Guidelines FY 2022-2023 ECIA Grant -1-
FY 2022-2023
RICHMOND - ENVIRONMENTAL & COMMUNITY INVESTMENT
AGREEMENT (ECIA)
COMMUNITY GRANT PROGRAM GUIDELINES &
APPLICATION
REQUEST FOR APPLICATION (RFA)
All interested applicants should check the City’s ECIA website (www.ci.richmond.ca.us/ECIAgrants) to ensure that they receive any addendums to this RFA, emails or special announcements.
Application is due on Sunday, February 13, 2022, at 11:59 p.m. (NO EXCEPTIONS)
Materials must be submitted electronically to:
www.ci.richmond.ca.us/ECIAapplications
Guidelines FY 2022-2023 ECIA Grant -2-
RICHMOND - ECIA COMMUNITY GRANT PROGRAM
FY 2022-2023 GRANT GUIDELINES AND APPLICATION
Table of Contents
ECIA Background ........................................................................... 3
Eligibility Requirements ................................................................... 4
Grant Award Amounts and Categories ........................................... 5
Eligible Uses of Grant Funds .......................................................... 6
Ineligible Uses of Grant Funds ........................................................ 6
Fiscal Sponsorships ........................................................................ 7
Collaborating Organizations ............................................................ 7
Application Submission Requirements ............................................ 8
Application Submission Details ....................................................... 9
Payment Provisions ........................................................................ 9
Review Criteria ............................................................................. 10
Application Review and Selection Process ................................... 11
Application Deadline ..................................................................... 11
Late Application or Modification to Applications ............................ 12
Applicant Assistance Prior to Due Date ........................................ 12
Schedule ....................................................................................... 12
Questions or Addendums to the Applications ............................... 13
Grantee Requirements .................................................................. 13
City Staff Contact .......................................................................... 14
General Terms and Conditions ..................................................... 14
Exhibits ......................................................................................... 16
Guidelines FY 2022-2023 ECIA Grant -3-
RICHMOND - ECIA COMMUNITY GRANT PROGRAM
FY 2022-2023 GRANT APPLICATION GUIDELINES
ECIA BACKGROUND
On July 29, 2014, the Richmond City Council approved the Chevron Environmental and Community Investment Agreement (ECIA), which will invest $90 million dollars to the Richmond community over 10-years. The ECIA includes investments in community programs, a scholarship program, competitive community grants, community-based greenhouse gas reduction programs, and a photovoltaic solar farm.
The ECIA specifies the amount and disbursement timeline of Chevron’s funding obligation, as well as funding allocations over a ten-year period (beginning in 2016) for the following programs:
Scholarship program - $35 million
Electric City and Easy Go - $18 million
Roof-top solar, energy retrofi t, zoning ordinance update - $6.25 million Job training program - $6 million
Competitive grant program - $6 million
Transportation and transit p rograms - $2.75 million
Public safety pr ograms - $2 million
Urban Forestry - $2 million
Free internet access - $1 million
Climate Action Plan - $1 million
It is proposed that $375,000 is allocated for the FY 2022-23 grant cycle.
It is the goal of the Richmond City Council to provide opportun ities for organizations with varying capacities and financial needs to have access to ECIA g rant funds. ECIA grant funds are awarded on an annual bas is and therefore, organizations should not become reliant on this funding source. All Richmond-serving non-profit organizations are eligible to apply for funding; however, in an attempt to fund a variety of organizations, the City Council would like to allocate the majority of the available gr ant funding to organizations that have smaller annual budgets, greater needs for capacity building and limited staffing, and that might not have access to other forms of funding.
Guidelines FY 2022-2023 ECIA Grant -4-
ELIGIBILITY REQUIREMENTS
Organizations must meet the following conditions to be eligible to apply for a grant:
Provide services focused on the community, youth and/or youth sports to Richmond and North Richmond residents
Operate as a non-prof it entity with 501(c)(3 ) tax status with current financial statements (i.e., Fil ed I.R.S. Form 990 or 990-N or current aud ited financials). Fiscal sponsors can be used.
Provide services to Richmond residents (Richmond-serving) A minimum of 80% of the organi zations proposed grant-funded programs/services must be provided to Richmond residents. If aw arded an ECIA grant, grant funds can only be spent serving Richmond residents.
Did not receive an ECIA grant award of more than $10,000 during the previous (FY 2021-22) ECIA grant cycle
Organizations are prohibited from receiving funding awards fro m both the ECIA Grant Program and the Ricmond Fund for Children and Youth Grant Program in the same fiscal year.
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GRANT AWARD AMOUNTS AND CATEGORIES
Grant allocation amount: The amount available for the FY 2022-2023 grant cycle (July 1, 2022 – June 30, 2023) is $375,000.
Minimum and maximum grant awards: The minimum grant award is $5 ,000. The maximum grant award is $50,000 . The number of awards available will be determined based on the amount of each award.
Number of applications per grant cycle: Organizations may submit only one application per grant cycle.
Award categories: $375,000 available for grants is allocated over four different categories listed below. Categories 1 and 2 are relevant to this Request for Application:
Grant Award
Options
Eligibility Award Decision
Made By
Award Range Total Award
Amount
1 Competitive
Grant Awards
(Relevant for this
Application)
Non-profit organizations
reporting gross receipts of
less than $50,000
annually
City Council
(Recommendations
made by ECIA
Review Panel)
$5,000 - $50,000
$225,000
See Special
Note Below
2 Competitive
Grant Awards
(Relevant for this
Application)
Non-profit organizations
reporting gross receipts of
more than $50,000
annually
City Council
(Recommendations
made by ECIA
Review Panel)
3 City Council
Approved
Awards
Organizations that applied
for the ECIA Grant
(categories 1 and 2) but
were not recommended
for funding
City Council Amounts based
on Council
discretion
$ 100,000
4 Community
Services Mini-
Grant Awards
Non-profit organizations
with 501(c)(3) tax status
with programming
connected to the
Community Services
Department
Community
Services
Department
Up to $5,000 $ 50,000
T O T A L $375,000
SPECIAL NOTE:
A maximum of $100,000 in grant a wards is available to organizations with annual budgets over $750,000 (per last completed 990s or audited financials).
Guidelines FY 2022-2023 ECIA Grant -6-
ELIGIBLE USES OF GRANT FUNDS
Grants will be awarded to projects or programs in the following areas:
Youth programs (through age 21)
Youth sports progr ams (through age 21)
Community-focused programs
*Youth-serving organizations are defined as those organizations where 80% of ECIA grant-funded programs/serv ices will be provided to youth (birth through age 21)
Examples of eligible projects or programs include but are not limited to:
Youth enrichment projects
Summer camps
Youth sports programs
Programs that support health and wellness and eliminate health disparities Bike and pedestrian pathway enh ancements and construction projects Programs that support students and parents at Richmond schools Service-learning programs
Gardening and urban greening projects
INELIGIBLE USES OF GRANT FUNDS
Grant funds may not be used for the following reasons:
Repayment of existing debt or pr e-existing tax liens or obligations Legal, loan, or bank fees
Subsidization of existing contracts
Political campaigns or lobbying
Advancement of certain sectarian, politically partisan, or rel igious projects (grant funds should be used for specific programs and not to advance the causes of any of the stated groups)
Fundraisers or other events not open to the general public A project or program which is clearly intended for commercial gain A project or program that occurs before or after the grant award period Support of individuals
For businesses established fo r personal benefit or profit To support annual fund drives
To fund an agency’s deficit or endowment
To repay loans
Furniture
Cell phones
Bonuses
For the direct support of religi ous activities. Secular activities offered to the Richmond community that is provided by religious organizations regardless of congregational membership or statements of belief may be eligible for grant funds.
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FISCAL SPONSORSHIPS
What types of organizations should utilize a fiscal sponsor? A non-governmental organization (sponsoree) that does not have 501(c)(3) tax status must utilize a fiscal sponsor to apply for this grant. It is the sole responsibility of the sponsoree to find an organization with 501(c)(3) tax status that is willing to serve as a fiscal sponsor.
What is fiscal sponsorship?
Fiscal sponsorship allows organizations without 501(c)(3) tax status to apply for the ECIA grant, as well as other grants that require an organization to have such status. A fiscal sponsorship agreemen t should be entered into between the sponsoree and an organization that has 501(c)(3) tax status.
The fiscal sponsorship agreement allows the sponsoree to raise tax-deductible contributions through grants and individual donations.
Tax-deductible funds are given to the fiscal sponsor and restricted to the use of the sponsoree.
How does a fiscal sponsorship work for the ECIA grant process?:
The fiscal sponsor will serve as the applicant. Fiscal sponsors will enter into a grant services agreement with the City of Richmond and must meet all requirements and submit all required documents.
A signed agreement between the sponsoree and fiscal sponsor must be included in the submitted application. The organization actually implementing the program and performing the services will act as the sponsoree or fiscal sponsor’s sub-grantee. Fiscal sponsors can also apply for grants.
In addition to requesting funds fo r its own purposes, organizations may also act as a fiscal agent for other organizations.
COLLABORATING ORGANIZATIONS
Through this grant program, the City strongly encourages applicants to collaborate with other organizations. Collaboration is a mutually beneficial relationship to meet a common goal. Collaboration can come in many forms, from information sharing to joint programming. It can help organizations reduce redundancy in service sectors, leverage resources, share strengths, and increase efficiencies.
For purposes of this grant, when partnering with another organization, the application and budget of the lead organization will be considered for review and determination of funding. Therefore, the partnering organization is free to apply independently for funding for another project or program.
