HomeMy WebLinkAboutSALVATION ARMY OF ORANGE COUNTY, THECity of Santa Ana
k -fit Clerk of the Council
AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement and all
amendments (if any) are no longer in effect.
Note: If your agreement is grant related, please ensure that all grant retention requirements
have been satisfied prior to signing the termination form.
Is the agreement(s) a permanent record? Yes N>C
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with
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7314 E4",f 31 PH 2: CO
No. N-2019-205 was completed on and final payment has been made.
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Date:�� �ZI
Revised: 10-18-16
w,SURANCE ON FILE N-2019-205
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UN NIL INSURANCE EXPIRES
\Nc CITY OF SANTA ANA
�p CLERK OlF`COUNCILL RENTAL ASSISTANCE PROGRAM
r^ DATE: OCT 11 2919 PARTNERSHIP AGREEMENT
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THIS PARTNERSHIP AGREEMENT is made and entered into on this 1st day of October ,
O wM 2019, by and between The Salvation Army of Orange County, ("Partner'T 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 Home 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.
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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 furnish 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.
7. 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 terms 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,
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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 shalt 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, termination 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,
subject 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 further 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,
pen -nits, 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
N1on
Captain Nesan Kistan
Divisional Secretary Orange County
The Salvation Army of Orange County
10200 Pioneer Road
Tustin, CA 92782
Fax: (714) 832-2361
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.
�► I ���3di�lid
aisy Gomez
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City
By:
Rya
Assi
RECOMMENDED FOR APPROVAL:
Sten&"
Executive Directo
Community Development Agency
CITY OF SANTA ANA
Kristine Ridge
City Manager
PARTNER:
Captain Nesan Kistan; Divisional Secretary
The Salvation Army of Orange County
Tax ID# 94-1156347
Page 8 of 8
EXHIBIT A
041610 pla el:i7
City of Santa Ana Rental Assistance Program Scope of Work
Program Year 2019-20 (October 1, 2019 - June 30, 2020)
Name of Organization The Salvation Army 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.
80 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
35
35
10
80
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
asp,
6CATHOLIC �
C;HA1L1TIES °
Of ORANGE COUNTY ,
NOAH WY --
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.
Objectives
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, Safety 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. 16`h 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 o rarm 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 fiends 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.
IM
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IJCATHOLIC '
CHARITIES
Or ORANGE COUNTY
Safely Home 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 June 30, 2020. The Agreement
includes a program 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 Eligibility & 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 201
FY 2019 FM R 1 $1,415 $1,632 $2,037 $2,862
*agreement between tenant and Landlord. Acceptable documentation of the agreement will be deterr
third party verification by a nonprofit agency in cases where there is an oral lease or domestic violence.
$3,304
by TSA or CCOC and may
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CATHOLIC i
CHARITIES
Or ORANGE COUNTY
P.,[AM A"
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 tollowinQ Area Median Income (AMI) Limits:
100
f�)(_ THOLIC
CHARITIES
or OMNO eooNrsv
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 Emer¢ency 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)
OWN
6 CATHOLIC s +
CHARITIES
OF ORANGE COUNTY a
ParbA Mnirtry __. _ . -
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.
Requirements:
Please bring ALL of the following items with you to expedite the assistance Process
(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 SSI/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.
CATHOLICOVA'!
CHARITIES
OF ORANGECCAIMY
Vx,hh NM4fry
Safely Home in Santa Ana
Eviction Prevention Program
Application (Page 1 of 2)
Name: Date:
Address:
City: Santa Ana
Phone:
State: CA Zip:
Email:
Total individuals in the household: Veterans in the household:
Adults: Seniors (62+): Children (over IS): 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
(I£ 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:
❑ Wages/Salaries ❑ Gen. Relief
❑ Unemployment ❑ Calworks
❑ Other Income:
(including benefits/aid)
❑ SSI/SSDI ❑ Child Support ❑ V.A./Retirement
❑ IHSS ❑ CalFresh/Food Stamps
Monthly Rent: ❑ Section 8
CATHOLIC r
CHARITIES
Or ORANGE COUNTY
parirhMinbtry •..-..�...
