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Interval House - 2017-08-21
Dept. ID ED 17-22 Page 1 of 2 Meeting Date: 8/21/2017 CITY OF HUNTINGTON BEACH REQUEST FOR. CITY COUNCIL ACTION MEETING DATE: 8/21/2017 SUBMITTED TO: Honorable Mayor and City Council Members SUBMITTED BY: Fred A. Wilson, City Manager PREPARED BY: Kellee Fritzal, Deputy Director of Business Development SUBJECT: Approve and authorize execution of a HOME Recipient Agreement between City and Interval House; and, approve an appropriation of $37,000 Statement of Issue: Approve and authorize execution of a HOME Recipient Agreement between the City and Interval House to administer a tenant -based rental assistance (TBRA) program for one year. The TBRA program will assist extremely low, very low and low income homeless households with rental assistance, security and utility deposits. Interval House qualifies the households, performs unit health and safety inspections, and provides support services to the clients. Financial Impact: The TBRA Agreement has two separate funding sources: (1) Federal HOME Investment Partnership Act Funds in the amount of $165,278 that will be used for rental assistance, security and utility deposits; and (2) Affordable Housing In -Lieu Fee (Fund 217) in the amount of $37,000 (21780101.75300) that will be used to administer the program. Recommended Action: A) Approve and authorize the Mayor and City Clerk to execute a one-year "HOME Recipient Agreement between the City of Huntington Beach and Interval House" for Tenant Based Rental Assistance (TBRA) program; and, B) Approve an appropriation in the amount of $37,000 from the Affordable Housing In -Lieu Fee (217); and, C) Authorize the City Manager to sign all necessary documents to effectuate the Agreement and any future minor amendments to contract and/or US Department of Housing and Urban Development (HUD) documents, with review by the City Attorney. Alternative Action(s): Do not approve and direct staff as necessary. Analysis: On September 21, 2015, the City Council approved the implementation of a TBRA Program and a two-year agreement between the City and Interval House in the amount of $448,156. Interval House set-up a TBRA program that targeted homeless and at -risk of homelessness in Huntington Beach with a priority for providing assistance to veterans, seniors, and victims of domestic violence. The current TBRA Program agreement provides short and medium term rental assistance as well as housing relocation and stabilization services for 18 households. The TBRA Program met the City's investment criteria by dedicating program assistance to homeless households with incomes at or below 30% area median income (AMI). On June 30, 2017, a minor amendment in the amount of $17,000 was granted to Interval House to house an additional five (5) households increasing their goal to 23 households. HB -205- Item 18. - I Dept. ID ED 17-22 Page 2 of 2 Meeting Date: 8/21/2017 The current agreement expires September 30, 2017. By the time the current Interval House contract concludes, they will have provided assistance to 29 homeless households, thereby exceeding their goal of 23 households. Of the 29, 19 households have completed the program and maintained their residency at the assisted apartment unit. One (1) household relocated to another affordable unit and one (1) household moved out of state. Eight (8) households are still receiving rental assistance. A one-year extension to the existing agreement is requested to assist an additional 11 eligible households for Fiscal Year 2017-18. Extending the agreement will provide for rental assistance priority to households that are referred by the Homeless Task Force and homeless families, in addition to veterans, seniors and domestic violence victims. In addition to implementing the City's first TBRA Program, Interval House has extensive experience in providing services to households impacted by domestic violence, and works closely with the City's Police Department in providing housing for eligible households. In 2009, Interval House also implemented the City's Homelessness Prevention and Rapid Re -housing (HPRP), a similar federal funding program providing assistance to prevent homelessness and provide rapid re -housing. Annually, the City is allocated HOME funds from the US Department of Housing and Urban Development (HUD). A TBRA program is eligible under HOME guidelines to allocate funds to provide a rental subsidy to individual households to afford housing costs such as rental assistance and security deposits. The TBRA program one-year agreement with Interval House is included in the 2017-2018 Action Plan approved by the City Council on August 7, 2017. The Economic Development Committee reviewed the TBRA program on June 14, 2017, and recommended approval of a one-year agreement with Interval House as a sub -recipient of HOME funds to further implement the City's TBRA program. Environmental Status: Not applicable Strategic Plan Goal: Improve quality of life Attachment(s): 1. HOME Recipient Agreement between the City of Huntington Beach and Interval House (Tenant Based Rental Assistance) Item 18. - 2 H B -206- HOME RECIPIENT AGREEMENT BETWEEN THE CITY OF HUNTINGTON BEACH AND INTERVAL HOUSE (Tenant Based Rental Assistance) This HOME RECIPIENT AGREEMENT (Tenant Based Rental Assistance) ("Agreement") is made and entered into as of 08/21/2017 (`Effective Date") by and between the CITY OF HUNTINGTON BEACH, a municipal corporation and charter city ("City"), and INTERVAL HOUSE, a California nonprofit public benefit corporation ("Subrecipient"). RECITALS A. City is a California municipal corporation and charter city under the laws of the State of California. B. City has applied for and received funds ("HOME Funds") from the United States Department of Housing and Urban Development ("HUD") pursuant to the HOME Investment Partnerships Act and HOME Investment Partnerships Program, 42 U.S.C. §12701, et seq., and the implementing regulations set forth in 24 CFR § 92.1, et seq. (together, "HOME Program") for the purposes of strengthening public -private partnerships to provide more affordable housing, and particularly to provide decent, safe, sanitary, and affordable housing for very low income and lower income citizens of Huntington Beach in accordance with the HOME Program. As used herein, the HOME Program includes the HUD Final Rule set forth at 78 FR 142, adopted July 24, 2013, which adopts substantial amendments to the HOME Program regulations set forth at 24 CFR Part 92. C. City is currently implementing a coordinated one-year strategy and program to provide financial assistance to eligible extremely low, very low and lower income families and households to enable such households to secure housing available at an affordable housing cost in the City. D. City has developed a Tenant Based Rental Assistance Program to assist veteran and senior families in the City to transition into permanent, supportive housing. City wishes to have fifty percent (50%) of new clients referred by the Huntington Beach Task Force. E. City wishes to engage the Subrecipient to assist the City in utilizing HOME Funds to provide tenant based rental assistance, security deposit assistance and utility assistance to veteran and senior residents of the City, in accordance with the terms and provisions set forth in this Agreement. NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows: 17-5919/162143/RLS 7/14/17/DO ARTICLE 1 SCOPE OF SERVICES 1.1 Scope of Services. During the entire Term (defined below) of this Agreement, Subrecipient shall administer the City's HOME -funded Tenant Based Rental Assistance Program ("TBRA Program"), all in accordance with this Article 1 (collectively, the "Services") and the TBRA Program Operating Guidelines attached hereto as Exhibit A. In connection with the Services, Subrecipient shall comply with all requirements of the HOME Program, this Agreement and all applicable federal, state and local laws and regulations. Subrecipient shall further take all reasonable actions necessary to enable City to comply with City's obligations under the HOME Program relating to the TBRA Program. The Subrecipient shall perform the Services set forth in this Article 1 in furtherance of the TBRA Program. 1.2 Marketing and Outreach; Application Process. (a) Marketing and Outreach. Subrecipient shall undertake affirmative marketing and outreach activities to find prospective Eligible Households interested in the TBRA Program, all in accordance with HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. Subrecipient shall describe its marketing and outreach efforts in quarterly progress reports submitted to the City under this Agreement, as described in Exhibit B. (b) Waiting List. Subrecipient shall maintain a waiting list of prospective Eligible Households. The waiting list shall be prioritized first based on the most urgent need as determined by the Client Outcome Matrix Form set forth in Appendix I to the TBRA Program Operating Guidelines, prospective Eligible Households of equally urgent need will be helped on a first come -first served basis, based on the date and time of referral or initial direct contact with the Subrecipient. (c) Intake Process. Upon being contacted by a prospective Eligible Household (recruited through Subrecipent's affirmative marketing and outreach efforts), Subrecipient shall initially meet with such prospective Eligible Household to fill out an Initial Qualification Document in substantially the form attached as Appendix A to the TBRA Program Operating Guidelines, including an income calculation based on three months of source documentation (bank account statements, pay stubs, etc.) to prequalify such prospective Eligible Household. Subrecipient shall then meet with prequalified Eligible Households to determine and verify their qualifications and eligibility for assistance under the TBRA Program, provide such prequalified Eligible Households with the TBRA Program application and other documentation described below, assist prospective Eligible Households with the completion of the application and gross income calculation worksheet and qualify Eligible Households for the TBRA Program. Subrecipient shall provide every prequalified Eligible Household with all of the following documentation. 17-5919/162143/RLS 7/14/17/DO 2 (i) Fifty percent (50%) of new clients will be referred by the Huntington Beach Homeless Task Force. (ii) TBRA Application in the form attached to the TBRA Program Operating Guidelines as Appendix B, or as otherwise approved in writing by the Executive Director of Community Development (or his designee) on behalf of the City ("Deputy Director"). The TBRA Application shall solicit information regarding each applicant household's income and assets, household size and composition (number of children and adults), names of household members, Housing Unit (defined below) size and location preferences, specific needs and considerations, and a race/ethnicity survey. (iii) Declaration of Homelessness Status or Declaration of At -Risk of Homelessness Status, as appropriate, in the forms attached to the TBRA Program Operating Guidelines as Appendix C. (iv) Rental Assistance Contracts for the landlord and the Eligible Households, in the forms attached to the TBRA Program Operating Guidelines. Income Calculation Form in the form attached to this Agreement as Exhibit C. (v) Household Budget Worksheet in the form attached to this Agreement as Exhibit D. (vi) Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in Your Home" attached to this Agreement as Exhibit E. (d) Guidance for Eligible Households. Subrecipient shall meet with prospective Eligible Households throughout the application process and shall continue to meet with and counsel each Eligible Household regarding the TBRA Program, the Eligible Household's responsibilities as participants of the TBRA Program, and the goals and objectives of the TBRA Program. 1.3 Determination of Eligibility. Subrecipient shall qualify all Eligible Households in accordance with the selection criteria described in this Section. Further, for all Eligible Households Subrecipient shall implement the selection criteria and policies in compliance with the City's Consolidated Plan and the City's housing needs and priorities. (a) Eligible Household. As used in this Agreement, "Eligible Household" refers to extremely low income households that are (i) currently residents of the City of Huntington Beach, and (i) currently homeless or at risk of homelessness and (iii) include at least one child (under the age of 19) enrolled and attending school in the City of Huntington Beach for at least 90 days prior to the time of admission into the TBRA Program. It is anticipated that the Eligible Households assisted pursuant to the TBRA Program will be the same households assisted pursuant to the ESG Agreement. 17-5919/162143/RLS 7/14/17/DO 3 (i) As used in this Agreement, "at risk of homelessness" refers to a household that is at risk of being evicted due to an economic hardship in paying rent or staying current with rent, as determined in accordance with the ESG Program. (ii) For purposes of determining eligibility for the TBRA Program, a prospective Eligible Household's (or for continuing compliance, a participating Eligible Household's) gross annual income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. For purposes of this Agreement, annual income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken (and for a participating household, income anticipated for the 12 months following verification described in § 1.3(b)(11) below.) When collecting income verification documentation, Subrecipient may also consider any likely changes in income. (iii) For purposes of this Agreement and the TBRA Program, income limits for extremely -low, very -low and low income households are established annually by HUD for the Orange County income limit area. (b) Income Verification. (1) Initial Verification. To determine if TBRA Program applicants (collectively, "Applicants") are income -eligible, Subrecipient must verify each Applicant's household income using source documentation such as wage statements, interest statements, unemployment compensation statements, and bank account statements, and other documentation types approved by HUD. Once an initial income verification is completed, the Subrecipient is not required to re-examine the Eligible Household's income unless six months has elapsed before assistance is provided. (ii) Annual Eligibility Verification. Subrecipient shall annually re -certify income and re -qualify each Eligible Household, including examination of source assistance must be terminated following a 30 day notification period. For households between 60% and 80% AMI the Subrecipient must obtain approval from the City before rental assistance is continued. (c) Verification of Eligibility. Subrecipient shall collect and examine source documentation submitted by the Applicant to verify the identity of the members of the Eligible Household and that the Eligible Household includes at least one child (under 19 years old) attending school in the City (and enrolled in a school in the City as of January 1, 2014). Subrecipient shall make a determination that the Eligible Household is currently experiencing homelessness or is at risk of 17-5919/162143/RLS 7/14/17/DO 4 homelessness, as defined in the ESG Program (24 CFR 576.2), based on caseworker observations and certification and Applicant certification. (d) Written Notice of Eligibility Determination. Subrecipent shall provide written notice to each Applicant stating whether such Applicant was determined to be eligible for assistance under the TBRA Program. Applicants determined to be ineligible for TBRA Program assistance shall have an opportunity to appeal the determination to the Subrecipient's Executive Director. If the issue is not resolved, the case will be referred to the Deputy Director. The definitions of "homelessness" and "at risk of homelessness" under the ESG Program (24 CFR 576.2) are applicable to this Agreement. 1.4 Selection of Housing Units. (a) Housing Unit Selection. Subrecipient shall assist Eligible Households with finding and selecting an appropriate housing unit (each a "Housing Unit") that meets federal housing quality standards ("HQS") or such other standards as may be made applicable to the TBRA Program by HOME Program statutes and/or regulations, specifically including Uniform Physical Condition Standards (UPCS), and that satisfies the requirements of the TBRA Program, HOME Program and this Agreement. Eligible Households shall also be entitled to find a Housing Unit for themselves, subject to compliance with the requirements of the TBRA Program, HOME Program and this Agreement; however, the parties anticipate that in most cases, Subrecipient shall be responsible for locating and qualifying an appropriate Housing Unit for occupancy by each Eligible Household. Subrecipient may refer Eligible Households to appropriate Housing Units but may not require an Eligible Household to select a particular Housing Unit. Subsidy Payments shall only be provided in connection with the rental of a qualified Housing Unit located in the City, unless Subrecipient documents reason for selecting housing outside the City. Subsidy Payments under this Agreement are portable within the City. Subsidy payments under this Agreement are portable within the City. Subrecipient's obligations under this Section 1.4 apply to each Housing Unit to be occupied by an Eligible Household receiving Subsidy Payments hereunder. (b) Housing Unit Size; Occupancy Standards. Housing unit selection shall comply with the following "Occupancy Standards" for the applicable Eligible Household: No more than two persons per bedroom plus one may occupy the Housing Unit. Thus, no more than three persons may occupy a one bedroom Housing Unit, no more than five persons may occupy a two bedroom Housing Unit; no more than seven persons may occupy a three bedroom Housing Unit; no more than nine persons may occupy a four bedroom Housing Unit. 17-5919/162143/RLS 7/14/17/DO 5 (c) Property Inspection. Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual (or more often) verification process, Subrecipient shall cause a certified HQS inspector to inspect each Housing Unit occupied or to be occupied by an Eligible Household to ensure the Housing Unit complies with HQS as set forth in the HOME Program, including without limitation 24 CFR 92.251, as well as all applicable state and local codes and ordinances, including zoning ordinances. Subrecipient shall provide the City with documentation of each HQS inspector's certification. Each HQS inspection shall include all of the following: (1) Verification of the age of the Housing Unit; (ii) Complete HQS Inspection Checklist in the form attached as Exhibit G, including a rating for the Housing Unit of Pass, Pass with Comment, or Fail; (iii) Lead -based hazard assessment, dissemination of lead -based hazard information pamphlet and disclosure form and lead -based hazard reduction activities, if required by the HOME Program or applicable federal, state and/or local laws; (iv) Adequate opportunity for the Landlord (defined below) to correct any deficiencies indicated in the HQS Inspection Form to bring the Housing Unit into compliance with HQS requirements; (v) Verification that occupancy by the Eligible Household will comply with the Occupancy Standards set forth in Section 1.4(b); and (vi) Certification of rent reasonableness regarding the rent being charged for the Housing Unit based on comparable non -assisted Housing Units in the same area. Subrecipient shall perform the rent reasonableness review subject in each instance to review and approval by the City. City may elect to perform the rent reasonableness reviews on behalf of Subrecipient by providing written notice to Subrecipient. The rent charged under the written lease agreement for the Housing Unit shall conform to the rent reasonableness standard pursuant to the TBRA Program Operating Guidelines, which is based on local market conditions. The contract rent for Housing Units that are restricted to an affordable rent by agreement with the City or by regulation or ordinance, or otherwise, shall be likewise restricted to such affordable rent in accordance with the contractual, statutory or regulatory restrictions governing the permitted rents for such Housing Units and the Rental Assistance Subsidy Payment shall be limited and calculated accordingly, as described in Section 1.5(a), below. 17-5919/162143/RLS 7/14/17/DO 6 (d) Coordination with Landlords. (i) Landlord Guidance. Subrecipient shall provide guidance to the property owners, property owners' representatives, or property management companies hired by property owners (each a "Landlord" and collectively referred to as "Landlords") participating in the TBRA Program regarding the TBRA Program requirements and procedures that impact Landlords. (ii) Landlord Agreement. Subrecipient shall enter into a Landlord Agreement with each participating property owner/Landlord in substantially the form attached to the TBRA Program Operating Guidelines as Appendix E. The Landlord Agreement will establish the Subsidy Payments to be made by Subrecipient on behalf of the Eligible Household as well as the Eligible Household's initial share of the contract rent. The Landlord Agreement shall further establish the terms and conditions under which the Subsidy Payments shall be paid to the Landlord for the applicable Housing Unit, including applicable HOME Program requirements. The Landlord Agreement shall have an initial term of 6-12 months, subject to extensions approved by Subrecipient and City (as applicable) pursuant to the TBRA Program Operating Guidelines. (iii) Tenant Protection Agreement. Subrecipient shall require each Landlord to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit owned and/or managed by such Landlord, which lease agreement shall include a Tenant Protection Agreement in substantially the form attached to the TBRA Program Operating Guidelines as Appendix F, or an updated form of Tenant Protection Agreement as may be prepared and provided by the City to the Subrecipient, and then by Subrecipent to Landlord. The Tenant Protection Agreement shall be executed in connection with the lease agreement between the Landlord and Eligible Household. The Tenant Protection Agreement will prohibit the inclusion of prohibited lease terms listed at 24 CFR 92.253; confirm the Landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401; and prohibit discrimination by the Landlord against the Eligible Household. Interval House will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. If the Landlord's form of rental agreement is not acceptable, Subrecipient shall require the Landlord and Eligible Household to enter into a lease agreement that complies with state law, HOME requirements, and City requirements. 1.5 Subsidy Payments. Subrecipient shall make rent payments, security deposit payments and/or utility deposit payments, as applicable (collectively, the "Subsidy Payments"), to Landlords and/or to utility providers, as applicable, on behalf of Eligible Households. Subsidy payments must be provided in accordance to the Subrecipient's TBRA Program Operating Guidelines. Eligible Households are not expected to repay Subsidy Payments 17-5919/162143/RLS 7/14/17/DO 7 received pursuant to the TBRA Program. Except as may be permitted by the HOME Program, Subrecipient's sole remedy in the event of noncompliance or breach by an Eligible Household shall be non -renewal of assistance under the TBRA Program. (a) Rental Assistance Calculation. Subrecipient shall calculate the "Rental Assistance" payments to be paid on behalf of each Eligible Household under this Agreement. The initial household rent is equivalent to the maximum subsidy amount allowed under the HOME regulations and is calculated as the difference between 30% of the Eligible Household's gross monthly income and the payment standard for the size of the unit. (b) Payment Standards. Subrecipient must use the City's current payment standards as set forth in the Rent Reasonable Standards attached to the TBRA Program Operating Guidelines as Appendix G. The Housing Authority's payment standards represent the cost of rent and utilities for moderately priced units in Huntington Beach. Payment standards are established by bedroom size. (c) Utility Allowance. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the Eligible Households entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the Eligible Household is directly responsible for payment of utility services, the Eligible Household's initial share will be determined by subtracting a utility allowance from 30% of the Eligible Household's gross monthly income. The Subrecipient must use the County of Orange's Housing Authority's Utility Allowance Schedule attached to the TBRA Program Operating Guidelines as Appendix H. (d) Term, 12. The Subrecipient will provide rental assistance for an initial term of 6- 12 months, which can be extended in 6-12 month intervals, up to a total of six times, for a cumulative term of up to 24 months. Extensions will be granted at the discretion of the Subrecipient and shall be based on continued program compliance and ongoing need. The Subrecipient will evaluate ongoing need. (e) Security Deposit Assistance. Subrecipient may provide security deposit assistance to each Eligible Household. It is anticipated that Subrecipient shall provide Security Deposit Assistance to each Eligible Household in an amount of up to the lesser of. (A) two months' non -subsidized tenants. The lease agreement must provide that the security deposit is refundable in accordance with state law. Security deposit refunds shall be provided by the Landlord directly to the Eligible Household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by Eligible Household and landlord, as provided for in the lease. (f) Utility Deposit Assistance. Subrecipient may provide utility deposit assistance on behalf of each Eligible Household. It is anticipated that the Subrecipient will provide utility deposit assistance to each Eligible Household in the full amount of 17-5919/162143/RLS 7/14/17/DO 8 any utility deposit required for electricity, gas, and/or water service to the utility provider when needed to assist the Eligible Household in establishing tenancy. Utility deposit assistance may be provided only if the following requirements are met: (i) Utility deposit assistance is only available where rental assistance and/or security deposit assistance are also being provided. (ii) Utility deposit assistance shall be paid directly to the Landlord or utility provider, as applicable, on behalf of the Eligible Household. Utility deposit refunds shall be returned directly to the Eligible Household. 