HomeMy WebLinkAboutCARE COUNSLING CENTER 2-2004
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7 -1'7-05
CLERK OF COUNCIL .J.
DATE: 1~-15-0 {
A-2004-087-08
8/04
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AGREEMENT BETWEEN THE CITY OF SANTA ANA AND
C.A.R.E. COUNSELING CENTER FOR USE OF
COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS
This Agreement, is hereby made and entered into this 3rd day of May, 2004, by and
between the City of Santa Ana, a charter city and municipaJ corporation of the State of California
("CITY") and C.AR.E. Counseling Center, a California nonprofit corporation
("SUBRECIPIENT").
WIINESSJHH
Recita1s:
A The CITY, as an entitlement recipient and grantee of the United States Department of
Housing and Urban Development ("HUD") Community Development Block Grant ("CDBG")
Program, desires to enter this Agreement with the SUBRECIPIENT for the expenditure of CDBG
funds in accordance with Title 24, Part 570 of Code of FederaJ Regulations 24 CFR 570.000, et seq.
("CDBG REGS''); and
B. CITY has applied for and received CDBG funds ITom HUD pursuant to Title I of the
Housing and Community Development Act of 1974, Public Law 93-383, as amended ("ACT"); and
C. The SUBRECIPIENT is a private nonprofit agency that has been selected by the CITY
to receive CDBG funds and administer such financial assistance; and to provide the services
described in "Exhibit A," in accordance with the schedule of performance included therein,
hereinafter referred to as "said program". SUBRECIPIENT represents that it is quaJified and
willing to operate said program and certifies that the activities carried out with funds provided under
this Agreement will meet one or more of the CDBG program's NationaJ Objectives (24 CFR Part
570.208).
D. The CITY and SUBRECIPIENT have duly executed this Agreement for the expenditure of
such funds; and
WHEREFORE, it is agreed by and between the parties that the foregoing Recitals are a
substantive part of this Agreement and the following terms and conditions are approved and
together with aJl exhibits and attachments hereto, shall constitute the entire Agreement between the
CITY and SUBRECIPIENT:
I. SUBRECIPIENT'S OBLIGATIONS
A Non-Profit Status - Representations and Warranties.
(a) Authority. SUBRECIPIENT is a duly organized and existing non-profit corporation
in good standing and authorized to do business under the laws of the State of CaJifornia.
SUBRECIPIENT has full right, power and lawful authority to accept the funding hereunder and
to undertake all obligations as provided herein and the execution, performance and delivery of
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this Agreement by SUBRECIPIENT has been fully authorized by all requisite actions on the part
of SUBRECIPIENT.
(b) Experience. SUBRECIPIENT is a qualified provider ofthe services to be provided
hereunder.
(c) Familiarity With Services Required. By executing this Agreement,
SUBRECIPIENT warrants that (i) it has thoroughly investigated and considered the services to
be performed and provided hereunder, (ii) it has carefully considered how the services should be
performed, and (iii) it fully understands the facilities, difficulties and restrictions attending
performance of the services under this Agreement.
(d) No Conflict. To the best of SUB RECIPIENT'S knowledge, SUBRECIPIENT'S
execution, delivery and performance of its obligations under this Agreement will not constitute a
default or a breach under any contract, agreement or order to which SUBRECIPIENT is a party
or by which it is bound.
(e) No Bankruptcy. SUBRECIPIENT is not the subject of any current or threatened
bankruptcy proceeding.
(I) No Pending Legal Proceedings. SUBRECIPIENT is not the subject of a current or
threatened litigation that would or may materiaJly affect SUBRECIPIENT'S performance under
this Agreement.
(g) Application Veracity, All provisions of and information provided in
SUBRECIPIENT'S application for funding submitted to CITY including any exhibits are true
and correct in all material respects.
(h) No Pending Investigation. SUBRECIPIENT is not aware that it is the
subject of any current or threatened criminal or civil action investigation by any public agency,
including without limitation a police agency or prosecuting authority, that would relate to affect
performance of the Agreement or provision of services hereunder.
B, Amount of Grant and Quarterlv Disbursement. The amount granted to
SUBRECIPIENT is $ 5,000 ("CDBG FUNDS"), and such funds shall be expended by
SUBRECIPIENT on or before June 30, 2005. The CDBG FUNDS shall be disbursed by CITY
to SUBRECIPIENT on a quarterly basis (October, January, April and July) subject to and upon
receipt and approval of a complete quarterly activity report from SUBRECIPIENT, with the final
payment subject to the satisfaction of the condition precedent of submittal of complete reporting
information due on or before July 15 of the applicable funding year, as hereinafter more fully set
forth. SUBRECIPIENT shaJl be obligated to perform such duties as would normally extend
beyond the term, including but not limited to obligations with respect to indemnification, audits,
reporting, data retention/reporting, and accounting.
C. Use of Funds, SUBRECIPIENT agrees to use all federaJ funds provided by CITY to
SUBRECIPIENT pursuant to this Agreement to operate said program, as set forth in "Exhibit A,"
attached hereto and by this reference incorporated herein. SUBRECIPIENT'S failure to perform as
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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 SUBRECIPIENT hereunder.
