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HomeMy WebLinkAbout05265 - PALM SPRINGS SUNUP ROTARY FOUNDATION CDBG SUBRECIPIENT AGR October 18, 2010 PS Sunup Rotary Foundation Re: Certificate of Insurance REMINDER 02 City of Palm Springs Agreement No. A5265 Dear : During a review of the agreement file, it has been noted there are discrepancies relating to the certificate of insurance on file as listed below: The General Liability policy expired on 07/01/2007, Please contact your insurance office and request a current Certificate of Insurance be emailed to Kathie.Hart@PalmSpringsCA.gov or sent to: Kathie Hart, CIVIC Office of the City Clerk City of Palm Springs P. O. Box 2743 Palm Springs, CA 92263 If you fax or email the certificate there is no need to forward a copy via U.S. Mail. This will avoid duplication. Sincerely, Kathie Hart, CIVIC Chief Deputy City Clerk ✓ �\ SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this�7�day of PtPR,� , 2001 by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Palm Springs Sunup Rotary Foundation., (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 at sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et Leg. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed under the Act, and WHEREAS, the Provider is a nonprofit organization which operates a program which is eligible for a grant of CDBG funds and the City desires to assist in the operation of the program by granting CDBG Funds to the Provider to pay for all or a portion of those costs incurred in operating the program permitted by the Act and the Regulations on terms and conditions more particularly set forth herein; NOW, THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF PROVIDER. 1.1 Scope of Services. Provider agrees to provide to City all of the services specified and detailed in its application for funding and Exhibit A, and to conduct all programs specified therein in a manner to reflect credit upon the City and Provider. Provider represents and warrants to City that it is able to provide, and will use funds granted by the City to provide the services represented in the Provider's application for funding. City provided funds shall be used only for those purposes specified in such application. 1.2 Compliance with 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 2006 — 2007 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. 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 FIFTEEN THOUSAND DOLLARS ($15.000.0J (the "Contract Sum") in accordance with the Budget attached hereto in Exhibit B and incorporated herein by this reference; and as herein provided. The budget cost categories set out in Exhibit B are general guidelines and if mutually agreed by both parties, may be amended administratively by no more than 10%, without the requirement of a formal amendment to this Agreement, but in no event shall such adjustments increase the Contract Sum. The Provider shall submit to the City monthly statements on reimbursable expenditures pursuant to the attached Budget along with pertinent supporting documentation. The City shall promptly review the monthly expenditure statements and, upon approval, reimburse the Provider its authorized operating costs. 2.2 Payroll Records. In cases where the contract sum will reimburse payroll expenses as part of operations, the Provider will establish a system of maintaining accurate payroll records which will track daily hours charged to the project by the Provider's respective employees, as set forth in OMB Circular A-122 Attachment B.6. 2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30, March 31, and June 30) shall result in the immediate forfeiture of 25% of the total grant. 3.0 COORDINATION OF WORK. 3.1 Representative of Provider. The following principals of Providers are hereby designated as being the principals and representatives of Provider authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith. fo$C^❑T (3I1.1K0u) Re 51�ooT 32 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 -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 at 41 CFR Chapter 60; (e) Executive Order 11063, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107, (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42, (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570.200 0); (j) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (k) The Program Income requirements as set forth in 24 C.F.R. 570.5021(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 Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et sect.); (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 Properly 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 farm of a loan) in excess of$25,000 is either: (i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or (ii) Not used in accordance with paragraph (s)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (s) of this section.) (u) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers' Compensation laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the -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 parry 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. 