AGR-6980.07 - JD & A CORPORATION DBA GOLDEN LEISURE HOME - SMALL BUSINESS ASSISTANCE GRANT; COVID-19 PANDEMICR-I°1$o°7
CITY OF ORANGE
5MALL SUSINESS
ASSISTANCE PROGRAM GRANT AGREEMENT
This SMALL SUSINESS ASSISTANCE PROGRAM GRANT AGREEMENT
Grant Agreement")is made and entered into as of the -t-1, day of`J em., 2020("Effective
Date") by and between the CITY OF ORANGE, a municipal corporation ("City"), and JD & A
CORP., doing business as, GOLDEN LEISURE HOME ("Recipient"), a California corporation
with reference to the following:
RECITALS
WHEREAS, the novel coronavirus (COVID-19) has become a world-wide pandemic, in
which the federal, state, county and city governments, including the City of Orange, have all
declared a state of emergency; and
WHEREAS, the efforts to minimize the spread of COVID-19 have, among other things,
created for many Orange businesses the loss of income as a result, of a significant reduction of
hours and operations,hindering the ability,to keep up with payrolls,rents,mortgages,utility bills,
business operations and other related expenses; and
WHEREAS, the City has determined that encouraging and promoting stability among
commercial businesses and their employees is conducive to the public health_and welfare of the
City; and
WHEREAS, the Community Development Block Grant program has made available to
the City,funds to be used for certain specific purposes related to small businesses and the retention
of their low- and moderate-income employees; and
WHEREAS, the City wishes to grant to Recipient, and Recipient wishes to receive said
grant funds.
NOW, THEREFORE, both the City and Recipient, in consideration of the mutual
promises, covenants and conditions contained herein and the substantial public benefits to be
derived therefrom, do hereby agree as follows:
AGREEMENT
1. Purpose of Grant. This Small Business Assistance Program Grant ("Grant") is
awarded by the City to Recipient for the sole purpose of retaining low- and moderate-income
employees, defined as employees earning < 80% of the HUD Area Median Income during the
economic emergency caused by the COVID-19 pandemic.
2. Total Amount of Grant. The Grant awarded to Recipient shall be in the amount
of TWENTY THOUSAND DOLLARS and 00/100 ($20,000.00), payable in one lump sum, and
subject to the terms and conditions contained herein.
3. Recipient Obli ations.
A. Recipient acknowledges the certifications and promises contained in the
Small Business Assistance Program Participant Certification, attached as Exhibit "A" and
incorporated herein, including acknowledgement of the federal prohibition on the receipt of
benefits, including insurance payments, totaling more than the documented losses for the
applicable period of time and the promise to repay any such excess assistance, and agrees to abide
by them during the term of this Grant Agreement.
B. Recipient shall retain those employees designated in the Grant Application
approval as low- and moderate-income for a period not less than ninety(90) days after receipt of
the Grant at the same or better rate of pay and with the same or better benefits as those existing as
of the date of this Grant Agreement.
C. Recipient shall maintain payroll records showing the date, designated
employee's name, rate of pay, and benefits during the term of this Grant Agreement. At the
expiration of ninety (90) days after receipt of the Grant, Recipient shall submit to the City the
Certification of Compliance letter that is attached hereto as Exhibit"B" and provide the required
payroll records and any additional documentation requested by the City. City shall review said
records for compliance with the terms and conditions of this Grant Agreement.
4. Review of Payroll Records bv City. After review of the Certification of
Compliance letter, the payroll records and any other documentation submitted by Recipient, City
will either:
A. Approve said records,in which case Recipient will not incur any obligation
to repay the Grant and this Grant Agreement will terminate; or
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B. Disapprove said records, in which case Recipient will be obligated to repay
to City thos`e amounts determined by City to have been not used for the intended purpose of this
Grant Agreement.
5. Repavment of Grant. If Recipient is required to repay all or part of the Grant,
said repayment to City shall be made according to a schedule as determined by the City.
6. Governing Law and Venue. This Grant Agreement shall be construed in
accordance with and governed by the laws of the State of California and Recipient agrees to submit
to the jurisdiction of California courts. Venue for any dispute arising under this Grant Agreement
shall be in Orange County, California.
