HomeMy WebLinkAbout2013-532 NS DSS - NCDHHS for Homeless Grant $116,011 Contract Number 00029953/Page 1 of 33
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GENERAL CONTRACT COVER
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
(http://dhhsopenwindow.nc.gov/index.aspx?pid=doc Reference Documents).
(a) Travel: Policies Governing Travel Related Expenses for Contractors
(b) General Statutes G.S.143C6 NonState Entities Receiving State Funds
(c) 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 1/1/2014 and shall terminate on 9/30/2014, 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 $116,011. This amount consists of$0 in State funds, $0 in Local funds, $0 in Other funds
and$116,011 in Federal funds.
The total contract amount is$116,011.
NCDHHS GCT1007 (Contract) (General) (Rev. 9/12)
Contract Number 00029953/Page 2 of 33
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. Reversion of Unexpended Funds:
Any unexpended grant funds shall revert to the Division upon termination of this contract.
9. 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.
10. Reporting Requirements:
The Division has determined that this is a contract for financial assistance, and therefore 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.
11. 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.
12. 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 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.
NCDHHS GCT1007(Contract) (General)(Rev. 9/12)
Contract Number 00029953/Page 3 of 33
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: ()--
Email: Michael.Leach dhhs.nc.gov
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Sharron Hinton, Human Services Manager, Sharron Hinton, Human Services Manager,
Dept. of Social Services Dept. of Social Services
Orange County Orange County
PO Box 8181 PO Box 8181
Hillsborough, NC 27278 Hillsborough, NC 27278
Telephone: (919)-245-2840
Fax: ()--
Email: shintonQorangecountync.gov
13. 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.
14. 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.
15. 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.
16. Signature Warranty:
NCDHHS GCT1007 (Contract) (General) (Rev. 9/12)
Contract Number 00029953/Page 4 of 33
The undersigned represent and warrant that they are authorized to bind their principals to the
terms of this agreement.
17. 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 00029953/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.
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Dennis Streets Director
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NCDHHS GCT1007 (Contract) (General) (Rev. 9/12)
Contract Number 00029953/ 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. 10.15.13)
Contract Number 00029953/Page 7 of 33
strikes, civil insurrection, earthquake, hurricane, tornado,
or other catastrophic natural event or act of God. For additional information regarding the specific
requirements and exemptions, vendors and contractors
Survival of Promises: All promises, requirements, are encouraged to review Governor Perdue's October 1,
terms, conditions, provisions, representations, 2009 Executive Order 24 and G.S. Sec. 133-32.
guarantees, and warranties contained herein shall
survive the contract expiration or termination date unless To find Governor Perdue's October 1, 2009 Executive
specifically provided otherwise herein, or unless Order 24:
superseded by applicable Federal or State statutes of
limitation. Go to http://www.governor.state.nc.us/;
• Click on"Newsroom";
Intellectual Property Rights Click on "Executive Orders and Proclamations";
• Scroll down and click on the words"click here"in
Copyrights and Ownership of Deliverables: All the sentence that states, "To view previous
deliverable items produced pursuant to this contract are Executive Orders, please click here;"and
the exclusive property of the Division. The Contractor Scroll down and click on "EO 24: Gift Ban."
shall not assert a claim of copyright or other property
interest in such deliverables.
Confidentiality
Compliance with Applicable Laws
Confidentiality: Any information, data, instruments,
Compliance with Laws: The Contractor shall comply documents, studies or reports given to or prepared or
with all laws, ordinances, codes, rules, regulations, and assembled by the Contractor under this agreement shall
licensing requirements that are applicable to the conduct be kept as confidential and not divulged or made
of its business, including those of federal, state, and available to any individual or organization without the
local agencies having jurisdiction and/or authority. prior written approval of the Division. The Contractor
acknowledges that in receiving, storing, processing or
Equal Employment Opportunity: The Contractor shall otherwise dealing with any confidential information it will
comply with all federal and State laws relating to equal safeguard and not further disclose the information
employment opportunity. except as otherwise provided in this contract.
Oversight
Health Insurance Portability and Accountability Act
(HIPAA):The Contractor agrees that, if the Division Access to Persons and Records: The State Auditor
determines that some or all of the activities within the shall have access to persons and records as a result of
scope of this contract are subject to the Health all contracts or grants entered into by State agencies or
Insurance Portability and Accountability Act of 1996, P.L. political subdivisions in accordance with General Statute
104-91, as amended ("HIPAA"), or its implementing 147-64.7. Additionally, as the State funding authority,
regulations, it will comply with the HIPAA requirements the Department of Health and Human Services shall
and will execute such agreements and practices as the have access to persons and records as a result of all
Division may require to ensure compliance. contracts or grants entered into by State agencies or
political subdivisions.
