HomeMy WebLinkAboutPK07-090 - Original - Kent Youth & Family Services - Family & Teen Substance Abuse Counseling, Teen Parent Housing - 01/01/2007 Records Management
W AS NINGTON wwmmp�KENT Document
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission to City Clerks Office. All
portions are to be completed, if you have questions, please contact Mary Simmons, City
Clerks Office.
Vendor Name: AY i A f Vendor Number:
( i ce� _ JD Edwards Number
Contract Number: ` ' ��- ?0
This is assigned by Mary Simmons
Description:
Detail: Ouflyart LyeS L-eAtrAI fUnd (onh2cf:
Project Name: 4
Contract Effective Date: V Termination Date: 1 Z 31 "0A
Contract Renewal Notice (Days):
v
Number of days required notice for termination or renewal or amendment
Contract Manager: M� � 4A#IS" Department:
Nvn46Werv�ens
Abstract:
S Public\RecordsManagement\Forms\ContractCover\ADCL7832 07/02
0000044
KEN I
W..S...GTO.
CONSULTANT SERVICES AGREEMENT
between the City of Kent and
Kent Youth & Family Services
THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation
(hereinafter the "City"), and Kent Youth & Family Services organized under the laws of the State of
Washington, located and doing business at 232 2"d Ave S., Kent, WA 98032 (hereinafter the "Consultant").
I. DESCRIPTION OF WORK.
Consultant sball perform the following services for the City in accordance with the following described
plans and/or specifications:
Consultant shall provide family counseling for Kent children and their families, teen substance
abuse treatment for Kent youth ages 12-18, and transitional housing and case management for
homeless teenage mothers and their children. The following exhibits are attached and
incorporated by this reference as if fully set forth herein: Exhibit A, Scope and Schedule of
Work; Exhibit B, Billing Voucher and Service Report, Exhibit C, Kent First and Final Outcome
Report; Exhibit D, Demographic Report; Exhibit E, Insurance Certificate; and Exhibit F,
Debarment Certification.
Consultant further represents that the services furnished under this Agreement will be performed in
accordance with generally accepted professional practices in effect at the time those services are performed.
IL TIME OF COMPLETION. The term of this Agreement shall run from January 1,2007, through
December 31, 2008. However, due to the delay in execution of this Agreement, the parties agree that all actions
consistent with the authority of this Agreement and prior to the date of the Agreement's execution are hereby
ratified and affirmed, and the terms of this Agreement shall be deemed to have applied. The parties agree that
Consultant shall complete the work described in Section I by December 31, 2009. This Agreement,however, is
contingent upon the availability of funds to be allocated through the City's budget process During the term of
this Agreement should the City determine that funds to support Consultant's services are no longer available,
the City shall provide Consultant seven(7) days advance written notice of summary termination.
III. COMPENSATION.
A. The City shall pay the Consultant, based on time and materials, an amount not to exceed
$139,000 ($69,500 per year) for the services described in this Agreement. This is the maximum
amount to be paid under this Agreement for the work described in Section I above, and shall not
be exceeded without the prior written authorization of the City in the form of a negotiated and
executed supplemental agreement. The Consultant agrees that the hourly or flat rate charged by
it for its services contracted for herein shall remain locked at the negotiated rate(s)for a period of
CONSULTANT SERVICES AGREEMENT- 1
(Over$10,000)
one (1) year from the effective date of this Agreement. The Consultant's billing rates shall be as
delineated in Exhibit A.
B. The Consultant shall submit quarterly payment invoices to the City for work performed, and a
final bill upon completion of all services described in this Agreement. The City shall provide
payment within forty-five (45) days of receipt of an invoice. If the City objects to all or any
portion of an invoice, it shall notify the Consultant and reserves the option to only pay that
portion of the invoice not in dispute. In that event, the parties will immediately make every
effort to settle the disputed portion.
IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor-
Employer Relationship will be created by this Agreement and that the Consultant has the ability to control and
direct the performance and details of its work, the City being interested only in the results obtained under this
Agreement.
V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon
providing the other party thirty (30) days written notice at its address set forth on the signature block of this
Agreement. After termination, the City may take possession of all records and data within the Consultant's
possession pertaining to this project, which may be used by the City without restriction. If the City's use of
Consultant's records or data is not related to this project, it shall be without liability or legal exposure to the
Consultant.
VI. DISCRIMINATION. In the hiring of employees for the performance of work under this
Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the
Consultant or subcontractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national
origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is
qualified and available to perform the work to which the employment relates. Consultant shall execute the
attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative
Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement.
VII. INDEMNIFICATION. Consultant shall defend, indemnify and hold the City, its officers,
officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits,
including all legal costs and attorney fees, arising out of or in connection with the Consultant's performance of
this Agreement, except for that portion of the injuries and damages caused by the City's negligence.
The City's inspection or acceptance of any of Consultant's work when completed shall not be grounds to
avoid any of these covenants of indemnification.
Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115,
then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused
by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials, employees,
agents and volunteers, the Consultant's liability hereunder shall be only to the extent of the Consultant's
negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE
INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF
IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF
THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE
MUTUALLY NEGOTIATED THIS WAIVER.
CONSULTANT SERVICES AGREEMENT-2
(Over$10,000)
The provisions of this section shall survive the expiration or termination of this Agreement.
VIII. INSURANCE. The Consultant shall procure and maintain for the duration of the Agreement,
insurance of the types and in the amounts described in Exhibit E attached and incorporated by this reference.
IX. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide
reasonable accuracy of any information supplied by it to Consultant for the purpose of completion of the work
under this Agreement.
X. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents,
drawings, designs, reports, or any other records developed or created under this Agreement shall belong to and
become the property of the City. All records submitted by the City to the Consultant will be safeguarded by the
Consultant. Consultant shall make such data, documents, and files available to the City upon the City's request.
The city's use or reuse of any of the documents, data and files created by Consultant for this project by anyone
other than Consultant on any other project shall be without liability or legal exposure to Consultant.