7. Inte ration. This Grant Agreement constitutes the entire agreement of the parties.
No other agreement, oral or written, pertaining to the duties and obligations of each party under
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this Grant.Agreement shall be of any force or effect unless it is in writing and signed by both
parties.
S. Notice. Except as otherwise provided herein, all notices requ'vred under this Grant
Agreetnent shall be in writing and detivered personaily, by e-nciail, or by first class U.S. mail,
postage prepaid, to each party at the address listed below. Either party may change the notice
address by notifying the other party in writing. Notices shall be deerned received upon receipt of
sazne or within three (3) days of deposit in the U.S.Mail,whichever is earlier. Notices sent by e-
mail shall be deemed received on the date of the e-mail transYxiission.
RECIl'IENT" CITY"
JD&A Carp. City of 4range
487 S.Dunas St. 300 E. Chapman Avenue
Orange,CA 92869 Orange, CA 92866-1591
Attn.: Alma Divinagracia Attn.: Aaron Schulze
Telephone: 714-420-3516 Telephone: 714-7 4-2202
E-Mail: divinagracia.alnna@gmail.com E-Mail: aschulze@cityoforange.org
9. Counterparts. This Crrant Agreement may be executed in one or more
counterparts, each of which shall be deemed an oniginal,but a1X of which together shall constitute
one and the same instrument. Signatures transmitted via facsimile and electronic mail shall have
the same effect as original.signatures.
IN WiTNESS of this Grant Agreement,the parties have entered into this Grant A reement
as of the year and day first above written.
RECIPIENT" CITY"
JD &A C RP.,a California Carporation CITY OF ORA,NGE, a municipal corporation
By. ,... . .,1/'•.,...:.,`cl'Ui l,;G; -
Printed Name:Alma Divina aci Rick Otto,City Manager
Title: Owner
By. APPROVED AS TO F RM:
Printed Name:
Title:
U
Mary E. B' ng
Senior Assis ant City Attorney
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EXHIBIT "A"
CITY OF ORANGE
SMALL BUSINESS ASSISTANCE PROGRAM
PARTICIPANT CERTIFICATION
Beneath this sheet]
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City of Orange
Small Business
Assistance Program
APPLICATION PACKET
The purpose of this gran#program is to assist smakl business owners irt Orange that have been ad ersely
affected by COVID-19 to retain jobs that are hefd by their low and moderate-income workers. Funds will
be provided to assist with payroll costs for qualified small businesses that pledge to keep their low and
modera#e-income employees employed for three manths after receiving the grant.
Who can quaGfy?
1. The business is physically located in Orange, has been in the City for a minimum of ane year and
is not a franchise or part of a chain of more than three locations.
2. The business is a for profrt business with at least 2, but not more than 50 employees.
3. The busir ess has gross annual revenues of at feast$100,000, #aut no more than $5 mi#lion. .
4. The busiRess has experienced at least a 25% reductian in revenue due to COVIa-19 and is
able ta provide documentation showing the loss in r.evenue. ,
5. 50% of empfoyees of the business meet low- and moderate-incorr e requirement of<_8fl% of the
HUD Area Median Income.
6. The business continues to operate legaiky during the COVID-19 crisis and the designated
employees are actively working at the business.
7. The business has not received full coverage of emp[oyee payroll from an insurance provider or
any other entity_
8. Tt e business has had no major code violations in the last twelve months.
9. Adult businesses, rnassage parlors, and largely cash-based businesses are r ot eligible.
10. Individuals that awn or have interest in more than one business may be limited to one grant total
i.e., if a person has ownership interest in three businesses, only one of those businesses may
receive a grant uncfer this program).
How much is the grant? .
The grant is ta be used for payroll costs#or your low-and moderate-income employees for three months
up to a maximum of$20,OQd.
How do I apply?
Completethe GrantApplicatian anline at www.cityoforanpe.ora and attach all fhe required information
on the Document Checklist. Yau will receive an email advising you that your application has been
received:An incomplete application will delay the review of your application. Listed documentatian is a
minimum requirement and staff may request additional documen#ation to determine eligibility.
Ef you have any questions, please email Aaron Schulze, Senior Administrative Analyst at
aschufzeCa?cityoforanae.org, or call (714) 744-2202. Funding is limited and will be disbursed on a first
come, first served basis.
