O-CUCS POL 87(2)(a) (PBS)

Modification
EPIN: 07122P8036KXLA002

This Amendment (“Amendment”), effective on the date specified on the Signature

Page, is between the City of New York, acting by and through its Department of
Homeless Services (“Department”), with offices at 33 Beaver Street, New York,
New York 10004 and Center for Urban Community Services, Inc.
(“Contractor”), with offices at 198 East 121st Street, 6th Floor, New York, NY
10035 (hereinafter "the Parties").

WITNESSETH

WHEREAS, the Parties entered into an agreement for the Contractor to operate a
shelter for single adults located at POL 87(2)(a) ,
for the period of January 15, 2021 through June 30, 2052 (together with all
Appendices, Exhibits and Riders thereto, hereinafter referred to as the
“Agreement”); and

WHEREAS, pursuant to a modifcation agreement dated June 3, 2022, the Parties

previously amended the Appendices E and F of the Agreement; and

WHEREAS, the Department desires to modify the Agreement in order to update

sections of the Human Services Standard Contract, as well as to replace Appendix
C, Appendix D, Appendix E and Appendix F in their entirety.

NOW THEREFORE, the parties agree to amend the Agreement as follows:

1. Except as modified herein all of the terms, conditions and covenants of the
Agreement shall remain in full force and effect.

2. Article 2, Section 2.01 of the Human Service Standard Contract is hereby

replaced with the following end date:

Term. The term of this Agreement begins on January 15, 2021, and ends on
June 30, 2054, unless earlier terminated or extended pursuant to the terms of
this Agreement (“Term”).

3. Article 3, Section 3.03(A) through (D) of the Human Services Standard

Contract is hereby replaced with the following:

A. The Department shall pay Contractor an amount not to exceed two

hundred twenty-three million two hundred forty-six thousand eight
hundred seventy-eight dollars ($223,246,878.00) for all services
provided under the Agreement including the Residence Services, Start-
up costs, Building Rent Payments, Insurance Rent, Annual Owner
Costs, and Building Rent, and Allowance for Repairs. Start-up costs
shall not exceed one million one thousand three dollars
($1,001,003.00) as defined in Section 3.03 (C) below and the total

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O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002
Building Rent Payments shall not exceed fifty-one million three
hundred sixty-seven thousand six hundred seventy dollars
($51,367,670.00) as defined in Section 3.03 (F). Total Insurance Rent
shall not exceed one million seven hundred thirty eight thousand
forty eight dollars ($1,738,048.00) plus any Insurance Deficiencies.
The Allowance for Repairs as defined in Section 3.03 (E) below shall
not exceed nineteen million two hundred seventy-four thousand six
hundren twenty-seven dollars ($19,274,627.00). Payment shall be
made in accordance with the Budget and the Fiscal Manual and subject
to the following terms and conditions. Notwithstanding the foregoing,
Building Rent Payments shall be set forth on Appendix E and shall not
be subject to adjustment except pursuant to a replacement of Appendix
E as set forth below. Appendix E shall not be replaced except (i) to
address any changes approved by the Department pursuant to Appendix
B, Article 3(B)(3) or (4), or (ii) in the event that the Construction Loan
and the Permanent Loan are separate loans and the parties agree to
replace Appendix E at the time of the closing of the Permanent Loan, or
(iii) in the event the parties agree to replace Appendix E in connection
with any Refinancing in accordance with Appendix B, Article 20, or (iv)
in the event that the City requires the Permanent Loan to be prepaid in
accordance with Appendix B, Article 20, resulting in the automatic
reduction of Building Rent to One Dollar ($1.00) per year for the
remainder of the Term. Any replacement of Appendix E in accordance
with the immediately preceding sentence shall be memorialized in an
amendment to this Agreement by the City and the Contractor and
requires the prior written consent of any lender that may be affected by
such change, which consent may be withheld in such lender's sole and
absolute discretion. For the sake of clarity, in the event that the
Construction Loan and the Permanent Loan are a single loan, Appendix
E, including, without limitation, the Building Rent Commencement
Date, the amount of Building Rent Payments, the number of Building
Rent Payments and the Building Rent Payment Dates, may not be
replaced and Building Rent may not be reduced for any reason (except
that Building Rent may be terminated as expressly set forth in Section
3.03(T) below in connection with an Assignment Remedy Election
followed by a failure of the Site Availability Condition to be satisfied in
accordance with its terms and Section 3.03 (U) in connection with a
Casualty or Condemnation) after the Construction Loan Closing Date
without the prior written consent of the Construction Lender and
Permanent Lender, as applicable, in their sole and absolute discretion.

B. The operating budget annual amount is as follows:

Fiscal Years 2021: $1.00

Fiscal Years 2022: $3,250,846.00

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O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002
Fiscal Years 2023: $6,731,090.00
Fiscal Years 2024- 2052: $6,953,717.00
Fiscal Years 2053: $6,817,841.00
Fiscal Years 2054: $4,789,307.00

This amount includes Building Rent Payments as specified in Section

3.03(F) below and Allowance for Repairs which shall be disbursed only
if necessary repairs are approved by the Department as specified in
Section 3.03(D) below. Payments to the Contractor for amounts other
than Building Rent Payments, Insurance Rent and Tax Rent, if
applicable, shall be made in accordance with either the presently
approved State daily rate or any other State approved method of
payment for temporary, emergency housing. If the State rate changes
during the term of this Agreement, the Department may change the per
diem rate to be paid under this Agreement, other than with respect to
Building Rent, Insurance Rent, and Tax Rent.

C. During the Start-up period, the Contractor shall be paid Start-up costs
not to exceed one million one thousand three dollars ($1,001,003.00)
in accordance with the Start-up budget, a copy of which is attached
hereto and made a part hereof as Appendix D (“Start-up Costs”). The
Start-up shall be advanced to the Contractor in one lump sum. The
Contractor shall submit to the Department such documentation as
requested by the Department substantiating the expenditures set forth in
the Start-up budget.

D. An amount not to exceed ten percent (10%) of the total contract value
exclusive of the start-up costs nineteen million two hundred seventy-
four thousand six hundren twenty-seven dollars ($19,274,627.00)
will be budgeted for necessary repairs for the Premises. Such amount
shall be divided by the number of years of the Term and included in the
Budget in each fiscal year as an installment specified as an Allowance
for Repairs. The annual installments for Allowance for Repairs shall be
retained by the Department until necessary repairs are approved for
expenditure pursuant to the Standard New Needs Procedure.