XI. CITY'S RIGHT OF INSPECTION. Even though Consultant is an independent contractor
with the authority to control and direct the performance and details of the work authorized under this
Agreement, the work must meet the approval of the City and shall be subject to the City's general right of
inspection to secure satisfactory completion.
XII. WORK PERFORMED AT CONSULTANT'S RISK. Consultant shall take all necessary
precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the
performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be
done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials, tools,
or other articles used or held for use in connection with the work.
XIII. MISCELLANEOUS PROVISIONS.
A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its
contractors and consultants to use recycled and recyclable products whenever practicable. A price preference
may be available for any designated recycled product.
B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the
covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement
in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements
or options, and the same shall be and remain in full force and effect.
C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and
construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute,
difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving
that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction
of the King County Superior Court, King County, Washington, unless the parties agree in writing to an
alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties'
performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending
or bringing such claim or lawsuit, in addition to any other recovery or award provided by law; provided,
however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section
VII of this Agreement.
CONSULTANT SERVICES AGREEMENT-3
(Over$10,000)
D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the
addresses listed on the signature page of the Agreement, uness roti icd iv the contrary. Any written notice
hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail,
and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such
other address as may be hereafter specified in writing.
E. Assignment. Any assignment of this Agreement by either party without the written consent of
the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment, the terms
of this Agreement shall continue in full force and effect and no further assignment shall be made without
additional written consent.
F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement
shall be binding unless in writing and signed by a duly authorized representative of the City and Consultant.
G. Entire Agreement. The written provisions and terms of this Agreement, together with any
Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the
City, and such statements shall not be effective or be construed as entering into or forming a part of or altering
in any manner this Agreement. All of the above documents are hereby made a part of this Agreement.
However, should any language in any of the Exhibits to this Agreement conflict with any language contained in
this Agreement, the terms of this Agreement shall prevail.
H. Compliance with Laws. The Consultant agrees to comply with all federal, state, and municipal
laws, rules, and regulations that are now effective or in the future become applicable to Consultant's business,
equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance
of those operations.
IN WITNESS, the parties below execute this Agreement,which shall become effective on the last
date entered below.
CONSULTANT: CITY OF
j�
li By: 1"^.�L°� �" By:
mm (signature) - (s,gmture)
Print Name: A ,e)17,j Prin ame !!ette Cooke
Its z-, Q . /e e_ry Its Mayor
(Tale (Tile)
DATE: 47 DATE: D 7
NOTICES TO BE SENT TO: NOTICES TO BE SENT TO:
CONSULTANT: CITY OF KENT:
Mike Heinisch, Executive Director Katherin Johnson, Human Services Manager
Kent Youth& Family Services City of Kent
232 2"d Ave S. 220 Fourth Avenue South
Kent, WA 98032 Kent, WA 98032
(253) 859-0300 (telephone) (253) 856-5070 (telephone)
(253) 859-0745 (facsimile) (253) 856-5073 (facsimile)
APPROVED AS TO FORM:
CONSULTANT SERVICES AGREEMENT-4
(Over$10,000)
e t Lan T' p merit
P Human Servlces\General FundlGeneral Fund 2007-2008 ContractlKYFS CSA 2007-20081
CONSULTANT SERVICES AGREEMENT-5
(Over$10,000)
DECLARATION
CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY
The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all
contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with
the regulations of the City's equal employment opportunity policies.
The following questions specifically identify the requirements the City deems necessary for any contractor,
subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of
the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier
willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of
contract and it will be at the City's sole determination regarding suspension or termination for all or part of the
Agreement;
The questions are as follows:
1. I have read the attached City of Kent administrative policy number 1.2.
2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color,
national origin, age, or the presence of all sensory, mental or physical disability.
3. During the time of this Agreement the prime contractor will provide a written statement to all new
employees and subcontractors indicating commitment as an equal opportunity employer.
4. During the time of the Agreement 1, the prime contractor, will actively consider hiring and promotion of
women and minorities.
5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime
Contractor, that the Prime Contractor complied with the requirements as set forth above.
By signing below, I agree to fulfill thefive requirements referenced above.
Dated this `7 3 day of /"��� ,200 7
For: 1<e,►i�' Flo V+/- 0,�
n-, !y �e�✓is���
Title: rl- e P G u; 4 VG
Date: ���� -7
EEO COMPLIANCE DOCUMENTS- 1
CITY OF KENT
AIZMINISTRATIVE PUO LICY
NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998
SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996
CONTRACTORS APPROVED BY Jim White, Mayor
POLICY:
Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All
contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity
within their organization and, if holding Agreements with the City amounting to $10,000 or more within any
given year, must take the following affirmative steps:
1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal
opportunity employer.
2. Actively consider for promotion and advancement available minorities and women.
Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and
equal opportunity requirements shall be considered in breach of contract and subject to suspension or
termination for all or part of the Agreement.
Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works
Departments to assume the following duties for their respective departments.
1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are
familiar with the regulations and the City's equal employment opportunity policy.
2. Monitoring to assure adherence to federal, state and local laws,policies and guidelines.
EEO COMPLIANCE DOCUMENTS-2
CITY OF KENT
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT
This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the
Agreement.
I, the undersigned, a duly represented agent of Company, hereby
acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement
known as that was entered into on the (date) ,
between the firm I represent and the City of Kent.
I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent
Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part
of the before-mentioned Agreement.
Dated this day of 1200 ._
By:
For:
Title:
Date:
EEO COMPLIANCE DOCUMENTS-3
EXHIBIT A 11
SCOPE AND SCHEDULE OF WORK
2007
CONSULTANT SERVICES AGREEMENT
KENT YOUTH & FAMILY SERVICES
Family Counseling
This program provides individual, family and group counseling, case management, and
psychiatric services in the schools.
This funding will provide:
Outputs
Unduplicated Kent Clients 200
Number of Counseling Hours provided 580
Membership and participation in the South King Council of Human Services
Outcome
Children and youth will be better able to function in critical life areas, increasing their ability to
become self-sufficient.
