HomeMy WebLinkAboutBOYS AND GIRLS CLUB OF SANTA ANA 83 - 2008City of Santa A z
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Clerk of the Council
'- AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
Return form to the Clerk of the Council Office (M -30). n«,a
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AGREEMENT BETWEEN THE CITY OF SANTA ANA AND
BOYS & GIRLS CLUB OF SANTA ANA FOR USE OF
COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS
A- 2008- 069 -083
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This Agreement, is hereby made and entered into this 1 st day of July, 2008, by and between
the City of Santa Ana, a charter city and municipal corporation of the State of California ( "CITY ")
and BOYS & GIRLS CLUB OF SANTA ANA, a California nonprofit corporation
( "SUBRECIPIENT ").
WITNESSETH
Recitals:
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 Federal Regulations 24 CFR 570.000, et seq.
( "CDBG REGS "); and
B. CITY has applied for and received CDBG funds from 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 qualified 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 National Objectives (24 CFR Part 570.208).
D. SUBRECIPIENT agrees that it will adhere to the performance measurements and
outcomes as indicated on Exhibit A -I (Outcome Tracking). Failure to follow the measurements
and meet the stated outcomes may constitute breach of contract that could result in termination
of this Agreement or serve as reason for the City to recapture the grant funds awarded to
SUBRECIPIENT pursuant to this Agreement.
E. 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 all exhibits and attachments hereto, shall constitute the entire Agreement between the
CITY and SUBRECIPIENT:
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I. SUBR_ECIPIENT'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 California.
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
this Agreement by SUBRECIPIENT has been fully authorized by all requisite actions on the part
of SUBRECIPIENT.
(b) Experience. SUBRECIPIENT is a qualified provider of the 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 SUBRECIPIENT'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.
(f) No Pending Legal Proceedings. SUBRECIPIENT is not the subject of a current or
threatened litigation that would or may materially affect SUBRECIPIENT'S perfonnance 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 Quarterly Disbursement. The amount granted to
SUBRECIPIENT is $ 40,000 ( "CDBG FUNDS "), and such funds shall be expended by
SUBRECIPIENT on or before June 30, 2009. The CDBG FUNDS shall be disbursed by CITY
to SUBRECIPIENT on a quarterly basis (October, January, April and July) subject to and upon
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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 shall 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 federal 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
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, 2009 and to use said funds to pay for necessary and reasonable costs allowable under the
federal law and regulations to operate said program. Said amounts shall include, but not be limited
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 shall 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 all required licenses,
registrations, accreditation and inspections from all agencies governing its operations.
SUBRECIPIENT shall ensure that its staff shall also obtain and maintain all required licenses,
registrations, accreditation and inspections from all 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 specifically 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 federal rules and regulations relating thereto, SUBRECIPIENT 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.
SUBRECIPIENT 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. 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 fields received by SUBRECIPIENT from CITY
pursuant to this Agreement shall be maintained in an account in a federally insured banking or
savings and loan institution with record keeping of such accounts maintained pursuant to applicable
OMB Circular A -110 requirements. SUBRECIPIENT is not required to maintain separate
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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 -110 requirements.
H. Audit Report Requirements. SUBRECIPIENT agrees that if SUBRECIPIENT
receives Five Hundred Thousand Dollars ($500,000.00) or more in federal funds, SUBRECIPIENT
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.
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.
L Record Keeping/Reportine. SUBRECIPIENT shall keep and maintain complete and
adequate records and reports to assist CITY iii meeting and maintaining its record keeping
responsibilities under the CDBG REGS, including the following:
(1) Records
a. Documentation evidencing program income requirements in
conforinity 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
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evidencing how the CDBG FUNDS have been expended during
the applicable quarter.
(ii) Quarterly Activity Report: SUBRECIPIENT agrees to keep monthly
records of all 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
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 Records/Required Length of Record Keeping. All accounting records,
reports, and evidence pertaining to all costs, expenses and the CDBG FUNDS of
SUBRECIPIENT and all 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 all 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 Law/Program 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 all pertinent
regulations issued by agencies of the federal government, including, but not 1united to, all
regulations found at Title 24 of the Code of Federal Regulations. Program income received by
SUBRECIPIENT shall be returned to CITY unless otherwise provided for in this Agreement.
