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AG 23-035 - CONGOLESE INTEGRATION NETWORKRETURN TO: victoria Banks EXT: 2604 CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: CD/CS 2. ORIGINATING STAFF PERSON: Patti Spaulding-Klewin EXT: 2651 3. DATE REQ. f ; N': 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ® PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT R HUMAN SERVICES / CDBG ❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS) ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRACT AMENDMENT (AG#): ❑ INTERLOCAL ❑ OTHER 5. ��++ �] ` PROJECT NAME: L.T �J 6. NAME OF CONTRACTOR: Floribert Mubalama ADDRESS: 19550 International Blvd,Ste. 103, Seatac, WA 98188 TELEPHONE 206-556-6998 E-MAIL: flodbert@cinseattle.org FAX: SIGNATURENAME: Congolese Integration Network TITLE 7. EXHIBITS AND ATTACHMENTS:11 SCOPE, WORK OR SERVICES A COMPENSATION A INSURANCE REQUIREMENTS/CERTIFICATE d ALL OTHER REFERENCED EXHIBITS 0 PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: 01/0112023 COMPLETION DATE: 12/3112024 9. TOTAL COMPENSATION $ 3©, c4 o • O O (INCLUDE EXPENSES AND SALES TAX, IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: ❑ YES S NO IF YES, MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ®YES ONO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ CITY RETAINAGE: RETAINAGE AMOUNT: ❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED ❑ PURCHASING: PLEASE CHARGE TO: 001-7300-083-562-10-410 10. DOCUMENT/CONTRACT REVIEW INITIAL / DATE REVIEWED INITIAL / DATE APPROVED ❑ PROJECT MANAGER SB 12/29/2022 ❑ DIRECTOR ❑ RISK MANAGEMENT (IF APPLICABLE) ® LAW KVA 12129/2022 11. COUNCIL APPROVAL (IF APPLICABLE) COMMITTEE APPROVAL DATE: N/A COUNCIL APPROVAL DATE: 11/15/2022 12. CONTRACT SIGNATURE ROUTING ® SENT TO VENDOR/CONTRACTOR DATE SENT: 1/23/23 DATE REC'D:2/16/23 ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS ❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR I MONTH PRIOR TO EXPIRATION DATE (Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.) INITIAL / DATE SIGNED X LAW DEPARTMENT It 1 2021 9.MGNATORY (MAYOR OR DIRECTOR) ❑ CITY CLERK f All ❑ ASSIGNED AG# AG# COMMENTS: Approved Council budget 11/15/2022 2/2017 cl7r OF CITY HALL ��.. 33325 Sth Avenue South Federal Way, WA 98003-6325 Fe a ra I Way (253) 835-7000 www cityoffederalway com HUMAN SERVICES AGREEMENT FOR CIN HEALTH BOARD PROGRAM This Human Services Agreement ("Agreement") is made between the City of Federal Way, a Washington municipal corporation ("City"), and Congolese Integration Network, a Washington non-profit corporation ("Agency"). The City and Agency (together "Parties") are located and do business at the below addresses which shall be valid for any notice required under this Agreement: CONGOLESE INTEGRATION NETWORK: Floribert Mubalama 19550 International Blvd, Ste 103 SeaTac, WA 98188 206-556-6998 (telephone) The Parties agree as follows: CITY OF FEDERAL WAY: Patti Spaulding-Klewin 33325 8th Ave. S. Federal Way, WA 98003-6325 (253) 835-2651 (telephone) Patti. Spaulding-Klewin@cityoffederalway.com 1. TERM. The term of this Agreement shall be for a period commencing on January 1, 2023 and terminating on December 31, 2024 ("Term"). Funding for the second year of the Agreement is contingent upon satisfactory Agreement performance during the first year of the Agreement term and upon funding availability. This Agreement may be extended for additional periods of time upon the mutual written agreement of the City and the Agency. 2. SERVICES. The Agency shall perform the services more specifically described in Exhibit A, attached hereto and incorporated by this reference ("Services"), in a manner consistent with the accepted professional practices for other similar services within the Puget Sound region in effect at the time those services are performed to the City's satisfaction, within the time period prescribed by the City and pursuant to the direction of the Mayor or his or her designee. The Agency warrants that it has the requisite training, skill, and experience necessary to provide the Services and is appropriately accredited and licensed by all applicable agencies and governmental entities, including but not limited to obtaining a City of Federal Way business registration. Services shall begin immediately upon the effective date of this Agreement. Services shall be subject, at all times, to inspection by and approval of the City, but the making (or failure or delay in making) such inspection or approval shall not relieve the Agency of responsibility for performance of the Services in accordance with this Agreement, notwithstanding the City's knowledge of defective or non -complying performance, its substantiality or the ease of its discovery. 3. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) days' written notice at its address set forth above. The City may terminate this Agreement immediately if the Agency fails to maintain required insurance, breaches confidentiality, or materially violates Section 12, and such may result in ineligibility for further City agreements. 4. COMPENSATION. 4.1 Amount. In return for the Services, the City shall pay the Agency an amount not to exceed a maximum amount and according to a rate or method as delineated in Exhibit B, attached hereto and incorporated by this reference. The City shall reimburse the Agency only for the approved activities and in accordance with the procedures as specified in Exhibit B. The Agency shall be solely responsible for the payment of any taxes imposed by any lawful jurisdiction resulting from this Agreement. 