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STATE OF TEXAS
COUNTY OF TARRANT
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1'his contrzct ("Contract") is made anel entered into by and between the City
I�ort Worth (hereatter "City") and Girls Inc. of Tarrant County (hereafter "A�ency"),
"I'exas nonprofit corporation. City �nd Agency may be referred to individually �is
"Party" and jointly as "the Pa►rties".
Tl�e Parties state as follows:
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WHEREAS, City receives grant monies from the United States Department ot
Housing and Urban Development ("HUD") through the Community Development Block
Grant ("CDBG") Program, Nrogram No. B�13-MC-48-OO10, Catalog of Federal
Domestic Assistance No. 14.218;
WHEREAS, a national objective of the CDBG program is to benetit low and
moderate income citizens in accordance with 24 CFR Part 570.200 (a)(2); ;
WHEREAS, Agency submitted a proposal to use CDBG funds for an eligible
program under the CDBG Regulations whereby Agency will provide services to low and
moderate income City citizens;
WHEREAS, City citizens, the Community Development Council, and the City
Council have determined that CDBG programs are needed by the City's citizens;
NOW, THEREFORE, the Parties understand and agree as follows:
L [NCORPORATION OF RECITALS.
City and Agency hereby agree that the recitals set forth above are true and correct
and form the basis upon which the Parties have entered into this Contract.
2. DEFINITIONS.
In addition to terms detined in the body of this Contract, the terms set forth below
shall have the detinitions ascribed to them as follows:
Area Median Income or AMI means the median family income for the Fort Worth-
Arlington metropolitan statistical area as established annually by HUD. The 2013 income
limits are attached hereto as Exhibit "A-1" — 2013 HUD Income Limits.
Business Diversity Enterprise Ordinance or BDE means the City's Business Diversity
Ordinance, Ordinance No. 20020-12-2011.
CDBG means Community Development Block Grant.
CDBG PSA CONTRACT 2013-201 �t - GIRLS INC. OF TARRANT CO
OFFICIAL RECORD
CITY SECRETi4RY
�T. WORTH, 'i'X
I;���IV�� t)�i � 1 L01�
Complete Documentntion means the following documentation as applicable:
• Attachments I, II, and III, with supporting documentation including:
o Proof of espense: copies of timesheets, invoices, leases, service
contracts or other documentation showing that payment is due by
Agency.
o Proof of payment: cancelled checks, bank statements, or wire
transfers necessary to demonstrate that amounts due by Agency
were actually paid by Agency.
o Proof of client eligibility: (i) Source Documentation sufticient to
show that clients participating in the Pro�ram are CDBG Eligible
Clients; or (ii) documentation other than Source Documentation to
show that clients served by the Program are CDBG Eligible
Clients.
• Complete Documentation shall meet the standards described in the
attached Exhibit "F" - Standards for Complete Documentation.
• Any other document or record reasonably necessary to verify costs spent
and client eligibility for the Program.
CDBG Eligible Client means a client whose annual income adjusted for family size does
not exceed 80% of AMI using the most current HUD Income Guidelines and Technical
Guidance for Determining Income and Allowances verified by either Source
Documentation or the form in Exhibit "E" - Form of Income Self-Certification.
Agencies Serving 100% Clientele must follow the requirements set forth in Section 6.1.3.
CDBG Funds means the CDBG grant funds supplied by City to Agency under the terms
of this Contract,
CDBG Regulations means regulations found at 24 CFR Part 570 et seq.
DBE means disadvantaged business enterpnse.
Director means the Director of the City's Housing and Economic Development
Department.
Effective Date means October 1, 2013.
HED Department means the City's Housing and Economic Development Department.
HUD means the United States Department of Housing and Urban Development.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNT'Y
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IDIS means t�IUD's [nte�rated Disbursement Information System.
National Objective means at least 51% of the clients served under this Contract must
have incomes at or below 80 % of AMI in accordance with 24 CFR 570.208(a)(2).
ProgrAm means the services described in Exhibit "A" — Program Summary.
Reimbursement Request means all reports and other documentation described in
Section �).
Source Documentation means 1ny documentation allowed under the detinition of annual
incoine in 24 CFR Part 5.609
Unduplieated Clients means a count of CDBG Eligible Clients served once in the
Contract Term. CDBG Eligible Clients served more than once in the Contract Term will
only be counted once when determining the number of Unduplicated Clients.
3. TERM.
The term of this Contract begins on October 1, 2013 and terminates on September
30, 2014 unless earlier terminated as provided in this Contract.
:�. DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Provide CDBG Funds.
City shall provide up to EIGHTY-TWO THOUSAND' SEVENTY'-FNE.` and
00/100 Dollars ($82,075:00} of CDBG Funds on a reimbursement of expenses basis,
under the terms and conditions herein.
�.2 Monitor.
City will monitor the activities and performance of Agency and any of its
contractors, subcontractors or vendors as necessary, but no less than annually.
5. DUTIES AND RESPONSI_BILITIES OF AGENCY.
5.1 Required Services.
Agency shall perform the services described in Exhibit "A" — Program
Summary in accordance with the terms and conditions of this Contract.
5.2 Use of CDBG Funds.
5.2.1. Compliance with CDBG Re�ulations and Contract.
Agency shall be reimbursed for eligible Program costs with CDBG Funds only if
City determines in its sole discretion that:
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNT'Y 3
5.2.1.1 Costs are eligible
Regulations.
expenditures in accordance with CDBG
5.2.1.2 Costs are in compliance with this Contract and are reasonable
and consistent with industry norms.
5.2.1.3 Complete Documentation is submitted to City by Agency.
5.2.2 Bud�et•
Agency abrees that CDBG Funds will be paid on a reimbursement basis in
accordance with Exhibit `B" - Budget. During the term of this Contract, Agency may
submit written requests to increase or decrease line-item amounts in the Budget,
including an explanation of why such increases or decreases are necessary. All such
requests must be approved by the Director in writing, with such approval being in the
Director's sole discretion. If Director approves the Agency's proposed Budget
amendment (as approved, the "Amended BudgeY'), then the Amended Budget will take
effect on the tirst day of the month following the month in which it was approved by
Director, unless otherwise specitied in the amendment. All requests for Budget
amendments must be submitted by August 15, 2014.
5.2.3 Change in ProEram Budget.
5.2.3.1 Agency will notify City promptly of any additional funds it
receives for operation of the Program, and City reserves the
right to amend this Contract in such instances to ensure
compliance with HUD regulations governing cost allocation.
5.2.3.2 Agency agrees to utilize funds available under this Contract to
supplement rather than supplant funds otherwise available for
use in the Program.
5.2.4 Pavment of CDBG Funds to Agencv.
CDBG Funds will be disbursed to Agency upon City's approval of Agency's
written and signed Reimbursement Requests including submission of Complete
Documentation to City in compliance with Section 9. If Agency expends all funds
budgeted for the Program prior to September 20, 2014, City may hold back a small
amount of the CDBG Funds until the end of the term. During this interim period, Agency
must continue to submit Reimbursement Requests with an invoiced amount of $0. It is
expressly agreed by the Parties that any CDBG Funds either not spent or not approved for
reimbursement to Agency shall remain with City.
CDBG PSA CONTRACT 2013-201=� - GIRLS INC. OF TARRANT COUNT'Y �
5.3 Pro�ram Perform3nce Milestones.
A�;ency watrants that the Pro�;ram will achieve the following milestones:
Failure of Agency to meet these milestones or a inaterial deviation from them as
outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section,
'`material deviation" shall mean more than 10% lower than the specitied goal. In the
event of such breach, City reserves the right at its sole option to delay or withhold
payment of Reimbursement Requests, to lower Agency's allocation of CDBG Funds, or
to terminate this Contract.
5.4 Identifv Pro�ram Expenses Paid with CDBG Funds.
Agency will keep accounts and records in such a manner that City may readily
identify and account for Program expenses reimbursed with CDBG Funds. These
records shall be made available to City for audit purposes and shall be retained as
required hereunder.
5.5 Meet National Obiective.
Agency certifies that the activities carried out under the Program and this Contract
will meet the National Objective.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eli�ibilitv.
Agency will document the eligibility of all prospective clients. Ageney wil�
document client eligibility using the specifie: method deseribed= belo� in- 5ectio�t
6.1.2. All other subsections of this Section 6.1 are not applicable to Agency under
this Contract.
6.1.1 ALencies Serving a Presumed Benefit Clientele.
Agency must document that all clients served fall under a"presumed benetit"
category as defined in 24 CFR 570. Relevant categories of presumed benefit are:
severely disabled adults, homeless persons, abused or neglected children and youth or
elderly persons. Eligible forms of documentation include:
6.1.1.1 Severely Disabled Adults. Agency form, approved by the
City, tilled out by Agency staff or the CDBG Client indicating
client meets the Census definition of '`severely disabled." As
an acceptable alternative, Agency may use the form attached
CDBG PSA CONTRACT ?013-201-� - GIRLS INC. OF TARRANT COUNTY
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hereto as Exhibit "H" — Severely Disabled Certi�cation
Form.
6.1.1.2 Homeless Persons. Written, signed and dated certification
ti•om an outreach worker.
6.1.1.3 Abused or Neglected Children and Youth. Written, signed
and dated certitication from an outreach worker.
6.1.1.4 Elderly Persons. A birth certiticate, driver's license, passport,
immigration card, military identitication, or any other state,
(ocal, national or international documentation, provided it
contains current information about the age or birth of the
possessor. The form in Exhibit "E" — Form of Income Self
Certification also requires that potential clients list their age
and certify the validity of the information provided. This may
be sufficient but should only be used as a last resort with an
explanation in the iile case notes indicating why the formal
Forms of verification were not available. An elderly person is
defined as being at least 62 years of age.
6.1.2 A�encies Serving a General Clientele.
Agency must verify all new clients' income eligibility with either Source
Documentation or the form attached as Exhibit "E" — Form of Income Self
Certification. Agency must use the annual income definition in 24 CFR 5.609 to
establish client income eligibility and must use the tnost current HUD Income
Guidelines. All clients' income must be documented, but only 51% of clients must meet
income eligibility requirements described in 24 CFR 5.609.
6.13 Elgencies Serving 100% Clientele.
Agency must verify income eligibility of all Unduplicated Clients with Source
Documentation. Source Documentation must be collected and maintained in Agency
files even if Agency reports income eligibility using the form attached as Exhibit "E" —
Form of Income Self Certification.
6.2 Submission of Complete Documentation.
Agency must submit copies of all eligibility veritication documentation described
in Section 6.1 with Attachment III in each month's Reimbursement Request for all
Unduplicated Clients served for the first time, and must maintain copies of such
documentation as required under this Contract.
7. �dditional CDBG Repuirements.
Agency agrees to comply with all requirements of the CDBG Program as stated in
the CDBG Regulations, including but not limited to the following:
7.1 Environmental Review.
CDBG PSA CONTRACT 2013-201 �4 - GIRLS INC. OF TARRANT COUNTY 6
CDI3G Funds will not be paid, and costs cannot be incurred until City has
�unduc;ted ��nd completed an environmental ceview as i•eyuired by 24 CFR Part 58. The
�nvironmental review may result in a ciecision to proceed with, modify, or cancel the
Cunding tor the Program. Further, Agency will not undertake or commit any funds to
physical or choice limiting actions as clescribed in any applicable Federal regulations.
Any violation of this provision will (i) cause this Contract to terminate immediately; and
(ii) require Agency to repay to City the CBDG Funds it has already received and forfeit
any future payments af CDBG Funds.
7.1.2 Environmentzl Miti�ation.
lf applicable, Agency must take the mitigation actions outlined in Exhibit "A-2"
— Environmental Nlitigation Actions. Failure to complete the required mitigation
action is an event of default under this Contract.