4. Article 3, Section 3.03(F)(1) of the Human Services Standard Contract is

hereby replaced with the following:

The total not-to-exceed annual amount for Building Rent Payments for the
Term of the contract shall be one million six hundred fifty three thousand
one hundred sixty two dollars ($1,653,162.00) in accordance with the Fixed
Costs Schedule, as defined in Appendix B and attached hereto as Appendix
E. Appendix E attached hereto shall include a schedule of Building Rent
Payments. To the extent that the Building Rent Commencement Date

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O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002
determined pursuant to Appendix B, Article 3 (B)(4) is different than the first
(1st) payment date shown on Appendix E, the parties hereby agree to replace
Appendix E with an accurate schedule on or prior to the Loan Closing Date.
Notwithstanding any such replacement of Appendix E, the total not-to-exceed
amount set forth in the first sentence of this Section 3.03(F)(1) shall not
change. Such Building Rent Payment obligation shall continue through the
Building Rent Term and the Building Rent Payment obligation shall survive
any termination of this Agreement, including, without limitation, the
Agreement Term or Appendix A, Article 10 (except as expressly set forth in
Section 3.03(U) in connection with Casualty and Condemnation of the
Premises and Section 3.03(T) below in connection with an Assignment
Remedy Election followed by a failure of the Site Availability Condition to
be satisfied in accordance with its terms). The City’s Building Rent Payment
obligation shall survive an assignment of this Agreement by the City pursuant
to Appendix A, Section 3.01. The City hereby confirms that Building Rent
Payments do not exceed normal costs of ownership as described in NYCRR
Title 18, Chapter II, Part 491 as though the Contractor had secured title to the
Premises, and as described in 45 CFR Section 75.449.

5. Appendix C – Budget Exhibits, is hereby replaced in its entirety with

Appendix C that is attached hereto and made a part hereof, as Exhibit A.

6. Appendix D – Start Up Budget, is hereby replaced in their entirety with

Appendix D that is attached hereto and made a part hereof, as Exhibit B.

7. Appendix E – Fixed Cost Schedule, is hereby replaced in their entirety with

Appendix E that is attached hereto and made a part hereof, as Exhibit C.

8. Appendix F – Project Schedule, is hereby replaced in its entirety with

Appendix F that is attached hereto and made a part hereof, as Exhibit D.

9. This Amendment is subject to the Rules of Procurement Policy Board of the

City of New York (the “Rules”). In the event of a conflict between the said
Rules and a provision of the Amendment, the Rules shall take precedence.

10. This Amendment shall be neither binding nor effective unless and until it is
registered pursuant to Charter Section 328 of the New York City Charter. The
requirement of this Section shall be in addition to, and not in lieu of, any
approval or authorization otherwise required for this Amendment to be
effective, and for the expenditure of City funds.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

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O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002

Exhibit A

Appendix C – Budget Exhibits

5
 NEW YORK CITY DEPARTMENT OF HOMELESS SERVICES
Contract Exhibit
BUDGET SUMMARY FORM

Agency/Provider Center for Urban Community Services (CUCS) Contract No CT1-071-20221403002

Program/Facility Washington Street Safe Haven Fiscal Year FY21
Term of Contract 1/15/2021 - 6/30/2054
Agency Representative
Agency Telephone Date 08/08/22

I PERSONNEL SERVICES (PS) BUDGET

Administration $0
Counseling $0
Child Care (Tier IIs only) $0
Recreation $0
Direct Care $0
Security $0
Maintenance $0
MVO $0
Kitchen $0

TOTAL PERSONNEL SERVICES $0

II FRINGE BENEFITS (31%) $0

III TOTAL PS $0

IV OTHER THAN PERSONNEL SERVICE (OTPS)

Office Equipment $0
Client Supplies/Furniture $0
Client Transportation $0
Staff Transportation
Client Stipends
Utilities $0
Insurance $0
Office Expenses $0
Professional Costs $0
Behavioral Services $0
Maintenance/Repair $0
Mechanical System Contracts $0
Food $0
Contracted Security $0
Vehicle Expenses $0

V TOTAL OTPS $0

VI TOTAL PS & OTPS ( III + IV ) $0

VI ADMINISTRATIVE OVERHEAD (10%) $0

VII BUILDING RENT PAYMENTS $0

VIII INSURANCE RENT & ANNUAL HDFC COSTS $0

IX TOTAL ( V + VI + VII + VIII) $0

X START UP $0

XI ALLOWANCE FOR REPAIR $0

XII GROSS AMOUNT (IX + X +XI) $1

XIII ACCRUALS ( Max 5% of Net Funding - DHS Funding ) $0

XIV REVENUE $0

XV DHS FUNDING ( XII - XIII - XIV ) $1

FUNDING TYPE
DHS DIRECT $0
ESG $0
DoHMH $0
CITY COUNCIL $0
TOTAL FUNDING $0

Note: If the Budget Summary Form is not returned with all original signatures within ten (10) days of receipt, DHS will assume your approval of the Annual Review.

APPROVALS:

DHS Program Representative Date

DHS Budget Date

Provider Date
 NEW YORK CITY DEPARTMENT OF HOMELESS SERVICES
Contract Exhibit
BUDGET SUMMARY FORM

Agency/Provider Center for Urban Community Services (CUCS) Contract No CT1-071-20221403002

Program/Facility Washington Street Safe Haven Fiscal Year FY22
Term of Contract 1/15/2021 - 6/30/2054
Agency Representative
Agency Telephone Date 02/02/22

I PERSONNEL SERVICES (PS) BUDGET

Administration $76,055
Counseling $82,298
Child Care (Tier IIs only) $0
Recreation $67,879
Direct Care $190,660
Security $179,732
Maintenance $10,801
MVO $0
Kitchen $0

TOTAL PERSONNEL SERVICES $607,424

II FRINGE BENEFITS (31%) $188,301

III TOTAL PS $795,725

IV OTHER THAN PERSONNEL SERVICE (OTPS)

Office Equipment $10,995

Client Supplies/Furniture $21,526
Client Transportation $4,319
Staff Transportation $0
Client Stipends $0
Utilities $39,851
Office Expenses $8,082
Professional Costs $0
Behavioral Services $193,665
Maintenance/Repair $116,523
Mechanical System Contracts $4,211
Food $88,359
Contracted Security $125,591
Vehicle Expenses $0

