HomeMy WebLinkAbout2016-478-E DSS - The Dispute Settlement Center, Inc. for dispute resolution onnunign Envelope ID:oonsxe1a-CC �ouo�1o�uo
� Contract#68-1012
The Dispute Settlement Center, Inc.
Contract#_d8-|0|2 Fiscal Year Begins Jub/l` 20l6___]Cmdm June 30, 2017
This contract is hereby entered into by and between the Orange County Department of Social Services(the"County")and The
Dispute Settlement Center, Inc. (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
(|) 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 RegardingNondiscrimination(Attachment C)
(5) Conflict of Interest(Attachment D)
(6) No Overdue Taxes(Attachment E)
(7) IRS Federal Tax Exempt Letter or 501(c)(3) (Attachment K)
(8) State and Local Certifications(Attachment M)
(9) Outcomes and Reporting(Attachment N)
(TO)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 and this Agreement,the terms of this Agreement shall control. In the event of a conflict between or among the
terms of the Contract Documents,then the Contract Documents with the highest relative precedence shall prevail. The
order of precedence shall be the order of documents as listed in Section 1,above,with Attachment A having precedence
over Attachment B and so forth. 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 July 1, 2016 and shall terminate on June 30, 2017.
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.
5. 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 f
applicable).
[X] a. There are no matching requirements from the Contractor.
[ ] b. The Contractor's matching requirement is $ , which shall consist of:
[ ] In-kind [ ] Comh
[ ] 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. Reporting Requirements:Contractor shall comply with audit requirements as described in N.C.G.S. § l43C-6'228t23
and OMB Circular/\-]33 and shall disclose all information required hy42lJSC455.\04,ur42OSC455.l05,or42D3C
455.|Ud.
Contract-General (07/10) Page 1 of 5
DocuSign Envelope ID:BC6E8913-CC �ouo�1o�uo
� Contract 468'1012
The Dispute Settlement Center, Inc.
7. Payment Provisions: Payment shall be made in accordance with the Contract Documents as described in the Scope of
Work, Attachment B.
8. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions aboit
the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. Th3
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 ANY OTHER |
---- ~
Sharron Hinton, Community Services Manager Sharron Hinton, Community Services Manager
Orange County Department of Social Services Orange County Department of Social Services
P.O. Box 8181 113 Mayo Street
Hillsborough,NC27Z7X Hillsborough, NC 27278
(9l9)245-2040
sbiotourc3co.Vrun_eucus
Program Contact:
Robert Gilmore, Work Firs
Orange County Department of Social Services
P.O. Box 8181
300 West Trvon Street
Hillsborough, NC2727N
(919)245-2847
ruUn'oreacoonungeao.us
For the County:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS |
Denise Shaffer, Social Work Program Director Denise Shaffer, Social Work Program Director
Orange County Department of Social Services Orange County Department of Social Services
P.O. Box 8181 2501 Homestead Road
Hillsborough, NC 27278 Chapel Hill,NC 27516
(919)245-2246
dsaffer@cg�ran_g_e_=nc.us
Contract-General (07/10) Page 2 of 5
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
Contract#68-1012
The Dispute Settlement Center, Inc.
Program Contact:
Duston Lowell, Program Manager
Orange County Department of Social Services
113 Mayo Street
Hillsborough, NC27278
(919)245-2857
d I owell@orangecountvnc.gov
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE lFDEL[VEREDB`/ /\NY OTHER��EANS
Frances Henderson Frances Henderson
The Dispute Settlement Center, Inc. The Dispute Settlement Center, Inc.
302 West Weaver Street 302 West Weaver Street
Carrboro,NC 27510 Carrboro,NC 27510
(919) 929-8800
9. 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.
10. Supplementation of Expenditure of Public Funds: The Contractor assures tha funds received pursuant to this contra 1
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.
11, 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:
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.
12, 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.
13. 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.
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onnunign Envelope 0�oonsxe1a�z� �ouo�1o�uo
ID: � - — — —' Contract 468'l01 '
The Dispute Settlement Center,|n.'.
14. Relationship of the Parties: Contractor is an independent contractor of the County. Contractor represents that it has o.
will secure, at its own expense, all personnel required in performing the services under this Agreement. Snohpersouo.|
shall not be employees of or have any contractual relationship with the County. All personnel engaged in work underthi
Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such serviee:,.
It is further agreed by Contractor that it shall obey all State and Federal statutes,rules and regulations which are applicabl-
to provisions of the services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed a,
officer, employee or agent of the County.
15. Termination: This Agreement may be terminated as specified in Attachment A, General Terms And Conditions.
16. Insurance Requirements:Contractor shall obtain,at its sole expense,all insurance as required in Attachment A,Gener.il
Terms And Conditions.
17. Indem nification: Contractor agrees to defend, indemnify, and hold harmless the County, for all loss, liability,claims *r
expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage. to an
person or persons caused in whole or in part by Contractor in accordance with Attachment A, General Terms An 1
Conditions. It is the intent of this Section that Contractor indemnify County to the full extent permitted by law.
