Subrecipient_Sample_Agreement.pdf

SUBRECIPIENT AGREEMENT BETWEEN ________________, A FLORIDA NOT-FOR-

PROFIT CORPORATION, AND THE CITY OF HOMESTEAD FOR THE DISTRIBUTION

OF FUNDS AWARDED UNDER THE COMMUNITY DEVELOPMENT BLOCK GRANT

(CDBG) PROGRAM

THIS AGREEMENT, entered into this _____ day of ____ 2024 by and between the City of Homestead, Florida, a municipal corporation hereinafter referred to as the "CITY", and _________ , a Florida not for profit corporation, hereinafter referred to as "SUBRECIPIENT."

WITNESSETH:

WHEREAS, the CITY submitted an application for CDBG Entitlement funding through the U.S. Department of Housing and Urban Development (“HUD”); and

WHEREAS, HUD has awarded the CITY a grant to assist the CITY in providing benefits to low and moderate income residents in accordance with the FY 2023-2024 Action Plan and the CITY’s Consolidated Plan (the “Award”); and

WHEREAS, the CITY issued Request for Proposal _______ Swimming Lessons at Roby George Pool (the “RFP”) soliciting applications from non-profit organizations seeking funds for the provision of public services for swimming lessons opportunities that serve low and moderate income residents of the CITY; and

WHEREAS, the SUBRECIPIENT was a responsible respondent to the RFP; and

WHEREAS, the CITY desires to grant a portion of the Award to the SUBRECIPIENT for the provision of those services identified in Exhibit “A” Scope of Work, in order to accomplish the goals established in the CITY’s Consolidated Plan.

NOW, THEREFORE, in consideration of the mutual covenants, promises and representations contained herein, the parties hereto agree as follows:

1. Incorporation. The above recitals are true and correct and are hereby incorporated into this Agreement. The RFP is incorporated herein and made a part hereof as Exhibit 1.

ARTICLE ONE: DEFINITIONS

1.1 "CDBG Consultant" means consulting personnel as agents acting on behalf of the CITY that will provide project delivery services to the CITY’s Community Development Block Grant (CDBG) Program.

1.2 "CDBG Program" means the CITY’s Community Development Block Grant Program awarded by HUD.

1.3 "CDBG Regulations" means 24 CFR 570, 2 CFR Part 200, and related Federal regulations.

1.4 "CITY" means the City of Homestead, Florida, a municipal corporation of the

State of Florida.

1.5 “Community Development Office” means the CITY of Homestead, Florida.

1.6 “HUD” means the Department of Housing and Urban Development

1.7 "Low and Moderate-Income" means those who fall within the income range set by HUD for participating in the CDBG program. The HUD income range is contained in Exhibit “C”.

1.8 “Program income” means only those funds generated by the SUBRECIPIENT from the use of CDBG funds.

1.9 “Project” means the provision of the _______ program in accordance with the

Scope of Work enumerated in Exhibit “A” of this Agreement.

2.0 “Project Delivery” means the management and implementation of the specific activities funded through this SUBRICIPIENT Agreement, including the enforcement of applicable rules and regulations related to the CDBG program.

ARTICLE TWO: SUBRECIPIENT

2.1 The SUBRECIPIENT, shall carry out or cause to be carried out the Scope of Work which is attached hereto as Exhibit “A” and made a part hereof.

2.2 The SUBRECIPIENT shall, in consultation with the CDBG Consultant develop a schedule for the completion of the Project which shall be attached hereto as Exhibit “B” (the “Project Schedule”). Modifications of the Schedule shall be made with the mutual consent of both parties.

2.3 SUBRECIPIENT shall provide CITY with monthly reports (Exhibit D) and invoices demonstrating Project costs incurred during the previous month. The CITY shall, upon receipt, review the invoices to ensure that all expenditures comply with CDBG Regulations.

2.4 SUBRECIPIENT shall report on a quarterly basis, all program income (as defined at 24 CFR 570.500(a)) generated by activities carried out with CDBG funds made available under this contract. The use of program income by the Subrecipient shall comply with the requirements set forth at 24 CFR 570.504.

By way of further limitations, the Subrecipient may use such income during the contract period for activities permitted under this contract and shall reduce requests for additional funds by the amount of any such program income balances on hand. All unexpended program income shall be returned to the CITY at the end of the contract period. Any interest earned on cash advances from the U.S. Treasury and from funds held in a revolving fund account is not program income and shall be remitted promptly to the CITY.