7,2 Contract Not Constitutin� Commitment of Funds.
Notwithstanding any provision of this Contract, the Parties agree and
acknowled�;e that this Contract does not constitute a commitment of funds, and that such
commitrnent of funds or approval may occur only upon (i) satisfactory completion of
environmental review and receipt by City of an authorization to use grant funds from
HUD under 24 CFR Part 58, (ii) approval of City's 2013-2014 Action Plan, and (iii)
receipt by City of grant agreement from HUD.
7.3 Monitoring.
7.3.1 Agency understands and agrees that City will monitor the adequacy and
timeliness of Agency's performance under the terms of this Contract as well as its
compliance with the CDBG Regulations. Agency is subject to such monitoring during
the term of this Contract and for 5 years atter the Contract term ends. Agency will
provide reports and access to Program tiles as requested by City for during this 5 year
period. For purposes of this Contract, this 5 year period for monitoring is deemed to
begin on October l, 2014 and end on September 30, 2019 regardless of whether or not
this Contract is earlier terminated.
7.3.2 Representatives of City, HUD, and the United States Comptroller General
shall have access during regular business hours, upon 48 hours prior notice, to Agency's
offices and records pertaining to the use of the CDBG Funds, and to Agency's officers,
directors, �gents, employees, contractors, subcontractors and vendors for the purpose of
such monitoring.
7.3.3 In addition to other provisions of this Contract regarding frequency of
monitoring, City reserves the right to perform desk reviews or on-site monitoring of
Agency's compliance with the terms and conditions of this Contract. After each
monitoring visit, City shall provide Agency with a written report of the monitor's
tindings. If the inonitoring report notes deficiencies in �lgency's performance, the report
shall include requirements for the timely correction of said deficiencies by Agency.
Failure by Agency to take the action specified in the monitoring report may be cause for
suspension or termination of this Contract as provided herein.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY �
7.3,4 A�;ency agrees to likewise monitor the effectiveness of the services and
�vork to be performed by its contractors, subcontractors and vendors.
'1.3.5 This Section 7.3 shall survive the earlier termination or expiration of this
Contract.
7.4 A�encv Procurement Standards.
Agency shall comply with all applicable federal, state and local laws, regulations,
and ordinances for making procurements under this Contract. Agency shall establish
procurement procedures to ensure that materials and services are obtained in a cost
effective manner. When procuring services to be provided under this Contract, Agency
shall comply at a minimum with the procurement standards at 24 CFR Part 84.40 through
24 CFR Part 84.48.
7.5 Cost Princiules/Cost Reasonableness.
Agency shall administer its use of CDBG Funds in compliance with OMB
Circular A-122, "Cost Principles for Non-Profit Organizations", as amended from time to
time. The allowability of costs incurred for performance rendered shall be determined in
accordance with OMB Circular A-122 as supplemented by the provisions of this
Contract.
7.6 Accountins Standards.
Agency agrees to comply with OMB Circular A-110, "Uniform Administrative
Requirements for Grants and Agreements with Institutions of Higher Education,
Hospitals and other Non-Profit Organizations", and agrees to adhere to the accounting
principles and procedures required therein, utilize adequate internal controls, and
maintain necessary supporting and back-up documentation for all costs incurred.
7,7 Uniform Administrative ReQuirements.
Agency will comply with the Uniform Administrative Requirements set forth in
24 CFR Part 57.502 or any reasonably equivalent procedures and requirements that City
may require.
7.8 Terms Apalicable to Contractors. Subcontractors and Vendors.
Agency understands and agrees that all terms of this Contract, whether regulatory
or otherwise, shall apply to any and all contractors, subcontractors and vendors of
Agency which are in any way paid with CDBG Funds or who perform any work in
connection with the Program. Agency shall cause all applicable provisions of this
Contract to be included in and made a part of any contract or subcontract executed in the
performance of its obligations hereunder including its obligations regarding the CDBG
IZegulations. Agency shall monitor the services and work performed by its contractors,
subcontractors and vendors on a regular basis for compliance with the CDBG
Regulations and Contract provisions. Agency must cure all violations of the CDBG
Regulations committed by its contractors, subcontractors or vendors. City maintains the
right to insist on Agency's full compliance with the terms of this Contract and the CDBG
Regulations and Agency is responsible for such compliance regardless of whether actions
CDBG PSA CONTRACT ?013-201� - GIRLS INC. OF TAR.RANT COUNTY S
taken to fulfill the requirements of this Contract are taken by Agency or by Agency's
contractors, subcontractors or vendors. Agency acknowledges that the provisions of this
Section shall survive the earlier termination or expiration of this Contract.
7.9 Copvrisht and Patent RiEhts.
No reports, maps, or other documents produced in whole or in part under this
Contract shall be the subject of an application for copyright by or on behalf of Agency.
HUD and City shall possess all rights to invention or discovery, as well as rights in data,
which may arise as a result of Agency's performance under this Contract.
8. RECORD KL�:Ylivci;
[2EQUIREMENTS; AUDIT.
8.1 Record KeepinE.
Agency shall maintain a record-keeping system as part of its performance of this
Contract and shall promptly provide City with copies of any document City deems
necessary for the effective fulfillment of City's monitoring and evaluation
responsibilities. Specifically, Agency will keep or cause to be kept an accurate record of
all actions taken and all funds spent, with supporting and back-up documentation.
Agency will maintain all records and documentation related to this Contract for 5 years
after the Contract term ends. If any claim, litigation, or audit is initiated before the
expiration of the 5 year period, the relevant records and documentation must be retained
until all such claims, litigation or audits have been resolved. For purposes of this
Contract, this 5 year period for record retention is deemed to begin on October l, 2014
and end on September 30, 2019 regardless of whether or not this Contract is earlier
terminated.
8.2 Access to Records.
City and any duly authorized officials of the Federal government will have full
access to, and the right to examine, audit, copy, excerpt and/or transcribe any of
Agency's records pertaining to all matters covered by this Contract for 5 years after the
Contract tertn ends. Such access shall be during regular business hours and upon at least
-�8 hours prior notice. For purposes of this Contract, this 5 year period for access to
records is deemed to begin on October l, 2014 and end on September 30, 2019 regardless
of whether or not this Contract is earlier terrninated.
8.3 Reports.
Agency will submit to City all reports and documentation described in this
Contract in such form as City may prescribe. Agency may also be required to submit a
tinal performance and/or final financial report if required by City at the termination of
this Contract in such form and within such times as City may prescribe. Failure to submit
to City any report or documentation described in this Contract shall be an event of default
of this Contract and City may exercise all of its remedies for default under this Contract.
8.4 Chanse in Reportin� Repuirements and Forms.
City retains the right to change reporting requirements and forms at its discretion.
City will notify Agency in writing at least 15 days prior to the effective date of such
CDBG PSA CONTRACT 2013-2014 - G1RLS INC. OF TARRANT COUNTY 9
change, and the Parties shall execute an amendment to the Contract retlecting such
change iF necessary.
8.5 Audit.
8.5.1 Entities that EYpend !�500,000 or more in rederal Funds Per Year.
,�11 non-federal entities that expend �500,000 or more in Federal funds within one
year, regardless of the source of the Federal award, must submit to City an annual audit
prepared in accordance with specific reference to OMB Circular A- I 33. The audit shall
cover the Agency's tiscal years during which this Contract is in force. The audit must be
prepared by an independent certitied public accountant, be completed within 6 months
following the end of the period being audited and be submitted to City within 30 days of
its completion. Agency's audit certitication is attached hereto as Exhibit "C" —"Audit
Certification Form" and "Audit Requirements". The Audit Certification Form must
be submitted to City prior to or with the tirst Reimbursement Request. Entities that
expend less than $500,000 a year in Federal funds are exempt from Federal audit
requirements for that year, but records must be available for review or audit by
appropriate officials of the Federal agency, City, and General Accounting Office.
8.5.2 Citv Reserves the Ri�ht to Audit.
City reserves the right to perform an audit of Agency's Program operations and
tinances at any time during the term of this Contract and for 5 years after the Contract
Term ends if City deternunes that such audit is necessary for City's compliance with the
CDBG Regulations or other City policies. Agency agrees to allow access to all pertinent
materials as described herein for such audit. For purposes of this Contract, this 5 year
period for City audit is deemed to begin on October l, 2014 and end on September 30,
2019 regardless of whether or not this Contract is earlier terminated. If such audit reveals
a questioned practice or expenditure, such questions must be resolved within 15 business
days atter notice to Agency of such questioned practice or expenditure. If questions are
not resolved within this period, City reserves the right to withhold further funding under
this Contract and/or any future contracts with Agency. IF A5 A RESULT OF ANY
�UDIT IT IS DETERMINED THAT AGENCY HAS FALSIFIED ANY
DOCUMENTATION OR MISUSED, MISAPPLIED OR MISAPPROPRIATED
CDBG FUNDS OR SPENT CDBG FUNDS ON ANY INELIGIBLE ACTIVITIES,
.�GENCY AGREE5 TO REIMBURSE CITY THE AMOUNT OF SUCH MONIES
PLUS THE AMOUNT OF ANY SANCTIONS, PENALTY OR OTHER CHARGE
LEVIED AGAINST CITY BY HUD BECAUSE OF SUCH ACTIONS.
9. REIMBURSEMENT REQUIREMENTS.
9.1 Deadline for Submitting Reimbursement Requests.
Each Reimbursement Request shall be received by the City on or before the 15`"
day of the month following the month expenses were paid by Agency. For example, the
Reimbursement Request for June expenses must be received by July 15. In the event the
15`h falls on a weekend or City holiday, Reimbursement Requests shall be due the next
day that the City is open for business. Failure to submit a Reimbursement Request in a
timely fashion will result in City taking the actions outlined in Section 10.1.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COLJNTY l0
NOTWITHSTANDING ANYTHING ABOVE, EXPENSES FOR SEPTEMBER
2014 MUST 13E RECEIVED BY SEPTEMBER 20, 2014. FAILURE TO SUBMIT
A�INAL REINIBURSEMENT REQUEST BY SEPTEMBER 20, 2014 WILL
12ESULT IN AUTOMATIC FORFEITURE OF PAYMENT OF THE
SEPTEMBER REIMBURSENIENT REQUEST.
92 Agency shall provide City with Complete Documentation and the
Pollowing repoirts as shown in Exhibit "D" —Reimbursement Forms with each
Reimbursement Request:
9.2.1 Attachment I — Invoice.
This report shall contain the amount requested for reimbursement each month, the
cumulative reimbursement requested to date (inclusive of that month's request), and must
be signed by an authorized signatory of Agency. By signing Attachment I, Agency is
certifying that the costs are valid, eligible, consistent with the terms and conditions of this
Contract, and the data contained in the report is true and correct. This report must be
submitted even if Agency is requesting $0 for a particular month.
9.2.2 Attachment II — Expenditure Worksheet.
This report shall itemize each expense requested for reimbursement by Agency
and shall include the Account corresponding the expense to a Budget line item in
Attachment II. In order for this report to be complete the following must be submitted:
9.2.2.1 For payroll expenses, timesheets signed by employees and
approved by supervisor for all payroll expenses listed.
Timesheets must distinguish between CDBG-funded time and
non-CDBG funded time and retlect actual time spent on
CDBG-funded activities.
9.2.2.2 For non-payroll expenses, invoices for each expense listed with
an explanation as to how the invoiced expense pertains to the
Program.
9.2.2.3 Proof that each expense was paid by Agency, which proof can
be satisfied by cancelled checks, wire transfer documentation,
paid receipts or other appropriate banking documentation.
