HomeMy WebLinkAbout2005-148 Agmt - ACLT
SUBRECIPIENT AGREEMENT COVER SHEET
WRITTEN AGREEMENT FOR PROJECTS
FUNDED WITH COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) FUNDS
Project Title: Rehabilitate a Duplex at 264 Grant Street
SUBRECIPIENT Name: Ashland Community Land Trust
SUBRECIPIENT C,ontact: Shelley Austin, ACL T Executive Diredor
Telephone Numb4!r: 541-488-7276
Address: Site Addresses of property be Rehabilitated:
264 Grant Street units A and B
Ashland Oregon 97520
Mailing Address: Ashland Community Land Trust
PO Box 3027
Ashland, OR 97520
Agreement Amount: $14,000
Description: Rehabilitate the 2 rental units existing on the property inc;luding
but not limited to a roof replacement. The housing units c:ire to
benefit low-income or very-low households for a period of
affordability to of not less than 60 years.
City Contact: Brandon Goldman
Telephone Number: 552.2076
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CDBG Agreement
Proglram Year 2004
Page 1
9. Acces:s to Records
10. MaintElnance of Records
11. Audit Requirements
12. Monite.ring
13. Indemnity and Hold Harmless
14. Insurance Requirements
15. Minimum Scope of Insurance
16. Subcontracting and Assignment
17. IndepEmdent Contractor Status
18. Complliance with Laws'
19. Confli(~s of Interest
20. Agreement Administration
21. Property Management
22. Program Income
23. Expiration/Reversion of Assets
24. Oregon Law and Forum
25. Availability of Funds
26. Minimiizlng Displacement
27. Program Access by the Disabled
28. Publicity
29. Lobbying
30. Church-State
31. Nonsubstitution for Local Funding
32. Copyrights and Rights in Data
33. Nonparticipatlon in Political Adivities
34. Real Property Acquisition
35. Environmental Review
EXHIBIT E: INVOICE FOR SERVICES
EXHIBIT F: STATISTICAL REPORT
EXHIBIT F-1: CDSG CLIENT/HOUSEHOLD INFORMATION FORM
C[)BG ~reement
ProiJram Year 2004
Page 3
City of Ashland Contact
Brandon Goldman, Housing Program Specialist
Department of Community Development
Planning Division
City of Ashland
20 East Main street
Ashland, OR 97520
Subrecipi~!nt Contact(s)
Shelley Austin, ACL T Executive Director
Ashland Ct:>mmunity Land Trust
PO Box 3027
Ashland, OR 97520
:BRECI~:#t) . ~
Shelley AustIn" ACl T Executive Director
Date: ~o5
By:
'~/.......
I
.
-
CITY OF ASHLAND: BY:
Date: ~I /6(~
I, City Administrator ~
COBG Agreement
Proi;ram Year 2004
Page 5
works of art.
Subreclpient shall collect the family size and income information from eVElry client
served by the CDBG funded services described herein using the CDSG
ClientlFamily Information Form, Exhibit F-1 provided for in Condition 3, 8thibit C.
As the project entails the rehabilitation of property for the provision of afflordable
housing the Subreclplent shall provide such Information at each change in
tenancy. This requirement Is duplicated In the subreclplent contract exe<<:uted
between the City and the Ashland Community Land Trust dated 6-3-2004 in which
the City contributed $271,000 toward the acquisition of the property.
A family is defined by HUD as all persons living in the same household who arle related
by blood, marriage, or adoption. An individual living in a housing unit that contnins no
other perso1n(s) related to him/her is considered to be a one person family for this
purpose. Adult children who continue to live at home with their parent(s) are considered
to be part of the family for this purpose and their income must be counted in determining
the total family income. A dependent child who is living outside of the home (e..g.
students living in a dormitory or other student housing) is considered for these IPurposes
to be part of the family upon which he/she is dependent, even though he/she is, living in
another housing unit. Subrecipient shall maintain family size and income information on
all clients which may be reviewed by the City as provided for in COndition 4, E><hibit C.
Statistical Reports, Tables 1 and 3 of exhibit F, summarizing the family size, income and
demographic information shall be submitted to the City no later than 15 days a1!1er the
end of ead1 claim quarter commencing July 1, 2004, and conducting June 30, :2005.
