The URL can be used to link to this page

Home My WebLink AboutMERCY HOUSE LIVING CENTERS (ESG 2003a) """: 'w' -' AMENDMENT TO AGREEMENT FOR USE OF EMERGENCY SHELTER GRANT FUNDS THIS AMENDMENT, made and entered into this -(fI..- day Of!1tn12003, by and between Mercy House - Regina and Joseph, a California nonprofit organization ("Subrecipient") and the of the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). 11- Looz.,OIl3-0 1-1 RECIIALS A. The City and Subrecipient entered into that certain Agreement Between the City of Santa Ana and Mercy House - Regina and Joseph for the Use of Emergency Shelter Grant Funds dated April I, 2002, hereinafter referred to as "said Agreement", for Subrecipient to receive Emergency Shelter Grant Funds (ESG) in the amount of Thirty Two Thousand Dollars ($32,000.00) for the operation of an emergency shelter program for the homeless. B. The parties hereto now desire to amend the amount of the grant to increase it with an additional Five Thousand Five Hundred Ten Dollars ($5,510) for this fiscal year. This additional money is part of prior year funding that had been awarded to three subrecipients that were unable to expend their entire grant amounts in the federally mandated 24-month period. C. City Council authorized this reallocation at its regular meeting of April 7, 2003. WHEREFORE, in consideration of the mutual and respective covenants and promises hereinafter contained and made, and subject to all of the terms and conditions of said Agreement as hereby amended, the parties hereto do hereby agree as follows: 1. The total Grant Award to Subrecipient will be amended to include the additional Five Thousand Five Ten Hundred, for a total grant award of Thirty Seven Thousand Five Hundred Ten Dollars ($37,510.00) in ESG funds. 2. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Amendment to said Agreement the date and year first above written. ATTEST: CITYOFZAA a tfl;;z DAVID N. REAM City Manager fa a:: Q: UJo~ =t~Ul ..4 L.t..Ot.) a:~ zo;z z' og;~o ::>~ UJ "''-. 0 u~~~ ~ ~;:;;~~ l5'", g; ::.:: -' V' :lC ... cno::;:: a::~ ~~~ ~~ 11 ' (Plt._....) L> . lc- 1""'" ~~ 1\TRICIAE.HE Y Clerk of the Council APPROVED AS TO FORM: JOSEPH W. FLETCHER SUBRECIPIENT -MERCY HOUSE if:~ Title: ~c:.l.l..-h\JL ~Ir~c.. ~r dLl~ By: Lisa E. Storck Assistant City Attorney A CORD_ CERTIFICf TE OF LIABILITY INsunANCeeRgi~lDH OA~.:;'(;'40~ THIS CERTIFICATE SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P~OOt."CER Huntiagton Pacific Ins. Agency 18672 Florida St. Ste. 302D Huntington Beach CA 92648 Phone:714-B41-6283 INSURERS AFFORDING COVERAGE INSURED Mercy House Transitional Living Center ETAL P.O. Box 1905 Santa Ana CA 92702 I \.uvr:i-<AGES INSURER A: INSURER B; INSURER c: INSURER 0: INSURER E: Great American Insurance Co. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ~~o CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS. l~f~1 TYPE OF INSURANCE POLICY NUMBER DATEUMMIOOfYYl OATE"MM/DDrvYl LIMITS ~"- EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABIUTY PAC6536218 05/02/03 05/02/04 FIRE DAMAGE (Anyone fire) $200,000 CLAIMS MADE 0 OCCUR MEO EXP (Anyone person) $10,000 PERSONAL & ADV INJURY , 1,000,000 ~L AGGREGATE LIMIT APPL;S-PER I , I ';f~c.:RAL AGGRE~.... I c: li;',V~C/GG;l PRODUCTS. COMP/OP