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HomeMy WebLinkAbout05069 - STROKE ACTIVITY CENTER CDBG RECIPIENT FOR PARKING LOT ADA IMPROVEMENTS SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this 1 day of Jul, 2005, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Stroke Recovery Center, (herein "Provider"). WHEREAS, the City has entered into various funding agreements with the United States Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C. Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et semi. ("Regulations"): and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act; and WHEREAS,the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW,THEREFORE,the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified therein in a manner to reflect credit upon the City and Provider_ Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application. 12 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 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 31 n of the current fiscal year. ANDIO R Al.i'V1EE E71(l 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 THIRTY THOUSAND EIGHT HUNDRED and NINETY-EIGHT DOLLARS ($30.898.001 (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 Providers 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: Beverly Greer, Administrator 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 0 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 semi-annual reports on program status; (b) Section 109 of the Housing and Community Development Act of 1974, as amended and the regulations issued pursuant thereto; (c) Section 3 of the Housing and Urban Development Act of 1968, as amended; (d) Executive Order 11246, as amended by Executive Orders 11375 and 12086, and implementing regulations at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 6); (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 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); q (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.C_4801 et sea-); (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 Providers 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 n 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 parry. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. Provider shall be entitled to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Stroke Recovery Center 2800 E A ego Rd a m prings , 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 J F CITY OF PALM SPRINGS ATTEST: a municipal corporation By: t�71 n -y Sy < City Clerk City Manager APPROV D T7/7 : APPROVED BY CITY COUNCIL ,r City Attorney PROVIDER: Check one: v Individual _Partnership _Corporation (Corporations require two notarized signatures: One signature must be from the Chairman of Bo �! ent, or a Vice President. The second signature must be from the Secretary, Ass stab[.�iec a asu r, Assistant Treasurer, or Chief Financial Officer). r� By: By: Notarized Signatur of Chai a of Board, Notarized Signature"Secretary,Asst Secretary, Pr -dent o ny Vice r i fit Treasurer,Asst Treasurer or Chief Financial Officer r� � _ Name: Name: /�CUC—wc y z Title: �. 62—o"L Title: (_A � 55 sT• Ste= - State of /-P'Ws a State of County of iC LL S/DF- -ss County of Z_ss rtOn,'" 6O'�"Q 7 before me, fonp (P �7- /�9� hen `/ before me, A H'OMA), ��;D&BwP,personally appeared M t l�'I eli e ft mil.