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HomeMy WebLinkAbout2016-577 Finance - The Arc of the Triangle - Outside Agency Performance Agreement ,v f 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 The Arc of the Triangle, a not-for-profit corporation, located at 1709 Legion Road, Suite 100,Chapel Hill,NC 27517("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 The Arc of the Triangle 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 6000. 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$1,500. 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. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Revised 812016 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: L 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. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Rev. 8116 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. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Rev.8116 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 The Arc of the Triangle 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: ahe Arc pf the Triangle) Orange County Outside Agency Performance Agreement Rev. 8116 County: Finance&Administrative Services Provider:The Arc of the Triangle Orange County 1709 Legion Road,Suite 100 Post Office Box 8181 Chapel Hill,NC 27517 Hillsborough,NC 27278 16. Entire 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 1 IA 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. For and on b/ehalf/o�f the Provider Date For and on 4bealt Pran a County Government A, a-7 Bonnie Hammersley,County Manager/. Date `(The Arc of the Triangle) Orange County Outside Agency Performance Agreement Rev. 8116 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. Certified b __, _ Title: IZ 1&,/ �'z'�Yfii✓ Date: /e? <" 1� (Provider's Signature} (The Arc of the Triangle) Orange County Outside Agency Per Agreement Rev.8116 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency The Arc of the Triangle, Inc. Date/Time / Complete Y Program(s) Social and Volunteer Programs Section . : • . Regulations 1. Cover Page a. x Applicant.Contact Information b. x Project/Program Contact Information c. x Funding Requests Identified d. ❑ Signed Application Cover Page 2. Agency a. x Agency's Years in operation 24 CFR 570.506, Information - b. x Agency's Purpose/Mission 570.507, 570.610; 24 c. x Agency's Types of Services Provided CFR Parts 84 or 85 d. x Agency's Experience e. x Other Pertinent Information 3. Program/ a. x Type of Application and Program Identified 24 CFR 570.200(a), Project b. x Summary of Program 570.201-570. 208, Information - c. x Description of Identified Need 507.503 (for each d. x Description of Population to be Served program/ project for e. x Activity Manager and Location Description which funding f. x Activity Implementation Timeline is requested) g• x Agency Collaboration h. x Describe Impact of Reduced/No Allocation i. x Other Pertinent Information j. x Complete Target Population/Beneficiary Chart k. x Complete Schedule of Positions I. ❑ Signed Conflict of Interest Disclosure m. x Complete Work Statement i Page Exhibit 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. X Program Budget Worksheet 570.602, 570.607(b), is requested) b. X Program Budget Detail 570.611 c. x Cost Per Unit 24 CFR 570.502-570.504, d. x Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 orA 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG &HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. x Audit: Organizations receiving$300,000 or more in OMB Circular A-133 Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit b. x IRS Federal Form 990 c. x NC Solicitation License d, x IRS Federal Tax-Exemption Letter e. x Certificate of Insurance f. x List of Board of Directors 24 CFR Parts 84 or 85 g. x Articles of Incorporation/Bylaws 24 CFR 570.208, h. x Authorization to Request Funds 570.500(c), 570.611 1. x Authorized official designation j. x 3-R Fee Verification Main Application 5/25/2016 10:10:25 AM Page, 2 of 24 Exhibit A - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: The Arc of the Triangle Inc. Applicant Organization's Physical Address: 1709 Legion Road, Suite 100 Chapel Hill NC 27517 Applicant Organization's Mailing Address: same Applicant Organization's Web Address: www.arctriangle.org Executive Director: Robin Baker Telephone Number: 919 942 5119 E-Mail: rbaker(a)-arctriangle.org DUNS Number: 95-638-8177 (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Proiect/Program Contact Information Project/Program Name: Social and Volunteer Opportunities Project/Program Primary Contact and Title: Susan Chandler, Assistant Director of Volunteer and Social Programs Telephone Number: 919 942 5119 xt 111 E-Mail: schandleraarctriangle.org c) Funding Request Identification Total Project/Program Cost: $23,000.00 Total Amount of Funds Requested: $23,000.00 Proposed Use of Funds Requested (2-3 Line Maximum): People with Intellectual and Developmental Disabilities (IDD) often lead lives that have limited opportunities for social inclusion and participation. Restricted and sedentary lifestyles significantly reduce quality of life. Funding for this program will go directly to coordinate and monitor activities that enable people with IDD become engaged with the community through the use of community volunteers, spaces and resources. 