HomeMy WebLinkAbout06223 - AIDS ASSISTANCE PROGRAM CDBG SUBRECIPIENT AGR SUBRECIPIENT AGREEMENT
THIS AGREEMENT(herein"Agreement"), is made and entered into this_day of Ai c j r:T'
2012, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and
charter city, and the AIDS Assistance Program , (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 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, and to conduct all programs specified
therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to City
that it is able to provide, and will use funds granted by the City to provide the services represented in the
Providers application for funding. City provided funds shall be used only for those purposes specified in
such application.
1.2 Compliance with Law. All services rendered hereunder shall be provided in
accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal,
State or local governmental agency of competent jurisdiction.
1.3 Reports. No later than ten (10) days prior to any payment date specified in
Section 22, within ten (10)days following the termination of this Agreement, and at such other times as
the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the
services provided during the period of time since the last report and accounting for the specific
expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law,
the Provider shall provide to the City, the Department of Housing and Urban Development, the
Comptroller General of the United States, any other individual or entity, and/or their duly authorized
representatives, any and all reports and information required for compliance with the Act and the
Regulations.
1.4 Financial Reporting. Any Provider receiving or due to receive or due to receiver
$20,000.00 or more from the City during the 2012 —2013 Fiscal Year shall provide to City a financial
statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance
Director completed within the most recent twelve (12) months showing the Providers financial records to
be kept in accordance with generally accepted accounting standards. The report shall include a general
ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate
contract compliance and be balanced to bank statements. Any organization receiving or due to receive
less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's
most recent charitable trust report to the Attorney General, or other financial information satisfactory to
City's Finance Director. The financial information provided for in this paragraph shall be furnished not
later than January 31�of the current fiscal year.
ORIGINAL BID
AND/OR AGREENIEP�
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, FIVE HUNDRED AND SIXTY DOLLARS
($15,560.00) (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and
incorporated herein by this reference; and as herein provided. The budget cost categories set out in
Exhibit B are general guidelines and if mutually agreed by both parties, may be amended
administratively by no more than 10%, without the requirement of a formal amendment to this
Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall
submit to the City monthly statements on reimbursable expenditures pursuant to the attached Budget
along with pertinent supporting documentation. The City shall promptly review the monthly expenditure
statements and, upon approval, reimburse the Provider its authorized operating costs.
2.2 Payroll Records. In cases where the contract sum will reimburse payroll
expenses as part of operations, the Provider will establish a system of maintaining accurate payroll
records which will track daily hours charged to the project by the Provider's respective employees, as set
forth in OMB Circular A-122 Attachment B.6.
2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of
at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30,
March 31, and June 30)shall result in the immediate forfeiture of 25%of the total grant.
3.0 COORDINATION OF WORK.
3.1 Representative of Provider. The following principals of Providers are hereby
designated as being the principals and representatives of Provider authorized to act in its behalf with
respect to the work specified herein and make all decisions in connection therewith:
Mark Anton CEO/Executive Director
32 Contract Officer. The Contract Officer shall be such person as may be
designated by the chief administrative officer of City.
3,3 Prohibition Against Subcontracting or Assignment. Provider shall not contract
with any other entity to perform in whole or in part the services required hereunder without the express
written approval of the City. Neither this Agreement nor any interest herein may be assigned or
transferred, voluntarily or by operation of law, without the prior written approval of the City.
3.4 Independent Contractor. Neither the City nor any of its employees shall have
any control over the manner, mode or means by which Provider, its agents or employees, perform the
services required herein, except as otherwise set forth herein. Provider shall perform all services
required herein as an independent contractor of City and shall remain at all times as to City a wholly
independent contractor with only such obligations as are consistent with that role. Provider shall not at
any time or in any manner represent that it or any of its agents or employees are agents or employees of
City.
4.0 COMPLIANCE WITH FEDERAL REGULATIONS.
4.1 The Provider shall maintain records of its operations and financial activities in
accordance with the requirements of the Housing and Community Development Act and the regulations
promulgated thereunder, which records shall be open to inspection and audit by the authorized
representatives of the City, the Department of Housing and Urban Development and the Comptroller
General during regular working hours. Said records shall be maintained for such time as may be
required by the regulations of the Housing and Community Development Act, but in no case for less than
five years after the close of the program.
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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 11 and the acquisition requirements
of Title III of the Uniform Relocation Assistance and Real Property
Acquisition at 24 CFR Part 42,
(1) 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 Incomerequirements as set forth in 24 C.F.R.