9.2.3 Attachment III — Client Data Report.
This report shall list each Unduplicated Client served during the month along with
his or her demographic information. The Client Data Report must contain a list of all
clients served during the Contract period. In order for this report to be complete the
following must be submitted:
9.2.3.1 Documentation of income verification for each Unduplicated
Client the tirst time he or she is served, which will either be the
Source Documentation described in Section 6.1 or the
completed form attached hereto as Exhibit "E" - Form of
CDBG PSA CONTRACT 2013-?01 �- GIRLS 1NC. OF TARRANT COUNT'Y
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[ncome Setf Certification. AGENCIES SERVING l0U%
CLIENTELE MUST FOLLOW THE REQUIREMENTS
SET FORTH IN SECTION 6.1.3.
9.3 Withholding Pavment.
CITY HAS NO OBLIGATION TO MAKE PAYMENT ON ANY
REIMBURSEMENT REQUEST THAT IS NOT RECEIVED BY THE DUE DATE.
Failure to timely submit Reimb��rsement Requests and Complete Documentation
along with any required reports shalt be an event of default.
10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Required Documentation
10.1.1 If Agency fails to submit a Reimbursement Request, or if the
submitted Reimbursement Request is incomplete or otherwise not in compliance with this
Contract or CDBG Regulations as determined by City in its sole discretion, Agency shall
be in default of this Contract. City will notify Agency in writing of such default and the
Agency will have 10 calendar days from the date of the written notice to submit or
resubmit any such Reimbursement Request to cure the default. If Agency fails to cure
the default within such time, Agency shall forfeit any payments otherwise due that
month.
10.1.2 NOTWITHSTANDING THE PROVISION5 OF SECTION
10.1.1, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST
DUE SEPTEMBER 20, 2014, OR IF THE SUBMITTED REIMBUR5EMENT
REQUEST FOR SEPTEMBER 20, 2014 IS LATE, INCOMPLETE OR
OTHERWISE NOT IN COMPLIANCE WITH THIS CONTRACT OR CDBG
REGULATION5 AS DETERMINED BY CITY IN ITS SOLE DISCRETION,
THERE WILL BE NO CURE PERIOD AND ANY REIMBURSEMENT WILL BE
AUTOMATICALLY FORFEITED.
10.1.3 In the event of (i) an uncured default under Section 10.l.lor (ii) more
than 2 instances of default, cured or uncured, under such Section, City reserves the right
at its sole option to terminate this Contract effective immediately upon written notice of
such intent with no penalty or liability to City.
10.1.4 Notwithstanding anything to the contrary herein, City will not be
required to pay any CDBG Funds to Agency during the period that any Reimbursement
Request, report or documentation is past due or is not in compliance with this Contract or
the CDBG Regulations, or during any period during which Agency is in default of this
Contract.
10.1.5 In the event of termination under this Section 10.1, all CDBG Funds
awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited
and Agency shall have no further right to such f'unds.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TAR.RANT COUNTY 12
► 0,2 �ailure to Maintain Kecoras or �unm�t tceuor�s .���u
Docucnentation.
[ f A�;ency fails to maintain all records and documentation as required in Section
3, or if the maintained or a submitted report or documentation is not in compliance with
this Contract or the CDBG Re�,nxlations as determined by City in its sole discretion, City
�vill notify Agency in writing and Agency will have 30 calendar days f'rom the date of the
written request to obtain or recreate the missing records and documentation or submit or
resubmit any such report or documentation to City. It' Agency fails to maintain the
required reports or documentation, or fails to submit or resubmit any such report or
documentation within such tiine, City shall have the right to terminate this Contract
et�fective immediately upon written notice of such intent with no penalty or liability to
City.
10.2.1 In the event of termination under this Section 10.2, all CDBG Funds
awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited
and Agency shall have no f'urther right to such funds, and any CDBG Funds paid to
Agency must be repaid to City within 30 days of termination. If such CDBG funds are
not repaid to City within the 30 day period, City shall exercise all legal remedies
available under this Contract.
10.3 In General.
Subject to Section 10.1, and unless specifically provided otherwise in this
Contract, Agency shall be in default under this Contract if Agency breaches any term or
condition of this Contract. In the event that such a breach remains uncured ai'ter 30
calendar days following written notice by City (or such other notice period as may be
specitied herein) or, if Agency has diligently and continuously attempted to cure
following receipt of such written notice but reasonably requires more than 30 calendar
days to cure, as determined by both Parties mutually and in good faith, City shall have the
right to elect in City's sole discretion to (i) extend Agency's time to cure, (ii) terminate
this Contract effective immediately upon written notice of such intent to Agency, or (iii)
pursue any other legal remedies available to City.
10.3.1 In the event of termination under this Section 10.3, all CDBG Funds
awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited
and Agency shall have no further right to such funds, and any CDBG Funds already paid
to Agency must be repaid to City within 30 days of the termination. If such CDBG funds
are not repaid to City within the 30 day period, City shall exercise all legal remedies
available under this Contract.
10.4 No Funds Disbursed while in Breach.
Agency understands and agrees that no CDBG Funds will be paid to Agency until
all defaults are cured to City's satisfaction.
10.5 No Compensation After Date of Termination.
Agency shall not receive any compensation for work undertaken after the date of
the termination.
CDBG PSA CONTRACT ?013-?014 — GIRLS INC. OF TARRANT COLJNTY
13
10.6 Ri�hts of Citv Not Affected.
"i'ermination shall not atfect or tertninate any of the existing ribhts of City a�;ainst
Agency, or which may thereat'ter accrue because of Agency's default. Such termination
does not terminate any provisions of this Contract that have been expressly noted as
surviving the term or termination of the Contract.
{ 0.7 Waiver of Bre�ch Not W�iver of Subsequent Breach.
The waiver ot' a default or breach of any term, covenant, or condition of this
Contract shall not operate as a waiver of any subsequent default or breach of the same or
any other term, covenant or condition hereof.
10.8 Civil Criminal and Administrative Penalties.
Failure to perform all the Contract terms may result in civil, criminal or
administrative penalties, including, but not limited to those set out in this Contract.
10.9 Termination for Cause.
10.9.1 City may terminate this Contract in the event of Agency's default,
inability, or failure to perform subject to notice, grace and cure periods. In the event City
terminates this Contract for cause, all CDBG Funds awarded but unpaid to Agency
pursuant to this Contract shall be immediately rescinded and Agency shall have no
further right to such funds and any CDBG Funds already paid to Agency must be repaid
to City within 30 days of termination. Failure to repay such CDBG Funds within 30 days
will result in City exercising all legal remedies available to City under this Contract.
AGENCY ACKNOWLEDGES AND AGREES THAT IF CITY TERMINATES
THIS CONTRACT FOR CAUSE, AGENCY OR ANY AFFILIATES OF AGENCY
SHALL NOT BE CONSIDERED FOR ANY OTHER CITY CONTRACT FOR
CDBG FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE OF
TERMINATION.
10.9.2 Agency may terminate this Contract if City does not provide the
CDBG Funds substantially in accordance with this Contract.
10.10 Termination for Convenience.
In terminating in accordance with 24 C.F.R. 85.44 this Contract may be
terminated in whole or in part only as follows:
10.10.1 By City with the consent of Agency in which case the Parties shall
agree upon the termination conditions, including the effective date and in the case of
partial termination, the portion to be terminated; or
10.10.2 By the Agency upon written notification to City, setting forth the
►•easons for such termination, the effective date, and in the case of partial termination, the
portion to be terminated. In the case of a partial termination, City may terminate the
Contract in its entirety if City determines in its sole discretion that the remaining portion
of the Contract to be performed or CDBG Funds to be spent will not accomplish the
purposes for which the Contract was made.
CDBG PSA CONTRACT ?013-?O l 4- GIRLS INC. OF TARRANT COUNTY �`�
I 0.11 Dissolution of A�encv Terminates Contract.
In the event A�;ency is dissolved or ceases to exist, this Contract shall terminate.
[n the event of termination under this Section, all CDBG Funds are subject to repayment
and/or City may exercise all of its remedies under this Contract.
10.12 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired
with the CDBG Funds including cash, interest payments from loans or otherwise, all
outstanding notes, mortgages or other security instruments, any accounts receivable
attributable to the use of the CDBG Funds, and any real or personal property owned by
A�ency that was acquired or improved with CDBG Funds shall automatically transfer to
City or to such assignee as City may designate.
11. REPAYMENT OF CDBG FUNDS.
All CDBG Funds are subject to repayment in the event the Program does not meet
the requirements as set out in this Contract or in the CDBG Regulations. If Agency
takes any action that results in the City being required to repay all or any portion of
the CDBG Funds to HUD, Agency agrees it will reimburse City for such repayment.
[f Agency takes any action that results in City receiving a finding from HUD about
the Program, whether or not repayment of all or any portion of the CDBG Funds is
required of City, Agency agrees it will pay City 10% of the CDBG Funds as
liquidated damages. The Parties agree that City's damages in the event of either
repayment to HUD being required or receiving a finding from HUD are uncertain and
would be difficult to ascertain and may include an impact on City's CDBG grant or other
Federal grant funds, in addition to a tinding by HUD or a repayment of funds to HUD by
City. Therefore, the Parties agree that payment under this Section of 10% of the CDBG
Funds by Agency to City is liquidated damages and not a penalty.
12. CHANGE IN NON-PROFIT STATUS.
If the non-profit staius of Agency changes after the date of this Contract, City
may but is not obligated to, terminate this Contract. Agency must provide City with
written notification of any changes to its non-profit status within 15 calendar days of
being notified of the change. City has 30 calendar days to make such determination after
receipt of notice from Agency and failure to make such determination will constitute a
waiver. In the event of termination under this Section 12, all CDBG Funds awarded but
unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency
shall have no further right to such funds. Any CDBG Funds already paid to Agency must
be repaid to City within 30 calendar days of termination.
(3. SURVIVAL.
Any provision of this Contract that pertains to auditing, monitoring, client income
eligibility, record keeping and reports, City ordinances, or applicable CDBG
requirements, and any default and enforcement provisions necessary to enforce such
provisions, shall suivive the termination of this Contract for 5 years after the Contract
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COLJNTY l 5
term ends and shall be enforceable by City <igainst Agency. For purposes ot' this
Contract, this 5 year period tor survival of certain Contract provisions is deemed to begin
on October l, 2014 and end on September 30, 2019 re�ardless of whether or not this
Contract is earlier terminated.
14. GENERAL PROVISIONS
14,1 A�encv an Independent Contractor,
Agency shall operate hereunder as an independent contractor and not as an
otiicer, agent, servant or employee of City. Agency shall have exclusive control of, and
the exclusive right to control, the details of the work and services performed hereunder,
and all persons perfoiming same, and shall be solely responsible for the acts and
oinissions of its officers, members, agents, servants, employees, contractors,
subcontractors, vendors, clients, licensees or invitees.
14.2 Doctrine of Respondeat Superior.
The doctrine of respondeat superior shall not apply as between City and Agency,
or its officers, members, agents, servants, employees, contractors, subcontractors,
vendors, clients, licensees or invitees, and nothing herein shall be construed as creating a
partnership or joint enterprise between City and Agency. City does not have the legal
cight to control the details of the tasks performed hereunder by Agency, its officers,
members, agents, employees, contractors, subcontractors, vendors, clients, licensees or
invitees.
14.3 A�encv Propertv.
City shall under no circumstances be responsible for any property belonging to
Agency, or its officers, members, agents, employees, contractors, subcontractors,
vendors, clients, licensees or invitees that may be lost, stolen or destroyed or in any way
damaged and AGENCY HEREBY INDEMNIFIE5 AND HOLDS HARMLESS
CITY AND ITS OFFICERS, AGENTS, AND EMPLOYEES FROM ANY AND
ALL CLAIMS OR SUITS PERTAINING TO OR CONNECTED WITH SUCH
PROPERTY.
14.5 i2eli�ious Organization.