18. Entire Agreement: The parties have read this Agreement, including the Contract Documents,and agree to be bound b
all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between th
parties.
19. Interpretation: When the context in which words are used in this Agreement indicates that such is the intent,words sha |
in the singular number shall include the plural and vice versa. The masculine gender shall include the feminine and neute
INWlTNE8S WHEREOF,the County and the Contractor have been first duly authorized,have executed and entered int
this Agreement as of the day and year first above written.
TB�EI�X8P CENTER,INC.
| l�yakt1. AY�,itysok� 8/I5/2016
|
_
Signature Date
Frances Henderson Executive Di rector
Printed Name Title
ORANGE COUNTY
DocuSigned by:
�CY���
ENIAAnk ^' ' / 8/2]/Z0l6
»o37ouB7z5Euo7. - _ ___ ----- --
Bonnie llamrnersley, County Manager Date
,
Contract-General (07/10) Page 4 of 5
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
ATTACHMENT A
GENERAL TERMS AND CONDITIONS
Orange County Department of Social Services
Relationships of the Parties the County or the Contractor,receiving services or benefits
under this contract shall be deemed an incidental
Independent Contractor: The Contractor is and shall be beneficiary only.
deemed to be an independent contractor in the performance
of this contract and as such shall be wholly responsible for Indemnity and Insurance
the work to be performed and for the supervision of its
employees. The Contractor represents that it has, or shall Indemnification: The Contractor agrees to indemnify and
secure at its own expense, all personnel required in hold harmless the County and any of their officers,agents
performing the services under this agreement. Such and employees, from any claims of third parties arising out
employees shall not be employees of, or have any or any act or omission of the Contractor in connection with
individual contractual relationship with the County. the performance of this contract.
Subcontracting: The Contractor shall not subcontract any Insurance: During the term of the contract,the Contractor
of the work contemplated under this contract without prior at its sole cost and expense shall provide commercial
written approval from the County. Any approved insurance of such type and with such terms and limits as
subcontract shall be subject to all conditions of this may be reasonably associated with the contract. As a
contract.Only the subcontractors specified in the contract minimum, the Contractor shall provide and maintain the
documents are to be considered approved upon award of following coverage and limits:
the contract. The County shall not be obligated to pay for (a) Worker's Compensation - The contractor shall
any work performed by any unapproved subcontractor. provide and maintain Worker's Compensation
The Contractor shall be responsible for the performance of Insurance as required by the laws of North
all of its subcontractors. Carolina,as well as employer's liability coverage
with minimum limits of$500,000.00,covering all
Assignment: No assignment of the Contractor's of Contractor's employees who are engaged in any
obligations or the Contractor's right to receive payment work under the contract. If any work is sublet,the
hereunder shall be permitted. However, upon written Contractor shall require the subcontractor to
request approved by the issuing purchasing authority, the provide the same coverage for any of his
County may: employees engaged in any work under the
(a) Forward the Contractor's payment check(s) contract.
directly to any person or entity designated by the (b) Commercial General Liability - General
Contractor, or Liability Coverage on a Comprehensive Broad
(b) Include any person or entity designated by Form on an occurrence basis in the minimum
Contractor as a joint payee on the Contractor's amount of$1,000,000.00 Combined Single Limit.
payment check(s). (Defense cost shall be in excess of the limit of
In no event shall such approval and action obligate the liability.)
County to anyone other than the Contractor and the (c)Automobile Liability Insurance: The Contractor
Contractor shall remain responsible for fulfillment of all shall provide automobile liability insurance with a
contract obligations, combined single limit of$500,000.00 for bodily
injury and property damage; a limit of
Beneficiaries: Except as herein specifically provided $500,000.00 for uninsured/under insured motorist
otherwise,this contract shall inure to the benefit of and be coverage; and a limit of $25,000.00 for medical
binding upon the parties hereto and their respective payment coverage. The Contractor shall provide
successors. It is expressly understood and agreed that the this insurance for all automobiles that are:
enforcement of the terms and conditions of this contract, (a) owned by the Contractor and used in the
and all rights of action relating to such enforcement, shall performance of this contract;
be strictly reserved to the County and the named (b) hired by the Contractor and used in the
Contractor.Nothing contained in this document shall give performance of this contract; and
or allow any claim or right of action whatsoever by any (c) Owned by Contractor's employees and
other third person.It is the express intention of the County used in performance of this contract("non-
and Contractor that any such person or entity, other than owned vehicle insurance"). Non-owned
General Terms and Conditions—(06/16) Page 1 of 5
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
vehicle insurance protects employers when
employees use their personal vehicles for Termination Without Cause: The County may terminate
work purposes. Non-owned vehicle this contract without cause by giving 30 days written
insurance supplements, but does not notice to the Contractor.
replace,the car-owner's liability insurance.
