HomeMy WebLinkAboutSTATE OF CALIFORNIA DEPARTMENT OF REHABILITATIONINSURANCE NOT REQUIRED Return FULLY EXECUTED
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p�N-2021-233
'ktirctval)M CLERK OF COUNCIL
STATE OF CAlIgftNIA- DEPARTMENT OF GENERAL SERVICES
STANDARD AGREEMENT AGREEMENTNUMOER PURCHASINGAUTHORrYNUMBEROfAppllcabie)
SID 213 (Rev.03/2019) 1 31300
vCONTRACTING AGENCY NAME
c�Department of Rehabilitation
CONTRACTOR NAME
=City of Santa Ana
2. The term of this Agreement is:
START DATE
July 1, 2019
r.WUUn tNU UAI e
June 30, 2020
3.The maximum amount of this Agreement is:
$7,397.16
4. The parties agree to comply with the terms and conditions of the following exhibits, which are by this reference made a part of the Agreement.
EXHIBITS
TITLE
PAGES
Exhibit A
Scope of Work
1
Exhibit B
Budget Detail and Payment Provisions
2
Attachment 1
Budget Detail/Operating Cost
1
Exhibit C-
General Terms and Conditions 4-2017
Exhibit D
Special Terms and Conditions
7
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IN WITNESS WHEREOF, THISAGREEMENT HAS BEENEXECUTEDBYTHEPARTIESHERETO.
CONTRACTOR
CONTRACTOR NAME (if other than an individual, state whether a corporation, partnership, etc.)
City of Santa Ana
CONTRACTOR BUSINESS ADDRESS CITY STATE ZIP
20 Civic Center Plaza, M-13, P.O. Box 1964 Santa Ana CA 92702
PRINTED NAME OF PERSON SIGNING TITLE
Kristine Ridge City Manager
Approved as to form:
QeL—
Ryair; O.lHodge
Assistant City Attorney
DATE SIGNED
//12?1�/
RECOMMENDED FOR APPROVAL
Steven A. Mendoza
Community Development Executive Director
ATTEST:
'
By: aY,
1-f Daisy Gomez, MMC City Clerk
//" Clerk of the Council
Page 1 of 2
STATE OF CALIFORNIA - DEPARTMENT OF GENERAL SERVICES
STANDARD AGREEMENT AGREEMENTNUMBER
STD 213 (Rev.03/2019) 31300
STATE OF CALIFORNIA
CONTRACTING AGENCY NAME
Department if Rehabilitation
PURCHASING AUTHORITY NUMBER (If Applicable)
CONTRACTING AGENCY ADDRESS
CITY
STATE
ZIP
721 Capitol Mall, 6th Floor
Sacramento
CA
95814
PRINTED NAME OF PERSON SIGNING
TITLE
Julie Sanchez
Asst. Chief, Contracts & Procurement Section
CONTRACTING AGENCY AUTHORIZED SIGNATURE
DATE SIGNED
Julie Sanchez Digitally signed by Julie Sanchez
Date: 2021.12.2214.40:21 -08'00'
12/22/2021
CALIFORNIA DEPARTMENT OF GENERAL SERVICES APPROVAL
EXEMPTION (If Applicable)
per SCM Vol 1 4.04A2
Page 2 of 2
STATE OF CALIFORNIAAEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7)
STD 204 (Rev. 512018)
INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state
1
agency (departmentloffiice) address shown in Box 6. Prompt return of this fully completed form will prevent delays when
processing payments.
Information provided in this form will be used by California state agencies to prepare Information Returns (Form1099). See next
a for more information and Privacy Statement.
NOTE: Governmental entities, i.e. federal, state, and lo_c �nciuding school districts), are not required to submit this form.
BUSINESS NAME (AssMwn on yourhimme toe/alum)
2
SOLE PROPRIETOR, SINGLE MEMBER LLC, INDIVIDUAL (Name as shown on 85NmInM Last First, Ml
E-MAIL ADDRESS
MAILING ADDRESS
BUSINESS ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
3
ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):
NOTE:
PAYEE
PARTNERSHIP CORPORATION•
Payment will not
be processed
ENTITY
ESTATE OR TRUST Q MEDI L (e.g., dentistry, psychotherapy, chiropractic, etc.)
without an
TYPE
\ X Q AL (e.g., attorneyservices)
accompanying
YY
EXEMPT (nonprofit)
taxpayer
identification
CHECK
O ALLOTHERS
number.
ONE BOX
ONLY
ER SSN OR ITIN:
Z,OR
SOLE PROPRIETOR, INDIVIDSocial Security Number (SSN)orindividua( Taxpayerldenbficatlon
SINGLE MEMBER LLC (Dis ity) Number are required by authority of California Revenue and
Tax Code sections 18646 and 18661)
4
T- Qualified to do business in California or maintains a permanent place of business in California.
CALI/RNIAN7
�CALISIDENT( seenextpage for moreInformation)- Payments to nonresidents for services may be subject
PAYEE
to stathholdingRESIDENC
Oormed In CalforniaSTATUS
Oe Tax Board waiver of state withholding attached.
1 here certify under penalty of perjury that the information provided on this document is true and correct.
5
Sho d my residency status change, I will promptly notify the state agency below.
