HomeMy WebLinkAboutContract 56825ESG PSA CONTRACT 2021-2022 Page 1
SafeHaven of Tarrant County Rev. 8-30-2021
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 SafeHaven of Tarrant County (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 (“HUD”) through the Emergency Solutions Grant Program (“ESG”),
Program No. E-21-MC-48-0010, Catalog of Federal Domestic Assistance No. 14.231;
WHEREAS, the ESG program is intended to provide homeless persons or persons at risk
of becoming homeless with financial assistance, basic shelter, essential supportive services, and/or
operations, as applicable;
WHEREAS, Agency submitted a proposal to use ESG funds for an eligible program under
the ESG Regulations whereby Agency will provide services to low and moderate income City
citizens;
WHEREAS, City citizens, the Community Development Council, and the City Council
have determined that ESG 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 2021. income limits are attached
hereto as EXHIBIT “A-1” – 2021 HUD Income Limits.
Business Equity Ordinance or BEO means the City’s Business Equity Ordinance, Ordinance No.
25165-10-2021, as may be amended from time to time.
CSC No. 56825
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Complete Documentation means the following documentation as applicable:
•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 ESG 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.
Continuum of Care means the Tarrant Area Continuum of Care.
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, 2021.
ESG means Emergency Solutions Grant.
ESG Eligible Client means an individual or household that meets the definition of "homeless" or
"at risk of homelessness" as defined in the Hearth Act and the ESG Regulations.
ESG Funds means the ESG grant funds supplied by City to Agency under the terms of this
Contract.
ESG Regulations means regulations found at 24 CFR Part 576 et seq.
HEARTH Act means the Homeless Emergency Assistance and Rapid Transition to Housing Act
of 2009, 42 U.S.C. 11302 et seq.
HMIS means Homeless Management Information System required by HUD for client data
collection.
HUD means the United States Department of Housing and Urban Development.
IDIS means Integrated Disbursement Information System, HUD’s project tracking system.
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Neighborhood Services Department means the City’s Neighborhood Services Department.
Neighborly Software – Online database maintained by the City of Fort Worth through which
Agency is required to submit monthly reimbursement requests.
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 any documentation sufficient to show under ESG Regulations that
an individual or household is an ESG Eligible Client. Income documentation may include, but is
not limited to, copies of paychecks, Social Security and Disability verification letters, interest or
rental income statements, retirement income statements, child support and alimony verification,
unemployment benefit letters, or any similar documentation allowed under the definition of annual
income in 24 CFR Part 5.609.
Unduplicated Clients means a count of ESG Eligible Clients served at least once in the Contract
Term. ESG 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 (Contract Term) begins on the Effective Date and terminates on
September 30, 2022 unless earlier terminated as provided in this Contract. This Contract may be
extended, by the written mutual agreement of the parties, if such extension is necessary for
completion of the program, or to amend the contracts if necessary to achieve program goals
provided any amendment is within the scope of the program and in compliance with City
policies and all applicable laws and regulations governing the use of federal grant funds. The
Contract Term shall include any extension, if exercised, as provided herein.
4.DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Provide ESG Funds.
City shall provide up to $70,960.00 of ESG Funds under the terms and conditions herein.
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 ESG Regulations during the term
of this Contract.
5.DUTIES AND RESPONSIBILITIES OF AGENCY.
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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 ESG Funds.
5.2.1. Compliance with ESG Regulations and Contract.
Agency shall be reimbursed for eligible Program costs with ESG Funds only if City
determines in its sole discretion that:
5.2.1.1 Costs are eligible expenditures in accordance with ESG 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 Budget.
5.2.2.1. The ESG 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 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, 2022.
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 ESG Funds to supplement rather than
supplant funds otherwise available for the Program.
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5.2.4 Payment of ESG Funds to Agency.
ESG 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, 2022, City may hold back a
small amount of the ESG 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 ESG 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:
Month Expenditures
Unduplicated Clients as
specified in EXHIBIT
“A” – Program
Summary
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,
City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests,
to lower Agency’s allocation of ESG Funds, or to terminate this Contract.
5.3.3 Failure to meet at least 80% of its performance milestones or serve 480
Unduplicated Clients under this Contract may, in City’s sole discretion, disqualify Agency for
consideration under the City’s Request for Proposals for the 2022-2023 Program Year for federal
grant funds.
5.3.4 Amendments to performance milestones regarding ESG 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, 2022. 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 ESG Funds.
Agency will keep accounts and records in such a manner that City may readily identify and
account for Program expenses reimbursed with ESG Funds. These records shall be made
available to City for audit purposes and shall be retained as required hereunder.
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5.5 Match.
Agency must match ESG Funds dollar for dollar with other funding sources. Potential
sources of match include any sources described at 42 U.S.C. 11375(a). Some common sources
include: (i) Agency funding from non-federal sources and eligible federal grants, (ii) volunteer
time, which may be valued at $5/hour of time; and (iii) the value or fair rental value of any donated
materials or space. The monetary values Agency assigns to all sources of match are subject to
review and approval by City.
5.5.1 Prior to October 1, 2021, Agency must submit to City a completed Match Report
on the form attached hereto as EXHIBIT “H”- Match Report detailing anticipated match
sources.
5.5.2 With each Reimbursement Request, Agency must submit a log of funds expended
to date on the form provided in EXHIBIT “H” - Match Report, plus documentation of any match
expenditures first reported in that month’s Reimbursement Request.
5.5.3 Records regarding match funds must be kept by Agency in accordance with Section
8.
5.5.4 If the expenditure of match funds and ESG Funds is not happening at approximately
the same pace on a quarterly basis, then the City shall withhold ESG Funds until match
expenditures are substantially the same as ESG Funds reimbursed to date.
5.6 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 ESG 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 may use form attached hereto
as EXHIBIT “I” – Staff ESG Certification Form to document the eligibility of all prospective
clients that receive direct financial assistance as more particularly described as follows.
6.1.1 Agencies Receiving ESG Funds.
6.1.1.1 Coordination of Services. Agency must participate in the local
Continuum of Care and enter data in HMIS.
6.1.1.2 Homelessness Status. Agency must verify that all new clients are ESG
Eligible Clients. Acceptable forms of verification include:
i.For emergency shelter (shelter services for homeless including
childcare for homeless clients):
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A signed, dated statement from the client stating that the client is
homeless, or that the client is homeless by virtue of fleeing domestic
violence.
ii. For homelessness prevention- financial assistance services:
1. Documentation that the ESG Eligible Client meets the at risk
of homelessness definition consistent with 24 CFR Part
576.2 (1-3),
2. Source Documentation that the ESG Eligible Client has an
annual income at or below 30% of AMI,
3. Evidence documenting that the ESG Eligible Client does not
have sufficient resources or support networks immediately
available to prevent them from moving to an emergency
shelter or another place defined in Category 1 of the
“homeless” definition under the HEARTH Act,
4. Documentation of eligibility of the housing unit, habitability
inspection, lease, rent reasonableness, rental assistance
agreement between Agency and landlord,
5. Documentation of client’s reasonable prospects of resuming
payment of rent or utilities, as applicable, within a
reasonable time,
6. Evidence documenting that the ESG Eligible Client is not
receiving equivalent or same type of assistance from other
homelessness prevention agencies or funding sources, and
7. Documentation supporting the type and amount of assistance
provided, including, but not limited to, invoices, past due
notices, and/or executed leases, as applicable, and proof of
payment by Agency.
iii. For rapid re-housing services- financial assistance:
1. Documentation that the individual or household meets the
homeless definition in the HEARTH Act and that the client
is eligible consistent with the definition of homelessness in
24 CFR Part 576.2, paragraphs 1 and 4,
2. Documentation of eligibility of the housing unit, habitability
inspection, lease, rent reasonableness, rental assistance
agreement between Agency and landlord,
3. Documentation of client’s reasonable prospects of resuming
payment of rent and/or utilities, as applicable, within a
reasonable time,
4. Evidence documenting that the ESG Eligible Client is not
receiving equivalent or same type of assistance from other
rapid re-housing agencies or funding sources, and
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5.Documentation supporting the type and amount of assistance
provided, including, but not limited to, invoices, past due
notices, and/or executed leases, as applicable, and proof of
payment by the agency.
iv.For housing relocation and stabilization services:
1.Documentation that services are provided for ESG Eligible
Clients as defined in the HEARTH Act, as may be amended
from time to time, and
2.Documentation that any staff costs and or
relocation/stabilization services directly benefit the ESG
Eligible Client and are clearly distinguished from the general
administration of the Program.
6.1.2 Performance Standards.
Agency must verify that the Program is tracking ESG activities and outcomes in
accordance with the City’s performance standards as described in EXHIBIT “J” - ESG
Performance Standards.
6.1.3 Written Standards for ESG Assistance.
Agency must verify that the Program is documenting Client Eligibility in accordance with
the City’s written standards as described in EXHIBIT “J-1” – Written Standards for ESG
Assistance. Agency must maintain all records in accordance with Section 8.
6.2 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 for 5 years
following the expiration of the Contract term. This Section shall survive the earlier terminations
or expirations of this Contract.
7.ADDITIONAL ESG REQUIREMENTS.
Agency agrees to comply with all requirements of the ESG Program as stated in the ESG
Regulations, including but not limited to the following:
7.1 Environmental Review.
ESG Funds will not be paid, and costs cannot be incurred until City has conducted an
environmental review and 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
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will (i) cause this Contract to terminate immediately; and (ii) require Agency to repay City the
ESG Funds it has already received and forfeit any future payments of ESG 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 2021 - 2022 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 ESG 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. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for monitoring is deemed to begin on October 1, 2022, or October
1, 2023 if the Contract is extended, and shall end no later than September 30, 2028 regardless of.
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 ESG Funds, and to Agency’s
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
provisions 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
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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 ESG 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 ESG 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 ESG 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.
7.6 Financial Management 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 ESG 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 ESG Regulations. Agency shall monitor the services and work
performed by its contractors, subcontractors and vendors on a regular basis for compliance with
the ESG Regulations and Contract provisions. Agency must cure all violations of the ESG
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 ESG 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 termination
of the Contract.
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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. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
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 ESG Funds that provides
reasonable assurance that Agency is managing the ESG 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 Agency must have written procedures 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 Confidentiality of Client Information
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Consistent with the requirements of 24 CFR Part 576.500, Agency shall comply with the
City’s written standards as described in EXHIBIT “N” – Written Standards for Maintenance
of Personally Identifying Information. Furthermore, in compliance with this section, Agency
shall develop and implement written procedures to ensure the following:
7.13.1 Personally Identifying Information
All records containing personally identifying information (as defined in HUD’s standards
for participation, data collection, and reporting in a local HMIS) of any individual or family who
applies for and/or receives ESG assistance will be kept secure and confidential.
7.13.2 Victim Information
The address or location of any domestic violence, dating violence, sexual assault, or
stalking shelter project assisted by ESG funds will not be made public, except with written
authorization of the person responsible for the operation of the shelter.
7.13.3 Program Participant Information
The address or location of any housing of a client must not be made public, except as
provided under a preexisting policy of either City or Agency and consistent with state and local
laws regarding privacy and obligations of confidentiality.
7.14 Violence Against Women Act Requirements
7.14.1 Agency shall comply with the Violence Against Women Act (“VAWA”) and shall
ensure that any property owner, manager, or facility assisted by the ESG Funds shall, at the time
of application for services, provide all clients receiving rental assistance with a Notice of
Occupancy Rights under the Violence Against Women Act in substantially the same form as the
form attached and incorporated as Exhibit “O”-Notice of Occupancy Rights Under VAWA in
compliance with VAWA and 24 CFR Part 574.604(a)(2), where applicable.
7.14.2 Agency agrees that no applicant for ESG assistance may be denied admission or
assistance under the Program on the basis or as a direct result of the fact that they are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking, as long as they
would otherwise qualify for the Program.
7.14.3 Agency shall be responsible for reviewing VAWA and 24 CFR Part 574.604 and
shall respond to all emergency transfer requests in accordance with the requirements of those
provisions. Agency may request that all clients requesting an emergency transfer under VAWA
fill out the form attached and incorporated as Exhibit “P” – VAWA Emergency Transfer Request
Form.
8.RECORD KEEPING; REPORTING AND DOCUMENTATION
REQUIREMENTS; AUDIT.
8.1 Record Keeping.
Agency shall maintain a record-keeping system as part of its performance of this Contract
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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 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, unless this Contract is earlier terminated, this 5 year period for record retention is deemed
to begin on October 1, 2021, or October 1, 2022 if the Contract is extended, and shall end no later
than September 30, 2027.
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, unless this Contract is earlier terminated, this 5 year period
for access to records is deemed to begin on October 1, 2021, or October 1, 2022 if the Contract is
extended, and shall end no later than September 30, 2027.
