IGA WITH DES FOR COMMUNITY SERVICES.PDF

INTERGOVERNMENTAL AGREEMENT (IGA)
Contract between the Arizona Department of Economic Security ("ADES") and the Maricopa County
Administered by its Human Services Department ("Contractor").
WHEREAS the ADES is duly authorized to execute and administer contracts under A.R.S. §41-1954 and,
WHEREAS the Contractor is duly authorized to execute and administer contracts under A.R.S. §11-251 and,
WHEREAS the ADES and the Contractor are authorized by A.R.S. §11-952 et seq. to enter into agreements for
joint or cooperative action to contract for the services specified in this contract.
THEREFORE, the ADES and Contractor agree to abide by all the terms and conditions set forth in this Contract.
Contract Term: This contract shall be effective July 1, 2015, and shall terminate on June 30, 2020, unless
extended in accordance with the Terms and Conditions.
__________________________
BY SIGNING THIS FORM ON BEHALF OF THE CONTRACTOR, THE SIGNATORY CERTIFIES HE/SHE HAS THE AUTHORITY TO BIND
THE CONTRACTOR TO THIS CONTRACT.
FOR AND ON BEHALF OF THE ARIZONA FOR AND ON BEHALF OF THE MARICOPA
DEPARTMENT OF ECONOMIC SECURITY: COUNTY ADMINISTERED BY ITS HUMAN
SERVICES DEPARTMENT:
Procurement Officer Signature Signature
Printed Name Printed Name
Title Title
Date Date
ADES15-089115
ADES Contract Number Contract Number
IN ACCORDANCE WITH A.R.S. §11-952 THIS CONTRACT HAS BEEN REVIEWED BY THE UNDERSIGNED
WHO HAVE DETERMINED THAT THIS CONTRACT IS IN APPROPRIATE FORM AND WITHIN THE POWERS
AND AUTHORITY GRANTED TO EACH RESPECTIVE PUBLIC BODY.
ARIZONA ATTORNEY GENERAL’S OFFICE
By: ___________________________________ By: ______________________________________
Assistant Attorney General Public Agency Legal Counsel
Date: __________________________________ Date: ______________________________________
Revised: 8/20/13

Scope of Work
Community Action Program Services
1.0 ADES Mission and Vision Statement
1.1 ADES Mission — The Arizona Department of Economic Security (ADES) promotes the safety, well-being,
and self-sufficiency of children, adults, and families.
1.2 ADES Vision — Every child, adult, and family in the state of Arizona will be safe and economically secure.
2.0 Purpose
2.1 Purpose Statement — This Contract provides broad-ranging programs and services in rural and urban
areas that are intended to pursue the reduction of poverty, the revitalization of low-income communities
and the empowerment of low-income families and individuals to become fully self-sufficient.
2.2 Legal Authority — Pursuant to Arizona Revised Statutes (A.R.S.) Section §41-1954 (A)(6) provides the
Department the authority to Contract and incur obligations within the general scope of its activities and
operations subject to the availability of funds, and A.R.S. Section §41-1954 (A) (8), to make funding
available to provide an array of services for the reduction of poverty, the revitalization of low-income
communities and the empowerment of low-income families to become fully self-sufficient
2.3 Funding — Fund sources that support the services include the Community Services Block Grant (CSBG),
Temporary Assistance to Needy Families (TANF), Social Services Block Grant (SSBG), Low Income
Home Energy Assistance Program (LIHEAP), and Neighbors Helping Neighbors (NHN), The use of the
funding may be directed by statute or prescribed by federal requirements. Funding information is
summarized below.
FUND
SOURCE ALLOWABLE ACTIVITIES ADDITIONAL INFORMATION
Community Activities that are designed to Various objectives may include providing case management
Services Block assist low-income families services to individuals and families in securing services from
Grant (CSBG) and individuals to remove other agencies, or moving a family from crisis situations onto
— Federal obstacles and solve various stages of self-sufficiency.
problems that block the
achievement of self- Funds are distributed to designated Community Action
sufficiency, to secure and Agencies (CAAs) according to a funding formula that consists
retain meaningful of the following elements:
employment, attain adequate (1) Number of persons in poverty in the geographic area
education, make better use served.
of available income, obtain (2) Number of persons unemployed in the geographic area
and maintain adequate served.
housing, obtain emergency (3) Five percent of the overall funds are distributed only to
assistance, achieve greater rural counties.
participation from low-income (4) Funds are adjusted for tribes receiving CSBG dollars.
communities, establish
partnerships and strengthen Any Contractor whose allocation does not reach a minimum of
relationships with community $150,000 will receive an allocation of at least $150,000.
organizations, establish The Limited Purpose Contractor serving Migrant or Seasonal
youth development Farm Workers will receive two percent of the overall available
programs, create linkages to CSBG funds.
fill gaps in services, and
support innovative
community and
neighborhood based
initiatives.
Temporary Case management services, Funds are distributed to designated CAAs according to a
Assistance to emergency shelter, move-in funding formula that consists of the following elements:
Needy assistance, eviction (1) Number of persons in poverty in the geographic area
Families prevention, and utility served.
(TANF) — assistance (2) Five percent of the overall funds is distributed only to rural
Federal counties.
Any Contractor whose allocation does not reach a minimum of
$150,000 will receive an allocation of at least $150,000.
The Limited Purpose Contractor serving Migrant or Seasonal
Farm Workers will receive two percent of the overall available
TANF funds.
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FUND ALLOWABLE ACTIVITIES ADDITIONAL INFORMATION
SOURCE
Social Contractor operations, case Funding amounts are determined through the local planning
Services Block management, general process.
Grant — transportation, and
Locally supportive services, for Funding for General Transportation in Coconino, Yavapai, and
Planned individuals and families. Navajo Counties.
(SSBG-LP)
Federal
Low Income Utility Assistance Funds are distributed to designated CAAs and designated
Home Energy LIHEAP Contractors according to a funding formula that
Assistance consists of the following elements:
Program (1) Number of persons in poverty in the geographic area
(LIHEAP) served.
Federal (2) Number of persons unemployed in the geographic area
served.
(3) Five percent of the overall funds are distributed only to
rural counties.
Neighbors Utility Assistance Funds are distributed to designated CAAs and designated NHN
Helping according to a funding formula that consists of the following
Neighbors elements:
(NHN) (1) Number of persons in poverty in the geographic area
Local served.
(2) Number of persons unemployed in the geographic area
served.
(3) Five percent of the oyerall funds is distributed only to rural
counties.
2.4 Definitions — See Exhibit A, as may be amended.
3.0 Program Description
3.1 Community Services (provided in every county in Arizona) — The primary objectives of this service are to
strengthen community capabilities for planning and coordinating the use of a broad range of resources
related to the elimination of poverty; the organization of a range of services so that these services may
have a measurable and potentially major impact on the causes of poverty and help families and
individuals become self-sufficient; the greater use of innovative and effective community based
approaches to attacking the causes of poverty and of community breakdown; the maximum participation
of the poor to empower them to respond to the unique problems and needs within their communities; and
the broadening of the resource base of programs directed to the elimination of poverty.
3.2 Case Management (provided in every county in Arizona) — This service provides assistance to low-
income families and individuals by providing case management services that are intended to assist the
household in resolving crisis situations and move closer to self-sufficiency. Components of this service
include Short Term Crisis Services, Utility Assistance Services, and any other program or service the
Contractor deems necessary and appropriate, according to local community needs and priorities.
3.3 General Transportation (provided in Coconino, Navajo and Yavapai Counties only) — This service
provides or assists in obtaining various types of transportation for specific needs. This service may
include various types of transportation for employment, medical, training, or other supportive services with
the exception of ambulance services. It may be provided by Contractor-operated vehicles or through
vouchers for public transit.
4.0 Notices
4.1 The Contractor shall email all correspondence regarding this Contract to the assigned DAAS Contract
Specialist or address to:
Arizona Department of Economic Security
DAAS Contracts Unit
P. 0. Box 6123-Site Code 950A
Phoenix, AZ 85005-6123
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4.2 The Department will address all correspondence regarding this Contract to the individual(s) identified in
the letter of assurances (Attachment 9).
5.0 Reserve
6.0 Administrative Requirements — The Contractor shall:
6.1 Provide services that are culturally relevant and linguistically appropriate to the population served.
6.2 Comply with AIDES Policy and Procedure Manuals as may be amended, and all applicable federal, state,
and local laws, rules, and regulations as may be amended, including but not limited to the following:
6.2.1 COATES Human Services Reauthorization Act of 1998
6.2.2 Personal Responsibility and Work Opportunity Reconciliation Act of 1996
6.2.3 Stewart B. McKinney Homeless Assistance Act
6.2.4 ARS §46-241 - Short Term Crisis Services
6.2.5 ARS §46-701 - Utility Assistance
6.2.6 ARS §46-741 - Neighbors Helping Neighbors
6.2.7 ARS §46-140.01 - Verification of identity and citizenship and/or immigration status; and ARS §1-501-1-
502, regarding eligibility for federal and state or local public benefits.
6.3. Staffing and Security
6.3.1 Verify and assure that staff members and volunteers do not have conflicts of interest in the provision of
services and management of the programs,
6.3.2 Provide to all staff and volunteers timely and accurate information and appropriate training for the
services they provide.
6.3.3 Maintain client/recipient confidential information in a secure location.
6.4 Equipment
6.4.1 Communicate with ADES electronically through email to convey Microsoft-based text and spreadsheet
documentation, and access/utilize up-to-date information from ADES, U.S. Department of Health and
Human Services (DHHS) Office of Community Services (OCS), and other web sites.
6.4.2 Utilize computer backup/recovery systems and procedures to ensure no loss of data required for ADES
reports, and to ensure that there is no disruption or degradation of services provided.
6.4.3 Utilize a computer-based tracking system from which monthly, quarterly, and other reports may be
generated.
6.5 Service Provision
6.5.1 Provide services directly, as allowed, or through subcontractors.
6.5.2 Collect and report required client data.
6.5.3 Maintain documentation that key staff has received appropriate training or hold appropriate
certification/licensure in accordance with their job descriptions.
6.5.4 Maintain documentation that appropriate case management staff has received training on the
requirements of ARS §46-140.01 and ARS §1-501 and 1-502 regarding eligibility for State and local
benefits (this does not apply to tribal entities).
6.5.5 Maintain and utilize a policy and procedure manual that includes, at a minimum, detailed intake
procedures, program description and eligibility requirements, client grievance procedures, non-
discrimination policy, and confidentiality requirements,
6.5.6 Maintain client-focused facility locations which offer sufficient client waiting space or waiting rooms,
adequate seating, and restrooms for program applicants at all permanent facility locations indicated on
the Facility Location Chart (Attachment 1),
6.6 Networking
6.6.1 Develop partnerships and network with related programs to provide more immediate resolution to issues
and expand resources.
6.6.2 Form local partnerships with community agencies to address the needs of low-income families and
individuals.
6.6.3 Network with social service professionals within the community to expand their means to receive and
disseminate information for each service.
6.6.4 Facilitate and participate in education, training, and information seminars, workshops, and conferences.
6.6.5 Participate in conference calls and attend meetings initiated by ADES to receive training or obtain
information.
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6.7 Subcontract Related Service Provisions
6.7.1 Document all costs associated with provision of Contract services.
6.7.2 Provide administrative assistance, training and technical assistance to subcontractors in support of
administrative functions as needed or requested by subcontractors.
6.7.3 Require that subcontractors are in compliance with applicable administrative directives and forms.
6.7.4 Provide technical assistance to subcontractors through procedural interpretation or by additional research
upon request.
6.7.5 Develop and present initial and refresher training to subcontractor staff as deemed necessary by the
Contractor, subcontractor or ADES.
6.7.6 Implement a coordinated service delivery system that establishes standards for service delivery and
operations.
6.7.7 Hold periodic meetings with subcontractors to communicate new developments, discuss problems, share
ideas for improvements and address other identified topic areas.
6.7.8 Utilize client grievance procedures, which respond timely and effectively to customer complaints.
6.7.9 Develop linkages between the coordinated service delivery system and other community resources.
6.7.10 Identify service gaps among client populations and develop and implement services or resources to meet
identified needs.
6.7.11 Address client barriers to service.
6.7.12 Train appropriate personnel in the use and completion of the ADES EN-005 Application for Services
form(s) or other ADES approved written or electronic form(s) as may be amended (Exhibit B).
6.8 Monitoring and Evaluation
6.8.1 Utilize instruments for monitoring/evaluating subcontractors' performance and compliance with
Administrative Requirements stated in Section 6.0, as well as other requirements specified in service
scopes of work.
6.8.2 Conduct at a minimum, on-site Contract compliance monitoring of subcontractors at least every two
years, to include, but not limited to, facilities, administrative and financial operations, and programmatic
service delivery.
6.8.3 Establish and implement a process for service/performance improvement.
6.8.4 Participate in ADES evaluation studies, when required.
6.9 CSBG Organizational Standards
6.9.1 Participate in the implementation of the CSBG Organizational Standards and any training made available
to assist with the implementation and compliance with the Standards as recommended by OCS and
agreed to by CAAs and ADES, as may be amended (CAAs only).
7.0 General Reporting Requirements — The Contractor shall:
7.1 Email all correspondence regarding this Contract to the assigned DAAS Contract Specialist or address to:
Arizona Department of Economic Security
DAAS Contracts Unit
P. O. Box 6123-Site Code 950A
Phoenix, AZ 85005-6123
7.1.1 A complete and accurate monthly Contractor's Invoice and Statement of Expenditures. Note: Mileage will
be reimbursed at no greater than the current federal mileage reimbursement rate. Exceptions may be
requested in writing to, and considered for approval by, the Community Services Program Administrator.
7.1.2 Updated Cost Allocation Plan by October 1, 2015, if not provided prior to Contract start date.
7.1.3 A correctly completed "Contractor's Equipment List" (Form FES-1000A), as may be amended, for all
proposed equipment purchases costing $5,000 or more to be purchased in whole or in part with ADES
funds (Exhibit C).
7.1.4 Contractor's insurance certifications identified in the Terms and Conditions, Insurance Requirements
section.
7.1.5 Subcontractor's insurance certifications identified in the Terms and Conditions, insurance Requirements
section.
7.1.6 By June 30 annually, a twelve month monitoring plan that includes at a minimum: which direct service
subcontractors are to be monitored during the twelve month period beginning July 1 (of the same year),
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and for each: administrative, fiscal, and/or programmatic the specific service(s) to be monitored, and the
target monitoring start and completion dates.
7.1.7 Programmatic reports as specified under each service (i.e., Community Services, Case Management, and
General Transportation).
8.0 Items Provided by the Department — The Department shall provide, at a minimum:
8.1 Funding allocation information, as needed.
8.2 A Contractor's Invoice and Statement of Expenditures form.
9.0 Community Services
9.1 Service Description
9.1.1 Services that provide a range of activities that have a measurable and major impact on the causes of
poverty.
9.2 Service Information
9.2.1 The purposes of the CSBG are to provide assistance to local communities through a network of CAAs
that pursue six national goals outlined in federal law:
1. Low-income people become more self-sufficient
2. The conditions in which low-income people live are improved
3. Low-income people own a stake in their community
4. Partnerships among supporters and providers of services to low-income people are achieved
5. Agencies increase their capacity to achieve results
6. Low-income people, especially vulnerable populations, achieve their potential by strengthening family
and other supportive environments
9.2.2 These goals will be accomplished through:
1. The strengthening of community capabilities for planning and coordinating the use of a broad range of
federal, state, local and other assistance "including private resources" related to the elimination of
poverty, so that this assistance can be used in a manner responsive to local needs and conditions;
2. The organization of a range of services related to the needs of low-income families and individuals,
so that these services may have a measurable and potentially major impact on the causes of poverty
in the community and may help families and individuals to achieve self-sufficient;
3. The greater use of innovative and effective community-based approaches to attacking the causes
and effects of poverty and of community breakdown;
4. The maximum participation of residence of the low-income communities and members of the groups
served by programs assisted through the block grants to empower such residence and members to
respond to the unique problems and needs within their communities; and
5. The broadening of the resource base of programs directed to the elimination of poverty so as to
secure a more active role in the provision of services for (a) private, religious, charitable and
neighborhood-based organizations: and (b) individual citizens, and business, labor, and professional
groups, who are able to influence the quantity and quality of opportunities for the poor.
9.3 Board Requirements — The Contractor shall:
9.3.1 Private, non-profit CAAs:
1. Select a Tripartite Governing Board that administers the services.
2. Seat a Tripartite Governing Board that is comprised as follows:
(i) One-third are elected public officials, holding public office on the date of selection.
(ii) Not fewer than one-third of members are persons chosen in accordance with democratic
selection procedures adequate to ensure that these members are representative of low-income
individuals and families in the neighborhood served and each representative of low-income
individuals and families selected to represent a specific neighborhood within a community,
resides in the neighborhood represented by the member.
(iii) The remaining members are officials or members of business, industry, labor, religious, law
enforcement, education, or other major groups and interests in the community served.
3. Establish and follow written procedures identified in CSBG legislation to ensure the Tripartite
Governing Board membership that conforms to the Tripartite Board requirements, including a
description of the democratic selection process used in the appointment of members.
4. Establish and follow written procedures including board by-laws, to ensure the Tripartite Governing
Board fully participates in the development, planning, implementation, and evaluation of the program
and services to serve low-income communities, including but not limited to:
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(i) active participation in the development and on-going implementation and evaluation of the
Contractor Community Action Plan;
(ii) active participation in ensuring the completion of a Community Needs Assessment for the area
served, and in reviewing the results of the Assessment to ensure responsiveness to any identified
gaps in services; and
(iii) active participation in the identification and evaluation of Result Oriented Management and
Accountability (ROMA) Performance Outcomes used in measuring the Contractor's effectiveness
in achieving the six national goals.
5. Establish and follow written procedures that describe how a low-income individual, community
organization, religious organization, a representative of low-income individuals that considers its
organization and low-income individuals to be inadequately represented on the board, petition for
adequate representation on the Board.
6. Conduct a minimum of four quarterly Tripartite Governing Board meetings per state fiscal year.
a. For public and quasi-governmental entities, meetings must conform to Arizona open
meeting laws.
7. Maintain records of Tripartite Governing Board membership, election and selection process, and
detailed meeting minutes.
8. Provide upon request and maintain documentation demonstrating Tripartite Governing Board
members' training, including, but not limited to board member governance and advisory
responsibilities, the purposes of the CSBG and other programs administered by the Contractor, and
the requirement of the Board to participate in the ROMA System.
9. Maintain and provide, upon request, documentation of the democratic selection process utilized for
low-income representatives.
10. Document and communicate to ADES efforts to fill any vacancies.
11. Address any vacancies within 90 days of each occurrence; provide upon request and maintain
documentation of efforts to fill within 120 days of occurrence.
9.3.2 Public CAAs Advisory Board:
1. Select members to serve on a Board in which one-third of the board members are persons chosen in
accordance with democratic selection procedures adequate to assure that these members are
representative of low-income individuals and families. Select representatives to fill balance of seats
as set forth in governing documents.
2. Maintain and provide, upon request, documentation of democratic selection process for low-income
representatives.
3. Document and communicate to ADES efforts to fill any vacancies.
4. Address any vacancies within 90 days of each occurrence and provide and maintain documentation
of efforts to fill within 120 days.
9.4 Community Action Plan Requirements — The Contractor shall:
9.4.1 Develop, and implement when approved by ADES, a Community Action Plan that includes:
1. a description of a needs assessment for the community served, that may be coordinated with
community-needs assessments conducted for other programs;
2. Contractors' objectives that are aligned with the six (6) national goals;
3. a description of the Contractor that includes its primary functions, responsibilities, organizational
structure, and its association as part of a larger entity if appropriate;
4. a description of the service delivery system for services provided or coordinated with CSBG funds.
5. a narrative that demonstrates how the results of the Community Needs Assessment were used and
incorporated into the Community Action Plan;
6. a description of how linkages will be developed to fills gaps in services through the provision of
information, referrals, case management, and follow-up consultations;
7. a description of how CSBG funds will be coordinated with other public or private resources;
8, a description of how the Contractor will use CSBG funds to support innovative community and
neighborhood based initiatives;
9. a description of how the Contractor will provide, on an emergency basis, for the provisions of such
supplies and services, nutritious foods, and related services, as may be necessary to counteract
conditions of starvation and malnutrition among low-income individuals;
10. a description of how the Contractor will, to the maximum extent possible, coordinate programs and
form partnerships with other agencies serving low-income residents, including religious organizations,
charitable groups, and community- based organizations; and
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11. a description of the ROMA performance outcomes and any related indicators that will be used to
measure the Contractor's performance in achieving the six (6) CSBG national goals.
9.5 Results Oriented Management & Accountability (ROMA) Requirements — The Contractor shall:
9.5.1 Participate in the ROMA System as may be amended, for measuring performance and results of
programs and services.
9.6 Program Reporting Requirements — The Contractor shall:
9.6.1 Submit the following items as may be amended, by the dates indicated, as may be amended, by the
AIDES Community Services Program Administrator through written notification to the Contractor:
1. Annual Community Action Plan with a description of the Needs Assessment conducted for the
community served, by June 30 1h of each calendar year. Contractor must utilize format specified by
ADES (Exhibit ID).
2. Quarterly ROMA Outcomes Report (Exhibit E) by October 25, January 25, April 25 of each calendar
year. The Contractor shall not submit a Fourth Quarter Report, but shall include fourth quarter data
with the Annual CSBG IS Report. Contractor must utilize format specified by ADES (Exhibit F).
3. CSBG Information System (IS) Report by October 1 st of each calendar year (Exhibit F).
4. Schedule of planned Board meetings for the next twelve months, by June 30 of each calendar year.
5. Monthly Community Services Block Grant (CSBG) Contract Payment Verification Form (All CAAs), as
appropriate (Exhibit G).
6. Copy of complete and detailed minutes from Tripartite/Advisory Board meetings within 30 days of
Board approval of minutes.
7. Current Organizational Chart by June 30 of each year.
8. Current Agency Operations Spreadsheet by June 30 of each year.
9.7 Items Provided by the Department — The Department shall provide:
9.7.1 Formats for Annual Community Action Plan, Quarterly ROMA Outcomes Reports, and CSBG Final
Reports.
9.7.2 Training on Community Action Plan preparation, Quarterly ROMA Outcomes Report preparation, and
CSBG Final Reports.
10.0 Case Management
10.1 Service Description
10.1.1 A service or process that establishes a relationship with an individual or family in order to enhance their
functioning and/or integration into the community. Appropriate services and/or benefits are identified,
planned, obtained, provided, recorded, monitored, modified when necessary and/or terminated. This may
include: assessment to determine their needs and eligibility when applying for/receiving services,
assistance in finding necessary resources in addition to covered services to meet basic needs, assistance
in obtaining entitlements, communication and coordination of care as well as follow-up of crisis contact or
missed appointments.
10.1.2 This service specifically provides assistance to low-income families and individuals by providing case
management services that are intended to assist the household in resolving crisis situations and move
closer to self-sufficiency. Components of this service include Short Term Crisis Services, Utility
Assistance Services, and any other program or service the Contractor deems necessary and appropriate,
according to local community needs and priorities.
10.2 Service Information
10.2.1 The primary goal of this service is to assist low-income individuals and families in resolving crisis
situations, and moving households closer to self-sufficiency.
10.2.2 All CAAs shall provide the following:
1. Case Management.
2. Short Term Crisis Services (STCS) that provide temporary assistance to persons at or below 125
percent of poverty, or 150 percent if elderly or disabled, who have an emergent need that cannot be
met immediately with their own income or other resources.
The STCS program is funded with TANF and is available to low-income families with children. Benefits
available through the STCS program include the following:
1. temporary shelter at hotels/motels for homeless persons;
2. housing assistance for rent or mortgage assistance, move-in, and eviction prevention;
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3. utility assistance for families with a current or anticipated interruption of heating and/or cooling
services; and
4. special needs to secure or maintain employment.
10.2.3 All CAAs and designated LIHEAP agencies shall provide the following:
1. Utility Assistance Services that assist low-income households lower basic home energy bills with
specific emphasis on those households with the lowest income and highest energy burden and that
respond to problems related to the termination of heating and/or cooling. Utility Assistance is funded
with Low Income Home Energy Assistance Program (LIHEAP), and Neighbors Helping Neighbors
(NHN) funds. For LIHEAP eligibility, the household income limit is sixty (60) percent of the State
Median Income (5MI) or 150 percent of the Federal Poverty Guideline (FPG), whichever is greater,
as may be amended. For NI-IN eligibility, the household income limit is 125 percent of the FPG
except for individuals sixty years of age or older or disabled, where the household income limit is 150
percent of the FPG, as may be amended. The Contractor shall offer Utility Assistance Services as a
component program under the overall Case Management Service structure. Benefits include:
(i) Utility payments or deposits for heating and cooling
(ii) Temporary emergency shelter (if needed due to energy related crisis)
(iii) Payment of water bills related to cooling (May 1 through October 1)
(iv) Rental assistance where utility payment is included in the rent
10.2.4 Tribal entities shall provide utility assistance funded with LIHEAP. Benefits include the following:
1. Utility payments or deposits for heating and cooling
2 Payment of water bills related to cooling (May 1 through October 1)
3. Rental assistance where utility payment is included in the rent
10.3 Case Management Requirements (CAAs and designated LIHEAP agencies) — The Contractor shall:
10.3.1 Develop and implement client oriented intake procedures which are responsive to households in crisis
situations.
10.3.2 Develop and implement intake procedures responsive to applicants who are physically infirm and must
apply for benefits without leaving their homes.
10.3.3 Develop in collaboration with the client, a case management plan that includes the following:
1. An assessment of the client's resources and needs
2. Specific objectives that relate to the goal of alleviating any immediate crisis situation
3. Eligibility for supportive services including but not limited to STCS and Utility Assistance, through
direct provision or referral
10.3.4 Provide assessment of the househoid's needs in order to establish a case plan if necessary, and arrange
for the provision of services designed to:
1. resolve any immediate crisis in a timely manner;
2. assist the household in obtaining other benefits to which they may be eligible including but not limited
to Home Weatherization, Appliance Repair or Replacement, Child Care, Earned Income Tax Credit,
Supplemental Nutrition Assistance Program (SNAP), Social Security Benefits, and Utility Discount
Programs; and
3. arrange for training or counseling intended to remove obstacles and solve problems that block the
achievement of self-sufficiency, including but not limited to financial literacy classes, budget
counseling, energy conservation education, efforts intended to secure and maintain meaningful
employment, attain an adequate education, obtain and maintain adequate housing and a suitable
living environment, and to obtain emergency assistance to meet the immediate and urgent needs of
the family or individual.
10.3.5 Complete a closing summary that includes, at a minimum, the services provided, the number and type of
referrals made to alleviate the crisis situation.
10.3.6 Completion of the Self-Sufficiency Matrix, as may be amended located at
httbs://www.azdes.gov/uploadedFiles/Aging and Adult Services/Community Services Unit/SSM Englis
h-Soanish.pdfl, for all case managed households in which a member of the household is eighteen (18) to
fifty-nine (59) years of age, not disabled and not a full-time student, and is:
a. unemployed and seeking earned income; or
b. employed and seeking to reduce barriers to maintain earned income; or
c. employed and seeking increased earned income and/or employment benefits;
as may be amended.
10.3.7 Utilize report formats specified by ADES. Contract Payment Verification Reports shall be submitted on a
monthly basis with the Contractor's monthly invoice. As appropriate, revisions to Case Management and
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Contract Payment Verification Reports shall be submitted with Supplemental Invoices. A summary of the
revisions may be submitted with the Supplemental Invoices.
10.4 Short Term Crisis Services Requirements (CAAs only) — The Contractor shall:
10,4,1 Follow all eligibility and procedural policies set forth in the ADES/DAAS Short Term Crisis Services Policy
Manual and related Policy Clarifications or Revisions and as amended.
10,4.2 Use the ADES EN-005 Application or other ADES approved electronic or written Application for Services
form(s) as may be amended, in determining program eligibility (Exhibit B). Application forms shall be
uniform at all service locations within a designated service area.
10.5 Utility Assistance Service Requirements (CAAs and designated LIFIEAP agencies only) — The
Contractor shall:
10.5.1 Follow all eligibility and procedural policies set forth in the most current ADES LIHEAP Policy and
Procedure Manual as may be amended. Keep and maintain the Manual with all related policy
clarifications, additions or amendments. Contractor shall keep the most current version available to staff
at all times.
10.5.2 Use the ADES EN-005 Application or other ADES approved electronic or written application for Services
form(s) as may be amended, in determining program eligibility (Exhibit B). Application forms shall be
uniform at all service locations within a designated service area.
10.5.3 The Contractor must demonstrate and exercise the ability to pay all vendors on behalf of an eligible client.
10.5.4 Utilize an in-house system to make payments to utility companies.
10.6 Results Oriented Management & Accountability (ROMA) Requirements (CAAs only) — The
Contractor shall:
10.6.1 Participate in the Results Oriented Management and Accountability system for measuring performance
and results of programs and services.
10.6.2 Participate in a statewide "ROMA Advisory Committee" to identify standardized performance indicators for
the statewide Community Action Network.
10.7 Program Reporting Requirements — The Contractor shall:
10.7.1 Utilize and maintain a functional electronic system in which programmatic data shall be stored and reports
submitted to ADES. An agreed upon data bridge from an existing data system may be utilized if a
collective database system is used by Community Action Program Services Contractors. All other reports
such as, payment verification forms and narratives information shall be provided on the forms required by
this Contract, or as directed by ADES.
10.7.2 Submit the following reports as may be amended, for the timeframes indicated, as may be amended by
the ADES Community Services Program Administrator through written notification to the Contractor:
1. Monthly Case Management Report by the 25 th of each month (All CAAs and designated LIHEAP
agencies) (Exhibit H1, H2).
2. Tribal LIHEAP Monthly Report (Tribal entity only) (Exhibit l).
3. Social Services Block Grant Annual Report (All CAAs and designated LIHEAP agencies) (Exhibit K)
by August 31 st of each calendar year.
4. Quarterly ROMA Outcomes Report (All CAAs) (Exhibit E).
5. Monthly Short Term Crisis Services (STCS) Contract Payment Verification Form (All CAAs) (Exhibit
L).
6. Monthly Low Income Home Energy Assistance program Contract Payment Verification Form (All
CAAs and designated LIHEAP Contractors) (Exhibit M).
7. Monthly Community Services Block Grant Contract Payment Verification Form (All CAAs), as
appropriate (Exhibit G).
8. Monthly Neighbors Helping Neighbors Contract Payment Verification Form (All CAAs), as appropriate
(Exhibit N).
9. LIHEAP Leveraging Report (Exhibit Q), annually by October 15.
10. LIHEAP Annual Household Report (Exhibit J), Estimated Report by August 15 and Final Report by
October 15, for services provides within this Contract as applicable.
10.8 Items Provided by the Department — The Department shall provide:
10.8,1 The following report formats as may be amended by the ADES Community Action Program Administrator
through written notification to the Contractor: Case Management Monthly Report, Annual SSBG Report,
and Quarterly ROMA Performance Outcomes Reports.
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10.8.2 Training on completing the Case Management Monthly Report, Quarterly ROMA Outcomes Report
preparation, Short Term Crisis Services Program, and Low Income Home Energy Assistance Program.
10.8.3 Short Term Crisis Services Policy Manual, as may be amended.
10.8.4 Low Income Home Energy Assistance Program Policy and Procedure Manual.
(https://vvww.azdes.gov/uploadedFiles/Aging_and_Adult_Services/Community_Services_Unit/LIHEAP_P
olicy_Manual_SFY14.pdf).
11.0 General Transportation (Coconino, Yavapai and Navajo Counties only)
11.1 Service Description
11.1.1 This service provides or assists in obtaining various types of transportation for specific needs.
11.1.2 This service may include various types of transportation for employment, medical, training, or other
supportive services, with the exception of ambulance services. Service to assist eligible individuals and
households with mobility needs for various purposes such as employment, medical and/or training
reasons when they do not have any other means of transportation is also included. Services may be
provided using Contractor-operated vehicles and/or through vouchers for public transit.
11.2 Service Information
11.2.1 The goal of this service is to provide or arrange for transportation for eligible individuals of all ages and
abilities in order to access services or obtain medical care or employment, (e.g., medical appointments or
employment-related training interviews). Case managers typically assist clients to access transportation
to help increase or maintain client self-sufficiency.
11.2.2 Services in Coconino County are to assist elderly and/or persons with physical disabilities to remain as
independent as possible.
11.2.3 Services in Yavapai County are to assist persons in accessing, employment, social services, medical and
basic needs.
11,2.4 Services in Navajo County are to assist persons in accessing, employment, social services, medical and
basic needs.
11.3 Service Requirements — The Contractor shall:
11.3.1 Contractors that transport clients:
1. Maintain valid license plates on vehicles used to transport clients.
2. Utilize vehicles that meet current federal, state and local safety and maintenance, standards,
including vehicles for individuals with special needs, where applicable.
3. Maintain logs on all vehicles used for the transportation of clients.
4. Utilize paid and/or volunteer drivers that:
(i) have no history of felony convictions;
(ii) possess a valid State of Arizona Class D Operators Driver's License for vehicles up to fifteen (15)
passengers;
(iii) possess a valid State of Arizona Class B Commercial Driver's License with a passenger
endorsement for vehicles over fifteen passengers, such as a bus;
(iv) have a clean driving record with no suspensions within the past year;
(v) are at least eighteen years of age; and
(vi) pass a physical prior to providing transportation service to clients and pass a physical at least
every two years.
5. Require volunteers who provide transportation to carry a Contractor/Company Identification Card.
6. Assist clients in entering and exiting the vehicle as needed.
7. Transport clients to scheduled appointments on time and safely.
8. Utilize vehicles that have seat belts for every occupant.
9. Require drivers to verify all occupants utilize seatbelts during transport.
10. Track the beginning and ending odometer readings of Contractors' vehicles on days when used to
transport clients, and identify the clients/households served on each date.
11.3.2 Contractors that arrange transportation for clients shall:
1. Make arrangements for client transportation through public or private providers.
2. Make transportation arrangements for clients to arrive at scheduled appointments on time and safely.
11.4 Program Reporting Requirements — The Contractor shall:
11.4.1 Submit the following report as may be amended, for the timeframes indicated as may be amended, by the
ADES Community Services Program Administrator through written notification to the Contractor:
Page 10 of 11
2/13/16

1, Monthly Transportation Report to include at a minimum: the number of clients served, the number of
one-way trips (e.g., from client's home to client's work), total number of miles driven to transport
clients, and results of any client satisfaction research.
Page 11 of 11
2/13/15

