HomeMy WebLinkAbout064629 - General - Contract - Lighthouse for the Homeless dba True Worth PlaceCSC No. 64629
STATE OF TEXAS §
§
COUNTY OF TARRANT §
This contract ("Contract") is made and entered into by and between the City of Fort Worth
(hereafter "City") and Lighthouse for the Homeless dba True Worth Place (hereafter "Agency"),
a Texas non-profit corporation. City and Agency may be referred to individually as a"Party" and
jointly as "the Parties".
The Parties state as follows:
WHEREAS, City receives grant monies from the United States Department of Housing
and Urban Development through the Emergency Solutions Grant ("ESG") Program, Program No.
E-25-MC-48-0010, Catalog of Federal Domestic Assistance No. 14.231;
WHEREAS, the ESG program is intended to provide homeless persons or persons at risk
of becoming homeless with financial assistance, basic shelter, essential supportive services, and/or
operations, as applicable;
WHEREAS, Agency submitted a proposal to use ESG funds for an eligible program under
the ESG 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 ESG programs are needed by the City's citizens.
NOW, THEREFORE, the Parties understand and agree as follows:
1. INCORPORATION OF RECITALS.
City and Agency hereby agree that the recitals set forth above are true and correct and form
the basis upon which the Parties have entered into this Contract.
2. DEFINITIONS.
In addition to terms defined in the body of this Contract, the terms set forth below shall
have the definitions ascribed to them as follows:
Area Median Income or AMI means the median family income for the Fort Worth-Arlington
metropolitan statistical area as established annually by HUD. The 2025 income limits are
attached hereto as EXHIBIT "A-1" — 2025 HUD Income Limits.
Complete Documentation means the following documentation as applicable:
• Attachments I, II, and III within Exhibit "D", with supporting documentation
including:
o Proof of expense: copies of timesheets, invoices, leases, service contracts or
other documentation showing that payment is due by Agency.
ESG PSA CONTRACT 2025-2026 Page 1 oFFicia� RecoRo
Lighthouse for the Homeless dba True Worth Place GTYSECRETARY Rev.
FT. WORTH, TX
o Proof of payment: cancelled checks, bank statements, or wire transfers
necessary to demonstrate that amounts due by Agency were actually paid by
Agency.
o Proof of client eligibility: Source Documentation sufiicient to show that
clients participating in the Program are ESG Eligible Clients as described in
Section 6.
• Complete Documentation shall meet the standards described in the attached
EXHIBIT "F" - Standards for Complete Documentation.
• Any other document or record reasonably necessary to verify costs spent and client
eligibility for the Program.
Continuum of Care mean the Tarrant Area Continuum of Care.
DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26.
Director means the Director of the Neighborhood Services Department.
Effective Date means October 1, 2025.
ESG means Emergency Solutions Grant.
ESG Eligible Client means an individual or household that meets the definition of "homeless" or
"at risk of homelessness" as deiined in the Hearth Act and the ESG Regulations.
ESG Funds means the ESG grant funds supplied by City to Agency under the terms of this
Contract.
ESG Regulations means regulations found at 24 CFR Part 576 et seq.
HEARTH Act means the Homeless Emergency Assistance and Rapid Transition to Housing Act
of 2009, 42 U.S.C. 11302 et seq.
HMIS means the Homeless Management Information System required by HUD for client data
collection.
HUD means the United States Department of Housing and Urban Development.
IDIS means Integrated Disbursement Information System, HUD's project tracking system.
Neighborhood Services Department means the City's Neighborhood Services Department.
Neighborly Software means the online database Agency will utilize to submit monthly
reimbursement requests.
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Lighthouse for the Homeless dba True Worth Place Rev.
OMB means the Ofiice of Management and Budget.
Program means the services described in EXHIBIT "A" — Program Summary.
Reimbursement Request means all reports and other documentation described in Section 9.
Source Documentation means any documentation sufficient to show uner ESG Regulations that
an individual or household is an ESG Eligible Client. Income Documentation may include, but is
not limited to, copies of paychecks, Social Security and Disability verification letters, interest or
rental income statements, retiremment income statements, child support and alimony verification,
unemployment benefit letters, or any similar documentation allowed under the definition of annual
income in 24 CFR Part 5.609.
Unduplicated Clients means a count of ESG Eligible Clients served at least once in the Contract
Term. ESG Eligible Clients served more than once in the Contract Term will only be counted the
first time they are served when determining the total count of Unduplicated Clients.
3. TERM.
The term of this Contract begins on the Effective Date and terminates on September
30, 2026, unless earlier terminated as provided in this Contract. This Contract may be extended
by mutual agreement of the Parties in writing if such extension is necessary for completion of
the program. Extensions will be memorialized in an amendment to the Agreement so long as
the amendment is in compliance with City policies and all applicable laws and regulations
governing the use of federal grant funds. The Contract term shall include any extension, if
exercised, as provided herein.
4. DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Provide ESG Funds.
City shall provide up to $150,000.00 of ESG Funds under the terms and conditions of this
Contract.
4.2 Monitor.
City will monitor the activities and performance of Agency and any of its contractors,
subcontractors or vendors as necessary, but no less than annually. Monitoring by City will include
determining whether Agency is meeting the requirements of the ESG Regulations during the term
of this Contract.
5. DUTIES AND RESPONSIBILITIES OF AGENCY.
5.1 Required Services.
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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 ESG Funds.
5.2.1. Compliance with ESG Regulations and Contract.
Agency shall be reimbursed for eligible Program costs with ESG Funds only if City
determines in its sole discretion that:
5.2.1.1 Costs are eligible expenditures in accordance with ESG Regulations.
5.2.1.2 Costs are in compliance with this Contract and are reasonable and
consistent with industry norms.
5.2.1.3 Complete Documentation, as applicable, is submitted to City by
Agency.
5.2.2 Budget.
5.2.2.1 The ESG Funds will be paid on a reimbursement basis in accordance
with EXHIBIT "B" - Budget.
5.2.2.2 During the term of this Contract, Agency may submit written requests
to increase or decrease line-item amounts in the Budget, including an
explanation of why such increases or decreases are necessary. All
requests shall be approved by Director ar Director's designee in writing,
with such approval being in the City's sole discretion. If the Agency's
proposed Budget amendment is approved (as approved, the "Amended
Budget"), then the Amended Budget shall be memorialized in a written
amendment to this Contract. The Amended Budget will take effect on
the first day of the month following the month in which the Contract
amendment is executed, unless otherwise specified in the amendment.
All requests for Budget amendments must be submitted by
Apri115, 2026.
5.2.3 Change in Pro�ram Bud�et.
5.2.3.1 Agency will notify City promptly of any additional funds it receives for
operation of the Program, and City reserves the right to amend this
Contract in such instances to ensure compliance with HUD regulations
governing cost allocation.
5.2.3.2 Agency agrees to utilize the ESG Funds to supplement rather than
supplant funds otherwise available for the Program.
5.2.4 Pavment of ESG Funds to Agencv.
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ESG Funds will be disbursed to Agency upon City's approval of Reimbursement
Requests including submission of Complete Documentation to City in compliance with Section
9. If Agency expends all funds budgeted for the Program prior to September 30, 2026, City
may hold back a small amount of the ESG Funds until the end of the term. During this interim
period, Agency must continue to submit Attachment III — Client Data Report in Exhibit "D" —
Reimbursement Forms monthly. It is expressly agreed by the Parties that any ESG Funds not
spent or approved for reimbursement to Agency shall remain with City.
5.3 Pro�ram Performance Milestones, Review and Corrective Action Plans
5.3.1 Agency represents that the Program will achieve the following milestones in
accordance with EXHIBIT "A" — Program Summary and the table below:
uf Riiii�il
6
9
12
25%
50%
75%
100%
% of Unduplicated
Clients Served (as
specified in EXHIBIT
"A" — Program
Summary)
25%
50%
75%
100%
5.3.2 Failure of Agency to meet these milestones or a material deviation from them as
outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section, "material
deviation" shall mean more than 10% lower than the speciiied goal. In the event of such breach,
City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests,
(ii) institute a Corrective Action plan as described below, (iii) to lower Agency's allocation of
CDBG Funds, or terminate this Contract.
5.3.2.1 Corrective Action.
Corrective action will be unique to the Agency and the Program and will be designed to
ensure that the Agency (i) expends the funds allocated to it by the City, and (ii) serves the
required number of unduplicated clients through the Program. The City may issue verbal or
informal directive requiring the Agency to take corrective action. A corrective action may
require additional outreach or marketing, additional reporting, additional monitoring, or any
other mechanism that will reasonably ensure the Program goals are met and that expenditures are
roughly proportional to the number of eligible, unduplicated clients served. Informal corrective
action shall not be considered a formal written corrective action plan or amendment to this
Contract. Formal written corrective action shall be required only when expressly stated in writing
by the City.
5.3.3 Failure to meet at least 80% of its performance milestones or serve 3,375
Unduplicated Clients under this Contract may, in City's sole discretion, disqualify Agency for
consideration under the City's Request for Proposals for the 2026-2027 Program Year for federal
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grant funds.
5.3.4 Amendments to performance milestones must be approved by the Director in
writing, with such approval being in the Director's sole discretion. If Director approves the
Agency's proposed amended performance milestones (as approved, the "Amended Performance
Milestones"), then the Amended Performance Milestones will take effect on the iirst day of the
month following the month in which it was approved by the Director, unless otherwise specified
in the amendment. All requests for amendments to performance milestones must be submitted by
June 1, 2026. Except in extreme circumstances, notwithstanding the above, any amendments to
performance milestones shall not reduce the number for serving 3,375 Unduplicated Clients stated
in Section 5.3.3.
5.4 Identifv Pro�ram Expenses Paid with ESG Funds.
Agency will keep accounts and records in such a manner that City may readily identify and
account for Program expenses reimbursed with ESG Funds. These records shall be made
available to City for audit purposes and shall be retained as required hereunder.
5.5 Match.
Agency must match ESG Funds dollar for dollar with other funding sources. Potential
sources of match include any sources described at 42 U.S.C. 11375(a). Some common sources
include: (i) Agency funding from non-federal sources and eligible federal grants, (ii) volunteer
time, which may be valued at $5/hour of time; and (iii) the value or fair rental value of any donated
materials or space. The monetary values Agency assigns to all sources of match are subject to
review and approval by City.
5.5.1 Prior to October 1, 2025, Agency must submit to City a completed Match
Report on the form attached hereto as EXHIBIT "G"- Match Report
detailing anticipated match sources.
5.5.2 With each Reimbursement Request, Agency must submit a log of funds
expended to date on the form provided, plus documentation of any match
expenditures first reported in that month's Reimbursement Request.
5.5.3 Records regarding match funds must be kept by Agency in accordance with
Section.
5.6 Program Subcontracts.
Agency shall not enter into a subcontract with another agency, contractor, or vendor to
provide a service to clients for any part of the Program that will be paid with ESG Funds without
City's written consent.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eli�ibilitv.
Agency will document the eligibility of all prospective clients. Agency may redact the
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client's personal information and substitute with a client number. Agency may use form attached
hereto as EXHIBIT "H"- Staff ESG Certification Form to document the eligibility of all
prospective clients that receive direct financial assistance as more particularly described as
follows.
6.1.1 A�encies Receivin� ESG Funds
6.1.1.1 Coordination of Services. Agencies must participate in the local Continuum
of Care and enter data in HMIS.
6.1.1.2 Homelessness Status. Agency must verify that all new clients are ESG
Eligible Clients. Acceptable forms of verification include:
For emergency shelter (shelter services for homeless including childcare for
homeless clients): A signed, dated statement from the client stating that the client
is homeless, or that the client is homeless by virtue of fleeing domestic violence
ii. For homelessness prevention- financial assistance services:
1. Documentation that the ESG Eligible Client meets the at risk of homelessness
deiinition consistent with CFR 24 Part 576.2 (1-3),
2. Source Documentation that the ESG Eligible Client has an annual income at or
below 30% of AMI,
3. Evidence documenting that the ESG Eligible Client does not have sufficient
resources or support networks immediately available to prevent them from
moving to an emergency shelter or another place defined in Category 1 of the
"homeless" definition under the HEARTH Act,
4. Documentation of eligibility of the housing unit, habitability inspection, lease,
rent reasonableness, rental assistance agreement between Agency and
Landlord,
5. Documentation of client's reasonable prospects of resuming payment of rent
and utilities, as applicable, within a reasonable amount of time,
6. Evidence documenting that the ESG Eligible Client is not receiving equivalent
or same type of assistance from other homeless prevention agencies or funding
sources, and
7. Documentation supporting the type and amount of assistance provided,
including, but not limited to, invoices, past due notices, and/or executed leases,
as applicable, and proof of payment by Agency.
iii. For rapid-rehousing services — financial assistance:
1. Documentation that the individual or household meets the homeless definition
in the HEARTH Act and that the client is eligible consistent with the definition
of homelessness in 24 CFR Part 576.2, paragraphs 1-4,
2. Documentation of eligibility of the housing unit, habitability inspection, lease,
rent reasonableness, rental assistance agreement between Agency and
Landlord,
3. Documentation of client's reasonable prospects of resuming payment of rent
and/or utilities, as applicable, within a reasonable time,
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4. Evidence documenting that the ESG Eligible Client is not receiving equivalent
or same type of assistance from other rapid re-housing agencies or funding
sources, and
5. Documentation supporting the type and amount of assistance provided,
including, but not limited to, invoices, past due notices, and/or executed leases,
as applicable, and proof of payment by the Agency.
iv. For housing relocation and stabilization services:
1. Documentation that services are provided for ESG Eligible Client as
defined in the HEARTH Act, as may be amended from time to time, and
2. Documentation that any staff costs and relocation/stabilization services
directly benefit the ESG Eligible Client and are clearly distinguished from
the general administration of the Program.
If applicable, the Agency must comply with the eligibility and verification requirements
that apply under title IV of the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, as amended (8 U.S.C. 1601-1646) (PRWORA) and use the Systematic Alien Verification
for Entitlements (SAVE) or an equivalent verification system approved by the Federal
government, to prevent any Federal public benefit from being provided to an ineligible alien who
entered the United States illegally or is otherwise unlawfully present in the United States, unless
the Agency is a nonprofit charitable organization exempt from this requirement under 8 U.S.C. §
1642(d).
6.1.2 Performance Standards.
Agency must verify that the Program is tracking ESG activities and outcomes in
accardance with the City's performance standards as described in EXHIBIT "I"- ESG
Performance Standards.
6.1.3 Written Standard for ESG Assistance.
Agency must verify that the Program is documenting Client Eligibility in accordance with
the City's written standards as described in EXHIBIT "I-1"- Written Standards for ESG
Assistance. Agency must maintain all records in accordance with Section 8.
6.2 Submission of Complete Documentation.
Agency must submit copies of documentation of client eligibility described in Section 6.1
with Attachment III in each month's Reimbursement Request for all Unduplicated Clients.
6.3 Maintain Documentation.
Agency must maintain copies of all documentation required by this section for 5 years
following the expiration of this Contract term. This Section shall survive the earlier terminations
or expirations of this Contract.
7. ADDITIONAL ESG REOUIREMENTS.
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Agency agrees to comply with all requirements of the ESG Program as stated in the ESG
Regulations, including but not limited to the following:
7.1 Environmental Review.
ESG Funds will not be paid, and costs cannot be incurred until City has conducted an
environmental review and completed an Environmental Review Recard as required by 24 CFR
Part 58. The environmental review may result in a decision to proceed with, modify, or cancel the
funding for the Program. Further, Agency will not undertake or commit any funds to physical or
choice limiting actions as described in any applicable federal regulations. Any violation of this
provision will (i) cause this Contract to terminate immediately, and (ii) require Agency to repay
City the ESG Funds it has already received and forfeit any future payments of ESG Funds.
7.2 Contract Not Constitutin� Commitment of Funds.
Notwithstanding any provision of this Contract, the Parties agree and acknowledge that
this Contract does not constitute a commitment of funds, and that such commitment of funds or
approval may occur only upon (i) satisfactory completion of an environmental review and receipt
by City of an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of
City's 2025-26 Action Plan, and (iii) receipt by City of a grant agreement from HUD.
7.3 Monitoring.
7.3.1 Agency understands and agrees that it will be subj ect to monitoring by City for
compliance with terms and provisions of this Contract and the ESG Regulations for the term of
this Contract. Agency is subject to such monitoring during the term of this Contract and for 7 years
after the Contract term ends. Agency will provide reports and access to Program files as requested
by City during this 7-year period.
7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United
States Comptroller General shall have access during regular business hours, upon 48 hours prior
notice, to Agency's offices and records pertaining to the use of the ESG Funds, and to Agency's
officers, directors, agents, employees, contractors, subcontractors and vendors for the purpose of
such monitoring.
7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring,
City reserves the right to perform desk reviews or on-site monitoring of Agency's compliance with
the terms and conditions of this Contract. City shall provide Agency with a written report of the
monitor's findings after each monitoring visit. If the monitoring report notes deficiencies in
Agency's performance, the report shall include requirements for the timely correction of said
deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report
may be cause for suspension or termination of this Contract as provided herein.
7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract Term and for 5
years thereafter and shall survive the earlier termination or expiration of this Contract.
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7.3.5 Agency shall provide City annually the results of any state or federal monitoring.
Such results shall be submitted within sixty (60) days of receipt of such state or federal monitoring
report, or with the January Reimbursement Request, whichever is earlier.
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. In addition to the conflict of interest
provisions in Section 14.13.3, Agency shall establish written procurement procedures to ensure
that materials and services are obtained in a cost-effective manner and that provides for full and
open competition. When procuring materials and services for this Contract, Agency shall comply
at a minimum with the procurement standards in 2 CFR Part 200.317 through Part 200.326.
7.4.1 Contracts in excess of $10,000.00 made by Agency using ESG Funds must address
termination for cause and convenience including the manner by which such termination shall be
effected and the basis for settlement of the terminated contract, if any, as required by Appendix II
(B), 2 CFR Part 200.
7.4.2 Agency shall not make any contract with parties listed on the government wide
System for Award Management, www.sam.gov ("SAM"). Agency must confirm by search of
SAM that all contractors paid with ESG Funds are not listed by SAM as being debarred, both prior
to hiring and prior to submitting a Reimbursement Request which includes invoices from any such
contractor. Failure to submit such proofs of search shall be an event of default.
7.5 Cost Principles/Cost Reasonableness.
Agency shall administer its use of ESG Funds in compliance with 2 CFR Part 200, as
applicable. The eligibility of costs incurred for performance rendered shall be determined in
accordance with 2 CFR Part 200.400 through Part 200.475.
7.6 Financial Mana�ement Standards.
Agency agrees to comply with 2 CFR Part 200, as applicable. Agency also agrees to adhere
to the accounting principles and procedures required therein, utilize adequate internal controls, and
maintain necessary supporting and back-up documentation for all costs incurred in accordance
with 2 CFR Part 200.302 and Part 200.303.
7.7 Uniform Administrative Requirements, Cost Principles, and Audit
Requirements.
Agency will comply with the Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards in 2 CFR Part 200, as applicable, or any reasonably
equivalent procedures and requirements that City may require.
7.8 Terms Applicable to Contractors, Subcontractors and Vendors.
Agency understands and agrees that all terms of this Contract, whether regulatory or
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otherwise, shall apply to any and all contractors, subcontractors and vendors of Agency which are
in any way paid with ESG 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 ESG Regulations. Agency shall monitor the services and wark
performed by its contractors, subcontractors and vendors on a regular basis for compliance with
the ESG Regulations and Contract provisions. Agency must cure all violations of the ESG
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 ESG Regulations and
Agency is responsible for such compliance regardless of whether actions taken to fulfill the
requirements of this Contract are taken by Agency or by Agency's contractors, subcontractors or
vendors. Agency acknowledges that the provisions of this Section shall survive the earlier
termination or expiration of this Contract and shall be applicable for 5 years after the Contract term
ends.