D. Allowable Costs. SUBRECIPIENT agrees to complete said program on or before
June 30, 2005 and to use said funds to pay for necessary and reasonable costs aJlowable under the
federal law and regulations to operate said program. Said amounts shall include, but not be lirnited
to, wages, administrative costs, and employee benefits comparable to other similarly situated
employees. Other allowable program costs are detailed in the Budget, as set forth in "Exhibit B,"
attached hereto and by this reference incorporated herein. SUBRECIPIENT shaJl use all income
received from said funds only for the same purposes for which said funds may be expended
pursuant to the terms and conditions of this Agreement.
E. Licensing. SUBRECIPIENT agrees to obtain and maintain aJl required licenses,
registrations, accreditation and inspections ITom aJl agencies governing its operations.
SUBRECIPIENT shaJl ensure that its staff shaJl also obtain and maintain aJl required licenses,
registrations, accreditation and inspections ITom aJl agencies governing SUBRECIPIENT's
operations hereunder. Such licensing requirements include obtaining a City business license, as
applicable.
F. Zoning. SUBRECIPIENT agrees that any facility/property used in furtherance of
said program shall be specificaJly zoned and permitted for such use(s) and activity(ies). Should
SUBRECIPIENT fail to have the required land entitlement and/or permits, thus violating any local,
state or federaJ rules and regulations relating thereto, SUBRECIPIENT shaJl inunediately make
good-faith efforts to gain compliance with local, state or federaJ rules and regulations following
written notification of said violation(s) ITom the CITY or other authorized citing agency.
SUBRECIPIENT shaJl notify CITY immediately of any pending violations. Failure to notify CITY
of pending violations, or to remedy such known violation(s) shaJl result in termination of grant
funding hereunder. SUBRECIPIENT 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.
G. Separation of Accounts. All funds received by SUBRECIPIENT ITom CITY
pursuant to this Agreement shaJl be maintained in an account in a federaJly insured banking or
savings and loan institution with record keeping of such accounts maintained pursuant to applicable
OMB Circular A-IIO requirements. SUBRECIPIENT is not required to maintain separate
depository accounts for CDBG FUNDS; provided however, the SUBRECIPIENT must be able to
account for receipt, obligation and expenditure of CDBG FUNDS pursuant to applicable OMB
Circular A-II0 requirements.
H. Audit Report ReQuirements. SUBRECIPIENT agrees that if SUBRECIPIENT
receives Three Hundred Thousand Dollars ($300,000.00) or more in federaJ funds,
SUBRECIPIENT shaJl 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
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and Budget. SUBRECIPIENT 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.
I. Record KeepingfReporting. SUBRECIPIENT sha1l keep and maintain complete and
adequate records and reports to assist CITY in meeting and maintaining its record keeping
responsibilities under the CDBG REGS, including the following:
(1) Records
a. Documentation evidencing program income requirements in
conformity with 24 CFR 570.504(b«2)(i), (ii) and 24 CFR 570.503(b )(3) and 24
CFR 570.208(a)(2)(B) of the income level of persons and/or families participating
in or benefiting by the SUBRECIPIENT program.
b. Documentation of the number of persons and/or families participating
in or benefiting by the SUBRECIPIENT program.
c. Household information shall include number of persons, identification
of head of household, race/ethnicity, and income verification.
d. Documentation of all CDBG FUNDS received from CITY.
e, Documentation of expenses as identified in the Budget Proposal,
including evidence of incurring the expense, invoices for goods or services, copies
of any and all contracts or documentation pertaining to costs for subcontractors,
plus all other invoices for which CDBG FUNDS were expended, and any payments
therefor.
f. Any such other related records as CITY shall reasonably require or as
required to be maintained pursuant to the CDBG REGS.
(2) Reports
(i) Payment Request. Concurrently with the submittal of each
quarterly report, on or before the 15th day of October, January,
April and July, SUBRECIPIENT shall submit both: an original
invoice and true copies of invoices, receipts, agreements, copies
of any and all contracts or documentation pertaining to costs for
subcontractors or other documentation supporting and
evidencing how the CDBG FUNDS have been expended during
the applicable quarter.
(ii) Quarterly Activity Report: SUBRECIPIENT agrees to keep monthly
records of a1l ethnic and racial statistics of persons and families benefited by
SUBRECIPIENT 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, the number
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of female heads of households assisted, new program information and year-to-
date program statistics on expenditures, caseload and activities.
J. Access to Records. CITY and the United State Government and/or their representatives
shall have access for purposes of monitoring, auditing, and examining SUBRECIPIENT's activities
and performance, to books, documents and papers, and the right to examine records of
SUBRECIPIENT's subcontractors, bookkeepers and accountants, employees and participants in
regard to said program. CITY 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 is conducted or in which any of
the records of SUBRECIPIENT are kept. Nothing herein shall be construed to require access to any
privileged or confidential information as set forth in federal or state law.
K. Location of RecordslReQuired Length of Record Keeping. All accounting records,
reports, and evidence pertaining to all costs, expenses and the CDBG FUNDS of
SUBRECIPIENT and aJl documents related to this Agreement shall be maintained and kept
available at SUBRECIPIENT'S office or place of business for the duration of the Agreement and
thereafter for five (5) years after completion of an audit in conformity with the CDBG REGS's.
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 complete resolution or disposition of such appeals, litigation claims, or exceptions. In
the event SUBRECIPIENT does not make the above-referenced documents available within the city
of Santa Ana, California, SUBRECIPIENT agrees to pay aJl necessary and reasonable expenses
incurred by CITY in conducting any audit at the location where said records and books of account
are maintained.