SUBRECIPIENT 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.
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M. Standing. SUBRECIPIENT shall be in good standing, without suspension by the
California Secretary of State, Franchise Tax Board and Internal Revenue Service. Any change in
the corporate status or suspension of SUBRECIPIENT shall be reported immediately to CITY.
N. Confidentiality. Without prejudice to any other provisions of this Agreement,
SUBRECIPIENT shall, where applicable, maintain the confidential 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,
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 terns 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 disallowance and repay CITY all amounts spent
in violation thereof. If SUBRECIPIENT engaged in fraudulent 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 fraudulent circumstances.
Q. Equipment. SUBRECIPIENT 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 tern "non- expendable personal 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, meals or gifts.
S. Lobbviu. 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 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. 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 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 SUBRECIPIENT under the terms and conditions of this Agreement.
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If any funds other than Federal appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit a 'Disclosure Form to Report Lobbying," in accordance
with its instructions (see C -1).
T. Financial Interest. SUBRECIPIENT agrees that except for the use of CDBG funds
to pay salaries 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 financial interest or benefit from 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 official 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 alterations and repairs, in excess
of $2,000.00, financed in whole or in part with federal funds shall 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 276a - 276a -5. Any such construction contract
shall include and comply with the required contract provisions and rules set forth in 29 C.F.R. §5.5.
Further, the payroll reports (along 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 shall be approved by the federal 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
shall 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-free 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 federally funded
program.
2. As an employee working in conjunction with a federally funded program, the
employees of SUBRECIPIENT will be required to:
a) Abide by the terms above in statement 1.
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b) Notify appropriate officials of SUBRECIPIENT and CITY officials of
any criminal 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.
Each such employee shall be required 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.
H. CITY'S OBLIGATIONS
A. Payment of Funds. Upon execution of this Agreement by SUBRECIPIENT, CITY shall
pay to SUBRECIPIENT from CDBG fiends, when, if and to the extent received from HUD, for
CITY's 2008 -2009 CDBG program year amounts expended by SUBRECIPIENT iun carrying out
said program for fiscal year 2008 -2009 pursuant to this Agreement up to a maximum aggregate
payment of Forty Thousand Dollars ($40,000) in installments determined by CITY. Payments shall
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 shall 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 shall include an audit of the account maintained by
SUBRECIPIENT in CITY's annual audit of all CDBG FUNDS in accordance with Title 24 of
the Code of Federal Regulations and other applicable federal laws 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 staff has detailed knowledge of the
grant program requirements and monitors grant and subgrant supported activities to assure
compliance with Federal requirements. Such monitoring covers each program, function and activity
and performance goals are reviewed periodically.
D. Environmental Review: In accordance with 24 CFR 58, the CITY is responsible for
undertaking environmental review and maintaining environmental 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
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reasonable period of time after being notified by the CITY, contract suspension or termination
procedures will be initiated.
M. NONDISCREMNATION
SUBRECIPIENT agrees that no person on the ground of race, age, 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 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 -110, 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, shall serve as an officer of SUBRECIPIENT. Further, any conflict or
potential conflict of interest of any officer of SUBRECIPIENT shall be fully disclosed in writing
prior to the execution of this Agreement and said writing shall be attached and deemed fully
incorporated as a part hereof. Notice shall 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 shall provide with CDBG funds, in accordance
with 24 CFR 570.2000):
A. SUBRECIPIENT 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. SUBRECIPIENT shall not discriminate against any person applying for the services
SUBRECIPIENT agrees to provide under the tenns 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. SUBRECIPIENT 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. The parties agree that this covenant is
intended to and shall be construed for the limited purpose of assuring compliance with respect to the
use of CITY funds by SUBRECIPIENT with applicable constitutional 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 California Constitution, and is not in any
manner intended to restrict other activities of SUBRECIPIENT.
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D. Where the services to be provided under said program are rendered on property
owned by the prunarily religious entity SUBRECIPIENT, CDBG 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 CDBG
expenditure for rendering the services under said program.
