HomeMy WebLinkAbout05821 - PALM SPRINGS SUN-UP ROTARY FOUNDATION CDBG SUBRECIPIENT AGR SUBRECIPIENT AGREEMENT
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THIS AGREEMENT(herein"Agreement'), is made and entered into this d day of ,
2009, by and between the CITY OF PALM SPRINGS, (herein"City), a municipal corporation and charter
city, and the Palm Springs Sunup Rotary Foundation , (herein"ProvideP).
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 sea.), as amended from time to time (the "Act"), and the regulations promulgated
thereunder(24 C.F.R.Section 570 et sec. ("Regulations");and
WHEREAS,the Act provides that the City may grant the CDBG Funds to nonprofit organizations
for certain purposes allowed under the Act;and
WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible
for a grant of CDBG funds and the City desires to assist in the operation of the program by granting
CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program
permitted by the Act and the Regulations on terms and conditions more particularly set forth herein;
NOW,THEREFORE,the parties hereto agree as follows_
1.0 SERVICES OF PROVIDER.
1.1 Scope of Services. Provider agrees to provide to Guy 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 d 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 31 x 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 SEVENTEEN THOUSAND NINE HUNDRED & FORTY-SEVEN
DOLLARS($17.947.00)(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:
Robert Binkow
Doug Calvin
3.2 Contract Officer. The Contract Officer shall be such person as may be
designated by the chief administrative officer of City.
3.3 Prohibition Against Subcontracting or Assignment. Provider shall not contract
with any other entity to perform in whole or in part the services required hereunder without the express
written approval of the City. Neither this Agreement nor any interest herein may be assigned or
transferred,voluntarily or by operation of law,without the prior written approval of the City_
3.4 independent Contractor_ Neither the City nor any of its employees shall have
any control over the manner, mode or means by which Provider, its agents or employees, perform the
services required herein, except as otherwise set forth herein. Provider shall perform all services
required herein as an independent contractor of City and shall remain at all times as to City a wholly
independent contractor with only such obligations as are consistent with that role. Provider shall not at
any time or in any manner represent that it or any of its agents or employees are agents or employees of
City.
4.0 COMPLIANCE WITH FEDERAL REGULATIONS.
4.1 The Provider shall maintain records of its operations and financial activities in
accordance with the requirements of the Housing and Community Development Act and the regulations
promulgated thereunder, which records shall be open to inspection and audit by the authorized
representatives of the City, the Department of Housing and Urban Development and the Comptroller
General during regular working hours. Said records shall be maintained for such time as may be
required by the regulations of the Housing and Community Development Act, but in no case for less than
five years after the close of the program.
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42 The Provider certifies it shall adhere to and comply with the fellowing as they
may be applicable:
(a) Submit to City through its Community and Economic Development
Department semi-annual reports on program status;
(b) Section 109 of the Housing and Community Development Act of 1974,
as amended and the regulations issued pursuant thereto;
(c) Section 3 of the Housing and Urban Development Act of 1968, as
amended;
(d) Executive Order 11246, as amended by Executive Orders 11375 and
12086,and implementing regulations at 41 CFR Chapter 60;
(e) Executive Order 11063, as amended by Executive Order 12259, and
implementing regulations at 24 CFR Part 107;
(f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112). as
amended,and implementing regulations;
(g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and
implementing regulations;
(h) The relocation requirements of Title II and the acquisition requirements
of Title III of the Uniform Relocation Assistance and Real Property
Acquisition at 24 CFR Part 42;
(i) The restrictions prohibiting use of funds for the benefit of a religious
organization or activity as set forth in 24 CFR 570.200 0);
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;
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(p) Title VI of the Civil Rights Act of 1964 (P.L_ 88-352) and implementing
regulations issued at 24 CFR Part 1;
(q) Title VIII of the Civil Rights Act of 1968 (P.L_ 90-284) as amended;
(r) The lead-based paint requirements of 24 CFR Part 35 issued
pursuant to the Lead-Based Paint Poisoning Prevention Act (42
U.S.C.4801 et sew.);
(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 INDEMNIFICATIQN.
