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HomeMy WebLinkAboutORANGEWOOD CHILDREN'S FOUNDATION (4) - 2011 City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM COTC Office Use Only Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M-30). Call 647-6520 if you have any questions. The agreement with t)vzwyJJ)czA CAId ,s ()1U1-0(-CLAWA' No. P �!N`b-. 1Oa Lai-v( 1 was completed on CI and final payment has been made. (List all amendments. Use space below if needed.) ii,c)/1 I `V— Z'3. -D Department: C 'I s JL � l Phone/Ext.: X 2.10 9-I Signature: Date: 'a\ \� v Revised 08-23-10 INSURANCE1�ON FILE A- 2010 -123 -02 WORK MAY p[QT pROCEE CLERK OF COUNCIL '� SECOND AMENDMENT TO AGREEMENT DATE: %� _�a -L� UNDER THE WORKFORCE INVESTMENT ACT THIS SECOND AMENDMENT, made and entered into this 1s' day of October, 2011, by and between the Orangewood Children's Foundation ( "Contractor ") and the City of Santa Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of the State of California ( "City "). � RECITAL S J A. The City and Contractor entered into that certain Agreement Under the Workforce Investment Act effective July 1, 2010 (Agreement #A- 2010 -]23) hereinafter referred to as "said Agreement ". � B. The parties hereto now desire to amend the Agreement by extending the Term and to revise the Budget attached to said Agreement. Relevant exhibits affected by these changes will also be amended. WHEREFORE, in consideration of the mutual and respective covenants and promises hereinafter contained and �- made, and subject to all of the terms and conditions of said Agreement as hereby amended, the parties hereto do hereby agree as follows: 1. Section III. "Time Period of Agreement" shall be amended through December 31, 201 1, in accordance with said term which states: "The term of this Agreement may be extended by a writing executed by the Executive Director and the City Attorney ". 2. Exhibit F to said Agreement is hereby replaced with the amended Exhibit F (Budget), attached hereto and incorporated herein by reference. The amount of City's Obligation remains as stated in said Agreement. 3. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Amendment to said Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA � By: Maria D. Huizar Paul Walters Clerk of the Council Interim City Manager APPROVED AS TO FORM: Joseph Straka Interim(��C/ity Attorney Lisa E. Storck Assistant City Attorney CITY OF SANTA ANA COMMUNITY DEVELOPMENT AGENCY Nancy "h. Edwards Interim Executive Uir C r "CONTRACTOR" Orangewood Children's Foundation BY: Name: Robert Theemling Title: Chief Program Officer September 28, 2011 Ms. Julie Castro - Cardenas Santa Ana Workforce Investment Board 1000 E. Santa Ana Blvd_, #200 .Santa Ana, CA 92701 Dear Ms. Castro - Cardenas, As you know, the Orangewood Children's Foundation, Foster Youth Liaison Project was not funded by the City of Santa Ana WIB for PY 2011/2012. We are contracted and committed to provide 12 months of follow -up services for our current 26 PY 2010/2011 clients_ Since we are not receiving new funds, we face financial challenges to support staff, supportive services, and incentives to serve clients during the follow -up year. Therefore, we would like to request utilizing the remainder of the PY 2010/2011 contracted funds to extend our contract for