HomeMy WebLinkAboutAgenda - 11-05-2009 - 4fORANGE COUNTY
BOARD OF COMMISSIONERS
ACTION AGENDA ITEM ABSTRACT
Meeting Date: November 5, 2009
Action Agenda
Item No. ~{-- _-F
SUBJECT: American Recovery and Reinvestment Act Funding for Senior Lunch Program
DEPARTMENT: Aging
PUBLIC HEARING: (Y/N) L~
ATTACHMENT(S):
Agreement for Senior Nutrition Services
Award Provisions
Provider Services Summary
INFORMATION CONTACT:
Jerry Passmore, 245 2000
PURPOSE: To approve the receipt of $17,893 in American Recovery and Reinvestment Act
(ARRA) funding to purchase additional Senior Lunch meals that will be served at the two
Orange County senior centers.
BACKGROUND: The NC Division of Aging and Adult Services has awarded ARRA federal
funds to each congregate senior meals program .across the State. The Department on Aging
assumed management of the senior meal program in Orange County on July 1, 2009. Orange
County`s allocation of $17,893 will be used to purchase 4,400 additional meals to serve at the
Seymour and Central Orange Senior Centers. With the acceptance of the ARRA funds, the
Department on Aging is required to report to the State Division of Aging on the impact of jobs
created and/or saved by the local caterer.
FINANCIAL IMPACT: The ARRA funds are non-recurring. The required 10% match is
available in the current Department on Aging Community Based Services budget. The NC
Division of Aging and Adult Services requested that expenditure of these funds begin no later
than November 2009.
RECOMMENDATION(S): The Manager recommends that the Board:
1. Approve .the acceptance of the Orange County ARRA allocation for the Senior Lunch
Program; and
2. Authorize the Chair to sign the following:
• Agreement with the Triangle J Council of Governments for Provision of County-
Based Nutrition Services for the Elderly Through the American Recovery and
Reimbursement Act of 2009;
• Award Provision for ARRA Funds, County Nutrition Program Providers; and
• ARRA County Funding Plan
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November 1, 2009 Through December 31, 2010
Agreement for the Provision of County-Based Nutrition Services for the Elderly
Through the American Recovery and Reimbursement Act of 2009
This Agreement, entered into as of this first day of November, 2009, by and between the County of
Orange (hereinafter referred to as the "County") and the Triangle J Council of Governments' Area
Agency on Aging, (hereinafter referred to as the "Area Agency").
Witnesseth That:
WHEREAS, the Area Agency and the County agree to the terms and conditions for provision of
congregate meals and home delivered meals services in connection with activities financed by the
American Recovery and Reinvestment Act of 2009 funds, provided to the Area Agency from the
United States Department of Health and Human Services through the North Carolina Division of
Aging and Adult Services (DAAS) and state appropriations made available to the Area Agency
through the North Carolina Division of Aging and Adult Services, as set forth in a) this document, b)
the Division of Aging and Adult Services Home and Community Care Block Grant Procedures Manual
for Community Service Providers, d) the Division of Aging and Adult Services Service Standards
Manual, Volumes I through IV, e) the Division of Aging and Adult Services Community Service
Providers Monitoring Guidelines, the Award Provisions for ARRA funds, and directives for the
administration of ARRA funding provided through the Division of Aging and Adult Services.
NOW THEREFORE, in consideration of these premises, and mutual covenants and agreements
hereinafter contained, the parties hereto agree as follows:
1. Community nutrition service providers specified by the County are as follows:
Orange County Department on Aging
1.(a) The Community Service Provider(s), shall be those specified in the County Funding Plan on
the ARRA Provider Services Summary format(s) (ARRA-732) for the period ending December
31, 2010.
2. Availability of Funds. The terms set forth in this Agreement for payment are contingent upon
the receipt of American Recovery and Reinvestment Act funding by the Area Agency.
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3. Grant Administration. The grant administrator for the Area Agency shall. be Joan M. Pellettier,
Director, Triangle J Area Agency on Aging. The grant administrator for the County shall be
Gwen Harvey, Assistant Orange County Manager.
It is understood and agreed that the grant administrator for the County shall represent the
County in the performance of this Agreement. The County shall notify the Area Agency in
writing if the administrator changes during the grant period. Specific responsibilities of the
grant administrator for the County are provided in paragraph seven (7) of this Agreement.