4.2 Method of Payment. On a quarterly basis, the Agency shall submit to the City an invoice for payment on a form provided by the City and all reports as required by this Agreement. Payment shall be made on a quarterly basis by the City only HUMAN SERVICES AGREEMENT - 1 - 10/2022 CITY OF CITY HALL Federal WayFeder 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www cityoffederalway.com after the Services have been performed and within forty-five (45) days after the City's receipt and approval of a complete and correct invoice and reports. The City will use the quantity of Services actually delivered, as reported on the Agency's reports, as a measure of satisfactory performance under this Agreement. The City shall review the Agency's reports to monitor compliance with the performance measures set forth in Exhibit A. Should the Agency fail to meet the performance measures for each quarter, the City reserves the right to adjust payments on a pro rata basis at anytime during the term of this Agreement. Exceptions may be made at the discretion of the City's Human Services Manager in cases where circumstances beyond the Agency's control impact its ability to meet its service unit goals and the Agency has shown reasonable efforts to overcome these circumstances to meet its goals. If the City objects to all or any portion of the invoice, it shall notify the Agency and reserves the option to pay only that portion of the invoice not in dispute. In that event, the Parties will immediately make every effort to settle the disputed portion. 4.3 Final Invoice. The Agency shall submit its final invoice by the date indicated on Exhibit B. If the Agency's final invoice and reports are not submitted by the last date specified in Exhibit B, the City shall be relieved of all liability for payment to the Agency of the amounts set forth in said invoice or any subsequent invoice; provided, however, that the City may elect to pay any invoice that is not submitted in a timely manner. 4.4 Non -Appropriation of Funds. If sufficient funds are not appropriated or allocated for payment under this Agreement for any future fiscal period, the City will not be obligated to make payments for Services or amounts incurred after the end of the current fiscal period, and this Agreement will terminate upon the completion of all remaining Services for which funds are allocated. No penalty or expense shall accrue to the City in the event this provision applies. 5. INDEMNIFICATION. 5.1 Agency Indemnification. The Agency agrees to release, indemnify, defend, and hold the City, its elected officials, officers, employees, agents, representatives, insurers, attorneys, and volunteers harmless from any and all claims, demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards, injuries, damages, liabilities, taxes, losses, fines, fees, penalties expenses, attorney's fees, costs, and/or litigation expenses to or by any and all persons or entities, including, without limitation, their respective agents, licensees, or representatives arising from, resulting from, or in connection with this Agreement or the performance of this Agreement, except for that portion of the claims caused by the City's sole negligence. Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Agency and the City, the Agency's liability hereunder shall be only to the extent of the Agency's negligence. Agency shall ensure that each subcontractor shall agree to defend and indemnify the City, its elected officials, officers, employees, agents, representatives, insurers, attorneys, and volunteers to the extent and on the same terms and conditions as the Agency pursuant to this paragraph. The City's inspection or acceptance of any of Agency's work when completed shall not be grounds to avoid any of these covenants of indemnification. 5.2 Industrial. Insurance Act Waiver. It is specifically and expressly understood that the Agency waives any immunity that may be granted to it under the Washington State industrial insurance act, Title 51 RCW, solely for the purposes of this indemnification. Agency's indemnification shall not be limited in any way by any limitation on the amount of damages, compensation or benefits payable to or by any third party under workers' compensation acts, disability benefit acts or any other benefits acts or programs. The Parties further acknowledge that they have mutually negotiated this waiver. 5.3 CiV Indemnification. The City agrees to release, indemnify, defend and hold the Agency, its officers, directors, shareholders, partners, employees, agents, representatives, and subcontractors harmless from any and all claims, demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards, injuries, damages, liabilities, losses, fines, fees, penalties expenses, attorney's fees, costs, and/or litigation expenses to or by any and all persons or entities, including without limitation, their respective agents, licensees, or representatives, arising from, resulting from or connected with this Agreement to the extent solely caused by the negligent acts, errors, or omissions of the City. 5.4 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement with respect to any event occurring prior to such expiration or termination. HUMAN SERVICES AGREEMENT - 2 - 10/2022 CITY OF Federal Way CITY HALL 33325 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www crtyoffederalway. com 6. INSURANCE. The Agency agrees to carry insurance for liability which may arise from or in connection with the performance of the services or work by the Agency, their agents, representatives, employees or subcontractors for the duration of the Agreement and thereafter with respect to any event occurring prior to such expiration or termination as follows: 6.1. Minimum Limits. The Agency agrees to carry as a minimum, the following insurance, in such forms and with such carriers who have a rating that is satisfactory to the City: a. Commercial general liability insurance covering liability arising from premises, operations, independent contractors, products -completed operations, stop gap liability, personal injury, bodily injury, death, property damage, products liability, advertising injury, and liability assumed under an insured contract with limits no less than $2,000,000 for each occurrence and $2,000,000 general aggregate. b. Workers' compensation and employer's liability insurance in amounts sufficient pursuant to the laws of the State of Washington; C. Automobile liability insurance covering all owned, non -owned, hired and leased vehicles with minimum combined single limits in the minimum amounts required to drive under Washington State law per accident for bodily injury, including personal injury or death, and property damage. 