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 indemnity 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 Contraet Officer. Provider shall be entitied 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 Tahquilz Canyon Way
Palm Springs,CA 92262-6959
Attn: City Attorney
TO PROVIDER:
Palm Springs Sunup Rotary Foundation
100 S Sunrise Way, Ste 325
Palm Springs, CA 92262-6778
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7.2 Amendment. This Agreement may be amended at any time by the mutual
consent of the parties by an instrument in writing.
IN WITNESS WHEREOF,the parties have executed and entered into this Agreement as of the date
first written above.
[End—Signatures on Next Page]
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CITY OF PALM SPRINGS
ATTEST: a municipal cor�Toration
ty Clerk l c�jr s f 2O"i City Manager
APPROVE FChe&'om:
R
By:
APPROVED BY CITY COUNCIL
i' �
Ci Attom
PROW E —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,
Assistan ecretary,Tr ,asurer,Assistant Treasurer, or Chief Financial Officer).
By. By. ') /
Notarized Signature of aimtan of Board, Notarized S' nature Secretary,Asst Secretary,
President or any President Treasurer, st Treasurer or Chief Financial Officer
Name: f U Name: ITV (mil V1N
Title: ®t--'gL�s 76y") — Title: Q CryS� �cPa _
State of State offll
County of Ivy 3s County of PI / )$a
Onrr��11 -- t'. �21 C before me, On t 2.wq before me,
RV_fel4 4Uk fj l"G 1 personally appeared '-1')D f IL ,personally appeared
who proved to who proved to
me on the basis of satisfactory evidence to be the personw me on the basis of satisfactory evidence to be the person
whose name( IslaA subscribed to the within instrument and whose name IslaKsubscribed to the within instrument and
acknowledged to me that he/s"y executed the same in acknowledged to me ltrat helsl)PJtftEy executed the same In
hl"s�,,�,,,,4�.ffiutjr authorized capz (19,J,and that by hisiWA06ir hiagr*ir autho6zed Capadty(o),and that by hi rflfl�ir
slgnature(o on the instrument the person(y,��( or the entity signalu�re(� on the instrument t persono. or thif entity
upon behalf of which the person(o acted, executed the upon belfalf of which the pefson4 aced, executed the
Instrument. inSVumenL
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 We and State of California that the foregoing paragraph Is We and
coned correct_
WITNESS my hand and official seal. WITNESS my hand and official seal. (71
Notary Signature: Notary Signature:
Notary Seal: Notary Seal:
x TAMMY 7ARETZ 'fFl�fMY ?ARETZ
N TAMM.N ARET4 (AMMM 1629464 N
NOTARYPOELIC•CAMFORNU ! NOTARY PWNLIC-GWFORNU
RIVEA$IOE COUNTY RIvucin COUNTY
MY CONY.UP DEC.13,2007 ( MY comm.R2P•DEC.10,2000
RoglryFrMCi_SutxedpAgmmt qupOB
-7-
CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
ProiecVActivitv Title, Promect Number.
Palm Springs Sunup Rotary 0007
Shoes That Fit Program
Name/Address of Provider. Date:
Palm Springs Sunup Rotary Foundation
100 S Sunrise Way, Ste 325
Palm Springs, CA 92262-6778
Objectives/Activities
The intent of this program is to provide shoes to elementary and middle school students in the Palm
Springs Unified School District_ It is an innovated program which School Personnel distributes to needy
students in the Free and Reduced Federal Lunch Program. The program will serve eight thousand
(8,000) very low-to-moderate income students of which two thousand five hundred (2,500) Palm Springs
youth who do not have shoes that fit properly which is having a negative effect on their learning
achievement.
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
Re- 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 qualifies at least an approximately two thousand five hundred (2 500)
Palm Sorings Youth with new access to this service.
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 grogram.
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 8: 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 CUBG 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, At-Risk Youth. Severely Disabled
Adults, and Special Needs Population.