TERMS AND CONDITIONS
'1.0 Contract Term and Option to Extend
1.1 The term of the resultant Contract shall be effective the date specified on the Contract Signature page and
shall remain in effect for five (5) years or otherwise specified date, unless terminated, cancelled, or
extended as otherwise provided herein.
1.2 The State has no obligation to extend or renew this Contract However, this Contract may be extended or
renewed for multiple periods, or may be established as a multi-year Contract in its entirety or in part at the
sole option of the State.
1.3 The Contractor shall not provide services prior to Contract term commencing or after the end date of the
Contract. (No billable activity outside of the effective dates).
2.0 Definitions
2.1 "Attachment" means any item the Solicitation requires the Offeror to submit as part of the Offer.
2.2 "Award Date" means the date the Contract is executed by the Department. This may or may not be the
same date at the "Effective Date" which is the date specified on the Offer and Award or Signature page.
2.3 "Contract" means the combination of the Request for Applications, Instructions to Applicants, Terms and
Conditions, Scope of Work, Attachments, and Contract Amendments.
2.4 "Contract Amendment" means a written document signed by the Procurement Officer that is issued for the
purpose of making changes in the Contract.
2.5 "Contractor" means any person who has a Contract with the State.
2.6 "Days" means calendar days unless otherwise specified.
2.7 "Department" means the Arizona Department of Economic Security or ADES, unless otherwise indicated.
2.8 "Effective Date" means the date the Contractor is to start delivering services. The Effective Date is
specified on the Offer and Award or Signature page.
2.9 "Equipment" means all vehicles, furniture, machinery, electronic data processing (EDP) equipment,
software and all other equipment costing $5,000.00 or more, including all normal and necessary expenses
incurred to make the equipment ready for its intended use (e.g., axes, freight, installation, assembly and
testing charges, etc.), and with a useful life of greater than one year. Equipment as used herein does not
include real property (e.g., land, building, structures, or facilities' improvements).
2.10 'Exhibit" means any item labeled as an Exhibit.
2.11 "Gratuity" means a payment, loan, subscription, advance, deposit of money, services, or anything of more
than nominal value, present or promised, unless consideration of substantially equal or greater value is
received.
2.12 "Materials" means all property, including equipment, supplies, printing, insurance and leases of property but
does not include land, a permanent interest in land or real property or leasing space.
2.13 "May" indicates something that is not mandatory but permissible.
2.14 "Procurement Officer" means the person, or his or her designee, duly authorized by the State to enter into
and administer Contracts and make written determinations with respect to the Contract.
2.15 "Services" means the furnishing of labor, time or effort by a Contractor or subcontractor which does not
involve the delivery of a specific end product other than required reports and performance, but does not
include employment agreements or collective bargaining agreements,
2.16 "Shall, Must" indicates a mandatory requirement.
2.17 'Should" indicates something that is recommended but not mandatory. If the Contractor fails to provide
recommended information, the State may, at its sole option, ask the Contractor to provide the information.
2.18 "Subcontract" means any Contract, expressed or implied, between the Contractor and another party or
between a subcontractor and another party delegating or assigning, in whole or in part, the making or
furnishing of any material or any service required for the performance of the Contract.
2.19 "State" means the State of Arizona and Department or Agency of the State that executes the Contract.
2.20 "State Fiscal Year" means the period beginning with July 1 and ending June 30.
2.21 "Vulnerable adult" means an individual who is eighteen years of age or older who is unable to protect
himself from abuse, neglect or exploitation by others because of a physical or mental impairment.
3.0 Advertising, Publishing and Promotion of Contract
3.1 The Contractor shall provide to the Department for review and approval all reports or publications (written,
visual or sound) that are funded or partially funded under this Contract, a minimum of fifteen (15) calendar
days prior to public release. All reports and publications whether written, visual or verbal shall contain the
following statement: "This program was funded through a Contract with the Arizona Department of
Page 1 o1 21 Rev. 3/24/15
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Economic Security. Points of view are those of the author and do not necessarily represent the official
position or policies of the Department."
3.2 The Contractor shall not use, advertise or promote information for commercial benefit concerning this
Contract without the prior written approval of the Procurement Officer.
4.0 Amendments or Modifications
4.1 This Contract may be amended or modified at any time by mutual agreement. No agent, employee or other
representative of either party is empowered to alter any of the terms of the Contract, unless done in writing
and signed by the authorized representative of the respective parties.
4.2 Either party shall give written notice to the other party of any non-material alteration that affects the
provisions of this Contract Non-material alterations that do not require a written amendment are as
follows:
4.2.1 Change of telephone number;
4.2.2 Change in authorized signatory; and/or
4.2.3 Change in the name and/or address of the person to whom notices are to be sent.
4.3 This Contract is issued under the authority of the Procurement Officer who signed this Contract. The
Contract may be modified only through a Contract Amendment within the scope of the Contract. Changes
to the Contract, including the addition of work or materials, the revision of payment terms, or the
substitution of work or materials, directed by a person who is not specifically authorized by the
Procurement Officer in writing or made unilaterally by the Contractor are violations of the Contract and of
applicable law. Such changes, including unauthorized written Contract Amendments shall be void and
without effect, and the Contractor shall not be entitled to any claim under this Contract based on those
changes.
5.0 Applicable Law
5.1 This Contract shall be governed and interpreted by the laws of the State of Arizona.
5.2 The materials and services supplied under this Contract shall comply with all applicable Federal, state and
local laws, and the Contractor shall maintain all applicable license and permit requirements.
5.3 Nothing in this Contract shall be construed as a waiver of an Indian tribe's sovereign immunity; nothing
shall be construed as an Indian tribe's consent to be sued or as consent by an Indian tribe to the jurisdiction
of any State Court.
5.4 The Contractor shall comply with the requirements related to reporting to a peace officer or child protective
services incidents of crimes against children as specified in A.R.S. §13-3620 as may be amended.
5.5 The Contractor shall comply with P.L. 101-121, Section 319 (31 U.S.C. section 1352) as may be amended
and 29 C.F.R. Part 93 as may be amended which prohibit the use of federal funds for lobbying and which
state, in part: Except with the express authorization of Congress, the Contractor, its employees or agents,
shall not utilize any federal funds under the terms of this Contract to solicit or influence, or to attempt to
solicit or influence, directly or indirectly, any member of Congress regarding pending or prospective
legislation. Indian tribes, tribal organizations and any other Indian organizations are exempt from these
lobbying restrictions with respect to expenditures that are specifically permitted by other federal law.
5.6 The Contractor shall comply with all applicable state and federal statutes and regulations. This shall include
A.R.S. § 23-722.01 as may be amended relating to new hire reporting, A.R.S. § 23-722.02 as may be
amended relating to wage assignment orders to provide child support, and A.R.S. § 25-535 as may be
amended relating to administrative or court-ordered health insurance coverage for children.
5.7 The Arizona law applies to this Contract including, where applicable, the Uniform Commercial Code as
adopted by the State of Arizona and the Arizona Procurement Code, Arizona Revised Statutes (A.R.S.)
Title 41, Chapter 23, and its implementing rules, Arizona Administrative Code (A.A.C.) Title 2, Chapter 7.
5.8 Each provision of law and any terms required by law to be in this Contract are a part of this Contract as if
fully stated in it.
5.9 The Contractor shall comply with P. L. 105-285, Section 678F(a) which prohibits the use of funds for the
purchase of improvement of land, or purchase, construction or permanent improvement (other than low-
cost residential weatherization or other energy-related home repairs) of any building or other facility.
5.10 The Contractor shall comply with P.L. 105-285, Section 678F(b) which prohibits the use of CSBG funds for
the provision of services or the employment or assignment of personnel in a manner supporting any bi-
partisan or non-partisan political activity or any political activity associated with a candidate, or contending
faction or group, in an election for public or party office; any activity to provide transportation to the polls or
similar assistance in connection with and such election, any voter registration activity.
Page 2 of 21 Rev. 3/24/15
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6.0 Arbitration
6.1 The parties to this Contract agree to resolve all disputes arising out of or relating to this Contract through
arbitration, after exhausting applicable administrative review, to the extent required by A.R.S. §12-1518,
except as may be required by other applicable statutes (Title 41).
7.0 Assignment and Delegation
7.1 The Contractor shall not assign any right nor delegate any duty under this Contract without the prior written
approval of the Procurement Officer. The State shall not unreasonably withhold approval,
8.0 Audit
8.1 In accordance with A.R.S. § 35-214, the Contractor shall retain and shall contractually require each
subcontractor to retain all data, books and other records ("records") relating to this Contract for a period of
five years after completion of the Contract. All records shall be subject to inspection and audit by the State
at reasonable times. Upon request, the Contractor shall produce the original of any or all such records.
8.2 In compliance with the Federal Single Audit Act (31 U.S.C, Sections 7501-7507 as may be amended),
Contractors designated as subrecipients, as described in the Office of Management and Budget (OMB)
Circular A-133, expending Federal funds from all sources totaling $500,000 or more, shall have a yearly
audit conducted in accordance with the audit and reporting standards as prescribed in OMB Circular A-133
(A-133) as may be amended. As outlined in A-133 the audit Reporting Package shall include:
8.2.1 Financial statements and a Schedule of Expenditures of Federal Awards (SEFA)
8.2,2 Summary schedule of prior audit findings
8.2.3 Auditor's Reports (detailed in the A-133)
8.2.4 Corrective Action Plan.
8.3 The Department's Contract numbers and award amounts shall be included on the SEFA. A copy of the
Single Audit Reporting Package and Management Letter, if issued, shall be submitted to the Department's
Office of Audit and Management Services within thirty (30) days after completion of the audit or nine (9)
months after the audited period and to the Department's person designated to receive notices as specified
in the section 7.0 General Reporting Requirements in the Scope of Work.
8.4 All Contractors are subject to the programmatic and fiscal monitoring requirements of each Department
program to ensure accountability of the delivery of all goods and services, as required under the Federal
Single Audit Act. A minimum fiscal requirement for all Contractors designated as vendors is an annual
financial audit which includes Department Contract numbers and award amounts. The Audit Report,
Management Letter, if issued, and Auditor's Opinion shall be submitted within thirty (30) days after
completion of the audit to the Department's person designated to receive notices as specified in the
Reports Section in the Scope of Work.
8.5 As prescribed in OMB Circular A-133, for-profit subrecipients are subject to compliance requirements
established by the Department. Methods to ensure compliance for Federal awards made to for-profit
subrecipients may include pre-award audits, Department monitoring during the Contract, and post-award
audits.
8.6 Audits of non-profit corporations receiving Federal or State monies required pursuant to Federal or State
law shall be conducted as provided in 31 U.S.C. Section 7501 et seq. and A.R.S. Section 35-181.03 as
may be amended and any other applicable statutes, rules, regulations and standards.
9.0 Availability of Funds
9.1 The Department may reduce payments or terminate this Contract without further recourse, obligation or
penalty in the event that insufficient funds are appropriated or allocated. The Director of the Department
shall have the sole and unfettered discretion in determining the availability of funds. The Department and
the Contractor may mutually agree to reduce reimbursement to the Contractor when the payment type is
Fixed Price with Price Adjustment by executing a contract amendment
9.2 Availability of Funds for the Current State Fiscal Year
9.2,1 Should the State Legislature enter back into session and reduce the appropriations or for any reason and
these goods or services are not funded, the ADES may take any of the following actions without further
recourse obligation or penalty:
9.2.2 Reduce payments or units authorized;
9.2.3 Accept a decrease in price offered by the Contractor;
9.2.4 Cancel the Contract; or
9.2.5 Cancel the Contract and re-solicit the requirements.
9.3 Availability of Funds for the Next State Fiscal Year
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9.3.1 Funds may not presently be available for performance under this Contract beyond the current state fiscal
year. No legal liability on the part of the State for any payment may arise under this Contract beyond the
current state fiscal year until funds are made available for performance of this Contract.
10.0 Background Checks for Employment through the Central Registry If providing direct services to
children or vulnerable adults, the following shall apply:
10.1 The provisions of A.R.S. § 8-804 (as may be amended) are hereby incorporated in its entirety as provisions
of this Contract.
10.2 The Department will conduct Central Registry Background Checks and will use the information contained in
the Central Registry as a factor to determine qualifications for positions that provide direct service to
children or vulnerable adults for:
1. Any person who applies for a contract with this State and that person's employees;
2. All employees of a Contractor;
3. A subcontractor of a Contractor and the subcontractor's employees; and
4. Prospective employees of the Contractor or subcontractor at the request of the prospective employer.
10.3 Volunteers who provide direct services to children or vulnerable adults shall have a Central Registry
Background Check which is to be used as a factor to determine qualifications for volunteer positions.
10.4 1. A person who is disqualified because of a Central Registry Background Check may apply to the
Board of Fingerprinting for a Central Registry exception pursuant to A.R.S. § 41-619.57. A person
who is granted a Central Registry exception pursuant to A.R.S. § 41-619.57 is not entitled to a
Contract, employment, licensure, certification or other benefit because the person has been
granted a Central Registry exception,
2. Before being employed or volunteering in a position that provides direct services to children or
vulnerable adults, persons shall certify on forms that are provided by the Department whether an
allegation of abuse or neglect was made against them and was substantiated. The completed
forms are to be maintained as confidential.
10.5 A person awaiting receipt of the Central Registry Background Check may provide direct services to ADES
clients after completion and submittal of the Direct Service Position certification form if the certification
states:
1. The person is not currently the subject of an investigation of child abuse or neglect in Arizona or
another state or jurisdiction; and
2. The person has not been the subject of an investigation of child abuse or neglect in Arizona, or
another state or jurisdiction, which resulted in a substantiated finding. The Certification for Direct
Service Position is located at:
https://vvww.azdes.govilnternetFiles/InternetProorammaticForms/doc/ACY-1287AFORFF.doc.
10.6 If the Central Registry Background Check specifies any disqualifying act and the person does not have a
Central Registry exception, the person shall be prohibited from providing direct services to ADES clients.
10.7 The Contractor shall maintain the Central Registry Background Check results and any related forms or
documents in a confidential file for five (5) years after termination of the Contract. The Request for Search
of Central Registry for Background Check form is located at https://vvww.azdes.aov/ooac.
11.0 Cancellation for Conflict of Interest
11.1 Pursuant to A.R.S. § 38-511, the State may cancel this Contract within three (3) years after Contract
execution without penalty or further obligation if any person significantly involved in initiating, negotiating,
securing, drafting or creating the Contract on behalf of the State is or becomes at any time while the
Contract or an extension of the Contract is in effect an employee of or a consultant to any other party to this
Contract with respect to the subject matter of the Contract. The cancellation shall be effective when the
Contractor receives written notice of the cancellation unless the notice specifies a later time. if the
Contractor is a political subdivision of the State, it may also cancel this Contract as provided in A.R.S.
§ 38-511.
12.0 Certification of Cost or Pricing Data
12.1 The Contractor certifies that, to the best of the Contractor's knowledge and belief, any cost or pricing data
submitted is accurate, complete and current as of the date submitted or other mutually agreed upon date.
Furthermore, the price to the State shall be adjusted to exclude any significant amounts by which the State
finds the price was increased because the Contractor-furnished cost or pricing data was inaccurate,
incomplete or not current as of the date of submittal. Such adjustment by the State may include overhead,
profit or fees.
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13.0 Certification Regarding Lobbying
13.1 The Contractor agrees by submittal of the Certification Regarding Lobbying form, compliance with
49 CFR part 20. (Attachment)
14.0 Code of Conduct
14.1 The Contractor shall avoid any action that might create or result in the appearance of:
14.1.1 Inappropriate use or divulging of information gathered or discovered pursuant to the performance of its
duties under the Contract;
14.1.2 Acting on behalf of the State without appropriate authorization;
14.1.3 Provided favorable or unfavorable treatment to anyone;
14.1.4 Made a decision on behalf of the State that exceeded its authority, could result in partiality, or have a
political consequence for the State;
14.1.5 Misrepresent or otherwise impeded the efficiency, authority, actions, policies, or adversely affect the
confidence of the public or integrity of the State; or
14.1.6 Loss of impartiality when advising the State.
15.0 Competitive Bidding
15.1 The Contractor is authorized to purchase the supplies and equipment itemized in the Contract for utilization
in the delivery of contract services. Contractor shall procure all such supplies and equipment at the lowest
practicable cost and shall purchase all non-expendable items having a useful life of more than one year
and an acquisition cost of $1,000 or more, through generally accepted and reasonable competitive bidding
processes. Any procurement in violation of this provision shall be considered a financial audit exception.
16.0 Confidentiality
16.1 The Contractor shall observe and abide by all applicable State and federal statutes, rules and regulations
regarding the use or disclosure of information including, but not limited to, information concerning
applicants for and recipients of contract services. To the extent permitted by law, the Contractor shall
release information to the Department and to the Attorney General's Office as required by the terms of this
contract, by law or upon their request.
16.2 The Contractor shall comply with the requirements of Arizona Address Confidentiality Program, A.R.S. §41-
161 et. seq. The Arizona Department of Economic Security will advise the Contractor as to applicable
policies and procedures the Arizona Department of Economic Security has adopted for such compliance.
17.0 Cooperation
17.1 The Department may undertake or award other contracts for additional work related to the work performed
by the Contractor, and the Contractor shall fully cooperate with such other Contractors and State
employees, and carefully fit its own work to such other Contractors' work. The Contractor shall not commit
or permit any act which will interfere with the performance of work by any other Contractor or by State
employees. The Contractor shall cooperate as the State deems necessary, with the transfer of work,
services, case records and files performed or prepared by the Contractor to other Contractor(s).
18.0 Cooperation with the Department's investigation
18.1 All contractors, providers, vendors and volunteers are to cooperate fully and truthfully with any ADES
investigation, including but not limited to an Investigation by Division or Internal Affairs. Failure to adhere to
this policy may result in ADES taking whatever actions it deems appropriate, from removal of the subject
and or witness from working with ADES clients up to terminating the contract with ADES.
19.0 Data Sharing Agreement
19.1 When determined by the Department that sharing of confidential data will occur with the Contractor, the
Contractor shall complete the ADES Data Sharing Request Agreement and submit the completed
Agreement to the ADES Program Designated Staff prior to any work commencing or data shared. A
separate Data Sharing Request Agreement shall be required between the Contractor and each ADES
Program sharing confidential data.
20.0 Equipment
20.1 If the Contractor is authorized to purchase Equipment, it shall be itemized in the Contract for utilization in
the delivery of contract services. If Equipment is purchased as authorized by this Contract, the Contractor
shall maintain complete and up-to-date inventory records for all Equipment purchased hereunder.
Page 5 of 21 Rev. 3/24/15
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Equipment specifically designated within this Contract, to be purchased in whole or part with the
Department funds, shall be reported in accordance with Department inventory policies and procedures.
The Contractor shall report Equipment purchased with contract funds to the Department within thirty (30)
days of purchase, perform an annual inventory of all equipment purchased with Department funds and
submit the Equipment inventory form to the Department person designated to receive notices.
20.2 The Department shall retain an equitable interest equal to the purchase price paid, or a fair estimate or
appraisal of current market value, whichever is greater, in all Equipment purchased under this Contract.
The Department shall be included as a co-insured on any insurance policy which covers Equipment
purchased under this Contract.
20.3 The Contractor shall not dispose of any Equipment purchased under this Contract without the prior written
consent of the Department during and after the contract term. Such consent, if given, may include direction
as to the means of disposition and the utilization of proceeds, including any necessary adjustments to the
contract
20.4 Upon termination of this Contract, any Equipment purchased under this Contract shall be disposed of as
directed by the Department and, if sold, the Department shall be compensated in the amount of its
equitable interest.
20.5 Under a fixed price contract, Sections 20.1 through 20.4 do not apply unless specifically required by federal
or state law.
21.0 Evaluation
21.1 The Department may evaluate, and the Contractor shall cooperate in the evaluation of, contract services.
Evaluation may assess the quality and impact of contract services, either in isolation or in comparison with
other similar services, and assess the Contractor's progress and/or success in achieving the goals,
objectives and deliverables set forth in this Contract.
21.2 As requested by the Department, the Contractor shall participate in third party evaluations relative to
contract impact in support of Department goals.
22.0 E-Verify Requirements
22.1 In accordance with ARS §41-4401 as may be amended, Contractor warrants compliance with all Federal
immigration laws and regulations relating to employees and warrants its compliance with Section A.R.S.
§ 23-214, Subsection A as may be amended. (That subsection reads: "After December 31, 2007, every
employer, after hiring an employee, shall verify the employment eligibility of the employee through the E-
Verify program.")
22.2 A breach of a warrant regarding compliance with immigration laws and regulations shall be deemed a
material breach of the contract and the Contractor may be subject to penalties up to and including
termination of the Contract.
22.3 Failure to comply with a State audit process to randomly verify the employment records of Contractors and
subcontractors shall be deemed a material breach of the contract and the Contractor may be subject to
penalties up to and including termination of the contract
22.4 The Department retains the legal right to inspect the papers of any employee who works on the Contract to
ensure that the Contractor or subcontractor is complying with the warranty under paragraph 22.2.
23.0 Fair Hearings and Service Recipients' Grievances
23.1 The Contractor shall advise all applicants for and recipients of contract services of their right, at any time
and for any reason, to present to the Contractor and to the Department any grievances arising from the
delivery of contract services, including, but not limited to, ineligibility determination, reduction of services,
suspension or termination of services, or quality of services. The Department may assert its jurisdiction to
hear the grievance or refer the matter to the appropriate authority.
23.2 The Contractor, whenever authorized by law, shall maintain a formal system acceptable to and approved
by the Department for reviewing and adjudicating grievances by service recipients or subcontractors arising
from this contract.
24.0 Federal Immigration and Nationality Act
24.1 The Contractor warrants compliance with the Federal Immigration and Nationality Act (FINA) and all other
Federal immigration laws and regulations related to the immigration status of its employees. The
Contractor shall flow down this requirement to all subcontractors utilized during the term of the contract.
The State shall retain the right to perform random audits of Contractor and subcontractor records or to
inspect papers of any employee thereof to ensure compliance. The Contractor shall obtain statements
from its subcontractors certifying compliance and shall furnish the statements to the ADES upon request.
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These warranties shall remain in effect through the term of the Contract. The Contractor and its
subcontractors shall also maintain Employment Eligibility Verification forms (1-9) as required by the U.S.
Department of Labor's Immigration and Control Act, for all employees performing work under the Contract.
1-9 forms are available for download at USCIS.GOV .
24.2 The State may request verification of compliance for any Contractor or subcontractor performing work
under the Contract. Should the State determine that the Contractor or any subcontractors be found
noncompliant, the State may pursue all remedies allowed by law, including, but not limited to suspension of
work, termination of the contract for default and suspension and/or debarment of the Contractor.
25.0 Fees and Program Income
25.1 Unless specifically authorized in the Contract, the Contractor shall impose no fees or charges of any kind
upon recipients for contract services.
26.0 Fingerprinting
26.1 Contractor shall comply with, and shall ensure that all of Contractor's employees, independent contractors,
subcontractors, volunteers and other agents comply with, all applicable (current and future) legal
requirements relating to fingerprinting, fingerprint clearance cards, certifications regarding pending or past
criminal matters, and criminal records checks that relate to contract performance.
26.2 Applicable legal requirements relating to fingerprinting, certification, and criminal background checks may
include, but are not limited, to the following: A.R.S. §§ 36-594.01, 36-3008, 41-1964, and 46-141. All
applicable legal requirements relating to fingerprinting, fingerprint clearance cards, certifications regarding
pending or past criminal matters, and criminal records checks are hereby incorporated in their entirety as
provisions of this Contract. The Contractor is responsible for knowing which legal requirements relating to
fingerprinting, fingerprint clearance cards, certifications regarding pending or past criminal matters, and
criminal records checks relate to contract performance.
26.3 To the extent A.R.S. § 46-141 is applicable to contract performance or the services provided under this
Contract, the following provisions apply:
26.3.1 Personnel who are employed by the Contractor, whether paid or not, and who are required or allowed to
provide services directly to juveniles or vulnerable adults shall have a valid fingerprint clearance card or
shall apply for a fingerprint clearance card within seven working days of employment.
26.3.2 Except as provided in A.R.S. § 46-141, this Contract may be cancelled or terminated immediately if a
person employed by the Contractor and who has contact with juveniles certifies pursuant to the provisions
of A.R.S. § 46-141 (as may be amended) that the person is awaiting trial or has been convicted of any of
the offenses listed therein in this State, or of acts committed in another state that would be offenses in this
State, or if the person does not possess or is denied issuance of a valid fingerprint clearance card.
26.4 Federally recognized Indian tribes will submit and the Department of Economic Security shall accept
certifications that state that no personnel who are employed or who will be employed during the contract
term have been convicted of, have admitted committing or are awaiting trial on any offense as described in
A.R.S. § 36-594.01 (as may be amended).
27.0 Force Majeure
27.1 Except for payment of sums due, neither party shall be liable to the other nor deemed in default under this
Contract if and to the extent that such party's performance of this Contract is prevented by reason of force
majeure. The term 'force majeure" means an occurrence that is beyond the control of the party affected
and occurs without its fault or negligence. Without limiting the foregoing, force majeure includes acts of
God; acts of the public enemy; war; riots; strikes; mobilization; labor disputes; civil disorders; fire; flood;
lockouts; injunctions-intervention-acts; or failures or refusals to act by government authority; and other
similar occurrences beyond the control of the party declaring force majeure which such party is unable to
prevent by exercising reasonable diligence.
27.2 Force Majeure shall not include the following occurrences:
27.2.1 Late delivery of equipment or materials caused by congestion at a manufacturer's plant or elsewhere, or an
oversold condition of the market;
27.2.2 Late performance by a subcontractor unless the delay arises out of a force majeure occurrence in
accordance with this force majeure term and condition; or
27.2.3 Inability of either the Contractor or any subcontractor to acquire or maintain any required insurance, bonds,
licenses or permits.
27.3 If either party is delayed at any time in the progress of the work by force majeure, the delayed party shall
notify the other party in writing of such delay, as soon as is practicable and no later than the following
working day, of the commencement thereof and shall specify the causes of such delay in such notice.
Such notice shall be delivered or mailed certified-return receipt and shall make a specific reference to this
Page 7 of 21 Rev. 3124/15
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article, thereby invoking its provisions. The delayed party shall cause such delay to cease as soon as
practicable and shall notify the other party in writing when it has done so. The time of completion shall be
extended by Contract Amendment for a period of time equal to the time that results or effects of such delay
prevent the delayed party from performing in accordance with this Contract.
27.4 Any delay or failure in performance by either party hereto shall not constitute default hereunder or give rise
to any claim for damages or loss of anticipated profits if, and to the extent that such delay or failure is
caused by force majeure.
28.0 Inclusive Contractor
28.1 Contractor is encouraged to make every effort to utilize subcontractors that are small, women-owned
and/or minority owned business enterprises. This could include subcontractors for a percentage of the
administrative or direct service being proposed. Contractor who is committing a portion of its work to such
subcontractors shall do so by identifying the type of service and work to be performed by providing detail
concerning the Contractor's utilization of small, women-owned and/or minority business enterprises.
Emphasis should be placed on specific areas that are subcontracted and percentage of contract utilization
and how this effort will be administered and managed, including reporting requirements.
29.0 Indemnification
29.1 Indemnification for Contractor:
29.1.1 Contractor/Vendor Indemnification (Not Public Agency) The parties to this Contract agree that the State of
Arizona, its departments, agencies, boards and commissions shall be indemnified and held harmless by
the Contractor for the vicarious liability of the State as a result of entering into this Contract. However, the
parties further agree that the State of Arizona, its departments, agencies, boards and commissions shall be
responsible for its own negligence. Each party to this Contract is responsible for its own negligence.
29.1.2 Public Agency Language Only Each Party (as "I ndemnitor") agrees to indemnify, defend, and hold
harmless the other party (as "Indemnitee") from and against any and all claims, losses, liability, costs, or
expenses (including reasonable attorney's fees) (hereinafter collectively referred to as "Claims") arising out
of bodily injury of any person (including death) or property damage, but only to the extent that such Claims
which result in vicarious/derivative liability to the Indemnitee are caused by the act, omission, negligence,
misconduct, or other fault of the Indemnitor, its officers, officials, agents, employees, or volunteers.
29.1.3 Indemnification - Patent and Copyright The Contractor shall indemnify and hold harmless the State against
any liability, including costs and expenses, for infringement of any patent, trademark or copyright arising
out of contract performance or use by the State of materials furnished or work performed under this
Contract. The State shall reasonably notify the Contractor of any claim for which it may be liable under this
paragraph. If the Contractor is insured pursuant to A.R.S. § 41-621 and § 35-154, this section shall not
apply,
29.2 Indemnification Clause:
29.2.1 The parties to this Contract agree that the State of Arizona and the Department of Economic Security shall
be indemnified and held harmless by Contractor for the vicarious liability of the State as a result of entering
into this Contract. However, the parties further agree that the State of Arizona and the Department of
Economic Security shall be responsible for their own negligence. Each party to this Contract is responsible
for its own negligence.
This indemnity shall not apply if the Contractor or sub-contractor(s) is/are an agency, board, commission or
university of the State of Arizona.
29.3 Indemnification for Subcontractor:
29.3.1 In addition, the Contractor shall cause its Contractor(s) and subcontractors, if any, to indemnify, defend,
save and hold harmless the State of Arizona, any jurisdiction or agency issuing any permits for any work
arising out of this Agreement, and their respective directors, officers, officials, agents, and employees
(hereinafter referred to as "Indemnitee") from and against any and all claims, actions, liabilities, damages,
losses, or expenses (including court costs, attorneys' fees, and costs of claim processing, investigation and
litigation) (hereinafter referred to as "Claims") for bodily injury or personal injury (including death), or loss or
damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the
negligent or willful acts or omissions of the Contractor or any of the directors, officers, agents, or
employees or subcontractors of such Contractor. This indemnity includes any claim or amount arising out
of or recovered under the Workers' Compensation Law or arising out of the failure of such Contractor to
conform to any federal, state or local law, statute, ordinance, rule, regulation or court decree. It is the
specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely
from the negligent or willful acts or omissions of the Indemnitee, be indemnified by such Contractor from
and against any and all claims. It is agreed that such Contractor will be responsible for primary loss
investigation, defense and judgment costs where this indemnification is applicable.
Page 8 of 21 Rev. 3/24/15
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30.0 Insurance Requirements
30.1 Contractor and subcontractors shall procure and maintain until all of their obligations have been
discharged, including any warranty periods under this Contract, are satisfied, insurance against claims for
injury to persons or damage to property which may arise from or in connection with the performance of the
work hereunder by the Contractor, his agents, representatives, employees or subcontractors.
30.2 The insurance requirements herein are minimum requirements for this Contract and in no way limit the
indemnity covenants contained in this Contract The State of Arizona in no way warrants that the minimum
limits contained herein are sufficient to protect the Contractor from liabilities that might arise out of the
performance of the work under this Contract by the Contractor, its agents, representatives, employees or
subcontractors, and Contractor is free to purchase additional insurance.
A. Minimum Scope And Limits Of Insurance: Contractor shall provide coverage with limits of
liability not less than those stated below.
1 Commercial General Liability Occurrence Form
Policy shall include bodily injury, property damage, personal injury and broad
form contractual liability.
• General Aggregate $2,000,000
• Products — Completed Operations Aggregate $1,000,000
• Personal and Advertising Injury $1,000,000
• Blanket Contractual Liability Written and Oral $1,000,000
• Fire Legal Liability $ 50,000
• Each Occurrence $1,000,000
a. The policy shall be endorsed to include coverage for sexual abuse
and molestation.
b. The policy shall be endorsed to include the following additional insured
language: "The State of Arizona and the Department of Economic
Security shall be named as additional insureds with respect to
liability arising out of the activities performed by or on behalf of the
Contractor".
c. Policy shall contain a waiver of subrogation against the State of Arizona,
its departments, agencies, boards, commissions, universities and its
officers, officials, agents, and employees for losses arising from work
performed by or on behalf of the Contractor.
This requirement may be satisfied with a policy combining General and
Professional Liability, provided that the General Liability section of the policy
is written on an occurrence basis, and includes coverage for contractual
liability.
2. Business Automobile Liability
Bodily Injury and Property Damage for any owned, hired, and/or non-owned
vehicles used in the performance of this Contract.
Combined Single Limit (CSL) $1,000,000
a. The policy shall be endorsed to include the following additional insured
language: "The State of Arizona and the Arizona Department of
Economic Security shall be named as additional insureds with
respect to liability arising out of the activities performed by or on
behalf of the Contractor, involving automobiles owned, leased,
hired or borrowed by the Contractor".
b. Policy shall contain a waiver of subrogation against the State of Arizona,
its departments, agencies, boards, commissions, universities and its
officers, officials, agents, and employees for losses arising from work
performed by or on behalf of the Contractor.
c. This paragraph, Business Automobile Liability, shall not be applicable
in the event Contractor (or its Subcontractors) does not utilize a vehicle
in any manner in the performance of this Contract or if the utilization is
Page 9 of 21 Rev. 3/24/15
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used only for commuting purposes. In the event Contractor (or its
Subcontractors) subsequently utilizes the vehicle in the performance of
the Contract or utilizes it for other than commuting purposes, this
paragraph, Business Automobile Liability, shall be fully applicable,
effective the date the utilization is changed.
3. Worker's Compensation and Employer& Liability
• Workers' Compensation Statutory
• Employers' Liability
• Each Accident $ 500,000
• Disease — Each Employee $ 500,000
• Disease — Policy Limit $1,000,000
a. Policy shall contain a waiver of subrogation against the State of
Arizona, its departments, agencies, boards, commissions, universities
and its officers, officials, agents, and employees for losses arising from
work performed by or on behalf of the Contractor.
b. This requirement shall not apply to: Separately, EACH Contractor or
subcontractor exempt under A.R.S. 23-901, AND when such Contractor
or subcontractor executes the appropriate waiver (Sole
Proprietor/Independent Contractor) form.
4. Professional Liability (Errors and Omissions Liability)
Each Claim $1,000,000
Annual Aggregate $2,000,000
a. In the event that the professional liability insurance required by this
Contract is written on a claims-made basis, Contractor warrants that
any retroactive date under the policy shall precede the effective date of
this Contract; and that either continuous coverage will be maintained or
an extended discovery period will be exercised for a period of two (2)
years beginning at the time work under this Contract is completed.
b. The policy shall cover professional misconduct or lack of ordinary skill
for those positions defined in the Scope of Work of this Contract,
B. Additional Insurance Requirements: The policies shall include, or be endorsed to
include, the following provisions: The State of Arizona and the Arizona Department of
Economic Security, wherever additional insured status is required such additional
insured shall be covered to the full limits of liability purchased by the Contractor, even
if those limits of liability are in excess of those required by this Contract.
1. The Contractor's insurance coverage shall be primary insurance with respect to all other
available sources.
2. Coverage provided by the Contractor shall not be limited to the liability assumed under
the indemnification provisions of this Contract.
C. Notice Of Cancellation: Each insurance policy required by the insurance provisions of this
Contract shall provide the required coverage and shall not be suspended, voided, canceled, or
reduced in coverage or in limits except after thirty (30) days prior written notice has been given to
the State of Arizona. Such notice shall be sent directly to the Arizona Department of Economic
Security, Office of Procurement, 1789W. Jefferson St. Site Code 805Z, Phoenix, AZ 85007
unless the Scope of Work Reporting Requirements specifies otherwise and shall be sent by
certified mail, return receipt requested.
D. Acceptability Of Insurers: Insurance is to be placed with duly licensed or approved non-admitted
insurers in the state of Arizona with an A.M. Best" rating of not less than A-VI!. The State of
Arizona in no way warrants that the above-required minimum insurer rating is sufficient to protect
the Contractor from potential insurer insolvency.
If the Contractor utilizes the Social Service Contractors Indemnity Pool (SSCIP) or other approved
insurance pool for insurance coverage, SSCIP or the other approved insurance pool is exempt
Page 10 of 21 Rev. 3/24/15
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from the A.M. Best's rating requirements listed in this Contract. If the Contractor or subcontractor
chooses to use SSCIP, AMRRP, or another approved insurance pool as its insurance provider, the
Contract/subcontract would be considered as meeting the insurance requirements relating to the
AM. Best rating requirements.
Contractors or subcontractors submitting Certificates of Insurance identifying SSCIP, AMRRP, or
another approved insurance pool will be considered as meeting the insurance requirements
including those related to sexual abuse and molestation.
E. Verification Of Coverage: Contractor shall furnish the State of Arizona with certificates of
insurance (ACORD form or equivalent approved by the State of Arizona) as required by this
Contract. The certificates for each insurance policy are to be signed by a person authorized by that
insurer to bind coverage on its behalf.
All certificates and endorsements are to be received and approved by the State of Arizona before
work commences. Each insurance policy required by this Contract must be in effect at or prior to
commencement of work under this Contract and remain in effect for the duration of the project.
Failure to maintain the insurance policies as required by this Contract, or to provide evidence of
renewal, is a material breach of contract.
All certificates required by this Contract shall be sent directly to Arizona Department of Economic
Security, Office of Procurement, 1789 W. Jefferson St. Site Code 805Z, Phoenix, AZ 85007
unless the Scope of Work Reporting Requirements specifies otherwise. The State of Arizona
contract number and contract description shall be noted or referenced on the certificate of
insurance. The State of Arizona reserves the right to require complete, certified copies of all
insurance policies required by this Contract at any time. DO NOT SEND CERTIFICATES OF
INSURANCE TO THE STATE OF ARIZONA'S RISK MANAGEMENT SECTION.
F. Subcontractors: Contractors' certificate(s) shall include all subcontractors as insureds under its
policies or Contractor shall furnish to the State of Arizona separate certificates and endorsements
for each subcontractor. All coverages for subcontractors shall be subject to the minimum
requirements identified above.
G. Approval: Any modification or variation from the insurance requirements in this Contract shall be
made by the contracting agency in consultation with the Department of Administration, Risk
Management Division. Such action will not require a formal contract amendment, but may be
made by administrative action.
H. Exceptions: In the event the Contractor or sub-contractor(s) is/are a public entity, then the
Insurance Requirements shall not apply. Such public entity shall provide a Certificate of Self-
Insurance. If the contractor or sub-contractor(s) is/are a State of Arizona agency, board,
commission, or university, none of the above shall apply.
In the event that Contractor determines that it may not be able to comply fully with the insurance
requirements set forth above in Section 30.0 of these Terms and Conditions, the Contractor may
request that the insurance requirements be modified pursuant to paragraph 30.2(G), provided that
such request be delivered in writing to ADES at least ten days prior to the solicitation due date or, if
not a solicitation, prior to contract execution. Contractor shall include with such request
Contractor's justification for the modification with supporting documentation.
As provided in paragraph 30.2(G), the Department of Administration, Risk Management Section,
shall decide whether such modification may be permitted. If the Department of Administration, Risk
Management, decides to grant permission, the ADES Chief Procurement Officer shall then decide
whether to approve the modification.
Modifications that are approved will be done so on a case-by-case basis and shall not affect the
insurance requirements of other Contractors for whom modifications have not been approved. If a
Contractor's request has not been approved or a Contractor fails to deliver its request prior to the
applicable deadline, then the Contractor shall be required to comply fully with the insurance
requirements set forth in paragraph 30.0 above.
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31.0 IT 508 Compliance
31.1 Unless specifically authorized in the Agreement, any electronic or information technology offered to the
State of Arizona under this agreement shall comply with A.R.S. § 41-3531 and § 3532 as may be
amended, and Section 508 of the Rehabilitation Act of 1973, which requires that employees and members
of the public shall have access to and use of information technology that is comparable to the access and
use by employees and members of the public who are not individuals with disabilities.
32.0 Levels of Service
32.1 If the Contractor determines service recipient eligibility, the Contractor shall maintain and regulate services
set forth in this Contract to ensure continuity and availability of services to eligible persons during the term
of this Contract and during any transition to a subsequent Contractor.
32.2 The Department makes no guarantee to purchase specific quantities of goods or services, or to refer
eligible persons as may be identified or specified herein. Further, it is understood and agreed that this
Contract is for the sole convenience of the Department and that the Department reserves the right to obtain
like goods or services from other sources when such need is determined necessary by the Department.
32.3 Any administration within the Department may obtain services under this Contract.
32.4 Contract services may be moved or expanded to other site locations within the geographic area awarded
only by a written contract amendment.
32.5 The Department makes no guarantee to purchase all of the service units authorized or to provide any
number of referrals. If quantities of units are specified, they are estimates only and the Department may
decrease and/or increase them by providing written notice to the Contractor.
32.6 When the method of compensation for the service is Fixed Price with Price Adjustment, the contract may
be amended, by mutual agreement, to purchase additional services by increasing the contract service
budget and/or budget summary.
33.0 Monitoring
33.1 The Department may monitor the Contractor and/or subcontractor and they shall cooperate in the
monitoring of services delivered, facilities and records maintained and fiscal practices.
34.0 Non-Discrimination
34.1 The Contractor shall comply with State Executive Order No. 2009-09 and all other applicable Federal and
State laws, rules and regulations, including the Americans with Disabilities Act.
34.2 Unless exempt under Federal law the Contractor shall comply with Title VII of the Civil Rights Act of 1964
as amended. Contractor shall comply with the Age Discrimination in Employment Act. The Contractor
shall comply with the Rehabilitation Act of 1973, as amended, which prohibits discrimination in the
employment or advancement in employment of qualified persons because of physical or mental handicap.
The Contractor shall comply with the requirements of the Fair Labor Standards Act of 1938, as amended.
34.3 If Contractor is an Indian Tribal Government, Contractor shall comply with the Indian Civil Rights Act of
1968. It shall be permissible for an Indian Tribal Contractor to engage in Indian preference in hiring.
34.4 The Contractor shall comply with Title VI of the Civil Rights Act of 1964, which prohibits the denial of
benefits of or participation in contract services on the basis of race, color, or national origin. The Contractor
shall comply with the requirements of Section 504 of the Rehabilitation Act of 1973, as amended, which
prohibits discrimination on the basis of handicap, in delivering contract services; and with Title II of the
Americans with Disabilities Act, and the Arizona Disability Act, which prohibit discrimination on the basis of
physical or mental disabilities in the provision of contract programs, services and activities.
34.5 The following shall be included in all publications, forms, flyers, etc. that are distributed to recipients of
contract services:
"Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI and VII) and the Americans with Disabilities
Act of 1990 (ADA) Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975,
insert Contractor name here) prohibits discrimination in admissions, programs, services, activities or
employment based on race, color, religion, sex, national origin, age, and disability. The (insert Contractor
name here) must make a reasonable accommodation to allow a person with a disability to take part in a
program, service, or activity. Auxiliary aids and services are available upon request to individuals with
disabilities. For example, this means that if necessary, the (insert Contractor name here) must provide
sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print
materials. It also means that the (insert Contractor name here) will take any other reasonable action that
allows you to take part in and understand a program or activity, including making reasonable changes to an
activity. If you believe that you will not be able to understand or take part in a program or activity because
Page 12 of 21 Rev. 3124115
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of your disability, please let us know of your disability needs in advance if at all possible. To request this
document in alternative format or for further information about this policy please contact: (insert Contractor
contact person and phone number here)" Para obtener este documento en otro formato u obtener
informaciOn adicional sabre esta politica, (insert Contractor contact person and phone number here)"
35.0 No Parole Evidence
35.1 Contract is intended by the parties as a final and complete expression of their agreement. No course of
prior dealings between the parties and no usage of the trade shall supplement or explain any terms used in
this document and no other understanding either oral or in writing shall be binding.
36.0 No Waiver
36.1 Either party's failure to insist on strict performance of any term or condition of the Contract shall not be
deemed a waiver of that term or condition even if the party accepting or acquiescing in the nonconforming
performance knows of the nature of the performance and fails to object to it
37.0 Notices
37.1 All notices to the Contractor regarding this Contract shall be sent to the address indicated in Attachment 9.
37.2 All notices to the ADES regarding this contract shall be sent to the address indicated in section 4.0 Notices
in the Scope of Work.
37.3 All notices shall reference the Contract number.
37.4 The Contractor shall give written notice to the Department of changes to the following, and a written
amendment to the Contract shall not be necessary:
1. Change of telephone number;
2. Changes in the name and/or address of the person to whom notices are to be sent;
3. Changes in contract-related personnel positions of the Contractor which do not affect staffing ratios,
staff qualifications or specific individuals required under this Contract.
37.5 In a fixed price with price adjustment contract, a written amendment shall not be necessary to shift costs
among budget categories. The Contractor shall give written notice to the Department that includes
justification for the change and may receive written approval by the Department. Any such increase must
be offset by an equal value decrease in any budget category or categories.
38.0 Offshore Performance Of Work Prohibited •
38.1 Due to security and identity protection concerns, direct services under this Contract shall be performed
within the borders of the United States. Any services that are described in the specifications or scope of
work that directly serve the State of Arizona or its clients and may involve access to secure or sensitive
data or personal client data or development or modification of software for the State shall be performed
within the borders of the United States. Unless specifically stated otherwise in the specifications, this
definition does not apply to indirect or 'overhead' services, redundant back-up services or services that are
incidental to the performance of the Contract. This provision applies to work performed by subcontractors
at all tiers.
39.0 Order of Precedence
39.1 In the event of a conflict in the provisions of the Contract, as accepted by the State and as they may be
amended, the following shall prevail in the order set forth below:
1. Terms and Conditions;
2. Scope of Work;
3. Attachments;
4. Exhibits; and
5. Documents referenced or included in the Request for Application.
40.0 Ownership of Intellectual Property
40.1 Any and all intellectual property, including but not limited to copyright, invention, trademark, tradename,
service mark, and/or trade secrets created or conceived pursuant to or as a result of this Contract and any
related subcontract ("Intellectual Property"), shall be work made for hire and the State shall be considered
the creator of such Intellectual Property. The agency, department, division, board or commission of the
State of Arizona requesting the issuance of this Contract shall own (for and on behalf of the State) the
entire right, title and interest to the Intellectual Property throughout the world. Contractor shall notify the
State, within thirty (30) days, of the creation of any Intellectual Property by it or its subcontractor(s).
Contractor, on behalf of itself and any subcontractor(s), agrees to execute any and all document(s)
necessary to assure ownership of the Intellectual Property vests in the State and shall take no affirmative
Page 13 o121 Rev. 3124/15
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actions that might have the effect of vesting all or part of the Intellectual Property in any entity other than
the State. The Intellectual Property shall not be disclosed by Contractor or its subcontractor(s) to any entity
not the State without the express written authorization of the agency, department, division, board or
commission of the State of Arizona requesting the issuance of this Contract
40.2 Intellectual Property developed by the Contractor that is already in the public domain is exempt from this
requirement.
41.0 Pandemic Contractual Performance
41.1 The State shall require a written plan that illustrates how the Contractor shall perform up to contractual
standards in the event of a pandemic. The State may require a copy of the plan at anytime prior or post
award of a Contract. At a minimum, the pandemic performance plan shall include:
1. Key succession and performance planning if there is a sudden significant decrease in Contractor's
workforce.
2. Alternative methods to ensure there are services or products in the supply chain.
3. An up to date list of company contacts and organizational chart.
41.2 In the event of a pandemic, as declared by the Governor of Arizona, U.S. Government or the World Health
Organization, which makes performance of any term under this Contract impossible or impracticable, the
State shall have the following rights:
1. After the official declaration of a pandemic, the State may temporally void the Contract(s) in whole or
specific sections if the Contractor cannot perform to the standards agreed upon in the initial terms.
2. The State shall not incur any liability if a pandemic is declared and emergency procurements are
authorized by the Director of the Arizona Department of Administration per A.R.S. § 41-2537 as may be
amended of the Arizona Procurement Code.
3. Once the pandemic is officially declared over and/or the Contractor can demonstrate the ability to
perform, the State, at its sole discretion may reinstate the temporarily voided Contract(s).
42.0 Payments
42.1 Reimbursement to the Contractor shall be in accordance with actual allowable costs incurred consistent
with each service budget and/or budget summary not to exceed the service reimbursement ceiling. The
Contractor shall furnish the Department with an accounting of actual costs incurred consistent with the
categories set forth in the service budget(s). Budget categories, to include cost items in a category, may
be deleted, added, or modified by a contract amendment as specified in section 37.0 Notices of these
Terms and Conditions. Any change to the service reimbursement ceiling shall be reflected in a contract
amendment.
42.2 The Contractor shall report to the Department in the manner prescribed in section 7.0 Reporting
Requirements in the Scope of Work. Upon receipt of applicable, accurate and complete reports, the
Department will authorize payment or reimbursement in accordance with the type of payment indicated by
this Contract.
42.3 If the Contractor is in any manner in default in the performance of any obligation under this Contract, or if
audit exceptions are identified, the Department may, at its option and in addition to other available
remedies, either offset the amount of payment or withhold payment up to the amount in dispute or default.
42.4 Under no circumstances shall the Department make payment to the Contractor that exceeds the units
authorized or contract/service reimbursement ceilings indicated in the Service Budget(s), as may be
amended.
42.5 Under no circumstances shall the Department make payment to the Contractor for services performed after
the term of the Contract without timely extension or renewal of the Contract.
42.6 The Contractor may offer a price reduction adjustment at any time during the term of the Contract. Any
price reduction shall be executed by a contract amendment
42.7 Payments shall comply with the requirements of A.R.S. Titles 35 and 41, Net 30 days. Upon receipt and
acceptance of goods or services, the Contractor shall submit a complete and accurate invoice for payment
from the State within thirty (30) days.
42.8 The Contractor shall be responsible for paying all applicable taxes.
42.9 The State of Arizona is subject to all applicable state and local transaction privilege taxes. Transaction
privilege taxes apply to the sale and are the responsibility of the seller to remit. Failure to collect such
taxes from the buyer does not relieve the seller from its obligation to remit taxes.
42.10 Contractor and all subcontractors shall pay all Federal, state and local taxes applicable to its operation and
any persons employed by the Contractor. Contractor shall, and require all subcontractors to hold the State
harmless from any responsibility for taxes, damages and interest, if applicable, contributions required under
Federal, and/or state and local laws and regulations and any other costs including transaction privilege
Page 14 of 21 Rev. 3/24/15
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taxes, unemployment compensation insurance, Social Security and Worker's Compensation.
42,11 In order to receive payment the Contractor shall have a current I.R.S. W9 Form on file with the State of
Arizona, unless not required by law.
43.0 Payment Recoupment
43.1 The Contractor shall reimburse the Department upon demand or the Department may deduct from future
payments the following:
43.1.1 Any amounts received by the Contractor from the Department for contract services which have been
inaccurately reported or are found to be unsubstantiated;
43.1.2 Any amounts paid by the Contractor to a subcontractor not authorized in writing by the Department;
43.1.3 Any amount or benefit paid directly or indirectly to an individual or organization not in accordance with the
"Substantial Interest Disclosure" section of these Terms and Conditions;
43.1.4 Any amounts paid by the Department for services which duplicate services covered or reimbursed by other
specific grants, contracts, or payments;
43.1.5 Any amounts expended for items or purposes determined unallowable by the Department when this
Contract provides for the reimbursement of costs, see the "Unallowable Costs" section of this Contract;
43.1.6 Any amounts paid by the Department for which the Contractor's books, records, and other documents are
not sufficient to clearly substantiate that those amounts were used by the Contractor to perform contract
services;
43.1.7 Any amounts received by the Contractor from the Department which are identified as a financial audit
exception;
43.1.8 Any amounts paid or reimbursed in excess of the Contract or service reimbursement ceiling;
43,1.9 Any amounts paid to the Contractor which are subsequently determined to be defective pursuant to the
"Certification of Cost or Pricing Data" section of these Terms and Conditions.
43.1.10 Any payments made for services rendered after the Contract termination date.
44.0 Personnel
44.1 The Contractor's personnel shall satisfy all qualifications, carry out all duties, and work the hours as set
forth in this Contract.
45.0 Predecessor and Successor Contracts
45.1 The execution or termination of this Contract shall not be considered a waiver by the Department of any
rights it may have for damages suffered through a breach of this or a prior Contract with the Contractor.
46.0 Professional Standards
46.1 The Contractor shall deliver contract services in a humane and respectful manner and in accordance with
any and all applicable professional accreditation standards. Levels of staff qualifications, professionalism,
and numbers of staff and individuals identified by name must be maintained as presented in the Contract.
47.0 Reserve
48.0 Records
48.1 Under A.R.S. § 35-214 and § 35-215 as may be amended, the Contractor shall retain and shall
contractually require each subcontractor to retain all data and other "records" relating to the acquisition and
performance of the Contract for a period of five years after the completion of the Contract. All records shall
be subject to inspection and audit by the State at reasonable times. Upon request, the Contractor shall
produce a legible copy of any or all such records.
48.2 Contract service records will be maintained in accordance with this Contract. Records shall, as applicable,
meet the following standards:
48.2.1 Adequately identify the service provided and each service recipient's application for Contract and
subcontract activities;
48.2.2 Include personnel records which contain applications for employment, job titles and descriptions, hire and
termination dates, a copy of the fingerprint clearance card, wage rates, and effective dates of personnel
actions affecting any of these items;
48.2.3 Include time and attendance records for individual employees to support all salaries and wages paid;
48.2.4 Include records of the source of all receipts and the deposit of all funds received by the Contractor;
48.2.5 Include original copies of invoices, statements, sales tickets, billings for services, deposit slips, etc., and a
cash disbursement journal and cancelled checks to reflect all disbursements applicable to the Contract;
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48.2.6 Include a complete general ledger with accounts for the collection of all costs and/or fees applicable to the
Contract; and,
48.2.7 Include copies of lease/rental agreements, mortgages and/or any other agreements that in any way may
affect contract expenditures.
48.3 Any such records not maintained shall mandate an audit exception in the amount of the inadequately
documented expenditures.
48,4 Contractor shall preserve and make available all records for a period of five (5) years from the date of final
payment under this Contract except as may be provided in section 57.0 of these Terms and Conditions or if
subject to Health Insurance Portability & Accountability Act which is six (6) years from the date of final
payment:
48.4.1 If this Contract is completely or partially terminated, the records relating to the work terminated shall be
preserved and made available for a period of five years from the date of any such termination.
48.4.2 Records which related to disputes, litigation or the settlement of claims arising out of the performance of
this Contract, or costs and expenses of this Contract to which exception has been taken by the state, shall
be retained by the Contractor until such disputes, litigations, claims or exceptions have been disposed of.
49.0 Relationship of Parties
49.1 The Contractor under this Contract is an independent Contractor. Neither party to this Contract shall be
deemed to be the employee or agent of the other party to the Contract.
49.2 In the event that the Contractor or its personnel is sued or prosecuted for conduct arising from this
Contract, the Contractor or their personnel will not be represented by the Department of the Attorney
General.
49.3 Taxes or Social Security payments will not be withheld from a State payment issued hereunder and the
Contractor shall make arrangements to directly pay such expenses, if any.
50.0 Reporting Requirements
50.1 See section 7.0 Reporting Requirements in the Scope of Work.
50.2 Contractor shall submit programmatic and financial reports to the Department no later than the 25th day
following the end of each month or the end of each other applicable reporting period during the term of the
Contract, unless otherwise provided in this Contract. Contractor shall submit final program and fiscal
reports no later than the 60th day following termination of the Contract The final fiscal report for the
contract term shall include all adjustments to prior financial reports submitted for the contract term. Failure
to submit the final program and fiscal report within the above time period may result, at the option of the
Department, in forfeiture of final payment.
50.3 All reports shall reference the contract number and be submitted to the person designated by the
Department.
51.0 Responsibility for Payments Indemnification
51.1 The Contractor shall be responsible for issuing payment for services performed by the Contractor's
employees, subcontractors, suppliers, or any other third party incurred in the furtherance of the
performance or the arising out of the Contract and will indemnify and save the Department harmless for all
claims whatsoever out of the lawful demands of such parties. The Contractor shall, at the Department's
request, furnish satisfactory evidence that all obligations of the nature hereinabove designated have been
paid, discharged or waived.
52.0 Right of Offset
52.1 The State shall be entitled to offset against any sums due the Contractor, any expenses or costs incurred
by the State, or damages assessed by the State concerning the Contractor's non-conforming performance
or failure to perform the Contract, including expenses, costs and damages.
53.0 Severability
53.1 The provisions of this Contract are severable. Any term or condition deemed illegal or invalid shall not
affect any other term or condition of the Contract
54.0 State's Contractual Remedies
54.1 Right to Assurance. If the State in good faith has reason to believe that the Contractor does not intend to,
or is unable to perform or continue performing under this Contract, the Procurement Officer may demand in
writing that the Contractor give a written assurance of intent to perform. Failure by the Contractor to
Page 16 of 21 Rev. 3124115
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provide written assurance within the number of Days specified in the demand may, at the State's option, be
the basis for terminating the Contract under the Terms and Conditions or other rights and remedies
available by law or provided by the Contract.
54.1.1 For designated agencies, termination shall comply with Community Services Block Grant legislation.
54.2 Stop Work Order. The State may, at any time, by written order to the Contractor, require the Contractor to
stop all or any part, of the work called for by this Contract for period(s) of days indicated by the State after
the order is delivered to the Contractor. The order shall be specifically identified as a stop work order
issued under this clause. Upon receipt of the order, the Contractor shall immediately comply with its terms
and take all reasonable steps to minimize the incurrence of costs allocable to the work covered by the
order during the period of work stoppage.
54.2.1 If a stop work order issued under this clause is canceled or the period of the order or any extension
expires, the Contractor shall resume work. The Procurement Officer shall make an equitable adjustment in
the delivery schedule or contract price, or both, and the Contract shall be amended in writing accordingly.
54.3 Non-exclusive Remedies. The rights and the remedies of the State under this Contract are not exclusive.
54.4 Nonconforming Tender. Materials or services supplied under this Contract shall fully comply with the
Contract. The delivery of materials or services or a portion of the materials or services that do not fully
comply constitutes a breach of contract. On delivery of nonconforming materials or services, the State may
terminate the Contract for default under applicable termination clauses in the Contract, exercise any of its
rights and remedies under the Uniform Commercial Code, or pursue any other right or remedy available to
it.
55.0 Subcontracts
55.1 The Contractor shall not enter into any Subcontract under this Contract for the performance of this Contract
without the advance written approval of AIDES. The Contractor shall clearly list any proposed
subcontractors and the subcontractor's proposed responsibilities. The Subcontract shall incorporate by
reference the terms and conditions of this Contract.
55.2 Prior to adding a subcontractor to the Contract, the Contractor shall submit a formal, written request to the
Procurement Officer. The request shall:
55.2.1 Be on the Contractors company letterhead;
55.2.2 Be signed by an authorized representative of the Contractor; and
55.2.3 Contain the following information:
1. The subcontractor's name, address, phone number, e-mail and primary point of contact;
2. The certifications required of the subcontractor (if any);
3. The subcontractor's small business status (if applicable);
4. The type of goods and/or services to be provided by the subcontractor;
5. The amount of time or effort (as a percent of total contract performance) that the subcontractor will
perform in relation to total performance of the contract's requirements; and
6. A description of the quality assurance measures that the Contractor shall use to monitor the
subcontractor's performance.
55.2.4 The State reserves the right to request additional information deemed necessary about any proposed
subcontractor.
55.3 The Contractor shall provide copies of each contract with a subcontractor relating to the provision of
contract services to the Department upon five (5) calendar days of the request.
56.0 Substantial Interest Disclosure
56.1 Contractor shall not make any payments, either directly or indirectly, to any person, partnership,
corporation, trust, or any other organization which has a substantial interest in Contractor's organization or
with which Contractor (or one of its directors, officers, owners, trust certificate holders or a relative thereof)
has a substantial interest, unless Contractor has made a full written disclosure of the proposed payments,
including amounts, to the Department
56.2 Leases or rental agreements or purchase of real property which would be covered by Section 55.1 shall be
in writing and accompanied by an independent commercial appraisal of fair market rental, lease, or
purchase value, as appropriate.
56.3 For the purpose of this Section, "relative" shall have the same meaning as in A.R.S. §38-502 as may be
amended.
57.0 Supporting Documents and Information
57.1 In addition to any documents, reports or information required by any other section of this Contract,
Contractor shall furnish the Department with any further documents and information deemed necessary by
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the Department. Upon receipt of a request for information from ADES, the Contractor shall provide
complete and accurate information no later than fifteen (15) days after the receipt of the request
58.0 Suspension or Debarment
58.1 The State may, by written notice to the Contractor, immediately terminate this Contract if the State
determines that the Contractor has been debarred, suspended or otherwise lawfully prohibited from
participating in any public procurement activity, including but not limited to, being disapproved as a
subcontractor of any public procurement unit or other governmental body. If the Contractor becomes
suspended or debarred, the Contractor shall immediately notify the State.
58.2 The Contractor shall submit the Certification Regarding Debarment, Suspension and Voluntary Exclusion
Lower Tier Covered Transactions form Attachment 3.
59.0 Technical Assistance
59.1 The Department will provide technical assistance to the Contractor in the administration of contract
services, or relating to the terms and conditions, policies and procedures governing this Contract
Notwithstanding the foregoing, the Contractor shall not be relieved of full responsibility and accountability
for the provision of contract services in accordance with the terms and conditions set forth herein.
60.0 Termination
60.1 This agreement may be terminated by mutual agreement of the parties at any time during the term of this
agreement.
60.2 Cancellation for Conflict of Interest: Pursuant to A.R.S. § 38-511 as may be amended, the State may
cancel this Contract within three (3) years after Contract execution without penalty or further obligation if
any person significantly involved in initiating, negotiating, securing, drafting or creating the Contract on
behalf of the State is or becomes at any time while the Contract or an extension of the Contract is in effect
an employee of or a consultant to any other party to this Contract with respect to the subject matter of the
Contract The cancellation shall be effective when the Contractor receives written notice of the cancellation
unless the notice specifies a later time. If the Contractor is a political subdivision of the State, it may also
cancel this Contract as provided in A.R.S. § 38-511 as may be amended.
60.3 Gratuities: The State may, by written notice, terminate this Contract, in whole or in part, if the State
determines that employment or a Gratuity was offered or made by the Contractor or a representative of the
Contractor to any officer or employee of the State for the purpose of influencing the outcome of the
procurement or securing the Contract, an amendment to the Contract, or favorable treatment concerning
the Contract, including the making of any determination or decision about contract performance. The
State, in addition to any other rights or remedies, shall be entitled to recover exemplary damages in the
amount of three times the value of the Gratuity offered by the Contractor.
60.4 Suspension or Debarment: The State may, by written notice to the Contractor, immediately terminate this
Contract if the State determines that the Contractor has been debarred, suspended or otherwise [awfully
prohibited from participating in any public procurement activity, including but not limited to, being
disapproved as a subcontractor of any public procurement unit or other governmental body. Submittal of
an offer or execution of a contract shall attest that the Contractor is not currently suspended or debarred. If
the Contractor becomes suspended or debarred, the Contractor shall immediately notify the State,
60.5 Termination for Convenience: The State reserves the right to terminate the Contract, in whole or in part at
any time, when in the best interests of the State without penalty or recourse. Upon receipt of the written
notice, the Contractor shall stop all work, as directed in the notice, notify all subcontractors of the effective
date of the termination and minimize all further costs to the State. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the Contract shall become
the property of and be delivered to the State upon demand. The Contractor shall be entitled to receive just
and equitable compensation for work in progress, work completed and materials accepted before the
effective date of the termination. The cost principles and procedures provided in A.A.C. R2-7-701 shall
apply.
60.6 Termination for Default
60.6.1 In addition to the rights reserved in the Contract, the State may terminate the Contract in whole or in part
due to the failure of the Contractor to comply with any term or condition of the Contract, to acquire and
maintain all required insurance policies, bonds, licenses and permits, or to make satisfactory progress in
performing the Contract The Procurement Officer shall provide written notice of the termination and the
reasons for it to the Contractor.
60.6.2 Upon termination under this paragraph, all goods, materials, documents, data and reports prepared by the
Contractor under the Contract shall become the property of and be delivered to the State on demand.
60.6.3 The State may, upon termination of this Contract, procure, on terms and in the manner that it deems
Page 18 of 21 Rev. 3124/15
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appropriate, materials or services to replace those under this Contract The Contractor shall be liable to
the State for any excess costs incurred by the State in procuring materials or services in substitution for
those due from the Contractor.
60.6.4 The Department may immediately terminate this Contract if the Department determines that the health or
welfare or safety of service recipients is endangered.
60.6.5 For designated agencies, termination shall comply with Community Services Block Grant legislation.
60.7 Continuation of Performance Through Termination: The Contractor shall continue to perform, in
accordance with the requirements of the Contract, up to the date of termination, as directed in the
termination notice.
60.8 Termination for Any Reason: In the event the Contract is terminated, with or without cause, or expires, the
Contractor, whenever determined appropriate by the Department, shall assist the Department in the
transition of services or eligible persons to other Contractors. Such assistance and coordination shall
include, but not be limited to, the forwarding of program and other records as may be necessary to assure
the smoothest possible transition and continuity of services. The cost of reproducing and forwarding such
records and other materials shall be borne by the Contractor. The Contractor must make provisions for
continuing all management/administrative services until the transition of services or eligible persons is
complete and all other requirements of this Contract are satisfied.
60.9 In the event of termination or suspension of the Contract by the Department, such termination or
suspension shall not affect the obligation of the Contractor to indemnify the Department and the State for
any claim by any other party against the State or Department arising from the Contractor's performance of
this Contract and for which the Contractor would otherwise be liable under this Contract. To the extent
such indemnification is excluded by A.R.S. §41-621 et seq.as may be amended or an obligation is
unauthorized under A.R.S. §35-154 as may be amended, the provisions of this paragraph shall not apply.
60.10 In the event of early termination for any reason, any funds advanced to the Contractor shall be returned to
the Department within ten (10) days after the date of termination or upon receipt of notice of termination of
the Contract, whichever is earlier.
61.0 Third- Party Antitrust Violations
61.1 The Contractor assigns to the State any claim for overcharges resulting from antitrust violations to the
extent that those violations concern materials or services supplied by third parties to the Contractor, toward
fulfillment of this Contract.
62.0. Transfer of Knowledge
62.1 The Contractor shall, whenever feasible, share strategies and techniques with Department staff to transfer
the skills and knowledge acquired in the delivery of the contracted service.
63.0 Transition of Activities
63.1 In the event that a Contract is awarded to a new Contractor for services similar to those being performed by
Contractor under this Contract, there shall be a transition of services period. During this period, the
Contractor under this Contract shall work closely with the new Contractor's personnel and/or Department
staff to ensure a smooth and complete transfer of duties and responsibilities. The Department's authorized
representative will coordinate all transition activities. A transition plan will be developed in conjunction with
the existing Contractor to assist the new Contractor and/or Department staff to implement the transfer of
duties. The Department reserves the right to determine which projects/service delivery nearing completion
will remain with the current Contractor of record.
64.0 Unallowable Costs
64.1 The cost principles set forth in the Code of Federal Regulations, 48 CFR, Chapter 1, Subchapter e, Part 31,
(October 1, 1991), including later amendments and editions, on file with the Arizona Secretary of State and
incorporated by this reference, shall be used to determine the allow ability of incurred costs for the purpose
of reimbursing costs under contract provisions that provide for the reimbursement of costs. Those costs
which are specifically defined as unallowable therein will not be submitted for reimbursement by the
Contractor and may not be reimbursed with Department funds.
64.2 In addition, the Contractor shall comply with the following publications (including subsequent revisions), as
applicable:
64.2.1 OMB Circular A-87 for State, local and Indian Tribal Governments.
64.2.2 OMB Circular A-122 for private non-profit organizations other than institutions of higher education, hospitals
or others specified in A-122.
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64.2.3 OMB Circular A-21 for educational institutions.
64.2.4 OMB Circular A-133 for audits of institutions of higher education and other non-profit institutions.
66.0 Visitation, inspection and Copying
65.1 Contractor's and/or subcontractor's facilities, services and individuals served, books and records pertaining
to the Contract shall be available for visitation, inspection and copying by the Department and any other
appropriate agent of the State or Federal Government At the discretion of the Department, visitation,
inspection and copying may be at any time during regular business hours, announced or unannounced. If
the Department deems it to be an emergency situation, it may at any time visit and inspect the Contractor's
or subcontractor's facilities, services and individuals served, as well as inspect and copy their contract-
related books and records.
65.2 Facilities Inspection and Materials Testing: The Contractor agrees to permit access to its facilities,
subcontractor facilities and the Contractor's processes or services, at reasonable times for inspection of the
facilities or materials covered under this Contract. The State shall also have the right to test, at its own
cost, the materials to be supplied under this Contract Neither inspection of the Contractor's facilities nor
materials testing shall constitute final acceptance of the materials or services. If the State determines non-
compliance of the materials, the Contractor shall be responsible for the payment of all costs incurred by the
State for testing and inspection.
66.0 Warranties
66.1 The Contractor warrants that all services provided under this Contract shall conform to the requirements
stated herein and any amendments hereto. The Department's acceptance of services provided by the
Contractor shall not relieve the Contractor from its obligations under this warranty. ln addition to its other
remedies, the Department Procurement Officer may, at the Contractor's expense, require prompt correction
of any services failing to meet the Contractor's warranty herein. Services corrected by the Contractor shall
be subject to all of the provisions of this Contract in the manner and to the same extent as the services
originally furnished.
66.2 Liens: The Contractor warrants that the materials supplied under this Contract are free of liens and shall
remain free of liens.
66.3 Quality: Unless otherwise modified elsewhere in these terms and conditions, the Contractor warrants that,
for one year after acceptance by the State of the materials, they shall be:
1. Of a quality to pass without objection in the trade under the Contract description;
2. Fit for the intended purposes for which the materials are used;
3. Within the variations permitted by the Contract and are of even kind, quantity, and quality within each
unit and among all units;
4. Adequately contained, packaged and marked as the Contract may require; and
5. Conform to the written promises or affirmations of fact made by the Contractor.
66.4 Fitness: The Contractor warrants that any material supplied to the State shall fully conform to all
requirements of the Contract and all representations of the Contractor, and shall be fit for all purposes and
uses required by the Contract.
66.5 Inspection/Testing: The warranties set forth in subparagraphs 66.2 through 66.4 of this paragraph are not
affected by inspection or testing of or payment for the materials by the State.
66.6 Compliance With Applicable Laws: The materials and services supplied under this Contract shall comply
with all applicable Federal, state and local laws, and the Contractor shall maintain all applicable license and
permit requirements.
66.7 Survival of Rights and Obligations after Contract Expiration or Termination:
66.7.1 Contractor's Representations and Warranties: All representations and warranties made by the Contractor
under this Contract shall survive the expiration or termination hereof. In addition, the parties hereto
acknowledge that pursuant to A. RS. § 12-510, except as provided in A.R.S. § 12-529, the State is not
subject to or barred by any limitations of actions prescribed in A.R.S., Title 12, Chapter 5.
66.7.2 Purchase Orders: The Contractor shall, in accordance with all terms and conditions of the Contract, fully
perform and shall be obligated to comply with all purchase orders received by the Contractor prior to the
expiration or termination hereof, unless otherwise directed in writing by the Procurement Officer, including,
without limitation, all purchase orders received prior to but not fully performed and satisfied at the expiration
or termination of this Contract.
66.8 Risk of Loss: The Contractor shall bear all loss of conforming material covered under this Contract until
received by authorized personnel at the location designated in the purchase order or Contract. Mere receipt
does not constitute final acceptance. The risk of loss for nonconforming materials shall remain with the
Contractor regardless of receipt.
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67.0 Limited English Proficiency
67.1 The Contractor shall ensure that all services provided are culturally relevant and linguistically appropriate to
the population to be served following the ADES Policy, Limited English Proficiency, DES 1-01-34
(Exhibit 1).
68.0 Contract Documents
68.1 The following constitute an integral part of the Contract:
68.1.1 Terms and Conditions
68.1.2 Scope of Work
68.1.3 Administrative Methodology
68.1.4 Service Methodologies
68.1.5 Attachments
68.1.6 Exhibits
Page 21 of 21 Rev. 3/24/15
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Attachment 2
ATTACHMENTS TO DES SPECIAL TERMS AND CONDITIONS
CERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of an 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 contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or cooperative agreement
(2) If any funds other than Federal appropriated funds have been paid or will be paid 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 this
Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form-ILL, "Disclosure of Lobbying Activities," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included In the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants,
loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction Imposed by section 1352, title 31, U.S. Code. Any person who fails to file
the required certification shall be subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid 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 this commitment providing for the United States
to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-ILL,
"Disclosure of Lobbying Activities," in accordance with its instructions, Submission of this statement is a
prerequisite for making or entering into this transaction imposed by section 1362, title 31, U.S. Code.
Any person who fails to file the required statement shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
APPLICANT'S ORGANIZATION
Maricopa County / Human Services / Community Services .
* PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
Prefix:
* First Name: Sandra Middle Name: A. 'Last Name:Mendez Suffix:
* Title: Assistant Dire. • r Co unity Services
1 J, 02'23 e-
41IrA +
SIGN ' • . "F * DATE:
3/25/10

