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HomeMy WebLinkAboutContract 49972 5 6 7 8 CITY SECRETARY mg �► ����STATE OF TEXAS § CONTRACT NO. a ��G ,�OUNTY OF TARRANT § a *p <§�3 This contract ("Contract") is made and entered into by and between the City of Fort Worth 0V lle�after"City") and Tarrant County Samaritan Housing, Inc. (hereafter"Agency"), a Texas non- 611 9 : x' tt corporation. City and Agency may be referred to individually as a"Party"and jointly as"the Parties". The Parties state as follows: WHEREAS, City receives grant monies from the United States Department of Housing and Urban Development through the Housing Opportunities for Persons with AIDS Program ("HOPWA") Program, Program No. TX-H-17-17002, Catalog of Federal Domestic Assistance No. 14.241; WHEREAS, the HOPWA program is intended to address the needs of eligible persons associated with the challenge of living with HIV/AIDS and their families; WHEREAS, Agency submitted a proposal to use HOPWA funds for an eligible program under the HOPWA Regulations whereby Agency will provide services to low and moderate income persons; WHEREAS,City citizens,the Community Development Council,and the City Council have determined that HOPWA programs are needed by the City's citizens; NOW, THEREFORE,the Parties understand and agree as follows: 1. INCORPORATION OF RECITALS City and Agency hereby agree that the recitals set forth above are true and correct and form the basis upon which the Parties have entered into this Contract. 2. DEFINITIONS In addition to terms defined in the body of this Contract,the terms set forth below shall have the definitions ascribed to them as follows: Area Median Income or AMI means the median family income for the Fort Worth-Arlington metropolitan statistical area as established annually by HUD. The 2017 income limits are attached hereto as EXHIBIT "A-1"—2017 HUD Income Limits. Business Diversity Enterprise Ordinance or BDE means the City's Business Diversity Ordinance, Ordinance No. 20020-12-2011. Complete Documentation means the following documentation as applicab HOPWA PSA CONTRACT 2017-2018 r Tarrant County Samaritan Housing,Inc. Rev.9.22.10 7 • Attachments I,II,and III,with supporting documentation including: o Proof of expense: copies of timesheets, invoices, leases, service contracts or other documentation showing that payment is due by Agency. o Proof of payment: cancelled checks, bank statements, or wire transfers necessary to demonstrate that amounts due by Agency were actually paid by Agency. o Proof of client eligibility: Source Documentation sufficient to show that clients participating in the Program are HOPWA Eligible Clients as described in Section 6. • Complete Documentation shall meet the standards described in the attached EXHIBIT "F"- Standards for Complete Documentation. • Any other document or record reasonably necessary to verify costs spent and client eligibility for the Program. DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26. Director means the Director of the City's Neighborhood Services Department. Effective Date means October 1, 2017. HOPWA means Housing Opportunities for Persons with AIDS. HOPWA Eligible Client means a client whose annual income adjusted for family size does not exceed 80% of AMI using the most current HUD Income Guidelines and Technical Guidance for Determining Income and Allowances verified by Source Documentation. The client must also have a documented diagnosis of HIV/AIDS. HOPWA Funds means the HOPWA grant funds supplied by City to Agency under the terms of this Contract. HOPWA Regulations means regulations found at 24 CFR Part 574 et seq. HUD means the United States Department of Housing and Urban Development. IDIS means Integrated Disbursement Information System,HUD's project tracking system. Neighborhood Services Department means the City's Neighborhood Services Department. OMB means the Office of Management and Budget. Program means the services described in EXHIBIT"A"—Program Summary. Reimbursement Request means all reports and other documentation described in Section 9. Source Documentation means documentation of full household income of any type described under the definition of annual income in 24 CFR Part 5.609, including but not limited to copies of HOPWA PSA CONTRACT 2017-2018 Page 2 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 paychecks, Social Security and disability verification letters, interest or rental income statements, retirement income statements, child support and alimony verification,unemployment benefit letters, and the like. Unduplicated Clients means a count of HOPWA Eligible Clients served at least once in the Contract Term. HOPWA Eligible Clients served more than once in the Contract Term will only be counted the first time they are served when determining the total count of Unduplicated Clients. 3. TERM. The term of this Contract begins on the Effective Date and terminates on September 30, 2018 unless earlier terminated as provided in this Contract. 4. DUTIES AND RESPONSIBILITIES OF CITY. 4.1 Provide HOPWA Funds. City shall provide up to $523,343.54 of HOPWA Funds under the terms and conditions of this Contract. 4.2 Monitor. City will monitor the activities and performance of Agency and any of its contractors, subcontractors or vendors as necessary,but no less than annually. Monitoring by City will include determining whether Agency is meeting the requirements of the HOPWA Regulations during the term of this Contract. 5. DUTIES AND RESPONSIBILITIES OF AGENCY. 5.1 Required Services. Agency shall perform the services described in EXHIBIT "A" — Program Summary in accordance with the terms and conditions of this Contract. 5.2 Use of HOPWA Funds. 5.2.1. Compliance with HOPWA Regulations and Contract. Agency shall be reimbursed for eligible Program costs with HOPWA Funds only if City determines in its sole discretion that: 5.2.1.1 Costs are eligible expenditures in accordance with HOPWA Regulations. 5.2.1.2 Costs are in compliance with this Contract and are reasonable and consistent with industry norms. 5.2.1.3 Complete Documentation, as applicable, is submitted to City by Agency. 5.2.2 Budget 5.2.2.1 The HOPWA Funds will be paid on a reimbursement basis in accordance with EXHIBIT"B"-Budget. HOPWA PSA CONTRACT 2017-2018 Page 3 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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 1,2018. 5.2.3 Change in Program Budget. 5.2.3.1 Agency will notify City promptly of any additional funds it receives for operation of the Program, and City reserves the right to amend this Contract in such instances to ensure compliance with HUD regulations governing cost allocation. 5.2.3.2 Agency agrees to utilize the HOPWA Funds to supplement rather than supplant funds otherwise available for the Program. 5.2.4 Payment of HOPWA Funds to Agency. HOPWA Funds will be disbursed to Agency upon City's approval of Reimbursement Requests including submission of Complete Documentation to City in compliance with Section 9. If Agency expends all funds budgeted for the Program prior to September 30,2018, City may hold back a small amount of the HOPWA Funds until the end of the term. During this interim period, Agency must continue to submit Attachment III — Client Data Report in EXHIBIT "D" — Reimbursement Forms monthly. It is expressly agreed by the Parties that any HOPWA Funds not spent or not approved for reimbursement to Agency shall remain with City. 5.3 Program Performance Milestones. 5.3.1 Agency represents that the Program will achieve the following milestones in accordance with EXHIBIT "A"—Program Summary and the table below: Unduplicated Clients as specified in EXHIBIT "A"—Program Month Expenditures Summary 3 25% 25/0 6 50% 50% 9 75% 75% 12 1 100% 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 HOPWA PSA CONTRACT 2017-2018 Page 4 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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 HOPWA Funds, or to terminate this Contract. 5.3.3 Failure to meet at least 80%of its performance milestones or serve 108 Unduplicated Clients under this Contract may,in City's sole discretion,disqualify Agency for consideration under the City's Request for Proposals for the 2018-2019 Program Year for federal grant funds. 5.3.4 Amendments to performance milestones regarding HOPWA funds must be approved by the Director in writing, with such approval being in the Director's sole discretion. If Director approves the Agency's proposed amended performance milestones (as approved, the "Amended Performance Milestones"), then the Amended Performance Milestones will take effect on the first day of the month following the month in which it was approved by Director, unless otherwise specified in the amendment. All requests for amendments to performance milestones must be submitted by June 1,2018. Notwithstanding the above, any amendments to this Contract shall not reduce the number of Unduplicated Clients stated in Section 5.3.3 and in EXHIBIT"A"—Program Summary. 5.4 Identify Program Expenses Paid with HOPWA Funds. Agency will keep accounts and records in such a manner that City may readily identify and account for Program expenses reimbursed with HOPWA Funds. These records shall be made available to City for audit purposes and shall be retained as required hereunder. 5.5 Program Subcontracts. Agency shall not enter into a subcontract with another agency, contractor, or vendor to provide a service to clients for any part of the Program that will be paid with HOPWA Funds without City's written consent. 6. CLIENT ELIGIBILITY VERIFICATION. 6.1 Client Eligibility. Agency will document the eligibility of all prospective clients. Agency may redact the client's personal information and substitute a client number. Agency will document client eligibility as follows: 6.2.1 Income. Agency must verify all new clients' income eligibility with Source Documentation. Agency must use the annual income definition used by 24 CFR Part 5.609 to establish client income eligibility and must use the most current HUD Income Guidelines. 6.2.2 Diagnosis. Agency must submit a signed, dated statement that the client's file contains documentation of the client's diagnosis of HIWAIDS. The HIV/AIDS diagnosis must be made by a licensed health care provider; a client's self-certification of diagnosis is not sufficient. Agency should not submit the actual diagnosis to City. HOPWA PSA CONTRACT 2017-2018 Page 5 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 6.2.3 Emergency Need. For clients receiving short term rental, mortgage or utility assistance, Agency must also verify and document that the client has an emergency need, such as sudden loss of income,eviction, utility shutoff, or extraordinary and unexpected healthcare costs. Agency must submit its policy regarding documenting emergency need to City by October 1,2017. 6.3 Submission of Complete Documentation. Agency must submit copies of documentation of client eligibility described in Section 6.1 with Attachment III in each month's Reimbursement Request for all Unduplicated Clients. 6.3 Maintain Documentation. Agency must maintain copies of all documentation required by this Section 6 for 5 years following the expiration of the Contract term. This Section shall survive the earlier terminations or expirations of this Contract. 7. ADDITIONAL HOPWA REQUIREMENTS. Agency agrees to comply with all requirements of the HOPWA Program as stated in the HOPWA Regulations, including but not limited to the following: 7.1 Environmental Review. HOPWA Funds will not be paid, and costs cannot be incurred until City has conducted an environmental review and completed an Environmental Review Record as required by 24 CFR Part 58. The environmental review may result in a decision to proceed with, modify, or cancel the funding for the Program. Further, Agency will not undertake or commit any funds to physical or choice limiting actions as described in any applicable federal regulations. Any violation of this provision will(i)cause this Contract to terminate immediately;and(ii)require Agency to repay City the HOPWA Funds it has already received and forfeit any future payments of HOPWA Funds. 7.2 Contract Not Constituting Commitment of Funds. Notwithstanding any provision of this Contract,the Parties agree and acknowledge that this Contract does not constitute a commitment of funds,and that such commitment of funds or approval may occur only upon (i) satisfactory completion of an environmental review and receipt by City of an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of City's 2017- 2018 Action Plan, and(iii)receipt by City of grant agreement from HUD. 7.3 Monitoring. 7.3.1 Agency understands and agrees that it will be subject to monitoring by City for compliance with terms and provisions of this Contract and the HOPWA Regulations for the term of this Contract. Agency is subject to such monitoring during the term of this Contract and for 5 years after the Contract term ends. Agency will provide reports and access to Program files as requested by City during this 5 year period. For purposes of this Contract,this 5 year period for monitoring is deemed to begin on October 1,2018 and end on September 30,2023 regardless of whether or not this Contract is earlier terminated. HOPWA PSA CONTRACT 2017-2018 Page 6 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United States Comptroller General shall have access during regular business hours, upon 48 hours prior notice,to Agency's offices and records pertaining to the use of the HOPWA Funds,and to Agency's officers, directors, agents, employees, contractors, subcontractors and vendors for the purpose of such monitoring. 7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring, City reserves the right to perform desk reviews or on-site monitoring of Agency's compliance with the terms and conditions of this Contract. City shall provide Agency with a written report of the monitor's findings after each monitoring visit. If the monitoring report notes deficiencies in Agency's performance, the report shall include requirements for the timely correction of said deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report may be cause for suspension or termination of this Contract as provided herein. 7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract term and for 5 years thereafter and shall survive the earlier termination or expiration of this Contract. 7.3.5 Agency shall provide City annually the results of any state or federal monitoring. Such results shall be submitted within 60 days of receipt of such state or federal monitoring report, or with the January Reimbursement Request,whichever is earlier. 7.4 Agency Procurement Standards. Agency shall comply with all applicable federal, state and local laws, regulations, and ordinances for making procurements under this Contract. In addition to the conflict of interest provision in Section 14.13.3, Agency shall establish written procurement procedures to ensure that materials and services are obtained in a cost effective manner and that provides for full and open competition. When procuring materials and services for this Contract, Agency shall comply at a minimum with the procurement standards in 2 CFR Part 200.317 through 2 CFR Part 200.326. 7.4.1 Contracts in excess of $10,000.00 made by Agency using HOPWA 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 HOPWA Funds are not listed by SAM as being debarred, both prior to hiring and prior to submitting a Reimbursement Request which includes invoices from any such contractor. Failure to submit such proofs of search shall be an event of default. 7.5 Cost Principles/Cost Reasonableness. Agency shall administer its use of HOPWA Funds in compliance with 2 CFR Part 200, as applicable. The eligibility of costs incurred for performance rendered shall be determined in accordance with 2 CFR Part 200.400 through 2 CFR Part 200.475. HOPWA PSA CONTRACT 2017-2018 Page 7 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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 HOPWA Funds or who perform any work in connection with the Program. Agency shall cause all applicable provisions of this Contract to be included in and made a part of any contract or subcontract executed in the performance of its obligations hereunder including its obligations regarding the HOPWA Regulations. Agency shall monitor the services and work performed by its contractors, subcontractors and vendors on a regular basis for compliance with the HOPWA Regulations and Contract provisions. Agency must cure all violations of the HOPWA Regulations committed by its contractors, subcontractors or vendors. City maintains the right to insist on Agency's full compliance with the terms of this Contract and the HOPWA Regulations and Agency is responsible for such compliance regardless of whether actions taken to fulfill the requirements of this Contract are taken by Agency or by Agency's contractors, subcontractors or vendors. Agency acknowledges that the provisions of this Section shall survive the earlier termination or expiration of this Contract and shall be applicable for 5 years after the Contract Term ends. 7.9 Copyright and Patent Rights. No reports,maps, or other documents produced in whole or in part under this Contract shall be the subject of an application for copyright by or on behalf of Agency. HUD and City shall possess all rights to invention or discovery,as well as rights in data,which may arise as a result of Agency's performance under this Contract. 7.10 Conflict of Interest Disclosure. In accordance with the requirements of Section 14.13.2.1 and 14.13.4,Agency shall establish conflict of interest policies for federal awards. Agency shall disclose to City in writing any potential conflict of interest. 7.11 Compliance with FFATA and Whistleblower Protections. Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the Federal Funding Accountability and Transparency Act ("FFATA") governing requirements on executive compensation and provisions governing whistleblower protections contained in 10 U.S.C. 2409,41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C.4304 and 41 U.S.C. 4310. HOPWA PSA CONTRACT 2017-2018 Page 8 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 7.11.1 Agency shall provide City with its DUNS number. 7.12 Internal Controls. In compliance with the requirements of 2 CFR Part 200.303,Agency shall: 7.12.1 Establish and maintain effective internal control over the HOPWA Funds that provides reasonable assurance that Agency is managing the HOPWA Funds in compliance with federal statutes, regulations, and the terms and conditions of this Contract. These internal controls shall be in compliance with guidance in"Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control Integrated Framework" issued by the Committee of Sponsoring Organizations of the Treadway Commission ("COSO"); 7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this Contract; 7.12.3 Evaluate and monitor Agency's compliance with statutes, regulations and the terms and conditions of this Contract; 7.12.4 Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings; and 7.12.5 Take reasonable measures to safeguard protected personally identifiable information and other information that HUD or City designates as sensitive or Agency considers sensitive consistent with applicable federal, state, local and tribal laws regarding privacy and obligations of confidentiality. 7.13 Required Certification of Completion of Training. At least 1 Agency employee must complete the HUD required "Getting to Work Training Curriculum" by April 15, 2018 and submit the required certifications to City with the April 2018 Reimbursement Request as more particularly described on EXHIBIT "A-2" —Requirements for Completion of"Getting to Work Training Curriculum". 7.14 Housing Quality Standards. All housing assisted under this Contract must meet housing quality standards and habitability standards as required by 24 CFR Part 574.310(b). City shall have the right to inspect to confirm compliance with these standards. 8. RECORD KEEPING; REPORTING AND DOCUMENTATION REQUIREMENTS; AUDIT. 8.1 Record Keeping. Agency shall maintain a record-keeping system as part of its performance of this Contract and shall promptly provide City with copies of any document City deems necessary for the effective fulfillment of City's monitoring and evaluation responsibilities. Specifically, Agency will keep or cause to be kept an accurate record of all actions taken and all funds spent,with supporting and back- up documentation. Agency will maintain all records and documentation related to this Contract for HOPWA PSA CONTRACT 2017-2018 Page 9 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 5 years after the Contract term ends. If any claim,litigation,or audit is initiated before the expiration of the 5 year period, the relevant records and documentation must be retained until all such claims, litigation or audits have been resolved. For purposes of this Contract, this 5 year period for record retention is deemed to begin on October 1, 2018 and end on September 30, 2023 regardless of whether or not this Contract is earlier terminated. 8.2 Access to Records. Representatives of City, HUD and any duly authorized officials of the federal government will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of Agency's records pertaining to all matters covered by this Contract for 5 years after the Contract term ends. Such access shall be during regular business hours and upon at least 48 hours prior notice. For purposes of this Contract,this 5 year period for access to records is deemed to begin on October 1, 2018 and end on September 30, 2023 regardless of whether or not this Contract is earlier terminated. 8.3 Reports. Agency will submit to City all reports and documentation described in this Contract in such form as City may prescribe. Agency may also be required to submit a final performance and/or final financial report if required by City at the termination of this Contract in such form and within such times as City may prescribe. Failure to submit to City any report or documentation described in this Contract shall be an event of default of this Contract and City may exercise all of its remedies for default under this Contract. 8.3.1 Additional Information. Agency shall provide City with additional information as may be required by state or federal agencies to substantiate Program activities and/or expenditure eligibility. 8.4 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 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. HOPWA PSA CONTRACT 2017-2018 Page 10 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 8.5.2 City Reserves the Right to Audit. City reserves the right to perform an audit of Agency's Program operations and finances at any time during the term of this Contract and for 5 years after the Contract Term ends if City determines that such audit is necessary for City's compliance with the HOPWA Regulations or other City policies. Agency agrees to allow access to all pertinent materials as described herein for such audit. For purposes of this Contract,this 5 year period for City audit is deemed to begin on October 1, 2018 and end on September 30, 2023 regardless of whether or not this Contract is earlier terminated. If such audit reveals a questioned practice or expenditure, such questions must be resolved within 15 business days after notice to Agency of such questioned practice or expenditure. If questions are not resolved within this period, City reserves the right to withhold further funding under this Contract and/or any other contracts with Agency. IF AS A RESULT OF ANY AUDIT IT IS DETERMINED THAT AGENCY HAS FALSIFIED ANY DOCUMENTATION OR MISUSED, MISAPPLIED OR MISAPPROPRIATED HOPWA FUNDS OR SPENT HOPWA FUNDS ON ANY INELIGIBLE ACTIVITIES, AGENCY AGREES TO REIMBURSE CITY THE AMOUNT OF SUCH MONIES PLUS THE AMOUNT OF ANY SANCTIONS, PENALTY OR OTHER CHARGE LEVIED AGAINST CITY BY HUD BECAUSE OF SUCH ACTIONS. 9. REIMBURSEMENT REQUIREMENTS 9.1 Deadline for Submitting Reimbursement Requests. 