V TOTAL OTPS $613,123

VI TOTAL PS & OTPS ( III + IV ) $1,408,848

VI ADMINISTRATIVE OVERHEAD (10%) $140,885

VII BUILDING RENT PAYMENTS $478,151

VIII INSURANCE RENT & ANNUAL HDFC COSTS $17,428

IX TOTAL ( V + VI + VII + VIII) $2,045,312

X START UP $1,001,003

XI ALLOWANCE FOR REPAIR $204,531

XII GROSS AMOUNT (IX + X +XI) $3,250,846

XIII ACCRUALS ( Max 5% of Net Funding - DHS Funding ) $0

XIV REVENUE $0

XV DHS FUNDING ( XII - XIII - XIV ) $3,250,846

FUNDING TYPE
DHS DIRECT $3,250,846
ESG $0
DoHMH $0
CITY COUNCIL $0
TOTAL FUNDING $3,250,846

Note: If the Budget Summary Form is not returned with all original signatures within ten (10) days of receipt, DHS will assume your approval of the Annual Review.

APPROVALS:

DHS Program Representative Date

DHS Budget Date

Provider Date
 NEW YORK CITY DEPARTMENT OF HOMELESS SERVICES
Contract Exhibit
BUDGET SUMMARY FORM

Agency/Provider Center for Urban Community Services (CUCS) Contract No CT1-071-20221403002

Program/Facility Washington Street Safe Haven Fiscal Year FY23
Term of Contract 1/15/2021 - 6/30/2054
Agency Representative
Agency Telephone Date 02/02/22

I PERSONNEL SERVICES (PS) BUDGET AMENDMENT GRAND TOTAL

Administration $227,541
Counseling $246,220
Child Care (Tier IIs only) $0
Recreation $203,080
Direct Care $570,417
Security $537,723
Maintenance $32,313
MVO $0
Kitchen $0

TOTAL PERSONNEL SERVICES $1,817,294

II FRINGE BENEFITS (31%) $563,361

III TOTAL PS $2,380,655

IV OTHER THAN PERSONNEL SERVICE (OTPS)

Office Equipment $32,895

Client Supplies/Furniture $64,403
Client Transportation $12,921
Staff Transportation
Client Stipends
Utilities $119,227
Office Expenses $24,180
Professional Costs $0
Behavioral Services $579,407
Maintenance/Repair $348,614
Mechanical System Contracts $12,599
Food $264,353
Contracted Security $375,744
Vehicle Expenses $0

V TOTAL OTPS $1,834,343

VI TOTAL PS & OTPS ( III + IV ) $4,214,998

VI ADMINISTRATIVE OVERHEAD (10%) $421,500

VII BUILDING RENT PAYMENTS $1,430,535 $0 $1,430,535

VIII INSURANCE RENT & ANNUAL HDFC COSTS $52,140

IX TOTAL ( V + VI + VII + VIII) $6,119,173 $0 $6,119,173

X START UP $0 $0 $0

XI ALLOWANCE FOR REPAIR $611,917 $0 $6,731,090

XII GROSS AMOUNT (IX + X +XI) $6,731,090 $0 $6,731,090

XIII ACCRUALS ( Max 5% of Net Funding - DHS Funding ) $0

XIV REVENUE $0

XV DHS FUNDING ( XII - XIII - XIV ) $6,731,090 $0 $6,731,090

FUNDING TYPE
DHS DIRECT $6,731,090 $0 $6,731,090
ESG $0 $0 $0
DoHMH $0 $0 $0
CITY COUNCIL $0 $0 $0
TOTAL FUNDING $6,731,090 $0 $6,731,090

Note: If the Budget Summary Form is not returned with all original signatures within ten (10) days of receipt, DHS will assume your approval of the Annual Review.

APPROVALS:

DHS Program Representative Date

DHS Budget Date

Provider Date
 NEW YORK CITY DEPARTMENT OF HOMELESS SERVICES
Contract Exhibit
BUDGET SUMMARY FORM

Agency/Provider Center for Urban Community Services (CUCS) Contract No CT1-071-20221403002

Program/Facility Washington Street Safe Haven Fiscal Year FY24-FY52
Term of Contract 1/15/2021 - 6/30/2054
Agency Representative
Agency Telephone Date 02/02/22

I PERSONNEL SERVICES (PS) BUDGET AMENDMENT GRAND TOTAL

Administration $227,541
Counseling $246,220
Child Care (Tier IIs only) $0
Recreation $203,080
Direct Care $570,417
Security $537,723
Maintenance $32,313
MVO $0
Kitchen $0

TOTAL PERSONNEL SERVICES $1,817,294

II FRINGE BENEFITS (31%) $563,361

III TOTAL PS $2,380,655

IV OTHER THAN PERSONNEL SERVICE (OTPS)

Office Equipment $32,895

Client Supplies/Furniture $64,403
Client Transportation $12,921
Staff Transportation
Client Stipends
Utilities $119,227
Office Expenses $24,180
Professional Costs $0
Behavioral Services $579,407
Maintenance/Repair $348,614
Mechanical System Contracts $12,599
Food $264,353
Contracted Security $375,744
Vehicle Expenses $0

V TOTAL OTPS $1,834,343

VI TOTAL PS & OTPS ( III + IV ) $4,214,998

VI ADMINISTRATIVE OVERHEAD (10%) $421,500

VII BUILDING RENT PAYMENTS $1,430,535 $222,627 $1,653,162

VIII INSURANCE RENT & ANNUAL HDFC COSTS $52,140

IX TOTAL ( V + VI + VII + VIII) $6,119,173 $222,627 $6,341,800

X START UP $0

XI ALLOWANCE FOR REPAIR $611,917

XII GROSS AMOUNT (IX + X +XI) $6,731,090 $222,627 $6,953,717

XIII ACCRUALS ( Max 5% of Net Funding - DHS Funding ) $0

XIV REVENUE $0

XV DHS FUNDING ( XII - XIII - XIV ) $6,731,090 $222,627 $6,953,717

FUNDING TYPE
DHS DIRECT $6,731,090 $222,627 $6,953,717
ESG $0 $0 $0
DoHMH $0 $0 $0
CITY COUNCIL $0 $0 $0
TOTAL FUNDING $6,731,090 $222,627 $6,953,717

Note: If the Budget Summary Form is not returned with all original signatures within ten (10) days of receipt, DHS will assume your approval of the Annual Review.

