HomeMy WebLinkAbout05071 - COURT APPOINTED SPECIAL ADVOCATES (CASA) OF RIVERSIDE COUNTY INC CDBG FUNDING Page 1 of 1
Kathie Hart
From: Kathie Hart
Sent: March 10, 2008 3:18 PM
To: John Raymond
Cc: Dale Cook
Subject: CDBG Agreements
Tracking: Recipient Delivery
John Raymond Delivered! 03/10/08 3!18 PM
Dale Cook Delivered! 03/10/08 3:18 PM
JR
Per our conversation of Friday, March 7, 2008, 2 will close all CDBG Agreements through FY
2005-06, except for the YMCA agreement which I just sent you email on earlier today.
Kathie Hart, CMC
Chief bepaty City Clerk
Cady nr Palm Springs
,32V41 I ihqurV L,mypn Way
P.drri Sprngs Ca 022G2
Wh(e.Hart@palmsprings-cagov
O(lica ( riO)s2d-i32GG
03/10/08
DOCUMENT TRACKING Page: 23
Report: All Active Documents Summary March 10, 2008
Condition: Groups=COMMUNITY& ECONOMIC,ALL Services,ALL XRErs
DOCument ff Descriptign Anproval_Date Expiration Date Closed Date
A5070 CDBG sub-recipient FY 05-06 (Education Programs& Lectures) $15,000 04/06/2005
Company Name: Arthritis Foundation
Address: o„ ,
Group: COMMUNITY& ECONOMIC �1
Service: MIA lC
xRef: COMMUNITY& ECONOMIC �r
Ins. Status: No Certificate on file
A5071 CDBG sub-recipient FY 05-06 (Support Program) $18,000 04/06/2005
Company Name: CASA for Riverside County Inc
Address:
o
Group: COMMUNITY& ECONOMIC
Service: In File
xRef: COMMUNITY& ECONOMIC "
Ins. Status: Certificate and Policies are OK
A5072 CDBG sub-recipient FY 05-06 (Literacy& Summer Program) $10,000 04/06/2005
Company Name: PS Public Library
Address: z1
Group: COMMUNITY& ECONOMIC
ll
Service: MIAr�
xRef: COMMUNITY& ECONOMIC
Ins. Status: NOCERT- Letter printed 03/21/2006.
SURRECIPIENT AGREEMENT
THIS AGREEMENT (herein "Agreement"), is made and entered into this ileday of �,
200U, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and
charter city, and the Court Appointed Special Advocates (CASA) of Riverside County Inc. , (herein
"Provider"),
WHEREAS, the City has entered into various funding agreements with the United States
Department of Housing and Urban Development ("HUD"), which agreements provide funds ("CDBG
Funds") to the City under the Federal Housing and Community Development Act of 1974 (42 U.S.C.
Section 5301 et sec.), as amended from time to time (the "Act"), and the regulations promulgated
thereunder(24 C.F.R. Section 570 et sere- ("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 2005 - 2006 Fiscal Year shall provide to City a -
financial statement prepared by a recognized accounting firm approved by or satisfactory to City's y;
Finance Director completed within the most recent twelve (12) months showing the Provider's financial -
records to be kept in accordance with generally accepted accounting standards. The report shall
include a general ledger balance sheet which identifies revenue sources and expenses in sufficient _
detail to demonstrate contract compliance and be balanced to bank statements. Any organization "
receiving or due to receive less than $20,000-00 in the current fiscal year from the City shall provide a
copy of the organization's most recent charitable trust report to the Attorney General, or other financial -
information satisfactory to City's Finance Director. The financial information provided for in this
paragraph shall be furnished not later than January 31 st 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 EIGHTEEN THOUSAND DOLLARS ($18.000.00) (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 13.6.
2.3 Draw Downs. Failure by Provider to request reimbursement or encumbrance
of at least 25% of the total grant by the end of each fiscal year quarter (September 30, December 30,
March 31, and June 30) shall result in the immediate forfeiture of 25% of the total grant.
3.0 COORDINATION OF WORK.
3.1 Representative of Provider. The following principals of Providers are hereby
designated as being the principals and representatives of Provider authorized to act in its behalf with
respect to the work specified herein and make all decisions in connection therewith:
3.2 Contract Officer, The Contract Officer shall be such person as may be
designated by the chief administrative officer of City.
3.3 Prohibition Against Subcontracting or 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 or Housing and Urban Development and the
Comptroller General during regular working hours. Said records shall be maintained for such time as
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may be required by the regulations of the Housing and Community Development Act, but in no case
for less than three years after the close of the program
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 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.
570.504(c) and 570.503(b)(8);
(1) The Provider is to carry out each activity in compliance with all
Federal laws and regulations described in 24 C.F.R. 570, Subpart K,
except that the Provider does not assume the City's environmental
responsibilities described at 24 C.F.R. 570.604, nor does the
Provider assume the City's responsibility for initiating the review
process under the provisions of 24 C.F.R. Part 52;
(m) Executive Order 11988 relating to the evaluation of flood hazards and
Executive Order 11288 relating to the prevention, control and
abatement of water pollution;
(n) The flood insurance purchase requirements of Section 102(a) of the
Flood Disaster Protection Act of 1973 (P.L. 93-234);
- 3 -
(o) The regulations, policies, guidelines and requirements of 24 CFR
570; the "Common Rule", 24 CFR Part 85 and subpart J. OMB
Circular Nos, A-102, Revised, A-87, A-110 and A-122 as they relate
to the acceptance and use of federal funds under the federally-
assisted program;
(p) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and
implementing regulations issued at 24 CFR Part 1;
(q) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended;
(r) The lead-based paint requirements of 24 CFR Part 35 issued
pursuant to the Lead-Based Paint Poisoning Prevention Act (42
U.S.C. 4801 et seq.);
(s) Maintain property inventory system to numerically identify HUD
purchased property and document its acquisition date as is set forth
in OMB Circular A-110 Attachment N Property Management
Standard 6d; and
(t) Reversion of asset. Upon the Expiration of the agreement, the
subrecipient shall transfer to the City any CDBG funds on hand at the
time of expiration and any accounts receivable attributable to the use
of CDBG funds. Additionally, any real property under the
subrecipient's control that was acquired or improved in whale or in part
with CDBG funds (including CDBG funds provided to the subrecipient
in the form of a lean) 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 party may terminate this
Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party,
Upon receipt of the notice of termination the Provider shall immediately cease all services hereunder
except as may be specifically approved by the Contract Officer. Provider shall be entitled to
compensation for all services rendered prior to receipt of the notice of termination and City shall be
entitled to reimbursement for any services which have been paid for but not rendered-
TO MISCELLANEOUS PROVISIONS,
7.1 Notice. Any notice, demand, request, document, consent, approval, or
communication either party desires or is required to give to the other party shall be in writing and either
served personally or sent by prepaid, first-class mail to the address set forth below, or such other
addresses as may from time to time be designated by mail.
