HomeMy WebLinkAbout06221 - INDEPENDENT LIVING PARTNERSHIP (ILP) SUBRECIPIENT AGREEMENT P
V
THIS AGREEMENT(herein "Agreement), is made and entered into this A!f4ay of 2012,
by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city,
and the Independent Living Partnership, (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 sue. ( Regulations'); and
WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations
for certain purposes allowed under the Act; and
WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible
for a grant of CDBG funds and the City desires to assist in the operation of the program by granting
CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program
permitted by the Act and the Regulations on terms and conditions more particularly set forth herein;
NOW, THEREFORE,the parties hereto agree as follows:
1.0 SERVICES OF PROVIDER.
1.1 Scope of Services. Provider agrees to provide to City all of the services
specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified
therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to City
that it is able to provide, and will use funds granted by the City to provide the services represented in the
Provider's application for funding. City provided funds shall be used only for those purposes specified in
such application.
1.2 Compliance with Law. All services rendered hereunder shall be provided in
accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal,
State or local governmental agency of competent jurisdiction.
1.3 Reports. No later than ten (10) days prior to any payment date specified in
Section 2.2, within ten (10) days following the termination of this Agreement, and at such other times as
the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the
services provided during the period of time since the last report and accounting for the specific
expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law,
the Provider shall provide to the City, the Department of Housing and Urban Development, the
Comptroller General of the United States, any other individual or entity, and/or their duly authorized
representatives, any and all reports and information required for compliance with the Act and the
Regulations.
1.4 Financial Reporting. Any Provider receiving or due to receive or due to receiver
$20,000.00 or more from the City during the 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 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 3151 of the current fiscal year.
ORIGINAL BID
AN"D/OR AGREEMENT
2.0 COMPENSATION.
2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its
services a sum not to exceed FIFTEEN THOUSAND. FIVE HUNDRED AND SIXTY-ONE DOLLARS
($15.561.00) (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:
Richard Smith, Executive Director
3.2 Contract Officer. The Contract Officer shall be such person as may be
designated by the chief administrative officer of City.
3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract
with any other entity to perform in whole or in part the services required hereunder without the express
written approval of the City. Neither this Agreement nor any interest herein may be assigned or
transferred, voluntarily or by operation of law,without the prior written approval of the City.
3.4 Independent Contractor. Neither the City nor any of its employees shall have
any control over the manner, mode or means by which Provider, its agents or employees, perform the
services required herein, except as otherwise set forth herein. Provider shall perform all services
required herein as an independent contractor of City and shall remain at all times as to City a wholly
independent contractor with only such obligations as are consistent with that role. Provider shall not at
any time or in any manner represent that it or any of its agents or employees are agents or employees of
City.
4.0 COMPLIANCE WITH FEDERAL REGULATIONS.
4.1 The Provider shall maintain records of its operations and financial activities in
accordance with the requirements of the Housing and Community Development Act and the regulations
promulgated thereunder, which records shall be open to inspection and audit by the authorized
representatives of the City, the Department of Housing and Urban Development and the Comptroller
General during regular working hours. Said records shall be maintained for such time as may be
required by the regulations of the Housing and Community Development Act, but in no case for less than
five years after the close of the program.
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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 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
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;
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(p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing
regulations issued at 24 CFR Part 1;
(q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended;
(r) The lead-based paint requirements of 24 CFR Part 35 issued
pursuant to the Lead-Based Paint Poisoning Prevention Act (42
U.S.C. 4801 et seq.):
(s) Maintain property inventory system to numerically identify HUD
purchased property and document its acquisition date as is set forth
in OMB Circular A-110 Attachment N Property Management Standard
6d; and
(t) Reversion of asset. Upon the Expiration of the agreement, the
subrecipient shall transfer to the City any CDBG funds on hand at the
time of expiration and any accounts receivable attributable to the use of
CDBG funds. Additionally, any real property under the subrecipient's
control that was acquired or improved in whole or in part with CDBG
funds (including CDBG funds provided to the subrecipient in the form of
a loan) in excess of$25,000 is either.