L. Compliance with LawlProgram Income. SUBRECIPIENT acknowledges that the funds
being provided by CITY for said program are received by CITY pursuant to the ACT as amended
and that expenditures of these funds shall be in accordance with the ACT and aJl pertinent
regulations issued by agencies of the federaJ government, including, but not limited to, all
regulations found at Title 24 of the Code of Federal Regulations. Program income received by
SUBRECIPIENT shaJl be returned to CITY unless otherwise provided for in this Agreement.
SUBRECIPIENT agrees to comply fully with all federaJ, state and local laws and court orders
applicable to its operation whether or not referred to in this Agreement.
M. Standing, SUBRECIPIENT shall be in good standing, without suspension by the
CaJifornia Secretary of State, Franchise Tax Board and InternaJ Revenue Service. Any change in
the corporate status or suspension of SUBRECIPIENT shaJl be reported immediately to CITY.
N. ConfidentiaJitv. Without prejudice to any other provisions of this Agreement,
SUBRECIPIENT shaJl, where applicable, maintain the confidentiaJ nature of information provided
to it concerning participants in accordance with the requirements of federal and state law. However,
SUBRECIPIENT shall submit to CITY and or HUD or its representatives, all records requested,
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including audit, examinations, monitoring and verifications of reports submitted by
SUBRECIPIENT, costs incurred and services rendered hereunder.
O. Independent Contractor. SUBRECIPIENT agrees that the performance of
obligations hereunder is rendered in its capacity as an independent contractor and that it is in no way
an agency of CITY.
P. Violation of Terms and Conditions. SUBRECIPIENT agrees that if
SUBRECIPIENT violates any of the terms and conditions of this Agreement or any prior
Agreement whereby CDBG funds were received by SUBRECIPIENT, or if SUBRECIPIENT
reports inaccurately, or if on audit there is a disallowance of certain expenditures, SUBRECIPIENT
agrees to remedy the acts or omissions causing the disaJlowance and repay CITY all amounts spent
in violation thereof. If SUBRECIPIENT engaged in lTaudulent activity to obtain and/or justify
expenditure of the CDBG funds granted hereunder, SUBRECIPIENT shall be required to reimburse
the CITY of all such funds that were obtained/spent under ITaudulent circumstances.
Q. EQuipment. SUBRECIPIENT agrees to maintain a record for each item of non-
expendable personaJ property acquired under the terms of this Agreement. Said record shaJl be
made available to CITY upon request, The term "non-expendable personaJ property" shall include
leased and purchased equipment.
R. Prohibited Use. SUBRECIPIENT hereby certifies and agrees that it will not use
funds provided through this Agreement to pay for entertainment, meaJs or gifts.
S. Lobbving. SUBRECIPIENT certifies that it will comply with federal law (31
U.s.C. 1352) and regulations found at 24 CFR Part 87, which provide that no appropriated funds
may be expended by the recipient of a federa1 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 federaJ
contract, grant, loan or cooperative agreement. SUBRECIPIENT shall sign a certification to that
effect in a form as set forth in "Exhibit C," attached hereto and by this reference incorporated herein.
SUBRECIPIENT shaJl 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 SUBRECIPIENT under the terms and conditions of this Agreement.
If any funds other than FederaJ 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 sha1l complete and submit a "Disclosure Form to Report Lobbying," in accordance
with its instructions (see C-l).
T.
Financial Interest. SUBRECIPIENT agrees that except for the use of CDBG funds
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to pay saJaries and other related administrative or personnel costs, no persons who exercise or have
exercised any function with respect to CDBG 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 financiaJ interest or benefit ITom a CDBG-assisted activity of
SUBRECIPIENT, 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 officiaJ of CITY, or of
any designated public agencies, or the SUBRECIPIENT,
U. Davis-Bacon Act. All laborers and mechanics employed by contractors or
subcontractors in the performance of construction work, including aJterations and repairs, in excess
of $2,000.00, financed in whole or in part with federal funds shaJl be paid wages at rates not less
than those prevailing on similar construction in the 10caJity as determined in accordance with the
Davis-Bacon Act, as amended, 40 U.S.C. sections 276a - 276a-5. Any such construction contract
shaJl include and comply with the required contract provisions and rules set forth in 29 C.F.R §5.5.
Further, the payroll reports (aJong with the "Statement of Compliance'') and basic records are
required to be maintained and submitted, or made available, pursuant to 29 C.F.R. §5.5(a)(3). No
payment, advance, grant, loan or guarantee of funds shaJl be approved by the federaJ agency unless
there is on file with the agency a certification by the contractor that the contractor and its
subcontractors have complied with the provisions of 29 C.F.R §5.5. A breach of the contract
clauses in 29 C.F.R §5.5 may be grounds for termination of the contract, and for debarment as a
contractor/subcontractor, as provided in 29 C.F.R §5.12. Labor standards interviews/investigations
shaJl be made as necessary to assure compliance [29 C.F.R. §5.6(a)(3)].
V. Drug Free Workplace. SUBRECIPIENT certifies that it has established the following
drug-ITee workplace policy:
1. The unlawful manufacture, distribution, dispensing, possession or use of a
controlled substance is prohibited in the workplace for any employee involved in a federaJly funded
program.