1.6 Administrative Cost Reimbursements. The City will reimburse the Subrecipient for allowable costs incurred in administering the TBRA Program, which are associated with the determination of income eligibility, pursuant to 24 CFR 92.203, and property inspections under HQS, codified per 24 CFR 982.401. Administrative costs incurred in administering the TBRA Program that are ineligible under the HOME Program will be reimbursed from a non -HOME Program funding source, or Inclusionary Funds. The administrative costs to be reimbursed from the Inclusionary Funds include Intake Assessments, Housing Search, Case Management, Self -Sufficiency and related services and overhead. 1.7 Termination of Assistance and Returning Eligible Households. (a) Termination of Rental Assistance. Subrecipient may terminate assistance under the TBRA Program for any of the following reasons: (i) Eligible Household is evicted from the Housing Unit based on behavioral issues or unlawful activity; (ii) Eligible Household has violated TBRA Participant Program; (iii) Eligible Household will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based Programs. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must be terminated. 1.8 Returning Eligible Households. As needed, Eligible Households may be allowed to return to the program for rental assistance. A determination to allow re-entry shall be based on the following criteria: (i) Eligible Households must have left the program in good standing. To be in good standing, Eligible Households must have been engaged in their case management plan, voluntarily left the program (not in lieu of termination) 17-5919/162143/RLS 7/14/17/DO 9 diligent efforts to Enroll additional Eligible Households within not more than three (3) months following written notice from the City that such additional funds are expected to become available. (ii) Subrecipient shall assist each Enrolled Eligible Household in finding an appropriate Housing Unit and shall conduct an HQS inspection of such Housing Unit, all within two (2) months following Enrollment of such Eligible Household. (iii) Subrecipient shall commence providing Subsidiary Payments on behalf of each Eligible Household and shall assist each Eligible Household to move into an HQS-inspected and approved Housing Unit, all within three (3) months following Enrollment of such Eligible Household. (c) Subrecipient shall cause each Eligible Household to commence participation in the required self-sufficiency program immediately upon Enrollment of such Eligible Household, whether or not such Eligible Household has yet moved into a Housing Unit and received the benefit of Subsidy Payments hereunder. 1.10 City Oversight and Approval Rights. City shall have the right, by written notice to Subrecipient at any time during the Term of this Agreement, to require City review and/or pre -approval of any of the Services to be performed by Subrecipient hereunder, including for example income determinations, qualification of applicants as "Eligible Households," qualification of Housing Units, determination of reasonable rents, etc., to ensure compliance with the TBRA Program, the HOME Program, or other applicable requirements. ARTICLE 2 TERM 2.1 Term. Services of the Subrecipient under this Agreement shall start on 10/1/17 and end on the earlier to occur of (i) 9/30/18 or (ii) the date the full amount of HOME Funds available under Section 3.2(a) below has been disbursed to Subrecipient and expended by Subrecipient to provide Subsidy Payments pursuant to this Agreement ("Term"), unless this Agreement is earlier terminated pursuant to Section 8.3. The Term of this Agreement and the provisions herein shall be further extended to cover any additional time period during which the Subrecipient remains in control of HOME Funds or other HOME assets, including program income. ARTICLE 3 BUDGET AND PAYMENTS 3.1 Budget. Subrecipient has submitted a budget to City for approval ("Budget"), which sets forth the estimated timing and use of the HOME Funds contributed by the City pursuant to this Agreement. The Budget is attached hereto as Exhibit F. Any amendments to an approved Budget for the Services must be approved by the City's Deputy Director or his 17-5919/162143/RLS 7/14/17/DO 1 1 or her authorized designee. In the event this Agreement is extended past the initial Term or any additional moneys will be contributed to the TBRA Program by City pursuant to this Agreement, Subrecipient shall prepare and submit to the Deputy Director for approval an updated Budget for such additional moneys. Subrecipient shall prepare a Budget, for approval by Deputy Director, for each year during which this Agreement remains in effect. The City may require a more detailed line item breakdown of the Budget than the one contained herein, and the Subrecipient shall provide such supplementary information about the Budget in a timely fashion in the form and content prescribed by the City. 3.2 Reimbursement of Subsidy Payments. City shall reimburse Subrecipient for Subsidy Payment actually disbursed to or on behalf of Eligible Households pursuant to this Agreement and in accordance with line items on the approved Budget or as otherwise approved by the City's Deputy Director. City shall have no obligation to reimburse Subrecipient for ineligible administrative costs or expenses incurred by Subrecipient to manage or implement the TBRA Program or this Agreement, for the cost of social or supportive services provided to Eligible Households hereunder, or for any other costs or expenses incurred by Subrecipient in connection with its activities under this Agreement. City's payment obligations hereunder shall be limited to the actual amount of Subsidy Payments disbursed by Subrecipient and eligible administrative costs in accordance with the terms of this Agreement and the approved Budget. Payments may be contingent upon certification of the Subrecipient's financial management system in accordance with the standards specified in 24 CFR 84.21. (a) Amount of Payments. It is expressly agreed and understood that the total amount of Home Program Funds to be paid by the City under this Agreement shall not exceed One Hundred Sixty-five Thousand Two Hundred Seventy-eight Dollars ($165,278). The amount of Inclusionary Funds to be paid by the City under this Agreement shall not exceed Thirty-seven Thousand Dollars ($37,000) annually. The dollar amount stated in the immediately preceding sentence may be increased by written amendment of this Agreement, signed by an authorized representative of Subrecipient and the Deputy Director. (b) Requests for Payments. To receive each payment under this Agreement, Subrecipient shall submit to the City a written reimbursement request or invoice in a form approved by City, along with such supporting documentation as may be requested by the City to verify Subrecipient's performance of the Services for which the payment is requested. Reimbursement requests shall be submitted no more frequently than two times per month. Payments will be adjusted by the City in accordance with fund advances, if any, and program income balances available in Subrecipient accounts. In addition, the City reserves the right to liquidate funds available under this Agreement for costs incurred by the City on behalf of the Subrecipient. 3.3 Payments Subject to Availability of HOME Funds. City's obligation to provide payments to Subrecipient hereunder is subject to City's receipt of HOME Funds from HUD pursuant to the HOME Program. 17-5919/162143/RLS 7/14/17/DO 12 3.4 Accounting. Subrecipient shall, upon request, provide City with an accounting report, in form and content reasonably satisfactory to City, of any funds disbursed by City pursuant to Section 3.2. ARTICLE 4 INSURANCE AND INDEMNIFICATION 4.1 Insurance. Without limiting City's right to indemnification, Subrecipient shall secure prior to commencing the performance of any Services under this Agreement, and maintain during the Term of this Agreement, insurance coverage as set forth in this Section. (a) Required Insurance. Subrecipient shall secure and maintain the following coverage: (1) Workers' Compensation Insurance as required by California statutes; (ii) Comprehensive General Liability Insurance, or Commercial General Liability Insurance, including coverage for Premises and Operations, Contractual Liability, Personal Injury Liability, Products/Completed Operations Liability, Broad -Form Property Damage, Independent Contractor's Liability and Fire Damage Legal Liability, in an amount of not less than One Million Dollars ($1,000,000.00) per occurrence, combined single limit, written on an occurrence form; and (Ili) Comprehensive Automobile Liability coverage, including — as applicable — owned, non -owned and hired autos, in an amount of not less than One Million Dollars ($1,000,000.00) per occurrence, combined single -limit, written on an occurrence form. The Deputy Director, with the consent of City's Risk Manager is hereby authorized to modify the requirements set forth above in the event he or she determines that a modification, whether an increase or decrease, is in City's best interest. (b) Required Clauses in Policies. Each insurance policy required by this Agreement shall contain the following clauses: "This insurance shall not be canceled or allowed to lapse without at least ten (10) days' prior written notice given to the City Clerk of the City of Huntington Beach, 2000 Main Street, Huntington Beach, CA 92648." "It is agreed that any insurance maintained by the City of Huntington Beach shall apply in excess of and not contribute with insurance provided by this policy.'' Each insurance policy required by this Agreement, excepting policies for workers' compensation, shall contain the following clause: 17-5919/162143/RLS 7/14/17/DO 13 "The City of Huntington Beach, its officials, agents, employees, representative, and volunteers are added as additional insureds as respects operations and activities of, or on behalf of the named insured, performed under contract with the City of Huntington Beach. Subrecipient hereby agrees to waive subrogation which any insurer of the Subrecipient may acquire from the Subrecipient by virtue of the payment of any loss. If requested by City, Subrecipient agrees to obtain and deliver to City an endorsement from Subrecipient's general liability and automobile insurance insurer to effect this waiver of subrogation. (c) Property Insurance. Subrecipient shall further comply with the insurance requirements of 24 CFR 84.31. (d) Required Certificates and Endorsements. Prior to commencement of any Services under this Agreement, the Subrecipient shall deliver to City (i) insurance certificates confirming the existence of the insurance required by this Agreement, and including the applicable clauses referenced above, and (ii) endorsements to the above -required policies, which add to these policies the applicable clauses referenced above. Such endorsements shall be signed by an authorized representative of the insurance company and shall include the signator's company affiliation and title. Should it be deemed necessary by City, it shall be the Subrecipient's responsibility to see that City receives documentation, acceptable to City, which sustains that the individual signing such endorsements is indeed authorized to do so by the insurance company. Also, City reserves the right at any time to demand, and to receive within a reasonable time period, certified copies of any insurance policies required under this Agreement, including endorsements effecting the coverage required by these specifications. (e) Remedies for Defaults Re: Insurance. In addition to any other remedies City may have if the Subrecipient fails to provide or maintain any insurance policies or policy endorsements to the extent and within the time herein required, City may, at its sole option: (i) Obtain such insurance and deduct and retain the amount of the premium for such insurance from any sums due under the Agreement; (ii) Order the Subrecipient to stop work under this Agreement and/or withhold any payment(s) which become due to the Subrecipient hereunder until the Subrecipient demonstrates compliance with the requirements hereof; or (iii) Terminate this Agreement. Exercise of any of the above remedies, however, is an alternative to other remedies City may have and is not the exclusive remedy for the 17-5919/162143/RLS 7/14/17/DO 14 Subrecipient's failure to maintain insurance or secure appropriate endorsements. Nothing herein contained shall be construed as limiting in any way the extent to which the Subrecipient may be held responsible for payment of damages to persons or property resulting from the Subrecipient's or its subcontractor's performance of the Services covered under this Agreement. 4.2 Indemnification. (a) As respects acts, errors or omissions in the performance of Services under this Agreement, the Subrecipient agrees to defend, indemnify and hold harmless City, its officers, agents, employees, representatives and volunteers from and against any and all claims, demands, defense costs, liability or consequential damages of any kind or nature arising directly out of the Subrecipient's negligent acts, errors or omissions in the performance of Services under the terms of this Agreement. (b) As respects all acts or omissions which do not arise directly out of the performance of Services, including but not limited to those acts or omissions normally covered by general and automobile liability insurance, Subrecipient agrees to indemnify, defend (at City's option), and hold harmless City, its officers, agents, employees, representatives, and volunteers from and against any and all claims, demands, defense costs, liability, or consequential damages of any kind or nature arising out of or in connection with Subrecipient's performance or failure to perform, under this Agreement; excepting those which arise out of the sole negligence of City. ARTICLE 5 ADMINISTRATIVE REQUIREMENTS 5.1 Financial Management. (a) Accounting Standards. Subrecipient agrees to comply with 24 CFR 84.21 through 84.28 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. (b) Cost Principles. Subrecipient shall administer its program in conformance with OMB Circulars A-122, "Cost Principles for Non -Profit Organization." These principles shall be applied for all costs incurred whether charged on a direct or indirect basis. 5.2 Documentation, Recordkeeping, Reporting and Monitoring. Subrecipient shall maintain documents and records, prepare and submit reports, and permit City to monitor Subrecipient's activities all in accordance with the requirements set forth in Exhibit B and applicable laws and regulations. All requirements set forth in such Exhibit B are incorporated herein as if set forth in full in this Agreement. 17-5919/162143/RLS 7/14/17/DO 15 5.3 Use and Reversion of Assets. The use and disposition of property and equipment under this Agreement shall be in compliance with the requirements of 24 CFR Part 84 and 24 CFT 92.504, as applicable. The Subrecipient shall transfer to the City any HOME Funds on hand and any accounts receivable attributable to the use of HOME Funds under this Agreement at the time of the earliest to occur of expiration, cancellation, or termination. 5.4 Ownership of Documents. All documents and materials, both tangible and intangible, furnished by or through the City to Subrecipient pursuant to this Agreement are and shall remain the property of City and shall be returned to City upon the earliest to occur of expiration, cancellation, or termination of this Agreement. All documents and materials prepared by Subrecipient under or related to this Agreement shall become the property of City at the time of payment to Subrecipient of all fees, if any, for their preparation, and shall be delivered to City by Subrecipient at the request of City, and in any event upon the earliest to occur of expiration, cancellation, or termination of this Agreement. ARTICLE 6 PERSONNEL & PARTICIPANT CONDITIONS 6.1 Civil Rights. (a) Compliance. The Subrecipient agrees to comply with the Huntington Beach Municipal Code, Government Code Section 4450, et seq., the Unruh Civil Rights Act, Civil Code Section 51, et seq., Title VI of the Civil Rights Act of 1964, as amended, Title VIII of the Civil Rights Act of 1968 as amended, Section 104(b) and Section 109 of Title 1 of the Housing and Community Development Act of 1974, as amended, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, Executive Order 11063, and Executive Order 11246 as amended by Executive Orders 11375, 11478, 12107 and 12086. (b) Nondiscrimination. The Subrecipient agrees to comply with (1) the requirements of 24 CFR Part 5, subpart A, which relate to nondiscrimination and equal opportunity; (2) the nondiscrimination requirements of Section 282 of the HOME Investment Partnerships Act, 42 U.S.C. Section 12701, et seq. (c) Section 504. The Subrecipient agrees to comply with all federal regulations issued pursuant to compliance with Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), which prohibits discrimination against the individuals with disabilities or handicaps in any federally assisted program. 6.2 Affirmative Action. (a) Executive Order 11246. The Subrecipient agrees that it shall be committed to carry out pursuant to the City's specifications an Affirmative Action Program in 17-5919/162143/RLS 7/14/17/DO 16 keeping with the principles as provided in President's Executive Order 11246 of September 24, 1966. (b) Women- and Minority -Owned Businesses (W/MBE). The Subrecipient will use its best efforts to afford small businesses, minority business enterprises, and women's business enterprises the maximum practicable opportunity to participate in the performance of this Agreement. As used in this Agreement, the terms "small business" means a business that meets the "minority and women's business enterprise" means a business at least fifty-one percent (51 %) owned and controlled by minority group members or women. For the purpose of this definition, "minority group members" are Afro-Americans, Spanish-speaking, Spanish surnamed or Spanish -heritage Americans, Asian -Americans, and American Indians. The Subrecipient may rely on written representations by businesses regarding their status as minority and female business enterprises in lieu of an independent investigation. (c) Equal Employment Opportunity and Affirmative Action (EEO/AA) Statement. The Subrecipient will, in all solicitations or advertisements for employees placed by or on behalf of the Subrecipient, state that it is an Equal Opportunity or Affirmative Action employer. (d) Subcontract Provisions. The Subrecipient will include the provisions of Sections 6.1, Civil Rights, and 6.2, Affirmative Action, in every subcontract or purchase order, specifically or by reference, so that such provisions will be binding upon each of its own sub-subrecipients or subcontractors. 6.3 Employment Restrictions. (a) Prohibited Activity. The Subrecipient is prohibited from using HOME Funds provided herein or personnel employed in. the administration of the program for: political activities; inherently religious activities; lobbying; political patronage; and nepotism activities. (b) Labor Standard. The Subrecipient agrees to comply with the requirements of the Secretary of Labor in accordance with the Davis -Bacon Act as amended, the provisions of Contract Work Hours and Safety Standards Act (40 U.S.C. 327 et seq.) and all other applicable federal, state and local laws and regulations pertaining to labor standards insofar as and when those acts apply to the performance of this Agreement. The Subrecipient agrees to comply with the Copeland Anti -Kick Back Act (18 U.S.C. 874 et seq.) and the implementing regulations thereto issued by the U.S. Department of Labor at 29 CFR Part 5. The Subrecipient shall maintain documentation that demonstrates compliance with applicable hour and wage requirements. (c) Prevailing Wage. The Subrecipient agrees that, to the extent applicable, all contractors engaged under contracts for construction, renovation or repair work financed in whole or in part with assistance provided under this Agreement shall 17-5919/162143/RLS 7/14/17/DO 17 comply with the regulations of the Department of Labor, under 29 CFR Parts 1, 3, 5 and 7 and California Labor Code Section 1720, et seq. governing the payment of wages and ratio of apprentices and trainees to journey workers. The Subrecipient shall cause or require to be inserted in full, in all such contracts subject to such regulations, provisions meeting the requirements of this paragraph. (d) Section 3 Clause. The Subrecipient agrees, to the extent applicable, to comply with Section 3 of the HUD Act of 1968, as amended, and as implemented by the regulations set forth in 24 CFR 135. 6.4 Conduct (a) Assignment. The Subrecipient shall not assign or transfer any interest in this Agreement without the prior written consent of the City thereto; provided, however, that claims for money due or to become due to the Subrecipient from the City under this Agreement may be assigned to a bank, trust company, or other financial institution without such approval. Notice of any such assignment or transfer shall be furnished promptly to the City. (b) Subcontracts. (i) Approvals. The Subrecipient shall not enter into any subcontracts with any entity, agency or individual in the performance of this Agreement without the written consent of the City prior to the execution of such agreement. (ii) Monitoring. The Subrecipient will monitor all subcontracted services on a regular basis to assure contract compliance. Results of monitoring efforts shall be summarized in written reports and supported with documented evidence of follow-up actions taken to correct areas of noncompliance. (iii) Content. The Subrecipient shall cause all of the provisions of this Agreement in its entirety to be included in and made a part of any subcontract executed in the performance of this Agreement. (iv) Selection Process. The Subrecipient shall undertake to insure that all subcontracts let in the performance of this Agreement shall be awarded on a fair and open competition basis in accordance with applicable procurement requirements. Executed copies of all subcontracts shall be forwarded to the City along with documentation concerning the selection process. (c) Hatch Act. The Subrecipient agrees that no funds provided, nor personnel employed under this Agreement, shall be in any way or to any extent engaged in the conduct of political activities in violation of Chapter 15 of Title V of the U.S.C. 17-5919/162143/RLS 7/14/17/DO 18 (d) Conflict of Interest. The Subrecipient agrees to abide by the provisions of 24 CFR 84.42 and 92.356, which include (but are not limited to) the following: (i) The Subrecipient shall maintain a written code or standards of conduct that shall govern the performance of its officers. employees or agents engaged in the award and administration of contracts supported by HOME Funds. (ii) No employee, officer or agent of the Subrecipient shall participate in the selection, or in the award, or administration of, a contract supported by HOME Funds if a conflict of interest, real or apparent, would be involved. (iii) No covered persons who exercise or have exercised any functions or responsibilities with respect to HOME -assisted activities, or who are in a position to participate in a decision -making process or gain inside information with regard to such activities, may obtain a financial interest in any contract, or have a financial interest in any contract, subcontract, or agreement with respect to the HOME -assisted activity, or with respect to the proceeds from the HOME -assisted activity, either for themselves or those with whom they have business or immediate family ties, during their tenure or for a period of one (1) year thereafter. For purposes of this paragraph, a "covered person" includes any person who is an employee, agent, consultant, officer, or elected or appointed official of the City, the Subrecipient, or any designated public agency. (e) Lobbying. The Subrecipient hereby certifies that: (i) No federal appropriated funds have been paid or will be paid, by or on behalf of it, 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 1 oan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement; (ii) 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, it will complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; and (iii) It will require that the language of paragraph (iv) of this certification be included in the award documents for all subawards at all tiers (including 17-5919/162143/RLS 7/14/17/DO 19 subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all Subrecipients shall certify and disclose accordingly. (f) Lobbying Certification. 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, US.C. 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. (g) Religious Activities. The Subrecipient agrees that funds provided under this Agreement will not be utilized for inherently religious activities such as worship, religious instruction, or proselytization. ARTICLE 7 GENERAL CONDITIONS 7.1 General Compliance. The Subrecipient agrees to comply with the requirements of the HOME Program in the administration and implementation of the TBRA Program and this Agreement. The Subrecipient shall carry out each activity in compliance with all regulations described in subpart H of 24 CFR Part 92, except that the Subrecipient does not assume the City's responsibilities for environmental review under 24 CPR 92.352 and the intergovernmental review process described in 24 CFR 92.357 does not apply to the Subrecipient. The Subrecipient also agrees to comply with all other applicable federal, state and local laws, regulations, and policies governing the funds provided under this Agreement. The Subrecipient further agrees to utilize funds available under this Agreement to supplement rather than supplant funds otherwise available. 