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HomeMy WebLinkAbout05852 - SHELTER FROM THE STORM SUBRECIPIENT AGREEMENT THIS AGREEMENT(herein "Agreement"), is made and entered into this day of PJ�yaa�.e, 2009, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Shelter From The Storm Inc. , (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 semi. ("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 2009— 2010 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 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 TWENTY THOUSAND THREE HUNDRED AND SEVENTY DOLLARS Q20.370.00) (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: Lynn Moriarty, 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 - 42 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 (P1. 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); 0) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (k) The Program 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 attomeys'fees, for injury to or death of person(s), for damage to property (including property owned by the City) arising out of or related to Contractor's performance under this Agreement, except for such loss as may be caused by City's own negligence or that of its officers or employees. 6.0 DISCRIMINATION.TERMINATION, AND ENFORCEMENT. 6.1 Covenant Against Discrimination. Provider covenants that, by and for Itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal, state or local law. 6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1)year from the date hereof. 6.3 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-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: Shelter From The Storm, Inc. 73555 Alessandro Dr, Ste D Palm Desert, CA 92260-3635 -5 - 72 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 , - a municipal corporation v By. it Clerk d311 to 2UIa City Manager APPRO E TO FORM: APPROVED BY CITY COUNCIL By: Ctty orney 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 Ell, No arized Signature of Chairman of Board, rV0 Ign u Secretary, Asst Secretary, President or ar'y-Vice President TreasureY,Asst Treasurer or Chief Financial Officer Name: STEVE eLOOMQUIST Name: JEFFREY KRAMER Title: VICE PRESIDENT Title: /CHIEF FINANCIAL OFFICER State of State of County of rr t J 9-4A`2�1s$ Countyyof On --]�, 12 before me, On ) before me, r ' personally appeared /'1/���— &u ' f2/,j��% ��„ personally appeared who proved to -e� �' —F L u 7 Q r who proved to me on the basis of satisfactory evidence to be the person(s) me on the basi§ 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 capaelty(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. o^�fV Notary Signature `l� t/ Notary Seal: Notary Seal: t. Cwm lesion*1e41915 _ TISHA N.BLANKS i NOIOIy Publk-caffo RICI comm M1850551 Rwarildo C00mv �w•�. NOTARY PUBLIC•CALIFORNIA WCOM-Expkesim30,201 RIVERSIDE COUNTY + Canmisam '�+MAY232013 Da1eC1C0SG•Recovery/Shl1rFrm5trm_SubrmipAgrmnLOc109 -7- CITY OF PALM SPRINGS EXHIBIT A Scope of Services Project/Activity Title, project Number: Shelter From The Strom/ 0001 Domestic Violence Outreach &Advocacy Name/Address of Provider- Shelter From The Storm, Inc. 73555 Alessandro, Ste. D Palm Desert, CA 92260-3635 O b I ectives/Activities The intent of this program is to preserve the Shelter's bilingual domestic violence outreach and advocacy center, located in Palm Springs. This will be accomplished through the staffing for the Outreach and Advocacy Center facilitating a comprehensive range of `on-the-scene' crisis counseling and supportive services, as well as linkage and referral services to ensure that clients who are victims of domestic violence are not placed at further risk, are provided with strategies to help stop the abuse and, whenever necessary, are assisted in escaping their abuser in order to obtain unsubsidized employment while moving toward self-sufficiency. The staff will be the Advocates' role to provide identified victims with access to Shelter from the Storm's comprehensive range of domestic abuse services including emergency shelter, mental health counseling, case management, parenting skills training, independent living training, housing assistance, legal advocacy and linkage to health services. for two hundred and thirty(230) residents. 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 41 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 (LA_Provider, City, CDBG-Recovery, 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 clualifies at least an approximately two hundred and thin 230 residents with new access to services. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming for Palm Springs residents. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 Monthly Submit semi-annual reports—referenced Exhibit E. Objective 6: Manage/monitor crooram 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: Provide emergency housing services, including motel vouchers to homeless individuals as outlined in or000sal. TARGET DATE ACTIVITY#1 On-Going Conduct program activities, 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 07/16/09 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.). This Agreement is made pursuant to the authority of Title XII of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5) (the Recovery Act). The Provider acknowledges that the CDBG-Recovery(CDBG-R) Grant is one-time funding. This Agreement is governed by and the Provider shall comply with the requirements of the Recovery Act; the Notice of Program Requirements for Community Development Block Grant Program Funding under the American Recovery and Reinvestment Act of 2009, 74 Fed. Reg. 21816 (May 11, 2009) available at htto://www.hud.gov/recoverv/cdblo_ck_cfm (as now in effect and as may be amended from time to time) (the Notice); Title I of the Housing and Community Development Act of 1974, as amended (42 USC 5301 et seq.) (as modified by the Notice); and, the HUD regulations at 24 CFR part 570 (as not in effect and as may be amended from time to time) as modified by the Notice (the Regulations). The Provider shall comply with government-wide guidance and standard award terms established by the Office of Management and Budget (OMB) concerning the implementation of the Recovery Act, including Requirements for Implementing Sections 15Z 1605, and 1606 of the American Recovery and Reinvestment Act of 2009 for Financial Assistance Awards, 74 Fed. Reg. 18449 (April 23, 2009) (to be codified at 2 CFR Part 176) (as now in effect and as may be amended from time to time). Notwithstanding the foregoing, the Provider shall comply with Section 110 of the CDBG Statute concerning the Davis-Bacon Act. The Provider shall comply with reporting requirements established by HUD and OMB (including all revisions to such reporting requirements), as well as Sections 1511, 1515, and 1553 of the Recovery Act(including implementing guidance). The Provider shall maintain information on all expenditures and deposits of grant funds and program income under this Agreement and any other records required by applicable law, in its files, and shall make such information available for audit or inspection by duly authorized representatives of HUD, HUD's Office of the Inspector General, the Recovery Act Transparency Beard, or the Comptroller General of the United States. In addition to other lawful remedies, the City reserves the right to restrict access to Providers; CDBG-R funds for delinquent, incomplete, or inaccurate reporting. The Provided is advised that providing false, fictitious or misleading information with respect to CDBG-R funds may result in criminal, civil or administrative prosecution under 18 U.S.C. §3729, 31 U.S.C. §3801 or another applicable statute. The City is required to promptly refer to HUD's Office of the Inspector General any credible evidence that a principal, employee, agent, contractor, sub-grantee, subcontractor, or other person has submitted a false claim under the False Claims Act or has committed a criminal or civil violation of laws pertaining to fraud, conflict of interest, bribery, gratuity, or similar misconduct involving CDBG-R funds. In any contract involving the use of CDBG-R funds, the City shall include a project sign provision consistent with criteria established by HUD. The Provider shall extend all applicable terms and conditions of this grant award, including obtaining a DUNS number (or updating the existing DUNS record), and registering with the Central Contractor Registration (CCR). This Grant Agreement may be amended in writing by the City. In considering proposed amendments to this Agreement, the City shall review, among other things, whether the amendment is otherwise consistent with the Recovery Act, the Housing and Community Development Act, the Notice and the Regulations. CITY OF PALM SPRINGS EXHIBIT B Budget. Summary Proiect/Activity Title: Project Number: Shelter From The Strom 1 0001 Domestic Violence Outreach &Advocacy Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste, D Palm Desert, CA 92260-3635 Bt1DGET,St1MMARY COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel $20,370. $13,349. $33,719. 2 Consultant/Contract Services - 0 - - 0 - - 0 - 3 Travel - 0 - $200. $200. 4 Space Rental - 0 - $10,300. $10,300. 5 Consumable Supplies - 0 - $535. $535. 