2. As an employee working in conjunction with a federally funded program, the
employees of SUB RECIPIENT will be required to:
a) Abide by the terms above in statement 1.
b) Notify appropriate officials of SUBRECIPIENT and CITY officiaJs of
any criminaJ drug statute conviction for a violation occurring in the workplace not
later than five days after such conviction.
3. The CITY and the United State Department of Housing and Urban
Development will be notified within ten days after receiving notice of any such violation.
4. Within 30 days of receiving such notice, appropriate personnel action will be
taken against such employee, up to and including termination.
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Each such employee shaJl be required to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a federaJ, state or locaJ heaJth,
law enforcement, or other appropriate agency.
II.
CITY'S OBLIGATIONS
A. Payment of Funds. Upon execution of this Agreement by SUBRECIPIENT, CITY shall
pay to SUBRECIPIENT ITom CDBG funds, when, if and to the extent received ITom HUD, for
CITY's FiscaJ Year CDBG program year amounts expended by SUBRECIPIENT in carrying out
said program for fiscaJ year 2004-2005 pursuant to this Agreement up to a maximum aggregate
payment of Five Thousand Dollars ($ 5,000) in instalhnents determined by CITY. Payments shaJl
be made to SUBRECIPIENT through the submission of invoices on a quarterly basis (October,
January, April and July) in a form prescribed by CITY, detailing such expenses. CITY shaJl pay
such invoices within thirty (30) days after receipt thereof provided CITY is satisfied that such
expenses have been incurred and documented within the scope and provisions of this Agreement
and that SUBRECIPIENT is in compliance with the terms and conditions of this Agreement.
B. Audit of Account. CITY shaJl include an audit of the account maintained by
SUBRECIPIENT in CITY's annual audit of aJl CDBG FUNDS in accordance with Title 24 of
the Code of Federal Regulations and other applicable federaJlaws and regulations.
C. Common Rule: Pursuant to CFR 85.40(a), the CITY manages the day-to-day
operations of each grant and subgrant supported activities. CITY staffhas detailed knowledge of the
grant program requirements and monitors grant and subgrant supported activities to assure
compliance with FederaJ requirements. Such monitoring covers each program, function and activity
and performance goals are reviewed periodicaJly,
D. Enviromnental Review: In accordance with 24 CFR 58, the CITY is responsible for
undertaking enviromnentaJ review and maintaining enviromnentaJ review records for each
applicable project.
E. Performance Monitoring: CITY shall monitor the performance of the
SUBRECIPIENT against goals and performance standards required herein, Substandard
performance as determined by the CITY will constitute non-compliance with this Agreement. If
action to correct such substandard performance is not taken by the SUBRECIPIENT within a
reasonable period oftime after being notified by the CITY, contract suspension or termination
procedures will be initiated.
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III.
NONDISCRIMINATION
SUBRECIPIENT agrees that no person on the ground of race, age, color, nationa1 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 CDBG funds.
IV.
CONFLICT OF INTEREST
Pursuant to the conflict of interest requirements set forth in 24 CFR 576.57 and OMB
Circulars 1-102 and A-I 10, SUBRECIPIENT agrees that no officer, employee, agent or assignee of
CITY having direct or indirect control of any CDBG monies granted to the CITY, inclusive of the
subject CDBG FUNDS, sha1l serve as an officer of SUBRECIPIENT. Further, any conflict or
potentia1 conflict of interest of any officer of SUBRECIPIENT sha1l be fully disclosed in writing
prior to the execution of this Agreement and said writing sha1l be attached and deemed fully
incorporated as a part hereof. Notice sha1l be sent by SUBRECIPIENT to CITY regarding any
changes or modifications to its board of directors and list of officers.
V.
SPECIAL CERTIFICATION FOR RELIGIOUS ENTITIES
If SUBRECIPIENT is a religious entity, SUBRECIPIENT hereby agrees that in connection
with the provision of the services SUBRECIPIENT sha1l provide with CDBG funds, in accordance
with 24 CFR 570.200(j):
A SUBRECIPIENT sha1l not discriminate against any employee or applicant for
employment on the basis of religion and sha1l not limit employment or give preference in
employment to persons on the basis of religion.
B. SUBRECIPIENT shall not discriminate against any person applying for the services
SUBRECIPIENT agrees to provide under the terms of this Agreement on the basis of religion and
sha1l not limit such services or give preference to applicants for such services on the basis of
religion.
C. SUBRECIPIENT sha1l 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. The parties agree that this covenant is
intended to and sha1l be construed for the limited purpose of assuring compliance with respect to the
use of CITY funds by SUBRECIPIENT with applicable constitutiona1 limitations respecting the
establishment of religion as set forth in the establishment clause under the First Amendment of the
United States Constitution and Article I, Section 4 of the Ca1ifornia Constitution, and is not in any
manner intended to restrict other activities of SUB RECIPIENT.
D. Where the services to be provided under said program are rendered on property
owned by the primarily religious entity SUBRECIPIENT, CDBG funds may a1so be used for minor
repairs to such property which are directly related to the cost of rendering the services under said
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program, where the cost constitutes in dollar terms only an incidental portion of the CDBG
expenditure for rendering the services under said program.
VI.