Termination for Cause: If, through any cause, the
The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under this
automobile liability insurance on any vehicle—owned, contract in a timely and proper manner, the County shall
hired, or non-owned -- unless the vehicle is used in the have the right to terminate this contract by giving written
performance of this contract. notice to the Contractor and specifying the effective date
(d) The insurance coverage minimums specified in thereof. In that event,all finished or unfinished deliverable
subparagraph(a) are exclusive of defense costs. items prepared by the Contractor under this contract shall,
(e) The Contractor understands and agrees that the at the option of the County, become its property and the
insurance coverage minimums specified in Contractor shall be entitled to receive just and equitabl
subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on suc
Contractor's liability or obligations under this contract. materials,minus any payment or compensation previous!
(0 The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, th
of the requirements in subparagraph (a) by Contractor shall not he relieved of liability to the County
demonstrating that it has insurance that provides for damages sustained by the County by virtue of the
protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County may
and limits specified in subparagraph (a). The County withhold any payment due the Contractor for the purpose
shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damages
should be granted. due the County from such breach can be determined. In
(g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting any
of the requirements in paragraph(a)by demonstrating other remedies for breach available to it, the County may
that it is self-insured and that its self-insurance procure the contract services from other sources and hold
provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasioned
coverage and limits s specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by the
County shall be the sole judge of whether such a Contractor shall be an act of default under this contract.
waiver should be granted.
(h) Providing and maintaining the types and amounts of Waiver of Default: Waiver by the County of any default
insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract by
is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of any
essence of this contract. subsequent default or breach and shall not be construed to
(i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless stated
companies that are authorized to provide such to be such in writing, signed by an authorized
coverage and that are authorized by the Commissioner representative of the County and the Contractor and
of Insurance to do business in the State of North attached to the contract.
Carolina. All such insurance shall meet all laws of the
State of North Carolina. Availability of Funds: The parties to this contract agree
(j) The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified in
terms and conditions of its insurance policies and all this contract is dependent and contingent upon and subject
lawful requirements of its insurer, to the appropriation, allocation, and availability of funds
(k) The Contractor shall require its subcontractors to for this purpose to the County.
comply with the requirements of this paragraph.
(1) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be in
the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it is
certificates of insurance to the County before the prevented from performing g such obligations by any act of
Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes,
civil insurrection,earthquake,hurricane,tornado, or othe-
Transportation of Clients by Contractor:The contractor catastrophic natural event or act of God.
will maintain Insurance requirements if required as noted
under Article 7 Rule R2-36 of the North Carolina Utilities Survival of Promises: All promises,requirements,terms,
Commission. conditions, provisions, representations, guarantees, and
warranties contained herein shall survive the contract
Default and Termination expiration or termination date unless specifically provided
General Terms and Conditions—(06/16) Page 2 of 5
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
otherwise herein, or unless superseded by applicable that comply with all applicable federal, state and
Federal or State statutes of limitation, local laws, regulations, and rules.
Intellectual Property Rights (b) Duty to Report: The Contractor shall report a
suspected or confirmed security breach to the
Copyrights and Ownership of Deliverables: All local Department of Social Services Contract
deliverable items produced pursuant to this contract are the Administrator within twenty-four(24)hours
exclusive property of the County. The Contractor shall not after the breach is first discovered, provided that
assert a claim of copyright or other property interest in the Contractor shall report a breach involving
such deliverables. Social Security Administration data or Internal
Revenue Service Data within one(1) hour after
Federal Intellectual Property Bankruptcy Protection the breach is first discovered.
Act: The Parties agree that the County shall be entitled to
all rights and benefits of the Federal Intellectual Property (c) Cost Borne by Contractor: If any applicable
Bankruptcy Protection Act,Public Law 100-506,codified federal, state, or local law,regulation or rule
at 11 U.S.C. 365 (n) and any amendments thereto. requires the Contractor give written notice of a
security breach to affected persons, the Contract
Compliance with Applicable Laws shall bear the cost of the notice.
Compliance with Laws: The Contractor shall comply Trafficking Victims Protection Act of 2000:
with all laws, ordinances, codes, rules, regulations, and The Contractor will comply with the requirements of
licensing requirements that are applicable to the conduct of Section 106(g)of the Trafficking Victims Protection Act
its business, including those of federal, state, and local of 2000, as amended (22 U.S.C. 7104)
agencies having jurisdiction and/or authority. By
executing this Agreement Provider certifies that Executive Order#24: It is unlawful for any vendor,
Provider has not been identified, and has not utilized contractor, subcontractor or supplier of the state to make
the services of any agent or subcontractor, on the list gifts or to give favors to any state employee. For
created by the State Treasurer pursuant to G.S. 147- additional information regarding the specific
requirements and exemptions, contractors are
86.58. encouraged to review Executive Order 24 and G.S. Sec.
133-32.