TO CITY.
City of Palm Springs
3200 East Tahquitz Canyon Way
Palm Springs, CA 92262-6959
Attn: City Manager
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WITH COPY TO,
City of Palm Springs
3200 East Tahquitz Canyon Way
Palm Springs, CA 92262-6959
Attn: City Attorney
TO PROVIDER.
MEN Ar: N afGi�Si'�ti t✓7�i71�Pr ;�i�
�•D . _D �3 i7o
Nby
7.2 Amendment. This Agreement may be amended at any time by the mutual
consent of the parties by an instrument in writing.
IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date
first written above.
[ End—Signatures on Next Page]
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CITY OF PALM SPRINGS
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a corporation
Z 76/ City Manager
APPROV S TO��f ORM: APPROVED BY CITY COUNCIL
City Attorne �i
PROVIDER: Check one: Individual Partnership _Corporation
(Corporations require two notarized signatures: One signature must be from the Chairman of
Board, President, or any Vice President. The second signature must be from the Secretary,
Assistant Secretary, Treasurer, Assistant Treasurer, or Chief
/Financial Officer).
N tar d Sig' ature of Chairman of Board, Notarized'Signature Secreta Asst Secretary,
Preside ,Qr any Vice President Treasurer, Asst Treasurer or Chief Financial Officer
Name: �\kyk alb
Title: _C- �.\{fir t<� Title: Pea-S [ P
State of s.-rlv� 11c n�T = State ofc4fi a .+
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On 4- il' d to before me, OFn1 .0_ I� -- t'LP before me,
S"�" C'1 a-R —.personally appeared l� )`LI K 4.1.E(g f.i X3'VI ,personally appeared
r �i j t &'\ec`fir personally known C� T�'I�i-- �-' c1.B-z✓Yt L(� GL��personally known
to me(or proved to me on the basis of satisfactory evidence) to me (or proved to me on the basis -alisfactory evidence)
to be the person(skwhose name(* islare�subscribed to the to he the person6i�whose nameW)&6 subscribed to the
within instrument and acknowledged to me that Xelshellhj;y,' within instrument and acknowledged to me that tXlshe/tl4�.y,
executed the same in-ft1herltbeiC authorized capaci"ij), executed the same in�s'/her/tKrr authorized capacity
and that by=Ws(tierlthe..ivsignature(s) on the instrument the and that by his/her/their signatureN-on the instument the
person(s), or the entity upon behalf of which the personN person, or the entity upon behalf of which the pemon(lr�__
acted,executed the instrument acted,executed the instrument
WITNESS my hand and official seal. WITNESS my hand and official seal,
Notary Notary
Signature: Signature: LC1:1
Notary Seal: Notary Seal.
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CITY OF PALM SPRINGS
EXHIBIT A
Scope of Services
Proiect/Activity Title: Proiect Number.
Court Appointed Special Advocates (CASA)1 0002
Support Program
Name/Address of Provider:
Court Appointed Special Advocates (CASA) for Riverside County, Inc.
PO Box 3008; 44199 Monroe Street
India, CA 92202-3008
O b i ectives/Activities
The intent of this program is to recruit, train and supervise an additional nine (9) community volunteers to
work with up to twenty (20) to thirty (30) abused, neglected or abandoned children (birth to eighteen years
old), who reside in foster or group homes and are dependents of the Juvenile Court System within the
City. This will be accomplished through well-trained community volunteers who will become Sworn
Officers of the Juvenile Courts and the `child's voice in court'. One major benefit of this mentoring
approach, unlike other court principals who often rotate cases, the CASA volunteer is a consistent figure
in the proceedings, and provides continuity for a child
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 anKadditional information requested.
TARGET
DATE ACTIVITY#1
On-Going Make readily available any information relative to the successful implementation of the
activity.
Objective 2; Establish and maintain a programmatic and financial record keening process.
TARGET
DATE ACTIVITY#1
On-Going Establish and maintain an efficient program process/procedure for proper record keeping.
Set-up a filing system for CDBG files only Document and maintain all records related to
this program in a stable and secure location.
Objective 3: Advertise market and publicize the program to facilitate positive promotion for all parties
(i.e. Provider. City CDBG, etc.).
TARGET
DATE ACTIVITY#1
On-Going Draft a promotional piece and submit to City for approval. Advertise in the Desert Sun.
Submit final publication to City
Objective 4: Enroll and income qualify at least a total of thirty (30) Palm Spnnas residents from_v_ery
low income youth.
TARGET
DATE ACTIVITY#1
On-Going Thirty (30) Palm Springs residents will participate in CASA. 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 quarterly reports—referenced Exhibit E.
Objective 6: Manage/monitor program activities.