Current income limits are as follows.
Income Umits by Family Size: $/year
.For the Medford-Ashland Statistical Area as determined by the Department of Housing and Urban Development 2004.
Income Levell Number of Persons in Family
Category
1 2 3 4 5 6 7 8+
Extremely Low Income 10950 12500 14050 15650 16900 18150 19400 20650
low Income 50% 18250 20850 23450 26050 28150 30200 32300 34400
Moderate Income 29,200 33350 37500 41700 45000 48350 51700 55000
C[)OO Agreement
Proj~ram Year 2004
Page 7
EXHIBIT B
EXPENDITURE, PAYMENT AND BUDGET PROVISIONS
1. Program E~xpenditures
Subrecipient shall expend up to the Agreement a.mount in accordance with the
Subrecipient Agreement, Item 3 and the Line Item Budget, Exhibit B-1.
2. Budget Revisions
Subrecipient has the flexibility to spend 10 percent above or below budgeted lilne items
without a budget adjustment as long as total amount does not exceed the AgrE!ement
amount. Once the Uneltem Budget, Exhibit B-1, has been approved through the
execution c>f this Agreement, there can be no more than four requests for adju~rtments to
budget line~ item amounts during the Agreement period, including any final adjustments
done at thE~ end of the program year, June 30,2005.
Budget adjustments (i.e., those adjustments which do not alter (1) the basic scope of
services or other performance to be provided under this Agreement, or (2) the total
amount of money allocated hereunder) may be made upon mutual agreement between
the parties and shall only be valid when reduced to writing, and approved and signed by
the Subredpient and the Director of the Department of Community DevelopmElnt.
3. Unexpended Funds
Any unexpended or unobligated funds remaining as of June 30, 2005 shall be: resumed
to City unless approval to extend Agreement is authorized by City prior June, :W, 2005
in accordance with General Conditions, Exhibit 0, Item 7.
4. Payment Provisions
Payment will be made by the City up to the amount of the Agreement upon re(~eipt of a
properly executed Invoice for Services Provided form, Exhibit E. Invoices and reports
shall be si!~ned by Subrecipient's authorized representative(s). Invoices will bE! submitted
to the City Contad, Department of Community DevelopmentlPlanning Division, City of
Ashland, 5,1 Winburn Way, Ashland, OR 97520.
Invoices and reports shall be submitted quarterty t no later than 16 days after tlhe end of
each claim quarter commencing July 1, 2004 and concluding June 30, 2005. Final
invoice will be submitted to the City within 30 days of the end of the Agreement, June 30,
2005.
5. Invoice Documentation
All invoices shall be supported with signed and dated documentation such as bills,
receipts, invoices, payroll records including wages paid, and time sheets. Documentation
shall adequately identify the source and application of funds for activities within this
Agreement in 'accordance with the provisions of 24 CFR85.20, and shall contain
information pertaining to grant awards and authorizations, obligations, unobliglated
balances, assets, liabilities, outlays and income. All documentation shall be maintained
in Subrecipient's files for not less than seven years.
6. Program Ilncome
For COSG funded projects, the Subrecipient shall comply with provisions of 24 CFR
570.504(c) and 570.500 regarding program income. Program income is defined by
HUD as the gross income received by a sub recipient directly generated from 1the use of
COBG funds. Program income includes, but is not limited to, the following: 1) proceeds
from the disposition by saJe or long-term lease of real property purchased or improved
with CDB<3 funds; 2) proceeds from the disposition of equipment purchased v,ith CDSG
funds; 3) Uross income from the use or rental of real or personal property acquired by a
CI:>BG Agreement
Program Year 2004
Page 9
EXHIBIT B-1
Budget
The entire grant amount of $14,000 will be used for the rehabilitation of the duph!x at 264
Grant Street. Rehabilitation to include, but not be limited to, the replacement of 'the
existing roof.
