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HomeMy WebLinkAbout2013-016 Housing - NC Department of Health & Human Services for Emergency Shelter Solutions Grant $121,000 Contract Number 00027858 / Page 1 of 33 GENERAL CONTRACT COVER A This contract is hereby entered into by and between the North Carolina Department of Health and Human Services, Division of Aging and Adult Services (the "Division ") and Orange County (the "Contractor") (referred to collectively as the "Parties "). 1. Contract Documents: This contract consists of the following documents, which are incorporated herein by reference: (a) This contract cover (b) The General Terms and Conditions (c) Scope of Work (d) Performance Measures Chart (e) The Line Item Budget (f) Federal Certifications (g) State Certification Incorporated By Reference The following documents are reference materials and are available by going to the following website, Open Window ( hftp://dhhsopenwindow.nc.gov/index.aspx?pid=doc Reference Documents (a) Executive Order No. 24 (b) Travel: Policies Governing Travel Related Expenses for Contractors (c) General Statutes G.S.143C6 NonState Entities Receiving State Funds (d) Subchapter 03M Uniform Administration of State Grants These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or agreements. 2. Precedence Among 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 the contract document section, 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. 3. Effective Period: This contract shall be effective on 10/1/2012 and shall terminate on 9/30/2013, with the option to extend, if mutually agreed upon, through a written amendment as provided for in the General Terms and Conditions. 4. Contractor's Duties: The Contractor shall provide the services as described in the scope of work and in accordance with the approved budget. 5. Division's Duties: The Division shall pay the Contractor in the manner and in the amounts specified in the contract documents. The total amount paid by the Division to the Contractor under this contract shall not exceed $168,467. This amount consists of $0 in State funds, $0 in Local funds, $0 in Other funds and $168,467 in Federal funds. The Contractor's matching requirement is $168,467. iJV V l NCDHHS GCT1007 (Contract) (General) (Rev. 9/12) Contract Number 00027858 / Page 2 of 33 The total contract amount is $336,934. 6. Conflict of Interest Policy: The Division has determined that this contract is a financial assistance contract. The Contractor shall file with the Division, a copy of the Contractor's policy addressing conflicts of interest that may arise involving the Contractor's management employees and the members of its board of directors or other governing body. The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the Contractor's employees or members of its board or other governing body, from the Contractor's disbursing of state funds and shall include actions to be taken by the Contractor or the individual, or both to avoid conflicts of interest and the appearance of impropriety. The policy shall be filed before the Division may disburse the grant funds. (N.C.G.S. 143C- 6- 23(b)(2007)) 7. Statement of No Overdue Tax Debts: Contractor's sworn written statement pursuant to N.C.G.S. 143C- 6- 23(c), stating that the Contractor does not have any overdue tax debts, as defined by G.S. 105 - 243.1, at the federal, state, or local level. The Contractor acknowledges that the written statement must be filed before Division may disburse the grant funds. 8. Grants: The Contractor /Grantee has the responsibility to ensure that all sub - grantees, if any, provide all information necessary to permit the Contractor /Grantee to comply with the standards set forth in this contract. 9. Reporting Requirements: The Division has determined that this is a contract for financial assistance with a Public Entity. Local governmental agencies subject to N.C.G.S. § 159 -34, annual independent audit; rules and regulations, OMB Circular A-1 33, Audits of States, Local Governments, and Non - Profit Organizations, and N.C.G.S. § 143C -6 -22, use of state funds by non state entities. If subgranting is allowable, a nongovernmental subgrantee is subject to the reporting requirements described on the Notice of Certain Reporting and Audit Requirements. Regulations and Reporting Requirements of N.C. General Statute 143C -6.23 can be found at ncgrants.gov. 10. Payment Provisions: Upon execution of this contract, the Contractor shall submit to the Division Contract Administrator, a monthly reimbursement request for services rendered the previous month by the 10th of each month and, upon approval by the Division, receive payment within 30 days. Monthly payment shall be made based on actual expenditures made in accordance with the approved budget on file with both parties and reported on the monthly expenditure report submitted by the Contractor. If this contract is terminated, the Contractor shall complete a final accounting report and return any unearned funds to the Division within 30 days of the contract termination date. The Division shall have no obligation for payments based on expenditure reports submitted later than 30 days after termination or expiration of the contract period. All payments are contingent upon fund availability. Payment shall be made in accordance with the contract documents as described in the scope of work. 11. Contract Administrators: NCDHHS GCT1007 (Contract) (General) (Rev. 9/12) Contract Number 00027858 / Page 3 of 33 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 administrators 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 Division: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Michael Leach, Homeless Programs Michael Leach, Homeless Programs Coordinator Coordinator Division of Aging and Adult Services Division of Aging and Adult Services 2101 Mail Service Center 2101 Mail Service Center Raleigh, NC 27699 -2101 Raleigh, NC 27699 -2101 Telephone : (919)- 855 -4991 Fax: O -- Email: Michael. Leach@dhhs.nc.gov For the Contractor: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Jamie Rohe, Homeless Program Coordinator Jamie Rohe, Homeless Program Coordinator Orange County Orange County PO Box 8181 PO Box 8181 Hillsborough, NC 27278 Hillsborough, NC 27278 Telephone: (919)- 245 -2490 Fax: ()-- Email: jrohe@orangecountync.gov 12. Supplementation of Expenditure of Public Funds: The Contractor assures that funds received pursuant to this contract shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the Contractor otherwise expends for contract 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 Contractor's total expenditure of other public funds for such services. 