APPROVALS:

DHS Program Representative Date

DHS Budget Date

Provider Date
 NEW YORK CITY DEPARTMENT OF HOMELESS SERVICES
Contract Exhibit
BUDGET SUMMARY FORM

Agency/Provider Center for Urban Community Services (CUCS) Contract No CT1-071-20221403002

Program/Facility Washington Street Safe Haven Fiscal Year FY53
Term of Contract 1/15/2021 - 6/30/2054
Agency Representative
Agency Telephone Date 02/02/22

I PERSONNEL SERVICES (PS) BUDGET AMENDMENT GRAND TOTAL

Administration $0 $227,541 $227,541

Counseling $0 $246,220 $246,220
Child Care (Tier IIs only) $0 $0 $0
Recreation $0 $203,080 $203,080
Direct Care $0 $570,417 $570,417
Security $0 $537,723 $537,723
Maintenance $0 $32,313 $32,313
MVO $0 $0 $0
Kitchen $0 $0 $0

TOTAL PERSONNEL SERVICES $0 $1,817,294 $1,817,294

II FRINGE BENEFITS (31%) $0 $563,361 $563,361

III TOTAL PS $0 $2,380,655 $2,380,655

IV OTHER THAN PERSONNEL SERVICE (OTPS)

Office Equipment $0 $32,895 $32,895

Client Supplies/Furniture $0 $64,403 $64,403
Client Transportation $0 $12,921 $12,921
Staff Transportation $0 $0 $0
Client Stipends $0 $0 $0
Utilities $0 $119,227 $119,227
Office Expenses $0 $24,180 $24,180
Professional Costs $0 $0 $0
Behavioral Services $0 $579,407 $579,407
Maintenance/Repair $0 $348,614 $348,614
Mechanical System Contracts $0 $12,599 $12,599
Food $0 $264,353 $264,353
Contracted Security $0 $375,744 $375,744
Vehicle Expenses $0 $0 $0

V TOTAL OTPS $0 $1,834,343 $1,834,343

VI TOTAL PS & OTPS ( III + IV ) $0 $4,214,998 $4,214,998

VI ADMINISTRATIVE OVERHEAD (10%) $0 $421,500 $421,500

VII BUILDING RENT PAYMENTS $0 $1,517,286 $1,517,286

VIII INSURANCE RENT & ANNUAL HDFC COSTS $0 $52,140 $52,140

IX TOTAL ( V + VI + VII + VIII) $0 $6,205,924 $6,205,924

X START UP $0 $0 $0

XI ALLOWANCE FOR REPAIR $0 $611,917 $611,917

XII GROSS AMOUNT (IX + X +XI) $0 $6,817,841 $6,817,841

XIII ACCRUALS ( Max 5% of Net Funding - DHS Funding ) $0 $0 $0

XIV REVENUE $0 $0 $0

XV DHS FUNDING ( XII - XIII - XIV ) $0 $6,817,841 $6,817,841

FUNDING TYPE
DHS DIRECT $0 $6,817,841 $6,817,841
ESG $0 $0 $0
DoHMH $0 $0 $0
CITY COUNCIL $0 $0 $0
TOTAL FUNDING $0 $6,817,841 $6,817,841

Note: If the Budget Summary Form is not returned with all original signatures within ten (10) days of receipt, DHS will assume your approval of the Annual Review.

APPROVALS:

DHS Program Representative Date

DHS Budget Date

Provider Date
 NEW YORK CITY DEPARTMENT OF HOMELESS SERVICES
Contract Exhibit
BUDGET SUMMARY FORM

Agency/Provider Center for Urban Community Services (CUCS) Contract No CT1-071-20221403002

Program/Facility Washington Street Safe Haven Fiscal Year FY54
Term of Contract 1/15/2021 - 6/30/2054
Agency Representative
Agency Telephone Date 02/02/22

I PERSONNEL SERVICES (PS) BUDGET AMENDMENT GRAND TOTAL

Administration $0 $227,541 $227,541

Counseling $0 $246,220 $246,220
Child Care (Tier IIs only) $0 $0 $0
Recreation $0 $203,080 $203,080
Direct Care $0 $570,417 $570,417
Security $0 $537,723 $537,723
Maintenance $0 $32,313 $32,313
MVO $0 $0 $0
Kitchen $0 $0 $0

TOTAL PERSONNEL SERVICES $0 $1,817,294 $1,817,294

II FRINGE BENEFITS (31%) $0 $563,361 $563,361

III TOTAL PS $0 $2,380,655 $2,380,655

IV OTHER THAN PERSONNEL SERVICE (OTPS)

Office Equipment $0 $32,895 $32,895

Client Supplies/Furniture $0 $64,403 $64,403
Client Transportation $0 $12,921 $12,921
Staff Transportation $0 $0 $0
Client Stipends $0 $0 $0
Utilities $0 $119,227 $119,227
Office Expenses $0 $24,180 $24,180
Professional Costs $0 $0 $0
Behavioral Services $0 $579,407 $579,407
Maintenance/Repair $0 $348,614 $348,614
Mechanical System Contracts $0 $12,599 $12,599
Food $0 $264,353 $264,353
Contracted Security $0 $375,744 $375,744
Vehicle Expenses $0 $0 $0

V TOTAL OTPS $0 $1,834,343 $1,834,343

VI TOTAL PS & OTPS ( III + IV ) $0 $4,214,998 $4,214,998

VI ADMINISTRATIVE OVERHEAD (10%) $0 $421,500 $421,500

VII BUILDING RENT PAYMENTS $0 $0 $0

VIII INSURANCE RENT & ANNUAL HDFC COSTS $0 $52,140 $52,140

IX TOTAL ( V + VI + VII + VIII) $0 $4,688,638 $4,688,638

X START UP $0 $0 $0

XI ALLOWANCE FOR REPAIR $0 $100,669 $100,669

XII GROSS AMOUNT (IX + X +XI) $0 $4,789,307 $4,789,307

XIII ACCRUALS ( Max 5% of Net Funding - DHS Funding ) $0 $0 $0

XIV REVENUE $0 $0 $0

XV DHS FUNDING ( XII - XIII - XIV ) $0 $4,789,307 $4,789,307

FUNDING TYPE
DHS DIRECT $0 $4,789,307 $4,789,307
ESG $0 $0 $0
DoHMH $0 $0 $0
CITY COUNCIL $0 $0 $0
TOTAL FUNDING $0 $4,789,307 $4,789,307

Note: If the Budget Summary Form is not returned with all original signatures within ten (10) days of receipt, DHS will assume your approval of the Annual Review.