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 Change 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
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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.
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 ESG 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, unless this Contract is earlier terminated, this 5 year period
for City audit is deemed to begin on October 1, 2022, or October 1, 2023 if the Contract is
extended, and shall end no later than September 30, 2028. 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 ESG FUNDS OR SPENT ESG 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 15th 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 2022 MUST BE RECEIVED BY OCTOBER
1, 2022. COMPLETE DOCUMENTATION FOR ALL SEPTEMBER 2022 EXPENSES
MUST BE SUBMITTED BY OCTOBER 15, 2022. FAILURE TO SUBMIT A FINAL
REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY
OCTOBER 15, 2022 WILL RESULT IN AUTOMATIC FORFEITURE OF PAYMENT OF
THE SEPTEMBER REIMBURSEMENT REQUEST.
9.1.2 City will notify Agency by e-mail within 14 calendar days if a Reimbursement
Request is lacking Complete Documentation or corrections are needed. Agency will have 7
calendar days from the date of the e-mail notice to submit any requested information or missing
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documentation. Agency may be penalized, at City’s sole discretion, in the Request for Proposal
for the 2022-2023 Program Year for any notifications received under this Section. If Agency fails
to submit all the required information or missing documentation within 7 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.
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).
9.2.1.1 Agency must submit a separate invoice for each activity type, i.e.
Shelter Operations, Homeless Prevention, Rapid Rehousing, and HMIS.
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 ESG-funded time and non-ESG funded time and reflect actual
time spent on ESG-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. If Agency, receives funds from the United States
Department of Justice or the Victims of Crime Act, then Agency is prohibited from
submitting the Client Data Report to the City. However, Agency must complete all
required forms under this Section 9.2.3 and maintain in client files in accordance with
Section 8. In order for this report to be complete the following must be submitted:
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9.2.3.1 Documentation of income verification for each Unduplicated Client the
first time the client is served, which either will be the completed form
attached hereto as EXHIBIT “E”- Form of Income Self Certification
or Source Documentation.
9.2.3.2 Agency may use the form attached hereto as EXHIBIT “I” – Staff ESG
Certification Form to verify client eligibility as described in Section
6.1.
9.2.4 Delivery of Reimbursement Request.
Reimbursement Requests must be submitted through Neighborly Software by the
deadline in Section 9.1.1.
9.2.5 Match Report.
This report shall document actual expenditure of match funds, as further described in
Section 5.5.
9.2.6 ESG Quarterly HMIS Report.
Agency shall submit the ESG Quarterly HMIS Report, attached hereto as EXHIBIT “K”
– Quarterly Report, with the December, March, June and September Reimbursement Requests
to document Agency’s participation in the local Continuum of Care’s HMIS.
9.3 Withholding Payment.
CITY SHALL HAVE NO OBLIGATION TO PAY ON ANY REIMBURSEMENT
REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit
accurate and complete Reimbursement Requests and 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 5 calendar 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, 2022, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR
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OCTOBER 1, 2022 IS LATE, INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE
WITH THIS CONTRACT OR THE ESG 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.
10.1.5 Notwithstanding anything to the contrary herein, City will not be required to
pay any ESG 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 ESG 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 ESG 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
ESG 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 ESG 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 ESG Funds paid to Agency must be repaid to City within
30 days of termination. If such ESG 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
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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.
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 ESG Funds that have not yet been expended from
affected activities to other eligible activities or withhold ESG 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 ESG 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 ESG Funds already paid to Agency must be repaid to City
within 30 days of the termination. Failure to repay such ESG 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 ESG 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.
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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.
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 ESG 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 ESG Funds
already paid to Agency must be repaid to City within 30 days of termination. Failure to repay such
ESG 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
ESG 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 ESG 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 ESG 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 ESG Funds are subject to repayment and/or City may
exercise all of its remedies under this Contract.
10.12 Non-appropriation of Funds.
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In the event no funds or insufficient funds are appropriated by City in any fiscal period for
any payments due hereunder, City will notify Agency of such occurrence and this Agreement shall
terminate on the last day of the fiscal period for which appropriations were received without
penalty or expense to City of any kind whatsoever, except as to the portions of the payments herein
agreed upon for which funds have been appropriated.
10.13 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired by Agency
with the ESG 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 ESG Funds, and any real or personal property owned by Agency that was improved with the
ESG Funds shall automatically transfer to City or to such assignee as City may designate.
11. REPAYMENT OF ESG FUNDS.
All ESG Funds are subject to repayment in the event the Program does not meet the
requirements of this Contract or in the ESG Regulations. If Agency takes any action that results
in the City being required to repay all or any portion of the ESG Funds to HUD, Agency
agrees it will reimburse City within thirty days of notice from the City for such repayment.
Additionally, 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 ESG Funds is
required of City, Agency agrees City may require that 10% of the ESG 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 ESG 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 ESG 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 ESG 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
ESG 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, indemnity obligations,
client income eligibility, record keeping and reports, City ordinances, or applicable ESG
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
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enforceable by City against Agency. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for City audit is deemed to begin on October 1, 2022, or October 1,
2023 if the Contract is extended, and shall end no later than September 30, 2028.
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,
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 ESG 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 ESG-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 ESG 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
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activities must be offered separately, in time or location, from the programs or activities supported
by ESG Funds and participation must be voluntary for clients of a ESG-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 ESG-funded service with the notice attached as EXHIBIT “M”—Notice
of Beneficiary Rights. Such notice shall be provided to the client prior to enrollment in any ESG-
funded program or activity. In addition, if a client or prospective client of a ESG-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 state courts located in Tarrant County, Texas or the United States District Court
for the Northern District of Texas, Fort Worth Division 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.
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 Paragraph Headings for Reference Only, No Legal 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
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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:
ESG Regulations found in 24 CFR Part 576
SubtitleB of Title IV of the McKinney-Vento Homeless Assistance Act, as amended,
(42 USC 11371)
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
(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 et seq.) 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
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(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 Projects and Employment and other Economic
Opportunities; Section 3 Requirements.
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 5 as modified by 24 CFR Part
576.57(a) 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 during 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,
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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 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 Agency’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.
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14.14.1 Agency Safeguards.
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 Prohibition Against 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 ESG 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 ESG services, may
obtain a financial interest or benefit from a ESG-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 1 year
thereafter..
14.14.2.1 Agency shall comply with HUD requirements regarding
organizational conflicts of interest in provision of shelter, housing,
prevention and related services as more particularly described in 24
CFR Part 576.404.
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 576.57(d) of the ESG 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 14.14.3.2,
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
ESG PSA CONTRACT 2021-2022 Page 27
SafeHaven of Tarrant County Rev. 8-30-2021
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.
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 ESG 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 ESG 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.
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14.15.2.1 In order to comply with federal reporting requirements, Agency
must submit the form attached hereto as EXHIBIT “L” – MBE
Reporting Form for each contract or subcontract with a value of
$10,000.00 or more paid or to be paid with the ESG Funds. Agency
shall submit this form by the date specified in EXHIBIT “L” –
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.
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. Right to Inspect Agency 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
ESG-funded Program prior to any charges being incurred.
14.19 Force Majeure
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, pandemics, 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.
14.20 IMMIGRATION NATIONALITY ACT.
Agency shall verify the identity and employment eligibility of its employees who perform
work under this Contract, including completing the Employment Eligibility Verification Form (I-
9). Upon request by City, Agency shall provide City with copies of all I-9 forms and supporting
eligibility documentation for each employee who performs work under this Contract. Agency
shall adhere to all Federal and State laws as well as establish appropriate procedures and controls
so that no services will be performed by any Agency employee who is not legally eligible to
perform such services. AGENCY SHALL INDEMNIFY CITY AND HOLD CITY
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HARMLESS FROM ANY PENALTIES, LIABILITIES, OR LOSSES DUE TO
VIOLATIONS OF THIS PARAGRAPH BY AGENCY, AGENCY’S EMPLOYEES,
SUBCONTRACTORS, AGENTS, OR LICENSEES. City, upon written notice to Agency, shall
have the right to immediately terminate this Contract for violations of this provision by Agency.
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 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
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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
$70,960.00 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 ESG 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.
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
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$ 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.
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.
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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
ESG 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 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.
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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
200 Texas Street
Fort Worth, TX 76102
Telephone: 817-392-7600
Copy to:
Neighborhood Services Department
200 Texas Street
Fort Worth, TX 76102
Attention: Director
Telephone: 817-392-7540
Copy to:
Neighborhood Services Department
200 Texas Street
Fort Worth, TX 76102
Attention: Contract Administrator
Telephone: 817-392-8550
Agency:
SafeHaven of Tarrant County
Kathryn Jacob, President and CEO
1010 N. Center Street
Arlington, TX 76011
Telephone: 817-535-6462
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SafeHaven of Tarrant County Rev. 8-30-2021
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.
23.PROGRAM INCOME
Parties agree that no program income as defined by HUD shall be earned as a result of this
contract.
24.PROHIBITION ON CONTRACTING WITH COMPANIES THAT BOYCOTT ISRAEL
If Agency has less than ten employees, this contract is for less than $100,000, or Agency
does not meet the definition of a “company” under the applicable section of the Texas Government
Code, this provision shall not apply. Agency acknowledges that in accordance with Chapter 2270
of the Texas Government Code, the City is prohibited from entering into a contract with a company
for goods or services unless the contract contains a written verification from the company that it:
(1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract. The
terms “boycott Israel” and “company” shall have the meanings ascribed to those terms in Section
808.001 of the Texas Government Code. By signing this contract, Agency certifies that Agency’s
signature provides written verification to the City that Agency: (1) does not boycott Israel; and (2)
will not boycott Israel during the term of the contract.
25.PROHIBITION ON BOYCOTTING ENERGY COMPANIES
Agency acknowledges that in accordance with Chapter 2274 of the Texas Government
Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2, the City is prohibited from entering
into a contract for goods or services that has a value of $100,000 or more that is to be paid wholly
or partly from public funds of the City with a company with 10 or more full-time employees unless
the contract contains a written verification from the company that it: (1) does not boycott energy
companies; and (2) will not boycott energy companies during the term of the contract. The terms
“boycott energy company” and “company” have the meaning ascribed to those terms by Chapter
2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2. To the
extent that Chapter 2274 of the Government Code is applicable to this Agreement, by signing this
Agreement, Agency certifies that Agency’s signature provides written verification to the City that
Agency: (1) does not boycott energy companies; and (2) will not boycott energy companies during
the term of this Agreement.
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SafeHaven of Tarrant County Rev. 8-30-2021
26.PROHIBITION ON DISCRIMINATION AGAINST FIREARM AND
AMMUNITION INDUSTRIES
Agency acknowledges that except as otherwise provided by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1, the City is prohibited
from entering into a contract for goods or services that has a value of $100,000 or more that is to
be paid wholly or partly from public funds of the City with a company with 10 or more full-time
employees unless the contract contains a written verification from the company that it: (1) does
not have a practice, policy, guidance, or directive that discriminates against a firearm entity or
firearm trade association; and (2) will not discriminate during the term of the contract against a
firearm entity or firearm trade association. The terms “discriminate,” “firearm entity” and “firearm
trade association” have the meaning ascribed to those terms by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1. To the extent that Chapter
2274 of the Government Code is applicable to this Agreement, by signing this Agreement, Agency
certifies that Agency’s signature provides written verification to the City that Agency: (1) does not
have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm
trade association; and (2) will not discriminate against a firearm entity or firearm trade association
during the term of this Agreement.
[SIGNATURES APPEAR ON NEXT PAGE]
ESG PSA CONTRACT 2021-2022 Page 36
SafeHaven of Tarrant County Rev. 8-30-2021
IN WITNESS WHEREOF, the Parties hereto have executed 1 original of this Contract
in Fort Worth, Tarrant County, Texas.
CITY OF FORT WORTH
By: _____________________________________
Fernando Costa, Assistant City Manager
ATTEST:
_________________________________
Acting City Secretary
M&C: 21-0522
1295 Certification No. 2021-724019
Date: 8-3-2021
RECOMMENDED BY:
_____________________________
Victor Turner, Neighborhood Services
Director
APPROVED AS TO FORM AND LEGALITY:
_________________________________
Taylor Paris, Assistant City Attorney
CONTRACT COMPLIANCE MANAGER:
By signing, I acknowledge that I am the person responsible
for the monitoring and administration of this contract, including
ensuring all performance and reporting requirements
_________________________________________
Barbara Asbury
Compliance and Planning Manager
SAFEHAVEN OF TARRANT COUNTY
By: _____________________________
Kathryn Jacob, President and CEO
Kathryn Jacob (Dec 4, 2021 11:01 CST)
Barbara Asbury (Dec 6, 2021 13:51 CST)
Barbara Asbury
Fernando Costa (Dec 13, 2021 09:27 CST)Ronald P. Gonzales, Assistant City Secretary (Dec 13, 2021 11:47 CST)
Ronald P. Gonzales, Assistant City Secretary
ESG PSA CONTRACT 2021-2022 Page 37
SafeHaven of Tarrant County Rev. 8-30-2021
EXHIBITS:
EXHIBIT “A” – Program Summary
EXHIBIT “A-1” – 2021 HUD Income Limits
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” – Match Report
EXHIBIT “I” – ESG Staff Certification Form
EXHIBIT “J” - ESG Performance Standards
EXHIBIT “J-1” – Written Standards for ESG Assistance
EXHIBIT “K” – ESG Quarterly HMIS Report
EXHIBIT “L” – MBE Reporting Form
EXHIBIT “M” – Notice of Beneficiary Rights
EXHIBIT “N” – Written Standards for Maintenance of Personally Identifying Information
EXHIBIT “O” – Notice of Occupancy Rights Under VAWA
EXHIBIT “P” – VAWA Emergency Transfer Request Form
ESG PSA CONTRACT 2021-2022 ― EXHIBIT “A” ― PROGRAM SUMMARY Page 1
SafeHaven of Tarrant County
EXHIBIT “A” SAFEHAVEN OF TARRANT COUNTY
SafeSolutions for Fort Worth - Shelter Opr.
Svcs.
PROGRAM SUMMARY
PROGRAM SUMMARY
(ESG)
October 1, 2021 to September 30, 2022 $70,960.00
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
The Program provides emergency shelter to victims of domestic violence who are homeless,
including supportive services which consist of case management, safety planning, child care, food,
clothing, counseling, support groups, document replacement, and legal representation.
ESG Funds will be used to pay for salaries and fringe benefits for Program employees.
Agency’s office is located at 1010 N. Center Street, Arlington, TX 76011. Program services will
be available 24 hours a day 7 days a week. Addresses where Program services are provided cannot
be released due to confidentiality and risks to domestic violence victims.
REGULATORY CLASSIFICATION:
Service Category (if more than one category, specify amount for each): ESG Emergency Shelter
Component
Regulatory Citation(s): 24 CFR 576.102
Agency will maintain documentation that verifies that 100% clients served are homeless based
on the current HUD definitions.
PROGRAM GOALS:
Minimum Number of Fort Worth Clients to be Served: The Program must serve a minimum
of 600 Unduplicated Clients as shown by the monthly Attachment III and yearly SAGE (HMIS
reporting). Timely, accurate, and complete information should always be reported, but not be
limited, to the following number and percentage goals of those clients receiving Case
Management:
A.Those exiting ES to temporary or permanent housing destinations: 480; 80%
B.Those who have non-cash benefits at exit: 176 households; 65%
ESG PSA CONTRACT 2021-2022 ― EXHIBIT “A” ― PROGRAM SUMMARY Page 2
SafeHaven of Tarrant County
C.Number of persons in shelter less than 60 days: 510; 85%
D.Number of persons in shelter greater than 60+ days: 90; 15%
E.Unduplicated number of adults with increase in income: 95; 35%
EXHIBIT "A-1”
2021 HUD INCOME LIMITS
AMI 1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons
30% $17,000 $19,400 $21,850 $24,250 $26,200 $28,150 $30,100 $32,050
50% $28,300 $32,350 $36,400 $40,400 $43,650 $46,900 $50,100 $53,350
60% $33960 $38820 $43680 $48480 $52380 $56280 $60120 $64020
80% $45,300 $51,750 $58,200 $64,650 $69,850 $75,000 $80,200 $85,350
*Income limits are published at least annually by HUD.
Effective 6/1/2021
Page 1
Account Grant Budget A B C Total
ESSENTIAL SERVICES
Salaries 1001 63,741.00$ 473,040.08$ 314,199.04$ 850,980.12$
FICA 1002 3,424.00$ 236,520.04$ 157,099.52$ 397,043.56$
Life/Disability Insurance 1003 195.00$ 15,768.00$ 10,473.30$ 26,436.30$
Health/Dental Insurance 1004 3,600.00$ 39,420.01$ 26,183.25$ 69,203.26$
Unemployment-State 1005 -$ -$
Worker's Compensation 1006 -$ 23,652.00$ 15,709.95$ 39,361.95$
Office Supplies 1007 -$ -$
Food Supplies 1008 -$ -$
Insurance 1009 -$ -$
Accounting 1010 -$ -$
Contract Labor Security (City needs copy of
contract before expenses can be reimbursed)1011 -$ -$
Other()1012 -$ -$
SHELTER OPERATIONS
Maintenance 2001 -$ 79,437.51$ 235,724.94$ 315,162.45$
Security 2002 -$ -$
Insurance 2003 -$ -$
Utilities 2004 -$ -$
Supplies 2005 -$ -$
Repairs 2006 -$ -$
Other(meals)2007 -$ -$
SUBTOTAL EMERGENCY SHELTER 70,960.00$ 867,837.64$ 759,390.00$ -$ 1,698,187.64$
PREVENTION
Salaries 3001 -$ -$
FICA 3002 -$ -$
Life/Disability Insurance 3003 -$ -$
Health/Dental Insurance 3004 -$ -$
Unemployment-State 3005 -$ -$
Worker's Compensation 3006 -$ -$
Other()3007 -$ -$
REHOUSING
Salaries 4001 -$
FICA 4002 -$
Life/Disability Insurance 4003 -$
Health/Dental Insurance 4004 -$
Unemployment-State 4005 -$
Worker's Compensation 4006 -$
HRA 4007 -$
Retirement 4008 -$
Parking 4009 -$
Mileage 4010 -$
Rental Asistance/Security Deposits -$
Utility Deposits/Payments -$
Other: (Program supplies and admin): Food;
postage; telephone/network/internet; occupancy;
mileage; training and professional development;
other direct client and supportive services;
equipment rental/non-cap; indirect -$
Other (Fringe Benefits): Employee prescreening 4011 -$
SUBTOTAL HR&S
PREVENTION
Rental Assistance 5001 -$
Utility Payments 5002 -$
REHOUSING
Rental Assistance 6001 -$ .-$
Security Deposits 6002 -$
Utility Deposits 6003 -$
Utility Payments 6004 -$
Moving Costs 6005 -$
Motel/Hotel Vouchers 6006 -$
SUBTOTAL FINANCIAL ASSISTANCE -$ -$ -$ -$
HMIS Software Costs 7001 -$
SUBTOTAL HMIS
BUDGET TOTAL 70,960.00$ 867,837.64$ 759,390.00$ -$ 1,698,187.64$
FUNDING A: Texas Health and Human Services
FUNDING B: Texas Criminal Justice Division
FUNDING C:
HOMELESS MANAGEMENT INFORMATION SYSTEM (HMIS)
FINANCIAL ASSISTANCE
EXHIBIT "B" - BUDGET
EMERGENCY SHELTER
HOUSING RELOCATION AND STABILIZATION
ESG PSA CONTRACT 2021-2022 - EXHIBIT "B" - BUDGET
SafeHaven of Tarrant County Page 1
Annual Salary
Est. Percent to
Grant
Amount to
Grant
$ 28,614.00 100% $ 28,614.00
$ 23,847.00 100% $ 23,847.00
$ 28,203.90 40% $ 11,280.00
80,664.90$ 63,741.00$
Percent of
Payroll Amount
Est. Percent to
Grant
Amount to
Grant
FICA 7.65%4,876.00$ 70%3,424.00$
Life/Disability Insurance 0.52%331.45$ 60%195.00$
Health/Dental Insurance 9.45%6,023.52$ 60%3,600.00$
-$
TOTAL 11,230.97$ 64.3%7,219.00$
Total Budget
Est. Percent to
Grant
Amount to
Grant
Total Budget
Est. Percent to
Grant
Amount to
Grant
#DIV/0!
Total Budget
Est. Percent to
Grant
Amount to
Grant
#DIV/0!
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, 2022.
SALARY DETAIL
Position Title
TOTAL
FRINGE DETAIL
SUPPLIES AND SERVICES
Cook 1 FTE
Childcare Aide 1 FTE
Shelter Aide/Housekeeper 1 FTE
TOTAL
MISCELLANEOUS
Insurance
Accounting
Contract Labor (Security)
Other()
TOTAL
SHELTER OPERATIONS
Maintenance
ESG PSA CONTRACT 2021-2022 - EXHIBIT "B" - BUDGET
SafeHaven of Tarrant County Page 2
#DIV/0!
#DIV/0!
#DIV/0!
-$
Total Budget
Est. Percent to
Grant
Amount to
Grant
-$
-$
Total Budget
Est. Percent to
Grant
Amount to
Grant
Security
Utility Deposits
Insurance
Utilities
Supplies
Repairs
Other(Meals)
TOTAL
FINANCIAL ASSISTANCE
Rental Assistance
Security Deposits
Utility Payments
TOTAL
Moving Costs
Motel/Hotel Vouchers
TOTAL
HMIS
HMIS Software Costs
1 ESG PSA CONTRACT – EXHIBIT “C” ―
AUDIT CERTIFICATION FORM -- SAFEHAVEN
EXHIBIT “C”
AUDIT CERTIFICATION FORM
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency: SAFEHAVEN OF TARRANT COUNTY
Fiscal Year Ending: September 30, 2022
❑■ During the fiscal year in which funds will be received, we wiil exceed the federal expenditure
threshold of $750,000. We will have our Single Audit ar Frogram Specific Audit completed
and wili submit the audit repart 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,OOU federal
expenditure threshold required for a Single Audit or a Program Specific Audit to be performed
this fiscal year. (Fill out schedule below)
Federal Expendit�re D�sclosnwe
MUST be filled out if Sin le Audit or Pro Audit is NOT r� uired.
Pass Through Program Name & Contract
Federal Grantor �tor CFDA Number Number Expendit�res
Total Federal Ex enditures for this Fiscal Year:
` �
_���.. �, �,. �t1
�! � , f
Faiiure to submit this or a similar statement or failure to submit a campleted single aud'st package
as described in the federally required audit requirements described in 2 CFR Part 200, as
appGcable, by the required due date may result in suspension of funding and may affect eligibility
for future fundir�g. Notwithstanding the above, this certification acknowledges the agency's
commitment to meet all other financial reparting, financial statements, and other audit
requirements as may be set farth in the Contract.
ESG PSA CONTRACT 2021-2022 - SXHIBIT "G" - AUDIT CERTIFICATION
SAFEHAVEN OF TARRANT COUNTY
ESG PSA CONTRACT ― EXHIBIT “D” ― REPORTING FORMS Page 1
EXHIBIT “D”
REPORTING FORMS
ESG PSA CONTRACT ― EXHIBIT “D” ― REPORTING FORMS Page 2
ATTACHMENT I
Invoice
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Tax ID No.
P.O. No.
FID No.
This Invoice Cumulative to Date
Attachment I
INVOICE
AmountProgram
ESG PSA CONTRACT ― EXHIBIT “D” ― REPORTING FORMS Page 3
ATTACHMENT II
Expenditure Worksheet
Agency:
Program:
Only highlighted codes can be reimbursed
Please group like account codes.
Line
No.Check No.Date Payee Description/Job Title*
Account
Code (See
Key to Right)Amount
Expense Line Item
Account
1
2 Salaries 1001
3 FICA 1002
4 Life/Disability Insurance 1003
5 Health/Dental Insurance 1004
6 Unemployment-State 1005
7 Worker’s Compensation 1006
8 Retirement 1007
9
10 Office/Program Supplies 2001
11 Postage 2002
12 Printing 2003
13 Other()2004
14
15 Contract Labor 3001
16 Food Supplies 3002
17 Teaching Aids 3003
18 Craft Supplies 3004
19 Field Trip Expenses 3005
20 Mileage 3006
21 Other()3007
22 Other()3008
23
24 Telephone 4001
25 Electric 4002
26 Gas 4003
27 Water and Wastewater 4004
28 Solid Waste Disposal 4005
29 Rent 4006
30 Cleaning Supplies 4007
31 Other()4008
32
33 Fidelity Bond or Equivalent 5001
34 Directors and Officers 5002
35 General Commercial Liability 5003
36 Other()5004
37
38 Other()6001
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
Total $0.00
Expenditure Worksheet
ATTACHMENT II
City of Fort Worth
Neighborhood Services Department
*For Salaries, state employee's title under Description/Job Title. Rent must identify tenant
FACILITY AND UTILITIES
MISCELLANEOUS
LEGAL, FINANCIAL, AND INSURANCE
DIRECT ASSISTANCE
PROGRAM PERSONNEL
SUPPLIES AND SERVICES
ESG PSA CONTRACT ― EXHIBIT “D” ― REPORTING FORMS Page 4
ATTACHMENT III
Client Data Report
Agency:
Program:Shelter Operations/Services
Month:
#DIV/0!
*Do not revise the client goal unless the contract is amended, accordingly.
2 2A 3 4 5 10
<30%AMI 30%-50% AMI 51-80% AMI >80% AMI
1<$17,000 1<$28,300 1<$45,300 1>$45,300
2<$19,400 2<$32,350 2<$51,750 2>$51,750
3<$21,850 3<$36,400 3<$58,200 3>$58,200
4<$24,250 4<$40,400 4<$64,650 4>$64,650
5<$26,200 5<$43,650 5<$69,850 5>$69,850
6<$28,150 6<$46,900 6<$75,000 6>$75,000
7<$30,100 7<$50,100 7<$80,200 7>$80,200
8<$32,050 8<$53,350 8<$85,350 8>$85,350
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
YES NO
BLACK OR
AFRICAN
AMERICAN
AND WHITE
AMERICAN
INDIAN OR
ALASKA
NATIVE AND
BLACK OR
AFRICAN
AMERICAN
OTHER
MULTIPLE
RACE
COMBINAT-
IONS*YES NO
FHOH
(Indicate
One)
MALE FEMALE HISPANIC
NON-
HISPANIC
AMERICAN
INDIAN OR
ALASKAN
NATIVE
ASIAN AND
WHITE
RACE
(Indicate One)
DISABLED
(Indicate One)
HH
SIZE
HH INCOME
(Only choose 1 of the 4 columns)
ASIAN
BLACK OR
AFRICAN
AMERICAN
NATIVE
HAWAIIAN
OR OTHER
PACIFIC
ISLANDER WHITE
AMERICAN
INDIAN OR
ALASKAN
NATIVE AND
WHITE
12
DATE
CLIENT
RECEIVED
SERVICE
FORT
WORTH
RESIDENT?
YES OR NO
SERVICE
LOCATION (IF
APPLICABLE)
NAME STREET ADDRESS
(Client Address)
AGE
GENDER
(Indicate One)
ETHNICITY
(Indicate One)
1 6 7 8 9 11
Undup Clts for CURRENT MONTH * Please highlight new clients for the month.
CUMULATIVE Unduplicated Clients
*Proposed Household Goal Per Contract
% of Milestone Met
Instructions:This report is meant to list all unduplicated clients served during the Contract term (October 1, 2021 to September 30, 2022). Each month, please report the information of clients not previously reported. You are required to attach eligibility verification documentation for each new client. New unduplicated clients should be listed below any previously reported
clients so that this sheet will act as a rolling tally. Please only list clients one time during the first month that they receive service. Clients that continue to receive Program services for multiple months only need to be listed one time. Put an "X" in each appropriate box regarding the client's sex, ethnicity, race, etc. Please note that reimbursement for salaries will
require that the agency report to the City all the clients that were served by that particular staff person in that program. Information for each client listed below must have the demographic information reflected in columns 1 thru 12.
ATTACHMENT III
CLIENT DATA REPORT
SafeHaven
600
1
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Tax ID No.
This Invoice Cumulative to Date
ESG-Match
MATCH
Program Amount
Agency:
Program:
Line
No.Check No.Date Payee Description Funding Source Amount
1
2
3
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
Total $0.00
Neighborhood Services Department
MATCH Expenditure Worksheet
*Payroll must identify employee. Rent must identify tenant. Other payments should identify individuals, if applicable.
ESG PSA CONTRACT -- EXHIBIT “E” -- INCOME CERTIFICATION FORM
Page 1
EXHIBIT “E”
INCOME CERTIFICATION FORMS
ESG PSA CONTRACT -- EXHIBIT “E” -- INCOME CERTIFICATION FORM
Page 2
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
Income $$
Source of 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: Õ
Staff Assessment of Demographics:____________________________________________________________
Person Making Determination: Date:
NOTE: Address, income amounts and sources for ALL household members are required.
Ciudad de Fort Worth
ESG PSA CONTRACT -- EXHIBIT “E” -- INCOME CERTIFICATION FORM
Page 3
CERTIFICACIÓN DE DECLARACIÓN DE INGRESOS
Nombre del Solicitante:
Dirección de Actualidad: Teléfono:
Ciudad y Código Postal: ______
Miembros Del Hogar e Ingresos
(Incluyendo el/la Solicitante)
Apellido Nombre Edad Ingreso
Mensual
Origen de Ingresos
*TOTAL NÚMERO DE MIEMBROS DEL HOGAR (Inclúyase Usted.)
Total Anual de Ingresos del hogar:
**INFORMACIÓN PERSONAL: (Seleccione uno en cada artículo. Esta información es requerida por el Gobierno 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. ¿ES LA CABEZA DEL HOGAR MUJER?
HISPANO SI SI
NO-HISPANO NO NO
Certificación: Yo certifico que la información que yo estoy proporcionando es verdadera y puedo ser sujeto a
verificación a cualquiera hora por tercera parte. Yo también reconozco que la provisión de información falsa
puede dejarme sujeto a penalidades Federales, Estatales, y a ley local.
Firma del Solicitante Fecha
ADVERTENCIA: TITULO 18, SECCIÓN 1001 DEL CÓDIGO DE LOS ESTADOS UNIDOS INDICA QUE UNA
PERSONA ES CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE HACER DECLARACIONES FALSOS O
FRAUDULENTAS A CUALQUIER DEPARTAMENTO DE GOBIERNO DE LOS ESTADOS UNIDOS.
-----------------Para use de empleados de la agencia-----------------
# De Miembros de Familia: Ingreso Anual:
Límite de Ingreso: ¿Es solicitante elegible? :
Compruebe si el solicitante se negó a dar su información personal: Õ
Evaluación del empleado sobre información personal:____________________________________________
Persona haciendo la determinación: Fecha:
Note: La dirección de la casa y los ingresos (y sus orígenes) para todos miembros del hogar son requeridos
ESG PSA CONTRACT -- EXHIBIT “F” -- STANDARDS OF DOCUMENTATION Page 1
EXHIBIT “F”
STANDARDS OF DOCUMENTATION
InvoiceProof of Payment*TimesheetContract/AgreementSAM.gov SearchLeaseExplanation of how expense is related to ProgramNotes/Other
Salaries X X *
If an employee works on both a ESG eligible and non-ESG eligible program(s), the City will only reimburse for a reasonable portion of
the employee's salary. Prior to the execution of the ESG 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 ESG-funded Program, then 100% of
the employee's salary may be eligible for reimbursement. Agency must submit a written statement that 100% of the employee's time is
spent working directly with the ESG-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.
Reimbursement requests must include a timesheet and work log that reflects the hours worked by the employee(s) working directly on
the ESG-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 X
Life Insurance X X X
Health
Insurance X X X
Disability
Insurance X X X
Unemployment
Insurance X X X
Retirement X X X
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
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. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
Office Supplies X X X
Office
Equipment
Rental
X X X X X
Postage X X X
Printing X X X
Construction &
Building
Materials
X X X X This category is only available for the REACH Program and Habitat for Humanity.
Sport and
Recreation
Equipment
X X X
Cleaning
Supplies X X X
Teaching Aids X X X
Craft Supplies X X X
Food Supplies X X X This category is only available to the Program provided by Meals on Wheels.
Telephone X X
Gas X X
Water/Wastew
ater X X
Electric X X
Solid Waste X X
2021-22 Documentation Standards for
ESG Public Service Contract Expenses
Budget Line
Items
Employee Salaries and Benefits - City will only reimburse a percentage of any employee's salary and benefits who work directly with the ESG-funded Program. Percentages
will be cost allocated and determined prior to the execution of the ESG Contract. Agencies requesting the reimbursement of 100% of any Agency employee will require prior
City approval. Agencies must show calculation on how the ESG portion of employee salaries and benefits were calculated consistently with the ESG Contract.
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
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. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
Materials, Equipment, Goods and Supplies - City will only reimburse for the cost allocated percent or amount spent in support of the ESG-funded Program. Agencies
requesting reimbursement for these items will require prior City approval. Agencies must show calculation on how the ESG portion of these expenses were calculated
consistently with the ESG Contract.
Rent, Utilities and Maintenance - City will only pay for a portion of these expenses. The portion of these expenses will be determined by the square footage attributable to
the ESG-funded Program and shall be cost-allocated in accordance with the amount of space used for the ESG-funded Program. These expenses may only be in support of
the ESG-funded Program. The items listed below require prior City approval and the Agency is required to identify any funding source that pays for the portion of the
expenses that is not paid with ESG funds. Agencies must show calculation on how the ESG portion of these expenses were calculated consistently with the ESG Contract.
ESG PSA CONTRACT 2021-22 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION 1
Facility
Maintenance
and Repairs
X X X X This item requires approval by the City prior to the execution of the ESG Contract. Repairs may be categorized as major/minor
rehabilitation projects and must be approved through the full HUD Environmetal Review.
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 ESG-
funded program.
Contract Labor X X X X X
This item requires prior approval by the City. Prior to the execution of the ESG 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 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
Insurance 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
ESG-funded program.
Childcare
Scholarships X X
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
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
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
Certifications
Agecies that are required to verify and provide proof of household income to determine eligibility, must require that anyone who is over
the age of 18, living in the housohold, submit a $0 Income Certification.
Audit Services X X X X
If an audit is required because federal funds exceed $750,000, then the cost should be split evenly by all grant funding sources. Agency
must show calculation on how the ESG portion of the accounting services were calculated. For example, if the ESG 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.
Final as of 09/26/2017 DC
Miscellaneous
*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.
ESG PSA CONTRACT 2021-22 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION 1
ESG PSA CONTRACT 2021-22 -- EXHIBIT “G” -- SECTION 3 REPORTING FORMS Page 1
EXHIBIT “G”
SECTION 3 REPORTING FORMS
NOT APPLICABLE
ESG PSA CONTRACT 2021-22 -- EXHIBIT “H” – MATCH REPORT 1
EXHIBIT "H"
MATCH REPORT
ESG PSA CONTRACT 2021-22 -- EXHIBIT “H” – MATCH REPORT 2
CITY OF FORT WORTH
NEIGHBORHOOD SERVICES DEPARTMENT
EMERGENCY SOLUTIONS GRANT
This attachment is designed to document proposed sources and to assess compliance with the
required Emergency Shelter Grant (ESG) match portion at 24 CFR 576.51. ESG funds are matched
dollar-for-dollar for each program year allocation.
City of Fort Worth ESG Funds $ __________ Agency ESG Match $_________________
1.SOURCES OF LOCAL MATCH:
Other Federal (including pass-through funds, e.g., City CDBG, County FEMA, etc.)
MATCH SOURCE MATCH AMOUNT
$
$
TOTAL MATCH $
2. STATE/LOCAL GOVERNMENT FUNDING: (e.g., State Housing Trust Funds, Local
Assessment, etc.)
MATCH SOURCE MATCH AMOUNT
$
$
TOTAL MATCH $
3. PRIVATE (including recipient) FUNDING:
MATCH SOURCE MATCH $ AMOUNT
Fund Raising/Cash $
Loans $
Building Value or Lease $
Donated Goods $
ESG PSA CONTRACT 2021-22 -- EXHIBIT “H” – MATCH REPORT 3
Donated Computers $
New Staff Salaries $
Volunteers ($5/hr) $
Volunteer Medical/Legal $
TOTAL MATCH $
Comments:
CERTIFICATION: The undersigned, hereby, gives assurance that to the best of my knowledge and belief, the data
included in this report is true and accurate, and if submitted by a non-profit agency, has been approved by the governing
body of the organization prior to submission. The match funds identified in this report are not included as contribution for
any other federally assisted project or program as required by 24 CFR 84.23 (a) (2)
Date: __________ Submitted by: _______________________ Phone Number: ________
ESG PSA CONTRACT 2021-22 ― EXHIBIT “I” ― ESG STAFF CERTIFICATION FORM Page 1
EXHIBIT “I”
ESG STAFF CERTIFICATION FORM
ESG PSA CONTRACT 2021-22 ― EXHIBIT “I” ― ESG STAFF CERTIFICATION FORM Page 2
City of Fort Worth
STAFF CERTIFICATION OF ELIGIBILITY FOR ESG FINANCIAL ASSISTANCE
Instructions: In order for City to approve reimbursement for any client, agency must submit: (1) client documentation of income (source documentation or self-
certification); (2) documentation of homelessness; (3) copy of lease; and (4) this completed form. (1) - (4) must be submitted upon initial reimbursement request for
assistance for each client.
HOMELESS PREVENTION ONLY: (1)-(4) upon agency request for reimbursement for the 4th month of rent for a client (excluding arrears).
1. General Information
Head of Household Name: Age:
Names of Other Household Members: Age:
Age:
Age:
Age:
Age:
Household Income is less than 30% AMI? Yes No N/A (Rapid Rehousing Initial Evaluation Only)
Client Lacks Resources/Support Networks? Yes No
Type(s) of ESG Financial Assistance: Rent Rent Arrears Utility Deposit(s)
Unit Address (must be in City of Fort Worth):
2. Other ESG Requirements
Lease in agency file? Yes No
Client receives NO other rental subsidy (ie. Housing Choice Voucher)? Yes No
Rental Assistance Agreement between landlord and agency in agency file? Yes No
Fair Market Rent (FMR) & Rent Reasonableness:
Unit Number of Bedrooms:
Area FMR Limit (as published by HUD):
Unit Rent per lease:
Unit meets Habitability Standards? Yes No Date of Inspection:
3. Lead-Safe Housing:
Applicable when (1) providing ESG rental assistance for more than 3 months excluding arrears, (2) pre-1978 housing unit, AND (3) child under 6 in household.
Not Applicable
Number of Months Rental Assistance Provided (excluding arrears):
Year Housing Unit Built: Visual Inspection Indicates Unit and Property Free of Deteriorated Paint?
Yes No
Name of Visual Assessor*:
*For named, agency must have on file a certificate of completion of HUD’s Visual Assessment Course (http://www.hud.gov/offices/lead/training/visualassessment/h00100.cfm)
Required certifications: Each person signing below certifies to the following: (1) To the best of my knowledge, the program participant named above meets all requirements
to receive assistance under the Emergency Solutions Grant (ESG). (2) To the best of my knowledge and ability, all of the information used in making this eligibility
determination is true and complete. (3) I am not related to the program participant through family, business or other personal ties. (4) To the best of my knowledge, neither I
nor anyone related to me has received or will receive any financial benefit for this eligibility determination. (5) I understand that fraud is investigated by the Department of
Housing and Urban Development, Office of Inspector General, and may be punished under Federal laws to include, but not limited to, 18 U.S.C. 1001 and 18 U.S.C. 641 (6)
I understand that if any of these certifications is found to be false, I will be subject to criminal, civil and administrative penalties and sanctions.
ESG Staff Signature:_________________________________ Date:______________________
ESG Supervisor Signature:____________________________ Date:______________________
1 ESG PSA CONTRACT -- EXHIBIT “J” – ESG PERFORMANCE STANDARDS
EXHIBIT “J”
ESG PERFORMANCE STANDARDS
Emergency Solutions Grant Performance Standards
Activity Output/Outcome Measures
Street
Outreach
Number of Persons:
A.Total Unduplicated Served
B.Total Unduplicated Engaged
Of those receiving Case Management,
Number of Persons:
A.Those placed in temporary/transitional housing
B.Those placed in permanent housing
Emergency
Shelter
Operations
Include:
CDBG
(Moving
Home)
Number of Persons:
A.Total Unduplicated Served
Of those receiving Case Management, Number of
Persons:
A.Those exiting Emergency Shelter to temporary or
permanent housing destinations
B.Those who have more non-cash benefits at exit
C.Number of persons in shelter less than 60 days
D.Number of persons in shelter greater than 60+ days
E.Unduplicated number of adults with increase in
Income
Agency determines
number _______ and
% _____ in PY21-22
Homeless
Prevention
Number of Persons:
A.Total Unduplicated Served
Of those served, Number of Persons:
A.Those able to maintain housing at exit
B.Those who have more non-cash benefits at exit
Agency determines
number _______ and
% _____ in PY21-22
Rapid Re-
Housing
Number of persons:
A.Total Unduplicated Served
Of those receiving, Number of Persons:
A.Those who exited to permanent housing at exit
B.Those who have more non-cash benefits at exit
C.Those who have more case income at exit
D.Number of persons served less than 60 days between
project entry and move-in
E.Number of persons served that spent greater than 60+
days between project entry and move-in
Agency determines
number _______ and
% _____ in PY21-22
Coordinated
Entry
System
A.100% of Rapid Re-Housing enrollments come from
Coordinated Entry System
B.90% of Coordinated Entry System referrals must be
accepted by housing providers
C.The average length of time between referral to lease up
is less than 60 days
Pulled From:
Coordinated Entry System
Reporting Metrics under
development
A.HMIS Report
B.HMIS Report
C.CAPER Q22c
2 ESG PSA CONTRACT-- EXHIBIT “J” – ESG PERFORMANCE STANDARDS
In order to successfully record performance outcomes, the CoC system requires that once
a household is enrolled in an ESG program, non-domestic violence agencies must complete
an initial HUD Intake Assessment within the HMIS system (ETO), the HUD Mid-Program
Assessment, and the HUD Exit Assessment upon program exit. Performance outcomes will
be reported to the City using the HMIS generated ESG reports.
Domestic Violence Organizations will provide the same data utilizing their similar data
systems.
Reassessments are required for program participants receiving homelessness prevention
assistance and rapid re-housing assistance. Participants receiving homeless prevention
must be reassessed quarterly; rapid re-housing participants must be reassessed at least
yearly. All participants must receive an exit assessment and enter it into HMIS or a
comparable-level database.
ESG PSA CONTRACT EXHIBIT “J-1” ― Written Standards for ESG Assistance 1
EXHIBIT “J-1”
Written Standards for ESG Assistance
Individuals and families eligibility. Households receiving either emergency shelter or rapid re-housing
assistance must meet HUD’s revised definition of homelessness. Households receiving homelessness
prevention assistance must meet the definition of “at risk of homelessness”, have incomes at or below 30%
AMI, and lack sufficient resources and support networks to retain housing. Eligible ESG-assisted
individuals and households must reside in the City of Fort Worth. Individuals receiving rapid re-housing
assistance must be housed to a unit located in the City of Fort Worth. Agencies will conduct initial
evaluation of clients to determine program eligibility, and kind of assistance needed. Agencies will re-
evaluate quarterly the assistance provided to homelessness prevention recipients, and yearly, to rapid re-
housing clients. Re-evaluation will ascertain that: i) annual incomes do not exceed 30% AMI; ii) clients
lack resources and support networks to retain housing without ESG assistance. Annual incomes are
established per 24 CFR 5.609. All clients must receive an exit assessment that will then be entered into
HMIS or comparable database.
Coordination among emergency shelter, homelessness prevention, rapid re-housing, and other homeless
assistance and housing providers. To receive ESG funds, an agency has to be an active member of the
Continuum of Care (CoC). The CoC leads the coordination among agencies to assist the homeless and
prevent homelessness. It also engages and coordinates resources to improve current programs and funding
strategies.
Determining and prioritizing homelessness prevention and rapid re-housing assistance. Rapid re-housing
and homelessness prevention providers will determine prioritization among eligible clients. This should be
based on a risk assessment. Prioritization should take into account: 1) families with children, and elderly
and disabled persons who do not require permanent supportive housing; and 2) the share of rent and utilities
costs that each client must pay, if any, while receiving homelessness prevention or rapid re-housing
assistance. The City recommends that clients share in rent and utility costs, unless there are reasons for
receiving 100% ESG-assistance.
Duration of rental assistance. Per §576.103 and §576.104, agencies shall provide clients for no more than
24 months, during any 3-year period with short-term rental assistance, medium-term rental assistance,
payment of rental arrears, or any combination thereof. Short-term rental assistance is limited to 3 months.
Medium-term rental assistance extends over 3 months but not more than 24 months. Payment of rental
arrears consists of a one-time payment for up to 6 months of rent in arrears, including any late fees on those
arrears.
Type, amount, and duration of housing stabilization and/or relocation assistance. Agencies will establish
standards for the type, amount, and duration of housing stabilization and/or relocation services provided,
acknowledging that services may not extend for more than 24 months within a 3-year period. Housing
relocation and stabilization services include financial assistance (moving costs, rental application fees,
security deposits, last month’s rent, utility deposits and utility payments), and services (housing search and
placement, housing stability and case management, mediation, legal services, and credit repair.) The
amount and type of assistance provided shall aim at clients becoming self-sufficient. The City shall have
access to documentation that supports the amount and type of assistance provided.
ESG PSA CONTRACT - EXHIBIT “K” – ESG QUARTERLY HMIS REPORT Page 1
EXHIBIT "K"
ESG QUARTERLY HMIS REPORT
City of Fort Worth
Emergency Solutions Grant (ESG)
Quarterly HMIS Report
Prepared by: D.C. and C.A.
Updated: 2/11/2015 Page 1 of 2
Homelessness
Prevention
Rapid Re-
Housing
Emergency
Shelters
Veterans
Victims of Domestic Violence
Elderly
HIV/AIDS
Chronically Homeless
Severely Mentally Ill
Chronic Substance Abuse (Drug,
Alcohol)Other Disabilities (Physical,
Developmental)
Total
Adults
Children
Don't Know/Refused/Other
Missing Information
Total
Male
Female
Transgender
Don't Know/Refused/Other
Missing Information
Total Persons Served Total Persons
Served
(Cumulative)
Persons with Disabilities
Total Persons
Served This
Quarter
Special Populations Served-All Activities
Reporting Period: From ___________________
To ___________________
This report is meant to collect data that is required for the HUD Consolidated Annual Performance and Evaluation Report
(CAPER).This report is due each quarter, on January 15,April 15,July 15 and September 30 of each Contract year. Please
fill out the report according to your Agency's accomplishments.If a particular activity does not apply to your Agency (for
example,a shelter does not perform homeless prevention) please fill in all zeros for that particular column. This information
should be collected from HMIS and the total number of persons should match comparable figures on the City's Attachment III
Report.If this report does not match the City's Attachment III Report,the Agency may be required to resubmit the report and
provide an explanation for the discrepancy.
Number of Persons in Household
Gender-All Activities
Agency Name: ____________________________________
Contact Person: ____________________________________
Prepared by: D.C. and C.A.
Updated: 8/31/2015 Page 2 of 2
Homelessness
Prevention
Rapid Re-
Housing
Emergency
Shelters
Total Persons Served Total Persons
Served
(Cumulative)
Total Persons
Served This
Quarter
Total
Under 18
18-24
25 and over
Don't Know/Refused/Other
Missing Information
Total
Number of New Units -
Rehabilitation
Number of New Units - Conversion
Total Number of Bed-Nights
Available*
Total Number of Bed-Nights
Provided**
Received Case Management
Exited to transitional or permanent
housing
With higher cash income at exit
With non-cash benefits at exit
Exited to or maintained permanent
housing at exit
Did not enter CoC Shelter or
Transitional Housing during
remainder of ESG year
** The number of beds that were filled each night. Count all emergency shelter beds, whether or not they are ESG-funded.
*The total number of beds that are available in a year. For example,if they are all year-round beds,it would be 365 multiplied by the
number of emergency shelter beds;if some are seasonal as well (e.g., only winter) then add in the number of nights each bed is available.
Count all emergency shelter beds, whether or not they are ESG-funded.
Performance Standards
Age-All Activities
Shelter Utilization
ESG PSA CONTRACT -- EXHIBIT “L” -- MBE REPORTING FORM Page 1
EXHIBIT “L”
MBE REPORTING FORM
PH
IH
CPD
Housing
Grant/Project Number or HUD
Case Number or other
identification of property,
subdivision, dwelling unit, etc.
7a.
Amount of
Contract or
Subcontact
7b.
Type of Trade
Code
(See below)
7c.
Contractor or
Subcontractor
Business
Racial/Ethnic
(See below)
7d.
Woman Owned Business
(Yes or No)
7e.
Prime Contractor Identification (ID)
Number
7f.
Sec. 3
7g.
Subcontractor
Identification (ID)
Number
7h
Sec. 3
7i.
State Zip
CPD:
1 = New Construction 6 = Professional
2 = Education/Training 7 = Tenant Services
3 = Other 8 = Education/Training
0 = Other
7d: Racial/Ethnic Codes:
1 = White Americans
3 = Native Americans
4 = Hispanic Americans
5: Program Codes (Complete for Housing and Public and Indian Housing programs only):
2= Flexible Subsidy
1 = All Insured, including Section8 5 = Section 202
6 = HUD-Held (Management)
Housing/Public Housing:
7c: Type of Trade Codes:
2 = Black Americans1 = New Construction
9 = Arch./Engrg. Appraisal 5 = Asian/Pacific Americans
8 = Section 8114 = Insured (Management)
3 = Section 8 Noninsured, Non-HFDA 7 = Public/India Housing
OMB Approval No.: 2577-0088 OMB
Approval No.: 2502-0355
Executive Orders dated July 14, 1983, directs the Minority Business Development Plans shall be developed by each Federal Agency and the these annual plans shall establish minority business development objectives. The information is used by HUD to monitor and evaluate MBE activities against
the total program activity and the designated minority business enterprise (MBE) goals. The Department requires the information to provide guidance and oversight for programs for the development of minority business enterprise concerning Minority Business Development. If the information is
not collected HUD would not be able to establish meaningful MBE goals nor evaluate MBE performance against these goals.
Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The
Information is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB Control Number.
Oct. 1 - Sept. 30 (Annual -FY)
Check if:
Contract and Subcontract Activity
Contractor/Subcontractor Name and Address
7j.
Name Street City
U.S. Department of Housing and Urban Development
Privacy Act Notice = The United States Department of Housing and Urban Development, Federal Housing Administration, is authorized to solicit the Information requested in this form by virtue of Title 12, United States Code, Section 1701 et seq., and regulation. It will not be disclosed or
relesed outside the United States Department of Housing and Urban Development without your consetn, except as required or permitted by Law.
Previous editions are obsolete.form HUD-2516 (8/98)
2 = Substantial Rehab.
3 = Repair
5 = Project Mangt.
4 = Service
6 = Hasidic Jews
1. Grantee/Project Owner/Developer/Sponsor/Builder/Agency
3a. Name of Contact Person 3b. Phone Number (Including Area Code)4. Reporting Period 5. Program Code (Not applicable for CPD programs.)
See explanation of Codes at bottom of Page Use a
separate sheet for each program code.
6. Date Submitted to Field Office
2. Location (City, State Zip Code)
This report is to be completed by grantees, developers, sponsors, builders, agencies, and/or
project owners for reporting contract and subcontract activities of $10,000 or more under the
following programs: Community Development Block Grants (entitlement and small cities);
Urban Development Action Grants; Housing Development Grants; Multifamily Insured and
Noninsured; Public and Indian Housing Authorities; and contracts entered into by recipients of
CDBG rehabilitation assistance.
completed for public and Indian housing and most community development programs. Form HUD-
60002 is to be completed by all other HUD programs including State administered community
development programs covered under Section3. A Section 3 Contractor/subcontractor is a
business concern that provides economic opportunities to low and very Low-income residents of
the metropolitan area (or nonmetropolitan county), including a business concern that is 51 person
or more owned by low-income residents;
costs or unusually high or low-income families. Very low-income families (including single
persons) whose incomes do not exceed 50 per centum of the median family income for the area,
as determined by the Secretary with adjustments for smaller and larger families, except that the
secretary may establish income ceilings higher or lower than 50 per centum of the median for the
area on the basis of the Secretary's findings that such variations are necessary because of
unusually high or low family incomes.
Contracts/subcontracts of less than $10,000 need be reported only if such contracts represent a
significant portion of your total contracting activity. Include only contracts executed during
this reporting period.
or provides subcontracting or business development opportunities to businesses owned by low or
low-income residents. Low and very low-income residents; include participants in Youthbuild
programs established under Subtitle D of Title IV of the Cranston-Gonzalez National Affordable
Housing Act.
Submit two (2) copies of this report to your local HUD Office within ten (10) days after the end
of the reporting period you checked in item 4 on the front. Complete item 7h. Only once for each
contractor/subcontractor on each semi-annual report.
This form has been modified to capture Section 3 contract data in columns 7g and 7i. Section
3 requires that the employment and other economic opportunities generated by HUD financial
assistance for housing and community development programs shall, to the greatest extent
feasible, be directed toward low- and very low-income persons, particularly those who are
recipients of government assistance for housing. Recipients using this form to report Section 3
contract data must also use Part I of form HUD-60002 to report employment and training
opportunities data. Form HUD-2516 is to be
The terms “low-income persons” and “very low-income persons” have the same meanings given
the terms in section3(b)(2) of the United States Housing Act of 1937. Low-income persons mean
families (including single persons) whose incomes do not exceed 80 per centum of the median
income for the area, as determined by the Secretary, with adjustments for smaller an larger
families, except that the Secretary may establish income ceilings higher or lower than 80 per
centum of the median for the area on the basis of the Secretary's findings that such variations are
necessary because of prevailing levels of construction
Enter the prime contractor's ID in item 7f. for all contracts and subcontracts. Include only
contracts expected during this reporting period. PHAs/IHAs are to report all
contracts/subcontracts.
Community Development Programs Multifamily Housing Programs Public Housing and Indian Housing Programs
1. Grantee: Enter the name of the unit of government submitting this report.1. Grantee/Project Owner: Enter the name of the unit of government, agency or mortgagor
entity submitting this report.
PHAs/IHAs are to report all contracts/subcontracts. Include only contracts executed during this
reporting period.
3. Contact Person: Enter name and phone of person responsible for maintaining and
submitting contract/subcontract data.3. Contact Person: Same as item 3 under CPD Programs.1. Project Owner: Enter the name of the unit of government, agency or mortgagor entity
submitting this report. Check box as appropriate.
7a. Grant Number: Enter the HUD Community Development Block Grant Identification
Number (with dashes). For example: B-32-MC-25-0034. For Entitlement Programs and Small
City multi-year comprehensive programs, enter the latest approved grant number.
4. Reporting Period: Check only one period.3. Contact Person: Same as item 3 under CPD Programs.
7b. Amount of Contract/Subcontract: Enter the dollar amount rounded to the nearest dollar.
If subcontractor ID number is provided in 7f, the dollar figure would be for the subcontract
only and not for the prime contract.
5. Program Code: Enter the appropriate program code.4. Reporting Period: Check only one period.
7c. Type of Trade: Enter the numeric codes which best indicates the
contractor's/subcontractor's service. If subcontractor ID number is provided in 7f., the type of
trade code would be for the subcontractor only and not for the prime contractor.
7a. Grant/Project Number: Enter the HUD Project Number or Housing Development Grant or
number assigned.5. Program Code: Enter the appropriate program code.
The "other" category includes supply, professional services and all other activities except
construction and education/training activities.7b. Amount of Contract/Subcontract: Same as item 7b. under CPD Programs.7a. Grant/Project Number: Enter the HUD Project Number or Housing Development Grant or
number assigned.
7d. Business Racial/Ethnic/Gender Code: Enter the numeric code which indicates the
racial/ethnic/gender character of the owner(s) and controller(s) of 51% of the business. 7c. Type of Trade: Same as item 7c. under CPD Programs.7b. Amount of Contract/Subcontract: Same as item 7b. under CPD Programs.
When 51% or more is not owned and controlled by any single racial/ethnic/gender category,
enter the code which seems most appropriate. If the subcontractor ID number is provided, the
code would apply to the subcontractor and not to the prime contractor.7d. Business Racial/Ethnic/Gender Code: Same as item 7d. under CPD Programs.7c. Type of Trade: Same as item 7c. under CPD Programs.
7e. Woman Owned Business: Enter Yes or No.7e. Woman Owned Business: Enter Yes or No.7d. Business Racial/Ethnic/Gender Code: Same as item 7d. under CPD Programs.
7f. Contractor Identification (ID) Number: Enter the Employer (IRS) Number of the Prime
Contractor as the unique identifier for prime recipient of HUD funds. Note that the Employer
(IRS) Number must be provided for each contract/subcontract awarded.
7f. Contractor Identification (ID) Number: Same as item 7f. under CPD Programs.7e. Woman Owned Business: Enter Yes or No.
7g. Section 3 Contractor: Enter Yes or No.7g. Section 3 Contractor: Enter Yes or No.7f. Contractor Identification (ID) Number: Same as item 7f. under CPD Programs.
7h. Subcontractor Identification (ID) Number: Enter the Employer (IRS) Number of the
subcontractor as the unique identifier for each subcontract awarded from HUD funds. When
the subcontractor ID Number is provided, the respective Prime Contractor ID Number must
also be provided.
7h. Subcontractor Identification (ID) Number: Same as item 7h. under CPD Programs.7g. Section 3 Contractor: Enter Yes or No.
7i. Section 3 Contractor: Enter Yes or No.7i. Section 3 Contractor: Enter Yes or No.7h. Subcontractor Identification (ID) Number: Same as item 7h. under CPD Programs.
7j. Contractor/Subcontractor Name and Address: Enter this information for each firm
receiving contract/subcontract activity only one time on each report for each firm.7j. Contractor/Subcontractor Name and Address: Same as item 7j. under CPD Programs.7i. Section 3 Contractor: Enter Yes or No.
7j. Contractor/Subcontractor Name and Address: Same as item 7j. under CPD Programs.
ESG PSA CONTRACT -- EXHIBIT “M” – NOTICE OF BENEFICIARY RIGHTS Page 1
EXHIBIT “M”
NOTICE OF BENEFICIARY RIGHTS
ESG PSA CONTRACT -- EXHIBIT “M” – NOTICE OF BENEFICIARY RIGHTS Page 2
Notice of Beneficiary Rights
Name of Agency:
Name of Program:
Contact information for Program Staff (name, phone number, and e-mail address, if appropriate):
Because this program is supported in whole or in part by direct Federal financial assistance from
the Federal Government, we are required to let you know that:
• We may not discriminate against you on the basis of religion, religious belief, a refusal
to hold a religious belief, or a refusal to attend or participate in a religious practice;
• We may not require you to attend or participate in any explicitly religious activities that
are offered by us and any participation by you in these activities must be purely
voluntary;
• We must separate, in time or location, any privately funded explicitly religious activities
from activities supported by direct Federal financial assistance;
•If you object to the religious character of our organization, we must make reasonable
efforts to identify and refer you to an alternative provider to which you have no such
objection; and
• You may report an organization's violations of these protections, including any denial of
services or benefits, by contacting or filing a written complaint to HUD [or the
intermediary, if applicable].
We must give you this written notice before you enroll in our program or activity, as required by
24 CFR 5.109.
ESG PSA CONTRACT -- EXHIBIT “N” – NOTICE OF BENEFICIARY RIGHTS Page 1
EXHIBIT “N”
WRITTEN STANDARDS FOR MAINTENANCE OF PERSONALLY IDENTIFYING
INFORMATION
ESG PSA CONTRACT -- EXHIBIT “N” – NOTICE OF BENEFICIARY RIGHTS Page 2
Written Standards for Maintenance of Client Confidentiality
Personally identifying information. Households receiving assistance under ESG must have
reasonable assurance of confidentiality. All client records, including name, household members,
date of birth, Social Security number, Driver’s License Number, and any other identifying
information of any individual or family who applies for and/or receives ESG assistance will be
kept secure and confidential. This includes maintaining client records in a safe, locked file
cabinet, filing area, or office that is not accessible to the general public and with access that is
limited to staff persons providing direct services to the client(s).
Domestic Violence Shelter Locations. The address or location of any domestic violence, dating
violence, sexual assault, or stalking shelter with ESG funds will not published, disclosed or made
public, except with written authorization of the person responsible for the operation of the
shelter.
Domestic Violence Shelter Participants. The address or location of any housing of a program
participant will not be published, disclosed or made public to any individual not providing direct
services to the participant, except as provided under a preexisting privacy policy of the agency
and consistent with state and local laws regarding privacy and obligations of confidentiality.
Federal/Local Government Rights. City, HUD, the HUD Office of Inspector General, and the
Comptroller General of the United States, or any of their authorized representatives, must have
the right of access to all books, documents, papers, or other records of the agency that are
pertinent to the ESG grant, in order to make audits, examinations, excerpts, and transcripts.
These rights of access are not limited to the required retention period but last as long as the
records are retained.
Public Rights. Citizens, public agencies, and other interested parties must have reasonable
access (consistent with state and local laws regarding privacy and obligations of confidentiality
and the confidentiality requirements in this part) to records regarding any uses of ESG funds the
agency received during the preceding 5 years.
Reports. The agency must collect and report data on its use of ESG funds in the Homeless
Management Information System (HMIS)
Compliance. Agency must incorporate into its policies and procedures a process that will
ensure the confidentiality of program participants’ identifying information; records pertaining to
any individual or family provided family violence prevention; and treatment services offered
under any project assisted with ESG funds.
Agency Notification. Agency is provided the requirements for maintaining client confidentiality
via (a) annual Technical Assistance Training provided by City of Fort Worth Neighborhood
Services Department staff, (b) Individual Agency Technical Assistance visits (as scheduled), and
(c) annual monitoring visit conducted by City of Fort Worth Neighborhood Services Compliance
& Planning Division staff.
ESG PSA CONTRACT -- EXHIBIT “N” – NOTICE OF BENEFICIARY RIGHTS Page 3
Open Records Request. City staff required to comply with open records requests will receive
the requirements for maintaining client confidentiality and comply in accordance with HUD
regulations.
NOTICE OF OCCUPANCY RIGHTS UNDER
THE VIOLENCE AGAINST WOMEN ACT U.S. Department of Housing and Urban Development
OMB Approval No. 2577-0286
Expires 06/30/2017
Form HUD-5380
(12/2016)
EXHIBIT “O” – Notice of Occupancy Rights Under VAWA
[Insert Name of Housing Provider 1]
Notice of Occupancy Rights under the Violence Against Women Act 2
To all Tenants and Applicants
The Violence Against Women Act (VAWA) provides protections for victims of domestic
violence, dating violence, sexual assault, or stalking. VAWA protections are not only available
to women, but are available equally to all individuals regardless of sex, gender identity, or sexual
orientation.3 The U.S. Department of Housing and Urban Development (HUD) is the Federal
agency that oversees that [insert name of program or rental assistance] is in compliance with
VAWA. This notice explains your rights under VAWA. A HUD-approved certification form is
attached to this notice. You can fill out this form to show that you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking, and that you wish to use your
rights under VAWA.”
Protections for Applicants
If you otherwise qualify for assistance under [insert name of program or rental assistance],
you cannot be denied admission or denied assistance because you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking.
Protections for Tenants
1 The notice uses HP for housing provider but the housing provider should insert its name where HP is used.
HUD’s program-specific regulations identify the individual or entity responsible for providing the notice of
occupancy rights.
2 Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
3 Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national
origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made
available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or
marital status.
2
Form HUD-5380
(12/2016)
If you are receiving assistance under [insert name of program or rental assistance], you may
not be denied assistance, terminated from participation, or be evicted from your rental housing
because you are or have been a victim of domestic violence, dating violence, sexual assault, or
stalking.
Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,
dating violence, sexual assault, or stalking by a member of your household or any guest, you
may not be denied rental assistance or occupancy rights under [insert name of program or
rental assistance] solely on the basis of criminal activity directly relating to that domestic
violence, dating violence, sexual assault, or stalking.
Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom
you stand in the place of a parent or guardian (for example, the affiliated individual is in your
care, custody, or control); or any individual, tenant, or lawful occupant living in your household.
Removing the Abuser or Perpetrator from the Household
HP may divide (bifurcate) your lease in order to evict the individual or terminate the assistance
of the individual who has engaged in criminal activity (the abuser or perpetrator) directly relating
to domestic violence, dating violence, sexual assault, or stalking.
If HP chooses to remove the abuser or perpetrator, HP may not take away the rights of eligible
tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator
was the sole tenant to have established eligibility for assistance under the program, HP must
allow the tenant who is or has been a victim and other household members to remain in the unit
for a period of time, in order to establish eligibility under the program or under another HUD
housing program covered by VAWA, or, find alternative housing.
3
Form HUD-5380
(12/2016)
In removing the abuser or perpetrator from the household, HP must follow Federal, State, and
local eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for
documentation or certification of the incidences of domestic violence, dating violence, sexual
assault, or stalking.
Moving to Another Unit
Upon your request, HP may permit you to move to another unit, subject to the availability of
other units, and still keep your assistance. In order to approve a request, HP may ask you to
provide documentation that you are requesting to move because of an incidence of domestic
violence, dating violence, sexual assault, or stalking. If the request is a request for emergency
transfer, the housing provider may ask you to submit a written request or fill out a form where
you certify that you meet the criteria for an emergency transfer under VAWA. The criteria are:
(1)You are a victim of domestic violence, dating violence, sexual assault, or
stalking. If your housing provider does not already have documentation that you
are a victim of domestic violence, dating violence, sexual assault, or stalking, your
housing provider may ask you for such documentation, as described in the
documentation section below.
(2)You expressly request the emergency transfer. Your housing provider may
choose to require that you submit a form, or may accept another written or oral
request.
(3)You reasonably believe you are threatened with imminent harm from
further violence if you remain in your current unit. This means you have a
reason to fear that if you do not receive a transfer you would suffer violence in the
very near future.
4
Form HUD-5380
(12/2016)
OR
You are a victim of sexual assault and the assault occurred on the premises
during the 90-calendar-day period before you request a transfer. If you are a
victim of sexual assault, then in addition to qualifying for an emergency transfer
because you reasonably believe you are threatened with imminent harm from
further violence if you remain in your unit, you may qualify for an emergency
transfer if the sexual assault occurred on the premises of the property from which
you are seeking your transfer, and that assault happened within the 90-calendar-day
period before you expressly request the transfer.
HP will keep confidential requests for emergency transfers by victims of domestic violence,
dating violence, sexual assault, or stalking, and the location of any move by such victims and
their families.
HP’s emergency transfer plan provides further information on emergency transfers, and HP must
make a copy of its emergency transfer plan available to you if you ask to see it.
Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,
Sexual Assault or Stalking
HP can, but is not required to, ask you to provide documentation to “certify” that you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking. Such request
from HP must be in writing, and HP must give you at least 14 business days (Saturdays,
Sundays, and Federal holidays do not count) from the day you receive the request to provide the
documentation. HP may, but does not have to, extend the deadline for the submission of
documentation upon your request.
5
Form HUD-5380
(12/2016)
You can provide one of the following to HP as documentation. It is your choice which of the
following to submit if HP asks you to provide documentation that you are or have been a victim
of domestic violence, dating violence, sexual assault, or stalking.
•A complete HUD-approved certification form given to you by HP with this notice, that
documents an incident of domestic violence, dating violence, sexual assault, or stalking.
The form will ask for your name, the date, time, and location of the incident of domestic
violence, dating violence, sexual assault, or stalking, and a description of the incident.
The certification form provides for including the name of the abuser or perpetrator if the
name of the abuser or perpetrator is known and is safe to provide.
•A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or
administrative agency that documents the incident of domestic violence, dating violence,
sexual assault, or stalking. Examples of such records include police reports, protective
orders, and restraining orders, among others.
•A statement, which you must sign, along with the signature of an employee, agent, or
volunteer of a victim service provider, an attorney, a medical professional or a mental
health professional (collectively, “professional”) from whom you sought assistance in
addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of
abuse, and with the professional selected by you attesting under penalty of perjury that he
or she believes that the incident or incidents of domestic violence, dating violence, sexual
assault, or stalking are grounds for protection.
•Any other statement or evidence that HP has agreed to accept.
If you fail or refuse to provide one of these documents within the 14 business days, HP does not
have to provide you with the protections contained in this notice.
6
Form HUD-5380
(12/2016)
If HP receives conflicting evidence that an incident of domestic violence, dating violence, sexual
assault, or stalking has been committed (such as certification forms from two or more members
of a household each claiming to be a victim and naming one or more of the other petitioning
household members as the abuser or perpetrator), HP has the right to request that you provide
third-party documentation within thirty 30 calendar days in order to resolve the conflict. If you
fail or refuse to provide third-party documentation where there is conflicting evidence, HP does
not have to provide you with the protections contained in this notice.
Confidentiality
HP must keep confidential any information you provide related to the exercise of your rights
under VAWA, including the fact that you are exercising your rights under VAWA.
HP must not allow any individual administering assistance or other services on behalf of HP (for
example, employees and contractors) to have access to confidential information unless for
reasons that specifically call for these individuals to have access to this information under
applicable Federal, State, or local law.
HP must not enter your information into any shared database or disclose your information to any
other entity or individual. HP, however, may disclose the information provided if:
•You give written permission to HP to release the information on a time limited basis.
•HP needs to use the information in an eviction or termination proceeding, such as to evict
your abuser or perpetrator or terminate your abuser or perpetrator from assistance under
this program.
•A law requires HP or your landlord to release the information.
7
Form HUD-5380
(12/2016)
VAWA does not limit HP’s duty to honor court orders about access to or control of the property.
This includes orders issued to protect a victim and orders dividing property among household
members in cases where a family breaks up.
Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or
Assistance May Be Terminated
You can be evicted and your assistance can be terminated for serious or repeated lease violations
that are not related to domestic violence, dating violence, sexual assault, or stalking committed
against you. However, HP cannot hold tenants who have been victims of domestic violence,
dating violence, sexual assault, or stalking to a more demanding set of rules than it applies to
tenants who have not been victims of domestic violence, dating violence, sexual assault, or
stalking.
The protections described in this notice might not apply, and you could be evicted and your
assistance terminated, if HP can demonstrate that not evicting you or terminating your assistance
would present a real physical danger that:
1) Would occur within an immediate time frame, and
2) Could result in death or serious bodily harm to other tenants or those who work on the
property.
If HP can demonstrate the above, HP should only terminate your assistance or evict you if there
are no other actions that could be taken to reduce or eliminate the threat.
Other Laws
VAWA does not replace any Federal, State, or local law that provides greater protection for
victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to
8
Form HUD-5380
(12/2016)
additional housing protections for victims of domestic violence, dating violence, sexual assault,
or stalking under other Federal laws, as well as under State and local laws.
Non-Compliance with The Requirements of This Notice
You may report a covered housing provider’s violations of these rights and seek additional
assistance, if needed, by contacting or filing a complaint with [insert contact information for
any intermediary, if applicable] or [insert HUD field office].
For Additional Information
You may view a copy of HUD’s final VAWA rule at [insert Federal Register link].
Additionally, HP must make a copy of HUD’s VAWA regulations available to you if you ask to
see them.
For questions regarding VAWA, please contact [insert name of program or rental assistance
contact information able to answer questions on VAWA].
For help regarding an abusive relationship, you may call the National Domestic Violence Hotline
at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may
also contact [Insert contact information for relevant local organizations].
For tenants who are or have been victims of stalking seeking help may visit the National Center
for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-
programs/stalking-resource-center.
For help regarding sexual assault, you may contact [Insert contact information for relevant
organizations]
Victims of stalking seeking help may contact [Insert contact information for relevant
organizations].
Attachment: Certification form HUD-5382 [form approved for this program to be included]
Form HUD-5382
(06/2017)
EXHIBIT “P” – Emergency Transfer Request Form
CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286
DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017
DATING VIOLENCE,
SEXUAL ASSAULT, OR STALKING,
AND ALTERNATE DOCUMENTATION
Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and
program participants in certain HUD programs from being evicted, denied housing assistance, or
terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or
stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic
violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual
orientation.
Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your
housing provider may give you a written request that asks you to submit documentation about the incident
or incidents of domestic violence, dating violence, sexual assault, or stalking.
In response to this request, you or someone on your behalf may complete this optional form and submit it
to your housing provider, or you may submit one of the following types of third-party documentation:
(1)A document signed by you and an employee, agent, or volunteer of a victim service provider, an
attorney, or medical professional, or a mental health professional (collectively, “professional”) from
whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or
stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the
professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or
stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or
“stalking” in HUD’s regulations at 24 CFR 5.2003.
(2)A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or
administrative agency; or
(3)At the discretion of the housing provider, a statement or other evidence provided by the applicant or
tenant.
Submission of Documentation: The time period to submit documentation is 14 business days from the
date that you receive a written request from your housing provider asking that you provide documentation
of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing
provider may, but is not required to, extend the time period to submit the documentation, if you request an
extension of the time period. If the requested information is not received within 14 business days of when
you received the request for the documentation, or any extension of the date provided by your housing
provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or
issuance of this form does not serve as a written request for certification.
Confidentiality: All information provided to your housing provider concerning the incident(s) of
domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details
shall not be entered into any shared database. Employees of your housing provider are not to have access
to these details unless to grant or deny VAWA protections to you, and such employees may not disclose
this information to any other entity or individual, except to the extent that disclosure is: (i) consented to
2
Form HUD-5382
(06/2017)
by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing
regarding termination of assistance; or (iii) otherwise required by applicable law.
TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,
DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING
1.Date the written request is received by victim: _________________________________________
2. Name of victim: ___________________________________________________________________
3.Your name (if different from victim’s):________________________________________________
4. Name(s) of other family member(s) listed on the lease:___________________________________
___________________________________________________________________________________
5. Residence of victim: ________________________________________________________________
6. Name of the accused perpetrator (if known and can be safely disclosed):____________________
__________________________________________________________________________________
7. Relationship of the accused perpetrator to the victim:___________________________________
8. Date(s) and times(s) of incident(s) (if known):___________________________________________
_________________________________________________________________
10. Location of incident(s):_____________________________________________________________
This is to certify that the information provided on this form is true and correct to the best of my knowledge
and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,
dating violence, sexual assault, or stalking. I acknowledge that submission of false information could
jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or
eviction.
Signature __________________________________Signed on (Date) ___________________________
Public Reporting Burden: The public reporting burden for this collection of information is estimated to
average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The
information provided is to be used by the housing provider to request certification that the applicant or
tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is
subject to the confidentiality requirements of VAWA. This agency may not collect this information, and
you are not required to complete this form, unless it displays a currently valid Office of Management and
Budget control number.
In your own words, briefly describe the incident(s):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
City of Fort Worth, Texas
Mayor and Council Communication
DATE: 08/03/21 M&C FILE NUMBER: M&C 21-0522
LOG NAME: 19NS 2021-2022 ACTION PLAN
SUBJECT
(ALL) Conduct Public Hearing and Approve the City's 2021-2022 Annual Action Plan for the Use of Federal Grant Funds in the Amount of
$13,070,952.00 to be Awarded by the United States Department of Housing and Urban Development from the Community Development Block
Grant, HOME Investment Partnerships Program, Emergency Solutions Grant, and Housing Opportunities for Persons with AIDS Programs,
Authorize Collection and Use of Program Income, Authorize Execution of Related Contracts, Authorize the Use of Fee Waivers as HOME Match,
Adopt Attached Appropriation Ordinance, and Authorize Waiver of Indirect Costs
(PUBLIC HEARING - a. Report of City Staff: Sharon Burkley; b. Public Presentations; c. Council Action: Close Public Hearing and Act on the
M&C)
RECOMMENDATION:
It is recommended that City Council:
1. Conduct a public hearing to allow citizen input and consideration of the City's 2021-2022 Annual Action Plan for use of federal grant funds to
be awarded by the United States Department of Housing and Urban Development in the amount of $13,070,952.00 from the Community
Development Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant, and Housing Opportunities for Persons
with AIDS grant programs, and for the use of program income from activities using prior years' federal grant funds;
2. Approve the City's 2021-2022 Annual Action Plan for submission to the United States Department of Housing and Urban Development,
including allocations of grant funds to particular programs and activities as detailed below;
3. Authorize the collection and use of an estimated $75,000.00 of program income which is expected to result from activities using prior years'
Community Development Block Grant funds for the City's Priority Repair Program;
4. Authorize the collection and use of an estimated $75,000.00 of program income which is expected to result from activities using prior years'
HOME Investment Partnerships Program grant funds for the City's Homebuyer Assistance Program, and authorize the use of 10 percent of
the program income for administrative costs;
5. Authorize the City Manager or his designee to execute contracts for one year terms with the agencies listed in Tables 1, 2, and 3 below for
Program Year 2021-2022 for Community Development Block Grant, Emergency Solutions Grant, and Housing Opportunities for Persons
with AIDS grant funds, contingent upon receipt of funding, and satisfactory completion of all federal regulatory requirements;
6. Authorize the City Manager or his designee to extend the contracts for up to one year if an agency or department requests an extension and
such extension is necessary for completion of the program, or to amend the contracts if necessary to achieve program goals provided any
amendment is within the scope of the program and in compliance with City policies and all applicable laws and regulations governing the use
of federal grant funds;
7. Adopt the attached Appropriation Ordinance increasing the estimated receipts and appropriations to the Grants Operating Federal Fund in
the total amount of $13,070,952.00 consisting of $7,477,274.00 in Community Development Block Grant funds, $2,907,320.00 in HOME
Investment Partnerships Program grant funds, $632,124.00 in Emergency Solutions Grant funds, and $1,904,234.00 in Housing
Opportunities for Persons with AIDS grant funds, plus estimated program income in the amount of $150,000.00, all subject to receipt of such
funds; and
8. Authorize a waiver of the Neighborhood Services Department indirect cost rate of 18.73%, estimated total of $303,276.16.
DISCUSSION:
The City's 2021-2022 Annual Action Plan summarizes the major housing and community development activities and proposed expenditures for the
program year beginning October 1, 2021 and ending September 30, 2022 for use of federal grant funds totaling $13,070,952.00 from the United
States Department of Housing and Urban Development (HUD) from the Community Development Block Grant (CDBG), HOME Investment
Partnerships Program (HOME), Emergency Solutions Grant (ESG), and Housing Opportunities for Persons with AIDS (HOPWA) grant programs.
It also summarizes the use of program income resulting from activities using prior years' CDBG and HOME funds, the primary purpose of which is
to benefit low-and moderate-income persons in Fort Worth. ESG funds primarily benefit homeless persons, and HOPWA funds primarily benefit
low- and moderate-income persons with HIV/AIDS.
Staff developed initial recommendations for the allocation of the estimated funding from HUD based on prior years' funding levels. Two public
hearings were held on April 14, 2021 and May 12, 2021 to provide citizens the opportunity to participate in the development of the Annual Action
Plan. Recommendations for award amounts were considered and adopted by the Community Development Council on May 12, 2021. These
funding recommendations were presented in City Council Work Session on June 22, 2021.
A 30-day public comment period was held from July 1, 2021 to July 30, 2021. Notice of this public comment period was published in the Wise
County Messenger and Glen Rose Reporter on June 25, 2021; in the Cleburne Times-Review, Hood County News, and Weatherford Democrat
on June 26, 2021; in the Fort Worth Star-Telegram on June 27, 2021; and in La Vida News on July 1, 2021.
TABLE 1: CDBG AGENCIES
Any comments received are maintained by the Neighborhood Services Department in accordance with federal regulations. The City held two
public hearings as part of the HUD required citizen participation process. The first public hearing was held by staff on July 14, 2021, and the
second public hearing is scheduled for the City Council meeting on August 3, 2021.
A summary of staff's final funding recommendations is provided below and in Tables 1, 2, and 3. A spreadsheet of funding recommendations is
also attached. The 2021-2022 Annual Action Plan will be submitted to HUD by August 15, 2021.
Indirect costs totaling approximately $354,132.42 could be charged to these grants, as the Neighborhood Services Department indirect cost rate
is 18.73% in the City's most recent Cost Allocation Plan. A waiver of these costs is requested to allow allocation of these funds to further support
the programs and services to assist low-to-moderate income citizens.
COMMUNITY DEVELOPMENT BLOCK GRANT
For Program Year 2021-2022, it is recommended that the amount of $7,477,274.00 in CDBG funds and an estimated amount of $75,000.00 in
CDBG program income totaling $7,522,274.00 be allocated as follows:
Public Services - $1,121,591.00: Includes social services for low- and moderate-income persons, persons with disabilities, and
disadvantaged persons
Housing Programs - $2,848,219.00: Includes funding for the City's Priority Repair Program, Cowtown Brush-Up, homebuyer and housing
services, accessibility modifications for seniors and persons with disabilities, and related project delivery costs for these programs
Major Projects - $2,012,009.00: Includes funding for Southside Community Center improvements, Bunche Park improvements, and
Street/Sidewalk improvements
Administration - $1,495,455.00: Includes costs for administering the CDBG grant, including allocations for the Financial Management
Services and Development Services Departments
Estimated Program Income - $75,000.00: Includes up to $75,000.00 in funding for the City's Priority Repair Program. Any CDBG program
income over the estimated amount not used for the Priority Repair Program will be allocated to priority activities in the City's Consolidated
Plan, subject to City Council approval.
HOME INVESTMENT PARTNERSHIPS PROGRAM
For Program Year 2021-2022, it is recommended that the amount of $2,907,320.00 in HOME funds and an estimated amount of $75,000.00 in
HOME program income totaling $2,982,320.00 be allocated as follows:
Homebuyer Assistance Program - $500,000.00: Includes funding for down payment and closing cost assistance for low- and moderate-
income homebuyer
Community Housing Development Organizations - $1,116,588.00: HUD requires that a minimum of 15 percent of HOME funds be allocated
to Community Housing Development Organizations (CHDOs) for affordable housing projects. These funds will be used by Housing Channel
for a multifamily rental demolition/reconstruction project in the Polytechnic neighborhood. The City is also authorized by HUD to fund CHDO
operating costs to support community-based affordable housing development. These funds for operating costs will be used by Housing
Channel to support completion of the multifamily rental demolition/reconstruction project. All housing developed with these funds will be sold
to homebuyers making at or below 80 percent of area median income (AMI), set by HUD.
Major Projects - $1,000,000.00: Includes funds allocated to the multifamily project to be developed by Fort Worth Housing Solutions (FWHS)
as a part of its Choice Neighborhood Initiative (CNI) grant.
Administration - $290,732.00: Includes costs for administering the HOME grant
Estimated Program Income - $75,000.00: Includes funding for the Homebuyer Assistance Program and HOME grant administrative costs.
HUD allows the City to use 10 percent of any HOME program income towards the cost of administering the HOME grant. HOME program
income over the estimated amount not used for the Homebuyer Assistance Program will be allocated to priority activities in the City's
Consolidated Plan, subject to City Council approval.
HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS
For Program Year 2021-2022, it is recommended that the amount of $1,904,234.00 in HOPWA funds be allocated as follows:
Public Service Agencies - $1,148,627.00
Neighborhood Services Department/Community Action Partners - $698,480.00
Administration - $57,127.00
EMERGENCY SOLUTIONS GRANT
For Program Year 2021-2022, it is recommended that the amount of $632,124.00 in ESG funds be allocated as follows:
Public Service Agencies - $584,715.00
Administration - $47,409.00
CONTRACT RECOMMENDATIONS
The Community Development Council and Neighborhood Services Department staff recommend that contracts be executed with the listed
agencies for the amounts shown in the following tables.
Community Development Block Grant Contracts
AGENCY PROGRAM AMOUNT
AB Christian Learning Center After School Tutoring $85,000.00
AB Christian Learning Center Summer Reading Program $65,303.00
Artes de la Rosa Artes Academy $60,000.00
Big Brothers Big Sisters Lone Star Mentor 2.0 @ Young Men's Leadership
Academy $50,000.00
Big Brothers Big Sisters Lone Star Mentor 2.0 @ Young Women's Leadership
Academy $50,000.00
Boys & Girls Clubs of Greater Tarrant County, Inc.After School Program $60,000.00
United Community Centers, Inc.Educational Enrichment $100,000.00
Family Pathfinders of Tarrant County Financial Capability Program $50,000.00
The Ladder Alliance Computer Skills Training $70,000.00
Housing Channel Homebuyer Education and Housing
Counseling Services $125,000.00
Meals-On-Wheels, Inc. of Tarrant County Home-Delivered Meals $116,288.00
Guardianship Services, Inc.Financial Exploitation Prevention Center $70,000.00
The Presbyterian Night Shelter of Tarrant County,
Inc.Case Management for Homeless $145,000.00
The Salvation Army Red Shield Emergency Shelter $75,000.00
CDBG Public Service Agencies Total $1,121,591.00
Rehabilitation, Education and Advocacy for
Citizens with Handicaps DBA REACH, Inc.
Accessibility Improvements for Low
Income Residents $115,000.00
Fort Worth Area Habitat for Humanity, Inc. DBA
Trinity Habitat for Humanity Cowtown Brush Up Paint Program $455,000.00
Fort Worth Area Habitat for Humanity, Inc. DBA
Trinity Habitat for Humanity
Preserve-A-Home Program (Como
Neighborhood Improvement Strategy)$400,000.00
CDBG Subrecipient Agencies Total $970,000.00
TOTAL CDBG CONTRACTS $2,091,591.00
TABLE 2: HOPWA AGENCIES
AGENCY PROGRAM AMOUNT
Tarrant County
Samaritan Housing, Inc.
Supportive Services; Facility-Based Housing Operations; Tenant-
Based Rental Assistance; Administration $845,765.00
AIDS Outreach Center,
Inc.*
Short-Term Rent, Mortgage, and Utility Assistance; Supportive
Services; Administration $302,862.00
TOTAL HOPWA CONTRACTS $1,148,627.00
Housing Opportunities for Persons With AIDS Contracts
*The City has identified a potential conflict of interest under the HOPWA Regulations related to this award and is in the process of seeking a
waiver of the conflict of interest from HUD. A contract will not be executed with AIDS Outreach Center, Inc. unless and until the City receives
approval from HUD. In the event the City does not receive approval, an amended Action Plan will be submitted, as necessary, to address the
reallocation of the funds.
Emergency Solutions Grant Contracts
TABLE 3: ESG AGENCIES
AGENCY PROGRAM AMOUNT
The Presbyterian Night Shelter of Tarrant County, Inc.Shelter Operations/Services $130,315.00
Lighthouse for the Homeless DBA True Worth Place Shelter Operations/Services $177,000.00
The Salvation Army Homelessness Prevention $106,440.00
Center for Transforming Lives Rapid Re-Housing $100,000.00
SafeHaven of Tarrant County Shelter Operations/Services $70,960.00
TOTAL ESG CONTRACTS $584,715.00
All figures have been rounded to the nearest dollar for presentation purposes. These programs are available in ALL COUNCIL DISTRICTS.
FISCAL INFORMATION / CERTIFICATION:
The Director of Finance certifies that upon approval of the above recommendations and adoption of the attached appropriation ordinance, funds
will be available in the current operating budget, as appropriated, in the Grants Operating Federal Fund. The Neighborhood Services Department
(and Financial Management Services) will be responsible for the collection and deposit of funds due to the City. Prior to an expenditure being
incurred, the Neighborhood Services Department has the responsibility to validate the availability of funds. This is a reimbursement grant.
Submitted for City Manager's Office by: Fernando Costa 6122
Originating Business Unit Head:Victor Turner 8187
Additional Information Contact:Sharon Burkley 5785
Sean Stanton 5811