T—RIZED PAYEE REPRESENTATIVE'S NAME (Type or Print)
TITLE
TELEPHONE (include area code)
SIGNATURE
DATE
E-MAILADDRESS
Please return completed form to:
6
DEPARTMENT/OFFICE
UNIT/SECTION
MAILING ADDRESS
TELEPHONE (include area code)
FAX
CITY
STATE
ZIPCODE
E-MAILADDRESS
STATE OF CALIFORNIA-DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7)
STD 204 (Rev, e/2018)
Requirement to Complete the Payee Data Record, STD 204
7
A completed Payee Data Record, STD 204 form, is required for all payees (non -governmental entities or individuals) entering into
a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on
file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.
Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the
STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup
withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and
the California Revenue and Taxation Code (R&TC).
Enter the payee's legal business name. The name must match the name on the payee's tax return as filed with the federal
2
Internal Revenue Service. Sole proprietorships and single member limited liability companies (LLCs) must also include the
owner's full name. An individual must list his/her full name as shown on the SSN or as entered on the W-7 form for ITIN.
The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the
address of the business' physical location,
Check only one box that corresponds to the payee business type. Corporations must check the box that identifies the type of
corporation.
The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state
provide their Taxpayer Identification Number (TIN). The TIN is required by the RUC sections 18646 and 16661 to facilitate tax
compliance enforcement activities and the preparation of Form 1099 and other Information returns as required by the IRC section
6109(a) and RUC section 18662 and its regulations.
Payees must provide one of the following TINs on this form: social security number (SSN), individual taxpayer identification
number (ITIN), or federal employer identification number (FEIN). The TIN for sole proprietorships, single member LLC
(disregarded entities), and Individuals is the SSN or ITIN. Only partnerships, estates, trusts, corporations, and LLCs (taxed as
partnerships or corportations) will enter their FEIN.
Are you a California resident or nonresident?
Q
A corporation will be defined as a "resident" if it has a permanent place of business In California or is qualified through the
Secretary of State to do business in California.
A partnership is considered a resident partnership If it has a permanent place of business in California. An estate is a resident if
the decedent was a California resident at time of death. A trust is a resident if at least one trustee is a California resident.
For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or
transitory purpose and any individual domiciled In California who is absent for a temporary or transitory purpose. Generally, an
Individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident.
However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.
Payments to all nonresidents may be subject to withholding. Nonresident payees performing services in California or receiving
rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments
withheld for state income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the
calendar year.
For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:
Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@flb.ca.gov
For hearing impaired with TOO, call: 1-800-822-6268 Website: mniti .ca oov
5
Provide the name, title, email address, signature, and telephone number of the individual completing this form. Provide the date
the form was completed.
6
This section must be completed by the state agency requesting the STD 204.
Privacy Statement
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an
individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by
which statutory or other authority such number is solicited, and what uses will be made of it.
It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is
subject to federal backup withholding and state law Imposes noncompliance penalties of up to $20,000.
You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the
business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.
All questions should be referred to the requesting state agency listed on the bottom front of this form.
CCC 0412017
CERTIFICATION
I, the official named below, CERTIFY UNDER PENALTY OF
PERJURY that I am duly authorized to legally bind the prospective
Contractor to the clause(s) listed below. This certification is made
under the laws of the State of California.
Federal ID
Contractor/Bidder Firm Name (Printed)
Number
City of Santa Ana
95-6000785
By (Authorized Signature)
Printed Name and Title of Person Signing
Kristine Ridge, City Manager
Date Executed
Executed in the County of
1iJlZ,��%r
Orange
CONTRACTOR CERTIFICATION CLAUSES
1. STATEMENT OF COMPLIANCE: Contractor has, unless
exempted, complied with the nondiscrimination program
requirements. (Gov. Code §12990 (a-f) and CCR, Title 2, Section
11102) (Not applicable to public entities.)
2. DRUG -FREE WORKPLACE REQUIREMENTS: Contractor will
comply with the requirements of the Drug -Free Workplace Act of
1990 and will provide a drug -free workplace by taking the following
actions:
a. Publish a statement notifying employees that unlawful
manufacture, distribution, dispensation, possession or use of a
controlled substance is prohibited and specifying actions to be taken
against employees for violations.
b. Establish a Drug -Free Awareness Program to inform employees
about:
1) the dangers of drug abuse in the workplace;
2) the person's or organization's policy of maintaining a drug -free
workplace;
3) any available counseling, rehabilitation and employee assistance
programs; and,
4) penalties that may be imposed upon employees for drug abuse
violations.
c. Every employee who works on the proposed Agreement will:
1) receive a copy of the company's drug -free workplace policy
statement; and,
2) agree to abide by the terms of the company's statement as a
condition of employment on the Agreement.
Failure to comply with these requirements may result in suspension
of payments under the Agreement or termination of the Agreement or
both and Contractor may be ineligible for award of any future State
agreements if the department determines that any of the following
has occurred: the Contractor has made false certification, or violated
the certification by failing to carry out the requirements as noted
above. (Gov. Code §8350 et seq.)
3. NATIONAL LABOR RELATIONS BOARD CERTIFICATION:
Contractor certifies that no more than one (1) final unappealable
finding of contempt of court by a Federal court has been issued
against Contractor within the immediately preceding two-year period
because of Contractor's failure to comply with an order of a Federal
court, which orders Contractor to comply with an order of the National
Labor Relations Board. (Pub. Contract Code §10296) (Not applicable
to public entities.)