Budget
Personnel $47,000
Nonpersonnel $ -0-
Total $47,000
Reporting Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation.
Such documentation will include the following (as applicable) Billing Voucher & Service Report
(Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D).
These items must be submitted on forms provided by the City by the 10'h of following month for the
previous quarter of service The reporting timeline is as follows.
Billing Voucher&Service Report(Exhibit B) 10T"day following each quarter
Final Billing Voucher(4`h Qtr Exhibit B) December 14, 2007
Outcome Based Evaluation Report(Exhibit C) July 31, 2007/January 31, 2008
Client Demographic Data (Exhibit D) January 31,2008
Contract Administration
The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or
board membership
The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable.
All records related to this contract must be retained for three years plus the current year.
EXHIBIT A
SCOPE OF WORK (CONTINUED)
2007
CONSULTANT SERVICES AGREEMENT —
KENT YOUTH & FAMILY SERVICES
Counseling
Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007,
Kent Youth & Family Services shall provide the approximate number of City of Kent
clients with the following services:
Quarter Service Unit Number of Cumulative
Units 7otal
1St 1. Unduplicated City of Kent clients served 50 50
2. Counseling Hours 145 145
2nd 1. Unduplicated City of Kent clients served 50 100
2. Counseling Hours 145 290
3rd 1. Unduplicated City of Kent clients served 50 150
2. Counseling Hours 145 435
4th 1. Unduplicated City of Kent clients served 50 200
2 Counseling Hours 145 580
The above services shall be provided by December 31, 2007.
2007 Reimbursement: $47,000
Please sign to indicate acceptance of the Year 2007 Performance Measures listed above.
Mike Hemisch, Kent Youth&Family Services Executive Director Date 1
-J13 `� 7
Katherin ?bhn&dhTa0inWuman Services Manager Date
EXHIBIT A
SCOPE AND SCHEDULE OF WORK
2008
CONSULTANT SERVICES AGREEMENT
KENT YOUTH & FAMILY SERVICES
Family Counseling
This program provides individual, family and group counseling, case management,and
psychiatric services in the schools.
This funding will provide:
Outputs
Unduplicated Kent Clients 200
Number of Counseling Hours provided 580
Membership and participation in the South King Council of Human Services
Outcome
Children and youth will be better able to function in critical life areas, increasing their ability to
become self-sufficient.
j Budget
Personnel $47,000
Nonpersonnel $ -0-
Total $47,000
Reporting Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation.
Such documentation will include the following (as applicable). Billing Voucher & Service Report
(Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D)
These items must be submitted on forms provided by the City by the 10'h of following month for the
previous quarter of service The reporting timeline is as follows
Billing Voucher&Service Report(Exhibit B) 10T"day following each quarter
Final Billing Voucher(4`h Qtr Exhibit B) December 15, 2008
Outcome Based Evaluation Report(Exhibit C) July 31, 2008/January 30, 2009
Client Demographic Data (Exhibit D) January 30, 2009
Contract Administration
The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or
board membership
The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable
All records related to this contract must be retained for three years plus the current year
EXHIBIT A
SCOPE OF WORK (CONTINUED)
2008
CONSULTANT SERVICES AGREEMENT—
KENT YOUTH & FAMILY SERVICES
Counseling
Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007,
Kent Youth & Family Services shall provide the approximate number of City of Kent
clients with the following services:
Quarter Service Unit Number of Cumulative
Units Total
15t 1. Unduplicated City of Kent clients served 50 50
2. Counseling Hours 145 145
2nd 1. Unduplicated City of Kent clients served 50 100
2. Counseling Hours 145 290
3rd 1. Unduplicated City of Kent clients served 50 150
2. Counseling Hours 145 435
4th 1 Unduplicated City of Kent clients served 50 200
2. Counseling Hours 145 580
The above services shall be provided by December 31, 2008.
2008 Reimbursement: $47,000
Please sign to indicate acceptance of the Year 2008 Performance Measures listed above.
Mike Heinisch, Kent Youth & Family Services Executive Director Date
Katherin Jolinson, Ho'Uging& uman Services Manager Date
EXHIBIT A
SCOPE AND SCHEDULE OF WORK
2007
CONSULTANT SERVICES AGREEMENT —
KENT YOUTH & FAMILY SERVICES
Teen Parent Housing
This program provides transitional housing and support services for up to 2 years to single,
homeless, low-income 16-20 year old mothers and their children.
This funding will provide:
Outputs
Unduplicated Kent Clients 1
Provide educationallvocational skills 1
Provide independent living skills training 1
Membership and participation in the South King Council of Human Services
Outcome
Homeless teen families meet intermediate shelter needs, basic self-care needs, and increase
their ability to be self-sufficient and obtain permanent housing.
Budget
Personnel $ -0-
Nonpersonnel (Rent & Utilities) $8,000
Total $8,000
Reporting Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation
Such documentation will include the following (as applicable) Billing Voucher & Service Report
(Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D)
These items must be submitted on forms provided by the City by the loth of following month for the
previous quarter of service The reporting timeline is as follows
Billing Voucher& Service Report (Exhibit B) 10T" day following each quarter
Final Billing Voucher (4`h Qtr Exhibit B) December 14, 2007
Outcome Based Evaluation Report(Exhibit C) July 31, 2007/January 31, 2008
Client Demographic Data (Exhibit D) January 31, 2008
Contract Administration
The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or
board membership
The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable
All records related to this contract must be retained for three years plus the current year.
