HomeMy WebLinkAbout2016-481-E DSS - Chatham Transit Network for non-emergency Medicaid transportation DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
Contract 468-2030
Chatham Transit Network
Contract# 68'2030 Fiscal Year Begins Juh/|„2016 Ends 3O, 2017 _
This contract imhereb� entered into ~b� and b�twceothe Orange County Dcpu�oecdof Social Services hhc "Coonty°> 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 Co nditions(Attachment A)
(3) Th Scope of Wor k, description of services, and rate e ( \ttach000t&)
(4) l Certi cation Regarding Drug-Free Workplace&Certification
Regarding Nondiscrimination(Attachment C)
(5) Conflict of interest(Attachment D)
(6) No Overdue Taxes (Attachment E)
(7) Certification of Transportation (Attachment J)
(8) IRS F d oru)I ax Exempt Lett r or 501(c)(3) (
A1taobm «mtK)
(9) State and Local Certifications (Attachment M)
(10) Outcomes and Reporting(Attachment N)
(Ii)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,th terms of this greement 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 hv the County to the Contractor under this contract shall not exceed $l0,0OO. This
amount consists u[$|0,000in Federal (CFDA # ), State and County funds, $0 (s'ource of other funds if
applicable).
[X] a. There are no matching requirements from,the Contractor.
[ ] b. The Contractor's matching requirement is$ / which shall consist of:
] lu-kiod [ ] {�avh
' l Cash and In-kind [ ] Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federa 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. § 143C-6-22&23
and OMB Circular A,l33 and shall disclose all information required hy42USC455.lV4,or42DSC455.l05,mr42USC
455.106.
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Contract-General (87/10)
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DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
Contract#68-2030
Chatham Transit Netwmk
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 nllquestinnuuhout
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 I)ELIVERED BY ANY OTI-IER MEANS
Lindsey Shewmaker, Human Services Manager Lindsey Shewmaker, Human rvices 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
| |ahev/moker(c4)orunAoo ou.uYv �
For the Contractor:
`
IF DELIVEREE) BY US POSTAL SERVICE � BU2L8/BRED8Y ANY OTB��MEANS
Anna Testerma
Chatham Transit Network
P.O. Box 1032
9ittsbo,o,NC273l2
(919)`
9. No Assignment or Sub-Contract: Contractor shall not sub-contract out any of the services provided for in this
Agreement or make any assi ment of th is 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 that funds received pursuant to this contract
shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the
Contractor otherwise expends for Contract services and related programs.Funds received under this contract shall be used
to provide additional public funding for such services; the funds shall not be used to reduce the Contractor's total
expenditure of other public funds for such services.
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
i. Validity arid 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
u. Implement procedures to insure that account balance is solvent and reconcile the account monthly.
Contract-General (07/18) Page 2 of 5
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Envelope ID: Contract#68-2030
Chathani Transit Network
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 connpiiunocv/idzcn�aiu
` certibcn1ionurcquirodb` Dcderullap/oaodrcgola1ioox. Thocoubaotoriobcrchvcoruplying��i\hCerti5cm1ionar*gording
Nondiscrimination, Drug-Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension,
Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and
certifications acctnbenigncdhy the contractor's authorized representative.
14. 8�ela�uomhipof the l"andom: Contractor ieun independent contractor of the County.Contractor represents that b has or
' wil} sccurouti&np/oexpsnxe,nUpcnoune|roquin:dioporDxnmiugdboecrvicesnndcrihiu/\�ecnocut. Suchpe000uc\
sbuUnot b`employees ufor have any contractual rcludooabip*v�bthe(�nuoty. ��Upersonnel engaged iov/ork under this
&g7ccm�~~shall be fully qualified and xhaUhe authorized orpeooi�cd under state and local law 1oper�/oo such services.
ltisfurt~^^u�r��dh�ConU-aotortbatit�hu|luh�yul/StatcxmdF�d��als1ututeo,nUox and regulations vvbiuhare applicable
^^~^ of Contractor o n1ructoznhu|\bedccnocduo
officer, employee or agent of the County.
15. Termination: This Agreement may be terminated as specified in Attachment A, General Terms And Conditions.
16. Dmxoruno*Regoiromuemtx;CooLroutnroballobtuin"uthssn]e expense,all insurance as required in Attachment A,General
lerms And Conditions.
17. Indemnification:Contractor agrees to defend,indemnify,and hold harmless the County,for all loss, liability,claims or
expense (including reasonable attorney's fees) arising from boddyi jury, including death or property damage, to any
person or persons caused in whole or in part by Contractor in accordance with Attachment A, General Terms And
Conditions.
