HomeMy WebLinkAboutContracts & Agreements_247-2006_CCv0001.pdf INDEPENDENT CONTRACTOR AGREEMENT
This Agreement is made and entered into this 7"' day of November, 2006 by and
between the City of Redlands, a municipal corporation (hereinafter "City") Developing
Aging Solutions with Heart, Inc., (DASH, Inc.) (hereinafter"Contractor").
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;
i WHEREAS, Contractor has represented to City that it has the requisite experience,
special al knowledge and expertise similar to others in the industry conducting these services,
NOW,THEREFORE,in consideration of the mutual promises contained herein,the
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
above-described services and shall advise City of the same prior to
commencing any activities under this Agreement. Contractor further agrees
to perform such services to the best of its ability and in an efficient, safe and
competent manner.
C. As compensation for conducting these services, City shall reimburse the
contractor for services necessary to implement this program. Federal, State,
County and City rules and regulations will apply. Compensation shall not
exceed $5,000.00.
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 ser,,-ices performed,person(s)performing services and
cost breakdown shall also be provided to the City. Administration and
personnel records shall be available for examination by the City,
E. Contractor shall submit to City with each request for reimbursement
documentation in compliance with the requirements listed in 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 copy
of which is attached hereto and incorporated herein by reference as Exhibit
"B", for every month that CDBG funds are expended, and submit these
Monthly Program Progress Reports with Contractor's monthly reimbursement
request to the City. Copies of all submitted forms must be retained in
Contractor's records for a minimum period of three(3)years from November
7, 2006.
G. Contractor will submit all final claims for reimbursement to City no later than
June 30, 2007.
H. The City of Redlands will submit a final Request for Reimbursement for the
program year no later than July 21, 2007. After July 31, 2007 any balance
remaining in this account will be reprogrammed.
Section 2, Independent Contractor.
It is the express intention of the parties hereto 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. Both parties acknowledge that Contractor is
not an employee for State tax, Federal tax or any other purpose.
Section 3. Contractor's Employees.
A partici
listing of all Contractor's employees and agents who may pate in the
Z� participate
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 services hereunder 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 for the
duration of this Project and shall be primary with respect to City and non-contributing to any
insurance or self-insurance maintained by the 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 work. All insurance
policies shall include a provision prohibiting cancellation of the policy except upon thirty
(30) days prior written notice to City.
5.2 Workers' Compensation and Employer's Liability
A. 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.
B. Contractor expressly waives all rights to subrogation against City,its officers,
employees and volunteers for losses arising from work performed by
Contractor for City by expressly waiving Contractor's immunity for injuries
to Contractor's employees and agrees that the obligation to indemnify,defend
and hold harmless provided for in this Agreement extends to any claim
brought by or on behalf of any employee of Contractor. This waiver is
mutually negotiated by the parties. This shall not apply to any damage
resulting from the sole negligence of City, its agents and employees. To the
extent any of the damages referenced herein were caused by or resulted from
the concurrent negligence of City, its agents or employees, the obligations
provided herein to indemnify, defend and hold harmless is valid and
enforceable only to the extent of the negligence of Contractor, its officers,
agents and employees.
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 (52.000,000) aggregate for public
liability, property damage and personal injury is required. Contractor shall obtain an
endorsement 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 I million($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 on the project,hired and non-owned vehicles,and
employee non-ownership vehicles. Contractor shall obtain an endorsement that City shall be
named as an additional insured.
5.6 Assignment and Insurance Requirements. Contractor is expressly prohibited
from subletting or assigning any of the services covered by this Agreement without the
express written consent of City. In the event of mutual agreement between parties to sublet a
portion of the Services,the Contractor will 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; but excluding such actions, claims, demands, lawsuits and liability for
damages to persons or property arising from the sole negligence or intentionally wrongful
acts of City, its officers, employees or agents.
Section 6. Health Insurance Portability And Accountability Act of 1996
Pursuant to the Health Insurance Portability And Accountability Act of 1.996
(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 "U' hereby
incorporated by this reference.
Section 7. Entire Aggeement./Modification. This Agreement represents the entire
Agreement of the parties hereto as to the matters contained herein. Any modification of this
Agreement will be effective only if it is in writing and signed by the parties hereto.
Section 8. Assignment. 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.
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 costs or other relief, be entitled to recover its reasonable attorneys' fees.
Executed this 7th day of November 2006.
City of Redlands
Date: November 7, 2006
Joq;harrison, Mayor
Attest:
Lorric'Poyzer, Ci
y erk
City of Redlands
Developing Aging Solutions with Heart, Inc.
