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2016-595-E Finance - OE Enterprises, Inc. - Outside Agency Performance Agreement
DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 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 OE Enterprises, Inc., a not-for-profit corporation, located at 348 Elizabeth Brady Road, Hillsborough,NC 27278 ("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 OE Enterprises, 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 51100. 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$12,775. 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. (OE Enterprises,Inc.) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 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. (OE Enterprises,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 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. (OE Enterprises,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 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 OE Enterprises, 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: (OE Enterprises,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 County: Finance&Administrative Services Provider: OE Enterprises, Inc. Orange County 348 Elizabeth Brady Road Post Office Box 8181 Hillsborough,NC 27278 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 :the Provider or`^ S' 5 10/27/2016 RRCF63A714214_3F Date E For and :Orange County Government 156lA tit, tka"mt-I'Stt,t1 10/31/2016 fl 7°O R7Si5E477 Bonnie Hammersley, County Manager Date (OE Enterprises,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 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. by: S-asIS CEO 10/27/2016 Certified by: rDocuSigned Title: Date: (Provider's Signature) (OE Enterprises,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency OE Enterprises, Inc. Date/Time / Complete Y/N Program(s) Transitions to Employment Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. ® Applicant Contact Information b. ® Project/Program Contact Information c. ® Funding Requests Identified d. ® Signed Application Cover Page 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 c. ® Agency's Types of Services Provided CFR Parts 84 or 85 d. ® Agency's Experience e. ® Other Pertinent Information 3. Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), Project b. 570.201-570. 208, ® Summary of Program Information - c. ® Description of Identified Need 507.503 (for each d. ® Description of Population to be Served program/ project for e. ® Activity Manager and Location Description which funding f. ® Activity Implementation Timeline is requested) g. ® Agency Collaboration h. ® Describe Impact of Reduced/No Allocation i. ® Other Pertinent Information j. ® Complete Target Population/Beneficiary Chart k. ® Complete Schedule of Positions I. ® Signed Conflict of Interest Disclosure m. ® Complete Work Statement i ( o )age DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. ® Program Budget Worksheet 570.602, 570.607(b), is requested) b. ® Program Budget Detail 570.611 24 CFR c. ® Cost Per Unit 570.502-570.504, d. ® Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. ® Audit: Organizations receiving$300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ® IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors 24 CFR Parts 84 or 85 g. ® Articles of Incorporation/Bylaws 24 CFR 570.208, h. ® Authorization to Request Funds 570.500(c), 570.611 i. ® Authorized official designation j. ® Solid Waste Program Fee (SWPF) Verification Main Application 2/1/2016 11:26:11 AM Page 2 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t 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: OE Enterprises, Inc. Applicant Organization's Physical Address: 348 Elizabeth Brady Road Hillsborough, NC 27278 Applicant Organization's Mailing Address: 348 Elizabeth Brady Road Hillsborough, NC 27278 Applicant Organization's Web Address: www.oeenterprises.orp Executive Director: Margaret Samuels Telephone Number: 919-732-8124 E-Mail: samuelsm @oeenterprises.org DUNS Number: 189444938 (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Transitions to Employment Project/Program Primary Contact and Title: Tracey Craven, Director of Community Employment Telephone Number: 919-732-8124 E-Mail: cravent @oeenterprises.org c) Funding Request Identification Total Project/Program Cost: $1.295.000 Total Amount of Funds Requested: $66.100 Proposed Use of Funds Requested (2-3 Line Maximum): OE Enterprises seeks funding for provision of vocational placement, training, and community integration supports for students and adults who have disabilities. 