HomeMy WebLinkAboutDELHI CENTER - 2003 FEZAGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
Return form to the Deputy Clerk of the Council (M-30). Call 647-6520 if you have any
questions.
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The agreement with A-
was completed on and final payment has been made.
Az U
A - Zo04 - obo Department:
Signature:
Date:
City of Santa Ana
Revised 4-16-87 Clerk of the Council
INSURANCE ON FILE
WORK MAY PROCEEO
UNTIL INSURANCE EXPIRES
CLERK OF COUNCIL.
DATE: 13- I -L_3
CONSULTANT AGREEMENT
A-2003-160
THIS AGREEMENT, made and entered into this oZ/S day of
��.
V jee"2003 by and between Delhi Center (hereinafter "Consultant"), and the City o Santa Ana
// a municipal corporation organized and existing under the Constitution and laws of the
State of California (hereinafter "City").
RECITALS
A. The City desires to retain a consultant having special skill and knowledge in the
field of providing vocational/occupational training, employment strategies,
education and supportive services to individuals who reside in the Federal
Empowerment Zone.
B. Consultant represents that Consultant is able and willing to provide such
services to the City.
C. In undertaking the performance of this Agreement, Consultant represents that it
is knowledgeable in its field and that any services performed by Consultant
under this Agreement will be performed in compliance with such standards as
may reasonably be expected from a professional consulting firm in the field.
D. The City, through the Santa Ana Empowerment Corporation (SAEC), is the
recipient of Empowerment Zone ("FEZ") funds from the United States
Department of Housing and Urban Development ("HUD").
E. The City and Consultant have duly executed this Agreement for expenditure of
such funds.
NOW THEREFORE, in consideration of the mutual and respective promises, and
subject to the terms and conditions hereinafter set forth, the parties agree as follows:
SCOPE OF SERVICES
Consultant shall perform those services as set forth in Exhibit A to this
Agreement.
2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for its
services, the rates and charges identified in Exhibit B. The total sum to be expended
under this Agreement, shall not exceed $75,000.00 during the term of this Agreement.
b. Payment by City shall be made within thirty (30) days following receipt of
proper invoice evidencing work performed, subject to City accounting procedures.
Page 1 of 9
Payment need not be made for work which fails to meet the standards of performance
set forth in the Recitals which may reasonably be expected by City.
TERM
This Agreement shall commence on July 1, 2003 and terminate on June 30,
2004, unless terminated earlier in accordance with Section 12, below. The term of this
Agreement may be extended upon a writing executed by the Executive Director of the
Community Development Agency and the City Attorney.
4. INDEPENDENT CONTRACTOR
Consultant shall, during the entire term of this Agreement, be construed to be an
independent contractor and not an employee of the City. This Agreement is not
intended nor shall it be construed to create an employer-employee relationship, a joint
venture relationship, or to allow the City to exercise discretion or control over the
professional manner in which Consultant performs the services which are the subject
matter of this Agreement; however, the services to be provided by Consultant shall be
provided in a manner consistent with all applicable standards and regulations governing
such services. Consultant shall pay all salaries and wages, employer's social security
taxes, unemployment insurance and similar taxes relating to employees and shall be
responsible for all applicable withholding taxes.
5. INSURANCE
Prior to undertaking performance of work under this Agreement, Consultant shall
maintain and shall require its subcontractors, if any, to obtain and maintain insurance as
described below:
a. Commercial General Liability Insurance. Consultant shall maintain
commercial general liability insurance naming the City, its officers, employees, agents,
volunteers and representatives as additional insured(s) and shall include, but not be
limited to protection against claims arising from bodily and personal injury, including
death resulting therefrom and damage to property, resulting from any act or occurrence
arising out of Consultant's operations in the performance of this Agreement, including,
without limitation, acts involving vehicles. The amounts of insurance shall be not less
than the following: single limit coverage applying to bodily and personal injury, including
death resulting therefrom, and property damage, in the total amount of $1,000,000 per
occurrence. Consultant shall supply City with a fully executed additional insured
endorsement in substantially the form attached hereto as Exhibit F upon execution of
this Agreement and shall be approved in form by the City Attorney.
b. Business automobile liability insurance, or equivalent form, with a combined
single limit of not less than $1,000,000 per occurrence. Such insurance shall include
coverage for owned, hired and non -owned automobiles.