13. Disbursements: As a condition of this contract, the Contractor 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. NCDHHS GCT1007 (Contract) (General) (Rev. 9/12) Contract Number 00027858 / Page 4 of 33 14. Outsourcing to Other Countries: The Contractor certifies that it has identified to the Division all jobs related to the contract that have been outsourced to other countries, if any. The Contractor further agrees that it will not outsource any such jobs during the term of this contract without providing notice to the Division. 15. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their principals to the terms of this agreement. 16. Federal Certifications: Individuals and Organizations receiving federal funds must ensure compliance with certain certifications required by federal laws and regulations. The contractor is hereby complying with Certifications regarding Nondiscrimination, Drug -Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and certifications are accompanied by a signature page and can be found in the Contractor's Managed Documents section of DHHS Open Window. The signature page is to be signed by the contractor's authorized representative. Signatures follow on next page NCDHHS GCT1007 (Contract) (General) (Rev. 9/12) Contract Number 00027858 / Page 5 of 33 In Witness Whereof, the Contractor and the Division have executed this contract in duplicate originals, with one original being retained by each party. Orange Co u r Signature Date Frank Clifton County Manager Printed Name Title WITNESS & - Z" 1 Signature Date mac\ m , n - To ► � Printed Name Title Division of Aging and Adult Services, North Carolina Department of Health and Human Services <:::I — t�-!�� ti ature y,o, ('.e -f •. Date O� b Dennis Streets Division Director Printed Name Title NCDHHS GCT1007 (Contract) (General) (Rev. 9/12) Contract Number 00027858 / Page 6 of 33 GENERAL TERMS AND CONDITIONS Relationships of the Parties Indemnification: The Contractor agrees to indemnify and hold harmless the Division, the State of North Independent Contractor: The Contractor is and shall Carolina, and any of their officers, agents and be deemed to be an independent contractor in the employees, from any claims of third parties arising out of performance of this contract and as such shall be wholly any act or omission of the Contractor in connection with responsible for the work to be performed and for the the performance of this contract to the extent permitted supervision of its employees. The Contractor represents by law. that it has, or shall secure at its own expense, all personnel required in performing the services under this Default and Termination agreement. Such employees shall not be employees of, or have any individual contractual relationship with, the Termination Without Cause: The Division may Division. terminate this contract without cause by giving 30 days written notice to the Contractor. Subcontracting: The Contractor shall not subcontract any of the work contemplated under this contract without Termination for Cause: If, through any cause, the prior written approval from the Division. Any approved Contractor shall fail to fulfill its obligations under this subcontract shall be subject to all conditions of this contract in a timely and proper manner, the Division shall contract. Only the subcontractors specified in the have the right to terminate this contract by giving written contract documents are to be considered approved upon notice to the Contractor and specifying the effective date award of the contract. The Division shall not be thereof. In that event, all finished or unfinished obligated to pay for any work performed by any deliverable items prepared by the Contractor under this unapproved subcontractor. The Contractor shall be contract shall, at the option of the Division, become its responsible for the performance of all of its property and the Contractor shall be entitled to receive subcontractors. just and equitable compensation for any satisfactory work completed on such materials, minus any payment Assignment: No assignment of the Contractor's or compensation previously made. Notwithstanding the obligations or the Contractor's right to receive payment foregoing provision, the Contractor shall not be relieved hereunder shall be permitted. However, upon written of liability to the Division for damages sustained by the request approved by the issuing purchasing authority, Division by virtue of the Contractor's breach of this the State may: agreement, and the Division may withhold any payment (a) Forward the Contractor's payment check(s) due the Contractor for the purpose of setoff until such directly to any person or entity designated by the time as the exact amount of damages due the Division Contractor, or from such breach can be determined. In case of default (b) Include any person or entity designated by by the Contractor, without limiting any other remedies for Contractor as a joint payee on the Contractor's breach available to it, the Division may procure the payment check(s). contract services from other sources and hold the In no event shall such approval and action obligate the Contractor responsible for any excess cost occasioned State to anyone other than the Contractor and the thereby. The filing of a petition for bankruptcy by the Contractor shall remain responsible for fulfillment of all Contractor shall be an act of default under this contract. contract obligations. Waiver of Default: Waiver by the Division of any default Beneficiaries: Except as herein specifically provided or breach in compliance with the terms of this contract otherwise, this contract shall inure to the benefit of and by the Contractor shall not be deemed a waiver of any be binding upon the parties hereto and their respective subsequent default or breach and shall not be construed successors. It is expressly understood and agreed that to be