7.2 Familiarity with Services; Qualified Personnel. (a) By executing this Agreement, Subrecipient represents and warrants that Subrecipient (i) has thoroughly investigated and considered the Services to be performed, (ii) has carefully considered how the Services should be performed, and (iii) fully understands the requirements, difficulties and restrictions attending the performance of the Services under this Agreement. (b) Subrecipient represents that Subrecipient has or will secure and maintain, at Subrecipient's sole cost and expense, all qualified and licensed personnel required to perform the Services. Staff and any additional personnel hired by Subrecipient shall be employees of Subrecipient. Such personnel shall not be deemed to be employees of City or to have any contractual relationship with City. Such Personnel shall be authorized or permitted under state and local law to perform the Services. 17-5919/162143/RLS 7/14/17/DO 20 7.3 Independent Contractor. In performing under this Agreement, Subrecipient is and shall at all times be acting and performing as an independent contractor to City, performing its duties in accordance with its own judgment. City shall neither have nor exercise any control or direction over the methods by which Subrecipient performs its work and function nor shall City have the right to interfere with such freedom or action or prescribe rules or otherwise control or direct the manner in which such services are performed. The sole interest of the City in the Services performed by the Subrecipient is that such Services be performed in a legal competent, efficient and satisfactory manner. Nothing contained herein shall cause the relationship between the parties to this Agreement to be that of employer and employee. Subrecipient shall not have the authority to obligate City to any contract, obligation, or undertaking whatsoever and shall make no representation, either oral or in writing. 7.4 Subrecipient Representative. Subrecipient hereby designates Carol Williams as its Project Manager for the TBRA Program (" Subrecipient's Representative"). Subrecipient's Representative shall supervise and direct the Services, using his or her best skill and attention, and shall be responsible for all means, methods, techniques, sequences and procedures and for the satisfactory coordination of all portions of the Services under this Agreement. 7.5 Nepotism. Subrecipient shall not hire or permit the hiring of any person to fill a position funded through this Agreement if a member of the person's immediate family is employed in an administrative capacity by City's HOME Program or any department of the City which is administering the HOME Program. For the purposes of this section, the term "immediate- family' means spouse, child, mother, father brother, sister, brother-in-law, sister-in-law, father-in-law, mother-in-law, son-in-law, daughter-in-law, aunt, uncle, stepparent and stepchild. The term "administrative capacity" means having selection, hiring, supervisory or management responsibilities, including serving on the governing body of City. 7.6 Hold Harmless. The Subrecipient shall indemnify, hold harmless, and defend the City and their elected officials, officers, employees and agents and shall pay for expenses incurred by the City for any and all claims, actions, suits, charges and judgments whatsoever related in any manner to or that arise out of the Subrecipient's performance or nonperformance of the Services or subject matter called for in this Agreement. 7.7 City Recognition. The Subrecipient shall insure recognition of the role of the City in providing Services through this Agreement. All activities, facilities and items utilized pursuant to this Agreement shall be prominently labeled as to funding source. 7.8 Notices. Any approval, disapproval, demand, document or other notice ("Notice") which any party may desire to give to the other party under this Agreement must be in writing and may be given either by (i) personal service, (ii) delivery by reputable document delivery service such as Federal Express that provides a receipt showing date and time of delivery, (iii) facsimile transmission, or (vi) mailing in the United States mail, certified mail, postage prepaid, return receipt requested, addressed to the 17-5919/162143/RLS 7/14/17/DO 21 address of the party as set forth below, or at any other address as that party may later designate by Notice. Service shall be deemed conclusively made at the time of service if personally served; upon confirmation of receipt if sent by facsimile transmission; the next business if sent by overnight courier and receipt is confirmed by the signature of an agent or employee of the party served; the next business day after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by express mail; and three (3) days after deposit in the United States mail, properly addressed and postage prepaid, return receipt requested, if served by certified mail. Subrecipient: Interval House Carol Williams Interval House 6615 E. Pacific Coast Highway, #170 Long Beach, CA 90803 City: City Clerk City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 With copies to: Kellee Fritzal Office of Business Development 2000 Main Street Huntington Beach, CA 92648 Such addresses may be changed by Notice to the other party(ies) given in the same manner as provided above. 7.9 Amendment and Waiver. This Agreement may be amended, modified, or supplemented only by a writing executed by each of the parties. Any party may in writing waive any provision of this Agreement to the extent such provision is for the benefit of the waiving party. No action taken pursuant to this Agreement, including any investigation by or on behalf of any party, shall be deemed to constitute a waiver by that party or its or any other party's compliance with any representations or warranties or with any provision of this Agreement. 7.10 Entire Agreement. This Agreement, including all Exhibits attached hereto, embodies the entire agreement and understanding between the parties pertaining to the subject matter of this Agreement and supersedes all prior agreements, understandings, negotiations, representations, and discussions, whether verbal or written, of the parties pertaining to the subject matter. In the event of a conflict between this Agreement, on one hand, and any Exhibit attached hereto, on the other hand, the provisions of this Agreement shall control; provided, if it is possible to comply with the requirements of this Agreement and the Exhibits, the parties shall do so. The following Exhibits are attached to this Agreement and incorporated herein: 17-5919/162143/RLS 7/14/17/DO 22 Exhibit A TBRA Program Operating Guidelines Appendix A Initial Qualification Form Appendix B TBRA Application Appendix C Declaration of Homelessness Appendix D Housing Quality Standards (HQS) Inspection Checklist Appendix E Landlord Agreement Appendix F Tenant Protection Agreement Appendix G Rent Reasonableness Standard Appendix H Orange County Housing Authority — Utility Allowance Schedule Appendix I Participant Agreement Appendix J Case Management and Self Sufficiency Program Policies and Procedures Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Exhibit C Gross Income Calculation Form Exhibit D Household Budget Worksheet Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home" Exhibit F Budget Exhibit G Housing Quality Standards (HQS) Inspection Checklist 7.11 Governing Law. The validity, construction, and performance of this Agreement shall be governed by the laws of the State of California. 7.12 Non -Liability of Members, Officials and Employees of City. No member, official or employee of City shall be personally liable to Subrecipient, or any successor in interest, in the event of any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or on any obligation under the terms of this Agreement. Subrecipient hereby waives and releases any claim Subrecipient may have 17-5919/162143/RLS 7/14/17/DO 23 against the member, officials or employees of City with respect to any Default or breach by City or for any amount which may become due to Subrecipient or Subrecipient's successors, or any obligations under the terms of this Agreement. Subrecipient makes such release with the full knowledge of Civil Code Section 1542 and hereby waives any and all rights thereunder to the extent of this release, if such Section 1542 is applicable. Section 1542 of the Civil Code provides as follows: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR." ARTICLE 8 ENFORCEMENT; TERMINATION 8.1 Events of Default. (a) For purposes of this Agreement, the word "Default" shall mean the failure of Subrecipient to perform any of Subrecipient's duties or obligations or the breach by Subrecipient of any of the terms and conditions set forth in this Agreement; any failure by Subrecipient to comply with any of the rules, regulations or provisions referred to herein, or such statutes, regulations, executive orders, and HUD guidelines, policies or directives as may become applicable at any time; any ineffective or improper use of funds provided under this Agreement; or submission by the Subrecipient to the City reports that are incorrect or incomplete in any material respect. In addition, Subrecipient shall be deemed to be in Default upon Subrecipient's (i) application for, consent to, or suffering of, the appointment of a receiver, trustee or liquidator for all or a substantial portion of its assets, (ii) making a general assignment for the benefit of creditors, (iii) being adjudged bankrupt, filing a voluntary petition or suffering an involuntary petition under any bankruptcy, arrangement, reorganization or insolvency law (unless in the case of an involuntary petition, the same is dismissed within thirty (30) days of such filing), or (v) suffering or permitting to continue unstayed and in effect for fifteen (15) consecutive days any attachment, levy, execution or seizure of all or a substantial portion of Subrecipient's assets or of Subrecipient' s interests hereunder. (b) City shall not be deemed to be in Default in the performance of any obligation required to he performed by City hereunder unless and until City has failed to perform such obligation for a period of thirty (30) days after receipt of written notice from Subrecipient specifying in reasonable detail the nature and extent of any such failure; provided, however, that if the nature of City's obligation is such that more than thirty (30) days are required for its performance, then City shall not be deemed to be in Default if City shall commence to cure such performance 17-5919/162143/RLS 7/14/17/DO 24 within such thirty (30) day period and thereafter diligently prosecute the same to completion. 8.2 Institution of Legal Actions. In addition to any other rights and remedies, and subject to the restrictions otherwise set forth in this Agreement, either party may institute an action at law or in equity to seek the specific performance of the terms of this Agreement, to cure, correct or remedy any Default, to recover damages for any Default or to obtain any other remedy consistent with the purpose of this Agreement. Such legal actions must be instituted in the Superior Court of the County of California, State of California or in the United States District Court for the Central District of California. 8.3 Acceptance of Service of Process. In the event that any legal action is commenced by the Subrecipient against City, service of process on City shall be made by personal service upon the City Clerk or in such other manner as may be provided by law. In the event that any legal action is commenced by City against the Subrecipient, service of process on the Subrecipient shall be made by personal service upon Subrecipient's Representative or in such other manner as may be provided by law. 8.4 Rights and Remedies Are Cumulative. Except as otherwise expressly stated in this Agreement, the rights and remedies of the parties are cumulative, and the exercise by either party of one or more of such rights or remedies shall not preclude the exercise by it, at the same or different times, of any other rights or remedies for the same Default or any other Default by the other party. 8.5 Inaction Not a Waiver of Default. Any failures or delays by either party in asserting any of its rights and remedies as to any Default shall not operate as a waiver of any Default or of any such rights or remedies, or deprive either such party of its right to institute and maintain any actions or proceedings which it may deem necessary to protect, assert or enforce any such rights or remedies. 8.6 Attorney's Fees. City and Subrecipient agree that in the event of litigation to enforce this Agreement or terms, provisions and conditions contained herein, to terminate this Agreement, or to collect damages for a Default hereunder, the prevailing party shall not be entitled to costs and expenses, including reasonable attorney's fees, incurred in connection with such litigation, such that each party shall be responsible for their costs and attorneys' fees. 8.7 Termination. (a) Termination for Cause. In accordance with 24 CFR 85.43, the City may suspend or terminate this Agreement in the event of a Default by the Subrecipient under this Agreement. Subrecipient may suspend or terminate this Agreement if City fails to make payments to Subrecipient as required herein. (b) Termination for Convenience. In accordance with 24 CFR 85.44, this Agreement may also be terminated for convenience by either the City or the 17-5919/162143/RLS 7/14/17/DO 25 Subrecipient, in whole or in part, by setting forth the reasons for such termination, the date the termination will be effective, and, in the case of partial termination, the portion to be terminated. However, if in the case of a partial termination, the City determines that the remaining portion of the award will not accomplish the purpose for which the award was made, the City may terminate the award in its entirety. IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: INTERVAL HOUSE, a California nonprofit corporation By: Print narn�. � ITS: (circle one) Chairman6President/VicePr ident CITY: AND �o J By: printmame ITS: (circle one) Secretary/Chief Financial Officer/A"sst: Secretary—Treasurer`'tiao4 T-i✓F- ��i�EC� CO 4 CITY OF HUNTINGTON BEACH, a municipal corporation and charter city Mayor ATTEST: City Clerk APPROVED AS TO FORM: n By: City Attorney p l INITIATED AND APPROVED: By: Deputy Director of Business Development REVIEWED AND APPROVED: City Manager 17-5919/162143/RLS 7/14/17/DO 26 Subrecipient, in whole or in part, by setting forth the reasons for such termination, the date the termination will be effective, and, in the case of partial termination, the portion to be terminated. However, if in the case of a partial termination, the City determines that the remaining portion of the award will not accomplish the purpose for which the award was made, the City may terminate the award in its entirety. IN WITNESS WHEREOF, the parties have executed this HOME Recipient Agreement (Tenant Based Rental Assistance) as of the Effective Date, which is the date of the City Council approving this Agreement. SUBRECIPIENT: CITY: INTERVAL HOUSE, a California nonprofit corporation Print name ITS: (circle one) Chairman/President/Vice President CITY OF HUNTINGTON BEACH, a municipal corporation and charter city 60 0 Mayor AND ATTEST: City Clerk print name ITS: (circle one) Secretary/Chief Financial Officer/Asst. Secretary — Treasurer APPROVED AS TO FORM: k�'L ), E-' �' By: City Attorney ON -R-Wkn INITIATED AND APPROVED: By: Deputy Dir6efor of Business Development REVIEWELY,NND APPROVED: er 17-5919/162143/RLS 7/14/17/130 26 Exhibit A TBRA Program Operating Guidelines City of Huntington Beach Tenant -Based Rental Assistance Program Operating Guidelines I. Program Overview The City of Huntington Beach (City) has established a Tenant -Based Rental Assistance (TBRA) program (Program) that follows all the requirements of the HOME Program, as set forth in the HOME Program under Section 24, Part 92, of the code of Federal Regulations (24 CFR 92). In 2015, the City published a Request for Proposals (RFP) and selected Interval House to administer the Program through 2017. The City will evaluate the impact of the Program on homeless individuals and families at the end of the term to determine the merits of extending the program and the effectiveness of the services provided by Interval House. Key indicators of success will include the ability to transition off the Program and remain housed without assistance for at least six months, increases in earned income, and sustainable rent burden (at or below 30% of family income). The Program will provide short and medium -term rental assistance was well as housing relocation and stabilization services for homeless and at -risk of homeless households from Huntington Beach, who have extremely -low income. The Program will meet the City's Investment Criteria by targeting program assistance up to 11 homeless households, all with incomes at or below 30%AMI and preference given to veterans, seniors and victims of domestic violence. Fifty percent (50%) of Client served will be referred from the Huntington Beach Homeless Task Force. The procedures set forth herein establish the tenant selection guidelines for the Program, provide the necessary operating structure for the Program and clarify the roles and responsibilities of Interval House and the City. II. Marketing, Outreach and Application Process A. Marketing and Outreach Interval House is responsible for marketing and outreach activities to find prospective Eligible Households interested in the Program. Interval House will conduct community presentations, outreach, training to community organizations, and participate in community events to educate on TBRA resources available. Additionally, Interval House will continue to partner with Huntington Beach Police Department, OC211, Huntington Beach Homeless Task Force, and other housing providers to refer eligible residents of Huntington Beach eligible for TBRA assistance. Interval House will provide quarterly reports to the City that shall describe the marketing and outreach efforts for the quarter. All marketing need to be done to meet all affirmative marketing requirements. B. Waiting List Once the Program has reached maximum enrollment, estimated at 11 households over the one-year contract period, Interval House shall maintain a waiting list of prospective Eligible Households. This list will be prioritized as follows: ■ Clients who have been assessed for TBRA eligibility, completed intake process, and ready for housing placement. ■ Clients who have been assessed for TBRA eligibility, completed intake process, and searching for housing. ■ Clients who have been assessed for TBRA eligibility and pending intake. ■ Ready for housing placement means that the household has found a housing unit that meets TBRA requirements (many landlords won't accept third party payments, rent requested by landlord is too high, won't allow unit inspection, etc.) ■ Priority ranking will be given for Homeless Category 1 (24 CRF 91, 582 and 583) - literally homeless participants will come from the streets or other locations not meant for human habitation, emergency shelters, or safe havens. Targeted preference will be given to veterans, seniors, and victims of domestic violence (Homeless Category 4) to support the City's investment priorities. Within these categories, households will be helped on a first come — first served basis, based on the date and time of application completed. C. Intake Process As part of the intake process, Interval House will meet with the prospective Eligible Household to conduct a needs assessment and complete an Initial Qualifications Form (Appendix A). If the Program has reached maximum capacity, Interval House shall review the applicant to assess if other services may be offered while the applicant is waiting for a slot to open in the Program. As part of the intake process, Interval House shall also request and/or assist the prospective Eligible Household with the completion of the following documents: ■ TBRA Application (Appendix B) ■ Declaration of Homeless Status or Declaration of At -Risk of Homelessness Status (Appendix C) D. Guidance for Eligible Households Interval House will meet with the prospective Eligible Households throughout the application process and will continue to meet with and counsel each Eligible Household regarding the Program, the Eligible Household's responsibilities as participants of the Program, and the goals and objectives of the Program. III. Determination of Eligibility The Program will utilize HOME Program funds for supportive services and rental assistance. As such, the applicants must meet the eligibility qualifications of the HOME Program. Eligibility for services offered by the Program shall adhere to the following selection criteria: A. Income Eligible Households ■ To receive supportive services as well as rental assistance under the HOME Program, the Applicant's total household income must be at or below 30% of the Orange County area median income (AMI). However, once the Applicant is part of the Program, the household income can increase up to 80% of the AMI before Interval House must give notice of termination from the Program. ■ Income limits for extremely -low income households are established annually for the HOME Program by HUD for the Orange County income limit area. ■ Gross Annual Income shall be determined in accordance with 24 CFR 5.609, with the allowable exclusions from income established at 24 CFR 5.611. ■ Gross Annual Income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12-month period following the date of application and before any deductions are taken. ■ Interval House will determine and verify eligibility for assistance under the Program through the review of income source documents. As outlined in the revised HOME rules published in July 2013, applicants must provide evidence of income for the two (2) most recent months. Acceptable source documents include wage statements, check stubs, entitlement verification from another government agency and bank statements. The definition of income for the purposes of the Program is located at 24 CFR Part 5 (often referred to as the Section 8 definition). In cases where no evidence of income (third -party verification) is available, Interval House may allow clients to self -report their income. In such cases, Interval House staff will provide a written explanation for why they were unable to obtain third -party verification or documentation. ■ Interval House may also consider any likely changes in income when collecting income verification documentation. ■ Initial income verifications are valid for six months. If admission to the Program takes longer than 6 months, income verifications must be updated and reevaluated. After initial verification, income recertification shall be conducted annually. ■ Income verifications will be used for two purposes: To determine eligibility for services. A determination of eligibility will be completed as part of the admissions process and thereafter annually. Income information will be used to establish the household's initial contribution toward rent, which shall be set at 30% of the household income. The household's initial contribution will remain unchanged for at least six months. B. Current Residents of the City of Huntington Beach Due to the nature of the population served by the Program, it may not be possible to obtain traditional proof of residency documentation such as utility bills. The following documentation can be accepted to establish that an applicant household qualifies for the Huntington Beach live/work preference: ■ Documentation from a Huntington Beach school that the children in the household have been enrolled in and attending the school for at least the last 90 days from the time of admission into the Program. ■ Documentation from a partner agency, such as the Huntington Beach Police Department, evidencing that the family is known to be homeless in Huntington Beach. ■ Proof that the applicant's last place of stable residency was in the City of Huntington Beach. Verification from a landlord is acceptable. ■ Proof that an adult member of the household is working or has been recently hired to work in Huntington Beach. C. Currently Homeless or At -Risk of Homelessness ■ At -Risk of Homelessness refers to a household that is at imminent risk of being evicted due to an economic hardship in paying rent or staying current with rent. (Category 2 of HUD Homeless Definition) ■ Homelessness refers to a household who meets the HUD Homeless Definition at 24 CRF 91, 582 and 583: Category 1 (literally homeless) and Category 4 (fleeing/attempting to flee violence and living in a place described in Category 1). D. Preferences The following summarizes the populations that Interval House will target (note that the total percentages do not total to 100%): E. Annual Eligibility Verification ■ Interval House will requalify each Eligible Household, including examination of source documentation, on an annual basis. ■ Interval House may request that a participating Eligible Household provide verification(s) more often than annually, as reasonably necessary to confirm continued qualification and eligibility for the Program. ■ Interval House will provide written notice to each applicant stating whether the Eligible Household was determined to be eligible for continued assistance under the Program. IV. Selection of Housing A. Housing Unit Selection Eligible Households must be residents of Huntington Beach and may elect to rent any Housing Unit in the City so long as the unit meets federal housing quality standards (HQS) or such other standards as may be made applicable to the Program by HOME Program statues and/or regulations, specifically including Uniform Physical Condition Standards (UPCS) and passes a rent reasonableness test. Due to the nature of the population served by the Program, it