6.2. No Limit of Liabili . Agency's maintenance of insurance as required by the agreement shall not be construed to limit the liability of the Agency to the coverage provided by such insurance, or otherwise limit the City's recourse to any remedy available at law or in equity. The Agency's insurance coverage shall be primary insurance as respect the City. Any insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Agency's insurance and shall not contribute with it. 6:3. Additional Insured Verification. The City shall be named as additional insured on all commercial general liability insurance policies. Concurrent with the execution of this Agreement, Agency shall provide certificates of insurance for all commercial general liability policies attached hereto as Exhibit C and incorporated by this reference. At the City's request, Agency shall furnish the City with copies of all insurance policies and with evidence of payment of premiums or fees of such policies. If Agency's insurance policies are "claims made," Agency shall be required to maintain tail coverage for a minimum period of three (3) years from the date this Agreement is actually terminated or upon project completion and acceptance by the City. 6.4 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement. 7. CONFIDENTIALITY. All information regarding the City obtained by Agency in performance of this Agreement shall be considered confidential subject to applicable laws. Breach of confidentiality by the Agency may be grounds for immediate termination. All records submitted by the City to the Agency will be safeguarded by the Agency. The Agency will fully cooperate with the City in identifying, assembling, and providing records in case of any public records disclosure request. 8. WORK PRODUCT. All originals and copies of work product, including plans, sketches, layouts, designs, design specifications, records, files, computer disks, magnetic media or material which may be produced or modified by Agency while performing the Services shall belong to the City upon delivery. The Agency shall make such data, documents, and files available to the City and shall deliver all needed or contracted for work product upon the City's request. At the expiration or termination of this Agreement all originals and copies of any such work product remaining in the possession of Agency shall be delivered to the City. 9. BOOKS AND RECORDS. The Agency agrees to maintain books, records, and documents which sufficiently and properly reflect all direct and indirect costs related to the performance of the Services and maintain such accounting procedures and practices as may be deemed necessary by the City to assure proper accounting of all funds paid pursuant to this Agreement. These records shall be maintained for a period of six (6) years after the termination of this Agreement and may be subject, at all reasonable times, to inspection, review or audit by the City, its authorized representative, the State Auditor, or other governmental officials authorized by law to monitor this Agreement. 10. INDEPENDENT CONTRACTOR. The Parties intend that the Agency shall be an independent contractor and that the HUMAN SERVICES AGREEMENT - 3 - 10/2022 CITY OF CITY HALL Federal Way Feder 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www crryoffederalway, com Agency has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. The City shall be neither liable nor obligated to pay Agency sick leave, vacation pay or any other benefit of employment, nor to pay any social security or other tax which may arise as an incident of employment. Agency shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the Services and work and shall utilize all protection necessary for that purpose. All work shall be done at Agency's own risk, and Agency shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. The Agency shall pay all income and other taxes due except as specifically provided in, Section 4. Industrial or any other insurance that is purchased for the benefit of the City, regardless of whether such may provide a secondary or incidental benefit to the Agency, shall not be deemed to convert this Agreement to an employment contract. 11. CONFLICT OF INTEREST. It is recognized that Agency may or will be performing services during the Term for other parties; however, such performance of other services shall not conflict with or interfere with Agency's ability to perform the Services. Agency agrees to resolve any such conflicts of interest in favor of the City. Agency confirms that Agency does not have a business interest or a close family relationship with any City officer or employee who was, is, or will be involved in they Agency's selection, negotiation, drafting, signing, administration, or evaluating the Agency's performance. 