Executive Order#24: By Executive Order 24, issued
by Governor Perdue on October 1, 2009, and N.C. G.S.§ Record Retention: Records shall not be destroyed,
133-32, it is unlawful for any vendor or contractor( i.e. purged or disposed of without the express written
architect, bidder, contractor, construction manager, consent of the Division. State basic records retention
design professional, engineer, landlord, offeror, seller, policy requires all grant records to be retained for a
subcontractor, supplier, or vendor), to make gifts or to minimum of five years or until all audit exceptions have
give favors to any State employee of the Governor's been resolved, whichever is longer. If the contract is
Cabinet Agencies(i.e., Administration, Commerce, subject to Federal policy and regulations, record
Correction, Crime Control and Public Safety, Cultural retention may be longer than five years. Records must
Resources, Environment and Natural Resources, Health be retained for a period of three years following
and Human Services, Juvenile Justice and Delinquency submission of the final Federal Financial Status Report,
Prevention, Revenue, Transportation, and the Office of if applicable, or three years following the submission of a
the Governor). This prohibition covers those vendors revised final Federal Financial Status Report. Also, if
and contractors who: any litigation, claim, negotiation, audit, disallowance
action, or other action involving this Contract has been
(1) have a contract with a governmental agency; or started before expiration of the five-year retention period
(2) have performed under such a contract within the described above, the records must be retained until
past year; or completion of the action and resolution of all issues
(3) anticipate bidding on such a contract in the which arise from it, or until the end of the regular five-
future. year period described above, whichever is later. The
NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10.15.13)
Contract Number 00029953/Page 8 of 33
record retention period for Temporary Assistance for parts of the agreement and should not be used to
Needy Families (TANF) and MEDICAID and Medical construe the meaning thereof.
Assistance grants and programs must be retained for a
minimum of ten years. Time of the Essence: Time is of the essence in the
performance of this contract.
Miscellaneous
Key Personnel: The Contractor shall not replace any of
Choice of Law: The validity of this contract and any of the key personnel assigned to the performance of this
its terms or provisions, as well as the rights and duties of contract without the prior written approval of the Division.
the parties to this contract, are governed by the laws of The term "key personnel' includes any and all persons
North Carolina. The Contractor, by signing this contract, identified as such in the contract documents and any
agrees and submits, solely for matters concerning this other persons subsequently identified as key personnel
Contract, to the exclusive jurisdiction of the courts of by the written agreement of the parties.
North Carolina and agrees, solely for such purpose, that
the exclusive venue for any legal proceedings shall be Care of Property: The Contractor agrees that it shall be
Wake County, North Carolina. The place of this contract responsible for the proper custody and care of any
and all transactions and agreements relating to it, and property furnished to it for use in connection with the
their situs and forum, shall be Wake County, North performance of this contract and will reimburse the
Carolina, where all matters, whether sounding in Division for loss of, or damage to, such property. At the
contract or tort, relating to the validity, construction, termination of this contract, the Contractor shall contact
interpretation, and enforcement shall be determined. the Division for instructions as to the disposition of such
property and shall comply with these instructions.
Amendment: This contract may not be amended orally
or by performance. Any amendment must be made in Travel Expenses: Reimbursement to the Contractor for
written form and executed by duly authorized travel mileage, meals, lodging and other travel expenses
representatives of the Division and the Contractor. The incurred in the performance of this contract shall not
Purchase and Contract Divisions of the NC Department exceed the rates published in the applicable State rules
of Administration and the NC Department of Health and or approved local government travel policy. International
Human Services shall give prior approval to any travel shall not be reimbursed under this contract.
amendment to a contract awarded through those offices.
Sales/Use Tax Refunds: If eligible, the Contractor and
Severability: In the event that a court of competent all subcontractors shall: (a) ask the North Carolina
jurisdiction holds that a provision or requirement of this Department of Revenue for a refund of all sales and use
contract violates any applicable law, each such provision taxes paid by them in the performance of this contract,
or requirement shall continue to be enforced to the pursuant to G.S. 105-164.14; and (b) exclude all
extent it is not in violation of law or is not otherwise refundable sales and use taxes from all reportable
unenforceable and all other provisions and requirements expenditures before the expenses are entered in their
of this contract shall remain in full force and effect. reimbursement reports.
Headings: The Section and Paragraph headings in Advertising: The Contractor shall not use the award of
these General Terms and Conditions are not material this contract as a part of any news release or
commercial advertising.
NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10.15.13)
Contract Number 00029953/ Page 9 of 33
Scope of Work
ESG Emergency Response and Housing Stability Activities
BACKGROUND
On any given night,North Carolina has over 10,000 homeless people. Across the State,
homelessness affects more than 500 families including men,women and children who
experience financial difficulty and cannot recover. Families and individuals who are at or
below 30% area median income are served through this grant and are vulnerable and
cannot survive even a small financial crisis. The ESG program is designed to help
persons who are homeless and persons who are at-risk of homelessness.
The Emergency Solutions Grant(ESG) was created in the Homeless Emergency
Assistance and Rapid Transition to Housing (HEARTH)Act which combines the
previous Emergency Shelter Grant and the previous Homelessness Prevention and Rapid
Re-Housing programs under one federal act designed to prevent or end homelessness.
The ESG program is intended to assist people in preventing or ending their homelessness
through two primary functions: Emergency Response Activities, such as funding
emergency shelter operations and services and street outreach and Housing Stability
Activities, such as homeless prevention and rapid re-housing. Funds can also be used for
HMIS participation and administration. All contractors are expected to use ESG funds in
accordance with the grant regulations contained in 24 CFR Parts 91 and 576.
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. The Housing and Homelessness Unit
operates the Emergency Solutions Grant.
PURPOSE
The ESG Contractor is responsible for completing tasks from a menu of federally eligible
services. The ESG grant will support:
1. Emergency Response activities through:
• Operating expenses for homeless shelters,
• Services provided to residents of homeless shelters
2. Housing Stability activities through:
• Housing stability case management
• Providing flexible cash assistance for deposits,rent,utilities and/or past due
rent and utilities
The Contractor will ensure that both activities above are provided in Orange County.
The Contractor will provide services or shelter to homeless individuals and/or families
for the period during which the ESG assistance is provided,without regard to a particular
site or structure, so long as the Contractor serves the same type of persons (e.g., families
with children, unaccompanied youth,disabled individuals, or victims of domestic
violence) or persons in the same geographic area.
Contract Number 00029953/Page 10 of 33
The Contractor will assist homeless individuals in obtaining permanent housing,
appropriate supportive services(including medical and mental health treatment,
counseling supervision, and other services essential for achieving independent living),
and other Federal, State, local, and private assistance available for such individuals.
SCOPE OF WORK
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 all ESG trainings provided during the fiscal year
Type of Position Type of Required Training
Housing Stability Case Manager and Webinar/Conference Call
Supervisors
Grant Managers Webinar/Conference Call
CHIN data entry Face to Face
Financial Processing/Fiscal Webinar/Conference Call
Emergency Services Case Manager Webinar/Conference Call
Documentation: Copy of certificate.of training completion or training sign-in sheets
and sign off that all staff are trained within the time frame.
II. Eligibility Screening and Intake
For Emergency Response activities,the Contractor 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. The Contractor will only provide
ESG funded services to eligible participants. If the Contractor provides services to
ineligible participants using ESG funds or ESG matching funds the Contractor will
reimburse the State for those funds from a non-ESG funding source.
For Housing Stability activities,the Contractor will engage in ESG intake and re-
certification process that complies with federal and state guidance about documenting
all U.S. Department of Housing and Urban Development(HUD) eligibility criteria,
including,but not limited to using forms documenting housing status and, income
eligibility, and financial and social supports available to prevent homelessness. The
Contractor will only provide ESG funded services to eligible participants. If the
Contractor provides services to ineligible participants using ESG funds or ESG
matching funds,the Contractor 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 activities,the Contractor will have 3.5 months from execution
of contract to ramp-up to full case loads. By March 2014 Contractor caseloads
should be a minimum of 12 households per full-time rapid re-housing caseworker for
an agency serving multiple counties. The caseload should be a minimum of 25
Contract Number 00029953/Page 11 of 33
households per full-time rapid re-housing caseworker 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
IV. Financial Assistance Documentation
For Housing Stability activities,the Contractor 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 utility in the recipient's name, unit inspection, and assurance of
tenancy.
Documentation: Participant file and Reimbursement Requests
V. Recertification
For Housing Stability activities,the Contractor will be responsible for recertification
of any rapid re-housing household that is to receive more than 12 months of services.