Title VI,Civil Rights Compliance: In accordance with
Federal law and U.S. Department of Agriculture (USDA)
Confidentiality
and U.S. Department of Health and Human Services
(HHS) policy, this institution is prohibited from
Confidentiality: Any information, data, instruments,
discriminating on the basis of race, color, national origin,
documents, studies or reports given to or prepared or
sex age or disability. Under the Food Stamp Act and
assembled by the Contractor under this agreement shall be
USDA policy, discrimination is prohibited also on the
kept as confidential and not divulged or made available to
basis of religion or political beliefs. any individual or organization without the prior written
approval of the County.The Contractor acknowledges that
Equal Employment Opportunity: The Contractor shall
in receiving, storing, processing or otherwise dealing with
comply with all federal and State laws relating to equal
any confidential information it will safeguard and riot
employment opportunity. further disclose the information except as otherwise
provided in this contract.
Health Insurance Portability and Accountability Act
(HIPAA): The Contractor agrees that, if the County Oversight
determines that some or all of the activities within the
scope of this contract are subject to the Health Insurance
Access to Persons and Records: The State Auditor shall
Portability and Accountability Act of 1996, P.L. 104-91,
have access to persons and records as a result of all
as amended ("HIPAA"), or its implementing regulations,
contracts or grants entered into by State agencies or
it will comply with the HIPAA requirements and will
political subdivisions in accordance with General Statute
execute such agreements and practices as the County
147-64.7. Additionally,as the State funding authority,the
may require to ensure compliance. Department of Health and Human Services shall have
access to persons and records as a result of all contracts or
(a) Data Security: The Contractor shall adopt and
grants entered into by State agencies or political
apply data security standards and procedures
subdivisions.
General Terms and Conditions—(06/16) Page 3 of 5
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
subcontractors,complies with the requirements of Article 2
Record Retention: Records shall not be destroyed, of Chapter 64 of the NC General Statutes.
purged or disposed of without the express written consent
of the Division. State basic records retention policy Miscellaneous
requires all grant records to be retained for a minimum of
five years or until all audit exceptions have been resolved, Choice of Law: The validity of this contract and any of its
whichever is longer, If the contract is subject to federal terms or provisions, as well as the rights and duties of the
policy and regulations,record retention may be longer than parties to this contract, are governed by the laws of North
five years since records must be retained for a period of Carolina. The Contractor, by signing this contract, agrees
three years following submission of the final Federal and submits,solely for matters concerning this Contract,to
Financial Status Report, if applicable, or three years the exclusive jurisdiction of the courts of North Carolina
following the submission of a revised final Federal and agrees, solely for such purpose, that the exclusive
Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange County,
negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and all
involving this Contract has been started before expiration transactions and agreements relating to it, and their situ s
of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,where
records must be retained until completion of the action and all matters, whether sounding in contract or tort,relating to
resolution of all issues which arise from it,or until the end the validity,construction, interpretation,and enforcement
of the regular five-year period described above,whichever shall be determined.
is later. The record retention period for Temporary
Assistance for Needy Families (TANF) and MEDICAID Amendment: This contract may not be amended orally or
and Medical Assistance grants and programs must be by performance. Any amendment must be made in written
retained for a minimum of ten years. form and executed by duly authorized representatives of
the County and the Contractor.
Warranties and Certifications
Severability: In the event that a court of competent
Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of this
the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provision
contract("product"includes,without limitation,any piece or requirement shall continue to be enforced to the extent it
of equipment,hardware,firmware,middleware,custom or is not in violation of law or is not otherwise unenforceable
commercial software,or internal components,subroutines, and all other provisions and requirements of this contract
and interfaces therein)that perform any date and/or time shall remain in full force and effect.
data recognition function, calculation, or sequencing will
support a four digit year format and will provide accurate Headings: The Section and Paragraph headings in these
date/time data and leap year calculations. This warranty General Terms and Conditions are not material parts of the
shall survive the termination or expiration of this contract. agreement and should not be used to construe the meaning
thereof.
Certification Regarding Collection of Taxes: G.S. 143-
59.1 bars the Secretary of Administration from entering Time of the Essence: Time is of the essence in the
into contracts with vendors that meet one of the conditions performance of this contract.
of G.S. 105-164.8(b)and yet refuse to collect use taxes on
sales of tangible personal property to purchasers in North Key Personnel: The Contractor shall not replace any o
Carolina. The conditions include: (a) maintenance of a the key personnel assigned to the performance of this
retail establishment or office; (b) presence of contract without the prior written approval of the County
representatives in the State that solicit sales or transact The term "key personnel" includes any and all persons
business on behalf of the vendor; and (c) systematic identified as such in the contract documents and any odic.-
exploitation of the market by media-assisted, media- persons subsequently identified as key personnel by the
facilitated, or media-solicited means. The Contractor written agreement of the parties.
certifies that it and all of its affiliates (if any) collect all
required taxes. Care of Property: The Contractor agrees that it shall be
responsible for the proper custody and care of any property
E-Verify furnished to it for use in connection with the performance
of this contract and will reimburse the County for loss of,
Pursuant to G.S. 143-48.5,the undersigned hereby certifies or damage to, such property. At the termination of this
that the Contractor named below, and the Contractor's contract, the Contractor shall contact the County for
General Terms and Conditions-- (06/16) Page 4 of 5
=■.