2.5 SUBRECIPIENT and CITY shall use good faith efforts to cooperate to complete the Project in accordance with CITY and HUD guidelines.

ARTICLE THREE: NATIONAL OBJECTIVES

3.1 All activities funded with CDBG funds must meet one of the CDBG program’s National Objectives: benefit low- and moderate-income persons; aid in the prevention or elimination of slums or blight; or meet community development needs having a particular urgency, as defined in 24 CFR 570.208.

3.2 This activity is eligible under 24 CFR, Section 570.201(e), and will benefit low and moderate- income persons as qualified under Limited Clientele Activities, 570.208(a)(2).

ARTICLE FOUR: CITY’S RESPONSIBILITIES

4.1 The CDBG Consultant shall provide the SUBRECIPIENT with technical guidance on behalf of the CITY in order to ensure compliance with all CDBG Regulations and other related laws, rules and regulations.

ARTICLE FIVE: ADMINISTRATIVE REQUIREMENTS

5.1. The Subrecipient agrees to comply with 24 CFR 84.21−28 and 2 CFR Part 200 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.

5.2 The Subrecipient shall administer its program in conformance with OMB

Circulars A-122, “Cost Principles for Non-Profit Organizations,” or A-21, “Cost Principles for Educational Institutions,” as applicable. These principles shall be applied for all costs incurred whether charged on a direct or indirect basis.

5.3 The Subrecipient shall maintain all records required by the Federal regulations specified in 24 CFR 570.506, that are pertinent to the activities to be funded under this Agreement. Such records shall include but not be limited to:

a. Records providing a full description of each activity undertaken;

b. Records demonstrating that each activity undertaken meets one of the National Objectives of the CDBG program;

c. Records required to determine the eligibility of activities;

d. Records required to document the acquisition, improvement, use or disposition of real property acquired or improved with CDBG assistance;

e. Records documenting compliance with the fair housing and equal opportunity components of the CDBG program;

f. Financial records as required by 24 CFR 570.502, and 24 CFR 84.21−28; and

g. Other records necessary to document compliance with Subpart K of 24 CFR Part 570.

5.4 The Subrecipient shall retain all financial records, supporting documents, statistical records, and all other records pertinent to the Agreement for a period of four (4) years. The retention period begins on the date of the submission of the CITY annual performance and evaluation report to HUD in which the activities assisted under the Agreement are reported on for the final time.

Notwithstanding the above, if there is litigation, claims, audits, negotiations or other actions that involve any of the records cited and that have started before the expiration of the four-year period, then such records must be retained until completion of the actions and resolution of all issues, or the expiration of the four-year period, whichever occurs later.

5.5 The Subrecipient shall maintain client data demonstrating client eligibility for services provided. Such data shall include, but not be limited to, client name, address, income level or other basis for determining eligibility, and description of service provided. Such information shall be made available to CITY monitors or their designees for review upon request.

5.6 The Subrecipient understands that client information collected under this contract is private and the use or disclosure of such information, when not directly connected with the administration of the CITY’s or Subrecipient’s responsibilities with respect to services provided under this contract, is prohibited under Federal and Florida law, unless written consent is obtained from such person receiving service and, in the case of a minor, that of a responsible parent/guardian.

5.7 The Subrecipient’s obligation to the CITY shall not end until all close-out requirements are completed. Activities during this close-out period shall include, but are not limited to: making final payments, disposing of program assets (including the return of all unused materials, equipment, unspent cash advances, program income balances, and accounts receivable to the CITY), and determining the custodianship of records. Notwithstanding the foregoing, the terms of this Agreement shall remain in effect during any period that the Subrecipient has control over CDBG funds, including program income.

Closeout of funds will not occur unless all requirements of 2 CFR Part 200.343 are met.

5.8 All Subrecipient records with respect to any matters covered by this Agreement shall be made available to the CITY, grantor agency, and the Comptroller General of the United States or any of their authorized representatives, at any time during normal business hours, as often as deemed necessary, to audit, examine, and make excerpts or transcripts of all relevant data. Any deficiencies noted in audit reports must be fully cleared by the Subrecipient within 30 days after receipt by the Subrecipient. Failure of the Subrecipient to comply with the above audit requirements will constitute a violation of this contract and may result in the withholding of future payments. The Subrecipient hereby agrees to have an annual agency audit conducted in accordance with current CITY policy concerning subrecipient audits and OMB Circular A-133.