570.504(c) and 570.503(b)(8),
(I) The Provider is to carry out each activity in compliance with all
Federal laws and regulations described in 24 C.F.R. 570, Subpart K,
except that the Provider does not assume the City's environmental
responsibilities described at 24 C.F.R. 570.604; nor does the Provider
assume the City's responsibility for initiating the review process under
the provisions of 24 C.F.R. Part 52,
(m) Executive Order 11988 relating to the evaluation of flood hazards and
Executive Order 11288 relating to the prevention, control and
abatement of water pollution,
(n) The flood insurance purchase requirements of Section 102(a) of the
Flood Disaster Protection Act of 1973(P.L. 93-234);
(0) The regulations, policies, guidelines and requirements of 24 CFR
570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB
Circular Nos. A-102, Revised, A-87, A-110 and A-122 as they relate
to the acceptance and use of federal funds under the federally-
assisted program;
-3-
(p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing
regulations issued at 24 CFR Part 1;
(q) Title VIII of the Civil Rights Act of 1968(P.L. 90-284) as amended,
(r) The lead-based paint requirements of 24 CFR Part 35 issued
pursuant to the Lead-Based Paint Poisoning Prevention Act (42
U.S.C. 4801 et seq.);
(s) Maintain property inventory system to numerically identify HUD
purchased property and document its acquisition date as is set forth
in OMB Circular A-110 Attachment N Property Management Standard
6d; and
(t) Reversion of asset. Upon the Expiration of the agreement, the
subrecipient shall transfer to the City any CDBG funds on hand at the
time of expiration and any accounts receivable attributable to the use of
CDBG funds. Additionally, any real property under the subrecipient's
control that was acquired or improved in whole or in part with CDBG
funds (including CDBG funds provided to the subrecipient in the form of
a loan) in excess of$25,000 is either.
W Used to meet one of the national objectives in Section
570.208 (formerly Section 570.901) until five years after
expiration of the agreement, or for such longer period of time
as determined to be appropriate by the City; or
(ii) Not used in accordance with paragraph (s)(i) above, in which
event the subrecipient shall pay to the City an amount equal
to the current market value of the property less any portion of
the value attributable to expenditures of non-CDBG funds for
the acquisition of, or improvement to, the property. The
payment is program income to the City. (No payment is
required after the period of time specified in paragraph (s) of
this section.)
(u) Such other City, County, State, or Federal laws, rules, and regulations,
executive orders or similar requirements which might be applicable.
4.3 The City shall have the right to periodically monitor the program operations of
the Provider under this Agreement.
5.0 INSURANCE AND INDEMNIFICATION.
5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit
concurrently with its execution of this Agreement, public liability and property damage insurance against
claims for injuries against persons or damages to property resulting from Provider's acts or omissions
arising out of or related to Provider's performance under this Agreement. Provider shall also carry
Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such
insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without
thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the
foregoing and naming the City as an additional insured shall be delivered to and approved by the City
prior to commencement of the services hereunder. The procuring of such insurance or the delivery of
policies or certificates evidencing the same shall not be construed as a limitation of Provider's obligation
to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be
as required by the Contract Officer not exceeding Five Hundred Thousand Dollars($500,000).
-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 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, or any other basis Protected Characteristic by applicable
federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to
insure that applicants are employed and that employees are treated during employment without regard
to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin,
ancestry or any other basis Protected Characteristic by applicable federal, state or local law.
6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this
Agreement, this Agreement shall continue in full force and effect until completion of the services, but not
exceeding one(1)year from the date hereof.
6.3 Termination Prior to Expiration of Term. Either party may terminate this
Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party.
Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder
except as may be specifically approved by the Contract Officer. Provider shall be entitled to
compensation for all services rendered prior to receipt of the notice of termination and City shall be
entitled to reimbursement for any services which have been paid for but not rendered.
7.0 MISCELLANEOUS PROVISIONS.
7.1 Notice. Any notice, demand, request, document, consent, approval, or
communication either party desires or is required to give to the other party shall be in writing and either
served personally or sent by prepaid, first-Gass 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:
AIDS Assistance Program—AAP
P.O. Box 4182: 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
-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]
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CITY OF PALM SPRINGS
ATTEST: a municipal corporation
Ci�Cleerk �O4li8jZ6tZ— City Manager
APP )f/ED S�� 0 M:
APPROVED BY CITY COU
By: N L
ity Attorney
PROVIDER: Check one: _Individual _Partnership YE Corporation
(Corporations require two notarized signatures: One signature must be from the Chairman of
Board, President, or an Vice President. The second signature must be from the Secretary,
Assists ecretary, reas er, Assistant Treasurer, or Chief Fin ncial OffOff er).
By: By:
Notarized Signature of Chairman of Board, Notarized Signature Secretary,As retaFy
President or any Vice President Treasurer,Asst Treasurer or Chief Financial Officer
Name: h AF-V J F E . 1�3 70 Name:k-!'-' (2 -kEjEtj
Title: C• •E .Lo TEE A S u P
/n Title:
Stateof&fo&Of State ofC�rots)i A
County o ss County of )ss
on 09 ZR Zo f v before me, On 6 S 2R Z&z before me,
P.n.M u Personally appeared QO.h
_,Personald �
,personally appeared
t 1T� who proved to _ yr r�� C ��� v o proved to
me on the bans of satisfactory evidence to be the persons) 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/shelthey executed the same in acknowledged to me that he/she/they executed the same in
his/herttheir authorized capacity(ies),and that by hisrherttheir his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity sigmture(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 antl official seat.j��/y WITNESS my hand and
/ofyficial Seal�.,�,/
Notary Signaturel/ #q"( Notary Signature(:_, `
_ U` L/�(
Notary Seal: Notary Seal:
P. D. MCCOOL P. D. MCCOO�L
VOOMM.
