HomeMy WebLinkAbout2012-418 Soil & Water - NC Dept of Agriculture and Consumer Services for Matching Funds $56,950 m
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Steve Troxler North Carolina Department of Agriculture
p N.David Smith
Commissioner and Consumer Services Chief Deputy Commissioner
October 31, 2012
Ms. Lisa Pope
Orange Soil&Water Conservation District
USDA-NRCS, P.O. Box 8181
Hillsborough, NC 27278
Dear Ms. Pope:
NOTIFICATION OF FUNDING OFFER
On behalf of Commissioner Steve Troxler and the North Carolina Department of Agriculture and Consumer
Services—Division of Soil &Water Conservation, it is with great pleasure that I offer to you$56,960.00 of
district matching funds and cost share technical assistance funds for your soil and water conservation district
operations. The attached Contract is for the purpose of providing matching funds to support implementation
of a comprehensive conservation program for soil and water resources in your district. The funds for this are
provided to the Agency by the North Carolina General Assembly.
By completing the attached documents, you are agreeing to the specific stipulations,the general terms and
conditions, and specific reporting requirements.Two original Contract packets must be printed, completed
and returned to the NCDA&CS, making sure that the Contracts and certain forms have been signed and
dated. Some documents are required to be witnessed, please make certain documents are witnessed, as
applicable, before they are returned to the address provided on page 4 of your Contract cover document.
All Authorized Representative Signatures MUST be in BLUE INK. Use the Contract Check Off List to ensure
all attachments are included and are in the correct order for each Contract Packet.
Upon final execution by the Department, one original Contract will be returned to you for your records. If you
have any questions about your Contract or any of the forms contained in your offer packet, please call David
Williams at 919-715-6103, or feel free to send an email to David.B.Williams @ncagr.gov.
I would like to take this opportunity to thank you for contributions to assisting North Carolina's citizens and
protecting its natural resources.
Sincerely,
" %. k--
N. David Smith
Chief Deputy Commissioner
Enclosure
cc: Kathryn L. Caler, M.L.S., Grants Administrator
Email: David.Smith@ncagr.gov
1001 Mail Service Center,Raleigh,North Carolina,27699-1001
(919)707-3033• Fax(919)715-0026
An Equal Opportunity Affirmative Action Employer
Departmental Use Only
STATE OF NORTH CAROLINA CENTER: 1611-3701
COUNTY OF WAKE "- ACCOUNT: 536967
T= CFDA: NA
AMOUNT: $3,600.00
rr CENTER:2710
ACCOUNT: 532196002
CFDA: NA
AMOUNT: $53.350.00
North Carolina Department of Agriculture and Consumer Services
Division of Soil and Water Conservation
Contract Number
THIS Grant Contract is made and entered into by and between the North Carolina
Department of Agriculture and Consumer Services, Division of Soil & Water Conservation,
hereinafter referred to as "DSWC", and the Orange Soil and Water Conservation District,
hereinafter referred to as the "District"; and referred to collectively as the "Parties". The
District's federal tax identification number is 56-6000327 and is physically located in Orange
County, and is further located at USDA-NRCS, P.O. Box 8181 Hillsborough, NC 27278.
The District's fiscal year begins July 1 and ends June 30.
THAT WHEREAS, the DSWC is appropriated funds to support the operations and staff of
the 96 soil and water conservation districts (hereinafter referred to as "Districts"), and
WHEREAS, the DSWC is appropriated funds to cost share for technical assistance positions in
Districts, and
WHEREAS, the purpose of this Contract is to establish a procedure for the DSWC to support
District operations and staff, and
WHEREAS, the DSWC and the District are responsible for the conservation of the State's soil
and water resources, and
WHEREAS, the DSWC and the District have a history of cooperating to administer conservation
programs, including the Agriculture Cost Share Program, Community Conservation Assistance
Program, the Agricultural Water Resources Assistance Program, the Conservation Reserve
Enhancement Program, and other similar programs, and
WHEREAS, the DSWC and the Soil and Water Conservation Commission, hereinafter
referred to as "Commission" allocate funds to Districts to cost share for technical assistance
positions to support implementation of the cost share programs under its authority, and
WHEREAS, the DSWC and the Commission allocate funds to Districts to cost share for water
quality and water quantity best management practices with private and public landowners and
land users, and
WHEREAS, from time to time the DSWC may need to engage the District in other specific
activities to protect and restore the natural resources of the District.
NCDA&CS Soil&Water Contract(Rev): 9/12 1
L Contract Documents:
This Contract consists of the Grant Contract and its attachments, all of which are identified by
name asfollows:
1. This Contract
2. Scope of Work, Budget and District Application Packet(Attachment/ )
3. General Terms and Conditions (Attachment B)
4. Combined Certifications and Assurances (Attachment C)
5. NC {}penbooh Supplemental Information (Attachment [}\
0. Signature Card (Attachment E)
7. V\-9 Tax Information (Attachment F)
� 8 Electronic� . , -_ '
Among These documents constitute the entire Contract between the Parties and supersede all prior oral
or written statements or Contracts.
Ill. Precedence Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents, the terms in
the Contract Document with the highest relative precedence shall prevail. The order of
precedence shall be the order of documents as listed in Paragraph 1, above, with the first-listed
document having the highest precedence and the last-listed document having the lowest
precedence. If there are multiple Contract Amendments, the most recent amendment shall
have the highest precedence and the oldest amendment shall have the lowest precedence.
Ill. Effective Period:
The services of the District are to commence on the 1"day of July, 2012, and shall be
undertaken and completed in such sequence as to assure their expeditious completion in
the light of the purposes of this Contract, but in any event, all of the services required
hereunder shall be completed by the 30th day of June, 2015. The effective period may be
extended, if mutually agreed upon, with a written amendment as provided for in the
General Terms and Conditions as described in Attachment B.
IV. District Duties:
The District hereby agrees to perform, in a manner satisfactory to the DSWC, services
under a Scope of Work as described in Attachment A, which is incorporated as part of this
Contract. The District agrees that funds awarded under this Contract must be used for the
purposes for which they are intended.
Work to be performed under this Contract may be performed by employees of the District.
The District shall not substitute key personnel assigned to the performance of this Contract
without prior written approval by the Contract Administrator.
V. DSCW Duties:
The DSWC hereby agrees to pay the District a sum of money not to exceed $56,950.00 in
State and/or federal funds, said sum to be full and complete compensation for services
rendered or approved activities specified in Attachment A under this Contract.
The contributions from the Grantee shall be sourced from non-federal funds. Any funds
committed as matching funds must be spent concurrently with the statelfederal funds awarded
in this Contract (i.e. past expenditures prior to submission and execution of the Grantee's
NCDA&CS Soil&Water Contract(Rev): 9/12 2
Contract shall not beumed).
The matching requirement is: $66.950.00
The [Ucthot has committed the following nn|nirnunn match to this project:
In Kind $
Cash $
Cash and In-kind $
Cash and/or In-kind $56,950.00
Other/Specify $
The total Contract amount is $113,900.00.
V1. Payment Provisions:
Upon execution of this Contract the District shall submit to the DSWC Contract Administrator
a completed Request for Payment form, to be provided by the DSWC. All Request for
Payment forms should be received no more than quarterly, with a certified invoice showing
expenditures and matching funds, if applicable, for the current period and cumulatively for
the entire project, in addition to deliverables provided by the District, subject to approval by
DSWC. Upon approval by DSWC, payment may be made within 30 days.
Payment shall be made in accordance with the Contract Documents and limited to the
amounts in the Contract budget (Attachment A).
The parties to this Contract agree and understand that the payment of the sums specified in
this Contract is dependent and contingent upon and subject to the appropriation, allocation,
and availability of funds for this purpose to the DSWC.
