HomeMy WebLinkAbout2016-134-E DSS - Chatham Transit Network for Medicaid transportation DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D Contract 468-2030
Chatham Transit Network
Contract# 68-2030 Fiscal Year Begins jgly I_,,2015 Ends June 30 2016
This contract is hereby entered into by and between the Orange County Department of Social Services (the "County") and
Chatham Transit Network (the "Contractor") (referred to collectively as the "Parties"). The Contractor's federal tax
identification number or Social Security Number is_.
1. Contract Documents: This Contract consists of the following documents
(1) This contract
(2) The General Terms and Conditions(Attachment A)
(3) The Scope of Work, description of services, and rate(Attachment B)
(4) Federal Certification Regarding Drug-Free Workplace&Certification Regarding Nondiscrimination(Attachment C)
(5) Conflict of Interest(Attachment D)
(6) No Overdue Taxes(Attachment E)
(7) Certification Regarding Transportation (Attachment J)
(8) IRS Federal Tax Exempt Letter or 50 1(c)(3) (Attachment K)
(9) State Certifications(Attachment M)
(10) Outcomes and Reporting(Attachment N)
(11) Contract Determination Questionnaire
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 Paragraph 1, above, with the first-listed document having the
highest precedence and the last-listed document having the lowest precedence. If there are multiple Contract
Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
3. Effective Period: This contract shall be effective on January 25, 2016 and shall terminate on June 30, 2016.
This contract must be twelve months or less.
4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in
Attachment B, Scope of Work, and shall meet the requirements set forth in Attachment N,Outcomes and Reporting,
S. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the County to the Contractor under this contract shall not exceed $10,000. This
amount consists of$10,000 in Federal (CFDA # State and County funds, $0 (source of other funds if
applicable).
[X] a. There are no matching requirements from the Contractor.
b. The Contractor's matching requirement is $ ,which shall consist of:
In-kind Cash
Cash and In-kind Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federal funds.
The total contract amount including any Contractor match shall not exceed $10,000,
6. Reversion of Funds:
Any unexpended grant funds shall revert to the County Department of Social Services upon termination of this contract.
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DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D Contract#68-2030
Chatham Transit Network
7. Reporting Requirements:
Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22 & 23 and OMB Circular—CFR
Title 2 Grants and Agreements, Part 2060, and shall disclose all information required by 42 USC 455.104, or 42 USC
455.105, or 42 USC 455.106.
8. Payment Provisions:
Payment shall be made in accordance with the Contract Documents as described in the Scope of Work,
Attachment B.
9. 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.
For the County:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Lindsey Shewmaker, Human Services Manager Lindsey Shewmaker, Human Services Manager
Orange County Department of Social Services Orange County Department of Social Services
P.O. Box 8181 113 Mayo Street
Hillsborough,NC 27278 Hillsborough,NC 27278
(919)245-2817
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For the Contractor:
IF' DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Anna Testernian
Chatham Transit Network
P.O. Box 10)2
Pittsboro,NC 27312
(919) 542-5136
10. No Assignment or Sub-Contract: Contractor shall not sub-contract out any of the services provided for in this
Agreement or make any assignment of this Agreement(including rights to payments)without the prior written Consent of
the County as specified more fully in Attachment A, General Terms and Conditions.
11. 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 Linder 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.
12. 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:
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Chatham Transit Network
i, Validity and accuracy of payment
ii. Payment due date
iii. Adequacy of documentation supporting payment
iv. 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.
13. Outsourcing to Other Countries: The Contractor certifies that it has identified to the County 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 County.
14. 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 to be signed by the contractor's authorized representative.
15. Relationship of the Parties: Contractor is an independent contractor of the County. Contractor represents that it has or
will secure,at its own expense,all personnel required in performing the services under this Agreement. Such personnel
shall not be employees of or have any contractual relationship with the County, All personnel engaged in work Linder this
Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such services.
It is further agreed by Contractor that it shall obey all State and Federal statutes,rules and regulations which are applicable
to provisions of the services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed an
officer, employee or agent of the County.
16. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the terms of this agreement.
The Contractor and the County have executed this contract in duplicate originals, with one original being retained by each
party.
Contract-General (07/10) Page 3 of 4
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DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D Contract#68-2030
Chatham Transit Network
C7M 11 SIT NETWOIIK
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(_S )A_ 2/3/2016
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Signature Date
Anna Executive Director
Printed Name Title
ORANGE COUNTY
EDocuSigned by:
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Bonnie Harnmersley, County Manager Date
This, been approved as to technical content.
Nancy Coston, Department of Social Services Director Date
This it i ma%tAa�:been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act.
7
rl 2/3/2016
I
'T'I Date
Gary Donaldson Chief Financial Officer
Thic=gj ,been approved as to form and legal sufficiency.
2/3/2016
Annette'M' Dare,'Staff Attorney, County Attorney's Office Date
Contract-General (07/10) Page 4 of 4
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham.Transit Network
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services
Relationships of the Parties and Contractor that any such person or entity, other than
the County or the Contractor,receiving services or benefits
Independent Contractor: The Contractor is and shall be under this contract shall be deemed an incidental
deemed to be an independent contractor in the performance beneficiary only.
of this contract and as such shall be wholly responsible for
the work to be performed and for the supervision of its Indemnity and Insurance
employees. The Conti-actor represents that it has, or shall
secure at its own expense, all personnel required in Indemnification: The Contractor agrees to indemnify and
performing the services under this agreement. Such hold harmless the County and any of their officers,agents
employees shall not be employees of, or have any and employees,from any claims of third parties arising out
individual contractual relationship with the County. or any act or omission of the Contractor in connection with
the performance of this contract.
