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CATHOLIC CHARITIES OF ORANGE COUNTY
City of Santa Ana -� Clerk of the Council corc orrice use onq r4 AGREEMENT TERMINATION FORM I Please complete this form in its entirety when the attached agreement and all I amendments (if any) are no longer in effect. — 17DA t" P ?I Pf 12: QO Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination for ;A Is the agreement(s) a permanent record? Yes _ No — Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with �" , �rtt jl (_ ( Nl�1 v 7 7-7n _. _ A 4 No. N-2019-202 was completed on (List all amendments. Use space below if needed.) Revised: 10-18-16 and final payment has been made. Department: l Phone/Exf.: t` Signature: Date: IZ,) /Z1 21 N-2019-202 INSURANCE ON FILE WORK MAY PROCEED UNTIL INSU ANCE EXPIRES �O CLERK 0VCC1JNCIL ® DATEOCT 10 2019 CITY OF SANTA ANA RENTAL ASSISTANCE PROGRAM PARTNERSHIP AGREEMENT THIS PARTNERSHIP AGREEMENT is made and entered into on this 1st day of October , 2019, by and between Catholic Charities of Orange County, ("Partner"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. The City is implementing an eviction prevention program, Safely Dome in Santa Ana, in partnership with The Salvation Army of Orange County and Catholic Charities of Orange County ("Program"). The City will provide eviction prevention assistance to those facing the threat of eviction and homelessness due to a financial crisis. One-time rental assistance sponsored by the City will be available until funds are expended through the two nonprofit partner agencies. B. Partner represents that Partner is able and willing to provide such services to the City as necessary to implement the Program. C. In undertaking the performance of this Agreement, Partner represents that it is knowledgeable in its field and that any services performed by Partner under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Partner shall perform during the term of this Agreement, the tasks and obligations including all labor, materials, and incidental customary work required to fully and adequately complete the services described and set forth in the Scope of Work attached hereto as Exhibit A and incorporated herein by reference. 2. COMPENSATION a. Total funding distributed to Partner for the Program will be $50,000, which includes $5,000 for administrative expenses and $45,000 for rental assistance Program expenses, pursuant to the Program Budget attached herewith as Exhibit B and incorporated herein by reference. b. Activity Reports are due to City from Partner with the request for second disbursement, on March 31, 2020 and July 15, 2020. A sample Quarterly Report is attached herewith as Exhibit C and incorporated herein by reference. Page 1 of 8 c. An initial disbursement of $25,000 will be provided to Partner at the beginning of the Program year. Partner may request the second disbursement of $25,000 when its fund balance is $7,500 or below and the first activity report discussed in the Scope of Work has been completed and approved. A sample Request for Second Disbursement is attached herewith as Exhibit D and incorporated herein by reference. 3. TERM This Agreement shall commence on October 1, 2019, and expire on June 30, 2020, unless terminated earlier in accordance with Section 15, below. The Term of this Agreement may be extended pursuant to a writing executed by the City Manager and City Attorney. 4. INDEPENDENT CONTRACTOR Partner shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Partner performs the services that are the subject matter of this Agreement; however, the services to be provided by Partner shall be provided in a manner consistent with all applicable standards and regulations governing such services. Partner shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. OWNERSHIP OF MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Partner under this Agreement ("Documents & Data"). Partner shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Partner represents and warrants that Partner has the legal right to license any and all Documents & Data. Partner makes no such representation and warranty in regard to Documents & Data which were provided to Partner by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. 6. INSURANCE Prior to undertaking performance of work under this Agreement, Partner shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Partner shall maintain commercial general liability insurance naming the City, its officers, employees, agents, Page 2 of 8 volunteers and representatives as additional insured(s) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Partner's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence, with $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insureds provisions. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non -owned automobiles. c. Worker's Compensation Insurance. In accordance with the provisions of Section 3700 of the Labor Code, Partner, if Partner has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Partner agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. d. If Partner is or employs a licensed professional such as an architect or engineer: Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim with $2,000,000 in the aggregate. e. The following requirements apply to the insurance to be provided by Partner pursuant to this section: i. Partner shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. ii. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. iii. Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. iv. Where the amounts or coverage provided by the certificates of insurance provides coverage greater than those listed by this Agreement, the amounts provided by the certificates of insurance shall be incorporated by reference into the Agreement. V. Partner shall supply City with a fully executed additional insured endorsement. If Partner fails or refuses to produce or maintain the insurance required by this section or fails or refuses to firnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement. Such termination shall not affect Partner's right to be paid for its time and materials expended prior to notification Page 3 of 8 of termination. Partner waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. INDEMNIFICATION Partner agrees to defend, and shall indemnify and hold harmless the City, its officers, agents, employees, contractors, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Partner, its subcontractors, agents, employees, or other persons acting on its behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terns of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Partner further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. Notwithstanding the foregoing, to the extent Partner's services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Partner. 8. INTELLECTUAL PROPERTY INDEMNIFICATION Partner shall defend and indemnify the City, its officers, agents, representatives, and employees against any and all liability, including costs, for infringement of any United States' letters patent, trademark, or copyright infringement, including costs, contained in the work product or documents provided by Partner to the City pursuant to this Agreement. 9. RECORDS Partner shall keep records and invoices in connection with the work to be performed under this Agreement. Partner shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Partner under this Agreement. All such records and invoices shall be clearly identifiable. Partner shall allow a representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Partner shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to Partner under this Agreement. Page 4 of 8 10. CONFIDENTIALITY If Partner receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Partner agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent -of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Partner disclosed in a publicly available source; (c) is in rightful possession of the Partner without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Partner without reference to information disclosed by the City. 11. CONFLICT OF INTEREST CLAUSE Partner covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 12. NON-DISCRIMINATION Partner shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, tennination or other employment related activities. Partner affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 13. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Partner, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Partner. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Partner or the City. 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 is not embodied herein. Page 5 of 8 14. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Partner, Partner may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services that are the subject to this Agreement performed by City personnel or by other partners retained by City. 15. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Partner shall be entitled to receive and the City shall pay Partner compensation for all services performed by Partner prior to receipt of such notice of termination, subj ect to the following conditions: a. As a condition of such payment, the Executive Director may require Partner to deliver to the City all work product(s) completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Partner consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work that fails to meet the standard of performance specified in the Recitals of this Agreement. 16. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. 17. JURISDICTION - VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this.Agreement shall be determined and governed by the laws of the State of California. Both parties farther agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 18. PROFESSIONAL LICENSES Partner shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Partner shall notify the City immediately and in Page 6 of 8 writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 19. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Executive Director, Community Development Agency City of Santa Ana 20 Civic Center Plaza (M- 25) P.O. Box 1988 Santa Ana, California 92702 Fax:(714) 667-2225 To Partner: Teresa "Tita" Smith, LCSW Executive Director Catholic Charities of Orange County 1820 E. 16'' St. Santa Ana, CA, 92701 Fax: (714) 427-4585 A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 20. 