ATTACHMENT 3
Certification Regarding:
Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions
This certification is required by the regulations implementing Executive Order 12549-Debartnent and Suspension,
29 CFR Part 98, Section 98.510, Participant's responsibilities. The regulations were published as Part VII of the
May 26, 1988 Federal Register (pages 19160-19211).
(BEFORE COMPLETING CERTIFICATION, READ ATTACHED INSTRUCTIONS WHICH ARE AN
INTEGRAL PART OF THE CERTIFICATION)
(1) The prospective recipient of federal assistance funds certifies, by submission of this proposal, that
neither it nor its principals are presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this transaction by a federal department or
agency.
(2) Where the prospective recipient of federal assistance funds is unable to certify any of the statements
in this certification, such prospective participant shall attach an explanation to this proposal.
Marieopa County Human Services/Community Services
Name of Agency /Organization
Sandra A. Mendez -Assistant Director Community Services
Name and Title of AuthoTized Representative
0
Date

ATTACHMENT 3
Instructions for Certification
I. Ey signing and submitting this proposal, the prospective recipient of federal assistance funds is providing
the certification as 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 recipient of federal
assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to
the federal government, the Department of Labor (DOL) may pursue available remedies, including
suspension and/or debarment.
3. The prospective recipient of federal assistance funds shall provide immediate written notice to the person
to which this proposal is submitted if at any time the prospective recipient of federal assistance funds
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 those regulations.
5. The prospective recipient of federal assistance funds 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 debtured, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the DOL.
6. The prospective recipient of federal assistance funds further agrees by submitting this proposal that it will
include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion — Lower Tier Covered Transactions," 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 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 List of Parties Excluded from Procurement or Non-Procurement Programs.
S. 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 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, the DOL may pursue available remedies including
suspension and/or debarment.

POLICY NUMBER Page 1
DEPARTMENT OF ECONOMIC SECURITY DES 1 -01 -34
CHAPTER ARTICLE
01 Department of Economic Security 01 Director
SUBJECT EFFECTIVE DATE REVISION
34 Limited English Proficiency (LEP) August 8, 2014 2
DES 1-01-34
Limited English Proficiency (LEP)
I. POLICY STATEMENT
The policy of the Department of Economic Security (the Depai nent) is to provide quality and timely
language assistance services to customers with Limited English Proficiency (LEP) to ensure meaningful
access to programs, services, and activities. Each affected work unit of the Department shall:
• Develop and adhere to specific written procedures;
• Perform a needs and capacity assessment;
• Arrange for oral language assistance, as appropriate;
• Determine which of the Department documents meet the definition of a vital document;
• Translate vital documents into languages other than English;
• Provide notification to customers of the availability of language assistance services;
• Evaluate current Department Web sites for LEP compliance;
• Develop and implement standards to ensure LEP compliance on all future Web pages;
• Train all staff who are likely to have contact with Department customers and the management staff
who support them;
• Develop and incorporate an accessible issue resolution process; and
• Monitor customer access to language assistance.
IL AUTHORITY
This LEP policy, in its entirety, applies to all Department entities and contractors who provide direct
Department services to Department customers. The Department and all work units who provide services,
information, or assistance to Department customers shall be responsible for development of procedures to
ensure compliance with the Department LEP policy. Areas that do not provide services, information, or
assistance to Department customers are not responsible for developing procedures but, at a minimum
shall designate an LEP contact to ensure compliance.
The DES Director's Office of Equal Opportunity (DOE0) and the DES Policy and Planning
Administration's (PPA) Policy Unit are responsible for review and approval of work unit LEP
procedures. This review will be limited to ensuring the work unit LEP procedure is consistent and in
compliance with the Department LEP policy.

Page 2
III. PROCEDURES
This policy is supported by a departmental procedure which identifies how action related to this policy
will be conducted, including responsibilities, time frames, and required actions. To view this procedure,
access the link below.
DES 1-01-34-01 Limited English Proficiency Procedures
In addition, specific Division procedures can be found at this intranet Web page:
http://intranet.azdes.gov/main.aspx?menu=84&id=14558.
IV. AUTHORITY
Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq.
Arizona Constitution, Article 28
Section 601 of Title VI of the Civil Rights Act of 1964, 42 U.S.C. Section 2000d et seq. states, "No person
in the United States shall on the ground of race, color or national origin, be excluded from participation in,
be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal
financial assistance."
Regulations implementing Title VI provide in part at 45 C.F.R. Section 80.3 (b):
(1) "A recipient [the Department is a 'recipient' under this law] under any program to which this part
applies [generally any program that receives federal funds] may not, directly or through contractual
or other arrangements, on ground of race, or color, Of national origin:
(i) Deny an individual any service, financial aid, or other benefit provided under the program;
(ii) Provide any service, financial aid, or other benefit to an individual which is different, or is
provided in a different manner, from that provided to others in the program;
(2) A recipient, in determining the types of services, financial aid, or other benefits, or facilities which
will be provided under any such program or the class of individuals to whom, or the situations in
which such services, financial aid or other benefits, or facilities will be provided ... may not directly,
or through contractual or other arrangements, utilize criteria or methods of administration which
have the effect of subjecting individuals to discrimination, because of their race, color or national
origin, or have the effect of defeating or substantially impairing accomplishments of the objectives
of the program with respect to individuals of a particular race, color, or national origin." (emphasis
added)
V. DEFINITIONS
Customer: Any applicant, claimant, or recipient of Department services, including LEP customers.
Executive Leader: The Director, Deputy Director, Assistant Director, or their designee, with authority over a
programmatic or administrative work unit.
Interpret: Providing a verbal translation between two or more persons in a language other than English.
This may be done by on-site trained Department staff, contractors, or through commercially available
resources, including but not limited to telephonic interpretation services.