If the successful implementation of your proposed ECIA grant-funded program is dependent on the collaboration with a governmental entity (i.e., state, county, city, school district, etc.), then a written agreement authorizing the collaborative relationship must accompany your grant application. At a minimum, the agreement should contain the following information: names of the government entity(ies) or agency(ies) which will participate in the collaboration, contact information for the partner(s), and a description of
Guidelines FY 2022-2023 ECIA Grant -8- the primary purpose of the collaboration. For example, if the implementation of your proposed program is contingent upon working at a school in the West Contra Costa County Unified School District or utilizing space at a Richmond recreation center, then a letter from the collaborating entity must agree to the proposed partnership.
APPLICATION SUBMISSION REQUIREMENTS
The following materials must be submitted as part of a complete application packet by 11:59 p.m. on Sunday, Februar y 13, 2022, to be considered fo r funding (feel free to use this section as a check-list). The inability to adhere to the requirements below may impact an organization’s overall scores:
Completed application
o Eight (8) pages
o Applicant Organizational Budget
o Applicant Program Budget
Proof of 501(c)(3) status (Non- Profit Status Determination letter from the Internal Revenue Service) or fiscal sponsor’s corresponding documents Financial statements – most recent (current) audited financials or Internal Revenue Service Form 990 or 990-N for tax-exempt organizations whose gross receipts are typically $50,000 or less or fiscal sponsor’s corresponding documents. Faith-based organizations may submit reviewed or annual financial statements. List of Board of Directors and affiliations or fiscal sponsor’s corresponding documents
Letter describing and authorizin g collaboration (if with a governmental entity), if applicable
Signed agreement between the or ganization and the fiscal sponsor, if applicable
Note: City staff will confirm that the organization has filed the required document(s) in California and is authorized to carry out its business activities (California Secretary of State - https://businesssearch.sos.ca.gov/). Applications submitted by organizations not identified with “active” status may be disqualified.
For organizations with 501(c)(3) tax status, City staff may check websites such as the Internal Revenue Service at www.irs.gov and GuideStar at www.guidestar.org to gather additional information about the applicant organization.
Guidelines FY 2022-2023 ECIA Grant -9-
APPLICATION SUBMISSION DETAILS
Submit completed grant applicat ion (include budgets and résumés and/or descriptions of work experience with the application) and a set of all additional required documents. The responses to the applicati on questions shall be limited to eight (8) pages. This page limit is not inclusive of budgets, résumés, descriptions of work experience, or documents requested as part of the application.
All submitted materials shoul d be typed in a 12 point font size and Arial font style.
Applications must be easily reproducible on a standard copying machine. All costs incurred in the prepar ation of an application are the applicant’s responsibility. Applications must be completed and submitted electronically via www.ci.richmond.ca.us/ECIAapplication by Sunday, February 13, 2022, at 11:59 p.m.
Applications received after this date and time will not be considered and will not be eligible for review and scoring by the Review Panel.
PAYMENT PROVISIONS
An initial advance payment of fifty percent (50%) of the total award amount will be advanced to all grantees as part of the application award process. Grantees receiving an advance payment may be eligible for an additional advance of thirty-five percent (35%) of the award amount, contingent upon the submission of complete and adequate reporting and invoicing documentation. The remaining fifteen percent (15%) will be reserved until the completion of the grant program and final submittal of all required documentation.
Payments will only be made for the eligible items and amounts specified in the approved grant agreement budget and a manner consistent with the payment provisions contained in the executed grant agreement.
Guidelines FY 2022-2023 ECIA Grant -10-
REVIEW CRITERIA
All submitted applications, which comply with the grant requirements, will be evaluated and rated using the criteria listed below. The maximum score that an application can receive is 110 points. This includes 100 points from criteria areas #1-5 and an extra 10 points if the organization is Richmond-based (10 points)
Total Points Available for Criteria Areas #1-5: 100 Points
1. Program/Project Descripti on and Concept (Total 40 points) Applicant adhered to a ll stated guidelines
Application is complet e, clear and understandable
Program/project description and components are clearly stated and specific Timeline is practical, and the proposed activities are well defined and technically feasible
Management and staff ar e qualified to implement the project or program and achieve stated goals
Staff has experience working on the project or program and/or similar programs or projects
A collaborative initiative is described to deliver the program or project
2. Impact and Goals (Total 40 points)
The program or projec t has the ability to positively contribute to the targeted population
Goals are clearly art iculated and measurable
An evaluation component is included and connected to the progr am goals The organization has a plan on ho w to sustain the program or project after grant funds are expended
3. Financial Viability (Total 20 points)
Program/project budget and or ganizational budgets are included, clearly defined, cost-effective, accurate and realistic
Relationship between grant f unds requested and the program budget is clearly shown
Total Extra Points Available to Richmond-based organizations (10 Points) Richmond-based is defined as maint aining principal offices, studios, or other facilities within the boundaries of the City of Richmond. Applicable to organizations providing services (sponsoree), not fiscal sponsors.
Guidelines FY 2022-2023 ECIA Grant -11-
APPLICATION REVIEW AND SELECTION PROCESS
The City's overall objective is to award grants to highly qualified organizations that provide needed services to Richmond and North Richmond residents. Within this overall objective, it is also the City’s intent that the selection process is fair and transparent.
Applications will be evaluated and scored by a City Council-approved ECIA Grant Review Panel (Review Panel) consisting of no more than five (5) individuals residing in or employed in Richmond (not City of Richmond employees).
The selection process is divided into the following steps:
1. Applications are received by the due date.
2. All applications are reviewed in depth by City staff for responsiveness, completeness, and satisfaction of eligibility requirements. Based on this review, eligible claims will proceed to the application evaluation process.
3. All complete and eligible applications are forwarded to the Review Panel, which will review and score the applications using the criteria listed in the guidelines and make an award recommendation to City Council. The inability to adhere to the application requirements may impact an organization’s overall scores. Grant awards can be less than the applicant’s original request.
4. The Review Panel’s recommendat ions are forwarded to the City Council for review, discussion, and approval.
Any party applying shall not contact or lobby any City Council member, ECIA Review Panel member, City official, employee (except those specified for contact) or agent regarding the RFA. Any party attempting to influence or circumvent the RFA, application submittal, and/or review process may have their application rejected for violating this provision of the RFA.
All scores are final. There is no grievance process.
Copies of Review Panel comments and scoring will be made available upon request.
APPLICATION DEADLINE
The deadline to submit an application and all relevant attachments is Sunday, February 13, 2022, at 11:59 p.m. There are no exceptions for applications submitted after the deadline.
LATE APPLICATIONS OR MODIFICATIONS TO APPLICATIONS
Applications submitted after the specified date and time will not be considered.
Organizations assume responsibility for the timely submission of applications and all
Guidelines FY 2022-2023 ECIA Grant -12- required documents. Any applications may be withdrawn or modified by a written request signed by the applicant.
APPLICANT ASSISTANCE BEFORE DUE DATE
Capacity Building - The City, recognizing the technical, skill-based components of a grant application process, may provide free capacity-building workshops in 2022. The dates and times of all subsequent workshops will be shared via the City’s ECIA website. Although recommended, organizations are not required to attend any of the capacity building workshops offered by the City.
SCHEDULE
The schedule associated with the application is below. The City reserves the right to alter this schedule as necessary.
TASK DATE
Application Release Date December 27, 2021
Information Session January 2022
Applications Due (No exceptions) February 13, 2022
Application Review and Scoring February 2022 – March 2022 Capacity Building Workshops TBD 2022
City Council Review and Approval April 2022 – May 2022
Grant Award Notification April 2022 – May 2022
Grant Award Period
(start date is dependent upon execution date of grant
services a
greement)
July 1, 2022 – June 30, 2023
Guidelines FY 2022-2023 ECIA Grant -13-
QUESTIONS OR ADDENDUMS TO THE APPLICATIONS
It is strongly recommended that or ganizations register on the City’s E-Notify Me webpage (http://www.ci.richmond.ca.us/list.aspx) to ensure that they receive any addendums to or notifications regarding this RFA or the ECIA grant program.
Any requests for clarification or other questions concerning this RFA should be submitted in writing to City staff via [email protected].
GRANTEE REQUIREMENTS
If awarded a grant, organizations will be required to do the following:
A Grant Service Agreement with s pecific deliverables will be executed. All organizations are expected to initiate projects within three (3) months of execution of the grant agreement. The scope of work will be based on the application submitted.
Submit bi-annual progress repor ts and reimbursement requests (templates will be included as part of the executed grant agreement):
o Progress and Final Report - Reports will be required and must provide detailed information about the services provided. Grantees that do not s ubmit the required reports run the risk of forfeiti ng their funding. A final repor t at the conclusion of the project or program is also required.
o Funding Requests – Requests must include the necessary documen ts to substantiate the disbursement (e.g., receipts, time cards, payr oll records, etc.).
Grantees that do not adhere to the invoicing requirements run t he risk of forfeiting their funding.
Host City staff and/ or members of the Review Panel for one or more site visit and/or program evaluation.
Published program materials sha ll include the City seal or logo and shall state, “Made possible in part by the Richmond-ECIA Community Grant Program.” The material must be appropriate, relevant, and aligned with the approved project and should be reviewed and approved by City staff before release.
Complete and submit a W-9 form and Supplemental Vendor Application.
Obtain a City of Richmond business license. Organizations are responsible for all associated fees. Information can be found at
http://www.ci.richmond.ca.us/66/Business-Licenses.
Meet the City of Richmond insura nce requirements. Fiscal sponsors, serving as the grantee, must have insurance that covers all actions of the non-profit and/or community-based organization acting as the sub-grantee. Organizations may use grant awards to cover insurance costs.
Guidelines FY 2022-2023 ECIA Grant -14-
CITY STAFF CONTACT
For inquiries or clarification regarding this program or application, please contact ECIA staff at [email protected] or Shane Johnson, City Manager’s Office at (510) 620-5458 or Patrick Seals, Richmond Department of Children & Youth at (510) 307- 8016.
