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HomeMy WebLinkAbout05266 - SHELTER FROM THE STORM DOMESTIC VIOLENCE OUTREACH/ADVOCACY FY 2006-07 Page 1 of 1 Kathie Hart From: Dale Cook Sent: April 03, 2008 2:51 PM To: Kathie Hart Subject: RE: Shelter from the Storm -A5266 10-4, it has been completed From: Kathie Mart Sent: Friday, March 21, 2008 11:58 AM To: Dale Cook Subject: Shelter from the Storm - A5266 This was for FY 06-07. Is it ready to be closed? �, I' 4a' Kathie Hart, CMC Chief Deputy City Clerk City of Palm Spnngs 3200 7ahquwtz Canyon Way Palm Spnngs, CA 92.262 Kafhie,Nart@pa(msprmg5-cagav CNice (760)323=6206 04/03/09 r SUBRECIPIENT AGREEMENT THIS AGREEMENT (herein "Agreement"), is made and entered into this A,- day of -l&I�c u , 200L, by and between the CITY OF PALM SPRINGS, (herein "City), a municipal corporation and charter city, and the Shelter From The Storm 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 seg.), as amended From time to time (the "Act"), and the regulations promulgated thereunder(24 C.F.R. Section 570 et semi. ("Regulations"); and WHEREAS, the Act provides that the City may grant the CDBG Funds to nonprofit organizations for certain purposes allowed underthe 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 Reaorts. No later than ten (10) days prior to any payment date specified in Section 2.2, within ten (10) days following the termination of this Agreement, and at such other times as the Contract Officer shall request, Provider shall give the Contract Officer a written report describing the services provided during the period of time since the last report and accounting For the specific expenditures of contract funds hereunder, if applicable. At the times and in the manner required by law, the Provider shall provide to the City, the Department of Housing and Urban Development, the Comptroller General of the United States, any other individual or entity, and/or their duly authorized representatives, any and all reports and information required for compliance with the Act and the Regulations. 1.4 Financial Reporting- Any Provider receiving or due to receive or due to receiver $20,000-00 or more from the City during the 2006 — 2007 Fiscal Year shall provide to City a financial statement prepared by a recognized accounting firm approved by or satisfactory to City's Finance Director completed within the most recent twelve (12) months showing the Provider's financial records to be kept in accordance with generally accepted accounting standards. The report shall include a general ledger balance sheet which identifies revenue sources and expenses in sufficient detail to demonstrate contract compliance and be balanced to bank statements. Any organization receiving or due to receive less than $20,000.00 in the current fiscal year from the City shall provide a copy of the orgenization'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 31sr of the current fiscal year. n; V 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 (515,000.00) (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 26% 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 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 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 a); 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 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 seg.); (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. 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. 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: 72 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 ATTES a municipal corporation y: By: C rferk / b�i�z� City Manager APPROV D TO FORM: APPROVED By CITY COUNCIL GI W City Attorney PROVIDER: Check one: Individual J 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 Secr ary, Treasurer, Assistant Treasurer, or Chief Financial Officer). -By: By;�Ql! Notai'z ature of Chairman of Board, �Notar' SjgFtiat rue Secretary, Asst Secretary, President or any Vice President Treasurer, Asst Treasurer or Chef Financial Officer 1 Name: av-,'4- L. G��� S Name: ��rZ���y /2 7.yr /[ Title: Title: �Ffi � G%✓a u✓ r c State of� State of 1 Counly Dorf =sss Ccuntyof/ rbc"x'sir�[" _ss On T��/-;'f1 Ur. �D6/ ., before me On .'