HomeMy WebLinkAbouthealthpoint BG-120116, kl
AGREEMENT
Between The
CITY OF AUBURN, WASHINGTON
AND
HEALTHPOINT
THIS AGREEMENT, entered into this -3- day of a , 2012, between
the City of Auburn, State of Washington (hereinafter referred to as the "City ") and HealthPoint
(hereinafter referred to as the "Agency ")
WHEREAS, The City is an entitlement applicant for Community Development Block Grant
(CDBG) funds under the Housing and Community Development Act of 1974 (the Act), Pub
L 93 -383 as amended, and will receive CDBG funds for the purpose of carrying out eligible
community development and housing activities under the Act and under regulations
promulgated by the Department of Housing and Urban Development (HUD) at 24 CFR
Part 570, and
WHEREAS, The City desires to award certain funds to the Agency for use as described within
this Agreement, for the purpose of implementing eligible activities under the Act and HUD
regulations, and
WHEREAS, It is appropriate and mutually desirable that the Agency be designated by the City
to undertake the aforementioned eligible activities, so long as the requirements of the Act,
HUD Regulations, State law and local law are adhered to, as provided for herein, and
WHEREAS, The purpose of this Agreement is to provide for cooperation between the City and
the Agency, in implementing such eligible activities in the manner described herein, and
WHEREAS. The Legislature has declared that carrying out the purposes of federal grants or
programs is both a public purpose and an appropriate function for a city, town, county, or
public corporation, and
WHEREAS, the provisions of RCW 35 21 730 through RCW 35 21 755 and RCW 35 21 660
and 35 21 670 and the enabling authority as herein conferred to implement these provisions
are hereby construed to accomplish the purpose of RCW 35 21 730 through RCW
35 21 755,
NOW, THEREFORE, for and in consideration of payments, covenants, and agreements
hereinafter mentioned, to be made and performed by the parties hereto, the parties mutually
covenant and agree as provided for in this Agreement
PART I GENERAL CONDITIONS:
1 Scope of Agreement
2 Scope of Project
3 Commencement and Termination of Projects
4 Administration
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January 1, 2012
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5 Compensation and Method of Payment
6 Failure to Perform
7 Operating Budget
8 Funding Alternatives and Future Support
9 Amendments -
10 Assignment and Subcontracting
11 Hold Harmless and Indemnification
12 Insurance
13 Conflict of Interest
14 Terrninat!on
15 Reversion of Assets
PART II FEDERAL, STATE AND LOCAL PROGRAM REQUIREMENTS:
1 Procurement Standards
2 Environmental Review
3 Nondiscrimination
4 Labor Standards
5 Property Management
6 Acquisition and Relocation
7 National -Flood Insurance
8 Lead -Based Paint, Poisoning
9 Administrative Requirements and Cost Principles
10 Other Federal Requirements
11 Non - substitution for Local Funding.
12 Public Ownership
13 Public Information
14 Lobbying
15 Religious Organizations
PART III. EVALUATION AND RECORD KEEPING:
1 General
2 Evaluation
3 Audits and. Inspections
4 Records
5 Retention of Records
6 Reports
PART IV EXHIBITS:
PART V
ACCEPTANCE AND SIGNATURES:
ATTACHMENTS:
ATTACHMENT #1-
ATTACHMENT #2
ATTACHMENT #3
ATTACHMENT #4
ATTACHMENT #5
General Information
Project Budget
Special Conditions
Records and Reporting
Project Timeline /Performance Measurements
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PART I._ L. GENERAL CONDITIONS:
1; SCOPE OF AGREEMENT:
The Agreement between the parties shall consist of the signature page, the general
conditions, the Federal, State and local program requirements, the evaluation and
record keeping requirements; each and every project Exhibit and Attachment
incorporated into the Agreement, all matters and laws incorporated by reference herein,
and any written amendments made according to the general conditions This Agreement
supersedes any and all former agreements applicable to projects governed by this
Agreement
2. SCOPE OF PROJECT:
The Agency shall use funds only to perform the activities set forth in the Attachments
hereto In the case of multiple projects, each project shall correspond to a separate set
of Attachments This Agreement may be amended from time to time, in accordance with
the general conditions, for the purpose of adding new projects, amending the scope of
work, or for any other lawful purpose
3. COMMENCEMENT AND TERMINATION OF PROJECTS:
A. Upon release of project- related funds by HUD pursuant to 24 CFR Part 58, the City shall
furnish the Agency with written notice to proceed. No work on a project shall occur prior
to the notice to proceed without written approval from the City Termination dates for
individual projects shall be specified in the appropriate Attachments. Costs incurred after
the termination date will not be reimbursed. The termination date may be changed
through amendment of this Agreement
B Upon termination of individual projects covered by this Agreement, the Agency shall
transfer to the City any CDBG funds on hand at the time of termination and any
accounts receivable attributable to the use of CDBG funds.
4. ADMINISTRATION:
The Agency shall appoint a liaison who shall be responsible for overall administration of
CDBG funded project(s) and coordination with the City of Auburn's Department of
Planning and Community Development The Agency shall also_designate one or more
representatives who shall be authorized to sign the Voucher Reimbursement Requests
and Program Accomplishments Forms The names of the liaison and representatives
shall be specified in the Attachment(s)
5. COMPENSATION AND METHOD OF PAYMENT:
A The City shall reimburse the Agency only for the activities specified in the Attachments
in an amount not to exceed the amount specified on Attachment #1 -- "CDBG
APPROPRIATION " Reimbursement shall be based on a CDBG Voucher
Reimbursement Request and Program Accomplishments Form submitted and signed by
the Agency's authorized representative Reimbursement is subject to the terms of
Section 6 of this Part I
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B The Agency shall submit a properly executed Voucher Reimbursement Request and
Program Accomplishments Form as frequently as desired, but at a minimum no later
than fifteen (15) working days after the close of each calendar quarter throughout the
term of the project The City will make payment to the Agency not more than forty -five
(45) working days after said Reimbursement Request is received and approved by the
City. The City will issue a statement of correction in the event that the Voucher
Reimbursement Request is erroneous Payment does not constitute absolute approval
C. Any reimbursement must comply with conditions of Letter of Credit Procedure
Regulations 1900 23 (Revised) in that funds on hand should not exceed $5,000 if
retained beyond three (3) days and that any reimbursement in excess of the amount
required shall be returned to the City
6. FAILURE To PERFORM:
In the event of a failure to comply with any terms or conditions of this Contract or to
provide in any manner the activities or other performance as agreed to herein, the City
reserves the right, following written notice to the Agency, to withhold all or any part of
payment, suspend all or part of the contract, or prohibit the Agency from incurring
additional obligations of funds until the City is satisfied that corrective action has been
taken or completed as more specifically outlined in the Exhibit(s) and Attachment(s) to
this contract The option to withhold funds is in addition to, and not in lieu of, the City's
right to termination as provided in Section 14 of the General Conditions of this
Agreement
7. OPERATING BUDGET:
The Agency shall apply the funds received from the City under this Agreement in
accordance with the Budget Summary found on Attachment #2 No line item expense
thereunder shall cause total expenditures charged to this Agreement to exceed the total
amount appropriated to the Agency by the City as indicated in Attachment #1 -- "CDBG
APPROPRIATION "
8. FUNDING ALTERNATIVES AND FUTURE SUPPORT:
A The Agency shall report all project income generated under this Agreement for the
purposes specified herein or generated through the project(s) funded under this
Agreement Income which is not used to continue or benefit such project(s) shall revert
to the CDBG Fund for reallocation by the City. The City shall determine whether income
is being used to continue or benefit a project or projects authorized by this Agreement If
the City should authorize, the Agency will comply with all provisions of this Agreement in
expending such project income
B The City makes no commitment to future support and assumes no obligation for future
support of the activities contracted herein, except as expressly set forth in this
Agreement.