Page 3
Language Used Significantly: A language, other than English, that is used by five percent or 1,000 persons
(whichever is smaller) who are eligible for a Department service or are likely to be directly affected by a
Department program or activity in a specific geographic area.
Limited English Proficiency (LEP) Contact: The person within a work unit who is responsible for ensuring
their program or administrative work unit is LEP compliant.
Limited English Proficient (LEP) Customer: Any prospective, potential, or actual recipient of benefits or
services from the Department who cannot speak, read, write, or understand the English language at a level
that permits effective interaction with the Depai tment. This includes LEP parents or guardians of minor
children who are customers or LEP customers.
Non-Vital Documents: Documents that are not critical to access Department benefits and services.
Translate: Providing a written document in a language other than English.
Vital Document: A document that conveys information that affects the ability of the customer to make
decisions about his or her participation in the program. The decision of whether a document is vital may
depend upon the importance of the program information, encounter, or service involved, and the
consequence to the LEP person if the information is not provided accurately or in a timely manner.
Work Unit: A program or administrative area within the Department. Work unit includes all Department
work units as well as its contractors that provide direct service to Department customers.
VI STANDARDS
A. Overview
Title VI of the Civil Rights Act of 1964, as amended, requires that agencies take reasonable steps
to ensure meaningful access to their programs and activities for persons with limited English
proficiency. For the purposes of this Policy, individuals with LEP are defined as individuals who
do not speak English as their primary language and who have a limited ability to read, write, speak,
or understand English.
The Department's LEP policy ensures that the Department and all Department services, regardless
of funding source, comply with the requirements of Title VI of the Civil Rights Act of 1964 by
setting out standards for its work units to follow. Title VI of the Civil Rights Act of 1964 prohibits
discrimination based on race, color, or national origin by any entity receiving federal financial
assistance. The Department prohibits administrative methods or procedures that have the effect of
subjecting individuals to discrimination or defeating the objectives of these regulations.
In order to avoid discrimination on the grounds of national origin, all programs or activities
administered by the Department shall take adequate steps to ensure that their procedures do not
deny, or have the effect of denying, individuals with LEP equal access to benefits and services for
which such persons qualify. This Policy defines Departmental responsibilities to ensure that
individuals with LEP can communicate effectively.

Page 4
B. General Statement
All Depai tment staff shall provide services to Department customers in a manner that ensures the
customer has meaningful access to their programs and activities for all persons, including those
persons who have limited English proficiency.
C. Compliance and Enforcement
It is the responsibility of each Executive Leader overseeing a Department work unit, program, or
administrative area to ensure that activities within the Executive Leader's work unit are conducted
consistent with both the Department LEP policy and the specific work unit LEP procedures.
D. Work Unit Procedures
Each work unit identified as warranting language assistance services shall develop specific written
procedures related to language assistance services applicable to its program activities. These
procedures must be consistent with the standards listed in the Department LEP policy. Written
procedures shall address the following areas:
1. Provision of language services generally;
2. Identification and assessment of language needs;
3. Oral language assistance services;
4. Written translations;
5. Oral and written notification of the availability of language services;
6. Issue resolution rights;
7. Staff training on language service provision; and
8. Monitoring access to language assistance.
E. Needs And Capacity Assessment
The Department shall employ a four-step process to determine the need and capacity for LEP
services. Specifically, each work unit shall determine and indicate in writing if it has direct contact
with Department customers. If a work unit determines that it does, then:
1. Each work unit shall identify the steps in their service delivery process and identify the
anticipated number of customer interactions that occur at each of these steps. These steps
could include points of contact with Department staff where customers get information or
staff take an action that affects a customer's ability to meaningfully participate in a
Department program or activity. These points of contact include Department offices,
telephone numbers regularly used by the public, outreach activities, informational and
operational Web sites, and written notices. These contacts may be face-to-face, telephonic,
written, or electronic.

Page 5
2. The Department shall identift the languages used by the populations it serves. Both the
Department and each work unit shall use this information to determine the incidences in
which the Department and work unit expect to interact with customers in various
languages other than English. The Department shall use the most recent census data to
determine overall language trends in Arizona. Other demographic data sources include
information from other state agencies, commercial marketing data, school systems,
community organizations, national ethnic organizations, the Internet, and internally gathered
Department data. These trends will be used to determine the LEP population's alternative
language needs. The Department will update this infonnation with the issuance of new
census data.
3. Each work unit shall annually assess the language assistance needs of its LEP customers
and the capacity of its programs to meet these needs. Work unit procedures shall include
the methods used to conduct this assessment, including areas where it intends to use
departmentally produced data, and the frequency with which it will complete the
assessment.
4. Each work unit shall implement a process for gathering and recording LEP customer
language preferences:
a. The work unit procedures shall include sufficient detail to identify how the work
unit gathers language preference information, where it stores the information, and
how it will make the information readily available for future contact with LEP
customers and for statistics-gathering purposes.
b. Each work unit procedure shall include the use of an LEP language binder
containing language preference materials in each local office. These LEP language
binders are designed to provide an opportunity for LEP persons to self-declare their
language preference during local office contacts. The Department shall prominently
display the LEP language binders in all its offices in which customer interaction is
anticipated. These binders are developed, transmitted, and maintained as a
departmental function.
F. Oral Language Assistance
1. Each component, program, or administrative work unit of the Department shall arrange
for oral language assistance to LEP customers in face-to-face and telephone contact:
Work unit procedures shall identify the processes for providing oral language assistance and
the method for obtaining these services. The oral language assistance portion of the work
unit procedures for identifying individuals with LEP shall be consistent with those outlined
in this policy. LEP services shall be provided free of charge upon the request of the
customer. Work units may identify approaches specific to their work unit, but all
procedures shall include the minimum Department standard of ensuring that the provision of
bilingual/interpretive services is prompt and without undue delays. Necessary time frames
may vary based upon the nature and importance of the service. For example, time frames
for emergency services may be different from those time frames for non-emergency
services. In most circumstances, this requires language services to be available within
reasonable time frames during all operating hours by:

Page 6
a. Establishing interpreter service contracts. The Department maintains contracts with
multiple vendors to provide verbal interpretation. The Office of Procurement shall
provide direction to all work units on how to access and use contracts for interpreter
services. Work units shall, in their procedures, identify how they shall request and
coordinate these services. In addition, services through commercially available
telephonic interpretation services shall be available when needed.
Implementing a means to compensate bilingual staff. Subject to the availability of
funds, the Department shall have a bilingual stipend program in place that
compensates bilingual staff who meet required standards for performing verbal
interpretation services. Work unit procedures shall identify the offices in which a
need for bilingual staff has been established and which languages are needed.
C. Orally translating vital documents into languages other than English for LEP
customers.
2. Location and Accessibility of LEP Services: Work units shall ensure that their procedures
include provisions that respond to the language needs of the populations in each area in
which the work unit provides services. Each work unit shall determine the most efficient
and effective means to meet these needs. Accommodations such as translations of
commonly requested documents, bilingual staff, and telephone interpreter services should
be made available at locations that are readily accessible to the public, such as infoimation
desks, security checkpoints, and public information telephone lines.
3. Use of Bilingual Staff. The Department will make reasonable efforts to recruit and have
bilingual staffemployed in programs and activities where the number or percentage of LEP
customers or potential LEP customers is statistically significant, or where the frequency of
contact with such persons makes the employment of bilingual staff a more cost effective,
efficient, and effective mode for communication:
a. Each work unit shall make a decision to employ bilingual staff after a needs
assessment, with due consideration given to the budgetary, personnel, and other
constraints of the work unit.
b. Bilingual staff or contractors must be assessed for bilingual proficiency. Work units
should ensure that individuals providing interpretative services possess a level of
fluency and comprehension appropriate to the specific nature, type, and purpose of
information at issue.
4. Unacceptable Practices: Work units should only use family members or friends to interpret
for LEP customers if the LEP customer insists on using the friend or family member after
Department-provided language services have been offered. Minor children should never be
used to interpret, except in emergencies. If additional services are required, any information
obtained utilizing a minor child as the interpreter shall be verified through an approved
interpreter after the emergency situation has closed.
G. Translation of Written Materials
1. Each work unit shall identify its vital documents. Vital documents include, but are not
limited to, the following for any service, benefit, program, or administrative work unit
provided by or contracted with the Department:

Page 7
a. Applications;
b. Recertification or renewal applications;
c. Documents that require a response;
d. Letters or other written documents that contain information regarding participation
in a program;
e. Notices of eligibility criteria, authorization or denial, applicant or participant rights,
benefit or service changes, hearings, and actions affecting parental custody or child
support;
f. Consent and complaint forms;
g. Appeal rights and grievance procedures;
h. Written tests that do not assess English language competency but test competency
for a particular license, job, or skill for which knowing English is not required.
i. Notices advising LEP persons of free language assistance; and
Any other document that the work unit deems vital due to the importance of the
program, information, encounter, or service involved and the consequence to the
LEP person if the information in question is not provided accurately or in a timely
manner.
2. Each work unit shall translate its vital documents according to the requirements outlined
in the DES Translation Requirements document. Documents identified as vital shall be
translated into languages used significantly by its LEP customers. The Department
maintains two approved processes for having written material, including required posters
and signs, translated to languages other than English:
a. The Department Office of Graphics and Design; or
b. A state-approved translation contract.
Using one of these two processes ensures the quality of the translation activity. Department
documents for official public use may not be translated using any other method. Work unit
procedures shall identify which method for translation will be used within the work unit.
The work unit procedure shall also include a listing of the documents that meet the
definition of a vital document.
3. Each work unit shall respond to written communications from LEP customers in a
manner that is consistent with this policy. Work unit procedures shall address a process to
ensure that LEP customer case records are noted as LEP when work unit staff receive
information from a customer in a language other than English. Work unit staff shall interact
with the individual in a manner consistent with the Depaitment LEP policy unless the
customer indicates otherwise.

Page 8
4. Each work unit should be sensitive to the literacy levels of the LEP public. There are
situations in which the use of translated written material may not meet the needs of some
Department LEP customers. Some languages are historically unwritten or some LEP
customers may be illiterate in their native language. Work unit procedures must ensure that
staff use the most effective means to communicate with LEP individuals. This may include
either verbal or written communication.
Institutional Considerations for Translation
1. Each work unit shall ensure that the public is aware of available interpretation and
translation assistance. Each work unit shall include on all documents that are not translated
into a language other than English a statement in each significantly used language indicating
that all persons have the right to free language assistance and how the assistance can be
obtained. This notification shall be included on all documents that are routinely
disseminated to the public, including electronic text. This language shall be placed near the
front of the document in a format that brings attention to it.
2. Each work unit shall ensure that its electronic sources for providing vital information are
LEP compliant. The Department and each work unit shall ensure that its Web sites and
other electronic sources for vital information or documents provide this information in
significantly used languages other than English. Web sites shall prominently display access
to non-English versions of this information on any page that may be used as the initial point
of contact for LEP individuals. Web sites shall also identify methods to access language
assistance free of charge.
3. The Department shall produce and each work unit shall readily make available to its
customers, an LEP Rights pamphlet in English and all other signcantly used
languages. The pamphlet shall explain that LEP services are available from the Department
free of charge and shall explain procedures for accessing these services.
4. Each work unit may translate non-vital documents into languages other than English,
except to the extent prohibited by the Arizona Constitution, Article 28, English as the
Official Language.
I. Training
Training shall include a consistent message explaining why it is important for the Department to
ensure that LEP customers are served in a manner consistent with this policy. Persons with specific
knowledge of Title VI of the Civil Rights Act and the requirements contained therein shall develop
this training. Training shall include, but not be limited to:
1. General training. For all staff on the importance of providing services for individuals with
LEP.
2. Work unit-specific training. To ensure that work unit staff that deal with or are likely to
have contact with Department customers are trained on the LEP policies and procedures.
This includes, but is not limited to, specific training for staff who have LEP customer
contact to work effectively with in-person and telephone interpreters.

Page 9
3. Technical assistance training. For LEP contact staff.
4. Management level training. For supervisors and administrative staff assisting staff with
direct customer contact.
J. Providing Notice to LEP Customers of the Availability of Language Assistance Services and
Outreach
Work unit procedures shall identify how to inform LEP customers of the availability of free
language assistance services. The work unit shall make the notification at the first point of contact.
Notification includes signs in intake areas or other customer entry points, outreach documents such
as brochures or booklets, LEP posters and pamphlets, and telephone menus in significantly used
languages:
1. The work unit shall provide the notification of free language assistance in the language of
the LEP customer. LEP persons should also be advised that they may use an interpreter of
their own choosing at their own expense.
2. Consistent with its commitment to partnership and outreach, the Department engages in
comprehensive outreach to ensure awareness by LEP persons of its programs and activities.
Outreach includes the use of ethnic media such as radio, television, newspapers, magazines,
Web sites, faith-based organizations, and community-based organizations at local levels that
provide social services, healthcare, and classes. Work unit procedures shall acknowledge its
commitment to support the Department's outreach efforts in relation to the programs it
administers and the services it provides.
3. Work unit procedures shall include provisions to ensure that Web pages accessible to
members of the general public include information on the availability of language
assistance.
4. The Department shall maintain copies of written documents such as flyers or pamphlets
intended to be used to notify the public of language assistance. Pamphlets shall be
maintained in locations in which direct service to Department customers is provided and
shall be readily available to customers without the need of Department staff intervention.
K. Monitor Access to Language Assistance
1. Each work unit shall institute procedures to monitor the accessibility and quality of
language assistance activities for LEP customers. Work unit procedures shall include
specific time frames and methods to reassess language assistance activities to ensure that the
services provided by the work unit address the actual needs of the LEP customers based on
actual experiences of the work unit. Work unit procedures shall ensure that such monitoring
is completed no less than every 12 months. Work unit procedures should include a process
for obtaining community and customer feedback in this activity through surveys,
questionnaires, or other means. Data collection and record keeping are key to an effective
monitoring and compliance system. In order to determine the validity of any language
assistance complaints, it may be necessary to analyze and review data that reflect how the
work unit provides services to LEP customers. Data collection also allows the work unit to
obtain an overview of how their services are provided. The work unit procedure shall
include data collection and record keeping requirements to ensure that these assessments are
fact-based and reflect actual current activity. The work unit shall assess the effectiveness of
its LEP policies based on:

Page 10
a. Current LEP populations in service areas or population or specific populations
encountered;
b. Frequency of encounters with LEP customers;
c. Nature and importance of activities to LEP customers;
d. Availability of resources, including technological advances, additional resources,
and the costs imposed;
e. Whether existing assistance is meeting the needs of the LEP customers;
f. Whether staff know and understand the LEP procedures; and
g. Whether identified sources for assistance are still available and viable.
2. Each work unit shall develop and maintain a data collection system that ensures the
availability of data that includes the race and ethnicity of customers served in its
programs, the frequency of contact, and the primary language of those persons.
Work unit procedures shall require the collection of data on which the work unit has based
language needs assessment; the number of LEP customers, by language group, who
received language services; names and classifications of staff receiving training and dates of
training. Work unit procedures shall include activities that are designed to ensure that the
work unit:
a. Has up-to-date information on language needs in the communities it serves;
b. Has an adequate number of oral translators to ensure timely compliance with LEP
needs;
c. Translates vital written documents into the languages needed by the communities
being served;
d. Has adequate supplies of translated materials;
e. Trains those staff required to be trained in LEP activities; and
f. Keeps notification material up-to-date.
Work unit procedures shall also reflect those activities that it must perform in order to
comply with overall Department monitoring practices.
L. Provision of Technical Assistance
Each work unit shall identify an LEP contact for work unit staff: Work unit procedures shall
include a process to ensure that LEP-related questions that arise are addressed in a timely and
efficient manner. The LEP contact shall be available to coordinate efforts towards compliance with
the Department's LEP policy and the work unit's LEP procedures. Work unit procedures shall, at a
minimum, include a process for direct service staff to elevate LEP questions to their LEP contact.
The work unit procedure shall also include time frames for the LEP contact to respond or to elevate
the question to the DOE0. The DOE0 shall provide technical assistance to the LEP contact or
solicit additional assistance from the Director's Office or the Office of the Attorney General.

Page 11
M. Issue Resolution
1. Work unit level process: Work units shall create a procedure outlining an LEP issue-
resolution process that shall be used to resolve a concern or dispute arising from any action
or inaction taken by Department staff in administering programs or providing services. The
work unit process shall be the Level I resolution process.
a. Level I: The Level I procedure shall require that Department customers are advised
in writing of the appropriate procedure to raise an LEP-related concern. This
notification also advises the customer of their right to file a complaint at any point
in time with the federal agency responsible for the program for which they are
applying.
b. Work units shall ensure that any forms needed to request review of LEP-related
decisions are available at any location in which work unit customers may receive
services.
C. The work unit shall conduct the Level I procedure in a language that is
understandable by the person raising the concern. The work unit shall make
appropriate use of interpreter services, contracted provider services, or other
resources needed to facilitate the dispute resolution process.
d. The Level I process shall include the following:
The manager in charge at the site where an LEP-related concern is filed or his or her
designee will review the complaint with the assistance of the work unit LEP
contact. Staff shall reduce oral complaints to writing and shall place them in the
appropriate case record. At any point in the process, the manager is empowered to
resolve the complaint using methods and practices outlined in the Department LEP
policy and the work unit LEP procedures. It is the intention of the Department and
the work unit that most LEP issues will be resolved at this level. The Level I
resolution process shall be completed no later than three days following the day of
receipt of the complaint unless the LEP customer requests a delay in the process.
The manager shall ensure that all reasonable measures are pursued to immediately
verbally notify the LEP customer of the outcome of the issue resolution. The
Department shall provide a written confirmation of the decision within five business
days.
2. Department Level Process: The Department process is initiated whenever a LEP customer
expresses in writing to the Department that the work unit attempt to resolve the issue at the
Level I process has not met their need. This LEP issue escalation process ensures the rights
of LEP customers to have concerns resolved in their preferred language. Inherent in this
process is the availability of the DOE0 to assist either the Department or the LEP customer
in resolving a concern. This process conforms to other issue resolution/grievance processes
in regard to required time frames, based upon the program(s) from which the LEP customer
is seeking service.
a. Level II: If no resolution can be reached at Level I, the notification to the LEP
customer shall include the right to pursue the grievance, the time frames, and the
process to request verbally or in writing an Executive Leader review and decision.
The Executive Leader may request assistance from the DOE0 with the cooperation
of the work unit LEP contact. Level II action shall occur within five working days
of receipt of the request for review of the Level I decision from the LEP customer.

Page 12
The Executive Leader shall ensure that the LEP customer receives written notice of
the outcome of the Level II review and advises the LEP customer of the method and
time frame to obtain a Level III review.
b. Level HI: In the rare instances where no resolution can be accomplished at the
Level II review, the LEP customer may request a final decision from DOE0. If the
LEP customer is not satisfied with the DOEO-proposed resolution, the DOE0 will
again inform the LEP customer of their rights to file with the appropriate federal
agency. This process will be completed within five working days of receipt of the
request for review of the Level II decision from the LEP customer.
N. Reporting
Work units shall submit no less than annually a report to the DOE0 detailing the information
required in Section VI.K. of this policy. Work units shall utilize the departmental monitoring survey
instrument, which identifies all mandatory points of review for each work unit. The DOE0 shall
report the results to the Director and the Depat tent ' s Policy and Planning Administration (PPA).

2.0 Administrative Methodology:
2.2.1 One or two pages describing how culturally relevant and linguistically appropriate services
will be provided-and indicate how clients will have ready access to services considering their
diverse languages, cultures and geographic locations.
Maricopa County Human Services Department (MCHSD), Community Services Division (CSD)
requires all contract providers to ensure that services are delivered in a manner that does not preclude
an individual's ability to apply for services based upon language or cultural barriers. Contract terms
and conditions require that subcontractors:
• Offer and provide language assistance services, including bilingual staff and interpreter services
at no cost to the program applicant/participant;
• Inform program applicant / participants of their right to receive language assistance services at
no cost;
• Make available easily understood program-related materials and post signage in the languages of
the commonly encountered groups and/or groups represented in the service area;
Subcontractors are encouraged to recruit, retain and promote a diverse staff and leadership that are
characteristic of the service area, and to maintain current demographic and cultural profiles of the
community. We also encourage our service providers to accurately plan for and implement services
that respond to the cultural and linguistic characteristics of the community served and to ensure staff
members at all levels receive training in culturally and linguistically appropriate service delivery, and in
cultural sensitivity.
Set-vices are made available throughout the geographic service area using an infrastructure of service
providers in local communities, Rural areas of the county are covered through itinerate site locations
and schedules. In the event that transportation is a barrier to accessing program services or applicants
are homebound due to illness or disability, subcontractors may conduct home visits or identify
alternative locations for service delivery. Subcontractors are also encouraged to conduct outreach
activities or community initiatives to advertise available Set-vices in geographically remote locations, so
as to promote program awareness,
2.2.2 One or two paragraphs describing the Applicant's organizational structure, including key
staff members.
The MCHSD is the designated Community Action Agency (CAA) serving Maricopa County, etelusive
of Phoenix, Mesa, and Glendale. The MCHSD is comprised of five distinct program Divisions to
include:
• Early Education Division
• Workforce Development Division
• Community Development Division
• Senior and Adult Services Division, and
• Community Services Division
The CSD maintains responsibility for all Community Action Programs, and administers services to
over 25 local cities and towns through an infrstructure of subcontractors who operationalize
programmatic functions. CSD Maintains Intergovernmental Agreements (MAO or contracts with a
variety of governmental agencies or private, non-profit community based organizations, who work to
ensure services are provided according to .the unique needs of local communities.

As an administrative entity, CSD provides program oversight, on-site monitoring, quality assurance,
vendor payments, financial management and training or technical assistance to subcontractors when
necessaty or appropriate. CSD also acts as a direct service provider for specific service areas
throughout the county, and coordinates anti-poverty efforts with other programs including but not
limited to the Family Self-Sufficiency (FSS) Program, through a partnership with the Housing
Authority of Maricopa County. . Key CSD staff members include:
• CSD Assistant Director
This position acts as the CAA Director and provides overall administrative and program direction for
the Community Set-vices Division. The Assistant Director represents MCHSD at intergovernmental,
interagency community and professional meetings, task forces and committees, and also provides
support to the federal CSBG required tri-partite board, the advisory Maricopa County Community
Services Commission, to ensure compliance with federal law. This position also establishes, and
monitors management systems and controls for administrative, program and fiscal procedures, sets
and adjusts priorities and policies, provides technical assistance to key staff members, and interfaces
with the state and other revenue sources on funding and contract compliance.
• The Operations Supervisor
This position establishes and maintains program policy and procedures manuals, conducts Quality
Assurance case file reviews and related activities, coordinates or provides training and/or technical
assistance for means-tested programs to both subcontractors and CSD staff, and manages vendor
payment activities through an online database used for client demographic and payment tracking.
This staff member also acts as the primary contact for policy-related questions from case
management staff in the field, and also manages voucher fund expenditures to ensure full depletion
of voucher funding.
• The Direct Services Supervisor
This position provides oversight and daily supervision for staff engaged in case management
activities for various services administered by the CSD, including the Low Income Home Energy
Assistance Program, Short Term Crisis Services Program, Family Self-Sufficiency Program, and the
EASE Program. The position - plans, assigns and directs the work of staff engaged in making
eligibility determinations, implements program policies or procedures, manages the CSD telephone
intake process, selects and trains subordinate staff and responds to client complaints or inquiries"
from the general public. The position is also responsible for the design and implementation of data
collection tools and meeting fonder reporting requirements.
• The Community Action Program Coordinator
This position coordinates and supports high level and broad-ranging efforts of the CSD including the
implementation of legislative requirements outlined under the Community Services Block Grant
(CSBG) Act for designated CAAs. This includes acting as the programmatic lead for all strategic
planning efforts including Results Oriented Management and Accountability (R_OMA), Community
Action Board development and training, developing and implementing new programs or services
which address the causes of poverty in local communities, and serves as the CSD liaison for
Community Action program compliance.
• The CSD Contracts Administrator
This position administers CSD's contract compliance efforts and the development or release of
Requests for Proposals, evaluations of submissions, and subsequent contract negotiations. The
position also develops Intergovernmental Agreements (IGAs), contract amendments, manages
subcontract awards by monitoring performance and compliance, monitors expenditure levels,
2

develops monitoring tools, conducts on-site monitoring, monitors corrective action plans, and
provides training or technical assistance to subcontractors.
2.2.3 One or two paragraphs describing bow client/recipient confidential information will be
maintained.
CSD requires all -contract providers to assure that all efforts are made to maintain appropriate
confidentiality in creating, storing, transferring and disposing of client records. Contract terms and
conditions require that subcontractors:
• Ensure that client records are kept in a secure location such as locked file cabinets or locked file
rooms;
• -Ensure that only authorized persons have access to records;
• Utilize encrypted email technology when communicating client information;
• Utilize encrypted passwords, and electronic security levels, authorizing access to electronic client
files and to any database containing confidential client information;
• Ensure that case manners obtain written permission from clients to disclose or transfer records
to third parties;
All client tecotds are maintained for a period of five (5) years, Records older than 5 years are
shredded and destroyed.
2.2.4 One or two paragraphs describing the Applicant's Information Technology equipment and
capabilities, consistent with the requirements of the Scope of Work.
CSD has developed and utilizes 1-1SD On/the, a web-based computer application developed specifically
for client demographic and payment tracking. This system allows subcontractors to screen program
applications for prior assistance, determine program eligibility, and also allows complete data entry at
the time of application. This county-wide system eliminates the duplication of program services and
serves as the primary data collection tool used by the Community Action Network in the CSD
Geographic Service Area.
CST) administrative offices and subcontractor locations maintain the capability to communicate
electronically through email, convey Microsoft-based text and spreadsheet documentation, and have
access to the internet. The MCHSD, Office of Information Systems, has backup/recovery systems in
place to preserve electronic files and the information needed to meet all program and fonder audit
standards or reporting requirements.
MCI-ISD has implemented an IT Disaster Recovery Plan, and a Continuity of Operations Plan
(COOP). These plans work together to protect technology assets, and to ensure minimal disruption or
degradation of services. CSD uses FISD OniThe and Microsoft Office software to track monthly,
quarterly and annual reports, and maintains the ability to draw ad-hoc reports when necessary,
2.2.5 One or two paragraphs describing the Applicant's competitive bidding procedures including
time frames used to select subcontractors.
It is the practice of MCHSD/CSD to extend the Right of First Refusal to the municipalities within the
defined service areas as approved by the MCI-ISD Community Services Commission. Maricopa
County, through its Homan Services Department, contracts with cities and towns for the provision of
Community Action Programs for respective communities and service areas. When no municipality
within the service area wishes to provide these services, Maticopa County Materials Management
3

Department initiates source selection procedures outlined in the Mruicopa County Procurement Code.
All contract agreements or IGAs are reviewed and approved by the Maricopa County Attorney and
the Maricopa County Board of Supervisors,
2.2.6 One or two paragraphs describing the process used to ensure that direct service
subcontractors are in compliance with contractual requirements and CAP policies, including
specifically how and when on-site monitoring will be conducted (if direct services are
subcontracted for all or part of a service(s).
CSD utilizes a variety of methods to ensure that subcontractors are in compliance with contractual
and programmatic requirements. These include:
• Contractual requirements to utiliv,e the Maricopa County Human Services Department/ Comm nni#
Sendai Dioision Polly & Procednre Handbook, which delineates required intake procedures, program
description, eligibility requirements, and confidentiality requirements.
• All subcontractor staff is required to attend CSD Training upon original employment, and to
attend subsequent annual training every year thereafter.
• CSD facilitates quarterly CAP Directors meetings to communicate new developments, discuss
problems, address baniers to services, share ideas for improvements, and to address other
Identified topic areas.
CSD conducts on-site monitoring of subcontractors on a bi-annual basis. This may include facilities,
administrative and financial operations and programmatic service delivery. Site visits for contract
compliance monitoring may be made by CSD or its grantor agencies at any time during the
contractor's normal business hours, announced or unannounced.
Subcontractors are required to make available for and/or copying, all records and accounts
related to the work performed or the services provided under the contract, or for similar work and/or
service provided under other grants and contracts.
If issues or concerns are raised during the course of monitoring, the subcontractor is provided
technical assistance to resolve the issue, and permitted a reasonable timefratne to become contract
compliant% Subcontractor staff may request technical assistance and/or additional training at any time
during the contract term.
CSD requires that subcontractors maintain facility locations which provide sufficient waiting room
space, adequate seating, and restroorns for program applicants at all permanent facility locations,
2.2.7 A monitoring plan for the period beginning July 1, 2015 through June 30, 2020 to include: the
on-site monitoring, scope (administrative, fiscal, and/or programmatic) of monitoring, the
specific service(s) to be monitored, and the target monitoring start and completion dates.
CSD conducts on-site monitoring of all subcontractors on a biennial basis. This may include facilities,
administrative and financial operations and programmatic service delivery. The CSD Senior Grant
Accountant (or designee) completes the fiscal monitoring portion of the an-site visit. The CSD
Operations Supervisor conducts program monitoring to include case file reviews, personnel records,
compliance with Central Registry / Finger Printing requirements, and other administrative portions of
the visit.
4

The length of monitoring visits range from one to three days, depending on. the size and complexity
of the contract. On-site monitoring begins with an entrance interview, during which the scope of the
visit is explained and reviewed; subcontractor staff is afforded the opportunity to ask questions and
obtain clarification if needed. CSD staff use fund-specific monitoring tools to review randomly
selected client records. The sample ensures that the records selected are representative of all
subcontractor intake or case management staff. Client records are reviewed for completeness, client
eligibility and compliance with contract and fonder requirements. At the conclusion of the client
record review process, an exit interview is conducted with subcontractor staff, to discuss findings or
recommendations-identified during the on-site visit, A written monitoring report is distributed to the
subcontractor within 90 days from the date of the visit
Any findings, corrective actions, or disallowed expenditures will be noted on the report. If CSD staff
determine a need for additional training or technical assistance, this assistance is scheduled and
provided within reasonable timefraines to assure quality services and compliance with contract terms
and conditions.
WV 2016 Projected Monitoring Plan
AGENCY ::,:TV-v . . , : o ERvi. DAIk ..
Administrative Case
City of Avondale On-Site Programmatic Management September 2015
Fiscal
Chandler Christian On-Site Administrative Programmatic Case November 2015
Community Center Fiscal Management
Foundation for On-Site Administrative Programmatic Case January 2016
Senior LiVing Fiscal Management
Administrative Case
Town of Gila Bend On-Site Programmatic Management March 2016
Fiscal
SFY 2017 Projected Monitoring Plan
AGENCV TYLE SCOPE SERVICEL: ...
.•.. • ...::::.L.: , -T:..-.::.
Administrative Case
Town of Guadalupe On-Site Programmatic Management June 2016
Fiscal
Administrative Case
City of Scottsdale On-Site Programmatic Management September 2016
Fiscal
Tempe Community On-Site Administrative Programmatic Case January 2017
Action Agency Fiscal Management
Administrative Case
Town of Tolleson On-Site Programmatic Management April 2017
Fiscal
Note: The "Scope" and 'Date" demonstrated in the above plans are snlyeet to change based ttpon sabcontractor
availabili, and mmther of subcontracts in place dttri ng a siven year. SPY 2017 and SFY 2018 _MonitoringPlans
will demonstrate a rotation of snbcontmetors consistent with the pryeeted monitoring plans displged above.
5

3.0 Service Methodology
3.2.1 For the service of Community Setvices, submit the following:
3.2.2 No more than one page describing the procedures used by the Applicant to develop and
maintain a Tripartite Governing Board (for Private, Non-Profit Agencies), or an Advisory
Board (for Public Agencies).
MCHSD is a designatedpubfic CAA and consequently administers Community Action Programs and
Services and related activities through a Tripartite Adoiroty Board as required under federal law. The
Maricopa County Community Services Commission (Commission) was established pursuant to a
Resolution adopted by the Maricopa County Board of Supervisors on February 24, 1970.
Commission by-Laws require that members of the Commission be residents of the Community
Action service area, The Commission consists of no less than nine (9), nor more than fifteen (15)
persons_ Commission membership is delineated as follows:
• Consumer Sector
Not less than one-third (1/3) of the Commission members shall be person's representative of
low- income individuals and families in the community served,
• Public Official Sector
One third (1/3) of the Commission members shall be elected public officials, currently holding
office, of communities within Maricopa County, excluding the cities of Phoenix, Mesa, and
Glendale.
• Private Sector
The remainder shall be representatives of public agencies, business, industry, labor, religious,
welfare, education, law enforcement, or other private groups and interests in the community.
Commission members are recruited using a variety of methods including requests from local cities or
towns for elected officials or their representatives, communication with Subcontractors or local
service providers who can recommend a nomination for the Consumer Sector, and finally through
partnerships with public agencies, businesses, or other organizations having a stake in the community
and have an interest in serving on in an advisory capacity. Vacancies are filled in accordance with
Commission bylaws.
Commissioners fulfill their advisory roles through a variety of methods including policy development,
approval of various monthly, quarterly and annual reports, advice on the alignment of geographic
services areas, funding formula development, input into the CSD Community Action Plan, and review
of contract expenditure patterns. Commission members receive a variety of training to ensure they
understand the roles and responsibilities of CAA advisory boards, This is accomplished through
Commission orientation and ongoing training opportunities provided by MCHSD Staff, and partner
organizations including the Arizona Community Action Association, the National Community Action
Partnership, and CAPLAW.
CSD staff provides support and technical assistance to the Commission to ensure compliance with
approved bylaws and governing legislation including the Community Services Block Grant (CSBG).
The Commission complies with open meeting laws and notification requirements. Notices of
'meetings are posted in the lobby of the MCHSD administrative offices, the MCHSD website,
and ex-nailed to partner agencies stakeholders.
6

3.2.3 One or two paragraphs describing the democratic selection process used to ensure Board
participation from representatives of low-income neighborhoods.
Low-income representatives are selected utilizing various methods including, but not limited to:
• An election;
• Selection at a public forum attended by low-income members;
• Nomination from an organization that is predominately made of volunteer/staff/board
members who are from the consumer sector; or
• Another procedure that involves consumers in the selection process.
When a Consumer Sector Commission seat becomes available, the vacancy is announced to the
Commission, community members, subcontractors, and other stakeholders within the specific service
area represented by the vacant seat. Information regarding the nomination and democratic selection
Process is made available via the MCHSD website so to allow additional recruitment opportunities.
3.2.4 A narrative of no more than one page describing how the Applicant ensures that the Board
fully participates it the development, planning, implementation, and evaluation of the
programs and services to serve low-income communities.
Development - Commission members are primary sources of information and insight regarding the
conditions in their neighborhoods and communities, and as a result help to develop agency outreach
and communication strategies. They bring critical information and perspective to the needs
assessment process and assist in the development of new programs, resource identification, and help
to inform CSD Staff about the changing needs of low income households in each unique geographic
area served.
Planning - Commission members provide information and advice on how to reduce poverty within
the geographic area they represent and participate in strategic planning initiatives which lead to the
CSE) Community Action Plan, Commission members help CSD staff to identify goals, objectives and
performance outcomes for individual programs and also review the Results Oriented Management
and Accountability (ROMA) reports submitted to ADES. Commission members also participate in
annual program planning at the start of each year, and help to establish milestones, or intermediate
steps towards achieving program results. They also track progress through the. review of CSD
Dashboard Indicators provided at each Commission Meeting.
Implementation - Commission members carry out their implementation responsibilities through the
following activities:
• Regular attendance at board and committee meetings;
• Thorough familiarity with agency information, such as Commission bylaws, sources of funding,
agency goals and programs, and federal CSBG legislation;
• Careful review of materials and reports related to CSD activities;
• Full participation in their advisory capacity and any decision-making process;
• Knowledge of all major actions taken by the agency;
Commission members are kept informed of agency programs and activities throughout the year, and
receive periodic reports from_ CSD staff regarding service delivery and fund expenditure patterns.
Evaluation
Commission members review quarterly ROMA reports, and provide advice on the nature and level of
outcomes achieved by CSD Programs.
7

3.2.5 A roster of Board members demonstrating which segment of the community each represents,
i.e., public elected official, low-income representative, members of business, industry, labor,
religious, etc.
Prima Alternate Orkanization
1 Mr. Lorenzo Aguirre Consumer Sector
Foothills Food Bank
Ms. Pam DiPietro Private Sector
City of Tolleson
Ms. Kathy Fair Public Elected Official
Salvation Army
4 Ms. Madeira Pina . Private Sector
Salt River Project
5 Ms. Bonnie 'retinue Private Sector
Atizona Public Service
6 Ms. Cathy cbiang Private Sector
Valley of the Sun United Way
Ms. Amy Schwabenlender Public Elected Official
Chicanos For La Causa
8 Mr. Frank Galled° Private Sector
City of Avondale
9 Mr. Frank Scott Public Elected Official
Town of Guadalupe
10 Judge Lila Alvarez Public Elected Official
11 VACANT Consumer Sector
VACANT Consumer Sector
13 VACANT Consumer Sector
-
14 VACANT Public Elected Official
15 VACANT Private Sector
8