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
instructions as to the disposition of such property and shall
comply with these instructions. Orange County Living Wage: Orange County is
committed to providing its employees with a living wage
Travel Expenses: Reimbursement, if provided in this and encourages agencies to which it provides funding to
Agreement, to the Contractor for travel mileage, meals, pursue the same goal. The County's living wage hourly
lodging and other travel expenses incurred in the standard, as adopted by the Orange County Board of
performance of this contract shall not exceed the rates County Commissioners annually, can be found in the
established in County policy. Orange County Budget Ordinance. To the extent possible,
Orange County recommends that the Contractor and all
Sales/Use Tax Refunds: If eligible,the Contractor and all subcontractors provide a living wage, as defined in this
subcontractors shall: (a) ask the North Carolina section,to their employees.
Department of Revenue for a refund of all sales and use
taxes paid by them in the performance of this contract, Signatures: This Agreement together with any
pursuant to G.S. 105-164.14; and (b) exclude all amendments or modifications may be executed
refundable sales and use taxes from all reportable electronically. All electronic signatures affixed hereto
expenditures before the expenses are entered in their evidence the intent of the Parties to comply with Article
reimbursement reports. I IA and Article 40 of North Carolina General Statute
Chapter 66.
Advertising: The Contractor shall not use the award of
this contract as a part of any news release or commercial
advertising.
General Terms and Conditions—(06/16) Page 5 of 5
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN
Contract#
A. CONTRACTOR INFORMATION
I. Contractor Agency Name:_ J'he Dispute Settlement Cenr, Inc.
Z. If different from Contract Administrator Information in General Contract:
Address
_- -- -
Telephone Number: _ Fax Number: Email:
3. Name of Program (s): Conflict Resolution
4. Status: ( ) Public ( X ) Private,Not for Profit ( ) Private, For Profit
5. Contractor's Financial Reporting Year July l, 2016 through June 30,2017
B. Explanation of Services to be provided and to whom (include S1S Service Code): The
Contractor vil1 assist the County in meeting goals of family safety and sclf-sufficiency by
providing Job Readiness/Conflict Resolution classes and Team Building workshops to Work First
participants(SIS Code 547) Communication/Conflict Resoluticii classes to families involved in
Child Welfare Services, and Communication/Conflict Resolution/Team 8oi|dingtrainb`g_uud
training curriculum and materialsjo Department of Social Services staff Ihe 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.
$75.00/hnur
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. The
County will reimbursç the Contractor at a rate of S75.0Q/Jour for approved ser ices provided. For
reimbursement,the Contractor must submit an pr ~iou\uodtwoou"ieo of an invoice by the fifth
of the month for the preceding month's expenditures to the designated County Administrators.
The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed
report.
F. Area to be served/Delivery site(s): Orange Coon ___
Contract-Scope of Work(06/04) Page lof 1
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
DocuSigned by: DocuSigned by:
DocuSigned
C0340A 'ratAtt.s Att&I,Grsov,
•DAE-1-E-146Aa3B455_ _aK(DA452C124C8
Nancy Coston, Social Services Director (Signature of Contractor)
8/16/2016 8/15/2016
(Date Submitted) (Date Submitted)
Contract-Scope of Work(06/04) Page 2of 2
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
ATTACHMENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County Department of Social Services
I. Uy execution of this Agreement the Contractor ccrtificsthat d 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;
(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 re nb u1tbo1e ch 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
employrne:nt 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;
B. 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}(Z), wkh respect to any onnployeov/hmisxoconvicted:
--
(l) Tukinguppro iut 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 program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agcouy; uod
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&Nondiscrimination rev, 06-2015
Page 1 of 1
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
II. The site(s) for the performance performance of work done in connection with the specific agreement are listed
below:
—
(Street address)
(City, county, state, zip code)
2.
(Street
(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 82'518. 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 hut 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 O.S.C. 88168I-1683, and 1685-1086), 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 IJ.S.C.
886|0l-h|07), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.I.. 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. 91-610), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title VIII of the Civil Rights Act of 1908 (42 D.S.C. 8§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.
DocuSigned by:
yt,tk4t-s i-k-0k,AkstkA,
(
Executive Di
`-- .��2r,u^m - ---
Signature Title
Dispute settlement Center, Inc. 8/I5/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification - Drug-Free Workplace&Nondiscrimination rev, 06-2015
Page 2 of 2
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
Pee irt, 1i_a 2-
Dispute Settlement Center, Inc.
Conflict of Interest Policy
A. Agency officers, directors, employees, and agents are obli::ted to always act in the
best interest of the organization. This obli .tion requires that any officer, director,
employee, or agent,in the performance of Agency duties, seek only the furtherance of the
Agency mission.
B. The officers, directors,employees, or agents of the Agency should neither solicit nor
accept gratuities, favors, or anything of monetary value from contractors/vendors. This is
not intended to preclude bona-fide Agency fund-raising activities.