The District agrees to provide information required by the DSWC in order to comply with the
procedures for disbursement of grant funds and maintain reports and accounting records
that support the allowable expenditure of State funds.
Indirect costs are not allowable expenditures under this Contract.
VI 1. Reversion of Unexpencled Funds:
Any unexpended grant funds shall revert to the DSWC upon the termination of this Contract.
Vill. Reporting Requirements:
The District shall submit quarterly progress reports, with each report due on or before the
last day of April, July, October and January, continuing until the project is complete and final
project report is approved. The quarterly progress report is required even if no activity has
occurred for the quarter and no reimbursement is requested for the quarter.
IX. Supplementation of Expenditure of Public Funds:
The District assures that funds received pursuant to this Contract shall be used only to
supplement, no to supplant, the total amount of federal, state and local public funds that the
District otherwise expends for activities involved with specialty services and related
programs. Funds received under this Contract shall be used to provide additional public
funding for such services. The funds shall not be used to reduce the District's total
expenditure of other public funds for such services.
NCDA&CS Soil&Water Contract(Rev): 9/12 3
X. Contract Administrators:
All notices permitted or required to be given by one party to the other and all questions
about the Contract from one Party to the other shall be addressed and delivered to the other
party's Contract Administrator. The name, post office address, street address, telephone
number, fax number, and email address of the parties' respective initial Contract
Administrator are set out below. Either party may change the name, post office address,
street address, telephone number, fax number, or email address of its Contract
Administrator by giving timely written notice to the other party.
For the DSWC:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
David B. Williams David B. Williams
Division of Soil &Water Conservation Division of Soil &Water Conservation
1614 Mail Service Center 512 N. Salisbury Street, Room 417D
Raleigh, NC 27699-1614 Raleigh, NC 27604-1170
Telephone: 919-715-6103
Email: David.B.Williams@ncagr.gov
For the District:
District Contract Administrator District Principal Investigator or Key Personnel
Lisa Pope Same
USDA-NRCS, P.O. Box 8181
Hillsborough, NC 27278
Telephone: 919-732-8181 x 2752
Fax: 919-732-7559
Email: (pope co.orange.nc.us
XI. Disbursements:
As a condition of this Contract, the District acknowledges and agrees to make disbursements in
accordance with the following requirements:
a. Implement adequate internal controls over disbursements;
b. Pre-audit all vouchers presented for payment to determine:
• Validity and accuracy of payment
• Payment due date
• Adequacy of documentation supporting payment
• Legality of disbursement
c. Assure adequate control of signature stamps/plates;
d. Assure adequate control of negotiable instruments; and
e. Implement procedures to insure that account balance is solvent and reconcile the
account monthly.
XII. Outsourcing:
The District certifies that it has identified to the DSWC all jobs related to the Contract that have
been outsourced to other countries, if any. The District further agrees that it will not outsource
any such jobs during the term of this Contract without providing prior written notice to the
DSWC.
NCDA&CS Soil&Water Contract(Rev): 9/12 4
XIII. N.C.G.S. § 133-32 and Executive Order 24:
N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State
Employee of any gift from anyone with a contract with the State, or from any person seeking to
do business with the State. By execution of any response in this procurement or Contract, you
attest, for your entire organization and its employees or agents, that you are not aware that any
such gift has been offered, accepted, or promised by any employee of your organization.
Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the
terms of this Contract.
IN WITNESS WHEREOF, the Grantee and the Agency execute this Contract in two (2)
originals, one (1) of which is retained by the Grantee and one (1) which is retained by the
Agency.
Orange Soil and Water Conservation District
ti,PIUU-4 )j OVP&L-- - /,�A�-11.2—-
Signature of Authorized Re#r es ntative Date
Printed Name V Title
Witness:
Signature ate
Printed Name Title
A
' North Carolina Department of Agriculture and Consumer Services
Signature of Authorized Representative Date
N. David Smith, Chief Deputy Commissioner
Printed Name of Authorized Representative
NCDA&CS Soil&Water Contract(Rev): 9/12 5
ATTACHMENT A
Scope of Work and Payment Provisions
The District will complete the following activities and supply the following deliverables:
1. District Matching Funds— Funds for District operating support are allocated to each
county equally, subject to that District's documentation that matching funds equal to or
exceeding the allocated amount are available for match. To be eligible to receive
matching funds the District shall:
a. Submit by October 31 of each fiscal year an `Application for Matching Funds for Soil
& Water Conservation Districts' showing the amount of matching funds requested by
the District and documenting the source and amount of matching funds provided by
the District. The District shall not count as match the funds that were allocated by
the Commission for technical assistance cost share nor those local funds pledged to
match technical assistance cost share.
b. Submit by March 31 of each year a completed Request for Payment for DSWC
Matching Funds form. Matching Funds not requested by March 31 shall be
unencumbered from this Contract.
c. Submit to the DSWC minutes of all District board meetings held during the term of
the grant.
2. Cost Share Technical Assistance—cost share funds for technical assistance positions
are allocated to Districts by the DSWC and Commission in accordance with its rules and
procedures. To be eligible to receive technical assistance cost share, the District shall:
a. Submit by June 1 of each fiscal year, the District strategy plan for cost share
programs, including a request for technical assistance funds. The request for
technical assistance funds should include for each position proposed for cost
sharing:
i. a brief narrative of a proposed technical assistance budget showing salary,
benefits, and operating expense categories,
ii. staff name and title, and
iii. percentage or hours annually of staff time dedicated to implementing the ACSP,
AgWRAP, and CCAP.
b. Direct the staff in position(s) approved by the DSWC and Commission for cost share
to implement cost share program activities in the District. A District position cost
shared with program funds may work on other activities as delegated by the field
office supervisor, but the position must contribute at least 1,040 hours per FTE to
providing technical assistance or cost share program implementation. Positions cost
shared at less than 1 FTE, shall contribute a pro-rated number of hours for the same
purposes. All activities must be documented with a signed, original monthly
Attachment A—SOP&Budget(Rev): 9/12 a
activities tracking form which may be submitted quarterly with the Request for
Payment.
c. Submit a quarterly Request for Payment of Technical Assistance Form documenting
actual expenditures for salary, benefits, and operating expenses by the District or
county in support of the technical assistance position(s) approved by the DSWC and
Commission and listed in Attachment A. Any technical assistance funds
encumbered for the previous fiscal year that are not requested by the District on or
before June 30 of each year shall be unencumbered from this Contract.
Attachment A—SOP&Budget(Rev): 9/12 b
CONTRACT BUDGET
The following budget reflects the maximum authorized payment for each activity
described in the scope of work.
Activity 1: District Matching Funds
Fiscal Year
2012-13 2013-14 F 2014-15
Maximum Award $3,600.00
District Match Requirement $3,600.00
Activity 2: Cost Share Technical Assistance
Position FTE: 1.00 Maximum Allocation
1:
Fiscal Purpose Recurring Non-recurring District Match
Year Requirement
2012-13 Sala /Benefits $25,500.00 $26,675.00
Operatinq Ex p. $1,175.00
2013-14 Sala /Benefits $ 0.00
Op erating Ex p. $ 0.00
2014-15 Sala /Benefits 1 $ 0.00
Operating Ex p. $ 0.00
Position 2: FTE: 1.00 Maximum Allocation
Fiscal Year Purpose Recurring Non- District Match
recurring Requirement
2012-13 Sala /Benefits $25,500.00 $26,675.00
Operating Ex p. $1,175.00
2013-14 Sala /Benefits I $ 0.00
Operating Ex p. $ 0.00
2014-15 Sala /Benefits T $ 0.00
Operating Ex p. $ 0.00
Attachment A—SOP&Budget(Rev): 9/12 c
PUBLIC SECTOR CONTRACTS (including Local Governments)
Attachment B
General Terms and Conditions
DEFINITIONS
Unless indicated otherwise from the context, the amounts received as reimbursement for
following terms shall have the following meanings in services rendered to individuals for Medicare
this Contract. All definitions are from 9 NCAC and Medicaid patient services.