ARTICLE SIX: AWARD, DISTRIBUTION, LIMITATION OF COSTS

6.1 The CITY shall allocate grant funds in an amount not to exceed ______ Dollars and ____ Cents (________) for the completion of the Project (the “Grant”) and will be issued in accordance with the payment schedule.

6.2 The financial obligation of the CITY for the completion of the Project shall be limited to the Grant. SUBRECIPIENT shall be solely responsible for all costs associated with the Project exceeding the Grant unless otherwise specified in writing by the CITY.

6.3 If indirect costs are charged, the Subrecipient will develop an indirect cost allocation plan for determining the appropriate Subrecipient’s share of administrative costs and shall submit such plan to the CITY for approval, in a form specified by the CITY.

ARTICLE SEVEN: PAYMENTS

7.1 Invoices that have been reviewed and approved by the SUBRECIPIENT, the CDBG Consultant and the CITY shall be paid by the CITY, at its sole discretion, either directly to a third party contractor performing services for the Project or to the SUBRECIPIENT, utilizing CDBG funds. Payments made directly to a third party contractor for approved expenditures shall adhere to the payment schedule contained in the contract between the SUBRECIPIENT and the contractor.

7.2 The CITY shall not make payment for administrative costs incurred by the

SUBRECIPIENT or a contractor thereof unless required to carry out the Services as determined by the CITY.

ARTICLE EIGHT: COMPLIANCE WITH STATE AND FEDERAL RULES, REGULATIONS

AND LAWS

8.1 SUBRECIPIENT shall provide all required information and documentation necessary for the CITY to demonstrate compliance with all applicable state and Federal laws, rules, regulations and orders including but not limited to:

8.2 24 CFR Part 570, as amended - The regulations governing the expenditure of

Community Development Block Grant funds.

8.3 OBG Circular A-122, “Cost Principles for Non-Profit Organizations” or OMB

Circular A-21 “Cost Principles for Education Institutions,” as applicable

8.4 24 CFR Part 84, “Grants and Agreements with Institutions of Higher Education, Hospitals, and Other Non-Profit Organizations,” as modified by 24 CFR 570.502(b).

8.5 OMB Circular A-133, “Audits of States, Local Governments and Non-Profit Organizations.”

8.6 24 CFR Part 1 - The regulations promulgated pursuant to Title VI of the 1984 Civil Rights Act.

8.7 24 CFR Part 107 - The regulations issued pursuant to Executive Order 11063 which prohibits discrimination and promotes equal opportunity in housing.

8.8 Executive Order 11246, as amended by Executive Orders 11375 and

12086 - which establishes hiring goals for minorities and women on projects assisted with federal funds.

8.9 Title VII of the 1968 Civil Rights Act as amended by the Equal Employment

Opportunity Act of 1972 - which prohibits discrimination in employment.

8.10 Age Discrimination Act of 1973

8.11 Contract Work Hours and Safety Standards Act

8.12 Uniform Relocation Assistance and Real Property Acquisition Policies

Act of 1970

8.13 2 CFR Part 200 – UNIFORM ADMINISTRATIVE REQUIREMENTS, COST

PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS as required by the provisions of 24 CFR Part 570.503 (b) (4) and 24 CFR Part 570.502.

8.14 24 CFR Part 570.601 – PUBLIC LAW 88-352 AND PUBLIC LAW 90-284;

AFFIRMITIVELY AFFIRMING FAIR HOUSING; EXECTUIVE ORDER 11063.

8.15. 24 CFR Part 570.609 - USE OF DEBARRED, SUSPENDED OR INELIGIBLE

CONTRACTORS OR SUBRECIPIENTS – which requires the Subrecipient to verify the eligibility of contractors.

8.16. 24 CFR Part 570.611 - CONFLICT OF INTEREST – which states that conflicts of interest are prohibited unless persons covered apply for and receive and exemption prior to expenditure of grant funds.

8.17. 24 CFR PART 570.503 (b) (2) – which requires Subrecipients to submit

Subrecipient Reports, including contractor information, and necessary reimbursement information as specified by the City in the format provided for this purpose.

8.18 Florida Statutes, Sections 290.0401 through 290.048.

8.19 SUBRECIPIENT further agrees to abide by all other applicable laws, rules, regulations and orders that may be applicable to CDBG activities.

