemm)
ALL OWNED SCHEDULED
AUTOB AUT03
BODILY INJURY(P m:EeeI)
HIRED AUTO
NON-OWNED PROPERTY DAMAGE
AUTOS Pa emOmB
UMBRELLA JAB OCCUR EACH OCCURRENCE
IXCESS LMB CUUMS-MADE AGGREGATE
hT MrcMb
MORXkMPLLOMPG19A.n
FER OTT-
OYGNS'LIA81LlIV X STATUTE
ANY PROPRIETOR/PARTNERIIXECUTIVE YIN EL EACH ACCIDENT 1, 000y 000OFDCERIWWERELUDEWyyAA (U-daMry MNMfEl 76 WEG DS6741 06/25/2DI5 06/25/2016 EL.DISEAE6 EA EMROYEE ly ppQy QQQ
n yas,eeanloe Npd.
ELDISEASE-POLICYUMIT 1, 000, 000DEBCRIPTIONOFOPERATIONSEebx
CEBCMPTfON WOPERATIONS/LOCATORS I eERICl (AWRU 101,AEENpne Remade Be dePWbeetud,M N,me epee Is, u0 )
Those usual to the Insureds Operations.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
Cityo f Palm Springs
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE
IV IN ACCORDANCE WITH THE POLICYP VI
Attn: City Clerk AUTNOR¢®aEpaEsevra r/vE
PO SOX 2743
PALM SPRINGS, CA 92263
O 1998-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Proiect/Activity Title: Project Number:
Senior Advocates of the Desert/ 0005
Low Income Senior Services
Name/Address of Provider:
Senior Advocates of the Desert
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 grass annual income(Riverside-San Bernardino-Ontario,CA MSA-03106115)
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
50-80%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 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:
HISPANIC/LATINO ETHNICITY Yes No If yes,check one: Mexican/Chicano
Puerto Rican
CubanOther:
4. Are you female Head of Household? YES NO
S. 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: Project Number:
Senior Advocates of the Desert/ 0005
Low Income Senior Services
Name/Address of Provider:
Senior Advocates of the Desert
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 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:
Senior Advocates of the Desert/ 0005
Low Income Senior Services
Name/Address of Provider:
Senior Advocates of the Desert
801 E Tahquitz Canyon Way, Ste 202
Palm Springs, CA 92262-6763
BENEFICIARY QUALIFICATION STATEMENT
0-N.Iry sI ' C ail11 aCi
Personnel Services
7,500.00
Financial Assistance
7,500.00
L i 15,000.00
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
City of se Unly
Audited by: Examined by: Approved by:
If necessary,additional sheet(s)must be attached detailing cost breakdowns, and verified by original signatures.
Dale0CMG15-161SrAdwcates_SubrecpntExhbtstAug15