HomeMy WebLinkAbout05070 - ARTHRITIS FOUNDATION INC CDBG SUBRECIPIENT AGRS 2004-05 AND 2005-06 YEARS SUBRECIPIENT AGREEMENT
THIS AGREEMENT (herein "Agreement"), is made and entered into thisdday of
20A, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and
charter city, and the,Arthritis Foundation, 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 sew.), 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 Scone of Services. Provider agrees to provide to City all of the services
specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified
therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to
City that it is able to provide, and will use funds granted by the City to provide the services represented
in the Provider's application for funding. City provided funds shall be used only for those purposes
specified in such application.
1.2 Compliance with Law. All services rendered hereunder shall be provided in
accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any
Federal, State or local governmental agency of competentjurisdiction.
1.3 Rep_o_rts. 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 2005 — 2006 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.
i
2.0 COMPENSATION.
21 Contract Sum. The City shall pay to the Provider on a reimbursable basis for
its services a sum not to exceed FIFTEEN THOUSAND DOLLARS ($15.000.00) (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 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 Fand make all decisions in connection therewith:
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
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may be required by the regulations of the Housing and Community Development Act, but in no case
for less than three years after the close of the program.
42 The Provider certifies it shall adhere to and comply with the following as they
may be applicable-,
(a) Submit to City through its Community and Economic Development
Department 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 570.200 a);
(j) The labor standard requirements as set forth in 24 CFR Part 570,
Subpart K and HUD regulations issued to implement and
requirements;
M 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);
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(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;
(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.G. 4801 et seg.);
(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 Providers 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
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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
Contractor's performance under this Agreement, except for such loss as may be caused by City's own
negligence or that of its officers or employees.
6.0 DISCRIMINATION, TERMINATION, AND ENFORCEMENT.
6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its
heirs, executors, assigns, and all persons claiming under or through them that there shall be no
discrimination against or segregation of any person or group of persons on account of race, religious
creed, color, national origin, ancestry, physical disability, mental disability, medical condition,
pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by
applicable federal, state or local law in the performance of this Agreement. Provider shall take
affirmative action to insure that applicants are employed and that employees are treated during
employment without regard to their race, color, creed, religion, sex, marital status, physical or mental
disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal,
state or local law.
6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this
Agreement, this Agreement shall continue in full force and effect until completion of the services, but
not exceeding one (1) year from the date hereof.
6.3 Termination Prior to Expiration of Term. Either party may terminate this
Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party.
Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder
except as may be specifically approved by the Contract Officer. Provider shall be entitled to
compensation for all services rendered prior to receipt of the notice of termination and City shall be
entitled to reimbursement for any services which have been paid for but not rendered.
7.0 MISCELLANEOUS PROVISIONS.
7.1 Notice. Any notice, demand, request, document, consent, approval, or
communication either party desires or is required to give to the other party shall be in writing and either
served personally or sent by prepaid, first-class mail to the address set forth below, or such other
addresses as may from time to time be designated by mail.
TO CITY:
City of Palm Springs
3200 East Tahquitz Canyon Way
Palm Springs, CA 92262-6959
Attn: City Manager
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WITH COPY TO-
City of Palm Springs
3200 East Tahquitz Canyon Way
Palm Springs,-CA 92262-6959
Attn: City Attorney
TO PROVIDER:
frUT7s �l��nw
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
ATTE T: a municipal corporation
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C' Clerk - �0/ d —/�Ooq City Manager
APPROV RIT
FORM:
By. APPROVED BY CITY COiriNE l!
City Attornq ial 7
PROVIDER: Check one: _Individual _Partnership _Corporation
(Corporations require two notarized signatures: One signature must be from the Chairman of
Board, President, or any Vice President. The second signature must be from the Secretary,
Assistant Sec�reta urer, Assistant Treasurer, or Ch=—
N�pfi'zedlfficer).
By. • ' � By'Signature of Chairman of Board, Not ed Sridnature Secretary,Asst Secretary,
President or any
Vice
President Treasurer, Asst Treasurer or Chief Financial Officer
Name. / � r/3r�� r / G �r7� Name )4c° y/�m r / (a�
Title � � ��"L% ��d Title CF-0
State of 1 State of f
County of 1ss County of
On before me On UL efore me,
ersonally appeared rsonally appeared
personally known personally known
to me (or proved to me on?
n a basis of satisfactory evidence) to me(or proved to me9w' a basis of satisfactory evidence)
to be the persons) w e name(s) Is/are subscribed to the to be the person(s,YYtlose name(s) is/are subscribed to the
within Instrument acknowledged to me that he/she/they within instrum and acknowledged to me that helshe/they
executed the sr
me in his/her/their authorized capaclty(ies), executed same In his/her/their authorized capaclty(ies),
and that his/her/their signature(s) on the instrument the and t by his/her/their signature(s) on the Instrument the
persgW. or the entity upon behalf of which the person(s) person(s), or the entity upon behalf of which the person(s)
acted,executed the instrument. acted, executed the Instrument.
WITNESS my hand and official seal WITNESS my hand and official seal.
Notary Notary
Signature: Signature:
Notary Seal Notary Seal:
SubreaipAgrmnLJuI05
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California p '_
County of �� 1-rh r-, y�
On -- 7- b8 before me, �, s )Q r Y�E&rV,, I (G
Okla Here Inaert Ntte and Tltle Of the 011lcer
personally appeared UACA Ala- LUUl cxn/�- J aro Ij
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who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s)i5lare subscribed to the
within instrument and acknowledged to me that
ghefshe/they executed the same in his/herAheir authorized
capacity(fes), and that by ITWher/their signature(s) on the
instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
SHERIEL L ADAMS
Commisslon*158441e 1 certify under PENALTY OF PERJURY under the laws
Notary PUMC-Callromla of the State of California that the foregoing paragraph is
Log AngeimCoumy I true and correct.