Contractor is responsible for recertification for any prevention households every 3
months of service. 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)
The Contractor is responsible for ensuring that all staff involved in CHIN data entry
or CHIN data monitoring shall participate in ESG CHIN training and DHHS will seek
assurance through documentation that all staff was trained. 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. The Contractors 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 The Contractors 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
VII. Eligible Expenditures
Contract Number 00029953/Page 12 of 33
1. For Emergency Response Programs
i. Street Outreach
1. Engagement
2. Case management
3. Emergency health services
4. Emergency mental health services
5. Transportation
6. Services for special populations including: homeless youth,
victim services,and persons with HIV/AIDS
ii. Emergency Shelter
1. Case management
2. Child care
3. Education services
4. Employment assistance and job training
5. Outpatient health services
6. Legal services
7. Life skills training
8. Mental health services
9. Substance abuse treatment services
10. Transportation
11. Services for special populations including: homeless youth,
victim services,and persons with HIV/AIDS
12. Shelter operations
a. Maintenance
b. Rent
c. Security
d. Fuel
e. Equipment
f. Insurance
g. Utilities
h. Food
i. Furnishings
j. Supplies necessary for the operation of the
emergency shelter
2. For Housing Stability Programs
i. Financial Assistance
1. Rental application fees
2. Security deposits
3. Last month's rent
4. Utility deposits
5. Utility payments
6. Moving costs
ii. Services
1. Housing search and placement
2. Housing stability case management
3. Mediation
4. Legal services
5. Credit repair
Contract Number 00029953/Page 13 of 33
iii. Rent assistance
3. Systems Coordination
1. Coordinated Intake
2. HMIS
a. Staffing
b. Equipment
The Contractor may only spend funds in categories that were applied for in the NC
ESG application that was submitted to the State prior to the contracting period
January 1, 2014-September 30, 2014.
PERFORMANCE MONITORING/QUALITY ASSURANCE PLAN
I. Spending Rates
A. Contractors must expend 100% of funds and 100%of the matching funds by
September 30, 2014.
B. Contractors are allowed to spend 100%of funds before September 30, 2014.
Documentation: DHHS Fiscal reports
II. Monitoring
For Housing Stability activities,the Contractor will make electronic or paper copies
of intake forms and eligibility screening criteria for a minimum of the first 5 cases
enrolled and the 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 Unit of the Division of Aging and
Adult Services: Housing and Homelessness-DAAS-DHHS; 2101 MSC, Raleigh,NC
27699-2101. Copies of additional files may be requested.
For all activities,the Contractor 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)
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.
iii. For Housing Stability activities only: 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.
Contract Number 00029953/Page 14 of 33
Frequency of monitoring visits may be based on performance as documented in
CHIN and additional risk factors as identified in previous Contractor performance,
grant application forms, and monitoring reports from other state and federal agencies.
It is expected that contractors meet 75%or more of program standards on annual
monitoring.
Documentation: Monitoring reports and participant files
III. Reporting
A. Contractors 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. Contractors will be responsible for all other information required for federal
reporting. Contractors will be notified of these reporting requirements as federal
guidance is provided.
C. Contractors will be responsible for submission of semi-annual reports to the State.
Documentation: CHIN Reports;Annual reports, Semi-Annual reports
REIMBURSEMENTS
A. The Contractor will submit reimbursement requests to the N.C. Department of
Health and Human Services, Division of Aging and Adult Services—Housing and
Homelessness Unit using forms supplied by the State with required
documentation of expenses (copies of invoices/bills/receipts) and proof of
payment(copies of ledgers or copies of checks used to pay expenses).
Contractor will maintain additional required documentation in household
(participant)files and in the CHIN system. Reimbursement requests will be
verified against documentation of expenses and proof of payments and may be
verified against data in CHIN before payment is made.
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 Contractor staff will require timesheets or documentation of
indirect cost rates.
C. Reimbursement for any activities for which the Contractor sub-contracts will
require a paid invoice for reimbursement from the state. The Contractor will be
responsible for all funds allocated to a sub-contractor. If funds are misused by a
sub-contractor,the Contractor will reimburse the state with another funding
source.
Contract Number 00029953/Page 15 of 33
Documentation: Reimbursement forms, reimbursement documentation, CHIN
reports,participant files,timesheets or documentation of indirect cost rates, cost
allocation plans, copies of paid invoices/bills/receipts and copies of ledgers or checks
used to pay invoices/bills/receipts.
OTHER FEDERAL REQUIREMENTS
I. Homeless Participation
A homeless or formerly homeless person must participate to the fullest extent possible in
the development of ESG-funded programs and policies set forth by the Department of
Housing and Urban Development(HUD).
Additionally, to the maximum extent practicable, the Contractor will involve, through
employment, volunteer services, or otherwise, homeless individuals and families in
maintaining and operating facilities assisted under ESG, and in providing services for
occupants of facilities assisted under ESG.