(i) Used to meet one of the national objectives in Section
570.208 (formerly Section 570.901) until five years after
expiration of the agreement, or for such longer period of time
as determined to be appropriate by the City; or
(ii) Not used in accordance with paragraph (s)(i) above, in which
event the subrecipient shall pay to the City an amount equal
to the current market value of the property less any portion of
the value attributable to expenditures of non-CDBG funds for
the acquisition of, or improvement to, the property. The
payment is program income to the City. (No payment is
required after the period of time specified in paragraph (s) of
this section.)
(u) Such other City, County, State, or Federal laws, rules, and regulations,
executive orders or similar requirements which might be applicable.
4.3 The City shall have the right to periodically monitor the program operations of
the Provider under this Agreement.
5.0 INSURANCE AND INDEMNIFICATION.
5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit
concurrently with its execution of this Agreement, public liability and property damage insurance against
claims for injuries against persons or damages to property resulting from Provider's acts or omissions
arising out of or related to Provider's performance under this Agreement. Provider shall also carry
Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such
insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without
thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the
foregoing and naming the City as an additional insured shall be delivered to and approved by the City
prior to commencement of the services hereunder. The procuring of such insurance or the delivery of
policies or certificates evidencing the same shall not be construed as a limitation of Providers obligation
to indemnify the City, its officers, or employees. The amount of insurance required hereunder shall be
as required by the Contract Officer not exceeding 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 Citys own
negligence or that of its officers or employees.
6.0 DISCRIMINATION,TERMINATION,AND ENFORCEMENT.
6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its
heirs, executors, assigns, and all persons claiming under or through them that there shall be no
discrimination against or segregation of any person or group of persons on account of race, religious
creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy,
marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable
federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to
insure that applicants are employed and that employees are treated during employment without regard
to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin,
ancestry or any other basis Protected Characteristic by applicable federal, state or local law.
6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this
Agreement, this Agreement shall continue in full force and effect until completion of the services, but not
exceeding one(1)year from the date hereof.
6.3 Termination Prior to Expiration of Term. Either party may terminate this
Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party.
Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder
except as may be specifically approved by the Contract Officer. Provider shall be entitled to
compensation for all services rendered prior to receipt of the notice of termination and City shall be
entitled to reimbursement for any services which have been paid for but not rendered.
7.0 MISCELLANEOUS PROVISIONS.
7.1 Notice. Any notice, demand, request, document, consent, approval, or
communication either party desires or is required to give to the other party shall be in writing and either
served personally or sent by prepaid, first-class mail to the address set forth below, or such other
addresses as may from time to time be designated by mail.
TO CITY:
City of Palm Springs
3200 East Tahquitz Canyon Way
Palm Springs, CA 92262-6959
Attn: City Manager
WITH COPY TO:
City of Palm Springs
3200 East Tahquitz Canyon Way
Palm Springs, CA 92262-6959
Attn: City Attorney
TO PROVIDER:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
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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
City Clerk ��3`ZDfZ City Manager
APPRQYED AS o F RM: APPROVED BY CITY COUNCIL
BI
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 Sectary, Treasurer, Assistant Treasurer, or Chief Fi ancial Officer).
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By: 'L-- .' By:
Notarized Signature of Chairman of Board, Notarized Signature Secretary,Asst Secretary,
President or any Vice President Treasurer,Asst Treasurer or Chief Financial Officer
Name: IhIc.rlA6L CARl,'iai Name:-Cm YtcrZ ? �'iZtYct
Title: 09119e-cpAl Title: TVUE—O Sc ry —
State of i State County of ,....s' s County of Ir
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On
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personally appeared ) 'p@rs naly'appeared
who proved to who proved to
me on the basis of satisfactory evidence to be the person(s) me on the basis of satisfactory evidence to be the perso5K
whose name(sf is/are subscribed to the within instrument and whose nameSpf is/ a subscribed to the within instrument and
acknowledged to me that he/slle/they executed the same in admorWged to a that he/sh)/t executed the same in
hi3/FtEr/their authorized capacity(iors), and that by hisllkrftMeir his/h!(N�Err uthorized capac' and that by his/h v
signature(y) on the instrument the person(8), or the entity signature on the instrument the personK, or th ntity
upon behalf of which the person(* acted, executed the upon be�of which the personygf 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(((ann�`�d official seal. )) WITNESS my hand and official seal.