It is the intent of this Section that Contractor indemnify County to the full extent permitted by law.
88` Entire Agreement: The part Agreement,
all of its terms, and further agree that it constitutes the complete arid exclusive statement of the Agreement between the
parties.
19. Interpretation: When the context in which words are used in this Agreement indicates that such is the intent,words shall
in the singular number shall include the plural and vice versa. The masculine gender shall include the feminine and neuter.
IN WITNESS WHEREOF,the County and the Contractor have been first duly authorized,have executed and entered into
this Agreement as of the day and year first above written.
Contract-General-General� '0Contract-General (07/10) Po�o3of5
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DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
Contract#68'2030
Chatham Transit Network
CHATH
-rt,skoKain, 8/22/2015
0EG5F6248.9~
Signature --' --- ---' ----
[)ate
xnna Testerman Executive Di rector
Printed Name --- -- — ---
Title
ORANGE COUNTY
DocuSigned by:
,J.�
�� �
( � '
8/23/2016
63.7.99487_55E41.77
BoomieHoznoeoley, County Manager -- ----Date ---
Contract-General (07/10) Page 4 of 5
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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 he 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
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DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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 writte
insurance supplements, but does not notice to the Contractor.
replace,the car-owner's liability insurance.
Termination for Cause: If, through any cause, th-
The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under th s
automobile liability insurance on any vehicle—owned, contract in a timely and proper manner, the County sha I
hired, or non-owned --unless the vehicle is used in the have the right to terminate this contract by giving writte
performance of this contract. notice to the Contractor and specifying the effective dat
(d) The insurance coverage minimums specified in thereof In that event,all finished or unfinished deliverabl
subparagraph (a) are exclusive of defense costs. items prepared by the Contractor under this contract shal ,
(e) The Contractor understands and agrees that the at the option of the County, become its property and th-
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 sue
Contractor's liability or obligations under this contract. materials,minus any payment or compensation previousl.
(f) The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, tit
of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the Coun
demonstrating that it has insurance that provides for damages sustained by the County by virtue of th,
protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County ma
and limits specified in subparagraph (a). The County withhold any payment due the Contractor for the purpos,
shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damage
should be granted. due the County from such breach can be determined. h
(g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting an
of the requirements in paragraph(a)by demonstrating other remedies for breach available to it,the County ma
that it is self-insured and that its self-insurance procure the contract services from other sources and hol
provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasionei
coverage and limits specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by thi.
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 defaul
insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract b
is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of an
essence of this contract. subsequent default or breach and shall not be construed t
(i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless state.
companies that are authorized to provide such to be such in writing, signed by an authorize
coverage and that are authorized by the Commissioner representative of the County and the Contractor an
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 agre:
(j) The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified i
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 fund.
(k) The Contractor shall require its subcontractors to for this purpose to the County.
comply with the requirements of this paragraph.
(I) 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 i.:
certificates of insurance to the County before the prevented from performing such obligations by any act o'
Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes,
civil insurrection,earthquake, hurricane, tornado,or other
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
waiTanties 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:BD69DF46-15CD-49E6-8588-93617FCCFB94
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
(HEIS) 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 not
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:BD69DF46-15CD-49E6-8588-93617FCCFB94
subcontractors,complies with the requirements of Article F
Record Retention: Records shall not he 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 i's
whichever is longer. If the contract is subject to federal terms or provisions, as well as the rights and duties of di-
policy and regulations,record retention may be longer than parties to this contract, are governed by the laws of Nort
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,t
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 exclusiv
Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange Count ., 1
negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and a I
involving this Contract has been started before expiration transactions and agreements relating to it, and their situ'
of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,wher .
records must be retained until completion of the action and all matters,whether sounding in contract or tort,relating ti
resolution of all issues which arise from it, or until the end the validity, construction, interpretation, and enforcemet
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 o
and Medical Assistance grants and programs must be by performance. Any amendment must be made in writte I
retained for a minimum of ten years. form and executed by duly authorized representatives o
the County and the Contractor.
Warranties and Certifications
Severability: In the event that a court of competen
Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of thi:.,
the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provisio
contract("product" includes,without limitation,any piece or requirement shall continue to be enforced to the extent i
of equipment,hardware,finnware,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 contrac.