COMM.#1980171 O COMM.#1980171
QNOTARY PUBLIC-CALIFORNIAQNOTARY PUBLIC-CALIFORNIAQ
SAN BERNARDINO COUNTY O SAT BERNBRCNO COUNTY O
EXPIRES JUNE 26,20161
COMM.EXPIRES JUNE 26,2016
DaieC/CDBG 12-13/AAP_SubreopAgmn(Aug12
-7_
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Proiect/Activity Title: Project Number:
AIDS Assistance Program/ 0007
Home Bound Grocery Delivery Program
Name/Address of Provider:
AIDS Assistance Program -AAP
PO Box 4182; 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
Obi ectives/Activities
The intent of this program is to provide paramount nutritional support to low income (less than 170% of
the National Poverty Guidelines) persons living with AIDS/HIV and their dependent children under the age
of 18. This will be accomplished through AAP's twice monthly grocery delivery to fifty-seven (57) clients
of which will expand to thirty-two (32) new PS client homes. The Center of Disease Control had released
a 2005 study on HIV/AIDS which cited the need for good nutrition to sustain the health of HIV positive
individuals.
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 thirty-two (32) very low income to moderate-
income Palm Springs residents with new access to services.
TARGET
DATE ACTIVITY#1
On-Going Provide grocery delivery to fifty-seven (57) homebound 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.
Objective 6: Manage/monitor program activities.
TARGET
DATE ACTIVITY#1
On-Going Perform monitoring activities necessary to ensure that the program is being conducted in
compliance with the CDBG policies, federal regulations, and local statues, including
Davis-Bacon Act, Copeland Act, and Non-discrimination/EEO requirements.
Objective 7: Establish New and/or Expanded Services for Seniors. At-Risk Youth Severely Disabled
Adults and Special need Population.
TARGET
DATE ACTIVITY#1
On-Going Conduct program activities to improve availability/accessibility, as stipulated in the
proposal.
Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final
reimbursement.
TARGET
DATE ACTIVITY#1
07/15/13 Provide an evaluation and final report on all programmatic and financial activities.
General Administration
Provide the management oversight and leadership to address specific operational tasks in meeting the
established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.)
CITY OF PALM SPRINGS
EXHIBIT B
Budget Summary
Proiect/Activity Title: Project Number:
AIDS Assistance Program/ 0007
Home Bound Grocery Delivery Program
Name/Address of Provider:
AIDS Assistance Program-AAP
PO Box 4182; 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel - 0 - - 0 - - 0 -
Consultant/Contract Services - 0 - - 0 - - 0 -
Travel - 0 - - 0 - - 0 -
4 Space Rental - 0 - - 0 - - 0 -
5 Consumable Supplies - 0 - - 0 - - 0 -
Rental, Lease or Purchase of - 0 - - 0 - - 0 -
Equipment
7 Insurance - 0 - - 0 - - 0 -
8 Other $15,560. $1,283,140. $1,298,700.
Grocery Delive
1 £� F � 98 ,
'Yh�3 d 4yt 4 M
Mg
* If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions,
identify the source of funding,grantor/lending agency,and cost category information.
Other funding sources include fundraising activities conducted by AAP's Angel Donor Program, Desert
Healthcare District,and other local governmental grants,all totaling$1,283,140.
The Subrecipient shall receive reimbursements in accordance with the aforementioned cost categories and line
items. The program will pay for $40.52 per month for each Palm Springs' resident, at a total amount not to
exceed $15,560, approved by the Subrecipient and based upon the actual number of income eligible
scholarships awarded in the prior period, shall be paid by the 301h day of each month, provided that the payment
application has been submitted to the City on or before the first working day of the month.
The Subrecipient recognizes that the CDBG Funds are received from the HUD, and that the obligation of the
City to make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that
said funds, or any part thereof, are, or become, unavailable, then the City may immediately terminate or
amend this Agreement.
Services are to be performed over the twelve-month period of this 2012 — 13 Program Year— July 1, 2012
through June 30,2013.
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
PrOlect/ActiyitV Title: Project Number:
AIDS Assistance Program/ 0007
Home Bound Grocery Delivery Program
Name/Address of Provider:
AIDS Assistance Program-AAP
PO Box 4182; 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Travelers Insurance Co
Effective Dates of Policy 04/19/12 to 04/19/13
Claims Made Policy / / Per Occurrence Policy
Limits of Liability $2M General Aggregate
Deductibles:
Per Occurrence
Annual Aggregate
Additional Insured Endorsement (Certificate Holder) EI Yes ❑ No
Original Certificate of Insurance Attached ❑ Yes H No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company State Insurance Fund
Effective Dates 10/01/12 to 10/01/132
Limits of Liability $1 M Per Occurrence
Underlying Coverage Limits Unlimited
Original Certificate of Insurance Attached 0 Yes 0 No
./•'� AIDSA-1 OP ID:DM
CERTIFICATE OF LIABILITY INSURANCE °" 08129W"YYY'
08/29t12
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 I THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policyfies)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 endoreemenf s.