Notary Signature: t U�j—
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Notary Seal: \ Notary Seal:
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- 7-
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Proiect/Activity Title: Project Number:
Independent Living Partnership/ 0005
TRIP Volunteer Driver Program
Name/Address of Provider:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
Obiectives/Acdvities
The intent of this program is to provide TRIP Volunteer Driver Program. This will be accomplished
through to expand specialized transportation assistance for 28 extremely low-income to low-income Palm
Springs seniors to gain access to needed health and life sustaining services.
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 quality at least a total of twenty-eight (28) Palm Springs residents
from extremely low-income to low-income seniors with new access to this service.
TARGET
DATE ACTIVITY#1
On-Going Provide case management services, and if no other Provider resources exist, direct
transportation services to Palm Springs residents who lack access. 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
Monthly Submit quarterly 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. 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
07/15/09 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
ProiecUActivity Title: Project Number:
Independent Living Partnership/ 0005
TRIP Volunteer Driver Program
Name/Address of Provider:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
F of
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel — $2,525. - 0 - $2,525.
Wages &Taxes
2 Consultant/Contract Services - 0 - - 0 - - 0 -
3 Travel - 0 - - 0 - - 0 -
4 Space Rental & Utilities - 0 - - 0 - - 0 -
1
5 Consumable Supplies/Fees $245. - 0 - $245.
6 Equipment— - 0 - - 0 - - 0 -
Purchase, Lease or Maintenance
7 Insurance - 0 - - 0 - - 0 -
8 Other
Outreach/Marketing $700. - 0- $700.
Volunteer Drivers' Reimbursement $12,091. $8,230. $20,321.
TOTALS $15,561. 1 $8,230. 1 $23,791.
* 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 local governmental grants and Private/Business Donors, all totaling
$765,509.
The Subrecipient shall submit monthly reimbursement based on prorated and actual costs in accordance with the
aforementioned cost categories and pay items. In no month shall the Subrecipient submit for reimbursement more
than %of the total annual budget.
The Subrecipient recognizes that the CDBG Funds are received from the HUD,and that the obligation of the City to
make payment to Subrecipient is contingent upon receipt of such funds from HUD. In the event that said funds, or
any part thereof,are,or become, unavailable,then the City may immediately terminate or amend this Agreement.
Services are to be performed over the twelve-month period of this 2012—13 Program Year—July 1, 2012 through
June 30,2013.
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Proiect/Activity Title: Project Number:
Independent Living Partnership! 0005
TRIP Volunteer Driver Program
Name/Address of Provider: Date:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY Name of Providers Insurance Company /�'J P/ eA-r5/ - t S L4xA-y✓cb L( -L-m- j c -
Effective Dates of Policy Cc- ti t(- u c (.,L S
Claims Made Policy / / Per Occurrence Policy
Limits of Liability Z U 00 00 O
Deductibles:
Per Occurrence
Annual Aggregate
Additional Insured Endorsement (Certificate Holder) 0 Yes ❑ No
Original Certificate of Insurance Attached ❑Yes Q No
WORKER'S COMPENSATION POLICY "
Name of Provider's Insurance Company S7 y w 0
Effective Dates tro k)—r/ l4-0 u S
Limits of Liability ( O C7 n p O b
Underlying Coverage Limits
Original Certificate of Insurance Attached 0 Yes EI No
TEMADWYM
ACORD CERTIFICATE OF LIABILITY INSURANCE "`7/03/2012
n o7/o3/zolz
THIS CERTIFICATE IS ISSUED AS A NATTER 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: I the certificate holder is an ADDITIONAL INSURED,the po8cy(iies)must be endorsed. I SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,Certain policies may require an endorsenheM A sfaternent on this certificate does not confer rights to the
Certificate holder in lieu of such endorsement(s)-
PRODUCER NAME:
Comprehensive Insurance Services PNONE (949)709-8600 xe-(949)709-1668
22342 Avenida Eepresa ADDRESS
Suite 250 BSI AFFORDING COVERAGE NACR
RSN, CA 92688 IN A: NONPROFITS' INSURANCE ALLIANCE
INSURED
vallRah e:
Independent Living Partnership IBC:
6296 Rivercrest Drive INSURER D:
Ste. K ICE:
Riverside, CA 92507 INSURER F_
COVERAGES CERTIFICATE NUMBER:GL 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.