GENERAL TERMS AND CONDITIONS
Background Checks: Organizations that provide services to youth or other vulnerable populations (elderly, people with disabilities, etc.) must require comprehensive background checks and fingerprinting of all employees and/or volunteers that work directly with youth or such other vulnerable populations.
Limitations: All facts and opinions stated herein are based upon available information and no representations or warranties are made with respect to their accuracy or completeness.
The application and the selection process shall in no way be deemed to create a binding contract, agreement, or offer of any kind between the City and the applicant organization.
If the City selects a grantee pursuant to this RFA, any legal rights and obligations between the successful applicant, if any, and the City will come into existence only when a grant agreement is fully executed by the parties, and the legal rights and obligations of each party shall at that time be only those rights and obligations which are set forth in the grant agreement and any other documents specifically referred to in that grant agreement.
Each organization submitting applications in response to this RFA agrees that the preparation of all materials for submittal to the City are at the organization’s sole cost and expense, and the City shall not, under any circumstances, be responsible for any costs or expenses incurred by any candidate. In addition, each organization agrees that all documentation and materials submitted in response to this RFA shall remain the property of the City and may be used by the City for any reason whatsoever. In accordance with California law relating to access to public records, the City may be required to publicly disclose all submitted information and materials to third parties requesting such information.
Award: The City reserves the right to accept or reject any or all applications, to alter the selection process in any way, to postpone the selection process for its own convenience at any time for any reason whatsoever, to waive any defects in any application, to issue a new RFA at any time, or to provide a grant to any organization it deems appropriate in its sole and absolute discretion within or outside of the RFA evaluation process. City reserves the right to terminate a grant agreement within sixty (60) days without cause. All materials submitted become the property of the City and will not be returned. Funds awarded are public funds and any information submitted or generated is subject to public disclosure requirements, including the Public Records Act.
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Federal, State and Local Laws: As part of the RFA process, the selected grantee will be required to comply with all applicable federal, state and local laws, including the City of Richmond’s Nondiscrimination Ordinance (Chapter 2.28), Business Opportunity Ordinance (Chapter 2.50), Local Employment Program Ordinance (Chapter 2.56), and Living Wage Ordinance (Chapter 2.60), if applicable. Please contact the City Attorney’s office for further information regarding the above requirements.
FY 2022-23 ECIA Grant Application -1 - 2022-2023 ECIA COMMUNITY
GRANT PROGRAM APPLICATION
APPLICATION DEADLINE: Sunday, February 13, 2022, NO LATER THAN 11:59 p.m.
SECTION I – ORGANIZATION INFORMATION
Community-Based Organization Information (Applicant Information):
Fiscal Sponsor (Organization with 501(c)(3) tax status:
Name of Organization:
Click here to enter text.
Executive Director Name:
Click here to enter text.
Organization Address:
Click here to enter text.
Project Manager Name (primary contact for
the grant):
Click here to enter text.
Project Manager Title:
Click here to enter text.
Phone Number:
Click here to enter text.
Email Address:
Click here to enter text.
Program/Project Budget:
Program/Project Budget:
$ Click here to enter text.
Amount of Grant Funds requested:
$ Click here to enter text.
Organizational Budget:
$ Click here to enter text.
Fiscal-Sponsor Budget (If applicable):
$ Click here to enter text.
Program/Project:
Program/Project Title: Click here to enter text.
Program Project Summary (50-word limit): Click here to enter text.
% of Richmond Residents Served by Your Proposed Program/Project?: Click here to enter text.
Will Your Program or Project Serve Youth (through age 21)?: Click here to select “Yes” or “No”
Please select one (1) category that BEST describes the type of project or program that your organization plans to provide with the requested grant funds from the drop-down list:
CLICK HERE and Select the program category from the drop-down.
Name of Organization:
Click here to enter text.
Executive Director Name:
Click here to enter text.
Organization Address
Click here to enter text.
Project Manager Name (primary contact for
the grant):
Click here to enter text.
Project Manager Title:
Click here to enter text.
Email Address:
Click here to enter text.
Phone Number:
Click here to enter text.
FY 2022-23 ECIA Grant Application -2 - 2022-2023 ECIA COMMUNITY
GRANT PROGRAM APPLICATION
SECTION 2 – PROGRAM/PROJECT DESCRIPTION
a. Provide information about your organization (e.g. number of years in operation, description of services provided and the population served).
Click here to enter text.
b. Describe in detail the progr am or project your organization is proposing to implement with the grant funds. Clearly list the major components or aspects of your program or project.
Click here to enter text.
c. Provide a timeline for project implementation using the temp late below. Include specific tasks/activities that will be accomplished within each quarter.
Task/Activities Month
1st Term (July 1, 2022 – December 31, 2022)
Click here to list, bullet, or number entries. Click here to list corresponding dates.
2nd Term (January 1, 2023 – June 30, 2023)
Click here to list, bullet, or number entries. Click here to list corresponding dates.
d. List the staff members res ponsible for the implementation of the program or project. Briefly describe the staff’s experienc e working on the proposed program /project and/or similar projects. Include résumés or pro vide descriptions of work exper ience with each copy of the application.
Click here to enter text.
e. If you plan to collaborate with other entities (i.e. non-pro fits, governmental entities, private entities) to implement your program or project, please complete the table below.
Note: A letter of collaboration must be included as a part of your application ONLY IF your organization plans to partner with a government enti ty(ies) (e.g. city, state, county, school district, etc.).
Partner Specific Role:
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FY 2022-23 ECIA Grant Application -3 - 2022-2023 ECIA COMMUNITY
GRANT PROGRAM APPLICATION
SECTION 3 – PROJECT IMPACT AND GOALS
a. Describe the target populat ion and geographic area that your organization plans to serve with the grant funds and what im pact the proposed program or pr oject will have on the target population.
Click here to enter text.
b. List the number of individuals that will be served as a result of your program or project.
Total Number of Individuals Served by
Proposed ECIA Funded Program or
Project
Total Number of Richmond Residents
Served by Proposed ECIA Funded
Program or Project
Click here to enter text.
Click here to enter text.
c. List the major program or project goal(s) and how your organ ization will measure if you reach your desired goal. The goal should be measurable and data -driven. There should be at least one (1) expected outcome per major program or project component.
Major Program
Component(s)
Major Program
Outcome(s)
Indicator/
Measurement
Goal Evaluation
Method
Click here to enter text. Click here to enter
text.
Click here to
enter text.
Click
here.
Click here to enter
text.
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text.
Click here to
enter text.
Click
here.
Click here to enter
text.
d. How will your organization assess or gauge the success of yo ur program/project at its completion?
Click here to enter text.
e. How do you plan to sustain t he program or project after the grant funds are expended? Click here to enter text.
SECTION 4 – FINANCIAL VIABILITY
a. Attach your organizational budget to each copy of the application. The organizational budget can be submitted in any format as long as it shows reven ue and expenditures for your organization’s current operating year.
b. Complete the program budget table using the provided MS Word or MS Excel template to complete the table.
FY 2022-23 ECIA Grant Application -4 - 2022-2023 ECIA COMMUNITY
GRANT PROGRAM APPLICATION
FY 2022-23 ECIA GRANT APPLICATION SUBMISSION ACKNOWLEDGMENT
This page should be included in your application packet. It will not count toward your page limit.
By submitting this application and the supporting application materials, you agree that:
You are an Officer on the Board of Directors of the organization submitting the grant application
You have thoroughly read and under stand the grant program guidelines and application questions and City of Richmond requirements (business license, insurance, and grant agreement)
All questions contained in t he application have been answered and the following required documents are included as part of our application packet:
☐Completed application (all sections completed and questions answered, including resumes)
☐Organizational budget
☐Proof of 501(c)(3) status (Non-Profit Status Determination letter from the Internal Revenue Service)
☐Financial statements – most recent (current) audited financials or Internal Revenue Service Form 990 or 990-N. Reviewed or compiled annual financial statements are allowable for faith-based organizations.
☐List of Board of Directors and their affiliations
☐Letter describing and authorizing collaboration with a governmental entity(ies), if applicable
☐Signed agreement between the organization and the fiscal sponsor, if applicable
Your organization will obtain comprehensive background checks and/or fingerprinting of all employees and/or volunteers.
Volunteers that work directly w ith youth or such other vulnerable populations. (For applicable organizations requesting funds to support an existing or new youth program and/or program that works with other vulnerable populations.)
To the best of your knowledge, t he information included as part of this application is true and accurate
------------------------------------------
Click here to enter Organization Name.
Click here to enter a date from drop-down.
Click here to enter Name of Board Officer.
Click here to enter Title of Board Officer.
Signature – Officer of Board
ECIA Grant Application – Budget Table
ECIA COMMUNITY
GRANT PROGRAM APPLICATION
SECTION 4 – FINANCIAL VIABILITY
a. Total organization budget (based on prior year’s 990 or audited financials): Click here to enter Organizational Budget.
b. Include your organizational budget to each copy of the application
c. Complete the budget template below. If needed, add rows and provide as much detail as possible in the revenue and expenditure sections.
• Revenue section: List all of the revenue sources that will fund your proposed program (e.g. grants, program fees, in- kind donations) and state those sour ces are pending and/or approved. Include your organization’s ECIA request. • Expenditures: List, with as much detail as possible, the expenditure categories (e.g. salaries, benefits, program supplies)
• The revenue total and the expenditure total in the “ECIA Request” column should match. The same is true for the “Project Budget” column.
For example, if your organization is requesting a total of $10,000 from the ECIA grant program, that amount should be listed in the “Revenue” section of the budget table. You would then need to complete the “Expenditure” section of the budget table, making sure that the total amount of the expenditures is also equal to $10,000 (the total amount of the revenue requested).