My comm.Expirm Jun 3,2009
WITNESS my hand and official seal. / ,/
Signature I L( _C& ( /I ' // nM-5
Place Notary Seal Abevo Signature of WaryInblic
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
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❑ Guardian or Conservator 7 Guardian or Conservator
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CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Project/Activity Title: Protect Number
Arthritis Foundation, Inc. !Scholarship Program 0001
Name/Address of Provider:
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
O b i ectives/Activities
The intent of this program is to provide the opportunities of medically-supervised programs and services
which includes PACE (People with Arthritis Can Exercise) Land-based and warm water exercise program
and educational programs on diet, medications, joint-sage exercise, non-traditional forms of treatment,
doctor-patient relationships, communication skills, and fatigue, pain and stress management. This will be
accomplished through scholarship funding for very low-to-moderate income residents. The Foundation
will serve 4,000 very low to moderate income Palm Springs residents.
The Provider shall be responsible for the completion of the following objectives/activities in a manner
acceptable and satisfactory to the City and consistent with the standards required as a condition of
providing these CDBG funds.
Objective 1: Assist the City by timely providing any additional information requested.
TARGET
DATE ACTIVITY#1
On-Going Make readily available any information relative to the successful implementation of the
activity.
Objective 2: Establish and maintain a programmatic and financial record keeping process.
TARGET
DATE ACTIVITY#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.) with special outreach to minorities.
TARGET
DATE ACTIVITY#1
On-Going Draft a promotional piece(s) and submit to City for approval. Advertise in the Desert Sun
and minority media outlets. Submit final publication to City.
Objective 4: Enroll and income qualify at least a total of four thousand (4,000) very low to moderate-
income Palm Springs residents.
TARGET
DATE ACTIVITY#1
On-Going Provide Foundation opportunities to eligible Palm Springs residents. 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 astable and secure location.
ACTIVITY#2
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: Provide Foundation opportunities_ to eligible Palm Springs_residents as outlined in
proposal.
TARGET
DATE ACTIVITY#1
On-Going Conduct program activities, as stipulated in the proposal and in consultation with the City.
Objective 8: Provide an evaluation within fifteen (15) calendar days of the program_c_ompletion or final
reimbursement.
TARGET
DATE ACTIVITY#1
07/16/05 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
Pro ect/Activit Title: Project Number:
Arthritis Foundation, Inc. /Scholarship Program 0001
Name/Address of Provider:
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
13UDGET SUMMARY '
COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel $ $ $
2 Consultant/Contract Services $ $ $
3 Travel $ $ $
4 Space Rental $ $ $
5 Consumable Supplies $ $ $
6 Rental, Lease or Purchase of $ _ $ $
Equipment
7 Insurance $ $ $
8 Other- $15,000. $35,000. $50,000,
Scholarships $3.25/Person
$ $1,500. $1,500.
Educational Materials
$ $25,000. $25,000.
Support& Self-Help Groups
$15,000. " " $61,500. $76,500. "
TOTALS,
*If costs are to be shared by other sources of funding, including CDBG funds from other
jurisdictions, identify the source of funding, grantor/lending agency, and cost category information.
Other funding sources include fundraising activities conducted through the Desert Health
Care District, City of Palm Desert, City of Rancho Mirage, City of Indian Wells and private
donations.
The Subrecipient shall receive reimbursements in accordance with the aforementioned cast
categories and line items. The program will pay for 4,000 scholarships at $325 each. 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 301h 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 2005 — 06 Program Year—July
1, 2005 through June 30, 2006.
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Project/Activity Title Project Number:
Arthritis Foundation, Inc. /Scholarship Program 0005
Name/Address of Provider:
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
INSURANCEINVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company_ Atlantic Specialty Insurance Company
Effective Dates of Policy 05/01/05 to 05/01/06
Claims Made Policy / Per Occurrence Policy ! /
Limits of Liability 2 million General A re ate
Deductibles.
Per Occurrence
Annual Aggregate
Additional Insured Endorsement (Certificate Holder) L Yes ❑ No
Original Certificate of Insurance Attached ❑ Yes Ef No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company State Fund
Effective Dates 05/01/08 to 05/01/09
Limits of Liability $1 million
Underlying Coverage Limits Unlimited
Original Certificate of Insurance Attached 0 Yes O No
ACORD CERTIFICATE OF LIABILITY INSURANCE os i9/2 a'
PRODUCER 770.232.0202 FAX 770,232.9202 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MCCart Insurance & Risk Management ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2405 Satellite Boulevard ,f200 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Duluth GA 30096
INSURERS AFFORDING COVERAGE NAIC#
INSURED ARTHRITIS FOUNDATION INSURERA ASTC (Atlantic Specialty Ins. Co )
Southern California Chapter INSURERS
4311 Wilshire Blvd. #530 INSURER C:
Los Angeles CA 90010 msuRDR p
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR ZO0 TYPE OF INSURANCE POLICY NUMBER POUCYEFFECTIVR POuCTECP1RJkTION uM175
GENERAL MABILI Y EACH OCCURRENCE S 11000,000
X COMMERCIAL GENERAL LIABILITY 710-00-59-52-0001 05/01/2005 OS/01/2006 DAMAGE TO RENTED 5 1,0001000
CLAIMS MADE 7XOCCUR MB➢EXP(AAy pne person) S 10,000
A PERSONAL&ADV INJURY S 11000,000
GENERAI,AGGREGATE S 2.000,000
GEM L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP ACG S 2,000,000
POLICY JET F7 LOC
AUTOMCEILE LIABILITY COMBINED SINGLE LIMIT
X ANY AUTO (Eoae6denl) $ 1.000,00O
ALL OWNED AUTOS 710-00-59-52-0001 OS/01/2005 05/01/2006 BODILY INJURY
SCHEDULED AUTOS (Per person) S
A X HIREDAUTOS
BOO S
X NON-0WNED AUTOS (PPa acelde aoGdent)U
PROPERTY DAMAGE S
(Per oeeidenl)
GARAGE UARJUTY AUTO ONLY.EAACCIDENT S
ANYAUTO OTHER THAN EAACC S
AUTO ONLY; AGG 5
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR ❑CLAIMS MADE AGGREGATE $
§
DEDUCTIBLE §
RETENTION $ §
WORKERS COMPENSATION AND WC STATU• oTH•
EMPLDYERI NO COVERAGE PROVIDED EL EACH ACCmEi s
ANY PROPRIETORICTDRIPARPARTNER/EXECUTIVE
OFFICEHIMEMBER EXCLUDED? THROUGH MCCART E.L.DISEASE-EA EMPLOYE s
If yes,describe under
SPECIAL PROVISIONS hcl- EL DISEASE-POLICY LIMIT I S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
E: Evidence of Insurance
ity of Palm Springs, its officials, employees and agents, are Additional Insured as required by
ontract only as respects General Liability & Auto Liability. This insurance is primary and non-
ontributory. Waiver of Subrogation applies.