ACL T was also awarded a separate COSG award for $271 ,000 to be applied tCI
acquisition of the subject duplex and property. This award is covered under a separate
subrecipient agreement as was executed between the City of Ashland and the Ashland
Community Land Trust on June 3rd, 2004.
c[)ea Agreeme!'rt
ProSJram Year 2004
Page 11
EXHIBIT D
GENERAL CONDITIONS
These General Conditions cover the use of Community Development Block Grant (CDBG)
funds awarded under this Agreement to the Subrecipient by the City of Ashland.
1. Termination for Cause
In accordance with 24 CFR 85.43, if, through any cause, the Subrecipient shall fail to
fulfill in a timely and proper manner his/her obligations under this Agreement, c)r if the
Subrecipient shall violate any of the covenants, agreements, or stipulations of this
Agreement, the City may avail itself of such remedies as cited in 24 CFR 85.43, induding
termination of this Agreement, by giving written notice to the Subrecipient of such action
and specifying the effective date thereof. In such event, all finished or unfinished
documents, data, studies, and reports prepared by the Subrecipient under this
Agreement shall, at the option of the City, become the property of the City and the
Subrecipient shall be entitled to receive just and equitable compensation for any
satisfactory work completed on such documents, not to exceed the Agreement amount.
Notwithstanding the above, the Subreciplent shall not be relieved of liability to jthe City
for damages sustained by the City by virtue of any breach of the Agreement by the
Subrecipient, and the City may withhold any payments to the Subrecipient for the
purpose of set off until such time as the exact amount of damages due the Cit), from the
Subrecipient is determined.
2. Termination for Convenience
In accordance with 24 CFR 85.44, the City and Subrecipient may terminate this
Agreement at any time by mutual written agreement. If the Agreement is terminated by
the City as provided herein, the Subrecipient will be paid an amount which be~irs the
same ratio to the total compensation as the services actually performed bear t,o the total
services of the Subrecipient covered by this Agreement less payments of compensation
previously made.
3. Enforcement Remedies
In the event of termination under Section A hereof by the City due to a breach by the
Subrecipient, then the City may complete the worK either itself or by agreement with
another contractor, or by a combination thereof. In the event the cost of completing the
worK exceeds the amount actually paid to the Subrecipient hereunder plus the! remaining
unpaid balance of the compensation provided herein, then the Subrecipient shall pay to
the City the amount of excess. Allowable costs shall be determined in accordc~nce with
24 CFR 8S.43(c).
The remedies provided to the City under Sections 1 and 3 hereof for a breach by the
Subrecipient shall not be exclusive. The City also shall be entitled to any other equitable
and legal remedies that are available.
In the event of breach of this Agreement by the City, then the Subrecipient's r1emedy
shall be limited to termination of the Agreement and receipt of payment as prctvided in
Section 2 hereof.
4. Appeal
In the event of termination under Section 1, the City shall provide the SubrecilPient an
opportunity for an administrative appeal.
CI)OO Agreement
Program Year 2004
Page 13
all interested persons can reasonably obtain information about, and access to,
HUD-fundE~d activities. The Subrecipient agrees to comply with the following:
A. The requirements of the Fair Housing Ad (42 U.S.C. 3601-20) and impllementing
regulations at 24 CFR part 100; Executive Order 11063, as amended by
Executive Order 12259 (3 CFR, 1958-1963 Comp., p. 652 and 3 CFR, '1980
Comp., p. 307)(Equal Opportunity in Housing) and implementing regulations at
24 CFR part 107; and title V1 of the Civil Rights Act of 1964 (42 U.S.C. :2000d)
(Nclndiscrimination in Federally Assisted Programs) and implementing
regulations issued at 24 CFR part 1;
B. ThE~ prohibitions against discrimination on the basis of age under the A!~e
Discrimination Act of 1975 (42 U.S.C. 6101-07) and implementing regulations at
24 CFR part 146, and the prohibitions against discrimination against
handicapped individuals under section 504 of the Rehabilitation Act of '1973 (29
U.S.C. 794) and implementing regulations at 24 CFR part 8;
C. Tht~ requirements of Executive Order 11246 (3 CFR 1964-65, Comp., p.
339)(Equal Employment Opportunity) and the implementing regulatiom; issued at
41 CFR chapter 60;
D. The requirements of Section 3 of the Housing and Urban Development Act of
1968 (12 U.S.C. 1701) providing:
(I) To the greatest extent feasible, opportunities for training and employm4!nt be
given to low- income persons residing within the unit of general local government
or the metropolitan area; and
(ii) To the greatest extent feasible, contracts for work to be performed in oonnedion
with any such project be awarded to business concerns which are located in or
owned in substantial part by persons residing in the same metropolitan area as
the! projed; and -
E. The requirements of Executive Orders 11625 and 12432 (concerning Minority
Business Enterprise), and 12138 (concerning Women's Business Enterprise).