• Use the “Budget Narrative” section to justify and explain the expenditures outlined in your program budget table.
Program Budget Table
REVENUE
Category
(List Funding Sources)
ECIA Request Project Budget Revenue Status
(Approved/Pending)
Revenue Total $ $
EXPENDITURES
Category ECIA Request Project Budget Budget Narrative
(if applicable)
Expenditure Total $ $
1 GRANT SERVICES AGREEMENT
CITY OF RICHMOND
ENVIRONMENTAL & COMMUNITY INVESTMENT AGREEMENT
COMMUNITY GRANT PROGRAM
Department: City Manager’s Office,
Internal Services
Project Manager:
LaShonda Wilson
Project Manager’s E-mail:
[email protected]
Project Manager’s Phone Number:
(510) 620-6512
Grantee: Contact Name:
Email:
Phone:
Vendor No: ____________
Contract No: ____________
Term: 7/1/21 - 6/30/22 Payment Limit: $____________.
Program/Project Title:
Program/Project Summary:
THIS AGREEMENT is entered on _____________ ___, 2021 (Effective Date) by and between the City of Richmond, a municipal corporation and charter city (City) and ___________________, a California nonprofit corporation (Grantee).
RECITALS
A. On July 29, 2014, the Richmond City Council approved the Chevron Environmental and Community Investment Agreement (ECIA) between Chevron Products Company and City. The ECIA provides for the investment of Ninety Million Dollars ($90,000,000) to the Richmond community over ten (10) years. The ECIA includes investments in community programs, a scholarship program, competitive community grants, community-based greenhouse gas reduction programs, and a photovoltaic solar farm.
B. The ECIA in part allocates Six Million Dollars ($6,000,000) over ten years to a competitive grant program (Grant). The amount available for the FY 2021-2022 (July 1, 2021 – June 30, 2022) Grant cycle is Three Hundred Thousand Dollars ($300,000) (Grant Budget), of which a maximum of $100,000 of the Grant Budget is available to organizations with annual budgets over $750,000.
C. On February 5, 2021, Grantee submitted a Grant application that was evaluated and recommended for funding by the ECIA Grant Review Panel and approved by the City Council on ______________, 2021. Grantee and City now wish to enter into this Agreement for the provision of Grantee’s Program (as defined below) as approved by the City Council.
NOW, THEREFORE, it is agreed between the parties hereto that:
2 ARTILCE I
PROVISIONS
Section 1.1 Scope of Services.
A. Program Delivery. Grantee shall, to the satisfaction of City, perform and provide the program and/or services outlined in the Service Plan attached hereto and made a part hereof as Exhibit A (Program).
B. General Administration . Grantee shall provide program management and general administrative services to support the Program. Administrative support includes, but is not limited to the following: data collection and analysis, preparation and submission of a mid-year and a final (close-out) report, budget preparation and submission of demands for reimbursement, and any other function that will ensure compliance with this Agreement.
C. Staffing. For each employee funded by the Grant, Grantee shall provide the name of such employee(s), title, description of job responsibilities, hourly base pay rate or billable rate, and an estimate of time to be spent on the Program by employee per pay period. Such staff information shall be submitted within thirty (30) days of the Effective Date. Grantee shall inform City in writing, within ten (10) working days, of any changes of such staff that occur during the Term.
D. Performance Monitoring. City shall have the right to monitor Grantee’s compliance with the goals and performance standards established in this Agreement. Substandard performance as determined by City shall constitute noncompliance with t his Agreement. If action to correct such substandard performance is not taken by Grantee within thirty (30) days after being notified by City, this Agreement may be suspended or terminated. Substandard performance may be shared with future ECIA Grant Review Panel members, City Council and/or City staff and may impact Grantee’s ability to apply for and/or receive future City funds, including Grant funds.
E. Site Visits and Meetings. City may coordinate at least one (1) site visit of every Grant-funded Program during the Term . City may also convene at least one (1) mandatory meeting and/or training session. City will provide Grantee timely notice for each such meeting or training session.
Section 1.2 Term.
This Agreement shall commence effective July 1, 2021, and shall terminate on June 30, 2022, and thereafter the Agreement shall be null and void and of no further force or effect, except as to those provisions which expressly survive the termination of the Agreement . The Term may be extended to June 30, 2023, contingent on the availability of Grant funds and Grantee’s satisfactory performance of the Program, at City’s sole and absolute discretion.
Section 1.3 Funding.
This Agreement shall be deemed executory to the extent that the monies are appropri ated in the current Grant Budget for the purposes of this Agreement and no liability shall be incurred by City, or any
3 other department of City, beyond the monies budgeted and available for this purpose. The Agreement is not a general obligation of City. Neither the full faith and credit, nor the taxing power of City is pledged to the payment of any amount due or to become due under this Agreement. It is understood that neither this Agreement nor any representation by any City employee or officer creates any obligation to appropriate or make monies available for the purpose of the Agreement beyond those monies appropriated in the current Grant Budget for the purposes of this Agreement.
ARTICLE II
DISBURSEMENT LIMIT
Section 2.1 Amount.
It is expressly agreed and understood that the total amount to be disbursed by the City under this Agreement shall not exceed $ _______ (Disbursement Limit). To the extent practicable, the use of Grant funds shall be used on a pro rata basis with other funds provided to the Program.
Section 2.2 Demands.
The Project Manager will award a fifty percent (50%) advance payment of the Disbursement Limit to Grantee (Advance Payment). Grantees receiving an Advance Payment, may be eligible for an additional advance of thirty-five percent (35%), contingent upon the submission of complete and adequate reporting and invoicing documentation, as set forth in Section 4.1(C) of this Agreement. Unless the Project Manager approved Advance Payment, Grant funds will be disbursed on a reimbursement basis. The remaining fifteen percent (15%) will be reserved until the completion of the grant program and final submittal of all required documentation.
It is Grantees responsibility to ensure that Grant funds are used only for the eligibl e costs and amounts specified in the Program Budget, attached hereto and made a part hereof as Exhibit B. Should Grantee fail to use Grant funds in accordance with the Program Budget, the payment of Grant funds may be suspended or terminated.
Section 2.3 Non-Liability.
City shall not be liable for any cost that (a) has been paid, reimbursed or is subject to payment or reimbursement, from any other source; (b) was incurred prior to the beginning date of this Agreement; (c) is not in accordance with the terms of this Agreement including all attachments; or (d) has not been billed to City within thirty (30) calendar days after the date this Agreement terminates.
ARTICLE III
LIMITATION ON CITY OBLIGATIONS
Section 3.1 Limitations.
A. Nothing in this Agreement shall make Grantee or Grantee’s employees (a) subject to any of the memoranda of understanding that apply to employees of City, (b) subject to the Personnel Rules that apply to employees of City, (c) subject to any of the benefits received by employees of City, including but
4 not limited to, Medical, Dental, Vision, Retirement, Vacation Sick Leave, and Administrative Leave, (d) covered by City’s Workers’ Compensation Insurance, (e) employees of City for purposes of the Tort Claims Act (Govt. Code Sections 825 et seq).
B. Grantee and Grantee’s employees shall not be protected by the same immunities and right to indemnification and defense extended by the Tort Claims Act (Govt. Code Sections 825 et seq) to public employees.
Section 3.2 Termination for Convenience.
This Agreement may be terminated by the City, at its sole and absolute discretion, upon thirty (30) days advance written notice thereof to Grantee, or cancelled immediately by written mutual consent.
ARTICLE IV
ADMINISTRATIVE REQUIREMENTS
Section 4.1 Financial Management.
A. Accounting Standards. Grantee shall adhere to Generally Accepted Accounting Principles, utilize adequate internal controls, and maintain necessary source documentation for all costs incurred.
B. Documentation and Record-Keeping.
(1) Records to be Maintained. Grantee shall maintain all records required that are pertinent to the activities to be funded under this Agreement, in a manner satisfactory to the City.
(2) Retention. Grantee shall retain all records related to the Program for a period of five (5) years after the termination of all activities funded under this Agreement
(3) Client Data. Grantee shall maintain client data demonstrating client eligibility for the Program, including client name, address, 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.
(4) Close-Outs. Grantee’s obligation to City shall not end until all close-out requirements are completed, including preparation of a close-out report (Close-Out Report) at the end of the Term. Activities during the C lose-Out period shall include, but are not limited to:
submission of the Close-Out Report, making final payments, submission of the Final Invoice (as defined below), and the return of unspent cash advances.
(5) Audits and Inspections. All Grantee records with respect to any matters covered by this Agreement shall be made available to City at any time during normal business hours, as often as City deems necessary, to audit, examine, and make excerpts or transcripts of all relevant data. Any deficiencies noted in audit reports must be fully cleared by Grantee within thirty (30) days after receipt of such report by Grantee. Failure by Grantee to comply with any
5 audit requirements shall constitute a breach o f this Agreement and may result in the withholding of future payments.
C. Reporting and Payment Procedures.
(1) Budgets. The Program Budget (Exhibit B) shall include a list of expenditures to be met with Grant funds. City and Grantee may agree to revise the Program Budget from time to time in accordance with existing City policies.
(2) Payment Procedures. Subject to the Disbursement Limit, City will pay Grant funds available under this Agreement based upon information submitted by Grantee and consistent with the Program Budget and City policies concerning such payments. Payments will be made for eligible expenses actually incurred by Grantee up to the Disbursement Limit. Any funds remaining shall revert back to City. Payments will be adjusted by City in accordance with any advance payments to Grantee.