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 tho,
shall survive the termination or expiration of this contract. agreement arid should not be used to construe the meanin I
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 assigied 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 othe
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:BD69DF46-15CD-49E6-8588-93617FCCFB94
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. 1 1A 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
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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 Nctworj
2. /fJh9�ren/Iiwnn Contract&dnmioisho1nrInfhroahonin General Contract:
If —
&ddrcus_' _ - — — -- —
--- - _
Telephone Number: _ Fax Number: Email:
3. Name of Program (s): Medicaid Transportation
4. Status: ( ) Public (X)Private,Not for Profit ( ) Private For Profit
5. Contractor's Financial Reporting Year July 1, 2016 through June 30 2017
B. Explanation of Services to be provided and to whom(include SlS Service Code): The
Coutr�o�or�*U| providutranopo�n1iooverviceutoc}icn1�jideodf5edbytbuCounty. The
Contractor will transport client(s)to and from medical appointments. The Contractor is required
to meet all goals and outcomes listed i AttachmentN.
C. Rate per unit of Service(define the unit):
I. If Standard Fixed Rate, Maximum Allowable,(See Rates for Services Chart)
2. Negotiated County Rate.
$60.20/one way trip
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 original and two copies of an invoice by the fifth
of the month for the preceding iiionth's, penditures to he designated 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 approved trips.
F. Area to be served/Delivery site(s): Orange County� ___
Contract-Scope of Work(06/04) Page lof 1
■MME
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
DocuSigned by:
r
cost.,
-DAH-E-1436A83A455- DocuSigned by:
ra. Dt-sfunaituA,
.8E...3€43E105-52488.-
Nancy Coston, Social Services Director (Signature of Contractor)
8/23/2016
8/22/2016
(Date Submitted) (Date Submitted)
Contract-Scope of Work(06/04) Page 2of 2
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
ATTACHMENT C
CERTIFICATION REGARDING DRUG-FREE VVORKPLACERE8D]REMGNT3
AND CERTIFICATION REGARDING NONDISCRIMINATION
Orange County Department of Social Services
I. By 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 eozployornf any cdzoiouldrug statute conviction for uvio|udon occurring
` ' iu the'workplace uo later than five days after such conviction;
B. Notifying the County within ten days after receiving notice under subparagraph (D)(2) from an
cnop|'yucor otherwise receiving actual notice o[such conviction;
P. Taking one of the following actions, within 30 days of receiving notice under subparagraph
(i))(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)Requbingsucbczoy!oyeotopm1ioipate satisfactorily in a drug abuse assistance or
' rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency; and
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 of
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
D. The site(s) for the performance of work done in connection with the specific agreement are listed
below:
].
(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 codifioakionor violation of the certification shall bc grounds for suspension o[payment, suspension
or termination of grants, or government-wide Federal suspension or debarment
45 C.F.R. Section 02'510. Section 4 CFR Part 85, Section 85'615 and 86.020.
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 o[ l964 (PI- 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. §81681'l603, and 1685-1686), which prohibits discrimination on the basis
of sex; (c) Section 504ofdbeRobuhi|itadoo /\otofl973, aooz000dcd (29U.S.C. 8794), vvbicbpcohibi&
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C.
§86l01'6l07), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.[. 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.I... 91-610), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title VIII of the Civil Rights Act of 1068 (42 U.S.C. 883601 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 (h the
requirements of any other nondiscrImination statutes which may apply to this Agreement.
f—DocuSigned by:
atAAAA, ti-SkriklatA, Executive Di rector
Signutmro ^^~~~~~'~^`~^ Title ---- --
Chatham Transit Network 8/22/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification Drug-Free Workplace& Nondiscrimination rev. 86'2015
Page 2of2
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
I;1„ 11 1, II 11
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.
1
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
_
• 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 bonafide
Chatham Transit Network fundraising activities.
• Disclosure-All conflicts of interest shall 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
Tim Mounce
2
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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.
' i1
4
Chatham Transit Network
Pia Box |uaz
Pioshom.NCJ7312
(Date nf Certification(07l82016)l
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. 3. \O5'243.1/, o1dhe6mdora[ Stutu, or |oca! |evni We further understand that any
person who makes a false statement in violation of N.C.G.S. 143[-6-23(c) is guilty of a criminal
offense punishable as provided by N.C.G.S. 143C-l0'l(b).
Sworn Statement:
Tim Mounce and Anna Testerman being duly sworn,say that we are the Board Chair and the
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
mism .�ndo will bercpo�ed tn the appropriate uuthohhesfor further acbon.
- - �� �.�
- �` / \ �� `
w `
Board hair jcs
Executive Director
Sworn to and subscribed befor me on the day of the date of said certification.
010. My Commission Expires: Od 44 |��
� �
Deborah H.Brown
Notary Public
Lee County,North Carolina
G.S. 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 tax debt,however,if the taxpayer
entered into an installment agreement for the tax debt under 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 thc installment agreement."