8.20 CDBG Consultant shall provide assistance to the SUBRECIPIENT in the application of these law, rules and regulations as they apply to the SUBRECIPIENT’s Scope of Work.

ARTICLE NINE: PROJECT PUBLICITY

9.1 Any news release or other type of publicity pertaining to the project as stated herein must recognize the CITY as the recipient of U.S. Department of Housing and Urban Development (HUD) grant funds and the entity that provided funds for the project. SUBRECIPIENT shall post a sign at the project site recognizing the CITY as a Recipient of HUD grant funds and as a funding entity for the project.

ARTICLE TEN: MAINTENANCE AND RETENTION OF RECORDS

10.1 The SUBRECIPIENT shall maintain all records required by the CDBG Regulations and as deemed necessary by the appropriate Office of Management and Budget Circular. All records shall be retained for a period of six (6) years from the date of closeout of the project.

10.2 The SUBRECIPIENT shall maintain such records, accounts, property records, and personnel records, as are deemed necessary by the CDBG Consultant to assure proper accounting of project funds and compliance with the provisions of this Agreement.

10.3 SUBRECIPIENT shall maintain all necessary financial records as required by

CDBG Regulations. SUBRECIPIENT shall retain a copy of all invoices received and warranties for all items purchased during the completion of the Project.

10.4 The SUBRECIPIENT shall collect information recording the eligibility of all beneficiaries of the Award (the “Beneficiaries”) and shall make this information available to the CITY and the CDBG Consultant in an accurate and succinct format. The data will include the total number of Beneficiaries, their income level, race, age, ethnicity, handicap status, and Female Head of Household data.

10.5 All records and contracts of whatever nature required by this Agreement shall be available for audit, inspection or copying at any time during normal business hours and as often as the CDBG Consultant, CITY, HUD, or Comptroller General of the United States, or other federal agency, may deem necessary.

The CITY shall have the right to obtain and inspect any audit pertaining to the performance of this Agreement made by any local, state or federal agency. The SUBRECIPIENT shall retain all of its records and supporting documentation applicable to the Agreement for six (6) years after either the resolution of the final audit or HUD approval of the closeout CITY Performance Report, whichever is later.

ARTICLE ELEVEN: INDEPENDENT CONTRACTOR

11.1 SUBRECIPIENT is an independent contractor under this Agreement. Personal services provided by SUBRECIPIENT shall be by employees of SUBRECIPIENT and subject to supervision by SUBRECIPIENT, and not as officers, employees, or agents of CITY. Personnel policies, tax responsibilities, social security and health insurance, employee benefits, purchasing policies and other similar administrative procedures applicable to services rendered under this Agreement shall be those of SUBRECIPIENT.

ARTICLE TWELVE: CONTRACTS

12.1 All contracts entered into by the SUBRECIPIENT in order to facilitate the completion of the Project shall be made in accordance with all applicable laws, rules and regulations governing the expenditure of the Award. Any work or services contracted hereunder shall be specified by written contract or Agreement and shall be subject to each Article set forth in this Agreement.

ARTICLE THIRTEEN: PROHIBITION AGAINST CONTINGENT FEES

13.1. The SUBRECIPIENT warrants that it has not employed or retained any company or person, other than a bona fide employee working solely for the consultant, to solicit or secure this Agreement, and that it has not paid or agreed to pay any person(s), company, corporation, individual or firm, other than a bona fide employee working solely for the Consultant any fee, commission, percentage, gift or any other consideration, contingent upon or resulting from the award or making of this Agreement.

ARTICLE FOURTEEN: INDEMNIFICATION

14.1 SUBRECIPIENT shall defend, indemnify, and hold harmless the CITY, its officers, agents and employees, from and against any and all demands, claims, losses, suits, liabilities, causes of action, judgments or damages, and statutory fines and penalties (collectively referred to as "loss" or "losses") arising out of, related to, or in any way connected with SUBRECIPIENT's intentional breach of this agreement or a violation of applicable law, rules or regulations in connection with SUBRECIPIENT's performance under any provision of this Agreement; excluding, however, any such breach or violation that was in reliance upon instructions of the CITY, its officers, agents and employees (including, without limitation, the CDBG Consultant), or otherwise arising or resulting from any act or omission of the CITY, its officers, agents and employees (including, without limitation, the CDBG Consultant).