11. Access to Records
The City, IiUD, the Comptroller General of the United States, or any of their duly
authorized .representatives, shall have access to any books, general organizational and
administrative information, documents, papers, and records of the Subrecipient which
are directly pertinent to this Agreement, for the purpose of making audit or monitoring,
examination, excerpts, and transcriptions. All required records must be maint2:tined by
the Subrecipient for five years after the City makes final payments and all othE~r pending
matters are closed.
12. Maintenance of Records
The Subrecipient shall maintain fiscal records on a current basis to support It~, billings to
the City. The Subrecipient shall retain fiscal as well as all records relating to program
and dient eligibility for inspection, audit, and copying fOf five years from the d~lte of
completion or termination. of this Agreement. The City or its authorized repres1entative
shall have! the authority to inspect, audit, and copy on reasonable notice and from time to
time any records of the Subrecipient regarding its billings or its work hereundE~r.
13. Audit Requirements
CI)BG Agreement
Program Year 2004
Page 15
the City before Subrecipient will be authorized to start work. This provision will relate to
any rehabilitation work undertaken on the property.
17. Minimum :Scope of Insurance
A. Workers' Compensation and Employer's Uability insurance as required by state
law.
B. Commercial General Uability coverage at least as broad as an ISO fonn
CGOOO1. Umits no less than $500,000 per occurrence for bodily injury and
personal injury. Umits no less than $50,000 for property damage liabili1y.
C. Aut.omobile Liability coverage covering any auto, at least as broad as ISO fonn
CAOOO1. Umits no less than $500,000 for bodily injury and personal injury. Umits
no less than $50,000 for property dama9E' liability.
D. Each policy required by this Agreement shall be endorsed to state that coverage
shall not be suspended, voided, canceled by either party, reduced in coverage or
in limits except after thirty days prior written notice by certified mail, retum receipt
requested, has been given to the City.
The general liability and automobile liability policies are to contain, or be
endorsed to contain, the following provisions:
· For any claims related to this projed. the Consultant's insurance coverage
shall be primary insurance as respeds the City, its officers, official~>>, agents,
volunteers and employees. Any insurance or self-insurance maintained by
the City, its officers, offICials, agents, volunteers, and employees shall be
excess of Subrecipient's insurance and shall not contribute with it.
· Any failure to comply with reporting or other provisions of the Subn~cipient's
insurance policies induding breaches of warranties shall not affect the
coverage provided to the City, its officers, officials, agents, volunteers, and
employees.
· The Subrecipient's insurance shall apply separately to each insured against
whom daim is made or suit is brought, except with resped to the limits of
insurer's liability.
E. AC4~ptability of Insurers
Insurance that is placed with insurers having a current AM. Best ratin!J of no less
than B+:VII will be considered acceptable without the approval of the Gity. All
other insurers are subject to the approval of the City.
F. Verification of Coverage
Subrecipient shall furnish the City with certificates and original endors4~ments
effecting the. coverage herein required. Certified copies of policies mwrt be
furnished upon the request of the City. Endorsements must be signed by a
person authorized by that insurer to bind coverage on its behalf. The fionn of
endorsement is subjed. to the City's approval.
CI>BG Agreement
~~ram Year 2004
Page 17
Non-profit. C1ontractors shall comply with the applicable provisions of OMS Circular No's.
A-122, and A-110 Attachments B, F, H paragraph 2, and 0, as described by 24 CFR
92.505.
23. Property Management
The Subrecipient agrees that any real property, equipment or supplies purchas~~d wholly
or In part with program funds will be managed under the same guidelines applic:able to
the City in accordance with 24 CFR 570.505 (real property), 24 CFR Part 85.32
(equipment), and 24 CFR Part 85.33 (supplies).
