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HomeMy WebLinkAboutCA HISPANIC COMISSION ALCOHOL 2AAGREEMENT TERMINATION Please complete this form when the attached agreement is no lonjZ ri Mee. PH 2' f- Return form to the Sr. Deputy Clerk of the Council (M -10). Cally641r3238 ifyou have-any questions. = _- x The agreement with (,'Afiiont�C� i �S 1ltG� tritilSS�onoraIMCO No.A-d00, /-/ 6 (24) was completed on /y/5y/ q and fmal payment has been made_ Department: 6 T � Date: IU41MO V City of Santa Ana Revised 8 -7 -03 Clerk of the Council AMENDMENT TO AGREEMENT A- 2004 -146 I THIS AMENDMENT, made and entered into this 1st day of July, 2004, by and between the California Hispanic G ab), Commission on Alcohol and Drug Abuse ( "Contractor ") and the City of Santa Ana, a charter city and municipal �tu) corporation duly organized and existing trader the Constitution and laws of the State of California ( "City "). RECITALS 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 out -of- 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 1. WHEREFORE, in consideration of the mutual and respective covenants and promises hereinafter contained and made, and subject to all of the terms and conditions of said Agreement as hereby amended, the parties hereto do hereby agree as follows: 1. The "City's Obligation" section of said Agreement will be amended to read: ..a sum not to exceed $15.6,184" 2. The "Time Period of Agreement" section of said Agreement will be amended to read: "...shall have been performed by Tune 10, 3. "Exhibit B" to said Agreement will be replaced by 2004/05 Program Activity Work Plan commencing on July 1, 2004 ( "Exhibit B I"), attached hereto and incorporated herein by this reference. 4. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Amendment to said Agreement the date and year first above written. ATTEST: Patricia E. Heal-, Clerk of fhe Council APPROVED AS TO FORM: By: Lisa E. Storck Assistant City Attorney REC ED FOR AP O . atricia C. Whitaker, Executive Director Connnunity Development Agency CITY OF SANTA ANA David N. Ream, City anager CALIFORNIA HISPANIC COM 41SSION ON ALCOHOL AND DRUB, INC. James Hei Executive INSURANCE ON FILL WORK MAY PROCEED UNTIL INSURANCE EXPIRES 1 -1$ -uq ---- CLERK OF COUNCIL DATE: c)-AO-04 Program Name: California Hispanic Commission on Alcohol & Dru2 Abuse, Inc. Separate fyud'�C! it serkilk.L" tooll; in- Fx OUT-OF-SCHOOL BUDGET and Ow-11 �(-hool 1 ouch F-] IN SCHOOL BUDGET Line Item Budget 10/01/2003 to 6/30/2005 Administrative Program Total WIA Mateb/In Kind ersonne `fit^ i4zbhi a4 Salaries* $ 11,824 $ 66,250 $ 78,074 Benefits 3,979 $ 21,794 25,773 Other (list)* Total Personnel 15,803 $ 88,044 $ 103,847 iirtm Eli" hisp Operating? xpjp Rent or user fee* 21,195 $ 21,195 Utilities $ 1,279 $ 1,279 Phones $ 725 $ 725 Internet fees $ - Parking fees $ - Security $ - Maintenance $ 375 $ 375 Insurance $ - Equipment* $ - $ 12,040 Rental fees $ Purchase $ Vehicle lease charges (Vehicles may not be purchased) $ 1,750 Office expenses (consumables) 