LTR TYPE OF INSURANCE am VAID POLICY NUMBER umns
GENERAL LIABILITY 2011-02470- 0910112011 OSM2012 EACH OCCURRENCE s 1,000,00
X COMAHRCVILGENE+ALLMBILITY PREMISES aATarterce S 500,00
cLasls#IADE ❑X OCCIm NEED EXPWn Die pa ) s 20,00(
A X PERSONALSAwMBRY $ 1,000,00(
GENERAL AGGREGATE $ 2,000,00(
APPLIES PER PRODUCTS-CONP/OPAM s 2,000,00(X LOC $
AUTORoRILELIABILm 2011-02470-NK 091012M7 09/012012 (Eaaaeer> a 1,000,00
ANY AUTO BODILY QIAIRY(P-Pa ) $
A AUTOS AUTOSSCHEDULED BODILY NAM(Paa=de ) S
X HIRED AUTOS X AUTOS
Per a=dem PROPERIVORMACE S
$
LL48 OCCUR EACH OCCURRENCE I
EXCESSUAB ClAa6-YADE AGGREGATE s
DED I I RETENmNs I S
WORKERS COMPENSATIONAND EMPLOYERS'LIABILITY YIN TORY LINKS ER
ANY PROPRIETORWARTNERiFIfECUTNF EL EACH ACCIDENT $
OFFICERIMBNBER EXCLUDED? �j MIA
(10ea I,XVAYM MR) EL DISEASE-EA Ehp1.0 s
do I
DESCRIPTION OPERATIONS belm E-L DISEASE-POL1CYLoS S
DESCWPnONOFOP9tAIXMILOCATXM IVBICl.ES(A ACOROW%AAWaW R•wlw Sebeabr,ff p e bNq,OeY)
ITIONAL INSURED STATUS APPLIES PER ATTACHED ENDORSEMENT C12010 0704
THIS INSURANCE IS PRIMARY AND NON-CONTRIBUYORY
CERTIFICATE HOLDER CANCELLATION
SROULOANYWF AeoVEoesem®POLICESBECANCELLED eETTNtE
THE EXPIRATXNI DATE THEREOF,NOTICE WILTS DELIVERM3 W
ACCORDNkE WTH TIE POLICY PXOINS1016
CITY OF PALM SPRINGS
ATTN: CITY CLERK Aen ONSOM 1E36rrwThYE ®� ^„z
P.O. BOX 2743
PA SPRINGS, CA 92262 Richard Eynon, CIC/7EREMY
01986-2010 ACORD CORPORATION. AN rights reserved.
ACORD 25(201=6) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 2011-02470-NPO COMMERCIAL GENERAL LIABILITY
CG 2010 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Narne Of Additional Insured Person(s)
Or O anbmiti s . Location(s)Of Covered Operations
Any person or organization that you are required to All insured premises and operations
add as an additional insured on this poky, under a
written contract or agreement currently in effect, or
becoming effective during the term of this policy. The
additional insured status will not be afforded with
respect to liability arising out of or related to your
activities as a real estate manager for that person or
organization.
Information required to completathis Schedule, if not sham above will be shown in the Declarations-
A. Section 11 - Who Is An insured is amended to B. With resped to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the foliaving additional exclu-
organization(s) shown in the Schedule, but only siors apply:-
with respect to liability for 'bodily inlurym, 'property This insurance does not apply to Obochly in or
damage' or personal and advertising injury', injury"
caused, in whole or in part, try. 'pxopnertydamage'occurring after
c Your acts or omissions,or impart, by.