{ i 1` D-rCU persona ly appeared Z6.&_ Y personally known owo 10 GrOPr pwsenally-kemrm to me(or proved to me on the basis of satisfactory evidence) tome(or proved to me on the basis of satisfactory evidence) to be the person(s)whose name(s) is/are subscribed to the to be the person(s) whose name(s)-Ware subscribed to the within instrument and acknowledged to me that he/she/they within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), executed the same in his/her/[hair authorized capaeity(ies•}, and that by his/her/their signature(s) on the instrument the and that by-his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) person(s), or the entity upon behalf of which the persons) acted,executed the instrument. acted,executed the instrument- WITNESS my hand and official seal. WITNESS my hand and official seal. (� Notary .J Notary n I 7 UM-ki Signature: �. �-rr� �c7.� Signature ���1'✓//��y Notary Seal: Notary Seal: M. NORTON COMMIt ilon a 1736♦195 MII K.AC0 Notary Public -Cpllfornlo COrrrrtWlon 11652676 Riveralde County Notary Public -Callfolnio MVCo^m-E'9*ei'r'Pr42011 Riverside County NNComm,ExpnCm MUT 14 201 C' Stn keRemveryCntr Subn ip°grmnLRO.Ju105 7 _ dLB��: 8 r.Cr..ji^'xn 'y - p�•.,zo(��4J - C`iC.G ,t;�'�4'�. .4�^e`:' CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title: Project Number: Stroke Recovery Center 0014 Parking Lot ADA Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 Objectives/Activities The intent of this program is to programming, services and therapies for stroke survivors. This will be accomplished through the renovation of their existing physically-challenged parking. The improvements would increase the number and wider size of handicapped and standard spaces, as well as a new direct path of travel from the on-street parking spaces. The Stroke Recovery Center covers the entire Coachella Valley, serving 216 clients of which 65 are 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 rocess. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise market and publicize the program to facilitate positive_promotion for all parties (i.e.. Provider. City. CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income qualify at least a total of sixty-five 65 low and moderate-income Palm Springs residents. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming for Palm Springs residents. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5: Maintain records for all CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 On-Going Submit Semi-Annual 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: Renovate the existing physically-challenged parking which will increase the number and wider size of handicanned and standard spaces, as well as a new direct path of travel from the on-street parking spaces, in accordance with an'open competitive' procurement process as outlined in pr000sai. 