7A Notice. Any notice, demand, request, document, consent, approval, or communication either parry desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager - 5 - WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: ?0(3C(z-c &NkeuJ �a0.9 S. CALJENn ALV SP2NGS� C,tr �'Z26U P310 7.2 Amendment. This Agreement may be amended al, 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 ATT - a municipal corporation gy_ B Clerk a��l f �j 200 y City Manager APPROV D !�O FORM:By- APPROVED BY CITY COUNCIL City Attorney k 1 ( 0 �'`u '�� 0 PROVIDER: Check one, _Individual T 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, Treasurer, Assistant Treasurer, or Chief Finarlcta ar). Notarized Signature of Chairman of Board, Notarized Signature Secretary, Asst Secretary, President or any Vice President Treasurer,Asst Treasurer or Chief Financial Officer Name. [M�aV \ s O� Rs�na Name. C2Y 0 Y-OL. Title: Title: e gs�filre—r< State of �ll State of -" v - 1 f County of [ --)SS County Of ./�,&Ie� g l s On 1 F--r r�/'-E�.v_�p before me, On M Y` lr��-F�- � /� O- l�p-7 before me, personally appeared ��j:T� \S\ �l/--.T� personally appeared i v�CA�I�� i�i6G"`�"V�6.�t1 persanstllgimown yC.L1L��` ��1�F—FJ I.I� pecssr�eHq•knvwrr tome(or proved to me on the basis of satisfactory evidence) turns (or proved to me on the basis of satisfactory evidence) to be the person(s)•whose name(t isla subscribed to the to be the person(&)-whose name(s)-is/ar subscribed to the within instrument and acknowledged to me that hePshe/they- within Instrument and acknowledged to me that he/skelgloy executed the same in 4494ber/there authorized capacity(aes), executed the same in hislhs4tt4eir authorized cepacity(Aas), and that by iTF herkheir signatures) n the Instrument the and that by his/heNtheir signature(&&}-on the instrument the person*, or the entity upon behalf of which the person(-+} person(&),or the entity upon behalf of which the person(%}- acted,executed the instrument. acted,executed the instrument. WITNESS my and a7�office Ise WITNESS my ha and official seal Notary r An Notary Signature: 4' l Sgnature. ' f Notary Seal: Notary Seal: &V M T. GARRETT +ARI.FI T. G4RRETi Can'imlwlan#1693110 � Commission M 1 ETT zz Notary CdfaNp ;-� Notary Public - California 5 RlvatsIola Riverside County MyCowin.EXPI lSyp11,2010 MyComm Expires Sep11 2010 Shoes7hatFit SubrecipAgrmnt Juloc -7- CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proiect/Activity Title-- Proiect Number: Palm Springs Sunup Rotary 0005 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92284-0310 O b I ecti yes/Activities The intent of this program is to provide shoes to elementary and middle school students in the Palm Springs Unified School District. It is an innovated program which School Personnel distributes to needy students in the Free and Reduced Federal Lunch Program. The program will serve seven thousand (7,000) very low-to-low income students of which two thousand one hundred (2,100) Palm Spring youth who do not have shoes that Ft properly which is having a negative effect on their learning achievement. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping process TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only. Document and maintain all records related to this program in a stable and secure location Objective 3: Advertise market and publicize the re ram to facilitate positive promotion for all parties (Le., Provider, City. CDBG, etc.). TARGET DATE ACTIVITY#1 On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun. Submit final publication to City. Objective 4: Enroll and income gu_a_lifies at least an approximately two thousand one hundred (2,100) _Palm Sprino youth. 