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 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 referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. Page 7 of 8 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. t4 4 Daisy Gomez Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: ` Ryan RECOMMENDED FOR APPROVAL: Steven A. Mendoza Executive Director Community Development Agency CITY OF SANTA ANA �44/ Krfs e Ridge City Manager PARTNER: u Executive Director Catholic Charities of Orange County Tax ID# 95-3031389 Page 8 of 8 EXHIBIT A SCOPE OF WORK City of Santa Ana Rental Assistance Program Scope of Work Program Year 2019-20 (October 1, 2019 - June 30, 2020) Name of Organization Catholic Charities of Orange County Name of Funded Program Safely Home in Santa Ana Annual Accomplishment Goal Unduplicated Participants anticipated to be served during the 9-month contract period. 60 TOTAL Schedule of Performance (estimated) Quarter 1: OCT 1 - DEC 31 Quarter 2: JAN 1 - MAR 31 Quarter 3: APR 1 - JUN 30 Unduplicated Participants 20 20 20 60 The Safely Home in Santa Ana program provides eviction prevention assistance to those facing the threat of eviction and homelessness due to a financial crisis. One-time rental assistance sponsored by the City of Santa Ana, is available until funds are expended through two nonprofit partner agencies: The Salvation Army (TSA) of Orange County and Catholic Charities of Orange County. The Safely Home in Santa Ana Eviction Prevention Program Overview included herewith provides specifications for the Program related to: Grant Eligibilityand Criteria; Fiscal Year 2019 Fair Market Rent and Income Limits; Process and Requirements; the Application; Income Verification Affidavit; and, the Landlord Letter. EXHIBIT A y Y ' CATHOLIC 1 CHARITIES Or ORANGE COUNTY , Safely Home in Santa Ana Eviction Prevention Program Program Overview Mission Statement The Mission of the Safely Home in Santa Ana program is to prevent and reduce evictions for low-income residents of Santa Ana. Oblectives 1. Work with two experienced providers to provide eviction prevention rental assistance to residents of Santa Ana. 2. Coordinate effectively with nonprofit legal entities working with residents facing eviction. 3. Monitor the Safely Home in Santa Ana program through required quarterly reporting from the nonprofit providers of eviction prevention rental assistance. Description Realizing that an eviction can set off a cascade of negative consequences in a person's life, the City of Santa Ana is implementing an eviction prevention program, Safely Home in Santa Ana, in partnership with The Salvation Army (TSA) of Orange County and Catholic Charities of Orange County to provide an intervention to stabilize an individual or family in their home. The program is intended to be an emergency grant that is issued to pay rent in response to solving an unexpected crisis. • Catholic Charities of Orange County, Inc. (CCOC), established in 1976 and located at 1820 E. 161h Street, Santa Ana, CA 92701, is the social service agency of the Diocese of Orange and is well known as the Bishop's Charity. They implement programs that uphold the tradition of care to reduce poverty, strengthen families and build healthy communities. CCOC has been providing eviction prevention assistance for 10 years. • The Salvation Army (TSA) of Orange County, located at 1710 W. Edinger Ave., Santa Ana, CA 92704, seeks to holistically aid low-income families and individuals by meeting basic needs, providing financial, emotional and spiritual support and case management services. TSA has been providing eviction prevention assistance for 30 years. Available Funding The City Council of Santa Ana approved $100,000 in general funds at the July 2, 2019 City Council meeting to help residents of Santa Ana in need of rental assistance. Funding will be distributed equally to two experienced nonprofit organizations located in Santa Ana who already administer eviction prevention assistance: The Salvation Army of Orange County and Catholic Charities of Orange County. la &)CX&14,0.L1,C,ES Of lcbc COUNTY ,4hm Safely Horne in Santa Ana Eviction Prevention Program Agreement with the City of Santa Ana The City of Santa Ana will enter into an Agreement with each nonprofit providing eviction prevention rental assistance ("rental assistance") to Santa Ana residents on behalf of the City for a partial year term beginning on October 1, 2019 and ending on Jame 30, 2020. The Agreement includes aprogram scope of work. Funding provided by the City of Santa Ana Total funding distributed to each partner nonprofit for the Safely Home in Santa Ana program will be $50,000, including $5,000 for administrative expenses and $45,000 for program expenses (rental assistance). An initial disbursement of $25,000 will be provided to both TSA and Catholic Charities, respectively, at the beginning of the program year, with a second disbursement of $25,000 after the approval of at least one completed quarterly activity report is submitted to the City by the nonprofit agency. Reporting & Invoicing TSA and Catholic Charities may request the second disbursement of $25,000 when their fund balance is $7,500 or below and at least one activity report has been completed and approved. A second report is due by March 31, 2020, so that the successes and challenges of the program can be reported to City Council in April. If all