EXHIBIT A
SCOPE OF WORK (CONTINUED)
2007
CONSULTANT SERVICES AGREEMENT -
KENT YOUTH & FAMILY SERVICES
Teen Parent Housing
Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007,
Kent Youth & Family Services shall provide the approximate number of City of Kent
clients with the following services:
Quarter Service Unit Number of Cumulative
Units Total
1st 1. Unduplicated City of Kent clients served 1 1
2. Provide educational/vocational skills 1 1
3. Provide independent living skills training 1 1
2nd 1. Unduplicated City of Kent clients served 0 1
2 Provide educationallvocational skills 0 1
3. Provide independent living skills training 0 1
3`d 1. Unduplicated City of Kent clients served 0 1
2. Provide educational/vocational skills 0 1
3. Provide independent living skills training 0 1
4th 1 Unduplicated City of Kent clients served 0 1
2. Provide educational/vocational skills 0 1
3. Provide independent living skills training 0 1
The above services shall be provided by December 31, 2007.
2007 Reimbursement: $8,000
Please sign to indicate acceptance of the Year 2007 Performance Measures listed above.
Mike Heinisch, Kent Youth&Family Services Executive Director Date
C)3° n7
Katherin ohn6oT%*od5iF4&Human Services Manager Date
EXHIBIT A
SCOPE AND SCHEDULE OF WORK
2008
CONSULTANT SERVICES AGREEMENT—
KENT YOUTH & FAMILY SERVICES
Teen Parent Housing
This program provides transitional housing and support services for up to 2 years to single,
homeless, low-income 16-20 year old mothers and their children.
This funding will provide:
Outputs
Unduplicated Kent Clients 1
Provide educational/vocational skills 1
Provide Independent living skills training 1
Membership and participation in the South King Council of Human Services
Outcome
Homeless teen families meet intermediate shelter needs, basic self-care needs, and Increase
their ability to be self-sufficient and obtain permanent housing.
Budget
Personnel $ -0-
Nonpersonnel (Rent & Utilities) $8,000
Total $8,000
Reporting Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation.
Such documentation will include the following (as applicable). Billing Voucher & Service Report
(Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D)
These items must be submitted on forms provided by the City by the 10`h of following month for the
previous quarter of service. The reporting timeline is as follows.
Billing Voucher&Service Report(Exhibit B) 10T" day following each quarter
Final Billing Voucher(41h Qtr Exhibit B) December 15, 2008
Outcome Based Evaluation Report(Exhibit C) July 31, 2008/January 30, 2009
Client Demographic Data (Exhibit D) January 30, 2009
Contract Administration
The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or
board membership.
The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable.
All records related to this contract must be retained for three years plus the current year
EXHIBIT A
SCOPE OF WORK_ (CONTINUED)
2008
CONSULTANT SERVICES AGREEMENT -
KENT YOUTH & FAMILY SERVICES
Teen Parent Housing
Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007,
Kent Youth & Family Services shall provide the approximate number of City of Kent
clients with the following services:
Quarter Service Unit Number of Cumulative
Units Total
1st 1. Unduplicated City of Kent clients served 1 1
2. Provide educational/vocational skills 1 1
3. Provide independent living skills training 1 1
2"d 1. Unduplicated City of Kent clients served 0 1
2. Provide educational/vocational skills 0 1
3 Provide independent living skills training 0 1
3`d 1. Unduplicated City of Kent clients served 0 1
2. Provide educational/vocational skills 0 1
3 Provide independent living skills training 0 1
4t" 1. Unduplicated City of Kent clients served 0 1
2. Provide educational/vocational skills 0 1
3. Provide independent living skills training 0 1
The above services shall be provided by December 31, 2008
2008 Reimbursement: $ 8,000
Please sign to indicate acceptance of the Year 2008 Performance Measures listed above.
J
Mike Hemisch, Kent Youth&Family Services Executive Director Date
3- ;23
Katherin Jo ns ous' g & umhp Services Manager Date
EXHIBIT A
SCOPE AND SCHEDULE OF WORK
2007
CONSULTANT SERVICES AGREEMENT
KENT YOUTH & FAMILY SERVICES
Teen Substance Abuse Treatment
This program serves youth ages 12-18 in the Kent School District, providing substance abuse
outreach, prevention, intervention and treatment services to youth (and their families) who
are experimenting, abusing or have developed dependency/addictions with legal and illegal
substances.
This funding will provide:
Outputs
Unduplicated Kent Clients 30
Number of Counseling Hours (Group) 370
Number of Counseling Hours (Individual) 70
Membership and participation in the South King Council of Human Services
Outcome
Youth will reduce drug and alcohol abuse, and be better able to function in critical life areas,
increasing their ability to become self-sufficient
Budget
Personnel $14,500
Nonpersonnel $ -0-
Total $14,500
Reporting Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation.
Such documentation will include the following (as applicable) Billing Voucher & Service Report
(Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D)
These items must be submitted on forms provided by the City by the 10th of following month for the
previous quarter of service. The reporting timeline is as follows
Billing Voucher&Service Report (Exhibit B) 10T"day following each quarter
Final Billing Voucher(41h Qtr Exhibit B) December 14, 2007
Outcome Based Evaluation Report(Exhibit C) July 31, 20071January 31, 2008
Client Demographic Data (Exhibit D) January 31,2008
Contract Administration
The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or
board membership
The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable.
All records related to this contract must be retained for three years plus the current year
EXHIBIT A
SCOPE OF WORK (CONTINUED)
2007
CONSULTANT SERVICES AGREEMENT —
KENT YOUTH & FAMILY SERVICES
Teen Substance Abuse Treatment
Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007,
Kent Youth & Family Services shall provide the approximate number of City of Kent
clients with the following services:
Quarter Service Unit Number of Cumulative
Units Total
1St 1 . Unduplicated City of Kent clients served 7 7
2 Number of counseling hours (group) 92 92
3. Number of counseling hours (individual) 17 17
2nd 1. Unduplicated City of Kent clients served 7 7
2. Number of counseling hours (group) 92 184
3. Number of counseling hours (individual) 17 34
3rd 1. Unduplicated City of Kent clients served 8 8
2. Number of counseling hours (group) 93 277
3. Number of counseling hours (individual) 18 52
4th 1. Unduplicated City of Kent clients served 8 30
2. Number of counseling hours (group) 93 370
3. Number of counseling hours (individual) 18 70
The above services shall be provided by December 31, 2007.