1,801 $ 1,801 Accounting Services $ - Legal services $ Auditing services $ - Indirect costs 19,406 (attach indirect cost rate plan**) $ 19,406 Staff training $ - $ - Staff travel/mileage $ 1,100 $ 1,100 Customer Training* $ 1,690 $ 1,690 Support services* $ 13,866 $ 13,866 Profit (for profits only) $ - $ - Other (list)* $ 1,100 $ 1,100 Total Operating Expenses $ 19,406 $ 43,131 $ 62,537 $ 13,790 GRAND TOTAL (Total Personnel + Total $ 35,210 Operating Expenses) * $ 131,175 $ 166,384 $ 13,790 attach a separate sheet detailing these costs DETAILED PROJECTED PROPOSED BUDGET FOR WIA Youth - Fuerzas Unidas October 1, 2003 to June 30, 2005 July 1,2004 to June 30, 2005 SALARIES: Total SALARY RANGE PROGRAM Proposed ADMINISTRATIVE Total Project Director FTE Budget Proposed Budget In kind Administrative Assistant 0.02 $ 70,000 $ 84,460 $ 1,689 Secretary 0.02 $ 35,000 $ 43,260 $ 865 $ 1,689 Data Clerk/ Receptionist 0.02 $ 23,000 $ 26,000 $ 520 $ 865 Coordinator /Counselor 0.02 $ 20000 $ , 24 ,000 $ 480 $ 520 Counselor /Job Developer 1.00 $ 30,000 $ 34,000 $ 34,000 $ 480 TOTAL SALARIES 0.30 $ 25,000 $ 30,000 $ 9,000 $ 34,000 1.36 $ 43,000 $ 3,354 $ $ - $ 9,000 BENEFITS: 48,554 FICA $ - SUTA 2.00% $ 3,290 $ 272 $ 3,561 HEALTH WORKER'S COMP 12.00% $ $ 850 5,160 $ 71 $ $ 931 RETIREMENT 5.00 % $ 2.150 427 $ 178 $ 5,587 700% $ 3,010 $ 249 $ $ 2,328 TOTAL BENEFITS $ 3,259 (BENEFIT PERCENTAGE) 33.65% $ 14,470 $ 1,196 $ - $ 15,888 SUB -TOTAL SALARIES 8 BENEFITS OPERATIONAL EXPENSES: $ 57,470 S 4,750 $ $ - $ - 82,220 FACILITY RENT /LEASE: $ _ RENT $ TOTAL RENT $ 12,000 $ $ 12,000 EQUIPMENT AND /OR OTHER ASSETS LEASES: $ 12,000 $ - $ $ - $ 12,000 VAN LEASE($500 /MONTH for 2 months) $ _ TELEPHONE SYSTEM (2001MONTH - 10 %) $ $ _ COMPUTER AND PRINTER $ 1,000 $ COMPUTER FOR CLIENTS (1) $ 240 $ COPIER (200 /MONTH' 10 %) 1,200 $ $ 800 $ - TOTAL EQUIPMENT E OTHER ASSETS $ 240 $ SUPPORTIVE SERVICES: $ $ $ 3,480 $ _ CERTIFIED TRAINING $ - BOOKS AND SUPPLIES $ 1,000 $ CLOTHING $ $ 1,000 BUS PASSESrrOKENS $ 500 $ SOBER LIVING (i CLIENT ® $500 /MONTH FOR 6 MONTHS $ 450 $ 500 $ 3,000 $ $ 450 TOTAL SUPPORTIVE SERVICES 3,000 $ 4,930 $ - $ $ - $ 4,950 SERVICES AND SUPPLIES: $ ACTIVITIES - RECREATIONAL $ ADVERTISING $ 400 $ AUTO EXPENSE $ - $ 400 BOOKS AND PUBLICATIONS $ - $ - CONSUMMABLE /HOUSEHOLD SUPPLIES $ - $ CONFERENCE $ 225 $ - EDUCATIONAL MATERIALS $ - $ 225 FACILITY MAINTENANCE (350 /MONTH'10 %) $ 300 $ INSURANCE $ 150 $ 300 LICENSE /PERMIT FEES $ - $ 150 MATERIAL DEVELOPMENT $ 500 $ - MISCELANEOUS EXPENSES $ - $ - OFFICE MACHINE MAINTENANCE $ 200 $ OFFICE SUPPLIES $ - $ 200 POSTAGE $ 200 200 $ PRINTING $ 200 $ 200 OFFICE EQUIPMENT /FURNITURE $ - $ 200 TV $ - VCR $ Soo $ - Book cases (2 x 300 ea.) 200 $ - Desk (2 x 400 ea.) 600 $ - Filing Cabinets (2 x 200 ea) 600 $ - Chairs (2 x150 ea.) Boo $ Chairs (participants - group sessions) 300 $ - Tables (participants) 500 $ - TELEPHONE (501month) 200 $ - TRAVEL/MILEAGE $ 450 $ UTILITIES $ 900 $ 450 $ 604 $ 900 TOTAL SERVICES AND SUPPLIES $ 604 SUB -TOTAL OPERATIONAL EXPENSES $ 3,629 $ $ - $ 4,400 $ 3,828 TOTAL SALARIESIBENEFITS, SUPPORTIVE SERVICES AND OPERATIONAL EXPENSES $ 20,579 $ - $ 7,880 $ 20,579 ADMINISTRATIVE OVERHEAD: $ 78,049 $ 4,750 $ 7,e80 $ 82,7e9 INDIRECT COSTS (12 OF TOTAL SADBEN. AND OPER. EXP) TOTAL ADMINISTRATIVE OVERHEAD $ 11,706 $ 11,706 $ 11,706 $ 11,706 TOTAL SUB- CONTRACT TOTAL GROSS COST OF PROGRAM $ 78,049 $ 16,457 1 $ 7,880 1 $ 94,505 DETAILED PROJECTED PROPOSED BUDGET FOR WIA Youth - Fuerzas Unidas October 1, 2003 to June 30, 2005 SALARIES: Project Director Administrative Assistant Secretary Data Clerk/ Receptionist Coordinator /Counselor Counselor /Job Developer TOTAL SALARIES BENEFITS: FICA SUTA HEALTH WORKER'S COMP RETIREMENT TOTAL BENEFITS (BENEFIT PERCENTAGE) SUB -TOTAL SALARIES 6 BENEFITS OPERATIONAL EXPENSES: FACILITY RENT /LEASE RENT TOTAL RENT EQUIPMENT AND /OR OTHER ASSETS LEASES: VAN LEASE($500 /MONTH for 2 months) TELEPHONE SYSTEM (200 /MONTH' 10 %) COMPUTER AND PRINTER COMPUTER FOR CLIENTS (1) COPIER (200 /MONTH' 10 %) TOTAL EQUIPMENT 8 OTHER ASSETS SUPPORTIVE SERVICES: CERTIFIED TRAINING BOOKS AND SUPPLIES CLOTHING BUS PASSESrrOKENS SOBER LIVING ( 1 CLIENT @ $500 /MONTH FOR 6 MONTHS TOTAL SUPPORTIVE SERVICES SERVICES AND SUPPLIES: ACTIVITIES - RECREATIONAL ADVERTISING AUTO EXPENSE BOOKS AND PUBLICATIONS CONSUMMABLE /HOUSEHOLD SUPPLIES CONFERENCE EDUCATIONAL MATERIALS FACILITY MAINTENANCE (350 /MONTH -10 %) INSURANCE LICENSE /PERMIT FEES MATERIAL DEVELOPMENT MISCELANEOUS EXPENSES OFFICE MACHINE MAINTENANCE OFFICE SUPPLIES POSTAGE PRINTING OFFICE EQUIPMENT /FURNITURE: TV VCR Book cases (2 x 300 ea.) Desk (2 x 400 ea.) Filing Cabinets (2 x 200 ea) Chairs (2 x150 ea.) Chairs (participants - group sessions) Tables (participants) Total SALARY RANGE FTE $ 860 $ 0.02 $ 70,000 $ 0.02 $ 35,000 $ 0.02 $ 23.000 $ 0.02 $ 20,000 $ 1.00 $ 30,000 $ 0.30 $ 25,000 $ 1.38 1,689 43,260 7.65% 2.00% 1200% 5.00% 7.00% 33.65% TELEPHONE (50 /month) TRAVEL /MILEAGE UTILITIES TOTAL SERVICES AND SUPPLIES SUB -TOTAL OPERATIONAL EXPENSES TOTAL SALARIES /BENEFITS, SUPPORTIVE SERVICES AND OPERATIONAL EXPENSES ADMINISTRATIVE OVERHEAD: INDIRECT COSTS (12 OF TOTAL SAL/BEN. AND OPER. EXP) TOTAL ADMINISTRATIVE OVERHEAD $ 3,290 July 1,2004 to June 30, 2005 $ 860 $ 71 PROGRAM ADMINISTRATIVE 427 Total $ Proposed Proposed In kind $ 249 $ 14,470 Budget Budget $ 57,470 $ 84,460 $ 12,000 $ 1,689 $ 1,689 43,260 - $ $ 865 $ 865 26,000 $ 520 $ 520 24,000 $ 480 $ 480 34,000 $ 34,000 $ 34,000 30.000 $ 9,000 $ 9,000 $ 43,000 $ 3,554 S - $ 46,554 $ 3,290 $ 272 $ 860 $ 71 $ 5,160 $ 427 $ 2,150 $ 178 $ 3,010 $ 249 $ 14,470 $ 1196 $ $ 57,470 $ 4,750 $ $ 12,000 $ 12,000 $ - $ S - $ $ 1,000 $ 500 $ 450 $ 3,000 $ 4,950 $ - $ $ 400 $ 225 $ 300 $ 150 $ 200 $ 200 $ 200 $ 450 $ 900 $ 604 $ 3,629 $ $ $ 20,579 $ $ $ 79,049 $ 4,750 $ $ 11,706 $ 11,706 $ 3,561 $ 931 $ 5,587 $ 2,328 $ 3,259 $ 15,666 $ 62,220 $ 12,000 $ 12,000 a 1.000 $ 240 $ 1,200 $ 800 $ 240 $ 3,480 $ $ 1,000 $ 500 $ 450 $ 3,000 $ 4,950 $ 400 $ 225 $ 300 $ 150 500 $ - 200 500 $ 200 $ 600 $ 600 $ 800 $ 300 $ 500 $ 200 $ $ $ 4,400 $ 7,880 $ 7,880 $ E 200 200 200 450 900 604 3,629 20,579 82,799 11,706 11,706 TOTAL SUB- CONTRACT $ - TOTAL GROSS COST OF PROGRAM $ 78,049 1 $ 16,467 1 $ 7,880 1 $ 94,505 bETAILED PROJECTED PROPOSED BUDGI WIA Youth - Fuerzas Unicias October 1, 2003 to June 30, 2005 SALARIES: Project Director Administrative Assistant Secretary Data Clerk/ Receptionist Coordinator /Counselor Counselor /Job Developer TOTAL SALARIES BENEFITS: FICA SUTA HEALTH WORKER'S COMP RETIREMENT TOTAL BENEFITS (BENEFIT PERCENTAGE) SUB -TOTAL SALARIES & BENEFITS OPERATIONAL EXPENSES: FACILITY RENT /LEASE: RENT TOTAL RENT EQUIPMENT AND /OR OTHER ASSETS LEASES: VAN LEASE($500 1MONTH for 2 months) TELEPHONE SYSTEM (200 /MONTH - 10% COMPUTER AND PRINTER COMPUTER FOR CLIENTS (1) COPIER (200 1MONTH' 10 %) TOTAL EQUIPMENT & OTHER ASSETS SUPPORTIVE SERVICES: CERTIFIED TRAINING BOOKS AND SUPPLIES CLOTHING BUS PASSES/TOKENS SOBER LIVING ( 1 CLIENT @ $500 1MONTH FOR 6 MONTHS TOTAL SUPPORTIVE SERVICES SERVICES AND SUPPLIES: ACTIVITIES - RECREATIONAL ADVERTISING AUTOEXPENSE BOOKS AND PUBLICA1 IONS CONSUMMABLE /HOUSEHOLD SUPPLIES CONFERENCE EDUCATIONAL MATERIALS FACILITY MAINTENANCE (350 1MONTH`10 %) INSURANCE LICENSEIPERMIT FEES MATERIAL DEVELOPMENT MISCELANEOUS EXPENSES OFFICE MACHINE MAINTENANCE OFFICE SUPPLIES POSTAGE PRINTING OFFICE EQUIPMENT /FURNITURE: TV VCR Book cases (2 x 300 ea.) Desk (2 x 400 ea.) Filing Cabinets (2 x 200 ea) Chairs (2 x150 ea.) Chairs (participants - group sessions) Tables (participants) TELEPHONE (50 /month) TRAVEL /MILEAGE UTILITIES TOTAL SERVICES AND SUPPLIES SUB -TOTAL OPERATIONAL EXPENSES TOTAL SALARIESIBENEFITS, SUPPORTIVE SERVICES ANC ADMINISTRATIVE OVERHEAD' INDIRECT COSTS (12 OF TOTAL SAL/BEN. AND OPER. EXP) TOTAL ADMINISTRATIVE OVERHEAD TOTAL SUB- CONTRACT TOTAL GROSS COST OF PROGRAM 9195 9,195 $ 21,195 $ 9,195 $ - S 9,195 S 21,195 750 100 900 600 180 690 0 690 $ g 9,916 0 9.916 $ $ 10,606 $ - $ 2,610 $ 10,606 $ $ $ $ S 170 10 400 225 251 140 260 145 275 200 675 2,751 E 22.552 $ 53,126 S - E 11,053 7,700 7,700 375 150 375 150 450 450 600 226 375 170 $ - g 10 $ _ g 400 g - 9 - 9 225 1 251 1 140 260 145 160 October 1 2003 to June 30 2004(Act al Expenses) I Grand Total 275 $ 200 $ Program Admin Total Oct 1 to Jun 30, 2005 $ 22,552 $ $ Propose Budget Proposed Budget in kind 7,700 $ $ 7,700 $ 0.02 $ 70,000 $ 84,480 4,200 4,200 1,710 $ $ 5,889 2,575 0.02 $ 35,000 $ 43,260 1,710 980 $ 1500 0.02 $ 2B4O00 $ 30,900 980 1,380 1,380 $ 1,660 0.02 $ 20,000 $ 25,750 23,250 $ 57,250 1.00 $ 30,000 $ 34,000 23,250.00 - $ 9,000 0.50 $ 25,000 $ 30,000 - $ 9,270 S 31,520 $ 78,074 1.58 23,250.00 1,779.00 2,412 $ 5,973 .65 % 465.00 665 630 $ 1,561 1 1.00% 2,790.00 992 3,782 $ 9,369 10.50% 1,163.00 414 1,577 $ 3,905 3.00 % 1,127.00 579 1,706 $ 4,965 7.00 % $ 7,324 $ 2,783 $ 10,107 $ 25,773 $ 30.574 $ 11,053 $ 41,627 $ 103,847 9195 9,195 $ 21,195 $ 9,195 $ - S 9,195 S 21,195 750 100 900 600 180 690 0 690 $ g 9,916 0 9.916 $ $ 10,606 $ - $ 2,610 $ 10,606 $ $ $ $ S 170 10 400 225 251 140 260 145 275 