Page 2 of 9
c. Worker's Compensation Insurance. In accordance with the provisions of
Section 3300 of the Labor Code, Consultant, if Consultant has any employees, is
required to be insured against liability for worker's compensation or to undertake self-
insurance. Prior to commencing the performance of the work under this Agreement,
Consultant agrees to obtain and maintain any employer's liability insurance with limits
not less than $1,000,000 per accident.
d. The following requirements apply to the insurance to be provided by
Consultant pursuant to this section:
(i) Consultant shall maintain all insurance required above in full force
and effect for the entire period covered by this Agreement.
(ii) Certificates of insurance shall be furnished to the City upon
execution of this Agreement and shall be approved in form by the
City Attorney.
(iii) Certificates and policies shall state that the policies shall not be
canceled or reduced in coverage or changed in any other material
aspect without thirty (30) days prior written notice to the City.
e. If Consultant fails or refuses to produce or maintain the insurance required by
this section or fails or refuses to furnish the City with required proof that insurance has
been procured and is in force and paid for, the City shall have the right, at the City's
election, to forthwith terminate this Agreement. Such termination shall not effect
Consultant's right to be paid for its time and materials expended prior to notification of
termination. Consultant waives the right to receive compensation and agrees to
indemnify the City for any work performed prior to approval of insurance by the City.
6. INDEMNIFICATION
Consultant agrees to and shall indemnify and hold harmless the City, its officers,
agents, employees, consultants, special counsel, and representatives from liability: (1)
for personal injury, damages, just compensation, restitution, judicial or equitable relief
arising out of claims for personal injury, including health, and claims for property
damage, which may arise from the direct or indirect operations of the Consultant or its
contractors, subcontractors, agents, employees, or other persons acting on their behalf
which relates to the services described in section 1 of this Agreement; and (2) from any
claim that personal injury, damages, just compensation, restitution, judicial or equitable
relief is due by reason of the terms of or effects arising from this Agreement. This
indemnity and hold harmless agreement applies to all claims for damages, just
compensation, restitution, judicial or equitable relief suffered, or alleged to have been
suffered, by reason of the events referred to in this Section or by reason of the terms of,
or effects, arising from this Agreement. The Consultant further agrees to indemnify,
hold harmless, and pay all costs for the defense of the City, including fees and costs for
special counsel to be selected by the City, regarding any action by a third party
challenging the validity of this Agreement, or asserting that personal injury, damages,
just compensation, restitution, judicial or equitable relief due to personal or property
Page 3 of 9
rights arises by reason of the terms of, or effects arising from this Agreement. City may
make all reasonable decisions with respect to its representation in any legal proceeding.
7. CONFIDENTIALITY
If Consultant receives from the City information which due to the nature of such
information is reasonably understood to be confidential and/or proprietary, Consultant
agrees that it shall not use or disclose such information except in the performance of
this Agreement, and further agrees to exercise the same degree of care it uses to
protect its own information of like importance, but in no event less than reasonable care.
"Confidential Information" shall include all nonpublic information. Confidential
information includes not only written information, but also information transferred orally,
visually, electronically, or by other means. Confidential information disclosed to either
party by any subsidiary and/or agent of the other party is covered by this Agreement.
The foregoing obligations of non-use and nondisclosure shall not apply to any
information that (a) has been disclosed in publicly available sources; (b) is, through no
fault of the Consultant disclosed in a publicly available source; (c) is in rightful
possession of the Consultant without an obligation of confidentiality; (d) is required to be
disclosed by operation of law; or (e) is independently developed by the Consultant
without reference to information disclosed by the City.
8. CONFLICT OF INTEREST CLAUSE
Consultant covenants that it presently has no interests and shall not have
interests, direct or indirect, which would conflict in any manner with performance of
services specified under this Agreement.
9. SOURCE OF FUNDS
a. Consultant acknowledges that the FEZ funds being provided by City for
Consultant's services are received by City from HUD, and warrants that expenditures of
these funds shall comply with the laws, regulations and policies governing the use of
said funds as set forth in P.L. 106-74 (2000), 24 CFR 598.215 and Federal Register,
April 16, 1998.
b. Consultant has received and read a copy of the City's SUBRECIPIENT
Agreement with the Santa Ana Empowerment Corporation and agrees to be bound by
all of the terms and conditions of said SUBRECIPIENT Agreement, as set forth in
Exhibit C, Acknowledgement of Subrecipient Agreement, attached hereto and by this
reference incorporated herein.
10. CONSULTANT CERTIFICATIONS
a. Consultant has read and shall comply with any and all restrictions on lobbying
as set forth in the Certification Regarding Lobbying, attached hereto as Exhibit D and
incorporated herein by reference.