C Should anticipated sources of revenue become unavailable to the City for use in the
Community Development Block Grant Program, the City shall immediately notify the
Agency in writing and the City will be released from all contracted liability for that portion
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of the Agreement covered by funds not yet received by the City.
9. AMENDMENTS:
Either party may request modifications in the scope of permissible activities, terms, or
conditions of this Agreement Proposed modifications which are mutually agreed upon
shall be incorporated by written amendment to this Agreement A written amendment
may affect a project or projects authorized by this Agreement or may be of general
application
10. ASSIGNMENT AND SUBCONTRACTING:
A The Agency shall not assign any portion of this Agreement without the written consent of
the City, and it is further agreed that said consent must be sought in writing by the
Agency not less than fifteen (15) days prior to the date of any proposed assignment.
B Any work or services assigned or subcontracted hereunder shall be subject to each
provision of this Agreement and proper bidding procedures contained herein The
Agency agrees that it is as fully responsible to the City for the acts and omissions of its
subcontractors and their employees and agents, as it is for the acts and omissions of its
own employees and agents, as provided in paragraph 11 B
11. HOLD HARMLESS AND INDEMNIFICATION:
A The Agency agrees that it is financially responsible (liable) for any audit exception or
other financial loss to the City which occurs due to its negligence or its failure to comply
with the terms of this Agreement
B The Agency further agrees to defend, indemnify and hold harmless the City, its elected
and appointed officials, employees and agents from and against any and all claims,
demands and /or causes of action of any kind or character whatsoever arising out of or
relating to services provided under this Agreement by the Agency, its employees,
subcontractors, or agents for any and all claims by any persons for alleged personal
injury, death, or damage to their persons or property to the extent caused by the
negligent acts, errors or omissions of the Agency, its employees, agents, subcontractors
or representatives In the event that any suit or claim for damages based upon such
claim, action, loss, or damages is brought against the City, the Agency shall defend the
same at its sole cost and expense, provided that the City retains the right to participate
in said suit if any principle of governmental or public law is involved, and if final judgment
be rendered against the City and /or its officers, agents, and /or employees or any of
them or jointly against the City and the Agency and its respective officers, agents,
subcontractors, employees or any of them, the Agency agrees to fully satisfy the same
and the Agency shall reimburse the City for any cost and expense which the City has
incurred as a result of such claim or suit The provisions of this section shall survive the
expiration or termination of this Agreement
12. INSURANCE:
A Public Liability Insurance
The Agency shall, at all times during the term of this Agreement, at its cost and
expense, carry and maintain general public liability insurance against claims for bodily
injury, personal injury, death or property damage occurring or arising out of services
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provided under this Agreement, which insurance shall cover such claims as may be
occasioned by any act, omission, or negligence of the Agency or its officers, agents,
representatives, assigns or servants The limits of liability insurance, which may be
increased from time to time as deemed necessary by the City with the approval of the
Agency which shall not be unreasonably withheld, shall not be less than one million
dollars ($1,000,000) combined single limit personal injury and property damage
insurance. The insurance required above shall be issued by an insurance company or
companies authorized to do business within the State of Washington and must be
acceptable to the City The City shall be specifically named as an additional insured on
all such policies, and all such policy or policies shall be primary to any other valid and
collectible insurance
B Building Risk Insurance
The Agency shall cause to be maintained, during the period that any construction work
is in progress, All Risk Builder's Insurance (including fire, vandalism, malicious mischief
and extended coverage), in an amount not less than the value of destructible contract
work in place.
C Proof of Insurance:
Certificate or certificates or other evidence satisfactory to the City evidencing the
existence and terms and conditions of all insurance required above shall be delivered to
the City within five days of the Agency's receipt of the Authorization to Proceed The
policy or policies of insurance required to be maintained in accordance with this
Agreement shall not be canceled or given notice of non - renewal nor shall the terms or
conditions thereof be altered or amended without sixty (60) days written notice being
given to the City.
13. CONFLICT OF INTEREST:
A Interest of Officers, Employees, or Agents.
No officer, employee, or agent of the City or Agency who exercises any functions or
responsibilities in connection with the planning and carrying out of the City of Auburn
CDBG Program, or any other person who exercises any functions or responsibilities in
connection with the City, shall have any personal financial interest, direct or indirect, in
this Agreement, and the Agency shall take appropriate steps to assure compliance
B Interest of Contractor(s) and Their Employees.
The Agency agrees that it will incorporate into every subcontract required to be in
writing, and made pursuant to this Agreement, the following or equivalent provisions
The Contractor covenants that no person who presently exercises any
functions or responsibilities in connection with the CDBG Program, has any
personal financial interest, direct or indirect, in this Contract. The Contractor
further covenants that he or she presently has no interest and shall not
acquire any interest, direct or indirect, which would conflict in any manner or
degree with the performance of services hereunder The Contractor further
covenants that in the performance of this Contract no person having any
conflicting interest shall be employed Any such interest on the part of the
Contractor or the Contractor's employees must be disclosed to the Agency
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and the City
14. SUSPENSION AND TERMINATION:
A This Agreement is subject to suspension o r termination upon 30 days written notice by
the City should
1. The Agency mismanage or make improper or unlawful use of CDBG funds,
2 The Agency fail to comply with the terms and conditions- expressed herein or the
applicable regulations and directives of the Federal Government, State, or City;
3 CDBG funds become no longer available from the Federal Government or through
the City,
,4 _The Agency fail to carry out activities expressed by this Agreement, or
5 The'Agency fail to submit reports or submit incomplete or inaccurate reports in any
material respect
B This Agreement is subject to suspension or termination upon 30 days written notice by
the Agency should
1 The City fail in its commitment under this Agreement to provide funding for services
rendered, as herein provided; or
2. CDBG funds become no longer available from the Federal Government or through
the City
C This Agreement may be suspended or terminated at any time, in whole or in part, upon
the written agreement of the City and the Agency.
