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HomeMy WebLinkAbout05824 - WESTERN COACHELLA VALLEY POLICE ACTIVITIES LEAGUE CDBG SUBRECIPIENT AGR SUBRECIPIENT AGREEMENT ,�1.(Cau17 THIS AGREEMENT(herein"Agreement"), is made and entered into this day 0 1REr 2009, by and between the CITY OF PALM SPRINGS, (herein"City), a municipal corporation and charte� city, and the Western Coachella Valley Police Activities League(WCVPAL). 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 sec. ("Regulations"), and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW, THEREFORE, the parties hereto agree as follows. 1.0 SERVICES OF PROVIDER, 1.1 Scope of Services Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application. 12 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 22, 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"t of the current Fiscal year. 0F,;! 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 TWENTY THOUSAND FOUR HUNDRED AND FIFTY-T1M0 DOLLARS (120,452.00) (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)shalt 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. Alanna Reichle 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 Subcontractina 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 wntten approval of the City. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Provider, its agents or employees, perform the services required herein, except as otherwise set forth herein. Provider shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Provider shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. 4.0 COMPLIANCE WITH FEDERAL REGULATIONS 4.1 The Provider shall maintain records of its operations and financial activities in accordance with the requirements of the Housing and Community Development Act and the regulations promulgated thereunder, which records shall be open to inspection and audit by the authorized representatives of the City, the Department of Housing and Urban Development and the Comptroller General during regular working hours. Said records shall be maintained for such time as may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program- -2- 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable: (a) Submit to City through its Community and Economic Development Department semi-monthly reports on program status; (b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto, (c) Section 3 of the Housing and Urban Development Act of 1968, as amended; (d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P-L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42. (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570200 0), (I) 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.0 4801 et semi.); (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. 52 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. 5.3 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 parry shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney -5 - TO PROVIDER: Western Coachella Valley Police Activities League_Inc. 200 S Civic Dr Palm Springs, CA 02262-7201 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. [ End —Signatures on Next Page ] -6 - CITY OF PALM SPRINGS — _ AT T: a municipal corporation City Clerk o /( o f,2 On City Manager APPROS T FORM, APPROVED BY CITY COUNCIL By: / City Aorney PROVIDER: Check one: _Individual A Partnership Corporation (Corporations require two notarized signatures: One signature must be from the Chairman of Board, Presl ry t, orTr any Vice President. The second signature must be from the Secretary, Assistant ecreta , easurer, Assistant Treasurer, or Chief Financial Officer . By: ri/ �e' vl� By:� Notari nature of Chairman of Board, Nota(d ed Signature Secretary, Asst Secretary, P esid nt or any Vic resi e t Treasurer, Asst Treasurer or Chief Financial Officer /frfdr:� wl GG/ddR Name: .. . �f Name:��—fi r �V e a i1 Title: . 2 /aF Title: ! I !�_Ct_Cu ;/nA State ofLi4-GJ F0i21N0'q State 0441 r�P-A+lk--7 County of/ZIdFjLSNJe }Bs Countyof /A�lr/�jES/OG 15a On "yl G/ST � i l.�U? _r��7_before me. On n/�Jr ,W S7 0A71 ,�,�` ;�"' .--� before me, �✓�•/ZLr72r///�Or7,{e&=1 rl JVJ7t4rA A�zpersonally appeared l•2>%711• Jn>'!!r¢,� Nd�Qr !1[y(G personally appeared -rSr�IJ �Ga 1 .f AI— who proved to -y'3jLA77-2a;77+--— who proved to me on Ihe°basis of satisfactory evidence to be the persorK me on the baSiS of satisfactory evidence to be the persoo(4 whose nameWjRjare-subsoribed to the within instrument and whose name{sJd`gAa ubscribed to the within instrument and acknowledged to me that-h"-511bey executed the same in acknowledged to me lhatire�eNiey executed the Same in ,N?//�thei/ r authorized mf aclykesT and that by.hipt-?