PROVIDE FREE HEALTH CLINIC SERVICES TO THOSE IN NEED
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AGREEMENT
This Funds Agreement is made and entered into between the City of Clearwater, hereinafter
referred to as the City, and Greenwood Community Health Resource Center hereinafter referred
to as the Agency.
WHEREAS, it has been determined to be highly desirable and socially responsible to provide
free health clinic services to those who would not otherwise have a means to fill this need; and
WHEREAS, the City desires to help those in need by providing funding for the above services;
and
WHEREAS, the Agency provides such services and operates in the City;
NOW, THERFORE, the parties agree as follows:
ARTICLE I. TERM
The term of this agreement shall be for a period of 12 months commencing on the 1 st day of
October, 1999 and continuing through the 30th day of September, 2000 (the Termination Date)
unless earlier terminated under the terms of this agreement.
ARTICLE II. RESPONSIBILITIES OF THE AGENCY
I. Services to be Provided: The Agency shall provide the above stated service in
accordance with the proposal submitted by the Agency and approved by the City, which
is incorporated herein by reference.
2. Area to be Served: Services rendered through this agreement shall be provided within
the corporate limits of the City as it now exists and as its boundaries may be changed
during he term of this agreement.
3. Scheduled Reports of Agency Activities: The Agency shall furnish the City Human
Relations Department, Grants Coordinator, with an annual report of activities conducted
under the provisions of this agreement within sixty days of the end of the Agency's fiscal
year. Each report is to identify the number of clients served, the costs of such service,
and commentary on the viability, effectiveness, and trends affecting the program.
4. Use and Disposition of Funds Received: Funds received by the Agency from the City
shall be used to pay for the above services as further described in the grant proposal
submitted by the Agency to the City. Funds existing and not used for this purpose at the
end of this agreement term shall be deemed excess to the intended purpose and shall be
returned to the City.
5. Creation, Use, and Maintenance of Financial Records:
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a) Creation of Records: Agency shall create and maintain financial and accounting
records, books, documents, policies, practices, procedures and any information
necessary to reflect fully the financial activities of the Agency. Such records shall
be available and accessible atall times for inspection, review, or audit by
authorized City representatives.
b) Use of Records: Agency shall produce such reports and analyses that may be
required by the City and other duly authorized agencies to document the proper
and prudent stewardship and use of the monies received through this agreement.
c) Maintenance of Records: All records created hereby are to be retained and
maintained for a period not less than five (5) years from the termination ofthis
agreement.
6. Non-discrimination: Notwithstanding any other provisions of this agreement during the
term of this agreement, the Agency for itself, agents and representatives, as part of the
consideration for this agreement, does covenant and agree that:
a) No Exclusion from Use: No person shall be excluded from participation in,
denied the benefits of, or otherwise be subjected to discrimination in the operation
of this program on the grounds of race, color, religion, sex, age, national origin, or
disability.
b) No Exclusion from Hire: In the management, operation, or provision of the
program activities authorized and enabled by this agreement, no person shall be
excluded from participation in or denied the benefits of or otherwise be subject to
discrimination on the grounds of or otherwise be subjected to discrimination on
the grounds of race, color, religion, sex, age, national origin, or disability.
c) Inclusion in Subcontracts: The Agency agrees to include the requirement to
adhere to Title VI and Title VII of the Civil Rights Act of 1964 in all approved
sub-contracts.
d) Breach of Nondiscrimination Covenants: In the event of conclusive evidenced
of a breach of any of the above non-discrimination covenants, the City shall have
the right to terminate this agreement.
7. Liability and Indemnification: The Agency shall act as an independent contractor and
agrees to assume all risks of providing the program activities and services herein agreed
and all liability therefore, and shall defend, indemnify, and hold harmless the City, its
officers, agents, and employees from and against any and all claims of loss, liability, and
damages of whatever nature, to persons and property, including, without limiting the
generality of the foregoing, death of any person and loss of the use of any property,
except claims arising from the negligence or willful misconduct of the City or City's
agents or employees. This includes, but is not limited to matters arising out of or claimed
to have been caused by or in any manner related to the Agency's activities or those of any
approved or unapproved invitee, contractor, subcontractor, or other person approved,
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authorized, or permitted by the Agency in or about its premises whether or not based on
negligence
ARTICLE III. RESPONSIBILITIES OF THE CITY
1. Grant of Funds: The City agrees to provide a total grant of$6,014.00 to fund the
program in accordance with this agreement and subject to City Commission budget
approval.