4. CONTRACTS FOR LEGAL SERVICES $50,000 OR MORE- PRO
BONO REQUIREMENT: Contractor hereby certifies that Contractor
will comply with the requirements of Section 6072 of the Business
and Professions Code, effective January 1, 2003.
Contractor agrees to make a good faith effort to provide a minimum
number of hours of pro bono legal services during each year of the
contract equal to the lessor of 30 multiplied by the number of full time
attorneys in the firm's offices in the State, with the number of hours
prorated on an actual day basis for any contract period of less than a
full year or 10% of its contract with the State.
Failure to make a good faith effort may be cause for non -renewal of a
state contract for legal services, and may be taken into account when
determining the award of future contracts with the State for legal
services.
5. EXPATRIATE CORPORATIONS: Contractor hereby declares that
it is not an expatriate corporation or subsidiary of an expatriate
corporation within the meaning of Public Contract Code Section
10286 and 10286.1, and is eligible to contract with the State of
California.
6. SWEATFREE CODE OF CONDUCT:
a. All Contractors contracting for the procurement or laundering of
apparel, garments or corresponding accessories, or the procurement
of equipment, materials, or supplies, other than procurement related
to a public works contract, declare under penalty of perjury that no
apparel, garments or corresponding accessories, equipment,
materials, or supplies furnished to the state pursuant to the contract
have been laundered or produced in whole or in part by sweatshop
labor, forced labor, convict labor, indentured labor under penal
sanction, abusive forms of child labor or exploitation of children in
sweatshop labor, or with the benefit of sweatshop labor, forced labor,
convict labor, indentured labor under penal sanction, abusive forms of
child labor or exploitation of children in sweatshop labor. The
contractor further declares under penalty of perjury that they adhere
to the Sweatfree Code of Conduct as set forth on the California
Department of Industrial Relations website located at www.dir.ca.gov,
and Public Contract Code Section 6108.
b. The contractor agrees to cooperate fully in providing reasonable
access to the contractor's records, documents, agents or employees,
or premises if reasonably required by authorized officials of the
contracting agency, the Department of Industrial Relations, or the
Department of Justice to determine the contractor's compliance with
the requirements under paragraph (a).
7. DOMESTIC PARTNERS: For contracts of $100,000 or more,
Contractor certifies that Contractor is in compliance with Public
Contract Code section 10295.3.
8. GENDER IDENTITY: For contracts of $100,000 or more,
Contractor certifies that Contractor is in compliance with Public
Contract Code section 10295.35.
DOING BUSINESS WITH THE STATE OF CALIFORNIA
The following laws apply to persons or entities doing business with
the State of California.
1. CONFLICT OF INTEREST: Contractor needs to be aware of the
following provisions regarding current or former state employees. If
Contractor has any questions on the status of any person rendering
services or involved with the Agreement, the awarding agency must
be contacted immediately for clarification.
Current State Employees (Pub. Contract Code §10410):
1). No officer or employee shall engage in any employment, activity
or enterprise from which the officer or employee receives
compensation or has a financial interest and which is sponsored or
funded by any state agency, unless the employment, activity or
enterprise is required as a condition of regular state employment.
2). No officer or employee shall contract on his or her own behalf as
an independent contractor with any state agency to provide goods or
services.
Former State Employees (Pub. Contract Code §10411):
1). For the two-year period from the date he or she left state
employment, no former state officer or employee may enter into a
contract in which he or she engaged in any of the negotiations,
transactions, planning, arrangements or any part of the decision -
making process relevant to the contract while employed in any
capacity by any state agency.
2). For the twelve-month period from the date he or she left state
employment, no former state officer or employee may enter into a
contract with any state agency if he or she was employed by that
state agency in a policy -making position in the same general subject
area as the proposed contract within the 12-month period prior to his
or her leaving state service.
If Contractor violates any provisions of above paragraphs, such
action by Contractor shall render this Agreement void. (Pub. Contract
Code §10420)
Members of boards and commissions are exempt from this section if
they do not receive payment other than payment of each meeting of
the board or commission, payment for preparatory time and payment
for per diem. (Pub. Contract Code §10430 (e))
2. LABOR CODE/WORKERS' COMPENSATION: Contractor needs
to be aware of the provisions which require every employer to be
insured against liability for Worker's Compensation or to undertake
self-insurance in accordance with the provisions, and Contractor
affirms to comply with such provisions before commencing the
performance of the work of this Agreement. (Labor Code Section
3700)
3. AMERICANS WITH DISABILITIES ACT: Contractor assures the
State that it complies with the Americans with Disabilities Act (ADA)
of 1990, which prohibits discrimination on the basis of disability, as
well as all applicable regulations and guidelines issued pursuant to
the ADA. (42 U.S.C. 12101 et seq.)
4. CONTRACTOR NAME CHANGE: An amendment is required to
change the Contractor's name as listed on this Agreement. Upon
receipt of legal documentation of the name change the State will
process the amendment. Payment of invoices presented with a new
name cannot be paid prior to approval of said amendment.