D. Otherwise this Agreement shall terminate on the termination date specified on
Attachment #1 attached hereto and shall be subject to extension only by mutual
agreement and amendment in accordance with paragraph 9, Amendments, of this Part
E Upon termination of this Agreement, any unexpended balance of the CDBG funds
awarded through this Agreement shall lapse and remain in the City of Auburn's CDBG
fund
F In the event that termination occurs under paragraph A(1) of this section, the Agency
shall return to the City all funds which were expended in violation of the terms of this
Agreement
15: REVERSION OF ASSETS:
Upon expiration of this Agreement, the Agency shall transfer to the City any City CDBG
funds on hand at the time of expiration any accounts receivable attributable to the use of
City CDBG funds
In the event that the Agency ceases to use any asset acquired or improved with CDBG
funds for the purpose described in this Agreement, within five years following the
termination of this agreement, the Agency shall pay to the City the fair market value of
the asset less any portion of the value attributable to expenditures of non -CDBG funds
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PART II. FEDERAL, STATE AND LOCAL PROGRAM REQUIREMENTS:
1. PROCUREMENT STANDARDS:
In awarding contracts pursuant to this Agreement, the Agency shall comply with all
applicable requirements of local and State law for awarding contracts, including but not
limited to procedures for competitive bidding, contractor's bonds, and RCW60 28 010,
which addresses retained percentages In addition, the Agency shall comply with the
requirements of the U S Office of Management and Budget Circular A -110 and /or A-
102 and /or A -133, as applicable, relating to bonding, insurance and procurement
standards, and with Executive Order 11246 regarding nondiscrimination in bid
conditions for projects over $100,000 Where Federal standards differ from local or
State standards, the stricter standards shall apply The Federal standard of $100,000 for
competitive bidding shall apply only if the applicable State or local standard for
competitive bidding is greater than $100,000
2. ENVIRONMENTAL REVIEW:
A National Environmental Policy Act:
The City retains environmental review responsibility for purposes of fulfilling
requirements of the National Environmental Policy Act as implemented by HUD
Environmental Review Procedures (24 CFR Part 58) The City may require the Agency
to furnish data, information and assistance for the City's review and assessment in
determining whether an Environmental Impact Statement must be prepared
B Other Federal Environmental Laws'
In decision making and action pursuant to NEPA, and otherwise under this Agreement
the standards, policies, and regulations of the following laws and authorities shall be
followed The National Historic Preservation Act of 1966 (16 U S C 470 et seq.) as
amended, particularly section 106 (16 U S C 470(f)); Executive Order 11593, Protection
and Enhancement of the Cultural Environment, May 13, 1971 (36 FR 8921 et seq ),
particularly section 2(c), The Reservoir Salvage Act of 1960 (16 U.S C 469 et seq ),
particularly section 3 (16 U S C 469a -1), as amended by the Archaeological and
Historic Preservation Act of 1974, Flood Disaster Protection Act of 1973 (42 U.S C
4001 et seq ) as amended, particularly sections 102(a) and 202(a) (42 U S C 4012a(a)
and 4106(a)), Executive Order 11988, Floodplain Management, May 24, 1977 (42 FR
26951 et seq ), particularly section 2(a); Executive Order 11990, Protection of Wetlands,
May 24, 1977 (42 FR 26961 et seq ), particularly sections 2 and 5, The Coastal Zone
Management Act of 1972 (16 U S.0 1451 et seq ) as amended, particularly section
307(c) and (d) (16 U S C. 1456(c) and (d)); The Safe Drinking Water Act of 1974 (42
U.S.C. 201, 300(f) et seq , and 21 U S C 349) as amended, particularly section 1424(e)
(42 U.S.C. 300h- 303(e)), The Endangered Species Act of 1973 (16 U.S.C. 1531 et seq )
as amended, particularly Section 7 (16 U S C. 1536); The Wild and Scenic Rivers Act of
1968 (16 U S C 1271 et seq ) as amended, particularly section 7(b) and (c) (16 U S C
1278(b) and (c)), The Clean Air Act (42 U S C 7401 et seq ) as amended, particularly
section 176(c) and (d) (42 U S C 7506(c) and (d)), and HUD environmental standards
(24 CFR Part 51, Environmental Criteria and Standards (44 FR 40860 - 40866, July 12,
1979)
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C. State Environmental Policy Act
Agencies which are branches of government under RCW 43.21 C 030 retain
responsibility for•fulfilling the requirements of the State Environmental Policy Act, RCW
chap. 43 21 C, and regulations and ordinances adopted thereunder. If the Agency is not
a branch of government under RCW 43 21C 030, the City may require the Agency to
furnish data, information and assistance as necessary t� enable the City to comply with
the State Environmental Policy Act.
D. Satisfaction of Environmental Requirements:
Project execution under this Agreement by either the City or the Agency shall not
proceed until satisfaction of all applicable requirements of the National and State
Environmental Policy Acts A written notice to proceed will not be issued by the City until
all such requirements are complied with
3. NONDISCRIMINATION:
A General
The Agency shall comply with all Federal, State and local laws prohibiting discrimination
on the basis of age, sex, marital status, race, creed, color, national origin or the
presence of any sensory, mental or physical handicap._ These requirements are
specified, in RCW chapter 49.60, Section 109 of the Housing and Community
Development Act of 1974, Civil Rights Act of,1964, Title VI, Civil Rights Act of 1968,
Title VIII, Executive Order 11063, Executive Order 11246, Section 3 of the Housing and
Urban Development Act of 1968, Section 504 of the Rehabilitation Act of 1973; and, the
Age Discrimination Act of 1975. Specifically,`the Agency is prohibited from taking any
discriminatory actions defined in the HUD Regulations at 24 CFR 570.602 (b) (1) and
shall take such affirmative and corrective actions as are required by the Regulations at
24 CFR 570 602 (b)(4)
B. Specific Discriminatory Actions Prohibited
1. The Agency may not, under any program or activity to which this Agreement may
apply, `directly or through contractual or other arrangements, on the grounds of race,
color, national origin, or sex.
(i) - Deny any person facilities, services, financial aid or other benefits provided
under the program or activity
(ii) Provide any person with facilities, services, financial aid or other benefits
which are different, or are provided in a different form from that provided to
others under the program or'activity
(iii) Subject any person to segregated or separate treatment in any facility or in
any matter or process related to receipt of any service or benefit under the
program or activity
(iv) Restrict in any way access to, or in the enjoyment of, any advantage or
privilegeenjoyed by others in connection with facilities, services, financial aid
or other benefits under the program or activity
(v) Treat any person differently from others in determining whether the person
satisfies any admission, enrollment,'eligibility, membership, or other
requirement or condition which individuals must meet in order to be provided
any facilities, services or other benefit provided under the-program or activity.
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(vi) Deny any person any opportunity to participate in a program or activity as an
employee
2 The Agency shall not utilize criteria or methods of administration which have the
effect of subjecting individuals to discrimination on the basis of race, color, national
origin, or sex, or have the effect of defeating or substantially impairing
accomplishment of the objectives of the program or activity with respect to
individuals of a particular race, color, national origin, or sex.
3. The Agency, in determining the site or location of housing or facilities provided in
whole or in part with funds under this part, may not make selections of such site or
location which have the effect of excluding individuals from, denying them the
benefits of, or subjecting them to discrimination on the grounds of race, color,
national origin, or sex, or which have the purpose or effect of defeating or
substantially impairing the accomplishment of the objectives of the Act or of the HUD
Regulations
C Fair Housing.
The Agency shall take necessary and appropriate actions to prevent discrimination in
Federally assisted housing and lending practices related to loans insured or guaranteed
by the Federal government. (Civil Rights Act of 1968, Title VII; Executive Order 11063)
D Employment:
1 In all solicitations under this Agreement, the Agency shall state that all qualified
applicants will be considered for employment The words "equal opportunity
employer" in advertisements shall constitute compliance with this section
2. The Agency shall not discriminate against any employee or applicant for
employment in connection with this Agreement because of age, sex, marital status,
race, creed, color, national origin, or the presence of any sensory, mental, or
physical handicap, except when there is a bona fide occupational limitation. 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. (RCW chap
49.60, Executive Order 11246 as amended)
3 To the greatest extent feasible, the Agency shall provide training and employment
opportunities for lower income residents within the area served by CDBG assisted
projects (Section 3, Housing and Urban Development Act of 1968, as amended)
E. Contractors and Suppliers*
1. No contractor, subcontractor, union or vendor engaged in any activity under this
Agreement shall discriminate in the sale of materials, equipment or labor on the
basis of age, sex, marital status, race, creed, color, national origin, or the presence
of any sensory, mental, or physical handicap Such practices include* employment,
upgrading, demotion, recruiting, transfer, layoff, termination, pay rate, and
advertisement for employment (RCW chap 49 60, Executive Order 11246 as
amended)
2. All firms and organizations described above shall be required to submit to the
Agency certificates of compliance demonstrating that they have, in fact, complied
with the foregoing provisions, provided, that certificates of compliance shall not be
required from firms and organizations with fewer than 25 employees or on contracts
and /or yearly sales of less than $10,000.
