HomeMy WebLinkAbout06075 - DESERT SAMARITANS FOR SENIORS CDBG SUBRECIPIENT AGR SUBRECIPIENT AGREEMENT
THIS AGREEMENT (herein "Agreement'), is made and entered into this g� day of August ,
2011, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter
city, and the Desert Samaritans for Seniors, (herein"Provider").
WHEREAS, the City has entered into various funding agreements with the United States
Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG
Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C.
Section 5301 et seq.), as amended from time to time (the "Act"), and the regulations promulgated
thereunder(24 C.F.R. Section 570 et sec. ("Regulations"); and
WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations
for certain purposes allowed under the Act; and
WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible
for a grant of CDBG funds and the City desires to assist in the operation of the program by granting
CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program
permitted by the Act and the Regulations on terms and conditions more particularly set forth herein;
NOW, THEREFORE, the parties hereto agree as follows:
1.0 SERVICES OF PROVIDER.
1.1 Scope of Services. Provider agrees to provide to City all of the services
specified and detailed in its application for funding and Exhibit A, 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 2011 —2012 Fiscal Year shall provide to City a financial
statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance
Director completed within the most recent twelve(12) months showing the Provider's financial records to
be kept in accordance with generally accepted accounting standards. The report shall include a general
ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate
contract compliance and be balanced to bank statements. Any organization receiving or due to receive
less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's
most recent charitable trust report to the Attorney General, or other financial information satisfactory to
City's Finance Director. The financial information provided for in this paragraph shall be furnished not
later than January 31 at of the current fiscal year.
ORIGINAL BID
AND/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 FOURTEEN THOUSAND, ONE HUNDRED AND SEVENTY-SIX
DOLLARS (114.176.00) (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:
Dena Bates, Proiect 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 Aqainst 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 activifies 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);
Q) The labor standard requirements as set forth in 24 CFR Part 570,
Subpart K and HUD regulations issued to implement and
requirements;
(k) The Program Income requirements as set forth in 24 C.F.R.
570.504(c) and 570.503(b)(8);
(1) The Provider is to carry out each activity in compliance with all
Federal laws and regulations described in 24 C.F.R. 570, Subpart K,
except that the Provider does not assume the City's environmental
responsibilities described at 24 C.F.R. 570.604; nor does the Provider
assume the City's responsibility for initiating the review process under
the provisions of 24 C.F.R. Part 52;
(m) Executive Order 11988 relating to the evaluation of flood hazards and
Executive Order 11288 relating to the prevention, control and
abatement of water pollution;
(n) The flood insurance purchase requirements of Section 102(a) of the
Flood Disaster Protection Act of 1973 (P.L. 93-234);
(o) The regulations, policies, guidelines and requirements of 24 CFR
570; the "Common Rule", 24 CFR Part 85 and subpart J; OMB
Circular Nos. A-102, Revised, A-87, A-110 and A-122 as they relate
to the acceptance and use of federal funds under the federally-
assisted program;
-3-
(p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing
regulations issued at 24 CFR Part 1;
(q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended;
(r) The lead-based paint requirements of 24 CFR Part 35 issued
pursuant to the Lead-Based Paint Poisoning Prevention Act (42
U.S.C. 4801 at 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 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).
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5.2 Indemnification. The Provider shall defend, indemnify and hold harmless the
City, its officers and employees, from and against any and all actions, suits, proceedings, claims,
demands, losses, costs, and expenses, including legal costs and attorneys'fees, for injury to or death of
person(s), for damage to property (including property owned by the City) arising out of or related to
Contractor's performance under this Agreement, except for such loss as may be caused by City's own
negligence or that of its officers or employees.
6.0 DISCRIMINATION TERMINATION AND ENFORCEMENT.
6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its
heirs, executors, assigns, and all persons claiming under or through them that there shall be no
discrimination against or segregation of any person or group of persons on account of race, religious
creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy,
marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable
federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to
insure that applicants are employed and that employees are treated during employment without regard
to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin,
ancestry or any other basis Protected Characteristic by applicable federal, state or local law.
6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this
Agreement, this Agreement shall continue in full force and effect until completion of the services, but not
exceeding one(1)year from the date hereof.
6.3 Termination Prior to Expiration of Term. Either party may terminate this
Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party.
Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder
except as may be specifically approved by the Contract Officer. Provider shall be entitled to
compensation for all services rendered prior to receipt of the notice of termination and City shall be
entitled to reimbursement for any services which have been paid for but not rendered.