PROHIBITION OF NEPOTISM
SUBRECIPIENT 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 SUBRECIPIENT. For the purposes of this section, the term "inunediate
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, stepparent 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:
City of Santa Ana
Community Development Agency (M-25)
20 Civic Center Plaza
P.O, Box 1988
Santa Ana, CaJifornia 92702-1988
TO SUBRECIPIENT:
C.ARE. Counseling Center
1614 E. 17th St., Suite D
Santa Ana, CA 92701
VIII. ASSIGNABILITY
None of the duties of, or work to be performed by, SUBRECIPIENT under this Agreement
shaJl be subcontracted or assigned to any agency, consultant, or person without the prior written
consent of CITY, SUBRECIPIENT must submit all subcontracts and other agreements that relate
to this Agreement to CITY. No subcontract or assignment shaJl terminate or aJter the legal
obligations of SUBRECIPIENT pursuant to this Agreement.
IX.
HOLD HARMLESS
SUBRECIPIENT shall indemnify, defend 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
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agents of CITY, and shall defend, indenmify and save harmless CITY, its officers, employees,
agents, representatives and volunteers ITom and against any and aJl 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
ITom or arising out of the negligent or wrongful acts, errors or omissions of SUBRECIPIENT, its
officers, directors, employees, agents, subcontractors and suppliers arising out of
SUBRECIPIENT's performance of this Agreement.
X. INSURANCE
A In accordance with the provisions of Section 3300 of the Labor Code, if
SUBRECIPIENT has any employees it is required to be insured against liability for worker's
compensation or to undertake self-insurance. Prior to commencing performance of this
Agreement, SUBRECIPIENT agrees to obtain and maintain employer's liability insurance with
limits not less than $1,000,000 per accident. If SUBRECIPIENT has no employees, nor
workers' compensation coverage, it must execute a Declaration available ITom the CITY, and
update as is necessary.
B. SUBRECIPIENT shall undertake self-insurance, or shall obtain, at its sole cost, a
policy or policies of commercial general liability insurance, or equivalent form, with a combined
single limit of not less than $1,000,000 per occurrence.
Such insurance shall: (I) name the City of Santa Ana, its officers, agents,
representatives, employees and volunteers as additionaJ insured's; (2) be primary with respect to
insurance or self-insurance programs maintained by the CITY; (3) contain standard separation of
insured's provisions; and (4) give to CITY prompt and timely notice of claim made or suit
instituted arising out of SUB RECIPIENT's operations hereunder.
SUBRECIPIENT shall: (a) prior to exercising any right under this Agreement,
furnish properly executed certificates of insurance and additional insured endorsement to the
CITY which shall clearly evidence all coverages required above; (b) provide that such insurance
shall not be materially changed or terminated except on 30 days prior written notice to the CITY;
(c) maintain such insurance for the period covered by this Agreement; and (d) replace such
certificates for policies expiring prior to the expiration of this Agreement.
XI.
REVERSION OF ASSETS
A Upon the expiration of this Agreement, SUBRECIPIENT shall transfer to CITY any
CDBG funds on hand at the time of the expiration of this Agreement as well as any accounts
receivable attributable to the use ofCDBG funds. [24 CFR 570.503(b)(8).]
B. Any real property under SUBRECIPIENT's control that was acquired or improved
in whole or in part with CDBG funds in excess of $25,000.00 must either be:
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1. Used, where CITY has given written approval, to meet one of the nationaJ
objectives stated in 24 CFR 570.208 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, SUBRECIPIENT
shaJl pay to CITY an amount equaJ to the current fair market value of the property less any portion
of the vaJue attributable to the expenditure of non-CDBG 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 SUBRECIPIENT. When said equipment
which has been acquired in accordance with this Agreement and aJl applicable regulations is no
longer needed for said program, disposition of said equipment will be made as follows:
I. 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 vaJue of $5,000,00 or
more may be retained or sold and CITY shaJl have the right to an amount calculated by multiplying
the current market vaJue or proceeds ITom the saJe by CITY's share of federaJ funds used to acquire
the equipment, in accordance with 24 CFR 85.32(e)(2).
D. SUBRECIPIENT 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 SUBRECIPIENT's
right, title and interest (if any it may have) in and to CITY, CDBG or other federaJ, state and/or
10caJ accounts or program funds or aJlocation 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
SUBRECIPIENT on behalf of CITY, in furtherance of the activities hereunder or thereof.
SUBRECIPIENT's obligations and responsibilities set forth in this paragraph "XI.
REVERSION OF ASSETS." and in paragraph "XII. TERMINATION" and other requirements
pertaining to program income shaJl not be affected by the termination of this Agreement and shaJl
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
12
8/04
party. In the event of such termination, SUBRECIPIENT shall only be entitled to reimbursement
for approved expenses incurred to the effective date oftermination.
B. This Agreement may be suspended or terminated by CITY upon five (5) days'
written notice for violation by SUBRECIPIENT of FederaJ Laws governing the use of Community
Development Block Grant Funds. In the event of such suspension or termination, SUBRECIPIENT
shall only be entitled to reimbursement for approved expenses incurred up to the effective date of
suspension or termination.
C. Pursuant to 24 CFR 85.43, in the event SUBRECIPIENT 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 SUBRECIPIENT, which default and termination shall be effective
on a date stated in the notice which is to be not less than ten (IO) 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 (I) 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 under this Agreement may be terminated for convenience in
accordance with 24 CFR 85.44.
E. The grant of funds under this Agreement may be terminated due to the non-
performance of SUBRECIPIENT and/or failure of SUBRECIPENT to perform the work described
in Exhibits A and B or failure to meet the performance standards and program goaJs set forth
therein.