VI. PROHIBITION OF NEPOTISM
SUBRECIPIENT agrees not to hire or pen-nit 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 "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, 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, California 92702 -1988
TO SUBRECIPIENT: D Id Sidl 9019ei2T SiENT�4� A
Exec ive irector C Sher MtFVSSi W4*L 0 PF c 4-R
1615 E 7t' Street, Room 150 ZSb N CoL b4N t1KCLf_ 4:�-lOy
Sant Ana, A 92705 SANTA 4� of CA 12'j o r
VIII. ASSIGNABILITY
None of the duties of, or work to be perfonned by, SUBRECIPIENT under this Agreement
shall 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 assigmnent shall tenninate or alter the legal
obligations of SUBRECIPIENT pursuant to this Agreement.
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IX. HOLD HARAMESS
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
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 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 from 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: (1) name the City of Santa Ana, its officers, agents,
representatives, employees and volunteers as additional insureds; (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 SUBRECIPIENT'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.
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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 of CDBG 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:
1. Used, where CITY has given written approval, to meet one of the national
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
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 -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 all 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 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, 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 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
SU-BRECIPIENT on behalf of CITY, in furtherance of the activities hereunder or thereof.
12
5/05
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 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.
XIL TERMINATION
A. This Agreement may be terminated on thirty (30) days' written notice by either
party. In the event of such termination, SUBRECIPIENT shall only be entitled to reimbursement
for approved expenses incurred to the effective date of termination.
B. This Agreement may be suspended or tenninated by CITY upon five (5) days'
written notice for violation by SUBRECIPIENT of Federal Laws governing the use of Community
Development BIock Grant Funds. In the event of such suspension or tennination, SUBRECIPIENT
shall only be entitled to reimbursement for approved expenses incurred up to the effective date of
suspension or tennination.
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 tennination 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 tenninated for cause, CITY shall be relieved of further liability or
responsibility under this Agreement, or as a result of the tennination thereof, including the payment
of money, except for payment for approved expenses incurred for services satisfactorily and timely
perfonned prior to the mailing or service of the notice of tennination, 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 perfonnance.
D. The grant of funds under this Agreement may be terninated 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 goals set forth
therein.
F. In the event this Agreement is terminated as set forth in subparagraphs XILA.
through XII.E., inclusive, SUBRECIPIENT agrees to immediately return to CITY upon CITY's
demand and prior to any adjudication of SUBRECIPIENT's rights, any and all funds not used, and
to comply with paragraph "XI. REVERSION OF ASSETS" of this Agreement.
13
5/05
XM. LEMTATION OF FUNDS
The United States of America, through HUD, may in the future place programmatic or fiscal
limitations on the use of CDBG funds which lunitations 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
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, shall 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 withdrawal guidelines.
XTV. 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 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, 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
SUBRECIPIENT.
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.
14
5105
XVII. NIISC_ ELLANEOUS 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 shall
indemnify CITY fully, including reasonable costs and attorney's fees, for any injuries or damages to
CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn.
b. All Exhibits and Attachments referenced herein and attached hereto shall be
incorporated as if fully set forth in the body of this Agreement.
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
5/05
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and
year written below.
V
PATRICIA E. HEALY
Clerk of the Council
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
By: LISA E. STORCK
Assistant City Attorney
DATE:
16
CITY OF SANTA ANA
PDA7VID N. .11
City Manager
SUBRECIPIENT:
Name: Richard Porras
Title: President, Board of Director
Tax ID: 93- 1893417
City of Santa Ana
Scope of Work
Name of Organization Boys and Girls Club
Name of Funded Program Summer Youth Outreach Program
Annual Accomplishment Goal
1. Total number of unduplicated clients (Santa Ana and Non -Santa Ana Residents) anticipated to be served by the
funded program, named above, during the 12 -month contract period.
35-01 Persons
II. Number of ONLY unduplicated Santa Ana residents to be served by the funded program, named above, during the
12 -month contract period.
