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HomeMy WebLinkAbout05461 - PALM SPRINGS SUNUP ROTARY FOUNDATION SHOES THAT FIT SUBRECIPIENT AGR CITY OF PALM SPRINGS CONSOLIDATED PLAN ANNUAL PLAN UPDATE 2007 - 2008 FUNDING SUMMARY: The City received Request For Proposals (RFPs) from nineteen (19) funding requests totaling $1,215,727, compared to 15 proposals received last year,totaling $795,023 in requests. The following chart illustrates the proposed allocations of CDBG funds expected to be available during the FY 2007 - 2008 period in the City of Palm Springs. For specific project details, i.e., project description, location, proposed benefits, refer to attached tables- `Listing of Proposed Projects'. This coming fiscal year funding consists of$517,881 in new entitlement funding. The total funds available for the 2007 — 2008 Fiscal Year, by authorized category of basic eligibility, are: Public Facilities & Improvements...........................................................-----$336,623." Public Services........................ 7$ 7.68?-" TOTAL PROGRAMMATIC FUNDS-...........................................................$414,305, ADMIN (includes Citizen Participation & Fair Housing) ------------------------- 10$ 3,576.`"• TOTAL CDBG 2007—2008 ENTITLEMENT-------,--,-„--------------------------------$51, 7.8 Public Facilities & Improvements will also be partially funded with program income and the reprogramming of unexpended activity funds, both from prior years and current. Public Service is calculated at 15% of new entitlement funding. " Administration is calculated at 20% of new entitlement funding. 1 t The following chart indicates the specific strategy (as referenced in the 2005 — 2010 Consolidated Plan' Strat'{egic Plan Goals), to which the proposed allocation relates. Family29,744, YMCA efftoy Desert ments _. ..... .—__ ,... �. GCA 9�--__.- - ' L yii?�L �\b Nan-Hsn CC 1 �f� Pal 1l! neem�lg- Non=Hsng CID &3 96,879. � CiBese�rt-htB9. ro �___ ., . (p nrivP Skrr}1rp�Brpy u�� �1eci"- Non-Hsng CO 7 r ---- -J Pe1m-9prinega-0eparyuu�S-r3fi P=r��R-ReC�==r^�+-. Nan-Hsng CD 1 95,000 i� Jarneser s'sle'Bcs'cnt Highland Unity Center Energy-Etfciency Improvements Ar 1'rGr Mizell Senior Center Nan-Hsng 1 27,200, �T-rJ I Meals On Wheels&Outreach Hybrid Vehicle Court Appointed Special Advocates For Riverside County, Inc.- Non-Hsng 1 15,000 5 P Rotary mis 1 Support Program H Palm Springs Sunu Rota Foundation- �� �� Non-Hsng 1 15,482 §��Res That Fit mun R Smile Earl Childhood Oral Healthcare of the g 19,000. F_ i Hoesin uM- ivYerside - -- --Hsn sn 1 P Ear Factory for Children ea Desert- - No 15,000. ry n-H 9-eo-- Lnf$$_ ----- -- ---- 9 PBS-9epBitrnent-of�o�tlgmic Development- n/a 75,833, ,,,,,,_ a14Preg_ ___ hzen Participation ram7ttlrrnrriatlaGmrBr•C..i .....--°--'-'----------------- ------� ,..._,.�.�� . . . rLS.L;ipiar i� mm;ly ty Economic Development- Na 12,743. mdiraat�wogram-Ad�ninislration Costs TOTAL FUNDING Annual Allocation) $517,881. Hsng = Housing Goals Hmis= Homeless Goals Non-Hsng = Non-Housing Goals Non-Hsng CD = Non-Housing Community Development Goals CaleC/CDBG07-OB/AnnlPlnFndngSumry May07 SUBRECIPIENT AGREEMENT f THIS AGREEMENT (herein "Agreement"), is made and entered into this day ofJ �I 200 6y 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 et sec.), as amended from time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et seMc. ("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 2007 — 2008 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the organization's most recent charitable trust report to the Attorney General, or other financial information satisfactory to City's Finance Director. The financial information provided for in this paragraph shall be furnished not later than January 31st of the current fiscal year. � 7 a'uGv�4 prlD ' S 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 SIXTEEN THOUSAND FOUR HUNDRED & EIGHTY-TWO DOLLARS ($16,482.00) (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: [2Oee a-c GIN KOL�) At- <rXccr—i 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 - 2 - L may be required by the regulations of the Housing and Community Development Act, but in no case for less than five years after the close of the program. 