TARGET
DATE ACTIVITY#1
On-Going Perform monitoring activities necessary to ensure that the program is being conducted in
compliance with the CDBG policies, federal regulations, and local statues, including
Davis-Bacon Act, Copeland Act, and Non-discrimination / EEO requirements.
Objective 7: Provide food voucher distribution activities to person living with_HIV/AIDS. as outlined in
rA oposal -
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
07/15/05 Provide an evaluation and final report on all programmatic and financial activities.
General Administration
Provide the management oversight and leadership to address specific operational tasks in meeting the
established performance levels, as well as perform supportive activities (i.e , clerical, monitoring, etc.)
CITY OF PALM SPRINGS
EXHIBIT B
Budget Summary
Prolect/Activity Title: Project Number
Court Appointed Special Advocates (CASA)/ 0002
Support Program
Name/Address of Provider:
Court Appointed Special Advocates (CASA) for Riverside County, Inc.
PO Box 3008; 44199 Monroe Street
Indio, CA 92202-3008
BUDGET SUMMARY
cosTCATEGORY CDBG OTHER TOTAL
SHARE SOURCES COST
1 Personnel $15,800.00 $402,200.00 $418,000.00
2 Consultant/Contract Services - 0 - - 0 - - 0 -
Pa roll Processing
3 Travel $400.00 $13,600,00 $14,000.00
Mileage Reimbursement
4 Space Rental - 0 - - 0 - - 0 -
5 Consumable Supplies $1,000,00 $11,600.00 $12,600,00
Volunteer Trainin Material
6 Rental, Lease or Purchase of - 0 - - 0 - - 0 -
Equi ment _
7 Insurance $500,00 $19,500.00 $20,000,00
Liability
8 Other $300.00 $3,700.00 $4,000.00
Background Checks
$18,000.00 $450,600.00 $468,600.00
TOTALS
If costs are to be shared by other sources of funding, including CDBG funds from other
jurisdictions, identify the source of funding, grantor/lending agency, and cost category
information.
Other funding sources include BetterWorld Together, California Endowment, The California
Wellness Foundation, and Judicial Council, all totaling S146,400.
EXHIBIT B— Budget Summary
Page 2 of 2 Pages
�J DETAIL BUDGET
DESCRIPTION OF ACTIVITY/ CDBG OTHER TOTAL
PAY ITEMS SHARE SOURCES COST
Personnel $16,800,00 $402,200.00 $418,000.00
Consultant/Contract Services - 0 - - 0 - - 0 -
Space Costs - 0 - - 0 - - 0 -
Equipment— - 0 - - 0 - - 0 -
Purchase, Lease or Maintenance
Consumable Supplies $1,000-00 $11,600.00 $12,600-00
Travel $400.00 $13,600.00 $14,000-00
Insurance $500,00 $19,500.00 $20,000,00
Liability
Other operational costs $300.00 $3,700.00 $4,000.00
Total - I I I 1 18,,000,00 $450,600.00 $468,600.00
The Subrecipient shall submit monthly reimbursement based on prorated and actual costs in
accordance with the aforementioned cost categories and pay items. In no month shall the
Subrecipient submit for reimbursement more than Y4 of the total annual budget.
Services are to be performed over the twelve-month period of this 2005—06 Program Year—July 1,
2005 through June 30, 2006.
CITY OF PALM SPRINGS
EXHIBIT C
insurance Inventory
Project/Activity Title: Project Number:
Court Appointed Special Advocates (CASA)! 0002
Support Program
Name/Address of Provider: Date:
Court Appointed Special Advocates (CASA)
for Riverside County, Inc.
PO Box 3008; 44199 Monroe Street
Indio, CA 92202-3008
INSURANCE INVENTORY
LIABILITY INSURANCE POLICY
Name of Provider's Insurance Company Non-Profits' Insurance Alliance of California
Effective Dates of Policy 05/02/05 to 05/02/08
Claims Made Policy / / per Occurrence Policy,
Limits of Liability_ $1,000T000
Deductibles:
Per Occurrence S1,000,000
Annual Aggregate $1,000000
Additional Insured Endorsement (Certificate Holder) LQ Yes ❑ No
Original Certificate of Insurance Attached ❑ Yes E No
WORKER'S COMPENSATION POLICY
Name of Provider's Insurance Company_ Granite State Ins. Co. &Travelers Casualty
Effective Dates 11/01/04 to 11/01/06 & 11/01/06 to 11/011/2007
Limits of Liability 1 Million
Underlying Coverage Limits
Original Certificate of Insurance Attached ❑ Yes 0 No
:JUL 22 2005 2:01 PM F*H INSURANCE 760 360 4799 &637431 P.01i01
Clier tk 23192 2CA3 FO
ACORD„ CERTIFICATE OF LIABILITY INSURANCE o 1221 015
rRGOCICDC ONLY AEND CONFERS NO RRIICDH S UPON CCMTIFICAT9
HRH aF CGaC:h0071 VAIIsY NON
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTENO OR
Insummv Sendoes LIC a10S112B9 ALTER THE COVERAGEAFFOROE13 BY THE POLICIES BELOW.