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) $ ❑ Grant ❑ Loan ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan ❑ HOME CHDO $ ❑ Grant ❑ Loan ❑ HOME Other $ ❑ Grant ❑ Loan x Human Services: x Carrboro $5,000.00 x Chapel Hill $12,000.00 x Orange County $6,000.00 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. Main Application 5/25/2016 10:10:25 AM Page 3 of 24 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION Signature: Executive 'rector Date / Signature: , (/)o0 2 1 Board Chairperso Date Main Application 1/2112016 1:32:26 PM Page 4 of 24 Exhibit A- 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 project, or members of their immediate families, or their business associates: YES NO ❑ x a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? ❑ x b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? ❑ x c) Current beneficiaries of the project/program for which funds are requested? ❑ x 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. Signature ' Executive Director Date Signature: ktL L , VJOd I /z j f Board Chairpe on Date Main Application 1/21/2016 1:32:26 PM P a g e of 24 Exhibit 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: 37 Years Date of Incorporation (Month/Year): December 28, 1979 b) Agency's Purpose/Mission: The Arc of the Triangle works with and for people who have or are at risk for having intellectual and/or developmental disabilities (IDD). We strive to provide quality support to the individual, their family and the community in which they live. Additionally, The Arc seeks to promote the full participation of the people we serve in all areas of life in our community. The Arc seeks to accomplish this through advocacy, education and community collaboration. c) Types of Services the Agency Provides: As people change, their needs change. The Arc addresses this by providing services throughout the course of life of an individual with Intellectual and Developmental Disabilities (IDD.) There are three specific areas of services geared to but not limited to: 1. Individual Services provides a Support Professional to work with your child or loved one to teach independence and provide support in the home and the community. Support Professionals are trained and paid staff hired and employed through The Arc that work one-on-one with our individuals in the following areas of their lives: In Home Skill Building provides techniques that helps teach individuals to acquire and maintain skills to increase independence. It can be provided in the home or in the community, working on goals such as increasing community living skills, daily living skills and social skills. Personal Care provides support with bathing, feeding, dressing, and maintaining personal hygiene. Respite provides the family or loved one with a break in care. This service can be provided in the home or in the community. 2. Supported Employment provides employment assistance to individuals sixteen years old and older. This can include pre-training to prepare a person for meaningful work and assisting the individual to start a micro-enterprise. Support Professionals can assist the individual with initial job training, coaching and marinating skills learned on the job. 3. Community Health, Wellness and Volunteer Social Programs because The Arc's goal is for everyone to lead purposeful and healthy lives that make a difference, our social programs encourage our individuals to get involved and give back. These social programs are led by volunteers who incorporate healthy lifestyles while giving back to the community: Nutrition and Cooking Class allows adults to use hands-on experience to further their knowledge of nutrition as well as their skills in the kitchen. Each week a different "head-chef' picks out a recipe to prepare in the class with everyone cooking together. Giving back to the community means once a month thirty-six desserts are prepared and donated to local Meals on Wheels families. Petals with a Purpose is an effort to connect flowers to people in the community all the while making a difference on the environment. Using items destined for the landfill such as soup cans and water bottles individuals with and without disabilities gather together each week to create beautiful flower vases. The flower vases are then donated to people in hospice care, senior citizens and food pantries. We think of this as "A-R-C"-Acts of Random Compassion. HOOPs Basketball, Spin Class are