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HomeMy WebLinkAbout04297 - SHELTER FROM THE STORM CDBG SUBRECIPIENT �A0,4 City of Palm Springs = '1- Community Redevelopment Agency * MEMORANDUM Date: August 14, 2003 To: Barbara White, Assistant City Clerk From: John Raymond, Director of Community&Economic Develo Subject: Closing/termination of expired contracts Yesterday I sent over a long list of expired contracts that had been reviewed by Dale Cook, the Community Development Administrator, with instructions to close the ones indicated. These were mostly CDBG contracts that have expired, the services provided, and the funds paid out. The purpose of this memo is to inform you that I reviewed the list and concur with the recommendation to close those indicated. Please keep a copy of this memo in the file of each of the ideAffied closed contracts. Page: 6 Report: Expired Contracts: Oldest Date= / / and XREF= COMMUNITY& ECONOMIC DEV-Summary July 24, 2003 Contract mber Description Approval Date Expiration Date Closed Date A4269 Food Vouchers, Cdbg Subrecip.2000-01 08/23/2000 08/01/2001 j 1 �/� - e � Contractor :Aids Assistance Program Insurance Status: Certificate and Policies are OK may`% 1 ��•Z �f XREF: COMMUNITY &ECONOMIC DEVELOPMENT 'S Service: In FileAy A4296 CDBG SubrecipientAgr., Refrig/Freezer, 12-1-00 12/01/2000 12/01/2001 Contractor:Desert Aids Project Insurance Status:A policy will expire soon. �y�/ " r XREF: COMMUNITY& ECONOMIC DEVELOPMENT `r Service: In File A4297 C D B G Subrecipient 2001-02 Domestic Violence Outreach 06/27/2001 06/01/2002 / Contractor:Shelter From The Storm Insurance Status:A policy has Expired. XREF: COMMUNITY& ECONOMIC DEVELOPMENT Service: In File A429V C D B G Subrecipient 2000-01 Nightengale Manor 12/01/2000 12/01/2001 Contractor:Riverside County-Housing Authority y g ry Insurance Status: Certificate and Policies are OK XREF: COMMUNITY& ECONOMIC DEVELOPMENT '` '— Service: In File A4299 C D B G Subrecipient 2000-01 Fair Housing Program 12/13/2000 12/01/2001 Contractor:Fair Housing Council Insurance Status: Certificate and Policies are OK XREF: COMMUNITY& ECONOMIC DEVELOPMENT Service: In File 3.�-' A430 2000-01 CDBG Subrecipient Agreement 11/20/2000 11/01/2001 Contractor:Food In Need Of Distribution Insurance Status:A policy has Expired. �� *'—S XREF: COMMUNITY& ECONOMIC DEVELOPMENT Service: In File A4332 C D B G 2000/01 Homeless Outreach 04/05/2000 04/01/2001 Contractor:Catholic Charities z � Insurance Status: Certificate and Policies are OK XREF: COMMUNITY& ECONOMIC DEVELOPMENT Service: In File /�/�� �Shelter from the Storm DBG Subrecipient Agr AGREEMENT #4297 CM Signed 6-27-01 SUBRECIPIENT AGREEMENT - - -- --- ---- THIS AGREEMENT (herein "Agreement") , is made and entered into this - day of 7,,,6/„5�T— , 20oo, by and between the CITY OF PALM SPRINGS, (herein "City) , a municipal corporation, and the SHELTER FROM THE STORM, (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 seq. ) , as amended from time to time (the "Act") , and the regulations promulgated thereunder (24 C.F.R. Section 570 et seq. ("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 CONTRACTOR. 1. 1 Scope of Services. In compliance with all terms and conditions of this Agreement, the Provider shall provide those services specified in the "Scope of Services" attached hereto as Exhibit "A" and incorporated herein by this reference. Provider warrants that all services will be performed in a competent, professional and satisfactory manner. 