funds are not expended prior to March 31, a final report is due on July 15, 2020. The second disbursement should be received by the nonprofit partner within 30 days of invoice submission. All reports and invoices should be submitted via email to Mikelle Daily, Community Development Analyst at mdaily@Santa-ana.org. Grant Elijjibilij_Z & Criteria The City of Santa Ana seeks to keep families Safely Home in Santa Ana by providing eviction prevention assistance to those facing the threat of eviction and homelessness due to a financial crisis. One-time rental assistance sponsored by the City of Santa Ana, is available until funds are expended through two nonprofit partner agencies: The Salvation Army of Orange County and Catholic Charities of Orange County. Grant Maximums • Santa Ana households facing eviction are eligible for up to one-month's rent as stated in their lease agreement* up to the Fair Market Rent for their unit size (see FY 2019 Fair Market Rents table for maximums). FY 2019 FMR I $1,415 $1,632 $2,037 $2,862 $3,304 *agreement between tenant and Landlord. Acceptable documentation of the agreement will be determined by TSA or CCOC and may third party verification by a nonprofit agency in cases where there is an oral lease or domestic violence. CATHOLIC CHARITIES OFOIUNGKOONtY P,rhh W.W" Safely Home in Santa Ana Eviction Prevention Program Grant Maximums (cont'd) • Families facing a financial crisis because of an emergency situation or crisis due to 1) unexpected/unpaid medical expense(s), 2) job loss, 3) nonworking vehicle, or 4) forced reduction of income are eligible for rental assistance up to $1,500 based on need. • A Santa Ana household is eligible for rental assistance one-time only through the Safely Home in Santa Ana Eviction Prevention program during the program year (PY): October 1, 2019 through June 30, 2020 • A family/household may NOT apply for eviction prevention through Catholic Charities (CCOC) after receiving a grant from The Salvation Army (TSA) or vice versa. Grant Payment The emergency grant is paid to the Landlord on behalf of the resident by the nonprofit organization. Eligibility Criteria 1. Santa Ana resident 2. Notice of eviction for nonpayment of rent (no other reasons may be listed) or proof of financial crisis due to 1) unexpected/unpaid medical expense(s), 2) job loss, 3) nonworking vehicle, or 4) forced reduction of income. 3. Documentation as required by the nonprofit organization to determine family size, income, proof of address, and payment to Landlord 4. Verification that the family is low-income below 50% AMI (e.g. paystubs, SSI/SSDI, SNAP benefits verification, or Income Verification Affidavit). 5. Household must provide proof that they can pay next month's rent after receiving assistance. 6. Higher priority will be given to individuals who have previously been homeless. income must meet the following Area Median Income (AMI) Limits: CATHOLIC f&) e CHARITIES oraaAhateouNTY Aar&h MWd'y Safely Home in Santa Ana Eviction Prevention Program FY 2019 Income Limits Process and Requirements The following is an explanation of the process and requirements you must meet in order to be a candidate for receiving assistance. You must have ALL the required documents listed for the specific assistance you are requesting in order to be considered a candidate for an in -person interview. Eviction Prevention Emergency Assistance: Qualifications: (Check all that apply) ❑ Have not received rental assistance previously from Catholic Charities or The Salvation Army through the Safely Home in Santa Ana Program. ❑ All prior rent amounts from lease are paid in full (up-to-date) ❑ Notice of Eviction for nonpayment of rent (no other reasons may be listed on the notice) ❑ Proof of financial crisis including: • Unpaid/unexpected medical bills for services rendered within the last 90 days (invoice or receipts) • Verification of job loss (layoff notice, termination notice, EDD benefit) including application for unemployment, if applicable. • Estimate for the cost to repair a nonworking vehicle that became inoperable within the last 30 days • Other proof of a forced reduction in income or loss of income due to various factors including illness, injury, death, incarceration, family emergency, reduction in benefits, or reduction in working hours. ❑ Household must provide proof that they can pay next month's rent after receiving assistance. ❑ Meet income limit requirements (50% AMI) CATHOLIC CHARITIES OF ORANGE COUNTY Paebh Potnl*try - —� Safely Home in Santa Ana Eviction Prevention Program Process: After a preliminary interview, we will contact the Owner/Landlord to confirm your place of residence and rental amount, explain the rental assistance process, and verify the acceptance of a payment or partial payment from our organization. If the Owner/Landlord agrees, he/she must sign our Rental Assistance Agreement letter (once they have received your portion of the rental payment) and complete the W-9 form before payment processing can begin from our organization. This entire process may take up to 7-10 business days. (PERSONALLY IDENTIFIABLE INFORMATION WILL REMAIN CONFIDENTIAL with participating agencies): 1. Picture ID (Head of household — must match name on the lease agreement). 