(DASH)
Date:4-z—�&k
I:ca\1em\agreements\RCMA
ATTACHMENT A - ""QUEST TO INITIATE PROJECT/ACTIVITY
PROJECT NUMBS-R; 1 1 1-28 127 DATE OF ORIGINAL ISSUE: April 17, 2003
CASE NUMBER: 2288
ORIGINAL: REVISION #: 4
TARGET AREA: Redlands DATE OF REVISION. AUG 0 -t '200L,6
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 LOCATION: TOTAL PROJECT FUNDING:
306 W. Colton Ave., CITY CDBG ALLOCATION $ 21,500
Redlands, CA 921374 RELEASED- 21,500
CITY CDBG FIN
I DS EXPENDED
DATE OF RELEASE OF FUNDS: 07/17/06 AS OF: 07/17/06 16,500
BALANCE OF FUNDS AVAILABLE:
5 000
SCHEDULE OF CITY CDB-6-ALLOCATION: ,
Years 1-2,8 Year 29 Year 30 Year 31 Year 32 Year 33 Year 34
Act#— Act# Act# Act# Act# Act#
(75-2003) Act#
L2003 0-41 ..f200 -- TOTAL OF
$3,500 12-0-0—�--0-61 C2-Q000
2007:68)$3,000 $5000 $5,000 34 YEARS
5 $ 0 $ 0 $21,500 —
MAINTENANCE AND OPERATION BUDGET/AGREEMENT: The City will enter into a contract with Developing Aging
Solutions with Heart Inc. (DASH)for the-2-0-0-6---07Program Year.
OTHER-PERTINENT INFORMATION:, With Revision#4,an additional$5,000 in City CDBG funds is allocated to this program
for the 2006-07 Program Year.
ACCEPTANCE OF RE LEST TO INITIATE PRO
` VITY
I hereby acknowledge the receipt of the Request to Initiate the above Project/Activity and agree to implement the activity described
in Attachment B(Project/Activity Description)in accordance with the above Allocation and Balance of Funds Available subject to
necessary approvals of the Board of Supervisors. The proposed budget for this project is as follows:
LAND ACQUISITION: $— -0- PURCHASEF EQUIPME
STAFF COST RELATED NT
TO LAND ACQUISITION $ -0- CONSTRUCTION COST: $-.,. -0-
DESIGN: $— CITY STAFF COST:
CONSULTANT SERVICES: $- 5,000 CONTINGENCY: -0-
TOTAL CITY CDBG ALLOCATION AVAILABLE:
IMPLEMENTING CITY- Redia—110
DATE:
SIGNATURE:_
TITLE:
COUVAFY OF SAN BERNARDINO
J
DIRECTOR DATE:
DEPARTMENT FC' (yk'IM :1 NITY DEVELOPMENT AND HOUSING
2288 A&B Rev 4 Rcdhirds
(j7'20106/MKcb
ATTACHMENT 13- PROJECT/ACTIVITY DESCRIPTION
PROJECT NCLMBER- -28127
DATE—0—F—ORIGINAL ISSUE: April 17, 2003
CASE M TNAB r-D 2288 ORIGINAL: REVISION 4
TARGET AREA: Redlands RATE OF REVISION AUG
RR-0—JECTEA,CTIVITY 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 shall sign a contract with the City of Redlands addressing the scope of service and the terms and conditions.I 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 DASH
shall comply with requirements listed in 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.
In addition,DASH shall comply with all applicable regulations listed in the City-County Delegate Agency Agreement,#06-528,Attachment C,
Section IV. City shall maintain monthly program reports and records on the services provided. CDBG funds cannot be used for entertainment,
gifts or fund-raising activities. Reimbursement expenditures must be appropriately documented. City shall comply with conflict of interest
C,
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 Alzheimers and requires documentation that at least 51% of the adult
dependents benefiting from this program are low-and moderate-income. In order to document that 51%of the adult dependents benefiting from
the geriatric care management program are income-qualifying, a Bene icia Qua ifcati nStatement(Exhibit I of 2)must be completed for
its from the program. This form is available in both English and Spanish. The Beneficiary Qualification
each adult dependent who benefits fi 1Y I 1 0
Statement will then be used to complete and submit the Monthly Program ProgresslDirect Benefit Report(Exhibit 2 of 2) to the County
Department of Economic and Community Development. The Monthly Program Progress/Direct 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 L Monthly 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
Monthly Direct Benefit Report (Exhibit 2 of 2) 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 21, 2007.
Note: After July 31,2007, any balance remaining in this account will be^reprogrammed.