a second time beyond September 30, 2011. A contract extension and availability of remaining funds to deliver quality services will help support the following: • Availability of 1 staff at 20 to 29 hours per week • Job placement and /or enrollment in post- secondary education for up to 26 clients • Attainment of a diploma or credential for up to 26 clients • Distribution of incentives fior those who meet performance measure goals • Distribution of supportive services to assist clients with performance measure goals • Completion of 1�` quarter fiollow -ups for PY 2010/2011 clients • Completion of documentation in client files We will follow up with revised copies of our entire budget and budget narrative. A budget form indicating the funds that will be used during the extension period will also be included. Please feel free to contact me anytime should you have questions. My phone number is (714) 619 -0208 or you may contact me via email at rtheemlinQC�oranQewoodfoundation .ors. It has been a privilege to partner with the Santa Ana WIB since 2006 assisting foster youth with workforce development. Although we are not a funded agency in PY 2011/2012, we hope we can be of continued assistance to the WIB and partnering agencies as a resource and referral source for foster youth clients. Thank you for your consideration of an extension of our PY 2010/2011 contract period. Sincerely, Robert B. Theemling `� Chief Program Officer V!?^G�f2CfP.LUCnl3GL' GL2- GLCY/LP.YL Id " >CF- 12NQ'�.t�LISfZ 1575 EAST l 7TH STREET, SAN TA ANA, CA 92705 714679 -0200 www.orangewoodfoundation . org Tax ID 7195 - 3616628 Budget Form (October 1 , 201 1 - December 31 , 201 1 ) All costs related to the program activities described in the proposal must be included on the Budget Form. A budge narritive must be attached on a separate sheet of paper for all line items marked with an � astrisk. "`See Budget Form Instructions Note: Audit Requirements States, local governments and non - profit institutions who receive $500,000 or more in federal funds in a fiscal year shall meet the audit requirements of the OMB Circular A -133, "Audits of States, and Local Governments and Non- profit Institutions." Administrative No more than 10% allowed_ Program Total WIA Match /In -Kind Total P s.�`.` �'P.ersonr`iel�, " ' u . .rx,� =�. •,t�.��� : r x:z;; .. e. - ;ctw : .wuw 3�*� *�w,� -�,� a�- .� r . Salaries 1 . FYLP Peer Mentors (at .625 FTE at $14.00 /hr.) 2. FYLP Supervisor (.15 FTE) 3. Senior Accountant (.1 O FTE) Use separate sheet if necessary. $4,550 $4,550 $4,550 $1,751 $1,751 $1,751 Benefits' 1. FYLP Supervisor (23 %) 2. Senior Accountant (23 %) Use separate sheet if necessary. Total Personnel $O $6,301 $6,301 $6,301 �f( Oper "atin"Ezpen's`es � �,^� =iFf �_. a, �.._ .Y+Q �.. "� � ;i �� � .'$ .�. rfa � ��_dh�f.1 z°�3' �_ Est , �� r:Y b ? %' j -'+'�` � ..na L J '; M:, ot�::'%�a..t 'f Y�l +r 3 d y �� ,k Mt e v .a� F T Rent or user fee' Utilities Phones Internet fees Parking fees Securit Maintenance Insurance Equipment rental fees° Vehicle lease Office expenses consumables Accountin Services Legal services Auditing services Indirect costs` Staff training Staff travel /mileage Participant Wages" Sup ort services" $778 $778 $778 Participant Incentives* $200 $200 $200 Other (list " Total Operatin Expenses $O $978 $978 $O $978 v r .r s '+kSY ��*_�,.. .5=. '3 T ?'" � �a r. -Y 't��+:ii�.u.