HomeMy WebLinkAboutBOYS AND GIRLS CLUB - 2004
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AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
Return form to the Sr. Deputy Clerk of the Council (M-30). Call 647-5238 if you have any
questions.
---- - --- ----- - -- - ---- - ---- - - -- - -- - - --- -- - -- -- -- - --- - -- -----------
Theagreementwith~ ad. c'iv-ls CWJ 1J S.#. ,No.A-;)OO4-J16
was completed on 9~ -; 0 - d J , and final payment has been made.
Department: ({).A - IV/ tJ /l("'~
Signature: rlC.A,v '5U-rZ-1
Date: e '-:;','Ol
City of Santa Ana
Revised 8- 7-03 Clerk of the Council
A-2004-145
AMENDMENT TO AGREEMENT
ccÞ~
(fSJtI)
THIS AMENDMENT, made and entered into this 1st day of July, 2004, by and between the Doys and Girls
Club of Santa Ana ("Contractor") and the City of Santa Ana, a charter city and municIpal corporation duly
organized and cxisting under the Constitution and laws of the State of California ("City"),
RECIIALS
A. The City and Contractor entered into that certain Agreement dated October 1,2003, hereinafter referred to as
"said Agreement", to provide career preparation and basic skills services for disadvantaged youth who are in-school.
B. The parties hereto now desire to amend the "City's Obligations" amount found in Section 2 and the "Time
Period of Agreement" term of Section 3 of said Agreement, as well as substituting an updated Exhibit B I.
WHEREFORE, in consideration of the mutual and respective covenants and promises hereinafter contained and
made, and subject to all of the tern1s and conditions of said Agreement as hereby amended, the parties hereto do
hcrcby agree as follows:
1.
The "City's Obligation" section of said Agreement will be amcndcd to read:
H".a sum not to exceed $17R,7~0 "
2.
The "Timc Period of Agreement" section of said Agreement will be amended to read:
~""'-
".. .sha11 have been performed by-'hr\y;O 700~."
3.
"Exhibit B" to said Agreement will be replaced by 2004/05 Program Activity Work Plan commencing
on July 1, 2004 ("Exhibit B I "), attached hereto and incorporated herein by this reference.
4. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in
full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this Amendment to said Agreement the date and
year frrst above written.
ATffi", ~
(' 12. <
~Q , <-< -- '- . ,
Patricia E. Healy ~
Clerk ofthe Council
CITY OF SANTA ANA
{il"').1
I .../ i.
//-r;.ù~/" / 1/--<';""----
David N. Ream, Citÿ'Manager
APPROVED AS TO FORM:
BOYS AND GIRLS CLUB OF SANTA ANA
d.Lf~
By: Lisa E. Storck
Assista ity Attorney
atricia C. Whitaker, Executive Director
Community Development Agency
INSURANCE ON FILE.
WORK MAY PROCEED
UNTIL INSURANCE EXPIR~
. l - S -DS
CLERK DE COUNCIL
DATE: ']- ~D-04
BUDGET FORM
Provider Name
Boys & Girls Club of Santa Ana
Program Name
Career Prep Program
~
Administrative Program ~~,~ Kind
¡:;:-- '-IB(~ I~ ~~
l:.:' . . ..~. ~ "iJ'-.. . .1< - .,~. . "..,. ... ;,..$;¡¡$ '"
Salaries* 2,760 82,922.26 85,682.26
Benefits 797.89 23,590.77 24,388.66
Other (Iist)*
Total Personnel 3,557.89 106,513.03 110,070.92
!/Ø------êrå
h_~~~t~r user ce*
Utilities 550 550
Phones 250 250
Internet fees
Parking fees
Security
Maintenance 300 300
Insurance 750 750
Equipment*
Rental fees
Purchase
Vehicle lease charges
(vehicles may not be
purchased)
Office expenses 5,521.28 5,521.28
(consumables)
Accounting Services
Legal services
Auditing services
Indirect costs 284.28 10,018.52 10,018.52
(attach indirect cost
rate plan**)
Staff training
Staff travel/mileage 480 480
Customer Training*
Support services* 525 525
Profit ([or profits only)
Other (list)*
Total Operating Expenses 2,152.17 76,792.83 78,945
3,842.17 124,907.83 128,750
GRAND TOTAL
(Total Personnel + Total
Operating Expenses) --~
***attach a separate sheet detailing these costs***
..
" .