PRODUCER ',. 760-322-446 u°AMME"CT
Casswood Insurance Agency,Ltd. 760.322-4465 PROtaE - -- - 'FAX
560 South Passe,Dorotea Ste 4 x ac Me
Palm Springs,CA 92264-4434 EJIAIL
W Chad Ballard ADDRESS:
T
INSURERS AFFORDING COVERAGE NAIL*
INSURERA:Travelers Insurance Cc
INSURED Aids Assistance Program INSURER B:
Mark Anton IxsuRERc:
P.O.Box 4182
Palm Springs,CA 92262 INSUMRD:
INSURER E:
INSURER F: _-
COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWPFHSTANDING 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,
ILT
NSRR TYPE OF INSURANCE "DL SUB �LICYNUMBFR ICY
EFF POLICY
L1Mrr3
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
DAMAGE TO REN,—
A X COMMERCIAL GENERAL LIABILITY X 1660619X4243-11 1411W12 04/19/13 PREMISES(Ea aminenoe $ 100,00
C WM84AADE C OCCUR MED EXP(PnY one person) 1$ 5,00
PERSONAL&ACV INJURY :S 1,000,
j .._.— GENERA-AGGREGATE IS 2,000,0
GENL AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
X POLICY PIFGT" LOC $
AUTONIOBRP LM&LITY - COMBIN D INGLE LIMIT
Ea accident S
ANY AUTO - BODI LY INJURY(Par perwn) S
ALLOWNED SCHEDULED
AUTOS AUTOS - BODILY INJURY(Pera¢itlent) $
HIREDAUTOS AUTOS I PROPERtt DAMAGE $
Per accident
$
UMBRELLA LAB OCCUR A
CE F$ g
'EXDE8S LAB CIAIMSMADE
DEE) RETENTION$
WORKERS COMPENSAl1ON
AND EMPLOYERS'DABQN ,OTH
ER
ANYPROPRETOR,EXCLUDR/EXECUnVE Y/N - NT
i OEFK:ER/MElABER EXCLUDED? ❑ NIA -lMaMatory in NH) EMPLOYEDtSCHIPII IION OF OPERATIONS below E.L.DISEASE-POLICY LIMM
I
OESDRWTON�OPERATIONS I IJ]DATXINS/YEISCLE8 1ARad,ACDRp tat,Addlaer,al RamMNa ioIRYW0.Kmora spKw Is nquirW)
City of Palm Springs, its Officers, officials, employees and volunteers are
additional insureds under this policy.
CERTIFICATE HOLDER CANCELLATION
CITYPSP
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Palm Springs THE EXPIRATION DATE THEREOF, NOTICE MILL BE DELIVERED IN
City Clerk ACCORDANCE NTH THE POLICY PROVISIONS.
P.O.2743 nvrNOR�D REPRESENrATNE
Palm Springs,CA 92262
0 1988-201 D ACORD CORPORATION. All rights reserved.
ACORD 25(201OJ06) The ACORD name and logo are registered marks of ACORD
• • , a a 1.Endorsement No. 2.Issue Date(MMIDDNy)
a • a 001X 08/29/2012
lCasswood
ucer 5.Policy Information:
Canner: Travelers Prop&Casualty Cc of America
Insurance Agency Ltd. NAIL# 25674
60 S Paseo Dorotea,Ste 4 Policy No: 1660619X4243-11
Palm Springs,CA M64 Policy Period: 04/19/2012 to 04/19/2013
(760)322-4466 Coverage Trigger Zioccurrence
Telephone Loss Adjustment Expense:❑included in Limits ®In Addition to Limits
4.Insured (Cheek 114kh)
AIDS Assistance Program 6.❑Deductible $
Attn: Mark Anton ❑Self-Insured Retention of: -
PO Box 4182 $ with an Aggregate of$
Palm Springs,CA 92262 7.Applirrble.This insurance pertains tothe orerawru andlor tenancy of the named
haired under all written agreements and permits in force with the City of Palm
Springs unisss checked here❑ In wnkn case only me foaming speabc
agreemems and permits with the City a Palm Spnngs are covered:
City AgreememsfPennits
7=-
9. 10.Other Pmviaons
bility -
Coverages Liabils,Limits in Thousands$
Fach Occumende Aggregate
X Premises/Operations 1,000 2,000 11.Claims:Underwriters nepresemadw;fordaims pursuant
to Nis insuanre(address and telephone).
underground&collapse Huard Travelers Insurance Group
X Products/Gompletedoperations 1,000 2,000 800-238-6225
X Contractual , -Incl. Incl.
Independent Contractors
In consideration of the premium charged and notwithstanding any inconsistent statement in the policy to which this endorsement is attached
enclorsennimmoworhereafterthereto,it isagraed as follows:
12. Addlitional Insured.The City of Palm Springs and its officials,employees and agentsare included as additional insureds with regard to liability and
defense of all claim,lawsuits,liabilities or damages of whatsoever arising from the operations and uses performed by or on behalf of the named
insured.