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 07/15/06 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 Praiect/Activdy Title. Project Number- Stroke Recovery Center 0014 Parking Lot ADA Improvements Name/Address of Provider- Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 BUDGET SUMMARY COSTCATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel $ - 0 - $ - 0 - $ - 0 - 2 Consultant/Contract Services $ - 0 - $ - 0 - $ - 0 - 3 Travel $ - 0 - $ - 0 - $ - 0 - 4 Space Rental $ - 0 - $ - 0 - $ - 0 - 5 Consumable Supplies $ - 0 - $ 0 - $ - 0 - 6 Rental, Lease or Purchase of $ - 0 - $ - 0 - $ - 0 - E ui ment 7 Insurance $ - 0 - $ - 0 - $ - 0 - 8 Other $30,898. $31,805. $62,703 Construction Contract $ - 0 - $ - 0 - $ - 0 - $30,898. $31,805. $62,703. 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 City of Palm Desert CDBG and private donations. Progress payments, approved by the Subrecipient and based upon the percentage of completion of the work with a 10% retention, shall be paid by the 30r" 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. The Subrecipient shall receive reimbursements in accordance with the aforementioned cost categories and line items. Services are to be performed over a twelve month period of July 1, 2005 through June 30, 2006 with funds allocated from 2005—06 Program Year. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory prolect/Activity Title: protect Number: Stroke Recovery Center 0014 Parking Lot ADA Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company NIAC Effective Dates of Policy 02/01/07 - 02/02/2008 Claims Made Policy I I Per Occurrence Policy Limits of Liability 3 , 0 011 0 0 0 Deductibles: Per Occurrence 1 , 000 , 000 Annual Aggregate Additional Insured Endorsement (Certificate Holder) ❑Yes ❑ No Original Certificate of Insurance Attached ❑Yes ❑ No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Fund Effective Dates 01/01/07 - 01/01/08 Limits of Liability 1, 000 , 000 Underlying Coverage Limits Original Certificate of Insurance Attached or Yes ❑ No r C•d Lf Qc . ' e .Go rli rn ueoen , =,ir .rve illao✓u . ou 4foo IV r . W / ✓JJ I n :84 2STROREC PATS ACORD. CERTIFICATE OF LIABILITY INSURANCE 02/27r2007"Y ' FROcucER THIS CERTI LATE IS LSSt10D AS A MATTER OF INFORMATION Oasart EF"Pire Insurance ONLY AND CONFERS NO RIGHTS UPON THE CEFMFICATE 99ryleaa, Inc. LIC MOF09043 HOLOSR.THIS WITIFICATE Does NOT AMEND,EXTEND OR ALTAR THE COVERAGE AFFORDED BY THE POUCIle9 BELOW. 77-W COuRlry Club Dr.,#Q1 Palm Doiten,CA 92211 7 O- 3L, 1100 INSURERS AFFORDING COVERAGE NAIL e MBUI INSURER%' NIAC 36694 Stroke Recovery Center INSURER a State Fund 96076 2600 E.Alejo Read INSURER c: Philadelphia Insurance 23660 Palm Springs,CA 92262 1r�uRCR D. 1NBuneR a COVERAGES THE POLICIES OF INeURANCE LISTED ELILOW HAVE SEEN 199UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIRIMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISBUEO OR MAY FWAiN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 19 SLIBJECT TO ALL THE TERMS,IIXCLIJ&ONS AND CONDITIONS OF SUCH FOLJCIEa.ACORIOATE LIMIT%SHOWN MAY HAvE BE!rN REDUCED By PAID CLAIMS. 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Evidence of Insurance, CEFMFICATE HOLDER CANCI LATIO SNOULD ANYOPTHE ASO"POORIAED POMM BE CANCELLED BERM THE EILPIRATICN Insured's Copy DATE THEREOF,THE 35UIN01NwnM WILL FRcuVOR TO FAIL -Ix OATS wnmvd NOTICI TO THE CERTIR(x,T!NOLDM NAMED TO THE LEFT,BUT PA LUM TO DO BO SHALL IMPOSE NO DELIOATION OR LIABILITY OF ANY MIND UPON THE MbUPM,ITS AOENTe M B ATNEN A T1Y! ACORD 25(2001N6)T Of 2 N8100700/M100692 ( 2 O e ACORD CORPORATION 1sea V lull UQ QMUf 0 - ci rin rm WCnLm1 tl'IrlMt 1Nbbb JbU 4f8S (U 53258026 P . 