5. CORPORATE QUALIFICATIONS TO DO BUSINESS IN
CALIFORNIA:
a. When agreements are to be performed in the state by
corporations, the contracting agencies will be verifying that the
contractor is currently qualified to do business in California in order to
ensure that all obligations due to the state are fulfilled.
b. "Doing business" is defined in R&TC Section 23101 as actively
engaging in any transaction for the purpose of financial or pecuniary
gain or profit. Although there are some statutory exceptions to
taxation, rarely will a corporate contractor performing within the state
not be subject to the franchise tax.
c. Both domestic and foreign corporations (those incorporated outside
of California) must be in good standing in order to be qualified to do
business in California. Agencies will determine whether a corporation
is in good standing by calling the Office of the Secretary of State.
6. RESOLUTION: A county, city, district, or other local public body
must provide the State with a copy of a resolution, order, motion, or
ordinance of the local governing body which by law has authority to
enter into an agreement, authorizing execution of the agreement.
7. AIR OR WATER POLLUTION VIOLATION: Under the State laws,
the Contractor shall not be: (1) in violation of any order or resolution
not subject to review promulgated by the State Air Resources Board
or an air pollution control district; (2) subject to cease and desist order
not subject to review issued pursuant to Section 13301 of the Water
Code for violation of waste discharge requirements or discharge
prohibitions; or (3) finally determined to be in violation of provisions of
federal law relating to air or water pollution.
8. PAYEE DATA RECORD FORM STD. 204: This form must be
completed by all contractors that are not another state agency or
other governmental entity.
STATE OF CALIFORNIA-DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in Ileu of IRS W-9 or W-7)
STD 204 (ReV. 512018)
1
INSTRUCTIONS: Type or print the Information. Complete all Information on this form. Sign, date, and retu n to the state
agency (department/office) address shown in Box 6. Prompt return of this fully completed form will pre 6 t delays when
processing payments.
Information provided In this form will be used by California state agencies to prepare Information Rat r s (FOrm1099). See next
page for more information and Privacy Statement.
NOTE: Governmental entities, i.e. federal, state, and local (Including school districts), are not re fired to submit this form.
BUSINESS NAME(Asshmnonyourincomel mmm)
2
SOLE PROPRIETOR, SINGLEMEMBER LLC,INDIVIDUAL pamaosshmnon SSNorITIN)last Flat, Ml
AILADDRESS
MAILING ADDRESS
BUSINESS AD ESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIPCODE
3
ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): /
NOTE:
PAYEE
❑ PARTNERSHIP CORPORATION:
Payment will not
be processed
ENTITY
ESTATE OR TRUST O MEDICAL (,g„ dentistry, psychotherapy, cMropmollc, etc.)
withoutan
TYPE
LEGAL
0 (g.., attorney services)
accompanying
taxpayer
CHECK
Q EXEMP (nonprofit)
Q ALL, THEIRS
Identification
number.
ONE BOX
ONLY
ENTER SSN ]TIN:
SOLE PROPRIETOR, INDIVIDUAL, OR Sodal Security Number(SSIV) orindividuet Texpeyerldenfi6cation
SINGLE MEMBER LLC (Disregarded Entity) Number (MIN) ere Mqulmd by eutfrodty of Calltomla Revenue and
Tax Code sections 1S646 and 16661)
❑ CALIFORNIA RESIDENT- Quali/Iobusiness in California or maintains a permanent place of business In California.
CALIFORNIA NON RESIDENT (ge for morn lnhxnaaffon) -Payments to nonresidents for services maybe subject
PAYEE
to state Income tax wilhh0ldlrg.
IRESIDENCN
C7 No services performed in California
STATUS
0 Copy of Franchise Tax Board waiver of slate withholding attached.
1 hereby certify under peya Ity of perjury that the information provided on this document is true and correct.
6
Should my residency st tus change, I will promptly notify the state agency below.
AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print)
TITLE
TELEPHONE (Include area code)
SIGNATURE /,/
DATE
E-MAIL ADDRESS
Please re O rn Completed form to:
6
DEPARTMENTIOFFICE
UNITISECTION
MAILING ADDRESS
TELEPHONE (include area code)
FAX
CITY
STATE
ZIP CODE
EMAIL ADDRESS
STATE OF CALIFORNIA-DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7)
STD 204 (Rev. 6/2018)
Requirement to Complete the Payee Data Record, SYb 204
7
A completed Payee Data Record, STD 204 form, is required for all payees (non -governmental entitles or individuals) entering into
a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on
file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.
Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the
STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup
withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and
the California Revenue and Taxation Code (R&TC). .
Enter the payee's legal business name. The name must match the name on the payee's tax return as fled with the federal
2
Internal Revenue Service. Sole proprietorships and single member limited liability companies (LLCs) must also include the
owner's full name. An individual must list hislher full name as shown on the SSN or as entered on the W-7 form for ITIN.
The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the
address of the business' physical location.
Check only one box that corresponds to the payee business type. Corporations must check the box that Identifies the type of
3
corporation.
The State of California requires that all parties entering Into business transactions that may lead to payment($) from the state
provide their Taxpayer Identification Number (TIN). The TIN is required by the RUG sections 18646 and 18661 to facilitate tax
compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the IRC section
6109(s) and R&TC section 18662 and its regulations.