�-T-��'r 4 ���'� ' -7 before me, personaTlyappeared personally appeared ^ cP7 ° �� personally known /�A°rr—rr V personally known to me(or proved to a on the basis of satisfactory evidence) to me(or prov d to me on the basis of Satisfactory evidence) to be the person(s) whose name(s) islarEsubscribed to the to be the person(5) whose name(s) is/aFe-subscnbeci to the within instrument and acknowledged to me that he/AeAim-7 within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized eapaclty(ics), executed the same in his/her/thek authorized capaclty(lee), and that by his/beckpeiP signature(s) on the instrument the and that by his/herllheiF signature(4) on the instrument the person(s), or the entity upon behalf of which the person(s) person(,) or the entity upon behalf of which the person(8) acted,executed the instrument acted executed the Instrument. WITNFSS my hand and Official Seal. WITNESS my hand and official seal. Nora /�{ Notary Signature: O't --�-4G Signture: Notary Seal: Notary Seal: bl JANE P�EWAL'dA •4� EDMOND L96;0r iip _ CommJssicn# ]6610 �� �a Commis;lon u]111111 'fl Notary PUMC -CCItt01r�6 `z .(�a f No7ory Pu"ul,c-Califuinla y ptlyerside County ~� csverstdc Coun9 r I + ��-�. My Comm.expires Jun 9,201 °�I My Comm.Ecplres Doc 22.2008 t L � u ShtrrrmStrm SubrecipAgmtntSNs_RO Juice - 7 - CITY OF PALM SPRINGS EXHIBIT A Scope of Services Project/Activity Title: Proiect Number: Shelter From The Strom ! 0006 Domestic Violence Outreach &Advocacy Name/Address of Provider. Shelter From The Storm, Inc. 73555 Alessandro, Ste. D Palm Desert, CA 92260 Objectives/Activities The intent of this program is to provide domestic violence outreach and advocacy center, located in Palm Springs. This will be accomplished through the staffing of an Outreach and Advocacy Center facilitating a full range of 'on-the-scene' crisis counseling, supportive services and emergency shelter for two hundred (200) residents. The Provider shall be responsible for the completion of the following objectives/activities in a manner acceptable and satisfactory to the City and consistent with the standards required as a condition of providing these CDBG funds. Objective 1: Assist the City by timely providing any additional information requested TARGET DATE ACTIVITY#1 On-Going Make readily available any information relative to the successful implementation of the activity. Objective 2: Establish and maintain a programmatic and financial record keeping 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 CdV 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 hundred (200) residents. TARGET DATE ACTIVITY#1 On-Going Provide direct client programming for Palm Springs residents. Maintain records of names, addresses, demographics and service dates for all assistance. Objective 5; Maintain records for all_CDBG activities related to this program. TARGET DATE ACTIVITY#1 On-Going Document and maintain all records related to this program, including those required, in accordance with HUD Regulations, in a stable and secure location ACTIVITY#2 Monthly Submit semi-annual reports—referenced Exhibit E. Objective 6: Manacle/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 07/15/07 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 Proiect/Activity Title. Project Number: Shelter From The Strom / 0006 Domestic Violence Outreach &Advocacy Name/Address of Provider: Shelter From The Storm, Inc. 73555 Alessandro, Ste D Palm Desert, CA 92260 BUDGET SUMMARY• COST CATEGORY C�BG OTHER TOTAL SHARE SOURCES COST 1 Personnel $15,000. $3,716. $18,715. 2 Consultant/Contract Services $ $ $ 3 Travel $ $150. $150. 4 Space Rental $ $9,600. $9,600_ 5 Consumable Supplies $ $500, $500. 6 Rental, Lease or Purchase of $ $2,000, $2,000. Equipment 7 Insurance $ $ $ 8 Other $ $600. $600. Telephone $ $700. $700. Client Education Material $15,000. $17,266. $32,266. 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 primarily are Fundraising activities conducted by Shelter From the Storm's auxiliary, Angels' Alliance ($17,266). EXHIBIT B— Budget Summary Page 2 of 2 Pages DETAIL BUDGET DESCRIPTION OF ACTIVITY/ CDBG OTHER TOTAL PAY ITEMS SHARE SOURCES COST Personnel- $11,550, $2,861. S14,411. Salaries—Outreach Advocate Benefits—Outreach Advocate $3,450, $855.__. 54,305. Other Costs- - 0 - $13,550. $13,550, Operations & Overhead Expenses Total' 1 1 $15,000. $17,266. . . $32,266. The Subrecipient shall submit monthly reimbursement of Personnel Salaries/Benefits for Outreach Advocate at Palm Springs facility based on prorated salary and actual fringe benefits in accordance with the aforementioned cost categories. In no month shall the Subrecipient submit for reimbursement more than Yd 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 Title. Project Number: Shelter From The Strom / 0005 Domestic Violence Outreach &Advocacy Name/Address of Provider. Date- Shelter From The Storm, Inc. 73555 Alessandro, Ste D Palm Desert, CA 92260 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Philadelphia Insurance Companies Effective Dates of Policy 07/01/06 through 07/01/07 Claims Made Policy ! / Per Occurrence Policy / ! Limits of Liability_ General Aggregate $2,000 000 Deductibles! Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) C1 Yes El No Original Certificate of Insurance Attached ❑ Yes ❑ No WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 04/01/06 through 04/01/08 Limits of Liability $1 000.000 Per Occurrence Underlying Coverage Limits Original Certificate of Insurance Attached 0 Yes 0 No ACQRD CERTIFlvTI Or LIABI'L1 Q Y iNSU"_,CE DATE 06106/2007 CATC PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Weingarten & HDu h ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I HOLDER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P 0 Box 1866 ALTER THE COVERAGE AFFORDED 8Y THE POLICIES 9ELOW- Palm Springs CA 92263- INSURERS AFFORDING COVERAGE INSURED INSURFRAPHILADELPHIA INStTRANCF, COMPANY SHELTER FROM THE STORM INSURER B: 73555 ALESSPSTDRO DR. STE. D NSURERC INSURER 0 Palm Desert CA 92260- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HEREM 1$ SUBJCCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INER TYPE OF INSURANCE PCLICYNUMBER POLICY EFFECTIVE POLICY EXPIRATION UNITSLTR DATE !TM DATE MMIDO A GENERAL LIABILITY / / / / EACH OCCURRENCE S 1,000,000 X COMMERCIALGBNERALL(ABILITY FIRE DAMAGE Any one Tra 5 100,000 CLAIMS MADE a]OCCUR PFPPId77874 07/01/2006 07/01/2007 NEC E%P fAny mo pcI ) 5 5,000 X PROFESSIONAL LIRE PERSONAL aADVINJURY S 1,000,0oD X / / / / GENARALAGGREGATE S 2,000,000 GEN LAGGREGATE LIMITAPPUES PER PRODUCTS-COMPIOP AGG $ 1,000,000 POLICY ,Fn LGC A AUTOMOBILE LIABILITY / / / I COMDINP,D SINGLE LIMB ANYnU70 (Ea aCClyprf.) 5 7.r000,000 ALL OWNED AUTO& / I / / BODILY INJURY SCHEDULED AUTOS (Pcr peve.) S X HIRED AUTOS PRFKI77874 07/01/2006 07/C1/2007 BODILY INJURY X NON-OWNED AUTOS (PoracddwIj PROPER YDAMAGE (P&ac.00N) GARAGE LIABILITY AUTO ONLY-EAACGIDENT S MYAUTO / / / / OTHERTHAN EAACC 5 AUTO ONLY AGG 5 A EXCESS LIABILITY PRUB065748 07/01/2006 07/01/2007 EACI I OCCDRRENCE 5 2,000,000 X1 OCCUR CLAIMS MADE AGCREGATF S 2,000,0001 5 DEDUCTIBLE / / / / S X RETENTION 510,000 $ EMPLOYERS LIABILITY ON AND EL EACH ACCIDENT 5 CL DISEASE�EA EMPLOYEES E.L DIGEASC-POLICY LIMIT IS OTHER A BUSINESS INTERRUPTIN PBPR177874 07/01/2006 07/01/2007 1,000,0DO DESCRIPTION OF OPERATIONEILOCATIONSNEHIOLESIEXCLUSI ONE ADDED DY ENDORSEMENT/SPECIAL PROVISIONS OPPEATIONS OF THE INSVAED FOR TEP CERTZFICsTE SOLIDER- REFEREW= CONTRACT A526G. CITY OF PALM SPRINGS IS ,ADDIT1014AL INSURED- %0 DAY NOTICE OF C'ANCELL%TION FOR NONPAYMONT OF PREMIUM- CERTIFICATE HOLDER X ADDITIONAL INSURED;INSURER LETMR: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED DEPORE THE ( ) - (760) 322-8235 EXPIRATION DATE THEREOF, THE 15SUINO INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIRCATE HOLDER NAMED TO THE LEFT,BUT CITY OF PALM SPRINGS FAILURE TO DO SO SHALL IMPOSE NO 08WGATION OR LIABILITY OF ANY KIND UPON THE ATTN: DALE COOK INSURER ITS AGENTS OR REPRESEN TIVE5. P. O. BOX 2743 AUTHORIZED REPRESENTATIVE - PALM SPRINGS CA 92263- ACORD 26-S(7197) 0 ACORD CORPORATION 1988 i ,v INS025S ID510)Oz ELECTRONIC LASER FORMS,INC -(e00132T-0546 P,.I aft POLICY NUMBER: PI-TPT-'77574 COMMERCI.4 GENERAL LIAIiICi .- THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-CONTROLLING INTEREST This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL 1,lABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: CITY OF PALM SPRINGS (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 1. WHO IS AN INSURED(Section II) is amended b_ Premises they own,maintain or control while to include as an insured the person(s)or organi- you lease or occupy these premises, zation(s)shown in the Schedule,but only with respect to their liability arising out of: Z. This insurance does not apply to structural altera- tions,new construction,and demolition opera- s."Their financial control of you;or tions performed by or for that person or organiza- tion. I CG 20 05 11 85 Copyright,Insurance Services Office,Inc.,1984 POLICYHOLDER COPY 5K STATE P.D. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION IN S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-01-2006 GROUP: 000489 POLICY NUMBER 0000092-2008 CERTIFICATE 10. 