3M.0102 unless otherwise noted. If the rule or (8) "Financial Statement" means a report
statute that is the source of the definition is changed providing financial statistics relative to a
by the adopting authority, the change shall be given part of an organization's operations or
incorporated herein: status.
(9) "Grant" means financial assistance provided
(1) "Agency" (as used in the context of the by an agency, grantee, or subgrantee to
definitions below) shall mean and include carry out activities whereby the grantor
every public office, public officer or official anticipates no programmatic involvement
(State or local, elected or appointed), with the grantee or subgrantee during the
institution, board, commission, bureau, performance of the grant.
council, department, authority or other unit of (10)"Grantee" has the meaning in G.S. 143C-6-
government of the State or of any county, 23(x)(2): a non-State entity that receives a
unit, special district or other political grant of State funds from a State agency,
subagency of government. For other department, or institution but does not
purposes in this Contract, "Agency" shall include any non-State entity subject to the
mean the entity identified as one of the audit and other reporting requirements of the
parties hereto. Local Government Commission. For other
(2) "Audit" means an examination of records or purposes in this Contract, "Grantee" shall
financial accounts to verify their accuracy. mean the entity identified as one of the
(3) "Certification of Compliance" means a report parties hereto.
provided by the Agency to the Office of the (11) "Grantor" means an entity that provides
State Auditor that states that the Grantee has resources, generally financial, to another
met the reporting requirements established entity in order to achieve a specified goal or
by this Subchapter and included a statement objective.
of certification by the Agency and copies of (12)"Non-State Entity" has the meaning in
the submitted grantee reporting package. N.C.G.S. 143C-1-1(d)(18): Any of the
(4) "Compliance Supplement" refers to the North following that is not a State agency: an
Carolina State Compliance Supplement, individual, a firm, a partnership, an
maintained by the State and Local association, a county, a corporation, or any
Government Finance Agency within the other organization acting as a unit. The term
North Carolina Department of State includes a unit of local government and
Treasurer that has been developed in public authority.
cooperation with agencies to assist the local (13)"Public Authority" has the meaning in
auditor in identifying program compliance N.C.G.S. 143C-1-1(d)(22): A municipal
requirements and audit procedures for corporation that is not a unit of local
testing those requirements. government or a local governmental
(5) "Contract" means a legal instrument that is authority, board, commission, council, or
used to reflect a relationship between the agency that (i) is not a municipal corporation
agency, grantee, and subgrantee. and (ii) operates on an area, regional, or
(6) "Fiscal Year" means the annual operating multiunit basis, and the budgeting and
year of the non-State entity, accounting systems of which are not fully a
(7) "Financial Assistance" means assistance that part of the budgeting and accounting
non-State entities receive or administer in the systems of a unit of local government.
form of grants, loans, loan guarantees, (14) "Single Audit" means an audit that includes
property (including donated surplus an examination of an organization's financial
property), cooperative agreements, interest statements, internal controls, and compliance
subsidies, insurance, food commodities, with the requirements of federal or State
direct appropriations, and other assistance. awards.
Financial assistance does not include
NCDA&CS-General Terms and Conditions—Public-Local Governmental Entities
Eff.912005;Rev.11/11,8/12,9/12 Page 1 of 11
(15)"Special Appropriation" means a legislative subgrantees and shall not be relieved of any of the
act authorizing the expenditure of a duties and responsibilities of this Contract.
designated amount of public funds for a
|
specific purpose. Subgnmntmes: The Grantee has the responsibility to
�
(16) "State Fundo" means any funds ensure that all subgnsnbaeo. if ony, provide all
appropriated by the North Carolina General information necessary to permit the Grantee to
Assembly or collected by the State of North comply with the standards set forth in this Contract.
Carolina. State funds include federal
financial assistance received by the State Assignment: No assignment of the Grantee's
and transferred or disbursed to non-State obligations or the Grantee's right to receive payment
entities. Both federal and State funds hereunder shall be permitted. However, upon written
maintain their identity as they are subgranted request approved by the issuing purchasing authority,
to other organizations. Pursuant to N.C.G.S. the State may:
143C-6-23(a)(1), the terms "State grant
funds" and "State grants" do not include any (a) Forward the Grantee's payment check(s)
payment made by the Medicaid program, the directly to any person or entity designated by
Teachers' and State Employees' the Grantee, or
Comprehensive Major Medical Plan, or other (b) Include any person or entity designated by
similar medical programs. Grantee as a joint payee on the Grantee's
(17) "Subgrantee" has the meaning in G.S. payment check(s).
143C-6-23(a)(3): a non-State entity that
receives a grant of State funds from a In no event shall such approval and action obligate
grantee or from another subgrantee but does the State to anyone other than the Grantee and the
not include any non-State entity subject to Grantee shall remain responsible for fulfillment of all
the audit and other reporting requirements of Contract obligations.
the Local Government Commission. Beneficiaries: Except as herein specifically
(18) "Unit of Local Government has the meaning provided otherwise, this Contract shall inure to the
in G.S. 143C-1-1(d)(29): A municipal benefit of and be binding upon the parties hereto and
corporation that has the power to levy taxes, their respective successors. It is expressly
including a consolidated city-county as understood and agreed that the enforcement of the
defined by G.S. 160B-2(l), and all boards, terms and conditions of this Contract, and all rights of
agencies, commissions, authorities, and action relating to such enforcement, shall be strictly
institutions thereof that are not municipal reserved to the Agency and the named Grantee.
corporations. Nothing contained in this document shall give or
allow any claim or right of action whatsoever-by any
Relationships of the Parties other third person. It is the express intention of the
Agency and Grantee that any such person or entity,
Independent Contractor: The Grantee is and shall other than the Agency or the Grantee, receiving
be deemed to be an independent Contractor in the services or benefits under this Contract shall be
performance of this Contract and as such shall be deemed an incidental beneficiary only.
wholly responsible for the work to be performed and
for the supervision of its employees. The Grantee Indemnity
represents that it has, or shall secure at its own
expense, all personnel required in performing the Indemnification: The Grantee agrees to indemnify
services under this agreement. Such employees shall and hold harmless the Agency, including any of its
not be employees of, or have any individual Divisions, and any of its officers, agents and
contractual relationship with, the Agency. employees, from liability of any kind, and from any
claims of third parties arising out of any act or
Subcontracting: The Grantee shall not subcontract omission of the Contractor in connection with the
any of the work contemplated under this Contract performance of this Contract to the extent permitted
without prior written approval from the Agency. Any by law.
approved subcontract shall be subject to all
conditions of this Contract. Only the subcontractors Default and Termination
or subgrantees specified in the Contract documents
are to be considered approved upon award of the Termination by Mutual Consent: The Parties may
Contract. The Agency shall not be obligated to pay terminate this Contract by mutual consent with 60
for any work performed by any unapproved days notice to the other party, or as otherwise
subcontractor or subgrantee. The Grantee shall be provided by law.
