Loading...
HomeMy WebLinkAbout2016-597-E Finance - Orange Congregations in Mission - Samaritan Relief Ministry - Outside Agency Performance Agreement DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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 Orange Congregations in Mission-Samaritan Relief Ministry, a not-for-profit corporation, located at 300 Millstone Drive, 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 Orange Congregations in Mission-Samaritan Relief Ministry 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 33415. 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 $8,354. 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. (Orange Congregations in Mission-Samaritan Relief Ministry) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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. 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 (Orange Congregations in Mission-Samaritan Relief Ministry) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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. 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 (Orange Congregations in Mission-Samaritan Relief Ministry) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 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 Orange Congregations in Mission-Samaritan Relief Ministry 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 (Orange Congregations in Mission-Samaritan Relief Ministry) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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: County: Finance&Administrative Services Provider: Orange Congregations in Mission- Orange County Samaritan Relief Ministry Post Office Box 8181 300 Millstone Drive Hillsborough,NC 27278 Hillsborough,NC 27278 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and o :ahaliref he Provider rox. Stant& S. Frulauf, 10/27/2016 t -66-D675A'183... Date For and AaJOrange County Government 156lA uit, tkA mt-IrStui 10/31/2016 fl 7ooag7 F477 Bonnie Hammersley, County Manager Date (Orange Congregations in Mission-Samaritan Relief Ministry) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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. e. --DocuSigned by: rox. Swot& S. Frulauf, Executive Director 10/27/2016 Certified by: Title: Date: °,---BEG2ECGDG75A433... (Provider's Signature) (Orange Congregations in Mission-Samaritan Relief Ministry) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Orange Congregations in Mission Date/Time / 1 Complete Y/N Program(s) Samaritan Relief Ministry 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. x Agency's Years in operation 24 CFR 570.506, Information - b. x Agency's Purpose/Mission 570.507, 570.610; 24 c. x Agency's Types of Services Provided CFR Parts 84 or 85 d. x Agency's Experience e. x Other Pertinent Information 3. Program/ a. x Type of Application and Program Identified 24 CFR 570.200(a), Project b. 570.201-570. 208, ❑ Summary of Program 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. ❑ Complete Work Statement DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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. x Program 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 in OMB Circular A-133 Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. X IRS Federal Form 990 c. x NC Solicitation License d. x IRS Federal Tax-Exemption Letter e. x Certificate of Insurance f. x List of Board of Directors 24 CFR Parts 84 or 85 g. x Articles of Incorporation/Bylaws 24 CFR 570.208, h. x Authorization to Request Funds 570.500(c), 570.611 i. x Authorized official designation j. x 3-R Fee Verification Main Application 5/25/2016 9:39:17 AM 0 I:° 2 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 A - continued Provider'saith55Agication 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Orange Congregations in Mission, Inc. Applicant Organization's Physical Address: 300 Millstone Dr. Hillsborough, NC 27278 Applicant Organization's Mailing Address: 300 Millstone Dr. Hillsborough, NC 27278 Applicant Organization's Web Address: www.ocimnc.org Executive Director: Rev. Sharon S. Freeland Telephone Number: 919-732-6194 E-Mail: ocimexecdirembargmail.corn DUNS Number: 612251009 (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: Samaritan Relief Ministry Project/Program Primary Contact and Title: Kay Stagner, Manager of Client Services Telephone Number: 919-732-6194 ext. 12 E-Mail: ocimsrm(d.embargmail.com c) Funding Request Identification Total Project/Program Cost: $569,700 Total Amount of Funds Requested: $33,415 Proposed Use of Funds Requested (2-3 Line Maximum): These funds would be used to purchase food for the Samaritan Relief Ministry food pantry, and emergency assistance for rent and utilities; a portion goes to Support Services, which administratively supports Orange Congregations in Mission, for wages for the program manager. 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. El CDBG Non-Construction (CH) $ n Grant E Loan fl CDBG Construction (CH) n Grant ElLoan fl HOME CHDO (OC) n Grant I— Loan fl HOME Other(OC) fl Grant 0 Loan X Human Services: El Carrboro $ 0 Chapel Hill$ X Orange County$33,415 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature:Uwv, ) aVAA4- I / 2 / Executive Director Date Signature: Z 7- /4/di 7e)/6 Board Chairpers dr !Vat° Main 4nnliratinn 1/71/7111A 4..