APPROVALS:

DHS Program Representative Date

DHS Budget Date

Provider Date
O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002

Exhibit B

Appendix D – Start Up Budget

6
 MERV-13 filtration and UVC light 1 50,000 $50,000

Sub total $50,000

Client Furniture

Bed with Drawers 84 568 $47,694

Mattresses 84 132 $11,113
Dressers 84 557 $46,768
Bedroom Chairs 84 391 $32,877
Bed & Dresser Labels 168 7 $1,235
Lounge Area Sofas 4 1,266 $5,063
Lounge Area Chairs 17 729 $12,389
Lounge End Table 10 206 $2,062
Lounge TV (4th & 6th Fl) 2 1,575 $3,150
Computer Desks (4th & 6th Fl) 6 251 $1,508
Computer Desk Stools 6 84 $504
Reception Area Chairs (1st Fl) 4 210 $840
Dining Room Tables (6-top) 2 430 $860
Dining Room Tables (4-top) 5 232 $1,158
Dining Room Chairs 32 176 $5,645
Medical Area Waiting Rm Chairs 6 210 $1,260
Dining Room Large Screen TV 2 2,415 $4,830
Laundry Room Table 1 304 $304
Laundry Room Chairs 2 84 $168
Storage Shelving (Cellar) 12 224 $2,684
Pet Supplies 1 815 $815
Refrigerator (Dining Room) 1 923 $923
Delivery & Assembly 1 21,011 $21,011
Sub total $204,859

Outdoor Furniture

Picnic tables with chairs and umbrellas 4 1,286 $5,145

Benches 6 525 $3,150
Patio chairs 8 506 $4,049
Planters 6 1,000 $6,000
Delivery & Assembly 1 2,201 $2,201
Sub total $20,545

Medical Equipment & Supplies

Integrated Wall System 1 1,544 $1,544

Examination Table 1 1,615 $1,615
Eye Test Chart 1 11 $11
EKG Unit 1 2,914 $2,914
Defibrillator 1 1,659 $1,659
Carrying Case 1 133 $133
Blood Glucose Monitoring System 1 25 $25
Nebulizer Kit 1 49 $49
Percussion 1 21 $21
Scale w/Height Rod 1 363 $363
Rolling stool 1 309 $309
Freezer 1 434 $434
Fridge Memory Monitoring Thermometer 79345 2 95 $191
Oxygen Tank Cylinder 4 98 $392
Single Wheel E Cylinder Cart 1 71 $71
O2 Flow Meter Gauge (regulator) 1 292 $292
O2 Cylinder Sale-E Size 4 127 $507
Fridge Trays 4 4 $18
Cart Workstation 2 2,700 $5,400
Provone Touch Free Dispenser (for hand sanitize 3 29 $86
Biohazard Waste Receptacle 2 236 $472
Sharps Container 2 30 $61
Spot Vital Signs® Device 1 2,773 $2,773
 Mobile Stand For Spot Vitals Device 1 345 $345
BP Cuff 2 60 $119
General Exam Light 1 529 $529
Stethoscope 1 97 $97
Safety Glasses 1 11 $11
Medical Scissors 1 23 $23
Medical Nail Clipper 1 53 $53
Floor Scale 1 72 $72
Tape Measure 1 3 $3
Vaccine Fridge 1 1,133 $1,133
Phlebotomy Chair 1 683 $683
Privacy Curtain 1 1,575 $1,575
Equipment Delivery 1 2,471 $2,471
Sub total $26,453

Bed Bug Oven

Pack Tite Bed Bug Oven 1 4,200 $4,200
Shipping 1 500 $500
Sub total $4,700

Security System

Digital Recorder 1 9,570 $9,570

Managed switch for security cameras 2 3,743 $7,486
Uninterruptable Power Supply 1 330 $330
Cameras with mounting arms 47 189 $8,883
Outdoor Dome Cameras 5 184 $919
Dome Cameras 10 126 $1,260
Alarm Panel 2 835 $1,670
Key Pad 2 95 $189
Security Monitor and computer 1 2,867 $2,867
Battery Backup 6 32 $189
Motion Sensor 16 42 $672
Panic Buttons 39 326 $12,695
Front Door Intercom System 1 4,095 $4,095
Two-way radios 12 174 $2,088
Sub total $52,912

IT & Telecom Equipment

Staff IT and Telecom
Office Network Switch 1 4,410 $4,410
WiFi Switch 1 4,140 $4,140
Wifi Accesspoints 20 1,145 $22,900
WiFi cabling 20 200 $4,000
Firewall for VPN tunnel 1 1,200 $1,200
PCs with web cams 9 1,431 $12,880
Monitors 35 187 $6,542
iGel 26 610 $15,860
Web Cams for iGels 26 80 $2,080
Personal Printers 11 800 $8,800
Multifunction color network printer 2 2,600 $5,200
Management Server 0 3,000 $0
Team Viewer Tech License 1 400 $400
MS Windows CALs 35 116 $4,060
MS Office Licenses 35 48 $1,680
Office Rollback Licenses 32 91 $2,923
Kapersky Licenses 4 30 $120
Remote Desktop CALs 35 50 $1,750
Citrix User Licenses 35 54 $1,890
Large screen flat screen micros PC & room web 1 4,000 $4,000
Flat Panel TV 2 1,000 $2,000
Color Multifunction Copier 1 12,000 $12,000
Small Desktop Copier 1 2,300 $2,300
Network Cables 80 10 $800
Wiring Closet UPS 1 800 $800
 Long Network Cable 0 0 $0
Network Patch Cables 80 10 $800
IP phones and licenses 35 360 $12,600
Polycom conference phone 1 800 $800
PA system 1 10,000 $10,000
Power Strips 1 200 $200
Buildingwide Wifi System 1 39,258 $39,258
Client IT and Telecom Voice Firewall 1 800 $800
Client computers 6 1,300 $7,800
Monitors and Webcams--client 6 1,300 $7,800
Kaspersky licenses--Client 6 120 $720
Rollback Rx Software 1 65 $65
Client Computer Room Switch 1 2,240 $2,240
Client Network Cables 10 10 $100
Network patch cables 10 10 $100
Firewall/Content filters 1 1,200 $1,200
Large Screen TVs for client rec & dining 2 2,200 $4,400
Shipping 1 10,367 $10,367
Sub total $221,985

