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HomeMy WebLinkAboutContracts & Agreements_175-2008_CCv0001.pdf INDEPENDENT CONTRACTOR AGREEMENT This Agreement is made and entered into this 21 st day of October, 2008 ("Effective Date")by and between the City of Redlands,a municipal corporation(hereinafter"City")and Developing Aging Solutions with Heart,Inc.(hereinafter"Contractor"). City and Contractor are sometimes individually referred to herein as a"Party" and, together, as the "Parties." RECITALS WHEREAS, Contractor has expressed an interest in providing geriatric care management services,including counseling,educational assistance,and access to community resources, for both dependent adults with Alzheimers and their caregivers(the"Services"); and WHEREAS, Contractor has represented to City that it has the requisite experience, special knowledge and expertise similar to others in the industry performing such Services; NOW,THEREFORE,in consideration of the mutual promises contained herein,City and Contractor hereby agree as follows: AGREEMENT Section 1 Services A. City hereby authorizes Contractor to provide geriatric care management services, including counseling, educational assistance, and access to community resources, for both dependent adults with Alzheimers and their caregivers. B. Contractor shall determine the method, details and means of performing the Services and shall advise City of the same prior to commencing the performance of any Services. Contractor further agrees to perform the Services to the best of its ability and in an efficient, safe and competent manner. C. As compensation for conducting the Services, City shall reimburse Contractor in accordance with applicable Federal, State, County and City rules and regulations. Contractor's total compensation shall not exceed $6,000.00. D. Contractor shall submit to City a complete record of the Services performed including, but not limited to: copies of invoices, agreements, payroll expenses, administrative records, advertisements, and backup materials. A detailed account of the Services performed, the persons performing the L\ca\djm�Agreements\UASH 2008-09 Independent Contractor's Agreement-doe 1 I Services and cost breakdown shall also be provided to City. Administration and personnel records shall be available for examination by City. E. Contractor shall submit to City with each request for reimbursement documentation in compliance with the requirements of 24 CFR 570.503 including: Agreements with Subrecipients, Statement of Work,Records and Reports; Program Income; Uniform Administrative Requirements; Other Program Requirements,Conditions for Religious Organizations;Suspension and Termination; Reversion of Assets. F. Contractor shall submit to City, with each request for reimbursement, documentation that at least 51% of the adult dependents served are from income qualifying households. In order to document the number of low and moderate income adult dependents benefiting from the program, a Beneficiary Qualification Statements form,a copy of which is attached hereto and incorporated herein by reference as Exhibit "A", must be completed by Contractor for each adult dependent that benefits from the program. Using the Beneficiary Qualification Statements prepared for each adult dependent, Contractor must complete the Monthly Program Progress Report form,a cope of which is attached hereto and incorporated herein by reference as Exhibit "B", for every month that CDBG funds are expended, and submit such Monthly Program Progress Reports with Contractor's monthly reimbursement request to City. Copies of all submitted forms must be retained in Contractor's records for a minimum period of three (3) years from the Effective Date of this Agreement. G. Contractor shall submit all final claims for reimbursement to City no later than May 1, 2009. H. City will submit a final Request for