7.0 MISCELLANEOUS PROVISIONS.
7.1 Notice. Any notice, demand, request, document, consent, approval, or
communication either 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:
Desert Samaritans for Seniors
75105 Merle St Ste 500
Palm Desert CA 92211-5206
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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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7608379065 Desert Samaritans 03:12:19 p.m. 08-18-2011 2/2
CITY OF PALM SPRINGS
ATTEST: a municipal corporation
_ BY�
Clerk 1,0,1'1 2G4 City Manager
APP ED AST RM: APPROVED BY CITY COUNCIL
BY: 44
6 City Attorney
PROVIDER: Check one: _Individual _Partnership _Corporation .
(Corporations require two notarized signatures: One signature must be from the Chairman of
B esI ent, or any Vice President. The second signature must be from the Secretary,
V- t etary, Treasurer,Assistant Treasurer, or Chief Financial Officer).
By: By:
Notarized Sign lure of Chairman of Board, Notarized Signature Secretary,Asst Secretary,
President or any Vice President Treasurer,Asst Treasurer or Chief Flnandal Officer
Name: narrjr w wi 11 i nmR Name:
Title: Prpcirlan+ Title: ll
State of California State of f
Countyof Orange Jss County of )as
On August 18, 2011 before me, On before me,
Barbara J. MacAfee personally appeared personally appeared -
Barry K. Williams 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 persons)
whose name(s)islatff subscribed to the within instrument and whose name(s)is/are subscribed to the within instrument and
acknowledged to me that hels� hey executed the same In acknowledged to me that he/she/trey executed the same in
his/h#/their authorized capacity lea),and that by his/her/their hialherltheir authorized capa ity(ies),and that by hlslhedtheir
signature(s) on the instrument the person(s), or the entity signature(s) on the irtstmmerd the person(s), or the entity
upon behalf of which the person(s) acted, executed the upon behalf of which the person(s) aced, executed the
Instrument. Instrument.
I oertify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and
correct correct.
WITNESS my hand and official seal WITNESS my hand and official sea[.
Notary Signature: /fe1T Notary Signature:
Notary Seal: Notary Sea]:
BARBARA J.M ACAFEE
CrmmdssMn•1860Nt
NoUry Public-CafBornis
Orange county
M Comm.Expires Sag 1,2013+
D&MDBGl l�121DSFS_SubmeipAgrmntAug11
-7-
CITY OF PALM SPRINGS
ATTEST: a municipal corporation
By: By:
City Clerk City Manager
APPROVED AS TO FORM:
By:
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 Secretary, Treasurer,Assistant Treasurer, or Chief Financial Officer).
By.
Gc es� By:
Notarised Signature of Chairman of Board, Notarized Signature Secretary,Asst Secretary,
(��//
President or any Vice President Treasurer,Asst Treasurer or Chief Financial Officer
NameO( L A44keO Isla 11K3-t-i_- Name:
Title: [tee (�� 1 Title:
State o 1�/1 Q-tJ-I( Stale of �1
County
of�'N u 1Q1 �55 County of fss
/O�n f�c.LW�'f 19 1 � I i before me, On before me,
l _ �k Ll-a-Ll1 �7ersonally appeared ,personally appeared
(AtCU�L µxWA'kO 01' Va LL- 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 person(s)
whose name(s)is/are subscribed to the within instrument and whose name(s)is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their his/her/their authorized capacity(ies),and that by his/her/their
signature(s) on the instrument the person(s), or the entity signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the upon behalf of which the person(s) acted, executed the
instrument. instrument.
I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and
correct. correct.
WITNESS my hand and official seal. WITNESS my hand and official seal.
Notary Signature: Notary Signature:
■N�ota�ry Seal: Notary Seal:
C.19L1.
Commission i 1935749
Nomy Publk•CWdornia
RWeMm County
IMY Comm.Exphs May 9.2015+
Da1eC/CDBG11-12/DSFS_SubredpAgrmn Aug11
- 7-
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Proiect/Activity Title: Proiect Number:
Desert Samaritans for Seniors/ 0005
Financial Aid Program
Name/Address of Provider:
Desert Samaritans for Seniors
75105 Merle St, Ste 500 PO Box 10967
Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967
O biectives/Activities
The intent of this program is to provide financial Aid Program. The program caters to the needs of low-
income senior residents. This will be accomplished through direct financial assistance to one hundred
(100) Palm Springs residents during a time of crisis and hardship which will improve quality-of-life and
circumvent a myriad of problematic events of unwarranted trauma or even life threatening outcomes.
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 one-hundred (100) Palm Springs residents
from very low to moderate 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
financial assistance 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
Proiect/Activity Title: Project Number:
Desert Samaritans for Seniors/ 0005
Financial Aid Program
Name/Address of Provider:
Desert Samaritans for Seniors
75105 Merle St, Ste 500 PO Box 10967
Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel — - 0 - $6,230. $6,230.
Wages & Taxes
2 Consultant/Contract Services
Social Worker $5,003 $1,997. $7,000.