weekly basketball and cardio spin classes led by volunteers who encourage everyone to shoot some hoops, spin on stationery Main Application 5/25/2016 10:10:25 AM Page 5 of 2 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION bicycles, all the while listening to upbeat music, having fun, incorporating healthy lifestyle choices and making friends in the process. d) Agency's Experience with Similar Programs as the Funding Request The Arc of the Triangle originally formed thirty-seven years ago to serve individuals with Intellectual and Developmental Disabilities (IDD) living in Orange County, North Carolina. Where no other similar agencies existed, The Arc identified the need to provide people with healthy and purposeful life choices. What began as a small organization in 1979, The Arc of Orange County, has recently merged with Durham and Wake County, forming The Arc of the Triangle. The goal is to provide Durham and Wake County residents the same high quality and high level of service that Orange County residents have become accustomed to over the years. Through the success of these programs The Arc expanded to include Supported Employment and Social and Volunteer opportunities. Other programs and agencies that are similar to the Arc have gone out of business due to decreased funding or due to a lack of quality and comprehensive service. e) Other Pertinent Agency Information The Arc continues to face the economic reality of providing more services to more people while having less funding available. One service known as Developmental Therapy (DT) was completely eliminated. This meant a decrease of $190,000 to people that we continue to support. Our Local Management Entity (LME) has also moved 40% of the people we support to "non-habilitative" services that are reimbursed at a lower rate. We continue to serve these people in the same manner but with less pay. While The United Way was a major source of Arc funding their mission no longer addresses the needs of people with IDD. Lastly on 1/1/2015 the LME changed the reimbursement rate for two of the services that we provide. The result is a $3,000 per month reduction in funding. Main Application 5/25/2016 10:10:25 AM Page 6 of 24 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: The Arc of the Triangle Social and Volunteer Opportunities 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 application and supplemental application sections as specified below: x Human Services (Main Application Only) ❑ AH Non-Construction (Main Application Only) ❑ AH Construction—(Main Application AND Part B) ❑ AHDR Non-Construction (Main Application Only) ❑ AHDR Construction—(Main Application AND Part B) ❑ 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 Parts 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 x Health and Nutrition x Job Training x Sports and Arts Activities x Pre-School Activities After-School Activities x Mentoring x Transportation x Housing Other: Please specify Proaram/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? The Arc of the Triangle provides supports and services to more than three hundred children and adults with intellectual and developmental disabilities. A majority of our services are paid for through limited Medicaid or State funding. The funding that we are requesting would be used to offset the cost to provide educational and social experiences that are not funded through Medicaid or State funding. 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). Cite local data to support the need for this program and the population being served. People with Intellectual and Main Application 5/25/2016 10:10:25 AM Page 8 of 2 Exhibit A - continued Provider's Outside Agency Application MAIN APPLICATION Developmental Disabilities (IDD) often lead lives that have limited opportunities for social inclusion and participation. Restricted and sedentary lifestyles significantly reduce quality of life. Funding for this program will go directly to coordinate and monitor activities that enable people with IDD become engaged with the community through the use of community volunteers, spaces and resources. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. Populations to be served are individuals with Intellectual and Developmental Disabilities (IDD) that live in Orange, Durham and Wake counties. The Arc serves people ages three years and up throughout the course of their life. People identified with IDD are people that have or are at risk for having autism, Cerebral palsy, Mental Retardation/MR mild, severe or profound, Down syndrome, epilepsy and individuals that are classified as PDDNOS (Pervasive Development Delay Not Otherwise Specified). e) Who specifically will carry out the activities and in what location will they be carried out? The Assistant Director of Volunteer and Social Opportunities oversees the programs requested for funding. The Arc of the Triangle engages over forty active volunteers who lead Arc programs such as Nutrition and Cooking Class, Petals with a Purpose, HOOPs Basketball and Spin. Volunteers in our Community Connections Partner Program are matched with an Arc individual fostering friendships and giving opportunities for our folks to go out and about exploring the community. Other volunteers help with our social media, public relations, holiday parties, fundraising events, as well as interning on an administrative level. Our programs take place out in the community such as Meadowmont UNC Fitness Center, PNC Bank on Rosemary Street, and Hargraves Community Center to name a few. 