2007 Reimbursement: $14,500
Please sign to indicate acceptance of the Year 2007 Performance Measures listed above.
Mike Heinisch, ent Youth&Family Services Executive Director Date
3•,-23 . 0 7
Kathenn Johns ousi & an Services Manager Date
EXHIBIT A
SCOPE AND SCHEDULE OF WORK
I
2008
CONSULTANT SERVICES AGREEMENT
KENT YOUTH & FAMILY SERVICES
Teen Substance Abuse Treatment
This program serves youth ages 12-18 in the Kent School District, providing substance abuse
outreach, prevention, intervention and treatment services to youth (and their families) who
are experimenting, abusing or have developed dependency/addictions with legal and illegal
substances.
This funding will provide:
Outputs
Unduplicated Kent Clients 30
Number of Counseling Hours (Group) 370
Number of Counseling Hours (Individual) 70
Membership and participation in the South King Council of Human Services
Outcome
Youth will reduce drug and alcohol abuse, and be better able to function in critical life areas,
increasing their ability to become self-sufficient.
Budget
Personnel $14,500
Nonpersonnel $ -0-
Total $140500
Reporting Requirements and Timeline
The agency will be reimbursed on a quarterly basis, upon submittal of appropriate documentation.
Such documentation will include the following (as applicable) Billing Voucher & Service Report
(Exhibit B), Outcome Based Evaluation Report (Exhibit C), and Client Demographic Data (Exhibit D).
These items must be submitted on forms provided by the City by the 10th of following month for the
previous quarter of service The reporting timeline is as follows
Billing Voucher&Service Report(Exhibit B) 10T" day following each quarter
Final Billing Voucher(41h Qtr Exhibit B) December 15, 2008
Outcome Based Evaluation Report(Exhibit C) July 31,2008/January 30, 2009
Client Demographic Data (Exhibit DI January 30, 2009
Contract Administration
The Consultant will notify the City, in writing, within (10) days of any changes in program personnel or
board membership
The Consultant shall provide the City with a current list of its board of directors, general or limited
partners, as applicable.
All records related to this contract must be retained for three years plus the current year
EXHIBIT A
SCOPE OF WORK (CONTINUED)
2008
CONSULTANT SERVICES AGREEMENT—
KENT YOUTH & FAMILY SERVICES
Teen Substance Abuse Treatment
Pursuant to Item 1 of the Consultant Services Agreement executed on January 1, 2007,
Kent Youth & Family Services shall provide the approximate number of City of Kent
clients with the following services:
Quarter Service Unit Number of Cumulative
Units Total
1st 1. Unduplicated City of Kent clients served 7 7
2 Number of counseling hours (group) 92 92
3 Number of counseling hours (Individual) 17 17
2nd 1. Unduplicated City of Kent clients served 7 7
2 Number of counseling hours (group) 92 184
3. Number of counseling hours (individual) 17 34
3rd 1 Unduplicated City of Kent clients served 8 8
2 Number of counseling hours (group) 93 277
3. Number of counseling hours (individual) 18 52
4th 1. Unduplicated City of Kent clients served 8 30
2 Number of counseling hours (group) 93 370
3. Number of counseling hours (individual) 18 70
The above services shall be provided by December 31, 2008.
2008 Reimbursement: $14,500
Please sign to indicate acceptance of the Year 2008 Performance Measures listed above.
Mike Heimsch, ent Youth&Family Services Executive Director Date
8 -� 3 , o7
Katherin Jdhnso"A_uj1ng&Rhman Services Manager Date '
Exhibit B General Fund
KNT 2007 Billing Voucher
WASHINGTON and Service Report
PARKS, RECREATIONS •
COMMUNITY SERVICES
To:
Merina Hanson Agency: Kent Youth & Family Services
Housing & Human Services
Parks, Recreation &Community Services
220 4th Ave, South, Kent, WA 98032 Program Contact: Dennis Ballinger
Telephone: 253.859.0300 x3015
mhanson(cDci ke_a us
Phone: 253 856-5077 E-mail: dennisb@kyfs-org
Reporting Period Program .
Amount Requested
Family Counseling $
BUDGET SUMMARY
FOR DEPARTMENT USE ONLY Total Contract Amount
$ 47,000.00
VENDOR NUMBER#33841 " Current Request
$
ACCOUNT CODE 1000 6370-64150 4770 Amount Remaining $
2007 KENT FUNDED SERVICE UNITS
Note: Unduplicated client counts must be reported both quarterly and year-to-date
Service Unit Description Service Units Planned New City of KentFunded TFunded otal Kent Total Service
Each Quarter Service Units Service Units Units to Date
This Quarter To Date Sources
Service Unit/Performance Measure 1S 2n 3r 4
Undu licated * of Kent clients served 50 50 50 50
Number of cu seling hours 145 145 145 145
-Please attach a narrative explanation to this report in the event that the program is not meeting
performance measures.
Authorized Signature
Date
AUTHORIZED FOR PAYMENT FOR DEPARTMENT USE ONLY
BY:
DAZE:
Exhibit B General Fund
\114017
�KKNT 2007 Billing Voucher
WASHINGTON and Service Report
PARKS, RECREATION S
COMMUNITY SERVICES
To: I I . � ,
Merina Hanson Agency: Kent Youth & Family Services`
Housing & Human Services
Parks, Recreation & Community Services
220 4t" Ave. South, Kent, WA 98032 Program Contact: Laurie Peterson
Telephone: 253.859.0300 x3074
mhanson(b_ci kent wa us E-mail: lauriep@kyfs.org
Phone: 253 856-5077
Reporting Period Program Amount Requested
Teen Parent Housing $
BUDGET SUMMARY
FOR DEPARTMENT USE ONLY ,ilfl Total Contract Amount $ 8,000
1/END6R NUMBER#338413 y_ e ='� �_ Current Request $
ACCOUNT CODE 1000-6370-64150-4772 Amount Remaining $
2007 KENT FUNDED SERVICE UNITS
Note: Unduplicated client counts must be reported both quarterly and year-to-date
New City of Total Kent Total Service
Service Unit Description Service Units Planned Kent Funded Funded Units to Date
Each Quarter Service Units Service Units (ALL Funding
This Quarter To Date Sources
Service Unit/Performance Measure 1 st 2" 3rd 4
Unduplicated # of Kent clients served 1 0 0 0
EducatlonNocatlonal Skills Training 1 0 0 0
Independent Living Skills Training 1 0 0 0
*Please attach a narrative explanation to this report in the event that the program is not meeting
performance measures.