4.2 The Provider certifies it shall adhere to and comply with the following as they may be applicable. (a) Submit to City through its Community and Economic Development Department 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 Q); (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 G.F.R. 570, Subpart K, except that the Provider does not assume the City's environmental responsibilities described at 24 G.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 I (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 etM.), (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 underthis Agreement. 5.0 INSURANCE AND ] DEMNIFICATION- 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 Aaainst Discrimination. Provider covenants that, by and for itself, its heirs, executors, assigns, and all persons claiming under or through them that there shall be no discrimination against or segregation of any person or group of persons on account of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, pregnancy, marital status, age, sex, sexual orientation, or any other basis Protected Characteristic by applicable federal, state or local law in the performance of this Agreement. Provider shall take affirmative action to insure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, physical or mental disability, national origin, ancestry or any other basis Protected Characteristic by applicable federal, state or local law 6.2 Term. Unless earlier terminated in accordance with Section 6-3 of this Agreement, this Agreement shall continue in full force and effect until completion of the services, but not exceeding one (1) year from the date hereof. 6.3 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder except as may be specifically approved by the Contract Officer. Provider shall be entitied to compensation for all services rendered prior to receipt of the notice of termination and City shall be entitled to reimbursement for any services which have been paid for but not rendered. 7.0 MISCELLANEOUS PROVISIONS. 7.1 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party shall be in writing and either served personally or sent by prepaid, first-class mail to the address set forth below, or such other addresses as may from time to time be designated by mail. TO CITY: City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Manager - 5 - WITH COPY TO. City of Palm Springs 3200 East Tahquitz Canyon Way Palm Springs, CA 92262-6959 Attn: City Attorney TO PROVIDER: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92264-0310 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 - J , - CITY OF PALM SPRINGS ATTE = a municipal corporation By: B ity Jerk b7/2�/,��DO City Manager APPROVE] OF7ORM: APPROVED BY CITY COUNCIL By: i d �1 City Attorney r PROVIDER: Check one: J Individual —Partnership " Corporation (Corporations require two notarized signatures: One signature must be from the Chairman of Board, President, or any Vice President. The second signatur�mrrst from the Secretary, Assistant Treasurer, or Chief'Iin vial O�cer). By et ry Trea urer, sistant B� Notarized Signature Ghairma of Board, Notarized Signature Secretary, Asst Secretary, President or any Vice President Treasurer,Asst Treasurer or Chief Financial Officer Name: At k'Elu SM ooT Name: 17019e1M 19,d1co� Title: f2C ,,oa-r.o Title: C1atLF Frll�A�cirr OFFr�ra State of �A"FoRr•A �ll Stateof �a-`FPRwA f County of 1A U EM1S.o� Iss County of E ss On 4 �,`1 10, toe •7 before me On -�V Ly4 0 r Zo0� before me, '� pt )3 mkdefl I t✓G ,personally appeared '�' rn J?POde/ I C L ,personally appeared /-ILLIFP S'rd-/aUi personally known personally known to me (or proved to me on the basis of satisfactory evidence) to me(or proved to me on the basis of satisfactory evidence) to be the person(wf whose name(s) islaA Subscribed to the to be the personiX whose name(s) is/av� subscribed to the within instrument and acknowledged to me that helsti lth4 within instrument and acknowledged to me that he/sye/t* executed the sam in hislh,9�ltlir authorized capacity(ieSJ, executed the soma in hislhpflthr authorized capacity(ie ), and that by his/h;f/tvir signature(gj on the instrument the and that by his/h//th/ir signature(K an the instrument the person, or the entity upon behalf of which the person(X person(s�, or the entity upon behalf of which the person((+) acted,executed the instrument acted,executed the instrument WITNESS my hand and official seal. WITNESS my hand and official seal Nita G ,n /�' t ] Notary Signature: /i /!