responsible for the performance of all of its
NCDA&CS-General Terms and Conditions-Public-Local Governmental Entities Page 2 of 11
Termination for Cause: If, through any cause. the Intellectual Property Rights
Grantee shall fail to fulfill its obligations under this
Contract in a timely and proper manner, the Agency Copyrights and Ownership of Om|/vmrob/ea: All
shall have the right to terminate this Contract by deliverable items produced pursuant to this Contract
giving written notice to the Grantee and specifying are the exclusive property of the Agency. The
�
the effective date thereof. Grantee shall not assert a claim of copyright orother
In that event, all finished or unfinished deliverable
items prepared by the Grantee under this Contract Compliance with Applicable Laws
shall, at the option of the Agency, become its
property and the Grantee shall be entitled to receive Compliance with Laws: The Grantee shall comply
just and equitable compensation for any satisfactory with all laws, ordinances, codes, rules, regulations,
work completed on such materials, minus any and licensing requirements that are applicable to the
payment or compensation previously made. conduct of its business, including those of federal,
State, and local agencies having jurisdiction and/or
Notwithstanding the foregoing provision, the Grantee authority.
shall not be relieved of liability to the Agency for
damages sustained by the Agency by virtue of the Equal Employment Opportunity: The Grantee
Grantee's breach of this agreement, and the Agency shall take affirmative action in complying with all
may withhold any payment due the Grantee for the federal and State statutes and all applicable
purpose of setoff until such time as the exact amount requirements concerning fair employment of people
of damages due the Agency from such breach can be with disabilities, and concerning the treatment of all
determined. The filing of a petition for bankruptcy by employees without regard to discrimination by reason
the Grantee shall be an act of default under this of race, color, religion, sex, national origin or
Contract. disability. For additional information see Title VI of the
Civil Rights Act of 1964 (42 U.S.C., 2000d, 20OOe-
Waiver of Default: Waiver by the Agency of any 16), Title XI of the Education amendments of 1972,
default or breach in compliance with the terms of this as amended (20 U.S.C. 1681-1683 and 1685-1686),
Contract by the Grantee shall not be deemed a and section 504 of the Rehabilitation Act of 1973 as
waiver of any subsequent default or breach and shall amended (29 U.S.C. 794).
not be construed to be modification of the terms of
this Contract unless stated to be such in writing, Executive Order 24: In accordance with Executive
signed by an authorized representative of the Agency Order 24, issued by Governor Perdue, and N.C.G.S.§
and the Grantee and attached to the Contract. 133-32, a vendor or contractor (i.e. architect, bidder,
contractor, construction manager, design
Availability of Funds: The parties to this Contract professional, engineer, landlord, offeror, seller,
agree and understand that the payment of the sums subcontractor, supplier, vendor, or grantee), is
specified in this Contract is dependent and contingent prohibited from making gifts or giving favors to any
upon and subject to the appropriation, allocation, and employee of the Agency of Agriculture and Consumer
availability of funds for this purpose to the Agency. Services. This prohibition covers those vendors,
contractors, and/or grantees who:
Force Majeure: Neither party shall be deemed to be
in default of its obligations hereunder if and so long (a) have a Contract with a governmental
as it is prevented from performing such obligations by Agency; or
any act of war, hostile foreign action, nuclear (b) have performed under such a Contract within
explosion, riot, strikes, civil insurrection, earthquake, the past year, or
hurricane, tornado, or other catastrophic natural (c) anticipate bidding on such a Contract in the
event or act of God. future.
Survival of Promises: All promises, requirements, For additional information regarding the specific
terms, conditions, provisions, representations, requirements and exemptions, vendors, contractors,
guarantees, and warranties contained herein shall and/or grantees are encouraged to review Executive
survive the Contract expiration or termination date Order 24 and N.C.G.S. § 133-32.
unless specifically provided otherwise herein, or
unless superseded by applicable federal or State Confidentiality
statutes of limitation.
Confidentiality: Any information, data, instruments,
documents, studies or reports given to or prepared or
assembled by the Grantee under this agreement
shall be kept as confidential and not divulged or
NCDA&CS-General Terms and Conditions-Public-Local Governmental Entities
�
property interest in such deliverables.
made available to any individual or organization Headings: The Section and Paragraph headings in
without the prior written approval ofthe Agency. The these General Terms and Conditions are not material
Grantee acknowledges that in recek4ng, stohng, parts of the agreement and should not be used to
processing ur otherwise dealing with any confidential construe the meaning thereof.
information it will safeguard and not further disclose Time of the Essence: Time iaof the essence inthe
the information except ao otherwise provided in this performance of this Contract.
Contract.
�
Care of Property: The Grantee agrees that it shall
Oversight be responsible for the proper custody and care ofany
property furnished to it for use in connection with the
Access to Persons and Records: The State Auditor performance of this Contract and will reimburse the
and the using agency's internal auditors shall have Agency for loss of, or damage to, such property. At
access to persons and records as a result of all the termination of this Contract, the Grantee shall
Contracts or grants entered into by State agencies or contact the Agency for instructions as to the
political subdivisions in accordance with General disposition of such property and shall comply with
Statute 147-64.7 and Session Law 2010-194, Section these instructions.
21 (i.e., the State Auditors and internal auditors may
audit the records of the contractor during the term of Amendment: This Contract may not be amended
the Contract to verify accounts and data affecting orally or by performance. Any amendment must be
fees or performance). made in written form and executed by duly authorized
representatives of the Agency and the Grantee.
Record Retention: Records shall not be destroyed,
purged or disposed of without the express written Severability: In the event that a court of competent
consent of the Agency. State basic records retention jurisdiction holds that a provision or requirement of
policy requires all grant records to be retained for a this Contract violates any applicable law, each such
minimum of five years or until all audit exceptions provision or requirement shall continue to be
have been resolved, whichever is longer. If the enforced to the extent it is not in violation of law or is
Contract is subject to federal policy and regulations, not otherwise unenforceable and all other provisions
record retention may be longer than five years since and requirements of this Contract shall remain in full
records must be retained for a period of three years force and effect.
following submission of the final Federal Financial
Status Report, if applicable, or three years following Travel Expenses: Reimbursement to the Grantee
the submission of a revised final Federal Financial for travel mileage, meals, lodging and other travel
Status Report. Also, if any litigation, claim, expenses incurred in the performance of this
negotiation, audit, disallowance action, or other Contract shall be reasonable and supported by
action involving this Contract has been started before documentation. State rates shall be used.
expiration of the five-year retention period described International travel shall not be reimbursed under this
above, the records must be retained until completion Contract.
of the action and resolution of all issues which arise
from it, or until the end of the regular five-year period Sales/Use Tax Refunds: If eligible, the Grantee and
described above,whichever is later. all subgrantees shall: (a) ask the North Carolina
Department of Revenue for a refund of all sales and
Miscellaneous use taxes paid by them in the performance of this
Contract, pursuant to G.S. 105-164.14; and (b)
Choice of Law: The validity of this Contract and any exclude all refundable sales and use taxes from all
of its terms or provisions, as well as the rights and reportable expenditures before the expenses are
duties of the parties to this Contract, are governed by entered in their reimbursement reports.
the laws of North Carolina. The Grantee, by signing
this Contract, agrees and submits, solely for matters Advertising: The Grantee shall not use the award of
concerning this Contract, to the exclusive jurisdiction this Contract as a part of any news release or
of the courts of North Carolina and agrees, solely for commercial advertising.
such purpose, that the exclusive venue for any legal
proceedings shall be Wake County, North Carolina.
The place of this Contract and all transactions and
agreements relating to it, and their situs and forum,
shall be Wake County, North Carolina, where all
matters whether sounding-in Contract or tort, relating
to the validity, construction, interpretation, and
enforcement shall be determined.
NCDA&CS-General Terms and Conditions-Public-Local Governmental Entities
North Carolina Department of Agriculture and Consumer Services
Certifications and Assurances Section—State Funds
Attachment C
z;
r
fm
Steve Troxler, Commissioner
Certifications and Assurances Section
1/12 Rev 7112,9/12
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT,SUSPENSION AND OTHER
RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
The certifications shall be treated as a material representation of fact upon which reliance will be placed when the
Department of Agriculture determines to award the covered transaction, grant, or cooperative agreement.