200 675 2,751 E 22.552 $ 53,126 S - E 11,053 7,700 7,700 375 150 375 150 450 450 600 226 375 170 $ - g 10 $ _ g 400 g - 9 - 9 225 1 251 1 140 260 145 160 275 $ 200 $ 675 $ $ 3,300 $ 2,751 $ $ 22,552 $ $ 64,179 $ 7,700 $ $ 7,700 $ 1,690 500 450 12,916 15,556 570 10 625 300 375 261 340 460 345 725 1,100 1,279 6,380 43,131 146,978 19,406 19,406 JUL.01'2004 19:21 714 479 0153 LA FAMILiA #2197 P.003 /004 000co 0 0 0 00 0 ACS Q Q❑ O 0 0 6 G b O C O G U ¢¢ a U U 'sosss 's rdD U u U UUUUU 0 0 0 O o 0 0 0 0 0 o O O O s ¢a¢¢¢ ¢ as a << a L10Qf�Q Q Q❑ L� A❑ Q a <a66 UUUUU 6 V aZ u U ¢¢ a U U 'sosss 's rdD U u U UUUUU 0 0 0 ¢a¢¢¢ ¢ as a << a L10Qf�Q Q Q❑ L� A❑ Q a <a66 UUUUU 6 V aZ u U ¢¢ a U U K E U UU U u U UUUUU 0 0 0 O y 0 W a C g v 0 •VO G O W Q y p C vamU a¢woz a W O � e y d A� 00 Ea o ° v u s O^ Da i,�to G 6' e v °) a •� a t a E� o � u � 0 it p jc d O• P c 0 0 0 0 o p C O O O O u O a a O K E 0. 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So m pv ,f! h d A O b O e 0 I JU- 01'2009 14:21 71? 479 0153 LA FAMILIA c o 0 0 n b O o C 4 0 0 O b b 6 Q U U E PO V pry w a u ,YD t6 O 5 � s O T dt'0 C y O c• o d W�Ua o C d O y � •%o � u O C3�.E 93 7 V 9 OD 0�0 �V.• W n C V O . 7 u n C T T T D •� n 'ti v E C C 5 — biiW -j fV Pi v 0 o u n o G C �Tr e.s O n C u ns v m y U Q6 v O W v 0 T .Vi D .E n d t a - O u a � E ' e $ os- Ow O 7 C ° Q ❑ U x U 0 d a � o D � y v s � � O � » T � � o G .2 L m d a� L Q O N P h V E c o §2197 P.004/004 6 Q y O �❑QO q UUU m U U L c 000 0 m m m m v T ro p O —y 6 m 4J U E PO V pry w a u ,YD t6 O 5 � s O T dt'0 C y O c• o d W�Ua o C d O y � •%o � u O C3�.E 93 7 V 9 OD 0�0 �V.• W n C V O . 7 u n C T T T D •� n 'ti v E C C 5 — biiW -j fV Pi v 0 o u n o G C �Tr e.s O n C u ns v m y U Q6 v O W v 0 T .Vi D .E n d t a - O u a � E ' e $ os- Ow O 7 C ° Q ❑ U x U 0 d a � o D � y v s � � O � » T � � o G .2 L m d a� L Q O N P h V E c o §2197 P.004/004 6 Q LQ] O �❑QO q UUU U U U E PO V pry w a u ,YD t6 O 5 � s O T dt'0 C y O c• o d W�Ua o C d O y � •%o � u O C3�.E 93 7 V 9 OD 0�0 �V.• W n C V O . 7 u n C T T T D •� n 'ti v E C C 5 — biiW -j fV Pi v 0 o u n o G C �Tr e.s O n C u ns v m y U Q6 v O W v 0 T .Vi D .E n d t a - O u a � E ' e $ os- Ow O 7 C ° Q ❑ U x U 0 d a � o D � y v s � � O � » T � � o G .2 L m d a� L Q O N P h V E c o §2197 P.004/004 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM OD YYYY) •• [Attn: DUCER (916) 784 -9070 12/09/2003 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION l -Cal Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 Riverside Ave. Ste. #105 ALLTEDRRTHE CIOVERAGEIAFFORDED BY THE POLCIIES EXTEND BELOW. OR Nina or Beverly oseville CA 95678- _ INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A :NOn rOf3_t Ins Alliance California Hispanic Commission On Alcohol & Drug Abuse w BsuHER: B INSURER 2101 Capitol Avenue INSURER O'. Sacramento CA 95816- INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADD'L LTR INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MM /DO/YYI POLICY EXPIRATION DATE (MMVDD/VY) A X GENERAL LIABILITY