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HomeMy WebLinkAbout05954 - DESERT SAMARITANS FOR THE ELDERLY CDBG SUBRECIPIENT AGR 2010-11 SUBRECIPIENT AGREEMENT s THIS AGREEMENT (herein "Agreement"), is made and entered into thisX day of 2010, by and between the CITY OF PALM SPRINGS, (herein"City), a municipal corporation d ch Tter city, and the Desert Samaritans for the Elderly DSFTE , (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 secl. ("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 Scooe of Services. Provider agrees to provi� 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 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 2010 — 2011 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 shalt include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 315t of the current fiscal year. 2.0 COMPENSATION. 2.1 Contract Sum. The City shall pay to the Provider on a reimbursable basis for its services a sum not to exceed FIFTEEN THOUSAND, ONE HUNDRED AND FIFTY-FIVE DOLLARS ( 15155.00) (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: Bill Seals Executive Director Dena Bates,_Program Services Manager 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. -2 - 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-monthly 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 -3- to the acceptance and use of federal funds under the federally- assisted program; (p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; (q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; (r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seg.); (s) 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 cant' 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 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 Exeration 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 parry 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 - 5- TO PROVIDER: Desert Samaritan_s for the Elderly 75105 Merle St, Ste 500 Palm Desert CA 92211-5206 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. [ End—Signatures on Next Page] -6 - CITY OF PALM SPRINGS A T a municipal corporation �B�—Y. B r ity Clerk ©1 f 015[Zol I City Manager APPF� B y: ��A VIED As T FORM: APPROVED BY CITY COUNCIL "4t1� G ` 1 � Sato \1 10 w5� "City Attorney PROVIDER: Check one: _ Individual Partnership lCorporation (Corporations require two notarized signatures: One signature must be from the Chairman of Bo dent, or any Vice President. The second signature must be from the Secretary, sistant 7etary, Treasurer, Assistant Treasurer, or Chief Financial Officer). By: By: Notarized Signature of Chairman of Board, Notanz ignature Secretary,Asst Secretary, President or any Vice President Treasurer,Asst Treasurer or Chief Financial Officer Name: � Name: &�n Title: t Title: S E�,,ec T.9,P Y . State of R.���i 0�2N�/k } State of C App�� atiNppA ) County of yf�a•5��� Iss County of Iss On AAve^�,4, //, .2o/b � before me, On Nave.,,br.- At-A 24,ib before me, A1415Grrac.A. Naticy Publ,C personally appeared ` 'k"f' Qxc'*+ A/'T 7►Xy�,personally appeared Bat«y K• � � naS � Al who proved to me on the basis of satisfactory evidence to be the person(it) me on the b sis of satisfactory evidence to be the person* whose name(*WSW subscribed to the within instrument and whose name(V is/pre subscribed to the within instrument and acknowledged to me that he/ye/tt< executed the same in acknowledged to me that I:Wshe/tbay executed the same in his/bWtrlei[authorized capacityjws), and that by his/pwrtbi& bWher/fbbtr authorized capacity(jes), and that by'W/her/*4&q signatureN on the instrument the person*, or the entity signature04 on the instrument the person(*, or the entity upon behalf of which the person(X acted, executed the upon behalf of which the person( acted, executed the instrument. instrument. I certify under PENALTY OF PERJURY under the laws of the I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and State of California that the foregoing paragraph is true and correct. correct. WITNESS my hand4officiase WITNESS my hand and official se I. Notary SignatureNotary Signature: Notary Seal: Notary Seal: LlA GARCIA Commtissm*1855342 Lllffi GARCIA Notary PwIM ^California Comssin l 185 5 342 Notary vbk•Calitornle pirsniM County MONO County 2013 $ 20 10 DaleC/CDBG/DSFTE_SubrecipAgrmnt.Aug t 0 -7- CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiec ctivit Title: ro ect Number: Desert Samaritans for the Elderly/ 0007 Financial Aid Program Name/Address of Provider: Desert Samaritans for the Elderly 75105 Merle St, Ste 500 PO Box 10967 Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967 Ob'ectives/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 two-hundred and forty (240) 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 Cit y by timely providingany 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 pm9rammatic and financial record keeping rocess. 