HomeMy WebLinkAboutCAMBODIAN FAMILY, THE 3 - 2004
A-2004-167
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
3.- 9-c5
CLERK OF COUNCIL
DATE: 10 -/I-c4
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(6. ~+)
AGREEMENT BETWEEN
THE CITY OF SANTA ANA
AND
THE CAMBODIAN FAMILY
FOR USE OF EMPOWERMENT ZONE FUNDS
This Agreement, made and entered into this 1st day of July, 2004, by and between
the City of Santa Ana a charter city and municipal corporation duly organized and existing
under the Constitution and laws of the State of California ("CITY"), and The Cambodian
Family "CONTRACTOR").
W!INESSEIH
Recitals:
1. The City of Santa Ana, 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").
2. CITY desires to engage CONTRACTOR to provide the services at the cost
set forth in Exhibit A and for the services set forth Exhibit B, hereinafter
referred to as "said program" and CONTRACTOR represents that it is
qualified and willing to operate said program.
WHEREFORE, for and in consideration of the respective and mutual
covenants hereinafter contained and made, and subject to all the terms and
conditions hereof, the parties hereby agree as follows:
I. CONTRACTOR'S OBLIGATIONS
A. CONTRACTOR agrees to use all federal funds provided by CITY to
CONTRACTOR pursuant to this Agreement to operate said program, as set
forth in "Exhibit B," attached hereto and by this reference incorporated
herein. CONTRACTOR'S failure to perform as required may, in addition to
other remedies set forth in this Agreement, result in readjustment of the
amount of funds CITY is otherwise obligated to pay to CONTRACTOR
under Paragraph II hereof.
B. CONTRACTOR agrees to obtain and maintain all required licenses,
registrations, accreditation and inspections from all agencies governing its
operations. CONTRACTOR shall ensure that its staff shall also obtain and
maintain all required licenses, registrations. accreditation and inspections
from all agencies goveming CONTRACTOR operations hereunder.
C. CONTRACTOR agrees that any facility/property used in furtherance of said
program shall be specifically zoned and permitted for such use(s) and
activity(ies). Should CONTRACTOR fail to have the required land
entitlement and/or permits, thus violating any local, state or federal rules and
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regulations relating thereto, CONTRACTOR shall immediately make good-
faith efforts to gain compliance with local, state or federal rules and
regulations following written notification of said violation(s) from the CITY or
other authorized citing agency. CONTRACTOR shall notify CITY
immediately of any pending violations. Failure to notify CITY of pending
violations, or to remedy such known violation(s) shall result in termination of
grant funding hereunder. CONTRACTOR must make all corrections
required to bring the facility/property into compliance with the law within sixty
(60) days of notification of the violation(s); failure to gain compliance within
such time shall result in termination of grant funding hereunder.
D. All funds received by CONTRACTOR from CITY pursuant to this Agreement
shall be separately accounted for apart from any other funds of
CONTRACTOR, or of any principal or member of CONTRACTOR.
CONTRACTOR agrees that if CONTRACTOR receives $300,000 or more in
any Federal funds, CONTRACTOR shall have an annual audit conducted by
a certified public accountant in accordance with the standards as set forth
and published by the United States Office of Management and Budget
Circular A-133. CONTRACTOR shall provide CITY with a copy of said audit
by October 1 of the year following the program year in which this Agreement
is executed.
E. CONTRACTOR shall keep records of all funds received from CITY under
the terms and conditions of this Agreement in accordance with the
procedures set forth in the "Agreement Accounting and Administrative
Handbook", a copy of which shall be provided to CONTRACTOR by CITY.
CONTRACTOR agrees to keep monthly records of all ethnic and racial
statistics of persons and families benefited by CONTRACTOR in the
performance of its obligations under this Agreement, including, but not
limited to, the number of low and moderate income persons and households
assisted in accordance with federal income limits, number of female heads
of households, and number of senior citizens assisted.
CONTRACTOR agrees to provide CITY with written cumulative (year-to-
date) reports of its activities on or before the 15th day of July, October,
January and April for the period beginning October 1, 2004 and through and
including the previous three-month reporting period setting forth the
activities, program accomplishments, new program information and year-to-
date program statistics on expenditures, caseload and activities. When
appropriate, pictures should be included. This agreement shall terminate on
June 30, 2005, unless extended by mutual consent of the parties. Any
extension shall be in writing, and executed by the Executive Director of the
Community Development Agency and General Counsel on behalf of CITY.
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CITY, SAEC and the United State Government and/or their representatives
shall have access for purposes of monitoring, auditing, and examining
CONTRACTOR's activities and performance, to books, documents and
papers, and the right to examine records of CONTRACTOR's
subcontractors, bookkeepers and accountants, employees and participants
in regard to said program. CITY, SAEC and the United States Government
and/or their representatives shall also schedule on-site monitoring at their
discretion. Monitoring activities may also include, but are not limited to,
questioning employees and participants in said program and entering any
premises or any site in which any of the services or activities funded
hereunder are conducted or in which any of the records of CONTRACTOR
are kept. Nothing herein shall be construed to require access to any
privileged or confidential information as set forth in federal or state law.
In the event CONTRACTOR does not make the above-referenced
documents available within the CITY of Santa Ana, California,
CONTRACTOR agrees to pay all necessary and reasonable expenses
incurred by CITY in conducting any audit at the location where said records
and books of account are maintained.
F. All accounting records and evidence pertaining to all costs of
CONTRACTOR and all documents related to this Agreement shall be kept
available at the location where CONTRACTOR conducted the program, as
well as in the County of Orange, for the duration of the Agreement and
thereafter for five (5) years after completion of an audit. Records which
relate to (a) complaints, claims, administrative proceedings or litigation
arising out of the performance of this Agreement, or (b) costs and expenses
of this Agreement to which CITY or any other governmental agency takes
exception, shall be retained beyond the five (5) years until resolution or
disposition of such appeals, litigation, claims, or exceptions.
G. CONTRACTOR agrees to comply fully with all federal, state and local laws
and court orders applicable to its operation whether or not referred to in this
Agreement. CONTRACTOR agrees that it has read, understood and shall
follow the legal obligations referred in Exhibit C.
H. CONTRACTOR shall be in good standing, without suspension by the
California Secretary of State, Franchise Tax Board and Intemal Revenue
Service. Any change in the corporate status or suspension of
CONTRACTOR shall be reported immediately to CITY.
I. Subreceipient acknowledges and warrants that it shall at all times comply
with the laws, regulations and policies governing the use of FEZ funds,
including but not limited to, the limitations on use of FEZ funds set forth in
P.L. 106-74 (2000), 24 CFR section 598.215 and Federal Register, April
16,1998.
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J. Without prejudice to any other provisions of this Agreement, CONTRACTOR
shall, where applicable, maintain the confidential nature of information
provided to it conceming participants in accordance with the requirements of
federal and state law. However, CONTRACTOR shall submit to CITY,
SAEC and or HUD or its representatives, all records requested, including
audit, examinations, monitoring and verifications of reports submitted by
CONTRACTOR, costs incurred and services rendered hereunder.
K. CONTRACTOR agrees that the performance of obligations hereunder are
rendered in its capacity as an independent contractor and that it is in no way
an agency of CITY.
L. CONTRACTOR agrees that if CONTRACTOR violates any of the terms and
conditions of this Agreement or any prior Agreement whereby FEZ funds
were received by CONTRACTOR, or if CONTRACTOR reports inaccurately,
or if on audit there is a disallowance of certain expenditures, CONTRACTOR
agrees to remedy the acts or omissions causing the disallowance or repay
CITY all amounts spent in violation thereof.
M. CONTRACTOR agrees to maintain a record for each item of non-
expendable personal property acquired under the terms of this Agreement.