Authorized Signature Date
FOR DEPARTMENT USE ONLY
AUTHORIZED FOR PAYMENT
BY: DATE:
Exhibit B I General Fund
• 2007 Billing Voucher
KETi*PiT and service Report
W AS HINGTON
PARKS, RECREATION S
COMMUNITY SERVICES _
To: Agency: Kent Youth &Family Services
Merina Hanson
Housing & Human Services
Parks, Recreation & Community Services program Contact: Juliette Sauvage
220 4" Ave. South, Kent, WA 98032 Telephone: 263.859.0300 x3008
mhanson(@_ci kent.wa us E-mail: juliettes@kyfs.org
Phone: 253 856-5077
Program Amount Requested
Reporting Period
Teen Substance Abuse Treatment $
BUDGET SUMMARY
FOR DEPARTMENT USE ONLY Total Contract Amount $ 140500.00
Current Request $
VENDOR NUMBER#33841 q
ACCOUNT CODE 1000-6370.64150-4773 Amount Remaining $
2007 KENT FUNDED SERVICE UNITS
Note: Unduplicated client counts must be reported both quarterly and year-to-date
New Clty of Total Kent Total Service
Service Units Planned Kent Funded Funded Units to Date
Service Unit Description Each Quarter Service rte Service Units (ALL Funding
This Quaarter To Date Sources
Service Unit/Performance Measure 15 2n 3r 4
Undu licated# of Kent clients served 92 92 93 93
Number of counselinghours(group)
Number of counseling hours (individual) 17 17 18 18
*Please attach a narrative explanation to this report in the event that the program is not meeting
performance measures.
Date
Authorized Signature
FOR DEPARTMENT USE ONLY
AUTHORIZED FOR PAYMENT
DATE:
BY:
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Agency
KEAIT Exhibit D Program
PARKS,,RECREATION S
2007 Demographic report Date
COMMUNITY SERVICES Unduplicated Number of Clients Served*
Agency/Program Undu licated New Individuals this Year
Client Residence**
Algona
Auburn
Black Diamond
Buren
Covington
Des Moines
Enumclaw
Federal Way
Kent
Maple Valle
Milton
Normandy Park
Pacific
Renton
SeaTac
Seattle
Tukwila
Unincorporated King Count
Unknown
TOTAL
Household Income Level
30% of Median or Below
50% of Median or Below
80% of Median or Below
Above 80% of Median
Unknown
TOTAL
Gender
Male
Female
TOTAL
Age
0-4 years
5- 12 years
13- 17 years
18-34 years
35-54 years
55-74 years
75+years
Unknown
TOTAL
Ethnicity
Asian/Pacific Islander
Black/African American
Hispanic/Latino(a)
Native American/Alaskan Native
White/Caucasian
Other
Unknown
TOTAL
Female Headed Household
Disabling Condition
Limited English Speaking
* Unduplicated means count each client only once per calendar year
*"List of all clients served in client residence category and Kent clients only in rest of the categories
40 Agency
•
iicENT Exhibit D Program
WA9XINOT O"
PARKS, RECREATIONS 2008 Demographic Report Date.
COMMUNITY SERVICES Unduplicated Number of Clients Served`
A enc /Pro ram Unduplicated New Individuals this Year
Client Residence" �;' ae
Algona
Auburn
Black Diamond
Bunen
Covington
Des Moines
Enumclaw
Federal Way
Kent
Maple Valle
Milton
Normandy Park
Pacific
Renton
SeaTac
Seattle
Tukwila
Unincorporated King County
Unknown
TOTAL
Household Income Level -
30%of Median or Below
50%of Median or Below
80% of Median or Below
Above 80%of Median
Unknown
TOTAL
Gender
Male
Female
TOTAL
Age
0-4 years
5- 12 years
13- 17 years
18- 34 years
35- 54 years
55 -74 years
75+years
Unknown
TOTAL
Ethnicity
Asian/Pacific Islander
Black/African American
Hispanic/Latino(a)
Native American/Alaskan Native
White/Caucasian
Other
Unknown
TOTAL
Female Headed Household
Disabling Condition
Limited English Speaking___
Unduplicated means count each client only once per calendar year.
"List of all clients served in client residence category and Kent clients only in rest of the categories
i
ATTACHMENT E
INSURANCE REQUIREMENTS
Insurance
The Contractor shall procure and maintain for the duration of the Agreement, insurance
against claims for injuries to persons or damage to property which may arise from or in
connection with the performance of the work hereunder by the Contractor, their agents,
representatives, employees or subcontractors.
A. Minimum Scope of Insurance
Contractor shall obtain insurance of the types described below:
1. Commercial General Liability insurance shall be written on ISO occurrence form
CG 00 01 and shall cover liability arising from premises, operations, independent
contractors, products-completed operations,personal injury and advertising
injury, and liability assumed under an insured contract. The Commercial General
Liability insurance shall be endorsed to provide the Aggregate Per Project
Endorsement ISO form CG 25 03 11 85 There shall be no endorsement or
modification of the Commercial General Liability
insurance for liability arising from explosion, collapse or underground property
damage The City shall be named as an insured under the Contractor's
Commercial General Liability insurance policy with respect to the work
performed for the City using ISO additional
insured endorsement CG 20 10 1185 or a substitute endorsement providing
equivalent coverage.
2. Automobile Liability insurance covering all owned, non-owned, hired and leased
vehicles. Coverage shall be written on Insurance Services Office(ISO) form CA
00 01 or a substitute form providing equivalent liability coverage. If necessary,
the policy shall be endorsed to provide contractual liability coverage.