1. LOBBYING
The applicant certifies that:
A. No Federal, State or local government appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal,
State or local government agency, a Member of Congress, North Carolina's General Assembly or local
government body; an officer or employee of Congress, North Carolina's General Assembly or local government
body or an employee of a Member of Congress, North Carolina's General Assembly or local government body in
connection with the making of any Federal, State or local government grant, the making of any Federal, State or
local government loan, the entering into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal, State, or local government contract, grant, loan or cooperative
agreement;
B. If any funds other than Federal, State or local government appropriated funds have been paid or will be paid to
any person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, North Carolina's General Assembly or local government body; an officer or employee of Congress,
North Carolina's General Assembly or local government body; or an employee of a Member of Congress, North
Carolina's General Assembly or local government body in connection with the Federal, State or local government
contract, grant, loan or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL,
"Disclosure Form to Report Lobbying," in accordance with its instructions;
2. DEBARMENT, SUSPENSION,AND OTHER RESPONSIBILITY MATTERS
A. The applicant certifies that it and its principals:
a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal, State or local government agency;
b) Have not within a three-year period preceding this application been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public(Federal, State, or local)transaction or contract under a
public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen
property;
c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity(Federal,
State, or local)with commission of any of the offenses enumerated in paragraph 2. (A) (b)of this
certification; and.
d) Have not within a three-year period preceding this application had one or more public transaction
(Federal, State, or local)terminated for cause or default.
B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an
explanation to this certification.
1/12 Rev 7/12, 9/12 Page 6 of 11
3. DRUG-FREE WORKPLACE(GRANTEES OTHER THAN INDIVIDUALS)
A. The applicant certifies that it will or will continue to provide a drug-free workplace by:
a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession,or use of a controlled substance is prohibited in the grantee's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b) Establishing an on-going drug-free awareness program to inform employees about:
i. The dangers of drug abuse in the workplace;
ii. The grantee's policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
c) Making it a requirement that each employee to be engaged in the performance of the grant be given a
copy of the statement required by paragraph (a);
d) Notifying the employee in the statement required by paragraph (a)that, as a condition of employment
under the grant, the employee will:
i. Abide by the terms of the statement; and
ii. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute
occurring in the workplace no later than five calendar days after such conviction;
e) Notifying the agency, in writing, within 10 calendar days after receiving notice under subparagraph (d)(ii)
from an employee or otherwise receiving actual notice of such conviction.
Notice shall include the identification number(s)of each affected grant;
f) Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph
(d)(ii), with respect to any employee who is so convicted:
i. Taking appropriate personnel action against such an employee, up to and including termination,
; or
ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency;
g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
1/12 Rev 7/12, 9/12 Page 7 of 11
B. The grantee must provide the location site(s)for the performance of work done in connection with the specific
grant.
Place(s)of Performance(Street address, city, county, state, zip code)
County Wide-Orange County
306D Revere Rd
Hillsborough, NC 27278
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the
above certifications.
GRANTEE ORGANIZATION NAME:
Orange Soil &Water Conservation District
PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:
f
S TU DATE:
n /s-ba-
CONTRACT NUMBER:
1/12 Rev 7/12, 9/12 Page 8 of 11
NC OPENBOOK SUPPLEMENTAL INFORMATION
INSTRUCTIONS: Complete the information below and return it to the Contract Administrator identified in your original contract.
This information must be submitted as part of your contract. If you have questions, please contact the Contract Administrator
or the Alternate Contact as reflected in your contract.
PURPOSE: In January 2009, Executive Order 4 was signed by the Governor of North Carolina. This Executive Order
requires certain information be collected from Grantees to enhance accountability and transparency of State funds.
Therefore, the information outlined below shall be submitted prior to the disbursement of any State funds by the North
Carolina Department of Agriculture and Consumer Services.
DUNS Number: 091575191
Contract Number: Amendment Number:
Grantee Name: Orange Soil m Water Conservation District
TAX|DNumber:
Fiscal Year Ends: June 30
1, Brief Description and Background/History of your Organization.
Be sure to include the number of years in existence,number of employees,mission and goals of your organization,
The Orange Soil&Water Conservation District was orginally formed in 1938 consisting of Orange,Durham and Wake counties and was called the
Neuse River Soil Conservation District. The Orange Soil&Water Conservation District became an individual District in 1964. The District
currently has five employees which work towards the DistricVs mission of using available technical,financial,and educational resources,whatever
their source and focus or coordinate them so that they meet the needs of the local land user for conservation of their natural resources.
2, Current project timeline: Begin 7-1-2012 End 6-30-2015
3. Expected outcomes and specific deliverables.
(Example: Expected Outcome:Aquaculture operation will remain in business. Deliverable: Healthy food made available for human
Implementation of comprehensive program of natural resource conservation and delivery of Commission cost share programs.
4. The Grantee's WEB URL: http://www.orangecountync.gov/soilwater/index.asp
5. * Primary County of Performance. County Name: orange
(CONGRESSIONAL DISTRICT#MUST BE IDENTIFIED) Congressional District#: 4
6. "County of Benefit: Single County: Fo� Yes F-1 No County Name: Orange
Statewide: F-1 Yes F-1 No
Regional: F-1 Yes F-1 No
7. If the answer to question number 6 is"Regional", list the counties receiving benefit.
*Primary County of Performance: County in which grantee is located.
"County of Benefit., Identified county or counties in which funding will be spent andlor food commodities will be received.
NC Openbook: 1112 Rev:7/12,9/12 Page 9 of 11
�
EXPECTED OUTCOMES AND SPECIFIC DELIVERABLES
Attachment E
Signature Card
Division of Soil and Water Conservation
CONTRACT & FINANCIAL DOCUMENTS
INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable.
Provide the requested printed and written signatures (in Blue Ink) of agency representatives in the designated
areas. In the event the affixed signature(s) are no longer valid, a revised form must be submitted prior to
processing any contractual documents or submitting "Request for Payments" or any other financial
documents.
SECTION L
Date: 12-4-12
Legal Applicant Organization/Agency Name: Orange Soil &Water Conservation District
Federal Tax Identification Number: 56-6000327
SECTION II.
Certification:
By affixing my signature below, I certify that person(s) identified are designated having legal authorization to
sign on behalf of the organization named in Section I., above, for purposes of executing contractual
documents and preparing, approving and executing all financial documents; including "Requests for
Payments". I understand the legal implications of any and all misrepresentation of a sole purpose of
defrauding the State of North Carolina.
NON-PROFIT ORGANIZATIONS ONLY
Chairman of the Board of Directors(Contract Documents) Financial Representative Signature
Print Name: Print Name&Title:
Signature: Signature:
GOVERNMENTAL ENTITIES
Appropriate Governmental Official(Secretary, Chief Fiscal Officer Signature
Commissioner,etc.
Print.Name&Title: Print Name&Title:
6-. Cam; , tu -2'-F0
Signature: Signature:: f
Signature Card—NPO&Governmental Page 10 of 11
NCDA&CS: Rev 7/11,2/12, 5/12,7/12, 8/12
Form Re nest far'Tax a er ;v tern to the .
�! Pte._.... .. . . ... .
