HomeMy WebLinkAboutContract 39736 (2)rY SECRETARY
,NTF�p,c f� 1�jC)
STATE OF `I'E�'�S S
COL'''N'IY CiF'I'1�RRr1NT S
THIS contract ("Contract") is made and entered into by and between the City of Fort Worth
("City"), whose address is 1000 Throckmorton St., Fort Worth Texas 76102, acting by and through
I'Af. Higgins, its duly authorized assistant City Manager, and Crook Children's Health Care
System("Contractor"), whose address is 801 Seventh Avenue, Fort Worth, 'Texas, 76104, acting by
and through Linda S. Chappell its duly authorized Senior Vice President, Quality Managemem.
(Sometimes City and Contractor are referred to individually as a "Party" and collectively as the
"Parties".)
WHEIZE1�S, City has received grant monies from the United States Department of Horsing
and Urban Development ("HUD") under Title 1 of the Housing and Community Development Act
of 1974, as amended, (42 USC 5301 et seq.) for utilization in connection with its Community
Development Block Grant ("CDBG"), Program No. M9-MC4&0010, for Year XXYVV;
IVHEREc�S, one of the national objectives of the CDI3G prograrn is to benefit lo�v and
moderate income citizens (the "National Objective';
WI IEREaS, the assigned Catalog of Federal Domestic rlssistanee (CFDa) number is 14.21$ for
this Federal program, and
`�i'HF1ZF'AS City citizens, the Community Development Co(nncil, and the City Council have
determined that CDBCr programs are needed by the Cite s low and moderate -income citizens.
NOW, THT?REFO.RE, 'I"HIS aGRL,E.AiEiNT FUR'I"IIrR %jUI7NESS:ETI I:
'I'I-1<�T; the Parties covenant and agree as follouTs:
a.
b.
c.
of Scrvlccs
Contractor will administer Public services to citizens of the CitS� of Fort Worth under Liae
program name Save a 5nile {"prograrn"), .for the term ]une 1, 2009 to l�iay 31, 2010.
Contractor will be responsible for administering Save it Smile Program in a manner
satisfactory to City and consistent with any standards required as a condition of providing
the CDBG funds (as hereinafter defined). Contractor will proNride the services and activities
as set forth in Exhibit A -Program Summary in accordance with Exhibit B-Program
Services Schedule.
Contractor agrees to meet the National Objective of activities benefiting low and moderate -
income individuals and to maintain frill documentation supporting fillfillment of this
lNiational Objective in its files as defined in 24 CFR 570.208. Contractor certifies that the
activities carried out under this Contract will serve the required percentage of low and
moderate•income persons asset forth in Exhibit Am Program Summary. Contractor twill
obtain information on family size and income of Program participants. All such
documentation shall be furnished to (.fly upon request if necessary for City to fulfill its
obligations under its )federal grant. If this documentation is not maintained and furnished _
to City on request, City may exercise all remedies :available under this Con ract, includin r the
OFFICIAL �EDORD
C.11RG 1`S:AI2 XXXV S(ii(AEt:IP(EIV"1' CONTRACI`
i:lailrlren's health Cam System
CI°T)ft6ETARY
'tt',r�Y1Y�� 1
right to withhold payment to Contractor on this Contract or any other contract with
Contractor, or terminate this Contract as described herein.
d. City will monitor and evaluate Contractors performance using the goals and performance
standards required in this Contract. Substandard performance as determined by City
monitoring, including noncompliance u7tli arty applicable regulation of the U.S. Department
of .Mousing and Urban. Development, will constitute non-compliance with this Contract. If
action to correct such substandard performance is not taken by Contractor within a
reasonable period of time after being notified in writing by City, procedures to suspend or
terminate the Contract will be initiated.
e. If applicable, Contractor shill comply and assist City in complying with the provisions of
any federal requirements regarding displacement, relocation and/or real property acquisition,
uniform administrative requirements and cost principles; employment and contracting
opportunities, use of debarred, suspended or ineligible contractors or subrecipients;
eligibility restrictions for certain resident aliens; conflict of interest, and other requirements
of Subpart K of the CDBG Regulations. .
f. Contractor agrees to take reasonable steps to ensure meaningful access to the Program and
associated activities by limited English proficient persons,
2. C artr�ensutiort urrti 11lerhod of .! �lyrtrenr
a. City cyill disburse CDBG Fear 1'1X�' fiends {"CDI3Cr Funds' in an amount up to
I WLN I'YON:E THOUSAND EIGHT' HUNDRED AND SEVENTY AND N0/100
DOLLARS (21,870.00) to Contractor on a reimbursement of expenses basis. Contractor is
acting as a Subrecipient for the purposes of this Contract in carrying out the agreed -upon
eligible activities as set forth in Exhibit A — Program Summary.
b. Payment will be processed by City following receipt from Contractor of the following
monthly financial documents: (1) Attachment I- Request for Funds, (2) Attachment II -
Detail Statement of Costs, and (3) Attachment III -Expenditures Worksheet. Payment by
City to Contractor shall require completion of all City forms and copies of adequate
supporting documentation verifying eligibility of expenses as well as, where applicable,
eligibility of Program participants. Reimbursement for the payment of eligible expenses
shall be made against the budget specified in Exhibit C-Program Operating Budget and
in accordance with performance specified in Exhibit B-Prograin Services Schedule. City
will not disburse funds for expenditures that occurred prior to the beginning date of the
term of this Contract.
c. Contractor agrees to utilize all disbursed CDI3C.T Funds for the benefit of the Program.
Contractor agrees that <tll funds will be expended in accordance with Exhibit C-Program
Operating Budget. Contractor may not increase or decrease line -item amounts in the
approved CDBG Funds portion of Exhibit C-Program Operating Bridget without City's
prior written approval. Contractor acknowledges and agrees that any CDBG Funds not
used in accordance with the CDBG Regulations and the terms of this Contract will be
repaid to City.
d. It is understood that the total cost for operation of this Program is $346,98$1.00 and that
Contractor will obtain from other sources tine remaining funds in excess of the CDBG
Funds as detailed in Exhibit C-Program Operating Budget. Contractor will notify City
promptly of any additional funds it receives for operation of the Progrann, and City reserves
the right to ainend Exhibit C-Program Operating Budget in such instances to ensure
conpliance with HUD regulations governing cost edlocation.
CDBG YEAR YXXV SLittRi:CIPIL'N'1' CONTRACT
t�n�tl<s
Rev. 0&•2349
e. C;ouriactor agrees to keep all CDBG hands on hand in interest bearing accounts. all interest
earned shall be reported to City on a monthly basis, at the same time as submission of the
niontlily report following the end of the Contract month during tyhich the interest was
earned. Interest in an amount of 525.00 or less per month may be used for autliorized
Program expenses. These announts must be reported on the monthly financial statements
Cited pursuant to this Contract. Interest earned in excess of S.1: 00 per month is subject to
remittance to City as chrected by City.
E Contractor will not commingle CDBG Funds with any other bands in any manner that
would present City from readily' identifying expenditures for operation of the Program.
3. L�JIIfOt'I17.O�!%IIIlJ11�/1'Cl/Il.'P .I�z'C1lflli'7I1811/� illltf _�I"Oyli7lJt.'�'�tZlltlyflllNlll.S/flllf�clYf��
a. FinanciallIanagement
i. accounting Standards
Contractor agrees to comply with C )MB Circular A110, "Uniform Adtninistrarive
Requirements for Grants and agreements with Institutions of Higher Education,
Hospitals and other Non -Profit Organizations", and agrees to adhere to the SICCOL111tin9
principles and procedures required therein, utilize adequate _internal controls, and
maintain necessary- source documentation for all costs incurred.
ii. Cost Principles
Contractor shall administer the Program in conformance with O-MB Circular a-122,
"Cost principles for Non -Profit Organizations" and attachments and revisions thereto,
regarding principles for determining eligible and allocable costs for the Program.
b. Documentation and Record Keeping
i. Requirement
Contractor shall maintain all records pertinent to the activities to be fiunded under this
Contract required in 24 CFR ji 570.506. In addition, Contractor agrees to keep records
to fully docunnent all expenditures charged to the CDBG portion of the Program,
including records documenting the eligibility of Program participants as more
particularly described herein. The documentation must support the amounts charged to
the Program, the eligibility of the Program participants, and demonstrate that the
expenditures were appropriate to the stated goals of the Program and allowable and/or
eligible under applicable Federal, state and City guidelines.
ii. Records Retention
(1) all records pertaining to Program shall he .retained for four (4) rears following the
termination of this Contract. Contractor rune destroy Program records at the end of
this four (4) yca.r period .if no outstanding audit finding exists.
