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HomeMy WebLinkAboutA6512 - SUBRECIPENT AGREEMENT WITH JEWISH FAMILY SERVICE OF THE DESERT SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this 21'day of 0G0 6-L� 2019, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Jewish Family Service of the Desert , (herein"Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R.Section 570 et seg. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW,THEREFORE,the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application and this Agreement. 1.2 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 2.0, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting for the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting. Any Provider receiving or due to receive $20,000.00 or more from the City during the 2019 — 2020 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance 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 315t of the current fiscal year. 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed TWENTY-FIVE THOUSAND FIVE HUNDRED TWENTY-THREE DOLLARS 25 523.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City periodic statements, in the form of Exhibit F, on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Providers respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter(September 30, December 30, March 31, and June 30)shall result in the immediate forfeiture of 25%of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Maureen Forman, Executive Director 3.2 Contract Officer. The Contract Officer shall be such person as may be designated by the City Manager of City. 3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred,voluntarily or by operation of law,without the prior written approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS. 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as -2- may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable,and as may be amended from time to time: (a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; (b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; (c) Section 3 of the Housing and Urban Development Act of 1968, as amended; (d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P.L. 94-136, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 a); Q) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (k) The Program Income requirements as set forth in 24 C.F.R. 570.504(c) and 570.503(b)(8); (1) The Provider is to carry out each activity in compliance with all Federal laws and regulations described in 24 C.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 C.F.R. 570.604; nor does the Provider assume the City's responsibility for initiating the review process under the provisions of 24 C.F.R. Part 52; (m) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; (n) The flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); (o) The regulations, policies, guidelines and requirements of 24 CFR 570; the"Common Rule", 24 CFR Part 85 and subpart J; OMB Super -3- Circular 2 CFR 200 as they relate to the acceptance and use of federal funds under the federally-assisted program; (p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; (q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; (r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C.4801 et seg.); (s) Procure, use, manage and dispose of personal property in accordance with 2 CFR 200.310 and 2 CFR 200.312 through 2 CFR 200.316; (t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan)in excess of$25,000 is either: (i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or (ii) Not used in accordance with paragraph (t)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (t) of this section.) (u) Conflict of Interest. The Provider is required to disclose to the City in writing any potential conflict in accordance with 24 CFR Part 570.611; and (v) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers'Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the -4- foregoing and naming the City as an additional insured shall be delivered to and approved by the City prior to commencement of the services hereunder. The procuring of such insurance or the delivery of policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be as required by the Contract Officer not exceeding One Million Dollars($1,000,000). 5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the City, its officers and employees, from and against any and all actions, suits, proceedings, claims, demands, losses, costs, and expenses, including legal costs and attorneys' fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 CITY OFFICERS AND EMPLOYEES: NON-DISCRIMINATION, TERMINATION, AND ENFORCEMENT. 6.1 Non-Liability of City Officers and Employees. No officer or employee of City shall be personally liable to the Provider, or any successor-in-interest, in the event of any default or breach by City or for any amount which may become due to the Provider or its successor, or for breach of any obligation of the terms of this Agreement. 6.2 Conflict of Interest. Provider acknowledges that no officer or employee of the City has or shall have any direct or indirect financial interest in this Agreement nor shall Provider enter into any agreement of any kind with any such officer or employee during the term of this Agreement and for one year thereafter. Provider warrants that Contractor has not paid or given, and will not pay or give, any third party any money or other consideration in exchange for obtaining this Agreement. 