Reimbursement for the program year no later than July 15, 2009. After July 31, 2009 any balance remaining in the account will be reprogrammed. Section 2. Independent Contractor. It is the express intention of the Parties that Contractor is an independent contractor and not an employee or agent of City. Nothing in this Agreement shall be interpreted or construed as creating or establishing a relationship of employer and employee between Contractor and City. The Parties acknowledge that Contractor is not an employee for State tax, Federal tax or any other purpose. ] ca4mlAgreemcnts'DA4}3 2008-09 Independent Contractor's Acreement,doc 2 Section 3. Contractor's Employees. A listing of all of Contractor's employees and agents who may participate in the performance of Contractor's obligations hereunder is attached hereto as Exhibit "C" and incorporated herein by this reference. No other employees or agents of Contractor shall participate in the performance of the Services without the prior written consent of City. Section 4. Termination. City shall have the right to terminate this Agreement,with or without cause,upon twenty(20)day's prior written notice to Contractor. City shall have no liability for any claims or damages resulting to Contractor as a result of any exercise by City of its right to terminate this Agreement. Section 5. Insurance and Indemnification 5.1 Contractor's Insurance to be Primary All insurance required by this Agreement is to be maintained by Contractor during its performance of the Services and shall be primary with respect to City and non-contributing to any insurance or self-insurance maintained by City. Contractor shall not perform any Services pursuant to this Agreement unless and until all required insurance listed below is obtained by Contractor. Contractor shall provide City with Certificates of Insurance and endorsements evidencing such insurance prior to commencement of the Services. All insurance policies shall include a provision prohibiting cancellation or modification of coverage limits of the policy except upon thirty (30) days prior written notice to City. 5.2 Workers' Compensation and Employer's Liability. Contractor shall secure and maintain Workers' Compensation and Employer's Liability insurance throughout the duration of this Agreement in amounts-which meet statutory requirements with an insurance carrier acceptable to City. 5.3 Comprehensive General Liability Insurance. Contractor shall secure and maintain in force throughout the duration of this Agreement comprehensive general liability insurance with carriers acceptable to City. Minimum coverage of one million dollars ($1,000,000) per occurrence and two million dollars ($2,000,000) aggregate for public liability,property damage and personal injury is required. Contractor shall obtain and deliver to City certificates and endorsements that City shall be named as an additional insured. 5.4 Professional Liability Insurance. Contractor shall secure and maintain professional liability insurance throughout the duration of this Agreement in the amount of one million dollars ($1,000,000)per occurrence. 5.5 Business Auto Liability Insurance Contractor shall have business auto liability coverage,with minimum limits of one million dollars($1.000,000)per occurrence, combined single limit for bodily injury liability and property damage liability. This coverage shall include all Consultant owned vehicles used in connection with the performance of the Services.hired and non-owned vehicles,and employee non-ownership vehicles. Contractor shall obtain certificates and endorsements that City shall be named as an additional insured. I:%ea,djnn'kAgreements,DASH 2008-09 Independent Contractor's Agreement.doc 5.6 Assignment and Insurance Requirements Contractor is expressly prohibited from subletting or assigning any of the Services without the express prior written consent of City. In the event of mutual agreement between Parties to sublet a portion of the Services, Contractor shall add the subcontractor as an additional insured and provide City with the insurance endorsements prior to any work being performed by the subcontractor. Assignment does not include printing or other customary reimbursable expenses that may be provided in this Agreement. 