3.2.6 A schedule of planned_ Board meetings for the first contract year.
Commission meetings will be held a minimum of once every three months, to ensure compliance with
the AIDES contract requirements. The existing schedule is consistent with frequency requirements
outlined in Commission bylaws, and is subject to change based upon revisions made through the
bylaw review process.
1Date -:
July 27, 2015 Tatinary 25, 2016
August 24, 2015 February 22, 2016
-
September 28 2015 March 28, 2016
October 26, 2015 April 25, 2016
November 23, 2015 Aflay 23, 2016
December - No Board Meeting June 27, 2016
3.2.7 A narrative of no more than one page describing the service delivery system for services
provided or coordinated with CSBG funds.
CSD administers services and programs in 25 local communities throughout iviaricopa County
through partnerships with local cities and towns, and through contracts with local community-based
organizations who deliver related set-vices in the target area.
Subcontractors provide an array of community action program (CAP) services to include, but not
limited to, crisis case management and financial or non-financial assistance services that address the
CSBG national goals.
Direct Service funds are allocated according to a funding formula identified and recommended by the
Commission. Services provided include, but are not limited to:
• Crisis case management
• Direct financial assistance to address emergencies such as rent and utility assistance;
• Information and referral services
Ili Enrollment in telephone and utility discount programs
• Energy education
• Referral to low-income home \veatherization and utility related appliance repair/replacement
services
Additional services may include provision, food and clothing, advocacy, and enrollment in other
programs for which program applicants may be eligible.
Face-to-face interviews are conducted with program applicants. Interviews are scheduled through
pre-scheduled appointments, walk-ins, or home visits. If there is a medical or personal safety issue,
the interview arid application will be conducted via telephone and mail, In an application process,
9

'general social service interviewing, assessment, crisis case management, information and referral, and
recording techniques are employed. If financial assistance is deemed appropriate, staff will work
with the applicant to gather all necessary documentation to complete an application.
Each subcontractor administers programs and services unique to the needs of their own communities
and service areas. Additional services may include but are not limited to, emergency good boxes,
back-to-sehool drives, bolidity programs, VITA and Erre campaigns, financial literacy classes, and
community events such as health or wellness fairs. CSD is responsible for the provision of training &
technical assistance as well as program monitoring. Subcontractors utilize FISD Online to track all
client applications, client demographics, and benefit information.
Through an intergovernmental agreement and partnership with the Honsing Authority of Maticopa
County (HAIVIC), CSD provides long-term case management to participants in the Public Housing
Family Self-Sufficiency Program. The primary goal of this program is to reduce dependency on public
benefit programs, and move households participating in.Public Housing on to self-sufficiency,
3.2.8 No more than two paragraphs describing the Needs Assessment process within the service
area, the method to prioritize needs, and how the results of the most recent Needs
Assessment will be incorporated in the Applicant's Community Action Plan.
CSD is involved in various needs assessment and social service planning efforts. Human service
needs assessments occur , at the local community level and at the regional level, primarily coordinated
by the Maricopa Association of Governments (MAG). CSD and subcontractors are members of and
participate in subcommittees designed to implement the regional homeless plan initiated by MAG.
Additionally, the CSD Assistant Director is a member of the Maricopa County Emergency
Food and Shelter Board which conducts an annual environmental scan and the NIAG Human
Services Technical Committee which assesses and submits recommendations to AZ-DES on the
use of SSBG funds.
These activities serve as regional needs assessments of Maricopa County. These regional assessments,
together with poverty and population data reflected on the American Community Survey (US Census
Bureau), are used to prioritize needs on the CSD Community Action Plan.
3.2.9 No more than two paragraphs describing how linkages will be developed to fill gaps in
services through the provision of information, referrals, case management, and follow-up
consultations.
Linkages are created at various levels in the service delivery system to ensure that resources and
opportunities for collaboration, coordination and cooperation are maximized.
Coordination - Service coordination and linkages ate established by subcontractors through the
development of formal or informal referral mechanism with other community-based organizations or
service providers delivering similar services, or assisting common clients. The crisis case management
process allows subcontractor staff to determine pressing client needs, and coordinate services through
referrals to agencies including, but not limited to the St. Vincent De Paul, The United Way, The
Salvation Army, Habitat for Humanity, and local churches or philanthropic groups who administer
related programs. CSD routinely attends meetings arid coordinates discussions among and between
service providers and subcontractors to facilitate knowledge and information sharing, with a goal to
better serve our shared clients.
3.2.10 No more than two paragraphs describing how CSBG funds will be coordinated with other
public or private resources.
10

The following list demonstrates the types of public and private sources coordinated with CSBG:
• Social Services Block Grant
• Temporary Assistance to Needy Families
• Low Tncome Horne Energy Assistance Progmtn
• Maricopa County General Funds
• Arizona Public Service
• Salt River Project
• Southwest Gas
• ACAA Home Energy Assistance Fund
• Federal Housing & Urban Development
• Utility Repair, Replacement & Deposit
• Neighbor's Helping Neighbors
• Local Municipal Funds
• Housing Choice Vouchers
CSBG provides the platform from which other programs and services may be offered and allows
important operational resources which allow local providers to complete their important anti-poverty
work.
CSBG funds are critical to the provision of direct financial services as well as crucial in the
attainment, coordination, and leveraging of other fund sources.
3.2.11 No more than two paragraphs describing how the Applicant will provide, on an emergency
basis, for the provisions of such supplies, services nutritious foods, and related services, as
may be necessary to counteract conditions of starvation and malnutrition among low-income
Many subcontractors operate emergency food pantries in coordination with the regional food bank
for the service area and the Arizona Association of Food Banks. These agencies provide
emergency food boxes and may operate various other programs such as Senior Brown Bag
Programs and summer lunch programs for children. If a subcontracted agency does not directly
operate a food pantry, referrals to appropriate resources, food banks, and local pantries will
be made.
All subcontracted -agendes provide referrals to the Women, Infant, & Children (WIC) Program, the
Supplemental Nutrition Assistance Program_ (SNAP) and participate in the distribution of holiday
food baskets, as available. Some subcontractors are co-located with senior centers and may operate
the home delivered and congregate meal programs. Other subcontractors may provide food vouchers
as made available through donations by organizations and businesses. The MCI-ISD Education
Division ensures nutritious Meals are provided to over 2000 children through its Head Start
and Early Head Start programs.
3.2.12 No more than one or two paragraphs describing how the Applicant will, to the extent
possible, coordinate programs and form partnerships with other agencies serving low-income
residents, including religious organizations, charitable groups, and community-based
organizations.
11

Collaboration - CSD has created effective collaborative partnerships with various cities and towns
through formal relationships which establish common program objectives and demonstrate shared
resources for greater impact. These collaborative efforts allow CSD to achieve results which could not
be reached independently, and are evidenced by die Intergovernmental Agreements established for the
delivery of a broad array of services, wherein local cities and towns invest or match available in-kind,
human, or direct service resources to expand service delivery in local areas.
-
Coordination - Service coordination and litiltagcs are established by subcontractors through the
development of formal or informal referral mechanism with other community-based organizations or
service providers delivering similar services, or assisting common clients. The crisis case management
process allows subcontractor staff to determine pressing client needs, and coordinate services through
referrals to agencies including, but not limited to the St. Vincent De Paul, The United Way, The
Salvation Army, Habitat for Humanity, and local churches or philanthropic groups who administer
related programs.
CSD routinely attends meetings and coordinates discussions among and between service providers
and subcontractors to facilitate knowledge and information sharing, with 3 goal to better saw our
shared clients.
32.13 Identify ROMA performance outcomes and any related indicators that will be used to measure
the Applicant's performance in achieving the six CSBG national goals.
: -"10.0w.;hiCOine.penfile:beeOrneniiire .S-61f4Sufficient.:1:7 ,, ,-..
—I ØMPLOYMENT;gRiite- WifigigainUntag.{:liAg4'. ‘,.".g:n.
The number and percentage of low-income participants in Community Action employment
Initiatives who get a job or become self-employed, as measured by the following:
A. Unemployed and obtained a fob
ItaSTW5M141100.- ItESSE . MildeNEIZIVIIPISIVIL;
The number of low-income participants for whom barriers to initial or continuous employment are
reduced or eliminated through assistance from community action as measured by one or more of
the following:
B. Completed ABE/GED and received certificate or diploma
C. Completed post-secandag education program and obtained certificate or diploma
J. Obtained non-emergency L1HEAP energy assistance
K. Obtained non-erner:en , WX eneil assistance
3g.C1 NCOM 'ASSET NIX: jON/ T ADUTflIZATION-_5W1, ,--,
The number and percentage of low-income households that achieve an increase in financial assets
and/or Etnancial skills as a result of community action assistance, and the aggregated amount of
those assets and resources for all participants achieving the outcome, as measured by one or more
of the following:
0 iii:aiii:: i:;:g aiMPIttAii:::1;;AN :::;:ni:
1. Number and percent of participants in tax preparation programs who qualified for any type of
Federal or State tax credit and the expected aggregated dollar amount of credits
3. Number and percent of participants who were enrolled in telephone lifeline and/or energy
discounts with the assistance of the agency and the expected aggregated dollar amount of savings.
iit: -ai,qatac:;:faymK,:24. OTOMIRMWAtit-govinah
1. Number and percent of participants demonstrating ability to complete and maintain a budget for
over 90 days. -
2. Number and percent of participants opening an Individual Development Account (IDA) or
other savings account
12

3. Number and percent of participants who increased their savings through IDA or other savings
accounts and the aggregated amount of savings
4. Of participants in a community action assets development program (IDA and others):
b. Number and percent of participants pursuing post-secondary education with accumulated
savings
c. Number and percent of participants purchasing a home with accumulated savings
GOAL :11i....e.oti4itios'fiii8v" -Iii0116*,i46iiic: Iii)-.4...:" .iiiio- i0 -'.--- -- '
Increase in, or safeguarding of, threatened opportunities and community resources or services for
low-income people in the community as a result of community action projects/initiatives or
advocacy with other public and private agencies, as measured by one or more of the following:
C. Safe and affordable housing units created in the community
D. Safe and affordable housing units in the community preserved or improved through .
construction, weatherization or rehabilitation achieved by community action activity or advocacy
F. Accessible safe and affordable child care or child development placement opportunities for low-
income families ercated, or saved from reduction or elimination .
G. Accessible before-school and after-school program placement opportunities for low-income
families created, or saved from reduction or elimination
H. Accessible new or expanded transportation resources, or those that are saved from reduction or
elimination, that are available to low-income people, including public or private transportation
I. Accessible or increased educational and training placement opportunities, or those that are saved
from reduction or elimination, that are available for low-income people in the community,
including vocational, literacy, and life skill training, ABE/GED, and post-secondary education
-6*-i:him , hggvd:ji;o.t:,..,,,L.,w4*.4:,...,qo,..?--,w.::,,:..v.7.v.:,j..H:f,:,:.:::=.:;;.-:5k:..:,,;m::.,-:.. h.,:-.,,,,,,,,,...=.•-..,--inrA, , &.,..-.5.,:.:,, -.,,,,,,=,,-.F. ,.---:-.,=.5-::,..1:-;..s.s....-. . ., :.,,..',,, ,4.:,,,,,,, ,,,,,,,,,,,:,:v.,.:ri:5-7cri,h4-..,._ ,P,ik5,;t::..n: .,.
The number of community members working with community action to improve conditions in the
community
B. Number of volunteer hours donated to the agency (this includes ALL volunteer hours
.::0 . . N;‘,.'411:4)'in-e'lp-e-9 '*.-':ii*D4- 7::0.7'-'44.110j.be.:ii:7,:j6iiiiiia
r ..-47-13iiiiir . iiniia*OW*0 'k -, • 01. ' u .. :00.1 _ , , ... i 4 ...9 ..,i-- , . --.,',:--z7.7,1z?ii,- ,, •
The number of volunteer hours donated to community action
Total number of volunteer hours donated by low-income individuals to community action
is ONLY the number of volunteer hours from individuals who are low-income)
' iiiiiiiiiiiiirEntpowemcq thmigb: iliiiiiiit7Feasible ii ' iii4: 3k$2106a.VN:;V:=!.c=i
The number of low-income people mobilized as a direct result of community action initiative to
engage in activities that support and promote their own well-being and that of their community as
measured by one or more of the following.
A. Number of low-income people participating in formal community organizations, government,
boards or councils that provide input to decision-making and policy setting through community .
action efforts
C. Number of low-income people purchasing their own homes in their community as a result of
community action assistance
.-;0. 4; .P4O-OtSil1P"SfAniAttg.sOppii**'00 - providers 's OrvicMS :t6'::14.*; iti-644 0 peüpl
ate.-Ac iplie .
Oppo tbtougb Q tuA3.40 ' k r iikt;$
The number of organizations, both public and private, that community action actively works with
to expand resources and opportunities in order to achieve family and community outcomes.
13

The number of organizational Partnerships
Non Profit
Faith Based
Local. Government
State Government
Federal Government
For-Profit Business or Corporation
Consortiums/Collaboration
Housing Consortiums /Collaboration
School Districts
Institutions of post-secondary education/tr min
Financial/Banking Institutions
Health Services Institutions
State wide associations or collaborations
Regional associations or collaborations
GOAL_5 AgenciesJftera -s'e T Otco. .adtz57:,to Achieve Results : _ • :
' - 4.AsiikT [be - ki;$ia:§lagil§
The number of dollars mobilized by community action, including amounts and percentages from:
B. Non-CSBG Federal Programs
C. State Programs
D. Local Public Funding
E. Private Sources (including foundations and individual contributors, goods and services donated)
F. Value of Volunteer time pi ,A. times $19.51
11 174ii ,::i0 - ,tg.'-:Mgpa4iawt,N55.-.4NOP:
The number of human capital resources available to community action that increase agency capacity
to achieve family and community outcomes, as measured by one or more of the following:
Number of staff attendins
Number of board members attending trainings
Hours of staff imtrainings
Hours of board members in trainings
::.GOAL 6 '1 4W4ncoriWpeoliii;:a.60-6Myr-igi — vulnerable populations,: ::, .aelqe.lie:7t . their - ntienii41. . :. -
strengthenrng:4#14:and other supporuve enVironmen0
''.. P - irorgt Jvthg-V40645NOOMINUNAMow:- ,- ,W , t'w.6.dg
The number of vulnerable individuals receiving services from community action who maintain an
independent living situation as a result of those services:
A. Senior Citizens (seniors can be reported twice, once under senior citizens and agaii if they are
disabled under individuals with disabilities age 55-over)
B. Individuals with Disabilities,
a. Ages: 0-17
b. Ages 18-54
c, Ages: 55-over
iriaiWY.; pi44-0 :I.,IIiii, i,,,; , Zt4:01:502:!, ::EM:gattaRigti:UP.
The number of low income individuals served by community action who sought emergency
assistance and the number of those individuals for whom assistance was provided, including such
assistance as:
A. Emergency Food
B. Emergency fuel or utility payments funded by LEHEAP or other public and private funding
sources
C. Emergency Rent or Mortgage Assistance
14

-
D. Emergency Car or Home Repair (i.e. structural, appliance, heating system, etc, „
E. Emergency Temporary Shelter
-.405i4-tr.--74410(:*M0702.§.Z2Witt0.42 -01Z-MgggitgeggetaZignen
The number of services provided to low-income individuals and/or families, as measured by one or
more of the following:
A- Food Boxes (packages, bags, cartons, and meals distributed)
E.. Information and Referral Calls (# of calls)
THIS SECTION INTENTIONALLY LEFT BLANK
15

3.3.1 For the service of Case Management submit the following:
3.3.2 A narrative describing the Applicant's client intake procedures including:
1. A description of how the Applicant accommodates clients at the primary location and
alternative sites, if applicable, that cannot make an appointment during regular business
hours, including home visits.
The CSD Subcontractors are contractually required to make reasonable accommodations for those
clients who are unable to appear for an appointment during regular business hours. Such
accommodations include early or late day/evening appointments, home visits, seeing clients during
the client's lunch hour, or assessing other household members for a possible applicant who is available
during regular business hours.
2. A description of how clients' access services when staff is away during off-site meeting and
trainings
Clients may access services in a variety of ways if staff is away during off-site meetings. This includes
cross-training other staff members (such as a receptionist or accounting technician) to conduct
preliminary screening and payment guarantees until regular case management staff return to the site
location. Subcontractors normally do not experience accessibility issues as interviews are normally
scheduled during pre-determined week days (such as Tuesdays & Fridays), allowing the subcontractor
to attend off-site meetings during other days. CSD training events are offered in split sessions And on
separate dates to allow for flexibility and office coverage.
3. A description of the process used for scheduling client appointments at all locations.
CSD subcontractors each have a unique intake scheduling procedure that is responsive to the needs in
the community. csr) does not see Applicants in the MCI-ISD administrative office, but refers
potentially eligible applicants to the subcontractor that serves the area in which they live. The majority
of CSD subcontractors use a telephone intake system, which allows pre-screening and manages high-
volumn inquiries. An entity in a smaller community may be able to schedule appointments each day,
and take walk-in clients as needed. Scheduling procedures also vary during the course of the year,
dependent upon fund availability. Subcontracted agencies ensure that CSD is advised of any changes
to their scheduling procedures.
4. A description of the process used to immediately assist people in crisis situations at all
locations.
Each subcontractor has defined a process to immediately assist people in crisis situation, per their
contract, which states "Crisis assistance is provided within 48 hours after a household applies, if
the household is eligible for such benefits. Crisis assistance is provided within 18 hours after a
household applies, if a life-threatening situation exists and the household is eligible for such benefits."
A guarantee of utility payment to local utility vendors meets this assurance. For those eligible for
utility assistance, and to avoid utility shut off, each subcontractor ensures that a guarantee of
assistance is faxed to the utility company or guaranteed via the utility company website, for which the
assistance will be provided.
16

With eviction prevention assistance (rent or mortgage), the clients landlord receives and signs a
Maricopa County _financial Assistance Voucher agreeing that the guarantee of assistance will prevent
the eviction.
5. A description of the process used to assist clients when STCS and/or Utility Assistance
Funds have been depleted.
Each subcontractor has defined a process to assist clients when STCS and/or utility assistance funds
have been depleted. Some subcontractors have private and/or local funds which can be used in
situations when funds have been depleted, applicants do not qualify or applicants do not have the
required documents for STCS or Utility Assistance. Agencies that do not have access to other fund
sources maintain partnerships with local agencies offering assistance, such as the Salvation Army, St
Vincent de Paul, and other community-based organizations. Leveraging of these funds benefits
residents who are in need of additional funds or services in order to move forward with their plans for
employment or other activities helping them achieve self-sufficiency. In lieu of financial assistance,
subcontracted agencies may provide directly or referrals for utility and lent assistance, shelter, food,
bus tickets, WIA or job referrals enrollment in other programs such as SNAP, AHCCCS, WIC and
other health programs.
6. A description of how the Applicant provides information, referral assistance in response to
walk-in clients requesting assistance.
Each MCHSD/CSD subcontracted agency has a unique process for addressing walk-in requests For
service. All potential applicants are provided information regarding the regular scheduling process.
Some agencies accept walk-ins daily, while others have stand-by procedures whereby potential
applicants can wait for a cancellation, and others accept walk-ins only on. specific days. Generally, at
each intake appointment, referrals are provided for other services not available directly from the
subcontracted agency. The referrals are coded and recorded into I-ISD Online. Each subcontracted
agency utilizes the most recent edition of the Community In formation & Referral publication/book
provided annually by MCHSD/CSD. Referral information may also be provided in-person and on the
phone for residents who are not applying for services available through the subcontracted agency.
7. A description of how the Applicant provides services at alternative sites.
Services are made available throughout the geographic service area using an infrastructure of service
providers in local communities. Rural ateas of the county are covered through itinerate site locations
and schedules. In the event that transportation is a barrier to accessing program services or applicants
are homebound due to illness or disability, subcontractors may conduct home visits or identify
alternative locations for service delivery: Subcontractors are also encouraged to conduct outreach
activities or community initiatives to advertise available services in geographically remote locations, so
AS to promote program awareness.
8. The procedures used to advise clients of their rights and responsibilities.
Applicants are provided a 'Clients Rights and Responsibilities" form for their review and signature,
The applicant or -client is provided a copy of the signed document. The original of the signed
document is retained in the client file. The application for services "Applicant's Statement of Truth-
and the client "Notice of Approval/Denial/Appeal for Services" also serve to advise clients of their
rights and responsibilities. Staffs review the statements on both of documents with clients during the
interview process. Copies of these documents are retained in the client file.
17

9. A description of how clients that are missing documentation are handled.
CSD subcontractors each have a unique process for handling clients that are missing
documentation. Some allow the client to return later in the day with the documentation, or
reschedule the appointment for a later date to allow the client to obtain the documents, In some
cases subcontractors assist the client in obtaining the documentation (i.e, applying for a copy of a
birth certificate).
3.3.3 A description of no snore than two pages describing the Applicant's case management model
including:
1. The methods ip place to engage clients in the development of a case plan.
2. The steps taken in developing and monitoring the case plan.
3. The steps taken to effect closure of the case plan.
4. The process for referring clients to outside resources and methods used to follow-up on the
outcome of referrals.
5. The process used to evaluate the effectiveness of case management services, and how
evaluation results were used for program planning.
1. The methods in place to engage clients in the development of a case plan.
Subcontracted agencies provide crisis case management services to program applicants. Clients ate
engaged in crisis case management via their request for direct financial assistance with rent/mortgage
and/or utility assistance. Subcontracted agency staffs recognize that this is the client's plan and needs
to reflect the client's strengths to be effective. Based on the case worker's initial assessment and
interview, a Crisis Case Management Form is completed and signed by the client.
2, The steps taken in developing and monitoring the case plan.
The CSD Case Management Plan used by subcontractor's includes the Assessment, which identifies needs
and resources, and the Assistance Plan, identifying the services needed to stabilize the immediate crisis.
The plan development includes the completion of a self-sufficiency assessment by the applicant,
identifying whether they and/or their family is in crisis, vulnerable, Safe, building capacity or
empowered in identified category areas, such as Income, Employment, Shelter, Nutrition, and
Energy. The Self-Sufficiency Matrix is requited for all households (1-TH) in which a member of the f-LH is
18 to 59 of age, not disabled, not a full-time student and is:
1. Unemployed and seeking earned income: OR
2. Employed and seeking to reduce barriers to maintain earned income; OR
3 Are employed and seeking increased earned income and/or income employment benefits
Self -sufficiency assessment scores are recorded in HSD Online client database. Case notes are recorded
in the client file to document progress toward goals.
3. The steps taken to effect closure of the case plan.
Stabilization of the client's immediate "crisis need" signifies attainment of the short term g-oal. Clients
are engaged in crisis case management via their request for direct financial assistance with
rent/mortgage and/or utility assistance. Services provided, including referrals, goods and materials
provided, financial and non-financial services, will be documented by the caseworker on the CSD
18

Case Management Plan and in HSD Online client database. Case notes and any progress made on the
case plan are recorded in the client file to document progress toward goals,
4. The process for referring clients to outside resources and methods used to follow-up on the
outcome of referials,
If the client's requested services are not available through the CSD subcontractor, file caseworker -will
provide referrals and will assist the client in accessing those resources. The caseworker may call the
referral agency on the client's behalf to assist in eligibility determination or in scheduling an
appointment. The .caseworker may also provide the client written materials about needed services and
review those materials with them. If the client needs help with resume preparation or job search
assistance, the caseworker may assist the client utilize the One-Stop computerized career resources,
the WU Access Points, or refer the client to the nearest One- Stop Center. All services provided
will be documented on the CSD Case Management Plan and in USD Online. During subsequent
client contacts, caseworkers will review previous referrals to determine if the client followed
through, if services were received, and if there are any problems that require resolution. Results
of client follow-ups will be documented in the client file and in PISD
5. The process used to evaluate the effectiveness of case management services, and how
evaluation results were used for program planning.
The CSD Case Management Plan is used to evaluate the effectiveness of crisis case management
services. Stabilization of the client's immediate "crisis need" signifies attainment of the short term
goal. Attainment of goals will be documented by the caseworker on the CSD Case Management Plan
and in IISD Online.
33.4 A description of iiroposed ROMA performance outcomes and any other indicators that
demonstrate how case management services,_and the components of case management
services will assist in achieving the six CSBG national goals.
All subcontractors are required to ensure that CSBG goals and ROMA performance outcomes ate
reported to CSI) on a quarterly basis. CSD subcontractors provide case management services to
individuals and families seeking assistance and who are determined to be potential case management
participants. Subcontracted agencies use various resources and tools to ensure case managed
clients receive services and that the services provided and outcomes are reported via ROMA.
Below are a few examples of how CSD subcontractors demonstrate how case management services
assist in the achievement of the six CSBG national goals.
GOAL I: Low-income people become snore self-sufficient.
The Avondale agency assists low-income community members through the Card l at Avondale
Resource Center, The resource center was established in September of 2008 to meet the community's
needs of providing health and human services to residents of the Southwest Valley in one location.
Since the opening of the resource center it has grown and flourished, adding new agencies on a
regular basis, to provide a wide range of needed services to low and moderate income residents
throughout the Southwest Valley. The Avondale CAP refers clients to the appropriate agencies
based on the client's case management assessment. Some of the agencies that are housed within
the Carelst Avondale Resource Center are the Maricopa Workforce Connection (MWC) and the
Freedom to Invest in Tomorrow (FIT) program. The MWC provides various employment
resources such as resume writing, interviewing techniques and job referral. The FIT program
includes an Individual Development Account (IDA) program, which is a tool for families and
19

individuals to utilize in saving toward the purchase of a home. The Avondale agency partners with
those agencies where clients are referred to in tracking the outcomes and reporting those outcomes to
MCIISD/ CSD.
GOAL 2: The conditions in which low-income live are improved.
The Guadalupe agency seeks potential clients, tittouglicase management, for weatherization and
repair/replacement services. Referrals for --veatherization and repair/replacement arc made as
appropriate to MCHSD/CSD Weatheri7ation Unit. In addition, the Guadalupe agency refers case
managed clients to local subsidized housing programs, such as Tempe Housing Authority, Mercy
Housing, Housing Authority of Maticopa County, and Pascua Yaqui Tribal Housing. The Guadalupe
Agency has established partnerships with those agencies and is able to report the outcomes to
MCHSD/CSD.
GOAL 3: Low-income people own a stake in their community.
The Gila Bend agency provides both information and referral to assist in the purchase of housing
and/or starting a business. Staff refers clients to local realtors, financial institutions such as USDA,
HUD, and Veteran's Administration for loans in order to help clients find adequate and affordable
housing. Clients are encouraged to create and monitor a ninety-day budget in order to prepare for
savings. Clients are also encouraged to utilize resources such as tax refunds and first time buyer's
refunds in order to purchase a home of their own. Staff also coordinates with other organizations to
provide local workshops that provide valuable information about home purchases. Clients are referred
to the Small Business Association and other organizations that are geared toward helping low-income
individuals start their own business. Gila Bend agency staff assists in the review and completion of
necessary forms.
GOAL 4: Partnerships among supporters and providers of services to low-income people are
achieved.
The Town of Gila Bend is a subcontracted agency of MCHSD/CSD. A Carelst Resource Center was
established In the Town of Gila Bend in SFY2012. The staff providing emergency, utility, and rental
mortgage assistance has been relocated to the Resource Center, The Director of the Gila Bend
subcontracted agency is now also the Director of the Care 1st Resource Center.
Some of the agencies and services available at the Carelst Gila Bend Resource Center are the
Maticopa Workforce Connection (MWC), First Things First, Southwest Behavioral Health, financial
literacy classes, parenting skills classes, DESIF AA, etc.
GOAL 5; Agencies Increase Their Capacity to Achieve Results.
The Tempe Community Action Agency (TCAA) provides services to the Central East Community
Service Area, The TCAA staff and any new staff attend appropriate trainings and conferences
throughout the year such as peer-to- peer development, grievance and problem solving procedures,
and the non-discrimination policy. They also take full advantage of trainings provided by other
agencies such as the MCHSD/CSD and the Arizona Community Action Association (ACAA) who
offer training classes such as the case management writing skills class and Family Development
training. Attendance at these training classes is essential in the development and knowledge of out
case managers to providing services to out clients. The TCAA reports the outcomes of staff attending
trainings via the qnartedyRpMA report.
20

GOAL 6: Low-income people, especially vulnerable populations, achieve their potential by
strengthening family and other supportive environments.
On November 1, 2011, MCIISEVCSD entered into an intergovernmental agreement with the
Housing Authority of Maricopa County (RAMC) to administer their Public Housing Family Self-
sufficiency Program, The goal of this case management program is to case manage a minimum of 25
families, residing- in HAMC public housing, achieve & maintain economic self-sufficiency.
Indicators of success may include; termination of TAW cash assistance due to income, attainment
of educational vocational goals, attainment of escrow amount goal, purchase of home, acquisition
of employment or full employment, increase in pay rate, paying "flat rent (still in public housing,
but paying fait market rent).
Examples of some of the goals achieved by of MCBSD/CSD Public Housing FSS participants since
January 2012 are
• Six participants successfully completed financial Literacy/education Classes and received
certificates of completion.
• Four participants and/or family members obtained or returned to full-time employment
• One participant started part-time employment
• One participant received a raise in pay.
• Two participants are now paying "fair market rent' (no longer subsidized)
3.3.5 Case management tools to be used in the completion of an individual household assessment
of needs, case planning, monitoring, and final closure of the household case plan.
HSD Online application for Services is used by all CSD and subcontracted agency staff to
document financial assistance, nonfinancial assistance, referrals, and any goods or materials
provided to the applicant
• NICHSD/CSD Case Management Plan is completed by the applicant and caseworker at the time
of application intake/screening
• If required pet state guidelines the self-sufficiency assessment is completed by the client/applicant
at the initial intake. The assessment may also be completed intermittently if engaged in medium or
comprehensive case management self -sufficiency assessment scores are recorded in. HSD Online
client database
3.3.6 A client satisfaction survey/tool to be used, and a description of how and when it will be
used.
CSD is presently developing a revised client satisfaction tool and a protocol for utilization; contractors
will be required to develop a survey process and report results to the Commission.
3.3.7 A description of how the Utility Assistance Program and the STCS Program services will be
available to serve clients on an on-going basis, throughout the entire contract period.
CSD receives a variety Of funds which support utility assistance including Southwest Gas, Arizona
Public Service, Salt River Project, and deposit assistance from the Arizona Community Action
Association. These funds are leveraged with ADES funding to maximize resources and provide
services when LIHEAP or STCS funding are depleted for the month CSD staff monitor fund
depletion rates on HSD Online consistent with the time elapsed in the contract year, and set fund
thresholds on monthly basis to allow for a 12-month program.
21

3,3.5 Client grievance policy and procedures and a description of how clients are made aware of
their rights to appeal decisions made by the Applicant.
Each subcontracted agency is contractually required to establish a client grievance or problem solving
procedure. The grievance procedure is required to include provisions for notifying the
applicants/recipients of their eligibility for service, denial of service in total or partial denial, and their
right to appeal to DES/DAAS if the individual is _not satisfied with the response received from
MCI-ISID/CSD.
At initial assessment, each applicant/client is provided a "Clients Rights and Responsibilities for their
review and signature. The applicant or client is provided a copy of the signed document. The original
of the signed document is retained in the client file.
MCI-ISD requires Subcontractors to provide each applicant/client of direct financial services an
"MCI-ISD Approval/Denial/Appeal for Services" Form, and to retain of copy of that form in the
client's file.
3.3.9 A narrative describing how Client Satisfaction Survey data is shared with the
Tripartite/advisory board and how it will be used in program planning.
Client satisfaction data will be shared with the Commission on a yearly basis. Data will be used to
help inform strategic planning initiatives, identify subcontractor and staff training needs, and to
identify unmet service needs through the geographic area served.
4.0 Experience and Expertise: Submit the following;
4.1 Staff organization chart
Attached
4.2 Key staff Job Descriptions
Attached
4.3 Facility Location and Staffing Chart
Attached
4.4 Describe how the Agency provides staff development, how frequent and on what subject
matters.
CSD provides various staff development opportunities offered according to the position, and needs of
each individual staff member, All CSD staff attend the ACA A conference on an annual basis together
with other related training opportunities,
5.0 Additional Required Documents — Submit the following;
5.1 Assurances
Attached
22

Attachment I
Facility Location Chart
Organization (Contractor/Subcontractor)
Physical Address,
Mailing Address, .
Phone and Fax numbers Where the Geographic
service(s) shall be provided and agency Days and Hours Area to be
staff may be reached Sub Service of Operation Served
Administrative Offices: _
Maricopa County Human Services
Department
234 North Central Ave
Suite 3000 Maricopa
Phoenix, AZ 85004 County
Case excluding the
Community Services Division Management city limits of
(602) 506-4206 Phone 8:00 am- 5:00 Glendale,
(602) 5064749 Fax Community pm Mesa and
Services Monday - Friday Phoenix
City of Avondale Central West
1007 S. 3rd St Community
Avondale, AZ 85323 Service
(623) 333-2700 Phone Area: Cities of
(623) 333-0270 Fax Avondale,
Goodyear,
Care V I Avondale Resource & Housing Litchfield Park
328 W. Western Ave. 8:00 am- 5:00 and
Avondale, AZ 85323 Case pm surrounding
(623) 333-2751 Phone X Management Monday - Friday areas
Chandler Christian Community Center .
(866) 939-0950 Fax
345 S. California St — South East
Chandler, AZ 85225 Community
(480) 963-1423 Phone Service Area:
City of
• Chandler,
132 W. Bruce Ave Town of
Gilbert, AZ 85233 8:00 am- 5:00 Gilbert and
(480) 892-5331 Phone
Case pm surrounding
• X Management Monday - Friday areas
Town of Gila Bend Gila Bend
Care l st Resource Center Community
300 E Pima St Service Area:
Gila Bend, AZ 85337 8:00 am- 4:30 Town of Gila
(928) 683-6502 Phone pm Bend,
(928) 258-7241 Fax Monday — Friday Sentinel,
Paloma and
Gila Bend Community Center surrounding
202 N. Euclid area
Gila Bend, AZ 86337
Buckeye Community Center
201 E. Centre Ave Buckeye
Buckeye, AZ 85326 Community
- Service Area:
All: (928) 683-6502 Town of
(928) 683,-6511 Fax 8:00 am- 4:00 Buckeye,
pm Harquehala
Case Monday - Friday Valley,
X Management Rainbow

Valley, Palo
Verde and
surrounding
area
Town of Guadalupe
9241 S. Avenida del Yaqui
Guadalupe, AZ 85283 7:30 am- 5:30
(480) 505-5385 Phone pm Town of
(480) 505-5385 Fax Case Monday - Guadalupe
Management Thursday City Limits
MCHSD Community Services North West
Itinerant sites as scheduled July — every Community
(602) 372-0728 App Line Monday Services Area:
(602) 506-4749 Fax Balance 1 0 & 3cd of Monday year: cities of
Surprise,
of every month Peoria, El
8:00 am- 4:00 Mirage,
pm Youngtown,
Additional dates Sun Cities and
Case added as surrounding
Management needed areas
City of Tolleson
9555W. Van Buren St. -
Tolleson, AZ 5353
(623) 936-1407 Phone 7:30 am- 4:30
(623) 936-4252 Fax pm City of
' Case Monday - Friday Tolleson City
X Management Limits
FSL Wickenburg Wickenburg
255 N. Washington St. Community
Wickenburg, AZ 85390 Service Area:
(928) 684-7894 Phone Town of
(928) 684-7897 Fax Wickenburg,
8:00 am- 5:00 Wittman,
pm Morristown,
Monday — Friday Aguila and
Case surrounding
X Management areas
City of Scottsdale 8:00 am- 5:00
Vista del Camino pm
7700 E. Roosevelt Monday — Friday
Scottsdale, AZ 85257 Thursday
(480) 312-2323 Phone evening by City of
(480) 312-7715 Fax Case appointment Scottsdale
X Management City Limits
_
Tempe Community Action Agency
Escalante Community Center
2150 E. Orange St. 8:00 am- 5:00 Central East
Tempe, AZ 85281 pm Area: City of
(480) 350-5880 Case Monday — Friday Tempe and
(480) 350-5894 Fax . X Management Fountain Hills
ose holidays marked below (insert an X for applicable holidays):
ix] New Year's Day [ ) Good Friday NI President's Day [ 1 Yom Kippur
] Washington's Birthday [x] Martin Luther King Jr's Birthday [x] Memorial Day [ ] Rosh Hashanah
[x] Columbus Day [x] Labor Day [ ] Lincoln's Birthday [x] Independence Day
[x] Christmas [x] Veteran's Day [x] Thanksgiving Day [x] Day after Thanksgiving Day
Maricopa County works Columbus Day and doesn't work" Day after Thanksgiving Day".