Safely Home in Santa Ana
Eviction Prevention Program
Application (Page 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 Only:
• Unable to Assist:
❑ Do not qualify ❑ No Funds available ❑ Already received assistance in the past
Ej Do not have all required documentations
• Referred to/Notes:
+nN rtAIiRT 1OCRAN4EG[h"
Safely Horne 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:
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 of0000, which excludes deposit fees, late
fees, or other applicable fees.
You received a partial payment of $000'Q from the client on
of the above
to
from T[te �1,41V Lion„
rforthe purpose of
assisting the client with the completion of their rental payment for Ajdgb�W1 AdgUstl31 �2019r
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 TQf athalie Garstiesis 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 TSAR, athatic Charriiesz
The check for $QO,OQ will be made payable to:
following address:
and mailed to the
. It will be
received by you from The Salvation -Army / Catholic;Gharifiies 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
(D� '
)CATHOLIC
CHARITIES,
oroan cecau»n
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
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
2. Name: $ Month
❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income
3. Na
$ 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-Arnflog n-Irvine, CA HUD Metro FMR Area, so all information presented here applies
to all of the Santa Ana -Anaheim -Irvine, 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 donations for the Santa Ana -Anaheim -Irvine, CA HUD
Metro FMR. Area.
The Santa Ana-Anaheim-Irvia¢, CA HUD Metro FMR Area contains the following areas: Orange County, CA;
EXHIBIT B
PROGRAM BUDGET
PROGRAM YEAR 2019-2020
PROGRAM BUDGET
Organization Name The Salvation Army of Orange County
Program Name Safely Home in Santa Ana
EXPENDITURES
Enter budget categories and projected expenditures for the proposed program:
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%1
$5,000
$5,000
TOTAL BUDGET 1
$50,0001
$50,000
PROGRAM RESOURCES
FUNDING SOURCE
City of Santa Ana
$
50,000
V�
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
The Salvation Army 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
Un aid/Unex ected 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?
J�
°a E
LL —
EXHIBIT D
SAMPLE REQUEST FOR SECOND DISBURSEMENT
City of Santa Ana
Request for 2nd Disbursement
Safely Home in Santa Ana Eviction Prevention Program
Organization: The Salvation Army of Orange County
Program Name: Safely Home in Santa Ana
Mailing Address for Check:
a ance
Available
Prior to 2nd
Total
Disbursement
2nd
Amount
Initial
Request
Disbursement
Budget Category
Approved
Disbursement
($7,500 cr 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
1 10/1 /2019
Totals
1 $ 93,739.00
1 $ 25,000.00
1 $ -
$ 25,000.00
I certify that the Information provided an 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
l Page 1 of 2
AC"COR,C?°b CERTIFICATE OF LIABILITY INSURANCE DATE 03DDNYY1
/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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) 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 CONTACT
.:CAME _ _ _
Willie Towers Watson Insurance Services west, Inc. fka Willie HONE 1-877 945 7378 N 1-B88-967-2378
Insurance Services of California, Inc. p�lLg�E
c/o 26 Century Blvd p OREgS�. certificates@willis oom
P.O, Box 305191 INSURERS AFFORDING COVERAGE NAICq
Nashville, TH 372305191 USA--`---"___La"""`J AF" "
INaURFRA• Lexington insurance Company 19437
INSURED
The Salvation Army - Division 11
30840 Hawthorne Blvd., Bldg D
Rancho Palos Verdes, CA 90275
OVERAGES
Greenwich Insurance Company _ 22322
XL Specialty Insurance Company 37885
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,
(NSR-.__...._ ...�_....._._... _..,..�„:....._.:_ A $T1DR _.:"�.-.�®.-._.�_______.__ FOTI. CY. EFF. '�SCfCV�YV..
�.WPEOFINSURANCEjNqD WVQF_ POUCYKUMBER IMM DO)YYYY1 IMMIDD LIMRB .�»..