IMPLEMENTING CITY:
-----Redlands
. .... DA
SIGNATt
TITLE
DEPAfY-IVIENT OF COMM; _6N1T_`i, DEVELOPMENT AND FlOt.,'SING
A,,\1
AU4
DIRECTOR
DATE
EXHIBIT of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
Project/Activity Title: �Case—Number: 111-28127/2288
Redlands: Geriatric Care Services for Family Caregivers—DASH
Name/Address of Contractor �k encu: Date of Issue:
Developing Aging Solutions with Heart, Inc. _Original:
P.O. Box 8370 —, X Amendment#4 Beginning 07/01,106
Redlands, CA 91375-1570
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.
1. 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
2006 LOW-INCOME and LOW-AND MODERATE-INCOME categories*are presented below. Please
add up the combined gross annual income of all persons in Your household from all sources of income.
In the blank provided,write yes or no,that your combined gross annual income is equal to or less
than the L0'VN`-INCOME amount for the number of persons in your household:
In the blank provided, write, yes or no, if your combined gross annual income is equal to or less
than the LQW- AND MODERATE-INCOME amount for the number of persons in your
household.
Number of Persons in Your Household
LOW-INICOME 1 2 3 4
$20,150 $23,000 $25,900 $28,750
LOW- AND MODERATE- $32,200 $36,800 $41,400 $46,000
INCOME (COMBINED)
Number of Persons in Your Household
5 6 7 8
LOW-INCOME
$31.050
S33,350S35.650 $37,950
LOW- AND MODERATE- $49,700 $53,350 S57,050 $60,700
INCOME (COMBINED)
Paye 1 (if?
EXHIBIT I (a) of 2-
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
3. Please indicate how you identify yourself by checking only one (1) of the following choices:
Non-
White Hispanic Hispanic
Black/African American F-1 F�
Asian ❑
F-1
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander F]
FAmerican Indian/Alaskan Native & White
F1
Asian & White
F-1
Black/African American & White F1
D ❑
American Indian!Alaskan Native &Black/African American F-1 F�
Balance;Other 0 F-1
4. Please check whether you belong to a Female Headed Household: ❑Yes ❑No
5. Please describe the condition that would qualify you as being considered in one of the 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 DISCLAIMER
I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSEHOLD
STATEMENTS MADE ON THIS FORM ARE TRUE.
NAME: ATE:
ADDRESS: CITY: ZIP:
SIGNATURE: PHONE:
The information you provide on this form is for Community Development Block Grant (CDBG) program
purposes only and will be kept confidential.
*Taken from 2006 Section 8 Low-Income and -Very Low-Income Limits.
PaLre 2 of 2
EXHIBIT I(b
)_ of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
ftpject/Activ
Title: Case Number: 111-28127/2288
Redlands: Geriatric Care Services for Family Caregivers—DASH
Name/Address of Contractor Aaency: Date of Issue:
Developing Aging Solutions with Heart, Inc.
P.O. Box 8370 —Original:
Redlands, CA 92375-1570 X Amendment#4 Beginning 07/01/06
DECLARACIO' N DE LA CALIFICACION DEL BENEFICIAR10
Esta forma tiene el prop6sito de proporcionar la infon-naci6n necesaria para calificar el use de los fondos
federales del bloque del desarrollo de la cornunidad(CDBG)para el proyeeto/actividad descritc, arriba. Esta
declaraci6n se debe Ilenar y firman por la persona (o la tutela lecral de la Persona) que solicita para recibir
. I
beneficios del proyectol/actividad descrito. Solarnente una declarza:cion por persona, por aho se requiere.
Conteste por favor a eada una de las preguntas siguientes.
Esta pregunta le ayuda a detenninar el tarnaho de su casa. En esta pregunta un hogar es un goTupo de
personas relacionadas o sin relaci6n que ocupan la misma casa por to menos con un miembro que es la
cabeza de la casa. Los inquilinos no se pueden incluir corno,miernbros de la casa. XuAntas 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
?n
de 2006 de categorias de BAJOS-INGRESOS y del PUNTO BAJO Y de ING
RESOS-MODERADOS
se presenia abajo. Surne por favor para arriba los ingresos brutos anuales combinados de Codas las
personas en su hogar y de todas las fuentes de los ingresos. ED el espacio en blanco,escriba sf o no,si
su ingreso anual grueso combinado es igual o menos que la cantidad de INGRESO-BAJO para el
nfirnero de personas en su casa.
ED el espacio en blanco, escriba, si o no, si sus ingresos brutos anuales combinados son igual o
menos que la cantidad de INGRESOS BAJOS Y MODERADOS para el n6mero de personas en
su casa.