Payees must provide one of the following TINS on this form: social security number (SSN), individual taxpayer identification
number (ITIN), or federal employer Identification number (FEIN). The TIN for sole proprietorships, single member LLC
(disregarded entities), and individuals is the SSN or ITIN. Only partnerships, estates, trusts, corporations, and LLCs (taxed as
partnerships or corportations) will enter their FEIN,
Are you a California resident or nonresident?
Lr.
A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the
Secretary of State to do business in California.
A partnership is considered a resident partnership if it has a permanent place of business In California. An estate is a resident if
the decedent was a California resident at time of death. A trust is a resident if at least one trustee is a California resident,
For Individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or
transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an
individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident.
However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.
Payments to all nonresidents may be subject to withholding. Nonresident payees performing services In California or receiving
rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments
withheld for state income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the
calendar year.
For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:
Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs,gen@ftb.ca.gov
For hearing impaired with TDD, call: 1-800-822-6268 Website: mmA- ftb.ca.g4_v
5
Provide the name, title, email address, signature, and telephone number of the individual completing this form. Provide the date
the form was completed.
6
This section must be completed by the state agency requesting the STD 204.
Privacy Statement
Section 7(b) of the Privacy Act of 1074 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an
individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by
which statutory or other authority such number is solicited, and what uses will be made of it.
It Is mandatory to furnish the information requested. Federal taw requires that payment for which the requested information is not provided is
subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000.
You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the
business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.
All questions should be referred to the requesting state agency listed on the bottom front of this form.
Contract #31300
EXHIBIT A
SCOPE OF WORK
City of Santa Ana AJCC
1. Introduction
City of Santa Ana AJCC
DOR will participate in the America's Job Centers of America delivery system under
the Workforce Innovation and Opportunity Act (WIOA), the Department of
Rehabilitation (DOR) will financially participate cost shares towards the operating
costs of those America's Job Centers of California in which DOR staff is co -located.
The agreed allocation and payment of the operating costs of the America's Job
Centers of California that Is attributable to DOR are outlined in Exhibit B.
2. Services to Be Provided
DOR agrees to provide vocational rehabilitation services to individuals whom DOR
determines to be eligible for such services, and for whom such services are
necessary and appropriate, consistent with federal and state law.
3. Locations
City of Santa Ana AJCC
20 Civic Center Plaza, M-13
P.O. Box 1964
Santa Ana, CA 92702
4. Contract Administrators
Department of Rehabilitation
Sonia Magana
222 S. Harbor Blvd. #300
Anaheim, CA 92805
Phone: (714) 518-2949
Sonia.Maoana(a)dor.ca.gov
Exhibit A
City of Santa Ana
Deborah Sanchez
20 Civic Center Plaza, M-13
P.O. Box 1964
Santa Ana, CA 92702
Phone: (714) 565-2621
Fax: (714) 647-5414
DSanchez@sante-ana.org
Contract #31300 City of Santa Ana AJCC
EXHIBIT B
ONE STOP AGREEMENT
BUDGET DETAIL AND PAYMENT PROVISIONS
1. Invoicing and Payment
A. For services satisfactorily rendered, and upon receipt and approval of the
involce(s) by the DOR Contract Administrator, the DOR agrees to compensate,
in arrears, the Contractor for actual expenses incurred In accordance with the
rates specified herein (Attachment 1) and hereto attached and made a part of
this Agreement.
B. Invoices shall be submitted, in triplicate, to the DOR no later than thirty (30)
days after the service has been completed or within five (5) business days after
the DOR Contract administrator/designee has requested in writing for the
invoice to be submitted.
C. Submit invoices to: DOR Contract Administrator on page 1.
D. Payment shall be in arrears contingent upon receipt of an approved monthly
Invoice by the DOR Contract Administratorldesignee. The invoice must be
submitted on Contractor's letterhead signed by authorized representative, and
include:
1) A brief description of the work performed.
2) Location(s) of job.
3) The date(s) the work was performed.
4) The applicable rate and total dollar amount.
5) Contract Number
2. Budget Contingency Clause (State Funds)
A. It is mutually agreed that if the Budget Act of the current year and/or any
subsequent years covered under this Agreement does not appropriate sufficient
funds for the program, this Agreement shall be of no further force and effect. In
this event, the State shall have no liability to pay any funds whatsoever to
Contractor or to furnish any other considerations under this Agreement and
Contractor shall not be obligated to perform any provisions of this Agreement.
B. If funding for any fiscal year is reduced or deleted by the Budget Act for
purposes of this program, the State shall have the option to either cancel this
Exhibit B
Contract #31300
City of Santa Ana AJCC
Agreement with no liability occurring to the State, or offer an agreement
amendment to Contractor to reflect the reduced amount,
C. Federal and State funds are time limited; therefore, invoices (service and
certified match) must be submitted as soon as possible, but no later than 60
days after the service month. Final submission of all fiscal year-end invoices is
due no later than November 1st, to allow for payment and draw down prior to the
close out of Federal/State funds.
D. If budgetary funds revert due to failure to submit timely Invoices or failure to
submit a properly prepared invoice, related Federal and State funds will no
longer be available for use which will require the contractor to submit a claim
through the Victims Compensation and Government Claims Board, where
approval to pay is not guaranteed.
3. For Federally Funded Agreements
A. It is mutually understood between the parties that this Agreement may have
been written for the mutual benefit of both parties before ascertaining the
availability of congressional appropriation of funds, to avoid program and fiscal
delays that would occur if the Agreement were executed after that determination
was made.