TARGET
DATE ACTIVITY#1
On-Going Cgnduct 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
07115/O2 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
ro ect/ ctivi Title: Protect Number:
Palm Springs Sunup Rotary 0007
Shoes That Fit Program
Name/Address of Provider: Date:
Palm Springs Sunup Rotary Foundation
100 S Sunrise Way, Ste 325
Palm Springs, CA 92262-6778
BUDGET SUMMARY,
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel $
2 Consultant/Contract Services g
3 Travel $
4 Space Rental $
5 Consumable Supplies
6 Rental, Lease or Purchase $
of Equipment
7 Insurance $
8 Other—
FIi her Education Scholarships
Bicycle Program
Shoes That Fit Program $17,947 $37,053 $55,000.
$7.18 per student
Pre-K&K Back Packet Program
TOTALS $17,947. $37 053 S55 000.
*If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions,
identify the source of funding, grantor/lending agency, and cost category inforrnation-
Other funding sources primarily are Agua Caliente Band of Cahuilla Indians, PS Sunup Rotary Club, PS
Regional Association of Realtors and Individual Donors totaling$37,053-
The Subrecipient shall submit Request for Reimbursement in accordance with the aforementioned cost
categories. The program will pay for$7.18 per Palm Springs'student, not to exceed$17,947. In no quarter
shall the Subrecipient submit for reimbursement more than % of the total annual budget. Payments,
approved by the Subrecipient, shall be paid by the 30" 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
Proiect/Activy Title: Project Number'
Palm Springs Sunup Rotary 0007
Shoes That Fit Program
Name/Address of Provider: pate:
Palm Springs Sunup Rotary Foundation
100 S Sunrise Way, Ste 325
Palm Springs, CA 92262-6778
INSURANCEINVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company ACE American Ins. Co. &ACE P & C Ins. Co.
Effective Dates of Policy 7/1/2009 to 7/1/2010
Claims Made Policy / / Per Occurrence Polic /
Limits of Liability 5,000,000
Deductibles-
Per Occurrence N/A.
Annual Aggregate N/A
Additional Insured Endorsement (Certificate Molder) 0 Yes ❑ No
Original Certificate of Insurance Attached ❑ Yes 0 No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company N/A—Exem Lion Attached
Effective Dates
Limits of Liability
Underlying Coverage Limits
Original Certificate of Insurance Attached 0 Yes ❑ No
ACORD, CERTIFICATE OF LIABILITY INSURANCE D 09/MOM o
PRODUCER LOCK-FONCOMPANIBSJ LC-K CHICAGO THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
S25 W.Monroe,Snlm 600 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
CATCAGO n,60661 HOLDER.THIS CERTIRGATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
(312)669-690D
INSURERS AFFORDING COVERAGE NA1CX
INSURED pp AcriveVSY.aezyCluhs O.nistCet B=IWftA: A(EAmm,=Inemasue Cum 22667
Atm:Risk AA+±eier�Deputm=l StSURER& ACELMputy&a9211y4on MCO 20699
1560 She Ave. INSIPMQ
Evanston n.60201.3698
INSIIRII2 D:
WSIIPER�
COVERAGES "®nA,unxall¢micuxmmemmoar`�wTxE�rE,G,Eeoroar'"n
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABCNE FORTHE POLICY PERIOD INDICATED-NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS CERTIFICATE MAY RE ISSUED OR
MAY PIES,AG•RE(3INSURANCE SHOWN
A HAVE
l5 SUB.IF.CTtO ALLT?IEYERF&5,EJO::LL15lON5 AND CANDn1ONS OF SUCH
POLICIES,AGGRC-0ATE LIMITS SHOWN MAY HAVE BEEN REOl1C®U'(pAI6 CLAIMS.