Subcontracting: The Contractor shall not subcontract any
of the work contemplated under this contract without prior Insurance: During the term ofthe contract,the Contractor
written approval from the County. Any approved at its sole cost and expense shall provide commercial
subcontract shall be subject to all conditions of this insurance of such type and with such terms and limits as
contract.Only the subcontractors specified in the contract may be reasonably associated with the contract. As a
documents are to be considered approved upon award of minimurn, the Contractor shall provide and maintain the
the contract, The County shall not be obligated to pay for following coverage and limits:
any work performed by any unapproved subcontractor. (a) Worker's Compensation - The contractor shall
The Contractor shall be responsible for the performance of provide and maintain Worker's Compensation
all of its subcontractors. Insurance as required by the laws of North
Carolina,as well as employer's yer,s liability coverage
Assignment: No assignment of the Contractor's with minimum limits of$500,000,00,covering all
obligations or the Contractor's right to receive payment of Contractor's employees who are engaged in any
hereunder shall be permitted. However, upon written work tinder the contract. If any work is sublet,the
request approved by the issuing purchasing authority,the Contractor shall require the subcontractor to
County may: provide the same coverage for any of his
(a) Forward the Contractor's payment check(s) employees engaged in any work under the
directly to any person or entity designated by the contract.
Contractor,or (b) Commercial General Liability - General
(b) Include any person or entity designated by Liability Coverage on a Comprehensive Broad
Contractor as a Joint payee on the Contractor's Form oil an occurrence basis in the minimum
payment check(s). amount of$1,000,000.00 Combined Single Limit.
In no event shall such approval and action obligate the (Defense cost shall be in excess of the limit of
County to anyone other than the Contractor and the liability.)
Contractor shall remain responsible for fulfillment of all (c)Automobile Liability Insurance: The Contractor
contract obligations. shall provide automobile liability insurance with a
combined single limit of$500,000.00 for bodily
Beneficiaries: Except as herein specifically provided injury and property damage; a limit of
otherwise,this contract shall inure to the benefit of and be $500,000.00 for uninsured/under insured motorist
binding upon the parties hereto and their respective coverage; and a limit of$25,000.00 for medical
successors. It is expressly understood and agreed that the payment coverage. The Contractor shall provide
enforcement of the terms and conditions of this contract, this insurance for all automobiles that are:
and all rights of action relating to such enforcement, shall (a) owned by the Contractor and used in the
be strictly reserved to the County and the named performance of this contract;
Contractor.Nothing contained in this document shall give (b) hired by the Contractor and used in the
or allow any claim or right of action whatsoever by any performance of this contract; and
other third person. It is the express intention of the County
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DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
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Chatham Transit Network
(c) Owned by Contractor's employees and The contractor will maintain Insurance requirements if
used in performance of this contract("non- required as noted under Article 7 Rule i22-36 of the North
owned vehicle insurance"). Non-owned Carolina Utilities Commission.
vehicle insurance protects employers when
employees use their personal vehicles for Default and Termination
work purposes. Non-owned vehicle
insurance supplements, but does not Termination Without Cause: The County may terminate
replace,the car-owner's liability insurance. this contract without cause by giving 30 days written
notice to the Contractor.
The Contractor is not required to provide and maintain
automobile liability insurance on an),vehicle—owned, Termination for Cause: If, through any cause, the
hired, or non-owned --unless the vehicle is used in the Contractor shall fail to fulfill its obligations under this
performance of this contract. contract in a timely and proper manner, the County shall
(d) The insurance coverage minimums specified in have the right to terminate this contract by giving written
subparagraph (a)are exclusive of defense costs. notice to the Contractor and specifying the effective date
(e) The Contractor understands and agrees that the thereof. In that event,all finished or unfinished deliverable
insurance coverage minimums specified in items prepared by the Contractor under this contract shall,
subparagraph (a) are not limits, or caps, on the at the option of the County, become its property and the
Contractor's liability or obligations under this contract. Contractor shall be entitled to receive just and equitable
(f) The Contractor may obtain a waiver of any one or more compensation for any satisfactory work completed on such
of the requirements in subparagraph (a) by materials,minus any payment or compensation previously
demonstrating that it has insurance that provides made. Notwithstanding the foregoing provision, the
protection that is equal to or greater than the coverage Contractor shall not be relieved of liability to the County
and limits specified in subparagraph (a). The County for damages sustained by the County by virtue of the
shall be the sole judge of whether such a waiver Contractor's breach of this agreement,and the County may
should be granted. withhold any payment due the Contractor for the purpose
(g) The Contractor may obtain a waiver of any one or more of setoff until such time as the exact amount of damages
of the requirements in paragraph(a)by demonstrating due the County from such breach can be determined. In
that it is self-insured and that its self-insurance case of default by the Contractor, without limiting any
provides protection that is equal to or greater than the other remedies for breach available to it,the County may
coverage and limits specified in subparagraph(a). The procure the contract services from other sources and hold
County shall be the sole judge of whether such a the Contractor responsible for any excess cost occasioned
waiver should be granted. thereby. The filing of a petition for bankruptcy by the
(h) Providing and maintaining the types and amounts of Contractor shall be an act of default under this contract.
insurance or self-insurance specified in this paragraph
is a material obligation of the Contractor and is of the Waiver of Default: Waiver by the County of any default
essence of this contract. or breach in compliance with the terms of this contract by
(i) The Contractor shall only obtain insurance from the Provider shall not be deemed a waiver of any
companies that are authorized to provide such subsequent default or breach and shall not be construed to
coverage and that are authorized by the Commissioner be modification of the terms of this contract unless stated
of Insurance to do business in the State of North to be such in writing, signed by an authorized
Carolina.All such insurance shall meet all laws of the representative of the County and the Contractor and
State of North Carolina. attached to the contract.