(3) Progress Reports. Grantee shall submit a mid-year grant report (Progress Report) to the City in the form and content as set forth in Exhibit C (Grant Report Template). The Progress Report is due no later than January 31, 2022, unless an extension is authorized at the City’s sole and absolute discretion:
Period to be covered Due Date
July 1 through December 31 January 31
(4) Close-Out Report. The Close-Out Report, covering the entire grant period, is due by no later than thirty (30) days after the end of the Term, unless an extension is authorized at the City’s sole and absolute discretion.
Period to be covered Due Date
July 1 through June 30 July 31
(5) Invoices. Invoices shall contain, but not be limited to, the following information in sufficient detail and be submitted in a form which adequately de monstrates consistency with the Service Plan and Program Budget:
a. Number of hours Grantee staff performed work per task; b. Number of hours per staff member being billed for which stipends have been paid; c. Hourly or flat rate provided; and
d. Itemization of any other direct costs (e.g. supplies, travel, operating expenses, etc.) incurred for which reimbursement is being requested within that invoice period.
Note: Itemization of indirect cost (e.g. rent, utilities, etc.), although not required, may be requested and shall be made available to the City.
6 (6) Required Supporting Documentation. The following Required Supporting Documentation must be submitted with each Invoice, as applicable:
a. Every Invoice must be accompanied by a Progress Report, with the exception of the final invoice which must be accompanied by a Close-Out Report. Each Invoice must contain all of the information specified in the Grant Report Template, attached hereto and made a part hereof as Exhibit C.
b. If stipends are included in the Invoice, the Invoice must be accompanied by copies of participant’s daily logs or timesheets covering all stipend hours for which reimbursement is being requested.
c. If the Invoice is requesting reimbursement of any other direct costs (any costs other than staff time or stipends such as supplies, travel, operating expenses, etc. ), the Invoice must be accompanied by copies of actual itemized invoices or receipts for all applicable direct costs.
d. If staff time is included in the I nvoice, City may request that the I nvoice be accompanied by copies of timesheets or payroll records covering all staff hours for which reimbursement is being requested.
ARTICLE V
GENERAL PROVISIONS
Section 5.1 Relationship of Parties.
Nothing contained in this Agreement shall be interpreted or understood by any of the parties, or by any third persons, as creating the relationship of employer and employee, principal and agent, limited or general partnership, or joint venture by and between City and Grantee or their agents, employees, including Grantee’s employees, or subcontra ctors, and Grantee shall at all times be deemed an independent contractor and shall be wholly responsible for the manner in which it or its employees, agents, or both, perform the services required of it by the terms of this Agreement. Grantee has and retains the right to exercise full control of employment, direction, compensation, and discharge of all persons assisting in the performance of the Program under this Agreement.
Section 5.2 Compliance with Laws.
A. Grantee shall comply with all federal, sta te and local laws, statutes, ordinances, rules and regulations, and the orders and decrees of any courts or administrative bodies or tribunals, with respect to this Agreement, including without limitation environmental laws, disability laws, including the Americans with Disability Act, employment discrimination laws, living wage and prevailing wage laws. Compliance under this provision includes compliance with all provisions of the Municipal Code of the City of Richmond (Municipal Code), including Chapter 2.28 and Chapters 2.50, 2.52, 2.56, 2.60, and 2.65 if applicable, which are herein incorporated by reference.
B. Grantee acknowledges that under Section 2.60.070 of the Municipal Code (Living Wage Ordinance), Grantee shall promptly provide to City documents and information verifying its compliance with the Living Wage Ordinance. Also as prescribed in Section 2.60.070 of the Municipal Code, Grantee
7 shall notify each of its affected employees with regards to the wages that are required to be paid pursuant to the Living Wage Ordinance.
C. Grantee shall comply with Section 2.28.030 of the Municipal Code obli gating every contractor or subcontractor under a contract or subcontract with City for public work or for goods or for services to refrain from discriminatory employment or subcontracting practices on the basis of race, color, sex, sexual orientation, religious creed, national origin or ancestry of any employee, any applicant for employment or any potential subcontractor.
Section 5.3 Publicity and Acknowledgement of Support.
Grantee shall give appropriate credit to City and the ECIA program for its financial support in any and all press releases, publications, annual reports, video credits, dedications and other public communications regarding the Program and services performed pursuant to this Agreement, including but not limited to any tangible final products produced pursuant to this Agreement. Copies of such materials shall be provided to City for review. Grantee hereby grants to City the right and authority to publicize City and ECIA program support for the Program in press releases, publications, and other public communications of any type including, without limitation, digital and web publications, and to use Grantee’s name, likeness, logo or other official representation of Grantee in such communications.
Web Site Links: Grantee grants revocable permission to City to place links to Grantee’s web site on City’s ECIA web site. City grants revocable permission to Grantee to place links to City’s ECIA web site on Grantee’s web site.
Section 5.4 Background Checks.
If Grantee provides services to youth or other vulnerable populations (elderly, differently-abled, etc.), Grantee shall require comprehensive background checks and finger printing of all employ ees and/or volunteers that work directly with youth or such other vulnerable populations.
Section 5.5 Default.
In the event Grantee fails to perform properly any of its obligations hereunder and such failure of performance is not cured by Grantee within thirty (30) days after receipt of written notice from City or if the cure takes longer than thirty (30) days, if Grantee fails to commence to cure or within a reasonable time thereafter fails to complete the cure, City may in addition to any other remedies, suspend or terminate this Agreement, complete Grantee’s obligations in any reasonable manner it chooses, or operate or maintain the Program as the City may deem necessary to fulfill requirements of the Grant. Grantee shall reimburse City for any costs or expenses incurred by City because of such failure to perform. If Grantee fails to comply with any of rules, regulations, ordinances, requirements or provisions of City, in addition to other remedies as provided by law, this Agreement may be suspended or terminated.
Section 5.6 Copyright.
8 If this Agreement results in any copyrightable material, City reserves the right to royalty-free, non- exclusive and irrevocable license to reproduce, publish, or otherwise use and to authorize others to use, the work for government purposes.
Section 5.7 No Claims.
Nothing contained in this Agreement shall create or justify any claim against City by any person that Grantee may have employed or with whom Grantee may have contracted relative to the purchase of materials, supplies or equipment, or the furnishing or the performance of any work or services for the Program or otherwise.
Section 5.8 Indemnification.
A. To the fullest extent permissible by law, Grantee shall indemnify, defend and hold harmless, and require its contractors and subcontractors to defend, indemnify and hold harmless, City, and its elected and appointed officials, and all of t heir employees and agents ( Indemnified Parties), from all liability, penalties, costs, losses, damages, expenses, causes of action, claims or judgments, including attorney's fees and other defense costs (collectively, Claims), resulting from injury to or death sustained by any person (including Grantee’s or any contractors’ or subcontractors' employees), or damage to property of any kind, or any other injury or damage whatsoever, which Claims arise out of or are in any way connected with the provision of Program services hereunder or this Agreement, regardless of Grantee’s fault or negligence; provided, however, that Grantee’s indemnity obligations hereunder shall not apply to the extent any Claims are caused by the sole and active negligence or willful act or omission of an Indemnified Party. The indemnification obligations of Grantee and its contractors and subcontra ctors shall extend to Claims asserted after termination of this Agreement for whatever reason.
B. In Claims against any person or entity indemnified under Section 5.8A above by an employee of Grantee, or its contractors and subcontractors, anyone directly or indirectly employed by any one of them or anyone for whose acts one of them may be liable, the indemnification obligation under Section
5.8A above shall not be limited by a limitation on amount or type of damages, compensation of benefits payable under workers' compensation acts, disability benefit acts or other employee benefit acts.
Section 5.9 Non-Liability of City Officials, Employees and Agents.
No member, official, employee or agent of City shall be personally liable to Grantee in the event of any default or breach by City or for any amount which may become due to Grantee or its successor or on any obligation under the terms of this Agreement.
Section 5.10 Insurance.
Grantee shall submit to City evidence of and keep current the insurance coverage meeting the general requirements set forth in Exhibit D “Insurance Requirements.”
Section 5.11 No Third Party Beneficiaries.
9 There shall be no third party beneficiaries to this Agreement.
Section 5.12 Conflict of Interest.
A. Except for approved eligible administrative or personnel costs, no person described in Section
5.12B below who exercises or has exercised any functions or responsibilities with respect to the activities funded pursuant to this Agreement or who is in a position to participate in a decision-making process or gain inside information with regard to such activities, may obtain a personal or financial interest or benefit from the activity, or have an interest in any contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for themselves or those with whom they have family or business ties, during, or at any time after, such person's tenure. Grantee shall exercise due diligence to ensure that the prohibition in this Section 5.12A is followed.
B. The conflict of interest provisions of Section 5.12A apply to any person who is an employee, agent, consultant, officer, or any immediate family member of such person, or any elected or appointed official of City, or any person related within the third (3rd) degree of such person.
Section 5.13 Notices, Demands and Communications.
If at any time after the execution of this Agreement it shall become necessary or convenient for one of the parties hereto to serve any notice, demand or communication upon the other part y, such notice, demand or communication shall be in writing and shall be served personally or by depositing the same in the registered United States mail, return receipt requested, postage prepaid or delivered by express delivery service, return receipt requested and:
If intended for City shall be addressed to:
City of Richmond
450 Civic Center Plaza, Suite 300
Richmond, California 94804
Attention: City Manager
With copy to:
City of Richmond
450 Civic Center Plaza, Suite 340
Richmond, CA 94804
Attention: City Attorney
If intended for Grantee shall be addressed to:
___________________________
____________________________
____________________________
Any notice, demand or communication shall be deemed given, received, made or communicated on the date personal delivery is affected or, if mailed in the manner herein specified, on the delivery date or date
10 delivery is refused by the addressee, as shown on the return receipt. Any party may change its address at any time by giving written notice of such change at least ten (10) days prior to the date such change is desired to be effective.
Section 5.14 Applicable Law.