Maricopa County
Human Services Department
234 N. Central Avenue
Suite Phoenix, 3201 AZ maim
Phone: 602-506-5911
Vax; 60Z-5064886
www.maxicopa.gov
Arizona Department of Economic Security
Division of Aging & Adult Services
1789 West Jefferson, Site Code 950A
Phoenix, Arizona 85007
RE: DES Request for Application — Letter of Assurance
Dear Sir or Madam:
The Maricopa County Human Services Depar tment (MCHSD):
1. Assures that sufficient funds are available to meet financial obligations in a timely
manner, while awaiting payment reimbursement from the Arizona Department of
Economic Security.
2. Assures that the MCHSD and sub-contractors who provide direct services meet the
insurance requirements outlined in the Terms and Conditions of the contract.
3. Please send notices to:
Sandra A. Mendez, Assistant Director
Maricopa County Human Services Department
Community Services Division
234 North Central Ave., Suite 3000
Phoenix, Arizona 85004
Office: (602) 506-2316
Email: MendezS002@mail.maricopa.gov
Respectfully,

ITEMIZED SERVICE BUDGET
CONTRACT SERVICE: Case Management (CMG-CAP) Agency: Maricopa County HSD
Contract Period: 07/01/2015 - 06/30/2016
1. PERSONNEL
TOTAL
# of FTE Total Salary for the SERVICE DES
Positions Level Position Title Contract Period COST COST
1 0.25 Assistant Director $80,388 $20,097 $20,097
1 0.50 Programmer Analyst $65,000 $32,500 $32,500
1 1.00 Operations Supervisor $62,577 $62,577 $62,577
1 0.50 Contracts Admininistrator $67,454 $33,727 $33,727
1 1.00 Program Ops Spec. $39,464 $39,464 $39,464
1 1.00 Emerg. Assist. Spec. $38,002 $38,002 $38,002
1 0.75 Direct Svcs Supervisor $62,577 $46,933 $46,933
1 0.25 Family Self-Suff Spec $38,002 $9,501 $9,501
1 0.25 Family Self-Suff Spec $38,002 $9,501 $9,501
1 0.10 LAN Support Spec $58,801 $5,880 $5,880
1 0.10 Human Resources Analyst $58,323 $5,832 $5,832
5.70 subtotal $304,014 $304,014
2.5% Acticipated Cost of Living Raise $7,600 $7,600
TOTAL PERSONNEL $311,614 $311,614
2. EMPLOYEE RELATED EXPENSES
TOTAL DES
ITEM BASIS COST COST
% of Total Personnel
FICA Service Cost 34.00% $105,949 $105,949
Unemployment Insurance
Health Benefits
Life Insurance
Retirement
TOTAL EMPLOYEE RELATED EXPENSES $105,949 $105,949
3. PROFESSIONAL AND OUTSIDE SERVICES
TOTAL DES
ITEM BASIS COST COST
Sub-Contracted Providers of $630,635 $310,285
Crisis Case Mgt & Financial Asst Services
$0
TOTAL PROFESSIONAL AND OUTSIDE SERVICES $630,635 $310,285
4. TRAVEL
TOTAL DES
ITEM BASIS COST COST
Staff & Advisory Board: conference / 6 ind./events X ave. cost 8,479 8,479
training related lodging/travel
TOTAL TRAVEL $8,479 $8,479
5. SPACE
TOTAL DES
ITEM BASIS COST COST

TOTAL SPACE $0 $0
6. EQUIPMENT TOTAL DES
COST COST
ITEM BASIS
TOTAL EQUIPMENT $0 $0
7. MATERIALS AND SUPPLIES
TOTAL DES
ITEM BASIS COST COST
$0 $0
TOTAL MATERIALS AND SUPPLIES $0 $0
8. OPERATING SERVICES
TOTAL DES
ITEM BASIS COST COST
TOTAL OPERATING EXPENSES $0 $0
9 INDIRECT COSTS
TOTAL DES
ITEM BASIS COST COST
Maricopa County Human Services 20.20% $84,348 $84,348
provisional indirect cost rate is 20.2% of
Personnel and ERE only
TOTAL INDIRECT COSTS $84,348 $84,348
10 SUBTOTAL ADMIN COST $1,141,025 $820,675
11. VOUCHERS
TOTAL DES
ITEM COST COST
TANF $409,786 $409,786
LIHEAP $2,451,356 $2,451,356
NHN $6,154 $6,154
ACAA $259,400 $0
TOTAL VOUCHERS $3,126,696 $2,867,296
12. TOTAL SERVICE COST/DES TOTAL COST: $4,267,721 $3,687,971
REVENUE SOURCES:
Maricopa County General Fund $294,384
DES/DAAS $3,687,971 $3,687,971
Rev 4/1/2015 ACAA $285,366
TOTAL REVENUE: $4,267,721 $3,687,971

ITEMIZED SERVICE BUDGET
CONTRACT SERVICE: Community Services (CSV-CAP) Agency: Maricopa County
Contract Period: 07/01/2015 - 06/30/2016
1. PERSONNEL
TOTAL
# of FTE Total Salary for the SERVICE DES
Positions Level Position Title Contract Period COST COST
1 0.75 Assistant Director $80,388 $60,291 $60,291
1 1.00 Program Coordinator $61,262 $61,262 $61,262
1 0.50 Contracts Administrator $67,454 $33,727 $33,727
1 0.67 Sr. Grant Accountant $45,000 $30,150 $30,150
1 0.67 Admin. Specialist $40,000 $26,800 $26,800
1 0.25 Direct Svcs Supervisor $62,577 $15,644 $15,644
3.84 subtotal $227,874 $227,874
2.5% Cost of Living Raise $5,697 $5,697
TOTAL PERSONNEL $233,571 $233,571
2. EMPLOYEE RELATED EXPENSES
TOTAL DES
ITEM BASIS COST COST
FICA % of Total Personnel Service Cost 34.00% $79,414 $79,414
Unemployment Insurance
Health Benefits
Life Insurance
Retirement
TOTAL EMPLOYEE RELATED EXPENSES $79,414 $79,414
3. PROFESSIONAL AND OUTSIDE SERVICES
TOTAL DES
ITEM BASIS COST COST
Check Writing Fees/Issuance 600 Checks @ $18 per check $10,800 $10,800
Community Services Special Projects $100,000 $100,000
Community Action Sub-Contractors $237,525 $237,525
Database Consultant $20,000 $20,000
TOTAL PROFESSIONAL AND OUTSIDE SERVICES $368,325 $368,325

4. TRAVEL
TOTAL DES
ITEM BASIS COST COST
CSD Staff Mileage 300 miles X 12 mo X $10,170 $10,170
5 FTEs X .565 per mile
Staff & Advisory Board Conference 8 events X avg cost $1,432.25 Per Event $11,458 $11,458
and Training Related Lodging/Travel
TOTAL TRAVEL $21,628 $21,628
5. SPACE
TOTAL DES
ITEM BASIS COST COST
TOTAL SPACE $0 $0
6. EQUIPMENT TOTAL DES
COST COST
ITEM BASIS
TOTAL EQUIPMENT $0 $0
7. MATERIALS AND SUPPLIES
TOTAL DES
ITEM BASIS COST COST
CAP/Staff General Office Materials & Ave. $1153.00 per month $13,834 $13,834
Supplies/Postage/forms x 12 mo
TOTAL MATERIALS AND SUPPLIES $13,834 $13,834
8. OPERATING SERVICES
TOTAL DES
ITEM BASIS COST COST
Advisory Board / Community Mtgs Estimated $400 X 6 Events $2,400 $2,400
Conference/Training registrations est. 90 registrations X $187.488 $16,874 $16,874
(ACAA, ACEH, ADOH, etc)
Monthly Parking $78 X 11 FTE X 12 mo. $10,296 $10,296
Parking Validation for 981 stamps @$1.00 per hr. $981 $981
Community/Meeting/Training events
Reprographics (printing forms etc.) estimated cost $3,090 $3,090
Records Mgt Storage/Destruction Based on SFY15 estimate-to-date $4,194 $4,194
Fingerprint Clearance (card) staff & volunteers estimated 8x$85 $680 $680
TOTAL OPERATING EXPENSES $38,515 $38,515

9 INDIRECT COSTS
TOTAL DES
ITEM BASIS COST COST
Maricopa County Human Services 20.20% $63,223 $63,223
provisional indirect cost rate is 20.2% of
Personnel and ERE only
TOTAL INDIRECT COSTS $63,223 $63,223
10 SUBTOTAL ADMIN COST $818,510 $818,510
11. VOUCHERS
TOTAL DES
ITEM COST COST
TOTAL VOUCHERS $0 $0
12. TOTAL SERVICE COST/DES TOTAL COST: $818,510 $818,510
REVENUE SOURCES:
DES/DAAS $818,510 $818,510
Rev 4/1/2015
TOTAL REVENUE: $818,510 $818,510

EXHIBIT A
DEFINITIONS
1.0 ACC — The Arizona Administrative Code,
2.0 COATES — Community Opportunities, Accountability, Training and Educational Services Act of 1998, Public
Law 106-285.
3.0 CSBG — The Community Services Block Grant Act (42 U.S.C. § 9901 et seq.), as mended by Public Law
105-285
4.0 Community Action Agency (CAA) — A designated eligible entity as described under the federal Community
Services Block Grant Act.
5.0 Community Action Plan — A document submitted by the Community Action Agencies to the Community
Services Administration in order to receive the sub-grants or contracts from the Community Services
Administration grant provided under Section 676 of the Community Services Block Grant Act
6.0 Comprehensive and Coordinated Service System — A system for providing all necessary supportive services
within a Planning and Service Area.
7,0 DES EN-005 Application For Benefits — The standardized application for benefits used by DES to obtain
client demographic and financial information from program applicants.
8.0 Designated LIHEAP contractor — An agency designated to provide utility assistance services in a specified
geographic service area, as described under the Community Opportunities, Accountability, Training and
Educational Services Act of 1998.
9.0 Eligible Individual — An individual who meets the requirements for a particular service or program as outlined
under state and federal law.
10.0 Formal Services — Formal services are those services that are provided by an agency or organization.
11.0 Informal Resources — Informal resources are considered family and friends.
12.0 Planning and Service Area A geographical area in the state or state jurisdiction that is designated by the
Community Services Administration for the purposes of planning, development, and overall administration of
services under an approved Title XX, Social Services Plan.
13.0 Private, non-profit CAAs — A designated Community Action Agency that has been established and
maintained as a 501(c)(3) as recognized by the Internal Revenue Service.
14.0 Public CAAs — A designated Community Action Agency that is a unit of Local Government such as a
municipality, or a County Government.
15.0 ROMA — Results Oriented Management and Accountability is a system established by the federal
Department of Health and Human Services for the purpose of tracking and reporting outcomes of the
Community Services Block Grant.
16,0 State Agency — Department of Economic Security — The agency designated to develop and administer the
State Plan which is the focal point for services targeted to low-income individuals and families in the state.
17,0 Linguistically Appropriate and Culturally Relevant — Respect and responsiveness to explicit cultural and
linguistic needs of individuals that is reflected in behaviors, attitudes, and policies that form an agency
service system. Such a system enables the agency, to work effectively in cross-cultural situations. The
agency will offer culturally compatible service delivery in taking into account distinct nuances and differing
values, behaviors, expectations, and life skills that are often rooted in varied cultures.
Page 1 of 1

NO S
0 only) APPLICANT NH DNA Fil-t Received Deductions) Page
. , filHEAP - • WORKER Amount of back
HOMELESS Dyes (13Vure
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0
COUNTY UTILITY SEASONAL Yes Amoont Check Honisaoid income+ *Codes/definitions
ONLY household) No MONTHLY COUNTY 0 Gross Per
USE . - 1ln D is IN Pension linli Received Total' Cron
DES DISABLED Yes DATE NH - Date Copy
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fIlo4 APPLICANT Security No .94 Subagency's
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CRISIS INFORMATION IN D 0 Copy.;
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ECONOMIC uorarounuy ZIP) - El Frequency Chent's E0E/ADA
B BLACK HOUSEHOLD COAA education? INFORMATION Afonthiy, — for
OF — FOR IN CODE APPLICANT'S Shine, 111E.EJI PINK
Exhibit services SITE (City PAYMENTS DEMOGRAPHIC (e.g., ofEN-005-1
LEGIBLY ' No income enero INCOME ClientFile;
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aria PRINT ID CODE MAKE - 0 a cc, YV, Agency's
Am ETHNIC YOU NASCSP ISI income and/or support of See
ARIZONA ot WORKER'S DO Dyes child Method WC,. , 150% —
Division PLEASE i EDUCATION Other brochures to El CANARY
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1Vo.1 SUBSIDIZED and referral DATE PhiMe 0
APPLICATION Apt DATE 1-01 (4)* energy was Income-Source rine guidelines; (Contractect
Streer, BIRTH PROJECT Employment household, APPLICATION Name
. OF AC41 Kb., OR HOUSING with —DES/CM
DATE in poverty
NO Firot, ADDRESS cods/ HOUSING El provided NOTES
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soc, NAME MAILING (Include- IN II - NH applicant single By meets INFORMATION
(11-09) State,21,1 NO. LIVE TYPE TYPE-. Employment the DAYS Income Hinvromber,s client
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persons personas entencler of my porn Departamento applicant NO. deolaraciones
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INFORMATION APPLIPANT'S yes, statements of INFORMATION necessary to paga cantratado. ancilisis, STATEMENT process. program Client's
No.) If STATEMENT best declarocfones verdades made un 'REVIEWER'S reverse
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BLACK MAILING below,. benefits yojuro credit proposttos financial
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1 2 3 4 5
school
file,
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1 2 3 4 income, inducting in noted on
Type S52; and is noted
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e Rousing Homeless CA last 30
(4) Rent Own Other box; Compensation, the is visual document/information
I 2 3 4 5 6 — Nit payments. in -information for
DEFINITIONS Benefits Assistance- Reason
children-) applicoitun) Workmans' verifying acquire
the Insurance
household minor of in appliettion. to
AND Type arent/fernalc parent/male (no date apply temporary disability recetveciNutritton Contract on efforts
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1 2 3 days, self-employment (also may be SacurIV CC .-- facts and
. 30 days.) Scalar Administration. Compensation, in the repired client
one) last checked. including benefits "Benefits" 50 the by DES anyone All of I 2 3
only in the be AND all or last by Security ti made. Notification Status Resident
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only— COM:a employment, employment iTncome member (administered the section. file. resort. Citizenship Legal
public expenses household from from child in income- income from permanent Benefits he client documentation as last (5) U.S. Eligible Non-eligible Resident
Supplemental er crlf Beneits" was was from Is item zero household received "Bene,fits" is used 1 2. 3 4 5 6
Income unplanned condition by & Moony income income other was any Security income, Insurance of document of Code
Household (1411:EeLP of benefits and Safety received Employment any any any no there by AFDC otherincome retirement not pan of Verification Statement-was Ethnic American
reduction and If if Unemployment). if checked, if received Formerly Supplemental Unemployment is Copy (7) -White Black Native Hispanic Asian Other
RR Crisis or assistance Unexpected (Income and Cbeck Check Check is Check Any Any ilssOlance Hard Visual Client I 2 3 4 5
(2) Loss Health TYPE: = Income (Benefits ON:
REVRRSR 1 2 3 4 5 nEinploymette Benefits "no Nutrition completed graduate/GED
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51,4,001 Bri-005-1 Ethnic White Black Native Hispanic Asian Other NASCSP Specielnota Employment= Employment Other Special Income NASCSP = Social Pension Unemployment CS? INCOME RC=-. = EN-005-2 Last 00-08 09-12 High + some school College
(i) , No CA SSI MS VV CS (6) 12

(ADA), or to or (602)
activities, disability wheelchair program disability,
1990 a your contact
of a a
Act services, with deaf, understand of policy,
ties person am beconse this
programs, a who and about
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with . ions, to for takepart or information
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allows in
the part for
and discriinination. reasonable language that take or
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& a
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reasonable
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of Department Department any be doctunort
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of the and if believe
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of religion, activity,
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on or ' making of
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A. 'B. C. at Equal 1990 provide take If in

Exhibit D
COMMUNITY
ACTION
PLAN
SFY 20

Community Action Plan
I. Organization:
ADES Contract No:
State Fiscal Year Covered by this Community Action Plan: SFY
II. Executive Summary
A. Community Action Agency Director:
Address:
Phone:
FAX:
B. CSBG Contact Person:
Address:
Phone:
FAX:
Statement of CSBG Assurances
As part of the annual Community Action Plan required by Section 676 of the Community
Services Block Grant Act, as amended, (42 U.S. C. 9901 et seq.), the chief executive of
this Community Action Agency hereby agrees to the Assurances outlined below:
A. Programmatic Assurances
1, The CAA assures that fonds made available through the CSBG will be
used to:
Support activities that are designed to assist low-income families
and individuals, including homeless families and individuals,
migrant or seasonal farm workers, and elderly low-income
individnals and families; r 676(b)(I)]
Please select and provide a description of how such activities will
enable families and individuals:
Page 2

r"--- to remove obstacles and solve problems that block the
achievement of self-sufficiency;
Description:
Li to secure and retain meaningful employment;
Description:
n to attain an adequate education, with particular attention
toward improving literacy skills of the low-income families in
communities involved, which may include carrying out family
literacy initiatives;
Description:
n to make better use of available income;
Description:
0 to obtain and maintain adequate housing and a suitable
living environment;

Description:
to obtain emergency assistance through loans, grants, or
other means to meet immediate and urgent family and individual
.needs;
Description:
-1 to achieve greater participation in the affairs of the
communities involved, including the development of public and
private grassroots partnerships with local law enforcement
agencies, local housing authorities, private foundations, and other
public and private partners;
Description:
to address the needs of youth in low-income communities
through youth development programs that support the primary role
of the family, give priority to the prevention of youth problems and
crime, and promote increased community coordination and
collaboration in meeting the needs of youth, and support
development and expansion of innovative community-based youth
development programs that have demonstrated success in
preventing or reducing youth crime; r 676(b)(1)]
[J to make more effective use of, and to coordinate with, other
programs related to the purposes of CSI3G, (including State
welfare reform efforts); [1676(b)(1)]

2. The CAA assures that the agency will provide on. an emergency basis for
the provision of such supplies and services, nutritious foods, and related
services, as may be necessary to counteract conditions of starvation and
malnutrition among low-income individuals; [676(b)(4)]
Please provide information describMg how the CAA will arry out this
assurance:
3. The CAA assures that the agency will coordinate, and establish linkages
between, governmental and other social service programs to assure the
effective delivery of such services to low-income individuals and to avoid
duplication of such services, and a description of how the CAA will
coordinate the provision of employment and training activities, as defined
in section 101 of such Act, in the communities with entities providing
activities through local workforce investment systems -under the
Workforce Investment Act of 1998; r 676(b)(5)]

Please provide information desctibing how the CAA will carry out this
assurance:
4. The CAA assures that the agency will, to the maximum extent possible,
coordinate programs with and form partnerships with other organizations
serving low-income residents of communities and members of the groups
served by the State, including religious organizations, charitable groups,
and community organizations; {`676(b)(9)]
Please provide information describing how the CAA will carry out this
assurance:

5. The CAA assures that the agency will establish procedures under which a
low-income individual, community organization, or religious organization,
or representative of low-income individuals that considers its organization,
or low-income individuals to be inadequately represented on the board of
the CAA to petition for adequate representation; 1'676(b)(10)]
Please provide information describing how the CAA will carry out this
assurance:
6. The CAA assures that this Community Action Plan includes a community
needs assessment for the community served, which may be coordinated
with community needs assessments conducted for other programs;
[' 676(b)(11)]
a. Please provide information describing how the CAA will carry out this
assurance. Information should include a description of the Needs
Assessment process completed for the area to be served; the service
gaps and needs identified as a result of the, Needs Assessment; how
service gaps were prioritized; and how the results of the Needs
Assessment were factored into this Community Action Plan.
EXAMPLE;
The Gila County Community Needs Assessment was completed by the
Community Action Program on March 31, 2009. The Assessment
Page 7

included collection of existing data to describe the community
demographics and assets, a review of existing community assessments to
determine needs identified in the past and identification of the current
social, employment and health in the conummity. In addition to existing
data sources, X number of key informant interviews were conducted, a
service provider survey was completed by 37 providers in our service area
and three focus groups were held. Finally, information gained from
Community Forums conducted by Arizona State University on behalf of
the Arizona Community Action Association was incorporated into the
findings of the Assessment.
Service gaps were identified based an analysis of I) the social, health and
employment indicators, 2) perceptions of the key informants, and 3) the
community input from focus groups and the Community Forum.
In preparing the Community Action Program 201.0 Plan, the results of the
assessment were reviewed by the CAP Advisory Board and CAP
management to determine priorities relative to the Community Services
Block Grant Funding, The process for prioritizing included:
2.
3.
b. Please indicate the date this community needs assessment was
finalized:
Month Day Year
7, The CAA assures that the agency will administer the community services
block grant program through a tripartite board that fully participates in the
development, planning, implementation, and evaluation of the program to
serve low-income communities; t'676B1
a. Please provide information describing how the CAA will carry out
this assurance:

b. Please provide the current Tripartite Board Roster and contact
information immediately below:
Tripartite Board Roster
Hoard Member Address Telephone Indicate No More Indicate Length of
Name Number than One: Term and Term
Limit End Date
*Low —Income Rep
*Elected Official
*Business Or
Industry
.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
c. Please describe the democratic selection process used to elect a low-
income representative on the tripartite board:
Page 9

d. Please attach a copy of the current board by-laws as an addendum to
this document and indicate when these by-laws were last reviewed and
revised:
Month Day Year
B. Administrative Assurances
1. The CAA assures that unobligated funds carried forward into the
following State Fiscal Year (SFY) for expenditure will be consistent with
program purposes; [C675 ( C ) superseded by Public Law 107-116]
2. The CAA assures that it will comply with the terms of any contract with
the State, with the State plan, and to meet appropriate administrative
standsrds, performance goals, financial management requirements, and
other requirements established by the State (including performance
objectives); [C 678 C(a)]
3. The CAA assures that it will establish fiscal control and fund accounting
procedures necessary to assure the proper disbursal of accounting for
Federal and State funds paid to the CAA, including procedures for
monitoring funds provided under the CSBG; 678D(a)]
4. The CAA assures that it will participate in Results Oriented Management
and Accountability Practices for the purpose of measuring performance
and results. This includes defining outcomes under the six national goals
that promote self-sufficiency, building agency capacity, and community
revitalization; [`678E(a)(1)(A) and '678E(a)(1)(B)
5. The CAA assures that it will repay the State amounts found not to have
been expended in accordance with the CSBG Act, or the State may offset
such amounts against any other amount to which the CAA is or may
become entitled under the CSBG program; [679C(a)]
6. The CAA assures that CSBG funds will not be used for the purchase or
improvement of land, or the purchase, construction, or permanent
improvement (other than low-cost residential weatherization or other
energy-related home repairs) of any building or other facility; [C 678F(a)]
7. The CAA assures that programs assisted by community services block
grant funds shall not be carried out in a manner involving the use of
program funds, the provision of services, or the employment or
assignment of personnel in a manner supporting or resulting in the
identification of such programs with any partisan or nonpartisan political
activity or any political activity associated with a candidate, or contending
Page 10

faction or group, in an election for public or party office; any activity to
provide voters or prospective voters with transportation to the polls or
similar assistance with any such election, or any voter registration activity;
678F(b)]
8. The CAA assures that no person shall, on the basis of race, color, national
origin or sex be excluded from participation in, be denied the benefits of,
or be subjected to discrimination under, any program or activity funded in
whole or in part with community services block grant funds. Any
prohibition against distribution on the basis of age under the Age
Discrimination Act of 1975 or with respect to an otherwise qualified
individual with a disability as provided in Section 504 of the
Rehabilitation Act of 1973 shall also apply to any such program or
activity; 678F0]
9. The CAA assures that religious organizations will be considered on the
same basis as other non-governmental organizations to provide assistance
under the program so long as the program is implemented in a manner
consistent with the Establishment Clause of the first amendment of the
Constitution; not to discriminate against an organization that provides
assistance under, or applies to provide assistance under the community
services block grant program on the basis that the organization has a
religious character; and not to require a religious organization to alter its
form of internal government except as provided under the CSBG Section
678B or to remove religious art, icons, scripture or other symbols in order
to provide assistance under the community services block grant; r 679]
10. The CAA assures that it will comply with the requirements of Public Law
103-227, Part C Environmental Tobacco Smoke, also known as the Pro
Children Act of 1994, which requires that smoking not be permitted in any
portion of any indoor facility owned or leased or contracted for by an
entity and used routinely or regularly for the provision of health, day care,
education or library services to children under the age of 18 if the services
are funded by a Federal grant, contract, loan or loan guarantee. The CAA
further agrees that it will require the language of this certification be
included in any sub-awards, which contain provisions for children's
services and that all sub-contractors shall certify accordingly.
Signature
Authorized Signatory/Director of the Agency Date
Page 11

IV. Narrative Plan To Implement Assurances
1. Administrative Structure
Please provide a description of the CAA as an organization, its primary functions,
mission, responsibilities, organizational structure, and its association as a part of a
larger entity if appropriate;
2. Program Overview
A. Service Delivery System
Please provide a description of the service delivery system for services
provided or coordinated with CSBG funds, targeted to low-income
individuals and families in the community; [676(b)(3)(A)] This should
include services to be provided, current programs, geographical location,
population demographics, and socio-economic factors existing in the area
Page 12

B. Subcontracting Agencies
Please identify subcontracting agencies, CSBG funding levels, and
services provided by each agency.
SUBCONTRACTING AGENCIES
AGENCY NAME SERVICES PROVIDED CSBG FUNDS AWARDED
ADDRESS
TELEPHONE NUMBER
I.
2.
3.
4
5.
6.
7.
8.
9.
10.
11
12.
3.
14.
15.
16,
17.
18.
19.
20.
21.
22
23.
TOTAL
Page 13

3. Linkages
Please provide information which describes how linkages will be developed to fill
identified gaps in the services, through the provision of information, referrals,
case management, and follow up consultation; r 676(b)(3)(B)]
4. Coordination of Funds
Please provide information which describes how CSBG funds will be coordinated
with other public and private resources; r 676(b)(3)(C)}
Page 14

5. Innovative Community and Neighborhood Based Initiatives
Please provide information which describes how the CAA will use funds to
support innovative community and neighborhood-based initiatives related to the
purposes of CSBG, which may include fatherhood initiatives and other initiatives
with the goal of strengthening families and encouraging effective parenting;
[`676(b)(3)(0)]
6. Child Support Referrals
Please provide information which describes how the CAA will inform custodial
parents in single-parent families that participate in programs, activities, or
services carried out under the CSBG about the availability of child support
services; and refer eligible parents to the child support offices of the State.
[678G(b)(1) & (2)
Page 15

V. Results Oriented Management and Accountability (ROMA) Performance Measures
Please attach a copy of the ROMA Catalog and specify the performance measures the
CAA will report in the timeframe covered by this Community Action Plan, to measure
agency success in achieving the six OCS National Community Action Goals.
Page 16

Measures
Performance
Service
in
Gaps
I 17
Needs Page
Community
Self- Their in and People to Vulnerable by Supportive
More Low-Income Stake Low-Income Capacity Potential Other
Goals Become Which Improved. a Own Supporters to Their Especially their and
People in are People Among Service Increase People, Achieve Family
Low-income Conditions Live Income Community Partnerships of Achieved. Results Low-Income Populations, Strengthening
Sufficient The People Low Providers are Agencies Achieve Systems.

Exhibit E
Part II: Outcome of Efforts FY 20 - Quarter
National Performance Indicators - Agency Level Forms
Name of Agency Reporting: 1 . - .
Goal 1: Low-income people become more self-sufficient.
... 1 u 11
13,9 ii:Or n 4' r. a ofd 7-4-7.--e. — - if 0 00-112-'
....- ,__ P A itiliAriVr1;" . P.' _. 1-*.,_
,..--,. ._„ to - v eM- ,-- ' hl In c 493 7-7, n-
.-","., ltrA Ar0 rfi trAinteli, Da
Ybeallftb_qqafe W• ...w.gfjp_ifi-1.Arm ,:'.,,,,if,- - ,r-r, ' • ,i., ,I.1 'pan -6 -A 0
VATE7agifiti..16uitri -_. flitHiLM..ho,l'iViirm . ,, — 1i , -...,-; ,,, -,,
LniWilve-S.109 -----, . ,---. --- t'ii I .,..,
af4ti ---'''''''''' 1 ' rat-As-lea-1p - -A,.._ ,ff -'- - 4'''''''''a=W4.---:- _ '"-- -=7. -- ,-,_., .7 A_____ ''VE"F` "=--'''''4 __t j______,_
E'ettrn =,j=a__ a'-3, fahl -."4--:-7,-, !:..Nr=7'''''' ,_-'-' , '---: 7" -: If
A. Unemployed and obtained a job itLIMOi
(Pg.16)
B. Employed and maintained a lob for at least 90 days #DIV/iii
(P A.1 7)
C. Employed and obtallyd an
Increase in employment income and/or benefits #DIV/0!
(Pg.17)
D. Achieved "living wage"
employment amitor benefits #DIV10!
(PO 8)
In the rows below, please include any additional indicators that were not captured ahoy
#D NMI
#DIV/o!
#DIWOI

Goal 1: Low-income people become more self-sufficient.
— -., Tt , 47-7-,-
Nbil a Pi0 ancielidialerr, , -L- -.— le._,..,,
OM 9 'S
E Pei - ..• ift
_ M . - n , ...., sq,
Pm- a- Etiiti* teorlie5 11T4
b7g-rfi_ ictArelielifC40.1k1M,0.0-Y10 L--. One
00-004041--1 -. - Oh it041$ Rg ffr 0 =
gan:PliregolierikinAs 13.11 pmrto .....ii.--",,,-„--, _,••=3. -__!,-- ,---„ ..-,—, - ,,-4,
t - 04,11427734;4!" Ni-W.9=.4 `.- - '
A. Obtained skills/competencies required for employment
(P9.21)
B. Completed ABE/GEO and received certificate or diploma
(P9.21)
C. Completed post-secondary education program and obtained
certificate or diploma
(P9.21)
D. Enrolled children in before or after school programs
(P922)
C. Obtained care for child or other dependant
(P9)
F. Obtained access to reliable transportation arid/or driver's license
(P0.22)
G. Obtained health care services for themselves or family member
(Pg2a)
H. Obtained safe and affordable housing
(Pg.23)
I. Obtained food assistance
(Pg.23)
J. Obtained non-emergency LIHEAP energy assistance
(Pg.24)
K. Obtained non-emergency WX energy assistance
(P9.24)
L. Obtained other non-emergency energy assistance
(State/local/private energy programs. Do Not Include L1HEAP orWX)
(Pg,24)
In me rows below, please include any additional indicators that were not qtptared above.

!Goal 1! Low-income oeonle become more self-sufficient. _.
P:Ailiq...0 il i-IF Ok: • -= - ,,,,-.7.- — -
ihilfifitria3- r-..,-* b.7 -a5t.' „,-,_
- ,Ltri'-'- - - -,-,...i,-,-,---- V4717 .--
-''' .. . .140, 11 7. 4,7-1,7:7: 71.
.. ilA tl ia --,
..w ... ,,_ . '
1:310:11u " .,..r... ,4
,---
-4-:
ao ,miatrit. 4- 'ariC -f-,---Parts-ci be .9 ,- -.L.;.--,,,:.-:.
kiedW ., IclpanL - 4,4:.,-...-,-E. s 11.!
Kix .:6701-xiim -i/ ,.- xi . ' left —
,:&.tioTobrvf,,R1)_...*l , 2 - , --"-- - L'-'-' 15 f---' . eti .
' f' tTrAti-roS's se .,a -- - likfri:7.-- si.: - r --., ' e rt -,-,--,
tablitggil(3 TriltrirkCi '"''. he'll' AP --- ri eg. _,:„...
" ' -Y4-4h-aYsiotpcm_ - _. s .....:.p.4-1,q:•, :itlti.-P a W-Ing
g y01)813E1110 01 ---7=---=,, . -, --.:,.. -- 1,- . r,, a,_..__,_44, .,,o;,...-,i.
_
1. Number and percent
of participants in tax
preparation programs
who qualified for any type ,
of Federal or State tax #DIV/01
credit and the expected
aggregated dollar amount
E of credits
N
H 2, Number and percent
A of participants who obtained
N court-ordered child support
C payments and the expected #01V/0!
E annual aggregated
M dollar amount of payments
E (Pg.27)
N 3. Number and percent
T of participants who were
enrolled in telephone lifeline
and/or energy discounts
with the assistance of the #DIV/01
agency and the expected
aggregated dollar
amount of savings
_ (Pg.27)
tf-DIV/01
#DIV/01
#D11170 1

Goal 1: Low-income people become ore self-sufficient.
".; ,.. 1.
a pa itrarki vic,e -, 5--L ;.„. i,-
-(1-1C tiir-f r -X-1.to-ti nu" 0 .,
. --ea -.1- ,,.. Pip .
Ft friP #8.74; g p Oro — .1t.,.o,.. ma
altir -.. t ,, ns 114.14 .4 '611:1d.i! -.i.,
: -- , , rn o ,' e m -4.L5
ff , ke- - '-:-.- -- iti ari .7..,;,. ,9 m _.. in .ffifirtv er..1.k
— r.) . 0 no v., r o _ reit' 1. --ruz
--- ---: 4, v7:7 „.: dro,(0021 'e
• ' — .-,1,--_-
't4 m--fi -L=74- _ --. ', • , -=-4.=---7
1. Number and percent of
participants demonstrating
ability to complete and 4DIV/01
maintain a budget for over
90 days
(Pg.27) -
2. Number and percent of
participants opening an
Individual Development #DIV/01
Account (113A) or other
savings account
(Pg,28)
3. Number and percent
of participants who
increased their savings
through IDA or other 1/131V/01
savings accounts and
the aggregated amount
U of savings
T Pg.28
I 4. Of participants ill a
L Community Action assets
I development program --75.
z (IDA and others):
A (Pg .28) ,
T a, Number and percent ---.
I of participants capitalizing
0 a small business with #D1V/0 I
N accumulated savings -,.....:
(Pg.28) ,
b. Number and percent of
participants pursuing post- ,
secondary education with cr #Divio!
accumulated savings ---.s, ....,.i
(Pg.28) 4i7,
c. Number and percent of
participants purchasing a
home with accumulated -.T- #DIVICl/
,,....,
savings
(Pg.29)
d. Number and percent of
participants purchasing ..
other assets with #D1V/01
accumulated savings
(Pg.28) - 7-,-- -
In the rows below, please include any additional indicators (hat were not captured above.
#011110t
#DIV/Di
#DIV/01

Agency Notes and Clarifications on Goal 1:
Low-income people become more self-sufficient.
[See instructions , page 3]

Goal 2: The conditions in which low-income people live are improved_
-..i,
.--:,. -Odin
4 61
.,.. it
taitutra'l pro tanff}g°001lzati -4 .. 0 --7..,:„. .
i P a-
n°1° -irt-,R, g ig re „. a sy,gpgrAR -4, _ #:RoMffilin Ti°59!_1, ASiOREVICPAIT n, -rl'' n aI1VCS 7..az fir fi.
i OPOArlif*P70ii? OtIc 4q_iiiii)J6,44Y740r -1st '-'9fterkilVrAT _ 11=140#40WWW- - k'
a-±:_filitkiWitaionviT4IfaR45.ilAttilbriiiE 4-11t4giif 1i3Wiiikr6 .79f*bfidualitit.,._ -:-: s*. - ,
A. Jobs created, or saved, from reduction
or elimination in the community
(Pg.32)
B. Accessible "living wage" Jobs created, or saved, from
reduction or elimination in the community
(P9.32)
C. Safe and affordable housing units created in the community
(P1$3)
D. Safe and affordable housing units In the community preserved or improved
through construction, wcatherizalion or rehabilitation achieved by
Community Action activity or advocacy
(Pg.33)
E. Accessible safe and affordable health care services/facilities
for law-income people created, or saved from reduction or elimination
(Pg.33)
F. Accessible safe and affordable child care or child
development placement opportunities for low-Income
families created, or saved from reduction or elimination
(Pg.34)
G. Accessible before-school and after-school program
placement opportunities for low-income families created,
or saved from reduction or elimination
(Pg.34)
H. Accessible new or expanded transportation resources, or those that are
saved from reduction or elimination, that are available to low-Income
people, including public or private transportation
(Pc1.34)
. Accessible or increased educational and training placement opportunities,
or those that are saved from reduction or elimination, that are available
for low-Income people in the community, including vocational, literacy,
and life skill training, AIZIEtGED, and postsecondary education
(P9.35)
In the rows below, please include any additional indicators That were not captured above.