Page 4 of 9
b. Consultant shall maintain a drug free workplace as set forth in the
Certification regarding Drug Free Workplace Requirements, attached hereto as Exhibit
E, and incorporated herein by reference.
c. Consultant assures and certifies that it will not use any funds appropriated
under this agreement for religious activity or anti -religious activity, or to promote or
oppose any political candidate, party and/or belief.
d. Consultant assures and certifies that where applicable, classroom training
instructors are properly credentialed, and training curriculums comply with State
Education Codes.
e. Consultant assures and certifies that it is in good standing with the California
Secretary of State Franchise Tax Board and Internal Revenue Service.
f. Consultant agrees to cooperate with any monitoring, inspection, audit, or
investigations of activities related to this agreement as may be scheduled and
conducted by the Santa Ana WORK Center of the Santa Ana Empowerment
Corporation.
g. Consultant agrees to acknowledge the Santa Ana WORK Center and Santa
Ana Empowerment Corporation as the source of funds in all oral presentations, written
documents, publicity and advertisements regarding any activities that ensue from this
agreement.
11. NOTICE
Any notice, tender, demand, delivery, or other communication pursuant to this
Agreement shall be in writing and shall be deemed to be properly given if delivered in
person or mailed by first class or certified mail, postage prepaid, or sent by telefacsimile
or other telegraphic communication in the manner provided in this Section, to the
following persons:
To City:
Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
telefacsimile (714) 647-6956
With courtesy copy to:
Santa Ana WORK Center
1000 E. Santa Ana Boulevard, Suite 200
Page 5 of 9
Santa Ana, California 92701
telefacsimile (714) 565-2602
To Consultant:
Delhi Center
505 E. Central Avenue
Santa Ana, California 92707
Telefacsimile (714) 481-9600
A party may change its address by giving notice in writing to the other party.
Thereafter, any notice, tender, demand, delivery, or other communication shall be
addressed and transmitted to the new address. If sent by mail, any notice, tender,
demand, delivery, or other communication shall be effective or deemed to have been
given three (3) days after it has been deposited in the United States mail, duly
registered or certified, with postage prepaid, and addressed as set forth above. If sent
by telefacsimile, any notice, tender, demand, delivery, or other communication shall be
effective or deemed to have been given twenty-four (24) hours after the time set forth on
the transmission report issued by the transmitting facsimile machine, addressed as set
forth above. For purposes of calculating these time frames, weekends, federal, state,
County or City holidays shall be excluded.
12. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the
City and Consultant, and supersedes any and all other agreements, oral or written,
between the parties. In the event of a conflict between the terms of this Agreement and
any attachments hereto, the terms of this Agreement shall prevail. This Agreement may
not be modified except by written instrument signed by the City and by an authorized
representative of Consultant. The parties agree that any terms or conditions of any
purchase order or other instrument that are inconsistent with, or in addition to, the terms
and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to
this Agreement acknowledges that no representations, inducements, promises or
agreements, orally or otherwise, have been made by any party, or anyone acting on
behalf of any party, which are not embodied herein.
13. ASSIGNMENT
Inasmuch as this Agreement is intended to secure the specialized services of
Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest
herein without the prior written consent of the City and any such assignment, transfer,
delegation or subcontract without the City's prior written consent shall be considered
null and void. Nothing in this Agreement shall be construed to limit the City's ability to
have any of the services which are the subject to this Agreement performed by City
personnel or by other consultants retained by City.
Page 6 of 9
14. TERMINATION
This Agreement may be terminated upon thirty (30) days written notice by either
party. In such event, Consultant shall be entitled to receive and the City shall pay
Consultant compensation for all services performed by Consultant prior to receipt of such
notice of termination, subject to the following conditions:
a. As a condition of such payment, the Executive Director may require Consultant
to deliver to the City all work product completed as of such date, and in such case such
work product shall be the property of the City unless prohibited by law, and Consultant
consents to the City's use thereof for such purposes as the City deems appropriate.
Payment need not be made for work which fails to meet the standard of
performance specified in the Recitals of this Agreement.
15. DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex,
marital status, sexual orientation, age, national origin, ancestry, or disability, as defined
and prohibited by applicable law, in the recruitment, selection, training, utilization,
promotion, termination or other employment related activities. Consultant affirms that it
is an equal opportunity employer and shall comply with all applicable federal, state and
local laws and regulations.
16. JURISDICTION -VENUE
This Agreement and all questions relating to its validity, interpretation,
performance, and enforcement shall be governed and construed in accordance with the
laws of the State of California. This Agreement has been executed and delivered in the
State of California and the validity, interpretation, performance, and enforcement of any
of the clauses of this Agreement shall be determined and governed by the laws of the
State of California. Both parties further agree that Orange County, California, shall be
the venue for any action or proceeding that may be brought or arise out of, in
connection with or by reason of this Agreement.
17. PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, maintain all necessary
licenses, permits, approvals, waivers, and exemptions necessary for the provision of the
services hereunder and required by the laws and regulations of the United States, the
State of California, the City of Santa Ana and all other governmental agencies.
Consultant shall notify the City immediately and in writing of her inability to obtain or
maintain such permits, licenses, approvals, waivers, and exemptions. Said inability
shall be cause for termination of this Agreement.
Page 7 of 9
18. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature hereinbelow has
the power, authority and right to bind their respective parties to each of the terms of this
Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees,
for any injuries or damages to City in the event that such authority or power is not, in fact,
held by the signatory or is withdrawn.
b. All Exhibits referenced herein and attached hereto shall be incorporated as if
fully set forth in the body of this Agreement.
Page 8 of 9
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of
the last date and year written below.
CITY OF SANTA Ana, a municipal
Corporation of the State of California
DATED:
David N. Ream
City Manager
ATTEST: APPROVED AS TO FORM
A. _
PATRICIA E. HEALY, " (J j"~ BEN KAUFMAN,
Clerk of the Council City General Counsel
RECOMMENDED FOR APPROVAL
AL
JohnO. Reekstin, Executive Director
Community Development Agency
CONTRACTOR:
Federal Tax ID: 4i :24 �-O�5-LJ
Page 9 of -9
Delhi Center
FEZ Daisy Wheel Network Program
Scope of Work
I. TERM
July 1, 2003 through June 30, 2004
II. PURPOSE
The FEZ Daisy Wheel Network Program will provide vocational/occupational training, employment
strategies, education, and supportive services to individuals who reside in the Federal Empowerment
Zone.
III. POPULATION TO BE SERVED
The population to be served are Federal Empowerment Zone residents 18 years and older.
Eligibility will be determined by age, address, and by Right to Work documentation.
IV. PROGRAM DESIGN, ELEMENTS, AND OUTCOMES FOR DELHI CENTER
A. Program Design:
a. Provide an intake assessment (for screening) of each FEZ resident that includes a review
of academic and occupational skills levels as well as service needs;
b. Develop an Individual Service Plan including notifying achievement objectives.
B. Program Elements:
a. The following program elements will be made available to eligible residents expected to
enroll in the FEZ Daisy Wheel Network Program for participation in activities aimed at
providing a comprehensive strategy that addresses employment and training needs:
i. vocational/occupational training,
ii. employment strategies,
iii. education, and
iv. supportive services
C. Performance Outcomes
a. 100 will be served
b. Of the 100 FEZ residents served, 50 (50%) will be provided additional services as needed
c. Of the 100 FEZ residents served, 40 (40%) will be placed in jobs, given work experience,
receive On -the -Job Training, receive retention services, attend English as a Second
Language classes, be provided with skill upgrades, and have access to paid internships.
d. Planned enrollments by Quarter:
V. SERVICES WILL BE PROVIDED AT:
Delhi Center
505 E. Central Ave.
Santa Ana, CA 92707
EXHIBIT: A
I:t
Qtr.
Zoa
tr.
3 a
tr.
4m
Qtr.
35
15
1 35
15
V. SERVICES WILL BE PROVIDED AT:
Delhi Center
505 E. Central Ave.
Santa Ana, CA 92707
EXHIBIT: A
VI. WORK CENTER RESPONSIBILITIES
1. Develop contracts for partners
2. Provide orientation and training on eligibility, referral process, assessment, MIS tracking
system, joint policies and procedures, fiscal billing, documentation, etc.
3. Develop joint forms such as application, screening/intake tool, ISP, referral form, MIS
forms, etc.
4. Perform Program Monitoring
5. Perform Program Reporting
6. Provide partners with on-going technical assistance
7. Provide a quarterly FEZ newsletter
8. Facilitate monthly meetings
VII. DELHI CENTER RESPONSIBILITIES
1. Delhi Center will provide eligible FEZ residents with services designed to meet the FEZ
Board requirements. A participant will be provided with one or more of the following
services to assist them in obtaining unsubsidized employment and self-sufficiency:
• Case management
• Job readiness
• Job development
• Coordinate on-site recruitments
• Community forums on job related services
2. Evaluate participants for eligibility and assign those eligible for program services.
3. Perform client assessments. Assess education level of FEZ participants through TABE test
and using ISP form.
4. Report progress and job placements to WORK Center FEZ staff.
5. Incorporate all service navigator partners' information into each other's marketing materials.
6. Attend monthly partner meetings.
7. Provide WORK Center FEZ staff with monthly and quarterly progress reports.
8. Provide WORK Center FEZ staff with necessary information for conducting informal and
formal monitoring of program progress.