323 Persons
Program and Funding Description
III. Description of Work - In the space below, describe the program to be funded during the 12 -month contract period.
What specific activities will be undertaken during the contract period. Please be concise in your response. Only the
viewaDie space wui print.
Type in description here.
The Summer Youth Outreach Program will provide a day camp experience for youth out of school for the summer
break. They will have swimming lessons, tennis lessons, computer on -line safety classes, arts & crafts, life skills
activiites that focus on prevention, health and safety, sports and recreational activities, weekly field trips and even
overnight camping at accredited camps.
Schedule of Performace
Estimate the number of ONLY unduplicated Santa Ana residents to be served by the funded program during the 12-
month contract period per quarter. (Enter number of new Santa Ana clients served each quarter. If they were served
in quarter 1 do not count them again in quarter 2)
Quarter 1: July 1 - September 30 323 Persons
Quarter 2: October 1 - December 31 Persons
Quarter 3: January 1 - March 31 Persons
Quarter 4: April 1 -June 30 Persons
323 Total unduplicated Santa Ana Residents to be served.
Schedule of Invoicing
Estimate the amount of grant funds to be requested during the 12 -month contract period on a quarterly basis.
Quarter 1: July 1 - September 30
Quarter 2: October 1 - December 31 $ 40,000.00
Quarter 3: January 1 - March 31
Quarter 4: April 1 -June 30
$ 40,000.00 Total Grant
Exhibit A
Page 1 of 1
City of Santa Ana
Performance Outcome Tracking
Please find the activity most closety associated to the service that will be provided and place an "X" next to it then
answer the question below. Please note the tracking that is involved with this activity.
Place an
"X" next to
one
Activity
Activity/
Program
City Outcome Tracking
Goal
HUD Outcome Tracking
HUD Goal
3. Track children /youth
3. 90% of children /youth
Number of persons assisted:
Accessibility for the
seeking referrals that were
seeking referrals will be
-with new access to a service
purpose of creating
linked to the services
linked to the services
-with improved access to a service
Suitable Living
sought.
sought.
-where activity was used to meet a
Environments
quality standard or measurably
improved quality, report the number
that no longer only have access to
substandard service
Describe how you will gather the tracking information, noted above, for that activity.
Through the use of intake forms.
Exhibit A -1
Page 1 of 1
Program Year 2008 -2008
Final Budget
Organization Name Boys and Girls Club
Program Name Summer Youth Outreach Program
Expenditures
Category
Expenses Funded by
Santa Ana CDBG
Expenses Funded
by Other Sources
Total Program
Budget
Total Organizational
Budget
Administrative Staff
Salaries & Benefits
$ 1,435
$ 10,565
$ 12,000
General Contributions
Program Staff Salaries &
Benefits
$ 27,610
$ 129,390
$ 157,000
Contractual /Professional
Services
$ -
$ _
Office Supplies
$ 875
$ 4,825
$ 5,700
Rent
Total Funds for the Program
$ _
186,100
Communications
$ _
Utilities
$ 3,000
$ 500
$ 3,500
Insurance
$ 5,580
$ 820
$ 6,400
Other :List below
1 Mileage
$ _
2 Audit Fee
$ _
3 Printing
$ _
4 Equipment Rental
$ -
5 Others (.janitorial)
$ 1,500
$ 1,500
Total
$ 40,000
$ 146,100
$ 186,100
$ 2,037,110
LIST ALL OTHER PROGRAM FUNDS THAT HAVE BEEN SECURED FOR 08 -09
(Total Funds for Program must equal Total Program Budget above)
Source Amount
Santa Ana CDBG
$
40,000
Special Events
$
80,000
Direct Mail
$
20,000
General Contributions
$
46,100
Total Funds for the Program
$
186,100
Exhibit B
Page 1 of 1
2008 -2009 Funded Personnel
Name of Organization: Boys and Girls Club
Name of Program Summer Youth Outreach Program
NOTE: Please remember that this is only a budget and that reimbursement should be based on actual service.