-42- 2 AAA P n r n 1 7 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 A - continued Provider's mflopEia/ pcation 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 • r ; Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? • 7b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? Current beneficiaries of the project/program for which funds are requested? • Vd) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: (p_eiv) & & j ) Executive Director ate Signature: afr(---71- Board Chairperson D te Main Annliratinn 1121/7n1R Q-'R7. 7 AM P :atin I r f 9 9 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) May 1981 b) Agency's Purpose/Mission To minister to the urgent needs of citizens of northern Orange County through the volunteer efforts of diverse congregations and individuals inspired by faith in God, and to enhance self-sufficiency and awareness of community resources. c) Types of Services the Agency Provides Samaritan Relief Ministry: Provides emergency food, utility and rental payment, and prescription medication payment. Meals on Wheels: Provides a nutritious meal, Monday through Friday to primarily elderly people who are homebound, alone during lunchtime, and unable to prepare a nutritious meal themselves due to either cognitive or physical disability. Thrift Shop: A place where clothing, books, and household items can be purchased for very low cost and donors are able to make tax deductable donations. d) Agency's Experience with Similar Programs as the Funding Request The Samaritan Relief Ministry has been helping people in northern Orange County since 1981. The program has grown from a checkbook administered by a church secretary to a highly efficient food pantry and immediate financial assistance availability. Donations of food come from many community resources. The current program manager has been in place for over 18 years and has brought the program record keeping from index card files to a computerized database. e) Other Pertinent Agency Information Orange Congregations in Mission uses a calendar year budget. OCIM uses a certified public accountant to compile its financials each month. Main Application 5/25/2016 9:39:17 AM 0 I:° of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Orange Congregations in Mission, Samaritan Relief Ministry 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: X Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education Health and Nutrition Food Pantry ✓ ✓ ✓ ✓ Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify Rent, Utility assistance 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? Only applying for county funds. Main Application 5/25/2016 9:39:17 AM P 6 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION 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. The Samaritan Relief Ministry provides food and emergency financial assistance (rent, utilities, pharmacy) for people living in northern Orange County. Over the years, as the community has grown, the need for emergency assistance has grown. For historical perspective, in 1990, there were 94,232 people living in Orange County. That year the Samaritan Relief Ministry assisted 4,327 people, 3,009 of those were assisted with food; 3% of the people in Orange County received food assistance from the OCIM food pantry. In 2014, there were 140,420 people living in Orange County. That year the Samaritan Relief Ministry assisted 10,948 individuals, 8,946 of those received assistance from the OCIM food pantry; 6% of the population in Orange County received food assistance from the OCIM food pantry. There is an unknown factor regarding changes to the FNS Benefits (Food Stamp) program. To quote a News and Observer article from 1/9/2016, `According to Nancy Coston, director of Orange County Social Services, her staff has to speak with 700 people who are affected (by these changes.) They have to determine "who's working, who's in school, and we can't tell that without interviewing them all."'The article goes on to say, 'it is unclear at this time how many people will lose their food stamp benefits and need to turn to food banks, which expect more demand for emergency food supplies because of the change.' d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. Orange Congregations in Mission's Samaritan Relief Ministry provides emergency groceries as well as financial assistance for rent, utilities, and pharmacy to people living within the geographical boundaries of the Orange County School District. This area is primarily rural, with Hillsborough being the largest municipality. The Chapel Hill/Carrboro area is served by the Inter-Faith Council for Social Services. The Samaritan Relief Ministry is a referral-based program. Various Orange County departments, school social workers, pastors, mental health programs, and local non-profits make referrals for their clients who are in need of the services this program offers. e) Who specifically will carry out the activities and in what location will they be carried out? The program manger (or trained volunteer) receives referrals from the various Orange County agencies and congregations. An "order form" is generated and daily pantry volunteers pack groceries. When financial assistance is requested, the program manager either calls in a commitment or writes a check directly to the vendor. All transactions take place at the Orange Congregations in Mission building in Hillsborough. 