5.7 Hold Harmless and Indemnification. Contractor shall defend,indemnify and hold harmless City,its elected officials,officers,employees and agents,from and against any and all actions, claims, demands, lawsuits, losses and liability for damages to persons or property, including costs and attorney fees, that may be asserted or claimed by any person, firm, entity, corporation, political subdivision or other organization arising out of or in connection with Contractor's negligent and/or intentionally wrongful acts or omissions under this Agreement. Section 6. Health Insurance Portability And Accountability Act of 1996 Pursuant to the Health Insurance Portability And Accountability Act of 1996(HIPAA),regulations have been promulgated governing the privacy of individually identifiable health information. The HIPAA Privacy Regulations specify requirements with respect to contracts between an entity covered under the HIPAA Privacy Regulations and its Business Associates. A Business Associate is defined as a party that performs certain services on behalf of,or provides certain services for, a Covered Entity and, in conjunction therewith, gains access to individually identifiable health information. Therefore, in accordance with the HIPAA Privacy Regulations, Contractor shall comply with the terms and conditions as set forth in the attached Business Associate Agreement,Exhibit"D"hereby incorporated by this reference. Section 7. Entire Aueement/Modification. This Agreement represents the entire Agreement of the Parties with respect to the matters contained herein. Any modification of this Agreement will be effective only if it is in meriting and signed by the Parties. Section 8. Assi ng ment. This Agreement shall not be assigned without the prior written consent of City. Any assignment, or attempted assignment, without such prior written consent, shall be null and void and, at the option of City, result in the immediate termination of this Agreement. I,C&djrn,AgreementskDAsl{2008-09 Independent Contractor's Agreernent_Ioc 4 Section 9. Attorney's Fees. In the event any action is commenced to enforce or interpret the terms or conditions of this Agreement,the prevailing party shall,in addition to any casts or ether relief, be entitled to recover its reasonable attorneys' fees, including fees for use of in-house counsel by a Parity. Executed this / ` day of o C',�6 ht-w-.- 2005. City of Redlands Date: Jq Harrison, Mayor ,. Attest. _t -71 LzityeYzer,. %Clerk fRedlands Developing Aging Solutions with Heart, Inc. g � r' t b r_ f f X _ r, i Dae: r ; C;:J)o uments and Settings",mpetite.0 OFR tTocal Settings;;temporary Internet Files(_,1t.K 'J)ASl 12008-09 Independent Contractor's Agr€:ement.doc 9/23/08 3:56 p.m. ATTACHMENT A-REQUEST TO INITIATE PROJECT/ACTIVITY PROJECT NUMBER: 111-28127 DATE OF ORIGINAL ISSUE: April 17, 2003 CASE NNUMBER: 2288 ORIGINAL: REVISION No.: 6 TARGET AREA: Redlands DATE OF REVISION: AMq V Pursuant to the terms of the Delegate Agency Agreement between the .Department of Community Development and Housing (CDH)and the City of Redlands,dated 06/13/06,CDH hereby requests that the following project/activity be initiated. There will be no changes in Project/Activity Title, Activity Budget(Attachment A)or in the Activity Description (Attachment B)without written approval of the Director of the Department of Community Development and Housing, PROJECT/ACTIVITY TITLE: Redlands: Geriatric Care Services for Family Caregivers-DASH ACTIVITY LOCATIOhL TOTAL PROTECT FL?NDING: $ 32,500 