12. EQUAL OPPORTUNITY EMPLOYER. In all services, programs, activities, hiring, and employment made possible by or resulting from this Agreement or any subcontract, there shall be no discrimination by Agency or its subcontractors of any level, or any of those entities' employees, agents, sub -agencies, �or representatives against any person because of sex, age (except minimum age and retirement provisions), race, color, religion, creed, national origin, marital status, or the presence of any disability, including sensory, mental or physical handicaps, unless based upon a bona fide occupational qualification in relationship to hiring and employment. This requirement shall apply to, but not be limited to, the following: employment, advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including apprenticeship. Agency shall comply with and shall not violate any of the terms of Chapter 49.60 RCW, Title VI of the Civil Rights Act of 1964, the Americans With Disabilities Act, Section 504 of the Rehabilitation Act of 1973, 49 CFRPart 21, 21.5 and 26, or any other applicable federal, state, or local law or regulation regarding non-discrimination. 13. GENERAL PROVISIONS. 13.1 Interpretation and Modification. This Agreement, together with any attached Exhibits, contains all of the agreements of the Parties with respect to any matter covered or mentioned in this Agreement and no prior statements or agreements, whether oral or written, shall be effective for any purpose. Should any language in any Exhibits to this Agreement conflict with any language in this Agreement, the terms of this Agreement shall prevail. The respective captions of the Sections of this Agreement are inserted for convenience of reference only and shall not be deemed to modify or otherwise affect any of the provisions of this Agreement. Any provision of this Agreement that is declared invalid, inoperative, null and void, or illegal shall in no way affect or invalidate any other provision hereof and such other provisions shall remain in full force and effect. Any act done by either Party prior to the effective date of the Agreement that is consistent with the authority of the Agreement and compliant with the terms of the Agreement, is hereby ratified as having been performed under the Agreement. No provision of this Agreement, including this provision, may be amended, waived, or modified except by written agreement signed by duly authorized representatives of the Parties. 13.2 Assignment and Beneficiaries. Neither the Agency nor the City shall have the right to transfer or assign, in whole or in part, any or all of its obligations and rights hereunder without the prior written consent of the other Party. If the non - assigning party gives its consent to any assignment, the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. Subject to the foregoing, the rights and obligations of the Parties shall inure to the benefit of and be binding upon their respective successors in interest, heirs and assigns. This Agreement,is made and entered into for the sole protection and benefit of the Parties hereto. No other person or entity shall have any right of action or interest in this Agreement based on any provision set forth herein. HUMAN SERVICES AGREEMENT - 4 - 10/2022 CITY OF CITY HALL Fe d e ra I Way Feder 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www cityoffederalway com 13.3 Compliance with Laws. The Agency shall comply with and perform the Services in accordance with all applicable federal, state, local, and city laws including, without limitation, all City codes, ordinances, resolutions, regulations, rules, standards and policies, as now existing or hereafter amended, adopted, or made effective. If a violation of the City's Ethics Resolution No. 91-54, as amended, occurs as a result of the formation or performance of this Agreement, this Agreement may be rendered null and void, at the City's option. 13.4 Enforcement. Time is of the essence in this Agreement and each and all of its provisions in which performance is a factor. Adherence to completion dates set forth in the description of the Services is essential to the Agency's performance of this Agreement. Any notices required to be given by the Parties shall be delivered at the addresses set forth at the beginning of this Agreement. Any notices may be delivered personally to the addressee of the notice or may be deposited in the United States mail, postage prepaid, to the address set forth above. Any notice so posted in the United States mail shall be deemed received three (3) days after the date of mailing. Any remedies provided for under the terms of this Agreement are not intended to be exclusive, but shall be cumulative with all other remedies available to the City at law, in equity or by statute. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. Failure or delay of the City to declare any breach or default immediately upon occurrence shall not waive such breach or default. Failure of the City to declare one breach or default does not act as a waiver of the City's right to declare another breach or default. This Agreement shall be made in, governed by, and interpreted in accordance with the laws of the State of Washington. If the Parties are unable to settle any dispute, difference or claim arising from this Agreement, the exclusive means of resolving that dispute, difference, or claim, shall be by filing suit under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative process. If the King County Superior Court does not have jurisdiction over such a suit, then suit may be filed in any other appropriate court in King County, Washington. Each party consents to the personal jurisdiction of the state and federal courts in King County, Washington and waives any objection that such courts are an inconvenient forum. If either Party brings any claim or lawsuit arising from this Agreement, each Party shall pay all its legal costs and attorney's fees and expenses incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award provided by law; provided, however, however nothing in this paragraph shall be construed to limit the Parties' rights to indemnification under Section 5 of this Agreement. 