modification of the terms of this contract unless the enforcement of the terms and conditions of this stated to be such in writing, signed by an authorized contract, and all rights of action relating to such representative of the Department and the Contractor and enforcement, shall be strictly reserved to the Division attached to the contract. and the named Contractor. Nothing contained in this document shall give or allow any claim or right of action Availability of Funds: The parties to this contract whatsoever by any other third person. It is the express agree and understand that the payment of the sums intention of the Division and Contractor that any such specified in this contract is dependent and contingent person or entity, other than the Division or the upon and subject to the appropriation, allocation, and Contractor, receiving services or benefits under this availability of funds for this purpose to the Division. contract shall be deemed an incidental beneficiary only. Force Majeure: Neither party shall be deemed to be in Indemnity and Insurance default of its obligations hereunder if and so long as it is prevented from performing such obligations by any act of war, hostile foreign action, nuclear explosion, riot, NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10/22/09) Contract Number 00027858 / Page 7 of 33 strikes, civil insurrection, earthquake, hurricane, tornado, Oversight or other catastrophic natural event or act of God. Access to Persons and Records: The State Auditor Survival of Promises: All promises, requirements, shall have access to persons and records as a result of terms, conditions, provisions, representations, all contracts or grants entered into by State agencies or guarantees, and warranties contained herein shall political subdivisions in accordance with General Statute survive the contract expiration or termination date unless 147 -64.7. Additionally, as the State funding authority, specifically provided otherwise herein, or unless the Department of Health and Human Services shall superseded by applicable Federal or State statutes of have access to persons and records as a result of all limitation. contracts or grants entered into by State agencies or political subdivisions. Intellectual Property Rights Record Retention: Records shall not be destroyed, Copyrights and Ownership of Deliverables: All purged or disposed of without the express written deliverable items produced pursuant to this contract are consent of the Division. State basic records retention the exclusive property of the Division. The Contractor policy requires all grant records to be retained for a shall not assert a claim of copyright or other property minimum of five years or until all audit exceptions have interest in such deliverables. been resolved, whichever is longer. If the contract is subject to Federal policy and regulations, record Compliance with Applicable Laws retention may be longer than five years since records must be retained for a period of three years following Compliance with Laws: The Contractor shall comply submission of the final Federal Financial Status Report, with all laws, ordinances, codes, rules, regulations, and if applicable, or three years following the submission of a licensing requirements that are applicable to the conduct revised final Federal Financial Status Report. Also, if of its business, including those of federal, state, and any litigation, claim, negotiation, audit, disallowance local agencies having jurisdiction and /or authority. action, or other action involving this Contract has been started before expiration of the five -year retention period Equal Employment Opportunity: The Contractor shall described above, the records must be retained until comply with all federal and State laws relating to equal completion of the action and resolution of all issues employment opportunity. which arise from it, or until the end of the regular five - year period described above, whichever is later. Health Insurance Portability and Accountability Act Miscellaneous ( HIPAA): The Contractor agrees that, if the Division determines that some or all of the activities within the Choice of Law: The validity of this contract and any of scope of this contract are subject to the Health its terms or provisions, as well as the rights and duties of Insurance Portability and Accountability Act of 1996, P.L. the parties to this contract, are governed by the laws of 104 -91, as amended ( "HIPAA"), or its implementing North Carolina. The Contractor, by signing this contract, regulations, it will comply with the HIPAA requirements agrees and submits, solely for matters concerning this and will execute such agreements and practices as the Contract, to the exclusive jurisdiction of the courts of Division may require to ensure compliance. North Carolina and agrees, solely for such purpose, that the exclusive venue for any legal proceedings shall be Executive Order # 24: It is unlawful for any vendor, Wake County, North Carolina. The place of this contract contractor, subcontractor or supplier of the state to make and all transactions and agreements relating to it, and gifts or to give favors to any state employee. For their situs and forum, shall be Wake County, North additional information regarding the specific Carolina, where all matters, whether sounding in requirements and exemptions, contractors are contract or tort, relating to the validity, construction, encouraged to review Executive Order 24 and G.S. Sec. interpretation, and enforcement shall be determined. 