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. The Samaritan Relief Ministry is open year-round, Monday-Friday, 9:00 a.m. to 5:00 p.m.; households are able to receive food from the pantry a total of seven times during a 12- month period. As long as a request is not made twice in one week, the time between food referrals does not matter. Financial assistance has a maximum amount (usually $100) available every six months. 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. • Orange County Department of Social Services: The Samaritan Relief Ministry receives referrals for individuals and families needing food and emergency financial assistance. Main Application 5/25/2016 9:39:17 AM .. of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION • Orange County Health Department:"WIC" and other maternity/young children related programs make referrals for food, baby formula, and diapers. • Lutheran Family Services, RHA and other mental health case management programs; Social workers and case managers refer clients to the Samaritan Relief Ministry for food. • Orange County Schools: Social workers refer students and their families for food. During the holidays some schools hold food drives that are vital to restocking the Samaritan Relief Ministry food pantry. For the past two years, Cedar Ridge High School has also held a coat drive and the coats were brought to the Samaritan Relief Ministry for distribution to people needing warm coats. • Private and Charter Schools: These schools are becoming more active in collecting food for the pantry. • Area Congregations: Pastors of OCIM member congregations make referrals for food and financial support for people within these congregations. Food is available to people who are initially unaware of Orange County Department of Social Services and choose to go to churches for help. Many donations to the Samaritan Relief Ministry food pantry come through monthly food collections as well as general donations to the Samaritan Relief Ministry. Many of the Samaritan Relief Ministry volunteers come from member congregations. • Orange County Sheriff's Office: During the holidays, the Sheriff's Office makes referrals of individuals and families in Orange County who could use extra help with a traditional holiday meal. These are families who may not have previously been identified as needing help. The Sheriff's Office delivers these holiday boxes. The Sheriff's Office held a food drive and sock drive in 2015. The Samaritan Relief Ministry received donations from both of these drives. • Food Bank of Central and Eastern NC: The Samaritan Relief Ministry receives food at low or no cost. • Inter-Faith Food Shuttle: The Samaritan Relief Ministry receives produce and other food at a low fee. The food has previously been delivered at no cost to our agency. Because of their own budget challenges, a small fee will be charged, beginning January 2016. • PORCH Chapel Hill & Hillsborough: The Samaritan Relief Ministry pantry receives monthly donations of non-perishable food items from local neighborhoods. • Food Lion Stores: Local Food Lion stores are donating "pulled" or "near date" produce, meat, and bakery goods. They also provide food through the sale of their "Holiday's without Hunger" boxes. • Weaver Street Market: Through special fundraising campaigns, the pantry receives weekly deliveries of fresh eggs and apples. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the Samaritan Relief Ministry did not receive funding from Orange County, fresh milk and meat purchases would be greatly reduced, (we purchase nearly $800 worth of milk a month); 85 households would not receive help with rent and utilities, and the program manager would have to either have a cut in pay or funds would have to be diverted from Main Application 5/25/2016 9:39:17 AM 0 I:° of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION other areas to pick up the balance. i) Include any other pertinent information. The program demographics show duplicated numbers. Each time a household is assisted, it draws from the programs resources and each time is considered a separate "crisis" for the household. Some households may only need help once, while others need help the maximum number of times. For the demographic information; Gender is only collected for adults, for informational purposes, the children were divided 50% female and 50% male. Ethnicity is collected by household, not individuals (the chart will reflect that), likewise, we collect age group information a little bit differently (the chart will reflect that.) 