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2016-594-E Finance - Dispute Settlement Center, Inc. - Outside Agency Performance Agreement
DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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 Dispute Settlement Center, Inc., a not-for-profit corporation, located at 302 Weaver Street, Carrboro,NC 27510 ("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 Dispute Settlement Center, Inc. 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 80000. 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$20,000. 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. (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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. (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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. (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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 Dispute Settlement Center, Inc. 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: (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB County: Finance&Administrative Services Provider: Dispute Settlement Center, Inc. Orange County 302 Weaver Street Post Office Box 8181 Carrboro,NC 27510 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 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. For and o afgofi a e Provider Fr tAtt,S hIA,ArS6IA, 10/25/2016 ___. ,B2C124C8... Date For and••,figkelfoid Orange County Government 156lA n,tt, tka"mt-IrStt,t1 County Manager Bonnie HammersIey, Oounty Manager Date (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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. DocuSigned by: FrratAtt,S �t iAjt,V'SotA, Executive Di rector 10/25/2016 Certified by: Title: Date: 35903&4&2E124C8... (Provider's Signature) (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Date/Time a. Agency Dispute Settlement Center, Inc Complete Y/N rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrtrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrtrrrrrrr Program(s) Mediation Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. x Applicant Contact Information b. X Project/Program Contact Information c. X Funding Requests Identified d. X Signed Application Cover Page 2. Agency a. XAgency'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. XAgency'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. x Signed Conflict of Interest Disclosure m. x Complete Work Statement i o:° DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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. XProgram Budget Worksheet 570.602, 570.607(b), is requested) b. X Program Budget Detail 570.611 24 CFR c. X Cost Per Unit 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 or A- 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 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. 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 i. x Authorized official designation j. x 3-R Fee Verification Main Application 5/24/2016 9:47:14 AM 0 I:°3 2 of 2 MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Dispute Settlement Center Inc. Applicant Organization's Physical Address: 302 Weaver Street Carrboro NC Applicant Organization's Mailing Address: same Applicant Organization's Web Address: www.disputesettlement.org Executive Director: Frances Henderson Telephone Number: (919)929-8800 E=Mail: fenderson(a'7disputesettlement.orq DUNS Number: 361862451 (Dun&Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) ProiecUProgram Contact Information Project/Program Name: Mediation Project/Program Primary Contact and,Title: Frances Henderson Executive Director Telephone Number: (919) 929-8800 ext 11 E-Mail: fhendersone-disputesettlement.org. c) Funding Request Identification Total Project/Program Cost: $110,000 Total Amount of Funds Requested: $80,000 Proposed Use of Funds Requested (2-3 Line Maximum): Intake, Information, referral and mediation for Orange County citizens in Criminal District Court; and 2) mediations for separating couples, families, and neighbors on a sliding scale basis and Medicaid Appeals mediations. 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 $10,000 x Chapel Hill $ 14,000 ❑ Orange County $80,000 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. � "^ 1� _E'�C� Signature: s� E ire Dire /Date Signature; �( 2"t oan:YChair r n Date Y Main Application 1l 120 6 6:08:45 PM Page of 2 uoiteoilddy T�oue V apistnO s,aapiAOad penuituoo - V I eV6d990669Ve-eg6e-306b-3VZ9-gZgdbo09:ol ad010nu3 u6isnoop DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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. Date of Incorporation: September 28, 1978 b. Agency's Purpose/Mission "To promote and bring about the peaceful settlement of disputes and prevent the escalation of conflict through mediation,facilitation, conciliation and training." c. Types of Services the Agency provides: With the assistance of the Orange County