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3 To the greatest extent feasible, the Agency shall purchase supplies and services for
activities under this Agreement from vendors and contractors whose_businesses are
located in the area served by CDBG funded activities or owned in substantial part by
project area residents (Section 3, Housing and Urban Development Act of 1968, as
amended )
4 CDBG funds shall not be used directly or indirectly to employ, award contracts to, or
otherwiseengage the services of, or fund any contractor or subrecipient during any
period of debarment, suspension, or placement in ineligibility status under the
provisions of 24 CFR Part 24
F Notice
1 The Agency shall include the provisions of the appropriate subsections A, B, C, D,
and E of this section 3 entitled "Nondiscrimination" in every contract or purchase
order for goods and services under this Agreement and shall send to each labor
union or representative of workers with which it has a collective bargaining
agreement or other contract or understanding a notice advising the said labor union
or worker's representative of the commitments made in these subsections
2 In advertising for employees, goods or services for the activities under this
Agreement, the Agency shall comply with Attachment 0 to OMB Circular A -102 or A-
110, as applicable, Procurement Standards, paragraph 9, Contracting with Small
and Minority Firms, Women's Business Enterprise and Labor Surplus Area firms
Agencies shall be considered to be in compliance with this provision if at least one of
the following steps is taken. (a) advertise in a minority publication in addition to
publication of general circulation, (b) utilize a minority contractors bidding center,
and (c) utilize the King County Affirmative Action Office Certified Minonty/Women's
Business Enterprise Directory
4. LABOR STANDARDS:
The Agency shall require that project construction contractors and subcontractors pay
their laborers and mechanics at wage rates in accordance with the Davis -Bacon Act, as
amended (40 U S C. sections 276(a)- 276(a)(5)), and that they comply with the Copeland
"Anti- Kickback" Act (40 U S C. 276(c)), and the Contract Work Hours and Safety
Standards Act (40 U S C 327 et seq ) as prescribed at 29 CFR Parts 1,3,5,6 and 7,
provided that this section shall not apply to rehabilitation of residential property designed
for residential use by fewer than eight families
5. PROPERTY MANAGEMENT:
A. The Agency agrees that any non - expendable personal property (capital equipment),
purchased wholly or in part with project funds at a cost of $300 (three hundred dollars)
or more per item, is upon its purchase or receipt the property of the City and /or Federal
government Final ownership and disposition of such property shall be determined under
the applicable, provisions of Attachment N to the U S Office of Management and Budget
Circular No A -102, and /or Attachment N to the U S Office of Management and Budget
Circular No A -110.
B The Agency shall be responsible for all such property, including its care and
maintenance at the Agency's expense
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C The Agency shall admit the City's property management officer to Agency's premises for
the purpose of marking such property, as appropriate, with City property tags
D The Agency shall meet the following procedural requirements for all such property.
1 Property records shall be maintained accurately and provide for. a description of the
property, manufacturer's serial number or other identification number, acquisition
date and cost, source of the property, percentage of CDBG funds used in the
purchase of property, and location, use, and condition of the property
2 A physical inventory of property shall be taken and the results reconciled with the
property records at least once every two (2) years to verify the existence, current
utilization, and continued need for the property.
3 A control system shall be in effect to insure adequate safeguards to prevent loss,
damage, or theft of the property Any such loss, damage or theft of property shall be
investigated and fully documented
4 Adequate maintenance procedures shall be implemented to keep the property in
good condition
6. ACQUISITION AND RELOCATION:
A Any acquisition of real property by a State Agency for any activity assisted under this
Agreement shall comply with the Federal Uniform Relocation Assistance and Real
Property Acquisition Policies Act of 1970 (hereinafter referred to as the Uniform Act) (42
U S C 4601 et seq ) and the Regulations at 24 CFR Part 42
B Implementation of any project provided for in this Agreement will be undertaken so as to
minimize involuntary displacement of persons, businesses, nonprofit organizations, or
farms to the greatest extent feasible
C Any displacement of persons, businesses, nonprofit organizations, or farms occurring as
the result of acquisition of real property assisted under this Agreement shall comply with
the Uniform Act, the Regulations at 24 CFR Part 42, and the City of Auburn's
Displacement Policy required by Federal CDBG regulations at 24 CFR 570.305 The
Agency shall comply with the Regulations pertaining to costs of relocation and written
policies, as specified by 24 CFR 570 602 (c) and (d)
7. NATIONAL FLOOD INSURANCE:
To the extent indicated by 24 CFR 570 605, the Agency shall comply with the flood
insurance purchase requirements of Section 202(a) of the Flood Disaster Protection Act
of 1973 (42 U S.0 4001 et seq and the Federal regulations issued thereunder) The
Agency shall comply with the Regulations at 24 CFR section 570.605
8. LEAD -BASED PAINT POISONING:
The Agency shall comply with the HUD Lead -Based Paint Regulations (24 CFR Part 35)
issued pursuant to the Lead -Based Paint Poisoning Prevention Act (42 U S.0 sections
4831 et seq) requiring prohibition of the use of lead -based paint (whenever funds under
this Agreement are used directly or indirectly for construction, rehabilitation, or
modernization of residential structures) and notification of the hazards of lead -based
paint poisoning to purchasers and tenants of residential structures constructed prior to
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 12 of 27
1950.
9. ADMINISTRATIVE REQUIREMENTS AND COST PRINCIPLES:
A If the Agency is a governmental entity, the Agency shall comply with the requirements
and standards of OMB Circular A -128, "Audits of State and Local Government," and
Circular A -87, "Principles for Determining Costs Applicable to Grants and Contracts with
State, Local and Federally recognized Indian Tribal Governments," and with the
following Attachments to OMB Circular No A -102
Attachment A, "Cash Depositories," except for Paragraph 4 concerning deposit
insurance;
1 Attachment B, "Bonding and Insurance,"
2 Attachment C, "Retention and Custodial Requirements for Records,"
3 Attachment G, "Standards for Grantee Financial Management Systems,"
4 Attachment I, "Monitoring and Reporting Program Performance," Paragraph 2,
5 Attachment J, "Grant Payment Requirements;"
6 Attachment N, "Property Management Standards," except for Paragraph 3
concerning the standards for real property;
7 Attachment 0, "Procurement Standards," and
8. Attachment P, "Audit Requirements."
B If the Agency is not a governmental,entity, the Agency shall comply with the
requirements and standards of OMB Circular No. A -133,, "Audits of Institutions of Higher
Learning and Other Non - Profit Institutions," and No A -122,• "Cost Principles for Non -
Profit Organizations," and the following Attachments to OMB Circular No A -110
1. Attachment A, "Cash Depositories," except for Paragraph 4 concerning deposit
insurance,
2 Attachment B, "Bonding and Insurance;"
3. Attachment C, "Retention and Custodial Requirements for Records,"
4. Attachment H, "Monitoring and Reporting Program Performance," Paragraph 2;
5 Attachment N, "Property Management Standards," except for Paragraph 3
concerning the standards for real property; and
6. Attachment 0, "Procurement Standards "
10. OTHER FEDERAL REQUIREMENTS:
The absenceiof mention in this Agreement of any other Federal requirements which
apply to the award and expenditure of the Federal funds made available by this
Agreement is not intended to indicate that those Federal requirements are not
applicable to Agency activities. The Agency shall comply with all other Federal
requirements relating to-the expenditure of Federal funds, including but not limited to
The Architectural Barriers Act of 1968 (42 U S C. 4151), and the Hatch Act (5 U S C
Chapter 15). Additionally, the Agency shall comply with the Federal requirements
described by 24 CFR Part 570, Sections 600 through 603; Section 605, and Sections
607 through 612.