II. Accessibility of Spaces, Services and Activities
Contractor shall operate each existing program or activity receiving federal financial
assistance so that the program or activity, when viewed in its entirety, is equally
accessible to and usable by individuals with disabilities as by persons without disabilities.
III. Property Standards
All dwelling units that are a part of an ESG-funded activity shall meet minimum
habitability standards set by HUD. Shelters facilities are also required to meet state or
local government safety and sanitation standards, as applicable, including energy-
efficient appliances and materials.
IV. Lead-based Paint
All shelters assisted under the ESG program and all housing occupied by program
participants must adhere to the requirements of the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. 4821-4846), the Residential Lead-Based Paint Hazard
Reduction Act of 1992 (42 U.S.C. 4851-4856), and implementing regulations in 24 CFR
part 35, subparts A, B, H, J, K, M, and R. Such regulations pertain to all HUD-assisted
housing and require that all owners, prospective owners, and tenants of properties
constructed prior to 1978 be properly notified that such properties may include lead-
based paint. Such notification shall point out the hazards of lead-based paint and explain
the symptoms, treatment and precautions that should be taken when dealing with lead-
based paint poisoning and the advisability and availability of blood lead-level screening
for children under seven. The notice should also point out that if lead-based paint is
found on the property, abatement measures may be undertaken. The regulations further
require that, depending on the amount of Federal funds applied to a property, paint
testing,risk assessment,treatment and/or abatement may be conducted.
V. Termination of Services
Contractor shall ensure that if a participant violates program requirements, services will
be terminated in accordance with a formal written procedure established by the
Contractor that recognizes the rights of the individual affected. This policy shall include
Contract Number 00029953/Page 16 of 33
the option for reinstatement, under proscribed circumstances, as dictated by the Interim
Rule.
VI. Grievance Hearings
The Contractor shall establish a formal, written procedure to address grievances and shall
inform applicants and participants of their right to an appeal. The appeals policy must be
posted and must allow for appeals to be requested in writing and verbally.
VII. Conflicts of Interest
The Contractor must keep records to show compliance with the organizational conflicts-
of-interest requirements in 24 CFR §576.404(a), a copy of the personal conflicts of
interest policy or codes of conduct developed and implemented to comply with the
requirements in 24 CFR §576.404(b), and records supporting exceptions to the personal
conflicts of interest prohibitions.
The Contractor agrees to abide by the provisions of 24 CFR 84.42 and §576.404, which
include (but are not limited to)the following:
a. The Contractor shall maintain a written code or standards of conduct that shall
govern the performance of its officers, employees or agents engaged in the award and
administration of contracts supported by Federal funds.
b. No employee, officer or agent of the Contractor shall participate in the selection, or
in the award, or administration of, a contract supported by Federal funds if a conflict
of interest,real or apparent,would be involved.
c. No covered persons who exercise or have exercised any functions or
responsibilities with respect to HUD-assisted activities, or who are in a position to
participate in a decision-making process or gain inside information with regard to
such activities, may obtain a financial interest in any contract, or have a financial
interest in any contract, subcontract, or agreement with respect to the HUD-assisted
activity, either for themselves or those with whom they have business or immediate
family ties, during their tenure or for a period of one (1)year thereafter. For purposes
of this paragraph, a"covered person" includes any person who is an employee, agent,
consultant, officer, or elected or appointed official of the Grantee, the Contractor, or
any designated public agency.
The Contractor shall permit no officer or employee of the Contractor, no member of the
Contractor's governing body and no other public official of any governing body in its
County or the State of North Carolina area to exercise any functions or responsibilities in
the review or approval of the undertaking or carrying out of this project to (1) participate
in any discussion relating to this Contract if it affects his or her personal interest or the
interest of any corporation, partnership or association in which he or she is directly or
indirectly interested; or (2) have any interest, direct or indirect, in this Contract or the
proceeds thereof.
The Contractor shall permit no members of or delegates to the Congress of the United
States to be admitted to any share or part thereof or to any benefit to arise here from. The
Contract Number 00029953/Page 17 of 33
Contractor covenants that it presently has no interest and shall not acquire any interest,
direct or indirect, which would conflict in any manner or degree with the performance or
services required to be performed under this Contract. The Contractor further covenants
that no person having any such interest shall be employed in the performance of this
Contract. The Contractor shall make no loans to its directors or officers.
The Contractor shall be subject to and shall comply with the conflict of interest
provisions of the federal regulations as published at 24 CFR Part 570.611, 24 CFR Part
84.42 and 24 CFR Part 85.36.