[see Also Form #VCG 221 10 98 Additional Insureds by Contract, Agreement or Permit.]
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of Palm Springs 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: City Clerk BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO caLIGATION OR LIABILITY
3200 E. Tahquitz Canyon Way OF ANY IUND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Palm Springs, CA 9ZZ62 AUYROWTED REPRESENTATIVE n
Tina Gi17 IGBYA
ACORD 25(2001108) OACORD CORPORATION 15138
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSUREDS BY CONTRACT, AGREEMENT
OR PERMIT
This endorsement modifies insurance provided underthe following:
COMMERCIAL GENERAL.LIABILITY COVERAGE FORM
The WHO IS AN INSURED section is amended to include as an insured any person or organization with wham you
agreed in a written contract, written agreement or permit to provide insurance such as Is afforded under this
Coverage Part, but only with respectto your operations, "your work"or facilities owned or used by you,
This provision does not apply:
t. Unless the written contract, agreement or permit has an effective date and has been issued prior to the "bodily
injury", "property damage", "personal and advertising injrfry" or "personal injury" or "advertising injury"
(whichever definitions are used In your policy);
2. To any person or organization included as an insured under the Additional Insured - Broad Form Vendors
provision of this endorsement;
3. To any person or organization included as an insured by an endorsement issued by us and made part of this
Coverage Part;
4. To any lessor of equipment;
a. After the equipment lease expires;of
b. If the"bodily injury". °property damage", "personal and advertising injury"or"personal injury" or"advertising
injury"(whichever definitions are used in your policy), arises out of the sole negligence of the lessor;
S. To any person or organization it the "bodily injury", "property damage", "personal and advertising injury" or
"personal Injury"or"advertising injury" (whichever definitions are used in your policy),arises out of the rendering
of or failure to render professional services by or for you;
fi. To any:
a. Owners or other interests from whom land has been leased; or
b. Managers or lessors of premises it
(1) The"occurrence"takes place after you cease to be a tenant in that premises;or
(2) The "bodily injury", "property damage", "personal and advertising injury" or "personal injury" or
"advertising injury"(whichever definitions are used in your policy),arises out of structural alterations, new
construction or demolition operations performed by or ad behalf of the owners or other interests from
whom land has been leased.
VCG 211 10 99 Includes copyrighted material or Insurance services Office,Inc. Page T of 1
®,Atlantic Mulual Issuance Company,1999
PRODUCER
CERTHOLOER COPY
SP
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPI_NSATION INSURANCE
ISSUE DATE: 01-21-2009 GROUP:
POLICY NUMBER: 1780828-2008
CERTIFICATE ID: 45
CERTIFICATE EXPIRES:05-01-2009
05-01-2008/05-01-2009
CITY OF PALM SPRINGS SP
PO BOX 2743
PALM SPRINGS CA 92263-2743
This is to certify that we have Issued a valid Workers' Compensation Insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer-
We will also give you 30 days advance notice should this pollcq be cancelled prior to its normal expiration-
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
ley the policy listed herein. Notwithstanding any requlrerrent, term or condition of any contract or other document
wdh respect to which this certificate of insurance may be Issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy-
�J
TMORI2ED REPRESENTATI PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1.000,000 PER OCCURRENCE.
ENDORSEMENT A2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-01-2006 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
ARTHRITIS FOUNDATION OF SOUTHERN CALIF SP
4060 CHESTNUT ST
RIVERSIDE CA 92501
[514,5P]
IREV,2-05) PRINTED : 01-21-2009
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Project/Activity Title: Protect Number:
Arthritis Foundation, Inc. /Scholarship Program 0001
Name/Address of Provider:
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
BENEFICIARY QUALIFICATION STATEMENT
This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the
described project/activily. 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 boarders cannot be included as household members.
2. Circle your combined gross annual income(Riverside-San Bernardino,CA—02It 1/05)
MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME 1 2 3 4 5 6 7 a
LEVEL
VERY LOW
INCOME S19,500 S22,250 $25,050 S27 850 S30,050 $32,$00 $34,600 $36,750
Below 50%
LOW
INCOME $31.200 $35,650 S40,100 $44,550 $48,100 S51700 $55,250 $58,800
51-80%
MODERATE
INCOME 546,750 $53.450 $60,100 $66,800 $72,150 $77,500 $32,850 $88200
120%
3. What race/ethnicity do you identify yourself as;please note that this self-identification is voluntary in accordance with
equal opportunity laws?
❑ White ❑ American Indian or Alaska Native AND White
❑ Black/African American ❑ Asian AND White
❑ Asian ❑ Black/African American AND White
❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/Afrimn American
❑ Native Hawaiian or Other Pacific Islander ❑ Other:
HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes check one: 0 Mexican/Chicano
❑ Puerto Rican
❑ Cuban
❑ Other,
4. Are you area female Head of Household? ❑ YES 0 NO
5. Do you have a disability? ❑ YES ❑ NO If YES,please describe
ACKNOWLEDGEMENT AND DISCLAIMER
I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMENTS MADE ON THIS FORM ARE TRUE.