Legal &Accounting - 0 - $500. $500.
3 Travel - 0 - - 0 - - 0 -
4 Space Rental & Utilities $417. $683. $1,100.
5 Consumable Supplies/Fees - 0 - $600. $600.
6 Equipment— - 0 - $500. $500.
Purchase, Lease or Maintenance
7 Insurance - 0 - - 0 - - 0 -
8 Other
Outreach/Marketing - 0 - $200. $200.
Financial Assistance $4,170. $330. $4,500.
Transportation Assistance $2,500. - 0 - $2,500.
Grocery Relief $2,086. $914. $3,000.
TOTALS $14,176. $11,954. $26,130.
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$93,755.
EXHIBIT B— Budget Summary
Page 2 of 2 Pages
:� wiG T 111
_
DESCRIPTION OF ACTIVITY/ CDBG OTHER TOTAL
PAY ITEMS SHARE SOURCES COST
Wages _ _ 0 _ $4,610. $4,610.
Fringe Benefits/Payroll Taxes - 0 - $1,620. $1,620.
Consultant/Contract Services $5,003. $2,497. $7,500.
Travel - 0 - - 0 - - 0 -
Space Rental & Utilities $417. $683. $1,100.
Consumable Supplies Fees - 0 - $600. $600.
Equipment— - 0 - $500. $500.
Purchase, Lease or Maintenance
Insurance - 0 - - 0 - - 0 -
Other
Outreach/Marketing - 0 - $200. $200.
Financial Assistance $4,170. $330. $4,500.
Transportation Assistance $2,500. - 0 - $2,500.
Grocery Relief $2,086. $914. $3,000.
NINE 2.m�..
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 Y.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 2011 — 12 Program Year— July 1, 2011
through June 30,2012.
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Proiect/Activity Title: Proiect Number:
Desert Samaritans for Seniors/ 0005
Financial Aid Program
Name/Address of Provider: Date:
Desert Samaritans for Seniors
75105 Merle St, Ste 500 PO Box 10967
Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Philadelphia Indemnity
Effective Dates of Policy 08/18/11 to 08/18/2012
Claims Made Policy / / Per Occurrence Policy
Limits of Liability $2,000,000 General Aggregate
Deductibles:
Per Occurrence $1,000,000
Annual Aggregate $1,000,000
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 Southern Insurance Company
Effective Dates 08/01/11 to 08/01/2012
Limits of Liability $1,000,000
Underlying Coverage Limits $1,000,000
Original Certificate of Insurance Attached 0 Yes El No
7608379065 Desert Samaritans 11:16:44 a.m. 09-22-2011 214
ACORD. CERTIFICATE OF LIABILITY INSURANCE °"'�612011""
9/16/2011
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 BYTHE-POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURENS),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:U the cemucate holder is an ADDITIONAL INSURED,the pdiey(ies)must be endorsed.If SUBROGATION IS WAIVED,SO
to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does.not confarrights to the
Certificate holder in Neu of such endorsement(s).
DeserPRODUCet EDMURrR
aye S.Pluss
Desert Empire Insurance
Services,Inc. LIC#OF09643 760 360-4700 ^ NC Re•760360.4799
77-564 Country Club Drive aYe.pluss@desertempireins.com
Palm Desert,CA 92211 iNSURmaR 8 AFFORDING COVERAGE Nuc a
hOadeiphia Indemnity 18058
INSURED wsuReRa:Southern Insurance Company
Desert Samaritans For The Elderly
P.O.Box 10967 aRIORERC:
Palm Desert,CA 92255-0967 °°SURER°'
NSURER E•
NSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE pOLCES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE POUCYPERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 D R POU EFF PO
WVD POUCYNUMBER MMp Map UNITS
A GENERAL LIABILITY PHPK746448 8/18/201108/18f201 EAaArOaECTcuRRERCE $100
X COMMERCIAL GENERAL UASILTfY aEg $1,0000i00
o
CLAIMS-MADE51 OCCUR NEDEXPWw—pe SS000
PERSONAL aADVODURY ft 000,00D
GENE+ALAGGIEGATE s2,000 00O
GEHLAGG ITAPPLIES PER PROOuCTS-cOMPPGG f2000d00
u m X LOC f A. AuroMDwLELIAeam PHPK746448 81fi/2011 08/181201m
A AUTO sw«ELMr
1,000 0(10
ALL OWNED SCHEDULED BODILYRMRYIP«P ) f
AUTOS AUTOS BODILY INJURY(PerecddM
X HIREDAUmS XNowOMm PERT ) f
S
f
A X Ire LL42 OCCUR PHUB352657 r 8120'I I
EXCESS LIAR .
.p d8P201 EACH OCCURRENCE $1000 000.