6 Rental, Lease or Purchase of - 0 - $2,311. $2,311. Equipment 7 Insurance - 0 - - 0 - - 0 - 8 Other - 0 $960. $960. Telephone - 0 - $1,100, $1,100. Client Education Material $20,370, $28,755. $49,125. TOTALS If costs are to be shared by other sources of funding, including GDBG funds from other jurisdictions, identify the source of funding, grantor/lending agency, and cost category information. Other funding sources primarily are fundraising activities conducted by Shelter From the Storm's auxiliary, Angels' Alliance and In-Kind Donation of office space, totaling$15,225. EXHIBIT B—Budget Summary Page 2 of 2 Pages r DETAIL BUDGET . DESCRIPTION OF ACTIVITY/ CDBG OTHER TOTAL PAY ITEMS SHARE SOURCES COST Personnel - $15,074. $9,886. $24,960. Salaries—Outreach Advocate Benefits—Outreach Advocate $5.296. $3,463. $8,759. Other Costs- -0 - $15,406. $15,406. Operations &Overhead Ex enses Total $20,370. S28 755. S49,125. The Subrecipient shall submit monthly reimbursement of Personnel Salaries/Benefits for Outreach Advocate at Palm Springs facility based on prorated salary and actual fringe benefits in accordance with the aforementioned cost categories. In no month shall the Subrecipient submit for reimbursement more than '/a of the total annual budget. Payments, approved by the Subrecipient, shall be paid by the W' 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 2009-10 Program Year--July 1, 2009 through June 30, 2010. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Title, Prolect Number: Shelter From The Strom ! 0001 Domestic Violence Outreach &Advocacy Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste, D Palm Desert, CA 92260-3635 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Philadelphia Insurance Companies Effective Dates of Policy 07/01/09 through 07/01/10 Claims Made Policy / / Per Occurrence Policy / / Limits of Liability General Aggregate 2,000,000 Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 0 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes 0 No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 04/01/09 through 04/01/10 Limits of Liability $1 DOD 000 Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached 13 Yes 0 Ne CERTIFICATE OF LIABILITY INSURANCE OF ID HC FCATE(MMlDDMYq SHELT 1 1 10/27/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Curtis & Harris Insurance Sely ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CA License k OF30715 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P-O- Box 1585 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Palm Springs CA 92263 Phone: 760-778-8787 Fax:760-778-7676 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A' Ph1IAtlNIphla Insurance 2.38.50 INSURER B Shelter from the Storm INSURER C— _ — 73--555 Alessandro Dr. , Ste. D INSURER Palm Desert CA 92260 -- -- 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 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMSSIR uv _ LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIOOryyYY POLICY AT[MM1D�/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1000000 A X X� COMMERCIAL GENERAL LIABILITY PHPK430 676 07/01/09 07/01/10 PREMISES(Ea occurence) S100000_ CLAIMS MAUL �OCCUR MEO EhP(Any one Pureen) S 5000 PERSONAL E ADV INJURY Z1000000 x GENERAL AGGREGATE S 2000000 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-CCMPIOP AGG S1000000 X POLICY PRO" LQc 1000000 EC7 AUTOMOBILE LIABILITY COMBINED SINGLE 41MIT ANY AUTO (En accdent) S 1000000 _ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS PHPK430976 07/01/09 07/01/10 (Per person) S A X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Por accldenl) PROPERTY DAMAGE (Pcroccident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ANY AUTO OTHER THAN EAACC $ AUTO ONLY AGG 8 E%CESS/UMBRELLA LIABILITY EACH OCCURRENCE s2000000 A X OCCUR U CLAIMSMADE PHUB274319 07/01/09 07/01/10 AGGREGATE S 2000000 _ a DEDUCTIBLE S XJ RETENTION 510000 S WORKERS COMPENSATION TOR Y LIMITS ERl_ _ AND EMPLOYERS'LIABILI7Y YIN ANY PROPRIETOR/PARTN5WEXECUTIVqI E L EACH ACCIDENT v S OFFICERIMEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE S If yeB describe dndor SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT 3 OTHER A Professional Liab PHPK430676 07/01/09 07/01/10 PROF LIAR 1000000 1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CDBG-R FUNDS FOR 2009. THE CITY OF PALM SPRING$ AND ITS OFFICERS, OFFICIALS, EMPLOYEES, AND VOLUNTEERS ARE ADDITIONAL INSURED PER FORM PI-NP-- 003 SAND CC 20 10 10 01. COVERAGE IS PRIMARY AND NON-CONTRIBUTORY PER CG 0001. 