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. 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 SEVENTEEN THOUSAND DOLLARS ($17, 000) (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. G. 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: Lynn Moriarty Executive Director 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 2 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 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 Economic Development Division 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; 3 • (i) The labor standard requirements as set forth in 24 CFR Part 570, Subpart K and HUD regulations issued to implement and requirements; (j ) The Program Income requirements as set forth in 24 C.F.R. 570.504 (c) and 570. 503 (b) (8) ; (k) 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; (1) Executive Order 11988 relating to the evaluation of flood hazards and Executive Order 11288 relating to the prevention, control and abatement of water pollution; (m) The flood insurance purchase requirements of Section 102 (a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) ; (n) 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. (o) Title VI of the Civil Rights Act of 1964 (P.L. 88- 352) and implementing regulations issued at 24 CFR Part 1; (p) Title VIII of the Civil Rights Act of 1968 (P.L. 90-284) as amended; and (q) 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. ) ; (r) 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. (s) 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 4 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. ) (t) 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 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 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, color, creed, religion, sex, marital status, physical or mental disability, national origin, or ancestry 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, or ancestry. 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, California 92263 Attn: City Manager 6 WITH COPY TO: ' Rutan & Tucker 611 Anton Blvd. , Suite 1400 Costa Mesa, California 92626-1998 TO CONTRACTOR: Lynn Moriarty Executive Director Shelter From The Storm P 0 Box 14155 Palm Desert, CA 92255-4155 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 this Agreement on the date first above written. CITY OF PALM SPRINGS, CALIFORNIA Dated: City Manage Z T S T i( - y Clerk j �?`7fn �F V nV tl 1� aq�''�:."-emu APPROVED AS TO FORM: 'Q -77 City t orney CONTRACTOR: Shelter From The Storm, Inc. Dated: Cj 9—C By: [Name: Ps.�arns Vr�Gi:.'�r�e rt1e:1 k : vame imJ'. 73�fT s T t 1 e: (Corporations require two NOTARIZED signatures; one from each of the following: A. Chairman of Board, any Vice President; AND B. Secretary, Assistant Secretary, Treasurer, Assistant Treasurer, or Chief Financial Officer. ) 7 CALIFORNIA ALL-PURPON ACKNOWLEDGMENT • State ofI e d�f>P_Iu I raj r jCounty of On P--A a� = bC)b before me, )l ttA ���(lon P� /"fOi4F Date I Name and Tills of Officer(e. "Jane Doe,Nolary P bho") r; personally appeared <; Names]of sgner(s) k personally known to me-OR-El proved to me on the basis of satisfactory evidence to be the person(, r� whose name(A) is/ale subscribed to the within instrument f>� and acknowledged to me that he/,*LAtm executed the same in his/fjsrAbeir authorized capacity(i0sj,and that by his/h tlf,*r si nature on the instrument the person }, fC� wnnocnwcoanoaoamnonau000aoaaomm� a oa]ne � 9 � sHEfu3.m•�� � or the entity upon behalf of which the erson acted, � comet, � Y p P C� NotRve§l cca�omea executed the instrument. atve sfae cou tv 01 My Cornrn,,On Eges� :ppp00`oo 0000,,,,,o, �ooe ve WITNESS my hand and official seal. c frt li c, Signature of Nolary Public > J OPTIONAL Though the information below Is not required by law, it may prove valuable to persons relying on the document and could prevent f, fraudulent removal and reattachment of this form to another document. '4 f( N Description of Attached Document I 1 fi s(� Title or Type of Document: 2 )F,o1J '6t u7,t h)I�P3 h ��RP� Jx1p 1JT - -- w- n (;, _ . Document Date: �`f i QS . Q 00( umber of Pages: c � k c, -- I ? Iil w; s Signer(s) Other Than Named Above: v--tt 1I�� mc� f r�6S � f r�pcJ)c� r�tJt'� y(Z ��FnT ie�F&�E-5 � fCi 'a Capacity(ies) Claimed by Signer(s) A -S� Signers Name: P to gd a_b Signer's Name: C ❑ Individual ❑ Individual Corporate.e�Officer ' ❑ Corporate Officer << Title(s): A-kES iI b i I Title(s): 1� sl ❑ Partner—❑ Limited ❑ General ❑ Partner—❑ Limited ❑ General i ❑ Attorney-in-Fact ❑ Attorney-in-Fact <<;'I ❑ Trustee ❑ Trustee ❑ Guardian or Conservator ❑ Guardian or Conservator <i ❑ Other: Top of thumb here ❑ Other: Top of thumb here cl Signer Is Representing: Signer Is Representing: 'I ki (ram li it <� a�—'.—°-v- ,—., C_v_..—� ✓vS-"vb%'o�='v✓IS=%bJ= S`-U—, _ �._�.��;���o'� —�_ �—...w �-=<T O�r�Sc�✓�`:� G�_.-��> ©1995 National Notary Association•8236 Remmet Ave.,PO Box 7184•Canoga Park,CA 91309-7104 Prod No.5907 Reorder:Car Toff-Free i-eWi CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT T State of California s fi ss. County of Ida r 11 On � (� 2 5-��1 before me,����i (G( �? y � I Ttl(�[U U ,� Dele Nanne6d Title ofOHicer(e.g.,"Jano1 Nota' Public") personally appeared in. )"ice$Tr Narr of agnep personally known to me El proved to me on the basis of satisfactory It evidence to be the perso% hose name( 1D, � I subscribed to the within instrument and acknowledged to me tha hoe executed the same in atze theif authorized capacityjjesj and that by h s hefl4h r I signature�n the instrument the person_(sror w MwoYMccARTHY the entity upon behalf of which the persort(sr c +Z Comm acted, executed the instrument ission# 1171583 '' . 5 ric a.D No-cry Public-California z„ , r 'rim Riverside County lC �_. s / �yTN�SS my hand and_offic�l seal � � yCc rm,�iresion3p,2tp2 ( /- 151 `—l1% �c✓ Place Notary Seel Above rgnauo'Tic � fi � �m OPTIONAL «;l Though the information below Is not required by law,it may prove valuable to persons relying on the document �1 and could prevent fraudulent removal and reattachment of this form to another document. c _ Description of Attached Docum jnt Title or Type of Document: l-� �LS'T t� � yj/( n yl Document Date: P l 1/,h _� Number of Pages: l /1 Signer(s) Other Than Named Above:l 1 CIL o Y)I, Joh ( Ij U16� 1e1LB capacity(ies) Cl ' ed by Si�gne 9 I� Signer's Name: ')El Individual Individual . p ) �[i.��. .