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 01 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 Monthly Submit semi-annual reports—referenced Exhibit E. Objective 6: Managelmonitor 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 emergency housing services including motel vouchers to homeless individuals,. as outlined in proposal. TARGET DATE ACTIVITY#k1 On-Going Conduct program activities, as stipulated in the proposal Objective 8: Provide an evaluation within fifteen (15)calendar days of the program_ completion or final reimbursement. TARGET DATE ACTIVITY#1 07/16/02 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (i.e., clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Proiect/Actiwty Title. Proiect Number: Palm Springs Sunup Rotary 0005 Shoes That Fit Program Name/Address of Provider, Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92264-0310 _ 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— Sum $1,000, Higher Education Scholarships $1,000. $1,000. Bicycle Program Shoes That Fit Program $15,000. $38,000. $53,000, ($7.14 per student) $2,000, $2,000. Pre-K & K Back Packet Program TOTALS $15,000_ $42,000. $57,000. 'If costs are to be shared by other sources of funding, including CDBG funds from other jurisdictions, identify the source of funding, grantor/lending agency, and cost category information. Other funding sources primarily are Agua Caliente Band of Cahuilla Indians, PS Sunup Rotary Club, PS Regional Association of Realtors and Individual Donors. The Subrecipient shall submit Request for Reimbursement in accordance with the aforementioned cost categories. The program will pay for$7,14 per Palm Springs' student, not to exceed $17,790. In no quarter shall the Subrecipient submit for reimbursement more than Y4 of the total annual budget. Payments, approved by the Subrecipient, shall be paid by the 3& day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. Services are to be performed over the twelve-month period of this 2006-07 Program Year — July 1, 2006 through June 30, 2007. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Preiect/Activity Title: Project Number: Palm Springs Sunup Rotary 0005 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd z^p.f n Palm Springs, CA 92264-0310 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company GI?-EAT f�µr-1L%C AP Cc, Effective Dates of Policy -71 k_[Z oo , Claims Made Policy / / Per Occurrence Policy /x/ Limits of Liability b, 500, 000 _ Deductibles: Per Occurrence Annual Aggregate " Additional Insured Endorsement (Certificate Holder) ❑ Yes u No Original Certificate of Insurance Attached %Yes u No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company r �p Effective Dates Limits of Liability Underlying Coverage Limits Original Certificate of Insurance Attached ❑ Yes o No ACORDT CERTIFICATE OF LIABILITY INSURANCE 04/27/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LOCKTON COMPANIES,LIC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 525 W.Monroe,Suite C0 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR CHICAGO IL 00561 AF I (312)669.69DO INSURERS AFFORDING COVERAGE INSURED All Active US Rotary Clubs& INSURERA Grcat American Insurance Co. meni ls Attn:RRiskMBnaOemenl PBpanrtmenl INSURER B Wcstches[cr Fite Insurance Co. 1560 Sherman Ave. INSURER c EVanslon IL 00201.3698 INSURER D INSURER THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING COVERAGES 1 IRERS AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER 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 ODCUMENT WITH RESPECT TO WHICH TI.115 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONQITIONS OF SUCH PCLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN'0 POLICY EFFFLTIVD POLICY EXPIRATION TYPE OF INBUFlANCE POLICY NUMBER _ onTe rnnn LIMITS r GENERAL LIABILITY NCH OCCURRENCE 1 1000 000 A X COMMERCIAL GENERAL LIAWLI-Y GLP9251830 07/01/2006 07/0 U2D07 PIPE DAMAGE,(Any am Prn) 1 1 000000 CLAIM5 MADE � OCCUR MED ExP An ono rrry 1 XXXXXXX PEMO A A ADv INauRY s 1000 000 GENERALAGG ELATE $ 1500000 BEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AO G v 1.000.000 1 X JPEcOT LOC UOUOR LIABILITY $ WCLUDEO AUTOMOBILE LIABILITY COMBINED SINGLE OMIT y I,000,000 A ANY AUTO OLP925I B30 07JOI12006 07/01/2007 IEn nnddrnt) ALL OWNED AUTOS BODILY INJURY y XXXXXXX SCIIGOULED AUTOS IPpr pore--) X HIREDAUT05 BODILY INJURY m xxxxxxx X NON-OWNED AUTOS (For ucclJent) PROPERTY DAMAGE y X=XXX (Per ucciden) .SARAGE LIA014HY AUTO ONLY•EA ACCIDENT I XXXX2x ANY AUTO NOT APPLICA➢LE OTHER THAN _gahDr y XXXXXXX AUTO ONLY. AGO $ XXXxxxx EXCESS LIABILITY EICFI OCCURRENCE P 5,000.000 13 X1 OCCUR ❑CLAIMS MADE 022023032001 07/01/2006 07/01/2007 AnOREBaIE a 5000.000 uManE4u XXX xxxxx DEDUCTIBLE X FOHN XXXX HE I ENTION 4 y XxxxxxX WORKERS COMPENSATION AND NOT APPLICA}3 LE I we GrnlTUMl oiH- EMPLOYERS'LIAP141TY E.L FACH ACCIDENT m XXXXXXX E L PISEAGE•EA EMPLOYE m Xxxxxxx E4 PISEAGE•POLICY LIMIT i xxxxxxx OTHER DESCRIPTION OF OPEHA NONEILOLATIONSNEHICLESl CLU51ON5 ADDED BY ENDORSEMENTISPECIAL FROViEION5 The certificate holder is included as Additional Insured where required by