1. All work, including materials, parts or equip}
merit furnished In connection with such Work,
2- The ads or omissions of those acting on your on the project (other than service, maintenance
behalf; or repairs) to be performed by or on behalf of
in the performance of your ongoing operations for the additionwl insured(s) at the location of the
the additional insured(s) at the location(s) desig- covered operations has been completed; or
nated above. 2. That portion of °your wok" out of which the
injury or damage arises has been put to its in-
tended use by any person or organization other
than another contractor or subcontractor en-
gaged in performing operations for a principal
as a part of the same project.
CG 2010 07 04 ® ISO Properties, Inc., 2004 Page 1 of 1 13
POLICYHOLDER COPY SK
STATE
COMPENSATION P.O. BOX 8192, PLEASANTON, CA 94588
INSURANCE
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 07-25-2012 GROUP:
POLICY NUMOER: 1344879-2012
CERTIFICATE ID: 10
CERTIFICATE.EXPIRES: 08-01-2013
08-01-2012/08-01-2013
CITY OF PALM SPRINGS SK
PROCUREMENT & CONTRACTING
3200 E TAHWIT2 CANYON WAY
PALM SPRINGS. CA 92282-6959
This is to certify that we have issued a valid Workers' Compensation insurance pot.icy-in a,.torm....apRroved-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 80. days advance notice should this policy be canceller} prior 10 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.:
Authorized Representative. President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE CASTS: $1.,000,.000 PER OCCURRENCE.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2012 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
INDEPENDENT LIVING PARTNERSHIP (A.: NON PROFIT
CORP)
6235 RIVER CREST OR STE C
RIVERSIDE GA 92507
M0409
PRINTED 07-20-2012
IREV,1 20121
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Proiect/Activity Title: Project Number:
Independent Living Partnership/ 0005
TRIP Volunteer Driver Program
Name/Address of Provider: Date:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
BENEFICIARY QUALIFICATION STATEMENT
This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the
described projectlactivity. Please answer each of the following questions.
1. How many persons are in your household?
For this question a household is a group of related or unrelated persons occupying the same house with at least one member
being the head of the household. Renters,roomers,or borders cannot be included as household members.
2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA-12f13/11)
$63,300 NUMBER OF PERSONS IN YOUR HOUSEHOLD:
AREA MEDIAN 1 2 3 4 6 6 7 8
INCOME(AN)
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 $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 self4derdification is voluntary in accordance with
equal opportunity laws?
❑ White ❑ American Indian or Alaska Native AND White
❑ BladJAhican American ❑ Asian AND White
❑ Asian ❑ Black/African American AND White
❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND BlacktAf ican 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
6. Do you have a disability? ❑ YES ❑ NO If YES,please describe:
ACKNOWLEDGEMENT AND DISCLAIMER
I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE.
NAME: DATE:
ADDRESS: PHONE NO:
SIGNATURE:
The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes, a
Federally-funded program,governmental reporting purposes to monitor compliance.
CITY OF PALM SPRINGS
EXHIBIT E
Semi-Annual Program Progress Report
Proiect/Activity Title: Proiect Number:
Independent Living Partnership/ 0005
TRIP Volunteer Driver Program
Name/Address of Provider: Date:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
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 While
Black/African American Asian AND White
Asian Biack/African American AND White
American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American
Native Hawaiian or Other Pacific Islander Other.
HISPANICMTINO 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:
Independent Living Partnership/ 0005
TRIP Volunteer Driver Program
Name/Address of Provider: Date:
Independent Living Partnership
6235 River Crest Dr, Ste C
Riverside, CA 92507-0758
a a
Personnel— $2,525.
Wa es&Taxes
Consumable $245.
Supplies/Fees
Other
Outreach/Marketing $700.
Volunteer Drivers' $12,091.
Reimbursement
�W .
�+ $15,561.
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.