Smal! Business Assistance Program Application
BUSINESS 1NFORMATION
Name of 8usiness
C' .-::- I t" ";l!'I=
Type of Business(e.g.,LLC,corporation,soie proprietorship}
CL ''u 6'v`
Address of Business
v- '?. (,;11'S' {t.1 , lJ,.1:`#(c=
f +, `
t.-`''
r'
1 I
Business Employer ldentification Number(E!N} Years in Business
f . 3 t ,5
of Employees of Employees Meeting LowRUlod Income City Business License Number
Requirement
f
OWNER
INFORMATION
OWNER CO-OWNER
Name Name
f}-b? f i u r lv-'ti%,
Sociai Security Number Contact Phone(area code) Sociai Security Number Contact Phone(area code)
7 ti 7- z .51/v
Present Address(street,city,s#ate;zip)Present Address(street,city,state,zip)
f" ti U'`'-G
1"f- ` i j;P Nt:.S v 1 C/1 t V';, (' l • !
Email Address
I
Email Address
tVi 'JY'Lif`iE . Gi I )YLG c• v l il 1 G lr1
INCOME
REQUIREMENTS
See Income Verification Form for details on income requirements for eligible employees.
BUSINESS INCOME INFORMATION
2Q191NCOME 20201NCOME(USE THE SAME MONTHS AS 2019)
MontF#1 Gross Saies Month #1 Gross Sates f
U• -"
Month of .' 1. Month of 1''}=li J 7
Month#2 Gross Sales 7- ';. 3S Month#2 Gross Sales i, •
MoRth of t'1'1:., Molith Df U''1 1
Please provide a brief explanation of the adverse econom/iyc effects COVED-19 h'las had on your business:
U 1j L j .J rW I,%tf u]S ""U /7%• +lir '!!/i J !l iL fUrs j Y1in/ 1..L'l.s !'
j+1 7 7-/f/
r r U i.dv G.-7vs s, iv' L " . t "_, "7;s'`J 'L,
REQUIRED DOCUMENTS—SEE DOCUMENT CHECKLIST F R DOCUMENTS ACCEPTED FQR VERtFICATION
1. Revenue statements for 2 months in 2020 verifying 25% less revenue than the same r onths in 2019
2. Revenue statements for the same two months in 2019
2.Anrtual revenue statement for 2019
3. Payro{I recards for each qualifying employee
4. Documentation for any other CARES Act funds that you have received {PPP, EIDL,..etc.)
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Small Business Assistance Program Application
ACKNOWLEDGMENT AND CERTtFICATION
Acknowledgement: I/We understand that this grant is being provided by the City of Orange based solely upon
the information that l/we have pravided in this application_ I/We also certify that there are no outstanding tax
liens or legal judgements against the business.
Certificatiorr IM/e certify that the information provided in this application is true and complete to the best of
my/our knowledge as of the date set forth opposite my/our signature(s) in this application and acknowtedge
my/our understanding that any intentionai or negligent misrepresenfation(s) of the information contained in this
application may result in civi[ liability and/or criminaf penalties_
By signing below, I/we certify that the above statements are true and correct to the best of my/our knowledge.
I/We understand that a false statement may disqualify melus fcom benefits.
OwnerSi n;at Date.Co-Owner Signature Date
u..- t l G',
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City of Orange
Small Business Assistance Program
Owner Participant Certification
Business Name ` Z I` t 7S.: j!v(
Business Address - `-S. G41`4'' -r. dKi,},t1'L"c' Cfj ,L r
In order to participate in the City of Orange Sma{I Business Assistance Pragram ("Program")
and receive a grant, the City of Orange ("City") requires that you (Recipient") and your staff,
if applicable, certify the following:
You own a small business that employs befinreen 2 and 50 employees.
Your business is operating during the COVID-19 crisis and your qualified employees are
w rking at the business.
50% of your employees who are holding the jobs retained, make fess than the low- and
moderate-income requirement of <_80% of the H U'D Area Median Income (see {ncome.
Verification Form for details).
Your business has been in operation in Orange foc at least one year.
Your business has experienced a revenue decrease of at least 25% compared to 2019,
because of the impact of COVID-'l9.
Your business is not a franchise and is not a chairt of four or more lacations.
You commit to continue operating and keep yaur low and rr odera#e-income
employees empfoyed at.your business for a minimum of three months after receipt
of the grant funds.