2. Payments: The total amount requested will be paid by the City to the Agency within 30
days after execution of this agreement by the City and the Agency but no earlier than
October I of the budget year for which the funds are authorized.
ARTICLE IV. DISCLAIMER OF WARRANTIES
This Agreement constitutes the entire Agreement of the parties on the subject hereof and may not
be changed, modified, or discharged except by written Amendment duly executed by both
parties. No representations or warranties by either party shall be binding unless expressed herein
or in a duly executed Amendment hereof.
ARTICLE V. TERMINATION
1. For Cause: Failure to adhere to any ofthe provisions ofthis agreement as determined by
the City shall constitute cause for termination. This agreement may by terminated with 5
days notice without any further obligation by City.
2. Disposition of Fund Monies: In the event of termination for any reason, monies made
available to the Agency but not expended in accordance with this agreement shall be
returned to the City.
ARTICLE VI. NOTICE
Any notice required or permitted to be given by the provisions of this agreement shall be
conclusively deemed to have been received by a party hereto on the date it is hand-delivered to
such party at the address indicated below (or at such other address as such party shall specify to
the other party in writing), or if sent by registered or certified mail (postage prepaid), on the fifth
(5th) business day after the day on which such notice is mailed and properly addressed.
1.
If to City, addressed to Grants Coordinator, Human Relations Department, P.O Box 4748,
Clearwater, FL 33758
If to Agency, addressed to ~ ~ /~ ~
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ARTICLE VII. EFFECTIVE DATE
2.
The effective date of this agreement shall be as of the first day of October, 1999.
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ARTICLE VIII. CONTINGENCY
This agreement is contingent upon inclusion by the City Commission of funding for the Social
Services Grants Program in the City of Clearwater Fiscal Year 1999/2000 Operating Budget.
.IN WITNESS WHEREOF, the parties hereto have set their hands and seals this
day of 0 c (��- , 1999.
Countersigned:
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Brian J. A st, Aossione
Approved as to form:
r
ohn Carassas, Assistant City Attorney
Witnesses as to Agency:
Cit y of Clearwater, Florida
CITY pF CLEARWATER, FLORIDA
By:
Michael Roberto, City Manager
Attest:
Cynt E. Goudeau, City Clerk
By'(
President
Attest:
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CITY OF CLEARWATER
SOCIAL SERVICES GRANT
PROJECT APPLICATION FORM
Phone:
(727) 562-4060 for assistance
Due: June 7, 1999
A. Application Information
Applicant:
(Sponsor/Developer)
Greenwood Community Health Resource Center
Organization Name:
(If different)
City; State; Zip
1001 N. Greenwood Ave., Bldg. 22, Apt. 1&2
Clearwater FL 33755
Address:
Telephone Number:
(727) 467-9411
Contact Person:
Wi 11 R T.. l.<lr!=;on
Title:
ChRirppr~on, RoRrn of nirprtnr~
Telephone Number:
(777) 447-flqq1
Period for which funds
are being requested:
9/30/99 - 10/1/00
SignatU!e't)~;(C~
Wi.lla L.CaIl.4on.
B~COt.'D~S Chairperson
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Date-t~ 0-- 'f I i 'In
NOTE:
The City of Clearwater reserves the right to fund applicants ac a
level lower than requested.
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B. Activity (Check One)
Adult Crime
Child Abuse
Elderly
Hunger
Juvenile Crime
Physical Illness
Parenting
Adolescents
Substance Abuse
Unsupervised
Children
Youth Development
Other
(Describe Below)
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The Greenwood Community Health Resource Center is a free health clinic center
that offers health education, health physicals and support services to the
elderly and sick children. It is in the heart of the community which means
it is within walking distance for most patients.
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C. AMOUNT OF FUNDING CURRENTLY REQUESTED:
(Not to exceed $10,000)
$10,000.00
D. SPECIFICALLY FOR WHAT WILL THIS MONEY BE USED.
(Line item budget for this amount)
Money will be used to pay rental fee for the Center. utilities and
necessary medical supplies to aid in our efforts to assist the less
fortunate in our conmunity. Also, educational books for counseling and
teaching, telephone and other services as needed.
E. BRIEF DESCRIPTION OF PROJECT YOU WISH TO FUND UTILIZING THIS
GRANT.