774M Country Club Dr,ftal
Palm lactert,CA 12211 INSURERS AFFCkCING COVERAGE HAIL V
rleum Ix =RAv NIAC 30684
CASA ForMrslde County Risun6R&omnlieState Insurance Company 23M
P.0.8ox 3008 x suRERc
Indio.CA 9220E ayvRERo-
k SCMERE
COVERAGES
THE POLICIM OF PASURANCIE aIED BELOW FLLVF PEEN ISSUED TO THEINNURGDNANIEO ABOVE FORTFIE POLICYKAM INOICATEO,NOTWITHSTANDING
ANY REQ(JIQI;WNF.TEIW OR CONDITION OF AHY CONTRACT OR OTHER DOCUMENT MH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAYPERTAW.THE INBURAHCEAFFORDED BYTW POLICIES DESCRIBED mp mN IS SumarTo ALL THE TERM$,MOSIONS AND CONDITIONS OFSUCN
POLICIES,A66RECATE Lima SHOWN MAYNAYE BEEN REDUCED BY PAID CWMS,
YYPCOFIRWRARCe FOUCYRUMOM oar& I!aa uMRS
A QUEMUMArirY 2ODSO4Z07NP0 05/02ms 05/02/OB MCHOCCURFEENCE 110000DD
OOMMNRVALWiNRYLUAgLUY r Ir.NTrn 1100000
CAM WOE 10 OCCUR NEDEAPIAAr� fl s10000
PERGOM&ADVRNRY $1,00,600
GMERALAGGPEOATE 51.000.01M)
Oen AaGREGATELABTAPALTBB PER: pxpDUCFc.cOnPloPAaG 9700001M0
POLO M"- F1LOC
A AUIDMaxnEumu" 200594207HPO 05/02/m5 05/0MI5 sKMELIMFr i1,0001000
ANYAM (EawedelA)
AMOWNEDAITO3
..Lr LCNEDULEOAliT09 ��nI�NAAtY s i
1l HIPFDAVMI 69m IUURY s
x rwNax m A rOs IF. HR arA
0W omwe4 PE�MAMAGE s
GARYGIHMa1UFY IAUTOON.V.tAACMDENT r
ANY AVM OTHE TFLVt EAACG i
AGG I
I�[cESwangEI.H LIAIin[fl' EA OCOUNRENCE I
OCCUR CN MAPS AGGREGATE s
I
PECUCRYLE s
RETENTION S s
6 ncR!OLTCO M ATONA00 VV0009M419700 11/01/0R 11/01/05 A
OYMMILCIW ATY EL.EAu1ACCwBNr st D00 WO
°��y�v'cIAL�-. �aiEC ec I9aEASE-EAeMPLarEE 11000 00
PRb ESL OISEh9E-PDucvuMlr ST Otl0000
A Pm'R Dlrcetom 2MS04207DD O 002 OS 00/02/06 11000,000
arAcems Lirb
ocTpm,rpx orortluTlw¢ltounlvxsrwllcr.GSr E%CwsIDMSAaxtO PYETR)ORsORENTNSrccl/apRoraxlxs
Certiffok Holder is named as additional Insured
GT6 HOLbea! CA MI EL TION
cNOOw AxrevmEAeove xFsrneroiDCCCIEs Be C:ARco1c0 araarx:m¢FarRGTTGN
City of PalmSprmgy DATA,NFAcs.merewxclxaur, wnl.LurPcavoxtaHUL _3a„ aATswlmirx
3200EarATahquHtCfnyonWay xonGem410GGRIsxwTexd.OecNrWOTTnm[LEfl;avrlAlWks'ICDowSnaLL
Palm Springy,CA 92AZ RAPOVTE NO LIGATpMORLNpILTh'aFW1'gNO uroN TIIG V+IVRCR,nsADINTGOR
. PtrISG TriEs
AOrH IIGAAc arnAc -
ACORD20(MQIMO1T Olt MIM188099 2NAY0 0 ACORITCORPORATIONTsro
LICENSE 00511289
* TOTAL PgGE.91 **
Client#: 198 2CASAFOR °• ' L
ACORD., CERTIFICATE 4f�IABILITY INSURANCE Wnsis/zoosmm'
PRODUCER ) r I. 14 ..k I - 'THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Desert Empire Insurance p ❑p ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Services,Inc. LIC#OF09643 �L'01] [.i,l y J 0 H,q g: ? OLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
LTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
77-564 Country Club Dr.,#401
Palm Desert,CA 92211 ZA(`•i L-:7 I Y4li.�,I'�''-�INSURERS AFFORDING COVERAGE NAIC#
INSURED I / 11 ry INSURERA NIAC 36684
CASA for Riverside County Inc INSURER B.
P.O.Box 3008
NSURERC
Indio,CA 92202 INSURER D;
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLI Ctrs DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
R IN N^R TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRwTION
E MMIDDA(Y DATE MMIDOTYY LIMITS
A J GENERAL LLUBILITY 200604207NPO 05/02106 05/02/07 EACH OCCURRENCE $1000.000
X COMMERCIAL GENERAL LIABILITY DAMAGEAeP.—EO S100(00
CLAIMS MADE 51 CCCUR MED EXP(Any one,u=r) S10,000
PERSONAL&ADV INJURY S1,000,000
GENERALAGGREGATE S7 ow)000
GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS•COMP/OP AGG $1 ODD OOO
POLICY PRO LOC
AUTOMOBILE LIABILITY
COMBINED 51NCLE LIMIT
ANY AUTO (Ea acdeonp
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per Pnrson)
HIRED wUTOS
BODILY INJURY
NON•OWNEO AUTOS (Pcr PcGdcnu)nl)
PROPERTY DAMAGE
(Pcr acddem)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHEHAN EAACC 5
AUTO ON
AUTO ONLY AGO S
ERETENTION
ESSIUMBREU A LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE
S g
WORKERS COMPENSATION AMP OR
WCSTATU• OTH-
EMPLOYERS'LIABILITY
ER
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S
OM-GERPMEMBER EXCLUDED? EL,DISEASE-EA EMPLOYEE S
IFyos,doscnbc under
SPECIAL PROVISIONS beIeW E.L DISEASE-POLICY LIMIT S
OTHER
DESCRIPTION OF OPERATIONS I LO YIONs I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate Holder is named as additional insured.
•1 D Day Notice of Cancellation for non-payment.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Palm Springs DATE THEREOF,THE 155VIN15 INSURER WILL ENDEAVOR TO MAIL 1A DAYS WRITTEN
3200 East Tahquitz Canyon Way NOTICE TO THE cERTICIcATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SD SHALL
Palm Springs,CA 92262 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRE5ENT TNES.