VIII. Fair Housing Act Compliance Certification
The Contractor hereby warrants that it does not have any Fair Housing Discrimination
complaints pending against it. The Contractor also agrees that should any Fair Housing
Discrimination complaint be lodged against it during the term of this Contract, it will
immediately notify the Grantee in writing of the occurrence.
STANDARDS OF CONDUCT:
I. Procurement
HUD procurement standards found at 24 CFR 85.36, and OMB Circular A-110, Subpart
C are hereby incorporated into this contract by reference.
II. Faith-based activities
The Contractor agrees that funds provided under this Agreement will not be utilized for
inherently religious activities prohibited by 24 CFR§576.406.
III. HMIS Reporting
The Contractor shall report client-level data in a Homeless Management Information
System (HMIS) or a comparable database in accordance with HUD's standards on
participation, data collection, and reporting. If the Contractor is a victim service provider,
it may use a comparable database that collects client-level data over time and generates
duplicated aggregate reports based on the data.
IV. Match Requirements:
ESG funds are subject to a dollar for dollar match. The match can be obtained from any
source, including any Federal, state, local, and private sources. Ineligible sources include:
ESG funds and funds used to match another Federal program. Cash or noncash
contributions (i.e. donated material/property, $5 hour rate of volunteerism) are also
eligible.
In accordance with the terms of the grant contract, the Contractor shall document match
set aside under this Contract. The State requires submission of all match documentation
at the end of each program year. Contractors will submit copies of financial ledger,
checks and/or bank deposits from donations, documentation of volunteer hours and in-
kind services, depending on what the Contractor is using for match. Further, the
Contractor must provide proof that match expenditures support ESG eligible activities.
V. Additional Requirements
Contract Number 00029953/Page 18 of 33
Grantor reserves the right to impose any additional requirements upon Contractor, which
the Grantor shall deem reasonable or necessary for the purpose of verifying the legality
and propriety of any payment requested by the Contractor.
VI. Investigation of Noncompliant Activities
The Grantor may investigate any matter covered under this Contract and may withhold
any payments until the results of the investigation have been revealed. Reimbursement to
the Contractor will be determined upon resolution of the investigation by the Grantor.
OTHER APPLICABLE LAWS: CERTIFICATIONS AND COMPLIANCE
REQUIREMENTS
1. _x 24 CFR Part 84 Uniform Administrative Requirements for Grants and
Cooperative Agreements to Hospitals, Institutes of Higher Education and Non-profit
Organizations,which sets forth rules for administering all federal grant funds.
2. Davis Bacon Act, as amended(40 U.S.C. 276a-276a-7), and as supplemented by
Department of Labor regulations (29 CFR, Part 5), which requires fair wages be paid to
construction workers on any project that funded in whole or in part with federal dollars.
3. Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40
U.S.C. 327-333), as supplemented by the Department of Labor regulations (29CFR, Part
5), which requires affirmative nondiscrimination against workers and applicants for work
on construction projects funded in whole or in part with federal dollars.
4. X Title VI of the Civil Rights Act of 1964 (PL88-352) and regulations issued
pursuant thereto (24 CFR Part 1) on nondiscrimination in federally assisted programs.
5. _X_ Section 109 of the Housing and Community Development Act of 1974 and
regulations issued pursuant thereto (24 CFR Part 570.602 et seq., known as subpart K),
which requires that no person in the United States shall, on the grounds of age, race,
color, national origin, religion, disability or sex, be excluded from participation in, be
denied the benefits of, or be subjected to discrimination under any program or activity
receiving federal financial assistance
6. X Executive Order 11246 and the regulations issued pursuant thereto (41 CFR
Chapter 60) on nondiscrimination in employment.
7. Copeland "Anti Kick Back" Act (18 U.S.C. 874), which protects workers wages
on projects funded in whole or in part by federal funds.
8. Section 3 of the Housing and Urban Development Act of 1968, as amended, and
implementing regulations at 24 CFR Part 135 that sets guidelines for training and
employment of lower income residents of project areas and for awarding of contracts
within the project area.
9. X Lead Based Paint Poisoning Prohibition (Public Law 91-695), which requires
Contract Number 00029953/Page 19 of 33
that hazards posed by the presence of lead be addressed and made safe.
10. North Carolina General Statute 143-128 et seq. which proscribes procedures for
bidding and structuring contracts on publicly funded construction projects.
11. X Hatch Act(5 U.S.C. 1501-1508)prohibiting federal,state and local government
employees from benefiting from federal grants.
12. Building design, construction or alteration must comply with "American
Standard Specifications for Making Buildings and Facilities Accessible to, and Usable
by,the Physically Handicapped" (#A-117.1-R 197 1)
13. Executive Order 11296 relating to evaluation of flood hazards in areas where
construction or rehabilitation will be funded in whole or in part by federal funds.