AGG $1,000,000 ,[=tPRO. n X POLICY JEeT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 r-- (Eaaccident) ANY AUTO f- ALL OWNED AUTOS BODILY INJURY . r--- (Per person) SCHEDULED AUTOS A ex HIRED AUTOS PAC6536218 05/02/03 05/02/04 BODilY INJURY $ r--- (Per accident) ~ NON-DWNED AUTOS - PROPERTY DAMAGE . (Per accident) GARAGE LIABILITY AUTO ONL Y ~ EA ACCIDENT $ R ANY AUTO OTHER THAN EA ACC $ APPROVED AS Tu l-v -\..10. AUTO ONLY: AGG . EXCESS LIABILITY J>>. ",/,., EACH OCCURRENCE . :=J OCCUR D CLAIMS MADE AGGREGATE $ .d::::. LauVI She. oj' lJrnt $ =1,0EOUCTIBLE poputy City At . RETENTION $ . I WORKERS COMPENSATION AND I jTORYLlMrisl I"ER. EMPLOYfRS' LIASILITY E.L. EACH ACCIDENT $ ( t::.i... DISEASE. E,., ..;"r-:':':":::j W , I I 1E.-l~ISEASE. POLlZy LIMIT I $ IOTHER I DESCRIPTION OF OPERATIONSILOCATIONSNEHIClES/EXClUSIONS ADDEO BY ENDORSEMENT/SPECIAL PROVISIONS hOith respec ts to the additional insureds, this insurance shall not be cancelled or materially reduced in coverage or limits except after (30) days written notice has been given to the City of Santa Ana. '::.7: t:;r,. C' :::0.. ~--t: ~-'9 :~; 0 I:j::i CERTIFICATE HOLDER I y I ADDITIONAL INSURED; INSURER LETTER: SANTANA CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPlRATIO~< DATE THEREOF, THE ISSUING INSURER Will ~""'ijB MAll ..3..L OAYS WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, ~ '41~~ VJ R J.. r1-' ~~n}J..~'I"'l'O'fT'n"'rorfiftt<I#s# City of Santa Ana, Community Development Agency M-25 Att: John Maloney P.O. Box 1988 Santa Ana CA 92702-1988 I ACORD 25.S (7/97) AUTHORIZED REPRESENT~~E Don Heberden Ji}(frV ~ @ACORD CORPORATION 1988 O~_./"....~__ . -'-:-:-.:e"-'\t~'--- , "'" ......; I IMPORTANT If tI1e certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s}. If SUBROGATiON IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s}. DISCL.II.IMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer{s), authorized representative or producer, and the certificate holder, nor does it ...... affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25.S (7/97) t"t(U'/ . t-HX NU. ; (1.'1-04 (-0;)4';:1 oc:: J.:; .:::.t:.Jt::J.::. .,i...l..J.t:..If'"OI.. j..J j" . '-' ~ ADDITIONAL INSURED ENDORSEMENT FOR COMM.ERCIAL UENERAL LIABILITY POLICY Tnl<umnce Company Great American Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # PAC6536218 relating to the following: '. 1. The City of Santa Ana, 20 Civic CenterPla7..a, Santa Ana, California 92701; its officers, employees, agents, volunteers and representatives are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from tne operations and uses performed by or on behalf(]fthe named insured. 2. With respect to claims arising out of the operations and u.~es perfo~d by or on behalf of the named insured, such insurance llS is afforded by this policy is primary nnd is not additional to or contributing with any other insuranec carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or sui~ is brought except with rcspect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which sllch person or orguni7..ation would have as a claimant if not so includcd. . 