'""-¡-,
Date of 1 st Review
Date Approved
BJA Staff
BOYS & GIRLS CLUBS OF SANTA ANA
Workforce Investment Board
ESTIMATED 2004-2005 Teen Employment Budget
DATES COVERED BY THIS REPORT:
7/1/2004 6/30/2005
From To
Boys & Girls Club of Santa Ana
Name of Organization
Career Prep
Program
Santa Ana, CA
City, State
Enedina Mejia
Report Prepared By
714/565-2637
Phone Number
714/543-4613
Fax Number
FOR ITEMS (C) THROUGH (J) YOU MUST ATTACH COPIES OF RECEIPTS,
PAID BILLS, ETC. FOR ALL INDIVIDUAL PURCHASES/EXPENSES OVER $1,000
(A) GROSS SALARY (no documentation required)
(B) BENEFITS (no documentation required)
(C) BOOKKEEPING/CONSULTANT SERVICES
(D) TRAVELITRAINING
(E) EQUIPMENT
(F) SUPPLIES
(G) BUILDING COSTS
(H) TELEPHONE
(I) POSTAGE
(J) OTHER EXPENSES
$45,747.26 Receipts
$14,518.66 attached?
$0.00
$400.00
$0.00
J $5,476.28
$800.00
$250.00
$0.00
$5,842.80
$73,035.00 AI~ tV ¡:,
TOTAL
By signing below, I certify that:
1. the expenses charged to this grant are allowable as outlined in the letter of agreement, the Office of Justice
Programs (OJP) Financial Guide, and Office of Manågement and Budgel (OMB) Circulars A-122, A-110, and A-133.
2. ail travel expenses charged to the grant do not exceed the applicable maximum Federal per diem rates.
3. I understand, if requested by the Office of the Comptroller, Bureau of Justice Assistance, or Boys & Girls Clubs
of America, appropriate documentation of all expenses charged to this grant will be made available in a timely
and unrestricted manner.
4. documentation is attached for all individual non-personnel expenditures over $1,000.
5. I understand the closeout of this grant does not affect the right of the Bureau of Justice Assistance or Boys
& Girls Clubs of America to disallow costs and recover funds on Ihe basis of a later audit or review:
6. I understand any funds paid to the organization in excess of the amount to which the organization is finally
determined to be entitled under the terms and conditions of the award constitute a debt to the Federal Government.
G Jjf) IOLJ
I /
Date
WIB 02-03 Reimbursement Form
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
u-vt-.d.s
-fw \:u a..del..d.
Page 1
Submit separate Plan if serving both in-School and Out-of-School Youth.
Program Activity Work Plan 2004/05
'-
Provider Name
Boys & Girls Club of Santa Ana
Program Name
Career Prep Program
Your Population
In-School
Out-of-School
x
Ages
14-18
19-21
~Skill Attainment
Diploma Rate
Retention Rate
(#)
#
#
#
OBJECTIVES ACTIVITIES RESPONSIBLE ORGANIATION Start Date End Date
30 youlh ages 14-18 will be tested Conduct testing using CASAS Boys & Girls Club ot Santa Ana 7/1/2004 2/1/200
to determine basic skills.
30 youth ages 14-18 will complele Youth ages 15-18 wiil complete I Boys & Girls Club of Santa Ana I 7/1/20041 2/1/20051
age appropriate Career Prep Job Ready.
Program. Youth ages 14-15 will complete
Career Explorers.
130 youth ages 14-18 will complete IYOuth ages 14-18 will volunteer up to I Boys & Girls Club of Santa Ana 1 7/1/20041 6/30/2005'
unpaid work experience. 50 hours. Will receive a $200 incentive
upon completion.
I Boys & Girls Ciub of Santa Ana 1 7/1120041 I
i
30 youlh will receive leadership IYOuth will increase leadership skills by 6/30/2005'
development opportunities. participating in the foilowing programs:
Career Prep, Career Explorers, or Career
Launch.ln addition, youth have the
Submit separate Plan if serving both in-School and Out-of-School Youth.
OBJECTIVES
Conduct follow up services to 50
Iyouth ages 14-18.
Program Activity Work Plan 2004105
ACTIVITIES
opportunity to complete unpaid
work experience.
Contact youth for folllow up services.