X
COMMERCIAL GENERAL LIABILITY
-
EACH OCCURRENCE
$,, 2,000,000
'D%'hTATiE'Pil`REN7E6-""
_._
CLAIMS -MADE ]OCCUR
eff-i9J,�,asHigc0yrlatlae—
$ 1,000,000
A
)C
SIR: 4500,000 Pei Occurrence
_—_
MED EXPJAAn one personI __.$,
0
Y
027712409
10/01/2019
10/01/2020
PERSONAL2,000,000
GtNjjjt
AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
$ 4,000,000
Y--
ORGY) JECOT L^_,. LOC
PRODUCTS- COMPIOP AGO
4,000,000
$-
gT�iEIR;
$
AUTOMOBILE
LIABILITY
M Ila-loAgnot- NED SINGLELMIT
_
g 5, 000,OW
X
ANYAUTO
BODILY INJURY (Per Person):
$
H
OWNED ACIIEOULED
AUTOS ONLY AUTOS
Y
RA05000219-09
10/01/2019
10/01/2020
BODILY INJURY(Peraccidenl)
-
$
_
___
HIRED NON -OWNED
PROPERfY DAMAGE
_
_
AUTOS ONLY AUTOS ONLY
[_j
$
UMBRELLA LIAR OCCUR
EACHOCCURRENCE_.^
_
$
EXCESS LIAB c. sans-nennc
arnoc111 a
e
AND EMPLOYERS' LIABILITY AYIN
C NYPROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? NIA Y RWD5000217-09
(Mandatore In RID El
L EACH ACCIDENT $ 4 +,wu,
L, DISEASE -EA EMPLOYEE_ $_ 1,000,
L. DISEASE POLICY LIMIT $ 1,000,
C Excess Workers Compensation Y RM500021609 X110/01/2019 10/01/2020 E.L, Each Accident $1,000,000
and
EPerStatuteE.L, Diaeaee oiability Tel
Ea OL
WC - Eel $1,000,000
DESCRIPTION OF OPERATIONS l LOCATIONS I VEHICLES (ACOR0101, Additional R4marks Sch.dul., may b. attochod it more spec. W unielred)
Division N11-148
Workers Compensation:
Policy No. RWD5000217-09 provides coverage in the following states: HI,ID,MT,NM,NV,TX,DT
Policy No. RWE500021609 provides coverage in the following statesi AZ,CO,OR
SEE ATTACHED
ByRisk MANACI6NIENTDiVISION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
0 019 ACCORDANCE WITH THE POLICY PROVISIONS.
City of Santa Ana ^------ - -
Risk Management Division I AUTHORIZED REPRESENTATIVE
20 Civic Canter Plaza -RA I VILl ,AREAL
Banta Ana, CA 92702 IiIR Y viliL
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
ss xo: 18625509 un'rcn: 1395017
AGENCY CUSTOMER ID:
LOC #:
A O ADDITIONAL REMARKS SCHEDULE
Page 2 Of 2
AGENCY
NAMEOINSURED
The Salvation Arn, - Division 11
30840 Hawthorne Blvd., Bldg D
Rancho Palo. Verdes, CA 90275
POLICY NUMBER
See Page 1
CARRIER
NAIL CODE
See Page 1
800 Page 1
EFFECTIVE DATE: See Page I
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 2S FORM TITLE: Certificate of Liability Insurance
Policy No. RWR3000944-04 provides coverage in the following states:AX
Policy No. RWE500047504 provides coverage in the following states: CA
CA -Work. Comp is fully Self Insured per the attached State Certificate and CA - Auto
is fully Self Insured per the
attached State Certificate
City of Santa Ana, its officers, employees, agents, and representatives are included
as an Additional Insured as
respects to General Liability and Auto Liability as required by written contract or agreement. General Liability pulley
shall be Primary and Non -Contributory with any other insurance in force for or which
may be purchased by Additional
Insureds as required by written contract or agreement. Waiver of Subrogation applies
in favor of Additional Insureds
'I with respects to Workers Compensation as permitted by law.