Said record shall be made available to CITY upon request. The term "non-
expendable personal property" shall include leased and purchased
equipment.
N. CONTRACTOR hereby certifies and agrees that it will not use funds
provided through this Agreement to pay for entertainment, meals or gifts.
O. CONTRACTOR certifies that no appropriated funds may be expended by
the recipient of a federal contract, grant, loan or cooperative agreement to
pay any person for influencing or attempting to influence an officer or
employee of any agency, Member of Congress, or an officer or employee of
a Member of Congress in connection with awarding of any federal contract,
the making of any federal grant or loan, entering into any cooperative
agreement and the extension, renewal, amendment or modification of any
federal contract, grant, loan or cooperative agreement. CONTRACTOR
shall sign a certification to that effect in a form as set forth in "Exhibit D,"
attached hereto and by this reference incorporated herein. CONTRACTOR
shall submit said signed certification to CITY prior to performing any of its
obligations under this Agreement and prior to any obligation arising on the
part of CITY to pay any sums to CONTRACTOR under the terms and
conditions of this Agreement.
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
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shall complete and submit a "Disclosure Form to Report Lobbying," in
accordance with its instructions.
P. CONTRACTOR agrees that except for the use of FEZ funds to pay salaries
and other related administrative or personnel costs, no persons who
exercise or have exercised any function with respect to FEZ activities
assisted under the terms of this Agreement, or who are in a position to
participate in a decision-making process or gain inside information with
regard to such activities, may obtain a financial interest or benefit from a
FEZ-assisted activity of CONTRACTOR. either for themselves or those with
whom they have family or business ties, during their tenure or for one year
thereafter. This prohibition applies to any person who is an employee,
agent, consultant, officer, or elected or appointed official of CITY, or of any
designated public agencies, or the CONTRACTOR.
Q. CONTRACTOR acknowledges and warrants that prior to having any
contractor perform work paid for by FEZ funds, that it shall be responsible
(i) for providing such contractor with a copy of this Agreement, and (ii)
ensuring that any such contractor executes and provides to the Executive
Director of the Community Development Agency a letter in substantially
the form of Exhibit E hereto, agreeing to be bound by the terms of this
Agreement.
R. CONTRACTOR acknowledges and warrants that during the term of this
Agreement it shall to the maximum extent feasible collaborate with other
CONTRACTOR to ensure that duplication of services is avoided. Such
collaboration shall include, but not be limited to, regular attendance (i.e.,
an attendance record exceeding 50%) and active participation in the
appropriate committee or committees established pursuant to the
Strategic Plan.
S. CONTRACTOR agrees to provide a drug-free work place and to execute a
certification as set forth in "Exhibit F" attached hereto and incorporated
herein by this reference.
T. CONTRACTOR shall comply with general provisions, assurances, and
certifications attached hereto as "Exhibit G" and incorporated herein.
II. CITY'S OBLIGATIONS
Upon execution of this Agreement by CONTRACTOR, CITY shall pay to
CONTRACTOR from FEZ funds, when, if and to the extent received from HUD, for
CITY's 2004-05 FEZ program year amounts expended by CONTRACTOR in
carrying out said program for fiscal year 2004-05 pursuant to this Agreement up to
a maximum aggregate payment of eighty five thousand six hundred twenty nine
dollars ($85,629) for CONTRACTOR'S performance in accordance with the
payment schedule attached hereto as "Exhibit A". Payments shall be made to
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CONTRACTOR through the submission of periodic invoices, in a form prescribed
by CITY, detailing such expenses. CONTRACTOR agrees to submit the above-
stated document to the FEZ Navigator Office, 1000 E. Santa Ana Blvd., Suite 200,
Santa Ana, CA 92701. CITY shall pay such invoices within thirty (30) days after
receipt thereof provided CITY is satisfied that such expenses have been incurred
within the scope of this Agreement and that CONTRACTOR is in compliance with
the terms and conditions of this Agreement.
CITY has the right to de-obligate the funds hereunder and take such funding
back from CONTRACTOR due to any of the following reasons: (a) lack of
performance by CONTRACTOR; (b) lack of fiscal accountability of
CONTRACTOR; or (c) decrease in available funding.
III. PROGRAM INCOME
A. For the purposes of this Article (III) "Program income," shall mean gross
income received by the CONTRACTOR directly generated from the use of
FEZ funds, except as provided below in Paragraph III.C. When such income
is generated by an activity that is only partially assisted with FEZ funds, the
income shall be prorated to reflect the percentage of FEZ funds used.
B. Program income includes, but is not limited to the following:
1. Proceeds from the disposition by sale or long term lease of real
property purchased or improved with FEZ funds;
2. Proceeds from the disposition of equipment purchased with FEZ
funds.
3. Gross income from the use or rental of real or personal property
acquired by the CONTRACTOR with FEZ funds, less the costs
incidental to the generation of such income;
4. Gross income from the use or rental of real property owned by the
CONTRACTOR that was constructed or improved with FEZ funds,
less the costs incidental to the generation of such income;
5. Payments of principal and interest on loans made using FEZ funds;
6. Proceeds from the sale of loans made with FEZ funds;
7. Proceeds from the sale of obligations secured by loans made with
FEZ funds;
8. Interest earned on funds held in a revolving fund account;
9. Funds collected through special assessments made against
properties owned and occupied by households not of low and
moderate income, where such assessments are used to recover all
or part of the FEZ portion of a public improvement.
C. Program income does not include income on grant advances from the U.S.
Treasury. The following items of income earned on grant advances must be
remitted to HUD for transmittal to the U.S. Treasury.
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1. Interest eamed from the investment of the initial proceeds of a grant
advance by the U.S. Treasury;
2. Interest earned on loans or other forms of assistance provided with
FEZ funds that are used for activities determined by HUD either to be
ineligible or to fail to meet a national objective or other federal criteria.
3. Interest earned on the investment of amounts reimbursed to the FEZ
program account prior to the use of the reimbursed funds for eligible
purposes.
D. The receipt of program income (as defined in Paragraph IliA hereinabove)
by CONTRACTOR in the operation of said program shall be recorded by
CONTRACTOR and reported to CITY.
E. Program income received by CONTRACTOR shall be returned to CITY
unless otherwise provided for in this Agreement.
IV. NONDISCRIMINATION
CONTRACTOR agrees that no person on the ground of race, color, national origin,
religion or sex will be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity funded in whole or in part
with FEZ funds.
V. SPECIAL CERTIFICATION FOR RELIGIOUS ENTITIES
If CONTRACTOR is a religious entity, CONTRACTOR hereby agrees that in
connection with the provision of the services CONTRACTOR shall provide with
FEZ funds:
A. CONTRACTOR shall not discriminate against any employee or applicant for
employment on the basis of religion and shall not limit employment or give
preference in employment to persons on the basis of religion.
B. CONTRACTOR shall not discriminate against any person applying for the
services CONTRACTOR agrees to provide under the terms of this
Agreement on the basis of religion and shall not limit such services or give
preference to applicants for such services on the basis of religion.
C. CONTRACTOR shall NOT provide religious instruction or counseling,
conduct any religious worship or services, or engage in any religious
proselytizing, or exert any religious influence in the provision of the services
in said program.
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D. Where the services to be provided under said program are rendered on
property owned by the primarily religious entity CONTRACTOR, FEZ funds
may also be used for minor repairs to such property which are directly
related to the cost of rendering the services under said program, where the
cost constitutes in dollar terms only an incidental portion of the FEZ
expenditure for rendering the services under said program.
