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HomeMy WebLinkAbout05267 - COACHELLA VALLEY HOUSING COALITION COYOTE RUN AFTER SCHOOL PROGRAM SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this day ofi—bile., 2001 by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Coachella Valley Housing Coalition , (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 at 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 Providers application for funding. City provided funds shall be used only for those purposes specified in such application. 12 Compliance with Law. All services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Reports. No later than ten (10) days prior to any payment date specified in Section 22, within ten (1 D) 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 $2D,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 ($15.000.00) (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: Pedro S. G. 'vdn �e Ch F F na nu�l FF` iG T V ry 1 of VvrL ' S�rUic�S 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 Aqainst Subcontracting or As_si ng ment. 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; (a) Executive Order 11 D63, as amended by Executive Order 12259, and implementing regulations at 24 CFR Part 107; (f) Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and implementing regulations; (g) The Age Discrimination Act of 1975 (P.L. 94-135, as amended, and implementing regulations; (h) The relocation requirements of Title II and the acquisition requirements of Title III of the Uniform Relocation Assistance and Real Property Acquisition at 24 CFR Part 42; (i) The restrictions prohibiting use of funds for the benefit of a religious organization or activity as set forth in 24 CFR 570200 0); 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 Vill of the Civil Rights Act of 1968 (P.L. 90-284) as amended; (r) The lead-based paint requirements of 24 CFR Part 35 issued pursuant to the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 atseec.); (s) Maintain property inventory system to numerically identify HUD purchased property and document its acquisition date as is set forth in OMB Circular A-110 Attachment N Property Management Standard 6d; and (t) Reversion of asset. Upon the Expiration of the agreement, the subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. Additionally, any real property under the subrecipient's control that was acquired or improved in whole or in part with CDBG funds (including CDBG funds provided to the subrecipient in the form of a loan) in excess of$25,000 is either: (i) Used to meet one of the national objectives in Section 570.208 (formerly Section 570.901) until five years after expiration of the agreement, or for such longer period of time as determined to be appropriate by the City; or (ii) Not used in accordance with paragraph (s)(i) above, in which event the subrecipient shall pay to the City an amount equal to the current market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for the acquisition of, or improvement to, the property. The payment is program income to the City. (No payment is required after the period of time specified in paragraph (s) of this section.) (u) Such other City, County, State, or Federal laws, rules, and regulations, executive orders or similar requirements which might be applicable. 4.3 The City shall have the right to periodically monitor the program operations of the Provider under this Agreement. 5.0 INSURANCE AND INDEMNIFICATION. 5.1 Insurance. The Provider shall procure and maintain, at its cost, and submit concurrently with its execution of this Agreement, public liability and property damage insurance against claims for injuries against persons or damages to property resulting from Provider's acts or omissions arising out of or related to Provider's performance under this Agreement. Provider shall also carry Workers' Compensation Insurance in accordance with State Workers' Compensation-laws. Such insurance shall be kept in effect during the term of this Agreement and shall not be cancelable without thirty (30) days' prior written notice of the proposed cancellation to City. A certificate evidencing the -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. 62 Term. Unless earlier terminated in accordance with Section 6.3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1)year from the date hereof. 6.3 Termination Prior to Expiration of Term. Either 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. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other parry shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager - 5- WITH COPY TO: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Coa�hello.Valle }logs n 1��-rare - o onrck SMe -k G lo A,D., CTj 57-Z01 7.2 Amendment. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. [ End —Signatures on Next Page] - 6 - CITY OF PALM SPRINGS ATT T- a municipal corporation Bev / Ci Clerk QI 2 '112D07 City Manager APPROV (� TO FOR - APPROVED APPROVED By CITY COUNCIL By. City Attorney/ PROVIPBR: 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 sigramust be from the Secretary, Assistant Secretary, Treasurer, Assistant Treasurer, or Chil Officer). sy: . C/iP/✓ ^ ram-/. . By: Notarized Signature of Chairman orB rd, Notarized gnature Secretary, Secretary, President or any Vice President/ Treasurer,Asst Treasurer or Chieff Fin Officer Name: Lawrence A. Cox Name: Jerod Pannel Title: Board President Title: Board Secretary State of :zsl rev - = Stale of eaQiky lido = County of 12GfeY5idLt -ss County of,'L&levstrLr_ -ss Off,�n11 (a I I'-{1D, before me, o1nl Le 1 ICI IOy before me, `�+�r:"V_xd_l Ae'JAZ ,personally appeared 1 6m err+ f--1LLV)c,.L_L ,personally appeared LosjyP"C2 Fl.l='d( J,(. persrnralty-Imown jeyc^A tQ elell pefsar+all e;wn to,seie-(nr proved to me on the basis of satisfactory evidence) tooma or proved to me on the basis of satisfactory evidence) to be the person(&) whose name( islaw subscribed to the to be the person*whose name( Is/arasubscnbed to the within instrument and acknowledged to me that hela4a4hoy within instrument and acknowledged to me that he/stregbriy executed the same in his/hnF4hna authorized capacily(iac), executed the same in hisAerHheir authorized eapaeay¢es), and that by hislpennihesr signature*) on the instrument the and that by hisAwK44eir signature(d on the instrument the person(r4, or the entity upon behalf of which the person(&{ person(ej, or the entity upon behalf of which the person(6) acted,executed the instrument. acted,executed the Instrument. WITNESS my hand and official seal. WITNESS my hand and official seal. Notary �//�� Notary • . Signature -e_ L �' Signature: � Notary Seal: Notary Seal: ,MARTHA MENNEZ - MARTHA MENDEZ Comm.k1479041 ry� �p ' Comm.111479041 �e N NOTARY PUBLIC-CALIFORNIA UI f NOTARY PUBUG-CALIFORNIA N Rlvorsurn Cvunh Riverside County My Comm.Expires Comm.Expires Ma 26,ypCAM My Comm.Expires MamhA,200E�+ CVFIC_5U6recipAgnnnt-ACA_Rol Ju106 7_ CITY OF PALM SPRINGS EXHIBIT A Scope of Services Project/Activity Title: P_rolect Number. Coachella Valley Housing Coalition 0007 Coyote Run After-School Program Name/Address of Provider: Date: Coachella Valley Housing Coalition 3601 N Sunrise Way Palm Springs, CA 92262-9711 O b i ect ives/Activities The intent of this program is to expand and improve Coyote Run Apartment's after-school tutoring and computer class program for their development and the adjacent Santiago Sunrise Village Mobilehome Park with both are affordable housing developments. The program will serve forty-five (45) very low-to- low income Palm Springs youth. The Provider shall be responsible for the completion of the following abjectiveslactivities 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 reouested. 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 oositive 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 qualifies at least an approximately forty-five (45) Palm Spring 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#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location. ACTIVITY#2 Monthly Submit semi-annual reports—referenced Exhibit E. Objective 6: Manage/monitor 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#1 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 07/15/02 Provide an evaluation and final report on all programmatic and financial activities. General Administration Provide the management oversight and leadership to address specific operational tasks in meeting the established performance levels, as well as perform supportive activities (Le,, clerical, monitoring, etc.) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Praiect/Activity Title: Protect Number Coachella Valley Housing Coalition 0007 Coyote Run After-School Program Name/Address of Provider. Date: Coachella Valley Housing Coalition 3601 N Sunrise Way Palm Springs, CA 92262-9711 ;«•;r„ i�•,.,i, .,,,„i,IRn ,.,.:u� , i}.. • �:_'B,LIAGET'SU,MMARY. i.r ,,i., ..,r i ar ,i ' COSTCATEGORY CDBG OTHER TOTAL ' SHARE SOURCES COST 1 Personnel S $ 2 Consultant/Contract Services $ 3 Travel $ 4 Space Rental $ 5 Consumable Supplies $ 6 Rental, Lease or Purchase $6,000. $ of Equipment 7 Insurance $ 8 Other— $15,000 $ $15,000 Scholarships - $333.33 per youth TOTALS $15,000, $6,000. $31,000. *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. The Subrecipient shall submit Request for Reimbursement in accordance with the aforementioned cast categories. The program will pay for $333.33 per Palm Springs' youth, not to exceed $15,000. In no quarter shall the Subrecipient submit for reimbursement more than '/ of the total annual budget. Payments, approved by the Subrecipient, shall be paid by the 30th day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. Services are to be performed over the twelve-month period of this 2006-07 Program Year — July 1, 2006 through June 30, 2007. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Project/Activity Title: Project Number: Coachella Valley Housing Coalition 0007 Coyote Run After-School Program Name/Address of Provider: Date: Coachella Valley Housing Coalition 3601 N Sunrise Way Palm Springs, CA 92262-9711 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company &Gi eS ee k T11SU rayIre Effective Dates of Policy loll ocg — it) 8109 Claims Made Polic Per Occurrence,Policy 10118/0CP Limits of Liability 0m ccn (QQ61 oc uv rw ce) ,2 o00 oc0 Ccsevle,-aQ �5gre5a ) Deductibles: Per Occurrence liDCQ.Coo Annual Aggregate—A =2 bOC7 Additional Insured Endorsement (Certificate Holder) e/Yes ❑ No Original Certificate of Insurance Attached dyes ❑ No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company Gales Creek _-Fv�surayl(C Effective Dates I n 10 0lo AD 10110 1 0—1 Limits of Liability p e Underlying Coverage Limits 1 ow Cx]b Original Certificate of Insurance Attached VYes ❑ No A-C-QEPN CERTIFICATE OF LIABILITY INSURANCE 1 06/(15/2 07 PRODUCER (503)227-0491 FAX (503)227-097,7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Gales Creek Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 800 NW 6th, Suite 335 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER-THE COVERAGE-AFFORDED BY THE POLICIES-BELOW,- - - - Portland, OR 97209 INSURERS AFFORDING COVERAGE NAIL S INSURED The Coachella Valley Housing Coalition INSURERA Navigator Insurance Company (CR ) INSURERS Great American Insurance Compan 45-701 Monroe St. , Ste. G �INSURERD RERC. Unigard Insurance Company Indio, CA 92201 State Compensation Insurance Fu d RER 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 SUCPI POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSk DO WIPEOFINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIkAPON LIMITS cENERALLIABLLITY CE06CGL005001-01 10/18/2006 10/18/2007 FACHOCCURRENCE -S-1�000�QQQ X COMMGRCIAL GENERA4LIAB1UTY DAMAGE TO RENTED g SD 000 CLAIMS MADE L X J OCCUR MED CXP(Any one Poraon) 5 Excluded A PERSONAL a ADV INJURY S 1,000 000 GENERAL AGGREGATE 5 2,000,000 GEN L AGGREGATE OMIT APPLIES PER PRODUCTS-COMP/OP AGG S 2,00,000 X POLICY jTOE AUTOMODILE UABILAC 653 61 21 05 10/18/2006 10/18/2007 COMBINED SINGLE LIMIT y ANY AUTO (Ea accident) 1,000,000 ALL OWNED AUUTO PD[ $35,000 BODILY INJURY $ scHEDULEDAUNY ONE VEHICLE (Per Peron) B X HIREOAUTOSTO A $100 COMP BODILYMUURY 5 X NO AU #500 COLL DED. (Poeccident) X Hired Au PROPERTY DAMAGE 5 (Pe/accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5 ANYAUTO OTHER THAN EA ACC 5 AUTO ONLY AGG $ EXCESSNMBRELIA LIABI4ITY EACH OCCURRENCE OCCUR CLAIMS MADE AGGREGATE S 5 DEDUCTIBLE 5 RETENTION S ~` $ WORKRRS COMPENSATION AND 046-0015783-05 10/10/206 101/10/207 WCSTATU- I OTH• EMPLOYERS'LIABILITY MIT q FIR EL EACH ACCIDENT 5 1 000,00 D ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERR EXCLUOSOP EL DISEASE-EA EMPLOYE S 1,000,000 If you Oeaenbe cnbe under SPECIAL PROVISIONS below ELDISCASE-POLICY LIMN 15 1,000 DO C t Eipment PX 006460 10/18/2006 10/18/207 $75,000 limit ! $1,000 Deductible %ESCRIPTION OF PERAT1ONSILOcAT1ON5l V�HIGLES/,�cCW514NS ADDED VI(NOORSEMENT/SPECIAL PROVISIONS e- City o Palm Springs, its oTTicialS, employees and agents are named as an Additional Insured or any and all work performed with the City. This insurance is primary and non-contributory over any insurance or self-insurnace the City may have for any and all work performed with the City. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of Palm Springs BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIDATION OR LIABILITY 3200 E. Tahquitz Canyon OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENYApVE5, Palm Springs, CA92262 AUTHORIZED REPRESENTATIVE //jM Kim Hutchinson/LOUANN ACORD 26(2001/03) ©ACORD CORPORATION 1988 --- IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) POLICYHOLDER COPY SK STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142--0807 COMPENSATION INSURANCE F CERTIFICATE OF WORKERS' COMPENSATION INSURANCE „ ,_ , . ISSUE DATE: 06-05-2007 GROUP: 000045 POLICY NUMEER: 0015783-2006 CERTIFICATE ID: 26 CERTIFICATE EXPIRES: 10-10-2007 10-10-2006/10-10-2007 CITY OF PALM SPRINGS SK 3200 E TAHQUITZ CANYON WAY PALM SPRINGS CA 92262-6959 This is to certify that we have issued a valid Worlcers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period Indwated. This policy is not subject to cancellation by the Fund except upon30 days advance written notice to the employer. VVe will also give you 30 days advance nonce should this policy he cancelled prior to its normal expiration. This certificate of insurance is net an insurance policy and does not amend, extend or alter the coverage afforded by the policy listad herein. Notwithstanding any requirement, term or condition of any contract or other document with respect IQ 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. THORIZ- REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 03-22-2007 SS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2007-06-05 IS ATTACHED TO AND FORMS A PART OF THIS POLICY, THIRD PARTY NAME: CITY OF PALM SPRINGS EMPLOYER COACHELLA VALLEY HOUSING COALITION (A SK NON-PROFIT CORP) 45701 MONROE ST STE G INDIO CA 92201 [RCV,CS] IREV,2-051 PRINTED 06-05-2007 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation,- 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job : $5, 000 . 00 Sample Rate : 13 . 300s Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00!� .Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95) CITY OF PALM SPRINGS EXHIBIT D N rrQualtfi Project/Activity Title: Proiect Number- Coachella Valley Housing Coalition 0007 Coyote Run After-School Program Name/Address of Provider Data.- Coachella Valley Housing Coalition 3601 N Sunrise Way Palm Springs, CA 92262-9711 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 boAveers cannot be included as household members. 2. Circle your combined gross annual income(Riverside-San Bernardino-Ontario,CA MSA—03108106) E N NUMBER OF PERSONS IN YOUR HOUSEHOLD: E 1 2 3 A 5 6 7 8 WE 520,150 523,000 $25,900 528,750 831,050 533,350 535,650 537,350 0%ME $32,200 $36,801) S41,4D0 S46,000 S49,700 $53,350 $57,050 S60,700 TEE $48.300 $55,200 $62.100 $69,000 S74,500 580,000 S85,600 $9110D 3. What race/ethnicity do you identify yourself as;please note that this self-identification is voluntary in accordance with equal opportunity laws? ❑ White ❑ Amencan Indian/Alaska Native AND White ❑ Black/African American ❑ Asian AND White ❑ Asian ❑ Black/Afn=American AND White ❑ American Indian/Alaskan Native ❑ American Indian/Alaska Native AND Slack/African American ❑ Native Hawaiian!Other Pacific Islander ❑ Other Multi-Racial: HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one: ❑ Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: 4. Are you female Head of Household? ❑ YES ❑ NO S. 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 Infonnatlon you provide on this form is eoPfdentlal and Is only utilized for Community Development Block Grant(CDBG) program purposes, a Federally-funded program,govemmental reporting purposes to monitor compliance. CITY OF PALM SPRINGS EXHIBIT E Project/Activity Project/Activity Title: Proiect Number: Coachella Valley Housing Coalition 0007 Coyote Run After-School Program Name/Address of Provider: Date: Coachella Valley Housing Coalition T 3601 N Sunrise Way Palm Springs, CA 92262-9711 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/Alaska Native AND White Black/African American Asian AND White_ Asian — Black/African American AND While American Indian/Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian/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 Pro'ect/Activit Title: Project Number: Coachella Valley Housing Coalition 0007 Coyote Run After-School Program Name/Address of Provider. Data: Coachella Valley Housing Coalition 3601 N Sunrise Way Palm Springs, CA 92262-9711 BENEFICIARY QUALIFICATION STATEMENT ..„rq.i, . ...'.. -...... ^� r�C'�r' ,�^ ''I' praSed' nay .dll'r�t i,ppi ;.a ,biri ..i,;• 'gig ,y,., �.. .h ^eY"ov:'�;,ai.;- 'iGN 'r"+,a �y'I':'' c'7,. rrCA���n�4+r.1, j J'7d.r t,�i�;q4+r'+"Dascr'ptjdri' :.n,^^I,i, "�>i:,l'iG rant' l+;rr;�� ;).R'e-Imtiurscment� �`u(':Rclmbdrsc_m¢ht''[ "''�,1,•x R 9',TD!,. '�'�85tanee L�,;�:���i���� ::i,„ ..,�.:, 1`,."9"., r Hl,n. ,, Ir.' t, a,irrt , c+ i;. - ..,.,.7d • ,; 's.�,. - .,U i n " 'AinounYr ''fIrY ;s'�ri�,, :.F?er,otlfK- .,i parlods= .kauntidr$ement.4, PvailU der), :'laeri;'C�i�l.iiaj'�=,`�h" :Pd. . ... -. ,W:J " ',dr:;j ;.•qu`.r .,,,.,� l, l�` .�,...ir:,ru.. a1, � d.IIG. 71 Marv'. �,:;gi�r:- •ia;l,ry„"i�l ����� �T�O:SAL';%�;9'I'aii`Jtlti,. 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.