This Agreement shall be governed by California law. This Agreement is made in Contra Costa County, California, and any action relating to this Agreement shall be instituted and prosecuted in the courts of Contra Costa County, California.
Section 5.15 Parties Bound.
Except as otherwise limited herein, the provisions of this Agreement shall be binding upon and inure to the benefit of the parties and their heirs, executors, administrators, legal representatives, successors, and assigns. Any reference in this Agreement to a specifically named party shall be deemed to apply to any successor, heir, administrator, executor, successor, or assign of such party who has acquired an interest in compliance with the terms of this Agreement or under law. This Agreement shall be binding upon and inure to the benefit of the heirs, administrators, executors, successors in interest, and assigns of each of the parties.
Section 5.16 Attorneys' Fees.
If any lawsuit is commenced to enforce any of the terms of this Agreement, the prevailing party will have the right to recover its reasonable attorneys’ fees and costs of suit from the other party.
Section 5.17 Severability.
If any term of this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions shall continue in full force and effect unless the rights and obligations of the parties h ave been materially altered or abridged by such invalidation, voiding or unenforceability.
Section 5.18 Waivers.
Any waiver by City of any obligation or condition in this Agreement must be in writing. No waiver will be implied from any delay or failure by City to take action on any breach or default of Grantee or to pursue any remedy allowed under this Agreement or applicable law. Any extension of time granted to Grantee to perform any obligation under this Agreement shall not operate as a waiver or release from any of its obligations under this Agreement. Consent by City to any act or omission by Grantee shall not be construed to be consent to any other or subsequent act or omission or to waive the requirement for Grantee’s written consent to future waivers.
Section 5.19 Title of Parts and Sections.
11 Any titles of the sections or subsections of this Agreement are inserted for convenience of reference only and shall be disregarded in interpreting any part of the Agreement’s provisions.
Section 5.20 Entire Understanding of the Parties.
This Agreement constitutes the entire understanding and agreement of the parties with respect to its subject matter. All modifications, amendments, or waivers of any terms of this Agreement shall be in writing and signed by the duly authorized representatives of the parties.
Section 5.21 Multiple Originals; Counterpart.
This Agreement may be executed in multiple originals, each of which is deemed to be an original, and may be signed in counterparts.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first written above.
CITY OF RICHMOND:
Laura Snideman Date
City Manager
Approved as to form: Attest:
____________________________ ____________________________
Teresa Stricker Pamela Christian
City Attorney City Clerk
GRANTEE:
Name Date
_________________________________ ____________________________________ Title Signature
EXHIBIT C
GRANT REPORT TEMPLATE
(The Grant Report Template may be updated by the City of Richmond at any time)
Project Expenses to Date: Attach a completed Invoice for any reimbursable costs incurred during this reporting period.
Fiscal Year 2021-22
Progress Report (July 1, 2021 – December 31, 2021)
Richmond - ECIA Community Grant Program
Organization Name:
Project Name:
Contact Person:
Grant Award Amount: $ Project Duration: (in months)
Total number of clients served:
Total number of clients served from Richmond:
Indicate the area or neighborhood(s) where services were provided:
Program Project Description: (Provide a brief description of the project/programs your organization is providing with ECIA Grant funds. Activities must be consistent with the Service Plan attached as Exhibit A to the Grant Services Agreement)
Task Accomplished and Success to Date:
1. What task has your organization completed in whole or in part during this period?(Task should be consistent with those identified in the Service Plan for the reporting period)
2. Identify and discuss any challenges, issues or problems your organization faced during this period which might impact the program/project’s ability to meet the intended outcomes identified in the Service Plan.
3. What lessons have you learned from participants, staff and/or the community during the course of the project?
4. What feedback have participants and/or members of the community provided regarding the program/project? (e.g. quotes, e-mails/letters, summarized findings from surveys)
5. Did your staff participate in any capacity-building opportunities during the reporting period? If so, please identify.
EXHIBIT C
GRANT REPORT TEMPLATE
(The Grant Report Template may be updated by the City of Richmond at any time)
Project Expenses to Date: Attach a completed Invoice for any reimbursable costs incurred during this reporting period.
Complete the chart below. The chart should be completed using information from the Grant Service Agreement Exhibit A – 3 Outcomes Table. Add Lines if needed
Program Component Program Outcome Indicator/
Measurement Goal
1st Term 2nd Term Grant End
July 1st December
31st
January
1st June 30th July 1st – June 30th
Actuals at period
end
Actuals at
period end
Cumulative
Actuals at
grant end
School Preparedness Students return to class with
adequate supplies
# of backpacks
distributed 100 60 60 120
# of volunteers 20 5 3 8
14 EXHIBIT D
INSURANCE REQUIREMENTS
During the entire term of this Contract and any extension or modification thereof, the Grantee shall keep in effect insurance policies meeting the insurance requirements specified in the insurance provisions which are attached hereto and incorporated herein by this reference. ___ Exhibit F
___ Section 8
City of Richmond Insurance Requirements – Type 5:
Vendors, Suppliers, Small Grant Recipients & Nonprofit
Organizations
Type 5 - Page 1 of 3
Revised: September 2011
In all instances where CONTRACTOR or its representatives will be conducting business and/or providing services to the City of Richmond (City), or will be awarded City of Richmond (City) funds to provide programs or services, the City requires the following MINIMUM insurance requirements and limits.
CONTRACTOR shall procure and maintain for the duration of the contract, agreement, or other order for work, services or supplies, insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the CONTRACTOR, its agents, representatives, or subcontractors. Maintenance of proper insurance coverage is a material element of the contract. Failure to maintain or renew coverage or to provide evidence of renewal may be treated by the City as a material breach of contract.
CONTRACTOR agrees that in the event of loss due to any of the perils for which it has agreed to provide Commercial General Liability insurance, CONTRACTOR shall look solely to its insurance for recovery.
CONTRACTOR hereby grants to CITY, on behalf of any insurer providing Commercial General Liability insurance to either CONTRACTOR or CITY with respect to the services of CONSULTANT herein, a waiver of any right to subrogation which any such insurer of said CONTRACTOR may acquire against the CITY by virtue of the payment of any loss under such insurance.
Original, signed certificates and original, separate policy endorsements, naming the City as an additional insured for general liability, as well as a waiver of subrogation for Workers’ Compensation insurance, shall be received and approved by the City before any work may begin. However, failure to do so shall not operate as a waiver of these insurance requirements.
City reserves the right to modify or require additional coverages for specific risk exposures depending on scope of CONTRACTORS work.
Minimum coverage is detailed below. The policy limits of coverage shall be made available to the full limits of the policy. The minimum limits stated herein shall not serve to reduce the policy limits of coverage of CONTRACTOR.
Minimum Scope of Insurance – the following forms shall be provided and coverage shall be at least as broad as the following:
1. Insurance Services Office Commercial General Liability coverage (ISO Occurrence Form CG 0001)
2. Insurance Services Office Automobile Liability coverage (ISO Form CA 0001, Code 1, Any Auto)
3. Original and Separate Additional Insured Endorsements for General Liability (ISO Form CG 20 10 11/85 or its equivalent) with primary and non-contributory language.
4. Workers’ Compensation insurance as required by the State of California including Employer’s Liability (for CONTRACTOR’s with employees);
5. Original and Separate Waiver of Subrogation for Workers’ Compensation Insurance.
6. Fidelity Bond/Crime Coverage – in an amount stipulated by City depending upon scope of contract.
Required Coverage Minimum Limits
Workers’ Compensation and
Employers’ Liability
Statutory limits as required by the State of California including $1 million Employers’ Liability per accident, per employee for bodily injury or disease.
If CONTRACTOR is self-insured, provide a certificate of Permission to Self- Insure, signed by the California Department of Industrial Relations and Self- Insurance. If contractor is a sole proprietor (has no employees) than contractor must sign “Contractor Release of Liability” located at:
http://www.ci.richmond.ca.us/index.aspx?nid=61
.
General Liability
(primary and excess limits
combined)
$1,000,000 per occurrence for bodily injury, personal injury and property damage. If the policy includes a general aggregate, either the general aggregate shall apply separately to this project, service or location or the minimum required aggregate limit shall be twice the per occurrence limit ($4 million aggregate).
Policy shall also include coverage for liability arising out of the use and operation of any City-owned or City-furnished equipment used or operated by the CONTRACTOR, its personnel, agents or subcontractors.
Policy shall be endorsed to name the City of Richmond as an additional insured per the conditions detailed below.
___ Exhibit F
___ Section 8
City of Richmond Insurance Requirements – Type 5:
Vendors, Suppliers, Small Grant Recipients & Nonprofit
Organizations
Type 5 - Page 2 of 3
Revised: September 2011
Automobile Liability (If auto is used.) $1,000,000 per occurrence for bodily injury and property damage.
Fidelity Bond/Crime Coverage
(Applies if receiving City
funds.)
In an amount stipulated by City depending upon the scope of Contract. (Usually based upon the amount of money the Contractor is handling that could be embezzled over a period of time.)
Required Policy Conditions
Additional Insured Endorsement
Applicable to General Liability Coverage.
The City of Richmond, its officers, officials, employees, agents and volunteers are to be named as additional insureds for all liability arising out of the operations by or on behalf of the named insured including bodily injury, deaths and property damage or destruction arising in any respect directly or indirectly in the performance of this contract.
ISO form CG 20 10 (11/85) or its equivalent is required. The endorsement must not
exclude products and completed operations
coverage. If it does, then CG 20 37 (10/01) is also required.
SAMPLE ENDORSEMENT can be found at:
http://www.ci.richmond.ca.us/index.aspx?nid=61.
Waiver of Subrogation
Endorsement Form
Contractor’s insurer will provide a Waiver of Subrogation in favor of the City for Workers’ Compensation Insurance providing coverage during the life of this contract.