14. Title VIII of the Civil Rights Act of 1968 (Public Law 90-284), as amended Fair
Housing Policy, which requires that no person shall be prohibited from purchasing or
renting a home based on age,race, color, national origin,religion, disability or sex.
15. X Executive Order 11063 which addresses equal opportunity in housing and non-
discrimination.
16. X Section 306 of the Clean Air Act (42 U.S.C. 1857(h)) which sets forth
monitoring and reporting procedures for any program that affects air quality.
17. Environmental Protection Agency regulations (40 CFR, Part 15), which sets
requirements for protecting the environment on federally funded projects.
18. X Age Discrimination Act of 1967, as amended.
19. X The Rehabilitation Act of 1973, as amended, Sections 503 and 504, which
prohibit discrimination against the handicapped.
20. State of North Carolina Disadvantaged Business Enterprise Plan, which requires
that opportunities for contracts to provide goods and services be made available to small
and disadvantaged businesses in Durham.
21. X OMB Circular A-122: Cost Principles for Non-Profit Organizations, which sets
forth parameters for expenditures made with federal grant money.
22. Treasury Circular 1075 relating to the use of Community Development funds
within 72 hours after drawdown, which requires that the Grantee manage the grant funds
on a specific timetable.
23. Community Development Block Grant regulations at 24 CFR 570, which
describes all requirements and prohibitions for the administration of a program funded in
whole or in part with federal Community Development Block Grant money.
Contract Number 00029953/Page 20 of 33
24. X N. C. Fair Housing Law, which prohibits discrimination against any person for
reasons of age, race, color, national origin, religion, disability or sex in all transactions
relating to buying, selling, or renting housing units.
26. X OMB Circular A-133: Audits of States, Local Governments and Nonprofit
Organizations,which sets forth requirements and methodologies for auditing programs
funded in whole or in part with federal grant money.
Contract Number 00029953/Page 21 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.
Measure, Output Frequency .- Annual
Type
Measure The contractor and/or its subcontractor will serve at least 6 households through its
rapid re-housing program and at least 144 households through emergency
--- - - -- shelter(s)during the contract period.
Year= 2014 Preferred- Other
get
Tie-
Tat- A-0 The contractor and/or its subcontractor will serve at least 6
households through its rapid re-housing program and at least 144
households through emergency shelter(s) during the contract
Y
period.
Data_S CHIN, the statewide Homeless Management Information System
Collection . Contractor and/or subcontractor staff will collect and enter data
.roce s anc�
Calculet�o
Collec>(io Daily
Frecjuncs
Measure Output Frequency Annual
y
Measure 30%of exits from emergency shelters statewide will be to permanent housing.
Yeas 2014 Preferred X. Increase
T 36%of exits from emergency shelter are to permanent housing.
R_ CHIN, the statewide Homeless Management Information System
CQI 'o Contractor and/or subcontractor staff will collect and enter data
°P_ e
Ga
C - o Daily
Measure Output egncy Annual
�
Type
Measure, 80%of exits from rapid re-housing programs statewide will be to permanent
housing.
Y 2014 P.re a red Other
Performance Measures(Rev. 4//12)
Contract Number 00029953/Page 22 of 33
Trend
Target Value 80%of exits from rapid re-housing program to permanent housing.
Data Source CHIN, the statewide Homeless Management Information System
Collection Contractor and/or subcontractor staff will collect and enter data
Process and
Calculation
Collection Daily
Frequency
Performance Measures (Rev. 4//12)
ContrF
LINE ITEM BUDGET
This begins the line item budget for year 2014
Budget Detail-Year 2014
Category Item Narrative
Salary\Wages
Fringe Benefits
Other
Repair and Maintenance
Staff Development
Dues and Subscriptions
Subcontracts and Grants
Match
Cost Per Service
Line Item Budget Detail (08/11)
Conti
Budget Detail Year2014
Category Item Narrative
Operational Other Not Otherwise Classified Administrative Costs
Operational Other Not Otherwise Classified Rapid Re-housing Financial Assistance
Operational Other Not Otherwise Classified Emergency Shelter-Operating Costs
-------Sub Tot.