LIMITS X EACH OCCURRENCE $ 1,000,000 COMMERCIAL GEIJERA.L LIARUTt DAMAGE TO RENTED) CLAIMS MADE YOCCUR 2003 -03026 PREMISES�Ea occurrence) $ 50,000 11/18/200311/18 /2004 X PROFESSIONAL LIAB. MED EXP(Any one Person) S 5,000 PERSONAL B ADV INJURY 5 1,000,OOD X IMPROPER SEXUAL COND GENERA:. AGGREGATE $ 2,000, -DOD AGGREGATE LIMIT APPLIES PER XX X POLICY JECT LOC I / PRODUCTS - COMP /OP AGG 8 2,000,000 A, X AUTOMOBILE LIABILITY / I IMPROPER SERVAL COND 250, OOO ANY COMBINED SINGLE LIMIT AUTO (Ea accident) 5 1,000,000 ALL OWNEDAUios X SCHEDULED AUTOS 2003 -03026 11/119/2003 11/18/2004 BODILY INJURY (Per person) $ X HIRED AUTOS X NON- OVNED AUTOS r2OD I LY INJURY Per accident) S � X COMP: $250 / / / / - X ! COLLISION: $500 PROPERTY DAMAGE (Per accident) S GAPAGELIABILITY ANY AU TO AUTO ONLY - EAACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: A X EXCESSIUMBRELLA LIABILITY 2003- 03026UMBREI.LA 11/18/2003 11/18/2004 AGG S X OCCUR ICLAIMS MADE EACH OCCURRENCE $ 4,000,000 _ !� 't ) a 'AGGREGATE g 4,000,000 DEDUCTIBLE _ / $ RETENTION S r4> — -_ -,.- .. WORKERS COMPENSATION AND EMPLOYERIPCRIDTY LISA `' / / / / $ VICSTATU- OTH- TORY ANY IETOWPARTNER/EXECUTIVE OFFICER/MEMBER fi�SSISt8C7 ). LIMITS ER . E.L. EACII ACCIDENT EXCLUDED? / / / / c yes, e mbn If yes, describe under � E.L. DISEASE - EA EMPLOYE 8 SPECIAL PROVISIONS below O OTHER E.L. DISEASE - POLICY LIMIT S / / / / DESCRIPTION OF nPFRLTinuvi n ------ — - -••— uuc� Pr ervuVttStMI,NTISPECIAL PROVISIONS - THE CITY OF SANTA ANA, ITS OFFICERS, AGENTS, OFFICIALS, EMPLOYEES, AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED AS FUNDING SOURCE TO THE INSURED. FORM CG 2026 — FONDER APPLIES AS WELL AS EXHIBIT B (ATTACHED). ( ) ( ) SHOULD` ANY IOFY THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL X'p�1�CQ( MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, MY" CITY OF SANTA ANA WIC /YD) ANABELL BATES P.O. BOX 1988 —M -73 AUT RIZED REPR ENTATME SANTA ANA CA 92701 - A(qCORD 25 (2001108) ©ACORD CORPORATION 1988 P(�rn INS025 (0108).05 ELECTRONIC LASER FOR - (800)327 -0545 Page l of 2 DEC -2E -20011 10:ae FROM CITY OF SRNTFI aNR +COM.DEU TO ~19167840158 P.E5 EXHrBIT B ADDITIONAL TNTSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company 1 Erj 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 clairn is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person orlorganization 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 $ven to the City of Santa Ana, 20 Civic Center Plaza, Santa Amp, California 92701. (Completion of the ollowing, including countersignature, is required to make this endorsement effective.) Effective. �f /{�• Policy # _ Ln Issued io' ' ,,;0 �4a this endorsement form as a part of -f n n Insured Countersigned by A otize resentative *POLICY NUMBER: *INSURED COMPANY NAMI ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON or ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: i City of Santa Ana and its Officers, Agents, Employees and Volunteers are named as additional insured as respects their interest in connection with the named insured. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your operations or premises owned by or rented to you. IT IS AGREED THAT ANY INSURANCE MAINTAINED BY THE CITY OF SANTA ANA SHALL APPLY IN EXCESS OF, AND NOT CONTRIBUTE WITH, INSURANCE PROVIDED BY THIS POLICY. Agent's Signature: CG 2010 11 85 (218)C SAMPLE - Additional Insured with Primary/Non- Contributing Language Added aeJ �3 r• CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142 -0807 COMPENSATION I N S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07 -14 -2004 CITY OF SANTA ANA WIC \ YZ ATTN ANNABEL BATES PO BOX 1988 -M -73 SANTA ANA CA 92702 GROUP POLICY NUMBER: 1738022 -2004 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 04 -01 -2005 04 -01- 2004/04 -01 -2005 This is to certify that we have issued a valid Worker's 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 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an 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 document 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, exclusions, and conditions, of such policies. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT 42065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04 -01 -2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER CALIFORNIA HISPANIC COMMISSION ON ALCOHOL AND DRUG ABUSE, INC. A NON- PROFIT CORPORATION 2101 CAPITOL AVE SACRAMENTO CA 95816 SCIF 10262E Accept this certificate only if you see a faint watermark Nat read$ "OFFICIAL STATE FUND DOCUMENT" IKLS, NF' PRINTED: 07-14 -2004 PAGE i OF 1 12- 13 -'04 12:38 FROM- ALL -CAL INSURANCE 9167840158 T -358 P002/007 F -682 ACORD CERTIFICATE OF LIABILITY INSURANCE 1211 IBDOYYYY) 12/13/2004 PRODUCER (916) 784 -9070 qA �� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND AIL -Cal Insurance Agency -� - 'L HOLDER, TTHSOCERTTIIFICAOTER DOES NOT AMEND. EXTEND OR $01 Riverside Avenue #105 /� �ye-,� ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Attn: Beverly Al �y"''I�� INSURED mauntnn,.��• California Hispanic Commission on Alcohol INSURER S:NORTH AMERICAN ELITE NS. and Drug Abuse Prevention INSURER C: 2101 Capitol Avenue INSURER D: Cnnrwmnnrn CA 95816- INSURER _. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIGAT Eu. NU I WI I Hb IANUINU AN1 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 IN9RADD,L LTR INS LIMITS SHOWN MAY HAVE BEEN TYPE OF INSURANCE REOUGED BY PAID ULAIMb. POLICY NUMBER POLICYEFFECTIVE OATF ODIYY) F0UCYEXMRATION DATE(MMIDOYYI LIMITS A X GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY / / / / EACH OCCURRENCE 3 1,000,0( DAMAGE ;O RENTED PREMI E EaA T.1.1nee ' 50, OL MED EXF (AnY one ers0n) $ 5,OC CLNMSMADE ❑X OCCUR 2004 -03026 11/18/2004 11/18/2005 PERSONAL &ADV INJURY S 1,000,0C X PROFESSIONAL LIAR. X EMPLOYEE BENIFITS / / / / GENERA. AGGREGATE 3 2, 000, 0C GENL AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGO S 2, 000, OC ImIRiOPER SEXUAL COND 1,000,0( X POLICY F7 JECT LOC A X AUTOMOBILE LIABILITY / / / / COMBINED SINGLE UMIT (Ea a46dmt) S 1, On, OC ANYAUTO BOULY INJURv (Per PMGn) S ALL OWNED AUTOS scHEwLEDAUr05 2004 -03026 11/18/2004 11/18/2005 X X SODILYINJIMV (PerevA4an1) S HIRED AUTOS NONOV,NEDAUTOS VL) _.