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. ® Human Services: ®Carrboro $5,000 ®Chapel Hill $10,000 Orange County$51,100 d) To the best of my knowledge and belief all information and data in this application is true and current. The doc, ent has been duly authorized by the governing board of the applicant. / -i • IA/ 1/25/16 Signature: Executive Director Date Signature: ^e. 1/25/16 Board Chairperson Date Main Application 2/1/2016 11:26:11 AM I:' c 3 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency(Limit of 2 pages total): a. Years in Operation/Date of Incorporation: 35 years/ November 19, 1981 b. Agency's Purpose/Vision: The Purpose/Mission of OE Enterprises is creating opportunities for personal and professional growth for person with disabilities or other barriers to employment. OE Enterprises promotes achievements, self-reliance, life choices and respect through relationships with individuals in our community with disabilities and our community employers. c. Types of Services the Agency Provides: In order to accomplish our mission OE provides vocational opportunities through community-based work experiences, facility based contract work, volunteer work serving the community and community integration for individuals with disabilities including community members with intellectual/developmental disabilities, physical disabilities and other employment barriers. These services are designed to assist the individual with the acquisition, retention, and improvement of independence in areas such as self-help, socialization, adaptive, vocational skills, self- determination, decision making, resume completion, dress and appearance, interview skills and work habits. OE sub-contracts with local businesses in the areas of mailing sub-assemblies, packaging and product fulfillment. Services provided to individuals include evaluation, work adjustment, job placement, job coaching, long-term employment supports, career counseling, transitioning from school to work, retirement and employment. Individuals learn about their job strengths, needs and interests. Evaluation may take place at our Hillsborough facility or in the Orange County business community. Strategies used during evaluation will be based on the individual plan, and may include observation of work habits, interest and aptitude inventories,job site visits and interviews. When the evaluation is completed the individual will receive recommendations for how to enter, rejoin and maintain success in the work force. Job development helps each person find a job that is matched to their abilities and interests. On the job training is also provided. OE provides support to both the employee and the employer as needed to assist with job maintenance. d. Agency's Experience with Similar Programs as the Funding Request: Supported employment is offered to assist individuals, who have more significant disabilities, with job development and placement, on the job training, and long term job retention. OE Enterprises serves as a major employment resource for the Orange County community and provides vocational and pre-employment training to individuals with disabilities and other disadvantages. All training is geared to the individual's abilities and designed to meet specific vocational goals. OE Enterprises, Inc. has been a fixture in the North Carolina business community for over 40 years with its roots in the Orange County area. OE Enterprises, Inc. (OE) was incorporated on November 19, 1981 as Orange Industries, a public non-profit agency that was formerly part of OPC Mental Health Center serving individuals with disabilities in the Orange County area. In October, 2003 Orange Enterprises established a federal set-aside custodial operation in Winston-Salem and has since Main Application 2/1/2016 11:26:11 AM I:) c 41 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION established similar sites across North Carolina and in South Carolina. On July 1, 2005 Orange Enterprises began to provide vocational services for persons with disabilities in Alamance and Caswell counties, changing the organization's name to OE Enterprises. We expanded services to Durham County in 2009 and Rockingham County in 2010. Through our mission, OE meets the employment needs of Orange County citizens with disabilities as well as the Orange County employment community. OE's Transition program provides job experiences to students, allowing them to make informed choices upon graduation and explore employment or post-secondary education options. The purpose is to provide an opportunity for students to develop marketable and transferable skills. In addition to work skills, students learn life skills- such as resume building, daily living, and social skills. Our job coaches assist students with