B. This Agreement is valid and enforceable only if sufficient funds are made
available to the State by the United State Government for the current year
and/or any subsequent year for the purpose of this program. In addition, this
Agreement is subject to any additional restrictions, limitations, or conditions
enacted by Congress or to any statute enacted by Congress that may affect the
provisions, terms, or funding of this Agreement in any manner.
C. The parties mutually agree that if Congress does not appropriate sufficient funds
for the program, this Agreement shall be amended to reflect any reduction in
funds.
4. Prompt Payment Clause
The Department of Rehabilitation is obligated to promptly pay all Invoices
(Government Code Chapter 4.5 commencing with §927). However, invoices must
be properly submitted for prompt processing and payment. Under certain
conditions, the Department of Rehabilitation is required to pay Contractors a late
payment if a correct invoice for services/goods is not paid within 45 calendar days.
The Contractor does not need to request the late payment as the Department of
Rehabilitation will determine and send any late payment to the Contractor.
Exhibit B 2
Contract #31300 City of Santa Ana AJCC
ATTACHMENT
BUDGET DETAIL AND PAYMENT PROVISIONS
City of Santa Ana AJCC
DOR's Shared Cost
1. Operational Expenses:
■ Monthly Amount: $ 616.43
■ Annual Amount $ 7,397.16
Total Amount for
■ Term of Agreement $7,397.16
■ Allocation Method : Rental cost, Utilities and maintenance costs, equipment cost,
Technology to facilitate acess costs and common identified costs
Contract Monthly Amount: $ 616.43
Contract Annual Total: $7,397.16
Total Contract Amount: $7,379.16
Attachment 1 1
Contract #31300 City of Santa Ana AJCC
EXHIBIT D
SPECIAL TERMS AND CONDITIONS
AMERICA'S JOB CENTER OF CALIFORNIA AGREEMENT
Notification
All notices required by either party shall be in writing and sent by email, mail, or
personally delivered to the appropriate address. Mailing addresses may be
changed by written notice.
2. Disputes
A. If Contractor believes that there is a dispute or grievance between Contractor
and the State arising out of or relating to this agreement, Contractor shall first
discuss and attempt to resolve the issue informally with the DOR Contract
Administrator. If the issue cannot be resolved at this level, Contractor shall
follow the following procedures:
B. If the issue cannot be resolved informally with the DOR Contract Administrator,
Contractor shall submit, in writing, a grievance report together with any evidence
to the DOR Contract Administrator's Supervisor. The grievance report must
state the issues in the dispute, the legal authority, or other basis for the
Contractor's position and the remedy sought. Within ten (10) working days of
receipt of the written grievance report from the Contractor, the DOR Supervisor
shall make a determination on the problem, and shall respond in writing to the
Contractor indicating the decision and reasons therefore. Should the Contractor
disagree with the Supervisor's decision, Contractor may appeal to the next level,
following the procedure in "Disputes", paragraph 3, listed below.
C. Contractor must submit a letter of appeal to the Agency Director explaining why
the Supervisor's decision is unacceptable. The letter must include, as an
attachment, copies of the Contractor's original grievance report, evidence
originally submitted, and response from Supervisor. Contractor's letter of
appeal must be submitted within ten (10) working days of the receipt of the
Supervisor's written decision. The Director or designee shall, within twenty (20)
working days of receipt of Contractor's letter of appeal, review the issues raised
and shall render a written decision to the Contractor. The decision of the
Director or designee shall be final.
3. Right to Terminate
A. The State reserves the right to terminate this agreement subject to 30 days
written notice to the Contractor. Contractor may submit a written request to
terminate this agreement only if the State should substantially fail to perform its
responsibilities as provided herein.
Exhibit D
Contract #31300
City of Santa Ana AJCC
B. However, the agreement can be immediately terminated for cause. The term
"for cause" shall mean that the Contractor fails to meet the terms, conditions,
and/or responsibilities of the agreement. In this instance, the agreement
termination shall be effective as of the date indicated on the State's notification
to the Contractor.
C. This agreement may be suspended or cancelled without notice, at the option of
the Contractor, if the Contractor or State's premises or equipment are destroyed
by fire or other catastrophe, or so substantially damaged that it is impractical to
continue service, or in the event the Contractor is unable to render service as a
result of any action by any governmental authority.
4. Basic Insurance Requirements
A. General Provisions Applying to All Policies
1) Coverage Term — Coverage needs be in force for the complete term of the
Agreement. If insurance expires during the term of the Agreement, a new
certificate must be received by the State at least ten (10) days prior to the
expiration of the insurance. Any new insurance must still comply with the
terms of the Agreement.
2) Policy Cancellation of Termination & Notice of Non -Renewal —
Contractor shall provide to the State within five (5) business days following
receipt by contractor a copy of any cancellation or non -renewal of insurance
required by this agreement. In the event contractor fails to keep In effect at
all times the specified insurance coverage, the State may, in addition to any
other remedies it may have, terminate this agreement upon the occurrence
of such event, subject to the provisions of this Agreement.
3) Deductible — Contractor is responsible for any deductible or self -insured
retention contained within their insurance program.
