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2016-587-E Finance - Chapel Hill-Carrboro Meals on Wheels - Outside Agency Performance Agreement
DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2016, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Chapel Hill-Carrboro Meals on Wheels, a not-for- profit corporation, located at 1712 Willow Drive, Chapel Hill,NC 27514("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Chapel Hill-Carrboro Meals on Wheels agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit"A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 15000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $3,750. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Chapel Hill-Carrboro Meals on Wheels) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 13,April 14, and July 14 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Chapel Hill-Carrboro Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC& Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Chapel Hill-Carrboro Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per hour. To the extent possible, Orange County recommends that Chapel Hill-Carrboro Meals on Wheels provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Chapel Hill-Carrboro Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 County: Finance&Administrative Services Provider: Chapel Hill-Carrboro Meals on Orange County Wheels Post Office Box 8181 1712 Willow Drive Hillsborough,NC 27278 Chapel Hill,NC 27514 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. 7 ib igi136fthe Provider at 4 gtAs6 10/26/2016 El B0ABFD5602405... Date For and o,r elk , „ufiQrange County Government 6lA,Uttt, tka" tt-IrStt 10/26/2016 a6-`HcBY-55E4n... Bonnie Hammersley, County Manager Date (Chapel Hill-Carrboro Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DD1ocuSigned by: SI (�1A5�0 Executive Director 10/26/2016 Certified by: Title: Date: CI DOADFD402405... (Provider's Signature) (Chapel Hill-Carrboro Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Chapel Hill-Carrboro Meals on Wheels Date/Time / 1 Complete Y/N Program(s) Meals for the Homebound Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. ® Applicant Contact Information b. ® Project/Program Contact Information c. ® Funding Requests Identified d. ® Signed Application Cover Page 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 c. ® Agency's Types of Services Provided CFR Parts 84 or 85 d. ® Agency's Experience e. ® Other Pertinent Information 3. Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), Project b. 570.201-570. 208, ® Summary of Program Information - c. ® Description of Identified Need 507.503 (for each d. ® Description of Population to be Served program/ project for e. ® Activity Manager and Location Description which funding f. ® Activity Implementation Timeline is requested) g. ® Agency Collaboration h. ® Describe Impact of Reduced/No Allocation i. ® Other Pertinent Information j. ® Complete Target Population/Beneficiary Chart k. ® Complete Schedule of Positions I. ® Signed Conflict of Interest Disclosure m. ® Complete Work Statement i o:° DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. ® Program Budget Worksheet 570.602, 570.607(b), is requested) b. ® Program Budget Detail 570.611 24 CFR c. ® Cost Per Unit 570.502-570.504, d. ® Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. ® Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors 24 CFR Parts 84 or 85 g. ® Articles of Incorporation/Bylaws 24 CFR 570.208, h. ® Authorization to Request Funds 570.500(c), 570.611 i. ® Authorized official designation j. ® Solid Waste Program Fee (SWPF) Verification Main Application 5/24/2016 9:18:54 AM 0 I:°' 2 of 2 DocuSign Envelope ID:24839407 oe2D-47A2 e388-3eEA00100uC1 i /\ - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE program requires a rate H��� a) Applicant Contact Information Applicant Organization's Legal Name: Chapel Hill-Carrboro Meals on Wheels Applicant Organization's Ph i l Address: 1712 Willow Drive Chapel Hill NC 275104 Applicant Organization's Mailing Address: P0 Box 2102 Chapel HU| NC27515 Applicant Organization's Web Address www.chcmow.orq Executive Director: Stacey Yusko Telephone Number: 919-942-2948 E'K8ei|: stmceyohcnnow.org DUNS Number: na (Dun & Bradstreet, Inc. provides this number at no oharge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Meals for the Homebound Project/Program Primary Contact and Title: Stacey Yusko Executive Director Telephone Number: 919-942-2948 E-Mail: staceychcmow.orq c) Funding Request Identification Total Pr ject/Program Cost: $308,000 Total Amount of Funds Requested: $45.000 Proposed Use of Funds Requested (2-3 Line