VI. PROHIBITION OF NEPOTISM
CONTRACTOR agrees not to hire or permit the hiring of any person to fill a position
funded through this Agreement if a member of that person's immediate family is
employed in an administrative capacity by CONTRACTOR. For the purposes of
this section, the term "immediate family" means spouse, child, mother, father,
brother, sister, brother-in-law, sister-in-law, father-in-law, mother-in-law, son-in-law,
daughter-in-law, aunt, uncle, niece, nephew, step-parent and stepchild. The term
"administrative capacity" means having selection, hiring, supervisor or management
responsibilities.
VII. NOTICES
Notices to the parties shall, unless otherwise requested in writing, be sent by U.S.
Mail, postage prepaid, and addressed as follows:
TO CITY:
Santa Ana WORK Center
WORK Center Director
1000 E. Santa Ana Blvd., Suite 200
Santa Ana, California 92701
Telefacsimile (714) 565-2602
And,
CLERK:
Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 82702-1988
Telefacsimile (714) 647-6956
TO CONTRACTOR:
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VIII. ASSIGNABILITY
CONTRACTOR shall not assign nor transfer any interest in this Agreement,
whether by assignment or novation, without the prior written consent of CITY;
provided, however, that claims for money due or to become due CONTRACTOR
from CITY under this Agreement may be assigned to a bank, trust company or
other financial institution, or to a trustee in bankruptcy, without such approval.
Notice of any such assignment or transfer shall be promptly furnished to CITY.
IX. HOLD HARMLESS
CONTRACTOR shall indemnify and save harmless CITY, its officers, employees,
agents, representatives and volunteers from and against any and all damages to or
for loss of use of property and for injuries to or death of any person or persons,
including property and employees or agents of CITY, and shall defend, indemnify
and save harmless CITY, its officers, employees, agents, representatives and
volunteers from and against any and all claims, demands, suits, actions or
proceedings of any kind or nature, including, but not by way of limitation, workers
compensation claims and including attorney fees and reasonable expenses for
litigation or settlement, resulting from or arising out of the negligent or wrongful
acts, errors or omissions of CONTRACTOR, its officers, directors, employees,
agents, subcontractors and suppliers arising out of CONTRACTOR's performance
of this Agreement.
X. INSURANCE
CONTRACTOR shall obtain and maintain for the entire term of this Agreement
comprehensive general public liability insurance, in companies acceptable to the
City, authorized to issue such insurance in the State of California. Said
insurance shall consist of the following:
A. Commercial General Liability. CONTRACTOR agrees to obtain and keep
in force during the term of this Agreement a policy of comprehensive
commercial public liability insurance insuring the State of California, CITY,
and CONTRACTOR against any liability for accident, injury or death
arising out of or in consequence of this Agreement. Such insurance shall
be in an amount not less than One Million Dollars ($1,000,000.00) for any
injury to or death of any person or persons in any single accident or
occurrence. Said policy of comprehensive public liability insurance shall
be endorsed to provide to CITY and to the State of California, Employment
Development Department, at least thirty (30) days written notice prior to
cancellation; name CITY, its officers, agents, employees, and volunteers,
and the State of California, its officers, employees, and volunteers as
additional insureds; and state that such coverage is primary to any other
coverage or self-insurance of the State of California and CITY.
Governmental entities may substitute a certificate of self-insurance.
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B. Automobile Liabilitv Coveraqe. CONTRACTOR shall also obtain and
maintain, during the effective period of this Agreement, broad form
automobile liability coverage with a $1,000,000 limit unless reduced by
CITY, which applies to both ownedlleased and non-owned automobiles
used by CONTRACTOR employees or participants in performance of this
Agreement, or, in the event that CITY will not utilize such owned/leased
automobiles but intends to require employees, participants or other agents
to utilize their own automobiles in the performance of this Agreement,
CONTRACTOR shall secure and maintain on file from all such employees,
participants, or agents as self-certification of automobile insurance
coverage. Governmental entities may substitute a certificate of self-
insurance.
C. Workers' Compensation. If CONTRACTOR is an "employer", as set forth
in California Labor Code Section 3300 et seq., or utilizes participants as
"employees," as set forth in California Labor Code Section 3350 et seq.,
CONTRACTOR shall obtain and keep in force during the term of this
Agreement full Workers' Compensation insurance coverage for injuries
suffered by participants. Said insurance policy shall guarantee CITY at
least thirty (30) days written notice of cancellation or modification.
CONTRACTOR shall carry medical and accident insurance for those
participants not qualifying as "employees" for Worker's Compensation
Coverage, pursuant to California Labor Code Section 3350, et seq.
D. Equipment Coveraqe. CONTRACTOR shall purchase a policy or policies
of insurance covering loss or damage to any and all Equipment provided
to or purchased by CONTRACTOR in accordance with this Agreement.
Said insurance shall be in the amount of the full replacement value
thereof, providing protection against the classification of fire, extended
coverage, vandalism, malicious mischief, theft, and special extended
perils. Governmental entities may substitute a certificate of self-insurance.
E. Proof of Insurance. Certificates and endorsements (Exhibit H) must be
submitted and approved by CITY prior to any work under this Agreement.
CONTRACTOR understands that CITY will make no payments under this
Agreement until the required certificates and endorsements have been
approved by CITY.
XI. REVERSION OF ASSETS
A. Upon the expiration of this Agreement, CONTRACTOR shall transfer to
CITY any FEZ funds on hand at the time of the expiration of this Agreement
as well as any accounts receivable attributable to the use of FEZ funds.
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B. Any real property under CONTRACTOR's control that was acquired or
improved in whole or in part with FEZ funds in excess of $25,000.00 must
either be:
1. Used, where CITY has given written approval, to meet one of the
national objectives stated under federal law until five (5) years after
expiration of this Agreement, or for such longer period of time as
determined to be appropriate by CITY; or
2. If not used in accordance with subparagraph A above,
CONTRACTOR shall pay to CITY an amount equal to the current fair
market value of the property less any portion of the value attributable
to the expenditure of non-FEZ funds for acquisition of, or
improvement to, the property. Such payment is program income to
CITY.
C. Subject to the obligations set forth herein, title to equipment acquired
under the terms of this Agreement will vest upon acquisition in
CONTRACTOR. When said equipment which has been acquired in
accordance with this Agreement and all applicable regulations is no longer
needed for said program, disposition of said equipment will be made as
follows:
1. Items of equipment with a current per unit fair market value of less
than $5,000.00 may be retained, sold or otherwise disposed of with
no further obligation to CITY.
2. Items of equipment with a current fair market per unit value of
$5,000.00 or more may be retained or sold and CITY shall have the
right to an amount calculated by multiplying the current market value
or proceeds from the sale by CITY's share of federal funds used to
acquire the equipment.
C. CONTRACTOR hereby agrees, upon the demand of CITY, to execute,
acknowledge and deliver, or cause any person or entity who may have any
claim to rights hereunder or under any document, instrument or agreement
executed in furtherance of the services and activities to be performed
hereunder, to execute, acknowledge and deliver, to CITY assignment(s),
quit claim deed(s) or such other and further instruments, documents and
agreements as may be necessary, in the sole and absolute discretion of
CITY, to vest in CITY all of CONTRACTOR's right, title and interest (if any it
may have) in and to CITY, SAEC, FEZ or other federal, state and/or local
accounts or program funds or allocation of funds to which CITY is or may be
entitled, either for its own account or as fiduciary or trustee for others, which
were obtained for the purpose of the performance of this Agreement or any
previous agreements relating to the same subject matter or activities as this
Agreement, together with any instruments, loans, grants or advances by
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CONTRACTOR on behalf of CITY, in furtherance of the activities hereunder
or thereof.