9.1.1 Reimbursement Requests shall be submitted monthly to the City and must be received by the City on or before the 1511 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 15" 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 2018 MUST BE RECEIVED BY OCTOBER 1, 2018. COMPLETE DOCUMENTATION FOR ALL SEPTEMBER 2017 EXPENSES MUST BE SUBMITTED BY OCTOBER 15, 2018. FAILURE TO SUBMIT A FINAL REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY OCTOBER 15, 2018 WILL RESULT IN FORFEITURE OF PAYMENT OF THE SEPTEMBER REIMBURSEMENT REQUEST. 9.1.2 City will notify Agency by e-mail within 20 calendar days if a Reimbursement Request is lacking Complete Documentation or corrections are needed. Agency will have 10 business days from the date of the e-mail notice to submit any requested information or missing documentation. Agency may be penalized, at City's sole discretion, in the Request for Proposal for the 2018-2019 Program Year for any notifications received under this Section. If Agency fails to submit all the required information or missing documentation within 30 calendar days from the first e-mail, Agency shall forfeit any payments otherwise due that month and failure to submit any requested information will be considered an event of default as outlined in Section 10.1.2. HOPWA PSA CONTRACT 2017-2018 Page 11 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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. Administration, Facility Based Operating Costs, Supportive Services, Short-term Rent, Mortgage and Utility Assistance ("STRMU"), and Tenant Based Rental Assistance ("TBRA"). 9.2.2 Attachment II—Expenditure Worksheet This report shall itemize each expense requested for reimbursement by Agency and shall include the Account corresponding the expense to a Budget line item. In order for this report to be complete the following must be submitted: 9.2.2.1 For payroll expenses, timesheets signed by employees and approved by supervisor for all payroll expenses listed. Timesheets must distinguish between HOPWA-funded time and non-HOPWA funded time and reflect actual time spent on HOPWA-funded activities. Agency may not submit payroll expenses dated 60 calendar days prior to the date of the Reimbursement Request. 9.2.2.2 For non-payroll expenses, invoices for each expense listed with an explanation as to how the invoiced expense pertains to the Program. Agency may not submit invoices dated 60 calendar days prior to the date of the Reimbursement Request. 9.2.2.3 Proof that each expense was paid by Agency,which proof can be satisfied by canceled checks, wire transfer documentation, paid receipts or other appropriate banking documentation. 9.2.3 Attachment III—Client Data Report. This report shall list each Unduplicated Client served during the month along with his or her demographic information. The Client Data Report must maintain a list of all clients served during the Contract term. In order for this report to be complete,the following must be submitted: 9.2.3.1 Documentation of income verification for each Unduplicated Client the first time the client is served by the Program, which will be Source Documentation. 9.2.4 Overview Report. Agency shall submit the Overview Report, attached hereto as EXHIBIT "H"— Overview Report, quarterly with the December, March, June and September Reimbursement Requests. A HOPWA PSA CONTRACT 2017-2018 Page 12 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 paper copy must be submitted with the Reimbursement Request, and an electronic copy must also be emailed to psa@fortworthtexas.gov or to the Agency's designated City contract administrator. 9.2.E Delivery of Reimbursement Request. Reimbursement Requests can be mailed or delivered in person to Neighborhood Services Department, 908 Monroe Street, Fort Worth, Texas 76102. In addition, Agencies can submit Reimbursement Requests via email psa@fortworthtexas.gov or to the Agency's designated City contract administrator. 9.3 Withholding Payment. CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit Reimbursement Requests and Complete Documentation along with any required reports shall be an event of default. 10. DEFAULT AND TERMINATION. 10.1 Failure to Submit Reimbursement Request or Required Documentation. 10.1.1 If Agency fails to submit a Reimbursement Request in accordance with Section 9,Agency shall be in default of this Contract. City will notify Agency in writing of such default and the Agency will have 10 business days from the date of the written notice to submit such Reimbursement Request to cure the default. If Agency fails to cure the default within such time, Agency shall forfeit any payments otherwise due that month. 10.1.2 If Agency fails to submit requested information or missing documentation as set forth in Section 9.1.2, then Agency shall forfeit payment due that month and the failure to submit shall be considered an event of default that shall not be cured. 10.1.3 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR 10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE OCTOBER 1, 2018, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR OOCTOBER 1,2018 IS LATE,INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE WITH THIS CONTRACT OR THE HOPWA REGULATIONS AS DETERMINED BY CITY IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY REIMBURSEMENT WILL BE FORFEITED. 10.1.4 In the event of(i) an uncured default under Section 10.1.1 or an event of default under 10.1.2 (ii) or more than 2 instances of default, cured or uncured, under these Sections, City reserves the right at its sole option to terminate this Contract effective immediately upon written notice of such intent with no penalty or liability to City. 10.1.5 Notwithstanding anything to the contrary herein, City will not be required to pay any HOPWA Funds to Agency during the period that any Reimbursement Request, report or documentation is past due or is not in compliance with this Contract or the HOPWA Regulations,or during any period during which Agency is in default of this Contract. HOPWA PSA CONTRACT 2017-2018 Page 13 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 10.1.6 In the event of termination under this Section 10.1, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have no further right to such funds. 10.2 Failure to Maintain Records or Submit Reports and Documentation. If Agency fails to maintain all records and documentation as required in Section 8, or if the maintained or submitted report or documentation is not in compliance with this Contract or the HOPWA Regulations as determined by City in its sole discretion,City will notify Agency in writing and Agency will have 30 calendar days from the date of the written request to obtain or recreate the missing records and documentation or submit or resubmit any such report or documentation to City. If Agency fails to maintain the required reports or documentation, or fails to submit or resubmit any such report or documentation within such time, City shall have the right to terminate this Contract effective immediately upon written notice of such intent with no penalty or liability to City. 10.2.1 In the event of termination under this Section 10.2, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have no further right to such funds,and any HOPWA Funds paid to Agency must be repaid to City within 30 days of termination. If such HOPWA funds are not repaid to City within the 30 day period, City shall exercise all legal remedies available under this Contract. 10.3 In General. 10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this Contract, Agency shall be in default under this Contract if Agency breaches any term or condition of this Contract. In the event that such a breach remains uncured after 30 calendar days following written notice by City (or such other notice period as may be specified herein) or, if Agency has diligently and continuously attempted to cure following receipt of such written notice but reasonably requires more than 30 calendar days to cure, as determined by both Parties mutually and in good faith, City shall have the right to elect in City's sole discretion to (i) extend Agency's time to cure, (ii) terminate this Contract effective immediately upon written notice of such intent to Agency, or (iii)pursue any other legal remedies available to City under this Contract. 10.3.2 City's remedies may include: 10.3.2.1 Direct Agency to prepare and follow a schedule of actions for carrying out the affected activities, consisting of schedules, timetables and milestones necessary to implement the affected activities. 10.3.2.2 Direct Agency to establish and follow a management plan that assigns responsibilities for carrying out the remedial activities. 10.3.2.3 Reprogram HOPWA Funds that have not yet been expended from affected activities to other eligible activities or withhold HOPWA Funds. HOPWA PSA CONTRACT 2017-2018 Page 14 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 10.3.2.4 Any other appropriate action including but not limited to any remedial action legally available such as declaratory judgment, specific performance, damages, temporary or permanent injunctions, termination of this Contract or any other contracts with Agency, and any other available remedies. 10.3.3 In the event of termination under this Section 10.3, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have no further right to such funds, and any HOPWA Funds already paid to Agency must be repaid to City within 30 days of the termination. Failure to repay such HOPWA Funds within the 30 day period will result in City exercising all legal remedies available under this Contract. 10.4 No Funds Disbursed while in Breach. Agency understands and agrees that no HOPWA Funds will be paid to Agency until all defaults are cured to City's satisfaction. 10.5 No Compensation After Date of Termination. Agency shall not receive any compensation for work undertaken after the date of the termination. 10.6 Rights of City Not Affected. Termination shall not affect or terminate any of the existing rights of City against Agency, or which may thereafter accrue because of Agency's default and this provision shall be in addition to any and all other rights and remedies available to City under the law. Such termination does not terminate any provisions of this Contract that have been expressly noted as surviving the term or termination of the Contract. No delay or omission by City in exercising any right or remedy available to it under this Contract shall impair any such right or remedy or constitute a waiver or acquiescence in any Agency default. 10.7 Waiver of Breach Not Waiver of Subsequent Breach The waiver of a default or breach of any term, covenant, or condition of this Contract shall not operate as a waiver of any subsequent default or breach of the same or any other term, covenant or condition hereof. 10.8 Civil, Criminal and Administrative Penalties Failure to perform all the Contract terms may result in civil, criminal or administrative penalties, including,but not limited to those set out in this Contract. 10.9 Termination for Cause 10.9.1 City may terminate this Contract in the event of Agency's default, inability, or failure to perform subject to notice,grace and cure periods. In the event City terminates this Contract for cause, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately rescinded and Agency shall have no further right to such funds and any HOPWA Funds already paid to Agency must be repaid to City within 30 days of termination. Failure to repay such HOPWA Funds within 30 days will result in City exercising all legal remedies available to City HOPWA PSA CONTRACT 2017-2018 Page 15 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 under this Contract. AGENCY ACKNOWLEDGES AND AGREES THAT IF CITY TERMINATES THIS CONTRACT FOR CAUSE, AGENCY OR ANY AFFILIATES OF AGENCY SHALL NOT BE CONSIDERED FOR ANY OTHER CITY CONTRACT FOR HOPWA FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE OF TERMINATION. 10.9.2 Agency may terminate this Contract if City does not provide the HOPWA Funds substantially in accordance with this Contract. 10.10 Termination for Convenience. In terminating in accordance with 2 CFR Part 200, Appendix II, this Contract may be terminated in whole or in part only as follows: 10.10.1 By City with the consent of Agency in which case the Parties shall agree upon the termination conditions, including the effective date and in the case of partial termination, the portion to be terminated; or 10.10.2 By Agency upon at least 30 days written notification to City, setting forth the reasons for such termination,the effective date, and in the case of partial termination,the portion to be terminated. In the case of a partial termination, City may terminate the Contract in its entirety if City determines in its sole discretion that the remaining portion of the Contract to be performed or HOPWA Funds to be spent will not accomplish the purposes for which the Contract was made. 10.11 Dissolution of Agency Terminates Contract. This Contract shall terminate in the event Agency is dissolved or ceases to exist. In the event of termination under this Section, all HOPWA Funds are subject to repayment and/or City may exercise all of its remedies under this Contract. 10.12 Reversion of Assets. In the event this Contract is terminated with or without cause, all assets acquired by Agency with the HOPWA Funds including cash, interest payments from loans or otherwise, all outstanding notes,mortgages or other security instruments,any accounts receivable attributable to the use of the HOPWA Funds, and any real or personal property owned by Agency that was improved with the HOPWA Funds shall automatically transfer to City or to such assignee as City may designate. 11. REPAYMENT OF HOPWA FUNDS. All HOPWA Funds are subject to repayment in the event the Program does not meet the requirements of this Contract or in the HOPWA Regulations. If Agency takes any action that results in the City being required to repay all or any portion of the HOPWA Funds to HUD, Agency agrees it will reimburse City for such repayment. If Agency takes any action that results in City receiving a finding from HUD about the Program, whether or not repayment of all or any portion of the HOPWA Funds is required of City,Agency agrees City may require that 10% of the HOPWA Funds be repaid to City as liquidated damages. The Parties agree that City's damages in the event of either repayment to HUD being required or receiving a finding from HUD are uncertain and would be difficult to ascertain and may include an impact on City's HOPWA grant or other federal grant funds, in addition to the finding by HUD or a required repayment of funds to HUD by City. Therefore, the Parties agree that payment under this Section of 10% of the HOPWA Funds by Agency to City is liquidated damages and not a penalty. HOPWA PSA CONTRACT 2017-2018 Page 16 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 12. CHANGE IN NON-PROFIT STATUS. Agency must provide City with written notification of any changes to its non-profit status within 15 calendar days of being notified of the change. Regardless of notice by Agency, if the non- profit status of Agency changes after the date of this Contract, City may but is not obligated to, terminate this Contract. In the event of termination under this Section 12, all HOPWA Funds awarded but not yet paid to Agency pursuant to this Contract shall be immediately rescinded and Agency shall have no further right to such funds. City, in its sole discretion, may require that any HOPWA Funds already paid to Agency must be repaid to City within 30 calendar days of termination under this Section. 13. SURVIVAL. Any provision of this Contract that pertains to auditing,monitoring,client income eligibility, record keeping and reports, City ordinances, or applicable HOPWA requirements, and any default and enforcement provisions necessary to enforce such provisions, shall survive the termination of this Contract for 5 years after the Contract term ends and shall be enforceable by City against Agency. For purposes of this Contract,this 5 year period for survival of certain Contract provisions is deemed to begin on October 1, 2018 and end on September 30, 2023 regardless of whether or not this Contract is earlier terminated. 14. GENERAL PROVISIONS. 14.1 Agency an Independent Contractor. Agency shall operate hereunder as an independent contractor and not as an officer, agent, servant or employee of City. Agency shall have exclusive control of, and the exclusive right to control,the details of the work and services performed hereunder, and all persons performing same, and shall be solely responsible for the acts and omissions of its officers, members, agents, servants, employees, contractors, subcontractors,vendors,clients, licensees or invitees. 14.2 Doctrine of Respondeat Superior. The doctrine of respondeat superior shall not apply as between City and Agency, or its officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients, licensees or invitees, and nothing herein shall be construed as creating a partnership or joint enterprise between City and Agency. City does not have the legal right to control the details of the tasks performed hereunder by Agency, its officers, members, agents, employees, contractors, subcontractors,vendors, clients, licensees or invitees. 14.3 Agency Property. City shall under no circumstances be responsible for any property belonging to Agency, or its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR CONNECTED WITH SUCH PROPERTY. 14.5 _Religious Organization. Agency shall comply with all applicable requirements as more particularly described in 24 CFR Part 5.109. No portion of the HOPWA Funds shall be used in support of any sectarian or HOPWA PSA CONTRACT 2017-2018 Page 17 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 religious activity. In addition, there must be no religious or membership criteria for clients of a HOPWA-funded service. 14.5.1. Separation of Explicitly Religious Activities. Agency retains its independence and may continue to carry out its mission, including the definition,development practice, and expression of its religious beliefs,provided that it does not use HOPWA Funds to support or engage in any explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization), or in any other manner prohibited by law. 14.5.2 Explicitly Religious Activities. If Agency engages in explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization), the explicitly religious activities must be offered separately, in time or location, from the programs or activities supported by HOPWA Funds and participation must be voluntary for clients of a HOPWA-funded service. 14.5.3 Required Notices. If Agency constitutes a Faith-based organization under 24 CFR Part 5.109, Agency must provide all clients of a HOPWA-funded service with the notice attached as EXHIBIT "J"—Notice of Beneficiary Rights. Such notice shall be provided to the client prior to enrollment in any HOPWA-funded program or activity. In addition, if a client or prospective client of a HOPWA- funded service objects to the religious character of Agency, then Agency must promptly undertake reasonable efforts to identify and refer the client or prospective client to an alternate provider to which the client or prospective client has no such objection, as more particularly described in 24 CFR Part 5.109. 14.6 Venue. Venue shall lie in Tarrant County,Texas for any action,whether real or asserted, at law or in equity, arising out of the execution,performance, attempted performance or non-performance of this Contract. 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 HOPWA PSA CONTRACT 2017-2018 Page 18 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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 words "without limitation". 14.11 Compliance With All Applicable Laws and Regulations. Agency agrees to comply fully with all applicable laws and regulations that are currently in effect or that are hereafter amended during the performance of this Contract. Those laws include, but are not limited to: ➢ HOPWA Regulations found in 24 CFR Part 574 ➢ AIDS Housing Opportunity Act, as amended(42 USC 12901 et seq.) ➢ Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including provisions requiring recipients of federal assistance to ensure meaningful access by persons of limited English proficiency ➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections 3601 et seq.) ➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented by Department of Labor regulations 41 CFR Part 60 ➢ The Age Discrimination in Employment Act of 1967 ➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.) ➢ The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (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 HOPWA PSA CONTRACT 2017-2018 Page 19 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 Uniform Federal Accessibility Standards, 24 CFR Part 40,Appendix A ➢ Regulations at 24 CFR Part 87 related to lobbying, including the requirement that certifications and disclosures be obtained from all covered persons ➢ Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part 23, Subpart F ➢ Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on participation by ineligible, debarred or suspended persons or entities ➢ Section 6002 of the Solid Waste Disposal Act,as amended by the Resource Conservation and Recovery Act ➢ Guidelines of the Environmental Protection Agency at 40 CFR Part 247 ➢ For contracts and subgrants for construction or repair,Copeland"Anti-Kickback"act(18 U.S.C. 874)as supplemented in 29 CFR Part 5 ➢ For construction contracts awarded by Agency in excess of $2,000, and in excess of $2,500 for other contracts which involve the employment of mechanics or laborers, Sections 103 and 107 of the Contract Work Hours and Safety Standards Act(40 U.S.C. 327A 300) as supplemented by 29 CFR Part 5 ➢ Lead-Based Paint Poisoning Prevention Act(42 U.S.C.4801 et seq.),as amended by the Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et seq.) and implementing regulations at 24 CFR Part 35, subparts A,B,M, and R ➢ Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, 2 CFR Part 200 et seq. ➢ Federal Funding Accountability and Transparency Act of 2006("FFATA")(Pub.L. 109- 282,as amended by Section 6205(a)of Pub.L. 110-252 and Section 3 of Pub.L. 113-101) ➢ Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712, 10 U.S.C. 2324,41 U.S.C. 4304 and 41 U.S.C. 4310. 14.12 HUD�Assisted Pr-eeets —and Employment—and—other-Oppor-tunities; Seet-ien 3-R-e. ent�: 14.13 Prohibition Against Discrimination. 14.13.1 General Statement. Agency shall comply in the execution, performance or attempted performance of this Contract,with all non-discrimination requirements of 24 CFR Part 574.603 and Chapter 17,Article III, Division 4–Fair Housing of the City Code. Agency may not discriminate against any person because of race, color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression, or transgender, nor will Agency permit its officers,members, agents, employees,or clients to engage in such discrimination. This Contract is made and entered into with reference specifically to Chapter 17,Article III, Division 3 -Employment Practices of the City Code, and Agency hereby covenants and agrees that Agency, its officers, members, agents, employees and contractors, have fully complied with all provisions of same and that no employee, or applicant for employment has been discriminated against under the terms of such ordinances by either or its officers, members, agents, employees or contractors. HOPWA PSA CONTRACT 2017-2018 Page 20 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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 l will take affirmative action to ensure that applicants are hired without regard to race,color, sex,gender,religion,national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender and that employees are treated fairly during employment without regard to their race, color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender. Such action shall include, but not be limited to, the following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including apprenticeship. [Contractor's, Subcontractor's or Vendor's name] agrees to post in conspicuous places, available to employees and applicants for employment,notices setting forth the provisions of this nondiscrimination clause. [Contractor's Subcontractor's or Vendor's name] will, in all solicitations or advertisements for employees placed by or on behalf of[Contractor's. Subcontractor's or Vendor's name], state that all qualified applicants will receive consideration for employment without regard to race,color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender. [Contractor's, Subcontractor's or Vendor's name] covenants that neither it nor any of its officers, members, agents, employees, or contractors, while engaged in performing this Contract, shall,in connection with the employment,advancement or discharge of employees or in connection 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 HOPWA PSA CONTRACT 2017-2018 Page 21 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD CITY HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY THIRD PARTIES, CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS AGAINST CITY ARISING OUT OF AGENCY'S AND/OR ITS CONTRACTORS', SUBCONTRACTORS', VENDORS' OR AGENTS' OR THEIR RESPECTIVE EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE-REFERENCED LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF THIS CONTRACT. 14.14. Conflicts of Interest and Violations of Criminal Law. 14.14.1 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 Prohibitions 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 HOPWA funds or who are in a position to participate in a decision-making process or gain inside information with regard to these activities may utilize HOPWA services,may obtain a financial interest or benefit from a HOPWA-assisted activity, or have an interest in any contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for themselves or those with whom they have family or business ties, during their tenure or for 1 year thereafter. 14.14.2.1 Agency shall establish conflict of interest policies for federal awards including the HOPWA Funds and shall disclose in writing potential conflicts of interest to City as authorized by 2 CFR Part 200.112. 14.14.3 Conflicts of Interest Involving Procurement. The conflict of interest provisions of 2 CFR Part 200.318, shall apply in the procurement of property and services by Agency. In all cases not governed by those Sections,the provisions of 24 CFR Part 574.625 of the HOPWA Regulations shall apply. 14.14.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall maintain and submit to City written standards of conduct covering conflicts of interest and governing the performance of its employees engaged in the selection, award, and administration of contracts. No employee,officer,or agent may participate in the selection, award,or administration of a contract supported by a federal award if he or she has a real or apparent conflict of interest. The standards of conduct must provide for disciplinary actions to be applied for violations of such standards by officers, employees, or agents of Agency. HOPWA PSA CONTRACT 2017-2018 Page 22 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 14.14.3.2 The officers,employees,and agents of Agency shall neither solicit nor accept gratuities, favors, or anything of monetary value from contractors or parties to subcontracts. 14.14.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2, Agency may set standards of conduct for situations in which the financial interest is not substantial or the gift is an unsolicited item of nominal value. Such standards of conduct must provide for disciplinary actions to be applied for violations of such standards by Agency's officers, employees or agents. 14.14.3.4 Agency shall maintain written standards of conduct covering organizational conflicts of interest. Organizational conflicts of interest means that because of relationships with a parent company, affiliate,or subsidiary organization,Agency is unable or appears to be unable to be impartial in conducting a procurement action involving a related organization. 14.14.3.5 Agency must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. 14.14.4 Disclosure of Conflicts of Interest. In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in writing any potential conflict of interest. 14.14.5 Disclosure of Texas Penal Code Violations. Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit bribery and gifts to public servants. 14.14.6 Disclosure of Federal Criminal Law Violations. In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all violations of federal criminal law involving fraud,bribery or gratuity violations potentially affecting the Agency. 14.15 Subcontracting with Small and Minority Firms, Women's Business Enterprises and Labor Surplus Areas. 14.15.1 For procurement contracts$50,000.00 or larger that are paid for,in part or in full, with HOPWA Funds, Agency agrees to abide by City's policy to involve Minority Business Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for contracts for construction, provision of professional services, purchase of equipment and supplies and provision of other services required by City. Agency agrees to incorporate the City's BDE Ordinance, and all amendments or successor policies or ordinances thereto, into all contracts and subcontracts for procurement larger than$50,000.00 or larger that are paid for,in part or in full,with HOPWA PSA CONTRACT 2017-2018 Page 23 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 the HOPWA Funds and will further require all persons or entities with which it so contracts to comply with said ordinance. 14.15.2 It is national policy to award a fair share of contracts to disadvantaged business enterprises ("DBEs"), small business enterprises ("SBEs"), minority business enterprises ("MBEs"), and women's business enterprises ("WBEs"). Accordingly, affirmative steps must be taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized when possible as sources of supplies, equipment, construction and services. 14.15.2.1 In order to comply with federal reporting requirements,Agency must submit the form attached hereto as EXHIBIT"I"—MBE Reporting Form for each contract or subcontract with a value of$10,000.00 or more paid or to be paid with the HOPWA Funds. Agency shall submit this form by the date specified in EXHIBIT "I" — MBE Reporting Form. 14.16 Other Laws. The failure to list any federal, state or City ordinance, law or regulation that is applicable to Agency does not excuse or relieve Agency from the requirements or responsibilities in regard to following the law, nor from the consequences or penalties for Agency's failure to follow the law, if applicable. 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 HOPWA-funded Program prior to any charges being incurred. 14.19 Force Maieure If Agency becomes unable,either in whole or part,to fulfill its obligations under this Contract due to acts of God, strikes, lockouts, or other industrial disturbances, acts of public enemies, wars, blockades,insurrections,riots,epidemics,earthquakes,fires,floods,restraints or prohibitions by any court, board, department, commission or agency of the United States or of any States, civil disturbances, or explosions, or some other reason beyond Agency's control (collectively, "Force Majeure Event"),the obligations so affected by such Force Majeure Event will be suspended only during the continuance of such event. Agency will give City written notice of the existence, extent and nature of the Force Majeure Event as soon as reasonably possible after the occurrence of the event. Failure to give notice will result in the continuance of Agency's obligation regardless of the extent of any existing Force Majeure Event. Agency will use commercially reasonable efforts to remedy its inability to perform as soon as possible. HOPWA PSA CONTRACT 2017-2018 Page 24 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 14.20 IMMIGRATION NATIONALITY ACT. City actively supports the Immigration &Nationality Act(INA) which includes provisions addressing employment eligibility, employment verification, and nondiscrimination. Agency shall verify the identity and employment eligibility of all employees who perform work under this Agreement. Agency shall complete the Employment Eligibility Verification Form (I-9), maintain photocopies of all supporting employment eligibility and identity documentation for all employees, and upon request,provide City with copies of all l-9 forms and supporting eligibility documentation for each employee who performs work under this Agreement. Agency 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. Agency shall provide City with a certification letter that it has complied with the verification requirements required by this Agreement. Agency shall indemnify City from any penalties or liabilities due to violations of this provision. City shall have the right to immediately terminate this Agreement 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 HIND 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. HOPWA PSA CONTRACT 2017-2018 Page 25 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 IT IS THE EXPRESS INTENTION OF THE PARTIES,BOTH AGENCY AND CITY, THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES INDEMNITY BY AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE CONSEQUENCES OF CITY'S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE IS ALLEGED TO BE THE SOLE OR CONCURRING CAUSE OF THE INJURY,DAMAGE OR DEATH. AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS, EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY FOR INJURY,DEATH,DAMAGE OR LOSS TO PERSONS OR PROPERTY SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER THIS CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED BY CITY'S SOLE OR CONCURRENT NEGLIGENCE. AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS A RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME FORM AS ABOVE. 16. WAIVER OF IMMUNITY BY AGENCY. If Agency,as a charitable or nonprofit organization,has or claims an immunity or exemption (statutory or otherwise)from and against liability for damages or injury, including death,to persons or property, Agency hereby expressly waives its rights to plead defensively such immunity or exemption as against City. This Section shall not be construed to affect a governmental entity's immunities under constitutional, statutory or common law. 17. INSURANCE AND BONDING. Agency will maintain coverage in the form of insurance or bond in the amount of $523,343.54 to insure against loss from the fraud, theft or dishonesty of any of Agency's officers, agents, trustees, directors or employees. The proceeds of such insurance or bond shall be used to reimburse City for any and all loss of HOPWA Funds occasioned by such misconduct. To effectuate such reimbursement, such fidelity coverage shall include a rider stating that reimbursement for any loss or losses shall name the City as a Loss Payee. Agency shall furnish to City in a timely manner, but not later than the Effective Date, certificates of insurance as proof that it has secured and paid for policies of commercial insurance as specified herein. If City has not received such certificates by the Effective Date,Agency shall be in default of the Contract and City may, at its option,terminate the Contract. 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 HOPWA PSA CONTRACT 2017-2018 Page 26 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 Non-Profit Organization Liability or Directors & Officers Liability $1,000,000 Each Occurrence $1,000,000 Annual Aggregate Limit Business Automobile Liability Insurance $1,000,000 each accident on a combined single-limit basis, or $ 250,000 Property Damage $ 500,000 Bodily Injury per person per occurrence $2,000,000 Aggregate Insurance policy shall be endorsed to cover"Any Auto", defined as autos owned, hired, and non-owned. Pending availability of the above coverage and at the discretion of City,the policy shall be the primary responding insurance policy versus a personal auto insurance policy if or when in the course of Agency's business as contracted herein. Workers' Compensation Insurance Part A: Statutory Limits Part B: Employer's Liability $100,000 each accident $100,000 disease-each employee $500,000 disease-policy limit Note: Such insurance shall cover employees performing work on any and all projects including but not limited to construction, demolition, and rehabilitation. Agency or its contractors shall maintain coverages, if applicable. In the event the respective contractors do not maintain coverage, Agency shall maintain the coverage on such contractor, if applicable, for each applicable contract. Additional Requirements Such insurance amounts shall be revised upward at City's reasonable option and no more frequently than once every 12 months, and Agency shall revise such amounts within 30 days following notice to Contractor of such requirements. Agency will submit to City documentation that it has obtained insurance coverage and has executed bonds as required in this Contract prior to payment of any monies provided hereunder. 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. HOPWA PSA CONTRACT 2017-2018 Page 27 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 Insurers of Agency's insurance policies shall be licensed to do business in the state of Texas by the Department of Insurance or be otherwise eligible and authorized to do business in the state of Texas. Insurers shall be acceptable to City insofar as their financial strength and solvency and each such company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII or other equivalent insurance industry standard rating otherwise approved by City. Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise approved by City. In the event there are any local, federal or other regulatory insurance or bonding requirements for the Program, and such requirements exceed those specified herein, the former shall prevail. Agency shall require its contractors to maintain applicable insurance coverages, limits, and other requirements as those specified herein; and Agency shall require its contractors to provide Agency with certificate(s) of insurance documenting such coverage. Also, Agency shall require its contractors to have City and Agency endorsed as additional insureds (as their interest may appear) on their respective insurance policies. Directors and Officers Liability coverage shall be in force and may be provided on a claims-made basis. This coverage may also be referred to as Management Liability, and shall protect the insured against claims arising out of alleged errors in judgment, breaches of duty and wrongful acts arising out of their organizational duties. Coverage shall protect not only the entity,but all past,present and future directors, officers,trustees, employees,volunteers and committee members. Notwithstanding any provision in this Contract to the contrary,when applicable,Agency shall comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the equivalent insurance coverage for real property and equipment acquired or improved with HOPWA 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. HOPWA PSA CONTRACT 2017-2018 Page 28 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 This certification is a material representation of fact upon which reliance was placed when this Contract was made or entered into. Submission of this certificate is a prerequisite for making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than$100,000.00 for each such failure. Agency shall require that the language of this certification be included in all subcontracts or agreements involving the expenditure of federal funds. 19. LITIGATION AND CLAIMS. Agency shall give City immediate notice in writing of any action, including any proceeding before an administrative agency, filed against Agency in conjunction with this Contract or the Program. Agency shall furnish immediately to City copies of all pertinent papers received by Agency with respect to such action or claim. Agency shall provide a notice to City within 10 days upon filing under any bankruptcy or financial insolvency provision of law. HOPWA PSA CONTRACT 2017-2018 Page 29 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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: Director of Neighborhood Services Department 200 Texas Street Fort Worth, TX 76102 Attention: Assistant Director Telephone: 817-392-7540 Copy to: Director of Neighborhood Services Department 200 Texas Street Fort Worth, TX 76102 Attention: Management Analyst II Telephone: 817-392-7369 Agency: Tarrant County Samaritan Housing, Inc. Norbert White, President and CEO 929 Hemphill Street Fort Worth, Texas 76104 Telephone: 817-509-1697 HOPWA PSA CONTRACT 2017-2018 Page 30 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 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. [SIGNATURES APPEAR ON NEXT PAGE] HOPWA PSA CONTRACT 2017-2018 Page 31 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 IN WITNESS WHEREOF, the Parties hereto have executed 4 duplicate originals of this Contract in Fort Worth,Tarrant County,Texas. ATTES ' G�'CY F FORT WORTH City Secretary Fc do Costa,Assistant City Manager IA&C: G-1905 '• Qi _a 1295 Certification Indo. 2017-2361 Date: August 1,2017 APPROVED AS TO FORM AND LEGALITY: Qq ,`L I M o Vr- . Pat a Meba a Assista t Ci Att me g � t3' o Y 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 Plannip Manager TAT TY T HOUSING,INC. By: VNorbe White,President and CEO HOPWA PSA CONTRACT 2017-2018 Page 32 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 EXHIBITS: EXHIBIT "A"—Program Summary EXHIBIT "A-1"—2017 HUD Income Limits EXHIBIT "A-2" -Requirements for Completion of"Getting to Work Training Curriculum" EXHIBIT "B"—Budget EXHIBIT "C"—Audit Certification Form EXHIBIT "D"—Reimbursement Forms EXHIBIT "E"—Form of Income Self-Certification EXHIBIT "F"—Standards for Complete Documentation EXHIBIT "G"—Section 3 Reporting Forms (NOT APPLICABLE) EXHIBIT "H"—Overview Report EXHIBIT "I"—MBE Reporting Form EXHIBIT "J"—Notice of Beneficiary Rights HOPWA PSA CONTRACT 2017-2018 Page 33 Tarrant County Samaritan Housing,Inc. Rev.9.22.2017 TARRANT COUNTY SAMARITAN HOUSING, EXHIBIT "A" INC. Samaritan House Supportive Services PROGRAM SUMMARY PROGRAM SUMMARY (HOPWA) October 1, 2017 to September 30, 2018 $523,343.54 PERIOD AMOUNT Capitalized terms not defined herein shall have meanings assigned them in the Contract. PROGRAM: The Program provides supportive services and Tenant Based Rental Assistance (TBRA) to HOPWA Eligible Clients living in the Samaritan Villages Apartments,the Samaritan House Single Room Occupancy ("SRO") Facility, and in scattered-site rental-voucher supported housing. The supportive services include case management and housing counseling. Program services may also include congregate meals; medical case management; substance abuse counseling; medical transportation; recreational and social programs; educational programs; and life and job skills programs. TBRA includes long-term monthly rental assistance. Clients must be Income Eligible according to HUD guidelines, live in a rental unit that passes habitability inspections, and have an identified housing need as determined by the client's case manager. HOPWA Funds will pay for direct assistance for TBRA clinets. HOPWA Funds will be used to pay for a percentage of supportive service salaries and fringe benefits,associated with the Program. HOPWA Funds will also be used to pay for the operational expenses of the Agency's SRO Facility located at 929 Hemphill Street, Fort Worth, TX 76104. Operational expenses consist of salaries and fringe benefits for property management and maintenance staff. No more than 7% of the HOPWA Funds will be used to pay for administrative costs, including salaries and fringe benefits and City-required insurance associated with the Program. Agency's office and Program services will be available at 929 Hemphill Street,Fort Worth,Texas 76104,Monday through Friday, 9:00 a.m.to 5:00 p.m. Program services may also be provided at clients' homes. The SRO is staffed 24 hours a day, 7 days a week. The Program will provide services to HOPWA Eligible clients residing in Tarrant, Johnson, Parker, Wise,Hood and Somervell counties. HOPWA PSA CONTRACT 2017-2018—EXHIBIT"A"—PROGRAM SUMMARY Page 1 Tarrant County Samaritan Housing,Inc. REGULATORY CLASSIFICATION: IDIS matrix Code(s) and Service Category: 31D HOPWA Project Sponsor Administration 3 1 C HOPWA Project Sponsor Activity Regulatory Citation(s): 24 CFR 574.300(b)(10)—Administrative Expenses 24 CFR 574.300(b)(7)—Supportive Services 24 CFR 574.300(b)(8)Facility Based Operations 24 CFR 574.300(b)(6)—TBRA Agency will maintain documentation which verifies that 100% of clients served by the Program are eligible under HOPWA Regulations. PROGRAM GOALS: Minimum Number of Clients to be Served: The Program must provide Supportive Services to a minimum of 135 Unduplicated Clients. Unduplicated Clients must be residents of Tarrant, Johnson, Parker, Wise, Hood and Somervell counties as shown by the monthly reports on Attachment III. The Program will also provide Facility Based Housing Subsidy Assistance through the housing operations of 60 household housing units and TBRA services to a minimum of 18 households HOPWA PSA CONTRACT 2017-2018—EXHIBIT"A"—PROGRAM SUMMARY Page 2 Tarrant County Samaritan Housing,Inc. EXHIBIT "A-1" 2017 HUD INCOME LIMITS 2017 Median Family Income -Fort Worth/Arlington. TX* 1 Person 2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons 30%AMI $15,000 $17,150 $19,300 $21,400 $23,150 $24,850 $26.550 $28,250 50%AMI $25,000 $28,600 $32,150 $35,700 $38,600 $41,450 $44,300 $47,150 80%AMI $40,000 $45,700 $51,400 $57,100 $61.700 $66,250 $70,850 $75,400 *Income limits are published at least annually by HUD. HOPWA PSA CONTRACT 2017-2018 --EXHIBIT"A-1" 2017 HUD INCOME LIMITS Page 1 Tarrant County Samaritan Housing,Inc. EXHIBIT "A-2" REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM" HOPWA PSA CONTRACT 2017-2018 Page 1 EXHIBIT"A-2"REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM" Tarrant County Samaritan Housing,Inc. Getting to Work: A Training Curriculum for HIV/AIDS Service Providers and Housing Providers At least 1 Agency employee must complete this required training curriculum by the deadline of April 15,2018. Proof of completion must be submitted with the April reimbursement request. The Getting to Work Training Curriculum is divided into 3 online modules: Module 1: Understanding the Value of Work Module 2: Adopting an Employment and Training Mindset—Organizationally and Individually Module 3: Incorporating Employment into the HIV/AIDS Service Menu To view the modules: 1. Click the module title. 2. You will be prompted to either create or log into your HUD Exchange Learn account. 3. Follow this guidance when creating a HUD Exchange account: Step 1 of 2 screen: Fill out the required Personal Information,and Login Information sections. For the Organization Information, if you are not affiliated with a HUD program, choose None of the Above and I am an Individual. Step 2 of 2 screen: All HUD Program Experience fields on the Learner Profile page are optional. Click Update to complete the account creation process. 4. After creating an account or logging in, you will enter the HUD Exchange Learn system. 5. Click the Enroll button on the HUD Exchange Learn course description to access the course. 6. The module name will appear under Activities. Click the Module Name to access the course. 7. The module will launch in a new window, so please make sure your pop-up blockers are turned off. To receive credit for completing each module: 1. Take the completion quiz under Activities on the HUD Exchange Learn course description. Each module has a quiz. 2. Score 80% or better on the quiz. You may take the quiz multiple times. 3. After you pass the quiz,you will be able to print a completion certificate on the HUD Exchange Learn course description. You can access information about the modules by visiting the HUD Exchange website at www.hudexchan eg com or by using the following link: https://www.hudexchange.info/training= events/dol-hud-getting_to-work-curriculum-for-hiv-aid-providers. You may also contact your assigned contract administrator to get additional information. HOPWA PSA CONTRACT 2017-2018 Page 1 EXHIBIT"A-2"REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM" Tarrant County Samaritan Housing,Inc. EXHIBIT"B"-BUDGET Account Grant Budget I A B C Total ADMINISTRATIVE PERSONNEL S,11s.rie; $ 29,777.00 $ 14,467.00 1;.662,00 24 3.852-00 $ 301,758.00 FICA $ 2,278.00 $ 1,107.00 $ 1_1115.00 18,fr55.oiit S 23.085.00 Life/DisabilityInsurar $ 31.00 $ 145.00 $ 2.139.00 $ 2,752.00 Health,I trental 1004 $ 1,234.00 $ 3.137.00 $ 2.502.01} 1.188.00 $ 18,061.00 Unemplo,n,cnt-State 1005 $ 566.00 $ 7 S.t70 $ 250.01 4.o32.00 $ 5,733.00 Worker's Coinilcnsation 1006 $ 112.00 $ 1.871^)0 $ 5,551.00 COntr10 (Accounting) 1007 6I.;00.00 $ 11,500.00 Attd i t 1008 Insurance-Commercial Iimbrella Liability 1009 $ 1,578.00 $ 4,500.00 S 12.542.00 $ IS,620.00 Insurance-Directors and Officers 1010 In-�.trartce-Fidelity Bond or iquitalcrnt 1011 $ 297.00 $ 297.00 I-0I'AL ADMINISTRATIVE EXPENSES $ 34,295.00 $ 20,998.00 $ 22,379.00 $ 309,685.00 $ 387,357.00 y,o Administrative °ost 7,, SUPPORTIVE SERVICES PROGRAM PERSO SaExrir� 2001 $ 307,823.00 $ 13U 204.U(l 111,962.0H 19 1)71.0f1 �1f.17e0.i10 I ICA 2002 $ 23,548.00 $ 9,961.00 $ 9,407.` S 1.4,227.00 I ifC"Di"ahilit\ 1n_sa-a%e 2003 $ 730M $ 2,604.00 $ 2,459.00 5 3,719.00 $ 11.51 3 1lcalth l?crrtxl 2004 $ 59,5'.r .'ii $ 28.111)9.0f1 22,700.00 18,319.00 129,03-1-111) l�rtcmhdr �rtx�nt State 2005 5,847 2.-173.110 2, 36.001 1.533.00 I-1-]811.;10 1li,r€er';(_armhtn..aikr. n C; (1.23 -159.00 i- '19.00 15.0 i 7 SL'PPI.ITS AND SERVICES Otlice;N'lcdmll Supplies 3001 S 598.00 $ 500.00 11M2.00 i, 12.1140.00 00fce F(plihntertt FterrtL $ 1 5.03" . 5,737.00 Posta'_'c 2.;38.110 2,338.00 pri n t i rn- 300 -1. 4,700.00 MISCELLANEOUS Controet 4001 $ 8,797.00 $ 4,750.00 $ 7.124.00 5 211-1)71.()0 Food Srrhl)lies 4002 $ 80,-50.00 $ 39,800.00 $ 2".590.00 148,140.00 C-icnt I r'111TOrtation 4003 $ 10.221.00 $ 750.00 10.971.00 FACILITY AND UTILITIES 'I elc•171rc�ire Electric 5002 Gas 5003 Water and Wastewater 5004 Solid Waste Disposal 5005 Rent(City needs copy of lease before expenses can be reimbursed) 5006 Custodial Services 5007 $ 11,300.00 $ 11,300.00 Maintenance/Repairs 5008 Building Security 5009 HOPWA PSA CONTRACT 2017-2018-EXHIBIT"B"-BUDGET Tarrant County Samaritan House,Inc. Page 1 LEGAL,FINANCIAL AND INSURANCE Directory i:.'O+fie:s 1t„s ranW: 6001 $ 2,500.00 $ 2,500.00 TOTAL SUPPORTIVE SERVICE EXPENSES $ 403,699.00 1 $ 277,011.00 1 $ 208,123.00 $ 302,219.00 $ 1,191,052.00 DIRECT ASSISTANCE-STRMU qtr ryrt-tP:. Rent Assistance 7001 Short-serer-.Mori,-,a--e Assistance 7002 Assistance 7003 l'otal Direct Assistance-STRMU Tenant Based Rental Assistance (TBRA)* 8001 $ 13,139.54 5 205,000.00 $ 218,139.54 Total Direct Assistance-TBRA $ 13,139.54 T 205,000.00 $ 218,139.54 FACILITY BASED OPERATIONS PERSONNEL Salaries 9001 $ 61,130.00 $ 28.540.00 89,670.00 FICA 9002 $ 4,676.00 $ 2,183.00 $ 6.859.00 Life/Disability Insurance 9003 $ 117,00 $ 70.00 $ 187.00 Health/DentalInsurance 9004 $ 3,601.00 $ 12,022.00 $ 15.623.00 Unemployment-State 9005 $ 1,161..00 $ 20,530.00 $ 21691.00 Worker's Compensation 9006 $ 1.525.00 $ 270,00 .S 1,715.00 Insurance-Commercial Property and Professional Liability 9007 Telephone 9008 Electric 9009 Maintenance/Repairs 9010 Cleaning Supplies 9011 TOTAL FACILITY BASED OPERATION EXPENSES $ 72,210.00 $ 63,615.00 $ 135,825.00 BUDGET TOTAL $ 523,343.54 $ 298,009.00 $ 435,502.00 $ 675,519.00 $ 1,932,373.54 *TBRA costs may be incurred and are eligible for reimbursement beginning October 3,2017 FUNDING A:Tarrant County Public Health Department(Ryan White I,Il,&State Services) FUNDING B:Tarrant County Community Development-HOPWA SNPS/TBLA 15 FUNDING C:Fundraising/Donations HOPWA PSA CONTRACT 2017-2018-EXHIBIT"B”-BUDGET Tarrant County Samaritan House,Inc. Page 2 The following tables were created for the purpose of preparing, negotiating, and determining the cost reasonableness and cost allocation method used by the Agency for the line item budget represented on the first page of this EXHIBIT "B"—Budget. The information reflected in the tables is to be considered part of the terms and conditions of the Contract. Agency must have prior written approval by the City to make changes to any line item in the Budget as outlined in Section 5.2.2 in the Contract. The deadline to make changes to EXHIBIT "B"—Budget is June 1., 2018. SALARY DETAIL-ADMINISTRATIVE Est. Percent to Amount to Position Title Annual Salary Grant Grant Chief Executive Officer $ 134.078.00 9.0% $ 12,067.00 Chief Financial Officer $ 100,000.00 9.0% $ 9,000.00 Accounting Clerk $ 40,000.00 9.0% $ 3,600,00 Grant& Compliance Manager $ 56,782.00 9.0/0 $ 5,110.00 TOTAL $ 330,860.00 9.0% $ 29,777.00 FRINGE DETAIL -ADMINISTRATIVE Percent of Est.Percent to Amount to Payroll Amount Grant Grant FICA 7.65% $ 23,085.00 9.9% $ 2,278.00 Life/Disability Insurance $ 2,752.00 1.1% $ 31.00 Health/Dental Insurance $ 18,061.00 6,8% $ 1,234.00 Unemployment-State $ 5,733.00 9.9% $ 566.00 Worker's Compensation $ 5,551.00 2.0% $ 112.00 TOTAL $ 55,182.00 7.6% $ 4,221.00 MISCELLANEOUS -ADMINISTRATIVE Est. Percent to Amount to Total Budget Grant Grant Contract Labor(Accounting) $ 11,500.00 Audit Fees Insurance-Commercial Umbrella Liability $ 18,620.00 Insurance-Directors and Officers Insurance-Fidelity Bond or Equivalent $ 297.00 IWO% $ 297.00 TOTAL $ 30,417.00 1.0% $ 297.00 HOPWA PSA CONTRACT 2017-2018-EXHIBIT"B"-BUDGET Tarrant County Samaritan House,Inc. Page 3 SALARY DETAIL- SUPPORTIVE SERVICES Est.Percent to Amount to Position Title Annual Salary Grant Grant Chief Programs Officer $ 84,619.00 40.0% $ 33,848.00 Food Service Manager $ 46,996.00 37.0% $ 17,389.00 Cook $ 32,967.00 34.0% $ 11,209.00 Cook 2 $ 33,465.00 35.0% $ 11,713.00 Cook 3 $ 13,339.00 17.0% $ 2,268.00 Medical Case Manager $ 43,680.00 12.0% $ 5,242.00 Life Skills Enrichment Coordinator $ 28,080.00 100.0% $ 28,080.00 Life Skills Enrichment Specialist (FT) $ 23,795.00 100.0% $ 23,795.00 Life Skills Enrichment Specialist(FT) $ 22,880.00 100.0% $ 22,880.00 Life Skills Enrichment Specialist(PT) $ 11,898.00 100.0% $ 11,898.00 Life Skills Enrichment Specialist (PT) $ 11,898.00 100.0% $ 11,898.00 Life Skills Enrichment Specialist (PRN) $ 2,974.00 100.0% $ 2,974.00 Life Skills Enrichment Specialist(PRIG) $ 2,974.00 100.0% $ 2,974.00 Life Skills Enrichment Specialist(PRN) $ 2,974.00 100.0% $ 2,974.00 Life Skills Enrichment Specialist (PRN) $ 2,974.00 100.0% $ 2,974.00 Family Health and Education Manager $ 46,800.00 58.0% $ 27,144.00 Case Mangement Program Manager $ 49,920.00 65.0% $ 32,448.00 Patient Navigator $ 28,500.00 66.0% $ 18,810.00 Licensed Chemical Dependency Couselor $ 18,200.00 80.0% $ 14,560.00 Social Work Case Manager $ 8,736.00 40.0% $ 3,494.00 Social Work Case Manager $ 33,280.00 42.01'„ 13.978.00 Social Work Case Manager $ 40,560.00 13.0"011 5,273.00 TOTAL 1 $ 591,509.00 1 52.0%1 $ 307,823.00 FRINGE DETAIL- SUPPORTIVE SERVICES Percent of Est. Percent to Amount to Payroll Amount Grant Grant FICA 7.65% $ 57,143.00 41.2% $ 23,548.00 Life/Disability Insurance $ 9,512.00 7.7% $ 730.00 Health/DentalInsurance $ 128,634.00 46.3% $ 59,516.00 Unemployment-State $ 14,189.00 41.2% $ 5,847.00 Worker's Compensation $ 15,017.00 41.5% $ 6,235.00 TOTAL $ 224,495.00 42.7% $ 95,876.00 HOPWA PSA CONTRACT 2017-2018-EXHIBIT"B"-BUDGET Tarrant County Samaritan House,Inc. Page 4 SUPPLIES AND SERVICES - SUPPORTIVE SERVICES Est. Percent to Amount to Total Budget Grant Grant Office/Medical Supplies $ 12,940.00 Office Equipment Rental $ 5,737.00 Postage $ 2,338.00 Printing $ 4,700.00 TOTAL $ 25,715.00 MISCELLANEOUS - SUPPORTIVE SERVICES Est. Percent to Amount to Total Budget Grant Grant Contract Labor-Nutritionist $ 20,971.00 Food Supplies $ 148,140.00 Client Transportation 1 $ 10,971.001 1 TOTAL 1 $ 180,082.00 FACILITY AND UTILITIES - SUPPORTIVE SERVICES Est. Percent to Amount to Total Budget Grant Grant Telephone Electric Gas Water and Wastewater Solid Waste Disposal Rent(City needs copy of lease before expenses can be reimbursed) Custodial Services $ 11,300.00 Maintenance/Repairs BuildinE Security TOTAL $ 11,300.00 LEGAL,FINANCIAL AND INSURANCE- SUPPORTIVE SERVICES Est. Percent to Amount to Total Budget Grant Grant Directors and Officers Insurance $ 2,500.00 TOTAL $ 2,500.00 DIRECT ASSISTANCE- STRMU Est. Percent to Amount to Total Budget Grant Grant Short-Term Rent Assistance Short Term Mortgage Assistance Short Term Utilities Assistance TOTAL HOPWA PSA CONTRACT 2017-2018-EXHIBIT'B"-BUDGET Tarrant County Samaritan House,Inc. Page DIRECT ASSISTANCE- TBRA Est. Percent to Amount to Total Budget Grant Grant Tenant Based Rental Assistance* $ 218.139,54 6.0"i> 13.11'1',Q 54 TOTAL $ 218,139.5,4 6.0% $ 13,139.54 *TBRA costs may be incurred and are eligible for reimbursement beginning October 3,2017 SALARY DETAIL-FACILITY BASED OPERATIONS Est. Percent to Amount to Position Title Annual Salary Grant Grant Property Manager $ 57,482.00 86.0% $ 43,112.00 Driver'MaIntenance Manager $ 41,584.00 58.0% $ 9.149.00 Driver Maintenance Technician $ 21,632.00 65.0% $ 8.869,00 TOTAL 1 $ 120,698.00 50.6%1 $ 61,130.00 FRINGE DETAIL-FACILITY BASED OPERATIONS Percent of Est. Percent to Amount to Payroll Amount Grant Grant FICA 7.65% $ 6,859.00 68.2% $ 4,676.00 Life/Disability Insurance $ 187.00 62.6% $ 117.00 Health/DentalInsurance $ 15,623.00 13,0�4, $ 3,601.00 Unemployment-State $ 21,691.00 5.4% $ 1,161.00 Worker's Compensation $ 1,795.00 85.01%1 1,525.00 TOTAL $ 46,155.00 24.0% $ 11,080.00 MISCELLANEOUS -FACILITY BASED OPERATIONS Est. Percent to Amount to Total Budget Grant Grant Insurance-Commercial Property and Professional Liability Telephone Electric Maintenance/Repairs Cleaning Supplies TOTAL HOPWA PSA CONTRACT 2017-2018-EXHIBIT"B"-BUDGET Tarrant County Samaritan House,Inc. Page 6 EXHIBIT "C" AUDIT CERTIFICATION FORM HOPWA PSA CONTRACT 2017-2018--EXHIBIT"C"—AUDIT CERTIFICATION FORM 1 Tarrant County Samaritan Housing,Inc. AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS Agency: Tarrant County Samaritan Housing,Inc. Fiscal Year Ending: September 30,2018 Z During the fiscal year in which funds will be received,we will exceed the federal expenditure threshold of$750,000. We will have our Single Audit or Program Specific Audit completed and will submit the audit report described in 2 CFR Part 200 within 7 months after the end of the audited fiscal year or 30 days within its completion,whichever is the earlier date. ❑ During the fiscal year in which funds will be received,we will not exceed the$750,000 federal expenditure threshold required for a Single Audit or a Program Specific Audit to be performed this fiscal year.(Fill out schedule below) ryFederal Expenditure Disclosure 50 ' ,-MUST be filled out if Sirs le Audit or Program Audit is NOT required. Pass Through Program Name&' Contract F ederal GrantorGrantor CI DA Number Number Expenditures Total Federal Expenditures for this Fiscal Year: 10/09/2017 Sigto and T e Date Failure t submit this or a similar statement or failure to submit a completed single audit package as described in the federally required audit requirements described in 2 CFR Part 200, as applicable,by the required due date may result in suspension of funding and may affect eligibility for future funding. Notwithstanding the above, this certification acknowledges the agency's commitment to meet all other financial reporting, financial statements, and other audit requirements as may be set forth in the Contract. HOPWA PSA CONTRACT 2017-2018–EXHIBIT"C"—AUDIT CERTIFICATION FORM 2 Tarrant County Samaritan Housing,Inc. EXHIBIT "D" REPORTING FORMS HOPWA PSA CONTRACT 2017-2018—EXHIBIT"D"—REPORTING FORMS Page 1 Tarrant County Samaritan Housing,Inc. ATTACHMENT I Invoice Attachment I INVOICE Agency: Address: City, State, Zip: Program: Period of Service: Tax ID No. P.O. No. FID No. Amount Program This Invoice Cumulative to Date HOPWA PSA CONTRACT 2017-2018—EXHIBIT"U'—REPORTING FORMS Page 2 Tarrant County Samaritan Housing,Inc. ATTACHMENT II Expenditure Worksheet _C'rt�ofFort Worth NeiAhborbood Se Mees Department _. �� - F:x l>trndiYnre 3Yerksheet Wcnc:m Only highlightedeades carr bs reimbursed Please Ereup Iikc a—srrd codes. +'Fl 1 • s '� Aecouut ' I<. linen,._,,,^ .,.e. .._.., . ._.'T'"^� ` •'4r,raaq %'fr, 'rCo'de(see lml"` Eipensc Iine Item No. CbmkNo. Date P'avec ase- iorn/Job Title' K „Io RiZ tl .,Annum Acrolltit'" I ADNILVLSTP 4TINT _ 2Sal.v.y [001 3 W,!:1 1002 4 Ln�D,abifin-Insurance 1003 5 - EN n;urau" 1004 6 Uncnllc•.nrnt-Stec 1005 _ 7 1111� usk;�I's Co ensation 1006 8 nt; t Labor 1007 9 1008 10 sr�anea-Comvsns!Lab. 1009 11 lrtsuraucc-chye 10r;&MY— 1074 12 Insurance-Fide4r•.Brntd cr L: 1601 13 SCPPORTPVESERVICE 14 )1R0(;RU1 PERSPNNn, 15 Salaries -CYI 16 PPCA 2002 17 Lik/asabiEty Insurance 2003 l8 H_altit lkanval Insurance 20P1 19 20 r�ai eni 'u:e, 21 22muhA•s� L�;I 23 (111,11 ritY'�ri 1.\cw4 ) 31X22 24 _ frsta�;c�t 3003 25 •ohm, 3004 26 t.11.t_,tN11015 27 (n:ractLabor 91X1! 28 -,l S,pplies 400' 29 F4(_I1.II')ANIIITH 1,111(.N 30 icIe hone 31 Electric 32 Cris 33Waterand Wastewater 34 .___.. Solid Waste Dis osal 35 IL.nt 36i Custodial Services S(X)737 _.._..... .. 496ntena.nce.`Fa abs sfn8 38 39 LEGAL.ITNAN('1-11..WD 1:\41"R:a`r(�E 40 Prnl,1>rona;I:.nl%J"xis Aul. Ertl 41 _ D1RL7CTd.1;SLSLUti47FS'FRI14I1 42 Shv=. 43 -_ Shnr-rrm�lar!:�a,vc A�.ei:tuna 44 Shor,!.rtn ir :c A<usE Pia'.: 45 _DIRECC ASS ISTAN(Tf7-B R:1 46 ... � .. "l:nurn Base..!tlanal A 47 .�..�- F'ACII:CCY'R.iS'FI)OP b1tA'fIONS 48 _ rt'eil 49 50 Insurance 9W3 51 D. ,Ll lInsurance 9004 52 floe b ncntState 9005 53 Worker's Co enation 9006 54 Ins.-Corrin Prop.and Prof.Liab. 9007 55 56 57 58 59 60 total $1118) *For Salaries,state employee's title under Description/Job Title.Rent trust idenCdy tenant HOPWA PSA CONTRACT 2017-2018—EXHIBIT"D"—REPORTING FORMS Page 3 Tarrant County Samaritan Housing,Inc. ATTACHMENT III Client Data Report-Supportive Services and Operations ATT.1CIP1 1x 1 _TD.\T.\REPORT ♦� P�gpam: 1.kM: u r.x.r Letr,raem r....,...r,n.._,...-�......r.>.7.r..... y a.w.�+•..r�wa.r.W-e.r..wy r ..,mr...na..vr vr..e.-.r.... .i......r.r��u.w.,w.i..r, 11 MIR PIYY.SV P411'1 CY':.CIP,',— F+r!�1 4fertW +J:ort 1dA'e.r�.n.t.`.i cu•.Ts �xr.0 \u.u�r1 u,xri w,n mr,.x � Jr n EM= HOPWA PSA CONTRACT 2017-2018—EXHIBIT"D"—REPORTING FORMS Page 4 Tarrant County Samaritan Housing,Inc. ATTACHMENT III Client Data Report-Tenant Based Rental Assistance (TBRA) ATTACHMENT DI CULNT ATAR RT HOPW.�Pq:�Spoumn.ewy.TeU Aasm v Pn�gdm: mkoh Lntructiond: u..qp+o.b.w.w..»m.m..rnN.r.:r+yag.cw.rrdrrm.orr.rl.erm.r�aar.rw..ws oe.uuri..uwr».,i.n�.»t..r�IWr�n..§'.wrrnw�.e...Pam-.rr.ny..l.r.er.�.+Ra. sa.ai.¢.Y+dKr... ex..wrrwe....wru.r.al.M»ur s.nrv.lrr.a§un.w..lrr.w,.mya.r+^�.InorMre�e�v�lr.a.r..�m..wwu....lr.rrpµ•w..d»»e.runw�rr.0 r;lxr. T.I'RIl4�Mv k.�n i'Ik ti m wly..rm K,i ..i...li.....d�a.v.w...4.nl.�wc..wwls. IT ^ trdioR0.q rFi+hh.J Ub.4trI l� r WW�Slv.d�w) � wTa Sf®noWIDs ® ca_ff <.af�1N (3rtlAtrvl Ql�H6 3FAWX avrr..a* 1 %5].3 MxIla4 n N.iRVC A1ID ' - Kitt• ' 1 y p n HOPWA PSA CONTRACT 2017-2018—EXHIBIT"D"—REPORTING FORMS Page 5 Tarrant County Samaritan Housing,Inc. ATTACHMENT III Client Data Report-Short-Term Rental, Mortgage and Utility Assistance (STRMU) _--._- _ HOPWA PSA CONTRACT 2017-2018—EXHIBIT"D"—REPORTING FORMS Page 6 Tarrant County Samaritan Housing,Inc. EXHIBIT "E" INCOME CERTIFICATION FORMS HOPWA PSA CONTRACT 2017-2018--EXHIBIT"E"--INCOME CERTIFICATION FORM Tarrant County Samaritan Housing,Inc. Page 1 City of Fort Worth CERTIFICATION OF INCOME STATEMENT Applicant Name: Current Address: Phone#: City and Zip: Household Members and Income (including applicant) Last Name First Name Age Monthly Source of Income Income $$ TOTAL NUMBER OF FAMILY MEMBERS (Include Yourself,Spouse,Children,etc.) Total Gross Annual Household Income: PERSONAL INFORMATION:(Check one in each item. This Information is Required for Federal Reporting Purposes) a. ❑MALE b.❑WHITE ❑BLACK/AFRICAN AMERICAN ❑BLACK/AFRICAN AMERICAN&WHITE ❑FEMALE ❑AMERICAN INDIAN/ALASKAN NATIVE ❑ASIAN ❑AMERICAN INDIAN/ALASKAN NATIVE&WHITE ❑ASIAN&WHITE ❑NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER ❑BALANCE/OTHER ❑AMERICAN INDIAN/ALASKAN NATIVE&BLACK/AFRICAN AMERICAN c. ETHNICITY d. DISABLED e. IS HEAD OF HOUSEHOLD FEMALE? ❑HISPANIC ❑YES ❑YES ❑NON-HISPANIC ❑NO ❑NO Certification: I certify that the information I am providing is true and could be subject to verification at any time by a third party. I also acknowledge that the provision of false information could leave me subject to the penalties of Federal, State and local law. Signature of Applicant Date WARNING: TITLE 18,SECTION 1001 OF THE U.S.CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT. ---____--------For use by Agency staff only------------- Household ----- ______-_Household Size: Gross Annual Income: Applicable Income Limit: Is Applicant Eligible? Check if Applicant refused to provide demographic information: ❑ Staff Assessment of Demographics: Person Making Determination: Date: NOTE: Address, income amounts and sources for ALL household members are required. HOPWA PSA CONTRACT 2017-2018--EXHIBIT"E"--INCOME CERTIFICATION FORM Tarrant County Samaritan Housing,Inc. Page 2 Ciudad de Fort Worth CERTIFICACION DE DECLARACION DE INGRESOS Nombre del Solicitante: Direcci6n de Actualidad: Telefono: Ciudad y C6digo Postal: Miembros Del Hogar a Ingresos (Inclu endo el/la Solicitante) Apellido Nombre Edad Ingreso Origen de Ingresos Mensual *TOTAL NOMERO DE MIEMBROS DEL HOGAR (Incluyase Usted.) Total Anual de Ingresos del hogar: "INFORMACION PERSONAL:(Seleccione uno en cada articulo. Esta informaci6n 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. LES LA CABEZA DEL HOGAR MUJER? ❑HISPANO ❑SI ❑SI ❑NO-HISPANO ❑NO ❑NO Certificaci6n: Yo certifico que la informaci6n que yo estoy proporcionando es verdadera y puedo ser sujeto a verificaci6n a cualquiera hora por tercera parte. Yo tambien reconozco que la provision de informaci6n falsa puede dejarme sujeto a penalidades Federales,Estatales, y a ley local. Firma del Solicitante Fecha ADVERTENCIA:TITULO 18,SECCION 1001 DEL CODIGO DE LOS ESTADOS UNIDOS INDICA QUE UNA PERSONA ES CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE HACER DECLARACIONES FALSOS O FRAUDULENTAS A CUALQUIER DEPARTAMENTO DE GOBIERNO DE LOS ESTADOS UNIDOS. --------------Para use de em leados de la a encia---____________ #De Miembros de Familia: Ingreso Anual: Limite de Ingreso: ZEs solicitante elegible? Compruebe si el solicitante se neg6 a dar su informaci6n personal: ❑ Evaluaci6n del empleado sobre informaci6n personal: Persona haciendo la determinaci6n: Fecha: Note: La direccion de la casa y los ingresos (y sus origenes) para todos miembros del hogar son requeridos HOPWA PSA CONTRACT 2017-2018--EXHIBIT"E"--INCOME CERTIFICATION FORM Tarrant County Samaritan Housing,Inc. Page 3 EXHIBIT "F" STANDARDS OF DOCUMENTATION HOPWA PSA CONTRACT 2018-2018--EXHIBIT"F"--STANDARDS OF DOCUMENTATION Page 1 Tarrant County Samaritan Housing,Inc. 2017-2018 Documentation Standards for HOPWA Public Service Contract Expenses Budget Line Items ilk 10 dc Employee Salaries and Benefits-City will only reimburse a percentage of any employee's salary and benefits who work directly with the HOPWA-funded Program. Percentages will be cost allocated and determined prior to the execution of the HOPWA Contract Agencies requesting the reimbursement of 100%of any Agency employee will require prior City approval. Agencies must show calculation on how the HOPWA portion of employee salaries and benefits were calculated consistently with the HOPWA Contract. If an employee works on both a HOPWA eligible and non-HOPWA eligible program(s),the City will only reimburse for a reasonable portion of the employee's salary. Prior to the execution of the HOPWA Contract,the Agency will priovide the City with a written statement on how each employee's time will be allocated. ff an employee works 100%of their time directly with the HOPWA-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 HOPWA-funded Program. Statements must be signed by a person authorized to sign on behalf of the Agency and will be submitted with the October invoice. Salaries X x• Reimbursement requests must include a timesheet and work log that reflects the hours worked by the employee(s)working directly on the HOPWA-funded Program. For employees who are paid with multiple funding sources,timesheets must reflect all funding sources. If separate timesheets are kept for each funding source,all such timesheets must be submitted to City. Timesheets must be signed by employee and supervisor. Agency must show a calculation and documentation of howthe 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 xx 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 Insurance employee is enrolled in the benefit plan,must show a calculation and documentation of how the invoiced amount was calculated,and Disability x x x must provide documentation showing payment.Invoice and proof of payment are only required with the first reimbursement request and Insurance at any time there are changes to amounts,enrollments,disenrollments,etc. Unemployment X X V Insurance If the City pays gross salary,this is already included.If the City pays the employer portion,the Agency must provide proof that the employee is enrolled in the benefit pian,must show a calculation and documentation of how the invoiced amount was calculated,and Retirement must provide documentation show6ng psyroeint.Invoice and proof of payment are reous"Pd 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 HOPWA-funded Program. Agencies requesting reimbursement for these items will require prior City approval. Agencies must show calculation on how the HOPWA portion of these expenses were calculated consistently with the HOPWA Contract Office Supplies X X X Office Equipment X X X X X Rental Postage X X X Printing X X X Construction& Building X X X X This category is only available for the REACH Program and Habitat for Humanity. Materials Sport and Recreation X X X Equi ment Cleaning X X X $up lies Teaching Aids X X X Craft Sup lies X X X Food Suoplies X X X This category is only available to the Program provided by Meals on Wheels. 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 HOPWA-funded Program and shall be cost-allocated in accordance with the amount of space used for the HOPWA-funded Program. These expenses may only be in support of the HOPWA-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 HOPWA funds. Agencies must show calculation on how the HOPWA portion of these expenses were calculated consistently With the HOPWA Contract. Tele hone_ X X _ Gas X X Water/Wastew X X ater Electric X X Solid Waste X X HOPWA PSA CONTRACT 2017-2018 ElliDd"F—STANDARDS FOR COMPLETE DOCUMENTATION 1 Facility I This item requires approval by the City prior to the execution of the HOPWA Contract. Repairs maybe categorized as major/minor Maintenance X X X i X rehabilitation projects and must be approved through the full HUD Environmetal Review. and Repairs Rent X X X City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the HOPWA- funded program. Miscellaneous This item requires prior approval by the City. Prior to the execution of the HOPWA Contract,the Agency must submit a written statement that lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the Contract Labor X X X X X procurement of such services and will forward any information pertaining to the procurement process to City. This requirement applies to,but is not limited to,services retained for security services,legal,accounting,transportation providers,educational facilitators, custodial services,etc. Agencies may not use the contract services of any City of Fort Worth Department. City-required X X City will only pay for a percentage of the City-required insurance so long as it's in proportion to the square footage attributable to the Insurance HOPWA-funded program. City requires that the agency submit its fee schedule or formula on how the Agency calculates the childcare scholarship amount. The fee schedule/formula should demonstrate a breakout of income levels,and for each income level the schedule should demonstrate Childcare which portion of the expense is to be paid by the family and which portion of the expense is to be reimbursed by the City. A fee Scholarships X X schedule(formula must be submitted to the City prior to the first payment. Agency must submit documentation supporting that the client is income eligible and that the household is being charged in conformance with the fee schedule. If the fee schedule/formula changes at any time during the contract term,the Agency must immediately notify City on the date the new fee schedule/formula takes into effect. "$0"Income Agecies that are required to verify and provide proof of household income to determine eligibility,must require that anyone who is over Certifications the age of 18,living in the housohold,submit a$0 Income Certification. If an audit is required because federal funds exceed$750,000,then the cost should be split evenly by all grant funding sources. Agency Audit Services X X X X must show calculation on how the HOPWA portion of the accounting services were calculated. For example,if the HOPWA grant is 10%of your Agency's budget,then invoice shall not exceed 10%of the overall cost. Agency must show a calculation and documentation of how the invoiced amount was calculated,and must provide documentation showing payment. 'Proof of payment effective October 1,2013: payments or Expenses must be documented in the following manner: A)Image of the check AND bank statement showing the check cleared the bank;OR, B)Image of the cancelled check(ex.At end of bank statement);OR, C)Payroll Check Stub,"Advice",or Statement AND Bank Statement indicating payroll;OR, D)For wire or e-transfers:Reciept or statement from payee/vendor OR bank statement. Final as or 08/262017 DC HOPWA PSA CONTRACT 2017-2018 E#ibit'P'—STANDARDS FOR COMPLETE DOCUMENTATION 1 EXHIBIT "G" SECTION 3 REPORTING FORMS NOT APPLICABLE t HOPWA PSA CONTRACT 2017-2018--EXHIBIT"&'--SECTION 3 REPORTING FORMS Page 1 Tarrant County Samaritan Housing,Inc. EXHIBIT "H" OVERVIEW REPORT HOPWA PSA CONTRACT 2017-2018--EXHIBIT"If'—OVERVIEW REPORT Page I Tarrant County Samaritan Housing,Inc. q�e'Pty£NTpR+0 � z v G9e5%DEW-, Housing Opportunities for Persons with AIDS (HOPWA) Program Consolidated Annual Performance and Evaluation Report (CAPER) Measuring Performance Outcomes Revised 1/22/15 OMB Number 2506-0133(Expiration Date: 12/31/2017) The CAPER report for HOPWA formula grantees provides annual information on program accomplishments that supports program evaluation and the ability to measure program beneficiary outcomes as related to: maintain housing stability;prevent homelessness;and improve access to care and support. This information is also covered under the Consolidated Plan Management Process(CPMP)report and includes Narrative Responses and Performance Charts required under the Consolidated Planning regulations. The public reporting burden for the collection of information is estimated to average 42 hours per manual response,or less if an automated data collection and retrieval system is in use,along with 60 hours for record keeping,including the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Grantees are required to report on the activities undertaken only,thus there may be components of these reporting requirements that may not be applicable. This agency may not conduct or sponsor,and a person is not required to respond to a collection of information unless that collection displays a valid OMB control number. Previous editions are obsolete form HUD-40110-D(Expiration Date:10/31/2017 Overview. The Consolidated Annual Performance and Evaluation Report Assistance,Housing Relocation&Stabilization Services,Employment, (CAPER)provides annual performance reporting on client outputs and Education,General Health Status,,Pregnancy Status,Reasons for Leaving, outcomes that enables an assessment of grantee performance in achieving the Veteran's Information,and Children's Education. Other HOPWA projects housing stability outcome measure. The CAPER,in conjunction with the sponsors may also benefit from collecting these data elements. Integrated Disbursement Information System(IDIS),fulfills statutory and regulatory program reporting requirements and provides the grantee and Final Assembly of Report. After the entire report is assembled,please HUD with the necessary information to assess the overall program number each page sequentially. performance and accomplishments against planned goals and objectives. HOPWA formula grantees are required to submit a CAPER,and complete Filing Requirements. Within 90 days of the completion of each program annual performance information for all activities undertaken during each year,grantees must submit their completed CAPER to the CPD Director in program year in the IDIS,demonstrating coordination with other the grantee's State or Local HUD Field Office,and to the HOPWA Program Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain Office:at HOPWA(a),hud�ov. Electronic submission to HOPWA Program essential information on grant activities,project sponsors,Subrecipient office is preferred;however,if electronic submission is not possible,hard organizations,housing sites,units and households,and beneficiaries(which copies can be mailed to:Office of HIV/AIDS Housing,Room 7212,U.S. includes racial and ethnic data on program participants). The Consolidated Department of Housing and Urban Development,451 Seventh Street,SW, Plan Management Process tool(CPMP)provides an optional tool to integrate Washington,D.C. the reporting of HOPWA specific activities with other planning and reporting on Consolidated Plan activities. Record Keeping. Names and other individual information must be kept confidential,as required by 24 CFR 574.440.However,HUD reserves the Table of Contents right to review the information used to complete this report for grants management oversight purposes,except for recording any names and other PART 1:Grantee Executive Summary identifying information. In the case that HUD must review client level 1.Grantee Information data,no client names or identifying information will be retained or 2.Project Sponsor Information recorded. Information is reported in aggregate to HUD without 3.Administrative Subrecipient Information personal identification.Do not submit client or personal information in 4.Program Subrecipient Information data systems to HUD. 5.Grantee Narrative and Performance Assessment a.Grantee and Community Overview b.Annual Performance under the Action Plan Definitions c.Barriers or Trends Overview Adjustment for Duplication: Enables the calculation of unduplicated d.Assessment of Unmet Housing Needs output totals by accounting for the total number of households or units that PART 2:Sources of Leveraging and Program Income received more than one type of HOPWA assistance in a given service 1. Sources of Leveraging category such as HOPWA Subsidy Assistance or Supportive Services.For 2.Program Income and Resident Rent Payments example,if a client household received both TBRA and STRMU during the PART 3:Accomplishment Data:Planned Goals and Actual Outputs operating year,report that household in the category of HOPWA Housing PART 4•Summary of Performance Outcomes Subsidy Assistance in Part 3,Chart 1,Column[lb]in the following manner: 1.Housing Stability: Permanent Housing and Related Facilities 2.Prevention of Homelessness: Short-Term Housing Payments [11 Outputs' 3.Access to Care and Support: Housing Subsidy Assistance with HOPWA Housing Subsidy Supportive Services Number of PART 5:R orksheet-Determining Housing Stability Outcomes Assistance Households PART 6:Annual Certification of Continued Use for HOPWA Facility- Based Stewardship Units(Only) 1. Tenant-Based Rental Assistance I PART 7:Summary Overview of Grant Activities Permanent Housing Facilities: A.Information on Individuals,Beneficiaries and Households Receiving 2a. Received Operating HOPWA Housing Subsidy Assistance(TBRA,STRMU,PHP,Facility Subsidies/Leased units Based Units,Master Leased Units ONLY) Transitional/Short-term B.Facility-Based Housing Assistance Facilities: 26. Received Operating Subsidies Continued Use Periods. Grantees that received HOPWA funding for new construction,acquisition,or substantial rehabilitations are required to operate Permanent Housing Facilities: their facilities for HOPWA-eligible beneficiaries for a ten(10)years period. Capital Development Projects If no further HOPWA funds are used to support the facility,in place of 3a. placed in service during the completing Section 7B of the CAPER,the grantee must submit an Annual operating year Certification of Continued Project Operation throughout the required use periods. This certification is included in Part 6 in CAPER.The required use Transitional/Short-term period is three(3)years if the rehabilitation is non-substantial. Facilities: Capital Development Projects In connection with the development of the Department's standards for 3b' placed in service during the Homeless Management Information Systems(HMIS),universal data operating year elements are being collected for clients of HOPWA-funded homeless assistance projects. These project sponsor/subrecipient records would Short-term Rent,Mortgage,and include:Name,Social Security Number,Date of Birth,Ethnicity and Race, 4' Utility Assistance 1 Gender,Veteran Status,Disabling Conditions,Residence Prior to Program Adjustment for duplication Entry,Zip Code of Last Permanent Address,Housing Status,Program Entry 5' subtract 1 Date,Program Exit Date,Personal Identification Number,and Household 'TOTAL.Housing Subsidy Identification Number. These are intended to match the elements under 6. Assistance(Sum of Rows 1-4 1 HMIS.The HOPWA program-level data elements include:Income and minus Rav 5) Sources,Non-Cash Benefits,HIV/AIDS Status,Services Provided,and Housing Status or Destination at the end of the operating year. Other suggested but optional elements are:Physical Disability,Developmental Disability,Chronic Health Condition,Mental Health,Substance Abuse, Domestic Violence,Date of Contact,Date of Engagement,Financial Previous editions are obsolete Page i form HUD-401 10-D(Expiration Date:10/31/2017) Administrative Costs: Costs for general management,oversight, "grassroots." coordination,evaluation,and reporting. By statute,grantee administrative costs are limited to 3%of total grant award,to be expended over the life of HOPWA Eligible Individual: The one(1)low-income person with the grant. Project sponsor administrative costs are limited to 7%of the HIV/AIDS who qualifies a household for HOPWA assistance.This person portion of the grant amount they receive. may be considered"Head of Household."When the CAPER asks for information on eligible individuals,report on this individual person only. Beneficiary(ies):All members of a household who received HOPWA Where there is more than one person with HIV/AIDS in the household,the assistance during the operating year including the one individual who additional PWH/A(s),would be considered a beneficiary(s). qualified the household for HOPWA assistance as well as any other members of the household(with or without HIV)who benefitted from the HOPWA Housing Information Services: Services dedicated to helping assistance. persons living with HIV/AIDS and their families to identify,locate,and acquire housing.This may also include fair housing counseling for eligible Central Contractor Registration(CCR): The primary registrant persons who may encounter discrimination based on race,color,religion, database for the U.S.Federal Government.CCR collects,validates,stores, sex,age,national origin,familial status,or handicap/disability. and disseminates data in support of agency acquisition missions,including Federal agency contract and assistance awards.Both current and potential HOPWA Housing Subsidy Assistance Total: The unduplicated number federal government registrants(grantees)are required to register in CCR of households receiving housing subsidies(TBRA,STRMU,Permanent in order to be awarded contracts by the federal government.Registrants Housing Placement services and Master Leasing)and/or residing in units must update or renew their registration at least once per year to maintain of facilities dedicated to persons living with HIV/AIDS and their families an active status.Although recipients of direct federal contracts and grant and supported with HOPWA funds during the operating year. awards have been required to be registered with CCR since 2003,this requirement is now being extended to indirect recipients of federal funds Household: A single individual or a family composed of two or more with the passage of ARRA(American Recovery and Reinvestment Act). persons for which household incomes are used to determine eligibility and Per ARRA and FFATA(Federal Funding Accountability and for calculation of the resident rent payment. The term is used for Transparency Act)federal regulations,all grantees and sub-grantees or collecting data on changes in income,changes in access to services,receipt subcontractors receiving federal grant awards or contracts must have a of housing information services,and outcomes on achieving housing DUNS(Data Universal Numbering System)Number. stability.Live-In Aides(see definition for Live-In Aide)and non- beneficiaries(e.g.a shared housing arrangement with a roommate)who Chronically Homeless Person:An individual or family who:(i)is resided in the unit are not reported on in the CAPER. homeless and lives or resides individual or family who:(i)Is homeless and lives or resides in a place not meant for human habitation,a safe haven,or Housing Stability: The degree to which the HOPWA project assisted in an emergency shelter;(ii)has been homeless and living or residing in a beneficiaries to remain in stable housing during the operating year. See place not meant for human habitation,a safe haven,or in an emergency Part S:Determining Housing Stability Outcomes for definitions of stable shelter continuously for at least 1 year or on at least 4 separate occasions in and unstable housing situations. the last 3 years:and(iii)has an adult head of household(or a minor head of household if no adult is present in the household)with a diagnosable In-kind Leveraged Resources: These involve additional types of support substance use disorder,serious mental illness,developmental disability(as provided to assist HOPWA beneficiaries such as volunteer services, defined in section 102 of the Developmental Disabilities Assistance and materials,use of equipment and building space. The actual value of the Bill of Rights Act of 2000(42 U.S.C.15002)),post traumatic stress support can be the contribution of professional services,based on disorder,cognitive impairments resulting from a brain injury,or chronic customary rates for this specialized support,or actual costs contributed physical illness or disability,including the co-occurrence of 2 or more of from other leveraged resources. In determining a rate for the contribution those conditions.Additionally,the statutory definition includes as of volunteer time and services,use the rate established in HUD notices, chronically homeless a person who currently lives or resides in an such as the rate of ten dollars per hour. The value of any donated material, institutional care facility,including a jail,substance abuse or mental health equipment,building,or lease should be based on the fair market value at treatment facility,hospital or other similar facility,and has resided there time of donation. Related documentation can be from recent bills of sales, for fewer than 90 days if such person met the other criteria for homeless advertised prices,appraisals,or other information for comparable property prior to entering that facility.(See 42 U.S.C.11360(2))This does not similarly situated. include doubled-up or overcrowding situations. Disabling Condition: Evidencing a diagnosable substance use disorder, Leveraged Funds: The amount of funds expended during the operating serious mental illness,developmental disability,chronic physical illness, year from non-HOPWA federal,state,local,and private sources by or disability,including the co-occurrence of two or more of these grantees or sponsors in dedicating assistance to this client population. conditions. In addition,a disabling condition may limit an individual's Leveraged funds or other assistance are used directly in or in support of ability to work or perform one or more activities of daily living.An HOPWA program delivery. HIV/AIDS diagnosis is considered a disabling condition. Facility-Based Housing Assistance: All eligible HOPWA Housing Live-In Aide: A person who resides with the HOPWA Eligible Individual expenditures for or associated with supporting facilities including and who meets the following crit a: (1)is essential to the care and well- community residences,SRO dwellings,short-term facilities,project-based being of the person;(2)is not obligated for the support of the person;and rental units,master leased units,and other housing facilities approved by (3)would not be living in the unit except to provide the necessary HUD supportive services. See the Code of Federal Regulations Title 24,Pan 5.403 and the HOPWA Grantee Oversight Resource Guide for additional Faith-Based Organization: Religious organizations of three types:(1) reference. congregations;(2)national networks,which include national denominations,their social service arms(for example,Catholic Charities, Master Leasing:Applies to a nonprofit or public agency that leases units Lutheran Social Services),and networks of related organizations(such as of housing(scattered-sites or entire buildings)from a landlord,and YMCA and YWCA);and(3)freestanding religious organizations,which subleases the units to homeless or low-income tenants.By assuming the are incorporated separately from congregations and national networks. tenancy burden,the agency facilitates housing of clients who may not be able to maintain a lease on their own due to poor credit,evictions,or lack Grassroots Organization: An organization headquartered in the local of sufficient income. community where it provides services;has a social services budget of $300,000 or less annually,and six or fewer full-time equivalent Operating Costs: Applies to facility-based housing only,for facilities employees. Local affiliates of national organizations are not considered that are currently open. Operating costs can include day-to-day housing Previous editions are obsolete Page ii form HUD-401 10-D(Expiration Date:10/31/2017) function and operation costs like utilities,maintenance,equipment, Subrecipient Organization: Any organization that receives funds from a insurance,security,furnishings,supplies and salary for staff costs directly project sponsor to provide eligible housing and other support services related to the housing project but not staff costs for delivering services. and/or administrative services as defined in 24 CFR 574.300. If a subrecipient organization provides housing and/or other supportive Outcome: The degree to which the HOPWA assisted household has been services directly to clients,the subrecipient organization must provide enabled to establish or maintain a stable living environment in housing that performance data on household served and funds expended. Funding is safe,decent,and sanitary,(per the regulations at 24 CFR 574.310(b)) flows to subrecipients as follows: and to reduce the risks of homelessness,and improve access to HIV treatment and other health care and support. HUD Funding —j Grantee --->Project Sponsor-->Subrecipient Output: The number of units of housing or households that receive Tenant-Based Rental Assistance(TBRA): TBRA is a rental subsidy HOPWA assistance during the operating year. program similar to the Housing Choice Voucher program that grantees can provide to help low-income households access affordable housing. The Permanent Housing Placement: A supportive housing service that helps TBRA voucher is not tied to a specific unit,so tenants may move to a establish the household in the housing unit,including but not limited to different unit without losing their assistance,subject to individual program reasonable costs for security deposits not to exceed two months of rent rules. The subsidy amount is determined in part based on household costs. income and rental costs associated with the tenant's lease. Program Income: Gross income directly generated from the use of Transgender: Transgender is defined as a person who identifies with,or HOPWA funds,including repayments. See grant administration presents as,a gender that is different from his/her gender at birth. requirements on program income for state and local governments at 24 CFR 85.25,or for non-profits at 24 CFR 84.24. Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States. This does not include inactive military Project-Based Rental Assistance(PBRA): A rental subsidy program reserves or the National Guard unless the person was called up to active that is tied to specific facilities or units owned or controlled by a project duty. sponsor or Subrecipient. Assistance is tied directly to the properties and is not portable or transferable. Project Sponsor Organizations: Any nonprofit organization or governmental housing agency that receives funds under a contract with the grantee to provide eligible housing and other support services or administrative services as defined in 24 CFR 574.300. Project Sponsor organizations are required to provide performance data on households served and funds expended. Funding flows to a project sponsor as follows: HUD Funding ----> Grantee—>Project Sponsor Short-Term Rent,Mortgage,and Utility(STRMU)Assistance: A time-limited,housing subsidy assistance designed to prevent homelessness and increase housing stability. Grantees may provide assistance for up to 21 weeks in any 52 week period. The amount of assistance varies per client depending on funds available,tenant need and program guidelines. Stewardship Units: Units developed with HOPWA,where HOPWA funds were used for acquisition,new construction and rehabilitation that no longer receive operating subsidies from HOPWA. Report information for the units is subject to the three-year use agreement if rehabilitation is non-substantial and to the ten-year use agreement if rehabilitation is substantial. Previous editions are obsolete Page iii form HUD-40110-D(Expiration Date:10/31/2017) Housing Opportunities for Person with AIDS (HOPWA) Consolidated Annual Performance and Evaluation Report (CAPER) Measuring Performance Outputs and Outcomes OMB Number 2506-0133(Expiration Date: 10131/2017) Park 1: Grantee Executive Summary As applicable,complete the charts below to provide more detailed information about the agencies and organizations responsible for the administration and implementation of the HOPWA program.Chart 1 requests general Grantee Information and Chart 2 is to be completed for each organization selected or designated as a project sponsor,as defined by CFR 574.3. In Chart 3,indicate each subrecipient organization with a contract/agreement of$25,000 or greater that assists grantees or project sponsors carrying out their administrative or evaluation activities. In Chart 4,indicate each subrecipient organization with a contract/agreement to provide HOPWA-funded services to client households. These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006(Public Law 109-282). Note:Please see the definition section for distinctions between project sponsor and subrecipient. Note:If arty information does not apply to your organization,please enter N/A.Do not leave any section blank. 1.Grantee Information HUD Grant Number Operating Year for this report From(mm/dd/yy) To(mm/dd/)y) Grantcc Name Business Address City,County,State,Zip Employer Identification Number(EIN)or Tax Identification Number TIN DUN&Bradstreet Number(DUNS): feniral( orttractor Registration WCR): rw .. ..::five? ❑Yes ❑No If yes,provide CCR Number: Congressional District of Grantee's Business Addr t• s '`(mt„ressional District of Primary Service Arcajsj ''Cita{ies)and Count%i ies)of Primary Service Cities: _._ Counties: Arcai,i Organir.atioa's 11 cbsif(7 uldress Is there a waiting lisps)for 11011V%A llrowsinug Sahsids .ks,ista.nce Services in the Grawce service Area? ❑ i ❑ If yes,explain in the narrative section what services maintain a waiting list and how this list is administered. *Service delivery area information only needed for program activities being directly carried out by the grantee. Previous editions are obsolete Page 1 form HUD-40110-D(Expiration Date:10/31/2017) 2.Project Sponsor Information Please complete Chart 2 for each organization designated or selected to serve as a project sponsor,as defined by CFR 574.3. Use this section to report on organizations involved in the direct delivery of services for client households. These elements address requirements in the Federal Financial Accountability and Transparency Act of 2006(Public Law 109-282). Note.Please see the definitions for distinctions between project sponsor and subrecipient. Note.If any information does not apply to your organization,please enter N/A. Project Sponsor Agency Name Parent Company Name,ifapplicable Naaw and I We of(ontact at Project Sponsor Arencc Email Address Business Address City,County,State,Zip, Phone Number(with area code) Employer Identification Number(EIN)or Faa Number(with area code) Tax Identification Number(TIN) DUN&Bradstreet Number(M Ns): Congressional District of Project Sponsor's Business Address Congressional District(s)of Primary Service Area(s) City(ies)and County(ies)of Primary Service Cities: Counties: Area(s) Total HOPWA contract amount for this Organization for the operating ear Organization's Website Address Is the sponsor a nonprofit organization? El Yes ❑No Does your organization maintain a waiting list? Yes ❑Na Please check iif yes and a faith-based organization. ❑ If yes,explain in the narrative section how this list is administered. Please check fyes and a grassroots organization. ❑ Previous editions are obsolete Page 2 form HUD-401 10-D(Expiration Date:10/31/2017) 3.Administrative Subrecipient Information Use Chart 3 to provide the following information for each Subrecipient with a contract/agreement of$25,000 or greater that assists project sponsors to carry out their administrative services but no services directly to client households. Agreements include:grants,subgrants,loans,awards,cooperative agreements,and other forms of financial assistance;and contracts, subcontracts,purchase orders,task orders,and delivery orders. (Organizations listed may have contracts with project sponsors) These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006(Public Law 109- 282). Note:Please see the definitions for distinctions between project sponsor and subrecipient. Note:If any information does not apply to your organization,please enter N/A. Subrecipient Name Parent Company Name,iiapplicable Name ant-1-1 itle of Contact at Subrecipient Email Address Business Add ress City,State,Gip,County Phone Number(with area code) Fax Number(include area code) Em plower Identification.Nuanhcr(LIN)or ,-..x ldenlihrallou NOWher(I IN) Dl N k Bradstreet Number(DUNS): North American Industry Classification SystemINAICS Code Congressional District of Subrecipient's Business vddress Cim+wressfunal I)istrio iaf 1'rimary Service Area C'.itc(less and County(ics)n1 I'riniary Service (illies: Counties: Areas} Total 1101'N1'A Subcontract Amount of this 0r ani�ation for the o era ting year Previous editions are obsolete Page 3 form HUD-40110-D(Expiration Date:10/31/2017) 4.Program Subrecipient Information Complete the following information for each Subrecipient organization providing HOPWA-funded services to client households. These organizations would hold a contract/agreement with a project sponsor(s)to provide these services. For example,a subrecipient organization may receive funds from a project sponsor to provide nutritional services for clients residing within a HOPWA facility-based housing program.Please note that subrecipients who work directly with client households must provide performance data for the grantee to include in Parts 2-7 of the CAPER. Note:Please see the definition of a subrecipient for more information. Note:Types of contracts/agreements may include:grants,sub-grants, loans, awards, cooperative agreements, and other forms of financial assistance;and contracts,subcontracts,purchase orders, task orders, and delivery orders. Note:Ifarty information is not applicable to the organization,please report N/A in the appropriate box. Do not leave boxes blank. Sub-recipient Name Parent Corn any Name,ifappheable Name and Title of Contact at Contractor/ �V Sub-contractor Agency Email Address Business Address City,County,State,Zip Fax Number(include area code) Phone Number(included area code) Employer Identification Number(EIN)or Tax Identification Number(TIN) DUN&Bradstreet Number(DUNS) North American Industry Classification System(NAICS)Code Congressional District of the Sub-recipient's Business Address Congressional District(s)of Primary Service Area City(ies)and County(ies)of Primary Service Cities: Counties: Area Total HOPWA Subcontract Amount of this Organization for the operating year Previous editions are obsolete Page 4 form HUD-401 10-D(Expiration Date:10/31/2017) 5.Grantee Narrative and Performance Assessment a.Grantee and Communitv Overview Provide a one to three page narrative summarizing major achievements and highlights that were proposed and completed during the program year. Include a brief description of the grant organization,area of service,the name(s)of the program contact(s), and an overview of the range/type of housing activities provided. This overview may be used for public information,including posting on HUD's website. Note: Text fields are expandable. b.Annual Performance under the Action Plan Provide a narrative addressing each of the following four items: 1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance,as approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your program year among different categories of housing and geographic areas to address needs throughout the grant service area,consistent with approved plans. 2. Outcomes Assessed. Assess your program's success in enabling HOPWA beneficiaries to establish and/or better maintain a stable living environment in housing that is safe,decent,and sanitary,and improve access to care. Compare current year results to baseline results for clients. Describe how program activities/projects contributed to meeting stated goals. If program did not achieve expected targets,please describe how your program plans to address challenges in program implementation and the steps currently being taken to achieve goals in next operating year. If your program exceeded program targets,please describe strategies the program utilized and how those contributed to program successes. 3.Coordination. Report on program coordination with other mainstream housing and supportive services resources,including the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified in the Consolidated Plan/Strategic Plan. 4.Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries. c.Barriers and Trends Overview Provide a narrative addressing items 1 through 3.Explain how barriers and trends affected your program's ability to achieve the objectives and outcomes discussed in the previous section. 1.Describe any barriers(including regulatory and non-regulatory)encountered in the administration or implementation of the HOPWA program,how they affected your program's ability to achieve the objectives and outcomes discussed,and, actions taken in response to barriers,and recommendations for program improvement.Provide an explanation for each barrier selected. ❑HOPWA/HUD Regulations ❑Planning ❑Housing Availability ❑Rcm Determination and Fair Market Rents ❑Discrimination/Confidentiality ❑Multiple Diagnoses ❑Eligibility ❑Technical Assistance or Training ❑Supportive Services ❑Credit History ❑Rental History ❑Criminal Justice History ❑Housing Affordability ❑Geography/Rural Access ❑Other,please explain further Previous editions are obsolete Page 5 form HUD-401 10-D(Expiration Date:10/31/2017) 2.Describe any trends in the community that may affect the way in which the needs of persons living with HIV/AIDS are being addressed,and provide any other information important to the future provision of services to this population. 3.Identify any evaluations,studies,or other assessments of the HOPWA program that are available to the public. d.Unmet Housine Needs:An Assessment of Unmet Housine Needs In Chart 1,provide an assessment of the number of HOPWA-eligible households that require HOPWA housing subsidy assistance but are not currently served by any HOPWA-funded housing subsidy assistance in this service area. In Row 1,report the total unmet need of the geographical service area,as reported in Unmet Needs for Persons with HIV/AIDS, Chart 1B of the Consolidated or Annual Plan(s),or as reported under HOPWA worksheet in the Needs Workbook of the Consolidated Planning Management Process(CPMP)tool. Note:Report most current data available, through Consolidated or Annual Plan(s), and account for local housing issues, or changes in HIV/AIDS cases, by using combination of one or more of the sources in Chart 2. If data is collected on the type of housing that is needed in Rows a.through c.,enter the number of HOPWA-eligible households by type of housing subsidy assistance needed. For an approximate breakdown of overall unmet need by type of housing subsidy assistance refer to the Consolidated or Annual Plan(s),CPMP tool or local distribution of funds.Do not include clients who are already receiving HOPWA-funded housing subsidy assistance. Refer to Chart 2,and check all sources consulted to calculate unmet need. Reference any data from neighboring states'or municipalities'Consolidated Plan or other planning efforts that informed the assessment of Unmet Need in your service area. Note: In order to ensure that the unmet need assessment for the region is comprehensive,HOPWA formula grantees should include those unmet needs assessed by HOPWA competitive grantees operating within the service area. 1. Plannine Estimate of Area's Unmet Needs for HOPNN A-Tliaible Households 1. Total number of households that have unmet housing subsidy assistance need. 2. From the total reported in Row 1,identify the number of households with unmet housing needs by type of housing subsidy assistance: a.Tenant-Based Rental Assistance(TBRA) b.Short-Term Rent,Mortgage and Utility payments (STRMU) • Assistance with rental costs • Assistance with mortgage payments • Assistance with utility costs. �c.Housing Facilities,such as community residences, SRO dwellings,other housing facilities Previous editions are obsolete Page 6 form HUD-40110-D(Expiration Date:10/31/2017) 2.Recommended Data Sources for Assessing Unmet Need check all sources used X =Data as reported in the area Consolidated Plan,e.g.Table 1B,CPMP charts,and related narratives =Data established by area HN/AIDS housing planning and coordination efforts,e.g.Continuum of Care =Data from client information provided in Homeless Management Information Systems(HMIS) =Data from project sponsors or housing providers,including waiting lists for assistance or other assessments on need including those completed by HOPWA competitive grantees operating in the region. =Data from prisons or jails on persons being discharged with HIV/AIDS,if mandatory testing is conducted =Data from local Ryan White Planning Councils or reported in CARE Act Data Reports,e.g.number of clients with permanent housing =Data collected for HN/AIDS surveillance reporting or other health assessments,e.g.local health department or CDC surveillance data End of PART 1 Previous editions are obsolete Page 7 form HUD-401 10-D(Expiration Date:10/31/2017) PART 2: Sources of Leveraging and Program Income 1. Sources of Leveraging Report the source(s)of cash or in-kind leveraged federal,state,local or private resources identified in the Consolidated or Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column[1],identify the type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords. Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section.In Column[2]report the amount of leveraged funds expended during the operating year. Use Column[3]to provide some detail about the type of leveraged contribution(e.g.,case management services or clothing donations). In Column[4],check the appropriate box to indicate whether the leveraged contribution was a housing subsidy assistance or another form of support. Note: Be sure to report on the number of households supported with these leveraged funds in Part 3, Chart 1, Column d A. Source of Leveraging Chart [2]Amount of [4] Housing Subsidy Leveraged [3]Type of Assistance or Other 1 I Source of Leveraging Funds Contribution _ _ Support Public Funding nllnu it._ �.a•iayAssistance Ryan White-Ho using Assistance []t)thcr Sail a ❑l lnu,n ;� d Assistance RN Cul 11 hitt-Other ❑ ❑]Isni i:._ tiuhsidy Assistance Housing Choice Voucher Pro ram u n-n Low Income Housing Tar Credit [j Ay Assistance HOME [ ]ttili,:r 'Nulxxe 111 ,u, iwi Sub<i6% :lywistance Shelter Plus Care ❑,,i k"l Su r wrt ❑IIou,irwt Suh.id; \<s t,ance Emergency Solutions Grant ❑_t)ilr:r Suprort -- - 11{„u�in' Suh;id� Assistance Other Public: ❑c)t he r Support ❑I inusiit*Sub idy Assistance Other Public: ❑of h,:r Support ❑I Ic u:in<_ Sub id .1 [.,tante Other Public: ❑Other Supporl []11011;i112 S L&sAy Assistance Other Public: ❑(rthcr Support Ell lousing Subsidy Assistance Other Public: ❑O t h,:r Support Private Funding [1110u�in' Subsidy Assistance Grants ❑Other port _ ❑l hn,>in tiuL.i6" Assistance In-kind Resources ❑other Support [I1[ousiu, Suhsid) Assistance Other Private: []Other SLipport ❑1[nu�iut=_'SLIbsidy Assistance Other Private: �t lthcr Support Other l ending ❑1lotnin Suh�,,id% la,Naucc Grynlrr 1'rojc cl Sp„tt«;r UUthcr Su I Tort Rc�idcnr Rcnt 1•G Client io l'r'icatc I ;trldlord TO L.U.(Sum all RoNN a Previous editions are obsolete Page 8 form HUD-40110-D(Expiration Date:10/31/2017) 2. Program Income and Resident Rent Payments In Section 2,Chart A.,report the total amount of program income and resident rent payments directly generated from the use of HOPWA funds,including repayments.Include resident rent payments collected or paid directly to the HOPWA program. Do NOT include payments made directly from a client household to a private landlord. Note:Please see report directions section for definition of program income. (Additional information on program income is available in the HOPWA Grantee Oversight Resource Guide). A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year Total Amount of Program Income Program Income and Resident Rent Payments Collected (for this operating year) 1. Program income(e.g.repayments) 2. Resident Rent Payments made directly to HOPWA Program 3. Total Program Income and Resident Rent Payments(Sum of Rows I and 2) B. Program Income and Resident Rent Payments Expended To Assist HOPWA Households In Chart B,report on the total program income and resident rent payments(as reported above in Chart A)expended during the operating year. Use Row 1 to report Program Income and Resident Rent Payments expended on Housing Subsidy Assistance Programs(i.e.,TBRA,STRMU,PHP,Master Leased Units,and Facility-Based Housing). Use Row 2 to report on the Program Income and Resident Rent Payment expended on Supportive Services and other non-direct Housing Costs. Total Amount of Program Income Expended Program Income and Resident Rent Payment Expended on (for this operating year) HOPWA programs 1. Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs 2. Program Income and Resident Rent Payment Expended on Supportive Services and other non- direct housing costs 3. Total Program Income Expended(Sum of Rows 1 and 2) End of PART 2 Previous editions are obsolete Page 9 form HUD-401 10-D(Expiration Date:10/31/2017) PART 3:Accomplishment Data Planned Goal and Actual Outputs In Chart 1,enter performance information(goals and actual outputs)for all activities undertaken during the operating year supported with HOPWA funds. Performance is measured by the number of households and units of housing that were supported with HOPWA or other federal,state,local,or private funds for the purposes of providing housing assistance and support to persons living with HIV/AIDS and their families. Note: The total households assisted with HOPWA funds and reported in PART 3 of the CAPER should be the same as reported in the annual year-end IDIS data, and goals reported should be consistent with the Annual Plan information. Any discrepancies or deviations should be explained in the narrative section of PART 1. 1. HOPWA Performance Planned Goal and Actual Outputs []]Output: Households [2]Output:Funding HOPWA I.everaged HOPWA Performance Assistance Households HOPWA Funds Planned Goal a. b. d. C. f. and Actual a m a c7 � c7 4 x m x a OPWA Housing SubsidyAssistance 11I Output:Households r2T On nt:Funding 1. tenant-Based Rental Assistance a. Permanent Housing Facilities: Received Operating Subsidies/Leased units(Households Served b. Transitional/Short-term Facilities: Received Operating Subsidies/Leased units(Households Served) Households Served a. ermanent Housing Facilities: apital' -elopment Projects placed in service during the operating year Households Scrved 3b. Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year Households Served 4. Short-Term Rent,Mortgage and Utility Assistance 5. Permanent Housing Placement Services 6. Adjustments for duplication(subtract) 7. Total HOPWA Housing Subsidy Assistance Columns a.—d. equal the sum of Rows 1-5 minus Row 6; Columns e.and f. _equal the sum of Rows 1-5) Housing Development(Construction and Stewardship of facility based housing) [11 Output- Housing Units 121 Outout..Funding 8. Facility-based units, apital..;, . r.. .... not et opened(Housing Units) 9. Stewardship Units subject to 3 or 10 year use agreements 10. Total Housing Developed (Sum of Rows S&9 Supportive Sery ceS 1 output 2 ou ntrFundin 1 la. Supportive Services provided by project sponsors/subrecipient that also delivered OP WA housing subsidy assistance 1 lb. Supportive Services provided by project sponsors/subrecfpient that only provided —supportive services. 12. Adjustment for duplication(subtract) 13. Total Supportive Services (Columns a.—d.equal the sum of Rows 11 a.&b.minus Row 12;Columns e.and f.equal the sum of Rows 11a.&11 b.l Housing Information Services 111 outpul Ilousebolds 121 Output;Funding 14. Housing Information Services 15. Total Housing Information Services Previous editions are obsolete Page 10 form HUD-40110-D(Expiration Date:10/31/2017) Grant Administration and Other Activities Ill Output Households [21 Output:Funding 16. Resource Identification to establish,coordinate and develop housing assistance resource 17. Technical Assistance if approved it grant agreement) 18. rantee Administration maximum-i%of total HOPWA grant) 19. Project Sponsor Administration maximum 7%of portion of HOPWA ant awarded) 0. otal Grant Administration and Other Activities Sum of Rows 16—19) 121 Outputs: HOPWA Funds otal Expended Expended Budget Actual 1. Total Expenditures for program year(Sum of Rows 7,10,13,15,and 20) 2.Listing of Supportive Services Report on the households served and use of HOPWA funds for all supportive services. Do NOT report on supportive services leveraged with non-HOPWA funds. Data check:Total unduplicated households and expenditures reported in Row 17 equal totals reported in Part 3,Chart 1,Row 13. Supportive Services [ll Output:Number of Households 121 Output:Amount of HOPWA Funds Expended L Adult day care and personal assistance 2. Alcohol and drug abuse services 3. Case management 4. Child care and other child services 5. Education 6. Employment assistance and training Health/medicallintensive care services,if approved 7. Note: Client records must conform with 24 CFR'574.310 8. Legal services 9. Life skills management outside of case management) 10. Meals/nutritional services 11. Mental health services 12. Outreach 13. Transportation Other Activity(if approved in grant agreement). 14. Specify: Sub-Total Households receiving Supportive Services 15. (Sum of Rows 1-14 16. Adjustment for Duplication subtract TOTAL Unduplicated Households receiving Supportive Services(Column[1]equals Row 15 17. minus Row 16;Column 121 equals sum of Rows 1-14 Previous editions are obsolete Page ll form HUD-401 10-D(Expiration Date:10/31/2017) 3.Short-Term Rent,Mortgage and Utility Assistance(STRMU)Summary In Row a.,enter the total number of households served and the amount of HOPWA funds expended on Short-Term Rent, Mortgage and Utility(STRMU)Assistance. In Row b.,enter the total number of STRMU-assisted households that received assistance with mortgage costs only(no utility costs)and the amount expended assisting these households. In Row c.,enter the total number of STRMU-assisted households that received assistance with both mortgage and utility costs and the amount expended assisting these households. In Row d.,enter the total number of STRMU-assisted households that received assistance with rental costs only(no utility costs)and the amount expended assisting these households. In Row e.,enter the total number of STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these households. In Row f.,enter the total number of STRMU-assisted households that received assistance with utility costs only(not including rent or mortgage costs)and the amount expended assisting these households. In row g.,report the amount of STRMU funds expended to support direct program costs such as program operation staff. Data Check:The total households reported as served with STRMU in Row a.,column[1]and the total amount of HOPWA funds reported as expended in Row a.,column[21 equals the household and expenditure total reported for STRMU in Part 3,Chart 1,Row 4,Columns b.and f., respectively. Data Check:The total number of households reported in Column[1],Rows b.,c.,d.,e.,and f.equal the total number ofSTRMU households reported in Column[1],Row a. The total amount reported as expended in Column[2],Rows b.,c.,d.,e.,f.,and g.equal the total amount of STRMU expenditures reported in Column[2],Row a. [11 Output: Number of 121 Output:Total Housing Subsidy Assistance Categories(STRMU) Households Served HOPWA Funds Expended on STRMU during Operating Year TpUt1 Short-ti" mortgage,rent and/or utility(STRMU) a. aa�sashmce Of the total STRMU reeWrted on Row a,total who received b. assistance with mortgage costs ONLY Of the total STRMU reported on Row a.total who received C. assistance with mortgage and utility costs. Of the total STRMU reported on Row a total who received d. assistance with rental costs ONLY. Of the total STRMU reported on Row a total who received e. assistance with rental and utility costs. Of the total STRMU reported on Row a.total who received f assistance with utility costs ONLY. Direct program delivery costs(e.g.,program operations staff time) 9. End of PART 3 Previous editions are obsolete Page 12 form HUD-401 10-D(Expiration Date:10/31/2017) Part 4:Summary of Performance Outcomes In Column[1],report the total number of eligible households that received HOPWA housing subsidy assistance,by type. In Column[2],enter the number of households that continued to access each type of housing subsidy assistance into next operating year. In Column[3],report the housing status of all households that exited the program. Data Check:The sum of Columns[2](Number of Households Continuing)and[31(Exited Households)equals the total reported in Column[1]. Note:Refer to the housing stability codes that appear in Part 5: Worksheet-Determining Housing Stability Outcomes. Section 1.Housing Stability:Assessment of Client Outcomes on Maintaining Housing Stability(Permanent Housing and Related Facilities) A.Permanent ousing Subsidy Assistance [11 Output:Total [21 Assessment:Number of 131 Assessment:Number of Number of Households that Continued Households that exited this [41 HOPWA Client Households Receiving HOPWA Housing HOPWA Program;their Housing Outcomes Served Subsidy Assistance into the Next Status after Exiting Operating Year 1 Emergency Shelter/Streets Unstable Arrangements 2 Temporary Housing Temporarily Stable,with Reduced Risk of Homelessness 3 Private Housing Tenant-Based Rental 4 Other HOPWA Assistance Stable/Permanent Housing(PH) 5 Other Subsidy 6 Institution 7 Jai/Prison Unstable Arrangements 8 Disconnected/Unknown 9 Death Life Event 1 Emergency Shelter/Streets Unstable Arrangements 2 Temporary Housing Temporarily Stable,with Reduced Risk of Homelessness 3 Private Housing Permanent Supportive 4 Other HOPWA Housing Stable/Permanent Housing(PH) g 5 Other Subsidy Facilities/Units 6 Institution 7 Jail/Prison 8 Disconnected/Unknown Unstable Arrangements 9 Death Life Event B.Transitional Housing Assistance [11 Output: Total [21 Assessment:Number of [31 Assessment:Number of Number of Households that Continued Households that exited this Households Receiving HOPWA Housing HOPWA Program;their 141 HOPWA Client Outcomes Served Subsidy Assistance into the Next Housing Status after Exiting Operating Year 1 Emergency Shelter/Streets Unstable Arrangements 2 Temporary Housing Temporarily Stable with Reduced Risk of Homelessness Transitional/ 3 Private Housing Short-Term Housing 4 Other HOPWA Facilities/Units 5 Other Subsidy Stable/Permanent Housing(PH) 6 Institution 7 Jail/Prison Unstable Arrangements 8 Disconnected/unknown 9 Death Life Event Previous editions are obsolete Page 13 form HUD-401 10-D(Expiration Date:10/31/2017) B I:Total number of households receiving transitional/short-term housing assistance whose tenure exceeded 24 months Section 2.Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness (Short-Term Housing Subsidy Assistance) Report the total number of households that received STRMU assistance in Column[1]. In Column[2],identify the outcomes of the households reported in Column[1]either at the time that they were known to have left the STRMU program or through the project sponsor or subrecipient's best assessment for stability at the end of the operating year. Information in Column[3]provides a description of housing outcomes;therefore,data is not required. At the bottom of the chart: • In Row la.,report those households that received STRMU assistance during the operating year of this report,and the prior operating year. • In Row lb.,report those households that received STRMU assistance during the operating year of this report,and the two prior operating years. Data Check: The total households reported as served with STRMU in Column[1]equals the total reported in Part 3, Chart 1, Row 4, Column b. Data Check: The sum of Column[21 should equal the number of households reported in Column[1]. Assessment of Households that Received STRMU Assistance [1] Output:Total [2]Assessment of Housing Status [3] HOPWA Client Outcomes number of households Maintain Private Housing without subsidy (e.g.Assistance providedeompletedand,:,ent is stable,not likely to seek additional support) Other Private Housing without subsidy (e.g.client switched housing units and is now stable,not likely to seek additional support) Stable/Permanent Housing(PH) Other HOPWA Housing Subsidy Assistance Other Housing Subsidy(PH) Institution (e.g.residential and long-term care) Likely that additional STRMU is needed to maintain current housing arrangements Transitional Facilities/Short-term Temporarily Stable, with (e.g.temporary or transitional arrangement) Reduced Risk of Homelessness Temporary/Non-Permanent Housing arrangement (e.g.gave up lease,and moved in with family or friends but expects to live there less than 90 days) Emergency Shelter/street Jail/Prison Unstable Arrangements Disconnected Death Life Event Ia.Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the prior operating year(e.g.households that received STRMU assistance in two consecutive operating years). lb.Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the two prior operating years(e.g.households that received STRMU assistance in three consecutive operating years). Previous editions are obsolete Page 14 form HUD-40110-D(Expiration Date:10/31/2017) Section 3.HOPWA Outcomes on Access to Care and Support la. Total Number of Households Line[1]:For project sponsors/subrecipients that provided HOPWA housing subsidy assistance during the operating year identify in the appropriate row the number of households that received HOPWA housing subsidy assistance(TBRA, STRMU,Facility-Based,PHP and Master Leasing)and HOPWA funded case management services. Use Row c.to adjust for duplication among the service categories and Row d.to provide an unduplicated household total. Line[2]:For project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance identify in the appropriate row the number of households that received HOPWA funded case management services. Note.These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be used by HUD as a basis for analyzing the percentage of households who demonstrated or maintained connections to care and support as identified in Chart lb. below. Total Number of llouseholds 1. For Project Sponsors/Subrecipieills that provided I10 VWA Housing Subsidy Assistance: Identify the total number of households that received the foflrvwn_'.HOP%k A-;larded.wrcicrs. a. HoP.ism tiuhtiidw iduplicated)-]BR:1.c I RNIC,PHP,Facility-Based Housing,ani;:''` l.tasrne: b. C. tlanaLcrnent C. Adpnsrnwnt duplication{subtraction) d. Total llnuseholds Served by 1'rujectSponsors/Suhrecipients with Housinti Suhsid} 1lssislanre(Sum of Hons a.h. minus Han c.) 2. For Project Sponsors/Subrecipients did NOT provide lltll'WA housing Subsidy assistance: ldcrtiiy the total number of households that rcceiced the tollowwmL,,IfOPWA-fundc[l service: a. HOPWA Uase Manzw,eir ra T- b. Total Households Served b} Project Sponsors/Subrecipients without Housing Subsidy Assistance lb. Status of Households Accessing Care and Support Column[1]:Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA housing subsidy assistance as identified in Chart la.,Row Id.above,report the number of households that demonstrated access or maintained connections to care and support within the program year. Column[2]:Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance as reported in Chart la.,Row 2b.,report the number of households that demonstrated improved access or maintained connections to care and support within the program year. Note.For information on types and sources o income and medical insurance/assistance, refer to Charts below. [21 For project [1 J For project sponsors/subrecipients that sponsors/subrecipients that did NOT provide HOPWA Outcome Categories of Services Accessed provided HOPWA housing subsidy housing subsidy assistance, Indicator assistance,identify the households identify the households who who demonstrated the following: demonstrated the following: 1 Has a housing plan for maintaining or establishing stable on- Support for going housing Stable Housing 2.Had contact with case manager/benefits counselor consistent with the schedule specified in client's individual service plan Access to (may include leveraged services such as Ryan White Medical Support Case Management) 3.Had contact with a primary health care provider consistent Access to with the schedule specified in client's individual service plan Health Care 4.Accessed and maintained medical insurance/assistance Access to Health Care 5.Successfully accessed or maintained qualification for sources Sources of of income Income Previous editions are obsolete Page 15 form HUD-401 10-D(Expiration Date:10/31/2017) Chart lb.,Line 4: Sources of Medical Insurance and Assistance include,but are not limited to the following (Reference only) • MEDICAID Health Insurance Program,or • Veterans Affairs Medical Services use local program • AIDS Drug Assistance Program(ADAP) Ryan White-funded Medical or Dental name • State Children's Health Insurance Program Assistance • MEDICARE Health Insurance Program,or (SCHIP),or use local program name use local program name Chart lb.,Row 5: Sources of Income include,but are not limited to the following Reference only) • Earned Income • Child Support • General Assistance(GA),or use local • Veteran's Pension • Social Security Disability Income(SSDI) program name • Unemployment Insurance • Alimony or other Spousal Support • Private Disability Insurance • Pension from Former Job • Veteran's Disability Payment • Temporary Assistance for Needy • Supplemental Security Income(SSI) • Retirement Income from Social Security Families(TANF) • Worker's Compensation • Other Income Sources lc.Households that Obtained Employment Column[1]:Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA housing subsidy assistance as identified in Chart la.,Row ld.above,report on the number of households that include persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance,education or related case management/counseling services. Column[2]:Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance as reported in Chart la.,Row 2b.,report on the number of households that include persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance,education or case management/counseling services. Note:This includes jobs created by this project sponsor/subrecipients or obtained outside this agency. Note: Do not include jobs that resulted from leveragedjob training, employment assistance, education or case management/counseling services. 11 For project sponsors/subrecipients that [21 For project sponso rs/sub recipients that did Categories of Services Accessed provided HOPWA housing subsidy NOT provide HOPWA housing subsidy assistance, assistance,identify the households who identify the households who demonstrated the demonstrated the following: following: golds that m i7ir%uiic roducin 'ob End of PART 4 Previous editions are obsolete Page 16 form HUD-401 10-D(Expiration Date:10/31/2017) PART 5:Worksheet-Determining Housing Stability Outcomes(optional) 1.This chart is designed to assess program results based on the information reported in Part 4 and to help Grantees determine overall program performance. Completion of this worksheet is o tional. Permanent Stable Housing Temporary Housing Unstable Life Event Housing Subsidy (#of households (2) Arrangements (9) Assistance remaining in program (1+7+8) plus 3+4+5+6 Tenant-Based Rental Assistance (TBRA Permanent Facility- based Housing Assistance/Units Transitional/Short- Term Facility-based Housing Assistance/Units Total Permanent HOPWA Housing Sabsidv Assistance Reduced Risk of Mshls•I'rrnrxueui Icmpurnrilk St:rhlr.�Nith Reduced Risk of Unstable Life Events Homelessness: -ness Arrangements Short-Term Assistance _ Short-Term Rent, Mortgage,and Utility Assistance STRMU Total HOPWA Housing Subsidy Assistance Background on HOPWA Housing Stability Codes Stable Permanent Housing/Ongoing Participation 3=Private Housing in the private rental or home ownership market(without known subsidy,including permanent placement with families or other self-sufficient arrangements)with reasonable expectation that additional support is not needed. 4=Other HOPWA-funded housing subsidy assistance(not STRMU),e.g.TBRA or Facility-Based Assistance. 5=Other subsidized house or apartment(non-HOPWA sources,e.g.,Section 8,HOME,public housing). 6=Institutional setting with greater support and continued residence expected(e.g.,residential or long-term care facility). Temporary Housing 2=Temporary housing-moved in with family/friends or other short-term arrangement,such as Ryan White subsidy,transitional housing for homeless,or temporary placement in institution(e.g.,hospital,psychiatric hospital or other psychiatric facility, substance abuse treatment facility or detox center). Unstable Arrangements 1 =Emergency shelter or no housing destination such as places not meant for habitation(e.g.,a vehicle,an abandoned building, bus/train/subway station,or anywhere outside). 7=Jail/prison. 8=Disconnected or disappeared from project support,unknown destination or no assessments of housing needs were undertaken. Life Event 9=Death,i.e.,remained in housing until death.This characteristic is not factored into the housing stability equation. Tenant-based Rental Assistance: Stable Housine is the sum of the number of households that(i)remain in the housing and(ii) those that left the assistance as reported under:3,4,5,and 6.Temporary Housing is the number of households that accessed assistance,and left their current housing for a non-permanent housing arrangement,as reported under item:2.Unstable Situations is the sum of numbers reported under items: 1,7,and 8. Previous editions are obsolete Page 17 form HUD-40110-D(Expiration Date:10/31/2017) Permanent Facility-Based Housing Assistance: Stable Housing is the sum of the number of households that(i)remain in the housing and(ii)those that left the assistance as shown as items:3,4,5,and 6.Temporary Housing is the number of households that accessed assistance,and left their current housing for a non-permanent housing arrangement,as reported under item 2. Unstable Situations is the sum of numbers reported under items: 1,7,and 8. Transitionat/Short-Term Facility-Based Housing Assistance: Stable Housing is the sum of the number of households that(i) continue in the residences(ii)those that left the assistance as shown as items:3,4,5,and 6.Other Temporary Housing is the number of households that accessed assistance,and left their current housing for a non-permanent housing arrangement,as reported under item 2. Unstable Situations is the sum of numbers reported under items: 1,7,and 8. Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes,indicate the number of households whose tenure exceeded 24 months. STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain permanent housing living situation(as this is a time-limited form of housing support)as reported under housing status:Maintain Private Housing with subsidy;Other Private with Subsidy;Other HOPWA support;Other Housing Subsidy;and Institution. Temporarily Stable,with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain housing arrangements in the next year,as reported under housing status:Likely to maintain current housing arrangements,with additional STRMU assistance;Transitional Facilities/Short-term;and Temporary/Non-Permanent Housing arrangements Unstable Situation is the sum of number of households reported under housing status:Emergency Shelter;Jail/Prison;and Disconnected. End of PART 5 Previous editions are obsolete Page 18 form HUD-401 10-D(Expiration Date:10/31/2017) PART 6:Annual Certification of Continued Usage for HOPWA Facility-Based Stewardship Units(ONLY) The Annual Certification of Usage for HOPWA Facility-Based Stewardship Units is to be used in place of Part 7B of the CAPER if the facility was originally acquired,rehabilitated or constructed/developed in part with HOPWA funds but no HOPWA funds were expended during the operating year. Scattered site units may be grouped together on one page. Grantees that used HOPWA funding for new construction,acquisition,or substantial rehabilitation are required to operate their facilities for HOPWA eligible individuals for at least ten(10)years. If non-substantial rehabilitation funds were used they are required to operate for at least three(3)years. Stewardship begins once the facility is put into operation. Note.See definition of Stewardship Units. 1.General information Operating Year for this report HUD Grant Numbers) From(mm/dd/yy)To(mm/dd/yy) ❑Final Yr ❑Yr 1; ❑Yr 2; ❑Yr 3; ❑Yr 4; ❑Yr 5; ❑Yr 6; ❑Yr 7; ❑Yr 8; ❑Yr 9; ❑Yr 10; Grantee Name Date Facility Began Operations(mm/dd/yy) 2.Number of Units and Non-HOPWA Ex enditures Facility Name: Number of Stewardship Units Amount of Non-HOPWA Funds Expended in Support of the Developed with HOPWA Stewardship Units during the Operating Year funds Total Stewardship Units (subject to 3-or 10-year useperiods) 3.Details of Project Site Project Sites:Name of HOPWA-funded project Site Information:Project Zip Code(s) Site Information:Congressional District(s) Is the address of the project site confidential? ❑ Yes,protect information;do not list ❑ Not confidential;information can be made available to the public If the site is not confidential: Please provide the contact information,phone, email address/location,if business address is different from facility address I certify that the facility that received assistance for acquisition,rehabilitation,or new construction from the Housing Opportunities for Persons with AIDS Program has operated as a facility to assist HOPWA-eligible persons from the date shown above. I also certify that the grant is still serving the planned number of HOPWA-eligible households at this facility through leveraged resources and all other requirements of the grant agreement are being satisfied. I hereby certify that all the information stated herein,as well as any in ormatton provided in the accompaniment herewith,is true and accurate. Name&Title of Authorized Official of the organization that continues Signature&Date(mm/dd/yy) to operate the facility: Name&Title of Contact at Grantee Agency Contact Phone(with area code) (person who can answer questions about the report and program) End of PART 6 Previous editions arc obsolete Page 19 form HUD-40110-D(Expiration Date:10/31/2017) Part 7: Summary Overview of Grant Activities A. Information on Individuals,Beneficiaries,and Households Receiving HOPWA Housing Subsidy Assistance (TBRA, STRM1), Facility-Based Units,Permanent Housing Placement and Master Leased Units ONLY) Note. 1h portingfor this section should include ONLY those individuals, beneficiaries, or households that received and/or resided in a household that received HOPWA Housing Subsidy Assistance as reported in Part 3, Chart 1,Row 7, Column b. (e.g., do not include households that received HOPWA supportive services ONLY). Section 1. HOPWA-Eligible Individuals who Received HOPWA Housing Subsidy Assistance a.Total HOPWA Eligible Individuals Living with HIV/AIDS In Chart a.,provide the total number of eligible(and unduplicated)low-income individuals living with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the individual who qualified the household for HOPWA assistance,NOT all HIV positive individuals in the household. Individuals Served with Housing Subsidy Assistance Total Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance. Chart b.Prior Living Situation In Chart b.,report the prior living situations for all Eligible Individuals reported in Chart a. In Row 1,report the total number of individuals who continued to receive HOPWA housing subsidy assistance from the prior operating year into this operating year. In Rows 2 through 17,indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during the operating year. Data Check: The total number of eligible individuals served in Row 18 equals the total number of individuals served through housing subsidy assistance reported in Chart a. above. Total HOPWA Category Eligible Individuals Receiving Housing Subsidy Assistance 1. 1 Continuing to receive HOPWA support from the prior operating New Individ uAs A ho reeeked 110P`NA Housing Suhstdt assistance support during Operatin Ytear 2. Pl r h o l:um ur hahita[icn outside 3. Emergency shelf�,,.- mg hotel,motel,or ea aipground paid for w.':.emergency shelter voucher) 4. Transitional housing for homeless persons Total number of neIs 1^i able Individuals who rcceh ed 11f 5, �� ?Pt1',Y Hrrusinl,Subsidy kssistance with a Prior Uvutg Situation that meets 11111)definition of homel'essuess(Sint of Rows'2—4) 6. 'ermanent ht,using for iirrrnerly liunlcle„ eryurlr(Such Shelter NLJ,� Sill' or SRO Mod Rehab) 7. Psychiatric hospital or other psychiatric facility 8. Substance abuse treatment facility or detox center 9. Hospital(non-psychiatric facility) 10. Foster care home or foster care group home 11. Jail,prison or juvenile detention facility 12. Rented room,apartment,or house 13. House you own 14. Staying or living in someone else's(family and friends)room,apartment,or house 15. Hotel or motel paid for without emergency shelter voucher 16. Other 17. Don't Know or Refused 18. TOTAL Number of HOPWA Eligible Individuals(sum of Rows 1 and 5-17) Previous editions are obsolete Page 20 form HUD-40110-D(Expiration Date:10/31/2017) c.Homeless Individual Summary In Chart c.,indicate the number of eligible individuals reported in Chart b.,Row 5 as homeless who also are homeless Veterans and/or meet the definition for Chronically Homeless(See Definition section of CAPER). The totals in Chart c.do not need to equal the total in Chart b.,Row 5. Number of Number of Chronically Category Homeless Veteran(s) Homeless HOPWA eligible individuals served with HOPWA Housing Subsidy Assistance Section 2. Beneficiaries In Chart a.,report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing subsidy assistance(as reported in Part 7,4,Section 1, Chart a.),and all associated members of their household who benefitted from receiving HOPWA housing subsidy assistance(resided with HOPWA eligible individuals). Note.See definition of HOPWA Eligible Individual Note.See definition of Transeg nder. Note. See definition of BeneIciaries. Data Check:The sum of each of the Charts b. &c. on the following two pages equals the total number of beneficiaries served with HOPWA housing subsidy assistance as determined in Chart a.,Row 4 below. a.Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance Individuals and Families Served with HOPWA Housing Subsidy Assistance Total Number 1. Number of individuals with 111WAIDS who dual[Died the household to receive H01'%k A housing subsidy assistance(u uals the number of 1101'WA Elicibh+ . Indi,ideals rc xorted in Part 7,A.Seoion 1.Chart a) 2. Number of AL othcr diagnosed positk. , the 1-IOPWAeligible individuals identified in Row I and nho benefitted f roin the IIOP%1 hmib ing subsidy assistance 3. Number of ALL other i> sons NOT diagnosed as HIV .Psitive who reside with the HOPWA eligible individual identified in Roy I who benefited 40PWA housing subsidy 4. TOTAL number of ALL beneficiarics served with l{nusing Subsidy Assistance(Sum of Rows 1,2,&3) `t Previous editions are obsolete Page 21 form HUD-401 10-D(Expiration Date:10/31/2017) b.Age and Gender In Chart b.,indicate the Age and Gender of all beneficiaries as reported in Chart a.directly above. Report the Age and Gender of all HOPWA Eligible Individuals(those reported in Chart a.,Row 1)using Rows 1-5 below and the Age and Gender of all other beneficiaries(those reported in Chart a.,Rows 2 and 3)using Rows 6-10 below. The number of individuals reported in Row 11, Column E.equals the total number of beneficiaries reported in Part 7,Section 2,Chart a.,Row 4. HOPWA Eligible Individuals Chart a,Row 1 A. B. C. D. E. TOTAL(Sum of Male Female Trans ender M to F Trans ender F to M Columns A-D 1. Under 18 2. 18 to 30 years 3. 31 to 50 years 51 years and 4. Older Subtotal(Sum 5. of Rows 14 All Other Beneficiaries(Chart ar Row's 2 and 3 A. B. �..... C. D. E. TOTAL(Sum of Male Female Transgender M to F Trans ender F to M Columns A-D 6. Under 18 7. 18 to 30 years 8. 1 31 to 50 years 51 years and 4. Older Subtotal(Sum 10. of Rows 6 Total Beneficiaries Chart a,`Row 4 TOTAL(Sum 11. of Rows 5&10 Previous editions are obsolete Page 22 form HUD-401 10-D(Expiration Date:10/31/2017) c.Race and Ethnicity* In Chart c.,indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in Section 2,Chart a.,Row 4. Report the race of all HOPWA eligible individuals in Column[A]. Report the ethnicjjY of all HOPWA eligible individuals in column[B]. Report the race of all other individuals who benefitted from the HOPWA housing subsidy assistance in column[C]. Report the ethnicijy of all other individuals who benefitted from the HOPWA housing subsidy assistance in column[D]. The summed total of columns[A]and[C]equals the total number of beneficiaries reported above in Section 2,Chart a.,Row 4. HOPWA Eligible Individuals All Other Beneficiaries [A] Race [C] Race Category [all individuals [B]Ethnicity [total of [D]Ethnicity reported in [Also identified as individuals [Also identified as Hispanic or reported in Hispanic or Section 2,Chart p po p a.,Row 11 Latino] Section 2,Chart Latino] a.,Rows 2&31 1. American Indian/Alaskan Native 2. Asian 3. Black/African American 4. Native Hawaiian/Other Pacific Islander 5. White 6. American Indian/Alaskan Native&White 7. Asian&White 8. Black/African American&White 9 American Indian/Alaskan Native& Black/African American 10. Other Multi-Racial 11. Column Totals(Sum of Rows 1-10) Data Check:Sum of Raw 11 Column A and Row 11 Column C equals the total number HOPWA Beneficiaries reported in Part 3A,Section 2, Chart a,Row 4. *Reference(data requested consistent with Form MID-27061 Race and Ethnic Data Reporting Form) Section 3. Households Household Area Median Income Report the area median income(s)for all households served with HOPWA housing subsidy assistance. Data Check: The total number of households served with HOPWA housing subsidy assistance should equal Part 3C,Row 7, Column b and Part 7A,Section 1, Chart a. (Total HOPWA Eligible Individuals Served with HOPWA Housing Subsidy Assistance). Note: Refer to hgp://www.huduser.o_rg/portalldalaset&lillil2O101select Geographv mfi,odn for information on area median income in your community. Percentage of Area Median Income Households Served with HOPWA Housing Subsidy Assistance I. 0-30%of area median income(extremely low) 2. 31-50%of area median income(very low) 3. 51-80%of area median income(low) 4. Total(Sum of Rows 1,3) Previous editions are obsolete Page 23 form HUD-40110-D(Expiration Date:10/31/2017) Part 7: Summary Overview of Grant Activities B. Facility-Based Housing Assistance Complete one Part 7B for each facility developed or supported through HOPWA funds. Do not complete this Section for programs originally developed with HOPWA funds but no longer supported with HOPWA funds. If a facility was developed with HOPWA funds(subject to ten years of operation for acquisition,new construction and substantial rehabilitation costs of stewardship units,or three years for non-substantial rehabilitation costs),but HOPWA funds are no longer used to support the facility,the project sponsor or subrecipient should complete Part 6: Annual Certification of Continued Usage for HOPWA Facility-Based Stewardship Units(ONLY). Complete Charts 2a.,Project Site Information,and 2b.,Type of HOPWA Capital Development Project Units,for all Development Projects,including facilities that were past development projects,but continued to receive HOPWA operating dollars this reporting year. 1.Pro'ect S onsor/Subreci ient Agency Name(Required) 2. Capital Development 2a.Project Site Information for HOPWA Capital Development of Projects(For Current or Past Capital Development Projects that receive HOPWA Operating Costs this reporting year) Note:If units are scattered-sites, report on them as a group and under e o Facili write "Scattered Sites." HOPWA Name of Facility: Type of Funds Non-HOPWA funds Development Expended this operating this operating Expended (if applicable) year year _ff applicable El New construction S s Type of Facility [Check only one box.] Rehabilitation $ $ E] Permanent housing ❑ Short-term Shelter or Transitional housing Acquisition $ $ ❑ Supportive services only facility ❑Operating $ $ a. Purchase/lease of property: Date(mm/dd/yy): b. Rehabilitation/Construction Dates: Date started: Date Completed: C. Operation dates: Date residents began to occupy: ❑ Not vet occupied d. Date supportive services began: Date started: ❑ Not yet providing services e. Number of units in the facility: HOPWA-funded units= Total Units= f. Is a waiting list maintained for the facility? [I Yes [__1 No Ifyes,number ofparticipants on the list at the end of operating year g. What is the address of the facility(if different from business address)? h• Is the address of the project site confidential? ❑ Yesrrotect information;e, bIish list ❑ Na,curt he 1,i,,"< <,�; t+e ?4r: Previous editions are obsolete Page 24 form HUD-401 10-D(Expiration Date:10/31/2017) 2b. Number and Type of HOPWA Capital Development Project Units(For Current or Past Capital Development Projects that receive HOPWA Operating Costs this Reporting Year) For units entered above in 2a.please list the number of HOPWA units that fulfill the following criteria: Number Number Designated for the Chronically Designated to Number Energy- Number 504 Accessible Homeless Assist the Star Compliant Homeless Rental units constructed (new)and/or acquired with or without rehab Rental units rehabbed Homeownership units constructed(if approved) 3.Units Assisted in Types of Housing Facility/Units Leased by Project Sponsor or Subrecipient Charts 3a..3b.and 4 are required for each facility. In Charts 3a.and 3b.,indicate the type and number of housing units in the facility,including master leased units,project-based or other scattered site units leased by the organization,categorized by the number of bedrooms per unit. Note.The number units may not equal the total number of households served. Please complete separate charts for each housing facility assisted Scattered site units may be grouped together. 3a. Check one only ❑ Permanent Supportive Housing Facility/Units ❑ Short-term Shelter or Transitional Supportive Housing Facility/Units 3b.Type of Facility Complete the following Chart for all facilities leased,master leased,project-based,or operated with HOPWA funds during the reporting year. Name of Project Sponsor/Agency Operating the Facility/Leased Units: Total Number of Units in use during the Operating Year Type of housing facility operated by the Cate orized by the Number of Bedrooms per Units project sponsor/subrecipient SRO/Studio/0 1 bdrm 2 bdrm 3 bdrm 4 bdrm 5+bdrm bdrm a. Single room occupancy dwelling Community residence C. Project-based rental assistance units or leased units d Other housing facility S ci 4.Households and Housing Expenditures Enter the total number of households served and the amount of HOPWA funds expended by the project sponsor/subrecipient on subsidies for housing involving the use of facilities,master leased units,project based or other scattered site units leased by the organization. I Housing Assistance Category: Facility Based Housing Output: Number of Output: Total HOPWA Funds Expended during Households Operating Year by Project S onsor/subrecipient a leasing Costs b Operating Costs C. Project-Based Rental Assistance(PBRA)or other leased units d Other Activity(if approved in grant agreement)Specify: e Adjustment to eliminate duplication(subtract) TOTAL Facilit-N-Rased llmr ing A�aistance f (Sum 16ws a.throuub d.minus Rtl%c. Previous editions are obsolete Page 25 form HUD-40110-D(Expiration Date:10/31/2017) EXHIBIT "I" MBE REPORTING FORM HOPWA PSA CONTRACT 2017-2018--EXHIBIT"I"--MBE REPORTING FORM Page 1 Tarrant County Samaritan Housing,Inc. Contract and Subcontract Activity U.S.Department of Housing and Urban Development OMB Approve]No.:2577-0089 DIAB Approval No,:2502-0355 Public reporting burden for this collation of inflammation is estimated to—g..5 hours per response,including the time for review,,,a„,,,,,,,,,,,,,, ,;,ruya gathering and maintaining the data needed,and completing and reviewing the collection of information.The Wormation is voluntary.HUD may not collect this infwmetion,and you are not required to complete this forth,unless it displays a currently valid OMB Control Number, 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 infarmation is used by HUD to monitor and evaluate MBE activities against the total program activity and the designated mitmrity business enterprise(MBE)goals.The Department requires the information to provide guidance and oversight for programs for the development of minority business adeoprw concerning Minority Business Development.If the information is not collected HUD would not be able to establish meaningful MBE goals nor evaluate MBE perl'ortnace against these goals. Privacy Act Notice-The United States Department of Housing and Urban Dwdopment,Federal Housing Administration,is authorized m solicit the Information requested in this form by virtue of Title 12,United Steres Code,Section 1701 in seq.,and regulation.It will nes be disclosed a relesed outside the United States Department of Housing and Urban Development without your concern,except as required or permitted by Caw. 1.CaantealProjett Owna/DevelopedSponsorBudder/A e—y Check if: 2.Location(City,Stale Zip Code) PH IH CPD Hous n 3a Name of Cane.Perron 36Pfwm Number(including Arco Code) 4.Reporting Period S.Prapam Cade Mot applicable for CPD pelage s.) [7D 6.Date SubmimA ro Feld OfTm Seeeaplenemiouafcm dbo of Pane Uare Oct.I-Sept?0 Annual- aMaru diet for each P.F—code. Co.—.,or 0-117,cipon Number or HUD Sub:muacmr Care Number or ad., Amount of Type fT.. B-ureses Su6conuruor Contractor/Subcontractor Name and Address deacificacmofpmpaM, Cnaercror Code ItnciaUE3hoic women 0.cd B.vas,Prbne Cm—ldentdnetioa01)) IdentiFerbn(ID) 7j. nubdlvicon,di—fling unit.etc. 9.6— (San bebwj (See below) (Yea or No) Number Sm.3 Nwuber See.3 J fi. 7d. 7e. n 7o, 7, Nmne Street City State 2i le:Type of Trade Codes: 7d:Racial/Ethnic Codes: 5:Program Cad-(Complete for Homing and Public and Indian Housing programs only): CPD: Humlag/Public HonAmi: l-White Amadcam I-All Insured,including Sectma 5-Section 202 1=New Coatru.ioa 1-New Coruauctlon 6-Prn11eedoml 2-Back American 2-inc-irb W* 6-HUD-Had(Memgcvem) 2-UoauoaNftainag 2-Subnmriel Rehab. 7-Te-m Services 3-NuiveA�ricw 3-Section a Nonammd,Non-HFDA 7-Publwlada Hamieg 3-Oil- 3-Repair 8-Educetia✓haming 4-Raises:Amedn- 4-banned(Maaagancen 8-5-811 4-Service 4-M .Togrg.Apprise) S-AiaWPxifc Amuirans 5-Proiea Mma. D-OPoa 6-H.W.Ions Prcvioua mitime arc oh.oaae faro HUD-2516(&99) EXHIBIT "J" NOTICE OF BENEFICIARY RIGHTS HOPWA PSA CONTRACT 2017-2018--EXHIBIT"F'—NOTICE OF BENEFICIARY RIGHTS Page 1 Tarrant County Samaritan Housing,Inc. Notice of Beneficiary Rights Name of Agency: Tarrant County Samaritan Housing, Inc. Name of Program: Samaritan House Supportive Services 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. HOPWA PSA CONTRACT 2017-2018--EXHIBIT"J"—NOTICE OF BENEFICIARY RIGHTS Page 2 Tarrant County Samaritan Housing,Inc. M&C Review Page 1 of 6 Official site of the City of Fort Worth,Texas CITY COUNCIL AGENDA FoRTWoRTH COUNCIL ACTION: Approved on 8/1/2017 -Ordinance No. 22814-08-2017 DATE: 8/1/2017 REFERENCE G-19056 LOG NAME: 19NS HUDACTIONPLANPY2017- NO.: 2018 CODE: G TYPE: NOW PUBLIC YES CONSENT HEARING: SUBJECT: Conduct Public Hearing and Approve the City's 2017-2018 Action Plan for the Use of Federal Grant Funds in the Amount of$10,778,461.00 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 Grant Programs, Authorize Collection and Use of Program Income, Authorize Waiver of Application of Indirect Cost Rates, Authorize Execution of Related Contracts and Adopt Appropriation Ordinance (ALL COUNCIL DISTRICTS) RECOMMENDATION: It is recommended that the City Council: 1. Conduct a public hearing to allow citizen input and consideration of the City's 2017-2018 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$10,778,461.00 from the Community Development Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant, and Housing Opportunities for Person with AIDS grant programs, and for the use of program income from activities using prior years'federal grant funds; 2. Approve the City's 2017-2018 Action Plan for submission to HUD, including allocations of grant funds to particular programs and activities as detailed below; 3. Authorize the collection and use of an estimated $150,000.00 of program income which resulted 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 $300,000.00 of program income which resulted from activities using prior years' HOME Investment Partnerships Program funds, for the completion of the Hardy Street and HFC Terrell Single Family Infill housing development projects and 10 percent for administrative costs as detailed below; 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 2017-2018 for Community Development Block Grant, Emergency Solutions Grant, and Housing Opportunities for Person with AIDS grant funds, contingent upon receipt of funding and satisfactory completion of an Environmental Review and all 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; httn-finnnc rfixmat nrn/rnnnrril nni-I at/mn raviaxxr /7(11 7 1 1/1'VIM 7 M&C Review Page 2 of 6 7. Authorize a waiver of indirect cost rates as applicable for the Grants Fund in accordance with the City's Administrative Regulations; and 8. Adopt the attached appropriation ordinance increasing the estimated receipts and appropriations to the Grants Fund in the total amount of$10,778,461.00 consisting of$6,526,863.00 in Community Development Block Grant funds, $2,047,626.00 in HOME Investment Partnerships Program funds, $577,437.00 in Emergency Solutions Grant funds, and $1,176,535.00 in Housing Opportunities for Person with AIDS grant funds, plus any program income, all subject to receipt of such funds. DISCUSSION: The City's 2017-2018 Action Plan summarizes the major housing and community development activities and proposed expenditures for the program year beginning October 1 2017 and ending September 30, 2018 for use of federal grant funds totaling $10,778,461.00 from the United States Department of Housing and Urban Development(HUD)for 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 City of Fort Worth residents. 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. A public hearing was held on April 19, 2017 to provide citizens the opportunity to participate in the development of the Action Plan. The Staff recommendations for award amounts were presented to the Housing and Neighborhood Services Committee on May 6, 2017 and were adopted by the Community Development Council (CDC) on May 10, 2017. Following the publication of final funding amounts for FY2017-18 from HUD on June 14, 2017, Staff recommendations were updated to reflect the actual grant amounts and these revised recommendations were forwarded to the CDC and presented to the City Council through an Informal Report at the City Council Work Session on June 20, 2017. Notice of a 30 day public comment period from June 30, 2017 to July 31, 2017 was published in the Fort Worth Star-Telegram on June 25, 2017, in La Estrella on June 27, 2017, and in La Vida News: The Black Voice on June 29, 2017. Any comments received are maintained by the Neighborhood Services Department in accordance with federal regulations. The City must hold two public hearings as part of the HUD-required citizen participation process. The first public hearing is scheduled to be held by City Staff on July 19, 2017, and the second public hearing is scheduled for August 1, 2017 at the City Council meeting. A summary of Staffs final funding recommendations is provided below and in Tables 1, 2 and 3. Additionally, a spreadsheet of all specific funding recommendations is attached. The 2017-2018 Annual Action Plan must be submitted to HUD by August 15, 2017. A waiver of indirect costs is being requested to maximize program benefits. The CDBG program provides for 23 full-time positions with estimated salaries of$1.3 million. Addition of indirect costs would result in reduction in Staff and services. The indirect costs that are being asked to be waived are estimated to be $215,386.00. CDBG For Program Year 2017-2018, it is recommended that the amount of$6,526,863.00 in CDBG funds, and an estimated amount of$150,000.00 in CDBG program income totaling $6,676,863.00 be allocated as follows: Public Services -$979,029.00 htt„•//ar%"42 r-Rxmat rtan1rat/mn rav;acv /7l11 7 1 1/1 VIM 7 M&C Review Page 3 of 6 This item includes social services for low to moderate income, disabled and disadvantaged populations. Housing Program Services -$2,922,228.00 This item includes funding for the City's Priority Repair Program, Cowtown Brush-Up, homebuyer and housing services, accessibility modifications to the homes of senior and/or disabled individuals, the Lead Hazard Reduction Demonstration Grant Match, and related project delivery costs for these programs. Infrastructure Projects & Public Facilities -$579,255.00 This item includes funding for the Worth Heights Community Center Americans with Disability Act Improvements. CDBG Economic Development-$740,979.00 This item is the City's annual payment of its Section 108 loan from HUD. The Section 108 Program is a loan guarantee program which enables CDBG grantees to borrow up to five times the annual entitlement grant. CDBG Estimated Program Income -$150,000.00 This item includes funding for the City's Priority Repair Program. CDBG program income that is received which is over the estimated amount but not used for the City's Priority Repair Program will be allocated to priority activities in the City's Consolidated Plan subject to City Council approval. CDBG General Administration -$1,305,372.00 This item includes costs for administering the CDBG grant including allocations for Financial Management Services and Planning and Development Departments. HOME For Program Year 2017-2018, it is recommended that the amount of$2,047,626.00 in HOME funds, and an estimated amount of$300,000.00 in HOME program income totaling $2,347,626.00 be allocated as follows: Homebuyers Assistance Program (HAP) -$700,000.00 This item includes funding for down payment and/or closing cost assistance to low and moderate income homebuyers. Community Development Housing Organizations (CHDO) Set Aside -$307,144.00 HUD requires that a minimum of 15 percent of HOME funds be allocated to CHDOs for affordable housing projects and CHDO administrative operating costs. These funds will be used by Housing Channel (formerly Tarrant County Housing Partnership), a CHDO, for the Riverside Single Family Infill Development (COUNCIL DISTRICT 8). The houses will be sold to homebuyers making at or below 80 percent of the area median income as set by HUD. Rental Housing Development—$835,720.00 This item represents gap financing for a portion of the costs of developing Columbia Renaissance Square, Phase II, an affordable multifamily senior development(COUNCIL DISTRICT 8). httn-//.gnnC nfumPt nrcy/nnilm-A 11nol-Pt/TY o TPVIPVI7 /1017 11/1 S/7(1l 7 M&C Review Page 4 of 6 HOME General Administration —$204,762.00 This item includes costs for administering the HOME grant. HOME Estimated Program Income -$300,000.00 This item represents gap financing for the Columbia Renaissance Square, Phase II multifamily senior development. HOME program income that is received which is over the estimated amount but not used for the Columbia Renaissance Square, Phase 11 project will be allocated to the Riverside Single Family Infill development, or to priority activities in the City's Consolidated Plan subject to Council approval. HUD allows the City to take 10 percent of any HOME program income to be used for the costs for administering the HOME grant. HOPWA For Program Year 2017-2018, it is recommended that the amount of$1,176,535.00 in HOPWA funds be allocated as follows: Non-Profit Service Providers -$1,141,239.00 HOPWA Program Administration —$35,296.00 ESG For Program Year 2017-2018, it is recommended that the amount of$577,437.00 in ESG funds be allocated as follows: Non-Profit Service Providers -$534,130.00 ESG Program Administration—$43,307.00 CONTRACT RECOMMENDATIONS The CDC and Staff recommend that contracts be executed with the listed agencies for the amounts shown in the following tables: Community Development Block Grant Contracts: Table 1 —CDBG Agencies Organization Program Amount I AB Christian Learning Center Child Care Services $ 76 350.00 Catholic Charities Diocese of Fort Employment/Job Training $ 101,800.00 Worth, Inc, Girls Inc of Tarrant County Youth Services $ 111,080.00 Goodwill Industries of Fort Worth, Employment/Job Training $ 76,350.00 Inc. Housing Channel Housing Counseling $ 118,088.00 Services The Ladder Alliance Employment/Job Training $ 94,974.00 Meals on Wheels, Inc. of Greater General & Special Needs $ 76,350.00 Tarrant County 1kff11'//a""u nfT xrlPf nrrT/r•ni1rw-;1 rP[71P•17 /7(11 7 11/1V')01'7 M&C Review Page 5 of 6 Presbyterian Night Shelter of Public Service Special $ 144,987.00 Tarrant County Needs Sixty and Better, Inc. Public Services: Elderly $ 101,800.00 United Community Centers Child Care Services $ 76,350.00 CDBG Public Service Subtotal $ 979,029.00 Rehabilitation, Education and Accessibility $ 102,000.00 Advocacy for Persons with Handicaps, dba REACH, Inc.** Total CDBG Contracts $1,081,029.OQ **REACH will be funded from the CDBG Housing Programs and Services budget Housing Opportunities For Persons With AIDS Contracts: Table 2— HOPWA Agencies Organization Program Amount Tarrant County Samaritan Housing, Administration (seven $ 510,204.00 Inc. percent), Supportive Services and Facility Based housing Subsidy Assistance AIDS Outreach Center, Inc. Supportive Services, $ 631,035.00 Tenant Based Rental Assistance (TBRA), and Short Term Rent Mortgage and Utility Assistance (STRMU) Total HOPWA Contracts $1,141,239.00 Emergency Solutions Grant Contracts: Table 3— ESG Agencies Organization Program Amount Presbyterian Night Shelter of Shelter $ 126,625.00 Tarrant County Operations/Services SafeHaven of Tarrant County Shelter $ 75,975.00 Operations/Services Lighthouse for the Homeless dba Shelter $ 95,343.00 True Worth Place Operations/Services The Salvation Army, a Georgia Homeless Prevention $ 126,625.00 Corporation Center for Transforming Lives Rapid Rehousing $ 109,562.00 Total ESG Contracts $ 534,130.00 A waiver of the goal for MBE/SBE subcontracting requirements was requested by the Neighborhood Services Department and approved by the M/WBE Office, in accordance with the M/WBE or BDE Ordinance, because the purchase of goods or services from source(s)where subcontracting or supplier opportunities are negligible. httn• /nnne ofixmat nrrrinnnnril 0017 1 1/1 S/7()17 M&C Review Page 6 of 6 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, adoption of the attached appropriation ordinance and receipt of grant funds, funds will be available in the current operating budget, as appropriated, of the Grants Operating Federal Fund. This is a reimbursement grant. The Neighborhood Services Department has the responsibility to validate the availability of funds prior to an expenditure being made. TO Fund Department Account Project Program Activity Budget Reference# Amount ID ID Year Chartfleld 2 FROM Pro ect Rro ram_ _____.._____ __ . .. Fund DepiDment Account ID g i Activity Budget Reference 9 Amount Year (Chartfield 2) Submitted for City Manager's Office by: Fernando Costa (6122) Originating Department Head: Aubrey Thagard (8187) Barbara Asbury (7331) Additional Information Contact: David Reitz (7563) ATTACHMENTS 19NS HUDACTIONPLANPY2017-2018 019 AO 17.docx Form 1295-All Agencies.pdf HUD 2017-18 AP Selected Slides.pdf h tn-//annc (-.fumPt nra/rrnnn- l nnnlrat/mr 1 1/1';/')017 CERTIFICATE OF INTERESTED PARTIES FORM 1295 101`1 Complete Nos.1 4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos.1.2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2017-236116 Tarrant County Samaritan Housing,Inc. Fort Worth,TX United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 07/13!2017 being filed. City of Fort Worth Date Acknowledged: 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a description of the services,goods,or other property to be provided under the contract. HOPWAPY2017 Supportive service and facility operation services for individuals living with HIV/AIDS 4 Nature of interest Name of Interested Party City,State,Country(place of business) (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. X 6 1 V T 1 swear or affirm,under penalty of perjury,that the above disclosure is true and correct. T:EDA LOVATO �---- * Notary Public State of Texas / N� t ID#1041732-8 e OFA My Comm-Exp.01-18-2020 i urea u orized agent of contracting busin ss entity AFFIX NOTARY STAMP/SEAL ABOVE Sworn and subscribed before me,by the said N pr ba4- this the L4h day of J W 20 ,to certify which,witness rry hand and seal of office. ign tore Aoffi4ceradaministering oath Printed name of officer administering oath Title of officer ministering oath Farms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.88i