�._r'Z_o.r Top of thumb here ' Corporate Officer—Titles C' ❑ Partner—❑ Limited El General El Attorney in Fact I�} ❑ Trustee III� ❑ Guardian or Conservator 1�l ❑ Other: I a' Signer Is Representing:h LC��V� _ ;� _ 1 r �r I �-e� I ©1997 National Notary Association•9350 be Salo Ave,PO Box 2402•Chatswodh,CA 91313-2402 Prad N. 5907 Reorder.Call Toll-Free 1-800-876-6827 CITY OF PALM SPRINGS EXHIBIT A Scope of Services Project/Activity Title: Protect Number: Domestic Violence Outreach and Advocacy Center Name/Address of PARTICIPANT: Shelter From The Storm, Inc. P.O.Box 14155 Palm Desert, CA 92255-4155 PROJECT/ACTIVITY DESCRIPTION Under the project, Shelter From The Storm will continue a Domestic Violence Outreach and Advocacy Center, based in Palm Springs, that will specifically focus on serving families victimized by domestic violence who live in the community. The center will provide the following: • A comprehensive range of crisis counseling and support services for battered women and their children in a highly accessible community setting, including crisis intervention and counseling, assistance with restraining orders, connections to emergency food and shelter, options planning, and referrals to other community services, such as hospitals and emergency rooms, clinics, physicians, schools and churches and synagogues. • Ongoing advocacy on behalf of clients in the interactions with law enforcement, the courts,government benefits programs and other services providers. • Regular distribution of emergency cards with Shelter From The Storm's 24-hour Crisis Line number to the local police officers and other service providers in Palm Springs. • Collaboration and training for a wide range of local service providers on how to recognize the signs of domestic violence and respond to those in need. Outreach will be provided to social service agencies; police officers; personnel within hospital, emergency rooms and clinics; private physicians; school staff; business leaders; and congregations of churches and synagogues. The continuation of a Domestic Violence Outreach and Advocacy Center in the City of Palm Springs, with a Outreach Advocate devoting 100% time to serving residents, will enable Shelter From The Storm to introduce domestic violence education earlier in the abuse cycle and offer women and their children intervention options in more accessible and familiar environment. We anticipate that this program will reach an estimated 350 women and children and service providers and other interested community members annually. Estimated Number of City of PALM SPRINGS Persons/Households to be served 350 • CITY OF PALM SPRINGS- - ; EXHIBIT B Budget Summary Proiect/Activity Title: Project Number Domestic Violence Outreach and Advocacy Center Name/Address of PARTICIPANT: Shelter From The Storm, Inc. P.O. Box 14155 Palm Desert, CA 92255-4155 BUDGETSUMMARY COST CATEGORY CDBG SHARE OTHER TOTAL SOURCES COST 1 Personnel $ $ $ 17 000 3,280 20,280 2 Consultant/Contract Services $ $ $ -0- 3 Travel $ $ $ 200 200 4 Space Rental $ $ $ 2,400 2,400 5 Consumable Supplies $ $ $ -0- 6 Rental, Lease or Purchase of $ $ $ Equipment 1,800 1,800 7 Insurance $ $ $ 600 600 8 Other $ $ $ Crisis Line 1,200 1,200 80 $�26480 TOTALS $ 17,000 $ 9,4 *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 sources consist primarily of fundraising activities conduced by Shelter From The Storm auxiliary Angels Alliances. EXHIBIT B — Budget Summary Page 2 of 2 Pages DETAIL BUDGET DESCRIPTION OF ACTIVITY/ CDBG OTHER TOTAL PAY ITEMS SHARE SOURCES COST Personnel - $17,000.00 $3,280.00 $20,280.00 Salaries/Benefits—Outreach Advocate Other Costs- - 0 - $6,200.00 $6,200.00 Operations & Overhead Expenses Total l $ 7;000:00:_ '�, $9,480.00: $26,480.00 The Subrecipient shall submit monthly reimbursement for Personnel Salaries/Benefits for Outreach Advocate at Palm Springs facility based on a salary table of $9.784/hour and fringe benefits of 25.33%. In no month shall the Subrecipient submit for reimbursement