The Contractor shall comply at all times with all lawful
terms and conditions of its insurance policies and all Availability of Funds: The parties to this contract agree
lawful requirements of its insurer. and understand that the payment of the sums specified in
(k) The Contractor shall require its subcontractors to this contract is dependent and contingent upon and subject
comply with the requirements of this paragraph. to the appropriation, allocation, and availability of funds
(1) The Contractor shall demonstrate its compliance with for this purpose to the County.
the requirements of this paragraph by submitting
certificates of insurance to the County before the Force Majeure: Neither party shall be deemed to be in
Contractor begins work under this contract. default of its obligations hereunder if and so long as it is
prevented from performing such.obligations by any act of
Transportation of Clients by Contractor: war,hostile foreign action,nuclear explosion,riot,strikes,
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Chatham Transit Network
civil insurrection,earthquake,hurricane,tornado,or other
catastrophic natural event or act of God. Health Insurance Portability and Accountability Act
(HIPAA): 'The Contractor agrees that, if the County
Survival of Promises: All promises,requirements,terms, determines that some or all of the activities within the
conditions, provisions, representations, guarantees, and scope of this contract are subject to the Health Insurance
warranties contained herein shall survive the contract Portability and Accountability Act of 1996,P.L. 104-91,
expiration or termination date unless specifically provided as amended("HIPAA"), or its implementing regulations,
otherwise herein, or unless Superseded by applicable it will comply with the HIPAA requirements and will
Federal or State statutes of limitation. execute such agreements and practices as the County
may require to ensure compliance.
Intellectual Property Rights
(a) Data Security,. The Contractor shall adopt and
Copyrights and Ownership of Deliverables: All apply data security standards and procedures
deliverable items produced pursuant to this contract are the that comply with all applicable federal, state and
exclusive property of the County. The Contractor shall not local laws,regulations, and rules.
assert a claim of copyright or other property interest in
such deliverables. (b) Duty to Report: The Contractor shall report a
suspected or confirmed security breach to the
Federal Intellectual Property Bankruptcy Protection local Department of Social Services Contract
Act: The Parties agree that the County shall be entitled to Administrator within twenty-four(24)hours
all rights and benefits of the Federal Intellectual Property after the breach is first discovered, provided that
Bankruptcy Protection Act,Public I-aw 100-506,codified the Contractor shall report a breach involving
at 11 U.S.C. 365 (n)and any amendments thereto. Social Security Administration data or Internal
Revenue Service Data within one(1)hour after
Compliance with Applicable Laws the breach is first discovered.
Compliance with Laws: The Contractor shall comply (c) Cost Borne by Contractor: If any applicable
with all laws, ordinances, codes, rules, regulations, and federal, state, or local law, regulation or rule
licensing requirements that are applicable to the conduct of requires the Contractor give written notice of a
its business, including those of federal, state, and local security breach to affected persons,the Contract
agencies having jurisdiction and/or authority. Pursuant to shall bear the cost of the notice.
the terms of North Carolina General Statute 153A-449(b)
no County may enter into a contract with a contractor Trafficking Victims Protection Act of 2000
unless the contractor and the contractor's subcontractors The Contractor will comply with the requirements of
comply with the requirements of Article 2 of Chapter 64 of Section 106(g)of the Trafficking Victims Protection Act
the North Carolina General Statutes. Where applicable, of 2000,as amended (22 U.S.C. 7104)
failure to maintain compliance with the requirements of
Article 2 of Chapter 64 of the General Statutes constitutes Executive Order#24: It is unlawful for any vendor,
Provider's breach of this Agreement. By executing this contractor, subcontractor or supplier of the state to make
Agreement Provider affirms Provider is in compliance with gifts or to give favors to any state employee. For
Article 2 of Chapter 64 of the North Carolina General additional information regarding the specific
Statutes. requirements and exemptions, contractors are
encouraged to review Executive Order 24 and G.S. Sec.
Title VI,Civil Rights Compliance: In accordance with 133-32.
Federal law and U.S. Department of Agriculture(USDA)
and U.S. Department of Health and Human Services Confidentiality
(HHS) policy, this institution is prohibited from
discriminating on the basis of race,color, national origin, Confidentiality: Any information, data, instruments,
sex, age or disability. Under the Food Stamp Act and documents, studies or reports given to or prepared or
USDA policy, discrimination is prohibited also on the assembled by the Contractor under this agreement shall be
basis of religion or political beliefs. kept as confidential and not divulged or made available to
any individual or organization without the prior written
Equal Employment Opportunity: 'The Contractor shall approval of the County.The Contractor acknowledges that
comply with all federal and State laws relating to equal in receiving, storing,processing or otherwise dealing with
employment opportunity. any confidential information it will safeguard and not
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Contract X68-2030
Chatham Transit Network
further disclose the information except as otherwise sales of tangible personal property to purchasers in North
provided in this contract. Carolina. The conditions include: (a) maintenance of a
retail establishment or office; (b) presence of
Oversight representatives in the State that solicit sales or transact
business on behalf of the vendor; and (c) systematic
Access to Persons and Records: The State Auditor shall exploitation of the market by media-assisted, media-
have access to persons and records as a result of all facilitated, or media-solicited means. The Contractor
contracts or grants entered into by State agencies or certifies that it and all of its affiliates (if any) collect all
political subdivisions in accordance with General Statute required taxes.
