HomeMy WebLinkAboutContract 49724 CITY SECRETARY / (�
STATE OF TEXAS § CONTRACT N0.
COUNTIES OF TARRANT, WISE §
AND DENTON §
BOYS & GIRLS CLUBS OF GREATER FORT WORTH,INC.
SAFE HAVEN YOUTH PROGRAM—MARTIN
This Agreement is made between the City of Fort Worth("City"),a municipal corporation,
acting herein by and through Valerie R.Washington,its duly authorized Assistant City Manager,
and Boys&Girls Clubs of Greater Fort Worth,Inc.,("BGCGFW")acting by and through Daphne
Barlow Stigliano, its duly authorized CEO.
RECITALS
WHEREAS, City has determined that Safe Haven Youth Programs are necessary to
support the City's commitment to crime prevention throughout the City. The Safe Haven Youth
Programs will enhance the prevention focus previously adopted by the police department,support
the community,and provide a secure environment for children;and
WHEREAS, BGCGFW has agreed to operate a Safe Haven Youth Program which will
provide a secure environment in which children can receive educational tutoring assistance; and
support the adoption of a prevention focus by the police department and the community; and
WHEREAS, City desires to enter into an agreement with BGCGFW to operate the Safe
Haven Youth Program at their Martin Community Center("BGCGFW SITYP");and
WHEREAS, City, as consideration for the performance of BGCGFW, has appropriated
monies in the Crime Control and Prevention District ("CCPD") Fund Budget in the amount of
$307,015.00 ("Program Funds") to provide to BGCGFW on a reimbursement basis for the
operation of the BGCGFW SITYP subject to and in accordance with this agreement;
NOW, THEREFORE, in consideration of the mutual covenants herein expressed, the
parties agree as follows:
AGREEMENT DOCUMENTS
The Agreement documents shall include the following: QM 2 3 4 S
1. This Agreement for the BGCGFW SITYP
2. Exhibit A—Scope of Work CP
` REC do3. Exhibit B—Budget rIVE� o
4. Exhibit C—Request for Reimbursement o OCTQC2 2017
5. Exhibit D—Program Activities Report r- C1TyOF
6. Exhibit E—Program Effectiveness Measurement Report 0 Ql ,Ot RrwagrH
7. Exhibit F—Request for Budget Modification t-rAgy �a
9s
Exhibits A through F, which are attached hereto and incorporated here b & of this
Agreement for all purposes. In the event of any conflict between the terms and conditions of
OFFICIAL RECORD
BGCGFW SITYP FY 2018 CITY SECRETARY
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 1 of 24
FT.WORTH, TX ,
i
Exhibits A through F,and the terms and conditions set forth in the body of this Agreement,the
terms and conditions set forth in the body of this Agreement shall control.
DEFINITIONS
The term"City"shall include City,and its officers,agents,employees,and representatives.
The term"BGCGFW"shall include BGCGFW,and its officers,agents,employees,
representatives,servants,contractors,and subcontractors.
The term"Party"shall refer to either City or BGCGFW.
The term"Parties"shall refer to both City and BGCGFW.
AGREEMENT
1. Responsibilities of BGCGFW. BGCGFW covenants and agrees to fully perform, or
cause to be performed, with good faith and due diligence, all work and services described in
Exhibit"A"—Scope of Work. BGCGFW shall be responsible for day-to-day administration
of the BGCGFW SITYP. BGCGFW agrees to expend the Program Funds in accordance with
its BGCGFW SITYP budget, described in Exhibit `B"—Budget. Program activities shall be
reported in accordance with Exhibit "D" Program Activities Report and effectiveness
measurements shall be reported in accordance with Exhibit "E" Program Effectiveness
Measurement Report.
2. Program Funds.
2.1 In no event shall the total distribution from City made to BGCGFW during the
term of this Agreement exceed the total sum of$307,015.00("Program Funds").
2.2 Payment of the Program Funds from City to BGCGFW shall be made on a cost-
reimbursement basis following receipt by City from BGCGFW of a signed Request for
Reimbursement (RFR), as described in Exhibit "C," and copies of all receipts and support
documentation. BGCGFW shall deliver to City a written detailed Program Activities Report
and Program Effectiveness Measurement Report as described in Section 4.2 below with each
RFR to support expenditure of Program Funds. Such reports shall be signed by BGCGFW or
duly authorized officer of BGCGFW. The RFR and monthly Program Activities Report shall
be submitted to City no later than the 15'day following the end of the month. Submittal of a
monthly RFR and Program Activities Report is required even if services are not provided.
The monthly RFR with an original signature by an authorized representative must be submitted
to the to the Grant Management Section of the Fort Worth Police Department,ATTENTION:
Grant Specialist,Bob Bolen Public Safety Complex,505 W.Felix St.,Fort Worth,Texas,
76115.Reimbursements will not be made until after receipt of an acceptable and approved RFR
and a monthly Program Activities Report. Additionally, a quarterly Program Effectiveness
Measurement Report from BGCGFW is required as described in section 4.2 and must be
approved prior to reimbursements. Reimbursements shall be made within 30 days receipt of
said documents.
BGCGFW SITYP FY 2018
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2.3 BGCGFW is authorized to modify up to five(5)percent of any budgeted line-item
in the original approved budget without prior written permission from City. However,
BGCGFW must submit the Budget Modification Form(Exhibit"F")to City,with the monthly
RFR,in the month when the modification took place. The new modified budget cannot exceed
the total amount of Program Funds.
2.4 Any modifications of more than five(5)percent of any budgeted line-item in the
original approved budget must have prior written permission from City before any budget
modifications are made. The Budget Modification Form(Exhibit"F")must be submitted,and
request must be approved by City, before any money is moved to the line-item. Once the
Budget Modification is approved, the modified budget will take effect on the first day of the
following month. The new modified budget cannot exceed the total amount of Program Funds.
2.5 Any modifications to zero line-items in the original approved budget must have
prior written permission from City before any budget modifications are made. The Budget
Modification Form (Exhibit "F") must be completed and approved by City before money is
transferred into the new line-item. Once the Budget Modification is approved, the modified
budget will take effect on the first day of the following month. The new modified budget
cannot exceed the total amount of Program Funds.