4. Services authorized through the County Funding Plan, as specified on the ARRA Provider
Services Summary format(s) (ARRA-732) are to commence when funds become available to
counties and shall be undertaken and pursued in such sequence as to assure their expeditious
completion. All services required hereunder shall be completed on or before the end of the
Agreement period, December 31, 2010.
5. Assignability and Contracting. The County shall not assign all or any portion of its interest in
this Agreement. Any purchase of nutrition services with American Recovery and
Reinvestment Act (ARRA) funding shall be carried out in accordance with the procurement
and contracting policy of the community services provider or, where applicable, the Area
Agency, which does not conflict with procurement and contracting requirements contained in
45 CFR 92.36 and complies with the Award Provisions for ARRA Funds. Federal funds shall
not be awarded to any subreceipients who have been suspended or debarred by the Federal
government. In addition, Federal funds may not be used to purchase goods or services costing
over $100,000 from a vendor that has been suspended or debarred from Federal grant
programs.
6. Compensation and Payments to the County. The County shall be compensated for the work and
services actually performed under this Agreement by payments to be made monthly by the
Area Agency. Total reimbursement to the community service providers under this Agreement
may not exceed the grand total of ARRA nutrition funding, as specified on the ARRA Provider
Services Summary format (ARRA-732).
a) Reimbursement of Service Costs
Reimbursement of service costs are carried out as provided in Section 3 of the N.C.
Division of Aging and Adult Services Home and Community Care Block Grant
Procedures Manual for Community Service Providers, revised February 17, 1997.
b) Role of the County Finance Director
The County Finance Director shall be responsible for disbursing ARRA Nutrition
funding to Community Service Providers in accordance with procedures specified in the
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N.C. Division of Aging and Adult Services Home and Community Care Block Grant
Manual for Community Service Providers, revised February 17, 1997.
c) Payment of Administration on Aging Nutrition Services Incentive Program (NSIP)
Subsid
NSIP subsidy for congregate and home delivered meals will be disbursed by the
Division of Aging and Adult Services through the Area Agency to the County on a
monthly basis, subject to the availability of funds as specified in Section 3 of the N.C.
Division of Aging and Adult Services Home and Community Care Block Grant
Procedures Manual for Community Services Providers, revised February 17, 1997.
7. Reallocation of Funds and Budget Revisions. Any reallocation of ARRA funding between
counties shall be voluntary on the part of the County. If during the performance period of the
Agreement, the Area Agency determines that a portion of the ARRA funding will not be
expended, the grant administrator for the County shall be notified in writing by the Area
Agency and given the opportunity to make funds available for reallocation to other counties in
the Planning and Service Area or elsewhere in the state. ARRA DOES NOT ALLOW FOR
THE TRANSFER OF FUNDING BETWEEN CONGREGATE AND HOME DELIVERED
MEALS. ANY REALLOCATION OF FUNDING WILL BE DONE UNDER THE
DIRECTION OF THE AREA AGENCY ON AGING.
Unless community services providers have been given the capacity to enter data into the Aging
Resources Management System (ARMS), Area Agencies on Aging are responsible for entering
amended service data into the Division of Aging and Adult Services Management Information
System, as specified in the N.C. Division of Aging and Adult Services Home and Community
Care Block Grant Procedures Manual for Community Service Providers, revised February 17,
1997.
8. Monitoring. This Agreement will be monitored to assure that services are being provided in
compliance with the N.C. Division of Aging and Adult Services Service Standards Manual,
dated July 1, 1992, and the N.C. Division of Aging and Adult Services Home and Community
Care Block Grant Procedures Manual for Community Service Providers, revised February 17,
1997. Further, compliance with updated monitoring requirements, as specified in Office of
Management and Budget (OMB) Circular A-133 and NC General Statute 143C-6-22 and 23
shall be carried out. Monitoring shall also include compliance with conflict of interest
requirements. Monitoring requirements are discussed in Section 308 of the AAA Policies and
Procedures Manual (7/1/03). Private non-profit service providers will be monitored to ensure
compliance with conflict of interest policies, as stated in DoA Administrative Letter No. 03-14.