SUBRECIPIENT shall further defend, indemnify and hold harmless the CITY, its officers, agents and employees, from and against any and all demands, claims, losses, suits, liabilities, causes of action, judgments or damages, and statutory fines and penalties arising out of the SUBRECIPIENT’s provision of the Services performed in accordance with the SUBRECIPIENT Scope of Work as attached hereto as Exhibit “A”.

Notwithstanding anything to the contrary, SUBRECIPIENT shall not be liable or obligated with respect to any losses arising in connection with the acts or omissions of any third party contractor performing any work in connection with the Project; provided, however, that SUBRECIPIENT shall include in agreements with third party contractors engaged by SUBRECIPIENT to facilitate the completion of the Project language stating that the contractor defends, indemnifies and holds harmless the CITY, its officers, agents and employees (including, without limitation, the CDBG Consultant) from any and all demands, claims, losses, suits, liabilities, causes of action, judgments or damages, and statutory fines and penalties (collectively referred to as "loss" or "losses") arising out of, related to, or in any way connected with contractor’s work on the Project, and shall require the contractor to provide liability insurance that is acceptable to CITY.

Nothing in this Agreement shall be deemed or treated as a waiver by the CITY of any immunity to which it is entitled by law, including but not limited to the CITY’S sovereign immunity as set forth in Section 768.28, Florida Statutes.

ARTICLE FIFTEEN: ENTIRE AGREEMENT

15.1 This Agreement, the RFP, which is incorporated herein, and all attachments constitute the entire agreement between SUBRECIPIENT and CITY, and all negotiations and oral understandings between the parties are merged herein.

15.2 No modification, amendment or alteration in the terms or conditions of this

Agreement shall be effective unless contained in a written document executed with the same formality as this Agreement.

ARTICLE SIXTEEN: INSURANCE

16.1 The insurance requirements of this Agreement are outlined in Tab 4 e) INSURANCE of RFP#202330. SUBRECIPIENT shall carry and maintain the types and limits of insurance coverage as provided in the RFP.

ARTICLE SEVENTEEN: NON-ASSIGNABILITY

17.1 The SUBRECIPIENT may not assign this Agreement without the prior written consent of the CITY.

ARTICLE EIGHTEEN: PROGRAM INCOME

18.1 It is not anticipated that there will be program income under this activity;

however, in the event that any program income is received during the contract, the SUBRECIPIENT must retain such income for use as specified in this Agreement. Such program income will be immediately reported to the CITY and the reimbursement request of the SUBRECIPIENT will be reduced accordingly.

18.2 If any income is received after the term of this Agreement, or at the end of the year when all remaining items have been budgeted, the program income will be returned to the CITY.

ARTICLE NINETEEN: SUSPENSION AND TERMINATION

19.1 In accordance with 24 CFR 85.43, suspension or termination may occur if the SUBRECIPIENT materially fails to comply with any term of this Agreement.

The Agreement may also be terminated, by either party, for convenience in accordance with 24 CFR 85.44, which provides for termination for mutual convenience, or partial termination for specified reasons.

ARTICLE TWENTY: CONDITIONS FOR RELIGIOUS ORGANIZATIONS

20.1 CDBG funds may not be used for religious activities or provided to primarily religious organizations. 24 CFR 570.200(j) specifies the limitations on CDBG funds and is herein incorporated by reference.

ARTICLE TWENTY-ONE: CERTIFICATION REGARDING LOBBYING

21.1 The SUBRECIPIENT certifies, to the best of his or her knowledge and belief, that:

21.2 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.

21.3 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 SUBRECIPIENT shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its instructions.

21.4 The SUBRECIPIENT shall require that the language of this certification 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.

ARTICLE TWENTY-TWO: DRUG-FREE WORKPLACE REQUIREMENTS

22.1 The SUBRECIPIENT, as a condition of being awarded, must certify that they will provide drug-free workplaces in accordance with the Drug-Free Workplace Act of 1988 (42 U.S.C. 701) and with HUD rules at 24 CFR part 24, subpart F.

ARTICLE TWENTY-THREE: ADDITIONAL DOCUMENTATION

23.1 The SUBRECIPIENT, as a condition of being awarded must sign all other documentation required by the CITY, including but not limited to, a SUBRECIPIENT Agreement regarding the Services enumerated in the Exhibit “A”: SUBRECIPIENT Scope of Work.