more than 1/4 of the total annual budget. Services are to be performed over the twelve-month period of this 2000-01 Program Year— July 1, 2000 through June 30, 2001. CITY OF PALM SPRINGS EXHIBIT C Insurance Inventory Project/Activity Title: Project Number: Domestic Violence Outreach And Advocacy Center Name/Address of Provider: Date: Shelter From The Storm, Inc. PO Box 14155 Palm Desert, CA 92255-4155 INSURANCE INVENTORY LIABILITY INSURANCE POLICY Name of Provider's Insurance Company Philadelphia Insurance Companies Effective Dates of Policy 07/01/00 to 07/01/01 Claims Made Policy / / Per Occurrence Policy Limits of Liability $2 000 000 Deductibles: Per Occurrence Annual Aggregate Additional Insured Endorsement (Certificate Holder) )(Yes ❑ No Original Certificate of Insurance Attached ❑Yes XINO WORKER'S COMPENSATION POLICY Name of Provider's Insurance Company State Compensation Insurance Fund Effective Dates 04/01/01 to 04/01/02 Limits of Liability $1,000,000 Underlying Coverage Limits Original Certificate of Insurance Attached ❑ Yes �No CITY OF PALM SPRINGS EXHIBIT D Beneficiary Qualification Statement Project/Activity Title: Project Number: Name/Address of Provider: Date: 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 borders cannot be included as household members. 2. Circle your combined gross annual income NUMBER OF PERSONS IN YOUR HOUSEHOLD: 1 2 3 4 5 6 7 8 VERY LOW INCOME Below 50% $16,600 $18,950 $21,350 $23,700 $25,600 $27,500 $29,400 $31,300 LOW INCOME $26,550 $30,350 $34.150 $37,900 $40,950 $44,000 $47,000 $50,050 51 -80% 3. Do you identify yourself as: ❑ White ❑ Black ❑ Hispanic ❑ American Indian ❑ Asian ❑ Multi-ethnic 4. Please circle, ves or no,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: Thu information you provide on this form is for Community Development Block Cl(CDBG)program purposes only and will be kept confidential CITY OF PALM SPRINGS EXHIBIT E Quarterly Program Progress Report Protect/Activity Title: Protect Number: Name/Address of Provider: Date: PROGRAM PROGRESS REPORT For the Period Ending: DIRECT BENEFIT REPORT -Number of First-Time Program Beneficiaries Serviced#of Households #of Persons 0-50%below 51-80%below -Number of First-Time Female Headed Households: -Counts by Race/Ethnicity: White, Not Hispanic Origin Black, not Hispanic Origin Hispanic American Indian/Alaskan Native Asian Pacific Islander Multi-ethnic Signed Title Date CITY OF PALM SPRINGS EXHIBIT F Request for Reimbursement Proiect/Activity Title: Project Number: Name/Address of Provider: Date: BENEFICIARY QUALIFICATION STATEMENT Column 1 Column 2 Column 3 Column 4 Column 5 Total Grant Amount Current Prior Total Cumulative Grant Balance Reimbursement Reimbursement Reimbursement 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 Contract 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. PREPARED BY: Phone: APPROVED BY: Date: Name, Title Name, Title (must be an original signature) City of PALM SPRINGS Use Only Audited by: Examined by: Approved by: A detailed breakdown of costs expended must be attached to each Request for Reimbursement and verified by original signature. MAR-21-2001 WED 11 :36 AM SH TER FROM THE STORM FAX NO. 76 40440 P, 02 _ RECErvL1� DEC -( iM111�A�R g yf MINI <A? 'a<o-';.ftrr.