HomeMy WebLinkAboutContract 42369 CITY SECRETARY
CONTRACT N o, 4a3
3
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 United Community Centers, Inc. (hereafter
"Contractor"), a Texas nonprofit corporation. City and Contractor 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 ("HUD") through the Community Development Block
Grant Program ("CDBG"), Program No. B-11-MC-48-0010 Catalog of Federal Domestic
Assistance No. 14.218;
WHEREAS, a national objectives of the CDBG program is to benefit low and
moderate income citizens (the "National Objective");
WHEREAS, Contractor submitted a proposal to use CDBG funds for an eligible
Program (defined below) under the CDBG Regulations (defined below) whereby
Contractor will provide services as further described in Exhibit "A"- Program
Summary;
WHEREAS, City citizens, the Community Development Council, and the City
Council have determined that CDBG programs are needed by the City's citizens;
NOW, THEREFORE, the Parties understand and agree as follows:
1. INCORPORATION OF RECITALS.
City and Contractor 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 following terms shall
have the definitions ascribed to them as follows:
Area Median Income (AMI) means the median family income for the Fort Worth-
Arlington metropolitan statistical area as established by HUD. The 2011 income limits
are attached hereto as Exhibit F.
Complete Documentation means a report or reports i rm acceptable to City that
contains a summary of all CDBG eligib ex ei for the Program with the
supporting documentation as appropri te: ilLa�;Ak j for all expenses and other
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documents such as an approved check request, cancelled checks, bank statements, or wire
transfers necessary to demonstrate that such amounts were actually paid,; (ii) copies of
approved timesheets and other documents such as cancelled checks, bank statements,
direct deposit forms necessary to demonstrate that such amounts were actually paid; (iv)
sufficient proof to show client income eligibility; and (v) any other document or records
reasonably necessary to verify costs spent and client eligibility for such Program.
CDBG Eligible Client means a client whose annual income adjusted for family size does
not exceed 80% of AMI using the most current HUD Income Guidelines and Technical
Guidance for Determining Income and Allowances verified by either Source
Documentation or Income Self-Certification forms (Exhibit E). The definition of annual
income to determine client income eligibility under this Contract shall be the definition
contained in 24 CFR Part 5.609 as amended from time to time.
CDBG Funds means City's CDBG funds supplied by City to Contractor under the terms
of this Contract.
CDBG Regulations means regulations found in 24 CFR Part 570.
Program shall mean the service(s) described in Exhibit A—Program Summary.
Reimbursement Request shall mean all reports and other documentation described in
Section 9.
Source Documentation means any documentation allowed under the 24 CFR Part 5.609
definition of annual income.
3. TERM.
3.1 Term.
The term of this Contract begins on October 1, 2011 (the "Effective Date") and
terminates on September 30, 2012 unless terminated as provided in this Contract. This
contract is contingent upon receipts of CDBG funds by City. If CDBG funds are not
received or if City's allocation of CDBG funds changes, City reserves the right to amend
or terminate this Contract. Also, no funds will be available for reimbursement to agencies
until City's 2011-2012 Action Plan is approved by HUD and a grant agreement is
received by City.
4. DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Reimbursement of CDBG Funds.
City shall pay up to Twenty Eight Thousand One Hundred Fifty Four and No/100
($28,154.00) of CDBG Funds on a reimbursement of expenses basis, under the terms and
conditions herein.
4.2 City Will Monitor.
City will monitor the activities and performance of Contractor and any of its
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contractors or subcontractors as necessary, but no less than annually.
5. CONTRACTOR OBLIGATIONS.
5.1 Required Services.
In accordance with the terms and conditions of this Contract, Contractor shall
perform the service as described in Exhibit "A"—Program Summary.
5.2 Use of CDBG Funds.
5.2.1. Expenditures in Compliance with CDBG Regulations and Contract.
Contractor shall be reimbursed for the Program costs with CDBG Funds only if:
5.2.1.1 Costs are eligible expenditures in accordance with CDBG
Regulations as determined by the City in its sole discretion.
5.2.1.2 Costs are in compliance with this Contract as determined by the
City in its sole discretion and are reasonable and consistent with industry
norms.
5.2.1.3 Contractor must submit Complete Documentation as determined
by the City in its sole discretion.
5.2.2. Budget.
CDBG Funds will be reimbursed in accordance with Exhibit `B" - Budget.
During the Term, Contractor may submit written proposals to increase or decrease line-
item amounts in the Budget; such approvals are subject to approval by the director of the
City's Housing and Economic Development Department ("Director"). If Director gives
written approval of Contractor's proposed Budget amendment (as approved, the
"Amended Budget"), then the Amended Budget will take effect on the first day of the
month following the month in which it was approved by Director. No Amended Budgets
will be approved after August 15, 2012.
5.2.3. Payment of CDBG Funds to Contractor.
CDBG Funds will be disbursed to Contractor on a reimbursement basis upon
Contractor's written and signed request for reimbursement and submission of Complete
Documentation to City.
5.3 Program Performance Milestones. Contractor warrants that the Program
will achieve the following milestones:
% of Total Program Outputs See Exhibit A.
Month Ex enditures' > Unduplicated Clients Units
1 9.09% 9.09% 9.09%
2 18.18% 18.18% 18.18%
3 27.27% 27.27% 27.27%
4 36.36% 36.360 0 36.36%
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5 45.45% 45.45% 45.45%
6 54.54% 54.54% 54.54%
7 63.630 63.63% 63.63%
8 72.72% 72.72% 72.72%
9 81.81% 81.81% 81.81%
10 90.90% 90.90% 90.90%
11 100% 100% 100%
Failure of Contractor to meet or material deviation from the milestones outlined in
this Section 5.3 is a breach of the Contract. In the event of such breach, City reserves the
right at its sole option to delay or withhold reimbursement payments, to lower the
allocation of CDBG Funds, or to terminate this Contract.
5.4 Change in Contractor's Program Budget.
5.4.1 Contractor 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.
5.4.2 Contractor agrees to utilize funds available under this Contract to
supplement rather than supplant funds otherwise available for use in the Program.
5.5 Commingled Funds. Contractor will not commingle CDBG Funds with
any other funds in any manner that would prevent City from readily identifying
expenditures for operation of the Program.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eligibility. Contractor agrees that prior to offering any services to a
prospective client, Contractor will document the eligibility of the client in one of the
following ways. Only one of the following methods will apply to this Contract; the
relevant method for this contract is Section 6.1.4. All other subsections of Section 6.1 are
not applicable to this Contract. In all instances below, Contractor may redact the client's
personal information and substitute a client number.
6.1.1 Contractors Receiving HOPWA Funds.
6.1.1.1 Income. Contractor must verify all new clients' income eligibility
with either Source Documentation or the form attached as Exhibit
E — Form of Self Certification. Contractor must use the annual
income definition used by 24 CFR 5.609 to establish client income
eligibility. Contractor shall use the most current HUD Income
Guidelines.
6.1.1.2 Diagnosis. Contractor must submit a signed, dated statement that
the client's file contains documentation of the clients' diagnosis of
HIV/AIDS. The HIV/AIDS diagnosis must be made by a licensed
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health care provider; a client's self certification of diagnosis is not
sufficient. Contractor should not submit the actual diagnosis to
City.
6.1.1.3 Emergency Need. For clients receiving short term rental,
mortgage, or utility assistance, Contractor must also verify and
document that the client has an emergency need, such as sudden
loss of income, eviction, utility shutoff, or extraordinary and
unexpected healthcare costs.