2. Names of all children in the household (if applicable) 3. Current rental lease agreement* including Landlord/Owner's name, phone number, address and email 4. Eviction notice OR proof of financial crisis 5. Proof of all current household income including current paystubs and public benefits (SSI/SSDI, Social Security Retirement, CalFresh, VA benefits General Relief, Child Support, Unemployment, current bank statements, etc.). If deemed acceptable by the nonprofit organization, an Income Verification Affidavit form may be provided as proof of income. 6. Proof of financial crisis or emergency situation (i.e. unexpected auto repairs, unexpected medical bills, job loss or hours decrease (prior and current pay stubs that show change in monthly earned income, pending EDD benefit for SSl/SSDI, etc.) 7. Proof of your portion of rental payment, such as a copy of a personal or cashier's check money order, or a receipt of partial payment from Owner/Landlord (if assistance is not for the entire monthly rent amount). Please complete the attached Application Form *agreement between tenant and Landlord. Acceptable documentation of the agreement will be determined by TSA or CCOC and will include signatures of both parties to the agreement. CATHOLIC CHARITIES 6P ORANGE COUNTY Safely Home in Santa Ana Eviction Prevention Program Application (Pate 1 of 2) Name: Address: City: Santa Ana State: CA Phone: Email: Total individuals in the household: Date: Zip: Veterans in the household: Adults: Seniors (62+): Children (over 18): Children (under 18): How long have you been at this address?: years months Have you received rental assistance through the Safely Home in Santa Ana program before through Catholic Charities or The Salvation Army? ❑ Yes ❑ No (If yes, referrals will be provided. If no, continue completing application) Have you been helped by other agencies/organizations? ❑ Yes ❑ No If yes, which ones? How long ago? What type of assistance? Who referred you to CCOC or TSA? Have you ever been homeless? ❑ Yes ❑ No If yes, when? For how long? Employment/Income: Employment Status: ❑ Employed FT ❑ Employed PT ❑ Unemployed Monthly Household Income: (including benefits/aid) ❑ Wages/Salaries ❑ Gen. Relief ❑ SSI/SSDI ❑ Child Support ❑ V.A./Retirement ❑ Unemployment ❑ Calworlcs ❑ IHSS ❑ CalFresh/Food Stamps ❑ Other Income: Monthly Rent: ❑ Section 8 � YOry, �l CATHOLIC h; CHARITIES OFORANGECOMY Safely Home in Santa Ana Eviction Prevention Program Application (PaLye 2 of 2) Assistance Request: ❑ Rent (Eviction Prevention) Do you have an eviction (3-day) notice? ❑ Yes ❑ No If no, have you ever received a 3-day notice? ❑ Yes ❑ No If yes, how many times? Emergency' What is your unexpected emergency situation that is preventing you from paying your rent/bills? How will you pay your rent/bills next month? Client's Signature: Date: Consent and Release of Information: By signing this form, I, the applicant(s), certify that all information provided is true and accurate to the best of my knowledge. I authorize the City of Santa Ana (COSA), Catholic Charities of Orange County (CCOC) and The Salvation Army of Orange County (TSA) to share basic household information between themselves, such as my name and date of birth, to prevent duplication of services. I also authorize COSA, CCOC and TSA to make inquiries as necessary to verify the accuracy of the statements made, including, but not limited to, income. I understand that my demographic information (household size, income level, previous homelessness, amount of assistance provided, veterans status) will be shared on a quarterly basis with COSA for reporting purposes, but my name, date of birth, residency status, address, and any other personally identifiable information will not be shared outside of the agencies listed herein. ❑ I give consent for COSA, CCOC and TSA to share basic household information with other Social Service and voluntary organizations participating in client management services in order to coordinate available services. COSA, CCOC and TSA are committed to respecting your privacy and to using the information solely to prevent service duplication between the agencies and to provide appropriate referrals to additional supportive services when required. For Office Use On/y. o Unable to Assist: o Do not qualify ❑ No Funds available ❑ Already received assistance in the past Ei Do not have all required documentations Ei Referred to/Notes: 10 CATROLIC CHARITIES Ot ORANGECOUNW N'44 WA" Safely Home in Santa Ana Eviction Prevention Program Landlord Letter Date Landlord Name Name of Property or Management Co. Address Phone Number Re: Client Name Client Address Dear Landlord or Property Manager: El This letter is to certify that Client Name has a rental agreement with you for the above address. The client's rent was due on DATE in the amount of $00.00, which excludes deposit fees, late fees, or other applicable fees. You received a partial payment of $00.00 from the client on As the Owner/Manager of the above property, I agree to accept $00.00 from The Salvation Army (TSAI of Orange County/Catholic Charities of Orange County for the purpose of assisting the client with the completion of their rental payment for August 1 —August 31, 2019 This rental payment completion allows the tenants to continue in their place of residence for the entire month of