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 ositive promotion for all Darties i.e. Provider City, CDBG etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income gualify at least a total of two-hundred and forty 240 Palm Springs residents from very low to moderate income youth with new access to this service. TARGET DATE ACTIVITY#1 On-Going Two-hundred and forty (240) Palm Springs residents will participate. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 6: Maintain records for all CDBG activities related to this orogram. 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 com letion 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 the Elderly/ 0007 Financial Aid Program Name/Address of Provider: Desert Samaritans for the Elderly 75105 Merle St, Ste 500 PO Box 10967 Palm Desert, CA 92211-5206 Palm Desert, CA ((92255-0967 uwl... t;rria COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel -- - 0 - - 0 - - 0 - Wages & Taxes 2 Consultant/Contract Services - 0 - - 0 - - 0 - 3 Travel - 0 - - 0 - - 0 - 4 Space Rental - 0 - - 0 - - 0 - 5 Consumable Supplies - 0 - - 0 - - 0 - 6 Rental, Lease or Purchase of - 0 - - 0 - - 0 - E ui ment 7 Insurance - 0 - - 0 - - 0 - 8 Other $15,155. $74,845. $90,000. Elderl Financial Aid TOTALS $15,155. $74,845. $90,000. " 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 The Houston Family Foundation, Change A Life Foundation, Desert Healthcare District, 29 Palms Band of Mission Indians, The Auen Foundation, City of Indian Wells, City of Palm Desert, and Private/Business Donors, all totaling$127,036. The Subrecipient shall receive reimbursements in accordance with the aforementioned cost categories and line items. The program will pay assistance to Palm Springs' elderly, at a total amount not to exceed $15,155, 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. Services are to be performed over the twelve-month period of this 2010 — 11 Program Year—July 1, 2010 through June 30, 2011. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Pro'ect/Activi Title: Promect Number: Desert Samaritans for the Elderly/ 0007 Financial Aid Program Name/Address of Provider: Date: Desert Samaritans for the Elderly 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 e P�Lc�.v�_ &a Effective Dates of Policy to 2101 Claims Made Policy / / Per Occurrence Policy Limits of Liability / General A__ggregate Deductibles: Per Occurrence Annual Aggregate / vW U� Additional Insured Endorsement (Certificate Holder) ❑ Yes ❑ No Original Certificate of Insurance Attached gYes ❑ No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company 645t CQM� Effective Dates /- 2 01 d A> 3� v Limits of Liability_ Underlying Coverage Limits 7 Original Certificate of Insurance Attached Yes 11 No ACORD- CERTIFICATE OF LIABILITY INSURANCE 1DATE 2/0112010(MWDDIYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Desert Empire Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SarVIC85,Inc. LIC#OF09643 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 77.564 Country Club Drive Palm DeserE,CA 92211 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Philadelphia Indemni 18058 Desert Samaritans For The Elderly INSURER e: Southern Insurance Company P.O.Box 10967 INSURER C: Palm Desert,CA 92255-0967 INSURERD: INSURER E: COVERAGES 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 WrrH 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PUC LTR INS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVED DATEjMN LIMITS -A- GENERAL LIABILITY PHPK598307 . 