Goal 2: The conditions in which low-income people live are
Increases in community assets 555 result of a change in law, regulation or policy,
which results in improvements in quality of life and assets
or preservation of
community facilities
C. Increase in the availability or preservation of community
services to improve public health and safety
Increase in the availability or preservation of
within low-Income neighborhoods
Increase in or preservation of
resources
IA, Number of community memnars moorrizeo uy L.ommunay Att=uvri
I that participate in community revitalization and antipoverty initiatives
agency
(Pn.41)
Jobs created at least in part by ARRA funds
the rows below, please include any addffional indicators

Agency Notes and Clarifications on Goal 2:
The conditions in which low-income people live are improved.
[See Instructions, page 3]

Goal 3: Low-income people own a stake in their community.
'' ,'--,r' T,R,,. 4".:9,1AW '1•7=i-', '''..1 ,e. rl, "'" . 'L
WI ' a Ileiroliiii de- 141 Ica o 1 ' iiNgit ' - , — - ,
:4-,--, ",-...,-,4 — 1 to_P e -ii,7,
-ail:4A - n- ', --rrii0iknertthtgh te*JoutsJ
en.:uril: Ar , .. vs). ffi). eerai.00 . 0 6 ton! ,,.
Total number of volunteer hours donated by low-income individuals
to Community Action (This is ONLY the number of volunteer hours from
from individuals who are low-income)
(Pg,44)
In the rows below, please include any additional indicators that were not captured above.
-4 , _. ,,- .,. ., „i__",...., r,--q ,,--=-0--f-Virre. , ,,
if National -. enortliamelooldamr- , 7 .__.„ ,--41-.,--„-y;,.:-_,...--,---_," ---?--,,E-. r= - l'ajz-4, _ ..,,_., -- - , - .-r--
1.1,... ,772..
•4'*--t'-4..-,---. ,,....,2_, L., 7.-7,- r...„,.,-7C'— 7:4 ...._- ....;:fly..-,-.7-7----F"- ii:".. .''-'40L,7--.=,--- ..,,.... :.,.,.. E,77tr's." ,-.-• . F-.
Onytnifirrit 0,01eit n Mg amtinuitiFeatib
- '...74e4,-,-, ...: ,,,,,,- ,- -,--7-- ...,.-- m er -= , '.,,
er - owdricoma _ -,a--7---- -,!-.-- , ---_., eirio_i '. ._i z An-,1g2-_a qastra - " :: -t - -- ''' ---- .,, . =Fric,o ,, ..... .. ., 7,- L ., ,
e.gt=', ni ionTi fa 'Ff4 s.o7 -f- . --A,90 --- t - .;16 - - ' 1 n,., , e 0 .64 4 1
that ri). r. E7,... n$11 .-.1,_ o 07, -,...., rj! ",-e-, ,- `,...,...7. pirlown,w0-thein i-7-'- ,---i-i,,Z1 "3..ti.V.€,,-"" --ell- t.'". ' .-fil:',',-:.-4,- 7._-,------ -='-'3'.-q=4. __. -...-,, - :,.,..._,T.
• r,;COMUlg ' sur A5ftemr.:01Or TA 0 ri t-F.:4-:-..&,.. .,-..-4,_,-_,- _ 7:-._4..,
A. Number of low-income people participating in
formal community organizations, government,
boards or councils that provide input to decision-making
and policy-setting through Community Action efforts
(Pg.46)
B. Number of low-income people acquiring businesses
in their community as a result of Community
Action assistance
(Pg.47)
C. Number of low-Income people purchasing their own home
in their community as a result of Community Action
assistance
(Pg.47)
D. Number of low-income people engaged in non-governance
community activities or groups created or supported
by Community Action
(Pg.47)
In the rows below, please include any additional indicators that were not captured above.

Agency Notes and Clarifications on Goal 3:
Low-income people own stake in their community.
[See Instructions, page -31

Goal 4: Partnerships among supporters and providers of
services to low-income people are achieved.
.-. ..
Naito -a .0 aimain607.1ifttlitito ' ':.'-''. TaVS',T7, t , --- .3 , - _
.. _ .. .-,p,-- ..-„.. .1-7. ...„-..., ...‘„,,
'''' Z ,---r.---,--Ti_ _ -q.e..-_, , - ,
anditi 0 o on J00= rou , -
rtirunit i p. :0:, ttS, _ -
- '''----. .._.,.-
,_w,-,-.-- ..-,. -----
Th l zjif:Au znsbottUpublj ! %-.-4, _...L.- .-_,_ -- - --, :A, ;- ' --4-.- Nunibp
0110 01: , UV a , --'-fi.,,--,- -
-,-, Q Mat PO
,..-..--. -.6., - ...5_,.7'."...-ra., :ft:=. .-.1--,..
Non-Profit
Faith Based
Local Government
State Government
Federal Government
For-Profit Business or Corporation
Consortiums/Collaboration
Housing Consortiums/Collaboration
School Districts
Institutions of post secondary educationftraining
Financial/Banking Institutions
Health Service Institutions
State wide associations or collaborations
In the rows below, please add other types of partners with which your CAA has formed
relationships that were not captured above. Please describe these partnerships in Goa/ 4 Notes.
,
The total number of organizations CAAs
work with to promote family and community 0
outcomes

Agency Notes and Clarifications on Goal 4:
Partnerships among supporters and providers of services
to low-income people are achieved,
[See Instructions, page 3]

Goal 5: Agencies increase their capacity to achieve results.
L .-.- --- , ,._
i ortaiR iiice icatcir ---
.. ,
'
,
— ' - __-,
- t r:d WT:0i5 0 0., PAMYT-Pitt q, ,,, ,w:i .:,,,q so
‘p iiip Off; g.t`,1113VO: eag-dritiOa- atl - -,,:+. r,_.- -
tac - 1 . _ I. 'a Ulf] ."ttiLl co eg meit'SUr .---7-: 0 — 31-
1y:1)1* s orto 4:16 o — - ,-
Number of C-CAPs
Number of ROMA Trainers
Number of Family Development Trainers
Number of Child Development Trainers
Number of staff attending trainings
Number of board members attending trainings
Hours of staff in trainings
Hours of board members in trainings
In the rows below, please include any additional indicators that were not captured above. Please
describe these measures in Goal 5 Notes.

Agency Notes and Clarifications on Goal 5:
Agencies increase their capacity to achieve results.
[See Instructions page 3]

Goal 6: Low-income people, especially vulnerable populations, achieve their
potential by strengthening family and other supportive environments,
-4ticfroar-1343.r-VriTtAtocelni
-
Akiirktoiritaiiirc '' f46-14Nk4 00.0.0:41.
A. Senior Citizens (seniors can be reported twice, once under Senior Citizens and
(Pg.55) again If they are disabled under Individuals with Disabilities, ages 55-over)
B. Individuals with Disabilities
(Pg.55)
Ages: 11 -7
18-54
55-over
In The rows below, please include any additional indicators that were not captured above.
-34101ffi Ire*
-F-1.q
aw-ravyk- aitnitbdoa01-,
wr-oViditian 111—
B. Emergency fuel or utility payments funded byl_11-1PAP
or other public and private funding sources
(Pg.59)
C. Emergency Rent or Mortgage Assistance
(Pg.59)
D. Emergency Car or Home Repair
(Le. structural, appliance, heating system, etc.)
(Pg.59)
E. Emergency Temporary Shelter
(Pd.60)
F. Emergency Medical Care
1Pg.697
G. Emergency Protection from Violence
(Pg.6C11
H. Emergency Legal Assistance
(Pq.61)
I. Emergency Transportation
(Pq.61)
J. Emergency Disaster Relief
(Pg.61)
K. Emergency Clothing
(Pg.62)
In the rows below, please include any additional indicators that were not captured above,

Goal 6: Low-income people, especially vulnerable populations, achieve their
potential by strengthening family and other supportive environments.
,t-v.-..--v,-2,:.,4, t_q I - .„ --,--
atro'-n-arreit ifiiiiite: '----- ki ,14ftlnifi KO
4-. - ertki an
oiro: Ott Pam Oyeff> -11Pie'-' tr.T: ...., :=-E,), i$Olit:aii4
!! -1-7, Welting- T. V 7 -lititilii
rn-lierianti,pe_rgerita e=of: rinitiee.in r, e gfittiki ' tcó nen
Natek :00040. „,r-gp aiiiiiit.t: -, &.= t - triiiig,:7-7- JeJnrt1ng- ci
004raltiO. P1*,1qtWefii4 tólIdi et0 ,..,._
-4;.I76( : ----.- - -.. - L. --, --'-i- 4_. ,
lat9.90700 710:19_ 301*4 -, .3,- I--, ,..-
:--
,-, 7-7.vr4.--. -=-17-- -,74 ,-.- 7,-'.• ol
1. Infants and children obtain ---..."::
N age-appropriate -r=": #DIV/01
F immunizations, medical,
A and dental care
N 2. Infant and child health and ..:- 7:T.-K.- -
T physical development are #D1WO i
S improved as a result of -+-q`
adequate nutrition
&
1 Children participate in
C pre-school activities to 11DIV/01
H develop school readiness ..5.u.,,,,,,..-...-,,,,,,::
I skills -- .'F'7g:--tAz-
L 4. Children who participate in
D pre-school activities are _
R developmentally ready to ,7,--ri-7 #01\//01
E enter Kindergarten or ---2-:.=
N lst Grade -4,------,.-7w
1. Youth improve health and physical tF`-; lc-, .7,._„. #DiV/Di
development
Y 2. Youth improve social/emotional .--,-- i:::--,17.v.-„,-,-m,......,,--= ,...--4..:.--,,:r- #DN/01
0 development
U 3. Youth avoid risk-taking itDIV/01
1- behavior for a defined period of time
H 4. Youth have reduced involvement -- 1101V/111
with criminal justice system
S. Youth increase academic, athletic, -= -4 i.,-T-j., , —*:173,pL #01V/01
or social skills for school success
A I. Parents and other adults learn :Er.-,•-. 6-'' '
0 and exhibit improved parenting ,..,.., , #01V/01
U skills rerAza_,A444.:-.:4'
L 2. Parents and other adults learn . ..:1..:
T and exhibit improved family -4.c.,.e. _ #01V/O!
S functioning skills
In the rows below, please Include any additional indicators that were not captured above.
Family Maintenance: (specify outcome) EDIV/Ol
Family Maintenance: (specify outcome) #DIV/01
#DIV/O!

Goal 6: Low-income people, especially vulnerable populations, achieve their
potential by strengthening family and other supportive environments.
"P;_:•j ',OS!
A. Enrolled children in before or after school programs
(Pq.72)
B. Obtained care for child or other dependant
C. Obtained access lo reliable transportation andIordrivers license
fl Obtained health care services for themselves or family member
. Obtained safe and affordable housing
F. Obtained food ass jtance
G, Obtained non-emergency LIHEAP energy assistailce
Obtained eon-emergency WX energy assistance
I. Obtained other non-emergency energy assistance
(StatellocaUprivate energy programs. Do Not Include LIHEAP or WX)
. . .i •. r .7 - A-1 = -+ -.-. . .....+.:a v.,-". r rc. ... ... :,-, ••-_-,,,
4,,' ,.•&b Ll a •,---:•-s- KM—' c a • 5 sE f C -- A M
.., -=-7....4,,,-:,,,, ,... r e , -...z.7,.,,,—, ..2.4-,. r:,------:-.717:'.;._,_ , - .0: 3 , -1-, -. -; - - - - , -, ..„ 4.-•-• _,-E-_.
'OBIAIPAtftervicLe ovidedicL, vi ,Kico elnalta61,131.. -al QM 48-:=4-74:----_-;
=.4_,,, - -,--- fs--..- 657,1-#Mi.
A. Food Boxes
(Pg.76)_
B. Pounds of Food
(Pg•Th
C. Units of Clothing
(pg 77)
D. Rides Provided
(Pg•T7)
E Information and Referral Calls
(Pg 78)

Agency Notes and Clarifications on Goal 6:
Low-income people, especially vulnerable populations, achieve their
potential by strengthening family and other supportive environments.
[See Instructions, page 3]

Exhibit F
COMMUNITY SERVICES BLOCK GRANT
i INFORMATION SYSTEM (CSBG IS) SURVEY
1
Sections D-G and
National Performance Indicators for the Six National Goas 1-6
of
FISCAL YEAR 20
COMMUNITY SERVICES BLOCK GRANT
by
THE NATIONAL ASSOCIATION FOR STATE COMMUNITY SERVICES PROGRAMS
1

Exhibit F - CSBG1S Survey
Section D: Accomplishments and Coordination of Funds
A Use a separate sheet for your answers, or enter them here. Please do not use acronyms.
1. Strategic Thinking for Long-Term Solutions
a. Please describe an agency strategy which addresses a long-term solution to a persistent problem affecting members of the low-
income community, Address the following questions:
1. 1-low did the agency identify the community need?
How were CSBG funds used to plan, manage, and/or dovelokthe approach?
iii. What local partners were involved, and how did each contribute to the program?
iv. VVhat outcome indicators did the agency use to measure success?
v. What outcomes have resulted in FY 2013? If no outcomes yet, when?
2. Delivering High-Quality, Accessible, and Well-Managed Services
a, Please describe what you consider to be the top management accomplishment achieved by your State CSBG office during FY
2013. Show how responsible, informed leadership led to effective and efficient management of CSBG.
Top State Management Accomplishment
b. Please describe what you consider to be the top three management accomplishments achieved by your agencies during FY
2013. Show how responsible, informed leadership and effective, efficient processes led to high-quality, accessible, and welt-
managed services.
Top Three Agency Management Accomplishments:
2.
3.
Section D FY 2043 CSBG IS FORMS PAGE 1 OF 2

Exhib F - CSBG IS Survey
3, Mobilizing Resources to Support Innovative Solutions
a. Please describe how your agency addressed a cause or condition of poverty in the community using an innovative or creative
approach, Showcase how your agency relied on mobilization and coordination of resources to help reach interim and final
outcomes. Demonstrate how CSBG "works' as it funds staff activities, investments, or services to meet a community need.
Include the following elements:
I Agency name (no acronyms please)
ii. Program name
CSBG service category
iv. Description ofprogram (capacity, duration, targeted population, etc)
v. How was the agency's approach innovative Of creative? Please be specific.
vi. Outcomes achieved (include the number of people enrolled and areas affected)
vii. How were CSBG funds used? Please be specific.
viii. What local partners were involved, and how did each contribute to the program?
4. Providing Positive Results for Vulnerable Ponulations
a. Please describe one youth-focused initiative that illustrates how CSBG funding was used and coordinated with other programs
and resources. Include the following elements:
i, Description of initiative
IL What local partners were involved, and how did each contribute to the program?
iii. Outcomes achieved (include the number of people enrolled and areas affected)
iv. How were CSBG funds used? Please be specific.
b. Please describe one senior-focused initiative that illustrates how CSBG funding was used and coordinated with other programs
and resources, Include the following elements:
I. Description of initiative
ii. What local partners were involved, and how did each contribute to the program?
Ili, Outcomes achieved (include the number of people enrolled and areas affected)
iv. How were CSBG funds used? Please be specific.
Section D FY 2013 CSBG IS FORMS PAGE 2 OF 2

Exhibit F - CSBG IS Survey
Section E: CSBG Expenditures by Service Category
Agency Reporting:
Table 1: Total amount of CSI3G funds expended in FY 2013 by Service Category
Service Category CSBG Funds
1. Employment
2. Education
3. income Management
4. Housing
5. Emergency Services
6. Nutrition
7. Linkages
8. Self Sufficiency
5. Health
10. Other
Totals
Of the CSBG funds reported above - were for administration,
Please consult the instructions regarding what constitutes "administration."
Table 2: Of the funding listed in Table 1: Funds for Services by Demographic Category, rv 2013
Demographic Category CSBG Funds
1. Youth •
-
{Individuate aged ¶ 210 18)
2. Seniors
(Individuals aged 55 arid up) •
Section E FY 2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit F CSBG Is Survey
Section F. Resources Administered and Generated by the CSBG Network
1. Name of Local Agency Reporting
2. Amount of FY 2013 CSBG allocated to reporting agencies 2
Federal Resources (Other than CSBG)
3. Weatherization (DOE) (include oil overcharge $S) 3.
4. Health and Fluman Services (NHS)
a. LIHEAP - Fuel Assistance (include oil overcharge $$) 4a_
b. LIHEAP - Wealherization (include oil overcharge $$) 4b.
c, Head Start kc.
d, Early Head Start 4d.
e. Older Americans Act 4e.
f, Social Services Block Grant (5550) 41.
g. Medicare/Medicaid 4g.
h. Assets for Independence (AFI) 4h.
I. Temporary Assistance for Needy Families (TANF) 41.
J. Child Care Development Black Grant (CCDBG) 4j.
k. Other IIHS Resources:
CFDA 4k.i
CFDA ft: 4k.11
ill- CFDA #: 4k,111
iv. GFDA 4k.iv
Total Other NHS Resources 4k.
5. Department of Agriculture (USDA)
a. Special Supplemental Nutrition for Women, Infants, and Children (WIC) 5a.
b. Al USDA Non-Food programs (e.g. rural development) 6b.
c. All other USDA Food programs 5c.
6. Department of Housing and Urban Development (HUD)
a, Community Development Block Grant (COHG) - Fed., State, end local 6a.
b, Section 6b.
c. Secon 202 6c.
d. Horne tenant based assistance • 6d.
e. HOPE for Homeownem Program (H4H) Be.
f. Emergency Solutions Grant (ESG) 6f.
g, Conlinum of Care (CofC) 69.
Jr. All other HUD including homeless programs 611.
7, Department of Labor (00L)
a. Workforce Investment Act (MA) 75.
b. Other DOE Employment and training programs 7b.
c. All other DOE programs 7c.
B. Corp. for National & Community Service (CNCS) programs 8.
9. Federal Emergency Management Agency (FEMA) 9.
10. Department of Transportation 19.
11. Department of Education 11.
12. Department of Justice 12.
13. Department of Treasury
Other Federal Resources:
CFDA 14)
CFDA it: 14.11
CFDA #: 14.111
iv. CFDA #: 14.1v
14. Total Other Federal Resources 14.
15. TOTAL: NON-CSBG FEDERAL RESOURCES
Section F FY 2013 CSBG IS FORMS PAGE 1 OF 3

Exhibit F - CSRG IS Survey
SECTION F. Resources Administered and Generated
16. State Resources
a. State appropriated funds used for the same purpose as 16a. 11111111111111111111111
federal CSBG funds
b. State Housing and Homeless programs (inc.lude housing tax credits)
c, State Nutrition programs
d. State Day Care and Early Childhood programs
e. State Energy programs
f, State Health programs
g. State Youth Development programs
H. State Employment and Training programs
1, State llead Start programs
j. State Senior programs
K. State Transportation programs
F. State Education programs
m. State Community, Rural and Economic Development programs
n. State Family Development programs
cp. Other State Resources:
160,1.
16o.ii.
16o.iii.
Total Other State Resources
17. TOTAL: STATE RESOURCES IOSELL-WW41
18. If any of these resources were aIso reported under Item 16 (Federal Resources)
please estimate the amount
Section F FY 2013 CSBG 1S FORMS PAGE 2 OF 3 •

1
Exhibit r - CSBG IS Survey
Section F. Resources Administered and Generated
19. Local Resources
a Amount of unrestricted funds appropriated by local government 19a.
b. Amount of restricted funds appropriated by local government 191),
c. Value of Contract Services 190.
d. Value of in-kind goods/services received from local government 19d.
29. TOTAL: LOCAL PUBLIC RESOURCES 4_:-41TT.k.f.,a3$7.tr*I
21. If any of these resources were also reported under items 15 or 17, (Federal or
State resources) please estimate the amount. II
22. Private Sector Resources
a Funds from foundations, corps,, United Way, other nonprofits 22a.
b. Other donated funds 2213.
c. Value of other donated items, food, clothing, furniture, etc.
d. Value of in-kind services received from businesses 22d.
e. Payments by clients for services zze.
f Payments by private entities for goods or services for 22f,
low-income clients or communities
23. TOTAL PRIVATE SECTOR RESOURCES
24. If any of these resources were also Included in subtotal items 15, 17, or 29
(Federal, State, or Local resources) please estimate the amount.
ALL NON-CSBG RESOURCES
25. TOTAL: (FEDERAL STATE, LOCAL, PRIVATE)
less amount of double count from items 18, 21, and 24
26. TOTAL Including CSBO
(Item 25 plus Item 2)
Sedan F FY2013 CSBG 15 FORMS PAGE 3 OF 3

Exhibit F - C SSG IS Survey
Section G Program Participant Characteristics
1, Name of Agency Reporting
2a. Total Non CSBG Resources Reported in Section F
2b. Total amount of CSBG Funds allocated
Total Resourcs for FY 2013 (2a + 2b)
3. Total unduplicated number of persons about whom one or more characteristics were obtained:
4. Total unduplicated number of persons about whom no characteristics were °Waived:
5._ Total unduplicated number of families about whom one or room characteristics were obtained:
6, Total unduplicated number of families about whom no characteristics were obtained:
[7. Gender Number of Persons* 13. Family Size Number of Families'*
a. Male a. One
b. Female b. Two
TOTAL' a Three
d, Four
18. Age Number of Persons e. Five
a. 1-5 f. Six
b. 6-11 g. Seven
c, 12 . 17 h. Eight or more
d. 1 - 23 TOTAL'".
e. 24-44
I, 45-54 14. Source of Family income - Number of Families
g. 55-69 a. Unduplicated It Families Reporting
h. 76 + One or More Sources of income
TOTAL* b. Unduplicated # Families Reporting
/ere Income
19. Ethnicity/Race Number of Persons
L Ethnicity TOTAL Unduplicated 4 Families
a. Hispanic, Latino or Spanish Origin Reporting One or More Sources of
b, Not Hispanic, Latino, or Spanish Origin Income or Zero income..*"
TOTAL* 30-10 Below ',tease report the lofel IT of famMes
idanWna the applicable sources or Income
Race c. TANF
a. While SS]
b. Black or African American a. Social Security
c. American Indian and Alaska Native f, Pension
d. Asian 9. General Assistance
e. Native Hawaiian and Other Pacific Islander h. Unemployment Insurance
f. Other Employment + Other Source
g. Multi-Race (any two or more of the above) J. Employment Only
TOTAL* k. Other
I. Total (items c-I)
10. Education Levels of Adults # 15. Level of Family Income
OE For Adults 24 Years Or Older Only) (% Of HI-(5 Guideline) Number of Families"'
a, D-B a. Up to 50%
h, 9-12/Non-Graduate b. 51% to 75%
a High School Graduate/GED o. 76% to 100%
d, 12+ Same Post Secondary d, 101% to 126%
e. 2 or 4 years College Graduate e. 126% to 150%
TOTAL"' 1. 151%1o175%
g. 176% to 200%
1 11- Other Characteristics Number of Persons* h. 201% and over
YOs No TOTAL* TOTAL*** M7--g-K-i- 01
a. Health Insurance
b. Disabled 16. Housing Number or Families"
a. Own
112. Family Type Number of Fatallies.'' b. Rent
a. Single Parent Female C. Homeless
b. Single Parent Male d. Other'
c. Two Parent Household TO TA
d. Single Person
e. Two Adults NO children e. Thiease describe housing situations included in 16.d. Other;
f, Other
TOTAL."'"
The sum of this category should not exceed the value of Item 3
** The sum of this category should not exceed the value of Items 8 e-h
*** The sum of this category should not exceed the value or Item 5
Section G FY 2019 CSBG IS FORMS PAGE 1 OF 1

ExhIblt F - CS83 FS Survey
[Outcome of Efforts, FY 2013
National Performance Indicators -Agency Level Forms
[Name of Agency Reporting:
Goal 1; Low-Income people become more self-sufficient.
ii71154 ..1.
liatikkfRirflY afi el ba r 4 i 0,00 N P. Pgipe,. ,
1- , ... k , 0 , --'" , OP' - *if :
_ _ , _ Et - --- - c 10.140:' _ *
- „... fEcitridi - 1:ne
T nef irnbeand..Lpq.,it ._. _i.p.. ,) 4- ,- e. orb ,
dair L.:-.., ,g0tAlort , 7,-,.--..-,.-A., ."-- '.."."....,:jr,. 01I-&-- I^X P-W-• , -I - - -4,:7, , 4 1-37.--
self: e raS4TreSUI.MX4NIAPP .9 - tri ,Thre - _ j O
arreg4icore- 61direkkiim„. Vftili- — -4.-c ----- 4=2. -,.,--,,,-.--__as-
. fI
A. Unemployed and obtained a Job #nivico
R. Employed and maintained a job for at least 90 days #-DIV/Oi
C. Employed and obtained an
increase in employment Income and/or benefits #DIV/Oi
0. Achieved "living wage"
employment andlor benefits #Diviai
In the rows below, please include any additional indicators that were not captured above.
-#DIVN!
#DIV/0 I
#DIV/ol
Goal 1 FY 2013 GSBG IS FORMS PAGE 1 0F4

Exhibit F - CSBG IS Survey
Goal 1: Low-income people become more self-sufficient
4afnal Perforpnsnceinciteator, _.
,e... .14 Mb" r
... • -dip aft
:I.- }11.14-.V7P e J
The.,fittill ralbli,14gOittelk114 0,rjt,. tom ' ."- t- - - - Pfcants T P.40 eAl),
ik -,— gitigt001_1101N - 'ir:Olgirr4.4 tbfleirlii: . .... , Prktg ,
A.* kF.i,C1-664riji ', 1 i ' - or1444-1§, ,1;-6- ,, , ,,s- fa gannip --, P , -
tOrtisiCINV _ .t:- 1-- • i'ailifeTtF --,
itid***Iii _4 ' .±. - , '-'7=-4Y=Fi -,,....-_ ^- -,,,,,,.. 'V.rii-.= -..,,, ..., ,i •=1
A. Obtained skills/competencies required for employment
B. Completed ABDGED and received certificate or diploma
C. Completed post-secondary education program and obtained
certificate or diploma
D. Enrolled children in before or after school programs
E. Obtained care for child or other dependant
F, Obtained access to reliable transportation and/or driver's license
G. Obtained health care services for themselves or family member
H. Obtained andfor maintained safe and affordable housing
I. Obtained food assistance
J. Obtained non-emergency LIHEAP energy assistance
K. Obtained non-emergency WX energy assistance
L. Obtained other non-emergency energy assistance
(State/local/private energy programs, On Not Include tIHEAP orWX)
In the rows below, please include any additional indicators that were not captured above.
Goal 1 FY2013 CSBG IS FORMS PAGE 2 OF 4

Exhibit F - CSBG IS Survey
, --m- riq,,.r.,:i ,...."1.,7,;
,.,., ,..
-" Niticirial?rilriblin
' •„... _c0,1;9TrItO fl.gfil 07.95. -. r.1 aF
= ' 0.-
' - -.;=:,=-4,4r — -N
nçlpef .; . d..,
::..,.: ow;:ige".5MWou -I 5, N , ke ' ,.-
actiJOVe,.alyffir4a man a a , I urn --- , a. 7-
a-SePWariiflor,11114119L4J.:-$ a...$: ecte ol. , pp ....- cmantS , . Keen gi',, Vçjatd
't-",,(,. reitilateparnitinity ;Op —11' " 'IlievIn ' ' - ii
1.' .. WO if b ri4 iv i'diiir0 _ iiiiioilifiti: 10160.1rni) Mean
appitrit oseAS-th,tkhn itTaanIC ' 6 oitt .7 iii*iiii74!
14$.0 *if/ 11400 -''- - n todife, -,1& iPao rlpz zigAl
m ----- ,.., T .iii-.±2 _ I A ::_,W \n ti s y.P.' 5-
tiqii morel a b.----4 -...,-..
fa 611-"hitg47,;!f '.7- .,=, Y*--;-'.- J.-'4A -I- - :-74:-:(
A, Number and percent
of participants In tax
preparation programs
who qualified for any type
of Federal or State tax #DIV/131
credit and the expected
aggregated dollar amount
E of credits
N
H ii. Number and percent
A of participants who obtained
N court-ordered child support
C payments and the expected #D1V/01
E annual aggregated
M dollar amount of payments
E --
N C. Number and percent
T of participants who were
enrolled in telephone lifeline
andior energy discounts
with the assistance of the #DIV/01
agency and the expected
aggregated dollar
amount of savings
additional indicators that were not
#DIV/01
Goal 1 FY 2018 CSBG IS FORMS PAGE 3 0F4

Exhibit F CSBG IS Survey
n(nmR oeonle become more se -sufficient
-if fP-eirOnitin -'-'' , , .,-.
, - - daidillt d6 -fi -,-" . Oh - - a -
--1-. - -,- - ,-- . porfts 1 .N berO1
_.,,_,.. C'S.Oiti 1.047-ti Ifceirte .._.. ' ii_._. ....r ipants L IAT;:ekrei)" A§9 . . a ._ .
.i.- elitaI -,a
-.-.-. t #0 .. ?,l- 14 <:kal ' Duftri fl 2utcq!nin ,..
.1 ob rtIhg_ 0
!-: T ioIn 4- .... 0 _ .. 1.0 - Otdli
4fik4 1.1IA5
.---. —.,. ..... --
.., 7,
D. Number arid percent of
participants demonstrating
ability to complete and if DI V/01
maintain a budget for over
9g days
E Number and percent of '
participants opening an
Individual Development f/DIVKII
Account (IDA) or other
savings account
F. Number and percent
of participants who
Increased their savings
U through IDA or other #1311//01
T savings accounts and
I the aggregated amount
L of savings
I
Z 0. Number and percent
A a participants capitalizing
T a small business with #DIV/01
I accumulated IDA or
o other sayings
N H. Number and percent of
participants pursuing post.
secondary education with #DIV/Ol
accumulated IDA or
other savings
I. Number and percent of
participants purchasing a
home with accumulated #11V/01
IDA or other savings
J Number and percent of
participants purchasing
other assets with #DIV/DI
accumulated It3A or
other savings
In the rows below, please include any additional Indicators that were out captured above.
#DIV101..
#DIVIO1
#D11/101
Goal I FY 2013 OSEiG IS FORMS PAGE 4 OF 4

Exhibit F CSBG IS Survey
Agency Notes and Clarifications on Goal 1:
Low-income people become more self-sufficient,
Goal 'I Notes FY2(313 CSBG IS FORMS PAGE 1 OF 1

Exhibit F -ESBG IS Survey
Goal 2: The conditions in which low -income people live are improved.
tie 0 'CP orm rid i6 ,_. r .,_,, iiitiet
. .... .. 7:-...,.., _ ,,,- --, .._ ..an Lamm. in
ti) ri ltni)r4v.e.to *if IR VI -. 15 ' . 000- 0 _ -
- _resell:A
, :.i'ri0.1 :. P4,r40 v .-. 1WV,—PP., ,'',. n4wfiiicQrflrnuruly;Msf),4-r-CIT§ - --., -PTO Feat ....
fOrri-CONellikig'- - 061#rir .141 ,Nf.0 • , -, U :0,,CaC1) $IWOrt-SIrti*Ci -
opA vocucy,W1ih.eih ptibliealb 07:0-6*-i-Wrn - " Iiii6:131Y..iii6tWitiei 41 .• - ,----- • - .- .--L--'-'_7:
A. Jobs created, or saved, from reduction
or elimination in the community
B. Accessible "living wage" jobs created, or saved, from
reduction or elimination in the community
C. Safe and affordable housing units created in the community
D. Safe and affordable housing units In the community preserved or improved
through construction, weathorization or rehabilitation achieved by
community Action activity or advocacy
E. Accessible safe and affordable health care services/facilities
for low-income people created, or saved from reduction or elimination
F. Accessible safe and affordable child care or child
development placement opportunities for low-income
families created, or saved from reduction or elimination
G, Accessible before-school and after-school program
placement opportunities for low-Income families created,
or saved from reduction or elimination
H. Accessible new or expanded transportation resources, or those that are
saved from reduction or elimination, that are available to low-income .
people, including public or private transportation
I. Accessible or increased educational and training placement opportunities,
or those that are saved from reduction or elimination, that are available
for low-Income people in the community, including vocational, literacy,
and life skill training, ABE/GED, and post secondary education
In the rows below, please. Include any additional Indicators that ware net caphired above,
Goal 2 Fr 2013 CSEG IS FORMS PAGE 1 OF 2

Exhibit F - CSBG IS Survey
Goa' 2: The conditions in which low-income people live are improved.
,, - •-'1'4', l .P. ''' s.t. 7' '-"A 0-,,
-1?4i-rdgiitild d'aitrir. , „ P
.11/10)O. PM*, A
C01 ( 'IQ* '.,D.t.L.-*: _ and elr TE,-;,.;' li. , - - "S'eS7.-ar,
Alves ci 1 reSeive
0-0 h :L'il _ W''-' fix106c. 0§A-Tiii.dti*'0-00 - v06401, tr.0 nereaseci?-2
1,0041 .4bli) ten-initial : ; cacy, ,...w;-. - M.'- - -
mess1rett. .. • •rrri esiibme.folloWin.ac-=TP -.-4,,L4f,--,7_,
A. Increases in community assets as a result of a change in law, regulation or policy,
which results in improvements in quality of life and assets
B. Increase in the availability or preservation of
community facilities
C. Increase In the availability or preservation of community
services to Improve public health and safety
D. Increase in the availability or preservation of commercial services
within low-Income neighborhoods
E. Increase in Or preservation of neighborhood quallty-of•Ige
resources
trt the rows below, pioase Include an additional indicators- That were not captured above
N onal -PyffirMarlderIndi 4161• -
4----1-7,-:-.F‘-='..,--t-,----.2- _ ,-- ,_ bara _
Qtrtrintiiiii -,.. ngmak ,,, --,,,:,-, ::.,x .T._.-- - ,ra- Or :-... .. __'__=_j-_
, , -,, "-i 401 -
COr-aiiinitfAttiorKT rn136ve-bo-riti on, iie ihrmi r , ,,, ,7,-,=' ..
"A. Number of community members mobilized by Community Action
that participate in community revithlization and anti poverty initiatives
B. Number of volunteer hours donated to the agency (This will be ALL volunteer hours)
Goal 2 FY 2E113 CSBG IS FORMS PAGE 2 OF 2

Exhibit F - GSBG IS Survey
Agency Notes and Clarifications on Goal 2:
The conditions in which low-income people live are improved.
Goal 2 Notes FY 2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit F - CSBG IS Survey
Goal 3: Low-income people own a stake in their community.
j'iti Fr atOi"arie'sfif 6ted': _.
,--„,-, , ..,.-pLw,,,,,:. - 4-_,-- TRtil-144#040,0t-
_ iiiiiili 013_,En giow Oh, xioutry,R04ibleT fpg - —i.. ..
..,,z-,-,:i- -A--, - -,,---,,--:-- ..-'-------,.. -
g.Ukin'ide Or •fziti - 1.;.houro=fjci-oOta 0 7Iiiirk IACcin
A. Total number of volunteer hours donated by low-income
Individuals to Community Action (This is ONLY the number of
volunteer hours from individuals who are low-income)
In the rows below, please Include any additional indicatora that were note -ohm:I above,
kill R tritthiViiiik.atat ,.- ..-,-tigpi " __,E. _ - „,- 1: -,.....,-,,.......
3 -q.,.. , ..;3:,.V.- -.. .:7,: Vi-'4, g! • --.... ---,-- 7:: : a F.E-,
latiti40 ltilf4.02- ATihkot; taii1011P4Ofoas _ z•Lg;-::: ---,--• ••.-
, NI ...,,Mc-P0-119170-3:1ftig*I1 fr.,--4-7' com
, RIRTJA-4601-0:01 4150RidfdatitatM, W--.4--:-,14,._ •• • rpp -2,-.
.._ too -fa-pAy91:Ktf*Kovi.4-giyAIOptbd*O1 _ -'4;3:,_, - —
tiii31646710144asipii.latieaWntiii2errr6g, 1410/33r047-, ,,;x., „
A. Number of low-income people participating in
formal community organizations, government,
boards or councils that provide input to decision-making
and policy-setting through Community Action efforts
B. Number of low-income people acquiring businesses
in their community as a result of Community
Action assistance
C. Number of low-income people purchasing their own home
in their community as a result of Community Action
assIStanca
D_ Number of low-income people engaged in non-governance
community activities or groups created or supported
by Community Action
In the rows below, please include any additional lockators that were not- captured above.
Goal 3 FY 2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit F - GSBG IS Survey
Agency Notes and Clarifications on Goal 3:
Low-income people own stake in their community
Goal Notes FY 2013 GSBG IS FORMS PAGE 1 OF 1

Exhibit r- CSBG IS Survey
Goal 4: Partnerships among supporters and providers of
services to low-income people are achieved.
-, 4—
la' • I : % IO C , +
4,130,0 B' .. ...-... ttiffibP1
4,1iiiiii ' )614324- rs ' ,
...,-.
_ !,41 .-fi fr-gip-iiiikao (i, --go v , gr,o ,c, u AoTti...
4o,:pm ur.gto4064-- tkOldit-1/1/ 4.44/ Aiii3OkP '
ittsrsur rnlit_ppo I Di& itr.:a Wel i . ._,.,._. ii-.-
A. Nonprofit
B. Faith Based
C. Local Government
C, State Government
E. Federal Government
F. For-Profit Business or Corporation
G. Consortiums/Collaboration
II. I-lousing Consortiums/Collaboration
I. School Districts
J. Institutions of post secondary education/traintn
K. FinanciallBanking Institutions
I., Health Service Institutions
M. State wide associations or collaborations
In the rows below, please add other types of partners with which your CAA has formed relationships
that were not captured above.
N. The total number of organizations and total number
of partnerships CAAs work with to promote family and a 0
community outcomes (automatically calculates)
Goal 4 FY2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit F - CSBG IS Survey
Agency Notes and Clarifications on Goal 4:
Partnerships among supporters and providers of services
to low-income people are achieved.
Goal 4 Notes FY 2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit F - CSBG IS Survey
Goal 5: Agencies increase their capacity to achieve results.
,.--,.... "
Naiin Wirrontialc6 ..—..... hid0a. or 4.,
,
AeiicrDeveIOmeiit
1110,IiitirrINFPf_ Tarp gtkr.r,,q.put:44::atit.011aPle i3Re _..— 40 r
'_do'ffiffivii—A an. ,,nr,4540i.W.6:4:40. "-A —
-' v rN ti war' 't1163iireliAriaassi =Atufley
..-. ,
A, Number of Certified Community Action Professionals
B. Number of NatIonally Certified ROMA Trainers
C. Number of Family Development Certified Staff
D. Number of Child Development Certified Staff
E. Number of staff attending trainings
F. Number of board members attending irainings
G. Hours of staff In tralnings
Ii, Hours of board members In tramings
In the rows below, please include any additional indicators thatweie not
captured above.
Goal 5 F''2013 CS BG IS FORMS PAGE 1 OF 1