147-64.7. Additionally,as the State funding authority,the
Department of Health and Human Services shall have E-Verify
access to persons and records as a result of all contracts or
grants entered into by State agencies or political Pursuant to G.S. 143-48.5 and G.S. 147-33.95(g), the
subdivisions. undersigned hereby certifies that the Contractor named
below,and the Contractor's subcontractors,complies with
Record Retention: Records shall not be destroyed, the requirements of Article 2 of Chapter 64 of the NC
purged or disposed of without the express written consent General Statutes, including the requirement for each
of the Division. State basic records retention policy employer with more than 25 employees in North Carolina
requires all grant records to be retained for a minimum of to verify the work authorization of its employees through
five years or until all audit exceptions have been resolved, the federal E-Verify system." E-Verity System Link:
whichever is longer. If the contract is subject to federal www.uscis.gov
policy and regulations,record retention maybe longer than
five years since records must be retained for a period of Miscellaneous
three years following submission of the final Federal
Financial Status Report, if applicable, or three years ChoiceofLaw: The validity of this contract and any of its
following the submission of a revised final Federal. terms or provisions, as well as the rights and duties of the
Financial Status Report. Also, if any litigation, claim, parties to this contract, are governed by the laws of North
negotiation, audit, disallowance action, or other action Carolina. 'The Contractor, by signing this contract, agrees
involving this Contract has been started before expiration and submits,solely for matters concerningthis Contract,to
of the five-year retention period described above, the the exclusive jurisdiction of the courts of North Carolina
records must be retained until completion of the action and and agrees, solely for such purpose, that the exclusive
resolution of all issues which arise from it,or until the end venue for any legal proceedings shall be Orange County,
of the regular five-year period described above,whichever North Carolina. The place of this contract and all
is later, The record retention period for Temporary transactions and agreements relating to it, and their situs
Assistance for Needy Families (TANF) and MLDICAID and forum,shall be Orange County,North Carolina,where
and Medical Assistance grants and programs must be all matters,whether sounding in contract ortort,relating to
retained for a minimum of ten years. the validity,construction, interpretation,and enforcement
shall be determined.
Warranties and Certifications
Amendment: This contract may not be amended orally or
Date and Time Warranty: The Contractor warrants that by performance. Any amendment must be made in written
the product(s) and service(s) furnished pursuant to this form and executed by duly authorized representatives of
contract("product"includes,without limitation,any piece the County and the Contractor.
of equipment,hardware,firmware,middleware,custom or
commercial soft-ware,or internal components,subroutines, Severability: In the event that a court of competent
and interfaces therein.)that perform any date and/or time jurisdiction holds that a provision or requirement of this
data recognition function, calculation, or sequencing will contract violates any applicable law,each such provision
support a four digit year fon-nat and will provide accurate or requirement shall continue to be enforced to the extent it
date/time data and leap year calculations. This warranty is not in violation of law or is not otherwise unenforceable
shall survive the termination or expiration of this contract, and all other provisions and requirements of this contract
shall remain in full force and effect.
Certification Regarding Collection of Taxes: G.S. 143-
59.1. bars the Secretary of Administration from entering Headings: The Section and Paragraph headings in these
into contracts with vendors that meet one of the conditions General Terms and Conditions are not material parts of the
of G.S. 105-164,8(b)and yet refuse to collect use taxes on
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Chatham Transit Network
agreement and should not be used to construe the meaning Department of Revenue for a refund of all sales and use
thereof taxes paid by them in the performance of this contract,
pursuant to G.S. 105-164.14-, and (b) exclude all
Time of the Essence: Time is of the essence in the refundable sales and use taxes from all reportable
performance of this contract. expenditures before the expenses are entered in their
reimbursement reports.
Key Personnel: The Contractor shall not replace any of
the key personnel assigned to the performance of this Advertising: The Contractor shall not use the award of
contract without the prior written approval of the County. this contract as a part of any news release or commercial
The term "key personnel" includes any and all. persons advertising.
identified as such in the contract documents and any other
persons subsequently identified as key personnel by the Orange County Living Wage: Orange County is
written agreement of the parties. committed to providing its employees with a living wage
and encourages agencies to which it provides funding to
Care of Property: The Contractor agrees that it shall be pursue the same goal. The County's living wage hourly
responsible for the proper custody and care of any property standard, as adopted by the Orange County Board of
furnished to it for use in connection with the performance County Commissioners annually, can be found in the
of this contract and will reimburse the County for loss of Orange County Budget Ordinance. To the extent possible,
or damage to, such property. At the termination of this Orange County recommends that the Contractor and all
contract, the Contractor shall contact the County for subcontractors provide a living wage, as defined in this
instructions as to the disposition of such property and shall section, to their employees.
comply with these instructions. Signatures: This Agreement together with any
Travel Expenses: Reimbursement, if provided in this amendments or modifications may be executed
Agreement, to the Contractor for travel mileage, meals, electronically. All electronic signatures affixed hereto
lodging and other travel expenses incurred in the evidence the intent of the Parties to comply with Article
performance of this contract shall not exceed the rates 11A and Article 40 of North Carolina General Statute
established in County policy. Chapter 66.
Sales/Use Tax Refunds: If eligible,the Contractor and all
subcontractors shall: (a) ask the North Carolina
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DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham Transit Network
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN
Contract# 68-2030
A. CONTRACTOR INFORMATION
1. Contractor Agency Name: Chatham Transit Network
2. Ifdafftrent from Contract Administrator Information in General Contract:
Address
Telephone Number: Fax Number: Email:
3. Name of Program (s): Medicaid Transportation
4. Status: ( ) Public (X) Private,Not for Profit Private, For Profit
S. Contractor's Financial Reporting Year July 1, 2015 through— June 30,2016
B. Explanation of Services to be provided and to whom(include SIS Service Code): - The
Contractor will provide transportation services to client(s) identified by the County The
Contractor will transtiort client(s)to and from medical anwintments. The Contractor is required
to meet all goals and outcomes listed in Attachment N.