�ago � nf|
O���T�m- 0�80
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
ATTACHMENT
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:
1. 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 County Department of Social
Services;
5. Insuring that no more than one quarter of one percent of all trips be missed by the
contractor during the course of the contract period; (Medicaid only)
6. Insuring that that no more than five percent (5%) of trips should be late for recipient drop
off to their appointment per month; (Medicaid only)
7. 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.
8. Disclosing, at the outset of the contract, upon renewal and upon request, any criminal
convictions or other reasons for disqualifications from participation in Medicare,
• • aTitle XX programs (signature on this form confirms this statement).
atAAAA -rt,stunaictiA, Executive Di rector
82E360DC5F52488
Signature Title
Chatham Transit Network 8/22/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Transportation Certification(06/16) Page 1 of 1
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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(e)(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.
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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 signi
• The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at:
htt /www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_64/Artiele_2.pdf
• The text of G.S. l05-l64.8(b) can hc found online at:
.atuto.nc.us/EomctcdLcgislution/S<otu1cs/PD[/8ySochno/Cbaptcr_)O5/G3 185 l64.8.pdf
• The text nf(3.3. l43-48.5 (8].. 2Ol3'4l8, u. 2.(d))can bc found online at:
http://vv/w.nogu.ntutc.uc.uo/8essiooy/2OlJ/8i(|s/Houye/PZ)F/H7R0v6.Pd[
• The text ofG.S. l43-59.l can be found online at:
bKp://v/`,vacgu.siu\o.nc.un/Enuctcdlzgia|n1ion/Stntutcn/9DF/BYScctioo/Chnptcc 143/OS ]43'59.].pdf
• The text of G.S143-59.2� � �
http://www.ncga.state.nc.us/EnactedLe_=islation/Staiu<co/PDF/8v�ccdoo/[bup<�rl43�]S l4J-�92�*df
.
• The text of G.S. 147-33.95(g) (S.L. 2013-418, s. 2. (e))can be found online at:
htt ://mww.nctu.mtotc.uc.uu/8cooioos/20l3UBiUv/Bnuao/PI)F/B780v6.pd[
• 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 2-Verify system." E-Verify System Link:
11wwua«ix.-ov
Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina General Statutes.
However, local government is subject to and must comply with North Carolina General Statute §153A-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.B. 143-59,2(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[ux. Page | of 3
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
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 have
country" as set forth inG.S. I4]-59.l(o) (2)after December 3(, 20Ol; or ,
Fl reincorporated
as set forth in (].S. 143-59.1(c)(2) after December 31" 2001 but the United States is not dh.
principal market for the public trading of the stock of the corporation incorporated in the ta
haven country.
(3) Pursuant to G.S. 143-59.2(h), 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 of any violation of Chapt.r
78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 year..
immediately prior to the date of the bid solicitation.
(4) The undersigned hereby certifies further that:
(a) lie 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 ofth-,
Contractor; and
(c) He or she understands that any person who knowingly submits a false certification in response to t -
requirements of G.S l43'59.laod'5y.2 shall bc guilty ofw Class lfelony.
(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
living wage (in Orange County currently $13.15 per/hr.) Check here | | if contractor pays eznploye.o
pci-forming under this contract a living wage. If Contractor does riot pay employees a living wage,what is tl.e
wage that employees performing services under this contract pail
Chatham Transit Network
Contract(
`GU& 8/22/2016
!==20=x60n�5E524Es_
Signature of Contractor's Authorized Agent Date
xnna Testerman Executive Di rector
Printed N.ii Thäctor's Authorized Agent Title
�@�kmok� Finance coordinator
Signature o vy� ^s^�— Title
Angie Blackmon 8/29/2016
Printed Name of Witness Date
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and da e
this document immediately thereafter.
Contractor Certifications Required by North Carolina Law Page 2 o 3
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
Section I: General Government and Administration
Policy 10.0: Living Wage Contractor Policy
Reviewed by: County Attorney/County Manager
Approved by: County Manager
Original Effective Date: April 21, 2016
Revisions:
Policy Statement
It is the policy of Orange County to ensure its employees, and all individuals who provide services for()range 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] Living Wage
10.1.1 Orange County is committed to providing its employees with a living wage and encourages all contractors
and vendor doing business with Orange County to pursue the same goal. Orange County's living wage is $13.15
per hour. To the extent possible, Orange County recommends that contractors and vendors seeking 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 purb»oo 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 projects this statement should
be 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
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
ATTACHMENT N
OUTCOMES AND REPORTING
Orange County Departm nt of Social Services
By signing and submitting this document, the Contractor certifies that it agrees to the follo ' :
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 comp]iance 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.