Exhibi1 F C,SBG IS Suivey
Agency Notes and Clarifications on Goal 6:
Agencies increase their capacity to achieve results.
Goal 5 Notes FY 2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit F GSBG IS Survey
Goal 6: Low-income people, especially vulnerable populations, achieve their
potential by strengthening family and other supportive environments.
iIlailtinalIPOilOtrainte. nilicator .i_ tgara
7--..,,,i ,..., , ,,, . hno6a
)406-pogo et - „..,,,.-, - ,- -_,.- , .
,---,- 4 P4gflArl
XtIeiri lr PT 'e q A.4utll e---'' '' 01.0111.31z101.000.g.41-12 11 Ae - ,, .4,-- ,..
lAilW tbdapdibent I Ktiii,tliiiitiOri asiii.s—iili.011116Str,iiev '.:.--,.7. '1,=.-_
A. Senior Citixens (seniors can be reported twice, once under Senior Citlzena and
again if they are disabled under individuals with Disabilities, ages 55-over)
B. Individuals with Disabilities
Ages: 0-17
18-54
55-over
Age Unknown
TOTAL Individuals with disabilities (automatically calculates)
in the rows below, please include any acklitlo pal indicators that were not captur ed above,
,, ' --0,4_4-1., ... '."--,‘ i-.'1,.
.hiiiiial`PeitorManceibtillc-atOr '- --, -..
-.;_•:;,, . - -- ,;:.•-,0...:_.,0,--- " -"— • •-•: ..• f•-.., r --,—
,--,... ,:,= ,--...-. Mil Y_LI
--":7 nOlst 4 ali. . royigila ,
An'OlittlI4F(r;
14)611 (Oil - Tititip-1009, •assi n ''':.,-- 7sS tittie. sit-42.
pfyieMi?Mlivid lib -76t,V,hnmT '-
vet 4shr,
A. Emergency Food
B. Emergency fuel or utility payments funded by LIHEAP
or other public arid private funding sources
C. Emergency Rent or Mortgage Assistance
D. Emergency Car or Home Repair
(i.e. structural, appliance, beating system, etc.)
E. Emergency Temporary Shelter
F. Emergency Medical Care
G. Emergency Protection from Violence
H. Emergency Legal Assistance
I. Emergency Transportation
J. Emergency Disaster Relief
K. Emergency Clothing -
In the rows below, please inolud5 any additional indlUators that were not captured above.
Goal 6 FY 2013 GSBG IS FORMS PAGE 1 OF 3

Exhibit F CSBO IS Survey
Goal 6: Low-income people, especially vulnerable populations, achieve their
otential by strengthening family and other supportive environments.
ft4110.410-gila Ti:q1' itytqaPt . . 1161i14 k.
OiliPa - ri K Mil Ovilogirrnii X :p °:liNtli.46tij ,.-e'keptitg
4j - -TA _ — - c .
Ttifirro : „rtztf 04-11',Ibigits Num — 6 . er .. 'olitioiiiis - - ' - u o :AV o ... ., oftw -
Childmrior --- _ ' Niki ailicipalow ,...- . .. * -6 .. o. .... -C• i.)
0-10,.P.„-9 - 11:01PfPailtaiii5p, nrolledlit ,-, ,..., , • _el _ rio
.014 .00-tP "4414-R4--54-ev, ligiaiii)( ._ -,..
KaiRttEgOA $.`"A_ e -1'''• . - .._. ,,. -,---- — -
moreitififiie;fo ..
,..F.I.:,-.;$fa,- ..- , ._,:, - -.
I A. Infants arid children obtain
N age-appropriate #DIV/DI
F immunizations, medical,
A and dental care
N B. infant and child health and
T physical development are #IDIV/01
S improved as a result of
& adequate nutrition
C. Children participate in
C pre-school activities to #DIV/01
H develop school readiness
I skills
L 13. Children who participate i n
O pm-school activities are
R developmentally ready to #DIV/01
E enter Kindergarten or
N 1st Grade
E. Youth Improve health and physical #DIV/01
development
Y F. Youth Improve social/emotional #DIV/01
Ci development
U G. Youth avoid risk-taking #DIV/01
T behavior for a defined period of time
H H. Youth have reduced involvement #01V/01
with criminal lustice system
I. Youth increase academic, athletic, #DIV/01
or social skills for school success
A J. Parents and other adults learn
ID and exhibit improved parenting #DIV/01
U skills
L K. Parents and other adults learn
T and exhibit improved family #DIV/01
S functioning skills
In the Mows below, please include any additional indicators that were not cantured above.
#DIV/0!
#DIV/01
4
#DIV/D1
Goal 6 FY 2013 GSBG IS FORMS PAGE 2 OF S

Exhibit F- GSBC IS Survey
Goal 6: Low-income people, especially vulnerable populations, achieve their
otential by strenqtheninq family and other supportive environments.
atiOla!-pe ONM,a th e.A. Ikto;Mili r.:,_
--,-"•-•P'7,,J,-- —
FUiJ$gjiPia ag NA 'arid. Paregyes)_ - — - - .- - Il Niiijbr h1eyl
..... *.!6,:.:4*. ..,. Eri -
VOWat1OD 01110,0p e4iti_ :00jf) 0 eCia. sre.ifio
4'4,t40.ikififisaniiitieerigfirOn:rigIV-ors I-awrt bem10' -a.: ram ..4riQd
whiAbii.iyAiglifiWdyliiit av ,"5-Q
A. Enrolled children in before or after school programs
B. Obtained care far child or other dependant
C. Obtained access to reliable transportation andlor driver's license
II Obtained health care servicee for themselves or family member
E. Obtained ancittir maintained safe and affordable housing
F. Obtained food assistance
G. Obtained non emergency LIHEAP energy assistance
H. Obtained non-emergency %IX energy assistance
L Obtained other non-ernergency energy assistance
(State/local/private energy programs. Do Not Include LIHEAP or WX}
-..-:?-1,-,-. ,-- :.--- ,..-- ,-,...-:-:_ ,--, -
s- - "=1-;•"; ,-, _LL, . .... ,--- -"%
5
'#)011.)to4 ilsr.Appeot.crriorefotih'eifoilo-vii1ii,,..7,--
A. Food Boxes
B. Pounds of Food
C. Units of Clothing
0. Rides Provided
E. Information and Referral Calls
Goal FY 2013 CSBG IS FORMS PAGE 3 OF 3

Exhibit F - CS13G IS Survey
Agency Notes and Clarifications on Goal 6:
Low-income people, especially vulnerable populations, achieve their
potential by strengthening family and other supportive environments.
Goal 6 Notes FY 2013 CSBG IS FORMS PAGE 1 OF 1

Exhibit G
Monthly Payment Verification Form: Community Services Block Grant (CSBG)
Agency name: DES Contract no.:
Report month: Prepared by: Phone no.:
A. Client ID # B. Client name C. Application date D. Vendor name E. Amount
Mill1111111.11*Total is actua] dollar amount reported on monthly FVV110 *F Total: $0,00
A. Enter the assigned client ID number for the client assisted with this service (do not provide Social Security Numbers).
8. Enter the client's name as it appears on the application.
C. Enter the date the application was taken.
D. Enter the Vendor's name that rendered Services.
E. Enter the amount of benefit paid on behalf of the household.
F. No data entry necessary; this is an auto-sum cell.
Sep 8, 2010

2015
SFY
for
8-14
Revision
ES
tuyOggei IV/In
0'
AZ , ;1
Services 9-1-14
*AI
El
for '14,iiii 4'1 0
;
,
In
,t
Adult 1-44,:fiiii:k, populate. triangle DES:
Report Effective and
J, and . to
I net red
ow . Notes
trid . 'I SO Name with
and 4 '-. rill
Month . Submitted: 14 i ' In Provider
I Agertv
Tear . examples.
Monthly 2015) •r, XIV 0*. ,... highlighted for Hoveraversecticns
Reporting bate ig and Service
Aging 13- E
: Included
'.. keen
lIst McnIti. dIreCtions
June
I Wrf.1 Iis ,.,
of ROTES:
(CMT) ,,,,,Irnr, I- elnwn
Regular Supplemental IHEAP Reporting corner:far
,, ..t DRS Drop
TII 1 L
#0 ,, :st
, ...,4 ,I
Division through
''
44001 idifittl ,
N 0
44
04 ral 0? 4
Management 1
,, $1
2014 - 1r
t '1g
Security, C 4 -,4. ii„, iI
„Iil t i•I" ' I' d
If " I.4 ,,
r
(July g'
4 . T
- .,.. "
Case . l' -qt G
.. .-, p
- if
2015 , :„ .11}1
ta .i44,i,a' ,„1,..„
Economic :;1744-,,,:: :'%tagr.
ert Mr ID ,i,j, , ,-.!.;;..;
Action 1 t walk Other-I
t _-, ,i111.c .6.610010tbir.0.0 LA: WA' , ;;,,,,-.,,.,
Year . I kit
: ; Home_
Conhactt Telephone + I ASSISTED dalgOiii,44iiiii rnwr pfIce Workshnn Melted
of ,,...,:,
d 6.4.Z41 ":f.,_;,,;:,v: In In Total:
ii, Or A. S. C. D.
Fiscal . Q,,
ii- " WHETHER ,,,,,,,:
Community 1.''..' #00 ' rlyr
.1j0.1 .,-.r **1,iii4, .,..,.,.,._,,
Department ' : OF II•IIfilwilm
._/1 P9
State '
. id "
El in ,..r.. REGARDLESS '" ,.„...-,.,;. mownweimmimilimumI . o 0 0
. 9 • .4.. ': •
,„
;,,,, , Pliiiii.;
..1, .P16143W4Iiid ''' I,
, 1 ' -
-'1 :!','.., ylifil-14 r.ipm*kip fwp:f6i:poig 11K04000e-q: 0
ill -0.t.. CATEGORIES. .Arz'gie. -,
.. '
.." i. , ; MIESIONEMININNWORMIMANIVAW
0 .- 9 ':i :
A ' ' Or; Airti
l .., attiNZ,:.,.0t, ' ALL 'iikili0e*
4.1IL 1 .34,ppmr.:t.. 0
. MoftflottIO.tle,tilio:41;00q.11.6.110:00:010110,6.0i
isii6.':'.ig.i.,6iGiiiii ti'iiii-165"-
, ''''' 1 HOUSEHOLDS- i
11.L......RWLL,0 ,.. _..
• .„. at
: TOTAL ,i, 1,
' Of " . LIHEAR:
: VOUCHERS Motel ' ,p Etif,„5
HI Navel by.. Assistance CU .411 . '41 ... iiiiiilAtatifOii* n '.' i MEW
I .0 LIFIEAP APPLICANT , of
Renter l' H EmErmaszI LHEAP types
ExIibit Submitted Assistance 1.1.2. j#01 lib 4.' g, LIHEAP ,
Agency Needs of , et LINEAR p!votifitiCril
HOUSEHOLD e ,... • Sloptemental both
T4 Lin..., Supplemental LIHEAP r Regular of
, 1,1111I5i Mortgage, eclat re Regular Atplpii0 RegSlar
A. . S An EN iL tl I Pi E. A.. E Total

STCS total dollar from (For be we: not. nat. unduplicated
the the Assurance households needs This AUTO- duplicated duplicated can assistance Assistance LIHEAP. one L1HEAP benefit, not. or or or self-copulate.
received Enter deposits. Enter $", the The month. be data and of not. assisted assisted assisted not of
that month. LIHEAP under special WILL be can can this LIHEAP Utility regular disabled type assistance should or whether whether or number will
and month. and month. or reporting CELLS data data category; a if for one (This assisted whether assisted the They
Households needs. report the payments reporting # HH education reporting r. the THE FPL. FPL. FR._ this this of type example, Child) was who least at Supplemental month. FPL, FPL, FPL, of reports yellow.
the special during utility the "LIFIEAP the mortgage/rent/motel, during of of 150% category; category; LiHEAP each For Young received report whether of of 125% 150% whether section liaht
for c) and for conservation for Supplemental funds month. REQUIRED; FPL. 100% to 125% to and For - groups. or member that LIHEAP the FPL, 100% to to FPL, This in
amount motel, assistance regular Assistance #2 services of 75% 101% 126% FPL. LIHEAP LIHEAP Supplemental Child Disabled, one once a for of 75% to 75 101% 126% of 150% 4) and biahliahted
dollar or Include under energy 'LlHEAP utilities, budget. NefN the reporting ENTRY 75% between 150% younger). household contained and assisted under between between between over 3 are
total rent Motel or month. Utility included and received and for service with the aea wasjaetween b'efween over Supplemental Supplemental the or or (Elderly, household benefit not is is is is- is —Measures and "0"s
the mortgage, Rent be assistance that month funded for incorne'Was,,ander was was was younger). Category 5 Elderly/Disabled/Young vulnerable group Household a assistance. or income income income income income 2 have
Enter reporting Supplemental not :Useholds Supplemental" reporting Itheibit:m:zed thiellOusehold category)MN,..?DAJA income income income income Olinger), the or Age a Count assistance whether whose Tier 4, that
INSTRUCTIONS month. b) Mortgage, the should whose whose or 6 LIHEAP under three vulnerable If LIHEAP whose whose whose whose Table cells
report assistance, and during received data receiveVility tile110 "LOW the for LIHEAP:whose whose #,Ppategory:jor,the or LIHEOlgategory 'Age once the of any example; LIHEAP of 1_11-1EAR LlHEAP LlHEAP LiHEAP LIHEAP LIHEAP in data
the assistance that This that for jta0Wor funds,a0S4d1b utilitMelistanoiCOyment alarnount LINEAR Supplemenfat,LIHEAPfWhose LiH.tAp under Regular and UNDUPLICATED to any under UNDUPLICATED. regular types Measures, input
during utility a) assistance month. amount under assie Supplementa(Lloap :104SupplementelHEAP a; LIH or#WatertslAge5 the -elderly ASSiSTANCZ a two ASSISTEp Supplemental Supplemental Supplemental Supplemental Supplemental Supplemental Assistance Not
MANAGEMENT utility Motel households reporting households dollar and/or received a dollat' Supplemental MONTH Supplemental OtaSeiipplemental 'e,_ teaaa FOaglir Elc1410,0"`once Youtigekin und (911 meMber,beldigidg hOUSehibld.oke BE received receiving Do
services categories: regular or of of the $", that non-DAAS received the Enter theARgular EldekOirid H44 once MUST WHETHER and/or and/or and/or and/or and/or and/or (Energy application.
STCS the Rent number the for number enter "LIHEAP or that CATEGORY. the REPORT and/or .and/or — in or 5 .AiiiStance that THE'lVikNERAELE:CATEGORIES:4Another bitiVONCE). UHEAP DATA household of Data the
CASE to received the Also households Funds L1HEAP. anti/or Assistance Assistar4t4hd/or Assistarib0 Assistance* :orolder HousehCild,Member PhOeunder Age one -agent OF a OF Assistance Assistance Assistance Assistance Assistance Assistance Fuel of time
received according that Mortgage, Enter assistance the and # of households AUTO-SUM THE Assistance Disabled'06*under Member ari.'Peamder,DlSabled EACHlyPi:a haa.'at:;leett th'eti' fibOunted TYPE examplepf of out at
2015 that and - $ LIHEAP - Enter payments. 'LIHEAP amount Assistance of Supplemental AN Category FOR LIHEAP LIHEAP L1HEAP L1HEAP CATEGORY. -ei,P under,Pisabled 7151 ANY Assfstan664WHIS LIHEAPaassistanceNgardless LIHEAP LIHEAP LIHEAP LIHEAP LIHEAP LIHEAP CATEGORY or service
SFY households provided households LIHEAP 16$ utility number IS THIS L1HEAP A.3 AND LIHEAP memberAg Disabled HoUSehdld points: for would BY a For CATEGORIES'REGARDEEsS Regular etc.) Regular Regular Regular Regular Regular Disconnected no
be of Supplemental Assurance and under dollar Energy the or A2 Regular Regular Regular Regular Regular a under a once a prOV:Okci away, for fuel(had
of should number regular Supplemental reported and funds, Enter Regular NECESSARY; (Regular IN AUTO-SUM once contained receive Vulnerablireroup numberWigiiii0b#,Inat includes:ifirk,Wnerabre\MObers, thilOpusehold receivediMpAP of for for for for for AUTO-SUM of
number Data the LIHEAP LIHEAP deposits number local — either ENTERED received received received received received AN contained points: contained points: may HOUSEHOLDSiSERVED Type applied turned applied applied applied applied applied AN Currently out were
the month. Enter received received both be also the ESG, N) (NH in ENTRY ONLY that that that that that IS THIS that which receive which UNDuPLICAtEiTACROSS that assistance ANY —ALL that denied, that that that that that 1S and or
Enter - $ Household and # that and Include should Enter included Households", DATA receive may household Any unduplicated Younger, of under households THIS Notice disconnected
- $ reporting LIHEAP -(H HH# - $ CSBG, Neighbors DATA HOUSEHOLDB households households households households households NECESSARY; households may households households a by that or 5 OF Households type(s) once HOUSEHOLDS households were households households households households NECESSARY;
STCS the the Households 16 component here Other as be NOT NO - Assisted UPON of of of of of of household of example households the household BE Age NUMBER of the of that of of of of of already
VOUCHERS and and # that Supplemental the Assurance reported and such Helping of BASED number number number number number ENTRY Categories household of a number (For include a MUST was number of household households number number number number number ENTRY Notice/Non-delivery
# HH during Hil amount for program funds # HH sources should Total ASSISTED "Number the the the the the number a number example the of to DATA who total regardless that APPLICANT number the the the the the were that
112 HOUSEHOLD STCS services LIHEAP dollar L1HEAP amount LIHEAP 16 and Other other Neighbors number LIHEAP POPULATE Enter Enter Enter Enter Enter DATA NO Vulnerable the example the (For Enter duplicated Number provided, provided THIS member UNDUPLICATED the count the include Enter Enter Enter Enter Enter DATA No
LIHEAP Under 1. 2. 3. 4. 5. 6. Enter Enter Enter assistance then LIHEAP Enter 6. Disconnect households
Exhibit 1. 2. 3. 4. 5. 6. 7. 1. 2: 3. 4. 1, 2. 3. 4. 5. 7.
4. 3. — D. E. Erl.

2015)
has of 00'.
type means. June
household this system through
a utilize 2014
times duplicated. not delivery t, f
many do cJuly
how be office. Providers "other 2015
on can the what SFY
data section in Service defining for
benefit. collecting This offered Most 0-2014
is received. brochure home. section Date
LIHEAP
measure HE a DES:" Effective
benefit. the the office, office. household's to
LIHEAP receiving as benefit. education the the Notes
in of the
INSTRUCTIONS the to duplicated the of out to
Prior to type . kit
receiving be prior with workshop:offered
Service will off4SiteM aer4iCatiOnal Service
to data Service Count
prior No had This No Ell a be offered the in
Notice who had Enter can mailing note
MANAGEMENT or assistance. or - 2) & This workshop a
Fuel Fuel 1 through Enter
Non-Delivery of of Counseling) office. home. a
Out LIHEAP Measures the the through offered delivery. fomiulat
CASE or or Disconnected/Out I in in alter
Notice Supplemental Advocacy, Tier 9, offered offered offered Education education not
2015 Disconnected Table of Do
Disconnect been Education Education Education Energy
SIT were and have Education, Measures means populate.
a had that LIHEAP they Energy Energy Energy received "other
that households 'both times Energy Services received received that for automatically
of 16 received used
households of total many Client that that that households be will
of number the bow (Assurance also It
Enter and (Household households households households of can cell.
number the Type number it this
the Enter — Notices by - of of of in
Enter — LIHEAP Measure number number number the therefore; necessary
Non-delivery Education Enter
— LTHEAP of the the the - education,
LTHEAP type or Energy Performance Enter —Enter —Enter (other) entry
both — Kit for data
Regular Supplemental of Disconnect Household office Home Workshop Mailed delivery KC
Total LI1EEAP In In Total—No Rev
1. 2. 3. 12, 1. L 3. 4. 1-2014

Re .. E. A Agancy
$upplornerrta: puler --`' UHEAP Lli-IF-AP HOUSEHOLD Submitted D£S-Divizton
LREAP „.„ - fmn Hama:
LINEA ;,...4.:,..':, .--1,-,w. . APPLE...MT ASSISTED of
k.". & nWrIl, VOUCHERS Aging
..',._. HOW HOUSEHOLD* u.nd
4. HOLDS
.m. ONLY
vr"--
-ALLCATEGORIES AdJt.rIc-CommunityActien
.,..
1341
. _
.. ."7-gr7e.eorArKSER
L- Trihal
."-r.ze-.' REDARDLESSOFIYHETHER Cm
..,..m.m.... Man
• .
'a agemahl
• 'f.."er The
ASS= binnthly
"..40.
black
. kaport-ZrY20/2
----m.,.,..,,,r,
,vi..-•:',,:" .11,1.i.-- shaded Thleptione Contrast*
, • lit
•:..4::=.;- w 0..
4. areas
,
•:2,.. 47%-inw.-- ,.;‘,..,... do
,,,..... not
...,.„.
Tulai ,.,..e apply
applicant 7:iy. ,.:..f.z.,
to
,•-1 •.;:,.., . EXHIBIT
househalds ... , ...s...4- tribal
A. ' , , ......; r
k...i:. •,.: , : ,,,.---,.
• reporting.
4L. , ..1T.':':.:.' , -
1. x . . , ,..,
DAL
Suimoklecb

Exhibil
LOHEAP ONLY Household Report , Estimated Data for FFY 2014
Num.; Contest Person; Reporting Period: Oat 1, 2513 ...torn 35. 2r.14
APENGY
Dale Buhl/titled:
Phone Number Due In DES 8-1S-13
This form In to be used by Sanriee Proiedcra Mat have barn awarded 1.11-IFAP funrling, The FFY 2013 i.11-1V,AP Annus] Household Repast solkcis LIHEAP data only, The refueling period Iv Mon 15-043 through 5-35-14, lOin
undercleod ihat dela is not available for duly, Ati oust and Seplentber2a14, however data Intl 5-1-13 fleivighfi-311-44 ehould be available and be reporled. This report hes been sImprEed as Poi -Anna only ropons on thoseelions
before Thema-liming (1, 3, Sand 7) nonaiiresonslelont will the Federal Report Form. Reform these numbers Alen reading federal instructions, go rot repel data In the goy or yellow cells The yellow lists wil self-populate.
Reoaegga data is &Miens!. Number 1, FleatinutZoollng roporto TIVF-AP data, Number 3 tripods ITHE.Al. Supplemental clod Number 6 roped, weathenzaSon. It applioable. Number 7 ieports any type at LIHEAP easIslance
iundopllealed).. Section A reports hoUsefitdde Thor Warn assloled Ll HEAP furring end Seciton B reports MEV , applicant hou seholds reeantiess of Wm& ei assisted. Sectios B data should be [mud ol or more than See. A
data. Far example: Sedan A. UNEAP Assisted Households, 1. FleagoriCooiing, Under 75% Poverty -imp EIS) Acted be equal or less to Scetian S.UAERP Applicant Hoinielidde (iegartless nf whetherassistod), 1.
Heat ng/Baokng, Linder 75% Poverty {sell E44) hnotnilntonatn Me .m141 cap hontnwndhlt isticeoicelVeactIdiseov/progianrstocselnceptIonosehrpreirirsollone.long_turrn_12_06.02.12,p,11. tro.d inn*steed tannin KCnareadrageN
capyrng G0otaapIpazdas.0e4. II awe are any aN.es.ans pl... cavil dadi Balkan But et ova -.754-1.4.20 oelntroeinoednnneone anna. FAA. ot yatd)040.tenaz olanow. F.- 4,4,4 i0.1..$3..
A. L3HEAP ASSISTED HOUSEHOLDS
Age S
ea year or Snot/On ONunP1,1d.s.
Type of UHEAP older Disabled Wider Skirt*.
Assist.. Number of 7S%1.0 101%lo ASS to 6,,,,,,,,, disabled, vr
bantalad Salmis ed Under 6%, 100% 12" len% Over -10 A frildsdYf d, pose child
Ilmra h.frLs Tut.; VP Inc Vft PrB.
iL Healing irs.otos i IMIIIIIIIM MOM.
MI
11111
IIIMIM01111111111 M=IMIIIIIIIIIIIIIII .11111
- • .
-
7. Any type of ITISEAP 2' ^— 4
Assislonce fon& plivetedl . ''''- • - '1.-- .7*- - ''''''. ....,a ..... t_... - ill
B. IMEAE APPLICANT HOUSEliOLDs ardle.b of whether absister$ Sactio” B must lac equal to or greater thaal Bnation Al Service Provider Notes:
,,.....„...,,,,,,L,„L.-.2.7.744_, iitQuifiED7DA.Tp,,-,#...T.-2::.,- ,-.:- .
lyr. Nurnbbr of 75%10 104%10 12SV. to lrisome Data
.r applicanr Calculated Under's% T00% 125% 1"% CI" 1" unovallohle
essIstart. houseilokka Trial _smarty poverty poverty poVerly iravarty
1. Healing Mooting-
1. La1.1.1, SUPPLENENTIB -.7-4-'„_ .---
1. LISEAP ihresttedvadrin =...,. .e....o
-

Exhibit K
Annual SSBG Report
Arizona Department of Economic Security
Division of Aging and Adult Services (DAAS)
Reporting Agency Completes the Following Information
AGENCY: SFY20XX (July 1, 20XX- June 30, 20XX
SUBMITTED BY: DAAS CONTRACT NUMBER(S):
PHONE NUMBER:
Purpose
Data from this report is aggregated by the Department of Economic Security and used to
compile the annual Social Service Block Grant (SSBG) report that is submitted to the federal
Department of Health and Human Services.
Instructions
1. Column 1. Automatically populated for the DAAS contracted service(s) only that is
supported with SSBG.
2. Column 2. Enter the total number of unduplicated adults served in the service regardless of
fund source when the Primary Client is the Adult otherwise leave this column blank. The
number should be unduplicated for the entire contract fiscal year. All individuals receiving
services(s) in July will be considered new and counted as unduplicated individuals. Each month
thereafter only NEW individuals receiving services for the first time that month will counted. The
final number of unduplicated individuals for the year will be a cumulative, year-to-date number.
3. Column 3. Enter the total number of unduplicated children served in the service regardless
of fund source when the Primary Client is the Child otherwise leave this column blank. The
number should be unduplicated for the entire contract fiscal year. All individuals receiving
services(s) in July will be considered new and counted as unduplicated individuals. Each month
thereafter only NEW individuals receiving services for the first time that month will be counted.
The final number of unduplicated individuals for the year will be a cumulative, year-to-date
number.
4. This report must accompany the June Invoice,
CLIENTS SERVED
2. Number of 3. Number of
1. DAAS Contracted Service Unduplicated Unduplicated
Adults Children
Case Management
Last Updated: 9/23/2011

Exhibit L
Monthly Payment Verification Form: Short Term Crisis Services (STCS)
Agency name: DES Contract no.:
Report month: Prepared by: Phone no.:
A. Client ID 4 B. Client name C. Application date D. Vendor name E. Amount
is actual dollar amount reported on monthly FW110 *F. Total: $0.00
A. Enter the assigned client ID number for the client assisted with this service (do not provide Social Security Numbers),
B. Enter the client's name as it appears on the application.
C. Enter the date the application was taken.
D. Enter the Vendor's name that rendered Services.
E. Enter the amount of benefit paid on behalf of the household.
F. No data entry necessary; this is an auto-sum cell.
Sep 8, 2010

Exhibit M
Monthly Payment Verification Form: Low Income Home Energy Assistance Program (LIHEAP)
Agency name: DES Contract no.:
Report month: Prepared by: Phone no.:
A. Client ID # p. Client name C. Application date ID. Vendor name IE. Amount
.LIal
Total is actual dollar amount reported on monthly RA/1101*F Total: I $0.00
A. Enter the assigned client ID number for the client assisted with this service (do not provide Social Security Numbers),
B. Enter the clients name as it appears on the application.
C. Enter the date the application was taken.
D. Enter the Vendor's name that rendered Services.
E. Enter the amount of benefit paid on behalf of the household.
F. No data entry necessary; this is an auto-sum cell.
Sep 8,2010

Exhibit N
Monthly Payment Verification Form: Neighbors Helping Neighbors (NFIN)
Agency name: DES Contract no.:
Report month: Prepared by: Phone no.:
A. Client ID # B. Client name IC. Application date D. Vendor name E. Amount
*Total is actual dollar amount reported on monthly FW110 *F Total: $0.00
A. Enter the assigned client ID number for the client assisted with this service (do not provide Social Security Numbers).
B. Enter the client's name as it appears on the application.
C. Enter the date the application was taken.
D. Enter the Vendor's name that rendered Services.
E. Enter the amount of benefit paid on behalf of the household,
F. No data entry necessary; this is an auto-sum cell.
Sep 8, 2010

2Form No. ACE-119, Part 1 OMB Clearance No.: 0970-0121 Expiration Date: 03/31/2015
Exhibit 0
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
LIHEAP LEVERAGING REPORT
RESOURCE/BENEFIT DESCRIPTION PAGES
Complete this form for each separate leveraged resource/benefit that the grantee proposes to count for this base period.
Only resources/benefits that are provided to low income households (as defined in 45 CFR 96.87(b)(6)) may be counted.
Grantee: Base period:
Month/Day/Year - Month/Day/Year
1. Resource #
A. Resource/benefit name:
B. Gross value of countable benefits provided by resource during this base period:
C, Amount of grantee's own funds used to leverage this resource (not including
funds from grantee's Federal IMEAP allotment):
D. Costs and charges to low income households to participate/receive these benefits:
E. Net value of countable benefits provided by resource during this base period
(To calculate item E, subtract items C and D from item B):
2. Type of resource: Cash Discount/waiver In-kind contribution
If more than one type of resource is claimed: Gross value of countable benefits provided by each type of
resource:
3. Source of resource:
4. Brief description of resource:
5. Brief description of benefit(s) provided to low income households by this resource (if benefits are different from
resource as described in item 4, or if more information is needed):
6. Geographical area in which benefits were provided:
7. Month(s) and year(s) when benefits were provided to recipients during this base period:
8. Number of low income households to whom benefits were provided in this base period:
9. Eligibility standard(s) for low income households to whom benefits were provided:
Income at or below 150% of the poverty level
Income at or below 60% of State median income
Other—Specify:

Page 2 - Grantee: Resource #
10. Agency/agencies that administered resource/benefits:
11. Source(s) of data used to determine value of resource/benefits, and to determine associated costs to grantee and to
recipient low income households:
12. Brief description of how resource/benefits' value was quantified and how gross value of countable benefits was
calculated, and how any offsetting eosts to recipient low income households were calculated; also, for discounts,
reduced rate/price actually paid, and fair market value:
13. Criterion/criteria in 45 CFR 96.87(d)(2) that resource/benefits meet (check one or two): (Criteria are summarized
below. For full text, see regulations and instructions for form.)
The grantee's LIHEAP program had an active, substantive, significant role in developing and/or
acquiring the resource/benefits from home energy vendor(s) through negotiation, regulation, and/or
competitive bid.
(ii) The resource/benefit(s) were distributed through (within, as part or) the grantee's LIHEAP program to
low income households eligible under the grantee's LIETEAP standards, in accordance with the LIHEAP
statute and regulations and the grantee's LITIEAP plan.
(iii) The resource/benefit(s) were distributed to low income households as described in the grantee's LTHEAP
plan, as a supplement and/or alternative to the grantee's T ,THEAP program, outside (not through, within,
or as part of) the LIHEAP program. They met at least one of conditions A through H demonstrating that
they were integrated and coordinated with the grantee's L1HEAP program.
14. If criterion (i) is checked in item 13, and resource has gross value of $5,000 or more: Explanation of specific role
of grantee's LIFTEAP program in development and/or acquisition of resource/benefits, demonstrating that
involvement of LIHEAP program was active, substantive, and significant.
15. If criterion (iii) is checked in item 13: Condition(s) under criterion (ill.) that resource meets that demonstrate(s) -
resource's integration/coordination with grantee's LIHEAP program (check one or more):
A
16. If criterion (iii) is checked in item 13, and resource has gross value of $5,000 or more: Explanation of how
resource/benefits were integrated and coordinated with grantee's LIHEAP program.

State of Arizona Substitute W-9 & Vendor Authorization Form
G.....0 V Purpose: Establish or update a vendor account with the State of Arizona. This form meets the Federal requirements to request a taxpayer
't AU ounling identification number (TIN), request certain certifications and claims for exemption, as well as the State of Arizona requirements for vendor
.. i .._..— establishment.
Instructions: Complete form if 1. You are a U.S. person (including a resident alien);
oestos 2. You are a vendor that provides goods or services to an Arizona state agency; AND
3. You will receive payment from the State of Arizona,
Return completed form to the state agency with whom you do business, for review and authorization.
See instructions below or refer to the IRS instructions at www.irs,g0v for details on completing this form.
0 Type of Request (Must select at least ONE) C] Tax ID D Legal Name Entity Type fl Minority Business Indicator
New Location Change (Select the type(s) of •
(7 New Request ("` ' (Additional Mail Code) • . change from the following: Main Address Remittance Address Contact Information
0 Taxpayer Identification Number (TIN) (Provide ONE Only)
Social Security Number (SSN) OR Federal Employer Identification Number (FEIN) 86 - 6000472
1
43 Entity Name Must Provide Legal Name (*Must match SSN or FEIN given. If Individual or Sole Proprietorship enter First, Middle, Last Name.)
Legal Name* Maricopa County Administered by its Human Services Department
0 Entity Type Must Select One of the Following (Coding (X#) is for internal Purposes Only)
C Individual/Sole Proprietor or Sole Proprietor organized as LLC, PLLC (61) (" State of Arizona employee (1F) STATE HRIS El IN1
r Corporation NOT providing health care, medical or legal services (5A) r LLC, PLLC organized as corporation NOT providing health care, medical or legal services (SA)
C , Corporation providing health care, medical or legal services (5M) r. LLC, PLLC organized as corporation providing health care, medical or legal services (5M)
(", Partnership, LLP or Partnership organized as LLC or PLLC (5C) (*., A state, a possession of the US, or any of their political subdivisions or instrumentalities (4G)
C, An international organization or any of its agencies/instrumentalities (5U) re, Other: Tax Reportable Entity (SP)
Description Government
r The US or any or its political subdivisions or Instrumentalities (2G) r Other: Tax Exempt Entity (5H)
0 Minority Business Indicator Must select one of the following (Coding (X#) is for internal purposes only)
C", Small Business (01) r Small, Woman Owned Business- Hispanic (31) C, Minority Owned Business- African American (04)
('small Business-African American (4) ("Small, Woman Owned Business- Native American (33) ("Minority Owned Business- Asian (32)
C Small Business- Asian (24) ("Small, Woman Owned Business- Other Minority (11) C. Minority Owned Business- Hispanic (74)
C Small Business - Hispanic (25) (". Woman Owned Business (03) C Minority Owned Business- Native American (15)
((' Small Business- Native American (27) C. Woman Owned Business-African American (17) ("Minority Owned Business- Other Minority (02)
C Small Business- Other Minority (05) (" Womail Owned Business- Asian (18) ('Non-Profit, IRC §501(c) (88)
C Small, Woman Owned Business (06) r . Woman Owned Business- Hispanic (19) 61,' Non-Small Non-Minority or Non-Woman Owned
('Small, Woman Owned Business- African American (29) C Woman Owned Business- Native American (21) Business (00) '
('Small, Woman Owned Business- Asian (30) (--, Woman Owned Business- Other Minority (08) ("individual, Non-Business (00)
0 Main Address Where tax information and general correspondence is to be mailed () Remittance Address Where payment Is to be mailed LI Same as Main
DBA\Branch\ Location Maricopa County DBMBranch1Location Maricopa County Human Services
Address 301 West Jefferson, Suite 960 Address 234 North Central Ave, Suite 3300
City Phoenix State AZ-ARIZONA Zip code 85003 City Phoenix State AZ-ARIZONA Zip code 85004
°Vendor Contact Information
Name Sandra A. Mendez Title Assistant Director, Community Services Div
Phone71602 506-4983 Ext. Fax (602) 506- 11 (113 L Email mendezs002@mail.maricopa.gov
0 Certification Ei Exempt from backup withholding
Under Penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or lam waiting for a number to be issued to me) AND
2.1am not subject to backup withholding because: (all am exempt from backup withholding, or (b) I have out been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a
result of a failure to report all interest or dividends, or (c) the IRS has notified me that l are no longer subject to backup withholding AND
3.1am a U.S. person (including U.S. resident alien).
Certification Instructions. You must cress out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and
dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an
individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, butyou must provide your correctTIN.
The Internal Revenue Service does not re. fiire your consent to any provision of this document other than the certification required to avoid backup withholding.
Signature Title Financial Services Administration Date 3/27/2015
Egtllnllr
fi‘TE OF ARIZONA AGENCY USE ONLY . AGENCY AUTHORIZATION . VENDOR: DO NOT WRITE BELOW THIS LINE
State TIRIS LIN Print Name Signature
AGY Title Phone # Email Date
STATE OF ARIZONA GAO USE ONLY VENDOR & STATE AGENCY: DO NOT WRITE BELOW THIS LINE
IRS TIN Matching • Corporation Commission
Vendor Number Processed by Date Processed
HRIS LI GAO-03 111 Other
GAO-W-9 Revised 01/2010