disabilities transitioning from high school by developing a student's strengths and working towards independence in areas such as employability, transportation, and daily living skills. Individuals who receive services from OE have the opportunity to go to work every day, earn a salary, pay taxes, buy goods and contribute to their communities. Individuals learn needed skills and work habits that lead to community employment. Senior employees have the opportunity to participate in integrated community-based senior citizen and retirement activities. OE has helped thousands of individuals with disabilities gain employment and work towards self-sufficiency. e. Other Pertinent Agency Information: OE was invited to join a new commercial venture called the Consumer Products Packaging Initiative (CPPI). This was a very lengthy selection process with over 200 nonprofits applying to participate. First, OE went through desk audits of its financial records and quality control documents. After that was successfully completed, OE had an onsite assessment by a national team. OE is a founding member of this initiative. The Consumer Products Packaging (CPP) Group is scheduled to launch in Winter, 2016. OE will be working with other similar organizations in the network to provide kitting and packaging services for national business clients. We will receive support in marketing and business development as well as utilizing the strength of the group to seek discounts for consumables to support the CPP Group's members and increase job opportunities for individuals with disabilities in Orange County. The best way to illustrate the impact of OE services on the lives of Orange County residents with disabilities is through an individual's story from one of the many lives served by OE: Sandy is one of many consumers who face employment barriers that OE Enterprises is assisting in finding competitive employment within their communities. Sandy is a lifelong resident of Orange County and graduated from the Chapel Hill/Carrboro school system. Sandy is currently receiving training opportunities through OE's Adult Day Vocational Program in Hillsborough as well as participation in the Supported Employment Program. Within the Adult Day Vocational Program, Sandi has been able to learn important work skills and work habits. She also participates in the weekly Job Club at OE that involves issues around community employment including how to get and keep a job, different types of work and work requirements including interviewing skills, dressing for success and practicing on the job skills. Sandy has a great personality and likes working with people. She wants a part-time job that allows her to interact with others. Through OE's Supported Employment Program, Sandy receives job development services that include assistance with resume writing, completing job applications, mock interviewing and assistance during the interview process. She is currently working with OE's Job Development Specialist Melinda Shelton to help her find competitive employment within her community. Sandy recently moved to a supported apartment in Meadowmont in Chapel Hill and is living independently for the first time! She would like to have a job that is close to her new Main Application 2/1/2016 11:26:11 AM II:' c 5 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION apartment. The job search process will focus on finding employment that is tailored to meet Sandy's specific needs and vocational interests. 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: OE Enterprises, Inc. Transitions to Employment As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: Human Services (Main Application Only) 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 X X X X X Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other:Please specify Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Town/County priority: Job Training OE will utilize all funding from Human Services grant to expand our current mission and numbers served by supporting staffing and transportation. Our program addresses the above issues by providing employment readiness training, job coaching, volunteer experiences and vocational placement and support to high school students and adults with disabilities. By preparing individuals for the transition to employment from high school we increase their chances of obtaining and maintaining employment. By providing work training, placement, and support to adults with disabilities we are addressing the rate of unemployment among individuals with disabilities in Orange County. 