02 1 DSdertrfnrfll No. 2 ii 6pb(MikIQQ m • r • 06/06/2007 1.PMdltcw 5 Pdxry hdmnsam' nesert Fhgire Insurance Services, Inc . C4nw''NIAC NAIL i 36684 CA rres co try Club Dr., #401 Poky Paw 2007067613M p Palm Desert, CA 92211 Carw�•psTrOW ❑occow" Telaymnr g 00 LnM A*"w 1 Exp"4:❑InduaW m Uml4 ❑b Adaatr�ro Lhrw+ 4.Inemad (Chew W" Stroke Recovery Center a ❑n.daaww % 2800 141. Alejo Ibad ❑30"RMW R9WWn at Palm Springs, CA 92262 $ with an Appnp %as T.�hh6.Thlt iMWlMI ae�ll�{b Ih.optf•AOM n�dIMM1U�ly d ew MTW .dYM M��ill Ylillwl A/MM pwnxr M bfPrlRl er Qly OI PMYn *pruWu"m dmdwdhm nwaWleMM 4Ny�w hMM'n�/ttrC pnrxMNx rtep+.aw suit VN WN.rPYa��w•awPst Lbl�Llffft wThmANidSS 5.osw1'w wm Mrwxd 10 Day Abtice of Cancellation 1,000,000 ,for non-payment of.pranim. OMWd twos ShcsduW Autos 16 ekhnq a. w ft& rr r.�llww m a twenty '� HhW)rotas Ps.wnl•alsaswnwvl�nssll/rlter.wl. % NonOwmq Albs M am5 dwalm of dr 0—mm a w"d Mw ho"wimidlnp any r4molskm 0" M1M in iw pdicy ti wrm Wt eowmmw Is Mraalyd endxma A9w•rh•mMrdtrsb,i1+.+p1Mas Menus: 1A, AytMtimrinsulrr.TYr csyrPslmSPigaand hadiasw,mSlsTrre..lrpnYfanYritlrYrw7dMmslwlurkit+wnlwMbNsMwyane dellm•ofall dewy,4mimos,ll MMm erdsnwpeso(+M6Vv*wRwhft ham M Womb"MM Uu rm$nm•hywmbmwQ1i WNW n.trwd 'Z rat MMUMM Mot no**"hlMMM 6 Pfkr—Y W i M31M 10 any h'bt#wo mswwned by ew CXyaf Pstm Spline WA VM none a1 ila CtyaMyytefl�lormiobulion. 17. Cwryi.Msn Nallsa,Ytld1 ntsp.p b M fnt4rsb d M�'d Palm 9ptsgs its inWaMr thla n.i k ChIteWH,w nloisiniy ndttW w aurer+ie ar irtst steel MM dlhryl301 days pliar w Mw mA*bi wg0•dds7rwy lrn b wt phanb go C Cal pWm dplr LPusdrsue0 sw M711wd.CJy orPMFa 5 V t^w.Mlh.Ftlsk Maa+Or.a7AG 1.TSnPra Ca.ban W+y.PsYn E�dtyy ryV 92�a'�. B.crgrMsbdabawnaM:nphwaYtehs4Eillwldmw4.r.rirarulwprryotnrrw mndiMww.aprwm.rrtawleNlshramspWryw1 Ilb eltdwh.nwllis sNlChstl. r• chy6sytwanMarls•w1 15. s.•k1lzsdRsPrawawhw.:®gldkrrApsrs[]Undrrrlkr ❑ Cliynrpalm5prirga 1 Tina TiTrlc 3200 l�7ak1quk7 Canyon Way .orlalry n and the abawss aMagwed ileanna mmpwlr by wl nwno�,ldo�w Palm Springs. CA 32M hindmammpanynd�t (egirsan.4xa wquYrr�cagll Tw"hwwt (760)-3EQ=JZQQ--.. U. Blp. ; 06/06/20C17 06-08-2007 14:30 STROKE P.E000ERY CENTER 7603258026 PRGE2 ciirIML INbr4 .fbO 4 (y6 lu '�J25e026 P .03 1 findaaamela Ho 2.11 Da w(MWDOlM for thil City of PaIIII Spring's O6/O8/2007 In s.rwkr Inln M"' MAC Desert Empire swrance Sex-Aces, Inc. Ca„iw. LIC #CM09643 ruck P 36684 77-664 Country Club Dr., >#401 Palley fro' 200706766NPO Palm besert,CA 92211 P0""P'" " Q2/01/07 to 02/01/09 Cams"Tdggw raeaxlenca rw*hwr (760) 3604700 LA AqulW wA I-Vmm ❑VmWdad In hair ❑In A4*m In Lk* 4.Stroke Recovery Center o "IIbw s 2800 E. Alejo Road ❑ yN , Cr. Palm Springs, CA 92262 s wah an APsraywa of s xwy..a vn4r ar wawi a(yrrwnr.wW awm.�Iwn wiyl ay cur Npaan sodnra wrrnn OwkM em[p xI M'ch�. n.brats q+y�cuc 62anW4Mwlaerwrww arGgdhw Swryrwamrrah Cry t'+.nwal pJrYMly 10•01WFMA w 10 Day �btice oT Cancellation for non-payment of premium. CmIp bw1i r Fans $ p,�yNlpp frny $100P000 ,UUU,VUU I I CWmr:unsw.,.arffi wPW ftb%,kr dwa",W 01*W indw A co"HEMM M Ow mLmbvw Wdu ana Wpl ww), PmaululCmwwWd $7,000,000 �µ2,000,000 cowwawl mdekwdwr Cenr.mn er w4 dwaron of On erakaan 0*Wd and how9nwnd.9 any kM4%IUWI afakanwa In Me Peso b WNCh*k Mdwswnwa it aawfw •Idorewr�anowarhwradwnayap,kMspaedaafasowr. ri AdOhayswrn LnmCkycfP*m3 MlpzardiMof$C.l.,«npin�.Iland�.nnsn Flpudedafid4spn.IMIf11ra4+M�n{Idtia4tihand ddsl ofalydaNla.a.wn:r,s.err..ddrm,o..awnr..