306 W. Colton Ave., CITY CDBG ALLOCATION Redlands,CA 92374 RELEASED: S---32,500 CITY CDBG FUNDS EXPENDED AS OF: 07/22,'08 26,500 DATE OF RELEASE OF FUNDS: 0715,'08 :BALANCE OF FUNDS AVAILABLE: $ 6,000 SCHEDULE OF CITY'CDBG ALLOCATICtItiI: Years 1-28 Year 29 Year 30 Year 31 Year 32 Year 33 Year 34 Act# Act# Act# Act# Act# Act## 4785 Act# TOTAL OF (75-2003) (20(}3-04) 2004-0� 2005-061 2006-Qa 2007-081 (2008-49Z 34 YES $3,500 $3,000 $5,000 $5,000 $5„000 $5.000 $6,000 $32,500 MAINTENANCE AND OPERATION BUDGET/AGREEMENT: The City will enter into a contract with Developing Aging Solutions with Heart, Inc. (DASH),for the 2008-09 Program Year. OTHER PERTINENT INFORMATION: Revision#6 adds an additional$6,000 of FY 2008-09 CDBG funds to this program. ACCEPTANCE OF REQUEST TO INITIATE PROJECT/ACTIVITY I hereby acknowledge the receipt of the Request to Initiate the above Prrojectf`Activity and agree to implement the activity described in Attachment B(ProjectfAetivity Description)in accordance with the above Allocation and Balance of Funds Available subject to necessary approvals of the Beard of Supervisors. The proposed budget for this project is as follows: LAND ACQUISITIONT: -0- Pt�IRC�E C}FESC LrIPI FNT:. S.. -0- STAFF COST RELATED CONSTRUCTION COST: $ TO LAND ACQUISITION: $______ -0- CITY STAFF COST: $� -0- DESIGN: $ -0- CONTINGENCY: $ .0- CONSULTANT SERVICES: S6.000 TOTAL CITY CDBG ALLOCATION RELEASED FOR REVISION #6: $ 6,000 IMPLEMENTMG . Redlands DATE: � r SIGNATURE: COU-.+g -Y'C I~ SAN BER ARDINO ( V e �) DIRECTOR DATE: IEIARI`MINT O C3?fIl NITY DEVELOPMENT ANf31IE�I.SIN€� ATTACHIMENT B-PROJECT/ACTIVITY DESCRIPTION' ROJECT NUMBER: 111-281277 DATE OF ORIGINAL ISSUE: April 17, 2003 CASE NUMBER- 2288 OR1.t-..,I AL- REVISION No.: 6 TARGET AREA. Redlands DATE OF REVISION AUG 0 7 Mi PROJECLAC`I'IVITY TITLE: Redlands:Geriatric Care Services for Family Caregivers-DASH ACTIVITY LOCATION: 306 W. Colton Ave.,Redlands,CA. ACTIVITY DESCRIPTION: The City of Redlands will contract with the Developing Aging Solutions with Heart,Inc.(DASH)to reimburse DASH,Inc.,for authorized expenditures related to the provision of geriatric care management services, including counseling, educational assistance, and access to community resources for both dependent adults with Alzheimer's and their caregivers. The purpose of this program is to help caregivers apply more effective care-giving strategies for their adult dependents. The Department of Community Development and Housing will reimburse the City of Redlands in an amount not to exceed the"CDBG Allocation Released"on the Attachment A for the services necessary to implement this program.Federal,State,County and City rules and regulations will apply. DASH sha1l sign a contract with the City of Redlands addressing the scope of service and the terms and conditions. The contract shall remain in effect during the period that the services are provided for which CDBG funds will be requested for reimbursement The contract with DASA shall comply with requirements listed in 24 CFR 570.503 including:Agreements with Subrecipients,Statement ofWork;Records and Reports; Program Income;Uniform Administrative Requirements;Other Program Requirements;Conditions for Religious Organizations;Suspension and Termination,Reversion of Assets. In addition,DASA shall comply with all applicable regulations listed in the City-County Delegate Agency Agreement,x-528,Attachment C, Section IV. City shall maintain monthly program reports and records on the services provided. CDBG funds cannot be used for entertainrnent; gifts or fiord-raising activities. Reimbursement expenditures must be appropriately documented. City shall comply with conflict of interest provisions and shall not exclude any persons from,funded programs on the grounds of race,sex,creed,color,religion or national origin. This program is available to caregivers and their dependents with Alzhei ers