SAMPLE ENDORSEMENT can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61
.
Primary and Noncontributory The contractor’s insurance coverage must be primary coverage as it pertains to the City, its officers, officials, employees, agents and volunteers. Any insurance or self insurance maintained by the City is wholly separate from the insurance of the contractor and in no way relieves the contractor from its responsibility to provide insurance.
A. M. Best Rating A:VII or Better. If the A.M. Best Rating falls below the required rating, CONTRACTOR must replace coverage immediately and provide notice to City.
Deductibles and Self-Insured
Retentions
Any deductible or self-insured retention must be declared to and approved by the City. At the option of the City either the insurer shall reduce or eliminate such deductibles or self-insured retention as respects the City or the contractor shall procure a financial guarantee in an amount equal to the deductible or self-insured retention guaranteeing payment of losses and related investigations, claims administration and defense expenses.
Contractor is responsible for satisfaction of the deductible and/or self-insured retention for each loss.
Umbrella/Excess Liability Policies
If an Umbrella or Excess Liability Policy is used to meet the liability limits, coverage shall be as broad as specified for underlying coverages and cover those insured in the underlying policies.
___ Exhibit F
___ Section 8
City of Richmond Insurance Requirements – Type 5:
Vendors, Suppliers, Small Grant Recipients & Nonprofit
Organizations
Type 5 - Page 3 of 3
Revised: September 2011
Subcontractors
CONTRACTOR shall include all subcontractors as insured under its policies or shall furnish to the City for review and approval, separate certificates and endorsements for each subcontractor. All coverage for subcontractors shall be subject to all of the requirements stated herein.
CONTRACTOR agrees to defend and indemnify the City of Richmond for any damage resulting to it from failure of either CONTRACTOR or any subcontractor to take out or maintain the required insurance policies.
The fact that
insurance is obtained by CONTRACTOR, and/or CONTRACTOR’s subcontractors, will not be deemed to release or diminish the liability of CONTRACTOR, including, without limitation, liability under the indemnity provisions of this contract. Damages recoverable by CITY from CONTRACTOR or any third party will not be limited by the amount of the required insurance coverage.
Verification of Coverage
All original certificates and endorsements shall be received and approved by the City before work may begin .
The City of Richmond reserves the right to require complete, certified copies of all required insurance policies including endorsements affecting the coverage at any time.
Original insurance certificates and required policy endorsements shall be mailed or delivered to the Designated Project Manager for the City of Richmond.
Insurance certificates and endorsements may be faxed to the Designated Project Manager. However, Contractor must mail the original certificates and endorsements to Designated Project Manager once faxed.
Continuous Coverage
CONTRACTOR shall maintain the required insurance for the life of the contract. Should the CONTRACTOR cease to have insurance as required during this time, all work by the CONTRACTOR pursuant to this agreement shall cease until insurance acceptable to the City is provided. In the event that CONTRACTOR fails to comply with the City’s insurance requirements, the City may take such action as it deems necessary to protect the City’s interests. Such action may include but is not limited to termination of the contract, withholding of payments, or other actions as the City deems appropriate.
If services or the scope of work extend beyond the expiration dates of the required insurance policies initially approved by the City, CONTRACTOR
must provide updated certificates and endorsements indicating that the required coverage, terms and conditions are still in place. Renewal certificates and updated endorsements shall be mailed to the Designated Project Manager.
Cancellation
CONTRACTOR shall ensure that coverage shall not be cancelled, reduced or otherwise materially changed except after thirty (30) days’ prior written notice has been given to the City.
Reporting Requirements
Any failure to comply with reporting or other provisions of the policies including breaches of warranties shall not affect coverage provided to the City, its officers, officials, employees or volunteers.
Consistent with Public Policy
The insuring provisions, insofar as they may be judged to be against public policy shall be void and unenforceable only to the minimum extent necessary so that the remaining terms and provisions herein may be consistent with public policy and thus enforceable.
Part I
OMB No. 1545-0047
Return of Organization Exempt From Income Tax990Form
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
Department of the Treasury
Internal Revenue Service /H17075The organization may have to use a copy of this return to satisfy state reporting requirements.
For the 2006 calendar year, or tax year beginning , 2006, and ending , 20 D Employer identification numberName of organizationPlease use IRS
label or
print or
type.
See
Specific
Instruc-
tions.
E Telephone numberNumber and street (or P.O. box if mail is not delivered to street address) City or town, state or country, and ZIP + 4
Check here /H17075if the organization is not a 509(a)(3) supporting organization and its gross receipts are normally not more than $25,000. A return is not required, but if the organization chooses to file a return, be sure to file a complete return.
Revenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions.) Contributions, gifts, grants, and similar amounts received:1 1a
Direct public support (not included on line 1a) b 1b
Indirect public support (not included on line 1a) c 1c
Government contributions (grants) (not included on line 1a)d 1eTotal (add lines 1a through 1d) (cash $ noncash $ )e
2Program service revenue including government fees and contracts (from Part VII, line 93)2 3Membership dues and assessments3
4Interest on savings and temporary cash investments 4
5Dividends and interest from securities 5
6aGross rents 6a
6bLess: rental expenses b
6cNet rental income or (loss). Subtract line 6b from line 6ac 7Other investment income (describe /H17075 )7
(B) Other(A) SecuritiesGross amount from sales of assets other than inventory
8a
8a
Revenue
8bLess: cost or other basis and sales expensesb
8cGain or (loss) (attach schedule) c
8dNet gain or (loss). Combine line 8c, columns (A) and (B)d 9 Gross revenue (not including $ of
contributions reported on line 1b)
a
9a
9bLess: direct expenses other than fundraising expensesb 9cNet income or (loss) from special events. Subtract line 9b from line 9ac 10aGross sales of inventory, less returns and allowances 10a 10bLess: cost of goods sold b
10cGross profit or (loss) from sales of inventory (attach schedule). Subtract line 10b from line 10ac 11Other revenue (from Part VII, line 103) 11
12 Total revenue. Add lines 1e, 2, 3, 4, 5, 6c, 7, 8d, 9c, 10c, and 11 12 1313 Program services (from line 44, column (B))
14Management and general (from line 44, column (C)) 14
15Fundraising (from line 44, column (D)) 15
16Payments to affiliates (attach schedule) 16
Expenses
17 Total expenses. Add lines 16 and 44, column (A) 17
18Excess or (deficit) for the year. Subtract line 17 from line 12 18 19Net assets or fund balances at beginning of year (from line 73, column (A)) 19 Net Assets
2020 Other changes in net assets or fund balances (attach explanation) 21 21Net assets or fund balances at end of year. Combine lines 18, 19, and 20 Form 990 (2006)For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11282Y A
C
Room/suite
Accounting method:F
K
B Check if applicable:
Final return
Amended return
Address change
Organization type (check only one) /H17075
G
Group Exemption Number /H17075I
501(c) ( ) /H17076 5274947(a)(1) or
H(a) Yes NoIs this a group return for affiliates?
If “Yes,” enter number of affiliates /H17075
Is this a separate return filed by an
organization covered by a group ruling?
H(b)
H(d)
(insert no.)
Yes No
Initial return
Name change
Are all affiliates included?
(If “No,” attach a list. See instructions.)
H(c) Yes No
H and I are not applicable to section 527 organizations.● Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A (Form 990 or 990-EZ).
Open to Public
Inspection
Check /H17075if the organization is not required
to attach Sch. B (Form 990, 990-EZ, or 990-PF).
M
()
Application pending
Cash Accrual
Other (specify) /H17075
Website: /H17075
L Gross receipts: Add lines 6b, 8b, 9b, and 10b to line 12 /H17075 J
Special events and activities (attach schedule). If any amount is from gaming, check here /H17075 Contributions to donor advised funds a
1d
Statement of
Functional Expenses
All organizations must complete column (A). Columns (B), (C), and (D) are required for section 501(c)(3) and (4) organizations and section 4947(a)(1) nonexempt charitable trusts but optional for others. (See the instructions.) Do not include amounts reported on line
6b, 8b, 9b, 10b, or 16 of Part I.
(C) Management
and general
(B) Program
services (D) Fundraising(A) Total
Other grants and allocations (attach schedule)22b
23 Specific assistance to individuals (attach
schedule)
Benefits paid to or for members (attach
schedule)
24 Compensation of current officers, directors,
key employees, etc. listed in Part V-A (attach
schedule)
25a
Salaries and wages of employees not included
on lines 25a, b, and c
26 Pension plan contributions not included on
lines 25a, b, and c
27 Employee benefits not included on lines
25a – 27
28 Payroll taxes 29
Professional fundraising fees30
Accounting fees 31
Legal fees 32
Supplies33
Telephone34
Postage and shipping 35
Occupancy36
Equipment rental and maintenance 37
Printing and publications 38
Travel39
Conferences, conventions, and meetings 40
Interest41
Depreciation, depletion, etc. (attach schedule)42
Other expenses not covered above (itemize):43
b
c
d
Total functional expenses. Add lines 22a
through 43g. (Organizations completing
columns (B)–(D), carry these totals to lines
13–15)
44 Part II
If “Yes,” enter (i) the aggregate amount of these joint costs $ ; (ii) the amount allocated to Program services $ ; Yes No
22b
23 24
25a
26 27
28 29
30 31
32 33
34 35
36 37
38 39
40 41
42 43a
44 43b
43c
43d
Joint Costs. Check
/H17075 if you are following SOP 98-2.