No portion of the CDBG Funds shall be used in support of any sectarian or
i•eligious activity. In addition, there must be no religious or membership criteria for
clients of a CDBG-funded service.
14.6 Venue.
Venue for any action, whether real or asserted, at law or in equity, arising out of
the execution, performance, attempted performance or non-performance of this Contract,
shall lie in Tarrant County, Texas.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY I 6
14.7 GoverninE Law.
This Contract s}tall be goveined by and construed in accordance with the laws of
the State of Texas. If any action, whether real or asserted, at law or in equity, arises out
of the execution, performance or non-performance of this Contract or on the basis of any
provision herein, for any issue not governed by Federal law, the choice of law shall be the
laws of the State of Texas.
14.8 Severability.
The provisions of this Contract are severable, and, if for any reason a clause,
sentence, paragraph or other part of this Contract shall be determined to be invalid by a
court or Federal or state agency, board or commission having jurisdiction over the subject
matter thereot; such invalidity shall not affect other provisions which can be given effect
without the invalid provision.
149 Written Agreement Entire Contract.
This written instrument and the Exhibits, Attachments, and Addendums attached
hereto, which are incorporated by reference and made a part of this Contract for all
purposes, constitute the entire agreement by the Parties hereto concerning the work and
services to be pertormed under this Contract. Any prior or contemporaneous oral or
written agreement, which purports to vary the terms of this Contract, shall be void. Any
�imendments to the terms of this Contract must be in writing and must be executed by
each Party to this Contract.
14.10 Para�raph Headings for Reference On1Y, No Legal Significance;
Number and Gender.
The paragraph headings contained herein are for convenience in reference to this
Contract and are not intended to define or to limit the scope of any provision of this
Contract. When context requires, singular nouns and pronouns include the plural and the
inasculine gender shall be deemed to include the feminine or neuter and the neuter gender
to include the masculine and feminine. The words "include" and "including" whenever
used herein shall be deemed to be followed by the words "without limitation".
14.11 Compliance With All Applicable Laws and Re�ulations.
By signing this Contract, Agency certifies that it complies with all applicable laws
and regulations that are currently in effect or that are hereafter amended during the
performance of this Contract. Those laws include, but are not limited to:
> CDBG Regulations found in 24 CFR Part 570.
> Title I of the Housing and Community Development Act of 1974, as amended,
(42 USC 5301
> Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.)
including provisions requiring recipients of federal assistance to ensure
meaningful access by person of limited English proticiency
> The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C.
Sections 3601 et seq.)
> Executive Orders 11063, 11246 as amended by 11375 and 12086 and as
supplemented by Department of Labor regulations 41 CFR, Part 60
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY l 7
�'i'he Age Discrimination in Employment Act of 1967
� The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.)
:- Ti1e Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970 (42 U.S.C. Sections 4601 et seq. and 49 CFR Part 24) ("URA")
✓ Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.)
and 24 CFR Part 8 where applicable
➢ National Environmental Policy Act of 1969, as amended, 42 U.S.C. sections
4321 et seq. ("NEPA") and the related authorities listed in 24 CFR Part 58.
� The Clean Air Act, as arnended, (42 U.5.C. Sections 1251 et seq.) and the
Clean Water Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.} and
the related Executive Order 11738. In no event shall any amount of the
assistance provided under this Contract be utilized with respect to a facility
Ihat has given rise to a conviction under the Clean Air Act or the Clean Water
Act.
y Immigration Refoi�n and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.)
specifically including the provisions requiring employer verifications of legal
status of its employees
> The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et
seq.), the Architectural Barriers Act of 1968 as amended (42 U.S.C. sections
41 S 1 et seq.) and the Uniform Federal Accessibility Standards, 24 CFR Part
40, Appendix A
� Regulations at 24 CFR Part 87 related to lobbying, including the requirement
that certifications and disclosures be obtained from all covered persons
:i Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24
CFR Part 23, Subpart F
� Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on
participation by ineligible, debarred or suspended persons or entities
> Section 6002 of the Solid Waste Disposal Act, as amended by the Resource
Conservation and Recovery Act
> Guidelines of the Environmental Protection Agency at 40 CFR Part 247
➢ For contracts and subgrants for construction or repair, Copeland "Anti-
Kickback" act (18 U.S.C. 874) as supplemented in 29 CFR Part 5
> For construction contracts awarded by Agency in excess of $2,000, and in
excess of $2,500 for other contracts which involve the employment of
mechanics or laborers, Sections 103 and 107 of the Contract Work Hours and
Safety Standards Act (40 U.S.C. 327A 300) as supplemented by 29 CFR Part
5
� Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as
amended by the Residential Lead-Based Paint Hazard Reduction Act of 1992
(42 U.S.C. 4851 et seq.) and implementing regulations at 24 CFR Part 35,
subparts A, B, M, and R
> Uniform Administration Requirements of 24 CFR Part 85
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY � 8
1�.11
Opqortunities; Section 3 Reauirements.
14.11.1
n
seq ) and its Related Regulations at 24 CFR Part 135.
If the Program results in the creation of new employment, training, or contracting
opportunities on a contractor or subcontractor level resulting from the expenditure of the
CDBG Funds, Agency shall comply with the following and will ensure that its
contractors also comply. If the work performed under this Contract is on a project
assisted under a program providing direct Federal tinancial assistance from HUD, Section
3 of 24 CFR 135.38 ("Section 3") requires that the following clause, shown in italics, be
inserted in all covered contracts (`Section 3 Clause"):
Section to be quoted in covered contracts begins:
"A. The tivork to be performed arnder this contract is subject to the
rec�uirements of Section 3 of Hotrsing and Urban Development Act qf
1968, as amerrded, 12 U.S.C. section 1701u (Section 3). The purpose of
Section 3 is to ensure that employment and other economic opportunities
generated by HUD ussisted or HUD-assisted programs covered by
Section 3, sJiall to tl�e gr�eatest extent f'easible, be directed to low- nnd
very-low income persons, particularly persons wl�o are recipients of HUD
assistance for izousing.
f3. The parties to this contract agree to comply with HUD's
��egulations in 24 CFR Part 135, which implemer�t Section 3. As evidenced
by d�eir execution of tl�is contract, the parties to this contract certify t%nt
they are under no contractasal or other i�npediment that would prevent
tl�em from complying with the Part 135 regulations.
C. Tlie co�7tractor agrees to send to each lubor organization or
representative of workers with whiclt it has a collective bargaining
agreemerit or other imderstanding, if any, a notice advising tlze labor
or�ganization or workers' representatives of'the contractor's commitrnents
under this Section 3 clause a�zd will post copies of' the notice in
cor�spicuous places at tl�e tivork site where both employees and applicants
.for training and employmer�t positions can see the notice. The notice shall
�lescr•ibe the Sectio�7 3 preference, sl�all set forth minimum number and job
titles si�bject to /Tire, availability of apprerTtice anci trainir�g positions, t�ie
qualifications for euc/z; a�1d t/ie name and location of the person(,$) taking
clpplications f'or each of the positions; and tlze c�nticipated date tl�e work
shall begin.
D. Tlre contractor agrees that it tivill iraclude tlTis Section 3 clairse ir�
ei�ery sacbcontract to comply with Yegulation in 24 CFR Part 135, cmd
ugrees to take uppropr-iate action, as provided iri an crpplicable pr-ovision
of the sa�bcontract or in tl�is Section 3 cl�uise, irpon finding that tlze
st�bcontractor is in violazion oj�t/�e r•egzrlations in 24 CFR Part 135. Z7ae
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY 19
c�ontrcactor will not subcontrcrct ��vith nny subcontractor wiiere it has notice
��r knowledge thut lhe st�bcontruct�r hus heen �our�d in violution �f'
regrrlutions in 24 CFR 135.
E. The contr•czctor will certify that nny vucant employment positions,
inelucling training positions tlictt are ,filed: (1) czfter t/xe eontraetor is
selected but before the contract is executed, and (2) with persons other
thnn t{iose to whom the regulations of 24 CFR Pczrt 135. The contractor
tivil! not subcontract with any suhcontractor where it has notice or
/ulowle�lge thut the suhcontructor has been fotsnd in violation vF
f�e�,nslations in 24 CFR 135.
F. Noncompliance tivith HUD's reg��lcztion in 2� CFR Part 135 rnay
result in sunctions, termination of t/�is contract.for default, arld debarmerTt
or sitspension f'rom fitture HUD assisted contracts.
G. GVith respect to work performed in connection with Section 3
coverec! Indiuri hot�sing assistance, section 7(b) qf the Indian Self=
Deterntination and Edltcation Assistance Act (25 U.S.C. section 450e) ulso
applies to tlte work to be perf'ormed c�nder tltis Contract. Section 7(b)
re erence and
�•eqtiires t/iat to tlle grecztest extent feasible (i) p f�
npporttmities for training and employment shall be given to Indians, and
(ii) preference in the ativard of�contracts and st�bcontracts sl�all be given to
Indian organizations and Indian-owned Economic Enterprises. Parties to
this contract dTat are subject to the provisions of Section 3 and Section
79b) �7gree to comply with Section 3 to tl�e n�aximatm extent feasible, batt
��ot dn derogation of compliance tivith Section 7(b). "
Section to be quoted in covered contracts ends.
14.11.2 A�encV Kesponsin►i�nes ior �ec�.v.. � l.�yu==���-��--�.
City and Agency understand and agree that compliance with the provisions 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 Agency, and their respective successors, assigns, contractors and
subcontractors. Failure to fulfill these requirements shall subject Agency and its
contractors and 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. Agency's responsibilities
include:
14.11.2.1 Implementing procedures to notify Section 3 residents and
business concerns about training, employment, and
contracting opportunities generated by Section 3 covered
assistance;
14.11.2.2 Notiiying potential contractors working on Section 3
covered projects of their responsibilities;
14.11.2.3 Facilitating the training and employment of Section 3
residents and the award of contracts to Section 3 business
CDBG PSA CONTRACT 3013-2014 - GIRLS INC. OF TARRANT COt1NTY ��
concerns;
t 4.11.2.4 Assisting
Departmen
comply;
and
t in
actively cooperating with the HED
making contractors and subcontractors
14.11.2.5 Refraining from entering into contracts with contractors
that are in violation of Section 3 regulations;
14.11.2.6 Documenting actions taken to comply with Section 3; and
14.11.2.7 Submitting Section 3 Annual Summary Reports (form
HUD-60002) in accordance with 24 CFR Part 135.90.
14.11.3 Section 3 Reportin� Requirements.
In order to comply with the Section 3 requirements, Agency must submit the
forms attached hereto as Exhibit "G" - Section 3 Reporting Forms.
14.11.3.1 Report to the City on a quarterly basis all applicants for
employment, and all applicants for employment by
contractors and any subcontractors. This shall include
name, address, zip code, date of application, and status
(hired/not-hired) as of the date of the report.
14.11.3.2 Advertise available positions to the public for open
competition, and provide documentation to City with the
quarterly report that demonstrates such open advertisement,
in the form of printout of Texas Workforce Commission
posting, copy of newspaper advertisement, copy of flyers
and listing of locations where flyers were distributed, and
the like.
14.11.3.3 Report to the City on a quarterly basis all contracts awarded
by contractors and any subcontractors. This shall include
name of contractor and/or subcontractor, address, zip code,
and amount of award as of the date of the report.