6.1.2 Contractors Receiving ESG Funds.
6.1.2.1 Homelessness Status. Contractor must verify that all new clients
meet or are at imminent risk of meeting the definition of
homelessness described in 42 U.S.C. 11302, as amended from time
to time. Acceptable forms of verification include:
i. For emergency shelter or essential services for homeless
persons (including childcare for homeless clients):
1. 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 transitional housing services:
1. a signed, dated statement from the client stating that the
client is homeless,
2. a signed referral from an emergency shelter, or
3. evidence documenting that the client was evicted within
one week of receiving service from Contractor, such as a
formal eviction notice or a signed and dated statement from
the family member displacing the client.
iii. For prevention services:
1. documentation of sudden reduction in income,
2. one of the following: documentation of formal eviction
proceedings, utility termination notice, or signed and dated
statement from family member displacing client,
3. documentation of client's reasonable prospects of resuming
payment of rent or utilities, as applicable, within a
reasonable time, and
4. evidence documenting that the client is not receiving
assistance from other homelessness prevention agencies or
funding sources.
6.1.3 Contractors Receiving CDBG Funds and Serving a Presumed Benefit
Clientele.
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6.1.3.1 Presumed Benefit Status. Contractor must document that all
clients served fall under a "presumed benefit" category as defined
in 24 CFR 570. Relevant categories of presumed benefit are:
severely disabled adults, homeless persons, or abused or neglected
children and youth. Eligible forms of documentation include:
(a) Severely Disabled Adults. Written, signed and dated diagnosis
of a severe disability from a licensed diagnostic professional.
(b) Homeless Persons. A signed, dated statement from the client
stating that the client is homeless, or a referral from a homeless
service provider.
(c) Abused or Neglected Children and Youth. A written, signed,
and dated certification of abuse or neglect from a court or an
agent of the Texas Department of Family and Protective
Services.
6.1.4 Contractors Receiving CDBG Funds and Serving a 51% Client
Program.
6.1.4.1 Income. Contractor must verify all new clients' income eligibility
with either Source Documentation or the form attached as Exhibit
E — Form of Self Certification. Contractor must use the annual
income definition used by 24 CFR 5.609 to establish client income
eligibility. Contractor shall use the most current HUD Income
Guidelines. All clients' income must be documented, but only 51%
of clients must meet income eligibility requirements described in
24 CFR 5.609.
6.1.5 Contractors Receiving CDBG Funds and Serving a 100% Client
Program.
6.1.5.1 Income. Contractor must verify all new clients' income eligibility
with either Source Documentation or the form attached as Exhibit
E — Form of Self Certification. Contractor must use the annual
income definition used by 24 CFR 5.609 to establish client income
eligibility. Contractor shall use the most current HUD Income
Guidelines. All clients' income must be documented, and 100% of
clients must meet income eligibility requirements described in 24
CFR 5.609.
6.2 Eli0bility Documentation. Contractor must submit copies of all relevant
components of the eligibility verification documentation described under Section 6.1 with
Attachment III in each month's reimbursement request, and must maintain copies of
such documentation as required under this Contract. Contractor is only required to submit
the eligibility verification documentation for any given client the first month that the
client appears on Attachment III.
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7. Additional CDBG Requirements.
Contractor agrees to comply with all requirements of the CDBG Program as
stated in the CDBG Regulations, including, but not limited to the following:
7.1 Environmental Review.
CDBG Funds will not be paid, and costs cannot be incurred until City has
conducted and completed an environmental review as required under 24 CFR Part 58.
The environmental review may result in a decision to proceed with, modify, or cancel the
Program. Further, Contractor will not undertake or commit any funds to physical or
choice limiting actions. Any violation of this provision will result in the denial of any
funds under this Contract.
7.2. Contract Not Constituting 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 (1) satisfactory completion of
environmental review and receipt by City of an authorization to use grant funds from
HUD under 24 CFR Part 58, (2) approval of City's 2011-2012 Action Plan and receipt by
City of grant agreement from HUD.
7.3. Monitoring.
7.3.1 Contractor understands and agrees that it will be subject to monitoring by
City for compliance with the CDBG Regulations for the duration of this Contract and
until the Program is closed in HUD's IDIS system. Contractor will provide reports and
access to Program files as requested by City for 5 years after closeout of this Contract in
HUD's IDIS system, and will meet all the reporting requirements set out in this Contract.
This Section shall survive the termination or expiration of this Contract.
7.3.2 City, HUD, and the United States Comptroller General or their respective
representatives shall have access at all reasonable hours to the Contractor's offices and
records dealing with the use of the CDBG Funds that are the basis of this Contract, and
its officers, directors, agents, employees, and contractors 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
Contractor's compliance with the terms and conditions of this Contract, and of the
adequacy and timeliness of Contractor's performance under this Contract. After each
monitoring visit, City shall provide Contractor with a written report of the monitor's
findings. If the monitoring report notes deficiencies in Contractor's performance, the
report shall include requirements for the timely correction of said deficiencies by
Contractor. Failure by Contractor to take the action specified in the monitoring report
may be cause for suspension or termination of this Contract as provided herein.
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7.3.4 Contractor will maintain all records related to this Contract for a minimum
of five years after termination of the Contract.
7.4 Contractor Procurement Standards.
Contractor shall establish procurement procedures to ensure that materials and
services are obtained in a cost effective manner. When procuring services to be provided
under this Contract, Contractor shall comply at a minimum with the procurement
standards at 24 CFR Part 84.40 through 24 CFR Part 84.48.
7.5 Cost Principles/Cost Reasonableness.
Contractor shall administer its use of CDBG Funds in compliance with OMB
Circular A-122, "Cost Principles for Non-Profit Organizations", as amended from time to
time. The allowability of costs incurred for performance rendered shall be determined in
accordance with OMB Circular A-122 as supplemented by the provisions of this
Contract.
7.6 Accounting Standards.
Contractor agrees to comply with OMB Circular A-110, "Uniform Administrative
Requirements for Grants and Agreements with Institutions of Higher Education,
Hospitals and other Non-Profit Organizations", and agrees to adhere to the accounting
principles and procedures required therein, utilize adequate internal controls, and
maintain necessary source documentation for all costs incurred.
7.7 Terms Applicable to Contractors and Subcontractors.
Contractor understands and agrees that all terms of this Contract shall apply to
any and all contractors and subcontractors of Contractor which are in any way paid with
CDBG Funds or who perform any work in connection with Contractor's Program.
Contractor shall monitor the services and work performed by its contractors and
subcontractors for compliance with the CDBG Regulations. Contractor is liable for all
violations of the CDBG Regulations committed by its contractors or subcontractors.
8. REPORTING AND DOCUMENTATION REQUIREMENTS.
Contractor 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, Contractor will keep or cause to be kept an accurate record
of all actions taken and all funds spent, with source and back-up documentation.
9. REIMBURSEMENT REQUIREMENTS.
9.1 Each Reimbursement Request shall be received by the City on or before
the 15th day of the month following the month expenses were paid. For example,
Reimbursement Requests for June expenses must be received by July 15. In the event the
15th falls on a weekend or City holiday, Reimbursement Requests shall be due the next
business day. Failure to submit a Reimbursement Request in a timely fashion will result
in City initiating procedures as outlined in Section 10.1. NOTWITHSTANDING
ANYTHING ABOVE, EXPENSES FOR SEPTEMBER 2012 MUST BE
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RECEIVED BY SEPTEMBER 20, 2012, FAILURE TO SUBMIT A COMPLETE
REIMBURSEMENT REQUEST BY SEPTEMBER 20, 2012 WILL RESULT IN
AN AUTOMATIC FORFEITURE OF THE SEPTEMBER PAYMENT.
9.2 With each Reimbursement Request, Contractor shall provide City with the
following reports (found in EXHIBIT D — REPORTING FORMS) and Complete
Documentation:
9.2.1 Attachment I — Invoice. This report shall contain the amount requested
for reimbursement each month, and the cumulative reimbursement
requested to date(inclusive of that month's request). Even if Contractor
is requesting $0 for a particular month, this report must be submitted.