Be advised that additional monitoring and compliance criteria may be required by the Division
of Aging and Adult Services during the performance of the program.
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The monitoring of services provided under this Agreement shall be carried out by the Area
Agency on Aging in accordance with its Assessment Plan and/or by the DAAS Program
Compliance Representative (PCR).
Counties and community service providers will receive a written report of monitoring findings
in accordance with procedures established in Section 308 of the AAA Policies and Procedures
Manual (7/1/03) and DOA Administrative Letter No. 98-13. Any areas ofnon-compliance will
be addressed in a written corrective action plan with the community service provider.
9. Disputes and Appeals. Any dispute concerning a question of fact arising under this Agreement
shall be identified to the designated grants administrator for the Area Agency. In accordance
with Lead Regional Organization (LRO) policy, a written decision shall be promptly furnished
to the designated grants administrator for the County.
The decision of the LRO is final unless within twenty (20) days of receipt of such decision the
Chairman of the Board of Commissioners furnishes a written request for appeal to the Director
of the North Carolina Division of Aging and Adult Services, with a copy sent to the Area
Agency. The request for appeal shall state the exact nature of the complaint. The Division of
Aging and Adult Services will inform the Chairman of the Board of Commissioners of its
appeal procedures and will inform the Area Agency that an appeal has been filed. Procedures
thereafter will be determined by the appeals process of the Division of Aging and Adult
Services. The state agency address is as follows:
Director
North Carolina Division of Aging and Adult Services
2101 Mail Service Center
693 Palmer Drive
Raleigh, North Carolina 27699-2101
10. Termination for Cause. If through any cause, the County shall fail to fulfill in a timely and
proper manner its obligations under this Agreement, or the County has or shall violate any of
the covenants, agreements, representations or stipulations of this Agreement, the Area Agency
shall have the right to terminate this Agreement by giving the Chairman of the Board of
Commissioners written notice of such termination no fewer than fifteen (15) days prior to the
effective date of termination. In such event, all finished documents and other materials
collected or produced under this Agreement shall at the option of the Area Agency, become its
property. The County shall be entitled to receive just and equitable compensation for any work
satisfactorily performed under this .Agreement.
11. Audit. The County agrees to have an annual independent audit in accordance with North
Carolina General Statutes, North Carolina Local Government Commission requirements,
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Division of Aging and Adult Services Program Audit Guide for Aging Services and Federal
Office of Budget and Management (OMB) Circular A-133.
Community nutrition service providers, as specified in paragraph one (1), who are not units of
local government or otherwise subject to the audit and other reporting requirements of the
Local Government Commission are subject to audit and fiscal reporting requirements, as stated
in NC General Statute 143C-6-22 and 23 and OMB Circular A-133, where applicable.
Applicable community service providers must send a copy of their year-end financial
statements, and any required audit, to the Area Agency on Aging. Home and Community Care
Block Grant providers are not required to submit Activities and Accomplishments Reports.
For-profit corporations are not subject to the requirements of OMB Circular A-133, but are
subject to NC General Statute 143C-6-22 and 23 and Yellow Book audit requirements, where
applicable. Federal funds may not be used to pay for a Single or Yellow Book audit unless it
a federal requirement. State funds will not be used to pay for a Single or Yellow Book audit
if the provider receives less than $500,000 in state funds. The Department of Health and
Human Services will provide confirmation of federal and state expenditures at the close of the
state fiscal year. Information on audit and fiscal reporting requirements can be found at
http://www.ncauditor.net/nonprofitsite.
The following provides a summary of reporting requirements under NCGS 143C-6-22 and 23
and OMB Circular A-133 based upon funding received and expended during the service
provider's fiscal year.