NAME: DATE:
ADDRESS: PHONE NO:
SIGNATURE:
The mformatlon you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)pmgram purposes,a
Federally-Funded pmgram,governmental reporting purposes to monitor compllance
CITY OF PALM SPRINGS
EXHIBIT E
Program Progress Report
Project/Activity Title, Protect Number:
Arthritis Foundation, Inc. /Scholarship Program 0001
Name/Address of Provider,-
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
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 — Slack/African American AND White
American Indian or Alaskan Native American Indian/Alaska Native AND BlackWAfrncan American
Native Hawaiian or Other Pacific Islander Other
HISPANIC/LATINO ETHNICITY: Mexican/Chicano Puerto Rican
Cuban Other
♦ Number of Disabled:
ACCOMPLISHMENT NARRATIVE
LEVERAGING RESOURCES NARRATIVE
Signed Title Date
CITY OF PALM SPRINGS
EXHIBIT F
Request for Reimbursement
Pro ect/A� ctivity Title: Project Number:
Arthritis Foundation, Inc. /Scholarship Program 0001
Name/Address of Provider:
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
BENEFICIARY QUALIFICATION STATEMENT
Approved Curront Prior Total . Grant'
Description: Grant Ran) umemenR Reimbursemant, YTD Balance
Amount . period' pedod(e) ftaimbursement (Overt Under)
Scholarships $15,000.00
TOTAI.
I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CUBG, 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.
CITY OF PALM SPRINGS
EXHIBIT G
Employment Restrictions
1, Labgr Standards
The PROVIDER agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis-eaten Act as
amended, the provisions of Contract Work Hours and Safety Standards Act, the Copeland 'Anti-Kickback" Act (40 U.S.C.
276a-276a-5;40 USC 327 and 40 USC 2760)and all other applicable Federal, state and local laws and regulations pertaining
to labor standards insofar as those acts apply to the performance of this contract. The PROVIDER shall agree to submit
documentation provide by the CITY which demonstrates compliance with hour and wage requirements of this part.
The PROVIDER agrees that, all general contractors or subcontractors engaged under contracts in excess of$2,000.00 for
construction renovation or repair work financed in whole or In part with assistance provided under this contract, shall comply
with Federal requirements adopted by the CITY pertaining to such contracts and with the applicable requirements of the
regulations of the Department of labor, under 29 CFR Parts 1 3, 5 and 7 governing the payment of wages and ratio of
apprentices and trainees to journeyworkers; provided, that if wage rates higher than those required under the regulations are
imposed by state and local law, nothing hereunder is intended to relieve the PROVIDER of its obligation, if any, to require
payment of the higher wage. The PROVIDER shall cause or require to be inserted in full,in all such contracts subject to such
regulations,provisions meeting the requirements of this paragraph.
2. "Section 3 Clause"
a. Compliance
Compliance with the provisions of Section 3,the regulations set forth in 24 CFR 135, and all applicable rules and orders
issued hereunder prior to the execution of this contract shall be a condition of the Federal financial assistance provided
under this Contract and binding upon the CITY, the PROVIDER and any of the PROVIDER'S subrecipients and
subcontractors. Failure to fulfill these requirements shall subject the CITY, the PROVIDER and any of the PROVIDER'S
subrecipients and subcontractors, their successors and assigns, to those sanctions specified by the Agreement through
which Federal assistance is provided. The PROVIDER certifies and agrees that no contractual or other disability exists
which would prevent compliance with these requirements.
The PROVIDER further agrees to comply with these "Section 3" requirements and to include the following language in all
subcontracts executed under this Agreement
"The work to be performed under this contract is a project assisted under a program providing direct Federal financial
assistance from HUD and is subject to the requirements of Section 3 of the Housing and Urban Development Act of
1068, as amended, 12 U.S.0 1701. Section 3 requires that to the greatest extent feasible opportunities for training
and employment be given to law- and very low-income residents of the project area and contracts for work in
connection with the project be awarded to business concerns that provide economic opportunities for low-and very
low-income persons residing in the metropolitan area in which the project is located."
The PROVIDER further agrees to ensure that Opportunities for training and employment arising in connection with a housing
rehabilitation (including reduction and abatement of lead-based paint hazards), housing construction or other public
construction project are given to low-and very low-income persons residing within the metropolitan area in which the CDBG-
funded project is located:where feasible, priority should be given to low-and very low-income persons within the service area
of the project or the neighborhood in which the project is 10=0d, and to low-and very low-income participants in other HUD
programs and award contracts for work undertaken in connection with a housing rehabilitation (including reduction and
abatement of lead-based paint hazards), housing construction, or other public construction project are given to business
concerns that provide economic opportunities for low-and very low-income persons residing within the metropolitan area in
which the CDBG-funded project is located where feasible, priority should be given to business concerns which provide
economic opportunities to low-and very low-income residents within the service area or the neighborhood in which the project
is located,and to low-and very low-income participants in other HUD programs.
The PROVIDER certifies and agrees that no contractual or other legal incapacity exists which would prevent compliance with
these requirements
b. Notifications
The PROVIDER agrees to send to each labor organization or representative of workers with which it has a collective
bargaining agreement or other contract or understanding, if any, a notice advising said labor organization or worker's
representative of its commitments under this Section 3 clause and shall post copies of the notice in conspicuous places
available to employees and applicants for employment or training.
.Y
SUIBRECIPIENT AGREEMENT
nd
THIS AGREEMENT (herein "Agreement"), is made and entered into this �day of WLVy,
200 k by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and
charter city, and the Arthritis Foundation, 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 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 Sco e off Services. Provider agrees to provide to City all of the services
specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified
therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to
City that it is able to provide, and will use funds granted by the City to provide the services represented
in the Provider's application for funding. City provided funds shall be used only for those purposes
specified in such application.
1.2 Compliance with Law. All services rendered hereunder shall be provided in
accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any
Federal, State or local governmental agency of competent jurisdiction.
1.3 Reports. No later than ten (10) days prior to any payment date specified in
Section 2.2, within ten (10) days following the termination of this Agreement, and at such other times
as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing
the services provided during the period of time since the last report and accounting for the specific
expenditures of contract funds hereunder, if applicable. At the times and in the manner required by
law, the Provider shall provide to the City, the Department of Housing and Urban Development, the
Comptroller General of the United States, any other individual or entity, and/or their duly authorized
representatives, any and all reports and information required for compliance with the Act and the
Regulations.
1A Financial Reporting. Any Provider receiving or due to receive or due to
receiver $20,000.00 or more from the City during the 2004 — 2005 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 315�of the current fiscal year.