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. Social and Volunteer programs at The Arc such as Cooking Class, Petals with a Purpose take place weekly in the afternoons, other programs like Community Connections Partner Program can take place on weekends or evenings, HOPE Gardens is open each day until sundown. All our programs are offered and they are ongoing throughout the year. 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. • The North Carolina Division of Vocational Rehabilitation (VR) - persons recommended to the Arc from VR find gainful work with Arc Supported Employment Specialists. • Cardinal Innovations Health Care Solutions- families and individuals are recommended to the Arc to receive Home and Community Support, Respite Care, Supported Employment, Social and Volunteer opportunities. • Meals on Wheels — Arc participants volunteer weekly delivering and preparing meals for Chapel Hill and Carrboro Meals on Wheels recipients. • Extraordinary Ventures (EV) —Arc participants are hired and employed at EV for a variety of jobs including Office Solutions, EV Laundry, EV Candle making, EV Pet sitting, as well as partnering in Friday Night Live a weekly evening at EV for friendship and fun for teens and adults with or without intellectual/developmental disabilities. • The Seymour Center — Arc participants volunteer weekly at the Seymour Center assisting and creating friendships with senior citizens, The Arc's Petals with a Purpose program also supplies monthly lunch bouquets honoring senior birthdays that month. Main Application 5/25/2016 10:10:25 AM Page 9 of 24 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION • RSVP (Retired Seniors Volunteer Program) — senior citizen's volunteer with the Arc's social programs such as Petals with a Purpose and Spin class. • UNC Wellness Center Meadowmont — Are Spin, Weight and HOOPs basketball meet weekly at the health club at no charge to the Arc. • The Chapel Hill Carrboro Chamber of Commerce — each fall the Chamber sponsors one Arc employee to participate in the Chapel Hill Carrboro Chamber's Leadership Series. • The Hillsborough Chamber of Commerce — Arc staff speaks biannually to educate and encourage Hillsborough residents to utilize Arc services and programs. • Several sororities and fraternities at UNC (APO ZTA Phi Beta Chi, PKP) Arc's volunteer programs are comprised of a large percentage of sorority and fraternity students, students organize major fundraisers for the benefit of the Arc(Tar heel 10 Miler, ZTA Race for the Cure). • The Knights of Columbus— raise awareness and funding for the Arc's programs through the LAMB's Tootsie Roll event each year. • The University Mall — welcoming attitudes on Fridays when Arc participants frequent the restaurants and shops. In the past Arc held our annual Festival of Trees event at the mall. • The Cardinal Track Club and others — the Arc is chosen as one of the local non-profits to benefit from the awareness and the money raised from these 3 annual races, Annual "Turkey Gallop and Gorge," "Four on the Fourth," and Tour de Carrboro in October. • The Meadowmont Homeowners Association annual yard sale donating all proceeds to the Arc, welcoming to Arc individuals residing in townhomes built and designated for persons with intellectual and developmental disabilities (9 individuals total.) • PNC Bank —each Wednesday Petals with a Purpose gather in PNC conference room for Petals program at no charge to the Arc. PNC also allows Arc administrative staff to park for free in their parking lot. • Hargraves Community Center— on Tuesdays Hargraves hosts Arc health and wellness cooking class (no charge to the Arc.) • Mardi Gras Bowling — on periodic Fridays Arc individuals enjoy bowling alongside people with and without disabilities. • Amante Pizza —on periodic Fridays Are individuals enjoy lunching at Amante's alongside people with and without disabilities. • The Root Cellar — encourages their staff to volunteer at the Arc, flower bouquets are donated and displayed on their tables each week so patrons of the restaurant can take home and enjoy a free flower vase. The Root Cellar also supports our efforts by selling soaps and candles made at Extraordinary Ventures , Arc Barks doggie treats that are made at The Arc of Greensboro. • HOPE Gardens (Homeless Outreach Poverty Eradication)-Arc's cooking class plants two garden beds using food grown at garden for cooking class, flowers grown used in Petals class as well as teaching skills to Arc individuals learning how to grow organic food, how to eat healthier and enjoy the outdoors. • UNC School of Journalism APPLES intern students — Five Public Relations and Journalism students intern 30 hours a week each semester creating videos, website, blogs, marketing materials for the Arc, intern in social programs helping to lead Arc's Spin, HOOPs basketball, cooking classes. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Statistics prove that people live longer and have happier lives when they have friendships, healthy relationships, purpose and social capital. When people lead isolated and lonely lives their health suffers, they are prone to more emergency room visits and costly medical care. Arc believes in pro-action rather than re-action, so in the long run an ounce of prevention is worth more than a pound of cure. We provide the opportunities for individuals to become engaged in the community whether it is through volunteer work or paid employment, the less our individuals need us for support the better a job we have done. Our success is measured by their success. We will not be able to serve as many people Main Application 5/25/2016 10:10:25 AM P a g e 1 0 e f 2 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION with these programs if funding is not awarded or if reduced. i) Include any other pertinent information. Program/Proiect Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff 1) 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. 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: x Persons ❑ Households ❑ Units Program: Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gentler Transgender 1 1 1 Male 153 193 222 Female 85 110 126 Total 239 304 349 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 34 45 52 American Indian or Alaska Native Asian 13 15 Caucasian 158 178 205 Native Hawaiian or other Pacific Islander Other 47 68 78 Total 239 304 349 Of the above, how many Hispanic/Latino 9 9 10 Of the above, how many non- Hispanic/Latino 230 295 339 Total 1 239 1 304 1 349 Age Main Application 5/25/2016 10:10:25 AM P a g e 1 1 of 24 Exhibit A - continued Provider's Outside Agency Application MAIN APPLICATION 0-5 years 1 1 1 6-18 years 57 108 124 19-50 years 171 158 182 51-61 years 9 20 23 62+ years 1 17 19 Total 239 304 349 Geographic Location Chatham 9 Durham City 9 10 Durham County 14 11 13 Carrboro 26 13 15 Chapel Hill 100 118 135 Chapel Hill Public Housing Residents Orange County 55 46 53 Raleigh 54 62 Wake County 35 53 61 Total 239 304 349 Income Level—See following chart (Omit for HS) < 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 1 0 0 0 Main Application 5/25/2016 10:10:25 AM Page 12 of 2 Exhibit 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.orn/portal/datasets/il/i115/FY2015 IL nc.pdf Main Application 5/25/2016 10:10:25 AM Page 13 of 24 Exhibit 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 FTE* °y0 Actual Estimated Projected °%0 (R) *=Position * Program 2014-15 2015.16 2016-17 Total Retirement Vacant Staff+ Budget Plan (H) Health Plan Executive Director X1 103,229.00 103,229.00 106,326.00 H Social and Volunteer Asst. Dir. X1 48,122.00 49,565.00 51,051.00 H Business Manager X1 59,740.00 61,532.00 63,378.00 H Human Resource Dir. H X1 51,500.00 53,045.00 54,636.00 Individual Support Supervisors X4 139,000.00 143,170.00 147,465.00 1 H Admin X4 139,172.00 143,347.00 146,648.00 H Supported Employment X4 143,879.00 148,195.00 152,641.00 H Direct Support Professionals X60 1,229,932. 1,266,830. 1,304,835. 7H Volunteers X40 6240 hrs 8320 hrs 10,400 hrs 4.24 Management X7 239,399.00 246,581.00 253,978.00 H 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 5/25/2016 10:10:25 AM P o cg e 14 o f 2 4 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you,will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Actual Estimated Projected 2014-15 2015-16 2016-17 Using a combination of paid Using a combination of paid Using a combination of paid Direct Support Professionals Direct Support Professionals Direct Support Professionals Program Activity 1 and volunteers, participants and volunteers, participants and volunteers, participants engage in non-segregated engage in non-segregated engage in non-segregated community activities. community activities. community activities. 