� {` / v / / • • PROPERTYDAMAGE (Per�mU $ cow DED: $250 c1 t`l` P'.✓ 1 Y�J ?` I / ��- n. / / X COLLISION DED: $500 GARAGE LIABILITY ANVAUTO ` -i'j' OtG ell AUTO ONLY - ERACCIDENT 3 OTHERTHAN FA ACC AUTO ONLY: AGO 4 3 A X EXCESS/UMBRELLA LIABILITY X OCCUR r7 CLAIMS MADE PSc� \S� !I / / / / EACH OCCURRENCE S 4, 000, OC AGGREGATE $ 4, 000, OC 3 � 3 DEDUCTIBLE 2004- 03026Um) 11/18/2004 11/18/2005 3 X RETENTION $10,000 - WORKERS OOMPENBATION AND I TVW LIMITS 1 ITP El EACHACCIDENT 8 EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNER/VECUTIVE E.L. DISEASE - EAEMPLOYEES OFHCERAIEMBER EXCLUDED? / / / / E.L. DISEASE - POLICY LIMIT 13 It yea, des"ne under SPECIAL PROVISIONS bNOV, B OTHER EMPLOYEE DISHONESTY CWB 000 2271 02 03026 11/18/2004 11/18/2005 LIMIT $100, OL FORGERY /ALTERATION Cm 000 2271 02 03026 11/18/2004 11/18/2005 DEDUCTION $5C A DIRECTORS 6 OFFICERS 2004- 03026n0 11/18/2004111/18/2005 LIMIT $ 1,000,00 DESOMPRON.OF OPERATONSILOCATIONSNEHICLESIE XGLUSIONS ADDED BV ENDORBEMENTESPECIAL PROVISIONS THE CITY OF SANTA ANA, ITS OFFICERS, AGENTS, OFFICIALS, EMPLOYEES, AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED AS FUNDING SOURCE TO TITS INSURED. FORK CG 2026 APPLIES. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES EE CANCELLED BEFORE THE ANABELL BATES EXPIRATION DATE THEREOF. THE ISSUING INSURER PALL A)MOS(4MOM MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, INR CITY OF SANTA ANA 1@( 16MtlifXif Xtlt (XMM1t1W0A141t.10{16Y11GNH11E P.O. BOX 1988 M -73 k i@10WLWtSKI(kXDrItiAFXd(K 20 CIVIC CENTER PLAZA AU11iOWZ00 REPRESIONIATIVE SANTA ANA CA 92701 - ACORD 26 (2001/08) m ACORD CORPORATION 19 t�_ - INS025(0108).05 ELECTRONIC LASER FORMS,) (800)327 -OW Pege1 A 1r- 13 -'04 12:38 FROM- ALL -CAL INSURANCE 9167840158 T -358 P003/007 F -682 ADDITIONAL INSURED L= NDORSEMENT Insurance Company�� -Y-ns This endorsement modifies such insurance as is afforded by the provisions of Policy relating to the followirg: 1. The City of Santa Ana, 20 Civi -: Center Plaza, Santa Ana, California 92702; its officers, employees, agents and volu-i-ieers 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 --.f the named insured. 2. With respect to claims arising out _;f 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 separatef} to each insured against whom claim is made or suit Is brought except with respect tc 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 canceled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa P.na, 20 Civic Center Plaza, Santa Ana, California 92702. (Completion of the following, including coui.tarsignature, is required to make this endorsement effective.) Effective Policy # a % am -6 Issued to CiLI rD 92Y/A S A-sac? � �a. 0 ntersi l' this endorsement form as a part of by horized presentative `l RFr..FTAFTI 19- 1A -' @Q 1P'r? APrn- 41F4429729 Tn- art -cat TNSnPhMrT PARR /MM4