7.9 Copvright and Patent Rights.
No reports, maps, or other documents produced in whole or in part under this Contract shall
be the subject of an application for copyright by or on behalf of Agency. HUD and City shall
possess all rights to invention or discovery, as well as rights in data, which may arise as a result of
Agency's performance under this Contract.
7.10 Conflict of Interest Disclosure.
In accordance with the requirements of Section 14.13, Agency shall establish conflict of
interest policies for federal awards. Agency shall disclose to City in writing any potential conflict
of interest.
7.11 Comnliance with FFATA and Whistleblower Protections.
Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the
Federal Funding Accountability and Transparency Act ("FFATA") governing requirements on
executive compensation and provisions governing whistleblower protections contained in 10
U.S.C. 2409, 41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
7.1 L 1 Agency shall provide City with its DUNS number.
7.12 Internal Controls.
In compliance with the requirements of 2 CFR Part 200.303, Agency shall:
7.12.1 Establish and maintain effective internal control over the ESG Funds that provides
reasonable assurance that Agency is managing the ESG Funds in compliance with federal statutes,
regulations, and the terms and conditions of this Contract. These internal controls shall be in
compliance with guidance in "Standards for Internal Control in the Federal Government" issued
by the Comptroller General of the United States or the "Internal Control Integrated Framework"
issued by the Committee of Sponsoring Organizations of the Treadway Commission ("COSO");
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7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this
Contract;
7.12.3 Evaluate and monitor Agency's compliance with statutes, regulations and the terms
and conditions of this Contract;
7.12.4 Take prompt action when instances of noncompliance are identified including
noncompliance identified in audit findings; and
7.12.5 Agency must have written procedures to safeguard protected personally identifiable
information and other information that HUD or City designates as sensitive or Agency considers
sensitive consistent with applicable federal, state, local and tribal laws regarding privacy and
obligations of coniidentiality.
7.13 Confidentialitv of Client Information
Consistent with the requirements of 24 CFR Part 576.500, Agency shall comply with the
City's written standards as descried in EXHIBIT "M"- Written Standards for Maintenance of
Personally Identifying Information. Furthermore, in compliance with this section, Agency shall
develop and implement written procedures to ensure the following:
7.13.1 Personally Identifying Information
All records containing personally identifying information (as described in HUD's
standards for participation, data collection, and reporting in a local HMIS) of any individual or
family who applies for and/or receives ESG assistance will be kept secure and confidential.
7.13.2 Victim Information
The address or location of any domestic violence, dating violence, sexual assault, or
stalking shelter project assisted by ESG funds will not be made public, except with written
authorization of the person responsible for the operation of the shelter.
7.13.3 Program Participation Information
The address or location of any housing of a client must not be made public, except as
provided under a preexisting policy of either City or Agency and consistent with state and local
laws regarding privacy and obligations of confidentiality.
7.14 Violence Against Women Act Requirements
7.14.1 Agency shall comply with the Violence Against Women Act ("VAWA") and shall
ensure that any property owner, manager, or facility assisted by the ESG Funds shall, at the time
of application for services, provide all clients receiving rental assistance with a Notice of
Occupancy Rights under the Violence Against Women Act in substantially the same form as the
form attached and incorporated as Exhibit "N"- Notice of Occupancy Rights Under VAWA in
compliance with VAWA and 24 CFR Part 574.604(a)(2), where applicable.
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7.14.2 Agency agrees that no applicant for ESG assistance may be denied admission or
assistance under the Program on the basis or as a direct result of the fact that they are or have been
a victim of domestic violence, dating violence, sexual assault, or stalking, as long as they would
otherwise qualify for the Program.
7.14.3 Agency shall be responsible for reviewing VAWA and 24 CFR Part 574.604 and
shall respond to all emergency transfer requests in accordance with the requirements of those
provisions. Agency may request that all clients requesting an emergency transfer under VAWA
fill out the form attached and incorporated as Exhibit "O"- VAWA Emergency Transfer
Request Form.
S. RECORD KEEPING; REPORTING AND DOCUMENTATION
REOUIREMENTS; AUDIT.
8.1 Record Keepin�.
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 7 years after the Contract term ends, regardless of whether or not this Contract is
earlier terminated. If any claim, litigation, or audit is initiated before the expiration of the 7-year
period, the relevant records and documentation must be retained until all such claims, litigation or
audits have been resolved.
8.2 Access to Records.
Representatives of City, HUD and any duly authorized officials of the federal government
will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of
Agency's records pertaining to all matters covered by this Contract for 7 years after the Contract
term ends, regardless of whether or not this contract is earlier terminated. Such access shall be
during regular business hours and upon at least 48 hours prior notice.
8.3 Reports.
Agency will submit to City all reports and documentation described in this Contract in such
form as City may prescribe. Agency may also be required to submit a final performance and/or
final financial report if required by City at the termination of this Contract in such form and within
such times as City may prescribe. Failure to submit to City any report or documentation described
in this Contract shall be an event of default of this Contract and City may exercise all of its
remedies for default under this Contract.
8.3.1 AdditionalInformation.
Agency shall provide City with additional information as may be required by state or
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federal agencies to substantiate Program activities and/or expenditure eligibility.
8.4 Chan�e in Reporting Repuirements and Forms.
City retains the right to change reporting requirements and forms at its discretion. City
will notify Agency in writing at least iifteen (15) days prior to the effective date of such change,
and the Parties shall execute an amendment to the Contract reflecting such change if necessary.
8.5 Audit.
8.5.1 Entities that Exuend $1,000,000 or more in Federal Funds Per Year.
All non-federal entities that expend $1,000,000 or more in federal funds within 1 year,
regardless of the source of the federal award, must submit to City an annual audit prepared in
accordance with specific reference to 2 CFR Part 200.501 through Part 200.52L The audit shall
cover the Agency's fiscal years during which this Contract is in force. The audit must be prepared
by an independent certified public accountant, be completed within 9 months following the end of
the period being audited and be submitted to City within thirty (30) days of its completion.
Agency's audit certification is attached hereto as EXHIBIT "C" —"Audit Certification Form"
and "Audit Requirements". The Audit Certif'ication Form must be submitted to City prior to
or with the first Reimbursement Request. Entities that expend less than $1,000,000 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 finances at
any time during the term of this Contract and for 7 years after the Contract term ends, regardless
of whether or not this Contract is earlier terminated, if City determines that such audit is necessary
for City's compliance with the ESG Regulations or other City policies. Agency agrees to allow
access to all pertinent materials as described herein for such audit. If such audit reveals a
questioned practice or expenditure, such questions must be resolved within fifteen (15) business
days after notice to Agency of such questioned practice or expenditure. If questions are not
resolved within this period, City reserves the right to withhold further funding under this Contract
and/or any other contracts with Agency. IF AS A RESULT OF ANY AUDIT IT IS
DETERMINED THAT AGENCY HAS FALSIFIED ANY DOCUMENTATION OR
MISUSED, MISAPPLIED OR MISAPPROPRIATED ESG FUNDS OR SPENT ESG
FUNDS ON ANY INELIGIBLE ACTIVITIES, AGENCY AGREES TO REIMBURSE
CITY THE AMOUNT OF SUCH MONIES PLUS THE AMOUNT OF ANY SANCTIONS,
PENALTY OR OTHER CHARGE LEVIED AGAINST CITY BY HUD BECAUSE OF
SUCH ACTIONS.
9. REIMBURSEMENT REOUIREMENTS.
9.1 Deadline for Submittin� Reimbursement Requests.
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Reimbursement Requests shall be submitted monthly to the City and must be received by
the City on or before the 15th 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 15rh falls on a weekend or City holiday, Reimbursement Requests sha11 be due the next
day that the City is open for business. Failure to submit a Reimbursement Request in a timely
fashion will result in City taking the actions outlined in Section 10.1. NOTWITHSTANDING
ANYTHING ABOVE, THE REIMBURSEMENT REQUEST FOR EXPENSES
INCURRED FOR SEPTEMBER 2026 MUST BE RECEIVED BY OCTOBER 4, 2026.
COMPLETE DOCUMENTATION FOR ALL SEPTEMBER 2026 EXPENSES MUST BE
SUBMITTED BY OCTOBER 15, 2026. FAILURE TO SUBMIT A FINAL
REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY
OCTOBER 15, 2026 WILL RESULT IN FORFEITURE OF PAYMENT OF THE
SEPTEMBER REIMBURSEMENT REQUEST.
9.1.2 City will notify Agency by e-mail within fourteen (14) calendar days if a
Reimbursement Request is lacking Complete Documentation or corrections are needed. Agency
will have seven (7) calendar days from the date of the e-mail notice to submit any requested
information ar missing documentation. Agency may be penalized, at City's sole discretion, in the
Request for Proposal for the 2026-2027 Program Year for any notifications received under this
Section. If Agency fails to submit all the required information or missing documentation within
seven ('� calendar days from the first e-mail, Agency may forfeit any payments otherwise due that
month and failure to submit any requested information will be considered an event of default as
outlined in Section 10.1.2.
9.2 Submission of Reimbursement Requests.
Agency shall provide City with Complete Documentation and the following reports as
shown in EXHIBIT "D" —Reimbursement Forms with each Reimbursement Request:
9.2.1 Attachment I— Request Summary
This report shall contain the amount requested for reimbursement each month and,
the cumulative reimbursement requested to date (inclusive of that month's request).
9.2.2 Attachment II— Exnenditure Worksheet.
This report shall itemize each expense requested for reimbursement by Agency and shall
include the Account corresponding the expense to a Budget line item. In order for this report to
be complete the following must be submitted:
9.2.2.1 For payroll expenses, timesheets signed by employees and approved by
supervisor for all payroll expenses listed. Timesheets must distinguish
between ESG-funded time and non-ESG funded time and reflect actual
time spent on ESG-funded activities. Agency may not submit payroll
expenses dated sixty (60) calendar days prior to the date of the
Reimbursement Request.
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9.2.2.2 For non-payroll expenses, invoices for each expense listed with an
explanation as to how the invoiced expense pertains to the Program.
Agency may not submit invoices dated sixty (60) calendar days prior to
the date of the Reimbursement Request.
9.2.2.3 Proof that each expense was paid by Agency. 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 maintain a list of all clients served
during the Contract term. In order for this report to be complete, the following must be submitted:
9.2.3.1 Documentation of income verification for each Unduplicated Client the
first time the client is served, which either will be the completed form
attached hereto as EXHIBIT "E"- Self-Certification of Income Form
and Source Documentation.
9.2.3.2 Agency may use the form attached hereto as EXHIBIT "H"- Staff ESG
Certification Form to verify client eligibility as described in Section 6.1.
9.2.4 Delivery of Reimbursement Request.
Reimbursement Requests must be submitted through Neighborly Software or other
reporting software approved by the City by the deadline in Section 9.1.
9.2.5 Match Report.
This report shall document actual expenditure of match funds, as further described in
Section 5.5.
9.2.6 ESG CAPER Report.
Agency shall submit the ESG CAPER Report via Neighborly for review no later than
October 15, 2026 with the last draw submission, attached hereto as EXHIBIT "J"- ESG CAPER.
CAPER will be submitted by Agency in SAGE HMIS on an annual basis.
9.3 Withholding Pavment.
CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT
REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit
accurate and complete Reimbursement Requests and Complete Documentation along with
any required reports shall be an event of default.
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10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Reimbursement Reauest or Reauired Documentation.
10.1.1 Failure to submit a Reimbursement Request in accordance with Section 9 and
Exhibits "D" and "F," Agency shall be in default of this Contract. If Agency has not provided the
requested information or missing documentation within the seven (7) calendar day notice period
as provided for in Section 9.1.2, City will provide Agency with a written default notice. Agency
will have five (5) calendar days from the date of the written default notice to submit information
and documentation to cure the default. If Agency fails to cure the default within such time, Agency
shall forfeit any payments otherwise due that month and the failure to submit shall be considered
an event of default that shall not be cured.
10.1.2 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR
10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE
OCTOBER 4, 2026 OR IF THE SUBMITTED REIMBURSEMENT REQUEST DUE
OCTOBER 4, 2026 IS LATE, INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE
WITH THIS CONTRACT OR THE ESG REGULATIONS AS DETERMINED BY CITY
IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY
REIMBURSEMENT WILL BE FORFEITED.
10.1.3 In the event of an uncured default under this 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 ESG 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 ESG 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. l, all ESG Funds awarded but
unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds.
10.2 Failure to Maintain Records or Submit Reports and Documentation.
If Agency fails to maintain all records and documentation as required in Section 8, or if the
maintained or submitted report or documentation is not in compliance with this Contract or the
ESG Regulations as determined by City in its sole discretion, City will notify Agency in writing
and Agency will have thirty (30) calendar days from the date of the written request to obtain ar
recreate the missing records and documentation or submit or resubmit any such report or
documentation to City. If Agency fails to maintain the required reports or documentation, or fails
to submit or resubmit any such report or documentation within such time, City shall have the right
to terminate this Contract effective immediately upon written notice of such intent with no penalty
or liability to City.
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10.2.1 In the event of termination under Section 10.2, all ESG Funds awarded but
unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds.
10.2.2 In the event of termination under Section 10.2, any ESG Funds paid to Agency
must be repaid to City within thirty (30) days of termination. If such ESG Funds are not repaid to
City within the thirty (30) day period, City shall exercise all legal remedies available under this
Contract.
10.3 In General.
10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this
Contract, Agency shall be in default under this Contract if Agency breaches any term or condition
of this Contract. In the event that such a breach remains uncured after thirty (30) calendar days
following written notice by City (or such other notice period as may be specified herein) or, if
Agency has diligently and continuously attempted to cure following receipt of such written notice
but reasonably requires more than thirty (30) calendar days to cure, as determined by both Parties
mutually and in good faith, City shall have the right to elect in City's sole discretion to (i) extend
Agency's time to cure, (ii) terminate this Contract effective immediately upon written notice of
such intent to Agency, or (iii) pursue any other legal remedies available to City under this Contract.
10.3.2 City's remedies may include:
10.3.2.1 Direct Agency to prepare and follow a schedule of actions for
carrying out the affected activities, consisting of schedules,
timetables and milestones necessary to implement the affected
activities.
10.3.2.2 Direct Agency to establish and follow a management plan that
assigns responsibilities for carrying out the remedial activities.
10.3.2.3 Reprogram ESG Funds that have not yet been expended from
affected activities to other eligible activities or withhold ESG Funds.
10.3.2.4 Any other appropriate action including but not limited to any
remedial action legally available such as declaratory judgment,
specific performance, damages, temporary or permanent
injunctions, termination of this Contract or any other contracts with
Agency, and any other available remedies.
10.3.3 In the event of termination under this Section 10.3, all ESG 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 ESG Funds already paid to Agency must be repaid to City
within thirty (30) days of the termination. Failure to repay such ESG Funds within the thirty (30)
day period will result in City exercising all legal remedies available under this Contract.
10.4 No Funds Disbursed while in Breach.
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Agency understands and agrees that no ESG Funds will be paid to Agency until all defaults
are cured to City's satisfaction.
10.5 No Compensation After Date of Termination.
Agency shall not receive any compensation for work undertaken after the date of the
termination.
10.6 Rights of Citv Not Affected.
Termination shall not affect or terminate any of the existing rights of City against Agency,
or which may thereafter accrue because of Agency's default and this provision shall be in addition
to any and all other rights and remedies available to City under the law. Such termination does
not terminate any provisions of this Contract that have been expressly noted as surviving the term
or termination of the Contract. No delay or omission by City in exercising any right or remedy
available to it under this Contract shall impair any such right or remedy or constitute a waiver or
acquiescence in any Agency default.
10.7 Waiver of Breach Not Waiver of Subsequent Breach.
The waiver of a default or breach of any term, covenant, or condition of this Contract shall
not operate as a waiver of any subsequent default or breach of the same or any other term, covenant
or condition hereof.
10.8 Civil, Criminal and Administrative Penalties.
Failure to perform all the Contract terms may result in civil, criminal or administrative
penalties, including, but not limited to those set out in this Contract.
10.9 Termination for Cause.
10.9.1 City may terminate this Contract in the event of Agency's default, inability, or
failure to perform subject to notice, grace and cure periods. In the event City terminates this
Contract for cause, all ESG 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 ESG Funds
already paid to Agency must be repaid to City within thirty (30) days of termination. Failure to
repay such ESG Funds within thirty (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 ESG FUNDS FOR A MINIMUM OF 7 YEARS FROM THE DATE OF
TERMINATION.
10.9.2 Agency may terminate this Contract if City does not provide the ESG Funds
substantially in accordance with this Contract.
10.10 Termination for Convenience.
ESG PSA CONTRACT 2025-2026 Page 19
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In terminating in accordance with 2 CFR Part 200, Appendix II, this Contract may be
terminated in whole or in part only as follows:
10.10.1 By City with the consent of Agency in which case the Parties shall agree upon
the termination conditions, including the effective date and in the case of partial termination, the
portion to be terminated; or
10.10.2 By Agency upon at least thirty (30) days written notification to City, setting
forth the reasons for such termination, the effective date, and in the case of partial termination, the
portion to be terminated. In the case of a partial termination, City may terminate the Contract in
its entirety if City determines in its sole discretion that the remaining portion of the Contract to be
performed ar ESG Funds to be spent will not accomplish the purposes for which the Contract was
made.
10.11 Dissolution of Agencv Terminates Contract.
This Contract shall terminate in the event Agency is dissolved or ceases to exist. In the
event of termination under this Section, all ESG Funds are subject to repayment and/or City may
exercise all of its remedies under this Contract.
10.12 Non-appropriation of Funds.
In the event no funds or insufiicient funds are appropriated by City in any fiscal period for
any payments due hereunder, City will notify Agency of such occurrence and this Agreement shall
terminate on the last day of the fiscal period for which appropriations were received without
penalty or expense to City of any kind whatsoever, except as to the portions of the payments herein
agreed upon for which funds have been appropriated.
10.13 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired by Agency
with the ESG 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 ESG Funds, and any real or personal property owned by Agency that was improved with the
ESG Funds shall automatically transfer to City or to such assignee as City may designate.
11. REPAYMENT OF ESG FUNDS.
All ESG Funds are subject to repayment in the event the Program does not meet the
requirements of this Contract or in the ESG Regulations. If Agency takes any action that results
in the City being required to repay all or any portion of the ESG Funds to HUD, Agency
agrees it will reimburse City within thirty days of notice from the City for such repayment.
Additionally, if Agency takes any action that results in City receiving a finding from HUD
about the Program, whether or not repayment of all or any portion of the ESG Funds is
required of City, Agency agrees City may require that 10% of the ESG Funds be repaid to
City as liquidated damages. The Parties agree that City's damages in the event of either
ESG PSA CONTRACT 2025-2026 Page 20
Lighthouse for the Homeless dba True Worth Place Rev.
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 ESG grant or other federal grant funds,
in addition to the finding by HUD or a required repayment of funds to HUD by City. Therefore,
the Parties agree that payment under this Section of 10% of the ESG Funds by Agency to City is
liquidated damages and not a penalty.
12. CHANGE IN NON-PROFIT STATUS.
Agency must provide City with written notification of any changes to its non-profit status
within fifteen (15) calendar days of being notified of the change. Regardless of notice by Agency,
if the non-profit status of Agency changes after the date of this Contract, City may but is not
obligated to, terminate this Contract. In the event of termination under this Section 12, all ESG
Funds awarded but not yet paid to Agency pursuant to this Contract shall be immediately rescinded
and Agency shall have no further right to such funds. City in its sole discretion, may require that
any ESG Funds already paid to Agency must be repaid to City within thirty (30) calendar days of
termination under this Section.