A THOR REPRESENT TIVE
ACORD 25(2001/08)1 of 2 #SB7686/M87685 NA O (D ACORD CORPORATION 1988
LICENSE IF09043
Cliu ntl.INN 2C SAFOR
ACORa- CERTIFICATE OF LIABILITY INSURANCE
PAOaRCMc THIS CEIrT1RCA7E 19 U=1150 AS A MATTER OF INFORMATION
oxcart Empire Insurance ONLY AND CONS NO RWHYS UPON THE CEKTI FICAT!
SeMCas,lrc. I.IG 1Y0F0At47 At-TER THE COVERAGE AFFORDED B THIS CERTIFICATE DOES Y THEPOLICIES BEL EXTEND OW.
77.984 Country Club Dr.,■t01
Palm Pgert,CA 11=1 f msuRER7 AFFORDere cOYERAGE NAIG 0
weYPEP imuReRk NIAC S6684
CASA FDT RivemWe County Inc INSLW-n6
P.O.BO%3001 WRIFFRO
Indio,CA 9ZZ02 INLIAyEam
YA`AAIGRE
COVERAGES
THEPOkICIMOPINGUMMHCE L19TEOSELOW HAVE BEOU5UEO TO THE INSURE➢NA AIIOVE FGRTFE POLICY PEIGOP MICATEO.NOM]THSTANDING
ANY REODUWMENT•TERM ORCEMITKTN OF ANYCONRAC70R OTHER DOCUMENT WON RESPECTTOVw1047HISOERTIFl 7E MAY 6E ISSUED DR
MAY►EIT11m,THE MURANCE AFFORDED 9Y'rHE POLICIES OESCRPeEo HEREIN IS SUBJE w ALL THE TEAas1 ETGusid) s AND CONOITIOM OF SUCH
POLICIE5.AGGREGATvumrm sHwm MRTNAYe aeam Fmouam EY PAID CUUMS.
•oucF creed Wu npe
L 7TrEDrIWIwAxCE w1DCY NYtwER T LWITi
A oe1IFAALtiw 200704107NPO 03d02107 05102f00 EAarucWvxREncE e1009 0
X cGNHeFra�I.GO+ExuLPPLIrc s1pp000
LnNNt MADE ❑X aCC11n xeD G.wrAnT.ixT.ren t700
PEREaNx.a.cYlNim S 0 000
OEa1Ewu.ARoFECAr6 92,000,0110
GPM1AGGREGATF UNUYAANEl P6R• PRPOIICts•WlfAPAGG t 000000
fkYCY LOC
APrOnweAe WaIu1T
Atrl Nlfo �rA��SixGIFLPIK =
.1.OHNF➢AIJTM f10dLY INau11Y
SCH Ufi xnos 6Wnew.11 r
HIRFDAV W eDDILYIxunx
NCx-0mIFOAVTG6 IPwa.�m0 t
��DAPACE !
wwwae W48AR7 WTOOILY.EAACCIO t
' AID FAACC s
aPERTMN
AurooNLr. AO° i
A ExcEcsluwaiLuwearn 2007DazD7UMe 05/02107 05102100 a DacuRHEYCE S100000
CCGa CIAfAcuAIE AGGAC-0AT{ 31 000 00D
RCtNCTia.E t
X REIF1Ra7H si0 a
N'OAIfdn FRWEYHTGy Anp Y/C w
tllPl.PrniLe'W.aeiTr
AN'r rROARETCWPARTHWF�rirtAIE EL rAbnAcnoExT T
9RICFftMFler6n IXCU10ED7 [l.CU„"'
u 4a.ean wanr EAEPsLo s
GwsnNsnrP. E>_pIs[�7[•Ivucyuun !
A °1Nr"•Directors a 2007OM700 OUO2f07 OS102m9 $1,000,000
CfFicars
aEycAImOY aF tFLM71aNs r LouTrcr4nelslysrEuaumars rude°eT,e:rmwDeMrxrrsrecw.TRugG1011t
110 Pay Kok*of Cancellation for non-payment of premium.
Certir,e9te Helder is narned ns aft 10wral inwmd with respects to General Liabitity
only.
DERTIFICATG MOLDER CANCELLATION
SHW LOAN1'OFTHGILOYE aE5C66Ea ApuREi RE CANCELLFb 15EA0RE7HE EarNtA11RH
City Of Palm Sprinss PATaT11PCOP,T11e1glYYDIYsuLD{WILL eHOGVtlp7onwA R CAn WITTFN
=0 East TnhquiteCanyonWay HmIL�7onacElnwwsenwrxrlryE67oTxeurrlwrrrlwaeronoaP3H.LI.
Palm5prings.CA 9ZZ62 I Usv NocauaA* oft uMILRYOPAXT mn ummN WUwA rcsACFa m
AWMOR=RE1RETEWAI
ACOR025(2041M)l Oft A$10an911HATO4899
SNAVO OACORP CaRPORJLTIOM T11al
LICENSE*DF09E43
Nanp:oEits'Insurance
; l4_11 cg cf California
♦,W ro.-�...W Art-V��qK[Vn
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REAL]IT CAREFULLY.
ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the fallowing
COMMERCIAL GENERAL LLABILITY COVERAGE PART.
SCHEDULE
-Name of Person or Organization:
Any person ororganization that you arc required to add as an additional insured on this policy,under a written contract or
agreement currently in effect,or becoming effective during the term of this policy,and for which a certificate of insurance
naming such person or organization as additional insured has been issued,but only with respect to their liability arising out
of their requirements for certain perforrnartce placed upon you,as a nonprofit organization,in consideration for funding or
financial contributions you receive from them. The additional insured status will not be afforded with respect to liability
arising out of or related to your activities as a real estate manager for that person or organization
(If no entry appears above,information required to complete this endorsement wi11 be shown in the Declarations as applicable to
this endorsement.)
