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STATE OF TEXAS §
COUNTY OF TARRANT §
This contract ("Contract") is made and entered into by and between the City of Fort Worth
(hereafter "City") and Tarrant County Samaritan House, Inc. (hereafter "Agency"), a Texas non-
profit corporation. City and Agency may be referred to individually as a"Party"and jointly as"the
Parties".
The Parties state as follows:
WHEREAS, City receives grant monies from the United States Department of Housing and
Urban Development through the Housing Opportunities for Persons with AIDS Program
("HOPWA") Program, Program No. TX-H-15-F002, Catalog of Federal Domestic Assistance No.
14.241;
WHEREAS, the HOPWA program is intended to address the needs of eligible persons
associated with the challenge of living with HIV/AIDS and their families;
WHEREAS, Agency submitted a proposal to use HOPWA funds for an eligible program
under the HOPWA Regulations whereby Agency will provide services to low and moderate income
persons;
WHEREAS,City citizens,the Community Development Council, and the City Council have
determined that HOPWA programs are needed by the City's citizens;
NOW, THEREFORE,the Parties understand and agree as follows:
1. INCORPORATION OF RECITALS
City and Agency hereby agree that the recitals set forth above are true and correct and form
the basis upon which the Parties have entered into this Contract.
2. DEFINITIONS
In addition to terms defined in the body of this Contract, the terms set forth below shall
have the definitions ascribed to them as follows:
Area Median Income or AMI means the median family income for the Fort Worth-Arlington
metropolitan statistical area as established annually by HUD. The 2015 income limits are attached
hereto as EXHIBIT "A-1"—2016 HUD Income Limits.
Business Diversity Enterprise Ordinance or BDE means the City's Business Diversity Ordinance,
Ordinance No. 20020-12-2011.
Complete Documentation means the following documentation as applicable:
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Tarrant County Samaritan House,Inc. OFFICIAL RECORD Rev.9.12.2016
ti CITY SECRETARY"'
FTM WORTH.,TX
• Attachments I, II, and III,with supporting documentation including:
o Proof of expense: copies of timesheets, invoices, leases, service contracts or
other documentation showing that payment is due by Agency.
o Proof of payment: cancelled checks, bank statements, or wire transfers
necessary to demonstrate that amounts due by Agency were actually paid by
Agency.
o Proof of client eligibility: Source Documentation sufficient to show that
clients participating in the Program are HOPWA Eligible Clients as described
in Section 6.
• Complete Documentation shall meet the standards described in the attached
EXHIBIT "F"- Standards for Complete Documentation.
• Any other document or record reasonably necessary to verify costs spent and client
eligibility for the Program.
DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26.
Director means the Director of the City's Neighborhood Services Department.
Effective Date means October 1, 2016.
HOPWA means Housing Opportunities for Persons with AIDS.
HOPWA Eligible Client means a client whose annual income adjusted for family size does not
exceed 80% of AMI using the most current HUD Income Guidelines and Technical Guidance for
Determining Income and Allowances verified by Source Documentation. The client must also have
a documented diagnosis of HIV/AIDS.
HOPWA Funds means the HOPWA grant funds supplied by City to Agency under the terms of
this Contract.
HOPWA Regulations means regulations found at 24 CFR Part 574 et seq.
HUD means the United States Department of Housing and Urban Development.
IDIS means Integrated Disbursement Information System, HUD's project tracking system.
Neighborhood Services Department means the City's Neighborhood Services Department.
OMB means the Office of Management and Budget.
Program means the services described in EXHIBIT "A"—Program Summary.
Reimbursement Request means all reports and other documentation described in Section 9.
Source Documentation means documentation of full household income of any type described under
the definition of annual income in 24 CFR Part 5.609, including but not limited to copies of
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paychecks, Social Security and disability verification letters, interest or rental income statements,
retirement income statements, child support and alimony verification,unemployment benefit letters,
and the like.
Unduplicated Clients means a count of HOPWA Eligible Clients served at least once in the
Contract Term. HOPWA Eligible Clients served more than once in the Contract Term will only be
counted the first time they are served when determining the total count of Unduplicated Clients.
3. TERM.
The term of this Contract begins on the Effective Date and terminates on September 30,
2017 unless earlier terminated as provided in this Contract.
4. DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Provide HOPWA Funds.
City shall provide up to $485,844 of HOPWA Funds under the terms and conditions of this
Contract.
4.2 Monitor.
City will monitor the activities and performance of Agency and any of its contractors,
subcontractors or vendors as necessary, but no less than annually. Monitoring by City will include
determining whether Agency is meeting the requirements of the HOPWA Regulations during the
term of this Contract.
5. DUTIES AND RESPONSIBILITIES OF AGENCY.
5.1 Required Services.
Agency shall perform the services described in EXHIBIT "A" — Program Summary in
accordance with the terms and conditions of this Contract.
5.2 Use of HOPWA Funds.
5.2.1. Compliance with HOPWA Regulations and Contract.
Agency shall be reimbursed for eligible Program costs with HOPWA Funds only if City
determines in its sole discretion that:
5.2.1.1 Costs are eligible expenditures in accordance with HOPWA Regulations.
5.2.1.2 Costs are in compliance with this Contract and are reasonable and consistent
with industry norms.
5.2.1.3 Complete Documentation, as applicable, is submitted to City by Agency.
5.2.2 Budj4et
5.2.2.1 The HOPWA Funds will be paid on a reimbursement basis in accordance
with EXHIBIT `B" -Budget.
5.2.2.2 During the term of this Contract, Agency may submit written requests to
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increase or decrease line-item amounts in the Budget, including an
explanation of why such increases or decreases are necessary. All
requests shall be approved by Director in writing, with such approval
being in the Director's sole discretion. If Director approves the Agency's
proposed Budget amendment (as approved, the "Amended Budget"),
then the Amended Budget will take effect on the first day of the month
following the month in which it was approved by Director, unless
otherwise specified in the amendment. All requests for Budget
amendments must be submitted by June 1,2017.
5.2.3 Change in Program Budget.
5.2.3.1 Agency will notify City promptly of any additional funds it receives for
operation of the Program, and City reserves the right to amend this
Contract in such instances to ensure compliance with HUD regulations
governing cost allocation.
5.2.3.2 Agency agrees to utilize the HOPWA Funds to supplement rather than
supplant funds otherwise available for the Program.
5.2.4 Payment of HOPWA Funds to Agency.
HOPWA Funds will be disbursed to Agency upon City's approval of Reimbursement
Requests including submission of Complete Documentation to City in compliance with Section 9.
If Agency expends all funds budgeted for the Program prior to September 30,2017, City may hold
back a small amount of the HOPWA Funds until the end of the term. During this interim period,
Agency must continue to submit Attachment III — Client Data Report in EXHIBIT "D" —
Reimbursement Forms monthly. It is expressly agreed by the Parties that any HOPWA Funds not
spent or not approved for reimbursement to Agency shall remain with City.
5.3 Program Performance Milestones.
5.3.1 Agency represents that the Program will achieve the following milestones in
accordance with EXHIBIT "A"—Program Summary and the table below:
T_Tndupllcated Cheats as
specifiPd in E7�IT
.A Program
MonthExpenditures
3 25% 25%
6 50% 50%
9 75% 75%
12 100% 100%
5.3.2 Failure of Agency to meet these milestones or a material deviation from them as
outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section, "material
deviation" shall mean more than 10% lower than the specified goal. In the event of such breach,
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City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests,
to lower Agency's allocation of HOPWA Funds, or to terminate this Contract.
5.3.3 Failure to meet at least 80% of its performance milestones or serve 132 Unduplicated
Clients under this Contract may, in City's sole discretion,disqualify Agency for consideration under
the City's Request for Proposals for the 2016-2017 Program Year for federal grant funds.
5.3.4 Amendments to performance milestones regarding HOPWA funds must be approved
by the Director in writing, with such approval being in the Director's sole discretion. If Director
approves the Agency's proposed amended performance milestones (as approved, the "Amended
Performance Milestones"), then the Amended Performance Milestones will take effect on the
first day of the month following the month in which it was approved by Director, unless otherwise
specified in the amendment. All requests for amendments to performance milestones must be
submitted by June 1,2017. Notwithstanding the above, any amendments to this Contract shall not
reduce the number of Unduplicated Clients stated in Section 5.3.3 and in EXHIBIT"A"—Program
Summary.
5.4 Identify Program Expenses Paid with HOPWA Funds.
Agency will keep accounts and records in such a manner that City may readily identify and
account for Program expenses reimbursed with HOPWA Funds. These records shall be made
available to City for audit purposes and shall be retained as required hereunder.
5.5 Program Subcontracts.
Agency shall not enter into a subcontract with another agency, contractor, or vendor to
provide a service to clients for any part of the Program that will be paid with HOPWA Funds without
City's written consent.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eligibility.
Agency will document the eligibility of all prospective clients. Agency may redact the
client's personal information and substitute a client number. Agency will document client eligibility
as follows:
6.2.1 Income.
Agency must verify all new clients' income eligibility with Source Documentation. Agency
must use the annual income definition used by 24 CFR Part 5.609 to establish client income
eligibility and must use the most current HUD Income Guidelines.
6.2.2 Diagnosis.
Agency must submit a signed, dated statement that the client's file contains documentation
of the client's diagnosis of HIV/AIDS. The HIV/AIDS diagnosis must be made by a licensed health
care provider; a client's self-certification of diagnosis is not sufficient. Agency should not submit
the actual diagnosis to City.
6.2.3 Emergency Need.
For clients receiving short term rental, mortgage or utility assistance, Agency must also
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verify and document that the client has an emergency need, such as sudden loss of income, eviction,
utility shutoff, or extraordinary and unexpected healthcare costs. Agency must submit its policy
regarding documenting emergency need to City by October 1,2016.
6.3 Submission of Complete Documentation.
Agency must submit copies of documentation of client eligibility described in Section 6.1
with Attachment III in each month's Reimbursement Request for all Unduplicated Clients.
6.3 Maintain Documentation.
Agency must maintain copies of all documentation required by this Section 6 for 5 years
following the expiration of the Contract term. This Section shall survive the earlier terminations or
expirations of this Contract.
7. ADDITIONAL HOPWA REQUIREMENTS.
Agency agrees to comply with all requirements of the HOPWA Program as stated in the
HOPWA Regulations, including but not limited to the following:
7.1 Environmental Review.
HOPWA Funds will not be paid, and costs cannot be incurred until City has conducted an
environmental review and completed an Environmental Review Record as required by 24 CFR Part
58. The environmental review may result in a decision to proceed with, modify, or cancel the
funding for the Program. Further, Agency will not undertake or commit any funds to physical or
choice limiting actions as described in any applicable federal regulations. Any violation of this
provision will (i)cause this Contract to terminate immediately; and(ii)require Agency to repay City
the HOPWA Funds it has already received and forfeit any future payments of HOPWA Funds.
7.2 Contract Not Constituting Commitment of Funds.
Notwithstanding any provision of this Contract, the Parties agree and acknowledge that this
Contract does not constitute a commitment of funds, and that such commitment of funds or approval
may occur only upon (i) satisfactory completion of an environmental review and receipt by City of
an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of City's 2016-
2017 Action Plan, and (iii) receipt by City of grant agreement from HUD.
7.3 Monitoring.
7.3.1 Agency understands and agrees that it will be subject to monitoring by City for
compliance with terms and provisions of this Contract and the HOPWA Regulations for the term of
this Contract. Agency is subject to such monitoring during the term of this Contract and for 5 years
after the Contract term ends. Agency will provide reports and access to Program files as requested
by City during this 5 year period. For purposes of this Contract,this 5 year period for monitoring is
deemed to begin on October 1,2017 and end on September 30,2022 regardless of whether or not
this Contract is earlier terminated.
7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United
States Comptroller General shall have access during regular business hours, upon 48 hours prior
notice,to Agency's offices and records pertaining to the use of the HOPWA Funds,and to Agency's
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officers, directors, agents, employees, contractors, subcontractors and vendors for the purpose of
such monitoring.
7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring,
City reserves the right to perform desk reviews or on-site monitoring of Agency's compliance with
the terms and conditions of this Contract. City shall provide Agency with a written report of the
monitor's findings after each monitoring visit. If the monitoring report notes deficiencies in
Agency's performance, the report shall include requirements for the timely correction of said
deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report may
be cause for suspension or termination of this Contract as provided herein.
7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract term and for 5
years thereafter and shall survive the earlier termination or expiration of this Contract.
7.3.5 Agency shall provide City annually the results of any state or federal monitoring.
Such results shall be submitted within 60 days of receipt of such state or federal monitoring report,
or with the January Reimbursement Request, whichever is earlier.
7.4 Agency Procurement Standards.
Agency shall comply with all applicable federal, state and local laws, regulations, and
ordinances for making procurements under this Contract. In addition to the conflict of interest
provision in Section 14.13.3, Agency shall establish written procurement procedures to ensure that
materials and services are obtained in a cost effective manner and that provides for full and open
competition. When procuring materials and services for this Contract, Agency shall comply at a
minimum with the procurement standards in 2 CFR Part 200.317 through 2 CFR Part 200.326.
7.4.1 Contracts in excess of$10,000.00 made by Agency using CDBG Funds must address
termination for cause and convenience including the manner by which such termination shall be
effected and the basis for settlement of the terminated contract, if any, as required by Appendix II
(B), 2 CFR Part 200.
7.4.2 Agency shall not make any contract with parties listed on the government wide
System for Award Management, www.sam.gov ("SAM"). Agency must confirm by search of
SAM that all contractors paid with CDBG Funds are not listed by SAM as being debarred,both prior
to hiring and prior to submitting a Reimbursement Request which includes invoices from any such
contractor. Failure to submit such proofs of search shall be an event of default.
7.5 Cost Principles/Cost Reasonableness.
Agency shall administer its use of HOPWA Funds in compliance with 2 CFR Part 200, as
applicable. The eligibility of costs incurred for performance rendered shall be determined in
accordance with 2 CFR Part 200.400 through 2 CFR Part 200.475.
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7.6 Financial Manazement Standards.
Agency agrees to comply with 2 CFR Part 200, as applicable. Agency also agrees to adhere
to the accounting principles and procedures required therein, utilize adequate internal controls, and
maintain necessary supporting and back-up documentation for all costs incurred in accordance with
2 CFR Part 200.302 and Part 200.303.
7.7 Uniform Administrative Requirements, Cost Principles, and Audit
Requirements.
Agency will comply with the Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards in 2 CFR Part 200, as applicable, or any reasonably
equivalent procedures and requirements that City may require.
7.8 Terms Applicable to Contractors, Subcontractors and Vendors.
Agency understands and agrees that all terms of this Contract, whether regulatory or
otherwise, shall apply to any and all contractors, subcontractors and vendors of Agency which are
in any way paid with HOPWA Funds or who perform any work in connection with the Program.
Agency shall cause all applicable provisions of this Contract to be included in and made a part of
any contract or subcontract executed in the performance of its obligations hereunder including its
obligations regarding the HOPWA Regulations. Agency shall monitor the services and work
performed by its contractors, subcontractors and vendors on a regular basis for compliance with the
HOPWA Regulations and Contract provisions. Agency must cure all violations of the HOPWA
Regulations committed by its contractors, subcontractors or vendors. City maintains the right to
insist on Agency's full compliance with the terms of this Contract and the HOPWA Regulations and
Agency is responsible for such compliance regardless of whether actions taken to fulfill the
requirements of this Contract are taken by Agency or by Agency's contractors, subcontractors or
vendors. Agency acknowledges that the provisions of this Section shall survive the earlier
termination or expiration of this Contract and shall be applicable for 5 years after the Contract Term
ends.