F. In the event this Agreement is terminated as set forth in subparagraphs xn.A.
through xn.E., inclusive, SUBRECIPIENT agrees to immediately return to CITY upon CITY's
demand and prior to any adjudication of SUBRECIPIENT's rights, any and aJl funds not used, and
to comply with paragraph "Xl REVERSION OF ASSETS" of this Agreement.
XIII. LIMITATION OF FUNDS
The United States of America, through HUD, may in the future place programmatic or fiscaJ
limitations on the use of CDBG funds which limitations are not presently anticipated. Accordingly,
CITY reserves 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
SUBRECIPIENT's authority to commit and spend funds, or may restrict SUBRECIPIENT'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
13
8/04
Agreement, CITY's City Manager 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. If such a reduction in funding occurs, SUBRECIPIENT shall be permitted to de-scope
accordingly. Where CITY has reasonable grounds to question SUBRECIPIENT'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
SUBRECIPIENT of its intention to so act, pending an audit or other resolution of such questions.
In no event, however, shaJl any revisions made by CITY affect expenditures and legally binding
commitments made by SUBRECIPIENT 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 withdrawaJ guidelines.
XIV. EXCLUSIVITY AND AMENDMENT OF AGREEMENT
This Agreement supersedes any and all other agreements, either oraJ or in writing, between
the parties hereto with respect to the use of CITY's CDBG funds by SUBRECIPIENT 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, oraJly or otherwise, have been made by any party, or anyone
acting on behaJf of any party, which are not embodied herein, and that no other agreement or
amendment hereto shaJl be effective unless executed in writing and signed by both CITY and
SUBRECIPIENT.
xv.
LAWS GOVERNING THIS AGREEMENT
This Agreement shall be governed by and construed in accordance with the laws of the State
of CaJifornia, and all applicable federaJlaws and regulations.
XVI. VALIDITY
The invalidity in whole or in part of any provision of this Agreement sha11 not void or affect
the validity of any other provision of this Agreement.
XVII. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below has the power,
authority and right to bind their respective parties to each of the terms of this Agreement, and shaJl
indemnify CITY fully, including reasonable costs and attorney's fees, for any injuries or damages to
CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn.
b. All Exhibits and Attachments referenced herein and attached hereto shall be
incorporated as if fully set forth in the body of this Agreement.
14
8104
c. No delay or omission by either party hereto to exercise any right or power accruing
upon any noncompliance or default by the other party with respect to any of the terms of this
Agreement shall impair any such right or power or be construed to be a waiver thereof. A
waiver by either of the parties hereto of any of the covenants, conditions, or agreements to be
performed by the other shall not be construed to be a waiver of any succeeding breach thereof
or of any other covenant, condition or agreement herein contained.
15
8/04
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and
year written below.
DATED:
:¡rllià
City Manager
ATTEST:
APPROVED AS TO FORM:
JOSEPH W. FLETCHER
City Attorney
-~ ~
~A£~~.~~y .
Clerk of the Council
~"<- ;:~
By: LISA E. STORCK
Assistant City Attorney
SUBRECIPIENT:
DATE:
/;2 -lr-&1
;J
16
11/17/2004 13:27
7148369820
CARE COUNSELING
PAGE 02
/'
CITY OF SANA ANA
COMMUNITY DEVELOPMENT BLOCK GRANT
Scope of Work
~A ~ ~
I. Total number of cüents anticipated to be served during the 12-month contract pen =
~PERSONS
11. Total number ofunduplicated S.n~~. residents to be served with gnmt funds during the
12-month contract period = ¡; /J ð PERSONS
m. Description of Work - in space below, describe the ~rogram to be funded d~ the 12-
month contract period including, services to be prOVIded, program goals, chent
characteristics, & how grant funds will be utilized.
Dr. Penny Winkler, Psy.D., LMFf, and ber staff of Orange County approved
certified alcohol & drug counselors, certified domestic violence clinicians, and MFf
interns provide the residents of the Santa Ana community with outpatient individuaJ and
group couDSCling and treatment.
Program goals are to help improve the lives of clients through counseling and
education in the ~eas o~ J?e>mestic ~olencc, Anger Management, Parenting, and
Su~cc Abuse ID a bl-lmgual enVIrOnment. Qient characteristics are moderate to very
low mcome multi racial, bi-lingual Santa Ana Residents.
facility.9rant funds will be used exclusively to defray the increasing cost of rent for the
Scll.edllk of PulomMllCe
E'
co: ~~~~~uPlìcated Santa Ana residents to be served during the 12-month
Quarter 1; July 1 - September 30 .
Quarter 2: October 1 - December 31 -d. t:J ð Persons
Quarter J; January I - March 31 ......è. " ð Persons
Quarter 4: April 1 - June 30 :L "ð Persons
-::L. "" þ Persons
Total . ~Ze:r P
--4-1. - ersons
~
Estimate the amount of grant funds to be .
quarterly basis: requested durmg the 12-month contract period on a
Quarter 1: July 1 - September 30
Quarter 2: October 1 - December 31 $ 1..:1 S- 0 -
Quarter.3: January 1 - March 31 $ / ~ 1"~ -
Quarter 4: Aprill-June30 $ /;) 5"0 -
$ /.,p. S"a -
Total S So ðQo
EXHIBIT A
04/07/2004 00:56
949589576714
ELIZAB WARD NO 21
Organization Name:
Program Name:
Program Year:
CITY OF SANTA ANA
COMMUNITY DEVELOPMENT BLOCK GRANT
FINAL PROGRAM BUDGET
Gh. lc! AI.... H K'è.Gr."ùIt.Ki
C.Ate,* &VI\(" S <: Inv7
:!).oò'l- c9-oc:S-
t2 k....