6.3 Covenant Against Discrimination. In connection with its performance under this Agreement, Provider shall not discriminate against any employee or applicant for employment because of actual or perceived race, religion, color, sex, age, marital status, ancestry, national origin ( i.e., place of origin, immigration status, cultural or linguistic characteristics, or ethnicity), sexual orientation, gender identity, gender expression, physical or mental disability, or medical condition (each a "prohibited basis"). Provider shall ensure that applicants are employed, and that employees are treated during their employment, without regard to any prohibited basis. As a condition precedent to City's lawful capacity to enter this Agreement, and in executing this Agreement, Provider certifies that its actions and omissions hereunder shall not incorporate any discrimination arising from or related to any prohibited basis in any Provider activity, including but not limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship; and further, that Provider is in full compliance with the provisions of Palm Springs Municipal Code Section 7.09.040, including without limitation the provision of benefits, relating to non-discrimination in city contracting. 6.4 Term. Unless earlier terminated in accordance with Section 6.5 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1)year from the date hereof. 6.5 Termination Prior to Expiration of Term. a. In accordance with 2 CFR 200.339, the City may suspend or terminate, in whole or in part, this Agreement if Provider fails to comply with any term of this Agreement or the terms and conditions of the subaward; b. In accordance with 2 CFR 200.339, the City may terminate this Agreement with the consent of the Provider after both parties have -5- agreed upon the termination conditions, including the effective date and, in the case of a partial termination,the portion to be terminated; and C. The Provider may terminate this Agreement at any time, with or without cause, upon thirty (30) days' notification setting forth the reason(s) for such termination, the effective date and, in the case of partial termination, the portion to be terminated. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. However, if the City determines in the case of partial termination that the reduced or modified portion of the subaward will not accomplish the purposes for which the subaward was made, the City may terminate the subaward in its entirety. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, consent, approval, or communication that either party desires, or is required to give to the other party or any other person shall be in writing and either served personally or sent by pre-paid, first-class mail to the address set forth below. Notice shall be deemed communicated seventy-two (72) hours from the time of mailing if mailed as provided in this Section. Either party may change its address by notifying the other party of the change of address in writing. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Jewish Family Service of the Desert 490 S Farrell Dr. Ste C208 Palm Springs CA 92262-7944 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. [End—Signatures on Next Page] -6- CITY OF PALM SPRINGS ATTEST nicipal corpolAtion By: B Ci erk City Manager APPROVED AS TO FORM: APPROVED BY COUNCIL %st2�� fq City Attorney PROVIDER: Check one: _Individual _Partnership _Corporation (Corporations require two notarized signatures: One signature must be from the Chairman of Boar President, or any Vice President. The second signature must be from the Secretary, Assi to t Sec tary,Tree r, Ass v,fant Treasurer, or Chief Financial fficer). B By: otprized 1 nature of Cfid(hpah of Board, Notarized Sigirtature Secrets y,Asst Secretary, Presi nt or nil esident Treasurer,Asst' reas' er or C ief inancial Officer Name: Name: Titre: Title: G�� >V � State of (Ziam-• ) State of '� ) County of ss County of ss A notary public or other officer completing this certificate A notary public orcther officer completing this certificate verifies only the identity of the individual who signed the verifies only the identity of the individual who signed the document to which this certificate is attached, and not document to which this certificate is attached, and not the truthfulness,accuracy,or validity of that document. the truthfulness,accuracy,or validity of that document. State of CAt.lf-o1.Nm ) County of (AIJG&ATk1F- )ss. State of 1-lt �-(LN A H County of R-`"f -%njS )I ss. On C)C . Z3i W5 before me, On O C. , 13 '� before me,lgiDJ� �-r�to 1 ' 1P�10yo �fl�f�,.,Now PJ1�ht,.personally appeared nn5 personally appeared p,A•+ or� who proved to VJO.frlt%4 V '^a^ who proved to jho on the basis of sat actory evidence to be tha personl,� me on the sis of satisfactory evidence to be the personj) se names) re su bed tothewithin instrument ndwhose name( j i�'are sub ed to the within instrument and nowled ed totha he helthe executed same in owledged me tha he/ he/theyexecuted the same in her/their authored ca a i and thtb�lhiser/theirhrs erltheir authorized ca�ty(i�-and than der/their atur ) on the,instru �( a person, orra entity sr natureO on the instrument the personV, of the entity n behalf of which the person(J5)' acted, executed the upon behalf of which the person-acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of 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 a official seal. WITNESS my hand and official seal. Notary Signature: Notary Signature: Notary Seal: Notary Seal: mm 4afon Na 21 l�8643 €t J )i BEFiGST�OM d; 'NOTARY PUBLIC CAy1pORNIA CommisstontJa,Z19864 3 iA1 yyQammE.gei7UME40021 f9RR%rtR3 78 arw NEg, 3021. A6rCOmm.EaWres'JU CITY OF:PALM SPRINGS EXHIBIT A Scope of Services Pro'ect/Actiyity Title: Project Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 Oblectives/Activities The intent of this program is to provide extremely low income to low-income seniors, individuals and families with emergency assistance who are experiencing a severe financial crisis and at-risk for housing insecurity or becoming homeless. The program will serve 1180 clients Valley-wide and 381 Palm Springs'residents that will include seniors-55+years of age and individuals and families-underage 55. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely Providing any additional information requested TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise market and publicize the program to facilitate positive promotion for all parties (i.e., Provider, City. CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income gualify at least a total of three hundred and eighty-one (381) extremely low income to low-income Palm Springs' residents in accordance with Exhibit D for new access to services. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming to three hundred and eighty-one (381) extremely low income to low-income Palm Springs' residents. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual reports — referenced Exhibit E within fifteen (15) calendar days of the program mid-year, December 31s, and program completion, June 30th. Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination/EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors Individuals and Families. At-Risk Youth Severely Disabled Adults. and Special need Population. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in this Agreement. Objective 8: Provide an evaluation within fifteen (15)calendar days of the program completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/20 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary ProiecttActivity Title: Project Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BUUGETI3UMMARY COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 I Personnel -0- $237,732. $237,732 2 ConsultanUContract Services -0- -0- -0- 3 Travel -0- $880. $880. 4 Space Rental -0- $19,239. $19,239. 5 Consumable Supplies -0- $12,383. $12,383. 6 Rental, Lease or Purchase of -0- $3,938. $3,938. Equipment 7 Insurance -0- $3,766. $3,766. 8 Other— $12,761.50 $55,000 $67,761.50 Emergency Assistance for Seniors Emergency Assistance for $12,761.50 -0- $12,761.50 Individuals and Families Indirect Cost 10% 0- 36,294 TOTALS . 125,523. $369,232. $358,461 If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding,grantor4ending agency,and cost category information. Other funding sources include fundraising activities conducted by JFSD's through other local and non- governments[grants,all totaling$55,000 The Subrecipient shall submit Request for Reimbursements in accordance with the aforementioned cost categories and line items. The Subreciplent recognizes that the CDBG Funds are received from the HUD, and that the obligation of the City to make payment to Subreciplent is contingent upon receipt of such funds from HUD. In the event that said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or amend this Agreement. Services are to be performed over a twelve month period of July 1, 2019 through June 30, 2020 with funds allocated from 2019—20 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Proiect/ActivitV Title: Proiect Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Non-profits' Ins Alliance Effective Dates of Policy 02/23/2019 to 02/23/2020 Claims Made Policy / / Per Occurrence Policy Limits of Liability $2M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) I3 Yes ❑ No Original Certificate of Insurance Attached ❑Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 06/1/2019 to 06/1/2020 Limits of Liability $1M Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes 0 No CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number: Jewish Family Service of the Desert! 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described project(activity. Please answer each of the following questions. 1. How many persons are In your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be Included as household members. 2. Circle your combined gross annual income(Riverside-San Bemardino-Ontario,CA MSA—06128119) AREA MEDIAN- NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5r$66650+ 7 8 LEVEL-$65,800 EXTREMELY LO INCOME $15,100 $17.250 $21,330 $25,750 $30,170 $39,010 $43.430 0-30%ofAMI LOW INCOME $25,150 $28,750 $32,350 $35,900 $38,800 $44,550 $47,400 30-50%ofAMI MODERATE INCOME $40,250 $46.000 $51,750 $57,450 $62,050 $71,260 $75,850 50-8D•-ofAMI NON LOW&MOD INCOME $40,250+ $46,000+ $51,750+ $57,450+ $62,050+ $71,250+ $75,850+ >80% 3. What race/ethnicity do you identify yourself as;please note that this seifddentification Is voluntary In accordance with equal opportunity laws? ❑ While ❑ American Indian or Alaska Native AND White ❑ Black/Afdcan American ❑ Asian AND White ❑ Asian ❑ Black/African American AND White ❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/Afdcan American ❑ Native Hawaiian or Other Pacific Islander ❑ Other. HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one: ❑ Mekican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other. 4. Are you female Head of Household? ❑ YES ❑ NO 5. Do you have a disability? ❑ YES ❑ NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form Is confidential and Is only utilized for Community Development Block Grant(CDBG)program purposes,a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF'PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report ProiecUActivity Title: Proiect Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons <or=30%: 30-50%: 50-80%: >80%: ♦ Number of First-Time Female Headed Households: ♦ Counts by Race/Ethnicity: White American Indian or Alaska Native AND While Black/African American Asian AND While Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other. ♦ Number of Disabled: ♦ Number of Homeless Persons Given Overnight Shelter: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY .OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Jewish Family Service of the Desert/ 0009 Preventing Homelessness Among Low Income Name/Address of Provider: Jewish Family Service of the Desert-JFSD 490 S Farrell Dr, Ste C208 Palm Springs, CA 92262-7944 BENEFICIARY QUALIFICATION STATEMENT A roved Current Prlor ENMierlod(s� Reimbursement Relmburs - It Over/iUnder ther Emergency Assistance to $12,761.50 Seniors(Ages 55+ Emergency Assistance to $12,761.50 Individuals and Families (Under 55 years of age) TOTAL �, $25,523. I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b)funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 & 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name,Title, Date Name,Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: If necessary,additional sheet(s)must be attached detailing cost breakdowns,and verified by original signatures.