(cash $ noncash $ )
(iii) the amount allocated to Management and general $ ; and (iv) the amount allocated to Fundraising $ Form 990 (2006)
Are any joint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? /H17075 a
e
f
g
43e
43f
43g
If this amount includes foreign grants, check here /H17075 Grants paid from donor advised funds (attach schedule)22a (cash $ noncash $ )
If this amount includes foreign grants, check here /H17075 Compensation of former officers, directors,
key employees, etc. listed in Part V-B (attach
schedule)
Compensation and other distributions, not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) (attach schedule) b
c
25b
25c
22aNAME
ADDRESS
ASSETS
EXPENSES
GIFTS RECEIVED
REVENUE
GRANTS PAID
PROGRAM SERVICES
IRS Form 990
Exhibit '
Statement of Program Service Accomplishments (See the instructions.) Program Service
ExpensesWhat is the organization’s primary exempt purpose? /H17075 (Grants and allocations $ )
Other program services (attach schedule)
Total of Program Service Expenses (should equal line 44, column (B), Program services) /H17075 (Required for 501(c)(3) and
(4) orgs., and 4947(a)(1)
trusts; but optional for
others.)
Part III
All organizations must describe their exempt purpose achievements in a clear and concise manner. State the number of clients served, publications issued, etc. Discuss achievements that are not measurable. (Section 501(c)(3) and (4) organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and allocations to others.) a
b
c
d
e
f
(Grants and allocations $ )
(Grants and allocations $ )
(Grants and allocations $ )
Form 990 (2006)
If this amount includes foreign grants, check here /H17075 If this amount includes foreign grants, check here /H17075 If this amount includes foreign grants, check here /H17075 If this amount includes foreign grants, check here /H17075 (Grants and allocations $ ) If this amount includes foreign grants, check here /H17075 Form 990 is available for public inspection and, for some people, serves as the primary or sole source of information about a particular organization. How the public perceives an organization in such cases may be determined by the information presented on its return. Therefore, please make sure the return is complete and accurate and fully describes, in Part III, the organizati on’s programs and accomplishments.
Form 990 (2006) Page 4
Balance Sheets (See the instructions.)
(B)
End of year
(A)
Beginning of year
Note: Where required, attached schedules and amounts within the description column should be for end-of-year amounts only.
Assets
45Cash—non-interest-bearing45
4646 Savings and temporary cash investments
47aAccounts receivable 47a
47c47bLess: allowance for doubtful accounts b
48aPledges receivable 48a
48b 48cLess: allowance for doubtful accounts b
49Grants receivable 49
50a Receivables from current and former officers, directors, trustees, and key employees (attach schedule) 50a
51a
51a Other notes and loans receivable (attach
schedule)
51b 51cb Less: allowance for doubtful accounts
5252 Inventories for sale or use
5353 Prepaid expenses and deferred charges
54a54a Investments—publicly-traded securities /H17075
Investments—land, buildings, and
equipment: basis
55a
55a
Less: accumulated depreciation (attach
schedule)
b
55b 55c
56Investments—other (attach schedule) 56
57aLand, buildings, and equipment: basis 57a
57c57b
Less: accumulated depreciation (attach
schedule)
b
58 Other assets, including program-related investments
(describe /H17075 )
58 Total assets (must equal line 74). Add lines 45 through 58 59 59 Liabilities
60Accounts payable and accrued expenses 60
61Grants payable 61
62Deferred revenue62
63 Loans from officers, directors, trustees, and key employees (attach schedule)
63 64aTax-exempt bond liabilities (attach schedule) 64a 65Other liabilities (describe /H17075 )65
Total liabilities. Add lines 60 through 65 66 66
Part IV
64bMortgages and other notes payable (attach schedule) b Net Assets or Fund Balances
Organizations that do not follow SFAS 117, check here /H17075 6767 Unrestricted
6868 Temporarily restricted
6969 Permanently restricted
7070 Capital stock, trust principal, or current funds
7171 Paid-in or capital surplus, or land, building, and equipment fund 7272 Retained earnings, endowment, accumulated income, or other funds 73 73 Total net assets or fund balances. Add lines 67 through 69 or lines 70 through 72. (Column (A) must equal line 19 and column (B) must equal line 21)
7474 Total liabilities and net assets/fund balances. Add lines 66 and 73 and
Organizations that follow SFAS 117, check here /H17075and complete lines 67 through 69 and lines 73 and 74.
complete lines 70 through 74.
Cost FMV
Form 990 (2006)
Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) (attach schedule) b
Investments—other securities (attach schedule) /H17075 Cost FMV 54bb 50b
ASSETS
GRANTS PAID
Form 990 (2006) Page 5
Reconciliation of Revenue per Audited Financial Statements With Revenue per Return (See the instructions.)
a
b
c
d
e
1 2
3 Reconciliation of Expenses per Audited Financial Statements With Expenses per Return 4 1
2 a
b
c
d
e
1 2
3 4
1 2
Part IV-B
Part IV-A
Total revenue, gains, and other support per audited financial statements Amounts included on line a but not on Part I, line 12:
Net unrealized gains on investments
Donated services and use of facilities
Recoveries of prior year grants
Other (specify):
Add lines b1 through b4
Subtract line b from line a
Amounts included on Part I, line 12, but not on line a:
Investment expenses not included on Part I, line 6b
Other (specify):
Add lines d1 and d2
Total revenue (Part I, line 12). Add lines c and d /H17075 a
b
c
d
e
b1
b2
b3
b4
d1
d2
Total expenses and losses per audited financial statements Amounts included on line a but not on Part I, line 17:
Donated services and use of facilities
Prior year adjustments reported on Part I, line 20
Losses reported on Part I, line 20
Other (specify):
Add lines b1 through b4
Subtract line b from line a
Amounts included on Part I, line 17, but not on line a:
Investment expenses not included on Part I, line 6b
Other (specify):
Add lines d1 and d2
Total expenses (Part I, line 17). Add lines c and d /H17075 Form 990 (2006)
a
b
c
d
e
b1
b2
b3
b4
d1
d2
Current Officers, Directors, Trustees, and Key Employees (List each person who was an officer, director, trustee, or key employee at any time during the year even if they were not compensated.) (See the instructions.) (B)
Title and average hours per
week devoted to position
(C) Compensation
(If not paid, enter
-0-.)
(D) Contributions to employee
benefit plans & deferred
compensation plans
(E) Expense account
and other allowances(A) Name and address
Part V-A
Form 990 (2006) Page 6
Current Officers, Directors, Trustees, and Key Employees (continued) NoYesPart V-A Enter the total number of officers, directors, and trustees permitted to vote on organization business at board meetings
Are any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated employees listed in Schedule A, Part I, or highest compensated professional and other independent contractors listed in Schedule A, Part II-A or II-B, related to each other through family or business relationships? If “Yes,” attach a statement that identifies the individuals and explains the relationship(s) 75a
Former Officers, Directors, Trustees, and Key Employees That Received Compensation or Other Benefits (If any former officer, director, trustee, or key employee received compensation or other benefits (described below) during the year, list tha t person below and enter the amount of compensation or other benefits in the appropriate column. See the instructions.) (B) Loans and Advances
(E) Expense
account and other
allowances
(A) Name and address
Part V-B
Form 990 (2006)
Do any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated employees listed in Schedule A, Part I, or highest compensated professional and other independent contractors listed in Schedule A, Part II-A or II-B, receive compensation from any other organizations, whether tax exempt or taxable, that are related to the organization? See the instructions for the definition of “related organization.”
/H17075
Does the organization have a written conflict of interest policy? b
c
d
75b
75c
75d
Other Information (See the instructions.)
76 Did the organization make a change in its activities or methods of conducting activities? If “Yes,” attach a detailed statement of each change
76 7777 Were any changes made in the organizing or governing documents but not reported to the IRS? If “Yes,” attach a conformed copy of the changes.
78a
78a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return?
78bIf “Yes,” has it filed a tax return on Form 990-T for this year?b 79 79 Was there a liquidation, dissolution, termination, or substantial contraction during the year? If “Yes,” attach a statement
Is the organization related (other than by association with a statewide or nationwide organization) through common membership, governing bodies, trustees, officers, etc., to any other exempt or nonexempt organization?
80a
80a
and check whether it is exempt or nonexempt
b
81a81a Enter direct and indirect political expenditures. (See line 81 instructions.) 81bDid the organization file Form 1120-POL for this year?b Part VI Yes No
If “Yes,” enter the name of the organization /H17075
(C) Compensation
(if not paid,
enter -0-)
(D) Contributions to employee
benefit plans & deferred
compensation plans
/H17075
If “Yes,” attach a statement that includes the information described in the instructions.
OFFICERS, DIRECTORS,
TRUSTEES, AND
KEY EMPLOYEES
1/10/2017 2015IRS990N.png (1040×800)
http://www.circadiansleepdisorders.org/docs/tax/2015IRS990N.png 1/1
INTERNAL REVENUE SERVICE
P. O. BOX 2508
CINCINNATI, OH 45201
Date:
YOUR NONPROFIT, INC.
P. O. BOX 123
MISSION WAY, CA 95050
DEPARTMENT OF THE TREASURY
Employer Identification Number:
12-3456789
DLN:
123456789910
Accounting Period Ending:
December 31
Public Charity Status:
170(b)(1)(A)(vi)
Form 990 Required
Yes
Effective Date of Exemption
January 3, 2002
Contribution Deductibility:
Yes
Addendum Applies:
No
Dear Applicant:
We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c)(3) of the Internal Revenue Code.
Contributions to you are deductible under section 170 of the code.
You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code.
Because of this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records.
Organizations exempt under section 501(c)(3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter.
For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter “4221-PC” in the search bar to view Publication 4221-PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements.
Sincerely,
Ms. Mission
Director, Exempt Organization
Letter 111
This document is a sample for the sole purpose of displaying what an IRS determination letter looks like. This is not an actual determination letter. The use of this document is intended strictly for informational purposes and not any commercial purpose. This document is not for sale.
Exhibit (