10 DAY NOTICE OF CANCELLATION FOR NONPAYMENT OF PREMIUM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITYOFP DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SH LL THE CITY OF PALM SPRINGS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIN N3H[�NSHI2E�ITy, i5 DALE COOPS{ REPRESENTATIVES. �LulLph^� II vv== �ILLppSS ``11 II 3200 E. TAHQUITZ CXN WAY AUTH LED ES- TIV �� Z0�9 PALM SPRINGS CA 92262 I ACORD 25(2009101) ©1988.2009 ACORD CORPORAT All rights reserved. The ACORD name and logo are registered marks of ACORD �I By � ITT OCT 2 9 Z;O3 U IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101) 1.Endorsement No- 2.Issue Date(MMlDDM) FT RAJl1MK9fi ro12zi 11P,d!uar 5.Policy Information: CarrierC.P � Policy No: '�� Drr=7Lc� Policy Period: 7'/ '�a(A -7-72b 7� r ,,,y7 �•�/•�r � Coverage Trigger lVi3cumence Telephone `�(p ❑ L7 ! �7 Loss Adjustment Expense:Q Included in Limits In Addition to Limits 4 Insured r" (Check Mich) 6-[j Deductible $ ❑Self-Insured Retention of: S with an Aggregate of$ 7.Applicable.This insurance Oenalns to the operations and/or tenancy of the named insured under all written agreements and permits in forco with the City of Palm Springs unloss checked here❑ in which case only the following specific aproements and permits with the City of Palm Springs are covered. 8. • - of City AgreementsYPermits General Liability 10.Other Provisions Commercial General Liability Comprehensive Form 9. • _ Liabili Limits in Thousands S Each Occurrence Aggregate Premises/Operations '7(zx] as 5 r(r[7GYj(x 11.Claims:Underwriter's representative for claims puruanl to this insurance(address and telephone) Underground&Collapse Hazard _ L� Products/Completed Operations Y,000,64,<I 2,LlL cyj0 ej� , '� Contractual Independent Contractors In consideration of the premium charged and notwithstanding any Inconsistent statement in the policy to which this endorsement is attached endorsement now or hereafter thereto,it is agreed as follows: 12. Additional Insured.The City of Palm Springs and its officials employees and agents are included as additional insureds with regard to liability and defense of all claims,lawsuits liabilities or damages of whalsocver arising from the operations and uses performed by or on behalf of the named insured 13. Contribution Net Required.Insurance Is primary with respect to any insurance maintained by the City of Palm Springs and shall not call on the Clty's Insurance for contribution, 14. Cancellation Notice.With respect to the interests of the City of Palm Springs this insurance shall not be cancelled,or materially reduced in coverage or limits except after thirty(30)clays prior written notice by receipted delivery has been given to the City of Palm Springs addressed as follows:City of Palm Springs,Attn:Risk Manager,V00 E.Tahquitz Canyon way,Palm Springs CA 92252, Except as stated above nothing herein shall be held to waive alterorextend any ofthe limits,conditions,agreements or exclusions of the policy to which this endorsement is attached. Endorsement 15, City Department)Burcau 16. Authorized Representative;XBroker/Agent❑Underwriter ❑ City of Palm Springs I LiL 4 C LYf� /!S (print/type name),warrant that I have 3200 E.7ahquitz Canyon Way authority to bind he above mentioned insurance company and by my signature hereon do so Palm Springs, CA 92262 bind thiscempa to thisenddr men,. (ongr alsign uromgq�uireedddooncopy) L Telephone: )�i `_+ � `f CatetiS y 2 y 2009 l i 4 [104T 2 9 2009 D COMMERCIAL GENERAL LIABILITY CG 201 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(S) Location(s)Of Covered Operations Or Ox anization s : THE CITY OF PALM SPRINGS, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS A. Section II-Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured tho person(s)or additional, insured,the following additional organization(s)shown in the Schedule, but only exclusions apply: with respect to liability for`bodily injury", "property damage"or"personal and advertising This insurance does not apply to"bodily injury" injury'caused, in whole or in pan,by: or"property damage"occurring after: I. Your acts or omissions; or 1. All work, including materials,parts or equipment 2. The acts or omissions of tbose acting on furnished in connection with such work, on the your behalf; project (other than service, maintenance or repairs) to be performed by or on behalf of the in the performance of your ongoing operations for the additional insured(s) at the location of the additional insured(s)at the location(s)designated covered operations has been completed; or above. 