Signage and Fire Safety

Fire Safety & Evacuation Plans 1 5,744 $5,744
Room Signage 1 4,641 $4,641
Sign Installation 1 3,276 $3,276
Alarm Pull Station Covers 8 416 $3,328
Fire Guard Inspection Log Book 9 425 $3,827
Fire Alarm Log book and Building Inspection lo 9 737 $6,634
 Sprinkler and StandPipe Inspection Log Books 9 435 $3,912
Smoke Detector and Maintenance Log Books 9 387 $3,487
Fire Safety Plan Log Books 9 520 $4,678
K Fire extingusher 1 159 $159
Fire Extingushers 12 1,701 $20,412
Fire Extingushers Cabinets 12 1,701 $20,412
Sub total $80,509

Medication Cabinets
Medication Cabinets 3 2,835 $8,505
Sub total $8,505

Maintenance
Tool Cabinet with all tools 1 3,413 $3,413
Janitorial Carts & Tilt Truck 3 945 $2,835
Fuel oil for generator (150 lbs) 1 893 $893
Dome Safety Mirrors 6 38 $227
Trash Cans with Lids 16 32 $519
First Aid Kits 12 22 $265
Spill kit 12 23 $271
Snow Blower 1 1,050 $1,050
Key Box 2 210 $420
Safe 2 1,406 $2,812
Waste Baskets 35 7 $245
45 Gal. Trach Can 6 355 $2,130
Recycling bins 35 14 $490
28 gal. recycling Bins 4 28 $112
Sub total $15,681

Kitchen Equipment
Reach-in Refrigerator 1 3,510 $3,510
Reach-in Freezer 1 1,945 $1,945
Microwave Oven 1 570 $570
Shelf for microwave oven 1 507 $507
Dishwasher 1 5,763 $5,763
Serving Parts & Accessories 1 23,290 $23,290
Electric Serving Counter 1 5,096 $5,096
Electric Convection Oven 1 7,393 $7,393
Ice Machine and parts 1 4,666 $4,666
3-compartment Sink 1 1,230 $1,230
Work Table 1 499 $499
Commercial Hand Sink 1 524 $524
Countertop 2 926 $1,852
Base cabinet 2 827 $1,654
Overshelf for storage 5 303 $1,516
Shelving unit 1 987 $987
Work Table (L-shaped) 1 2,569 $2,569
Metal Splashguard 10 374 $3,737
Sub total $67,308

TOTAL OTHER THAN PERSONNEL SERVICES $899,221

TOTAL PERSONNEL AND OTHER THAN PERSONNEL COSTS $1,001,003

ADMINISTRATIVE COSTS @ 8.5% $0

TOTAL START UP COSTS $1,001,003

 MERV-13 filtration and UVC light 1 50,000 $50,000

Sub total $50,000

Client Furniture

Bed with Drawers 84 568 $47,694

Mattresses 84 132 $11,113
Dressers 84 557 $46,768
Bedroom Chairs 84 391 $32,877
Bed & Dresser Labels 168 7 $1,235
Lounge Area Sofas 4 1,266 $5,063
Lounge Area Chairs 17 729 $12,389
Lounge End Table 10 206 $2,062
Lounge TV (4th & 6th Fl) 2 1,575 $3,150
Computer Desks (4th & 6th Fl) 6 251 $1,508
Computer Desk Stools 6 84 $504
Reception Area Chairs (1st Fl) 4 210 $840
Dining Room Tables (6-top) 2 430 $860
Dining Room Tables (4-top) 5 232 $1,158
Dining Room Chairs 32 176 $5,645
Medical Area Waiting Rm Chairs 6 210 $1,260
Dining Room Large Screen TV 2 2,415 $4,830
Laundry Room Table 1 304 $304
Laundry Room Chairs 2 84 $168
Storage Shelving (Cellar) 12 224 $2,684
Pet Supplies 1 815 $815
Refrigerator (Dining Room) 1 923 $923
Delivery & Assembly 1 21,011 $21,011
Sub total $204,859

Outdoor Furniture

Picnic tables with chairs and umbrellas 4 1,286 $5,145

Benches 6 525 $3,150
Patio chairs 8 506 $4,049
Planters 6 1,000 $6,000
Delivery & Assembly 1 2,201 $2,201
Sub total $20,545

Medical Equipment & Supplies

Integrated Wall System 1 1,544 $1,544

Examination Table 1 1,615 $1,615
Eye Test Chart 1 11 $11
EKG Unit 1 2,914 $2,914
Defibrillator 1 1,659 $1,659
Carrying Case 1 133 $133
Blood Glucose Monitoring System 1 25 $25
Nebulizer Kit 1 49 $49
Percussion 1 21 $21
Scale w/Height Rod 1 363 $363
Rolling stool 1 309 $309
Freezer 1 434 $434
Fridge Memory Monitoring Thermometer 79345 2 95 $191
Oxygen Tank Cylinder 4 98 $392
Single Wheel E Cylinder Cart 1 71 $71
O2 Flow Meter Gauge (regulator) 1 292 $292
O2 Cylinder Sale-E Size 4 127 $507
Fridge Trays 4 4 $18
Cart Workstation 2 2,700 $5,400
Provone Touch Free Dispenser (for hand sanitize 3 29 $86
Biohazard Waste Receptacle 2 236 $472
Sharps Container 2 30 $61
Spot Vital Signs® Device 1 2,773 $2,773
 Mobile Stand For Spot Vitals Device 1 345 $345
BP Cuff 2 60 $119
General Exam Light 1 529 $529
Stethoscope 1 97 $97
Safety Glasses 1 11 $11
Medical Scissors 1 23 $23
Medical Nail Clipper 1 53 $53
Floor Scale 1 72 $72
Tape Measure 1 3 $3
Vaccine Fridge 1 1,133 $1,133
Phlebotomy Chair 1 683 $683
Privacy Curtain 1 1,575 $1,575
Equipment Delivery 1 2,471 $2,471
Sub total $26,453