and requires documentation that at.least 51%of the adult dependents benefiting from this program are loco-and moderate-income. In order to document that 51%ofthe adult dependents benefiting from the geriatric care management program are income-qualifying,a Beneficiary Qualification Statement(Exhibit I of 2)must be completed for each adult dependent who benefits from the program. This form is available in both English and Spanish.The Beneficiaq,Qualification Statement will then be used to complete and submit the Program ProgresslDirect Benefit Report(Exhibit 2 of 2)to the County Department of Community Development and Housing. The Program ProgresslDirect Benefit Reports must be submitted to the County for each month that CDBG reimbursement is requested. The units of service must be reported on Part I-Program Progress Report, (Exhibit 2 of 2). A unit of service is defined as one adult dependent participating in one geriatric care management session. DASH will provide a measurable outcome with quantifiable results for the duration of this contract. The measurable outcome will be recorded on Part II-Direct Benefit Report(Exhibit 2 of 21)and will consist of the number of unduplicated first-time clients(adult dependents)who participate in the program. The City of Redlands will submit a final Request for Reimbursement for the program year no later than July 15,2009. Mote:After July 31,2009,any balance remaining in this account willbe reprogrammed. IMPLEMENTING G CITY: Rc4lands �x� DATE SIGNATURE TITLE, DEPARTMENIT OF COMMUNITY DEVELOPMENT AND HOUSING ly DIRECT )R DATE COMDEV,CONSTRUCT€JOGS—aA&Ws'',-A B's 208T18 Redlands Ceriaurc Care`emices rf A&B 2288 Nfl- t e 07il6!08,NS!cb EXHIBIT 1 _of COL':^+sTY OF SAN BERilARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING Project,'Activrity Title: Case Number: 111-28127/2288 Redlands: Geriatric Care Services for Family Caregivers—DASH NimWAddress of Contractor Agency: Date of Issue: Developing Aging Solutions with Heart,Inc. Original:04/17/03 306 West Colton Ave, X Amendment No.6 Beginning 07/01/08 Redlands, CA 92374 BENEFICIARY QUALIFICATION STATEMENT This form has the purpose of providing information needed to qualify the use of federal Community Development Block Grant(CDBG) funds for the project/activity described above. This statement must be completed and signed by the person (or legal guardian of the person)requesting to receive benefits from the described project/activity. Only one statement per person,per year is required. Please answer each of the following questions. I. This question helps you determine the size of your household. For this question a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters, roomers, or borders cannot be included as household members. How many persons are in your household? 2. This question asks if you are from a low-and moderate-income household. For this question, a list of the 2008 EXTREMELY LOW-INCOME, LOW-INCOME and LOW- AND MODERATE-INCOME categories* are presented below. Please add up the combined oss annual income of all persons in your household from all sources of income. In the blanks provided,write(yes)or(no)if your combined grass annual income is equal to or less than the EXTREMELY LOW-ENCO E ; LOW-INCOME ;OR LOW-AND MODERATE-INCOME amount for the number of persons in your household. Number of Persons in Your Household 1 2 3 4 EXTREMELY LOW-INCOME $14,000 $16,000 $18,000 $20,000 LOW-INCOME $23,3€10 $26,650 $29,950 $33,300 LOW-AND MODERATE- $37,300 $42,650 $47,950 553,300 INCOME (COMBINED) Number of Persons in Your Household 5 6 7 8 EXTREMELY LOW-INCOME $21,600 $23,200 $24,800 526,400 LOW-INCOME $35,950 $38,650 $411,300 $43,950 LOW-AND MODERATE- $57,550 $61,.850 $66,100 INCOME (COMBINED) Pa ?e 1f 2 EXHIBFr__�a)of 2 COUNTY OF SAN BI RNARfDIIO DEPARTMENT OF COMMUNITY DEVELOPMENT ANID HOUSING Project/Activity Title: Case Number: 111-218127/2288 Redlands: Geriatric Care Services for Family Caregivers—DASH Name/Address of Contractor Agency: Date of Issue: Developing Aging Solutions with Heart, Inc. 6riginal: 04/17/03 306 West Colton Ave. X Amendment No. 6 Beginning 07/01/08 Redlands, CA 92374 3. Please indicate how you identify yourself by checking only one of the following choices: Non- Hispanic Hispanic White El ❑ BlacWAfrican American ❑ l Asian ❑ ❑] American Indian/Alaskan Native C] El Native Hawaiian/Other Pacific Islander ❑ ❑ American Indian/Alaskan Native&White E] ❑ Asian&White M ❑ Black/African American&White F] American Indian/Alaskan Native&BlackjAfrican American ❑ ❑ Balance/Other D E] 4. Please check whether you belong to a Female Headed Household: F]Yes ❑No 5. Please describe the condition that would qualify you as being considered in one ofthe following presumed low-and moderate-income categories:abused child,battered spouse,elderly person,homeless person,disabled adult,illiterate person, or migrant farm worker: (description) ACKNOWLEDGMENT AND DISCLAII4MER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSEHOLD STATEMENTS MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: CITY: ZIP: SIGNATUrRE: PHONE: The information you provide on this form is for Community Development Block Grant(CDBG)program purposes only and will be kept confidential. *Jaker from 20oS`pec:ors 8 Low-income and V e Limits, Page 2 cif? EXHIBIT`___1� of 2 COUNTY OF SA'4 BEItii�ARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING Project/Activity`I`itle. Case Number: 111-28127/228 Redlands: Geriatric Care Services for Family Caregivers -DASH Ngm_e/Address of Contractor Agency. Date of Issug: Developing Aging Solutions with Heart, Inc. original: 44/17/03 306 West Colton Ave. X Amendment No. 6 Beginning 07/01/08 Redlands,CA 92374 DECLARACION DE LA CALIF.ICACION DEL BENEFICIARIU Esta forma tiene el prop6sito de proporcionar la informacion necesana para calificar el use de los fondos federales del bloque del desarrollo de la comunidad(CDBG)para el proyeeto/actividad descrito arriba.Esta declaraci6n se debe llenar y firmar per la persona(o la tutela legal de la persona)que solicita para recibir bene0cios del proyecto/actividad descrito. Sola erste una declaraci6n por persona,por ano se requiere. Conteste por favor a sada una de las preguntas siguientes. I. Esta pregunta le ayuda a determinar el tamaAo de su casa. En esta pregunta un hogar es un grupo do personas relacionadas o sin relaci6n que ocupan la misma,Casa por to menos con un miernbro clue es la cabeza de la Casa. Los inquilinos no se pueden incluir coma mie Bros de la Casa. ZCunntas personas viven en su casa? 2. Esta pregunta explica si usted es de un hogar de ingresos bajos y moderados. Para esta pregunta,la lista de 2008 de categorias de ESTREMADO-BAJOS, INGRESOS-BAJOS, y del PUNTO BAJO Y de INGRESOS- MODERADOS*se presenta abajo. Sume por favor para arriba los ingr eros brutal anuales co binados cue Codas lass personas en su hogar y de Codas las fuentes de los ingresos. En el espacio on Blanco,escriba(si)o(no)si su ingreso anual grueso combinado es igual o mens que la cantidad de ESTREMADO-BAJOS INGRESO-BAJO ; O INGRESOS BAJOS Y MODERADOS para el nu ero de personas err su casa. FNumero de Personas en su Hogar 1 2 3 4 ESTREMADO-BAJOS $14,000 $16,000 $18,000 520,000 INGRESOS-BAJOS $23,300 $26,650 $29,950 $33,300 INGRESOS-BAJOS Y $37,300 $42,650 $47,950 $53,300 MODERADOS(COMBINADOS) Numero de Personas en su Hogar 5 6 7 8 ESTREADO-BAJO S $21,600 $23,200 $24,800 $26,400 INGRESOS-BAJOS $35,950 $38,650 $41,3010 543,950 INGRIySOS-BAJOS Y $57,55Q $61,850 S66,100 $70,350 MODERADOS(COMBIae ADOS) Paee I of 2 EXHIBIT—ice.._. of 2 COUNTY OF SAN BERINTARDINO DEPARTMENT OF COMMUNITY DEV ELOPMENT A D HOUSING ProjecVActivityjtit e: Case Nurnber: 111-281217/2288 Redlands: Geriatric Care Services for Family Caregivers-DASH Name/Address of Contractor Agency: Date of