Maximum): To offset the subsidy we provide those who can't contribute to the cost of the meal we deliver Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints, CDBG Non-Construction (CH) $ 0 Grant E Loan CDBG Construction (CH) � Grant Loan ` ' �� L HOME CHDO (OC) 0Grant ri Loan | HOME Other (OC) � Grant [7 Loan 141 Human Services: I Carrboro $15.000 I Chapel Hill $15.000 Orange County $15,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Signature: ' ° ' Main Application 1/20/2016 11:21:36 /\M Page 3 of � � � � . DocuSign Envelope ID:24839407 oe2D-47A2 e388-3eEA00100uC1 i /\ - continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this p ject, or members of their immediate families, or their business associates: YES NO El a a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrbono' orHillsborough? T b) Members of or closely related to members of the governing bodies of Chapel Hi|\, Carrboro, Hillsborough, or Orange County? [| u\ Current beneficiaries of the project/program forvvhichfundsorenaqueeted? E 'sr d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. /�� ) ' 2--( / (' Signature: // /«, �` ^ / ' Executive Director Date Signature: 000 'Board Chairperson Date Main Application 1/20/2016 11:21:36 AM P e I 2 0f 2 � DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application To Whom it May Concern: To be in compliance with the following condition of applying for Town Funding: MEALS WH E LS a) Designation of Authorized Official Documentation must be submitted of the governing body's action authorizing the representative of the agency to negotiate for and contractually bind the agency. Delivering more than Documentation of this requirement consists of a signed letter from the Chairperson of the meals since 1976 governing body providing the name,title, address and telephone number of each authorized individual. Board of Directors: The following individuals are designated as authorized officials. Patricia Bergey,Chair Stacey Yusko, Executive Director 2121 N Lakeshore Drive Chapel Hill NC 27514 919-942-2948 Madeline Blobe Patricia Bergey, Board Chair 1003 Gloucester Court Chapel Hill NC 27516 919-636-1360 Sharon Bushnell Alex Castro Madeline Blobe,Treasurer 200 Manor Ridge Drive Carrboro NC 27517 919-932-4411 Tina Cunningham Lisa Finegan Sincerely, Alyson Grine Dennis Horstman Amy McEntee P tricia Bergey, Board air Jenna Meints Chapel Hill-Carrboro eals on Wheels Yvette Missri Lee Strange Joyce Waterbury Chapel Hill-Carrboro Meals on Wheels is a 501(c)(3)non profit organization.Your contribution is tax deductible to the extent allowed by law,No goods or services were provided in exchange for your Stacey Yusko, donation. Executive Director Financial information about this organization and a copy of its license are available from the Charitable WWW.chcmow.org Solicitation Licensing Section at 888-830-4989.This license is not an endorsement by the State. Physical Address:Binkley Baptist Church 1712 Willow Drive Chapel Hill NC 27514 Mailing Address:PO Box 2102 Chapel Hill NC 27515 Partner Agency DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) 40 years, October 1976 b) Agency's Purpose/Mission We nourish the bodies and spirits of the homebound with a balanced meal and the human connection they need to help them live independently. c) Types of Services the Agency Provides We provide a hot nutritious meal and personal visit Monday through Friday to those living in the service area who are unable to prepare meals for themselves due to age, illness, disability or convalescence in order to improve their health, reduce their isolation and help them maintain independent living. d) Agency's Experience with Similar Programs as the Funding Request We believe that we are the only program that delivers meals to the home. We work in collaboration with other Meals on Wheels programs to be sure that all who need assistance receive it from the nonprofit in their geographic area. e) Other Pertinent Agency Information Chapel Hill-Carrboro Meals on Wheels has served the community for almost 40 years. The program provides meals Monday through Friday to more than 170 recipients in Chapel Hill, Carrboro and southern Orange County. Nutritionally approved meals are prepared by K&W Cafeteria and supplemented with fruit, milk, and desserts made by a "Baking Brigade" of volunteers. All meals are delivered to homebound seniors by volunteer drivers, and more than 41,000 meals have already been delivered to more than 265 recipients in 2015. Our motto, "We serve more"; is demonstrated every day through the efforts of more than 200 dedicated volunteers, Board members, and staff. NO WAITING LIST — The CHCMOW program