4) Primary Clause — Any required insurance contained in this Agreement shall
be primary, and not excess or contributory, to any other insurance carried by
the State.
5) Insurance Carrier Required Rating — All insurance companies must carry a
rating acceptable to the Department of General Services, Office of Risk and
Insurance Management. If the Contractor is self insured for a portion or all of
its insurance, review of financial information including a letter of credit may
be required.
6) Endorsements — Any required endorsements must be physically attached to
all requested certificates of insurance and not substituted by referring to such
coverage on the certificate of insurance.
Exhibit D 2
Contract #31300
City of Santa Ana AJCC
7) Inadequate Insurance — Inadequate or lack of insurance does not negate
the Contractor's obligations under the Agreement.
B. Insurance Coverage
1) Commercial General Liability -- Contractor shall maintain general liability on
an occurrence form with limits not less than $1,000,000 per occurrence for
bodily injury and property damage liability combined with a $2,000,000
annual policy aggregate. The policy shall include coverage for liabilities
arising out of premises, operations, independent contractors, products,
completed operations, personal & advertising injury, and liability assumed
under an insured Agreement. This insurance shall apply separately to each
insured against whom claim is made or suit is brought subject to the
Contractor's limit of liability. The policy must include:
(Agency/Department Name), The State of California, its officers, agents,
employees and servants as additional insured, but only with respect to work
performed under the Agreement.
Endorsements must be physically attached to all requested
certificates of insurance and not substituted by referring to such
coverage on the certificate of insurance. The endorsement must be
acceptable to the DGS Office of Risk and Insurance Management.
2) Workers Compensation and Employers Liability — Contractor shall maintain
statutory worker's compensation and employer's liability coverage for all its
employees who will be engaged in the performance of the Agreement.
Employer's liability limits of $1,000,000 are required.
The workers' compensation policy shall contain a waiver of
subrogation in favor of the State. The waiver of subrogation
endorsement shall be provided
3) If your business is a Sole Proprietorship and does not employ any other
individual(s), a signed statement on business letterhead stating:
"I certify under penalty of perjury under the laws of the State of California
that I do not employ any person in any manner as to become subject to the
Workers' Compensation laws of California. 1 further certify that the
Department of Rehabilitation will be notified within ninety (90) days of any
changes which results in the business becoming subject to the Workers'
Compensation laws of the State of California" must be on file for this
agreement
Exhibit D
Contract ##31300
5. Confidentiality
City of Santa Ana AJCC
A. Contractor agrees that any report or material created during the performance of
this agreement will not be released to any source except as required by this
agreement or otherwise authorized by DOR.
B. Contractor agrees that any Information obtained in the performance of this
agreement is confidential and shall not be published or open to public inspection
In any manner, except as authorized by DOR.
C. Contractor agrees to maintain the confidentiality of any information concerning
any consumers that the contractor may obtain in the performance of this
agreement and specifically agrees to comply with the provisions applicable to
such information as set forth in 34 Code of Federal Regulations, Section 361.38,
title 9, California code of Regulations, Section 7140 at seq., and the Information
Practices Act of 1977 (California Civil Code Section 1798 at seq.).
D. Contractor agrees to report any security breach or information security incident
involving DOR consumers' personal information to the DOR's Contract
Administrator and the DOR's Information Security Officer. The DOR's
Information Security Officer can be contacted via e-mail at isoinfo c4dor.ca.gov.
E. Security breaches or information security incidents that shall be reported
include, but are not limited to:
1. Inappropriate use or unauthorized disclosure of DOR consumers' persona[
information by the Contractor or the Contractor's assignees. Disclosure
methods include, but are not limited to, electronic, paper, and verbal.
2. Unauthorized access to DOR consumers' personal information. Information
can be held in medium that includes, but is not limited to, electronic and
paper.
3. Loss or theft of information technology (IT) equipment, electronic
devices/media, paper media, or data containing DOR consumers' personal
information. IT equipment and electronic devicestmedia include, but are not
limited to, computers (e.g., laptop and desktop, netbooks, tablets),
smartphones, cell phones, CDs, DVDs, USB flash drives, servers, printers,
peripherals, assistive technology devices (e.g., notetakers, videophones),
and copiers. Data can be held In medium that includes, but is not limited to,
electronic and paper.
F. Contractor agrees to provide annual security and privacy training for all
individuals who have access to personal, confidential, or sensitive information
relating to the performance of this agreement.
Exhibit D 4
Contract #31300
City of Santa Ana AJCC
G. Contractor agrees to obtain and maintain acknowledgements from all individuals
to evidence their understanding of the consequences of violating California
privacy laws and the contractor's information privacy and security policies.
H. For contractors that do not have a security program that includes annual security
and privacy training, a self -training manual is available on the DOR website
under the "Providers" tab in the "Becoming a Service Provider" section under
"Annual Security and Privacy Training for VR Service Providers." The self -
training manual is named "Protecting Privacy in State Government" and can be
downloaded at the following link:
https://www.dor.ca.gov/Home/SecurityandPrivacy.
I. Additional training and awareness tools are available at the California Office of
Information Security (OIS) website and the California Office of Privacy
Protection (COPP) website. The COPP created the self-tralning manual,
Protecting Privacy in State Government" that DOR revised to meet its business
needs.
6. Audit and Review Requirements
General Audit and Review Requirements
A. The Contractor shall submit to the State such reports, accounts, and records
deemed necessary by the State to discharge its obligation under State and
Federal laws and regulations, including the applicable OMB Circulars.
B. Contractor agrees to comply with all laws, regulations, ordinances, and policies
of any governmental unit having jurisdiction over the rehabilitation program with
regards to construction, medicine, health, safety, wages, hours, working
conditions, workers' compensation, licensing and all other activities requiring
compliance. Contractor shall accept financial responsibilities in the event of non-
compliance.
C. Contractor shall provide State's staff access to all Contractor records and
evaluations of individuals referred to the program, with the written consent of the
individual.
D. The State shall have the right to conduct inspections, reviews, and/or audits of
the Contractor to determine whether the services provided and the expenditures
invoiced by the Contractor were in compliance with this agreement and other
applicable federal or state statutes and regulations.
E. Contractor agrees that Department of Rehabilitation, State Controller's Office,
Department of General Services, Bureau of State Audits, Federal Department of
Education Auditors, or their designated representatives shall have the right to
review and to copy any records and supporting documentation pertaining to the
Exhibit D
Contract #31300
City of Santa Ana AJCC
performance of the agreement, including such books, records, accounts,
consumer service records, and other supporting documentation that may be
relevant to the audit or Investigation.
7. Potential Subcontractors
Nothing contained in this Agreement or otherwise, shall create any contractual
relation between the State and any subcontractors, and no subcontract shall relieve
the Contractor of his responsibilities and obligations hereunder. The Contractor
agrees to be as fully responsible to the State for the acts and omissions of its
subcontractors and of persons either directly or indirectly employed by any of them
as it is for the acts and omissions of persons directly employed by the contractor.
The Contractor's obligation to pay its subcontractors is an independent obligation
from the State's obligation to make payments to the Contractor. As a result, the
State shall have no obligation to pay or to enforce the payment of any moneys to
any subcontractor. Contractor shall not subcontract any services under this
Agreement without prior approval of the State.
8. Amendments
In the event that additional services must be performed which was wholly
unanticipated and is not specified in the written Scope of Work, but which in the
opinion of both parties is necessary to the successful accomplishment of the
general scope of work outlined, an amendment to this Agreement is required for
additional money and/or time.
The State has the option to renew the agreement for an additional (1) one-year
period under the same terms and conditions.
9. Licenses and Permits
A. The Contractor shall be an Individual or firm licensed to do business in California
and shall obtain at his/her expense all license(s) and permit(s) required by law
for accomplishing any work required in connection with this Agreement.
B. Contractor shall be located within the State of California, with a business license
from the city/county in which you are headquartered is necessary, however, if
you are a corporation, a copy of your incorporation documents/letter from the
Secretary of State's Office can be submitted.
C. In the event, any license(s) and/or permit(s) expire at any time during the term of
this AGREEMENT, Contractor agrees to provide agency a copy of the renewed
license(s) and/or permit(s) within 30 days following the expiration date. In the
event the Contractor fails to keep in effect at all times all required license(s) and
permit(s), the State may, in addition to any other remedies It may have,
terminate this AGREEMENT upon occurrence of such event.
Exhibit D
Contract #31300 City of Santa Ana AJCC
10. Non Eligible Alien —All Sole Proprietor Contracts:
Contractor shall comply with US Code, Title 8, Section 1621 (a), (b), (c), and (d),
concerning aliens or Immigrants ineligible for State and local public benefits.
11. Debarment, Suspension, Ineligibility and Voluntary Exclusion
Federal and State agencies shall not award assistance to applicants that are
debarred or suspended, or otherwise excluded from or ineligible for participation in
Federal assistance programs under Executive Order 12549, By signing this
Agreement, Contractor certifies that neither it nor its principals or subcontractors
are presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any Federal department
or agency. (Reference website: https.,//www.sam.gov/SAM/).
12. Prohibition on Tax Delinquency
Any Agreement that a state agency enters into after July 1, 2012, is void if the
contract is between a state agency and a contractor, or subcontractor, whose name
appears on either list of the 500 largest tax delinquencies pursuant to Section 7063
or 19195 of the Revenue and Taxation Code. (Public Contract Code Section
10295.4). In accordance with Public Contract Code Section 10295.4, agencies are
required to cancel Agreements with entities that appear on either list.
(Franchise Tax Board) htt s://www.ftb.ca. ov/about-ftb/newsroom/to -500- ast-due-
balances/index.html
(Board of Equalization) https://www.cdtfa.ca.gov/taxes-and-fees/top500.htm
13. False Claim Act
Contractor agrees that it shall promptly notify the State and refer to an appropriate
federal inspector general any credible evidence that a principal, employee, agent,
subcontractor or other person has committed a false claim under the False Claim
Act or has committed a criminal or civil violation of laws pertaining to fraud, conflict
of interest, bribery, gratuity, or similar misconduct involving this Contract.
14. Fraud Awareness Training
The Contractor, its employees or any individuals performing activities related to this
Contract shall review the "Fraud Awareness Overview" no later than 30 days upon
Contract award. The Fraud Awareness Overview maybe viewed at the following
Internet site: htt://indor/directorsofticelchief-de ut -director/audit-services/fraud-
awareness. Hard copy available upon request.
Exhibit D 7