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HomeMy WebLinkAbout05955 - GOLDEN RAINBOW SENIOR CENTER CDBG SUBRECIPIENT AGR FOR FOOD BANK DISTRIBUTION PROGRAM SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this,day of 2010, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and harter city, and the Golden Rainbow Senior Center. , (herein "Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et seg. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW, THEREFORE,the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A, 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 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 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 st of the current fiscal year. g., ,t, 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 ($15.155.00) (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: HarveyStem 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. - 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-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 11376 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; - 3 - (p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and implementing regulations issued at 24 CFR Part 1; (q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; (r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.); (s) Maintain property inventory system to numerically identify HUD purchased property and document its acquisition date as is set forth in OMB Circular A-110 Attachment N Property Management Standard 6d; and (t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan) in excess of$25,000 is either: (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). -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 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 - 5 - CITY OF PALM SPRINGS ATTEST: a municipal corporation By_ ity Clerk p/ t of zO City Manager APPROVED AS TO FORM: APPROVED By CITY COUNCIL i By ?abiS/o �j•� •1�J r(��Jr> /-City Attorney PROVIDER: Check one: Individual _Partnership Zcorporation (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, Treasure ssistant Treasurer, or Chief Fi a cial icer). Notari ed Signat a of Cha' an ard, z ignatu cretary,Asst ecretaryI President o Iany Vice President Treasurer,Asst Treasurer or Chief Financial Offic\r Name: ��U L� F L e3 W 4. Name: ��l �. Y 1A�t/' � Title: aAAIkffi6AJTitle: C-V\ C t~ State of j State of County of i 55 County of `t .'+- •k. lss On4(` t t ._ �- ( C before me, On ? I _ G `` before me, �� �;L., A y ►�,,c .a. ; 'l•,� L.personally appeared 3 i c ,personally appeared �.. A,•.- 1 � � �:�11 �L ,;_., � who proved to who proved to me on the bas'Is of satisfactory evidence to be the person('' me on the basis of satisfactory evidence to be the person($ whose name*X s/wa-subscribed to the within instrument and whose nameN60re subscribed to the within instrument and acknowledged to me that he%heA4ey executed the same in acknowledged to me that�he%heAI4ey executed the same in �hisjherlth"authorized capacity(ie&), and that by his#len4hek- (his(hert sj,eir authorized capacity(ie and that bpi his(herftheir• signatureN on the instrument the person(, or the entity signature on the instrument the person(&), 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;1 a .' Notary Signature: Notary Seal: f Notary Seal: ?. SHARpN M. DOTY SH, I P M. DOTY Commission# 1861750 Commission# 1861750 a-`~ y z+'� Notary Public-California z z • �,... Notary Public-California � � .-. � Riverside County ' Riverside County My Comm,Expires Sep 16,2013~ My Comm.Expires Se 16,2013 r DaleC/CDBG10-11/GoldenRainbowSrCntr SubrecipAgrmnt.Aug10 - 7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Project/Activity Title: Promect Number: Golden Rainbow Senior Center(GRSC)/ 0010 Food Bank Distribution Program Name/Address of Provider: Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92262-7201 Objectives/Activities The intent of this program is to provide nutritional assistance to low income and moderate income Lesbian, Gay, Bisexual and Transgender (LGBT) seniors. This will be accomplished through the acquisition capital equipment to accommodate the program's growth and upgrade the distribution area for greater multi-use which will include food storage units, industrial refrigerator, commercial freezer and air- circulating ceiling fans. GRSC is affiliated with Services &Advocacy for GLBT Elders (SAGE), the first in the State and the only in Coachella Valley, serving 1,291 clients Valley-wide and 797 Palm Springs' clients. 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 seven hundred and ninety-seven (797) Palm Springs_residents from very low to moderate income senior with new access to this service. TARGET DATE ACTIVITY#1 On-Going Seven hundred and ninety-seven (797) Palm Springs residents will participate in GRSC. 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 semi-annual reports—referenced Exhibit E. Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination/ EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors. Severely Disabled Adults, and S ecial_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 Project/Activity Title: Project Number: Golden Rainbow Senior Center/ 0010 Food Bank Distribution Program Name/Address of Provider: Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92252-7201 BEE 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 $15,155. $29,345 $44,500. Equipment 7 Insurance - 0 - - 0 - - 0 - 8 Other - 0 - - 0 - - 0 - $15,155, $29,345. $44,500. TOTALS 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 Private/Business Donors, all totaling $29,345. Progress payments, approved by the Subrecipient and based upon the percentage of completion of the work with a 10% retention, shall be paid by the 3& day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. The Subrecipient shall receive reimbursements and/or its suppliers/vendors shall receive direct payments by way of a two-party check, in accordance with the aforementioned cost categories and line items which are subject to receipt of an acceptable requisition in the form of a monthly Request for Reimbursement. Services are to be performed over a twelve month period of July 1, 2010 through June 30, 2011 with funds allocated from 2010— 11 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory ProAect/Activit Title: Project Number: Golden Rainbow Senior Center/ 0010 Food Bank Distribution Program Name/Address of Provider: Date: Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92262-7201 INSURANCEINVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Effective Dates of Policy to Claims Made Policy / / Per Occurrence Policy Limits of Liability M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) ❑ Yes ❑ No Original Certificate of Insurance Attached ❑ Yes ❑ No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company Effective Dates Limits of Liability Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes 0 No CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory ro ec Activit Title: Prole Prolegi Number: Golden Rainbow Senior Center 1 0010 Food Bank Distribution Program Name/Address of Providers Date: _ 2 Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92262-7201 INSURANCE INVENTORY LIABILITY INSURANCE POLICY / Name of Provider's Insurance Company d'1_1Z Effective Dates of Policy — 17 — e to Claims Made Policy. / I Per Occurrence Poligyl Limits of Liability, $ M General Aqcl=gte d°c' Deductibles: Per Occurrence ci Annual Aggregate Additional Insured Endorsement (Certificate Holder) 6-Ye-s © No Original Certificate of Insurance Attached I 11 No WORKER'S COMPENSATION POLICY "_�� Name of Provider's Insurance Company d 0 /6rt,. Effective Dates — — 4' Limits of Liability. Underlying Coverage Limits Original Certificate of Insurance Attached Comes 0 No OP ID: DW '�`coRo CERTIFICATE OF LIABILITY INSURANCE DA 10/19/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 518-373-8700 NAME: Casswood Insurance Agency,Ltd. 518-373-8799 PHONE FAx Five Executive Park Drive a AIL Ext: (A/C,No Clifton Park, NY 12065-5694 ROREss_-.