has an amazingly creative and dedicated group of volunteers who have worked very hard to raise funds to help with the subsidy needed by our recipients. The communities of Chapel Hill, Carrboro and Orange county have been supportive and we do not have a waiting list and are able to serve any qualified individual. This differs from the national norm, and even the norm in Durham and Raleigh, where seniors often have to wait weeks or months before they can receive meals. We are experiencing some fallout from their waiting lists, as others assume we also are unable to deliver services. We are addressing this with a robust marketing campaign (with the help of the Executive Service Corp) to raise our profile and be sure that we are reaching all who need our services. We have an intern developing a contact list of all possible referral sources for us (Healthcare providers, Social workers, Churches, Pharmacies) We continue to look for new space to house our program as demand continues to rise. We are outgrowing our home at Binkley Baptist Church. In 2015 we served 6,000 meals in Chapel Hill, 3,800 meals in Carrboro and 3,000 meals in Orange County completely free of charge, adjusting for holidays and length of service. The cost to us of $6.50 per meal makes this a significant investment in the welfare of our neediest neighbors. Our recipients paid only 20% of the costs of the meals in 2015. (Program fees collected were $39,000 and food costs (no salaries or overhead included)were $193,000 Main Application 5/24/2016 9:18:54 AM P of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION ,0 e Ari MEALS,,Id!iWHEELS f, i ///, �,// ii/ / 1141 ILE 114 uCy ii coif,1, , 1 ;IAA 4 1, IIIIIIIII2ILAI!JIIL, 1,144', ,„, de4;',711,4,, AAA,/ 1/IIII$IIIIIIIIII1j1III,IiIILLIIIIILIIIIII rf / ,4; r �%/ i f ' � iii�/ Rim" b�� � �f � ALL" J� 0wl`J"9,,Jp ✓4;rm,amw',4, A% f"UI� ,/a ',:,,4".1 rr,r rr,r r,i��vmua'�r;�j �j�, (� eke. aie� n�vv�rrca ^ �yntaiuuth 01'1111111, 1, �P �la�Pir Wpy VI M 5 i:/ ub rhr Mewu nYn�: e0,,: ir P.,t4,. �� P s�� r suer°enar'yau ^` ��v�6 �av+rtwrNi i w I y� p n A p i xp pTrr i/ r e rI rde'44447e4�AALL '114,414%. ➢444 N. I II .".I'�i 1�I. 14...di�k�I� I'.��'�:.L.0.V!I.. A o f,�'y �,�ll� n,�G',14n�V��/I �WUY4�'d tI� j�. l 6EY�w�` TOO MANY SENIORS IN NORTH CAROLINA ARE LEFT BEHIND, ALONE AND HUNGRY, STRUGGLING TO STAY INDEPENDENT AND HEALTHY. 4 e 0„:,3 143 seniors are isolated, living alone. 1 ;1,11( are threatened by hunger. 618,446 have difficulty paying for basic living needs. MEALS ON WHEELS DELIVERS THE SUPPORT THAT KEEPS SENIORS IN THEIR OWN HOMES, WHERE THEY WANT TO BE. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................... 41 i 11 lir�ll,sb y it ( iill)lr�;\1111 ""gi l\ r',,))y 11 alakca. .��� 1 a�)A 11 le I �"a�m���))] II„ 171 IO „ 01,i111 ��w1kV my Ili, iir fr r 1 � on) SENIORS REMAINING AT HOME, OUT OF HOSPITALS AND NURSING HOMES, SAVES BILLIONS IN MEDICARE & MEDICAID COSTS. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................... � �� � The cost of 1 YEAR [l, , ,,I 'WWI I `NII I �' for a senior to receive �,yl" €5111" I,ZII III "wy Meals on Wheels is less OW c, IHIl ll!IIIfiIC`' ,,ul c than 1 DAY in a hospital. \�, ,, , 1 DAY Psi"l(l E)(6Y" IIta9li)l"7. say Meals on Wheels improves their health Visit www.mealsonwheelsamerica.org/takeaction to learn more about how you can help in your state and community today. Main Application 5/24/2016 9:18:54 AM 0I:' a ; 5 0 f 2 it DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Chapel Hill-Carrboro Meals on Wheels - Meals for the Homebound As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: ® Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education Health and Nutrition x x x Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b. Summarize the program services proposed and how the program will address the chosen Town/County priority? Chapel Hill-Carrboro Meals on Wheels will provide a nutritious, affordable meal to residents of Chapel Hill, Carrboro and Southern Orange County who have an inability to manage meals for themselves. We directly impact the lives of those who are frail and disabled by providing food assistance to those who are in economic distress. This directly mirrors the community needs identified in the Chapel Hill 2011 Human Services Needs Report. c. Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). The Human Services Needs Main Application 5/24/2016 9:18:54 AM P 6 of 241 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION in Chapel Hill Report mentions "Food insecurity as well as access to affordable and healthy food" as concerns for the community. Cite local data to support the need for this program and the population being served. The chart below shows the anticipated changes in the county over the next 20 years. Clearly the largest demographic shift is in the population that Meals on Wheels serves. We need to be prepared to provide meals and support for our oldest and most vulnerable citizens. They raised us, taught us, employed us – now it's our turn to help them. Orange County Aging profile From the Division of Aging and Adult Services, NC Department of Health and Human Services 2014 2034 %Change Ages (2014-2034) Total 139,933 173,226 23.8% 0-17 27,521 20% 28,932 17% 5.1% 18-44 59,984 43% 71,452 41% 19.1% 45-59 27,985 20% 29,770 17% 6.4% 60+ 24,443 17% 43,072 25% 76.2% 65+ 16,279 12% 34,153 20% 109.8% 85+ 1,743 1% 4,662 3% 167.5% d. Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. Elderly, homebound and disabled who can't prepare their own meals. May have family living with them, but not present at lunch time. We serve a diverse client base that is 44% minority, 64% female, and increasingly more elderly-31% of our clients last year were 85 years of age or older. We aren't limited by age restrictions or income status. We identify beneficiaries in multiple ways. We accept referrals from friends, relatives, neighbors, social workers, healthcare professionals and people themselves. e. Who specifically will carry out the activities and in what location will they be carried out? Our Executive Director and Operations manager will do intake interviews to determine eligibility. Our volunteers (over 200 individuals) will deliver the meals and services to the recipients in their homes. f. Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. We deliver Monday through Friday, (excluding major holidays) between 10:30 am and 12:30 pm. Recipients determine if they want meals all 5 days or some subset. Implementation timeline is current and ongoing. In terms of starting services to specific individuals, referrals phone calls are returned within 24 hours and any eligible person will start services the following Monday. g. Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • Arc of Orange County, RSI, CHCCS special needs programs –we provide volunteer placements for those with challenges. They help set up, count out meals, and deliver. Main Application 5/24/2016 9:18:54 AM .. of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION • Porch —we partner to deliver monthly senior snack bags that are shelf stable and augment the clients' pantries • IFC —we refer clients who may be eligible for the Duke energy grant. We also talk to them about specific clients for additional services (vision care, Sec 8 housing challenges) • Farmer Foodshare—we purchase fruit every Tuesday • Book Harvest NC —we deliver books that are like new to our clients (they serve children, so we take donations that are suitable for adults) • HomeStart, Ronald McDonald House, SECU —we donate extra food that we can't distribute ourselves in a timely fashion. • Department on Aging —we distribute the Senior Times quarterly and refer clients who need more services to the Department • CHCCS —we provide service hour opportunities for high school students. In 2014 we started a new partnership with the Carrboro High School Exceptional Students program to have them come in every month and help us pack our snack bags. • Harris Teeter and Starbucks at University Mall, Trader Joe's, Panera —we "glean" food that is pulled from the shelves because of sell by date restrictions and deliver it the same day for our clients benefit • Orange County Executive Directors Board of the United Way and Food Security Work group —our Director served for three years as the representative to the UW Board and works on a subcommittee currently that addresses how to collaborate and make an impact on the problem of food security in our area. • The American Red Cross —we are the designated source for their meals in emergency situations • UNC School of Government, UNC School of Public Health, UNC School of Nursing, UNC School of Social Work, Kenan-Flagler MBA program UNC Journalism students— we have hosted and advised several volunteers and interns from these organizations. These opportunities for those volunteers and interns have supplemented their classroom work while giving us the benefit of wisdom gained in their academic endeavors. • Orange County Animal Shelter—we deliver donations of pet food on an annual basis from the shelter to those clients who have pets. h. Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If our request is denied, we would be compelled to search for funding from other sources. We try to maintain a very diverse income stream so that we aren't vulnerable should one entity stop supporting us. If we were unable to cover our expenses we would be forced to prioritize our clients and start a waiting list, serving those only as funds become available. i. Include any other pertinent information. In 2015 we started our strategic process of building infrastructure with two additional part time staff who help run operations and manage the volunteers. For almost 40 years we managed with 2 part time employees, but as we have tripled the number of meals served in the last 7 years (from 60 meals to 170) we knew this was no longer sustainable, nor best practices. We are excited about the growth and ready to meet the future with very dedicated and enthusiastic staff and volunteers. Program/Project Information j. Complete the Target Population and Program Beneficiary Demographics Chart k. Complete the Schedule of Positions Chart for Program Staff I. Disclosure of Potential Conflicts of Interested must be signed m. Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Main Application 5/24/2016 9:18:54 AM .. of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: ® Persons ❑ Households ❑ Units Program: Meals for the Homebound Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 91 93 100 Female 159 172 190 Total 250 265 290 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 101 100 109 American Indian or Alaska Native Asian 7 5 6 Caucasian 139 160 170 Native Hawaiian or other Pacific Islander Other 3 5 5 Total 250 265 290 Of the above, how many Hispanic/Latino 3 5 5 Of the above, how many non- Hispanic/Latino 247 260 285 Total 250 265 290 Age 0-5 years 0 0 0 6-18 years 0 0 0 19-50 years 9 9 10 51-61 years 45 42 46 62+ years 196 214 234 Total 250 265 290 Geographic Location Durham City Durham County Carrboro 78 84 92 Chapel Hill 117 112 123 Main Application 5/24/2016 9:18:54 AM P of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION Chapel Hill Public Housing Residents See note 1 Orange County 55 69 75 Raleigh Wake County Total 250 265 290 Income Level —See following chart (Omit for HS) See note 2 < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 0 NOTE 1 : We don't capture tf-fls data currently, but we do deHver to pubk houshig. (We deHver to the South Estes apartments and Trirflty Court) We also deHver to some dents who tell us they are Sedon 8 resdents. NOTE 2: We charge on a sldng scale based on monthly ncome and n 2015 137 of the 265 people we served were under 30% of arealmethan ncome. Main Application 5/24/2016 9:18:54 AM F a g :!!; 1 0 of 2 4 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.ord/portal/datasets/il/ill 5/FY2015 IL nc.pdf Main Application 5/24/2016 9:18:54 AM Pag , 11 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % (R) *= Position FTE* Program Actual Estimated Projected %Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Executive Director .5 1 $25,000 $26,800 $29,500 10% n/a Bookkeeper .25 1 $4,000 $4,500 $5,000 1.7% n/a Volunteer Coordinator .25 1 0 $2,500 $7,500 2.5% n/a Operations Manager .25 1 0 $2,500 4,000 1.3% n/a Board of Directors, Chair 500 hours 360 hours 200 hours Board of Directors, Members 40 hours 40 hours 40 hours Daychairs & Baker Coordinator 800 hours 800 hours 800 hours 11,440 12,100 12,300 Volunteer Drivers hours hours hours 2,160 2,300 2,500 Volunteer Bakers hours hours hours Cleanup 234 hours 234 hours 234 hours Setup/operations 858 hours 858 hours 858 hours Food runners 832 hours 936 hours 936 hours Publicity/Newsletter /Social Media/committee members 140 hours 160 hours 180 hours Fundraising/Events 500 hours 500 hours 500 hours Total Hours 9.46FTE Volunteered 17,514 18,128 18,548 2016-17 Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/24/2016 9:18:54 AM P , 12 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement SMART Goals Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Program Activity 1 Deliver meals to the home Deliver meals to the home Deliver meals to the home Provide nutritious meal Provide nutritious meal Provide nutritious meal Program Goal that nourishes that nourishes that nourishes Volunteer log and and Volunteer log and and Volunteer log and and Performance Measures client delivery records client delivery records client delivery records 38,000 meals plus 41,000 meals plus 45,000 plus additional additional groceries and additional groceries and groceries and food Program Results food donations delivered food donations delivered donations delivered Visit with client and Visit with client and Visit with client and Program Activity 2 perform basic safety check perform basic safety check perform basic safety check Provide a personal visit Provide a personal