4�
2.0 COMPENSATION.
21 • Contract Sum. The City shall pay to the Provider on a reimbursable basis for
its services a sum not to exceed THIRTEEN THOUSAND DOLLARS ($13,000.00) (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 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:
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 Assipnm_ent. 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
- 2 -
may be required by the regulations of the Housing and Community Development Act, but in no case
for less than three 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 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 at41 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);
Q) 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);
- 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
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 VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended;
(r) The lead-'based paint requirements of 24 CFR Pairt 35 issued
pursuant to the Lead-Based Paint Poisoning Prevention Act (42
U.S.C. 4801 et seq.);
(s) Maintain property inventory system to numerically identify HUD
purchased property and document its acquisition date as is set forth
in OMB 'Circular A-110 Attachment N Property Management
Standard 6d; and
(t) Reversion of asset. Upon the Expiration of the agreement, the
subrecipient shall transfer to the City any CDBG funds on hand at the
time of expiration and any accounts receivable attributable to the use
of CDBG funds. Additionally, any real property under the
subrecipient's control that was acquired or improved in whole or in part
with CDBG funds (including CDBG funds provided to the subrecipient
in the form of a loan) in excess of$25,000 is either:
(i) Used to meet one of the national objectives in Section
570.208 (formerly Section 570.901) until five years after
expiration of the agreement, or for such longer period of time
a$ 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. (Ro 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
Contractor's performance under this Agreement, except for such loss as may be caused by City's own
negligence or that of its officers or employees.
6.0 DISCRIMINATION, TERMINATION, AND ENFORCEMENT.
6.1 Covenant Against Discrimination. Provider covenants that, by and for itself, its
heirs, executors, assigns, and all persons claiming under or through them that there shall be no
discrimination against or segregation of any person or group of persons on account of race, religious
creed, color, national origin, ancestry, physical disability, mental disability, medical condition,
pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by
applicable federal, state or local law in the performance of this Agreement. Provider shall take
affirmative action to insure that applicants are employed and that employees are treated during
employment without regard to their race, color, creed, religion, sex, marital status, physical or mental
disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal,
state or local law.
6.2 Term. Unless earlier terminated in accordance with Section 6.3 of this
Agreement, this Agreement shall continue in full force and effect until completion of the services, but
not exceeding one (1) year from the date hereof.
6.3 Termination Prior to Expiration of Term. Either party may terminate this
Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party.
Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder
except as may be specifically approved by the Contract Officer. Provider shall be entitled to
compensation for all services rendered prior to receipt of the notice of termination and City shall be
entitled to reimbursement for any services which have been paid for but not rendered.
7.0 MISCELLANEOUS PROVISIONS.
7.1 Notice. Any notice, demand, request, document, consent, approval, or
communication either party desires or is required to give to the other party shall be in writing and either
served personally or sent by prepaid, first-class mail to the address set forth below, or such other
addresses as may from time to time be designated by mail.
TO CITY:
City of Palm Springs
3200 East Tahquitr 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.
F�
/IJ 5��UA4rfvr/
c F _cU. Nr2i� Sri !oy
72 Amendment. This Agreement may be amended at any time by the mutual
consent of the parties by an instrument in writing.
IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date
first written above. -
[ End—Signatures on Next Page]
- 6 -
CITY OF PALM SPRINGS
AT a municipal corporation
it lerk d`7i��Z P City Manager
APPRez�llollllx�t--X-.
S TO FORS APPROVED BY CITY COUNCIL rr
By:
City Atto> 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 the Secretary,
Assistant Secretary, Assistant Treasurer, or Chief Financial Off er).
By: By:
Nat d Signature of Chairman of Board, Notariz O Signature Secretary, Asst Secretary,
/President or any Vice President Treasurer,Asst Treasurer.or Chief Financial Officer
Name: rf�r��� �/ Name: ro V4^I dig(
r f
Title: �SrOill G Title: C �d
State of 1 State of
County of Iss TL County of �5$
On before me, On hef me,
�V sonally appeared ,persor]aH appeared
personally known personally known
tom r pYeved to me on C asis of satisfactory evidence) to me(or proved to me on the b of satisfactory evidence)
to be the p6rson(s) wh name(s) is/are subscribed to the to be the person(s) whose y e(s) is/are subscribed to the
Within instrument a acknowledged to me that he/she/they within instrument and owledged to me that he/she/they
executed the s e in his/her/their authorized eapacity(ies), executed the same his/her/their authorized capacity(ies)
and that b is/her/their signature(s) on the instrument the and that by hi r/their signature(s) on the instrument the
person or the entity upon behalf of which the person(s) person(s), he entity upon behalf of which the person(s)
act ,executed the instrument. ;acledre cuted the instrument
WITNESS my hand and official seal NESS my hand and official seal.
Notary ota
Signature: Signature:
Notary Seal: Notary Seal
8ubrocdpAgrmnuu1a4
- 7-
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California �JI �.
County of—I 25 Qf l nn
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Odle 1•I1,11•In I N,mr;find111N1.1 the 011icor
personally appeared L{IaLA?� D( 1CL�Pt� �f �4D_ I
Namelsl of Signeral
who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s)jeare subscribed to the
within instrument and acknowledged to me that
/they executed the same inl /their authorized
capacity(ies), and that bye/their signature(s) on the
instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
SNEMLADAM I certify under PENALTY OF PERJURY under the laws
N*"KCorniviiiiaon�CMr� of the State of California that the foregoing paragraph is
III ArKWnC u* — true and correct.
6jMVC0mm.EVN=Jur13.2
WITNESS my hand and official seal.