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. Main Application 2/1/2016 11:26:11 AM Page 6 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION Although the unemployment rate has dropped since the years of the recession, unemployment remains a major issue facing the US as a whole. In November 2015, the unemployment rate was 5.5% statewide with Orange County having an unemployment rate of 4.2%. Lower unemployment rates do not mean that Orange County does not face a serious unemployment issue, particularly among workers with disabilities. The 2011 Orange County Community Health assessment reported that the unemployment rate for individuals with a disability was 23.2% statewide, but jumps to 41.1% in Orange County. In 2013 Cornell University reported the employment rate of working-age people with disabilities in NC was 31.4 percent. In 2013, the employment rate of working-age people without disabilities in NC was 76.4 percent. (http://www.disabilitystatistics.orp/StatusReports/2013-PDF/2013-StatusReport NC.pdf) A troubling statistic includes the data that at all levels of education, persons with a disability were much less likely to be employed than were their counterparts with no disability http://www.bls.pov/news.release/pdf/disabl.pdf). Orange County employment is concentrated in government and University positions. Per the 2011 Community Health Assessment, the unemployment rate for individuals with only a high school diploma or equivalent stands at 26.2%. There are fewer opportunities for younger, entry level workers and there is increased competition for these jobs due to the UNC Student population (Orange County Community Health Assessment 2011, p70-71). There are few services available for integration of individuals with disabilities into established senior retirement and community activities Services for disabled senior citizens remain a critical need. Mobility, vision, hearing, and balance issues become even more impactful for seniors with disabilities. Most seniors lose community and family support as they age and for seniors with disabilities this can be life altering as family members may have been their caretakers. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. OE will serve students, adults and senior citizens who have a disability or other barriers to employment. Most of our referrals for adult services come from Vocational Rehabilitation and Cardinal MCO, but we also are connected with individuals seeking services from schools, Social Services, residential providers, families, self-referral and other community members. OE serves individuals with varying disabilities to include development/intellectual disabilities, physical disabilities, mental health issues, substance and alcohol abuse, hearing and vision impaired as well as those with extensive criminal backgrounds. OE also works with the student population served through Orange and Cedar Ridge High School's OCS Programs. Students served through this program are age 16 through 22 years of age. e) Who specifically will carry out the activities and in what location will they be carried out? OE's Job Development Specialists work with individuals during the process of finding employment that is tailored to their needs and interests and takes place at businesses throughout the community. Once employment is obtained, individuals receive job coaching from OE's coaching staff at the respective job sites in order to learn the tasks associated with the job. OE has based our work on the proven best practice system of Supported Employment. Supported Employment is a system of supports for people with disabilities to assist them with employment in integrated settings. This system uses "coaches" to train individuals on skills that are task specific and on "soft skills" such as appropriate socialization in a work setting. Coaches also provide ongoing support. This proven model can be applied to community integration into senior activities as well. With the use of the coach, senior participants can learn about their communities, develop task specific skills, and increase socialization experiences by overcoming existing barriers. Coaching for both Main Application 2/1/2016 11:26:11 AM of DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION employment and community integration are offered at locations throughout Orange County that meet the needs and choices of each individual. Vocational assessment services both in the facility and in the community. Facility based services are offered in Hillsborough at 348 Elizabeth Brady Road. Individuals participating in OE's Adult Day Vocational Program are able to increase their work skills and knowledge by participating in pre-vocational training within our facility provided by our Occupational Training Specialists. Individuals participating in the Adult Day Vocational Program also have the opportunity to participate in weekly Job Club classes at the facility that focus on aspects of finding competitive employment within their respective communities. Vocational assessment services both in the facility and in the community are offered. The services that take place with our student population takes place within the 2 high schools that OE currently works with within Orange County. Our Job Development Specialists teach weekly job club classes at each high school. Topics revolve around the complete job search process, interviewing techniques and maintaining employment. 