13. Contribution Not Required,insurance is primary with respect to any insurance maintained by the City of Palm Springs and shall not call on the
C h ys hsu rance for contribution.
14. Cancellation Notice.With respect to the interests of the Coy,of Palm Springs this insurance shall not be cancelled,or materially reduced in
coverage or limits except after thitly(30)days prior written notice by receipted delivery ties been given to the City of Palm Springs addressed as
follows:City of Palm Springs,Attn:Risk Manager,3200 E.Taltquilz Canyon Way,Palm Springs CA92262.
Exceptes stated above nothing herein shall be held towalve,attererextend anyofthe lints,conditions,agreements mexdusions of the policyto which
this endorsement is allached.
Endorsement Holder
15. City DepartmentlBureau - 10. Authorimd Representative:®Broker/Agent❑Unrderwnter ❑
City of Palm Springs I Jeffrey W Wodicka, Chmn&CEO (pdntrtype name),warrant that I have
3200 E.Tahquhz Canyon Way authority,to bind the above nboned insurance company and by my signature hereon do so
Palm Springs, CA 92262 bindthlscomper"thisentlo ent.
Signature J
rafu mquiredonmpyJ
Telephone. Q ) 322-4466 Date Signed: 0 812 9/2 0 1 2
COMMERCIAL GENERAL LIABILITY
POLICYNUMBER: X-660-6198424 3-x1L-12 ISSUEDATE: 03-28-12
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CHARITY FIRST -AMENDMENT OF COVERAGE -
WHO I& AN INSURED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization(Additional Insured):
Designation Of Premises(Part Leased to You)
AS PER 9 ULE OR FILE
WHO IS AN INSURED (Section II) is amended: to tion, in consideration for funding or financial
include as an insured: i contributions you receive from them;
A. Your members and volunteers but only with 3. The ownership, maintenance or use of that
respect to their liability',for your activities or ac- part of a premises leased to you; or
tivities they perform on your behalf; 4. "Your work"for that insured by or for you.
B. Your trustees or members of the board of goner- As respects Part C.3, above, this insurance does
nors while acting within the scope of their duties not apply to:
as such on your behalf;and
C. Person(s) or organization(a), whether or not (a) Structural alterations, new construction
shown in the Schedule above, but only with or demolition operations performed byor on behalf of the person(s) or organize-
respect to their liability arising out of: tion(s); or
1. Their financial control over you; (b) Any "occurrence" which takes place after
2. Their requirements:for certain performance you cease to be a tenant in that
placed upon you, as a non-profit organize- premises.
GIN 01 98 0196 Copyright,Travelers indemnity Company. Page 1 of 1
COMMON POLICY CONDITIONS
All Coverage Parts included in this policy are subject to the following conditions:
A. Cancellation during the policy period and up to three years
1. The first Named Insured shown in the Decla- afterward.
rations may cancel this policy by mailing or D. Inspections And Surveys
delivering to us advance written notice of 1. We have the right to:
cancellation.
a. Make inspections and surveys at any
2. We may cancel this policy or any Coverage time;
Part by mailing or delivering to the first
Named Insured written notice of cancellation b. Give you reports on the conditions we
at least: find;and
a. 10 days before the effective date of can- c. Recommend changes.
cellation if we cancel for nonpayment of 2. We are not obligated to make any inspeo-
premium; or tions, surveys, reports or recommendations
b. 30 days before the effective date of can- and any such actions we do undertake relate
cellation if we cancel for any other rea- only to insurability and the premiums to be
son, charged. We do not make safety inspections.
We do not undertake to perform the duty of
3. We will mail or deliver our notice to the first any person or organization to provide for the
Named Insured's last mailing address known health or safety of workers or the public. And
to us. we do not warrant that conditions:
4. Notice of cancellation will state the effective a. Are safe or healthful;or
date of cancellation, If the policy is cancelled,
that date will become the end of the policy b. Comply with laws, regulations, codes or
period. If a Coverage Part is cancelled, that standards.
date will become the end of the policy period 3. Paragraphs 1. and 2. of this condition apply
as respects that Coverage Part only. not only to us, but also to any rating, advi-
5. If this policy or any Coverage Part is ran- sory, rate service or similar organization
celled, we will send the first Named Insured which makes insurance inspections, surveys,
any premium refund due. If we cancel,the reports or recommendations.
fund will be pro rate. If the first Named in- 4. Paragraph 2. of this condition does not apply
sured cancels, the!refund may be less than to any inspections, surveys, reports or rec-
pro rate. The cancellation will be effective ommendations we may make relative to certi-
even if we have not made or offered a re- fication, under state or municipal statutes,or-
fund. dinances or regulations, of boilers, pressure
6. If notice is mailed, proof of mailing will be vessels or elevators.
sufficient proof of notice. E. Premiums
B. Changes 1. The first Named Insured shown in the Decla-
This policy contains all the agreements between rations:
you and us concerning the insurance afforded. a. Is responsible for the payment of all pre-
The first Named Insured shown in the Declara- miums; and
tions is authorized to rrake changes in the terms b. Will be the payee for any return premi-
of this policy with our consent. This policy's terms
can be amended or waived only by endorsement ums we pay.