� l�n����;,�;�/ Signature: LG�� Notary Seal: Notary Seal I E.M. BRODERICK E. M. BRODERICK Commisslon , 1736f167 I Cammission • 1736E67 Notary Public -California Notary Public -California Riverside County Riverside County WCOM.80 Apr3,2011 MYCaIs11.6�MESApr�,2011 Shoe ThatF4-Suti BppAgnnnt Ju107 -7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Proleat/AativitV Title' ProLect_Number, Palm Springs Sunup Rotary 0007 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92264-0310 O b iectives/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-ta-moderate income students of which two thousand one hundred (2,100) Palm Springs youth who do not have shoes that fit 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 re nested. TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity Objective 2: Establish and maintain a programmatic and financial record keeping process. TARGET DATE ACTIVITY#1 On-Going Establish and maintain an efficient program process/procedure for proper record keeping. Set-up a filing system for CDBG files only Document and maintain all records related to this program in a stable and secure location. Objective 3: Advertise, market and publicize the program to facilitate positive promotion for all parties (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 two thousand one hundred (2,100)- Palm S rin s outh with new access to this service 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: Establish New and/or Expanded Services for Seniors, At-Risk Youth, Severly Disabled Adults, and Special need Population. TARGET DATE ACTIVITY#1 On-Going Conduct program activities to improve availability/accessiblity, 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 (i.e., clerical, monitoring, etc ) CITY OF PALM SPRINGS EXHIBIT B Budget Summary Project/Activity Title Proiect_Number• Palm Springs Sunup Rotary 0007 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd Palm Springs, CA 92264-0310 BUIDGETSUMMARY_ . COST CATEGORY CDBG OTHER TOTAL SHARE SOURCES COST 1 Personnel $ 2 Consultant/Contract Services $ $ 3 Travel S $ 4 Space Rental S 5 Consumable Supplies $ 6 Rental, Lease or Purchase $ of Equipment 7 Insurance $ 8 Other— Hi her Education Scholarships Bicycle Program Shoes That Fit Program $16,482. $35,000, $51,482 $7.84 per student Pre-K & K Back Packet Program TOTALS $16,482. $42,000. $51,482. "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 totaling $35,750. The Subrecipient shall submit Request for Reimbursement in accordance with the aforementioned cost categories. The program will pay for$7,84 per Palm Springs' student, not to exceed $16,482. In no quarter shall the Subrecipient submit for reimbursement more than 1/4 of the total annual budget. Payments, approved by the Subrecipient, shall be paid by the 30�h day of each month, provided that the payment application has been submitted to the City on or before the first working day of the month. Services are to be performed over the twelve-month period of this 2007-08 Program Year — July 1, 2007 through June 30, 2008 CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Prolect/Activity Title: Protect Number: Palm Springs Sunup Rotary 0007 Shoes That Fit Program Name/Address of Provider: Date: Palm Springs Sunup Rotary Foundation 1999 S Caliente Rd J u u-t tO zo o� Palm Springs, CA 92264-0310 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company American Home Assurance Company Effective Dates of Policy 7/1/2007 to 7/1/2008 Claims Made Policy / / Per Occurrence Policy, / V1 Limits of Liability $5,000,000 Deductibles: Per Occurrence N/A. Annual Aggregate N/A Additional Insured Endorsement (Certificate Holder) 0 Yes © No Original Certificate of Insurance Attached ❑ Yes d No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company_ N/A— Exemption Attached Effective Dates Limits of Liability Underlying Coverage Limits Original Certificate of Insurance Attached ❑ Yes ❑ No ACO.W. CERTIFICATE DF LIABILITY INSURANCE ° ;°'" .noaleert LOCK FQN CCMPAME$,LLC TNI9 OE IFtCATE is Isme0 ASA MATTER OF INFOW1411 525 W.MOlroe,Sllne 800 RONLY EpAND TH15COCMRS G KO RIGHTS N6 MXTE IFND O31 CWCJIOO IL 91681 (31�)BB1v900 INSVRERS AFFORPiNii covanAOE nmugce AN Aatka USA A. Arurican Hom°AeAu[aaccCz>m �Y q�18 d W hiss Alin;pick"Aragw"Mi Cvpnftwl iE1S!9 ,, Inio°is National bj�Coin ISM sheneen Ave, o• Ev.NM IL MMI-269 N Rgs n EP[• Vr: clxryCA F1 iM $3�` C IVPr A vfi W 1 MAY RECI[CIIIkEMENT, TERM OR CONOITIONOF ANY ODNTAAcr OR OTHER oomwM w RIiFI RESPECT 70 WHICH CERnF1CAIMICA E mD.y BE iJ9D O MAY PERTAIN•THE IN6Vw WE AFFT]gnm pT TlE P0.CIE9 OESMMED RPAEN is HVRLJ'r TO ALL TNCTFAM9,!