4. With respect to the additional insureds, this insurance shall not 00 cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the rollowing, including countersignature, is required to make this endorsement effective.) Effective Policy # Issued to May 3, 2003 , tbis endorsement form as a part of PAC6536218 Mprr,y H()lI<;" Transitional Livinq Center ETAL Named Insured Countersigned by 7j~'~ Authorized Represen ative Robin Hatfield - Broker APPROVED AS i2..~y" . , . ~ ~ ~il:' fie ~.1Ura Sheedy 7~ ) t~ll!v c'- . / . ~ ..ty A[!ornr.v TO FORM ---~ >dE'a. 'T': ..,' .P.:l"C:::A'tE""'O:"F"':::L' <:t"A> :S...:,.[.:>:I:r...:y....::IKlS.. 'j:>io:AN' >'C' "'E"'::: >':':::':::':>': ... DATErMIIJ1lOIYY} :.:>.::.:.:...,:. :,:::::.....:!:y,:.:.}.::>.:::: :'::::.., .':,:,:.<:.::.:>.!,,:..YQb.:>.::.:...:.:.:~~:i. ...... 05/03/02 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR AlTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE NOY-eS-2aS2 83:20 PM -c,=, House '-' ACORD. PRODUCER HUT.~ington Pacific Ins. Agency ~8672 Florida St. Ste. 302D Huntington Beach CA 9~'4B Robin Hatfield Phone No. 714-841-6283 INSuneo F", No. 714-842-2538 A ~2M2-IM'-2'" 14 -~l. -"C/~ -~q Mercy Bouse Transitional Living Center E'I'AL A--'24n-1J1{3-1J~ P.O. Box 1905 Santa Ana CA 92702 71~ "36 7901 ....J COMPANY A Great American Insurance Co. COMPANV B COMPANY C COMPA.N'l' D ~Wr~~~~~iZT ';~~oLl6ES OF INSU;"N~~ L1ST~~.ELO~ ~~ ~~~~D;D .;~~ ~~D~~~ ~~6vE FO~~E ;.olley PERIOD' INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUI.lENT WITH RESPECT TO 'M-t10l THIS CERTIFICATE MA.Y Be ISSUeo OR MAY PERTotJN, THE INSURANCE AFFORDED BY THE POLICIES CESCRIllEO HEREIN IS SUBJECT TO All THE TERMS, EXClUSIONS ANO CONDITIONS OF SUCH POl.ICIE.S. l.IMlT8 SHOWN MAY HAVE e!!eN REDUCED BY PAID ClAIMS. co LTR TYPE OF INSURANCE: POLICY NUMeeR GENERAl llAalLnY t-= A X COMMERCIAl. GENeRAL LIABIlITY :::;: I CLAlMS""" [!] OCCUR Olh'NER'S & CONTRACTOR'S PROT - PAC65362J.B !.,:,:"OMOBILE LIABJlJTY ANY AUTO - ....LL OWNeD AUTOS - SCHEDULEO AUTOS A X HIRED ALn'OS ~ NON-O'o\INED AUTOS .-0 f- PAC6S362J.B ~MGE LIABILITY r-- ANY AUTO - EXCESS LIABILITY I UMBRelLA FORM I OTHEA THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS'LlABllITY POLICY G'fECTrve: POLICY EXPIRA rlCN DATE(Mf.IJODiYV) DATE(MfNCOfr'Y} 05/02/02 GENERAl AGGREGATE PRODUCTS. COMPJOP AGO PERSONAL & AOV IHJURY EACH OCCURRENCE FIRE OMIAGE (Any one nr~) NED EXP (My one pl!I"sonJ 05/02/03 COMBINED SINGLE lIMIT 05/02/02 BODn..VINJURY (P<<"""",) 05/02/03 eoOJLYJNJURY (Per.cddenl] PROPERTY OAMAGE AUTO ONLY. EA ACCIDENT OTHEA.1'HA.N AUTO ONLY: EACH ACCIO!NT AGGR.fGA TE EACH OCCURRfNCE AGGREGATE P.82 LIMITS 52,000,000 .J.,OOO,OOO 11,000,000 .s 1,. 000, 000 . 200,000 'J.O,OOO . J., 000, 000 . . . ~ S . . >\PPROVJ:;J) AS TO r{J!< Ih ./ )f';'/A'A /J "f4 I A Lliura Sheedy / Deputy City Attorne. . . 1~~~I.YiR I IO~'~ EL EACH ACCmENT 5 a. OJSEASE - POLICY LIMIT S EL DISEASe. EA EMPLOYEE $ THE PRQPFUETORI PARTNER~XECUT~ OFFICERS ARe: OTHER nlNeL NEXCl DESCRIPTION OF OPERATIOHSflOCATJONSNEHlClES'SPEClAllTEMS With respects to the additional insureds, this insurance shall not be cancelled or materially reduced in coverage or limits except after (3D) days written notice has ~ given to the City of Santa ana. CERTIF:r(;ATEi;OI:DEfl::::>,:,........ ... ...... ..... .... .........: :<:::,:C1\,'lI:;~Lli\:T!Dt-I,:::::.:::'",:::::::":"",, ... City of Santa Ana,~nitY Development Agency, -25 Att: John Maloney P.O. Box 1.988 Santa Ana CA 92702-J.988 SHOULD /4Nf OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BefORE THE t:XPJRATION DATE THEREOf, THE ISSUING COMPANY WILl_~-WJL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOlDER NAMEO TO THE LEFT. ...."~,,.O<<T__....,~!""<~t1t~~ m7'3.'",,::::;''Y' . !>N. . . AUTHORIZED REPRESENTATIVE SANTANA !icPRQ :~S;$l'$l<: ...~>:....... Robin Hatfie1d .:,.: ..:::':::A<:(:j"p:q9~QRh!10N ,1:9~8. NOV-21-20a2 04:11 PM M~rc~ Hou~e 714 836 79al P.12t3 11/20/2B02 22:5& --r<t.n, 7l4~538 <I FRX tn 17104-647-6549 '-' PAGE 02/02 Sep, 1:1 20B2 111111A'1 1"3 ADDI'I10NAL tNStJ'ARn RNDOIlSBMENl' FORCOMMF.RCIAT. OITNHRAL tTABlLITVPOLICY Jn~11TIIIl"" Cornpatl,y Great Amel:.i.can Insurancl: Con\:>aIlY This tndot1il!ml:nt modilies such iniurlncc as iI Afforded by the 1ll'OvisiOllS of :~clicy 1/ .J'.AC6~:l6218 rel~ 10 the fbllawine;: I, The Oly of Sama ^'" 20 Civic Centa' PI""", 5.1)18 AIIIl, catlfl/lnla 92701; ill officers, IlrXlpluyeea, aaentI. voJwlN:s IIIICl roplesentlltiv;s Il'Il named as addillllnallllSlnCl8 ("&ddlll.olla1lmun:ds") 1lli1h regard to llablllty IIld dcf'cD8c or suits Il'!aIDa from the operations and UllIlS p.o.!\" I 'led by (11' on belwlf of the nllllHld IIllIUI'lld. 2. Wnb I'CIpCet to cIaima wIns Ollt of the opcraIiODS and llItIl ""*!,,,wc:d by or on behalf of the .08IlIIId mlllnd, _h in~co 1& is Ilffonled by lbls polley ill primary Md Is not additional to or comrlbuUng with &lIY Olber iMItaocc caniaI by or tor the beneflt of the IIddiUan&llllBureds. 3. 'fhj, IllS1II'IOco applies sepuatel)'to each I.a.nred ~(IP;"qt whom (~a~ I. made or I1IIt Is btou&ht except w111t rcspa to thc compan)"s limit! of lfability. The Inchl.IOA or~ PIlliOn or Otphi...tiDll as III inaun:d shall nCllatrcct any rlsJrt which ~ pcmm or OI'JPUll:ra!lon wou14 havo as .. CllIinl8ut if not .0 Illcllldw, 4. With ~ ID the additimuillllllllNds, this illS1ltllllCe sbaU not \)<l Cll1lcolIed, Ol' ma1cl'i.llr reduced in COVI:llIgc or Jimi1I tlXllOpt I1Icr thlrt)' (30) days written ntltlee bJIs beea gMu to the City afBmta Ana, 20 Civic Center PIll%&, s.uu. Ana, Calilbmta 92101- (Com,pleLioll of th, following. including ClOUlIlarSipture, iM required to make tb.ls cnclo1'scmt.nt BffiK:tive.) El!'tc1ive Policy # Issued to MaV 3. 2002 .1hI. cndor8cmcltt form as~. part or p1.C6536218 ""'''7 H""'''. Trans:itional Livinq Center ETA!. __ Named IIlSIlI'Cd CO\lllll::rlignodby '4,~^~~ utl'lOTf:!Ald ~c live Robin Hatfield - Broker APPROVED AS TO FORM AJt~~~ LaIl1ra Sheedy f)('!l1Jty City Attorney ~J;;~~~~::~:~'"tSAN FRANCiSCO,CA 9:~4"'1':.'O."1:0'~8fo."-7':"-~~;{:~~i.~~,!:>~.f~~~:~:j:,~;~i~~~;~11~~i~ ". : COMPENSATION '\~~,_ _ ," >1 .,: - . - - - i ...- - - '-;^~'~~<';~' .;; . . -,". . ,-';~;!;:~~.;<~~.',~,:</'.-t . '" " , ' INS U 1'\ II< N C'E " .,' > ,. J I FUN ,0 CERTIFICATE QF! WOkKERifpQMPENSATlO~ \IN~URANCE l..