�wrw�ynanw.onmrem.+rw+nr ryeo,wfwarrwn.nr+ Inavaw, 1xc.roftwmaN.eK.*rw.rwMIMI.pdnWwwrtVM110 MYh�mafnl by0,CifydFaimsp*wamMa d"cam w+ Ch0kMMWwwkrcw4kAIn, rr. G-100k m No",VM napod to on W*wah d am Csy of Plan sp"3 Ryd kMM wa alias w to CM&A ,w•na*ft redom o aarwapaarradu faofAaMykily(��eayapc4wraWr naYwhynodplrd Wavwyhasbrae Vymbwa Cayd PwMW4lsr ar fa.ow,!cry of PM,n eP ram,Ale,:FU*Mw"w,32nd a T09LOZ unwr wa.Palm SOW CA krMz END"MosomGny rdw"hwalnraake.nelrawah�,Nwaredwgnr ydfb sna4.cardlinb,aarwnw■.ore.rwawrafm.pokyew.dl vir.ndan.n.nliaall.ch.l . fs clNnrrwalNauwww u. Aunorindgagryrna+�:[ eroard�arn❑urnWneMar ❑ CHy of PNlrn Spr fts I Tina Fads 04 M+rwn4 rwnw i wn I haws 3200IE.Ta6qult Canyon Way awwdynaadrw,aown.rael �r�wnpMyw.+gnyasm.ra+nrreardom Pa4nSprings, CA 922f:2 aJllnallaAPQ9AWan,wr) TefePhan.: (760 ) Ixrsimm! 06/af3/2007 ** TOTAL PRGE.03 66-08-2007 14:30 STROKE RECOVERY CENTER 7603P58026 PRGE3 Client#:8492 2STROREC ACORD:. CERTIFICATE OF LIABILITY INSURANCE 11f0(12008r l PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Desert Empire Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Services,Inc. LIC#OF09643 HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 77-564 Country Club Drive Palm Desert,CA 92211 INSURERS AFFORDING COVERAGE yy NAIL# INSURED INSURER NIAC 36664 Stroke Recovery Center NwRER a Tower Select Insurance Company 2800 E.Alejo Road INSURER C. Palm Springs,CA 92262 THEURER D NSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUEL)ECT TO ALL Till TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMIT 9 SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS N' r�F GURANCC POLICY NUMBER p TEY EFFECTIVE HbLICY L%41 ITYIYON LIMnS N NsR A, ' 20036766NPO 02l01/08 02109/09 EACH OCCURRENCE 51000000 DAMAG E E,T SENERALUA91LITY p 'A 5100000 AD"c �X OCCUq MED Eorsom G1Q.000 PERSINJLIRY 51000QOD GENERAL AGGREGATE; $2 QDD OOD LIMIT APPLIES PER: PRODUCTS-COMPIOP AEG s2000000 Pi0.JEGr LDc A AUTOMOBILE LIABILITY 20086766NPO Q2rD1/D6 02/01/09 COMBINED SINGLE LIMIT X ANY AUTO (Saacadk,Q 51,000,000 ALL D'ANED ALTOS BODILY INJURY SCHEDULED AUTOS (F,,,OesoN) $ JC HIRED AUTOS 5OVILY INJURY X NON-QANSOAUTO6 �,,,—COPERTY ...cd.m) 5 DAMAGE S �ncmnm7 GARAGE LIABILITY AUTO ONLY•EA ACCIDENT S ANYAUTO OYHEk THAN EA ACC S AUTO ONLY AGG s A ExCESSNMBaELu LIABILITY 2008067660MBNPO 02JO1/OS 02/01108 EACH OCCURRENCE s2000000 OCCUR FX7 CLAIMSALLDE AGGREGATE 5 5 bebUCTIBLE S X RETENTION 510000 15 $ WORKERS COMPENSATION AND TSIWD7080102400 01/01/08 01111 X WCRLC STATIJ- ETH- EMPLOYERVLIABILITY EL EACHACCIDENT 51,000,000 ANY OFFICE MEMBEER EXCLUDED'+ECl1TIVE OFFICER E L PIS`ASE-"A EMPLOYEizj S1,000,000 II Yu:�llk".dhP f,ntlfl" SPECIAL PROVJ5IDNS bMow EL DISEASE POLICY LIMIT 51,QQD,QDQ OTHER OESCRIPnON OF OPERATIONS I LOCATIONS I VEHICLES!EXCI,usIDNs ADDED 6Y ENDORGDMENTI SPECIAL PROVISIONS Certificate Holder is named as Additional Insured to Include Primary and Non-contributory wording. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRII POLICIES BE CANCELLED BEFORE THE EYPIMTION The City of Palm Springs,WE DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10- DAY-WRITTEN officials,employees and agents NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT,=T FAILURE TO DO W SHALL P.O.Box 2743 IMPOSE NO OBLIGA DON OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Palle rSlpring&,CA 92262 REPRESENTATIVES. AUTHORIZED RBPRESr11TATI�VE+'' ACORD 2S(2001/06)1 of 2 9S126019IM126018 2TEAD 0 ACORD CORPORATION 1988 POLICY NUMBER: 20086766NPo COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the fallowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anlzation s : Locations Of Covered Operations Ci Cy of Palm Springs P.O. Box 2743 Palm Springs, CA 92262 Attn: City Clerk Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only 5101­145 apply. with respect to liability for"bodily injury', 'property This Insurance does not apply to "bodily injury' or damage" or "personal and advertising injury" "property damage"occurring after: caused,in whole or in part,by. 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project(other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed,or noted above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 ©ISO Properties. Inc..2004 Page 1 of 1 ❑ pncUrdul-ILnI No Yl1 BpBpBp u'r " "I 'y'„;✓, �A"•'" i,!"w' :�6� f1.'x' `� 11/04/2008 ��1 Plunll.a $ PohCy IgIUrI shut' P Desert Fmpire Insurance Svcs, Inc. C,mur NT..•'C LTC #OF09643 NAIL '' 36684 77-564 Country Club Drive r-1n.m =I:I,nd 20D806776NP0 Palm Springs, ak 92262 C11'1-II.vTr.•Jr: �p2/01/2008 - 02/01/2009 Io Ir r,1u11 (760) 360-4700 LI1,q.'J1aor.,u Ln'Irr Stroke Recovery c 1 � rt] Center ❑3L�1 'In.,mc HeL:nlicn C; 2800 E. A1,ejo Road J, Palm Springs, CA 92262 --•---- 1 i A"i'.Iblc.I I , i,;-,.••e 1•11 •ho pr-.nI I ..It nr ry ., r I,• IIIIII I .u.I rl..r.1i, ii y,(r� tll rir i ,r, ie:l i 'r1 rlt•.r r1 I +li - a rur.r a ❑ ,r .,, r. i r r '.Jri r ,l' rq f CIE, A rii .L „llx,l'i1r 'is ! OL,wral Labdry b '-r,.'.'Ia:anm { X IC+1nn,rm nitcry ldl l.•,II,IIy ...`. w...._". . _" Inhrhly ln7Vs nTftnu,ar[1.5 '-ter....�� y Icaurra Ice A:i9ruya!o ^� r'I CI'IULs'�)}rLl itllLati �• •r ,.l 1,.`.rI t•r J4,AC•-.r_t rt 1 I I'.•rI1 . Ie no.l rl j •I • .i ler + ,r Vull;lt ati.IultiCU'Iry,',a H'2&IH $1,000,000 $2,000,000 ! —x J : JLI ,,;t [I1IrI:;Ca11„aldll 11•• $1,00D,000 $2,000,000 4 III .I+II d' I V ''.. ,.I:IILLn r,..1 u!,UJ dlld Ilpl.vd-elldnduly arty MILLI SISIIJII sJll'mLld III Ihtl -JIIJy 16 WhICI, th's cnJorscln]m 15 OLird va , aL111-,n'I.a.4j1 L,. LIIy'LIO.I:IB e!.,na.q OSlLII<:✓+s { 1? Aq[Illloq,ll 1paumC -ry,:CtlytlfP;iln1$pul gyanJ ltsoYlcrais emplOycusandacenlsam inrluncu US:alaurt']I lnsr rLds.d.dll rLyord l lhi,blll and Ilf r;ryfOP'✓ [,Lill<IIIrl., I,I!`r,,.IL 11:1411l(ILS UI lt:lixvi,t•+,'I Ju^n;)Irur,''n•0,1 rill III IIIIJl pls pe17+•I r'-+rl:p,('Drt 111,v PI+Ire dr Q'I nr Ira 1 13 t:It;u SIfI II It F,LiIU,e[I n....r mu I .......ar v.nl•IaLrp L::[t1 .!IV II wo I,I r_L meclPll I1.r,I.,'J� l.I 01 RM'r�,el IS'In„LI,IL Irol 1,111 un 11 d I j L1,, , d .. I rnn, hI In,I j 'I CIInce;I!rtiOr.Nu1,cL PJ I' I>;I OI D, II% n[t r[ld:,of It), Crj ,' •'"f9`q rrim qp III I),,if Iry d..11 nl r 0''N=lr I'lh t' ,1 1•IJ L:IIplly'ru UUCI:o 1n CI'.,rlo,C.or Lml I,, I.bl I fler Chic}(3II)d:,q;1;1101 w'Irlu l nL[ILL b I—I:qq.[' IAlduf f"ds•I CIOq ..In'o 111L C1.,d,PrJI-TI!