B. Minimum Amounts of Insurance
Contractor shall maintain the following insurance Inuits:
1. Commercial General Liability insurance shall be written with limits no
less than $1,000,000 each occurrence, $1,000,000 general aggregate
and a$1,000,000 products-completed operations aggregate limit.
2. Automobile Liability insurance with a minimum combined single
limit for bodily injury and property damage of $1,000,000 per
accident.
EXHIBIT E (Continued )
C. Other Insurance Provisions
The insurance policies are to contain, or be endorsed to contain,the following provisions
for Automobile Liability and Commercial General Liability insurance:
1. The Contractor's insurance coverage shall be primary insurance as respect the City.
Any Insurance, self-insurance, or insurance pool coverage maintained by the City
shall be excess of the Contractor's insurance and shall not contribute with it.
2. The Contractor's insurance shall be endorsed to state that coverage shall not be
cancelled by either party, except after thirty (30) days prior written notice by certified
mail, return receipt requested, has been given to the City.
3. The City of Kent shall be named as an additional insured on all policies (except
Professional Liability) as respects work performed by or on behalf of the contractor
and a copy of the endorsement naming the City as additional insured shall be attached
to the Certificate of Insurance. The City reserves the right to receive a certified copy
of all required insurance policies. The Contractor's Commercial General Liability
insurance shall also contain a clause stating that coverage shall apply separately to
each insured against whom claim is made or suit is brought, except with respects to
the limits of the insurer's liability.
D. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of not less than
AN IL
II.
E. Verification of Coverage
Contractor shall furnish the City with original certificates and a copy of the amendatory
endorsements, including but not necessarily limited to the additional insured
endorsement, evidencing the insurance requirements of the Contractor before
commencement of the work.
F. Subcontractors
Contractor shall include all subcontractors as insureds under its policies or shall furnish
separate certificates and endorsements for each subcontractor. All coverages for
subcontractors shall be subject to all of the same insurance requirements as stated herein
for the Contractor.
y 'ii;, �a,p';''_ /�.,:':, .. `N��7N'FR0FlT NSl .R►4NC ? toC3I
0.1C �1 ai1ri�� Q tNS�3ANC�' REVISED ISSUEF}AFE'tiM12A05'
THIS CERTIFICATE 161SSUEO AS A MATTER OF INFWMATION ONLY AND CONFERS NO RIGHTS VPON THE CERTIFICATE HOLDER. THIS CERTIFICATtE DOES NOT
AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
PRODUCER COMPANIES AFFORDING COVERAGE
Publlc Risk Underwriters GENERAL LIABILITY
19106 140th AVENUE WE, ACE AMERICAN INSURANCE COMPANY
WOODINVILLE.WASHINGTON 00012.6874 AUTOMOBILE LIABILITY
PHONE(4215)482-6767 FAX(426)482.2777 ACE AMERICAN INSURANCE COMPANY
PROPERTY
ENT YOUTH AND FAMILY SERVICES
NOW-PROFIT DIRECTORS,OFFICERS AND
M@MaMOF NONPROFIT INNRANCEMiOr" EMPLOYEES LIAIdILRTYI CRIME
232 2ND AVE SOUTH ZURICH AMERICAN INSURANCE COMPANY
KENT,WA 98032
COVERAGES ' a,V.,
THIS IS TO CERTIFY THAT THEPOLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE FOLIOY PRIOD
INOIOATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS CERTFICATI!
MAY BE ISSUM OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS EXCLUSIONSAND
CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS.
E ; 1. POLICYMUMBRR POLICY T E TIVE; POLICY IRATIQN ' " , t,IMITS
tYPE OFYN513R1fNC , ,
ENERAE,QA9ILITY
COMMERCIAL GENERAL LIABILITY XSLG22904425 6111200E 61112007 ANNUALAGGREQATE $3,000,000
OCCURENCEFORM EACH OCCURRENCE S6,000go
INCLUDES STOP OAP
ANY AUTO XSA H08019794 G/l/2006 $1112007 COMBINED SINGLE LIMIT $5,000,000
UM•UIM OCCURRENCE $5,OD0,000
PROP RTY', :i br' , . ,, ", FT
I
O(d-P,ROFIT DIRt'_CTaRS,OFFFa R4S AND EMPLOYEES LIABILITY 1 CRIME
FID 5435644 C2 6/1/2006 6l1/2007 EMPLOYEE DISHONESTY PER LOSS
82 ia,OtlC
pE&ORIPTTO�lOFiOp� 1�`,FdAN�lLOCI'FtON9tVEtfICLESI„SPkCtAL1TEM:4 :•' ' .. , '..': . . ,
THE CITY OF KENT,ITS ELECTED AND/OR APPOINTED OFFICIALS ARE NAMED ADDITIONAL INSUREDS RESPECTS FUNDING
RECEIVED COVERAGE FOR PROFESSIONAL LIABILITY FOR COUNSELERS,NURSES AND EMPLOYEES IS PROVIDED UNDER THE
GENERAL LIABILITY POLICY ENDORSEMENT ATTACHED
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 17ATE THEREOF.THE ISSUING COMPANY WILL MAIL45DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED 6ELCW,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO LIABILITY OROBLIGATCN OF A.WY KIND
UPON THE COMPANY,ITS AGENTS OR REPRESENTITIVES.