Signature �l-P�2.b2 1 �2�
Place Notary Seal Above F Signature otary Public I
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 r /
Title or Type of Document (.J grp_�-IF
Document Dates l` 2I o� Number of Pages: Gf�
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s) �(
Signer's Nam,-_M"LI lo�CL Signer's NameZ� yLlP 1(�, �X
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G.VCorporate Officer•—Title(s): L�� Corporate Officer—Title(s): GrU
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❑ Attorney in Fact ❑Attorney in Fact
El Trustee ❑Trustee
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❑ Guardian or Conservator _-- - - Cl Guardian or Conservator --
11 Other: - - ❑Other. --
Signer is Re resenting, !!rr- °':' ` Signer iYRepresenting:
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CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Project/Activity Title: Protect Number:
Arthritis Foundation, Inc. / Scholarship Program 0005
Name/Address of Provider,
Arthritis Foundation, Inc
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
O biectives/Activities
The intent of this program is to provide the opportunities of medically-supervised programs and services
which includes PACE (People with Arthritis Can Exercise) Land-based and warm water exercise program
and educational programs on diet, medications, joint-sage exercise, non-traditional forms of treatment,
doctor-patient relationships, communication skills, and fatigue, pain and stress management. This will be
accomplished through scholarship funding for very low-to-moderate income residents The Foundation
will serve 3,750 very low to moderate income Palm Springs residents.
The Provider shall be responsible for the completion of the following objectives/activities in a manner
acceptable and satisfactory to the City and consistent with the standards required as a condition of
providing these CDBG funds.
Objective 1: Assist the City by timely providing any additional information requested.
TARGET
DATE ACTIVITY#1
On-Going Make readily available any information relative to the successful implementation of the
activity.
Objective 2: Establish and maintain a programmatic and financial record keening process.
TARGET
DATE ACTIVITY#1
On-Going Establish and maintain an efficient program process/procedure for proper record keeping.
Set-up a filing system for CDBG files only Document and maintain all records related to
this program in a stable and secure location
Objective 3: Advertise, market and publicize the program to facilitate positive promotion for all parties
(i.e. Provider City. CDBG, etc.) with special outreach to minorities.
TARGET
DATE ACTIVITY#1
On-Going Draft a promotional piece(s) and submit to City for approval. Advertise in the Desert Sun
and minority media outlets. Submit final publication to City.
Objective 4: Enroll and income qualify at least a total of three thousand seven hundred and fifty
(3.750) very low to moderate-income Palm Springs residents
TARGET
DATE ACTIVITY#1
On-Going Provide Foundation opportunities to eligible Palm Springs residents. 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 thprogram.
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 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: Provide Foundation opportunities to eligible Palm Springs residents as outlined in
proposal
TARGET
DATE ACTIVITY#1
On-Going Conduct program activities, as stipulated in the proposal and in consultation with the City.
Objective 8: Provide an evaluation within fifteen (15) calendar days of the program completion or final
reimbursement.
TARGET
DATE ACTIVITY#1
07/15/05 Provide an evaluation and final report on all programmatic and financial activities.
General Administration
Provide the management oversight and leadership to address specific operational tasks in meeting the
established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.)
CITY OF PALM SPRINGS
EXHIBIT B
Budget Summary
Project/Activity Title: Project Number.
Arthritis Foundation, Inc. / Scholarship Program 0005
Name/Address of Provider:
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
_ BUDGET SUMMARY
^COST CATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel $ $ $
2 Consultant/Contract Services $ $ $
3 Travel $ $ $
4 Space Rental $ $ $
5 Consumable Supplies $ $ $
6 Rental, Lease or Purchase of $ $ $
Equipment
7 Insurance $ $ $
8 Other- $13,000. $15,000. $28,000.
Scholarships $3.50/Person
$ $1,280, $1,280,
Educational Materials _
__�..$ $1,720. $1,720.
Support& Self-Help Groups
$ $5,000. $5,000-
Pharmaceutical Underwriting
$13,000. $23,000. $36,000.
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 fundraising activities conducted through the Agua Caliente
Band of Indians Tribe, Pharmaceutical Companies, City of Rancho Mirage and private
donations.
The Subrecipient shall receive reimbursements in accordance with the aforementioned cast
categories and line items. The program will pay for 3,750 scholarships at$3.50 each. Payments,
approved by the Subrecpient and based upon the actual number of income eligible scholarships
awarded in the prior period, 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 2004— 05 Program Year—July
1, 2004 through June 30, 2005,
CITY OF PALM SPRINGS
EXHIBIT C
Insurance Inventory
Project/Activity Title, Project Number
Arthritis Foundation, Inc. /Scholarship Program 0005
Name/Address of Provider.
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 9 226 0-25 1 0
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Atlantic Specialty Insurance Company
Effective Dates of Policy 05/18/04 to 05/01/05
Claims Made Policy / / Per Occurrence Polices / /
Limits of Liability 2 million General Aggregate
Deductibles:
Per Occurrence
Annual Aggregate
Additional Insured Endorsement (Certificate Holder) ❑Yes ❑ No
Original Certificate of Insurance Attached ❑ Yes Q No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company State Fund
Effective Dates 05/01/08 to 05/01/09
Limits of Liability_ $1 million
Underlying Coverage Limits Unlimited
Original Certificate of Insurance Attached 0 Yes Z No
ACORDTB CERTIFICATE OF LIABILITY INSURANCE 08119/200a
PRODUCER 770.232.0202 FAX 770.232.9202 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
McCart Insurance & Risk Management ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2405 Satellite Boulevard A2D0 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Duluth CA 30096
INSURERS AFFORDING COVERAGE NAIC#
RISUReo ARTHRITIS FOUNDATION INSURERA. ASIC (Atlantic Specialty Ins. Co )
Southern California Chapter INSURERS
4311 Wilshire Blvd. #530 INSURER
Los Angeles CA 90010 INSURER❑
INSURER E
C VE AGE
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR ADM TYPE OFINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY E%PIMT ON LIMITS
Jim INAIN —DAMfMMJDD[YY1 DATE
GENERAL LIABILITY EACH OCCURRENCE S 1,000,00
X COMMERCIAL GENERAL LIABILITY 710-00-59-52-0000 05/18/2004 OS/01/2005 DAMAGETORENiED s 1,000,000
CLAIMS MADE FRIOCCUR MED E, P(My we person) S 10 DDD
A PERSONAL BADVINJURY $ 1,000,000
GENERAL AGGREGATE S 2.000.000
GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAM S 2,000.006
POLICY m LDC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5
X ANYAUTO (F. ...jdeop) 11000,000
ALLOWNEDAUTOS 710-00-59-52-0000 05/13/2004 05/01/2005 BODILYINJURY 5
A SCHEDULEDAu7D5 (Pcr pmw)
X HIRED AUTOS BODILY INJURY
X NON•OWNED AUTOS (PcrPWdcn1) §
PROPERTY DAMAGE §
(Perecclden)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5
ANY AUTO OTHERTHAN EAACC 5
AUTO ONLY: AGG 5
LXCESWUMBRELLA LIABILITY EACH OCCURRENCE 5
OCCUR ❑CLAIMS MADE AGGREGATE S
5
DEDUCTIBLE g
RETENTION S §
WORKERS COMPENSATION AND WC STAT U• OTH-
EMPLOYERS'LMBIUTY NO COVERAGE PROVIDED EL EACH ACCIDENT s
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICERMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S
If Yes,de jbe under
SPECAL PROVISIONS balm E.L.DISEASE-POUCYUMIT S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONs I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
E; Evidence of Insurance
ity of Palm Springs, its officials, employees and agents, are Additional Insured as required by
antract only as respects General Liability & Auto Liability. This insurance is primary and non-
ontributory. Waiver of Subrogation applies,
[See Also Farm NVCG 211 10 98 Additional Insureds by Contract, Agreement or Permit.]