RESPONSIBLE ORGANIATION
Start Date
Boys & Girls Club of Santa Ana
71112004
End Date
613012005
AkCiBD CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIYYYY)
'" 12/02/2003
PRODUCER (909) 587-2719 FAX (909)587-6001 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Anthem Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
42145 Lyndie Ln., #202 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Temecula, CA 92591
License # OB84551 INSURERS AFFORDING COVERAGE NAIC#
INSURED Boys and Girls Club of Santa Ana INSURER A" Markel Insurance Company
950 Highland St INSURER B.
Santa Ana, CA 92703 INSUH.ER c:
INSURER 0:
INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDINI
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
1~~~ ~R.9:~ ' POLICY EFFECTIVE POLICY EXPIRATION
TYPE OF INSURANCE POLlCY NUMBER LIMITS
~NERAL LIABILITY 8502CY073003 12/20/2003 01/05/2005 EACH OCCURRENCE $ 1 , OOO_,J.IQ!J
COMMERCIAL GENERAL LiABllr,y I ~~~~~~¿ 9L:~EN i ED I 50,000
-] CLAIMS MADE D OCCUR ~~p (Anyone parson) $ 5,000
A X - PERSONAL & AOV INJURY I 1,000,000
GENERAL AGGREGATE , 3,000,000
- ,-
GEN'L AGGREGATE LIMIT APPLIES PER" PRODUCTS ~ COMP/OP AGG ' 1,000,000
h .-Fl PRO, n
POLICY JEcr lOC
~TDMOBILE LIABILITY 1002CYC0730044 12/20/2003 01/05/2005 COMBINED SINGLE LIMIT
,
ANY AUTO (Ea accident) 1,000,000
~
f---- ALL OWNED AUTOS 80DIL Y INJURY
[\S ,\,0 (Per person) ,
. SCHEDULED AUTOS
A X ~ , (\O'J'£.D ,.'
f---- HIREiJ AU ros L17 ~~ BODILY INJURY
"{b l~~ (Per accident) ,
~ NON-OWNED AUTOS J..--- - ...
H ~ S\'O\1.(",I<'. PROPERTY DAMAGE ,
~-- \..ISp.. '",,\1 p\lW¡í'll'\! (Per accident)
lAGE LIABILITY r>,SSISt3\ \ VI of J D AUTO ONLY - EA ACCIDENT $
ANY AUTO --- OTHER THAN EA ACC ,
" AUTO ONLY' AGG ,
5ESS/UMBRELLA LIABILITY 4602CY0730105 12/20/2003 01/05/2005 EACH OCCURRENCE , 5,000,000
OCCUR 0 CLAIMS MADE AGGREGA T[ $ 5,000,000
A X I '
M DEOUCTIBLE $
X RETENTION $ 10,00Ð $
WORKERS COMPENSATION AND ITv,;~.7'T{';Jg;,,1 10J,i"
EMPLOYERS' LIABILITY
ANY PROPRIETORfPARTNERJEXECUTIVE EL EACH ACCIDENT ,
OFFICER/MEMBER EXCLUDED? ~_p..SE - EA EMPlOYEEI $
If ye~. describe under
SPECIAL PROVISIONS below , E_L- DISEASE - POLICY LIMIT $
OTH~
10 ay cancel non
payment of premium
DESCRIPTION OF OPERATIONS ¡lOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
"E: Certi fi cate holder is named as additional insured as respects to additional insured endorsement
flttached.
COVERAGES
Sanêa Ana WIBjYC
Anabel 1 Bates, Youth
P.O. Box 1988-M-73
Santa Ana, CA 92702
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~x~ MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
CERTIFICATE HOLDER
Council Coordinator
(iXIJOO(JúIój(~X¡( (~)(ü()@(¡j(:Jó ()(i}(JI\~J(¡ jJó1óXIi6. (iJOO(XX
¡¡iOOVJØij[¡XM¡¡!(j(¡Jé)OO(¡XI>A(X-XXIßó tXJl\ ()(øx~XXXXXXXX
(Ç)ACORD CORPORATION 1988
ACORD 25 (2001108)
. HOV. ~:. ' 2 0 C 3
12:56 949 263 86~6
l'J~THEl"! INS:;Ll'J\f,:7E SEHVI:::ES
#2CH P.004/004
Exhib:lt 1
ADDITIONAL INSURED ENDORSEMENT
Insurance Compðny
Markel Insurance COIDoanv
This endorðement modifies such lnsuranc:e as is afforded by the prDvisÎons of Policy
'# ~502CY073003 relating to the following:
1. The CIN of Santa Ana, 2D Civic Center Pii5za, Ssnta Ana, Ca1ifomia
9270'\: its Dfflc8rs, empJoys8S, agents and volunteers are named as additional insureds
("aòditJonal insureds") wIth regard to Habil\ty and defense of suits arìsing from ~he
o?erations and uses performed by or on' behalf of the named ins1.Jí8d.
2. With respect to o1a\ms 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
primery and is not additional to or contríbutii1g with any other íns~lra¡¡¡::e carried by or tor
the benefit of the additional Insureds. .