CERTIFtf AFP HDLbER' , '.' ' 'AUTHORIZED REPRESENTATIVE
CITY OF KENT PARKS,RECREATION AND COMMUNITY SERVICES
220 4TH AVE S
KENT,WA 98032
'Cevxasa it lubledi to$25,000 programme"inaurod retention,Claims paid within SIB are funded by non PrafIt Insurance Program
POLICY NUMDER:XSL G220W25 COMMERCIAL 0EMERALLtA6I1.11TY
CG 20 26 of 44
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL. INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies Insurance provided under the following-
COMMERCIAL GENERAL LIABILITY COVERAGE PAF2'r
SCHEDULE
Name Of Additional Insured Person(sl Or or anizatioa s
CITY OF KEI T PAMS,RECREATION AND COMMUNITY SERVICES i
220 4T" AVE S
KEN.r, WA g8o32
I
Mtormetion regaired to complete this Schedule,if not shown agave will be shown in the Deeiarations. I
Section It — Who Is An Insured is amended to in
elude AS an additional insured the person(s) or or-
ganization(s) shown in the Schedule, but only with
respect to liability for "bodily Injury" "property dam.
age" or "personal and advertising injury" caused, in
whole or in part, by your acts or omissions or the acts
or ennissions of those acting on your behalf:
A. In the performance of your ongoing operations,or
B, M connection vnlh your premises owned by or
rented In you.
I
4
1
I
Ct.20 26 07 04 0180 Properties, Inc.,2(X4 , Page 4 of 1 !7
iT Exhibit F
PARKS RECREATION G
COMMUNITY SERVICES City of Kent
Certification Regarding Debarment and Suspension
Agency Name of Program(s)
Certification A: Certification Regarding Debarment, Suspension, and Other Responsibility
Matters - Primary Covered Transactions
1. The prospective primary participant certifies to the best of its knowledge and belief that its principals;
a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal debarment or agency,
b) Have not within a three-year period preceding this proposal, been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a
public transaction, violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification, or destruction of records, making false statements, or receiving
stolen property,
c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this
certification, and
d) Have not within a three-year period preceding this application/ proposal had one or more public
transactions (Federal, State, or local) terminated for cause or default
2. Where the prospective primary participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal
Instructions for Certification (A)
1 By signing and submitting this proposal, the prospective primary participant is providing the
certification set out below
2 The friability of a person to provide the certification required below will not necessarily result in
denial of participation in this covered transaction The prospective participant shall submit an
explanation of why it cannot provide the certification set out below The certification or explanation
will be considered in connection with the department or agency's determination whether to enter
into this transaction. However, failure of the prospective primary participant to furnish a certification
or an explanation shall disqualify such person from participation in this transaction
3 The certification in this clause is a material representation of fact upon which reliance was placed
when the department or agency determined to enter into this transaction If it is later determined
that the prospective primary participant knowingly rendered an erroneous certification, in addition
to other remedies available to the Federal Government/City of Kent, the department or agency
may terminate this transaction for cause of default
4 The prospective primary participant shall provide immediate written notice to the department or
agency to whom this proposal is submitted if at any time the prospective primary participant learns
that its certification was erroneous when submitted or has become erroneous by reason of
changed circumstances
5 The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and
Coverage sections of the rules implementing Executive Order 12549 You may contact the
department or agency to which this proposal is being submitted for assistance in obtaining a copy
of these regulations
6. The prospective primary participant agrees by submitting this proposal that, should the proposed
covered transaction be entered into, it shall not knowingly enter into any lower tier covered
1 of 3
transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded
from participation in this covered transaction, unless authorized by the department or agency
entering into this transaction
7 The prospective primary participant further agrees by submitting this proposal that it will include
the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclu-
sion - Lower Tier Covered Transaction," provided by the department or agency entering into this
covered transaction, without modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions
8 A participant in a covered transaction may rely upon a certification of a prospective participant in a
lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded
from the covered transaction, unless it knows that the certification is erroneous A participant may
decide the method and frequency by which it determines this eligibility of its principals Each
participant may, but is not required to, check the Non-procurement List
9 Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause The knowledge and
information of a participant is not required to exceed that which is normally possessed by a
prudent person in the ordinary course of business dealings
10 Except for transactions authorized under paragraph (6) of these instructions, if a participant in a
covered transaction
11 knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies
available to the Federal Government/City of Kent, the department or agency may terminate this
transaction for cause of default
Certification B: Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion -Lower Tier Covered Transactions
1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency
2. Where the prospective lower tier participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal
Instructions for Certification (B)
1 By signing and submitting this proposal, the prospective lower tier participant is providing the
certification set out below
2. The certification in this clause is a material representation of fact upon which reliance was placed
when this transaction was entered into If it is later determined that the prospective lower tier
participant knowingly rendered an erroneous certification, in addition to other remedies available to
the Federal Government/City of Kent, the department or agency with which this transaction
originated may pursue available remedies, including suspension and/or debarment
3 The prospective lower tier participant shall provide immediate written notice to the person to which
this proposal is submitted if at any time the prospective lower tier participant learns that its
certification was erroneous when submitted or has become erroneous by reason of changed
circumstances
4 The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549 You may contact the person to
which this proposal is submitted for assistance in obtaining a copy of these regulations
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed
covered transaction be entered into, it shall not knowingly enter into any lower tier covered
transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded
from participation in this covered transaction, unless authorized by the department or agency with
which this transaction originated
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6. The prospective lower tier participant further agrees by submitting this proposal that it will Include
this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclu-
sion - Lower Tier Covered Transaction," without modification, in all lower tier covered transactions
and in all solicitations for lower tier covered transactions
7 A participant in a covered transaction may rely upon a certification of a prospective participant in a
lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded
from the covered transaction, unless it knows that the certification is erroneous A participant may
decide the method and frequency by which it determines the eligibility of its principals Each
participant may, but is not required to, check the Nonprocurement List.
8 Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause The knowledge and
information of a participant is not required to exceed that which is normally possessed by a
prudent person in the ordinary course of business dealings
9 Except for transactions authorized under paragraph (5) of these instructions, if a participant in a
lower covered transaction knowingly enters into a lower tier covered transaction with a person who
is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in
addition to other remedies available to the Federal Government/City of Kent, the department or
agency with which this transaction originated may pursue available remedies including suspension
and/or debarment
Primary Contractor/Sub-Contractor(Print) Title Date
Signature of Primary Contractor/Sub-Contractor Title Date
(3,
Adopted from HUD Form-2992
09/04
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