The Greenwood Community Health Re?ource Center needs additional funding
for daily operations as this is a free Clinic. All service~ Arp non~tpn
with the exception of a Center Administrator and a NlIr~inE A~~;~tAnt
paid with a one time grant from the Juvenile Welfare Boarn. All othpr
assistance has been gratis including donations from the pllhlir Ann fllnn
raisers.
F. BRIEF DESCRIPTION OF YOUR OVERALL ORGANIZATION.
Greenwood CommuRitv Health Resource CFntpr i~ A frpp hp~lth centQr
supported by volunteers, four volunteer doctors, four Registered
Nurses and two Registered Nurse Practitioners on dutv everv other week.
The County Mobile Unit is available once a week for three hours. The
Center is composed of a Board of Directors and a Communitv Support
Group.
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G.
G.
NUMBER OF CLIENTS SERVED BY THIS PROGRAM.
1;h?9 _ I~nm R/9R fn ,/99
H. PERCENTAGE OF THESE CLIENTS WHO ARE CITIZENS OF CLEARWATER.
99%
I. CURRENT OVERALL ORGANIZATION BUDGET (PLEASE ATTACH) .
Attached
J . IF THIS IS START UP OR MATCHING MONEY, SPECIFY THE DETAILS
i.e.:
WHICH AGENCY OR ORGANIZATION WILL PROVIDE THE MATCH, THE
REQUIREMENTS AND THE AMOUNT OF THE MATCH.
K. IS YOUR AGENCY A REGISTERED 501 (C).(3) NON-PROFIT AGENCY OR IN
THE PROCESS OF BECOMING ONE.
We are a SOl(C)(3) ~gency - see attached.
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L. DOES YOUR FACILITY HAVE OR IS IT IN THE PROCESS OF ACQUIRING
THE APPROPRIATE LICENSURE FOR THE DELIVERY OF THE SERVICES
DESCRIBED IN THIS APPLICATION.
Yo hnllo Pi,.onAO nO"~66(lnf} tOq o,'}Q.q,d.iQ/:l.. Pge.a!€
APP niin,.hor/
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M. HAS YO~ ORGANIZATION RECEIVED ORIS IT EXPECTING TO RECEIVE
FUNDING (WHETHER CASH OR IN-KIND CONTRIBUTIONS) FROM THE CITY
OF CLEARWATER DORING THE FISCAL YEAR FROM OCTOBER 1, 1999
THROUGH SEPTEMBER 30, 2000?
YES -L
IF YES, PLEASE EXPLAIN:
NO
7he Y~eenwood Communit~ ~p~eived a Social Se~vice Y~ant
r.~f7 1;00 00
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GREENWOOD COMMUNITY HEALTH RESOURCE CENTER, INC.,
PROJECTED BUDGET YEAR 1999-------2000
Account #
Title
3610
3690
Interest
Clearwater Social
Service Grant
JWB
Dr. Scholl Foundation
Donations
Fund Raising
Projected Total Income
Expenses: Administration
4110 Salaries
Center Administrator
Nursing Assistance
FICA
Payroll Tax
Workman Compo
Legal
4140 Printing! Promotion
4150 Training
4170 Audit! Accounting
4180 Rent
4190 Medical Supplies
Office Supplies
4190.1 Postage
4190.2 Telephone
4190.4 Educational Material
Utilities:
4310 Water/Sewer
4320 Electricity
Maintenance:/ Labor/ Building
4410 Labor
Amount
JWB
$ 100.00
10,000.00
25,988.00
16,000.00
6,000.00
5,000.00
$ 25,988.00
$ 63,088.00
14,400.00
8,160.00
1,811.00
2,528.00
121. 00
1,500.00
14,400.00
8,160.00
1,811.00
121 .00
1,500.00
1,000. 00
2,000.00
3,060.00
6,000.00
4,000.00
1,000.00
1,500.00
3,000.00
$ 255.00/monthXI2.Months
In-Kind
2,500.00
In-Kind
1,500.00
aeaa .. _IIINOOI) An. .... 2J Aft. Z. .....1fOOD an.. CIM.,rL. 33751
_ .- __ .'11 _"_"II
4420 Materials
4430 Contracts '.
Insurance:
4510 Liability/ Fire
4510.1 Liability/ Board
5100 Reserve
Total Projected Expenses
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1,000.00
800.00
2,000.00
2,000.00
4,000.00
$ 63, 380.00
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INTERNAL REVENUE SERVICE
DISTRICT DIRECTOR
P. O. BOX 2508 "
CINCINNATI, OH 45201
Date: HB 4 1998
DEPARTMENT OF THE TREASURY
GREENWOOD COMMUNITY HEALTH
RESOURCE CENTER INC
1000 N GREENWOOD AVE STE 2201
CLEARWATER, FL 34615
Employer Identification Number:
65-0743078
DLN:
17053340915007
Contact Person:
D. A. DOWNING
Contact Telephone Number:
(513) 241-5199
Accounting Period Ending:
December 31
Foundation Status Classification:
509 (a) (1)
Advance Ruling Period Begins:
AUgust 29, 1996
Advance Ruling Period Ends:
December 31, 2000
Addendum Applies:
No
Dear Applicant:
Based on information you supplied, and assuming your Operations will be as
stated in your application for recognition of exemption, we have determined you
are exempt from federal income tax under section 501(a) of the Internal Revenue
Code as an organization described in section 501(c) (3).
Because you are a newly created organization, we are not now making a
final determination of your foundation status under section 509(a) of the Code.
However, we have determined that you can reasonably expect to be a publicly
supported organization described in sections 509(a) (1) and 170 (b) (1) (A) (vi).
Accordingly, during an advance ruling period you will be treated as a
publicly supported organization, and not as a private foundation. This advance
ruling period begins and ends on the dates shown above.
Within 90 days after the end of your advance ruling period, you must
send us the information needed to determine whether you have met the require-
ments of the applicable support test during the advance ruling period. If you
establish that you have been a publicly supported organization, we will classi-
fy you as a section 509(a) (1) or 509(a) (2) organization as long as you continue
to meet the requirements of the applicable support test. If you do not meet:
the publiC support requirements during the advance ruling period, we will
classify you as a private foundation for future periods. A1so, if we classify
you as a private foundation, we will treat you as a private foundation from
your beginning date for purposes of section 507(d) and 4940.
Grantors and contributors may rely on our determination that you are not a
private foundation until 90 days after the end of your advance ruling period.
If you send us the required information within the 90 days, grantors and
contributors may continue to rely on the advance determination until we make
a final determination of your foundation status.
If we publish a notice in the Internal Revenue Bulletin stating that we
Letter 1045 (DO/CG)
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GREENWOOD COMMUNITY HEALTH
will no longer treat you as a publicly supported organization, grantors and
contributors may not rely on this determination after the date we publish the
notice. In addition, if you lose your status as a publicly supported organi-
zation, and a grantor or contributor was responsible for, or was aware of the
act or failure to act, that resulted in your loss of such status, that pe~son
may not rely on this determination from the date of the act or failure to act.
Also, if a grantor or contributor learned that we had given notice that you
would be removed from classification as a publicly supported organization, then
that person may not rely on this determination as of the date he or she
acquired such knowledge.
If you change your sources of support, your purposes, character, or method
of operation, please let us know so we can consider the effect of the change on
your exempt status and foundation status. If you amend your organizational
document or bylaws, please send us a copy of the amended document or bylaws.
. Also, let us know all changes in your name or address.
As of January 1, 1984, you are liable for social security taxes under
the Pederal Insurance Contributions Act on amounts of $100 or more you pay to
each of your employees during a calendar year. You are not liable for the tax
imposed under the Federal Unemployment Tax Act (FUTA).
Organizations that are not private foundations are not subject to the pri-
vate foundation excise taxes under Chapter 42 of the Internal Revenue Code.
However, you are not automatically exempt from other federal excise taxes. If
you have any questions about excise, employment, or other federal taxes, please
let us know.
Donors may deduct contributions to you as provided in section 170 of the
Internal Revenue Code. Bequests, legacies, devises, transfers, or gifts to you
or for your use are deductible for Federal estate and gift tax purposes if they
meet the applicable provisions of sections 2055, 2106, and 2522 of the Code.
Donors may deduct contributions to you only to the extent that their
contributions are gifts, with no consideration received. Ticket purchases and
similar payments in conjunction with fundraising events may not necessarily
qualify as deductible contributions, depending on the circumstances. Revenue
Ruling 67-246, published in Cumulative Bulletin 1967-2, on page 104, gives
guidelines regarding when taxpayers may deduct payments for admission to, or
other participation in, fundraising activities for charity.