13.5 Execution. Each individual executing this Agreement on behalf of the City and Agency represents and warrants that such individual is duly authorized to execute and deliver this Agreement. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original and with the same effect as if all Parties hereto had signed the same document. All such counterparts shall be construed together and shall constitute one instrument, but in making proof hereof it shall only be necessary to produce one such counterpart. The signature and acknowledgment pages from such counterparts may be assembled together to form a single instrument comprised of all pages of this Agreement and a complete set of all signature and acknowledgment pages. The date upon which the last of all of the Parties have executed a counterpart of this Agreement shall be the "date of mutual execution" hereof. [Signature page follows] HUMAN SERVICES AGREEMENT - 5 - 10/2022 CITY OF CITY HALL 7 Fe d e ra I Way Feder 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 vvww 0yoffederalway com IN WITNESS, the Parties execute this Agreement below, effective the last date written below. CITY OF FEDERAL WAY: ATTEST: - ( - . Nty-� &dw Jim F , -Mafor t h ie Courtney, CMC, Ci , Lerk APPROVED AS TO FORM: DATE: ":PRyanll,City Attoi CONGOLESE 1NTEGRAI]ON NETWORK: By: ' Printed Name: FL0A1 bE79-F _ M U & A=L Jk- M A - Title: EXtX U"F1 VC — DATE: _� —_ --- 0 C — t 0 STATE OF WASHINGTON ) ss. COUNTY OF } On this day per ona la- appeared be.. re me Ahvjl:ML&Ikm, to me known to be the of that executed the foregoing instrument, and acknowledged the said uastrunient to e the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that he/she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. GIVQ- i i , hand and official seal this day of 20B. a sioNN�A,0+1�►Z Notary's signature s+`�b�� i'�.,� y Notary's printed nameVlfc (Tip 50 + : Notary Public in and for th S to I W shin�lon. 189901 5,u xa= N , i0����0 ; 0 _ My commission expires 01 ,it 1P I1111' 0P WAg►,\ HUMAN SERVICES AGREEMENT - 6 - 10/2022 CITY OF ift�Federal Proiect Services Summar CITY HALL Way 33325 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www cityoffedera/way com EXHIBIT A SERVICES The Agency shall provide support for food, housing, utilities, rent, employment and education as well as access to mental health services/referrals in the City of Federal Way. The Agency shall ensure that services provided with funding under this Agreement are made available to Federal Way residents. Performance Measures A. Number Served The Agency agrees to serve, at minimum, the following unduplicated number of Federal Way residents with Human Services funds: 1st 2nd 3rd 4th Quarter Quarter Quarter Quarter Total JAN. — APRIL — JULY — OCT. — MARCH JUNE SEPT. DEC. No. of unduplicated Federal Way persons assisted in 2023 9 10 9 10 38 No. of unduplicated Federal Way persons assisted in 2024 9 10 9 10 38 B. Units of Service The Agency agrees to provide, at minimum, the following units of service by quarter: 1st 2nd 3rd 4th Quarter Quarter Quarter Quarter Total JAN. — APRIL — JULY — OCT. — MARCH JUNE SEPT. DEC. 2023 1. Case Management 9 10 9 10 38 2024 1. Case Management 9 1 101 9 10 38 Units of service are measured by the number of individuals who receive support for food, housing, utilities, rent, employment and education as well as access to mental health services/referrals. HUMAN SERVICES AGREEMENT - 7 - 10/2022 ,!CITY OF *§, Federal C. Performance Measure(s) CITY HALL Way 33325 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www.cityoffederahvay.com Outcome: Clients served will have sustainable housing and basic needs met Indicator: Client -directed service plan documented progress on stainable housing and basic needs. Target: 80% Records A. Project Files The Agency shall maintain files for this project containing the following items: 1. Notice of Grant Award. 2. Motions, resolutions, or minutes documenting Board or Council actions. 3. A copy of this Agreement with the Scope of Services. 4. Correspondence regarding budget revision requests. 5. Copies of all invoices and reports submitted to the City for this project. 6. Bills for payment with supporting documentation. 7. Copies of approved invoices and warrants. 8. Documentation of client address; residency verified via King County Parcel Viewer. HUMAN SERVICES AGREEMENT - 8 - 10/2022 CITY of CITY HALL �� Feder 8th Avenue South Federal Way, WA 98003-6325 Fed ra I Way (253) 835-7000 www crtyoffederalway. com 9. Documentation of client income. The Agency agrees to use the HUD Income Guidelines to report income of clients served under this Agreement. Income guidelines may be adjusted periodically by HUD. [Enter current Income Limits Summary chart below] King County FY 2022 Income Limits Summary Median FY 2022 Income Income 1 2 3 4 5 6 7 8 King Limit Person Persons Persons Persons Persons Persons Persons Persons County Category Extremely Low (30%) $27,200 $31,050 $34,950 $38,800 $41,950 $45,050 $48,150 $51,250 Income Limits Very Low $134,600 (50%) $45,300 $51,800 $58,250 $64,700 $69,900 $75,100 $80,250 $85,450 Income Limits Low (80%) $66,750 $76,250 $85,800 $95,300 $102,950 $110,550 $118,200 $125,800 Income Limits The Agency agrees to use updated Income Guidelines which will be provided by the City. Reports and Reporting Schedule The Agency shall collect and report client information to the City quarterly and annually on a Service Unit Report to be provided by the City in the format requested by the City. The Agency shall submit an Annual Demographic Data Report. The agency shall collect and retain the data requested on this form from the persons served through this contract. Data should be tracked in an ongoing manner and submitted annually no later