CONTRACTOR's obligations and responsibilities set forth in this paragraph
"XI. REVERSION OF ASSETS," and in paragraphs "XII. TERMINATION"
and "III. PROGRAM INCOME" shall not be affected by the termination of this
Agreement and shall survive the date of termination of this Agreement for
such period of time as CITY and/or HUD deems necessary for the
responsibilities, duties and obligations to be performed and completed to the
satisfaction of CITY and HUD.
XII. TERMINATION
A. This Agreement may be terminated on thirty (30) days' written notice by
either party. In the event of such termination, CONTRACTOR shall only be
entitled to reimbursement for approved expenses incurred to the effective
date of termination.
B. This Agreement may be suspended or terminated by CITY upon five (5)
days' written notice for violation by CONTRACTOR of the terms and
conditions of the this agreement or applicable State or Federal
requirements. In the event of such suspension or termination,
CONTRACTOR shall only be entitled to reimbursement for approved
expenses incurred up to the effective date of suspension or termination.
C. In the event CONTRACTOR defaults by failing to fulfill all or any of its
obligations hereunder, CITY may declare a default and termination of this
Agreement by written notice to CONTRACTOR, which default and
termination shall be effective on a date stated in the notice which is to be not
less than ten (10) days after certified mailing or personal service of such
notice, unless such default is cured before the effective date of termination
stated in such notice. If terminated for cause, CITY shall be relieved of
further liability or responsibility under this Agreement, or as a result of the
termination thereof, including the payment of money, except for payment for
approved expenses incurred for services satisfactorily and timely performed
prior to the mailing or service of the notice of termination, and except for
reimbursement of (1) any payments made for services not subsequently
performed in a timely and satisfactory manner, and (2) costs incurred by
CITY in obtaining substitute performance.
D. The grant of funds by CITY to CONTRACTOR pursuant to this Agreement
may be terminated for convenience upon two weeks written notice to
CONTRACTOR.
E. In the event this Agreement is terminated as set forth in subparagraphs
XIIA through XII.D., inclusive, CONTRACTOR agrees to immediately return
to CITY upon CITY's demand and prior to any adjudication of
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CONTRACTOR's rights, any and all funds not used, and to comply with
paragraph "XI. REVERSION OF ASSETS" of this Agreement.
XIII. LIMITATION OF FUNDS
The United States of America, through HUD, may in the future place programmatic
or fiscal limitations on the use of FEZ funds which limitations are not presently
anticipated. Accordingly, CITY reselVes the right to revise this Agreement in order
to take account of actions affecting HUD program funding. In the event of funding
reduction, CITY may, in its sole and absolute discretion, reduce the budget of this
Agreement as a whole or as to costs category, may limit the rate of
CONTRACTOR's authority to commit and spend funds, or may restrict
CONTRACTOR's use of both its uncommitted and its unspent funds. Where HUD
has directed or requested CITY to implement a reduction in funding, in whole or as
to a cost category, with respect to funding for this Agreement, CITY's Executive
Director or delegate is authorized to act for CITY in implementing and effecting
such a reduction and in revising, modifying, or amending the Agreement for such
purposes. Where CITY has reasonable grounds to question CONTRACTOR's
fiscal accountability, financial soundness, or compliance with this Agreement, CITY
may suspend the operation of this Agreement for up to sixty (60) days upon five (5)
days written notice to CONTRACTOR of its intention to so act, pending an audit or
other resolution of such questions. In no event, however, shall any revisions made
by CITY affect expenditures and legally binding commitments made by
CONTRACTOR before it received notice of such revision, provided that such
amounts have been committed in good faith and are otherwise allowable and that
such commitments are consistent with HUD cash withdrawal guidelines.
XIV. EXCLUSIVITY AND AMENDMENT OF AGREEMENT
This Agreement supersedes any and all other agreements, either oral or in writing,
between the parties hereto with respect to the use of CITY's FEZ funds by
CONTRACTOR and contains all the covenants and agreements between the
parties with respect to such employment in any manner whatsoever. 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, and that no other
agreement or amendment hereto shall be effective unless executed in writing and
signed by both CITY and CONTRACTOR.
XV. LAWS GOVERNING THIS AGREEMENT
This Agreement shall be governed by and construed in accordance with the laws of
the State of California, and all applicable federal laws and regulations.
XVI. VALIDITY
The invalidity in whole or in part of any provision of this Agreement shall not void or
affect the validity of any other provision of this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of
the last date and year written below.
DATED:
~-4
~e:t-.
PATRICIA E. HEALY,
Clerk of the Council
DATED:
?/2-b/o'-/
R
Patricia C. Whitaker, Execu Ive Director
Community Development Agency
CITY OF SANTA Ana, a municipal
Corporation of the State of California
( 6;2
/ ~. .
'17~~~./ . (t. v
David N. Ream
City Manager
APPROVED AS TO FORM:
f!:r ' AM-;;', ".l,
WB KAUFMAN, I
City General Counsel
CONT7f~~
Federal Tax ID: 9S-- :s ft J'f (j' 3/
Page 14 of 14
THE CAMBODIAN FAMILY
Daisy Wheel Program
July 1, 2004 - June 30, 2005
BUDGET FORM
Administrative Proaram Total FEZ Match/ln-Ki nd
Personnel
Salaries * $ 10,609 $ 47,831 $ 58,440 $ 113,060
Benefits 2,652 11,958 14,610 27,134
Other (list) * - - - -
Total Personnel 13,261 59,789 73,050 140,194
Ooeratina Exoenses
Rent * 5,826 5,826 38,160
Utilities 600 600 4,620
Phone/Fax/Internet fees 960 960 1,020
Janitorial Maintenance/Supplies 1,200 1,200
Insurance 420 420
Enuinment Rental/Maintenance * 540 540
Office Supplies 500 500 8,400
Professional Services 720 720
Audit 856 856
Staff Trainina 50 50
Travel/Mileaqe 660 660
Trainina SWJDjies 57 57
Otherliist\ *
Fees/MembershTD/Subscription 50 50
postaae 140 140
Total Ooeratina Exoenses - 12,579 12,579 52,200
GRAND TOTAL $ 13,261 $ 72,368 $ 85,629 $ 192,394
* Attach a separate sheet detailing these costs.
THE CAMBODIAN FAMILY
Daisy Wheel Program
July 1, 2004 - June 30, 2005
Budget Detail Sheet
Personnel
HE Funded
Annual Salary by FEZ Administrative
Program
Total Amount
Requested from FEZ
Executive Director
Secretary
Finance Manager
Bookkepper
Computer Specialist
ES Coordinator
Assistant ES Coordinator
Quality Control SpecialisVCounselor
Employment SpeCialists
Family Coaches
$67,025 3.0% $ 2,011 $ $ 2,011
27,144 3.0% 814 814
49,339 10% 4,934 4,934
37,271 5% 1,864 1,864
39,463 2.5% 987 987
50,425 5% 2.521 2,521
45,936 25% 11,484 11,484
35,496 10.0% 3,550 3,550
33,408 25% 8,352 8,352
29,232 75% 21,924 21,924
10,609 47,831 58,440
2,652 11,958 14,610
13,261 59,789 73,050
Total Salaries
Benefits @ 25% of total salaries
Total Personnel
Operating Expenses
Rent -700 sq. ft. x $.714/sq. ft. x 12 months
5.826
5,826
Equipment Rental/Maintenance - $45/mo x 12 months
copy machine, fax, drinking water system. and company van maintenance services.