133 -32. Amendment: This contract may not be amended orally Confidentiality or by performance. Any amendment must be made in written form and executed by duly authorized Confidentiality: Any information, data, instruments, representatives of the Division and the Contractor. The documents, studies or reports given to or prepared or Purchase and Contract Divisions of the NC Department assembled by the Contractor under this agreement shall of Administration and the NC Department of Health and be kept as confidential and not divulged or made Human Services shall give prior approval to any available to any individual or organization without the amendment to a contract awarded through those offices. prior written approval of the Division. The Contractor acknowledges that in receiving, storing, processing or Severability: In the event that a court of competent otherwise dealing with any confidential information it will jurisdiction holds that a provision or requirement of this safeguard and not further disclose the information contract violates any applicable law, each such provision except as otherwise provided in this contract. or requirement shall continue to be enforced to the NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10/22/09) Contract Number 00027858 / Page 8 of 33 extent it is not in violation of law or is not otherwise Division for loss of, or damage to, such property. At the unenforceable and all other provisions and requirements termination of this contract, the Contractor shall contact of this contract shall remain in full force and effect. the Division for instructions as to the disposition of such property and shall comply with these instructions. Headings: The Section and Paragraph headings in these General Terms and Conditions are not material Travel Expenses: Reimbursement to the Contractor for parts of the agreement and should not be used to travel mileage, meals, lodging and other travel expenses construe the meaning thereof. incurred in the performance of this contract shall not exceed the rates published in the applicable State rules Time of the Essence: Time is of the essence in the or approved local government travel policy. International performance of this contract. travel shall not be reimbursed under this contract. Key Personnel: The Contractor shall not replace any of Sales /Use Tax Refunds: If eligible, the Contractor and the key personnel assigned to the performance of this all subcontractors shall: (a) ask the North Carolina contract without the prior written approval of the Division. Department of Revenue for a refund of all sales and use The term "key personnel' includes any and all persons taxes paid by them in the performance of this contract, identified as such in the contract documents and any pursuant to G.S. 105 - 164.14; and (b) exclude all other persons subsequently identified as key personnel refundable sales and use taxes from all reportable by the written agreement of the parties. expenditures before the expenses are entered in their reimbursement reports. Care of Property: The Contractor agrees that it shall be responsible for the proper custody and care of any Advertising: The Contractor shall not use the award of property furnished to it for use in connection with the this contract as a part of any news release or performance of this contract and will reimburse the commercial advertising. NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10/22/09) Contract Number 00027858 / Page 9 of 33 Attachment B North Carolina ESG State Sub - recipient Scope of Work BACKGROUND: The Housing and Homelessness Unit within the Division of Aging and Adult Services is responsible for encouraging access to housing resources by all persons served by the Department of Health and Human Services. One specific program of the Housing and Homeless Unit is the Emergency Solutions Grant. The Emergency Solutions Grant (ESG) was created in the HEARTH Act by combining the previous Emergency Shelter Grant and the previous Homelessness Prevention and Rapid Re- Housing programs. The ESG program is intended to assist people in preventing or ending their homelessness through its support of homeless emergency services (primarily homeless shelters) and community housing stability programs. The program is designed to emphasize placement in permanent housing as the desired outcome. On any given night in North Carolina there are over 10,000 homeless people eligible for this assistance. PURPOSE: ESG Grantees are responsible for completing tasks from a menu of federally eligible services. The ESG grant will support - Operating expenses for homeless shelters, including but not limited to case management, insurance, facility rent and utility payments - Housing Stability expenses aimed at preventing homelessness, or assisting a homeless household to become stably housed through housing stability case management and/or providing flexible cash assistance for deposits, rent, utilities and/or past due rent and utilities. Grantees may provide one or both of these services. SCOPE OF WORK As a regional fiscal sponsor, the recipient is responsible for ensuring that the following occur: I. Training All core ESG project staff, including housing stability managers, case management supervisors, grant managers, Emergency Services case managers, CHIN data entry, and financial processors must attend ESG training provided by the State within 45 days of contract execution. Attachment A, pg. 1 Scope of Work Contract Number 00027858 / Page 10 of 33 Type of Position Type of Required Trainin Housing Stability Case Manager and Face to Face Supervisors Grant Managers Webinar /Conference Call CHIN data entry Face to Face Financial Processing/Fiscal Webinar /Conference Call Emergency Services Case Manager I Webinar /Conference Call Documentation: Copy of certificate of training completion or training sign -in sheets. II. Eligibility Screening and Intake For Emergency Response Programs: Sub - recipient will engage in ESG intake and eligibility process to comply with U.S. Department of Housing and Urban Development (HUD) and state guidance documenting all federally required eligibility criteria, including but not limited to homeless status. Sub - recipient will only provide ESG funded services to eligible participants. If sub - recipient provides services to ineligible participants using ESG funds or ESG matching funds the sub - recipient will reimburse the State for those funds from a non -ESG funding source. For Housing Stability Programs: Sub - recipient will engage in ESG intake and re- certification that will comply with federal and state guidance about documenting all HUD eligibility criteria, including but not limited to using forms documenting housing status, income eligibility, and financial and social supports available to prevent homelessness. Sub - recipient will only provide ESG funded services to eligible participants. If sub - recipient provides services to ineligible participants using ESG funds or ESG matching funds the sub - recipient will reimburse the State