MYR' POL MICE WDDIYTv1 YGSRthTION t1Mn8 LTR riPE DF1NSDRMK?: K:1'NDN eER
M.Lunu.mr acawnExce2,000,000
A X colMlRpACGEwERK UARRm PhEIGL3161355 711112ppg 71112010 S 500.000
LTADMS MADE 0OCCUR MEDOWWwun PNFII) i )--OOQ t
X Lignnrl.isbility PERSONAL&AWWUR! S 2.0K000
IRC1Yded UFNFNALA[ICi1HiATE 5 4,000,000 .
SEKLAGGREGATEUMRAPPUEDPDC PRODUCTS-COMPIOPAGD S 4,oD0,000
1XI POLICY lJ'MT LOG
AUTONOWLE L4.NILrLY COMem 04LE UMIT
A Am'Aum FACG238613SS 7/1/2009 7/1/2010 (racd�N(1 S 1,000,000
ALL OWNED AUTOS BODILY RUURY S XXXx xX j
scNEDULEDAvnz^, O'kr+�m)
X HIREDAUTOS BOOILYY/MNY
X• NONaVYf+ED AVNS « I S XXXXXXX
PROPERTY DAAN6E
(PeructlmQ i � i
GAItAGEIIASILRY AUIOONLY-FAACGDENr S )0000 oc
ArmAvm NOT APPLICABLE OTHFRTIAN E Aw i =0C(xx
AUTDONLr. AW i x=0OO:
�CCE98NMBRFrra LWRD.RY EACH OCCURRENCE i $(D 0DD
!i i K *=N, ❑cuuLsw OE MWS34%2 71u2009 7A12010 ABATE a 5 000
UMBRELLA i xXX7d.7IX
DEDUCTIBLE O S xx]OCxxx
Rt,f-fEM1ON i i
YIDRI�RS CONPENi&i10N AND WCSTATIL OTH-
EMPLOYEIIi"DACIIIrT NOTAPrLIG3LE IINRS FR
µy PR�IyP � EL EACIIIY.CIDETIr Is XXX=
OFnCFRA1e.18Efi tlfCUAmT FI DEE SE-E(EMPLOYEE S xxxxXxX
IFyy��F,,NxTND aMrt
�ECNL PFOVI&gN56alow EL b6E11BE-paDCYDNR Is XXXXXXK
OTHER
nEscwrnOx OF new,rwnirl.OrwTwrBIYET.cLEs1ExCLua•WSAODw Nv�roCm&Erarr/spErdwLmOYIaONs
The Certificate Holder is included as Additional Insured where required by written contract or permit subject to the
terms and conditions of the General Liability policy,but only to the extent bodily injury or property damage is caused
in whole or in part by the acts or omissions of the insured,
CERTIFICATE HOLDER CANCELLATION
SHOULDwNYOFTNEwNDYEpEemsEn POLICES RE GNCELI en BEFOtaE Tr1E Ey(pWA,TION
City of Palm Springs 30 DAYSWRMEN
P.O. Box 2743 NmwsTDTNECFmwcwTExOLOFRw.rwmTNElnT.unFMLvaEr000sOaRAu
Palm Springs,CA 92262 D�DENOaewAR°"atwscrtT°PANYIa°Iv°NTNe'"suR,;x,DSAceNTaaR
Attn: City Clerk
ACORD 25(2001/0) RD CORPORATION 1900
Certificate of Exemption from
Workers' Compensation Insurance
TO: City of Palm Springs
ATTN: City Clerk and Risk Manager
SUBJECT. Sale Proprietor/Partnership/Closely Held Corporation with No Employees
Please let this memorandum notify the City of Palm Springs that I am a
❑ sole proprietor
❑ partnership
losely held corporation
and do not have any employees whose employment requires me to carry workers'
compensation insurance. Therefore, I do not carry workers' compensation insurance
coverage. I further warrant that I understand the requirements of Section 3700, et seq.,
of the California Labor Code with respect to providing Workers' Compensation coverage
for any employees. I agree to comply with the code requirements and all other
applicable laws and regulations regarding workers' compensation, payroll taxes, FICA
and tax withholding and similar employment issues. I further agree to hold the City of
Palm Springs harmless from loss or liability which may arise from the failure to comply
with any such laws or regulations.