Notwithstanding any other rights of the City under other Sec#ions of this Certfication or applicable
law, if the Recipient violates any of the terms, covenants or pro isions of the Certification, or if
any representation or warranty made by the Recipient in this Certification or in any document
or application submitted in connection with this Certification or the Program shall prove #alse or
misieading, or if, in the sole judgment of the City, the conducfi of the Recipient is such that the
interests of#he City have been or are {ike[y to be impaired or prejudiced, the City shall thereupon
have the right to terminate any grant or withhold payrnents due under the Program and/or demand
and obtain the return of payments already made which are equai to the damages the City may
have already suffered due to a breach by the Recipient. Any such action by the City shall not give
rise to any cause of action far damages against the City.
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CERTIFICATfONS
1} I certify that my business has been 9n operation for at least one year in the City of
Orange.
2) I certify that I currentiy employ a total of employees.
3) ! cerfify that at (east 50% of my current employees make fess than the fow- and
moderate-income requirement of<80% of the HUD Area Median Income.
4) I certify that as a result of COVID-19, my business experienced at least a .25%
decrease in revenue for finro consecuti e months after January 1st, 2Q20, compared
to #he average revenue for the same two-month period in calendar year 2019 (or
average monthfy revenue based on total 20'!9 sales).
5) I certify that my business did not recei e fu{f coverage of employee payroll from an
insurance provicier or any.other entity.
6) I certifythat the tatal CARES Act assistance (PPP, EIDL.__etc_) that my business has
received is $ . (j
7) I certify that my business is continuing to operate during the COV4D-19 crisis.
8) 1 certify that my business will retain and pay the listed emp{oyees their salary
for a three-manth period commencing on the date -of receiving their
reimbursement and the employee is working at the business_
9) ! certify that my business will comply with ali iaws and rules appiicable to the
program, including City, s#a#e and federal laws_
10) I certify that I have not misrepresented the eligibility of my business for the Program.
By signing befow, I certify that fihe above statements are true and correct to the best of .
my knowfedge and belief_ f understand that willfu!or fraudulent submission of a ma#erially .
false statement in connection with this certification may disqualify my business from
eligibility for the Program benefits and may subject my business or,myself to criminal
charges.
This certification shall be deemed executeci in the City of Orange and State of California
and shalk be governed and construed in accordance with the laws of the State af
California and the laws of the United States.
J lLf`LG:°'
i,-.
Business Owner Sig ature) Date)
Business wner Signature) ate)
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City o€Orange
Small Business Assistance Program- Docurnent Checkiist
Document Why we need this Documents accepted
Signed participation Verification that the business employs between 2 and
certification 50 employees,has experienced a loss of revenue,has
a commitment to retain employees by participating in
this program, employees meet income qualifications
and has not already been fully relmbursed by
insurance for wages.
Revenue statements for pocumentation of revenue following COVID-19 impact One or more of-the following for the entire impacted period: point-af-
two consecutive months in sales reports,sales reports(demonstrating fees collected or earned
2020 income), bank statements, quarterly sales tax filings, or CPA-
certified profit&loss statements for two consecutive months in 2020
Revenuestatementsfor Comparison of typical operating revenue to verify One or more of the following for the same two manths in 2019:
the same two consecutive loss of revenue as a result of COVID-19 point-of-sales reports,sales reports(demonstrating fees collected
months in 2019 or earned income), bank statements, quarterly sales tax filings, or
CPA-certified profit&loss statements for two consecutive months
in 2019
Annual revenue statements Comparison of typicai operating revenue to verify One or.more of the following for total 2099 sales: point-of-sales
for 2019 loss of revenue as a result of COVID-19 reports, sales reports {demonstrating fees collecfed or earned
income), bank statements, quarterly sa€es tax filings, 2019 tax
returns, CPA-certified profit & ioss statements, 2019 Tax
Returns(all pages), or Federal 990
Income verification forms To determine if your employees meet the income
filled out and signed by each requirements for the program
employee)
Payroll records for each To verify empfoyment Payroli records or cancelled checks to each employee
employee
Proof of Orange location To verify that the business is located in the City City of Orange business license number on application, signed
federal tax forms,signed copy of lease agreernent,or 3 months
of operatianal bills
If you do not have a City business/icense you will be required to obtain
one prior to fund,distribution
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City of Orange
Small Business :Assistance Program
Income Verification Form
Susiuess Nam.e• Alma Divinagracia
Fiscal Year: 2020-2 21 P rograinl Fame: Sr II Bu.sin.ess Assistance Program
playee Name: Alma Divinagracia
Address: 487 S. Dunas 5t ^
LL.