ADMLNISTRATIVE STAFF
Position Title
Annual
Salary
Annual
Benefits
Total
Compensation
CDBG Funds
Requested for
this position
Of this time
percent of
time serving
Santa Ana
Maximum
Amount of
eligible
Compensation
Business Manager
S 70.000
S 8.000
$ 78.000
$ 1.435
100%
$ 78.000.00
1.800
$
20.520
$ 3.149
100%
S
20.520.00
Unit Director
S
40,250
1 $
7.000
$
47.250
S 3.906
100%
$
47.250.00
Director of Quality Control
S
22.500
$
3.000
$
25.500
S 3.063
100%
$
25.500.00
Director of Sports & Rec
S
35.000
S
6.000
$
41.000
$ 5.192
100%
$
41.000.00
Field Trip Coordinator
$
43.000
$
8.000
S
51,000
$ 5.865
100%
$
51.000.00
Program Assistant: Earl' Bird
$
22.000
S
3.000
Total Amount Requested
$ 1,435
$ 3.090
100%
Must equal amount indicated on Exhbit B
PROGRAM STAFF
Position Title
Annual Contract Amount
Annual
Salary
CDBG Funds
Requested for
this position
Annual
Benefits
Total
Compensation
CDBG Funds
Requested for
this position
Of this time
percent of
time serving
Santa Ana
Compensation
Maximum
Amount of
eligible
Program Manager; Earh Bird
$
18.720
$
1.800
$
20.520
$ 3.149
100%
S
20.520.00
Unit Director
S
40,250
1 $
7.000
$
47.250
S 3.906
100%
$
47.250.00
Director of Quality Control
S
22.500
$
3.000
$
25.500
S 3.063
100%
$
25.500.00
Director of Sports & Rec
S
35.000
S
6.000
$
41.000
$ 5.192
100%
$
41.000.00
Field Trip Coordinator
$
43.000
$
8.000
S
51,000
$ 5.865
100%
$
51.000.00
Program Assistant: Earl' Bird
$
22.000
S
3.000
S
25.000
$ 3.090
100%
$
25.000.00
Front Desk Clerk
$
18.000
$
1.800
$
19.800
$ 3.345
100%
$
19.800.00
S
-
S
_
Total Amount Requested
$ 27.610
$ 7
$
230.070
Must equal amount indicated on Exhbit B
CONTRA CTUA-UPROFESSIONAL SFRVrCF.c
Type of Service
Annual Contract Amount
Total
Compensation
CDBG Funds
Requested for
this position
Of this time
percent of
time serving
Santa Ana
Maximum
Amount of
eligible
Compensation
$
S
$
S
$ -
S
Total Amount Requested
S
Must equal amount indicated on Exhbit B
'Please note for personnel whose time is not directly traced to serving Santa Ana and instead a percentage is used please
confirm the percentage is accurate prior to requesting reimbursement.
Exhibit B -1
Page 1 of l
4DIV /0!
4DIV /0!
#DIV /0!
4DIV /0!
#DIV /0!
#DIV /0!
#DIV /0!
#DIV /0!
#DIV /0!
4DIV /0!
4DIV /0!
4DIV /0!
#DIV /0!
#DIV /0!
#DIV /0!
4DIV /0!
#DIV /0!
"DIV /0!
#DIV /0!
Certification Regarding Lobbying
Certification for Contracts Grants Loans and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of Congress, or
an employee of a Member of Congress in connection with the awarding of any Federal
contract, the making of any 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 Federal contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form -LLL, "Disclosure
Form to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the
award documents for all subawards at all tiers (including subcontract, 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.
SuwnW1t4z 1ZRPA
i6etor Or amzation Program Title
Name of Certifying Officer Signature Date
EXHIBIT C
Page 1 of 2
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 1.
2. No person in the United States shall on the ground of race, 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 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 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 12372.