Nurnero de Personas en su Hogar
INGRESOS-BAJOS 1 2 3 4
$20,150 $23,000 $25,900 $28,750
INGRESOS-BAJOS Y $32,200 $36,800 $41,400 $46,000
MODERADOS (COMBINADOS)
Humero de Personas en su Ho-ar 1501
)00
VNIGRESOS-BAJOS 5 6 8
$31,050 $33,350 $355,650 $37,950
1 y
�JOS
EENNGRESOS-BAJOS Y
S49.700 $53,350 $57.050 S60,700
NIO)DER-ADOS (COMBITNTADOS)
EXHIBIT of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
3. Indique por favor c6mo se Identifica usted, marcando solamente una (1) de las opciones siguientes:
No-
Blanco Hispano Hispano
M
Negro/Afro Americano F-1
Asidtico F-1 F-1
1-1
Indio AmericanoNativo de Alaska D
F-1 D
Nativo Hawaiano/Otra Isla del Pacifico
F-1
Indio AmericanoNativo de Alaska&Blanco
D ❑
Asiatico, &Blanco
F] F-1
Negro/Afro Americano &Blanco
F-1
Indio AmericanoNativo de Alaska&Negro/Afro Americano
Balance/Otro
4. Marque por favor si usted pertenece a un hogar encabezado femenino: E]Si RNo
5. Describa por favor la condici6n que le calificaria como siendo considerado en una de las categorfas de
presumidos ingresos bajos y moderados siguientes: nift abusado, esposo, estropeado, persona mayor,
persona sin hogar, adulto incapacitado, persona analfabeta, o trabajador migratorio de granja:
(descripci6n)
RECONOCIMIENTO Y NEGACION
CERTIFICO BAJO PENA DE PERJURIO QUE LAS DECLARACIONES HECHAS EN ESTA
FORMA,ACERCA DE LOS INGRESOS Y DE LAS CUENTAS DE LA CASA SON VERDADERAS.
NOMBRE: FECHA:
DOMICILIO: CRJDAD: -..CODIGO:
FIRMA: TELtFONO:
La informaci6n que usted proporciona en esta forma es para los prop6sitos del programa de Tondos del bloque
del desarrollo de la comunidad (CDBG)solamente y sera mantenida confidencial.
*Tornado de 2006 Secci6n 8 Ingresos bajos,
P-k
EXHIBIT 2 of 2
COUNTY OF SAN BERNARDINO DEPARTMENT OF COMMUNITY DEVELOPMENT AND HOUSING
Pro ect/Activity Title: Case Dumber: 111-28127/2288
Project/Activit--------— —
Redlands: Geriatric Care Services for Family Caregivers—DASH
Name/Address of Contractor Ag-enc Date of Issue:
Developing Aging Solutions with Heart, Inc. —Original:
P.O. Box 8370 X Amendment#4 Beginning 07/01/06
Redlands, CA 92375-1570
MONTHLY PROGRAM PROGRESS AND DIRECT BENEFIT REPORT For the Month of 200_
PART 1: MONTHLY 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,services/benefits 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 Service: Units of Service:
1. Geriatric Care Management: Goal/mo.: 10 Actual/mo.:
(Each adult dependent equals one(1)unit of service.)
B. Monthly Beneficiary Count(may include individual persons(P)or households(H)previously counted during this grant1progrant year)
Total number of beneficiaries(clients/participants)served this month(choose one cafe ory only}:
#of Persons— OR #of Households
PART11:DIRECT-BENEFIT REPORT
Direct Benefit Statistics(!jqduplicated first-time client counts since start of contract;taken from Beneficiary Qualification Statement forms)
Enter the number of first-time program beneficiaries directly assisted this month
Count only as: 1_71 individual Persons or 171 Households(check one box)
Low-income(qqAl ): Low-arced!Moderate-Incorne(cQmbinedAll Beneficiaries:
Racial Identity Categories Non- Non-
Hispanic Hispanic Hispanic Hispanic
White (a) (b) (c) (d)
Black/African American American Indian/Alaskan Native&whitee—
Asian Asian&White
Black/African American&White
American Indian/Alaskan Native
Amer.Indian/Alaskan Native&African Amer.
—
Native Hawaiian/Other Pacific Islander Balance/Other
Grand Total of*Racial Identity Categories,Sum of colun-ins_a,b,c,and d should equal the`:All Beneficiaries"totai above!
Female Headed Households:
Signed Title— Date
Printed Name Telephone No,/Ext.
Page I of I
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