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HomeMy WebLinkAbout05462 - THE SMILE FACTORY FOR THE CHILDREN OF THE DESERT CDBG SUBRECIPIENT AGR Page 1 of 1 Cindy Berardi From: Dale Cook Sent: Thursday, February 05, 2009 4:16 PM To: Cindy Berardi Subject: RE: Status of Contract A5462 Hello Cindy—This contract has been completed and can be closed. Thanks. Dale From: Cindy Berardi Sent:Tuesday, February 03, 2009 8:47 AM To: Dale Cook Subject:Status of Contract A5462 Hi Dale, Can you let me know the status of the attached contract? It looks like we received new insurance from them on 1013/08 so that may satisfy whatever insurance issues existed back in July. Cindy 5arai-Jl Dcputy City Clark f 7f-F(.or thc.City Clcrk City of Palm Springs R 0.Box 2743 Palm Springs,CA 92262 (760)322-8355 Cindv.Berard @pa mspnnggo .gavv 2/6/2009 SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement'), is made and entered into this IS day of c 20081 by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the The Smile Factory for the Children of the Desert, (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 seg.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et seq. ("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 Caw. 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 2007 —2008 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 3151 of the current fiscal year. ANaJ�aR aznmmFzunT 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 NINETEEN THOUSAND DOLLARS ($19.000.00) (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 6.6. 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: Sharon Stevens. 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 pad 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 -2 - 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. 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable: (a) Submit to City through its Community and Economic Development Department semi-annual reports on program status; (b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; (0) Section 3 of the Housing and Urban Development Act of 1968, as amended; (d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P-L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); (j) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (k) The Program Income requirements as set forth in 24 G.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); -3- (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 rcu to the acceptance and use of federal funds under the federally- assisted program; (p) Title VI of the Civil Rights Act of 1964 (P.L_ 88-352) and implementing regulations issued at 24 CFR Part 1; (q) Title Vill 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 sue.); (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 570208 (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 -4- 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). 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 Contractors 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. 62 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 -5- WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER.- The Smile Factory for the Children of the Desert 100 S Sunrise Way, Ste A-409 Palm Springs, CA 92262 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 ATTEST: • al corporation By, City Clerk City Manager APPRO T FORM: AHW E LYCI C0B\CIL By: —� City Attom)ey 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 -ythye Secretary, Assistant Secretary, Treasurer, Assistant Treasurer, or C " f inancial I By: �ZA, �� By: Notarized Sign re of Chairman of Board, Notarized Si ature Secretary,Asst Secretary, President or any Vice President Treasurer,As t 1 reasurer or Chief Fiinnanncial.Officer Name: Name: Title: Title:_ f?