~,/' r " .... '" "j , ISSUEDA TE, 10-01-02 POLICY NUMBER 1209902 - 02 CERTIFICATE EXPIRES, 10-01-03 CITY OF SANTA ANA COMMUN ITY' DEVELOPMENT AGENCY M-25 POBOX 1988 ATTN JOHN'~ALONEY SANTA ANA CA 92702 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' advarlce notice should this policy be cancelled prior to its normal -expiration. ., ,'-" -' " This cer.tific;:ate:~off-tnsllrAanc:eis "ot~n insurance policy and does not amend, extend or alter__tlle.,coverageafforded by the P9Iicie~-' li$ted herei(L~, Nqtwithstandirl."g any r.e,quirer:n.i!nt. term, or condition ~f any contract ,or' other d.pcumenL with resp-~ct}o.which this c'ertificate of irisuraqce,_,may. pe '-i~sued or may pertain" the Insurance afforded~by' the) policies described herein is subject to all the t(lrms, exclusions and conditions of such policies. -:" , ~ ,,' ;.. .,,-f ,.' ~ ./1> /7c !/i/ . ""::_V?'~ " PRESIDENT .. . ,.',.. EMPLOXE~'~ LIABILITY LIMIT INCLUDING DEFENSE COSTS: $l~QOO;OOO.OO P~Rlbcqu~RENCE. ,v, _~, ^ ~ -;. '.. .'1: 'ENDORSEMENT"'2065 'ENTI~'rL.~DCERTIFIC.ATE HOLDERS' NOTICE EFFECTIVE '10/01/02 IS 'ATi/l.giEDTO AND FORMS A PART 'OF THIS poqCY.' , "'" \; ..' ~ . '~,',- ,.' \ APPROVED AS '~LV~ }:a raSheedy Do:rl:l} C:t~!A:ttorney 10 FORNI EMPLOYER LEGAL NAME .-:" ;: MERCY. HOUSE TRANSITIONAL CENTERS ; PO BOX 1905 . ..... ' SANTA ANA CA'92702 .' ,- . , - '-" MERCY HOUSE;.T~A/'lS;TIONAL LIVING CENTERS (~~i~,~-P~O~~:~ ~;~~,)'~i~ '\'~1.~f,~i;;;< ' .t,--eX}-. :"'0"'''' ..,:i" ,_ >'/ ,> .'<'09: 18.702. i':I~~.r.lt{IJlrll~~III:'l'i~~~i..~i'''i~*.~:I~-1-::t.I~,~.{~~(~i:~.i~~~;;""'';- ,', .~. "{~I'.[';;'~~~ LIVING ;.1;] III '-" "" SP S'TATE COMPENSA1'"iON INSURANCE FUND P.O. BOX ~07, SAN FRANCISCO,CA 94101-0$07 CERTIFICATE OF, WORKERS'COMPENSA T10N1NSURANCE ~'" .. ,,' ISSUE DATE: 10-01-02 POLICY NUMBER: 1209902 - 02 CERTIFICATE EXPJRES:l0-0 1-03 C.I TY OF SANTA ANA COMMUNITY'OEVEUOPMENLAGENCY M-25 POBOX 1988, :ATTN eJOHN'MALONEY SANTA ANA CA '9270~ . This is to certify that we have issued a valid Workers' Compensation insurance polic{'in a -forni"approvedby^the California Insurance Commissioner to the employer named below for the policy perioq_indicated. This policy is not subject to cancellation by the Fund except upon 30 days' advance written~o_tjce t~.__theemployer. We will also give you: 39 d.a'ysi-a9va~ee notice should this pOlicy be cancelled prjortojts,:norniaf~xpiration. , '- ,,::-:,:}~ .,-'..,' -/,", , \-";' This certificate,'bf)insur~nce_ is ,,' not, an insurance policy and does not Jme~d/ eXlend or-alter__ tt1f3,co"erag~:afforded bX the pQlicies li,$te.d her~in.<,_~qt~ithstand~~g any_requirl!I'I'J~~t, term, or corydit!o,ry' q1 ;any contra,c,tor'ptherdoculT!enL, with resp~ct to Which thiS certificate of_ Insural')ce :.mayl?e-~I~sued or may pertam,:,the Insurance ',afforded:by the "",,~ policies de~crjbed herein 'S subject to tdl the t,rrrjs,excl~sj~ns and conditi~,ns ,of such policies. ,. ",.' ;. "~ID1~ ,,,'" -','"',,',, ,''''',' .-" EN60.~SEMEm.#20llSENTiTLED CERTIFICATE HOLDERS' fORMS A PART Of THIS POLICY. " '. EMPLOYER'S LIABIL~TY LIMIT INCLUOING DEFENSE CDSTS: c':" '" ' , , $1,ood;o~.oo PERjoCCURRENCE. .:, '__', ,"',", ",c' ",",<'i.:' __ .,',:'....:"',"- ,:;.,: ",', "; NOTICE EFFECTIVE '10/01/02 IS ATTACHED TO AND <' ,,' " t {: "^>_'" . LY(:;G.. ~ ~!{wu- ~ E"SG, ~~. ~"'t r~r.f..~ ~idY\ ;-. , '; ,./,;~ Al'yROVED AS TO FORM Li~Lu~ IJeputy City Attorney' EMPLOYER 0'Z.. -03 , LEGAL NAME MERCY f-ItiUSE TRANSITIONAL LIVING CENTERS PO BOX 1905 SANTA ANA CA 92702 MERCY HOUSE. TRANSITIONAL, LIVING CENTERS (A NON-PROFIT 'ORG,) (' ' : r ""--'; ;C"';',.>' . J -: ~ . . . .- THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 (REV 201) .. ."09'-IB-02