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 13 of 27
11. NONSUBSTITUTION FOR LOCAL FUNDING:
The CDBG funding made available under this Agreement shall not be utilized by the
Agency to reduce substantially the amount of local financial support for community
development activities below the level of such support prior to the availability of funds
under this Agreement.
12. PUBLIC OWNERSHIP:
For Agencies which are not municipal corporations organized under the laws of the
State of Washington, it may become necessary to grant the City a property interest
where the subject project calls for the acquisition, construction, reconstruction,
rehabilitation, or installation of publicly owned facilities and improvements. The Agency
shall comply with current City requirements regarding transfer of a property interest
sufficient to meet any public ownership requirement imposed by law
13. PUBLIC INFORMATION:
A In all news releases and other public notices related to projects funded under this
Agreement, the Agency shall include information identifying the source of funds as the
City of Auburn CDBG Program
B For all construction projects the Agency shall erect a sign to City specifications at the
construction site, identifying the source of funds, except that this requirement may be
waived for construction projects of $100,000 or less.
C The Agency acknowledges that this Agreement and any other information provided by it
to the City and /or relevant to the Project(s) described in the Exhibit(s) and Attachment(s)
are subject to the Washington State Public Disclosure Act, Chapter 42.17 RCW
14. LOBBYING:
The Agency certifies, to the best of his or her knowledge and belief, that:
A No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, 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,
or an employee of a Member 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
B If any funds other than Federal 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, a
Member of Congress, an officer or employee of Congress, or an employee of a Member
of Congress in connection with this Federal contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form -LLL, "Disclosure
Form to Report Lobbying," in accordance with its instructions
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 14 of 27
C The Agency shall require that the language of this certification, or equivalent language,
be included in the award documents for all subawards at all tiers (including
subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) and that all subrecipients shall certify and disclose accordingly
This certification is a material representation of fact upon which reliance was placed
when this transaction was made or entered into Submission of this certification is a
prerequisite for making or entering into this transaction imposed by section 1352, title
31, U S Code Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each such failure
15. RELIGIOUS ORGANIZATIONS:
The Agency will comply with all federal requirements concerning religious organizations
and the use of Community Development Block Grant funds. All services delivered must
be dispensed in a clearly non - sectarian manner, devoid of any religious influence
PART III. EVALUATION AND RECORD_KEEPING:
1. GENERAL:
The Agency agrees to maintain records and provide reports as listed in Attachment #4
of this Contract, and as defined in this Part, below
2. EVALUATION:
The Agency agrees to,participate with the City in any evaluation project or performance
report, as designed by the-City or the appropriate Federal Agency, and to make
available all information required by any such evaluation process
3. AUDITS AND INSPECTIONS:
The records and documents with respect to all matters covered by this Agreement shall
be-subject at all times to inspection, review or audit by the City, Federal or State officials
so authorized by law during the performance of this Agreement and'during the period of
retention specified in this Part III
A Audits
The Agency will provide at or before the contract signing a copy of the Agency's most
recent audit The Agency will provide to the City a copy of the Agency's most recent
audit for each year in which a contract for the use of funds exists with the City Failure to
provide such audit will be considered a material breach of the contract and result in a
refund to the City of all moneys paid or due under the contract
B Audit Requirements
Agencies receiving $300,000 or more in federal funds will provide to the City the above
required audits conducted in a manner pursuant to OMB Circular A -133.
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 15 of 27
s
4. RECORDS:
All Agencies receiving Community Development Block Grant funds from the City shall
maintain a certified public audit for the City Community Development Block Grant year in
which the funds are awarded and through each Community Development Block Grant
year or portion thereof, in which the funds are used or a contract exists between the
Agency and the City As required by HUD Regulations, 24 CFR Part 570, the Agency
shall compile and maintain the following records:
A Financial Management
Such records shall identify adequately the source and application of funds for activities
within this Agreement, in accordance with the applicable provisions of Attachment G to
the U S. Office of Management and Budget Circular A -110 These records shall contain
information pertaining to grant awards and authorizations, obligations, unobligated
balances, assets, liabilities, outlays, and income
B Relocation
Agency record keeping must comply with the Uniform Act implementing regulations at
24 CFR Part 42 Indication of the overall status of the relocation workload and a
separate relocation record for each person, business, organization, and farm operation
displaced or in the relocation workload must be kept
C. Property Acquisition
Agency files must contain a separate acquisition file for each acquisition process
documenting compliance with the implementing regulations for the Uniform Act at 24
CFR Part 42 Major requirements include (a) invitation to owner to accompany
appraiser during inspection, (b) at least one property appraisal, (c) statement of basis
for determination of just compensation, (d) written offer of just compensation, (e) all
documents involving conveyance, (f) settlement cost reporting statement, and (g) notice
to surrender possession of premises.
D. Equal Opportunity
The Agency shall maintain racial, ethnic, and gender data showing the extent to which
these categories of persons have participated in, or benefited from, the activities carried
out under this Agreement The Agency shall also maintain data which records its
affirmative action in equal opportunity employment, and its good -faith efforts to identify,
train, and /or hire lower-income residents of the project area and to utilize business
concerns which are located in or owned in substantial part by persons residing in the
area of the project
E Labor Standards
Records shall be maintained regarding compliance of all contractors performing
construction work under this Agreement with the labor standards made applicable by
24 CFR 270 603 and any State labor standards, as applicable.
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 16 of 27
F Miscellaneous Records.
The Agency shall maintain such other records as may be required by HUD or the City.
Such records shall include, but shall not be limited to, a separate and current file for
each separate CDBG funded project (as represented by separate Exhibits and
Attachments to this Agreement), containing copies of originals of the following.
1 Original Funding Application.
2 Grant Award Letter.
3 Notice to Proceed and /or equivalent written approval from City.
4 Project or program related authorizations, motions, resolutions or meeting minutes
of the Agency's governing body
5. Contract Attachments, Exhibits and any amendments thereto.
6 This Agreement and any amendments thereto.
7. Voucher reimbursement requests and program accomplishment forms
8 Bills for payment
9. Approved vouchers and warrants
10 Where CDBG funds will support Agency staff salary and /or fringe benefit costs,
payroll time sheets signed by the employee and the employee's supervisor,
annotated to document percent of time charged against the project if less than full
time
11 Where CDBG funds will be used to offset the cost of communications, travel and
office supplies, and where these costs are shared with other programs and no
invoice is available, documentation such as log sheets (for copy machine use,
odometer readings, etc ). As an alternative, annotated invoices may be used to
document charges as appropriate.