for those funds from a non -ESG funding source. Documentation: Participant files and appropriate data entered into CHIN III. Case Management For Housing Stability Programs: Sub - recipient will have 3.5 months from execution of contract to ramp -up to full case loads. By February 2013 grantee caseloads should be a minimum of 12 households per full -time rapid re- housing caseworker or 22 households per full -time prevention caseworker for an agency serving multiple counties. The caseload should be a minimum of 15 households per full -time rapid re- housing caseworker or 25 households per full -time prevention for an agency serving one county. Case workers will be responsible for financial assistance eligibility determination as well as for assisting the program participant to develop and implement a Housing Stabilization Action Plan. Documentation: CHIN Reports and Timesheets Attachment A, pg. 2 Scope of Work Contract Number 00027858 / Page 11 of 33 IV. Financial Assistance Documentation For Housing Stability Programs Sub - recipient will be responsible for all required documentation for financial assistance. Such documents include, but are not limited to, housing assistance payment agreements, leases, utility payment receipts, documentation of utilities in the recipients name, unit inspection, and assurance of tenancy. Documentation: Participant file and Reimbursement Requests V. Recertification For Housing Stability Programs Sub - recipient will be responsible for recertification of any prevention household that is to receive more than 3 months of services. Sub - recipient will be responsible for recertification of any rapid re- housing household that is to receive more than 12 months of services. Recertification will include all steps prescribed by HUD to verify that the household still meets the eligibility criteria, including but not limited to income certification. Documentation: CHIN Reports VI. Carolina Homeless Information Network (CHIN) Sub - recipient will be responsible for ensuring that all staff involved in CHIN data entry or CHIN data monitoring shall participate in ESG CHIN training. Staff responsible for CHIN data entry or monitoring is expected to take advantage of available technical assistance in an assertive, proactive manner to ensure their ability to meet the requirements for accurate data entry. Sub - recipients will input, regularly review, and correct, if necessary, 100% of required data fields into CHIN within two weeks of client contact and/or service. Data fields include, but are not limited to: Eligibility, demographic, and risk factor data for participant households, services provided to households, Financial Assistance (dollar amounts per individual) and salaried staff time spent directly on work with ESG households. In addition, CHIN will provide monthly data quality reports to sub - recipients and the Housing and Homelessness Unit. Domestic Violence programs are prohibited from entering data into CHIN. They are required, however, to collect all of the same data in a separate system and to report aggregate information to the State as needed for State and federal reports. Documentation: CHIN reports, Participant files Attachment A, pg. 3 Scope of Work Contract Number 00027858 / Page 12 of 33 VII. Eligible Expenditures For Emergency Response Programs (only for programs that received Emergency Services funding) 1. Street Outreach i. Engagement ii. Case management iii. Emergency health services iv. Emergency mental health services v. Transportation vi. Services for special populations including: homeless youth, victim services, and persons with HIV /AIDS 2. Emergency Shelter i. Case management ii. Child care iii. Education services iv. Employment assistance and job training v. Outpatient health services vi. Legal services vii. Life skills training viii. Mental health services ix. Substance abuse treatment services x. Transportation xi. Services for special populations including: homeless youth, victim services, and persons with HIV /AIDS xii. Shelter operations 1. Maintenance 2. Rent 3. Security 4. Fuel 5. Equipment 6. Insurance 7. Utilities 8. Food 9. Furnishings 10. Supplies necessary for the operation of the emergency shelter For Housing Stability Programs (only for programs receiving Housing Stability funds) 1. Financial assistance a. Rental application fees b. Security deposits c. Last month's rent d. Utility deposits e. Utility payments f. Moving costs Attachment A, pg. 4 Scope of Work Contract Number 00027858 / Page 13 of 33 2. Services a. Housing search and placement b. Housing stability case management c. Mediation d. Legal services e. Credit repair 3. Rent assistance Systems Coordination 4. Coordinated Intake 5. HMIS a. Staffing b. Equipment Please Note: Funds can only be spent on prevention if a sub - recipient applied specifically for prevention dollars in its application. PERFORMANCE MONITORING /QUALITY ASSURANCE PLAN I. Spending Rates A. Sub - recipients must expend 100% of funds and 100% of the matching funds by September 30, 2013. B. Sub - recipients are allowed to spend 100% of funds before June 30, 2013. Documentation: Fiscal reports II. Monitoring For Housing Stability Programs: Sub - recipient will make electronic or paper copies of intake forms and eligibility screening criteria for a minimum of the first 5 cases enrolled and first 3 cases not enrolled into the ESG Housing Stability program. Copies will be made with names and social security numbers blacked out. Paper copies will be sent to Housing and Homelessness — DAAS — DHHS; 2101 MSC, Raleigh, NC 27699 -2101. Copies of additional files may be requested. For All Programs: Sub - recipient will participate in all monitoring activities, programmatic and/or fiscal, state and/or federal, field and/or desk monitoring (materials mailed/emailed in to the state offices). a. At a minimum, participant file monitoring will include review of households that were not enrolled into the program, households that are currently enrolled in the program, and households that have exited the program (unless no households have yet exited) Attachment A, pg. 5 Scope of Work Contract Number 00027858 / Page 14 of 33 i. Fiscal monitoring will include monitoring of fiscal processes, financial documentation of expenses, and eligibility