%[LN800 AND CO MON6 OF WCH Pau E9-A 5P4EGAT2LINI WN MAY M4VE9 RECUCEB AV P CLA etww.iLeluTr 1 Q�7 AJ=TPcuLeam�awmm aNl xACe �cuA GL7Z181t3 7/1r2007 7/1/2008 ul u on oan a h1A l rmp PER 1 X pay o S1C110R LIIHILfiY { Rk=U Am rLR NN¢1Y A Aarp r.wm91N°LEuIAn , 1,000,000 ALL°WHm AVIa@ aOER=AVTM M1218113 7/1/2007 7/1r2008 X NRO1 AU X NO¢pµTdFa Atlri9 i�.Y.le Y XXIDD+= AgOE[¢TlgMtlai ! 7000OdOC IPMMtlCaM AlnAvm NOTAPPL1CA818 ' MCEM A LnT' IJInH dCCNRi6wCE . s 6 X omn DcwWr m BE 7235491 7[112007 7/V2D0B S 0 ue.au 3OLCQC Y aWUC[91a IOIY X tom y eerer+rml P , 1WRIM v GCF FF AT WA NOT AFRUCAELE wxarAas•Aueartv XXXXXXX er_lACH ACCgLTR . va olseue. e . EL MI6 M-Pa um I a ZQDC QCt mein elvcavrlox o!o.a¢nnnn.eAnnaTK410YlNG8atalamaw¢o¢v W W N.L4RIVPL4lFnWluole The certificate holder is included as Addidonal Insured where required by a written contractor 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 pan by the acts or omissions of the insured. •�""'"^^"'^ ^*•* '•••'••• clUffIN ■ City of Patin Springs vevcwA nrTw AeOYeo MEJap MgcA kmxlayPv The urw,nON P,O. 9Ox 2743 OAT!TllEPCG,TH!�xo.wnel Wa �WP�o.ws eAye Tvlmp Patin Springs,CA 92262 noTKa To rw ccMMIOAT!Hol.me wuanTo THc li T,puT Pu WnlTp Do ao.e.0 Attn:City Clerk r•pwk as anwATion os NAennvw ANvltleo wa¢rHe runpvR,ITs 4aEN1a on POMf'UffaTNGS ACCM025-B plsn — a ACORO COReORA-VION i9.e ExemptionCertificate of . Workers' 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 ❑.safe proprietor ❑ partnership ® QkW4122yh corporation NoN - PrzoF.f and do not have any employees whose employment requires me to carry workers' compensation insurance. Therefore, I do not carry workers' compensation insurance coverage. I 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 Springs harmless from loss or liability which may arise from the failure to comply wit 7ny or regulations. Risk Management Approval: Contractor Signature 1W Qj�R� �lfl iCPc+7 Printed Name of Contractor Bate Date CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number Palm Springs Sunup Rotary 0007 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 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—03/20/07) MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME 1 2 3 4 5 6 7 8 LEVEL VERY LOW INCOME $20 700 $23,700 $26,650 S29 600 S31 950 S34 350 $36,700 $39,050 Below 50% LOW INCOME S33150 S37,900 S42,600 S47350 S51,150 $54,950 $58,700 $62,500 51 —80% MODERATE INCOME $49.700 $56,800 $63,900 $70 000 $76 700 $82,400 588,000 S93,700 120% 3. What race/ethnicity do you identify yourself as; please note that this self-identification is voluntary in accordance with equal opportunity laws? ❑ White ❑ American Indian/Alaska Native AND White ❑ Black/African American ❑ Asian AND White Asian ❑ Black[Afncan American AND White 0 American Indian/Alaskan Native 71 American Indian/Alaska Native AND Black/Afrimn American ❑ Native Hawaiian/Other Pacific Islander ❑ Other Multi-Racial HISPANIC/ATINO ETHNICITY ❑ Yes ❑ No If yes,check one D Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: 4. Are you female Head of Household? ❑ YES ❑ NO 5. Do you have a disability? ❑ YES r-I 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 information you provide on this farm is confidential and Is only utlllzed for Community Development Block Grant(CDBG) program purposes, a Federally-funded program governmental reporting purposes to monitor compliance CITY OF PALM SPRINGS EXHIBIT E Semi-Annual Program Progress Report Proiect/Activity Title: Proiect Number: Palm Springs Sunup Rotary 0007 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 0-50%below 51-80%below 120% below • Number of First-Time Female Headed Households: • Counts by Race/Ethnicity: White _ American lndan/Alaska Native ANDWhite Black/African American Asian AND White Asian Black/African American AND White 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 Request for Reimbursement Proiect/Activity Title: Project Number: Palm Springs Sunup Rotary 0007 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 A raved current , Prior Total Grant Pp boserlption Grant, Reimbursement Rolmbursemant YTb Balance Amount Period Period(s) Raimb�rsement (Overt Under) Shoes That Fit Program $16,482, ($7 84 per student) TOTAL $15,482 I CERTIFY THAT, (a) the City of PALM SPRINGS, as grantee of the CD8G, 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 shest(s) must be attached detailing cost breakdowns, and verified by original signatures.