visit Provide a personal visit each weekday to each weekday to each weekday to clients,relieving isolation clients,relieving isolation clients,relieving isolation and depression. Check for and depression. Check for and depression. Check for any obvious problems or any obvious problems or any obvious problems or issues that may need issues that may need issues that may need attention from family or attention from family or attention from family or Program Goal other service providers other service providers other service providers Notes in client files and Notes in client files and Notes in client files and incident reports submitted incident reports submitted incident reports submitted Performance Measures by volunteers by volunteers by volunteers Main Application 5/24/2016 9:18:54 AM P 141 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION About 110 volunteers deliver each week, so every weekday one of these drivers makes contact (unless the recipient is not at home). We had 250 clients in this period, delivered all weekdays excluding 6 major holidays for an estimated 45,000 interactions.This is higher than the meal count because we have two volunteers on some of the routes, meaning more interactions.We have contacted family about heating issues, unusual changes in mood or appearance, called Adult Protective Services and the Department on Aging with 110 volunteers, 265 clients, 120 volunteers, 290 clients, Program Results concerns. 46,000 interactions 47,000 interactions Program Activity 3 "Deliver MORE" "Deliver MORE" "Deliver MORE" Serve as gateway to other serve as gateway to other serve as gateway to other services, both tangible and services, both tangible and services, both tangible and Program Goal informational. informational. informational. Director keeps a record of Director keeps a record of Director keeps a record of extra services provided and extra services provided and extra services provided and all collaborations with all collaborations with all collaborations with Performance Measures partner agencies. partner agencies. partner agencies. 250 Clients received information about Duke Energy grants, free smoke detectors from the fire department, access to discounted prescription (only a partial list)The receive books, magazines, gifts at the holidays, snack bags and flowers and cards 290 clients will be Program Results on their birthdays 265 clients impacted impacted Main Application 5/24/2016 9:18:54 AM P 15 of 211" DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Activity 3 "Deliver MORE" "Deliver MORE" "Deliver MORE" Serve as gateway to other serve as gateway to other serve as gateway to other services, both tangible and services, both tangible and services, both tangible and Program Goal informational. informational. informational. Director keeps a record of Director keeps a record of Director keeps a record of extra services provided and extra services provided and extra services provided and all collaborations with all collaborations with all collaborations with Performance Measures partner agencies. partner agencies. partner agencies. 250 Clients received information about Duke Energy grants,free smoke detectors from the fire department, access to discounted prescription (only a partial list)The receive books, magazines, gifts at the holidays,snack bags and flowers and cards Program Results on their birthdays 265 clients impacted 290 clients will be impacted Main Application 5/24/2016 9:18:54 AM 0 I:°' , 16 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 9:18:54 AM 0 I:°' of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Prograrr CHC MOW Meals for the Homebound Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 71,350 $ 83,528 $ 77,000 -8% Agency Generated Revenue (fees) $ 54,000 $ 39,424 $ 38,000 -4% Local Government Grants: Orange County $ 10,000 $ 10,000 $ 15,000 50% Town of Chapel Hill $ 9,000 $ 9,000 $ 15,000 67% Town of Carrboro $ 10,000 $ 10,500 $ 15,000 43% Other Local: 0 Other Local: 0 Other Local: 0 If more than 3 sources, please provide a separate list. Non-Local Government Grants Triangle United Way $ 28,280 $ 27,893 $ 28,400 2% State Government 0 Federal Government 0 Other Grants:Walmart or GSK $ 25,000 $ 25,000 $ 25,000 0% Other Grants:Other $ 10,100 $ 12,650 $ 10,000 -21% Miscellaneous/Other Revenue $ 92,207 $ 92,878 $ 86,500 -7% Please list 3 largest Miscellanous sources: events/fundraisers $ 42,000.00 :orporations/congregation: $ 27,500.00 in-kind $ 12,000.00 Total Agency Revenue $ 309 937 $ 310 873 $ 309 900 0% AGENCY EXPENSES Compensation $ 29,626 $ 35,806 $ 46,487 30% Rent&Utilities $ 1,960 $ 2,040 $ 2,200 8% Supplies&Equipment $ 4,911 $ 2,167 $ 4,800 122% Travel&Training $ 494 $ 1,500 0 Other Expenses: $ 220,080 $ 237,017 $ 238,430 1% Please list 3 largest"Other Expenses": Food Costs $204,830.00 Professional $ 9,500.00 Events $ 8,000.00 Total Agency Expenses $ 257,071 $ 277,030 $ 293,417 6% SURPLUS/(DEFICIT)FOR PERIOD: I $ 52,866 I $ 33,843] $ 16,483 I _ -51% Main Application 5/24/2016 9:18:54 AM Pa 1 o of 2 4 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/24/2016 9:18:54 AM .. , 1 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Meals for the homebound Cost Elements Cost( ) Quantity/Unit of measure Subtotal( ) Food (meals, trays, supplies) 4.67 45,000 210,000 Salaries 18.40 2,500 hours 46,000 Insurance/licenses/audit/website 13,000 Rent/utilities/Supplies 6,000 Postage/printing 3,000 Other 12,000 Total 290,000 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 257,071 277,030 293,417 Total # of Units 38,000 meals/250 41,000 meals/265 45,000 meals/290 people people people $6.77 a meal/ $6.76 a meal/ $6.52 a meal/ Cost Per Unit $1,028 per $1,045 per person $1,011per person person (annual) (annual) (annual) Main Application 5/24/2016 9:18:54 AM P 20 of 2 " DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/24/2016 9:18:54 AM P 21 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in your own format. Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 9:18:54 AM P 22 of 241" DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: PROGRAM&AGENCY BUDGETS ARE IDENTICAL Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 71,350 $ 83,528 $ 77,000 -8% • Generated Revenue(fees) $ 54,000 $ 39,424 $ 38,000 -4% • Government Grants: Orange County $ 10,000 $ 10,000 $ 15,000 50% • of Chapel Hill $ 9,000 $ 9,000 $ 15,000 67% • of Carrboro $ 10,000 $ 10,000 $ 15,000 50% • Local: 0 Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 28,280 $ 27,893 $ 28,400 2% • Government 0 Federal Government 0 Other Grants:Walmart or GSK $ 25,000 $ 25,000 $ 25,000 0% • Grants: $ 10,100 $ 12,650 $ 10,000 -21% Revenue $ 92,207 $ 92,878 $ 86,500 -7% • list 3 largest Miscellanous sources: $ - $ - Total Agency Revenue $ 309 937 $ 310 373 $ 309 900 0% AGENCY EXPENSES Compensation $ 29,626 $ 35,806 $ 46,487 30% • &Utilities $ 1,960 $ 2,040 $ 2,200 8% $ 4,911 $ 2,167 $ 4,800 122% • &Training $ 494 $ 1,500 0 Other Expenses: $ 220,080 $ 237,017 $ 238,430 1% • list 3 largest"Other Expenses": Food Costs $ rofessonal(Acctg and web fee $ 9,500.00 Insurance $ 3,000.00 Total Agency Expenses $ 257,071 $ 277,030 $ 293,417 6% SURPLUS/(DEFICIT)FOR PERIOD: $ 52,866 $ 33,343 $ 16,483 -51% Main Application 5/24/2016 9:18:54 AM P 23 of 2 DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Chapel Hill-Carrboro Meals on Wheels Funding Award: $15,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Meal Subsidy—provided to those who can't contribute to the cost of the meals delivered. 15,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Deliver Meals to the home • Visit with client and perform basic safety check • Deliver"MORE" Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Groceries and food donations delivered 45,000 Note in client files and incident reports submitted by volunteers 120 volunteers 290 Clients 47,000 interactions Extra services provided and all collaborations with partner agencies 290 clients Docfu�Siiggned by: Certified by: LE1BOABFD56O24O5 Title: Date: 10/26/2016 Executive Director (Provider's Signature) DocuSign Envelope ID:24839407-DB2D-47A2-B399-3BEA061662C1 NCCHAP7 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/14/2016 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 NAME: Nayab Alam The CIMA Companies, Inc. PHONE Fax (A/C,No,Ext):703-778-7304 (A/C,No): 703-778-7354 2750 Killarney Dr,Suite 202 E-MAIL ADDRESS: nalam @cimaworld.com Woodbridge,VA 22192-4124 PRODUCER CUSTOMER ID#: 703 739-9300 INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURER A:Alliance of Nonprofits for Ins 10023 Chapel Hill-Carrboro INSURER B: Meals on Wheels INSURER C: PO Box 2102 INSURER D: Chapel Hill, NC 27514 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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.NOTWITHSTANDING 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) A GENERAL LIABILITY 201636882 07/01/2016 07/01/2017 EACH OCCURRENCE $1,000,000 DAMAGE RETED X COMMERCIAL GENERAL LIABILITY PREMISES O(Ea occurrence) $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $20,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY JECT LOC $ A AUTOMOBILE LIABILITY 201636882 07/01/2016 07/01/2017 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE aCteAk e . A ©1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S342895/M342894 NPA