This report must be signed by an authorized signatory of the Contractor
(authorized signatories of Contractor are:
Celia Esparza President & CEO
Pablo Calderon Director of Programs
Don Campion Director of Finance.
By signing Attachment I, Contractor is certifying that the costs are valid,
eligible, and consistent with the terms and conditions of this Contract,
and the data contained in the report is true and correct.
9.2.2 Attachment II — Expenditure Worksheet. This report shall itemize
each expense requested for reimbursement by Contractor and shall
include the Account corresponding the expense to a budget line item in
Attachment II. Expenses must comply with the rates and allocations
described in Exhibit B—Budget. In order for this report to be complete
the following must be submitted:
9.2.2.1 Timesheets signed by employees and approved by supervisor for
all payroll expenses listed. Timesheets must distinguish between
CDBG funded time and non-CDBG funded time and reflect actual
time spent on CDBG funded activities.
9.2.2.2 Invoices for all non-payroll expenses listed — the invoice must
clearly show it pertains to the Program described in the Program
description.
9.2.2.3 Proof that the expenses were paid by Contractor, which proof can
be satisfied by cancelled checks, wire transfer documentation, paid
receipts or other appropriate banking documentation.
9.2.3 Attachment III — Client Data Report. This report shall list each
client served during the month along with their demographic information. Clients served
in multiple months should be listed each month. The report shall be cumulative
throughout the Program, with new clients added to the form each month. In order for this
report to be complete the following must be submitted:
9.2.3.1 Documentation of income verification for each client, which will
either be the Source Documentation described in Section 6.2.1, or
the completed Form of Self Certification attached hereto as
Exhibit E. This documentation shall only be submitted the first
time a client is listed on Attachment III—Client Data Report.
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The City retains the right to change reporting requirements and forms at its
discretion. Upon such change, then the Parties shall execute an amendment to the
Contract.
9.3 Withholding Payment. IF THE REQUIRED REPORTS AND
APPROPRIATE SUPPORTING DOCUMENTATION ARE NOT RECEIVED BY
THE DUE DATE, CITY SHALL WITHHOLD PAYMENTS REQUESTED
UNDER THIS CONTRACT. Failure to submit required reports shall be an event
of default.
10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Required Documentation
10.1.1 If Contractor fails to submit a Reimbursement Request by the
deadline stated in Section 9.1, or if the submitted Reimbursement Request is
incomplete or otherwise not in compliance with this Contract or CDBG
Regulations as determined by City, Contractor shall be in default of this Contract.
City will notify Contractor in writing of such default and the Contractor will have
10 calendar days from the date of the written notice to submit or resubmit any
such Reimbursement Request to cure the default. If the Contractor fails to cure
the default within such time, Contractor shall forfeit any payments otherwise due
that month.
10.1.2 NOTWITHSTANDING 10.1.1, FOR THE
REIMBURSEMENT REQUEST DUE SEPTEMBER 20, 2012, IF
CONTRACTOR FAILS TO SUBMIT A REIMBURSEMENT REQUEST,
OR IF THE SUBMITTED REIMBURSEMENT REQUEST IS
INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE WITH THIS
CONTRACT OR CDBG REGULATIONS AS DETERMINED BY CITY,
THERE WILL BE NO CURE PERIOD AND ANY REIMBURSEMENT
WILL BE AUTOMATICALLY FORFIETED.
10.1.3 In the event of more than two instances of default, cured or
uncured, City reserves the right at its sole option to terminate this Contract
effective immediately upon written notice of such intent with no penalty or
liability to City.
10.1.4 Notwithstanding anything to the contrary herein, City will not be
required to pay any CDBG Funds to Contractor during the period that any report
or documentation is past due or is not in compliance with this Contract or the
CDBG Regulations, or during any period during which Contractor is in default of
this Contract. In the event of termination under this Section 10.1, all CDBG Funds
awarded but unpaid to Contractor pursuant to this Contract shall be immediately
forfeited and Contractor shall have no further right to such funds.
10.2 In General.
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Subject to Section 10.1, and unless specifically provided otherwise in this
Contract, Contractor shall be in default under this Contract if Contractor 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 Contractor has diligently and continuously attempted to
cure following receipt of such written notice but reasonably required 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, as determined in City's sole discretion, to terminate this
Contract effective immediately upon written notice of such intent to Contractor, or to
pursue any other legal remedies available to City. In the event of termination under this
Section 10.2, all CDBG Funds awarded but unpaid to Contractor pursuant to this
Contract shall be immediately rescinded and Contractor shall have no further right to
such funds, and any CDBG Funds already paid to Contractor must be repaid to City
within 30 days of the termination.
10.3 No Funds Disbursed while in Breach.
Contractor understands and agrees that no CDBG Funds will be paid to
Contractor until all defaults are cured to the satisfaction of City.
10.4 No Compensation After Date of Termination.
In the event of termination, Contractor shall not receive any compensation for
work undertaken after the date of the termination.
10.5 Rights of City Not Affected.
Termination shall not affect or terminate any of the existing rights of City against
Contractor, or which may thereafter accrue because of such default. Such termination
does not terminate any applicable provisions of this Contract that have been expressly
noted as surviving the term or termination of the Contract.
10.6 Waiver of Breach Not Waiver of Subsequent Breach.
The waiver of a breach of any term, covenant, or condition of this Contract shall
not operate as a waiver of any subsequent breach of the same or any other term, covenant
or condition hereof.
10.7 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.
10.8 Termination for Cause.
City may terminate this Contract in the event of Contractor's default, inability, or
failure to perform, or otherwise whenever such termination is determined by City to be in
City's best interest. Likewise, Contractor may terminate this Contract if City does not
provide the CDBG Funds substantially in accordance with this Contract.
10.9 Termination for Convenience.
In terminating in accordance with 24 C.F.R. 85.44 this Contract may be
terminated in whole or in part only as follows:
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10.9.1 By City with the consent of Contractor 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
10.9.2 By the Contractor upon 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. However, if, in the case of a partial
termination, City determines that the remaining portion of the Contract to be
performed or CDBG Funds to be spent will not accomplish the purposes for
which the Contract was made, City may terminate the Contract in its entirety.
10.10 Dissolution of Contractor Terminates Contract.
In the event Contractor is dissolved or ceases to exist, all assets acquired with
CDBG Funds including cash, interest payments from loans or otherwise, all outstanding
notes, mortgages or other security instruments used to secure CDBG Funds, any accounts
receivable attributable to the use of CDBG Funds, and any real or personal property
owned by Contractor that was acquired or improved with CDBG Funds shall
automatically transfer to City and this Contract shall terminate.
11. REPAYMENT OF CDBG FUNDS.
All CDBG Funds are subject to repayment in the event the Program does not meet
the requirements as set out in this Contract or in the CDBG Regulations.
12. CHANGE IN NON-PROFIT STATUS.
If the non-profit status of Contractor changes after the date of this Contract, City
may but is not obligated to, terminate this Contract. Contractor must provide City with
written notification of any changes to its non-profit status within 15 days of being
notified of the change. City has 30 days to make such determination after receipt of
notice from Contractor and failure to make such determination will constitute a waiver.
In the event of termination under this Section 12, all CDBG Funds awarded but unpaid to
Contractor pursuant to this Contract shall be immediately rescinded and Contractor shall
have no further right to such funds, and any CDBG Funds already paid to Contractor
must be repaid to City within 30 days of the termination.