INSURER AFFORDING COVERAGE: XL Specialty Insurance Company
NAICN: 37885
POLICY NUMBER: RWES00047504 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020
SUBROGATION WAIVED: Y
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT;
Excess Workers Compensation E.L. Each Accident 0 000,000
and Employer's Liability E.L. Disease Pol Lim $1,000,000
WC - Per Statute E.L. Disease - Ea Emp $1,000,000
ADDITIONAL REMARKS:-
Workers Compensation is Self Insured,
INSURER AFFORDING COVERAGE: XL Specialty Insurance Company
POLICY NUMBER: RWR3000944-04 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020
ADDITIONAL INSURED: Y
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Workers Compensation & E.L, Each Accident $1,000,000
Employers Liability E.L. Disease Pol Lim $1,000,000
WC - Per Statute E.L. Disease - Ea Emp $1,000,000
INSURER AFFORDING COVERAGE: Greenwich Insurance Company
POLICY NUMBER: RAE5000218-09 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020
ADDITIONAL INSURED: Y
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Auto Liability - CA Any Auto / CSL $5,000,000
REVIEWED & APPROVED
By Risk MIANFlGEMENT DivisiON
T 0 3 19
ACORD 101 (2008101) na IT A,QNEA �„ I� ��S}'2008ACORD
The ACORD name BIt ego are reg s Gre mar s O ACORD
SR ID: 18625509 HATCH: 1395017 CURT: W13279389
NAIL#: 37BB5
NAICN: 22322
DEPARTMENT OF MOTOR VEHICLES
P. O. BOX 942994
SACRAMENTO, CA 94204-0604
(910) 667-6620
August 13, 2019
S.I. # 202
The Salvation Army
36840 Hawthorne Boulevard
Rancho Palos Verde, California 90276
Attention: Ms. Doris Hall
Dear Salvation -Army,
Your, annual report/financial statements have been reviewed and the requirements
for renewal of ,your self-insurance certificate have been met. Your self-insurance
status is valid from August 19, 2019, through August 18, 2020,
Vehicle Code Section 16020 requires that every driver and every owner shall at all
times be able to establish financial responsibility and shall at all times carry in the
vehicle evidence of the form of financial responsibility in effect for the vehicle. A
copy of your Certificate of Self -Insurance or a copy of this letter constitutes written
evidence of financial responsibility and should be placed in each of your affected
vehicles.
If you have any questions or need further information, please call the administrative
staff at (916) 667.6520.
Sincerely,
George Torres, Unit Manager
Financial Responsibility Unit
REVIEWED & APPROVED
By Rlsk M1AMAgEM NT DiVi5i0 v
CT 0 3 2019
F ly i ILLARFAL
DL 126(REV. aoe) - A Pj&lic Semice Agency
This is to certify that;
CERTIFICATE OF SELF-INSURANCE
The -Salvation. .Army.. . .. _.. _.. . ._.,
NAME OF FBLMNSUREP
30840 Hawthorne Boulevard, Rancho Palos Verde, California 00275
Awme, ORY, STATE, 4P
has been approved as a Self -Insurer under the California Compulsory Financial Responsibility
Law and assigned Self -Insurance #, 202 pursuant to Section 16053 of the California
Uohfcle Code for the period Auguot 19, 2019 through August 18, 2020
MANAGER
Financial Responsibility Unit
Department of Motor Vehicles
OR 27 (REV 10100) UN
REVIEWED & APPROVED
By Risk MANAGEWNT DivisioN
�YOLCR
FRANCINE R. VILLAREAln
ENDORSEMENT #
This endorsement, effective 12:01 A.M., 10/01/2019
Forms a part of Policy No.: 027712409
Issued to: THE SALVATION ARMY
By: LEXINGTON INSURANCE COMPANY
ADVICE OF CANCELLATION TO ENTITIES OTHER THAN THE NAMED INSURED LIMITED
TO E-MAIL NOTIFICATION
This policy is amended as follows:
In the event that the Insurer cancels this policy for any reason other than non payment of
premium, and
1. The cancellation effective date is prior to this policy's expiration date;
2. The First Named Insured is under an existing contractual obligation to notify a
certificate holder when this policy is canceled (hereinafter, the "Certificate
Holder(s)"); and has provided to the Insurer, either directly or through its broker
of record, the email address of the contact at such entity,
and the Insurer received this information after the First Named Insured receives
notice of cancellation of this policy and at least 60 days prior to this policy's
cancellation effective date, via an electronic spreadsheet that is acceptable to the
Insurer,
the Insurer will provide 30 days advance notice of advice of cancellation (the "Advice") via
e-mail to such Certificate Holders.