You are not required to file Form 990, Return of Organization Exempt Prom
Income Tax, if your gross receipts each year are normally $25,000 or less. If
you receive a Form 990 package in the mail, simply attach the label provided,
check the box in the heading to indicate that your annual gross receipts are
normally $25,000 or less, and sign the return.
If a return is required, it must be filed by the 15th day of the fifth
month after the end of your annual accounting period. A penalty of $20 a day
is charged when a return is filed late, unless there is reasonable cause for
Letter 1045 (DO/CG)
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GREENWOOD COMMUNITY HEALTH
the delay. However, the maximum penalty charged cannot exceed $10,000 or
5 percent of your gross receipts for the year, whichever is less. For
organizations with gross receipts exceeding $1,000,000 in any year, the penalty
is $100 per day per return, unless there is reasonable cause for the delay.
The maximum penalty for an organization with gross receipts exceeding
$1,000,000 shall not exceed $50,000. This penalty may also be charged if a
return is not complete. So, please be sure your return is complete before you
file it .
You are not required to file federal income tax returns unless you are
subject to the tax on unrelated business income under section 511 of the Code.
If you are subject to this tax, you must file an income tax return on Form
990-T, Bxempt Organization Business Income Tax Return. In this letter we are
not determining whether any of your present or proposed activities are unre-
lated trade or business as defined in section 513 of the Code.
You are required to make your annual return available for public
inspection for three years after the return is due. You are also required to
make available a copy of your exemption application, any supporting documents,
and. this exemption letter. Failure to make these documents available for
public inspection may subject you to a penalty of $20 per day for each day
there is a failure to comply (up to a maximum of $10,000 in the case of an
annual return).
You need an employer identification number even if you have no employees.
If an employer identification number was not entered on your application, we
will assign a number to you and advise you of it. Please use that number on
all .returns you file and in all correspondence with the Internal Revenue
Service.
If we said in the heading of this letter that an addendum applies, the
addendum enclosed is an integral part of this letter.
Because this letter could help us resolve any questions about your exempt
status and foundation status, you should keep it in your permanent records.
If you have any questions, please contact the person whose name and
telephone number are shown in the heading of this letter.
Sincerely yours,
/( ~t~t~
Bnclosure(s) :
Form 872-C
Letter 1045 (DO/CG)
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################~####*#~########~########**###########'~##~*~######*##n~
# CERTIFICATE OF OCCUPANCY
:#
#
# CI:Y OF CLEARWATER
# CENTRAL PERMITTING DEF'ARMI::NT
# 100 S. MYRTLE AVE
# P.O. BOX 4748
# CLEARWATER, FLORIDA
# 34618-4748
###"jj#####4i:####:tHUt#################f.####4t######I~###########..n##~#### .~{;:
THIn CERTIFICATE ISSUED FURSUANT TO THE REQUIREtiENTS OF S~CTIQI\i 106.1 O!=='
THE SH\NDARO aUILDn.IG CODE CERTXI=YINB THAT AT THE TH1E" IJF ISSLlPNCF~ THIS
8TRUCTUHE laJAS I!\15PECTED FOR cerl'IFLIAI\ICE l.IJITH CITY ORDINAhlCES. mJILD!NG
REBUU\TrONS, AND STl=lTE LAWS REGULATING BUILDING CONSTRUCTION DR [JEt::.
PREMISES LOCATED AI": 1001 N GREENWOOD AVE~8~2-1
BUILDING ~2 APT #1
BUH.DHm FER/'lIT #: 97020357
BUILDING USEr REM/RE~l/V-U
FLOOD lONE: NCNl:.
CONTRACTOR: CL1.Nt::: DESIGN BUILD lNC
ERNEST CLINE L/H 461-2751
l521;J '1 I SSOUR I AVE S
CLE':lf~l"ATE::R, FL 3461~~
OWNER: CLEARv!(~TER H:J!JS tNG AU-!-i'JF:
210 EWIN!3 AVr::
CLEAF:WA TER ~ r-L 3 461 ~.:
THIS f:ERTIFICAT~ 1B J.86UEO ON!.- Y FDR HIE SlRUCrURE MID OCCUPA"'~V 8TATE;'~
ABOVE AI".jD IS VOID IF THERE IS ANY CHANGE iN EITHER OCCUP~I~.ICY DR STRUCTUHE.
Df1TE OF ISSUANCE:
03/21/97
ISSUED BY:
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