Annual Expenditures Report Required to AAA Allowable Cost for Reporting
• Less than $25,000 in Certification form and State N/A
State or Federal funds Grants Compliance Re-
porting <$25,000 (item # 11,
Activities and Accomplishments
does not have to be completed)
OR
Audited Financial Statements in
Compliance with GAO/GAS
(i.e. Yellow Book)
Greater than $25,000 Certification form and Schedule of N/A
and less that $500,000 Grantee Receipts >$25,000 and
in State or Federal Funds Schedule of Receipts and Expendi-
tures
OR
Audited Financial Statements in
Compliance with GAO/GAS
(i.e. Yellow Book)
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• $500,00+ in State funds Audited Financial Statement in
and Federal pass through compliance with GAO/GAS (i.e.
in an amount less than Yellow Book)
$500,000
$500,000+ in State funds
and $500,000+ in Federal
pass through funds (i.e.
at least $1,000,000)
Audited Financial Statement in
compliance with OMB Circular
A-133 (i.e. Single Audit)
• Less than $500,000 in State
funds and $500,000+ in
Federal pass through funds
Audited Financial Statement in
compliance with OMB Circular
A-133 (i.e. Single Audit)
May use State funds, but
not Federal Funds
May use State and Federal
funds
May use Federal funds,
but not State funds.
12. Audit/Assessment Resolutions and Disallowed Cost. It is further understood that the
community service providers are responsible to the Area Agency for clarifying any audit
exceptions that may arise from any Area Agency assessment, county or community service
provider single or financial audit, or audits conducted by the State or Federal Governments. In
the event that the Area Agency or the Department of Health and Human Services disallows any
expenditure made by the community service provider for any reason, the County shall promptly
repay such funds to the Area Agency once any final appeal is exhausted in accordance with
paragraph nine (9). The only exceptions are if the Area Agency on Aging is designated as a
community service provider through the County Funding Plan or, if as a part of a procurement
process, the Area Agency on Aging enters into a contractual agreement for service provision
with a provider which is in addition to the required County Funding Plan formats. In these
exceptions, the Area Agency is responsible for any disallowed costs. The County or Area
Agency on Aging can recoup any required payback from the community service provider in the
event that payback is due to a community service provider's failure to meet OMB Circular A-
122 requirements, requirements of A-110, requirements of 45CFR, Part 1321, and 45CFR, Part
92, or state eligibility requirements as specified in policy.
13. Indemnity. The County agrees to indemnify and save harmless the Area Agency, its agents,
and employees from and against and all loss, cost, damages, expenses, and liability arising out
of performance under this Agreement to the extent of errors or omissions of the County.
14. Equal Employment Opportunity and Americans with Disabilities Act Compliance. Both the
County and community service providers, as identified in paragraph one (1), shall comply with
all federal and state laws relating to equal employment opportunity and accommodation for
disability.
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15. Data to be Furnished to the County. All information which is existing, readily available to the
Area Agency without cost and reasonably necessary, as determined by the Area Agency's staff,
for the performance of this Agreement by the County shall be furnished to the County and
community service providers without charge by the Area Agency. The Area Agency, its agents
and employees, shall fully cooperate, with the County in the performance of the County's duties
under this Agreement.
16. Rights in Documents, Materials and Data Produced. 'The County and community service
providers agree that at the discretion of the Area Agency, all reports and other data prepared by
or for it under the terms of this Agreement shall be delivered to, become and remain, the
property of the Area Agency upon termination or completion of the work. Both the Area
Agency and the County shall have the right to use same without restriction or limitation and
without compensation to the other. For the purposes of this Agreement, "data" includes
writings, sound recordings, or other graphic representations, and works of similar nature. No
reports or other documents produced in whole or in part under this Agreement shall be the
subject of an application for copyright by or on behalf of the County.
17. Interest of the Board of Commissioners. The Board of Commissioners covenants that neither
the Board of Commissioners nor its agents or employees presently has an interest, nor shall
acquire an interest, direct or indirect, which conflicts in any manner or degree with the
performance of its service hereunder, or which would prevent, or tend to prevent, the
satisfactory performance of the service hereunder in an impartial and unbiased manner.
18. Interest of Members of the Area Agency Lead Regional Organization and Others. No officer,
member or employee of the Area Agency or Lead Regional Organization, and no public official
of any local government which is affected in any way by the Project, who exercises any
function or responsibilities in the review or approval of the Project or any component part
thereof, shall participate in any decisions relating to this Agreement which affects his personal
interest or the interest of any corporation, partnership or association in which he is, directly or
indirectly, interested; nor shall any such persons have any interest, direct or indirect, in this
Agreement or the proceeds arising therefrom.