540
540
Other
Fees/Membership/Subscription
Postage - stamp
50
111
50
111
THE CAMBODIAN FAMILY
Daisy Wheel Program
July 1, 2004 - June 30, 2005
In-Kind Detail Sheet
PERSONNEL
TOTAL
In-Kind
Prop10 - Child care
Project Coordinator
Childcare Assistants
$18.5/hr x 40 hrs/wk x 52 weeks $ 38,480
$121hr x 30 hrs/wk x 52 weeks $ 18,720
$30/hr x 38 hrs/wk x 46 weeks $ 52,440
$19/hr x 15 hrs/wk x 12 weeks $ 3,420
$ 113,060
$ 27,134
$ 140,194
Santa Ana Colleae - ESL Classes
ESL Instructors
ESL Instructors
Total Salaries
Benefits @ 24% of total salaries
Total Personnel
OPERATING EXPENSES
Prop10 - Child care
Chiidcare project supplies and malerials
Rent
Telephone
Utilities
Refuaee Emplovment Services Proaram -ESL Classes
Rent
Utilities
$700/month x 12 months
$2080/month x 12 months
$85/month x 12 months
$250/month x 12 months
$1100/month x 12 months
$135/month x 12 months
$ 8,400
$ 24,960
$ 1,020
$ 3,000
$ 13,200
$ 1,620
$ 52,200
$ 192,394
Total Operating Expenses
GRAND TOTAL
The Cambodian Family
FEZ Daisy Wheel Network Program
Scope of Work
I. TERM
July I, 2004 through June 30, 2005
II. PURPOSE
The FEZ Daisy Wheel Network Program will proyide 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 Fcdcral 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 THE CAMBODIAN F AMIL Y
A. Program Design:
a. Provide an intake assessment (for screening) of cach 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 achieyement objectives.
B. Program Elements:
a. The following program elements will be made ayailable to eligible residents expected to
enroll in the FEZ Daisy Wheel Network Program for participation in actiyities aimed at
providing a comprehensive strategy that addresses employment and training needs:
i. vocational/occupational training,
ii. employment strategies,
Ill. education, and
tv. supportive services
C Performance Outcomes
a. 90 will be served
b. Of the 90 FEZ residents served, 45 (50%) will be provided additional services as needed
c. Of the 90 FEZ residents served, 36 (40%) will be placed in jobs, given work experience,
receive On-the-Job Training, receive retention services, attend English as a Second
Languagc classcs, bc proyidcd with skill upgrades, and have access to paid
d. Of the 90 FEZ residents served, 27 (30%) will be placed in unsubsidized employment
(this 30% number can be counted as part of the 40% mentioned in item # 3).
e. Planned enrollments by Quarter:
1"
Qtr.
31
2nd
Qtr.
14
3'd I 4'h
Qtr. Qtr.
31 14
EXHIBIT B
V. SERVICES WILL BE PROVIDED AT:
The Cambodian Farnily
1111 E. Wakeham Ave., Suite E
Santa Ana, CA 92705
VI. WORK CENTER RESPONSIBILITIES
1. Develop contracts for partners
2. Provide oricntation 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 Rcporting
6. Provide partners with on-going technical assistance
7. Proyide a quarterly FEZ newsletter
8. Facilitate monthly meetings
VII. THE CAMBODIAN F AMIL Y RESPONSIBILITIES
1. The Cambodian Family will proyide 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
. Comprehensive support services
. Job development
. Placement and retention services
. Job training / education
. Workforce preparation workshops
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. Proyide 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 5th of every
month. Report should include new enrollments and a continuous Activity Enrollment Form.
II. Maintain a current and complete file (electronic as well as a hard copy) for each FEZ
participant: eligibility documentation; registration form; enrollment form; assessment;
Indiyidual Service Plan (ISP); EEO/Grievance; case notes; supportive services
documentation; attendance records; training documentation; etc.
EXHIBIT B
12. Comply with allowable expenses. To be allowable, costs must: a) be reasonable for the
performance o[the program; b) confoD11 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, f) be adequately
documented.
13. Submit in triplicate, a monthly lnyoice on City of Santa Ana, Federal Empowerment Zone
Program Subrecipient Request for Reimbursement, showing in detail the amount of money
already expended. Accounting records rnust 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 (loth) day of the month following the
month in which services are performed.
EXHIBIT B
SUB RECIPIENT wan-ants the following:
I. SUBRECIPIENT will comply with Public Law 88-352, title VI of the Civil Rights Act of
1964 (42 U.S.c. 92000 ET SEQ.) and implementing regulations in 24 CFR Part I.
2. No person in the United States shall on the ground ofrace, color, religion, national origin, or sex,
be excluded from participation in, or be denied the benefits of, or be subjected to discrimination under,
any program or activity funded in whole or in part with community development funds made available
pursuant to the ACT.
3. All laborers and mechanics employed by contractors or subcontractors in the performance of
construction work financed in whole or in part with community development funds shall be paid wages
at rates not less than those prevailing on similar construction on the locality as detennined in accordance
with the Davis-Bacon Act, as amended, 40 U.S.c. 9 9276a-276a-5, except for individuals who perform
services for which they voluntccrcd; do not rcccivc compcnsation for such services; or are paid expenses,
reasonable benefits, or a nominal fee for such services; and are not otherwise employed at any time in
construction work.
4. SUBRECIPIENT will comply with all Federal statutes applicable to projects funded with community
development funds, except that (a) SUBRECIPIENT does not assume CITY's environmental responsibilities
described at 24 CFR 570.604; and (b) SUBRECIPIENT does not assume CITY's responsibility for initiating
the review process under Executive Order] 2372.
EXHIBIT C
Certification Regarding Lobbying
Certifi,_,!!ign for Contracts, Grants, Loans, and Coopcrativc Agrcements
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 intluence 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 fWlds have been paid or will be paid to any person for
influencing or attempting to intluence 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
cOlUlection with this Federal contract, grant, loan, or cooperative agreement, the wldersigned 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.
dram f(
Grantee/Contractor Organization
Pell's W/"u( lve-llA./o,-(
Program Title
R.c "'"KA 'ff I ~.s t#
Signature
lex
Date
EXHIBIT D
Part I
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form 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 fonn 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 uf Management and Budget fur additiunal infurmatiun.
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. Ifthis 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 'l 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, ifknov.....n.
6. Enter the name of the Federal agency making the award or loan commitment. Includc at Icast one organizational1cvel 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 (eFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the must appropriatt: Federal idt:ntifying number available for the Federal action identified in item 1 (e.g.) Request for Proposal (RFP)
number; invitation for Bid (lFB) number; grant announcement numbt:r; the cuntract, grant, or loan award number; the application/proposal control
number assigned by the Fedcral agcncy). Include prcfixes, 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.
1 O. (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) Entcr the full names of the individual(s) performing services, and include full address if Jiffen:nt from 10 (a). Enter Last Name, First Name, and
Middle initial (MI).
II. 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. Cht:ck 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 bc cxpected 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 whethl:r ur nut a SF-LLL-A Continuation Sheet(s) is attached.
16. The certifying official shall sign and datc the fonn, print hislher 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 tor reducing this burden, to the Office of
Management and Budget, Paperwork Reduction Pruject (0348-0046), Washington. D.C.20503.
EXHIBIT D
Part II
ACKNOWLEDGEMENT OF
SUB RECIPIENT AGREEMENT
To: Patricia C. Whitaker
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
Empowem1ent Corporation.
Subcontractor/Assignee further agrees to bc bound to all of the terms and proyisions of
SUBRECIPIENT's Agreement with the Santa Ana Empowerment Corporation.
Executed this d (Q t1t day of ~
BY tV~~
Name: If\<fl t-1IR'5.C:tf
Title: ~xf.ct4.TI Ve. ~I~R
, ~C{) 'f
EXHIBIT E
Certification Reqardinq Druq-Free Workolace Requirements
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 awarenoss 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 F
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:
'7/:J..~ /0 'f
I / .
RvjIM ~
Ttffi:. LwmPDdtfh> Fwm~
Program Operator
Subcontractor agrees that in addition to those agreements and obligations
specified in the contract boiler plate and scope of work, it will also adhere to and
obey the following provisions, assurances, and certifications.
