HomeMy WebLinkAboutCENTENNIAL HERITAGE MUSEUM 1-2003 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Please complete this form when the attached agreement is no longer in effect.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.
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Signature:
Date: f 1 1 S
City of Santa Ma
Revised 4-16-87 Clerk of the Council
-ticitfRANCE NOT ON riLE
WORK MAY tiQLPROCEED
CLERK OF COUNCIL
DATE: il<~S -°3 AGREEMENT BETWEEN THE CITY OF SANTA ANA AND
CENTENNIAL HERITAGE MUSEUM FOR USE OF
COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS
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A.2003.074."~ 12..
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lc.~) This Agreement, made and entered into this 1st day of July, 2003, by and between the City
of Santa Ana, a charter city and municipal corporation of the State of California ("CITY") and
CENTENNIAL HERITAGE MUSEUM, a California nonprofit corporation ("SUBRECIPIENT").
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Recitals:
A. The CITY, as an entitlement recipient and grantee of the United States Department of
Housing and Urban Development ("HUD") Community Development Block Grant ("CDBG")
Program, desires to enter this Agreement with the SUBRECIPIENT for the expenditure of CDBG
funds in accordance with Title 24, Part 570 of Code of Federal Regulations 24 CFR 570.000, et seq.
("CDBG REGS"); and
B. CITY has applied for and received CDBG funds from HUD pursuant to Title I of the
Housing and Community Development Act of 1974, Public Law 93-383, as amended ("ACT"); and
C. The SUBRECIPIENT is a private nonprofit agency that has been selected by the CITY
to receive CDBG funds and administer such financial assistance; and to provide the services
described in "Exhibit A," in accordance with the schedule of performance included therein,
hereinafter referred to as "said program" and SUBRECIPIENT represents that it is qualified and
willing to operate said program.
D. The CITY and SUBRECIPIENT have duly executed this Agreement for the expenditure of
such funds; and
WHEREFORE, it is agreed by and between the parties that the foregoing Recitals are a
substantive part of this Agreement and the following terms and conditions are approved and
together with all exhibits and attachments hereto, shall constitute the entire Agreement between the
CITY and SUBRECIPIENT:
I. SUBRECIPIENT'S OBLIGATIONS
A. Non-Profit Status - Representations and Warranties.
(a) Authority. SUBRECIPIENT is a duly organized and existing non-profit corporation
in good standing and authorized to do business under the laws ofthe State of California.
SUBRECIPIENT has full right, power and lawful authority to accept the funding hereunder and
to undertake all obligations as provided herein and the execution, performance and delivery of
this Agreement by SUB RECIPIENT has been fully authorized by all requisite actions on the part
of SUB RECIPIENT.
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(b) Experience. SUB RECIPIENT is a qualified provider of the services to be provided
hereunder.
(c) Familiarity With Services Required. By executing this Agreement,
SUBRECIPIENT warrants that (i) it has thoroughly investigated and considered the services to
be performed and provided hereunder, (ii) it has carefully considered how the services should be
performed, and (iii) it fully understands the facilities, difficulties and restrictions attending
performance of the services under this Agreement.
(d) No Conflict. To the best of SUB RECIPIENT'S knowledge, SUBRECIPIENT'S
execution, delivery and performance of its obligations under this Agreement will not constitute a
default or a breach under any contract, agreement or order to which SUB RECIPIENT is a party
or by which it is bound.
(e) No Bankruptcy. SUBRECIPIENT is not the subject of any current or threatened
bankruptcy proceeding.
(I) No Pending Legal Proceedings. SUBRECIPIENT is not the subject of a current or
threatened litigation that would or may materially affect SUBRECIPIENT'S performance under
this Agreement.
(g) Application Veracity. All provisions of and information provided in
SUBRECIPIENT'S application for funding submitted to CITY including any exhibits are true
and correct in all material respects.
(h) No Pending Investigation. SUBRECIPIENT is not aware that it is the
subject of any current or threatened criminal or civil action investigation by any public agency,
including without limitation a police agency or prosecuting authority, that would relate to affect
performance of the Agreement or provision of services hereunder.
B. Amount of Grant and Ouarterlv Disbursement. The amount granted to
SUBRECIPIENT is $ 10,000 ("CDBG FUNDS"), and such funds shall be expended by
SUBRECIPIENT on or before June 30, 2004. The CDBG FUNDS shall be disbursed by CITY
to SUBRECIPIENT on a quarterly basis (October, January, April and July) subject to and upon
receipt and approval of a complete SUBRECIPIENT'S quarterly activity report, with the final
payment subject to the satisfaction ofthe condition precedent of submittal of complete reporting
information due on or before July 15 of the applicable funding year, as hereinafter more fully set
forth. SUBRECIPIENT shall be obligated to perform such duties as would normally extend
beyond the term, including but not limited to obligations with respect to indenmification, audits,
reporting, data retention/reporting, and accounting.
C. Use of Funds. SUBRECIPIENT agrees to use all federal funds provided by CITY to
SUBRECIPIENT pursuant to this Agreement to operate said program, as set forth in "Exhibit A,"
attached hereto and by this reference incorporated herein. SUBRECIPIENT'S failure to perform as
required may, in addition to other remedies set forth in this Agreement, result in readjustment of the
amount of funds CITY is otherwise obligated to pay to SUB RECIPIENT hereunder.
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D. Allowable Costs. SUB RECIPIENT agrees to complete said program on or before
June 30, 2004 and to use said funds to pay for necessary and reasonable costs allowable under the
federal law and regulations to operate said program. Said amounts shall include, but not be limited
to, wages, administrative costs, and employee benefits comparable to other similarly situated
employees. Other allowable program costs are detailed in the Budget, as set forth in "Exhibit B,"
attached hereto and by this reference incorporated herein. SUBRECIPIENT shall use all income
received ITom said funds only for the same purposes for which said funds may be expended
pursuant to the tenns and conditions of this Agreement.
E. Licensing. SUBRECIPIENT agrees to obtain and maintain all required licenses,
registrations, accreditation and inspections from all agencies governing its operations.
SUBRECIPIENT shall ensure that its staff shall also obtain and maintain all required licenses,
registrations, accreditation and inspections ITom all agencies governing SUBRECIPIENT's
operations hereunder.
F. Zoning. SUBRECIPIENT agrees that any facility/property used in furtherance of
said program shall be specifically zoned and permitted for such use(s) and activity(ies). Should
SUBRECIPIENT fail to have the required land entitlement and/or permits, thus violating any local,
state or federal rules and regulations relating thereto, SUBRECIPIENT shall immediately make
good-faith efforts to gain compliance with local, state or federal rules and regulations following
written notification of said violation(s) ITom the CITY or other authorized citing agency.