Issue: Developing Aging Solutions with Heart,Inc. Original: 04/17/03 306 West Colton Ave. X Amendment No. 6 Beginning 07/01/08 Redlands, CA 92374 3. Indu}ue por favor e6mo se identifica usted,marcando solamente uns de las opciones siguientes: No- Blanco Hispano, Hispano Q Negro/Afro AmericanaEl 0 Asiatica India Americano/Nativo de Alaska Native Hawaiano/Otra Isla del PacificaEl F-1 Indio AmericanoeNativo de Alaska&Blanco El Asiatica&Bianco Q Negro/Afro Arnericano&Blanca Ej India Americana/Nativo de Alaska&Negro/Afro A ericano ❑ M Balance/Otro ❑ ❑ 4. Marque por favor si usted pertenece a un hogar encaezado femenino: QSi FINTo 5. Describa por favor la condici6n que le calificaria Como siendo considerado en una de las categorias de presumidos ingresos bajos y rnoderados siguientes:nino abusado,esposo estropeado,persona mayor,persona sin hogar,adulto incapacitado,persona analfabeta,o trabajador migratorio de granja: (descripci6n) RECO NOCIMIENTO Y NEGAC16N CERTIFICO BAJO PENA DE PERJURIO QUE LAS DECLARA.CIONES HECHAS EN ESTA FORMA, ACERCA LIE LOS INGRESOS Y DE LAS CUENTAS DE LA CASA SON VERDADERAS. HOMBRE: FECHA: DOMICII.,10: CILTDAI): CODIGO: FIR�t�A:__ _ TELI�I*O?ti0: La inform cin que tested praporciona en esta forma es para lis prop4sitos Ciel programa de tondos del bloque del desarrollo de la comumdad(CDBG)sculanwnte y sera m ntetuda conl1dencial. *Tonmdo d:-2,0 8 Sec:i n�S 1 jgret,c�s bk i�,j. Page 2 of 2 EXHIBIT 2 of 2 COUNTY OF SAN BERNARDIN0 DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING Project/Activity Title: Case Number: 111-28127/2288 Redlands: Geriatric Care Services for Family Caregivers—DASH Nwnc/Address of Contractor Agency: Date of Issue: Developing Aging Solutions with Heart, Inc. Original: 04/17/03 306 West Colton Ave. �X - Amendment No. 6 Beginning 07/01,08 Redlands,CA 92374 PROGRAM PROGRESS AND DIRECT BENEFIT REPORT For FY 2008-2009 PART 1:PROGRAM PROGRESS REPORT A. Units of Service Provided and Description Under each type of service listed below,summarize what your program has accomplished during this month. Include location,number of persons served,servicesibenefrts provided,and a description of the clients served. Also report the number of"Units of Service"provided,as defined in the Project/Activity Description(Exhibit I of the agreement). Type of Seryice: Units of Service: 1. Geriatric C-ge Mianaeement., Goal.: 10 Actual.: (Each adult dependent participating in one geriatric care session equals one unit of service.) B. Beneficiary Count(may include individual persons(P)or householdv(H)previously counted during this grant/program y=ear) Total number of beneficiaries(clients/participants)served(choose one caISgory only Number of Persons OR Number of Households PART II:DIRECT BENEFIT REPORT Direct Benefit Statistics(tndooiicated first-time client counts Wnee start of contract;taken from nenetidary Quaiificatton Statement forms) Enter the number of first-time program beneficiaries directly assisted Count only as: 0 Individual Persons 2r ©Households(check one box) Low-income(21w: __- Low-ag Moderate-Imotne (combiwW All Beneficiaries: Racial Identity Categories Non- Non- Hispanic Hispanic Hispanic Hispanic White (a) (b) (c) (d) American IndiaNAlaskan Native&White, Black/African AmericanAsian Asian&WhiteAmer _ Black/African American&White Native Fi Indian/Alaskan Native ___ _ Amer.Indian Alaskan Native&African Amer. - Native awaiiam`tkher pacific Islander Balanceodw Grand Total of Racial Identity Categories.Sum of columns a,b,c,and d should equal the"All Beneficiaries"tota)above: Female Headed Households: Siped _ Tit{e - --- — Y bate Printcxi Mame y� '-""---- ------ _ Telephone l4r0.I X1 Pate I of I Exhibit C Contract: FY 08/09 Project# 1.11-281.2' Case#2288 Developing Aging Solutions with Heart, Inc. will haveCa0 employees attached to this contract, they are as follows: Vicky L. Dickinson, MSW; ACC;FAPA K. Lawrence Townend