is expected that Interval House will assist Eligible Households with finding and selecting an appropriate Housing Unit that meets all program requirements. If an appropriate Housing Unit cannot be located within the City boundaries, a Housing Unit can be located outside of the City boundaries when housing is not suitable within City boundaries. While Interval House can refer Eligible Households to appropriate Housing Units, households may not be required to select a particular Housing Unit. Rental assistance under the Program is only provided for Housing Units that meet the criteria established by the City of Huntington Beach HOME/TBRA Program. B. Occupancy Standards The number of persons in each Eligible Household will determine the required unit type. Each household must comply with the two per bedroom plus one occupancy standard. The following table provides the occupancy standards by unit type: C. Property Inspections Prior to occupancy of any Housing Unit by an Eligible Household, and again during the annual verification process, Interval House will have a certified HQS inspector, inspect each Housing Unit to ensure the unit complies with HQS as set forth in the HOME Program (24 CFR 92.251), as well as all applicable state and local codes and ordinances, including zoning ordinances. Each HQS inspection will include the following: ■ Verification of the age of the Housing Unit (on Rent Reasonableness Form); ■ Completed HQS Inspection Form (HUD-52580); ■ Lead -based paint hazard assessment, dissemination of lead -based paint information pamphlet and disclosure form and lead -based paint reduction activities, if required; ■ Adequate opportunity for landlord to correct any deficiencies indicated in the HQS Inspection form to bring the Housing Unit into compliance; and ■ Verification that occupancy by the Eligible Household will comply with occupancy standards. The HQS Inspection Form is located in Appendix D. D. Rent Reasonableness Rental assistance paid on behalf of the Eligible Household must be in compliance with federal Rent Reasonableness requirements which require that rents paid by or on behalf of assisted households be similar to rents paid by non -assisted households. Rent Reasonableness reviews will be performed by Interval House. The factors listed below shall be considered when determining rent comparability: ■ Location and age; ■ Unit size including the number of rooms and square footage or rooms; ■ The type of unit including construction type (e.g., single family, duplexes, garden, low-rise, high- rise); ■ The quality of the unit, which includes the building construction, maintenance and improvements; and ■ Amenities, services and utilities included in the rent. Interval House will follow both the rent reasonableness regulations established for the Housing Choice Voucher (HCV) program at 24 CFR 982.507 to evaluate rents. In the event that a rent request does not meet rent reasonableness requirements, Interval House shall attempt to negotiate a lower rent with the property owner. If the owner is not willing to accept a lower rent, the household must be instructed to search for another unit. Under no circumstances shall Interval House or the assisted household agree to pay more than approved through the rent reasonableness review. Additionally, the assisted household is not allowed to make up any difference in the rent offer. E. Coordination with Landlords Interval House will meet with and provide guidance to landlords participating in the Program regarding the requirements and procedures that impact landlords. L Landlord Agreement (Appendix E) ■ Interval House will enter into a Landlord Agreement with each participating landlord or property owner. The Landlord Agreement will establish the security deposit assistance payment and the initial rental assistance payments to be paid on behalf of the household. The Agreement will also establish the participating household's initial share of the contract rent. The Agreement will also require the landlord to provide Interval House with notice of a lease termination, and reaffirm the tenant protections included in the Tenant Protection Agreement. ■ The Eligible Household's share of rent will be re-evaluated every 6 months. ■ This contract will have an initial term of 12 months. ii. Tenant Protection Agreement (Appendix F) ■ The landlord will be required to enter into a lease agreement with a term of 12 months with any Eligible Household occupying a Housing Unit. ■ The lease agreement will include a Tenant Protection Agreement that will be executed in connection with the lease between the landlord and the Eligible Household. ■ The Tenant Protection Agreement will include the following elements: ■ Prohibit the inclusion of the following provisions in the lease, as required by 24 CFR 92.253: ■ (1) Agreement to be sued; ■ (2) Treatment of property; ■ (3) Excusing owner from responsibility; ■ (4) Waiver of notice; ■ (5) Waiver of legal proceedings; ■ (6) Waiver of a jury trial; ■ (7) Waiver of right to appeal court decision; ■ (8) Tenant chargeable with cost of legal actions regardless of outcome; and 0 (9) Mandatory supportive services. ■ Confirm the landlord's obligation to maintain the Housing Unit in accordance with HQS, as established at 24 CFR 982.401. ■ Prohibit discrimination by the landlord against the Eligible Household. ■ Interval House will review the lease agreement to confirm its compliance with state law and all HOME Program requirements. V. Payment Standards, Rent Calculation, Term and Subsidy Reductions As authorized by HOME TBRA regulations, the Program will rely on a traditional rental assistance calculation. The model allows for the rent subsidy determination based on 30% of household income. A. Rent Assistance Calculation Interval House will complete a rental assistance calculation for each Eligible Household. The calculation will determine each household's Program subsidy and share of the rent. The maximum amount of monthly assistance that Interval House may pay on behalf of a family is the difference between the rent standard for the unit size and 30% of the household's monthly adjusted income. Each household's maximum rent subsidy will vary since the calculation involves the use of individualized factors such as the household's actual income and family size. The initial household contribution to rent will remain unchanged for at least six months. Minimum tenant contribution to rent under the Program is set at $50.00. This minimum is used if the maximum subsidy calculation would result in the household paying less than $50.00 towards the monthly rent (e.g. if 30% of the household's monthly adjusted income is less than $50.00). This minimum contribution may be waived in exceptional circumstances. B. Rent Reasonableness Standards The Program must use the Rent Reasonableness Standard (Appendix G) to calculate monthly rental assistance. The payment standards represent the cost of rent and utilities for moderately priced units in Huntington Beach. Payment standards are established by bedroom size. When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the household's entire share of the housing costs will go directly to the owner. When the cost of utilities is not part of the rent, that is, the household is directly responsible for payment of utility services, the household's initial share will be determined by subtracting a utility allowance from 30% of the household's income. Interval House must use the Orange County Housing Authority utility allowance schedule (Appendix H) to determine the household's utility allowance. In these cases, the household's share of the rent is equal to 30% of the household's monthly adjusted income minus the applicable monthly utility allowance. Each household is responsible for paying their rent share directly to the landlord each month. If a selected Housing Unit is subject to contractual, statutory and/or regulatory affordability restriction, the monthly rental assistance payments will not exceed the difference between the required affordable rent amount for the Housing Unit and 30% of the Eligible Household's monthly adjusted income. i. Participant Agreement (Appendix I) Interval House will enter into a Participant Agreement with each participating client household. The Participant Agreement will establish the Eligible Household's responsibilities towards rent payments. The Agreement will establish the participating household's initial share of the contract rent, which will be adjusted every 6 months. ii. Term Interval House will provide rental assistance for an initial term of 6 months, which can be extended every 6-12 months, for a cumulative term of up to 24 months. Extensions will be granted at the discretion of Interval House and shall be based on continued Program compliance and ongoing need. Interval House will utilize the Gap Analysis and Income Re -Evaluation to assess ongoing need and adjust household's share of rent as appropriate. Households with income above 60% AMI will be notified about income eligibility limits. iii. Subsidy Reductions The participant's household income will be reevaluated every six months. If the household income has increased since the previous evaluation, the participant's monthly rent responsibility will be adjusted accordingly per Rent Assistance Calculation as stated in above section V. A. VI. Security Deposits As needed, Interval House will provide security deposit assistance to Eligible Households. Such assistance shall be the lesser of: ■ Two months approved rent for the Housing Unit; or ■ The standard security deposit required by the landlord for non -subsidized tenants. Security deposit assistance provided to participating households will be in the form of a grant. As such, the landlord can provide a security deposit refund directly to the household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by the tenant and landlord, as provided for in the lease. VII. Annual Recertification, Termination of Assistance and Returning Households A. Annual Recertification Recertification of income and Program eligibility will occur annually. Interval House will gather source documentation for participating households to determine annual income. Annual income must be calculated in accordance with 24 CFR Part 5. If the total household income is above 80% AMI, rental assistance must be terminated following a 30 day notification period. B. Termination of Rental Assistance Assistance can be terminated for the following reasons: ■ Eviction from the assisted rental unit based on behavioral issues and/or unlawful activity. ■ The family will be assisted by another rental assistance program such as the Section 8 Tenant -Based or Project -Based program. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must terminate. C. Returning Participant Households As needed, participants may be allowed to return to the Program for either support services, rental assistance or both. A determination to allow re-entry shall be based on the following criteria: ■ Participants must have left the Program in good standing. To be in good standing, participants must have been engaged in their case management plan, voluntarily left the program (not in -lieu of termination) or have been released because their household income exceeded eligible limits. In general, participants will not be allowed to re-enter the Program if they were terminated for non- compliance. ■ At the discretion of Interval House, a request for readmission from a non -compliant household may be considered when compelling reasons exist. In such cases, re -admission will require concurrence from the City. ■ The Participant's previous rental assistance did not exceed 24 months. Cumulatively, participants will only be allowed to receive rental assistance for a maximum of 24 months. VIII. Self Sufficiency Program Interval House will request each Eligible Household receiving rental assistance payments to participate in a Self -Sufficiency Program administered by Interval House. The Case Management and Self - Sufficiency Program Policies and Procedures are outlined in Appendix J. The Self -Sufficiency Program provides participating households with intense case management, which is designed to assist participants move to self-sufficiency within a 12 to 24 month period. Income recertifications will be completed annually for participating households. If the participating household's income exceeds the low (80% AMI) income limits, Interval House must terminate the rental assistance. Listed below are some of the Self -Sufficiency Case Management Services offered by Interval House: A. Case Management The Interval House Case Management model maximizes client success by developing individualized service plans and addressing clients' specific needs in securing permanent housing and self-sufficiency. Clients will meet with their Case Manger on a minimum of a monthly basis to update goals, monitor progress, and ensure long-term housing stability. Self-sufficiency groups are also held weekly to assist with financial management, job development, life skills, personal empowerment, and accessing other resources needed to gain housing stability. B. Individualized Housing and Service Plan Participants meet with their Case Manager at intake and monthly to review their Goal Worksheet and Individualized Service Plan to help establish and identify participant goals and plans for housing, education, employment, financial (including budgeting and credit repair), legal, and other housing stabilization and relocation resources needed. C. Housing Search and Placement Interval House advocates assists clients with comprehensive housing search and placement into affordable permanent housing. Interval House has established close partnerships with permanent housing agencies, including affordable housing providers, apartment associations, and private landlords/owners. D. Legal Services Staff attorneys, legal advocates and volunteer attorneys provide comprehensive legal services and representation in multiple languages. Legal assistance includes lease agreements, legal advocacy, court accompaniment, and other legal issues affecting homeless and at -risk homeless persons and their children. E. Financial Management / Credit Repair Interval House has designed an 8-week comprehensive financial empowerment curriculum with weekly workshops conducted to assist program participants with credit repair, financial literacy, and job placement and retention. Assistance will also be provided to access mainstream financial benefits including social security, veteran's benefits, CalWORKs, disability, unemployment, and other public assistance. F. Employment Assistance Obtaining self-sufficiency is a critical goal for families served by Interval House. Interval House Case Managers work with clients to identify interests, life experiences and talents that lend themselves to employment. Housing Advocates also: ■ Help clients develop resumes, complete job application and prepare for interviews; ■ Obtain educational scholarships through AmeriCorps and other sources to increase leadership skills and/or further their education; ■ Provide transportation solutions to job interviews and job -related activities; and ■ Provide job placement in career -level jobs and job retention assistance. G. Transportation Interval House provides support services at Community Service Center and Satellite sites in Huntington Beach conveniently accessible via public transportation routes or via home visits as needed. Interval House provides assistance with transportation via bus passes and accessing mainstream resources available for transportation through CalWORKs and disability access. Interval House also maintains agreements with local taxi companies to provide emergency transportation assistance and works closely with the Huntington Beach Police Department to assist transport participants in crisis situations. H. Behavioral Health Interval House provides an array of individual and group counseling programs on -site and works closely with other mental health providers to address behavioral health needs of participants. Appendix A Initial Qualification Form INTERVAL HOUSE w 9Ana fr.s a11� � o.r fYe Client Name: Last Known Address: Home Phone: Email: Names and ages of other Adults in Household: Names and ages of all Children in the home: Is client currently pregnant? Household size: Cell: Emergency Contact: Yes No (Example: Client and 2 children = 3 in household) The annual income for household is: $ See examples of documentation of income on page 3 Is client currently residing within a shelter program? If yes, what type of program? ❑ Emergency Shelter ❑ Transitional Shelter ❑ Domestic Violence Shelter ❑ Substance Abuse Treatment Program ❑ Hotel/Motel Voucher from Name of Program: Source: ❑ Yes ❑ No Location: Case manager: Contact number: Page 1 of 3 INTERVAL HOUSE G6t 9eln L Gm la Fame d � Na W � Page 2 of 3 HAS CLIENT RECEIVED ANY RENTAL ASSISTANCE IN THE PAST 3 YEARS? ❑ Yes ❑ No (Includes rent, utility and move -in costs) If "Yes", please indicate what agency provided assistance: Name of Agency How long did they receive assistance? Type of assistance provided (please check all that apply): ❑ Rental assistance ❑ Security deposit ❑ Rapid Re -housing ❑ Utility assistance ❑ Moving cost assistance ❑ Other TENANT SECREENING BARRIERS (mark all that apply) ❑ Evictions: how many? ❑ Poor reference from prior landlords ❑ Lack of rental history ❑ Unpaid rent or utility bills ❑ Lack of or poor credit history ❑ One or more misdemeanors ❑ Critical felony (sex crime, arson, drugs) ❑ Other felony CLIENT'S POTENTIAL TO SUSTAIN HOUSING AFTER SUBSIDY Contact Number ❑ Eviction prevention ❑ Motel voucher ❑ Employment ❑ Employability/Strong Work History ❑ Dual parent household ❑ Evidence of increased income ❑ Evidence of approval for housing subsidy (Section 8, HUD VASH) ❑ Other: INTERVAL HOUSE GM M.,. Gars I.M. d D a YA- Page 3 of 3 Scan and attach the following documents. Without the following documentation, we cannot provide rental assistance. ❑ CLIENT NEEDS ASSESSMENT ❑ IDENTIFICATION FOR ADULTS: ❑ Driver's License ❑ Passport ❑ California ID ❑Green Card ❑ Other ID ❑ SOCIAL SECURITY CARDS for everyone that will be living in the apartment or home. *Not required, bring only if you have it. ❑ BIRTH CERTIFICATES for all children that will be living in the apartment or home *Required for First 5 rental assistance ONLY. Not required for other kinds of rental assistance. ❑ BANK STATEMENT for all adults (Most Recent) ❑ DOCUMENTATION OF INCOME FOR ALL ADULTS Check below if you have any of the following income documentation (i.e. two check stubs, verification of benefits within 30 days, or deposit statements): ❑ Employment ❑ Public Benefits (Calworks) ❑ Social Security (SSI) ❑ Disability (SSDI) ❑ Unemployment ❑ Alimony ❑ Child Support ❑ Veteran Benefits ❑ Retirement ❑ Other (please specify): NO INCOME VERIFICATION? If you don't have any of the income verifications listed above, is there any other kind of income verification you have? Yes No IF YES, Attach information about it and how much the income adds up to. ❑ HOMELESS STATUS FORMS and all documentation requested on these forms. ❑ Household falls under Category 1 (homeless) AND ❑ No appropriate subsequent housing options have been identified; AND ❑ Household lacks the financial resources and support networks needed to obtain immediate housing ❑ If you were unable to collect any of the requested documentation, please explain why: Appendix B TBRA Application INTERVAL. HOUSE Client Intake Part 1 ❑ Full Name reported ❑ Partial Name reported ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Referred By: Agency: ❑Court ❑Law Enforcement ❑Health ❑Social Services ❑FRC: Other: Contact Tel.# ❑ Male ❑ Transgender _Male to Female _Female to Male ❑ Other ❑ Don't know ❑ Refused to answer Household ID # Client Personal ID # Entry Date Type: ❑Outreach ❑Emergency ❑Trans. ❑Hotel ❑Rental Assistance Residential Move -In Date: In Permanent Housing? ❑ Y ❑ N If yes, Date of Move -In: Client Location: ❑Orange County (CoC CA-602) ❑Long Beach (CoC CA- 606) ❑LA County (CoC CA- 600) Staff Name Grant ID: Grant Start Date: Grant End Date: Approval Status: ❑Shelter/Hotel ❑LA CalWORKS ❑OC CalWORKS ❑Approved Special Referral ❑Needs Approval ❑ Full SSN reported ❑ Partial SSN reported ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected ❑ DL/ID: # ❑ None ❑ Other: ❑ ID Copied & filed in chart ❑ Hispanic/Latino ❑ Asian ❑ Non-Hispanic/Non- ❑ Native Hawaiian or Other Pacific Islander Latino ❑ Black or African -American ❑ Client Does Not Know ❑ White (includes Hispanic/Latino) ❑ Full DOB reported ❑ Client Refused ❑ American Indian or Alaskan Native ❑ Approximate or Partial ❑ Data Not Collected ❑ Client Does Not Know DOB reported ❑ Client Refused ❑ Client Does Not Know ❑ Data Not Collected ❑ Client Refused ❑ Data Not Collected fital.t Lxforttiattt►rt xN '� , . -. :a F Y� / �/� Y;4 1 . Address City Zip Code: Home Phone# Work Phone# ❑ Full or partial Zip Code Reported ❑ Client Does Not Know ❑ Client Refused ❑ Emergency shelter, including hotel or motel paid for with emergency shelter voucher ❑ Transitional housing for homeless persons (including homeless youth) ❑ Rental by client, no ongoing housing subsidy ❑ Owned by client, no ongoing housing subsidy ❑ Staying or living in a family member's room, apartment, or house ❑ Staying or living in a friend's room, apartment, or house ❑ Foster care home or foster care group home ❑ Hospital or other non -psychiatric medical facility ❑ Hotel or motel paid for without emergency shelter voucher ❑ Jail, prison or juvenile detention facility ❑ Long-term care facility or nursing home ❑ Owned by client, with ongoing housing subsidy ❑ Permanent housing for formerly homeless persons (such as a CoC project; HUD legacy programs; or HOWPA PH) ❑ Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere ❑ One day or less ❑Two days to one week ❑ More than one week, but less than one month ❑ One to three months ❑ More than 3 months, but less than 1 yr. ❑ One year or longer ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected outside) ❑ Psychiatric hospital or other psychiatric facility ❑ Rental by client, Veterans Assistance Supportive Housing Subsidy ❑ Rental by client, other (non--VASH) ongoing housing subsidy ❑ Rental by client, with GPD TIP subsidy ❑ Residential project or halfway house with ho homeless criteria ❑ Safe Haven ❑ Substance abuse treatment facility or detox center ❑ Other ❑ Client doesn't know ❑ Client refused ❑ Data Not collected ❑ Yes ❑ No If yes, where? when? ❑ Entering from the streets, shelter or Safe Haven? ❑ Y ❑ N ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected If yes, approximate Date Started Regardless of where they stayed last night —Number of times the client has been homeless on the streets, in Emergency Shelter, or Safe Haven in the past three years including today? ❑ Never in the 3 years ❑ One time ❑ Two times ❑ Three times ❑ Four or more times: Total number of months homeless on the street, in Emergency Shelter, or Safe Haven in the past 3 years: ❑ One month (this is the first month months (2-12) ❑ more than 12 months 0 Client doesn't know ❑ Client refused Proof of homeless status collected and filed in chart: ❑ Y ❑ N Income received for any source ❑ Y 0 N ❑ Client doesn't know ❑ Client Refused ❑ Data Not Collected If yes, indicate all sources and dollar amounts for the sources that apply: Source of Monthly Cash Income: Check as many as needed Employed (earned income) ❑ Y O N (if yes) Monthly amount $ Unemployment (Desempleo) ❑ Y ❑ N (if yes) Monthly amount $ SSI ❑ Y ❑ N (if yes) Monthly amount $ SSDI ❑ Y ❑ N (if yes) Monthly amount $ VA Service -Connected Disability Compensation ❑ Y ❑ N (if yes) Monthly amount $ VA Non -Service -Connected Disability Compensation ❑ Y ❑ N (if yes) Monthly amount $ Private Disability Insurance ❑ Y ❑ N (if yes) Monthly amount $ Workers Compensation ❑ Y ❑ N (if yes) Monthly amount $ GR (General Relief) ❑ Y ❑ N (if yes) Monthly amount $ Retirement Income from Social Security (Seguro Social) ❑ Y 0 N (if yes) Monthly amount $ Pension or retirement income from a former job ❑ Y ❑ N (if yes) Monthly amount $ Child Support (Mantenimiento de hijos) ❑ Y ❑ N (if yes) Monthly amount $ Alimony or other spousal support ❑ Y ❑ N (if yes) Monthly amount $ Other (Otro) ❑ Y ❑ N (if yes) Monthly amount $ Ca1WORKs Cash Aid (Ayuda monetaria) ❑ Y ❑ N (if yes) Monthly amount ❑ Mother & Children (Madre a hijos) monthly amount $ ❑ Children only(Hijos solamente) monthly amount $ ❑ Proof of income: ❑ Collected and filed in chart ❑ None - explain: Case # Name and Phone # Non -Cash Benefits received from any source ❑ Y ❑ N ❑ Client doesn't know ❑ Client Refused ❑ Data Not Collected Source of Monthly Non -Cash Benefits: Check as many as needed ❑ Food Stamps/SNAPS (Estampillas) $ ❑ Medi-CAL ❑ Medi-CARE ❑ State Children's Health Insurance ❑ WIC ❑ Veteran's (VA) Medical Services ❑ Ca1WORKs Childcare Services ❑ Ca1WORKs Transportation Services ❑ Other CalWORKs Services ❑ Section 8, public housing, or other ongoing rental assistance ❑ Other source: ❑ Temporary Rental Assistance Covered by health insurance? ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused ❑ Data Not Collected (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults Total Monthly Income Occupation Client Education from all sources ❑ High School Graduate ❑ _th Grade ❑ No School ❑ Some CollegeNocational ❑ College Graduate ❑ Other month ❑ Single ❑ Married ❑ Divorced ❑ Other: Ll Yes ❑ No Does Client Have ll Condition? "t ❑ Yes ❑ No ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected ❑ Self (Head of Household) ❑ Head of Household's Child ❑ Head of Household's Spouse or Partner ❑ Head of Household's Other Relation Member (other relation to head of household) ❑ Other: Non -relation Member ❑ Boyfriend ❑ Husband ❑ Girlfriend ❑ Wife ❑ Other: ❑ Heterosexual ❑ Lesbian ❑ Gay ❑ Bisexual ❑ Other ❑ Declined to answer ❑ Yes, for physical needs ❑ Yes, for emotional needs ❑ No Is medication life - sustaining? ❑ Yes ❑ No Chronic Health Condition? (Examples of Chronic Health conditions include, but are not limited to: heart disease; severe asthma; diabetes; arthritis -related conditions; traumatic brain injury; PTSD, dementia, severe headache/migraine; cancer; chronic bronchitis; liver condition; stroke; or emphysema) ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected IF YES: Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected HIV/AIDS ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused IF YES : Expected to substantially impair ability to live independently? ❑ No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently Receiving Services/treatment for this condition? 