C. No officer, director, employee or agent of the Agency shall participate in the
selection, award, or administration of a purchase or contract with a vendor where, to his
knowledge,any of the following has a financial interest in that purchase or contract:
1. the officer, director, employee, or agent;
2. any member of their immediate family,
3. their partner;
4. an organization in which any of the above is an officer,director,or
employee;
5. a person or organization with whom any of the above individuals is
negotiating or has any arrangement concerning prospective employment.
D. Disclosure — Any possible conflict of interest shall be disclosed by the person or
persons concerned.
E. Board Action—When a conflict of interest is relevant to a matter requiring action by
the Board, the interested person(s) shall call it to the attention of the Board and said
person(s) shall not vote on the matter. In addition, the person(s) shall not participate in
the final deliberation or decision regarding the matter under consideration and shall leave
the room during the vote of the Board. When there is doubt as to whether a conflict
exists, the matter shall be resolved by vote of the Board, excluding the person(s)
concerning whose situation the doubt has arisen.
F. Record of Conflict—The official minutes of the Board shall reflect that the conflict of
interest was disclosed and the interested person(s) was (were) present during the final
discussion.or vote and did not vote on the matter.
Adopted by the Dispute Settlement enter,Inc.Board ofDirectors, 10127/04
Signed: re-Ce_r_4_,t,S date: 7:27-
Print name: /1:1(--a/ices#efride 1,-164
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
Par, zof
INDIVIDUAL ACKNOWLEDGMENT
Commonwealth/State of OC, I SS:
County of Dr ei _
t.
On this, the 2,---rft' day of , 2D t , before
me, the undersigned officer, personally appeared -Frok,kce
4e-4er'>-)11 .3 known to me (or satisfactorify.proven) to be the
person(s) whose name(s) is/are subscribed to the within instrument, and
acknowledged that he/she/they executed the same for the purposes therein
contained.
In Witness Whereof, I hereunto set my hand and official seal.
wIck -
P Notary Public
etfor;fletAlAcitt2CV/2-C/;12‘,"
(Notary'seal/stamp)
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
� ° � _ ~��� ��
�o°"��� ' —
Settlement '
-- - - -` '' July 18, 2016
o, od.AwOLcouwTY
TO: Orange Count and to whom it may concern
Certification
We certify that the Dispute Settlement Center, Inc. has no overdue tax debts, as defined
by N-[G.S. 105-2431, at the federal, state, or local level. We further understand that
any person who makes� falsestatement i n violation on qfNI.G.S. 143-6.2(b2) is guilty of
a
criminal offense punishable as provided byN.C.G.S. 143-34(b).
Sworn Statement
Neil Offen and Frances Henderson, being duly sworn, say that they are the President
and Executive Director, respectively, of the Dispute Settlement Center, Inc. in the State
of North Carolina; and that the foregoing certification is true, accurate, and complete to
the best of their knowledge and was made and subscribed to by them. They also
acknowledge and understand that any misuse of State funds will be reported to the
appropriate authorities for further action.
(Neil Offen) Sworn to and subscribed before me on the day of the date of said
cert'`fat|on.
q- /�� �u°
/ . ` /
di
�
Neil Offen, Presid Date
(Frances Henderson) Sworn to and subscribed before me on the day of the date of said
certification.
(
0
�4x '. / , '_ ' !� _
_ ~—_-_�' ' ^_ ~ - � .°~-
Frances Henderson, Executive Director Date
Notary Public 5�~° ^t ikteleboil United
Way v.7,7:7
rir.��° m=[0 3O2 West Weaver Street,Cxr6bora,N.c`275lVw(9Ig)929- 8V0m fax: (919) 942-6931 • www.
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
Pitt.5-4.- 2 D`C
INDIVIDUAL ACKNOWLEDGMENT
Commonwealth/State of tje---
} SS:
County of 0 rex -
On this, the 1c64-4--N, day o J4 •, 20 t , before
me, the undersigned officer, personally appeared FfeLveL.i. flevjecer--..„
4- 1\61 b. OC-Ce14 known to me (or satisfactori/y proven) to be the
person(s) whose name(s) is/are subscribed to the within Instrument, and
acknowledged that he/she/they executed the same for the purposes therein
contained,
In Witness Whereof, hereunto set my hand and official seal.
wic•
^ • •
-4tr
\alA -%
- Az-
Notary Public
(Notary seal/stamp)
DocuSign Envelope ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
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 501(c)(3) private non profits.
Who can obtain a 501(c)(3) designation?
Answer: Any organization or group can apply for 501(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 www.irs.gov, 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.