7.9 Copyright and Patent Rights.
No reports, maps, or other documents produced in whole or in part under this Contract shall
be the subject of an application for copyright by or on behalf of Agency. HUD and City shall possess
all rights to invention or discovery, as well as rights in data,which may arise as a result of Agency's
performance under this Contract.
7.10 Conflict of Interest Disclosure.
In accordance with the requirements of Section 14.13.2.1 and 14.13.4,Agency shall establish
conflict of interest policies for federal awards. Agency shall disclose to City in writing any potential
conflict of interest.
7.11 Compliance with FFATA and Whistleblower Protections.
Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the
Federal Funding Accountability and Transparency Act ("FFATA") governing requirements on
executive compensation and provisions governing whistleblower protections contained in 10 U.S.C.
2409, 41 U.S.C. 47125 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
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7.11.1 Agency shall provide City with its DUNS number.
7.12 Internal Controls.
In compliance with the requirements of 2 CFR Part 200.303, Agency shall:
7.12.1 Establish and maintain effective internal control over the HOPWA Funds that
provides reasonable assurance that Agency is managing the HOPWA Funds in compliance with
federal statutes, regulations, and the terms and conditions of this Contract. These internal controls
shall be in compliance with guidance in"Standards for Internal Control in the Federal Government"
issued by the Comptroller General of the United States or the "Internal Control Integrated
Framework" issued by the Committee of Sponsoring Organizations of the Treadway Commission
("COSO");
7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this
Contract;
7.12.3 Evaluate and monitor Agency's compliance with statutes, regulations and the terms
and conditions of this Contract;
7.12.4 Take prompt action when instances of noncompliance are identified including
noncompliance identified in audit findings; and
7.12.5 Take reasonable measures to safeguard protected personally identifiable information
and other information that HUD or City designates as sensitive or Agency considers sensitive
consistent with applicable federal, state, local and tribal laws regarding privacy and obligations of
confidentiality.
7.13 Required Certification of Completion of Trainin,.
At least 1 Agency employee must complete the HUD required "Getting to Work Training
Curriculum" by April 15, 2017 and submit the required certifications to City with the April 2017
Reimbursement Request as more particularly described on EXHIBIT "A-2" —Requirements for
Completion of"Getting to Work Training Curriculum".
7.14 Housing Quality Standards.
All housing assisted under this Contract must meet housing quality standards and habitability
standards as required by 24 CFR Part 574.310(b). City shall have the right to inspect to confirm
compliance with these standards.
8. RECORD KEEPING; REPORTING AND DOCUMENTATION REQUIREMENTS;
AUDIT.
8.1 Record KeepinLy.
Agency shall maintain a record-keeping system as part of its performance of this Contract
and shall promptly provide City with copies of any document City deems necessary for the effective
fulfillment of City's monitoring and evaluation responsibilities. Specifically, Agency will keep or
cause to be kept an accurate record of all actions taken and all funds spent,with supporting and back-
up documentation. Agency will maintain all records and documentation related to this Contract for
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5 years after the Contract term ends. If any claim,litigation,or audit is initiated before the expiration
of the 5 year period, the relevant records and documentation must be retained until all such claims,
litigation or audits have been resolved. For purposes of this Contract, this 5 year period for record
retention is deemed to begin on October 1, 2017 and end on September 30, 2022 regardless of
whether or not this Contract is earlier terminated.
8.2 Access to Records.
Representatives of City, HUD and any duly authorized officials of the federal government
will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of
Agency's records pertaining to all matters covered by this Contract for 5 years after the Contract
term ends. Such access shall be during regular business hours and upon at least 48 hours prior notice.
For purposes of this Contract,this 5 year period for access to records is deemed to begin on October
1, 2017 and end on September 30, 2022 regardless of whether or not this Contract is earlier
terminated.
8.3 Reports.
Agency will submit to City all reports and documentation described in this Contract in such
form as City may prescribe. Agency may also be required to submit a final performance and/or final
financial report if required by City at the termination of this Contract in such form and within such
times as City may prescribe. Failure to submit to City any report or documentation described in this
Contract shall be an event of default of this Contract and City may exercise all of its remedies for
default under this Contract.
8.3.1 Additional Information.
Agency shall provide City with additional information as may be required by state or federal
agencies to substantiate Program activities and/or expenditure eligibility.
8.4 Chanize in Reporting Requirements and Forms
City retains the right to change reporting requirements and forms at its discretion. City will
notify Agency in writing at least 15 days prior to the effective date of such change, and the Parties
shall execute an amendment to the Contract reflecting such change if necessary.
8.5 Audit
8.5.1 Entities that Expend $750,000 or more in Federal Funds Per Year
All non-federal entities that expend $750,000 or more in federal funds within 1 year,
regardless of the source of the federal award, must submit to City an annual audit prepared in
accordance with specific reference to 2 CFR Part 200.501 through Part 200.521. The audit shall
cover the Agency's fiscal years during which this Contract is in force. The audit must be prepared
by an independent certified public accountant, be completed within 6 months following the end of
the period being audited and be submitted to City within 30 days of its completion. Agency's audit
certification is attached hereto as EXHIBIT "C" — "Audit Certification Form" and "Audit
Requirements". The Audit Certification Form must be submitted to City prior to or with the first
Reimbursement Request. Entities that expend less than$750,000 a year in federal funds are exempt
from federal audit requirements for that year, but records must be available for review or audit by
appropriate officials of the federal agency, City, and General Accounting Office.
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8.5.2 City Reserves the Right to Audit.
City reserves the right to perform an audit of Agency's Program operations and finances at
any time during the term of this Contract and for 5 years after the Contract Term ends if City
determines that such audit is necessary for City's compliance with the HOPWA Regulations or other
City policies. Agency agrees to allow access to all pertinent materials as described herein for such
audit. For purposes of this Contract,this 5 year period for City audit is deemed to begin on October
1, 2017 and end on September 30, 2022 regardless of whether or not this Contract is earlier
terminated. If such audit reveals a questioned practice or expenditure, such questions must be
resolved within 15 business days after notice to Agency of such questioned practice or expenditure.
If questions are not resolved within this period, City reserves the right to withhold further funding
under this Contract and/or any other contracts with Agency. IF AS A RESULT OF ANY AUDIT
IT IS DETERMINED THAT AGENCY HAS FALSIFIED ANY DOCUMENTATION OR
MISUSED, MISAPPLIED OR MISAPPROPRIATED HOPWA FUNDS OR SPENT
HOPWA FUNDS ON ANY INELIGIBLE ACTIVITIES, AGENCY AGREES TO
REIMBURSE CITY THE AMOUNT OF SUCH MONIES PLUS THE AMOUNT OF ANY
SANCTIONS, PENALTY OR OTHER CHARGE LEVIED AGAINST CITY BY HUD
BECAUSE OF SUCH ACTIONS.
9. REIMBURSEMENT REQUIREMENTS
9.1 Deadline for Submitting Reimbursement Requests.
9.1.1 Reimbursement Requests shall be submitted monthly to the City and must be
received by the City on or before the 15"day of the month following the month expenses were paid
by Agency. For example, the Reimbursement Request for June expenses must be received by July
15. In the event the 15th falls on a weekend or City holiday, Reimbursement Requests shall be due
the next day that the City is open for business. Failure to submit a Reimbursement Request in a
timely fashion will result in City taking the actions outlined in Section 10.1.
NOTWITHSTANDING ANYTHING ABOVE, THE REIMBURSEMENT REQUEST FOR
EXPENSES INCURRED FOR SEPTEMBER 2017 MUST BE RECEIVED BY OCTOBER 1,
2017. COMPLETE DOCUMENTATION FOR ALL SEPTEMBER 2017 EXPENSES MUST
BE SUBMITTED BY OCTOBER 15, 2017. FAILURE TO SUBMIT A FINAL
REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY OCTOBER
15, 2017 WILL RESULT IN FORFEITURE OF PAYMENT OF THE SEPTEMBER
REIMBURSEMENT REQUEST.
9.1.2 City will notify Agency by e-mail within 20 calendar days if a Reimbursement
Request is lacking Complete Documentation or corrections are needed. Agency will have 10
business days from the date of the e-mail notice to submit any requested information or missing
documentation. Agency may be penalized, at City's sole discretion, in the Request for Proposal for
the 2017-2018 Program Year for any notifications received under this Section. If Agency fails to
submit all the required information or missing documentation within 30 calendar days from the first
e-mail, Agency shall forfeit any payments otherwise due that month and failure to submit any
requested information will be considered an event of default as outlined in Section 10.1.2.
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9.2 Submission of Reimbursement Requests.
Agency shall provide City with Complete Documentation and the following reports as shown
in EXHIBIT "D"—Reimbursement Forms with each Reimbursement Request:
9.2.1 Attachment I—Invoice
This report shall contain the amount requested for reimbursement each month, the
cumulative reimbursement requested to date (inclusive of that month's request), and must be signed
by an authorized signatory of Agency. By signing Attachment I,Agency is certifying that the costs
are valid, eligible, consistent with the terms and conditions of this Contract, and the data contained
in the report is true and correct.
9.2.1.1 Agency must submit a separate invoice for each activity type, i.e.
Administration, Facility Based Operating Costs, Supportive Services,
Short-term Rent, Mortgage and Utility Assistance ("STRMU"), and
Tenant Based Rental Assistance ("TBRA").
9.2.2 Attachment II—Expenditure Worksheet
This report shall itemize each expense requested for reimbursement by Agency and shall
include the Account corresponding the expense to a Budget line item. In order for this report to be
complete the following must be submitted:
9.2.2.1 For payroll expenses, timesheets signed by employees and approved by
supervisor for all payroll expenses listed. Timesheets must distinguish
between HOPWA-funded time and non-HOPWA funded time and reflect
actual time spent on HOPWA-funded activities. Agency may not submit
payroll expenses dated 60 calendar days prior to the date of the
Reimbursement Request.
9.2.2.2 For non-payroll expenses, invoices for each expense listed with an
explanation as to how the invoiced expense pertains to the Program.
Agency may not submit invoices dated 60 calendar days prior to the date
of the Reimbursement Request.
9.2.2.3 Proof that each expense was paid by Agency,which proof can be satisfied
by canceled checks, wire transfer documentation, paid receipts or other
appropriate banking documentation.
9.2.3 Attachment III—Client Data Report.
This report shall list each Unduplicated Client served during the month along with his or her
demographic information. The Client Data Report must maintain a list of all clients served during
the Contract term. In order for this report to be complete,the following must be submitted:
9.2.3.1 Documentation of income verification for each Unduplicated Client the
first time the client is served by the Program, which will be Source
Documentation.
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9.2.4 Overview Report.
Agency shall submit the Overview Report, attached hereto as EXHIBIT "H" — Overview
Report,quarterly with the January,April,July and October Reimbursement Requests. A paper copy
must be submitted with the Reimbursement Request, and an electronic copy must also be emailed to
psa@fortworthtexas.gov or to the Agency's designated City contract administrator.
9.2.5 Delivery of Reimbursement Request.
Reimbursement Requests can be mailed or delivered in person to Neighborhood Services
Department, 908 Monroe Street, Fort Worth, Texas 76102. In addition, Agencies can submit
Reimbursement Requests via email psa@fortworthtexas.gov or to the Agency's designated City
contract administrator, but Agency must submit a signed original of Attachment I by the deadline
in Section 9.1.1.
9.3 Withholding Payment.
CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT
REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit
Reimbursement Requests and Complete Documentation along with any required reports shall
be an event of default.
10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Reimbursement Request or Required Documentation.
10.1.1 If Agency fails to submit a Reimbursement Request in accordance with Section
9,Agency shall be in default of this Contract. City will notify Agency in writing of such default and
the Agency will have 10 business days from the date of the written notice to submit such
Reimbursement Request to cure the default. If Agency fails to cure the default within such time,
Agency shall forfeit any payments otherwise due that month.
10.1.2 If Agency fails to submit requested information or missing documentation as set
forth in Section 9.1.2, then Agency shall forfeit payment due that month and the failure to submit
shall be considered an event of default that shall not be cured.
10.1.3 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR
10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE
OCTOBER 1, 2017, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR
OOCTOBER 1,2017 IS LATE,INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE
WITH THIS CONTRACT OR THE HOPWA REGULATIONS AS DETERMINED BY
CITY IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY
REIMBURSEMENT WILL BE FORFEITED.
10.1.4 In the event of(i) an uncured default under Section 10.1.1 or an event of default
under 10.1.2 (ii) or more than 2 instances of default, cured or uncured, under these Sections, City
reserves the right at its sole option to terminate this Contract effective immediately upon written
notice of such intent with no penalty or liability to City.
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10.1.5 Notwithstanding anything to the contrary herein, City will not be required to pay
any HOPWA Funds to Agency during the period that any Reimbursement Request, report or
documentation is past due or is not in compliance with this Contract or the HOPWA Regulations, or
during any period during which Agency is in default of this Contract.
10.1.6 In the event of termination under this Section 10.1, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds.
10.2 Failure to Maintain Records or Submit Reports and Documentation.
If Agency fails to maintain all records and documentation as required in Section 8, or if the
maintained or submitted report or documentation is not in compliance with this Contract or the
HOPWA Regulations as determined by City in its sole discretion, City will notify Agency in writing
and Agency will have 30 calendar days from the date of the written request to obtain or recreate the
missing records and documentation or submit or resubmit any such report or documentation to City.
If Agency fails to maintain the required reports or documentation, or fails to submit or resubmit any
such report or documentation within such time, City shall have the right to terminate this Contract
effective immediately upon written notice of such intent with no penalty or liability to City.
10.2.1 In the event of termination under this Section 10.2, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds, and any HOPWA Funds paid to Agency must be repaid to City within
30 days of termination. If such HOPWA funds are not repaid to City within the 30 day period, City
shall exercise all legal remedies available under this Contract.
10.3 In General.
10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this
Contract, Agency shall be in default under this Contract if Agency breaches any term or condition
of this Contract. In the event that such a breach remains uncured after 30 calendar days following
written notice by City (or such other notice period as may be specified herein) or, if Agency has
diligently and continuously attempted to cure following receipt of such written notice but reasonably
requires more than 30 calendar days to cure, as determined by both Parties mutually and in good
faith, City shall have the right to elect in City's sole discretion to (i) extend Agency's time to cure,
(ii) terminate this Contract effective immediately upon written notice of such intent to Agency, or
(iii)pursue any other legal remedies available to City under this Contract.
10.3.2 City's remedies may include:
10.3.2.1 Direct Agency to prepare and follow a schedule of actions for carrying
out the affected activities, consisting of schedules, timetables and
milestones necessary to implement the affected activities.
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10.3.2.2 Direct Agency to establish and follow a management plan that assigns
responsibilities for carrying out the remedial activities.
10.3.2.3 Reprogram HOPWA Funds that have not yet been expended from
affected activities to other eligible activities or withhold HOPWA
Funds.
10.3.2.4 Any other appropriate action including but not limited to any remedial
action legally available such as declaratory judgment, specific
performance, damages, temporary or permanent injunctions,
termination of this Contract or any other contracts with Agency, and
any other available remedies.
10.3.3 In the event of termination under this Section 10.3, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds, and any HOPWA Funds already paid to Agency must be repaid to
City within 30 days of the termination. Failure to repay such HOPWA Funds within the 30 day
period will result in City exercising all legal remedies available under this Contract.