24. Explrationl'Reverslon of Assets
For CDBG-funded projects, the Subrecipient shall comply with the Reversion of Assets
provision of' 24 CFR 570.503(b)(8). Upon expiration of this agreement, the Subrecipient
shall transfE~r to the recipient any CDBG funds on hand at the time of expiration and any
accounts re,ceivable attributable to the use of CDSG funds.
The CDSG benefit of acquisition or improvement to real property with CDSG funds will
be realized only after ten years of public service to extremely low-, low- and moderate-
income Ashland residents at a level of 51 % of all clients served at the property. The
Subrecipient shall use real property acquired or improved with CDSG funds to provide
eligible CDSG client services to a population of at least 51% or more extremely low-,
low- and moderate-Income persons as classified by the U.S. Department of Hc)Using
and Urban Development until 1 0 years after expiration of this agreement. It is the City's
intention that the full public benefit of this project inure to the Subrecipient's cUEmts, or in
the alternative, that City recover the monetary equivalent of an unrealized public benefit
as follows:
A. If the Subrecipient should sell property acquired or improved with CDSG funds" or for
any reason discontinue using the property to provide eligible CDBG client services to ~
population of at least 51 % or more extremely low-, low- and moderate-income lPersons
as classified by the U.S. Department of Housing and Urban Development, priol~ to five
years from the completion date, the Subrecipient will be obligated to repay COl3G grant
funds in the full amount to City. If the Subrecipient should sell property acquireid or
improved with CDBG funds, or for any reason discontinue using the property tC) provide
eligible CDBG client services to a population of at least 51 % or more extreme~, low-,
low- and moderate-income persons as classified by the U.S. Department of Hctusing and
Urban Development, after five full years of use and prior to ten years from the
completion date, the Sub recipient will be obligated to repay COBG grant funds to City,
upon demand, that percentage of the grant equal to the percentage of time the!n
remaining until the expiration of ten years from the completion of the work. (For
example. i1~ the Subrecipient discontinues service and the property is sold after six years,
the Subrec:ipient shall repay 40% of the grant funds to City. Payment shall be made by
the Subrecipient within 90 days of the date the SUbrecipient sells the property or
otherwise discontinues its use for the approved, eligible public services.
B. If within the 10 year period, the Subrecipient moves to a new location where it continues
to deliver client services similar to those it now provides, City may, at its sole Ctption, find
the replacement facility a satisfactory replacement and waive the reimbursemunt
payment required by paragraph 23.A.
C. The Subrecipient may not change the use or planned use of real property acquired or
improved with CDSG funds unless the Subrecipient receives approval from thl;' City, and
either:
CI:IOO Agreement
Pr~,ram Year 2004
Page 19
provided by the U.S. Department of Housing and Urban Development (HUD)". The
words U.S. Department of Housing and Urban Development shalt be in 4 inch block
letters. Subrecipients may use the design and pattern of previously developed project
signs, provided that the sign is amended to acknowledge the contribution by thE! U.S.
Departmen1: of Housing and Urban Development, in lettering no smaller than th4:rt used to
acknowledge other contributors to the project.
30. Lobbying
No Federal appropriated funds have been paid or will be paid, by or on behalf clf the
Subreciplent, to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of Congress, or
an employee of a Member of Congress in connection with the awarding of any Federal
loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal Agreement, grant, loan, or
cooperativEt agreement.
If any funds other than Federal.appropriated funds have been paid or will be p21id to any
person for influencing or attempting to influence an officer or employee of any ngency, a
member of Congress, an officer or employee of Congress, or an employee of a Member
of Congress in connection with this Federal Agreement, grant, loan, or coopen:!ltive
agreement11 the Subrecipient shall complete and submit Standard F orm-LLL, "Disclosure
Form to Report Lobbying," in accordance with its instructions.
The Subrecipient shall require that the language of this certification be included in the
award documents for aU subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans and cooperative agreement) and that all Subcontractors
shall certify and disclose accordingly.
31. Church-State
The Subrecipient agrees to comply with the applicable provisions of 24 CFR 5JO.200(j)
regarding the use of federal funds by religious organizations. No religious content or
materials will be disseminated in any part of the programs or services funded under this
Agreement.
