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HomeMy WebLinkAboutA6838 - CATHOLIC CHARITIES - San Bernardino & Riverside CountiesSUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this day of DL , 2017, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Catholic Charities San Bernardino & Riverside Counties, (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 seq.), 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 sc of the current fiscal year. QRIGULBID 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: Belinda Marquez, Director, Family & Community Services — Riverside County 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); (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 sec.); (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 -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 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: Catholic Charities San Bernardino & Riverside Counties 1450 N D St San Bernardino, CA 92405-4739 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 ] CITY OF PALM SPRINGS ATTEST: 1tat�io' orporation° By:_ 1 `By: City Clerk } City Manager APPROVE AS TO FORM: APPROVED WYCOUNCIL By. jo City Attorney 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 re/ry, easurer, Assistant Treasurer, or Chief Financial Officer). Y B 'I Notarized Sign ure of Chairman of Board, Pre 'dent an Vice President Name: nat� Title: State of G 4 ) County of S.%,u 6,va v 0-0 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of CA • ) Countyof ea tA-y9 w-p On t1 V U `i ! ( -rr )a f I_ before me, a46t Q . Qo s►3y e�N► 4 to, personally appeared /Zf A/4/-S7al `42 ANCr Y S P aJ& who proved to me on the basis of satisfactory evidence to be the person(s) whose nameK is/aid subscribed to the within instrument and acknowledged to me that he/speftbe y executed the same in his/tyer/thetr authorized capacity(ige), and that by his/hertthefr signature('• on the instrument the person(W or the entity upon behalf of which the person(ly acted, executed the instrument. I certify under PENALTY OF State of California tha/thfic correct. WITNESS my hand an Notary Signature: By: z. )I L - Notari d Si ture Secretary, Asst Secretary, Treasurer, Asstt Treasurer or Chief Financial Officer Name: #.lee ^ e 6ic Title: a-'� State of GA ) County of e,•vAA)Ns#O A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of CA� ) County of S eJ 1v4)►-a- 110 On N i �r-t �� f before me, Rc. '1,1',ielso aq appeared k'k-rr.t (e f%J ki.10,;T1I 2 if who proved to me on the basis of satisfactory evidence to be the person(s) whose name(A is/ice subscribed to the within instrument and acknowledged to me that Wshe/tt}ey executed the same in hid`/her/th4RF authorized capacity(ipe), and that by pi6/her/tpsir signature($) on the instrument the person(4 or the entity upon behalf of which the person,(•b') acted, executed the instrument. under a laws of the I certify under PENALTY V PE JURY under a laws of the Fag h is true and State of California that a fore inff paragrh is true and correct. / , COMM. i 2031241 MOTAIlYtN1BLIC •CALrfOltlpll SAN SERNAROtNO COUNTY Comm. Exp. JUNE 27, 2017 WITNESS my hand anp official Notary Notary ; C". 0 2031241 NOTARY/USLIC OCUMMOMA SAN BERWDMO COUNTY -7- CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Project Number: Catholic Charities San Bemardino & Riverside Counties - CCSBR / 0008 In -Home Casework Services Name/Address of Provider: Catholic Charities San Bernardino & Riverside Counties 1450 N D St San Bernardino, CA 92405-4739 Obiectives/Activities The intent of this program is to provide intensive casework services to extremely low income to moderate income individuals and families that are homebound or facing the barrier of limited transportation. Caseworkers will deliver much needed crisis intervention services to the most vulnerable population in their homes within the city. The program will serve 250 Palm Springs' seniors. 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 two -hundred and fifty (250) extremely low income to moderate 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 two -hundred and fifty (250) 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 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 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 Project/Activity Title: Project Number: Catholic Charities San Bernardino & Riverside Counties - CCSBR / 0008 In -Home Casework Services Name/Address of Provider: Catholic Charities San Bernardino & Riverside Counties - CCSBR 1450 N D St San Bernardino, CA 92405-4739 MARY COST CATEGORY CDBG SHARE OTHER SOURCES TOTAL COST 1 Personnel - 0 - $30,000. $30,000. 2 Consultant/Contract Services - 0 - 1,500. 1,500. 3 Travel/Mileage - 0 - 2,500. 2,500. 4 Space Rental/Telephone - 0 - 3,600. 3,600. 5 Consumable Supplies - 0 - 2,500. 2,500. 6 Rental, Lease or Purchase of Equipment - 0 - 1,750. 1,750. 7 Insurance - 0 - 2,700. 2,700. 8 Other — Direct Client Assistance Rent, Utilities, Basic Needs, Etc. $15,000. 20,000. 35,000. TOTALS $15,000. $64,550. $79,550. * 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 other federal governmental grants, non -governmental grants, donations/gifts, CCSBR contribution and in -kind, all totaling $64,550. 