SUBRECIPIENT shall notifY CITY immediately of any pending violations. Failure to notifY CITY
of pending violations, or to remedy such known violation(s) shall result in termination of grant
funding hereunder. SUBRECIPIENT must make all corrections required to bring the
facility/property into compliance with the law within sixty (60) days of notification of the
violation(s); failure to gain compliance within such time shall result in termination of grant funding
hereunder.
G. Separation of Accounts. All funds received by SUBRECIPIENT ITom CITY
pursuant to this Agreement shall be maintained in an account in a federally insured banking or
savings and loan institution with record keeping of such accounts maintained pursuant to applicable
OMB Circular A-llO requirements. SUBRECIPIENT is not required to maintain separate
depository accounts for CDBG FUNDS; provided however, the SUBRECIPIENT must be able to
account for receipt, obligation and expenditure of CDBG FUNDS pursuant to applicable OMB
Circular A-I 10 requirements.
H. Audit Report Requirements. SUBRECIPIENT agrees that if SUBRECIPIENT
receives Three Hundred Thousand Dollars ($300,000.00) or more in federal funds,
SUBRECIPIENT shall have an annual audit conducted by a certified public accountant in
accordance with the standards as set forth and published by the United States Office of Management
and Budget. SUBRECIPIENT shall provide CITY with a copy of said audit by October 1 of the
year following the program year in which this Agreement is executed.
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I. Record Keeping/Reporting. SUBRECIPIENT shall keep and maintain complete and
adequate records and reports to assist CITY in meeting and maintaining its record keeping
responsibilities under the CDBG REGS, including the following:
(I) Records
a. Documentation evidencing program income requirements in
conformity with 24 CFR 570.504(b«2)(i), (ii) and 24 CFR 570.503(b)(3) and 24
CFR 570.208(a)(2)(B) ofthe income level of persons and/or families participating
in or benefiting by the SUBRECIPIENT program.
b. Documentation of the number of persons and/or families participating
in or benefiting by the SUB RECIPIENT program.
c. Household information shall include number of persons, identification
of head of household, race/ethnicity, and income verification.
d. Documentation of all CDBG FUNDS received from CITY.
e. Documentation of expenses as identified in the Budget Proposal,
including evidence of incurring the expense, invoices for goods or services, copies
of any and all contracts or documentation pertaining to costs for subcontractors,
plus all other invoices for which CDBG FUNDS were expended, and any payments
therefor.
f. Any such other related records as CITY shall reasonably require or as
required to be maintained pursuant to the CDBG REGS.
(2) Reports
(i) Payment Request. Concurrently with the submittal of each
quarterly report, on or before the 15th day of October, January,
April and July, SUBRECIPIENT shall submit both: an original
invoice and true copies of invoices, receipts, agreements, copies
of any and all contracts or documentation pertaining to costs for
subcontractors or other documentation supporting and
evidencing how the CDBG FUNDS have been expended during
the applicable quarter.
(ii) Quarterly Activity Report: SUBRECIPIENT agrees to keep monthly
records of all ethnic and racial statistics of persons and families benefited by
SUBRECIPIENT in the performance of its obligations under this Agreement,
including, but not limited to, the number oflow and moderate income persons
and households assisted in accordance with federal income limits, the number
of female heads of households assisted, new program information and year-to-
date program statistics on expenditures, caseload and activities.
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J. Access to Records. CITY and the United State Govemment and/or their representatives
shall have access for purposes of monitoring, auditing, and examining SUBRECIPIENT's activities
and performance, to books, documents and papers, and the right to examine records of
SUB RECIPIENT's subcontractors, bookkeepers and accountants, employees and participants in
regard to said program. CITY and the United States Government and/or their representatives shall
also schedule on-site monitoring at their discretion. Monitoring activities may also include, but are
not limited to, questioning employees and participants in said program and entering any premises or
any site in which any of the services or activities funded hereunder is conducted or in which any of
the records of SUB RECIPIENT are kept. Nothing herein shall be construed to require access to any
privileged or confidential information as set forth in federal or state law.
K. Location of RecordslRequired Length of Record Keeping. All accounting records,
reports, and evidence pertaining to all costs, expenses and the CDBG FUNDS of
SUBRECIPIENT and all documents related to this Agreement shall be maintained and kept
available at SUBRECIPIENT'S office or place of business for the duration of the Agreement and
thereafter for five (5) years after completion of an audit in conformity with the CDBG REGS., s.
Records which relate to (a) complaints, claims, administrative proceedings or litigation arising
out of the performance of this Agreement, or (b) costs and expenses of this Agreement to which
CITY or any other governmental agency takes exception, shall be retained beyond the five (5)
years until complete resolution or disposition of such appeals, litigation claims, or exceptions. In
the event SUBRECIPIENT does not make the above-referenced documents available within the city
of Santa Ana, California, SUBRECIPIENT agrees to pay all necessary and reasonable expenses
incurred by CITY in conducting any audit at the location where said records and books of account
are maintained.
L. Compliance with LawlProgram Income. SUBRECIPIENT acknowledges that the funds
being provided by CITY for said program are received by CITY pursuant to the ACT as amended
and that expenditures of these funds shall be in accordance with the ACT and all pertinent
regulations issued by agencies of the federal government, including, but not limited to, all
regulations found at Title 24 of the Code of Federal Regulations. Program income received by
SUB RECIPIENT shall be returned to CITY unless otherwise provided for in this Agreement.
SUBRECIPIENT agrees to comply fully with all federal, state and local laws and court orders
applicable to its operation whether or not referred to in this Agreement.
M. Standing. SUBRECIPIENT shall be in good standing, without suspension by the
California Secretary of State, Franchise Tax Board and Internal Revenue Service. Any change in
the corporate status or suspension of SUB RECIPIENT shall be reported immediately to CITY.
N. Confidentiality. Without prejudice to any other provisions of this Agreement,
SUB RECIPIENT shall, where applicable, maintain the confidential nature of information provided
to it concerning participants in accordance with the requirements of federal and state law. However,
SUBRECIPIENT shall submit to CITY and or HUD or its representatives, all records requested,
including audit, examinations, monitoring and verifications of reports submitted by
SUBRECIPIENT, costs incurred and services rendered hereunder.
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O. Independent Contracto~. SUBRECIPIENT agrees that the performance of
obligations hereunder is rendered in its capacity as an independent contractor and that it is in no way
an agency of CITY.
P. Violation of Terms and Conditions. SUBRECIPIENT agrees that if
SUBRECIPIENT violates any of the terms and conditions of this Agreement or any prior
Agreement whereby CDBG funds were received by SUBRECIPIENT, or if SUBRECIPIENT
reports inaccurately, or if on audit there is a disallowance of certain expenditures, SUBRECIPIENT
agrees to remedy the acts or omissions causing the disallowance and repay CITY all amounts spent
in violation thereof. If SUBRECIPIENT engaged in ITaudulent activity to obtain and/or justifY
expenditure of the CDBG funds granted hereunder, SUBRECIPIENT shall be required to reimburse
the CITY of all such funds that were obtained/spent under ITaudulent circumstances.
Q. Equipment. SUBRECIPIENT agrees to maintain a record for each item of non-
expendable personal property acquired under the terms of this Agreement. Said record shall be
made available to CITY upon request. The term "non-expendable personal property" shall include
leased and purchased equipment.
R. Prohibited Use. SUBRECIPIENT hereby certifies and agrees that it will not use
funds provided through this Agreement to pay for entertainment, meals or gifts.
S. Lobbving. SUBRECIPIENT certifies that it will comply with federal law (31
US.C. 1352) and regulations found at 24 CFR Part 87, which provide that no appropriated funds
may be expended by the recipient of a federal contract, grant, loan or cooperative agreement to pay
any person for influencing or attempting to influence an officer or employee of any agency,
Member of Congress, or an officer or employee of a Member of Congress in connection with
awarding of any federal contract, the making of any federal grant or loan, entering into any
cooperative agreement and the extension, renewal, amendment or modification of any federal
contract, grant, loan or cooperative agreement. SUB RECIPIENT shall sign a certification to that
effect in a form as set forth in "Exhibit C," attached hereto and by this reference incorporated herein.
SUBRECIPIENT shall submit said signed certification to CITY prior to performing any of its
obligations under this Agreement and prior to any obligation arising on the part of CITY to pay any
sums to SUBRECIPIENT under the terms and conditions of this Agreement.
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 a "Disclosure Form to Report Lobbying," in accordance
with its instructions (see C-I).
T. Financial Interest. SUBRECIPIENT agrees that except for the use of CDBG funds
to pay salaries and other related administrative or personnel costs, no persons who exercise or have
exercised any function with respect to CDBG activities assisted under the terms of this Agreement,
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or who are in a position to participate in a decision-making process or gain inside information with
regard to such activities, may obtain a financial interest or benefit ITom a CDBG-assisted activity of
SUBRECIPIENT, either for themselves or those with whom they have family or business ties,
during their tenure or for one year thereafter. This prohibition applies to any person who is an
employee, agent, consultant, officer, or elected or appointed official of CITY, or of
any designated public agencies, or the SUBRECIPIENT.
U. Davis Bacon Act. All laborers and mechanics employed by contractors or
subcontractors in the performance of construction work, including alterations and repairs, in excess
of $2,000.00, financed in whole or in part with federal funds shall be paid wages at rates not less
than those prevailing on similar construction in the locality as determined in accordance with the
Davis-Bacon Act, as amended, 40 U.S.C. sections 276a - 276a-5. Any such construction contract
shall include and comply with the required contract provisions and rules set forth in 29 C.F.R. §5.5.
Further, the payroll reports (along with the "Statement of Compliance") and basic records are
required to be maintained and submitted, or made available, pursuant to 29 c.F.R. §5.5(a)(3). No
payment, advance, grant, loan or guarantee of funds shall be approved by the federal agency unless
there is on file with the agency a certification by the contractor that the contractor and its
subcontractors have complied with the provisions of 29 c.F.R. §5.5. A breach of the contract
clauses in 29 c.F.R. §5.5 may be grounds for termination of the contract, and for debarment as a
contractor/subcontractor, as provided in 29 C.F.R. §5.12. Labor standards interviews/investigations
shall be made as necessary to assure compliance [29 c.F.R. §5.6(a)(3)].
V. Drug Free Workplace. SUBRECIPIENT certifies that it has established the following
drug-ITee workplace policy:
I. The unlawful manufacture, distribution, dispensing, possession or use of a
controlled substance is prohibited in the workplace for any employee involved in a federally funded
program.
2. As an employee working in conjunction with a federally funded program, the
employees of SUBRECIPIENT will be required to:
a) Abide by the terms above in statement I.
b) NotifY appropriate officials of SUBRECIPIENT and CITY officials of
any criminal drug statute conviction for a violation occurring in the workplace not
later than five days after such conviction.
3. The City and the United State Department of Housing and Urban
Development will be notified within ten days after receiving notice of any such violation.
4. Within 30 days of receiving such notice, appropriate personnel action will be
taken against such employee, up to and including termination.
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Each such employee shall be required 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.
II.
CITY'S OBLIGATIONS
A. Pavment of Funds. Upon execution of this Agreement by SUBRECIPIENT, CITY shall
pay to SUBRECIPIENT ITom CDBG funds, when, if and to the extent received ITom HUD, for
CITY's 2003-2004 CDBG program year amounts expended by SUBRECIPIENT in carrying out
said program for fiscal year 2003-2004 pursuant to this Agreement up to a maximum aggregate
payment ofTen Thousand Dollars ($ 10,000) in installments determined by CITY. Payments shall
be made to SUBRECIPIENT through the submission of invoices on a quarterly basis (October,
January, April and July) in a form prescribed by CITY, detailing such expenses. CITY shall pay
such invoices within thirty (30) days after receipt thereof provided CITY is satisfied that such
expenses have been incurred and documented within the scope and provisions of this Agreement
and that SUBRECIPIENT is in compliance with the terms and conditions of this Agreement.
B. Audit of Account. CITY shall include an audit of the account maintained by
SUB RECIPIENT in CITY's annual audit of all CDBG FUNDS in accordance with Title 24 of
the Code of Federal Regulations and other applicable federal laws and regulations.
C. Common Rule: Pursuant to CFR 85.40(a), the CITY manages the day-to-day
operations of each grant and subgrant supported activities. CITY staff has detailed knowledge of the
grant program requirements and monitors grant and sub grant supported activities to assure
compliance with Federal requirements. Such monitoring covers each program, function and activity
and performance goals are reviewed periodically.
D. Environmental Review: In accordance with 24 CFR 58, the CITY is responsible for
undertaking environmental review and maintaining environmental review records for each
applicable project.
III.
NONDISCRIMINATION
SUBRECIPIENT agrees that no person on the ground of race, age, color, national origin,
religion or sex will be excluded ITom participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity funded in whole or in part with CDBG funds.
IV.
CONFLICT OF INTEREST
SUBRECIPIENT agrees that no officer, employee, agent or assignee of CITY having direct
or indirect control of any CDBG monies granted to the CITY, inclusive of the subject CDBG
FUNDS, shall serve as an officer of SUBRECIPIENT. Further, any conflict or potential conflict of
interest of any officer of SUBRECIPIENT shall be fully disclosed in writing prior to the execution
ofthis Agreement and said writing shall be attached and deemed fully incorporated as a part hereof.
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Notice shall be sent by SUBRECIPIENT to CITY regarding any changes or modifications to its
board of directors and list of officers.
V.
SPECIAL CERTIFICATION FOR RELIGIOUS ENTITIES
If SUBRECIPIENT is a religious entity, SUBRECIPIENT hereby agrees that in connection
with the provision of the services SUBRECIPIENT shall provide with CDBG funds:
A. SUBRECIPIENT shall not discriminate against any employee or applicant for
employment on the basis of religion and shall not limit employment or give preference in
employment to persons on the basis of religion.
B. SUBRECIPIENT shall not discriminate against any person applying for the services
SUBRECIPIENT agrees to provide under the terms of this Agreement on the basis of religion and
shall not limit such services or give preference to applicants for such services on the basis of
religion.
C. SUB RECIPIENT shall NOT provide religious instruction or counseling, conduct
any religious worship or services, or engage in any religious proselytizing, or exert any religious
influence in the provision of the services in said program. The parties agree that this covenant is
intended to and shall be construed for the limited purpose of assuring compliance with respect to the
use of CITY funds by SUBRECIPIENT with applicable constitutional limitations respecting the
establishment of religion as set forth in the establishment clause under the First Amendment of the
United States Constitution and Article I, Section 4 of the California Constitution, and is not in any
manner intended to restrict other activities of SUBRECIPIENT.
D. Where the services to be provided under said program are rendered on property
owned by the primarily religious entity SUBRECIPIENT, CDBG funds may also be used for minor
repairs to such property which are directly related to the cost of rendering the services under said
program, where the cost constitutes in dollar terms only an incidental portion of the CDBG
expenditure for rendering the services under said program.
VI.
PROHIBITION OF NEPOTISM
SUBRECIPIENT agrees not to hire or permit the hiring of any person to fill a position
funded through this Agreement if a member of that person's immediate family is employed in an
administrative capacity by SUBRECIPIENT. For the purposes of this section, the term "immediate
family" means spouse, child, mother, father, brother, sister, brother-in-law, sister-in-law, father-in-
law, mother-in-law, son-in-law, daughter-in-law, aunt, uncle, niece, nephew, stepparent and
stepchild. The term "administrative capacity" means having selection, hiring, supervisor or
management responsibilities.
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VII.
NOTICES
Notices to the parties shall, unless otherwise requested in writing, be sent by U.S. Mail,
postage prepaid, and addressed as follows:
TO CITY:
City of Santa Ana
Community Development Agency (M-25)
20 Civic Center Plaza
P.O. Box 1988
Santa Ana, Califomia 92702-1988
TO SUBRECIPIENT:
Centennial Heritage MuseumlPathways
3101 W. Harvard Street
Santa Ana, CA 92704
VIII. ASSIGNABILITY
None of the duties of, or work to be performed by, SUBRECIPIENT under this Agreement
shall be subcontracted or assigned to any agency, consultant, or person without the prior written
consent of CITY. SUBRECIPIENT must submit all subcontracts and other agreements that relate
to this Agreement to CITY. No subcontract or assignment shall terminate or alter the legal
obligations of SUBRECIPIENT pursuant to this Agreement.
IX.
HOLD HARMLESS
SUBRECIPIENT shall indenmifY, defend and save harmless CITY, its officers, employees,
agents, representatives and volunteers ITom and against any and all damages to or for loss of use of
property and for injuries to or death of any person or persons, including property and employees or
agents of CITY, and shall defend, indenmifY and save harmless CITY, its officers, employees,
agents, representatives and volunteers ITom and against any and all claims, demands, suits, actions
or proceedings of any kind or nature, including, but not by way of limitation, workers compensation
claims and including attorney fees and reasonable expenses for litigation or settlement, resulting
ITom or arising out of the negligent or wrongful acts, errors or omissions of SUBRECIPIENT, its
officers, directors, employees, agents, subcontractors and suppliers arising out of
SUBRECIPIENT's performance of this Agreement.
X. INSURANCE
A. In accordance with the provisions of Section 3300 of the Labor Code, if
SUBRECIPIENT has any employees it is required to be insured against liability for worker's
compensation or to undertake self-insurance. Prior to commencing performance of this
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Agreement, SUBRECIPIENT agrees to obtain and maintain employer's liability insurance with
limits not less than $1,000,000 per accident. If SUBRECIPIENT has no employees, nor
workers' compensation coverage, it must execute a Declaration available from the CITY, and
update as is necessary.
B. SUBRECIPIENT shall obtain, at its sole cost, a policy or policies of commercial
general liability insurance, or equivalent form, with a combined single limit of not less than
$1,000,000 per occurrence.
Such insurance shall: (I) name the City of Santa Ana, its officers, agents,
representatives, employees and volunteers as additional insured's; (2) be primary with respect to
insurance or self-insurance programs maintained by the CITY; (3) contain standard separation of
insured's provisions; and (4) give to CITY prompt and timely notice of claim made or suit
instituted arising out of SUB RECIPIENT's operations hereunder.
SUBRECIPIENT shall: (a) prior to exercising any right under this Agreement,
furnish properly executed certificates of insurance and additional insured endorsement to the
CITY which shall clearly evidence all coverages required above; (b) provide that such insurance
shall not be materially changed or terminated except on 30 days prior written notice to the CITY;
(c) maintain such insurance for the period covered by this Agreement; and (d) replace such
certificates for policies expiring prior to the expiration of this Agreement.
XI.
REVERSION OF ASSETS
A. Upon the expiration of this Agreement, SUBRECIPIENT shall transfer to CITY any
CDBG funds on hand at the time of the expiration of this Agreement as well as any accounts
receivable attributable to the use ofCDBG funds. [24 CFR 570.503(b)(8).]
B. Any real property under SUBRECIPIENT's control that was acquired or improved
in whole or in part with CDBG funds in excess of$25,000.00 must either be:
1. Used, where CITY has given written approval, to meet one of the national
objectives stated in 24 CFR 570.208 until five (5) years after expiration of this Agreement, or for
such longer period of time as determined to be appropriate by CITY; or
2. If not used in accordance with subparagraph A above, SUBRECIPIENT
shall pay to CITY an amount equal to the current fair market value of the property less any portion
of the value attributable to the expenditure ofnon-CDBG funds for acquisition of, or improvement
to, the property. Such payment is program income to CITY.
C. Subject to the obligations set forth herein, title to equipment acquired under the
terms of this Agreement will vest upon acquisition in SUBRECIPIENT. When said equipment
which has been acquired in accordance with this Agreement and all applicable regulations is no
longer needed for said program, disposition of said equipment will be made as follows:
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I. Items of equipment with a current per unit fair market value of less than
$5,000.00 may be retained, sold or otherwise disposed of with no further obligation to CITY.
2. Items of equipment with a current fair market per unit value of $5,000.00 or
more may be retained or sold and CITY shall have the right to an amount calculated by multiplying
the current market value or proceeds ITom the sale by CITY's share of federal funds used to acquire
the equipment, in accordance with 24 CFR 85.32(e)(2).
D. SUBRECIPIENT hereby agrees, upon the demand of CITY, to execute,
acknowledge and deliver, or cause any person or entity who may have any claim to rights hereunder
or under any document, instrument or agreement executed in furtherance of the services and
activities to be performed hereunder, to execute, acknowledge and deliver, to CITY assignment(s),
quit claim deed(s) or such other and further instruments, documents and agreements as may be
necessary, in the sole and absolute discretion of CITY, to vest in CITY all of SUBRECIPIENT's
right, title and interest (if any it may have) in and to CITY, CDBG or other federal, state and/or
local accounts or program funds or allocation of funds to which CITY is or may be entitled, either
for its own account or as fiduciary or trustee for others, which were obtained for the purpose of the
performance of this Agreement or any previous agreements relating to the same subject matter or
activities as this Agreement, together with any instruments, loans, grants or advances by
SUBRECIPIENT on behalf of CITY, in furtherance of the activities hereunder or thereof.
SUBRECIPIENT's obligations and responsibilities set forth in this paragraph "XL
REVERSION OF ASSETS." and in paragraph "XII. TERMINATION" and other requirements
pertaining to program income shall not be affected by the termination of this Agreement and shall
survive the date of termination of this Agreement for such period of time as CITY and/or HUD
deems necessary for the responsibilities, duties and obligations to be performed and completed to
the satisfaction of CITY and HUD.
XII.
TERMINATION
A. This Agreement may be terminated on thirty (30) days' written notice by either
party. In the event of such termination, SUBRECIPIENT shall only be entitled to reimbursement
for approved expenses incurred to the effective date of termination.
B. This Agreement may be suspended or terminated by CITY upon five (5) days'
written notice for violation by SUBRECIPIENT of Federal Laws governing the use of Community
Development Block Grant Funds. In the event of such suspension or termination, SUBRECIPIENT
shall only be entitled to reimbursement for approved expenses incurred up to the effective date of
suspension or termination.
C. Pursuant to 24 CFR 85.43, in the event SUBRECIPIENT defaults by failing to fulfill
all or any of its obligations hereunder, CITY may declare a default and termination of this
Agreement by written notice to SUBRECIPIENT, which default and termination shall be effective
on a date stated in the notice which is to be not less than ten (10) days after certified mailing or
personal service of such notice, unless such default is cured before the effective date of termination
12
stated in such notice. If terminated for cause, CITY shall be relieved of further liability or
responsibility under this Agreement, or as a result of the termination thereof, including the payment
of money, except for payment for approved expenses incurred for services satisfactorily and timely
performed prior to the mailing or service of the notice of termination, and except for reimbursement
of (1) any payments made for services not subsequently performed in a timely and satisfactory
manner, and (2) costs incurred by CITY in obtaining substitute performance.
D. The grant of funds under this Agreement may be terminated for convenience in
accordance with 24 CFR 85.44.
E. In the event this Agreement is terminated as set forth in subparagraphs XII.A.
through XII.D., inclusive, SUBRECIPIENT agrees to immediately return to CITY upon CITY's
demand and prior to any adjudication of SUBRECIPIENT's rights, any and all funds not used, and
to comply with paragraph "XI. REVERSION OF ASSETS" of this Agreement.
XIII. LIMITATION OF FUNDS
The United States of America, through HUD, may in the future place programmatic or fiscal
limitations on the use ofCDBG funds which limitations are not presently anticipated. Accordingly,
CITY reserves the right to revise this Agreement in order to take account of actions affecting HUD
program funding. In the event of funding reduction, CITY may, in its sole and absolute discretion,
reduce the budget of this Agreement as a whole or as to costs category, may limit the rate of
SUBRECIPIENT's authority to commit and spend funds, or may restrict SUBRECIPIENT's use of
both its uncommitted and its unspent funds. Where HUD has directed or requested CITY to
implement a reduction in funding, in whole or as to a cost category, with respect to funding for this
Agreement, CITY's City Manager or delegate is authorized to act for CITY in implementing and
effecting such a reduction and in revising, modifYing, or amending the Agreement for such
purposes. Where CITY has reasonable grounds to question SUBRECIPIENT's fiscal
accountability, financial soundness, or compliance with this Agreement, CITY may suspend the
operation of this Agreement for up to sixty (60) days upon five (5) days written notice to
SUBRECIPIENT of its intention to so act, pending an audit or other resolution of such questions.
In no event, however, shall any revisions made by CITY affect expenditures and legally binding
commitments made by SUB RECIPIENT before it received notice of such revision, provided that
such amounts have been committed in good faith and are otherwise allowable and that such
commitments are consistent with HUD cash withdrawal guidelines.
XIV. EXCLUSIVITY AND AMENDMENT OF AGREEMENT
This Agreement supersedes any and all other agreements, either oral or in writing, between
the parties hereto with respect to the use of CITY's CDBG funds by SUBRECIPIENT and contains
all the covenants and agreements between the parties with respect to such employment in any
manner whatsoever. 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, and that no other agreement or
13
amendment hereto shall be effective unless executed in writing and signed by both CITY and
SUBRECIPIENT .
xv.
LAWS GOVERNING THIS AGREEMENT
This Agreement shall be governed by and construed in accordance with the laws of the State
of California, and all applicable federal laws and regulations.
XVI. VALIDITY
The invalidity in whole or in part of any provision of this Agreement shall not void or affect
the validity of any other provision of this Agreement.
XVII. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below has the power,
authority and right to bind their respective parties to each of the terms of this Agreement, and shall
indemnifY CITY fully, including reasonable costs and attorney's fees, for any injuries or damages to
CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn.
b. All Exhibits and Attachments referenced herein and attached hereto shall be
incorporated as if fully set forth in the body of this Agreement.
c. No delay or omission by either party hereto to exercise any right or power accruing
upon any noncompliance or default by the other party with respect to any of the terms of this
Agreement shall impair any such right or power or be construed to be a waiver thereof. A
waiver by either of the parties hereto of any of the covenants, conditions, or agreements to be
performed by the other shall not be construed to be a waiver of any succeeding breach thereof
or of any other covenant, condition or agreement herein contained.
14
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and
year written below.
DATED: // /17/03
I /
CITY OF SANTA ANA
DAvm~~
City Manager
ATTEST:
APPROVED AS TO FORM:
~~
j;., JOSEPH W. FLETCHER
City Attorney
SUBRECIPIENT:
DATE:
15
. Oct. 23 03 03:14p
Di5cove,..~ Mu5eum
714 540-1932
p.2
FROM :
FAX NO. : 714-647-6549
D~t. .213 2Øø3 11:20AM F'.2
EXHIBIT A
Scope of War (
Annual Accomplishment Goal
I. NUinbcr ofundupticalcd Sant.., Ana "'$id"nIS 10 be served with Grant (Md. durinl:l the 12-
month conlraCt pcriO<! ~ / ~.:38 PERSONS
n. Description of Work - ÌII 'I*~ below, describe rho program 10 be fund<d du,ong the lZ.moll.b conu'acl
period including. servi",,; to be provided. program gaal.. client chara.~n.tic.. I< bow Ctan! fulldo will be utilized.
SbJdents are introdueed to the enVÌIOJU11ent and taught about the process of recycling. After
viewing a short environmental video, children experience nature first-nand. Through hands-on
activities and demonstrations childmt learn about the life cycle of a plant, the air cycle, water
cycle, and food chains.
The Kellogg House educational history tour teaches children of what life was like 100 years ago.
They also learn about Mr. Hiram Clay ICeIlogg, a civil engineer n!sponsible for designing mo.t of
thc roads, railroad and sewer systems throughout the city.
Schedule of l'er(tlrrnøn""
Esl1matc the number ofundvplicated Santa An;a residents to be served during the 12-month
contract pcriO<! per quarter:
Quarter I: July I - SeptC1nbcr 30
Qrlorter 2: October 1 -. DecembeT 31
Quarter 3: January 1 .- March 31
Quarttzr 4: April 1 - June 30
Tota'
:;JJiJ Persons
~~ Pet'~ons
( () Persons
~ Per!!IQn.'
Persons
Invoicing Schedule
Estimate tile amount of grant funds to be rcq\tcsted during the 12-month contract period On 3
quarterly hasis:
Quarler I: July 1 .- September 30
Quartcr 2: October ! -- December 31
QuaTtOfT J; January 1 -. March 31
Qr.<art"T 4: April! - June 30
Total
$ ~'.:J;;"
$ "7J,c9-I (r:1ß. '-:
s t". tJÐ
: ' ~ÌJ'bJ,~
EXHIBIT A
j.'
'~,'. ';.
if, "
.1"
'I' "
¡¡I'
.""',8.,'..,.',"..
" ,..
if ...
Ma~.30 03 10:52a
Disoover~ Museum
714 540-1932
1>.2
Attachment 4
PROGRAM BUDGET PROPOSAL
C '.,ganizational Name; Centennial HerltagG MutJOumlCíscoVGrÿ Mu......m of Orange Co...-nty
Program Name: Your Pathw;ly Back in Time
CategorY
~ïñ¡riistratille Staff
Salaries & Benefits
Program Staff Salaries
& Benefits
Suoolies
L"",se
. ,'mmunicatìons
.,-ofessional Serv,
Trainino
Travel Expenses
Insurance
Other (Please Soecifiv\
Utilities
ReMirs
TOTAL
Santa Ana Grant Reoue$t
Other Sources
Program Total
$
1,05000 $
22,050.00 $
$
6,550.00 $
,..., 44,738,00 $
$
850.00 $
29900 $
$
$
1,00 $
-
$
450.00 $
3,546.00 $
$
$
.
$
-
$
$
00000 $
.
$
100.00 $
-
$
... '."-'"
$
400,00 $
1,878.00 $
$
$
..
$
-
$
600.00 $
6,066.00 $
$
$
. $
10,000.00 $
2,650.00 $
132,1213.00 $
"-.ote: All expenditures must be fully documented by receipts, time records, invoices,
oançelled checks, inllentory records or other appropriate documentation that fully and
çompletely disclosess the amounts and nature of the expenditures.
Program Resources
Sourc.."
Fee for Service
ÇOBG
Exhibit B
Amount
$ 82,128.00
$ 10,000.00
Total
$
92,128.00
23,100,00
51,288.00
1,149.00
1,00
3,996.00
-
900,00
1pO,00
2,278.00
.
6,666.00
2,650.00
92,128.00
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:
(I) No Federal appropriated funds have been paid or will be paid, by or on behalf ofthe
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 cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal contact, grant, loan or cooperative
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 subcontract, sub grants, 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.
Centennial Heritage Museum / Pathways Back In Time
Grantee/Contactor Organization
Program Title
j)CLWit1\et5ê.
Name of Certifying Officer
lO~l
Signature
Date
EXHIBIT C
Page 1 of2
SUBRECIPIENT warrants the following:
I. SUBRECIPIENT will comply with Public Law 88-352, Title VI of the Civil Rights
Act of 1964 (42 U. S. C. section 2000 et seq.) and implementing regulation in 24 CFR
Part 1.
2. No person in the United States shall on the ground ofrace, color, religion, national
origin, or sex, be excluded ITom participation in, or be denied the benefits of, or be
subjected to discrimination under any program or activity funded in whole or in part with
community development funds made available pursuant to the ACT.
3. All laborers and mechanics, employed by contractors or subcontractors in the
performance of construction work financed in whole or in part with community
development funds shall be paid wages at rates not less than those prevailing on similar
construction in the locality as determined in accordance with the Davis-Bacon Act, as
amended, 40 U. S. C. Sections 276 a 1-5, except for individuals who perform services for
which they volunteered; do not receive compensation for such services; or are paid
expenses, reasonable benefits, or a nominal fee for such services; and are not otherwise
employed at any time in construction work.
4. SUBRECIPIENT will comply with all Federal statutes applicable to projects funded
with community development funds, except that (a) SUBRECIPIENT does not assume
CITY'S environmental responsibilities described at 24 CFR 570.604; and (b)
SUBRECIPIENT does not assume CITY'S responsibility for initiating the review process
under Executive Order 12372.
EXHIBIT C
Page 2 of2
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
See reverse for public burden disclosure.)
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
D a. contract Da. bid/offer/application D a. initial filing
b. grant b. initial award b. material change
c. cooperative agreement c. post-award For Material Change Only:
d.loan year ----- quarter ------
e. loan guarantee date of last report ------------
f. loan insurance
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name
0 Prime 0 Subaward.. and Address of Prime:
Tier --' if known:
ConQresslonal District, if known: Congressional District, if known:
6. Federal DepartmenttAgency: 7. Federal Program Name/Description:
CFDA Number, if applicable: -----
8. Federal Action Number, ff known: 9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if
(if individual, last name, first name, M/): different from No. 10a)
(last name, first name, M/):
(attach Conlinualion Shee/(s) SF-LLLA, ¡(necessary)
11. Amount of Payment (check aI/ that apply): 13. Type of Payment (check all that apply):
$ ---- 0 actual 0 planned 0 a. retainer
0 b. one-time fee
0 c. commission
0 d. contingent fee
0 e. deferred
0 f. other: specify: --------
12. Form of Payment (check all that apply):
0 a. cash
0 b. irHtind: specify: nature ---
value --
14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s),
employee(s), or Member(s) contacted, for Payment Indicated in Item 11:
(attach Conlinualion Shee/(s) SF-LLLA. if necessary)
15. Continuation Sheet s SF-LLLA attached: 0 Ves 0 No
16.::-:-:: =..::. ';,....:,::=.:. '::'.::..":. ti:::~~:;: '::;; Signature:
:::.= ::.~:";~-:::.tiy.""':::"":;= ~'3~1;~ m;;:: Print Name:
==..:: ':::;:'::"'wh"::Mk> ':"=~::' :':::"":::::: TItle:
...... k> . "". ,,- of 001 .... ~.. $'0.000 ."" 001 ~. ~." $100.000 1",
."h"""",,~.. Telephone No.:
Date:
Authorized for Local Reproduct;on
Standa,d Fo>m LLL (Rev. 7-97)
. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
ACORD. OP IDl~ 03/12/04
CENTE01
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Barlocker Ins. - Laguna Hills HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
23332 Mill Creek Dr. Suite 105 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Laguna Hills CA 92653
Phone: 949-461-3640 Fax: 949-461-3644 INSURERS AFFORDING COVERAGE NAIC#
INSURED A- d-.OO3 ~ tJ7f-1Z- f 5(P INSURER A' Hartford Casualtv Ins. Co. 29424
-- INSURER B,
Centennial Heritage Museum INSURER C,
3101 West Harvard INSURER 0,
Santa Ana CA 92705
INSURER E,
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT. TERM OR CONDITION OF IWY CONTRACT OR OTHER OOCUMENTWITH 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.
'~~~ ~s':ó! TYPE OF INSURANCE POLICY NUMBER DATEMMIDDiYY DATE M UMITS
~NERAL LIABIUTY EACH OCCURRENCE S 1 000,000
A X ~ OMERCIAL GENERAL LIABILITY 57SBAAV8856 03/15/04 03/15/05 PREMISES E. """"""') s100,000
I--- CLAIMS MADE ŒJ OCCUR MEDEXP¡"""",," ""on) s 10,000
I--- PERSONAL' ADV INJURY S 1,000 000
I--- GENERAL AGGREGATE s2 000,000
ñ.~ AGG~EñE ~~ APñS PER. PRODUCTS. COMP/OP AGG S 2,000,000
POLICY JECT LOC IEmn- Ben. 1 000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
I--- S 1,000,000
A ANY AUTO 57SBAAV8856 03/15/04 03/15/05 (E. "d'M')
I---
I--- ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS ¡Per....on) $
I---
e-!- HIRED AUTOS BODILY INJURY
~ NON-OWNED AUTOS (P"""'M') $
PROPERTY DAMAGE S
(Per 'Od'M')
GARAGE LIABIUTY AUTO ONLY. EA ACCIDENT $
==1 ANY AUTO OTHER THAN EAACC $
AUTO ONLY, AGG $
5~SSlUMBRELLA LIABILITY EACH OCCURRENCE S 1 00O-r000
A X X OCCUR 0 CLAIMS MADE 57SBAAV8856 03/15/04 03/15/05 AGGREGATE sl,OOO,OOO
$
~ ~EDUCTIBLE S
X RETENTION $10 000 ~, ;./r","'.l' S
WORKERS COMPENSATION AND ~u '~:- '/h ITö',\'v"t',:":i'š I ¡UJ..
EMPLOYERS' L,.BIUTY
IWY PROPRIETDRIPARTNERÆXECUTIVE E.L. EACH ACC'DENT S
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
g~Mr~v'r"s,tNS b~"" !(¡'-~' L~aSÚr.[ S',C' 1':;---- E.L.DlSEASE-POLICYLIMIT $
OTHER ASJ¡,\6lll CilY .'-ll H"CY
-
DESCRIPTION OF OPERATIONS' LOCATIONS 'VEHICLES' EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
City of Santa Ana is named as additional insured with respects to claims
arising out of the operation and uses preformed by or on behalf of the named
insure, such insurance as is afforded by this policy is primary and not
additional to or contributing with any other insurance carried by or for the
benefit of the additional insured. 10 day notice for non-payment of premium
.
CITYOFS
CANCELLATION
SHOULD IWY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL _MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. /iIIi ~
~ Ø1#IPN fj ~*-tJ U"~
~
AUTHORIZED REPRESENTATIVE
CERTIFICATE HOLDER
City of Santa Ana
Community Development Agency,
M-25
P.O. Box 1988
Santa Ana CA 92702
Kell
Peterson
@ ACORD CORPORATION 1988
}tty
ACORD 25 (2001/08)
COMMERCIAL GENERAL LIABILITY
Inured: Centennial Heritage Museum
Company: Hartford Casualty Ins. Co.
Policy Number: 57SBAAV8856
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED-OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person of Organization:
City of Santa Ana
Community Development Agency M-25
P.O. Box 1988
Santa Ana, CA 92702.1988
(If no entry appears above, the information required to complete this endorsement will be
shown in the Declarations as applicable to this endorsement)
WHO IS INSURED (Section II) is amended to include as an insured the person or
organization shown in the Schedule but only with respect to liability arising out of .your
work" for that insured by or for you.
IT IS HEREBY AGREED THAT THIS INSURANCE IS PRIMARY AND NON-
CONTRIBUTORY WITH ANY OTHER INSURANCE THE ADDITIONAL INSURED MAY
CARRY.
CG 201011 85
AlTRavED ¡\S TO FORM
-~ ..A//¿/;;¿
~l'ši,:'::;~~---
A""""L ~IlY ¡"""",ey
. Jan'05 04 02:57p
Disoover~ Museum
714 540-1932
p.l
STATE
COMPENSATION
INSUFOANC",
FUND
HOME OFFICE
SAN FRANCISCO EFFECTIVE
ALL EFFECTIVE DATES ARE
AT 12001 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
EXECUTIVE OFFICERS
MINIMUM/MAXIMUM LIMITS
1594455-03
RENEWAL
SP
2-70-70-02
PAGE 1L
ENDORSEMENT AGREEMENT
JUNE 30, 2003 AT 12.01 A.M.
A -d.-OO3 -014-51.0
CENTENNIAL HERITAGE MUSEUM
INC.
3101 W HARVARD ST
SANTA ANA, CA 92704
ANY CONTRADIc'THiN RF.TWF.EN THE POLICY AND TH1S ENDORSEMENT
WILL BE CONTROLLED BY THIS ENDORSEMENT.
IT IS AGREF.n THAT UNLESS OTHERWISE EXCLUDED BY ENDORSEMENT
THE ACTUAL REMUNERATION EARNED BY EACH EXECUTIVE OPfICER
DURING THE POLICY PERIOD SHALL BE USED AS THE BASIS OF
PRF.I'!TITM, SITEJECT TO
THE .MINIMUM AMOUNT OF $
28,600
PER ANNUM
AND THE MAXIMUM AMOUNT OF $
79,300
PER ANNUM
AS SPECIFIED IN THE CALIFORNIA WORKERS' COMP£NSAHON
UNIFORM STATlSTICAL REPORTING PlAN, FOR WORKERS'
COMPENSATION INSURANCE IN EFFECT DURING THE POLICY PERIOD.
~C-~..//'
/C:À'.Vl'~ //q
NOTHING IN THIS ENDORSeMENT CONTAINED SHALL aE HELD TO VAPor, ALTER, WAIVE
OR EXTEND ANY OF THE TEPoMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POliCY OTHER THAN AS STA'"'D. NOTHING ELSEWH.R. IN THIS POLICY SHALL BE
HElD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNEIJ AND ISSUED AT SAN FRANCISCO:
'tf/Jtdn-
JULY 22, 2003
,ð.~ {!.
&£-
3015
AUTHORIZED REPRESENTATIVE
PRESIDENT
.. J"~,' 05 04 02: 57p
Di~oov~r~ Mu~~um
714 540-1932
p.2
STATE
COMPENSATION
INSURANCE
F=UNO
HOME OFFICE
SAN FRANCISCO EFFECTIVE
All5FFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
ÞACIFIC STANDARD TIME
PREMIUM ADJUSTMENT ENDORSEMENT
WC 04 04 07
ENDORS8M~NT AGREEMENT
JUNE 30, 2003 AT 12.01 A.M.
1594455-03
RENEWAL
SP
2-70-70-02
PAGE lL
CENTENNIAL HERITAGE MUSEUM
INC.
3101 W HARVARD ST
SANTA ANA, CA 92704
WE HAVE THE RIGHT TO ADJUST THE POLICY PREMIUM AFTER
ISSUANCE OF THE POLICY TF THE COST OF PROVIDING nœ
BENEFITS REQUIRED UNDER THE WORKERS' COMPENSATION LAWS
OF CALIFORNIA IS AFFECTED BY LEGISLATIVE OR REGULATORY
CHANGES ADOPTED AFtER ¡ SSUANCE OF THE POLICY. TH~
AMOUNT OF THE ADJUSTMENT WILL NOT EXCEED THE CHANGE TN
THE COST OF PROVIDING THE BENEFITS AS REFLECTED IN THE
PURE PREMIUM RATES APPROVED BY THE INSURANCE COM!1l~SIONER.
, /~31u¿7 2/q
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATE!). NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY. ALTER, WAIVE OR LIMIT TIlE TERMS. CONDIfIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO:
~
AUTHORIZEO REPRESENTATIVE
JULY 22, 2003
t1~C.
~
2023
PRESIDENT
SCIF FORM "'" IREV.3-0"
Ja~ 05 04 02:58p
Disoove~~ Museum
714 540-1932
p.1
STATE HOM~ OFFICE SAN FRANCISCO I ANNUAL RATING ENDORSEMENT
COMPENSATION IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUN~RATION APPEARING
INSURANCE
FUND IN THE CONTINUOUS POLICY ISSUED ro THIS EMPLOYER ARE AMENDED AS SHOWN BELOW
HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD
BE CORRECTED OR IF INSURANCE IS NDT NEEDED FOR NEXr YEAR, PLEASE TELL US.
IMPORTANT THIS IS NOT A BILL CONrlNUOUS POLICY 1594455-03
SEND NO MONEY UNLESS STATEMENT IS ENCLOSED
THE ~TING PERIOD BEIiINS AND END~ AT 12,ðUN
PACIfIC STANDARD TIME
RATING PERIOD
6-30-03 TO
6-30-04
* INTERIM BILLING RATES WILL BE USED ON PAYROLL REPORTS. THEY TAKE INTO ACCOUNT
RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN
~STIMATE Or- YOUR PRfJUUI1 DlSCOUNT AS DETAILED BELOW.
RATING PLAN CREDITS (DEBITS) EFFECTIVE FROII 06-30-03 TO 06-30-.Qi!
RATING PLAN IIODIFIER
1.00000
ESTII1AT~D PREMIU/I DlSCOUNT MODIfIER
0.89319
COMPOSITE FACTOR APPLIED TO BASE RATES TO DERIVE
INTERI/I BILLlN(j RATES
0.89319
*,'** ** ** H,,* *,,*** ****** * ** *,,* **',* Mo',' H** "*'°' *,,*,,**,,** * ',H**,',' H', ,'", *" ,',H'", *,' *""""
i,
* PREMIUM DISCOUNT SCHEDULE EFFECTIVE FROII 06-30-03
" ESTlMATED MODIFIED PRE/HUM IS DISCOUNTED ACCORDING TO THE
" FIRST ABOVE
$2,500 $2,500
0.0% 17.5%
TO 06-30-04
FOLLOWING SCHEDULE: "
,~
"
"
*
",. ,**H.*"**"**"~WW"**"**.* ,,*,>;,,>.********. ."Hi,H.""**"""""'.*".""". "*H,'",***,,,,***
THE ESTIMATED PREMIUI! DISCOUNT TS BASED ON AN ESTIMATE OF YOUR PAYROlL ACTUAL
P¡Œ/liUM DISCOUNT APPLIED AT FINAL BILLING WILL BE BASED ON THE ACTUAL PAYROLL
REPORTED ON YOUR POLICY AND SUBJECT TO AUDIT.
'yt} ¡ , ~
A/I lkJC'j .5?¡,y
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO
JULY 22, 2003
POLICY FORM L
2L
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DisOOV~~~ Mus~um
714 540-1832
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STATE ""M~ Df"OE SAN FRANCISOO.¡ ANNUAL RATING ENDORSEMENT
COMPIiNSATION IT IS AGREED THAT THE CLASSIFICATIONS AND RATES pm $100 OF REMUNERATION APPEARING
INSURANCE
FUND IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW.
HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. iF YOUR NAME OR ADDRESS SHOULD
BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL us.
IMPORT ANT" THIS IS NOT A BILL CONTINUOUS POLICY 15!14455-03
SEND NO MOIIEY UNLESS STATEMENT IS ENCLOSED
THE RAl' PERIOD BEGINS AND ~NDS AT 12o0'AM
PACIFIC Sl'ANDARD TIME
RATING PERIOD
6-30-03 TO
6-30-04
CENTENNIAL HERITAGE MUSEUM
INC.
3101 W HARVARD ST
SANTA ANA, CALIF 92704
DEPOSIT PREMIUM
MINIMUM PREMIUM
PREMIUM ADJUSTMENT pERIOD
$1,419.00
$200.00
QUARTERLY
R SP
NAME OF EMPLOYER-
CENTENNIAL HERITAGE MUSEUM INC.
(A NON-PROFIT CORP.)
COPE NO.
PRINCIPAL WORK AND RATES EFFECTIVE FROM 06-30-03 TO 06-30-04
8017
8838
STORES--RETAIL--N. O.c.
JNl¡,;¡UI1
BASE BILLING
RATE RATE:"
12.52 11.18
5.25 4.69
MUSEUMS--ALL EMPLOYEES
**"""""'*BUREAU NOTE INFORM.ATION*"""*"**
FEIN 953665050
-7 y/y
;..
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO
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JULY 22, 2003
POLICY FORM L
1