3. This insuranc:e applies separately to eaoh insured against whom claim is
made or suit is brought exoept with respect to the company's limits of liability. The
inclusion of any person or organization as an Insured shall not affect any rignt which
such person or organization would have as a claimant if not so Inoluded.
4. With resped: to the additional Insureds, this insurance shall né)t b'" .
. -
canceled, or materially reduced in coverage> or limits except after thirty (30) days written
notlce has been given to the City Df Santa Ana, 20 Civic Center Plaza, Santa Ana,
California 92701.
(Cûmpletion of the f;jllowif1~, Including countarsigT'ls,ture, is required to make this
endorsement effective.) .
Effective
11-21-03
, this endorsement fü1Tll as a part of
Policy #
Issued to
8502CYOnOOi
Boys and Girls Club of
S;:¡nt'-;::¡ Ån;=¡
Named Insured
,¿,OVED AS TO 1'(
!df /J --
.~v,
,.,.;:.;\,)(\\ CItY AHornc'Y
(j o~ 'J )
CountersignBd .by
\~"\.'\~ C(m('jS\ >-"
Authorized Represent~ti"ve
. , .
SP
CERTHOLDER COpy
STATE
COMPENSATION
INSURANCE
FUND
PO BOX 807, SAN FRANCISCO,CA 94142-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
CITY OF SANTA ANA
WORKCENTER ATTN: ANABELL YATES
1000 E. SANTA ANA BLVD., #200
SANTA ANA CA 92701
SP
GROUP: 000723
POLICY NUMBER: 0000075-2004
CERTIFICATE 10: 1
CERTIFICATE EXPIRES: 06"01-2005
06-01-2004/06-01-2005
JOB: ALL OPERATIONS
ISSUE DATE:
06-01-2004
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 10 day_s' 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 Însurance is not an insurance policy and does not amend; extend or alter the coverage afforded
by the P91ièieslisted herei~'f\Jotwithstanding any r~quìn?rTl,ent. term. or condition ~f any contract or other document
with respect,:to which this certificate of'insuranqe maybe issued or maypert~¡n.the insurance afforded by the
policies described herein IS subject to aU the ter:;ms, exclusions and conditions of such policies.
~
~~C
&L-
AUTHORIZED REPRESENTATIVE
PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:
$1 , 000, 000.00 PER OCCURRENCE.
.ENDDRSEMENT #0015 ENTITLEO AODITIDNAL. INSURED EMPLOYER EFFECTIVE 06-01-2004 IS ATTACHEO TO AND
FORMS A PART OF THIS PDLICY.
NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA
SP
;""'''ROVED AS TO
"--~ -----
~--' LISA E.--C;TORCK
(~r~~ ~)ttnr .
EMPLOYER
LEGAL NAME
BOYS AND GI RLS CLUB
950 HIGHLAND ST
SANTA ANA CA 92703
OF SANTA ANA
BOYS AND GIRI,;S CL.UB OF SANTA ANA
(A NON PRoFIT CORPORATION)
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10265
(REV.3-03)
PRINTE~: ." 05/17/2004 P040B
~ar 17 05 11: 12a
Bo~s & Girls Club or Sant 714-565-1099
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A- al?06-~;l.
A- -)..OOA- OL d..
A-;2tO'-/ -/~
A ;).cotJ _ /'/5
1\ - - 1 Policy Number:
0$1 Entered: 3/1 fi/200!i
ACQRD.. CERTIFICATE OF LIABILITY INSURANCE .. l 0;7::::051'
,
-- ~_ .l1l_llra1ICe "rY'1CM' '!Hie CERTlFIOAT! 1& ISSum AlIrr1MATTeR 0' 1NF0RIII\1ION
22'12 r.o~ia ~k Dz *200 OtILV AND CONFl!RS NO _ UP~ Cl:l:ICATE
A1i~ Vi.jo, CA 926S6 IIOUlI!Il TIllS 0EIlTII'I0A1'E IlOEI NOT . NO OR
Al~1'l TIlE COVEI'lAGE AfF~ BY THI' POLletES BELOW.
{'.":;U.5-'631
123 45. INSUIlERS AFFORDING OD\lElWil& : NAfC"
...- Bo~ .c. Ciir~1I M S.-nU -., Q 92'03 MU/l.~i.TC.ftl.r. ~aItOe ~~
10]'. , Gtl:l. ot Sant.. Ana 5"0\U1~ t:.ion -..
950.. H'19hland, l~iRC:
AanU Ana, CA 12103 I__n
, -~ ..