9. Meet performance measures. All staff and agencies participating in this project will be held
accountable for achieving their agency FEZ performance measures.
10. Submit Monthly Statistics Report documentation to FEZ Liaison staff by the 5`h of every
month. Report should include new enrollments and a continuous Activity Enrollment Form.
11. Maintain a current and complete file (electronic as well as a hard copy) for each FEZ
participant: eligibility documentation; registration form; enrollment form; assessment;
Individual Service Plan (ISP); EEO/Grievance; case notes; supportive services
documentation; attendance records; training documentation; etc.
12. Comply with allowable expenses. To be allowable, costs must: a) be reasonable for the
performance of the program; b) conform to any limitations or exclusions set forth in the
program as to types or amount of cost items; c) be consistent with policies and procedures
that apply uniformly to both federally -financed and other activities of the organization; d) be
determined in accordance with generally accepted accounting principles (GAAP); e) not be
included as a cost or used to meet cost sharing or matching requirements of any other
federally -financed program in either the current or a prior period; and, I) be adequately
documented.
13. Submit in triplicate, a monthly Invoice on City of Santa Ana, Federal Empowerment Zone
Program Subrecipient Request for Reimbursement, showing in detail the amount of money
EXHIBIT. A
already expended. Accounting records must be supported by source documentation such as
cancelled checks, paid bills, payrolls, and attendance records. Submit the above stated
documents to Osiel "Ozzie" Madrigal by the tenth (10`x') day of the month following the
month in which services are performed.
Imo' 9TW
DELHI
BUDGET FORM
* Attach a separate sheet detailing these costs.
** Please Note: pursuant to audit requirements, states, local governments and non-profit
institutions that receive $300,000 or more in federal funds in a fiscal year shall meet the
audit requirements of the OMB Circular A-133, "Audits of States, and Local
Governments and Non -Profit Institutions."
EXHIBIT .B
Form 3 29
Administrative
Program
Total FEZ
Match/In
Kind
Personnel
Salaries*
9,250
40,500
49,750
0
Benefits
1,850
8,100
9,950
0
Other Subcontract Trainr *
Total Personnel
11,100
48,600
59,700
0
Opera inExpenses
Rent or user fee*
0
4,200
0
4,200
Utilities
0
2,000
2,000
0
Phones
0
1,200
1,200
0
Internet fees
Included Above
Parking fees
0
0
0
0
Security
0
0
0
0
Maintenance
0
3,200
3,200
0
Insurance
0
1,350
1,350
0
Equipment*
Rental fees
0
500
500
0
Purchase
0
0
0
0
Vehicle lease charges
(vehicles may not be
purchased)
0
0
0
0
Office expenses
(consumables)
0
2,500
2,500
0
Accounting Services
0
1,200
1,200
0
Legal services
0
0
0
0
Auditing services
0
800
800
0
Indirect costs
(attach indirect cost
rateplan*)
0
0
0
0
Staff training
0
800
800
0
Staff travel/mileage
0
500
500
0
Customer Training*
0
0
0
0
Support services*
0
10,000
0
10,000
Profit for profits only)
n/a
n/a
n/a
n/a
Other marketin meetin s
0
2,000
1,250
750
Total Operating Expenses
0
30,250
15,300
14,950
GRAND TOTAL
(Total Personnel + Total
Operating Expenses)
$11,100
$78,850
$75,000
$14,950
* Attach a separate sheet detailing these costs.
** Please Note: pursuant to audit requirements, states, local governments and non-profit
institutions that receive $300,000 or more in federal funds in a fiscal year shall meet the
audit requirements of the OMB Circular A-133, "Audits of States, and Local
Governments and Non -Profit Institutions."
EXHIBIT .B
Form 3 29
ACKNOWLEDGEMENT OF
SUBRECIPIENT AGREEMENT
To: John P. Reekstin
Executive Director
Santa Ana Empowerment Corporation
From: Subcontractor/Assignee
Subcontractor/Assignee hereby stipulates that it has been provided with a copy, has read,
and is familiar with all of the terms of SUBRECIPIENT's Agreement with the Santa Ana
Empowerment Corporation.
Subcontractor/Assignee further agrees to be bound to all of the terms and provisions of
SUBRECIPIENT's Agreement with the Santa Ana Empowerment Corporation.
Executed this day of 5.
BY:
Name: Ugh
Title: L-xf��r lU �l2�CT77/�
EXHIBIT c
Certification Regarding Lobbying
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
or cooperaive agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form -LLL, "Disclosure Form to Report Lobbying," in accordance
with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.