13. SURVIVAL.
Any provision of this Contract that pertains to auditing, monitoring, client income
eligibility, record keeping and reports, City ordinances, or applicable CDBG
requirements, and any default and enforcement provisions necessary to enforce such
provisions, shall survive the termination of this Contract for five (5) years after the
termination date and shall be enforceable by City against Contractor.
14. GENERAL PROVISIONS
14.1 Independent Contractor.
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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 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, clients,
licensees or invitees.
14.2 Doctrine of Respondeat Superior.
The doctrine of respondeat superior shall not apply as between City and
Contractor, its officers, members, agents, servants, employees, contractors, clients,
licensees or invitees, and nothing herein shall be construed as creating a partnership or
joint enterprise between City and Contractor. City does not have the legal right to
control the details of the tasks performed hereunder by Contractor, its officers, members,
agents, employees, contractors, licensees or invitees.
14.3 Contractor Property. City shall under no circumstances be responsible
for any property belonging to Contractor, its officers, members, agents, employees,
contractors, clients, licensees or invitees that may be lost, stolen or destroyed or in any
way damaged and CONTRACTOR 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 Organization.
No portion of the CDBG 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 a CDBG-funded service.
14.5 Audit.
14.5.1 Entities that Expend $500,000 or more in Federal Funds Per Year.
All non-federal entities that expend $500,000 or more in Federal funds within one
year, regardless of the source of the Federal award, must submit to City an annual audit
prepared in accordance with specific reference to OMB Circular A-133. The audit shall
cover the Contractor's fiscal years during which this Contract is in force. The audit must
be prepared by an independent certified public accountant, be completed within 6 months
following the end of the period being audited and be submitted to City within 30 days of
its completion. Contractor's audit certification is attached hereto as Exhibit "C" —
"Audit Certification Form" and "Audit Requirements". The Audit Certification Form
must be submitted to City within 60 days of the end of period being audited (Contractor's
fiscal year). Entities that expend less than $500,000 a year in Federal funds are exempt
from Federal audit requirements for that year, but records must be available for review or
audit by appropriate officials of the Federal agency, City, and General Accounting
Office.
14.5.2 City Reserves the RiLyht to Audit.
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City reserves the right to perform an audit of Contractor's Program operations and
finances at any time during the term of this Contract and for five (5) years after the
termination thereof. Contractor agrees to allow access to all pertinent materials as
described herein. If such audit reveals a questioned practice or expenditure, such
questions must be resolved within 15 business days after notice to Contractor of such
questioned practice or expenditure. If questions are not resolved within this period, City
reserves the right to withhold further funding under this and/or future contract(s) with
Contractor. IF AS A RESULT OF ANY AUDIT IT IS DETERMINED THAT
CONTRACTOR HAS FALSIFIED ANY DOCUMENTATION OR MISUSED,
MISAPPLIED OR MISAPPROPRIATED CDBG FUNDS OR SPENT CDBG
FUNDS ON ANY INELIGIBLE ACTIVITIES, CONTRACTOR 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.
14.6 Venue.
Venue for any action, whether real or asserted, at law or in equity, arising out of
the execution, performance, attempted performance or non-performance of this Contract,
shall lie in Tarrant County, Texas.
14.7 Governing Law.
In any questions involving state law, for any action, whether real or asserted, at
law or in equity, arising out of the execution, performance or non-performance of this
Contract, in any issue not governed by federal law, the choice of law shall be the law
from the State of Texas.
14.8 Severability.
The provisions of this Contract are severable, and, if for any reason a clause,
sentence, paragraph or other part of this Contract shall be determined to be invalid by a
court or Federal or state agency, board or commission having jurisdiction over the subject
matter thereof, such invalidity shall not affect other provisions which can be given effect
without the invalid provision.
14.9 Written Agreement Entire Contract.
This written instrument and the Addendums, Attachments, and Exhibits attached
hereto, which are incorporated by reference and made a part of this Contract for all
purposes, constitute the entire agreement by the Parties hereto concerning the work and
services to be 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 must be executed by
each Party to this Contract.
14.10. Paragraph Headings for Reference Only,No Leal Significance.
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.
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14.11 Compliance With All Applicable haws and Rellulations.
By signing this Contract, Contractor certifies that it complies with all applicable
laws and regulations that are currently in effect or that are hereafter amended during the
performance of this Contract. Those laws include, but are not limited to:
➢ CDBG Regulations found in 24 CFR Part 570.
Title I of the Housing and Community Development Act of 1974, as amended,
(42 USC 5301
Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.)
including provisions requiring recipients of federal assistance to ensure
meaningful access by person of limited English proficiency
➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C.
Sections 3601 et seq.)
➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as
supplemented by Department of Labor regulations 41 CFR, Part 60
➢ The Age Discrimination in Employment Act of 1967
➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.)
➢ 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 Clean 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
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➢ For construction contracts awarded by Contractor in excess of$2,000, and in
excess of $2,500 for other contracts which involve the employment of
mechanics or laborers, Sections 103 and 107 of the Contract Work Hours and
Safety Standards Act (40 U.S.C. 327A 300) as supplemented by 29 CFR Part
5
➢ Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as
amended by the Residential Lead-Based Paint Hazard Reduction Act of 1992
(42 U.S.C. 4851 et seq.) and implementing regulations at 24 CFR Part 35,
subparts A, B, M, and R
➢ Uniform Administration Requirements of 24 CFR Part 85
Requirement that Law Be Quoted in Covered Contracts. — Certain Requirements
Pertaining to Section 3 of the Housing and Urban Development Act of 1968 as amended
(12 U.S.C. Sections 1701 et sect) and its related regulations at 24 CFR Part 135
If the work performed under this Contract is on a program assisted under a
program providing direct Federal financial assistance from HUD, Section 3 of 24 CFR
135.38 ("Section 3") requires that the following clause, shown in italics, be inserted in all
covered contracts("Section 3 Clause"):
Section to be quoted in covered contracts begins:
"A. The work to be performed under this contract is subject to the
requirements of Section 3 of Housing and Urban Development Act of
1968, as amended, 12 U.S.C. section 1701u (Section 3). The purpose of
Section 3 is to ensure that employment and other economic opportunities
generated by HUD assisted or HUD-assisted programs covered by
Section 3, shall to the greatest extent feasible, be directed to low- and
very-low income persons,particularly persons who are recipients of HUD
assistance for housing.
B. The parties to this contract agree to comply with HUD's
regulations in 24 CFR Part 135, which implement Section 3. As evidenced
by their execution of this contract, the parties to this contract certify that
they are under no contractual or other impediment that would prevent
them from complying with the Part 135 regulations.
C. The contractor agrees to send to each labor organization or
representative of workers with which it has a collective bargaining
agreement or other understanding, if any, a notice advising the labor
organization or workers' representatives of the contractor's commitments
under this Section 3 clause and will post copies of the notice in
conspicuous places at the work site where both employees and applicants
for training and employment positions can see the notice. The notice shall
describe the Section 3 preference, shall set forth minimum number and job
titles subject to hire, availability of apprentice and training positions, the
qualifications for each; and the name and location of the person(s) taking
applications for each of the positions; and the anticipated date the work
shall begin.
D. The contractor agrees that it will include this Section 3 clause in
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every subcontract to comply with regulation in 24 CFR Part 135, and
agrees to take appropriate action, as provided in an applicable provision
of the subcontract or in this Section 3 clause, upon finding that the
subcontractor is in violation of the regulations in 24 CFR Part 135. The
contractor will not subcontract with any subcontractor where it has notice
or knowledge that the subcontractor has been found in violation of
regulations in 24 CFR 135.
E. The contractor will certify that any vacant employment positions,
including training positions that are filed: (1) after the contractor is
selected but before the contract is executed, and (2) with persons other
than those to whom the regulations of 24 CFR Part 135. The contractor
will not subcontract with any subcontractor where it has notice or
knowledge that the subcontractor has been found in violation of
regulations in 24 CFR 135.