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: Catholic Charities San Bernardino & Riverside Counties - CCSBR / 0008 In -Home Casework Services Name/Address of Provider: Catholic Charities San Bernardino & Riverside Counties - CCSBR 1450 N D St San Bernardino, CA 92405-4739 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance CompanyThe Catholic Mutual Relief Society of America Effective Dates of Policy 07/01 /2016 to 07/01 /2017 Claims Made Policy / / Per Occurrence Policy 1 ! Limits of Liability $1,000,000 General Aggregate Deductibles: Per Occurre Annual Aggregate Additional Insured Endorsement (Certificate Holder) 0 Yes 0 No Original Certificate of Insurance Attached ❑ Yes 2 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company Church Mutual Insurance Co Effective Dates 01 /01 /2017 to 01 /01 /2018 Limits of Liability $1,000,000 Per Occurrence $1,000,000 Underlying Coverage Limits Original Certificate of Insurance Attached ❑ Yes 2 No Certificate of Coverage Date:6/21/2017 Certificate Holder This Certificate is issued as a matter of information only and The Roman Catholic Bishop of San Bernardino, CA confers no rights upon the holder of this certificate. This certificate A Corporation Sole does not amend, extend or alter the coverage afforded below. 1201 E. Highland Avenue San Bernardino, CA 92404 Company Affording Coverage THE CATHOLIC MUTUAL RELIEF SOCIETY OF AMERICA Covered Location 10843 OLD MILL RD Catholic Charities OMAHA, NE 68154 1450 North D St. San Bernardino, CA 92405-0000 Coverages This is to certify that the coverages listed below have been issued to the certificate holder named above for the certificate 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 coverage afforded described herein is subject to all the terms, exclusions and conditions of such coverage. Limits shown may have been reduced by paid claims. Type of Coverage Certificate Number Coverage Effective Date Coverage Expiration Date Limits Property Real & Personal Property D. General Liability Each Occurrence 1,000,000 General Aggregate ®✓ Occurrence ® Claims Made 8571 7/1/2016 7/1/2017 Products-Comp/OP Agg Personal & Adv Injury Fire Damage (Any one fire) Med Exp (Any one person) Excess Liability Each Occurrence Annual Aggregrate Other Each Occurrence Claims Made Annual Aggregrate Limit/Coverage Description of 0perations/LocationsNehicles/Special Items (the following language supersedes any other language in this endorsement or the Certificate in conflict with this language) Coverage only extends for claims directly arising out of the contract between the City of Palm Springs and Catholic Charities, CDBG Subrecipient Project No. 0008 to provide intensive casework services to extremely low income to moderate income individuals and families that are homebound or facing the barrier of limited transportation. The City of Palm Springs is named as additional protected person(s) as it pertains to passive negligence only. Holder of Certificate Cancellation Additional Protected Person(s) Should any of the above described coverages be cancelled before the expiration date thereof, the issuing company will endeavor to mail 30 days written notice to the holder of City of Palm Springs certificate named to the left, but failure to mail such notice shall P.O. Box 2743 Palm Springs, CA 92262 Attu: City Clerk 0309006175 impose no obligation or liability of any kind upon the company, its agents or representatives. Authorized Representative .s ENDORSEMENT (TO BE ATTACHED TO CERTIFICATE) Effective Date of Endorsement: 7/1/2016 Cancellation Date of Endorsement: 7/1/2017 Certificate Holder: The Roman Catholic Bishop of San Bernardino, CA A Corporation Sole 1201 E. Highland Avenue San Bernardino, CA 92404 Location: Catholic Charities 1450 North D St. San Bernardino, CA 92405-0000 Certificate No. 8571 of The Catholic Mutual Relief Society of America is amended as follows: SECTION II - ADDITIONAL PROTECTED PERSON(S) It is understood and agreed that Section II - Liability (only with respect to Coverage D - General Liability), is amended to include as an Additional Protected Person(s) members of the organizations shown in the schedule, but only with respect to their liability for the Protected Person(s) activities or activities they perform on behalf of the Protected Person(s). It is further understood and agreed that coverage extended under this endorsement is limited to and applies only with respect to liability assumed by contract or agreement; and this extension of coverage shall not enlarge the scope of coverage provided under this certificate or increase the limit of liability thereunder. Unless otherwise agreed by contract or agreement, coverage extended under this endorsement to the Additional Protected Person(s) will not precede the effective date of this certificate of coverage endorsement or extend beyond the cancellation date. Schedule - ADDITIONAL PROTECTED PERSON(S) City of Palm Springs P.O. Box 2743 Palm Springs, CA 92262 Attn: City Clerk Remarks (the following language supersedes any other language in this endorsement or the Certificate in conflict with this language): Coverage only extends for claims directly arising out of the contract between the City of Palm Springs and Catholic Charities, CDBG Subrecipient Project No. 0008 to provide intensive casework services to extremely low income to moderate income individuals and families that are homebound or facing the barrier of limited transportation. The City of Palm Springs is named as additional protected person(s) as it pertains to passive negligence only. Authoriz Representative PKS-122(10-11) AC "R" CERTIFICATE OF LIABILITY INSURANCE ATE Dg/2g/2016Y) 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 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 CONTACT Rachel Stewart CIC NAME: PHONE ($OO) 995-7525 aAC No: (800)995-7521 