19. Officials not to Benefit. No member of or delegate to the Congress of the United States of
America, resident Commissioner or employee of the United States Government, shall be
entitled to any share or part of this Agreement or any benefits to arise herefrom.
20. Prohibition Against Use of Funds to Influence Le islation. No part of any funds under this
Agreement shall be used to pay the salary or expenses of any employee or agent acting on
behalf of the County to engage in any activity designed to influence legislation or
appropriations pending before Congress.
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21. Auplicable Law. This Agreement is executed and is to be performed in the State of North
Carolina, and all questions of interpretation and construction shall be construed by the laws of
such State.
In witness whereof, the Area Agency and the County have executed this Agreement as of the
day first written above.
Orange County
Attest:
By:
Chair, Board of Commissioners
Triangle J Council of Governments/Area A~ency
Attest:
Joan M. Pellettier
Director,
Area Agency Director
By:
Kirby M. Bowers
Executive Director,
Lead Regional Organization
Provision for payment of the monies to fall due under this Agreement within the current fiscal year
have been made by appropriation duly authorized as required by the Local Government Budget and
Fiscal Control Act.
BY:
Judy A. Weller
Finance Director
Triangle J Council of Governments
(Lead Regional Organization)
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AWARD PROVISIONS
ARRA Funds
County Nutrition Program Providers
By submission of a proposal, Contractor agrees to comply with the following provisions.
Failure to comply with any and all provisions herein may be cause for the contracting
agency to issue a cancellation notice to a contractor.
Reporting Requirements
The Contractor is notified that this project will be financed with American Recovery and
Reinvestment Act of 2009 (hereinafter, "ARRA") Funds. The Contractor shall ensure that
all subcontracts and other contracts for goods and services for an ARRA-funded project
have the mandated provisions of this directive in their contracts. Pursuant to Title XV,
Section 1512 of the ARRA, the State shall require that the Contractor provide reports and
other employment information as evidence to document the number of jobs created or
jobs retained by this contract from the Contractor's own workforce and any sub-
contractors. No direct payment will be made for providing said reports, as the cost for
same shall be included in the various items in the contract.
Posting with the Local Employment Security Commission
In addition to any other job postings the Contractor normally utilizes, the Office of
Economic Recovery & Investment (hereinafter, "OERI") requires that the Contractor
shall post with the local Employment Security Commission Office all positions for which
he intends to hire workers as a result of being awarded this contract. Labor and semi-
skilledpositions must be posted for at least 48 hours before the hiring decision. All other
positions must be posted a minimum of five days before the hiring decision. The
Contractor and any Subcontractor shall report the new hires in the manner prescribed by
the Employment Security Commission and the OERI.
Required Contract Provision to Implement ARRA Section 902
Section 902 of the ARRA requires that each contract awarded using ARRA funds must
include a provision that provides the U.S. Comptroller General and his representatives
with the authority to:
(1) examine any records of the contractor or any of its subcontractors, or any State or
local agency administering such contract, that directly pertain to, and involve
transactions relating to, the contract or subcontract; and
(2) interview any officer or employee of the contractor or any of its subcontractors,
or of any State or local government agency administering the contract, regarding
such transactions.
Contract Provisions 1
11
Accordingly, the Comptroller General and his representatives shall have the authority and
rights prescribed under Section 902 of the ARRA with respect to contracts funded with
recovery funds made available under the ARRA. Section 902 further states that nothing
in 902 shall be interpreted to limit or restrict in any way any existing authority of the
Comptroller General.
Authority of the Inspector General provision
Section 1515(a) of the ARRA provides authority for any representatives of the United
States Inspector General to examine any records or interview any employee or officers
working on this contract. The contractor is advised that representatives of the Inspector
General have the authority to examine any record and interview any employee or officer
of the contractor, its subcontractors or other firms working on this contract. Section
1515(b) further provides that nothing in this section shall be interpreted to limit or restrict
in any way any existing authority of an Inspector General.
Buy American provision
Section 1605 of the ARRA requires that iron, steel and manufactured goods used in
public buildings or public works projects be manufactured in the United States.
Contractor agrees to abide by this provision and shall maintain records of such purchases
for inspections by authorized agents of the State of North Carolina and federal agencies.