F. Noncompliance with HUD's regulation in 24 CFR Part 135 may
result in sanctions, termination of this contract for default, and debarment
or suspension from future HUD assisted contracts.
G. With respect to work performed in connection with Section 3
covered Indian housing assistance, section 7(b) of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. section 450e) also
applies to the work to be performed under this Contract. Section 7(b)
requires that to the greatest extent feasible (i) preference and
opportunities for training and employment shall be given to Indians, and
(ii)preference in the award of contracts and subcontracts shall be given to
Indian organizations and Indian-owned Economic Enterprises. Parties to
this contract that are subject to the provisions of Section 3 and Section
79b) agree to comply with Section 3 to the maximum extent feasible, but
not in derogation of compliance with Section 7(b). "
Section to be quoted in covered contracts ends.
City and Contractor understand and agree that, if applicable to the Program,
compliance with the provisions of Section 3, the regulations set forth in 24 CFR Part 135,
and all applicable rules and orders of HUD shall be a condition of the Federal financial
assistance provided to the Program binding upon City and Contractor, and their
respective successors, assigns and the contractors. Failure to fulfill these requirements
shall subject Contractor and its contractors and their respective successors and assigns to
those sanctions specified by the grant agreement through which Federal assistance is
provided and to such sanctions as are specified by 24 CFR Part 135.
14.12 Prohibition Against Discrimination.
14.12.1 General Statement.
Contractor, in the execution, performance or attempted performance of this
Contract, shall comply with all non-discrimination requirements of 24 CFR 570.607 and
the ordinances codified at Chapter 17, Article III, Division 4 — Fair Housing of the City
Code . Contractor may not discriminate against any person because of race, color, sex,
gender, religion. national origin, familial status. disability or perceived disability, sexual
(DW, 5UBRFCIPIGNT CONTRACT 17
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orientation, gender identity, gender expression, or transgender, nor will Contractor permit
its officers, members, agents, employees, or clients to engage in such discrimination.
14.12.2 No Discrimination in Employment during the Performance of
this Contract.
During the performance of this Contract Contractor 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:
United Community Centers, Inc. 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. United Community Centers, Inc. will
take affirmative action to ensure that applicants are hired without regard to race, color,
sex, gender, religion, national origin, familial status, disability or perceived disability,
sexual orientation, gender identity, 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. United Community
Centers, Inc. agrees to post in conspicuous places, available to employees and applicants
for employment, notices setting forth the provisions of this nondiscrimination clause.
United Community Centers, Inc. will, in all solicitations or advertisements for
employees placed by or on behalf of United Community Centers, Inc. , 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.
United Community Centers, Inc. covenants that neither it nor any of its officers,
members, agents, employees, or contractors, while engaged in performing this Contract,
shall, in connection with the employment, advancement or discharge of employees or in
connection with the terms, conditions or privileges of their employment, discriminate
against persons because of their age or because of any disability or perceived disability,
except on the basis of a bona fide occupational qualification, retirement plan or statutory
requirement.
United Community Centers, Inc. further covenants that neither it nor its officers,
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
fide occupational qualification, retirement plan or statutory requirement.
14.12.3 Contractor's Contractors and ADA.
In accordance with the provisions of the Americans With Disabilities Act of 1990
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("ADA"), Contractor 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 and/or conditions of employment for applicants for
employment with, or employees of Contractor or any of its contractors. CONTRACTOR
WARRANTS IT WILL FULLY COMPLY WITH ADA'S PROVISIONS AND
ANY OTHER APPLICABLE FEDERAL, STATE AND LOCAL LAWS
CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD
CITY HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED
BY THIRD PARTIES OR CONTRACTORS AGAINST CITY ARISING OUT OF
CONTRACTOR'S AND/OR ITS CONTRACTORS', AGENTS' OR
EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE-
REFERENCED LAWS CONCERNING DISABILITY DISCRIMINATION IN
THE PERFORMANCE OF THIS CONTRACT.
This Contract is made and entered into with reference specifically to the ordinances
codified at Chapter 17, Article III, Division 3 -Employment Practices of the City Code,
and Contractor hereby covenants and agrees that Contractor, its officers, members,
agents, employees and contractors, have fully complied with all provisions of same and
that no employee, applicant or client has been discriminated against under the terms of
such ordinances by either or its officers, members, agents, employees or contractors.
14.13. Prohibition Against Interest/Conflict of Interest.
14.13.1 Contractor 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. Contractor
shall disclose to City any conflict of interest or potential conflict of interest described
above, immediately upon discovery of such.
14.13.2 No persons who are employees, agents, consultants,
officers or elected officials or appointed officials of City or of Contractor who exercise or
have exercised any functions or responsibilities with respect to activities assisted with
CDBG funds or who are in a position to participate in a decision-making process or gain
inside information with regard to these activities may utilize CDBG services, may obtain
a financial interest or benefit from a CDBG-assisted activity, or have an interest in any
contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either
for themselves or those with whom they have family or business ties, during their tenure
or for 1 year thereafter, unless they are accepted in accordance with the procedures set
forth at 24 CFR 570.611.
14.13.3 Contractor affirms that it will adhere to the provisions of
the Texas Penal Code which prohibits bribery and gifts to public servants.
14.13.4. In the procurement of property and services by Contractor,
the conflict of interest provisions of 24 CFR Part 85.36 and 24 CFR Part 84.42,
respectively, shall apply. In all cases not governed by those sections, the provisions of 24
CDBG SUBRE:CIPII IN F CONTRACT 19
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CFR 570.611 of the CDBG Regulations shall apply.
14.13.5 For procurement contracts larger than $25,000.00
Contractor agrees to abide by City's policy to involve Minority and Women Business
Enterprises and to provide them equal opportunity to compete for contracts for
construction, provision of professional services, purchase of equipment and supplies and
provision of other services required by City. Contractor agrees to incorporate City
Ordinance No. 15530, and all amendments or successor policies thereto, into all contracts
and subcontracts for procurement larger than $25,000.00 and will further require all
persons or entities with whom it so contracts to comply with said ordinance.
14.16 Other Laws.
The failure to list any federal, state or City ordinance, law or regulation that is
applicable to Contractor does not excuse or relieve Contractor from the requirements or
responsibilities in regard to following the law, nor from the consequences or penalties for
Contractor's failure to follow the law, if applicable.
14.17 Assignment.
Contractor 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.
14.18. Right to Inspect Contractor Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed
contracts between Contractor and any contractor engaged in any activity in conjunction
with this CDBG funded Program.
14.19 Force Maieure
If Contractor becomes unable, either in whole or part, to fulfill its obligations
under this Contract due to acts of God, strikes, lockouts, or other industrial disturbances,
acts of public enemies, wars, blockades, insurrections, riots, epidemics, earthquakes,
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 such Contractor's control (collectively, "Force Majeure Event"), the
obligations so affected by such Force Majeure Event will be suspended only during the
continuance of such event. Contractor 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 the
Contractor's obligation regardless of the extent of any existing Force Majeure Event.
Contractor will use commercially reasonable efforts to remedy its inability to perform as
soon as possible.
15. Indemnification and Release.
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
(A)BG SUBIOX]PIENT CONTRACT 20
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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 CONTRACTOR
HEREBY ASSUMES ALL LIABILITY AND RESPONSIBILITY OF CITY AND
ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FOR ANY AND
ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR
PERSONAL INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF
WHATSOEVER KINDS OR CHARACTER, WHETHER REAL OR ASSERTED,
ARISING OUT OF OR IN CONNECTION WITH THE EXECUTION,
PERFORMANCE, ATTEMPTED PERFORMANCE OR 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. 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, 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
CONTRACTOR AND CITY, THAT THE INDEMNITY PROVIDED FOR THIS
SECTION INCLUDES INDEMNITY BY CONTRACTOR 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.