� � ,, "'` � � 'f' ��"� GRAND�.T.O1�AL, z4,�, tTotal Pe sonnel?+ T��,��x'•�'�� O �ratlq�enSeS �'�.fz .i�. - •.y, :. d s c+ �»` . i1 a � $O m � t:,NY.�'�wa a ,�" ��` ^ +a�- f• „��s �'a T .�w° �. K .a � T N x �Y 4 k M:" � r'±,�' 7�2 9�a -�r + ,+"� h�L �`�a BHA .��,� T bL9 i.p -. a '" r,. =r+ ,i'" °iv4 ,�""'�: $ x !x ry.�,t+s w r� x t` $ �2t .9 : � a,� � � �s�pJ �� ,� '^t V ° Y.rSk 9 . - •rte � �. gs'?.y' f *" '�� r.,, r R � �: � i$O „ "'a�� "` �;x "� V �' � �:.,' l", - V4 P �:'.".i y, 4 .. � '� t, $' �+� v.i .r � .'`� . �,�7 '279 .� ,�',tE�"��,�`"�i��i Y � f •Y n,� ,f.' >� i� t -x: "`See Budget Form Instructions Note: Audit Requirements States, local governments and non - profit institutions who receive $500,000 or more in federal funds in a fiscal year shall meet the audit requirements of the OMB Circular A -133, "Audits of States, and Local Governments and Non- profit Institutions." Attachment C BUDGET FORM (October 1 , 201 1 - December 31 , 201 1 ) All costs related to the program activities described in the proposal must be included on the Budget Form. A budge narritive must be attached on a separate sheet of paper for all line items marked with an � astrisk. "'See Budget Form Instructions Note: Audit Requirements States, local governments and non - profit institutions who receive $500,000 or more in federal funds in a fiscal year shall meet the audit requirements of the OMB Circular A -1 33, "Audits of States, and Local Governments and Non- profit Institutions." Administrative No more than 1 O% allowed. Program Total WIA Match /In -Kind Total ,.. � Personnel ,,.,,: :. . � . Salaries' 1 _ FYLP Peer Mentors (4 at .450 FTE at $14.00 /hr.) 2. FYLP Supervisor (.50 FTE) 3. Senior Accountant (.10 FTE) Use separate sheet if necessary. $70,061 $70,061 $70,061 $17,768 $17,768 $17,768 $5,300 $4,71 O $4,71 O Benefits' 1 . FYLP Supervisor (23 %) 2. Senior Accountant (23 %) Use separate sheet if necessary_ $3,684 $3,684 $3,684 $1,219 $1,083 $1,083 Total Personnel $6,519 $91,513 $97,306 $97,306 ..... __ O_perating"lE�jie"nse "s � _ _. , . _, �.� � "i. -`' r ,� �^ �,{ x, .� a- s�,r�,,. Rent or user fee" $9,000 $9,000 Utilities $7,200 $3,600 $3,600 $7,200 Phones $4,800 $2,400 $2,400 $4,800 Internet fees $2,000 $1,000 $1,000 $2,000 Parking fees Securit Maintenance Insurance $6,000 $3,000 $3,000 $6,000 Equipment rental fees' Vehicle lease" Office expenses consumables) $7,000 $3,500 $3,500 $7,000 Accounting Services Legal services Auditing services $1,000 $500 $500 $1,000 Indirect costs Staff training $1,300 $1,300 $1,300 Staff travel /mileage $275 $275 $275 Participant Wa es• Support services $16,913 $16,913 $16,91 3 Participant Incentives' $2,595 $2,595 $2,595 Other list " Total O erating Expenses $O $49,083 $33,508 $24,575 $58,083 � ,��.m aa�:�� ri. , a r. v G f ,;,GRAND TOT�4L �'� >F T�"otal -Perso -_ el +'Total, 1 �d. y �Il`�'.�T 7 OpeYatmg,E�penses � � �� $6 519 �,, � ' � Oj'!f..V � :��_ b�5f s* ze�'�d G ��`$140�,596 >F � �� a < <" " k� � S ,,, .r r "Y � 2 � $130 894 +af p ra` �' `° try d § '" y "' $24`575 �' � �_�, � � J. _• v , :: c � $155 389 ''+ t V.