12 In capital projects where CDBG funds will be used to hire physical laborers and /or
tradespeople (regardless of Davis -Bacon applicability to the project), hours that
these employees worked, and their rate of pay per hour
Additionally, each project file shall include documentation on all persons who have
benefited from the project, as follows residence status (Auburn resident, non - Auburn
resident), income status (below 30% of County Median, below 50% of County median,
below 80% of County median, above 80% of county median), ethnic status (white, black,
American Indian or Alaskan Native, Hispanic, Asian or Pacific Islander), and whether or
not beneficiary is a member of a female- headed household
5. RETENTION OF RECORDS:
Required records shall be retained for a period of three (3) years after termination of this
Agreement, except as follows (1) Records that are the subject of audit findings shall be
retained for three (3) years after such findings have been resolved (2) Records for
nonexpendable property shall be retained for three (3) years after its final disposition.
Nonexpendable property is defined in Attachment N to U S Office of Management and
Budget Circular No. A -102, for governmental entities, and Circular No. A -110 for non-
governmental organizations
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 17 of 27
6. REPORTS:
The Agency shall submit such reports as required by the City at such times as required
by the City. Notwithstanding any other provision of this Agreement to the contrary, the
reports required by the City shall be submitted by the Agency no less than on an annual
basis Such reports shall also be submitted prior to project completion
PART IV. EXHIBITS:
The following exhibits are incorporated herein by reference
A Original Grant Application as submitted June 2008
B Environmental Determination
C Contract Scope of Work, Completion Date and Contact Information
PART V. ACCEPTANCE AND SIGNATURES:
The parties hereto agree and accept the terms, conditions, covenants and all matters and laws
incorporated by reference herein and therefore cause their hands to affix their signatures as
evidence to their acceptance of this Agreement before their designated witnesses and /or
notaries
REMAINDER OF PAGE INTENTIONALLY BLANK
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 18 of 27
May.. 4. 2012 4:41,PM , City of Auburn Mayors Office
No. 1433 P. 1
MAYOR
ATTEST: APP
Dantelle,Da skarn,
City Clerk
STATE OF WASHINGTON
COUNTY OF KING
ie(B. Heid,
City Attorney
TITLE: a+ t-i e-C Gy -t,- Ve. I.JT`t' cci7
) ss
On this 9'' day of , 2012, before me, the undersigned, a Notary
Public in and for the State of Washington, personally appeared aslhomcc s I ("o eelP,t ;-
to me known to be the LEO of HealthPoint, the non - profit corporation
referenced as Agency within the foregoing instrument, and acknowledged said instrument to be
the free and voluntary act and deed of said non - profit corporation for the uses and purposes
therein mentioned, and on oath stated that he /she is authorized to execute said instrument on
behalf of said non - profit corporation.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the data
hereinabove set forth.
1 YVONNE L. WESTOVER
NOTARY PUBLIC
STATE OF WASHINGTON
COMMISSION EXPIRES
IJ, DECEMBER 29, 2012
N o RY, PUBLIC in an rthe ate of
W , hington; residing in ein
MY COMMISSION expires: I)j 2 / i 2
City of Auburn Agreement: BG -1201, HealltiPoint — Primary Health Care (Medical and Dental)
-'January 1;-2012
- Denn,10 AF77
May. 4. 2012 4:41PM City of Auburn Mayors Office No.1433 P. 2
ATTACHMENT #1— BG 1201
Community Development Block Grant Contract
General Information
PROJECT NO.. BG 1201
TITLE' HealthPoint - Primary Health Care
PROJECT SUMMARY: Primary health and dental care for un- and under-insured
Auburn clients.
ELIGIBILITY: 570.201(e) - Health Services (05M)
NATIONAL OBJECTIVE: 570.208(a)(2) - Low /Mod Limited Clientele
CDBG APPROPRIATION . $57,500
TYPE OF PROJECT: Public Service
PROJECT LOCATION: 126 Auburn Ave, Suite 300, Auburn 98002
SPECIAL CONDITIONS: See Attachment #3: Special Conditions
TERMINATION DATE: December 31, 2012
CONTACT PERSON: Beth Church
TITLE: Resource Development Manaaer
MAILING ADDRESS: 955 Powell Ave SW Ste A Renton. WA 98057
LOCATION ADDRESS. 126 Auburn Ave Ste 300 Auburn, WA 98002
PHONE / FAX NUMBER: (425) 203 -0419 / (425) 277 -1566
E -MAIL: bchurch a@healthpointchc.om _
PERSON(S) AUTHORIZED TO SIGN VOUCHER REIMBURSEMENT REQUEST AND
PROGRAM ACCOMPLISHMENTS FORM:
NAME/TITLE•
SIGNATURE:
(optional) NAME/TITLE:
SIGNATURE:
Beth Church, Resource Development Manager
t4OS ar/2
alem Director of Plannin • and Develo merit .
City of Auburn Agreement: BG -1201. HealthPotnt — Primary Health Care (Medical and Dental)
January 1, 2012
Pape 20 of 27
ATTACHMENT #2 — BG 1201
Community Development Block Grant Contract,
Project Budget
PROJECT NO BG 1201 TITLE HealthPoint
SUMMARY OF TASKS AND COSTS
PERSONNEL COSTS
List Employees by Position Title
Physician(s) I ,Dentist(s)
Fringe Benefits
Category Total
(Should be the same as No. 1 in
Budget Detail)I
Annual
Salary
Percent of
Time to
Project
Item Total
100% $57,500
$57,500
(continued)
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
" January 1, 2012
Page 21 of 27
ATTACHMENT #2 (continued)
Community Development Block Grant Contract
BUDGET DETAIL
Source of Funds
Column A
Column B
Column C
Cost Categories
Total Budget
Item
CDBG
Funds
Other Non -
CDBG Funds
-- Personnel Costs
1,666,039
57,500
1,636,029
-- Office /Operating Supplies
120,437
120,437
-- Consultant or Purchased
-r -
218,237
218,237
-- Construction Contracts/ Real
Pro•ert Ac•uisition
-- Communications and
Advertisements
51,022
57,500
51,022
-- Travel and /or Training
17,531
17,531
-- Intra- Agency Support {i e
administrative overhead
-- Capital Outlay - Construction
-- Other (Detail)
Rent, Utilities, Maintenance,
639,071
639,071
Total Project Costs
{Note : Column A must equal
sum of Column B and C
2,712,337
57,500
2,682,327
Source of Funds
Column A
Total
Column B
City of Auburn
Column C
Other Sources
-- City of Auburn CDBG Funds
57,500
57,500
-- Other Funds
2,652,337
2,652,337
* Medical portion only of Auburn
General Funds
Grand Total
{Note : Column A must equal
sum of Column B and C
2,709,837
57,500
2,652,337
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 22 of 27
ATTACHMENT #3 — BG 1201
Community Development Block Grant Contra_ ct
Special Conditions
1. Resolution #3938 In accordance with the legislative intent of the City Council as
expressed in PY2006 Annual Action Plan adopted by Resolution #3938, the Agency must
Provide primary health care to low income, uninsured residents at facilities located in
Auburn {CDBG Eligible under 24CFR570 201(e)}
2 Timely Progression of Project The Agency agrees that it will complete the above project
in a timely manner, and comply with the time line as set forth in Attachment #4, Project
Time Line
3 Limitations on Expenditures and Adjustments In the event that the City receives less
CDBG revenues than originally estimated in the CDBG budget ordinance, the Agency will
receive a proportionately equal reduction in its appropriation relative to the total decrease
in total CDBG revenues The amount of CDBG funds available to the Agency is stipulated
in the "Notice of Grant Award." If the amount CDBG funds available to the Agency is less
than appropriated, then the City will notify the Agency in writing when additional -CDBG
funds become available
4 Termination of the Contract This Agreement between the CITY OF AUBURN and the
AGENCY shall terminate on December 31, 2012 In accordance with the terms of the
Agreement, all unspent CDBG funds at the time of termination shall lapse and return to
the City of Auburn's CDBG fund
5 Public Information. The stipulations of Section 13(B) of the Agreement regarding the
erection of sign identifying the source of funds is hereby waived
6. Reversion of Assets. In the event that the activity or use conducted upon the premises
acquired or improved by the Agency with the City's CDBG funds changes within twenty
(20) years from the date of this Agreement, then the City of Auburn shall be entitled to
reimbursement from the Agency The amount of reimbursement shall be equal to the
current market value of the property, less any portion of the value attributable to
expenditures from non -CDBG funds for the acquisition or improvement to the property,
multiplied ,by the following ratios for each respective year No reimbursement is required If
the use or ownership of the asset changes after twenty (20) years from above termination
date
Evoked Year
0 - 5 years
Reimbursement Ratio
100%
6 years
90%
7 years
8 v-
80%
70%
9 years
60%
10 years
50%
11 -12 v-- s
13 -14v -- s
40%
30%
15 -16 years
17 -18 years
20%
10%
19 -20 ve. rs
5%
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 23 of 27
ATTACHMENT #4 — BG 1201
Community Development Block Grant Contract
Project Timeline
Part 1. Schedule by Task
Milestones Medical /Dental
Unduplicated City Clients served
Projected Actual
1st Quarter (1/1/2012 — 3/31/2012) Clients.