Church 6 Casualty Ins Agency Inc 3440 Irvine Ave E-MAIL ADDRESS: Rachel@ y' churchandcasualt com INSURERS AFFORDING COVERAGE NAIC If INSURERA:Church Mutual Insurance Co 18767 Newport Beach CA 92660 INSURED INSURER B : INSURER C: Diocese Of San Bernardino INSURER D: 1201 E Highland Ave INSURER E : INSURERF: San Bernardino CA 92404-4641 COVERAGES CERTIFICATE NUMBER:CL1682947612 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDlYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR � DAMAGE PREM SESO Ea occur ence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED AUTOS NON -OWNED AUTOS UMBRELLALIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N 0304652-07-648318 1/1/2016 1/1/2017 PER OTH- STATUTE I ER E.L. EACH ACCIDENT $ 1,000,00C OFFICERIMEMBER EXCLUDED? N 1 A E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) Y If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance — Waiver of Subrogation Applies — See Attached lei=.il1 City of Palm City Clerk PO Box 2743 Palm Springs, 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Springs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CA 92262 I AUTHORIZED REPRESENTATIVE R Bradhurst CISR/BECK —--$--- © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) INS025 (201401) The ACORD name and logo are registered marks of ACORD Rm WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 0484) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be otherwise due on such remuneration. PERSON OR ORGANIZATION CITY OF PALM SPRINGS CITY CLERK PO BOX 2743 PALM SPRINGS CA 92262 % of the California workers' compensation premium SCHEDULE JOB DESCRIPTION ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. Agent A� Ro® CERTIFICATE OF LIABILITY INSURANCE DATE (MMlODIYWY) 6/16/2017 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 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 CONTACT Rebecca Bradhurst CISR NAME: FAX ac ro Eli: (800) 995-7525 A/C No: (800)995-7521 Church & Casualty Ins Agency Inc E-MAIL ADDRESS: y' beckie@churchandcasualt com 3440 Irvine Ave INSURERS AFFORDING COVERAGE NAIC # INSURERA:Church Mutual Insurance Cc 18767 Newport Beach CA 92660 INSURED INSURER B: INSURERC: Diocese Of San Bernardino INSURER D: 1201 E Highland Ave* INSURER E INSURER F: San Bernardino CA 92404-4607 COVERAGES CERTIFICATE NUMBER:CL1712654406 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 LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP M / DIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ OCCUR _7CLAIMS-MADE DAMAGE TO PREM SES (Ea occu RENTED nce) $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PRJECOT I LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED ED HIRED AUTOS AUTOS UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED RETENTION $ $ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN R PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N / A y 0304652-07-945886 1/1/2017 1/1/2018 E.L. DISEASE - EA EMPLOYE $ 1,000,000 If as, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Evidence of insurance for Workers Compensation - Waiver of Subrogation Applies to this holder. CERTIFICATE HOLDER CANCELLATION City of Palm Springs City Clerk PO Box 2743 Palm Springs„ CA 92262 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE R Bradhurst CISR/BECK ��'�•- "- ^"'" �� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) N WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT— CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be otherwise due on such remuneration. Person or Organization Job Description 1 . 0 0 % of the California workers' compensation premium Schedule AS REQUIRED BY CONTRACT OR AGREEMENT This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Date: 01 / 01 / 2 017 policy No. 0304652 0 7- 9 4 5 8 8 6 Endorsement No. Policy Effective Date: 01 / 01 / 2 017 to 01 / 01 / 2 018 Insured: DIOCESE Or SAN BERNARDINO DBA: Carrier Name; Code: Church Mutual Insurance Company Countersignec WC 04 03 06 (Ed. 4-84) Premium $ CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title: Project Number: Catholic Charities San Bernardino & Riverside Counties - CCSBR / 0008 In -Home Casework Services Name/Address of Provider: Catholic Charities San Bernardino & Riverside Counties - CCSBR 1450 N D St San Bernardino, CA 92405-4739 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 Bernard [no -Ontario, CA MSA — 03/28/16) 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 8 MOD INCOME $35,801 $40,901 $46,001 $51,11 $55,201 ;59,301 $63,401 $67,501 > 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 4. Are you female Head of Household? ❑ YES 5. Do you have a disability? ❑ YES If yes, check one: ❑ Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: ❑ NO ❑ 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: ADDRESS: SIGNATURE: DATE: PHONE NO: 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: Catholic Charities San Bernardino & Riverside Counties - CCSBR / 0008 In -Home Casework Services Name/Address of Provider: Catholic Charities San Bernardino & Riverside Counties - CCSBR 1450 N D St San Bernardino, CA 92405-4739 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: Catholic Charities San Bernardino & Riverside Counties - CCSBR / 0008 In -Home Casework Services Name/Address of Provider: Catholic Charities San Bernardino & Riverside Counties - CCSBR 1450NDSt San Bernardino, CA 92405-4739 BENEFICIARY QUALIFICATION STATEMENT ^� •di �Y TTA x'?� $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 & 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.