COYEIIAGD
'HE. POUCIES OF &NSUAANcE LlBt'EO 8El.OW MAVE eu.. tSSUEC TO tHE INSURED ~ ABOVE FOR"nte POUCY PCRIOD lNDlCAiEO. NOTWIT~AMOING
_ AE_IIl!NT. TIiRN ORCOI<<1mONOF _ CONTRACT 011 O_1lOClJMfHT WIJIf 1lE8I'fCrTO _TIflS Cl!llTlpej\TE....V BE_Qft
MAY PMT., THe lHSURI\NaN'fO~ BY ntE PO\ACIES DESCNIlmH.!l\elN I8IUBJI!CT TO AU. 1'lQi TEM18. su:uJSIOfS NlD CQNbIT10NS OF SUCH
POUCIES. AQOREGATE LIMITS SHQ\NN MA,V HA~ lEEK REOUtED BY PAlO CtAWlS.
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PRtlDUI;1'8.&.C'M/PIt1PAGO ,1,000,000
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CERTIl'ICATIi IIOUlER
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'l'bo Ci.ty or $antit. .an.. 'Dle eMit.-. OAlE lNIMOf'. ,... ilIUM IIISlIRU WlU. "IR~ lUll.. 30 DNtlI WIUT....
....vtl1.~t AqM.ay, 1"', oU:I.cv$. ~.~. 1IOftaI1O TMI ClRI'I'II;A18 MOI.tIP..... ~.THl un; .(MIi_....'l~R'
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Bo~s L Girls Club or Sant 714-585-1099
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EX8J1lI'l .
ADDrrIDNAL INSlJRliD t:NnnII"~:"""1!NT
'fOR. NlUMl'.RMAl OllNl!llAL U"JlllITVPOLICY
~Compoll)'
k4'{/~k",~..s;
This tIlMIcm;cmenI modifies Neb inounnoc u ia alfonled by 1M proviaiOM of Polioy
, 6'6PVD7.f.~",7J...t"Id"co 1Il,(01lo..a.s:
I. TIlcCilyofSQmAII.. ZOCi>ic Ceaf8rP_ S-An.. C.Jifi>m;.
92101; III olll..... CIIlPIo_. qaiu. vollll1_' IIld repr<SeDtadves "'" 1lII1I." as
...........01-.... (""'iticmol iMbmds") will> repnllO Uabilioy _ deI'_ or...;..
arising &vm 1M opcrlIIiens lIIId _ porl>.OWd by or on b_ oft"" .......d iltstRd.
2. Willt fCSPOICl to claims uilri"l 0111 of.... ..,..aciGoIa_ .-llldOmlIlI by
or Oft bdlaIt of1M Nmlld iDslDed. ndI m..nnc. II is alfoItIod by .... polk;y ill primary
Mil is DOtadclillaDal toGl'ClIIIIributmawitb 1D)'0t!ler insurw:ew.rioclbyorfor....
belwlll of llIe addl1ionaI inaindc.
3. This dtBlll'ltlCC"I'PliII seplPtely 10 BICh in5urecl rpa.t whom claim is
m. or .wI is b<tIllJIII..copt widI IIIJl'ICI III IIlc ..........y'.liIDito ofliability. Tho
j11clu8loG of mypouon or orpeIutioD II III _roc! sIIIIllIOl afIWct my II.,. which SIIOh
person or.....2Iliaft _ld. ba'ltllll' elaimllllt if IIOt so iDcIudc4.
4. Willi ""IItet to the aWitiollll ;,.",.. rhIlI iIlsln_lIflall 001 be
..""dIed, or -iaJIlr rocIucocl ill......... ot limlts.....,,1 aft...1hiny (30) days wti_
IIIlticc has b-. pv... 10 lhc Cil)' ofSanla ADa. :lO Civic CCIIlCI' Plaa, S_ AlIa.
Calilbmia 92701,
(Cootplelion oCm. 1i>IIowma. lDtladin& _..-.. ia roquirod to JIIair.e 111).
~_..ent etl;ctivc.)
Efibolivo
Pulley.
Issued to
~./g,,~/Y ~ ~$- ,Ihi.-.-lbrmtuponof
.lfiSItJ'741A.:i7.:J -d~
~y's * d'...',-/..r c/_~ Ir ("'....A; ~~
, , NllIJocI'IIlSlItcd
Co......>ipW.,. ~~~
APPROVED AS TO FORM
.,
~~)2/c
.aura Stitt Sheedy
ASSIstant City Att
orney
eluelil 39t'd
30.!0JS.u .B'al:
613SS-Stz-61>6
E13:gr S1313eILr/E13