ARTICLES
1) Subcontractor 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, parties, and/or
beliefs.
2) Contractor assures and certifies that where applicable, classroom training
instructors are properly credentialed, and training curriculums comply with
State Education Codes.
3) Subcontractor assures and certifies that any requested modification to this
agreement must be submitted in writing, explaining requested changes
and rationale. Subcontractor further assures that no modification will be
implemented without prior written approval from the Santa Ana WORK
Center.
4) Contractor assures and certifies that they are in good standing with the
California Secretary of State Franchise Tax Board and Internal Revenue
Service.
5) Subcontractor 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 or the Santa
Ana Empowerment Corporation.
6) Subcontractor agrees to acknowledge (give credit) the Santa Ana WORK
Center and the Santa Ana Empowerment Corporation as the source of
funds in all oral presentations, written document, publicity, and
advertisements regarding any activities that ensue from this agreement.
EXHIBIT G
DIVISION OF EMPLOYMENT SERVICES
PLACE OF PERFORMANCE
FOR CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
Name: Kt-fko, f-li r-sci-,
Name of Contractor: ~~
Contractor 'Number:
La.....; 0oj(~n ForM; Iv
/
Fe) :co # '?s-- 3?S"QR'3/
Date:
:Tvly..2..6 2.00'1
( I
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):
/ / / / C. (IV'., ke /1 0. VIA Are., 5 ,,; te. G... s... vt-h.. ~c.. OVQt/1 '7e {~c..4- 'l:z.. 7 CJ S-
, . ' v
. J4.CO'RD CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYYYY)
'" 04/06/2004
PRODUCER (714)838-1912 FAX (714)838-7568 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Lake Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
13891 Newport Ave., Suite 285 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
L ic #0747473
Tustin, CA 92780 INSURERS AFFORDING COVERAGE NAIC#
INSURED Cambodian Family INSURER A: Philadelphia Ind, Ins. Co.
1111 East Wakeham Avenue INSURER B:
Suite E INSURER c:
Santa Ana, CA 92705 INSURER 0:
INSURER E:
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 gy PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER O':-TE "MMfDDlY'il- DATE'IM.t6"6',w,N LIMITS
GENERAL LIABILITY PHPK074625 03/09/2004 03/09/2005 EACH OCCURRENCE $ 1,000,000
'x COMMERCIAL GENERAL LIABILITY PREMISES lEa occurence\ $ 300,000
I CLAIMS MADE [K] OCCUR MED EXP (Anyone person) $ 5,000
A ~ o deductible PERSONAL & AQV INJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
I--
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $ included
!xl 'n ~RO' n
X POLICY JEer LOC
AUTOMOBILE LIABILITY PHPK074625 03/09/2004 03/09/2005 COMBINED SINGLE LIMIT
I-- $
ANY AUTO (Ea accident) 1,000,000
I--
ALL OWNED AUTOS BOOIL Y INJURY
- $
SCHEDULED AUTOS (Per person)
A ~
HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
.~ $0 Deductible PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILlrf AUTO ONLY. EA ACCIDENT $
==1 ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESS/UMBRELLA LIABILITY - EACH OCCURRENCE
$
~ OCCUR D CLAIMS MADE . . " \i: AGGREGATE $
.', ,- ~ .' , ' ' ..
/\, F~ r' >, (.I \ " $
=J ~EDUCTlBLE J rJj /'I ~j 1 /13 $
RETENTION $ .. $
WORKERS COMPENSATION AND (/ 1:7 ,,/ I TOR,m.'TS Ilo~.
EMPLOYERS' LIABILITY ''''./''"v ,.
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $
~.
OFFICER/MEMBER EXCLUDED? E.l. DISEASE. EA EMPLOYEE $
~~~Ei~tS~R~v~s1~~s below E.L. DISEASE. POLICY LIMIT $
OTHER PHPK074625 03/09/2004 03/09/2005 $1,000,000 Each Claim
A ~buse & Molestation $3,000,000 Aggregate
$0 Deductible
E~ESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
~mployee Dishonesty Liability $200,000 / 0 Ded.
ertificate holder is named as additional insured per contract with named insured.
chedule of vehicles and drivers on file.
'10 day notice of cancellation due to non-payment of premium.
Santa Ana Work Center
1000 Santa Ana Blvd.,
Suite 200
Santa Ana, CA 92701
0:.: h CllA- 1"\014,1'\-.0 1"\.1
ACORD 25 (2001/08)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~~ MAil
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
CERTIFICATE HOLDER
~r
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.
\ ,; !. -~ . :, .l'" ~. :-'.
~&--
ACORD 25 (2001/08)
. MAYJJ.3-2004 09: 24
THE CAMBODIAN FAMILY
714 571 1974
P.04
. .
. .
.
ADDITIONAL .INSURED ENDORSEMENT
Insurance Company PHILADELPHIA INDE1-;NITY INSURANCE CO.
This endOl'Seqleot mOdIfies such Insur8n06 as Is affor~ad by the provisions of Policy
# PHPK074bZ5 I'8laUng to the folloWing:
1. 'The Clly OIl Santa Ana, 20 Civic c.nter Plaza, Santa Arta. California 92701;
ItS oIfIcers. employees. 8g1!ln13 end representatiws Bre named as addltlonel insureds
("add'Jtional InSIJreds") with regard to Rablily and defense of suItS arising from the
<meretlons and IJS@S performecI bv or on behalf 01 the named InsUred.
.'. ,
2. Wdh respect to dllirns 9tItIng out Of the operatlQnIS and uses per1Ol'l1led by
or on behalf of \he named InSUred. suotllnsuranca as is afforded by lJ'IiS policy is primary
and i$ not addIiloMI to or contributing with Iny ClIher insurance carried by 01" for the
bendt of the addtionBl insUreds-
3. ,"TNa II'l5UI1tllt;tI appUes separately to ~ Insured against whom daim is
made or suit Is brought except with respect to the ccmpany's Omits or labll1ly. The
lnofusion of 3l1'/ person or cxglWllz8don as an insur-d $haI1 not affect any right which such
person or organI2aIIon woUd haVe as a dalmem if nOl so 1neIuded.
4. WIth~ to1M eddiIIanBIlnsureds.lhis insurance shall not be canoeIIed.
or materially rIductcI In coverage QI" imil:l exc:eQt etter IhIrty (3D) d8ys written notice has
been given to the Cly 01 Santa Me. 20 CMQ Center Pl8Z9, Santa Ana, ,Callf0mi8 92701.
(Comp\.QUon of the following, including counterslgn;atUre, is required to make thIs
endorsement .etreotiVe.)
. Erf~vlll 03/09/04
.
I this endorsement form as B part of
Policy # PHPK074625
Issued to . THE CAMBODIAN FAMILY
Named Insured
Caunters.lgned by
~vo~
.\f'FH)\:: '
-.--YtP 3/3.. .
UIlIAtT 0
TOTAL P.04
. , DATE (MMlDDNYYY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP 10 J9 06/24/04
THECA-1
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License #0522024 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Box 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pasadena CA 91117-0455
Phone: 626-405-8031 Fax:626-405-0585 INSURERS AFFORDING COVERAGE NAIC#
--... -.. -
INSURED INSURER A: State Compensation Ins rune!
_._-~
INSURER B:
The Cambodian Family INSURER c: ---
1111 E. Wakeham Ave., Suite E INSURER 0:
Santa Ana CA 92705 --
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 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.