<r<TINNAuiu� :e�en>,hi. R'' ' ,>'�i•� >e • T a I �oiN' 11 130 0 { PRODUCER Weingarten & Hough-Lic#0086542 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION P O Box 1866 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Palm Springs CA 92263 COMPANIES AFFORDING COVERAGE (760) 37.5-2526 cauPnon INSURED A Philadelphia Insurance Com aniee COMPANY Shelter from the Storm B P. 0. Box 14155 COMPANY C Palm Desert CA 92211-4155 COMPANY (760) 328-7233 D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, Exc WSIONS AND CONDITIONS OF SUCH POLICIES,.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ TYPE OF INSURANCE POUCYNUMBET1 POLIMMEGME POUCYEXPIBATION LTA DATE(MMMDNY) DATE(MMPoD/YY) UNIT] A GENERALUABIUTY GENERAL AGGREGATE 2 ( 000, 000 X ODMMERQALGENERALUABIUTY PHPG205104 07/01/00 07/01/01 PRooucTE-coMP/CPAcG ELL-0 0�O 000 CLAIMS MADE nOCCUR PERSONAL.&ADYJ INJURY s1 000 000 OWNER'S&CONTRACTORS PROT EACH OCCURRENCE $1, 0, 0 O 0, 0 0 0 FIRE DAMA9E("onc fim) S 100, 000 MEDEZP(AyonePeaonl a 1, 000 AUTOMOBILE Le1BIUTY ANY AUTO / / / / COMBINEDSINGLEUMIT L ALL OWNIM AUTOS BODILY INJURY S SCHEDULED AUT02 (Per Perron) HIRED AUTOS BODILY INJURY NON-ONNED AUTOS (Per wukem) S PROPERTY DAMAGE s GRAOE LIASIUTY AUTO ONLY-EA ACCIDENT S ANYAUTO / / / / OTHER THAN AUTO ONLY: EACH AGUDENT 5 AOORECATE S EXCESS LIABILITY EACH OCCURRENCE 3 UMWELLA FORM I / I I AGGREGATE s ,-- - OTHER,TI IAN UMBRELLA FORM s WORKERS COMPEN&ATION AND STATUTORY UMITS EMPLOYERS'LIABILRY EACH ACCIDENT — s THE P%t':TORE INCL DISEASE•POLICY LIMIT T PARTNfF✓s/E%ECUTNE -. OFFK:EFL^s ARE: D(CL DISEASE EACH EMPLOYEE s OTHER DESCRIPTION OF OPERATIONS/LOMnON3 EHICLES/EPEGAL ITEM] CITY OF PALM SPRINGS IS ADDITIONAL INSURED AS REGARDS CDBG #A4138 FOR SHELTER FROM THE STORM. 30 DAY NOTICE OV CANCELLATION APPLIES . FAXED TO TRICIA AT 322-8332 1,.. SHOULD ANY OF THE ABOVE DESCRIBED POMOIEB DE CANCELLLO BEFORE THE EXPIRATION RATE THEREOF, THE ISSUING COMPANY WILLXRUp%XOWXX MAIL CITY OF PALM SPRINGS 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LFFr, P. 0. BOX 2743 �tmcsex pIPk967i 6tWtDGiPAIRR RkY%UOk0.9RR71A R9P7RAA0PxWlC5N4x RT PALM SPRINGS, CA. 9226334 wx GYoc K ?i YdblvN x> Xr Xg rRI,YR AUYHOµI REPR NTA _ _ SK- STATE P.O, BOX 807, SAN FRANCISCO,CA 94101-0807 COMpEN SATION ' INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICY'NUM,BER 488-01 UN7T O6000'82 ISSUE DATE 04-01-ol CERTIFICATE EXPfRES: 04701^02 CITY OF PALM SPRINGS CITY CLERKS OFFICE P 0 BOX 2743 PALM SPRINGS CA 92263 — This is to certify that we have Issued a valid Woryera' 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 1Ddays' advance written notice to the employer. We will also give you 10 days' advance native should this policy he cancelled prior to its normal expiration. ,. This.certificate of Insurance is not w insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other'dodument ; with respect to which this certificate of insurance may be Issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, excluslons and conditions of such policies, �t ;. PnSIDENT EMPLOYER1S ,LIABILTTY LIMIT INCLUDING DEFENSE COSTS: 31,000,000,00 PER 'Q15PURRENCE: ' EHIKOYER • 'LEGAL NAME . SHELTER FROM THE STORM, INC. SHELTER FROM THE STORM,, INCr PO BOX 14155 A NON-PROFIT, MUTUAL" BENEFIT CORPORA'TI PALM DESERT CA 92255 PRINTED: 03-17701 P0409 '• as / � • a JUL-09-2003 WED 01 :50 PM WE6RTEN & HOUGH FAX NO. 31§68 P. 02/02 A ORS,„ CERTIFICATE OF LIABILITY INSURANCE DATE 07 09 2003 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Weingarten & Hough ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P O Box 1866 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Palm Springs CA 92263- INSURERS AFFORDING COVERAGE INSURED INSURERA:PHILADELPHIA INSURANCE COMPANY ✓';-� (,, Shelter from the Storm wsuRERB: ��'�ll..