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 CONTRACT, EVEN IF THE INJURY, DEATH,
DAMAGE OR LOSS IS CAUSED BY CITY'S SOLE OR CONCURRENT
NEGLIGENCE.
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CONTRACTOR 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 Contractor.
If Contractor, 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, Contractor 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.
Contractor will maintain blanket fidelity coverage in the form of insurance or
bond in the amount of $28,154.00 to insure against loss from the fraud, theft or
dishonesty of any of Contractor's officers, agents, trustees, directors or employees. The
proceeds of such bond shall be used to reimburse City for any and all loss of CDBG
Funds occasioned by such misconduct. To effectuate such reimbursement, such fidelity
coverage shall include a rider stating that reimbursement for any loss or losses thereunder
shall be made directly to City.
Contractor 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, Contractor shall be in default of the Contract and City may, at its
option,terminate the Contract.
Such insurance shall cover all insurable risks incident to or in connection with the
execution, performance, attempted performance or nonperformance of this Contract.
Contractor shall maintain, or require its general contractor to maintain, the following
coverages and limits thereof.
Commercial General Liability (CGL) Insurance
$500,000 each occurrence
$1,000,000 aggregate limit
Non Profit Organization Liability or Directors& Officers Liability
$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
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1nited Community Centers, Inc.
$2,000,000 Aggregate
Insurance policy shall be endorsed to cover"Any Auto"
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 Contractor'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
Programs including but not limited to construction, demolition, and rehabilitation.
Contractor or its contractors shall maintain coverages, if applicable. In the event
the respective contractors do not maintain coverage, Contractor 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 Contractor shall revise such amounts
within thirty (30) days following notice to Contractor of such requirements.
Contractor 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.
Each insurance policy shall be endorsed to provide City with a minimum sixty (60) days
notice of cancellation, non-renewal, and/or material change in policy terms or coverage.
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.
The Workers' Compensation Insurance policy shall be endorsed to include a waiver of
subrogation, also referred to as a waiver of rights of recovery, in favor 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 Contractor'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
CDBG St 13RECIPII:N F CONTRACT 23
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t!sited Commwlity Centers, Inc.
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.
Contractor shall require its contractors to maintain applicable insurance coverages, limits,
and other requirements as those specified herein; and, Contractor shall require its
contractors to provide Contractor with certificate(s) of insurance documenting such
coverage. Also, Contractor shall require its contractors to have City and Contractor
endorsed as additional insureds (as their interest may appear) on their respective
insurance policies.
18. Certification Rej!ardiniz Lobbyin;?.
The undersigned representative of Contractor 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 Contractor, 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, 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, Contractor 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 file 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.
Contractor shall require that the language of this certification be included in
all subcontracts or agreements involving the expenditure of Federal funds.
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19. Litigation and Claims
Contractor shall give City immediate notice in writing of any action, including
any proceeding before an administrative agency, filed against Contractor in conjunction
with this Contract or the Program. Contractor shall furnish immediately to City copies of
all pertinent papers received by Contractor with respect to such action or claim.
Contractor shall provide a notice to City within 10 days upon filing under any bankruptcy
or financial insolvency provision of law.
20. Notice.
All notices required or permitted by this Contract must be in writing and are
deemed delivered on the earlier date of the date actually received or the third day
following deposit in a United States Postal Service post office or receptacle; with proper
postage, certified mail return receipt requested; and addressed to the other Party at the
address set out below or at such other address as the receiving Party designates by proper
notice to the sending Party.
Crty:
City Attorney's Office
1000 Throckmorton Street
Fort Worth, TX 76102
Telephone: 817-392-7600
Copy to:
Director of Housing and Economic Development
1000 Throckmorton Street
Fort Worth,TX 76102
Telephone: 817-392-7540
Copy to:
Program Coordinator
1000 Throckmorton Street
Fort Worth, TX 76102
Telephone: 817-392-6342
Contractor:
Celia Esparza, President& CEO
United Community Centers, Inc.
1200 E. Maddox
Fort Worth, TX 76104
Telephone: 817-927-5556
21. Contractor Has Leal Authority to Enter Into Contract.
Contractor 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.
CDBO Y BRECIPIFN"I CON FRACT 25
Rev 09/0 1/2011
t!nited Community Centers, Inc.
[SIGNATURES APPEAR ON NEXT PAGE]
CDBG SURRECINE'N I CONTRACT 26
Rev 09/0 1/2011
United Community Centers,Inc.
IN WITNESS WHEREOF, the Parties hereto have executed three copies of this
Contract in Fort Worth, Tarrant County, Texas,this 61A-day of
2011.
ATTEST: CITY O O T WORTH
City Secretary Su an A nis, Assistant City Manager
M&C: C-25066
Date: August 2, 2011
APPROVED AS TO FO AND LEGALITY: p�Q°°000000°OooO��
Assistant City Attorneys co o� d
* d
UNIT=Y TERS,INC. �� °O0000°°°oo XY
By:
Celia Esparza
President& CEO
STATE OF TEXAS § ud
COUNTY OF TARRANT §
This instrument was acknowledged before me on ;2n ,'2011 by
Susan Alanis, Assistant City Manager of the Cityof F rt Worth,�on behalf the City of
Fort Worth.
!.INDWHIRRCOMMI 510"'. lP1.GER Notary ublic, State of Texas
MY CU�hA41SS10Pl EXPIRES
February 2,;
.van-.+ni
STATE OF TEXAS §
COUNTY OF TARRANT §
This instrument was acknowledged before me on Z J `' by Celia
Esparza, President & CEO of United Community Cent rs, Inc., a non-profit corporation,
on behalf of said corporation.
Notary Public, State of Texas
MOHAMMED A ASSADUDoiN
My Commission Expires
+Ran,►`
Of June 14,2015 R�C'QRD
S�RESpR`(
C�Sy RtH,SX
fT,w0
('t)aG SUBRECm11-:N I CONTRA("I �� 27
Rev 09/01/2011
1 nited Community Ccnters, Inc.
United Community Centers, Inc. EXHIBIT A
Junior Counselors- Poly Center PROGRAM SUMMARY
PROGRAM SUMMARY
Community Development Block Grant
(CDBG)
October 1,2011 to September 30,2012 $28,154.00
PERIOD AMOUNT
PROGRAM SUMMARY
The program will provide child care for 5-8 graders after school from 2:30 pm to 6:00 pm.
During holidays & summer it is a full day program from 7 a.m.-6 p.m. The program will
close for two weeks for the Christmas holiday.
Services are available at UCC Poly Center,3100 Avenue I,Fort Worth,TX 76105.
CDBG funds will be used to pay for a portion of personnel, transportation, and contract
costs associated with the program.
REGULATORY CLASSIFICATION:
IDIS Matrix Code(s) and Service Category: 05D Youth Services
National Objective Citation: 570.208(a)(2)
Regulatory Citation(s): 24 CFR 570.201(e)
Based on the nature of the service provided, United Community Centers,Inc. will maintain
documentation that verifies that 51% of clients served by the Junior Counselors - Poly
Center Program are income eligible with current household incomes under 80% of Area
Median Income (AMI) as established or defined by the United States Department of
Housing and Urban Development(HUD).
GEOGRAPHICAL LOCATION:
Site Address: 3100 Avenue I, Fort Worth,TX
Client Beneficiary Location (Neighborhood Name, Council District Number, or
Citywide): 8
PROGRAM GOALS �'��: ;a:;�,• c :�uMA V
Provide care for 30 clients. ae.•..•.r- -•
(DIM SUBRFCIPIGNT CONTRACT 28
Rev 09/01/2011
United Community CenterS,Inc.