� u I' tlrp aLlrlr(I it.'9 Clpllr"•Il rr_,.In;p: nLl h:,6\1r.uJ4r.I J37Dv I;I Iu,i4 Cr r 1,I,I. , r'III p,,1II ` i,.v.,.l rs lIbL:I! dnl.I;:lutlrl LllOr['1rr[.I I'1II I,,til,ltl It, i,;w W e.r.,L.UIq,N tii� miI,.am,hwsn,rr_I_r1,111 Of vn.11ralulb ul 11 IL[IU+II�y luwYWal Ihl•i�,npr,�-I e.1111' fl nlo,l , 1 JwE16) or'ay{rlD�� ......"...r.._._._. . ..r. . .� ...rv. ....n........��m. —� W ! �, CI['/U,;pzlttl+cr+L'9urcab uI ALIIInn_cd Re,;rasent'it1,.o T 61 nnti r ,%grant❑U1id,Iait, L� van `Iann0%' ..- (V uIII . Il lsara!IIa 1•Lr.o CityofPaflnSpiir;yS --_-- Y;,,.!I,,Irr,1 3200 E,Tah QliiCa yo� vay .urthcl I110 binrl the nrvL II In.uIdll.:;LdmF"ny C"I'D!r my ,rcn:-it"' IIGIu+rI JII 11 S PnlrnSprirles, CA 92262 d"II:vnitlpany7w/vu/slr s',Ln r:11t G r h_,,nalli'rlrrr (760) 360-4700 ed,rl J 11104/zoos 1� S Polizy,nln r•,eor 11/04/2008 NIAC " 36684 Desert Empire Insurance Svcs Inc, f'r'I 200806776NP0 ' LIC #0F09643 02r01/2008 -- 02/01/2009 77-564 Country Club Drive c•I,,n[1- n,+,lln[rr,lnlrr„r,. '1•+•• Lw,�e n{j Iu.au7Gd„lunge Tlacex r[,'f 977�] 1'7!,l11 7fi(1-L __- ___,.--___.."....._.........:W Stroke Recovery Center ❑ ) , ;Iv,, 2800 E. Alejo Road n•;I It I LI, f r•.I rntrru of i Palm Sprinss, CA 92262 I V 7 AppbceulL "e'iIitr,i1w a:n.lul: Ic.Im.1.. 111 I.1 o m., :II I in•olr:n Jr go,,�'v.I ,:I o[,r IC^1•r'I, l II.I II r'. "M1" r,rlil l'• jy5', p1.g.,nlp•v, ill,,�hi,J qr�❑ ":•qrv-ri,m...rl- Lr_Lrv�.,n,l:b JI •It.•nl I II III 14 My Agreuwlla Turrnl[n r;y, _ - •.M_., 'vI cq 7I It •,_� Onlw Pr,,Ion, I f)ccWrP nco .��r.. :L7 r•rl•a� r �.yCSZ: G ,.•1 .. .'Ily $1,000,000 .� "i 1,L,I,..I Ilj EOI 10,Cl""' L1nrlcnvrl!cr's•cgrrsr;nlcpe+•br eUln,� p[ NI•LJ Aldus pw5unn[10 IhL:im orancv oowoss: td 0.4cn1,onc4 {d 1 _ 1 { I e ['..rand'Ia11.lu -+I I 'I'-w!,.n1 l tU In):n111rv,1. ,,fln.) qny rno +,.n{,":: -.,A 1.11 ry t11e id A.[y If v. ,II 'Iw I: r A ,If lilCnpll .u an I.n, •1111n., I 1.I .I IL 111•, ,I d'1, 11,1'1 11'1,1 Iluw 11 .:,ddit,onll 111M1wed I 131 lY L I'J,i 11 n 3 I)r I I i:5.IM Ili Ol it Lldli dl9}'6_LL'i.I11.1a,Iorl,ItI1l lrll:lul:i d as eUd I l lenld q l}In'erS L.11'1 c)•lr!I III I.Ib111y.R1� 1 d,iul 11.1 11 I 1:1111, ' .:JI!Ir';I•n 1!•,r•1�ru.5„hW a�15:0'rl'r 8r 1gI.��1 W b Il I( I,pcluLul 1,.UP11 1.r•,1 CrII, rn.11 Ly nl of ln•p::, 1;!11 %gdrlvd ' Il l:al lltl + 12 Cnningp Yq!1 tgbt Nuquir'd PI:•UIJPCv IS primm" -mlh rCSpGc110 0P) In Stl,IPCC r'Idn1l,llnG(1 by II 1;1,11;0f Pp In�lun•y; "Na 11,.11 nu'[ ,II u',fl), ' ::11.611:,ur.0 cL'W�.,I III F1LIuo 1[! Qa 3Ce 141:1 11 No;l ee.'A I II, I021k bl tC II'.Inle"S::i N Ih0 Cdy 0f P.111n SIir 111'ju If,Ia I•.b:;II lra:ShW 11 Id,t Jv bur 16b Y rq rrrI I y ICIJ Yt,11.I �I I.NI IC .nm IIS,;..n:pl artn•II,1rty(3J)da ys onor.unoI tt IQ+IU+by Ie^.rllll(etlt,u1,%c-tJ'IJs'IpL'I,c),den lu dn)L:rty Of Pn it n S;1 nyp ddd•ess,pd,Is UII";. ,};y„IPt'1)1L';itl.1y`a.Aitrl I?I;.nhA.ln.:g6r 32110 E. '::I yurti CI JJn N111 ".,I"I 5,mnga C6 J2lbL F,r•I+nlJn I ..r,n(nl,ruff 1"l'I;`III$11,11 hr,Il)10u,,1N, .,'1r:(Or Cx lr+n(I ,rI I,I IhI'IIrII:'Ill')1)IIII(:nS I, ncnis,eL-;Illy:rn11Z,0I11)fr,11:;y 1(1',vl I CI { ' 1.:. UI}DL IL111.1 LI 115.11 I1a fJ J A1.1'wI"�':J ;"i'I �,n'nhvl L:6un11'At jJ Jndl•r:.dlor City oTPalmSpnngs Van Tanner r 3200E.Tahquitz Canyon Way I � - - - - --- .