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HomeMy WebLinkAboutContract 41945 (2)CITY SECRETARY CONTRACT NO, 1-4 ta91 4 AGREEMENT FOR SERVICES THIS AGREEMENT ("Agreement") is made and entered into by and between THE CITY of FORT WORTH, a hone rule municipal corporation of the State of Texas (hereinafter referred to as "City"), acting by and through Susan Tanis, its duly authorized Assistant City Manager, and YWCA, a nonprofit Texas corporation (hereinafter referred to as "Contractor"), acting by and through Ms. Carol Klocek, its duly authorized Executive Director. RECITALS WHEREAS, Contractor provides counseling services to youth and young adults; and WHEREAS, such services serve a public purpose in serving low to moderate income individuals which benefits the Fort Worth community; and WHEREAS, City and Contractor desire to enter into a contract to have such services provided which benefit the Fort Worth community. NOW, THEREFORE, E, in consideration of the mutual covenants herein expressed, the parties agree as follows: AGREEMENT 1. SCOPE OF SERVICES. Contractor covenants and agrees to fully perform, or cause to be performed, with good faith and due diligence, all services and objectives described in Exhibit "A," attached and incorporated herein for all purposes incident to this Agreement ("Services"). 2m COMPENSATION. In consideration of the Services to be performed hereunder by Contractor, City agrees to reimburse Contractor via monthly installments up to a total amount not to exceed Wive Thousand Eight Hundred Seventh. Six and No/100 ($5,876OO) ("Funds"). Any funds not requested as provided in Section 3 shall remain with the City. OFFICIAL . ECORD CITY SECRETARY Ft WORM TX REPORTING OF EXPENDITURES a. Contractor shall deliver to City a monthly statement of the request for reimbursement ("Request f©i Reimbui sement") of Funds detailing how the Funds were expended by Contractor to accomplish performance of the Services. All expenditures included in the Request for Reimbursement must be eligible for reimbursement by federal funds as determined by City in its sole discretion. The monthly statement shall be in the same format as the attached Exhibit "13" which is incorporated herein for all purposes. b. Each month's Request for Reimbursement is due to City by 5:00 p.m. on the 10th day of the following month (for example, all expenses for June must be submitted to City by July 10th). City will not accept late Requests for Reimbursement. If a. timely Request for Reimbursement is not received for any month, Contractor will not receive reimbursement for that month Notwithstanding the above, the Request for Reimbursement for the month of September shall be due by September 23, 2011. The failure to make such request by September 23, 2011 shall result in no funds being paid for the month of September. c. Each Request for Reimbursement must be prepared and signed by an authorized representative of the Contractor. d. If the Contractor deviates from the reporting requirements in Sections 3(a), 3(c) or Section 4, the Contractor will be considered in non-compliance with this Agreement. City will notify Contractor of such non-compliance, and Contractor will have ten (10) business clays to cure such non compliance (the "Cure Period"). If the noncompliance is not cured by the expiration of the Cure Period to City's satisfaction, Contractor will be in default of this Agreement and «-ill not receive reimbursement. e. Any non-compliance by Contractor under Section 3 of this Agreement may jeopardize the Contractor's ability to receive future funding from the City. 4. RFPORTING Of SERVICES. A report of services shall accompany each Request for Reimbursement. The report of services shall be in substantial conformity with the attached Exhibit "C" and Exhibit "C-1" and Exhibit ` C-2", if applicable. Contractor shall be subject to a review by the City of its services and activities in pet formance of this Agreement. 5. TERM AND TERMINATION. a. This Agreement shall be for a term beginning June 1, 2011 and ending September 30, 2011. b. hither party may cancel this Agreement upon thirty (30) days notice in writing to the other party of such intent to terminate. c. The City may terminate this Agreement immediately for any violation by Contractor of Section 3, "Request for Reimbursement" or Section 4, "Reporting of Services," above. d. In the event no funds or insufficient funds are appropriated by the City in any fiscal period for any payments hereunder, City will notify the Contractor of such occurrence and this Agreement shall terminate on the last day of the fiscal period for which appropriations `tiere received without penalty or expense to City of any kind whatsoever, except as to the portions of the payments herein agreed upon for which funds shall have been appropriated. 6. RIGHT TO MONITOR SERVICES. Contractor covenants and. agrees to fully cooperate with City in monitoring the effectiveness of the Services to be performed under this Agreement, and City shall have access at all reasonable hours to offices and records of Contractor for the purpose of such monitoring during the teen of this agreement. 7. INDEPENDENT CONTRACTOR. Contractor shall operate hereunder as an independent contractor and not as an officer, agent, servant, or employee of City. Contractor shall have exclusive control of and the exclusive right to control the details of the Services performed hereunder, and all persons performing same, and shall be solely responsible for the acts and omissions of its officers, agents, servants, employees, subcontractors and program participants. The doctrine of respondeat superior shall not apply as bete een the City and Contractor, its officers, agents, sere ants, employees, subcontractors, or program participants, 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, agent, employee, or subcontractor of Contractor is in the paid service of City. S. LIABILITY AND INDEMNIFICATION. CITY SHALL IN NO WAY OR UNDER ANY CIRCUMSTANCES BE RESPONSIBLE FOR ANY PROPERTY BELONGING TO CONTRACTOR, ITS O FFICERS AGENTS, EMPLOYEES SUBCONTRACTORS PROGRAM P ARTICIPANTS, OR RECIPIENTS, WHICH MAY BE LOS f, STOI. EN, DESTROYED, O R IN ANY WAY DAMAGED. CONTRACTOR HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS THE CITY ITS OFFICERS, AGENTS, AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS CONCERNING SUCH P ROPERTY. CONTRACTOR COVENANTS AND AGREES TO INDEMNIFY, HOLD HA LESS AND DEFEND, AT II'S OWN EXPENSE, CITY ANI) 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 WILATSOEVER KIND OR CHARACI ER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED P ERI,ORIVIANCE OR NONPERFORMANCE OF THIS AGREEMENT AND/OR THE 3 OPERATIONS, ACTIVITIES AND SERVICES DESCRIBED HEREIN, WHETHER OR N OT CAUSED, IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF O FFICERS, AGENTS SERVANTS, EMPLOYEES, CONTRACTORS, OR SUBCONTRACTORS OF CITY; AND CONTRACTOR HEREBY ASSUMES ALL LIABILI'I Y ANI) 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 ANI) AI..L PERSONS, OF WHATSOEVER KINDS OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION %ti ITH THE EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE, OR NON- PFRFORNIANCE OF THIS AGREEMENT AND/OR THE OPERATIONS, ACTIVITIES ANI) SERVICES DESCRIBED HEREIN, WHETHER OR NOT CAUSED IN WHOLE O R IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY. CONTRACTOR LIKEWISE COVENANTS AND AGREES TO AND DOES HEREBY INDFMNIFY AND HOLD HARMLESS CITY FROM AND AGAINST ANY AND ALL INJURY, DAMAGE O R DES I RUC PION OF PROPERTY OF CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF CONTRACTOR ITS O FFICERS MEMBF'RS, AGENTS, EMPLOYEES, SUBCONTRACTORS, INVITEES, LICENSEES, PROGRAM PARTICIPANTS, OR RECEIPIENTS WHETHER OR NOT CAUSED, IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFF ICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY. CONTRACTOR AGREES TO AND SHALL RELEASE CITY ITS AGENTS, EMPLOYEES OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY FOR INJURY, DEr1I'H, DAMAGE OR LOSS TO PERSONS OR PROPERTY SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE U NDER THIS AGREEMENT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED BY CITY'S SOLE OR CONCURRENT NEGLIGENCE. Contractor shall require all of its subcontractors and Recipients to include in their subcontracts a release and indemnity in favor of City in substantially the same form as above. 9. MISAPPRORIATION OF FUNDS. IN THE EVENT IT IS DETERMINED THAT CONTRACTOR HAS MISUSED, MISAPPLIED OR MISAPPROPRIATED ALL OR ANY PART OF THE I+UNDS PROVIDED HEREUNDER, CONTRACTOR AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND THE CITY OF FORT WORTH, ITS OFFICERS, AGENTS, SERVANTS, ANI) EMPLOYEES, FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS RESULTING FROM SUCH MISUSE MISAPPLICA TION OR MISAPPROPRIATION. 4 10. CHARITABLE IMMUNITY. If Contractor, as a charitable or nonprofit organization, has or claims an immunity or exemption (statutory or otherwise) from and against liability for damage or injury, including death to persons or property, Contractor hereby expressly waives its rights to plead defensi\ ely such immunity or exemption as against the City. 11. ASSIGNMENT AND SUBCONTRACTING. Contractor shall not assign or subcontract all or any part of its rights, privileges or duties under this Agreement without the prior written consent of City, and any attempted assignment or subcontract of same without such prior written approl, al shall be void and constitute a breach of this agreement. 12. COMPLIANCE WITH LAWS, ORDINANCES, RULES AND REGULATIONS. Contractor, its officers, agents, employees and subcontractors, shall abide by and comply with all laws, federal, state and local, including all ordinances, rules and regulations of City. It is agreed and understood that, if City calls to the attention of Contractor any such violation on the part of Contractor or any of its officers, agents, employees or subcontractors, then Contractor shall immediately desist from and correct such violation. 13. NON-DISCRIMATION COVENANT. Contractor, in the execution, performance or attempted performance of this contract and Agreement, will not discriminate against any person or persons because of disability, age, familial status, sex, race, religion, color, national origin, gender identity, gender expression or transgender nor will Contractor permit its officers, agents, employees, or subcontractors to engage in such discrimination. This Agreement is made and entered into with reference specifically to Chapter 17, Article III, Division 3, of the City Code of the City of Fort Worth ( 'Discrimination in Employment Practices"), and Contractor hereby covenants and agrees that Contractor, its agents, employees and subcontractors have fully complied with all provisions of same and that no employee or employee -applicant has been discriminated against by either Contractor, its agents, employees or subcontractors. 14. INSURANCE. Contractor shall procure and shall maintain during the term of this Agreement the foliowing insurance coN ei age: 1. Commeicial General Liability (CGL): $1,000,000 per occurrence, with a 52,000 000.00 annual aggregate limit, in a. form that is acceptable to the City's Risk Manager. 2. Non -Profit Organization Liability of Directors & Officers Liability: $1,000,000 per occurrence, with a $1,000,000 annual aggregate limit, in a form that is acceptable to the Crty's Risk Manager. Contractor's insurer(s) must be authorized to do business in the State of Texas for the lines of insurance coverage provided and he currently rated in terms of financial strength and solvency to the satisfaction of the City 's Risk Manager. Each insurance policy required herein shall be endorsed with a waiver of subrogation in favor of the City. Each insurance policy required by this Agreement, except for policies of worker's compensation or accident/medical insurance shall list the City as an additional insured. City shall have the right to revise insurance coverage requirements under this Agreement Contractor further agrees that it shall comply with the Worker's Compensation Act of Texas and shall provide sufficient compensation insurance to protect Contractor and City from andagainst any and all Worker's Compensation claims arising from the work and services provided under this Agreement. 15. RIGHT TO AUDTI:' RECORDS. Contractor agrees that the City shall, until the expiration of three (3) years after final payment under this Agreement, have access to and the right to examine, whether in hard copy or electronic format, any directly pertinent books, documents, papers and records of the Contractor involving transactions relating to this Agreement Contractor agrees that the City shall have access during normal working hours to all necessary Contractor facilities and shall be provided adequate and appropriate workspace in order to conduct audits in compliance with the provisions of this section. The City shall give Contractor reasonable advance notice of intended audits. Contractor further agrees to include in all of its subcontractor and Recipient agreements hereunder a pro' ision to the effect that the subcontractor and/or the Recipient agrees that the City shall, until the expiration of three (3) years after final payment under the subcontract or this Agreement, have access to and the right to examine, whether in hard copy or electronic format, any directly pertinent books, documents, papers and records of such subcontractor involving transactions to the subcontract or this Agreement, and further that City shall have access during normal working hours to all subcontractor or Recipient facilities and shall be provided adequate and appropriate workspace in order to conduct audits in compliance with the provisions of this paragraph City shall give subcontractor or Recipient reasonable advance notice of intended audits. This Section 16 shall survive the expiration of the term of this Agreement. 16. GOVERNING LAW AND VENUE.. This Agreement shall be governed by and construed under the laws of the state of Texas. Should any action, whether real or asserted, at law or in equity, arise out of the execution, performance, attempted performance of this Agreement, venue for said action shall he in Tarrant County, Texas. 6 17. NOTICES. Notices to be provided hereunder shall be sufficient if forwarded to the other party by hand -delivery or via U.S. Postal Service certified mail, postage prepaid, to the address of the other party shown below: Jesus "Jay" Chapa Director of Economic Development City of Fort Worth 1000 Throclmorton St. Fort Worth, Texas 76102 18. NO WAIVER. Ms Carol Klocek Executive Director YWCA 512 West 4th Street Fort Worth, TX 76102 The failure of City or Contractor to insist upon the performance of any term or provision of this Agreement or to exercise any right herein conferred shall not be construed as a waiver or relinquishment to any extent of City's or Contractor's right to assert or rely upon any such term or right on any fixture occasion. 19. DISCLOSURE OF CONFLICTS ANI) CONFIDENTIAL INFORMATION. Contractor hereby warrants to the City that Contractor has made frill disclosure in writing of any existing or potential conflicts of interest related to Contractor's services under this Agreement. In the event that any conflicts of interest arise after the Fffective Date of this Agreement, Contractor hereby agrees immediately to make hill disclosure to the City in writing Contractor, for itself and its officers, agents and employees, finther agrees that it shall treat all information provided to it by the City as confidential and shall not disclose any such information to a third party without the prior written approval of the City. Contractor shall store and maintain City Information in a secure manner and shall not allow unauthorized users to access, modify, delete or otherwise corrupt City Information in any way. Contractor shall notify the City immediately if the security or integrity of any City information has been compromised or is believed to have been compromised. 20. SEVERABILITY. If any provision of this Agreement is held to be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired. 21. FORCE MAJEURE. The City and Contractor shall exercise their best efforts to meet their respective duties and obligations as set forth in this Agreement, but shall not be held liable for any delay or omission in performance due to force rnaieure or other causes beyond their reasonable control (force maieure j, including, but not limited to, compliance with any government law, ordinance or regulation, acts of God, acts of the public enemy, fires, strikes, lockouts, natural disasters, 7 wars, riots, material or labor restrictions by any governmental authority. transportation problems and/or any other similar causes. 22. HEADINGS NOT CONTROLLING. Headings a.nd titles used in this Agreement are for reference purposes only and shall not be deemed a part of this Agreement. 23. ENTIRETY OF AGREEMENT. This written instrument constitutes the entire agreement by the parties hereto concerning the work and services to be performed hereunder, and any prior or contemporaneous, oral or written agreement, which purports to vain from the terms hereof shall be void. [SIGNATURES APPEAR ON FOLLOWING PAGE.] 8 IN WITNESS WHEREOF, the parties hereto have executed this agreement in multiples in Fort Worth, Tarrant County, Texas, to be effective June 1, 2011.. ATTE ,sco.-\.nvtitri, CITY OF FORT WORTH 4. le,0000000040 16, orei ORS endrixit-toli? . 0 it. , '300 ci?• By: Afii; . '�o Q ¢ S s Alanis artya * o . ;`ial Assistant CityManager er City Secretary ' x - t �g 1 Po/JDate: Datc. i . a+( 4 d' �oOOrO�v �.,.Y *ztt ?EXJ&' APPROVED AS TO FORM AND LEGALITY: CONTRACT AUTHORIZATION: at eann D. Guzrna Assistant City Attorney Date: L• r e ri E S rr �(L Name: Title: M&C: C-24905 Date Approved: 05/17/2011 YWCA: By: Name: Ms. Carol Klocek Title: Executive Director Date: (D/ / frOP OFFICIAL RECORD CITY SECRETS'' RV E WORTH, TX 9 STATE OF TEXAS S COUNTY OF TARRANT 4§, BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas, on this day personally appeared Ms. Carol Klocek, known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that the same was the act of the YWCA and that she executed the sane as the act of said YWCA for the purpose and consideration therein expressedand in the capacity therein stated. GIVEN UNDER MY HANlD AND SEAL OF OFFICE this 2011. STA.T . OF TEXAS COUNTY of TARRANT (Sk day of Notary Public in a- z y s for the State of Texas BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas, on this day personally appeared Susan Alanis, known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that the same was the act of the City of Fort Worth for the purpose and consideration therein expressed and in the capacity therein stated. UNDER MY HAND ANDSEAL OF OFFICE this GIVEN ...-__._..-.._._ dad of V h- 2011. oLo , frt ot'ary Public in and for the Sta`te of Texas taisarsdans LINDA M. HIFIRLINGER MY COMMISSION EXPIRES February 2, 2014 OFFICIAL RECORD CITY SECRETARY 10 EXHIBIT A SERVICES 11 YWCA Fort Worth & 'Tarrant County EXHIBIT A MY OWN PLACE SCOPE OF SERVICES COMMUL PROGRAM SUMMARY f'Y DEVELOPMENT BLOCK GRANT (CDBG) June 1, 2011 — September 30, 2011 PERIOD SCOPE OF SERVICES 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 (REP) 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. YWCA Fort Worth & Tarrant County will provide a two-year residentialprogram for young women 18-21 years of age who are exiting the foster care system or are homeless at YWCA Fort Worth & Tarrant County. The My Own Place program will include the following tasks and activities: provide housing, intensive case management mentoring, and counseling All services will be provided at 512 West 4th St., Fort Worth, TX 76102, 24 hrs/day, 7 days a week; agency business hours are Monday -Friday, 8-5 pin. The purpose of the program will be to provide a two-year residential program for young women who are exiting the foster care system or are homeless. 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, 2011-September 30, 2011. The funds will be used to pay for staff salary which is consistent with Exhibit B - Detailed Statement of Costs. 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, YWCA. Fort Worth & Tarrant County will maintain documentation that verifies that 51% of clients served by the Advocate 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: 512 West 4th St., Fort Worth, TX 76102 Client Beneficiary Location (Neighborhood, District, Citywide...): Citywide PROGRAM GOALS: Program goal is to assist young women who are aging out of foster care or homeless to reach self-sufficiency. PROG t M OBJECTIVES: Provide temporary stable housing to targeted young women in specified at -risk populations 0 Provide intensive case management, mentoring, and counseling sessions that lead toward self-sufficiency PROGRAM SERVICES and ACTIVITIES Number of Unduplicated Clients Served Nights of Housing (365 days/year) Hours of Case Management Hours of Counseling Hours of Mentoring EXHIBIT B FORM OF REQUEST FOR REIMBURSEMENT [ATTACHED] 12 CITY OF FORT WORTH HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT COMPLIANCE DIVISION REQUEST FOR FUNDS AGENCY: PROGRAM: ADDRESS: CONTRACT NUMBER: CONTRACT AMOUNT: CONTRACT DATE: DATE OF REQUEST: IDIS NUMBER: S ECTION I (AGENCY) CURRENT MONTH CUMULATIVE 1. Reimbursement Request A. Expenditures: $ $ B. Reimbursement $ $ 2. Requested By: A. Agency (Name) (Signature) (Date) S ECTION II (CITY) 1. BUYSPEED - Purchasing Request A. BUYSPEED INPUT: Vendor/PO Number/Requisition Number: B. Fund/Account/Center: C. Total Amount of this Request: S ECTION III (CITY) 1. Verification A. Contract Compliance Specialist B. Accounting 2. Authorization A. Grants Manager B. Sr. Admin. Services Mgr C. Director Mark Folden (Name) (Signature) (Date) Benedict George (Name) (Signature) (Date) Robin Bentley (Name) (Signature) (Date) Socorro Gray (Name) (Signature) (Date) Jesus Chapa (Name) N ote: Any Request for Funds that exceeds $25,000 requires the Director's signature (Signature) (Date) CITY OF FORT WORTH HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT DETAIL STATEMENT OF COSTS AGENCY PROGRAM CONTRACT NO. TO DATE REPORT PERIOD COST CATEGORY PROGRAM BUDGET EXPENDITURES MONTHLY CUMULATIVE TO BALANCE DATE ADMINISTRATIVE COSTS Salaries FICA Life Insurance Health Insurance Unemployment Tax Workers Comp Legal and Accounting Office Supplies ��� � � _��__—�...m� _ M1M4�� PROGRAMMATIC COSTS Salaries 5,876.00 FICA Life Insurance Health Insurance Unemployment — Federal Unemployment — State Workers Compensation Medical Supplies Security Utilities Water (Telephone, aste ater, Electric, Waste Disposal) Gas, Rent Office Equipment Rental Printing Accounting Postage Building Maintenance and Repair Office Su..lies Food Other Operating Supplies Liability Insurance Private Auto Allowance Childcare Scholarships Meals Teaching Aids Contractual Services Contract Labor Conferences and Seminars Short Assistance Term Rent (STRMU) Mortgage and Utility Tenant (TBRA) Based Rental Assistance TOTAL , $0.00 $0.00 $0.00 $0.00 Contractors Certification: I certify that the costs incurred are taken from the books of accoun consistent with the terms of the agreement. NAME and TITLE OF AUTHORIZED OFFICER SIGNATURE and DATE CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT EXPENDITURES WORKSHEET Agency Contract Number Date To Progra Report Period NO DATE CHECK NO PAYEE DESCRIPTION ACCOUNT NO. AMOUNT 1 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL $0.00 TITLE OF AUTHORIZED OFFICER SIGNATURE AND DATE FtXHIBIT C FORM OF SERVICES REPORT 16 CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT I1. Name and Address of Sub -Grantee 2. Program Name 5. Program Services and Activities Number of New Households and/or Persons Served 6. Direct Benef"t (Continued) Current Month Cumulative Month & Year Current Month Cumulative Extremely Low Very Low Income Low Income Income (0<30%) (31-50%) (51-80°61 Above Low Income (80Ta Household Size 0-30% 31-50% 51-80% 13,850 $23,100 $36,950 $15,850 $26,400 $42,250 $17,800 $29,700 $19,800 33,000 $21,400 $22,950 $35,650 $38,300 $24,550 $40, 900 $26,150 $43, 550 $47,500 $52,800 $57,000 $61,250 $65,450 $69,700 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: Phone No. Signature Required 17 1. Name and Address of Sub -Grantee CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name Month & Year S. Direct Benefit Data (New Household and for Persons Served) Race Section us be Completed Current Month Cumulative White Black/AfricanAmerican Asian American indian/Alaskan Native Native Hawanan/Other Pacific Islander Indian/Alaskan Native & White Asian & White Black/African American&White American Indian/Alaskan Native & Black African American Other Multi -Racial TOTAL Current Month Cumulative 0 Female Head of Household Ethnicity: (Section Must be Completed) Hispanic Current Month Hispanic Cumulative Non - Hispanic Current Month Non Hispanic Cumulative. 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. Submitted by: Signature Required Date: 18 1, Name and Address of Sub -Grantee CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name 5. PROGRAM SERVICES AND ACTIVITIES: Unduplicated Clients vxmi CURRENT CUMULATIVE 6. SCOPE OF WORK NARRATIVE• 7. PROBLEMS ENCOUNTERED / SOLUTIONS PROPOSED: 8. ANTICIPATED ACTIVITY DURING THE NEXT MONTH 16.6 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: Phone No. Signature Required 19 CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT CLIENT DATA REPORT 1. Name and Address of Sub -Grantee 2. Program Name onth & Year Name A Sex Ethnicity Race Disabled # Fam Income FHOH Street Address 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: Phone Number: EXHIBIT CA ADDITIONAL FORM OF SN:RtiICKS REPORT - ESG AGENCIES 1. Name and Address of Sub -Grantee CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2 Program Name 3. Contract Number 4. Date of Request Date and Year Beneficiary by Housing Type: EMERGENCY OR TRANSITIONAL SHELTERS Chronically Homeless (Emergency Shelter only) Severely Mentally III Chronic Substance Abuse Other Disability Veterans Current Month Cumulative Persons with HIV/AIDS Victims of Domestic Violence Elderly TOTAL Beneficiary by Housing Type: Number served in Emergency or Transitional Shelters Current Month SHELTER TYPE Barracks Cumulative 0 Group/Large House Scattered Site Apartment Single Family Detached House Single Room Occupancy Mobile Horne/Trailer Hotel/Motel Other TOTAL 0 0 ESG Funding Sources : ESG Funding Amount Current Month Cumulative Total Other Federal Local Government Private Fees Other Total 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 offici Date: Submitted by: Phone No. Signature Required 1. Name and Address of Sub -Grantee CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name 3. Contract Number 4. Date of Request Date and Year EMERGENCY OR TRANSITIONAL SHELTERS NUMBER OF INDIVIDUAL HIOUSEHOLDS (SINGLES): Current Month Cumulative Unaccompanied 18 and over Male Female Unaccompanied under 18 Male _ Female NUMBER OF FAMILY HOUSEHOLDS WITH CHILDREN HEADED BY: Current Month Cumulative Single 18 and over Male Female Single under 18 Male Female NUMBER OF FAMILY HOUSEHOLDS WITH NO CHILDREN: TOTAL I true Certification: The undersigned, hereby, gives assurance that to the best of my knowledge and belief, the data included in this report is and accurate. Date: It is also acknowledged Submitted by: that the provision of false information could leave Phone the certifying No. offici Signature Required H`XHIBIT C�2 ADDITIONAL FORM OF SERVIC ES REPORT - HOPWA AGENCIES 24 1. Name and Address of Sub -Grantee CITY OF FORT worm 1=lOUSli''IG L4 ECONOMIC DEVELOPMENT DEPARTMENT 2, Program Name 3. Contract Number 4-. Date of Request deport lients. otr Payments Date and Year CURRENT HOPIN Cumulative # With Assisted Funds Other Amount Other Funds of MONTH ONLY a.il of Tenant -Based Rental Assistance (TUBA) bit of Short -Term Rental, Mortgage and Utility Assistance (STRMU) c.# of STRMU clients that have moved to TGRA d.Total # of Unduplicated Clients (a+b)-c - Number of Households O. Supportive Services , Resource Identification/ Technical Assistance HOPVVA CURRENT MONTH ONLY CUMULATIVE AMOUNT OF HOPVVA FUNDS ASSISTED / OTHOTHER FUNDS AMOUNT OF OTHER FUNDS 8. Information Services 9. Permanent Housing Placement Services 10. Monthly income Groups of Households for ail Unduplicated Clients 6 %t f 6 Vt 6. a• . -. e. t ...a v vc . r v . Y va a e. v •v a m v ... •• ._ w t - -, $501-1000 $1001 -1500 $1501-2000 Over $2000 TOTAL $0 250 $2510 500 - .u____ . .__. _..�__. .v__�._.....___.. Current Month\ nt,l nt . �_... 0 ____..�..� I __.._._... �.. u,uuu..__... _.�.__u_...__..__._. ____ - Cumulative Short, Term, Rent, i lortgge, Utrlit.. Asst. (STRMU) $251. 500 Current Month Cumulative $O-250 $5014000 For Clients Receiving Supportive Services Only (unduplicated) Current Month Ow250 Cumulative AAA 251r 500 $1001 b1500 $501-1000 $1001-1500 Tsai 50`1-2000 TOTAL 1 0 Over $2000 TOTAL 0 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 infoi matron could leave the certifying official subject to the penalties of federal, state, and local law. DATE: Submitted by: Phone Number: Signature Required 25 1. Name and Address of Sub -Grantee Tenant Based Rental Assistance-(TBRA) Race: Section Must be Completed). CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name 3. Contract Number 4. Date of Request Current Month Cumulative White Black/African America, Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander Indian/Alaskan Native & White Asian & White Black/African American&White American Indian/Alaskan Native & Black African American Other Multi -Racial TOTAL Date and Year Non - Hispanic Hispanic Hispanic Current Current Month Cumulative Month Non - Hispanic Cumulative Unduplicated Beneficiary Data Total Number Children received of with Housing persons HIV/AIDS Assistance (Adults and who Number unit Assistance who of received Other Persons in Housing Family Households Previously Homeless Of Households, were Previously Chronically number Homeless Homeless of those who This data relates to participants Current Month Cumulative Female Head of Household Current Month Unduplicated Age Female TBRA Participants Male TBRA Participants 17 and Under 18 to 30 Years 31to50 Years 51 and Years Older Total 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: Phone No, Signature Required 1. Name and Address of Sub -Grantee CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name 3. Contract Number b. Date of Request Short Term Rent, Mortgage, and Utility Assistance (STRMU) Race: Section Must be Completed) Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islande Indian/Alaskan Native & White Asian & White Black/African American&White American Indian/Alaskan Native & Black African American Other Multi -Racial TOTAL Curren h Cumulative Date and Year Non- Hispani Hispanic Hispanic Current Current Month Cumulative Month Non - Hispanic Cumulative Unduplicated Number Children received Beneficiary Data Total of with Housin persons HIV/AIDS Assistance (Adults who and Number unit Assistance who of Other received Persons Housing in Family Households Previousl Homeless Of Previously Households, were Chronically Homeless number of those who Homeless This data relates to participants Current Month Cumulative Female Head of Household Current Month Unduplicated Age Female TBRA Participants Male TBRA Participants 17 and Under 18to30 Years 31 Years to 50 51 and Years Older Total 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 subiect to the penalties of federal, state, and local law. Date: Submitted by: Phone No. Signature Required 27 1. Name and Address of Sub -Grantee S upportive Services Race: Section Must be Completed} White Black/African American Asian American Indian/Alaskan Nativ N ative Hawaiian/Other Pacific Islander Indian/Alaskan Native & White Asian & White Black/African American&White American Indian/Alaskan Native & Black African American Other Multi -Racial TOTAL CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name 3. Contract Number 4. Date of Request Current Month Cumulative Date and Year Ethnicity: (Section Must be Completed} Hispanic Hispanic Current Month Cumulative Non - Hispanic Non - Current Hispanic Month Cumulative U nduplicated Beneficiary Data Total Number Children received Number unit Assistance who of of with Housing received persons Other HIV/AIDS Assistance (Adults who and Persons in Family Housing Households Previously Homeless Of Previously Households, were Chronically number Homeless of those who Homeless This data relates to participants Current Month Cumulative Female Head of Household Current Month Unduplicated Female TBRA Participants Male TBRA Participants 17 Under and 18 to 30 Years 31 Years to 50 51 and Years Older Total 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: Phone No. Signature Required 1. Name and Address of Sub -Grantee CITY OF FORT WORTH HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT 2. Program Name 3. Contract Number 4. Date of Request "All data reported should be unduplicated for the current month Supportive Services a. Outreach Number ofi 'households with HOPWA. funds Current Month Expenditures Amount of HOPWA funds Date and Year Numberof households with Other funds (whether from Grantee or other sources) Amount of Other funds (whether from Grantee or other sources) b. Case Management c. Life Management d. Nutritional Services/Meals e . Adult Day Care and Personal Assistance f Child Care and other Children's Services g. Education h Employment Assistance '. Alcohol and Drug Abuse Services j. Mental Health Services k. Health/Medical/Intensive Care Services I. Transportation m. Other (specify) n . Other (specify) o . Number of Jobs that resulted from g_and h. TOTAL (current month HOPWA expenditure column should equal total in supportive service section on Attachment ll) Current Month Undu licated Onl. Supportive Services Assistance Receiving Housing w/ Supportive Receiving Onl Services Persons with HIV/AIDS ■ Other Persons in Farnil Unit 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: Phone No. Signature Required