B. Discuss the specific situation, and present evidence of cause, with the County prior to
termination of services for any client.
I. 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 pet-formance standards such that no more than 5% 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.
0. 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.
B. 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
"c o
k�x^� | �5�4o�N�.
sxecutive oirectnr
Signature Title
Chatham Transit Network 8/22/2016
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Outcomes (06/04) Page 1 of
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
N O R T H ` C A R O L I N A
ASSOCIATION OF COUNTY COMMISSIONERS
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
na|wigx.mocr$OV and is issued as a m*xev,in�rm�ion only. Tmsoe�i�oo�uomemn"
rights upon the certificate holder other than those provided inthe
MEMBER:
coverage document. This certificate does not amend,extend,or alter the
Chatham Transit Network coverage afforded by the coverage documents listed herein
*ao Hillsboro Street,Suite 110
Pittsboro,NC 27312
COVERAGES
Type of Coverage Coverage Effective Expiration
Contract# Date Date Limits
Coverage A:
WORKERS'COMPENSATION
vvC'oH-*75-16 July 1.un1s July 1,2017 Statutory
Coverage B:
EMPLOYERS'LIABILITY
. WC-CH-475-16 July 1.cn1w July 1.uo1r. $2,000,000
Coverage C:
OTHER STATES
vvC-CH'475'16 July 1.zo1n July 1.2o1r Statutory
Additional Information: Evidence fo Coverage.
CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before
m*oxpinuivoda\euhown mewCACC Pools vwnendeavor m mail umxannuonotoma
Orange County Dept o '
� Certificate Holder named herein,but failure m mail such notice shall impose noobligation
Services or liability of any kind upon the NCACC Pools,its agents or representatives,or the issuer of
P.O. Box 8181 this certificate.
Hillsborough,moeruru
By: Collin Klein, Underwriting | -~��� I Tvu»niuianmrtmamnAco | —� ' 7/12s016
Certificate MeiIed/E-Mailed or Faxed to:
Orange County Dept. o Social
Services
P.O. Box 8181
Hillsborough, NC 27278
DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94
gAla .41`tlr"
••
NORTH --- CAROLINA
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
216 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
480 Hillsboro Street,Suite 110 coverage documents listed herein.
Pittsboro,NC 27312
COVERAGES
Type of Coverage I Coverage I Effective I Expiration 1
I Contract# 1 Date 1 Date I Limits
Liability
General Liability—
X Each Occurrence,
No Aggregate applies LP-CH-475-16 July 1,2016 July 1,2017
X Public Officials Liability, $2,000,000 occurrence
Each Wrongful Act LP-CH-475-16 July 1,2016 July 1,2017
X Law Enforcement Liability,
Each Occurrence
$1,000,000 aggregate
Cyber Liability LP-CH-475-16 July 1,2016 July 1,2017 Claims Made
Excess Liability
Automobile Liability
All Owned Autos,
X
Each Accident LP-CH-475-16 July 1,2016 July 1,2017
Hired Autos,
X $2,000,000 occurrence
Each Accident LP-CH-475-16 July 1,2016 July 1,2017
Excess Auto Liability for
X
Non-Owned Autos _ LP-CH-475-16 July 1,2016_July 1,2017
Automobile Physical Damage
X Scheduled Vehicles Actual Cash Value at the time of
LP-CH-475-16 July 1,2016 July 1,2017 the Loss,unless otherwise
Hired Autos(if coverage is not specified in the Coverage
X Document;Deductible Applies
purchased elsewhere)
LP-CH-475-16 July 1,2016 July 1,2017
Limit Deductible
Property—Risks of Direct Physical Loss,
Blanket Limit LP-CH-475-16 July 1,2016 July 1,2017 $ 1,117,200 I $1,000
Additional Information: Evidence of Coverage.
CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be
cancelled before the expiration date shown, the NCACC Pools will endeavor to
Orange County Dept.Social Services
mail written notice to the Certificate Holder named herein,but failure to mail such
P.O.Box 8181 notice shall impose no obligation or liability of any kind upon the NCACC Pools,its
Hillsborough,NC 27278 agents or representatives,or the issuer of this certificate,
By:Willie J.Allen Jr.,
/ref/ "X ) I
Underwriter for the NCACC 7/12/2016
Certificate Mailed/E-Mailed or Faxed to:
Orange County Dept.Social Services
P.O. Box 8181
Ilillsborough, NC 27278
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