32. Nonsubstitutlon for Local Funding
For CDBG-funded projects, the SUbrecipient will not utilize grant funds to reduce
substantially the amount of local financial support for community development activities
belOYl the level of such support prior to the availability of funds under this Agreement.
33. Copyrights and Rights in Data
Subrecipient shall not publish or transfer any materials produced or resulting from
activities supported by this Agreement without the express written consent of the City
Administrator. If any material Is subject to copyright, the City reserves the right to
copyright such, and the Subrecipient agrees not to copyright such material. If 1the
material is copyrighted, the City reserves a royalty-free, nonexclusive, and irre!vocable
license to Ireproduce, publish, and use such materials, in whole or in part, and to
authorize ()thers to do so.
34. Nonparticlpatlon In Political Activities
The Subre!cipient shall comply with the provisions of the Hatch Act (5 USC, Chapter 15).
35. Real Property Acquisition
The Subrecipient shall comply with the applicable provisions of 49 CFR 24 re~~arding the
use of federal funds for acquisition of real property, and with the applicable pr1ovisions of
CDBG Subrecipient Agreement
Pro1~m Year 2004
Page 21
Education, l-tospitals, and other Non-Profrts. Non-profits receiving CDBG funds shall
establish written procurement procedures as per the requirements of 24 CFR 84.44.
CDOO Subrecipient Agreement
Pro'gram Year 2004
Page 23
EXHIBIT F
STATISTICAL REPORT OF SERVICES PROVIDED
(TABLE 1 NOT APPUCABLE TO LAND ACQUISITION - PROCEED TO TABLE 2and 3 and
Exhibit F-1)
Project Title:
Month(s) of:
Subrecipient Name~:
TABLE 1
Cumulative
for Quarter
Month 1
Month 2
Month 3
Number % of Number % of
Total Total
Number % of
Total
Number
%of
Total
Extremely
Low
Low
Moderate
Total of
Persons.
Served
Meeting
Program
Income
LImits
Total
Persons
Served
· Client data must be collected based on the client's family. A low- to moderate-income
person Is defined by HUD as a member of a family having an Income equal to olr less than
the low- to moderate-lncome limits established by HUD In the table on page 7. ,~family is
defined by HUD as all persons living in the same household who are related by blood,
marriage, or adoption. An individual living in a housing unit that contains no O1ther
person(s) related to him/her is considered to be a one person family for this pUlrpose.
Adult children who continue to live at home with their parent(s) are considered to be part
of the family for this purpose and their income must be counted In determining the total
family Income. A dependent child who Is living outside of the home (e.g. students living
In a dormitory 010 other student housing) is considered for these purposes to 1M! part of
the family upon which helshe Is dependent, even though he/she is living in an()lther
housing unit. '
CDBG Subrecq)ient Agreement
Program Year 2004
Page 25
EXHIBIT F-1
CDBG CLIENT/FAMILY INFORMATION FORM
Client's Name:
Address:
Total Number of Persons In Family (see definitions below):
List Names of Family Members Living In Household:
Client:
Additional Members:
Total Monthly Inc,ome Sources for All Family Members Living In Household
Employment, 'Gross Income:
Other Resources
Social Security/5SI:
Other Pension:
Unemployment
Public Welfare:
Child Support:
Alimony:
Veteran's Benefits:
Total Monthly Income:
Ethnlcity and Race
Grantees are to ask respondents to identify their clients ethnicity prior to askin" them to
Identify their race. Hispanic will now be considered an ethnicity category rather than a
race category .
Please check one ethnlclty about the client:
Hispanic or Latino
Not Hispanic lor Latino
Please select one or more of the following as self identified by the client:
American Indian/Alaskan Native
Asian
Black/African American
Native HawaUanlPacific Islander
White
Please complete the following about the client.