issued by us as part of this policy. 2. We compute all premiums for this policy in
C. Examination Of Your Books And Records accordance with our rules, rates, rating plans,
We may examine and audit your books and premiums and minimum premiums. The pre-
mium shown in the Declarations was corTM
records as they relate to this policy at any time puted based on rates and rules in effect at
IL TO 01 01 07(Rev.06.09) Includes the copyrighted material of Insurance seMces Office,Inc,with its permission. Page 1 of 2
the time the policy was issued. On each, re- acting within the scope of duties as your legal
newal continuatiomor anniversary of the ef- representative. Until your legal representative is
fective date of this policy, we will compute appointed, anyone having proper temporary cus-
the premium in accordance with our rates tody of your property will have your rights and
and rules then in effect. duties but only with respect to that property.
F. Transfer Of Your Rights And Duties Under
This Policy G. Equipment Breakdown Equivalent to Boiler
Your rights and duties under this policy may not and Machinery
be transferred without our written consent except On the Common Policy Declarations, the term
in the rase of death of an individual named in- Equipment Breakdown is understood to mean
sured. and include Boiler and Machinery and the term
If you die, your rights and duties will be trans- Boiler and Machinery is understood to mean and
ferred to your legal representative but only while include Equipment Breakdown.
This policy consists of the Common Policy Declarations and the Coverage Parts and endorsements listed in that
declarations form.
In return for payment of the premium, we agree with the Named Insured to provide the insurance afforded by a
Coverage Part forming part of this policy. That insurance will be provided by the company indicated as insuring
company in the Common Policy Declarations by the abbreviation of its name opposite that Coverage Part.
One of the companies listed below(each a stock company) has executed this policy, and this policy is counter-
signed by the officers listed below:
The Travelers Indemnity Company(IND)
The Phoenix Insurance Company(PHX)
The Charter Oak Fire Insurance Company(COF)
Travelers Property Casualty Company of America(TIL)
The Travelers Indemnity Company of Connecticut(TCT)
The Travelers Indemnity Company of America(TIA)
Travelers Casualty Insurance Company of America(ACJ)
Secretary President
Page 2 of 2 Includes the copyrighted material of Insurance seMces Office,Inc.with its permission. IL TO 01 01 07(Rev.09-09)
COMMERCIAL GENERAL LIABILITY
b. Does not include any person who is your 2. The following is added to the DEFINTIONS
"employee", "temporary worker" or 'inde- Section:
pendent contractor". "Designated products' means apparel, but-
"Not-for-profit invitee property damage" tons, CDs, DVDs, tapes, posters, stickers and
means "property damage" to personal prop- other similar products used to promote a spe-
erty owned or rented by a "not-for-profit in- cial event related to your business.
vitae", other than any of the following prop- D. MALICIOUS PROSECUTION —EXCEPTION TO
ems' KNOWING VIOLATION OF RIGHTS OF AN-
a. Accounts, bills, :currency, deeds, money, OTHER EXCLUSION
notes, securitiesi or debt instruments; The following is added to Exclusion a., Knowing
b. Mechanical drawings, blueprints, docu- Violation Of Rights Of Another, in Paragraph 2.
ments, records,'manuscripts or valuable of SECTION I — COVERAGES — COVERAGE B
papers;or PERSONAL AND ADVERTISING INJURY:
c. Contraband or other property in the This exclusion does not apply to "personal injury"
course of illegal transportation or trade. caused by malicious prosecution.
B. SPECIAL EVENT PREMIUM RATING E. WHO IS AN INSURED —YOUR LIABILITY FOR
The following is added to SECTION IV — COM- YOUR CONDUCT OF UNNAMED PARTNER-
MERCIAL GENERAL LIABILITY CONDITIONS: SHIP OR JOINT VENTURE (EXCESS BASIS)
Special Event Premium Rating 1. The following replaces the last paragraph of
SECTION II—WHO IS AN INSURED:
a. The Not-For-Profit 'Entity Amendatory En-
dorsement includes the following: No person or organization is an insured with
respect to the conduct of any current or past
(1) All indoor events with less than 1000 at-
tendees and shorter than 24 hours in du- partnership, joint venture, limited liability
company or trust that is not shown as a
ration; and Named Insured in the Declarations. This sub-
(2) All outdoor events with less than 500 at- paragraph does not apply to your liability with
tendees and shorter than 24 hours in du- respect to your conduct of the business of
ration. any current or past partnership or joint ven-
b. The following events will be rated separately ture that is not shown as a Named Insured in
for additional premium: the Common Policy Declarations.