14.12 Prohibition A�ainst Discrimination.
14.12.1 General Statement.
Agency, in the execution, performance or attempted performance of this Contract,
shall comply with all non-discrimination requirements of 24 CFR 570.607 and the
ordinances codified at Chapter 17, Article III, Division 4— Fair Hoassing of the City
Code. Agency may not discriminate against any person because of race, color, sex,
gender, religion, national origin, familial status, disability or perceived disability, sexual
orientation, gender identity, gender expression, or transgender, nor will Agency permit its
officers, members, agents, employees, or clients to engage in such discrimination.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COLJNTY � 1
'This Contract is made and entered into with reFerence specitically to the
ordinances codified at Chapter 17, Article III, Division 3- Employment Practices of the
City Code, and Agency hereby covenants and agrees that Agency, its otficers, members,
agents, employees and contractors, have fully complied with all provisions of same and
that no employee, or applicant for ernployment has been discriminated a�ainst under the
terms of such ordinances by either or its officers, members, agents, employees or
contractors.
14.12.2 No Discrimination �n �:mp�ovmenc aur���� �ilG r C. ��l ��=n,=�� �_ -
Contract.
During the performance of this Contract Agency agrees to the following
provision, and will require that its contractors and subcontractors also comply with such
provision by including it in all contracts with its contractors:
[Contractor or subcontractor's name] will not unlawfully discriminate against
any employee or applicants for employment because of race, color, sex, gender, religion,
national origin, familial status, disability or perceived disability, sexual orientation,
gender identity, gender expression or transgender. Agency will take affirmative action to
ensure that applicants are hired without regard to race, color, sex, gender, religion,
national origin, familial status, disability or perceived disability, sexual orientation,
gender identity, �;ender expression or transgender and that employees are treated fairly
during employment without regard to their race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender
identity, gender expression or transgender. Such action shall include, but not be limited
to, the following: employment, upgrading, demotion or transfer, recruitment or
recruitment advertising, layoff or ter�rnination, rates of pay or other fortns of
compensation, and selection for training, including apprenticeship. Agency agrees to post
in conspicuous places, available to employees and applicants for employment, notices
setting forth the provisions of this nondiscrimination clause.
[Con�ractor or sarbcontractor's rrame] will, in all solicitations or advertisements
for employees placed by or on behalf of Agency, state that all qualified applicants will
receive consideration for employment without regard to race, color, sex, gender, religion,
national origin, familial status, disability or perceived disability, sexual orientation,
gender identity, gender expression or transgender.
[Contractor or saibcontractor's narne] covenants that neither it nor any of its
officers, members, agents, employees, or contractors, while engaged in performing this
Contract, shall, in connection with the employment, advancement or discharge of
employees or in connection with the terms, conditions or privileges of their employment,
discriminate against persons because of their age or because of any disability or
perceived disability, except on the basis of a bona fide occupational qualification,
retirement plan or statutory requirement.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COLJNTY �2
[Cvntractor or .saibcontrnctor's name] further covenants that neither it nor its
ufticers, mecnbers, agents, employees, contractors, or persons acting on their behalf, shall
specify, in solicitations or advertisements tor employees to work on this Contract, a
maximum age limit for such employment unless the specitied maximum age limit is
based upon a bona tide occupational qualitication, retirement plan or statutory
requirement.
l4.12.3 A�encv's Contractors and the ADA.
[n accordance with the provisions of the Americans With Disabilities Act of 1990
('`ADA"), Agency warrants that it and any of its contractors will not unlawfully
discriminate on the basis of disability in the provision of services to the general public,
nor in the availability, terms anci/or conditions of employment for applicants for
employment with, or employees of Agency or any of its contractors. AGENCY
WARRANTS IT WILL FULLY COMPLY WITH ADA'S PROVISIONS AND
ANY OTHER APPLICABLE FEDERAL, STATE AND LOCAL LAWS
CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD
CITY HARMLESS AGAINST ANY CLAIM5 OR ALLEGATIONS ASSERTED
BY THIRD PARTIES OR CONTRACTORS AGAINST CITY ARISING OUT OF
AGENCY'S AND/OR IT5 CONTRACTORS', AGENTS' OR EMPLOYEES'
ALLEGED FAILURE TO COMPLY WITH THE ABOVE-REFERENCED LAWS
CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF
THIS CONTRACT.
14.13. Prohibition A¢ainst Interest / Conflict of Interest.
14.13.1 Agency shall establish safeguards to prohibit its employees, board
tnembers, advisors and agents from using positions for a purpose that is or gives the
appearance of being motivated by a desire for private gain f'or themselves or others,
particularly those with whom they have family, business or other ties. Agency shall
disclose to City any conflict of interest or potential conflict of interest described above,
immediately upon discovery of such.
14.13.2 No persons who are employees, agents, consultants, officers or elected
officials or appointed officials of City or of Agency who exercise or have exercised any
functions or responsibilities with respect to activities assisted with CDBG funds or who
are in a position to participate in a decision-making process or gain inside information
with regard to these activities may utilize CDBG services, may obtain a financial interest
or benetit from a CDBG-assisted activity, or have an interest in any contract, subcontract
or agreement with respect thereto, or the proceeds thereunder, either for themselves or
those with whom they have family or business ties, during their tenure or for 1 year
thereat'ter, unless they are accepted in accordance with the procedures set forth at 24 CFR
570.611.
14.13.3 Agency affirms that it will adhere to the provisions of the Texas Penal
Code which prohibits bribery and gifts to public servants.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY
?3
l�.13.4 The conflict of interest provisions of 24 CFR Part 85.36 and 24 CFR
Pai�t 84.42, respectively, shall apply in the procurement of property and seivices by
A�;ency. [n all cases not governed by those sections, the provisions of 24 CFR 570.611
af the CDBG Regulations shall apply.
14.14 Subcontractin� with Small and Minoritv Firms, Women's
I3usiness Enterprises and Labor Surulus Areas.
14.14.1 For procurernent contracts larger than $50,000.00 Agency agrees to
abide by City's policy to involve Minority Business Enterprises and Small Business
Enterprises and to provide them equal opporlunity to compete for contracts for
construction, provision of professional services, purehase of equipment and supplies and
provision of other services required by City. Agency agrees to incorporate the City's
BDE Ordinance, and all amendments or successor policies or ordinances thereto, into all
contracts and subcontracts for procurement larger than $50,000.00 and will further
require all persons or entities with which it so contracts to comply with said ordinance.
14.14.2 It is national policy to award a fair share of contracts to disadvantaged
business enterprises ("DBEs"), small business enterprises ("SBEs"), minority business
enterprises (`MBEs"), and women's business enterprises ("WBEs"). Accordingly,
affirmative steps must be taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized
when possible as sources of supplies, equipment, construction and services.
14.15 Other Laws.
The failure to list any federal, state or City ordinance, law or regulation that is
applicable to Agency does not excuse or relieve Agency from the requirements or
responsibilities in regard to following the law, nor from the consequences or penalties for
Agency's failure to tiollow the law, if applicable.
14.16 Assignment.
Agency shall not assign all or any part of its rights, privileges, or duties under this
Contract without the prior written approval of Director. Any attempted assignment of
same without approval shall be void, and shall constitute a breach of this Contract.
14.17. Right to Inspect Asencv Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed
contracts between Agency and any contractor engaged in any activity in conjunction with
this CDBG-funded Program prior to any charges being incuned.
14.18 Force Maieure
If Agency becomes unable, either in whole or part, to fulfill its obligations under
this Contract due to acts of God, strikes, lockouts, or other industrial disturbances, acts of
public enemies, wars, blockades, insurrections, riots, epidemics, earthquakes, tires,
tloods, restraints or prohibitions by any court, board, department, commission or agency
of the United States or of any States, civil disturbances, or explosions, or some other
reason beyond Agency's control (collectively, "Force Majeure Event"), the obligations so
affected by such Force Majeure Event will be suspended only during the continuance of
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY �=�
�uch event. Agency will give City written notice of the e�cistence, extent and nature of
the Force Majeure Event as soon as reasonably possible after the occurrence ot' the event.
Failure to give notice will result in the continuance of Agency's obligation regardless of
the extent of any existing Force Majeure Event. Agency will use commercially
reasonable efforts to remedy its inability to perform as soon as possible.
15. INDEMNIFICATION AND RELEASE.
AGENCY COVENANTS AND AGREES TO INDEMNIFY, HOLD
HARMLESS AND DEFEND, AT ITS OWN EXPEN5E, CITY AND ITS
OFFICERS, AGENT5, SERVANTS AND EMPLOYEES FROM AND AGAINST
f�NY AND ALL CLAIM5 OR SUITS FOR PROPERTY LOSS OR DAMAGE
AND/OR PER50NAL 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
EYECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS,
ACTNITIES AND SERVICES OF THE PROGRAM DE5CRIBED HEREIN,
WHETHER OR NOT CAUSED IN WHOLE OR IN PART, BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANT5, EMPLOYEES,
CONTRACTORS OR SUBCONTRACTORS OF CITY; AND AGENCY HEREBY
ASSUMES ALL LIABILITY AND RESPONSIBILITY OF CITY AND ITS
OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FOR ANY AND ALL
CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR
PERSONAL INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF
WHATSOEVER KINDS OR CHARACTER, WHETHER REAL OR ASSERTED,
ARISING OUT OF OR IN CONNECTION WITH THE EXECUTION,
PERFORMANCE, ATTEMPTED PERFORMANCE OR NONPERFORMANCE
OF THIS CONTRACT AND/OR THE OPERATIONS, ACTIVITIES AND
SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER OR NOT
CAU5ED IN WHOLE OR IN PART BY ALLEGED NEGLIGENCE OF
OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR
SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND
AGREES TO AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS
CITY FROM AND AGAINST ANY AND ALL INJURY, DAMAGE OR
DE5TRUCTION OF PROPERTY OF CITY, ARISING OUT OF OR IN
CONNECTION WITH ALL ACTS OR OMISSIONS OF AGENCY, ITS
OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS, INVITEES, LICENSEE5, OR CLIENTS, OR CAUSED, IN
WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS,
SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTOR5 OF
CITY.
IT IS THE EXPRESS INTENTION OF THE PARTIES, BOTH AGENCY
AND CITY, THAT THE INDEMNITY PROVIDED FOR THIS SECTION
[NCLUDES INDEMNITY BY AGENCY TO INDEMNIFY AND PROTECT CITY
FROM THE CONSEQUENCES OF CITY'S OWN 1VEGLIGENCE, WHETHER
CDBG PSA CONTRACT 2013-?014 - GIRLS INC. OF TARRANT COUNT'Y �S
9
TI-IAT NEGLIGENCE IS ALLEGED TO BE THE SOLE OR CONCURRING
CAUSE OF THE INJURY, DAMAGE OR DEATH.
:#GENCY AGREES TO AND SHALL ItELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICER5 AND LEGAL REPRESENTATIVES FROM ALL
LIABILITY FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR
PItOPERTY SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO
PERFORMANCE UNDER THIS CONTRACT, EVEN IF THE INJURY, DEATH,
DAMAGE OR LOSS IS CAUSED BY CITY'S SOLE OR CONCURRENT
NEGLIGENCE.
AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND
SUBCONTRACTORS TO [NCLUDE IN THEIR CONTRACTS AND
SUBCONTRACTS A RELEASE AND INDEMNITY IN FAVOR OF CITY IN
SUBSTANTIALLY THE SAME FORM AS ABOVE.
16. WAIVER OF IMMUNITY BY AGENCY.
If Agency, as a charitable or nonprofit organization, has or claims an immunity or
exemption (statutory or otherwise) from and against liability for damages or injury,
including death, to persons or property, Agency hereby expressly waives its rights to
plead defensively such immunity or exemption as against City. This section shall not be
construed to affect a governmental entity's immunities under constitutional, statutory or
common law.
17. INSURANCE AND BONDING.
Agency will maintain coverage in the forin of insurance or bond in the amount of
�82,075.00 to insure against loss from the fraud, theft or dishonesty of any of Agency's
officers, agents, trustees, directors or employees. The proceeds of such insurance or bond
shall be used to reimburse City for any and all loss of CDBG Funds occasioned by such
misconduct. To effectuate such reimbursement, such fidelity coverage shall include a
rider stating that reimbursement for any loss or losses shall name the City as a Loss
Payee.
Agency shall furnish to City in a timely manner, but not later than the Effective
Date, certificates of insurance as proof that it has secured and paid for policies of
commercial insurance as specified herein. If City has not received such certiticates by
the Effective Date, Agency shall be in default of the Contract and City may, at its option,
terminate the Contract.
Such insurance shall cover all insurable risks incident to or in connection with the
execution, performance, attempted performance or nonperformance of this Contract.
Agency shall maintain, or require its general contractor to maintain, the following
coverage and limits thereoi
CDBG PSA CONTRACT 2013-201 �4 - GIRLS INC. OF TARRANT COLJNTY
�6
Commercial General Liabilitv (CGL) Insurance
$500,000 each occurrence
$1,000,000 aggregate limit
Non-Protit Or�anization Liabilitv or Directors & Officers Liabilitv
$1,000,000 Each Occurrence
$1,000,000 Annual A�gregate Limit
Business Automobile Liabilitv Insurance
$1,000,000 each accident on a combined single-limit basis, or
$250,000 Property Damage
$500,000 Bodily Injury per person per occurrence
$2,000,000 Aggregate
[nsurance policy shall be endorsed to cover "Any Auto", deiined as autos owned, hired, and non-
owned. Pending availability of the above coverage and at the discretion of City, the policy
shall be the primary responding insurance policy versus a personal auto insurance policy if
or when in the course of Agency's business as contracted herein.
Workers' Compensation Insurance
Part A: Statutory Limits
Part B: Employer's Liability
$100,000 each accident
$100,000 disease-each employee
$500,000 disease-policy limit
Note: Such insurance shall cover employees performing work on any and all projects
including but not limited to construction, demolition, and rehabilitation. Agency or its
contractors shall maintain coverages, if applicable. In the event the respective contractors
do not maintain coverage, Agency shall maintain the coverage on such contractor, if
applicable, for each applicable contract.
Additional Requirements
Such insurance amounts shall be revised upward at City's reasonable option and no more
frequently than once every 12 months, and Agency shall revise such amounts within 30
days following notice to Contractor of such requirements.
Agency will submit to City documentation that it has obtained insurance coverage and
has executed bonds as required in this Contract prior to payment of any monies provided
hereunder.
Where applicable, insurance policies required herein shall be endorsed to include City as
an additional insured as its interest may appear. Additional insured parties shall include
employees, officers, agents, and volunteers of City.
CDBG PSA CONTRACT 2013-201�1- GIRLS INC. OF TARRANT COUNTY �7
'1'he Workers' Compensation Insurance policy shatl be endorsed to include a waiver of
subrogation, also referred to as a waiver of ri�;hts of recovery, in tavor of City.
Any failure on part of City to request certiticate(s) of insurance shall not be construed as
a waiver of such requirement or as a waiver of the insurance rec{uirements themselves.
Insurers of Agency's insurance policies shall be licensed to do business in the state of
Texas by the Department of Insurance or be otherwise eligible and authorized to do
business in the state of Texas. [nsurers shall be acceptable to City insofar as their
tinancial strength and solvency and each such company shall have a current minimum
A.M. Best Key Rating Guide rating ot� A-: VII or other equivalent insurance industry
standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless
otherwise approved by City.
In the event there are any local, federal or other regulatory insurance or bonding
requirements for the Program, and such requirements exceed those specified herein, the
Former shall prevail.
Agency shall require its contractors to maintain applicable insurance coverages, limits,
and other requirements as those specitied herein; and Agency shall require its contractors
to provide Agency with certiticate(s) of insurance documenting such coverage. Also,
Agency shall require its contractors to have City and Agency endorsed as additional
insureds (as their interest may appear) on their respective insurance policies.
Directors and Officers Liability coverage shall be in force and may be provided on a
claims-made basis. This coverage may also be referred to as Management Liability, and
shall protect the insured against claims arising out of alleged errors in judgment, breaches
of duty and wrongful acts arising out of their organizational duties. Coverage shall
protect not only the entity, but all past, present and future directors, officers, trustees,
employees, volunteers and committee members.
18. CERTIFICATION REGARDING LOBBYING.
The undersigned representative of Agency hereby certities, to the best of his or
her knowledge and belief, that:
No Federal appropriated funds have been paid or will be paid, by or on behalf of
Agency, to any person for intluencing or attempting to influence an ofiicer or
employee of any agency, a member of Congress, an officer or employee of
Congress in connection with the awarding of any Federal contract, the making of
any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan or cooperative agreement.
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY
:
[f any funds other than federally appropriated funds have been paid or will be paid
to any person for intluencing or attempting to iniluence an officer ar e�nployee of
any agency, member of Congress in connection with this Federal contract, grant,
loan or cooperative agreement, Agency shall complete and submit Standard
Form-LLL, ``Disclosure Form to Report Lobbying," in accordance with its
instructions.
This certification is a material representation of fact upon which reliance was
�laced when this Contract was made or entered into. Submission of this
certiticate is a prerequisite for making or entering into this Contract imposed by
31 U.S.C. Section 1352. Any person who fails to tile the required certitication
shall be subject to a civil penalty of not less than $10,000.00 and not more than
$100,000.00 for each such failure.
Agency shall require that the language of this certification be included in all
subcontracts or agreements involving the expenditure of Federal funds.
19. LITIGATION AND CLAIMS.
Agency shall give City immediate notice in writing of any action, including any
proceeding before an administrative agency, tiled against Agency in conjunction with this
Contract or the Program. Agency shall furnish immediately to City copies of all pertinent
papers received by Agency with respect to such action or claim. Agency shall provide a
notice to City within 10 days upon filing under any bankruptcy or financial insolvency
provision of law.
20. NOTICE.
All notices required or permitted by this Contract must be in writing and are
deemed delivered on the earlier date of the date actually received or the third day
following deposit in a United States Postal Service post office or receptacle; with proper
postage, certified mail return receipt requested; and addressed to the other Party at the
address set out below or at such other address as the receiving Party designates by proper
notice to the sending Party.
Citv:
City Attorney's Office
1000 Throckmorton Street
Fort Worth, TX 76102
Telephone: 817-3 92-7600
Copy to:
Director of Housing and Economic Development
1000 Throckmorton Street
Fort Worth, TX 76102
Telephone: 817-392-7540
CDBG PSA CONTRACT 3013-201-t - GIRLS INC. OF TARRANT COUNTY
�9
Copy to:
Program Coordinator
I 000 Throckmorton 5treet
Fort Worth, TX 76102
Telephone: 817-392-6342
f� enc :
Girls Inc: of Tarrant Count}�
Executive Directo�
2820 Matlock
Arlington, TX' 76Q1 �
817-468=030�
21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT.
Agency represents that it possesses the legal authority, pursuant to any proper,
appropriate and official motion, resolution or action passed or taken, to enter into this
Contract and to perform the responsibilities herein required.
22. COUNTERPARTS.
This Contract may be executed in multiple counterparts, each of which shall be
considered an original, but all of which shall constitute one instrument which may be
sufficiently evidenced by one counterpart.
[SIGNATURES APPEAR ON NEXT PAGE]
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNT'Y 30
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WITNESS WHEREOF, the Parties hereto have executed 4 duplicate
this Contract in Foi� Worth, Tai7•ant County, Texas.
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C�ty Secretaiy
M&C: C-2636� �
Date: August 6, 2013
APPRQVED AS TO F(
�� . / (
_- �l� C_ ��: �C.��.--� i'�� �
Assistant City Attorney
CITY OF FORT WORTH
� f � !_-- B Y � �`%�J'�6r L.///�--�
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' Feinando Costa, Assistant City Manager
AND LEGALITY:
GIRLS INC. OF TARRANT COUNTY
:
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STATE OF TEXAS §
COUNTY OF TARRANT §
This instiuinent was acicnowledged before me on % ` 2� , 2013 by
Feinando Costa, Assistant City Manager of the C,jty of Fort Worth, on behalf the City of
Fort Worth.
EVONIA DANIELS
Notary Publlc, State of Texas
My Commisslon Expires
July 10, 2017
Public, State of Texas
STATE OF TEXAS §
COUNTY OF TARRANT §
Th�i instiument was acknowledge,d before me on ��� �' ��� �� , 2013 by
�'.�� t+'i , 1' [Name], the [Title] of Girls Inc. of'I`ai-�•ant County, a Texas
non-profit corporation, on behalf of said coiporatio�
PATRICIA E. MATTHEWS
Notary PubliC, $tate of Texas
My Commis$►on Expires
June 2q, 2017
AFFICIAL RECORD
.
� � �
CDBG PSA CONTRACT 2013-2014 — GIRLS INC OF TARRANT CO
,. g,�; � �
Notaiy Public, State of Texas
EXHIBITS:
Exhibit "A" — Program Summary
Exhibit "A-1" — 2013 HUD Income Limits
Exhibit "A-2" — Environmental Mitigation Action
Exhibit "B" — Budget
Exhibit "C" — Audit Certification Form
Exhibit "D" — Reimbursement Forms
Exhibit "E" — Form of Income Self-Certification
Exhibit "F" — Standards for Complete Documentation
Exhibit "G" — Section 3 Reporting Forms
Exhibit "H" — Severely Disabled Certification Form
CDBG PSA CONTRACT 2013-2014 - GIRLS INC. OF TARRANT COUNTY 32
Girls Inc. of Tarrant County
Girls Inc. in Northside Fort Worth
EXHIBIT A
PROGRAM SUMMARY
PROGRAM SUMMARY
Community Development Block Grant
(CDBG)
October 1, 2013 to 5eptember 30, 2014
PERIOD
$82,075.00
AMOUNT
PROGRAM:
The program will provide youth services to Fort Worth girls. Program services include in-
school, after-school, and summer education and activities to improve life-skills, promote
academic success, and prevent juvenile crime and delinquency.
CDBG funds will be used to pay for salaries and fringe benefits for program employees and
program facility rent.
Girls Inc.'s office is located at 2100 N. Main Street, Suite 214, Fort Worth, TX 76164.
Program services will be available at the locations listed below* on various days and times:
North Side High School - 2211 McKinley Avenue, Fort Worth, TX 76164
Fort Worth Public Library, North Side Branch - 601 Park St., Fort Worth, TX 76164
Fort Worth Public Library, Diamond Hill-Jarvis Branch - 1300 N. E. 35th 5t., Fort
Worth, TX 76106
*For information purposes only, locations subject to change
REGULATORY CLASSIFICATION:
IDIS Matrix Code(s) and Service Category: 05D Youth Services
National Objective Citation: LMC Low/Mod Limited Clientele 24 CFR 5'10.208(a)(2)
Regulatory Citation(s): 25 CFR 570.201(e)
Based on the nature of the service provided, Agency will maintain documentation that
verifies that 51 % of clients served by the Program are income eligible with current
household incomes at or below 80% of Area Median Income (AMI) as established or
de�ned by the United States Department of Housing and Urban Development (HUD).
PROGRAM GOALS:
Provide program services to approximately 100 Unduplicated Clients
EXHIBIT A- CDBG: GIRLS INC. OF TARRANT COUNTY
EXHIBIT "A-1"
2013 HUD INCOME LIMITS
*Income limits are established and published at least annually by HUD.
EXHIBIT "A-2"
ENVIRONMENTAL MITIGATION ACTION
NONE REQUIRED
EXHIBIT B - BUDGET
EXHIBIT B- CDBG: GIRLS INC. OF TARRANT COUNTY
FUNDING C: Other — portion of grant from Sid W. RichardsonVFoundation; portion of grant from Girls 1nc. National; Hasbro; and
individuaUcorporate contributions, special events, donations, etc. if all funding sources received.
The following tables are pure(y informational and were created solely for purposes of preparing, negotiating, and
determining the reasonableness of the overall line item budget on the first page of this EXHIBIT B— BUDGET and
are not to be considered part of the tenns and conditions of tliis Contract. Contractor may make changes to any
column except the "Position" column in the "Salary Detail" table without the City's consent so long as the total
amounts charged to the grant do not exceed the line items on the first page of the EXHIBIT B— BUDGET."
Changes to the column labeled "Position" may only be made with the prior written consent of the City.
SALARY DETAtL
Position Name Rate Annual Hours Percent to Grant Amount to Grant
Sr. Pro ram Director 50,250 2080 29.2% 14,673
Pro ram Director/Facilitator 30,000 2080 100% 30,000
Pro ram Director/Facilitator 33,000 2080 55% 18,150
FRINGE DETAIL
Percent of Pa oll Amount Percent to Grant Amount to Grant
FICA .0765 4,805 5.9% 4,805
Life Insurance
Health Insurance .15 9,424 11.5% 9,424
Unem lo ment
Workers Com ensation
Retirement
SUPPLIES AND SERVICES
Total Bud et Percent to Grant Amount to Grant
Office Su lies 3,000 0% 0
Office E ui ment Rental 9,123 0% 0
Posta e 200 0% 0
Printin 1,300 0% 0
MISCELLANEOUS
Total Budget Percent to Grant Amount to Grant
Contract Labor 4,820 0% 0
Craft Su lies 3,400 0% 0
Facilit Fees 0% 0
Field Tri Costs 1,600 0% 0
Food Su lies 3,779 0% 0
Teachin Aids 4,700 0% 0
FACILITY AND UTiLITTF,S
Total Bud et Percent to Grant Amount to Grant
Tele hone 4,500 0% 0
Electric included in rent 0% 0
Gas included in rent 0% 0
Water and Wastewater included in rent 0% 0
Solid Waste Dis osal included in rerrt 0% 0
Rent 10,795 46.5%of.e„�fo.Na.��,aep.�gr�, 5 023.00
�o�o�
,
Custodial Services included in rent 0% 0
Re airs 0 0% 0
Cleanin Su lies 0 0% 0
EXHIBIT B- CDBG: GIRLS INC. OF TARRANT COUNTY 2
FTNANCIAL AND INSURANCE
Total Bud et Percent to Grant Amount to Grant
Fidelit Bond or E uivalent 1,778 0% 0
General Commercial Liabilit 362 0% 0
Directors and Officers 874 0% 0
Contract Accountin 2,404 0% 0
DIRECT ASSISTANCE
Total Budget Percent to Grant Amount to Grant
Childcare Scholarshi s 0 0% 0
Short-Term Rent Assistance 0 0% 0
Short Term Mort a e Assistance 0 0% 0
Short Term Utilities Assistance 0 0% 0
Tenant Based Rental Assistance 0 0% 0
EXHIBIT B- CDBG: GIRLS INC. OF TARRANT COUNTY 3
EXHIBIT "C"
Audit Certification Form
[See attached]
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency:
Fiscal Year Ending:
September 30, 2014
❑ 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-133 audit report within seven (7) months after the end of the audited fscal 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)
Signatory and Title Date
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.
Exhibit "D" - Reimbursement Forms
[See attached]
Attachment I
INVOICE
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Agency's (;ertitication: 1 certity that the costs incurred are valid and
consistent with the terms and conditions of the contract between
City and Agency. By signing this invoice, I certify that to the best
of my knowledge and belief the data included in this report is true
and accurate. It is acknowledged that the provision of false
information could leave the certifying official subject to the
Signature and Date:
Name:
Title:
Attachment II
Clly of Port Worih
❑omfng and Hconomlc Ucvelopmmt Deparlment
Eipendlture Worinhat
Agcncy: �ame
Pro�ynm: Pmknm Name
'Payroll must identiCy empioyx. Rrnt musl identify tenent. O�her paymenb shoutd identify individuaL
IIIghOghtcdaretheonlyrdev�nteodaforthbPro�am. �::�� .
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Form of Income 5elf-Certification
[See attached]
CERTIFICATION OF INCOME STATEMENT
Applicant Name:
Current Address:
Phone #:
**PERSONAL INFORMATION: (Check one in each item. Optional Information for Federal Reporting Purposes)
a. ❑ MALE b. 0 WHI'i'E ❑ BLACK/AFRICAN AMERICAN ❑ BLACK/AFRICAN AMERICAN & WHITE
❑ FEMALE ❑ AMERICAN INDIAN/ALASKAN NATIVE ❑ ASIAN
❑ AMERICAN INDIAN/ALASKAN NATIVE & WHI1'E ❑ ASIAN & WHITE
❑ NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER ❑ BALANCE/OTHER
❑ AMERICAN INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AMERICAN
c. ETHNICITY d. DISABLED e. IS CLIENT WOMEN HEAD OF HOUSEHOLD
❑ HISPANIC ❑ YES ❑ YES
❑ NON-HISPANIC ❑ NO ❑ NO
* TOTAL NUMBER OF HOUSEHOLD (Include Yourseif AND everyone who
MEMBERS lives in the house.)
Total Anticipated Annual Household Income:
Certification:
Federal, State and local law.
I certify that the information I am providing is true and could be subject to verification at any time by a third
party. I also acknowledge that the provision of false information could leave me subject to the penalties of
WARNING: TITLE 1H, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAHING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF
THE UNITED STATES GOVERNMENT.
Signature of Applicant
For use by funding agency:
Household Size:
Income Limit:
Annual Income:
Is Applicant Eligible:
Date
Person Making Determination: Date:
Household Members and Income
CERTIFICACION DE DECLARACION DE INGRESOS
Nombre del Solicitante:
Domicilio Actual:
Numero de Telefono:
**INFORMACION PERSONAL: (Seleccione uno en cada categoria. Informacion opcional para propositos de informacion Federal)
a. ❑ MASCULINO b. Q CAUC.4SIC0 ❑ NEGRO/AFRICANO AMERICANO
❑ NEGRO/AFRICANO AMERICANO & CAUCASICO
❑ FEMININO ❑ 1NDI0 AMERICANO/NATIVO DE ALASKA ❑ ASIATICO
❑ INDIO AMERICANO/NATIVO DE ALASKA & CAUCASICO ❑ ASIATICO & CAUCASICO
❑ NATIVO HAWAIANO/OTRO DE LAS ISLAS PACIFICAS ❑ BALANCE/OTRO
❑ INDIO AMERICANO / NATIVO DE ALASKA & NEGRO/AFRICANO AMERICANO
c. ETNICIDAD d. DISCAPACITADO e. �ES EL SOLICITANT'E LJNA MiJJER Y CABECERA DEL HOGAR?
❑ HISPANO ❑ SI ❑ SI
❑ NO-HISPANO ❑ NO ❑ NO
* NUMERO TOTAL DE MIEMBROS EN EL HOGAR
Ingreso total del hogar anual anticipado:
(Inciuye a si mismo y a todos los que viven en
ta casa)
Certificacion:
Certifico que la informacion que proporciono es verdad y podria ser susceptible a la comprobaci6n a cualquier
tiempo por terceros. Yo tambien reconozco que la provision de informacion falsa me podria dejar sujeto a las
penalidades Federales, Estatales y locales.
ADVERTENCIA: TITULO 18, SECCION 1001 DEL CODIGO DE EE.UU. QUE UNA PER50NA ES
CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE HACER DECLARACIONES
FALSAS O FRAUDULENTA5 A CUALQUIER DEPARTAMENTO DEL GOBIERNO
ESTADOUNIDENSE.
Firma del Solicitante
Fecha
Para el uso de la agencia financiando:
# De Miembros en el Hogar:
Limite de Ingreso:
Persona haciendo la determinacion:
Ingreso Anual:
�Es el solicitante elegible? :
Fecha:
Miembros en el Hogar e In rg esos
Exhibit "F" - Standards for Complete Documentation
[See attached]
2013-2014 Documentation Standards for
Public Service Contract Expenses
an employee vrorks solety wilh Contrect eligible cl(ents and solely on Conlrect eligible items, lhen lhe employee's entife salary (s eligibla tor
imbursement. Twice in eacb calendar year, the Gient must submit a wr0tan statement verirying Ihat the above condRions are still We. The
atement must also be signed be a person authorized to sign on behaN of the agency.
an empbyee worka on a variety of programs, or works with a mixture of Conired ei'gibie dients and non-eligible dlents, then lhe Ciry wili onty
imburse for a reasoneble portion oi the emp�oyee's salary. Each reimbursement request must Indude not onty the empbyee's timesheet, but also
work bg breakiog out Ihe empbyee's time by projed or adiv'Ay. For employees paid with mWtiple funding sources, limesheets must retlect aII
nding sourcas. li sepa2te timesheets are kept tor each funding source, ali such timesheels must be submitted to Ciry.
f employees are paid by direct deposR rethar Ihan check, then tha agency must submit both the dired deposd payment companys repoA (such as
� ADT report) and a bank stalement or check showing paymenl to lhe direct deposit company.
pays
he City pays gross salary, this is already includeA. Itwe pay the empioyet ponron, tnen me emp�oyer musc snow a caicma�ron ana owi
how the invoiced amount was caiculaled, must include an Invoice fmm the insurer, and must Include documental'an shmving paymant.
he City pays gmss saiary, lhis is already induded. Itwe pay the emplayer portion, lhen the employer must show a calculatlon and doa
how Ihe (moiced amount was caiculaled, musl include an invoice from lhe insurer, and must include documentatbn showing payment.
he City pays gross salary, this is aiready inGuded. It we pay the employer portbn, then lbe employer must show a calculalbn and doci
how Uie invoiced amounl was calculated, must Inciude an invoice from Me insurer, and must include documentation showing payment.
pays
if we pay gross saiary, th
lhe invoiced amount was
must and
"uC'�J
showing payment, and prior lo lhe first reimbursement, must include !he
sources.
must be on file. Likevrise, "rf mail is
fon to atlmisston expenses, Tootl expenses wiu a�so ne anowea so �ong as me agency
purchases on all field trips, not just Contract•funded field Uips.
�uls. If the agency has a Pilney Bowes machine or like poslage macnine, the recoras ol
by payment source, lhen tFase records must be on file. For large mailouta, lhe agency
and
lhe
�
City requires that Ule agency submit ils fee schedule, showing a breaKout ot mcome ieve�s, ana ror eapl revei a oreaKouc m me portwn m ma
expense to be paid by family and ihe portion to be reimbursed 6y the City. This fea schedule is required prior to the first payment. We also require
lhe income eligiblity of each household so that we can determine Bwe are being changed in wnfortnance with the fee schedule. It lha fee schedule
changes at any Ume during tha contract year, the agency must notity City and provide a new schedule within 30 days of tha change.
'Proof of payment effective October 1, 2013: Payments or Expenses must be documented in the folbwing manner.
A) Image of the check AND bank statement showing the check deared lhe ba�k; OR,
8) Image of the cancelled chedc (ex. At end of bank statemenQ; OR,
C) Payroil'Advace' or Statement AND Bank Statement indicating paymll; OR,
D) For wire or e-transfers: fteciept or statement fmm payeefvendor OR bank stalement.
EXHIBIT "G"
SECTION 3 REPORTING FORMS
EXHIBIT "G"
Section 3 Summary Report
Economic Opportunities for
Low — and Very Low-Income Persons
U.S. Department of Housing
and Urban Development
Office of Fair Housing
And Equal Opportunity
OMB Approval No: 2529-0043
(exp. 11 /30/2010)
HUD Field Office:
Section back of pege for Public Reporting Burden statement
t. Recipient Name 8 Address: (street, city, state, zip) 2. Federel Iden�cation: (grent no.) 3. Tolal Amount of Award:
4. Contact Person 5. Phone: (InGude area code)
6. Length of Granl: 7. Reporting Period:
8. Date Report Submitted: 9. Program Code: (Use separata sheel 10. Progrem Name:
for each program code)
Part i: Em lo ment and Trainin "` Columns B, C and F are mandato fields. Include New Hires in E&F
A B C D E F
Number of Num6er of New % of Aggregate Number % of Total Staff Hours Number of Section 3
Job Category New Hires Hires lhat are of Staff Hours of New Hires for Section 3 Employees Treinees
Sec. 3 Residents that are Sec. 3 Residents and Tratnees
Professionals
Technicians
O�ce/Clerical.
Construction by Trade (List)
Trade
Trade
Trade
Trade
Trade
Other List
Total
` Program Codes 3= Public/Indian Housing 4= Homeless Assistance
1= Flexible Subsidy A= Development, 5= HOME
2= Section 202/811 8= Operation 6= HOME Sfate Administered
C= Modemization 7= CDBG EnliOement
Page 1 of 2
8 = CDBG State Administered
9 = Olher CD Programs
10 = Other Housing Programs
form HUD 60002 (6/2001)
Ref 24 CFR 135
Part il: Contracts Awarded
Construction Contracts:
A. Total dollar amount of aIl contracts awarded on the project
B. Total doilar amount of contracts awarded to Section 3 businesses
�
C. Percentage of the totai doilar emount that was awarded to Section 3 businesses I %
D. Total number of Section 3 businasses receiving contracts
2. Non-Construction Contracis:
A. Total doilar amount all non-construction contracts awarded on the projecUactivity
8. Total dollar amount of non-construction coniracts awarded to Section 3 businesses � $
C. Percentage of the total doliar amount that was awarded to Section 3 businesses
D. Total number of Section 3 businesses receiving non-construction contracts
Part Iil: Summary
%
Indicate the efforts made to direct the empioyment and other economic opportunities generated by HUD financial assistance for housing
and community development programs, to the greatest extent feasible, toward low-and very low-income persons, particularly those who
are recipients of government assistance for housing. (Check all that appiy.)
Attempted to recruit low-income residents through: local advertising media, signs prominently displayed at the project site,
contracts with the community organizations and public or private agencies operating within the metropolitan area (or
nonmetropolitan county) in which the Section 3 covered program or project is located, or similar methods.
Participated in a HUD program or other program which promotes the training or employment of Section 3 residents.
Participated in a HUD program or other program which promotes the award of contracts to business concems which meet the
definition of Section 3 business concerns.
Coordinated with Youthbuild Programs administered in the metropolitan area in which the Section 3 covered project is Iocated.
Other; describe below.
Public reporting for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions,
searchi�g existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
This agency may not collect this information, and you are not required to compiete this form, uniess it displays a currently valid OMB
number.
Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701 u, mandates that the Department ensures that
empioyment and other economic opportunities generated by its housing and community development assistance programs are directed
toward low- and very-low income persons, particularly those who are recipients of government assistance housing. The regulations are
found at 24 CFR Part 135. The information will be used by the Department to monitor program recipients' compliance with Section 3, to
assess the results of the DepartmenYs efforts to meet the statutory objectives of Section 3, to prepare reports to Congress, and by
recipients as self-monitoring tool. The data is entered into a database and will be analyzed and distributed. The collection of information
involves recipients receiving Federal financial assistance for housing and community development programs covered by Section 3. The
information will be collected annually to assist HUD in meeting its reporting requirements under Section 808(e)(6) of the Fair Housing Act
and Section 916 of the HCDA of 1992. An assurance of confidentiaiity is not applicabie to this form. The Privacy Act of 1974 and OMB
Circular A-108 are not applicable. The reporting requirements do not contain sensitive questions. Data is cumulative; personal identifying
information is not included.
Page 2 of 2 (ortn HUD 60002 (11/2010)
Ref 24 CfR 135
Form HUD-60002, Section 3 Summary Report, Economic Opportunities for Low- and Very Low-Income Persons.
Instructions: This form is to be used to report annuai
accompiishments regarding employment and other economic
opportunities provided to low- and very low-income persons under
Seciion 3 of ihe Housing and Urban Development Act of 1968. The
Section 3 regulations appiy to any publlc and Indlan housing
programs that receive: (1) development assistance pursuant to
Section 5 of the U.S. Housing Act of 1937; (2) operating assistance
pursuant to Section 9 ot the U.S. Housing Act of 1937; or (3)
modernization grants pursuant to Section 14 of the U.S. Housing Act
of 1937 and to recipients of housing and community development
assistance io excess of SZ00,000 expended for: (1) housing
rehabilitation (including reduction and abatement of lead-based paint
hazards); (2) housing construction; or (3) other public construction
projects; and to confracts and subcontracts In excess of $100,000
awarded in connection with the Section-3-covered activity.
Form HUD-60002 has three parts, which are to be completed for
ail programs covered by Section 3. PaR I relates to employment
and bafning. The recipient has the option to determine numerical
empioymenUtraining goals either on the basis of the number of hours
worked by new hires (columns 8, D, E and F). Part II of ihe form
relates to contracting, and Part 111 summarizes recipients' efforts to
comply with Section 3.
Recipients or contractors subject to Section 3 requirements must
maintain appropriate documentation to establish that HUD financial
assistance for housing and community development programs were
directed toward low- and very low-income persons.' A recipient of
Section 3 covered assistance shail submit one copy of this report to
HUD Headquarters, Office of Fair Housing and Equal Opportunity.
Where the program providing assistance requires an annual
performance report, this Section 3 report is to be submitted at ihe
same time the program performance report is submitted. Where an
annual perfortnance report is not required, this Section 3 report is to be
submitted by January 10 and, if the project ends before December 31,
within 10 days of project completion. Only Prlme Recipfents are
required to report to HUD. The report must include
accomplishments of all recip/ents and fhelr Sectlon 3 covered
contractors and subcontractors.
HUD Field O�ce: Enter the Field O�ce name .
1. Recipient: Enter the name and address of the recipient
submitting this report.
2. Federal Identification: Enter the number that appears on ihe
award form (with dashes). The award may be a grant,
cooperative agreement or contract.
3. Dollar Amount of Award: Enter the dollar amount, rounded to the
nearest dollar, received by the recipient.
4& 5. Contact PersonlPhone: Enter the name and telephone number
of ihe person with knowledge of the award and the recipient's
impiementation of Section 3.
6. Reporting Period: Indicate the time period (months and year)
this report covers.
7. Date Report Submitted: Enter the appropriate date.
8. Program Code: Enter the appropriate program code as listed at
the bottom of the page.
9. Program Name: Enter the name of HUD Program corresponding
with the "Program Code" in number S.
Part I: Employment and Training Opportunities
Column A: Contains various Job categories. Professionals are
defined as people who have special knowiedge of an occupation (i.e.
supervisors, architects, surveyors, pianners, and computer
programmers). For construction pasitions, list each trade and provide
data in columns B through F for each trade where persons were
employed. The category of "Other" includes occupations such as
service workers.
Column B: (Mandatory Fleld) Enter the number of new hires for
each category of worlcers identified in Coiumn A in connection with
this award. New hire refers to a person who is not on the contractor's
or recipienYs payroll for employment at the time of selection for the
Section 3 covered award or at the time of receipt of Section 3 covered
assistance.
Column C: (Mandatory Field) Enter the number of Section 3 new
hires for each category of workers identified in Column A in
connection with this award. Section 3 new hire refers to a Section 3
resident who is not on the contractors or recipienYs payroil for
employment at the time of selection for the Section 3 covered award or
at the time of receipt of Section 3 covered assistance.
Column D: Enter the percentage of all the staff hours of new hires
(Section 3 residents) in connection with this award.
Coiumn E: Enter ihe percentage of the total staff hours worked for
Section 3 employees and trainees (including new hires) connected
with this award. Include staff hours for part-time and full-time
positions.
Colum� F: (Mandatory Field) Enter the number of Seciion 3
residents ihat were trained in connection with this award.
Part II: Contract Opportunities
Block 1: Construction Contracts
Item A: Enter the total dollar amount of all contracts awarded on the
project/program.
Item B: Enter the totai doilar amount of contracts connected with this
projecUprogram that were awarded to Section 3 businesses.
Item C: Enter the percentage of the total dollar amount of contracts
connected with thfs projecUprogram awarded to Section 3 businesses.
Item D: Enter the number of Section 3 businesses receiving awards.
Block 2: Non-Construction Contracts
item A: Enter the total doilar amount of all contracts awarded on the
project/program.
Item B: Enter ihe total dollar amount of contracts connected with this
project awarded to Section 3 businesses.
Item C: Enter the percentage of the total dollar amount of contracts
connected with this projecUprogram awarded to Section 3 businesses.
Item D: Enter the number of Section 3 businesses receiving awards.
Part III: Summary of Efforts — Self -explanatory
Submit one (1) copy of this report to the HUD Headquarters Office of
Fair Housing and Equal Opportunity, at the same time ihe
performance report is submitted to the program office. The Section 3
report is submitted by January 10. Inciude oniy contracts executed
during the period specified in item 8. PHAs/1HAs are to report all
contracts/s u bcontracts.
` The terms `low-income persons" and very low-income persons" have
the same meanings given the terms in section 3(b) (2) of the United
States Housing Act of 1937. Low-Income persons mean families
(including single persons) whose incames do not exceed 80 percent of
the median income for the area, as determined by the Secretary, with
adjustments for smailer and Iarger families, except that
��
The Secretary may establish income ceilings higher or lower than 80 percent
of the median for the area on the basis of the Secretarys findings such that
variations are necessary because of prevailing levels of construction costs
or unusualiy high- or low-income families. Verylow-income persons mean
low-income families (inciuding singie persons) whose incomes do not
exceed 50 percent of the median family income area, as determined by the
Secretary with adjustments or smaller and larger families, except that the
Secretary may establish income ceilings higher or lower than 50 percent of
the median for the area on the basis of the Secretary's findings that such
variations are necessary because of unusuaily high or low family incomes.
form HUD 60002 (11/2010)
Ref 24 CFR 135
EXHIBIT "H" — Severely Disabled Certi�ication Form
[See attached]
[AGENCY]
CERTIFICATION FORM
DOCUMENTING CLIENT STATUS AS "SEVERELY DISABLED ADULT"
Client Name:
Address:
Ciry, State, Zip
Client Identification No.
CHECK ALL THAT APPLY
�
�
'�I,
C
�
u
Has used a wheelchair, a walker, cane , crutches or other special aid for six
months or longer
Has been diagnosed with one of the following conditions: Alzheimer's
disease, mental retardation or other developmental disability, senility or
dementia, cerebral palsy, or autism; or has another mental or emotional
condition that seriously interferes with eve day tasks.
Is unable to perform one or more of the following "Functional Activities":
seeing, hearing, speaking and having one's speech understood, lifting or
carrying, using stairs, gras ing small objects, or walking.
Is unable to perfortn or needs assistance to perform one or more of the
following Activities of Daily Living (ADL): getting around inside the home,
ettin in or out of bed or a chair, bathin , dressin , eatin , and toiletin .
Is unable to perform or needs assistance to perform one or more of the
following Instrumental Activities of Daily Living (IADL): going outside the
home, keeping track of money and bills, preparing meals, doing light
housework, taking prescription medications in the right amount and at the right
time, and usin the tele hone.
Has a condition that revents them from working at a job or doin housework.
The undersigned agency representative conducted a visual assessment of the client
identified on this form and certifies that the client meets at least one of the conditions
indicated above, which determines that he/ she meets the definition of "severely
disabled" according to the U.S. Census Bureau.
Certified by:
Signature/Title:
Date:
CFW HED: Revised as ofAugust 30, 2013