(Rev: 002}
`� tdent ficatfcrn Dumber as i G"ertI Teation r Qu
Depa,>?tnent of the Treasury ....,
Internal itev2nue Service Send t0 t11G Ill :
-Business name,if different above
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Ta Individual/ / G -,^�4� E�tempf Frorn liacifup
Check_appropriate box: ❑•Sole proprietor Corporation 0 Partnership L_t Other 1► _L __ ___C-._a_.. 0 withholding
bei,'' t;and a't,dtsuiie ' _ -__...�. :..:_ -. ... - -- -• - -
Add - ((hixi�J p Requester's name;;d address-
0. '
M
City" i ;and IP cod
N t /1
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List account number(s)here•(optional)
Cox:a er:[ eritiIFitatiott Number:{Tt(11)
Enter your.TIN in the appropriate box. For individuals,this is'your socials muritynumber(SSN); So'craPsecurity'nUmber
Hovrrever,fol a resident alien,sole proprietor,or disregarded-entity,see the..Part t itistructior?s or
page-2,-For other entities,it is yout"employer identification number(EIN).If you do-nothave a riumtier,' ��'
see How to'get a,TW orr page 2.- or it
Note:•If-the account is in more than one name,see the chart an page 2 far guidelines on whale number [Employer identification number
to enter.
ZL
• - Certification
Under penaltles'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)1 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 aft 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.person(including.a U.S, resident alien).
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 required to sign the Certification, but you must
provide your correct TIN.(See the-instructions on page 2.)
Sigh Signature
Here U.S.pers Date 0- ��Y v
Purpose of Form What is backup withholding?Persons making 5.You do not certify to the requester that you
certain payments to you must under certain are not subject to backup withholding under 4
A person who is required to file an Information conditions withhold and pay to the IRS 30%of above(for reportable interest-and dividend
return with the IRS must get your correct such payments after December 31,2001 (29% accounts opened after 1983 only). --
taxpayer identification number(TIN),to report,for after December 31,2003).This is called"backup Certain payees and payments are exempt
transactions,mortaide merest you aid, withholdirig.• Payments that may be subject to from backup withholding.See the instructions on
mortgage Y p backup withholding include:interest dividends, page 2 and*the separate Instructions for the
acquisition or abandonment of secured property, broker and barter exchange transactions,rents. Requester of Form W-9.
cancellation of debt,or contributions you made royalties,nonempioyee pay,acid certain , q
to an IRA. payments from fishing boat operators.Real Penalties
Use Form W-9 only if you are a U.S.persoh estate transactions are not subject to backup
(Including a•resident alien);to give your correct withholding. Failure to fuinish TIN.If you fall to furnish your -
TIN to the person requesting it(the requester) Yau will nat be subject to backu withhaldin correct TIN to a requester,you are subject to a
and,when applicable,to: on payments you receive if you give the g Penalty of$SO for each such failure Mess your
failure is due to reasonable cause and of to
1.Certify the TIN you are giving Is correct(or requester your correct TIN,make the proper willful neglect
you are waiting for a number to be issued), certifications,and report all your taxable interest
and dividends on your tax return. Civil'penatty for false information with respect
2. Certify you are not subject to backup to withholding.If you make a false"statement
Withholding,or Payments you receive will be subject to with no reasonable basis that results in no
3.Claim exemption from backup withholding if backup withholding iE backup withholding,you are subject to a$Soo
you are a U.S.exempt payee. 1.You do not€urnish your TIN to the penalty.
if you are a foreign person,use the requester,or Criminal penalty for falsifying information:.
appropriate Form W-8.See Pub.515,- 2.You do not certify your TIN when required Milifully falsifying certifications or affirmations
Mthholding of Tart.on Nonresident Aliens and (see the Part If-instructions on page 2 for may subject you to criminal penalties including
Foreign Entities. . . details),or fines and/or imprisonment.
Note:if a requester gibes you a form other than 3.The IRS tells-the requester that you Mtsuse of TINS.-4f the requester discloses or
Form.W-3 to regraesf.your TIN,you must-use the furnished an iticoirect TIN,or •,. uses TINS.in violation of Federal law,the
requester's fonn if i2 is substantially similar to this 4.The' it Veils oil that ou'are subject to requester may be subject to civil astd criminal
Y. Y. j penalties.-
Form 1N--9, backup•withhotdjhj tieca'U"s)?you,dick.no'treport
all your interest and;dividends i?f►your.tax;reiurn
.
(for reportable interest and.dividends oniy),or
Cat No.10231X ..,. ..r;, ".: Form W iA' (Rev.i_2hn?i
Form W-9(Rev.1-2011) Page 2
The person who gives Form W-9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding.
establishing its U.S.status and avoiding withholding on its allocable See the instructions below and the separate Instructions for the
share of net income from the partnership conducting a trade or business Requester of Form W-9.
in the United States is in the following cases: Also see Special rules for partnerships on page 1.
•The U.S.owner of a disregarded entity and not the entity, Updating Your Information
•The U.S.grantor or other owner of a grantor trust and not the trust,
and You must provide updated Information to any person to wham you
•The U.S.trust{other than a grantor trust}and not the beneficiaries of claimed to be an exempt payee if you are no longer an exempt payee
the trust. and anticipate receiving reportable payments in the future from this
person.For example,you may need to provide updated information if
Foreign person.If you are a foreign person,do not use Form W-9. you are a C corporation that elects to be an S corporation,or if you no
Instead,use the appropriate Form W-8(see Publication 515, longer are tax exempt.In addition,you must furnish a new Form W-9 if
Withholding of Tax on Nonresident Aliens and Foreign Entities). the name or TIN changes for the account,for example,if the grantor of a
Nonresident alien who becomes a resident alien.Generally,only a grantor trust dies.
nonresident alien individual may use the terms of a tax treaty to reduce Penalties
or eliminate U.S.tax on certain types of income.However,most tax
treaties contain a provision known as a"saving clause."Exceptions Failure to furnish TIN.If you fail to furnish your correct TIN to a
specified in the saving clause may permit an exemption from tax to requester,you are subject to a penalty of$50 for each such failure
continue for certain types of income even after the payee has otherwise unless your failure is due to reasonable cause and not to willful neglect.
become a U.S.resident alien for tax purposes. Civil penalty for false information with respect to withholding.If you
If you are a U.S.resident alien who is relying on an exception make a false statement with no reasonable basis that results in no
contained in the saving clause of a tax treaty to claim an exemption backup withholding,you are subject to a$500 penalty.
from U.S.tax on certain types of income,you must attach a statement Criminal penalty for falsifying information.Willfully falsifying
to Form W-9 that specifies the following five items: certifications or affirmations may subject you to criminal penalties
1.The treaty country.Generally,this must be the same treaty under including fines and/or imprisonment.
which you claimed exemption from tax as a nonresident alien. Misuse of TINs.If the requester discloses or uses TINs in violation of
2.The treaty article addressing the income. federal law,the requester may be subject to civil and criminal penalties.
3.The article number(or location)in the tax treaty that contains the
saving clause and its exceptions. Specific Instructions
4.The type and amount of income that qualifies for the exemption Name
from tax.