Cit1:Orange G Zip Code g2869
1. H d;of Household: Nlaie (,] Female Z. Hameless es No
3. Check on1-one. Elderly(62+)
ff p Iirablel Di.sabled C?
4. First check your househald size. Then read across and check the bot on the same row that applies
to yuur household's gxoss anmial income.{G7-oss imr t.u l irr ome is irteorne frorn«!!svtsrces t efore t zxc s.}
2020 Income I.imits
Househa d
Category 1 Category 2 C tegary 3 Category 4Sze
1 526,950 ar less 26;951 to C.-1,850 .3=4,551 to,1:50 S 1,51 ab ve.
2 ,30,800 or less 530,$02 to 551,250 551,25I to S82,Odd SS2,001&above
3 534,650 or less 4S3,651 to 55 i,650 "[..55 7,651 to 59,25 Q 92,25 L&above
4 S38,450 or Iess 538;51 to 56.,5 S6};051 to 102,450 S1.02;51&abo e
S 41,550 or less 541,551 to 69,2 4 Q 569;2 i ta 110,6S0 [ 1Z0:65i Sr ah vre.
6 I,650 r r less 544,651 to r,300 5-,302. to S113,S50 118,51 aho r I
i [J 5=,oo or iess 5-,fl1 to 5 9,450 579,51 to 512,U5U 512,051 Sabo r
8 50,80U or Iess 550.801 to 8,550 s8#,SSI to 5].35,250 ] SZ35,251&abo.ue
5nt 1'ce: 1:.5.U y t4nter:of Hoi sirt cuat f.rh.ml.)e.•elu rrttent_p301ncorr,e l.ifntts for Urart e Cottrih;t:•1.
5. Ethnicity-annci Race O
Etliniciri' (Gzeck one.)
Hispanic or Latino Yes No
K ce.(Check an.)
Single Race Categories or Multiple Raee (tegories
R2i r3r,1C
fRACE Arr,vricu
P,lackur
n:riiar ut 1ltnerEranir.cim:c 3i.!akn j(J"[.,. 1 I:lar_l cx Htn+,ui.a: ! Asiac A['ricatz UChLt
nnian or 12 tska 4.B r.j tti'tiii• :Viic.is: Asia. utGthe• anQ nericata 11t11tipleVask.i Kati•e md
4111it?C3r, wtice
PeeiSe i `\lile• .t± Bl.ukor C+lC@
I l.mdet
Rfiite
W1UIe ,
Iric:u:i
V:rirar:
Oran e Resident f 0...,.,..0
i..._
s Non-Or e Resident J ;
ccox cilnt; tc Title IS, Section Lt}Ol of ihe L.S. Ccide, it is a felon for an}• rrsc>n to kno ingl}and ti iElittglt make f tlse or frauduIc r
i
st<iteine its to<ury department of ilie[,nite l Siatzs Ga-enmtent. I t ie tndersignc:d, hereb}certiiy th<it all etacernents cancainecl herrin,
re trur a ld c rrect tc th best nf in iot ir d e and hrlief. I ur:derstand tl e ir.f rruaricx I prc itie ir. dus certifiraflori is sub,ject to
Prifi..-;,r,;;,,...;mct._=<;;;rr E m.lro idfr n:cessary dor.umentati ui if requestcd fo do so.
J(.FI2CI OC LlII.Lt.l.L LQ.CXGL ;
s,,,,,,>,:.:,,::. 11/03/2020
L'mplovec Si,n ture Date .
1; See P3ge 2 of'3 for ciefiniaon of Disablecl
See Page 3 of 3 fur Ltttnic:it}:n.d kace d Iinirians.
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Pagc 1 of 3 h'.tCt'JUilIf UtiI?.U'.Ci+(icAF•.vm.15c1!'C^rthl"_'!iiY.}4 SS[..i nol:
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DISABILITY DEFINITION
I
Persnns svith c isc biiities means a household composed of one ar more persons, a.t least one of v>hom
is an aduit, yho has a disabilin.