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 OTSO Properties, Inc.,2004 Page I of 1 OCT 2 9 2s09 u - P-003 (9103) By THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ ITC LSr GENERAL, LIABILITY DELUXE ENDORSEMENT It is understood and agreed that the following extensions only apply In the event that no other specific coverage for the indicated loss exposures are provided under this policy. if such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy Throughout this endorsement the words"you" and "your" refer to the Named Insured shown in the Declarations. The words "we", "US"and our' refer to the Company providing this insurance. This endorsement modifies Insurance provided under the following, COMMERCIAL GENERAL LIABILITY COVERAGE The following is a summary of the Limits of Insurance and additional coverage provided by this endorsement. For complete details on specific coverages, consult the policy contract wording A. Medical Payments-Limit increased to$15,000; B. Supplementary Payments-Bail bonds increased to$2,500/Loss of earnings increased to$500 each day, C. Tenant's Legal Liability- for Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers- Limit increased to $300,000; D. Broadened Definition of Who is An Insured, E. Amended Duties In The Event Of Occurrence, Claim Or Suit; F. Broadened definition of Advertising Injury-Includes Televised Or Videotaped Publication, 0. Amended definition of Bodily Injury to include Mental Anguish,- H. Broadened definition of Personal Injury- includes Abuse of Process/discrimination; I. Amended Unintentional Failure To Disclose Hazards, J. Amended Liberalization Clause K. Added Employee Indemnification Defense Coverage- We will pay up to $25,000 in defense costs for an "employee"in a criminal proceeding (subject to established criteria),- L. "Property Damage"Removed exclusion for"Property damage"resulting from the use of reasonable force to protect persons or property; M. Added blanket Additional Insured-Funding Source; N. Added blanket Additional Insured- Managers or Lessors of Premises, 0. Nan-owned Watercraft- coverage length is increased to 58 ft.. Pabe 1 of 5 Includes copyright material of the Insurance Service Office Inc used with its permission DV L5 L'I La I�I I�1 OCT 2 9 2009 LJ PI-NP-003 (9/03) By_ A. Medical Payments =� If Medical Payments Coverage (Coverage C ) is not otherwise excluded from this Coverage Part: 1. The Medical Expense Limit is changed subject to all the terms of Limits Of Insurance (Section III) to the greater of: a. $15,000or b. The Medical Expense Limit shown in the Declarations of this Coverage Part- 2 The requirement in the Insuring Agreement of Coverage C., that expenses must be incurred and reported to us within "one year" of the accident date is changed to " three years." 3 Exclusion a. of Coverage C. at your option, does not apply to your volunteer workers or any person or organization under your direct supervision and control B. Supplementary Payments In the Supplementary Payments-Coverages A and B. provision: 1. The limit for the cost of ball bonds is changed from $250 to $2,500; and 2 The limit for loss of earnings is changed from $250 a day to$500 a day. C. Fire, Lightning, Explosion, Smoke and Leaks from Sprinklers If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" is changed to "fire, lightning, explosion, smoke, or leakage from automatic fire protective systems" where it appears in: 1. The Limits Of Insurance section of the Declarations as the Fire Damage Limit. That limit: a. Is changed subject to all the terms of Limit Of Insurance (Section III) to the greater of: (1.)$300,000; or , (2.)The amount shown in the declarations as the Fire Damage Limit. b. Subject to a, above is the most we will pay to all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. 2. The last paragraph of Coverage A. (Section 1) after the Exclusions; 3. Paragraph 6. of Limits of Insurance (Section III); 4 Paragraph b (1)(b) of the Other Insurance Condition (Section IV), and 5 Paragraph a, of the definition of"Insured contract' D Who Is An Insured Who is An Insured (Section II) is changed as follows: 1. If coverage for newly acquired or farmed organizations is not otherwise excluded from this Coverage Part. paragraph 4.a is changed to read: a. Coverage under this provision is afforded until the end of the policy period. 2 Each of the following is also an insured a At the first Named Insured's option, your volunteer workers; and b Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient. c. At the first Named Insured's option, any person or organization under your direct supervision and control while providing for you private home respite or foster home care for the developmentally disabled. However, the insurance afforded by b above is excess over any other insurance covering any person or organization under your direct control or supervision d If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. e. Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, the insurance afforded by a above, for any organization and subsidiary thereof not named in the Declarations as a Named Insured, does not apply to injury or damage with respect to which an Insured under this Coverage Part is also an Insured under another policy, or would be an insured under such policy but for its termination or the exhaustion of its limits of insurance. Page 2 of 5 Includes copyright material of the Insurance Servna Office.Int used with its permission FLI OCT 2 9 2JO9 L j By PI-NP-003 (9/03) E. Duties In The Event Of Occurrence, Claim Or Suit I The requirement in condition 2 a. (Conditions, Section IV) that you must see to it that we are notified as soon as practicable of an "occurrence" or an offense, applies only when the"occurrence" or offense is known to: (a)You, if you are an individual, (b)A partner, If you are a partnership; or (c) An executive officer or insurance manager, if you are a corporation 2. The requirement in condition 2 .b. that you must see to It that we receive notice of a claim or"suit" as soon as practicable will not be considered breached unless the breach occurs after such claim or "suit" Is known to: (a)You, if you are an individual; (b)A partner, if you are a partnership: or (c)An executive officer or Insurance manager, if you are a corporation F. Advertising Injury -Televised Or Videotaped Publication 1 The definition of"Personal and advertising injury" items 14, (d),(e),(f) and (g) is changed to read: "Personal and Advertising injury" means injury arising out of one or more of the following offenses: d. Oral, written, televised or videotaped publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral, written, televised or videotaped publication of material that violates a person's right of privacy; f. Misappropriation of advertising ideas or style of doing business; or g. Infringement of copyright, title or slogan. 2, Exclusions a (2) and a (3) of Coverage B., Personal And Advertising Injury Liability, are changed to read: a. (2)Arising out of oral, written, televised or videotaped publication of material, if done by or at the direction of the insured with knowledge of its falsity; a. (3) Arising out of oral, written, televised or videotaped publication of material whose first publication took place before the beginning of the policy period G. Bodily Injury.Mental Anguish The definition of"bodily injury" Is changed to read. "Bodily Injury": a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and b. Except for mental anguish, includes death resulting from the foregoing (item a. above) at any time H. Personal Injury -Abuse Of Process/Discrimination If Personal and Advertising injury Liability Coverage (Coverage B.) is not otherwise excluded from this Coverage Part: 1., The definition of"Personal and advertising Injury' Is changed by: a Revising item b. of that definition to read: Malicious prosecution or abuse of process: b. Adding the following: "Personal Injury" also means discrimination based on race, color, religion, sex, age or national origin, except when: (1) Done intentionally by or at the direction of, or with the knowledge or consent of: (a)Any Insured, or (b)Any executive officer, director, stockholder, partner or member of the insured; or (2) Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an Insured. or Page 3 of 5 Includcs copyright material orthe Insurance Service Office Inc used wah its permission oCT 9 9 �"09 a I a sy2L_U 3 C24_ (3) Directly or indirectly related to the sale, rental, lease or sub-lease or prospective sales, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured; or (4) Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling. The insurance afforded by H 1 b, above does not apply to fines or penalties imposed because of discrimination I. Unintentional Failure To Disclose Hazards It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prier to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. J. Liberalization If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state. K. Employee Indemnification Defense Coverage Under SUPPLEMENTARY PAYMENTS_COVERAGES A AND 8 the following is added: 3. We will pay on your behalf defense costs incurred by an"employee" in a criminal proceeding, However, you must have a prior written agreement with such "employee"whereby you agree to indemnify the"employee" for such defense costs and the agreement includes a provision for repayment of defense costs In the event of an adverse judgement The most we will pay for any "employee" who is alleged to be directly involved in a criminal proceeding Is $25,000 regardless of the number of employees, claims or"suits" brought or persons or organizations making claims or bringing "suits.' L, Extended "Property Damage" SECTION I -COVERAGES, COVERAGE A, 2. Exclusions a. is deleted and replaced by the following: a. Expected or Intended Injury "Bodily Injury" or"Property Damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or"property damage" resulting from the use of reasonable force to protect persons or property.. M. Additional Insured- Funding Source Under SECTION II-WHO IS AN INSURED the following is added- 5 Any person or organization with respect to their liability arising out of: a. Their financial control of you; or b. Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. N. Additional insured-Managers or Lessors of Premises Under SECTION 11 -WHO IS AN INSURED the following is added- 6 Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you subject to the following additional exclusions: This insurance does not apply to: a. Any"occurrence'which takes place after you cease to be a tenant in that premises. b. Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. 0. Non-owned Watercraft SECTION I -COVERAGES, 2.Exclusions, paragraph g. (2) is amended to read as follows: (2) A watercraft you do not own that is: Page 4 of 5 Includes copyright material of die Insurance Service Office Inc used with its permission O uT j i_I L� II O C T 2 93 �� I- P-003 (9/03) (a) Less than 58 feet long, and By (b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft This insurance is excess over any other valid and collectible insurance available to the Insured whether primary, excess or contingent Page 5 of 5 Includes copyright material of the Insurance Sc ue Office.Inc used wide its permission POLICYHOLDER COPY SK STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 C0MPENSA71pN INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-01-2009 GROUP: 00048E POLICY NUMBER: 0000092-200g CERTIFICATE ID: 1 CERTIFICATE EXPIRES:04-01-2010 04-01-2009/04-01-2010 CITY OF PALM SPRINGS SK CITY CLERKS OFFICE P 0 BOX 2743 PALM SPRINGS CA 92263 This is to certify that we have issued a valid Workers' Compensation insurance policy in s form approved by the California Insurance Commissioner to the employer named below for the policy period indicated, This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the Insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. THORIZED REPRESENTgTI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT H2O65 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER SHELTER FROM THE STORM, INC. A NON-PROFIT, MUTUAL BENEFIT CORPORATION 73555 ALESSANDRO OR STE D PALM DESERT CA 92260 [P17,SK] IR�V,;;051 PRINTED : 03-08-2010 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Proiect_Number: Shelter From The Strom/ 0001 Domestic Violence Outreach &Advocacy Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste. D Palm Desert, CA 92260-3635 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—03110/09) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AM[) 1 2 3 4 5 6 7 8 LEVEL EXTREMELY LO INCOME $14,000 $16,000 $18,000 $20,000 $21,600 $23,200 $24.800 $26,400 0-30%ofAMI VERY LOW INCOME $23,300 $26,650 $29,950 $33,300 $35.950 $38,650 $41,300 $43,950 31-50%ofAM1 LOW INCOME $371300 $42,650 $47,950 $53,300 S57,550 $61,850 $66.100 $70.350 51-80%of AMI MODERATE INCOME $54,200 $81,900 $69,650 $77,400 $83.600 $89,800 $96,000 S102,150 81-120% 3. What racelethnicity 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 ❑ Blac dAfrican American AND White O American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/Afna@n American 0 Native Hawaiian or Other Pacific Islander ❑ Other: HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one: 0 Meximn/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other 4. Are you female Head of Household? p 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: ProiectNumber: Shelter From The Strom/ 0001 Domestic Violence Outreach &Advocacy Name/Address of Provider: Shelter From The Storm, Inc. 73566 Alessandro, Ste. D Palm Desert, CA 92260-3635 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/Afrimn 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 HISPANICILATINO 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 Project/Activity Title. Project Number: Shelter From The Strom / 0001 Domestic Violence Outreach &Advocacy Name/Address of Provider Shelter From The Storm, Inc. 73555 Alessandro, Ste. D Palm Desert, CA 92260-3635 BENEFICIARY QUALIFICATION STATEMENT Approved Current Prior' Total Grant Description Grant Reimbursement Reimbursement YTP " Balance ffAmount " Period - Period(s)7Reimbursement (over/Under)'' Salaries—Outreach Advocate $15.074.00 Benefits—Outreach Advocate $5,296.00 TOTAL' 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 casts 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.