WHO IS AN INSURED(Secrion 11)is amended to.include as an insured the person or organization shown in the Schedule as an
-insured but only widrrespcct to&biliry arising out of-your operations or premises ovmcd by or rented to you_
CG 2026(l 1185)
IMPORTANT
If the certificate holder is an ADOITIONAL INSURED.the policy(iae)rnust he endorsed. Aatalement
on thus certificate does rot confer rights to the caA'Ticale holder in lieu of such endor*emerd(s)-
If SVUROGATION 15 WAIVED, subject to the terms and wndllions of the policy.certern policlee may
requlre an endorsement. A statement on this certificate does not confer dghts to the dartlflrate
holder In lieu of such endorsenlerKsl
DISCLAIMER
The Certifieak of Insurance an the reverse side of this farm does not eermthute a contract between
the isMing insurer(*), eutlof4ed reprowntlative or producer,and the certificate holder, nor deal it
ahRmmlivuly or negatively amend, mdend or after the coverage afforded by the policies listed thereon
ACelto 25a(260111111) 2 of *$1a851*1104M
** TOTRL PRGE. 02
i
•i CI , 2 T. SAFOR
AC - CERTIFICAtE OF LIABILITY INSURANCE 11103105°m Y'
HRH of Coachella Valley R E C PRODUCER �''qf E TgNIS�YCJEIND CONFERS NO RIGHTS UPON TIFICATE IS ISSUED ASA THE GERT1OF 0�INFORMATION
Insurance Services LIC#0511289 CITY or PALM 5 RI(6f•DER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDEED BY THE POLICIES BELOW.
77-564 Country Club Dr.,9401 tad
Palm Desert,CA 92211 2005 NOV
I LI Af NSl1RER5 AFFORDING COVERAGE NA1C#
INSURED << N ERA: Granite State Insurance Company 23809
CASA for Riverside Ccunty lnc J 3.�i E.5
- ••i}nj 1p}C•in(
P.O.Box3008 CITY CLER RES:INSUR INSURER C!
Indio,CA 92202
INSI1RERv
INSURERS
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE aEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTMTHSTANOING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITW_8ESPECT TO WHICH THIS CERTIFICATEMAY-REISSUED OR - -----
MAY PERTAIN,THE INSURANCE-AFFORDEO'BYTHE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR x TYPE OF INSURANCE POMCYNUMCER PALIC YEFFRGnVE POLIOYEXPIRA
MMIDURONffft LIMBS
GENERAL U"ILITY E&CHOCCURRENCE S
TO
LOMutERC1Al GExERAy UnBIUTY DAMAGE RENRO S
CLAIMS MADE ❑OCCUR MEO E(P(MY wa Paaon T
PERSONAL&ADVINJURY §
GENERAL AGGREGATE S
/ 0EN2 AGOREDATE LIMIT APPLES PEN' PRODUCT$-COMPIOPAGG S
POLICYr—j PRO. LOC
AUTOMOBILE LNRILRY COMBINED SINGLE LIMIT
ANYAUTO (E ACPfy,IQ S
ALL OWNED AUTOS
ROro IN S
SCHEDULED AUTOS (P¢rp¢M1On)
NRiED AUTO$ BODILY INJURY
NON•OWNEDAUTCG (ParacrW¢PU S
PROPERTY DAMAGE S
[PeraccidonN
GARAGE WARILrtY AUTO ONLY-EAACCIDBNT S
ANYAUTO OTHERTHAII EAACC S
AUYOONLY. AGO $
IXCEMUtIMERELIA LuoTLDY EACH OCCURRENCE S
OCCUR 171CLNMS MADE AGGREGATE $
S '
,i DEDUCTIBLE 5
RRTEMION S $
A mIvtEns coMPENGAnoN AND WC03954419700" - 1W1105 11/01106 X we srATu- oTT�
EMPLOYrRS LIABrtJiT
ANY PROPRIETOR/PARTNERIEXECUTIVB E.L,EACX ACCIDENT $1 OOO,ODD
�;i QMCER/MENBER EXaUDED7 E.L.DISEASE-EA EMPLO •- S10ti0000
Ilayn G¢udbr w '
SPECIALPROVISIOHSew G-L,DISEASE-POLCYUMIT 51,000000
omcR �r-• ��
DESCRIPTION OF OPERATIONS I LOCATIONS/VENICLESf EXCLUSIONS MDW By ENDORSEMENT/SPECIAL PROVISIONS
ALL OPERATIONS.
Certificate Holder Is named as additional insured. '},
l{s NOV 28 2005 {,
CERTIFICATE HOLDER CANCELLATION }
SHOULD ANY OF THe AROVL DESCRMW POLICES RE CANCELLED BEFORE THE KORIRAnON
City Of PalmSpfings 61; DATE' EMOF,THEISSWNGIN$URERWILLEHbE VORTOMAIL qO OAYSWRRTEN
3200 East Tahqultz Canyon Way NOTICE TO TOE CERTIFICATE HOLDER x WTOTHELEPT,$UTPAILUREToDoSOSHAU.
Palm Springs,CA 92262 RPOSERDODUU71ON99UADILITYofA KIND UPON THE INSURCR,ITS ACENTsOR
RMUFSENTATIVEs.
AUTHO Dm RE-P/YR_Mv-_ TATIM
"F �4
ACORD 25(2001108)1 off #S207131/M207130 20GRE a ACORD CORPORATION 1988
LUMNSE#0511289
Jun 11 07 09:31a India 7 13546 p2
�S�go CERTIFICATE OF LIABILITY INSURANCE �T(pINIQQTriY]
c8TD5lz0oT
moWCEA THIS CERTIFICATE 15 ISSUED A MATTER OF INFORMATION
PAYCHEX AGENCY INC ONLY AND CONKERS NO RIGHTS UPON THE CERTIFICATE
154 SAWGRAS9 DRIVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ROCHESTER,NY 1482C ALTER THr CO ERAGE AF ORDED BY THE UrIESBELD
5577)5S7-6785
5V996 70A INSURERS AFFORDING COVERAGE NAIC!