CERTIFICATF.HOLDER
SHOULD PRY OF THE ABOVE DESCRIBED FOUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of Palm Springs 30 DAYS W n7rEN NOTICE TO THE CERTIFICATE HOLPER NAMED TO THE LEFT,
Attn: City Clerk BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIMIUTY
3200 E. Tahquitz Canyon Way OFMYIONb UPON THE INSURER.ITS AGENT50R REPRESENTATIVES.
Palm Springs, CA 92262 AUTHORED REPRESENTATIVE
Tina Gill MICBYA lyh'I p�
ACORO 25(2001/08) OACORD CORPORATION 1988
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REAL) IT CAREFULLY.
ADDITIONAL INSUREDS BY CONTRACT, AGREEMENT
OR PERMIT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
The WHO IS AN INSURED section is amended to include as an insured any person or organization with whom you
agreed in a written oontract, written agreement or permit to provide insurance such as is afforded under this
Coverage Part, but only with respeetto your operations,"your work"or facilities owned or used by you.
This provision does not apply:
L Unless the written contract, agreement or permit has an effective date and has been issued prior to the"bodily
injury", "property damage", "personal and advertising injury" or 'personal injury" or "advertising injury"
(whichever definitions are used in your policy);
2. To any person or organization included as an insured under the Additional Insured - Broad Form Vendors
provision of this endorsement;
3. To any person or organization included as an insured by an endorsement issued by us and made part of this
Coverage Part;
4. To any lessor of equipment;
a. After the equipment lease expires;or
b. If the"bodily injury", "property damage","personal and advertising injury"or"personal injury"or"advertising
injury"(whichever definitions are used in your policy),arises out of the sale negligence of the lessor;
5. To any person or organization if the "bodily injury", 'property damage", "personal and advertising injury" or
"personal injury"or"advertising injury"(whichever definitions are used in your policy),arises out of the rendering
of arfailure to render professional services by or foryou;
6, To any:
a. Owners or other interests from whom land has been leased;or
b. Managers or lessors of premises if:
(1) The"occurrence"takes place after you cease to be a tenant in that premises; or
(2) The "bodily injury "property damage", "personal and advertising injury" or "personal injury" or
"advertising injury"(whichever definitions are used in your policy),arises out of structural alterations, new
construction or demolition operations performed by or on behalf of the owners or other interests from
whom land has been leased.
YCG 21110 98 Includes copyrighted material of Insurance Services Office,Inc. Page 1 of 1
®,Atlantic MuWal insurance Company,1998
PRODWER
POLICYHOLDER COPY
SIR
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94 1 4 2--080 7
COMPENSATION
114SU RAN CE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01-21-2009 GROUP:
POLICY NUMBER: 1786628-2008
CERTIFICATE ID: 45 -
CERTIFICATE EXPIRES:05-01-2009
05-01-2008/05-01-2009
CITY Or PALM SPRINGS SIR
PO BOX 2743
PALM SPRINGS CA 92263-2743
This Is to certify that we have issued a valid Workers' Compensation insurance policy In a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund excapt upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the polley described herein is subject to all the terms, exclusions, and conditions, of such policy.
=10RIZE1REPRESENTATI C PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1.000,000 PER OCCURRENCE.
ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-01-2006 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
ARTHRITIS FOUNDATION OF SOUTHERN CALIF SP
4080 CHESTNUT ST
RIVERSIDE CA 92501
[814,SP]
(REV.2-051 PRINTED : 01-21-2009
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Project/Activity Title: Project Number:
Arthritis Foundation, Inc. /Scholarship Program 0005
Name/Address of Provider
Arthritis Foundation, Inc
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
BENEFICIARY QUALIFICATION STATEMENT
This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the
described prolect/activity Please answer each of the following questions.
i. HOW many persons are in your household?
For this question a household is a group of related or unrelated persons occupying the same house with at least one member
being the head of the household. Renters, roomers,or boarders cannot be included as household members.
2. Circle your combined grass annual income(Riverside-San Bernardino,CA—01128104)
MEDIAN NUMBER OF PFR$ONS IN YOUR HOUSEHOLD:
INCOME 1 2 3 4 5 6 7 8
LEVEL
VERY LOW
INCOME $19,000 $21.700 $24,450 $27,150 $29300 S31,500 $33,650 S35,850
Below 50%
LOW
INCOME 530400 S34,750 S39,100 S43,450 $46,900 $5,400 $W.850 $57,350
51 —60%
MODERATE
INCOME 345,600 $52,100 $58,$60 $66,150 $70.350 S75550 S80800 S86,000
120%
3. What race/ethnicity do you identify yourself as; please note that this self-identification Is voluntary in accordance with
equal opportunity laws?