08/18/10 08/18/11 EACH OCCURRENCE $1000000 x X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $100 000 CLAIMS MADE 7 OCCUR MED EXP(Anyone person) $$000 P" PERSONAL&ADV INJURY S1 000 OOO ITE: GENERAL AGGREGATE $Z 000 000 .Sf 77�- PEN%AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2 OOO OOO POLICY 7 PRO LOC J AUTOMOBILE LIAB4 TY PHPK598307 08/18/10 08118/11 COMBINED SINGLE LIMIT ANY AUTO (EaaocideM) $1,000,000 ALL OWNED AUTOS BODILY INJURY - SCHEDULED AUTOS (Per person) S X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Persoddent) $ PROPERTY DAMAGE; 1 R --- ^`" (Persocident) $ A GARAGE UA131UTY AUTO ONLY-EA ACCIDENT $ „ ANY AUTO OTHER THAN EA ACC $ _ ^I AUTO ONLY: AGG $ A. EXCESSIUMBRFILA LIABILITY PHUB315311 08/18/2010 08/18/2011 EACH OCCURRENCE 51,Q00,000 X 1 OCCUR ❑CUUMS MADE AGGREGATE $1 000 000 DEDUCTIBLE $ X RETENTION $ 10 000 a �. WORKERS COMPENSATION AND WS1002633202 08101/10 08/01/11 XS A NTH' EMPLOYERS,LIABILITY E.L.EACH ACCIDENT $1 00O 000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE•EA EMPLOYEE $1 00O 000if yes,dewAN under — SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1 000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSWILUT 1 SPECIAL PROVISIONS _ Dertificate holder and Its officers,officials,employees and volunteers are named as additional Insured per form attached.This Insurance shall be primary and non-contrubutory to any Insurance maintained by the certificate holder. RTIFICATE HOLDER CANCELLATION- 10 De s for Non-Pa ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION P City Of Palm Springs DATE THEREOF,THE ISSUING INSURERWILL ENDEAVOR TOMAIL --%L DAYSWRITTEN- �'4 Attn:City Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL:_ P.Q.Box 2T43 IMPOSE NO OBLIGATION OR LU1BILrrY OF ANY KIND UPON THE INSURER.ITS AGENTS OR g Palm Springs,CA 92262 RE+RESMTA AUTHOR IZE�D REPRESENTATIVE ACORD 26(2001/08)1 of 2 #S1646361M164269 2KPLU 0 ACORD CORPORATIONS Insured: Desert Samaritans For the Elderly c� Re: General Liability Ins Company: Philadelphia Indemnity Policy#PHPK598307 4 Effective: 08/18/10 to 08/18/11 �r•1 f„ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY w . 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. s• 7. Endorsement Effective: 08/18/2010 NAME OF PERSON OR ORGANIZATION: ' City of Palm Springs its officers, officials, employees and volunteers _. P.O. Box 2743 - Palm Springs, CA 92262 t«y Attn: City Clerk - r!. WHO IS AN INSURED(Section 11) 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 insured(s)shall be excess and non-contributory with the insurance provided here under, F CG 2010 10 93 Copyright, Insurance Services Office, Inc., 1992 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Actiyity-itle: Project Number: Desert Samaritans for the Elderly/ 0007 Financial Aid Program Name/Address of Provider: Date: Desert Samaritans for the Elderly 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 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-05/20110) 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 31-60%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 Q American Indian or Alaskan Native 0 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 11 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 Quarterly Program Progress Report Proiect/Activlty Title: ro'ect Number: Desert Samaritans for the Elderly/ 0007 Financial Aid Program Name/Address of Provider: Date: Desert Samaritans for the Elderly 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/L.ATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: ♦ Number of Disabled: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT E Annual Program Progress Report Project/Activity Title: Project Number: Name/Address of Provider: PROGRAM PROGRESS REPORT Period: July 1, 2007 to June 30, 2008 DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Served: #of Households #of Persons 0-50%below 51-80%below 120%below • Number of First-Time Female Headed Households Served: • Counts by Race/Ethnicity Served: 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 First-Time Disabled Served: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date Da1eC/Forms1SubrecpntExhbtE CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement roiect/Acti&Title: Proiect umber: Desert Samaritans for the Elderly/ 0007 Financial Aid Program Name/Address of Provider: Date: Desert Samaritans for the Elderly 75105 Merle St, Ste 500 PO Box 10967 Palm Desert, CA 92211-5206 Palm Desert, CA 92255-0967 ali j9 ii �tl jp Financial Aid $15,155.00 ar ,, F15,155.00 R � 4,' 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.