13. SURVIVAL.
Any provision of this Contract that pertains to auditing, monitoring, indemnity obligations,
client income eligibility, record keeping and reports, City ordinances, or applicable ESG
requirements, and any default and enforcement provisions necessary to enforce such provisions,
shall survive the termination of this Contract for 7 years after the Contract term ends, regardless
of whether or not this Contract is earlier terminated, and shall be enforceable by City against
Agency.
14. GENERAL PROVISIONS.
14.1 Agencv an Independent Contractor.
Agency shall operate hereunder as an independent contractor and not as an officer, agent,
servant or employee of City. Agency shall have exclusive control of, and the exclusive right to
control, the details of the work and services performed hereunder, and all persons performing
same, and shall be solely responsible for the acts and omissions of its officers, members, agents,
servants, employees, contractors, subcontractors, vendors, clients, licensees or invitees.
14.2 Doctrine of Respondeat Superior.
The doctrine of respondeat superior shall not apply as between City and Agency, ar its
officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients,
licensees or invitees, and nothing herein shall be construed as creating a partnership or joint
enterprise between City and Agency. City does not have the legal right to control the details of
the tasks performed hereunder by Agency, its officers, members, agents, employees, contractors,
subcontractors, vendors, clients, licensees or invitees.
14.3 Agencv Propertv.
ESG PSA CONTRACT 2025-2026 Page 21
Lighthouse for the Homeless dba True Worth Place Rev.
City shall under no circumstances be responsible for any property belonging to Agency, or
its officers, members, agents, employees, contractors, subcontractars, vendors, clients, licensees
or invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY
INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND
EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR
CONNECTED WITH SUCH PROPERTY.
14.4 Religious Or�anization.
Agency shall comply with all applicable requirements as more particularly described in 24
CFR Part 5.109. No portion of the ESG Funds shall be used in support of any sectarian or religious
activity. In addition, there must be no religious or membership criteria for clients of an ESG-
funded service.
14.4.1. Separation of Explicitiv Religious Activities.
Agency retains its independence and may continue to carry out its mission, including the
definition, development practice, and expression of its religious beliefs, provided that it does not
use ESG Funds to support or engage in any explicitly religious activities (including activities that
involve overt religious content such as worship, religious instruction, or proselytization), or in any
other manner prohibited by law.
14.4.2 Explicitiv Religious Activities.
If Agency engages in explicitly religious activities (including activities that involve overt
religious content such as worship, religious instruction, or proselytization), the explicitly religious
activities must be offered separately, in time or location, from the programs or activities supported
by ESG Funds and participation must be voluntary for clients of an ESG-funded service.
14.4.3 Required Notices.
If Agency constitutes a Faith-based organization under 24 CFR Part 5.109, Agency must
provide all clients of an ESG-funded service with the notice attached as EXHIBIT "L"—Notice
of Beneficiary Rights. Such notice shall be provided to the client prior to enrollment in any ESG-
funded program or activity. In addition, if a client or prospective client of an ESG-funded service
objects to the religious character of Agency, then Agency must promptly undertake reasonable
efforts to identify and refer the client or prospective client to an alternate provider to which the
client or prospective client has no such objection, as more particularly described in 24 CFR Part
5.109.
14.5 Venue.
Venue shall lie in state courts in Tarrant County, Texas or the United States District
Court for the Northern District of Texas, Fort Worth Division for any action, whether real ar
asserted, at law or in equity, arising out of the execution, performance, attempted performance or
non-performance of this Contract.
ESG PSA CONTRACT 2025-2026 Page 22
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14.6 Governin� Law.
This Contract sha11 be governed by and construed in accordance with the laws of the State
of Texas. If any action, whether real or asserted, at law or in equity, arises out of the execution,
performance or non-performance of this Contract or on the basis of any provision herein, for any
issue not governed by federal law, the choice of law shall be the laws of the State of Texas.
14.7 Severabilitv.
The provisions of this Contract are severable, and if for any reason a clause, sentence,
paragraph or other part of this Contract shall be determined to be invalid by a court or federal or
state agency, board or commission having jurisdiction over the subject matter thereof, such
invalidity shall not affect other provisions which can be given effect without the invalid provision.
14.8 Written A�reement 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 concerning the work and services to be performed under this
Contract. Any prior or contemporaneous oral or written agreement which purports to vary the
terms of this Contract shall be void. Any amendments to the terms of this Contract must be in
writing and executed by the Parties.
14.9 Paragrauh Headin�s for Reference Onlv, No Le�al Significance; Number
and Gender.
The paragraph headings contained herein are for convenience in reference to this Contract
and are not intended to define or to limit the scope of any provision of this Contract. When context
requires, singular nouns and pronouns include the plural and the masculine gender shall be deemed
to include the feminine or neuter and the neuter gender to include the masculine and feminine.
The words "include" and "including" whenever used herein shall be deemed to be followed by the
words "without limitation".
14.10 Compliance with All Applicable Laws and Regulations.
Agency agrees to comply fully with all applicable laws and regulations that are currently
in effect or that are hereafter amended during the performance of this Contract. Those laws
include, but are not limited to:
➢ ESG Regulations found in 24 CFR Part 576
➢ Subtitle B of Title IV of the McKinney-Vento Homeless Assistance Act, as amended,
(42 USC 11371)
➢ Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including
provisions requiring recipients of federal assistance to ensure meaningful access by
persons of limited English proficiency
➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections
ESG PSA CONTRACT 2025-2026 Page 23
Lighthouse for the Homeless dba True Worth Place Rev.
3601 et seq.)
➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented
by Department of Labor regulations 41 CFR Part 60
➢ The Age Discrimination in Employment Act of 1967
➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 etseq.)
➢ The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
(42 U.S.C. Sections 4601 et seq. and 49 CFR Part 24) ("URA")
➢ Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.) and 24
CFR Part 8 where applicable
➢ National Environmental Policy Act of 1969, as amended, 42 U.S.C. Sections 4321 et
seq. ("NEPA") and the related authorities listed in 24 CFR Part 58.
➢ The Clean Air Act, as amended, (42 U.S.C. Sections 1251 et seq.) and the Clean Water
Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.) and the related Executive
Order 11738. In no event shall any amount of the assistance provided under this
Contract be utilized with respect to a facility that has given rise to a conviction under
the Clean Air Act or the C1ean Water Act.
➢ Immigration Reform and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.)
specifically including the provisions requiring employer verifications of legal status of
its employees
➢ The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.), the
Architectural Barriers Act of 1968 as amended (42 U.S.C. Sections 4151 et seq.) and
the Uniform Federal Accessibility Standards, 24 CFR Part 40, Appendix A
➢ Regulations at 24 CFR Part 87 related to lobbying, including the requirement that
certifications and disclosures be obtained from all covered persons
➢ Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part
23, Subpart F
➢ Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on
participation by ineligible, debarred or suspended persons or entities
➢ Section 6002 of the Solid Waste Disposal Act, as amended by the Resource
Conservation and Recovery Act
➢ Guidelines of the Environmental Protection Agency at 40 CFR Part 247
➢ For contracts and subgrants for construction or repair, Copeland "Anti-Kickback" act
(18 U.S.C. 874) as supplemented in 29 CFR Part 5
➢ For construction contracts awarded by Agency in excess of $2,000, and in excess of
$2,500 for other contracts which involve the employment of inechanics or laborers,
Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C.
327A 300) as supplemented by 29 CFR Part 5
➢ Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as amended by
the Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et
seq.) and implementing regulations at 24 CFR Part 35, subparts A, B, M, and R
➢ Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards, 2 CFR Part 200 et seg.
➢ Federal Funding Accountability and Transparency Act of 2006 ("FFATA") (Pub.L.
109-282, as amended by Section 6205(a) of Pub.L. 110-252 and Section 3 of Pub.L.
113-101)
➢ Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712,
10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
ESG PSA CONTRACT 2025-2026 Page 24
Lighthouse for the Homeless dba True Worth Place Rev.
➢ The Build America, Buy America Act (BABA) enacted under Division G, Title IX of
the Infrastructure Investment and Jobs Act (IIJA, Pub. L. No. 117-58) signed into law
on November 15, 2021.
➢ General Administrative, National, and Departmental Policy Requirements and Terms
for HUD's Financial Assistance Programs (2025), as referenced in the Notice of
Funding Opportunity (NOFO) for this award.
➢ Compliance with OMB requirements on the Unique Entity Identifier (UEI) and
SAM.gov registration, as well as reporting under 2 CFR Part 25 and Part 170.
➢ Adherence to a11 applicable requirements related to noncompliance and termination, as
described in 2 CFR §§ 200.339-200.340.
➢ Report suspected fraud, waste, and abuse to HUD and the Office of Inspector General
(OIG), and to inform employees of their protections under 41 U.S.C. § 4712.
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14.12 Prohibition A�ainst Discrimination.
14.12.1 General Statement.
Agency shall comply in the execution, performance or attempted performance of this
Contract, with all non-discrimination requirements of 24 CFR Part 570.607 and Chapter 17, Article
III, Division 4— Fair Housing of the City Code. Agency may not discriminate against any person
because of race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression, or transgender, nor will Agency
permit its officers, members, agents, employees, ar clients to engage in such discrimination.
This Contract is made and entered into with reference specifically to Chapter 17, Article
III, Division 3- E�nployment Practices of the City Code, and Agency hereby covenants and agrees
that Agency, its officers, members, agents, employees and contractors, have fully complied with
all provisions of same and that no employee, or applicant for employment has been discriminated
against under the terms of such ordinances by either or its officers, members, agents, employees
or contractors.
14.12.2 No Discrimination in Emplovment durin� the Performance of This
Contract.
During the performance of this Contract Agency agrees to the following provision, and
will require that its contractors and subcontractors also comply with such provision by including
it in all contracts with its contractors:
[Contractor's, Subcontractor's or Vendor's name] will not unlawfully discriminate against
any employee or applicants for employment because of race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender. �Contractor's, Subcontractor's or Vendor's name� 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
ESG PSA CONTRACT 2025-2026 Page 25
Lighthouse for the Homeless dba True Worth Place Rev.
identity, gender expression or transgender and that employees are treated fairly during employment
without regard to their race, color, sex, gender, religion, national origin, familial status, disability
or perceived disability, sexual orientation, gender identity, gender expression or transgender. Such
action shall include, but not be limited to, the following: employment, upgrading, demotion or
transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other forms
of compensation, and selection for training, including apprenticeship. [Contractor's.
Subcontractor's or Vendor's namel agrees to post in conspicuous places, available to employees
and applicants for employment, notices setting forth the provisions of this nondiscrimination
clause.
�Contractor's, Subcontractor's or Vendor's name� will, in all solicitations or
advertisements for employees placed by or on behalf of �Contractor's, Subcontractor's or
T�endor's nainel , state that all qualified applicants will receive consideration for employment
without regard to race, color, sex, gender, religion, national origin, familial status, disability or
perceived disability, sexual orientation, gender identity, gender expression or transgender.
�Contractor's, Subcontractor's or Vendor's naine] covenants that neither it nor any of its
ofiicers, members, agents, employees, or contractors, while engaged in performing this Contract,
shall, in connection with the employment, advancement or discharge of employees or in
connection with the terms, conditions or privileges of their employment, discriminate against
persons because of their age or because of any disability or perceived disability, except on the
basis of a bona fide occupational qualification, retirement plan or statutory requirement.
�Contractor's, Subcontractor's or T�endor's naine� further covenants that neither it nor its
ofiicers, members, agents, employees, contractors, or persons acting on their behalf, shall specify,
in solicitations or advertisements for employees to work on this Contract, a maximum age limit
for such employment unless the specified maximum age limit is based upon a bona iide
occupational qualification, retirement plan or statutory requirement.
14.12.3 Agencv's Contractors and the ADA.
In accordance with the provisions of the Americans With Disabilities Act of 1990
("ADA"), Agency warrants that it and any of its contractors will not unlawfully discriminate on
the basis of disability in the provision of services to the general public, nor in the availability, terms
andlor conditions of employment for applicants for employment with, or employees of, Agency or
any of its contractors. AGENCY WARRANTS IT WILL FULLY COMPLY WITH THE
ADA'S PROVISIONS AND ANY OTHER APPLICABLE FEDERAL, STATE AND
LOCAL LAWS CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND
HOLD CITY HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY
THIRD PARTIES, CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS
AGAINST CITY ARISING OUT OF AGENCY'S AND/OR ITS CONTRACTORS',
SUBCONTRACTORS', VENDORS' OR AGENTS' OR THEIR RESPECTIVE
EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE-REFERENCED
LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF
THIS CONTRACT.
14.13 Conflicts of Interest and Violations of Criminal Law.
ESG PSA CONTRACT 2025-2026 Page 26
Lighthouse for the Homeless dba True Worth Place Rev.
14.13.1 Agencv Safeguards.
Agency shall establish safeguards to prohibit its employees, board members, advisors and
agents from using positions for a purpose that is or gives the appearance of being motivated by a
desire for private gain for themselves or others, particularly those with whom they have family,
business or other ties. Agency shall disclose to City any such conflict of interest or potential
conflict of interest, immediately upon discovery of such.
14.13.2 General Prohibitions Against Conflicts of Interest.
No employees, agents, consultants, officers or elected officials or appointed officials of
City or of Agency who exercise or have exercised any functions or responsibilities with respect to
activities assisted with ESG 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 ESG services, may
obtain a financial interest or benefit from a ESG-assisted activity, or have an interest in any
contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for
themselves or those with whom they have family or business ties, during their tenure or for 1 year
thereafter.
14.13.2.1 Agency shall establish conflict of interest policies for federal awards
including the ESG Funds and shall disclose in writing potential
conflicts of interest to City as authorized by 2 CFR Part 200.112.
14.13.3 Conflicts of Interest Involvin� Procurement.
The conflict of interest provisions of 2 CFR Part 200.318 shall apply in the procurement
of property and services by Agency. In all cases not governed by this Section, the provisions of
24 CFR Part 576.57(d) of the ESG Regulations shall apply.
14.13.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall
maintain and submit to City written standards of conduct covering
conflicts of interest and governing the performance of its employees
engaged in the selection, award, and administration of contracts. No
employee, ofiicer, or agent may participate in the selection, award,
or administration of a contract supported by a federal award if he or
she has a real or apparent conflict of interest. The standards of
conduct must provide for disciplinary actions to be applied for
violations of such standards by officers, employees, or agents of
Agency.
14.13.3.2 The officers, employees, and agents of Agency shall neither solicit
nor accept gratuities, favors, or anything of monetary value from
contractors or parties to subcontracts.
14.13.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2,
Agency may set standards of conduct for situations in which the
financial interest is not substantial or the gift is an unsolicited item
of nominal value. Such standards of conduct must provide for
ESG PSA CONTRACT 2025-2026 Page 27
Lighthouse for the Homeless dba True Worth Place Rev.
disciplinary actions to be applied for violations of such standards by
Agency's officers, employees or agents.
14.13.3.4 Agency shall maintain written standards of conduct covering
organizational conflicts of interest. Organizational conflicts of
interest means that because of relationships with a parent company,
affiliate, or subsidiary organization, Agency is unable or appears to
be unable to be impartial in conducting a procurement action
involving a related organization.
14.13.3.5 Agency must maintain records sufficient to detail the history of
procurement. These records will include, but are not necessarily
limited to the following: rationale for the method of procurement,
selection of contract type, contractor selection or rejection, and the
basis for the contract price.
14.13.4 Disclosure of Conflicts of Interest.
In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in
writing any potential conflict of interest.
14.13.5 Disclosure of Conflicts of Interest for Agencv Clients.
Agency understands that its clients will be receiving assistance partially or fully funded
utilizing Housing and Urban Development (HUD) funds received by City. Agency will assist City
in determining whether eligible clients have a potential relationship to the City that constitutes a
conflict of interest by having clients fill out the Conflict of Interest Disclosure Form, attached
hereto as Exhibit "P". In the event a conflict of interest exists, this may affect the client's
eligibility to receive services. As a result, if a potential client provides information on the form
that a conflict may exist, Agency must notify City for a determination prior to providing services.
14.13.6 Disclosure of Texas Penal Code Violations.
Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit
bribery and gifts to public servants. Agency will timely disclose to City all violations.
14.13.7 Disclosure of Federal Criminal Law Violations.
In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all
violations of federal criminal law involving fraud, bribery or gratuity violations potentially
affecting the Agency.
14.14 Subcontracting with Small and Minoritv Firms, Women's Business
Enterprises and Labor Surplus Areas.
14.14.1 For procurement contracts $100,000.00 or larger that are paid for, in part or in
full, with the ESG Funds, Agency agrees to abide by City's policy to involve Minority Business
Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for
ESG PSA CONTRACT 2025-2026 Page 28
Lighthouse for the Homeless dba True Worth Place Rev.
contracts for construction, provision of professional services, purchase of equipment and
supplies and provision of other services required by City. To the extent applicable, Agency
agrees to comply with all City Ordinances, and all amendments or successor policies or
ordinances thereto, into all contracts and subcontracts for procurement larger than $100,000.00
or larger that are paid for, in part or in full, with the ESG Funds 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.
14.14.2.1 In order to comply with federal reporting requirements in 24 CFR
Part 570.506 (g)(6), Agency must submit the form attached hereto
as EXHIBIT "K" — MBE Reporting Form for each contract or
subcontract with a value of $25,000.00 or more paid or to be paid
with the ESG Funds. Agency shall submit this form by the date
specified in EXHIBIT "K" — MBE Reporting Form.
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 follow 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 City. Any attempted assignment of same without approval
shall be void, and shall constitute a breach of this Contract.
14.17 Ri�ht to Inspect A�encv Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed contracts
between Agency and any contractor or vendor engaged in any activity in conjunction with this
ESG-funded Program prior to any charges being incurred.
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, pandemics, earthquakes, fires, floods,
restraints or prohibitions by any court, board, department, commission or agency of the United
States or of any States, civil disturbances, or explosions, or some other reason beyond Agency's
control (collectively, "Force Majeure Event"), the obligations so affected by such Force Majeure
ESG PSA CONTRACT 2025-2026 Page 29
Lighthouse for the Homeless dba True Worth Place Rev.
Event will be suspended only during the continuance of such event. Agency will give City written
notice of the existence, extent and nature of the Force Majeure Event as soon as reasonably
possible after the occurrence of the event. Failure to give notice will result in the continuance of
Agency's obligation regardless of the extent of any existing Force Majeure Event. Agency will
use commercially reasonable efforts to remedy its inability to perform as soon as possible.
14.19 IMMIGRATION NATIONALITY ACT.
Agency shall verify the identity and employment eligibility of its employees who perform
work under this Contract, including completing the Employment Eligibility Verification Form (I-
9). Upon request by City, Agency shall provide City with copies of all I-9 forms and supporting
eligibility documentation for each employee who performs work under this Contract. Agency
shall adhere to all Federal and State laws as well as establish appropriate procedures and controls
so that no services will be performed by any Agency employee who is not legally eligible to
perform such services. AGENCY SHALL INDEMNIFY CITY AND HOLD CITY
HARMLESS FROM ANY PENALTIES, LIABILITIES, OR LOSSES DUE TO
VIOLATIONS OF THIS PARAGRAPH BY AGENCY, AGENCY'S EMPLOYEES,
SUBCONTRACTORS, AGENTS, OR LICENSEES. City, upon written notice to Agency, shall
have the right to immediately terminate this Contract for violations of this provision by Agency.
15. INDEMNIFICATION AND RELEASE.
AGENCY COVENANTS AND AGREES TO INDEMNIFY, HOLD HARMLESS
AND DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS, AGENTS,
SERVANTS AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR
SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY,
INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER KIND OR
CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE
OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED
HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART, BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS
OR SUBCONTRACTORS OF CITY; AND AGENCY HEREBY ASSUMES ALL
LIABILITY AND RESPONSIBILITY OF CITY AND ITS OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES FOR ANY AND ALL CLAIMS OR SUITS FOR
PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH,
TO ANY AND ALL PERSONS, OF WHATSOEVER KINDS OR CHARACTER,
WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH
THE EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS,
ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER
OR NOT CAUSED IN WHOLE OR IN PART BY ALLEGED NEGLIGENCE OF
OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR
SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND AGREES TO
AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS CITY FROM AND
AGAINST ANY AND ALL INJURY, DAMAGE OR DESTRUCTION OF PROPERTY OF
ESG PSA CONTRACT 2025-2026 Page 30
Lighthouse for the Homeless dba True Worth Place Rev.
CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF
AGENCY, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS, INVITEES, LICENSEES, OR CLIENTS, OR CAUSED, IN
WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS,
SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY.
IT IS THE EXPRESS INTENTION OF THE PARTIES, BOTH AGENCY AND
CITY, THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES
INDEMNITY BY AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE
CONSEQUENCES OF CITY'S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE
IS ALLEGED TO BE THE SOLE OR CONCURRING CAUSE OF THE INJURY,
DAMAGE OR DEATH.
AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY
FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY
SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER
THIS CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED
BY CITY'S SOLE OR CONCURRENT NEGLIGENCE.
AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND
SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS
A RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME
FORM AS ABOVE.
16. WAIVER OF IMMUNITY BY AGENCY.
If Agency, as a charitable or nonprofit organization, has or claims an immunity or
exemption (statutory or otherwise) from and against liability for damages or injury, including
death, to persons or property, Agency hereby expressly waives its rights to plead defensively such
immunity or exemption as against City. This Section shall not be construed to affect a
governmental entity's immunities under constitutional, statutory or common law.
17. INSURANCE AND BONDING.
Agency will maintain coverage in the form of insurance or bond in the amount of
$150,000.00 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 ESG Funds occasioned by such misconduct. To effectuate
such reimbursement, such fidelity coverage shall include a rider stating that reimbursement for
any loss or losses shall name the City as a Loss Payee.
Agency shall furnish to City in a timely manner, but not later than the Effective Date,
certificates of insurance as proof that it has secured and paid for policies of commercial insurance
as specified herein. If City has not received such certificates by the Effective Date, Agency shall
be in default of the Contract and City may, at its option, terminate the Contract.
ESG PSA CONTRACT 2025-2026 Page 31
Lighthouse for the Homeless dba True Worth Place Rev.
Such insurance shall cover all insurable risks incident to or in connection with the
execution, performance, attempted performance or nonperformance of this Contract. Agency shall
maintain the following insurance coverage and limits:
Commercial General Liabilitv (CGL) Insurance
$ 500,000 each occurrence
$1,000,000 aggregate limit
Non-Profit Or�anization Liabilitv or Directors & Officers Liabilitv
$1,000,000 Each Occurrence
$1,000,000 Annual Aggregate Limit
Business Automobile Liability Insurance
$1,000,000 each accident on a combined single-limit basis, or
$ 250,000 Property Damage
$ 500,000 Bodily Injury per person per occurrence
$2,000,000 Aggregate
Insurance policy shall be endorsed to cover "Any Auto", 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 sha11 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 thirty (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.
ESG PSA CONTRACT 2025-2026 Page 32
Lighthouse for the Homeless dba True Worth Place Rev.
Where applicable, insurance policies required herein shall be endorsed to include City as an
additional insured as its interest may appear. Additional insured parties shall include employees,
officers, agents, and volunteers of City.
Any failure on part of City to request certificate(s) of insurance shall not be construed as a waiver
of such requirement or as a waiver of the insurance requirements themselves.
Insurers of Agency's insurance policies shall be licensed to do business in the state of Texas by
the Department of Insurance or be otherwise eligible and authorized to do business in the state of
Texas. Insurers shall be acceptable to City insofar as their financial strength and solvency and
each such company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII
or other equivalent insurance industry standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise
approved by City.
In the event there are any local, federal or other regulatory insurance or bonding requirements for
the Program, and such requirements exceed those specified herein, the former shall prevail.
Agency shall require its contractors to maintain applicable insurance coverages, limits, and other
requirements as those specified herein; and Agency shall require its contractors to provide Agency
with certificate(s) of insurance documenting such coverage. Also, Agency shall require its
contractors to have City and Agency endorsed as additional insureds (as their interest may appear)
on their respective insurance policies.
Directors and Officers Liability coverage shall be in force and may be provided on a claims-made
basis. This coverage may also be referred to as Management Liability, and shall protect the insured
against claims arising out of alleged errors in judgment, breaches of duty and wrongful acts arising
out of their organizational duties. Coverage shall protect not only the entity, but all past, present
and future directors, officers, trustees, employees, volunteers and committee members.
Notwithstanding any provision in this Contract to the contrary, when applicable, Agency
shall comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the
equivalent insurance coverage for real property and equipment acquired or improved with
ESG Funds as provided to property owned by Agency.
18. CERTIFICATION REGARDING LOBBYING.
The undersigned representative of Agency hereby certifies, to the best of his or her
knowledge and belief, that:
No federal appropriated funds have been paid or will be paid, by or on behalf of Agency,
to any person for influencing or attempting to influence an officer or employee of any
agency, a member of Congress, an officer or employee of Congress in connection with the
awarding of any federal contract, the making of any federal grant, the making of any federal
loan, the entering into of any cooperative agreement and the extension, continuation,
ESG PSA CONTRACT 2025-2026 Page 33
Lighthouse for the Homeless dba True Worth Place Rev.
renewal, amendment, or modification of any federal contract, grant, loan or cooperative
agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency,
member of Congress in connection with this federal contract, grant, loan or cooperative
agreement, Agency shall complete and submit Standard Form-LLL, "Disclosure Form to
Report Lobbying," in accordance with its instructions.
This certification is a material representation of fact upon which reliance was placed when
this Contract was made or entered into. Submission of this certificate is a prerequisite for
making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person
who fails to iile the required certification shall be subject to a civil penalty of not less than
$10,000.00 and not more than $100,000.00 for each such failure.
Agency shall require that the language of this certification be included in all subcontracts or
agreements involving the expenditure of federal funds.
19. LITIGATION AND CLAIMS.
Agency shall give City immediate notice in writing of any action, including any proceeding
before an administrative agency, filed against Agency in conjunction with this Contract or the
Program. Agency shall furnish immediately to City copies of all pertinent papers received by
Agency with respect to such action or claim. Agency shall provide a notice to City within ten (10)
days upon filing under any bankruptcy or iinancial 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.
City
City Attorney's Office
100 Fort Worth Trail
Fort Worth, TX 76102
Telephone: 817-392-7600
Copv to:
Neighborhood Services Department
100 Fort Worth Trail
Fort Worth, TX 76102
Attention: Kacey Thomas
Telephone: 817-392-7540
ESG PSA CONTRACT 2025-2026 Page 34
Lighthouse for the Homeless dba True Worth Place Rev.
Copv to:
Neighborhood Services Department
100 Fort Worth Trail
Fort Worth, TX 76102
Attention: Jaylon Scott
Telephone: 817-392-5118
A�encv:
Agency Name: Lighthouse for the Homeless dba True Worth Place
Contact: Toby Owen
Address: 2400 Cypress Street
Fort Worth, TX 76102
Telephone: 817-632-7440
21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT.
Agency represents that it possesses the legal authority, pursuant to any proper, appropriate
and official motion, resolution or action passed or taken, to enter into this Contract and to perform
the responsibilities herein required.
22. COUNTERPARTS.
This Contract may be executed in multiple counterparts, each of which shall be considered
an original, but all of which shall constitute one instrument which may be sufficiently evidenced
by one counterpart.
23. PROGRAM INCOME
Parties agree that no program income as defined by HUD shall be earned as a result of this
contract.
24. PROHIBITION ON CONTRACTING WITH COMPANIES THAT BOYCOTT
ISRAEL
If Agency has less than ten employees, this contract is for less than $100,000, or Agency
does not meet the definition of a"company" under the applicable section of the Texas Government
Code, this provision sha11 not apply. Agency acknowledges that in accordance with Chapter 2270
of the Texas Government Code, the City is prohibited from entering into a contract with a company
for goods or services unless the contract contains a written verification from the company that it:
(1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract. The
terms "boycott Israel" and "company" shall have the meanings ascribed to those terms in Section
808.001 of the Texas Government Code. By signing this contract, Agency certifies that Agency's
signature provides written verification to the City that Agency: (1) does not boycott Israel; and (2)
will not boycott Israel during the term of the contract.
25. PROHIBITION ON BOYCOTTING ENERGY COMPANIES
« ESG PSA CONTRACT 2025-2026 Page 35
Lighthouse for the Homeless dba True Worth Place Rev.
Agency acknowledges that in accordance with Chapter 2274 of the Texas Government
Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2, the City is prohibited from entering
into a contract for goods or services that has a value of $100,000 or more that is to be paid wholly
or partly from public funds of the City with a company with 10 or more full-time employees unless
the contract contains a written verification from the company that it: (1) does not boycott energy
companies; and (2) will not boycott energy companies during the term of the contract. The terms
"boycott energy company" and "company" have the meaning ascribed to those terms by Chapter
2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2. To the
extent that Chapter 2274 of the Government Code is applicable to this Agreement, by signing this
Agreement, Agency certifies that Agency's signature provides written verification to the City that
Agency: (1) does not boycott energy companies; and (2) will not boycott energy companies during
the term of this Agreement.
26. PROHIBITION ON DISCRIMINATION AGAINST FIREARM AND
AMMUNITION INDUSTRIES
Agency acknowledges that except as otherwise provided by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1, the City is prohibited
from entering into a contract far goods or services that has a value of $100,000 or more that is to
be paid wholly or partly from public funds of the City with a company with 10 or more full-time
employees unless the contract contains a written verification from the company that it: (1) does
not have a practice, policy, guidance, or directive that discriminates against a firearm entity or
firearm trade association; and (2) will not discriminate during the term of the contract against a
firearm entity or firearm trade association. The terms "discriminate," "firearm entity" and "firearm
trade association" have the meaning ascribed to those terms by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1. To the extent that Chapter
2274 of the Government Code is applicable to this Agreement, by signing this Agreement, Agency
certifies that Agency's signature provides written verification to the City that Agency: (1) does not
have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm
trade association; and (2) will not discriminate against a firearm entity or firearm trade association
during the term of this Agreement.
27. ELECTRONIC SIGNATURES
This Contract may be executed by electronic signature, which will be considered as an
original signature for all purposes and have the same force and effect as an original signature. For
these purposes, "electronic signature" mean electronically scanned and transmitted versions (e.g.
via pdf file or facsimile transmission) of an original signature, or signatures electronically inserted
via software such as Adobe Sign.
[SIGNATURES APPEAR ON NEXT PAGE]
« ESG PSA CONTRACT 2025-2026 Page 36
Lighthouse for the Homeless dba True Worth Place Rev.
IN WITNESS WHEREOF, the Parties hereto have this Contract in Fort Worth, Tarrant
County, Texas.
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Assistant City Manager
M&C: M&C 25-0676
Date: August 12, 2025
1295 Certification No. 2025-1269233
RECOMMENDED BY:
����"�
Kacey Thomas
Neighborhood Services Director
APPROVED AS TO FORM AND LEGALITY:
so�Gcr'e Ma�l�ewJ
Sophie Mathews
Assistant City Attorney
CONTRACT COMPLIANCE ADMINISTRATOR:
By signing, I acknowledge that I am the person responsible
for the monitoring and administration of this contract, including
ensuring all performance and reporting requirements
/�a�e� �c.e�t
ir
Jaylon Scott, Neighborhood Development Specialist
LIGHTHOUSE FOR THE HOMELESS DBA TRUE WORTH PLACE
��—
Tobv Owen (Jan 14, 2026 09:35:42 CSTI
(]FFICIAL RECORD
Toby Owen, CEO
« ESG PSA CONTRACT 2025-2026 Page 37
Lighthouse for the Homeless dba True Worth Place
CITY SECRETARY
FT. WORTH, TX
Rev.
EXHIBITS:
EXHIBIT "A" —Program Summary
EXHIBIT "A-1" — 2025 HUD Income Limits
EXHIBIT "B" — Budget
EXHIBIT "C" — Audit Certification Form
EXHIBIT "D" — Reimbursement Forms
EXHIBIT "E" — Self-Certification of Income Form
EXHIBIT "F" — Standards for Complete Documentation
EXHIBIT "G" — Match Report
EXHIBIT "H" — ESG Staff Certification Form
EXHIBIT "I" — ESG Performance Standards
EXHIBIT "I-1"—Written Standards for ESG Assistance
EXHIBIT "J" — ESG CAPER Report
EXHIBIT "K" — MBE Reporting Form
EXHIBIBT "L" --Notice of Beneficiary Rights
EXHIBIT "M"—Written Standards for Maintenance of Personally Identifying
Information
EXHIBIT "N"—Notice of Occupancy Rights Under VAWA
EXHIBIT "O"—VAWA Emergency Transfer Request Form
EXHIBIT "P" — Conflict of Interest Disclosure Form
EXHIBIT "Q" — Certificate of Compliance: Additional Program-Specific Policy
Requirements
« ESG PSA CONTRACT 2025-2026 Page 38
Lighthouse for the Homeless dba True Worth Place Rev.
Lighthouse for the Homeless
True Worth Place
PROGRAM SUMMARY
Emergency Solutions Grant
(ESG)
EXHIBIT "A"
October l, 2025 to September 30, 2026 $150,000
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
True Worth place is a day shelter and resource facility for persons 18 years and older
experiencing homelessness. True Worth Place provides services from 7:OOam to 3:OOpm 365
days a year to any adult who presents with a need for day shelter services or needs to access
community resources available on site. True Worth Place provides a safe place for guests to
escape extreme or inclement weather, receive basic services, and offers an array of instructional
programming to guests.
ESG Funds will support staff salaries for essential day-shelter services including four Journey
Home Advocates, Guest Coordinator, FICA, and a small portion of utilities until City ESG funds
are depleted. The percentage of any Program employee's salary will not exceed the percentage of
clients participating in the program and shall be cost allocated in accordance with the amount
applicable to the ESG funded Program.
Basic services provided in the facility include access to bathrooms and showers, day storage for
belongings, laundry, medication storage, access to over-the-counter medication, mail service,
phone use, safe keeping for critical documents, computer access, and lunch.
Services at True Worth Place link guests to other critical services and resources such as public
benefits, housing, employment services, health and mental health care, critical document
assistance, and substance abuse treatment.
Instructional programming includes skills classes, educational courses, recovery and therapeutic
groups, and recreational activities.
As a resource facility and partner in the efforts to end homelessness, True Worth Place provides
partner agencies with space and tools to increase service accessibility for guests.
Shelter services are available 7 days per week, 365 days per year at 1513 E. Presidio Street, Fort
Worth, TX 76102.
Agency shall not change any locations without prior City written approval. Costs incurred at any
locations that have not been approved by City shall not be reimbursed. Service location revisions
will trigger the City's Citizen Participation Plan and will require a 30-day public notice.
Agency will provide a monthly match contribution to supplement the ESG program in an amount
that equals the Agency's recipient's fiscal year grant for ESG as required by 24 CFR 576.201.
ESG PSA CONTRACT 2025-2026 — EXHIBIT "A" — PROGRAM SUMMARY
Lighthouse for the Homeless — True Worth Place
Page 1
REGULATORY CLASSIFICATION:
Service Category (if more than one category, specify amount for each): ESG Emergency
Shelter
Component
Regulatory Citation(s): 24 CFR 576.102(3)
PROGRAM GOALS:
Minimum Number of Fort Worth Clients to be Served: The Program must serve
approximately 3,375 Unduplicated Clients from Fort Worth as shown by the monthly reports on
Attachment III-Client Data Report.
OTHER AGENCY REOUIREMENTS:
Upon completion of the program year, Agency will provide, with the final reimbursement
request, client surveys and HMIS reports, personal narratives, and other collected data to
measure client success.
ESG PSA CONTRACT 2025-2026 — EXHIBIT "A" — PROGRAM SUMMARY
Lighthouse far the Homeless — True Warth Place
Page 2
EXHIBIT "A-1"
2025 HUD INCOME LIMITS
AMI
30%
50%
80%
1 person 2 people 3 people
$22,400 $25,600 $28,800
$37,350 $42,700 $48,050
$59,750 $68,300 $76,850
4 people
$32,200
$53,350
$85,350
5 people
$ 34, 600
$57,650
$92,200
*Income limits are published at least annually by HUD.
6 people
$37,150
$61,900
$99,050
7 people
$39,700
$66,200
$105,850
8 people
$42,250
$70,450
$112,700
Effective 6/01/2025
EXHIBIT "B"
BUDGETS
EXHIBIT "B" - BUDGET
Aceou Grant A B C
nt Bud�et
EMERGENCYSHELTER
�ESSENTIAL SERVICES
�Salaries 1001 $ 125,121.00 $ 715,131.00
�FICA 1002 $ 9,572.00 $ 57,060.00
�Life/DisabiliryInsurance 1003
�Health/Dental Insurance 1004 $ 13,342.00 $ 56,658.00
�Unemployment-State 1005
� Worker's Compensarion 1006 $ 9,211.00
�Office Supplies 1007
�Food Supplies 1008
�Insurance 1009
� Accounting 1010
� Contract Labar Security (City needs 1011
�Other 1012 $ 2,000.00
� SHELTER OPERATIONS
� Maintenance 2001
� Securiry 2002
� Vehicle Expenses 2003
�Utilities 2004 $ 1,965.00 $ 22,637.00 $ 115,898.00
� Supplies 2005
�Technology 2006
�Other 2007 $ 20,000.00 $ 228,658.00
� SUBTOTAL EMERGENCY $ 150,000.00 $ 22,637.00 � 20,000.00 � t,784,616.00
HOUSING RELOCATION AND STABILIZATION
� Salaries
� FICA
� Life/Disabiliry Insurance
� Health/Dental Insurance
�Unemployment-State
� Worker's Compensation
� OtherQ
� REHOUSING
� Salaries
� FICA
�Life/Disability Insurance
� Health/Dental Insurance
� Unemployment-State
� Worker's Compensation
� HRA
� Reti rement
� Parking
�Mileage
� Rental Asistance/Securiry Deposits
�Utility Deposits/Payments
�Other. (Program supplies and
�Other (Fringe Benefits): Parking,
�
SUBTOTAL HR&S
3001
3002
3003
3004
3005
3006
3007
4001
4002
4003
4004
4005
4006
4007
4008
4009
4010
4011
Total
$ 840,252.00
$ 66,632.00
$ 70,000.00
$ 9,211.00
$ 2,000.00
$ 140,500.00
$ 248,658.00
� 1.377.253Ai
$ -
$ $ -
$ -
$ • $ $ $
FINANCIAL ASSISTANCE
�Rental Assistance
�Utility Payments
� REHOUSING
�Rental Assistance
� Securiry Deposits
5001
5002
6001
6002
.� -
$ -
$ -
Utiliry Deposits 6003 $ -
Uriliry Payments 6004 $ -
Moving Costs 6005 $ -
Motcl/Hotcl Vouchcrs 6006
SUBTOTAL FINANCIAL $ $ $ $ -
HOMELESS MANAGEMENT INFORMATION SYSTEM (HMIS)
HMIS Software Costs 7001
SUBTOTAL HMIS
BUDGET TOTAL $150,000.00 $ 22,637.00 $ 20,000.00 � 1,184,616.00 $ 1,377,253.00
FLTNDING A: Tarrant County - ESG FLJNDING B: DH - DCSF
ESG PSA CONTRACT 2025-2026 - EXHIBIT "B" - Lighthouse far the Homeless, dba True Worth Place
The following tables were created for the purpose of preparing, negotiating, and determining the cost
SALARY DETAIL
Positiou Title Annual Salary Est. Percent to Amount to
Journey Home Advocate $ 32,614.00 85% $ 27>722.00
Journey Home Advocate $ 26,478.00 85% $ 22,507.00
Journey Home Advocate $ 25,709.00 85% $ 21,852.00
Journey Home Advocate $ 35,360.00 85% $ 30,056.00
Guest Coordinator $ 27,040.00 85% $ 22,984.00
Program Staff $ 693,051.00
TOTAL $ 840,252.00 14.9% $ 125,121.00
'�'�*Staff will be charged (a�, 100% until budget is depleted.'���
Percent of Amount Est. Percent to Amount to
FICA $ 66,632.00 14% $ 9,572.00
Life/Disabiliry Insurance
Health/Dental Insurance
Unemployment-State
Worker's Compensation
HRA
Retirement
Parking
Mileage
Other
TOTAL
Office Supplies
Food Supplies
TOTAL
Insurance
Accounting
Contract Labor (Security)
OtherQ
TOTAL
Maintenance
Security
Insurance
Uriliries
Supplies
Repairs
Other
TOTAL
Rental Assistance
Securiry Deposits
$ 70,000.00 19.06% $ 13,342.00
$ 9,211.00
$ 145,843.00
***Staff will be charged (�a, 100% until budget is depleted.***
Total Budget Est. Percent to
MISCELLANEOUS
Total Budget
$2,000.00
$2,000.00
SHELTER OPERATIONS
Total Budget
$140,500.00
$248,658.00
�389,158.00
FINANCIAL ASSISTANCE
ITotal Bud�et
$
Est. Percent to
Est. Percent to
Est. Percent to
16% $ 22,914.00
Amount to
Amount to
Amount to
1% $ 1,965.00
� 1,965.00
� Amount to
Utility Payments
Utility Deposits
Moving Costs
Motcl/Hotel Vouchers
TOTAL
HMIS Software Costs
TOTAL
HMIS
Total Budget � Est. Percent to � Amount to
$ 150,000.00
EXHIBIT "C"
AUDIT CERTIFICATION FORM
PSA CONTRACT - EXHIBiT "C" - AUDIT
CERTIFICATION FORM --
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency: Li�hthouse for the Homeless, dba True Worth Place
Fiscal Year Ending: September 30, 2026
� During the fiscal year in which funds will be received, we will exceed the federal expenditure
threshold of $1,000,000.00. We will have our Single Audit or Program Specific Audit
completed and will submit the audit report described in 2 CFR Part 200 within 7 months
after the end of the audited fiscal year or 30 days within its completion, whichever is the
� earlier date.
During the fiscal year in which funds will be received, we will not exceed the
$1,000,000.00 federal expenditure threshold required for a Single Audit or a Program
Specific Audit to be performed this fiscal year. (Fill out schedule below)
Federal Expenditure Disclosure
MUST be iilled out if Single Audit or Program Audit is NOT required.
Pass Through Program Name & Contract
Federal Grantor Grantor CFDA Number Number Expenditures
Total Federal Expenditures for this Fiscal Year:
� ' ��,� 9/19/2025
v Signatfiry 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 2 CFR Part 200, as
applicable, by the required due date may result in suspension of funding and may affect eligibility
for future funding. Notwithstanding the above, this certification acknowledges the agency's
commitment to meet all other financial reporting, financial statements, and other audit
requirements as may be set forth in the Contract.
PSA CONTRACT - EXHIBIT "C" - AUD1T CERTIFICATION FORM 2
Exhibit D
Attachment I- Request Summary
Agency:
Address:
City, State, Zip:
Program:
Month of Service:
Tax ID Number:
Contract Number:
Case ID:
P.O. Number:
FID Number:
IDIS Number:
Program Account Amount
OriQinal Amount This Invoice Cumulative to Date Remaining Balance
(Program Name) Case ID
Salaries
FICA
Life/Disability Insurance
H ealth/Dental Insurance
Unemployment-State
Worker's Coinpensation
Office Supplies
Food Supplies
Insurance
Accounting
ContractLabor
ToraL
1001 $ - $
1002 $ - $ - $ -
1003 $ - S - S -
1004 $ - S - S -
1005 $ - S - S -
1006 $ - $ - $ -
1007 $ - $ -
IOOA $ - $ - $ -
1009 $ - $ - $ -
1010 $ - $ - $ -
1011 $ - $ - $ -
$ - $ - $ -
$
S
S
S
S
$
$
$
$
$
$
$
$
$
ATTACHMENTII
Cify of Fort Worth
Neighborhood Services Department
Ezpenditure Worksheet
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*For Salaries, state employee's title under Deseriptionqob Trtle. Reut must �deut `ry teuaut
Only highlighted codes cau be reiuiburecd
Expcnsc Linc Itcm
Ac�ouot
EMERGENCYSHELTER
I�:SSI�:NTI:1I. SF.RVICI�:S
I Salance� 1001 �
P[C� 1002 �
� e�ee�n�sand� ms��a�co ioos I
� x�imi�e�r���d� �e iooa I
� uncmplopnrnt-statc� loos �
� Worke� s Compencation 1006 �
� orroosuuu�;oy �om I
� �
� �
� Food Supplies 1008 �
� InSurance 1009 �
� Accouuti�� 1010 �
� ConhxctLbor 1011 �
� OLhcrQ 1012 �
� SHELTER OPERATIONS I
� M���vc�a�cc zooi �
� s��dry zooz �
� [n5u�ao� zoos I
� ummes Zooa �
� s��pp��� zoos I
I Rgpp�cs 2006 I
OthuQ 2007
HOUSING RELOCATION AND STABILIZATIOY
PREVENTION
� Salarics 3U01 �
� FIC9 3002 �
� LiCc/DisabiG�ylnsurancc 3003 �
� Heaflh/Dentallnsueance 3004 �
� UJ}��p to_@nenbStat� 3005 �
� Worker s 2�ompenset�on 3006 �
� OthuQ 3007 �
� RCHOUSING I
� Salaries 4001 �
� FICA 4002 �
� Life/Disabili�y I�sura�ce d003 �
� llcahh/Dcme insurancc ��� I
I ugg� �o e�i-siaee �oos I
� �orker's�umprncation -1006 �
OtherQ i007
FINANCIAL ASSISTA.VCE
PRI�:VI�:N"1'IOV
� Re�tal Assista�ce 5001 �
� �
� UtiliryPa�nnents 5002 �
� REHO[151NG I
� Re�ral Ass�sta�ce 6001 �
� Secu�ityDeposf�s 6002 �
� Un1�vDeposits 6003 �
� Ucihiy�aNncnts 6004 �
� Moving Cosls 6005 �
Motcl/Ilotcl Vouchcrs 6006
HMIS
HMISSoltwamCosts 7001
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Exhibit D1
MATCH
Agency:
Address:
City, State, Zip:
Program:
Month of Service:
Tax ID Number:
Contract Number:
Case ID:
P.O. Number:
FID Number:
IDIS Number:
Amount
Program This Invoice Cumulative to Date
ESG- Match
$ �
ATTACHMENT II
City of Fort Worth
Neighborhood Services Department
MATCH Expenditure Worksheet
Aaency:
Program:
Please group like account codes.
Line Funding
No. CheckNo. Date Pavee Description/Job Tide* Source Amount
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� 4
� 5
� 6
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� 9
� 10
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� 20
� 21
� 22
� 23
� 24
� 25
� 26
� 27
� 28
� 29
� 30
� 31
� 32
� 33
� 34
� 35
� 36
� 37
� 38
� 39
� 40
� 41
� 42
� 43
� 44
� 45
� 46
� 47
� 48
� 49
�
I Total
EXHIBIT "E"
SELF-CERTIFICATION FORMS
INCOME CERTIFICATION
(NOT SUBJECT TO CITIZENSHIP AND IMMIGRATION VERIFICATION)
INCOME AND CITIZENSHIP/IMMIGRATION CERTIFICATION
(SUBJECT TO CITIZENSHIP AND IMMIGRATION VERIFICATION)
City of Fort Worth
CERTIFICATION OF INCOME STATEMENT
Applicant Name:
Current Address:
Last Name
Phone #:
City and Zip:
Household Members and Income
(including applicant)
First Name Age � Monthly Income
�
�
�
�
�
Total Gross Annual Household Income:
TOTAL NUMBER OF FAMILY MEMBERS
�$
(Include Yourself, Spouse, Children, etc.)
Source of Income
PERSONAL DEMOGRAPHIC INFORMATION: (Check one box in each category. This information is required forfederal reporting underHUD guidelines.)
a. ❑ MALE
❑ FEMALE
c. ETHNICITY
❑ HISPANIC
❑ NON-HISPANIC
b. ❑ AMERICAN INDIAN/ALASKAN NATIVE ❑ ASIAN
❑ BLACK/AFRICAN AMERICAN ❑ NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER
❑ WHITE ❑ AMERICAN INDIAN/ALASKAN NATIVE & WHITE
❑ ASIAN & WHITE ❑ BLACK/AFRICAN AMERICAN & WHITE
❑ AMERICAN INDIAN/ALASKAN NATIVE ❑ OTHER MULTI-RACIAL
& BLACK/AFRICAN AMERICAN
d. DISABLED e. IS HEAD OF HOUSEHOLD FEMALE?
❑ YES ❑ YES
❑NO ❑NO
Certification: I certify that all information I provide is true and may be subject to verification at any time by a third party. I agree to
furnish accurate and truthful information when applying for and receiving services. I understand that providing false or misleading
information may subject me to penalties under applicable Federal, State, and local laws.
Signature of Applicant
Date
WARNING: T�T�E 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY
MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT.
-----------------For use by Agency staff only-----------------
Household Size:
Applicable Income Limit:
Gross Annual Income:
Is Applicant Eligible?
Check if Applicant refused to provide demographic informafion:
Staff Assessment of Demographics:
Person Making Determination:
Date:
NOTE: Agency sfaff are required to verify all information provided in this Certificafion of Income Statement. This form must include the address,
income amounts, and income sources for all household members, and all information must be verified.
2025-2026 ESG PSA Contract
City of Fort Worth
CERTIFICATION OF INCOME & U.S. CITIZENSHIPIIMMIGRATION STATEMENT
Applicant Name:
Current Address:
Name (First & Last Name)
Total Gross Annual Household Income:
TOTAL NUMBER OF FAMILY MEMBERS
Phone #:
City and Zip:
Household Members and Income
(including applicant)
DOB Monthly Income
$
Source of Income
(Include Yourself, Spouse, Children, etc.)
With/out U.S.
Citizenship/
Immigration
Verification
❑YES ❑NO
❑YES ❑NO
❑YES ❑NO
❑YES ❑NO
❑YES ❑NO
PERSONAL DEMOGRAPHIC INFORMATION: (Check one box in each category. This information is required forfederal reporting underHUD guidelines.)
a. ❑ MALE b. ❑ AMERICAN INDIAN/ALASKAN NATIVE ❑ ASIAN
❑ FEMALE ❑ BLACK/AFRICAN AMERICAN ❑ NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER
❑ WHITE ❑ AMERICAN INDIAN/ALASKAN NATIVE & WHITE
❑ ASIAN & WHITE ❑ BLACK/AFRICAN AMERICAN & WHITE
❑ AMERICAN INDIAN/ALASKAN NATIVE ❑ OTHER MULTI-RACIAL
& BLACK/AFRICAN AMERICAN
c. ETHNICITY d. DISABLED e. IS HEAD OF HOUSEHOLD FEMALE?
❑ HISPANIC ❑ YES ❑ YES
❑ NON-HISPANIC ❑ NO ❑ NO
Certification: I certify that all information I provide is true and may be subject to verification at any time by a third party. I agree to furnish accurate
and truthful information when applying for and receiving services. I understand that providing false or misleading information may subject me to
penalties under applicable Federal, State, and local laws.
Signature of Applicant
Date
WARNING: T�T�e 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR
FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT.
-----------------For use by Agency sfaff only-----------------
Household Size: Gross Annual Income: $ Applicable Income Limit: $
Is applicant income eligible? ❑YES ❑NO Is everyone in the household a U.S. citizen or able to provide immigration verification?
❑YES ❑NO
Applicant citizenshiplimmigration status verification method used: ❑SAVE Documentation ❑Government-issued Documents
❑ Check if Applicant refused to provide demographic information:
Staff Assessment of Demographics:
Person Making Determination:
Date:
NOTE; Agency staff are required to verify all information provided in this Certification of Income Statement. This form must include the address,
income amounts, and income sources for all household members, citizenship status and all information must be verified.
2025-2026 ESG PSA Contract
EXHIBIT "F"
STANDARDS OF DOCUMENTATION
ESG PSA CONTRACT -- EXHIBIT "F" -- STANDARDS OF DOCUMENTATION
2025-26 Documentation Standards for
ESG Public Service Contract Expenses
Employee Salaries and Benefits - City will only reimburse a percentage of any employee's salary and benefits who work directly with the ESG-funded Program.
Percentages will be cost allocated and determined prior to the execution of the ESG Contract. Agencies requesting the reimbursement of 100% of any Agency employee
will require prior City approval. Agencies must show calculation on how the ESG portion of employee salaries and benefits were calculated consistently with the ESG
Contract.
Salaries
If an employee works on both a ESG eligible and non-ESG eligible program(s), the City will only reimburse for a reasonable portion of
the employee's salary. Prior to the execution of the ESG Contract, the Agency will provide the City with a written statement on how
each employee's time will be allocated. If an employee works 100 % of their time directly with the ESG-funded Program, then 100% of
the employee's salary may be eligible for reimbursement. Agency must submit a written statement that 100°/ of the employee's time is
spent working directly with the ESG-funded Program. Statements must be signed by a person authorized to sign on behalf of the
Agency and will be submitted with the October invoice.
X X Reimbursement requests must include a timesheet and work log that reflects the hours worked by the employee(s) working directly on
the ESG-funded Program. For employees who are paid with multiple funding sources, timesheets must reflect all funding sources. If
separate timesheets are kept for each funding source, all such timesheets must be submitted to City. Timesheets must be signed by
employee and supervisor. Agency must show a calculation and documentation of how the employee's salary was calculated and
invoiced to City.
FICAIMedicare X X X
Life Insurance X X X
Health x x x
Insurance
Disability x x x
Insurance
Unemployment X X X
Insurance
*If employees are paid by direct deposit rather than check, then the agency must submit both the direct deposit payment company's
report (such as an ADT report) and a bank statement or check showing payment to the direct deposit company.
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and
must provide documentation showing payment. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
If the City pays gross saiary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
Retirement x x x employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and
must provide documentation showing payment. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
Materials, Equipment, Goods and Supplies - City will only reimburse for the cost allocated percent or amount spent in support of the ESG-funded Program. Agencies
requesting reimbursement for these items will require prior City approval. Agencies must show calculation on how the ESG portion of these expenses were calculated
consistently with the ESG Contract.
Office Supplies X X X
Office
Equipment X X X X X
Rental
Postage X X X
Printinq X X X
Construction &
Building X X X X This category is only available for the REACH Program and Habitat for Humanity.
Materials
Sport and
Recreation X X X
Equipment
Cleaning X X X
Supplies
Teaching Aids X X X
I Craft Supplies X X X
Food Supplies X X X This category is only available to the Program provided by Meals on Wheels.
Rent, Utilities and Maintenance - City will only pay for a portion of these expenses. The portion of these expenses will be determined by the square footage attributable to
the ESG-funded Program and shall be cost-allocated in accordance with the amount of space used for the ESG-funded Program. These expenses may only be in support of
the ESG-funded Program. The items listed below require prior City approval and the Agency is required to identify any funding source that pays for the portion of the
expenses that is not paid with ESG funds. Agencies must show calculation on how the ESG portion of these expenses were calculated consistently with the ESG Contract.
Telephone X X
Gas X X
Water/Wastew X X
ater
Electric X X
Solid Waste X �
ESG PSA CONTRACT 2025-2026 Exhibi[ "F" -- STANDARDS FOR COMPLETE DOCUMENTATION
Facility This item requires approval by the City prior to the execution of the ESG Contract. Repairs may be categorized as major/minor
Maintenance X X X X rehabilitation projects and must be approved through the full HUD Environmental Review.
and Repairs
Rent X X X City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the ESG-
funded program.
Miscellaneous I
This item requires prior approval by the City. Prior to the execution of the ESG Contract, the Agency must submit a written statement
that lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the procurement of such
Contract Labor X X X X X services and will forward any information pertaining to the procurement process to City. This requirement applies to, but is not limited to,
services retained for security services, legal, accounting, transportation providers, educational facilitators, custodial services, etc.
Agencies may not use the contract services of any City of Fort Worth Department.
City-required X X City will only pay for a percentage of the City-required insurance so long as iPs in proportion to the square footage attributable to
Insurance the ESG-funded program.
City requires that the agency submit its fee schedule or formula on how the Agency calculates the childcare scholarship amount. The
fee schedule/formula should demonstrate a breakout of income levels, and for each income level the schedule should demonstrate
Childcare X X which portion of the expense is to be paid by the family and which portion of the expense is to be reimbursed by the City. A fee
Scholarships schedule/formula must be submitted to the City prior to the first payment. Agency must submit documentation supporting that the client
is income eligible and that the household is being charged in conformance with the fee schedule. If the fee schedule/formula changes at
any time during the contract term, the Agency must immediately notify City on the date the new fee schedule/formula takes into effect.
"$0" Income Agecies that are required to verify and provide proof of household income to determine eligibility, must require that anyone who is over
Certifications the age of 18, living in the housohold, submit a$0 Income Certification.
If an audit is required because federal funds exceed $1,000,000.00, then the cost should be split evenly by all grant funding sources.
Audit Services X X X X Agency must show calculation on how the ESG portion of the accounting services were calculated. For example, if the ESG grant is
10% of your Agency's budget, then invoice shall not exceed 10°/ of the overall cost. Agency must show a calculation and
documentation of how the invoiced amount was calculated, and must provide documentation showing payment.
'Proof of payment effective October 1,2025: payments or Expenses must be documented in the following manner:
A) Image of the check AND bank statement showing the check cleared the bank; OR,
B) Image of the cancelled check (ex. At end of bank statement); OR,
C) Payroll Check Stub, "Advice", or Statement AND Bank Statement indicating payroll; OR,
D) For wire or e-transfers: Reciept or statement from payee/vendor OR bank statement.
Revised as of 09/29/2025 MT
ESG PSA CONTRACT 2025-2026 Exhibit "F' — STANDARDS FOR COMPLETE DOCUMENTATION
EXHIBIT "G"
MATCH REPORT
ESG PSA CONTRACT 2025-26 -- EXHIBIT "G" - MATCH REPORT
CITY OF FORT WORTH
NEIGHBORHOOD SERVICES DEPARTMENT
EMERGENCY SOLUTIONS GRANT
This attachment is designed to document proposed sources and to assess compliance with the
required Emergency Shelter Grant (ESG) match portion at 24 CFR 576.51. ESG funds are matched
dollar-for-dollar for each program year allocation.
City of Fort Worth ESG Funds $ Agency ESG Match $
1. SOURCES OF LOCAL MATCH:
Other Federal (including pass-through funds, e.g., City CDBG, County FEMA, etc.)
I MATCH SOURCE MATCH AMOUNT I
TOTAL MATCH
$
$
$
2. STATE/LOCAL GOVERNMENT FUNDING: (e.g., State Housing Trust Funds, Local
Assessment, etc.)
I MATCH SOURCE MATCH AMOUNT
TOTAL MATCH
3. PRIVATE (including recipient) FUNDING:
MATCH SOURCE
� Fund Raising/Cash
Loans
Building Value or Lease
Donated Goods
$
$
$
MATCH $ AMOUNT
$
$
$
$
ESG PSA CONTRACT 2025-26 -- EXHIBIT "G" — MATCH REPORT 2
Donated Computers
New Staff Salaries
Volunteers ($5/hr)
$
$
$
Volunteer Medical/Legal $
TOTAL MATCH
Comments:
$
CERTIFICATION: The undersigned, hereby, gives assurance that to the best of my knowledge and belief, the data
induded in this report is true and accurate, and if submitted by a non-profit agency, has been approved by the governing
body of the organization prior to submission. The match funds identified in this report are not included as contribution for
any othcr federally assisted project or program as requircd by 24 CFR 84.23 (a) (2)
Date: Submitted by: Phone Number:
ESG PSA CONTRACT 2025-26 -- EXHIBIT "G" — MATCH REPORT
EXHIBIT "H"
ESG STAFF CERTIFICATION FORM
ESG PSA CONTRACT 2025-26 — EXHIBIT "H" — ESG STAFF CERTIFICATION FORM Page 1
City of Fort Worth
STAFF CERTIFICATION OF ELIGIBILITY FOR ESG FINANCIAL ASSISTANCE
Instructions: In order far Ciry to approve reimbursement for any client, agency must submit (1) client documentation of income (source documentarion or self-
certification); (2) documentation of homelessness; (3) copy of lease; and (4) this completed form. (1) -(4) must be submitted upon initial reimbursement request for
assistance for each client.
HOMELESS PREVENTION ONLY: (1)-(4) upon agency request for reimbursement for the 4`h month of rent for a client (excluding arrears).
1. General Information
Head of Household Name:
Names of Other Household Members:
Household Income is less than 30% AMI? Yes ❑
Client Lacks Resources/Support Networks? Yes ❑
Type(s) of ESG Financial Assistance:
Unit Address (must be in City of Fort Worth):
2. Other ESG Requirements
Lease in agency file?
Age:
Age:
Age:
Age:
Age:
Age:
No ❑ N/A (Rapid Rehousinglnitial Evaluation Only) ❑
No ❑
Rent Arrears ❑ Utility ❑ Deposit(s) ❑
Rent ❑
No ❑
Yes ❑
Client receives NO other rental subsidy (ie. Housing Choice Voucher)? Ycs ❑ No ❑
Rental Assistance Agreement between landlord and agency in agency file? Yes ❑ No ❑
� Unit Number of Bedrooms:
Fair Market Rent (FMR) & Rent Reasonableness: � Area FMR Limit (as published by HUD):
Unit Rent per lease:
Unit meets Habitability Standards? Yes ❑ No ❑ � Date of Inspection:
3. Lead-Safe Housin�:
Applicable when (1) providing ESG rental assistance for more than 3 months excluding arrears, (2) pro-1978 housing unit, AND (3) child under 6 in housebold.
Not Applicable ❑
Number of Months Rental Assistance Provided (excluding arrears):
Year Housing Unit Built: Visual Inspection Indicates Unit and Property Free of Deteriarated Paint?
Yes ❑ No ❑
Name of Visual Assessor*:
*For named, agency must have on file a certificate of completion of HUD's Visual Assessment Course (httn://www.hud.eo��/oCGccs/Icad/trainine/visualasscssmcnt/h00100.cCml
Required certifications: Each person signing below certifies to the following: (1) To the best of my knowledge, the program participant named above meets all requirements
to receive assistance under the Emergency Solutions Grant (ESG). (2) To the best of my knowledge and ability, all of the information used in making this eligibility
determ�nation is true and complete. (3) T am not related to the program participant through family, business or other personal ties. (4) To the best of my knowledge, neither I
nor anyonc rclatcd to mc has rcccivcd or will rcccivc any financial bcncfit for this cligibility dctcrmination. (5) I undcrstand that fraud is invcstigatcd by thc Dcpartmcnt of
Housing and Urban Development, Office of Tnspector General, and may be punished under Federal laws to include, but not limited to, 18 U.S.C. 1001 and 18 U.S.C. 641 (6)
I understand that if any of these certifications is found to be false, i will be subject to criminal, civil and administrative penalties and sanctions.
ESG Staff Signature:
ESG Supervisor Signature:
Date:
Date:
ESG PSA CONTRACT 2025-26 — EXHIBIT "H" — ESG STAFF CERTIFICATION FORM Page 2
EXHIBIT "I"
ESG PERFORMANCE STANDARDS
Activity
Street
Outreach
Emergency
Shelter
Operations
Include
CDBG
(Moving
Home)
Homeless
Prevention
Rapid Re-
Housing
Coordinated
Entry
System
Emergency Solutions Grant Performance Standards
Output/Outcome Measures
Number of Persons:
A. Total Unduplicated Served
B. Total Unduplicated Engaged
Of those receiving Case Management,
Number of Persons:
A. Those placed in temporary/transitional housing
B. Those placed in permanent housing
Number of Persons:
A. Total Unduplicated Served
Of those receiving Case Management, Number of
Persons:
A. Those exiting Emergency Shelter to temporary
permanent housing destinations
B. Those who have more non-cash benefits at exit
C. Number of persons in shelter less than 60 days
D. Number of persons in shelter greater than 60+ days
E. Unduplicated number of adults with increase
Income
Number of Persons:
A. Total Unduplicated Served
Of those served, Number of Persons:
A. Those able to maintain housing at exit
B. Those who have more non-cash benefits at exit
or
Agency determines
numbe�^ and
% in PY25-26
in
Agency
number
%
Number of persons:
A. Total Unduplicated Served
Of those receiving, Number of Persons:
A. Those who exited to permanent housing at exit
B. Those who have more non-cash benefits at exit
C. Those who have more case income at exit
D. Number of persons served less than 60 days between
proj ect entry and move-in
E. Number of persons served that spent greater than 60+
days between project entry and move-in
A. 100% of Rapid Re-Housing enrollments come from
Coordinated Entry System
B. 90% of Coordinated Entry System referrals must be
accepted by housing providers
C. The average length of time between referral to lease up
is less than 60 days
Agency
number
%
determines
and
in PY25-26
determines
and
in PY25-26
Pulled From:
Coordinated Entry System
Reporting Metrics under
development
A. HMIS Report
B. HMIS Report
C. CAPER Q22c
IoI►Y�13.Y:�K�7►111C7_���o►VOII:�YliilfiOx.Y�`f��IC���7.�►i/_�►[f1�i.�11:�►D7:�.��7. I
In order to successfully record performance outcomes, the CoC system requires that once
a household is enrolled in an ESG program, non-domestic violence agencies must complete
an initial HUD Intake Assessment within the HMIS system (ETO), the HUD Mid-Program
Assessment, and the HUD Exit Assessment upon program exit. Performance outcomes will
be reported to the City using the HMIS generated ESG reports.
Domestic Violence Organizations will provide the same data utilizing their similar data
systems.
Reassessments are required for program participants receiving homelessness prevention
assistance and rapid re-housing assistance. Participants receiving homeless prevention
must be reassessed quarterly; rapid re-housing participants must be reassessed at least
yearly. All participants must receive an exit assessment and enter it into HMIS or a
comparable-level database.
i�Ye��y����.��:���m�►v:n:���r��Yes��:����:�► r_�.c���r:vu�:r�.� a
EXHIBIT "I-1"
Written Standards for ESG Assistance
Individuals and families eligibility. Households receiving either emergency shelter or rapid re-housing
assistance must meet HUD's revised definition of homelessness. Households receiving homelessness
prevention assistance must meet the definition of "at risk of homelessness", have incomes at or below 30%
AMI, and lack sufficient resources and support networks to retain housing. Eligible ESG-assisted
individuals and households must reside in the City of Fort Worth. Individuals receiving rapid re-housing
assistance must be housed to a unit located in the City of Fort Worth. Agencies will conduct initial
evaluation of clients to determine program eligibility, and kind of assistance needed. Agencies will re-
evaluate quarterly the assistance provided to homelessness prevention recipients, and yearly, to rapid re-
housing clients. Re-evaluation will ascertain that: i) annual incomes do not exceed 30% AMI; ii) clients
lack resources and support networks to retain housing without ESG assistance. Annual incomes are
established per 24 CFR 5.609. All clients must receive an exit assessment that will then be entered into
HMIS or comparable database.
Coordination among emergency shelter, homelessness prevention, rapid ve-housing, and other homeless
assistance and housing providers. To receive ESG funds, an agency has to be an active member of the
Continuum of Care (CoC). The CoC leads the coordination among agencies to assist the homeless and
prevent homelessness. It also engages and coordinates resources to improve current programs and funding
strategies.
Determining andprioritizing homelessnessprevention and rapid re-housing assistance. Rapid re-housing
and homelessness prevention providers will determine prioritization among eligible clients. This should be
based on a risk assessment. Prioritization should take into account: 1) families with children, and elderly
and disabled persons who do not require permanent supportive housing; and 2) the share of rent and utilities
costs that each client must pay, if any, while receiving homelessness prevention or rapid re-housing
assistance. The City recommends that clients share in rent and utility costs, unless there are reasons for
receiving 100% ESG-assistance.
Duration of rental assistance. Per §576103 and §576.104, agencies shall provide clients for no more than
24 months, during any 3-year period with short-term rental assistance, medium-term rental assistance,
payment of rental arrears, or any combination thereof. Short-term rental assistance is limited to 3 months.
Medium-tertn rental assistance extends over 3 months but not more than 24 months. Payment of rental
arrears consists of a one-time payment for up to 6 months of rent in arrears, including any late fees on those
arrears.
Type, amount, and duNation of housing stabilization andlor relocation assistance. Agencies will establish
standards for the type, amount, and duration of housing stabilization and/or relocation services provided,
acknowledging that services may not extend for more than 24 months within a 3-year period. Housing
relocation and stabilization services include financial assistance (moving costs, rental application fees,
security deposits, last month's rent, utility deposits and utility payments), and services (housing search and
placement, housing stability and case management, mediation, legal services, and credit repair.) The
amount and type of assistance provided shall aim at clients becoming self-sufficient. The City shall have
access to documentation that supports the amount and type of assistance provided.
ESG PSA CONTRACT EXHIBIT "I-1" — Written Standards far ESG Assistance
EXHIBIT "J"
ESG CAPER Report
PSA CONTRACT — EXHIBIT "J"
ESG CAPER Report
ESG CAPER Report Questions
Question Name
Project Identifiers in HMIS
Report Validations Table
Data Quality: Personally Identifiable Information
Data Quality: Universal Data Elements
Data Quality: Income and Housing Data Quality
Data Quality: Chronic Homelessness
Data Quality: Timeliness
Data Quality: Inactive Records: Street Outreach and Emergency
Shelter
Number of Persons Served
Point-in-Time Count of Persons on the Last Wednesday
Number of Households Served
Point-in-Time Count of Households on the Last Wednesday
Number of Persons Contacted
Number of Persons Newly Engaged
Gender
Gender by Age Ranges
Age
Race and Ethnicity
Physical and Mental Health Conditions at Start
Physical and Mental Health Conditions at Exit
Physical and Mental Health Conditions for Stayers
History of Domestic Violence Sexual Assault, Dating Violence,
Stalking, or Human Trafficking
Most recent experience of domestic violence, sexual assault,
dating violence, stalking, or human trafficking
Living Situation
Cash Income - Ranges
Cash Income - Sources
Disabling Conditions and Income for Adults at Exit
Type of Non-Cash Benefit Sources
Health Insurance
Length of Participation - ESG Projects
Length of Time between Project Start Date and Housing Move-in
Date
Length of Participation by Household Type
Length of Time Prior to Housing - based on 3.917 Date
Homelessness Started
Length of Time between Project Start Date and Housing Move-in
Date by Race and Ethnicity
Length of Time Prior to Housing by Race and Ethnicity - based on
3.917 Date Homelessness Started
Exit Destination
Exit Destination — Subsidy Type of Persons Exiting to Rental by
Client With An Ongoing Subsidy
ES&TH
x
x
x
x
x
x
x
**
x
x
x
x
**
**
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x*
x*
x
x
Street
Outreach
x
x
*
�
�
�
*
*
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
RRH
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
HP
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x x x
x x
x
x x
x x x
x x
Question Name
Exit Destination Type by Race and Ethnicity
Homelessness Prevention Housing Assessment at Exit
Language of Persons Requiring Translation Assistance
Number of Veterans
Number of Chronically Homeless Persons by Household
Street
ES & TH Outreach
x x
x x
x x
x x
* Data quality for Street Outreach begins at Engagement Date
** Night-by-night Shelters only
RRH I HP
x x
x
x x
x x
x x
This material is based upon work supported, in whole or in part, by Federal award number H-20-NP-OH-0002 awarded to The
Partnership center, Ltd by the U.S. Department of Housing and Urban Development. The substance and findings of the work are
dedicated to the public. Neither the United States Government, nor any of its employees, makes any warranty, express or
implied, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information,
apparatus, product, or process disclosed, or represents that its use would not infringe privately-owned rights. Reference herein
to any individuals, agencies, companies, products, process, services, service by trade name, trademark, manufacturer, or
otherwise does not constitute or imply an endorsement, recommendation, or favoring by the author(s), contributor(sJ, the U.S.
Government or any agency thereof. Opinions contained herein are those of the author(sJ and do not necessarily reflect the
official position of, or a position that is endorsed by, HUD or any Federal agency.
EXHIBIT "K"
MBE REPORTING FORM
ESG PSA CONTRACT -- EXHIBIT "K" -- MBE REPORTING FORM Page 1
EXHIBIT "L"
NOTICE OF BENEFICIARY RIGHTS
ESG PSA CONTRACT -- EXHIBIT "L" — NOTICE OF BENEFICIARY RIGHTS Page 1
Notice of Bene�ciary Ri�hts
Name of Agency:
Name of Program:
Contact information for Program Staff (name, phone number, and e-mail address, if appropriate):
Because this program is supported in whole or in part by direct Federal financial assistance from
the Federal Government, we are required to let you know that:
• We may not discriminate against you on the basis of religion, religious belief, a refusal
to hold a religious belief, or a refusal to attend or participate in a religious practice;
• We may not require you to attend or participate in any explicitly religious activities that
are offered by us and any participation by you in these activities must be purely
voluntary;
• We must separate, in time or location, any privately funded explicitly religious activities
from activities supported by direct Federal financial assistance;
• If you object to the religious character of our organization, we must make reasonable
efforts to identify and refer you to an alternative provider to which you have no such
obj ection; and
• You may report an organization's violations of these protections, including any denial of
services or benefits, by contacting or filing a written complaint to HUD [or the
intermediary, if applicable].
We must give you this written notice before you enroll in our program or activity, as required by
24 CFR 5.109.
ESG PSA CONTRACT -- EXHIBIT "L" — NOTICE OF BENEFICIARY RIGHTS Page 2
EXHIBIT "M"
WRITTEN STANDARDS FOR MAINTENANCE OF PERSONALLY IDENTIFYING INFORMATION
ESG PSA CONTRACT -- EXHIBIT "M" — WRITTEN STANDARDS OF MAINTENANCE OF PERSONALLY IDENTIFYING
INFORMATION Page 1
Written Standards for Maintenance of Client Confidentiality
Personally identifying information. Households receiving assistance under ESG must have reasonable
assurance of confidentiality. All client records, including name, household members, date of birth, Social
Security number, Driver's License Number, and any other identifying information of any individual or family
who applies for and/or receives ESG assistance will be kept secure and confidential. This includes maintaining
client records in a safe, locked file cabinet, filing area, or office that is not accessible to the general public and
with access that is limited to staff persons providing direct services to the client(s).
Domestic Violence Shelter Locations. The address or location of any domestic violence, dating violence,
sexual assault, or stalking shelter with ESG funds will not published, disclosed or made public, except with
written authorization of the person responsible for the operation of the shelter.
Domestic Violence Shelter Participants. The address or location of any housing of a program participant will
not be published, disclosed or made public to any individual not providing direct services to the participant,
except as provided under a preexisting privacy policy of the agency and consistent with state and local laws
regarding privacy and obligations of confidentiality.
Federal/Local Government Rights. City, HUD, the HUD Office of Inspector General, and the Comptroller
General of the United States, or any of their authorized representatives, must have the right of access to all
books, documents, papers, or other records of the agency that are pertinent to the ESG grant, in order to make
audits, examinations, excerpts, and transcripts. These rights of access are not limited to the required retention
period but last as long as the records are retained.
Public Rights. Citizens, public agencies, and other interested parties must have reasonable access (consistent
with state and local laws regarding privacy and obligations of confidentiality and the confidentiality
requirements in this part) to records regarding any uses of ESG funds the agency received during the preceding
5 years.
Reports. The agency must collect and report data on its use of ESG funds in the Homeless Management
Information System (HMIS)
Compliance. Agency must incorporate into its policies and procedures a process that will ensure the
confidentiality of program participants' identifying information; records pertaining to any individual or family
provided family violence prevention; and treatment services offered under any project assisted with ESG funds.
Agency Notification. Agency is provided the requirements for maintaining client confidentiality via (a) annual
Technical Assistance Training provided by City of Fort Worth Neighborhood Services Department staff, (b)
Individual Agency Technical Assistance visits (as scheduled), and (c) annual monitoring visit conducted by
City of Fort Worth Neighborhood Services Compliance & Planning Division staff.
Open Records Request. City staff required to comply with open records requests will receive the requirements
for maintaining client confidentiality and comply in accordance with HUD regulations.
ESG PSA CONTRACT -- EXHIBIT "M" — WRITTEN STANDARDS OF MAINTENANCE OF PERSONALLY IDENTIFYING
INFORMATION Page 2
NOTICE OF OCCUPANCY RIGHTS iTNDER U.S. Department of Housing and Urban Development
THE VIOLENCE AGAINST WOMEN ACT OMB Approval No. 2577-0286
Expires 06/30/2017
EXHIBIT "N" — Notice of Occupancv Ri�hts Under VAWA
JInsert Name of Housing Providerl]
Notice of Occupancy Rights under the Violence Against Women Act2
To all Tenants and Applicants
The Violence Against Women Act (VAWA) provides protections for victims of domestic
violence, dating violence, sexual assault, or stalking. VAWA protections are not only available
to women, but are available equally to all individuals regardless of sex, gender identity, or sexual
orientation.3 The U.S. Department of Housing and Urban Development (HUD) is the Federal
agency that oversees that �insert name of pro�ram or rental assistance] is in compliance with
VAWA. This notice explains your rights under VAWA. A HUD-approved certification form is
attached to this notice. You can fill out this form to show that you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking, and that you wish to use your
rights under VAWA."
Protections for Applicants
If you otherwise qualify for assistance under �insert name of pro�ram or rental assistance�,
you cannot be denied admission or denied assistance because you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking.
Protections for Tenants
' The notice uses HP for housing provider but the housing provider should insert its name where HP is used.
HUD's program-specific regulations identify the individual or entity responsible for providing the notice of
occupancy rights.
Z Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
3 Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national
origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made
available to all otherwise eligible individuals regardless of actual or perceived sexual arientarion, gender idenriry, or
marital status.
Form HUD-5380
(12/2016)
�
If you are receiving assistance under �insert name of pro�ram or rental assistance�, you may
not be denied assistance, terminated from participation, or be evicted from your rental housing
because you are or have been a victim of domestic violence, dating violence, seXual assault, or
stalking.
Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,
dating violence, sexual assault, or stalking by a member of your household or any guest, you
may not be denied rental assistance or occupancy rights under [insert name of nro�ram or
rental assistance� solely on the basis of criminal activity directly relating to that domestic
violence, dating violence, sexual assault, or stalking.
Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom
you stand in the place of a parent or guardian (for example, the affiliated individual is in your
care, custody, or control); or any individual, tenant, or lawful occupant living in your household.
Removing the Abuser or Perpetrator from the Household
HP may divide (bifurcate) your lease in order to evict the individual or terminate the assistance
of the individual who has engaged in criminal activity (the abuser or perpetrator) directly relating
to domestic violence, dating violence, sexual assault, or stalking.
If HP chooses to remove the abuser or perpetrator, HP may not take away the rights of eligible
tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator
was the sole tenant to have established eligibility for assistance under the program, HP must
allow the tenant who is or has been a victim and other household members to remain in the unit
for a period of time, in order to establish eligibility under the program or under another HUD
housing program covered by VAWA, or, find alternative housing.
Form HUD-5380
(12/2016)
3
In removing the abuser or perpetrator from the household, HP must follow Federal, State, and
local eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for
documentation or certification of the incidences of domestic violence, dating violence, sexual
assault, or stalking.
Moving to Another Unit
Upon your request, HP may permit you to move to another unit, subject to the availability of
other units, and still keep your assistance. In order to approve a request, HP may ask you to
provide documentation that you are requesting to move because of an incidence of domestic
violence, dating violence, sexual assault, or stalking. If the request is a request for emergency
transfer, the housing provider may ask you to submit a written request or fill out a form where
you certify that you meet the criteria for an emergency transfer under VAWA. The criteria are:
(1) You are a victim of domestic violence, dating violence, sexual assault, or
stalking. If your housing provider does not already have documentation that you
are a victim of domestic violence, dating violence, sexual assault, or stalking, your
housing provider may ask you for such documentation, as described in the
documentation section below.
(2) You expressly request the emergency transfer. Your housing provider may
choose to require that you submit a form, or may accept another written or oral
request.
(3) You reasonably believe you are threatened with imminent harm from
further violence if you remain in your current unit. This means you have a
reason to fear that if you do not receive a transfer you would suffer violence in the
very near future.
Form HUD-5380
(12/2016)
0
1:
You are a victim of sexual assault and the assault occurred on the premises
during the 90-calendar-day period before you request a transfer. If you are a
victim of sexual assault, then in addition to qualifying for an emergency transfer
because you reasonably believe you are threatened with imminent harm from
further violence if you remain in your unit, you may qualify for an emergency
transfer if the sexual assault occurred on the premises of the property from which
you are seeking your transfer, and that assault happened within the 90-calendar-day
period before you expressly request the transfer.
HP will keep confidential requests for emergency transfers by victims of domestic violence,
dating violence, sexual assault, or stalking, and the location of any move by such victims and
their families.
HP's emergency transfer plan provides further information on emergency transfers, and HP must
make a copy of its emergency transfer plan available to you if you ask to see it.
Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,
Sexual Assault or Stalking
HP can, but is not required to, ask you to provide documentation to "certify" that you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking. Such request
from HP must be in writing, and HP must give you at least 14 business days (Saturdays,
Sundays, and Federal holidays do not count) from the day you receive the request to provide the
documentation. HP may, but does not have to, extend the deadline for the submission of
documentation upon your request.
Form HUD-5380
(12/2016)
You can provide one of the following to HP as documentation. It is your choice which of the
following to submit if HP asks you to provide documentation that you are or have been a victim
of domestic violence, dating violence, sexual assault, or stalking.
• A complete HUD-approved certification form given to you by HP with this notice, that
documents an incident of domestic violence, dating violence, sexual assault, or stalking.
The form will ask for your name, the date, time, and location of the incident of domestic
violence, dating violence, sexual assault, or stalking, and a description of the incident.
The certification form provides for including the name of the abuser or perpetrator if the
name of the abuser or perpetrator is known and is safe to provide.
• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or
administrative agency that documents the incident of domestic violence, dating violence,
sexual assault, or stalking. Examples of such records include police reports, protective
orders, and restraining orders, among others.
A statement, which you must sign, along with the signature of an employee, agent, or
volunteer of a victim service provider, an attorney, a medical professional or a mental
health professional (collectively, "professional") from whom you sought assistance in
addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of
abuse, and with the professional selected by you attesting under penalty of perjury that he
or she believes that the incident or incidents of domestic violence, dating violence, sexual
assault, or stalking are grounds for protection.
• Any other statement or evidence that HP has agreed to accept.
If you fail or refuse to provide one of these documents within the 14 business days, HP does not
have to provide you with the protections contained in this notice.
Form HUD-5380
(12/2016)
G
If HP receives conflicting evidence that an incident of domestic violence, dating violence, sexual
assault, or stalking has been committed (such as certification forms from two or more members
of a household each claiming to be a victim and naming one or more of the other petitioning
household members as the abuser or perpetrator), HP has the right to request that you provide
third-party documentation within thirty 30 calendar days in order to resolve the conflict. If you
fail or refuse to provide third-party documentation where there is conflicting evidence, HP does
not have to provide you with the protections contained in this notice.
Confidentiality
HP must keep confidential any information you provide related to the exercise of your rights
under VAWA, including the fact that you are exercising your rights under VAWA.
HP must not allow any individual administering assistance or other services on behalf of HP (for
example, employees and contractors) to have access to confidential information unless for
reasons that specifically call for these individuals to have access to this information under
applicable Federal, State, or local law.
HP must not enter your information into any shared database or disclose your information to any
other entity or individual. HP, however, may disclose the information provided i£
• You give written permission to HP to release the information on a time limited basis.
• HP needs to use the information in an eviction or termination proceeding, such as to evict
your abuser or perpetrator or terminate your abuser or perpetrator from assistance under
this program.
• A law requires HP or your landlord to release the information.
Form HUD-5380
(12/2016)
7
VAWA does not limit HP's duty to honor court orders about access to or control of the property.
This includes orders issued to protect a victim and orders dividing property among household
members in cases where a family breaks up.
Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or
Assistance May Be Terminated
You can be evicted and your assistance can be terminated for serious or repeated lease violations
that are not related to domestic violence, dating violence, sexual assault, or stalking committed
against you. However, HP cannot hold tenants who have been victims of domestic violence,
dating violence, sexual assault, or stalking to a more demanding set of rules than it applies to
tenants who have not been victims of domestic violence, dating violence, sexual assault, or
stalking.
The protections described in this notice might not apply, and you could be evicted and your
assistance terminated, if HP can demonstrate that not evicting you or terminating your assistance
would present a real physical danger that:
1) Would occur within an immediate time frame, and
2) Could result in death or serious bodily harm to other tenants or those who work on the
property.
If HP can demonstrate the above, HP should only terminate your assistance or evict you if there
are no other actions that could be taken to reduce or eliminate the threat.
Other Laws
VAWA does not replace any Federal, State, or local law that provides greater protection for
victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to
Form HUD-5380
(12/2016)
additional housing protections for victims of domestic violence, dating violence, sexual assault,
or stalking under other Federal laws, as well as under State and local laws.
Non-Compliance with The Requirements of This Notice
You may report a covered housing provider's violations of these rights and seek additional
assistance, if needed, by contacting or filing a complaint with [insert contact information for
any intermediary, if applicable] or [insert HUD field office].
For Additional Information
You may view a copy of HUD's final VAWA rule at [insert Federal Register link].
Additionally, HP must make a copy of HUD's VAWA regulations available to you if you aslc to
see them.
For questions regarding VAWA, please contact [insert name of qro�ram or rental assistance
contact information able to answer questions on VAWA�.
For help regarding an abusive relationship, you may call the National Domestic Violence Hotline
at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may
also contact [Insert contact information for relevant local organizations].
For tenants who are or have been victims of stalking seeking help may visit the National Center
for Victims of Crime's Stalking Resource Center at https://www.victimsofcrime.org/our-
programs/stalking-resource-center.
For help regarding sexual assault, you may contact [Insert contact information for relevant
organizations]
Victims of stalking seeking help may contact [Insert contact information for relevant
organizations].
Attachment: Certification form HUD-5382 [form approved for this program to be included]
Form HUD-5380
(12/2016)
EXHIBIT "O" — Emergency Transfer Request Form
CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286
DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017
DATING VIOLENCE,
SEXUAL ASSAULT, OR STALKING,
AND ALTERNATE DOCUMENTATION
Purpose of Form: The Violence Against Women Act ("VAWA") protects applicants, tenants, and
program participants in certain HUD programs from being evicted, denied housing assistance, or
terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or
stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic
violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual
orientation.
Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your
housing provider may give you a written request that asks you to submit documentation about the incident
or incidents of domestic violence, dating violence, sexual assault, or stalking.
In response to this request, you or someone on your behalf may complete this optional form and submit it
to your housing provider, or you may submit one of the following types of third-party documentation:
(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an
attorney, or medical professional, or a mental health professional (collectively, "professional") from
whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or
stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the
professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or
stalking occurred and meet the definition of "domestic violence," "dating violence," "sexual assault," or
"stalking" in HUD's regulations at 24 CFR 5.2003.
(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or
administrative agency; or
(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or
tenant.
Submission of Documentation: The time period to submit documentation is 14 business days from the
date that you receive a written request from your housing provider asking that you provide documentation
of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing
provider may, but is not required to, extend the time period to submit the documentation, if you request an
extension of the time period. If the requested information is not received within 14 business days of when
you received the request for the documentation, or any extension of the date provided by your housing
provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or
issuance of this form does not serve as a written request for certification.
Confidentiality: All information provided to your housing provider concerning the incident(s) of
domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details
shall not be entered into any shared database. Employees of your housing provider are not to have access
to these details unless to grant or deny VAWA protections to you, and such employees may not disclose
this information to any other entity or individual, except to the extent that disclosure is: (i) consented to
Form HUD-5382
(06/2017)
2
by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing
regarding termination of assistance; or (iii) otherwise required by applicable law.
TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,,
DATING VIOLENCE, SEXUAL ASSAULT. OR STALKING
l. Date the written request is received by victim:
2. Name of victim:
3. Your name (if different from victim's):
4. Name(s) of other family member(s) listed on the lease:
5. Residence of victim:
6. Name of the accused perpetrator (if known and can be safely disclosed):
7. Relationship of the accused perpetrator to the victim:
8. Date(s) and times(s) of incident(s) (if known):
10. Location of incident(s):
In your own words, briefly describe the incident(s):
This is to certify that the information provided on this form is true and correct to the best of my knowledge
and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,
dating violence, sexual assault, or stalking. I acknowledge that submission of false information could
jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or
eviction.
Signature Signed on (Date)
Public Reporting Burden: The public reporting burden for this collection of information is estimated to
average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The
information provided is to be used by the housing provider to request certification that the applicant or
tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is
subject to the confidentiality requirements of VAWA. This agency may not collect this information, and
you are not required to complete this farm, unless it displays a currently valid Office of Management and
Budget control number.
Form HUD-5382
(06/2017)
EXHIBIT "P"
CONFLICT OF INTEREST DISCLOSURE:
FOR CITY OF FORT WORTH PROGRAMS ONLY
ESG PSA CONTRACT -- EXHIBIT "P" -- CONFLICT OF INTEREST DISCLOSURE
F���r �o��rx
CONFLICT OF INTEREST DISCLOSURE:
FOR CITY OF FORT WORTH PROGRAMS ONLY
The assistance you are applying for is funded using Housing and Urban Development (HUD) funds and because
of this our office is requesting the following information in order to comply with the funding requirements. Please
complete this form to the best of your ability, sign it, and return it to this Agency at your earliest convenience.
NAME:
TELEPHONE:
ADDRESS:
E-MAIL ADDRESS (if applicable)
1. Are you employed by the City of Fort Worth?
la. If yes, by which Department and Division:
2. Were you employed by the City of Fort Worth within the most recent 12-month period?
2a. If yes, by which Department and Division:
� YES � � NO
❑ YES � ❑ NO
3. Are any members of your immediate family currently employed by the City of Fort Worth?
(`7mmediate Fantily" includes (whether bv hlood or adoption): the spouse, parent (including a stepparent), ❑�s � N�
child (including a stepchild), brother, sister (including a stepbrother or stepsister), grandparent, grandchild,
and in-laws.)
3a. If yes, please provide relative's name(s), Department(s), and Division(s):
4. If No, were any members of your immediate family employed by the City of Fort Worth yES NO
within the most recent 12-month period? ❑ ❑
4a. If yes, please provide relative's name(s), previous Deparhnent(s), and Division(s):
5. Are you an elected or appointed official, or agent ar consultant, of the City of Fort Worth?
Sa. If yes, by which Department and Division:
6. Are any immediate family members an elected ar appointed official, or agent or consultant
of the City of Fort Worth?
6a. If yes, please provide relative's name(s), Department(s), and Division(s):
� YES � � NO
❑ YES I ❑ NO
Certification: I understand and agree that the City may/will contact the City of Fort Worth department including all supervisars in
order to determine whether any of these persons' employment or official functions are or were related to the City's use of federal
grant funds and whether federal funds can be provided. I certify that the information I am providing is true and could be subject
to verification at any time by a third party. I also acknowledge that the provision of false information could leave me subject
to the penalties of Federal, State and local law.
WARNING: TITLE IH� SECTION IOOI 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.
Applicant/Prospective Applicant Signature
Date
-------------------------------------- --------------------------- --------------------------- ---
For Ci_ty_ Staff_Only: Once this form is completed and if "Yes" is marked on any of the above questions, please return it
to your Compliance Specialist as soon as possible for processing. If you have any questions, please contact Leticia
Rodriguez, Compliance Administrator, Compliance Division, at 817-392-7319, or Charletta Moaning, Sr. Contract
Compliance Specialist, at 817-392-7333 or at charl_c_tta,moaning�fortworthtcxasgov.
Neighborhood Services Department-Conflict Disclosure Form, Dated September 23, 2024-City Only
EXHIBIT "Q"
CERTIFICATE OF COMPLIANCE:
ADDITIONAL POLICY REQUIREMENTS
CERTIFICATE OF COMPLIANCE:
ADDITIONAL POLICY REQUIREMENTS
The terms and conditions set forth in EXHIBIT "Q" — Certificate of Compliance: Additional
Policy Requirements are hereby incorporated by reference into this Contract and shall be binding
upon the Agency. The Agency shall comply with all applicable provisions of EXHIBIT "Q" —
Certificate of Compliance: Additional Program-Specific Policy Requirements as if fully
stated herein.
In addition to all applicable federal statutes and regulations, the Subrecipient certifies that it has
read and agrees to comply with the following policy requirements, if applicable, established under
the federal award agreement between the Department of Housing and Urban Development and the
City of Fort Worth, and which are a material condition of this Agreement.:
1. Prohibition on Use of Funds to Promote Gender ldeology
Grant funds awarded under this Contract sha11 not be used to promote "gender ideology,"
as defined in Executive Order 14168, Defending Women from Gender ldeology Extremism
and Restoring Biological Truth to the Federal Government.
2. Materiality of Compliance with Federal Anti-Discrimination Laws
Agency acknowledges that its compliance in all respects with all applicable Federal anti-
discrimination laws is material to the U.S. Government's payment decisions within the
meaning of 31 U.S.C. § 3729(b)(4).
3. Certiiication of Compliance with Anti-Discrimination Laws
Agency certifies that it does not operate, and will not operate, any program or activity in
violation of any applicable Federal anti-discrimination laws, including but not limited to
Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq.).
4. Prohibition on Use of Funds for Elective Abortions
Agency shall not use any federal grant funds to fund or promote elective abortions, as
required by Executive Order 14182, Enforcing the Hyde Amendment and any applicable
appropriations laws.
5. Revocation of Prior Executive Orders
Notwithstanding anything in the Notice of Funding Opportunity (NOFO), grant
application, or related guidance, this Contract shall not be governed by Executive Orders
that have been revoked by Executive Order 14154, including Executive Order 14008, nor
by any NOFO provisions that were based on such revoked Executive Orders.
6. Compliance with Immigration Restrictions under PRWORA
Agency must administer all aspects of this grant in compliance with the eligibility and
verification requirements of Title IV of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (PRWORA), as amended (8 U.S.C. §§ 1601-1646), as well as
any related requirements established by HUD, the Attorney General, or the U.S.
Citizenship and Immigration Services pursuant to PRWORA, Executive Order 14218, or
other applicable federal immigration laws or executive orders, except that the veritication
requirements do not apply if the Agency is a nonprotit charitable organization deemed
exempt under 8 U.S.C. § 1642(d). .
Prohibition on Use of Funds to Promote Illegal Immigration
Agency shall not use funds in any way that, by design or effect, facilitates the subsidization
or promotion of illegal immigration, or shields illegal aliens from deportation, including
through policies or practices that material ly impede the enforcement of federal immigration
laws.
8. Use of SAVE for lmmigration Status Veritication
Agency shall use the Systematic Alien Veritication for Entitlements (SAVE) program, or
another Federal government-approved veritication system, to ensure that no Federal public
benetit is provided under this grant to any individual who is ineligible due to unlawful
immigration status.
9. Equal T�reatment of Faith-Based Organizations
Faith-based organizations may participate as subrecipients on the same basis as any other
eligible organization and shall not be discriminated against any organization on the basis
of religious character, aftiliation, or religious exercise.
Certification anJ Acknowledgement
This certihcation shall be deemed incorporated by reference into the main Contract. By signing
below, the Agency hereby certities, acknowledges, and a�rees that:
. Agency has read and understands all terms and conditions set forth in this EXHBIT "Q"
— Certificate of Compliance: Additional Program-Specific Polic�- Requirements;
. Agency shall comply with these requirements in both program practice and w�ritten policies
and procedures;
. Agency agrees to be in compliance with these requirements is a material condition of this
Contract and a prerequisite to the receipt and continued use of grant funds; and
. Agency understands that any violation of these terms may result in the suspension or
termination of funding, repayment of funds, or other remedies available under law or
regulation.
Authorized Certification
Name of Agency: Lighthouse for the Homeless, dba True Worth Place
Name of Authorized Official: Toby Ow�en
Title: Chief Execut' tticer
Signature: �''
Date: 1 1 / 14/20
M&C Review
CITY COUNCIL AGENDA
Create New From This M&C
DATE: 8/12/2025 REFERENCE NO.: M&C 25-0676 LOG NAME:
CODE: C TYPE: NON- PUBLIC
CONSENT HEARWG:
Page 1 of 5
Offlclal site of the City of Fort Worth, Texas
FJRT��ORTH
_�_
192025-2026 HUD
ANNUAL ACTION
PLAN
YES
SUBJECT: (ALL) Conduct Public Hearing and Approve the City of Fort Worth's 2025-2026 Annual
Action Plan for the Use of Federal Grant Funds in the Amount of $13,273,355.77 to be
Awarded by the United States Department of Housing and Urban Development from the
Community Development Block Grant, HOME Investment Partnerships Program,
Emergency Solutions Grant, and Housing Opportunities for Persons with AIDS Program,
Authorize Collection and Use of Program Income, Authorize Execution of Related
Contracts, Adopt Appropriation Ordinance, and Authorize Waiver of Indirect Costs
(PUBLIC HEARING - a. Staff Available for Questions: Juliet Moses; b. Public Comment c.
Council Action: Close Public Hearing and Act on M&C)
RECOMMENDATION:
It is recommended that City Council:
1. Conduct a public hearing to allow citizen input and consideration of the City's 2025-2026 Annual
Action Plan for use of federal grant funds to be awarded by the United States Department of
Housing and Urban Development in the amount of $13,273,355.77 for the Community
Development Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant,
and Housing Opportunities for Persons with AIDS grant programs;
2. Approve the City's 2025-2026 Annual Action Plan for submission to the United States Department
of Housing and Urban Development, including allocations of grant funds to particular programs
and activities as detailed below;
3. Authorize the collection and use of an estimated $30,000.00 of program income which is
expected to result from activities using prior years' Community Development Block Grant funds
for the City's Priority Repair Program;
4. Authorize the collection and use of an estimated $30,000.00 of program income which is
expected to result from activities using prior years' HOME Investment Partnerships Program grant
funds for the City's Homebuyer Assistance Program, and authorize the use of 10 percent of the
program income for administrative costs;
5. Authorize the City Manager or his designee to execute contracts for one-year terms with the
agencies listed in Tables 1, 2, and 3 below for Program Year 2025-2026 for Community
Development Block Grant, Emergency Solutions Grant, and Housing Opportunities for Persons
with AIDS grant funds, contingent upon receipt of funding, and satisfactory completion of all
federal regulatory requirements;
6. Adopt the attached appropriation ordinance increasing estimated receipts and appropriations in
the Grants Operating Federal Fund in the total amount of $13,273,355.77 consisting of
$7,116,438.00 in Community Development Block Grant funds, $2,814,431.77 in HOME
Investment Partnerships Program funds, $615,818.00 in Emergency Solutions Grant funds, and
$2,726,668.00 in Housing Opportunities for Persons with AIDS grant funds, all subject to receipt
of such funds; and
7. Authorize a waiver of the Neighborhood Services Department indirect cost of 21.05\%, estimated
total of $264,698.00.
DISCUSSION:
The City's 2025-2026 Annual Action Plan summarizes the major housing and community development
activities and proposed expenditures for the program year beginning October 1, 2025 and ending
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M&C Review
Page 2 of 5
September 30, 2026 for use of federal grant funds totaling $13,273,355.77 from the United States
Department of Housing and Urban Development (HUD) from the Community Development Block Grant
(CDBG), HOME Investment Partnerships Program (HOME), Emergency Solutions Grant (ESG), and
Housing Opportunities for Persons with AIDS (HOPWA) grant programs, plus program income from the
CDBG and HOME grant programs totaling $60,000.00. It also summarizes the use of program income
resulting from activities using prior years' CDBG and HOME funds, the primary purpose of which is to
benefit low-and moderate-income persons in Fort Worth. ESG funds primarily benefit persons experiencing
homelessness, and HOPWA funds primarily benefit low-and moderate-income persons with HIV/AIDS.
A Request for Proposals from social service agencies and nonprofit organizations seeking grant funding
was published on January 15, 2025. All proposals were received on March 3, 2025. Staff reviewed all
proposals and developed recommendations for the allocation of estimated funding from HUD based on the
capacity of applicant organizations, grant experience, fiscal stability, and compliance with applicable
federal regulations. One public hearing was held on July 14, 2025, to provide citizens with the opportunity
to participate in the development of the Annual Action Plan. Recommendations for award amounts were
considered and adopted by the Community Development Council on June 11, 2025.
A 30-day public comment period was held from June 16, 2025, through July 16, 2025. Notice of this public
comment period was published in the Cleburne Times Review on June 10, 2025; in the Fort Worth Star
Telegram and Weatherford Democrat on June 11, 2025; and in La Vida News and the Wise County
Messenger on June 12, 2025.
Any comments received are maintained by the Neighborhood Services Department in accordance with
federal regulations. The City held two public hearings as a part of the HUD required citizen participation
process. The first public hearing was held by staff on July 14, 2025, and the second public hearing is
scheduled for the City Council Meeeting on August 12, 2025.
A summary of staff's final funding recommendations is provided below in Tables 1, 2, and 3. The 2025-
2026 Annual Action Plan will be submitted to HUD by August 15, 2025.
Indirect costs totaling approximately $264,698.00 could be charged to these grants, as the Neighborhood
Services Department indirect cost rate is 21.05\°/o in the City's most recent Cost Allocation Plan. A waiver
of these costs is requested to allow allocation of these funds to further support the programs and services
to assist low-to-moderate income citizens.
COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG)
For Program Year 2025-2026, it is recommended that the amount of $7,116,438.00 in CDBG funds and an
estimated amount of $30,000.00 in CDBG program income totaling $7,146,438.00 be allocated as follows:
Public Service Agencies -$1,067,465.00 (Limited to 15\% of the grant allocation): Includes social services
for low- and moderate income persons, persons with disabilities, and disadvantaged persons; Housing
Programs -$2,665,000.00: Includes funding for the City's Priority Repair Program, Cowtown Brush-Up, and
accessibility modifications for seniors and persons with disabilities; Major Projects -$1,000,685.00:
Includes funding for street improvements; Program Delivery -$960,000.00: Includes program delivery
costs for housing programs; Administration -$1,423,288.00 (Limited to 20\% of the grant allocation):
Includes costs for administering the CDBG grant; Estimated Program Income -$30,000.00: Includes up to
$30,000.00 in funding for the City's Priority Repair Program. Any CDBG program income over the
estimated amount not used for the Priority Repair Program will be allocated to priority activities in the City's
Consolidated Plan, subject to the City Council approval.
HOME INVESTMENT PARTNERSHIPS PROGRAM (HOME)
For Program Year 2025-2026, it is recommended that the amount of $2,814,431.77 in HOME funds and an
estimated amount of $30,000.00 in HOME program income totaling $2,844,431.77 be allocated as follows:
Homebuyer Assistance Program -$1,110,824.77: Includes funding for down payment and closing cost
assistance for low- and moderate-income homebuyers through the Fort Worth Community Land Trust, the
City of Fort Worth and Trinity Habitat for Humanity; Community Housing Development Organizations
(CHDOs) for affordable housing projects -$422,164.00: These funds will be used by Housing Channel for
the Mason Heights affordable housing development in southeast Fort Worth. Funds will be used for the
acquisition of land and the new construction of 236 units. An estimated 183 units (approximately 77\%) will
be sold to low to moderate income households at or below 80\% Area Median Income (AMI); Major
Projects -$1,000,000.00 allocated to Fort Worth Housing Solutions (FWHS) as a part of Phase Six of the
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M&C Review
Page 3 of 5
Choice Neighborhood Initiative (CNI) grant benefiting low-moderate come residents in the Stop Six
Neighborhood of Fort Worth; Administration -$281,443.00 (Limited to 10\% of the grant allocation):
Includes costs for administering the HOME grant; Estimated Program Income -$30,000.00: Includes
funding for the Homebuyer Assistance Program and HOME grant administrative costs. HUD allows the City
to use 10 percent of any HOME program income towards the cost of administering the HOME grant.
HOME program income over the estimated amount not used for the Homebuyer Assistance Program will
be allocated to priority activities in the City's Consolidated Plan, subject to City Council approval.
HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS (HOPWA)
For Program Year 2025-2026, it is recommended that the amount of $2,726,668.00 in HOPWA funds be
allocated as follows: Public Service Agencies -$1,670,868.00; Neighborhood Services Department -
$974,000.00; Administration -$81,800.00 (Limited to 3\°/a of the grant allocation)
EMERGENCY SOLUTIONS GRANT (ESG)
For Program Year 2025-2026, it is recommended that the amount of $615,818.00 in ESG funds to be
allocated as follows: Public Service Agencies -$569,632.00; Administration -$46,186.00 (Limited to 7.5\%
of the grant allocation)
CONTRACT RECOMMENDATIONS
The Community Development Council and Neighborhood Services Department staff recommend that
contracts be executed with the public service and subrecipient agencies listed below for the amounts
shown in the following tables:
Community Development Block Grant Contracts
AGENCY
Housing Channel
Meals-On-Wheels, Inc. of
Tarrant County
TABLE 1: CDBG AGENCIES
ICONSOLGOAL D PLAN I pROGRAM
IAffordable Housing IHousing Counseling &
Education
IHealthy Living and INutrition Program
Wellness
Guardianship Services Inc. Aging In Place
�United Community Centers, Inc IChildren and Youth
Services
�Boys & Girls Club of Greater IChildren and Youth
Tarrant County Services
IGirls Inc of Tarrant County IChildren and Youth
� Services
ICamp Fire First Texas IChildren and Youth
� Services
�Junior Achievement of the IChildren and Youth
Chisholm Trail, Inc. Services
�The Women's Center of Tarrant IEconomic Empowerment
County and Financial Resilience
IEaster Seals North Texas, Inc. IEconomic Empowerment
� and Financial Resilience
Money Smart+ Elder
Financial Fraud
Prevention Workshops
IEducation Literacy
Program
IYouth Development at
Eastside Branch
IWhole Girl Program
ITeens In Action
ICradle to Career
Initiative
IEmployment Solutions
IEmployment Services
AMOUNT
$111,000.00
$120,000.00
'�:1 111 11
$125,000.00
$72,000.00
$90,281.00
$62,184.00
$50,000.00
$90,000.00
$92,000.00
Homelessness
Presbyterian Night Shelter Prevention and Special Moving Home Program $175,000.00
Needs Support
�CDBG Public Services Agencies Total II$1,067,465.00I
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M&C Review
**Rehabilitation, Education and Accessibility
Advocacy for Citizens with Improvements Project Ramp
Handicaps dba REACH, Inc.
**Fort Worth Area Habitat for Housing Preservation and
Humanity, Inc. DBA Trinity Rehabilitation Cowtown Brush Up
Habitat for Humanity
�CDBG Subrecipient Agencies Total
�TOTAL CDBG CONTRACTS
Page 4 of 5
$165,000.00
$500,000.00
� $665,000.00�
�$1,732,465.00�
**REACH and Trinity Habitat will be funded from the CDBG Housing Programs and Services budget.
Housing Opportunities for Persons with AIDS Contracts
TABLE 2: HOPWA AGENCIES
AGENCY CONSOLIDATED PLAN
GOAL
Tarrant County Homelessness Prevention
Samaritan Housing, and Special Needs
Inc. Support
AIDS Outreach
Center, Inc.
Homelessness Prevention
and Special Needs
Support
TOTAL HOPWA CONTRACTS
Emergency Solutions Grants Contracts
PROGRAM
HOPWA Program -
Administration, Tenant-
Based Rental Assistance
(TBRA), Short-Term
Rent, Mortgage, and
Utility Assistance
(STRMU), Supportive
Services, Facility-Based
Operations (FBO)
'The Housing Assistance
Program
- Administration, Tenant-
Based Rental Assistance
(TBRA), Short-Term
Rent, Mortgage, and
Utility Assistance
(STRMU), Supportive
Services
TABLE 3: ESG AGENCIES
AGENCY CONSOLIDATED PLAN pROGAM
GOAL
The Presbyterian Night Homelessness Prevention and Shelter
Shelter of Tarrant County, Special Needs Support Operations/Services
Inc.
Lighthouse for the Homelessness Prevention and Day Shelter
Homeless dba True Worth Special Needs Support Operations/Services
Place
IThe Salvation Army
�
�Center for Transforming
Lives
Homelessness Prevention and Homelessness
Special Needs Support Prevention
Homelessness Prevention and Rapid Re-Housing
Special Needs Support
�� ��
AMOUNT
$1,406,188.00
$264,680.00
$1,670,868.00�
AMOUNT
$139,491.00
$150,000.00
$127,141.00
$73,000.00
II $80,00O.00I
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M&C Review
�SafeHaven of Tarrant Homelessness Prevention and Shelter
County Special Needs Support Operations/Services
�TOTAL ESG CONTRACTS
All figures have been rounded to the nearest dollar for presentation purposes.
Page 5 of 5
��$569,632.00�
Each of these grants are an entitlement grant rather than a competitive grant received from the United
States Department of Housing and Urban Development (HUD). Entitlement grants provide funds to
agencies based on a formula prescribed in legislation or regulation, rather than based on review. These
specific grants are allocated to the City of Fort Worth based on population size and per capita income each
year. The grants have been consistently awarded to the City since 1974 with the inception of the
Community Development Block Grant (CDBG) through the Housing and Community Development Act of
1974. The Emergency Shelter (renamed Solutions) Grant (ESG) was authorized in 1987 through the
McKinney-Vento Homelessness Assistance Act. The HOME Investment Partnerships Program (HOME)
and the Housing Opportunities for Persons with AIDS (HOPWA) Program were authorized through the
Cranston-Gonzales National Affordable Housing Act of 1990. With these grants, administrative and
program delivery allocations support approximately 90 FTE positions in the Neighborhood Services
Department, which is funded nearly 60\% with various grants including these entitlement grants.
Positions funded with HUD Entitlement grants are subject to grant availability. In the event of a grant award
being decreased or eliminated, the Neighborhood Services Department would review programs and
services funded by the grants and determine a level of service and staffing that aligns with the available
funding. Alternatives to consider may include staff and program reductions or eliminations.
The City of Fort Worth has certified that all programs receiving funding through the HOPWA, HOME, ESG,
and CDBG grants comply with applicable Executive Orders.
These programs are available in ALL COUNCIL DISTRICTS.
�6��_1��L'7►�i/_��[�I�iIL��:i�l�C�_��[�]`F
The Director of Finance certifies that upon approval of the above recommendations and adoption of the
attached appropriation ordinance, funds will be available in the current operating budget, as appropriated,
of the Grants Operating Federal Fund. The Neighborhood Services Department (and Financial
Management Services) will be responsible for the collection and deposit of funds due to the City. Prior to
an expenditure being incurred, the Neighborhood Services Department has the responsibility to validate
the availability of funds. These are reimbursement grants.
TO
Fund Department Account Project Program Activity Budget Reference # Amount
ID ID � Year (Chartfield 2)
FROM
Fund Department Account Project
ID , I ID
Submitted for Citv Manaqer's Office bv:
Program Activity Budget � Reference # Amount
Year (Chartfield 2)
Dana Burghdoff (8018)
Oriainatinq Deaartment Head:
Additional Information Contact:
ATTACHMENTS
Kacey Bess (8187)
Juliet Moses (6203)
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CERTIFICATE OF INTERESTED PARTIES
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Lighthouse for The Homeless dba True Worth Place
Fort Worth, TX United States
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
Ciry of Fort Worth, Texas
FORM 1295
1 of 1
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2025-1269233
Date Filed:
02/13/2025
Date Acknowledged:
g Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a
description of the services, goods, or other property to be provided under the contract.
NSD25-001
2025-2026 PSA (ESG)
Nature ofinterest
4
Name of Interested Party City, State, Country (place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party
6 UNSWORN DECLARATION
My name is Toby Owen
My address is 1513 E Presidio
(street)
I declare under penalty of perjury that the foregoing is true and correct.
, and my date of birth is March 3, 1972
Fort Worth TX 76102 USA
(city) (state) (zip code) (country)
Executed in Tarrant Countv counry, State of Texas , on the 13 day of FebrilarY , 20 25 .
(month) (year)
1
nature of authorized agent of contracting business entity
(Declarent)
❑X
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V4.1.0.5dd2ace2
Does Agency limit the eligibility of qualified handicapped employees for
promotion, training or other opportunities?
Does every Agency training program allow equal participation by
qualified handicapped employees?
❑ ❑✓ ❑
� � �
Checklist of Physical Requirements
Are accessible parking spaces available?
(Accessible parking spaces must be the closest to an accessible entrance.) �✓ � �
Is there an accessible ramp at the curb? I� ❑ ❑
(Curb ramp should be the closest to an accessible entrance.)
Are common use entrances accessible to persons with mobility � ❑ ❑
impairments?
Is an elevator available when needed for a client or employee? � ❑ ❑
(if the_ facility has two stories or more)
Is an accessible restroom available at the facility? � � �
Agency's Certification:
By signing this Self-Evaluation, 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 penalties of federal, state, and local law.
organiZation: LighthOUSe for the HOrt`�eleSS, dba True Worth Place
Typed Name: TOb)/ �WeCI
T'tle: hief Executive Officer
Signature: � Date: 2�12/2025
TI-�E CITY WILL NOT CONSIDER ANY PROPOSAL IN WHICH A SECTION 504 SELF-
EVALUATION/QUESTIONNAIRE IS NOT RECEIVED BY FRIDAY FEBRUARY 7, 2025
AT S:OOP.M.
SECTION 504 SELF-EVALUATION/OUESTIONNAIRE
The purpose of this self-evaluation is to assess the accessibility of City of Fort Worth sub-recipient Agencies'
federally funded programs and activities, and to assess whether persons with disabilities are given the same
opportunities for agency employment and for participation in such programs and activities as mandated by
Section 504 of the Rehabilitation Act of 1973 and 24 CFR Part 8 of HUD regulations.
Requirement
Yes No N/A Explain process
(as applicable)
Checklist of Administrative Requirements
For Agencies employing ] 5 or more employees, has an employee been
designated as a Section 504 coordinator?
(If so, please list the name of the employee(s).)
Has a Grievance Procedure for complaints of discrimination against
disabled persons been established?
(If so, please attach a copy.)
Can Agency furnish appropriate auxiliary aids to a disabled client when
appropriate?
(E.g. large print materials, hearing aids, notes, etc.)
Does Agency ensure that clients are made aware of Agency's non-
discriminatory policy? If so, by what means?
(E.g. website, application, etc.)
Can Agency provide application, pamphlets, contracts, etc. in large print if
requested by a client? (for the visually impaired)
Can Agency provide application, pamphlets, contracts, etc. in braille if
requested by a client?
(for the visually impaired)
Does Agency provide the national relay service phone number or
Telecommunicarion Devise for the Deaf (TDD) number on all
applications, pamphlets, contracts, etc.?
(for the hearing impaired)
Could Agency provide a sign language interpreter if needed for a client?
(for the hearing impaired)
Carrie Taylor,
� ❑ ❑ VP of HR
� ❑ ❑
See attached.
� � �
large print,
no hearing
aides
website,
� ❑ ❑ aPPlication,
posters displayed
at all locations
✓❑ ❑ ❑
❑ ❑✓ ❑
will provide
� � � upon request.
0 � �
Checklist of Employment Requirements
Note: Please attach a copy of the relevant portion(s) of your Program or Personnel Policies which address the
following items:
Does Agency ensure that all employees receive equal and fair treatment? � � �
Do Agency job announcements include a nondiscrimination statement? If � ❑ ❑ Presbyterian Night Shelter is an
equal opportunity employer.
so, please include the statement in the explanation column.
Are Agency job announcements posted in physically accessible areas? ✓ website
(E.g. Person in a wheelchair is able to read job announcement.) ❑ ❑ ❑
Are job announcements published in a manner that accommodates the website
needs of persons with disabilities? (E.g. on website, newspaper, etc.) ❑✓ ❑ ❑
��RT�OI�TH��
City Secretary's Office
Contract Routing & Transmittal Slip
Contractor's Name
Lighthouse for the Homeless dba True Worth Place
Subject of the Agreement: This agreement is between the City and the above agency receiving ESC
funds in the award amount of $150,000.00 to serve 3,375 unduplicated Fort Worth clients from October 1, 2025
to September30, 2026.
M&C Approved by the Council? * Yes ❑✓ No ❑
If so, the M&C must be attachecl to the cont�act.
Is this an Amendment to an Existing contract? Yes ❑ No ❑✓ N/A
If so, p�ovide the original contract nurnber and the amendment number.
Is the Contract "Permanent"? *Yes ❑ No 0
If unsuNe, see back page fo� permanent cont�^act listing.
Is this entire contract Confidentiial? *Yes ❑ No ❑✓ Ifonly specific info�mation is
Confidentzal, please list what information is Confidential and the page it is loeated.
N/A
Effective Date: 01 october 2025 Expiration Date: 3o September 2026
If �different from the approval date. If �applicable.
Is a 1295 Form required? * Yes ❑✓ No ❑
*If so, please ensure it is attached to the approving M&C or attached to the contract.
PrOjeCt Number: Ifapplicable. N�A
*Did you include a Text field on the contract to add the City Secretary Contract (CSC)
number? Yes ✓❑ No ❑
Contracts need to be routed for CSO nrocessin� in the followin� order:
1. Katherine Cenicola (Approver)
2. Jannette S. Goodall (Signer)
3. Allison Tidwell (Form Filler)
*Indicates the information is required and if the information is not provided, the contract will be
�eturned to the department.