50%of persons served with 50%of persons served with 50%of persons served with intellectual and intellectual and intellectual and Program Goal developmental disabilities developmental disabilities developmental disabilities will will participate in inclusive will participate in inclusive participate in inclusive community activities. community activities. community activities. Person centered plans, Person centered plans, Person centered plans, Performance Measures service notes and annual service notes and annual service notes and annual surveys provided data to surveys provided data to surveys provided data to verify this information. verify this information. verify this information. Out of 184 people served 88 Out of 193 people served Out of 304 people served people(almost 50%)did 50%will increase their 50%will increase their increase their participation in participation in community participation in community community activities that activities that were included activities that were included Program Results were included but not limited but not limited to: but not limited to:educational to: educational educational opportunities, opportunities, volunteer and opportunities, volunteer and volunteer and paid work, paid work, advocacy paid work, advocacy advocacy activities, religious activities, religious activities activities, religious activities activities and social and social functions. and social functions. functions. With appropriate support With appropriate support With appropriate support like like transportation, like transportation, transportation, participants participants are involved in participants are involved in are involved in activities in Program Activity 2 activities in community activities in community community spaces or in spaces or in programs that spaces or in programs that programs that include include persons that do not include persons that do not persons that do not have have disabilities. have disabilities. disabilities. 50%of persons served with 50%of persons served with intellectual and intellectual and 50%of persons served with Program Goal developmental disabilities developmental disabilities intellectual disabilities will will access community will access community access community spaces. spaces. spaces. Main Application 5/25/2016 10:10:25 AM P a g e 1 6 o f 2 4 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION Person centered plans, Person centered plans, Person centered plans, Performance Measures service notes and annual service notes and annual service notes and annual surveys provided data to surveys provided data to surveys provided data to verify this information. verify this information. verify this information. Out of 184 people served Out of 193 people served Out of 304 people 88 people(almost 50%)did 50% of program participants served 50%of program increase their usage of will increase their usage of participants will increase their community spaces. In the community spaces. In the usage of community spaces. Program Results case of respite for children, case of respite for children, In the case of respite for some services are required some services are required children, some services are to take place in the home. to take place in the home. required to take place in the Otherwise the number would Otherwise the number would home. Otherwise the have been greater. have been greater. number would have been nrpatpr Each participants person Each participants person Each participants person centered plan will include centered plan will include centered plan will include goals for increasing the goals for increasing the goals for increasing the number of people that they number of people that they number of people that they Program Activity 3 have relationships with and have relationships with and have relationships with and staff and volunteers will staff and volunteers will staff and volunteers will promote and ensure promote and ensure promote and ensure relationship building relationship building relationship building activities. activities. activities. 50%of persons served with 50%of persons served 50%of persons served with intellectual and with intellectual and intellectual and Program Goal developmental disabilities developmental disabilities developmental disabilities will will increase the number of will increase the number of increase the number of relationships and people in relationships and people in relationships and people in their circle of support. their circle of support. their circle of support. Person centered plans, Person centered plans, Person centered plans, Performance Measures service notes and annual service notes and annual service notes and annual surveys provided data to surveys provided data to surveys provided data to verify this information. verify this information. verify this information. 50%of program about 88 50%of program 50%of program participants people, have increased the participants will increase the will increase the number of Program Results number of relationships and number of relationships and relationships and people in people in their circle of people in their circle of their circle of support. support. support. Participants will have Participants will have Participants will have Program Activity 4 opportunities to engage in opportunities to engage in opportunities to engage in exercise and nutrition exercise and nutrition exercise and nutrition classes. classes. classes. 