INWRED INSURERATRAVELERSCASUALTYINSLNIANCEcO PANYOF"EIE"
CAS&FOR RIVERSIDE COUNTY INC
44199 MONROE STREET IN511RER B:
STE D INSURERC
INDIO•CA 92201 INSURER 0
NsuRER L.
COVERAGES
TNp P ICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REODIREUENT.TERM OR CONDITION OF ANY CONTRACT CR O-HER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 9E ISSUED OR
MAY PERTAIN,THE NSURANGI AFFORDED BY ME FCL101E5 DESCRIBED HEREIN 15 S1BICCT TO ALL THE TERNS. EXCLUSIONS AND CONDITIONS OF RNCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE SFFN REDUCED BY PAID CLAIMS
]NSAAPP MMYEPFECTIYE POLICxg"iRAYmN
TTPE OF INSDRLNCB POLIcT NUNNER OArE TOD" TE AVM] m LIMITS
CMERALLIAOIRT r�ypcwgg
mMr1ERCLILCENERK UASA+rT LwnnGEYORE"Tt
p/IM5MADL OCCUR A •ua
A£DE%P Mvenn r S
BOY PLUMY,
IS
GENL AZ, 'R M DMITAPPUEE PER: IICIS LPAP
PRO
Pd.ID! LIJECT F7 LOC
AVTOMGSILE uAMNT! (YWEINEQ SINGLE OMty
ANYN fEa sssen]
ALLOWNEOALIT65 Ra IR`f WARY
SCHBPULXA AUTCe
HIREDAIfIQ4 gIDlLn Ay
WN-0WNEDAVIQ5 IRoramG�nl S
�OP(HN OPANCE $
GARAGE UA1UTv AUTOOutv•EA ACCIDENY 5
PINYAUM ACC
AVTODPEN
E%cMMMMII,AL�AWIun FACHOCGu AENCE 5
CCCIIR F—jaA SMADC- AGCAEGATE
$
CEDUOMS E s
iETEN N $ a
A WOREERSCOAIPEN.SATWm ANO UB-e4380144.06 11101(2006 111131121307 x T c
EMPLOTEr6'IIAWUTY
ANV PRpPRETORmN[1NEwYNEW1IYE E.L EACH lICCmENT SS DOO 000
OFFI6.RAA-TILCPENOILOF01 E1011aFA5E.EA[MPLOMEF 51000000
C LT a PRW.=rS El DISFASF,POUCYLIWT 51.000.000
OiNCR
CCscBPnoN oFOPEPATICNS LOCAOOxsTvFXICIE!IEXCWRON5ACOEO BY EHOORTEMENT I SPECIAL FROv CN5
It,THE EVENT OF NONPAYMENT OF PREMIUM,ONLY 7EN(10)DAYS NOTICE OF CANCELLATION SHALL BE GIVEN
CERTIFICATE HOLDER CANCELLATION
WIOIILG ANY OF THE ABOVE WL MTV N
CITY OF PALM SPRINGS DATE TMMIN:OF,THE ISSUING In:LIEA Tnu Hlo[AYOn TO MA14 ZQ DAYS WAITTEN
S2DOETAHOUIT70ANYON WAY NOTICE TO THE CERTIFICATC HOLOER NAMED TO THE LOT,R IR FMLUIE TO DO 90 SNLLL
PALM SPRINGS,CA 92262
IMPOSE Vp oaIIGATION OR LRFILTY OF ANY XIHP pPON 7HE WeuREp,ITC AcsrTs OR
REPTESEWA¶M.
AUT10R6®rEPRc:,I.NlfAT1YE
ACORD 25(2001108) CORD CORPORATION 19B8
CITY OF PALM SPRINGS
EXHIBIT D
Beneficiary Qualification Statement
Project/Activity,Title: Project Number:
Court Appointed Special Advocates (CASA) ! 0002
Support Program
Name/Address of Provider: Date:
Court Appointed Special Advocates (CASA)
for Riverside County, Inc.
PO Box 3008; 44199 Monroe Street
Indio, CA 92202-3008
BENEFICIARY QUALIFICATION STATEMENT
This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the
described prolecUactivlty 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 border$cannot be included as household members
2. Circle your combined gross annual income(Riverside-San Bernardino,CA—02/11105)
MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD:
INCOME 1 2 3 4 5 6 7 8
LEVEL
VERY LOW
INCOME $19.500 522,250 $25,050 S27,850 $30,050 532,300 S34,500 $30,760
Below 50%
LOW INCOME $31,200 $35,650 $40.100 $44,550 S48,100 $51,700 $55,250 S58,800
51 —80%
MODERATE
INCOME $46,750 553,450 S50,100 $66,800 572150 $77,500 $82,850 $88,200
20%
3. What race/ethnicity do you identify yourself as; please note that this self-identification is voluntary in accordance with
equal opportunity laws?
❑ White ❑ American Indian or Alaska Native AND White
❑ Black/African American ❑ Asian AND White
❑ Asian ❑ 61ack/Afncan American AND White
L'J American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/Afncen American
❑ Native Hawaiian or Other Pacific Islander ❑ Other
HISPANICILATINO ETHNICITY U Yes ❑ No If yes check one. ❑ Mexioan/Chicano
❑ Puerto Rican
❑ 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 Information you provide on this farm is confdemlal and Is only ublized for Community Development Block Grant(CDBG) program purposes, a
Federally-funded program,governmental reporting purposes to monitor compliance
CITY OF PALM SPRINGS
EXHIBIT E
Quarterly Program Progress Report
Proiect/Activity Title: Project Number:
Court Appointed Special Advocates (CASA)/ 0002
Support Program
Name/Address of Provider: Date,
Court Appointed Special Advocates (CASA)
for Riverside County, Inc.