1. a person is considered to have disability if the person has a phy sical, mental, or emotional
impairment that:j
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i Is xpected to be of long-cantinued and indefinite duration:
ii Substantially impedes his or her abilin-to li e independently; and
iii. Is of such a nature that such ability could be imgro•ed by mare suita le hausir.g
conditions.
2. A person 4ti ill also be consider d to have a disabilit if he or she has a de-elopmental
disabilit`-, .tiihieh is a severe, chronic disability that:
i.Is attributable to a mental or ph sical impairment or combination af inental and
physical impai.rments;
ii. Is manifested b.fore the person attains age 22;
iii. Is li etjr to continue indefinitel;
iv. Results in substantial functional limitations in three or more o the follo hing areas of I
major life acti in; self-care, r ceptive and pressi e Iar guage, learning, mobilit, self-
direetian, capacityT for independent li-ir, and economic self-sufficiency; and
Reflects the person's need for a combination and sequence of special, interdisciplinar=,
or generic care, treatment, or other ser-ices that are of lifelong or e tended duration
and are individually planned and coordinated. Nottivithstanding the preceding i
provisions of this definition, the term "persons +ith disabilities" includes t vo or more
persons t ith disahilities living together, one or mare such persons living v Zth another
person zv°ho is determined to be important to thei care or-ell-bei, and the sur i`ing
member of inembers of anv household described in the first sentence of this definztion
1 ho w ere lit-ing, in a unit assisted vith HO1 IE funds, ith the deceased member of the
househoid at the time or his or her death.
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soacrc: 2 C'F'R,§ 9?2
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P lg 2 of 3 t uF.r ai:ti u;,('L1H.i1E•i umiticYi i•.r rti•_a>s.ro i t s t.;r.yt,.,
ETHNICITY AND RACE CATEGORY DEFINTTIONS
I
Ethnic Category Def nitions
Ethnic Categaries are defined as follows:
A Hispanic/Latino.
A person of Cuban, I exiean, Puerto Rican, South or Central American, or ather Spanish
culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to
iHispanicorLatina."
B. Non-Hispanic/Non-Latino.
A person not of Cuban, Nle ican, Puerto Rican, South or Central American, or other Spanish
culture ar ori in, regardless of race.
Racial Categor Definitians
Racial Categories are defined as follovvs i
A .merican Inclian or Alaska Native.
A person haE ing origins in any of the original peoples or North and South America fincluding
Central America), and ti ho maintains ti-ibal affiliation or community attachment.
B. Asian.
A rson havi ori ins in an of the or' malpenggig' peoples af the Far East, Southeast Asia; or th
Indian subcontinent including, for example, Cunbodia, China, India, Japan, Itorea, I Ialaysia,
Pal stan, the Philippine Islands, Thailand, and Vietnam.
C. Black or African nerican.
A persan ha ing origins in any of the black raciai groups of frica. Terzns such as "Haitian"
Ior"Negro" can be used in addition to "Black or African American."
D. Nanve Haw aiian or Qther Parific Islander.
A person having origins in an of the original peogles of Ha vaii, Guam, Samoa, or othex
Pacific Islands.
E White.
A person having origins in any of the original peoples of Europe, the l iid le East, or North
frica.
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P ige 3 of 3 N::t uinr u!:tnr.t:ueu`.P'a:n:niSaliCcri t'asus i_vis.„
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c ty of €.?raxige
Small Business Assistance Program
ncome`erifir tion Form
B usiness Name: Golden Leisure Home
Fisc l Yc r: Zt72-2C 21 Pro amNa ue: SmaIl Business ssistance Fro Tam --- i
Emplayee Na ne: Joel Div'tnagracia ___._.---------_._..----.._._____....._..__.,_.-- ..--.__._..__...._____ i
ddress: 487 S. Dunas St. I
C ry Orange
i_^..,
CA Zip Code 92869 _.._._..._____---
1. H d of Household: [ hlale Female Z. Harueless Yes Ivo
3. Check anly on. E,1clerly(GZ+j I
If A pliccrbtel Disal led L) I
First check y'aiir household size. Then read acxoss and eherk the l ox on the same row that applies
to yonr household's gross annttal income. (C:ross canrcucal ir corne is incama from ail so rces t e'vre tn.tes.)