( "'See Budget Form Instructions Note: Audit Requirements States, local governments and non - profit institutions who receive $500,000 or more in federal funds in a fiscal year shall meet the audit requirements of the OMB Circular A -1 33, "Audits of States, and Local Governments and Non- profit Institutions." Budget Narrative (October 1 , 201 1 — December 31 , 201 1 ) PERSONNEL Salaries: List each individual position dedicated to this project. List title, percentage of full time equivalent (FTE) or the amount of time to be charged to this project. Benefits: List each individual position dedicated to this project. List title, percentage of full time equivalent (FTE) or the amount of time to be charged to this project. Key Staff and staffing IeveZ rationale Between October 1, 2011 and December 31, 2011, The Foster Youth Liaison Project will staff 1 part -time Peer Mentor. As a minimum requirement, the Peer Mentor will be currently enrolled in college level studies with a focus on Human Services and /or related fields. The Peer Mentor is a young adult who has emancipated from the foster care system and has successfully provided mentoring services through other Orangewood Children's Foundation programs. The Peer Mentor will be responsible for follow -up services for all 26 PY 201 O /2011 clients. This project will also provide a Foster Youth Liaison Project Supervisor who will provide oversight on client progress and Peer Mentor performance and a Staff Accountant who will track program expenditures and provide overall finance support. The Supervisor salary will partially be included in this revised budget, but the Staff Accountant's salary and benefits will not be included. The following is a description of the individual positions dedicated to this project: 1 Peer Mentors @ .625 FTE (or average of 25 hours per week). Peer Mentor hourly rate is $14.00 per hour. 1 Peer Mentor at .625 FTE equals 325 hours, which amounts to $4,550 for this extension period. We may reallocate funds to the line in case more Peer Mentor hours are needed to serve program participants and meet program objectives. 1 Supervisor @ .15 FTE will be allocated to this line, which equals $1,751. We may reallocate funds to the line in case more supervision hours are needed to serve program participants and meet program objectives. 1 Staff Accountant at .1 O FTE Rent or User Fee: Provide percent of office space that will be charged to this project. Describe how percentage was determined. N/A Equipment Rental Fee (equipment may not be purchased): List items that will be used for this project. Provide percent of rental fee that will be charged to this project. Describe how percentage was determined_ N/A Vehicle Lease (vehicles may not be purchased): Provide list of vehicles dedicated for this project. Describe vehicle use and percentage of use that will be charged to this project_ Describe how percentage was determined. Note: CONTRACTOR shall also obtain and maintain, during the effective period of this Agreement, broad form automobile liability coverage with a $1,000,000 minimum limit. N/A Indirect Cost: Provide indirect cost rate plan . N/A Participant Wages: Describe costs directly related to individual participants such as paid training and/or work experience. Include number of youth, hourly wage, benefits and bonuses. Include length of activity. N/A Support Services: Attach policies and procedures for supportive services. Policy must include spending limits. During