SAHTAANACDBG OTHER ..
CATEGORY TOTAL PROG
GRANT RESOURCES BUDGET
Administrative Staff $ () $ :)..~ Ò 6 0 $ ð'i D
Salaries & Benltflts
Program Staff Sala"," & -_._-
0 c. " Ö4ò $" ( 0
Benefits
OffIce Supplies/ uc,,; ~ 0 J' ðOò Øf?(6
Rent/Lease 5'000 /)' /00 4;;0,/6
Communications C:> {. It Oó 4b (jC>
Utilities D 6 6>
Contractual/Professional ..- ----.-.
rt/
Services / (! (elWl"'''' D I d-C1C ' ;}-ó
-1Pleas8 SþO Çlfy)
...""-.-
Insurance 0 tø 066 1>. t. Þc>
Other (Please Specify) 0 . ,.. "._--
111'/Ó4!)u
7 ¡.,fi¡2.w $7;~HJ D ¡;,ÖDO
~iU4<'- ~tT:> 0 ,;).., 11 ø 0 ~ ~;,¡.' óco
~1fÞU- StPl..JI(.# 0 'f ðD . I, ~cJ 0
I,
TOTAL $ 5 ÒOO $ " 7:»,700 .~L / S017
EXPENDITURES
RAM
60
00
óó
0
0
I
ð
ð
òú
OTHER PROGRAM RESOURCES
c:
AMOUNT
/~u 0"0
D60
~ lè ..7
TOTAL $
I£ov
/6"1..') D60 J
EXHIBIT B
8/04
Certification Regarding Lobbying
Certification for Contracts. Grants. Loans. and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(I) No Federal appropriated funds have been paid or will be paid, by or on behaJf ofthe
undersigned, to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal contract, the making of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of
any Federal contact, grant, loan or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this FederaJ contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontract, sub grants, and contracts under
grants, loans, and cooperative agreements) and that aJl subrecipients shaJl certify and disclose
accordingly.
This certification is a materiaJ 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.
Program Title
Ç/
EXHBIT C
Page 1 of 2
17
8/04
SUBRECIPIENT warrants the following:
1. SUBRECIPIENT will comply with Public Law 88-352, Title VI of the Civil Rights Act of
1964 (42 U. S. C. section 2000 et seq.) and implementing regulation in 24 CFR Part I,
2. No person in the United States shall on the ground of race, color, religion, national origin, or
sex, be excluded ITom 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 sha1l be paid
wages at rates not less than those prevailing on similar construction in the locality as determined
in accordance with the Davis-Bacon Act, as amended, 40 U. S. C. Sections 276 a 1-5, except for
individuals who perform services for which they volunteered; do not receive compensation 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 a1l 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 12372.
EXHIBIT C
Page 2 of 2
18
...,.
.
PATRICK PERLAS
851 8Ø3 ZØZ8
11/24/04
04:08pm
P. øØZ
.
.
ACORD",
CERTIFICATE OF LIABILITY INSURANCE
I o.\TEIMWDDf't'YYY)
11/24/2004
TIiIS CERTIFICA. TE IS ISSUED AS A MATTER OF INFORMA. nON
ONLY AND CONFIiRS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
INSURERS AFFOIU1ING COVERAGE I NAIC'
INS"''''A. SEQUOIA INSURANCE CO. !
_em
PERLAS INSURANCE SERVICES
401 N. Brand Blvd., Suite 445
GLENDALE, CA 91203
(818) 543-1133
~~~ C.A.R.E. COUNSELING
1614 EAST 17TH STREET *D
SANTA ANA, CA 92705
.lNSU~E~ R~._.-
1NSURER C
._--~
,
COVERAGES
THE POlICIES OF INSURANCE liSTED BElOW HAVE e.EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POliCY FERIOO INDICATED NOTWITHSTAND:NG
ANY R.QUIREII.1ENT. TERM OR CONDITION OF ÞNf CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS.CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSVRANCE AffORDED BY THE POi.ICIES DiSCRIBED HEREIN IS SUBJECT TO AU. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
!'OllCIE3. AGGftEGATE UMIT3SI~OWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
INSURER E.
INSURER D-
...-...- ~
~y EFR!CTM.:
I
111-17-04
~YUAMTION
UMIT1I
'~E
I ~........ UAIIIUT'f
X C01lll!ÆFt(:IAL (:;¡¡::~~All.IAm"rTV
, I CIJ\lI\of6MACË []J OCCUR
-".",
POUCY-
x
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07-14-05
EACH OCCURRENCE
~11.11'U~NII::IJ
. ~eMIS!~J~EI,OC;:U~,~J., .