CLAIMS-MADE AGGREGATE S1000000
DIED X REMMON$ 10 000
B WORKERS COMPENSATION $
AND EMPLOYERS'LURRSJTY MWCOOD948301 8101/2011 08/01/201 7EA(0*HACCIDEW
OTK-
ANY PROPMETOWPARTNERemcUTIVE Y I N
OFFICERRMEMBER EXCLUDED7 a NIA $1000.000
Nyypn�wEaM 109
uuww A EMPLOYEE $1.000 000DESCRIPTION OF OPERATINS below OLICY LIMIT SI OOO OOO
A Directors 8 PHSD650147 8/18/2011 08N8/201 $1,000,000 ea policy
Officers $1,000,000 aggregate
Em to ment Pract $7 000 000 I.limitDESCR@TIDNOFOPERILTIMILOCATNINS/VEWrLEBOUSeb ACORD101,A[tllaenaiRanmU30wd,l%Imes*P Iere9Uk00)
Certificate'holder and Its officers,officials,employees and volunteers are named as additlonal insured
per form attached.This insurance shall be primary and non-contrubutory to any Insurance maintained by the
certificate holder.
CERTIFICATE HOLDER CANCELLATION
City of Palm Springs SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
- Attn:City ClerkACCORDANCE WITH THE.POLICY. PROVISIONS.
P.O.Box 2743
Palm Springs,CA 92262 AUTHORIZED REPRESENTATIVE
®1988.2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S179646/M177986 2KPLU
7608379065 Desert Samaritans 11:17:23 a.m. 09-22-2011 314
Insured: Desert Samaritans For The Elderly
Re: General Liability
Ins Company: Philadelphia Indemnity Policy#PHPK746448
Effective:08/18/2011 to 08/18/2012
THHS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTOR (FORM B)
This endorsement modifies insurance provided under the COMMERCIAL GENERAL LIABILITY
COVERAGE FORM. This endorsement changes the policy effective on the inception date of the
Policy unless another date is indicated below.
Endorsement Effective: 08/18/2011
NAME OF PERSON OR ORGANIZATION:
City of Palm Springs it's officers, officials, employees and volunteers
P.O. Box 2743
Palm Springs, CA 92262
Attn: City Clerk
WHO IS AN INSURED (Section H) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of your ongoing operations
Performed for that insured.
It is further agreed that such insurance as is afforded by this policy for the benefit of the above
additional insured(s) shall be primary insurance as respects any claim, loss or liability arising out
of the named insured's operations and any other insurance maintained by the additional insureds)
shall be excess and non-contributory with the insurance provided here under,
CG 20 10 10 93 Copyright, Insurance Services Office, Inc., 1992
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Proiect/Activity Title: Proiect Number:
Desert Samaritans for Seniors/ 0005
Financial Aid Program
Name/Address of Provider: Date:
Desert Samaritans for Seniors
75105 Merle St, Ste 500 PO Box 10967
Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967
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/activily. 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(Riversid"an Bemardino-Ontario,CA MSA-06131111)
AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME(AMI) 1 2 3 4 5 6 7 8
LEVEL
EXTREMELY LO
INCOME $13,650 $15,600 $17,550 $19,500 $21,100 $22,650 $24,200 $25,750
0-30%of AMI
VERY LOW
INCOME $22,750 $26,000 $29,250 $32,500 $35,100 $37,700 $40,300 $42,900
31-50%of AMI
LOW INCOME $36,400 $41,600 $46,800 $52,000 $56,200 $60,350 $64,500 $68,650
51-80%of AMI
MODERATE
INCOME $54,600 $62,400 $70,200 $78,000 $84,250 $90,500 $96,700 $102,950
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
S. Do you have a disability? ❑ YES ❑ NO If YES,please describe:
ACKNOWLEDGEMENT AND DISCLAIMER
I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE.
NAME: DATE:
ADDRESS: PHONE NO:
SIGNATURE:
The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes,a
Federally-funded program,governmental reporting purposes to monitor compliance.
CITY OF PALM SPRINGS
EXHIBIT E
Quarterly Program Progress Report
Proiect/Activity Title: Project Number:
Desert Samaritans for Seniors/ 0005
Financial Aid Program
Name/Address of Provider: Date:
Desert Samaritans for Seniors
75105 Merle St, Ste 500 PO Box 10967
Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967
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
Proiect/Activity Title: Project Number:
Desert Samaritans for Seniors/ 0005
Financial Aid Program
Name/Address of Provider: Date:
Desert Samaritans for Seniors
75105 Merle St, Ste 500 PO Box 10967
Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967
onsultant/Contract Srvs
Social Worker $5,003
Legal &Accounting -0-
pace Rental & Utilities $417.
Other
Financial Assistance $4,170.
Transportation Assistance $2,500.
Grocery Relief $2,086.
$14,176.
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.