(1) Any event that exceeds the attendees or 2. The following is added to Paragraph 4.b., Ex"
duration described in a.(1)or a.(2)above; cess Insurance, of SECTION IV — COM-
(2) Any parade,fair or carnival;or MERCIAL GENERAL LIABILITY CONDI-
TIONS:
(3) Any athletic, sporting or motor vehicle The insurance is excess over any valid and
event including Walks, runs, tournaments, collectible other insurance, whether primary,
demonstrations,!rallies or competitive ac- excess, contingent or on any other basis,
tivities. which is available to you for your liability with
C. SPECIAL EVENT DESIGNATED PRODUCTS respect to your conduct of the business of
1. The following is added to the definition of any current or past partnership or joint ven-
"products-completed operations hazard" in ture that is not shown as a Named Insured in
the DEFINITIONS Section: / the Common Policy Declarations and which is
�([ issued to such partnership or joint venture.
Includes all "bodily injury" and "property dam-
age"arising out of your"designated products" BLANKET ADDITIONAL INSURED - MORT-
on premises you own or rent, on premises GAGEES, ASSIGNEES, SUCCESSORS OR
used by you for a :special event related to RECEIVERS
your business, or on the ways next to.any The following is added to SECTION II —WHO IS
such premises you own or rent, or use for a AN INSURED:
special event. Any person or organization that is a mortgagee,
assignee, successor or receiver and that you
Page 2 of 4 0 2008 The Travelers Companies,Inc. CG D4 43 07 08
COMMERCIAL GENERAL LIABILITY
have agreed in a written contract or agreement to ownership, use, maintenance, repair, construc-
include as an additional;insured on this Coverage tion, erection or removal of advertising signs,
Part is an insured, but only with respect to its li- awnings, canopies, cellar entrances, coal holes,
ability as mortgagee, assignee, successor or re- driveways, manholes, marquees, hoist away
ceiver for"bodily injury",',"property damage", "per- openings, sidewalk vaults, elevators, street ban-
sonal injury"or"advertising injury"that: ners or decorations for which that state or political
a. Is "bodily injury" or "property damage" that �" subdivision has issued such permit.
occurs, or is "personal injury" or "advertising yp� BLANKET ADDITIONAL INSURED — STATES
injury" caused by an offense committed, after OR POLITICAL SUBDIVISIONS — PERMITS
you have signed and executed that contract RELATING TO OPERATIONS
or agreement; and ! The following is added to SECTION II —WHO IS
b. Arises out of the ownership, maintenance or AN INSURED:
use of the premises for which that mortgagee, Any state or political subdivision that has issued a
assignee, successor or receiver is required permit in connection with operations performed by
under that contract',or agreement to be in- you or on your behalf is an insured, but only with
cluded as an additional Insured on this Cov- respect to liability for "bodily injury", "property
erage Part. damage", "personal injury" or "advertising injury"
The insurance provided:to such mortgagee, as- arising out of such operations.
signee, successor or receiver is subject to the fol- Coverage under this provision does not apply to:
lowing provisions:
1. Any "bodily injury", "property damage", "per-
(1) The limits of insurance provided to such
sonal injury" or"advertising injury' arising out
mortgagee, assignee, successor or receiver of operations performed for that state or po-
will be the limits which you agreed to provide Ildcal subdivision; or
in the written contract or agreement, or the
limits shown in the Declarations for this Cov- 2. Any "bodily injury" or "property damage' in-
erage Part,whichever are less; and cluded in the "products — completed opera-
(2) Coverage under this:provision does not apply
tions hazard".
to: BLANKET ADDITIONAL INSURED—PERSONS
OR ORGANIZATIONS WHERE REQUIRED BY
(a) Any "bodily injury" or "property damage" WRITTEN CONTRACT OR AGREEMENT
that occurs, or any "personal injury" or
"advertising injury" caused by an offense The following is added to SECTION 11 —WHO IS
committed, after such contract or agree- AN INSURED:
ment is no longer in effect; or Any person or organization that you have agreed
(b) Any "bodily injury", "property damage", in a written contract or agreement to include as
"personal injury' or 'advertising injury" an additional insured on this Coverage Part is an
arising out of any structural alterations, insured,but only with respect to liability for'bodily
new construction or demolition operations injury"or"property damage"that:
performed by or on behalf of such mort- 1. Occurs after you have signed and executed
gagee, assignee; successor or receiver. that contract or agreement; and
-XG. BLANKET ADDITIONAL INSURED — STATES 2. Is caused, in whole or in part, by your acts or
OR POLITICAL SUBDIVISIONS — PERMITS omissions in the performance of your ongoing
RELATING TO PREMISES operations to which the written contract or
The following is added t0 SECTION II —WHO IS agreement applies or the acts or omissions of
AN INSURED: any person or organization performing such
Any state or political subdivision that has issued a operations on your behalf.