❑ White ❑ American Indian or Alaska Native AND White
❑ Black/African American ❑ Asian AND White
❑ Asian ❑ Black/African American AND White
❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/African American
❑ Native Hawaiian or Other Pacific Islander ❑ Other
HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one: 0 Mexican/Chicano
❑ Puerto Rican
❑ Cuban
❑ Other
4. Are you are a female Head of Household? ❑ YES ❑ NO
5. Do you have a disability? ❑ YES ❑ NO If YES,please describe:
ACKNOWLEDGEMENT AND DISCLAIMER
I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSHOLD STATEMFNTS MADE ON THIS FORM ARE TRUE.
NAME: DATE:
ADDRESS: PHONE NO:
SIGNATURE:
The information you provide on this form is confidential and is only utilized for Community Development Block Grant(CDBG)program purposes,a
Federally-Funded program,governmental reporting purposes to monitor Compliance
CITY OF PALM SPRINGS
EXHIBIT E
Program Progress Report
Proiect/Activity Title: Project Number:
Arthritis Foundation, Inc. / Scholarship Program 0005
Name/Address of Provider
Arthritis Foundation, Inc
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
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
81ack/African American Asian AND White
Asian Black/African American AND White
American Indian or Alaskan Native American Indian/Alaska Native AND Black/Afrimn American
Native Hawaiian or Other Pacific Islander Other.
HISPANIC/LATINO ETHNICITY Mexican/Chicano Puerto Rican
Cuban T Other:
♦ Number of Disabled:
ACCOMPLISHMENT NARRATIVE
LEVERAGING RESOURCES NARRATIVE
Signed Title Date
CITY OF PALM SPRINGS
EXHIBIT F
Request for Reimbursement
Prolect/Activity Title: Project Number:
Arthritis Foundation, Inc. / Scholarship Program 0005
Name/Address of Provider,
Arthritis Foundation, Inc.
73-710 Fred Waring Drive, Suite 104
Palm Desert, CA 92260-2510
BENEFICIARY QUALIFICATION STATEMENT
Approved Current Prior Total Grant
Gescrlptlan Grant Reimbursement Reimbursement YTD Balance
Amount Period Period(s) Reimbursement (Overt lender)
Scholarships $13,000.00
TOTAL � $13,000.00 ����
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 sheet(s) must be attached detailing cost breakdowns, and verified by original signatures.
Y
CITY OF PALM SPRINGS
EXHIBIT G
Employment Restrictions
1. Labor Standards
The PROVIDER agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis-Bacon Act as
amended, the provisions of Contract Work Hours and Safety Standards Act, the Copeland "Anti-Kickback" Act (40 U.S.C.
276a-276a-5:40 USC 327 and 40 USC 276c)and all other applicable Federal,state and local laws and regulations pertaining
to labor standards insofar as those acts apply to the performance of this contract. The PROVIDER shall agree to submit
documentation provide by the CITY which demonstrates compliance with hour and wage requirements of this part
The PROVIDER agrees that, all general contractors or subcontractors engaged under contracts in excess of$2 000.00 for
construction, renovation or repair work financed in whole or in part with assistance provided under this contract, shall comply
with Federal requirements adopted by the CITY pertaining to such contracts and with the applicable requirements of the
regulations of the Department of labor, under 29 CFR Parts 1, 3, 5 and 7 governing the payment of wages and ratio of
apprentices and trainees to journeyworkers provided,that if wage rates higher than those required under the regulations are
imposed by state and local law, nothing hereunder is intended to relieve the PROVIDER of its obligation, if any, to require
payment of the higher wage. The PROVIDER shall Cause or require to be inserted in full,in all such contracts subject to such
regulations,provisions meeting the requirements of this paragraph.
2 "Section 3 Clause"
a. Compliance
Compliance with the provisions of Section 3,the regulations set forth in 24 CFR 135, and all applicable rules and orders
issued hereunder prior to the execution of this contract shall be a condition of the Federal financial assistance provided
under this Contract and binding upon the CITY, the PROVIDER and any of the PROVIDER'S subrecipients and
subcontractors. Failure to fulfill these requirements shall subject the CITY, the PROVIDER and any of the PROVIDER'S
subrecipients and subcontractors, their successors and assigns, to those sanctions specified by the Agreement through
which Federal assistance is provided. The PROVIDER certifies and agrees that no contractual or other disability exists
which would prevent compliance with these requirements.
The PROVIDER further agrees to comply with these "Section 3" requirements and to include the following language in all
subcontracts executed under this Agreement:
"The work to be performed under this contract is a project assisted under a program providing direct Federal financial
assistance from HUD and is subject to the requirements of Section 3 of the Housing and Urban Development Act of
1968, as amended, 12 U.S.0 1701, Section 3 requires that to the greatest extent feasible opportunities for training
and employment be given to low- and very low-income residents of the project area and contracts for work in
connection with the project be awarded to business concerns that provide economic opportunities for low-and very
low-income persons residing in the metropolitan area in which the project is located"
The PROVIDER further agrees to ensure that opportunities for training and employment arising in connection with a housing
rehabilitation (including reduction and abatement of lead-based paint hazards), housing construction, or other public
construction project are given to low-and very low-income persons residing within the metropolitan area in which the CDBG-
funded project is located;where feasible, priority should be given to low-and very low-income persons within the service area
of the project or the neighborhood in which the project is located, and to low-and very low-income participants in other HUD
programs; and award contracts for work undertaken in connection with a housing rehabilitation (including reduction and
abatement Of lead-based loaint hazards), housing construction, or other public construction project are given to business
concerns that provide economic opportunities for low-and very low-income persons residing within the metropolitan area in
which the CDBG-Funded project is located: where feasible, priority should be given to business concerns which provide
economic opportunities to law-and very low-income residents within the service area or the neighborhood in which the project
is located and to low-and very low-income participants in other HUD programs.
The PROVIDER certifies and agrees that no contractual or other legal incapacity exists which would prevent compliance with
these requirements.
b. Notifications
The PROVIDER agrees to send to each labor organization or representative of workers with which it has a Collective
bargaining agreement or other contract or understanding, if any, a notice advising said labor organization or worker's
representative of its commitments under this Section 3 clause and shall post copies of the notice in Conspicuous places
available to employees and applicants for employment or training.