August 2019. Date Property Owner/Manager Signature As per Civil Code 1947.3, this letter is an acknowledgement that TSA/Catholic Charities is not currently a tenant of the premises for which the rent payment is being made and the acceptance of the rent payment does not create a new tenancy with TSAICatholic Charities. The check for $00.00 will be made payable to: following address: and mailed to the It will be received by you from The Salvation Army / Catholic Charities within 7 to 10 days of return receipt of this agreement and the signed W-9 by email or fax, and our submission of the check request to our main office. Please ensure the name on the check and rental lease agreement matches the name on the W-9 form for payment to process. Case Manager Name, Title Organization Address Phone, Email Date (T)ATHOLIC CHARITIES Of OMNGEOUN'IY pm'hmih" 0 1; Safely Home in Santa Ana Eviction Prevention Program INCOME VERIFICATION AFFIDAVIT The Income Verification Affidavit: CAN BE USED FOR • For household members who receive cash payment for work, and do not have any proof of income: Example: Day laborers, self employed • For household members who receive money from sources such as family and friends, recycling. • Mandatory use of this form If the applicant is claiming the total household income is $0 CANNOT BE USED FOR • Employed household members who are paid with checks and have paystubs • Household members who receive Social Security, SSI, SSP, public assistance, disability, workers compensation, unemployment, pension, interest, or any other income with documented proof. Please provide the name of the person who is utilizing the income affidavit as proof of income, supply the total amount received, and check the box for proof of income. 1. Name: $ Month ❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income $ Month ❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income 3. Name: $ Month ❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income By signing below, I certify under penalty of perjury under the laws of the State of California that this information is true and correct. Applicant Signature: Date: Orange County, CA is part of the Santa Ana -Anaheim -Irvine, CA HUD Metro FMR Area, which consists of the following counties: Orange County, CA. All information here applies to the entirety of the Santa Ana -Anaheim -Irvine, CA HUD Metro FMR Area. FY 2019 Income Limits Summary Selecting any of the buttons labeled "Explanation" will display detailed calculation steps for each of the various parameters. NOTE; Orange County is part of the Santa Ana -Anaheim -Irvine, CA NUO Metro FMR Area, so all Information presented here applies to all of the Santa Ana-Anaheim-Irvme, CA HUD Metro FMR Area. HUD generally uses the Office of Management and Budget (OMB) area definitions in the calculation of Income limit program parameters. However, to ensure that program parameters do not vary significantly due to area definition changes, HUD has used custom geographic defWtlons for the Santa Ana -Anaheim -Irvine, CA HUD Metro FMR Arco. The Santa Ana-Anaheim-Trvine, CA HUD Metro FMR Area contains the Following areas; Orange County, CA; EXHIBIT B PROGRAM BUDGET PROGRAM YEAR 2019-2020 PROGRAM BUDGET Organization Name Catholic Charities of Orange County Program Name Safely Home in Santa Ana EXPENDITURES Enter budget categories and projected expenditures for the proposed oroeram: Category Expenditures Funded By City of Santa Ana Program Budget Eviction Prevention Assistance $45,000 $45,000 TOTAL Direct Costs $45,000 $45,000 Indirect Costs 10% $5,000 $5,000 TOTAL BUDGET 1 $50,0001 $50,000 PROGRAM RESOURCES FUNDING SOURCE City of Santa Ana $ 50,000 TOTAL $ 50,000 EXHIBIT B EXHIBIT C SAMPLE ACTIVITY REPORT Organization: Program Name: Reporting Contact Name: Reporting Contact Phone: Reporting Contact Email: Quarter Number: Projected Goals: Date Submitted: City of Santa Ana Activity Report Safely Home in Santa Ana Eviction Prevention Program Catholic Charities of Orange County Safely Home in Santa Ana Goals Oct -Dec Jan -Mar Apr -June TOTAL Total # of Santa Ana Client Contacts/Inquiries 0 Total # of Households that received Eviction Prevention Rental Asisstance 0 Total # of Persons Served (including all household members 0 # of Households Assisted due to Eviction Notice 0 # of Households Assisted due to Unpaid/Unexpected Medical Expense 0 # of Households Assisted due to Job Loss 0 # of Households Assisted due to Nonworking Vehicle 0 # of Households Assisted due to Other Forced Reduction in Income 0 # of "New" Clients (have not received any services from TSA/CCOC before 0 Narrative Questions: Describe your progress on meeting contracted goals and expending the funds awarded. Describe any additional accomplishments the program has achieved. What are the biggest challenges you currently face in administering the funded program? What technical assistance, if any, could the City offer to improve the funded program? D � � � E EXHIBIT D SAMPLE REQUEST FOR SECOND DISBURSEMENT City of Santa Ana Request for 2nd Disbursement Safely Home in Santa Ana Eviction Prevention Program Organization: Catholic Charities of Orange County Program Name: Safely Home in Santa Ana Mailing Address for Check: a ante Available Prior to 2nd Total Disbursement 2nd Amount Initial Request