5.Sufficient facts to justify the exemption from tax under the terms of If you are an individual,you must generally enter the name shown on
the treaty article. your income tax return.However,if you have changed your last name,
for instance,due to marriage without informing the Social Security
Example.Article 20 of the U.S.-China income tax treaty allows an Administration of the name change,enter your first name,the last name
exemption from tax for scholarship income received by a Chinese shown on your social security card,and your new last name.
student temporarily present in the United States.Under U.S.law,this If the account is in joint names,list first,and then circle,the name of
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years.However,paragraph 2 of the person or entity whose number you entered in Part I of the form.
the first Protocol to the U.S.-China treaty(dated April 30,1984)allows Sole proprietor.Enter your individual name as shown on your income
the provisions of Article 20 to continue to apply even after the Chinese tax return on the"Name"line.You may enter your business,trade,or
student becomes a resident alien of the United States.A Chinese "doing business as(DBA)"name on the"Business name/disregarded
student who qualifies for this exception(under paragraph 2 of the first entity name"line.
protocol)and is relying on this exception to claim an exemption from tax Partnership,C Corporation,or S Corporation.Enter the entity's name
on his or her scholarship or fellowship income would attach to Form on the"Name"line and any business,trade,or"doing business as
W-9 a statement that includes the information described above to (DBA)name"on the"Business name/disregarded entity name"line.
support that exemption. Disregarded entity.Enter the owner's name on the"Name"line.The
If you are a nonresident alien or a foreign entity not subject to backup name of the entity entered on the"Name"line should never be a
withholding,give the requester the appropriate completed Form W-8. disregarded entity.The name on the"Name"line must be the name
What is backup withholding?Persons making certain payments to you shown on the income tax return on which the income will be reported.
must under certain conditions withhold and pay to the IRS a percentage For example,if a foreign LLC that is treated as a disregarded entity for
of such payments.This is called"backup withholding." Payments that U.S.federal tax purposes has a domestic owner,the domestic owner's
may be subject to backup withholding include interest,tax-exempt name is required to be provided on the"Name"line.If the direct owner
interest,dividends,broker and barter exchange transactions,rents, of the entity is also a disregarded entity,enter the first owner that is not
royalties,nonemployee pay,and certain payments from fishing boat disregarded for federal tax purposes.Enter the disregarded entity's
operators.Real estate transactions are not subject to backup name on the"Business name/disregarded entity name"line.If the owner
withholding. of the disregarded entity is a foreign person,you must complete an
You will not be subject to backup withholding on payments you appropriate Form W-8.
receive if you give the requester your correct TIN,make the proper Note.Check the appropriate box for the federal tax classification of the
certifications,and report all your taxable interest and dividends on your person whose name is entered on the"Name"line(IndividuaVsole
tax return. proprietor,Partnership,C Corporation,S Corporation,Trust/estate).
Payments you receive will be subject to backup Limited Liability Company(LLC).If the person identified on the
withholding if: "Name"line is an LLC,check the"Limited liability company"box only
i.You do not furnish your TIN to the requester, and enter the appropriate code for the tax classification in the space
provided.If you are an LLC that is treated as a partnership for federal
2.You do not certify your TIN when required(see the Part II tax purposes,enter"P"for partnership.If you are an LLC that has filed a
instructions on page 3 for details), Form 8832 or a Form 2553 to be taxed as a corporation,enter"C"for
3.The IRS tells the requester that you furnished an incorrect TIN, C corporation or"S"for S corporation.If you are an LLC that is
disregarded as an entity separate from its owner under Regulation
4.The IRS tells you that you are subject to backup withholding section 301.7701-3(except for employment and excise tax),do not
because you did not report all your interest and dividends on your tax check the LLC box unless the owner of the LLC(required to be
return(for reportable interest and dividends only),or identified on the"Name"line)is another LLC that is not disregarded for
5.You do not certify to the requester that you are not subject to federal tax purposes.If the LLC is disregarded as an entity separate
backup withholding under 4 above(for reportable interest and dividend from its owner,enter the appropriate tax classification of the owner
accounts opened after 1983 only). identified on the"Name"line.
Form W-9(Rev.1-2011) Page 3
Other entities.Enter your business name as shown on required federal Part I.Taxpayer Identification Number(TIN)
tax documents on the"Name"line.This name should match the name
shown on the charter or other legal document creating the entity.You Enter your TIN in the appropriate box.If you are a resident alien and
may enter any business,trade,or DBA name on the"Business name/ you do not have and are not eligible to get an SSN,your TIN is your IRS
disregarded entity name"line. individual taxpayer identification number(ITIN).Enter it in the social
security number box.If you do not have an ITIN,see How to get a TIN
Exempt Payee below.
If you are exempt from backup withholding,enter your name as If you are a sole proprietor and you have an EIN,you may enter either
described above and check the appropriate box for your status,then your SSN or EIN.However,the IRS prefers that you use your SSN.
check the"Exempt payee"box in the line following the"Business name/ If you are a single-member LLC that is disregarded as an entity
disregarded entity name,"sign and date the form. separate from its owner(see Limited Liability Company(LLC)on page 2),
Generally,individuals(including sole proprietors)are not exempt from enter the owner's SSN(or EIN,if the owner has one).Do not enter the
backup withholding.Corporations are exempt from backup withholding disregarded entity's EIN.if the LLC is classified as a corporation or
for certain payments,such as interest and dividends. partnership,enter the entity's EIN.
Note.If you are exempt from backup withholding,you should still Note.See the chart on page 4 for further clarification of name and TIN
complete this form to avoid possible erroneous backup withholding. combinations.
The following payees are exempt from backup withholding: How to get a TIN.If you do not have a TIN,apply for one immediately.
1.An organization exempt from tax under section 501 To apply for an SSN,get Form SS-5,Application for a Social Security
9 p (a),any IRA,or a Card,from your local Social Security Administration office or get this
custodial account under section 403(b)(7)if the account satisfies the form online at www.ssa.gov.You may also get this form by calling
requirements of section 401(f)(2), 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer
2.The United States or any of its agencies or instrumentalities, Identification Number,to apply for an ITIN,or Form SS-4,Application for
3.A state,the District of Columbia,a possession of the United States, Employer Identification Number,to apply for an EIN.You can apply for
or any of their political subdivisions or instrumentalities, an EIN online by accessing the IRS website at www.irs.gov/businesses
and clicking on Employer Identification Number(EIN)under Starting a
4.A foreign government or any of its political subdivisions,agencies, Business.You can get Forms W-7 and SS-4 from the IRS by visiting
or instrumentalities,or IRS.gov or by calling 1-800-TAX-FORM(1-800-829-3676).
5.An international organization or any of its agencies or If you are asked to complete Form W-9 but do not have a TIN,write
instrumentalities. "Applied For"in the space for the TIN,sign and date the form,and give
Other payees that may be exempt from backup withholding include: it to the requester.For interest and dividend payments,and certain
6.A corporation, payments made with respect to readily tradable instruments,generally
7.A foreign central bank of issue, you will have 60 days to get a TIN and give it to the requester before you
are subject to backup withholding on payments.The 60-day rule does
8.A dealer in securities or commodities required to register in the not apply to other types of payments.You will be subject to backup
United States,the District of Columbia,or a possession of the United withholding on all such payments until you provide your TIN to the
States, requester.
9.A futures commission merchant registered with the Commodity Note.Entering"Applied For"means that you have already applied for a
Futures Trading Commission, TIN or that you intend to apply for one soon.
10.A real estate investment trust, Caution:A disregarded domestic entity that has a foreign owner must
11.An entity registered at all times during the tax year under the use the appropriate Form W-8.
Investment Company Act of 1940, Part II.Certification
12.A common trust fund operated by a bank under section 584(a), To establish to the withholding agent that you are a U.S.person,or
13.A financial institution, resident alien,sign Form W-9.You may be requested to sign by the
14.A middleman known in the investment community as a nominee or withholding agent even if item 1,below,and items 4 and 5 on page 4
custodian,or indicate otherwise.
15.A trust exempt from tax under section 664 or described in section For a joint account,only the person whose TIN is shown in Part 1
4947. should sign(when required). In the case of a disregarded entity,the
The following chart shows types of payments that may be exempt person identified on the"Name"line must sign.Exempt payees,see
from backup withholding.The chart applies to the exempt payees listed Exempt Payee on page 3.
above,1 through 15. Signature requirements.Complete the certification as indicated in
items 1 through 3,below,and items 4 and 5 on page 4.