0 No ❑ Yes ❑ Client doesn't know ❑ Client refused ❑ Data Not Collected Does client have a primary physician or health Physical Disability? ❑ No ❑ Yes ❑ Client Does Not Know clinic for medical care? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Y (Si)❑ N (No) ❑ Client Refused ❑ Data Not Collected ❑ Data Not Collected Name of doctor: Phone #: Name of pediatrician: Phone #: Is Client Pregnant?❑ Y (Si) ❑ N (No) IF YES Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Developmental Disability? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected IF YES Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected ❑ Yes ❑ No ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected IF YES Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected Do you exercise? ❑ Yes ❑No If so, how many times per week? Family Composition ❑ Single Parent ❑Foster Parent(s) ❑Unaccompanied (single person) ❑Two Parents ❑Adults No Children (couple w/no kids) 1. ❑Y ❑Y ❑Y ❑M El ❑N ❑N El Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults 2. El ❑Y ❑Y ❑M ❑F ❑N ❑N ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults 3. ❑Y ❑Y ❑Y ❑M ❑F ❑N ❑N ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults Have any of the children ever been removed from the home by court or social services? ❑ No ❑ Yes If yes, When? Notes: 4. ❑Y ❑Y El ❑M ❑F ❑N ❑N ❑N Covered by Health ❑ Y ❑ N ❑ Client Does Not Know ❑Client Refused Insurance? (If yes, indicate all sources that apply) ❑ Medi-CAL ❑ State Children's Health Insurance ❑ Veterans (VA) Medical Services ❑ Employer provided Health Insurance ❑ Health Insurance obtained through COBRA ❑ Private Pay Health Insurance ❑ State Health Insurance for Adults Have any of the children ever been removed from the home by court or social services? ❑ No ❑ Yes If yes, When? Notes: jO Abuse Type (ALL Applicable) Mle Weapons Used (All Applicable) Victim of DV? ❑ Yes ❑ No ❑ Physical ❑ Gun ❑ Client Does Not Know ❑ Emotional/Mental ❑ Cut. Instrument ❑ Client Refused ❑ Sexual ❑ Blunt Obj. ❑ Data Not Collected ❑ Stalking ❑ Bodily Force ❑ Financial ❑ Other If yes, last time abused? ❑ Within the past 3 months ❑ 3 months— 6 months ago (excluding 6 months exactly) ❑ 6 months- 1 yr. ago (excluding 1 yr. exactly) ❑ One year ago or more ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected If yes, currently fleeing ❑ Yes ❑ No ❑ Client Refused ❑ Data Not Collected Substance Abuse Problem? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected If Yes: ❑ Client ❑ Barterer ❑ Both If Client: ❑ Alcohol ❑ Drugs ❑ Both Previous drug or alcohol treatment services? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected If yes: ❑ Residential ❑ Outpatient When? ❑ Currently ❑ Previously ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected Expected to be of long -continued and indefinite duration and substantially impairs ability to live independently? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client refused ❑ Data Not Collected Documentation of disability and severity on file? ❑ No ❑ Yes Currently receiving services/treatment for this condition? ❑ No ❑ Yes ❑ Client Does Not Know ❑ Client Refused ❑ Data Not Collected STATEMENT OF CONSENT I am informed and consent to receive domestic violence support services (including advocacy/ case management) through Interval House. I certify that all information provided (including income) is true and correct. Client signature: Date: Staff signature: Date: Client Intake Part 2 Do you have a safety plan? ❑ Y ❑ N I Left your partner before? ❑ Y ❑ N Reason for returning? Where did you go? Previous assistance through DV programs? Y (Si) 0 N (No) I When? I Where? Contact person at DV program/shelter Phone #: Have you ever been arrested? ❑ Y ❑ N Offense: When: Where Legal Status (optional): ❑ US Citizen ❑ Green Card ❑Other Religious Preference (optional): Transportation P ��, �E What form of transportation do you use? If you have a car: Make: Model: Year: License plate#: Do you have insurance? 0 Y 0 N Ever had therapy? Currently? ❑Y❑N ❑Y❑N When? Where? Therapist: Hospitalized? ❑ Y ❑ N When? Where? Therapist: Doctor: Ever Suicidal? ❑Y0N Wed[ aMyAad. z Ever seen doctor due to abuse? ❑ Y ❑ N If yes, how many times? What type of injuries? With whom? I Hospitalized? ❑ Y ❑ N When? I Where? Name: Gender Date of Birth / / Legal Status ❑ M ❑ F ❑ US Citizen ❑ Green Card ❑Other Ethnicity: Height: Weight: Hair Color: Eyes: Age: Describe your abuser's physical appearance including any identifying marks, scars, tattoos: Occupation: I Vehicle description: Uses alcohol? 0 Y 0 N What kind? How much? Uses drugs? ❑ Y ❑ N What kind? How much? How does it influence their behavior? Ever in a psychiatric hospital or treated for emotional problems? ❑ Y ❑ N Where? When? Why? Has he/she ever threatened to harm your friends, relatives, counselor, etc. for assisting you? ❑ Y ❑ N Has he/she ever acted on those threats? ❑ Y (Si) ❑ N (No) Describe: How would he/she feel if they knew you were seeking assistance from Interval House? Is he/she the father/mother of any of your children? ❑ Y ❑ N If yes, how will he/she respond that children are with you? Appendix C Declaration of Homelessness Rental Assistance Program DECLARATION OF HOMELESSNESS STATUS Applicant Name: ❑ I certify, under penalty of perjury, that following information is true and complete: Applicant Signature: Date: Verification types: *T=Third Party/ O=Observation / S=Self-certification Attach Third Party verification documentation and Intake Observation statements in back pocket of folder Req form — HB HOME Verification Type T/O/s* Situation 1 ❑ An individual or family who lacks a fixed, regular, and adequate nighttime residence AND Check one of the following: ❑ An individual or family with a primary nighttime residence that is a public or private place not designed for or T-not required for ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, emergency bus or train station, airport, or camping ground shelter or street outreach ❑ An individual or family living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals ❑ An individual who is exiting an institution where he or she resided for 90 days or less AND who resided in an 0-not allowed emergency shelter or place not meant for human habitation immediately before entering that institution Verification Type T/O/S* Situation 2 ❑ An individual or family who will imminently lose their primary nighttime residence, provided that: The primary nighttime residence will be lost within 14 days of the date of application for homeless assistance AND No subsequent residence has been identified AND The individual or family lacks the resources or support networks, e.g., family, friends, faith -based or other social networks, needed to obtain other permanent housing Verification Type T/o/s* Situation 3 ❑ Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless under this definition, but whoa, qualifies as "homeless" under another federal statute AND Only T is allowed have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time during the 60 O is not allowed days immediately preceding the date of application for homeless assistance AND have experienced persistent instability as measured by two moves or more during the 60-day period immediately O is not allowed preceding the date of applying for homeless assistance AND can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic S is not allowed physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse O is not allowed (including neglect), the presence of a child or youth with a disability, OR two or more barriers to employment, for barriers to which include the lack of a high school degree or General Education Development (GED), illiteracy, low English employment proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment; Safety should never be put at risk in order to obtain documentation under this situation. If the provider is a DV provider self- Verification Type certification sufficient. For non -DV providers, if there is no threat of safety supporting verification should be provided. T/o/S* Situation 4- ❑ Any individual or family who Is fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life -threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual's or family's primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence AND has no other residence AND lacks the resources or support networks, e.g., family, friends, faith -based or other social networks, to obtain other permanent housing Rental Assistance Program Req fo11 rm L: I : HOM E DECLARATION OF HOMELESSNESS STATUS (continued) Applicant Name: Staff Certification I understand that third -party verification is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for assistance. I understand self -declaration is only permitted when I have attempted to but cannot obtain third party verification. Describe in detail efforts made for Third Party verification and attach documentation behind this form (email, phone logs, etc.) For clients in Situation 4 (Domestic violence),,safety should never be`put at'risk in ©rder to obtain'. documentation. If the provider is a DV provider, self -certification is sufficient. You can state that you di obtain third -party documentation because it would have put client's safety at risk. (See instruction sheet for examples of what to write here if you are unable to obtain third -party documentation.) Staff Signature: Date: Appendix D HQS Inspection Form Inspection Checklist Housing Choice Voucher Program U.S. Department of Housing OMB Approval No. 2577-0169 and Urban Development (Exp. 04/30/2018) Office of Public and Indian Housing Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number Assurances of confidentiality are not provided under this collection. This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The information is used to determine if a unit meets the housing quality standards of the section 8 rental assistance program. Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of the name and address of both family and the owner is mandatory. The information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation. Name of Family Tenant ID Number Date of Request (mm/dd/yyyy) Inspector Neighborhood/Census Tract Date of Inspection (mmldd/yyyy) Type of Inspection Date of Last Inspection (mmlddlyyyy) PHA Initial ❑ Special ❑ Reinspection ❑ A. General Information Inspected Unit Year Constructed (yyyy) Q C3Usittg Type (check as appropriate; Single Family Detached Full Address (including Street, City, County, State, zip) Duplex or Two Family 0 Row House or Town House 0 Low Rise: 3, 4 Stories, Including Garden Apartment Number of Children in Family Under 6 0 High Rise; 5 or More Stories FJ Manufactured Home Congregate Cooperative Owner Name of Owner or Agent Authorized to Lease Unit Inspected Phone Number F1 Independent Group 0 Residence Single Room Occupancy Address of Owner or Agent Shared Housing 0 Other B. Summary Decision On Unit To be completed after form has been filled out Number of Bedrooms for Purposes Number of Sleeping Rooms T of the FMR or Payment Standard clusive Inspection Checklist l m No. 1. Living Room Yes Pass No Fail In- Conc. Comment Final Approval Date(mm/dd/yyyy) 1.1 Living Room Present 1.2 Electricity 1.3 Electrical Hazards 1.4 Security 1.5 Window Condition 1.6 Ceiling Condition 1.7 Wall Condition 1.8 Floor Condition Previous editions are obsolete Page 1 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room); 2 = Dining Room or Dining Area, 3 = Second Living Room, Familv Room, Den, Playroom, TV Room; 4 = Entrance Halls, Corridors, Halls, Staircases; 5 = Additional Bathroom; 6 = Other Rem 1. Living Room (Continued) No. Yes Pas No Fail In- Conc. Comment Final Approval Date mm/dd 1.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 2. Kitchen 2.1 Kitchen Area Present 2.2 Electricity 2.3 Electrical Hazards 2.4 Security 2.5 Window Condition 2.6 Ceiling Condition 2.7 Wall Condition 2.8 Floor Condition 2.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 2.10 Stove or Range with Oven 2.11 Refrigerator 2.12 Sink 2.13 Space for Storage, Preparation, and Serving of Food 3. Bathroom 3.1 Bathroom Present 3.2 Electricity 3.3 Electrical Hazards 3.4 Security 3.5 Window Condition 3.6 Ceiling Condition 3.7 Wall Condition 3.8 Floor Condition 3.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 3.10 Flush Toilet in Enclosed Room in Unit 3.11 Fixed Wash Basin or Lavatory in Unit 3.12 Tub or Shower in Unit 3.13 Ventilation Previous editions are obsolete Page 2 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 ftem M. 4. Other Rooms Used For Living and Halls 4.1 Room Code* and Room Location Yes No I In- Final Approval Pass Fail ;Concj Comment date(mm/dgftE (Circle One) (Circle One) i Riaht/Center/Left Front/Center/Rear Floor Level i 4.2 Electricit y/Illumination 4.3 Electrical Hazards t 4.4 Security I 4.5 Window Condition E 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint ❑ Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors g.I Moom ",oae ana tc+rcieune/ tuircieunel Room Location M Right/Center/Left Front/Center/Rear _Floor Level 1( 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Not applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors 4.1 Room Code* and Room Location (Circle One) ((;irlie one) Right/Center/Left Front/Center/Rear _Floor Level Electricity/Illumination _4.2 4.3 Electrical Hazards E 4.4 Security 4.5 Window Condition I 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition ...... .Am......-..r.-� -. 4.9 Lead -Based Paint ❑ Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Previous editions are obsolete Page 3 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Item 4. Other Rooms Used For Living and Halls No. Yes Pass No Fall In. Conc. Comment Final Approval Date (mm/dd/yyyy) 4.1 Room Code* and Room Location (Circle One) (Circle One) Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 4.1 Room Code` and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricity/illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 5. All Secondary Rooms (Rooms not used for living) 5.1 None Go to Part 6 5.2 Security 5.3 Electrical Hazards 5.4 Other Potentially Hazardous Features in these Rooms Previous editions are obsolete Page 4 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Item 6. Building Exterior NO. vea Pass No Fail In- onc. Final Approval Comment Date(mm/dd/yyyy) 6.1 Condition of Foundation 6.2 Condition of Stairs, Rails, and Porches 6.3 Condition of Roof/Gutters 6.4 Condition of Exterior Surfaces 6.5 Condition of Chimney 6.6 Lead Paint: Exterior Surfaces Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed 20 square feet of total exterior surface area? Not Applicable 6.7 Manufactured Home: Tie Downs 7. Heating and Plumbing 7.1 Adequacy of Heating Equipment 7.2 Safety of Heating Equipment 7.3 Ventilation/Cooling 7.4 Water Heater 7.5 Approvable Water Supply 7.6 Plumbing 7.7 Sewer Connection 8. General Health and Safety 8.1 Access to Unit 8.2 Fire Exits 8.3 Evidence of Infestation 8.4 Garbage and Debris 8.5 Refuse Disposal 8.6 Interior Stairs and Commom Halls 8.7 Other Interior Hazards 8.8 Elevators 8.9 Interior Air Quality 8.10 Site and Neighborhood Conditions 8.11 Lead -Based Paint: Owner's Certification Not Applicable If the owner is required to correct any lead -based paint hazards at the property including deteriorated paint or other hazards identified by a visual assessor, a certified lead -based paint risk assessor, or certified lead -based paint inspector, the PHA must obtain certification that the work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice. Receipt of the completed and signed Lead -Based Paint Owner Certification signifies that all HQS lead -based paint requirements have been met and no re -inspection by the HQS inspector is required. Previous editions are obsolete Page 5 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 �Req form - HB Hd E C. Special Amenities (Optional) This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present. Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in decisions about renting the unit and the reasonableness of the rent. Check/list any positive features found in relation to the unit. ng Hoom High quality floors or wall coverings Working fireplace or stove Balcony, patio, deck, porch Special windows or doors Exceptional size relative to needs of family Other: (Specify) 2. Kitchen Dishwasher — Separate freezer — Garbage disposal — Eating counter/breakfast nook Pantry or abundant shelving or cabinets Double oven/self cleaning oven, microwave Double sink — High quality cabinets — Abundant counter -top space Modern appliance(s) Exceptional size relative to needs of family Other: (Specify) 3. Other Rooms Used for Living DHigh quality floors or wall coverings 1—I Working fireplace or stove Balcony, patio, deck, porch Special windows n or doors #� Exceptional size relative to needs of family Other. (Specify) 4. Bath Special feature shower head Built-in heat lamp Large mirrors Glass door on shower/tub Separate dressing room Double sink or special lavatory Exceptional size relative to needs of family Other. (Specify) 5. Overall Characteristics Storm windows and doors Other forms of weatherization (e.g., insulation, weather stripping) Screen doors or windows Good upkeep of grounds (i.e., site cleanliness, landscaping, condition of lawn) Garage or parking facilities _ Driveway — Large yard Good maintenance of building exterior Other. (Specify) 6. Disabled Accessibility Unit is accessible to a particular disability. Yes a No Disability Previous editions are obsolete Page 6 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 1:1 1. Does the owner make repairs when asked? Yes No 2. How many people live there? 3. How much money do you pay to the owner/agent for rent? $ - 4. Do you pay for anything else? (specify) 5. Who owns the range and refrigerator? (insert O = Owner or T = Tenant) Range Refrigerator Microwave❑ 6. Is there anything else you want to tell us? (specify) Yes ❑ No ❑ Previous editions are obsolete Page 7 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 on Summary/Comments (Optional) Provide a summary description of each item which resulted in a ratin of "Fail' or "Pass with Comments." Tenant ID Number I Inspector f Date of Inspection (mm/dd/yyyy) Address of Inspected Unit Type of Inspection Initial Special Reinspection Item Number Reason for "Fail' or "Pass with Comments" Rating Continued on additional page Yes 1:1No Previous editions are obsolete Page 8 of 8 form HUD-52580 (4/20151 ref Handbook 7420. Appendix E Landlord Agreement INTERVAL HOUSE anus ,■ LANDLORD — INTERVAL HOUSE RENTAL ASSISTANCE AGREEMENT cm �, oo wd To: (Landlord, Property Manager or Property Owner Name): On Behalf of. (Participant name): Address of Rental Property: Date: Dear Landlord: We are very pleased to inform you that (Participant name) has been approved for short -/medium -term rental assistance through the City of Huntington Beach. Through this Rental Assistance program, Interval House will make rental payments as a contractor of the City of Huntington Beach. Payments will be made directly to (Landlord, Property Manager or Property Owner name), on behalf of (Participant name), using a corporate check or money order. The payment will be mailed or hand delivered by Interval House staff to (Landlord, Property Manager or Property Owner name)'s address noted at the bottom. If at any time during the term of this agreement the tenant is given a notice to vacate the housing unit, or any complaint used under state or local law to commence an eviction action against (Participant name), (Landlord, Property Manager or Property Owner) shall also provide copy of said notice to Interval House at the address noted at the bottom. Interval House will make timely payments to (Landlord, Property Manager or Property Owner name) in accordance with the tenant rental agreement information below: Payment Due Date: Grace Period: Late Payment Requirements: Interval House will provide rental assistance in the following amount: $ Security Deposit (not to exceed two months' rent) $ Rental for month of This contribution will be reassessed on a monthly basis and may be subject to change depending on the client's level of need and other circumstances. The amount above may represent the entire or partial amount of the month's rent and (Participant name) shall be responsible for any balance due. In the case that any late fees or penalties are incurred, they are the responsibility of (Participant name). The term of this contract begins on the first day of the term of the lease. If a lease is terminated due to lease term violation, our assistance will end at time of termination. By signing this agreement, the landlord commits to complying with the tenant protections in 24 CFR §92.253. Please see the attached Tenant Protection Agreement for more information. Interval House is a nationally recognized award -winning non-profit organization offering housing and comprehensive support services to families in Los Angeles and Orange Counties since 1979. Interval House works closely with many cities and agencies to provide housing assistance for our local communities. We are proud to be able to offer housing subsidy programs for eligible and worthy individuals. Your prospective tenant has been approved for our housing subsidy. Please feel free to contact us with any questions or for any additional information at the phone number listed below. Both Interval House and (Landlord, Property Manager or Property Owner Name) agree to the terms noted above. Please sign below: Signature Print Name Interval House P.O. Box 3356 Seal Beach, CA 90740 Phone: (562) 594-9492 admin@intervalhouse.org Signature Print Name (Landlord, Property Manager or Property Owner Name): Address Line 1 Address Line 2 Phone/Fax # Email Address Appendix F Tenant Protection Agreement � a INTERVAL HOUSE Gee%b. 6(.0.fsi'W'au 10—*"— TENANT PROTECTION AGREEMENT (attach to lease) Dear Landlord: Req. form — HBIHOME We are very pleased to be working with you to provide short -/medium -term rental assistance to (participant name). We would like to inform you of some important tenant protections required by the city of Huntington Beach. We recognize that these terms are unlikely to be in your lease. However, we must ensure you understand that we are unable to support a lease that includes such terms. The written lease between yourself and the tenant may not contain any of the following provisions: (1) Agreement to be sued. Agreement by the tenant to be sued, to admit guilt, or to a judgment in favor of the owner in a lawsuit brought in connection with the lease; (2) Treatment of property. Agreement by the tenant that the owner may take, hold, or sell personal property of household members without notice to the tenant and a court decision on the rights of the parties. This prohibition, however, does not apply to an agreement by the tenant concerning disposition of personal property remaining in the housing unit after the tenant has moved out of the unit. The owner may dispose of this personal property in accordance with State law; (3) Excusing owner from responsibility. Agreement by the tenant not to hold the owner or the owner's agents legally responsible for any action or failure to act, whether intentional or negligent; (4) Waiver of notice. Agreement of the tenant that the owner may institute a lawsuit without notice to the tenant; (5) Waiver of legal proceedings. Agreement by the tenant that the owner may evict the tenant or household members without instituting a civil court proceeding in which the tenant has the opportunity to present a defense, or before a court decision on the rights of the parties; (6) Waiver of a jury trial. Agreement by the tenant to waive any right to a trial by jury; (7) Waiver of right to appeal court decision. Agreement by the tenant to waive the tenant's right to appeal, or to otherwise challenge in court, a court decision in connection with the lease; (8) Tenant chargeable with cost of legal actions regardless of outcome. Agreement by the tenant to pay attorney's fees or other legal costs even if the tenant wins in a court proceeding by the owner against the tenant. The tenant, however, may be obligated to pay costs if the tenant loses; and (9) Mandatory supportive services. Agreement by the tenant (other than a tenant in transitional housing) to accept supportive services that are offered. Furthermore, by signing this agreement you recognize your obligation to maintain the Housing Unit in accordance with the Housing Quality Standards established at 24 CFR 982.401, and to refrain from discriminating against the tenant's household. Please sign below as agreement to these terms: Signature Print Name Appendix G Rent Reasonableness RENTAL ASSISTANCE RENT REASONABLENESS CERTIFICATION Proposed Unit Unit #1 Unit #2 Address Number of Bedrooms Square Feet Type of Unit/Construction Housing Condition/Quality Location/Accessibility Amenities Unit: Site: Neighborhood: Age in Years Utilities (type) Unit Rent Utility Allowance Gross Rent Handicap Accessible? CERTIFICATION: A. Rent Two comparable units must be identified in order to certify Rent Reasonableness. Find listings for comparable units online (on Craigslist or a similar site). ** Print out the listings and attach them in back pocket of folder as proof. Proposed Contract Rent + Utility Allowance = Proposed Gross Rent (from utility allowance spreadsheet on next page) B. Compliance with Rent Reasonableness Rent ❑ is ❑ is not reasonable in comparison to rent for other comparable unassisted units. (to be reasonable, the rent must not exceed the rent of comparable units) Staff Name: Staff Signature: Date: Appendix H Utility Allowance dO R A N G E C 0 U N T Y CCommunftyResources Our Community. Our Commitment. 