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. Each person served participates in creating a written individual plan to meet their unique needs. Length of service, frequency and amount of time spent in different phase of service is customized for each person. Individuals participating in OE's pre-vocational services through ADVP are offered services 7 hours a day/5 days a week. Our community based employment services may vary from daily to weekly services. The frequency varies depending on the stage in which the individual is with their employment search and training phase. For our student population served in the high school settings, the frequency of activity led by our Job Development specialists is once per week at each high school. Implementation Timeline: July 1 2016-June 30, 2017 July-August,2016 Funding secured Planning for 16-17 OC Schools and identify facility clients who are preparing for competitive employment August-September,2016 Clients/Students identified Work with EC and OCS teachers and families to identify students for Transitions to Employment Program September,2016 Identify senior clients Work with referral agencies and caregivers on goals for senior clients October-December,2016 Intake,assessment,skills training and Work with all level of clients on defining identification on needs and resources goals and outcomes January-April 2017 Work on person centered goals and Individualized plan work and integration employment outcomes into competitive employment and retirement/senior activities May-June 30,2017 Assessment and measurement of goals Goal tracking and outcome measurement and outcomes work g. Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • Chamber of Commerce, Cardinal Innovations, and the United Way Greater Triangle. We maximize opportunities, create relationships with local business that may employ Orange County residents with disabilities and ensure that we network for all the available opportunities for our clients. We organize and participate in job fairs and community training with DSS and the school systems. We work with the college systems to engage volunteers, assist in recruiting staff and provide information to students interested in this profession. Main Application 2/1/2016 11:26:11 AM l) ace of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION • Food insecurity and basic needs- Because of our longevity OE has strong connections with Orange Congregation in Mission (OCIM); Interfaith Council for Social Services; Orange County Department of Social Services and through these relationships we assist our clients with unmet basic needs including food. We also hold an annual blood collection drive at our Orange County location in collaboration with the American Red Cross. • Third Sector Alliance - Through the Third Sector Alliance, OE is able to take an active part with other funded agencies to "provide a collective voice for the nonprofit sector". OE is member of the Third Sector Alliance and is represented on the steering committee. • State Organizations - OE also interacts with other agencies in our field throughout North Carolina by participating in two organizations, the NC Association for Persons in Supported Employment (NCAPSE) and the NC Association of Rehabilitation Facilities (NCARF), to share ideas and training. We have two staff active in the North Carolina Employment First Steering Committee, one serving as the NCEF co-chair. • Group Homes/Housing supports and Transportation - Many of the individuals we support receive services through various residential providers in the area. Housing is extremely important in employment success. Collaborating with these agencies assists our consumers in meeting their residential needs. We collaborate closely with OPT and Chapel Hill Transit as our clients rely heavily on public transportation to get back and forth to work. h. Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. OE has worked hard in the Orange County community for over 40 years. We continually look for efficiencies and ways to maximize all of our funding. We are so grateful and appreciative to the funds provided by Orange County, Town of Chapel Hill and the Town of Carrboro. Over the years we have seen both local and state dollars decrease due to the recession, lack of investment in social services and mental health needs and constant change to systems of managing Medicaid dollars and cuts in rates to federal and state dollars. Without the Orange County funds work with students in the high schools and seniors would be in jeopardy. It is challenging for individuals with disabilities to find, obtain and keep jobs. Our staff engages in difficult work and we are always maximizing efficiencies to ensure we are utilizing public dollars efficiently and effectively. 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: ® Persons ❑ Households ❑ Units Program: Transitions to Employment Program Beneficiary Demographics Main Application 2/1/2016 11:26:11 AM c of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 129 129 129 Female 105 105 105 Total 234 234 234 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 104 104 104 American Indian or Alaska Native Asian Caucasian 121 121 121 Native Hawaiian or other Pacific Islander Other 9 9 9 Total 234 234 234 Of the above, how many Hispanic/Latino 7 7 7 Of the above, how many non- Hispanic/Latino 227 227 227 Total 234 234 234 Age 0-5 years 0 0 0 6-18 years 25 25 25 19-50 years 164 164 164 51-61 years 35 35 35 62+ years 10 10 10 Total 234 234 234 Geographic Location Durham City Durham County 5 5 5 Carrboro 40 40 40 Chapel Hill 74 74 74 Chapel Hill Public Housing Residents 15 15 15 Orange County 98 98 98 Raleigh Wake County 2 2 2 Total I 234 234 234 I k.) Schedule of Positions Main Application 2/1/2016 11:26:11 AM II:' c 10 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION 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* Progra Actual Estimate Projected Total Retirement *= Position Vacant * m Staff 2014-15 d 2015-16 2016-17 Budge Plan + t (H) Health Plan Occupational Training Specialists* (entire 1,064,07 1,069,39 agency) 45 50% 1,058,781 5 5 20% (H) Employment Service Lead 4 50% 201,443 202,451 203,463 4% (H) Program Service Lead 6 50% 164,802 165,626 166,454 3% (H) Case Support Specialist 4 50% 65,834 66,163 66,494 1% (H) Business Relations Representative 1 50% 44,094 44,314 44,536 1% (H) Project Manager 2 50% 109,041 109,586 110,134 2% (H) Job Development Specialist 8 21% 199,141 200,137 201,138 4% (H) Senior Management 7 17% 635,268 638,444 641,637 12% (H) Job Retention Coordinator 2 0% 42,760 42,974 43,189 1% (H) Federal Contract 1,959,49 1,969,29 Employees 72 0% 1,949,743 2 0 37% (H) Administrative Staff 8 0% 187,727 188,665 189,609 4% (H) Production Staff 47 0% 635,268 638,444 641,637 12% (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 2/1/2016 11:26:11 AM 4:) c 11 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t 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 ❑ ® a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? ❑ ® b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? ❑ ® c) Current beneficiaries of the project/program for which funds are requested? ❑ ® 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 inel'gible for funding, but the existence of an undisclosed conflict may result in the terminal,n of any grant awarded. Signature: / p � 1/25/16 Executive I rector Date 1/25/16 Signature: (91.44- aligir:(114-° Board Chairperson Date Main Application 2/1/2016 11:26:11 AM I:' c 12 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 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. Main Application 2/1/2016 11:26:11 AM I:) c 13 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Program Activity 1 15 student participants will obtain jobs in the Program Goal community 15 15 Number of students Number of students Number of students placed in comeptitive placed in comeptitive placed in comeptitive Performance Measures employment employment employment 12 obtained competitive Program Results employment Mid year-2 15 Program Activity 2 50 adults will obtain jobs Program Goal in their community 50 50 Adults obtaining Adults obtaining Adults obtaining competitive competitive competitive Performance Measures employment employment employment 51 adults obtained jobs Program Results in Orange County Mid year-27 50 Program Activity 3 5 senior adult with participants (age55+) will participate in Community Senior and Program Goal retirement activities 5 5 Measuring meaningful Measuring meaningful Measuring meaningful senior activities and senior activities and senior activities and retirement participation retirement participation retirement participation of