1 CERTIFICATE EXPIRES: 04-01-2007 04-01-2006/04-01-2007 CITY OF PALM SPRINGS SK CITY CLERKS OFFICE P O BOX 2743 PALM SPRINGS CA 92263 This is to Certify that we have issued a valid Workers' Compensation Insurance policy In a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated This policy is not subject to cancellation by the Fund except upon 3O days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not on insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any Contract or other document with respect to 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. �64dvl_,_ TIIOPoZEO REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT N2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER SHELTER FROM THE STORM, INC. A NON-PROFIT, MUTUAL BENEFIT CORPORATION 73555 ALESSANDRO OR PALM DESERT CA 92260 M0409 (REV.2.053 PRINTED : 03-18-2006 POLICYHOLDER COPY SK STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-D807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-01-2007 GROUP: 000489 POLICY NUMBER: 0000092-2007 CERTIFICATE ID: 1 CERTIFICATE EXPIRES: 04-01-2008 04-01-2007/04-01-20D8 CITY OF PALM SPRINGS SK CITY CLERKS OFFICE P 0 BOX 2743 PALM SPRINGS CA 92263 This is to certify that we have issued a valid Worker:' Compensation insurance policy In a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated This policy is not subject to cancellation by the Fund except upon3O days advance written notice to the employer. We will also give you 8p days advance notice should this policy be cancelled prior to its normal expiration. This certificate Of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed heroin. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of Insurance may he 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. V tTHORIZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING OFFENSE COSTS: S1,000,000 PER OCCURRENCE. ENDORSEMENT V206S ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-01-2005 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER SHELTER FROM THE STORM, INC. A NONPROFIT, MUTUAL BENEFIT CORPORATION 73555 ALESSANDRO OR PALM DESERT CA 92260 M0409 IREV.2.051 PRINTED : 03-16-2007 CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number: Shelter From The Strom( 0006 Domestic Violence Outreach &Advocacy Name/Address of Provider. Date: Shelter From The Storm, Inc. 73555 Alessandro, Ste D Palm Desert, CA 92250 BENEFICIARY QUALIFICATION STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits form the described projectlactivity. Please answer each of the following questions. 1. How many persons are in your household? For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household Renters,roomers,or borders cannot be included as household members 2. Circle your combined gross annual Income(Riverside-San Bernardino-Ontario,CA MSA—03108106) MEDIAN NUMBER OF PERSONS IN YOUR HOUSEHOLD: INCOME 1 2 3 4 5 6 7 8 LEVEL VERY LOW INCOME $20 150 S23,000 $25,900 $28 750 337,050 $33,350 $35,650 S37,350 Below'9 LOW INCOME S32,200 $36,800 $41,400 $46.000 $49,700 S53,350 S57,050 $$0,700 51 —80% MODERATE INCOME 548,300 S55,200 $62.100 S69,000 $74,500 $80,000 S85600 $91,100 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 ❑ Bleok/Afrlcan American AND White ❑ American Indian or Alaskan Native ❑ American Indian/Alaska Native AND Black/African American ❑ Native Hawaiian or Other Pacific Islander 0 Other HISPANIC/LATINO ETHNICITY ❑ Yes ❑ No If yes,check one 0 Mexican/Chicano ❑ Puerto Rican ❑ Cuban ❑ Other: 4. Please check, ves or n�if you are a female Head of Household? ❑ YES ❑ NO 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 Inrormation you provide on this form Is for Community Development Block Grant(CDBG)program purposes only and will be kept confidential. CITY OF PALM SPRINGS EXHIBIT E Program Progress Report Proiect/Activity Title: Project Number: Shelter From The Strom/ 0006 Domestic Violence Outreach & Advocacy Name/Address of Provider Date: Shelter From The Storm, Inc. 73555 Alessandro, Ste. D Palm Desert, CA 92260 PROGRAM PROGRESS REPORT Period: DIRECT BENEFIT REPORT • Number of First-Time Program Beneficiaries Serviced: #of Households #of Persons 0-50%below 51-80%below 120%below ♦ Number of First-Time Female Headed Households: Counts by Race/Ethnicity: White American Indian or Alaska Native AND White Black/African American Asian AND White Asian Black/African American AND White American Indian or Alaskan Native American Indian/Alaska Native AND Black/African American Native Hawaiian or Other Pacific Islander Other HISPANIC/LATINO 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/ActiyitKTitle: Project Number: Shelter From The Strom/ 0006 Domestic Violence Outreach &Advocacy Name/Address of Provider: Date: Shelter From The Storm, Inc. 73555 Alessandro, Ste, D Palm Desert, CA 92260 t Approved '1F CurronC'� Pnor Total Grant` Doscri on, . Grant bibursement Reim6urse.MIe YTD Balance Amounts � �Piiriad Periodis) ,Rolm6utsement (avert lender) Salaries—Outreach Advocate $11,550 Benefits—Outreach Advocate $3.450. TOTAL a15,000. [�E:=F � 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.