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2020 Iacome Limits
HoE sehold
Category 1 Category 2 Category 3 Gategor<<
Size . I
0 1 526,950 or less 5 6,951 to 5=•;8S0 S=,851 to S L.;50 571.:SI &above i
2 S3b,S0 or 3ess 3Q,SOI to$51,5.0 551,51 to 582,000 SS2,()01 St aba e
Qr3 S34,fi50 oz less $3=1,(iSl to S57,650 5Si,651 to$92.2 0 Q $92,51 aba e
I
Q S3S,45U or less ] .38;5Z to 56;050 6;051 to 102.lSO Q 5IO2;4518 ab
5 1,550 or less 5 1,551 ta 569,200 69,201 ta I10,65U .S:tZU,65I bo
6 _ Q 14;650 or less 5-1:651 tn S 1,300 S 4,301 to 5I1$:850 5118,851&aba
0 r 1,i0U or less ]S r,01 to Si9,450 5 9,151 to 5 2i,Q50 12e.OS1&z abo c: I
S 550,SOQ or Iess .: [j 5,801 to 58,550 [ 584,551 to 13a;250 [ .135,25I,&above
y
R crrce:L:5.UeZ u'ti te u ot lia silr r uirt LirZ ein U veluF,rner!?[I:,hc,rerne Limits(or Onu E/e Cncuap,C:1.
5. Etlznics.tyr anci Raee I
Ethniciri%(Ch ck nne.) I
Hispanic or Lat na j Yes No i
Race (Check as e.}
LL,
Single Race Categories ur Niullmle Race Categori s i i
i n::r,ri t ; .
iut cric,J, F U di,u:uc
1.• vnrr.iran
Rvr .
t:di.u:na
R(a l:.i!r :
1Iav1.1
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i 112.ie: :1liic.ui .asi.u:
EI7f2t.lF!i1Y
or Otltier i Vasi x
c l .-1nir:ric.ui .•`
61e A1t$Lijile i11asl:a tidEi•[ j mv_/
tras•rics:e - P u fir tilhiti
aii•a irnr.i I ti ft3:tt:1:oa R CC
Is4an ir•r
l htte
ti 71itz :
1t ri.,an
1 ne^ican j
c ran e Resident r d•••••.••
Non-Uran€kesident ___ __ ..__.._ --...
r. ---
wo T__
4ccordul+ to'1'itic: ifi, Sec.Tio 100! tif the L;.S. Code, it is a [elon}; tor an-pers<m ro I:no 4ing1} anct i4illii;i'ma:e faIse r r ffdLlfllllPTir i
stat me nts tca any depariment of the L:nited States Go rmvent. I, ttie unciersinned, hrrrb5•certifi-that al2 stat•r.nzents cv ntained herNin, I
rr• true'anc c•orrect t the best oi rny knoi ird.,e +nd.beliFf, i tu dcrslatid the in#c rznaticx ] protidr in rhis eertification is subjrct cc
erifi_.-`_.'-::=:;'T.>ez to grv Zdr r ecessar}dur.amen.tation if requeste:d ta do so.
C oeL c cvuzagxacl,rz _.
11/04/2020
v....,,..s,..........,.....,
tplo5°er Si2uature L)ate i
1'J See I'af7e 2 of 3.for r:efiniiion f Ilisabfr.d
5 e Pa;e 3 c i 3 for LriYnic7t and P,ce definitions. j
I
d E 1 of 3 Cflh S1UC511'C,1CitF;G.:;rnn:ti.•ic Qrl t l':ti:S.i4 i 4Yi:,i.u.ii.i
i
DISABII.ITY DEFINITI4N
Per•sons tztF c isabiIit es means a household composed of one or more persons; at least ane of vhom
is an arlult, ho has a disabiliry.
1. : persan is considered to have a disability if the person has a phS sical, mental, or emotional
impairment that:
i.Is expected to be of long-continued and indefinite duratian:
ii.. Substantiall impedes his or her bility to li independentl; and
iii. Is of such a nature that suel. ability could be impro;Pd Uy mor suitable housing '
canditions.