Grantee/Contractor Organization I Program Title
Name of
EXHIBIT D
Part I
Date
INSTRUCTIONS FOR COMPLETION OF SF -LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure farm still be completed by the reporting entity, whether subawardee or prime Federal recipient, at the Initiation or receipt of a covered
Federal action, or a material change to a previous filling, pursuant to title 31 U.S.C. section 1352. The filling of a form be required for each payment or
agreement to make payment for any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a member of
Congress an officer or employee of Congress, or an employee of a Member of Congress in connection with a Federal Action. Used the SF -LLL -A
Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filling and material
change report. Refer to the Implementing guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal Action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal
action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported,
enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this
covered Federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate
classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g,
the first subawardee of the prime is the 1" tier. Seaboard include but are not limited to subcontracts, subcontracts, subgrants and contract awards
under grants.
5. If the organization filling the report in item 4 checks "subwardee" then enter the full name, address, city, state and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if
known. For example, Department of Transportation, United States Coast Gaurd.
7. Enter the Federal program name or description for the covered Federal action (iteml). If known, enter the full Catalog of Federal Domestic
Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item I (e.g.) Request for Proposal (RFP)
number; invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control
number assigned by the Federal agency). Include prefixes, e.g. "RFP -DE -90-001."
9. For a covered Federal action where these has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the
covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle initial (MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate
whether the payment has been made (actual) or will be made (planned). Check all boxes that apply, if this is a material change report, enter the
cumulative amount of payment made or planned to be made.
12. Check the appropriate box(es). Check all boxes that apply, if payment is made through an in-kind contribution, specify the nature and value of the
in-kind payment.
13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) for any
services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal
official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.
15. Check whether or not a SF -LLL -A Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of
Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D.C.20503.
EXHIBIT D
Part II
Certification Regarding Drug -Free Workplace Reauirements
The certification set out below is a material representation upon which reliance is placed by the
U.S. Department of Housing and Urban Development in awarding the grant. If it is later
determined that the contractor knowingly rendered a false certification, or otherwise violates the
requirements of the Drug -Free Workplace Act, the U.S. Department of Housing and Urban
Development, in addition to any other remedies available to the Federal Government, may take
action authorized under the Drug -Free Workplace Act.
CERTIFICATION
A. The contractor certifies that it will provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is prohibited
in the contractor's workplace and specifying the actions that will be taken against
employees for violation of such prohibition;
(b) Establishing a drug-free awareness program to inform employees about -
(1) The dangers of drug abuse in the workplace;
(2) The contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance
program; and
(4) the penalties that may be imposed upon employees for drug abuse
violations occurring in the workplace;
(c) Making it a requirement that each employee who will be engaged in the
performance of the grant be given a copy of the statement required by paragraph
(a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a
condition of employment under the contract, the employee will -
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five days after such conviction.
(e) Notifying the U.S. Department of Housing and Urban Development within ten days
after receiving notice under subparagraph (d)(2) from an employee or otherwise
receiving actual notice of such conviction;
EXHIBIT E
Pg. 2
(f) Taking one of the following actions, within 30 days of receiving notice under
subparagraph (d)(2), with respect to any employee who is so convicted -
(1) Taking appropriate personnel action against such an employee, up to and
including termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a
Federal, State, or local health, law enforcement, or other appropriate
agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e) and (f).
B. The contractor shall insert in the space provided on the attached "Place of Performance"
form the site(s) for the performance of work to be carried out with the grant funds
(including street address, city, county, state, and zip code). the contractor further
certifies that, if it is subsequently determined that additional sites will be used for the
performance of work under the contract, it shall notify the U.S. Department of Housing
and Urban Development immediately upon the decision to use such additional sites by
submitting a revised "Place of Performance" form.
Dated: �(
ogram Oper or
EXHIBIT E
DIVISION OF EMPLOYMENT SERVICES
PLACE OF PERFORMANCE
FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
Name:
Name of
Contractor Number:
Date:
The Contractor shall insert in the space provided below the site(s) expected
to be used for the performance of work under the contract convered by the
certification:
Place of Performance (include street address, city, county, state, zip code
for each site):
EXHIBIT E
EXHIBIT F
ADDITIONAL INSURED ENDORSEMENT
FOR COMMERCIAL GENERAL LIABILITY POLICY
Insurance Company
This endorsement modifies such insurance as is afforded by the provisions of Policy
relating to the following:
1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California
92701; its officers, employees, agents, volunteers and representatives are named as
additional insureds ("additional insureds") with regard to liability and defense of suits
arising from the operations and uses performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by
or on behalf of the named insured, such insurance as is afforded by this policy is
primary and is not additional to or contributing with any other insurance carried by or for
the benefit of the additional insureds.