Proof of the Insurer emailing the Advice, using the information provided by the First Named
Insured, will serve as proof that the Insurer has fully satisfied its obligations under this
endorsement.
This endorsement does not affect, in any way, coverage provided under this policy or the
cancellation of this policy or the effective date thereof, nor shall this endorsement invest
any rights in any entity not insured under this policy.
The following Definitions apply to this endorsement:
1. First Named Insured means the Named Insured shown on the Declarations Page of
this policy.
2. Insurer means the insurance company shown in the header on the Declarations Page
of this policy.
All other terms, conditions and exclusions shall remain the same.
REVIEWED & APPROVED
BY Risk l49ANAOEMENr DivisioN
Authorized Repro^ a i D 3
Manuscript Form Page 1 of 1R�� I
ENDORSEMENT
This endorsement, effective 12:01 AM 10/01/2019
Forms a part of policy no.: 027712409
Issued to: THE SALVATION ARMY
By: LEXINGTON INSURANCE COMPANY
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
FOR A SPECIFIC PROJECT OR LOCATION
This endorsement modifies insurance provided by the policy:
SCHEDULE
Name of Additional Insured Person(s) or Organization(s)
BLANKET WHERE REQUIRED BY WRITTEN CONTRACT
Specific Contract/Project or Location
A. Section II - Who Is An Insured is amended to include as an additional insured the persons)
or organizatiori(s) shown in the Schedule, but only with respect to liability for "bodily injury",
"property damage" or "personal and advertising injury" caused, In whole or in part, by your acts
or omissions or the acts or omissions of those acting on your behalf:
1, in the performance of your ongoing operations with respect to the Specific
Contract/Project or Location as shown in the Schedule; or
2. in connection with your premises owned by or rented to you,
However:
1. The insurance afforded to such additional insured only applies to the extent permitted
by law; and
2. If coverage provided to the additional insured is required by a contract or agreement,
the insurance afforded to such additional insured will not be broader than that which you
are required by the contract or agreement to provide for such additional insured.
REVIEWED &APPROVED
By Risk Pll+AN4QEmrivr DivisioN
"R32J8-t6--'rncru7ees opyrig fetl Tinformabon of the Insurance Servroes age of-2'—
Offices, Offices, Inc., with its permission. All Rights Reserved,�u
B. With respect to the Insurance afforded to these additional insureds, the following is added to
Section III - Limits Of Insurance
If coverage provided to the additional insured is required by a contract or agreement, the most
we will pay on behalf of the additional insured is the amount of insurance;
1. Required by the contractor agreement; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the
Declarations.
All other terms and conditions of the policy remain the same.
��I! MA,NAGE.MEN1 DiViSION
O T 09 2019
Fti%tVCtPq �. V ' R E-AL
Authorized Representative
a to In or a nghtRes ere eg.,"'e ` ..'oi
vdtli its permission. All Rights Reserved. "
OP WORRSR9 "' COMPMOATiON
TO WHOM IT MAY. CONCERN;
Thiscertifies that Certificate of C6hserit to Self -Insure
No. 566. was issued"by the Director of Industrial Relations
to:
THE SALVATION ARMY
under the: provisions. of Section 3700, Labor Code of
California, on November'15, 19�3. The. Certificate is now
and has been in full force and effective since that date.
Dated. at. Sacramento,. California
This I" day of .February, 2002
4"j, (A�
MAU S. ASH Ma 2
Self Z0suraX�ce lalan�t
Orig: Nancy .Cookson
LAW Offices of
Laughlin, Falco, Levy & Xoresi
P.O, 11ox .492617
Redding, CA 96049-26.17
aC; -:;Jbilij'MciCektll�r- �
Director of Risk Management
The Salvation Army
160-East Ocean Blvd.; 100"71.
Long Eeach, CA 90801-5646
r
REVIEWED & APPROVED
tip. R4 =Q,N'A(Flyl CN7 i" W""ON
0 0
FRANCINE R. VIIV REAL