this extension period, our program will dedicate resources to Supportive Services on an as needed, emergency basis to assist clients with performance measure goals. We will attempt to utilize non -WIA resources prior to using WIA funds for Supportive Services. Participant Incentives: Indicate the type of payment, rate of payment and describe what youth must achieve to receive the incentive. The Foster Youth Liaison Project program model builds in incentives that help our youth achieve goals. In addition to the performance goals set forth by the grant, our program model has established additional activities that will assist youth in becoming empowered, self - reliant and productive adults within one year of their enrollment. Participants will have the opportunity to complete the following: Goal Incentive If Basic Skills Deficient, improve at least One $50 Gift Card Educational Level in Math and /or Reading by Exit. Retain or Enter Unsubsidized Employment after Exit $50 Gift Card and by the end of the ls` Quarter after Exit. $50 Bonus Gift Card will be provided if the job is identified as Green, High Demand, and /or STEM Retain or Enroll in Post - Secondary Education after $50 Gift Card it and by the end of the 1 sc Quarter after Exit_ Complete a Diploma or Certificate after Enrollment $50 Gift Card anI by the end of the 3Ta Quarter after Exit. Stay connected with your Case Manager throughout $50 Gift Card the Program Year and Follow -Up Year by com feting Exit, and all Follow-Ups. Complete My Action Plan Goals by Exit $100 Gift Card Upon successful completion of the above objectives, participants will be given a gift card valued at their listed amounts above. 26 participants may earn up to $400 dollars in gift cards each, which totals to a budgeted amount of $10,400. Gift cards will be from a WIA authorized list to ensure clients may purchase items that may directly benefit their ability to access employment, education, etc. The incentives amount included in this revised budget includes an estimated amount to be expended during the extension period. However, we are committed to the total amount of up to $10,400 according to our contracted agreement through the end of our follow -up year. Other: This item may include fieldtrips and youth stipends. All items must be listed and include cost details. N/A ACORD„ CERTIFICATE OF LIABILITY f NSURANCE 06/13/2011 rlaouuceR (714)$38 -1912 FAX (714) 838 -7568 Lal<e II1sTlrattca Agency 13891 NB(yport AVa. , 5(li to 285 Lic N0747473 TNStin, CAJ2780 THIS CERTIFICATE IS 19SUE:0 A6 A MATTER OF INFORMATION ONLY AND CONFe R3 NO R10HT8 UPON THE CERTIFICATE HOLDER. THk3 CER71FiCAT5 DOES NOT AMEND, EXTEND OR LTER T E COVERAGE AFFORDED (3Y THE P LIC[E!S B LOW. IN8URER8 AFFORDING COVERAGE NAIC fl ursuREP range County C ron s T Terapeut c Art Cente 2215 N. Broadway SalltB Ana, CA 92706 INeUAERA: Philadelphia Insurance Co. IN8URER O: oErIERAL L1A61LnY INSURER C: 12/21/2010 IN8URER D: encH OCCURRENCC IN8URER E: OAI.IAOET RCNTCD InCA E4A[a+[snrn THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERA1 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMtN7 WITH RESPECT TO WHICH THl3 CERTIFICATE IMY BE ISSUED OR A(AY PERTAIN, THE INSURANCE Af•FOROE❑ BY THE POLICIES DESCRIBED HEREIN i3 SUBJC -CT 70 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN AV\Y HAVE BEEN REDUCED BY PAID CL.AIM3.