T'he Contractor must obtain written exception from this provision from the agency issuing
the contract.
Wage Rate Provision
Section 1606 of the ARRA requires that all laborers and mechanics employed by
contractors and subcontractors with funds from the ARRA shall be paid wages at rates
not less than the prevailing wage rate under the Davis-Bacon Act. The contractor agrees
that by the submission of a proposal in response to a solicitation funded in whole or in
part with recovery funds, continuous compliance will be maintained with the Davis-
Bacon Act.
Availability and Use of Funds
Contractors understand and acknowledge that any and all payment of funds or the
continuation thereof is contingent upon funds provided solely by ARRA or required state
matching funds. Pursuant to Section 1604 of the ARRA, contractors agree not to
undertake or make progress toward any activity using recovery funds that will lead to the
development of such activity as casinos or other gambling establishments, aquariums,
zoos, golf courses, swimming pools or any other activity specifically prohibited by the
Recovery Act.
Contract Provisions 2
12
Whistleblower Provisions
Contractors understand and acknowledge that Article 14 of Chapter 124, NCGS 126-84
through 126-88 (applies to the State and state employees), Article 21 of Chapter 95,
NCGS 95-240 through 85-245 (applies to anyone, including state employees), and
Section 1553 of the Recovery Act (applies to anyone receiving federal funds), provide
protection to State, Federal and contract employees.
Outsourcing outside the USA without Specific Prior Approval Provision
Contractor agrees not to use any recovery funds from a contract or any other performance
agreement awarded by the State of North Carolina, its agencies, or political subdivisions
for outsourcing outside of the United States, without specific prior written approval from
the agency issuing the contract.
Federal, State and Local Tax Obligations
By submission of a proposal, contractors and subcontractors assert and self-certify that all
Federal, State and local tax obligations have been or will be satisfied prior to receiving
recovery funds.
Anti-Discrimination and Equal Opportunity
Pursuant to Section 1.7 of the guidance memorandum issued by the United States Office
of Management and Budget on Apri13, 2009, recovery funds must be distributed in
accordance with all anti-discrimination and equal opportunity statutes, regulations, and
Executive Orders pertaining to the expenditure of funds.
Office of State Budget and Management Access to Records
OERI requires that the contractor and subcontractor agree to allow the Office of State
Budget and Management internal auditors and state agency internal auditors access to
records and employees pertaining to the performance of any contract awarded by a public
agency.
Subgrantee Agency/ Name:
Authorized Agency Signature Title Date
(Certification signature should be same as ARRA contract signature.)
Contract Provisions 3
NAME AND ADDRESS AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009 (ARRA)
COMMUNITY NUTRITION SERVICE PROVIDER ARRA-732 (8/09)
Orange Coun Department on Aging County Funding Plan County: Oran¢e
P O Box 8181 11/05/09 throw h 12/31/ 2010
Hillsborough, NC 27278 Nutrition Provider Services Summary REVISION # ,DATE
A B C D E F G H I
Ser. Delivery
(check one) ARRA Fundin
Required
Net
NSIP
Total Projected
ARRA Projected
eimburse Projected
ARRA Projected
Total
Services Direct Purch. Con egate Home Delivered Total Local Matc Serv Cost Subsidy Funding Units Rate Clients Units
/////////////////////////////// X 17893 \\\\\\\\\\\\\\\\\\ 1988 19881 2640 22521 4400 4.97 100 38125
/////////////!///////////////// \\\\\\\\\\\\\\\\\ 0 0 0
/////////////!///////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
//!/!////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
/////////////////////////////// \\\\\\\\\1\\\\\\\\ 0 0 0
///////!//!//////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
////!///!/!//////////////////// \\\\\\\\\\\\\\\\\ 0 0 0
/////////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
/!///////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
/////////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
//////////////////////!/////1// \\\\\\\\\\\\\\\\\\ 0 0 0
/////////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
/////////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
/!///////////////////////////// \\\\\\\\\\\\\\\\\\ 0 0 0
Total \\\\\\\ \\\\\\\ 17893 0 17893 1988 19881 2640 22521 4400 \\\\\\\\\\\\\\ 100 38125
Authorized Signature, Title Date
Community Service Provider
Signature, Chairman, Boazd of Commissioners Date
....
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