20 people served with 25 people served with 30 people served with intellectual and intellectual and intellectual and developmental disabilities developmental disabilities Program Goal developmental disabilities will will learn about and will learn about and learn about and participate in participate in leading healthy participate in leading healthy leading healthy lifestyles. lifestyles. lifestyles. Person centered plans, Person centered plans, Person centered plans, Performance Measures service notes and annual service notes and annual service notes and annual surveys provided data to surveys provided data to surveys provided data to verify this information. verify this information. verify this information. 20 people increased 25 people will increase 25 people will increase physical health by physical health by physical health by Program Results participating in cooking participating in cooking participating in cooking nutrition classes and nutrition classes and nutrition classes and exercise classes. exercise classes. exercise classes. Main Application 5/25/2016 10:10:25 AM P a n e 17 of 24 Exhibit A - continued Provider's Outside Agency Application MAIN APPLICATION People with intellectual and People with intellectual and People with intellectual and developmental disabilities developmental disabilities developmental disabilities will will be involved in Petals will be involved in Petals be involved in Petals with a Activity 5 with a Purpose and HOPE with a Purpose and HOPE Purpose and HOPE Gardens Gardens both community Gardens both community both community programs programs where individuals programs where individuals where individuals participate participate in civic minded participate in civic minded in civic minded activities. activities. activities. 18 people served with 25 people served with 25 people served with intellectual and intellectual and intellectual and Program Goal developmental disabilities developmental disabilities developmental disabilities will have participated in will participate in activities participate in activities that activities that give back to that give back to the give back to the community the community at large. community at large. at large. Person centered plans, Person centered plans, Person centered plans, service notes and annual service notes and annual service notes and annual Performance Measures surveys provided data to surveys provided data to surveys provided data to verify this information. verify this information. verify this information. t artici le will people participate 18 people participated with 25 p 25 people will participate with volunteers on a weekly with volunteers on a weekly volunteers on a weekly basis Program Results basis and 100%of ° basis and 100%of and 100/o of participants will participants met their goal. Participants will meet their meet their goal. goal. Main Application 5/25/2016 10:10:25 AM P a g e 1 8 o f 2 4 Exhibit 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 5/25/2016 10:10:25 AM P a 9 e 1 s o f 2 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program The Arc of the Triangle,Social Programs Actual , Estimated Projected Percent AGENCY REVENUE 2014-1`� 2015 16 , 2016-17 Change Private Donations $ 1,000 $ 1,500 $ 1,800 20% Agency Generated Revenue(fees) $ 8,000 $ 8,000 $ 8,000 0% i Local Government Grants: Orange County $ 5,000 $ 12,000 $ 12,000 0% Town of Chapel Hill $ 6,000 $ 6,000 $ 6,000 0% Town of Carrboro $ 3,615 $ 5,000 $ 5,000 0% Other Local: 0 Other Local 0 Other Local: 0 tf more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government $ 35,000 $ 35,000 $ 35,000 0% Federal Government 0 Other Grants:ZTA Sorority $ 12,000 $ 15,000 $ 15,000 0% Other Grants:Cardinal Track Club $ 8,000 $ 8,000 $ 8,000 0% Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: $ $ $ Total Agency Revenue $ 78 615 $ 90 500 $ 90 800 0% AGENCY EXPENSES Compensation $ 50,000 $ 51,050 $ 53,000 4% Rent&Utilities $ 2,472 $ 2,750 $ 2,750 0% i Supplies&Equipment $ 2,500 1 $ 2,800 $ 2,800 0% Travel&Training $ 1,300 $ 1,500 $ 1,500 0% i Other Expenses: 0 Please list 3 largest"Other E)Venses": $ $ II Total Agency Expenses $ 56,272 $ 58,100 $ 60,050 3% 'SURPLUS/(DEFICIT)FOR PERIOD: $ 22,343 $ 32,400 $ 30,750 -5% Main Application 5/25/2016 10:10:25 AM Page 20 of 24 Exhibit 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 C Quantity/Unit 6 1 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: The Arc of the Triangle Volunteer and Social Programs Cpst Elements. =p C S 0 Quariti' 1lwlffit of measure Subtotal $.LL. Salary $49,565. ear 4130.00 per month Rent and Utilities $2750.month --$2750,00 per month Supplies $2800. ear $233.00 per month Total $7113.00 