Indirect Cost
Total Budgi
Subcontracting and Grants Budget Detail -Year 2014
Category Item Narrative
Sub Tot;
Salaries -Year 2014
Persons Position or Title Annual Salary Hourly Months Work% Fringe
Rate Amount Total
p $0.00 0.0000 0 0% $0.00
Line Item Budget Detail (08/11)
COnta
Line Item Budget Detail (08/11)
FEDERAL CERTIFICATIONS Contract Number 00029953/Page 26 of 33
The undersigned states that:
1. He or she is the duly authorized representative of the Contractor named below;
2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor, 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)
[ j He or she has completed the attached Disclosure Of Lobbying Activities because the Contractor 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
He or she has not completed the attached Disclosure Of Lobbying Activities because the Contractor 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 Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
Y
Signature Title
QirQ>�lc,� _ot, D �aAmen+ r)r ie l Se_jrVi PS
Contrac r Name T- i Date
[This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page] .
1. Certification Regarding Nondiscrimination
The Contractor 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.C. §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 (P.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 Vill 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 00029953/Page 27 of 33
11. Certification Regarding Drug-Free Workplace Requirements
1. The Contractor 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 Contractor'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;
H. The Contractor'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;
I. Taking orie of the following action's; within-30 days of receiving notice under subparagraph (d)(H);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
u a Q
City, State, Zip Code
�1 sbf�Yn�a �C, 272jg
Street
?-SDI - Aumes"Ci Rd
City, State, Zipp`Code
Contract Number 00029953/ Page 28 of 33
3. Contractor will inform the Department of any additional sites for performance of work under this agreement.
4. f=alse 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.
III. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Aet), 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 governments, 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
andlor the imposition of an administrative compliance order on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act. The Contractor 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.
1V. Certification Regarding Debarment,Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase"prospective lower tier participant" means the Contractor.]
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 tower 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.
Contract Number 00029953/Page 29 of 33
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.
V. Certification Regarding Lobbying
The Contractor certifies, to the best of his or her knowledge and belief, that:
I. 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 6hy ,a ncy, a Member of Congress, an officer or emp oyee 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.
Contract Number 00029953/Page 30 of 33
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.
S. 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.
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., "RFP-DE-90-001."
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 will 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.
Contract Number 00029953 3
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
Contract Number 00029953/Page 32 of 33
State Certification
Contractor Certifications Required by North Carolina Law
instructions
The person who signs this document should read the text of the statutes fisted below and consult with counsel and other
knowledgeable persons before signing.
• The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at:
hitp:Itwww.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByATticle/Chapter WArticle 2 odf
• The text of G.S. 105-164.8(b)can be found online at:
http:/Iwww.nega.state nc uslEnactedLegislation/Statutes/PDF/BySection/Chapter 105/GS 105-164 8 ndf
• The text of G.S. 143-48.5(S.L. 2013-418,s. 2.(d))can be found online at:
http://www.nccia.state.nc.us/Sessions/2013/Bills/House/PDF/H786v6 pdf
• The text of G.S. 143-59.1 can be found online at:
htto://www.ngga.state.nc.us/EnectedLegislation/Statutes/PDF/BySection/Chapter 143/GS 143-591pdf
• The text of G.S. 143-59.2 can be found online at:
http://www.ncaa.state.nc.us/EnactedLeoislation/Statutes/PDF/BySection/Chapter 143/GS 143-59 2 pdf
• The text of G.S. 147-33.95(g)(S.L. 2013-418, s. 2.(e))can be found online at:
http://www.ncga.state,n c.us/Sessions/2013/Bills/House/PDF/H786v6 pdf
Certifications
(1) Pursuant to G.S. 14348.5 and G.S. 147-33.95(g), the undersigned hereby certifies that the Contractor named
below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC
General Statutes, including the requirement for.each..employer.with more..than.25 ernployees..in.North Carolina..to
verify the work authorization of its employees through the federal E Verify system." E-Verify System Link:
www.uscis.gov
(2) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an
"ineligible Contractor"as set forth in G.S. 143-59.1(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 aMiiates 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.
(3) 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.
(4) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the Contractor named below;
Contractor Certifications Required by North Carolina Law Page 1 of 2
Contract Number 00029953/Page 33 of 33
(b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the
Contractor; and
(C) He or she understands that any person who knowingly submits a false certification in response to the
requirements of G.S. 143-59.1and -59.2 shall be guilty of a Class I felony.
' OYamf- Cajn A rYIf !y)(-A' oc �hcl&j S-eYV14,5S
Contra4of(r'onj e 7
Signatuactor's Authorized Agent Date
hl( K" (Ad-1*1 b\Yedby-
Printed N me of Contractor's Authorized Agent Title
` y ,V\`: O M?,� MQt1Ptl�C YV1Et'1 jtl r��C�
Signature of Witness I q Title �—
R-b_ekcJo 2tlo 26 I i -1 13
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.
Contractor Certifications Required by North Carolina Law Page 2 of 2