EXHIBIT C
Page 2 of 2
A '�00Y U 6 9 -v Y3
ACORD CERTIFICATE OF LIABILITY INSURANCE OPID PC DATE(MM/)DIYYYY)
BOYS -10 01/15/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO
Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License #0522024 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. o. Sox 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Pasadena CA 91117 -0455
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU BJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS
Phone: 626 -405 -8031 Fax: 626 - 405 -0585
INSURERS AFFORDING COVERAGE NAIC 0
INSURED
INSURERA: Great American
POLICY NUMBER
DATE MMIFDD/YY)
INSURER B:
LIMITS
Boys & Girls Club of Santa Ana
1615 E. 17th Street, Ste. 150
Santa Ana CA 92703
INSURER C:
GENERAL
INSURER D:
INSURER E:
rnt>co A r_ rc
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU BJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS
OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NS
TYPE OF INSURANCE
POLICY NUMBER
DATE MMIFDD/YY)
DATE (MMIDDM 1
LIMITS
GENERAL
LIABILITY
EACH OCCURRENCE
$1,000,000
A
X
X
COMMERCIAL GENERAL L"LITY
CAP8049630
01/01/08
01/01/09
PREMISES (Ee ocurence)
$100,000
CLAIMS MADE FX OCCUR
MED EXP (Any one person)
$5,000
PERSONAL & ADV INJURY
$1,000,000
GENERAL AGGREGATE
$3,000,000
GENLAGGREGATELIMfr APPLES PER:
PRODUCTS - COMPIOPAGG
$1,000,000
POLICY PRO -
.ECT LOC
AUTOMOBILE
LIABILITY
A
X
ANY AUTO
CAP8049630
01/01/08
01/01/09
COMBINED SINGLE LIMIT
(Esacddent)
$ 1000000
ALL OWNED AUTOS
SCHEDULEDAUTOS
BODILY
erperson)
(Per person)
$
X
HIREDAUTOS
X
NON- OWNEDAUTOS
BODILY IN,AIRY
peraccbent)
$
PROPERTY DAMAGE
$
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN EA
$
AUTO ONLY: AGG
$
EXCESS/UMBRELLA UABILITY
EACH OCCURRENCE
$ 5000000
AGGREGATE
$5000000
A
X OCCUR EICLAIMSMADE
MdBS049631
01/01/08
01/01/09
$
0 DEDUCTIBLE
$
X RETENTION $10000
$
VYORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
TORYLIMITS I ER
E.L. EACH ACCIDENT
$
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYE
$
If Yes, desa�e under
SPECIAL PROVISIONS below
E.L DISEASE- POLICY Lrv11T
$
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS If VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
City of Santa Ana is named additional insured with respect to the
operations of the named insured per the attached endorsement. 10 days
notice of cancellation for non - payment of premium.
SAWXIL3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIC
DATE THEREOF, THE ISSUING INSURER VNLL ENDEAVOR TO MAIL 30 DAYS WRITTEN
City of Santa Ana NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Santa Ana Redevelopment Agency
Attn: Frank Hernandez IMPOSE NO OBLIGATION OR LIABILITY OFANY KIND UPON THE INSURER, ITS AGENTS OR
P.O. BOX 1988 REPRESENTATIVES.
Santa Ana, CA 92702 AUWC91PEDREP _ Nrn j*
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.
ADDITIONAL INSURED ENDORSEMENT
Insurance Company
Great American Insurance Company
This endorsement modifies such insurance as is afforded by the provisions of Policy
# CAPS04MM relating to the following:
1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California
92701; its officers, employees, agents and volunteers are named as additional insureds
('additional insureds ") with regard to liability and defense of suits arising from the
operations and uses performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by
or on behalf of the named insured, such insurance as is afforded by this policy is
primary and is not additional to or contributing with any other insurance carried by or for
the benefit of the additional insureds.
3. This insurance applies separately to each insured against whom claim is
made or suit is brought except with respect to the company's limits of liability. The
inclusion of any person or organization as an insured shall not affect any right which
such person or organization would have as a claimant if not so included.
4. With respect to the additional insureds, this insurance shall not be
canceled, or materially reduced in coverage or limits except after thirty (30) days written
notice has been given to the City of Santa Ana; 20 Civic Center Plaza, Santa Ana,
California 92701.
(Completion of the following, including countersignature, is required to make this
endorsement effective.)
Effective 01101108 - 01101109 , this endorsement form as a part of
Policy #
CPJW49630
Issued to Boys & Girls Club of Santa Ana
Named Insured
Countersigned by 02
Authorized Representative