Risk Management Approval:
Contractor Signature
Printed Name of Contractor
$tii' y ZU Date
Date
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
roiect/ActivityTitle: Project Number:
Palm Springs Sunup Rotary 0007
Shoes That Fit Program
Name/Address Df Provider. Date:
Palm Springs Sunup Rotary Foundation
100 S Sunrise Way,Ste 325
Palm Springs, CA 92262-6778
BENEFICIARY QUALIFICATION STATEMENT
This statement must be completed and signed by each person or head of household(legal guardian) receiving benefits farm the
described projectlactivity. Please answer each of the following questions,
1. How many persons are in your household?
For this question a household is a group of related or unrelated persons occupying the same house with at least one member
being the head of the household. Renters,roamers,or boAveers cannot be included as household members.
2. Circle your combined gross annual Income(RlvemIde-San Bemardlno-Ontado,CA NSA—03110109)
AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME(AMI) 1 2 3 4 5 1a 7 a
LEVEL
EXTREMELY LO
INCOME $14,000 $16,000 $18.000 $20,000 $21.600 $23,200 $24,80D $20,400
0-30%ofAMI
VERY LOW
INCOME $23,300 $25.650 $29.950 $33,300 $35,950 $38.650 $41,300 $43,950
31-50%ofAMI
LOW INCOME $37.300 $42.650 $47,950 S53,300 $57,550 $61,850 $06,100 $70,350
51-80%ofA&V
MODERATE
INCOME $54,200 $61.900 $69,650 S77,400 $83,600 $89.800 $96,000 $102,150
81-120%
3. What mca/ethniclty do you Identify yoursalr as;please note that this self-ldentiticallon is voluntary In accordance with
equal opportunity laws?
❑ White l7 American Indian f Alaska Native AND While
O SlackfAfrican American ❑ Asian AND White
Asian ❑ Black/ATrican American AND White
• American Indian f Alaskan Native 0 American IndianfAlaska Native AND Black/African American
❑ Naive Hawaiian f Other Pacific Islander ❑ Other Multi-Racial:
HISPANIC/LATINO ETHNICITY iJ Yes ❑ No If yes,check one:Q Mexican/Chicano
❑ Puerto Rican
❑ Cuban
❑ Other.
4. Are you female Head of Household? ❑ YES ❑ NO
S. Do you have a disability? ❑ YES ❑ NO If YES,please describe:
ACKNOWLEDGEMENT AND DISCLAIMER
I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOt1SHOLD STATEMENTS MADE ON THIS FORM ARE TRUE.
NAME: DATE:
ADDRESS: PHONE NO:
SIGNATURE:
The uttornetion you provide on this form is conrNenhal and is only ublited for Community Development Block Chad(CDBG)propmm purposes,a
Fedorally-funded program,govemmenhal reporing purposes to mortar comphanoe.
CITY OF PALM SPRINGS
EXHIBIT E
Semi-Annual Program Progress Report
rolect/Actiylty Title: Praiect Number.
Palm Springs Sunup Rotary 0007
Shoes That Fit Program
Name/Address of Provider: Date:
Palm Springs Sunup Rotary Foundation
100 S Sunrise Way, Ste 325
Palm Springs, CA 92262-6778
PROGRAM PROGRESS REPORT Period:
DIRECT BENEFIT REPORT
♦ Number of First-Time Program Beneficiaries Serviced:
#of Households N 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:
While_ American Indian or Alaska Native AND While
alacklAfrican American Asian AND While—
Asian — 6lacklmrican American AND While
American Indian or Alaskan Native_ American IndiaNAlaska Native AND BlacIvAfrican American—
Native Hawaiian or Other Pacific Islander _ Other:
HISPANICILATINO ETHNICITY:Mekican/ChiranoL_ Puerto Rican
Cuban Other:
♦ Number of Disabled:
ACCOMPLISHMENT NARRATIVE
LEVERAGING RESOURCES NARRATIVE
Signed Tice Date