ARTICLE TWENTY-FOUR: REVERSION OF ASSETS

24.1 In accordance with 24 CFR 570.503 (b) (7), any real property under the SUBRECIPIENT’s control that was acquired or improved in whole or in part with CDBG funds in excess of $25,000 will be used to meet a national objective until five years after the expiration of this agreement. In the event that the property is not used to meet a national objective for five years after the expiration of this agreement, the entire amount of CDBG funds expended must be returned to the CITY, and such funds will be considered as program income.

This obligation will be secured with a note and forgiveness mortgage forgiven after a term of five years, except in those cases where the real property is controlled by the City of Homestead or another governmental entity.

ARTICLE TWENTY-FIVE: NOTICES

Notices required by this Agreement shall be in writing and delivered via mail (postage prepaid), commercial courier, or personal delivery or sent by facsimile or other electronic means. Any notice delivered or sent as aforesaid shall be effective on the date of delivery or sending. All notices and other written communications under this Agreement shall be addressed to the individuals in the capacities indicated below, unless otherwise modified by subsequent written notice.

City of Homestead Name of Organization City Manager Officer signing 100 Civic Court Address Homestead, FL 33030 City, State, Zip code

ARTICLE TWENTY-SIX: EXPIRATION OF SUBRECIPIENT AGREEMENT

26.1 This agreement will expire on __________

IN WITNESS WHEREOF, the parties have executed the Agreement as of the date first above written.

SUBRECIPIENT:

By: ____________________________ (Sign and Print Name)

Its: ______________________________

GRANTEE:

ATTEST:

CITY OF HOMESTEAD, FLORIDA

By: _________________________ By: ______________________

City Clerk City Manager

Approved as to form and legal sufficiency For reliance of the CITY only:

WEISS SEROTA HELFMAN

COLE & BIERMAN, P.L.

By: ________________________ City Attorney

EXHIBIT A: SUBRECIPIENT SCOPE OF WORK

The SUBRECIPIENT will utilize CDBG funds to provide

SCOPE OF WORK

Budget Breakdown

EXHIBIT B: PROJECT SCHEDULE

Work Task Start Date Date of Completion

EXHIBIT C- INCOME LIMITS

Miami-Dade County 2024 Income Limits 1 2 3 4 5 6 7 8

$59,150 $67,550 $76,050 $84,450 $91,200 $98,000 $104,750 $111,500 **Income Limits Effective April 2024. Income Guidelines are subject to Change**

EXHIBIT D- MONTHLY PROGRESS REPORT

MONTHLY PROGRESS REPORT

Please submit this report with your reimbursement request. Reimbursement requests will not be processed without this form.

Reporting Period:

Date Report Prepared:

Project Information:

Agency Name Person Preparing the Report Job Title Signature Project Name Project Start Date Project Completion Date Amended Completion Date (if applicable)

Project Cost

Funded Expended to Date

Percentage

Total Project CDBG Funding

Request for Payment

Vendor Name Invoice # Description of Service Amount

Total Request for reimbursement $

ACCOMPLISHMENTS

Please provide a narrative below describing your accomplishments and any challenges you encountered during the course of your project. Please include the project location(s).

DEMOGRAPHIC INFORMATION

Only unduplicated counts should be given.

Ethnicity Total number served This Month

Total number served year to date

Hispanic Non-Hispanic Total

Race Total number served This Month

Total number served year to date

White Black/African American Asian American Indian/Alaskan Native Native Hawaiian or other Pacific Islander

American Indian/Alaskan Native & White

Asian & White Black/African American & White Other Multi-Racial

I certify to the best of my knowledge that all the information provided in this report is true and accurate.

Signature and Title of Authorized Official Date

Name/ Title

EXHIBIT E: REGISTRATION FORM

Registration Form Each participant must complete the registration form in order to participate in the program. The following information must be provided by the parent/guardian. (provide copies)

Photo Identification Proof of Address (Utility Bill) Approval of Free/Reduced Lunch or Medicaid Card

Address:

APT:

City: State: Zip Code:

Phone: Email:

Parent/Guardian First Name: Parent/Guardian Last Name:

First time attending?

Yes No

Race Ethnicity

Black Hispanic White Non-Hispanic Asian American Indian/American Native Native Hawaiian/ Other Pacific Islander Other

Parent/Guardian Signature Date

Child First Name: Child Last Name:

EXHIBIT F

Request for Payment Checklist

___ Total Reimbursement Request included in cover letter

___ Exhibits completely filled out

___ List of unduplicated clients

___ Advertisement/flyer and calendar events/classes provided

___ Sign-in sheets for classes/events

___ Proof of eligibility