C. Rate per unit of Service(define the unit):
1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart)
2. Negotiated County Rate.
D.Number of units to be provided:
E. Details of Billing process and Time Frames; The County will reimburse the Contractor for
services described in this contract up to the budgetary limits of the contract allotment. For
reimbursement,the Contractor must submit an origin il and two copies of an invoice by the fifth
of the month for the preceding month's expenditures to the des4aynated County Administrator.
The County will reimburse the Contractor monthly upon..receipt of a complete and correctly filed
report.
The Contractor shall be compensated at the rates set out in this Attachment for all avoroved trins.
F. Area to be served/Delivery, site(s): Orange Count
Contract-Scope of Work(06/04) Page 1 of 1
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
DocuSigned by, WeTcansit Network
f6v, 11'shyw aA&
E�N=IIAEI ra;---I-
IE F_9 F 9
Nancy Coston, Social Services Director (Signature of Contractor)
2/3/2016 2/3/2016
(Date Submitted) (Date Submitted)
Contract-Scope of Work(06/04) Page 2of 2
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham Transit Network
ATTACHMENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County,Department of Social Services
I. 13-y execution of this Agreement 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:
(1)The dangers of drug abuse in the workplace;
(2)The Contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) '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:
(1)Abide by the terms of the statement; and
(2)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 County within ten days after receiving notice under subparagraph (D)(2)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)(2),with respect to any employee who is so convicted:
(1)Taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily, in a drug abuse assistance or
rehabilitation prograrn approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(A), (B), (C), (D), (E), and (F).
Federal Certification -Drug-Free Workplace(07,,,r 10) Page I of 1
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham Transit Network,
11. The site(s)for the performance of work done in connection with the specific agreement are listed
below:
L
(Street address)
(City, county, state, zip code)
2.
(Street address)
(City, county, state, zip code)
Contractor will inform the County of any additional sites for performance of work under this agreement.
False certification or violation of the certification shall be grounds for suspension of payment, suspension
or termination of grants, or government-wide Federal suspension or debarment(45 C.F.R. Section
82.51.0. Section 4 CFR Part 85, Section 85.615 and 86.620).
CERTIFICATION REGARDING NONDISCRIMINATION
The Vendor 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 V111 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; (b)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.
E DocuSigned by:
Executive Director
ULMUG5E52488
Signature Title
Chatham Transit Network 2/3/2016
Agency/Organization Date
(Certification signature should be same as Conti-act signature.)
Federal Certification-Drug-F'ree Workplace(07/10) Page 2 oft
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Is at
Transit
Conflict of Interest Policy
Definitions and Expectations
Conflict of Interest Defined:
A conflict of interest is defined as an actual or perceived interest by an employee or Board
member, in an action that results in, or has the appearance of resulting in, personal,
organizational, or professional gain. A conflict of interest occurs when an employee/Board
member has a direct or fiduciary interest in another relationship. A conflict of interest could
include:
• Ownership with a member of the Board of Directors or an employee where one or the
other has supervisory authority over the other or with a client who receives services.
• Employment of or by a member of the Board of Directors or an employee where one or
the other has supervisory authority over the other or with a client who receives services.
• Contractual relationship with a member of the Board of Directors or an employee where
one or the other has supervisory authority over the other or with a client who receives
services.
• Creditor to debtor to a member of the Board of Directors or an employee where one or
the other has supervisory authority over the other or with a client who receives services.
• Consultative or consumer relationship with a member of the Board of Directors or an
employee where one or the other has supervisory authority over the other or with a client
who receives services.
The definition of conflict of interest includes any bias or the appearance of bias in a decision-
making process that would reflect a dual role played by a member of the organization or
group. An example, for instance, might involve a person who is an employee and a Board
member, or a person who is an employee and who hires family members as consultants.
When selecting a person to join the Chatham Transit Network Board of Directors every effort
will be made to ensure none of the above conditions exist.
Board/Employee Expectations:
• All board members shall avoid conflicts of interest and the appearance of
impropriety. Certain board members of the Chatham Transit Network are
representatives/employees of various organizations that benefit from actions taken by
the board. Should an instance arise when a conflict may be perceived, any individual
who may benefit directly or indirectly from any action taken by the board shall
abstain from participating in any decision or deliberations by the board regarding that
action.
• At all times, employees are prohibited from using their job title, the organization's
name or property for private profit.
--------------..........
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
• The director, officers, or employees of Chatham Transit Network should neither,
solicit or accept gifts, entertainment, favors, or other items for more than nominal
value form contractors/vendors. This policy is not intended to preclude bonarlde
Chatham Transit Network fundraising activities.
• Disclosure-All conflicts of interest shall be disclosed by the person or persons
concerned.
• Record of Conflict-All official minutes of the Board of Directors shall reflect any
conflict of interest that was disclosed and the person(s) with conflicts of interest did
not participate in discussion or vote on the matter.
AFFIRMED this day, March 27, 2015
For the Board of Directors, Chatham Transit Network
Board President
AN
Tim Mounce
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham Transit Network
ATTACHMENT E
OVERDUE TAXES
Orange County Department of Social Services
Instructions: Grantee/Provider should complete this certification for all funds received. Entity
should enter appropriate data in the yellow highlighted areas. The completed and signed form
must be provided to the County Department of Social Services.