PO Box 3008; 44199 Monroe Street
Indio, CA 92202-3008
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
r Number of First-Time Female Headed Households:
Counts by Race/Ethnicity:
White Amencan Indian or Alaska Native AND White
Black/African American Asian AND White
Asian Black/African American AND White
American Indian or Alaskan Native Amencan Indian/Alaska Native AND Black/African American
Native Hawaiian or Other P2CIfC Islander Other
HISPANIC/LATINO ETHNICITY, Mexican/Chicano Puerto Rican
Cuban Other-
ACCOMPLISHMENT NARRATIVE
LEVERAGING RESOURCES NARRATIVE
Signed Title Date
CITY OF PALM SPRINGS _
EXHIBIT F
Request for Reimbursement
Project/Activity Title: Project Number:
Court Appointed Special Advocates (CASA) / 0002
Support Program
Name/Address of Provider: Date:
Court Appointed Special Advocates (CASA)
for Riverside County, Inc
PO Box 3008; 44199 Monroe Street
Indio, CA g2202-3008
Approved currents Prior Total Grant
Description Grant Reimbursement Raimburs('ent YTD I Balance )
Amount Period Periods Reimbursement Ovor!Under
Personnel $15,800.00
Consumable Supplies $1,000.00
Volunteer Training Material
Travel $400,00
Mileage Reimbursement
Insurance $500.00
Liability
Other $300 00
Background Checks
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: Examined by. Approved by
If necessary, additional sheet(s) must be attached detailing cost breakdowns, and verified by original signatures.
CITY OF PALM SPRINGS
EXHIBIT G
Employment Restrictions
1 Labor Standards
The PROVIDER agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis-Bacon Act as
amended, the provisions of Contract Work Hours and Safety Standards Act the Copeland "Anti-Kickback" Act (40 U.S.C.
276a-2762-5 40 USC 327 and 40 USC 276c)and all other applicable Federal,state and local laws and regulations pertaining
to labor standards Insofar as those acts apply to the performance of this contract. The PROVIDER shall agree to submit
documentation provide by the CITY which demonstrates compliance with hour and wage requirements of this part.
The PROVIDER agrees that, all general contractors or subcontractors engaged under contracts in excess of 52 000,00 for
construction, renovation or repair work financed in whole or in part with assistance provided under this contract, shall comply
with Federal requirements adopted by the CITY pertaining to such contracts and with the applicable requirements of the
regulations of the Department of labor, under 29 CFR Parts 1, 3, 5 and 7 governing the payment of wages and ratio of
apprentices and trainees to journeyworkers: provided, that if wage rates higher than those required under the regulations are
imposed by state and local law nothing hereunder Is intended to relieve the PROVIDER of its obligation, if any to require
payment of the higher wage. The PROVIDER shall cause or require to be inserted in full, In all such contracts subject to such
regulations,provisions meeting the requirements of this paragraph.
2 "Section 3 Clause"
a. Compliance
Compliance with the provisions of Section 3,the regulations set forth in 24 CFR 1$5, and all applicable rules and orders
issued hereunder prior t0 the execution of this contract, shall be a condition of the Federal financial assistance provided
Under this Contract and binding upon the CITY, the PROVIDER and any of the PROVIDER'S subreeipients and
subcontractors Failure to fulfill these requirements shall subject the CITY, the PROVIDER and any of the PROVIDER'S
subrecipients and subcontractors, their successors and assigns, to those sanctions specified by the Agreement through
Which Federal assistance is provided. The PROVIDER certifies and agrees that no contractual or other disability exists
which would prevent compliance with these requirements
The PROVIDER further agrees to comply with these 'Section 3" requirements and to include the fallowing language in all
subcontracts executed under this Agreement:
'The work to be performed under this contract is a project assisted under a program providing direct Federal financial
assistance from HUD and is subject to the requirements of Section 3 of the Housing and Urban Development Act of
1968, as amended, 12 U.S.0 1701. Section 3 requires that to the greatest extent feasible opportunities for training
and employment be given to low- and very low-income residents of the project area and contracts for work in
connection with the project be awarded to business concerns that provide economic opportunities for low-and very
low-income persons residing in the metropolitan area in which the project is located."
The PROVIDER further agrees to ensure that opportunities for training and employment arising in connection with a housing
rehabilitation (including reduction and abatement of lead-based paint hazards), housing construction, or other public
construction project are given to low-and very low-income persons residing within the metropolitan area in which the CDBG-
funded project is located;where feasible, priority should be given to low-and very low-Income persons within the service area
of the project or the neighborhood in which the project is located, and to low- and very low-income participants in other HUD
programs, and award contracts for work undertaken in connection with a housing rehabilitation (including reduction and
abatement of lead-based paint hazards), housing construction, or other public construction project are given to business
concerns that provide economic opportunities for low- and very low-income persons residing within the metropolitan area In
which the CDBG-funded project is located; where feasible, priority should be given to business concerns which provide
economic opportunities to low-and very low-income residents within the service area or the neighborhood in which the project
Is located, and to Iew-and very low-income participants In other HUD programs
The PROVIDER certifies and agrees that no contractual or other legal incapacity exists which would prevent compliance with
these requirements,
b Notifications
The PROVIDER agrees to send to each labor organization or representative of workers with which it has a collective
bargaining agreement or other contract or understanding, if any, a notice advising said labor organization or worker's
representative of its commitments under this Section 3 clause and shall post copies of the notice in conspicuous places
available to employees and applicants for employment or training