_ C\CV � ate of — a!e of Co ty of sss Co my of sss On before me, On before me, personally appeared ,personally appeared personally known personally known to me(or proved bR me on the basis of satisfactory evidence) to me(or proved to me on the basis of satisfactory evidence) to be the person(s) Vy+hose name(s) is/are subscribed to the to be the person(s)"whose name(s) is/are subscribed to the within instrument ands cknowledged to me that he/she/they within instrument an acknowledged to me that he/she/they executed the Same in -slherltheir authorized capacity(ies), executed the same in Whentheir authorized capaeity(reS), and that by his/hedtheir nature(s) on the instrument the and that by hislher/their ignature(s) on the instrument the pemon(s), or the entity up behalf of which the person(s) person(s), or the entity up n behalf of which the person(s) acted,executed the instrumen acted,executed the instrume WITNESS my hand and ofFcial 5 al, WITNESS my hand and official al. Notary Notary Signature: Signature; Notary Seal: Notary Seal: 5�c ,�rrac�r-fr�D Ca t.l s✓oR�ii�- /k t.vl_ — "7�2�o s� Smi1CFac1nry_SubrecipAgrmntJu107 - 7- CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT yvr--rcrrr•.�.rc:-+�crr-.r-.-s�r,�r�-ems r-...�=--r..cc;rzrun�cc�.sr"i��r_�.<:�^re�cc.�rz�^.�r.�,�ce�rc�.+zc�^,r�-r--...�,.�ry-„s..c=tee State of California� County of \j CV- 'J On l nr 1_ 8 _ before me, I y G. �ryr 1�2+G1 /vim tt r i t L bete n ( -,ro Insert Nam Andq•life of 11m,officer personally appeared Names)of S,9nnrfs) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her their authorized iY G. FROMI!WG capacity(les), and that by his/her/their signature(s) on the Commission# 1518676 , -. Notary Public -Calltoriva instrument the person(s), or the entity upon behalf of Rlversklo County which the person(s) acted, executed the instrument. MyCwM6q WN0c110,20M I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. �— Signature Place NotaYy Sc-rl Above Si9newro of N8ttfrY Puh io OPTIONAL Though the information below is not required by law it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document 1 n Title or Type of Document:Document Date:J 14 LA L O 2� ^, Number of Pages:1 . Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name:- L.] Individual --] Individual ❑ Corporate Officer—Title(s): LJ Corporate Officer—Title(s): ❑ Partner—❑ Limited ❑ General _ ❑ Partner—❑ Limited ❑ General ❑ Attorney in Fact - ❑Attorney in Fact ❑ Trustee Top�I mama Here ❑Trustee ion aI thumb Here 7 Guardian or Conservator ❑ Guardian or Conservator rl Other: ❑Other: Signer Is Representing: Signer Is Representing: F02007Natloml Notary Assccinlion•0350 be Solo Ave,PC.6nx 2dO'•Chalm.rlh CA 01313-2602-wkw NallonJN.f� fg Item 115907 Reordel.C.rll TolbFree tA00-G]GQP8 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT r-z.^�.Etr.,r•..aFr-.wc. .cmcrerxcz��^�,c�.:�r-�-e��'wi's ���=� =r.�x"wK"..�'r^C�.crcr..�r�rc:-�r-r-r�r�.cr� State of California County of f CI V2 r I d C- On June (�', ZDd� before me, G • �,�ny cJ [ Date Here Inearl Nvmc antl Itielof the officer personally appeared ��G� I'Y7� C-t--atn e- Name(•;)of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he she/they executed the same in his/her/their authorized capacity(ies), and that by hWher/their signature(s) on the ro w G. FROIAKt7G It Instrument the person(s), or the entity upon behalf of Commission • 161"/75 9 serson which the acted, executed the instrument. Notary ftwc-CatMofta € person(s)) R1Yersuft Cowtly10.20 7 MyCcmn.6q�ksac1J I certify under PENALTY OF PERJURY under the laws 7� s of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Pl+ca Notary Seal Ahovc Signature— /,-ignnlure of f Clary P. �E OPTIONAL - o Though the information below is not required by law, it may prove valuable to persons relying on the document and Could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document ] Title or Type of Document: S"r'e-CG( P e11 I trEPJt^e�-i Document Date J i Af, I E', �-OO tS _Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signers Name: Signer's Name: ❑ Individual LJ Individual * Corporate Officer-Title(s): _- ❑Corporate Officer-Title(s): ❑ Partner-❑ Limped ❑ General _ ❑ Partner-❑ Limited Fl General ❑ Attorney In Fact • ❑Attorney In Fact - ❑ Trustee Top of thump here n Trustee Tap of rhumb hprp ❑ Guardian or Conservator ❑Guardian or Conservator ❑ Other: ❑ Other; Signer Is Representing: Signer Is Representing; �._ e- . . . r➢200]Naryonol Notary A::ocnflon•9350 Cn Sofa Ave PC Oax?,a02•ChaL'vwrlh CA 91313-2402•wsw NatlonelNolarynrp Item f15907 IacoMer.Cell Toll-Frc:c 1-800-8]6-882] CITY OF PALM SPRINGS EXHIBIT A Scope of Services ProiecttActivity Title: Proiect