10.4 No Funds Disbursed while in Breach.
Agency understands and agrees that no HOPWA Funds will be paid to Agency until all
defaults are cured to City's satisfaction.
10.5 No Compensation After Date of Termination.
Agency shall not receive any compensation for work undertaken after the date of the
termination.
10.6 Rights of City Not Affected.
Termination shall not affect or terminate any of the existing rights of City against Agency,
or which may thereafter accrue because of Agency's default and this provision shall be in addition
to any and all other rights and remedies available to City under the law. Such termination does not
terminate any provisions of this Contract that have been expressly noted as surviving the term or
termination of the Contract. No delay or omission by City in exercising any right or remedy
available to it under this Contract shall impair any such right or remedy or constitute a waiver or
acquiescence in any Agency default.
10.7 Waiver of Breach Not Waiver of Subsequent Breach
The waiver of a default or breach of any term, covenant, or condition of this Contract shall
not operate as a waiver of any subsequent default or breach of the same or any other term, covenant
or condition hereof.
10.8 Civil Criminal and Administrative Penalties
Failure to perform all the Contract terms may result in civil, criminal or administrative
penalties, including, but not limited to those set out in this Contract.
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10.9 Termination for Cause
10.9.1 City may terminate this Contract in the event of Agency's default, inability, or
failure to perform subject to notice,grace and cure periods. In the event City terminates this Contract
for cause, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be
immediately rescinded and Agency shall have no further right to such funds and any HOPWA Funds
already paid to Agency must be repaid to City within 30 days of termination. Failure to repay such
HOPWA Funds within 30 days will result in City exercising all legal remedies available to City
under this Contract. AGENCY ACKNOWLEDGES AND AGREES THAT IF CITY
TERMINATES THIS CONTRACT FOR CAUSE, AGENCY OR ANY AFFILIATES OF
AGENCY SHALL NOT BE CONSIDERED FOR ANY OTHER CITY CONTRACT FOR
HOPWA FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE OF TERMINATION.
10.9.2 Agency may terminate this Contract if City does not provide the HOPWA Funds
substantially in accordance with this Contract.
10.10 Termination for Convenience.
In terminating in accordance with 2 CFR Part 200, Appendix II, this Contract may be
terminated in whole or in part only as follows:
10.10.1 By City with the consent of Agency in which case the Parties shall agree upon
the termination conditions, including the effective date and in the case of partial termination, the
portion to be terminated; or
10.10.2 By Agency upon at least 30 days written notification to City, setting forth the
reasons for such termination, the effective date, and in the case of partial termination,the portion to
be terminated. In the case of a partial termination, City may terminate the Contract in its entirety if
City determines in its sole discretion that the remaining portion of the Contract to be performed or
HOPWA Funds to be spent will not accomplish the purposes for which the Contract was made.
10.11 Dissolution of Agency Terminates Contract.
This Contract shall terminate in the event Agency is dissolved or ceases to exist. In the event
of termination under this Section, all HOPWA Funds are subject to repayment and/or City may
exercise all of its remedies under this Contract.
10.12 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired by Agency
with the HOPWA Funds including cash, interest payments from loans or otherwise, all outstanding
notes, mortgages or other security instruments, any accounts receivable attributable to the use of the
HOPWA Funds, and any real or personal property owned by Agency that was improved with the
HOPWA Funds shall automatically transfer to City or to such assignee as City may designate.
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11. REPAYMENT OF HOPWA FUNDS.
All HOPWA Funds are subject to repayment in the event the Program does not meet the
requirements of this Contract or in the HOPWA Regulations. If Agency takes any action that
results in the City being required to repay all or any portion of the HOPWA Funds to HUD,
Agency agrees it will reimburse City for such repayment. If Agency takes any action that
results in City receiving a finding from HUD about the Program, whether or not repayment
of all or any portion of the HOPWA Funds is required of City,Agency agrees City may require
that 10% of the HOPWA Funds be repaid to City as liquidated damages. The Parties agree that
City's damages in the event of either repayment to HUD being required or receiving a finding from
HUD are uncertain and would be difficult to ascertain and may include an impact on City's HOPWA
grant or other federal grant funds, in addition to the finding by HUD or a required repayment of
funds to HUD by City. Therefore, the Parties agree that payment under this Section of 10% of the
HOPWA Funds by Agency to City is liquidated damages and not a penalty.
12. CHANGE IN NON-PROFIT STATUS.
Agency must provide City with written notification of any changes to its non-profit status
within 15 calendar days of being notified of the change. Regardless of notice by Agency,if the non-
profit status of Agency changes after the date of this Contract, City may but is not obligated to,
terminate this Contract. In the event of termination under this Section 12, all HOPWA Funds
awarded but not yet paid to Agency pursuant to this Contract shall be immediately rescinded and
Agency shall have no further right to such funds. City, in its sole discretion, may require that any
HOPWA Funds already paid to Agency must be repaid to City within 30 calendar days of
termination under this Section.
13. SURVIVAL.
Any provision of this Contract that pertains to auditing,monitoring, client income eligibility,
record keeping and reports, City ordinances, or applicable HOPWA requirements, and any default
and enforcement provisions necessary to enforce such provisions, shall survive the termination of
this Contract for 5 years after the Contract term ends and shall be enforceable by City against
Agency. For purposes of this Contract,this 5 year period for survival of certain Contract provisions
is deemed to begin on October 1, 2017 and end on September 30, 2022 regardless of whether or
not this Contract is earlier terminated.
14. GENERAL PROVISIONS.
14.1 Agency an Independent Contractor.
Agency shall operate hereunder as an independent contractor and not as an officer, agent,
servant or employee of City. Agency shall have exclusive control of, and the exclusive right to
control,the details of the work and services performed hereunder, and all persons performing same,
and shall be solely responsible for the acts and omissions of its officers, members, agents, servants,
employees, contractors, subcontractors,vendors, clients, licensees or invitees.
14.2 Doctrine of Respondeat Superior.
The doctrine of respondeat superior shall not apply as between City and Agency, or its
officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients,
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licensees or invitees, and nothing herein shall be construed as creating a partnership or joint
enterprise between City and Agency. City does not have the legal right to control the details of the
tasks performed hereunder by Agency, its officers, members, agents, employees, contractors,
subcontractors, vendors, clients, licensees or invitees.
14.3 Agency Property.
City shall under no circumstances be responsible for any property belonging to Agency, or
its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or
invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY
INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND
EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR
CONNECTED WITH SUCH PROPERTY.
14.5 Religious Organization.
Agency shall comply with all applicable requirements as more particularly described in 24
CFR Part 5.109. No portion of the HOPWA Funds shall be used in support of any sectarian or
religious activity. In addition, there must be no religious or membership criteria for clients of a
HOPWA-funded service.
14.5.1. Separation of Explicitly Religious Activities.
Agency retains its independence and may continue to carry out its mission, including the
definition, development practice, and expression of its religious beliefs,provided that it does not use
HOPWA Funds to support or engage in any explicitly religious activities (including activities that
involve overt religious content such as worship, religious instruction, or proselytization), or in any
other manner prohibited by law.
14.5.2 Explicitly Religious Activities.
If Agency engages in explicitly religious activities (including activities that involve overt
religious content such as worship, religious instruction, or proselytization), the explicitly religious
activities must be offered separately, in time or location, from the programs or activities supported
by HOPWA Funds and participation must be voluntary for clients of a HOPWA-funded service.
14.5.3 Required Notices.
If Agency constitutes a Faith-based organization under 24 CFR Part 5.109, Agency must
provide all clients of a HOPWA-funded service with the notice attached as EXHIBIT "K"—Notice
of Beneficiary Rights. Such notice shall be provided to the client prior to enrollment in any
HOPWA-funded program or activity. In addition, if a client or prospective client of a HOPWA-
funded service objects to the religious character of Agency, then Agency must promptly undertake
reasonable efforts to identify and refer the client or prospective client to an alternate provider to
which the client or prospective client has no such objection, as more particularly described in 24
CFR Part 5.109.
14.6 Venue.
Venue shall lie in Tarrant County, Texas for any action,whether real or asserted, at law or
in equity, arising out of the execution,performance, attempted performance or non-performance of
this Contract.
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14.7 Governing Law.
This Contract shall be governed by and construed in accordance with the laws of the State of
Texas. If any action, whether real or asserted, at law or in equity, arises out of the execution,
performance or non-performance of this Contract or on the basis of any provision herein, for any
issue not governed by federal law,the choice of law shall be the laws of the State of Texas.
14.8 Severability.
The provisions of this Contract are severable, and if for any reason a clause, sentence,
paragraph or other part of this Contract shall be determined to be invalid by a court or federal or
state agency,board or commission having jurisdiction over the subject matter thereof,such invalidity
shall not affect other provisions which can be given effect without the invalid provision.
14.9 Written Agreement Entire Contract.
This written instrument and the Exhibits, Attachments, and Addendums attached hereto,
which are incorporated by reference and made a part of this Contract for all purposes, constitute the
entire agreement by the Parties concerning the work and services to be performed under this
Contract. Any prior or contemporaneous oral or written agreement which purports to vary the terms
of this Contract shall be void. Any amendments to the terms of this Contract must be in writing and
executed by the Parties.
14.10 Paral4raph Headings for Reference Only, No Lel4al Significance; Number
and Gender.
The paragraph headings contained herein are for convenience in reference to this Contract
and are not intended to define or to limit the scope of any provision of this Contract. When context
requires, singular nouns and pronouns include the plural and the masculine gender shall be deemed
to include the feminine or neuter and the neuter gender to include the masculine and feminine. The
words"include"and"including"whenever used herein shall be deemed to be followed by the words
"without limitation".
14.11 Compliance With All Applicable Laws and Regulations.
Agency agrees to comply fully with all applicable laws and regulations that are currently in
effect or that are hereafter amended during the performance of this Contract. Those laws include,
but are not limited to:
➢ HOPWA Regulations found in 24 CFR Part 574
➢ AIDS Housing Opportunity Act, as amended (42 USC 12901 et seq.)
➢ Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including
provisions requiring recipients of federal assistance to ensure meaningful access by
persons of limited English proficiency
➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections
3601 et seq.)
➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented
by Department of Labor regulations 41 CFR Part 60
➢ The Age Discrimination in Employment Act of 1967
➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.)
➢ The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
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(42 U.S.C. Sections 4601 et seq. and 49 CFR Part 24) ("URA")
➢ Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.) and 24
CFR Part 8 where applicable
➢ National Environmental Policy Act of 1969, as amended,42 U.S.C. Sections 4321 et seq.
("NEPA") and the related authorities listed in 24 CFR Part 58.
➢ The Clean Air Act, as amended, (42 U.S.C. Sections 1251 et seq.) and the Clean Water
Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.) and the related Executive
Order 11738. In no event shall any amount of the assistance provided under this Contract
be utilized with respect to a facility that has given rise to a conviction under the Clean
Air Act or the Clean Water Act.
➢ Immigration Reform and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.)
specifically including the provisions requiring employer verifications of legal status of
its employees
➢ The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.), the
Architectural Barriers Act of 1968 as amended(42 U.S.C. Sections 4151 etseq.) and the
Uniform Federal Accessibility Standards, 24 CFR Part 40, Appendix A
➢ Regulations at 24 CFR Part 87 related to lobbying, including the requirement that
certifications and disclosures be obtained from all covered persons
➢ Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part 23,
Subpart F
➢ Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on
participation by ineligible, debarred or suspended persons or entities
➢ Section 6002 of the Solid Waste Disposal Act,as amended by the Resource Conservation
and Recovery Act
➢ Guidelines of the Environmental Protection Agency at 40 CFR Part 247
➢ For contracts and subgrants for construction or repair,Copeland"Anti-Kickback"act(18
U.S.C. 874) as supplemented in 29 CFR Part 5
➢ For construction contracts awarded by Agency in excess of $2,000, and in excess of
$2,500 for other contracts which involve the employment of mechanics or laborers,
Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C.
327A 300) as supplemented by 29 CFR Part 5
➢ Lead-Based Paint Poisoning Prevention Act(42 U.S.C. 4801 et seq.), as amended by the
Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et seq.)
and implementing regulations at 24 CFR Part 35, subparts A, B, M, and R
➢ Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards, 2 CFR Part 200 et seq.
➢ Federal Funding Accountability and Transparency Act of 2006("FFATA") (Pub.L. 109-
282,as amended by Section 6205(a)of Pub.L. 110-252 and Section 3 of Pub.L. 113-101)
➢ Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712, 10
U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
14.12 HUD Assisted Pro4ee-ts and Employment and otheir E.,,,,,,,..,;,
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14.13 Prohibition Against Discrimination.
14.13.1 General Statement.
Agency shall comply in the execution, performance or attempted performance of this
Contract, with all non-discrimination requirements of 24 CFR Part 574.603 and Chapter 17, Article
III, Division 4—Fair Housing of the City Code. Agency may not discriminate against any person
because of race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression, or transgender, nor will Agency
permit its officers, members, agents, employees, or clients to engage in such discrimination.
This Contract is made and entered into with reference specifically to Chapter 17,Article III,
Division 3 -Employment Practices of the City Code, and Agency hereby covenants and agrees that
Agency, its officers, members, agents, employees and contractors, have fully complied with all
provisions of same and that no employee, or applicant for employment has been discriminated
against under the terms of such ordinances by either or its officers, members, agents, employees or
contractors.
14.13.2 No Discrimination in Employment durinI4 the Performance of This Contract.
During the performance of this Contract Agency agrees to the following provision, and will
require that its contractors and subcontractors also comply with such provision by including it in all
contracts with its contractors:
[Contractor's, Subcontractor's or Vendor's name] will not unlawfully discriminate against
any employee or applicants for employment because of race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender. [Contractor's, Subcontractor's or Vendor's name will take affirmative
action to ensure that applicants are hired without regard to race, color, sex, gender,religion,national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender and that employees are treated fairly during employment without regard
to their race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression or transgender. Such action shall
include, but not be limited to, the following: employment, upgrading, demotion or transfer,
recruitment or recruitment advertising, layoff or termination, rates of pay or other forms of
compensation, and selection for training, including apprenticeship. [Contractor's, Subcontractor's
or Vendor's name] agrees to post in conspicuous places, available to employees and applicants for
employment, notices setting forth the provisions of this nondiscrimination clause.
[Contractor's Subcontractor's or Vendor's name] will, in all solicitations or advertisements
for employees placed by or on behalf of[Contractor's Subcontractor's or Vendor's name], state
that all qualified applicants will receive consideration for employment without regard to race, color,
sex, gender, religion, national origin, familial status, disability or perceived disability, sexual
orientation, gender identity, gender expression or transgender.
[Contractor's, Subcontractor's or Vendor's name] covenants that neither it nor any of its
officers, members, agents, employees, or contractors, while engaged in performing this Contract,
shall, in connection with the employment, advancement or discharge of employees or in connection
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with the terms, conditions or privileges of their employment, discriminate against persons because
of their age or because of any disability or perceived disability, except on the basis of a bona fide
occupational qualification, retirement plan or statutory requirement.
[Contractor's, Subcontractor's or Vendor's name] further covenants that neither it nor its
officers, members, agents, employees, contractors, or persons acting on their behalf, shall specify,
in solicitations or advertisements for employees to work on this Contract, a maximum age limit for
such employment unless the specified maximum age limit is based upon a bona fide occupational
qualification, retirement plan or statutory requirement.
14.13.3 Asency's Contractors and the ADA.
In accordance with the provisions of the Americans With Disabilities Act of 1990 ("ADA"),
Agency warrants that it and any of its contractors will not unlawfully discriminate on the basis of
disability in the provision of services to the general public, nor in the availability, terms and/or
conditions of employment for applicants for employment with, or employees of, Agency or any of
its contractors. AGENCY WARRANTS IT WILL FULLY COMPLY WITH THE ADA'S
PROVISIONS AND ANY OTHER APPLICABLE FEDERAL, STATE AND LOCAL LAWS
CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD CITY
HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY THIRD
PARTIES, CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS AGAINST
CITY ARISING OUT OF AGENCY'S AND/OR ITS CONTRACTORS',
SUBCONTRACTORS', VENDORS' OR AGENTS' OR THEIR RESPECTIVE
EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE-REFERENCED
LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF
THIS CONTRACT.
14.14. Conflicts of Interest and Violations of Criminal Law.
14.14.1 Aizency Safeivards.
Agency shall establish safeguards to prohibit its employees, board members, advisors and
agents from using positions for a purpose that is or gives the appearance of being motivated by a
desire for private gain for themselves or others, particularly those with whom they have family,
business or other ties. Agency shall disclose to City any such conflict of interest or potential conflict
of interest, immediately upon discovery of such.
14.14.2 General Prohibitions Aizainst Conflicts of Interest.
No employees, agents, consultants, officers or elected officials or appointed officials of City
or of Agency who exercise or have exercised any functions or responsibilities with respect to
activities assisted with HOPWA funds or who are in a position to participate in a decision-making
process or gain inside information with regard to these activities may utilize HOPWA services,may
obtain a financial interest or benefit from a HOPWA-assisted activity, or have an interest in any
contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for
themselves or those with whom they have family or business ties, during their tenure or for I year
thereafter.
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14.14.2.1 Agency shall establish conflict of interest policies for federal awards
including the CDBG Funds and shall disclose in writing potential
conflicts of interest to City as authorized by 2 CFR Part 200.112.
14.14.3 Conflicts of Interest Involving Procurement.
The conflict of interest provisions of 2 CFR Part 200.318, shall apply in the procurement of
property and services by Agency. In all cases not governed by those Sections, the provisions of 24
CFR Part 574.625 of the HOPWA Regulations shall apply.
14.14.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall
maintain and submit to City written standards of conduct covering
conflicts of interest and governing the performance of its employees
engaged in the selection, award, and administration of contracts. No
employee, officer, or agent may participate in the selection, award, or
administration of a contract supported by a federal award if he or she
has a real or apparent conflict of interest. The standards of conduct
must provide for disciplinary actions to be applied for violations of
such standards by officers, employees, or agents of Agency.
14.14.3.2 The officers,employees,and agents of Agency shall neither solicit nor
accept gratuities, favors, or anything of monetary value from
contractors or parties to subcontracts.
14.14.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2,
Agency may set standards of conduct for situations in which the
financial interest is not substantial or the gift is an unsolicited item of
nominal value. Such standards of conduct must provide for
disciplinary actions to be applied for violations of such standards by
Agency's officers, employees or agents.
14.14.3.4 Agency shall maintain written standards of conduct covering
organizational conflicts of interest. Organizational conflicts of
interest means that because of relationships with a parent company,
affiliate,or subsidiary organization,Agency is unable or appears to be
unable to be impartial in conducting a procurement action involving a
related organization.
14.14.3.5 Agency must maintain records sufficient to detail the history of
procurement. These records will include, but are not necessarily
limited to the following: rationale for the method of procurement,
selection of contract type, contractor selection or rejection, and the
basis for the contract price.
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14.14.4 Disclosure of Conflicts of Interest.
In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in
writing any potential conflict of interest.
14.14.5 Disclosure of Texas Penal Code Violations.
Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit
bribery and gifts to public servants.
14.14.6 Disclosure of Federal Criminal Law Violations.
In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all
violations of federal criminal law involving fraud,bribery or gratuity violations potentially affecting
the Agency.
14.15 Subcontracting with Small and Minority Firms, Women's Business
Enterprises and Labor Surplus Areas.
14.15.1 For procurement contracts$50,000.00 or larger that are paid for, in part or in full,
with HOPWA Funds, Agency agrees to abide by City's policy to involve Minority Business
Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for
contracts for construction, provision of professional services, purchase of equipment and supplies
and provision of other services required by City. Agency agrees to incorporate the City's BDE
Ordinance, and all amendments or successor policies or ordinances thereto, into all contracts and
subcontracts for procurement larger than$50,000.00 or larger that are paid for, in part or in full,with
the HOPWA Funds and will further require all persons or entities with which it so contracts to
comply with said ordinance.
14.15.2 It is national policy to award a fair share of contracts to disadvantaged business
enterprises ("DBEs"), small business enterprises ("SBEs"), minority business enterprises
("MBEs"), and women's business enterprises ("WBEs"). Accordingly, affirmative steps must be
taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized when possible as sources of
supplies, equipment, construction and services.
14.15.2.1 In order to comply with federal reporting requirements,Agency must
submit the form attached hereto as EXHIBIT "I"—MBE Reporting
Form for each contract or subcontract with a value of$10,000.00 or
more paid or to be paid with the HOPWA Funds. Agency shall submit
this form by the date specified in EXHIBIT "I" —MBE Reporting
Form.
14.16 Other Laws.
The failure to list any federal, state or City ordinance, law or regulation that is applicable to
Agency does not excuse or relieve Agency from the requirements or responsibilities in regard to
following the law, nor from the consequences or penalties for Agency's failure to follow the law, if
applicable.
HOPWA PSA CONTRACT 2016-2017 Page 24
Tarrant County Samaritan House,Inc. Rev.9.12.2016
14.17 Assignment.
Agency shall not assign all or any part of its rights, privileges, or duties under this Contract
without the prior written approval of City. Any attempted assignment of same without approval
shall be void, and shall constitute a breach of this Contract.
14.18. RiLFht to Inspect A14ency Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed contracts
between Agency and any contractor or vendor engaged in any activity in conjunction with this
HOPWA-funded Program prior to any charges being incurred.
14.19 Force Maieure
If Agency becomes unable,either in whole or part,to fulfill its obligations under this Contract
due to acts of God, strikes, lockouts, or other industrial disturbances, acts of public enemies, wars,
blockades, insurrections,riots,epidemics,earthquakes,fires,floods,restraints or prohibitions by any
court, board, department, commission or agency of the United States or of any States, civil
disturbances, or explosions, or some other reason beyond Agency's control (collectively, "Force
Majeure Event"),the obligations so affected by such Force Majeure Event will be suspended only
during the continuance of such event. Agency will give City written notice of the existence, extent
and nature of the Force Majeure Event as soon as reasonably possible after the occurrence of the
event. Failure to give notice will result in the continuance of Agency's obligation regardless of the
extent of any existing Force Majeure Event. Agency will use commercially reasonable efforts to
remedy its inability to perform as soon as possible.
15. INDEMNIFICATION AND RELEASE.
AGENCY COVENANTS AND AGREES TO INDEMNIFY,HOLD HARMLESS AND
DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS, AGENTS, SERVANTS
AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR
PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH,
TO ANY AND ALL PERSONS, OF WHATSOEVER KIND OR CHARACTER,WHETHER
REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE
EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS,ACTIVITIES
AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER OR NOT
CAUSED IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS,
AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF
CITY; AND AGENCY HEREBY ASSUMES ALL LIABILITY AND RESPONSIBILITY OF
CITY AND ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FOR ANY AND
ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL
INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER
KINDS OR CHARACTER, WHETHER REAL OR ASSERTED,ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE
OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED
HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS
OR SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND AGREES
HOPWA PSA CONTRACT 2016-2017 Page 25
Tarrant County Samaritan House,Inc. Rev.9.12.2016
TO AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS CITY FROM AND
AGAINST ANY AND ALL INJURY, DAMAGE OR DESTRUCTION OF PROPERTY OF
CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF
AGENCY, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS,INVITEES,LICENSEES, OR CLIENTS,OR CAUSED,IN WHOLE
OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS,
EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY.
IT IS THE EXPRESS INTENTION OF THE PARTIES,BOTH AGENCY AND CITY,
THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES INDEMNITY BY
AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE CONSEQUENCES OF
CITY'S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE IS ALLEGED TO BE
THE SOLE OR CONCURRING CAUSE OF THE INJURY,DAMAGE OR DEATH.
AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY
FOR INJURY,DEATH,DAMAGE OR LOSS TO PERSONS OR PROPERTY SUSTAINED
IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER THIS
CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED BY
CITY'S SOLE OR CONCURRENT NEGLIGENCE.
AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND
SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS A
RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME
FORM AS ABOVE.
16. WAIVER OF IMMUNITY BY AGENCY.
If Agency, as a charitable or nonprofit organization, has or claims an immunity or exemption
(statutory or otherwise)from and against liability for damages or injury, including death,to persons
or property, Agency hereby expressly waives its rights to plead defensively such immunity or
exemption as against City. This Section shall not be construed to affect a governmental entity's
immunities under constitutional, statutory or common law.
17. INSURANCE AND BONDING.
Agency will maintain coverage in the form of insurance or bond in the amount of$485,844
to insure against loss from the fraud,theft or dishonesty of any of Agency's officers,agents,trustees,
directors or employees. The proceeds of such insurance or bond shall be used to reimburse City for
any and all loss of HOPWA Funds occasioned by such misconduct. To effectuate such
reimbursement, such fidelity coverage shall include a rider stating that reimbursement for any loss
or losses shall name the City as a Loss Payee.
Agency shall furnish to City in a timely manner, but not later than the Effective Date,
certificates of insurance as proof that it has secured and paid for policies of commercial insurance
as specified herein. If City has not received such certificates by the Effective Date,Agency shall be
in default of the Contract and City may, at its option,terminate the Contract.
HOPWA PSA CONTRACT 2016-2017 Page 26
Tarrant County Samaritan House,Inc. Rev.9.12.2016
Such insurance shall cover all insurable risks incident to or in connection with the execution,
performance, attempted performance or nonperformance of this Contract. Agency shall maintain
the following insurance coverage and limits:
Commercial General Liability, (CGL) Insurance
$ 500,000 each occurrence
$1,000,000 aggregate limit
Non-Profit Organization Liability or Directors & Officers Liability
$1,000,000 Each Occurrence
$1,000,000 Annual Aggregate Limit
Business Automobile Liability Insurance
$1,000,000 each accident on a combined single-limit basis, or
$ 250,000 Property Damage
$ 500,000 Bodily Injury per person per occurrence
$2,000,000 Aggregate
Insurance policy shall be endorsed to cover"Any Auto", defined as autos owned, hired,
and non-owned. Pending availability of the above coverage and at the discretion of
City,the policy shall be the primary responding insurance policy versus a personal
auto insurance policy if or when in the course of Agency's business as contracted
herein.
Workers' Compensation Insurance
Part A: Statutory Limits
Part B: Employer's Liability
$100,000 each accident
$100,000 disease-each employee
$500,000 disease-policy limit
Note: Such insurance shall cover employees performing work on any and all projects
including but not limited to construction, demolition, and rehabilitation. Agency or its
contractors shall maintain coverages, if applicable. In the event the respective contractors
do not maintain coverage, Agency shall maintain the coverage on such contractor, if
applicable, for each applicable contract.
Additional Requirements
Such insurance amounts shall be revised upward at City's reasonable option and no more frequently
than once every 12 months, and Agency shall revise such amounts within 30 days following notice
to Contractor of such requirements.
Agency will submit to City documentation that it has obtained insurance coverage and has executed
bonds as required in this Contract prior to payment of any monies provided hereunder.
HOPWA PSA CONTRACT 2016-2017 Page 27
Tarrant County Samaritan House,Inc. Rev.9.12.2016
Where applicable, insurance policies required herein shall be endorsed to include City as an
additional insured as its interest may appear. Additional insured parties shall include employees,
officers, agents, and volunteers of City.
Any failure on part of City to request certificate(s) of insurance shall not be construed as a waiver
of such requirement or as a waiver of the insurance requirements themselves.
Insurers of Agency's insurance policies shall be licensed to do business in the state of Texas by the
Department of Insurance or be otherwise eligible and authorized to do business in the state of Texas.
Insurers shall be acceptable to City insofar as their financial strength and solvency and each such
company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII or other
equivalent insurance industry standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise
approved by City.
In the event there are any local, federal or other regulatory insurance or bonding requirements for
the Program, and such requirements exceed those specified herein, the former shall prevail.
Agency shall require its contractors to maintain applicable insurance coverages, limits, and other
requirements as those specified herein; and Agency shall require its contractors to provide Agency
with certificate(s) of insurance documenting such coverage. Also, Agency shall require its
contractors to have City and Agency endorsed as additional insureds (as their interest may appear)
on their respective insurance policies.
Directors and Officers Liability coverage shall be in force and may be provided on a claims-made
basis. This coverage may also be referred to as Management Liability, and shall protect the insured
against claims arising out of alleged errors in judgment, breaches of duty and wrongful acts arising
out of their organizational duties. Coverage shall protect not only the entity, but all past,present and
future directors, officers, trustees, employees, volunteers and committee members.
Notwithstanding any provision in this Contract to the contrary,when applicable,Agency shall
comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the
equivalent insurance coverage for real property and equipment acquired or improved with
CDBG Funds as provided to property owned by Agency.
18. CERTIFICATION REGARDING LOBBYING.
The undersigned representative of Agency hereby certifies, to the best of his or her
knowledge and belief,that:
No federal appropriated funds have been paid or will be paid, by or on behalf of Agency, 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 in connection with the awarding
of any federal contract, the making of any federal grant, the making of any federal loan, the
HOPWA PSA CONTRACT 2016-2017 Page 28
Tarrant County Samaritan House,Inc. Rev.9.12.2016
entering into of any cooperative agreement and the extension, continuation, renewal,
amendment, or modification of any federal contract, grant, loan or cooperative agreement.
If any funds other than federally 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,
member of Congress in connection with this federal contract, grant, loan or cooperative
agreement, Agency shall complete and submit Standard Form-LLL, "Disclosure Form to
Report Lobbying," in accordance with its instructions.
This certification is a material representation of fact upon which reliance was placed when
this Contract was made or entered into. Submission of this certificate is a prerequisite for
making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than
$10,000.00 and not more than$100,000.00 for each such failure.
Agency shall require that the language of this certification be included in all subcontracts or
agreements involving the expenditure of federal funds.
19. LITIGATION AND CLAIMS.
Agency shall give City immediate notice in writing of any action, including any proceeding
before an administrative agency, filed against Agency in conjunction with this Contract or the
Program. Agency shall furnish immediately to City copies of all pertinent papers received by
Agency with respect to such action or claim. Agency shall provide a notice to City within 10 days
upon filing under any bankruptcy or financial insolvency provision of law.
20. NOTICE
All notices required or permitted by this Contract must be in writing and are deemed delivered
on the earlier date of the date actually received or the third day following deposit in a United States
Postal Service post office or receptacle;with proper postage, certified mail return receipt requested;
and addressed to the other Party at the address set out below or at such other address as the receiving
Party designates by proper notice to the sending Party.