PROGRAM OBJECTIVES:
Provide a safe and nurturing environment for children.
Unit of Service Number of Units
Unduplicated Clients 30
Homework Service Units 2800
Character Service Units 1600
Recreational Service Units 3600
Parent Activity Units 40
CUI36 Y BRECIP11:N I CON"IRACI 29
Rev 09/011201 1
United Community Centers, Inc.
EXHIBIT B-BUDGET
United CommunityCenters Inc. Account Grant Budget A B C' D
Junior Counselors-Pol Center
lll x_=
ADMINISTRATIVE
Salaries 1001
FICA/Medicare 1002
Life Insurance 1003
Health Insurance 1004
Disability Insurance 1005
Unem Io mens-State 1006
Workers Compensation 1007
Legal&Accounting 1008
TOTAL ADMIN EXPENSES
%Administrative Cost
PROGRAM PERSONNEL
Salaries 2001 19506 130,454 94,122 71,004 37,507
FICA/Medicare 2002 1492 9,434 6,807 5,135 2,712
Life Insurance 2003 98 770 556 419 221
Health Insurance 2004 1137 7,819 5,642 4,256 2,248
Unemployment 2005 312 1,730 1,248 942 497
Worker's Compensation 2006 201 2,008 1,449 1,093 577
Retirement 2007 148 1,701 1,227 926 489
SUPPIIES'ANDSERVICES
Office Supplies 3001 3,121 2,252 1,699 897
Office Equipment Rental 3002
Postage 3003 1 2,114 1,525 1,150 608
Printing 3004 2,617 1,888 1,424 752
;
-MISCELLANEOUS ` = �r~�
Conference&Seminars 4001 1,792 1,293W 975 515
Construction/Building Materials 4002
Contract Labor 4003 1600 3,790 2,734 2,063 1,090
Craft Supplies 4004 250
Athletic Su lies 4005 250
Facility Fees 4006
Field Trip Costs 4007
Food Supplies 4008
Mileage 4009 1660 2,684 1,936 1,461 772
Teaching Aids 4010 1500
Training Costs 4011
TACILITYAND=UTILITIES
Telephone 5001 5,424 3,913 2,952 1,559
Electric 5002 10,120 7,302 5,508 2,910
Gas 5003 1,191 859 648 342
Water and Wastewater 5004 2,456 1,772 1,337 706
Solid Waste Disposal 5005
Rent 5006
Custodial Services 5007 5,507 3,973 2,997 1,583
Repairs 5008 15,188 10,958 8,267 4,367
Cleaning Supplies 5009
LEGAL,EWANCIAL,ANDINSURANCE -
Fidelity Bond or Equivalent 6001 240 173 130 69
Directors and Officers 6002
General Commercial Liability 6003 1,396 1,007 760 401
Legal Fees 6004 4,051 2,923 2,205 1,165
Contract Accounting 6005
DIRECT ASSISTANCE OR PER UNIT RATE
Childcare Scholarships 7001
Counseling-Individual Session 7002
Counseling-Grou Session 7003
Short-term Rent Assistance 7004
Short-term Mortgage Assistance 7005
Short-term Utilities Assistance 7006
Tenant Based Rental Assistance 7007
Volunteer Training 7008
CAPITAL OUTLAY •.
Furniture,Fixtures 8001
Computers 8002
Office Equipment 8003
)ort and Recreation P.yui mp ent 8004
FUNllINGA UNI"IEDV A) �VZRAN"I CU
FUNDING R I'RIVA11,GRAN I S
FUNDING C CON1'RIMITIONS
FUNDING I) (>OVGRNMIiN f GRANTS
UNITED COMMUNITY CENTERS, INC. JUNIOR COUNSELORS-POLY CENTER
SALARY DETAIL
Position Rate Annual Hours Percent to Grant Amount to
(Annual Grant
Estimated)
Lead Junior Counselor 10.00 1907 75 14303
Center Director/Supervisor 19.23 1907 10 3667
Quality Assurance Specialist I6.11 1907 5 1536
United Community Centers,Inc. Junior Counselors-Poly Center
FRINGE DETAIL
Percent of Payroll Amount Percent to Grant Amount to Grant
(Annual Estimated
FICA/Medicare 7.65% $1,492 100% $1,492
Life Insurance 0.50% $98 100% $98
Health Insurance 5.82% $1,137 100% $1,137
Disability Insurance
Unemployment 1.60% $312 100% $312
Workers Compensation 1.03% $201 100% $201
Retirement 0.76% $148 100% $148
SUPPLIES AND SERVICES
Total Budget Percent to Grant Amount to Grant
(Annual Estimated
Office Supplies
Office Equipment Rental
Postage
Printing
MISCELLANEOUS
Total Budget Percent to Grant Amount to Grant
(Annual Estimated
Conference&Seminars
Construction/Building Materials
Contract Labor 1600 100 1600
Craft Supplies 250 100 250
Athletic Supplies 250 100 250
Facility Fees
Field Trip Costs
Food Supplies
Mileage $1660 @$0.51/mile 100 $1660
Teaching Aids 1500 1 100 1500
FACILITY AND UTILITIES
Total Budget Percent to Grant Amount to Grant
(Annual Estimated
Telephone
Electric
Gas
Water and Wastewater
Solid Waste Disposal
Rent
Custodial Services
Repairs
Cleaning Supplies
LEGAL, FINANCIAL AND INSURANCE
Total Budget Percent to Grant Amount to Grant
(Annual Estimated)
Fidelity Bond or Equivalent)
General Commercial Liability
Directors and Officers
Legal Fees
Contract Accounting
DIRECT ASSISTANCE OR PER UNIT RATE CHARGES
Total Budget Basis Percent to Grant Amount to Grant
(Annual Estimated)
Childcare 100
Scholarships
Counseling 100
-Individual
Session
Counseling 100
—Group
Session
Short-Term 100
Rent
Assistance
Short Term 100
Mortgage
Assistance
Short Term 100
Utilities
Assistance
Tenant 100
Based
Rental
Assistance
Volunteer 100
Training
CAPITAL OUTLAY
Total Budget Description Percent to Amount to
Grant Grant
(Annual
Estimated
Furniture,Fixtures
Computers
Office Equipment
Sport and Recreation
E ui ment
EXHIBIT C—AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency:
Fiscal Year Ending: 3l3 f 2 0 12--
During
Z.During the fiscal year in which funds will be received, we will exceed the federal expenditure
threshold of$500,000. We will have our Single Audit or Program Specific Audit completed and
will submit the A-133 audit report within seven (7) months after the end of the audited fiscal year
or thirty (30)days within its completion,whichever is the earlier date.
[During the fiscal year in which funds will be received, we will not exceed the $500,000 federal
expenditure threshold required for a Single Audit or a Program Specific Audit to be performed this
fiscal year. (Fill out schedule below)
�Fe(�eral�xp---dit'r6i sclosure�' � ` �
a s9c i K �x} §
,m_;;, .t MUSTY�belfilieii,out ifSm'le Aud�t.orPro mAudit.is NO
ar" y r�?s' 4` ;r hPa§sI hroughProgrni`I�aine& r,Confract � � `
xendiuures
um e�..��. _�.n
Z4 �5'i4 Cs�,.�c Je res /Z S6 ti
U•S.D� 3.lda�.�l.► - Fint� �,c ���H S��t pct 3 0 0
Total Federal Expenditures for this Fiscal Year: / S 4733
(�Iore, �-X-0 irro"q 9 1 4jr-611
Signatory an Title Date
Failure to submit this or a similar statement or failure to submit a completed single audit package as
described in the federally required audit requirements described in OMB Circulars A-133 by the
required due date may result in suspension of funding and ma y affect eligibility for future funding.