Number. Smile Factory for the Children of the Desert 0008 Early Childhood Oral Healthcare Name/Address of Provider: The Smile Factory for the Children of the Desert 1140 N Indian Canyon Dr; 100 S Sunrise Way, Ste A-409 Palm Springs, CA 92262�4872 Obiectiy_es/Activities The intent of this program is to provide funds for the operation of The Smile Factory, a mobile dental clinic, which visits elementary schools, providing free oral screening and dental health care services to very low / low-income children qualified for the National School Lunch and School Breakfast Programs, often referred to the School Free or Reduced Lunch Program. Each qualifying child will receive a basic dental examination (i.e., x-rays, fluoride cleaning, and sealants on non-decayed teeth). In addition, some of those children receiving basic dental care may need more extensive dental treatment (i.e., cavities, infection, gum disease and other dental problems). This will be accomplished through dental scholarship funding for very low to low income Palm Springs school-age children attending the Palm Springs Unified School District who are not covered under a public insurance program. The Smile Factory will serve 2,366 Palm Springs children and 1,599 very law to low income youth will receive scholarship assistance. The Provider shall be responsible for the completion of the following objecbves/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 providingan.V.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 (Le., 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 One Thousand Five Hundred Ninety-Nine (1,599) very low to low income Palm Springs Elementary School-age children with new access to this service. TARGET DATE ACTIVITY#1 On-Going Provide The Smile Factory program opportunities and services to eligible Palm Springs children living within the Palm Spring Unified School District. Applicants must meet criteria in Exhibit D. 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 progrim 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 The Smile Factory omoram opportunities and services to eligible Palm Springs children living within the Palm Spring Unified,School District as outlined in proposal TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessibility, as stipulated in the proposaL Objective B., Provide an evaluation within fifteen (15) calendar days of the orooram completion or final reimbursement. TARGET DATE ACTIVITY#1 07/15/02 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 (Le., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Project/Activity Title: Project Number: Smile Factory for the Children of the Desert 0008 Early Childhood Oral Healthcare Name/Address of Provider: The Smile Factory for the Children of the Desert 1140 N Indian Canyon Dr- 100 S Sunrise Way, Ste A-409 Palm Springs, CA 922614872 BUDGET SUMMARY COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel -0- $35,340. $35,340. 2 Consultant/Contract Services -0- -0- -0- 3 Travel - -0- $1,250. $1,250. Clinic Relocation 4 Space Rental -0- -0- -0- 5 Consumable Supplies -0- $5,250. $5,250. 6 Rental, Lease or Purchase of -0- -0- -0- Equipment 7 Insurance -0- $7,900, $7,900. 8 Other- -0- $700- $700. Telephones $19,000. -0- $19,000. Dental Scholarships $19,000, $50,440. $69,440. 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 that have been awarded total $526,216 and pending awards total $313,452. Funding sources include fundraising activities conducted by Denti-Cal and Healthy Families Public Insurance Programs, Cities Rancho Mirage, Cathedral City, Desert Hot Springs, Indian Wells, Indio, La Quinta, Palm Desert, and private donations. The Subrecipient shall receive reimbursements in accordance with the aforementioned cast categories and line items. The program will pay for $11.88 per Palm Springs' student, at a total amount not to exceed $19,000, in accordance with Denti-Cal and Healthy Families preset amounts. Payments, approved by the Subrecipient and based upon the actual number of income eligible scholarships awarded in the prior period, shall be paid by the 3& day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. Services are to be performed over the twelve-month period of this 2007—08 Program Year—July 1, 2007 through June 30, 2008. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Title: Project Number: Smile Factory for the Children of the Desert 0008 Early Childhood Oral Healthcare Name/Address of Provider: The Smile Factory for the Children of the desert 1140 N Indian Canyon Dr, 100 S Sunrise Way, Ste A-409 Palm Springs, CA 92262-4872 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Great American Insurance Co. Effective Dates of Policy 07/25/07 to 07/26/08 Claims Made Policy / / Per Occurrence Policy! / Limits of Liability $2,000,000 Deductibles: Per Occurrence NIA Annual Aggregate N/A Additional Insured Endorsement (Certificate Holder) R1 Yes ❑ No Original Certificate of Insurance Attached ❑ Yes Q No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company Everest National Effective Dates 07/25/07 to 07/25/08 Limits of Liability $1_M per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached Q Yes EI No ACORD. CERTIFICATE OF LIABILITY INSURANCE OP IDrc SM3LE-2 07/I7/08 nROrn'ccR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chapman & Assocyatca ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE, Lf.ennnc 40522024 HOT-DER•THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. 0. sox 5455 ALTER THE COVE RAGE AFFORDED BY THE POLICIES BELOW. Pasadena CA 91117-Oa55 Phone: 626-405-8031 Fax: 626-405-0595 INSURERS AFFORDING COVERAGE NAIC$ ° 16691 Everest National Smile Factory of Tiempo de log Nines uxenc 100 S SI Way Ste A-409 'rvcw,g�o Palm Springs C1 92262 N:oRCR c COVERAGES .uR„N[[LIx11 D,l. ...,e°LL.aNL'L°I[,III INrL'111D N..,LD,n°„r.DR,n[RDND.RIRIDD NOV,[D NO..NwsT..NDIND ^ n nv a[mnx nlC Ix6UP CCnI Nquku uv,n r°uuic.°[cm cIIII°[°n[RD cum[cPLIYONTINIH i,D ALL,n[[Rm:CACLUIjn cnxnmoNa Or�:yG' rRCrn,"11117610 1 U1 Hn'211,lEOucPD nvvrvD c11mc I I.AL Lin " ,c lmmm¢m�N DEnENnuneuvr ix r.+w wwI PP : 1000000 A X x CLimERu.L oanenu unmmr FAc5603764 07/25/07 07/25/06 FA.A.ToPoxmnw 100000 luru..or nGrcLmi.r.z:.>e.� 5000 X rC%[Abuse/Molest IeNCDN,,Le,mnI : 1000000 L ncGREGmc ; 2000000 cRrD RnLle,'•t, : 1000000 WO-ONLE--nIIL'ry 1000000 A n"remD PAc5603764 07/25/07 07/25/00 irA.��i,,,°1r'INrirnun y I nwxm„u,nn x H11OD,uTD. x NON Oun+E)m,Od nmRv -------------- uAdILn. IIT1r.r:•.'Or11 _ ILI.IJTo .71111 ,D.00Nl ; EXCE" Um LLALmunnv cmi n c ix.wnD[ ne FEGn,C v NIIJAI WOFHEnac°ni•[xann°x AIo ][ .011711 E P.RmrxRIMOINPm, *IVr 6600000129071 07/25/07 07/25/08 [L[nm�n°Dmo1, R � • 1000000 ornccrua1MI IPLU u olxr,,.r rn rNa,O.rc 1000000 1000000 .eRimgy Oc upEn�naxanacnnwcrvenlDL[crv[wclDx:.w DCD nr RNDDRcvmrxvmrelni exmi.lY'+•, The City of Palm Springs, its officers, officials, employees and valuntcczs are named additional insured with roopcct to the operations of the named ensured Fur the attached CG 2010 endorsement. Such insuGance is primary and non-contributory. WbrXern Compcnaation coverage excluded, evidence only. Waiver of subrogaticIn for workers compensation policy applies in (Contd.) CERTIFICATE HOLDER CANCELLATION CITYPAI GWI OR,xc.RONRn.x kIkN Dlno°Ienee DnnceL.m err°ee,HEPPrI r.naN xnm+nenmr,nmsemxelNDURERma�mn 1. 30 vewm„en m a 10E-O,4R e ,Icice,r xa OPR NANEO TO inE LEni� —_— City of pa],uL Springs Attnc City Clerk PO Sex 2743 Palm Springs, CA 92262 ACORD 25(2001108) ©ACORD CORPORATION 1988 NOTEPAD: OLDER CODE CITYPA . . saixelzi PAGE.' ' AGE'IN$PREO'S NAME 1 5mile Factory _ �OP'DpC DATE 07/n/06 favor of certificate holder per the attached endereennnL•. 10 dayn notice of cancrilatxon for non-payment of pre==. x IMPORTANT If the certificate holder is an ADDITIONAL INSURED the policy(oi muss be endorsed A statement on Otis certificate does not confer rights to the certificate holder in lieu of su@1 endors'emant(s). ItSDBROGATION IS WAIVED,subject to the terms and cendilzon8 of the policy certain policies may require an endorsement A statement on this certificate does not con for rights to the certiie@ e holder in lieu of such ondorsomont(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 cemicate holder nor does it affirmalively or negatively amend,extend or alter the coverage afforded by the policies listed thereon ACORD 25(2001109) C w S1 .07/02/08a*603764-00 C39134208 RD/B � ORIG IMAGE COPY