2017 Utility Allowances for Housing Choice Voucher Program The following Utility Allowances will be used by the Orange County Housing Authority (OCHA) for administration of the Housing Choice Voucher Program effective October 1, 2016. Bedroom 0 1 2 3 4 5+ y K Cooking 2 8 8 11 14 19 Heating 14 17 22 32 39 40 Water 8 10 10 17 22 24 Heatin Electric Basic 12 17 21 36 36 36 Cooking 5 7 8 12 16 18 Heating 10 14 18 23 30 33 Water 14 19 24 32 33 33 Heatin v Water 16 19 1 23 1 32 1 38 43 Trash/Sewer 23 Refrigerator 9 Stove 7 e is 68 Orange County Housing u r' 1 770 N. BROADWAY, SANTA ANA CA. 92706 0 PHONE (714) 480-2700 FAX (714) 480-2945 Appendix I Participant Agreement Agreement between Interval House Rental Assistance/Participation Agreement (participant name) and Interval House The Interval House Rental Assistance program aims to provide homeless and low-income households at extremely high risk of homelessness with financial assistance accompanied by supportive services to rapidly secure housing. You have been approved for initial financial assistance for a period of months in the amount of. Initial 6-month period: This contribution will be reassessed after 6 months Your total rent: $ and may be subject to change depending on the client's level of need and other circumstances. Interval House contribution: $ Client contribution: $ (from Calculation of Client Contribution form) I understand that receipt of this assistance is contingent upon my agreeing to and complying with the programs requirements outlined below. I further understand that financial assistance has been approved for a period of months. In order for additional financial assistance to be approved I must be reassessed for continued eligibility at the end of this time period. I agree to the following: • Provide accurate and honest information to my case manager or other agency staff. • Meet with my case manager at intervals established in my housing and service plan. • Work collaboratively with my case manager to establish a housing and service plan and take necessary steps to achieve the goals outlined in this plan. • Provide current proof of income for reassessment meetings. • Pay my portion of the rent on time every month and immediately advise my case manager if I have any trouble doing so. • Provide any documentation required by my case manager as it pertains to my services plan, rent or income (i.e. attendance record for job training, proof of debt payments, etc.) • Sign a release of information so that my case manager can collaborate with any other service providers that I'm working with. • Have a written lease for my apartment with a legitimate landlord. I may not sublet my unit or have anyone not already approved staying there for an extended period of time without the program approval. I must comply with all the requirements of my lease. • Agree to be responsible for my rent on my own after the rental assistance ends. • Agree to be contacted for follow-up calls after I complete the program. My signature represents that I understand what is expected of me by the Interval House Rental Assistance Program. I also agree to cooperate with my individual housing and services plan. I understand that the sponsoring agency is not responsible for my rent or lease. Financial assistance will only be paid on my behalf if I am in full compliance with the program requirements. Print Client Name: Client Signature: Date: Print Staff Name: Staff Signature: Date: Appendix J Case Management and Self Sufficiency Program Policies and Procedures ,ora zak, .eu.1'. r ca.c fq. e" x;0,--J INTERVAL HOUSE Crisis Shelters & (enters forVictims of Domestic Violence Self-Sufficiency "Case Management" Program Section 1: OVERVIEW Interval House utilizes a client -centered, trauma informed approach for our self-sufficiency - case management program. Key staff and specialists, who will be working with the household, participate in the Assessment/Goal Tracking Sheet interview in a team approach so that the client will only need to share their story once. This also enables specialized staff to further assess the client's needs and goals. We work hand in hand with the client to empower them and help them to determine the steps needed to successfully reach their goals. Interval House has developed the Individualized Service Plan/Goal Worksheet as a guide and checklist for our Self -Sufficiency program from entry to exit. These forms outline the comprehensive assessments and services that are offered to rental assistance clients and their children throughout their program at Interval House. The following services are offered as part of the Self- Sufficiency Case Management program: 1. Individualized Housing and Service Plan 2. Housing Search and Placement 3. Legal Services 4. Financial Management/Credit Repair 5. Employment Assistance 6. Transportation 7. Counseling Section 2: HOUSING & SERVICE PLAN The Interval House Case Management model maximizes client success by developing individualized service plans and addressing clients' specific needs in securing permanent housing and self-sufficiency. Each participant will also develop an individualized Service Plan with their Case Manager addressing specific goals and time frames for short-term and long-term goals. Individualized services and resources are planned to meet the unique needs of rental assistance participants. Case Managers will monitor client's progress on a regular basis (at minimum monthly) and make revisions as needed with the participant. The service plan components include: • Housing • Interpersonal/emotional • Medical • Legal • Financial • Educational & vocational • And other immediate needs (such as transportation, clothing, food, etc.). All clients deserve devoted housing advocate case managers who are sensitive to their needs and who meets regularly with each client for ongoing support. Case managers will coordinate the delivery of all supportive services needed, working closely with clients and local community resources. Section 3.0 HOUSING SEARCH 8. PLACEMENT Attaining safe, permanent housing is a primary goal for all Interval House rental assistance participants. Housing search, placement, and establishment activities are planned in detail from the clients' intake assessment. Housing Advocates will work closely with clients to design carefully planned steps and activities in researching neighborhoods, negotiating leases, and advocating tenants' rights. Families are given the choice for selecting their housing and some may transition sooner and some take longer for their preferred housing options. For over 36 years, Interval House has worked closely with local Apartment Association and Housing networks to secure and strengthen relationships with landlords and property owners on behalf of homeless families. Interval House also maintains strong working relationships with building industry and private housing executives to strengthen housing inventory in Orange County. Landlords are provided with the incentive that Interval House has properly screened the family and will continue to provide support services as long as needed to the family to ensure housing stability and self-sufficiency. Interval House regularly follows up with landlords and monitors clients to see if any needs have been identified that would benefit from program advocacy. Interval House's maintains operational agreements with private landlords/owners and permanent housing providers for first option of over 40 units, and linkages to hundreds of vacancies as the adopted charity partner for the Apartment Association, Southern CA cities. Section 4: LEGAL SERVICES Staff attorneys, legal advocates and volunteer attorneys provide comprehensive legal services and representation in multiple languages. Legal assistance includes lease agreements, legal advocacy, court accompaniment, and other legal issues affecting homeless and at -risk homeless persons and their children. Interval House legal advocates provide legal assistance through individual legal counseling sessions, group legal clinics, court accompaniment and representation, and legal advocacy. Staff are trained to fully understand and explain relevant laws to clients and to help "walk them through" the relevant legal systems. Section 5: FINANCIAL MANAGEMENT/ CREDIT REPAIR Obtaining financial self-sufficiency is a critical goal for households served by Interval House. Financial Empowerment support includes: setting individual financial goals and timelines; developing, implementing, and monitoring a financial plan; increasing financial income; active budgeting and savings; repairing/improving credit; and reducing debt. A unique component is our award -winning financial management program, provided in partnership with the Financial Planning Association and its volunteer financial advisors. A partnership with nationally recognized financial expert Suze Orman provides all participants with financial tool kits, which assists clients with credit repair, financial literacy, and job placement and retention. Interval House has designed an 8-week comprehensive financial empowerment curriculum with weekly workshops conducted to assist program participants with credit repair, financial literacy, and job placement and retention. Assistance will also be provided to access mainstream financial benefits including social security, veteran's benefits, CaIWORKs, disability, unemployment, and other public assistance. Section 6.0 EMPLOYMENT ASSISTANCE Obtaining self-sufficiency is a critical goal for families served by Interval House. Interval House Case Managers work with clients to identify interests, life experiences and talents that lend themselves to employment. Housing Advocates also: ■ Help clients develop resumes, complete job application and prepare for interviews; ■ Obtain educational scholarships through AmeriCorps and other sources to increase leadership skills and/or further their education; ■ Provide transportation solutions to job interviews and job -related activities; and ■ Provide job placement in career -level jobs and job retention assistance. Section 7: TRANSPORTATION Interval House provides support services at our Community Service Center and Satellite sites in Huntington Beach conveniently accessible via public transportation routes or via home visits as needed. Interval House provides assistance with transportation via bus passes and accessing mainstream resources available for transportation through CalWORKs and disability access. Interval House also maintains agreements with local taxi companies to provide emergency transportation assistance and works closely with the Huntington Beach Police Department to assist transport participants in crisis situations. Section 8: COUNSELING Interval House provides an array of individual and group counseling programs on -site and works closely with other mental health providers to address behavioral health needs of participants. Sensitive and flexible counseling services will be available from peer support to therapeutic individual and group counseling provided by skilled professional and paraprofessional counselors in over 70 different languages. a� o U O � � U �w Cd a� •o � I..�i C U ca O y C3 U C ~ C3 O Q 4° 0 0 � .� p. c a� ..q O 0 YC y� U T N O i3 Cd a� ai o a Q „ o > a 4j o O a� w d o U 4-. z7¢3w�o T a ° o 3 0 �- 0 C T � Cd 0o a a 0 �0 Cd 0 to 0 Cd r- oA 3 O to E 41 T 14 cn Ut •°" o c «� o¢'� Cd O a� 3.5 3 ' Cd o = Nto 3 cl vi T C U w 3 aL c a°o 3 Q O tiA O ° o o ' O a cn o o ON o 3 40, -d � .0 2 ° ate+ N U Hb�°-43Fa . 01 L is, N E 8 LL W I IN z CA CA Li Li Li co 0 r. U 0 IZ, cc to W� It -1;3 p. 0 to b4 c'8 0 q- Q Z- En Kj m u r. c ad -r- CA .2.2 v CA 04 >4 0 0 -0 0 0 0 A on V, Ile Cf) m Z4 371 O Mal ON 2 9iL El El AT7 Li Ll Li cd r- > 0.0 m C40 Ulf (D SS- E!" -hA cl. '15 ob 0 bA r as rA tn M �5 7 El E] 4 A 'Alm Ohs, -v gl' O r4 El El CSC MGM it 4. -E t IRE 2 Za 11 El ini ........... u 6: a) r-I Itz ca F-I Li U :,,, MOE Vt r- ER UP ci Exhibit B Documentation, Recordkeeping, Reporting and Monitoring Requirements Documentation, Recordkeeping, Reporting and Monitoring Requirements Interval House (Subrecipient) shall comply with the requirements set forth in this document at all times during the term of the HOME Subrecipient Agreement (Agreement) between the City of Huntington Beach (City) and Subrecipient, to which this document is attached. I. Documentation and Recordkeeping A. Records to be Maintained Subrecipient shall maintain all records required by the federal regulations specified in 24 CFR 92.508(a)(3), which are pertinent to the Services to be funded under the Agreement. Records shall be maintained for each prospective participant, each Eligible Household and each Housing Unit inspected and/or occupied by an Eligible Household pursuant to the Agreement. Such records shall include but are not limited to: ■ Records providing a full description of each activity undertaken. ■ Records required to determine the eligibility of activities for use of HOME funds. ■ Records (including property inspection reports) demonstrating that each Housing Unit occupied by an Eligible Household meets the property standards of 24 CFR 92.251(d) and 24 CFR 982.401 upon occupancy and at the time of each annual inspection. ■ Records demonstrating compliance with the property standards and financial reviews and actions pursuant to 24 CFR §92.504(d). ■ Records demonstrating that each Eligible Household is income eligible in accordance with 24 CFR 92.203, including all TBRA applications, eligibility determinations and documentation regarding any appeals of eligibility determinations. ■ Records demonstrating that Subrecipient is in compliance with the City's written tenant selection policies and criteria of 24 CFR 92.209(c), including any targeting provisions of 24 CFR 92.209(h), and calculation of each Subsidy Payment. ■ Records demonstrating that each rental agreement for an Eligible Household receiving Subsidy Payments complies with the tenant and participant protections of 24 CFR 92.253. ■ Records documenting compliance with Subrecipients marketing and outreach obligations under the Agreement, including compliance with the fair housing and equal opportunity components of the HOME program and HUD's Affirmative Fair Housing and Marketing regulations and the City's Affirmative Fair Housing Marketing Plan, when adopted. ■ Records documenting compliance with the lead -based hazards requirements under the Agreement, the HOME Program, and 24 CFR Part 35, subparts A, B, J, K, M and R. ■ Financial records as required by 24 CFR §92.508(a)(5) and 24 CFR §92.222. ■ Records documenting the HOME Matching Contributions made by Subrecipient pursuant to the Agreement and the HOME Program, specifically including 24 CFR 92.218 through 24 CFR 92.222. B. Retention The Subrecipient shall retain all financial records, supporting documents, statistical records, and all other records pertinent to the Agreement for a period of five years after the period of Subsidy Payments terminates. Notwithstanding the above, if there are litigation matters, claims, audits, negotiations or other actions that involve any of the records cited and that have started before the expiration of the five-year period, then all pertinent records must be retained until completion of the actions and resolution of all issues, or the expiration of the five-year period, whichever occurs later. C. Client Data 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. D. Disclosure The Subrecipient understands that client information collected under this Agreement 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 Agreement, is prohibited unless written consent is obtained from such person receiving services and, in case of a minor, that of a responsible parent/guardian. E. Close Outs The Subrecipient's obligation to the City shall not end until all close-out requirements are completed. Activities during the 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 HOME funds, including program income. F. Audits and Inspections All Subrecipient records with respect to any matters covered by this Agreement shall be made available to the City, HUD 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 the Agreement 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-122. II. Quarterly Progress Reports Subrecipient shall submit quarterly progress reports to the City in a form approved or directed by the City on or before each April 15, July 15, October 15 and January 15, which shall include all of the following information regarding Subrecipient's activities during the prior quarter: ■ The number of TBRA applications received, processed, approved and disapproved. ■ The number of Housing Units inspected, approved and disapproved and a description of any corrective work performed by Landlords to comply with HQS. ■ The number of Eligible Households assisted, including specific information regarding the number of and ages of all household members, income categories, types and amounts of assistance provided to each Eligible Household, and remaining terms of assistance expected to be provided to such households. ■ Description of each Eligible Household's participation in required self-sufficiency program and other optional social and supportive Services provided or otherwise made available to each Eligible Household. ■ Budget reconciliation information, including year-to-date expenditures and remaining balance available for Subsidy Payments in accordance with the Budget and the Agreement. ■ Number of additional Eligible Households Subrecipient expects to qualify and assist within the following three-month period. ■ Updated schedule of performance of the Services under the Agreement, including a schedule for qualifying and assisting additional Eligible Households as permitted by the Budget. ■ Information regarding any complaints receipted from Applicants or Eligible Households and any correspondence received from community members or organizations or other nonprofit organizations regarding the Program or specific activities or individuals involved in the Program. ■ Documentation of the HOME Matching Contributions made by Subrecipient pursuant to the Agreement and the HOME Program, specifically including 24 CFR 92.218 through 24 CFR 92.222. III. Performance Monitoring A. Monthly Reports Subrecipient shall provide progress reports on a Monthly basis during the first quarter of the Term of the Agreement in order for the City to review Subrecipient's activities and progress under the Agreement and to ensure that the Program is progressing smoothly. B. City Oversight and Review City will monitor the performance of the Subrecipient against the goals and performance standards set forth in the Agreement. From time to time, City shall be entitled to audit and review Subrecipient's performance of the Services in accordance with the terms of the Agreement and compliance with the HOME Program. Substandard performance as determined by the City will constitute noncompliance with the Agreement. If action to correct such substandard performance is not taken by the Subrecipient within a reasonable period of time after being notified by the City, termination procedures will be initiated in accordance with Section 8.3 of the Agreement. Exhibit C Gross Income Calculation Form Req. form —HB HOME RENTAL ASSISTANCE PROGRAM Income Information • Income Checklist o Documentation of Income • Declaration of Income Form o Income Regulations • Declaration of Assets and Calculation of Total Household Income o Asset Regulations • Calculation of Client Contribution; Gap Analysis Fteq_ form -HB HOME Income CHECKLIST Step 1: Staff member interviews client and collects copies of any documentation from checklist below. Attach proof of all income for every household member age 18 or older. All income information/documentation should be collected for the past two months for HB HOME. ***Do not ask an employer to provide documentation, especially if this could jeopardize the client's employment. You should get everything from the client. Income includes but is not limited to: • The full amount of gross income earned before taxes and deductions. • The net income earned from the operation of a business, i.e., total revenue minus business operating expenses. This also includes any withdrawals of cash from the business or profession for your personal use. • Monthly interest and dividend income credited to an applicant's bank account and available for use. • The monthly payment amount received from Social Security, annuities, retirement funds, pensions, disability and other similar types of periodic payments. • Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI, and worker's compensation. • Monthly income from government agencies excluding amounts designated for shelter, and utilities, WIC, food stamps, and childcare. • Alimony, child support and foster care payments received from organizations or from persons not residing in the dwelling. • All basic pay, special day and allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire. ❑ Copy of Bank Statements for the past two months attached in back pocket of folder. Req. form —HB HOME ❑ Proof of any Employment Income for the past two months is attached in back pocket of folder. (i.e. paycheck stubs, W-2/1099 tax form) ** Employment income should include the total income, before taxes and deductions are taken out. ❑ Proof of any Payments and/or Benefit Income for the past two months is attached in back pocket of folder. Check the types of payments and/or benefits AND attach proof (i.e. notice or stub or deposit statements): ❑ Social Security/SSI ❑ Pension/Retirement ❑ TAN F ❑ Public Assistance ❑ Disability/SSDI ❑ Unemployment Compensation ❑ Workers Compensation ❑ Alimony Payments ❑ Foster Care Payments ❑ Child Support Payments ❑ Armed Forces Income ❑ Other (please specify): ❑ Documentation of any other source of income for the past two months is attached in back pocket of folder. ❑ Proof of school enrollment attached in back pocket of folder, for any household member age 18 or over who is a full-time student. Client Signature: Date: Signature of Staff responsible for assessment: Date: Supervisor Signature: Date: Req. form —HB HOME Step 2: Declaration of Income form ❑ Declaration of Income form is filled out by a trained staff member and signed for every household member age 18 or older. ❑ Staff member reviewed Annual Income Inclusions and Exclusions (see attached 24 CFR Part 5 guidelines). Information on all relevant included income has been collected and recorded on form. NO excluded income has been recorded on form. ❑ ALL relevant documentation is attached in back pocket of folder (see boxes in Step 1). ❑ If staff member was unable to obtain third -party verification or documentation, they have described efforts made for third -party verification and attached any documentation of these efforts in back pocket of folder. ❑ Staff member has signed the bottom of the form. Client Signature: Signature of Staff responsible for assessment: Supervisor Signature: Date: Date: Date: 4 Req. form-HB HOME Step 3: Declaration of Assets and Calculation of Total Household Income ❑ Declaration of Assets section is filled out by a trained staff member and ALL relevant documentation is attached in back pocket of folder. ❑ Staff member reviewed Net Family Asset Inclusions and Exclusions (see attached 24 CFR Part 5 guidelines). Information on all relevant included assets has been collected and recorded on form. NO excluded assets has been recorded on form. ❑ Total household income is calculated and recorded by a trained staff member on page 2. Client Signature: Signature of Staff responsible for assessment: Supervisor Signature: Date: Date: Date: 1. Req. form'-HB HOME Step 4: Income requirement **** This information must be collected at intake and 6-month re-evaluation. ❑ Refer to Calculation of Total Household Income (Step 3) to find the household's total annual income. Refer to Demographic Information (Section 1) to find the household size (total number of adults and children). ❑ Does client have an annual household income below 30 percent of median family income for the area, as determined by HUD? ❑ Yes ❑ No Extremely Low (30%) Income Limit for OC (FY 2017): deb', ffho d Size Extremely Low Income 30% to 0% 1 Person $ 21,950 - $0 2 Persons $ 25,050 - $0 3 Persons $ 28,200 - $0 4 Persons $ 31,300 - $0 5 Persons $ 33,850 - $0 6 Persons $ 36,350 - $0 7 Persons $ 38,850 - $0 8 or More Persons $ 41,350 - $0 Source: https://www.huduser.gov/portal/datasets/il/il2017/2017summary odn Client Signature: Date: Signature of Staff responsible for assessment: Date: Supervisor Signature: Date: 0 Req. form —HB HOME Step 5: Calculation of Client Contribution; Gap Analysis ❑ Calculation of Client Contribution form is filled out by a trained staff member. ❑ Gap Analysis form is filled out by a trained staff member and Funds Needed is calculated at the bottom (amount of assistance cannot exceed the amount of funds needed). ** Enter the information into the Gap Analysis spreadsheet on the computer and the spreadsheet will do the math for you. ** Fill out the Schedule of Assistance every 6 months as decisions are made. Client Signature: Date: Signature of Staff responsible for assessment: Date: Supervisor Signature: Date: Step 6: Client Certification certify, under penalty of perjury, that I have no other income or assets other than what I have stated above. I certify that all information provided on this form is true and complete. Client's Signature Client's Printed Name Date 7 -HB HOME RULE The Huntington Beach HOME grant requires households to have an income no greater than 30% of the annual median income (AMI) at time of entry. Household income can increase to up to 80% of AMI during participation in program. 24 CFR 92.209 (c) (1) Low-income families. Tenant -based rental assistance may only be provided to very low- and low-income families. The pa-rtcipating jurisdiction must determine that the family is veryipw or low. -income before the assistance is provided. During the period of assistance, the participating jurisdiction must annually determine that the family continues to be low- income. (i) Local market conditions; or (ii) The Section 8 Housing Choice Voucher Program (24 CFR part 982). 