/their .A<jir theff authorized capacityaW, and that by-hisAigibeir signature(sj on the instrument the persop(5j, or the entity signature(ey on the instrument the persoruM, or the entity upon behalf of which the persogl s) acted executed the upon behalf of which the persoror 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 a correct. correct. WITNESS my hand and official seal. WITNESS my hand and Official seal. Notary Signature A .l ./�✓y/J,G` Notary Signature:,// /Z;Zly Notary Seal: Notary Seal M.RENEE MONTANTE M.RENEE MONTA Cornn'IlHlan f 1790342 Commlula 90342 Notory Publicldo -CollCounty -w Noto Ic•CalltofMa RlvardW County Ivertlde County Cann. Feb2p.2012 C4ntm. Fab26.2012 xrw DaleC/CDBCANJCVPAL—SubrccipAgnnnLAugog -7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Project/Activity Project/Activity Title: Project Number: Western Coachella Valley Police Activities League / 0010 Partial Summer Scholarship Program Name/Address of Provider: Western Coachella Valley Police Activities League 200 S Civic Dr Palm Springs, CA 92262-7201 Objectives/Activities The intent of this program is to provide diverse activities bringing to youth a wide range of cultural and recreational programming. The PAL program brings youth under the supervision and positive influence of a law enforcement agency and expands public awareness about the role of a police officer and the reinforcement of the responsible values and attitudes instilled in young people by their parents. This will be accomplished through partial summer scholarships to keep ninety-five (95) at-risk Palm Springs youth off the streets and into a safe and educational environment. 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 rovidin 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 rocess. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise. market and publicize the program to facilitate 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 ninet -five 95 Palm S rin s residents from very low to moderate income youth with new access to this service. TARGET DATE ACTIVITY#1 On-Going Ninety-five (95) Palm Springs residents will participate in PAL. 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 42 Monthly Submit quarterly reports—referenced Exhibit E. Objective 6: Manage/monitor program activities. TARGET DATE ACTIVITY#1 On-Going Perform monitoring activities necessary to ensure that the program is being conducted in compliance with the CDBG policies, federal regulations, and local statues, including Davis-Bacon Act, Copeland Act, and Non-discrimination /EEO requirements. Objective 7: Establish New and/or Expanded Services for Seniors At-Risk Youth. Severely Disabled Adults and Special need Population TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in the proposal. Objective 8: Provide an evaluation within fifteen 15 calendar da s 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. ProLect_Number: Western Coachella Valley Police Activities League! 0010 Partial Summer Scholarship Program Name/Address of Provider: Western Coachella Valley Police Activities League 200 S Civic Dr Palm Springs, CA 92262-7201 BUDGET SUMMARY 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 - v - 0 - - 0 - 6 Rental, Lease or Purchase of - 0 - - 0 - - 0 - Equipment 7 Insurance - 0 - - 0 - - 0 - 8 Other $20,452. $58,673. $79,125. Summer Scholarships $20,452. $58,673. $79,125. 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 Agua Caliente Band of Cahuilla Indians, Loin Club of Palm Springs, County Supervisors Ashley, American Medical Response, Morongo Band of Mission Indians, City of Palm Desert, and Private/Business Donors, all totaling `b58,673. The Subrecipient shall receive reimbursements in accordance with the aforementioned cost categories and line items. The program will pay for $215,28 per Palm Springs' youth, at a total amount not to exceed $20,452, approved by the Subrecipient and based upon the actual number of income eligible scholarships awarded in the prior period, shall be paid by the 30th 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/Activity Title. Project Number: Western Coachella Valley Police Activities League/ 0010 Partial Summer Scholarship Program Name/Address of Provider: Date: Western Coachella Valley Police Activities League 200 S Civic Dr Palm Springs, CA 92262-7201 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company_ Lexington Insurance Effective Oates of Policy 01/01/09 to 01/01/10 Claims Made Policy / ! Per Occurrence Policy Limits of Liability_ $3M General Aggregate Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) 0 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes IRT No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company N/A—Worker's Comp Waiver Attached Effective Dates Limits of Liability Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes rZ No DATE[ comp CERTIFICATE OF LIABILITY INSURANCE 4/3/2009 MMIDDIYYYY) PRODUCER (661)327-3111 FAX: (661)327-1262 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Thomas E. Mes cmakar Ins & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR c/o Wilson Paves & Associates ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2300 Bahamas Drive Bakersfield CA 93309 INSURERS AFFORDING COVERAGE NAIC 9 INSURED INSUKERA Lexington Insurance 119437 Western Coachella Valley PAD INSURER S National 17nmQn Fire Ins. 19445 2005. Civic Dr. INSURERC INSURER O Palm Springs CA 92262 wSURERE CQVFRAGFS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TliE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTnATHSTANQING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MTN RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AG G LIMITS SHOWN MAY}AVE BEEN REDUCED BY PA AIMS INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION IN Rn TYPE OF INSURANCE POLICY NUMBER PATE IMMIDD DATE MMIDD LIMITS n ENERAL LIABILITY EACH OCCURReNCE 1,000,000 X COMMERCIAL GENERAL LIABILITY TO RENTED TV P ISf,S,(•.I o cartnnca 5 100,000 A X CLAIMS IMS MADE OCCUR 9491044 1/g,/$009 1/1/2010 MED ExP An nnr; Eryonl excluded X Sexual A'sune p R ;Any IN.IURY 5 1,000,000 LiMit $100,000 .f ERALAGGREGATE z 3,000,000 GIN L AGC•REGATE LIMIT APPLIES PER PR Ir•T - 0 AGE, 1,000,000 }C ROIICY IIF T F7 L C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ca-sdArlj i ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (PC,person) HIREDAUTOS BODILY INJURY S NON-OWNED AUTOS (Per atc1aenO PROPERTY DAMAGE j1 (Pcrsceden0 GARAGE LIABILITv AUTO ONLY-EA ACCIDENT & ANVAU TO OTHERTHAN H..AACT�S AUTO ONLY AGG 5 e(CESSIUMBRELLA LIABILITY Fq Hn Q �NCEE OCCUR CLAIMS MADE AG REGATF. 