� ? ft;'' P. O. Box 14155 INSURER INSURERS: Palm Desert CA 92261- INSURER E: J ✓+ /`� n �� `�" �r COVERAGES "`i df THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWIT REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE... BE ISSUED OR N, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPEOFINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LM DATE MM/DDI V DATE MWr)DlYY GENERAL LIABILITY A EACH OCCURRENCE $ 1,000,00( X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any ono lire $ 100100( CLAIMSMADE 7X OCCUR PHPY053458 07/01/2003 07/01/2004 MED FxP(Any one arson $ 5,001 X PROFESSIONAL LIAH PERSONAL&ADV INJURY $ 1,000,DO( X GENERAL AGGREGATE S 2,0OD,00( GENT,AGGREGATE LIMIT APPLIES PER: .PRODUCTS-COMPIOPAGG $ 11000,001 POLICY JRCPT LOC AUTOMOBILE LIABILITY / COMBINED SINGLE LIMIT ANY AUTO (Ea accldent) g ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) S HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per axidanl) S PROPERTYDAMAGE (Par accident) S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EAACC 5 AUTO ONLY: AGO S EXCESS LIABILITY / EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE S __ S DEDUCTIBLE / $ RETENTION $ yyi�pp Tq I� S WORKERS ANDMPOYRABLIY / 70I'y Sl-IMITS OER E.L.EACH ACCIDENT S / � / E.L.DISEASE-EA EMPLOYEES E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTJSPECIAL PROVISIONS OPERATIONS OF THE INSURED FOR THE CERTIFICATE HOLDER. REFERENCE AGREEMENT #19 A4138, IL4297, A4481, A4677. CITY OF PALM SPRINGS IS ADDED AS ADDITIONAL INSURE➢. 10 DAY NOTICE OF CANCELLATION APPLIES TO NON PAYMENT OF PREMIUM. CERTIFICATE HOLDER X I ADDITIONAL INSURED•INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT CITY OF PALM SPRINGS FAILURE TO DO SO SHALL IMPOSE OBLIGATION LIABILITY OF ANY KIND UPON THE P. O. BOX 2743 INSURER ITS AGENTS OR REPRESTTATIVFA AUTHORIZED REPRESENTATIY + PALLS SPRINGS CA 92263- ACORD 25.5(7/97) o ACORD CORPORATION 198 �. INS025S(9010).02 ELECTRONIC LASER FORMS,INC.-(800)327-0545 Papa 1 of r SK * _ THOLDER COPY ,�TAT E P O BOX 807, SAN 'RRANCISCO CA $41°42 0807 tcoMPENSATION ' - _ 2b 'VN SiJR'AN, C� FUND -CtRTIFICATE QF ,WORKERS` COMPENSATION -INSURANCE ' ,�-'19SUE.DPSE 04 01-2003 _ 'GROUP: 0,0048,,8 POLICY NUMBER: 0000092-2003 CERTIFIC/-TF ID,, 1 , Y CERTIFICATE EXPIRES: 04-01-2004 04-01.-2003/04-01-2004 C I;TY OF PA LW SPRINGS SK , I - CI Ty GLERICS` OFO,,I,G;E 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 Inquran`e�Cemtiiiseton=_r to the"',employer named below for the policy period indicated. .This policy is-!not subject to cancellation by the Fund except upon 10days' advance written notice to the employer. We will also give you 10 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 policies listed herein,%Notwlthstanding ,any requirement, term, or condition of any contract or other document with respect to which this certificate ef;,insurance'may"be issued or may pertain, the insurance afforded by the policies descrihed herein is subject to all the terms, exclusions and conditions of such policies. "AUTHORIZED REPRESENTATIVE PRESIDENT ' ' ,EMPLOYER'S .LIABILITY. LIMIT INCLUDING DEFENSE COSTS,: $.1,000',000.00 PER OCCURRENCE. J. • .. ,,. is � .:...,..:. EMPLOYER. - .- '-^LEGAL NAME . ,SHELTER FRM THE°-'STORM, ,INC. SHELTER FROM THE STORM, INC. i PO� BOX 14155 .,A NON-PROFIT, MUTUAL BENEFIT QORPORATIC PALM DES.ERT' CA ','92255 PRINTED: 03=17-2003 P0408 -