0) Security deposits. (2) The relevant State or local definition of "security deposit" in the jurisdiction where the unit is located is applicable for the purposes of this part, except that the amount of HOME funds that may be provided for a security deposit may not exceed the equivalent of two month's rent for the unit. 24 CFR 92.203 (a) (2) For all other families (i.e., homeowners receiving rehabilitation assistance, homebuyers, and recipients of HOME tenant -based rental assistance), the participating jurisdiction must determine annual income by examining at least 2 months of source document e'ridencir g annual in( (e.g., wage statement, interest statement, unemployment compensation statement) for the family. (c) Although the participating jurisdiction may use either of the definitions of "annual income" permitted in paragraph (b) of this section to calculate adjusted income, it must apply exclusions frorrr income established at 24 CFR 5.611. The HOME rents for very low-income families established under §92.252(b)(2) are based on adjusted income. In addition, the participating jurisdiction may base the amount of tenant -based rental assistance on the adjusted income of the family. The participating jurisdiction may use only one definition for each HOME -assisted program (e.g., downpayment assistance program) that it administers and for each rental housing project. d) (1) The Darticiaatina iurisdiction must calculate the annual inco 9 Req info — LB / Req form — GG/HB/WM/QC HUD-SA/HB HOME lmft� Am ° Rental Assistance Program Step 2 law DECLARATION OF INCOME INTERVAL HOUSE Applicant Name: Income for: A Declaration of Income should be filled out for the head of household and each other household member age 18 or over. Check only one box and complete only that section ❑ I certify, under penalty of perjury, that I currently receive the following income: Income source: Amount: Income source: Income source: Amount: Amount: Frequency: Frequency: Frequency: ** Employment income should include the total income, before taxes and deductions are taken out. Frequency Key: Paid weekly: 52 times/year Paid every other week (biweekly): 26 times/year Total Monthly income: Paid twice a month (semimonthly): 24 times/year Total Expected. Annual income: Paid monthly: 12 times/year Please attach any relevant documentation of this household member's income that you collected from the yellow checklist (Step 1) in back pocket of folder. Remember, one of these forms should be filled out for the head of household and each other household member age 18 or over. I certify, under penalty of perjury, that I have no other income or assets other than what I have stated above. Applicant Signature: Date: ❑ I certify, under penalty of perjury, that I do not have any income from any source at this time. Applicant Signature: Staff Verification Date: I understand that third -party verification is the preferred method of certifying income for rental assistance. For third -party verification, you do not have to speak to an employer or other person — you can use any of the income documentation that you collected from the yellow checklist (Step 1). If you were unable to obtain third -party verification or documentation, please explain why. (For example: Contacting the client's employer could jeopardize their job, in certain situations). Staff Signature: Financial supervisor approval signature: Date: Date: INTERVAL HOUSE Cf&WW&GftW6 d ZI Req. info — LB I Req. form — GG/HB/WM/OC HUD -SA/ HB HOME' Rental Assistance Program Step 3 DECLARATION OF ASSETS Applicant Name: ASSETS Family Member Asset Description Current Cash Value of Assets Actual Income from Assets 3. Net Cash Value of Assets................................................................................................... 3. 4. Total Actual Income from Assets..................................................................................... 4. 5. If line 3 is greater than $5,000, multiply line by (Passbook Rate) and enter results here; otherwise, leave blank. 5. Please attach documentation of any assets listed in back pocket of folder. CALCULATION OF TOTAL HOUSEHOLD INCOME HUU LI IC IIIUI IL I I CII IU 011HUal 111LUIIICZ-) IIUIII LI IC UCLIQIQLIUII VI IIIL.U111C IUII113 IUI all 11UUJCI IUIU 111CILJIUCIa. Household head Household member #2 Household member #3 Household member #4 TOTAL FOR HOUSEHOLD Total Annual Income: Total annual household income from blue box in chart above: +The amount from Line 4 or 5 (whichever is bigger) in the assets table: + Total'a"6nual income 1 Re,, farm - HB HOME Rental Assistance Program Step 5 v CALCULATION OF CLIENT CONTRIBUTION INTERVAL HOUSE Applicant Name: rns s4m & fags 6 Vda d km*rr&o I HB HOME RENT PAYMENT STANDARD i EFFICIENCY I -BEDROOM 2-BEDROOM BEDROOM 4-BEDROOM HUNTINGTON BEACH N/A $1,635 $1,938 $2,712 $4,003 . . OTHER ORANGE COUNTY— $1,119 $1,370 $1,645 $2,310 $2,509 CENTRAL - - - -------- - ---- --- ------ ------------------------ .... ... .......... ...... . . . . . F OTHER ORANGE COUNTY— $1,119 $1,515 $1,780 $2,460 $2,509 RESTRICTED OTHER ORANGE COUNTY f $1,119 $1,312 ................................... ........................... ............. ........ .... ......... ............ ....... .......-----------...._......_.................................. _........ _._..... - ....._...... —. OTHER LA COUNTY $1,041 $1,269 $1, 610 1 $2, 254 $2, 509 _--............................. -.... ...._............................................_...__ $1,564 $2,021 $2,404 *Orange County — Central Cities: Costa Mesa, Fountain Valley, Yorba Linda *Orange County — Restricted Cities: Aliso Viejo, Dana Point, Irvine, Laguna Beach, Laguna Hills, Laguna Niguel, Lake Forest, Mission Viejo, Newport Beach, Rancho Santa Margarita, San Juan Capistrano, San Clemente, Tustin Calculation of Client's Contribution to Rent Family's monthly adjusted income: (from Calculation of Total Household Income) IZIw1l 30% of family's monthly adjusted income: If utilities not included in rent, Subtract utility allowance for city where they are moving: - (from Utility allowance form in Lease/Landlord section) Client Contribution: _ ** If this calculation results in a contribution less than $50, the Client Contribution shall be set at $50 (this minimum can be waived in exceptional circumstances.) Calculation of Maximum Subsidy from Interval House Rent standard for unit size: (see chart above based on city where housing is) Subtract Client Contribution from above: _ Exhibit D Household Budget Worksheet GAP ANALYSIS Applicant Name: MONTHLY INCOME This income should already incorporate inclusions and from 24 CFR Part 5 MONTHLY EXPENSES Rentallnsurance Utilities Water/Sewer/Trash Communication (Phone, Cable, Internet) Maintenance/Supplies/Household Cleaning Other Vehicle Payments Auto Insurance Fuel Bus/Taxi/Train Fare Repairs Registration/ License Other Health Insurance Doctor/ Dentist Medicine/Drugs Life Insurance Veterinarian/ Pet Care Other Groceries Education/Lessons Pet expenses Personal Supplies (toiletries, hygiene, etc.) Clothing Cleaning (laundry, dry cleaning, etc.) Dining/Eating Out Salon/Barber Other Total Monthly EXPENSES Step 5 SAVINGS Emergency Fund Transfer to Savings Retirement (401k, IRA) Investments Education Other TAXES "This includes taxes taken out of monthly income TAXES MONTHLA Federal Taxes State/Local Taxes Total TAXES OBLIGATIONS/DEBTS Other Loan Credit Cards Alimony/Child Support Medical debts Rental Arrears Other • Total Monthly Expenses + Housing Relocation and Stabilization Expenses '. ''"' These are one-time expenses of moving into new housing Total Monthly Income $ = Funds Needed OR (Funds available) = Maximum initial assistance (assistance cannot exceed funds needed) SCHEDULE OF 1st Month / First 6 months (HB HOME) 2nd Month / Second 6 months (HB HOME) 3rd Month / etc. (HB HOME) Total Assistance Exhibit E Lead -Based Hazard Information Pamphlet "Protect Your Family from Lead in your Home" Req info/not req form — GG/HB/WM/OC'HUD/LB/SA/ HB HOME' „VININ INTERVAL HOUSE {r&WL(ft*slar%&d1%11AYfdnn Lead Screening Worksheet About this Tool The lead screening worksheet is intended to guide grantees through the lead -based paint inspection process to ensure compliance with the rule. Staff can use this worksheet to document any exemptions that may apply, whether any potential hazards have been identified, and if safe work practices and clearance are required and used. A copy of the completed worksheet along with any additional documentation should be kept in each program participant's case file. Instructions To prevent lead -poisoning in young children, grantees must comply with the Lead -Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. Under certain circumstances, a visual assessment of the unit is not required. This screening worksheet will help program staff determine whether a unit is subject to a visual assessment, and if so, how to proceed. A copy of the completed worksheet along with any related documentation should be kept in each program participant's file. Note: ALL pre-1978 properties are subject to the disclosure requirements outlined in 24 CFR 35, Part A, regardless of whether they are exempt from the visual assessment requirements. BASIC INFORMATION Name of Participant Address Unit Number City State Zip Program Staff PART 1: DETERMINE WHETHER THE UNIT IS SUBJECT TO A VISUAL ASSESSMENT If the answer to one or both of the following questions is 'no,' a visual assessment is not triggered for this unit and no further action is required at this time. Place this screening worksheet and related documentation in the program participant's file. If the answer to both of these questions is 'yes,' then a visual assessment is triggered for this unit and program staff should continue to Part 2. 1. Was the leased property constructed before 1978? ❑ Yes ❑ No 2. Will a child under the age of six and/or pregnant woman be living in the unit occupied by the household receiving assistance? ❑ Yes ❑ No Req info/not req form — GG/HB/WMIOC'HUD/LB/SA/ HB HOME PART 2: DOCUMENT ADDITIONAL EXEMPTIONS If the answer to any of the following questions is 'yes,' the property is exempt from the visual assessment requirement and no further action is needed at this point. Place this screening sheet and supporting documentation for each exemption in the program participant's file. If the answer to all of these questions is 'no,' then continue to Part 3 to determine whether deteriorated paint is present. 1. Is it a zero -bedroom or SRO -sized unit? ❑ Yes ❑ No 2. Has X-ray or laboratory testing of all painted surfaces by certified personnel been conducted in accordance with HUD regulations and the unit is officially certified to not contain lead -based paint? ❑ Yes ❑ No 3. Has this property had all lead -based paint identified and removed in accordance with HUD regulations? ❑ Yes ❑ No 4. Is the client receiving Federal assistance from another program, where the unit has already undergone (and passed) a visual assessment within the past 12 months (e.g., if the client has a Section 8 voucher and is receiving rental assistance for a security deposit or arrears)? ❑ Yes (Obtain documentation for the case file.) ❑ No 5. Does the property meet any of the other exemptions described in 24 CFR Part 35.115(a). ❑ Yes ❑ No Please describe the exemption and provide appropriate documentation of the exemption. Fa Req info/not req form - GG/HB/WM/OC HUD/LB/SA/ HB HOME PART 3: DETERMINE THE PRESENCE OF DETERIORATED PAINT To determine whether there are any identified problems with paint surfaces, program staff should conduct a visual assessment prior to providing financial assistance to the unit as outlined in the following training on HUD's website at: http://www.hud.gov/offices/lead/training/visualassessment/h0010l.htm. If no problems with paint surfaces are identified during the visual assessment, then no further action is required at this time. Place this screening sheet and certification form (Attachment A) in the program participant's file. If any problems with paint surfaces are identified during the visual assessment, then continue to Part 4 to determine whether safe work practices and clearance are required. 1. Has a visual assessment of the unit been conducted? ❑ Yes ❑ No 2. Were any problems with paint surfaces identified in the unit during the visual assessment? ❑ Yes ❑ No (Complete Attachment A — Lead -Based Paint Visual Assessment Certification Form) PART 4: DOCUMENT THE LEVEL OF IDENTIFIED PROBLEMS All deteriorated paint identified during the visual assessment must be repaired prior to clearing the unit for assistance. However, if the area of paint to be stabilized exceeds the de minimus levels (defined below), the use of lead safe work practices and clearance is required. If deteriorating paint exists but the area of paint to be stabilized does not exceed these levels, then the paint must be repaired prior to clearing the unit for assistance, but safe work practices and clearance are not required. 1. Does the area of paint to be stabilized exceed any of the de minim us levels below? • 20 square feet on exterior surfaces ❑ Yes ❑ No • 2 square feet in any one interior room or space ❑ Yes ❑ No • 10 percent of the total surface area on an interior or exterior component with a small surface area, like window sills, baseboards, and trim ❑ Yes ❑ No If any of the above are'yes/ then safe work practices and clearance are required prior to clearing the unit for assistance. Req info/not req form — GGIHB/WMIOC HUD/LB/SA/ HB HOME PART 5: CONFIRM ALL IDENTIFIED DETERIORATED PAINT HAS BEEN STABILIZED Program staff should work with property owners/managers to ensure that all deteriorated paint identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not exceed the de minimus level, safe work practices and a clearance exam are not required (though safe work practices are always recommended). In these cases, the program staff should confirm that the identified deteriorated paint has been repaired by conducting a follow-up assessment. If the area of paint to be stabilized exceeds the de minimus level, program staff should ensure that the clearance inspection is conducted by an independent certified lead professional. A certified lead professional may go by various titles, including a certified paint inspector, risk assessor, or sampling/clearance technician. Note, the clearance inspection cannot be conducted by the same firm that is repairing the deteriorated paint. 1. Has a follow-up visual assessment of the unit been conducted? ❑ Yes ❑ No 2. Have all identified problems with the paint surfaces been repaired? ❑ Yes ❑ No 3. Were all identified problems with paint surfaces repaired using safe work practices? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. 4. Was a clearance exam conducted by an independent, certified lead professional? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. 5. Did the unit pass the clearance exam? ❑ Yes ❑ No ❑ Not Applicable —The area of paint to be stabilized did not exceed the de minimus levels. Note: A copy of the clearance report should be placed in the program participant's file. Req info/not req form - GG/HBMM/OC HUD/LB/SA/ HB HOME ATTACHMENT 1: LEAD -BASED PAINT VISUAL ASSESSMENT CERTIFICATION TEMPLATE I, , certify the following: • I have completed HUD's online visual assessment training and am a HUD -certified visual assessor. • 1 conducted a visual assessment at on • No problems with paint surfaces were identified in the unit or in the building's common areas. (Signature) (Date) Client Name: Case Number: If you think your home has high Navels of lead: Get your young children tested for lead, even if they seem healthy. *Wash children's hands, bottles, pacifiers, and toys often. * Make sure children eat healthy, low -fat foods. * Get your home checked for lead hazards. * Regularly clean Floors, window sills, and other surfaces. * Wipe soil off shoes before entering house. Talk to your landlord about fixing surfaces with peeling or chipping paint. Take precautions to avoid exposure to lead dust when remodeling or renovating (call 1-800-424- LEAD for guidelines). * Don't use a belt -sander, propane torch, high temperature heat gun, scraper, or sandpaper on painted surfaces that may contain lead. * Don't try to remove lead -based paint yourself. ............. rOfCt_= Your-- Fermi1, _y IN Fr_o�rn- U� Q L-in -.7; Wl-, Your No- -'e , P.- United States - Environmental EPA Environmental Protection ite_Agency r�r—��ec ' • aS Und _States •71 h `'� e • "Consumer Product _Safety Commissio _Q n c �` ice_ �^�� ^PMsxr� � !ti% United States Department of Hous�r►g and Urban Development - - e You Planning To Buy, Beat, or Renovate a Hume Built Before 1 978? a.ny houses and apartments built before 1978 have paint that contains high levels of lead (called lead - based paint). Lead from paint, chips, and dust can pose serious health hazards if not taken care of properly. K'® OWNERS, BUYERS, and RENTERS are encouraged to check for lead (see page G) before renting, buying or renovating pre- 1978 housing. ederal law requires that individuals receive certain. information before renting, buying, or renovating pre- 1978 housing: LANDLi3iRDS have to disclose known infor- ��`_' mation on lead -based paint and lead -based ' paint hazards before leases take effect. Leases must include a disclosure about lead -based paint. SELLERS have to disclose known informa- tion on lead -based paint and lead -based paint hazards before selling a house. Sales contracts must include a disclosure about lead -based paint.. Buyers have up to 10 days to check for lead. RENOVATORS disturbing more than Z square feet of painted surfaces have to give you 00001, this pamphlet before starting work. Y I� ' Lead From Faint, Dust, and Soil Can Be Dangerous 1f Not Managed Properly FACT-. Lead exposure can harm young children and babies even before they are born. FACT Even children who seem healthy can have high levels of lead in their bodies. TACT. People can get lead in their bodies by breathing or swallowing lead dust, or by eating soil or paint chips containing lead. FACT. People have many options for reducing lead hazards. In most cases, lead -based paint that is in good condition is not a hazard. FACT Removing lead -based paint improperly can increase the danger to your family. If you think your home might have lead hazards, read this pamphlet to learn some simple steps to protect your family. Leach Gets in the Body in Many Ways can get lead in their body if they: ChildhoodPeople Breathe in lead dust (especially during ���� renovations that disturb painted poisoning surfaces). remains a � Put their hands or other objects major covered with lead dust In their mouths. environmen- Eat paint chips or soil that contains $ai health lead. problem in the U.S. Lead is even more dangerous to children under the age of 6: At this age children's brains and nervous systems are more sensitive to the dam- aging effects of lead. Even children 4� Children's growing bodies absorb more who appear lead, healthy caaa Sables and young children often put have clanger- their hands and other objects in their oars levels of mouths. These objects can have lead lead in their dust on them. bodies. Lead is also dangerous to women of childbearing age: 0 Women with a high lead level in their system prior to pregnancy would expose a fetus to lead through the placenta during fetal development. Lead's Effects It is important to know that even exposure to low levels of lead can severely harm children. In children, lead can cause: Nervous system and kidney damage. Learning disabilities, attention deficit disorder, and decreased intelligence. Speech, language, and behavior problems. Poor muscle coordination. Decreased muscle and bone growth. 4� Hearing damage. While low -lead exposure is most common, exposure to high levels of lead can have devastating effects on children, including seizures, uncon- sciousness, and, in some cases, death. Although children are especially susceptible to lead exposure, lead can be dangerous for adults too. In adults, lead can cause: Increased chance of illness during pregnancy. 4 Harm to a fetus, including brain damage or death. Digestive, Problems Reproductive Problems (Adults) 4� Fertility problems (in men and women) ,O� High blood pressure. Digestive problems. Nerve disorders. Memory and concentration problems. Muscle and joint pain. or Nerve Damage - Hearing n� Least affects the body in many ways, 3 Where Lead -Based Paint Is Found if general, En homes built before 1978 have lead - $be older YOUr based paint. The federal government based banned lead -based paint from housing in home, the 1978. Some states stopped its use even More likely it earlier. Lead can be found: has lead- In homes in the city, country, or suburbs. based paint. � In apartments, single-family homes, and both private and public housing. Inside and outside of the house. In soil around a home. (Soil can pick up lead from exterior paint or other sources such as past use of leaded gas In cars.) Checking Your F'amilly for Lead To reduce your child's exposure to lead, Get your get your child checked, have your home children and tested (especially if your home has paint home tested in poor condition and was built before if you think 1978), and fix any hazards you may have. �'ur~�� Children's blood lead levels tend to increase rapidly from 6 to 12 months of age, and has high lee- tend to peak at 18 to 24 months of age. eis of lead. Consult your doctor for advice on testing your children. A simple blood test can detect high levels of lead. Blood tests are usually recommended for: Children at ages 1 and 2. Children or other family members who have been exposed to high levels of lead. Children who should be tested under your state or local health screening plan. Your doctor can explain what the test results mean and If more testing will be needed. 4 Identifying Lead Hazards Lead -based paint is usually not a hazard if it is in good condition, and it is not on an Lead from impact or friction surface, like a window.. it paint chips, is defined by the federal government as which you paint with lead levels greater than or equal c'!<i�0 and to 1,0 milligram per square centimeter, or more than 0.5% by weight. lead dust, Deteriorating lead -based paint (peeling, which you chipping, chalking, cracking or damaged) can't always is a hazard and needs immediate attention. see, can both It may also be a hazard when found on sur- be serious faces that children can chew or that get a hazards. lot of wear -and -tear, such as: Windows and window sills. Doors and door frames. +Oo Stairs, railings, banisters, and porches. Lead dust can form when lead -based paint is scraped, sanded, or heated. Dust also forms when painted surfaces bump or rub togeth- er. Lead chips and dust can get on surfaces and objects that people touch. Settled lead dust can re-enter the air when people vacuum, sweep, or walk through it. The following two federal standards have been set for lead hazards in dust: * 40 micrograms per square foot (Ug/ft2) and higher for floors, including carpeted Floors. * 250 pg/ft2 and higher for interior window sills. Lead in soil can be a hazard when children play in bare soil or when people bring soil into the house on their shoes. The following two federal standards have been set for lead hazards in residential soil; 400 parts per million (ppm) and higher in play areas of bare soil. 1,200 ppm (average) and higher in bare soil in the remainder of the yard. The only way to find out if paint, dust and soil lead hazards exist Is to test for them. The next page describes the most common meth- ods used. 5 Checking Your Home for Lead just knowing that a home has lead - based paint may not tell you of .there is a hazard. 