than January 15 in the format requested by the City. The Agency shall implement and track at least one measurable outcome for the program as presented in the application. Changes to the outcome presented in the application must be approved by the City prior to implementation. The Agency shall report the results of its outcome measure(s) annually on the Annual Outcome Data Report to be submitted by January 15 in the format requested by the City. Public Information In all news releases and other public notices related to projects funded under this Agreement, the Agency will include information identifying the source of funds as the City of Federal Way Human Services General Fund Program. HUMAN SERVICES AGREEMENT - 9 - 10/2022 CITY OF Federal Proied Budget CITY HALL Way 33325 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www.cilyoffederalway com EXHIBIT B COMPENSATION The Agency shall apply the following funds to the project. The total amount of compensation pursuant to this Agreement shall not exceed Thirty Thousand and 00/100 Dollars ($30,000.00). City of Federal Way Funds 2023 2024 City of Federal Way General Fund: $15,000.00 $15,000.00 Total City of Federal Way Funds: $15,000.00 $15,000.00 Reimbursement Requests and Service Unit Report forms shall be submitted no less frequently than quarterly and are due on the following dates: 1 st Quarter: April 15 or within 10 days of notice to proceed, whichever is later; 2nd Quarter: July 15; 3rd Quarter: October 15; and 4th Quarter: Final Reimbursement Request and Service Unit Report forms due January 8; Demographic Data Report and Annual Outcome Data Report due January 15. The Agency shall submit payment requests in the format requested by the City. Payment requests shall include a copy of the Service Unit Report. Estimated Quarterly Payments: 2023 1st Qtr $3,750.00 2nd Qtr $3,750.00 3rd Qtr $3,750.00 4th Qtr $3,750.00 2024 1 st Qtr $3,750.00 2nd Qtr $3,750.00 3rd Qtr $3,750.00 4th Qtr $3,750.00 Quarterly payment requests shall not exceed the estimated payment without prior written approval from the City. Estimated quarterly payments are contingent upon meeting or exceeding the above performance measure(s) for the corresponding quarter. This requirement may be waived at the sole discretion of the City with satisfactory explanation of how the performance measure will be met by year-end on the Service Unit Report. HUMAN SERVICES AGREEMENT - 10 - 10/2022 CITY OF .L Federal Way CITY HALL 33325 8th Avenue South Federal Way, WA 98003-6325 (253) 835-7000 www cityoffederalway. com City of Federal Way Human Services Contract for 2023-2024 General Fund Authorized Signatures for Invoices I authorize the following individuals to sign invoices and quarterly reports on behalf of: cc y\0�'p _ + (Contracting Agency), for the following: D v-Z o 'Tkk D (Program Title). Authorizing Signature: (must be signed by person who signs the contract, generally, Executive Director) (Printed Na)ne) a (Ville) 1. ©I -- 0 2 -- Zo.2 3 (Signature) (Date) CTO A -- Additional Authorized Signature: (Printed ame) (Title) � =--- �- � � (Signature) (Date) Additional Authorized Signature: D r. X 0 c. h i + f 6 &r c l rk A re c+ av o ,;� f e oc /M axf� (Printed Names' (Title) — oa. (Date) Note: It is the responsibility of the contractor to inform the City of Federal Way if they wish to add a name to or delete names from this list. W!7 Request for Taxpayer Give Form to the =orm Identification Number and Certification requester. Do not Rev. October2018) ]apartment of the Treasury send to the IRS. ntemal Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line hunk CONGOLESE INTEGRATION NETWORK 2 Business name/disregarded entity name, if different from above m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to rofollowing seven boxes. certain entities, not individuals; see p_ o ❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate instructions on page 3): rn ai c single -member LLC Exempt payee code (if any) CL Z+ 5 ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► p i Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting v LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code if an ( y) dcei another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that w is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑✓ Other (see Instructions) ► 501 c3 (Applies to accounts maintained outside the U.S) CL 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) (D 19950 International Blvd Ste 103 U) 6 City, state, and ZIP code Seatac, WA, 98188 7 List account number(s) here (optional) MM Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number backup withholding. For individuals, this is generally your social security number . However, fora , late resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other _ m - entities it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. F871 - 3 1 5 1 1 1 8M34 Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not 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 I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross 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 rWuired do sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Signature of f� Here I U.S. person ► Date ► 0 +� J General Instructfions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S, person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) Cl" of Federal Vllay 33325 8th Avenue South, Federal Way, WA 98003 ❑X New Vendor [] Update Form To add your business to our vendor file, or update information, please complete this form and mail to 33325 8's Ave South Federal _ Way,. WA 98003 or fax #253-835-2509 or email accountspayablcf#tcityoffederalway.com_ _ I Business Information (as shown on your federal tax rebrrn) (For office use only) VN#: 1. Business Name: CONGOLESE INTEGRATION NETWORK DBA 2. Contact Name: FLORIBERT MUBALAMA 3. Business Address: 19950 INTERNATIONAL BLVD STE 103 ,SEATAC, WA , 98188 City State Zip Cock 4, Remit To Address (if different): City/State Zap Code 5. Phone #: 206-556-6998 Fax 97 E-Mail: ^ info@cinseattle.org 6. Will you provide suppplies or service to the City of Federal Way? ❑ Supplies Q Services 7. City ofFederal Way Staff/Department Contact Name: Patti Spaulding-Klewin NAE&H zk(Please Clreslr 22 bass for federal t= clamfcadon_oLrxrsnnlenig2 enwed on line 1) ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Government Agency ❑ Trust/Estate ® Non -Profit tifc. a. Ee+vi w.