permit in connection with premises owned oroc- The insurance provided to such person or organi-
cupied by, or rented or loaned to, you is an in- zation where required by written contract or
sured, but only with respect to liability for "bodily agreement is subject to the following provisions:
injury", "property damage", "personal injury" or (1) The limits of insurance provided to such in-
.advertising injury" adsirjg out of the existence, sured will be the limits which you agreed to
CG D4 43 07 08 0 2008 The Travelers Companies,Inc. Page 3 of 4
COMMERCIAL GENERAL LIABILITY
provide in the written contract or agreement, (3) Coverage under this provision does not apply
or the limits shown in the Declarations for this to:
Coverage Part, whichever are less; (a) Any person or organization that has been
(2) If such insured is an architect, engineer or added as an additional insured by at-
surveyor, the insurance provided to such in- tachment of an endorsement under this
sured does not apply to "bodily injury" or Coverage Part which names such person
"property damage" ,arising out of such in- or organization In the endorsement's
sured's providing or failing to provide any pro- schedule;
fessional services, including: (b) Any person or organization who distrib-
(a) The preparing, approving or failing to utes or sells "your product" in the regular
prepare or approve, maps, shop draw- course of that person's or organization's
ings, opinions, reports, surveys, field or- business; or
ders or change orders, or the preparing,
approving or failing to prepare or ap- (c) Any Person or organization from whom
you have acquired "your product", or any
prove, drawings and specifications; and ingredient of, or that contains, your prod-
(b) Supervisory or inspection activities per- uct".
formed as part of any related architectural
or engineering activities;and
Page 4 of 4 ®2008 The Travelers Companies.Inc. CG D4 43 07 08
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
OTHER INSURANCE - ADDITIONAL INSUREDS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PROVISIONS b. The"personal injury'or"advertising injury"for
COMMERCIAL GENERAL LIABILITY CONDITIONS which coverage is sought arises out of an of-
(Section IV), Paragraph 4. (Other Insurance), is fense committed
amended as follows: subsequent to the signing and execution of that
1. The following is added!to Paragraph a. Primary contract or agreement by you.
Insurance: 2. The first Subparagraph (2) of Paragraph b. Ex-
However, N you specifically agree in a written con- cess Insurance regarding any other primary in-
tract or written agreement that the insurance pro- surance available to you is deleted.
vided to an additional insured under this 3. The following is added to Paragraph b. Excess
Coverage Part must apply on a primary basis, or Insurance, as an additional subparagraph under
a primary and noncontributory basis, this insur- Subparagraph(1):
ance is primary to other insurance that is avail- That is available to the insured when the insured
able to such additional insured which covers such is added as an additional insured under any other
additional insured as a; named insured, and we
will not share with that other insurance, provided Policy, including any umbrella or excess policy.
that:
a. The "bodily injury" br "property damage' for
which coverage is sought occurs; and
CG DO 37 04 05 Copyright 2005 The St. Paul Travelers Companies, Inc.All rights reserved. Page 1 of 1
POLICYHOLDER COPY
SK
STATECOMPHNSATION P.O. BOX 8192, PLEASANTON, CA 94588
FUND
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 10-01-2011 GROUP:
POLICY NUMBER: 1423846-2011
CERTIFICATE ID: 4
CERTIFICATE EXPIRES: 10-01-2012
10-01-2011/10-01-2012
CITY OF PALM SPRINGS SK
DEPT OF BUILDING & SAFETY
PO BOX 2743
PALM SPRINGS CA 92263-2743
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Zo4ll� F/�
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2008 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
AIDS ASSISTANCE PROGRAM (NON PROFIT SK
CORPORATION)
PO BOX 4182
PALM SPRINGS CA 92263
[SMA,CN]
(REV.1-2012) PRINTED : 09-04-2012
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Proiect/Activity Title: Project Number:
AIDS Assistance Program/ 0007
Home Bound Grocery Delivery Program
Name/Address of Provider:
AIDS Assistance Program-AAP
PO Box 4182; 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
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-12113111)
AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME(AMI) 1 2 3 4 5 6 7 8
LEVEL
EXTREMELY LO
INCOME $14,100 $16,100 $18,100 $20,100 $21,750 $23,350 $24,950 $26,550
0-30%of AMI
VERY LOW
INCOME $23,450 $26,800 $30,150 $33,500 $36,200 $38,900 $41,550 $44,250
31-50%of AMI
LOW INCOME $37,550 $42,900 $48,250 $53,600 $57,900 $62,200 $66,500 $70,800
51-80'-of AMI
MODERATE
INCOME $53,200 1 $60,800 $68,400 $76,000 $82,000 $88,100 $94,200 $100,300
81-120%
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:
AIDS Assistance Program/ 0007
Home Bound Grocery Delivery Program
Name/Address of Provider:
AIDS Assistance Program-AAP
PO Box 4182; 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
PROGRAM PROGRESS REPORT Period:
DIRECT BENEFIT REPORT
♦ Number of First-Time Program Beneficiaries Serviced:
#of Households #of Persons
0-30%below: 31-50%below: 51-80%below: 81-120%below:
♦ Number of First-Time Female Headed Households:
♦ Counts by Race/Ethnicity:
White _ American Indian or Alaska Native AND White
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
Proiect7Activity Title: Project Number:
AIDS Assistance Program/ 0007
Home Bound Grocery Delivery Program
Name/Address of Provider:
AIDS Assistance Program-AAP
PO Box 4182; 1276 N Palm Canyon Dr, Ste 108
Palm Springs, CA 92262-4429
BENEFICIARY QUALIFICATION STATEMENT
=minim
Other
Grocery Delivery $15,560.00
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 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.