IF the payment is for... THEN the payment is exempt 1.Interest,dividend,and barter exchange accounts opened
for... before 1984 and broker accounts considered active during 1983.
Interest and dividend payments All exempt payees except You must give your correct TIN,but you do not have to sign the
for 9 certification.
2.Interest,dividend,broker,and barter exchange accounts
Broker transactions Exempt payees 1 through 5 and 7 opened after 1983 and broker accounts considered inactive during
through 13.Also,C corporations. 1983.You must sign the certification or backup withholding will apply.If
Barter exchange transactions and Exempt payees 1 through 5 you are subject to backup withholding and you are merely providing
patronage dividends your correct TIN to the requester,you must cross out item 2 in the
certification before signing the form.
Payments over$600 required to be Generally,exempt payees 3.Real estate transactions.You must sign the certification.You may
reported and direct sales over 1 through 7 2 cross out item 2 of the certification.
$5,000'
'See Form 1099-MISC,Miscellaneous Income,and its instructions.
z However,the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from backup withholding:medical and health care
payments,attorneys'fees,gross proceeds paid to an attorney,and payments for
services paid by a federal executive agency.
Form W-9(Rev.1-2011) Page 4
4.Other payments.You must give your correct TIN,but you do not Note.If no name is circled when more than one name is listed,the
have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed.
have previously given an incorrect TIN."Other payments"include
payments made in the course of the requester's trade or business for Secure Your Tax Records from Identity Theft
rents,royalties,goods(other than bills for merchandise),medical and Identity theft occurs when someone uses your personal information
health care services(including payments to corporations),payments to such as your name,social security number(SSN),or other identifying
a nonemployee for services,payments to certain fishing boat crew information,without your permission,to commit fraud or other crimes.
members and fishermen,and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax return
(including payments to corporations). using your SSN to receive a refund.
5.Mortgage interest paid by you,acquisition or abandonment of To reduce your risk:
secured property,cancellation of debt,qualified tuition program
payments(under section 529),IRA,Coverdell ESA,Archer MSA or •Protect your SSN,
HSA contributions or distributions,and pension distributions.You •Ensure your employer is protecting your SSN,and
must give your correct TIN,but you do not have to sign the certification. e Be careful when choosing a tax preparer.
What Name and Number To Give the Requester If your tax records are affected by identity theft and you receive a
�i notice from the IRS,respond right away to the name and phone number
For this type of account Give name and SSN of printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
1.Individual The individual think you are at risk due to a lost or stolen purse or wallet,questionable
2.Two or more individuals Qoint The actual owner of the account or, credit card activity or credit report,contact the IRS Identity Theft Hotline
account) if combined funds,the first
individual on the account' at 1-800-908-4490 or submit Form 14039.
3.Custodian account of a minor The minor' For more information,see Publication 4535,Identity Theft Prevention
(Uniform Gift to Minors Act) and Victim Assistance.
4.a.The usual revocable savings The grantor-trustee Victims of identity theft who are experiencing economic harm or a
trust(grantor is also trustee) system problem,or are seeking help in resolving tax problems that have
b.So-called trust account that is The actual owner' not been resolved through normal channels,may be eligible for
not a legal or valid trust under Taxpayer Advocate Service(fAS)assistance.You can reach TAS by
state law calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
5.Sole proprietorship or disregarded The owner' 1-800-829-4059.
entity owned by an individual Protect yourself from suspicious emails or phishing schemes.
6.Grantor trust filing under optional The grantor* Phishin Is the creation and use of email and websites designed to
Form 1099 Filing Method 1(see g 9
Regulation section 1.671-4(b)(2)(i)(A)) mimic legitimate business emails and websites.The most common act
For this type of account Give name and EIN of is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
7.Disregarded entity not owned by an The owner
individual private information that will be used for identity theft.
8.A valid trust,estate,or pension trust Legal entity' The IRS does not initiate contacts with taxpayers via emails.Also,the
9.Corporation or LLC electing The corporation IRS does not request personal detailed information through email or ask
corporate status on Form 8832 or taxpayers for the PIN numbers,passwords,or similar secret access
Form 2553 information for their credit card,bank,or other financial accounts.
10.Association,club,religious, The organization If you receive an unsolicited email claiming to be from the IRS,
charitable,educational,or other forward this message to phishing @irs.gov.You may also report misuse
tax-exempt organization of the IRS name,logo,or other IRS property to the Treasury Inspector
11.Partnership or mufti-member LLC The partnership General for Tax Administration at 1-800-366-4484.You can forward
12.A broker or registered nominee The broker or nominee suspicious emails to the Federal Trade Commission at:spam @uce.gov
13.Account with the Department of The public entity or contact them at www.ftc.goWidtheft or 1-877-IDTHEFT
Agriculture in the name of a public (1-877-438-4338).
entity(such as a state or local Visit IRS.gov to learn more about identity theft and how to reduce
government,school district,or your risk.
prison)that receives agricultural
program payments
14.Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2(see
Regulation section 1.671-4(b)(2)()(B))
'List first and circle the name of the person whose number you furnish.If only one person on a
joint account has an SSN,that person's number must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
'You must show your individual name and you may also enter your business or"DBA"name on
the"Business nameldisregarded entity"name line.You may use either your SSN or EIN(if you
have one),but the IRS encourages you to use your SSN.
'List first and circle the name of the trust,estate,or pension trust.(Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.)Also see Special rules for partnerships on page 1.
`Note.Grantor also must provide a Form W-9 to trustee of trust.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons(including federal agencies)who are required to file information returns with
the IRS to report interest,dividends,or certain other income paid to you;mortgage interest you paid;the acquisition or abandonment of secured property;the cancellation
of debt;or contributions you made to an IRA,Archer MSA,or HSA.The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information.Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities,states,the District
of Columbia,and U.S.possessions for use in administering their laws.The information also may be disclosed to other countries under a treaty,to federal and state agencies
to enforce civil and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN whether or not you are required to
file a tax return.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other payments to a payee who does not give a
TIN to the payer.Certain penalties may also apply for providing false or fraudulent information.
�„yG14xY,yK,�
FOR NcDA& ONLY: North Carolina Department of Agriculture
Return Request to: p g
Pam Winstead,supervisor and Consumer Services Terri S.Overton,
Accounts Payable, NCDA&CS Director
1001 Mail Service Center Steve Troxler, Commissioner Budget&Finance
Raleigh,N.C. 27699-1001
ELECTRONIC PAYMENT REQUEST FORM
For your convenience and benefit, the State of North Carolina offers payees the opportunity to receive future
payments electronically, rather than by check. Your payments will be deposited into the checking or savings
account of your choice. In addition to having the money deposited electronically, you also will be notified of the
deposit electronically, either by fax or by e-mail. The fax or e-mail will provide you with all the information that
would normally be on your check stub.
• ATTACH A VOID CHECK,PRINT THE INFORMATION BELOW and MAIL to your Contract
Administrator as identified in your cover contract document.
Payee Name
Federal ID#/Social Security#
Bank Name
Bank routing number
( }Checking account #
{ )Savings account #
• FAX number or e-mail address for payment notification. Place a check mark in front of the method of notification
you prefer. Identify the Grant Program you are participating in as requested below.
( )FAX# { _ ) _ — - ` — _ _ OR
( ) E-mail address
Authorized Signature: Date:
Title:
( }Phone#
(ATTACH A VOID CHECK)
PLEASE IDENTIFY THE GRANT PROGRAM YOU ARE
PARTICIPATING IN:
E-mail: Pam.Winstead @ncagr.gov
1001 Mail Service Center,Raleigh,N.C. 27699-1001 • (919)707-3030
An Equal Opportunity Affirmative Action Employer