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 X Households ❑ Units Program: Samaritan Relief Ministry Program Beneficiary Demographics Actual Estimated Projected 2015 2016 2017 2014-15 2015-16 2016-17 Gender Male 4799 5075 5075 Female 5976 6203 6203 Total 10,775 11,278 11,278 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity by Household African-American 1613 1687 1687 American Indian or Alaska Native Asian Caucasian 2094 2181 2181 Native Hawaiian or other Pacific Islander Other 223 247 247 Main Application 5/25/2016 9:39:17 AM P of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION Total 3930 4,116 4,116 Of the above, how many Hispanic/Latino 201 206 206 Of the above, how many non- Hispanic/Latino 3729 3910 3910 Total Households 3930 4,116 4,116 Age 0-4 0-5 years 1498 1578 1578 5-17 6-18 years 2872 3045 3045 18-64 19-50 years 6089 6315 6315 65 +51-61 years 316 340 340 62+ years Total 10,775 11,278 11,278 Geographic Location Durham City Durham County Carrboro Chapel Hill Chapel Hill Public Housing Residents Orange County 10,775 11,278 11,278 Raleigh Wake County Total 10,775 11,278 11,278 Income Level —See following chart (Omit for HS) < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 0 Main Application 5/25/2016 9:39:17 AM P 10 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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 5/25/2016 9:39:17 AM Pag , 11 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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 1 .30 49,457.98 50,243 50,243 .05 R/H Manager of Client Services 1 100 46,052 45,007 45,007 .048 R/H Meals on Wheels Coordinator/pantry helper .75 .25 12,398.43 14,040 14,040 .012 All others (2 f/t, 3 p/t) 3.75 0 115,598.56 135,710 135,710 .12 2 R/H SRM volunteers (5,718 hours) 3 Total volunteers (10,033 hours) 5 Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/25/2016 9:39:17 AM P , 12 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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 5/25/2016 9:39:17 AM P 1 ,1 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual 2015 Estimated 2016 Projected 2017 2014-2015 2015-2016 2016-2017 Individuals or households Individuals or households Individuals or households needing food assistance needing food assistance are refered to the are refered to the are refered to the Samaritan Relief Ministry Samaritan Relief Ministry Samaritan Relief Ministry by Orange County by Orange County by Orange County agencies and pastors of agencies and pastors of agencies and pastors of OCIM member OCIM member OCIM member Program Activity 1 congregations. congregations. congregations. In 2015, 11,500 individuals 10,000 qualified 10,000 of qualified will receive up to one referrals/individuals will referrals/individuals will week of groceries a receive up to one week of receive up to one week of maximum of six times in groceries a maximum of groceries a maximum of Program Goal 12-months. seven times in 12-months. seven times in 12-months. A database of clients A database of clients A database of clients served is maintained on served is maintained on served is maintained on each household,detailing each household, detailing each household, detailing when and what assistance when and what assistance when and what assistance has been requested and has been requested and has been requested and Performance Measures given. given. given. 100% of qualified referrals received food, providing 9,497 food insecure individuals with a week's 100%of qualified referrals 100% of qualified referrals worth of groceries. The will receive food,thus will receive food,thus anticipated increase in providing 10,000 food providing 10,000 food referrals did not occur as insecure individuals with a insecure individuals with a Program Results anticipated. week's worth of groceries. week's worth of groceries. Households are referred Households are referred Households are referred to the Samaritan Relief to the Samaritan Relief to the Samaritan Relief Ministry by Orange Ministry by Orange Ministry by Orange County agencies and County agencies and County agencies and pastors of OCIM member pastors of OCIM member pastors of OCIM member Program Activity 2 congregations. congregations. congregations. 130 households will 130 households will 130 households will receive emergency receive emergency receive emergency financial assistance to be financial assistance to be financial assistance to be able to retain housing or able to retain housing or able to retain housing or utilities an additional 30 utilities an additional 30 utilities an additional 30 Program Goal days. days. days. A database of clients A database of clients A database of clients served is maintained on served is maintained on served is maintained on Main Application each househon,W iF rli6gg: I1liicA hold, detailing reaghjhpu5W„olcb cjet it g when and what assistance when and what assistance when and what assistance has been requested and has been requested and has been requested and DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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 5/25/2016 9:39:17 AM 0 I:°' of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Orange Congregations in Mission:Samaritan Relief Ministry Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 440,680 $ 344,000 $ 344,000 0% Agency Generated Revenue(fees) $ 8,779 $ 11,000 $ 11,000 0% Local Government Grants: Orange County $ 33,415 $ 33,415 $ 33,415 0% Town of Chapel Hill 0 Town of Carrboro 0 Other Local: Town of Hillsborough Water Assistance $ 2,828 $ 5,600 $ 5,600 0% Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 19,752 $ 14,500 $ 14,500 0% State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 14,386 $ 18,585 $ 18,585 0% Please list 3 largest Miscellanous sources: Duke Energy $ 4,596.59 Other foundations/groups $ 9,789.00 Total Agency Revenue $ 519,840 $ 427,100 $ 427,100 0% AGENCY