documentation in client files. ii. Programmatic monitoring will also include review of CHIN data entry and monitoring practices. For Housing Stability Programs Only: iii. Participant file monitoring will include, but is not limited to, eligibility determination and recertification, Housing Stabilization Action Plans, financial assistance determination, financial assistance documentation, referral and follow up documentation, and CHIN consent forms. Frequency of monitoring visits may be based on performance as documented in CHIN and additional risk factors as identified in previous grantee performance, grant application forms, and monitoring reports from other state and federal agencies. Documentation: Monitoring reports and participant files III. Reporting A. Sub - recipients will be responsible for accurate and complete CHIN data entry (comparable data for Domestic Violence programs) and reimbursement requests. All CHIN data entry for the quarter must be entered into CHIN by the end of the third month of the quarter B. Sub - recipients will be responsible for all other information required for federal reporting. Sub - recipients will be notified of these reporting requirements as federal guidance is provided. C. Sub - recipients will be responsible for submission of semi - annual reports to the State. Documentation: CHIN Reports; Annual reports, Semi - Annual reports REIMBURSEMENTS I. Reimbursement A. Sub - recipient will submit reimbursement requests to the N.C. Department of Health and Human Services — Housing and Homelessness Unit using forms supplied by the State with required documentation/proof of payment and maintaining additional required documentation in household (participant) files and in the CHIN system. Reimbursement requests may be verified against data in CHIN before payment is made. Attachment A, pg. 6 Scope of Work Contract Number 00027858 / Page 15 of 33 When reimbursements request are made in a timely and complete manner: a. Emergency Services reimbursements will be paid on a monthly basis. b. Staff cost will be paid on a monthly basis. c. Flexible cash assistance may be paid twice a month. B. Reimbursements for sub - recipient staff will require timesheets or documentation of indirect cost rates. C. Reimbursement for any activities for which the sub - recipient sub - contracts will require a paid invoice for reimbursement from the state. Sub - recipient will be responsible for all funds allocated to a sub - contractor. If funds are misused by a sub - contractor the sub - recipient will reimburse the state with another funding source. Documentation: Reimbursement forms, reimbursement documentation, CHIN reports, participant files, timesheets or documentation of indirect cost rates, cost allocation plans and paid invoices. Attachment A, pg. 7 Scope of Work Contract Number 00027858 / Page 16 of 33 PERFORMANCE MEASURES CHART The Department of Health and Human Services uses performance measures rubrics as a tool to determine the success of a project and how well services and products are being delivered. Together they enable the Department to gauge efficiency, determine progress toward desired results and assess whether the Department is on track with meeting its goals. The contractor shall adhere to all of the performance requirements /standards in the scope of work, including performance measures in the performance measures chart below. s Outcome Semi - annual eas Increase the percentage of households that exit to permanent housing 2013 Increase 30% CHIN, the statewide homeless management information system Staff enter data into the CHIN system Daily eas Quality Semi- annual as Maintain HMIS bed coverage for the region 2013 Maintain 90 -100% The HUD required EHIC, electronic housing inventory chart CoC Lead Agency enters data into the EHIC Annually as Quality Semi - annual as Decrease percentage of households that exit to unknown destination 2013 Decrease 50% Performance Measures (Rev. 4//12) Contract Number 00027858 / Page 17 of 33 CHIN, the statewide homeless management information system Staff enter client level data into the CHIN system Daily Performance Measures (Rev. 402) M M O O O O O O O O O O N 4 O O O O O M f-� O CA of W, EA 6} V) 63 O IT 63. 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O V N lQ O 4 co 0 co p' y ° co to rl CV a ° i ° o U N C O V d O C b} q o n O N r ° Cl) O O O � O C) a° o° ° o 0 � o 0 m y _C a Q C7 r P Q Co r fv - am CIO a � C Contract Number 00027858 / Page 25 of 33 FEDERAL CERTIFICATIONS The undersigned states that: 1 He or she is the duly authorized representative of the Provider named below; 2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Provider, as set out herein: a• The Certification Regarding Nondiscrimination; b. The Certification Regarding Drug -Free Workplace Requirements; c The Certification Regarding Environmental Tobacco Smoke; d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions; and e. The Certification Regarding Lobbying; 3 He or she has completed the Certification Regarding Drug -Free Workplace Requirements by providing the addresses at which the contract work will be performed; 4 [Check the applicable statement] [ ] He or she has completed the attached Disclosure Of Lobbying Activities because the Provider has made, or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action; OR [X] He or she has not completed the attached Disclosure Of Lobbying Activities because the Provider has not made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or employee of any agency, any Member of Congress, any officer or employee of Congress, or any employee of a Member of Congress in connection with a covered Federal action. 5. The Provider shall require its subcontractors, if any, to make the same certifications and disclosure. . M 4Z A-e�� Signature Title Orange County, NC G f fl - z-- Provider Name Date [This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page] L Certification Regarding Nondiscrimination The Provider certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S C. § §1681 -1683, and 1685- 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U S.0 §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U S.C. § §6101- 6107), which prohibits discrimination on the basis of age; (e) ' the Drug Abuse Office and Treatment Act of 1972 (R.L. 