=
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
ATTACHMENT M
STATE AND LOCAL 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 Caroliiia General Statutes can be found online at:
hrhp://v.ww.ncgA.ututc.uc.us/[nuctedLc ix|ation/Statutea/9I)F le/Chapter 64/Article _2.pdf
• The text of G.S. lO5-\64.8(b)can be found online at:
http:ywvvt2IcAa.a{atc.nc.us/Enuctcd[.ogis|ubln/5tututes/P othoo/[bxptcr 105/G5 105 I64.8.ndF
• The text ofG.S. l43-4Q.5 (S.L. 2Ul3'4lD, a. 2.(d)) can he found online at:
bKp://wv?.2cgu.otadc.nc.us/Sesnioos/20\3/BiUs/Housc/PDF/H788v6pdf
• The text of G.S. 143-59.1 can be found online at:
bttp://w**. Aota¢e.oc.us/[nuote dL rgi lcki on/3tut 1es/PUF/B 3 ec ti on/Chu ter_l43/GS 143-59.1.pi
• The text of G,S. 143-59.2 can be found online at:
http://ww/vv.ncgu.s|ute.nc.us/FoactcdLegiu}olion/ pDF/BYSccdon/Chuotor 143/(}S 143 df
• The text ofG.3. I47-3395(g) (SI. 28|3-4|8, a. 2. (e))canbcfbundoolincx1:
hUp:Xvvv/vvmcga.sta8e.oc.uo/Sessions/20l3/Bi\|o/Rouse/PDF/H786v6.pdf
• The text of Orange County Living Wage Contractor Policy which is attached to this document.
Certifications
(1) Pursuant to G.S. 143-48.5, 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:
w2v.nsois.Qov
Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina General Statutes.
F[ovvevor, |oca] go*ccnnoontimoobjcu{1oundnuum(cooup|ywidhNorthCuroliuuGuuoral5tatcte8I53A,99.I.,
which states in part as follows:
Counties Must Use E-Verify. - Each county shall re ister and participate in E-Verify to verif 'the work
authorization of new employees hired to work in the United States.
(2) Pursuant to G.S. 143-59.1(h), the undersigned hereby certifies that the Contractor named below is not an
"ineligible Contractor"as set forth in O.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 185 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 1 of I
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
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. l43'59.l(u) (Z) after December 3l, 2OO>; or
Fl
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(u)(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. 143-50.2(b), the undersigned hereby certifies that none of the Contractor's officers, director,,
or owners (if the Contractor is an unincorporated business entity) has been convicted ofany violation ofChup1cc
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) Be or she understands that any person who knowingly submits a false certification in response to the
requirements of G.S. l4]'59.lamd -5q.2 shall he guilty of a Class I felony.
(5) Pursuant to the Orange County Living Wage Contractor's Policy:
(a) The undersigned certifies that the Contractor pays the employees who perform services under this contract a
living wage (in Orange County currently $13.15 per/hr.) Check here E if contractor pays employees
performing under this contract a living wage. If Contractor does not pay employees a living wage, what is the
wage that employees performing services under this contract paid
------'
Dispute Settlement center, Inc.
ElactiSigned r -- — ---
or;s Name ,L
'
�ratAw tl-GlAjtXSO\u
8/15/2016
Signature of Contractor's Authorized Agent Date
Frances Henderson
Executive Director
_
Printed�� � -- uivr`s Authorized Agent Title
itA. ['MS
wediator
- _
Signature of Witness Title
Julie Potts 8/I5/2016
Printed Name ofWitness 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
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
Section I: General Government and Administration
Policy 10.0: Living Wage Contractor Policy
Reviewed by: County ounty Manager
Approved by: County Manager
Original Effective Date: April 2l, 20|§
Revisions:
Policy Statement
It is the policy of Orange County to ensure its employees, and all individuals who provide services for Orange County, are
paid a living wage.
Purpose
To encourage all vendors and contractors to pay a living wage to all employees who perform work pursuant to a contract
with Orange County.
Applicability
Applies to all Orange County contracts and purchases.
Policy
10.1 Living Wage
10.1.1 Orange County is committed to providing its employees with a living wage and encourages all contractors
and vendors doing business with Orange County to pursue the same goal. Orange County's living wage is $13.15
per hour. Tu the extent possible, Orange County re000�oueodethat oonUactooand veodooseeking to do business
with Orange County provide a living wage to their employees.
10.1.2 Prior to final execution of a contract with Orange County all contractors and vendors seeking to do
business with Orange County shall submit to the County's representative a statement indicating whether those
employees who will perform work on the Orange County contract are paid at least the living wage amount set out
above. If such employees do not make at least the living wage amount set out above the contractor or vendor
shall indicate in the statement the actual amount paid to such employees. For bid p jects this statement should
he submitted as part of the bid packet.
This policy may be reviewed annually and updated as needed by the Manager's Office
Contractor Certifications Required by North Carolina Law Page 3 of 3
onnunign Envelope ID:oonsxe1a-CC Fo20F10E29
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:
). The Contractor aQroua10 participate in program, fiuouland 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. Provide Job Readiness/Conflict Resolution Workshops to Work First clients referred by the
County.
a. The maximum number of billable hours per class is 33 and includes all prep time.
B. Provide Team Building Workshops to Work First clients referred by the County.
a. The maximum number of billable hours per class is 6 and includes all prep time.