EXPENSES Compensation $ 14,241 $ 12,448 $ 12,448 0% Rent&Utilities $ 11,382 $ 10,300 $ 10,300 0% Supplies&Equipment $ 2,492 $ 3,180 $ 3,180 0% Travel&Training $ 201 $ 100 $ 100 0% Other Expenses: $ 541,383 $ 414,172 $ 414,172 0% Please list 3 largest"Other Expenses": Client Assistance $ 475,304.00 Personnel Costs $ 65,717.00 Depreciation $ 362.00 Total Agency Expenses $ 569,699 $ 440,200 $ 440,200 0% SURPLUS/(DEFICIT) FOR PERIOD: I $ (49,859)1 $ (13,100)1 $ (13,100)1 0%+ Main Application 5/25/2016 9:39:17 AM Pa 1 o of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 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: Samaritan Relief Ministry Cost Elements Cost( ) Quantity/Unit of measure Subtotal( ) Personnel 79,958 1 f/t with H/R & 1 p/t 79,958 Occupancy 11,382 11,382 Food Purchase 27,045 27,045 Food Donation/assistance value 1.69 Per pound 406,374 Client Financial Assistance 42,094 42,094 Miscellaneous/other 2,846 2,846 Total 569,699 C.) Cost per Unit: A unit is one person assisted. Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 569,699 440,200 440,200 Total # of Units 10,775 11,278 11,278 Cost Per Unit 52.87 39.03 39.03 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/25/2016 9:39:17 AM .. , 1 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in your own format. Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/25/2016 9:39:17 AM .. g 20 of 22 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Orange Congregations in Mission Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 517,545 $ 449,000 $ 449,000 0% Agency Generated Revenue(fees) $ 201,456 $ 236,726 $ 236,726 0% Local Government Grants: Orange County $ 50,415 $ 50,415 $ 50,415 0% Town of Chapel Hill 0 Town of Carrboro 0 Other Local: Town of Hillsborough $ 5,000 $ - $ - 0 Other Local: Towi of Hillsborough eeter assistance $ 2,828 $ 5,600 $ 5,600 0% Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 39,974 $ 29,000 $ 29,000 0% State Government 0 Federal Government FEMA $ - $ 15,000 $ 15,000 0% Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 68,741 $ 109,994 $ 109,994 0% Please list 3 largest Miscellanous sources: Duke Energy Foundation $ 4,596.59 Other grants $ 61,145.00 Miscellaneous/Recycling $ 2,999.37 Total Agency Revenue $ 885 959 $ 895 735 $ 895 735 0% AGENCY EXPENSES Compensation(Exec.Dir.salary included) $ 143,033 $ 147,763 $ 147,763 0% Rent&Utilities $ 43,952 $ 37,250 $ 37,250 0% Supplies&Equipment $ 16,092 $ 15,655 $ 15,655 0% Travel&Training $ 4,179 $ 5,650 $ 5,650 0% Other Expenses: $ 748,707 $ 691,502 $ 691,502 0% Please list 3 largest"Other Expenses": Client Assistance $ 502,099.00 Salaries(exclude Exec.Dir.) $ 174,049.00 Accounting Fees $ 35,903.00 Total Agency Expenses $ 955,963 $ 897,820 $ 897,820 0% SURPLUS/(DEFICIT)FOR PERIOD: I $ (70,004)1 $ (2,085)1 $ (2,085)1 0%I Main Application 5/25/2016 9:39:17 AM .. 2 1 o of 2 2 DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission-Samaritan Relief Ministry Funding Award: $33,415 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel—Salaries 33,415 Rent&Utilities Programmatic Expenses 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. • Emergency financial assistance for households facing eviction and utility shut-off • A week of groceries, Severn times a year for individuals and families facing hunger 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 Qualitfied households receiving financial assistance for rent and utilities 130 Number of individuals receiving groceries 10,000 DocuSigned by: Ekv.. Sat S. Frulald 10/27/2016 Certified by: Title: Executive vi rector Date: y• 8E62EC6D675A483 (Provider's Signature) DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 OP ID: NE ,a CC)RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `••--°''� 07/21/2016 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 Jeff Rubish High&Rubish Insurance Agency PHONE FAX P.O.Box 3040 (a/c,No,EXt):919-913-1144 (A/C, . 919-913-1155 6015 Farrington Rd.Ste 101 E-MAIL Cha el Hill,NC 27517 ADDRESS: natalie @highandrubish.com Jeffrey A.Rubish CUSTOMER ID#:OCIM--1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Orange Congregations In INSURER A:Cinci nnati Insurance Company 10677 Missions, Inc. INSURER B:Hartford Underwriters Ins. 30104 300 Millstone Drive Hillsborough, NC 27278 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR TYPE OF INSURANCE I POLICY EFF POLICY EXP INSR WVD POLICY NUMBER /Y LIMITS (MM/DD YYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY ECP0349072 10/15/2015 10/15/2018 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 2,000,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE A X HIRED AUTOS EBA0349072 10/15/2015 10/15/2018 (PER ACCIDENT) $ X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE 22WECBV6360 08/18/2016 08/18/2017 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) 22WECBV6360 08/18/2015 08/18/2016 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 (Attach ACORD 101,Additional Remarks Schedule,if more space is required) evidence of coverage in force CERTIFICATE HOLDER CANCELLATION ORANG-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ORANGE COUNTY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN O O O Box 81O ACCORDANCE WITH THE POLICY PROVISIONS. P 302 W.Tryon St. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD