HomeMy WebLinkAboutContract 41939 CITY SECRETARY
CONTRACT NO. l
AGREEMENT FOR SERVICES
THIS AGREEMENT ("Agreement") is made and entered into by and between THE
CITY OF FORT WORTH, a home rule municipal corporation of the State of Texas
(hereinafter referred to as "City"), acting by and through Susan Alanis, its duly authorized
Assistant City Manager, and UNITED COMMUNITY CENTERS, a nonprofit Texas
corporation (hereinafter referred to as "Contractor"), acting by and through Ms. Celia Esparza,
its duly authorized Executive Director.
RECITALS
WHEREAS, Contractor provides crisis intervention services; and
WHEREAS, such services serve a public purpose in serving low to moderate income individuals
which benefits the Fort Worth community; and
WHEREAS, City and Contractor desire to enter into a contract to have such services provided
which benefit the Fort Worth community.
NOW, THEREFORE, in consideration of the mutual covenants herein expressed, the parties
agree as follows:
AGREEMENT
1. SCOPE OF SERVICES.
Contractor covenants and agrees to fully perform, or cause to be performed, with
good faith and due diligence, all services and objectives described in Exhibit "A," attached and
incorporated herein for all purposes incident to this Agreement("Services").
2. COMPENSATION.
In consideration of the Services to be performed hereunder by Contractor, City agrees to
reimburse Contractor via monthly installments up to a total amount not to exceed Five Thousand
Four Hundred and No/100 ($5,400.00) ("Funds"). Any funds not requested as provided in
Section 3 shall remain with the City.
OFFICIAL RECORD
CITY SECRETARY
FT WORTHo TX
3. REPORTING OF EXPENDITURES.
a. Contractor shall deliver to City a monthly statement of the request for reimbursement
("Request for Reimbursement") of Funds detailing how the Funds were expended by
Contractor to accomplish performance of the Services. All expenditures included in the Request
for Reimbursement must be eligible for reimbursement by federal funds as determined by City in
its sole discretion. The monthly statement shall be in the same format as the attached Exhibit
"B"which is incorporated herein for all purposes.
b. Each month's Request for Reimbursement is due to City by 5:00 p.m. on the I 01 day
of the following month (for example, all expenses for June must be submitted to City by July
10th). City will not accept late Requests for Reimbursement. If a timely Request for
Reimbursement is not received for any month, Contractor will not receive reimbursement for that
month. Notwithstanding the above, the Request for Reimbursement for the month of September
shall be due by September 23, 2011. The failure to make such request by September 23, 2011
shal l result in no funds being paid for the month of September.
c. Each Request for Reimbursement must be prepared and signed by an authorized
representative of the Contractor.
d. If the Contractor deviates from the reporting requirements in Sections 3(a), 3(c) or
Section 4, the Contractor will be considered in non-compliance with this Agreement. City will
notify Contractor of such non-compliance, and Contractor will have ten (10) business days to
cure such non compliance (the "Cure Period"). If the noncompliance is not cured by the
expiration of the Cure Period to City's satisfaction, Contractor will be in default of this
Agreement and will not receive reimbursement.
e. Any non-compliance by Contractor under Section 3 of this Agreement may jeopardize
the Contractor's ability to receive future funding from the City.
4. REPORTING OF SERVICES.
A report of services shall accompany each Request for Reimbursement. The report of
services shall be in substantial conformity with the attached Exhibit "C" and Exhibit "C-1"
and Exhibit "C-2", if applicable. Contractor shall be subject to a review by the City of its
services and activities in performance of this Agreement.
5. TERM AND TERMINATION.
a. This Agreement shall be for a term beginning June 1, 2011 and ending September
30, 2011.
b. Either party may cancel this Agreement upon thirty (30) days notice in writing to
the other party of such intent to terminate.
2
C. The City may terminate this Agreement immediately for any violation by
Contractor of Section 3, "Request for Reimbursement" or Section 4, "Reporting of Services,"
above.
d. In the event no funds or insufficient funds are appropriated by the City in any fiscal
period for any payments hereunder, City will notify the Contractor of such occurrence and this
Agreement shall terminate on the last day of the fiscal period for which appropriations were
received without penalty or expense to City of any kind whatsoever, except as to the portions of
the payments herein agreed upon for which funds shall have been appropriated.
6. RIGHT TO MONITOR SERVICES.
Contractor covenants and agrees to fully cooperate with City in monitoring the
effectiveness of the Services to be performed under this Agreement,and City shall have access at
all reasonable hours to offices and records of Contractor for the purpose of such monitoring
during the term of this agreement.
7. INDEPENDENT CONTRACTOR.
Contractor shall operate hereunder as an independent contractor and not as an officer,
agent, servant, or employee of City. Contractor shall have exclusive control of and the exclusive
right to control the details of the Services performed hereunder, and all persons performing same,
and shall be solely responsible for the acts and omissions of its officers, agents, servants,
employees, subcontractors and program participants. The doctrine of respondeat superior shall
not apply as between the City and Contractor, its officers, agents, servants, employees,
subcontractors, or program participants, and nothing herein shall be construed as creating a
partnership or joint enterprise between City and Contractor. It is expressly understood and
agreed that no officer, agent, employee, or subcontractor of Contractor is in the paid service of
City.
8. LIABILITY AND INDEMNIFICATION.
CITY SHALL IN NO WAY OR UNDER ANY CIRCUMSTANCES BE
RESPONSIBLE FOR ANY PROPERTY BELONGING TO CONTRACTOR, ITS
OFFICERS, AGENTS, EMPLOYEES, SUBCONTRACTORS, PROGRAM
PARTICIPANTS, OR RECIPIENTS, WHICH MAY BE LOST, STOLEN, DESTROYED,
OR IN ANY WAY DAMAGED. CONTRACTOR HEREBY AGREES TO INDEMNIFY
AND HOLD HARMLESS THE CITY, ITS OFFICERS, AGENTS, AND EMPLOYEES
FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS CONCERNING SUCH
PROPERTY. CONTRACTOR COVENANTS AND AGREES TO INDEMNIFY, HOLD
HARMLESS AND DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS,
AGENTS, SERVANTS, AND EMPLOYEES FROM AND AGAINST ANY AND ALL
CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL
INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER
KIND OR CHARACTER, WHETHER REAL OR ASSERTED,ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS AGREEMENT AND/OR THE
3
OPERATIONS, ACTIVITIES AND SERVICES DESCRIBED HEREIN, WHETHER OR
NOT CAUSED, IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF
OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS, OR
SUBCONTRACTORS OF CITY; AND CONTRACTOR HEREBY ASSUMES ALL
LIABILITY AND RESPONSIBILITY OF CITY AND ITS OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES FOR ANY AND ALL CLAIMS OR SUITS FOR
PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH,
TO ANY AND ALL PERSONS, OF WHATSOEVER HINDS OR CHARACTER,
WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH
THE EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR NON-
PERFORMANCE OF THIS AGREEMENT AND/OR THE OPERATIONS,ACTIVITIES
AND SERVICES DESCRIBED HEREIN, WHETHER OR NOT CAUSED IN WHOLE
OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS,
EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY. CONTRACTOR
LIKEWISE COVENANTS AND AGREES TO AND DOES HEREBY INDEMNIFY AND
HOLD HARMLESS CITY FROM AND AGAINST ANY AND ALL INJURY, DAMAGE
OR DESTRUCTION OF PROPERTY OF CITY, ARISING OUT OF OR IN
CONNECTION WITH ALL ACTS OR OMISSIONS OF CONTRACTOR, ITS
OFFICERS, MEMBERS, AGENTS, EMPLOYEES, SUBCONTRACTORS, INVITEES,
LICENSEES, PROGRAM PARTICIPANTS, OR RECEIPIENTS, WHETHER OR NOT
CAUSED, IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS,
AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF
CITY. CONTRACTOR AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY
FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY
SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE
UNDER THIS AGREEMENT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS
CAUSED BY CITY'S SOLE OR CONCURRENT NEGLIGENCE.
Contractor shall require all of its subcontractors and Recipients to include in their
subcontracts a release and indemnity in favor of City in substantially the same form as
above.
9. MISAPPRORIATION OF FUNDS.
IN THE EVENT IT IS DETERMINED THAT CONTRACTOR HAS MISUSED,
MISAPPLIED OR MISAPPROPRIATED ALL OR ANY PART OF THE FUNDS
PROVIDED HEREUNDER, CONTRACTOR AGREES TO INDEMNIFY, HOLD
HARMLESS AND DEFEND THE CITY OF FORT WORTH, ITS OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES, FROM AND AGAINST ANY AND ALL CLAIMS OR
SUITS RESULTING FROM SUCH MISUSE, MISAPPLICATION OR
MISAPPROPRIATION.
4
10. CHARITABLE IMMUNITY.
If Contractor, as a charitable or nonprofit organization, has or claims an immunity or
exemption (statutory or otherwise) from and against liability for damage or injury, including
death, to persons or property, Contractor hereby expressly waives its rights to plead defensively
such immunity or exemption as against the City.
11. ASSIGNMENT AND SUBCONTRACTING.
Contractor shall not assign or subcontract all or any part of its rights, privileges or duties
under this Agreement without the prior written consent of City, and any attempted assignment or
subcontract of same without such prior written approval shall be void and constitute a breach of
this agreement.
12. COMPLIANCE WITH LAWS, ORDINANCES,RULES AND REGULATIONS.
Contractor, its officers, agents, employees and subcontractors, shall abide by and comply
with all laws, federal, state and local, including all ordinances, rules and regulations of City. It is
agreed and understood that, if City calls to the attention of Contractor any such violation on the
part of Contractor or any of its officers, agents, employees or subcontractors, then Contractor
shall immediately desist from and correct such violation.
13. NON-DISCRIMATION COVENANT.
Contractor, in the execution, performance or attempted performance of this contract and
Agreement, will not discriminate against any person or persons because of disability, age,
familial status, sex, race, religion, color, national origin, gender identity, gender expression or
transgender nor will Contractor permit its officers, agents, employees, or subcontractors to
engage in such discrimination. This Agreement is made and entered into with reference
specifically to Chapter 17, Article III, Division 3, of the City Code of the City of Fort Worth
("Discrimination in Employment Practices"), and Contractor hereby covenants and agrees that
Contractor, its agents, employees and subcontractors have fully complied with all provisions of
same and that no employee or employee-applicant has been discriminated against by either
Contractor, its agents, employees or subcontractors.
14. INSURANCE.
Contractor shall procure and shall maintain during the term of this Agreement the
following insurance coverage:
1. Commercial General Liabilitv (CGL): $1,000,000 per occurrence, with a
$2,000,000.00 annual aggregate limit, in a form that is acceptable to the
City's Risk Manager.
2. Non-Profit Organization Liability or Directors & Officers Liability_:
$1,000,000 per occurrence, with a $1,000,000 annual aggregate limit, in a
form that is acceptable to the City's Risk Manager.
5
Contractor's insurer(s) must be authorized to do business in the State of Texas for the lines of
insurance coverage provided and be currently rated in terms of financial strength and solvency to
the satisfaction of the City's Risk Manager.
Each insurance policy required herein shall be endorsed with a waiver of subrogation in favor of
the City. Each insurance policy required by this Agreement, except for policies of worker's
compensation or accident/medical insurance shall list the City as an additional insured. City
shall have the right to revise insurance coverage requirements under this Agreement.
Contractor further agrees that it shall comply with the Worker's Compensation Act of Texas and
shall provide sufficient compensation insurance to protect Contractor and City from and against
any and all Worker's Compensation claims arising from the work and services provided under
this Agreement.
15. RIGHT TO AUDIT RECORDS.
Contractor agrees that the City shall, until the expiration of three (3) years after final
payment under this Agreement, have access to and the right to examine, whether in hard copy or
electronic format, any directly pertinent books, documents, papers and records of the Contractor
involving transactions relating to this Agreement. Contractor agrees that the City shall have
access during normal working hours to all necessary Contractor facilities and shall be provided
adequate and appropriate workspace in order to conduct audits in compliance with the provisions
of this section. The City shall give Contractor reasonable advance notice of intended audits.
Contractor further agrees to include in all of its subcontractor and Recipient agreements
hereunder a provision to the effect that the subcontractor and/or the Recipient agrees that the
City shall, until the expiration of three (3) years after final payment under the subcontract or this
Agreement, have access to and the right to examine, whether in hard copy or electronic format,
any directly pertinent books, documents, papers and records of such subcontractor involving
transactions to the subcontract or this Agreement, and further that City shall have access during
normal working hours to all subcontractor or Recipient facilities and shall be provided adequate
and appropriate workspace in order to conduct audits in compliance with the provisions of this
paragraph. City shall give subcontractor or Recipient reasonable advance notice of intended
audits. This Section 16 shall survive the expiration of the term of this Agreement.
16. GOVERNING LAW AND VENUE.
This Agreement shall be governed by and construed under the laws of the state of Texas.
Should any action, whether real or asserted, at law or in equity, arise out of the execution,
performance, attempted performance of this Agreement, venue for said action shall lie in Tarrant
County, Texas.
6
17. NOTICES.
Notices to be provided hereunder shall be sufficient if forwarded to the other party by
hand-delivery or via U.S. Postal Service certified mail, postage prepaid, to the address of the
other party shown below:
Jesus"Jay"Chapa Ms. Celia Esparza
Director of Economic Development Executive Director
City of Fort Worth United Community Centers
1000 Throckmorton St. 1200 E. Maddox
Fort Worth, Texas 76102 Fort Worth, TX 76104
18. NO WAIVER.
The failure of City or Contractor to insist upon the performance of any term or provision
of this Agreement or to exercise any right herein conferred shall not be construed as a waiver or
relinquishment to any extent of City's or Contractor's right to assert or rely upon any such term
or right on any future occasion.
19. DISCLOSURE OF CONFLICTS AND CONFIDENTIAL INFORMATION.
Contractor hereby warrants to the City that Contractor has made full disclosure in
writing of any existing or potential conflicts of interest related to Contractor's services under
this Agreement. In the event that any conflicts of interest arise after the Effective Date of this
Agreement, Contractor hereby agrees immediately to make full disclosure to the City in
writing. Contractor, for itself and its officers, agents and employees, further agrees that it shall
treat all information provided to it by the City as confidential and shall not disclose any such
information to a third party without the prior written approval of the City. Contractor shall store
and maintain City Information in a secure manner and shall not allow unauthorized users to
access, modify, delete or otherwise corrupt City Information in any way. Contractor shall notify
the City immediately if the security or integrity of any City information has been compromised
or is believed to have been compromised.
20. SEVERABILITY.
If any provision of this Agreement is held to be invalid, illegal or unenforceable, the
validity, legality and enforceability of the remaining provisions shall not in any way be affected
or impaired.
21. FORCE MAJEURE.
The City and Contractor shall exercise their best efforts to meet their respective duties
and obligations as set forth in this Agreement, but shall not be held liable for any delay or
omission in performance due to force majeure or other causes beyond their reasonable control
(force majeure), including, but not limited to, compliance with any government law, ordinance
or regulation, acts of God, acts of the public enemy, fires, strikes, lockouts, natural disasters.
7
wars, riots, material or labor restrictions by any governmental authority, transportation problems
and/or any other similar causes.
22. HEADINGS NOT CONTROLLING.
Headings and titles used in this Agreement are for reference purposes only and shall not
be deemed a part of this Agreement.
23. ENTIRETY OF AGREEMENT.
This written instrument constitutes the entire agreement by the parties hereto concerning
the work and services to be performed hereunder, and any prior or contemporaneous, oral or
written agreement, which purports to vary from the terms hereof shall be void.
[SIGNATURES APPEAR ON FOLLOWING PAGE.]
8
IN WITNESS WHEREOF, the parties hereto have executed this agreement in multiples in Fort
Worth, Tarrant County, Texas,to be effective June 1,2011.
ATTE • CITY OF ORT WORT
B XAr
is �x F® a`� y.S se* nt is
ty Secretary o oeUo
pp�Uo �QO0�t�� As ity Ma nager
o
Date: X d�`$ o
Date: �t
o-
APPROVED AS TOFOI > y. CONTRACT
AUTHORIZATION.• aXM,j a�
uu
M&C: C-24905
Leann D. Guzman
Assistant City Attorney Date Approved: 05/17/2011
Date: �(
ATTEST United Community Centers:
By:
Name:
Title: Name: Ms. Celia Esparza
Title: Executive Director
Date: 31 - /1
M IAI.RE�p Y SECRE'w®RTtI,TX
9
STATE OF TEXAS §
COUNTY OF TARRANT §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas,
on this day personally appeared Ms. Celia Esparza, known to me to be the person whose name
is subscribed to the foregoing instrument and acknowledged to me that the same was the act of
the United Community Centers and that she executed the same as the act of said United
Community Centers for the purpose and consideration therein expressed and in the capacity
therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this day of
2011.
li�r Y
SHARON A. BARTEIIS
rvrn �� Gfi 2�J1 e_-D
Notary Public,State of Texas Notary Public in and for the State of Texas
,tits; My Commission Expires
December 16,2012
STATE OF TEXAS §
COUNTY OF TARRANT §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of Texas,
on this day personally appeared Susan Alanis, known to me to be the person whose name is
subscribed to the foregoing instrument and acknowledged to me that the same was the act of the
City of Fort Worth for the purpose and consideration therein expressed and in the capacity
therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this A_day of�JLU1e, ,
2011.
otary Public in and for the StOte of Texas
rt LINDA M.HIRRLINGER
L RECORD ?' "= MY COMMISSION EXPIRES
OFFICIA �..... r-ennary2,2oia
CITY SECRETARY
„�
F. .WORTH,'TX
10
EXHIBIT A
SERVICES
11
United Community Centers,Inc. EXHIBIT A
Crisis Intervention Program SCOPE OF SERVICES
PROGRAM SUMMARY
COMMUNITY DEVELOPMENT BLOCK GRANT(CDBG)
June 1, 2011 — September 30, 2011
PERIOD
SCOPE OF SERVICES
This Scope of Services is based on the proposal prepared and submitted by the Subrecipient through the City of Fort
Worth's annual Request for Proposal(RFP)process. The Subrecipient agrees to operate this Community Development
Block Grant(CDBG)program in a manner consistent with the program delivery stated in the approved proposal.
However, in the event of any conflict between the proposal and any provision contained,herein,this Agreement shall
control.
The United Community Centers, Inc. will provide Public services to 900 eligible clients at United Community Centers,
Inc. The Crisis Intervention program will include the following tasks and activities;provide emergency groceries to
income eligible households and families,and provide supplemental groceries for Senior Citizens on fixed incomes, and
provide short term case management services for those families needing further services. All services will be provided at
3103 Avenue J from 9:00 am— 1:00 pm Monday, Wednesday and Thursday and 9:00 am— 11:00 am on Fridays. In
addition,each 3rd Friday of each month serves only senior citizens.
The purpose of the program will be to provide emergency grocery assistance and case management to low-income
individuals and families. The specific objectives,goals and level of services to be provided are listed below along with
the geographical location of clients served. All services will be provided from June 1,2011 to September 30,2011.
The funds will be used to pay for salaries for a Client Intervention Specialist and Bi-lingual Case Manager(describe
costs)which is consistent with Exhibit C-Detailed Budget.
REGULATORY CLASSIFICATION:
National Objective Citation: 24 CFR 570.208(a)(2)(B)Limited Clientele
Regulatory Citation: 24 CFR 570.201(e)Public Service
Based on the nature of the service provided, United Community Centers,Inc. will maintain documentation that verifies
that 51%of clients served by the Crisis Intervention program are income eligible with current household incomes under
80%of Area Median Income(AMI)as established by the Department of Housing and Urban Development(HUD).
GEOGRAPHICAL LOCATION:
Site Address: 3103 Avenue J,Fort Worth, Texas, 76105
Client Beneficiary Location (Neighborhood, District, Citywide...): Southeast Fort Worth, Council
District 8
PROGRAM GOALS:
I. Clients needing more intensive case management intervention will receive that assistance from the Case Management
Coordinator or from the Client Intervention Specialists.
2. Client Intervention Program will develop a network of providers and referral sources so that clients can access needed
services.
3. Client Intervention Program will provide supplemental food to Senior Citizens.
4. Client Intervention Program will provide food for individuals and families in crisis.
PROGRAM OBJECTIVES:
• 80%of clients who receive case management services will be able to access needed services.
• Coordinator will schedule 60 families for additional resource referrals and intervention services.
• The Client Intervention Program will serve all Senior Citizens on a fixed income who apply for assistance by providing
monthly supplemental groceries;the groceries will be picked up by the Senior Citizens or delivered to their homes.
• The Client Intervention Program will provide emergency food for all clients in crisis that apply for assistance.
PROGRAM SERVICES and ACTIVITIES
Level of service should be identified in a quantifiable unit and directly related to specified objectives.
Number of Unduplicated Clients Served
Provide resource referrals to clients
Provide supplemental groceries to Senior Citizens
Provide emergency food for Fort Worth residents in need
EXHIBIT B
FORM OF REQUEST FOR REIMBURSEMENT
[ATTACHED]
12
CITY OF FORT WORTH
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
COMPLIANCE DIVISION
REQUEST FOR FUNDS
AGENCY:
ADDRESS: PROGRAM:
CONTRACT NUMBER:
CONTRACT AMOUNT:
CONTRACT DATE:
DATE OF REQUEST:
IDIS NUMBER:
SECTION I(AGENCY) CURRENT MONTH CUMULATIVE
I. Reimbursement Request
A. Expenditures: $
B. Reimbursement $
2.Requested By:
A. Agency
(Name) (Signature)
(Date)
SECTION II(CITY)
1. BUYSPEED-Purchasing Request
A.BUYSPEED INPUT:Vendor/PO Number/Requisition Number:
B. Fund/Account/Center:
C.Total Amount of this Request: $
SECTION III(CITY)
1. Verification
A. Contract Compliance Specialist Mark Folden
(Name) (Signature) Date
B. Accounting Benedict George (Date)
2.Authorization (Name) (Signature) (Date)
A. Grants Manager Robin Bentley
(Name) (Signature) (Date)
B.Sr.Admin.Services Mgr Socorro Gray
(Name) (Signature) (Date)
C. Director Jesus Chapa
(Name) (Signature) (Date)
Note:Any Request for Funds that exceeds$25,000 requires the Director's signature
CITY OF FORT WORTH
HOUSING AND ECONOMIC DEVELOPMENT DEPARTMENT
DETAIL STATEMENT OF COSTS
AGENCY CONTRACT NO. DATE
TO
PROGRAM REPORT PERIOD
PROGRAM MONTHLY CUMULATIVE
COST CATEGORY BUDGET EXPENDITURES TO DATE BALANCE
ADMINISTRATIVE COSTS
Salaries
FICA
Life Insurance
Health Insurance
Unemployment Tax
Worker's Comp
Legal and Accounting
Office Supplies
PROGRAMMATIC COSTS
Salaries 5,400.00
FICA
Life Insurance
Health Insurance
Unemployment—Federal
Unemployment—State
Workers Compensation
Medical Supplies
Security
Utilities(Telephone,Electric,Gas,
Water,Wastewater,Waste Disposal)
Rent
Office Equipment Rental
Printing
-Accounting
Postage
Building Maintenance and Repair
Office Supplies
Food
Other Operating Supplies
Liability Insurance
Private Auto Allowance
Childcare Scholarship s
Meals
Teaching Aids
Contractual Services
Contract Labor
Conferences and Seminars
Short Term Rent,Mortgage and Utility
Assistance STRMU
Tenant Based Rental Assistance
TBRA
TOTAL $0.00 $0.00 $0.00 $0.00
Contractor's Certification: I certify that the costs incurred are taken from the books of account and that such costs are valid and
consistent with the terms of the agreement.
NAME and TITLE OF AUTHORIZED OFFICER SIGNATURE and DATE
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
EXPENDITURES WORKSHEET
Agency Contract Number Date
Pr ram
Report Period To
NO DATE CHECK NO PAYEE DESCRIPTION ACCOUNT NO. AMOUNT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
TOTAL 50.00
TITLE OF AUTHORIZED OFFICER SIGNATURE AND DATE
15
EXHIBIT C
FORM OF SERVICES REPORT
16
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
Month&Year
5. Program Services and Activities
Current Month Cumulative
Number of New
Households and/or
Persons Served
6.Direct Benefit
tConttnued)
Extremely Low Very Low Income Low Income Above Low Income
_ Income 0<30% 31-50% 51-80% 80°/*>
Current Month
Cumulative
Household Size 1 2 3 4 5 6 7 8
O-30% $13,850 $15,850 $17,800 $19,800 $21,400 $22,950 _$24,550 $26,150
31-50% $23,100 $26,400 $29,700 $33,-000 $35,650 $38,300 $40,900 $43,550
51-80% $36,950 $42,250 $47,500 $52,800 $57,000 $61,250 $65,450 $69,700
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and accurate. It
is also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,state,and local law.
Date: Submitted by: Phone No.
Signature Required
17
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
Month&Year
8. Direct Benefit Data(New Household and/or Persons Served)
Ethnicity:
(Section
Race:Section Must be Com leted Completed)Must be
Non-
Hispanic Hispanic Non-
Current Current Hispanic Current Hispanic
Month Cumulative Month Cumulative Month Cumulative
White
Black/AfricanAmerican
Asian
American indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
Indian/Alaskan Native&White
Asian&White
Black/African American&White
American Indian/Alaskan Native&Black
African American
Other Multi-Racial
TOTAL 0 0 0 0 0 0
Female
Head of
Household
Current Month
Cumulative
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this
report is true and accurate. It is also acknowledged that the provision of false information could leave the certifying official
subject to the penalties of federal,state,and local law.
Date: Submitted by:
Signature Required
18
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
CURRENT
5. PROGRAM SERVICES AND ACTIVITIES: CUMULATIVE
Unduplicated Clients
6. SCOPE OF WORK NARRATIVE:
7. PROBLEMS ENCOUNTERED / SOLUTIONS
PROPOSED:
8. ANTICIPATED ACTIVITY DURING THE NEXT
MONTH:
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and
accurate. It is also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,
state,and local law.
Date: Submitted By: Phone No
Signature
Required
19
ayi m
L L
L
id
m
L 41
V) o
C
Y
V
m
= o
� m
= m
LL
ai N
C� � C
G v
0 d
C A
m
E
co
w
L v
L
o
r
z od c
W
a 0 G
G
G1 m a
H V 'o c
0: W O r m
O a a row
W y
H
� w Q a m
> a m
LL c o
LL U
0
Wes, m aoi
vov W 3=
U Y C
a
W
a
o� m
E m
R o
D m�
O a m
s c 0 Ya
IL Q ° m
.. m
lV �p V
r
m O
A
A .�
m m �
Im
�m �
m 3 �
m L O
m 0 v
C 0
�O
M
Lo
0
m
Z m~f
R O O
C A O �
E
m E o m :3 0 UCLOZ
z
EXHIBIT C-1
ADDITIONAL FORM OF SERVICES REPORT-ESG AGENCIES
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
Beneficiary by Housing Type:EMERGENCY OR TRANSITIONAL SHELTERS
Current Month Cumulative
Chronically Homeless(Emergency Shelter only)
Severely Mentally III
Chronic Substance Abuse
Other Disability
Veterans
Persons with HIV/AIDS
Victims of Domestic Violence
Elder)
TOTAL 0 0
Beneficiary by Housing Type:Number served in Emergency or Transitional Shelters
SHELTER TYPE Current Month Cumulative
Barracks
Group/Large House
Scattered Site Apartment
Single Family Detached House
Single Room Occupancy
Mobile Home/Trailer
Hotel/Motel
Other
TOTAL 0 0
ESG Funding Sources: Funding Amount Current Month Cumulative Total
ESG
Other Federal
Local Government
Private
Fees
Other
Total
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and accurate. It is
also acknowledged that the provision of false information could leave the certifying offici
Date: Submitted by: Phone No.
Signature Required
22
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
EMERGENCY OR TRANSITIONAL SHELTERS
NUMBER OF INDIVIDUAL HIOUSEHOLDS SINGLES: Current Month Cumulative
Unaccompanied 18 and over Male Female
Unaccompanied under 18 Male Female
NUMBER OF FAMILY HOUSEHOLDS WITH CHILDREN HEADED BY: Current Month Cumulative
Single 18 and over Male Female
Single under 18 Male Female
NUMBER OF FAMILY HOUSEHOLDS WITH NO CHILDREN:
TOTAL
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true
and accurate. It is also acknowledged that the provision of false information could leave the certifying offici
Date: Submitted by: Phone No.
Signature Required
23
EXHIBIT C-2
ADDITIONAL FORM OF SERVICES REPORT-HOPWA AGENCIES
24
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
5. Program Services and Activities(Report Clients,Not Payments)
HOPWA
CURRENT #Assisted Amount of
MONTH With Other Other
ONLY Cumulative Funds Funds
a.#of Tenant-Based Rental Assistance TBRA
b.#of Short-Term Rental,Mortgage and Utility Assistance STRMU
c.#of STRMU clients that have moved to TBRA
d.Total#of Unduplicated Clients a+b-c
Number of Households
HOPWA #
CURRENT ASSISTED AMOUNT
MONTH AMOUNT OF Wr OTHER OF OTHER
ONLY CUMULATIVE HOPWA FUNDS FUNDS FUNDS
6.Supportive Services
7. Resource Identificationrrechnical Assistance
8. Housing Information Services
9. Permanent Housing Placement Services
10. Monthly Income Groups of Households for all Unduplicated
Clients
Tenant Based Rental Assistance TBRA
$251-
50-250 500 $501-1000 $1001-1500 $1501-2000 Over$2000 TOTAL
Current
Month 0
Cumulative 0
Short,Term Rent,Mort a Utilltv Asst.(ST MU)
$251-
50-250 500 $501-1000 $1001-1500 $1501-2000 Over$2000 TOTAL
Current
Month 0
Cumulative 0
For Clients Receiving Sup rtive Services 0 I(unduplicated)
$251-
$0-250 500 $501-1000 $1001-1500 $1501-2000 Over$2000 TOTAL
Current
Month 0
Cumulative 0
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and
accurate. It is also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,state,
and local law.
DATE: Submitted by: Phone Number:
Signature Required
25
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
Tenant Based Rental Assistance-(TBRA)
Ethnicity:(Section
Race:Section Must be Completedi Must be
Completed)
Non-
Hispanic Non-
Hispanic Hispanic Current Hispanic
hite Current Month Cumulative Current Month Cumulative Month Cumulative
W
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific
Islander
Indian/Alaskan Native&White
Asian&White
Black/African AmericanBWhite
American India NAlaskan Native&
Black African American
Other Multi-Racial
TOTAL 0 1 0 0 0
0 p
Current
Month
Undu Ilcated Beneficia Data Total Unduplicated Female TBRA Male TBRA
Number of A Particl nts Participants
persons(Adults and
Children with HIV/AIDS who 17 and
received Housing Assistance Under
Number of Other Persons In Family
unit who received Housing 18 to 30
Assistance Years
Households Previously Homeless 31 to 5o
Of Previously Homeless Years
Households,number of those who 51 Years
were Chronlcal Homeless and Older
Total
Female Head
This data re/ages to participants of Household
Current Month
Cumulative
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and accurate. It is
also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,state,and local law.
Date: Submitted by: Phone No.
Signature Required
26
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
I. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
Short Term Rent,Mortgage,and Utility Assistance STRMU
Ethnicity:(Section
Must be
Race:Section Must be Completed) Completed)
Non-
Hispanic Non-
Hispanic Hispanic Current Hispanic
White Current Month Cumulative I Current Month Cumulative Month Cumulative
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific
Islander
Indian/Alaskan Native$White
Asian 8 White
Black/African AmericanBWhite
American Indian/Alaskan Native 8
Black African American
Other Multi-Racial
TOTAL 0 0 0 0 0 0
Current
Month
Unduplicated Female TBRA Male TBRA
Unduplicated Beneficla Data Total A Participants Partici nts
Number of persons(Adults and
Children with HIV/AIDS who 17 and
received Housing Assistance Under
Number of Other Persons In Family
unit who received Housing 18 to 30
Assistance Years
31 to 50
Households Previously Homeless Years
Of Previously Homeless
Households,number of those who 51 Years
were Chronically Homeless and Older
Total
Female Head
This data relates to participants of Household
Current Month
Cumulative
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and accurate. It is
also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,state,and local law.
Date: Submitted by: Phone No.
Signature Required
27
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
Supportive Services
Ethnicity:(Section
Must be
Race:Section Must be Completed) Completed)
Non-
Hispanic Non-
Hispanic Hispanic Current Hispanic
White Current Month Cumulative Current Month Cumulative Month Cumulative
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific
Islander
Indian/Alaskan Native&White
Asian&White
Black/African American&White
American Indian/Alaskan Native&
Black African American
Other Multi-Racial
TOTAL 0 0 0 0 0 0
Current
Month
Unduplicated Female TBRA Male TBRA
Unduplicated Beneficiary Data Total Age Participants Participants
Number of persons(Adults and
Children with HIV/AIDS who 17 and
received Housing Assistance Under
Number of Other Persons in Family
unit who received Housing 18 to 30
Assistance Years
31 to 50
Households Previously Homeless =andlder
Of Previously Homeless
Households,number of those who
were Chronically Home k�ss
Female Head
This data relates to participants of Household
Current Month
Cumulative
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and accurate. It is
also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,state,and local law.
Date: Submitted by: Phone No.
Signature Required
28
CITY OF FORT WORTH
HOUSING&ECONOMIC DEVELOPMENT DEPARTMENT
1. Name and Address of Sub-Grantee 2. Program Name
3. Contract Number
4. Date of Request
Date and Year
"All data reported should be unduplicated for the current month
Number of Current Month Number of households Amount of Other
households Expene tares with Other funds(whether funds(whether
with HOPWA Amount of HOPWA from Grantee or other from Grantee or
Supportive Services funds funds sources) other sources
a. Outreach
b. Case Management
c. Life Management
d. Nutritional Services/Meals
e. Adult Day Care and Personal Assistance
f. Child Care and other Children's Services
g. Education
h. Employment Assistance
i. Alcohol and Drug Abuse Services
j. Mental Health Services
k. Health/Medical/Intensive Care Services
I. Transportation
m. Other(specify)
n. Other(specify
o. Number of Jobs that resulted from g.and h.
TOTAL
(current month HOPWA expenditure column
should equal total in supportive service section on
Attachment/1
Receiving
Supportive
Services w/ Receiving
Housing Supportive Services
Current Month Undu licated Only Assistance Only
Persons with HIV/AIDS
Other Persons in Family Unit
Certification: The undersigned,hereby,gives assurance that to the best of my knowledge and belief,the data included in this report is true and
accurate. It is also acknowledged that the provision of false information could leave the certifying official subject to the penalties of federal,state,
and local law.
Date: Submitted by: Phone No.
Signature Required
29