2. A person vill also be con.sidered to ha e a disabilit5% if he or she h ts a developmental
disabiliCc-, vhich is a se ere, chranic disability that:
i Is attributa le to a mental or ph sical 'zmpairment or combination of inental and
physic l impairments;
u. Is manifested before the person attains age 22;
iii. Is likely ta continuP indefinitel;
i. Results in substantial funetic nai limitations in three or more of the ft llo ving areas of ;
major life activity; self-care, receptive and e4pressi-e language, learning, mobilit', self- ;
direction, cap cit for independent li ir, and economic self-sufficienct; and
v. Reflects the person's need far a cumbination and sequence of special, interciisciplinar,
ar eneric care, treatment, or other ser zces that are of lifelong or ettended duration
and ar indi iduall- planned and coordinated. Notsvithstandin, the recedi.ng
pro lsions of this definition, the term "persons ith disabilities" includes t vo or more
gersons ith disabilities li il together, one or more such persons li`ing ith another
person ho is detPrmined to be import nt to their care or F ell-being, and the sur iving
member of inembers of ant household described in the first sentence of this c efinition '
Fb'Yl0 1 Ere li<<ing, in a unit assisted °ith HOl iE funds, °ith the deceased member af the :
hous hold at th time or his or her death.
Sot.crce: CFR§ f12?
c1 C". Of tird:bl7•H(l3!Sl:ti(tC'I1B(1`,!':v tk:S:i!Ccri I l''_;'iiffi P+i•_'4si;iLti*':it i
i
ETHNICITY AND RACE CATEGORY DEFINITIQNS
Efihnic Cate or Definitions
Ethnic Categoi-ies are defined as follows:
A Hispanic/Latino.
person of Cuban, n2exican, Puerto Rican, South or Central American, or other Spazush
culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to
Hispanic or Latin."
S. Non-Hispanie/Non-Latin o.
A person_not of Cuban, ri Ie c n, Puerto Rican, South or Central merican, or other Spanish
cultuxe or origin, egardless of race.
Racial Cate ory Definitions
Racial Categories are defined as follo s:
rierican Iudian or Alaska Native.
person ha in; origins in anSr of the original peoples or North and South nerica (incluc3ing ;
Central Ameriea), and vho maintains tribal affiliation or ammunity attachanent.
B. :,sian.
A person ha ing ori.gins in any of the original peoples of th Far East, Southe st sia, or the .
Indian subcontinent including, for example, Cambodia, China, Indi, Japazi, Korea, iala 7sia,
Pal<istan, the Philippine Islands, Thailand, and Vietnam.
C. Black ar Afric_an .merican.
A persan ha ing origins in any of the black racial groups of Africa. Terms such as "Haitian"
or "Negro" can be used in addition to `Black or African mc rican.°
D. Native Havvaiian or ther Pacific Islaua.cler,
A persnn having arigins in an of the original peoples of HaE vaii, t uam, Samaa, or other ,
PaciPic Islands.
E. 'rhite_
A person ha zng origins in any of the original peoples of Europe, the I Iiddle East, or North
fric.
i
P a e 3 of 3 C'iYEI•.ilUl:tii(;\C`Df3iitPnnm:Yefi Cot FY 2i 15.lN?pi l.imihi
EXHIBIT "B"
CERTIFICATION OF COMPLIANCE
Beneath this sheet]
5
Date:
Lisa Tamburelli .
Community Services Department
City of Orange
300 East Chapman Avenue
Orange, California 92866
Re: Certification of Compliance Pursuant to City of Orange Small Business
Assistance Program Grant Agreement
Dear Ms. Tamburelli:
This Certification is submitted to the City of Orange in accordance with the Small
Business Assistance Program Grant Agreement ("Agreement"), and constitutes the Final
Compliance Report. The undersigned authorized representative(s)of GOLDEN LEISURE
HOMES, hereby certifies(y) each of the following statements:
1.The 90-day compliance period for this Agreement began on November 6, 2020,
and ended on January 6, 2021.
2. During the compliance period, the business continued to operate legally.
3. During the compliance period, the business continued to employ all of its Low- and
Moderate-Income (LMI) employees.
4. Both prior to and during the compliance period, the business did not receive
federal, state or local assistance or insurance payments totaling more than the
documented losses for the applicable period of time.
5. The enclosed payroll documentation is accurate and reflects the continued
employment of the LMI employees.
Dated:
Signature:
By: Alma Divinaqracia
Title: Owner