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CAMBODIAN FAMILY, THE 2
AGREEMENT TERMINATION Please complete this form when the attached agreement is no longer in effect. Return form to the Deputy Clerk of the Council (M -30). Call 647 -6520 if you have any questions. ---------------- ---- -, -`-- --- j- ; - - - -- - ------------------------------ -- - - - - -- ------------/-" -- The agreement with l ff4o� �i J� , A- c9003 -1 Ls� com was completed on e (� 2 4 A 1004-00 Department, Signature: Date. City of Santa Ana Revised 4 -16 -87 Clerk of the Council INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPI ES CLERK OF COUNCIL DATE: t,;2--4-C,3 CONSULTANT AGREEMENT A- 2003 -165 C -06A THIS AGREEMENT, made and entered into this _oq::L day of 2003 by and between The Cambodian Family (hereinafter "Consultant'), d t City of � Santa Ana, a municipal corporation organized and existing under the Constitution and laws of the State of California (hereinafter "City "). RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of providing vocational /occupational training, employment strategies, education and supportive services to individuals who reside in the Federal Empowerment Zone. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm in the field. D. The City, through the Santa Ana Empowerment Corporation (SAEC), is the recipient of Empowerment Zone ( "FEZ ") funds from the United States Department of Housing and Urban Development ( "HUD "). E. The City and Consultant have duly executed this Agreement for expenditure of such funds. 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: SCOPE OF SERVICES Consultant shall perform those services as set forth in Exhibit A to this Agreement. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit B. The total sum to be expended under this Agreement, shall not exceed $80,000.00 during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Page 1 of 9 Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on July 1, 2003 and terminate on June 30, 2004, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Executive Director of the Community Development Agency and the City Attorney. 4. INDEPENDENT CONTRACTOR Consultant 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 Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant 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. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, 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 Consultant'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. Consultant shall supply City with a fully executed additional insured endorsement in substantially the form attached hereto as Exhibit F upon execution of this Agreement and shall be approved in form by the City Attorney. 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. Page 2 of 9 c. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant 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, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. d. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (i) Consultant 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 in form by the City Attorney. (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. e. If Consultant 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 effect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, 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 health, and claims for property damage, which may arise from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their 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 Consultant 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 Page 3 of 9 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. 7. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and /or proprietary, Consultant 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 Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 8. CONFLICT OF INTEREST CLAUSE Consultant 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. 9. SOURCE OF FUNDS a. Consultant acknowledges that the FEZ funds being provided by City for Consultant's services are received by City from HUD, and warrants that expenditures of these funds shall comply with the laws, regulations and policies governing the use of said funds as set forth in P.L. 106 -74 (2000), 24 CFR 598.215 and Federal Register, April 16, 1998. b. Consultant has received and read a copy of the City's SUBRECIPIENT Agreement with the Santa Ana Empowerment Corporation and agrees to be bound by all of the terms and conditions of said SUBRECIPIENT Agreement, as set forth in Exhibit C, Acknowledgement of Subrecipient Agreement, attached hereto and by this reference incorporated herein. 10. CONSULTANT CERTIFICATIONS a. Consultant has read and shall comply with any and all restrictions on lobbying as set forth in the Certification Regarding Lobbying, attached hereto as Exhibit D and incorporated herein by reference. Page 4 of 9 b. Consultant shall maintain a drug free workplace as set forth in the Certification regarding Drug Free Workplace Requirements, attached hereto as Exhibit E, and incorporated herein by reference. c. Consultant assures and certifies that it will not use any funds appropriated under this agreement for religious activity or anti - religious activity, or to promote or oppose any political candidate, party and /or belief. d. Consultant assures and certifies that where applicable, classroom training instructors are properly credentialed, and training curriculums comply with State Education Codes. e. Consultant assures and certifies that it is in good standing with the California Secretary of State Franchise Tax Board and Internal Revenue Service. f. Consultant agrees to cooperate with any monitoring, inspection, audit, or investigations of activities related to this agreement as may be scheduled and conducted by the Santa Ana WORK Center of the Santa Ana Empowerment Corporation. g. Consultant agrees to acknowledge the Santa Ana WORK Center and Santa Ana Empowerment Corporation as the source of funds in all oral presentations, written documents, publicity and advertisements regarding any activities that ensue from this agreement. 11. 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 telefacsimile or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M -30) P.O. Box 1988 Santa Ana, CA 92702 -1988 telefacsimile (714) 647 -6956 With courtesy copy to: Santa Ana WORK Center 1000 E. Santa Ana Boulevard, Suite 200 Page 5 of 9 Santa Ana, California 92701 telefacsimile (714) 565 -2602 To Consultant: The Cambodian Family 1111 E. Wakeham Avenue, Suite E Santa Ana, California 92705 Telefacsimile (714) 571 -1974 A party may change its address by giving notice in writing to the other party. Thereafter, any notice, tender, demand, delivery, or other communication shall be addressed and transmitted to the new address. If sent by mail, any notice, tender, demand, delivery, or other 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 telefacsimile, any notice, tender, demand, delivery, or other 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. 12. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, 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 Consultant. 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 Consultant nor 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 are not embodied herein. 13. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant 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 which are the subject to this Agreement performed by City personnel or by other consultants retained by City. Page 6 of 9 14. TERMINATION This Agreement may be terminated upon thirty (30) days written notice by either party. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant 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 Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 15. DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 16. JURISDICTION -VENUE This Agreement and all questions relating to its validity, interpretation, performance, and enforcement shall be governed and construed in accordance with the laws of the State of California. 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. 17. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of her inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. Page 7 of 9 18. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature hereinbelow 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 8 of 9 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and year written below. DATED: ATTEST: PATRICIA E. HEALY, Clerk of the Council DATED: ! IoZS/ D3 RECOMMENDED FOR APPROVAL Joh . Reekstin, Executive Director Community Development Agency CITY OF SANTA Ana, a municipal Corporation of the State of Califomia Ly t 'tea 'rci% � ✓/ -,1�- `� . -� David N. Ream City Manager APPROVED AS TO FORM: i° BEN KAUFMAN, City General Counsel CONTRACTOR: Federal Tax ID: Page 9 of 9- The Cambodian Family FEZ Daisy Wheel Network Program Scope of Work L TERM July 1, 2003 through June 30, 2004 II. PURPOSE The FEZ Daisy Wheel Network Program will provide vocational /occupational training, employment strategies, education, and supportive services to individuals who reside in the Federal Empowerment Zone. III. POPULATION TO BE SERVED The population to be served are Federal Empowerment Zone residents 18 years and older. Eligibility will be determined by age, address, and by Right to Work documentation. IV. PROGRAM DESIGN, ELEMENTS, AND OUTCOMES FOR THE CAMBODIAN FAMILY A. Program Design: a. Provide an intake assessment (for screening) of each FEZ resident that includes a review of academic and occupational skills levels as well as service needs; b. Develop an Individual Service Plan including notifying achievement objectives. B. Program Elements: a. The following program elements will be made available to eligible residents expected to enroll in the FEZ Daisy Wheel Network Program for participation in activities aimed at providing a comprehensive strategy that addresses employment and training needs: i. vocational/occupational training, ii. employment strategies, iii. education, and iv. supportive services C. Performance Outcomes a. 90 will be served b. Of the 90 FEZ residents served, 45 (50 %) will be provided additional services as needed c. Of the 90 FEZ residents served, 36 (40 %) will be placed in jobs, given work experience, receive On- the -Job Training, receive retention services, attend English as a Second Language classes, be provided with skill upgrades, and have access to paid internships. d. Planned enrollments by Quarter: V. SERVICES WILL BE PROVIDED AT: The Cambodian Family 1111 E. Wakeham Ave., Suite E Santa Ana, CA 92705 EXHIBIT A rt tr, 2"d Qtr. 3 r Qtr. 4m tr. 31 14 31 14 V. SERVICES WILL BE PROVIDED AT: The Cambodian Family 1111 E. Wakeham Ave., Suite E Santa Ana, CA 92705 EXHIBIT A VI. WORK CENTER RESPONSIBILITIES 1. Develop contracts for partners 2. Provide orientation and training on eligibility, referral process, assessment, MIS tracking system, joint policies and procedures, fiscal billing, documentation, etc. 3. Develop joint forms such as application, screening/intake tool, ISP, referral form, MIS forms, etc. 4. Perform Program Monitoring 5. Perform Program Reporting 6. Provide partners with on -going technical assistance 7. Provide a quarterly FEZ newsletter 8. Facilitate monthly meetings VII. THE CAMBODIAN FAMILY RESPONSIBILITIES 1. The Cambodian Family will provide eligible FEZ residents with services designed to meet the FEZ Board requirements. A participant will be provided with one or more of the following services to assist them in obtaining unsubsidized employment and self - sufficiency: • Case management • Comprehensive support services • Job development • Placement and retention services • Job training / education • Workforce preparation workshops 2. Evaluate participants for eligibility and assign those eligible for program services. 3. Perform client assessments. Assess education level of FEZ participants through TABE test and using ISP form. 4. Report progress and job placements to WORK Center FEZ staff. 5. Incorporate all service navigator partners' information into each other's marketing materials. 6. Attend monthly partner meetings. 7. Provide WORK Center FEZ staff with monthly and quarterly progress reports. 8. Provide WORK Center FEZ staff with necessary information for conducting informal and formal monitoring of program progress. 9. Meet performance measures. All staff and agencies participating in this project will be held accountable for achieving their agency FEZ performance measures. 10. Submit Monthly Statistics Report documentation to FEZ Liaison staff by the 5 t of every month. Report should include new enrollments and a continuous Activity Enrollment Form. 11. Maintain a current and complete file (electronic as well as a hard copy) for each FEZ participant: eligibility documentation; registration form; enrollment form; assessment; Individual Service Plan (ISP); EEO /Grievance; case notes; supportive services documentation; attendance records; training documentation; etc. 12. Comply with allowable expenses. To be allowable, costs must: a) be reasonable for the performance of the program; b) conform to any limitations or exclusions set forth in the program as to types or amount of cost items; c) be consistent with policies and procedures that apply uniformly to both federally - financed and other activities of the organization; d) be determined in accordance with generally accepted accounting principles (GAAP); e) not be included as a cost or used to meet cost sharing or matching requirements of any other federally- financed program in either the current or a prior period; and, f) be adequately documented. EXHIBIT A 13. Submit in triplicate, a monthly Invoice on City of Santa Ana, Federal Empowerment Zone Program Subrecipient Request for Reimbursement, showing in detail the amount of money already expended. Accounting records must be supported by source documentation such as cancelled checks, paid bills, payrolls, and attendance records. Submit the above stated documents to Osiel "Ozzie" Madrigal by the tenth (10"') day of the month following the month in which services are performed. EXHIBIT A THE CAMBODIAN FAMILY Daisy Wheel Program July 1, 2003 - June 30, 2004 BUDGETFORM * Attach a separate sheet detailing these costs. EXHIBIT B Administrative Program Total FEZ Match /In -Kind Personnel Salaries * $ 7,645 $ 44,647 $ 52,292 $ 153,620 Benefits 1,955 11,140 13,095 36,869 Other list * - - Total Personnel 9,600 55,787 65,387 190,489 Operating Expenses Rent * 5,998 5,998 38,160 Utilities 1,080 1,080 4,620 Phone /Fax/Internetfees 960 960 1,020 Janitorial Maintenance/Supplies 1,800 1,800 Insurance 540 540 Equipment Rental /Maintenance * 540 540 Office Supplies 720 720 8,400 Professional Services 660 660 Audit 800 800 Staff Training 180 180 Travel/Mileage 900 900 Training Supplies 100 100 Other list * Advertising 100 100 Fees/Membership/Subscription 50 50 Postage 185 185 Total Operating Expenses 14,613 14,613 52,200 GRAND TOTAL $ 9,600 $ 70,400 $ 80,000 $ 242,689 * Attach a separate sheet detailing these costs. EXHIBIT B THE CAMBODIAN FAMILY Daisy Wheel Program July 1, 2003 - June 30, 2004 Budget Detail Sheet Operating Expenses Rent - 700 sq. ft. x $.714/sq. ft. x 12 months - 5,998 FTE Funded Equipment Rental /Maintenance - $45 /mo x 12 months - 540 Total Amount Personnel Annual Salary by FEZ Administrative Program Requested from FEZ Executive Director $66,816 2.5% $ 1,670 $ - $ 1,670 Secretary 26,309 2.5% 658 - 658 Finance Manager 49,339 5% 2,467 - 2,467 Bookkepper 37,271 5% 1,864 - 1,864 Computer Specialist 39,463 2.5% 987 - 987 ES Coordinator 50,425 5% - 2,521 2,521 Assistant ES Coordinator 41,760 5% - 2,088 2,088 Quality Control Specialist/Counselor 35,496 2.5% - 887 887 Employment Specialists 31,320 30% - 9,396 9,396 Family Coaches 29,754 100% - 29,754 29,754 Total Salaries 7,645 44,647 52,292 Benefits @ 25% of total salaries 1,955 11,140 13,095 Total Personnel 9,600 55,787 65,387 Operating Expenses Rent - 700 sq. ft. x $.714/sq. ft. x 12 months - 5,998 5,998 Equipment Rental /Maintenance - $45 /mo x 12 months - 540 540 copy machine, fax, drinking water system, and company van maintenance services. Other Advertising - to recrut for staff positon - 100 100 Fees /Membership /Subscription - 50 50 Postage - stamp - 185 185 EXHIBIT B THE CAMBODIAN FAMILY Daisy Wheel Program July 1, 2003 - June 30, 2004 In -Kind Detail Sheet PERSONNEL TOTAL In -Kind Prop10 - Childcare Project Coordinator $20 /hr x 40 hrs /wk x 52 weeks $ 41,600 Childcare Teacher $16 /hr x 40 hrs /wk x 52 weeks $ 33,280 Childcare Assistants $11 /hr x 40 hrs /wk x 52 weeks $ 22,880 Santa Ana Colleae - ESL Classes ESL Instructors $30 /hr x 38 hrs /wk x 46 weeks $ 52,440 ESL Instructors $19 /hr x 15 hrs/wk x 12 weeks $ 3,420 Total Salaries $ 153,620 Benefits Q 24% of total salaries $ 36,869 Total Personnel $ 190,489 OPERATING EXPENSES Prop10 - Childcare Childcare project supplies and materials $700 /month x 12 months $ 8,400 Rent $2080 /month x 12 months $ 24,960 Telephone $85 /month x 12 months $ 1,020 Utilities $250 1month x 12 months $ 3,000 Refugee Employment Services Proaram -ESL Classes Rent $1100 /month x 12 months $ 13,200 Utilities $135 /month x 12 months $ 1,620 Total Operating Expenses $ 52,200 GRAND TOTAL $ 242,689 EXHIBIT B ACKNOWLEDGEMENT OF SUBRECIPIENT AGREEMENT To: John P. Reekstin Executive Director Santa Ana Empowerment Corporation From: Subcontractor /Assignee Subcontractor /Assignee hereby stipulates that it has been provided with a copy, has read, and is familiar with all of the terms of SUBRECIPIENT's Agreement with the Santa Ana Empowerment Corporation. Subcontractor /Assignee further agrees to be bound to all of the terms and provisions of SUBRECIPIENT's Agreement with the Santa Ana Empowerment Corporation. Executed this cZ5"7% day of ' 02003 . BY: 41 Name: P-1 F KA f'( /RSUf Title: - Xr —w77W bj,clE0UR EXHIBIT c Certification Regarding Lobbying Certification for Contracts, Grants, Loans, and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperaive agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. F- x9LY77vE �QjF-CT4R Organization r Program Title Name of Certifying Officer EXHIBIT D Part I 9 INSTRUCTIONS FOR COMPLETION OF SF -LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form still be completed by the reporting entity, whether subawardee or prime Federal recipient, at the Initiation or receipt of a covered Federal action, or a material change to a previous filling, pursuant to title 31 U.S.C. section 1352. The filling of a form be required for each payment or agreement to make payment for any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a member of Congress an officer or employee of Congress, or an employee of a Member of Congress in connection with a Federal Action. Used the SF -LLLA Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filling and material change report. Refer to the Implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal Action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g, the first subawardee of the prime is the 1" tier. Seaboard include but are not limited to subcontracts, subcontracts, subgrants and contract awards under grants. 5. If the organization filling the report in item 4 checks "subwardee" then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Gaurd. 7. Enter the Federal program name or description for the covered Federal action (iteml). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g.) Request for Proposal (RFP) number; invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the apnlication/proposal control number assigned by the Federal agency). Include prefixes, e.g. "RFP -DE -90 -001." 9. For a covered Federal action where these has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and Middle initial (MI). 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply, if this is a material change report, enter the cumulative amount of payment made or planned to be made. 12. Check the appropriate box(es). Check all boxes that apply, if payment is made through an in -kind contribution, specify the nature and value of the in -kind payment. 13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) for any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted. 15. Check whether or not a SF -LLL -A Continuation Sheet(s) is attached. 16. The certifying official shall sign and date the form, print his/her name, title, and telephone number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348 -0046), Washington, D.C.20503. EXHIBIT D Part II Certification Regarding Drug -Free Workplace Requirements The certification set out below is a material representation upon which reliance is placed by the U.S. Department of Housing and Urban Development in awarding the grant. If it is later determined that the contractor knowingly rendered a false certification, or otherwise violates the requirements of the Drug -Free Workplace Act, the U.S. Department of Housing and Urban Development, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug -Free Workplace Act. CERTIFICATION A. The contractor certifies that it will provide a drug -free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the contractor's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing a drug -free awareness program to inform employees about - (1) The dangers of drug abuse in the workplace; (2) The contractor's policy of maintaining a drug -free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance program; and (4) the penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee who will be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the contract, the employee will - (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction. (e) Notifying the U.S. Department of Housing and Urban Development within ten days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction; EXHIBIT E Pg. 2 (f) Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted - (1) Taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug -free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). B. The contractor shall insert in the space provided on the attached "Place of Performance" form the site(s) for the performance of work to be carried out with the grant funds (including street address, city, county, state, and zip code). the contractor further certifies that, if it is subsequently determined that additional sites will be used for the performance of work under the contract, it shall notify the U.S. Department of Housing and Urban Development immediately upon the decision to use such additional sites by submitting a revised "Place of Performance" form. p 6e/. &A64,7DR' Dated: ! ©3 %hQ Ca &dla Program Operator EXHIBIT E DIVISION OF EMPLOYMENT SERVICES PLACE OF PERFORMANCE FOR CERTIFICATION REGARDING DRUG -FREE WORKPLACE REQUIREMENTS Name: 1r5C_ Exec,_4,ve. Rvec4r Name of Contractor: Contractor Number: I c e, , ( %c,,t T D 4s -- 3 5'4 Fl a Date: '1 /2S-/c 3 The Contractor shall insert in the space provided below the site(s) expected to be used for the performance of work under the contract conveyed by the certification: Place of Performance (include street address, city, county, state, zip code for each site): 111 1 E, vVa4, edic..', A-v'e. Svi'Fc. C .Sa114c, Af A !?vav4e �'o. G4 9Z70s- EXHIBIT E EXHIBIT F ADDITIONAL INSURED ENDORSEMENT FOR COMMERCIAL GENERAL LIABILITY POLICY Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents, volunteers and representatives are named as additional insureds ( "additional insureds ") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective Policy # _ Issued to this endorsement form as a part of Named Insured Countersigned by Authorized Representative ACOaRDATE CERTIFICATE OF LIABILITY INSURANCE IMNm WYYYV) 1 09/11/2003 PRODUCER (714)838 -1912 FAX (714) 638 -7568 CAM -BMR Insurance Agency P.O. Box 102S Tustin, CA 92781 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC 0 INSURED Cambodian Family 1111 East Wakeham Avenue Suite E Santa Ana, CA 92705 �, yb ✓�o�7 -V I 3- I 5 INSURER& Philadelphia Indemnity Ins. Co. PO EFFE OVE INSURER B: UMI13 INSURER C. INSLWERO PHPK043151 INSURER E: 03/09/2004 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTLMTHSTANDIN( ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TOM ICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 113L ADD't h= TYPEOPINSURANCE POLICY NUMBER PO EFFE OVE POLIC711011%9`4 UMI13 GENERAL LIABIUW PHPK043151 03/09/2003 03/09/2004 EACHOCCURRENCE f 1,000,00( X COMMERCIALGENERALUABIUTY DAMAGETORENTED f 400.00 CLAIMS MADE Fx] OCCUR $ 5,00( MED EXP (MS. pdn.n) A X Abuse/Molestation PERSONAL AADV INJURY $ 1,000,00( GENERAL AGGREGATE S 11000.00 OENL AGGREGATE LIMIT APPLIES PER; X POLICY JET LOC PRODUCTS -COMPIOP AGO ! include AUMMOatt LIAA ITY ANY AUTO PHPK0431SI 09/01/2003 03/09/2004 COMBINED SINGLE LIMB 1ESY ft) S 1,000,00C BODILY INJURY IPK Wnon) ! A ALL OWNED AUTOS SCHEDULEDAUTOS HREDAUTOB WN NONAED AUTOS X X BOOILYINJ) IPV ACTJaRM S X Hired Phys Dam. X PROPERTY DAMAGE (P. Rcdd") f X 10000m/1000co11 GARAGE LABILITY AUTO ONLY - EA ACCIDENT S ANY AUTO / \."i li : �' �� L.. 1U i`�''" 1'(i l \;:v OTHER THAN EA ACC AUTOONLY: AGG ! S EXCESS&WBKMLA UIBEJTY OCCUR CLAIMS MADE EACH OCCURRENCE S AGGREGATE $ S DEDUCTIBLE f RETENTION 3 S WORNERSCOMPEHSATIONAND WC AT U- OTH- EMPLOYER 11.11 NTY E.L. EACH ACCIDENT S ANY PROPRIETOUPARTNERIEXECUTIVE OFFICERNEMBER EXOLUDE07 It SXyW Owalb, InBEr SPECIAL PROVISIONS DMOP E.L DISEABE - EA EMPLOYE 3 E.L. DISEASE - POLICY LIMIT f A oTHEnRercial Crime / mployee Dishonesty PHPK0431SI 09/05/2003 03/09/2004 Limit: $200,000 / Ded $2,500 I-WSORIPnON OP OPERATIONS I LOCATIONS I VEHICLES I EICLIISH)NS ADDED BY ENOORSEMENT/ S►ECVIL PROWSIONS e Santa Ana Empowerment Corporation and The City of Santa Ana are named as dditional insured's as respects the additional insured endorsement attached. Subject to 10 days notice of cancellaiton due to non- payment of premium. The City of Santa Ana P.O. Box 1988 Santa Ana, CA 92702 ACORD 26 (2001/08) SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ID RUUIDON DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL +30�TDAYS WRTTEN NOTICETO THE CERTIFICATE HOLDER "MOM THE LEFT, BIp'1rA1LURE 70 MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OACORD CORPORATION 1988 . 1 1 ./I' 3 ft ay: 0; 0000000; OCT -8 -03 14:54; PAGE 2/2 lnsuranceCompanY a Companies This endorsement modifies such insurance as is afforded by the provisions of Policy 0 ilE}PA Q4 31 St 'relating to the following: 1. The Santa Me Empowument Corporation and the City of Santa Ana, 20 Civic Center Plaza, F.O. Box 1998, Santa Ana California 92702; and their respective officers, employees, agents, volunteers and representatives are named at additional insureds ("additional insureds') with regard to liability and defense of suits arising Gram the operations and uses perfotnted by or on behalf of the nutted insured. With reaped to claims arlAns out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insuredr. 3, This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liabitlty. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a al"ant if not so included, 4. Wilk respect to the additional insureds, this insurance shall not be cancelled, or materially raduoed in coverage or limits except situ thirty (30) days written notice has been given to the Unit Ana EmpowenneAt Corporation, Inc. 20 Civic Center Plaza (M -21), P.O, Bd* 1988, Santa Ana, California 92702. (Completion of the following, including eounteraigaatwe is required to make this endorsement effective,) Effective _ , this endorsement form as a part of Policy #,yuvxnd Issued to Famil ame Cou iteraigned by AutbVdzcdlteprtswr 've EXMITH., . \i r_�nl y tATa O Go STATE . P.O. BOX 420807, SAN FRANCISCO, CA 9 4142 -00 0 7 COMP6.NSATION INSURANCrE .. .; FUNiD CERTIFICATE OF WORKERS" COMPENSATION INSURANCE .AUGUST 4, 2003:. POLICY NUMBER' 1696 %70 - 01 '- CERTIFICATE EXPIRES: 6- 30 -04' CITY OF -SANTA!ANA ', 'SAW ANA ' CA 92 702 This is to certify. that we have Issued a valid Workers' Compensation-i nsurance policy in a form approved by the California Insurance Conim ssio6er'ia the employer r amee'belowforthe. policy period indicated. This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer. We will also give you TEWdays ativ@ncq notice should this policy be cancelled prior to its normal expiration. - This certificate of, insuranc9 is not an insurance policy and does not amend, extend of "alter the coverage afforded by the policies listed herein. Notwifhst8ndmg apy �"equlremert,_ term, or condition of.Anv contract or other document with respect to' =which this certificafe of insurinde may be is §iied or may pertain, fhe` insurance afforded by the policies. described herein -is subject to all the terms,'.explusions;and cdriditions of such policies. AD• _ e ALI THOR IZiFDREPRESE NTATI VE% j PRESIDENT MKOYER S LIAPli_10 LIMIT. INCL�IDSNG DEFENSE ' $TS: f1,000,000 PEk OCGUf ;kEhICE:.. EMPL¢YER L Ai �sf I, .- 1 � -, 1111 WAkE id` "gUE ` E a s`RNTAi AN A c i CERTIFICATE OF D LIABILITY INSURANCE 004 M PRODUCER 714)838 -1912 FAX (714)838 -7568 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lake Insurance Agency ONLY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 13891 Newport Ave., Suite 285 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Li c #0747473 INSURERS AFFORDING COVERAGE NAIC # Tustin, CA 92780 INSURED Cambodian Family X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR INSURERA Philadelphia Ind. Ins. Co. INSURER B: MED EXP (Any one person) 1111 East Wakeham Avenue PERSONAL& AUV INJURY INSURER C: A Suite E X 0 deductible INSURER D: Santa Ana, CA 92705 GENERAL AGGREGATE INSURER E: COVERACitS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - LTR NSR TYPE OF INSURANCE GENERAL LIABILITY POLICY NUMBER PHPK074625 DATE MMlDDlYV 03/09/2004 DATE MM /DD/YY 03/09/2005 LIMITS EACH OCCURRENCE $ 1 000 DDO PREMISES Ea occurence $ 300,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR MED EXP (Any one person) $ 5,000 PERSONAL& AUV INJURY $ 1,000,000 A X 0 deductible GENERAL AGGREGATE S 3,000,000 PRODUCTS - COMP /OP AGG $ included GEN -L AGGREGATE -LIMIT APPLIES PER: X POLICY PE OC AUTOMOBILE LIABILITY ANY AUTO PHPK074625 03/09/2004 03/09/2005 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ A HIRED AUTOS X X NON -OWNED AUTOS - $0 Deductible PROPERTY DAMAGE (Per accident) $ X GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGO $ ANY AUTO S EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE S AGGREGATE $ OCCUR CLAIMS MADE `.. S DEDUCTIBLE RETENTION $ -1 2 $ $ WORKERS COMPENSATION AND .. -. - -'' ... - TORY LIMITS ER I I E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? `' _ - - E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If yes describe under SPECIAL PROVISIONS below - A OTHER Abuse & Molestation PHPK074625 03/09/2004 03/09/2005 $1,000,000 Each Claim $3,000,000 Aggregate $0 Deductible DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Employee Dishonesty Liability $200,000 / 0 Ded. ertificate holder is named as additional insured per contract with named insured. Schedule of vehicles and drivers on file. '°10 day notice of cancellation due to non - payment of premium. CERTIFICATE HOLDER GANGtLLA I iON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL X MAIL *10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Santa Ana Work Center XXx�Xxy��ppl�pXgl�XpXXX 1000 Santa Ana Blvd., Suite 200 K*irA9PiC)W1KXM%MXIXXXXXM)QKX 3CmXXXXXXX X Santa Ana, CA 92701 A" ZED D ' .1 ©ACORD ACORD 25f(2001108) IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. J - „ ACORD 25 (2001/08) MAY -'13 -2004 09:24 THE CAMBODIAN FAMILY 714 571 1974 P.04 ADDITIONAL .INSURED ENDORSEMENT insurance Company PHILADELPHIA INDEMNITY INSURANCE CO. This endorSgrn��qan�tt mooMes such Insurance as is afforded by the provisions of Policy # PHPKO74625 re6aong to the iollowing; t. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; Its officers, employees, agents and representatives are named as additional insureds ('a aional Insureds') with regard to Nabilky and defense of salts arising from the operations and uses performed by or an behalf of the named Insured. 2. With respect to claims artstng out of the operation and uses performed by or on behaK of the named Insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. 'tnra nstrre = applies separately to each Insured against whore claim is, made or suit Is brougtd wcept with rasped to the company's lin is of Aabil>ty. The Inolusian of any parson or organtudon as an insured shall not affect any right which such person or orcankwilon would have as a cla mm if not so included. 4. With MSpeCt to tto additl ld insureds, this imstxanoe Sf mall not be cartoeuad, or matetWy reduced In covwae or 6mib except after thirty (80) days wriden notice has been given to the trey, of Sarft Ana. 20 Civic Center Plaza, Santa Ana„Caafomla 82701. (Completion of the following, including counterslgnattite, is required to make arts endorsement -efteotilve.) Effpotive 03 / 09 / 04 this endorsement form as a part of Policy# PHPK074625 Issued to ' THB CAMBODIAN FAMI_ LPL Named insured Countersigned by AF 1,0%:.. TOTAL P.04