20 medical / 18 dental
Visits'
59 medical /35 dental
2nd Quarter (4/1/2012 — 6/30/2012) Clients
20 medical / 18 dental
Visits
59 medical /35 dental
3rd Quarter (7/1/2012 — 9/30/2012)
Clients
19 medical / 17 dental
Visits:
58 medical / 35 dental
4th Quarter (10/1/2012 — 12/31/2012) Clients'
19 medical / 17 dental
Visits -
58 medical / 35 dental
Total Unduplicated Annual Clients Medical' 78 / Dental 70
Total Unduplicated Annual Visits Medical: 234 / Dental 140
Part 2. CDBG Expenditure Rate
CDBG Funds Vouchered
Projected Actual
1st Quarter (1/1/12 — 3/31/12) $14,375 00
2nd Quarter (4/1/12 — 6/30/12) $14,375.00
3rd Quarter (7/1/12 — 9/30/12) $14,375 00
4th Quarter (10/1/12 — 12/31/12) $14,375 00
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 24 of 27
ATTACHMENT #5 — BG 1201
Community Development Block Grant Contract
Project Timeline /Performance Measurements
All CDBG subrecipients must bill the City in order to access funds from their grant. The City
advances funds to subrecipients in order to expedite payments and then requests a drawdown
from HUD to reimburse the City fund This is how HUD keeps track of our Timely Expenditure
Requirement and if you do not bill, the City cannot meet its drawdown requirement Checks are
available generally within 45 days from the date your payment is processed Quarterly payment
request forms will be customized for your specific activity
• Quarterly payment request forms record expenditures incurred by the organization for a
given period
• Quarterly service unit reports number of unduplicated clients served and other contract -
established service units.
• Direct Benefit reports (demographic reports) maintain data on direct beneficiaries who
were assisted with the funds requested
1. Reimbursement Schedule
(a) The Agency must submit a request for reimbursement at least once a quarter and may
submit such a request on a monthly basis, beginning with the date of this Agreement,
and applicable to all costs incurred toward this grant beginning January 1, 2012.
(b) Failure to submit a quarterly request for reimbursement in accordance with Part 1,
Section 5 of this Agreement may cause the City to consider the Project abandoned and
the CDBG funds made available for re- appropriation Continued failure to request
reimbursement and submit required performance reports will cause the City to take
corrective action as it deems necessary.
(c) The City shall reimburse the Agency for its expenses incurred implementing this
Agreement within the forty -five (45) days following the receipt of a Voucher
Reimbursement Request.
2. Required Contents of Reimbursement Request.
(a) Reimbursement Cover Sheet as supplied, showing Agency name, address, contact
information, and budget information,
(b) Accomplishments data sheet as supplied for the Agency, showing how the Agency has
progressed toward its goals as set forth in Attachment #4.
(c) Failure to properly submit a reimbursement request, through the omission of the above -
required items or through material omissions within those documents, will cause the
request to be returned to the Agency and will cause a delay in the disbursement of
funds.
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 25 of 27
CITY OF
WASHINGTON
BG 1201 - Cover Page
HUMAN SERVICE AGREEMENT
2012 INVOICE FOR CONTRACTED SERVICES
To: CITY OF AUBURN, ATTN COMMUNITY SERVICES
25 WEST MAIN STREET, AUBURN WA 98001
Agency: HealthPoint
Site location: Mailing address:
126 Auburn Ave, Suite 300 955 Powell Ave SE, Suite A
Auburn, WA 98002 Renton, WA 98057
Program. Primary Health Care
Amount Requested: 114,. 375.
Invoice for:
Contact, Title: Beth Church,
Resource Development Manager
Phone: (425) 203 -0419
Email: bchurch @healthpointchc org
❑ 1st Quarter, January to March — Due April 13, 2012
❑ 2nd Quarter, April to June — Due. July 13, 2012
❑ 3`d Quarter, July to September — Due. October 12, 2012
❑ 4th Quarter, October to December — Due: January 31, 2013
Attachments: ❑ Quarterly Service Report (due every Quarter) - Exhibit 1
❑ Quarterly Financial Report (due every Quarter) — Exhibit 2
❑ Quarterl ;Timecard Report (due every Quarter) — Agency's Templat6
❑ Demographic Report (due 2nd and 4th Quarters only) — Exhibit 3
❑ Outcomes Report (due 4th Quarter only) — Exhibit 4
❑ Logic Model (due 1st Quarter only) — Suggested Template
❑ Proof of Insurance (1st Quarter or if expired)
I certify to the best of my knowledge that this invoice and attachments reflect actual service provided to
Auburn residents
Signature of Authorized Representative Date
The City of Auburn will issue payment upon this invoice within forty -five (45) business days of receipt. To
ensure prompt payment, please submit this form and all required attachments by the date listed above.
FOR CITY OF AUBURN USE ONLY:
Contract Amount $57,500
Payments Year to Date.
Payment this invoice. Contract Balance.
Authorized to Pay:
Signature Date
CITY OF AUBURN
COVER PAGE — MUST BE SIGNED AND SUBMITTED WITH EACH PAYMENT REQUEST
HUMAN SERVICE AGREEMENT
2012 SCOPE OF SERVICES AND QUARTERLY SERVICE UNIT REPORT
Agency Information
HealthPoint
Site location:
126 Auburn Ave, Suite 300
Auburn, WA 98002
Contact, Title:
Phone:
Email:
Beth Church,
Resource Development Manager
(425) 203 -0419
bchurch @healthpointchc org
Mailing address:
955 Powell Ave SE, Suite A
Renton, WA 98057
Are professional services (e.g., counseling, case management) provided as part of this
Agreement?
Contract Information
Contract Amount: $57,500
Program Name: Primary Health Care
Description of Service to be provided:
Reporting Information
Report for _ 1st Qtr /Jan -Mar _ 2nd Qtr /Apr -Jun
2012 Service Units
_ 3`d Qtr /Jul -Sep _ 4th Qtr /Oct -Dec
Narrative: Please attach other relevant information, including current trends, program developments,
special events, publicity, community education, etc If actual service units are lower than anticipated,
please explain.