AMENDED 07/01 /2008 0694804 GREAT AMERICAN llVeUq&N&� CO 05192 Ad Lnlava mlcvativo of{icua 520 $ircet Policy No , PAC 560.37-64 - 00 G IiLAT Cincinnati, Ohl045202 Effective Date of Change 07/01 /2008 t1p f1;AIC,'AN Tal: 1-513-a59-5000 iWUFA�LE CROUP BUSINBSSPRO POLICY CHANGES NAMED INSURED SMILE FACTORY OF TIEMPO DE LOS NINOS AND ADDRESS: 100 S SUNRISE WAY, STE A-409 PALM SPRINGS . CA 92262 THIS ENDORSEMENT AGENT'S NAME AND ADDRESS: CHANGES THE POLICY, CHAPMAN & ASSOCIATES , INC . PLEASE READ IT PO BOX 5455 CAREFULLY. PASADENA, CA 91117 0455 Onsurance is afforded by the Company named below, a Capital Stack Corporation : GREAT AMERICAN INSURANCE COMPANY POLICY PERIOD: From 07/25 /2007 To 07/25 /2008 12 :01 A.M. Standard Time at the address of the Named Insured NO CHANGE IN PREMIUM IT IS HEREBY UNDERSTOOD AND AGREED THAT THE POLICY IS AMENDED AS FOLLOWS : ADDING FORM CG2010-ADDITIONAL INSURED-OWNERS , LESSEES OR CONTRACTORS- SCHEDULED PERSON OR ORGANIZATION TO THE POLICY AS RESPECTS TO: THE CITY OF PALM SPRINGS . ITS OFFICERS , OFFICIALS , EMPLOYEES AND VOLUNTEERS CITY OF PALM SPRINGS ATTN : CITY CLERK P .O. BOX 2743 PALM SPRINGS, CA 92262 ENDORSEMENT 1 ANY AMENDED FORMS ATTACHED TO THIS CHANGE DISPLAY PREMIUMS FOR A FULL POLICY TERM. Forms and Endorsement Activity CG2010 07/04 ADDL INS- FORM B - OWN/LESS/CONT ADDED Countersigned By Date Authorized Signature Copyright , Insurance Services Office , Inc . , 1991 IL 70 02 05/92 (Page 1 of 1 1 TOADMdK + 7 4- 9 1 42 •D B ORIG IMAGE COPY AMENDED 07/01 /2008 0694804 GREAT AMERICAN INSURANCE CO in!�untwo ..mess CG 20 10 ( Ed .07/04 )550 W t GREAT clnclnnati, Ohio AS202 AA(F.RICA,'V, Tee �•sca-ass-5000 ,N.....wrwc,j, Policy : PAC 560-37-64 00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED--OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following : COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization ! THE CITY OF PALM SPRINGS , PRIMARY INSURANCE . ITS OFFICERS , OFFICIALS , THIS INSURANCE IS PRIMARY AND ANY OTHER EMPLOYEES AND VOLUNTEERS INSURANCE MAINTAINED BY SUCH ADDITIONAL CITY OF PALM SPRINGS INSUREDS IS NONCONTRIBUTING WITH THIS ATTN : CITY CLERK INSURANCE AS RESPECTS LEGAL LIABILITIES P . O. BOX 2743 OR CLAIMS CAUSED BY, ARISING OUT OF OR PALM SPRINGS , CA 92262 RESULTING FROM THE ACTS OR OMISSIONS OF THE NAMED INSURED , OR OF OTHERS PERFORMED ON BEHALF OF THE NAMED INSURED . Location & Description of Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Copyright , Insurance Services Office Properties , Inc . . 2000 CG 20 10 07104 ( Page 1 of 2 ) 1 420$ -D/B QRIQ IMAGE COPY —AMENDED 07/01 /2008 0694804 GREAT AMERICAN INSURANCE CO 590 WeInut,gr,o}fices CG 20 10 ( Ed .07/04 ) G yr Cincinnati, Ohio 45202 AMF.RICAN. Tnl• t-5t3-369-5000 I.,UIIANLIr�,MIJI Policy : PAC 660-37-64 00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED--OWNERS, LESSEES OR CONTRACTORS (FORM B) A. SECTION II - WHO IS AN INSURED is amended to Include as an Additional Insured the persen(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily Injury," "property damage" or "personal and advertising injury" caused, in whole or In parl, by: 1. your acts or omissions; or 2. the acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the Additional Insured(s) at the location($) designated above- E. With respect to the insurance afforded to these Additional Insureds, the following additional exclusions apply: This Insurance does not apply to "bodily injury" or "property damage" occurring after: 1. all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or 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. Copyright . Insurance Services Office Properties , Inc . , 2000 CG 20 10 07/04 ( Page 2 of 2 ) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 0s 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CAi_IFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform Work under a vvritten contract that requires you to obtain this agreement from us.) You must maintain payroll records ar-curaisly segregating the remuneration of your employees white engaged in the Work described in the Schedule. The additional prairium for this endorsement shalt be "/a of the Calrforma workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION CITE OF P_=tLiv'1 SFRI7dGS :ALL J03S -DENT.i?L Sd:Rv'10ES .ATT: CITY CLERK P.O. BOX 274 PALM SPRIIJGS, CA 92262 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 10-0 1-0 7 Policy No. 660000012D071 Endorsement No. dal Insured SMILE FACTORY OF TIZZWO OE LOS Premium $ INCL- Insurance Company EVEREST NATIONAL INSURANCE COMPAYY Countersigned By -1998 by the Wakers'Cnmpensatlon lmura nce ruing bureau of Calaornis. Ai rietm reserved. From the WCIRS's California Workers'Compensation insurance Forms Manual-1999, NR)RFu GQIl CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Proiect/Activity Title: Protect Number: Smile Factory for the Children of the Desert 0008 Early Childhood Oral Healthcare Name/Address of Provider: The Smile Factory for the Children of the Desert 1140 N Indian Canyon Dr, 100 S Sunrise Way, Ste A-409 Palm Springs, CA 92262-4872 BENEFICIARY QUALIFICATION STATEMENT This statement must be Completed and signed by each person or head of household (legal guardian) receiving benefits farm the described projecUactivlty. 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,CA—03120107) MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME 1 2 3 4 5 6 7 B LEVEL VERY LOW INCOME $20,700 $23.700 $22.650 $29600 $31950 $34,350 $36,700 $39,050 Below 50 LOW INCOME $33,150 $37.900 S42$00 $47,350 $51,150 $54,950 $58,700 $62,500 51-80% MODERATE INCOME $49,700 $56,800 $63,900 $71,000 $76,700 $82.400 $88,000 $93,700 120% 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/Afrimn American ❑ Asian AND White ❑ Asian IJ Black/African American AND White ❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/African American ❑ Native Hawaiian or Other Pack Islander ❑ Other, HISPANIC/LATINO ETHNICITY 0 Yes ❑ No If yes,check one: ❑ Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: 4, Please check,for n�if you are a female Head of Household9 ❑ YES 11 NO ACKNOWLEDGEMENT AND DISCLAIMER 1 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 u1d¢ed for Community Development Block Grant(CDBG)program purposes a Federally-funded program,governmental mpoding purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Quarterly Program Progress Report Project/Activity Title: Project Number: Smile Factory for the Children of the Desert 0008 Early Childhood Oral Healthcare Name/Address of Provider: The Smile Factory for the Children of the Desert 1140 N Indian Canyon Dr; 100 S Sunrise Way, Ste A-409 Palm Springs, CA 92262-4872 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons 0-50%below 51-80%below 120%below ♦ Number of First-Time Female Headed Households: ♦ Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White_ American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other: HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican Cuban Other: ACCOMPLISHMENT NARRATIVE LEVERAGING RESOURCES NARRATIVE Signed Title Date CITY OF PALM SPRINGS 0 EXHIBIT F Request for Reimbursement Project/Activity Title: Protect Number: Smile Factory for the Children of the Desert 0008 Early Childhood Oral Healthcare Name/Address of Provider: The Smile Factory for the Children of the Desert 1140 N Indian Canyon Dr; 100 S Sunrise Way, Ste A-409 Palm Springs, CA 92262-4872 BENEFICIARY QUALIFICATION STATEMENT Approved rav Currant Prior Total Grant Description Grant Raimhursement Reimbursement 7TP Balance Amount Period Periad(s) Relmbursanwnt (Over/Under) Other- g1 g 000. Dental Scholarships TOTAL $1g,t7tx). E==E::7-1� I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDBG, has not previously been billed for the costs covered by this invoice, (b) funds have not been received from the Federal Government or expended for such costs under the terms of the Agreement or grant pursuant to FMC-74-4 & 24 CFR Part 58;(c) this agency is in full compliance with all applicable provisions under the terms of the Contractor grant; and (d) this agency Is in full compliance with all applicable tax laws and hereby affix original signatures. PREPARED BY: APPROVED BY: Name, Title, Date Name, Title, Date City of PALM SPRINGS Use Only Audited by: Examined by: Approved by. If necessary,additional sheets)must be attached detailing cost breakdowns,and verified by original signatures.