3. This insurance applies separately to each insured against whom claim is
made or suit is brought except with respect to the company's limits of liability. The
inclusion of any person or organization as an insured shall not affect any right which
such person or organization would have as a claimant if not so included.
4. With respect to the additional insureds, this insurance shall not be
cancelled, or materially reduced in coverage or limits except after thirty (30) days written
notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana,
California 92701.
(Completion of the following, including countersignature, is required to make this
endorsement effective.)
Effective
Policy # _
Issued to
this endorsement form as a part of
Named Insured
Countersigned by
Authorized Representative
ACORP. CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYVY)
1 12/11/2003
PRODUCER (949) 553-9700 FAX (949) 553-9797
Westland Insurance Brokers
2192 Martin Street, Suite 130
Irvine, CA 92612
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED Delhi Community CenterA
505 South Central Ave.
Santa Ana, CA 92707-3504
INSURERA: TRAVELERS PROPERTY CAS INS CO 36361
INSURERS. Carolina Casualty Insurance Co
INSURER C:
INSURER D.
INSURERS
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
NDO'L
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE( IDD
POLICY EXPIRATION
DATEIMMIDDIYYI
LIMITS
GENERAL LIABILITY
660818X4872-03
12/14/2003
12/14/2004
EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $ 100,00
CLAIMS MADE O OCCUR
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
A
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $ 2,000,00
POLICY PRO LOC
JECT
AUTOMOBILE
LIABILITY
8103123W685-03
12/14/2003
12/14/2004
COMBINED SINGLE LIMIT
ANYAUTO
(Ea accident) $
1,000,00
BODILY INJURY $
ALL OWNED AUTOS
A
SCHEDULED AUTOS
(Per person)
BODILY INJURY $
X
HIRED AUTOS
X
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHERTHAN EA ACC $
ANY AUTO
AUTO ONLY: AGO $
EXCESSIUMBRELLA LIABILITY
CUP 3289W520-03
12/14/2003
12/14/2004
EACH OCCURRENCE $ 1,000,000
X OCCUR FICLAIMS MADEx,
�'i (✓
('
q
int,'.
AGGREGATE $ 1,000,000
Limit $ 10,00
ARetained
-� l:v
l.r �i
DEDUCTIBLE'
$
$
RETENTION $
19,.2
_ _
WORKERS COMPENSATION AND
,,
.
WC STATU- OTH-
TOR MIS FR
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTNESSl�
1I i� f� l.f'
Nv
E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
EL DISEASE - EA EMPLOYE $
If yes, describe under
E. L. DISEASE -POLICY LIMIT S
SPECIAL PROVISIONS below
OTHER
irectors & Officers
3336857
01/14/2003
01/14/2004
$1,000,000 Per Claim/Aggregate
B
$1,000 Deductible
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
Fidelity Bond: The Hartford #72BDDAM2830 - 7/2/2002-2003 Limit: $600,000 Deductible: $2,500
The Santa Ana Empowerment Corporation and the City of Santa Ana are named as Additional Insured's
s per attached GN0188 (0196) and CGD037 (0199)
"Except non-payment of premium which is a 10 day notice of cancellation
Santa Ana Work Center
Laura
1000 E. Santa Ana Blvd
Suite 200
Santa Ana, CA 92701
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL i4XMXJ)6 MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
YJI�i300GIf�CiN6Y��SX�KMd(i(dE�W(�'Jfd(SOkYXIi06ffi(dCAkl04�OGXX�KIfi(XX
AUTHORIZED
OACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
LhLII l lf:....-•
:.J
�:;:, Ctif3.l f, tjCy P,. CtD�oHr
AGURU 25 (2001/08)
POLICY NUMBER: X -660 -818X4872 -TIL -03 _.
COM,.._ACiAL GENERAL LIABILITY
ISSUE DATE: 12/14/03
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CHARITY FIRST -AMENDMENT OF COVERAGE -
WHO IS AN INSURED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization (Additional Insured):
THE SANTA ANA EMPOWERMENT CORPORATION AND THE CITY OF SANTA ANA
Designation Of Premises (Part Leased to You)
WHO IS AN INSURED (Section II) is amended to
include as an insured:
A. Your members and volunteers but only with
respect to their liability for your activities or ac-
tivities they perform on your behalf;
B. Your trustees or members of the board of gover-
nors while acting within the scope of their duties
as such on your behalf; and
C. Person(s) or organization (s), whether or not
shown in the Schedule above, but only with
respect to their liability arising out of:
1. Their financial control over you;
2. Their requirements for certain performance
placed upon you, as a non-profit organiza-
tion, in consideration for funding or financial
contributions you receive from them;
3. The ownership, maintenance or use of that
part of a premises leased to you; or
4. "Your work'forthat Insured by or for you.