Disabled
Female Headed Household
yes_ no
yes_ no
CDBG Subrecipiient Agreement
Prog'ram Year 2004
Page 27
$
Page 1 /1
r~'
CITY OF
ASHLAND
20 E MAIN ST.
ASHLAND, OR 97520
(541) 488-5300
06191
VENDOR: 005068
ASHLAND COMMUNITY LAND TRUST
PO BOX 3027
ASHLAND, OR 97'520
SHIP TO: Ashland Planning Department
(541 ) 488-5305
51 WINBURN WAY
ASHLAND, OR 97520
FOB Point:
Terms: Net
Req. Del. Date:
Speciallnst:
Req. No.:
Dept.: COMMUNITY DEVELOPMENT
Contact: Brandon Goldman
Confirming? No
BILL TO: Account Payable
20 EAST MAIN ST
541-552-2028
ASHLAND, OR 97520
SUBTOTAL
TAX
FREIGHT
TOTAL
14000.00
0.00
0.00
14,000.00
~ ~ P7~.r
Aut rlzed Signature
VENDOR COPY
CITY OF
A~;HLAND
REQUISITION FORM
THIS REQUEST IS A: Purchase Order
o Change Order( existing PO # )
Date of REK1uest:
8-04-05
Required Date of Delivery/Service:
8-30-05
completion
Vendor Name
Address
City, State, Zip
Telephone Number
Fax Number
Contact Name
Ashland Community Land Trust
PO Box 3027
Ashland, OR, 97520
488.7276
Shelley Austin, ACL T Executive Director
Sole Source
Written findings attached
Invitation to Bis(
(Copies on file)
f:1ennediate Procurement
(3) Written Quotes
(Copies attached)
Eroerative Procurement
State of ORIWA contract
X Other government agency contract
CDBG
Contract #
Reauest for p~~
(Copies on file)
SoecIall Exemm
Written findings attached
Emeraencv
Written findings attached
X Copy of contract attached
Description of SERVICES
T'otal Cost
x , Per CDSG Subrecipient Contract (attached) for Rehabilitation of the duplex at 264 Grant Street.
ACL T is the Subrecipient for the CDBG federal grant. ACL T contracts with contractors to complete
the rehabilitation work as eligible and in accordance the CDSG program regulations, Incfuding
but not limited to Roof re lacement, bathroom re air, aintin and weatherization.
Item # Quantity
Unit
Description of MATERIALS
Unit PrlCl8
Total Cost
Project Number _ _ _ _ _ _. _ __
o Per attached QUOTE
Account Number 250.09.00.00.609199
* Items and services must be charged to the appropriate account numbers for the financials to reflect the actual expenditures accurate/}'.
By signing this requisition form, Ilcsrtify that the iJformation provided above meets the City of Ashland public contracting
wW~ docunemaUon can bepro1ffL
Employee SlgnatuaM . _ ) Supervlsor/Dept. Head Signature:' tJ
. . ~
Upda1ed on: 814/2005
G: Flnance\Procedure\AP\Fonns\8_Requisltbra form revised.doc
CITY OF
ASHL.AND
Today's Date: August 4.2005
Requested Check Issue Date ASAP
Please note Vendors an~ paid Net 30 (30days) from today's date if not otherwise specifi~oo.
Request(s) must be in A~ccounts Payable Inbox by 5:00pm Friday to be issued the follovring Friday.
I
Reguest for Check ~
To be used for the following:
· Grants and Debt Services (CDBG GRANT)
Payee:
Ashland Community Land Trust
Address:
_Po Box 3027
City, State, Zip Ashland.. Oree:on.. 97520
ACLT to pick up the eheck by hand. Please call Shelley Austin (ACLT, Exec. Director) at
488-7276 once available and she will retrieve it directly.
Description
Partial Payment for rehabilitation work on 264 Grant Street as funded by the Communi1ty
Development Block Grant Program. (CDBG Subrecipient contract attached). The total CDBG
grant amount is for 14,000, however remainder ($3193.05) will only be distributed after completion
of the remaining work.
1'.0. ~
~<A.~Q11J1tl'tljmb.e..
250.09.00.00.609199
Amount
10,806.95
.JUnoilnt
Requested by: Brandon ~Goldman
I Return check to:
Send check with I
attachment
G:\comm-dev\Housing\CDBG\projo::ts by subrecipients\ACL 1\2003-Grant_ duplex\4 _ req for check _REHAB _ 8-03-05.docUpdated on :08/04/05