disabled elderly of disabled elderly of disabled elderly Performance Measures program participants program participants program participants 5 senior adults either transitioned to retirement or particpated in senior Program Results activities Mid year-2 5 Main Application 2/1/2016 11:26:11 AM II ) age 14 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 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 2/1/2016 11:26:11 AM Page 15 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 2,064 $ 2,000 $ 2,000 0% Agency Generated Revenue (fees) $ 1,181,022 $ 1,205,000 $ 1,205,000 0% Local Government Grants: Orange County $ 45,100 $ 45,100 $ 51,100 13% Town of Chapel Hill $ 3,000 $ 6,000 $ 10,000 67% Town of Carrboro $ 3,500 $ 3,600 $ 5,000 39% 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 $ 200 $ 1,000 $ 1,000 0% Please list 3 largest Miscellanous sources: Total Agency Revenue $ 1 234 886 $ 1 262 700 $ 1 274 100 1% AGENCY EXPENSES Compensation $ 990,708 $ 1,003,661 $ 1,008,000 0% Rent&Utilities $ 44,962 $ 48,655 $ 50,000 3% $ 93,408 $ 95,100 $ 97,000 2% Travel &Training $ 42,488 $ 45,000 $ 50,000 11% Other Expenses: $ 90,475 $ 90,000 $ 90,000 0% Please list 3 largest"Other Expenses": Subcontractor& Professional Fee: $ 65,300.00 Workers Comp Ins $ 25,175.00 Total Agency Expenses $ 1,262,041 $ 1,282,416 $ 1,295,000 1% SURPLUS/(DEFICIT) FOR PERIOD: $ 27,155 $ 19,716 $ 20,900 -6°/; Main Application 2/1/2016 11:26:11 AM Page 16 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Transitions to Employment Cost Elements Cost ($) Quantity/Unit of measure Subtotal($) Job coaches/Employment Counselors $21.49 257 hours per month x 12 $66,100 Total $66,100 c.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $1,262,041 $1,282,416 $1,295,000 Total # of Units 60,250 60,250 60,250 Cost Per Unit $20.94 $21.28 $21.49 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 2/1/2016 11:26:11 AM of DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 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. 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 2/1/2016 11:26:11 AM II ) age 1 of 1 DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI. Financial Data Operating Budget for Entire Agency AGENCY NAME: OE ENTERPRISES,INC. Actual Estimated Projected 2016 AGENCY REVENUE 2014-15 2015-16 17 Private Donations $ 2,164 $ 2,000 $ 2,000 0% Agency Generated Revenue(fees) $ 7,251,647 $ 7,281,650 $ 7,311,650 0% Local Government Grants: Orange County $ 45,100 $ 45,100 $ 51,100 EIMI Town of Chapel Hill $ 3,000 $ 6,000 $ 10,000 67% Town of Carrboro $ 3,500 $ 3,600 $ 5,000 39% Other Local: --- I Other Local: --- I Other Local: --- I ff more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 15,000 $ 15,000 $ 15,000 0% State Government --- I Federal Government --- I Other Grants: --- I Other Grants: --- I Miscellaneous/Other Revenue --- 0 Rease list 3 largest Iviscellanous sources: $ - $ - Total Agency Revenue $ 7 320 411 $ 7 353 350 $ 7 394 750 1% AGENCY EXPENSES Compensation $ 5,293,903 $ 5,315,079 $ 5,341,654 0% Rent&Utilities $ 187,242 $ 187,991 $ 188,931 0% Supplies&Equipment $ 790,000 $ 793,160 $ 797,126 1% Travel&Training $ 150,805 $ 151,408 $ 152,165 1% Other Expenses: $ 894,746 $ 898,325 $ 902,817 0% Rease list 3 largest"Other Expenses": ubcontract&Professional Fee $191,119.00 Insurance Expenses $173,869.00 Incentive Expenses $108,571.00 Total Agency Expenses $ 7 316 696 $ 7 345 963 $ 7 382 693 0% SURPLUS/(DEFICIT)FOR PERIOD: I$ 3,715 1 $ 7,387 1 $ 12,057 1 63%I Main Application 2/1/2016 11:26:11 AM Page I I • DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: OE Enterprises, Inc. Funding Award: $51,100 Outline how the agency will spend Orange County's funding award. Expense Description Amount Funding for provision of vocational placement, training, and community integration 51,100 supports for students and adults who have disabilities. Programmatic and Personnel Expesnes 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. • Employment related services provided to students includes job placement, Job Club, Job shadowing experiences, career explorations/ counseling, assessments, assistance with volunteer experiences, and developing work portfolios. • Employment related services provided to adults includes self-determination training, vocational assessment,pre-vocational training,job placement services, intensive on-the-job training, and job follow up services as needed. 