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S C § §3601 et seq ), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement Contract Number 00027858 / Page 26 of 33 11. Certification Regarding Drug -Free Workplace Requirements 1 The Provider certifies that it will 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 Provider's workplace and specifying the actions that will be taken against employees for violation of such prohibition; b Establishing a drug -free awareness program to inform employees about: i. The dangers of drug abuse in the workplace; ii The Provider'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 be engaged in the performance of the agreement 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 agreement, the employee will: i Abide by the terms of the statement; and ii. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; e Notifying the Department within ten days after receiving notice under subparagraph (d)(ii) from an employee or otherwise receiving actual notice of such conviction; f Taking one of the following actions, within 30 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; and 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) 2. The sites for the performance of work done in connection with the specific agreement are listed below (list all sites; add additional pages if necessary): Address Street 200 S. Cameron Street City, State, Zip Code Hillsborough, NC 27278 Street 300 W Tryon Street City, State, Zip Code Hillsborough, NC 27278 Contract Number 00027858 / Page 27 of 33 Street 2501 Homestead Road City, State, Zip Code Chapel Hill, NC 27514 Street 113 S. Mayo Street City, State, Zip Code Hillsborough, NC 27278 Street 100 W. Rosemary Street City, State, Zip Code Chapel Hill, NC 27514 Street 110 W. Main Street City, State, Zip Code Carrboro, NC 27510 Street 2505 Homestead Road City, State, Zip Code Chapel Hill, NC 27514 3 Provider will inform the Department of any additional sites for performance of work under this agreement 4. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination of grants, or government -wide Federal suspension or debarment. 45 C F.R. 82 510 Ill. Certification Regarding Environmental Tobacco Smoke Public Law 103 -227, Part C- Environmental Tobacco Smoke, also known as the Pro - Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local govemments, by Federal grant, contract, loan, or loan guarantee, The law does not apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day and /or the imposition of an administrative compliance order on the responsible entity.. The Provider certifies that it will comply with the requirements of the Act. The Provider further agrees that it will require the language of this certification be included in any subawards that contain provisions for children's services and that all subgrantees shall certify accordingly. Contract Number 00027858 / Page 28 of 33 IV.. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions Instructions [The phrase "prospective lower tier participant" means the Provider.] 1. By signing and submitting this document, the prospective lower tier participant is providing the certification set out below.. 2 The certification in this clause is a material representation of the fact upon which reliance was placed when this transaction was entered into If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originate may pursue available remedies, including suspension and/or debarment. 3 The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4 The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations. 5 The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended, determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the department or agency with which this transaction originated, 6. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - -Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List 8 Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9 Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension, and /or debarment Certification 1 The prospective lower tier participant certifies, by submission of this document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. 2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Contract Number 00027858 / Page 29 of 33 V. Certification Regarding Lobbying The Provider certifies, to the best of his or her knowledge and belief, that: 1.. No Federal 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 agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2 If any funds other than Federal 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, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form SF -LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. 3: The undersigned shall require that the language of this certification be included in the award document for subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) who receive federal funds of $100,000.00 or more and that all subrecipients shall certify and. disclose accordingly 4. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000,00 and not more than $100,000 00 for each such failure Vi. Disclosure Of Lobbying Activities Instructions This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C.. section 1352 The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF -LLL -A Continuation Sheet for additional information if the space on the form is inadequate Complete all items that apply for both the initial filing and material change report, Refer to the implementing guidance published by the Office of Management and Budget for additional information.. 1. Identify the type of covered Federal action for which lobbying activity is and /or has been secured to influence the outcome of a covered Federal action 2 Identify the status of the covered Federal action 3. Identify the appropriate classification of this report. If this is a follow -up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred Enter the date of the last previously submitted report by this reporting entity for this covered Federal action 4. Enter the full name, address, city, state and zip code of the reporting entity Include Congressional District, if known Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub - award recipient. Identify the tier of the subawardee, e.g.., the first subawardee of the prime is the 1st tier Subawards include but are not limited to subcontracts, subgrants and contract awards under grants 5.. If the organization filing the report in Item 4 checks "Subawardee ", then enter the full name, address, city, state and zip code of the prime Federal recipient Include Congressional District, if known. 