(2) Contractor will retain any Program loan records until four (4) years after the
expiration of any loan.
iii. Real Property- Records
Contractor shall naintain real property inventory records that cicarly idenrify properties
purchased, improved, or sold. Properties retained shall meet eligibility criteria and shall
conform to the requirements of 24 CFR ,t, 570.DC?5.
ic'. Closeouts
Contractor's obligation to City shall not end until ;ill closeout requirements are
coMpleted. activities during this closeout period shall include, but are not linuted to:
making final payments, disposing of Program assets Including the return of all unused
materials, equipment, unspent cash advalice s, Program hico nie balances, and accounts
CDBG 1'E:IR X]X\y StBRECIPIEtiT COi`TrRr1CT Rev, 03-24-09
Ctu7ks C;hildren's Health Care Svstcm Pxgc 3
receAai7le to City), and determuhinq) the custodianship of records and verification of
complL.Ince with record retention requirements.
t-. Audits and Inspections
(P City; HUD, and the United States Comptroller General, or their respective
representatives, shall have access to any books, documents, records and papers
relating to the operations of Contractor under this Contract for tie purpose of
audit, exanvnation, exception and transcription at all of Contractor's offices at all
reasonable hours.
(?) All non-federal entities that expend 5500,000 or snore in Federal funds within one (1)
Vear, regardless of the source of the Federal award, must submit to City- an annual
audit prepared in accordance with 24 CFIZ Sections 5�0.502-5�C1.503 generally
(known as a Single Audit), with specific reference to 0NfB Circulars (with
attachments) A-122, "Cost Principles for Non -Profit Organizations", and A-133,
"Audits of States Local Governments, and won -Profit Organizations", as
appropriate. "The audit mays cover either Contractor's fiscal tear during which this
Contract is in force or cover the period of this Contract. The audit must be prepared
by an independent certified public accountant, be completed within tune (9) months
following the end of the period being auclited and be subnutted to City within tiirty
(30) days of its conhpletion. Contractor's audit certification is attached hereto as
Exhibit D - Audit Certification Form. The Audit Certification Form must be
submitted toCite= within sixty(60) days of the end of the period being audited
(Contractor's Fiscal year). Costs of preparation of this audit inay be in allowable
expenditure of C:DBG Funds in in amount proportional to that of the CDBG
Funds used in C;ontractor's total agency operating budget. Non-profit entities that
expend less than S500,000 a year in Federal funds are exempt from Federal audit
regturements for that rear, but records must be available for review or audit by
appropriate officials of the Federal agency, City, and General Accounting Office
("GAO" ).
(3) All non-federal entities acting as it Subrecipient for Cityr grant funds that expend less
than S500,000 in any federal funds xvithin one. year shall provide City with a copy of
any other financial audit or audited financial statements prepared during the contract
terin, if available.
(4) City reserves the right to perform an audit Of Contractor's agency- operations and
finances at any time dtuing the term of this Contract, if City- determines that such
audit is necessary- for City's compliance with OMB Circular. A-133. Contractor
agrees to aHow access to all relevant hooks, records and materials. If such audit
reveals a questioned practice or expenditure, such questions must be resolved within
fifteen (15) days after notice to Contractor. If questions are not resolved within this
period, Ciry reserves the right to withhold further funding under this Contract
and,%or :,uw other contracts) with Contractor.
{5) If as a result of any- audit it is deternh.ined that Contractor his misused, misapplied or
nhisappropriated all or any part of the CDBG Funds, Contractor agrees to reirnburse
the C:itr the amount of suclh monies so misused, Misapplied or misappropri
ated, plus
the amount of aliv sathctiou, penalty or other. charge levied ag.unst Cin7 because of
such misuse, nusapplication or misappropriation,
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1. Rtporizq 1)i01V e
a. Pu7ancial Reports
Contractor will submit to City on a monthly basis: ('1) attachment I -Request for Funds, (2)
Attachment II -Detailed Statement of Costs, (3) Attachment .III -:Expenditures %Vorksheet, as
applicable, for expenses incurred for services and activities accomplished by Contractor .in
performance of this Contract. Actual casli receipts for claimed expenditures must be
provided at the time the request for funds is presented. The reports trust be signed by a
dilly authorized agent of the Contractor and submitted by the 15F' of the month following
the month being reported. City- is under no obligation to disburse funds for expenditures
that occurred prior to the first day of the month for which the report is submitted.
b. Progress Reports
Contractor will submit to Cit}f on a monthly basis: (1) attachment IVda-Program Services
Report, (2) attachment lVb-Direct Benefit Data Report, (3) attachment V-Performance
Report, and (4) attachment VI -Client Data Report for services and activities undertaken by
Contractor in performance of this Contract. The report will be signed by a duly authorized
agent of Contractor and submitted by the. 1 "' of the month following the month that is
reported. City is under no obligation to disburse funds for expenditures that occurred prior
to the beginning date of this Contract
c. Program Income
Contractor agrees that all program income from operation of the Program in proportion to
the amount of CDBG Funds received hereunder will be expended prior to expending
CDBG Funds and that any such program income is subject to the terms of this Contract.
Contractor May expend C:DBC:r Funds only if program income is insufficient to meet all
eligible Program activity- expenses. Contractor agrees to return to Cit)r at the end of the
Contract any remaining program income earned from operation of the Program in
proportion to the amount of CDBG funds in Exhibit A -Program Summary and Exhibit
B-Program Operating Budget.
d. Procurement
i. Compliance
Contractor shall comply with City policy- concerning the purchase of equipment and
Shall maintain inventory records of all non -expendable personal property, as defined by
such policy, procured kith funds provided under this Contract.
I OMB Standards
Contractor shall procure all materials, property, or services in accordance with the
requirements of 24 CIk'R Part 84, Procurement Standards and Property Standards, as
modified by 21 CFR Part 5 70,502(b)(G), covering utilization and disposal Of property-.
c.. Program Participant Records
i. Contractor will keep or cause to be kept an accurate record of all actions taken and all
C:I�BC�i Funds expended, with sourcc documents, in performance of this Contract. Suc:hl
records shall be kept for the time period mandated by the CDBG Regulations and this
Contract.
ii. Contractor will obtain and keep on file and furnish to City on request the follo%wing
info.ri-natl'on and/or documentation on each Program participant served by the Program
demonstrating such participant's eligibility for services provided:
a. Participrant's name, address, annual income level or other basis for determining
I
ncome eligibility, and famihy size of pat'ticipanrs household.
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b. Source dOJ Ilmetrtat1oil used for Income vcrituatiOil including but not limited to pay
check stubs, food stamp award letters, income tas return,, SSI avvird letters, letters
awarding unemplo%nient benefits, W2s and the like.
c. City shall h2Ve the fuial determination, in its sole discretion, as to N�hethe> source
documentation used for income verification is adequate.
�. I�era��ioiroj .=1��elr
a. Contractor agrees to reatrn to C:itt' any CDBG funds remaining on hand ttt the end of the
Contract.
b. All property purchased with CDBG Funds under this Contract will be used solely for
operation of the Program. Contractor agrees to obtain City approval prior to purchase of
property and Contractor agrees to notin- City upon receipt of property so that it inay be
properly- tagged and inventoried. Title to such property will be rested in City, and
Contractor will deliver all such property, to City for disposition at City's sole discretion at the
term.iiiatioii of the Program.