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 Student participants will obtain jobs in the community 15 students Adults will obtain jobs in their community 50 adults Senior adult participants(age55+)will participate in Community Senior and retirement activities 5 seniors ,. -- Akaroara DocuSigned by:c� JS CEO 10/27/2016 --DocuSignedbyy: tiralul r,V'aAJA /27/2016 Certifed by: Title: organizational Devel o men tt si 4� (Provider's Signature) DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 ACCORD DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/15/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Tammy Brown NAME _._...... Jennings Bryan—Chappell Insurance Services d of (336)227.7458 FAX fpc,Not (336)343-1000 PO Box 1118 EMAIL tamm b @'bcins com ADORE s, y._ INSURERS AFFORDING COVERAGE NAIC A ...._ .. INSURER P y Burlington NC 27216 uRER A:Philadelphia Indemini OE Enterprises, Inc. NSURER B United Heartland t Ins Co 18058 INSURED rp , nc. INSURER _.. .. I C, 348 Elizabeth Brady Road INSURER D INSURER E: Hillsborough NC 27278 INSURER F: ........... COVERAGES CERTIFICATE NUMBER:CL167702198 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, 1 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ITR . FOOL SUM" POLICEF POLICY L TYPE OF INSURANCE INSO WVO POLICY NUMBER IM A IMDD/YYY Y). ...,.n................,., ........ LIMITS X :COMMERCIAL GENERAL LIABILITY 1,000,000 A I' j CLAIMS-MADE ..X I OCCUR ( PREM 5ES(PV o m) .... $ 100,000 PHPK1515803 6/30/2016 6/30/2017 MED EXP(Any one person) $ 5,000 PERSONAL $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PI PER GENERAL PRO JECT LOC AGGREGATE $ 2,000,000 : PRODUCTS COMP/OPAGG $ 2,000,000 POLICY OTI1i/R: $ ° U TOMOBILE LIABILITY �............... COMEINNE C(�GIHGLE ti ' $ 1,000 000 I A X ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED i SCHEDULED 1 _ AUTOS ,,, AUTOS .EHPR1515803 6/30/2016 6/30/2017 l BODILY INJURY(Per acci cident)I $ HIRED AUTOS i AUTOS PROPERTY de ,p NON-OWNED DAMAGE I ---_ PAT accfdenl X X I �I Medical.a menu $ 5,000 X UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ 4,000,000 EXCESS LIAR A DED X RETENTION$ CLAIMS-MADE 10 000 AGGREGATE $ 4,000,000 PHUB54610 1 6/30/2016 6/30/2017 $ WORKERS COMPENSATION OFFICER/MEMBER PRE EXCLUDED?D� Y/N N/A ■ EL. SST EACH ACCIDENT $ ..... 500,000,,, ANY PROPRIETOR/PARTNER/EXECUTIVE B DESCRIPTION OF OPERATIONS below 2000014173 7/1/2016 7/1/2017 EASEL O ECP�O SEE $ 500,000 If yes,describe under A Professional Liability I 'PHSD1145531 6/30/2016 ' 6/30/2017 1,000,000 2,000,000 A Sexual Abuse / Molestation PHSD1055405 6/30/2016 6/30/2017 1,000,000 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Building Inspections Dept. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 1 AUTHORIZED REPRESENTATIVE r/mnyr By wn/"LF ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/7n1401/ DocuSign Envelope ID: 112713E4-A11 E-4CO3-B5A6-92020A894CD7 ADDITIONAL COVERAGES Ref#Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium ................ Ref# Description Coverage Code Form No. Edition W..............u. P Date Uninsured motorist combined single limit UMCSL Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 Ref# Description Coverage Code Form No. Edition Date Underinsured motorist combined single limit UNCSL mmimmm Limit 1 1. ........� Limit 2 ...........{....._.Limit 3 Deductible Amount Deductible Type Premium 1,000,000 I. .�........... Ref# Description Coverage Code Form No. Edition Date Terrorism TERRO Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $757.00 Ref# Description Coverage Code Form No. Edition Date WCOT4 WCOT4 I Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Experience Mod Factor 1 EXPO1 _._._ Limit 1..............._.mwmw Limit 2 Limit 3 Deductible Amount Deductible Type Premium,.W $824.00 Ref# 1 Description Coverage Code 1 Form No. Edition Date Experience Mod Factor 1 EXPO1 Limit 1 Limit 2 P Limit 3 Deductible Amount Deductible Type Premium Ref# ...................................... ___...........__...............__....................................... ........... .......... _ _.'' Description on Terrorism _....... Coverage Code Form No. TERRO Edition Dat e Deductible Type Premium $757.00 3 Deductible Amount Limit 1 Limit 2 ............... Limit � ..................... Ses ri Debit Coverage Code Form No. Edition Date P bit Modification SDM Ref#... .Descri do _ ............................ w Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium .......................... . . $12,479.00 Ref# 1 Description Coverage Code Form No. Edition Date Premium discount PDIS Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium -$10,141.00 Ref# Description Coverage Code Form No. Edition Date Increased employer's liability INEL Limit 1 Limit............ .. ..�,-,,-..,,...... m____.m......-�....._... ,m._. ......- - .. .... -..-. 2 Limit 3 Deductible Amount Deductible Type Premium $98.00 OFADTLCV Copyright 2001,AMS Services,Inc.