per month c.) Cost per Unit _ Actualrfl145 estimated 201.5-16 !?rajected 2©16 17=T Total Cost of Program $56,272. $58,100. $60,050. Total # of Units Cost Per Unit 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 5/25/2016 10:10:25 AM Page 2 1 of 2 Exhibit 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 5/25/2016 10:10:25 AM Page 22 of 24 Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION Section M. Financial Data Operating Budget for Entire Agency AGENCY NAME: The Arc of the Triangle Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Chan e Private Donations $ 1,000 $ 1,500 $ 1,800 20% Agency Generated Revenue (fees) $ 80$ 5,000 $000 $ 8,000 $ 8,000 0% Local Government Grants: Orange County 12,000 $ 12,000 "001. Town of Chapel Hill $ 6,000 $ 12,000 $ 12,000 0% Town of Carrboro $ 5,000 $ 5,000 $ 5,000 0% Other Local: 0 Other Local: 0 Other Local: 0 r more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 8,000 $ 8,000 $ 8,000 0% State Government $ 235,014 $ 235,000 $ 235,000 0% Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: Total Agency Revenue $ 268 014 281 500 281 800 0% AGENCY EXPENSES Compensation $ 2,289,575 $ 2,678,967 $ 2,767,303 3% Rent&Utilities $ 65,248 $ 77,000 $ 79,000 3% Supplies&Equipment $ 44,821 $ 44,500 $ 47,000 6% Travel &Training $ 96,774 $ 104,250 $ 108,000 4% Other Expenses: $ 190,235 $ 196,450 $ 199,000 1% Please list 3 largest"Other Expenses": Main pplication Exhibit A- continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/25/2016 10:10:25 AM P a g e 24 of 24 EXHIBIT"B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: The Arc of the Triangle Funding Award: $6,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Programmatic Expenses—Supplies 6,000 Rent and Utilities Personnel Expenses—Salaries,Travel 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. • Use a combination of paid Direct Support Professionals and volunteers,to assist participants in non-segregated community activities. • Provide transportation to participants involved in activities in community spaces or in programs that include persons that do not have disabilities a Each participants person centered plan will include goals for increasing the numbe rof people that they have relationships with and staff and volunteers will promote and ensure relationship building activities. • Participants will have opportunities to engage in exercise and nutrition classes. 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 Anticipate d Results Percentage of 304 people served will increase their participation in community activities 50% Percentage of 304 people served will increase their usage of community spaces 50% Program participants will increase the number of relationships and people in their circle of support. 50% People will increase physical health by participating in cooking nutrition classes and exercise classes 30 people People will participate with volunteers on a weekly basis and meet their goal. 25 people Certified by. Title: &351- Date: �L ' - (Provider's Signature) Ud Jj4.(tl f -50(% e,L off 04vrif,)fS ARCOF-4 OP ID: KB CERTIFICATE OF LIABILITY INSURANCE DATE 06/141201 Y) 06/1412016 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 Senn Dunn-Charlotte NAME: Kendra A Biddle,CPCU,CIC 440 South Church St.,Ste 500 ac°NN Ext:336-899-2410 ac No):336-841-5319 Charlotte,NC 28202 E-MAIL M.Bryan Beasley,CIC ADDRESS:kbiddle@senndunn.com INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Eastern Alliance Insurance Co. 10724 INSURED The Arc of the Triangle,Inc. INSURERS:Firemans Ins of Washington DC 21784 1709 Legion Road,Suite 100 Chapel Hill,INC 27517 INSURER C: INSURER D: 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 L UBR POLICY NUMBER MWDD/YYYY MM LTR /DD//YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE OCCUR CPA4256553 07/01/2016 07101/2017 PREMISES Ea occurrence $ 1,000,00 MED EXP(Any one person) $ 20,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,00 POLICY❑ PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 100000 Ea accident) , , B ANY AUTO CPA4256553 07/01/2016 07/01/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ X AUTOS X NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 B EXCESSUAB CLAIMS-MADE CPA4256553 0710112016 07101/2017 AGGREGATE $ 1,000,00 DED I X I RETENTION$ 0 $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER YIN A ANY PROPRIETOR/PARTNER/EXECUTIVE ❑NIA 03-0000038729-08 0710412016 07/04/2017 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE_-POLICY LIMIT $ 500,00 B Professional CPA4256553 07/01/2016 07101/2017 Incident 1,000,00 Liability Aggregate 3,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION ORANG18 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS. Finance&Administrative Sery 200 S Cameron Street AUTHORIZED REPRESENTATIVE P O Box 8181 Hillsborough,NC 27278 h� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD