HomeMy WebLinkAboutBOYS AND GIRLS CLUB 5 - 2005U�bto
AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect.
Return form to the Sr. Deputy Clerk of the Council (M -30). Call 647 -5238 if you have any
questions.
The agreement witl d� ct' G pis
was completed on 1 a d to and final payment has been made.
Department:
Signature:
Date: 2
City of Santa Aria
Revised 8 -7 -03 Clerk of the Council
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
CLERK OF COUNCIL
A- 2005 -078 -005
5,05
DATE' OCT 19 2005 AGREEMENT BETWEEN THE CITY OF SANTA ANA AND
BOYS AND GIRLS CLUB OF SANTA ANA, INC FOR USE OF
L -. Ct1 P COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS
CL. t- ltx'eS�
This Agreement, is hereby made and entered into this 100' day of June, 2005, by and
between the City of Santa Ana, a charter city and municipal corporation of the State of California
( "CITY ") and Boys and Girls Club of Santa Ana, Inc, a California nonprofit corporation
( "SUBRECIPIENT ").
WITNESSETH
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 ". SUBRECIPIENT represents that it is qualified and willing to operate
said program and certifies that the activities carried out with funds provided under this Agreement
will meet one or more of the CDBG program's National Objectives (24 CFR Part 570.208).
D. SUBRECIPIENT agrees that it will adhere to the performance measurements and
outcomes as indicated on Exhibit B (Scope of Work). Failure to follow the measurements and
meet the stated outcomes may constitute breach of contract that could result in termination of
this Agreement or serve as reason for the City to recapture the grant funds awarded to
SUBRECIPIENT pursuant to this Agreement.
E. 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:
5;05
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 of the 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 SUBRECIPIENT has been fully authorized by all requisite actions on the part
of SUBRECIPIENT.
(b) Experience. SUBRECIPIENT 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 SUBRECIPIENT'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 SUBRECIPIENT is a party
or by which it is bound.
(e) No Bankruptcy. SUBRECIPIENT is not the subject of any current or threatened
bankruptcy proceeding.
(1) 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 Quarterly Disbursement. The amount granted to
SUBRECIPIENT is S 29,000( "CDBG FUNDS "), and such funds shall be expended by
SUBRECIPIENT on or before June 30, 2006. The CDBG FUNDS shall be disbursed by CITY
to SUBRECIPIENT on a quarterly basis (October, January, April and July) subject to and upon
5.05
receipt and approval of a. complete quarterly activity report from SUBRECIPIENT, with the final
payment subject to the satisfaction of the 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 indemnification, 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 SUBRECIPIENT hereunder.
D. Allowable Costs. SUBRECIPIENT agrees to complete said program on or before
June 30, 2006 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 from said funds only for the same purposes for which said funds may be expended
pursuant to the terms 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 from all agencies governing SUBRECIPIENT's
operations hereunder. Such licensing requirements include obtaining a City business license, as
applicable.
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) from 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 from 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 -110 requirements. SUBRECIPIENT is not required to maintain separate
3
5/05
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 -110 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.
I. Record KeepinWReporting. 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:
(1) 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) of the 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 SUBRECIPIENT 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
5iO
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 of low 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.
J. Access to Records. CITY and the United State Government 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
SUBRECIPIENT'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 SUBRECIPPIENT 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 Records /Required 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 SUBRECIP[ENT'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 Law/Program 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
SUBRECIPIENT 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.
5
505
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 SUBRECIPIENT shall be reported immediately to CITY.
N. Confidentiality. Without prejudice to any other provisions of this Agreement,
SUBRECIPIENT 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.
O. Independent Contractor. 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 CT1BG 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 fraudulent 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 fraudulent 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. Lobbying. SUBRECIPIENT certifies that it will comply with federal law (31
U.S.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. SUBRECIPIENT 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.
6
5,105
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 -1).
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,
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 from 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 /orkplace. SUBRECIPIENT certifies that it has established the following
drug -free workplace policy:
1. 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 1.
7
s /05
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.
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. Payment of Funds. Upon execution of this Agreement by SUBRECIPIENT, CITY shall
pay to SUBRECIPIENT from CDBG funds, when, if and to the extent received from HUD, for
CITY's 2005 -2006 CDBG program year amounts expended by SUBRECIPIENT in carrying out
said program for fiscal year 2005 -2006 pursuant to this Agreement up to a maximum aggregate
payment of Twenty -Nine Thousand Dollars ($ 29,000) 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
SUBRECIPIENT 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 subgrant 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.
E. Performance Monitoring: CITY shall monitor the performance of the
SUBRECIPIENT against goals and performance standards required herein. Substandard
performance as determined by the CITY will constitute non - compliance with this Agreement. If
8
5/05
action to correct such substandard performance is not taken by the SUBRECIPIENT within a
reasonable period of time after being notified by the CITY, contract suspension or termination
procedures will be initiated.
III. NONDISCRIMINATION
SUBRECIPIENT agrees that no person on the ground of race, age, color, national origin,
religion or sex will be excluded from 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
Pursuant to the conflict of interest requirements set forth in 24 CFR 576.57 and OMB
Circulars 1 -102 and A -110, 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 of this Agreement and said writing shall be attached and deemed fully
incorporated as a part hereof. 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, in accordance
with 24 CFR 570.2000):
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. SUBRECIPIENT 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.
5/05
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.
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, California 92702 -1988
TO SUBRECIPIENT: Boys and Girls Club of Santa Ana, Inc
950 W. Highland
Santa Ana, CA 92703
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.
10
5d0
IX. HOLD HARMLESS
SUBRECIPIENT shall indemnify, defend and save harmless CITY, its officers, employees,
agents, representatives and volunteers from 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, indemnify and save harmless CITY, its officers, employees,
agents, representatives and volunteers from 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
from 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
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 undertake self - insurance, or 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: (1) 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 SUBRECIPIENT'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 of CDBG funds. [24 CFR 570.503(b)(8).]
11
5105
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 of non -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:
1. 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 from 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 "XI.
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.
12
5/05
XIL 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
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. The grant of funds under this Agreement may be terminated due to the non-
performance of SUBRECIPIENT and/or failure of SUBRECIPENT to perform the work described
in Exhibits A and B or failure to meet the performance standards and program goals set forth
therein.
F. In the event this Agreement is terminated as set forth in subparagraphs XII.A.
through XII.E., 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 of CDBG 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,
13
5105
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. If such a reduction in funding occurs, SUBRECIPIENT shall be permitted to de -scope
accordingly. 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 SUBRECIPIENT 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
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.
XVIL 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
14
5 /05
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.
15
5/05
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the last date and
year written below.
ATTEST:
PATRICIAE. HEALY'
Clerk of the Council
APPROVED AS TO FORM:
JOSEPH W. FLETCHE',R
City Attorney
Z& - � 5
By: LISA E. STORCK
Assistant City Attorney
DATE:
W-M
CITY O SANTA ANA
dew - - -�
DAVID N. RE
City Manager
SUBRECIPIENT:
Title: Board President
Tax ID: 95- 1893417
CITY OF SANTA ANA
Community Development Block Grant
Scope of Work
Annual Accomplishment Goal
Total number of clients anticipated to be served during 12 -month contract period= 300
PERSONS
II. Number of unduplicated Santa Ana residents to be served with grant funds during the 12-
month contract period = 300 PERSONS
III. Indicate below one City performance outcome that the sub - recipient will be tracking with a
check mark in the appropriate box.
COMMUNITY PRIORITY NEEDS: Public Services -Youth Services
Youth Services
in pre -test,
post -test scores.
E] 2. Track number of individuals
exposed to the fine arts.
El 3. Track children/youth seeking
referrals that were linked to the
services sought.
1. For education -based programs,
improve pre -test post -test scores by
50 %.
2. Provide opportunities for exposure
to the fine arts.
3. 90% of children /youth seeking
referrals will be linked to the services
Low- and Moderate - Income Track program participants that were 90% of program participants will be
Services linked to services sought. linked to services sought.
IV
Description of Work - in space below, describe the program to be funded durin,
month contract period including, services to be provided, program goals, client
characteristics, & how grant funds will be utilized.
12-
Youth will participate in a Summer Youth Outreach Program. Programs will include an "Early
Birds" program that will provide a summer day camp experience, swimming lessons, daily free
lunch, a teen volunteer program, computer learning activities and life skills programs.
Program goalsinclude-
• A minimum of 100 youth will enroll in the Early Birds program.
• A minimum of 100 youth will increase their swimming ability by one level.
• A minimum of 50 teenage youth will participate in the Teen Summer Volunteer program,
volunteering a minimum of 50 hours each.
• A minimum of 66 youth will participate in life skills programs focusing on drug, alcohol
and gang- prevention as well as health- education activities.
• A minimum of 66 youth will participate in computer learning activities including
NetSmartz online internet safety program.
• An average of 82 youth will receive a free lunch daily.
Youth participants will be between the ages of 6 -18, will be Santa Ana residents, and will come
from moderate to low- Income families.
�x" A
Grant funds will be used for staff salaries, program supplies, office supplies, and swim lesson
fees.
Schedule of Performance
Estimate the number of unduplicated Santa Ana residents to be served during the 12 -month
contract period per quarter:
Quarter 1: July 1 — September 30 300 Persons
Quarter 2: October 1 — December 31 Persons
Quarter 3: January 1 — March 31 Persons
Quarter 4: April 1 — June 30 Persons
Total 300 Persons
Invoicing Schedule
Estimate the amount of grant funds to be requested during the 12 -month contract period on a
quarterly basis:
Quarter 1:
July 1 — September 30
$
14,000
Quarter 2:
October 1 — December 31
$
10,000
Quarter 3:
January 1 — March 31
$
Quarter 4:
April 1 — June 30
$
5,000
Total
$
29,000
EXHIBIT A
2005 -2006
CITY OF SANTA ANA
COMMUNITY DEVELOPMENT BLOCK GRANT
FINAL PROGRAM BUDGET
Organization Name: _Boys & Girls Club of Santa Ana
Program Name: Summer Youth Outreach Program
Program Year: 2005 -2006
EXPENDITURES
OTHER PROGRAM RESOURCES
ACTUAL FUNDING SOURCE AMOUNT
Santa Ana High School Swimming Pool $24,000
TOTAL
EXHIBIT B
SANTA ANA C BG
OTHER
TOTAL PROGRAM
CATEGORY
GRANT
RESOURCES
BUDGET
Administrative Staff
$1,058.63
$1,540
$2,598.63
Salaries & Benefits
Program Staff Salaries &
18,756.69
23,510
42,266.69
Benefits
64.68
2,915
2,979.68
Office Supplies
Rent/Lease
580
580
Communications
800
2,150
2,950
Utilities
Contractual /Professional
Services
Please Specify)
1,000
3,000
4,000
Insurance
Other (Please Specify)
1. Swim class fees
5,000
5,000
2. Indirect Costs (8 %)
2,320
2,590
4,910
3. Evaluation
1,070
1,070
TOTAL
$29,000
$37,355
$66,355
OTHER PROGRAM RESOURCES
ACTUAL FUNDING SOURCE AMOUNT
Santa Ana High School Swimming Pool $24,000
TOTAL
EXHIBIT B
Name of Organization: Boys & Girls Club of Santa Ana
CDBG FUNDED PERSONNEL
ennnINISTROTIVF STAFF
Position
Title
Annual
Salary
Annual
Benefits
Total
Compensation
CDBG
Funds
Requested
% of Time
Position is
Dedicated
to
Program
Bus. Mgr.
60,000
15,000
75,000
1058.63
9%
Prg. Mgr.
37,000
10,000
47,000
5,917.82
75%
Prg.
Mgr./Health
33,600
9,900
43,500
1,442.69
20%
Prg.
Mgr. /Educ.
& Tech.
14,400
3,600
18,000
2,122.56
75%
Early Birds
Staff (3)
38,880
6,967
45,847
3,820.62
100%
PROGRAM STAFF
Position
Title
Annual
Salary
Annual
Benefits
Total
Compensation
CDBG
Funds
Requested
% of Time
Position is
Dedicated
to
Program
Unit Dir.
43,000
12,900
55,900
5,453.00
60%
Prg. Mgr.
37,000
10,000
47,000
5,917.82
75%
Prg.
Mgr./Health
33,600
9,900
43,500
1,442.69
20%
Prg.
Mgr. /Educ.
& Tech.
14,400
3,600
18,000
2,122.56
75%
Early Birds
Staff (3)
38,880
6,967
45,847
3,820.62
100%
CONTRACT PERSONNEL
CDBG
% of Time
Total
Funds
Position is
Position
Annual
Annual
Compensation
Requested
Dedicated
Title
Salary
Benefits
to
Pro ram
Sep 29 05 02:12p Hods & Girls Club Of Sant 714 -565 -1099 p.3
FROM :CITY OF SANTA ANA CDR FAX NO. :714 647 -6736 Sep. 27 2005 05:29AM P3
Certification Regarding Lobbying
Certification for Gmtracts. Grants. Loons. and Cotticrative Agreements
The undersigned cettifics, to the hest of his or her knowledge and belief, that,
(t) 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 uny 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 he paid to
any person for influencing or attempting to influence an officer or employee of any
agency, a Member of Congrex+, an officer or employee of Congress, or an employe 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, subgrants, and
contracts under grunts, loans, and cooperative agreements) and that, all subrecipientx shall
certify and disclose accordingly.
This certification is a material representation of fact upon which relianco wax placed
when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transachon imposed by Section 1352, Title
31, U. S. Code. Any person who fails to file the required certification shall he suhject to
a civil penalty of riot less than $10,000 and not more than S 100,000 for each such failure.
nano: or �eartty1u:9 Utrrcer Signature Date
exH19IT C
Page I oft
SUBRECIPIENT warrants the following
1. 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 of race, color, religion, national
origin, or sex, be excluded from 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 of 2
/
RuC 15 05 11:15a Boys t Girls Club CC Sent 714 -SGS -1099
M
M CERTMATE OF L ABOW
NOMM-N.- ,.,. 71.
=Piz Pa,aria tick Dr. � pM
Nita 700
.Il0e T"Jo. 6 07050
I.a.12i 7'. -.471
me wa0►la./ at
3mft 7... Q 57705
p.2
r 6/012
.I.e.. A
III Sri"
mumem"
claim
110101
11ewo
awnco.71E1.1rr
aMY/El1,A.t
�N61lOMFlMIL9alA1117t107F
tea /w,�lamcolmpala marts E9101ee01e ommoc
T6YpIC0/M110.atrIVLbMAII ' fMQ11610R.1►e11
11E�/1/I�R'LNltl10 ®.Yii MMAMU gVft WKNiEY6CGrY0Y1tlf
8y1FL14' Opl'f110ow.6
mm mm"eO:Tlpw71E/cmvmc.�m"fOm LOmacc(/fefi
�NR6REt TD1�TSItcgIIF�M
161Y.. COZYOOQtMOCO1tl11YioFiY01
Y..te
Wt
a
x
.w.aLYCY.t
Cap91[.l..i:a14.111�1n
a{AaOYNL ®o0CV1
0015x•27'3 -05
1/117005
7/7!700.
t 1.x00,
Y ®BIB
i .
tl."O NO.00o
.mplo,r.;
..00
M.ra.w�n:t
r to<
.000.000
.
X
r:m.ul.rl.v
.
,a.ew4rawm
110 o179m7-95
-
,nno.s
.
vine0.
sa.rurr
.1.Oeo,00a
�.ta.r
e0rno
-aavw.
s
�� oc
a
_
fey
4ctln Qu..q..a0
aea.'w.c
4i,alpe 170,000
) OI55[6]9-Wl
7/1 S
-
000
aQ0111011.
tl,N►.
,
p�
wtacr.arresr
�'�
4049545 -05
5/7/2005
5/7/2006
µ.elEaa
1 ' •�
APPROVED
AS TO F
;taatel 7.....t: e;tT .5 776!7 L.O O..a .1M. se.a 5towse, Laura Sri Sheed
.. so ei.J< eeea wn Y
mw wv Ca 07702 Assistant CitY Attorne
City 47 0.wta 7w
t.d awe a..a ,le.-
a. u.f4 c wa.. a -c,
see" a... G 027.7
EO /Z0 39041
E@/Z@ 3Wd
ru.rr 1�a10:5 w0i,lam �0awarop wet.MaSa
sac niKM ,l0 sp.o wuu..r.7OYi0r01 616!0 aM O.pp
weepn,a :e wa.a.cappBepoo"b *
37PYb51I33E19 6Y%- 5TZ -fiK 10-69 99mis1/16
)RM
302110S1I -M38 6855- &M -6V6 19 :E1 SOOZ /g Uee
Hue 15 05 11:15a Boys L Girls Club Of Sant 714 -565 -1099 17.9
Hue ho ua hutaaa r"
AD0rr10NA1 MMF1) FTMR—.SP.MtFNT
t'UR LOMhat3tclAL CfiNERAL_1 UIBF ITY t
'this codow3mac l modifies uxb wasance as is afforded by the pror'tsiotts of Policy
0 wo4o7912ia. -o9 �lafia�kochCfollowing
1. 'The Ciy of gamier Ana. 20 Civic Ceata Mai, i, Strata Att; California 92701; its
otfihaxs, taapioyme. agma_ v..lumecm and ropola gaUvesixt wood as addiuorN i %UUC&
(,"tdditloual itrtreda7 wilt aegard to SaWrAy and dcfwm of wits angler( from the oparadood
and n rs Wmnedby or on behalf of the named inswed.
3 with nsp to claims airing oat of tba operations ani hues pw*xn od by or an
bebWof css am named Inswed. sack ilmuonce as u ofronied by this policy is pirnwy and is aw
aild6uuaal to orcanaribnling with any Gib" iwraax wtried by OF fordw be atitof the
additional instaeds.
I This ukwwKv ayq m sgxw, holy b each im'atd isg ima wham claim iv matt or
sail 6 bosgM except with scapccs m the I Pany'S fiaitr of liabiitr. the irxbatioa of any
person or ownisWian as as bayed shell ant afrect airy 60it wbich such palm or organi>atw m
womb havcas a daimaa irmn w in indw.
4. Widr rMgtwa to the adtktiond anac" this hrtanmce stmt trot be cancilk 1. or
materb* rtdaeed m eowxagc w lbaks exeeps after tidy (30) days written atWM has boss
given in the City of Santo Ana. 20 Civic,C bvm Pkmk State Ana. Califemis 92'10!.
(Completion of do following, including cotntwsiphwma. is nquuaed to onake dus adorscarnt
efroctift 1
areetive 1/1/05 , dws todoseetoa form as a law of
Policy A --A6f1ed79H77:i -l�5
L tw to �atrrs i rata IS cstpg or sntrl7, 14A
Nam Insatd
Cauaasigwd by
Audtwlxd 14prmutmttivt
APPROVED AS TO FORM
h 2
aura Stitt Sheedy�" -"`
- A"'i tact City Attornev
E01EO 39va 30dMI33439 bogs -siZ -6176 TS:EI 99@Z /51 180
f SP
C HOLDER COPY
STATE E P.O. BOX 807, SAN FRANCISCO,CA 94142 -0807
COMPENSATION _
INSURANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 06-01 -2005 GROUP: 000723
POLICY NUMBER: 0000075 -2005
- CERTIFICATE ID: 2
CERTIFICATE. EXPIRES: 06-01-2006
06 -01 2005/06 -01 -2006
CITY OF SANTA ANA SP JOB:
COMMUNITY DEVELOPMENT AGENCY
PO BOX 1988 M -25 f
SANTA ANA CA 927!02
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer.
We will also give you 30 days - advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies listed' heroin. Notwithstanding any requirement term, or condition of any contract or other document
with respect to which this certificate of insurance may _ be issued or may pertains the insurance afforded by the
policies described herein is subject to all the terms,: exclusions and conditions of such policies.
AUTHORIZED REPRESENTATIVE PRESIDENT.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000.00 PER OCCURRENCE.
ENDORSEMENT #00.15.. ENTITLED.. ADDITIONAL. INSURED EMPLOYER" EFFECTIVE... 06-01 -2005 IS ATTACHED TO AND
FORMS .A PART OF THIS POLICY. -_
NAME OF ADDITIONAL INSURED: CITY OF SANTA ANA SP
'ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2005 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
EMPLOYER
APPROVED AS To FORM
3 alfra Stitt Sh Y
Assistant City AttorneY.
._LEGAL NAME
BOYS AND GIRLS CLUB OF SANTA ANA
950 HIGHLAND ST
SANTA ANA CA 92703
(REV.3 -03)
BOYS AND GIRLS CLUB OF SANTA ANA
(A NON PROFIT CORPORATION)
PRINTED: 05/17/2005