- 1 OD' TYPE OPINSURAIICB POLIOY I7U /ABER POLIOV F P LIC B% 1 TOti 411,!178 oErIERAL L1A61LnY � PHPKG515Z2 12/21/2010 12/21/2011 encH OCCURRENCC b 1 000 000 OAI.IAOET RCNTCD InCA E4A[a+[snrn S SOO OOO x COAV,IERCIAL GENERAL LIABILITY i 5 QQQ CLAV.161.1A0E QOCCUR NEO EXP (Any moparson) PERSONAL S.ADViNJURY f 1 QQQ QQQ A GENERAL AOOflEOATE b 2 QQQ QQQ OErrI AGGREGATE LAAV�IIY APPLIEB PER PRODUOTS- COI,V'/Op A00 i 2 QQQ QQ POLICY jECOT' LOC AUTOMOBILE UADILITY ANYAVTO PHPK651522 lz /zl /zolo 12/21/2011 COMBINED BINOlfi LIhUT (Ee EOC!d W) b 1 OOO OOO BODX.Y INJURY (per person) b A ALL 04YNED nVT09 8CHEOVLED AVTOB X HIRED AVTOB X NON.oWNEO nUT08 14ipPROV E AS TO _._... ORN! BOPA.Y INJVAY (Par acddsAl) $ PROPERTY Day.Pe (Del a«Idsnl) b GARAGE LIABILITY __.,.._ AUTO ONLY • en ACCIOENr b E. STORCK Attorn oT1/ER THAN eA ACC nuiooNLr. AGG b MIY AUTO 1_ISA >V $ E %CE88NMBRELLA DABILITY OCCUR O CLAl1A9 A44DE �� � eACH OCCVMENCE b AQOREOATE S b b DEOUCTIBLB ; RETENTION S wORKfiRB COMPENSATION ANO U- O E.L. EACH ACOIDEHT b _ BMPLOYERE• UADILIiY NNPROPNETORA'ARTNERIEXECViIVP OFFN:ERAAEr.1BER EXCLV DEDI E.L. OISEABE -FA EMPLOYEE S E.L, 018EA8B- POLIOY LVAR b 11yaa, dsscnT�e under SPECIAL PAOVIS IONS belmv q P °�o�essional Liability PNPKG51522 12/21/2010 12/21/2011 Incident Linlit: 1,000,000 Aggregate Limit: 52,000,000 DESCR P iON OF OPE IONS T L OAT 0119 / V MICLE9 / E 6USIOHS g9DEp BY ENDO EMEIIY SPECIAL P O 10779 a0t-�t?icata f�o�der �s �lama(� as Ac�c�Tt7otTa1 Insure(�per Form C42 S Cll /85) Attached hLlse Fi Fiolastation is included witEt General Liability , $25,000 Eacit Sncident and 550,000 Aggregate his Insurance shall be primary and Non - Contributory but Only in the Event of the Named nsured's Solo Negligence •Except 10 Days Notice of Cancellation for Non- Payment of Premium - SHOULD AtiY OF TH6 ABGVB DHBCRIPED POLICIES BB CANOELLED BEFORB Tr18 CXPIRATION DATB Tt1ERBOF. T 1[B LSBUINO 11re URER PALL ENDEAVOR TO I,IJUL TITe City of Santa Ana n ZtS OPfice rs, Employees, Agents 81 VOl(Iltt @ar5 3i DAY81YAn TRNt10TICB TO THE CERTIFICATE HOLbER NAMCO TO TNC LEP 7, AttlTl Julie Castro = Cardenas BUT FAILURE T061NL SUCH NOTlCB SHALL IraPOaR NO OBLIPATIO}i OA LIABILITY 2Q Ci ViC Canter Plaza OP ANYRIND UPON TNEI 0.BR ITS AGENTS OA PREeENTATNEB. Santa Ana, CA 927Q2 AUTIIOR12eD REPREBBIITA Acot:D 2s laoBiroat FAX: C714)565 -2G02 ®ACORD CORPORATION 1988 POLICY CHANGE DOCUMENT POLICY NO.: PHpK65�522 Phlladalphla Indemnity Insurance Company 21526 Lake Insurance Agency NAMED INSURED Orange County Chlidren's Therapeutic Art Center, [nc MAILINGADORESS 2215 N Broadway Santa Ana, CA 92706 -2663 POLICY PERIOD: FROM 12/21/2010 70 12/21/2011 at 12:01 A.M. Standard Tlme at your mailing address ahowmabovo. CHANGE EFFECTIVE 06/13/2011 CHANGE # 1 DESCRIPTION In consideration of the prernlum reflected, lltie policy Is amended as Indicated below: ADDED: Addltlonal Insured: The City of Santa Ana, Its Officers, Employees, Agents and Volunteers 20 Clvlc Center Plaza Santa Ana CA 92702 As respects the pr•Imary Insured's therapeutic art services under contract with the city .. Form: CG2026 Designated Person or Orgalzatlon Per attached schedule Path ID 5432771 Total Annual AddtUonal/Relurn Premium $ COUNTERSIGNED 0.00 NO CHANGE (Dafe) U'1'1 Total Prorate