C. Provide Communication/Conflict Resolution classes to families or individuals involved with
Child Welfare Services and referred by the County per year.
a. The maximum number of billable hours per class is 27 and includes all prep time.
D. Submit invoices to the appropriate administrator.
a. Work First and staff training invoices to Sharron Hinton
b. Child Welfare Services invoices to Denise Shaffer
E. Help to ensure that 80% of Work First clients enrolled in classes obtain employment within 3
months of completion and maintain employment for at least 6 months after the class ends.
E. Help to ensure that 80Y6 of clients referred through child welfare will have no instances or no
repeat instances of child maltreatment.
O. Maintain client records that date and document the service delivered to the individual,a valid
authorization for service, program records, and documents and other evidence that reflect
program operations.
H. Furnish information to the County, as requested, to support provision of service(s) pursuant to
this Contract and the full cost of the service; and submit changes, as needed or required for
review and approval by the County.
I. Maintain books, records, documents and other evidence and accounting procedures that reflect
all direct and indirect costs expended under this Contract. A current, complete inventory of all
equipment purchased under the terms of this Contract must be kept.
J. Retain all financial aiid program records fora period of three years from the date of fmal
payment under this agreement or until all audits continued beyond this period are completed.
Federal auditors and any persons authorized by the Division of Social Services or the County
mla,wbriawusetheriub1tnexamoinupnyofthcnonouLcriu|s.
ht4y,txsau
Executive Di rector
`2^oo-
Signuurc Title
Dispute Settlement Center, Inc. 8/I5/2015
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 1 *fl
DocuSi n Envelo e ID:BC6E8913-CCF6-4358-9785-EOFD20F10E29
a RIJ CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDOIYYYY)
1/15/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Crystal Ireland
Business Insurers of Carolinas PHONE (919)968-4611 I FAX,Nol:(915)568-8591
INC.Nn.Ertl__W800 Eastowne Drive, Suite 208 IL :cirelandwzbusiness-insurers.com
—....
PO Box 2536 INSURERISI AFFORDING COVERAGE NAIC 4
NC 27515-2536 INSUREBA:Hamilton Mutual Insurance Co 14125
Chapel hill y
. ' INSURED INSURER s Employers Mutual Casualty 21415
DISPUTE SETTLEMENT CENTER INC INSURER C: -.°.°.-,..._.
302 W WEAVER ST 8TE A INSURER D
INSURER E: -- -
._.,_..............-- -
CARRBORD NC 27510-6004 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL156313007 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLIC4ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID „.CLAIMS.
MR _. ...---AlIZE Ugl2_ . POLICYEFF � YI POLICY E7cI _-.___ LILIMITS .,_....-.._...._°.._ -`
LTR TYPE OF INSURANCE IMVD POUCY NUMBER (MM/DDIYYYY) (MM/DDIYYY .
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000'000,000
INTl E7
A CLPJMS-MADE I7{JOCCUR PREMISES fEaoc4¢!?N(L:I?1____..S 300,000
4W54457 6/17/2015 6/17/2016 MF_i)E%P(Any one pYrxerr) S 5,000
PERSONAL&ADV INJURY 5
GEIIL AGGREGATE LIMIT APPLIES PER: GENERA!-AGGREGATE S
_
X POLICY r.7£CT j LOC PRODUCTS-COMP/OP AGG 5 2,000,000
HiedPoorrcwed 5 1,000,000
l COMB NFi:'1N6 LIMIT S
AUIrOMoniLP LIAr11LYrr Ea accident;
I ANY AUTO BODILY NJURY(Per person) $
111 PROPERTY DANAC,Eadent)'I$
`^-��-
ALLOS SCHEDULED
IAUTOS _ NON-U
(Per accident) .. .,_..,,._°..,_.
1 HIRED AUTOS AUTOS $
UMBRELLA LIAR I OCCUR i ',EACH OCCURRENCE E..
EXCESS LIAB CLAIMS-MADE AGGREGA-E $ ,
DED RETENTION$ I S
WORKERS COMPENSATION ...... x__STATUTE I I ERA I ...
AND EMPLOYERS LWBIIJTY Y I N
AM'PROPRIETORIPARTNER/EXECUTIVE I N/A E,L.EACH AL:CIDEN I !S 100,000
OFFIratorin NH) 41154487 6/17/2015 6/17/2016 F DSEASE-EA EMPLOYE $ 100,000
B (Mandatory in NH) --.. •°
Pr Yes.derlalbe Lnder
DESCRIPTION OF OPERATIONS below E_L U!3EASE-POLICY UM T $ 500,000
°
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AM:Rimed imed Remarks Schedule,maybe attached C more space Is required)
CERTIFICATE HOLDER CANCELLATION
jethompson @orangecountync.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Orange County THE EXPIRATION ON TH POLICY THEREOF, NI TICE WILL BE DELIVERED EN
PO Box 8181
Hillsborough, NC 27278
AUTHORIZED REPRESENTATIVE /
C Ireland/IRELO1 � �awwrlGJ
al 1988-2014 ACORD CORPORATION, All rights reserved.
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