2.6 Budget modification can only occur within the Direct and Indirect costs. Funds
may not be moved from a Direct line-item into an Indirect line-item, or vise versus.
Modification of Direct and Indirect approved budgets must follow the guidelines outlined in
sections 2.3,2.4 and 2.5.
The Budget Modification Form (Exhibit "F") shall be submitted to the Grant Management
Section of the Fort Worth Police Department, ATTENTION: Grant Specialist at Bob
Bolen Public Safety Complex at 505 W.Felix St.,Fort Worth,Texas,76115.
3. Term. This Agreement shall commence upon October 1, 2017 ("Effective Date"), and
shall end on September 30, 2018 ("End Date"). All of BGCGFW's expenditures under this
Agreement must be completed no later than September 30,2018.
4. Program Performance.
4.1 BGCGFW agrees to maintain full documentation supporting the performance of
the work and fulfillment of the objectives set forth in Exhibit"A."
4.2 BGCGFW agrees to provide a monthly Program Activities Report and quarterly
Program Effectiveness Measurement Report to document the performance of the work
described in Exhibit "D" and Exhibit `B," respectively. The Program Activities and
Effectiveness Measurements shall document the program activity names, numbers of
participants attending,details of the activities,and a description of the goals achieved in support
of the CCPD goals. Program Effectiveness Measurement shall be reported on a quarterly basis
and included in the January, April, July, and October RFR and Program Activities Report
submittals. Additionally, the Program Effectiveness Measurement Report must include any
successes realized in descriptive detail. The monthly Program Activities and quarterly Program
Effectiveness Measurement Reports shall be submitted to City no later than the 15'day after
the end of each month.
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4.3 BGCGFW agrees that the monthly RFR and Program Activities Report and
quarterly Program Effectiveness Measurement Report will be submitted to City no later than
the 151 day after the end of each month. Should BGCGFW not meet these requirements,
BGCGFW will be given an additional 15 days to submit the required reports to City. If,at the
end of this 15-day extension period, BGCGFW has not submitted the required reports, City
will send a non-compliance letter notifying BGCGFW's duly authorized representative of a
possible suspension of program funding.
5. Default and Termination.
5.1 This Agreement is wholly conditioned upon the actual receipt by City of Program
Funds from the CCPD. All monies distributed to BGCGFW hereunder shall be exclusively
from monies received from the CCPD, and not from any other monies of City. In the event
that funds from the CCPD are not received prior to the execution of this contract by the parties,
in whole or in part,City may,at its sole discretion,terminate this Agreement and City shall not
be liable for payment for any work or services performed by BGCGFW under or in connection
with this Agreement.
5.2 In the event no funds or insufficient funds are appropriated by the City in any fiscal
year for any payments due hereunder, City will notify BGCGFW 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 the City of any kind whatsoever,except as to the portions
of payments herein agreed upon for which funds have been appropriated.
5.3 This Agreement may be terminated by City, in whole or in part, at any time and
for any reason upon written notice as specified in section 5.4.
5.4 Termination will be effected by delivering to BGCGFW a notice of termination,
specifying the portion of the Agreement affected and the effective date of termination. Upon
BGCGFW's receipt of notice of termination, BGCGFW shall:
(a) Stop work under the Agreement on the date and to the extent specified in the notice of
termination;
(b) Place no further order or subcontracts, except as may be necessary for completion of the
work not terminated;
(c) Terminate all orders and contracts to the extent that they relate to the performance of the
work terminated by the notice of termination;and
(d) Cease expenditures of Program Funds, except as may be necessary for completion of the
work not terminated.
5.5 In the event City suspends or terminates this Agreement, BGCGFW expressly
waives any and all rights to monetary damages, including but not limited to actual,
consequential,and punitive damages,court costs,and attorney's fees.
5.6 Within thirty(30)days following the date of termination of this Agreement,BGCGFW
shall return to City any property provided hereunder.City will have no responsibility or liability
for BGCGFW's expenditures or actions occurring after the effective date of termination of the
Agreement.
BGCGFW SITYP FY 2018
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6. Equipment and Maintenance. All equipment purchased with Program Funds must meet
all eligibility requirements of City. BGCGFW shall maintain all equipment used in the
administration and execution of the BGCGFW SITYP. BGCGFW shall maintain, replace, or
repair any item of equipment used in support of the BGCGFW SITYP and/or for use under the
terms of this Agreement that no longer functions or is lost or stolen. The cost for maintenance,
replacement,or repair of any equipment used in support of the BGCGFW SITYP and/or for use
under the terms of this Agreement is the sole responsibility of BGCGFW. BGCGFW shall not
use Program Funds to repair or replace said equipment. BGCGFW shall use any and all
equipment purchased with Program Funds exclusively in support of the BGCGFW SITYP.
Within 10 days following the purchase of equipment,BGCGFW shall submit to City a detailed
inventory of all equipment purchased with Program Funds to the Grant Management Section
at the address set forth in paragraph 2.2 above. The equipment inventory shall include an
itemized description of each piece of equipment, the date each piece of equipment was
purchased,the cost of purchase for each piece of equipment,and the location of each piece of
equipment.
7. Administrative Requirements.
7.1 BGCGFW agrees to keep sufficient records to document its adherence to
applicable local, state, and federal regulations, along with documentation and records of all
receipts and expenditures of Program Funds. All records shall be retained for three(3)years
following the termination or completion of this Agreement. City or its representatives shall
have the right to investigate, examine, and audit at any time any and all such records relating
to operations of BGCGFW under this Agreement. BGCGFW, its officers, members, agents,
employees, and subcontractors, upon demand by City, shall make such records readily
available for investigation,examination,and audit. In the event of such audit by City,a single
audit of all BGCGFW's operations will be undertaken and may be conducted either by City or
an independent auditor of City's choice.BGCGFW shall submit a copy of any audit performed
by their independent auditor within 30 days of receipt of the final audit report.
7.2 If any audit reveals a questioned practice or expenditure, such questions must be
resolved within fifteen (15) days after notice to BGCGFW by City. If questions are not
resolved within this period,City reserves the right to withhold further funding under this and/or
future contract(s)with BGCGFW.
7.3 If,as a result of any audit,it is determined that BGCGFW misused,misapplied,or
misappropriated all or any part of the Program Funds,BGCGFW agrees to reimburse City the
amount of such monies so misused, misapplied, or misappropriated, plus the amount of any
sanction,penalty, or other charge levied against City because of such misuse,misapplication,
or misappropriation.
7.4 BGCGFW's obligation to City shall not end until all closeout requirements are
completed. Activities during this closeout period shall include, but are not limited to:
providing final Program Activities Report and Program Effectiveness Measurement Reports,
making final payments, disposing of BGCGFW SITYP assets as appropriate, if deemed
required by City in its sole discretion.
7.5 BGCGFW covenants and agrees to fully cooperate with City in monitoring the
effectiveness of the services and work to be performed by BGCGFW under this Agreement
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and City shall have access at all reasonable hours to offices and records of BGCGFW, its
officers,members, agents,employees, and subcontractors for the purpose of such monitoring.
Section 7 shall survive the expiration or termination of this Agreement.
8. Independent Contractor.
8.1 BGCGFW shall operate hereunder as an independent contractor and not as an
officer,agent,or servant or employee of City. BGCGFW 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, subcontractors, program participants,
licensees,or invitees. The doctrine of respondeat superior shall not apply as between City and
BGCGFW, its officers, members, agents, servants, employees, subcontractors, program
participants, licensees, or invitees, and nothing herein shall be construed as creating a
partnership or joint enterprise between City and BGCGFW.No federal, state, or local income
tax,nor any payroll tax of any kind,shall be withheld or paid by City on behalf of BGCGFW.
BGCGFW shall not be treated as an employee with respect to the services performed pursuant
to this Agreement for federal or state tax purposes. It is expressly understood and agreed that
officers,members,agents,employees,subcontractors,licensees,or invitees of BGCGFW,and
any program participants hereunder are not eligible for, and shall not participate in any
employer pension, health, or other fringe benefit plan provided by City. It is expressly
understood and agreed that City does not have the legal right to control the details of the tasks
performed hereunder by BGCGFW,its officers,members,agents,employees, subcontractors,
program participants,licensees,or invitees.
8.2 City shall in no way nor under any circumstances be responsible for any property
belonging to BGCGFW, its officers, members, agents, employees, subcontractors, program
participants, licensees, or invitees, which may be lost, stolen, destroyed, or in any way
damaged.
9. Liability and Indemnification.
BGCGFW SHALL BE LIABLE AND RESPONSIBLE FOR ANY AND ALL PROPERTY
LOSS,PROPER TYDAMAGE,AND/OR PERSONAL INJURY,INCL UDING DEATH, TO
ANY AND ALL PERSONS, OF ANY KIND OR CHARACTER, WHETHER REAL OR
ASSERTED, TO THE EXTENT CAUSED BY THE NEGLIGENT ACT(S) OR
OMISSION(S), MALFEASANCE, OR INTENTIONAL MISCONDUCT OF BGCGFW,
ITS OFFICERS,AGENTS,SERVANTS, OR EMPLOYEES.
BGCGFW AGREES TO DEFEND, INDEMNIFY, AND HOLD THE CITY, ITS
OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES HARMLESS AGAINST ANY
AND ALL CLAIMS,LAWSUITS,ACTIONS, COSTS,AND EXPENSES OF ANY KIND,
INCLUDING, BUT NOT LIMITED TO, THOSE FOR PROPERTY DAMAGE OR LOSS
(INCLUDING ALLEGED DAMAGE OR LOSS TO OWNER'S BUSINESS AND ANY
RESULTING LOST PROFITS) AND/OR PERSONAL INJURY(INCLUDING DEATH)
THAT MAY RELATE TO, ARISE OUT OF, OR BE OCCASIONED BY(I) BGCGFW'S
BREACH OF ANY OF THE TERMS OR PROVISIONS OF THIS AGREEMENT OR (II)
ANY NEGLIGENT ACT OR OMISSION OR INTENTIONAL MISCONDUCT OF
BGCGFW, ITS OFFICERS, AGENTS, ASSOCIATES, EMPLOYEES, CONTRACTORS
(OTHER THAN THE CITY), OR SUBCONTRACTORS RELATED TO THE
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PERFORMANCE OF THIS AGREEMENT, EXCEPT THAT THE INDEMNITY
PROVIDED FOR IN THIS SECTION SHALL NOT APPLY TO ANY LIABILITY
RESULTING FROM THE SOLE NEGLIGENCE OF THE CITY OR ITS OFFICERS,
AGENTS, EMPLOYEES, OR SEPARATE CONTRACTORS, AND IN THE EVENT OF
JOINT AND CONCURRENT NEGLIGENCE OF BOTH CONSULTANT AND CITY,
RESPONSIBILITY, IF ANY, SHALL BE APPORTIONED COMPARATIVELY IN
ACCORDANCE WITH THE LAWS OF THE STATE OF TEXAS. NOTHING HEREIN
SHALL BE CONSTRUED AS A WAIVER OF THE CITY'S GOVERNMENTAL
IMMUNITY AS FURTHER PROVIDED BY THE LAWS OF TEXAS.
BGCGFW shall require all of its subcontractors to include in their subcontracts a release and
indemnity in favor of City in substantially the same form as above.
This section shall survive the expiration or termination of this Agreement.
10. Non-Assignment. No assignment or delegation of duties under this Agreement by
BGCGFW shall be effective without City's prior written approval.
11. Prohibition Against Interest.
11.1 No member,officer,or employee of City,or its designees or agents;no member
of the governing body of the locality in which the BGCGFW SITYP is situated;and no other
public official of such locality or localities who exercises any functions or responsibilities
with respect to the BGCGFW SITYP during his tenure or for one year thereafter, shall have
any interest,direct or indirect, in any contract or subcontract,or the proceeds thereof,for
work to be performed hereunder. BGCGFW shall incorporate,or cause to be incorporated,
like language prohibiting such interest, in all contracts and subcontracts hereunder.
11.2 No officer, employee, member, or program participant of BGCGFW shall have a
financial interest, direct or indirect, in this Agreement or the monies transferred hereunder,or
be financially interested,directly or indirectly,in the sale to BGCGFW of any land,materials,
supplies, or services purchased with any funds transferred hereunder, except on behalf of
BGCGFW, as an officer,employee,member,or program participant. Any willful violation of
this paragraph with the knowledge, expressed or implied, of BGCGFW or its subcontractors,
shall render this Agreement voidable by City of Fort Worth.
12. Nondiscrimination.
12.1 In accordance with the federal, state, and local laws and ordinances, BGCGFW
covenants that neither it nor any of its officers, members, agents, employees, program
participants, or subcontractors, while engaged in performing this Agreement shall in
connection with the employment,advancement,or discharge of employees,in connection with
the terms, conditions or privileges of their employment, discriminate against persons because
of their age, except on the basis of a bona fide occupational qualification, retirement plan,
statutory requirement,or statutory or ordinance exception.
12.2 BGCGFW will not unlawfully discriminate against any person or persons because
of age, race, color, religion, sex, disability, national origin, or sexual orientation, nor will
BGCGFW permit its officers, members, agents, employees, subcontractors, or program
participants to engage in such discrimination.
BGCGFW SITYP FY 2018
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13. Compliance.
13.1 BGCGFW, its officers, members, agents, employees, program participants, and
subcontractors, shall abide by and comply with all laws, federal,state, and local,including all
ordinances,rules,and regulations of City. If City calls to the attention of BGCGFW in writing
any such violation on the part of BGCGFW or any of its officers,members,agents,employees,
subcontractors, or program participants, then BGCGFW shall immediately desist from and
correct such violation.
13.2 BGCGFW shall utilize Program Funds strictly for those purposes and goals
intended under the terms and conditions of this Agreement. If City calls the attention of
BGCGFW in writing to any such violations on the part of BGCGFW or any of its officers,
members, agents, employees, program participants, or subcontractors, then BGCGFW shall
immediately desist from and correct such violation.
14. Waiver of Immunity. If BGCGFW is a charitable or nonprofit organization and has or
claims an immunity or exemption (statutory or otherwise) from and against liability for
damages or injury,including death,to persons or property,BGCGFW hereby expressly waives
its rights to plead defensively such immunity or exemption as against City. This section shall
not be construed to affect City's immunities under constitutional, statutory,or common law.
15. Insurance Requirement.
15.1 BGCGFW shall procure and shall maintain during the term of this Agreement the
following insurance coverage:
(a) Commercial General Liability(CGL): $1,000,000 per occurrence,with a$2,000,000.00
annual aggregate limit,in a form that is acceptable to the City's Risk Manager.
(b) Non-Profit Organization Liability or Directors & Officers Liability: $1,000,000 per
occurrence,with a$1,000,000 annual aggregate limit,in a form that is acceptable to the
City's Risk Manager.
(c) Automobile Liability: $1,000,000 each accident on a combined single limit basis OR
split limits are acceptable if limits are at least $250,000 Bodily Injury per person,
$500,000 Bodily Injury per accident and$100,000 Property Damage.
(d) Any other insurance the City may reasonably require to protect the interests of the City.
15.2 BGCGFW's insurer(s)must be authorized to do business in the State of Texas for
the lines of insurance coverage provided and be currently rated in terms of financial strength
and solvency to the satisfaction of the City's Risk Manager.
15.3 Each insurance policy required herein shall be endorsed with a waiver of
subrogation in favor of the City. Each insurance policy required by this Agreement,except for
policies of worker's compensation or accident/medical insurance shall list the City as an
additional insured. City shall have the right to revise insurance coverage requirements under
this Agreement.
15.4 BGCGFW further agrees that it shall comply with the Worker's Compensation Act
of Texas and shall provide sufficient compensation insurance to protect BGCGFW and City
from and against any and all Worker's Compensation claims arising from the work and services
provided under this Agreement.
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15.5 The commercial general liability policy shall name the City as an additional insured
thereon,as its interests may appear.
15.6 A minimum of Thirty(30)days'notice of cancellation or reduction in limits of coverage
shall be provided to the City. Ten (10) days' notice shall be acceptable in the event of non-
payment of premium. Notice shall be sent to the Risk Manager,City of Fort Worth,200 Texas
Street,Fort Worth,Texas 76102,with copies to the City Attorney at the same address.
15.7 Any failure on the part of the City to request required insurance documentation shall not
constitute a waiver of the insurance requirement.
15.8 Certificates of Insurance evidencing that the BGCGFW has obtained all required
insurance shall be delivered to the City prior to BGCGFW proceeding with any work pursuant
to this Agreement.
16. Miscellaneous Provisions.
16.1 The provisions of this Agreement are severable, and, if for any reason a clause,
sentence,paragraph,or other part of this Agreement 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.
16.2 City's failure to insist upon the performance of any term or provision of this
Agreement or to exercise any right herein conferred shall not be construed as a waiver or
relinquishment to any extent of City's right to assert or rely upon any such term or right on any
future occasion.
16.3 Should any action, whether real or asserted, at law or in equity, arise out of the
execution,performance,attempted performance,or non-performance of this Agreement,venue
for said action 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.
16.4 BGCGFW 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
Agreement and to perform the responsibilities herein required.
16.5 This written instrument, including Exhibits A through F, constitutes the entire
agreement between the parties concerning the work and services to be performed hereunder,
and any prior or contemporaneous oral or written agreement which purports to vary from the
terms hereof shall be void. Any amendments to the terms of this Agreement must be in writing
and must be signed by authorized representatives of each party.
16.6 All notices required or permitted by this Agreement must be in writing and are
deemed delivered on the earlier of the date actually received or the third day following (i)
deposit in a United States Postal Service post office or receptacle; (ii) with proper postage
(certified mail,return receipt requested);and(iii)addressed to the other party at the address as
follows or at such other address as the receiving party designates by proper notice to the sending
ply:
CITY: Valerie R.Washington,Assistant City Manager
BGCGFW SITYP FY 2018
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City Manager's Office
City of Fort Worth
200 Texas Street
Fort Worth,TX 76102
Copies To: Grant Management Section
Bob Bolen Public Safety Complex
505 W.Felix St.
Fort Worth,TX 76115
City Attorney's Office
ATTN: Police Contracts
200 Texas Street
Fort Worth,TX 76102
BGCGFW: James Newson,Chief Operations Officer
Boys&Girls Clubs of Greater Fort Worth
3218 E.Belknap St.
Fort Worth,TX 76111
16.7 None of the performance rendered under this Agreement shall involve, and no
portion of the Program Funds received hereunder shall be used, directly or indirectly, for the
construction, operations, maintenance, or administration of any sectarian or religious facility
or activity, nor shall said performance rendered or funds received be utilized so as to benefit,
directly or indirectly, any such sectarian or religious facility or activity.
16.8 Captions and headings used in this Agreement are for reference purposes only and
shall not be deemed a part of this Agreement.
16.9 The provisions and conditions of this Agreement are solely for the benefit of City
and BGCGFW and are not intended to create any rights,contractual or otherwise,to any other
person or entity.
16.10 The parties acknowledge that each party and its counsel have reviewed this
Agreement and that the normal rules of construction to the effect that any ambiguities are to be
resolved against the drafting party shall not be employed in the interpretation of this Agreement
or exhibits hereto.
16.11 City actively supports the Immigration & Nationality Act (INA) which includes
provisions addressing employment eligibility, employment verification, and
nondiscrimination. Contractor shall verify the identity and employment eligibility of all
employees who perform work under this Agreement. Contractor shall complete the
Employment Eligibility Verification Form (1-9), maintain photocopies of all supporting
employment eligibility and identity documentation for all employees, and upon request,
provide City with copies of all 1-9 forms and supporting eligibility documentation for each
employee who performs work under this Agreement. Contractor shall establish appropriate
procedures and controls so that no services will be performed by any employee who is not
legally eligible to perform such services.Contractor shall provide City with a certification letter
that it has complied with the verification requirements required by this Agreement. To the
extent allowed by law, Contractor shall indemnify City from any penalties or liabilities due to
BGCGFW SITYP FY 2018
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violations of this provision.City shall have the right to immediately terminate this Agreement
for violations of this provision by Contractor.
16.12 It is understood that by execution of this Agreement,the City does not waive or surrender
any of it governmental powers.
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[SIGNATURE PAGE TO FOLLOW]
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IN WITNESS WHEREOF,the parties hereto ha�Xay
uted this a ee ent in multi s in Fort
Worth,Tarrant County,Texas,to be effective this of 2Q
APPROVED AND AGREED FOR CITY APPROVED AND AGREED FOR BOYS&
OF FORT WORTH GIRLS CLUBS OF GREATER FORT
WORTH
Valerie R.Washington _0•jj� X*4.✓ 41604�
Assistant City Manager Daphne_arlow Stigliano
CEO
Date: ���(��
Date: q
APP VAL RECOMMENDED
APPROVED AS TO FORM AND
LEGALITY FOR BOYS AND GIRLS
1�✓Chief"JoV F. Fitzgerald CLUBS OF GREATER FORT WORTH
Chief of Police
Date: BGCGFW Attorney
APPROVED AS TO FORM AND ORT
LEGALITY FOR CITY OF FORT Date:
WORT
U
ATTEST
Vstn Pa ............••ant City Attorney
ary J. KT
Date: 611" 02-7 Citv Secret _
Form 1295 Certification No: 2017-250323 Date:
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.
Na ie
Title
w� -1— OFFICIAL RECORD
CITY SECRETARY
FT.WORTH,TX
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 12 of 24
EXHIBIT A
SCOPE OF WORK
The Scope of Work is to be performed and documented in compliance with the monthly
program activities and quarterly effectiveness measurement reports outlined in exhibits D
and E.
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 13 of 24
Exhibit B
BUDGET NARRATIVE FY 2018
Please attach a detailed budget narrative that explains the need for all proposed expenditures by
individual item. The budget narrative should clearly explain how funds will be used and why
expenditures are necessary for successful implementation of your program. Please explain how costs
are calculated.
DIRECT COSTS—Total$276,314.00
A. Program Personnel—Total$193,375.93
Branch Director—The Branch Director has direct daily contact with participants and oversees
program staff to insure implementation of programs and activities designed to maximize program
outcomes. 100%of the Branch Director's time and efforts are spent at this location.
($53,581.00 @ 100% _$53,581.00)
Other Program Staff—Other Program Staff are directly involved with participants in the
program or maintenance of the program site on a daily basis. Activity Leaders provide program
participants with instruction and lead participants in educational,health,social,and cultural
activities. Other Program Staff also provide transportation to the facility from school for
participants.
Education Specialist($33,309.12 @ 100%_$33,309.12)
Activity Leader(Asst.Healthy Lifestyles)($10.00/hr. @1,365 hrs._$13,650.00)
Teen&Early Intervention Specialist($10.20/hr. @ 1,040 hrs._$10,608.00)
Activity Leader(Asst. Education)($10.20/hr. @ 1,365 hrs._$13,923.00)
Activity Leader(Culture and Art)($11.04/hr. @ 1,384 hrs. _$15,279.36)
Activity Leader(Social Development)($10.40/hr.@ 1,365 hrs._$14,196.00)
Front Desk Specialist($11.38/hr. @ 1,365 hrs._$15,533.70)
After School Driver($10.00/hr. @ 220 hrs._$2,200.00)
After School Driver($10.00/hr. @ 555 hrs._$5,550.00)
Janitor II($12.13/hr. @ 1,040 hrs._$12,615.20)
Activity Leader($10.00/hr. @ 1,365 hrs._$13,650.00)
Activity Leader($10.00/hr. @ 1,365 hrs._$13,650.00)
Activity Leader Summer($10.00/hr. @ 200 hrs._$2,000.00)
Vacancy Allowance—During the program year vacancies in staff positions will occur. The
current staff vacancy rate is estimated for the program year at 12%. Budgeted program salaries
are reduced by this amount. ($219,745.38 X-12% _($26,369.45))
B. Fringe Benefits—Total$27,793.26
FICA—7.65%of the portion of the above listed salaries allocated to this program are budgeted in
this line item. (7.65% X$193,375.93)_$14,793.26)
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 14 of 24
Health, Dental,Vision Insurance—(2 FTE @$6,500.00/yr.=$13,000.00)
C. Travel and Training—To provide program staff and participants travel for supplies,
training,trips to administration building, and field trips—Total$22,210.00
Mileage(Vehicle Operating)—Staff mileage for supplies,to and from admin building,other
program related travel. (375 miles/mo. X 12 mo. X.535=$2,407.50)
Participant Travel—Member travel/training/field trips/field trip entry fees. ($272.50 @
100%).
Staff Travel/Training—Staff meals and travel to and from training and training expense.
($3,000.00 @ 100%)
Bus Mileage -($1.74 per mile @ 9,500 miles per year=$16,530.00) Buses are used to
transport program participants from school to the program site and are essential to the successful
achievement of program goals. Without access to transportation many students in the program
would be unable to participate in program activities. Operation of buses from the school sites to
the program sites occur during peak traffic hours. In order to be available to participants and to
provide them with a comfortable environment while waiting for other participants arrive,buses are
deployed early and are typically left running,depending on weather conditions. All of these
circumstances increase the fuel and maintenance costs associated with providing bus service to
program participants. Costs included in the mileage rate in this budget include fuel costs,bus
insurance costs for the specific buses assigned to the program,and a conservative estimate of
average bus repair costs for the buses specifically assigned to the program. Depreciation expense
is not included in the mileage rate calculation.
D. Equipment
E. Supplies-To provide materials and supplies needed to conduct the program,
perform direct program administrative tasks, track participant attendance, and
track program effectiveness—Total$26,334.81
Office Supplies—Background and employment screening,drug screening,job posting fees,
pens,pencils,pencil lead refills,erasers,highlighters,paper,staplers, staple removers,scissors,
letter openers,tape dispensers,tape,staples,notepads,notebooks,binders,post-it notes,calendars,
paper clips,tissues,toner/ink cartridges,hand sanitizers, folders, files,desk organizers. Office
furniture and equipment(less than$5,000.00 cost)for direct program staff including office chairs,
desks,file cabinets,storage cabinets, computers,software,keyboards,monitors,replacement parts,
charge cords,calculators. ($7,500.00 @ 100% =$7,500.00).
Postage—($50.00 @ 100%)
Printing—Advertising,brochures,event promotions,schedules,communications with parents.
($50.00 @ 100%).
Food Supplies—Participant/Direct Staff meals and snacks,drinks ($2,000.00 @ 100%)
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 15 of 24
Teaching Aids/Program Supplies—Program supplies will include the following: Computer
software for academic studies,attendance tracking,and program effectiveness measurement;
Security camera system maintenance,game consoles and supplies,community service supplies,
education room supplies,athletic equipment and event entry/participation fees; Sports equipment,
books,videos,and classroom computers,monitors,and operating systems;Classroom and
lunchroom furniture used by program participants;Paint,paint brushes,paper,scissors,pencils,
pens,markers,glue,and craft materials. ($16,734.81 @ 100%)
F. Contracts/Consultants r...Total $6,600.00
Copier Lease—($100.00/mo.X 12 =$1,200.00 @ 100%)
Referees—Throughout the program year referees are contracted to officiate program sporting
events. ($50/hr.X 9/hrs._ $450.00 @ 100%)
IT Contract Labor—Routine IT repairs and maintenance for education&teen room
computers,direct staff computers,and other IT infrastructure at the program site are contracted at
$25.00/hr. ($25.00/hr.X 198 hrs. _$4,950.00 @ 100%)
G. Other Approved Expenses
INDIRECT COSTS—Total$30,701.00
A. Personnel
B. Fringe Benefits
C. Travel & Training
D. Equipment
E. Supplies
F. Contracts/Consultants-Total $3,575.00
Audit-Audit fees for annual independent audit to assure sound financial practices,procedures,
and internal controls. ($35,500.00 @ 5% _$1,775.00)
Professional Fees—Accounting and HR employee tracking/hiring/allocation software billed per
active program employee. ($150.00/month X 12 months=$1,800.00)
G. Other Approved—Total$27,126.00
Electricity—Comin' Up program staff and participants occupy the program site for 50%of total
operating hours for nine months of the year and 31%of their total operating hours for three
months of the year. 70%of electric service cost will be charged to the Save Haven program.
($1,285.71 X 70% =900.00/mo. X 12 mos._$10,800.00)
Gas—Comin' Up program staff and participants occupy the program site for 50%of total
operating hours for nine months of the year and 31%of their total operating hours for three
months of the year. 70%of gas service cost will be charged to the Safe Haven program. ($285.71
X 70% _$200.00/mo.X 12 mos. _$2,400.00)
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 16 of 24
Water& Sewer—Comin'Up program staff and participants occupy the program site for 50%
of total operating hours for nine months of the year and 31%of their total operating hours for three
months of the year. 70%of water&sewer service cost will be charged to the Safe Haven
program. ($571.43 X 70% = $400.00/mo.X 12 mos. =$4,800.00)
Building Maintenance—Comin' Up program staff and participants occupy the program site for
50%of total operating hours for nine months of the year and 31%of their total operating hours for
three months of the year. 70%of building maintenance costs will be charged to the Safe Haven
program. Building maintenance costs will include lawn care in addition to repairs conducted to
maintain a safe,secure,sanitary, functional,and comfortable environment for program
participants. ($1,086.43 X 70% =$760.50/mo.X 12 mos. =$9,126.00)
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 17 of 24
Exhibit B
Budget Summary
Fiscal Year 2018
DIRECT PROGRAM COSTS(90%Minimum) Total $276,314.00
A. PERSONNEL
Salaries 193,375.93
PERSONNEL TOTAL: $193,375.93
B. FRINGE BENEFITS
FICA $14,793.26
Health Insurance $13,000.00
FRINGE BENEFITS TOTAL $27,793.2.6
C.TRAVEL AND TRAINING
Mileage $2,407.50
Participant Travel $272.50
Staff Travel/Training $3,000.00
Bus Mileage $16,530.00
TRAVEL AND TRAINING TOTAL $22,210.00
D.EQUIPMENT
None
EQUIPMENT TOTAL $0.00
E.SUPPLIES
Office Supplies $7,500.00
Postage $50.00
Printing $50.00
Food Supplies $2,000.00
Teaching Aids/Program Supplies $16,734.81
SUPPLIES TOTAL $26,334.81
F.CONTRACTS/CONSULTANTS
Copier Lease $1,200.00
Referees $450.00
IT Contract Labor $4,950.00
CONTRACTS/CONSULTANTS TOTAL $6,600.00
G. OTHER APPROVED
FACILITY AND UTILITIES—PROGRAM SITE:
None
OTHER APPROVED TOTAL $0,00
INDIRECT PROGRAM COSTS(30%,Maximum) Total $30,701.00
A.PERSONNEL
None
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 18 of 24
PERSONNEL TOTAL: $0..00
B.FRINGE BENEFITS
None
FRINGE BENEFITS TOTAL $0.00
C.TRAVEL AND TRAINING
None
TRAVEL AND TRAINING TOTAL $0.00
D.EQUIPMENT
None
EQUIPMENT TOTAL $0.00
E.SUPPLIES
None
SUPPLIES TOTAL $0.00
F.CONTRACTS/CONSULTANTS
Audit $1,775.00
Professional Fees $1,800.00
CONTRACTS/CONSULTANTS TOTAL $3,575.00
G. OTHER APPROVED
Program Site Electricity $10,800.00
Program Site Gas $2,400.00
Program Site Water&Sewer $4,800.00
Program Site Building Maintenance $9,126.00
OTHER APPROVED TOTAL $27,126.00
GRAND TOTAL $307,015.00
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 19 of 24
FORT WORTH Exhibit C
Request for Reimbursement(RFR)
FY 2018
CRIML CON 17ROL
AND PREVEY110N DISTRICT
Boys&Gids Club of Greater Fort
Submit To: Submitting Agency: Worth-Safe Haven
Bob Bolen Public Safety Complex Contact Name: Bob Ehret
Atte: Brittany Taylor
Financial Management Division Phone Number: 817-8344711 ext 211
505 West Felix St. Email behret0fortworthkids.ora
Fort Worth,TX 76115 Remit Address: 3218 E Belknap Fort Worth,TX 76111
Invoice Number:
Month ofRequest:
DIRBUr COSTS(90%Minimum)
A B C D E
Total or PreviousThis B+C) (A-D)Budget Category Budget Amount ReimbursemenU Requestquest
'Total Requested Remaining Balsam
Requested To-Date Available
A Personncl S 193,375.93 $ - $ 193,375.93
B Fringe Benefits S 27,793.26 $ - $ 27,793.26
"` ITmvel&Training S 22,210.00 $ - $ 22,210.00
Equipnl nt $ $ $
Suppiica $ 26,334.81
F Contracts Consultants $ 61600.00
Total Direct Costs S 276,314.00 S S S S 276,314.00
INDUUD[7rCOSTS(10%;1laaimum)
A B C D E
Total or PreviousThis Month's B+C (A-D?
Budget Category Budget Amount Reimbursements Total Requested Remaining Balsam
Requested Request To-Date Available
A Personncl $ - $ $
B Fringe Benefits S - $ - $
C Travel&Training S $ - S -
D Equipment S $ - S -
E Supplies S - $ - $ -
F Contracts Consultants $ 3,575.00 $ - $ 3,575.00
G Other ApprovedS 27,126.00 $ S 27,126.00
Total lnDirectCosts $ 30701.00 $ $ $ $ 30,701.00
Supporting documents required with monthly requests. ms
This includes,timesheets depietmgCCPD funded activities, Total Budget: $ 307,015.00
copy of paychecks,invoices and receipts detailing all CCPD Previous Requests: S
funded expenditures. This Request: S
Total Requested To-Date S
Remaining Funds S 307,015.00
1 have reviewed this request and certify that these listed expenses and support documentation are accurate.
Authorized Signatory Signatory Tile Date
FiscalA ent Use Only
Purchase Order q Fund Dept ID Aceount
RFR Approwd For Paywent
.- —..._.-----
_........._-.�..._.
Grant Staff Signature Date
Finance Received Startup Placed Below
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 20 of 24
Exhibit D
Fiscal Year 2018
Monthly Program Activities Report
Current Reporting Month
Submitting Agency Boys &Girls Clubs of Greater Fort Worth
Contact Name Matthew Sinclair
Phone Number and Email msinclair@fortworhtkids.org
Remit Address 3218 E. Belknap St. Ft. Worth,TX. 76111
Activity Current To Date Year End
Month Total Goal
Total
1 Total Unduplicated Participants 750
2 Power Hour- number of participant visits in power hour/homework help. 25,000
3 Literacy- number of participant visits in literacy activities. 12,000
4 STEM - number of participant visits in STEM (Science,Technology, 12,000
Engineering& Math) activities. Example: Engineering team competitions.
5 Daily Challenges/Exercise- number of participant visits in daily physical 33,000
challenges/exercise.
6 Healthy Habits/Nutrition - number of participant visits in healthy 10,000
habits/nutrition activities.
7 Practices/Clinics- number of participant visits in sports practices/clinics. 8,000
8 Character& Leadership-number of participant visits in Leadership Clubs 3,000
including Keystone,Torch,Triple Play and Junior Staff.
9 High Yield Learning Activities-number of participant visits in high yield 12,000
learning activities.
I have reviewed this report and certify that the measures provided are accurate and appropriately
reflect the CCPD goals set forth in the contract.
Authorized Signatory Signatory Title Date
BGCGFW S14YP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 21 of 24
Exhibit E
Fiscal Year 2018
Quarterly Program Effectiveness Measurement Report
Current Reporting Quarter
Submitting Agency Boys&Girls Clubs of Greater Fort Worth
Contact Name Matthew Sinclair
Phone Number and Email msinclair@fortworthkids.org
Remit Address 3218 E. Belknap St.
Ft. Worth,TX. 76123
Please include outcome narrative that describes how measure was accomplished for each
quarter.
Effectiveness Measures and Quarterly Outcomes
Measure 1 Average Daily Attendance(ADA) is 200 members per day.
Outcome
Measure 2 Average Daily Attendance(ADA)for members between the ages of 13—18 is 40 members per day.
Outcome
Measure 3 50%of members reach an annual goal of 52 visits per year.
Outcome
Measure 4 85%of members progress to the next school grade on time(measured annually)
Outcome
Measure 5 50%of overall membership is made up of renewing members.
Outcome
I have reviewed this report and certify that the measures provided are accurate and appropriately reflect the
CCPD goals set forth in the contract.
Authorized Signatory Signatory Title Date
Report due each quarter: 111 Quarter(Oct-Dec)due January 15 2nd Quarter(Jan-Mar)due April 15
3rd Quarter(Apr-June)due July 15 4"'Quarter(Jul-Sep)due October 15
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 22 of 24
• Up to 5%of any budgeted line-item does not need prior approval but form must be sent to City
with monthly RFR
• More than 5%of any budgeted line-item must have prior City approval
• An increase in a zero line-item must have prior City approval
• Modifications cannot be made between Direct and Indirect costs
Exhibit F
Request for Budget Modification
Fiscal Year 2018
Date
Submitting Agency Submitting Agency
Contact Name Matthew Sinclair
Phone Number and Email msinclair@fortworhtkids.org
Remit Address 3218 E. Belknap St. Ft.Worth,TX. 76111
DIRECT COSTS(90%minimum)
Budget Category Approved Budget Change Requested Revised Budget
Personnel
Fringe Benefits
Travel and Training
Equipment
Supplies
Contracts/Consultants
Other Approved
Total Direct Costs
INDIRECT COSTS(10%maximum)
Budget Category Approved Budget Change Requested Revised Budget
Personnel
Fringe Benefits
Travel and Training
Equipment
Supplies
Contracts/Consultants
Other Approved
Total Indirect Costs
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 23 of 24
Modification Narrative (describe in detail what change is for)
I have reviewed this request and certify that the listed modifications are correct.
Authorized Signatory Signatory Title Date
FWPD STAFF USE ONLY
❑ Modification Approved ❑ Modification NOT Approved
FWPD Staff Signature Date
BGCGFW SITYP FY 2018
City of Fort Worth and Boys&Girls Clubs of Greater Fort Worth Page 24 of 24
M&C Review Page 1 of 2
Official site of the City offcQ Fort Worth,oh,�h,Texas
f
CITY COUNCIL AGENDA
oRTH
REFERENCE ** 35BOYS AND GIRLS CLUB
DATE: 9/26/2017 NO.: C-28401 LOG NAME: SAFE HAVEN YOUTH
PROGRAM FY18
CODE: C TYPE: CONSENT PUBLIC NO
HEARING:
SUBJECT: Authorize Execution of a Contract with the Boys and Girls Clubs of Greater Fort Worth,
Inc., in the Amount of$307,015.00 for the Operation of a Safe Haven Youth Program at the
Boys and Girls Club Martin Branch Located at 3123 Avenue G for Fiscal Year 2018 (CCPD
Funded) (COUNCIL DISTRICT 8)
RECOMMENDATION:
It is recommended that the City Council authorize the execution of a Contract with the Boys and Girls
Clubs of Greater Fort Worth, Inc., in the amount of$307,015.00 for the operation of a Safe Haven
Youth Program at the Boys and Girls Club Martin Branch, located at 3123 Avenue G for Fiscal Year
2018.
DISCUSSION:
Youth Safe Havens are places where children in targeted neighborhoods can play and learn with
other children without fear of being victims of a crime. The original Safe Haven Program was
operated in the southeast part of Fort Worth and was later expanded to other neighborhoods in Fort
Worth. The Boys and Girls Clubs of Greater Fort Worth, Inc., provides a Youth Safe Haven Program
for youth living within a five-mile radius of the Boys and Girls Club Martin Branch, located at 3123
Avenue G.
The program strives to offer character and leadership development, educational activities, cultural
arts, health and life skills, and recreational opportunities. Program Staff address any additional
educational, social, psychological, and physical needs that the youth may have. Program Staff
provide the youth with the tools they need to become responsible adults.
This Agreement will be effective October 1, 2017, and will end on September 30, 2018.
This program serves COUCNIL DISTRICT 8.
FISCAL INFORMATION/CERTIFICATION:
The Director of Finance certifies that, contingent upon adoption of the Fiscal Year 2018 Budget by
City Council, funds will be available in the Fiscal Year 2018 Budget of the Crime Control and
Prevention District Fund and the Police Department is responsible for verifying the availability of
funds prior to an expenditure being made.
TO
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year Chartfield 2
FROM
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year Chartfield 2
http://apps.cfwnet.org/council_packet/mc review.asp?ID=25063&councildate=9/26/2017 9/27/2017
01 M&C Review Page 2 of 2
Submitted for City Manager's Office by: Valerie Washington (6199)
Originating Department Head: Joel Fitzgerald (4231)
Additional Information Contact: Tiffany Moore (4223)
ATTACHMENTS
HB1295 SH Boys and Girls.pdf
http://apps.cfwnet.org/council_packet/mc review.asp?ID=25063&councildate=9/26/2017 9/27/2017
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CERTIFICATE OF INTERESTED PARTIES
FORM 1295
l of l
Complete Nos.l-4 and a if there are Interested parties. OFFICE USE ONLY
Complete Nos.1,P,3.5.and 6 If there are no Interested parties. CERTIFICATION OF FILING
I Nome of business entity filing form,and the city,state and country of the business entlWs place Certificate Number:
of business. 2017-250323
Boys&Girls Clubs of Greater Fort Worth
Fort Worth,TX United Stales Date Filed:
2 Nameo governmental entity or state agency that Is a party to the contract for whia t e orm s 08/16/2017
Ming riled.
City of Fort Worth,TX Date Acknow dge
3 Provide the Identification number used by the governmental entity or slate agency to track or Identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
FY 18 CCPD Program
Sate Haven Youth Program
4 Nature of Interest
Name of Interested Party qty,State,Country(place of business) (check applicable)
Controlling Intermediary
S Check only if there is NO Interested Party. ❑
X
6 AFFIDAVIT
-tsw,u.o,u..sz I swear,or aflfrm,under penalty of er{ury,that the above disclosure Is true and correct.
RBBECCAJ.MMO
(S"
Notary Public
- "++e STAnOFTBXAS
o� My Comm Esp_A jril 16,20111 1 8
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP/SEAL ABOVE �r�--
Sworn to and subscribed before me,by the said 4�4r'A rt` this The,�day of
20 to certify which,witness my hand and seal of office.
I b4l a&= - Xr,#W-0 A
Signature of officer a stering oath Printed name of officer administering oath Title of officer admin' tering oath
Forms provided by Texas Ethics Commission www.ethics.state.ix.us Version V1.0.883