City:
City Attorney's Office
1000 Throckmorton Street
Fort Worth, TX 76102
Telephone: 817-392-7600
HOPWA PSA CONTRACT 2016-2017 Page 29
Tarrant County Samaritan House,Inc. Rev.9.12.2016
Copy to:
Director of Neighborhood Services Department
1000 Throckmorton Street
Fort Worth, TX 76102
Attention: Assistant Director
Telephone: 817-392-7540
Copy to:
Director of Neighborhood Services Department
1000 Throckmorton Street
Fort Worth, TX 76102
Attention: Management Analyst II
Telephone: 817-392-7369
Agency:
Tarrant County Samaritan House, Inc.
Norbert White,President& CEO
929 Hemphill St.
Fort Worth, TX 76104
Telephone: 817-332-6410
21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT.
Agency represents that it possesses the legal authority, pursuant to any proper, appropriate
and official motion, resolution or action passed or taken, to enter into this Contract and to perform
the responsibilities herein required.
22. COUNTERPARTS.
This Contract may be executed in multiple counterparts, each of which shall be considered
an original, but all of which shall constitute one instrument which may be sufficiently evidenced by
one counterpart.
[SIGNATURES APPEAR ON NEXT PAGE]
HOPWA PSA CONTRACT 2016-2017 Page 30
Tarrant County Samaritan House,Inc. Rev.9.12.2016
IN WITNESS WHEREOF, the Parties hereto have executed 4 duplicate originals of this
Contract in Fort Worth, Tarrant , Texas.
ATTEST: °®° -1,°�fiO CITY OF FORT WORTH
°
y:�GZ dO Leg�—
?z'O �
Ci y Secrg q 2 Fernando Costa, Assistant City Manager
M&C: G-18793 °�
Date: August 9, 201600000,00
OVED S TQ FORM A EGALITY:
Assistant CAY Attorney
TARRANT CO TY SAMARITAN HOUSE,
INC.
By:
No_ ert Whaite, President& CEO
OFFICIAL RECORD
CITY SECRETARY
FT.WORTH,TX
HOPWA PSA CONTRACT 2016-2017 Page 31
Tarrant County Samaritan House,Inc. Rev.9.12.2016
EXHIBITS:
EXHIBIT "A"—Program Summary
EXHIBIT "A-1"—2016 HUD Income Limits
EXHIBIT "A-2" -Requirements for Completion of"Getting to Work Training Curriculum"
EXHIBIT "B"—Budget
EXHIBIT "C"—Audit Certification Form
EXHIBIT "D"—Reimbursement Forms
EXHIBIT "E"—Form of Income Self-Certification
EXHIBIT "F"—Standards for Complete Documentation
EXHIBIT "G"—Section 3 Reporting Forms (NOT APPLICABLE)
EXHIBIT "H"—Overview Report
EXHIBIT "I"—MBE Reporting Form
EXHIBIT "J"—Duties of the Parties for Use of NSD Community Centers
EXHIBIT "K"—Notice of Beneficiary Rights
HOPWA PSA CONTRACT 2016-2017 Page 32
Tarrant County Samaritan House,Inc. Rev.9.12.2016
TARRANT COUNTY SAMARITAN HOUSING,INC. EXHIBIT "A"
Samaritan House Supportive Services PROGRAM SUMMARY
PROGRAM SUMMARY
(HOPWA)
October 1, 2016 to September 30, 2017 $485,844
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
The Program provides supportive services to HOPWA Eligible Clients living in the Samaritan
Villages Apartments, the Samaritan House Single Room Occupancy ("SRO") Facility, and in
scattered-site rental-voucher supported housing. The supportive services include case
management and housing counseling. Program services may also include congregate meals;
medical case management; substance abuse counseling; medical transportation; recreational and
social programs; educational programs; and life and job skills programs.
HOPWA Funds will be used to pay for a percentage of supportive service salaries, fringe
benefits, supplies, and contract labor associated with the Program. HOPWA Funds will also be
used to pay for the operational expenses of the Agency'sSRO Facility located at 929 Hemphill
Street, Fort Worth, TX 76104. Operational expenses consist of but are not limited to salaries and
fringe benefits for property management and maintenance staff.
No more than 7% of the HOPWA Funds will be used to pay for administrative costs, including
salaries and fringe benefits, City-required insurance, taxes, and legal/accounting fees associated
with the Program.
Agency's office and Program services will be available at 929 Hemphill Street, Fort Worth,
Texas 76104, Monday through Friday, 9:00 a.m. to 5:00 p.m. Program services may also be
provided at clients' homes. The SRO is staffed 24 hours a day, 7 days a week.
The Program will be provided services to HOPWA Eligible clients residing in Tarrant, Johnson,
Parker, Wise,Hood and Somervell counties.
Use of Neighborhood Centers:
In conjunction with services provided under the Program, Tarrant County Samaritan Housing,
Inc. will also provide HIV/AIDS education at one of the City's Neighborhood Centers. Testing
will also be provided in tandem with MHMR HIV Early Intervention when available.
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"A"—PROGRAM SUMMARY Page 1
Tarrant County Samaritan Housing,Inc.
City of Fort Worth Neighborhood Center:
Worth Heights Neighborhood Center
3551 New York Avenue, Fort Worth, TX 76110
Services will be provided on a quarterly basis in 45 minute increments
REGULATORY CLASSIFICATION:
IDIS matrix Code(s) and Service Category: 31D HOPWA Project Sponsor Administration
31 C HOPWA Project Sponsor Activity
Regulatory Citation(s): 24 CFR 574.300(b)(10)—Administrative Expenses
24 CFR 574.300(b)(7)— Supportive Services
24 CFR 574.300(b)(8)Facility Based Operations
Agency will maintain documentation which verifies that 100% of clients served by the Program
are eligible under HOPWA Regulations.
PROGRAM GOALS:
Minimum Number of Clients to be Served: The Program must provide Supportive Services to
a minimum of 165 Unduplicated Clients. Unduplicated Clients must be a resident of Tarrant,
Johnson, Parker, Wise, Hood and Somervell counties as shown by the monthly reports on
Attachment III. The Program will also provide Facility Based Housing Subsidy Assistance
through the housing operations of 60 household housing units.
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"A"—PROGRAM SUMMARY Page 2
Tarrant County Samaritan Housing,Inc.
EXHIBIT "A-1"
2016 HUD INCOME LIMITS
2016 Median Family Income -Fort Worth/Arlington, TX*
1 Person 2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons
Extremely $14,600 $16,650 $20,160 $24,300 $28,440 $32,580 $36,730 $40,890
Low
Income
50%AMI $24,300 $27,800 $31,250 $34,700 $37,500 $40,300 $43,050 $45,850
80%AMI $38,850 $44,400 $49,950 $55,500 $59,950 $64,400 $68,850 j $73,300
*Income limits are published at least annually by HUD.
HOPWA PSA CONTRACT 2016-2017--EXHIBIT"A-1"—2016 HUD INCOME LIMITS Page 1
Tarrant County Samaritan House,Inc.
EXHIBIT "A-2"
REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING
CURRICULUM"
HOPWA PSA CONTRACT 2016-2017 Page 1
EXHIBIT"A-2"REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM"
Tarrant County Samaritan House,Inc.
Getting to Work:
A Training Curriculum for HIV/AIDS Service Providers and Housing Providers
At least 1 Agency employee must complete this required training curriculum by the deadline of April 15,2017.
Proof of completion must be submitted with the April reimbursement request.
The Getting to Work Training Curriculum is divided into 3 online modules:
Module 1: Understanding the Value of Work
Module 2: Adopting an Employment and Training Mindset—Organizationally and Individually
Module 3: Incorporating Employment into the HIV/AIDS Service Menu
To view the modules:
1. Click the module title.
2. You will be prompted to either create or log into your HUD Exchange Learn account.
3. Follow this guidance when creating a HUD Exchange account:
Step 1 of 2 screen: Fill out the required Personal Information, and Login Information sections. For the
Organization Information, if you are not affiliated with a HUD program, choose None of the Above
and I am an Individual.
Step 2 of 2 screen: All HUD Program Experience fields on the Learner Profile page are optional.
Click Update to complete the account creation process.
4. After creating an account or logging in, you will enter the HUD Exchange Learn system.
5. Click the Enroll button on the HUD Exchange Learn course description to access the course.
6. The module name will appear under Activities. Click the Module Name to access the course.
7. The module will launch in a new window, so please make sure your pop-up blockers are turned off.
To receive credit for completing each module:
1. Take the completion quiz under.Activities on the HUD Exchange Learn course description. Each
module has a quiz.
2. Score 80% or better on the quiz. You may take the quiz multiple times.
3. After you pass the quiz, you will be able to print a completion certificate on the HUD Exchange
Learn course description.
You can access information about the modules by visiting the HUD Exchange website
at www.hudexchange.com or by using the following link: https://www.hudexchange.info/training-events/dol-
hud-getting-to-work-curriculum-for-hiv-aids-providers. You may also contact your assigned contract
administrator to get additional information.
HOPWA PSA CONTRACT 2016-2017 Page 2
EXHIBIT"A-2"REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM"
Tarrant County Samaritan House,Inc.
DRAFT EXHIBIT"B"-BUDGET
„:Account" GrautBnd et A= B % G Total
r DMINISTRA:hIi?E
PERS;ONNEI: `
Salaries 1001 $ 7,029.00 $ 23,638.00 $ 17,251.00 $ 334,646.00 $ 382,564.00
FICA 1002 $ 538.00 $ 1,808.00 $ 1,320.00 $ 25,600.00 $ 29,266.00
Life/Disability Insurance 1003 $ 5.00 $ 236.00 $ 173.00 $ 3,346.00 $ 3,760.00
Health/DentalInsurance 1004 $ 581.00 $ 4,255.00 $ 3,105.00 $ 60,236.00 $ 68,177.00
Unemployment-State 1005 $ 138.00 $ 464.00 $ 339.00 $ 6,569.00 $ 7,510.00
Worker's Compensation 1006 $ 27.00 $ 236.00 $ 173.00 $ 3,346.00 $ 3,782.00
Contract Labor 1007
Other(Audit Fees) 1008 $ 528.00 $ 10,972.00 $ 11,500.00
Insurance-Commercial Umbrella
Liability 1009 $ 986.00 $ 9,970.00 $ 2,366.00 $ 19,078.00 $ 32,400.00
Insurance-Directors and
Officers 1010 $ 1,700.00 $ 1,700.00
Insurance-Fidelity Bond or
Equivalent 1011 $ 500.00 $ 500.00
TOTAL ADMINISTRATIVE
EXPENSES $ 10,332.00 $ 40,607.00 $ 24,727.00 $ 465,493.00 $ 541,159.00
%Administrative Cost 2%
PROGRAM PERSONNEI.,`;
Salaries 2001 $ 272,892.00 $ 209,875.00 $ 107,190.00 $ 14,932.00 $ 604,889.00
FICA 2002 $ 20,876.00 $ 16,055.00 $ 8,200.00 $ 1,142.00 $ 46,273.00
Life/Disability Insurance 2003 $ 492.00 $ 2,099.00 $ 1,072.00 $ 149.00 $ 3,812.00
Health/DentalInsurance 2004 $ 66,563.00 $ 37,778.00 $ 19,294.00 $ 2,688.00 $ 126,323.00
Unemployment-State 2005 $ 5,357.00 $ 4,120.00 $ 2,104.00 $ 293.00 $ 11,874.00
Worker's Compensation 2006 $ 5,652.00 $ 2,099.00 $ 1,072.00 $ 149.00 $ 8,972.00
SI7PPLIES:ANDSERVICES`. `,, . _ "
Office/Medical Supplies 3001 $ 1,426.00 $ 474.00 $ 13,722.00 $ 15,622.00
Office Equipment Rental 3002 $ 674.00 $ 150.00 $ 3,976.00 $ 4,800.00
Postage 3003 $ 500.00 $ 240.00 $ 2,260.00 $ 3,000.00
Printing 3004 $ 500.00 $ 4,500.00 $ 5,000.00
MISCELLANEOUS
Contract Labor-Nutritionist 4001 $ 11,905.00 $ 3,088.00 $ 10,492.00 $ 25,485.00
Food Supplies 4002 $ 104,355.00 $ 13,575.00 $ 117,930.00
FACILITY;AND UTILITIES `., ... ,,
Telephone 5001 $ 6,000.00 $ 6,000.00
Electric 5002 $ 12,000.00 $ 12,000.00
Gas 5003
Water and Wastewater 5004 $ 1,200.00 $ 1,200.00
Solid Waste Disposal 5005 $ 1,200.00 $ 1,200.00
Rent(City needs copy of lease
before expenses can be
reimbursed) 5006
Custodial Services 5007 $ 12,500.00 $ 12,500.00
Maintenance/Repairs 5008 $ 6,000.00 $ 6,000.00
Building Security 5009
LEGAL,FINANCIAL AND ,
HOPWA PSA CONTRACT 2016-2017-EXHIBIT"B"-BUDGET
Tarrant County Samaritan House,Inc. Page 1
Professional Liability/Business
Auto 6001
TOTAL SUPPORTIVE
SERVICE EXPENSES $ 371,832.00 $ 391,386.00 $ 156,459.00 $ 93,203.00 $ 1,012,880.00
DIRECT ASS�S. ANCE-STI2MI3 '
Short-term Rent Assistance 7001
Short-term Mortgage Assistance 7002
Short-term Utilities Assistance 7003
Total Direct Assistance-STRMU
r ` :::°..DIRECTASSISTANCE-TBRf ,
�. .
Tenant Based Rental Assistance
(TBRA) 8001 $ 131,082.00 $ 63,978.00 $ 195,060.00
Total Direct Assistance-TBRA $ 131,082.00 $ 63,978.00 $ 195,060.00
EAGIIITYBASED OPERATIONS .;
PERSONNEL <; _ ,
Salaries 9001 $ 85,609.00 $ 13,512.00 $ 133,185.00 $ 232,306.00
FICA 9002 $ 6,549.00 $ 1,034.00 $ 10,189.00 $ 17,772.00
Life/Disability Insurance 9003 $ 194.00 $ 135.00 $ 1,332.00 $ 1,661.00
Health/DentalInsurance 9004 $ 8,525.00 $ 2,432.00 $ 23,973.00 $ 34,930.00
Unemployment-State 9005 $ 1,681.00 $ 265.00 $ 2,614.00 $ 4,560.00
Worker's Compensation 9006 $ 1,122.00 $ 135.00 $ 1,332.00 $ 2,589.00
Insurance-Commercial Property
and Professional Liability 9007
TOTAL FACILITY BASED
OPERATION EXPENSES $ 103,680.00 $ 17,513.00 1 $ 172,625.00 1 $ 2939818.00
BUDGET TOTAL 1 1 $ 485,844.00 1 $ 431,993.00 1 $ 329,781.00 1 $ 795,299.00 1 $ 2,0429917.00
FUNDING A:RW I,II,&State Services
FUNDING B:HOPWA SNPS
FUNDING C:CoC/Grace Village&Fundraising/Donations
HOPWA PSA CONTRACT 2016-2017-EXHIBIT"B"-BUDGET
Tarrant County Samaritan House,Inc. Page 2
The following tables were created for the purpose of preparing, negotiating, and determining the cost
reasonableness and cost allocation method used by the Agency for the line item budget represented on
the first page of this EXHIBIT "B"—Budget. The information reflected in the tables is to be
considered part of the terms and conditions of the Contract. Agency must have prior written approval
by the City to make changes to any line item in the Budget as outlined in Section 5.2.2 in the
Contract. The deadline to make changes to EXHIBIT "B"—Budget is June 1, 2017.
SALARY DETAIL-ADMINISTRATIVE
Est. Percent to Amount to
Position Title Annual Salary Grant Grant
President/CEO $ 123,521.00 1.0% $ 1,235.00
Vice President/Chief Operations Officer $ 98,500.00 3.0% $ 2,955.00
Accounting Assistant $ 23,673.00 8.0% $ 1,894.00
Grant Manager $ 47,271.00 2.0% $ 945.00
TOTAL $ 292,965.00 1 2.4%1 $ 7,029.00
FRINGE DETAIL -ADMINISTRATIVE
Percent of Est. Percent to Amount to
Payroll Amount Grant Grant
FICA 7.65% $ 29,266.00 1.8% $ 538.00
Life/Disability Insurance 1.28% $ 3,760.00 0.1% $ 5.00
Health/DentalInsurance 23.27% $ 68,177.00 0.9% $ 581.00
Unemployment-State 1.963% $ 7,510.00 1.8% $ 138.00
Worker's Compensation 1.29% $ 3,782.00 0.7% $ 27.00
TOTAL $ 112,495.00 1.1% $ 1,289.00
MISCELLANEOUS -ADMINISTRATIVE
Est. Percent to Amount to
Total Budget Grant Grant
Contract Labor
Other(Audit Fees) $ 11,500.00 4.6% $ 528.00
Insurance-Commercial Umbrella Liability $ 34,100.00 2.9% $ 986.00
Insurance-Directors and Officers $ 1,700.00
Insurance-Fidelity Bond or Equivalent $ 500.00 100.0% $ 500.00
TOTAL $ 47,800.00 4.2% $ 2,014.00
HOPWA PSA CONTRACT 2016-2017-EXHIBIT"B"-BUDGET
Tarrant County Samaritan House,Inc. Page 3
SALARY DETAIL- SUPPORTIVE SERVICES
Est. Percent to Amount to
Position Title Annual Salary Grant Grant
Vice President/Chief Programs Officer $ 77,490.00 12.0% $ 9,299.00
Food Service Manager $ 43,037.00 21.0% $ 9,038.00
Cook $ 30,638.00 38.0% $ 11,642.00
Cook 2 $ 30,784.00 38.0% $ 11,698.00
Cook 3 $ 13,530.00 34.0% $ 4,600.00
Medical Case Manager $ 62,400.00 15.0% $ 9,360.00
Resident Care Coordinator $ 31,364.00 100.0% $ 31,364.00
Resident Care Attendant $ 24,960.00 100.0% $ 24,960.00
Resident Care Attendant 2 $ 22,880.00 100.0% $ 22,880.00
Resident Care Attendant 3 $ 11,440.00 100.0% $ 11,440.00
Resident Care Attendant 4 $ 11,440.00 100.0% $ 11,440.00
Resident Care Attendant 5 $ 5,720.00 100.0% $ 5,720.00
Family Health and Education Manager $ 45,000.00 41.0% $ 18,450.00
Case Mangement Program Manager/LCDC $ 42,000.00 16.0% $ 6,720.00
LCDC $ 14,112.00 2.0% $ 282.00
Support Services Manager $ 39,690.00 65.0% $ 25,799.00
Social Services Case Manager $ 40,000.00 65.0% $ 26,000.00
Social Services Case Manager 2 $ 34,000.00 74.0% $ 25,160.00
Social Services Case Manager 3 $ 32,000.00 22.0% $ 7,040.00
TOTAL $ 430,536.00 63.4% $ 272,892.00
FRINGE DETAIL- SUPPORTIVE SERVICES
Percent of Est. Percent to Amount to
Payroll Amount Grant Grant
FICA 7.65% $ 46,273.00 45.1% $ 20,876.00
Life/Disability Insurance 0.89% $ 3,812.00 12.9% $ 492.00
Health/DentalInsurance 29.34% $ 126,323.00 52.7% $ 66,563.00
Unemployment-State 1.96% $ 11,874.00 45.1% $ 5,357.00
Worker's Compensation 2.08% $ 8,972.00 63.0% $ 5,652.00
TOTAL $ 197,254.00 50.2% $ 98,940.00
SUPPLIES AND SERVICES - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Office/Medical Supplies $ 15,622.00
Office Equipment Rental $ 4,800.00
Postage $ 3,000.00
Printing $ 5,000.00
TOTAL $ 28,422.00
HOPWA PSA CONTRACT 2016-2017-EXHIBIT"B"-BUDGET
Tarrant County Samaritan House,Inc. Page 4
MISCELLANEOUS - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Contract Labor-Nutritionist $ 25,485.00
Food Supplies $ 117,930.00
TOTAL $ 143,415.00
FACILITY AND UTILITIES - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Telephone $ 6,000.00
Electric $ 12,000.00
Gas
Water and Wastewater $ 1,200.00
Solid Waste Disposal $ 1,200.00
Rent (City needs copy of lease before
expenses can be reimbursed)
Custodial Services $ 12,500.00
Maintenance/Repairs $ 6,000.00
Building Security
TOTAL $ 38,900.00
LEGAL, FINANCIAL AND INSURANCE - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Professional Liability/Business Auto
TOTAL
DIRECT ASSISTANCE- STRMU
Est. Percent to Amount to
Total Budget Grant Grant
Short-Term Rent Assistance
Short Term Mortgage Assistance
ShortTerm Utilities Assistance
TOTAL
DIRECT ASSISTANCE-TBRA
Est. Percent to Amount to
Total Budget Grant Grant
Tenant Based Rental Assistance $ 195,060.00
TOTAL $ 195,060.00
HOPWA PSA CONTRACT 2016-2017-EXHIBIT"B"-BUDGET
Tarrant County Samaritan House,Inc. Page 5
SALARY DETAIL-FACILITY BASED OPERATIONS
Est. Percent to Amount to
Position Title Annual Salary Grant Grant
Property Manager $ 48,830.00 86.0% $ 41,994.00
Property Support-Admin Assistant $ 31,200.00 30.0% $ 9,360.00
Driver/Maintenance Manager $ 38,081.00 58.0% $ 22,087.00
Driver/Maintenance Technician $ 18,720.00 65.0% $ 12,168.00
TOTAL $ 136,831.00 62.6% $ 85,609.00
FRINGE DETAIL -FACILITY BASED OPERATIONS
Percent of Est. Percent to Amount to
Payroll Amount Grant Grant
FICA 7.65% $ 17,772.00 36.9% $ 6,549.00
Life/Disability Insurance 1.21% $ 1,661.00 11.7% $ 194.00
Health/DentalInsurance 25.53% $ 34,930.00 24.4% $ 8,525.00
Unemployment-State 1.96% $ 4,560.00 36.9% $ 1,681.00
Worker's Compensation 1.89% $ 2,589.00 43.3% $ 1,122.00
TOTAL $ 61,512.00 29.4% $ 18,071.00
MISCELLANEOUS -FACILITY BASED OPERATIONS
Est. Percent to Amount to
Total Budget Grant Grant
Insurance-Commercial Property and
Professional Liability
TOTAL
HOPWA PSA CONTRACT 2016-2017-EXHIBIT"B"-BUDGET
Tarrant County Samaritan House,Inc. Page 6
EXHIBIT"C"
AUDIT CERTIFICATION FORM
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"C"—AUDIT CERTIFICATION FORM Page 1
Tarrant County Samaritan Housing,Inc.
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency: Tarrant County Samaritan Housing,Inc.
Fiscal Year Ending: September 30,2017
During the fiscal year in which funds will be received, we will exceed the federal
expenditure threshold of$750,000. We will have our Single Audit or Program Specific
Audit completed and will submit the audit report described in 2 CFR Part 200 within 7
months after the end of the audited fiscal year or 30 days within its completion, whichever
is the earlier date.
❑ During the fiscal year in which funds will be received, we will not exceed the $750,000
federal expenditure threshold required for a Single Audit or a Program Specific Audit to be
performed this fiscal year. (Fill out schedule below)
Federal Exgendifurel?asclostre
11'IUB'�'`be�illedo>xtifStngle,Audztvpr�?x{� �,tnAud��trsl�QT,xe urged �,,:.� -
Pass Through Program ltlarne&_= Contract
Federal Grnto _ xpeditures
GranfgrFIATumber
Total Federal Expenditures for this Fiscal Year:
Jcaff L00 /0/�q/ �
S natory And Title Date
Failure to submit this or a similar statement or failure to submit a completed single audit package
as described in the federally required audit requirements described in 2 CFR Part 200, as
applicable, by the required due date may result in suspension of funding and may affect
eligibility for future funding. Notwithstanding the above, this certification acknowledges the
agency's commitment to meet all other financial reporting, financial statements, and other
audit requirements as may be set forth in the Contract.
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"C"—AUDIT CERTIFICATION FORM Page 2
Tarrant County Samaritan Housing,Inc.
EXHIBIT "D"
REPORTING FORMS
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"D"—REPORTING FORMS Page 1
Tarrant County Samaritan House,Inc.
ATTACHMENT I
Invoice
Agency: '
Address: '
City, State, Zip:
Program:
Period of Service:
Tax ID No.
P.O. No.
FID No.
Amount
Program ,�
Thrs Invoice Cumulatwe to Date
Agency's Certification: By signing this report, I certify to the best of my
knowledge and belief that the report is true, complete, and accurate,
and the expenditures, disbursements and cash receipts are for the
purposes and objectives set forth in the terms and conditions of the
Federal award. I am aware that any false, fictitious or fraudulent
f'f'f information, or the omission of any material fact, may subject me to
criminal, civil, or administrative penalties for fraud, false statements,
false claims, or otherwise. U.S. Code Title 18, Sec. 1001 and Title 31, "!
Sec. 3729-3730 and 3801-3812.
Signature and Date:
Name:
Title:
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"D"—REPORTING FORMS Page 2
Tarrant County Samaritan House,Inc.
ATTACHMENT II
Expenditure Worksheet
.......City of Fort SVorth
_ Neighborhood Services Department
j Expenditure NVorksheet
Agency:
Program _. _..
Only highlightedcodes canbereimbursed
Please g oup like account codes.
Code(See
..
No- Cheol:No� -"Daft, =<P6vee% ""-1Iksori[ionllob Trtk* 's be to Ri bit 'Amount" Account
.w,
1
ADDIINISTRA=,,:'`.
2 Salaries 1001
3 FICA 1002
4 Lif&Disabihty Insurance IOD3
5 Health/Dental Insurance 1004
6 Unen avraentState 1005
7 Worker's Corapensntion 1006
8 Contract Labor 1007
9 OthetO 1008
10 Insurance-Commercial Liab. 1009
11 Insurance-Directors&Officers 1010
12 Insurance-Fidelity Bond or Eq. 1011
13 ,:.;,; SUPP.ORTIVESEP VICES ,
14 PROGRAM PERSONNEL
15 Salaries 2001
16 FICA 2002
17 Life/Disability Insurance 2003
18 Health/Dental Insurance 20D4
19 Uncr levreentState 2005
20 Worker's CorMensation 2OD6
21 SUPPLIES AND SFRVLCES
22 Office/Medical Supplies 3001
23 Office Equipment Rental 3002
24 Postage 3003
25 Pn ting 3004
26 _.MISCII.I.ANDOLS
27 Contract Labor 40DI _
28 Food Supplies 4002
29 FACILf1YANDUITfSL'IFS
30 Telephone 5001
31 Fketric 5002
32 Cas 5003
33 Water and Wastewater 5004
34 Solid Waste Disposal 5005
35 Rent 5006
36 Custodial Services 5007
37 Maintenance/Px airs 5008
38 Building Security 5009
39 LEGAL,FINANCIAL AND INS URANCE
40 Pro fess anal liabJBuss.Auto 6001
41 ,_',"?'DIRECTASS)STANCES7Ri13U"„;` .
42 Short-term Rent Assistance 7001
43 Short-term Mortgage Assistance 7002
44 Short-term Utilities Assistance 7003
45DIlLHCPASSISTANCFTBRA
46 Tenant Based Rental Assistancel 8001
47 -z;,FACUMBASRD"OPERATIONS”;
ATTACHMENT III
Client Data Report-Supportive Services and Operations
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HOPWA PSA CONTRACT 2016-2017—EXHIBIT"D"—REPORTING FORMS Page 4
Tarrant County Samaritan House,Inc.
ATTACHMENT III
Client Data Report-Tenant Based Rental Assistance (TBRA)
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CLI I'DATAR-T
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11
HOPWA PSA CONTRACT 2016-2017—EXHIBIT"D"—REPORTING FORMS Page 5
Tarrant County Samaritan House,Inc.
ATTACHMENT III
Client Data Report-Short-Term Rental, Mortgage and Utility Assistance (STRMU)
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HOPWA PSA CONTRACT 2016-2017—EXHIBIT"D"—REPORTING FORMS Page 6
Tarrant County Samaritan House,Inc.
EXHIBIT "E"
INCOME CERTIFICATION FORMS
HOPWA PSA CONTRACT 2016-2017--EXHIBIT`B"--INCOME CERTIFICATION FORMS Page 1
Tarrant County Samaritan House,Inc.
City of Fort Worth
CERTIFICATION OF INCOME STATEMENT
Applicant Name:
Current Address: Phone#:
City and Zip:
Household Members and Income
(including applicant)
Last Name First Name Age Monthly Source of Income
Income $$
TOTAL NUMBER OF FAMILY MEMBERS (Include Yourself, Spouse, Children,etc.)
Total Gross Annual Household Income:
PERSONAL INFORMATION:(Check one in each item. This Information is Required for Federal Reporting Purposes)
a. ❑MALE b.❑ WHITE ❑BLACK/AFRICAN AMERICAN ❑BLACK/AFRICAN AMERICAN&WHITE
❑FEMALE ❑AMERICAN INDIAN/ALASKAN NATIVE ❑ASIAN
❑AMERICAN INDIAN/ALASKAN NATIVE&WHITE ❑ASIAN&WHITE
❑NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER ❑BALANCE/OTHER
❑AMERICAN INDIAN/ALASKAN NATIVE&BLACK/AFRICAN AMERICAN
c. ETHNICITY d. DISABLED e. IS HEAD OF HOUSEHOLD FEMALE?
❑HISPANIC ❑YES ❑YES
❑NON-HISPANIC ❑NO ❑NO
Certification: I certify that the information I am providing is true and could be subject to verification at any
time by a third party. I also acknowledge that the provision of false information could leave me subject to the
penalties of Federal, State and local law.
Signature of Applicant Date
WARNING: TITLE 18,SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF
THE UNITED STATES GOVERNMENT.
-----------------For use by Agency staff only-----------------
Household Size: Gross Annual Income:
Applicable Income Limit: Is Applicant Eligible?
Check if Applicant refused to provide demographic information: O
Staff Assessment of Demographics:
Person Making Determination: Date:
NOTE: Address, income amounts and sources for ALL household members are required.
HOPWA PSA CONTRACT 2016-2017--EXHIBIT"E"--INCOME CERTIFICATION FORMS Page 2
Tarrant County Samaritan House,Inc.
Ciudad de Fort Worth
CERTIFICACION DE DECLARACION DE INGRESOS
Nombre del Solicitante:
Direcci6n de Actualidad: Telefono:
Ciudad y C6digo Postal:
Miembros Del Hogar r e Ingresos
(Incluyendo el/la Solicitante)
Apellido Nombre Edad Ingreso Origen de Ingresos
Mensual
* TOTAL NOMERO DE MIEMBROS DEL HOGAR (Incluyase Usted.)
Total Anual de Ingresos del hogar:
"INFORMACION PERSONAL:(Seleccione uno en cada articulo. Esta infonnaci6n es requerida por el Gobiemo federal.)
a. ❑MASCULINO b.❑BLANCO ❑NEGRO/AFRICANO AMERICANO ❑NEGRO/AFRICANO AMERICANO&BLANCO
❑FEMININO ❑INDIO AMERICANO/NATIVO DE ALASKA ❑ASIATICO
❑INDIO AMERICANO/NATIVO DE ALASKA&BLANCO ❑ASIATICO&BLANCO
❑NATIVO HAWAIANO/OTRO DE LAS ISLAS PACIFICAS ❑BALANCE/OTRO
❑INDIO AMERICANO/NATIVO DE ALASKA&NEGRO/AFRICANO AMERICANO
c. ETHNICIDAD d. INCAPACITADO e. LES LA CABEZA DEL HOGAR MUJER?
❑HISPANO ❑SI ❑SI
❑NO-HISPANO ❑NO ❑NO
Certificaci6n: Yo certifico que la informaci6n que yo estoy proporcionando es verdadera y puedo ser sujeto a
verificaci6n a cualquiera hora por tercera parte. Yo tambien reconozco que la provisi6n de informaci6n falsa
puede dejarme sujeto a penalidades Federales, Estatales, y a ley local.
Firma del Solicitante Fecha
ADVERTENCIA: TITULO 18,SECCION 1001 DEL CODIGO DE LOS ESTADOS UNIDOS INDICA QUE UNA
PERSONA ES CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE RACER DECLARACIONES FALSOS O
FRAUDULENTAS A CUALQUIER DEPARTAMENTO DE GOBIERNO DE LOS ESTADOS UNIDOS.
-----------------Para use de em leados de la a encia-----------------
#De Miembros de Familia: Ingreso Anual:
Limite de Ingreso: eEs solicitante elegible?
Compruebe si el solicitante se neg6 a dar su informaci6n personal: O
Evaluaci6n del empleado sobre informaci6n personal:
Persona haciendo la determinaci6n: Fecha:
Note: La direccion de la casa y los Ingresos (y sus origenes) para todos miembros del hogar son requeridos.
HOPWA PSA CONTRACT 2016-2017--EXHIBIT"E"--INCOME CERTIFICATION FORMS Page 3
Tarrant County Samaritan House,Inc.
EXHIBIT "F"
STANDARDS OF DOCUMENTATION
HOPWA PSA CONTRACT 2016-2017--EXHIBIT"F"--STANDARDS OF DOCUMENTATION Page 1
Tarrant County Samaritan House,Inc.
2016-2017 Documentation Standards for
HOPWA Public Service Contract Expenses
0 cc
Budget Line E E! 0
Items (D 0.0 Notes/Other
CL
Employee Salaries and Benefits Crty wrll only reimburse a percentage of any employee salary and benefits who wQrkdrrectly with the HOPWA funded Program
Percentages will be Cost allocated and determined pnor#o the execution of#fie HOPWA Contract Agencres reques#mg the reimbursement of 100%of any Agency�employee
. _. �.
will require pnor Crty approval Agencres must show calculatron`on how the HOPWA'portron o'f employee salarres:and beiiefits.were calculates consisfently withthe HOPiNA'
Contract '
r r�
If an employee works on both a HOPWA eligible and non-HOPWA eligible program(s),the City will only reimburse for a reasonable
portion of the employee's salary. Prior to the execution of the HOPWA Contract,the Agency will priovide the City with a written
statement on how each employee's time will be allocated. If an employee works 100%of their time directly with the HOPWA-funded
Program,then 100%of the employee's salary maybe eligible for reimbursement. Agency must submit a written statement that 100%of
the employee's time is spent working directly with the HOPWA-funded Program. Statements must be signed by a person authorized to
sign on behalf of the Agency and will be submitted with the October invoice.
Salaries X x• Reimbursement requests must include a timesheet and work log that reflects the hours worked by the employee(s)working directly on
the HOPWA-funded Program. For employees who are paid with multiple funding sources,timesheets must reflect all funding sources.
If separate timesheets are kept for each funding source,all such timesheets must be submitted to City. Timesheets must be signed by
employee and supervisor. Agency must show a calculation and documentation of how the employee's salary was calculated and
invoiced to City.
*If employees are paid by direct deposit rather than check,then the agency must submit both the direct deposit payment company's
report(such as an ADT report)and a bank statement or check showing payment to the direct deposit company.
FICA/Medicare X X
Life Insurance X x
Health X X
Insurance If the City pays gross salary,this is already included.If the City pays the employer portion,the Agency must provide proof that the
mployee is enrolled in the benefit plan,must show a calculation and documentation of how the invoiced amount was calculated,and
Disability e
Insurance x X must provide documentation showing payment.
Unemployment x x
Insurance
If the City pays gross salary,this is already included.If the City pays the employer portion,the Agency must provide proof that the
Retirement X x employee is enrolled in the benefit plan,must show a calculation and documentation of how the invoiced amount was calculated,and
must provide documentation showing payment.
�VlaterralsEpwpment Goodsand.Supphes-,city willo%niyreimburseforthe;costaliocatedpercentoramountspenfinsupportofthe:HOPWA=fundedProgram agencies=.
M �..�
requesYing'reniitiursem"ant fortfiese ttems`Wiil require prior city,approval:`Agencies must`shoiu'aiculatiori ori how.the HOPWA poition`of these expenses were caicblated
aonsistentljfvVith fhe'HOPWA Contract.
Office Supplies X X X
Office
Equipment X X X X X
Rental
Postage X X X
Printing X X X
Construction&
Building X X X X This category is only available for the REACH Program.
Materials
Sport and
Recreation X X X
Equipment
Cleaning X X X
Supplies
Teaching Aids X X X
Craft Supplies X X X
Food Supplies X X1 I X This category is only available to the Program provided by Meals on Wheels.
Rent Uttirtres and Maintenance Ctty wdt only pay fgr a portion of these expenses The portron`of#hese;expenses will be determined bythe square footage attributable to
the HOP111fA funded Program and shall becost-allocated in aceortlance with the amount of space used for the HOPWA funded Program These expenses may only be rn
support of the HOPIIIIA funded Program The items hstetl below r`egmre pnor Crty approval and the Agency a requited to rdenhfy any funding source thaCpays for the
portion of the expenses that
rs not pard with HOPWA funds Agencres mustshow calculatron on how the;HOPtNA aortron ofthese expenses were calculated consistently
with the HOPWA Contract
x
Telephone X X
Gas X X
WatedWastew X X
ater
Electric X X
Solid Waste X X
HOPWA PSA CONTRACT 2016-2017 El�lbft"F-STANDARDS FOR COMPLETE DOCUMENTATION 1
Facility This item requires approval by the City prior to the execution of the HOPWA Contract. Repairs may be categorized as major/minor
Maintenance X X X X rehabilitation projects and must be approved through the full HUD Environmetal Review.
and Repairs
Rent X X X City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the HOPWA-
funded program.
Miscellaneous
This item requires prior approval by the City. Prior to the execution of the HOPWA Contract,the Agency must submit a written
statement that lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the
Contract Labor X X X X X procurement of such services and will forward any information pertaining to the procurement process to City. This requirement applies
to,but is not limited to,services retained for security services,legal,accounting,transportation providers,educational facilitators,
custodial services,etc. Agencies may not use the contract services of any City of Fort Worth Department.
City-required X X City will only pay for a percentage of the City-required insurance so long as it's in proportion to the square footage attributable to the
Insurance HOPWA-funded program.
City requires that the agency submit its fee schedule or formula on how the Agency calculates the childcare scholarship amount. The
fee schedule/formula should demonstrate a breakout of income levels,and for each income level the schedule should demonstrate
Childcare which portion of the expense is to be paid by the family and which portion of the expense is to be reimbursed by the City. A fee
Scholarships X X schedule/formula must be submitted to the City prior to the first payment. Agency must submit documentation supporting that the client
is income eligible and that the household is being charged in conformance with the fee schedule. If the fee schedule/formula changes at
any time during the contract term,the Agency must immediately notify City on the date the new fee schedule/formula takes into effect.
"$0"Income Agecies that are required to verify and provide proof of household income to determine eligibility,must require that anyone who is over
Certifications the age of 18,living in the housohold,submit a$0 Income Certification.
If an audit is required because federal funds exceed$750,000,then the cost should be split evenly by all grant funding sources. Agency
Audit Services X X X X must show calculation on how the HOPWA portion of the accounting services were calculated. For example,if the HOPWA grant is
10%of your Agency's budget,then invoice shall not exceed 10%of the overall cost. Agency must show a calculation and
documentation of how the invoiced amount was calculated,and must provide documentation showing payment.
*Proof of payment effective October 1,2013: payments or Expenses must be documented in the following manner:
A)Image of the check AND bank statement showing the check cleared the bank;OR,
B)Image of the cancelled check(ex.At end of bank statement);OR,
C)Payroll Check Stub,"Advice",or Statement AND Bank Statement indicating payroll;OR,
D)For wire or e-transfers:Reciept or statement from payee/vendor OR bank statement.
Final as of 09/162016 do
HOPWA PSA CONTRACT 2016-2017 E kbit"F'—STANDARDS FOR COMPLETE DOCUMENTATION 1
EXHIBIT "G"
SECTION 3 REPORTING FORMS
NOT APPLICABLE
HOPWA PSA CONTRACT 2016-2017--EXHIBIT"G"--SECTION 3 REPORTING FORMS Page 1
Tarrant County Samaritan House,Inc.
EXHIBIT "H"
OVERVIEW REPORT
HOPWA PSA CONTRACT 2016-2017--EXHIBIT"Fr'—OVERVIEW REPORT Page 1
Tarrant County Samaritan House,Inc.
Q
Housing Opportunities for Persons with AIDS
(HOPWA) Program
Consolidated Annual Performance and
Evaluation Report (CAPER)
Measuring Performance Outcomes
Revised 1/22/15
OMB Number 2506-0133(Expiration Date: 12/31/2017)
The CAPER report for HOPWA formula grantees provides annual information on program accomplishments
that supports program evaluation and the ability to measure program beneficiary outcomes as related to:
maintain housing stability;prevent homelessness; and improve access to care and support. This information is
also covered under the Consolidated Plan Management Process(CPMP)report and includes Narrative
Responses and Performance Charts required under the Consolidated Planning regulations. The public reporting
burden for the collection of information is estimated to average 42 hours per manual response,or less if an
automated data collection and retrieval system is in use,along with 60 hours for record keeping, including the
time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and
completing and reviewing the collection of information.Grantees are required to report on the activities
undertaken only,thus there may be components of these reporting requirements that may not be applicable. This
agency may not conduct or sponsor,and a person is not required to respond to a collection of information unless
that collection displays a valid OMB control number.
Previous editions are obsolete form HUD-40110-D(Expiration Date:10/31/2017
Overview. The Consolidated Annual Performance and Evaluation Report Assistance,Housing Relocation&Stabilization Services,Employment,
(CAPER)provides annual performance reporting on client outputs and Education,General Health Status,,Pregnancy Status,Reasons for Leaving,
outcomes that enables an assessment of grantee performance in achieving the Veteran's Information,and Children's Education. Other HOPWA projects
housing stability outcome measure. The CAPER,in conjunction with the sponsors may also benefit from collecting these data elements.
Integrated Disbursement Information System(IDIS),fulfills statutory and
regulatory program reporting requirements and provides the grantee and Final Assembly of Report. After the entire report is assembled,please
HUD with the necessary information to assess the overall program number each page sequentially.
performance and accomplishments against planned goals and objectives.
HOPWA formula grantees are required to submit a CAPER,and complete Filing Requirements. Within 90 days of the completion of each program
annual performance information for all activities undertaken during each year,grantees must submit their completed CAPER to the CPD Director in
program year in the IDIS,demonstrating coordination with other the grantee's State or Local HUD Field Office,and to the HOPWA Program
Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain Office:at HOPWA(cr)�hud.gov. Electronic submission to HOPWA Program
essential information on grant activities,project sponsors,Subrecipient office is preferred;however,if electronic submission is not possible,hard
organizations,housing sites,units and households,and beneficiaries.(which copies can be mailed to:Office HIV/AIDS Housing,Room 7212,U.S.
includes racial and ethnic data on program participants). The Consolidated Department of Housing and Urban Development,451 Seventh Street,
t,SW,
Plan Management Process tool(CPMP)provides an optional tool to integrate Washington,D.C.
the reporting of HOPWA specific activities with other planning and reporting
on Consolidated Plan activities. Record Keeping. Names and other individual information must be kept
confidential,as required by 24 CFR 574.440.However,HUD reserves the
Table of Contents right to review the information used to complete this report for grants
management oversight purposes,except for recording any names and other
PART 1:Grantee Executive Summary identifying information. In the case that HUD must review client level
1.Grantee Information data,no client names or identifying information will be retained or
2.Project Sponsor Information recorded. Information is reported in aggregate to HUD without
3.Administrative Subrecipient Information personal identification.Do not submit client or personal information in
4.Program Subrecipient Information data systems to HUD.
5.Grantee Narrative and Performance Assessment
a.Grantee and Community Overview
b.Annual Performance under the Action Plan Definitions
c.Barriers or Trends Overview Adjustment for Duplication: Enables the calculation of unduplicated
d.Assessment of Unmet Housing Needs output totals by accounting for the total number of households or units that
PART 2:Sources of Leveraging and Program Income received more than one type of HOPWA assistance in a given service
1. Sources of Leveraging category such as HOPWA Subsidy Assistance or Supportive Services.For
2. Program Income and Resident Rent Payments example,if a client household received both TBRA and STRMU during the
PART 3:Accomplishment Data:Planned Goals and Actual Outputs operating year,report that household in the category of HOPWA Housing
PART 4:Summary of Performance Outcomes Subsidy Assistance in Part 3,Chart I,Column[lb]in the following manner:
1.Housing Stability: Permanent Housing and Related Facilities
2.Prevention of Homelessness: Short-Term Housing Payments 11] Outputs:
3.Access to Care and Support: Housing Subsidy Assistance with HOPWA HOUSlrig Subsidy
Supportive Services Number Of
PART 5:Worksheet-Determining Housing Stability Outcomes ASSIStaIICe Households
PART 6:Annual Certification of Continued Use for HOPWA Facility-
Based Stewardship Units(Only) 1. Tenant-Based Rental Assistance I
PART 7:Summary Overview of Grant Activities Permanent Housing Facilities:
A.Information on Individuals,Beneficiaries and Households Receiving 2a. Received Operating
HOPWA Housing Subsidy Assistance(TBRA,STRMU,PHP,Facility Subsidies/Leased units
Based Units,Master Leased Units ONLY) Transitional/Short-term
B.Facility-Based Housing Assistance 26 Facilities:
Received Operating Subsidies
Continued Use Periods. Grantees that received HOPWA funding for new
construction,acquisition,or substantial rehabilitations are required to operate Permanent Housing Facilities:
their facilities for HOPWA-eligible beneficiaries for a ten(10)years period. Capital Development Projects
If no further HOPWA funds are used to support the facility,in place of 3a. placed in service during the
completing Section 7B of the CAPER,the grantee must submit an Annual operating year
Certification of Continued Project Operation throughout the required use
periods. This certification is included in Part 6 in CAPER.The required use Transitional/Short-term
period is three(3)years if the rehabilitation is non-substantial. Facilities:
Capital Development Projects
In connection with the development of the Department's standards for 3b' placed in service during the
Homeless Management Information Systems(HMIS),universal data operating year
elements are being collected for clients of HOPWA-funded homeless
assistance projects. These project sponsor/subrecipient records would Short-term Rent,Mortgage,and
include:Name,Social Security Number,Date of Birth,Ethnicity and Race, 4' Utility Assistance 1
Gender,Veteran Status,Disabling Conditions,Residence Prior to Program Adjustment for duplication
Entry,Zip Code of Last Permanent Address,Housing Status,Program Entry 5' subtract 1
Date,Program Exit Date,Personal Identification Number,and Household TOTAL Housing Subsidy
Identification Number. These are intended to match the elements under 6. Assistance(Sum of Rows 1-4 I
HMIS.The HOPWA program-level data elements include:Income and minus Row 5)
Sources,Non-Cash Benefits,HN/AIDS Status,Services Provided,and
Housing Status or Destination at the end of the operating year. Other
suggested but optional elements are:Physical Disability,Developmental
Disability,Chronic Health Condition,Mental Health,Substance Abuse,
Domestic Violence,Date of Contact,Date of Engagement,Financial
Previous editions are obsolete Page i form HUD-401 10-D(Expiration Date:10/31/2017)
Administrative Costs: Costs for general management,oversight, "grassroots."
coordination,evaluation,and reporting. By statute,grantee administrative
costs are limited to 3%oftotal grant award,to be expended over the life of HOPWA Eligible Individual: The one(1)low-income person with
the grant. Project sponsor administrative costs are limited to 7%of the HIV/AIDS who qualifies a household for HOPWA assistance.This person
portion of the grant amount they receive. may be considered"Head of Household."When the CAPER asks for
information on eligible individuals,report on this individual person only.
Beneficiary(ies):All members of a household who received HOPWA Where there is more than one person with HIV/AIDS in the household,the
assistance during the operating year including the one individual who additional PWH/A(s),would be considered a beneficiary(s).
qualified the household for HOPWA assistance as well as any other
members of the household(with or without HN)who benefitted from the HOPWA Housing Information Services: Services dedicated to helping
assistance. persons living with HIV/AIDS and their families to identify,locate,and
acquire housing.This may also include fair housing counseling for eligible
Central Contractor Registration(CCR): The primary registrant persons who may encounter discrimination based on race,color,religion,
database for the U.S.Federal Government.CCR collects,validates,stores, sex,age,national origin,familial status,or handicap/disability.
and disseminates data in support of agency acquisition missions,including
Federal agency contract and assistance awards.Both current and potential HOPWA Housing Subsidy Assistance Total: The unduplicated number
federal government registrants(grantees)are required to register in CCR of households receiving housing subsidies(TBRA,STRMU,Permanent
in order to be awarded contracts by the federal government.Registrants Housing Placement services and Master Leasing)and/or residing in units
must update or renew their registration at least once per year to maintain of facilities dedicated to persons living with HIV/AIDS and their families
an active status.Although recipients of direct federal contracts and grant and supported with HOPWA funds during the operating year.
awards have been required to be registered with CCR since 2003,this
requirement is now being extended to indirect recipients of federal funds Household: A single individual or a family composed of two or more
with the passage of ARRA(American Recovery and Reinvestment Act). persons for which household incomes are used to determine eligibility and
Per ARRA and FFATA(Federal Funding Accountability and for calculation of the resident rent payment. The term is used for
Transparency Act)federal regulations,all grantees and sub-grantees or collecting data on changes in income,changes in access to services,receipt
subcontractors receiving federal grant awards or contracts must have a of housing information services,and outcomes on achieving housing
DUNS(Data Universal Numbering System)Number. stability.Live-In Aides(see definition for Live-In Aide)and non-
beneficiaries(e.g.a shared housing arrangement with a roommate)who
Chronically Homeless Person:An individual or family who:(i)is resided in the unit are not reported on in the CAPER.
homeless and lives or resides individual or family who:(i)Is homeless and
lives or resides in a place not meant for human habitation,a safe haven,or Housing Stability: The degree to which the HOPWA project assisted
in an emergency shelter;(ii)has been homeless and living or residing in a beneficiaries to remain in stable housing during the operating year. See
place not meant for human habitation,a safe haven,or in an emergency Part 5:Detennining Housing Stability Outcomes for definitions of stable
shelter continuously for at least 1 year or on at least 4 separate occasions in and unstable housing situations.
the last 3 years;and(iii)has an adult head of household(or a minor head
of household if no adult is present in the household)with a diagnosable In-kind Leveraged Resources: These involve additional types of support
substance use disorder,serious mental illness,developmental disability(as provided to assist HOPWA beneficiaries such as volunteer services,
defined in section 102 of the Developmental Disabilities Assistance and materials,use of equipment and building space. The actual value of the
Bill of Rights Act of 2000(42 U.S.C. 15002)),post traumatic stress support can be the contribution of professional services,based on
disorder,cognitive impairments resulting from a brain injury,or chronic customary rates for this specialized support,or actual costs contributed
physical illness or disability,including the co-occurrence of 2 or more of from other leveraged resources. In determining a rate for the contribution
those conditions.Additionally,the statutory definition includes as of volunteer time and services,use the rate established in HUD notices,
chronically homeless a person who currently lives or resides in an such as the rate often dollars per hour. The value of any donated material,
institutional care facility,including a jail,substance abuse or mental health equipment,building,or lease should be based on the fair market value at
treatment facility,hospital or other similar facility,and has resided there time of donation. Related documentation can be from recent bills of sales,
for fewer than 90 days if such person met the other criteria for homeless
prior to entering that facility.(See 42 U.S.C. 11360(2))This does not advertised prices,appraisals,or other information for comparable property
include doubled-up or overcrowding situations. similarly situated.
Disabling Condition: Evidencing a diagnosable substance use disorder, Leveraged Funds: The amount of funds expended during the operating
serious mental illness,developmental disability,chronic physical illness, year from non-HOPWA federal,state,local,and private sources by
or disability,including the co-occurrence of two or more of these grantees or sponsors in dedicating assistance to this client population.
conditions. In addition,a disabling condition may limit an individual's Leveraged funds or other assistance are used directly in or in support of
ability to work or perform one or more activities of daily living.An HOPWA program delivery.
HIV/AIDS diagnosis is considered a disabling condition.
Facility-Based Housing Assistance: All eligible HOPWA Housing Live-In Aide: A person who resides with the HOPWA Eligible Individual
expenditures for or associated with supporting facilities including and who meets the following criteria: (1)is essential to the care and well-
community residences,SRO dwellings,short-term facilities,project-based being of the person;(2)is not obligated for the support of the person;and
rental units,master leased units,and other housing facilities approved by (3)would not be living in the unit except to provide the necessary
HUD supportive services. See the Code of Federal Regulations Title 24,Part
5.403 and the HOPWA Grantee Oversight Resource Guide for additional
Faith-Based Organization: Religious organizations ofthree types:(1) reference.
congregations;(2)national networks,which include national
denominations,their social service arms(for example,Catholic Charities, Master Leasing;Applies to a nonprofit or public agency that leases units
Lutheran Social Services),and networks of related organizations(such as of housing(scattered-sites or entire buildings)from a landlord,and
YMCA and YWCA);and(3)freestanding religious organizations,which subleases the units to homeless or low-income tenants.By assuming the
are incorporated separately from congregations and national networks. tenancy burden,the agency facilitates housing of clients who may not be
able to maintain a lease on their own due to poor credit,evictions,or lack
Grassroots Organization: An organization headquartered in the local of sufficient income.
community where it provides services;has a social services budget of
$300,000 or less annually,and six or fewer full-time equivalent Operating Costs: Applies to facility-based housing only,for facilities
employees. Local affiliates of national organizations are not considered that are currently open. Operating costs can include day-to-day housing
Previous editions are obsolete Page ii form HUD-401 10-D(Expiration Date:10/31/2017)
function and operation costs like utilities,maintenance,equipment, Subrecipient Organization: Any organization that receives funds from a
insurance,security,furnishings,supplies and salary for staff costs directly project sponsor to provide eligible housing and other support services
related to the housing project but not staff costs for delivering services. and/or administrative services as defined in 24 CFR 574.300. If a
Subrecipient organization provides housing and/or other supportive
Outcome: The degree to which the HOPWA assisted household has been services directly to clients,the Subrecipient organization must provide
enabled to establish or maintain astable living environment in housing that performance data on household served and funds expended. Funding
is safe,decent,and sanitary,(per the regulations at 24 CFR 574.310(b)) flows to subrecipients as follows:
and to reduce the risks of homelessness,and improve access to HIV
treatment and other health care and support. HUD Funding —>Grantee ---> Project Sponsor Subrecipient
Output: The number of units of housing or households that receive Tenant-Based Rental Assistance(TBRA): TBRA is a rental subsidy
HOPWA assistance during the operating year. program similar to the Housing Choice Voucher program that grantees can
provide to help low-income households access affordable housing. The
Permanent Housing Placement: A supportive housing service that helps TBRA voucher is not tied to a specific unit,so tenants may move to a
establish the household in the housing unit,including but not limited to different unit without losing their assistance,subject to individual program
reasonable costs for security deposits not to exceed two months of rent rules. The subsidy amount is determined in part based on household
costs. income and rental costs associated with the tenant's lease.
Program Income: Gross income directly generated from the use of Transgender: Transgender is defined as a person who identifies with,or
HOPWA funds,including repayments. See grant administration presents as,a gender that is different from his/her gender at birth.
requirements on program income for state and local governments at 24
CFR 85.25,or for non-profits at 24 CFR 84.24. Veteran: A veteran is someone who has served on active duty in the
Armed Forces of the United States. This does not include inactive military
Project-Based Rental Assistance(PBRA): A rental subsidy program reserves or the National Guard unless the person was called up to active
that is tied to specific facilities or units owned or controlled by a project duty.
sponsor or Subrecipient. Assistance is tied directly to the properties and is
not portable or transferable.
Project Sponsor Organizations: Any nonprofit organization or
governmental housing agency that receives funds under a contract with the
grantee to provide eligible housing and other support services or
administrative services as defined in 24 CFR 574.300. Project Sponsor
organizations are required to provide performance data on households
served and funds expended. Funding flows to a project sponsor as
follows:
HUD Funding -----> Grantee---->Project Sponsor
Short-Term Rent,Mortgage,and Utility(STRMU)Assistance: A
time-limited,housing subsidy assistance designed to prevent homelessness
and increase housing stability. Grantees may provide assistance for up to
21 weeks in any 52 week period. The amount of assistance varies per
client depending on funds available,tenant need and program guidelines.
Stewardship Units: Units developed with HOPWA,where HOPWA
funds were used for acquisition,new construction and rehabilitation that
no longer receive operating subsidies from HOPWA. Report information
for the units is subject to the three-year use agreement if rehabilitation is
non-substantial and to the ten-year use agreement if rehabilitation is
substantial.
Previous editions are obsolete Page iii form HUD-40110-D(Expiration Date:10/31/2017)
Housing Opportunities for Person with AIDS (HOPWA)
Consolidated Annual Performance and Evaluation Report (CAPER)
Measuring Performance Outputs and Outcomes
OMB Number 2506-0133(Expiration Date: 10/31/2017)
Part 1: Grantee Executive Summary
As applicable,complete the charts below to provide more detailed information about the agencies and organizations responsible
for the administration and implementation of the HOPWA program. Chart 1 requests general Grantee Information and Chart 2 is
to be completed for each organization selected or designated as a project sponsor,as defined by CFR 574.3. In Chart 3,indicate
each subrecipient organization with a contract/agreement of$25,000 or greater that assists grantees or project sponsors carrying
out their administrative or evaluation activities. In Chart 4,indicate each subrecipient organization with a contract/agreement to
provide HOPWA-funded services to client households. These elements address requirements in the Federal Funding and
Accountability and Transparency Act of 2006(Public Law 109-282).
Note:Please see the definition section for distinctions behveen project sponsor and subrecipient.
Note:If any information does not apply to your organization,please enter N/A. Do not leave any section blank.
1. Grantee Information
HUD Grant Number Operating Year for this report
From(in nlddl"q To(nwVdd1jy)
Grantee Name
Business Address
City,County,State,Zip
Employer Identification Number(EIN)or
Tax Identification Number TIN)
DUN&Bradstreet Number(DUNs): Central Contractor Registration(CCR):
Is the grantee's CCR status currently active?
❑Yes ❑No
If yes,provide CCR Number:
Congressional District of Grantee's Business
Address
*Congressional District of Primary Service
Area(s)
*City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Organization's Website Address Is there a waiting list(s)for HOPWA Housing Subsidy Assistance
Services in the Grantee service Area? ❑Yes ❑No
If yes,explain in the narrative section what services maintain a waiting
list and how this list is administered.
x Service delivery area information only needed for program activities being directly carried out by the grantee.
Previous editions are obsolete Page 1 form HUD-401 10-D(Expiration Date:10/31/2017)
2. Project Sponsor Information
Please complete Chart 2 for each organization designated or selected to serve as a project sponsor,as defined by CFR 574.3.
Use this section to report on organizations involved in the direct delivery of services for client households. These elements
address requirements in the Federal Financial Accountability and Transparency Act of 2006(Public Law 109-282).
Note:Please see the definitions for distinctions betiveen project sponsor and subrecipient.
Note:If any information does not apply to your organization,please enter N/A.
Project Sponsor Agency Name Parent Company Name,ifapplicable
Name and Title of Contact at Project
Sponsor Agency
Email Address
Business Address
City,County,State,Zip,
Phone Number(with area code)
Employer Identification Number(EIN)or Fax Number(with area code)
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNS):
Congressional District of Project Sponsor's
Business Address
Congressional Distriet(s)of Primary Service
Area(s)
City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Total HOPWA contract amount for this
Organization for the operating ear
Organization's Website Address
Does your organization maintain a waiting list? El Yes El No
Is the sponsor a nonprofit organization? El Yes El No
Please check ifyes and a faith-based organization. ❑ If yes,explain in the narrative section how this list is administered.
Please check if yes and a grassroots organization. ❑
Previous editions are obsolete Page 2 form HUD-401 10-D(Expiration Date:10/31/2017)
3.Administrative Subrecipient Information
Use Chart 3 to provide the following information for each Subrecipient with a contract/agreement of$25,000 or greater that
assists project sponsors to carry out their administrative services but no services directly to client households. Agreements
include: grants,subgrants,loans,awards,cooperative agreements,and other forms of financial assistance; and contracts,
subcontracts,purchase orders,task orders,and delivery orders. (Organizations listed may have contracts with project sponsors)
These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006(Public Law 109-
282).
Note:Please see the definitions for distinctions between project sponsor and subrecipient.
Note:If any information does not apply to your organization,please enter N/A.
Subrecipient Name Parent Company Name,ifapplicable
Name and Title of Contact at Subrecipient
Email Address
Business Address
City,State,Zip,County
Phone Number(with area code) Fax Number(include area code)
Employer Identification Number(EIN)or
Tax Identification Number TIN
DUN&Bradstreet Number(DUNs):
North American Industry Classification
System(NAICS)Code
Congressional District of Subrecipient's
Business Address
Congressional District of Primary Service
Area
City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Total HOPWA Subcontract Amount of this
Organization for the operating ear
Previous editions are obsolete Page 3 form HUD-401 10-D(Expiration Date:10/31/2017)