Addltlonal /Return Premium $ 0.00 NO CHANGE 14.1P7P:Eic"UV€fl 1�i� `r© �'OR1VI LI�STORCK -Insurance Policy Assistant City Attorney (�� (Authorized Representative) Page 1 of i POLICY NUMBER: PHPI< &51522 COMMERCIAL GENERAL LIABILITY CO 20 26 OT 04 TH15 ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR..ORGANIZATION Thls endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE The Clty of Santa Ana, Its Officers, Employees, Agents and Volunteers Secllon II —Who Is An Insured Is emended to In- clude as an additional Insured the persons) or or- ganlzatlo»(s)) shown In the Schedule, but only wllh respect to liability for "bodily InJury ", "property dam- age" or "personal and advartieln� injury" oaused, In whole or In part, by your acts or omissions or the acts or dmisslons of Ehoae acting on your behalf: A. In the performance of your ongoing operallons; or B. In connection with your prernlses owned by or rented fo you. _ APPI�tp'V`�.� A� TO FORM �,� E. STORCK CG 20 26 O'7�Igtan /t City Attorney ©ISO Properties, Inc., 2004 Page 1 of 1 O �- -���o - / � .� -� �. OP ID• PC '`'t,�°.� °' CERTIFICATE OF LIABILITY INSURANCE °ATE(M1 /JOD/YYY`n 02/2A/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH)S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES hOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sj, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If tho co Hl(laate holder is an AookTIONAL INSURED, the pollcy(las) niLlst be elldorsod. if SUBROGATION tS WAIVED, stll)Ject to the terms Rnd cwid ltlons of the policy, cerlaln pollclea may roqulre an endorsomont. A eta lemon[ on this certiticate does not confer rlDhts to the certiticate holder In IIetI of such eETdorso_ntonE s . _ PRODUCER � 82B -4O$ -8031 Chapman 820 -405 -0685 License N0622024 P. O. BOX 6465 Pasadena, CA 91117 -0456 E; T _ /�c � c. Hot: ���)� -- noD :��_, od.ORANG -7 _ INSURB a AFF ORDt7f0 GOVERAQE t1AIC Y II+sURw Orangewood Childron's Foundation 1676 E, 17th Street Santa Ana, CA 92706 IwsuRERn:Non rofits' Insurance AI[lance 10023 HlsuaERa;EVerest National Insurance Co 10120 It1aVRERC,FidelFty &Deposit Co Maryland __ 38305 msufteRO,Oroat American Insurance Co 1G681 1I19URER E $ 20,00 1 SURER F _ $ 1.000,00 COVE RAC3E3 CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSUfiANCE L}STED 6ELOW HAVE BEEN ISSUL'D TO THE INSURED NAMED ABOVE FOR TFiE POLICY PERIOD INOICATEO. NOTVNT HSTANDINO ANY REQUIREMENT, TERtt OR CONDITION OF ANY CONTRACT OR OTHER OOCUA(ENT 1MTH RESPECT TO WHICH THIS CERTIFICATE fJIAY BE ISSUED OR htAY PERTAIN, THE INSURANCE AF FORGED BY THE POLICIES DESC(31BED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUS {DNS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MIRY HAVE BEEN REDUCED BY PA]D CLAIl+IS-� 1 TYPE OF1+19URAHCB POLICY NU BE ME O LIIdIT3 A GENEFIAL UASILITY X COhiME RCIAL GENE RAL LIABILITY CLAIMS MADE � OCCUR X Profesalo Rel LIAb X 201 11 2 7 7 8NP0 03!01111 03!01!12 EACI4 CCCV RRENCE S 1,000,UB ° E�,II�q�F7 Eaa�E a $ GOO,OO MED EXP An one rson $ 20,00 PERSO+LtI d AOV INIURY _ $ 1.000,00 X AOuaB Llanlllty GENERAL AGGii L "GATE $ 3,000,00 OENL AGGREGATE POLICY LIAEIT APPLIkiS PER: P O- LOC PROOVCTS •COM PpP A00 S 3,000.00 $ A AUTOFIOBILE LIAUILITY ANY AUro ALL OWNED AUTOS 6CHE WLEO AVT03 EIIRF.DAVT09 NON -0WNEOAUT09 2 0111 277 8NP0 �` y-� N T_� ^�II �v�Y 03101!11 �] O ��}, 03f01l12 CO!ABINED 911JGLE UREIT (Ee eocldanl) $ 1,000,00 BODILY INJURY (Per pefaon) S BODILY INJURY (Per OtUdonl) S PROPERTY OMIAOE -- (POfe WdenU S X X U /BBRELLA LIAB Excess LlAB OCCUR CLAIt.i S'LUDI' S.