Transit
Chatham Transit Network
P,O.Box 1032
Pittsboro,NC 27312
01292016
To: Orange County Department of Social Services
Certification:
We certify that the Chatham Transit Network does not have any overdue tax debts,as defined by
N.C,G.S. 105-243.1', at the federal, State, or local level. We further understand that any person
who makes a false statement in violation of N.C.G.S. 1430-6-23(c) is guilty of a criminal offense
punishable as provided by N,C.G.S. 1430-10-1(b).
Sworn Statement:
Tim Mounce and Anna,resterman being duly sworn, say that we are the Board Chair and
Executive Director, respectively, of Chatham Transit Network of Pittsboro in the State of North
Carolina;and that the foregoing certification is true,accurate and complete to the best of our
knowledge and was made and subscribed by us. We also acknowledge and understand that any
misuse of State funds will be reported to the appropriate authorities for further action.
Boar Chair
xec five Director
Sworn to and subscribed before me on the day of the date of said certification.
My Commission Expires:
(N
61021 I MvIdN9 u011 u"U 3
"usloilo 4144"(JunoD 2WI
'1!11qnd AMON
umals'm qwoqoa
QS. 105-243.1 defines:Overdue tax debt.-Any part of a tax debt that remains unpaid 90 days or more after the
notice of final assessment was mailed to the taxpayer.The term does not include a tax debt,however, if the taxpayer
entered into an installment agreement for the tax debt tinder G.S. 105-237 within 90 days after the notice of final
assessment was mailed and has not failed to make any payments due under the installment agreement."
Overdue Taxes-(07/08) Page I of I
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
INTWNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY
PIS-TICT DIRECTOR
P, 0, BOX 2508
P:NCINNAT: . OH 45203
Employer Identification Number:
ARIT 1! 7, 199,9
DLW
17053254768029
TRPNSIT 1',TETWOIRK Contact Person:
PC BOX 1032 THOMAS E D BRIEN IQ 31187
PIT?SBORO, NC 21312-1032 Contact Telephone Number�
(8 7"'7) 829-5500
Our Letter Dated:
July 1995
Addendum Applies:
No
tear Applicant:
Wis modifies our letter of the above date in which we stated that you
woi d he treated as an organization that is not a private foundation until the
expiratLon of your advance ruling period.
Your exempt status under section 501 (a) of the Internal Revenue Code as an
-roanization described in section 501 (c) (3) is still in effect. Based an the
inlarmation you submitted, we have determirmd chat you are not a private
foundation within the meaning of section 509 (a) of the Code because you are an
argarizaHon of the type described in section 509(a) (1) and 170 (b) (1) (A) (vi) .
Grantors and contributors may rely on this determination unless the
internal Revenue Service publishes notice to the contrary. However, it you
Lose your section 509 (a) (1) status, as grantor or contributor may not rely on
this determination it he or she was in part responsible for, or was aware of,
the act or failure to act, or the substantial or material change on the paxt of
rhp nrqanization that resulted in your lose of such status, or if he or she
acquired knowledge that the Internal Revenue Service had given notice that you
woold no longer be classified as a section 509 (a) (1) organization.
:f we have indicated in the heading of this letter that an addendum
ippl &s, tFe addendum enclosed is an integral part of this le.t gear ,
occause
,..h.,. ,; lctter could help resolve any questions about youx private
toondation status, please keep it in your pernonent records.
you have any questions, please contact the person whose name and
LeJephone number are shown above.
Sincerely yours,
trict Director
Letter 050 (DONG)
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract 468-2030
Chatham Transit Network
ATTACHMENT J
CERTIFICATION REGARDING TRANSPORTATION
Orange County Department of Social Services
By execution of this Agreement the Contractor certifies that it will provide safe client transportation by:
I. Insuring that all drivers(including employees, contractors, contractor's employees,and
volunteers) shall be at least 18 years of age;
2. Insuring that all drivers(including employees, contractors, contractor's employees, and
volunteers) shall be licensed to operate the specific vehicle used in transporting clients in
accordance with Chapter 20-7 of the General Statutes of North Carolina and the Division of
Motor Vehicle requirements;
3. Insuring that all vehicles transporting clients shall have at least the minimum level of liability
insurance appropriate for the type of vehicle as defined by Article 7,Rule R2-36 of the North
Carolina Utilities Commission;
4. Insuring that the contractor shall have written policies and procedures regarding how drivers
handle and report client emergencies and/or vehicle crashes involving clients to contractor and
how contractor notifies the Orange County Department of Social Services;
5. Contractor will maintain records documenting the following(County may require contractor to
provide):
a.Valid current copies of Drivers License for all drivers;
b.Current valid Vehicle Registration, for all vehicles transporting clients;
c.Driving records for all drivers for the past three years and with annual updates;
d.Criminal Background checks through North Carolina Law Enforcement or NCIC
prior to employment and every three years thereafter;
e.Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines.
6. Disclosing, at the outset of the contract, upon renewal and upon request, any criminal convictions
or other reasons for disqualifications from participation in Medicare, Medicaid or Title XX
gMMpd9i:gnature on this form confirms this statement.
VAAA j'GSkMa1A,
82E60DC5F52488 Executive Director
Signature Title
Chatham Transit Network 2/3/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(05/09) Page 1 of I
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract 468-2030
Chatham Transit Network
ATTACHMENT K
501(c)(3) and TAX EXEMPT STATUS
Orange County Department of Social Services
What is a Private Non Profit Agency?
Answer: A private non profit is an organization that is incorporated under State law and whose purpose is
not to make a profit,but rather to further a charitable, civic, religious, scientific, or other lawful purpose.
The Secretary of State's office grants corporate status to organizations in North Carolina.
What is a 501(c)(3)designation?
Answer: When the agency becomes a state private non profit corporation, it can then apply for 501(c)(3)
designation through the IRS. Once the IRS grants 501(c)(3)status,the organization is exempt from
certain taxes and any donations to the charitable organization are tax deductible. Many individuals and
organizations prefer to make donations to 50 1(c)(3)private non profits.
Who can obtain a 501(c)(3)designation?
Answer: Any organization or group can apply for 50 1(c)(3) status, provided their charter or mission
focuses on the non profit's objective.
Another option is to apply for a 509(a)(1)status which falls under the 501.(c)(3) umbrella. Being a
509(a)(1)designates an organization as a tax-free public charity that receives most of its support from a
governmental unit or from the general public. Becoming a 509(a)(1)provides public recognition of tax-
exempt status, advance assurance to donors of deductibility of contributions, exemption from certain State
and federal taxes, and non profit mailing privileges. Organizations that typically qualify are churches,
educational institutions, hospitals, and governmental units.
To learn more about non profits,visit w�Jrs.�Yov, or call the tax-exempt helpline at 877-829-4933.
How does a Private Non Profit obtain Tax Exempt Status?
A private non profit must apply to the IRS for tax exempt status. To qualify, applicants must complete
and submit to the IRS Form 1023. Once federal tax exempt status is granted,the private non profit applies
for State tax exempt status by completing Form CD-435 and submitting it to the N. C. Department of
Revenue,
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — -
Please attach proof of 501(c)(3)or IRS tax-exempt status to this page.
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract 468-2030
Chatham Transit Network
ATTACHMENT M
STATE CERTIFICATION
Contractor Certifications Required by North Carolina Law
Orange County Department of Social Services
Instructions
The person who signs this document should read the text of the statutes listed 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:
jLtj,p:0wwNV.gc zt..state.n c.us/Enact ed Le
....... - ----------------
• The text of G.S. 105-164.8(b)can be found online at:
ia r 105/GS 105J64XV0
.1 ff
- gi,slation/Statut 1-1 3 ect.on/Cll-p ------------.............
ll".,�l-l�.I.I.........--�-�-.-L, F
• The text of G.S. 143-48.5 (S.L. 2013-418, s. 2.(d))can be found online at:
Wttr.-(/w✓ yiy iie,tis/Sessiot-)s/201,3/Bills/ll(,)use,/]')I,)F/117.86v6,..p,df
• The text of G.S. 143-59.1 can be found online at:
http state--.-ic us/Enactedl,�I,b�1�41cr�7 ii,Statt.�te /P[) /I-1-YS.g ioll/Cf
r 143./..G..........—-1---4- 3-59j,11f
• The text of G.S. 143-59.2 can be found online at:
jq 1.41/GS 143-59�2....�ff
g� !,, -1-......—.-- -p
• The text of G.S. 147-33.95(8)(S.L. 2013-418, s. 2. (e))can be found online at:
nc.tis/Sessioris/2013/Bills/1-fo�aise/P[)F/'fl"/86N,6,Ildf
..........
Certifications
(1) Pursuant to G.S. 143-48.5 and G.S. 147-33.95(8), 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 employees in North Carolina to
verify the work authorization of its employees through the federal E-Verify system." E-Verify System Link:
WN"(wV,USCiS
Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina General Statutes.
f-lowever, local government is subject to and must comply with North Carolina General Statute §I 53A-99.1.,
which states in part as follows:
Counties Must Use E-Verify. - Each county shall register and participate in E-Verify to verify the work
authorization of new employees hired to work in the United States.
(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
Contractor Certifications Required by North Carolina Law Page I of I
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham Transit Network
more of the conditions of G.S. 105-164.8(b);and
(b) [check one of the following boxes]
F-1 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.
(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;
(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.land -59.2 shall be guilty of a Class I felony.
Chatham Transit Network
CU e Y:
Contract -'s Tarn
jI*Y*MA, 2/3/2016
-HIE-360 F52488
Signature of Contractor's Authorized Agent Date
Anna Executive Director
U�111
Printed faage mp I'' ctor's Authorized Agent Title
k1tV
, MOG Finance coordinator
8?q6YZB485AF:40-q.--
Signature of Witness Title
Angie 2/3/2016
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
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
Contract#68-2030
Chatham Transit Network
ATTACHMENT N
OUTCOMES AND REPORTING
Orange County Department of Social Services
By signing and submitting this document,the Contractor certifies that it agrees to the following:
1. The Contractor agrees to participate in program, fiscal and administrative monitoring and/or audits,
making records and staff time available to Federal, State and County staff.
2. The Contractor agrees to take necessary steps for corrective action, as negotiated within a corrective
action plan, for any items found to be out of compliance with Federal, State, and County laws,regulations,
standards and/or terms of the Contract.
3. The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the
following requirements. The Contractor agrees to:
A. Adhere to all Federal and State transportation laws®ulations.
B. Transport client(s)to and from medical appointments as requested by the County.
C. Transport approved, authorized client(s)to specified destinations within and outside of Orange
County upon request, on time, and in accordance with arrangements made by the County.
D. Transport clients only to approved destinations. Any additional destinations cannot be provided
without the expressed consent and authorization of the County.
E. Provide services to enrolled participants within three days of a request.
F. Provide critical services on short notice when requested.
G. Coordinate maintenance with private vendors to ensure vehicles are in safe operating order.
Fl. Discuss the specific situation, and present evidence of cause,with the County prior to
termination of services foi-any client.
l. Complete the DMA 5124 as part of the annual contract process.
J. Use the provided transportation billing codes on invoices to the County for reimbursement.
K. Only submit invoices for trips approved by the County. Trips included on invoices that were
not pre-approved will not be reimbursed.
L. Meet on-time performance standards such that no more than 51/16 of trips should be late for client
drop-off to his appointment per month. Late is defined as past the client's appointment time.
M. Not miss more than one quarter of one percent of all trips during the course of the contract year.
N. Report all no-shows on a daily basis and cancellations on a monthly basis to the County.
O. Record all client complaints which deal with the matters under the control of Contractor,
including the date of the complaint,the nature of the complaint, and what steps were taken to
resolve the complaint.
P. Provide names of all owners,managers, management entities, and subcontractors.
Q. Report any changes such as insurance provider, business ownership or management.
R. Disclose,at the outset of the contract, upon renewal and upon request, any criminal convictions
or other reasons for disqualifications from participation in Medicare,Medicaid or Title XX
E QDINIO PMA14S
In A JIGS{-f,MaA& Executive Director
R�3�ES2488_w
Signature 'Title
Chatham Transit Network 2/3/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 1 of 1
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
N 0 R T I-I" W- CCAROLI _N_A
AssociATiON OF COUNTY COMMISSIONERS
LIABILITY AND PROPERTY COVERAGE CERTIFICATE
COVERAGE PROVIDER:
NCACC Liability and Property Pool This certificate is provided by the NCACC Liability and Property
215 North Dawson Street Pool and is issued as a matter of information only, This
Raleigh,NC 27603 certificate confers no rights upon the certificate holder other than
MEMBER: those provided in the coverage document. This certificate does
Chatham Transit Network not amend,extend,or alter the coverage afforded by the
P.O.Box 1032 coverage documents listed herein.
Pittsboro, NC 27312
COVERAGES
Type of Coverage Coverage I Effective I Expiration
Contract# Date Date Limits
Liability
General Liability—
x Each Occurrence, LP-CH-475-
No Aggregate applies 15 July 1,2015 July 1,2016
x Public Officials Liability, LP-CH-475- $2,000,000 occurrence
Each Wrongful Act 15 July 1,2015 July 1,2016
Law Enforcement Liability,
Each Occurrence I I I
Cyber Liability LH-UH-4fb- $1,000,000 aggregate
15 July 1,2015 July 1,2016 Claims Made
Excess Liability —rr"rrr-4"-
15 j July 11,2015 July 1,2016 $3,000,000
Automobile Liability
x All Owned Autos, LP-CH-475-
Each Accident 15 July 1,2015 July 1,2016
x Hired Autos, LP-CH-475- $2,000,000 occurrence
Each Accident 15 July 1,2015 July 1,2016
x Excess Auto Liability for LP-CH-475-
I Non-Owned Autos 1 15 1 July 1,2015 1 Jul l 1,2016 1
Automobile Physical Damage
x Scheduled Vehicles LP-CH-475- Actual Cash Value at the time of
15 Jul 1,2015 July 1,2016 the Loss,unless otherwise
Hired Autos(if coverage is not specified in the Coverage
X purchased elsewhere) LP-CH-475- Document;Deductible Applies
15 July 1,2015 July 1,2016
Property—Risks of Direct Physical Loss, LP-CH-475- Limit Deductible
Blanket Limit 15 July 1,2015. Jul l 1,2016 $ 1,091,060 $1,000
Additional Information:
CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be
Orange County Dept.of Social Services cancelled before the expiration date shown, the NCACC Pools will endeavor to
mail written notice to the Certificate Holder named herein,but failure to mail
PO Box 8181 such notice shall impose no obligation or liability of any kind upon the NCACC
Hillborough,INC 27278 Pools,its agents or representatives,or the issuer of this certificate.
By:Willie J.Allen Jr.,
Underwriter for the NCACC 1/2 612 01 6
Certificate Mailed/E-Mailed or Faxed to:
Orange County Dept. of Social Services
PO Box 8181
Hillborough, NC 27278
DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D
N C) R T H w CC A R 0 L I N A
ASSOCIATION 01P COUN-1-Y COMMISSIONFRS
WORKERS COMPENSATION COVERAGE CERTIFICATE
COVERAGE PROVIDER:
NCACC Liability and Property Pool
215 North Dawson Street This certificate is provided by the NCACC Workers'Compensation Pool
Raleigh, NC 27603 and is issued as a matter of information only. This certificate confers no
MEMBER: rights upon the certificate holder other than those provided in the
coverage document. This certificate does not amend,extend,or alter the
Chatham Transit Network coverage afforded by the coverage documents listed herein.
P.O.Box 1032
Piftsboro,NC 27312
COVERAGES
Type of Coverage Coverage Effective Expiration
Contract# Date Date Limits
Coverage A:
WORKERS'COMPENSATION
WC-CH-475-15 July 1,2015 July 1,2016 Statutory
Coverage B:
EMPLOYERS'LIABILITY
WC-CH-475-15 July 1,2015 July 1,2016 $2,000,000
Coverage C:
OTHER STATES
WC-CH-475-15 July 1,2015 July 1,2016 Statutory
Additional Information: Evidence of Coverage
CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before
Orange County Dept.of Social Services the expiration date shown, the NCACC Pools will endeavor to mail written notice to the
Certificate Holder named herein,but failure to mail such notice shall impose no obligation
PO Box 8181 or liability of any kind upon the NCACC Pools, its agents or representatives,or the issuer of
Hillsborough,NC 27278 this certificate,
By: Willie Allen, Underwriter
for the NCACC 112712:0116
Certificate Malled/E-Mailed or Faxed to:
Orange County Dept.of Social Services
PO Box 8181
Hillsborough, NC 27278