&) _ 81-3511834 Federal ID/EIN # (9 digits) ❑ Sole Proprietor _ Federal ID # (9 digits) or Social Security Number If you are not a cotporation, is your Business subject to 1099 reporting? ❑ Yes ® No State of Washington U. B. I. # T_ ❑ Limited liability company. Ether the tax classification (C—C corporation, S-S corporation, P-Partnership) > Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for US federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (see instructions)> Exemptions (codes apply only to certain entitles, not individuals; see instruction) Exempt payee code (if any) Exemption from FATCA reporting code (if any) Certification: Under penalties of perjury, I certify that: 1. The number shown on this form is rrry correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2, 1 am not subject to backup witholding because: (a) I am exempt from backup withholding or (b)1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a resull of a failure to report all interest or dividends, or (e) the IRS has notified me that 1 am no longer subject to backup witholding; and 3. 1 am a US citizen or other U.S. person (definedbelow); and 4. The FATCA code(s) entered on this form (i f any) indicating that I am exempt from FATCA reporting is correct. The haernsl Revesue Service does not rcvldte Your consent to any prpllikn e41hk4-_M tt other than the cerd11ca an required to avoid backup-rgithholdJn sip V qq 4 q Here t<tureofU-S rson;5 Date> a� ` ®L •G Q (� For information call: 253.835.2525 or Fax: 253.835.2509 or e-mail: accnunlkg1vahlctstcitvaffederalwa�.com Rev 1 2021 �-- , DATE (MMIDDIYYYY) ACQRV CERTIFICATE OF LIABILITY INSURANCE llllt� 1 01 /20/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT Cert Request DML Insurance Services 4005 20th Ave W Ste132 PWr HONE (206)838-9077 FAX (206)838-9076 E-MAIL certs@dmlinsurance.com Seattle WA 98199- Alliance of NonProfits for Insurance 110023 INSURED INSURER B : _ Congolese Integration Network INSURER C. 19550 International Blvd Ste. 103 INSURERD: _ SeaTac WA 98188- INSURER E INSURERF: rnvclaer.Fe r_FRTIFICATF NIIMRFR- RFVISION NUMRFR: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR P ICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY X 2022-67918 33/24/2022 03/24/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR $ 500,000 DAMAGE TO RENTED SFS lFa ore MED EXP JAny oneperson) $ 20,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POUCY jE [XI LOC GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG 3,000,000 A AUTOMOBILE LIABILITY X 2022-67918 33/24/2022 03/24/2023 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Bar amidanf� $ A X UMBRELLA LIAB X OCCUR X 2022-67918-UMB 12/14/2022 33/24/2023 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 EXCESS LIAB CLAIMS -MADE X I0 4,000,000 A WORKERS COMPENSATION ;2022-67918 33/24/2022 33/24/2023 PERTuTi X OTH- AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ i(WA Stop Gap) E.L EACH ACCIDENT 11000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A EL. DISEASE - POLICY LIMIT If yes, describe under DFSCR)PT)ON OF OPERATIONS btlgn 1,000,000 A Professional Liability X 2022-67918 03/24/2022 '03/24/2023 Ea Event/Aggregate $1,000,000 A Improper Sexual Conduct X 2022-67918 03/24/2022 03/24/2023 Ea Occ/Aggregate i $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The City of Federal Way, a Washington municipal corporation is listed as an additional Insured with respect to work being performed by the named insured. The insured is performing the following kind of work: nonprofit work. Coverage is Primary & Non -Contributory. rr_DrtGIrA'r= unl nGo r ANr r-I I ATION Al U 15`JU.S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Federal Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Patti Spaulding-Klewin ACCORDANCE WITH THE POLICY PROVISIONS. 33325 8th Ave. S AUTHORIZED REPRESENTATIVE ��1p� 1 ` r� lra "'� �Q �/ Federal Way WA 98003-6325 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACARn 25 12n1R/031 Tha ACARn names and Innn ara ranicfPra_d marks of AcoRn On,t%_LL1ANk.Iv ur NONPROFITS FOR INSURANCE A Head far Insurance. A Heartfor Nonprofits. POLICY NUMBER: 2022-67918 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT FOR PUBLIC ENTITIES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: A. Section II — WHO IS AN INSURED is amended to include: 4. Any public entity as an additional insured, and the officers, officials, employees, agents and/or volunteers of that public entity, as applicable, who may be named in the Schedule above, when you have agreed in a written contract or written agreement presently in effect or becoming effective during the term of this policy, that such public entity and/or its officers, officials, employees, agents and/or volunteers be added as an additional insured(s) on your policy, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a. Your negligent acts or omissions; or b. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations. No such public entity or individual is an additional insured for liability arising out of the sole negligence by that public entity or its designated individuals. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. B. Section III — LIMITS OF INSURANCE is amended to include: 8. The limits of insurance applicable to the public entity and applicable individuals identified as an additional insured(s) pursuant to Provision A.4. above, are those specified in the written contract between you and that public entity, or the limits available under this policy, whichever are less. These limits are part of and not in addition to the limits of insurance under this policy. C. With respect to the insurance provided to the additional insured(s), Condition 4. Other Insurance of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance a. Primary Insurance This insurance is primary if you have agreed in a written contract or written agreement: (1) That this insurance be primary. If other insurance is also primary, we will share with all that other insurance as described in c. below; or ANI-RRG-E61 02 19 Page 1 of 2 1'1LLIANI.t Vt .❑ NONPROFITS FOR INSURANCE A Head for Insurance. A Heartfor Nonprofits. POLICY NUMBER: 2022-67918 (2) The coverage afforded by this insurance is primary and non-contributory with the additional insured(s)' own insurance. Paragraphs (1) and (2) do not apply to other insurance to which the additional insured(s) has been added as an additional insured or to other insurance described in paragraph b. below. b. Excess Insurance This insurance is excess over: 1. Any of the other insurance, whether primary, excess, contingent or on any other basis: (a) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for "your work"; (b) That is fire, lightning, or explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner; (c) That is insurance purchased by you to cover your liability as a tenant for "property damage" to premises temporarily occupied by you with permission of the owner; or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION I — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE. (e) Any other insurance available to an additional insured(s) under this Endorsement covering liability for damages which are subject to this endorsement and for which the additional insured(s) has been added as an additional insured by that other insurance. (1) When this insurance is excess, we will have no duty under Coverages A or B to defend the additional insured(s) against any "suit" if any other insurer has a duty to defend the additional insured(s) against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured(s)' rights against all those other insurers. (2) When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (b) The total of all deductible and self -insured amounts under all that other insurance. (3) We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Methods of Sharing If all of the other insurance available to the additional insured(s) permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any other the other insurance available to the additional insured(s) does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. ANI-RRG-E61 02 19 Page 2 of 2 11 /8/22, 1:10 PM Washington State Department of Revenue Washington State Department of Revs, < Business Lookup License Information: Entity name: CONGOLESE INTEGRATION NETWORK Business name: CONGOLESE INTEGRATION NETWORK Entity type: Nonprofit Corporation UBI #: 604-018-041 Business ID: 001 Location ID: 0001 Location: Active Location address: 19550 INTERNATIONAL BLVD STE 103 SEATAC WA 98188-5428 Mailing address: 19550 INTERNATIONAL BLVD STE 103 SEATAC WA 98188-5428 n New search Back to results https://secure.dor.wa.gov/gteunauth/_/#17 1 /3 11 /8/22, 1:10 PM Excise tax and reseller permit status: Secretary of State status: Endorsements Endorsements held at this to License # Federal Way Nonprofit Business SeaTac Nonprofit Business Washington State Department of Revenue Click here Click here Count Details Status Expiration da First issuance Pending Oct-31-2023 Governing People May include governing people not registered with Secretary of State Governing people MUBALAMA, FLORIBERT H Active Jul-31-2023 Feb-17-2021 The Business Lookup information is updated nightly. Search date and time: 11/8/2022 1:10:28 PM https://secure.dor.wa.gov/gteunauth/_/#17 2/3 11 /8/22, 1:10 PM Washington State Department of Revenue Contact us How are we doing? Take our survey! Don't see what you expected? Check if your browser is supported https://secure.dor.wa.gov/gteunauth/_/#17 313 10/14/22, 1:14 PM Corporations and Charities System E+ or ss%r Bsnand Charities Filing System BUSINESS INFORMATION Business Name: CONGOLESE INTEGRATION NETWORK UBI Number: 604 018 041 Business Type: WA NONPROFIT CORPORATION Business Status: ACTIVE Principal Office Street Address: 19550 INTERNATIONAL BLVD STE 103, SEATAC, WA, 98188-5428, UNITED STATES Principal Office Mailing Address: 19550 INTERNATIONAL BLVD STE 103, SEATAC, WA, 98188-5428, UNITED STATES Expiration Date: 07/31/2023 Jurisdiction: UNITED STATES, WASHINGTON Formation/ Registration Date: 07/22/2016 Period of Duration: PERPETUAL Inactive Date: Nature of Business: BRINGING COMMUNITY TOGETHER AND ADVOCATING FOR THEIR HEALTH AND WELL-BEING, WE FACILITATE INTEGRATION OF REFUGEES IN WASHINGTON STATE Charitable Corporation: https://ccfs.sos.wa.gov/#/BusinessSearch/Businesslnformation 1/2 10/14/22, 1:14 PM Corporations and Charities System FEIN Number: 81-3511834 Gross Revenue exceed $500,000: Has Members: Public Benefit Designation: Host Home: REGISTERED AGENT INFORMATION Registered Agent Name: FLORIBERT MUBALAMA 2212 67TH AVE NE, TACOMA, WA, 98422-3724, UNITED STATES 19550 INTERNATIONAL BLVD STE 103, SEATAC, WA, 98188-5428, UNITED STATES GOVERNORS Title GOVERNOR Back Street Address: Mailing Address: Governors Type Entity Name First Name Last Name INDIVIDUAL FLORIBERT H MUBALAMA Filing History Name History f Print Return to Business Search https://ccfs.sos.wa.gov/#/BusinessSearch/Businessinfonnation L 2/2