� `�ISA �'• psslstant Ctty R(j {` AttoxneY // �/ EACH CCCVRRENCE 3 _ AGGREGATE _ s _ _ DEDUCTIBLE RETEMION S $ S B \YORI(Efta COh1PENSA710N AIEOEMPLOYERS•LlABILI7Y yRf AN1 'PROPN£TOR/PARTNERIEXECUTIVE� OFFl CC-rVME7.IBER EXCLUDED? (tfmdalory In NH) If yes desMhe uMer DESCRIPTION OF OPERATIONS boiorr E17A 0000001013111 03 /01/11 03/01712 'C STA V- EA. etCH ACCIDENT $ 1,000,00 E.L. DISEASE -EA EMPLOYE $ 1,000,00 E.L. Dt9EASE - POLICY LI7.11T $ 1,000,00 C p CrlR10 Covora9u Proporly Covora£le CCP00818e8e6 PAC7676S480b 02/01!11 03lofl1l 02lOiN2 03101/12 Blk! Cont 66a,00 Empt Dlah 600,00 DESCRIPRON OF OPERATIONS/ LOCATIDN3! VENICLE9 (Allath ACORO 101, Addlllonal Re,narko bchedulo, 11 mono apace Is required) Tlio Clty of Santa Arta, It's of(Icers empptoyoes, aDelTte, voluliteera and rep reaentalives aro Hamad as an dddillonal lnaured as resPecta uabmty arlslnD from the oporatlona of the named lnaured per the attached CG 2028 endorsement. Workers compensation coveraDe ezciuded, oVldenco only. L:bK I11'IGAI t IYVLV tit vNIViCI -LH 1I�IV _ CITYSAN SHOULD ANY OP THE ABOVE DE3C RIBEO pOLIC l68 BE CANCELLED BEPORE THE EXPIRATION PATE THEREOF, NOTICE WILL BE OE LIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROV)S[O N8. 20 Civic Celttar Plaza - Santa Ana, CA 92701 AUT KORI2ED REPRESENTATNE � 1988 -2000 ACORD CORPORATION. All rinlTta reserved. ACORD 26 (2009/00) The ACORD namo and l00o are reDlatered marks of ACORD POLICY NUMBER: 201 1 1 27 78NP0 COMMERCIAL t3ENERAL LIABILITY CO 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ lT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COtv1MERCIAL GENERAL LIABILITY COVERAGE PART SCH6DULH Name Of Additional In Any person or organization that you are required to add as an additional insured on ihis policy, t.in<ler� a wriften contract or agreerrteitt ctirrenfly In effect, or becoming effective during the term of this polEcy, and for which a certificate of Insurance namtrtg such person or organization as add[Elonal inscrred has been Issued, but only with respect to ihelr liability arising Dirt of their requirements for certain perform- ance pierced upon you, as a nonprofit organization, in consideration for funding or financial contribtt- tions yott receive from them. The additional insured status will not bo affordod with respect to liability arisfny out of or relatod to your activities as a real estate manager for that person or organization. The Cily of Santa Ana, it's ofticers, employees, agents, volunteers and representatives Section II — Wito Is An Insured Is amended to In- clude as an additional Insured the persons) or organi- zations) shown in the Schedule, but only wllh respect to Ifabidty for "bodily Injury", "property damage" or "personal and advertising injury" caused, in whole or In part, by your aots or pinlsslons or tits acts or omis- sions of those acting on your behalf: A. In tits perforntartce of your ongoing operations; or B. In connection with your premises owned by or rented to you. �O r �� QUO � ����o ���i�ey .� � �\5 a��G��y PS���� CD 20 28 07 Ora ®ISO Properties, Inc., 2004 - Page 7 of 1 D