Board of Commissioners the Dispute Settlement Center (DSC) was founded in 1978 in order to provide an alternative for the resolution of community disputes, including those brought to Criminal District Court. The Center relieves the local criminal court of hundreds of interpersonal cases which can be best handled through mediation. With County and community support the DSC has grown to include youth, training and public disputes programs, serving nearly 3000 people each year. Separating couples, neighbors, family members, business people, co-workers, Medicaid recipients, school staff, local government departments, nonprofits agencies, congregations, and others call upon the DSC for conflict intervention including training, mediation, and facilitation. With the support of the Juvenile Crime Prevention Council, DSC provides a parent-teen training series for court-referred youth and their families, as well as mediations with the court- referred youth. Dispute Settlement Center's renowned Public Disputes Program provides meeting facilitation, consensus building and process design, and group facilitation and mediation training. Dispute Settlement Center's Youth Programs include peer mediation trainings for middle and high school students, school mediation for students, faculty, and staff, afterschool programs, and support for suspended students in the Boomerang program. The program is a leader in developing "restorative practices" for school communities, and currently contracts with the Orange County Schools and Chatham County Schools to develop ways to re-integrate suspended students (or students after infractions) in to the school community. d. Agency's Experience with Similar Programs as the Funding Request Our funding request is similar to ones we have made since FY13. From the early 1980s through FY11, state legislative support enabled DSC to provide mediators in Orange County Criminal District Court, relieving the system of hundreds of cases involving interpersonal disputes. Legislative cuts reduced the allocation for this service from $84,530 to $60,227 to zero for FY12. Main Application 5/24/2016 9:47:14 AM P of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Since FY13 Orange County support has enabled DSC to again provide mediations in Criminal District Court for which we are very grateful. This support has for the last four years consisted of$60,000 in support of mediations in Orange County Criminal District Court, and $16,000 in support of community mediations including sliding scale separation and divorce mediations. The Orange County Board of County Commissioners in FY13 granted this funding in order to increase the efficiency of the court system (and potentially keep the jail population down) while providing Orange County citizens respectful alternatives to fighting. Since then, our program has functioned successfully in this way, and has the strong support of the judges and the District Attorney's office. To quote Chief District Court Judge Joseph Buckner, "My court would be in lock-down without DSC." In addition, DSC provides sliding scale separation and divorce mediation sessions on issues including parenting arrangements, financial divisions, alimony and custody. We have seen an expansion of separation/divorce mediations, with the sliding scale fee basis being very important for people who are underemployed or experiencing job loss. We also help families with eldercare issues and neighbors and small business people with disputes. e. Other Pertinent Agency Information It is pertinent to note that mediation is a practice which does not lend itself to easy evaluation. We maintain demographic information on clients and resolution rates, but this does not tell the whole story. In many cases, we talk the parties separately through the conflict, encourage ways of conciliation, and then they may not mediate, or one side refuses. In other cases, there may be a long mediation but no resolution—nonetheless progress has been made. Mediators are trained to not focus on resolutions but on first, doing no harm, and second, empowering the parties to communicate and negotiate for themselves. Of course, resolutions can be great things, and we note that in well over 80% of mediations held, there is a resolution. Main Application 5/24/2016 9:47:14 AM P , 5 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Dispute Settlement Center: Mediation 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 Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify X–could be MEDIATION X X X 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 County priority? Dispute Settlement Center, through mediation, offers a forum for the resolution of interpersonal disputes. We propose to offer mediation in 1) Orange County Criminal District Court; 2) for families in separation and divorce and eldercare disputes; and 3)for Medicaid Appeals. Unresolved conflict can lead to public health problems and even threats to public safety. The local court system needs help with appropriate handling of a large volume of cases from civilian-generated warrants. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or Main Application 5/24/2016 9:47:14 AM .. g 6 of 23 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION other community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program and the population being served. Orange County has a role to play in making sure that the local court system functions effectively. The increasingly crowded docket strains resources and lack of efficiency in case management could also mean increased crowding and liability in the local jail. Chief District Court Judge Joseph Buckner has said that his courthouse would "be in lock-down" without the assistance of Dispute Settlement Center mediators relieving the court of hundreds of cases each year. In addition, we believe that offering disputants a chance to sit down with mediators helps them reach lasting resolutions so that behaviors leading to warrants are less likely to be repeated. Families in Orange County need affordable mediation services when faced with separation and divorce, or eldercare transition issues. Numerous studies show that parental conflict can lead to behavioral issues in children (Jaffee 1997 et alia) According to Dr. Robert Emery's long-term research at University of Virginia's Center for Children, Families, and the Law, couples who mediate have better relationships with their children years later. In addition, as the population ages, more families struggle with transitions around care of elders. We offer a different way, beyond fighting, litigation, or suffering in silence. This includes assisting the Orange County Clerk of Court with family situations at his request. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. In Orange County Criminal District Court, the judges and assistant district attorneys refer cases to us and we then screen for appropriateness and voluntariness. An appropriate case involves an interpersonal dispute (leading to, for example, charges of harassment, communicating a threat, injury to personal property, etc.) without domestic violence, in which the parties agree to mediate. Most court clients have very few resources and often need to get back to their jobs. They also need real resolution of the problem between themselves and their neighbor, co-worker, or family member. In the case of family mediation, clients are referred to Dispute Settlement Center through attorneys, therapists, or social services agencies, or self-referred. Medicaid Appeals cases are referred to us through a program through Office of Administrative Hearings. This program serves the very poor and disabled in Orange County who have been denied Medicaid services or support and have appealed the denial. e) Who specifically will carry out the activities and in what location will they be carried out? Our trained mediation staff (Mediation Coordinator with 20 years mediation experience, Mediator with a law degree and Certificate in Dispute Resolution, and executive director with law degree and 25 years mediation experience) will oversee staff and volunteer mediators who have 60 hours+ training in mediation, an apprenticeship, and experience. We attend court sessions for case referrals, and hold mediation sessions at our Carrboro offices. 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. Main Application 5/24/2016 9:47:14 AM P of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION During FY17, we will attend Orange County Criminal District Court sessions (currently Monday and Thursday mornings) for case referral. For court settings held twice a month (called "People's Court") DSC sends a team of staff and volunteer mediators to be available for potentially numerous mediations. For family cases, we maintain office hours and schedule mediations throughout the day and evenings as needed. The services are on-going. 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. We receive case referrals from these entities, among others: Orange County Criminal District Court; Orange County Civil District Court (50-B cases) Orange County Magistrates; Orange County Small Claims Court; Orange County Animal Control; Orange County Senior Centers; Orange County Clerk of Court; Orange County Department on Aging, Homeowners' Associations (HOAs) Chapel Hill Police Department Crisis Unit; Orange County DSS; Town of Chapel Hill Ombuds Office; Town of Chapel Hill Human Resources; Chapel Hill Carrboro City Schools; Orange County Schools; Family law attorneys; Family therapists; NC Office of Administrative Hearings (Medicaid Appeals) Compass Center; Congregations, nonprofits and businesses; Senior Care providers. Main Application 5/24/2016 9:47:14 AM .. of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. 1. Without Orange County funding we could not provide serves in court. A reduced allocation would be problematic as all court dates need to be covered. 2. Without funding or with reduced funding, we could not offer family clients a sliding scale that starts at $25 for a two-hour session. Many of these clients are unemployed or in financial distress, and would not have other options. i) Include any other pertinent information. We are requesting an additional 5% as our costs have grown since 2011. Our long-tenured professional staff has received 1-2% cost of living increases each year. In addition, getting in to compliance with the ACA has meant additional costs, as we now provide payments in lieu of health insurance on a taxable basis, which is more costly to staff and the agency. The agency has also lost United Way funding due to United Way's change in emphasis. More recently, the Town of Hillsborough has stopped providing funds to nonprofit agencies including DSC. 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. 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: Mediation Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 274 292 300 Female 365 368 350 Total 639 660 650 Main Application 5/24/2016 9:47:14 AM P of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 165 170 180 American Indian or Alaska Native Asian Caucasian 426 425 400 Native Hawaiian or other Pacific Islander Other 48 65 70 Total 639 660 650 Of the above, how many Hispanic/Latino 35 40 40 Of the above, how many non- Hispanic/Latino 604 620 610 Total 639 660 650 Age 0-5 years 6-18 years 19-50 years 51-61 years 62+ years Total 0 0 0 Geographic Location Durham City Durham County Carrboro 87 90 110 Chapel Hill 190 200 200 Chapel Hill Public Housing Residents Orange County 362 350 340 Raleigh Wake County Total 639 660 650 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 Main Application 5/24/2016 9:47:14 AM P 10 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION People with HIV/Aids Total 0 0 0 Main Application 5/24/2016 9:47:14 AM P 1 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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 9:47:14 AM 0 I:° 12 of 23 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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 F 20% 84626 86318 88044 18 R, H Public Dispute Coord F 0 69734 71129 72551 15 R, H Mediation Coord 36 75% 51244 52269 53314 11 R, H Training Coord F 0 44509 45120 46022 9 R,H Mediation/Youth 20/35 15% 20000 35000 35700 7 H AA/Divorce Intake 32/30 40% 28762 28265 28830 6 R,H Youth Trainer 25 0 0 0 22500 5 H Johnson Service Corps 30 0 12085 0 0 3 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 9:47:14 AM P , 13 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency_Application t7Z JO e6ed V\Id OZ:£V9 9 GOMM. uopo!iddy upiAj 91204 /.1 uoyed.lietio paeof3_ ) :einwals pleb Joioalia en!1 ex3 r :9J npuB!s -papieme luein Au e jo uopeuluua;ay; u! wisei Amu plijuoa pasops!pun ue o aoualsIxe ay; ;nq `Bu!puni Joj ely!Bnaul paroJd ay; a4eui Apessaoau ;ou saop ;salawi JO pfljuo3 iegualod e Jo aouals!xe BL; puelsJapun pue apaprouve i lualin3 pue am; si uogeuLiolui anoqe ay; jo lie janaq pue a6paimou4 Aw o saq ay; 01 -moiaq uolleueidxa lIJ e apykoJci aseald `uoRsenb Aue o SA peJemsue eAeq noA JI Lwai6o.id eq Lii iseielui lepueuij.INTO 6IJIABL.1 JO weiftud eq o SOOVIJOS JO spoo6 JO sJepino.id Pled (p X Ei pesenbe am spun y. goiqmioj wei6aidpoefoid NJ Jo sepepijeueq weiino (o ebueio Jo Vnaloqs11!H VHX1-11e0 `1111-1 ledeqo Jo seipoq 6uiweAo5 eq jo sieqwew o peieie iesop JO jo sieqweiAl (q x LI 1,0noiocisim JO icuoq.ueo `Alunoo e6ueio ledeqo Jo umoi oq Jo seeAoldwe o peeiei Aiesoio JO 1.0 seeAoidws (e X ri ON SA :seleposse sseuisnq Jieqi.Jo `seiliwei empewwi siequiew JO 'pefoid siq no 6uifuJeo eq IiM gown Aoue6e eq jo seeAoidwe JO aieqweini pleog eql O Aue aid IS31131N1 AO S1911ANO9 1VIIN310d JO minsmosia NOLLVOIlddV NIVIAI _ _ _ DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t 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 Program Activity 1 MEDIATION MEDIATION MEDIATION Program Goal 650 660 650 Performance Measures Served in mediation Served in mediation Program Results 639 672 Program Activity 2 Program Goal Performance Measures Program Results Program Activity 3 Program Goal Performance Measures Program Results Program Activity 4 Program Goal Performance Measures Program Results Activity 5 Program Goal Performance Measures Program Results Main Application 5/24/2016 9:47:14 AM 0 I:° 15 of 23 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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 9:47:14 AM 0 I:°' 16 of 23 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Prograrr MEDIATION/Dispute Settlement Center Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations 0 Agency Generated Revenue (fees) $ 27,889 $ 28,000 $ 30,000 7% Local Government Grants: Orange County $ 76,000 $ 76,000 $ 80,000 5% Town of Chapel Hill 0 Town of Carrboro 0 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 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: $ - $ $ - Total Agency Revenue $ 103 889 $ 104 000 $ 110 000 6% AGENCY EXPENSES Compensation $ 90,931 $ 92,268 $ 95,070 3% Rent& Utilities $ 2,433 $ 2,608 $ 2,658 2% Supplies& Equipment $ 1,938 $ 1,940 $ 1,950 1% Travel &Training $ 2,299 $ 2,250 $ 2,500 11% Other Expenses: $ 7,041 $ 8,309 $ 7,822 -6% Please list 3 largest"Other Expenses": Professional fees $ - Telecom $ - Main Application Insurance 5324/2016 9 Total Agency Expenses $ 104,642 $ 107,375 $ 110,000 2%I DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/24/2016 9:47:14 AM .. , 1 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/24/2016 9:47:14 AM .. , 1 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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: MEDIATION Cost Elements Cost( ) Quantity/Unit of measure Subtotal( ) Personnel costs (90% of budget) $ 95,070 Staff time allocated to program 95,070 Travel $ 1,800 To courthouse and back, etc. 1,800 Supplies and support incl space, telecom, $ 13,130 13,130 And Equip, printing, insurance, auditing Total 110,000 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 104,462 107,375 110,000 Total # of Units 639 660 650 Cost Per Unit 163.47 162.60 169.23 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 9:47:14 AM P 20 of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB 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. July 1, 2016—June 30, 2017 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 9:47:14 AM 0 I:°' g 21 of 23 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Dispute Settlement Center Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 47,323 $ 48,000 $ 50,000 4% Agency Generated Revenue(fees) $ 185,138 $ 224,000 $ 226,000 1% Local Government Grants: Orange County $ 76,000 $ 76,000 $ 80,000 5% Town of Chapel Hill $ 12,000 $ 12,000 $ 14,000 17% Town of Carrboro $ 7,800 $ 8,000 $ 10,000 25% Other Local: Hillsborough $ 2,000 $ 2,000 $ - -100% Other Local: Orange County match DJJ $ 7,661 $ 7,611 $ 7,611 0% Other Local: Chatham County DJJ -- $ 6,000 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 11,320 $ 2,146 $ - -100% State Government --- 0 Federal Govemment --- 0 Other Grants:DJJ-JCPC $ 25,538 $ 25,538 $ 25,538 0% Other Grants:Chatham County DJJ -- $ 20,000 0 Miscellaneous/Other Revenue $ 56,826 $ 41,854 $ 47,823 14% Rease list 3 largest Miscellanous sources: Private Foundations UW designation Misc $ 431 606 $ 447 149 $ 486 972 9% AGENCY EXPENSES Compensation $ 389,360 $ 405,689 $ 437,838 8% Rent&Utilities $ 12,285 $ 10,600 $ 10,356 -2% Supplies&Equipment $ 7,763 $ 7,600 $ 7,800 3% Travel&Training $ 7,184 $ 8,000 $ 8,000 0% Other Expenses: $ 14,283 $ 16,380 $ 22,978 40% Rease list 3 largest"Other Expenses": telecom $ 4,073.00 printing $ 3,232.00 prof fees $ 4,960.00 Total Agency Expenses $ 430 875 $ 448 269 $ 486 972 9% SURPLUS/(DEFICIT)FOR PERIOD: $ 731 I$ (1,120)1 $ - I 1000/al Main Application 5/24/2016 9:47:14 AM .. 2 2 o of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/24/2016 9:47:14 AM OP 2 3 o of 2 DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB Exhibit B Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Dispute Settlement Center,Inc. Funding Award: $80,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel—Salaries and FICA 80,000 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. • Intake, information, referral and mediation for Orange County residents in Criminal District Court • Mediations for separating couples, families, and neighbors on a sliding scale basis and Medicaid Appeals mediations. 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 Provide Mediation Services 650 DocuSigned by: lAtA Gt.S tkt,141-V'Sbin, Certified by: 35CO3A4B2c124c8_. Title: Executive Di rector Date: 10/25/2016 (Provider's Signature) DocuSign Envelope ID:6CD4A528-52AE-410E-B18B-BA619068A9AB AC J CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/7/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Crystal Ireland NAME: y Business Insurers of Carolinas (A/CNNo,Ext): (919)968-4611 FAX No): (919)968-8991 800 Eastowne Drive, Suite 208 aDRle55.cireland @business-insurers.com PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Hamilton Mutual Insurance Co 14125 INSURED INSURER B Employers Mutual Casualty 21415 DISPUTE SETTLEMENT CENTER INC INSURER C: 302 W WEAVER ST STE A INSURER D: INSURER E: CARRBORO NC 27510-6004 INSURERF: COVERAGES CERTIFICATE NUMBER:CL166315431 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 LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 300,000 4W54487 6/17/2016 6/17/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Hired/borrowed $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A B (Mandatory in NH) 4H54487 6/17/2016 6/17/2017 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION jethompson @orangecountync. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE � ., C Ireland/IREL01 ti/L x ^�tek.,/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmam i