HomeMy WebLinkAboutContract 41959 (2)AGREEMENT FOR SERVICES
THIS AGREEMENT ("Agreement") is made and entered into by and between THE
CITY OF FORT WORTH, a home rule municipal corporation of the State of Texas
(hereinafter referred to as "City"), acting by and through Susan Alanis, its duly authorized
Assistant City Manager, and SALVATION ARMY, a nonprofit tWtorporation (hereinafter
referred to as "Contractor"), acting by and through Beckie Wach its duly
authorized uOperations Director.
RECITALS
WHEREAS, Contractor provides services to the homeless; 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, 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 gence, all services and objectives described in Exhibit "A," attached and
incorporated herein for all purposes incident to this Agreement ("Services").
2. 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 Six Thousand
Six Hundred Sixty Eight and No/100 ($6,668.00) ("Funds"). Any funds not requested as
provided in Section 3 shall remain with the City.
OFFICIAL RECORD
CIT�I SECRETI�RY
IyTo WORTH TX
3. REPORTING OF EXPENDITURES.
a. Contractor shall deliver to City a monthly statement of the request for reimbursement
("Request for Reimbursement") 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
B" 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 days 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 will 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. REPORTING 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 performance 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. Either party may cancel this Agreement upon thirty (30) days notice in writing to
the other party of such intent to terminate.
2
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 were
received without penalty or expense to City of any kind whatsoever, except as to the portions of
the payments herein agreed upon for which funds 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 term 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 between the City and Contractor, its officers, agents, servants, 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.
8. LIABILITY AND INDEMNIFICATION.
CITY SHALL IN NO WAY OR UNDER ANY CIRCUMSTANCES BE
RESPONSIBLE FOR ANY PROPERTY BELONGING TO CONTRACTOR, ITS
OFFICERS, AGENTS, EMPLOYEES, SUBCONTRACTORS, PROGRAM
PARTICIPANTS, OR RECIPIENTS, WHICH MAY BE LOST, STOLEN, DESTROYED,
OR 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
PROPERTY. CONTRACTOR COVENANTS AND AGREES TO INDEMNIFY, HOLD
HARMLESS AND DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS,
AGENTS, SERVANTS, AND EMPLOYEES FROM AND AGAINST ANY AND ALL
CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL
INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER
KIND OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS AGREEMENT AND/OR THE
3
OPERATIONS, ACTIVITIES AND SERVICES 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 ALL 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 AGREEMENT AND/OR THE OPERATIONS, ACTIVITIES
AND SERVICES 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, PROGRAM PARTICIPANTS, OR RECEIPIENTS, WHETHER OR NOT
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 FROM ALL LIABILITY
FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY
SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE
UNDER 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 FUNDS
PROVIDED HEREUNDER, CONTRACTOR AGREES TO INDEMNIFY, HOLD
HARMLESS AND DEFEND THE CITY OF FORT WORTH ITS OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES, FROM AND AGAINST ANY AND ALL CLAIMS OR
SUITS RESULTING FROM SUCH MISUSE, MISAPPLICATION 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 defensively
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 approval 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
following insurance coverage:
1. Commercial General Liability (CGL): $1,000,000 per occurrence, with a
$2,000,000 00 annual aggregate limit, in a form that is acceptable to the
City's Risk Manager.
2. Non -Profit Organization Liability or Directors & Officers Liability:
$1,000,000 per occurrence, with a $1,000,000 annual aggregate limit, in a
form that is acceptable to the City's Risk Manager.
5
Contractor's insurer(s) must be authorized to do business in the State of Texas for the lines of
insurance coverage provided and be currently rated in terms of financial strength and solvency to
the satisfaction of the City's Risk Manager.
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 and against
any and all Worker's Compensation claims arising from the work and services provided under
this Agreement.
15. RIGHT TO AUDIT 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 appropi fate 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 provision 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 Throckmorton St
Fort Worth, Texas 76102
18. NO WAIVER.
Beckie Wach - Operations Director
The Salvation Army - Mabee Center
1855 East Lancaster
Fort Worth, Texas 76103
Direct Line: 817-344-1811
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 future occasion.
19. DISCLOSURE OF CONFLICTS AND CONFIDENTIAL INFORMATION.
Contractor hereby warrants to the City that Contractor has made full 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 Effective Date of this
Agreement, Contractor hereby agrees immediately to make full disclosure to the City in
writing. Contractor, for itself and its officers, agents and employees, further 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 majeure or other causes beyond their reasonable control
(force majeure), 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 and 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 vary 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.
ark Hendrix r; �'�,,o
ity Secretary 'PP 10'
o
l C
Date: �/ �/ Oa u
APPROVED AS TO FORM AND
AUTHORIZATION:
Assistant City Attorney
Dater
ATTE
IE MATHIS
Title:
ASSfS7AN7 SECRETARY
OFFICIAL RECORD
61TY SECRETARY
rT. WORTH, TX
CITY
0 S san A anis
x A§v City Manager
i
ate:
CONTRACT
Date Approved: N�� µ''
Salvation Arm,�GEORGIA CORPORATION
By
0.
STATE OF §
�04441e_
COUNTY OF TA i §
Ci
e iek
BEFORE ME, the undersigned authority, a Notary Public in and for the State of
on this day personally appeared JOHN R. JONES 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 Salvation Army and tbWHN R. J 4ed the same as the act of said
Salvation Army for the purpose and consideration therein expressed and in the capacity therein
stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this �5 day of gwrx ,
2011. ���,,,,„1 1
�.%``Sp: F11�
•so Ar
do
old f• EXPIRES ,
IMF
so
1110 GEORGIA i Notary Public in and for the State of
AddAdds so
'so
sold old
IMF I
op•: SEPT. 17, 2012dd
do �+
do
Oodd C%.odo11 BL�GOJ�'%:
ALE
STATE OF TEXAS §
COUNTY OF TARRANT §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas,
on this day personally appeared Susan Alams, 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.
GIVEN UNDER MY HAND
2011.
GI-1 I almunam III
i
AND SEAL OF OFFICE this �9day of ,
i1 n
Notary Public in -and for the State of Texas
EVONIA DANIELS
MY COMMISSION EXPIRES
July 10, 2013
10
EXHIBIT A
SERVICES
11
Salvation Army
S.T.A.R.T.
EXHIBIT A
SCOPE OF SERVICES
PROGRAM SUMMARY
COMMUNITY 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.
The Salvation Army will provide a safe substance free environment for individuals who do not yet meet the requirement
of the longer term programs they need or who need a place to stay only long enough to stay off the streets and stay
healthy 365 days a year, 24 hours a day at the Salvation Army. The Stabilizing to Achieve Richer Tomorrows
(S.T.A.R.T.) program will include the following tasks and activities: needs assessments and intensive case management
to prepare clients to succeed at stable living. All services will be provided at 1855 E Lancaster; Fort Worth, TX 76103;
business hours are 8:00 a.m — 5:00 p.m., Monday - Friday.
The purpose of the program will be to provide supportive services that Lead to self-sufficiency to homeless individuals.
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 to September 30, 2011.
The funds will be used to pay for a portion of a case manager's salary which is consistent with Exhibit B - Detailed
Statement of Costs.
REGULATORY CLASSIFICATION:
National Objective Citation: 24 CFR 570.208(a)(2){C} Limited Clientele
Regulatory Citation: 24 CFR 570.201(e) Public Service
Based on the nature of the service provided, Salvation Army will maintain documentation that verifies that 100% of
clients served by the S.T.A.R.T. 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: 1855 E. Lancaster, Fort Worth, TX 76103
Client Beneficiary Location (Neighborhood, District, Citywide...): Citywide
PROGRAM GOALS:
The program goal is to identify and coordinate ways to serve the homeless in cooperation with local communities to
guide this population to self reliance and independence.
PROGRAM OBJECTIVES:
Fill a gap in the community Continuum of Care by helping clients prepare for the next positive step in their lives,
whether its additional programming, assisted living health care or permanent housing.
Thoroughly assess clients to meet their immediate needs and help them accomplish whatever will end their
homelessness in the longer term.
For those individuals who go on to long term programming or permanent housing, increase the percentage who
successfully complete their programming or remain stably housed.
Increase the number of clients served in long-term programming by decreasing the amount of time individual
clients need to complete their program.
PROGRAM SERVICES and ACTIVITIES
Number of Unduplicated Clients Served
Lodging (nights of stay)
Meals Provided
Case Management Units
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:
SECTION 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 11I (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)
Robin Bentley
(Signature) (Date)
(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
PROGRAM
MONTHLY
CUMULATIVE
COST CATEGORY
BUDGET
EXPENDITURES
TO DATE
BALANCE
ADMINISTRATIVE COSTS
Salaries
FICA
Life Insurance
Health Insurance
Unemployment
Tax
Worker's Comp
Legal
and Accounting
Office Supplies
PROGRAMMATIC COSTS
Salaries
6,668.00
FICA
Life Insurance
Health Insurance
Unemployment
— Federal
Unemployment
- State
Workers Compensation
Medical Supplies
Security
Utilities (Telephone, Electric, Gas,
Water, Wastewater, Waste Disposal)
Rent
Office Equipment
Rental
Printing
Accounting
Postage
Building
Maintenance and Repair
Office Supplies
Food
Other Operating
Supplies
Liability Insurance
Private Auto Allowance
Childcare Scholarships
Meals
Teaching
Aids
Contractual Services
Contract Labor
Conferences and Seminars
Short Term
Assistance
Rent, Mortgage and Utility
(STRMU)
Tenant Based Rental Assistance
(TBRA)
N
M
TOTAL
£(t
tD DS.(0)
-$9:69'
$0.00
$0.00
$0.00
ontractor's Certification: 1 certify that the costs incurred are taken from the books of account and that such costs are valid and
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
Program
Contract Number
Date
To
NO
DATE
CHECK NO
PAYEE
DESCRIPTION
ACCOUNT NO.
AMOUNT
1
2
__
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTAL
$0.00
TITLE OF AUTHORIZED OFFICER
SIGNATURE AND DATE
EXHIBIT C
FORM OF SERVICES REPORT
16
CITY OF FORT WORTH
HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub -Grantee
2. Program Name
5. Program Services and Activities
Number of New
Households and/or
Persons Served
Current Month
Month & Year
Cumulative
6. Direct Benefit
(Continued)
Current Month
Cumulative
Extremely Low Very Low Income
Income (0<30%) (31-50%)
Low Income
(51-80%)
Above Low Income
(80%>)
Household Size
1
2
3
4
5
6
7
8
0-30%
$13,850
$15,850
$17,800
$19,800
$21,400
$22,950
$24,550
$26,150
31-50%
$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
$69,700
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
8. Direct Benefit Data (New Household and /or Persons Served)
Race: Section Must be Completed)
st
4
au
: t a
fed
Current
Month
Cumulativea
e �
�t
��er
C.
ark
,�. 1Iy
to
White
Black/AfricanAmerican
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
0
0
0
0
0
0
TOTAL
Female
Head of
Household
Current Month
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 certifyingofficial
subject to the penalties of federal, state, and local law.
Date: Submitted by:
Signature Required
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
•
alid
CURRENT
CUMULATIVE
6. SCOPE OF WORK NARRATIVE
7. PROBLEMS ENCOUNTERED / SOLUTIONS
PROPOSED*
111
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. 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
Month & Year
Name Age 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 C-1
ADDITIONAL FORM OF SERVICES 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
Current Month
Cumulative
Shelter only)
Chronically Homeless
(Emergency
Severely Mentally III
Chronic Substance Abuse
Other Disability
Veterans
Persons with HIV/AIDS
Victims of Domestic Violence
Elderly
TOTAL
0
0
Beneficiary by Housing Type: Number served in Emergency or Transitional Shelters
SHELTER TYPE
Current Month
Cumulative
Barracks
Group/Large
House
Scattered Site Apartment
Single
Family Detached House
Single
Room Occupancy
Mobile Home/Trailer
Hotel/Motel
Other
TOTAL
0
0
ESG Funding
Sources :
Funding
Amount
Current Month
Cumulative Total
ESG
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
IOUSEHOLDS
NUMBER OF INUnaccompanied D181aDnd
(SINGLES
Current Month Cumulative
averUAL
Male
m
Unaccompanied
under 18
Male
Feale
i
NUMBER OF FAMILY HOUSEHOLDS WITH CHILDREN HEADED BY Current Month Cumulative
Single
18 and over
Male Female
Single
under 18
Male
Female
I
NUMBER
WITH NO CHILDREN:
OF FAMILY HOUSEHOLDS
TOTAL
I
Certification:
and accurate.
Date:
assurance that to the best of my knowledge and belief, the data included
the provision of false information could leave the certifying offici
Phone No.
in this report is t ue
The undersigned, hereby, gives
It is also acknowledged that
Submitted by:
Signature
Required
EXHIBIT C-2
ADDITIONAL FORM OF SERVICES REPORT - HOPWA AGENCIES
24
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
5. Program Services and Activities (Report Clients. Not Payments
HOPWA
Cumulative
# Assisted
With Other
Funds
Amount of
Other
Funds
CURRENT
MONTH
ONLY
a.# of Tenant -Based Rental Assistance
(TBRA)
b.# of Short -Term Rental, Mortgage
and Utility Assistance
(STRMU)
c.# of STRMU clients that have moved to TBRA
d.Total # of Unduplicated
Clients
(a+b)-c
Number of Households
HOPWA
CURRENT
MONTH
ONLY
CUMULATIVE
AMOUNT OF
HOPWA FUNDS
#
ASSISTED
W/ OTHER
AMOUNT
OF OTHER
FUNDS
FUNDS
6. Supportive
Services
7. Resource Identification/Technical Assistance
8. Housing
Services
Information
9. Permanent Housing
Placement Services
10. Monthly Income Groups of Households for all Unduplicated
Clients
asez( Renta
Agststaftc {TBRR�..
r i e tan£
$0-250
$251-
500
$501-1000
$1001-1500
$1501-2000
Over $2000
TOTAL
Current
Month
0
Cumulative
0
$0-250
$251-
500
$501-1000
$1001-1500
$1501-2000
Over$2000
TOTAL
Current
Month
0
Cumulative
0
$0-250
$251-
500
$501-1000
$1001-1500
$1501-2000
Over$2000
TOTAL
Current
Month
0
Cumulative
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 information could leave the certifying official subject to the penalties of federal, state,
and local law.
DATE: Submitted by:
Signature Required
Phone Number:
25
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
Tenant Based Rental Assistance-(TBRA)
Race: Section Must be Completed)
White
Black/African American
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
Current Month Cumulative
0
Unduplicated Beneficiary Data
Total
Number of persons
Children with HIV/AIDS
received Housing
Assistance
(Adults and
who
Number of Other
unit who received
Assistance
Persons in Family
Housing
Households Previously Homeless
Of Previously Homeless
Households, number of those who
were Chronically Homeless
This data relates to participants
Current Month
Cumulative
Female Head
of Household
Current
Month
Unduplicated
A
Female TBRA
Participants
Male TBRA
Participants
17 and
Under
18 to 30
Years
31 to 50
Years
51 Years
and 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
26
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
Short Term Rent, Mortgage, and Utility Assistance (STRMU)
Race: Section Must be Completed)
White
Black/African American
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
Current Month Cumulative
0
:#litchi%=.(Sep
Unduplicated Beneficiary Data
Total
Number of persons
Children with HIV/AIDS
received Housing
Assistance
(Adults and
who
Number of Other
unit who received
Assistance
Persons in Family
Housing
Households Previously Homeless
Of Previously Homeless
Households, number of those who
were Chronically Homeless
This data relates to participants
Current Month
Cumulative
Female Head
of Household
Current
Month
Unduplicated
A
Female TBRA
Participants
Male TBRA
Participants
17 and
Under
18 to 30
Years
31to50
Years
51 Years
and 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
27
1. Name and Address of Sub -Grantee
Supportive Services
Race: Section Must be Completed)
White
Black/African American
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
Unduplicated Beneficiary Data
CITY OF FORT WORTH
HOUSING & ECONOMIC DEVELOPMENT DEPARTMENT
2. Program Name
3. Contract Number
4. Date of Request
Current Month Cumulative
Total
Number of persons
Children with HIV/AIDS
received Housing
Assistance
(Adults and
who
Number of Other
unit who received
Assistance
Persons in Family
Housing
Households Previously Homeless
of those who
Of Previously Homeless
Households, number
were Chronically Homeless
This data relates to participants
Current Month
Cumulative
Female Head
of Household
Current
Month
Unduplicated
Ape
Date and Year
Female TBRA
Participants
Male TBRA
Participants
17 and
Under
18 to 30
Years
31 to 50
Years
51 Years
and 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
28
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
**A11 data reported should be unduplicated for the current month
a. Outreach
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
i. Alcohol and Drug Abuse Services
1. 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 Unduplicated Only
Receiving
Supportive
Services w/
Housing
Assistance
Receiving
Supportive Services
Only
Persons with HIV/AIDS
Other Persons in Family 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 oflateral, state,
and local law.
Date: Submitted by: Phone No.
Signature Required
THE SALVATION ARMY POLICY STATEMENT
ON RELATIONSHIPS WITH OTHER GROUPS AND ORGANIZATIONS
The Salvation Army in the United States works cooperatively with many groups --
governmental, social service, civic, religious, business, humanitarian, educational,
health, character building and other groups -- in the pursuit of its mission to preach the
Christian Gospel and meet human need.
Any agency, governmental or private, which enters into a contractual or cooperative
relationship with The Salvation Army should be advised that.
1. The Salvation Army is an international religious and charitable movement organized
o n a quasi -military/ pattern and is a branch of the Christian church.
2. All programs of The Salvation Army are administered by Salvation Army Officers
who are ministers of the Gospel.
3. The motivation of the organization is love of God and a practical concern for the
n eeds of humanity.
4. The Salvation Army's provision of food, shelter, health services, counseling, and
other physical, social, emotional, psychological and spiritual aid, is given to persons
in need simply because they are in need, regardless of race, color, religion, sex, age,
n ational origin or handicap.
Organizations contracting and/or cooperating with The Salvation Army may be assured
that because The Salvation Army is rooted in Christian compassion and is governed by
Judeo-Christian ethics, the provisions of its contracts and agreements will be strictly
observed.
Commissioners Conference: February, 1993
The Salvation Army -Mabee Center 14