L TR NSR
TYPE OF INSURANCE
~NERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
I CLAIMS MADE D OCCUR
POLICY NUMBER
PD~~~1J~DDNtXE Pgk\-CEY(ft~b'}f,R~N
LIMITS
EACH OCCURRENCE S
PREMISES Ea occurence) S
MED EXP (Anyone person) S
,__~ERSO~~~~?~I~J~_RY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
--~
.-
--..-
J-
~'L AGGREGATE LIMIT APPLIES PER:
I POLICY n ~r8T n LOC
~TOMOB1LE LIABILITY
_ ANY AUTO
_ ALL OWNED AUTOS
SCHEDULED AUTOS
-
._ HIRED AUTOS
_ NON.OWNED AUTOS
GARAGE LIABILITY
~ ANY AUTO
EXCESS/UMBRELLA LIABILITY
=:J OCCUR D CLAIMS MADE
I DEDUCTIBLE
I RETENTION S
.,~(\
\,0""
c 0
" 1'-;>
O<"J~V ~'~ .___-.
",,\l.C ' '. . I,,,' .___-.
1'-< < !. .. if' .-
, /c(d
~,\ ~ .~,,,){n'C'
1..:.\\\1>- , C\ ~
. ';',\'3,J'\\.
p...'i>~\
COMBINED SINGLE LIMIT
(Eaaccident)
.
BODILY INJURY
(Per person)
.
BODILY INJURY
(Per accident)
.
PROPERTY DAMAGE
(Per accident)
.
AUTO ONLY - EA ACCIDENT
.
EA ACC $
AGG $
.
.
.
.
.
_u_
OTHER THAN
AUTO ONLY:
EACH OCCURRENCE
AGGREGATE
..-
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
~PE(;I~tS~~~VIS~6~S below
OTHER
1696570
06/30/03
06/30/04
x IT~~/~I~:f's I IU~~.
E.L EACH ACCIDENT S 1000000
El.D!SEASF-EAEMPI.OYFF.: $1000000_~
E.L. DISEASE - POLICY LIMIT $ 10000 0 0
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Evidence of Coverage
CERTIFICATE HOLDER
City of Santa Ana
P.O. Box 1988
Santa Ana CA 92702
CANCELLATION
SANTANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUT ED REPRE E
@ACORD CORPORATION 1988
ACORD 25 (2001/08)
SC
CERTHOLDER COpy
STATE po. BOX 807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 06-30-2004
GROUP:
POLICY NUMBER: 1696570-2004
CERTIFICATE 10: 3
CERTIFICATE EXPIRES: 06-30-2005
06-30-2004/06-30-2005
CITY OF SANTA ANA
PO BOX 1988
SANTA ANA CA 92702
SC
A - :A.oot.f-ot'1-o9
A - J..o04 - [G/l
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 days' advance written notice to the employer.
We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend. extend or alter the coverage afforded
by the policies listed herein.. Notwithstanding any requirf3ment. term, or condition of any contract or other document
with respect to which this certificate of insurance may bei~sued or may pertain, the insurance afforded by the
policies described herein is subject to all the terms. exclusions and conditions of such policies.
~
A~t!
&L-
AUTHORIZED REPRESENTATIVE
PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUOING DEFENSE COSTS:
$1,000,000.00 PER OCCURRENCE.
TO FORM
APPROVED AS
~---
.. c.--- -'--
v Launl;'Hi::'~~ ",
. .Clty AtlUrnC)
ASSIstant. .
Oij 1'0. I.,i!:r:.',-.~ ')"'1" ()L'! F'1" "1: /~?
i ~--'(;; f"., _ ~", i "v' " ... ...
EMPLOYER
LEGAL NAME
THECAMBOOrAN FAMILY
1111 WAKEHAM AVE STE E
SANTA ANA CA 92705
THE CAMBODIAN FAMILY
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265
(REV 3-03)
PRINTED' 05/17/2004 P040B
RPR-29-2005 11:06
,
THE C0~BODIRN FRMILY
714 571 1'374
F' . '32134
.
ACORQ. CERTIFICATE OF LIABILITY INSURANCE I O;~~;~)
..n' _
..oouc.. (7H)l34-1912 FAX (714)134-7561 THIS CERTIFICATE IS IS8UED AS A MATTER OF INFORMATION
Lake Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLD!fl THIS CERTIFICATE DOES NOT AMeND, eXTEND OR
13891 Newport AVO!" Suite 2&5 AL Tf:R THE COVERAG~ ,y'fORDED BY THE POLlCIE8 BELOW,
...
Lie '0747473
Tust;n, CA 92780 INSURERS AFFORDING COVERAGE NAle,
l.suO'. caOibiidiait'fa..ny-- .... .__n. - ............ -_..._- 'Ins, -.~.
INlUMR lie Ph i1"'~,l phi a Ind. Co.
p. -;;<UY-!-087'07 ..
1111 EAst Wakeham Avenue IHSUIltR 8: .'--
Suite E A- .;<<ld-/- i~1 --_._- .-....
lf4l1R'AC:
..
Santa Ana, CA 92705 A- ;;;C-o'f-.;;<o3 INlLlfW' D:
;1,- =5- O!S-bDW h.. ..-... . ..
INll,J1IR r
In
THE POLICIES OF 1N$UIlANCE LISTED 8ELOWHAVE BEEN ISSUED TO THI INSURED N.....ED ABOVE FOR THE POLICY PERIOD INDIC~TED NOTWITHSTANDING
ANY REQUlItEMENT, TERM OR CONaTION OF ANY CONTRACT OR On-tER DOCUMENT WTH RESPECT TO WHICH THIS CER:TIFICATF MAY BE IS~UEO OR
OlAV PERTAI~, THE INSURANCE AF'ORDED BY THE POLICIES DESCRIBED HEREIN IS SU8JECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS or SUCH
,'i':~~~u~~TE LIMITS SHOWN.....V KAVE BEEN REDUCED BY P~ID C~IM~ .. ,0..._. ..
'rt: i'i.~'r TYPE a. ........c. I'OUCY NU...~._ _.. . _ ."ali! Inrc n- UMI!~._.. . !.!19.9,000
':"........ ".."rry PHPKll044J 03/09/2005 OJ/09/2006 !ACH OCCURRENCE .
T~-'- DAii\GE'TO REII1tD . 100,00~
. ~.J (:1 AIUS WAOF l!J Qt;f'.t1R .. ._.....h~
"'ED E,lC"IMr 0fIe 1*'10'1] .
-
A X 0 deduetibl e PEllUONAl & Ar:N INJI"lRV . 1,000,000
._ ___..~ _N__.
GENEfW.. J.G.CM:GATf: I 3,000,~!l0
GEN'l,A,GGReGA.1l: LNtT .a.PPLliS PiA PROOUCT!I - COMPoOf' AGG t.~_.. included
.111.a_Lf.yO.!~d~.:..~ --
AUTOIIC)aLE UAWlY ... ....jijjPKiio443 ijjjo9)2'ociS' jji7ii9iz006 COMIIltED S1NOlE UMIT I
-. .
ANY AUrO (1!1MICWIIr't) 1,000,900
.-- AU. OMEn AlJros IIOD... y I~JUlty
SCMiOUIEO AUtos (P'.,pereon) .
A X 11lRfD NJT~ .__on
8ool'. Y INJUFlY
X HlJN.()WhED AUTOS (P.~l .
X I SO Deductible PR()PEA~-C~~~--
i 1"'1Il'~1
--.-. --.---
GAAAGE LIA.UlY NJTO OHt Y . EA ACCIDENT .
=:r ~_<A.UT~" 'n --
OTHER n-wo E"''''CC .
.~.APPROy-' D AS TO FORM. Auro ONL V AM; .
..... ._-. ._-~,~_.,._..'"... ___.....__M"_._ Vj---~;, ,I
tlCCUlNIIIJW.LA ~TY A EACH OCCURRENCE .
I OCCUR r-I ""'..."""" '- t -._,.....
AOOlilEOIl.Tf .
.......-_.._---....-
Lall fa Stitt Sheed " I
:i: .~._--_.-
DfoueTIILf .
... Mt!.nNlION Assist nt City Atto ney ...-.
I .
WORK!Q COMPENSA1lON.....D I we 'TAW-, I 10rH.
!M~O'I'EU.LI48IL.ITV TOR" LIMIT!! E~
~N~~ROPR~T~~lN~~1XECUT~' .~_~_~~ ACCIDENT I
U"U~E.~utEltCt.uDEO' EL DISf"SE.E~_~~E .
"r.: _u_
..- .Jlli.~"'~'tJ!l!'$..J!!!:!'__ .._..,_.............~_._-.'""" 'l DISCAS'. POlM:Y LWIT .
1l.T>l.R PHPKll044J '03709i2'005- OU09/2006 S1,000,Ooo Each ClaiM
use . MOlest~tion
A Sl,ooo,OOO Aggregate
SO DeGuctib1 e
o~""nON Of r.~"o''', L'Ano..'.....". / EllJL~"'$8 """ED:?; EJlDOI'2""'{" ''''''jljP.OY'''r.'&o
mp oyee 0 S onesty 200,000 De ,00 Pro eSSlona Li~bi ity 1. 0,000 Each,Occ/l Mil Aggregat.
ertificate holder is named as additionAl insured per eon~raet with uIIled insured.
chedule of vehicles and drivers on file.
'Non-Profit Organization "
~10 day notice of cancellation shall be given in the event of non-paYMent of premiuII
C1~y of Santa Ana
Community DevelopMent Agency
CDBG-M-25
P,O, Box 1938
Santa Ana, CA 92702
SHOULD ANY Of' mE A.ov! OElCAlalC I"OUCIES H CANCILU!D "FORI! THe
fltJtllU,TION DATE TMIIIlEOF, TMlllSUtHC I....U.ERWlU. ~~ .....IL
*10 DAys""""mt.l N011ClTOTHE CI!Imfl'IC4~ HOLl)f:Jl;NANIDTO TifE lEFT
~VlU"14)Y'."""lIIl.llllx.16l~l"D.X".~MK-YA'I'...xX
lID ~_XXXXXXXX
CACORD CORPORATION 198&
AUT" "
ACORD 25 (2ot11/0S) FAX: (714)571-1974
APR-29-2005 11:06
,
THE CPMBODIAN FAMILY
714 571 1974
F'.OJ'D4
POLICY NUMBER: PHPK110443
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFUllY.
ADDITIONAL INSURED - DeSIGNATED PERSON OR
ORGANIZATION
Thi. endorsement madlfiec insurance provided undllr lIle folowlng:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Harrllt of Person or OrgenlZllllon:
CITY OF SANTA ANA, ITS OFFICERS, ITS
AGENTS &. EMPLOYERS CDGB M.34
(If no enll)' appears lIbo.,., information required to complet. this endorsement will be shown in the Oeclaratio"s
a. appNClIbIe to lIlis endorsement)
WHO IS AN INSURED (Section II) is amended to Include as an insured the person or organization shown in the
Schedule as an ins\.nd but only with respect \0 6abilily arlslng oul of your operations or premises owned by or
rented \0 you.
APPROVED AS TO FORM
:/53 z/j,
Laura Stitt Sheedy
Assistant City Attorney
CG202tl,,85
Copyright, Insunt"ce Services Office, Inc., '984
Page 1 of ,
o
APR-29-2005 11:07
.
THE C0~BODIAN FAMILY
714 571 1974 F' .04.-/[14
.
ADDnlONAL INSURED ENDORSEMENT
IRlIu..ao..... Compan,
P/!I1AIl!:LPIII :oonm1Y IN5t.1RA1a (Xl.
..
ThI8 endorsement madIieI cuch nUl'<nl8 as .. afforded by ltIa pravIsIcnI at Policy
# PHPKl1 cv.i.. ~ __ Ill' '\ lQ 10 the ratow'o1g: .
t. 1M cay of .... AnI. :OlO CI\Ac QtntlIr PIaD, SIIr1lII AnII, CaIlJomla 82701;
ill cIIIceIs. ~ll" egents Ind l'Ipr r I ~.III are nemed IS eddIlIllllllllnIurIds
('aCJdIIIonIII ......, wIIh (IQ8I'd to RmlIIty end d8f.we of sUIs arfalg from 1he
operaIIa . and U$e$ perti:lcmed bY a on bthII of ltIe nI/1'I!d hsUted.
!L WIt! reepecc to clIImt IIfIInSI out d tile ope.cdbll WId UAS pet1bm'IId ~
lll' aJ bIhIIr orb named DIAd, IUCh ~ as is Mbdlld by 1nIS poley 18 primary
8I'ld is not ....~ to Cll" c:anIrIluIIncl wIh IilP/ olha' Iranr108 ~ by 01' for f10
benIIIt of the ..d:ilIb f' InwredI.
3. thIS II1IlnnC8 BAilS ~ to eec:h InIur8d agIIInIt wtlam c:IIim it
made or ..at Is Ilrought tll~ wilt ruplCl ~ Ihe ~. ImIII of 1IabIIy. 1118
IncUIcn d WFf~ tII ~ I d. -, . en nur.d ... not 6cI WI)' rtght 1IIf1k:h8UCh
perscI'I 01' .......ih.ttL.i Wl:UI.... . ~lt. not so Indudlld. '
4.. \WI '~1Df'8 tdlIIonIlIntreds. ttlIaNll1lasf1el nctbe~WlIIed,
01' n.... taIy r-dl1OIId ~ COlIldg8 or 1mb IDlllIIPt Iller tNrty CSO) d8ya ... 111M nolIoI h8s
bttn given to fie Qly ci Santa Me, 20 CMo Genter Pfeu, SIInIII Ma,.0a/iI0trie 92701,
(com,.aon of 1M fOIJoWIng, including counlerillgn.td&it., is required to mBlca this
,"dOPement~)
Efiecave 03/09/2005
-".
Polley /I PHl'lG.l~3
, this endorlement lonn as a part of
18CUGCI to
nlE CNlOODIAN FAMILY
Nm.d Insured
Co~/gned by
~ r---~~~ J/,Js'
APPROVED AS TO FOKM
~56
EXHIBH D
Laura Stitt Sheedy'
Assistant City Attorn.;;'\
TDTAL F'. 04
SC
CYHOLDER COpy
STATE PO BOX 807, SAN FRANCISCO,CA 94142-0807 RECEIVED HAY 2 6 2005
COMPENSATION
INS U ~AN C E
FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE, 06-30-2005
GROUP,
POLICY NUMBER 1696570-2005
CERTIFICATE ID: 3
CERTIFICATE EXPIRES, 06-30-2006
06-30-2005/06-30-2006
CITY OF SANTA ANA
PO BOX 1988
SANTA ANA CA 92702
SC
This is to certify that we have issued a valid Work.ers' 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 days' advance written notice to the employer.
We will also give you 10 days'advance notice should thiS' policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies listed herein. Notwithstanding any requirement. term, or condition of any contract or other document
with respect to which this certificate 01 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.
~
/!~c
&L-
AUTHORIZED REPRESENT A TIVE PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE.
APPROVED AS TO FORM
it!i"-V' ~4
, Laura Stitt syedY
Assistant City Attorney
EMPLOYER
LEGAL NAME
THE CAMBODIAN FAMILY
1111 WAKEHAM AVE STE E
SANTA ANA CA 92705
THE CAMBODIAN FAMILY
(REV.3-0J)
PRINTED: 05/17/2005 P0409
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND se" >0".