As respects Part C.3. above, this insurance does
not apply to:
(a) Structural alterations, new construction
or demolition operations performed by
or on behalf of the person(s) or organize-
tion(s); or
(b) Any 'occurrence" which takes place after
you cease to be a tenant in that
premises.
Sbr--
t City .'. ttu:..ec
GN 01 88 01 96 Copyright, Travelers Indemnity Company. Page 1 of 1
005564
_JMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
OTHER INSURANCE - ADDITIONAL INSUREDS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PROVISIONS
Paragraph 4.b. of CONDITIONS (SECTION IV) is
amended as follows:
b. Excess Insurance
This insurance is excess over any of the other in-
surance; whether primary, excess, contingent or
on any other basis:
(1) That is Fire, Extended Coverage, Builder's
Risk, Installation Risk, or similar coverage for
.your work";
(2) That is Fire Insurance for premises rented to
you or temporarily occupied by you with
permission of the owner;
(3) If the loss arises out of the maintenance or
use of aircraft, "autos", or watercraft to the
extent not subject to Exclusion g. of Cover-
age A (Section 1); or
(4) That is valid and collectible insurance avail-
able to you if you are added as an additional
insured under any other policy.
When this insurance is excess, we will have no
duty under Coverage A or B to defend the in-
sured against any "suit" if any other insurer has a
duty to defend the insured agairjst that "suit". If no
other insurer defends, we will undertake to do so,
but we will be entitled to the insured's rights
against all those other insurers.
When this insurance is excess over other insur-
ance, we will pay only our share of the amount of
the loss, if any, that exceeds the sum of:
(1) The total amount that all such other insur-
ance would pay for the loss in the absence of
this insurance; and
(2) The total of all deductible and self-insured
amounts under all that other insurance.
We will share the remaining loss, if any, with any
other insurance that is not described in this Ex-
cess Insurance provision and was not bought
specifically to apply in excess of the Limits of In-
surance shown in the Declarations of this Cover-
age Part.
CG DO 37 01 99 Copyright, The Travelers Indemnity Company, 1999 Page 1 of 1
Jan 14 04 07:50a Delhi Center Human Resour 17141481-9698 p.2
Deo 18 03 05:22P Delhi Center Hunan Resour 17141481-9698 P•2
:C -TY DF SWTR AHA CDR FRX mm :714 647-6736 Dec. IS 2003 10:4W' P4
ADDITIONAL INSURED 6NDORSEMeNf
FOR (,QMUMCIAL GMMRAL LL4bR 1W l*OLlCY
ltstraneeCotnpary Travelers Property & Casualty Ins Cc
This ouduseaumt modifies such insurance as is offmW by the provisions of Policy
# 660818X4872-03 ung to the following:
1. 7be City of Santa Ana, 20 Civic Center Plena, Santa Atat, Califomia 92701; it:
officers, employee, agents, volunteers gad representatives we named as addidotal Insureds
("additional insorods'7 with regard to liability and defense of suits arising Sem the opowous
and twee pft*cmed by or an behalfof the named insured.
2. With respect to claims arising out of 66 operations and uses perfoonad by or on
behalf of the named iroulsd, such ilaauance as Is a9brded by this policy is primary sud Is not
additional, so or contributing with any other insurance carried by or for the benefit of the
additional insureds.
3. Tlds insurence applies separately to each insured against whom claim Is made or
suit is brought except with respect to ria a mpeny'a IhWb of liability. The inelael0n of any
person or organization as ea beamed shall not affect any right vAieh such person or orga mtbm
would have as a claimant if not so included.
4. With reaped io the additional insureds, this insurance shell not be cancow, or
materially reduced in covoage at limits mumpt after thirty (30) days written notice her been
given to the Clair of the Council, City of Santa Ana, 20 Civic Getter Plaza, Santa Ana,
California 42701.
(Completion of the following, including coantaaignadre, is required to make this andorsement
Wbotive.)
Et%etire 12/14/03 this endorsement tbrm as a put of
Polley # 66081BX4872-03
Imued to Delhi community Center
Countersigned by
Au d MVmennift
1'- � -"t
L.�u;2 �Lll! ,ti.;c�ty
a»�swn� Cite :°, ��ornev
.11eyAloles