Disbursement Budget Category Approved Disbursement ($7,e00 or under) Request Rental Assistance $ 45 000.00 $ 22,500.00 $ 22,500.00 Indirect Cost 10% $ 5,000.00 $ 2,500.00 $ $ 2,500.00 Date 10/1 /2019 Totals $ 93,739.00 1 $ 25,000.00 1 $ - $ 25,000.00 I certify that the information provided on this request is correct and that expenditures reflected hereon are made in accordance with the conditions of the Agreement. I have also attached all backup documents (XXXXX) as necessary to reflect this disbursement. Print Name & Title Vendor Number Agreement Number Invoice Number Date Received AU/AC Approved Date Approved Quarter 1 Certificate of Coverage Date:9/26/2019 Certificate Holder This Certificate is issued as a matter of information only and The Roman Catholic Bishop of Orange confers no rights upon the bolder of this certificate. This certificate 13280 Chapman Ave, does not amend, extend or alter the coverage afforded below. Garden Grove, CA 92840 Compnny Affording Coverage THE CATHOLIC MUTUAL RELIEF SOCIETY OF AMERICA 10843 OLD MILL RD Covered Location Catholic Charities of Orange County OMAHA, NE 68154 1820 E 16TH Street Santa Ana, CA 92701 Coverages This is to certify that the coverages listed below have been issuer] to the certificate holder named above for the certificate indicated, notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate may be issued or may pertain, the coverage afforded described herein is subject to all the terms, exclusions and conditions of such coverage. Limits shown may have been reduced by paid claims. Type of Coverage Certificate Number Coverage Effective Date Coverage Expiration Date Limits Property Real& Personal Properly A General Liability Each Occurrence - 1000000 General Aggregate 2,000,000 �X Occurrence 'PI•oducts-Cnmp/OPAgj" - 9129 7(1/2019 7/1/2020 Personal & Adv Injury - ® Claims Made Fire Damage (Any one lire) Men Exp (Any one person) Esccss l,iebiI ty Each Occurrence Annual Aggregate _ Olher Each Occurrence 700,000 Excess Auto Liability Claims Niadc 9129 7!1/2019 7/1/2020 ___ Annual Aggregate 1 •imit/Cnvcrxge Description of Operations/Locations/Vehieles/Special Items (the following language supersedes any other language in this endorsement or the Certificate in conflict with this harms Coverage only axtentlsfor claims directly arising out of Catholic Charities Rental Assistance Program partnership with the City of Santa Ana commencing on October 1, 2019 and expiring on .June 30, 2020. This coverage is primary and nun -contributory. The City of Santa Ana, its officers, employees, agents, and representatives are named as additional protected except as it pertains to their own active negligence. This coverage is primary and non-contributory. CMRS Excess Liability $700,000 XS $300,000 CMIC Auto Liability. Total Auto Liability $1,000,000. Holder of Certificate Cancellation AP Addi ionat. roteC e (Rson s " � � � i �hould any of the above described coverages be cancelled By Risk MANAgF.MFN7 DMsi �Sefore die date thereof, the issuing exilire tiara company will City of Santa Ana y� p endeavor to and 30 .days written notice to the holder of but failure Risk Management Division 1 V certificate named to the left, to mail such notice shall 20 Civic Center Plaza impose no obligation or liability of any kind upon the company, VFA Santa Ana, CA 92702 NCINC ti VII.J ARE a s ngents or representatives.— AnthorizedRepresentative / � 0821002546 ENDORSEMENT (TO BE ATTACHED TO CERTIFICATE) Effective Date of Endorsement: 10/1/2019: Cancellation Date of Endorsement: 7/l/2020 Certificate Holder: The Roman Catholic Bishop of Orange 13280 Chapman Ave. Garden Grove, CA 92840 Location: Catholic Charities of Orange County 1820 E 16TH Street Santa Ana, CA 92701 Certificate No. 9129 of The Catholic Mutual Relief Society of America is amended as follows: SECTION II -ADDITIONAL PROTECTED PERSON(S) It is understood and agreed that Section II - Liability (only with respect to Coverage D - General Liability), is amended to include as an Additional Protected Person(s) members of the organizations shown in the schedule, but only with respect to their liability for the Protected Person(s) activities or activities they perform on behalf of the Protected Person(s). It is further understood and agreed that coverage extended under this endorsement is limited to and applies only with respect to liability assumed by contract or agreement; and this extension of coverage shall not enlarge the scope of coverage provided under this certificate or increase the limit of liability thereunder. Unless otherwise agreed by contract or agreement, coverage extended under this endorsement to the Additional Protected Person(s) will not precede the effective date of this certificate of coverage endorsement or extend beyond the cancellation date, Schedule - ADDITIONAL PROTECTED PERSON(S) City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Remarks (the following language supersedes any other language in this endorsement or the Certificate in conflict with this language): Coverage only extends for claims directly arising out of Catholic Charities Rental Assistance Program partnership with the City of Santa Ana commencing on October 1, 2019 and expiring on June 30, 2020, This coverage is primary and non-contributory. The City of Santa Ana, its officers, employees, agents, and representatives are named as additional protected except as it pertains to their own active negligence. This coverage is primary and non-contributory. CMRS Excess Liability $700,000 XS $300,000 CMIC Auto Liability. Total Auto Liability $1,000,000. REVIEWED & APPROVED By Disk MANAG2M[NT DiV!Si0N �12AiVI1VE R. VIl..I. AREAL. �'0 t Anghurize/`Reptesentative PKS-122(10-11) CERTIFICATE OF LIABILITY INSURANCE I DATEJAMIODNYYYI 1 09/30/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed, 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 andorsement(s) PRODUCER 402-551-6765 �"',Te C:G,A�rencvIncfa C.M.C. Agency, Inc O���s II 4p2 551 876510843 Old Mill Road 6RCCA, INSURED The Roman Catholic Bishop of Orange 13280 Chapman Ave THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IAAN, ..®..v.,®_...,®.._.®._ ,,..W._,..,_.. A i1R.-...v-_._�.�.;_.. PO C.-aw, P t H% TYPE OFINSURANCB POLICYNUMBER. OD YY MMIDD Y LIMITS COMMERCIAL GENERAL LIABILITY ,mow EACH OCCURRENCE -1 CIAIMS.MADE OCCUR :Pi3F_MISEs trr'q,w lta+Tear S_ .MEO EXP (Any onep roan) $ PERSONAL&AOV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 8 EJECT El POLICY .PRODUCTS -COMPIOP AGG $... ER: a.w q_ $ B AifVTOLIABILITY ✓ ........ d€nMBI DSINGLE 1 1300000 ANYAUTO BODILY INJURY (Per paleon) $ OWNED SCHEDULED W� AUTOS ONLY AUTo5 0313008409-010951 07/01/2019 07/01/2020 BODILY INJURY(P., eccmnnq ,—.__....,.>—.:J._ $ HIRED NON -OWNED Ry-MRW} AAOS AUTOS ONLY AUTOS ONLY �(pr cridantl $ _ Y VMeRELLA LIAS _ OCCUR FW EACH OCCURRENCE $ _ CUIMSLMADE .AGGREGATE OED RETFNTIONS-. $.. WORKERS COMPENSATION _ - PEf OTC ---��' AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOWPARTNENEXECU71VE @TG (TE. �_Fgaf E,L. EACH ACCIDENT. $.. OFFICF.RIMFMBFRCXCLUOFDy NIA _---._._,.-"L --- -- W� (MendnrorylnNHl E.L.DBEASF-EAEM?LOVEE $ Iryyae, Jasmibe under OFp.PERATI " -r-----_ DES RI TIO ONE I ny+ €A.. -DISEASE --POLICY LIMIT $ DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD 101, Addlllanal Renlarks Sfbedalo, maybe allachad lf,varR space is re'.4 0) Coverage is verified for Catholic Charities of Orange County for the term of the certificate, City Oi Santa Ana REVIEWED APPROVED LtF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Risk f Santa Ana DIVi50D gy ry Wq r> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN By Risk IY iANACIE(t'EM D iViSiON ACCORDANCE WITH IHE POLICY PROVISIONS. 20 Civic Center Plaza Santa Ana, CA 92702 0 022 2 1� AIITHORIEfD REPRESENTATIVE iJ L%Fz cii yjp. /�p+nry, Vic. FR/AN4 Nt C2, VILL"ARY-Al-. 01988.2 115 ACORD CORPORATION, All rights reservo ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD RUMAN-5 all HJ! VA (MMIDCERTIFICATE OF LIABILITY INSURANCE D0912612019YI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER 949366.5104 9RWT Patricia Anderson Brakke-Schafnitz Ins. Brokers PHONE 949.366 6104 PAX 949 313 3265 "- License #OK07568 )wc, No Exn __ _ _-In7c� 28202 Cabot Road, Suite 600 ILc pattt anderson9+Sslg Laguna Niguel, CA 92677-1251 p n ss. __.�__.__.�_ " —. _ —,JN..UWLsiAFFOeg. ovE-ggq.F.—.._.__.___._. yalc n — "_ NsuaERg_GuideOne Mutual INSURED Catholic Charties of Orange County 1820 E 16th Street UNg-C----------------""----- Santa Ana, CA 92701 INSURER F: AGO CERTIFICATE NUMBER: REVISION'NUMB THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. II la TYPE OF INSURANCE ADDL SUB POLICY NUMBER PWQ EFF POLICY E%P LIMITS COMMERCIAL GENERAL LIABILITY .._ _ .EACH OC7C(U]RRENCE_- CLAIMS-MADE El OCCUR C'R AEMi$ES-{Ej 4�$41ErC0_NOXII ,_,,... ,,,_.-»-•----••-_,,,_,,.,,., MED EXP.-.1NDY.94 1?afaoni_.,$_.. . __........... F,jt- LAq MrPAT LIMIT APPLES PER: GENERAL AGGR_E9ATE POLICY jE LOC PRODUCTS+COMPIOPAGG ..�..� AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO PdJOLY-INJD (�sr DSl$9$i.,.?_ OWNED SCHEDULED AUTOS ONLY AUUTTOOSWI�Fp 19AX IN JURY eracrdPA __. AUTOS ONLY .._...AUTOS UNLY PA PERQ DAMAS3E J�. "--- . _ UMBRELLA LIAR _ OCCUR 1EAGH QOCIJIj[2FxNG,F�_.____.. §..� EXCESS LIAR .". CLAIMS -MADE DED I RETENTION$ A WORKERS COMPENSAJION PCR - �i OTN— ANDEMPLOYERS'LIABLITY YIN X SSATUTF. 511 ANY PROPRIETORIPARTNERIEXECUTIVE Y 10005295 07/0112019 07/01/2020 tlA 9 1 000,000 pF�FICERIM M EXCLUDED4 NIA E L EAL C, QU N $ ._ Usechord e and ear lEP s,_gg yP,LOyOp 3_-_ 11000,000 Use dss. be under 1 000,000 D (-RIPTigN 4F PPFBAS40NS b9MW E L OISE.ASE-POLICY LIMIT , $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 1Uf, Addltlonal Remarks Sch.d.la, maybe aaa.hed if mare spec. Is r.q.1r.d) Waiver of subrogation WC0403060484 is extended on behalf of City of Santa Ana, its officers,. employees, agents and representatives City of Santa Ana REVIEWED & APP Risk Management II Risk MANAGEMENT 20 Civic Center Plaza Santa Ana, CA 92702 my An nod ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved ad marks of ACORD Named Insured: Catholic Charities of Orange County Policy Number: 10005295 Corporate Id: WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees Person or Organization while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on such remuneration. Schedule Job Description City of Santa Ana, its officers, employees, agents and representatives Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 REVIEWED & APPROVED By Risk MANAgFMENT iiiviSION WC0403060484 p ,�1- °.o-,....> Page 1 of 1 FRANCINE R. VILLAREAL