Notwithstanding the above, this certification acknowledges the agency's commitment to meet all
other financial reporting, financial statements, and other audit requirements as may be set forth
in the Contract.
EXHIBIT D-REPORTING FORMS
INVOICE
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
M
0,+ �° du
IS ;``: `s,� as. .�sx
9 s x � Cumulati�e to Date
Contractor's Certification: I certify that the costs incurred are valid and
consistent with the terms and conditions of the contract between City and
Agency. By signing this invoice, I certify that to the best of my knowledge
and belief the data included in this report is true and accurate. It is
acknowledged that the provision of false information could leave the
certifying official subject to the penalties of federal, state, and local law.
Signature and Date:
Name:
Title:
Attachment II
City of Fort Worth
Housing and Economic Development Department
Expenditure Worksheet
Agency:
Program:
Line No. Date Check No. - Pay"or Beneficiary* Description* Account Amount - Expense Line Item - Account
1 lHeafth
:Insurance
ATIVE HOPWA Only) -
2 1001
3 1002
4 nce 1003
5 1004
6 sbili Insurance 1005
7 Unem o men'-State 1006
8 Le alb Accountin 1007
9 PROGRAM PERSONNEL"
10 Salaries 2001
11 FICA 2002
12 Life Insurance 2003
13 Health Insurance 2004
14 Uneto ment 2005
15 WorV;Compensation 2006
16 Retirement 2007
17 SUPPUES AND SERVICES
18 Office Supplies 3001
19 Office E ui ment Rental 3002
20 Postage 3003
21 Printing 3004
22 MISCELLANEOUS`'
23 Conference 8 Seminars' 4001(
24 Co.st..o,.ui,(fi.g Materials 4002
25 Contract Labor 4003
26 Craft Supplies 4004
27 Credit Reports 4005
28 Facility Fees 4006
29 Field Top Costs 4007
30 Food Supplies 4008
31 Mileage 4009
32 TeachingAids 4010
33 FACILITY AND.UTIL(TIES
34 Telephone 5001
35 Electric 5002
36 Gas 5003
37 Water and Wastewater 5004
38 Solid Waste Disposal 5005
39 Rent 5006
40 Custodial Services 5007
41 Repairs 5008
42 Cleaning Supplies 5009
43 LEGAL.FINANCIAL,AND INSURANCE-
44 FidelityBond or E uivalent 6001
45 Directors and Officers 6002
46 General Commercial Liability 6003
47 Le al Fees 6004
48 Contract Acwunbng 6005
49 DIRECT ASSISTANCE - - -
50 Childcare Scholarships 7001
51 Counseling-Individual Sessions 7002
52 Counseling-Group Sessions 7003
53 Shod-term Rent Assistance 7004
54 Short-term Mortgage Assistance 7005
55 Short-tens Utilities Assistance 7006
56 Tenant Based Rental Assistance 7007
57 Volunteer Training 7008
58 CAPITALOUTLAY - -
59 Fumiture,Fixtures 8001
60 Computers 8002
Total Office Equipment 8003
Sport and Recreation Equipment 8004
'Payroll must identity employee Rent must identity tenant Other payments should identify mrlviduals,it applicable.
m
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1-11051
------------------
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EXHIBIT E-INCOME SELF-CERTIFICATION FORMS
CERTIFICATION OF INCOME STATEMENT
Applicant Name:
Current Address: Phone #:
Household Members and Income
(i cluding app licant
Last Name First Name Age Monthly Source
Income
**PERSONAL INFORMATION:(Check one in each item. Optional Information for Federal Reporting Purposes)
a. ❑MALE b.❑WHITE ❑BLACK/AFRICAN AMERICAN ❑BLACK/AFRICAN AMERICAN&WHITE
❑FEMALE ❑AMERICAN INDIAN/ALASKAN NATIVE ❑ASIAN
❑AMERICAN INDIAN/ALASKAN NATIVE&WHITE ❑ASIAN&WHITE
❑NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER ❑BALANCE/OTHER
❑AMERICAN INDIAN/ALASKAN NATIVE&BLACK/AFRICAN AMERICAN
c. ETHNICITY d. DISABLED e. IS CLIENT WOMEN HEAD OF HOUSEHOLD
❑HISPANIC ❑YES ❑YES
❑NON-HISPANIC ❑NO ❑NO
*TOTAL NUMBER OF FAMILY MEMBERS (Include Yourself,Spouse,Children,etc.)
Total Anticipated Annual Household Income:
Certification:
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.
Signature of Applicant Date
WARNING: TITLE 18,SECTION 1001 OF THE U.S.CODE STATES THAT A PERSON IS GUILTY OFA FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF
THE UNITED STATES GOVERNMENT.
For use by funding agency:
Household Size: Annual Income:
Income Limit: Is Applicant Eligible:
Person Making Determination: Date:
CERTIFICACION WJE DECLARACION WJE INGRESOS
Nombre del Solicitante:
Direccion de Actualidad: Teldfono:
Miembros Del Hogar e Ingresos
(incluir el/la Solicitante)
Apellido Nombre Had Ingreso Fuente de Ingresos
Mensual
**INFORMACION PERSONAL:(Seleccione uno en cads articulo. Informacion opcional)
a. ❑MASCULINO b.❑BLANCO ❑NEGRO/AFRICANO AMERICANO ❑NEGRO/AFRICANO AMERICANO&BLANCO
❑FEMININO ❑INDIO AMERICANO/NATIVO DE ALASKA ❑ASIATICO
❑INDIO AMERICANO/NATIVO DE ALASKA&BLANCO ❑ASIATICO&BLANCO
❑NATIVO HAWAIANO/OTRO DE LAS ISLAS PACIFICAS ❑BALANCE/OTRO
❑INDIO AMERICANO/NATIVO DE ALASKA&NEGRO/AFRICANO AMERICANO
c. ETHNICIDAD d. INCAPACITADO e. SES EL SOLICITANTE MUJER CABACERA DEL HOGAR?
❑HISPANO ❑SI ❑SI
❑NO-HISPANO ❑NO ❑NO
*TOTAL NUMERO DE MIEMBROS DE LA FAMILIA (Incluirse usted mismo,esposo/a,ninos,etc.)
Total Anual de Ingresos del hogar por anticipado:
Certificacion:
Yo certifico la informacion que yo estoy proporcionado es verdadero y puede ser sujeto a verificacion a
cualquiera hora por tercera parte. Yo tambien reconozco que la provision de informacion falsa puede dejarme
sujeto a penalidades Federales, Estatales, y a ley local.
Firma del Solicitante Fecha
ADVERTENCIA: TITULO 18,SECCION 1001 DEL CODIGO DE LOS E.U.A.DICE QUE UNA PERSONA ES
CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE HACER FALSO O FRAUDALENTAS DECLARACIONES
A CUALQUIER DEPARTAMENTO DE GOVIERNO DE LOS ESTADOS UNIDOS.
Para use de fondos de la agencia:
# De Miembros de Familia: Ingreso Anual:
Unite de Ingreso: SEs solicitante elegible?
Persona haciendo la determinaci6n: l�echa:
C) o O kr)
00 669 641 6�9
O O O
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arq
696969
O O O
O 00 �
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F�- 6N9 6M9 6`O9
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N O O O
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k!1
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O
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A w o 0 0
p O kn kr)
a�
Ln t
x p� r M N
O 69 69 69
o �
I
++ C2 O O O Okr) kn O
qt r'- N
W a 69 64 69
O k!1 N
N 69
O O O
O v-) kr) O
Rr M 00
N M
69 69 69
G
Q Q Q
0 0 0
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