6.. Enter the name of the Federal agency making the award or loan commitment Include at least one organizational level below agency name, if known For example, Department of Transportation, United States Coast Guard. Contract Number 00027858 / Page 30 of 33 7. Enter the Federal program name or description for the covered Federal action (Item 1).. If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8 Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e g., Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant, or loan award number, the application /proposal control number assigned by the Federal agency). Include prefixes, e g, "UP-DE-90-00I.." 9.. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5. 10.. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in Item 4 to influence the covered Federal action (b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name and Middle Initial (MI) 11 Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or wiil be made (planned) Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made 12 Check the appropriate boxes. Check all boxes that apply If payment is made through an in -kind contribution, specify the nature and value of the in -kind payment 13 Check the appropriate boxes. Check all boxes that apply, If other, specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.. 15. Check whether or not a SF -LLL -A Continuation Sheet(s) is attached. 16 The certifying official shall sign and date the form, print his/her name, title, and telephone number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D. C. 20503 Disclosure Of Lobbying Activities Contract Number 00027858 / Page 31 of 33 (Approved by OMB 0344 -0046) Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1362 1. Type of Federal Action: 2 Status of Federal Action: 3 Report Type: ❑ a.. contract ❑ a, Bidlofferlapplication ❑ a. initial filing ❑ b. grant ❑ b Initial Award ❑ b. material change ❑ c. cooperative agreement ❑ c Post -Award ❑ d loan For Material Change Only: ❑ e. loan guarantee ❑ f. loan insurance Year Quarter Date Of Last Report: 4 Name and Address of Reporting Entity: 5.. If Reporting Entity in No.. 4 is Subawardee, Enter Name and Address of Prime: ❑ Prime ❑ Subawardee Tier (if known) Congressional District (f known) Congressional District (if known) 6. Federal Department/Agency: 7. Federal Program Name /Description: CFDA Number (if applicable) 8 Federal Action Number (if known) 9. Award Amount (if known) $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, Ml): different from No 10a ) (last name, first name, M0: (attach Continuation Sheets) SF-UL-A, if necessary) (attach Continuation Sheet(s) SF-UL-A, if necessary) 11. Amount of Payment (check all that apply): 13.. Type of Payment (check all that apply): $ actual planned ❑ a. retainer ❑ b one -time fee 12 Form of Payment (check all that apply): ❑ c commission ❑ d. contingent fee ❑ a cash ❑ e.. deferred ❑ b. In -kind; specify: Nature ❑ f. other, specify: Value 14 Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11 (attach Continuation Sheets) SF -LLL A, if necessary): 15. Continuation Sheet(s) SF -LLL -A attached: ❑ Yes ❑ No 16. Information requested through this form is authorized by Signature: title 31 U.. S. C section 1352. This disclosure of lobbying activities is a material representation of fact upon which Print Name: reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required Title: pursuant to 31 U. S C. 1352 This information will be reported to the Congress semi - annually and will be Telephone No: Date: available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Authorized for Local Reproduction Standard Form - LLL Contract Number 00027858 / Page 32 of 33 Contractor Certifications Required by North Carolina Law Instructions The person who signs this document should read the text of the statutes cited herein and consult with counsel and other knowledgeable persons before signing. The text of G..S.. 143 -59..1 can be found online at: http: / /www.ncea. state. nc. us/ FnactedLe. islation /Statutes/PDFBySection/ChUter 143/GS 143- 59.1.pdf The text of G.S.. 143 -59.2 can be found online at: htip: / /www.ncga. state. nc. us/ EnactedLeg islation /Statutes/PDFBySection/Chapter 143/GS 143 -59.2. coif The text of G..S 105- 164..8(b) can be found online at: http: / /www.ncea. state. nc. us/ EnactedLe= islation /Statutes/PDFBySection/Chapter 105 /GS 105- 164.3.pdf Certifications (1) Pursuant to G.S. 143- 591(b), the undersigned hereby certifies that the Contractor named below is not an "ineligible Contractor" as set forth in G.S.. 143- 59..l(a) because: (a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 105- 164.8(b); and (b) [check one of the following boxes] ® Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven country" as set forth in G.S., 143- 59..1(c)(2) after December 31, 2001; or ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a "tax haven country" as set forth in G.,S. 143- 59..1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the tax haven country. (2) Pursuant to G.S. 143- 59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or owners (if the Contractor- is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the. General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. (3) The Contractor shall require its subcontractors, if any, to make the same certifications before they perform any work under the contract. (4) The undersigned hereby certifies further that: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor; and Page 1 of 2 Contract Number 00027858 / Page 33 of 33 (c) He or she understands that any person who knowingly submits a false certification shall be guilty of a Class T felony.. Orange County, NC Contractor's _Name n -, Signature of Contract s uthor zed Agent Date / l r 7 ti - 1 Printed Name o ontractor's Authorized`Agent Title . Signature of ALN itness }� Title a— -C--) Y`-' //1 - /Z Printed Name of Witness Date The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter Page 2 of 2