6. .:<Ij�,fili<-crllle L.�r:n.�
a. Fecicial
Con.tractot agrees to comply with the followAllig laws and the applicable regmations as they
are currently written or are hereafter amended during performance of this Contract:
® Regulariotrs <tt 34 C1�1Z Tart 5 � 0 pertaining to C.;DI3G ("CD�BG .Regulations")
Title I of the Housing and Community Development Act of 1974 as amended (42
USC 5301 et seq.)
Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
(42 USC 4601 e/ stTej.) and its related regulations at 49 CI'R Part 24
• Tide VI of the Civil Rights Act of 1964 (42 USC: 2000d el et1.)
Title \'III of the Civil Rights Act of 1968 (42 USC 3601 V feq.)
• ExecntiVe Orders 11063, 1 1246, as amended by Executive Orders 1 1375 and 12086 and
as supplemented by 41 CFR Part 60
The Age Discrimination in Employment Act of 1967 (29 USC 621)
e The Age Disc i7mination Act of 1975 (42 USC 6101 el,eeq-)
Section 5104 of the Rehabilitation .Act of 1973 (29 USC 794 et secl.) and 24 CFR Part S
Where applicable
The lnzericans with Disabilities Actof 1991? (42 USC 121CtO
s National Environmental Policy Act of 1969, as amended 42 USC 4321 4-/ 3 :J. (Ni?P \'.,
Mid the related authorities listed 24 C.:FR Part 58
• The Clean :Air .Act, as amended (42 USC 74o1 et j-eq.), the Clean \\''ater _Act of 1977, as
amended (3.3 [; SC 1251 et ='r9 / and the related EP_A regi larlons at 40 C1" R Part 15, as
artiended from time to time, and F'Necutive Order 11738. In no event shall any amount
of the assistance provided under this Contract be utilized with respect to a facilin' that
h:is 1 iverr rise to a conviction under, the (lean Air Act or the Clean \rater _Act.
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+ The Imnugration Reform and Control Act of 1986, (8 L`SC 1101 et oeq.), specifically
including the provisions requiring en7plover verification of the: legal status of its
employees
Drug Free \Workplace Act of 1988 (441 USC 'Ctl el seel.) and 24 CFR Part 2.3, Subpart F
Regulations as 24 Cl"* Tart 87 related to lobbying, including the requirement that
certifications and disclosures be obtained from all covered persons
Executive Order 12549 and 24 CFR Part 5.105 (c) pertaining to restrictions on
participation by ineligible, debarred, or suspended persons or entities.
b. Section 3 of flue I-lousinzg and urban Developrnent�lct r3f 1968, as amended, (12 USC: 1?01u
el well.) :and its related regulations at 24 CFR Part 135
If the wort: to be performed under this Contract is on a project assisted Linder a program
providing direct Federal financial assistance from HUD, Section .3 of 24 CFR 135.38
([`Section 3") requires that the following clause be inserted in all covered contracts ("Section
3 Clause") Such covered contracts or activities include CDBG-funded construction,
reconstruction, conversion or rehabilitation of housing as set forth at 24 C:FR 135.5.
A. The work to be performed under this contract is subject to the requirements of section
3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701u
{section 3). The purpose of Section 3 is to ensure that employment and other economic
opporttuaities generated by HUD assistance or HUD -assisted projects covered by
Section 3, shall, to the greatest extent feasible, be directed to lowand very low-income
persons, particularly persons who are recipients of HUD assistance for housing.
13. The Parties to this contract agree to comply with I IUD's regulations ua 24 CPR Part 135,
which implement Section 3. As evidenced by their executioti of this contract, the Parties
to this contract certif r that they are under no contractual or other impediment that
would prevent theta from complying xvitli the Part 135 regulations.
C. ".I'lie contractor .agrees to send to each labor organization or representative of workers
with which the contractor has a collective bargaining agreement or other understanding,
if aa notice advising the labor organizati
ny; on or workers' .representative of the
contractor's commitments under this section 3 clause, and will post copies Of the notice
in conspicuous places at the work site where both employees and applicants for training
and employment positions can see the notice. The notice shall describe the Section 3
preference, shall set forth minimum number and job titles subject to hire, availability of
apprenticeship and training positicnn, the: qualifications for each; and the name and
location of the person(s) taking :applications for each of the positions; and the
ntici apated date the work shall begin.
D. The contractor agrees to include this section 3 clause in every subcontract subject to
compliance with regtalatiorzs in 24 CFR Part 135, and agrees to take appropriate ;action,
as provided in an applicable provision of the subcontract or in this Section 3 clatise,
upon a Ending that the subcontractor is in violation of the regulations in 24 CFR Part
135. 'File contractor will not subcontract with a11V subcontractor where due contractor
has notice or knowledge that the subcontractor has been found in violation of the
regulations in 24 CFR Part 135.
I;'I'lie contractor will certify that any vacant enaplol•ment positions, including training
positions, that .are filled (1) after the contractor is selected but, before the contract is
e ccuted, and (2) with persons other than those to whom the regulations of 24 CFR Part
(.Dti<; 4'E:iti .l"Y,ZV 5LI3I{FL;IPIE�IT CO:� I'iL��CT
Ccx�ks Chiltiren's Hc;tttti Care 55stem
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135 require emplo��rnent opportunities to he directed, were not filled to circumvent the
continctor's obligations under 24 CFR Haut 135.
F. Noncompliance -kvith HUD's regulations in 24 CFR part 135 may result in sanctions,
termination of this contract for default, and debarment or suspension From future HUD
assisted contracts.
With respect to work performed in connection with Section 3 covered Indian housing
assistance, section 7(b) of the Indian Self-Deternninadon and Education Assistance Act
(25 6S.C. 450e) also applies to the work to be performed under this contract. Section
7(b) requires that to the greatest extent feasible (i) preference and opportunities for
training and employment shall be given to Indians, and (ii) preference in the award of
contracts and subcontracts shall be given to Indian organizations and Indian -owned
F?corlomic Enterprises. Parties to this contract that are subject to the provisions of
section 3 and section 7(b) agree to comply with Section 3 to the maximuln extent
Feasible, but not in derogation of cotnplisnce with section t (b)."
City and Contractor understand and agree that compliance «-it1h the pro�risions of Section 3,
the regulations set Forth in 24 CFR part 135, and all applicable rules and orders of HUD shall be
a condition of the Federal Financial assistance provided to the Program, binding upon City and
Contractor, and their respective successors, assigns and subcontractors. Failure to fulfill these
requirements shall subject Contractor and its subcontractors, and their respective successors and
assigns, to those sanctions specified by the Grant .Agreement through which Federal assistance is
provided and to such sanctions as are specified by 24 CFR Part 135.
e. Cjther Laws
Contractor covenants and agrees that its ofEicets, members, agents, enhplo�-ees, .Program
participants and subcontractors shall abide by and comply with all other laws, Federal, state
and local, relevant. to the performance of this Contract, including ill applicable City
ordinances, rules and regulations and Title I of the Housing and Community Development
.Act of 19i4 (42 USC 53p1 et feq.), as amended, and the CDBG Regulations, as amended, (24
CFR Part 570 e/ seq.). Contractor further promises and agrees that it has read, and is familiar
with, the terms and conditions of the Community Development Block Grant. under which
CDBG Funds are granted and any applicable provisions of the C:D13G Regulations and that
it will f1illy comply- with there. It is agteed and understood that, If C.Ity notifies Contractor
of any such violatiotl on the part of Contractor or ally of its officers, members, agents,
employees, Progtain participants or subcontractors, then Contractor shall immediately desist
from and correct such violation.
e�()l1if1.Ci7':l/lllltlilgll
a. (..Yatltr:tctor 1vL11 Ilot ttrtla\t=ft.tll4 t11:�Cr.1I111I1aCC :ti�31t1sC any pCTs<?ih �lY pt'.CSOthS ltecnllSe of 9(:�,
race, religion, nge, disability, color, nntionaI origin, or fatnihal status, nor twill Contractor
pertnu its officers, members, agents, employees, stbcontractors or Program participants to
engage in such discrimination.
b. Contractor covenants that neither it nor any of its officers, members, agents, employees,
Program participants or subcontractors, while engaged in performing this Contract, shall, in
conna
ection with the employment, advncement or discharge of employees or in connection
with the terms, conditions or privileges of their employmerit, discriminate against persons
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(;o�>ks {:hilclren's FIealth {;are titi�stem
because of their age except on the basis of bona tide occupational qualification., retirement
plan or statutory requirement.
c. Contractor further covenants that neither it nor its officers, members, agents, employees,
subcontractors, program participants, or persons acting on their behalf, shall speci67, in
solicitations or advertisements for employees to work on this contract a maximum age limit
For such employment unless the specified maxirnurn age limit is based upon a bona fide
occupational qualification, retirement plan or statutory requirement.
d. In accordance with the provisions of the ,\mericans With Disabilities Act of i )c)Cl {"_\D
Contractor warrants that it and :ily and all of its subcontractors will not unlawfully
discrinunate 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 Contractor, or employees of Contractor or any of its subcontractors. Contractor
warrants it will fully comply with r\Drys provisions and any other applicable Federal, state
and local laws concerning disability and krill defend, indenulify and hold City harmless
against any claims or allegations asserted by third parties or subcontractors against City
arising out of Contractor's and/or its subcontractors' alleged failure to compl}. with the
above -referenced laws concerning disability discrimination in the performance of this
Contract.
e. This Contract is made and entered into with reference specifically to the ordinances codified
at Chapter 17, Article III, Division 3 "Discrimination in Employment Practices", of the Cit-c
Code, and Contractor hereby covenants and agrees that Contractor, its officers, members,
agents employees and subcontractors, ha filly complied with all provisions of same and
that iio employee, ernploy ee-applicant or Program participant has been discriminated against
by the terms of such ordinances by either the Contractor or its officers, members, agents,
employees or subcontractors.
1'ro1,64G1t1
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a. Ao member, officer or employee of City or its desi�hces or agents; no member of the
governing body of the locality in which the Program is situated; and no other public official
of such locality Or localities, wwlho exercises any functions or responsibilities with respect to
the. Program funded hereunder during his or her tenure or for one rear thereafter, shall have
any interest, direct or indirect, in any contract or subcontract, or the proceeds thereof, for
work to be performed hereunder. Contractor shall incorporate, or causee to be incorporated,
like- language prohibiting such interest in all contracts and subcontracts entered into in
connection with the Program.
b. No member, officer, employee, or Program participant of Contractor or its subcr)ntractors
shall have a tmancial interest, direct or uidirect, in this Contract or. the CDBGr Funds
transferred hereunder or be financially interested, directly, or indirectlt, in the sale to
Contractor of any land, materials, supplies or services purchased with any CDRG Funds
transferred hereunder, except on behalf of Contractor, as an officer, employee, menil.wr or
Program participant. Any iyillful violation of this paragraph with the expressed or implied
kiu::)wledge of Contractor or its subcontractors shall reader this Contract voidable by City,
i). blixc}rrt3 rind Il'i».n:�rr Brnrress fntdri�rz.ie° Ccr»rnritir>>rrl
Contractor
agrees to abide. by C.ity's lx:Aicy to inyolrc Minority and \\��rnen 13usrttc" l nterpriscs
"`\I11�1�Es") in all phases of its procurernerix practices end topr<.;z�ide theca an eyua opportunity
c:ntir Yr::ta x,�xy st.-rsttErtrtEN r coN'ra:u;T
Cixaks
Rev, 08-2-W)9
to compete for contracts for construction, provision of professional services, purchase. of
equipment and supplies -and provision of other services required by City. Contractor agrees to
incorporate Cit-1' Ordinance No. 13330, and all amendments or successor policies thereto, into all
contracts and will further require all persons or entities -with u-hom it contracts to comply with
said MW B s policy.
1 L�. 1�'�11-f1StiY�J1IIIG'tl/
No assignnment or delegation of duties under this Contract by Cont.ractc>r shall be effective
without City's prior written approval. If such assignment occurs, Contractor shall ensure that all
requirements of this Contract are enforced and maintained by any such Subcontractor or
assignee by means of a currently executed written agreerrient covering the Contract term, a copy
A which shall be inside available to City
l I. Ittrlrft�tt:zrettt' Contrrt�'l�Iz•
a. Contractor shall operate hereunder as an independent ec)ntractor and not as an oEticcr,
agent, servant or employee of City, Contractor 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, enployees, subcontractors, Program participants,
licensees or invitee. -I'he doctrine of respondeat superior shall not apply as between City and
Contractor, its officers, members, agents, servants, employees, subcontractors, Program
participants, licensees or hivitees, and nothing herein shall be construed as creating a
partnership or joint enterprise between City and Contractor. It is expressly understood and
agreed that no officer, member, agent, employee, subcontractor licensee or invitee of the
Contractor, nor any Program participant hereunder, is in the paid service of City and that
Citn= does not have the legal right to control the details of the tasks 1erformed hereunder by
Contractor its officers, members, agents, employees subcontractors, Program participants,
licensees or invitees.
b. City shall in no way nor (.under any circumstances be responsible for any property belonging
to Contractor, its officers, members, agents, employees, subcontractors, Program
participants, licensees or invitees, which may be lost, stolen, destroyed or in any NvaN
damaged; and Contractor herebj- indemnities and holds harmless City and its officers,
agents, and employees from anti against any and all claims or suits.
i �. .jtNl�llNllfli71i7(Jti, �tl_+'tll'tllll"? rttlC✓' %11JJIt7tiJ5
t. CONTRACTOR COVENANTS AND AGREES TO I.NDEI�il'�IIFY, HOLD
I-IARi1.1LESS AND DEFEND, A'T ITS Ol�%N EXPENSE, CITY AND :ITS
OFFICERS, AGENTS, SERVANTS AND EMPLOYEES FROM AND AGAINST
ANY AND ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAINIAGE
AND/OR PERSONAL INJURY, INCLUDING DEATH, 'I'O ANY AND ALL
PERSONS, OF WHATSOEVER KIND OR CHARACTER, WHETHER REAL OR
ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE
EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS,
Gll13U 1'E;1R tixxN' SliF3RL-f.IPIENT CC)N"I'RAC:T
Cooks Children's Ilrilth Care Svstem
a«-. 08-24-09
Page 10
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 CONTRACTOR
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 tALLL PERSONS, OF
WHATSOEVER KINDS OR CHARACTER, WHETHER REAL OR ASSERTED,
ARISING OUT OF OR IN CONNECTION WITH THE EXECUTION,
PERFORMANCE, ATTEMPTED PERFORMANCE OR NON-PERFORMANCE
OF THIS CONTRACT AND AGREEMENT AND/OR THE OPERATIONS,
ACTIVITIES AND SERVICES OF THE PROGRAMS DESCRIBED HEREIN,
WHETHER OR NOT CAUSED IN WHOLE OR IN PART, BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES,
CONTRACTORS OR SUBCONTRACTORS OF CITY. CONTRACTOR
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 CONTRACTOR, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES,
SUBCONTRACTORS, INVITEES, LICENSEES, OR PROGRAM
PARTICIPANTS, OR CAUSED, IN WHOLE OR IN PART, BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES,
CONTRACTORS OR SUBCONTRACTORS OF CITY,
CONTRACTOR AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FRONT 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 THE CITY'S SOLE OR
CONCURRENT NEGLIGENCE,
CONTRACTOR SHALL REQUIRE ALL OF ITS SUBCONTRACTORS TO
INCLUDE IN THEIR SUBCONTRACTS A RELEASE At'�tD INDE>1�iNITY IN
FAVOR OF THE CITY IN SUBSTANTIALLY THE SAME FORM AS ABOVE.
b. C:ontl�actor u��ill m;iutt.zin blanket fidelity in the torrYr Of a hntzcl in the amount: e)f
S21,S�I).�)t}, to it��:urc against Ic�ss frc�ul the fr.�ud, tfleft or dish<,nest�• of ins- of Contractc�c's
offtcers, agents, trustees, directors or employees. The procceds of such bond shall be used
to reimburse Cites,' for any and all loss c>f (;C)BG Funds occasioned by Such misconduct. Io
effectuate such reimbursement, such b0tld shall inctitcle a rioter stating; that rcimbursement
frig any Bass or losses thereunder shall be made directly to City Cor (lie uses and benefit of
Contractor.
<:. Contractor -shall furnish certificates of insurmice as proof that it ha.s secured and paid for
policies of workers' compensation, public liability and autotliobtle liability insurance covering
all risks incident to or in connection vkoith the c ecution, performance, attempted
ri�ttc> rsAtc xtxv sL 13RLCIriLti�r cc»Tant:-r x«•. 08-2449
{:cx�ks C;hitdren's E{riltla Care Svstcit, Pala 11
perforinance or nonperf )rniance of this Contract. "I he amouunts of such insuratce shall not
he less than the maxium liability that can be imposed on City under the laws of the State
Of `I`esas. Contractor understands and agrees that such insurance amounts may be revised
upward at City's option and that Contractor shall revise such amounts within thirty (30) days
following notice to Contractor of suchrequirements.
d. Contractor will subinit documentation to Ciry that it has Obtained insurance coverage and
has executed bonds as required in this contract widen third= (30) daVS of the executiOn Of
this Contract and prior to payment of any monies hereunder.
e. art Of the City to request certificate(s) of insurance shall not be construed a
11ny failure on ps
a waiver of such requirement or as a waiver of the insurance regtdretnenta themselves.
Insurers of Contractor 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 business in
the state of Texas. Insurers shall be acceptable to City insofar as their financial strength and
solvency and each sacln company shall have a current minimum A,1I. Best Key Rating Guide
rating of A: V11 or other equivalent insurance industry standard rating unless otherwise
approved by City. Deductible limits on insurance policies shall not exceed S5,flOt� per
occurrence unless otherwise approved by City.
£ Any local, federal or other regulatory or or bonding requirements for the Program
that exceed those specified herein shall prevail.
g. Contractor shall agree to require its subcontractors to maintain applicable insurance
coverages, limits, and other requirements as those specified herein; and, Contractor shall
require its subcontractors to prox•ide Contractor with certificate(s) of insurance documenting
such coverage. Also, Contractor shall require its subcontractors to have City and Contractor
endorsed as additional insured (as their interests may appear) on their respective insurance
policies. Contractor shall require its subcontractors to maintain builders risk insurance at the
Iirnit of applicable project(s) costs when the value of materials involved exceeds S 10,000 or
at a different limit value limit as specified by City.
f�ririer ref Lr�mrnu/
If Contractor is a charitable or nonprofit organization and has or claims an irn>lnunin� cir
exennpt.ion {statutortir or otherwise) fronh arul against lial7ility fc>r damages cFr injury, including
death, to persons or property; Contractor hereby expressly waives its rights to plead defensively
such inunutnit-V or exemption as against City. This section shill not be construed to affect a
governmental entity's iurununities under constitutional, statutory Or common law.
Renrerlies j%>r' Breach of C,rrnlr=rc7
L'poll _'identification of possible lhreaches Of this Contract, wind }riot to e:.ercising its Termination
Bights under this Contract, Litt• neat• elect to escxcist� any of the f<-allowing Remedies: a) issuance
of a warning letter indice tng that further failure to comply with applicable requirements will
result in serious sanction and giving the Contractor a limited time to correct the deficiency; b)
placing conditions upon award of future grants; c) directing the Contractor to stop incurring
costs until the deficiency is corrected and the correction is verified; d) requiring repayment of
r.DBCT Funds previt:nnsiv disbursed to the Contractor; and/or e) reducing the atnouunt of future
grant awards or disallowing of future atvards to the Contractor,
t:Dl3t: l'h:r\It 11X� SLF3RECtPtliti"I' (:oNI'12alCI'
C�a�ks Chiidren's Health Care Scstera
Page 12
15. Jt'/'lIIZIIQ/1011
a. I11 add1tI011 to, and I10t III SC1b;Cltutlotl for, other I11S % Chls C.C)nt.C3Ct >egard111g Che
provision of public services with CDBG Funds, pursuant to Title I of the Housing and
Community Development Act of 1974, as amended, (41. L`SC 3301 el seq.) and the CDBG
Regulations, it is expressly understood and agreed by and between the Parties that this
Contract is wholly conditioned upon the actual receipt by City- of Federal C:DI3G fear
XXXV fields; that all monies distributed to Contractor hereunder shall be exclusively- from
Federal monies received under solid grant and not from any other monies of Cite; ilnd that if
such funds under City's grant are not timely forthcoming, in whole or in part, City 1`1111y at
its scale d3iscretion, terminate this Contract and City shall not be liable for payment for any
work or services performed be Contractor under or in connection with this Contract.
b. C.ity may terminate .rhis Contract whenever such termination is determined to be in C;ii-'
best interest, in event of Contractor's default, inability or failure to perform or to comply-
with any of the terms herein, or., for other good cause.
c. The Parties acknowledge that CDBG Funds paid hereunder are intended to provide only
partial funding for Contractor's agency operations. Cite may terminate this Contract if non-
CDBG funds included in the Operating Budget are not forthconlulg to Contractor during
the Contract term.
d. CDBG Funds provided hereunder may not be used as collateral for loans to Contractor to
defray agency oper,ution expenses, and any attempted use of CDBG Funds for this purpose
will result in termination of this Contract be City.
e. Termination will be effected by written notice to Contractor, Specifying the portions of the
Contract affected and the effective date of termination. upon Contractor's receipt of such
termination Ilotice, Contractor will:
G Stop work under the Contract on the date and to the extent specified by City;
a Crease expenditures of CDBG Punds, except as necessary, for completion of the
portions of the Contract not terminated; and
® Terminate all orders and contracts to the extent that they relate to portions of the
Contract being terminated.
E. Contractor will return to Citv any unused CDBG Funds previously advanced by City- under
this Contract within thirty (30) days of the effective date of Contract termination. Clty will
have no responsibilinr or liability for Contractor `s expenditures or actions occurring after the
effective date of Contract termination.
1
t%j/r11is:jli0tt [Zc,y<<rr/iirs.I_a�li)jettjj
a. `I'lle undersigned represenratic-e of Contractor hereby' certifies, to the_ best of ]lis or her
lulotvledge wild l.>elief, that: �t7 federal appropriated fiurlds h:Ive been paid or will be paid, by
of out behalf of Contractor, to any person Cot influencing or attempting to influence arl
officer or e111ph_yce of any agency`, a member of C:;ongress, an officer or employee of
Congress or an employee of a member of Congress in connection with the awarding of anti
Federal contract, the making of any federal grant, the malcinp of any Federal loan, the
entering into of ally Cooperative agreement and the extension, eontilnlation, renewal
sul�cndlnent or modification of auy federal contract, grant, loaf or cooperative agreement.
(::outractor stall require that the language �>f this certification be included in all subcontracts
>r agreements involving the expenditure of Federal funds.
CDBG YEA It NDCAS SUBRECIPICNT CONTRACT Rey-. 08-24-09
Cimks Children's Health Care System Pale 13
b. If any funds other than I=ederal appropriated funds have been paid or will )e paid to
person for influencing or attempting to influence all officer or employee of any agency a
member of Congress, an officer or employee, of Congress, or an employee of a member of
G�ngress in connection with this Federal contract, grant, loan or cooperative agreement,
Contractor shall complete and submit Standard Dorm-I..LI.,, "Disclosure Form to Report
L,obbving,it ill accordance With its instructions.
c. 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 e prerequisite for
making or entering; into this Contract unposed by 31 L SC Section 1312. 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 S 100,000.00 for each such failure.
1?. �1:11����1r'r»rrurrti f�r�uihi�ir.'
a. r\11 terms of this Contract shall apply to auy and all subcontractors of Contractor wlio are in
any way paid with CDBGr Funds or who perform any work in connection with Contractor's
Program.
b. The provisions of this OF 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, quell iivalidity shall not affect other provisions which can be given effect without
the invalid provision.
c. C:ity's failure to insist upon the performance of any term or provision of this Contract or to
exercise arty right herein conferred shall not be construed as a war -ter or relinquishment to
any extent" of Cin''s right to assert or reh upon ally such term or right on any future
OCCastoll.
c1. Should and= action, whether real or asserted at law or in equity, arise out of the execution,
performance, attempted performance or nouperfotmance of this Contract, venue for action
Shall lie in Tarrant Counn'; Texas.
e. 'This written instrument and the exhibits attached hereto, which are incorporated by
refcrence and made a part of this Contract for all purposes, constitute the entire agreement
between the Parties concerning; the work and services to be performed hereunder, and any
prior or contemporaneous, oral or written agreement which purports to vary from the terms
hereof shall be void. Ally amendments to the terms of this Contract must be in writing; and
trust be approved by each Parry.
f. .A1.1 notices required or permitted by this Contract trust be in writing and are deerned
delivered on the earlier of the date actually received or the third day following (i deposit in
a United States Postal Service post office or receptacle; (ii with proper postage ;certified
mail, return receipt requested); and (iii) addressed to the other Dart, at the address set Deft in
the preamble of this Contract or at such other address as the receiving Party- designates by
proper notice to the .endIng Party.
g. None of the performance rendered under thus Contract shall involve, send n.o portion of the.
C::DI3G Funds received hereunder shall be used, director or indirectly; for the construction,
operations, maintenance or administration of ;any sectarian or religious facility or activity, nor
OF
shall said performm lice rendered Or funds received be utilized so as to benefit, directh or
indirecty, ansr such sectarian or religious facility- or activity.
CI.)I1G 1"E.1R XX.�iV 511DI2F•,{:CY[hti'i' CON"I'I2:1e;T• t2ec•. �)3-21.07
{:oohs Chitdren's I icalth {:are Svstcm Page IQ
h. C.,ontsactor. represents that it possesses the legal authoritlr pursuant to an�� proper,
appropriate and official motion, resolution or action passed or taken, to enter into this
Contract and to perform the responsibilities herein required.
i. Contractor cerriFIes that it has obtained a 501 (c) (:7} Certificate from the Internal Revenue
Service, Contractor sliall nodfv City In Writing of any changes to its 'DO] (c) (1) tax-exempt
status during the terns of this Contract.
[SIGH:<\TLRIti iI'PL:_\R (_)�i I=OI.LC)ll�'ItiG 1'\CAI)
CDI3G I'I�\RXY`CV St F312F:CIPFE'ti"I" COV"I"ILICI' Rev. OS-24-09
C�x�ks Cl+itdren's Ilcaltt� Care Svsteai Ya;;e ��
IN tiWI`INFSS EWFIFIOF, the Parties hereto have exec Led three copies of t{lis GontraCt in
I%ort Worth, Tarrant County, Texas, this o� - day of .a , 20QA
C.tT�' OF FORT �WORTI-i
T, M. Higgins ,
;assistant City Manager
r1PI'I2C.��rI<;ll AS TO FURnI AND LEG�II.IT�':
orl
City t�ttorney
AT'TES I':
City Secretary
S Ii�TE UI"I'E��S
COUN"LY OF TARRANT
T`lus instruument was acknowledged before me on
Fligguls, the s�ssistant City 14lanager of the City of
,Worth.
MARIA S• gANCHEZ
MY COMMISSION EXPIRES
December 14l 2p13
c,o>~IN,� CaF'L'�1RP.r�N'I°
Gook Ghildren's I Iealth Care S�=stc��
Linda 9 ppel1
Senior Vic President, QuaVIANIanqgement
..Phis instrument was acknowledged before I
Linda S. Chappell, the Senior Vice President, ual• a
Syste, a Texas non-profit corporati mon, on behoUf of said
SUSpN D. ROBERTSFIAW
MY COMMISSION EXPIRES
Ap1125, 2012
COBG YFi�1it YXXV 5t311RIiCIPILN'I' CON'i'RAC'I'
t;cwka Cifildren's T�Tealth Ccire System
Contract Author; i zatioia
a� I _, 20L by T.I�•I.
EWorth, od behalf of the City of Dort
N ary Public, State of Texas/
Go<.�k t;llildren� I-{ealth Care
Nosy Public, State of "Txas
OFFICIAL RECORD
CITY SECRETARY
F`I: VI ORT+i;OTX
Page 16
Cook Children's Health Care System EXHIBIT A
Save a Smile SCOPE OF SERVICES
PROGRAM SUMMARY
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG)
CONTRACT NO.
SCOPE OF SERVICES
June 1, 2009 - May 31, 2010
PERIOD
$21,0 tv
AMOUNT
This Scope of Services is based on the proposal prepared and submitted by the Subrecipient through the City of Fort
Worth's annual Request for Proposal (RFP) process. The Subrecipient agrees to operate this Community Development
Block Grant (CDBG) program in a manner consistent with the program delivery stated in the approved proposal.
However, in the event of any conflict between the proposal and any provision contained, herein, this Agreement shall
control.
The Cook Children's Health Care System will provide Oral Health Care and Screening to low income elementary school
(K - P) children. The Save a Smile program will include the following tasks and activities; 1) dental screening and oral
health classification to a projected 5,500 children; 2) oral health kits (containing a toothbrush, toothpaste, floss, fluoride
wash [2°d and 3`d graders only], a sticker, tooth fairy box, educational information regarding dental care and a list of low-
cost providers in the community, all provided in English and Spanish), to a projected 5,500 children, and 3) a free visit
with a volunteer provider or referral to Medicaid or other dentist to 300 children and 4) at least 400 free follow-up visits
with volunteer providers, to targeted low-income pre -kindergarten through P grade children, all at no cost to children or
families. All services will be provided at Fort Worth ISD, HEB ISD and Keller ISD low income public elementary schools
from school year during June 1, 2009 to May 31, 2010 (service hours, including days of operation).
The purpose of the program will be to provide Oral Health Care and Screening to low income elementary children. The
specific objectives, goals and level of services to be provided are listed below along with the geographical location of
clients served. All services will be provided from June 1, 2009 to May 31, 2010.
CDBG funds will assist with the salaries of six Case Aides and their supervising Master's level Social Worker,
who facilitate the provision of free dental care, translation services and transportation services to targeted low-
income children, pre --kindergarten through third grade, who would otherwise lack access to dental care.
*CDBG funds will be used to support staff time for at least 175 initial dental appointments, 250 follow
up appointments and 1,200 follow up phone calls only. As income verification for these services sample
Do y stubs, certification of income verification documents and letters from homeless shelters_ _will be
obtained. All services will be provided at Fort Worth ISD, HEB ISD and Keller ISD low income public elementary
schools from school year during June 1, 2009 to May 31, 2010 (service hours, including days of operation).
REGULATORY CLASSIFICATION:
National Objective Citation: 24 CFR 570.208(a)(2){b} Limited Clientele
Regulatory Citation: 24 CFR 570.201(e) Public Service
Based on the nature of the service provided, Subrecipient Communities in Schools will maintain documentation that
verifies that 51% of clients served by the Save a Smile program are income eligible with current household incomes under
80% of Area Median Income (AMI) as established by the Department of Housing and Urban Development (HUD).
GEOGRAPHICAL LOCATION:
Site Address:
801 Seventh Ave
Fort Worth, TX 76104
Client Beneficiary Location (Neighborhood, District, Citywide...): Citywide
Eight FWISD elementary schools: Diamond Hill, San Rosen, Oakhurst, Natha Howell, Hubbard heights,
Dolares Huerta, Meadowbrook, M.H. Moore; and the following two Keller ISD schools: North Riverside,
Parkview. Please note: The two Keller Schools Served are in the Fort Worth city limits. Please see
attached list of schools including addresses.
PROGRAM GOALS:
To improve the dental health and awareness of proper dental care of children in the above mentioned Client Beneficiary
Locations.
PROGRAM OBJECTIVES:
Educate 100% of targeted children seen by Save a Smile volunteer dentist in proper oral health, provide 100% of targeted
children with dental hygiene kit and provide referral to a volunteer provider or Medicaid/CHM for children in need of
treatment.
PROGRAM SERVICES and ACTIVITIES Total Units of Services for Year
Number of Unduplicated Clients Served 55500
Dental Screenings
3,900
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CITY OF FORT WORTH
CDBG YEAR XXXV
EXHIBIT C
Page 1 of 3
CONTRACTPERIODI From: June 1, 2009 To: 5/31/2010
Name of Sub Grantee Cooks Children's Health Care System Name of Program Save a Smile
Program
CDBG
Cost Category
Budget
Funds a b c d
PERSONAL SERVICES
Salaries
$109,783,00
109,783.00
FICA
$7,685.00
$7,685.00
Life Insurance
$439.00
$439,00
Health Insurance
$11,966.00
$11,966.00
Employment Tax - State
$110.00
$110,00
Worker's Comp
$878.00
$878.00
Retirement
$33403.00
$3,403.00
Other
$3,185.00
$3,185,00
SUPPLIES
Office Supplies
$1,250,00
$1,250.00
Postage
$2,100,00
$2,100.00
Teaching Aids
Food Supplies
$3,000.00
$3,000400
Other Operating Expenses(Dental
Hygiene Kits)
$26,550.00
$26,550.00
CONTRACTUAL SERVICES
Telephone
Electric
Gas
Water/Waste Disposal
Rent [Building]
$2,028,00
$2,028.00
Custodial Services
Office Equipment Rental*
Printing
Repairs
Fidelity Bond***
Liability Insurance***
Legal & Accounting
Travel/Parking
$1, 500,00
$1,500,00
Advertising
$169971,00
$16,971.00
Conference & Seminars
$250.00
$250.00
Contractual Services
$154,423.00
$21,870.00
$132,553.00
Miscellaneous
$1,260.00
$1,260,00
CAPITAL OUTLAY
office Furniture
Computer Equipment
Other: office equipment]
$200.00
$200,00
TOTAL $346,981.00 $21,870.00 $3251111.00
* Specify on Budget Detail (following pages)
*` Use one column for each non -grant funding sours; note below which column equates to each source (from Leverage of Funds)
**` Fidelity bond & liability insurnace are required of all subcontractors & may be paid from grant funds or other funds.
MATCHING FUND SOURCES
[a] Other Grants/Gifs (CCHCS4-Kind Contribution over $25,000 in support services)
[b]
(c]
[d]
BUDGET DETAIL
Page 2 of 3
Hourly Annual % of
Position / Title Rate Hours Time Amount
1 Licensed Master's Social Worker $20683 $ 43,326.40 8% $3,466.11
2 Case Aide 1 FTE $11484 $ 20,933.12 18% $3,767.96
3 Case Aide 3 FTEs @ $11.33 each $11.33 $ 60,094.32 15% $%014.15
4 Case Aide 1 FTE $11.00 $ 19,448600 18% $3,500.64
5 Case Aide 1 F'1'E $10.00 $ 10,400.00 20% $2,121 s60
6
7
8
9
10
TOTAL STAFF SALARIES
CATEGORY
FICA
Life Insurance
Health Insurance
Employment Tax
Worker's Comp
Retirement
TOTAL FRINGE BENEFITS
TOTAL PERSONNEL SERVICES
Total Progam
Amount %Paid %Paid
Amount by Agency by CDBG Amount
CATEGORY
Telephone
Electric
Gas
WasteMater Disposal
Other
Total Utilities
1
2
3
TOTAL BUILDING LEASE
CATEGORY
Fidelity Bond
Liability Insurance
Legal & Accounting
Postage
Printing
Mileage
Advertising
Teaching Aids/Office Supplies
Contractual Service (Case Aides)
TOTAL OTHER EXPENSES
EVENT
BUDGET DETAIL
NUMBER OF MONTHS
AVERAGE COST PER MONTH
Page 3 of 3
AMOUNT
LOCATION NO. SQUARE FOOT FOOT AMOUNT
TOTAL CHARGE
TOTAL CHARGE
OTHER EXPENSES
CHARGED TO CDBG
CONFERENCES AND SEMINARS
%CHARGED TO CDBG
AMOUNT
AMOUNT
1
2
3
TOTAL CONFERENCES AND SEMINARS $ -
ITEM TOTAL CHARGE
1 Copier Lease
2
TOTAL OFFICE EQUIPMENT RENTAL
OFFICE EQUIPMENT RENTAL
CHARGED TO CDBG
AMOUNT
Attachment I
CITY OF FORT WORTH
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
REQUEST FOR FUNDS
AGENCY: Cook Children's Health Care System PROGRAM:
ADDRESS: 801 Seventh Avenue CONTRACT NUMBER:
Fort Worth, TX 76104 CONTRACT AMOUNT:
CONTRACT DATE:
DATE OF REQUEST:
SECTION 1 (AGENCIf�
1. Reimbursement Request
A Expenditures:
B. Reimbursement
2. Requested By:
A Agency
Linda s. Chappell
(Name)
SECTION 11 (CITIf�
1. BUYSPEED -Purchasing Request
A BUYSPEED INPUT: Vendor/PO Number/Requisition Number:
B. Fund/Account/Canter
C. Total Amount of this Request
SECTION III (CITY)
1. Verification
A Contract Compliance Specialist
B. Accounting
2. Authorization
A Grants Manager
Sherry Johnson
(Name)
(Name)
Barbara Asbury
(Name)
J@SUS "Jay" Chapa
(Name)
IDIS NUMBER:
CURRENT MONTH
(Signature)
G R76/539120/017206350510
(Signature)
(Signature)
(Signature)
(Signature)
Dis6lbution:
t Copy -Accounting
1 Copy - Complance
Note: Any Request for Funds that exceed $8500 require the signature of both Grants Manager/Designee and Director
Save a Smile
19870
CUMULATIVE
(Date)
(Date}
(Date)
(Date)
(Date)
Attachment II
CITY OF FORT WORTH
HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
DETAIL STATEMENT OF COSTS
AGENCY CONTRACT NO.
PROGRAM
TO
DATE
COST CATEGORY
ACCOUNT
PROGRAM
BUDGET
MONTHLY
EXPENDITURES
CUMULATIVE
TO DATE
BALANCE
PERSONAL SERVICES
Salaries
516 010
FICA
518 010
Life Insurance
518 050
Health Insurance
518 060
Unemployment Tax- State
518 090
Worker's Comp
518 040
Retirement
518 070
SUPPLIES
Office Supplies
521 010
Postage
521 020
Teaching Aids (Equipment)
522 030
Food Supplies
522 030
Other Operating Supplies
523 300
CONTRACTUAL SERVICES
Telephone
535 040
Electric
535 020
Gas [UtiliM
535 010
Water/Waste Disposal
535 030
Rent[Building]
537 010
Custodial Services
539 220
Office Equipment Rental
537 030
Printing
533 030
Repairs
536 010
Fidelity Bond
538 210
Liability Insurance
534 020
Legal & Accounting
538 050
Private Auto Allowance- Local
532 130
Advertising
533 010
Conferences & Seminars
531 180
Contractual Services
539 120
$21 870.00
CAPITAL OUTLAY
Furniture Fixtures
541 330
Office Equipment, Computers
541 370
Other Equipment
541 320
TOTAL
$21,870.00
$0000
$0600
$0000
Contractor's Certification: I certify that the costs incurred are taken from the books of account and that such costs are valid
anA consistent with the terms of the agreement.
NAME and TITLE OF AUTHORIZED OFFICER SIGNATURE and DATE
Attachment III
CITY OF FORT WORTH
HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
EXPENDITURES WORKSHEET
Cook Children Health Care System
Agency
Save a Smile
To
Report Period
Nrogram
NO
1
2
3
4
5
6
DATE
CHECK NO
PAYEE
DESCRIPTION
ACCOUNT NO.
AMOUNT
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
TOTAL $0.00
TITLE OF AUTHORIZED OFFICER SIGNATURE AND DATE
CITY OF FORT WORTH Attachment IVa
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
CDBG YEAR XXXV
1. Name and Address of Sub -Grantee
2. Project Name Save a Smile
Cook Children's Health Care System
801 Seventh Avenue
3. Contract No.
Fort Worth, TX 76104
4. Date of Request
Month & Year
6. Program Services and Activities
Current
Month
Cumulative
Number of New
Households andfor
Persons Served
S. Direct Benefit
(Continued)
Extremely Low
Very Low Income Low Income
Income
(0<30%)
(3140%) (61-80%)
Above Low Income (80%>)
Current Month
Cumulative
Household Size
1
2 3
4
5
6
7
8
040%
$13,850
$15,850 $17,800
$19,800
$21,400
$22,950
$24,550
$26,150
31060%
$23,100
$26,400 $29,700
$33,000
$35,650
$38,300
$40,900
$43,550
51.80%
$36,950
$42,250 $47,500
$52,800
$57,000
$61,250
$65,450
$69 7700
Certification: The undersigned, hereby, gives assurance that
to the best of my knowledge and
belief, the data
included in this report is true
and accurate.
It is also
acknowledged that the provision of false information could leave the certifying official subject to
the penalties of federal, state,
and local law.
Date: Submitted by:
Signature Required
Phone No.
CITY OF FORT WORTH
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
CDBG YEAR XXXV
Name and Address of Sub -Grantee
Cook Children's Health Care
801 Seventh Avenue
Fort Worth, TX 76104
Direct Benefit Data (New Household and /or Persons
Current Month Cumulative
White
Black/African
American
Asian
American
Indian/Alaskan Native
Native Hawaiian/Other
Pacific Islander
Indian/Alaskan Native
& White
Asian & White
Black/African
American&White
Indian/Alaskan Native
& Black African
2. Project Nam Save a Smile
3. Contract No.
4. Date of Request
Month &Year
Ethnici
(Section Must be
Completed)
Hispanic
Current Month
Attachment IVb
Hispanic
Non -Hispanic
Cumulative Current Month
Other Multi -Racial
TOTAL 0 0 0 0 0
Female Head of Household
Month
Ave
cation: The undersigned, hereby, gives assurance that to the best of my knowledge and belief, the data included in this report is true and
ate. It is also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,
and local law.
Date:
Submitted by:
Phone No.
Ethnicity- Report whether client identifies themselves as Hispanic or Non -Hispanic
Race- Identify the category chosen by the client
CITY OF FORT WORTH Attachment IVb
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
Ethnicity- Report whether client identifies themselves as Hispanic or Non -Hispanic
Race- Identify the category chosen by the client
CITY OF FORT WORTH Attachment V
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
CDBG YEAR XXXV
Agency/Address 2. Program Name: Save a Smile
Cook Children's Helth Care System 3. Contract No: Contract Date: June 1, 2009
801 Seventh Avenue Contract Amount: $21,870
Fort Worth, TX 76104 4. Date of Request:
Month &Year
5. PROGRAM SERVICES AND ACTNITIES:
**Goals listed on Contract Exhibits A&B should be listed here.
CURRENT CUMULATNE
Dental Screenings ---
*Initial Dental Appointments
*Follow -Up Appointments
*Follow -Up Phone Calls
6.
7. PROBLEMS ENCOUNTERED / SOL.UTIONS PROPOSED:
8. ANTICIPATED ACTIVITY DURING THE NEXT MONTH:
Certification: The undersigned, hereby, gives assurance that to the best of my knowledge and belief, the data included in this report is true and
accurate. ft is also acknowledged that the provision of false information could Issue the certifying official subject to the penalties of federal, state, and
local law.
Submitted
Signature Req
Phone No.
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EXHIBIT D
CITY OF FORT WORTH HOUSING &ECONOMIC DEVELOPMENT
Audit Certification Form
Subrecipient:Cook Children's Medical Center Fiscal Year Endinga09/30/09
Mo Day Yr
® During the fiscal year in which funds will be received, we will exceed the federal
expenditure threshold of $500,000. We will have our Single Audit or Program Specific Audit
completed and will submit the A-l33 audit report within nine (9) months after the end of the
audited fiscal year or thirty (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
$500,000 federal expenditure threshold required for a Single Audit or a Program Specific Audit
to be performed this fiscal year. (Fill out schedule below)
Federal Expenditure Disclosure
Federal Funds
Must be filled out if Single Audit or Program Audit is not required:
Federal Grantor
Pass Through
Grantor
Program Name &
CFDA Number
Contract
Number
Expenditures
Total Federal Expenditures for this Fiscal Year $
Linda S. Chappell Sr. VP Quality Management
Prin d Name Title (Must be CFO, CEO or equivalent)
� .� 4
rized Signature
be CFO, CEO or equivalent)
_(682) 885-2103
01 /21 /10
Failure to submit this or a similar statement or failure to submit a completed single
audit package as described in the federally required audit requirements described in OMB
Circulars A-133 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.'
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Cooks Children's Health Care System
Save a Smile
EXHIBIT E
CONFLICT OF INTEREST
All Applicants
The standards in OMB Circular A -I 10, Subpart C, provide that no employee, officer, or agent shall participate in the
selection, award, or administration of a contract supported by Federal funds if real or apparent conflict of interest would
be involved. Such a conflict would arise when an employee, officer, or agent, any member of his or her immediate
family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has
a financial or other interest in the firm selection for an award.
CDBG and HOME Applicants Only
The CDBG regulations at 24 CFR 570 570.611 and HOME regulations at 24 CFR 92.356 provide that no person who is
an employee, agent, consultant, officer, or elected official or appointed official of the recipient or Subrecipient that are
receiving CDBG or HOME funds and (1) who exercises or has exercised any functions or responsibilities with respect to
activities assisted with CDBG funds; or (2) who is in a position to participate in a decision -making process or gain inside
information with regard to these activities, may obtain a financial interest from a CDBG-assisted or HOME -assisted
activity, or have any interest in any contract, subcontract, or agreement with respect thereto, or the proceeds, thereunder,
either for themselves or those with who they have family or business ties, during their tenure or for one (1) year
thereafter.
IF NO CONFLICTS EXIST, COMPLETE THE FOLLOWING:
I certify to the best of my knowledge that no conflict of interest exists between The City of Fort Worth and
Cook Children's Health Care System
(Name of Organization)
I certify to the best of my knowledge that no conflict of interest exists between the subcontractors of and
Cook Children's Health Care System
(Name of Organization)
IF THERE IS A CONFLICT, COMPLETE THE FOLLOWING:
I certify that a conflict of interest does exist between The City of Fort Worth and
(Name of Organization)
I certify that a conflict of interest does exist between
(Name of subcontractor)
(Name of Organization)
Describe the nature of the conflict of interest below: (Pleaseidentify the individual, employment, and the con'.
Signature of Authorized Agency �ci�l
Linda S. Cha ell, Sr. Vice President Quali Management
A th dA Off ' 1N P T' I
u onze gency icia amp osthon rt e
Typed Name and Title
and
ict or potential conflict [their
IAL ECORD
CITY SgtWARY
, FT. RT TX
Nation with your