a written contract or permit subject to the terms and conditions of the General Liability policy, but only to the extent bodily injury or property damage is caused in whole or in part by the acts or omissions of the insured. CERTIFICATE HOLDER CANCELLATION City of Palm Springs SHOULD ANY OF TI IE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE THE EXPIRATION P.O.Box 2743 DATE TML9LOF,ThG ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRR EN Palm Springs, CA 92262 NOTICE TO THE CERTIFICATR HOLDER NAMED TO THE LEFT, BUT FAILUnE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Attn:City Clerk JtPHESENTATIVES, AUTHORIZED REPRESENTATIVE ACOSD R5-S(7197) m ACORP CORPORATION 19BO Certificate of Exernption froni • Compensation Insurance TO: City of Palm Springs ATTN. City Clerk and Risk Manager SUBJECT, Sole Proprietor/Partnership/Closely Held Corporation with No Employees Please let this memorandum notify the City of Palm Springs that I am a ❑sole proprietor ❑ partnership ®-closely held corporation (No N F"F, r) and do not have any employees whose employment requires me to carry workers' compensation insurance. Therefore, 1 do not carry workers' compensation Insurance coverage. 1 further warrant that i understand the requirements of Section 3700, et seq., of the California Labor Code with respect to providing Workers' Compensation coverage for any employees. I agree to comply with the code requirements and all other applicable laws and regulations regarding workers' compensation, payroll taxes, FICA and tax withholding and similar employment issues. I further agree to hold the City of Palm Spr rml000e���ss from loss or liability which may arise from the failure to comply - such la re ulations. a✓7►i/�9. Risk Management Approval: Can ra or Signature l?otA?- 'r 12r0Kdw --r UXCL- Printed Name of Contra r 2 �as 9. .r-r� Pam,,, sPiuNar cJ/NUN 9aTtr Y 6A /0,7` Date Date CITY OF PALM SPRINGS EXHIBIT D Beneficiary qualification Statement ProiecUACtivity Title. Prolect Number: Palm Springs Sunup Rotary 0005 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92264-0310 BENEFICIARY QUALIFICATION STATEMENT This Statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described pro)eol/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 boAveers cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA—03108106) MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME 1 2 3 4 5 6 7 8 LEVEL VERY LOW INCOME $20.150 $23,000 $25,g00 $28,750 S31050 $33,350 S35,650 $37,350 Below 50% LOW INCOME $32,200 $36,800 $41,400 $46,000 $49.700 $53,350 $67.050 $60,700 51 -80% MODERATE INCOME $48300 S55,200 $62,100 $69000 $74,500 $80,000 $85600 $91,100 120 3. What race/ethnicity CIO you Identify yourself as;please note that this self-identification is voluntary in accordance with equal opportunity laws? D White ❑ American Indian/Alaska Native AND White ❑ Black/African American ❑ Asian AND White ❑ Asian ❑ BlacIdAfrican American AND White ❑ American Indian/Alaskan Native ❑ American IndianlAlaska Native AND Black/African American © Native Hawaiian/Other Pacific Islander D Other Multi-Racial: HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,oheck one. ❑ Mexican/Chicano LI Puerto Rican r1 Cuban ❑ Other: 4. Are you 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 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) program purposes a Federafiy-funded program,governmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Projeci/Activity Title' Project Number: Palm Springs Sunup Rotary 0005 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92264-0310 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT ♦ Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons 050%below 51-80%below 120% below ♦ Number of First-Time Female Headed Households. ♦ Counts by Race/Ethnicity: White American Indian/Alaska Native AND White Black/African American Asian AND White_ Asian Black/Afncan American AND White American Indian!Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian/Other P201FIC 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 Prolect/ActivitV Title. Project Number: Palm Springs Sunup Rotary 0005 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92254-0310 BENEFICIARY QUALIFICATION STATEMENT Approved Current Prior Tota, ( Grant ) Description Grant Reimbursement Reimbursement YTP Balance FAmount Period Periods Reimbursement Over/Under TOTAL 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 Pan 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 Exarnlned by. Approved by: If necessary, additional sheet(s) must be attached detailing cost breakdowns,and verified by original signatures.