5 S DEDUCTIBLE S RrrFNTION S S WORKERS COMPENSATION AND TWO STATU• O'H- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNEFVEXCCUTIVE EL EACH ACCIDENT S UPwOER1MCIdBER EXCLUDED E L DISEASE-Fn EMPI9YEEIf I SPEC,tlLPROnbe IgIO SPECIAL PROVISInNS tnlow EL DISEASE•POLICY IMIT 5 H OTHER Accident/Medical SR139101690 1/1/2009 1/1/2010 txmpg $50,000 Deduce;pLa $5D.00 DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMSNTISPECIAL PROVISIONS The City Of palm Springs, I;Is Officers, offirciale, employees & volunteers arc included as Additional Insured pox p Et4ched Farm CG2D261185 as required by written contract with respechn to the General Liability Bad only with regaadT to Cho operation ed tho Named ineueed. w10 day cnnecZl,ttti.On for nen payment as per L•he disclaimer Shown below. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE; DESCRIBED POLICIES BE CANCELLED BEFOkE THE City of Palm Springs EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENtEAVOR TO MAIL Attn: City Clerk *30 DAYS WRITTEN NOTICE TO THE CERTIAgATE HOLDER NAMED TO THE LEFT,BUT PO BOX 2743 Palm Springs, CA 92262 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES AUTHORITED REPRESENTATIVE Mike Wilson/AM �----- ACORD 25(2001108) In ACORD CORPORATION 1988 INED25 I010F)DSu Pagc 1 of 2 IMPORTANT If the corifcate holder is an ADDITIONAL INSURED, the policy(ies) must he 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 The Certificate of Insurance on the reverse side of this form 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(2001M) INS025 pica)OBE Page 2 cf 2 POLICY NUMBER: 9471044 POLICY PERIOD: 1/1/2009- 1/1/2010 COMMERCIAL GENERAL LIABRAT"Y THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCLAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of Patin Spriggs PO Box 2743 Palm Springs,CA 92262 (If no entry appears above, information required to cwmptete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. "CG 20 26 1185 Copyright, Insurance Services Office, Inc.. 1984 Page I of 1 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 ❑ closely held corporation 'P�mu,) -1'eoF r r ,-� cc��s�cry 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 S-53 Date date CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity,Title- Protect Number: Western Coachella Valley Police Activities League/ 0010 Partial Summer Scholarship Program Name/Address of Provider Date: Western Coachella Valley Police Activities League 200 S Civic Dr Palm Springs, CA 92252-7201 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described prolectfactivity. 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 Bemardino-Ontario,CA MSA--03/10109) AREA MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME(AMI) 1 2 3 4 5 6 7 8 LEVEL _ EXTREMELY LO INCOME $14,000 $16,000 518 000 S20,000 $21,600 $23 200 S24 800 $26,400 0-30%of AMI VERY LOW INCOME S23,300 $26,650 $29,950 $33300 $35,950 S38,650 $41.300 S43950 31.50%of AMI LOW INCOME S37,300 $42,650 $47950 $53300 $67,660 $61850 S66,100 $70,350 51-60%of AMI MODERATE - INCOME 554,200 S61,900 $69,660 S77400 S83600 S89,800 $96,000 $102,150 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 BlackfAfrican American ❑ Native Hawaiian or Other Pack Islander ❑ Other: HISPANICILATINO ETHNICITY 0 Yes ❑ No If yes,check one. ❑ MexicanfChlCano ❑ Puerto Rican ❑ Cuban ❑ Other: 4. Are you female Head of Household? ❑ YES ❑ NO S. Do you have a disability? 0 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 confidentlal and is only utilized for Community Development Block Grant(CDBG) program purposes a Poderally-Funded program,governmental reporting purposes to monitor compliance CITY OF PALM SPRINGS EXHIBIT B Quarterly Program Progress Report Proiect/Activity Title. Project Number: Western Coachella Valley Police Activities League! 0010 Partial Summer Scholarship Program Name/Address of Provider: Date. Western Coachella Valley Police Activities League 200 S Civic Dr 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 Slack/African American Native Hawauan or Other Pacific Islander Other HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: • Number of Disabled. ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title. Proiect Number Western Coachella Valley Police Activities League/ 0010 Partial Summer Scholarship Program Name/Address of Provider' Date: Western Coachella Valley Police Activities League 200 S Civic Dr Palm Springs, CA 92262-7201 Approved current Prior Total Grant Description, Grant , Reimdursement aeimbursamant YTD Balance Amount Period Penod(s) (Over/Under) Summer Scholarship $20,452.00 TOTAL $20,452.00 E==1== 1 CERTIFY THAT, (e) the City of PALM SPRINGS, as grantee of the COBG, 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.