10 You can get your home tested_ for lead in several different ways: ♦ A paint inspection tells you whether your home has lead -based paint and where it is located. It won't tell you whether or not your home currently has lead hazards. * A risk assessment tells you if your home currently has any lead hazards .from lead in. paint, dust, or soil. It also tells you what actions to take to address any hazards. A combination risk assessment and inspection tells you if your home has any lead hazards and if your home has any lead -based paint, and where the lead -based paint is located. Hire a trained and certified testing profes- sional who will use a range of reliable methods when testing your home. * Vlsual inspection of paint condition and location. * A portable x-ray Fluorescence (XRF) machine. * Lab tests of paint, dust, and soil samples. There are state and federal programs in place to ensure that testing is done safely, reliably, and effectively. Contact your state or local agency (see bottom of page 1 1) for more information, or call 1-800-424-LEAD (5323) for a list of contacts In your -area. Home test kits for lead are available, but may not always be accurate. Consumers should not rely on these kits before doing renovations or to assure safety, What You Can Do Now To Protect Your family If you suspect that your house has lead hazards, you can take some immediate steps to reduce your family's risk: if you rent, notify your landlord of peeling or chipping paint. • Clean up paint chips immediately. Clean floors, window frames, window sills, and other surfaces weekly. Use a mop or sponge with warm water and a general all-purpose cleaner or a cleaner made specifically for. lead. REMEMBER: NEVER M1X.AMMONIA AND BLEACH PRODUCTS TOGETHER SINCE -THEY CAN FORM A DANGEROUS GAS. Thoroughly rinse sponges and mop hearts after cleaning dirty or dusty areas. Wash children's hands often, especial- ly before they eat and before nap time and bed time. Keep play areas clean. Wash bottles, pacifiers, toys, and stuffed animals regularly. * Keep children from chewing window sills or other painted surfaces. Clean or remove shoes before entering your home to avoid tracking In lead from soil. Make sure children eat nutritious, low -fat meals high in iron and calcium, -such as spinach and dairy products. Children with good diets absorb less lead. Ked.ucing Lead Hazards In The Home Removing lead improperly can increase the hazard to your gas;lrnily by spreading even more lead dust around the house. Always use a professional who is trained to remove lead hazards safely. M. In addition to day-to-day cleaning and good nutrition: You can temporarily reduce lead hazards by taldng actions such as repairing dam- aged painted surfaces and planting grass to cover soil with high lead levels. These actions (called: "interim controls") are not permanent solutions and will need ongo- ing attention. To permanently remove lead hazards, YOU should hire a certified lead "abate- ment" contractor. Abatement (or perma- nent hazard elimination) methods include removing, sealing, or enclosing lead -based paint with special materials. Just painting over the hazard with regular paint is not permanent removal. Always hire a person with special training for correcting lead problems —someone who knows how to do this work safely and has the proper equipment to clean up thoroughly. Certified contractors will employ qualified workers and follow strict safety rules as set by their state or by the federal government. Once the work is completed, dust cleanup activities must be repeated until testing indicates that lead dust levels are below the following: 40 micrograms per square foot Cuglft2) for floors, including carpeted floors; * 250 jtg/ft7- for interior windows sills; and 400 I Wft2 for window troughs. Call your state 'or local agency (see bottom of page 11) for help in locating certified professionals in your area and to see if financial assistance is available. Rlmodel]IRS or Renovating a Home With Lead -Rased Faint Take precautions before your contractor or you. begin remodeling or renovating any- thing that disturbs painted surfaces (such as scraping off paint or tearing out walls): Have the area tested for lead -based paint. Do not use a belt -sander, propane torch, high temperature heat gun, dry scraper, or dry sandpaper to remove lead -based paint. These actions create large. amounts of lead dust and fumes. Lead, dust can remain In your home long after the work is done. 4� Temporarily move your family (espe- cially children and pregnant women) out of the apartment. or house until the work Is done and the area is prop- erly cleaned. If you can't move your family, at least completely seal off the work area. Follow other safety measures to reduce lead hazards. You can rind out about other safety measures by calling 1-800-424-LEAD. Ask for the brochure "Reducing Lead Hazards When Remodeling Your Home." This brochure explains what to do before, during, and after renovations. If you have already completed renova- tions or remodeling that could have released lead -based paint or dust, get your young children tested and follow the steps outlined on page 7 of this 1 brochure. I If not conducted properly, certain types of renova- tions can release least from paint and dust into the Air. 9 Other Sources of Lead Drinking water. Your home might have plumbing with lead or lead solder. Call your local health department or water supplier to find out about testing your Water. You cannot see, smell, or taste lead, and boiling your water will not get rid of lead. If you think your plumbing might have lead in it: • Use only cold water for drinking and While paint, dust, cooking. and soil are the . Run water for 15 to 30 seconds most common sources lead' before drinking it, especially if you .d other lead have not used your water for a few sources also exist.hours. The job. If you work with lead, you could bring it home on your hands or clothes. Shower and change clothes before coming home. Launder your work clothes separately from the rest of your family's clothes. 40o Old painted toys and furniture. Food and liquids stored In lead crystal or lead -glazed pottery or porcelain. Lead smelters or other industries that release lead into the air. Hobbles that use lead, such as making pottery or stained glass, or refinishing furniture. Folk remedies that contain lead, such as "greta" and "azarcon" used to treat an s upset stomach. t0 For More Information The National Lead Information Center Call 1-800-424-LEAD (424-5323) to learn how to protect children from lead poisoning and for other information on lead hazards. To access lead information via the web, visit www.epa.goy/lead and www.hud.govfoffices/lead/. EPA's Safe Drinking Water Hotline Call 1-800-426-4791 for information about lead in drinking water. Consumer Product Safety Commission (CPSC) Hotline To request information on lead in consumer products, or to report an ! unsafe consumer product or a prod- ;T; =_ uct-related Injury call 1-800-638- 2772, or visit CPSC's Web site at: O www.cpsc.gov. Health and Environmental Agencies Some cities, states, and tribes have their own rules for lead -based paint activities. Check with your local agency to see which laws apply to you. Most agencies can. also provide information on finding a lead abatement firm in your area, and on possible sources of financial aid for reducing lead hazards. Receive up -to -elate address and phone information for your local con- tacts on the Internet at www.epa.gov/lead or contact the National Lead Information Center at .1-800-424-LEAD. For the hearing impaired, call the Federal Information Relay Service at 11-800-877-833Vto access any of the phone numbers in this brochure. EPA Regional Offices Your Regional EPA Office can provide further information regard- ing regulations and lead protection programs. EPA Regional Offices Region 1 (Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont) . Regional Lead- Contact U.S. EPA Region I Suite 1 100 (CPT) One Congress Street Boston, MA 021 14-2023 1 (888) 3 72-7341 Region 2 (New Jersey, New York, Puerto Rico, Virgin Islands) Regional Lead Contact US..EPA Region 2 2890 Woodbridge Avenue Building 209, Mail Stop 225 Edison, NJ 06837-3679 (732) 321.-6671 Region 3 (Delaware, Maryland, Pennsylvania, Virginia, Washington DC, West Virginia) Regional Lead Contact U,S. EPA Region 3 (3WC33) 1650 Arch Street Philadelphia, PA 19103 (215) 814-5000 Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee) Regional Lead Contact U.S. EPA.Reglon 4 61 Forsyth Street, SW Atlanta,. GA 30303 (404) 562-8998 Region 5 (Illinois, Indiana, Michigan Minnesota, Ohio, Wisconsin) Regional Lead Contact U.S. EPA Region 5 (DT-81) 77 West Jackson Boulevard Chicago, IL 60604-3666 (312) 886-6003 12 Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, Texas) Regional Lead Contact U.S. EPA Region 6 1445 Ross Avenue, 12th Floor Dallas, TX 75202-2733 (214) 665-7577 Region 7 (Iowa, Kansas, Missouri, Nebraska) Regional Lead Contact U.S.. EPA Region 7 (ARTD-RALI) 901 N. 5th Street Kansas City, KS 66101 (913) 551-7020 Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming) Regional Lead Contact U.S. EPA Region 8 999 18th Street, Suite 500 Denver, CO 80202-2466 (303) 312-6021 Region.9 (Arizona, California, Hawaii, Nevada) Regional Lead Contact U.S. Region 9 75 Hawthorne Street San Francisco, CA 94105 (415)947-4164 Region 10 (Alaska, Idaho, Oregon, Washington) Regional. Lead Contact US. EPA Region 10 Toxics Section WCM-128 1200 Sixth Avenue Seattle, WA 9810 1 -1128 (206) 553-1985 CPSC Regional Offices Your Regional CPSC Office can provide further information regard- ing regulations and consumer product safety. Eastern Regional Center Western. Regional Center Consumer Product Safety Commission Consumer Product Safety Commission 201 Varick Street, Room 903 1301 Clay Street, Suite 610-N New York, NY 10014 Oakland, CA 94612 (212) 620-4120 (510) 637-4050 Central Regional. Center Consumer Product Safety Commission 230 South Dearborn Street, Room 2944 Chicago, IL 60604 (312) 353-8260 HUD Lead Office Please contact HUD's Office of Healthy Homes and Lead Hazard Control for information on lead regulations, outreach efforts, and lead hazard control and research grant programs. U.S.. Department of Housing and Urban Development Office of Healthy Homes and Lead Hazard Control 451 Seventh Street, SW, P-3206 Washington, DC 20410 (202) 755-1785 This document is in the public domain. It may be reproduced by an Individual or organization without permission. Information provided In this booldet Is based upon current scientific and technical understanding of the issues presented and Is reflective of the jurisdictional boundaries established by the statutes governing the cc -authoring agencies. Following the advice given will not necessarily pro- vide complete protection in all situations or against all health hazards that can be caused by lead exposure.. U.S. EPA Washington DC 20460 EPA747-K-99-001 U.S. CPSC Washington DC 20207 June 2003 U.S. HUD Washington DC 20410 13 Exhibit F Interval House TBRA Program Budget Huntington Beach, California Contract 2017/18 HOME Funds TBRA & Security Deposits "2 147,278 HQS Inspections 3 10,000 Income Eligibility" 8,000 Total Home Funds 165,278 City Inclusionary s 37,000 Total City Contract 202,278 Interval House Funding Sources 6 106,964 Total Budget 309,242 1 Approximately 11 Eligible Households can receive assistance for 6 to 12 months per year z Assumes 20 inspections per year at $500 per inspection. Assumes inspections every six months for each 3 Eligible Household and some households will need more than one inspection before move -in. Average of 10 hours per Housing Unit. Activities will include inspection advocacy with landlord, agreements with landlord, inspection on -site, travel time, review and approval, and follow-up. ° Assumes 20 screenings per year at $400 per screening in 2017/18 fiscal yar. Assumes income eligibility screenings every six months for each adult and some households will have more than one adult. Average of 8 hours per adult with income. Activities will include income documentation screening, verification and review, calculation of gross, adjusted, exclusions, advocacy with client on income, and follow up. 5 Includes ineligible administrative costs under the HOME Program, such as Intake Assessment, Housing Search, Case Management, Self -Sufficiency, related Support Services, and Overhead. 6 Includes ineligible administrative costs under the HOME Program, such as Intake Assessment, Housing Search, Case Management, Self -Sufficiency, related Support Services, and Overhead that will be funded with other funding sources available to Interval House. Exhibit G Housing Quality Standards (HQS) Inspection Checklist Inspection Checklist U.S. Department of Housing OMB Approval No. 2577-0169 and Urban Development (Exp. 04/30/2018) Housing Choice Voucher Program Office of Public and Indian Housing Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number Assurances of confidentiality are not provided under this collection. This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The information is used to determine if a unit meets the housing quality standards of the section 8 rental assistance program. Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of the name and address of both family and the owner is mandatory. The information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation. Name of Family Tenant ID Number Date of Request (mm/dd/yyyy) Inspector Neighborhood/Census Tract Date of Inspection (mmlddlyyyy) Type of Inspection —7-1Date of Last Inspection (mmldd/yyyy) PHA Initial Special Reinspection 0 A. General Information Inspected Unit Year Constructed (yyyy) 0 Hoiusing Type (check as appropriate; Single Family Detached Full Address (including Street, City, County, State, Zip) Duplex or Two Family 0 Row House or Town House Low Rise: 3, 4 Stories, Including Garden Apartment Number of Children in Family Under 6 0 High Rise; 5 or More Stories F-1 0 0 Manufactured Home Congregate Cooperative Owner Name of Owner or Agent Authorized to Lease Unit Inspected Phone Number Independent Group 0 Residence Single Room Occupancy Address of Owner or Agent Shared Housing 0 Other B. Summary Decision On Unit (To be completed after form has been filled out Pass Number of Bedrooms for Purposes Number of Sleeping Rooms Fail of the FMR or Payment Standard Inconclusive Inspection Checklist Ilan No. 1. Living Room Yes Pass No Fail In- Conc. Comment Final Approval Date (mm/dd/yyyy) 1.1 Living Room Present 1.2 Electricity 1.3 Electrical Hazards 1.4 Security 1.5 Window Condition 1.6 Ceiling Condition 1.7 Wall Condition 1.8 Floor Condition Previous editions are obsolete Page 1 of 8 form HUD•52580 (4/2015) ref Handbook 7420.8 eq form - HB HOME Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room); 2 = Dining Room or Dining Area, 3 = Second Living Room, Family Room, Den, Playroom, TV Room, 4 = Entrance Halls, Corridors, Halls, Staircases, 5 = Additional Bathroom, 6 = Other Item 1, Living Room (Continued) No. Yes Pas No Fail In- Conc. Comment Final Approval Date mm/dd/ 1.9 Lead -Based Paint Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 2. Kitchen 2.1 Kitchen Area Present 2.2 Electricity 2.3 Electrical Hazards 2.4 Security 2.5 Window Condition 2.6 Ceiling Condition 2.7 Wall Condition 2.8 Floor Condition 2.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 2.10 Stove or Range with Oven 2.11 Refrigerator 2.12 Sink 2.13 Space for Storage, Preparation, and Serving of Food 3. Bathroom 3.1 Bathroom Present 3.2 Electricity 3.3 Electrical Hazards 3.4 Security 3.5 Window Condition 3.6 Ceiling Condition 3.7 Wall Condition 3.8 Floor Condition 39 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 3.10 Flush Toilet in Enclosed Room in Unit 3.11 Fixed Wash Basin or Lavatory in Unit 3.12 Tub or Shower in Unit 3.13 Ventilation Previous editions are obsolete Page 2 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 BCj ft ; HB HOME Item No. 4. Other Rooms Used For Living and Halls 4.1 Room Code" and Room Location I Pass j Fail 'Cone; comment (Circle One) (Circle One) Right/Center/Left Front/Center/Rear Floor Level Final Approval 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition I 4.8 Floor Condition 4.9 Lead -Based Paint -._.._......... ........--......_. `❑ Not Applicable _ - Are all painted surfaces free of deteriorated paint? 1 If not, do deteriorated surfaces exceed two I square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors t 4.1 Room Code" and (Circle One) (Circle One) ❑ Room Location RighUCenter/Left Front/Center/Rear _Floor Level 1-, _ .. _ _.__. .. .. ..� - 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition ; 4.6 Ceiling Condition t ) 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint ❑ Not Applicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? 4.10 Smoke Detectors 4.1 Room Code' and ❑ (Circle One) (Circle One) Room Location RighUCenter/Left Front/Center/Rear _Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition i 4.8 Floor Condition 4.9 Lead -Based Paint ❑'NotApplicable Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? i i ( i € I Previous editions are obsolete Page 3 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Item 4. Other Rooms Used For Living and Halls No. Yes Pass No Fail In, Cone. Comment Final Approval Date (mm/dd/yyyy) 4.1 Room Code* and Room Location (Circle One) (Circle One) RighUCenter/Left Front/Center/Rear Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 4.1 Room Code' and (Circle One) (Circle One) Room Location Right/Center/Left Front/Center/Rear Floor Level 4.2 Electricity/Illumination 4.3 Electrical Hazards 4.4 Security 4.5 Window Condition 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition 4.9 Lead -Based Paint Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed two square feet per room and/or is more than 10% of a component? Not Applicable 4.10 Smoke Detectors 5. All Secondary Rooms (Rooms not used for living) 5.1 None Go to Part 6 5.2 Security 5.3 Electrical Hazards 5.4 Other Potentially Hazardous Features in these Rooms Previous editions are obsolete Page 4 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 Item 6. Building Exterior No. Yes Fag ", No Fail In- ono Final Approval Comment Date(mm/dd/yyyy) 6.1 Condition of Foundation 6.2 Condition of Stairs, Rails, and Porches 6.3 Condition of Roof/Gutters 6.4 Condition of Exterior Surfaces 6.5 Condition of Chimney 6.6 Lead Paint: Exterior Surfaces Are all painted surfaces free of deteriorated paint? If not, do deteriorated surfaces exceed 20 square feet of total exterior surface area? Not Applicable 6.7 Manufactured Home: Tie Downs 7. Heating and Plumbing 7.1 Adequacy of Heating Equipment 7.2 Safety of Heating Equipment 7.3 Ventilation/Cooling 7.4 Water Heater 7.5 Approvable Water Supply 7.6 Plumbing 7.7 Sewer Connection 8. General Health and Safety 8.1 Access to Unit 8.2 Fire Exits 8.3 Evidence of Infestation 8.4 Garbage and Debris 8.5 Refuse Disposal 8.6 Interior Stairs and Commom Halls 8.7 Other Interior Hazards 8.8 Elevators 8.9 Interior Air Quality 8.10 Site and Neighborhood Conditions 8.11 Lead -Based Paint: Owner's Certification Not Applicable If the owner is required to correct any lead -based paint hazards at the property including deteriorated paint or other hazards identified by a visual assessor, a certified lead -based paint risk assessor, or certified lead -based paint inspector, the PHA must obtain certification that the work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice. Receipt of the completed and signed Lead -Based Paint Owner Certification signifies that all HQS lead -based paint requirements have been met and no re -inspection by the HQS inspector is required. Previous editions are obsolete Page 5 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 C. Special Amenities (Optional) This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present. Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in decisions about renting the unit and the reasonableness of the rent. Check/list any positive features found in relation to the unit. High quality floors or wall coverings J Working fireplace or stove Balcony, patio, deck, porch Special windows J or doors Exceptional size relative to needs of family Other: (Specify) 2. Kitchen Dishwasher Separate freezer Garbage disposal — Eating counter/breakfast nook Pantry or abundant shelving or cabinets Double oven/self cleaning oven, microwave Double sink — High quality cabinets — Abundant counter -top space Modern appliance(s) — Exceptional size relative to needs of family Other: (Specify) 3. Other Rooms Used for Living High quality floors or wall coverings j� Working fireplace or stove Balcony, u� patio, deck, porch Special windows or doors Exceptional size relative to needs of family Other. (Specify) 71 4. Bath Special feature shower head Built-in heat lamp Large mirrors Glass door on shower/tub Separate dressing room Double sink or special lavatory —1 Exceptional size relative to needs of family Other: (Specify) 5. Overall Characteristics Storm windows and doors Other forms of weatherization (e.g., insulation, weather stripping) Screen doors or windows Good upkeep of grounds (i.e., site cleanliness, landscaping, condition of lawn) — Garage or parking facilities — Driveway Large yard Good maintenance of building exterior Other: (Specify) 6. Disabled Accessibility Unit is accessible to a particular disability. ❑ Yes ❑ No Disability Previous editions are obsolete Page 6 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 1. Does the owner make repairs when asked? Yes No 2. How many people live there? 3. How much money do you pay to the owner/agent for rent? $ . 4. Do you pay for anything else? (specify) _ 5. Who owns the range and refrigerator? (insert O = Owner or T = Tenant) Range _ Refrigerator Microwave❑ 6. Is there anything else you want to tell us? (specify) Yes1-1 No ❑ Previous editions are obsolete Page 7 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 E. Inspection Summary/Comments (Optional) Provide a summary description of each item which resulted in a ratin of "Fail' or "Pass with Comments." Tenant ID Number I Inspector T Date of Inspection (mm/dd/yyyy) Address of Inspected Unit type of Inspection Initial Special Reinspection Item Number Reason for "Fail' or "Pass with Comments" Rating Continued on additional page Yes 1:1No Previous editions are obsolete Page 8 of 8 form HUD-52580 (4/2015) ref Handbook 7420.8 A17 DATE (Mid/DD/YYYY) �COREP CERTIFICATE OF LIABILITY INSURANCE 7/14/20M/ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER krthur J. Gallagher & Co. nsurance Brokers of CA, Inc. LIC #0726293 i05 N Brand Blvd, Suite 600 3lendale CA 91203 INSURED INTEHOU-03 Interval House P.O. Box 3356 Seal Beach, CA 90740 NGk' Mei Cha iA"/c°Nuo Exe: 818-539_2300 - - 1 (A/c. No. 818 539-2301 - E MAILSS _ Mei ADORE _chan@a COm j9' INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Berkley National Insurance Company 138911 INSURER B:New York Marine And General Insurance •16608 INSURER D : F: CCIVFRAGFS CFRTIFICATF NIIMRFR. 25735552 RFVICInN NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD I WVD I POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y HHS8525626-10 10/112016 10/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE XI OCCUR APPROVED AS TO © M PRE�NAI�SE56 as occ rrence $100,000 - X X GEN'LAGGREGATE X Sexual Abuse Lia 1MM/3MM I E. GA $ CITY ATTORNEY CITY OF HUNTINGTON BEACH ` MED EXP (An one person) PERSONAL & ADV INJURY $5,000 $1,000,000 LIMIT APPLIES PER: POLICY , PE u LOC OTHER: GENERAL AGGREGATE $3,000,000 PRODUCTS - COMP/OP AGG $3,000,000 professional Liab $1MM/3MM AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMI I Ea accident)$ BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ - HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Per accident) $ A UMBRELLA LIAB X OCCUR HHN 8565362-10 10/112016 10/1/2017 EACH OCCURRENCE $2,000,000 X EXCESS LIAB CLAIMS -MADE AGGREGATE $2,000,000 DED X RETENTION $0 Sexual misconduct $Included B WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N /A Y WC201700005078 2/1/2017 2/1/2018 X STATUTE STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE --" -- $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $1,000,000 A ACrime Property Coverage -Theft Forgery & Alteration HHS6525626-10 1HHS8525626-10 HHS8525626-10 10/112016 10/1/2016 10/112016 10/1/2017 Limit: $4,339,200 Deductible: $1,000 10/1/2017 Limit:300,000 Ded:$1,000 10/1/2017 Iimit:$300,000 Ded $1000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Policy: Cyber Liability, Policy#:NET 1-28-06-74-01,Retro Date:7/1/2016 Term:7/1/2016 to 10/1/2017 Limit /Aggregate: 1,000,000 Retention:$5,000 Re:Certificate holder is named additional insured with respect to the operations of the named insured. Waiver of Subrogation for Workers Compensation policy applies in favor of certificate holder. CFRTIFICATF Hnl-DER CANCFI 1 ATInN1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Huntington Beach Economic Development Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Denise Bazant ACCORDANCE WITH THE POLICY PROVISIONS. 2000 Main St., 5th Floor Huntington Beach CA 92646 AUTHORIZED REP ESENTATIVE �V © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5.00% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description City of Huntington Beach City of Huntington Beach, Economic Development Dept Attn: Denise Bazant Huntington Beach, CA 92468 Re: Contract#]HCS0617. The City of Huntington Beach, its officers, elected or appointed officials, employees, agents, and volunteers All Operations of the Named Insured This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 2017-02-01 Insured Interval House Insurance Company New York Marine and General Insurance Company / 28746 WC 04 03 06 Policy No. Endorsement No. WC201700005078 Countersigned By (Ed. 04-84) ©1998 by the workers' Compensation Insurance Rating Bureau of California. All rights reserved. POLICY NUMBER: HHS8525626-10 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 Berkley National Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of Huntington Beach Economic Development Department Attn: Denise Bazant 2000 Main St., 5th Floor Huntington Beach CA 92646 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury' caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1, In the performance of your ongoing operations; or 2, In connection with your premises owned by or rented to you. However: 1, The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 O Insurance Services Office, Inc., 2012 Page 1 of 1 CERTIFICATE OF LIABILITY INSURANCE PATE/08/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER STEVE DWIGHT State Farm 4625 E ANAHEIM ST ® LONG BEACH, CA 90804 CONTACT PO BOX NAME: Fax 562-597-6680 PHCONENo Ex 562-494-4494 AIC No ADDRESS: patty.driessen.isbe@statefarm.com INSURER(S) AFFORDING COVERAGE NAICR INSURERA:State Farm Mutual Automobile Insurance Company 25178 INSURED INTERVAL HOUSE PO BOX 3356 SEAL BEACH, CA 90740 INSURER B: INSURERC: INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL S BR POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE S AMA E TO RENTED PREMISES Ea occurrence S MED EXP (Any one person) S PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PRO LOC JECT OTHER: GENERAL AGGREGATE S PRODUCTS - COMPIOP AGG S S A AUTOMOBILE X X LIABILITY 1 ANY AUTO SCHEDULED AUTOS AUTOS ALL OWNED 1xxx HIRED AUTOS AUTOS 076-7305-007-75D 003-9955-F29-751 032 4308-C21-751NON-OWNED 292.2671-C19-756X 03/07/2017 03/0712018 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per parson) S BODILY INJURY (Per accident) S Perr accidenlDAMAGE$x s UMBRELLA LIAB EXCESS LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE S AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERRAEMBER EXCLUDED? r (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS balow NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYE — S E.L. DISEASE - POLICY LIMIT I S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER IS NAMED ADDITIONAL INSURED WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED, GtK I It-llI t HULUtK (;AN(;tLLAI-ION CITY OF HUNTINGTON BEACH ECONOMIC DEVELOPMENT DEPARTMENT ATTN: DENISE BAZANT 2000 MAIN ST 5TH FLOOR HUNTINGTON BEACH, CA 92646 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. n 1ARR_2n1A ACr)Ri) Cr)RPORATInN All rinhfs rPCPR/P!f ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 City of Huntington Beach 2000 Main Street ♦ Huntington Beach, CA 92648 (714) 536-5227 ♦ www.huntingtonbeachca.gov Office of the City Clerk Robin Estanislau, City Clerk August 28, 2017 Interval House Attn: Carol Williams Interval House 6615 E. Pacific Coast Highway, #170 Long Beach, CA 90803 Dear Ms. Williams. - Enclosed is a copy of the fully executed "Home Recipient Agreement Between the City of Huntington Beach and Interval House" to administer a tenant -based rental assistance (TBRA) program for one year. Sincerely, 20 10 � =1 W4E N Robin Estanislau, CIVIC City Clerk RE:pe Enclosure Sister Cities: Anjo, Japan ♦ Waitakere, New Zealand