� (rnlN'YII,. n�r•Ie, !,.,11,r'Im,:17a�c 'II a u:hont";o',wo lac ahcvn 'ru•;nco crinp,:ny orr;' ;my :1t;r1u1r1, norm,ar so Pahl Springs, CA 92262 'Irrl"nS CI, ', ny to 11"6 y. 11om i J I,'rlr) ,;I I I rrI, j r 1:Iw{+1'JI 1• 760 3fi0r47QQ.-__. _ J.1 `_I¢,111J. 11/04/20P8 I CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number: Stroke Recovery Center 0014 Parking Lot ADA Improvements Name/Address of Provider: Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 BENEFICIARY QUALIFICATION STATEMENT This statement must be Completed and signed by each person or head of household (legal guardian) receiving benefits form the described project/activity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters,roomers,or borders cannot be Included as household members. 2- Circle your combined gross annual income(Riverside-San Bernardino,CA—02111105) MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME 1 2 3 4 5 6 7 8 LEVEL VERY LOW INCOME $19,500 $22 250 $25 050 $27,850 330,050 532,300 $34,500 $36,750 Below 50% LOW INCOME $31,200 $35,650 $40,100 $44,550 $48,100 $51.700 $55,250 558,800 51-80/ MODERATE INCOME $46750 853,450 560,100 $66,800 $72,150 $77500 $82,850 $88,200 120% 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 0 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 ETI•INICITY ❑ Yes 0 No If yes,check one: 0 Mexican/Chicano fJ Puerto Rican ❑ Cuban Other. 4. Are you female Head of Household? ❑ YES ❑ NO 5. De you have a disability? ❑ YES 0 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 infonnadon you provide on this form Is Confidential and is only uhlized for Community Development Block Grant(CDBG)program purposes, a Federally-funded program governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT F Semi-Annual Program Progress Report Project/Activity Title: Project Number: Stroke Recovery Center 0014 Parking Lot ADA Improvements Name/Address of Provider. Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 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 While Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/Afncsn 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 EXHIBIT F Request for Reimbursement Project/Activity Title: Prolec�t Nu_mbeF: Stroke Recovery Center 0014 Parking Lot ADA Improvements Name/Address of Provider-- Stroke Recovery Center 2800 E Alejo Rd Palm Springs, CA 92262-6253 BENEFICIARY QUALIFICATION STATEMENT Approved current Prior Total Grant �escrlptlon Grant, Reimbursement Reimbursement Yio Balance Amount Period Period(s) Reimbursement (Over/,under) TOTAL �IE= I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CDeG, 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. 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. 2762-2762-5;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 S2,000.00 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 PROVIDERS subreclpients 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 vdth 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 COBG- 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 protect 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 paint hazards'), housing construction, or other public construction protect 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 doncems 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.