-.-....P W Chad Ballard PCUSTOMER RODUCER PRIME-5 _ INSURER(S)AFFORDING COVERAGE _ NAIC# INSURED Golden Rainbow Senior Center INSURER A:North American Elite Ins.Co. 700 Tahquitz Canyon Dr.Ste G . Palm Springs,CA 92262 INSURER B:Southern Insurance Company INSURER C: INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 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. INSR TYPE OF INSURANCE ODL UBR POLICY NUMBER Po YlYYYY MM DDYIYYYY LIMITS FxP LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X 200922073NPO 11/20/09 11/20/10 PREMISES Ea occurrence $ 100,00 CLAIMS-MADE Fx_�OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO-JE LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 ----A ANY AUTO 200922073NPO 11/20/09 11/20/10 (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS ____...... BODILY INJURY(Par accident) $ .. SCHEDULED AUTOS ... ..-- ----....._.- -_ PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,00 A ____._.-.-...-. 200922073NPO 11/20/09 11/20/10 - - DEDUCTIBLE $ X.j RETENTION $ 10,000 $ WORKERS COMPENSATION WC DRYSTATLIMU• OTR- AND EMPLOYERS'LIABILITY •--- --- - - B ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N WS10032251-012 11/27/09 11/27/10 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ — 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION.OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Certificate Holder is an addtional insured per attached forms CIS 2010 0704 and CG 2037 0704. 30 days notice of cancellation will be given to the certificate holder in the event of cancellation of these policies. CERTIFICATE HOLDER CANCELLATION CITYPA1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Palm Springs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. its employees and officers City Clerk AUTHORIZED REPRESENTATIVE P.O. Box 2743 Palm Springs,CA 92262 le, t--/�� +f600't'.' fT �©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 200922073NP0 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons) Location And Description Of Completed Opera- Or Organ ization • tions Any person or organization that you are required All insured premises and operations to add as an additional insured on this policy, under a written contract or agreement currently in Coverage is Primary and Non-Contributory 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 complete this Schedule if not shown above, will be shown in the Declarations. Section 11 - Who Is An Insured is amended to The City of Palm Springs include as an additional insured the person(s) or City Clerk organization(s) shown in the Schedule, but only with p,O. Box 2743 respect to liability for "bodily injury" or "property Palm Springs, Ca. 92262 damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 0 180 Pronertips Inn. 7nna CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Promect Number: Golden Rainbow Senior Center/ 0010 Food Bank Distribution Program Name/Address of Provider: Date: Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92262-7201 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described project/activity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA-05/20/10) 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 $29,260 $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 5. Do you have a disability? ❑ YES ❑ NO If YES,please describe: ACKNOWLEDGEMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE NO: SIGNATURE: The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG) program purposes, a Federally-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Project Number: Golden Rainbow Senior Center/ 0010 Food Bank Distribution Program Name/Address of Provider: Date: Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92262-7201 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/Activit Title: Project Number: Golden Rainbow Senior Center/ 0010 Food Bank Distribution Program Name/Address of Provider: Date: Golden Rainbow Senior Center 700 E Tahquitz Way, Ste F Palm Springs, CA 92262-7201 Appt n W •, 1 , M Purchase of Equipment $15,155.00 "` $15,155.00 1 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. The PROVIDER further agrees to ensure that opportunities for training and employment arising in connection with a housing rehabilitation (including reduction and abatement of lead-based paint hazards), housing construction, or other public construction project are given to low-and very low-income persons residing within the metropolitan area in which the CDBG- funded project is located;where feasible, priority should be given to low-and very low-income persons within the service area of the project or the neighborhood in which the project is located, and to low-and very low-income participants in other HUD programs; and award contracts for work undertaken in connection with a housing rehabilitation (including reduction and abatement of lead-based paint hazards), housing construction, or other public construction project are given to business concerns that provide economic opportunities for low- and very low-income persons residing within the metropolitan area in which the CDBG-funded project is located; where feasible, priority should be given to business concerns which provide economic opportunities to low-and very low-income residents within the service area or the neighborhood in which the project is located,and to low-and very low-income participants in other HUD programs. The PROVIDER certifies and agrees that no contractual or other legal incapacity exists which would prevent compliance with these requirements. b. Notifications The PROVIDER agrees to send to each labor organization or representative of workers with which it has a collective bargaining agreement or other contract or understanding, if any, a notice advising said labor organization or worker's representative of its commitments under this Section 3 clause and shall post copies of the notice in conspicuous places available to employees and applicants for employment or training.