Bed Bug Oven

Pack Tite Bed Bug Oven 1 4,200 $4,200
Shipping 1 500 $500
Sub total $4,700

Security System

Digital Recorder 1 9,570 $9,570

Managed switch for security cameras 2 3,743 $7,486
Uninterruptable Power Supply 1 330 $330
Cameras with mounting arms 47 189 $8,883
Outdoor Dome Cameras 5 184 $919
Dome Cameras 10 126 $1,260
Alarm Panel 2 835 $1,670
Key Pad 2 95 $189
Security Monitor and computer 1 2,867 $2,867
Battery Backup 6 32 $189
Motion Sensor 16 42 $672
Panic Buttons 39 326 $12,695
Front Door Intercom System 1 4,095 $4,095
Two-way radios 12 174 $2,088
Sub total $52,912

IT & Telecom Equipment

Staff IT and Telecom
Office Network Switch 1 4,410 $4,410
WiFi Switch 1 4,140 $4,140
Wifi Accesspoints 20 1,145 $22,900
WiFi cabling 20 200 $4,000
Firewall for VPN tunnel 1 1,200 $1,200
PCs with web cams 9 1,431 $12,880
Monitors 35 187 $6,542
iGel 26 610 $15,860
Web Cams for iGels 26 80 $2,080
Personal Printers 11 800 $8,800
Multifunction color network printer 2 2,600 $5,200
Management Server 0 3,000 $0
Team Viewer Tech License 1 400 $400
MS Windows CALs 35 116 $4,060
MS Office Licenses 35 48 $1,680
Office Rollback Licenses 32 91 $2,923
Kapersky Licenses 4 30 $120
Remote Desktop CALs 35 50 $1,750
Citrix User Licenses 35 54 $1,890
Large screen flat screen micros PC & room web 1 4,000 $4,000
Flat Panel TV 2 1,000 $2,000
Color Multifunction Copier 1 12,000 $12,000
Small Desktop Copier 1 2,300 $2,300
Network Cables 80 10 $800
Wiring Closet UPS 1 800 $800
 Long Network Cable 0 0 $0
Network Patch Cables 80 10 $800
IP phones and licenses 35 360 $12,600
Polycom conference phone 1 800 $800
PA system 1 10,000 $10,000
Power Strips 1 200 $200
Buildingwide Wifi System 1 39,258 $39,258
Client IT and Telecom Voice Firewall 1 800 $800
Client computers 6 1,300 $7,800
Monitors and Webcams--client 6 1,300 $7,800
Kaspersky licenses--Client 6 120 $720
Rollback Rx Software 1 65 $65
Client Computer Room Switch 1 2,240 $2,240
Client Network Cables 10 10 $100
Network patch cables 10 10 $100
Firewall/Content filters 1 1,200 $1,200
Large Screen TVs for client rec & dining 2 2,200 $4,400
Shipping 1 10,367 $10,367
Sub total $221,985

Signage and Fire Safety

Fire Safety & Evacuation Plans 1 5,744 $5,744
Room Signage 1 4,641 $4,641
Sign Installation 1 3,276 $3,276
Alarm Pull Station Covers 8 416 $3,328
Fire Guard Inspection Log Book 9 425 $3,827
Fire Alarm Log book and Building Inspection lo 9 737 $6,634
 Sprinkler and StandPipe Inspection Log Books 9 435 $3,912
Smoke Detector and Maintenance Log Books 9 387 $3,487
Fire Safety Plan Log Books 9 520 $4,678
K Fire extingusher 1 159 $159
Fire Extingushers 12 1,701 $20,412
Fire Extingushers Cabinets 12 1,701 $20,412
Sub total $80,509

Medication Cabinets
Medication Cabinets 3 2,835 $8,505
Sub total $8,505

Maintenance
Tool Cabinet with all tools 1 3,413 $3,413
Janitorial Carts & Tilt Truck 3 945 $2,835
Fuel oil for generator (150 lbs) 1 893 $893
Dome Safety Mirrors 6 38 $227
Trash Cans with Lids 16 32 $519
First Aid Kits 12 22 $265
Spill kit 12 23 $271
Snow Blower 1 1,050 $1,050
Key Box 2 210 $420
Safe 2 1,406 $2,812
Waste Baskets 35 7 $245
45 Gal. Trach Can 6 355 $2,130
Recycling bins 35 14 $490
28 gal. recycling Bins 4 28 $112
Sub total $15,681

Kitchen Equipment
Reach-in Refrigerator 1 3,510 $3,510
Reach-in Freezer 1 1,945 $1,945
Microwave Oven 1 570 $570
Shelf for microwave oven 1 507 $507
Dishwasher 1 5,763 $5,763
Serving Parts & Accessories 1 23,290 $23,290
Electric Serving Counter 1 5,096 $5,096
Electric Convection Oven 1 7,393 $7,393
Ice Machine and parts 1 4,666 $4,666
3-compartment Sink 1 1,230 $1,230
Work Table 1 499 $499
Commercial Hand Sink 1 524 $524
Countertop 2 926 $1,852
Base cabinet 2 827 $1,654
Overshelf for storage 5 303 $1,516
Shelving unit 1 987 $987
Work Table (L-shaped) 1 2,569 $2,569
Metal Splashguard 10 374 $3,737
Sub total $67,308

TOTAL OTHER THAN PERSONNEL SERVICES $899,221

TOTAL PERSONNEL AND OTHER THAN PERSONNEL COSTS $1,001,003

ADMINISTRATIVE COSTS @ 8.5% $0

TOTAL START UP COSTS $1,001,003

O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002

Exhibit C

Appendix E – Fixed Cost Schedule

7
APPENDIX E1 ‐ FIXED COSTS SCHEDULE
Project Name: Washington Street Safe Haven
Project Address: POL 87(2)(a) New York, NY 10006
Block/Lot: Block 53, Lot 4

DEVELOPMENT BUDGET PROJECT USES

ACQUISITION COST Acquisition $12,865,000
Land Acquisition Cost $12,865,000 Hard Cost $13,492,675
Total Acquisition Costs $12,865,000 Soft Cost $4,027,042
Developer Fee $1,458,000
HARD COST TOTAL USES $31,842,717
Hard Cost $12,266,068
Contingency $1,226,607 PROJECT SOURCES
Total Hard Cost $13,492,675 CONSTRUCTION SOURCES
Construction Loan $31,842,717
SOFT COSTS PERMANENT SOURCES
Professional Fees Permanent Loan $31,842,717
Borrower Legal $307,346
Architect/Engineering Fees $698,000 PERMANENT LOAN TERMS
Green Consultant $0 Interest Rate 3.00%
Bank Engineer $0 Loan Term (Yrs) 30
Bank Legal $185,000 Fully amortizing loan with monthly payments
Appraisal $0
Environmental Phase I & II, etc. $0 BUILDING RENT PAYMENTS
Survey $28,400 Not to Exceed Annual Amount $1,653,162
Title Insurance $199,320
Permits & Expediting Fees $100,000
Controlled Inspections $47,600
Owner's Rep for Construction Monitoring $253,000
Total Professional Fees $1,818,666