MEDE~(Þ.nyOMþ~n)
I PC:~NAL&ACV HJURY
I GENERAl AOOREGAìE
PRODUCTS. CQMPIOÞ AGO
,1.,000,000
-;--'.'[q]ïf: oß:f"
, 10,000
1",000,000
¡,2, 000, DCa
,2,000,000
--
I
I
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.Q!,N'I..¡'GOO~~ ~MrT AP~~ PtP.:
lPOLICYl I~ j ILOC
~OIÞLEUABLfTT
- AN'I'Al!TO
- ALL OVIINEOAUTOS
- SCHetJUI.I!O AUTOS
- PoitRF.D AJftOB
--- NQt.I-OWNEDAlJTDS
-- ........--------....-..--
COMBlNE.O SINGlE UMlT "
(Eia8Cl:lðent) I
BODtlYINJURY I,
(""'-) ,
BQOtlYINJURY ,
(~fto:lOrvri)
PROPERTY DAMAGE i,
(hrsCQdenO ;
! ~C:ESslUMBM:LLA. UABILfTY
( ~"OCCtlR 0 Cl.AtMSMAOt
! l-"l oeOUC"BlE
I 1'1 "ETeNTION .
\ WO~EMCQMPSNSAT1ON""'o
; !MPlOYERS' UAØIlJT'I'
" AV! Mo~!tC!l:lt>~TN~IV!"J!r:t:<I"i"õVI"
,OI""JC.B'!/1IIr::",~PsrC'.VD'E.¡;'
¡!;?J¡ {; .2/;!Z/
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AUTOONLy.eAACCICENT ! $
....-~_._..~----:--'--~~- -- ,-
OTH¡:;;RTHAN E^I',CC j ~
AUTOONIoY: AGG j $
MCH OCCUPRI;:NCE ¡ S
--
GAlWJl!LJAINI.lTY
::rANYAUfO
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:$
: 11~. dftr;rlb!Jvn(l9f
, SPF.:CI^I.PROVISIONSIJI'I01I'I"
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..__.L:r~~r~~~.1..,_.I~~t!---.. . .'~'------'--
~.L. [ACH ACCIDENT ; ~
.!~~!~~~~---~ ~~?"~.l.~:.- -. ----" -----.-.--
I I:.l. OI5t:ASt: - F'Cl:CY UMii : 5
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I
DESCRIPT.ION OFO"ERAT1ONSI LOCATlONliIWHICLUf2lCLtJ9lONGADDI!DBYENDORSEfI1ENT I SÞEQAL ~O\lJ&IQr.IS
CERTIFICATE HOLDER NAMED AS ADDITIONAL INSURED.
CERTIFICATE IiOLDER
CANCELI.A TION
CITY OF SANTA ANA -CDBG-25
COMMUNITY DEVELOPMENT AGENCY
P.O. BOX 1988 -25
SANTA ANA, CA 92702
St1OULO ,.,....1' of "tHE ABO~ DESCR:I:ØEO POUC:1ES BE CANC;kUE.tI aE~Ti1E EX"!~:" ,;.:,1,
)An: i~t:OF. 'tHe t;5úJIIIQ II\u!iURER i/IIllL EHCEAVOR Tö MA!L ~ o)t.,'7S. \¡~x~::;::>:
NOTICE TO THf. caulffCl'T£ HOLoEft; NM'IF.O TO -nE \..En, øuf fAlLlJR'E; 1'0 CO $0 sH..Iu..
IMPOSE rwo OBUOATtON OR LJABIUTY OF ANT IQNg \/PO"': I".9UfŒR. In AGENTS ~
REPRE8ENTATlVES.
AUTHORfZI!D ttePFtEJeNTATM!
"ri3/06/2004
13:41
7148369820
CARE COUNSELING
-
ALLIED HEAL THCARE PROFESSIONAL AND SUPPLEMEW 1\
INSURANCE POLICY DECl..
RENEWAL DEC, ' ,
. ,
ATTACH THIS RENEWAL DECLARATIONS TO YOUR EXPIRING POLlCV
Policy Number: PHCP021386
Philadelphia Indemnity Insurance Company
Administered by CPh ,.
7"1 S Dea¡!x
Ctw-'ð¡
CAR.E Counseling Center
Penny VVinkler
1614 E, 17th 5t, Ste D
Santa Ana, CA 92701
Affiliation: CAMFT
Professional Occupation: MARRIAGE&FAMll Y
Coverage Term From: (Effectiva Date) 03/26/04 To (Expiration Date) 03/26/05
at 12:01 a.m. Standa~ Time at the Insured's Mailing Address shown above.
Retroactive Date (if applicable)
COVERAGE A - PROFESSIONAL liABiliTY COVERAGE LIMITS OF
LlASI LlTY
Individual - Each Incident: N/A
Aaareaate: N/A
Association partnen;hio or Corooration - Each Incident: $1 000,000
AQQreQate: $3,000,000
COVERAGE B - SUPPLEMENTAL LIABILITY COVERAGE
Each Incident: $1,000,000
ACIOreaate: $3,000,000 .~'-'--
.-.
COVERAGE C - NON-OWNED AUTOMOBILE (optional)
Each Occurrence:
Aooreoate:
-
-TpRE/.ÌmJh'
r"'t
f-----
,
~-----
---+---.- .
,
~I----'-
I
-c::
.---------
Policy Forms and Endorsement: The expiring policy forms, endorsements and limits of Insurance aDC'
renewal unless changes are shown on this Renewal Declaration.
Premium (including taxes): $590.00
Call the Administrator to Verify Claims History at 1-800-875-1911
ðð00
Jamie Maguire, Authorized Representative
PHCP-01 (3/01 )