City Funding
Onl
All Funding Sources
Actual Service
Units to Date,
all Fund
Sources
Service Unit Description:
Auburn Residents Only
Total
Projected
Annual Units
Actual Units by Quarter
Service Unit/Performance Measure
1st
2nd
3rd
4th
Unduplicated number
clients served for Medis al - Seryi ces■■■■
Number of Medical _Visits by Auburn
23
■■■■
clients
Service Unit/Performance Measure
1st
2nd
3rd 4th
Unduplicated number Auburn
7g
■■■■
clients served for Dental alSer'vices
Number of Dental Visii by Auburn
140
■■■■
clients
Narrative: Please attach other relevant information, including current trends, program developments,
special events, publicity, community education, etc If actual service units are lower than anticipated,
please explain.
Agency HealthPoint
Program Primary Health Care
Report for _ 15t Qtr /Jan -Mar
CITY OF AUBURN
2012 Quarterly Financial Report
2nd Qtr /Apr -Jun
BG 1201 - Exhibit 2
Date
3rd Qtr /Jul -Sep
4th Qtr /Oct -Dec
Requested
Reimbursement
Detail as Applicable
Cost Categories
Budget
Award
This
Request
Cumulative
to date
Award
Balance
1
Personal /Agency Services
2
Office /Operating Supplies
3
Consultant or Purchased
Services
4
Direct Client Assistance
5
Communications
6
Travel & Training
7
Intra- Agency Support
8
Other per Detail
Grand Total
$57,500.00
Requested
Reimbursement
Detail as Applicable
CITY OF AUBURN
2012 CDBG Demographic Report
Agency HealthPoint
Program Primary Health Care
BG 1201 - Exhibit 3
Date
Category
15 Quarter
2"' Quarter
3" Quarter
4 Quarter
Total YTD
Client Income
Level
= Family
income
Inc
Extreme) Low Income 0 -30% of MFI
-
-
-
--
Low Income 31 -50% of MFI
-
-
-
--
Moderate Income 51 -80% of MFI
-
-
-
--
Above Moderate Mod Income 80% of MFI
-
-
-
--
TOTAL
-
-
-
--
Client Gender
Female
-
-
-
--
Male
-
-
-
--
Client Age
0-4
-
-
-
--
5 -12
-
-
-
--
13 -17
-
-
-
--
18 -34
-
-
-
-
-
-
--
--
--
--
35-54
-
-
55-74
-
-
75+
-
-
Unknown
-
-
-
--
TOTAL
-
-
-
--
Ethnicity
Hispanic
Hispanic
Hispanic
Hispanic
Hispanic
White
Black / African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific
Islander
■-..I
U
I
American Indian or Alaska Native
AND White
■..-....,■
Asian AND White
Black / African American AND White
American Indian / Alaska Native AND
Black / African American
■-.-...-.■
Other Multi-Racial
Condition
Disablin• Condition
-
-
-
--
ESL
Limited En•lish S•eakin•
-
-
-
--
Head of
Household
Female- Headed Household
=
-
-
--
Male- Headed Household
-
-
--
Homeless * only for
Households been assisted
with transitional and/or
ermanent h assisted
• ermanent housing
Individuals
Families
- -
- --
TOTAL
CITY OF AUBURN
• - • • • • • •
• _ .s
- • • ' • Period:
to
OUTCOMES REPORT - EXHIBIT 4
Date Form Com • leted:
Agency:
Program:
Contact Person:
E -mail:
Phone:
Outcome Information
Goal Area
Outcome Statement
Measurable Indicator s
Measurement Tool s
Outcome Results Auburn Clients Served this Year:
Narrative this section should be corn • leted for each outcome re sorted
Describe your interpretation or explanation of the outcome data. Explain over or under - performance Describe factors or causes affecting
•erformance Indicate how our •erformance corn •ares with an available re• tonal or national data, or benchmark studies
Describe any problems you had with data collection. Note any strategies you are implementing to improve the process.
Overall Feedback This section should be com•Ieted for the overall •ro•ram
1. How is our a • enc usin • information on outcomes?
2. Describe chan • es, if an , that ou will be makin • as a result of what ou have learned.
3. Do you have general feedback on outcomes reporting requirements, form design, data collection /reporting process?
How well did the measurable indicators and measurement tools work in measuring outcomes?
4. OPTIONAL: Please share a client story that highlights the effectiveness of your program in reaching outcomes. If more space is
're•uired, attach extra •a•e -
CITY OF AUBURN
• A •urn
R- • ortin. Period:
to
LOGIC MODEL
BG 1201 - Exhibit.
LOGIC MODEL REPORT - s�9 eSted Template
Date Form Corn • leted:
Agency:
Program:
Contact Person:
E -mail:
Phone:
Program Evaluation Logic Model
PROCESS
RESOURCES
ACTIVITIES
OUTPUTS
OUTCOME
OUTCOMES
INDICATORS
GOAL
MEMORANDUM OF UNDERSTANDING
This Memorandum of Understanding is an addendum to the agreement for services between
the City of Auburn and HealthPoint, the original of which was executed on the day of
, 2012 All other terms and conditions of the agreement for services shall
remain igJfull force and effect except as specifically amended by this Memorandum of
Understanding
I It is the goal of the City of Auburn to increase the availability of healthcare to its low
income residents by 15%
II The grant funds provided to the Agency during the 2012 year are provided with the
objective of achieving the result of increasing the availability of healthcare to low
income residents.
Ill. Agencies receiving funding from the City of Auburn agree to participate in the
conceptual development of the One Stop Center and to collaborate with other
agencies concerning the delivery of services to clients when the Center is
operational. The nature and extent of the collaboration to be determined when the
One Stop Center is operational.
IV. The City of Auburn will utilize the following performance measures in evaluating the
effectiveness of reaching this goal.
a. Performance Indicators
• Auburn's children under the age of 19 will have access to healthcare.
• Auburn babies and children are healthy and have adequate nutrition and
prenatal care.
• The number of sites within Auburn where low income residents can access
healthcare will continue to increase.
• Reduction in the number of emergency room visits
• Better dissemination of information about the availability of health care to
low- income residents throughout the community
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 26 of 27
-kL441,_
Danielle Daskam,
City Clerk
STATE OF WASHINGTON
COUNTY OF KING
On this v1:411 day of 1^(1 , 2012, before me, the undersigned, a Notary
Public in and for the State of Washington, personally appeared as-Tho rna c \ (korrk.ee,i-er,
to me known to be the C CO of HealthPoint, the non - profit corporation
referenced as Agency within the foregoing instrument, and acknowledged said instrument to be
the free and voluntary act and deed of said non - profit corporation for the uses and purposes
therein mentioned, and on oath stated that he /she is authorized to execute said instrument on
behalf of said non - profit corporation
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the date
hereinabove set forth.
AP
niel B. He
City Attorney
) ss
)
•
TITLE :l t 6 6Xe` j
lt. CCQ iv
YVONNE L WESTOVER
li NOTARY PUBLIC
I 1 STATE OF WASHINGTON EC COMMISSION EXPIRES
1 D
�I EMBER 29, 2012
say -._`a`
,latanuzi0
NOT RY PUBLIC in and for the State of
Wa Ington, residing in' e-r\ ko r'
MY OMMISSION expires. 0-4 -2-51112—
City of Auburn Agreement BG -1201, HealthPoint — Primary Health Care (Medical and Dental)
January 1, 2012
Page 27 of 27