Financing Fees
Construction Loan ‐ Bank Fee $290,625
Permanent Loan ‐ Bank Fee $195,065
Bond Lender Legal $135,000
Total Fees & Cost of Financing $620,690

Carrying Costs
Construction Interest $947,689
Water & Sewer $2,500
Utilities $36,000
Construction Insurance $75,000
Total Carrying Costs $1,061,189

Contingency & Reserves

Soft Cost Contingency $106,017
Building Rent Payment Reserve $378,480
Capitalized Reserves $42,000
Total Contingency & Start‐Up $526,497
Developer Fee Schedule:
Total Soft Cost $4,027,042 20% Construction Closing
DEVELOPER FEE $1,458,000 30% Construction Completion
TOTAL DEVELOPMENT COST $31,842,717 50% Shelter Opening
APPENDIX E2 ‐ FIXED COSTS SCHEDULE
Project Name: Washington Street Safe Haven
Project Address: POL 87(2)(a) New York, NY 10006
Block/Lot: Block 53, Lot 4

Projected Buidling Rent Payment Commencement Date: June 1, 2023

Projected Building Rent Payment End Date: May 31, 2053

30‐YR FIXED COST SCHEDULE ANNUAL NOT TO EXCEED BUILDING RENT

PAYMENT AMOUNT
Year 1 $478,151
Year 2 $1,653,162
Year 3 $1,653,162
Year 4 $1,653,162
Year 5 $1,653,162
Year 6 $1,653,162
Year 7 $1,653,162
Year 8 $1,653,162
Year 9 $1,653,162
Year 10 $1,653,162
Year 11 $1,653,162
Year 12 $1,653,162
Year 13 $1,653,162
Year 14 $1,653,162
Year 15 $1,653,162
Year 16 $1,653,162
Year 17 $1,653,162
Year 18 $1,653,162
Year 19 $1,653,162
Year 20 $1,653,162
Year 21 $1,653,162
Year 22 $1,653,162
Year 23 $1,653,162
Year 24 $1,653,162
Year 25 $1,653,162
Year 26 $1,653,162
Year 27 $1,653,162
Year 28 $1,653,162
Year 29 $1,653,162
Year 30 $1,653,162
Year 31 $1,653,162
Year 32 $1,466,012
TOTAL $51,539,023
O-CUCS POL 87(2)(a) (PBS)
Modification
EPIN: 07122P8036KXLA002

Exhibit D

Appendix F – Project Schedule

8
APPENDIX F ‐ PROJECT SCHEDULE
Project Name: Washington Street Safe Haven
Project Address: POL 87(2)(a) New York, NY 10006
Block/Lot: Block 53, Lot 4

Projected construction loan closing, construction completion, permanent

loan closing, and shelter operations commencement:

1) Construction Loan Closing: June 3, 2022

2) Anticipated Construction Completion: June 1, 2023
3) Anticipated Shelter Operations Commencement: June 1, 2023
DocuSign Envelope ID: 0FB83418-BD73-44DB-9B4D-172ED7520CED

CONTRACT SIGNATURE PAGE

This Contract is entered by and between the City of New York (“City”), acting by and through
the DEPARTMENT OF HOMELESS SERVICES, and CENTER FOR URBAN COMMUNITY
SERVICES INC (“Contractor”).

This Contract consists of this contract signature page as well as the following documents (“Contract
Documents”) which are located in the Documents tab of the PASSPort record titled Washington Street Safe
Haven-POL 87(2)(a) - Extension.

1. Contract - CUCS - POL 87(2)(a) - 2nd Mod (07122P8036KXLA002) - Apr 24 2023 6:39PM

The above order does not represent an order of precedence. The Contract shall be governed by the order of
precedence, if any, in the Contract Documents or by ordinary contract principles if no such order of precedence
exists.

Each party is signing this Contract electronically on the date stated in that party's electronic signature.

The City of New York

By: DEPARTMENT OF HOMELESS SERVICES

__________________________________
(Signature)
Vincent Pullo
Name: ____________________________
ACCO
Title:
4/26/2023 | 06:39:52 PDT
Date:

Contractor
By: CENTER FOR URBAN COMMUNITY SERVICES INC

__________________________________
(Signature)
Mary T Mahedy
Name: ____________________________
Director Of Budget and Contracts
Title:
4/26/2023 | 09:15:58 EDT
Date:
27th July 22
 PO Box 66699, Albany, NY 12206
| nysif.com

CERTIFICATE OF WORKERS' COMPENSATION INSURANCE (RENEWED)

^ ^ ^ ^ ^ ^ POL 87(2)(d)
FRIEDLANDER GROUP INC
2500 WESTCHESTER AVE #400A
PURCHASE NY 10577
SCAN TO VALIDATE
AND SUBSCRIBE

POLICYHOLDER CERTIFICATE HOLDER

CENTER FOR URBAN COMMUNITY NEW YORK CITY DEPARTMENT
SERVICES INC T/A CUCS OF HOMELESS SERVICES
198 E 121ST ST 33 BEAVER STREET
NEW YORK NY 10035 NEW YORK NY 10004

POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE

M2281 220­0 907218 07/02/2022 TO 07/02/2023 7/5/2022

THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE
FUND UNDER POLICY NO. 2281 220­0, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR
WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL
OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW.

IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS,
OR TO VALIDATE THIS CERTIFICATE, VISIT OUR WEBSITE AT HTTPS://WWW.NYSIF.COM/CERT/CERTVAL.ASP. THE NEW
YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS.

THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT
OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN
WORKERS' COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE
EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN
CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED.

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE
COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICY.

NEW YORK STATE INSURANCE FUND

DIRECTOR,INSURANCE FUND UNDERWRITING

VALIDATION NUMBER: 631820735

U­26.3